Click Here For Full Text of Senate 2,074 Page Bill Released 11-19

Click Here For Full Text  of Senate 2,074 Page Bill Released 11-19
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AMENDMENT NO.llll
S.L.C.
Calendar No.lll
Purpose: In the nature of a substitute.
IN THE SENATE OF THE UNITED STATES—111th Cong., 1st Sess.
H. R. 3590
To amend the Internal Revenue Code of 1986 to modify
the first-time homebuyers credit in the case of members
of the Armed Forces and certain other Federal employees, and for other purposes.
Referred to the Committee on llllllllll and
ordered to be printed
Ordered to lie on the table and to be printed
AMENDMENT IN THE NATURE OF A SUBSTITUTE intended
to be proposed by Mr. REID (for himself, Mr. BAUCUS,
Mr. DODD, and Mr. HARKIN) llllllllll
Viz:
1
Strike all after the enacting clause and insert the fol-
2 lowing:
3
4
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE.—This Act may be cited as the
5 ‘‘Patient Protection and Affordable Care Act’’.
6
(b) TABLE
OF
CONTENTS.—The table of contents of
7 this Act is as follows:
Sec. 1. Short title; table of contents.
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TITLE I—QUALITY, AFFORDABLE HEALTH CARE FOR ALL
AMERICANS
Subtitle A—Immediate Improvements in Health Care Coverage for All
Americans
Sec. 1001. Amendments to the Public Health Service Act.
‘‘PART A—INDIVIDUAL
‘‘SUBPART
‘‘Sec.
‘‘Sec.
‘‘Sec.
‘‘Sec.
‘‘Sec.
AND
GROUP MARKET REFORMS
II—IMPROVING COVERAGE
2711.
2712.
2713.
2714.
2715.
No lifetime or annual limits.
Prohibition on rescissions.
Coverage of preventive health services.
Extension of dependent coverage.
Development and utilization of uniform explanation of coverage documents and standardized definitions.
‘‘Sec. 2716. Prohibition of discrimination based on salary.
‘‘Sec. 2717. Ensuring the quality of care.
‘‘Sec. 2718. Bringing down the cost of health care coverage.
‘‘Sec. 2719. Appeals process.
Sec. 1002. Health insurance consumer information.
Sec. 1003. Ensuring that consumers get value for their dollars.
Sec. 1004. Effective dates.
Subtitle B—Immediate Actions to Preserve and Expand Coverage
Sec. 1101. Immediate access to insurance for uninsured individuals with a preexisting condition.
Sec. 1102. Reinsurance for early retirees.
Sec. 1103. Immediate information that allows consumers to identify affordable
coverage options.
Sec. 1104. Administrative simplification.
Sec. 1105. Effective date.
Subtitle C—Quality Health Insurance Coverage for All Americans
PART I—HEALTH INSURANCE MARKET REFORMS
Sec. 1201. Amendment to the Public Health Service Act.
‘‘SUBPART I—GENERAL
‘‘Sec.
‘‘Sec.
‘‘Sec.
‘‘Sec.
2701.
2702.
2703.
2704.
‘‘Sec. 2705.
‘‘Sec. 2706.
‘‘Sec. 2707.
‘‘Sec. 2708.
REFORM
Fair health insurance premiums.
Guaranteed availability of coverage.
Guaranteed renewability of coverage.
Prohibition of preexisting condition exclusions or other discrimination based on health status.
Prohibiting discrimination against individual participants and
beneficiaries based on health status.
Non-discrimination in health care.
Comprehensive health insurance coverage.
Prohibition on excessive waiting periods.
PART II—OTHER PROVISIONS
Sec. 1251. Preservation of right to maintain existing coverage.
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Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers
and group health plans.
Sec. 1253. Effective dates.
Subtitle D—Available Coverage Choices for All Americans
PART I—ESTABLISHMENT
Sec.
Sec.
Sec.
Sec.
1301.
1302.
1303.
1304.
OF
QUALIFIED HEALTH PLANS
Qualified health plan defined.
Essential health benefits requirements.
Special rules.
Related definitions.
PART II—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH
HEALTH BENEFIT EXCHANGES
Sec. 1311. Affordable choices of health benefit plans.
Sec. 1312. Consumer choice.
Sec. 1313. Financial integrity.
PART III—STATE FLEXIBILITY RELATING
TO
EXCHANGES
Sec. 1321. State flexibility in operation and enforcement of Exchanges and related requirements.
Sec. 1322. Federal program to assist establishment and operation of nonprofit,
member-run health insurance issuers.
Sec. 1323. Community health insurance option.
Sec. 1324. Level playing field.
PART IV—STATE FLEXIBILITY
TO
ESTABLISH ALTERNATIVE PROGRAMS
Sec. 1331. State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid.
Sec. 1332. Waiver for State innovation.
Sec. 1333. Provisions relating to offering of plans in more than one State.
PART V—REINSURANCE
AND
RISK ADJUSTMENT
Sec. 1341. Transitional reinsurance program for individual and small group
markets in each State.
Sec. 1342. Establishment of risk corridors for plans in individual and small
group markets.
Sec. 1343. Risk adjustment.
Subtitle E—Affordable Coverage Choices for All Americans
PART I—PREMIUM TAX CREDITS
AND
COST-SHARING REDUCTIONS
SUBPART A—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS
Sec. 1401. Refundable tax credit providing premium assistance for coverage
under a qualified health plan.
Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health
plans.
SUBPART B—ELIGIBILITY DETERMINATIONS
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Sec. 1411. Procedures for determining eligibility for Exchange participation,
premium tax credits and reduced cost-sharing , and individual
responsibility exemptions.
Sec. 1412. Advance determination and payment of premium tax credits and
cost-sharing reductions.
Sec. 1413. Streamlining of procedures for enrollment through an exchange and
State Medicaid, CHIP, and health subsidy programs.
Sec. 1414. Disclosures to carry out eligibility requirements for certain programs.
Sec. 1415. Premium tax credit and cost-sharing reduction payments disregarded for Federal and Federally-assisted programs.
PART II—SMALL BUSINESS TAX CREDIT
Sec. 1421. Credit for employee health insurance expenses of small businesses.
Subtitle F—Shared Responsibility for Health Care
PART I—INDIVIDUAL RESPONSIBILITY
Sec. 1501. Requirement to maintain minimum essential coverage.
Sec. 1502. Reporting of health insurance coverage.
PART II—EMPLOYER RESPONSIBILITIES
Sec.
Sec.
Sec.
Sec.
Sec.
1511.
1512.
1513.
1514.
1515.
Automatic enrollment for employees of large employers.
Employer requirement to inform employees of coverage options.
Shared responsibility for employers.
Reporting of employer health insurance coverage.
Offering of Exchange-participating qualified health plans through
cafeteria plans.
Subtitle G—Miscellaneous Provisions
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
1551.
1552.
1553.
1554.
1555.
1556.
1557.
1558.
1559.
1560.
1561.
1562.
Definitions.
Transparency in government.
Prohibition against discrimination on assisted suicide.
Access to therapies.
Freedom not to participate in Federal health insurance programs.
Equity for certain eligible survivors.
Nondiscrimination.
Protections for employees.
Oversight.
Rules of construction.
Health information technology enrollment standards and protocols.
Conforming amendments.
TITLE II—ROLE OF PUBLIC PROGRAMS
Subtitle A—Improved Access to Medicaid
Sec. 2001. Medicaid coverage for the lowest income populations.
Sec. 2002. Income eligibility for nonelderly determined using modified gross income.
Sec. 2003. Requirement to offer premium assistance for employer-sponsored insurance.
Sec. 2004. Medicaid coverage for former foster care children.
Sec. 2005. Payments to territories.
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Sec. 2006. Special adjustment to FMAP determination for certain States recovering from a major disaster.
Sec. 2007. Medicaid Improvement Fund rescission.
Subtitle B—Enhanced Support for the Children’s Health Insurance Program
Sec. 2101. Additional federal financial participation for CHIP.
Sec. 2102. Technical corrections.
Subtitle C—Medicaid and CHIP Enrollment Simplification
Sec. 2201. Enrollment Simplification and coordination with State Health Insurance Exchanges.
Sec. 2202. Permitting hospitals to make presumptive eligibility determinations
for all Medicaid eligible populations.
Subtitle D—Improvements to Medicaid Services
Sec.
Sec.
Sec.
Sec.
2301.
2302.
2303.
2304.
Coverage for freestanding birth center services.
Concurrent care for children.
State eligibility option for family planning services.
Clarification of definition of medical assistance.
Subtitle E—New Options for States to Provide Long-Term Services and
Supports
Sec. 2401. Community First Choice Option.
Sec. 2402. Removal of barriers to providing home and community-based services.
Sec. 2403. Money Follows the Person Rebalancing Demonstration.
Sec. 2404. Protection for recipients of home and community-based services
against spousal impoverishment.
Sec. 2405. Funding to expand State Aging and Disability Resource Centers.
Sec. 2406. Sense of the Senate regarding long-term care.
Subtitle F—Medicaid Prescription Drug Coverage
Sec. 2501. Prescription drug rebates.
Sec. 2502. Elimination of exclusion of coverage of certain drugs.
Sec. 2503. Providing adequate pharmacy reimbursement.
Subtitle G—Medicaid Disproportionate Share Hospital (DSH) Payments
Sec. 2551. Disproportionate share hospital payments.
Subtitle H—Improved Coordination for Dual Eligible Beneficiaries
Sec. 2601. 5-year period for demonstration projects.
Sec. 2602. Providing Federal coverage and payment coordination for dual eligible beneficiaries.
Subtitle I—Improving the Quality of Medicaid for Patients and Providers
Sec. 2701. Adult health quality measures.
Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions.
Sec. 2703. State option to provide health homes for enrollees with chronic conditions.
Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization.
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Sec. 2705. Medicaid Global Payment System Demonstration Project.
Sec. 2706. Pediatric Accountable Care Organization Demonstration Project.
Sec. 2707. Medicaid emergency psychiatric demonstration project.
Subtitle J—Improvements to the Medicaid and CHIP Payment and Access
Commission (MACPAC)
Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries.
Subtitle K—Protections for American Indians and Alaska Natives
Sec. 2901. Special rules relating to Indians.
Sec. 2902. Elimination of sunset for reimbursement for all medicare part B
services furnished by certain indian hospitals and clinics.
Subtitle L—Maternal and Child Health Services
Sec.
Sec.
Sec.
Sec.
Sec.
2951.
2952.
2953.
2954.
2955.
Maternal, infant, and early childhood home visiting programs.
Support, education, and research for postpartum depression.
Personal responsibility education.
Restoration of funding for abstinence education.
Inclusion of information about the importance of having a health
care power of attorney in transition planning for children aging
out of foster care and independent living programs.
TITLE III—IMPROVING THE QUALITY AND EFFICIENCY OF
HEALTH CARE
Subtitle A—Transforming the Health Care Delivery System
PART I—LINKING PAYMENT TO QUALITY OUTCOMES UNDER
MEDICARE PROGRAM
Sec.
Sec.
Sec.
Sec.
3001.
3002.
3003.
3004.
Sec. 3005.
Sec. 3006.
Sec. 3007.
Sec. 3008.
Hospital Value-Based purchasing program.
Improvements to the physician quality reporting system.
Improvements to the physician feedback program.
Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs.
Quality reporting for PPS-exempt cancer hospitals.
Plans for a Value-Based purchasing program for skilled nursing facilities and home health agencies.
Value-based payment modifier under the physician fee schedule.
Payment adjustment for conditions acquired in hospitals.
PART II—NATIONAL STRATEGY
Sec.
Sec.
Sec.
Sec.
Sec.
3011.
3012.
3013.
3014.
3015.
THE
TO
IMPROVE HEALTH CARE QUALITY
National strategy.
Interagency Working Group on Health Care Quality.
Quality measure development.
Quality measurement.
Data collection; public reporting.
PART III—ENCOURAGING DEVELOPMENT
OF
NEW PATIENT CARE MODELS
Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation
within CMS.
Sec. 3022. Medicare shared savings program.
Sec. 3023. National pilot program on payment bundling.
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Sec.
Sec.
Sec.
Sec.
3024.
3025.
3026.
3027.
Independence at home demonstration program.
Hospital readmissions reduction program.
Community-Based Care Transitions Program.
Extension of gainsharing demonstration.
Subtitle B—Improving Medicare for Patients and Providers
PART I—ENSURING BENEFICIARY ACCESS
SERVICES
TO
PHYSICIAN CARE
AND
OTHER
Sec. 3101. Increase in the physician payment update.
Sec. 3102. Extension of the work geographic index floor and revisions to the
practice expense geographic adjustment under the Medicare
physician fee schedule.
Sec. 3103. Extension of exceptions process for Medicare therapy caps.
Sec. 3104. Extension of payment for technical component of certain physician
pathology services.
Sec. 3105. Extension of ambulance add-ons.
Sec. 3106. Extension of certain payment rules for long-term care hospital services and of moratorium on the establishment of certain hospitals and facilities.
Sec. 3107. Extension of physician fee schedule mental health add-on.
Sec. 3108. Permitting physician assistants to order post-Hospital extended care
services.
Sec. 3109. Exemption of certain pharmacies from accreditation requirements.
Sec. 3110. Part B special enrollment period for disabled TRICARE beneficiaries.
Sec. 3111. Payment for bone density tests.
Sec. 3112. Revision to the Medicare Improvement Fund.
Sec. 3113. Treatment of certain complex diagnostic laboratory tests.
Sec. 3114. Improved access for certified nurse-midwife services.
PART II—RURAL PROTECTIONS
Sec. 3121. Extension of outpatient hold harmless provision.
Sec. 3122. Extension of Medicare reasonable costs payments for certain clinical
diagnostic laboratory tests furnished to hospital patients in certain rural areas.
Sec. 3123. Extension of the Rural Community Hospital Demonstration Program.
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 3125. Temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals.
Sec. 3126. Improvements to the demonstration project on community health integration models in certain rural counties.
Sec. 3127. MedPAC study on adequacy of Medicare payments for health care
providers serving in rural areas.
Sec. 3128. Technical correction related to critical access hospital services.
Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility program.
PART III—IMPROVING PAYMENT ACCURACY
Sec. 3131. Payment adjustments for home health care.
Sec. 3132. Hospice reform.
Sec. 3133. Improvement to medicare disproportionate share hospital (DSH)
payments.
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Sec. 3134. Misvalued codes under the physician fee schedule.
Sec. 3135. Modification of equipment utilization factor for advanced imaging
services.
Sec. 3136. Revision of payment for power-driven wheelchairs.
Sec. 3137. Hospital wage index improvement.
Sec. 3138. Treatment of certain cancer hospitals.
Sec. 3139. Payment for biosimilar biological products.
Sec. 3140. Medicare hospice concurrent care demonstration program.
Sec. 3141. Application of budget neutrality on a national basis in the calculation of the Medicare hospital wage index floor.
Sec. 3142. HHS study on urban Medicare-dependent hospitals.
Subtitle C—Provisions Relating to Part C
Sec. 3201. Medicare Advantage payment.
Sec. 3202. Benefit protection and simplification.
Sec. 3203. Application of coding intensity adjustment during MA payment
transition.
Sec. 3204. Simplification of annual beneficiary election periods.
Sec. 3205. Extension for specialized MA plans for special needs individuals.
Sec. 3206. Extension of reasonable cost contracts.
Sec. 3207. Technical correction to MA private fee-for-service plans.
Sec. 3208. Making senior housing facility demonstration permanent.
Sec. 3209. Authority to deny plan bids.
Sec. 3210. Development of new standards for certain Medigap plans.
Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and
MA–PD Plans
Sec. 3301. Medicare coverage gap discount program.
Sec. 3302. Improvement in determination of Medicare part D low-income
benchmark premium.
Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals under
prescription drug plans and MA–PD plans.
Sec. 3304. Special rule for widows and widowers regarding eligibility for lowincome assistance.
Sec. 3305. Improved information for subsidy eligible individuals reassigned to
prescription drug plans and MA–PD plans.
Sec. 3306. Funding outreach and assistance for low-income programs.
Sec. 3307. Improving formulary requirements for prescription drug plans and
MA–PD plans with respect to certain categories or classes of
drugs.
Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries.
Sec. 3309. Elimination of cost sharing for certain dual eligible individuals.
Sec. 3310. Reducing wasteful dispensing of outpatient prescription drugs in
long-term care facilities under prescription drug plans and
MA–PD plans.
Sec. 3311. Improved Medicare prescription drug plan and MA–PD plan complaint system.
Sec. 3312. Uniform exceptions and appeals process for prescription drug plans
and MA–PD plans.
Sec. 3313. Office of the Inspector General studies and reports.
Sec. 3314. Including costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the
annual out-of-pocket threshold under part D.
Sec. 3315. Immediate reduction in coverage gap in 2010.
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Subtitle E—Ensuring Medicare Sustainability
Sec. 3401. Revision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not
already incorporate such improvements.
Sec. 3402. Temporary adjustment to the calculation of part B premiums.
Sec. 3403. Independent Medicare Advisory Board.
Subtitle F—Health Care Quality Improvements
Sec. 3501. Health care delivery system research; Quality improvement technical
assistance.
Sec. 3502. Establishing community health teams to support the patient-centered medical home.
Sec. 3503. Medication management services in treatment of chronic disease.
Sec. 3504. Design and implementation of regionalized systems for emergency
care.
Sec. 3505. Trauma care centers and service availability.
Sec. 3506. Program to facilitate shared decisionmaking.
Sec. 3507. Presentation of prescription drug benefit and risk information.
Sec. 3508. Demonstration program to integrate quality improvement and patient safety training into clinical education of health professionals.
Sec. 3509. Improving women’s health.
Sec. 3510. Patient navigator program.
Sec. 3511. Authorization of appropriations.
TITLE IV—PREVENTION OF CHRONIC DISEASE AND IMPROVING
PUBLIC HEALTH
Subtitle A—Modernizing Disease Prevention and Public Health Systems
Sec.
Sec.
Sec.
Sec.
4001.
4002.
4003.
4004.
National Prevention, Health Promotion and Public Health Council.
Prevention and Public Health Fund.
Clinical and community preventive services.
Education and outreach campaign regarding preventive benefits.
Subtitle B—Increasing Access to Clinical Preventive Services
Sec. 4101. School-based health centers.
Sec. 4102. Oral healthcare prevention activities.
Sec. 4103. Medicare coverage of annual wellness visit providing a personalized
prevention plan.
Sec. 4104. Removal of barriers to preventive services in Medicare.
Sec. 4105. Evidence-based coverage of preventive services in Medicare.
Sec. 4106. Improving access to preventive services for eligible adults in Medicaid.
Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant
women in Medicaid.
Sec. 4108. Incentives for prevention of chronic diseases in medicaid.
Subtitle C—Creating Healthier Communities
Sec. 4201. Community transformation grants.
Sec. 4202. Healthy aging, living well; evaluation of community-based prevention
and wellness programs for Medicare beneficiaries.
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Sec. 4203. Removing barriers and improving access to wellness for individuals
with disabilities.
Sec. 4204. Immunizations.
Sec. 4205. Nutrition labeling of standard menu items at chain restaurants.
Sec. 4206. Demonstration project concerning individualized wellness plan.
Sec. 4207. Reasonable break time for nursing mothers.
Subtitle D—Support for Prevention and Public Health Innovation
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
4301.
4302.
4303.
4304.
4305.
4306.
Research on optimizing the delivery of public health services.
Understanding health disparities: data collection and analysis.
CDC and employer-based wellness programs.
Epidemiology-Laboratory Capacity Grants.
Advancing research and treatment for pain care management.
Funding for Childhood Obesity Demonstration Project.
Subtitle E—Miscellaneous Provisions
Sec. 4401. Sense of the Senate concerning CBO scoring.
Sec. 4402. Effectiveness of Federal health and wellness initiatives.
TITLE V—HEALTH CARE WORKFORCE
Subtitle A—Purpose and Definitions
Sec. 5001. Purpose.
Sec. 5002. Definitions.
Subtitle B—Innovations in the Health Care Workforce
Sec. 5101. National health care workforce commission.
Sec. 5102. State health care workforce development grants.
Sec. 5103. Health care workforce assessment.
Subtitle C—Increasing the Supply of the Health Care Workforce
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
5201.
5202.
5203.
5204.
5205.
5206.
5207.
5208.
5209.
5210.
Federally supported student loan funds.
Nursing student loan program.
Health care workforce loan repayment programs.
Public health workforce recruitment and retention programs.
Allied health workforce recruitment and retention programs.
Grants for State and local programs.
Funding for National Health Service Corps.
Nurse-managed health clinics.
Elimination of cap on commissioned corps.
Establishing a Ready Reserve Corps.
Subtitle D—Enhancing Health Care Workforce Education and Training
Sec. 5301. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship.
Sec. 5302. Training opportunities for direct care workers.
Sec. 5303. Training in general, pediatric, and public health dentistry.
Sec. 5304. Alternative dental health care providers demonstration project.
Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric education.
Sec. 5306. Mental and behavioral health education and training grants.
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Sec. 5307. Cultural competency, prevention, and public health and individuals
with disabilities training.
Sec. 5308. Advanced nursing education grants.
Sec. 5309. Nurse education, practice, and retention grants.
Sec. 5310. Loan repayment and scholarship program.
Sec. 5311. Nurse faculty loan program.
Sec. 5312. Authorization of appropriations for parts B through D of title VIII.
Sec. 5313. Grants to promote the community health workforce.
Sec. 5314. Fellowship training in public health.
Sec. 5315. United States Public Health Sciences Track.
Subtitle E—Supporting the Existing Health Care Workforce
Sec.
Sec.
Sec.
Sec.
Sec.
5401.
5402.
5403.
5404.
5405.
Centers of excellence.
Health care professionals training for diversity.
Interdisciplinary, community-based linkages.
Workforce diversity grants.
Primary care extension program.
Subtitle F—Strengthening Primary Care and Other Workforce Improvements
Sec. 5501. Expanding access to primary care services and general surgery services.
Sec. 5502. Medicare Federally qualified health center improvements.
Sec. 5503. Distribution of additional residency positions.
Sec. 5504. Counting resident time in outpatient settings and allowing flexibility
for jointly operated residency training programs.
Sec. 5505. Rules for counting resident time for didactic and scholarly activities
and other activities.
Sec. 5506. Preservation of resident cap positions from closed hospitals.
Sec. 5507. Demonstration projects To address health professions workforce
needs; extension of family-to-family health information centers.
Sec. 5508. Increasing teaching capacity.
Sec. 5509. Graduate nurse education demonstration.
Subtitle G—Improving Access to Health Care Services
Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs).
Sec. 5602. Negotiated rulemaking for development of methodology and criteria
for designating medically underserved populations and health
professions shortage areas.
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services for
Children Program.
Sec. 5604. Co-locating primary and specialty care in community-based mental
health settings.
Sec. 5605. Key National indicators.
Subtitle H—General Provisions
Sec. 5701. Reports.
TITLE VI—TRANSPARENCY AND PROGRAM INTEGRITY
Subtitle A—Physician Ownership and Other Transparency
Sec. 6001. Limitation on Medicare exception to the prohibition on certain physician referrals for hospitals.
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Sec. 6002. Transparency reports and reporting of physician ownership or investment interests.
Sec. 6003. Disclosure requirements for in-office ancillary services exception to
the prohibition on physician self-referral for certain imaging
services.
Sec. 6004. Prescription drug sample transparency.
Sec. 6005. Pharmacy benefit managers transparency requirements.
Subtitle B—Nursing Home Transparency and Improvement
PART I—IMPROVING TRANSPARENCY
OF
INFORMATION
Sec. 6101. Required disclosure of ownership and additional disclosable parties
information.
Sec. 6102. Accountability requirements for skilled nursing facilities and nursing
facilities.
Sec. 6103. Nursing home compare Medicare website.
Sec. 6104. Reporting of expenditures.
Sec. 6105. Standardized complaint form.
Sec. 6106. Ensuring staffing accountability.
Sec. 6107. GAO study and report on Five-Star Quality Rating System.
PART II—TARGETING ENFORCEMENT
Sec.
Sec.
Sec.
Sec.
6111.
6112.
6113.
6114.
Civil money penalties.
National independent monitor demonstration project.
Notification of facility closure.
National demonstration projects on culture change and use of information technology in nursing homes.
PART III—IMPROVING STAFF TRAINING
Sec. 6121. Dementia and abuse prevention training.
Subtitle C—Nationwide Program for National and State Background Checks
on Direct Patient Access Employees of Long-term Care Facilities and Providers
Sec. 6201. Nationwide program for National and State background checks on
direct patient access employees of long-term care facilities and
providers.
Subtitle D—Patient-Centered Outcomes Research
Sec. 6301. Patient-Centered Outcomes Research.
Sec. 6302. Federal coordinating council for comparative effectiveness research.
Subtitle E—Medicare, Medicaid, and CHIP Program Integrity Provisions
Sec. 6401. Provider screening and other enrollment requirements under Medicare, Medicaid, and CHIP.
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions.
Sec. 6403. Elimination of duplication between the Healthcare Integrity and
Protection Data Bank and the National Practitioner Data
Bank.
Sec. 6404. Maximum period for submission of Medicare claims reduced to not
more than 12 months.
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Sec. 6405. Physicians who order items or services required to be Medicare enrolled physicians or eligible professionals.
Sec. 6406. Requirement for physicians to provide documentation on referrals to
programs at high risk of waste and abuse.
Sec. 6407. Face to face encounter with patient required before physicians may
certify eligibility for home health services or durable medical
equipment under Medicare.
Sec. 6408. Enhanced penalties.
Sec. 6409. Medicare self-referral disclosure protocol.
Sec. 6410. Adjustments to the Medicare durable medical equipment, prosthetics, orthotics, and supplies competitive acquisition program.
Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program.
Subtitle F—Additional Medicaid Program Integrity Provisions
Sec. 6501. Termination of provider participation under Medicaid if terminated
under Medicare or other State plan.
Sec. 6502. Medicaid exclusion from participation relating to certain ownership,
control, and management affiliations.
Sec. 6503. Billing agents, clearinghouses, or other alternate payees required to
register under Medicaid.
Sec. 6504. Requirement to report expanded set of data elements under MMIS
to detect fraud and abuse.
Sec. 6505. Prohibition on payments to institutions or entities located outside of
the United States.
Sec. 6506. Overpayments.
Sec. 6507. Mandatory State use of national correct coding initiative.
Sec. 6508. General effective date.
Subtitle G—Additional Program Integrity Provisions
Sec.
Sec.
Sec.
Sec.
Sec.
6601.
6602.
6603.
6604.
6605.
Prohibition on false statements and representations.
Clarifying definition.
Development of model uniform report form.
Applicability of State law to combat fraud and abuse.
Enabling the Department of Labor to issue administrative summary
cease and desist orders and summary seizures orders against
plans that are in financially hazardous condition.
Sec. 6606. MEWA plan registration with Department of Labor.
Sec. 6607. Permitting evidentiary privilege and confidential communications.
Subtitle H—Elder Justice Act
Sec. 6701. Short title of subtitle.
Sec. 6702. Definitions.
Sec. 6703. Elder Justice.
Subtitle I—Sense of the Senate Regarding Medical Malpractice
Sec. 6801. Sense of the Senate regarding medical malpractice.
TITLE VII—IMPROVING ACCESS TO INNOVATIVE MEDICAL
THERAPIES
Subtitle A—Biologics Price Competition and Innovation
Sec. 7001. Short title.
Sec. 7002. Approval pathway for biosimilar biological products.
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14
Sec. 7003. Savings.
Subtitle B—More Affordable Medicines for Children and Underserved
Communities
Sec. 7101. Expanded participation in 340B program.
Sec. 7102. Improvements to 340B program integrity.
Sec. 7103. GAO study to make recommendations on improving the 340B program.
TITLE VIII—CLASS ACT
Sec. 8001. Short title of title.
Sec. 8002. Establishment of national voluntary insurance program for purchasing community living assistance services and support.
TITLE IX—REVENUE PROVISIONS
Subtitle A—Revenue Offset Provisions
Sec. 9001. Excise tax on high cost employer-sponsored health coverage.
Sec. 9002. Inclusion of cost of employer-sponsored health coverage on W–2.
Sec. 9003. Distributions for medicine qualified only if for prescribed drug or insulin.
Sec. 9004. Increase in additional tax on distributions from HSAs and Archer
MSAs not used for qualified medical expenses.
Sec. 9005. Limitation on health flexible spending arrangements under cafeteria
plans.
Sec. 9006. Expansion of information reporting requirements.
Sec. 9007. Additional requirements for charitable hospitals.
Sec. 9008. Imposition of annual fee on branded prescription pharmaceutical
manufacturers and importers.
Sec. 9009. Imposition of annual fee on medical device manufacturers and importers.
Sec. 9010. Imposition of annual fee on health insurance providers.
Sec. 9011. Study and report of effect on veterans health care.
Sec. 9012. Elimination of deduction for expenses allocable to Medicare Part D
subsidy.
Sec. 9013. Modification of itemized deduction for medical expenses.
Sec. 9014. Limitation on excessive remuneration paid by certain health insurance providers.
Sec. 9015. Additional hospital insurance tax on high-income taxpayers.
Sec. 9016. Modification of section 833 treatment of certain health organizations.
Sec. 9017. Excise tax on elective cosmetic medical procedures.
Subtitle B—Other Provisions
Sec. 9021. Exclusion of health benefits provided by Indian tribal governments.
Sec. 9022. Establishment of simple cafeteria plans for small businesses.
Sec. 9023. Qualifying therapeutic discovery project credit.
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6
TITLE I—QUALITY, AFFORDABLE
HEALTH
CARE
FOR
ALL
AMERICANS
Subtitle A—Immediate Improvements in Health Care Coverage
for All Americans
7
SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE
1
2
3
4
5
8
9
ACT.
Part A of title XXVII of the Public Health Service
10 Act (42 U.S.C. 300gg et seq.) is amended—
11
12
(1) by striking the part heading and inserting
the following:
13
‘‘PART A—INDIVIDUAL AND GROUP MARKET
14
REFORMS’’;
15
16
(2) by redesignating sections 2704 through
2707 as sections 2725 through 2728, respectively;
17
18
(3) by redesignating sections 2711 through
2713 as sections 2731 through 2733, respectively;
19
(4) by redesignating sections 2721 through
20
2723 as sections 2735 through 2737, respectively;
21
and
22
23
(5) by inserting after section 2702, the following:
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1
2
3
‘‘Subpart II—Improving Coverage
‘‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.
‘‘(a) IN GENERAL.—A group health plan and a health
4 insurance issuer offering group or individual health insur5 ance coverage may not establish—
6
7
‘‘(1) lifetime limits on the dollar value of benefits for any participant or beneficiary; or
8
‘‘(2) unreasonable annual limits (within the
9
meaning of section 223 of the Internal Revenue
10
Code of 1986) on the dollar value of benefits for any
11
participant or beneficiary.
12
‘‘(b) PER BENEFICIARY LIMITS.—Subsection (a)
13 shall not be construed to prevent a group health plan or
14 health insurance coverage that is not required to provide
15 essential health benefits under section 1302(b) of the Pa16 tient Protection and Affordable Care Act from placing an17 nual or lifetime per beneficiary limits on specific covered
18 benefits to the extent that such limits are otherwise per19 mitted under Federal or State law.
20
21
‘‘SEC. 2712. PROHIBITION ON RESCISSIONS.
‘‘A group health plan and a health insurance issuer
22 offering group or individual health insurance coverage
23 shall not rescind such plan or coverage with respect to an
24 enrollee once the enrollee is covered under such plan or
25 coverage involved, except that this section shall not apply
26 to a covered individual who has performed an act or prac-
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1 tice that constitutes fraud or makes an intentional mis2 representation of material fact as prohibited by the terms
3 of the plan or coverage. Such plan or coverage may not
4 be cancelled except with prior notice to the enrollee, and
5 only as permitted under section 2702(c) or 2742(b).
6
‘‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.
7
‘‘(a) IN GENERAL.—A group health plan and a health
8 insurance issuer offering group or individual health insur9 ance coverage shall provide coverage for and shall not im10 pose any cost sharing requirements for—
11
‘‘(1) evidence-based items or services that have
12
in effect a rating of ‘A’ or ‘B’ in the current rec-
13
ommendations of the United States Preventive Serv-
14
ices Task Force;
15
‘‘(2) immunizations that have in effect a rec-
16
ommendation from the Advisory Committee on Im-
17
munization Practices of the Centers for Disease
18
Control and Prevention with respect to the indi-
19
vidual involved; and
20
‘‘(3) with respect to infants, children, and ado-
21
lescents, evidence-informed preventive care and
22
screenings provided for in the comprehensive guide-
23
lines supported by the Health Resources and Serv-
24
ices Administration.
25
‘‘(b) INTERVAL.—
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1
‘‘(1) IN
GENERAL.—The
Secretary shall estab-
2
lish a minimum interval between the date on which
3
a recommendation described in subsection (a)(1) or
4
(a)(2) or a guideline under subsection (a)(3) is
5
issued and the plan year with respect to which the
6
requirement described in subsection (a) is effective
7
with respect to the service described in such rec-
8
ommendation or guideline.
9
‘‘(2) MINIMUM.—The interval described in
10
paragraph (1) shall not be less than 1 year.
11
‘‘(c) VALUE-BASED INSURANCE DESIGN.—The Sec-
12 retary may develop guidelines to permit a group health
13 plan and a health insurance issuer offering group or indi14 vidual health insurance coverage to utilize value-based in15 surance designs.
16
17
‘‘SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.
‘‘(a) IN GENERAL.—A group health plan and a health
18 insurance issuer offering group or individual health insur19 ance coverage that provides dependent coverage of chil20 dren shall continue to make such coverage available for
21 an adult child (who is not married) until the child turns
22 26 years of age. Nothing in this section shall require a
23 health plan or a health insurance issuer described in the
24 preceding sentence to make coverage available for a child
25 of a child receiving dependent coverage.
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1
‘‘(b) REGULATIONS.—The Secretary shall promul-
2 gate regulations to define the dependents to which cov3 erage shall be made available under subsection (a).
4
‘‘(c) RULE
OF
CONSTRUCTION.—Nothing in this sec-
5 tion shall be construed to modify the definition of ‘depend6 ent’ as used in the Internal Revenue Code of 1986 with
7 respect to the tax treatment of the cost of coverage.
8
‘‘SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM
9
EXPLANATION OF COVERAGE DOCUMENTS
10
11
AND STANDARDIZED DEFINITIONS.
‘‘(a) IN GENERAL.—Not later than 12 months after
12 the date of enactment of the Patient Protection and Af13 fordable Care Act, the Secretary shall develop standards
14 for use by a group health plan and a health insurance
15 issuer offering group or individual health insurance cov16 erage, in compiling and providing to enrollees a summary
17 of benefits and coverage explanation that accurately de18 scribes the benefits and coverage under the applicable plan
19 or coverage. In developing such standards, the Secretary
20 shall consult with the National Association of Insurance
21 Commissioners (referred to in this section as the ‘NAIC’),
22 a working group composed of representatives of health in23 surance-related consumer advocacy organizations, health
24 insurance issuers, health care professionals, patient advo-
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20
1 cates including those representing individuals with limited
2 English proficiency, and other qualified individuals.
3
‘‘(b) REQUIREMENTS.—The standards for the sum-
4 mary of benefits and coverage developed under subsection
5 (a) shall provide for the following:
6
‘‘(1) APPEARANCE.—The standards shall en-
7
sure that the summary of benefits and coverage is
8
presented in a uniform format that does not exceed
9
4 pages in length and does not include print smaller
10
than 12-point font.
11
‘‘(2) LANGUAGE.—The standards shall ensure
12
that the summary is presented in a culturally and
13
linguistically appropriate manner and utilizes termi-
14
nology understandable by the average plan enrollee.
15
‘‘(3) CONTENTS.—The standards shall ensure
16
that the summary of benefits and coverage in-
17
cludes—
18
‘‘(A) uniform definitions of standard insur-
19
ance terms and medical terms (consistent with
20
subsection (g)) so that consumers may compare
21
health insurance coverage and understand the
22
terms of coverage (or exception to such cov-
23
erage);
24
25
‘‘(B) a description of the coverage, including cost sharing for—
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1
‘‘(i) each of the categories of the es-
2
sential health benefits described in sub-
3
paragraphs (A) through (J) of section
4
1302(b)(1) of the Patient Protection and
5
Affordable Care Act; and
6
‘‘(ii) other benefits, as identified by
7
the Secretary;
8
‘‘(C) the exceptions, reductions, and limita-
9
tions on coverage;
10
‘‘(D) the cost-sharing provisions, including
11
deductible, coinsurance, and co-payment obliga-
12
tions;
13
14
‘‘(E) the renewability and continuation of
coverage provisions;
15
‘‘(F) a coverage facts label that includes
16
examples to illustrate common benefits sce-
17
narios, including pregnancy and serious or
18
chronic medical conditions and related cost
19
sharing, such scenarios to be based on recog-
20
nized clinical practice guidelines;
21
22
‘‘(G) a statement of whether the plan or
coverage—
23
‘‘(i) provides minimum essential cov-
24
erage (as defined under section 5000A(f)
25
of the Internal Revenue Code 1986); and
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1
‘‘(ii) ensures that the plan or coverage
2
share of the total allowed costs of benefits
3
provided under the plan or coverage is not
4
less than 60 percent of such costs;
5
‘‘(H) a statement that the outline is a
6
summary of the policy or certificate and that
7
the coverage document itself should be con-
8
sulted to determine the governing contractual
9
provisions; and
10
‘‘(I) a contact number for the consumer to
11
call with additional questions and an Internet
12
web address where a copy of the actual indi-
13
vidual coverage policy or group certificate of
14
coverage can be reviewed and obtained.
15
‘‘(c) PERIODIC REVIEW
AND
UPDATING.—The Sec-
16 retary shall periodically review and update, as appropriate,
17 the standards developed under this section.
18
19
‘‘(d) REQUIREMENT TO PROVIDE.—
‘‘(1) IN
GENERAL.—Not
later than 24 months
20
after the date of enactment of the Patient Protection
21
and Affordable Care Act, each entity described in
22
paragraph (3) shall provide, prior to any enrollment
23
restriction, a summary of benefits and coverage ex-
24
planation pursuant
25
the Secretary under subsection (a) to—
to the standards developed by
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1
2
3
4
‘‘(A) an applicant at the time of application;
‘‘(B) an enrollee prior to the time of enrollment or reenrollment, as applicable; and
5
‘‘(C) a policyholder or certificate holder at
6
the time of issuance of the policy or delivery of
7
the certificate.
8
‘‘(2) COMPLIANCE.—An entity described in
9
paragraph (3) is deemed to be in compliance with
10
this section if the summary of benefits and coverage
11
described in subsection (a) is provided in paper or
12
electronic form.
13
14
‘‘(3) ENTITIES
IN GENERAL.—An
entity de-
scribed in this paragraph is—
15
‘‘(A) a health insurance issuer (including a
16
group health plan that is not a self-insured
17
plan) offering health insurance coverage within
18
the United States; or
19
‘‘(B) in the case of a self-insured group
20
health plan, the plan sponsor or designated ad-
21
ministrator of the plan (as such terms are de-
22
fined in section 3(16) of the Employee Retire-
23
ment Income Security Act of 1974).
24
‘‘(4) NOTICE
25
OF MODIFICATIONS.—If
a group
health plan or health insurance issuer makes any
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1
material modification in any of the terms of the plan
2
or coverage involved (as defined for purposes of sec-
3
tion 102 of the Employee Retirement Income Secu-
4
rity Act of 1974) that is not reflected in the most
5
recently provided summary of benefits and coverage,
6
the plan or issuer shall provide notice of such modi-
7
fication to enrollees not later than 60 days prior to
8
the date on which such modification will become ef-
9
fective.
10
‘‘(e) PREEMPTION.—The standards developed under
11 subsection (a) shall preempt any related State standards
12 that require a summary of benefits and coverage that pro13 vides less information to consumers than that required to
14 be provided under this section, as determined by the Sec15 retary.
16
‘‘(f) FAILURE
TO
PROVIDE.—An entity described in
17 subsection (d)(3) that willfully fails to provide the infor18 mation required under this section shall be subject to a
19 fine of not more than $1,000 for each such failure. Such
20 failure with respect to each enrollee shall constitute a sep21 arate offense for purposes of this subsection.
22
23
‘‘(g) DEVELOPMENT
‘‘(1) IN
OF
STANDARD DEFINITIONS.—
GENERAL.—The
Secretary shall, by
24
regulation, provide for the development of standards
25
for the definitions of terms used in health insurance
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1
coverage, including the insurance-related terms de-
2
scribed in paragraph (2) and the medical terms de-
3
scribed in paragraph (3).
4
‘‘(2) INSURANCE-RELATED
TERMS.—The
insur-
5
ance-related terms described in this paragraph are
6
premium, deductible, co-insurance, co-payment, out-
7
of-pocket limit, preferred provider, non-preferred
8
provider, out-of-network co-payments, UCR (usual,
9
customary and reasonable) fees, excluded services,
10
grievance and appeals, and such other terms as the
11
Secretary determines are important to define so that
12
consumers may compare health insurance coverage
13
and understand the terms of their coverage.
14
‘‘(3) MEDICAL
TERMS.—The
medical terms de-
15
scribed in this paragraph are hospitalization, hos-
16
pital outpatient care, emergency room care, physi-
17
cian services, prescription drug coverage, durable
18
medical equipment, home health care, skilled nursing
19
care, rehabilitation services, hospice services, emer-
20
gency medical transportation, and such other terms
21
as the Secretary determines are important to define
22
so that consumers may compare the medical benefits
23
offered by health insurance and understand the ex-
24
tent of those medical benefits (or exceptions to those
25
benefits).
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1
2
3
‘‘SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON
SALARY.
‘‘(a) IN GENERAL.—The plan sponsor of a group
4 health plan (other than a self-insured plan) may not estab5 lish rules relating to the health insurance coverage eligi6 bility (including continued eligibility) of any full-time em7 ployee under the terms of the plan that are based on the
8 total hourly or annual salary of the employee or otherwise
9 establish eligibility rules that have the effect of discrimi10 nating in favor of higher wage employees.
11
‘‘(b) LIMITATION.—Subsection (a) shall not be con-
12 strued to prohibit a plan sponsor from establishing con13 tribution requirements for enrollment in the plan or cov14 erage that provide for the payment by employees with
15 lower hourly or annual compensation of a lower dollar or
16 percentage contribution than the payment required of
17 similarly situated employees with a higher hourly or an18 nual compensation.
19
20
21
‘‘SEC. 2717. ENSURING THE QUALITY OF CARE.
‘‘(a) QUALITY REPORTING.—
‘‘(1) IN
GENERAL.—Not
later than 2 years
22
after the date of enactment of the Patient Protection
23
and Affordable Care Act, the Secretary, in consulta-
24
tion with experts in health care quality and stake-
25
holders, shall develop reporting requirements for use
26
by a group health plan, and a health insurance
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1
issuer offering group or individual health insurance
2
coverage, with respect to plan or coverage benefits
3
and health care provider reimbursement structures
4
that—
5
‘‘(A) improve health outcomes through the
6
implementation of activities such as quality re-
7
porting, effective case management, care coordi-
8
nation, chronic disease management, and medi-
9
cation and care compliance initiatives, including
10
through the use of the medical homes model as
11
defined for purposes of section 3602 of the Pa-
12
tient Protection and Affordable Care Act, for
13
treatment or services under the plan or cov-
14
erage;
15
‘‘(B) implement activities to prevent hos-
16
pital readmissions through a comprehensive
17
program for hospital discharge that includes pa-
18
tient-centered education and counseling, com-
19
prehensive discharge planning, and post dis-
20
charge reinforcement by an appropriate health
21
care professional;
22
‘‘(C) implement activities to improve pa-
23
tient safety and reduce medical errors through
24
the appropriate use of best clinical practices,
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1
evidence based medicine, and health informa-
2
tion technology under the plan or coverage; and
3
‘‘(D) implement wellness and health pro-
4
motion activities.
5
‘‘(2) REPORTING
6
‘‘(A) IN
REQUIREMENTS.—
GENERAL.—A
group health plan
7
and a health insurance issuer offering group or
8
individual health insurance coverage shall annu-
9
ally submit to the Secretary, and to enrollees
10
under the plan or coverage, a report on whether
11
the benefits under the plan or coverage satisfy
12
the elements described in subparagraphs (A)
13
through (D) of paragraph (1).
14
‘‘(B) TIMING
OF
REPORTS.—A
report
15
under subparagraph (A) shall be made available
16
to an enrollee under the plan or coverage dur-
17
ing each open enrollment period.
18
‘‘(C) AVAILABILITY
OF
REPORTS.—The
19
Secretary shall make reports submitted under
20
subparagraph (A) available to the public
21
through an Internet website
22
‘‘(D) PENALTIES.—In developing the re-
23
porting requirements under paragraph (1), the
24
Secretary may develop and impose appropriate
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29
1
penalties for non-compliance with such require-
2
ments.
3
‘‘(E) EXCEPTIONS.—In developing the re-
4
porting requirements under paragraph (1), the
5
Secretary may provide for exceptions to such
6
requirements for group health plans and health
7
insurance issuers that substantially meet the
8
goals of this section.
9
‘‘(b) WELLNESS
AND
PREVENTION PROGRAMS.—For
10 purposes of subsection (a)(1)(D), wellness and health pro11 motion activities may include personalized wellness and
12 prevention services, which are coordinated, maintained or
13 delivered by a health care provider, a wellness and preven14 tion plan manager, or a health, wellness or prevention
15 services organization that conducts health risk assess16 ments or offers ongoing face-to-face, telephonic or web17 based intervention efforts for each of the program’s par18 ticipants, and which may include the following wellness
19 and prevention efforts:
20
‘‘(1) Smoking cessation.
21
‘‘(2) Weight management.
22
‘‘(3) Stress management.
23
‘‘(4) Physical fitness.
24
‘‘(5) Nutrition.
25
‘‘(6) Heart disease prevention.
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1
‘‘(7) Healthy lifestyle support.
2
‘‘(8) Diabetes prevention.
3
‘‘(c) REGULATIONS.—Not later than 2 years after the
4 date of enactment of the Patient Protection and Afford5 able Care Act, the Secretary shall promulgate regulations
6 that provide criteria for determining whether a reimburse7 ment structure is described in subsection (a).
8
‘‘(d) STUDY
AND
REPORT.—Not later than 180 days
9 after the date on which regulations are promulgated under
10 subsection (c), the Government Accountability Office shall
11 review such regulations and conduct a study and submit
12 to the Committee on Health, Education, Labor, and Pen13 sions of the Senate and the Committee on Energy and
14 Commerce of the House of Representatives a report re15 garding the impact the activities under this section have
16 had on the quality and cost of health care.
17
18
19
‘‘SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE
COVERAGE.
‘‘(a) CLEAR ACCOUNTING
FOR
COSTS.—A health in-
20 surance issuer offering group or individual health insur21 ance coverage shall, with respect to each plan year, submit
22 to the Secretary a report concerning the percentage of
23 total premium revenue that such coverage expends—
24
25
‘‘(1) on reimbursement for clinical services provided to enrollees under such coverage;
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1
‘‘(2) for activities that improve health care
2
quality; and
3
‘‘(3) on all other non-claims costs, including an
4
explanation of the nature of such costs, and exclud-
5
ing State taxes and licensing or regulatory fees.
6 The Secretary shall make reports received under this sec7 tion available to the public on the Internet website of the
8 Department of Health and Human Services.
9
10
‘‘(b) ENSURING THAT CONSUMERS RECEIVE VALUE
FOR
THEIR PREMIUM PAYMENTS.—
11
‘‘(1) REQUIREMENT
TO PROVIDE VALUE FOR
12
PREMIUM PAYMENTS.—A
health insurance issuer of-
13
fering group or individual health insurance coverage
14
shall, with respect to each plan year, provide an an-
15
nual rebate to each enrollee under such coverage, on
16
a pro rata basis, in an amount that is equal to the
17
amount by which premium revenue expended by the
18
issuer on activities described in subsection (a)(3) ex-
19
ceeds—
20
‘‘(A) with respect to a health insurance
21
issuer offering coverage in the group market,
22
20 percent, or such lower percentage as a State
23
may by regulation determine; or
24
‘‘(B) with respect to a health insurance
25
issuer offering coverage in the individual mar-
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1
ket, 25 percent, or such lower percentage as a
2
State may by regulation determine, except that
3
such percentage shall be adjusted to the extent
4
the Secretary determines that the application of
5
such percentage with a State may destabilize
6
the existing individual market in such State.
7
‘‘(2) CONSIDERATION
IN SETTING PERCENT-
8
AGES.—In
9
graph (1), a State shall seek to ensure adequate par-
10
ticipation by health insurance issuers, competition in
11
the health insurance market in the State, and value
12
for consumers so that premiums are used for clinical
13
services and quality improvements.
determining the percentages under para-
14
‘‘(3) TERMINATION.—The provisions of this
15
subsection shall have no force or effect after Decem-
16
ber 31, 2013.
17
‘‘(c) STANDARD HOSPITAL CHARGES.—Each hospital
18 operating within the United States shall for each year es19 tablish (and update) and make public (in accordance with
20 guidelines developed by the Secretary) a list of the hos21 pital’s standard charges for items and services provided
22 by the hospital, including for diagnosis-related groups es23 tablished under section 1886(d)(4) of the Social Security
24 Act.
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1
‘‘(d) DEFINITIONS.—The Secretary, in consultation
2 with the National Association of Insurance Commissions,
3 shall establish uniform definitions for the activities re4 ported under subsection (a).
5
6
‘‘SEC. 2719. APPEALS PROCESS.
‘‘A group health plan and a health insurance issuer
7 offering group or individual health insurance coverage
8 shall implement an effective appeals process for appeals
9 of coverage determinations and claims, under which the
10 plan or issuer shall, at a minimum—
11
12
‘‘(1) have in effect an internal claims appeal
process;
13
‘‘(2) provide notice to enrollees, in a culturally
14
and linguistically appropriate manner, of available
15
internal and external appeals processes, and the
16
availability of any applicable office of health insur-
17
ance consumer assistance or ombudsman established
18
under section 2793 to assist such enrollees with the
19
appeals processes;
20
‘‘(3) allow an enrollee to review their file, to
21
present evidence and testimony as part of the ap-
22
peals process, and to receive continued coverage
23
pending the outcome of the appeals process; and
24
‘‘(4) provide an external review process for such
25
plans and issuers that, at a minimum, includes the
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1
consumer protections set forth in the Uniform Ex-
2
ternal Review Model Act promulgated by the Na-
3
tional Association of Insurance Commissioners and
4
is binding on such plans.’’.
5
SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION.
6
Part C of title XXVII of the Public Health Service
7 Act (42 U.S.C. 300gg-91 et seq.) is amended by adding
8 at the end the following:
9
10
11
‘‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.
‘‘(a) IN GENERAL.—The Secretary shall award
12 grants to States to enable such States (or the Exchanges
13 operating in such States) to establish, expand, or provide
14 support for—
15
16
17
18
19
‘‘(1) offices of health insurance consumer assistance; or
‘‘(2) health insurance ombudsman programs.
‘‘(b) ELIGIBILITY.—
‘‘(1) IN
GENERAL.—To
be eligible to receive a
20
grant, a State shall designate an independent office
21
of health insurance consumer assistance, or an om-
22
budsman, that, directly or in coordination with State
23
health insurance regulators and consumer assistance
24
organizations, receives and responds to inquiries and
25
complaints concerning health insurance coverage
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1
with respect to Federal health insurance require-
2
ments and under State law.
3
‘‘(2) CRITERIA.—A State that receives a grant
4
under this section shall comply with criteria estab-
5
lished by the Secretary for carrying out activities
6
under such grant.
7
‘‘(c) DUTIES.—The office of health insurance con-
8 sumer assistance or health insurance ombudsman shall—
9
‘‘(1) assist with the filing of complaints and ap-
10
peals, including filing appeals with the internal ap-
11
peal or grievance process of the group health plan or
12
health insurance issuer involved and providing infor-
13
mation about the external appeal process;
14
15
‘‘(2) collect, track, and quantify problems and
inquiries encountered by consumers;
16
‘‘(3) educate consumers on their rights and re-
17
sponsibilities with respect to group health plans and
18
health insurance coverage;
19
‘‘(4) assist consumers with enrollment in a
20
group health plan or health insurance coverage by
21
providing information, referral, and assistance; and
22
‘‘(5) resolve problems with obtaining premium
23
tax credits under section 36B of the Internal Rev-
24
enue Code of 1986.
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1
‘‘(d) DATA COLLECTION.—As a condition of receiving
2 a grant under subsection (a), an office of health insurance
3 consumer assistance or ombudsman program shall be re4 quired to collect and report data to the Secretary on the
5 types of problems and inquiries encountered by con6 sumers. The Secretary shall utilize such data to identify
7 areas where more enforcement action is necessary and
8 shall share such information with State insurance regu9 lators, the Secretary of Labor, and the Secretary of the
10 Treasury for use in the enforcement activities of such
11 agencies.
12
13
‘‘(e) FUNDING.—
‘‘(1) INITIAL
FUNDING.—There
is hereby ap-
14
propriated to the Secretary, out of any funds in the
15
Treasury not otherwise appropriated, $30,000,000
16
for the first fiscal year for which this section applies
17
to carry out this section. Such amount shall remain
18
available without fiscal year limitation.
19
‘‘(2)
AUTHORIZATION
FOR
SUBSEQUENT
20
YEARS.—There
21
the Secretary for each fiscal year following the fiscal
22
year described in paragraph (1), such sums as may
23
be necessary to carry out this section.’’.
is authorized to be appropriated to
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1
SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR
2
3
THEIR DOLLARS.
Part C of title XXVII of the Public Health Service
4 Act (42 U.S.C. 300gg-91 et seq.), as amended by section
5 1002, is further amended by adding at the end the fol6 lowing:
7
8
9
10
‘‘SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR
THEIR DOLLARS.
‘‘(a) INITIAL PREMIUM REVIEW PROCESS.—
‘‘(1) IN
GENERAL.—The
Secretary, in conjunc-
11
tion with States, shall establish a process for the an-
12
nual review, beginning with the 2010 plan year and
13
subject to subsection (b)(2)(A), of unreasonable in-
14
creases in premiums for health insurance coverage.
15
‘‘(2) JUSTIFICATION
AND DISCLOSURE.—The
16
process established under paragraph (1) shall re-
17
quire health insurance issuers to submit to the Sec-
18
retary and the relevant State a justification for an
19
unreasonable premium increase prior to the imple-
20
mentation of the increase. Such issuers shall promi-
21
nently post such information on their Internet
22
websites. The Secretary shall ensure the public dis-
23
closure of information on such increases and jus-
24
tifications for all health insurance issuers.
25
‘‘(b) CONTINUING PREMIUM REVIEW PROCESS.—
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1
‘‘(1) INFORMING
SECRETARY OF PREMIUM IN-
2
CREASE PATTERNS.—As
3
grant under subsection (c)(1), a State, through its
4
Commissioner of Insurance, shall—
a condition of receiving a
5
‘‘(A) provide the Secretary with informa-
6
tion about trends in premium increases in
7
health insurance coverage in premium rating
8
areas in the State; and
9
‘‘(B) make recommendations, as appro-
10
priate, to the State Exchange about whether
11
particular health insurance issuers should be
12
excluded from participation in the Exchange
13
based on a pattern or practice of excessive or
14
unjustified premium increases.
15
‘‘(2) MONITORING
16
17
BY SECRETARY OF PREMIUM
INCREASES.—
‘‘(A) IN
GENERAL.—Beginning
with plan
18
years beginning in 2014, the Secretary, in con-
19
junction with the States and consistent with the
20
provisions of subsection (a)(2), shall monitor
21
premium increases of health insurance coverage
22
offered through an Exchange and outside of an
23
Exchange.
24
25
‘‘(B) CONSIDERATION
CHANGE.—In
determining
IN
OPENING
under
EX-
section
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1
1312(f)(2)(B) of the Patient Protection and Af-
2
fordable Care Act whether to offer qualified
3
health plans in the large group market through
4
an Exchange, the State shall take into account
5
any excess of premium growth outside of the
6
Exchange as compared to the rate of such
7
growth inside the Exchange.
8
9
‘‘(c) GRANTS IN SUPPORT OF PROCESS.—
‘‘(1) PREMIUM
REVIEW GRANTS DURING 2010
10
THROUGH 2014.—The
11
program to award grants to States during the 5-year
12
period beginning with fiscal year 2010 to assist such
13
States in carrying out subsection (a), including—
Secretary shall carry out a
14
‘‘(A) in reviewing and, if appropriate under
15
State law, approving premium increases for
16
health insurance coverage; and
17
‘‘(B) in providing information and rec-
18
ommendations to the Secretary under sub-
19
section (b)(1).
20
‘‘(2) FUNDING.—
21
‘‘(A) IN
GENERAL.—Out
of all funds in the
22
Treasury not otherwise appropriated, there are
23
appropriated to the Secretary $250,000,000, to
24
be available for expenditure for grants under
25
paragraph (1) and subparagraph (B).
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1
‘‘(B) FURTHER
AVAILABILITY FOR INSUR-
2
ANCE REFORM AND CONSUMER PROTECTION.—
3
If the amounts appropriated under subpara-
4
graph (A) are not fully obligated under grants
5
under paragraph (1) by the end of fiscal year
6
2014, any remaining funds shall remain avail-
7
able to the Secretary for grants to States for
8
planning and implementing the insurance re-
9
forms and consumer protections under part A.
10
‘‘(C) ALLOCATION.—The Secretary shall
11
establish a formula for determining the amount
12
of any grant to a State under this subsection.
13
Under such formula—
14
‘‘(i) the Secretary shall consider the
15
number of plans of health insurance cov-
16
erage offered in each State and the popu-
17
lation of the State; and
18
‘‘(ii) no State qualifying for a grant
19
under paragraph (1) shall receive less than
20
$1,000,000, or more than $5,000,000 for a
21
grant year.’’.
22
23
SEC. 1004. EFFECTIVE DATES.
(a) IN GENERAL.—Except as provided for in sub-
24 section (b), this subtitle (and the amendments made by
25 this subtitle) shall become effective for plan years begin-
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41
1 ning on or after the date that is 6 months after the date
2 of enactment of this Act, except that the amendments
3 made by sections 1002 and 1003 shall become effective
4 for fiscal years beginning with fiscal year 2010.
5
(b) SPECIAL RULE.—The amendments made by sec-
6 tions 1002 and 1003 shall take effect on the date of enact7 ment of this Act.
8
9
Subtitle B—Immediate Actions to
Preserve and Expand Coverage
10
SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNIN-
11
SURED INDIVIDUALS WITH A PREEXISTING
12
CONDITION.
13
(a) IN GENERAL.—Not later than 90 days after the
14 date of enactment of this Act, the Secretary shall establish
15 a temporary high risk health insurance pool program to
16 provide health insurance coverage for eligible individuals
17 during the period beginning on the date on which such
18 program is established and ending on January 1, 2014.
19
20
(b) ADMINISTRATION.—
(1) IN
GENERAL.—The
Secretary may carry out
21
the program under this section directly or through
22
contracts to eligible entities.
23
24
25
(2) ELIGIBLE
ENTITIES.—To
be eligible for a
contract under paragraph (1), an entity shall—
(A) be a State or nonprofit private entity;
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1
(B) submit to the Secretary an application
2
at such time, in such manner, and containing
3
such information as the Secretary may require;
4
and
5
(C) agree to utilize contract funding to es-
6
tablish and administer a qualified high risk pool
7
for eligible individuals.
8
(3) MAINTENANCE
OF EFFORT.—To
be eligible
9
to enter into a contract with the Secretary under
10
this subsection, a State shall agree not to reduce the
11
annual amount the State expended for the operation
12
of one or more State high risk pools during the year
13
preceding the year in which such contract is entered
14
into.
15
(c) QUALIFIED HIGH RISK POOL.—
16
(1) IN
GENERAL.—Amounts
made available
17
under this section shall be used to establish a quali-
18
fied high risk pool that meets the requirements of
19
paragraph (2).
20
(2) REQUIREMENTS.—A qualified high risk pool
21
meets the requirements of this paragraph if such
22
pool—
23
(A) provides to all eligible individuals
24
health insurance coverage that does not impose
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1
any preexisting condition exclusion with respect
2
to such coverage;
3
(B) provides health insurance coverage—
4
(i) in which the issuer’s share of the
5
total allowed costs of benefits provided
6
under such coverage is not less than 65
7
percent of such costs; and
8
(ii) that has an out of pocket limit not
9
greater than the applicable amount de-
10
scribed in section 223(c)(2) of the Internal
11
Revenue Code of 1986 for the year in-
12
volved, except that the Secretary may mod-
13
ify such limit if necessary to ensure the
14
pool meets the actuarial value limit under
15
clause (i);
16
(C) ensures that with respect to the pre-
17
mium rate charged for health insurance cov-
18
erage offered to eligible individuals through the
19
high risk pool, such rate shall—
20
(i) except as provided in clause (ii),
21
vary only as provided for under section
22
2701 of the Public Health Service Act (as
23
amended by this Act and notwithstanding
24
the date on which such amendments take
25
effect);
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1
(ii) vary on the basis of age by a fac-
2
tor of not greater than 4 to 1; and
3
(iii) be established at a standard rate
4
for a standard population; and
5
(D) meets any other requirements deter-
6
7
mined appropriate by the Secretary.
(d) ELIGIBLE INDIVIDUAL.—An individual shall be
8 deemed to be an eligible individual for purposes of this
9 section if such individual—
10
(1) is a citizen or national of the United States
11
or is lawfully present in the United States (as deter-
12
mined in accordance with section 1411);
13
(2) has not been covered under creditable cov-
14
erage (as defined in section 2701(c)(1) of the Public
15
Health Service Act as in effect on the date of enact-
16
ment of this Act) during the 6-month period prior
17
to the date on which such individual is applying for
18
coverage through the high risk pool; and
19
(3) has a pre-existing condition, as determined
20
in a manner consistent with guidance issued by the
21
Secretary.
22
(e) PROTECTION AGAINST DUMPING RISK
23
24
25
BY INSUR-
ERS.—
(1) IN
GENERAL.—The
Secretary shall establish
criteria for determining whether health insurance
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1
issuers and employment-based health plans have dis-
2
couraged an individual from remaining enrolled in
3
prior coverage based on that individual’s health sta-
4
tus.
5
(2) SANCTIONS.—An issuer or employment-
6
based health plan shall be responsible for reimburs-
7
ing the program under this section for the medical
8
expenses incurred by the program for an individual
9
who, based on criteria established by the Secretary,
10
the Secretary finds was encouraged by the issuer to
11
disenroll from health benefits coverage prior to en-
12
rolling in coverage through the program. The cri-
13
teria shall include at least the following cir-
14
cumstances:
15
(A) In the case of prior coverage obtained
16
through an employer, the provision by the em-
17
ployer, group health plan, or the issuer of
18
money or other financial consideration for
19
disenrolling from the coverage.
20
(B) In the case of prior coverage obtained
21
directly from an issuer or under an employ-
22
ment-based health plan—
23
(i) the provision by the issuer or plan
24
of money or other financial consideration
25
for disenrolling from the coverage; or
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1
(ii) in the case of an individual whose
2
premium for the prior coverage exceeded
3
the premium required by the program (ad-
4
justed based on the age factors applied to
5
the prior coverage)—
6
(I) the prior coverage is a policy
7
that is no longer being actively mar-
8
keted (as defined by the Secretary) by
9
the issuer; or
10
(II) the prior coverage is a policy
11
for which duration of coverage form
12
issue or health status are factors that
13
can be considered in determining pre-
14
miums at renewal.
15
(3) CONSTRUCTION.—Nothing in this sub-
16
section shall be construed as constituting exclusive
17
remedies for violations of criteria established under
18
paragraph (1) or as preventing States from applying
19
or enforcing such paragraph or other provisions
20
under law with respect to health insurance issuers.
21
(f) OVERSIGHT.—The Secretary shall establish—
22
23
24
25
(1) an appeals process to enable individuals to
appeal a determination under this section; and
(2) procedures to protect against waste, fraud,
and abuse.
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1
2
(g) FUNDING; TERMINATION OF AUTHORITY.—
(1) IN
GENERAL.—There
is appropriated to the
3
Secretary, out of any moneys in the Treasury not
4
otherwise appropriated, $5,000,000,000 to pay
5
claims against (and the administrative costs of) the
6
high risk pool under this section that are in excess
7
of the amount of premiums collected from eligible in-
8
dividuals enrolled in the high risk pool. Such funds
9
shall be available without fiscal year limitation.
10
(2) INSUFFICIENT
FUNDS.—If
the Secretary es-
11
timates for any fiscal year that the aggregate
12
amounts available for the payment of the expenses
13
of the high risk pool will be less than the actual
14
amount of such expenses, the Secretary shall make
15
such adjustments as are necessary to eliminate such
16
deficit.
17
(3) TERMINATION
18
(A) IN
OF AUTHORITY.—
GENERAL.—Except
as provided in
19
subparagraph (B), coverage of eligible individ-
20
uals under a high risk pool in a State shall ter-
21
minate on January 1, 2014.
22
(B)
TRANSITION
TO
EXCHANGE.—The
23
Secretary shall develop procedures to provide
24
for the transition of eligible individuals enrolled
25
in health insurance coverage offered through a
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1
high risk pool established under this section
2
into qualified health plans offered through an
3
Exchange. Such procedures shall ensure that
4
there is no lapse in coverage with respect to the
5
individual and may extend coverage after the
6
termination of the risk pool involved, if the Sec-
7
retary determines necessary to avoid such a
8
lapse.
9
(4) LIMITATIONS.—The Secretary has the au-
10
thority to stop taking applications for participation
11
in the program under this section to comply with the
12
funding limitation provided for in paragraph (1).
13
(5) RELATION
TO STATE LAWS.—The
standards
14
established under this section shall supersede any
15
State law or regulation (other than State licensing
16
laws or State laws relating to plan solvency) with re-
17
spect to qualified high risk pools which are estab-
18
lished in accordance with this section.
19
SEC. 1102. REINSURANCE FOR EARLY RETIREES.
20
21
(a) ADMINISTRATION.—
(1) IN
GENERAL.—Not
later than 90 days after
22
the date of enactment of this Act, the Secretary
23
shall establish a temporary reinsurance program to
24
provide reimbursement to participating employment-
25
based plans for a portion of the cost of providing
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1
health insurance coverage to early retirees (and to
2
the eligible spouses, surviving spouses, and depend-
3
ents of such retirees) during the period beginning on
4
the date on which such program is established and
5
ending on January 1, 2014.
6
7
(2) REFERENCE.—In this section:
(A)
HEALTH
BENEFITS.—The
term
8
‘‘health benefits’’ means medical, surgical, hos-
9
pital, prescription drug, and such other benefits
10
as shall be determined by the Secretary, wheth-
11
er self-funded, or delivered through the pur-
12
chase of insurance or otherwise.
13
(B)
EMPLOYMENT-BASED
PLAN.—The
14
term ‘‘employment-based plan’’ means a group
15
health benefits plan that—
16
(i) is—
17
(I) maintained by one or more
18
current or former employers (includ-
19
ing without limitation any State or
20
local government or political subdivi-
21
sion thereof), employee organization, a
22
voluntary employees’ beneficiary asso-
23
ciation, or a committee or board of in-
24
dividuals appointed to administer such
25
plan; or
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1
(II) a multiemployer plan (as de-
2
fined in section 3(37) of the Employee
3
Retirement Income Security Act of
4
1974); and
5
(ii) provides health benefits to early
6
retirees.
7
(C) EARLY
RETIREES.—The
term ‘‘early
8
retirees’’ means individuals who are age 55 and
9
older but are not eligible for coverage under
10
title XVIII of the Social Security Act, and who
11
are not active employees of an employer main-
12
taining, or currently contributing to, the em-
13
ployment-based plan or of any employer that
14
has made substantial contributions to fund such
15
plan.
16
17
(b) PARTICIPATION.—
(1) EMPLOYMENT-BASED
PLAN ELIGIBILITY.—
18
A participating employment-based plan is an em-
19
ployment-based plan that—
20
(A) meets the requirements of paragraph
21
(2) with respect to health benefits provided
22
under the plan; and
23
(B) submits to the Secretary an applica-
24
tion for participation in the program, at such
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1
time, in such manner, and containing such in-
2
formation as the Secretary shall require.
3
(2) EMPLOYMENT-BASED
HEALTH BENEFITS.—
4
An employment-based plan meets the requirements
5
of this paragraph if the plan—
6
(A) implements programs and procedures
7
to generate cost-savings with respect to partici-
8
pants with chronic and high-cost conditions;
9
10
11
12
(B) provides documentation of the actual
cost of medical claims involved; and
(C) is certified by the Secretary.
(c) PAYMENTS.—
13
(1) SUBMISSION
14
(A) IN
OF CLAIMS.—
GENERAL.—A
participating employ-
15
ment-based plan shall submit claims for reim-
16
bursement to the Secretary which shall contain
17
documentation of the actual costs of the items
18
and services for which each claim is being sub-
19
mitted.
20
(B) BASIS
FOR CLAIMS.—Claims
submitted
21
under subparagraph (A) shall be based on the
22
actual amount expended by the participating
23
employment-based plan involved within the plan
24
year for the health benefits provided to an early
25
retiree or the spouse, surviving spouse, or de-
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1
pendent of such retiree. In determining the
2
amount of a claim for purposes of this sub-
3
section, the participating employment-based
4
plan shall take into account any negotiated
5
price concessions (such as discounts, direct or
6
indirect subsidies, rebates, and direct or indi-
7
rect remunerations) obtained by such plan with
8
respect to such health benefit. For purposes of
9
determining the amount of any such claim, the
10
costs paid by the early retiree or the retiree’s
11
spouse, surviving spouse, or dependent in the
12
form of deductibles, co-payments, or co-insur-
13
ance shall be included in the amounts paid by
14
the participating employment-based plan.
15
(2) PROGRAM
PAYMENTS.—If
the Secretary de-
16
termines that a participating employment-based plan
17
has submitted a valid claim under paragraph (1),
18
the Secretary shall reimburse such plan for 80 per-
19
cent of that portion of the costs attributable to such
20
claim that exceed $15,000, subject to the limits con-
21
tained in paragraph (3).
22
(3) LIMIT.—To be eligible for reimbursement
23
under the program, a claim submitted by a partici-
24
pating employment-based plan shall not be less than
25
$15,000 nor greater than $90,000. Such amounts
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1
shall be adjusted each fiscal year based on the per-
2
centage increase in the Medical Care Component of
3
the Consumer Price Index for all urban consumers
4
(rounded to the nearest multiple of $1,000) for the
5
year involved.
6
(4) USE
OF PAYMENTS.—Amounts
paid to a
7
participating employment-based plan under this sub-
8
section shall be used to lower costs for the plan.
9
Such payments may be used to reduce premium
10
costs
11
(a)(2)(B)(i) or to reduce premium contributions, co-
12
payments, deductibles, co-insurance, or other out-of-
13
pocket costs for plan participants. Such payments
14
shall not be used as general revenues for an entity
15
described in subsection (a)(2)(B)(i). The Secretary
16
shall develop a mechanism to monitor the appro-
17
priate use of such payments by such entities.
18
for
an
entity
(5) PAYMENTS
described
in
subsection
NOT TREATED AS INCOME.—
19
Payments received under this subsection shall not be
20
included in determining the gross income of an enti-
21
ty described in subsection (a)(2)(B)(i) that is main-
22
taining or currently contributing to a participating
23
employment-based plan.
24
(6) APPEALS.—The Secretary shall establish—
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1
(A) an appeals process to permit partici-
2
pating employment-based plans to appeal a de-
3
termination of the Secretary with respect to
4
claims submitted under this section; and
5
(B) procedures to protect against fraud,
6
waste, and abuse under the program.
7
(d) AUDITS.—The Secretary shall conduct annual au-
8 dits of claims data submitted by participating employ9 ment-based plans under this section to ensure that such
10 plans are in compliance with the requirements of this sec11 tion.
12
(e) FUNDING.—There is appropriated to the Sec-
13 retary, out of any moneys in the Treasury not otherwise
14 appropriated, $5,000,000,000 to carry out the program
15 under this section. Such funds shall be available without
16 fiscal year limitation.
17
(f) LIMITATION.—The Secretary has the authority to
18 stop taking applications for participation in the program
19 based on the availability of funding under subsection (e).
20
SEC. 1103. IMMEDIATE INFORMATION THAT ALLOWS CON-
21
SUMERS TO IDENTIFY AFFORDABLE COV-
22
ERAGE OPTIONS.
23
(a) INTERNET PORTAL
24 OPTIONS.—
TO
AFFORDABLE COVERAGE
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1
(1) IMMEDIATE
ESTABLISHMENT.—Not
later
2
than July 1, 2010, the Secretary, in consultation
3
with the States, shall establish a mechanism, includ-
4
ing an Internet website, through which a resident of
5
any State may identify affordable health insurance
6
coverage options in that State.
7
(2)
8
ERAGE.—An
9
paragraph (1) shall, to the extent practicable, pro-
10
vide ways for residents of any State to receive infor-
11
mation on at least the following coverage options:
CONNECTING
TO
AFFORDABLE
COV-
Internet website established under
12
(A) Health insurance coverage offered by
13
health insurance issuers, other than coverage
14
that provides reimbursement only for the treat-
15
ment or mitigation of—
16
(i) a single disease or condition; or
17
(ii) an unreasonably limited set of dis-
18
eases or conditions (as determined by the
19
Secretary);
20
(B) Medicaid coverage under title XIX of
21
22
23
the Social Security Act.
(C) Coverage under title XXI of the Social
Security Act.
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1
(D) A State health benefits high risk pool,
2
to the extent that such high risk pool is offered
3
in such State; and
4
(E) Coverage under a high risk pool under
5
6
7
8
section 1101.
(b) ENHANCING COMPARATIVE PURCHASING OPTIONS.—
(1) IN
GENERAL.—Not
later than 60 days after
9
the date of enactment of this Act, the Secretary
10
shall develop a standardized format to be used for
11
the presentation of information relating to the cov-
12
erage options described in subsection (a)(2). Such
13
format shall, at a minimum, require the inclusion of
14
information on the percentage of total premium rev-
15
enue expended on nonclinical costs (as reported
16
under section 2718(a) of the Public Health Service
17
Act), eligibility, availability, premium rates, and cost
18
sharing with respect to such coverage options and be
19
consistent with the standards adopted for the uni-
20
form explanation of coverage as provided for in sec-
21
tion 2715 of the Public Health Service Act.
22
(2) USE
OF FORMAT.—The
Secretary shall uti-
23
lize the format developed under paragraph (1) in
24
compiling information concerning coverage options
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1
on the Internet website established under subsection
2
(a).
3
(c) AUTHORITY
TO
CONTRACT.—The Secretary may
4 carry out this section through contracts entered into with
5 qualified entities.
6
7
8
SEC. 1104. ADMINISTRATIVE SIMPLIFICATION.
(a) PURPOSE
TION.—Section
OF
ADMINISTRATIVE SIMPLIFICA-
261 of the Health Insurance Portability
9 and Accountability Act of 1996 (42 U.S.C. 1320d note)
10 is amended—
11
12
(1) by inserting ‘‘uniform’’ before ‘‘standards’’;
and
13
(2) by inserting ‘‘and to reduce the clerical bur-
14
den on patients, health care providers, and health
15
plans’’ before the period at the end.
16
(b) OPERATING RULES
FOR
HEALTH INFORMATION
17 TRANSACTIONS.—
18
(1) DEFINITION
OF OPERATING RULES.—Sec-
19
tion 1171 of the Social Security Act (42 U.S.C.
20
1320d) is amended by adding at the end the fol-
21
lowing:
22
‘‘(9) OPERATING
RULES.—The
term ‘operating
23
rules’ means the necessary business rules and guide-
24
lines for the electronic exchange of information that
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1
are not defined by a standard or its implementation
2
specifications as adopted for purposes of this part.’’.
3
(2)
TRANSACTION
STANDARDS;
OPERATING
4
RULES AND COMPLIANCE.—Section
5
cial Security Act (42 U.S.C. 1320d–2) is amended—
6
(A) in subsection (a)(2), by adding at the
7
1173 of the So-
end the following new subparagraph:
8
‘‘(J) Electronic funds transfers.’’;
9
(B) in subsection (a), by adding at the end
10
the following new paragraph:
11
‘‘(4) REQUIREMENTS
12
13
FOR FINANCIAL AND AD-
MINISTRATIVE TRANSACTIONS.—
‘‘(A) IN
GENERAL.—The
standards and as-
14
sociated operating rules adopted by the Sec-
15
retary shall—
16
‘‘(i) to the extent feasible and appro-
17
priate, enable determination of an individ-
18
ual’s eligibility and financial responsibility
19
for specific services prior to or at the point
20
of care;
21
‘‘(ii)
be
comprehensive,
requiring
22
minimal augmentation by paper or other
23
communications;
24
‘‘(iii) provide for timely acknowledg-
25
ment, response, and status reporting that
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1
supports a transparent claims and denial
2
management process (including adjudica-
3
tion and appeals); and
4
‘‘(iv) describe all data elements (in-
5
cluding reason and remark codes) in un-
6
ambiguous terms, require that such data
7
elements be required or conditioned upon
8
set values in other fields, and prohibit ad-
9
ditional conditions (except where necessary
10
to implement State or Federal law, or to
11
protect against fraud and abuse).
12
‘‘(B) REDUCTION
OF
CLERICAL
BUR-
13
DEN.—In
14
rules for the transactions referred to under
15
paragraph (1), the Secretary shall seek to re-
16
duce the number and complexity of forms (in-
17
cluding paper and electronic forms) and data
18
entry required by patients and providers.’’; and
19
(C) by adding at the end the following new
20
21
22
adopting standards and operating
subsections:
‘‘(g) OPERATING RULES.—
‘‘(1) IN
GENERAL.—The
Secretary shall adopt
23
a single set of operating rules for each transaction
24
referred to under subsection (a)(1) with the goal of
25
creating as much uniformity in the implementation
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1
of the electronic standards as possible. Such oper-
2
ating rules shall be consensus-based and reflect the
3
necessary business rules affecting health plans and
4
health care providers and the manner in which they
5
operate pursuant to standards issued under Health
6
Insurance Portability and Accountability Act of
7
1996.
8
‘‘(2) OPERATING
RULES
DEVELOPMENT.—In
9
adopting operating rules under this subsection, the
10
Secretary shall consider recommendations for oper-
11
ating rules developed by a qualified nonprofit entity
12
that meets the following requirements:
13
14
‘‘(A) The entity focuses its mission on administrative simplification.
15
‘‘(B) The entity demonstrates a multi-
16
stakeholder and consensus-based process for de-
17
velopment of operating rules, including rep-
18
resentation by or participation from health
19
plans, health care providers, vendors, relevant
20
Federal agencies, and other standard develop-
21
ment organizations.
22
‘‘(C) The entity has a public set of guiding
23
principles that ensure the operating rules and
24
process are open and transparent, and supports
25
nondiscrimination and conflict of interest poli-
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1
cies that demonstrate a commitment to open,
2
fair, and nondiscriminatory practices.
3
‘‘(D) The entity builds on the transaction
4
standards issued under Health Insurance Port-
5
ability and Accountability Act of 1996.
6
‘‘(E) The entity allows for public review
7
and updates of the operating rules.
8
‘‘(3) REVIEW
9
10
AND RECOMMENDATIONS.—The
National Committee on Vital and Health Statistics
shall—
11
‘‘(A) advise the Secretary as to whether a
12
nonprofit entity meets the requirements under
13
paragraph (2);
14
15
‘‘(B) review the operating rules developed
and recommended by such nonprofit entity;
16
‘‘(C) determine whether such operating
17
rules represent a consensus view of the health
18
care stakeholders and are consistent with and
19
do not conflict with other existing standards;
20
‘‘(D) evaluate whether such operating rules
21
are consistent with electronic standards adopted
22
for health information technology; and
23
‘‘(E) submit to the Secretary a rec-
24
ommendation as to whether the Secretary
25
should adopt such operating rules.
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1
2
‘‘(4) IMPLEMENTATION.—
‘‘(A) IN
GENERAL.—The
Secretary shall
3
adopt operating rules under this subsection, by
4
regulation in accordance with subparagraph
5
(C), following consideration of the operating
6
rules developed by the non-profit entity de-
7
scribed in paragraph (2) and the recommenda-
8
tion submitted by the National Committee on
9
Vital and Health Statistics under paragraph
10
(3)(E) and having ensured consultation with
11
providers.
12
13
14
‘‘(B) ADOPTION
REQUIREMENTS; EFFEC-
TIVE DATES.—
‘‘(i) ELIGIBILITY
FOR
A
HEALTH
15
PLAN AND HEALTH CLAIM STATUS.—The
16
set of operating rules for eligibility for a
17
health plan and health claim status trans-
18
actions shall be adopted not later than
19
July 1, 2011, in a manner ensuring that
20
such operating rules are effective not later
21
than January 1, 2013, and may allow for
22
the use of a machine readable identifica-
23
tion card.
24
25
‘‘(ii) ELECTRONIC
FUNDS TRANSFERS
AND HEALTH CARE PAYMENT AND REMIT-
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1
TANCE
2
rules for electronic funds transfers and
3
health care payment and remittance advice
4
transactions shall—
ADVICE.—The
set of operating
5
‘‘(I) allow for automated rec-
6
onciliation of the electronic payment
7
with the remittance advice; and
8
‘‘(II) be adopted not later than
9
July 1, 2012, in a manner ensuring
10
that such operating rules are effective
11
not later than January 1, 2014.
12
‘‘(iii) HEALTH
CLAIMS OR EQUIVA-
13
LENT ENCOUNTER INFORMATION, ENROLL-
14
MENT AND DISENROLLMENT IN A HEALTH
15
PLAN, HEALTH PLAN PREMIUM PAYMENTS,
16
REFERRAL CERTIFICATION AND AUTHOR-
17
IZATION.—The
18
health claims or equivalent encounter in-
19
formation, enrollment and disenrollment in
20
a health plan, health plan premium pay-
21
ments, and referral certification and au-
22
thorization transactions shall be adopted
23
not later than July 1, 2014, in a manner
24
ensuring that such operating rules are ef-
25
fective not later than January 1, 2016.
set of operating rules for
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1
‘‘(C) EXPEDITED
RULEMAKING.—The
Sec-
2
retary shall promulgate an interim final rule
3
applying any standard or operating rule rec-
4
ommended by the National Committee on Vital
5
and Health Statistics pursuant to paragraph
6
(3). The Secretary shall accept and consider
7
public comments on any interim final rule pub-
8
lished under this subparagraph for 60 days
9
after the date of such publication.
10
11
12
‘‘(h) COMPLIANCE.—
‘‘(1) HEALTH
PLAN CERTIFICATION.—
‘‘(A) ELIGIBILITY
FOR A HEALTH PLAN,
13
HEALTH CLAIM STATUS, ELECTRONIC FUNDS
14
TRANSFERS, HEALTH CARE PAYMENT AND RE-
15
MITTANCE ADVICE.—Not
16
31, 2013, a health plan shall file a statement
17
with the Secretary, in such form as the Sec-
18
retary may require, certifying that the data and
19
information systems for such plan are in com-
20
pliance with any applicable standards (as de-
21
scribed under paragraph (7) of section 1171)
22
and associated operating rules (as described
23
under paragraph (9) of such section) for elec-
24
tronic funds transfers, eligibility for a health
later than December
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1
plan, health claim status, and health care pay-
2
ment and remittance advice, respectively.
3
‘‘(B) HEALTH
CLAIMS
OR
EQUIVALENT
4
ENCOUNTER INFORMATION, ENROLLMENT AND
5
DISENROLLMENT IN A HEALTH PLAN, HEALTH
6
PLAN PREMIUM PAYMENTS, HEALTH CLAIMS
7
ATTACHMENTS, REFERRAL CERTIFICATION AND
8
AUTHORIZATION.—Not
9
2015, a health plan shall file a statement with
10
the Secretary, in such form as the Secretary
11
may require, certifying that the data and infor-
12
mation systems for such plan are in compliance
13
with any applicable standards and associated
14
operating rules for health claims or equivalent
15
encounter
16
disenrollment in a health plan, health plan pre-
17
mium payments, health claims attachments,
18
and referral certification and authorization, re-
19
spectively. A health plan shall provide the same
20
level of documentation to certify compliance
21
with such transactions as is required to certify
22
compliance with the transactions specified in
23
subparagraph (A).
24
‘‘(2) DOCUMENTATION
25
later than December 31,
information,
enrollment
OF
and
COMPLIANCE.—A
health plan shall provide the Secretary, in such form
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1
as the Secretary may require, with adequate docu-
2
mentation of compliance with the standards and op-
3
erating rules described under paragraph (1). A
4
health plan shall not be considered to have provided
5
adequate documentation and shall not be certified as
6
being in compliance with such standards, unless the
7
health plan—
8
‘‘(A) demonstrates to the Secretary that
9
the plan conducts the electronic transactions
10
specified in paragraph (1) in a manner that
11
fully complies with the regulations of the Sec-
12
retary; and
13
‘‘(B) provides documentation showing that
14
the plan has completed end-to-end testing for
15
such transactions with their partners, such as
16
hospitals and physicians.
17
‘‘(3) SERVICE
CONTRACTS.—A
health plan shall
18
be required to ensure that any entities that provide
19
services pursuant to a contract with such health
20
plan shall comply with any applicable certification
21
and compliance requirements (and provide the Sec-
22
retary with adequate documentation of such compli-
23
ance) under this subsection.
24
25
‘‘(4) CERTIFICATION
BY OUTSIDE ENTITY.—
The Secretary may designate independent, outside
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1
entities to certify that a health plan has complied
2
with the requirements under this subsection, pro-
3
vided that the certification standards employed by
4
such entities are in accordance with any standards
5
or operating rules issued by the Secretary.
6
‘‘(5) COMPLIANCE
WITH REVISED STANDARDS
7
AND OPERATING RULES.—
8
‘‘(A) IN
GENERAL.—A
health plan (includ-
9
ing entities described under paragraph (3))
10
shall file a statement with the Secretary, in
11
such form as the Secretary may require, certi-
12
fying that the data and information systems for
13
such plan are in compliance with any applicable
14
revised standards and associated operating
15
rules under this subsection for any interim final
16
rule promulgated by the Secretary under sub-
17
section (i) that—
18
‘‘(i) amends any standard or oper-
19
ating rule described under paragraph (1)
20
of this subsection; or
21
‘‘(ii) establishes a standard (as de-
22
scribed under subsection (a)(1)(B)) or as-
23
sociated operating rules (as described
24
under subsection (i)(5)) for any other fi-
25
nancial and administrative transactions.
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1
‘‘(B) DATE
OF COMPLIANCE.—A
health
2
plan shall comply with such requirements not
3
later than the effective date of the applicable
4
standard or operating rule.
5
‘‘(6) AUDITS
OF HEALTH PLANS.—The
Sec-
6
retary shall conduct periodic audits to ensure that
7
health plans (including entities described under
8
paragraph (3)) are in compliance with any standards
9
and operating rules that are described under para-
10
graph (1) or subsection (i)(5).
11
‘‘(i) REVIEW
AND
AMENDMENT
OF
STANDARDS
AND
12 OPERATING RULES.—
13
‘‘(1) ESTABLISHMENT.—Not later than Janu-
14
ary 1, 2014, the Secretary shall establish a review
15
committee (as described under paragraph (4)).
16
‘‘(2) EVALUATIONS
AND REPORTS.—
17
‘‘(A) HEARINGS.—Not later than April 1,
18
2014, and not less than biennially thereafter,
19
the Secretary, acting through the review com-
20
mittee, shall conduct hearings to evaluate and
21
review the adopted standards and operating
22
rules established under this section.
23
‘‘(B) REPORT.—Not later than July 1,
24
2014, and not less than biennially thereafter,
25
the
review
committee
shall
provide
rec-
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1
ommendations for updating and improving such
2
standards and operating rules. The review com-
3
mittee shall recommend a single set of oper-
4
ating rules per transaction standard and main-
5
tain the goal of creating as much uniformity as
6
possible in the implementation of the electronic
7
standards.
8
‘‘(3) INTERIM
9
‘‘(A) IN
FINAL RULEMAKING.—
GENERAL.—Any
recommendations
10
to amend adopted standards and operating
11
rules that have been approved by the review
12
committee and reported to the Secretary under
13
paragraph (2)(B) shall be adopted by the Sec-
14
retary through promulgation of an interim final
15
rule not later than 90 days after receipt of the
16
committee’s report.
17
18
‘‘(B) PUBLIC
COMMENT.—
‘‘(i) PUBLIC
COMMENT PERIOD.—The
19
Secretary shall accept and consider public
20
comments on any interim final rule pub-
21
lished under this paragraph for 60 days
22
after the date of such publication.
23
‘‘(ii) EFFECTIVE
DATE.—The
effective
24
date of any amendment to existing stand-
25
ards or operating rules that is adopted
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1
through an interim final rule published
2
under this paragraph shall be 25 months
3
following the close of such public comment
4
period.
5
‘‘(4) REVIEW
COMMITTEE.—
6
‘‘(A) DEFINITION.—For the purposes of
7
this subsection, the term ‘review committee’
8
means a committee chartered by or within the
9
Department of Health and Human services that
10
has been designated by the Secretary to carry
11
out this subsection, including—
12
13
‘‘(i) the National Committee on Vital
and Health Statistics; or
14
‘‘(ii) any appropriate committee as de-
15
termined by the Secretary.
16
‘‘(B)
COORDINATION
OF
HIT
STAND-
17
ARDS.—In
18
this subsection, the review committee shall en-
19
sure coordination, as appropriate, with the
20
standards that support the certified electronic
21
health record technology approved by the Office
22
of the National Coordinator for Health Infor-
23
mation Technology.
24
‘‘(5) OPERATING
25
developing recommendations under
RULES FOR OTHER STAND-
ARDS ADOPTED BY THE SECRETARY.—The
Secretary
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1
shall adopt a single set of operating rules (pursuant
2
to the process described under subsection (g)) for
3
any transaction for which a standard had been
4
adopted pursuant to subsection (a)(1)(B).
5
‘‘(j) PENALTIES.—
6
‘‘(1) PENALTY
7
‘‘(A) IN
FEE.—
GENERAL.—Not
later than April
8
1, 2014, and annually thereafter, the Secretary
9
shall assess a penalty fee (as determined under
10
subparagraph (B)) against a health plan that
11
has failed to meet the requirements under sub-
12
section (h) with respect to certification and doc-
13
umentation of compliance with—
14
‘‘(i) the standards and associated op-
15
erating rules described under paragraph
16
(1) of such subsection; and
17
‘‘(ii) a standard (as described under
18
subsection (a)(1)(B)) and associated oper-
19
ating rules (as described under subsection
20
(i)(5)) for any other financial and adminis-
21
trative transactions.
22
‘‘(B) FEE
AMOUNT.—Subject
to subpara-
23
graphs (C), (D), and (E), the Secretary shall
24
assess a penalty fee against a health plan in the
25
amount of $1 per covered life until certification
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1
is complete. The penalty shall be assessed per
2
person covered by the plan for which its data
3
systems for major medical policies are not in
4
compliance and shall be imposed against the
5
health plan for each day that the plan is not in
6
compliance with the requirements under sub-
7
section (h).
8
9
‘‘(C) ADDITIONAL
REPRESENTATION.—A
PENALTY
FOR
MIS-
health plan that know-
10
ingly provides inaccurate or incomplete informa-
11
tion in a statement of certification or docu-
12
mentation of compliance under subsection (h)
13
shall be subject to a penalty fee that is double
14
the amount that would otherwise be imposed
15
under this subsection.
16
‘‘(D)
ANNUAL
FEE
INCREASE.—The
17
amount of the penalty fee imposed under this
18
subsection shall be increased on an annual basis
19
by the annual percentage increase in total na-
20
tional health care expenditures, as determined
21
by the Secretary.
22
‘‘(E) PENALTY
LIMIT.—A
penalty fee as-
23
sessed against a health plan under this sub-
24
section shall not exceed, on an annual basis—
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1
2
‘‘(i) an amount equal to $20 per covered life under such plan; or
3
‘‘(ii) an amount equal to $40 per cov-
4
ered life under the plan if such plan has
5
knowingly provided inaccurate or incom-
6
plete information (as described under sub-
7
paragraph (C)).
8
‘‘(F) DETERMINATION
9
VIDUALS.—The
OF COVERED INDI-
Secretary shall determine the
10
number of covered lives under a health plan
11
based upon the most recent statements and fil-
12
ings that have been submitted by such plan to
13
the Securities and Exchange Commission.
14
‘‘(2) NOTICE
AND DISPUTE PROCEDURE.—The
15
Secretary shall establish a procedure for assessment
16
of penalty fees under this subsection that provides a
17
health plan with reasonable notice and a dispute res-
18
olution procedure prior to provision of a notice of as-
19
sessment by the Secretary of the Treasury (as de-
20
scribed under paragraph (4)(B)).
21
‘‘(3) PENALTY
FEE REPORT.—Not
later than
22
May 1, 2014, and annually thereafter, the Secretary
23
shall provide the Secretary of the Treasury with a
24
report identifying those health plans that have been
25
assessed a penalty fee under this subsection.
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1
‘‘(4) COLLECTION
2
‘‘(A) IN
OF PENALTY FEE.—
GENERAL.—The
Secretary of the
3
Treasury, acting through the Financial Man-
4
agement Service, shall administer the collection
5
of penalty fees from health plans that have been
6
identified by the Secretary in the penalty fee re-
7
port provided under paragraph (3).
8
‘‘(B) NOTICE.—Not later than August 1,
9
2014, and annually thereafter, the Secretary of
10
the Treasury shall provide notice to each health
11
plan that has been assessed a penalty fee by the
12
Secretary under this subsection. Such notice
13
shall include the amount of the penalty fee as-
14
sessed by the Secretary and the due date for
15
payment of such fee to the Secretary of the
16
Treasury (as described in subparagraph (C)).
17
‘‘(C) PAYMENT
DUE DATE.—Payment
by a
18
health plan for a penalty fee assessed under
19
this subsection shall be made to the Secretary
20
of the Treasury not later than November 1,
21
2014, and annually thereafter.
22
‘‘(D)
UNPAID
PENALTY
FEES.—Any
23
amount of a penalty fee assessed against a
24
health plan under this subsection for which pay-
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1
ment has not been made by the due date pro-
2
vided under subparagraph (C) shall be—
3
‘‘(i) increased by the interest accrued
4
on such amount, as determined pursuant
5
to the underpayment rate established
6
under section 6621 of the Internal Rev-
7
enue Code of 1986; and
8
‘‘(ii) treated as a past-due, legally en-
9
forceable debt owed to a Federal agency
10
for purposes of section 6402(d) of the In-
11
ternal Revenue Code of 1986.
12
‘‘(E) ADMINISTRATIVE
FEES.—Any
fee
13
charged or allocated for collection activities con-
14
ducted by the Financial Management Service
15
will be passed on to a health plan on a pro-rata
16
basis and added to any penalty fee collected
17
from the plan.’’.
18
19
(c) PROMULGATION OF RULES.—
(1) UNIQUE
HEALTH PLAN IDENTIFIER.—The
20
Secretary shall promulgate a final rule to establish
21
a unique health plan identifier (as described in sec-
22
tion 1173(b) of the Social Security Act (42 U.S.C.
23
1320d-2(b))) based on the input of the National
24
Committee on Vital and Health Statistics. The Sec-
25
retary may do so on an interim final basis and such
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1
rule shall be effective not later than October 1,
2
2012.
3
(2) ELECTRONIC
FUNDS TRANSFER.—The
Sec-
4
retary shall promulgate a final rule to establish a
5
standard for electronic funds transfers (as described
6
in section 1173(a)(2)(J) of the Social Security Act,
7
as added by subsection (b)(2)(A)). The Secretary
8
may do so on an interim final basis and shall adopt
9
such standard not later than January 1, 2012, in a
10
manner ensuring that such standard is effective not
11
later than January 1, 2014.
12
(3) HEALTH
CLAIMS ATTACHMENTS.—The
Sec-
13
retary shall promulgate a final rule to establish a
14
transaction standard and a single set of associated
15
operating rules for health claims attachments (as de-
16
scribed in section 1173(a)(2)(B) of the Social Secu-
17
rity Act (42 U.S.C. 1320d-2(a)(2)(B))) that is con-
18
sistent with the X12 Version 5010 transaction
19
standards. The Secretary may do so on an interim
20
final basis and shall adopt a transaction standard
21
and a single set of associated operating rules not
22
later than January 1, 2014, in a manner ensuring
23
that such standard is effective not later than Janu-
24
ary 1, 2016.
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1
(d) EXPANSION
OF
ELECTRONIC TRANSACTIONS
IN
2 MEDICARE.—Section 1862(a) of the Social Security Act
3 (42 U.S.C. 1395y(a)) is amended—
4
5
6
7
8
9
(1) in paragraph (23), by striking the ‘‘or’’ at
the end;
(2) in paragraph (24), by striking the period
and inserting ‘‘; or’’; and
(3) by inserting after paragraph (24) the following new paragraph:
10
‘‘(25) not later than January 1, 2014, for
11
which the payment is other than by electronic funds
12
transfer (EFT) or an electronic remittance in a form
13
as specified in ASC X12 835 Health Care Payment
14
and Remittance Advice or subsequent standard.’’.
15
16
SEC. 1105. EFFECTIVE DATE.
This subtitle shall take effect on the date of enact-
17 ment of this Act.
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1
2
3
Subtitle C—Quality Health Insurance Coverage for All Americans
4 PART I—HEALTH INSURANCE MARKET REFORMS
5
6
7
SEC. 1201. AMENDMENT TO THE PUBLIC HEALTH SERVICE
ACT.
Part A of title XXVII of the Public Health Service
8 Act (42 U.S.C. 300gg et seq.), as amended by section
9 1001, is further amended—
10
11
12
(1) by striking the heading for subpart 1 and
inserting the following:
‘‘Subpart I—General Reform’’;
13
(2)(A) in section 2701 (42 U.S.C. 300gg), by
14
striking the section heading and subsection (a) and
15
inserting the following:
16
‘‘SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EX-
17
CLUSIONS
18
BASED ON HEALTH STATUS.
19
OR
OTHER
DISCRIMINATION
‘‘(a) IN GENERAL.—A group health plan and a health
20 insurance issuer offering group or individual health insur21 ance coverage may not impose any preexisting condition
22 exclusion with respect to such plan or coverage.’’; and
23
(B) by transferring such section (as amended
24
by subparagraph (A)) so as to appear after the sec-
25
tion 2703 added by paragraph (4);
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1
(3)(A) in section 2702 (42 U.S.C. 300gg-1)—
2
(i) by striking the section heading and all
3
4
that follows through subsection (a);
(ii) in subsection (b)—
5
(I) by striking ‘‘health insurance
6
issuer offering health insurance coverage in
7
connection with a group health plan’’ each
8
place that such appears and inserting
9
‘‘health insurance issuer offering group or
10
individual health insurance coverage’’; and
11
12
13
(II) in paragraph (2)(A)—
(aa) by inserting ‘‘or individual’’
after ‘‘employer’’; and
14
(bb) by inserting ‘‘or individual
15
health coverage, as the case may be’’
16
before the semicolon; and
17
18
19
20
21
22
23
(iii) in subsection (e)—
(I) by striking ‘‘(a)(1)(F)’’ and inserting ‘‘(a)(6)’’;
(II) by striking ‘‘2701’’ and inserting
‘‘2704’’; and
(III) by striking ‘‘2721(a)’’ and inserting ‘‘2735(a)’’; and
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1
(B) by transferring such section (as
2
amended by subparagraph (A)) to appear after
3
section 2705(a) as added by paragraph (4); and
4
(4) by inserting after the subpart heading (as
5
added by paragraph (1)) the following:
6
‘‘SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS.
7
‘‘(a)
PROHIBITING
DISCRIMINATORY
PREMIUM
8 RATES.—
9
‘‘(1) IN
GENERAL.—With
respect to the pre-
10
mium rate charged by a health insurance issuer for
11
health insurance coverage offered in the individual
12
or small group market—
13
‘‘(A) such rate shall vary with respect to
14
the particular plan or coverage involved only
15
by—
16
17
‘‘(i) whether such plan or coverage
covers an individual or family;
18
19
‘‘(ii) rating area, as established in accordance with paragraph (2);
20
‘‘(iii) age, except that such rate shall
21
not vary by more than 3 to 1 for adults
22
(consistent with section 2707(c)); and
23
‘‘(iv) tobacco use, except that such
24
rate shall not vary by more than 1.5 to 1;
25
and
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1
‘‘(B) such rate shall not vary with respect
2
to the particular plan or coverage involved by
3
any other factor not described in subparagraph
4
(A).
5
‘‘(2) RATING
6
‘‘(A) IN
AREA.—
GENERAL.—Each
State shall es-
7
tablish 1 or more rating areas within that State
8
for purposes of applying the requirements of
9
this title.
10
‘‘(B) SECRETARIAL
REVIEW.—The
Sec-
11
retary shall review the rating areas established
12
by each State under subparagraph (A) to en-
13
sure the adequacy of such areas for purposes of
14
carrying out the requirements of this title. If
15
the Secretary determines a State’s rating areas
16
are not adequate, or that a State does not es-
17
tablish such areas, the Secretary may establish
18
rating areas for that State.
19
‘‘(3) PERMISSIBLE
AGE
BANDS.—The
Sec-
20
retary, in consultation with the National Association
21
of Insurance Commissioners, shall define the permis-
22
sible age bands for rating purposes under paragraph
23
(1)(A)(iii).
24
25
‘‘(4) APPLICATION
OF VARIATIONS BASED ON
AGE OR TOBACCO USE.—With
respect to family cov-
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1
erage under a group health plan or health insurance
2
coverage, the rating variations permitted under
3
clauses (iii) and (iv) of paragraph (1)(A) shall be
4
applied based on the portion of the premium that is
5
attributable to each family member covered under
6
the plan or coverage.
7
‘‘(5) SPECIAL
RULE FOR LARGE GROUP MAR-
8
KET.—If
9
that offer coverage in the large group market in the
10
State to offer such coverage through the State Ex-
11
change (as provided for under section 1312(f)(2)(B)
12
of the Patient Protection and Affordable Care Act),
13
the provisions of this subsection shall apply to all
14
coverage offered in such market in the State.
15
‘‘SEC. 2702. GUARANTEED AVAILABILITY OF COVERAGE.
16
a State permits health insurance issuers
‘‘(a) GUARANTEED ISSUANCE
17 INDIVIDUAL
AND
OF
COVERAGE
IN THE
GROUP MARKET.—Subject to sub-
18 sections (b) through (e), each health insurance issuer that
19 offers health insurance coverage in the individual or group
20 market in a State must accept every employer and indi21 vidual in the State that applies for such coverage.
22
‘‘(b) ENROLLMENT.—
23
‘‘(1) RESTRICTION.—A health insurance issuer
24
described in subsection (a) may restrict enrollment
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1
in coverage described in such subsection to open or
2
special enrollment periods.
3
‘‘(2) ESTABLISHMENT.—A health insurance
4
issuer described in subsection (a) shall, in accord-
5
ance with the regulations promulgated under para-
6
graph (3), establish special enrollment periods for
7
qualifying events (under section 603 of the Em-
8
ployee Retirement Income Security Act of 1974).
9
‘‘(3) REGULATIONS.—The Secretary shall pro-
10
mulgate regulations with respect to enrollment peri-
11
ods under paragraphs (1) and (2).
12
13
‘‘SEC. 2703. GUARANTEED RENEWABILITY OF COVERAGE.
‘‘(a) IN GENERAL.—Except as provided in this sec-
14 tion, if a health insurance issuer offers health insurance
15 coverage in the individual or group market, the issuer
16 must renew or continue in force such coverage at the op17 tion of the plan sponsor or the individual, as applicable.
18
‘‘SEC. 2705. PROHIBITING DISCRIMINATION AGAINST INDI-
19
VIDUAL PARTICIPANTS AND BENEFICIARIES
20
BASED ON HEALTH STATUS.
21
‘‘(a) IN GENERAL.—A group health plan and a health
22 insurance issuer offering group or individual health insur23 ance coverage may not establish rules for eligibility (in24 cluding continued eligibility) of any individual to enroll
25 under the terms of the plan or coverage based on any of
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1 the following health status-related factors in relation to
2 the individual or a dependent of the individual:
3
‘‘(1) Health status.
4
‘‘(2) Medical condition (including both physical
5
and mental illnesses).
6
‘‘(3) Claims experience.
7
‘‘(4) Receipt of health care.
8
‘‘(5) Medical history.
9
‘‘(6) Genetic information.
10
11
‘‘(7) Evidence of insurability (including conditions arising out of acts of domestic violence).
12
‘‘(8) Disability.
13
‘‘(9) Any other health status-related factor de-
14
termined appropriate by the Secretary.
15
‘‘(j) PROGRAMS
16
17
18
EASE
OF
HEALTH PROMOTION
OR
DIS-
PREVENTION.—
‘‘(1) GENERAL
PROVISIONS.—
‘‘(A) GENERAL
RULE.—For
purposes of
19
subsection (b)(2)(B), a program of health pro-
20
motion or disease prevention (referred to in this
21
subsection as a ‘wellness program’) shall be a
22
program offered by an employer that is de-
23
signed to promote health or prevent disease
24
that meets the applicable requirements of this
25
subsection.
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1
‘‘(B) NO
CONDITIONS BASED ON HEALTH
2
STATUS FACTOR.—If
3
obtaining a premium discount or rebate or
4
other reward for participation in a wellness pro-
5
gram is based on an individual satisfying a
6
standard that is related to a health status fac-
7
tor, such wellness program shall not violate this
8
section if participation in the program is made
9
available to all similarly situated individuals
10
and the requirements of paragraph (2) are com-
11
plied with.
12
none of the conditions for
‘‘(C) CONDITIONS
BASED ON HEALTH STA-
13
TUS FACTOR.—If
14
taining a premium discount or rebate or other
15
reward for participation in a wellness program
16
is based on an individual satisfying a standard
17
that is related to a health status factor, such
18
wellness program shall not violate this section if
19
the requirements of paragraph (3) are complied
20
with.
21
‘‘(2) WELLNESS
any of the conditions for ob-
PROGRAMS NOT SUBJECT TO
22
REQUIREMENTS.—If
23
taining a premium discount or rebate or other re-
24
ward under a wellness program as described in para-
25
graph (1)(B) are based on an individual satisfying
none of the conditions for ob-
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1
a standard that is related to a health status factor
2
(or if such a wellness program does not provide such
3
a reward), the wellness program shall not violate
4
this section if participation in the program is made
5
available to all similarly situated individuals. The
6
following programs shall not have to comply with the
7
requirements of paragraph (3) if participation in the
8
program is made available to all similarly situated
9
individuals:
10
‘‘(A) A program that reimburses all or
11
part of the cost for memberships in a fitness
12
center.
13
‘‘(B) A diagnostic testing program that
14
provides a reward for participation and does
15
not base any part of the reward on outcomes.
16
‘‘(C) A program that encourages preven-
17
tive care related to a health condition through
18
the waiver of the copayment or deductible re-
19
quirement under group health plan for the costs
20
of certain items or services related to a health
21
condition (such as prenatal care or well-baby
22
visits).
23
‘‘(D) A program that reimburses individ-
24
uals for the costs of smoking cessation pro-
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1
grams without regard to whether the individual
2
quits smoking.
3
‘‘(E) A program that provides a reward to
4
individuals for attending a periodic health edu-
5
cation seminar.
6
‘‘(3) WELLNESS
PROGRAMS SUBJECT TO RE-
7
QUIREMENTS.—If
8
a premium discount, rebate, or reward under a
9
wellness program as described in paragraph (1)(C)
10
is based on an individual satisfying a standard that
11
is related to a health status factor, the wellness pro-
12
gram shall not violate this section if the following re-
13
quirements are complied with:
any of the conditions for obtaining
14
‘‘(A) The reward for the wellness program,
15
together with the reward for other wellness pro-
16
grams with respect to the plan that requires
17
satisfaction of a standard related to a health
18
status factor, shall not exceed 30 percent of the
19
cost of employee-only coverage under the plan.
20
If, in addition to employees or individuals, any
21
class of dependents (such as spouses or spouses
22
and dependent children) may participate fully
23
in the wellness program, such reward shall not
24
exceed 30 percent of the cost of the coverage in
25
which an employee or individual and any de-
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1
pendents are enrolled. For purposes of this
2
paragraph, the cost of coverage shall be deter-
3
mined based on the total amount of employer
4
and employee contributions for the benefit
5
package under which the employee is (or the
6
employee and any dependents are) receiving
7
coverage. A reward may be in the form of a dis-
8
count or rebate of a premium or contribution,
9
a waiver of all or part of a cost-sharing mecha-
10
nism (such as deductibles, copayments, or coin-
11
surance), the absence of a surcharge, or the
12
value of a benefit that would otherwise not be
13
provided under the plan. The Secretaries of
14
Labor, Health and Human Services, and the
15
Treasury may increase the reward available
16
under this subparagraph to up to 50 percent of
17
the cost of coverage if the Secretaries determine
18
that such an increase is appropriate.
19
‘‘(B) The wellness program shall be rea-
20
sonably designed to promote health or prevent
21
disease. A program complies with the preceding
22
sentence if the program has a reasonable
23
chance of improving the health of, or preventing
24
disease in, participating individuals and it is
25
not overly burdensome, is not a subterfuge for
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1
discriminating based on a health status factor,
2
and is not highly suspect in the method chosen
3
to promote health or prevent disease.
4
‘‘(C) The plan shall give individuals eligible
5
for the program the opportunity to qualify for
6
the reward under the program at least once
7
each year.
8
‘‘(D) The full reward under the wellness
9
program shall be made available to all similarly
10
situated individuals. For such purpose, among
11
other things:
12
‘‘(i) The reward is not available to all
13
similarly situated individuals for a period
14
unless the wellness program allows—
15
‘‘(I) for a reasonable alternative
16
standard (or waiver of the otherwise
17
applicable standard) for obtaining the
18
reward for any individual for whom,
19
for that period, it is unreasonably dif-
20
ficult due to a medical condition to
21
satisfy the otherwise applicable stand-
22
ard; and
23
‘‘(II) for a reasonable alternative
24
standard (or waiver of the otherwise
25
applicable standard) for obtaining the
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1
reward for any individual for whom,
2
for that period, it is medically inadvis-
3
able to attempt to satisfy the other-
4
wise applicable standard.
5
‘‘(ii) If reasonable under the cir-
6
cumstances, the plan or issuer may seek
7
verification, such as a statement from an
8
individual’s physician, that a health status
9
factor makes it unreasonably difficult or
10
medically inadvisable for the individual to
11
satisfy or attempt to satisfy the otherwise
12
applicable standard.
13
‘‘(E) The plan or issuer involved shall dis-
14
close in all plan materials describing the terms
15
of the wellness program the availability of a
16
reasonable alternative standard (or the possi-
17
bility of waiver of the otherwise applicable
18
standard) required under subparagraph (D). If
19
plan materials disclose that such a program is
20
available, without describing its terms, the dis-
21
closure under this subparagraph shall not be re-
22
quired.
23
‘‘(k) EXISTING PROGRAMS.—Nothing in this section
24 shall prohibit a program of health promotion or disease
25 prevention that was established prior to the date of enact-
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1 ment of this section and applied with all applicable regula2 tions, and that is operating on such date, from continuing
3 to be carried out for as long as such regulations remain
4 in effect.
5
‘‘(l)
WELLNESS
PROGRAM
DEMONSTRATION
6 PROJECT.—
7
‘‘(1) IN
GENERAL.—Not
later than July 1,
8
2014, the Secretary, in consultation with the Sec-
9
retary of the Treasury and the Secretary of Labor,
10
shall establish a 10-State demonstration project
11
under which participating States shall apply the pro-
12
visions of subsection (j) to programs of health pro-
13
motion offered by a health insurance issuer that of-
14
fers health insurance coverage in the individual mar-
15
ket in such State.
16
‘‘(2)
17
PROJECT.—If
18
Secretary of the Treasury and the Secretary of
19
Labor, determines that the demonstration project
20
described in paragraph (1) is effective, such Secre-
21
taries may, beginning on July 1, 2017 expand such
22
demonstration project to include additional partici-
23
pating States.
24
EXPANSION
OF
DEMONSTRATION
the Secretary, in consultation with the
‘‘(3) REQUIREMENTS.—
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1
‘‘(A) MAINTENANCE
OF COVERAGE.—The
2
Secretary, in consultation with the Secretary of
3
the Treasury and the Secretary of Labor, shall
4
not approve the participation of a State in the
5
demonstration project under this section unless
6
the Secretaries determine that the State’s
7
project is designed in a manner that—
8
9
‘‘(i) will not result in any decrease in
coverage; and
10
‘‘(ii) will not increase the cost to the
11
Federal Government in providing credits
12
under section 36B of the Internal Revenue
13
Code of 1986 or cost-sharing assistance
14
under section 1402 of the Patient Protec-
15
tion and Affordable Care Act.
16
‘‘(B) OTHER
REQUIREMENTS.—States
that
17
participate in the demonstration project under
18
this subsection—
19
‘‘(i) may permit premium discounts or
20
rebates or the modification of otherwise
21
applicable copayments or deductibles for
22
adherence to, or participation in, a reason-
23
ably designed program of health promotion
24
and disease prevention;
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1
‘‘(ii) shall ensure that requirements of
2
consumer protection are met in programs
3
of health promotion in the individual mar-
4
ket;
5
‘‘(iii) shall require verification from
6
health insurance issuers that offer health
7
insurance coverage in the individual mar-
8
ket of such State that premium dis-
9
counts—
10
‘‘(I) do not create undue burdens
11
for individuals insured in the indi-
12
vidual market;
13
14
15
‘‘(II) do not lead to cost shifting;
and
‘‘(III) are not a subterfuge for
16
discrimination;
17
‘‘(iv) shall ensure that consumer data
18
is protected in accordance with the require-
19
ments of section 264(c) of the Health In-
20
surance Portability and Accountability Act
21
of 1996 (42 U.S.C. 1320d-2 note); and
22
‘‘(v) shall ensure and demonstrate to
23
the satisfaction of the Secretary that the
24
discounts or other rewards provided under
25
the project reflect the expected level of par-
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1
ticipation in the wellness program involved
2
and the anticipated effect the program will
3
have on utilization or medical claim costs.
4
‘‘(m) REPORT.—
5
‘‘(1) IN
GENERAL.—Not
later than 3 years
6
after the date of enactment of the Patient Protection
7
and Affordable Care Act, the Secretary, in consulta-
8
tion with the Secretary of the Treasury and the Sec-
9
retary of Labor, shall submit a report to the appro-
10
priate committees of Congress concerning—
11
‘‘(A) the effectiveness of wellness programs
12
(as defined in subsection (j)) in promoting
13
health and preventing disease;
14
‘‘(B) the impact of such wellness programs
15
on the access to care and affordability of cov-
16
erage for participants and non-participants of
17
such programs;
18
‘‘(C) the impact of premium-based and
19
cost-sharing incentives on participant behavior
20
and the role of such programs in changing be-
21
havior; and
22
‘‘(D) the effectiveness of different types of
23
rewards.
24
‘‘(2) DATA
25
COLLECTION.—In
preparing the re-
port described in paragraph (1), the Secretaries
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1
shall gather relevant information from employers
2
who provide employees with access to wellness pro-
3
grams, including State and Federal agencies.
4
‘‘(n) REGULATIONS.—Nothing in this section shall be
5 construed as prohibiting the Secretaries of Labor, Health
6 and Human Services, or the Treasury from promulgating
7 regulations in connection with this section.
8
9
‘‘SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.
‘‘(a) PROVIDERS.—A group health plan and a health
10 insurance issuer offering group or individual health insur11 ance coverage shall not discriminate with respect to par12 ticipation under the plan or coverage against any health
13 care provider who is acting within the scope of that pro14 vider’s license or certification under applicable State law.
15 This section shall not require that a group health plan
16 or health insurance issuer contract with any health care
17 provider willing to abide by the terms and conditions for
18 participation established by the plan or issuer. Nothing
19 in this section shall be construed as preventing a group
20 health plan, a health insurance issuer, or the Secretary
21 from establishing varying reimbursement rates based on
22 quality or performance measures.
23
‘‘(b) INDIVIDUALS.—The provisions of section 1558
24 of the Patient Protection and Affordable Care Act (relat25 ing to non-discrimination) shall apply with respect to a
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1 group health plan or health insurance issuer offering
2 group or individual health insurance coverage.
3
‘‘SEC. 2707. COMPREHENSIVE HEALTH INSURANCE COV-
4
ERAGE.
5
‘‘(a) COVERAGE
FOR
ESSENTIAL HEALTH BENEFITS
6 PACKAGE.—A health insurance issuer that offers health
7 insurance coverage in the individual or small group market
8 shall ensure that such coverage includes the essential
9 health benefits package required under section 1302(a) of
10 the Patient Protection and Affordable Care Act.
11
‘‘(b)
COST-SHARING
UNDER
GROUP
HEALTH
12 PLANS.—A group health plan shall ensure that any an13 nual cost-sharing imposed under the plan does not exceed
14 the limitations provided for under paragraphs (1) and (2)
15 of section 1302(c).
16
‘‘(c) CHILD-ONLY PLANS.—If a health insurance
17 issuer offers health insurance coverage in any level of cov18 erage specified under section 1302(d) of the Patient Pro19 tection and Affordable Care Act, the issuer shall also offer
20 such coverage in that level as a plan in which the only
21 enrollees are individuals who, as of the beginning of a plan
22 year, have not attained the age of 21.
23
‘‘(d) DENTAL ONLY.—This section shall not apply to
24 a plan described in section 1302(d)(2)(B)(ii)(I).
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1
2
3
‘‘SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS.
‘‘A group health plan and a health insurance issuer
4 offering group or individual health insurance coverage
5 shall not apply any waiting period (as defined in section
6 2704(b)(4)) that exceeds 90 days.’’.
7
PART II—OTHER PROVISIONS
8
SEC. 1251. PRESERVATION OF RIGHT TO MAINTAIN EXIST-
9
10
11
ING COVERAGE.
(a) NO CHANGES TO EXISTING COVERAGE.—
(1) IN
GENERAL.—Nothing
in this Act (or an
12
amendment made by this Act) shall be construed to
13
require that an individual terminate coverage under
14
a group health plan or health insurance coverage in
15
which such individual was enrolled on the date of en-
16
actment of this Act.
17
(2) CONTINUATION
OF COVERAGE.—With
re-
18
spect to a group health plan or health insurance cov-
19
erage in which an individual was enrolled on the
20
date of enactment of this Act, this subtitle and sub-
21
title A (and the amendments made by such subtitles)
22
shall not apply to such plan or coverage, regardless
23
of whether the individual renews such coverage after
24
such date of enactment.
25
(b) ALLOWANCE
FOR
FAMILY MEMBERS
TO
JOIN
26 CURRENT COVERAGE.—With respect to a group health
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1 plan or health insurance coverage in which an individual
2 was enrolled on the date of enactment of this Act and
3 which is renewed after such date, family members of such
4 individual shall be permitted to enroll in such plan or cov5 erage if such enrollment is permitted under the terms of
6 the plan in effect as of such date of enactment.
7
(c) ALLOWANCE
FOR
NEW EMPLOYEES
TO
JOIN
8 CURRENT PLAN.—A group health plan that provides cov9 erage on the date of enactment of this Act may provide
10 for the enrolling of new employees (and their families) in
11 such plan, and this subtitle and subtitle A (and the
12 amendments made by such subtitles) shall not apply with
13 respect to such plan and such new employees (and their
14 families).
15
16
(d) EFFECT
MENTS.—In
ON
COLLECTIVE BARGAINING AGREE-
the case of health insurance coverage main-
17 tained pursuant to one or more collective bargaining
18 agreements between employee representatives and one or
19 more employers that was ratified before the date of enact20 ment of this Act, the provisions of this subtitle and sub21 title A (and the amendments made by such subtitles) shall
22 not apply until the date on which the last of the collective
23 bargaining agreements relating to the coverage termi24 nates. Any coverage amendment made pursuant to a col25 lective bargaining agreement relating to the coverage
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1 which amends the coverage solely to conform to any re2 quirement added by this subtitle or subtitle A (or amend3 ments) shall not be treated as a termination of such collec4 tive bargaining agreement.
5
(e) DEFINITION.—In this title, the term ‘‘grand-
6 fathered health plan’’ means any group health plan or
7 health insurance coverage to which this section applies.
8
9
10
11
SEC. 1252. RATING REFORMS MUST APPLY UNIFORMLY TO
ALL
HEALTH
INSURANCE
ISSUERS
AND
GROUP HEALTH PLANS.
Any standard or requirement adopted by a State pur-
12 suant to this title, or any amendment made by this title,
13 shall be applied uniformly to all health plans in each insur14 ance market to which the standard and requirements
15 apply. The preceding sentence shall also apply to a State
16 standard or requirement relating to the standard or re17 quirement required by this title (or any such amendment)
18 that is not the same as the standard or requirement but
19 that is not preempted under section 1321(d).
20
21
SEC. 1253. EFFECTIVE DATES.
This subtitle (and the amendments made by this sub-
22 title) shall become effective for plan years beginning on
23 or after January 1, 2014.
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2
Subtitle D—Available Coverage
Choices for All Americans
3
PART I—ESTABLISHMENT OF QUALIFIED
4
HEALTH PLANS
1
5
6
7
8
SEC. 1301. QUALIFIED HEALTH PLAN DEFINED.
(a) QUALIFIED HEALTH PLAN.—In this title:
(1) IN
GENERAL.—The
term ‘‘qualified health
plan’’ means a health plan that—
9
(A) has in effect a certification (which may
10
include a seal or other indication of approval)
11
that such plan meets the criteria for certifi-
12
cation described in section 1311(c) issued or
13
recognized by each Exchange through which
14
such plan is offered;
15
16
17
18
(B) provides the essential health benefits
package described in section 1302(a); and
(C) is offered by a health insurance issuer
that—
19
(i) is licensed and in good standing to
20
offer health insurance coverage in each
21
State in which such issuer offers health in-
22
surance coverage under this title;
23
(ii) agrees to offer at least one quali-
24
fied health plan in the silver level and at
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1
least one plan in the gold level in each
2
such Exchange;
3
(iii) agrees to charge the same pre-
4
mium rate for each qualified health plan of
5
the issuer without regard to whether the
6
plan is offered through an Exchange or
7
whether the plan is offered directly from
8
the issuer or through an agent; and
9
(iv) complies with the regulations de-
10
veloped by the Secretary under section
11
1311(d) and such other requirements as
12
an applicable Exchange may establish.
13
(2) INCLUSION
OF CO-OP PLANS AND COMMU-
14
NITY HEALTH INSURANCE OPTION.—Any
15
in this title to a qualified health plan shall be
16
deemed to include a qualified health plan offered
17
through the CO-OP program under section 1322 or
18
a community health insurance option under section
19
1323, unless specifically provided for otherwise.
20
(b) TERMS RELATING
TO
reference
HEALTH PLANS.—In this
21 title:
22
23
(1) HEALTH
(A) IN
PLAN.—
GENERAL.—The
term ‘‘health plan’’
24
means health insurance coverage and a group
25
health plan.
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1
(B) EXCEPTION
FOR SELF-INSURED PLANS
2
AND MEWAS.—Except
3
provided by this title, the term ‘‘health plan’’
4
shall not include a group health plan or mul-
5
tiple employer welfare arrangement to the ex-
6
tent the plan or arrangement is not subject to
7
State insurance regulation under section 514 of
8
the Employee Retirement Income Security Act
9
of 1974.
10
(2)
HEALTH
to the extent specifically
INSURANCE
COVERAGE
AND
11
ISSUER.—The
12
and ‘‘health insurance issuer’’ have the meanings
13
given such terms by section 2791(b) of the Public
14
Health Service Act.
15
terms ‘‘health insurance coverage’’
(3) GROUP
HEALTH PLAN.—The
term ‘‘group
16
health plan’’ has the meaning given such term by
17
section 2791(a) of the Public Health Service Act.
18
SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.
19
(a) ESSENTIAL HEALTH BENEFITS PACKAGE.—In
20 this title, the term ‘‘essential health benefits package’’
21 means, with respect to any health plan, coverage that—
22
23
24
25
(1) provides for the essential health benefits defined by the Secretary under subsection (b);
(2) limits cost-sharing for such coverage in accordance with subsection (c); and
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1
(3) subject to subsection (e), provides either the
2
bronze, silver, gold, or platinum level of coverage de-
3
scribed in subsection (d).
4
(b) ESSENTIAL HEALTH BENEFITS.—
5
(1) IN
GENERAL.—Subject
to paragraph (2),
6
the Secretary shall define the essential health bene-
7
fits, except that such benefits shall include at least
8
the following general categories and the items and
9
services covered within the categories:
10
(A) Ambulatory patient services.
11
(B) Emergency services.
12
(C) Hospitalization.
13
(D) Maternity and newborn care.
14
(E) Mental health and substance use dis-
15
order services, including behavioral health treat-
16
ment.
17
(F) Prescription drugs.
18
(G) Rehabilitative and habilitative services
19
and devices.
20
(H) Laboratory services.
21
(I) Preventive and wellness services and
22
23
chronic disease management.
(J) Pediatric services, including oral and
24
vision care.
25
(2) LIMITATION.—
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1
(A) IN
GENERAL.—The
Secretary shall en-
2
sure that the scope of the essential health bene-
3
fits under paragraph (1) is equal to the scope
4
of benefits provided under a typical employer
5
plan, as determined by the Secretary. To in-
6
form this determination, the Secretary of Labor
7
shall conduct a survey of employer-sponsored
8
coverage to determine the benefits typically cov-
9
ered by employers, including multiemployer
10
plans, and provide a report on such survey to
11
the Secretary.
12
(B) CERTIFICATION.—In defining the es-
13
sential health benefits described in paragraph
14
(1), and in revising the benefits under para-
15
graph (4)(H), the Secretary shall submit a re-
16
port to the appropriate committees of Congress
17
containing a certification from the Chief Actu-
18
ary of the Centers for Medicare & Medicaid
19
Services that such essential health benefits meet
20
the limitation described in paragraph (2).
21
(3) NOTICE
AND HEARING.—In
defining the es-
22
sential health benefits described in paragraph (1),
23
and in revising the benefits under paragraph (4)(H),
24
the Secretary shall provide notice and an oppor-
25
tunity for public comment.
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1
(4) REQUIRED
ELEMENTS
FOR
CONSIDER-
2
ATION.—In
3
under paragraph (1), the Secretary shall—
defining the essential health benefits
4
(A) ensure that such essential health bene-
5
fits reflect an appropriate balance among the
6
categories described in such subsection, so that
7
benefits are not unduly weighted toward any
8
category;
9
(B) not make coverage decisions, deter-
10
mine reimbursement rates, establish incentive
11
programs, or design benefits in ways that dis-
12
criminate against individuals because of their
13
age, disability, or expected length of life;
14
(C) take into account the health care needs
15
of diverse segments of the population, including
16
women, children, persons with disabilities, and
17
other groups;
18
(D) ensure that health benefits established
19
as essential not be subject to denial to individ-
20
uals against their wishes on the basis of the in-
21
dividuals’ age or expected length of life or of
22
the individuals’ present or predicted disability,
23
degree of medical dependency, or quality of life;
24
(E) provide that a qualified health plan
25
shall not be treated as providing coverage for
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1
the essential health benefits described in para-
2
graph (1) unless the plan provides that—
3
(i) coverage for emergency department
4
services will be provided without imposing
5
any requirement under the plan for prior
6
authorization of services or any limitation
7
on coverage where the provider of services
8
does not have a contractual relationship
9
with the plan for the providing of services
10
that is more restrictive than the require-
11
ments or limitations that apply to emer-
12
gency department services received from
13
providers who do have such a contractual
14
relationship with the plan; and
15
(ii) if such services are provided out-
16
of-network, the cost-sharing requirement
17
(expressed as a copayment amount or coin-
18
surance rate) is the same requirement that
19
would apply if such services were provided
20
in-network;
21
(F) provide that if a plan described in sec-
22
tion 1311(b)(2)(B)(ii) (relating to stand-alone
23
dental benefits plans) is offered through an Ex-
24
change, another health plan offered through
25
such Exchange shall not fail to be treated as a
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1
qualified health plan solely because the plan
2
does not offer coverage of benefits offered
3
through the stand-alone plan that are otherwise
4
required under paragraph (1)(J); and
5
(G) periodically review the essential health
6
benefits under paragraph (1), and provide a re-
7
port to Congress and the public that contains—
8
(i) an assessment of whether enrollees
9
are facing any difficulty accessing needed
10
services for reasons of coverage or cost;
11
(ii) an assessment of whether the es-
12
sential health benefits needs to be modified
13
or updated to account for changes in med-
14
ical evidence or scientific advancement;
15
(iii) information on how the essential
16
health benefits will be modified to address
17
any such gaps in access or changes in the
18
evidence base;
19
(iv) an assessment of the potential of
20
additional or expanded benefits to increase
21
costs and the interactions between the ad-
22
dition or expansion of benefits and reduc-
23
tions in existing benefits to meet actuarial
24
limitations described in paragraph (2); and
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1
(H) periodically update the essential health
2
benefits under paragraph (1) to address any
3
gaps in access to coverage or changes in the
4
evidence base the Secretary identifies in the re-
5
view conducted under subparagraph (G).
6
(5) RULE
OF CONSTRUCTION.—Nothing
in this
7
title shall be construed to prohibit a health plan
8
from providing benefits in excess of the essential
9
health benefits described in this subsection.
10
(c) REQUIREMENTS RELATING
11
(1) ANNUAL
12
(A)
TO
COST-SHARING.—
LIMITATION ON COST-SHARING.—
2014.—The
cost-sharing
incurred
13
under a health plan with respect to self-only
14
coverage or coverage other than self-only cov-
15
erage for a plan year beginning in 2014 shall
16
not exceed the dollar amounts in effect under
17
section 223(c)(2)(A)(ii) of the Internal Revenue
18
Code of 1986 for self-only and family coverage,
19
respectively, for taxable years beginning in
20
2014.
21
(B) 2015
AND LATER.—In
the case of any
22
plan year beginning in a calendar year after
23
2014, the limitation under this paragraph
24
shall—
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1
(i) in the case of self-only coverage, be
2
equal to the dollar amount under subpara-
3
graph (A) for self-only coverage for plan
4
years beginning in 2014, increased by an
5
amount equal to the product of that
6
amount and the premium adjustment per-
7
centage under paragraph (4) for the cal-
8
endar year; and
9
(ii) in the case of other coverage,
10
twice the amount in effect under clause (i).
11
If the amount of any increase under clause (i)
12
is not a multiple of $50, such increase shall be
13
rounded to the next lowest multiple of $50.
14
(2) ANNUAL
15
16
LIMITATION ON DEDUCTIBLES FOR
EMPLOYER-SPONSORED PLANS.—
(A) IN
GENERAL.—In
the case of a health
17
plan offered in the small group market, the de-
18
ductible under the plan shall not exceed—
19
20
21
22
(i) $2,000 in the case of a plan covering a single individual; and
(ii) $4,000 in the case of any other
plan.
23
The amounts under clauses (i) and (ii) may be
24
increased by the maximum amount of reim-
25
bursement which is reasonably available to a
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1
participant under a flexible spending arrange-
2
ment described in section 106(c)(2) of the In-
3
ternal Revenue Code of 1986 (determined with-
4
out regard to any salary reduction arrange-
5
ment).
6
(B) INDEXING
OF LIMITS.—In
the case of
7
any plan year beginning in a calendar year
8
after 2014—
9
(i) the dollar amount under subpara-
10
graph (A)(i) shall be increased by an
11
amount equal to the product of that
12
amount and the premium adjustment per-
13
centage under paragraph (4) for the cal-
14
endar year; and
15
(ii) the dollar amount under subpara-
16
graph (A)(ii) shall be increased to an
17
amount equal to twice the amount in effect
18
under subparagraph (A)(i) for plan years
19
beginning in the calendar year, determined
20
after application of clause (i).
21
If the amount of any increase under clause (i)
22
is not a multiple of $50, such increase shall be
23
rounded to the next lowest multiple of $50.
24
25
(C) ACTUARIAL
VALUE.—The
limitation
under this paragraph shall be applied in such a
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1
manner so as to not affect the actuarial value
2
of any health plan, including a plan in the
3
bronze level.
4
(D) COORDINATION
WITH
PREVENTIVE
5
LIMITS.—Nothing
6
construed to allow a plan to have a deductible
7
under the plan apply to benefits described in
8
section 2713 of the Public Health Service Act.
9
(3) COST-SHARING.—In this title—
10
(A) IN
11
ing’’ includes—
12
13
in this paragraph shall be
GENERAL.—The
term ‘‘cost-shar-
(i) deductibles, coinsurance, copayments, or similar charges; and
14
(ii) any other expenditure required of
15
an insured individual which is a qualified
16
medical expense (within the meaning of
17
section 223(d)(2) of the Internal Revenue
18
Code of 1986) with respect to essential
19
health benefits covered under the plan.
20
(B) EXCEPTIONS.—Such term does not in-
21
clude premiums, balance billing amounts for
22
non-network providers, or spending for non-cov-
23
ered services.
24
(4) PREMIUM
25
ADJUSTMENT PERCENTAGE.—For
purposes of paragraphs (1)(B)(i) and (2)(B)(i), the
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1
premium adjustment percentage for any calendar
2
year is the percentage (if any) by which the average
3
per capita premium for health insurance coverage in
4
the United States for the preceding calendar year
5
(as estimated by the Secretary no later than October
6
1 of such preceding calendar year) exceeds such av-
7
erage per capita premium for 2013 (as determined
8
by the Secretary).
9
(d) LEVELS OF COVERAGE.—
10
(1) LEVELS
OF COVERAGE DEFINED.—The
lev-
11
els of coverage described in this subsection are as
12
follows:
13
(A) BRONZE
LEVEL.—A
plan in the bronze
14
level shall provide a level of coverage that is de-
15
signed to provide benefits that are actuarially
16
equivalent to 60 percent of the full actuarial
17
value of the benefits provided under the plan.
18
(B) SILVER
LEVEL.—A
plan in the silver
19
level shall provide a level of coverage that is de-
20
signed to provide benefits that are actuarially
21
equivalent to 70 percent of the full actuarial
22
value of the benefits provided under the plan.
23
(C) GOLD
LEVEL.—A
plan in the gold level
24
shall provide a level of coverage that is designed
25
to provide benefits that are actuarially equiva-
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1
lent to 80 percent of the full actuarial value of
2
the benefits provided under the plan.
3
(D) PLATINUM
LEVEL.—A
plan in the
4
platinum level shall provide a level of coverage
5
that is designed to provide benefits that are ac-
6
tuarially equivalent to 90 percent of the full ac-
7
tuarial value of the benefits provided under the
8
plan.
9
(2) ACTUARIAL
10
(A)
IN
VALUE.—
GENERAL.—Under
regulations
11
issued by the Secretary, the level of coverage of
12
a plan shall be determined on the basis that the
13
essential health benefits described in subsection
14
(b) shall be provided to a standard population
15
(and without regard to the population the plan
16
may actually provide benefits to).
17
(B)
EMPLOYER
CONTRIBUTIONS.—The
18
Secretary may issue regulations under which
19
employer contributions to a health savings ac-
20
count (within the meaning of section 223 of the
21
Internal Revenue Code of 1986) may be taken
22
into account in determining the level of cov-
23
erage for a plan of the employer.
24
(C) APPLICATION.—In determining under
25
this title, the Public Health Service Act, or the
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1
Internal Revenue Code of 1986 the percentage
2
of the total allowed costs of benefits provided
3
under a group health plan or health insurance
4
coverage that are provided by such plan or cov-
5
erage, the rules contained in the regulations
6
under this paragraph shall apply.
7
(3) ALLOWABLE
VARIANCE.—The
Secretary
8
shall develop guidelines to provide for a de minimis
9
variation in the actuarial valuations used in deter-
10
mining the level of coverage of a plan to account for
11
differences in actuarial estimates.
12
(4) PLAN
REFERENCE.—In
this title, any ref-
13
erence to a bronze, silver, gold, or platinum plan
14
shall be treated as a reference to a qualified health
15
plan providing a bronze, silver, gold, or platinum
16
level of coverage, as the case may be.
17
(e) CATASTROPHIC PLAN.—
18
(1) IN
GENERAL.—A
health plan not providing
19
a bronze, silver, gold, or platinum level of coverage
20
shall be treated as meeting the requirements of sub-
21
section (d) with respect to any plan year if—
22
(A) the only individuals who are eligible to
23
enroll in the plan are individuals described in
24
paragraph (2); and
25
(B) the plan provides—
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1
(i) except as provided in clause (ii),
2
the essential health benefits determined
3
under subsection (b), except that the plan
4
provides no benefits for any plan year until
5
the individual has incurred cost-sharing ex-
6
penses in an amount equal to the annual
7
limitation in effect under subsection (c)(1)
8
for the plan year (except as provided for in
9
section 2713); and
10
(ii) coverage for at least three primary
11
care visits.
12
(2)
13
MENT.—An
14
for any plan year if the individual—
15
16
INDIVIDUALS
ELIGIBLE
FOR
ENROLL-
individual is described in this paragraph
(A) has not attained the age of 30 before
the beginning of the plan year; or
17
(B) has a certification in effect for any
18
plan year under this title that the individual is
19
exempt from the requirement under section
20
5000A of the Internal Revenue Code of 1986
21
by reason of—
22
(i) section 5000A(e)(1) of such Code
23
(relating to individuals without affordable
24
coverage); or
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1
2
3
(ii) section 5000A(e)(5) of such Code
(relating to individuals with hardships).
(3) RESTRICTION
TO INDIVIDUAL MARKET.—If
4
a health insurance issuer offers a health plan de-
5
scribed in this subsection, the issuer may only offer
6
the plan in the individual market.
7
(f) CHILD-ONLY PLANS.—If a qualified health plan
8 is offered through the Exchange in any level of coverage
9 specified under subsection (d), the issuer shall also offer
10 that plan through the Exchange in that level as a plan
11 in which the only enrollees are individuals who, as of the
12 beginning of a plan year, have not attained the age of 21,
13 and such plan shall be treated as a qualified health plan.
14
15
SEC. 1303. SPECIAL RULES.
(a) SPECIAL RULES RELATING
TO
COVERAGE
OF
COVERAGE
OF
16 ABORTION SERVICES.—
17
18
19
(1) VOLUNTARY
CHOICE
OF
ABORTION SERVICES.—
(A) IN
GENERAL.—Notwithstanding
any
20
other provision of this title (or any amendment
21
made by this title), and subject to subpara-
22
graphs (C) and (D)—
23
(i) nothing in this title (or any
24
amendment made by this title), shall be
25
construed to require a qualified health plan
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1
to provide coverage of services described in
2
subparagraph (B)(i) or (B)(ii) as part of
3
its essential health benefits for any plan
4
year; and
5
(ii) the issuer of a qualified health
6
plan shall determine whether or not the
7
plan provides coverage of services described
8
in subparagraph (B)(i) or (B)(ii) as part
9
of such benefits for the plan year.
10
11
(B) ABORTION
SERVICES.—
(i) ABORTIONS
FOR WHICH PUBLIC
12
FUNDING
13
described in this clause are abortions for
14
which the expenditure of Federal funds ap-
15
propriated for the Department of Health
16
and Human Services is not permitted,
17
based on the law as in effect as of the date
18
that is 6 months before the beginning of
19
the plan year involved.
20
IS
PROHIBITED.—The
(ii) ABORTIONS
services
FOR WHICH PUBLIC
21
FUNDING IS ALLOWED.—The
22
scribed in this clause are abortions for
23
which the expenditure of Federal funds ap-
24
propriated for the Department of Health
25
and Human Services is permitted, based
services de-
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on the law as in effect as of the date that
2
is 6 months before the beginning of the
3
plan year involved.
4
(C) PROHIBITION
ON
FEDERAL
5
FOR
6
HEALTH INSURANCE OPTION.—
7
ABORTION
(i)
SERVICES
IN
DETERMINATION
FUNDS
COMMUNITY
BY
SEC-
8
RETARY.—The
9
mine, in accordance with subparagraph
10
(A)(ii), that the community health insur-
11
ance option established under section 1323
12
shall provide coverage of services described
13
in subparagraph (B)(i) as part of benefits
14
for the plan year unless the Secretary—
15
16
Secretary may not deter-
(I) assures compliance with the
requirements of paragraph (2);
17
(II) assures, in accordance with
18
applicable provisions of generally ac-
19
cepted accounting requirements, circu-
20
lars on funds management of the Of-
21
fice of Management and Budget, and
22
guidance on accounting of the Govern-
23
ment Accountability Office, that no
24
Federal funds are used for such cov-
25
erage; and
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(III)
notwithstanding
section
2
1323(e)(1)(C) or any other provision
3
of this title, takes all necessary steps
4
to assure that the United States does
5
not bear the insurance risk for a com-
6
munity health insurance option’s cov-
7
erage of services described in subpara-
8
graph (B)(i).
9
(ii) STATE
REQUIREMENT.—If
a State
10
requires, in addition to the essential health
11
benefits required under section 1323(b)(3)
12
(A), coverage of services described in sub-
13
paragraph (B)(i) for enrollees of a commu-
14
nity health insurance option offered in
15
such State, the State shall assure that no
16
funds flowing through or from the commu-
17
nity health insurance option, and no other
18
Federal funds, pay or defray the cost of
19
providing coverage of services described in
20
subparagraph (B)(i). The United States
21
shall not bear the insurance risk for a
22
State’s required coverage of services de-
23
scribed in subparagraph (B)(i).
24
(iii) EXCEPTIONS.—Nothing in this
25
subparagraph shall apply to coverage of
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services described in subparagraph (B)(ii)
2
by the community health insurance option.
3
Services described in subparagraph (B)(ii)
4
shall be covered to the same extent as such
5
services are covered under title XIX of the
6
Social Security Act.
7
(D) ASSURED
8
9
AVAILABILITY OF VARIED
COVERAGE THROUGH EXCHANGES.—
(i) IN
GENERAL.—The
Secretary shall
10
assure that with respect to qualified health
11
plans offered in any Exchange established
12
pursuant to this title—
13
(I) there is at least one such plan
14
that provides coverage of services de-
15
scribed in clauses (i) and (ii) of sub-
16
paragraph (B); and
17
(II) there is at least one such
18
plan that does not provide coverage of
19
services described in subparagraph
20
(B)(i).
21
(ii) SPECIAL
22
RULES.—For
purposes of
clause (i)—
23
(I) a plan shall be treated as de-
24
scribed in clause (i)(II) if the plan
25
does not provide coverage of services
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described
2
(B)(i) or (B)(ii); and
in
either
subparagraph
3
(II) if a State has one Exchange
4
covering more than 1 insurance mar-
5
ket, the Secretary shall meet the re-
6
quirements of clause (i) separately
7
with respect to each such market.
8
9
(2) PROHIBITION
ON THE USE OF FEDERAL
FUNDS.—
10
(A) IN
GENERAL.—If
a qualified health
11
plan provides coverage of services described in
12
paragraph (1)(B)(i), the issuer of the plan shall
13
not use any amount attributable to any of the
14
following for purposes of paying for such serv-
15
ices:
16
(i) The credit under section 36B of
17
the Internal Revenue Code of 1986 (and
18
the amount (if any) of the advance pay-
19
ment of the credit under section 1412 of
20
the Patient Protection and Affordable Care
21
Act).
22
(ii) Any cost-sharing reduction under
23
section 1402 of thePatient Protection and
24
Affordable Care Act (and the amount (if
25
any) of the advance payment of the reduc-
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1
tion under section 1412 of the Patient
2
Protection and Affordable Care Act).
3
(B) SEGREGATION
OF FUNDS.—In
the case
4
of a plan to which subparagraph (A) applies,
5
the issuer of the plan shall, out of amounts not
6
described in subparagraph (A), segregate an
7
amount equal to the actuarial amounts deter-
8
mined under subparagraph (C) for all enrollees
9
from the amounts described in subparagraph
10
11
12
13
(A).
(C) ACTUARIAL
VALUE
OF
OPTIONAL
SERVICE COVERAGE.—
(i) IN
GENERAL.—The
Secretary shall
14
estimate the basic per enrollee, per month
15
cost, determined on an average actuarial
16
basis, for including coverage under a quali-
17
fied health plan of the services described in
18
paragraph (1)(B)(i).
19
20
(ii)
CONSIDERATIONS.—In
making
such estimate, the Secretary—
21
(I) may take into account the im-
22
pact on overall costs of the inclusion
23
of such coverage, but may not take
24
into account any cost reduction esti-
25
mated to result from such services, in-
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1
cluding prenatal care, delivery, or
2
postnatal care;
3
(II) shall estimate such costs as
4
if such coverage were included for the
5
entire population covered; and
6
(III) may not estimate such a
7
cost at less than $1 per enrollee, per
8
month.
9
(3) PROVIDER
CONSCIENCE PROTECTIONS.—No
10
individual health care provider or health care facility
11
may be discriminated against because of a willing-
12
ness or an unwillingness, if doing so is contrary to
13
the religious or moral beliefs of the provider or facil-
14
ity, to provide, pay for, provide coverage of, or refer
15
for abortions.
16
(b) APPLICATION
OF
STATE
AND
FEDERAL LAWS
17 REGARDING ABORTION.—
18
(1) NO
PREEMPTION OF STATE LAWS REGARD-
19
ING ABORTION.—Nothing
20
strued to preempt or otherwise have any effect on
21
State laws regarding the prohibition of (or require-
22
ment of) coverage, funding, or procedural require-
23
ments on abortions, including parental notification
24
or consent for the performance of an abortion on a
25
minor.
in this Act shall be con-
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1
(2) NO
2
EFFECT ON FEDERAL LAWS REGARDING
ABORTION.—
3
(A) IN
GENERAL.—Nothing
in this Act
4
shall be construed to have any effect on Federal
5
laws regarding—
6
(i) conscience protection;
7
(ii) willingness or refusal to provide
8
abortion; and
9
(iii) discrimination on the basis of the
10
willingness or refusal to provide, pay for,
11
cover, or refer for abortion or to provide or
12
participate in training to provide abortion.
13
(3) NO
EFFECT ON FEDERAL CIVIL RIGHTS
14
LAW.—Nothing
15
rights and obligations of employees and employers
16
under title VII of the Civil Rights Act of 1964.
17
(c)
in this subsection shall alter the
APPLICATION
OF
EMERGENCY
SERVICES
18 LAWS.—Nothing in this Act shall be construed to relieve
19 any health care provider from providing emergency serv20 ices as required by State or Federal law, including section
21 1867 of the Social Security Act (popularly known as
22 ‘‘EMTALA’’).
23
SEC. 1304. RELATED DEFINITIONS.
24
(a) DEFINITIONS RELATING
25 title:
TO
MARKETS.—In this
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1
(1) GROUP
MARKET.—The
term ‘‘group mar-
2
ket’’ means the health insurance market under
3
which individuals obtain health insurance coverage
4
(directly or through any arrangement) on behalf of
5
themselves (and their dependents) through a group
6
health plan maintained by an employer.
7
(2) INDIVIDUAL
MARKET.—The
term ‘‘indi-
8
vidual market’’ means the market for health insur-
9
ance coverage offered to individuals other than in
10
11
connection with a group health plan.
(3) LARGE
AND SMALL GROUP MARKETS.—The
12
terms ‘‘large group market’’ and ‘‘small group mar-
13
ket’’ mean the health insurance market under which
14
individuals obtain health insurance coverage (directly
15
or through any arrangement) on behalf of them-
16
selves (and their dependents) through a group health
17
plan maintained by a large employer (as defined in
18
subsection (b)(1)) or by a small employer (as defined
19
in subsection (b)(2)), respectively.
20
(b) EMPLOYERS.—In this title:
21
(1) LARGE
EMPLOYER.—The
term ‘‘large em-
22
ployer’’ means, in connection with a group health
23
plan with respect to a calendar year and a plan year,
24
an employer who employed an average of at least
25
101 employees on business days during the pre-
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1
ceding calendar year and who employs at least 1 em-
2
ployee on the first day of the plan year.
3
(2) SMALL
EMPLOYER.—The
term ‘‘small em-
4
ployer’’ means, in connection with a group health
5
plan with respect to a calendar year and a plan year,
6
an employer who employed an average of at least 1
7
but not more than 100 employees on business days
8
during the preceding calendar year and who employs
9
at least 1 employee on the first day of the plan year.
10
(3) STATE
OPTION TO TREAT 50 EMPLOYEES AS
11
SMALL.—In
12
January 1, 2016, a State may elect to apply this
13
subsection by substituting ‘‘51 employees’’ for ‘‘101
14
employees’’ in paragraph (1) and by substituting
15
‘‘50 employees’’ for ‘‘100 employees’’ in paragraph
16
(2).
17
18
(4)
the case of plan years beginning before
RULES
SIZE.—For
FOR
DETERMINING
EMPLOYER
purposes of this subsection—
19
(A) APPLICATION
OF AGGREGATION RULE
20
FOR EMPLOYERS.—All
persons treated as a sin-
21
gle employer under subsection (b), (c), (m), or
22
(o) of section 414 of the Internal Revenue Code
23
of 1986 shall be treated as 1 employer.
24
25
(B) EMPLOYERS
PRECEDING YEAR.—In
NOT IN EXISTENCE IN
the case of an employer
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1
which was not in existence throughout the pre-
2
ceding calendar year, the determination of
3
whether such employer is a small or large em-
4
ployer shall be based on the average number of
5
employees that it is reasonably expected such
6
employer will employ on business days in the
7
current calendar year.
8
(C) PREDECESSORS.—Any reference in
9
this subsection to an employer shall include a
10
reference to any predecessor of such employer.
11
12
(D) CONTINUATION
OF
PARTICIPATION
FOR GROWING SMALL EMPLOYERS.—If—
13
(i) a qualified employer that is a small
14
employer makes enrollment in qualified
15
health plans offered in the small group
16
market available to its employees through
17
an Exchange; and
18
(ii) the employer ceases to be a small
19
employer by reason of an increase in the
20
number of employees of such employer;
21
the employer shall continue to be treated as a
22
small employer for purposes of this subtitle for
23
the period beginning with the increase and end-
24
ing with the first day on which the employer
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1
does not make such enrollment available to its
2
employees.
3
(c) SECRETARY.—In this title, the term ‘‘Secretary’’
4 means the Secretary of Health and Human Services.
5
(d) STATE.—In this title, the term ‘‘State’’ means
6 each of the 50 States and the District of Columbia.
7 PART II—CONSUMER CHOICES AND INSURANCE
8
COMPETITION THROUGH HEALTH BENEFIT
9
EXCHANGES
10
SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT
11
PLANS.
12
13
14
(a) ASSISTANCE
ICAN
TO
STATES
TO
ESTABLISH AMER-
HEALTH BENEFIT EXCHANGES.—
(1)
PLANNING
AND
ESTABLISHMENT
15
GRANTS.—There
16
retary, out of any moneys in the Treasury not other-
17
wise appropriated, an amount necessary to enable
18
the Secretary to make awards, not later than 1 year
19
after the date of enactment of this Act, to States in
20
the amount specified in paragraph (2) for the uses
21
described in paragraph (3).
22
(2) AMOUNT
shall be appropriated to the Sec-
SPECIFIED.—For
each fiscal year,
23
the Secretary shall determine the total amount that
24
the Secretary will make available to each State for
25
grants under this subsection.
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1
(3) USE
FUNDS.—A
OF
State shall use
2
amounts awarded under this subsection for activities
3
(including planning activities) related to establishing
4
an American Health Benefit Exchange, as described
5
in subsection (b).
6
7
(4) RENEWABILITY
(A) IN
OF GRANT.—
GENERAL.—Subject
to subsection
8
(d)(4), the Secretary may renew a grant award-
9
ed under paragraph (1) if the State recipient of
10
such grant—
11
12
(i) is making progress, as determined
by the Secretary, toward—
13
(I) establishing an Exchange;
14
and
15
(II) implementing the reforms
16
described in subtitles A and C (and
17
the amendments made by such sub-
18
titles); and
19
(ii) is meeting such other benchmarks
20
as the Secretary may establish.
21
(B)
LIMITATION.—No
grant
shall
be
22
awarded under this subsection after January 1,
23
2015.
24
(5) TECHNICAL
25
PARTICIPATION
IN
ASSISTANCE
SHOP
TO
FACILITATE
EXCHANGES.—The
Sec-
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1
retary shall provide technical assistance to States to
2
facilitate the participation of qualified small busi-
3
nesses in such States in SHOP Exchanges.
4
(b) AMERICAN HEALTH BENEFIT EXCHANGES.—
5
(1) IN
GENERAL.—Each
State shall, not later
6
than January 1, 2014, establish an American Health
7
Benefit Exchange (referred to in this title as an
8
‘‘Exchange’’) for the State that—
9
10
(A) facilitates the purchase of qualified
health plans;
11
(B) provides for the establishment of a
12
Small Business Health Options Program (in
13
this title referred to as a ‘‘SHOP Exchange’’)
14
that is designed to assist qualified employers in
15
the State who are small employers in facili-
16
tating the enrollment of their employees in
17
qualified health plans offered in the small group
18
market in the State; and
19
(C) meets the requirements of subsection
20
(d).
21
(2) MERGER
OF INDIVIDUAL AND SHOP EX-
22
CHANGES.—A
23
Exchange in the State for providing both Exchange
24
and SHOP Exchange services to both qualified indi-
25
viduals and qualified small employers, but only if the
State may elect to provide only one
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1
Exchange has adequate resources to assist such indi-
2
viduals and employers.
3
(c) RESPONSIBILITIES OF THE SECRETARY.—
4
(1) IN
GENERAL.—The
Secretary shall, by reg-
5
ulation, establish criteria for the certification of
6
health plans as qualified health plans. Such criteria
7
shall require that, to be certified, a plan shall, at a
8
minimum—
9
(A) meet marketing requirements, and not
10
employ marketing practices or benefit designs
11
that have the effect of discouraging the enroll-
12
ment in such plan by individuals with signifi-
13
cant health needs;
14
(B) ensure a sufficient choice of providers
15
(in a manner consistent with applicable network
16
adequacy provisions under section 2702(c) of
17
the Public Health Service Act), and provide in-
18
formation to enrollees and prospective enrollees
19
on the availability of in-network and out-of-net-
20
work providers;
21
(C) include within health insurance plan
22
networks those essential community providers,
23
where available, that serve predominately low-
24
income, medically-underserved individuals, such
25
as health care providers defined in section
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340B(a)(4) of the Public Health Service Act
2
and
3
1927(c)(1)(D)(i)(IV) of the Social Security Act
4
as set forth by section 221 of Public Law 111-
5
8, except that nothing in this subparagraph
6
shall be construed to require any health plan to
7
provide coverage for any specific medical proce-
8
dure;
providers
described
in
section
9
(D)(i) be accredited with respect to local
10
performance on clinical quality measures such
11
as the Healthcare Effectiveness Data and Infor-
12
mation Set, patient experience ratings on a
13
standardized
14
Healthcare Providers and Systems survey, as
15
well as consumer access, utilization manage-
16
ment, quality assurance, provider credentialing,
17
complaints and appeals, network adequacy and
18
access, and patient information programs by
19
any entity recognized by the Secretary for the
20
accreditation of health insurance issuers or
21
plans (so long as any such entity has trans-
22
parent and rigorous methodological and scoring
23
criteria); or
Consumer
Assessment
of
24
(ii) receive such accreditation within a pe-
25
riod established by an Exchange for such ac-
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1
creditation that is applicable to all qualified
2
health plans;
3
4
(E) implement a quality improvement
strategy described in subsection (g)(1);
5
(F) utilize a uniform enrollment form that
6
qualified individuals and qualified employers
7
may use (either electronically or on paper) in
8
enrolling in qualified health plans offered
9
through such Exchange, and that takes into ac-
10
count criteria that the National Association of
11
Insurance Commissioners develops and submits
12
to the Secretary;
13
(G) utilize the standard format established
14
for presenting health benefits plan options; and
15
(H) provide information to enrollees and
16
prospective enrollees, and to each Exchange in
17
which the plan is offered, on any quality meas-
18
ures for health plan performance endorsed
19
under section 399JJ of the Public Health Serv-
20
ice Act, as applicable.
21
(2) RULE
OF
CONSTRUCTION.—Nothing
in
22
paragraph (1)(C) shall be construed to require a
23
qualified health plan to contract with a provider de-
24
scribed in such paragraph if such provider refuses to
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1
accept the generally applicable payment rates of
2
such plan.
3
(3) RATING
SYSTEM.—The
Secretary shall de-
4
velop a rating system that would rate qualified
5
health plans offered through an Exchange in each
6
benefits level on the basis of the relative quality and
7
price. The Exchange shall include the quality rating
8
in the information provided to individuals and em-
9
ployers through the Internet portal established
10
11
12
under paragraph (4).
(4)
INTERNET
PORTALS.—The
Secretary
shall—
13
(A) continue to operate, maintain, and up-
14
date the Internet portal developed under section
15
1103(a) and to assist States in developing and
16
maintaining their own such portal; and
17
(B) make available for use by Exchanges a
18
model template for an Internet portal that may
19
be used to direct qualified individuals and quali-
20
fied employers to qualified health plans, to as-
21
sist such individuals and employers in deter-
22
mining whether they are eligible to participate
23
in an Exchange or eligible for a premium tax
24
credit or cost-sharing reduction, and to present
25
standardized information (including quality rat-
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1
ings) regarding qualified health plans offered
2
through an Exchange to assist consumers in
3
making easy health insurance choices.
4
Such template shall include, with respect to each
5
qualified health plan offered through the Exchange
6
in each rating area, access to the uniform outline of
7
coverage the plan is required to provide under sec-
8
tion 2716 of the Public Health Service Act and to
9
a copy of the plan’s written policy.
10
11
(5) ENROLLMENT
PERIODS.—The
Secretary
shall require an Exchange to provide for—
12
(A) an initial open enrollment, as deter-
13
mined by the Secretary (such determination to
14
be made not later than July 1, 2012);
15
(B) annual open enrollment periods, as de-
16
termined by the Secretary for calendar years
17
after the initial enrollment period;
18
(C) special enrollment periods specified in
19
section 9801 of the Internal Revenue Code of
20
1986 and other special enrollment periods
21
under circumstances similar to such periods
22
under part D of title XVIII of the Social Secu-
23
rity Act; and
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1
(D) special monthly enrollment periods for
2
Indians (as defined in section 4 of the Indian
3
Health Care Improvement Act).
4
5
(d) REQUIREMENTS.—
(1) IN
GENERAL.—An
Exchange shall be a gov-
6
ernmental agency or nonprofit entity that is estab-
7
lished by a State.
8
9
(2) OFFERING
(A) IN
OF COVERAGE.—
GENERAL.—An
Exchange shall
10
make available qualified health plans to quali-
11
fied individuals and qualified employers.
12
13
(B) LIMITATION.—
(i) IN
GENERAL.—An
Exchange may
14
not make available any health plan that is
15
not a qualified health plan.
16
(ii) OFFERING
17
TAL BENEFITS.—Each
18
State shall allow an issuer of a plan that
19
only provides limited scope dental benefits
20
meeting
21
9832(c)(2)(A) of the Internal Revenue
22
Code of 1986 to offer the plan through the
23
Exchange (either separately or in conjunc-
24
tion with a qualified health plan) if the
25
plan provides pediatric dental benefits
the
OF STAND-ALONE DEN-
Exchange within a
requirements
of
section
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1
meeting
2
1302(b)(1)(J)).
the
3
(3) RULES
4
QUIRED BENEFITS.—
5
(A) IN
requirements
RELATING
TO
of
section
ADDITIONAL
GENERAL.—Except
RE-
as provided in
6
subparagraph (B), an Exchange may make
7
available a qualified health plan notwith-
8
standing any provision of law that may require
9
benefits other than the essential health benefits
10
11
12
13
specified under section 1302(b).
(B) STATES
MAY REQUIRE ADDITIONAL
BENEFITS.—
(i) IN
GENERAL.—Subject
to the re-
14
quirements of clause (ii), a State may re-
15
quire that a qualified health plan offered
16
in such State offer benefits in addition to
17
the essential health benefits specified
18
under section 1302(b).
19
(ii) STATE
MUST ASSUME COST.—A
20
State shall make payments to or on behalf
21
of an individual eligible for the premium
22
tax credit under section 36B of the Inter-
23
nal Revenue Code of 1986 and any cost-
24
sharing reduction under section 1402 to
25
defray the cost to the individual of any ad-
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1
ditional benefits described in clause (i)
2
which are not eligible for such credit or re-
3
duction under section 36B(b)(3)(D) of
4
such Code and section 1402(c)(4).
5
6
(4) FUNCTIONS.—An Exchange shall, at a minimum—
7
(A) implement procedures for the certifi-
8
cation, recertification, and decertification, con-
9
sistent with guidelines developed by the Sec-
10
retary under subsection (c), of health plans as
11
qualified health plans;
12
(B) provide for the operation of a toll-free
13
telephone hotline to respond to requests for as-
14
sistance;
15
(C) maintain an Internet website through
16
which enrollees and prospective enrollees of
17
qualified health plans may obtain standardized
18
comparative information on such plans;
19
(D) assign a rating to each qualified health
20
plan offered through such Exchange in accord-
21
ance with the criteria developed by the Sec-
22
retary under subsection (c)(3);
23
(E) utilize a standardized format for pre-
24
senting health benefits plan options in the Ex-
25
change, including the use of the uniform outline
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1
of coverage established under section 2715 of
2
the Public Health Service Act;
3
(F) in accordance with section 1413, in-
4
form individuals of eligibility requirements for
5
the medicaid program under title XIX of the
6
Social Security Act, the CHIP program under
7
title XXI of such Act, or any applicable State
8
or local public program and if through screen-
9
ing of the application by the Exchange, the Ex-
10
change determines that such individuals are eli-
11
gible for any such program, enroll such individ-
12
uals in such program;
13
(G) establish and make available by elec-
14
tronic means a calculator to determine the ac-
15
tual cost of coverage after the application of
16
any premium tax credit under section 36B of
17
the Internal Revenue Code of 1986 and any
18
cost-sharing reduction under section 1402;
19
(H) subject to section 1411, grant a cer-
20
tification attesting that, for purposes of the in-
21
dividual responsibility penalty under section
22
5000A of the Internal Revenue Code of 1986,
23
an individual is exempt from the individual re-
24
quirement or from the penalty imposed by such
25
section because—
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(i) there is no affordable qualified
2
health plan available through the Ex-
3
change, or the individual’s employer, cov-
4
ering the individual; or
5
(ii) the individual meets the require-
6
ments for any other such exemption from
7
the individual responsibility requirement or
8
penalty;
9
(I) transfer to the Secretary of the Treas-
10
ury—
11
(i) a list of the individuals who are
12
issued a certification under subparagraph
13
(H), including the name and taxpayer
14
identification number of each individual;
15
(ii) the name and taxpayer identifica-
16
tion number of each individual who was an
17
employee of an employer but who was de-
18
termined to be eligible for the premium tax
19
credit under section 36B of the Internal
20
Revenue Code of 1986 because—
21
22
(I) the employer did not provide
minimum essential coverage; or
23
(II) the employer provided such
24
minimum essential coverage but it
25
was
determined
under
section
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1
36B(c)(2)(C) of such Code to either
2
be unaffordable to the employee or
3
not provide the required minimum ac-
4
tuarial value; and
5
(iii) the name and taxpayer identifica-
6
tion number of each individual who notifies
7
the Exchange under section 1411(b)(4)
8
that they have changed employers and of
9
each individual who ceases coverage under
10
a qualified health plan during a plan year
11
(and the effective date of such cessation);
12
(J) provide to each employer the name of
13
each employee of the employer described in sub-
14
paragraph (I)(ii) who ceases coverage under a
15
qualified health plan during a plan year (and
16
the effective date of such cessation); and
17
(K) establish the Navigator program de-
18
scribed in subsection (i).
19
(5) FUNDING
LIMITATIONS.—
20
(A) NO
21
OPERATIONS.—In
22
under this section, the State shall ensure that
23
such Exchange is self-sustaining beginning on
24
January 1, 2015, including allowing the Ex-
25
change to charge assessments or user fees to
FEDERAL FUNDS FOR CONTINUED
establishing an Exchange
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1
participating health insurance issuers, or to
2
otherwise generate funding, to support its oper-
3
ations.
4
(B) PROHIBITING
WASTEFUL
USE
OF
5
FUNDS.—In
6
subsection, an Exchange shall not utilize any
7
funds intended for the administrative and oper-
8
ational expenses of the Exchange for staff re-
9
treats, promotional giveaways, excessive execu-
10
tive compensation, or promotion of Federal or
11
State legislative and regulatory modifications.
12
(6) CONSULTATION.—An Exchange shall con-
13
sult with stakeholders relevant to carrying out the
14
activities under this section, including—
15
16
carrying out activities under this
(A) health care consumers who are enrollees in qualified health plans;
17
(B) individuals and entities with experience
18
in facilitating enrollment in qualified health
19
plans;
20
21
(C) representatives of small businesses and
self-employed individuals;
22
(D) State Medicaid offices; and
23
(E) advocates for enrolling hard to reach
24
populations.
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1
(7) PUBLICATION
COSTS.—An
OF
Exchange
2
shall publish the average costs of licensing, regu-
3
latory fees, and any other payments required by the
4
Exchange, and the administrative costs of such Ex-
5
change, on an Internet website to educate consumers
6
on such costs. Such information shall also include
7
monies lost to waste, fraud, and abuse.
8
(e) CERTIFICATION.—
9
10
(1) IN
GENERAL.—An
Exchange may certify a
health plan as a qualified health plan if—
11
(A) such health plan meets the require-
12
ments for certification as promulgated by the
13
Secretary under subsection (c)(1); and
14
(B) the Exchange determines that making
15
available such health plan through such Ex-
16
change is in the interests of qualified individ-
17
uals and qualified employers in the State or
18
States in which such Exchange operates, except
19
that the Exchange may not exclude a health
20
plan—
21
22
23
24
(i) on the basis that such plan is a
fee-for-service plan;
(ii) through the imposition of premium price controls; or
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1
(iii) on the basis that the plan pro-
2
vides treatments necessary to prevent pa-
3
tients’ deaths in circumstances the Ex-
4
change determines are inappropriate or too
5
costly.
6
(2)
PREMIUM
CONSIDERATIONS.—The
Ex-
7
change shall require health plans seeking certifi-
8
cation as qualified health plans to submit a justifica-
9
tion for any premium increase prior to implementa-
10
tion of the increase. Such plans shall prominently
11
post such information on their websites. The Ex-
12
change may take this information, and the informa-
13
tion and the recommendations provided to the Ex-
14
change by the State under section 2794(b)(1) of the
15
Public Health Service Act (relating to patterns or
16
practices of excessive or unjustified premium in-
17
creases), into consideration when determining wheth-
18
er to make such health plan available through the
19
Exchange. The Exchange shall take into account any
20
excess of premium growth outside the Exchange as
21
compared to the rate of such growth inside the Ex-
22
change, including information reported by the
23
States.
24
(f) FLEXIBILITY.—
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1
(1) REGIONAL
2
CHANGES.—An
3
one State if—
4
5
OR
OTHER
Exchange may operate in more than
erates permits such operation; and
(B) the Secretary approves such regional
7
or interstate Exchange.
8
(2) SUBSIDIARY
EXCHANGES.—A
State may es-
tablish one or more subsidiary Exchanges if—
10
11
EX-
(A) each State in which such Exchange op-
6
9
INTERSTATE
(A) each such Exchange serves a geographically distinct area; and
12
(B) the area served by each such Exchange
13
is at least as large as a rating area described
14
in section 2701(a) of the Public Health Service
15
Act.
16
(3) AUTHORITY
17
(A) IN
TO CONTRACT.—
GENERAL.—A
State may elect to
18
authorize an Exchange established by the State
19
under this section to enter into an agreement
20
with an eligible entity to carry out 1 or more
21
responsibilities of the Exchange.
22
23
24
(B) ELIGIBLE
ENTITY.—In
this para-
graph, the term ‘‘eligible entity’’ means—
(i) a person—
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1
(I) incorporated under, and sub-
2
ject to the laws of, 1 or more States;
3
(II) that has demonstrated expe-
4
rience on a State or regional basis in
5
the individual and small group health
6
insurance markets and in benefits cov-
7
erage; and
8
(III) that is not a health insur-
9
ance issuer or that is treated under
10
subsection (a) or (b) of section 52 of
11
the Internal Revenue Code of 1986 as
12
a member of the same controlled
13
group of corporations (or under com-
14
mon control with) as a health insur-
15
ance issuer; or
16
(ii) the State medicaid agency under
17
18
title XIX of the Social Security Act.
(g) REWARDING QUALITY THROUGH MARKET-
19 BASED INCENTIVES.—
20
(1) STRATEGY
DESCRIBED.—A
strategy de-
21
scribed in this paragraph is a payment structure
22
that provides increased reimbursement or other in-
23
centives for—
24
(A) improving health outcomes through the
25
implementation of activities that shall include
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1
quality reporting, effective case management,
2
care coordination, chronic disease management,
3
medication and care compliance initiatives, in-
4
cluding through the use of the medical home
5
model, for treatment or services under the plan
6
or coverage;
7
(B) the implementation of activities to pre-
8
vent hospital readmissions through a com-
9
prehensive program for hospital discharge that
10
includes patient-centered education and coun-
11
seling, comprehensive discharge planning, and
12
post discharge reinforcement by an appropriate
13
health care professional;
14
(C) the implementation of activities to im-
15
prove patient safety and reduce medical errors
16
through the appropriate use of best clinical
17
practices, evidence based medicine, and health
18
information technology under the plan or cov-
19
erage; and
20
(D) the implementation of wellness and
21
health promotion activities.
22
(2) GUIDELINES.—The Secretary, in consulta-
23
tion with experts in health care quality and stake-
24
holders, shall develop guidelines concerning the mat-
25
ters described in paragraph (1).
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1
(3) REQUIREMENTS.—The guidelines developed
2
under paragraph (2) shall require the periodic re-
3
porting to the applicable Exchange of the activities
4
that a qualified health plan has conducted to imple-
5
ment a strategy described in paragraph (1).
6
(h) QUALITY IMPROVEMENT.—
7
(1) ENHANCING
PATIENT SAFETY.—Beginning
8
on January 1, 2015, a qualified health plan may
9
contract with—
10
11
(A) a hospital with greater than 50 beds
only if such hospital—
12
(i) utilizes a patient safety evaluation
13
system as described in part C of title IX
14
of the Public Health Service Act; and
15
(ii) implements a mechanism to en-
16
sure that each patient receives a com-
17
prehensive program for hospital discharge
18
that includes patient-centered education
19
and counseling, comprehensive discharge
20
planning, and post discharge reinforcement
21
by an appropriate health care professional;
22
or
23
(B) a health care provider only if such pro-
24
vider implements such mechanisms to improve
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1
health care quality as the Secretary may by reg-
2
ulation require.
3
(2) EXCEPTIONS.—The Secretary may establish
4
reasonable exceptions to the requirements described
5
in paragraph (1).
6
(3) ADJUSTMENT.—The Secretary may by reg-
7
ulation adjust the number of beds described in para-
8
graph (1)(A).
9
(i) NAVIGATORS.—
10
(1) IN
GENERAL.—An
Exchange shall establish
11
a program under which it awards grants to entities
12
described in paragraph (2) to carry out the duties
13
described in paragraph (3).
14
15
(2) ELIGIBILITY.—
(A) IN
GENERAL.—To
be eligible to receive
16
a grant under paragraph (1), an entity shall
17
demonstrate to the Exchange involved that the
18
entity has existing relationships, or could read-
19
ily establish relationships, with employers and
20
employees, consumers (including uninsured and
21
underinsured consumers), or self-employed indi-
22
viduals likely to be qualified to enroll in a quali-
23
fied health plan.
24
(B) TYPES.—Entities described in sub-
25
paragraph (A) may include trade, industry, and
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1
professional associations, commercial fishing in-
2
dustry organizations, ranching and farming or-
3
ganizations, community and consumer-focused
4
nonprofit
5
unions, small business development centers,
6
other licensed insurance agents and brokers,
7
and other entities that—
8
9
10
11
groups,
chambers
of
commerce,
(i) are capable of carrying out the duties described in paragraph (3);
(ii) meet the standards described in
paragraph (4); and
12
(iii) provide information consistent
13
with the standards developed under para-
14
graph (5).
15
16
(3) DUTIES.—An entity that serves as a navigator under a grant under this subsection shall—
17
(A) conduct public education activities to
18
raise awareness of the availability of qualified
19
health plans;
20
(B) distribute fair and impartial informa-
21
tion concerning enrollment in qualified health
22
plans, and the availability of premium tax cred-
23
its under section 36B of the Internal Revenue
24
Code of 1986 and cost-sharing reductions under
25
section 1402;
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1
2
(C) facilitate enrollment in qualified health
plans;
3
(D) provide referrals to any applicable of-
4
fice of health insurance consumer assistance or
5
health insurance ombudsman established under
6
section 2793 of the Public Health Service Act,
7
or any other appropriate State agency or agen-
8
cies, for any enrollee with a grievance, com-
9
plaint, or question regarding their health plan,
10
coverage, or a determination under such plan or
11
coverage; and
12
(E) provide information in a manner that
13
is culturally and linguistically appropriate to
14
the needs of the population being served by the
15
Exchange or Exchanges.
16
(4) STANDARDS.—
17
(A) IN
GENERAL.—The
Secretary shall es-
18
tablish standards for navigators under this sub-
19
section, including provisions to ensure that any
20
private or public entity that is selected as a
21
navigator is qualified, and licensed if appro-
22
priate, to engage in the navigator activities de-
23
scribed in this subsection and to avoid conflicts
24
of interest. Under such standards, a navigator
25
shall not—
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1
(i) be a health insurance issuer; or
2
(ii) receive any consideration directly
3
or indirectly from any health insurance
4
issuer in connection with the enrollment of
5
any qualified individuals or employees of a
6
qualified employer in a qualified health
7
plan.
8
(5) FAIR
9
AND IMPARTIAL INFORMATION AND
SERVICES.—The
Secretary, in collaboration with
10
States, shall develop standards to ensure that infor-
11
mation made available by navigators is fair, accu-
12
rate, and impartial.
13
(6) FUNDING.—Grants under this subsection
14
shall be made from the operational funds of the Ex-
15
change and not Federal funds received by the State
16
to establish the Exchange.
17
(j) APPLICABILITY
OF
MENTAL HEALTH PARITY.—
18 Section 2726 of the Public Health Service Act shall apply
19 to qualified health plans in the same manner and to the
20 same extent as such section applies to health insurance
21 issuers and group health plans.
22
(k) CONFLICT.—An Exchange may not establish
23 rules that conflict with or prevent the application of regu24 lations promulgated by the Secretary under this subtitle.
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1
2
3
SEC. 1312. CONSUMER CHOICE.
(a) CHOICE.—
(1) QUALIFIED
INDIVIDUALS.—A
qualified indi-
4
vidual may enroll in any qualified health plan avail-
5
able to such individual.
6
(2) QUALIFIED
7
EMPLOYERS.—
(A) EMPLOYER
MAY SPECIFY LEVEL.—A
8
qualified employer may provide support for cov-
9
erage of employees under a qualified health
10
plan by selecting any level of coverage under
11
section 1302(d) to be made available to employ-
12
ees through an Exchange.
13
(B) EMPLOYEE
MAY CHOOSE PLANS WITH-
14
IN A LEVEL.—Each
employee of a qualified em-
15
ployer that elects a level of coverage under sub-
16
paragraph (A) may choose to enroll in a quali-
17
fied health plan that offers coverage at that
18
level.
19
(b) PAYMENT
20
UALS.—A
OF
PREMIUMS
BY
QUALIFIED INDIVID-
qualified individual enrolled in any qualified
21 health plan may pay any applicable premium owed by such
22 individual to the health insurance issuer issuing such
23 qualified health plan.
24
(c) SINGLE RISK POOL.—
25
(1) INDIVIDUAL
26
MARKET.—A
health insurance
issuer shall consider all enrollees in all health plans
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1
(other than grandfathered health plans) offered by
2
such issuer in the individual market, including those
3
enrollees who do not enroll in such plans through
4
the Exchange, to be members of a single risk pool.
5
(2) SMALL
GROUP MARKET.—A
health insur-
6
ance issuer shall consider all enrollees in all health
7
plans (other than grandfathered health plans) of-
8
fered by such issuer in the small group market, in-
9
cluding those enrollees who do not enroll in such
10
plans through the Exchange, to be members of a
11
single risk pool.
12
(3) MERGER
OF MARKETS.—A
State may re-
13
quire the individual and small group insurance mar-
14
kets within a State to be merged if the State deter-
15
mines appropriate.
16
(4) STATE
LAW.—A
State law requiring grand-
17
fathered health plans to be included in a pool de-
18
scribed in paragraph (1) or (2) shall not apply.
19
(d) EMPOWERING CONSUMER CHOICE.—
20
(1) CONTINUED
OPERATION OF MARKET OUT-
21
SIDE EXCHANGES.—Nothing
22
construed to prohibit—
in this title shall be
23
(A) a health insurance issuer from offering
24
outside of an Exchange a health plan to a
25
qualified individual or qualified employer; and
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1
(B) a qualified individual from enrolling in,
2
or a qualified employer from selecting for its
3
employees, a health plan offered outside of an
4
Exchange.
5
(2) CONTINUED
OPERATION OF STATE BENEFIT
6
REQUIREMENTS.—Nothing
7
strued to terminate, abridge, or limit the operation
8
of any requirement under State law with respect to
9
any policy or plan that is offered outside of an Ex-
10
11
12
in this title shall be con-
change to offer benefits.
(3) VOLUNTARY
NATURE OF AN EXCHANGE.—
(A) CHOICE
TO ENROLL OR NOT TO EN-
13
ROLL.—Nothing
14
to restrict the choice of a qualified individual to
15
enroll or not to enroll in a qualified health plan
16
or to participate in an Exchange.
17
in this title shall be construed
(B) PROHIBITION
AGAINST
COMPELLED
18
ENROLLMENT.—Nothing
19
construed to compel an individual to enroll in a
20
qualified health plan or to participate in an Ex-
21
change.
22
(C) INDIVIDUALS
in this title shall be
ALLOWED TO ENROLL IN
23
ANY PLAN.—A
24
in any qualified health plan, except that in the
25
case of a catastrophic plan described in section
qualified individual may enroll
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1
1302(e), a qualified individual may enroll in the
2
plan only if the individual is eligible to enroll in
3
the plan under section 1302(e)(2).
4
5
(D) MEMBERS
OF CONGRESS IN THE EX-
CHANGE.—
6
(i) REQUIREMENT.—Notwithstanding
7
any other provision of law, after the effec-
8
tive date of this subtitle, the only health
9
plans that the Federal Government may
10
make available to Members of Congress
11
and congressional staff with respect to
12
their service as a Member of Congress or
13
congressional staff shall be health plans
14
that are—
15
16
(I) created under this Act (or an
amendment made by this Act); or
17
(II) offered through an Exchange
18
established under this Act (or an
19
amendment made by this Act).
20
(ii) DEFINITIONS.—In this section:
21
(I) MEMBER
OF
CONGRESS.—
22
The term ‘‘Member of Congress’’
23
means any member of the House of
24
Representatives or the Senate.
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1
(II) CONGRESSIONAL
STAFF.—
2
The term ‘‘congressional staff’’ means
3
all full-time and part-time employees
4
employed by the official office of a
5
Member of Congress, whether in
6
Washington, DC or outside of Wash-
7
ington, DC.
8
(4) NO
PENALTY FOR TRANSFERRING TO MIN-
9
IMUM ESSENTIAL COVERAGE OUTSIDE EXCHANGE.—
10
An Exchange, or a qualified health plan offered
11
through an Exchange, shall not impose any penalty
12
or other fee on an individual who cancels enrollment
13
in a plan because the individual becomes eligible for
14
minimum essential coverage (as defined in section
15
5000A(f) of the Internal Revenue Code of 1986
16
without regard to paragraph (1)(C) or (D) thereof)
17
or such coverage becomes affordable (within the
18
meaning of section 36B(c)(2)(C) of such Code).
19
(e) ENROLLMENT THROUGH AGENTS
20
KERS.—The
OR
BRO-
Secretary shall establish procedures under
21 which a State may allow agents or brokers—
22
(1) to enroll individuals in any qualified health
23
plans in the individual or small group market as
24
soon as the plan is offered through an Exchange in
25
the State; and
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1
(2) to assist individuals in applying for pre-
2
mium tax credits and cost-sharing reductions for
3
plans sold through an Exchange.
4 Such procedures may include the establishment of rate
5 schedules for broker commissions paid by health benefits
6 plans offered through an exchange.
7
8
(f) QUALIFIED INDIVIDUALS
CESS
LIMITED
TO
CITIZENS
9
(1) QUALIFIED
10
(A) IN
AND
AND
EMPLOYERS; AC-
LAWFUL RESIDENTS.—
INDIVIDUALS.—In
GENERAL.—The
this title:
term ‘‘qualified in-
11
dividual’’ means, with respect to an Exchange,
12
an individual who—
13
(i) is seeking to enroll in a qualified
14
health plan in the individual market of-
15
fered through the Exchange; and
16
(ii) resides in the State that estab-
17
lished the Exchange (except with respect to
18
territorial
19
1312(f)).
20
(B)
21
CLUDED.—An
22
a qualified individual if, at the time of enroll-
23
ment, the individual is incarcerated, other than
24
incarceration
25
charges.
agreements
INCARCERATED
under
section
INDIVIDUALS
EX-
individual shall not be treated as
pending
the
disposition
of
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1
2
(2) QUALIFIED
(A) IN
EMPLOYER.—In
GENERAL.—The
this title:
term ‘‘qualified
3
employer’’ means a small employer that elects
4
to make all full-time employees of such em-
5
ployer eligible for 1 or more qualified health
6
plans offered in the small group market
7
through an Exchange that offers qualified
8
health plans.
9
(B) EXTENSION
10
(i) IN
TO LARGE GROUPS.—
GENERAL.—Beginning
in 2017,
11
each State may allow issuers of health in-
12
surance coverage in the large group mar-
13
ket in the State to offer qualified health
14
plans in such market through an Ex-
15
change. Nothing in this subparagraph shall
16
be construed as requiring the issuer to
17
offer such plans through an Exchange.
18
(ii) LARGE
EMPLOYERS ELIGIBLE.—If
19
a State under clause (i) allows issuers to
20
offer qualified health plans in the large
21
group market through an Exchange, the
22
term ‘‘qualified employer’’ shall include a
23
large employer that elects to make all full-
24
time employees of such employer eligible
25
for 1 or more qualified health plans offered
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1
in the large group market through the Ex-
2
change.
3
(3) ACCESS
LIMITED TO LAWFUL RESIDENTS.—
4
If an individual is not, or is not reasonably expected
5
to be for the entire period for which enrollment is
6
sought, a citizen or national of the United States or
7
an alien lawfully present in the United States, the
8
individual shall not be treated as a qualified indi-
9
vidual and may not be covered under a qualified
10
health plan in the individual market that is offered
11
through an Exchange.
12
SEC. 1313. FINANCIAL INTEGRITY.
13
14
(a) ACCOUNTING FOR EXPENDITURES.—
(1) IN
GENERAL.—An
Exchange shall keep an
15
accurate accounting of all activities, receipts, and ex-
16
penditures and shall annually submit to the Sec-
17
retary a report concerning such accountings.
18
(2) INVESTIGATIONS.—The Secretary, in co-
19
ordination with the Inspector General of the Depart-
20
ment of Health and Human Services, may inves-
21
tigate the affairs of an Exchange, may examine the
22
properties and records of an Exchange, and may re-
23
quire periodic reports in relation to activities under-
24
taken by an Exchange. An Exchange shall fully co-
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1
operate in any investigation conducted under this
2
paragraph.
3
4
5
(3) AUDITS.—An Exchange shall be subject to
annual audits by the Secretary.
(4) PATTERN
OF ABUSE.—If
the Secretary de-
6
termines that an Exchange or a State has engaged
7
in serious misconduct with respect to compliance
8
with the requirements of, or carrying out of activi-
9
ties required under, this title, the Secretary may re-
10
scind from payments otherwise due to such State in-
11
volved under this or any other Act administered by
12
the Secretary an amount not to exceed 1 percent of
13
such payments per year until corrective actions are
14
taken by the State that are determined to be ade-
15
quate by the Secretary.
16
(5)
PROTECTIONS
AGAINST
FRAUD
AND
17
ABUSE.—With
18
this title, the Secretary shall provide for the efficient
19
and non-discriminatory administration of Exchange
20
activities and implement any measure or procedure
21
that—
respect to activities carried out under
22
(A) the Secretary determines is appro-
23
priate to reduce fraud and abuse in the admin-
24
istration of this title; and
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1
(B) the Secretary has authority to imple-
2
ment under this title or any other Act.
3
(6) APPLICATION
4
5
OF
THE
FALSE
CLAIMS
ACT.—
(A) IN
GENERAL.—Payments
made by,
6
through, or in connection with an Exchange are
7
subject to the False Claims Act (31 U.S.C.
8
3729 et seq.) if those payments include any
9
Federal funds. Compliance with the require-
10
ments of this Act concerning eligibility for a
11
health insurance issuer to participate in the Ex-
12
change shall be a material condition of an
13
issuer’s entitlement to receive payments, includ-
14
ing payments of premium tax credits and cost-
15
sharing reductions, through the Exchange.
16
(B)
DAMAGES.—Notwithstanding
para-
17
graph (1) of section 3729(a) of title 31, United
18
States Code, and subject to paragraph (2) of
19
such section, the civil penalty assessed under
20
the False Claims Act on any person found liable
21
under such Act as described in subparagraph
22
(A) shall be increased by not less than 3 times
23
and not more than 6 times the amount of dam-
24
ages which the Government sustains because of
25
the act of that person.
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1
(b) GAO OVERSIGHT.—Not later than 5 years after
2 the first date on which Exchanges are required to be oper3 ational under this title, the Comptroller General shall con4 duct an ongoing study of Exchange activities and the en5 rollees in qualified health plans offered through Ex6 changes. Such study shall review—
7
(1) the operations and administration of Ex-
8
changes, including surveys and reports of qualified
9
health plans offered through Exchanges and on the
10
experience of such plans (including data on enrollees
11
in Exchanges and individuals purchasing health in-
12
surance coverage outside of Exchanges), the ex-
13
penses of Exchanges, claims statistics relating to
14
qualified health plans, complaints data relating to
15
such plans, and the manner in which Exchanges
16
meet their goals;
17
18
(2) any significant observations regarding the
utilization and adoption of Exchanges;
19
(3) where appropriate, recommendations for im-
20
provements in the operations or policies of Ex-
21
changes; and
22
(4) how many physicians, by area and specialty,
23
are not taking or accepting new patients enrolled in
24
Federal Government health care programs, and the
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1
adequacy of provider networks of Federal Govern-
2
ment health care programs.
3
PART III—STATE FLEXIBILITY RELATING TO
4
EXCHANGES
5
SEC. 1321. STATE FLEXIBILITY IN OPERATION AND EN-
6
FORCEMENT OF EXCHANGES AND RELATED
7
REQUIREMENTS.
8
9
(a) ESTABLISHMENT OF STANDARDS.—
(1) IN
GENERAL.—The
Secretary shall, as soon
10
as practicable after the date of enactment of this
11
Act, issue regulations setting standards for meeting
12
the requirements under this title, and the amend-
13
ments made by this title, with respect to—
14
15
(A) the establishment and operation of Exchanges (including SHOP Exchanges);
16
17
(B) the offering of qualified health plans
through such Exchanges;
18
(C) the establishment of the reinsurance
19
and risk adjustment programs under part V;
20
and
21
22
(D) such other requirements as the Secretary determines appropriate.
23
The preceding sentence shall not apply to standards
24
for requirements under subtitles A and C (and the
25
amendments made by such subtitles) for which the
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Secretary issues regulations under the Public Health
2
Service Act.
3
(2) CONSULTATION.—In issuing the regulations
4
under paragraph (1), the Secretary shall consult
5
with the National Association of Insurance Commis-
6
sioners and its members and with health insurance
7
issuers, consumer organizations, and such other in-
8
dividuals as the Secretary selects in a manner de-
9
signed to ensure balanced representation among in-
10
terested parties.
11
(b) STATE ACTION.—Each State that elects, at such
12 time and in such manner as the Secretary may prescribe,
13 to apply the requirements described in subsection (a)
14 shall, not later than January 1, 2014, adopt and have in
15 effect—
16
17
(1) the Federal standards established under
subsection (a); or
18
(2) a State law or regulation that the Secretary
19
determines implements the standards within the
20
State.
21
(c) FAILURE
22
23
24
25
MENT
TO
ESTABLISH EXCHANGE
OR
IMPLE-
REQUIREMENTS.—
(1) IN
GENERAL.—If—
(A) a State is not an electing State under
subsection (b); or
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1
2
(B) the Secretary determines, on or before
January 1, 2013, that an electing State—
3
(i) will not have any required Ex-
4
change operational by January 1, 2014; or
5
(ii) has not taken the actions the Sec-
6
retary determines necessary to imple-
7
ment—
8
(I) the other requirements set
9
forth in the standards under sub-
10
section (a); or
11
(II) the requirements set forth in
12
subtitles A and C and the amend-
13
ments made by such subtitles;
14
the Secretary shall (directly or through agreement
15
with a not-for-profit entity) establish and operate
16
such Exchange within the State and the Secretary
17
shall take such actions as are necessary to imple-
18
ment such other requirements.
19
(2) ENFORCEMENT
AUTHORITY.—The
provi-
20
sions of section 2736(b) of the Public Health Serv-
21
ices Act shall apply to the enforcement under para-
22
graph (1) of requirements of subsection (a)(1) (with-
23
out regard to any limitation on the application of
24
those provisions to group health plans).
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1
(d) NO INTERFERENCE WITH STATE REGULATORY
2 AUTHORITY.—Nothing in this title shall be construed to
3 preempt any State law that does not prevent the applica4 tion of the provisions of this title.
5
(e) PRESUMPTION
FOR
CERTAIN STATE-OPERATED
6 EXCHANGES.—
7
(1) IN
GENERAL.—In
the case of a State oper-
8
ating an Exchange before January 1, 2010, and
9
which has insured a percentage of its population not
10
less than the percentage of the population projected
11
to be covered nationally after the implementation of
12
this Act, that seeks to operate an Exchange under
13
this section, the Secretary shall presume that such
14
Exchange meets the standards under this section
15
unless the Secretary determines, after completion of
16
the process established under paragraph (2), that
17
the Exchange does not comply with such standards.
18
(2) PROCESS.—The Secretary shall establish a
19
process to work with a State described in paragraph
20
(1) to provide assistance necessary to assist the
21
State’s Exchange in coming into compliance with the
22
standards for approval under this section.
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1
SEC. 1322. FEDERAL PROGRAM TO ASSIST ESTABLISHMENT
2
AND OPERATION OF NONPROFIT, MEMBER-
3
RUN HEALTH INSURANCE ISSUERS.
4
(a) ESTABLISHMENT OF PROGRAM.—
5
(1) IN
GENERAL.—The
Secretary shall establish
6
a program to carry out the purposes of this section
7
to be known as the Consumer Operated and Ori-
8
ented Plan (CO-OP) program.
9
(2) PURPOSE.—It is the purpose of the CO-OP
10
program to foster the creation of qualified nonprofit
11
health insurance issuers to offer qualified health
12
plans in the individual and small group markets in
13
the States in which the issuers are licensed to offer
14
such plans.
15
(b) LOANS
16
17
AND
GRANTS UNDER
THE
CO-OP PRO-
GRAM.—
(1) IN
GENERAL.—The
Secretary shall provide
18
through the CO-OP program for the awarding to
19
persons applying to become qualified nonprofit
20
health insurance issuers of—
21
22
(A) loans to provide assistance to such person in meeting its start-up costs; and
23
(B) grants to provide assistance to such
24
person in meeting any solvency requirements of
25
States in which the person seeks to be licensed
26
to issue qualified health plans.
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1
2
3
(2) REQUIREMENTS
FOR AWARDING LOANS AND
GRANTS.—
(A) IN
GENERAL.—In
awarding loans and
4
grants under the CO-OP program, the Sec-
5
retary shall—
6
(i) take into account the recommenda-
7
tions of the advisory board established
8
under paragraph (3);
9
(ii) give priority to applicants that will
10
offer qualified health plans on a Statewide
11
basis, will utilize integrated care models,
12
and have significant private support; and
13
(iii) ensure that there is sufficient
14
funding to establish at least 1 qualified
15
nonprofit health insurance issuer in each
16
State, except that nothing in this clause
17
shall prohibit the Secretary from funding
18
the establishment of multiple qualified
19
nonprofit health insurance issuers in any
20
State if the funding is sufficient to do so.
21
(B) STATES
WITHOUT ISSUERS IN PRO-
22
GRAM.—If
23
be a qualified nonprofit health insurance issuer
24
within a State, the Secretary may use amounts
25
appropriated under this section for the award-
no health insurance issuer applies to
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1
ing of grants to encourage the establishment of
2
a qualified nonprofit health insurance issuer
3
within the State or the expansion of a qualified
4
nonprofit health insurance issuer from another
5
State to the State.
6
7
(C) AGREEMENT.—
(i) IN
GENERAL.—The
Secretary shall
8
require any person receiving a loan or
9
grant under the CO-OP program to enter
10
into an agreement with the Secretary
11
which requires such person to meet (and to
12
continue to meet)—
13
(I) any requirement under this
14
section for such person to be treated
15
as a qualified nonprofit health insur-
16
ance issuer; and
17
(II) any requirements contained
18
in the agreement for such person to
19
receive such loan or grant.
20
(ii) RESTRICTIONS
ON USE OF FED-
21
ERAL FUNDS.—The
22
clude a requirement that no portion of the
23
funds made available by any loan or grant
24
under this section may be used—
agreement shall in-
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1
(I) for carrying on propaganda,
2
or otherwise attempting, to influence
3
legislation; or
4
(II) for marketing.
5
Nothing in this clause shall be construed
6
to allow a person to take any action pro-
7
hibited by section 501(c)(29) of the Inter-
8
nal Revenue Code of 1986.
9
(iii) FAILURE
TO
MEET
REQUIRE-
10
MENTS.—If
11
a person has failed to meet any require-
12
ment described in clause (i) or (ii) and has
13
failed to correct such failure within a rea-
14
sonable period of time of when the person
15
first knows (or reasonably should have
16
known) of such failure, such person shall
17
repay to the Secretary an amount equal to
18
the sum of—
the Secretary determines that
19
(I) 110 percent of the aggregate
20
amount of loans and grants received
21
under this section; plus
22
(II) interest on the aggregate
23
amount of loans and grants received
24
under this section for the period the
25
loans or grants were outstanding.
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1
The Secretary shall notify the Secretary of
2
the Treasury of any determination under
3
this section of a failure that results in the
4
termination of an issuer’s tax-exempt sta-
5
tus under section 501(c)(29) of such Code.
6
(D) TIME
FOR
AWARDING
LOANS
AND
7
GRANTS.—The
8
July 1, 2013, award the loans and grants under
9
the CO-OP program and begin the distribution
10
of amounts awarded under such loans and
11
grants.
12
(3) ADVISORY
13
(A) IN
Secretary shall not later than
BOARD.—
GENERAL.—The
advisory board
14
under this paragraph shall consist of 15 mem-
15
bers appointed by the Comptroller General of
16
the United States from among individuals with
17
qualifications described in section 1805(c)(2) of
18
the Social Security Act.
19
20
(B)
RULES
RELATING
TO
APPOINT-
MENTS.—
21
(i) STANDARDS.—Any individual ap-
22
pointed under subparagraph (A) shall meet
23
ethics and conflict of interest standards
24
protecting against insurance industry in-
25
volvement and interference.
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1
(ii) ORIGINAL
APPOINTMENTS.—The
2
original appointment of board members
3
under subparagraph (A)(ii) shall be made
4
no later than 3 months after the date of
5
enactment of this Act.
6
(C) VACANCY.—Any vacancy on the advi-
7
sory board shall be filled in the same manner
8
as the original appointment.
9
10
(D) PAY
AND REIMBURSEMENT.—
(i) NO
COMPENSATION FOR MEMBERS
11
OF ADVISORY BOARD.—Except
12
in clause (ii), a member of the advisory
13
board may not receive pay, allowances, or
14
benefits by reason of their service on the
15
board.
16
(ii) TRAVEL
as provided
EXPENSES.—Each
mem-
17
ber shall receive travel expenses, including
18
per diem in lieu of subsistence under sub-
19
chapter I of chapter 57 of title 5, United
20
States Code.
21
(E) APPLICATION
OF FACA.—The
Federal
22
Advisory Committee Act (5 U.S.C. App.) shall
23
apply to the advisory board, except that section
24
14 of such Act shall not apply.
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1
(F) TERMINATION.—The advisory board
2
shall terminate on the earlier of the date that
3
it completes its duties under this section or De-
4
cember 31, 2015.
5
(c) QUALIFIED NONPROFIT HEALTH INSURANCE
6 ISSUER.—For purposes of this section—
7
(1) IN
GENERAL.—The
term ‘‘qualified non-
8
profit health insurance issuer’’ means a health insur-
9
ance issuer that is an organization—
10
11
(A) that is organized under State law as a
nonprofit, member corporation;
12
(B) substantially all of the activities of
13
which consist of the issuance of qualified health
14
plans in the individual and small group markets
15
in each State in which it is licensed to issue
16
such plans; and
17
(C) that meets the other requirements of
18
this subsection.
19
(2) CERTAIN
ORGANIZATIONS PROHIBITED.—
20
An organization shall not be treated as a qualified
21
nonprofit health insurance issuer if—
22
(A) the organization or a related entity (or
23
any predecessor of either) was a health insur-
24
ance issuer on July 16, 2009; or
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1
(B) the organization is sponsored by a
2
State or local government, any political subdivi-
3
sion thereof, or any instrumentality of such
4
government or political subdivision.
5
(3) GOVERNANCE
REQUIREMENTS.—An
organi-
6
zation shall not be treated as a qualified nonprofit
7
health insurance issuer unless—
8
9
(A) the governance of the organization is
subject to a majority vote of its members;
10
(B) its governing documents incorporate
11
ethics and conflict of interest standards pro-
12
tecting against insurance industry involvement
13
and interference; and
14
(C) as provided in regulations promulgated
15
by the Secretary, the organization is required to
16
operate with a strong consumer focus, including
17
timeliness, responsiveness, and accountability to
18
members.
19
(4) PROFITS
INURE
TO
BENEFIT
OF
MEM-
20
BERS.—An
21
qualified nonprofit health insurance issuer unless
22
any profits made by the organization are required to
23
be used to lower premiums, to improve benefits, or
24
for other programs intended to improve the quality
25
of health care delivered to its members.
organization shall not be treated as a
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1
(5) COMPLIANCE
WITH
STATE
INSURANCE
2
LAWS.—An
3
qualified nonprofit health insurance issuer unless the
4
organization meets all the requirements that other
5
issuers of qualified health plans are required to meet
6
in any State where the issuer offers a qualified
7
health plan, including solvency and licensure require-
8
ments, rules on payments to providers, and compli-
9
ance with network adequacy rules, rate and form fil-
10
ing rules, any applicable State premium assessments
11
and any other State law described in section
12
1324(b).
13
organization shall not be treated as a
(6) COORDINATION
WITH STATE INSURANCE
14
REFORMS.—An
15
a qualified nonprofit health insurance issuer unless
16
the organization does not offer a health plan in a
17
State until that State has in effect (or the Secretary
18
has implemented for the State) the market reforms
19
required by part A of title XXVII of the Public
20
Health Service Act (as amended by subtitles A and
21
C of this Act).
22
(d) ESTABLISHMENT
organization shall not be treated as
OF
PRIVATE PURCHASING
23 COUNCIL.—
24
25
(1) IN
GENERAL.—Qualified
nonprofit health
insurance issuers participating in the CO-OP pro-
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1
gram under this section may establish a private pur-
2
chasing council to enter into collective purchasing
3
arrangements for items and services that increase
4
administrative and other cost efficiencies, including
5
claims administration, administrative services, health
6
information technology, and actuarial services.
7
(2) COUNCIL
MAY NOT SET PAYMENT RATES.—
8
The private purchasing council established under
9
paragraph (1) shall not set payment rates for health
10
care facilities or providers participating in health in-
11
surance coverage provided by qualified nonprofit
12
health insurance issuers.
13
14
15
(3) CONTINUED
APPLICATION OF ANTITRUST
LAWS.—
(A) IN
GENERAL.—Nothing
in this section
16
shall be construed to limit the application of the
17
antitrust laws to any private purchasing council
18
(whether or not established under this sub-
19
section) or to any qualified nonprofit health in-
20
surance issuer participating in such a council.
21
(B) ANTITRUST
LAWS.—For
purposes of
22
this subparagraph, the term ‘‘antitrust laws’’
23
has the meaning given the term in subsection
24
(a) of the first section of the Clayton Act (15
25
U.S.C. 12(a)). Such term also includes section
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1
5 of the Federal Trade Commission Act (15
2
U.S.C. 45) to the extent that such section 5 ap-
3
plies to unfair methods of competition.
4
(e) LIMITATION
ON
PARTICIPATION.—No representa-
5 tive of any Federal, State, or local government (or of any
6 political subdivision or instrumentality thereof), and no
7 representative of a person described in subsection
8 (c)(2)(A), may serve on the board of directors of a quali9 fied nonprofit health insurance issuer or with a private
10 purchasing council established under subsection (d).
11
12
(f) LIMITATIONS ON SECRETARY.—
(1) IN
GENERAL.—The
Secretary shall not—
13
(A) participate in any negotiations between
14
1 or more qualified nonprofit health insurance
15
issuers (or a private purchasing council estab-
16
lished under subsection (d)) and any health
17
care facilities or providers, including any drug
18
manufacturer, pharmacy, or hospital; and
19
(B) establish or maintain a price structure
20
for reimbursement of any health benefits cov-
21
ered by such issuers.
22
(2) COMPETITION.—Nothing in this section
23
shall be construed as authorizing the Secretary to
24
interfere with the competitive nature of providing
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health benefits through qualified nonprofit health in-
2
surance issuers.
3
(g) APPROPRIATIONS.—There are hereby appro-
4 priated, out of any funds in the Treasury not otherwise
5 appropriated, $6,000,000,000 to carry out this section.
6
(h) TAX EXEMPTION
FOR
QUALIFIED NONPROFIT
7 HEALTH INSURANCE ISSUER.—
8
(1) IN
GENERAL.—Section
501(c) of the Inter-
9
nal Revenue Code of 1986 (relating to list of exempt
10
organizations) is amended by adding at the end the
11
following:
12
13
‘‘(29) CO-OP
‘‘(A) IN
HEALTH INSURANCE ISSUERS.—
GENERAL.—A
qualified nonprofit
14
health insurance issuer (within the meaning of
15
section 1322 of the Patient Protection and Af-
16
fordable Care Act) which has received a loan or
17
grant under the CO-OP program under such
18
section, but only with respect to periods for
19
which the issuer is in compliance with the re-
20
quirements of such section and any agreement
21
with respect to the loan or grant.
22
‘‘(B) CONDITIONS
FOR EXEMPTION.—Sub-
23
paragraph (A) shall apply to an organization
24
only if—
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‘‘(i) the organization has given notice
2
to the Secretary, in such manner as the
3
Secretary may by regulations prescribe,
4
that it is applying for recognition of its
5
status under this paragraph,
6
‘‘(ii) except as provided in section
7
1322(c)(4) of the Patient Protection and
8
Affordable Care Act, no part of the net
9
earnings of which inures to the benefit of
10
any private shareholder or individual,
11
‘‘(iii) no substantial part of the activi-
12
ties of which is carrying on propaganda, or
13
otherwise attempting, to influence legisla-
14
tion, and
15
‘‘(iv) the organization does not par-
16
ticipate in, or intervene in (including the
17
publishing or distributing of statements),
18
any political campaign on behalf of (or in
19
opposition to) any candidate for public of-
20
fice.’’.
21
(2) ADDITIONAL
REPORTING REQUIREMENT.—
22
Section 6033 of such Code (relating to returns by
23
exempt organizations) is amended by redesignating
24
subsection (m) as subsection (n) and by inserting
25
after subsection (l) the following:
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‘‘(m) ADDITIONAL INFORMATION REQUIRED FROM
2 CO-OP INSURERS.—An organization described in section
3 501(c)(29) shall include on the return required under sub4 section (a) the following information:
5
‘‘(1) The amount of the reserves required by
6
each State in which the organization is licensed to
7
issue qualified health plans.
8
‘‘(2) The amount of reserves on hand.’’.
9
(3) APPLICATION
OF TAX ON EXCESS BENEFIT
10
TRANSACTIONS.—Section
11
(defining applicable tax-exempt organization) is
12
amended by striking ‘‘paragraph (3) or (4)’’ and in-
13
serting ‘‘paragraph (3), (4), or (29)’’.
14
(i) GAO STUDY AND REPORT.—
4958(e)(1) of such Code
15
(1) STUDY.—The Comptroller General of the
16
General Accountability Office shall conduct an ongo-
17
ing study on competition and market concentration
18
in the health insurance market in the United States
19
after the implementation of the reforms in such
20
market under the provisions of, and the amendments
21
made by, this Act. Such study shall include an anal-
22
ysis of new issuers of health insurance in such mar-
23
ket.
24
(2) REPORT.—The Comptroller General shall,
25
not later than December 31 of each even-numbered
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1
year (beginning with 2014), report to the appro-
2
priate committees of the Congress the results of the
3
study conducted under paragraph (1), including any
4
recommendations for administrative or legislative
5
changes the Comptroller General determines nec-
6
essary or appropriate to increase competition in the
7
health insurance market.
8
9
10
SEC. 1323. COMMUNITY HEALTH INSURANCE OPTION.
(a) VOLUNTARY NATURE.—
(1) NO
REQUIREMENT FOR HEALTH CARE PRO-
11
VIDERS TO PARTICIPATE.—Nothing
12
shall be construed to require a health care provider
13
to participate in a community health insurance op-
14
tion, or to impose any penalty for non-participation.
15
(2) NO
in this section
REQUIREMENT FOR INDIVIDUALS TO
16
JOIN.—Nothing
17
require an individual to participate in a community
18
health insurance option, or to impose any penalty for
19
non-participation.
20
(3) STATE
21
in this section shall be construed to
OPT OUT.—
(A) IN
GENERAL.—A
State may elect to
22
prohibit Exchanges in such State from offering
23
a community health insurance option if such
24
State enacts a law to provide for such prohibi-
25
tion.
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1
(B) TERMINATION
OF OPT OUT.—A
State
2
may repeal a law described in subparagraph (A)
3
and provide for the offering of such an option
4
through the Exchange.
5
6
(b) ESTABLISHMENT
SURANCE
OF
COMMUNITY HEALTH IN-
OPTION.—
7
(1) ESTABLISHMENT.—The Secretary shall es-
8
tablish a community health insurance option to
9
offer, through the Exchanges established under this
10
title (other than Exchanges in States that elect to
11
opt out as provided for in subsection (a)(3)), health
12
care coverage that provides value, choice, competi-
13
tion, and stability of affordable, high quality cov-
14
erage throughout the United States.
15
(2)
COMMUNITY
HEALTH
INSURANCE
OP-
16
TION.—In
17
insurance option’’ means health insurance coverage
18
that—
this section, the term ‘‘community health
19
(A) except as specifically provided for in
20
this section, complies with the requirements for
21
being a qualified health plan;
22
23
(B) provides high value for the premium
charged;
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(C) reduces administrative costs and pro-
2
motes administrative simplification for bene-
3
ficiaries;
4
(D) promotes high quality clinical care;
5
(E) provides high quality customer service
6
to beneficiaries;
7
8
(F) offers a sufficient choice of providers;
and
9
(G) complies with State laws (if any), ex-
10
cept as otherwise provided for in this title, re-
11
lating to the laws described in section 1324(b).
12
(3) ESSENTIAL
13
HEALTH BENEFITS.—
(A) GENERAL
RULE.—Except
as provided
14
in subparagraph (B), a community health in-
15
surance option offered under this section shall
16
provide coverage only for the essential health
17
benefits described in section 1302(b).
18
(B) STATES
MAY OFFER ADDITIONAL BEN-
19
EFITS.—Nothing
in this section shall preclude a
20
State from requiring that benefits in addition to
21
the essential health benefits required under sub-
22
paragraph (A) be provided to enrollees of a
23
community health insurance option offered in
24
such State.
25
(C) CREDITS.—
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1
(i) IN
GENERAL.—An
individual en-
2
rolled in a community health insurance op-
3
tion under this section shall be eligible for
4
credits under section 36B of the Internal
5
Revenue Code of 1986 in the same manner
6
as an individual who is enrolled in a quali-
7
fied health plan.
8
9
(ii)
COST.—A
NO
ADDITIONAL
FEDERAL
requirement by a State under
10
subparagraph (B) that benefits in addition
11
to the essential health benefits required
12
under subparagraph (A) be provided to en-
13
rollees of a community health insurance
14
option shall not affect the amount of a pre-
15
mium tax credit provided under section
16
36B of the Internal Revenue Code of 1986
17
with respect to such plan.
18
(D) STATE
MUST ASSUME COST.—A
State
19
shall make payments to or on behalf of an eligi-
20
ble individual to defray the cost of any addi-
21
tional benefits described in subparagraph (B).
22
(E) ENSURING
ACCESS
TO
ALL
SERV-
23
ICES.—Nothing
24
dividual enrolled in a community health insur-
25
ance option from paying out-of-pocket the full
in this Act shall prohibit an in-
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1
cost of any item or service not included as an
2
essential health benefit or otherwise covered as
3
a benefit by a health plan. Nothing in subpara-
4
graph (B) shall prohibit any type of medical
5
provider from accepting an out-of-pocket pay-
6
ment from an individual enrolled in a commu-
7
nity health insurance option for a service other-
8
wise not included as an essential health benefit.
9
(F) PROTECTING
ACCESS TO END OF LIFE
10
CARE.—A
11
offered under this section shall be prohibited
12
from limiting access to end of life care.
13
(4) COST
community health insurance option
SHARING.—A
community health in-
14
surance option shall offer coverage at each of the
15
levels of coverage described in section 1302(d).
16
17
(5) PREMIUMS.—
(A) PREMIUMS
SUFFICIENT
TO
COVER
18
COSTS.—The
19
graphically adjusted premium rates in an
20
amount sufficient to cover expected costs (in-
21
cluding claims and administrative costs) using
22
methods in general use by qualified health
23
plans.
24
25
Secretary shall establish geo-
(B) APPLICABLE
RULES.—The
provisions
of title XXVII of the Public Health Service Act
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1
relating to premiums shall apply to community
2
health insurance options under this section, in-
3
cluding modified community rating provisions
4
under section 2701 of such Act.
5
(C) COLLECTION
OF
DATA.—The
Sec-
6
retary shall collect data as necessary to set pre-
7
mium rates under subparagraph (A).
8
(D)
NATIONAL
POOLING.—Notwith-
9
standing any other provision of law, the Sec-
10
retary may treat all enrollees in community
11
health insurance options as members of a single
12
pool.
13
(E) CONTINGENCY
MARGIN.—In
estab-
14
lishing premium rates under subparagraph (A),
15
the Secretary shall include an appropriate
16
amount for a contingency margin.
17
(6) REIMBURSEMENT
18
RATES.—
(A) NEGOTIATED
RATES.—The
Secretary
19
shall negotiate rates for the reimbursement of
20
health care providers for benefits covered under
21
a community health insurance option.
22
(B) LIMITATION.—The rates described in
23
subparagraph (A) shall not be higher, in aggre-
24
gate, than the average reimbursement rates
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1
paid by health insurance issuers offering quali-
2
fied health plans through the Exchange.
3
(C) INNOVATION.—Subject to the limits
4
contained in subparagraph (A), a State Advi-
5
sory Council established or designated under
6
subsection (d) may develop or encourage the
7
use of innovative payment policies that promote
8
quality, efficiency and savings to consumers.
9
(7) SOLVENCY
AND CONSUMER PROTECTION.—
10
(A) SOLVENCY.—The Secretary shall es-
11
tablish a Federal solvency standard to be ap-
12
plied with respect to a community health insur-
13
ance option. A community health insurance op-
14
tion shall also be subject to the solvency stand-
15
ard of each State in which such community
16
health insurance option is offered.
17
(B) MINIMUM
REQUIRED.—In
establishing
18
the standard described under subparagraph
19
(A), the Secretary shall require a reserve fund
20
that shall be equal to at least the dollar value
21
of the incurred but not reported claims of a
22
community health insurance option.
23
(C) CONSUMER
PROTECTIONS.—The
con-
24
sumer protection laws of a State shall apply to
25
a community health insurance option.
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1
2
3
(8) REQUIREMENTS
ESTABLISHED IN PARTNER-
SHIP WITH INSURANCE COMMISSIONERS.—
(A) IN
GENERAL.—The
Secretary, in col-
4
laboration with the National Association of In-
5
surance Commissioners (in this paragraph re-
6
ferred to as the ‘‘NAIC’’), may promulgate reg-
7
ulations to establish additional requirements for
8
a community health insurance option.
9
(B)
APPLICABILITY.—Any
requirement
10
promulgated under subparagraph (A) shall be
11
applicable to such option beginning 90 days
12
after the date on which the regulation involved
13
becomes final.
14
(c) START-UP FUND.—
15
16
(1) ESTABLISHMENT
(A) IN
OF FUND.—
GENERAL.—There
is established in
17
the Treasury of the United States a trust fund
18
to be known as the ‘‘Health Benefit Plan Start-
19
Up Fund’’ (referred to in this section as the
20
‘‘Start-Up Fund’’), that shall consist of such
21
amounts as may be appropriated or credited to
22
the Start-Up Fund as provided for in this sub-
23
section to provide loans for the initial oper-
24
ations of a community health insurance option.
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1
Such amounts shall remain available until ex-
2
pended.
3
(B) FUNDING.—There is hereby appro-
4
priated to the Start-Up Fund, out of any mon-
5
eys in the Treasury not otherwise appropriated
6
an amount requested by the Secretary of
7
Health and Human Services as necessary to—
8
(i) pay the start-up costs associated
9
with the initial operations of a community
10
health insurance option; and
11
(ii) pay the costs of making payments
12
on claims submitted during the period that
13
is not more than 90 days from the date on
14
which such option is offered.
15
(2) USE
OF START-UP FUND.—The
Secretary
16
shall use amounts contained in the Start-Up Fund
17
to make payments (subject to the repayment re-
18
quirements in paragraph (4)) for the purposes de-
19
scribed in paragraph (1)(B).
20
(3) PASS
THROUGH OF REBATES.—The
Sec-
21
retary may establish procedures for reducing the
22
amount of payments to a contracting administrator
23
to take into account any rebates or price conces-
24
sions.
25
(4) REPAYMENT.—
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1
(A) IN
GENERAL.—A
community health in-
2
surance option shall be required to repay the
3
Secretary of the Treasury (on such terms as the
4
Secretary may require) for any payments made
5
under paragraph (1)(B) by the date that is not
6
later than 9 years after the date on which the
7
payment is made. The Secretary may require
8
the payment of interest with respect to such re-
9
payments at rates that do not exceed the mar-
10
ket interest rate (as determined by the Sec-
11
retary).
12
(B) SANCTIONS
IN CASE OF FOR-PROFIT
13
CONVERSION.—In
14
retary enters into a contract with a qualified
15
entity for the offering of a community health
16
insurance option and such entity is determined
17
to be a for-profit entity by the Secretary, such
18
entity shall be—
any case in which the Sec-
19
(i) immediately liable to the Secretary
20
for any payments received by such entity
21
from the Start-Up Fund; and
22
23
24
(ii) permanently ineligible to offer a
qualified health plan.
(d) STATE ADVISORY COUNCIL.—
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1
(1) ESTABLISHMENT.—A State (other than a
2
State that elects to opt out as provided for in sub-
3
section (a)(3)) shall establish or designate a public
4
or non-profit private entity to serve as the State Ad-
5
visory Council to provide recommendations to the
6
Secretary on the operations and policies of a com-
7
munity health insurance option in the State. Such
8
Council shall provide recommendations on at least
9
the following:
10
(A) policies and procedures to integrate
11
quality improvement and cost containment
12
mechanisms into the health care delivery sys-
13
tem;
14
(B) mechanisms to facilitate public aware-
15
ness of the availability of a community health
16
insurance option; and
17
(C) alternative payment structures under a
18
community health insurance option for health
19
care providers that encourage quality improve-
20
ment and cost control.
21
(2) MEMBERS.—The members of the State Ad-
22
visory Council shall be representatives of the public
23
and shall include health care consumers and pro-
24
viders.
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1
(3) APPLICABILITY
OF RECOMMENDATIONS.—
2
The Secretary may apply the recommendations of a
3
State Advisory Council to a community health insur-
4
ance option in that State, in any other State, or in
5
all States.
6
(e) AUTHORITY
7
TO
CONTRACT; TERMS
OF
CON-
TRACT.—
8
(1) AUTHORITY.—
9
(A) IN
GENERAL.—The
Secretary may
10
enter into a contract or contracts with one or
11
more qualified entities for the purpose of per-
12
forming
13
functions described in subsection (a)(4) of sec-
14
tion 1874A of the Social Security Act) with re-
15
spect to a community health insurance option in
16
the same manner as the Secretary may enter
17
into contracts under subsection (a)(1) of such
18
section. The Secretary shall have the same au-
19
thority with respect to a community health in-
20
surance option under this section as the Sec-
21
retary has under subsections (a)(1) and (b) of
22
section 1874A of the Social Security Act with
23
respect to title XVIII of such Act.
24
25
administrative
(B) REQUIREMENTS
functions
APPLY.—If
(including
the Sec-
retary enters into a contract with a qualified
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1
entity to offer a community health insurance
2
option, under such contract such entity—
3
4
5
(i) shall meet the criteria established
under paragraph (2); and
(ii) shall receive an administrative fee
6
under paragraph (7).
7
(C) LIMITATION.—Contracts under this
8
subsection shall not involve the transfer of in-
9
surance risk to the contracting administrator.
10
(D) REFERENCE.—An entity with which
11
the Secretary has entered into a contract under
12
this paragraph shall be referred to as a ‘‘con-
13
tracting administrator’’.
14
(2) QUALIFIED
ENTITY.—To
be qualified to be
15
selected by the Secretary to offer a community
16
health insurance option, an entity shall—
17
18
19
20
21
22
23
24
(A) meet the criteria established under section 1874A(a)(2) of the Social Security Act;
(B) be a nonprofit entity for purposes of
offering such option;
(C) meet the solvency standards applicable
under subsection (b)(7);
(D) be eligible to offer health insurance or
health benefits coverage;
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1
2
(E) meet quality standards specified by the
Secretary;
3
4
(F) have in place effective procedures to
control fraud, abuse, and waste; and
5
6
(G) meet such other requirements as the
Secretary may impose.
7
Procedures described under subparagraph (F) shall
8
include the implementation of procedures to use ben-
9
eficiary identifiers to identify individuals entitled to
10
benefits so that such an individual’s social security
11
account number is not used, and shall also include
12
procedures for the use of technology (including
13
front-end,
14
technology similar to that used by hedge funds, in-
15
vestment funds, and banks) to provide real-time
16
data analysis of claims for payment under this title
17
to identify and investigate unusual billing or order
18
practices under this title that could indicate fraud or
19
abuse.
prepayment
intelligent
data-matching
20
(3) TERM.—A contract provided for under
21
paragraph (1) shall be for a term of at least 5 years
22
but not more than 10 years, as determined by the
23
Secretary. At the end of each such term, the Sec-
24
retary shall conduct a competitive bidding process
25
for the purposes of renewing existing contracts or
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1
selecting new qualified entities with which to enter
2
into contracts under such paragraph.
3
(4) LIMITATION.—A contract may not be re-
4
newed under this subsection unless the Secretary de-
5
termines that the contracting administrator has met
6
performance requirements established by the Sec-
7
retary in the areas described in paragraph (7)(B).
8
(5) AUDITS.—The Inspector General shall con-
9
duct periodic audits with respect to contracting ad-
10
ministrators under this subsection to ensure that the
11
administrator involved is in compliance with this sec-
12
tion.
13
(6) REVOCATION.—A contract awarded under
14
this subsection shall be revoked by the Secretary,
15
upon the recommendation of the Inspector General,
16
only after notice to the contracting administrator in-
17
volved and an opportunity for a hearing. The Sec-
18
retary may revoke such contract if the Secretary de-
19
termines that such administrator has engaged in
20
fraud, deception, waste, abuse of power, negligence,
21
mismanagement of taxpayer dollars, or gross mis-
22
management. An entity that has had a contract re-
23
voked under this paragraph shall not be qualified to
24
enter into a subsequent contract under this sub-
25
section.
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1
2
(7) FEE
FOR ADMINISTRATION.—
(A) IN
GENERAL.—The
Secretary shall pay
3
the contracting administrator a fee for the
4
management, administration, and delivery of
5
the benefits under this section.
6
(B) REQUIREMENT
FOR
HIGH
QUALITY
7
ADMINISTRATION.—The
8
the fee described in subparagraph (A) by not
9
more than 10 percent, or reduce the fee de-
10
scribed in subparagraph (A) by not more than
11
50 percent, based on the extent to which the
12
contracting administrator, in the determination
13
of the Secretary, meets performance require-
14
ments established by the Secretary, in at least
15
the following areas:
Secretary may increase
16
(i) Maintaining low premium costs
17
and low cost sharing requirements, pro-
18
vided that such requirements are con-
19
sistent with section 1302.
20
(ii) Reducing administrative costs and
21
promoting administrative simplification for
22
beneficiaries.
23
24
(iii) Promoting high quality clinical
care.
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1
(iv) Providing high quality customer
2
service to beneficiaries.
3
(C) NON-RENEWAL.—The Secretary may
4
not renew a contract to offer a community
5
health insurance option under this section with
6
any contracting entity that has been assessed
7
more than one reduction under subparagraph
8
(B) during the contract period.
9
(8) LIMITATION.—Notwithstanding the terms
10
of a contract under this subsection, the Secretary
11
shall negotiate the reimbursement rates for purposes
12
of subsection (b)(6).
13
(f) REPORT
14
15
BY
HHS
AND
INSOLVENCY WARN-
INGS.—
(1) IN
GENERAL.—On
an annual basis, the Sec-
16
retary shall conduct a study on the solvency of a
17
community health insurance option and submit to
18
Congress a report describing the results of such
19
study.
20
(2) RESULT.—If, in any year, the result of the
21
study under paragraph (1) is that a community
22
health insurance option is insolvent, such result shall
23
be treated as a community health insurance option
24
solvency warning.
25
(3) SUBMISSION
OF PLAN AND PROCEDURE.—
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1
(A) IN
GENERAL.—If
there is a community
2
health insurance option solvency warning under
3
paragraph (2) made in a year, the President
4
shall submit to Congress, within the 15-day pe-
5
riod beginning on the date of the budget sub-
6
mission to Congress under section 1105(a) of
7
title 31, United States Code, for the succeeding
8
year, proposed legislation to respond to such
9
warning.
10
(B) PROCEDURE.—In the case of a legisla-
11
tive proposal submitted by the President pursu-
12
ant to subparagraph (A), such proposal shall be
13
considered by Congress using the same proce-
14
dures described under sections 803 and 804 of
15
the Medicare Prescription Drug, Improvement,
16
and Modernization Act of 2003 that shall be
17
used for a medicare funding warning.
18
(g) MARKETING PARITY.—In a facility controlled by
19 the Federal Government, or by a State, where marketing
20 or promotional materials related to a community health
21 insurance option are made available to the public, making
22 available marketing or promotional materials relating to
23 private health insurance plans shall not be prohibited.
24 Such materials include informational pamphlets, guide-
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1 books, enrollment forms, or other materials determined
2 reasonable for display.
3
(h) AUTHORIZATION
OF
APPROPRIATIONS.—There is
4 authorized to be appropriated such sums as may be nec5 essary to carry out this section.
6
7
SEC. 1324. LEVEL PLAYING FIELD.
(a) IN GENERAL.—Notwithstanding any other provi-
8 sion of law, any health insurance coverage offered by a
9 private health insurance issuer shall not be subject to any
10 Federal or State law described in subsection (b) if a quali11 fied health plan offered under the Consumer Operated and
12 Oriented Plan program under section 1322, a community
13 health insurance option under section 1323, or a nation14 wide qualified health plan under section 1333(b), is not
15 subject to such law.
16
(b) LAWS DESCRIBED.—The Federal and State laws
17 described in this subsection are those Federal and State
18 laws relating to—
19
(1) guaranteed renewal;
20
(2) rating;
21
(3) preexisting conditions;
22
(4) non-discrimination;
23
(5) quality improvement and reporting;
24
(6) fraud and abuse;
25
(7) solvency and financial requirements;
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1
(8) market conduct;
2
(9) prompt payment;
3
(10) appeals and grievances;
4
(11) privacy and confidentiality;
5
(12) licensure; and
6
(13) benefit plan material or information.
7
PART IV—STATE FLEXIBILITY TO ESTABLISH
8
ALTERNATIVE PROGRAMS
9
SEC.
1331.
STATE
FLEXIBILITY
TO
ESTABLISH
BASIC
10
HEALTH PROGRAMS FOR LOW-INCOME INDI-
11
VIDUALS NOT ELIGIBLE FOR MEDICAID.
12
13
(a) ESTABLISHMENT OF PROGRAM.—
(1) IN
GENERAL.—The
Secretary shall establish
14
a basic health program meeting the requirements of
15
this section under which a State may enter into con-
16
tracts to offer 1 or more standard health plans pro-
17
viding at least the essential health benefits described
18
in section 1302(b) to eligible individuals in lieu of
19
offering such individuals coverage through an Ex-
20
change.
21
(2) CERTIFICATIONS
AS TO BENEFIT COVERAGE
22
AND COSTS.—Such
23
State may not establish a basic health program
24
under this section unless the State establishes to the
program shall provide that a
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1
satisfaction of the Secretary, and the Secretary cer-
2
tifies, that—
3
(A) in the case of an eligible individual en-
4
rolled in a standard health plan offered through
5
the program, the State provides—
6
(i) that the amount of the monthly
7
premium an eligible individual is required
8
to pay for coverage under the standard
9
health plan for the individual and the indi-
10
vidual’s dependents does not exceed the
11
amount of the monthly premium that the
12
eligible individual would have been required
13
to pay (in the rating area in which the in-
14
dividual resides) if the individual had en-
15
rolled in the applicable second lowest cost
16
silver
17
36B(b)(3)(B) of the Internal Revenue
18
Code of 1986) offered to the individual
19
through an Exchange; and
plan
(as
defined
in
section
20
(ii) that the cost-sharing an eligible
21
individual is required to pay under the
22
standard health plan does not exceed—
23
(I)
the
cost-sharing
required
24
under a platinum plan in the case of
25
an eligible individual with household
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1
income not in excess of 150 percent of
2
the poverty line for the size of the
3
family involved; and
4
(II) the cost-sharing required
5
under a gold plan in the case of an el-
6
igible individual not described in sub-
7
clause (I); and
8
(B) the benefits provided under the stand-
9
ard health plans offered through the program
10
cover at least the essential health benefits de-
11
scribed in section 1302(b).
12
For purposes of subparagraph (A)(i), the amount of
13
the monthly premium an individual is required to
14
pay under either the standard health plan or the ap-
15
plicable second lowest cost silver plan shall be deter-
16
mined after reduction for any premium tax credits
17
and cost-sharing reductions allowable with respect to
18
either plan.
19
(b) STANDARD HEALTH PLAN.—In this section, the
20 term ‘‘standard heath plan’’ means a health benefits plan
21 that the State contracts with under this section—
22
23
24
25
(1) under which the only individuals eligible to
enroll are eligible individuals;
(2) that provides at least the essential health
benefits described in section 1302(b); and
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1
(3) in the case of a plan that provides health
2
insurance coverage offered by a health insurance
3
issuer, that has a medical loss ratio of at least 85
4
percent.
5
(c) CONTRACTING PROCESS.—
6
(1) IN
GENERAL.—A
State basic health pro-
7
gram shall establish a competitive process for enter-
8
ing into contracts with standard health plans under
9
subsection (a), including negotiation of premiums
10
and cost-sharing and negotiation of benefits in addi-
11
tion to the essential health benefits described in sec-
12
tion 1302(b).
13
(2) SPECIFIC
ITEMS TO BE CONSIDERED.—A
14
State shall, as part of its competitive process under
15
paragraph (1), include at least the following:
16
(A)
INNOVATION.—Negotiation
with
17
offerors of a standard health plan for the inclu-
18
sion of innovative features in the plan, includ-
19
ing—
20
(i) care coordination and care man-
21
agement for enrollees, especially for those
22
with chronic health conditions;
23
24
(ii) incentives for use of preventive
services; and
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1
(iii) the establishment of relationships
2
between providers and patients that maxi-
3
mize patient involvement in health care de-
4
cision-making, including providing incen-
5
tives for appropriate utilization under the
6
plan.
7
(B)
HEALTH
AND
RESOURCE
DIF-
8
FERENCES.—Consideration
9
of suitable allowances for, differences in health
10
care needs of enrollees and differences in local
11
availability of, and access to, health care pro-
12
viders. Nothing in this subparagraph shall be
13
construed as allowing discrimination on the
14
basis of pre-existing conditions or other health
15
status-related factors.
16
(C) MANAGED
of, and the making
CARE.—Contracting
with
17
managed care systems, or with systems that
18
offer as many of the attributes of managed care
19
as are feasible in the local health care market.
20
(D) PERFORMANCE
MEASURES.—Estab-
21
lishing specific performance measures and
22
standards for issuers of standard health plans
23
that focus on quality of care and improved
24
health outcomes, requiring such plans to report
25
to the State with respect to the measures and
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1
standards, and making the performance and
2
quality information available to enrollees in a
3
useful form.
4
(3) ENHANCED
5
AVAILABILITY.—
(A) MULTIPLE
PLANS.—A
State shall, to
6
the maximum extent feasible, seek to make
7
multiple standard health plans available to eligi-
8
ble individuals within a State to ensure individ-
9
uals have a choice of such plans.
10
(B) REGIONAL
COMPACTS.—A
State may
11
negotiate a regional compact with other States
12
to include coverage of eligible individuals in all
13
such States in agreements with issuers of
14
standard health plans.
15
(4) COORDINATION
WITH OTHER STATE PRO-
16
GRAMS.—A
17
istration of, and provision of benefits under, its pro-
18
gram under this section with the State medicaid pro-
19
gram under title XIX of the Social Security Act, the
20
State child health plan under title XXI of such Act,
21
and other State-administered health programs to
22
maximize the efficiency of such programs and to im-
23
prove the continuity of care.
24
(d) TRANSFER OF FUNDS TO STATES.—
State shall seek to coordinate the admin-
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1
(1) IN
GENERAL.—If
the Secretary determines
2
that a State electing the application of this section
3
meets the requirements of the program established
4
under subsection (a), the Secretary shall transfer to
5
the State for each fiscal year for which 1 or more
6
standard health plans are operating within the State
7
the amount determined under paragraph (3).
8
(2) USE
OF FUNDS.—A
State shall establish a
9
trust for the deposit of the amounts received under
10
paragraph (1) and amounts in the trust fund shall
11
only be used to reduce the premiums and cost-shar-
12
ing of, or to provide additional benefits for, eligible
13
individuals enrolled in standard health plans within
14
the State. Amounts in the trust fund, and expendi-
15
tures of such amounts, shall not be included in de-
16
termining the amount of any non-Federal funds for
17
purposes of meeting any matching or expenditure re-
18
quirement of any federally-funded program.
19
20
21
(3) AMOUNT
OF PAYMENT.—
(A) SECRETARIAL
(i) IN
DETERMINATION.—
GENERAL.—The
amount deter-
22
mined under this paragraph for any fiscal
23
year is the amount the Secretary deter-
24
mines is equal to 85 percent of the pre-
25
mium tax credits under section 36B of the
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1
Internal Revenue Code of 1986, and the
2
cost-sharing
3
1402, that would have been provided for
4
the fiscal year to eligible individuals en-
5
rolled in standard health plans in the State
6
if such eligible individuals were allowed to
7
enroll in qualified health plans through an
8
Exchange established under this subtitle.
9
reductions
(ii) SPECIFIC
under
section
REQUIREMENTS.—The
10
Secretary shall make the determination
11
under clause (i) on a per enrollee basis and
12
shall take into account all relevant factors
13
necessary to determine the value of the
14
premium tax credits and cost-sharing re-
15
ductions that would have been provided to
16
eligible individuals described in clause (i),
17
including the age and income of the en-
18
rollee, whether the enrollment is for self-
19
only or family coverage, geographic dif-
20
ferences in average spending for health
21
care across rating areas, the health status
22
of the enrollee for purposes of determining
23
risk adjustment payments and reinsurance
24
payments that would have been made if
25
the enrollee had enrolled in a qualified
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1
health plan through an Exchange, and
2
whether any reconciliation of the credit or
3
cost-sharing reductions would have oc-
4
curred if the enrollee had been so enrolled.
5
This determination shall take into consid-
6
eration the experience of other States with
7
respect to participation in an Exchange
8
and such credits and reductions provided
9
to residents of the other States, with a spe-
10
cial focus on enrollees with income below
11
200 percent of poverty.
12
(iii) CERTIFICATION.—The Chief Ac-
13
tuary of the Centers for Medicare & Med-
14
icaid Services, in consultation with the Of-
15
fice of Tax Analysis of the Department of
16
the Treasury, shall certify whether the
17
methodology used to make determinations
18
under this subparagraph, and such deter-
19
minations, meet the requirements of clause
20
(ii). Such certifications shall be based on
21
sufficient data from the State and from
22
comparable States about their experience
23
with programs created by this Act.
24
(B) CORRECTIONS.—The Secretary shall
25
adjust the payment for any fiscal year to reflect
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1
any error in the determinations under subpara-
2
graph (A) for any preceding fiscal year.
3
(4) APPLICATION
OF
SPECIAL
RULES.—The
4
provisions of section 1303 shall apply to a State
5
basic health program, and to standard health plans
6
offered through such program, in the same manner
7
as such rules apply to qualified health plans.
8
(e) ELIGIBLE INDIVIDUAL.—
9
(1) IN
GENERAL.—In
this section, the term ‘‘el-
10
igible individual’’ means, with respect to any State,
11
an individual—
12
(A) who a resident of the State who is not
13
eligible to enroll in the State’s medicaid pro-
14
gram under title XIX of the Social Security Act
15
for benefits that at a minimum consist of the
16
essential health benefits described in section
17
1302(b);
18
(B) whose household income exceeds 133
19
percent but does not exceed 200 percent of the
20
poverty line for the size of the family involved;
21
(C) who is not eligible for minimum essen-
22
tial coverage (as defined in section 5000A(f) of
23
the Internal Revenue Code of 1986) or is eligi-
24
ble for an employer-sponsored plan that is not
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1
affordable coverage (as determined under sec-
2
tion 5000A(e)(2) of such Code); and
3
4
(D) who has not attained age 65 as of the
beginning of the plan year.
5
Such term shall not include any individual who is
6
not a qualified individual under section 1312 who is
7
eligible to be covered by a qualified health plan of-
8
fered through an Exchange.
9
(2) ELIGIBLE
INDIVIDUALS MAY NOT USE EX-
10
CHANGE.—An
11
as a qualified individual under section 1312 eligible
12
for enrollment in a qualified health plan offered
13
through an Exchange established under section
14
1311.
15
(f) SECRETARIAL OVERSIGHT.—The Secretary shall
eligible individual shall not be treated
16 each year conduct a review of each State program to en17 sure compliance with the requirements of this section, in18 cluding ensuring that the State program meets—
19
20
21
22
23
24
(1) eligibility verification requirements for participation in the program;
(2) the requirements for use of Federal funds
received by the program; and
(3) the quality and performance standards
under this section.
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1
(g) STANDARD HEALTH PLAN OFFERORS.—A State
2 may provide that persons eligible to offer standard health
3 plans under a basic health program established under this
4 section may include a licensed health maintenance organi5 zation, a licensed health insurance insurer, or a network
6 of health care providers established to offer services under
7 the program.
8
(h) DEFINITIONS.—Any term used in this section
9 which is also used in section 36B of the Internal Revenue
10 Code of 1986 shall have the meaning given such term by
11 such section.
12
13
14
SEC. 1332. WAIVER FOR STATE INNOVATION.
(a) APPLICATION.—
(1) IN
GENERAL.—A
State may apply to the
15
Secretary for the waiver of all or any requirements
16
described in paragraph (2) with respect to health in-
17
surance coverage within that State for plan years be-
18
ginning on or after January 1, 2017. Such applica-
19
tion shall—
20
21
22
23
(A) be filed at such time and in such manner as the Secretary may require;
(B) contain such information as the Secretary may require, including—
24
(i) a comprehensive description of the
25
State legislation and program to imple-
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1
ment a plan meeting the requirements for
2
a waiver under this section; and
3
(ii) a 10-year budget plan for such
4
plan that is budget neutral for the Federal
5
Government; and
6
(C) provide an assurance that the State
7
has enacted the law described in subsection
8
(b)(2).
9
(2) REQUIREMENTS.—The requirements de-
10
scribed in this paragraph with respect to health in-
11
surance coverage within the State for plan years be-
12
ginning on or after January 1, 2014, are as follows:
13
(A) Part I of subtitle D.
14
(B) Part II of subtitle D.
15
(C) Section 1402.
16
(D) Sections 36B, 4980H, and 5000A of
17
the Internal Revenue Code of 1986.
18
(3) PASS
THROUGH OF FUNDING.—With
re-
19
spect to a State waiver under paragraph (1), under
20
which, due to the structure of the State plan, indi-
21
viduals and small employers in the State would not
22
qualify for the premium tax credits, cost-sharing re-
23
ductions, or small business credits under sections
24
36B of the Internal Revenue Code of 1986 or under
25
part I of subtitle E for which they would otherwise
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1
be eligible, the Secretary shall provide for an alter-
2
native means by which the aggregate amount of such
3
credits or reductions that would have been paid on
4
behalf of participants in the Exchanges established
5
under this title had the State not received such waiv-
6
er, shall be paid to the State for purposes of imple-
7
menting the State plan under the waiver. Such
8
amount shall be determined annually by the Sec-
9
retary, taking into consideration the experience of
10
other States with respect to participation in an Ex-
11
change and credits and reductions provided under
12
such provisions to residents of the other States.
13
(4)
14
PARENCY.—
15
WAIVER
(A) IN
CONSIDERATION
GENERAL.—An
AND
TRANS-
application for a
16
waiver under this section shall be considered by
17
the Secretary in accordance with the regula-
18
tions described in subparagraph (B).
19
(B) REGULATIONS.—Not later than 180
20
days after the date of enactment of this Act,
21
the Secretary shall promulgate regulations re-
22
lating to waivers under this section that pro-
23
vide—
24
(i) a process for public notice and
25
comment at the State level, including pub-
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1
lic hearings, sufficient to ensure a mean-
2
ingful level of public input;
3
(ii) a process for the submission of an
4
application that ensures the disclosure of—
5
(I) the provisions of law that the
6
State involved seeks to waive; and
7
(II) the specific plans of the
8
State to ensure that the waiver will be
9
in compliance with subsection (b);
10
(iii) a process for providing public no-
11
tice and comment after the application is
12
received by the Secretary, that is sufficient
13
to ensure a meaningful level of public
14
input and that does not impose require-
15
ments that are in addition to, or duplica-
16
tive of, requirements imposed under the
17
Administrative Procedures Act, or require-
18
ments that are unreasonable or unneces-
19
sarily burdensome with respect to State
20
compliance;
21
(iv) a process for the submission to
22
the Secretary of periodic reports by the
23
State concerning the implementation of the
24
program under the waiver; and
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1
(v) a process for the periodic evalua-
2
tion by the Secretary of the program under
3
the waiver.
4
(C) REPORT.—The Secretary shall annu-
5
ally report to Congress concerning actions
6
taken by the Secretary with respect to applica-
7
tions for waivers under this section.
8
(5) COORDINATED
WAIVER PROCESS.—The
Sec-
9
retary shall develop a process for coordinating and
10
consolidating the State waiver processes applicable
11
under the provisions of this section, and the existing
12
waiver processes applicable under titles XVIII, XIX,
13
and XXI of the Social Security Act, and any other
14
Federal law relating to the provision of health care
15
items or services. Such process shall permit a State
16
to submit a single application for a waiver under any
17
or all of such provisions.
18
19
(6) DEFINITION.—In this section, the term
‘‘Secretary’’ means—
20
(A) the Secretary of Health and Human
21
Services with respect to waivers relating to the
22
provisions
23
through (C) of paragraph (2); and
described
in
subparagraph
(A)
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1
(B) the Secretary of the Treasury with re-
2
spect to waivers relating to the provisions de-
3
scribed in paragraph (2)(D).
4
5
(b) GRANTING OF WAIVERS.—
(1) IN
GENERAL.—The
Secretary may grant a
6
request for a waiver under subsection (a)(1) only if
7
the Secretary determines that the State plan—
8
(A) will provide coverage that is at least as
9
comprehensive as the coverage defined in sec-
10
tion 1302(b) and offered through Exchanges es-
11
tablished under this title as certified by Office
12
of the Actuary of the Centers for Medicare &
13
Medicaid Services based on sufficient data from
14
the State and from comparable States about
15
their experience with programs created by this
16
Act and the provisions of this Act that would
17
be waived;
18
(B) will provide coverage and cost sharing
19
protections
20
spending that are at least as affordable as the
21
provisions of this title would provide;
against
excessive
out-of-pocket
22
(C) will provide coverage to at least a com-
23
parable number of its residents as the provi-
24
sions of this title would provide; and
25
(D) will not increase the Federal deficit.
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1
2
(2) REQUIREMENT
(A) IN
TO ENACT A LAW.—
GENERAL.—A
law described in this
3
paragraph is a State law that provides for State
4
actions under a waiver under this section, in-
5
cluding the implementation of the State plan
6
under subsection (a)(1)(B).
7
(B) TERMINATION
OF OPT OUT.—A
State
8
may repeal a law described in subparagraph (A)
9
and terminate the authority provided under the
10
11
12
waiver with respect to the State.
(c) SCOPE OF WAIVER.—
(1) IN
GENERAL.—The
Secretary shall deter-
13
mine the scope of a waiver of a requirement de-
14
scribed in subsection (a)(2) granted to a State under
15
subsection (a)(1).
16
(2) LIMITATION.—The Secretary may not waive
17
under this section any Federal law or requirement
18
that is not within the authority of the Secretary.
19
(d) DETERMINATIONS BY SECRETARY.—
20
(1) TIME
FOR
DETERMINATION.—The
Sec-
21
retary shall make a determination under subsection
22
(a)(1) not later than 180 days after the receipt of
23
an application from a State under such subsection.
24
(2) EFFECT
OF DETERMINATION.—
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1
(A) GRANTING
OF WAIVERS.—If
the Sec-
2
retary determines to grant a waiver under sub-
3
section (a)(1), the Secretary shall notify the
4
State involved of such determination and the
5
terms and effectiveness of such waiver.
6
(B) DENIAL
OF WAIVER.—If
the Secretary
7
determines a waiver should not be granted
8
under subsection (a)(1), the Secretary shall no-
9
tify the State involved, and the appropriate
10
committees of Congress of such determination
11
and the reasons therefore.
12
(e) TERM
OF
WAIVER.—No waiver under this section
13 may extend over a period of longer than 5 years unless
14 the State requests continuation of such waiver, and such
15 request shall be deemed granted unless the Secretary,
16 within 90 days after the date of its submission to the Sec17 retary, either denies such request in writing or informs
18 the State in writing with respect to any additional infor19 mation which is needed in order to make a final deter20 mination with respect to the request.
21
22
23
24
25
SEC. 1333. PROVISIONS RELATING TO OFFERING OF PLANS
IN MORE THAN ONE STATE.
(a) HEALTH CARE CHOICE COMPACTS.—
(1) IN
GENERAL.—Not
later than July 1, 2013,
the Secretary shall, in consultation with the National
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1
Association of Insurance Commissioners, issue regu-
2
lations for the creation of health care choice com-
3
pacts under which 2 or more States may enter into
4
an agreement under which—
5
(A) 1 or more qualified health plans could
6
be offered in the individual markets in all such
7
States but, except as provided in subparagraph
8
(B), only be subject to the laws and regulations
9
of the State in which the plan was written or
10
11
12
issued;
(B) the issuer of any qualified health plan
to which the compact applies—
13
(i) would continue to be subject to
14
market conduct, unfair trade practices,
15
network adequacy, and consumer protec-
16
tion standards (including standards relat-
17
ing to rating), including addressing dis-
18
putes as to the performance of the con-
19
tract, of the State in which the purchaser
20
resides;
21
(ii) would be required to be licensed in
22
each State in which it offers the plan
23
under the compact or to submit to the ju-
24
risdiction of each such State with regard to
25
the standards described in clause (i) (in-
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1
cluding allowing access to records as if the
2
insurer were licensed in the State); and
3
(iii) must clearly notify consumers
4
that the policy may not be subject to all
5
the laws and regulations of the State in
6
which the purchaser resides.
7
(2) STATE
AUTHORITY.—A
State may not enter
8
into an agreement under this subsection unless the
9
State enacts a law after the date of the enactment
10
of this title that specifically authorizes the State to
11
enter into such agreements.
12
(3) APPROVAL
OF COMPACTS.—The
Secretary
13
may approve interstate health care choice compacts
14
under paragraph (1) only if the Secretary deter-
15
mines that such health care choice compact—
16
(A) will provide coverage that is at least as
17
comprehensive as the coverage defined in sec-
18
tion 1302(b) and offered through Exchanges es-
19
tablished under this title;
20
(B) will provide coverage and cost sharing
21
protections
22
spending that are at least as affordable as the
23
provisions of this title would provide;
against
excessive
out-of-pocket
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1
(C) will provide coverage to at least a com-
2
parable number of its residents as the provi-
3
sions of this title would provide;
4
5
(D) will not increase the Federal deficit;
and
6
(E) will not weaken enforcement of laws
7
and
8
(1)(B)(i) in any State that is included in such
9
compact.
10
regulations
(4) EFFECTIVE
described
DATE.—A
in
paragraph
health care choice
11
compact described in paragraph (1) shall not take
12
effect before January 1, 2016.
13
(b) AUTHORITY FOR NATIONWIDE PLANS.—
14
(1) IN
GENERAL.—Except
as provided in para-
15
graph (2), if an issuer (including a group of health
16
insurance issuers affiliated either by common owner-
17
ship and control or by the common use of a nation-
18
ally licensed service mark) of a qualified health plan
19
in the individual or small group market meets the
20
requirements of this subsection (in this subsection a
21
‘‘nationwide qualified health plan’’)—
22
(A) the issuer of the plan may offer the
23
nationwide qualified health plan in the indi-
24
vidual or small group market in more than 1
25
State; and
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1
(B) with respect to State laws mandating
2
benefit coverage by a health plan, only the
3
State laws of the State in which such plan is
4
written or issued shall apply to the nationwide
5
qualified health plan.
6
(2) STATE
OPT-OUT.—A
State may, by specific
7
reference in a law enacted after the date of enact-
8
ment of this title, provide that this subsection shall
9
not apply to that State. Such opt-out shall be effec-
10
tive until such time as the State by law revokes it.
11
(3) PLAN
REQUIREMENTS.—An
issuer meets
12
the requirements of this subsection with respect to
13
a nationwide qualified health plan if, in the deter-
14
mination of the Secretary—
15
(A) the plan offers a benefits package that
16
is uniform in each State in which the plan is of-
17
fered and meets the requirements set forth in
18
paragraphs (4) through (6);
19
(B) the issuer is licensed in each State in
20
which it offers the plan and is subject to all re-
21
quirements of State law not inconsistent with
22
this section, including but not limited to, the
23
standards and requirements that a State im-
24
poses that do not prevent the application of a
25
requirement of part A of title XXVII of the
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1
Public Health Service Act or a requirement of
2
this title;
3
(C) the issuer meets all requirements of
4
this title with respect to a qualified health plan,
5
including the requirement to offer the silver and
6
gold levels of the plan in each Exchange in the
7
State for the market in which the plan is of-
8
fered;
9
(D) the issuer determines the premiums
10
for the plan in any State on the basis of the
11
rating rules in effect in that State for the rat-
12
ing areas in which it is offered;
13
(E) the issuer offers the nationwide quali-
14
fied health plan in at least 60 percent of the
15
participating States in the first year in which
16
the plan is offered, 65 percent of such States
17
in the second year, 70 percent of such States in
18
the third year, 75 percent of such States in the
19
fourth year, and 80 percent of such States in
20
the fifth and subsequent years;
21
(F) the issuer shall offer the plan in par-
22
ticipating States across the country, in all geo-
23
graphic regions, and in all States that have
24
adopted adjusted community rating before the
25
date of enactment of this Act; and
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1
(G) the issuer clearly notifies consumers
2
that the policy may not contain some benefits
3
otherwise mandated for plans in the State in
4
which the purchaser resides and provides a de-
5
tailed statement of the benefits offered and the
6
benefit differences in that State, in accordance
7
with rules promulgated by the Secretary.
8
(4) FORM
REVIEW FOR NATIONWIDE PLANS.—
9
Notwithstanding any contrary provision of State
10
law, at least 3 months before any nationwide quali-
11
fied health plan is offered, the issuer shall file all na-
12
tionwide qualified health plan forms with the regu-
13
lator in each participating State in which the plan
14
will be offered. An issuer may appeal the disapproval
15
of a nationwide qualified health plan form to the
16
Secretary.
17
(5) APPLICABLE
RULES.—The
Secretary shall,
18
in consultation with the National Association of In-
19
surance Commissioners, issue rules for the offering
20
of nationwide qualified health plans under this sub-
21
section. Nationwide qualified health plans may be of-
22
fered only after such rules have taken effect.
23
(6) COVERAGE.—The Secretary shall provide
24
that the health benefits coverage provided to an indi-
25
vidual through a nationwide qualified health plan
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1
under this subsection shall include at least the es-
2
sential benefits package described in section 1302.
3
(7) STATE
LAW
MANDATING
BENEFIT
COV-
4
ERAGE BY A HEALTH BENEFITS PLAN.—For
5
purposes of this subsection, a State law mandating
6
benefit coverage by a health plan is a law that man-
7
dates health insurance coverage or the offer of
8
health insurance coverage for specific health services
9
or specific diseases. A law that mandates health in-
10
surance coverage or reimbursement for services pro-
11
vided by certain classes of providers of health care
12
services, or a law that mandates that certain classes
13
of individuals must be covered as a group or as de-
14
pendents, is not a State law mandating benefit cov-
15
erage by a health benefits plan.
the
16 PART V—REINSURANCE AND RISK ADJUSTMENT
17
SEC. 1341. TRANSITIONAL REINSURANCE PROGRAM FOR
18
INDIVIDUAL AND SMALL GROUP MARKETS IN
19
EACH STATE.
20
(a) IN GENERAL.—Each State shall, not later than
21 January 1, 2014—
22
(1) include in the Federal standards or State
23
law or regulation the State adopts and has in effect
24
under section 1321(b) the provisions described in
25
subsection (b); and
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1
(2) establish (or enter into a contract with) 1
2
or more applicable reinsurance entities to carry out
3
the reinsurance program under this section.
4
(b) MODEL REGULATION.—
5
(1) IN
GENERAL.—In
establishing the Federal
6
standards under section 1321(a), the Secretary, in
7
consultation with the National Association of Insur-
8
ance Commissioners (the ‘‘NAIC’’), shall include
9
provisions that enable States to establish and main-
10
tain a program under which—
11
(A) health insurance issuers, and third
12
party administrators on behalf of group health
13
plans, are required to make payments to an ap-
14
plicable reinsurance entity for any plan year be-
15
ginning in the 3-year period beginning January
16
1, 2014 (as specified in paragraph (3); and
17
(B) the applicable reinsurance entity col-
18
lects payments under subparagraph (A) and
19
uses amounts so collected to make reinsurance
20
payments to health insurance issuers described
21
in subparagraph (A) that cover high risk indi-
22
viduals in the individual market (excluding
23
grandfathered health plans) for any plan year
24
beginning in such 3-year period.
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1
(2)
HIGH-RISK
INDIVIDUAL;
PAYMENT
2
AMOUNTS.—The
3
lowing in the provisions under paragraph (1):
4
Secretary shall include the fol-
(A) DETERMINATION
OF HIGH-RISK INDI-
5
VIDUALS.—The
6
will be identified as high risk individuals for
7
purposes of the reinsurance program estab-
8
lished under this section. Such method shall
9
provide for identification of individuals as high-
10
method by which individuals
risk individuals on the basis of—
11
(i) a list of at least 50 but not more
12
than 100 medical conditions that are iden-
13
tified as high-risk conditions and that may
14
be based on the identification of diagnostic
15
and procedure codes that are indicative of
16
individuals with pre-existing, high-risk con-
17
ditions; or
18
(ii) any other comparable objective
19
method of identification recommended by
20
the American Academy of Actuaries.
21
(B) PAYMENT
AMOUNT.—The
formula for
22
determining the amount of payments that will
23
be paid to health insurance issuers described in
24
paragraph (1)(A) that insure high-risk individ-
25
uals. Such formula shall provide for the equi-
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1
table allocation of available funds through rec-
2
onciliation and may be designed—
3
(i) to provide a schedule of payments
4
that specifies the amount that will be paid
5
for each of the conditions identified under
6
subparagraph (A); or
7
(ii) to use any other comparable meth-
8
od for determining payment amounts that
9
is recommended by the American Academy
10
of Actuaries and that encourages the use
11
of care coordination and care management
12
programs for high risk conditions.
13
14
15
(3) DETERMINATION
OF REQUIRED CONTRIBU-
TIONS.—
(A) IN
GENERAL.—The
Secretary shall in-
16
clude in the provisions under paragraph (1) the
17
method for determining the amount each health
18
insurance issuer and group health plan de-
19
scribed in paragraph (1)(A) contributing to the
20
reinsurance program under this section is re-
21
quired to contribute under such paragraph for
22
each plan year beginning in the 36-month pe-
23
riod beginning January 1, 2014. The contribu-
24
tion amount for any plan year may be based on
25
the percentage of revenue of each issuer and
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1
the total costs of providing benefits to enrollees
2
in self-insured plans or on a specified amount
3
per enrollee and may be required to be paid in
4
advance or periodically throughout the plan
5
year.
6
(B) SPECIFIC
REQUIREMENTS.—The
meth-
7
od under this paragraph shall be designed so
8
that—
9
(i) the contribution amount for each
10
issuer proportionally reflects each issuer’s
11
fully insured commercial book of business
12
for all major medical products and the
13
total value of all fees charged by the issuer
14
and the costs of coverage administered by
15
the issuer as a third party administrator;
16
(ii) the contribution amount can in-
17
clude an additional amount to fund the ad-
18
ministrative expenses of the applicable re-
19
insurance entity;
20
(iii)
the
aggregate
contribution
21
amounts for all States shall, based on the
22
best estimates of the NAIC and without
23
regard to amounts described in clause (ii),
24
equal $10,000,000,000 for plan years be-
25
ginning in 2014, $6,000,000,000 for plan
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1
years beginning 2015, and $4,000,000,000
2
for plan years beginning in 2016; and
3
(iv) in addition to the aggregate con-
4
tribution amounts under clause (iii), each
5
issuer’s contribution amount for any cal-
6
endar year under clause (iii) reflects its
7
proportionate
8
$2,000,000,000 for 2014, an additional
9
$2,000,000,000 for 2015, and an addi-
10
share
of
an
additional
tional $1,000,000,000 for 2016.
11
Nothing in this subparagraph shall be con-
12
strued to preclude a State from collecting addi-
13
tional amounts from issuers on a voluntary
14
basis.
15
(4) EXPENDITURE
16
OF FUNDS.—The
provisions
under paragraph (1) shall provide that—
17
(A) the contribution amounts collected for
18
any calendar year may be allocated and used in
19
any of the three calendar years for which
20
amounts are collected based on the reinsurance
21
needs of a particular period or to reflect experi-
22
ence in a prior period; and
23
(B) amounts remaining unexpended as of
24
December, 2016, may be used to make pay-
25
ments under any reinsurance program of a
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1
State in the individual market in effect in the
2
2-year period beginning on January 1, 2017.
3
Notwithstanding the preceding sentence, any con-
4
tribution amounts described in paragraph (3)(B)(iv)
5
shall be deposited into the general fund of the
6
Treasury of the United States and may not be used
7
for the program established under this section.
8
(c) APPLICABLE REINSURANCE ENTITY.—For pur-
9 poses of this section—
10
(1) IN
GENERAL.—The
term ‘‘applicable rein-
11
surance entity’’ means a not-for-profit organiza-
12
tion—
13
(A) the purpose of which is to help sta-
14
bilize premiums for coverage in the individual
15
and small group markets in a State during the
16
first 3 years of operation of an Exchange for
17
such markets within the State when the risk of
18
adverse selection related to new rating rules
19
and market changes is greatest; and
20
(B) the duties of which shall be to carry
21
out the reinsurance program under this section
22
by coordinating the funding and operation of
23
the risk-spreading mechanisms designed to im-
24
plement the reinsurance program.
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1
(2) STATE
DISCRETION.—A
State may have
2
more than 1 applicable reinsurance entity to carry
3
out the reinsurance program under this section with-
4
in the State and 2 or more States may enter into
5
agreements to provide for an applicable reinsurance
6
entity to carry out such program in all such States.
7
(3) ENTITIES
ARE TAX-EXEMPT.—An
applicable
8
reinsurance entity established under this section
9
shall be exempt from taxation under chapter 1 of
10
the Internal Revenue Code of 1986. The preceding
11
sentence shall not apply to the tax imposed by sec-
12
tion 511 such Code (relating to tax on unrelated
13
business taxable income of an exempt organization).
14
(d)
COORDINATION
WITH
STATE
HIGH-RISK
15 POOLS.—The State shall eliminate or modify any State
16 high-risk pool to the extent necessary to carry out the re17 insurance program established under this section. The
18 State may coordinate the State high-risk pool with such
19 program to the extent not inconsistent with the provisions
20 of this section.
21
SEC. 1342. ESTABLISHMENT OF RISK CORRIDORS FOR
22
PLANS IN INDIVIDUAL AND SMALL GROUP
23
MARKETS.
24
(a) IN GENERAL.—The Secretary shall establish and
25 administer a program of risk corridors for calendar years
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1 2014, 2015, and 2016 under which a qualified health plan
2 offered in the individual or small group market shall par3 ticipate in a payment adjustment system based on the
4 ratio of the allowable costs of the plan to the plan’s aggre5 gate premiums. Such program shall be based on the pro6 gram for regional participating provider organizations
7 under part D of title XVIII of the Social Security Act.
8
9
(b) PAYMENT METHODOLOGY.—
(1) PAYMENTS
OUT.—The
Secretary shall pro-
10
vide under the program established under subsection
11
(a) that if—
12
(A) a participating plan’s allowable costs
13
for any plan year are more than 103 percent
14
but not more than 108 percent of the target
15
amount, the Secretary shall pay to the plan an
16
amount equal to 50 percent of the target
17
amount in excess of 103 percent of the target
18
amount; and
19
(B) a participating plan’s allowable costs
20
for any plan year are more than 108 percent of
21
the target amount, the Secretary shall pay to
22
the plan an amount equal to the sum of 2.5
23
percent of the target amount plus 80 percent of
24
allowable costs in excess of 108 percent of the
25
target amount.
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1
(2) PAYMENTS
IN.—The
Secretary shall provide
2
under the program established under subsection (a)
3
that if—
4
(A) a participating plan’s allowable costs
5
for any plan year are less than 97 percent but
6
not less than 92 percent of the target amount,
7
the plan shall pay to the Secretary an amount
8
equal to 50 percent of the excess of 97 percent
9
of the target amount over the allowable costs;
10
and
11
(B) a participating plan’s allowable costs
12
for any plan year are less than 92 percent of
13
the target amount, the plan shall pay to the
14
Secretary an amount equal to the sum of 2.5
15
percent of the target amount plus 80 percent of
16
the excess of 92 percent of the target amount
17
over the allowable costs.
18
(c) DEFINITIONS.—In this section:
19
(1) ALLOWABLE
20
(A) IN
COSTS.—
GENERAL.—The
amount of allow-
21
able costs of a plan for any year is an amount
22
equal to the total costs (other than administra-
23
tive costs) of the plan in providing benefits cov-
24
ered by the plan.
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1
(B) REDUCTION
FOR RISK ADJUSTMENT
REINSURANCE
PAYMENTS.—Allowable
2
AND
3
costs shall reduced by any risk adjustment and
4
reinsurance payments received under section
5
1341 and 1343.
6
(2) TARGET
AMOUNT.—The
target amount of a
7
plan for any year is an amount equal to the total
8
premiums (including any premium subsidies under
9
any governmental program), reduced by the adminis-
10
trative costs of the plan.
11
SEC. 1343. RISK ADJUSTMENT.
12
(a) IN GENERAL.—
13
(1) LOW
ACTUARIAL RISK PLANS.—Using
the
14
criteria and methods developed under subsection (b),
15
each State shall assess a charge on health plans and
16
health insurance issuers (with respect to health in-
17
surance coverage) described in subsection (c) if the
18
actuarial risk of the enrollees of such plans or cov-
19
erage for a year is less than the average actuarial
20
risk of all enrollees in all plans or coverage in such
21
State for such year that are not self-insured group
22
health plans (which are subject to the provisions of
23
the Employee Retirement Income Security Act of
24
1974).
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1
(2) HIGH
ACTUARIAL RISK PLANS.—Using
the
2
criteria and methods developed under subsection (b),
3
each State shall provide a payment to health plans
4
and health insurance issuers (with respect to health
5
insurance coverage) described in subsection (c) if the
6
actuarial risk of the enrollees of such plans or cov-
7
erage for a year is greater than the average actu-
8
arial risk of all enrollees in all plans and coverage
9
in such State for such year that are not self-insured
10
group health plans (which are subject to the provi-
11
sions of the Employee Retirement Income Security
12
Act of 1974).
13
(b) CRITERIA
AND
METHODS.—The Secretary, in
14 consultation with States, shall establish criteria and meth15 ods to be used in carrying out the risk adjustment activi16 ties under this section. The Secretary may utilize criteria
17 and methods similar to the criteria and methods utilized
18 under part C or D of title XVIII of the Social Security
19 Act. Such criteria and methods shall be included in the
20 standards and requirements the Secretary prescribes
21 under section 1321.
22
(c) SCOPE.—A health plan or a health insurance
23 issuer is described in this subsection if such health plan
24 or health insurance issuer provides coverage in the indi25 vidual or small group market within the State. This sub-
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1 section shall not apply to a grandfathered health plan or
2 the issuer of a grandfathered health plan with respect to
3 that plan.
5
Subtitle E—Affordable Coverage
Choices for All Americans
6
PART I—PREMIUM TAX CREDITS AND COST-
7
SHARING REDUCTIONS
8
Subpart A—Premium Tax Credits and Cost-sharing
9
Reductions
4
10
SEC. 1401. REFUNDABLE TAX CREDIT PROVIDING PREMIUM
11
ASSISTANCE
12
QUALIFIED HEALTH PLAN.
13
FOR
COVERAGE
UNDER
A
(a) IN GENERAL.—Subpart C of part IV of sub-
14 chapter A of chapter 1 of the Internal Revenue Code of
15 1986 (relating to refundable credits) is amended by insert16 ing after section 36A the following new section:
17
18
19
‘‘SEC. 36B. REFUNDABLE CREDIT FOR COVERAGE UNDER A
QUALIFIED HEALTH PLAN.
‘‘(a) IN GENERAL.—In the case of an applicable tax-
20 payer, there shall be allowed as a credit against the tax
21 imposed by this subtitle for any taxable year an amount
22 equal to the premium assistance credit amount of the tax23 payer for the taxable year.
24
‘‘(b) PREMIUM ASSISTANCE CREDIT AMOUNT.—For
25 purposes of this section—
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1
‘‘(1) IN
GENERAL.—The
term ‘premium assist-
2
ance credit amount’ means, with respect to any tax-
3
able year, the sum of the premium assistance
4
amounts determined under paragraph (2) with re-
5
spect to all coverage months of the taxpayer occur-
6
ring during the taxable year.
7
‘‘(2) PREMIUM
ASSISTANCE AMOUNT.—The
pre-
8
mium assistance amount determined under this sub-
9
section with respect to any coverage month is the
10
amount equal to the lesser of—
11
‘‘(A) the monthly premiums for such
12
month for 1 or more qualified health plans of-
13
fered in the individual market within a State
14
which cover the taxpayer, the taxpayer’s spouse,
15
or any dependent (as defined in section 152) of
16
the taxpayer and which were enrolled in
17
through an Exchange established by the State
18
under 1311 of the Patient Protection and Af-
19
fordable Care Act, or
20
‘‘(B) the excess (if any) of—
21
‘‘(i) the adjusted monthly premium
22
for such month for the applicable second
23
lowest cost silver plan with respect to the
24
taxpayer, over
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1
‘‘(ii) an amount equal to 1/12 of the
2
product of the applicable percentage and
3
the taxpayer’s household income for the
4
taxable year.
5
‘‘(3) OTHER
TERMS AND RULES RELATING TO
6
PREMIUM ASSISTANCE AMOUNTS.—For
7
paragraph (2)—
8
‘‘(A) APPLICABLE
9
‘‘(i) IN
purposes of
PERCENTAGE.—
GENERAL.—Except
as pro-
10
vided in clause (ii), the applicable percent-
11
age with respect to any taxpayer for any
12
taxable year is equal to 2.8 percent, in-
13
creased by the number of percentage
14
points (not greater than 7) which bears the
15
same ratio to 7 percentage points as—
16
‘‘(I) the taxpayer’s household in-
17
come for the taxable year in excess of
18
100 percent of the poverty line for a
19
family of the size involved, bears to
20
‘‘(II) an amount equal to 200
21
percent of the poverty line for a fam-
22
ily of the size involved.
23
‘‘(ii) SPECIAL
RULE FOR TAXPAYERS
24
UNDER 133 PERCENT OF POVERTY LINE.—
25
If a taxpayer’s household income for the
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1
taxable year is in excess of 100 percent,
2
but not more than 133 percent, of the pov-
3
erty line for a family of the size involved,
4
the taxpayer’s applicable percentage shall
5
be 2 percent.
6
‘‘(iii) INDEXING.—In the case of tax-
7
able years beginning in any calendar year
8
after 2014, the Secretary shall adjust the
9
initial and final applicable percentages
10
under clause (i), and the 2 percent under
11
clause (ii), for the calendar year to reflect
12
the excess of the rate of premium growth
13
between the preceding calendar year and
14
2013 over the rate of income growth for
15
such period.
16
‘‘(B) APPLICABLE
SECOND LOWEST COST
17
SILVER PLAN.—The
18
cost silver plan with respect to any applicable
19
taxpayer is the second lowest cost silver plan of
20
the individual market in the rating area in
21
which the taxpayer resides which—
applicable second lowest
22
‘‘(i) is offered through the same Ex-
23
change through which the qualified health
24
plans taken into account under paragraph
25
(2)(A) were offered, and
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1
2
3
‘‘(ii) provides—
‘‘(I) self-only coverage in the case
of an applicable taxpayer—
4
‘‘(aa) whose tax for the tax-
5
able year is determined under
6
section 1(c) (relating to unmar-
7
ried individuals other than sur-
8
viving spouses and heads of
9
households) and who is not al-
10
lowed a deduction under section
11
151 for the taxable year with re-
12
spect to a dependent, or
13
‘‘(bb) who is not described
14
in item (aa) but who purchases
15
only self-only coverage, and
16
‘‘(II) family coverage in the case
17
of any other applicable taxpayer.
18
If a taxpayer files a joint return and no credit
19
is allowed under this section with respect to 1
20
of the spouses by reason of subsection (e), the
21
taxpayer shall be treated as described in clause
22
(ii)(I) unless a deduction is allowed under sec-
23
tion 151 for the taxable year with respect to a
24
dependent other than either spouse and sub-
25
section (e) does not apply to the dependent.
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1
‘‘(C) ADJUSTED
MONTHLY
PREMIUM.—
2
The adjusted monthly premium for an applica-
3
ble second lowest cost silver plan is the monthly
4
premium which would have been charged (for
5
the rating area with respect to which the pre-
6
miums under paragraph (2)(A) were deter-
7
mined) for the plan if each individual covered
8
under a qualified health plan taken into account
9
under paragraph (2)(A) were covered by such
10
silver plan and the premium was adjusted only
11
for the age of each such individual in the man-
12
ner allowed under section 2701 of the Public
13
Health Service Act. In the case of a State par-
14
ticipating in the wellness discount demonstra-
15
tion project under section 2705(d) of the Public
16
Health Service Act, the adjusted monthly pre-
17
mium shall be determined without regard to
18
any premium discount or rebate under such
19
project.
20
‘‘(D) ADDITIONAL
BENEFITS.—If—
21
‘‘(i) a qualified health plan under sec-
22
tion 1302(b)(5) of the Patient Protection
23
and Affordable Care Act offers benefits in
24
addition to the essential health benefits re-
25
quired to be provided by the plan, or
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1
‘‘(ii) a State requires a qualified
2
health plan under section 1311(d)(3)(B) of
3
such Act to cover benefits in addition to
4
the essential health benefits required to be
5
provided by the plan,
6
the portion of the premium for the plan prop-
7
erly allocable (under rules prescribed by the
8
Secretary of Health and Human Services) to
9
such additional benefits shall not be taken into
10
account in determining either the monthly pre-
11
mium or the adjusted monthly premium under
12
paragraph (2).
13
‘‘(E) SPECIAL
RULE FOR PEDIATRIC DEN-
14
TAL COVERAGE.—For
15
the amount of any monthly premium, if an indi-
16
vidual enrolls in both a qualified health plan
17
and
18
1311(d)(2)(B)(ii)(I) of the Patient Protection
19
and Affordable Care Act for any plan year, the
20
portion of the premium for the plan described
21
in such section that (under regulations pre-
22
scribed by the Secretary) is properly allocable
23
to pediatric dental benefits which are included
24
in the essential health benefits required to be
25
provided by a qualified health plan under sec-
a
plan
purposes of determining
described
in
section
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1
tion 1302(b)(1)(J) of such Act shall be treated
2
as a premium payable for a qualified health
3
plan.
4
5
‘‘(c) DEFINITION
CABLE
AND
RULES RELATING
TO
APPLI-
TAXPAYERS, COVERAGE MONTHS, AND QUALIFIED
6 HEALTH PLAN.—For purposes of this section—
7
‘‘(1) APPLICABLE
8
‘‘(A) IN
TAXPAYER.—
GENERAL.—The
term ‘applicable
9
taxpayer’ means, with respect to any taxable
10
year, a taxpayer whose household income for
11
the taxable year exceeds 100 percent but does
12
not exceed 400 percent of an amount equal to
13
the poverty line for a family of the size in-
14
volved.
15
‘‘(B) SPECIAL
RULE FOR CERTAIN INDI-
16
VIDUALS LAWFULLY PRESENT IN THE UNITED
17
STATES.—If—
18
‘‘(i) a taxpayer has a household in-
19
come which is not greater than 100 per-
20
cent of an amount equal to the poverty line
21
for a family of the size involved, and
22
‘‘(ii) the taxpayer is an alien lawfully
23
present in the United States, but is not eli-
24
gible for the medicaid program under title
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1
XIX of the Social Security Act by reason
2
of such alien status,
3
the taxpayer shall, for purposes of the credit
4
under this section, be treated as an applicable
5
taxpayer with a household income which is
6
equal to 100 percent of the poverty line for a
7
family of the size involved.
8
9
‘‘(C) MARRIED
RETURN.—If
COUPLES MUST FILE JOINT
the taxpayer is married (within
10
the meaning of section 7703) at the close of the
11
taxable year, the taxpayer shall be treated as an
12
applicable taxpayer only if the taxpayer and the
13
taxpayer’s spouse file a joint return for the tax-
14
able year.
15
‘‘(D) DENIAL
OF
CREDIT
TO
DEPEND-
16
ENTS.—No
17
section to any individual with respect to whom
18
a deduction under section 151 is allowable to
19
another taxpayer for a taxable year beginning
20
in the calendar year in which such individual’s
21
taxable year begins.
22
‘‘(2) COVERAGE
23
subsection—
credit shall be allowed under this
MONTH.—For
purposes of this
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1
‘‘(A) IN
GENERAL.—The
term ‘coverage
2
month’ means, with respect to an applicable
3
taxpayer, any month if—
4
‘‘(i) as of the first day of such month
5
the taxpayer, the taxpayer’s spouse, or any
6
dependent of the taxpayer is covered by a
7
qualified health plan described in sub-
8
section (b)(2)(A) that was enrolled in
9
through an Exchange established by the
10
State under section 1311 of the Patient
11
Protection and Affordable Care Act, and
12
‘‘(ii) the premium for coverage under
13
such plan for such month is paid by the
14
taxpayer (or through advance payment of
15
the credit under subsection (a) under sec-
16
tion 1412 of the Patient Protection and
17
Affordable Care Act).
18
‘‘(B) EXCEPTION
19
20
FOR MINIMUM ESSEN-
TIAL COVERAGE.—
‘‘(i) IN
GENERAL.—The
term ‘cov-
21
erage month’ shall not include any month
22
with respect to an individual if for such
23
month the individual is eligible for min-
24
imum essential coverage other than eligi-
25
bility for coverage described in section
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1
5000A(f)(1)(C) (relating to coverage in the
2
individual market).
3
‘‘(ii)
4
ERAGE.—The
5
coverage’ has the meaning given such term
6
by section 5000A(f).
7
‘‘(C) SPECIAL
MINIMUM
ESSENTIAL
COV-
term ‘minimum essential
RULE FOR EMPLOYER-SPON-
8
SORED MINIMUM ESSENTIAL COVERAGE.—For
9
purposes of subparagraph (B)—
10
‘‘(i) COVERAGE
MUST
BE
AFFORD-
11
ABLE.—Except
12
an employee shall not be treated as eligible
13
for minimum essential coverage if such
14
coverage—
as provided in clause (iii),
15
‘‘(I) consists of an eligible em-
16
ployer-sponsored plan (as defined in
17
section 5000A(f)(2)), and
18
‘‘(II) the employee’s required
19
contribution (within the meaning of
20
section 5000A(e)(1)(B)) with respect
21
to the plan exceeds 9.8 percent of the
22
applicable taxpayer’s household in-
23
come.
24
This clause shall also apply to an indi-
25
vidual who is eligible to enroll in the plan
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1
by reason of a relationship the individual
2
bears to the employee.
3
‘‘(ii) COVERAGE
MUST PROVIDE MIN-
4
IMUM
5
clause (iii), an employee shall not be treat-
6
ed as eligible for minimum essential cov-
7
erage if such coverage consists of an eligi-
8
ble employer-sponsored plan (as defined in
9
section 5000A(f)(2)) and the plan’s share
10
of the total allowed costs of benefits pro-
11
vided under the plan is less than 60 per-
12
cent of such costs.
13
VALUE.—Except
‘‘(iii) EMPLOYEE
as provided in
OR FAMILY MUST
14
NOT
15
PLAN.—Clauses
16
if the employee (or any individual de-
17
scribed in the last sentence of clause (i)) is
18
covered under the eligible employer-spon-
19
sored plan or the grandfathered health
20
plan.
BE
COVERED
UNDER
EMPLOYER
(i) and (ii) shall not apply
21
‘‘(iv) INDEXING.—In the case of plan
22
years beginning in any calendar year after
23
2014, the Secretary shall adjust the 9.8
24
percent under clause (i)(II) in the same
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1
manner as the percentages are adjusted
2
under subsection (b)(3)(A)(ii).
3
4
‘‘(3) DEFINITIONS
‘‘(A)
AND OTHER RULES.—
QUALIFIED
HEALTH
PLAN.—The
5
term ‘qualified health plan’ has the meaning
6
given such term by section 1301(a) of the Pa-
7
tient Protection and Affordable Care Act, ex-
8
cept that such term shall not include a qualified
9
health plan which is a catastrophic plan de-
10
11
scribed in section 1302(e) of such Act.
‘‘(B) GRANDFATHERED
HEALTH PLAN.—
12
The term ‘grandfathered health plan’ has the
13
meaning given such term by section 1251 of the
14
Patient Protection and Affordable Care Act.
15
‘‘(d) TERMS RELATING TO INCOME AND FAMILIES.—
16 For purposes of this section—
17
‘‘(1) FAMILY
SIZE.—The
family size involved
18
with respect to any taxpayer shall be equal to the
19
number of individuals for whom the taxpayer is al-
20
lowed a deduction under section 151 (relating to al-
21
lowance of deduction for personal exemptions) for
22
the taxable year.
23
‘‘(2) HOUSEHOLD
INCOME.—
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1
‘‘(A) HOUSEHOLD
INCOME.—The
term
2
‘household income’ means, with respect to any
3
taxpayer, an amount equal to the sum of—
4
5
‘‘(i) the modified gross income of the
taxpayer, plus
6
7
‘‘(ii) the aggregate modified gross incomes of all other individuals who—
8
‘‘(I) were taken into account in
9
determining the taxpayer’s family size
10
under paragraph (1), and
11
‘‘(II) were required to file a re-
12
turn of tax imposed by section 1 for
13
the taxable year.
14
‘‘(B)
MODIFIED
GROSS
INCOME.—The
15
term ‘modified gross income’ means gross in-
16
come—
17
‘‘(i) decreased by the amount of any
18
deduction allowable under paragraph (1),
19
(3), (4), or (10) of section 62(a),
20
‘‘(ii) increased by the amount of inter-
21
est received or accrued during the taxable
22
year which is exempt from tax imposed by
23
this chapter, and
24
25
‘‘(iii) determined without regard to
sections 911, 931, and 933.
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1
‘‘(3) POVERTY
2
‘‘(A) IN
LINE.—
GENERAL.—The
term ‘poverty
3
line’ has the meaning given that term in section
4
2110(c)(5) of the Social Security Act (42
5
U.S.C. 1397jj(c)(5)).
6
‘‘(B) POVERTY
LINE USED.—In
the case of
7
any qualified health plan offered through an
8
Exchange for coverage during a taxable year
9
beginning in a calendar year, the poverty line
10
used shall be the most recently published pov-
11
erty line as of the 1st day of the regular enroll-
12
ment period for coverage during such calendar
13
year.
14
‘‘(e) RULES
FOR
INDIVIDUALS NOT LAWFULLY
15 PRESENT.—
16
‘‘(1) IN
GENERAL.—If
1 or more individuals for
17
whom a taxpayer is allowed a deduction under sec-
18
tion 151 (relating to allowance of deduction for per-
19
sonal exemptions) for the taxable year (including the
20
taxpayer or his spouse) are individuals who are not
21
lawfully present—
22
‘‘(A) the aggregate amount of premiums
23
otherwise taken into account under clauses (i)
24
and (ii) of subsection (b)(2)(A) shall be reduced
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1
by the portion (if any) of such premiums which
2
is attributable to such individuals, and
3
‘‘(B) for purposes of applying this section,
4
the determination as to what percentage a tax-
5
payer’s household income bears to the poverty
6
level for a family of the size involved shall be
7
made under one of the following methods:
8
‘‘(i) A method under which—
9
‘‘(I) the taxpayer’s family size is
10
determined by not taking such indi-
11
viduals into account, and
12
‘‘(II) the taxpayer’s household in-
13
come is equal to the product of the
14
taxpayer’s household income (deter-
15
mined without regard to this sub-
16
section) and a fraction—
17
‘‘(aa)
the
numerator
of
18
which is the poverty line for the
19
taxpayer’s family size determined
20
after application of subclause (I),
21
and
22
‘‘(bb) the denominator of
23
which is the poverty line for the
24
taxpayer’s family size determined
25
without regard to subclause (I).
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1
‘‘(ii) A comparable method reaching
2
the same result as the method under
3
clause (i).
4
‘‘(2) LAWFULLY
PRESENT.—For
purposes of
5
this section, an individual shall be treated as law-
6
fully present only if the individual is, and is reason-
7
ably expected to be for the entire period of enroll-
8
ment for which the credit under this section is being
9
claimed, a citizen or national of the United States
10
11
or an alien lawfully present in the United States.
‘‘(3) SECRETARIAL
AUTHORITY.—The
Secretary
12
of Health and Human Services, in consultation with
13
the Secretary, shall prescribe rules setting forth the
14
methods by which calculations of family size and
15
household income are made for purposes of this sub-
16
section. Such rules shall be designed to ensure that
17
the least burden is placed on individuals enrolling in
18
qualified health plans through an Exchange and tax-
19
payers eligible for the credit allowable under this
20
section.
21
‘‘(f) RECONCILIATION
OF
CREDIT
AND
ADVANCE
22 CREDIT.—
23
‘‘(1) IN
GENERAL.—The
amount of the credit
24
allowed under this section for any taxable year shall
25
be reduced (but not below zero) by the amount of
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1
any advance payment of such credit under section
2
1412 of the Patient Protection and Affordable Care
3
Act.
4
‘‘(2) EXCESS
5
‘‘(A) IN
ADVANCE PAYMENTS.—
GENERAL.—If
the advance pay-
6
ments to a taxpayer under section 1412 of the
7
Patient Protection and Affordable Care Act for
8
a taxable year exceed the credit allowed by this
9
section (determined without regard to para-
10
graph (1)), the tax imposed by this chapter for
11
the taxable year shall be increased by the
12
amount of such excess.
13
‘‘(B) LIMITATION
ON INCREASE WHERE
14
INCOME LESS THAN 400 PERCENT OF POVERTY
15
LINE.—
16
‘‘(i) IN
GENERAL.—In
the case of an
17
applicable taxpayer whose household in-
18
come is less than 400 percent of the pov-
19
erty line for the size of the family involved
20
for the taxable year, the amount of the in-
21
crease under subparagraph (A) shall in no
22
event exceed $400 ($250 in the case of a
23
taxpayer whose tax is determined under
24
section 1(c) for the taxable year).
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1
‘‘(ii) INDEXING
OF AMOUNT.—In
the
2
case of any calendar year beginning after
3
2014, each of the dollar amounts under
4
clause (i) shall be increased by an amount
5
equal to—
6
‘‘(I) such dollar amount, multi-
7
plied by
8
‘‘(II) the cost-of-living adjust-
9
ment determined under section 1(f)(3)
10
for the calendar year, determined by
11
substituting ‘calendar year 2013’ for
12
‘calendar year 1992’ in subparagraph
13
(B) thereof.
14
If the amount of any increase under clause
15
(i) is not a multiple of $50, such increase
16
shall be rounded to the next lowest mul-
17
tiple of $50.
18
‘‘(g) REGULATIONS.—The Secretary shall prescribe
19 such regulations as may be necessary to carry out the pro20 visions of this section, including regulations which provide
21 for—
22
‘‘(1) the coordination of the credit allowed
23
under this section with the program for advance
24
payment of the credit under section 1412 of the Pa-
25
tient Protection and Affordable Care Act, and
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1
‘‘(2) the application of subsection (f) where the
2
filing status of the taxpayer for a taxable year is dif-
3
ferent from such status used for determining the ad-
4
vance payment of the credit.’’.
5
(b) DISALLOWANCE
OF
DEDUCTION.—Section 280C
6 of the Internal Revenue Code of 1986 is amended by add7 ing at the end the following new subsection:
8
‘‘(g) CREDIT FOR HEALTH INSURANCE PREMIUMS.—
9 No deduction shall be allowed for the portion of the pre10 miums paid by the taxpayer for coverage of 1 or more
11 individuals under a qualified health plan which is equal
12 to the amount of the credit determined for the taxable
13 year under section 36B(a) with respect to such pre14 miums.’’.
15
16
17
(c) STUDY ON AFFORDABLE COVERAGE.—
(1) STUDY
AND REPORT.—
(A) IN
GENERAL.—Not
later than 5 years
18
after the date of the enactment of this Act, the
19
Comptroller General shall conduct a study on
20
the affordability of health insurance coverage,
21
including—
22
(i) the impact of the tax credit for
23
qualified health insurance coverage of indi-
24
viduals under section 36B of the Internal
25
Revenue Code of 1986 and the tax credit
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1
for employee health insurance expenses of
2
small employers under section 45R of such
3
Code on maintaining and expanding the
4
health insurance coverage of individuals;
5
(ii)
the
availability
of
affordable
6
health benefits plans, including a study of
7
whether the percentage of household in-
8
come
9
36B(c)(2)(C) of the Internal Revenue Code
10
of 1986 (as added by this section) is the
11
appropriate level for determining whether
12
employer-provided coverage is affordable
13
for an employee and whether such level
14
may be lowered without significantly in-
15
creasing the costs to the Federal Govern-
16
ment and reducing employer-provided cov-
17
erage; and
used
for
purposes
of
section
18
(iii) the ability of individuals to main-
19
tain essential health benefits coverage (as
20
defined in section 5000A(f) of the Internal
21
Revenue Code of 1986).
22
(B) REPORT.—The Comptroller General
23
shall submit to the appropriate committees of
24
Congress a report on the study conducted under
25
subparagraph (A), together with legislative rec-
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1
ommendations relating to the matters studied
2
under such subparagraph.
3
(2)
APPROPRIATE
COMMITTEES
OF
CON-
4
GRESS.—In
5
committees of Congress’’ means the Committee on
6
Ways and Means, the Committee on Education and
7
Labor, and the Committee on Energy and Com-
8
merce of the House of Representatives and the Com-
9
mittee on Finance and the Committee on Health,
this subsection, the term ‘‘appropriate
10
Education, Labor and Pensions of the Senate.
11
(d) CONFORMING AMENDMENTS.—
12
(1) Paragraph (2) of section 1324(b) of title
13
31, United States Code, is amended by inserting
14
‘‘36B,’’ after ‘‘36A,’’.
15
(2) The table of sections for subpart C of part
16
IV of subchapter A of chapter 1 of the Internal Rev-
17
enue Code of 1986 is amended by inserting after the
18
item relating to section 36A the following new item:
‘‘Sec. 36B. Refundable credit for coverage under a qualified health plan.’’.
19
(e) EFFECTIVE DATE.—The amendments made by
20 this section shall apply to taxable years ending after De21 cember 31, 2013.
22
23
24
SEC. 1402. REDUCED COST-SHARING FOR INDIVIDUALS ENROLLING IN QUALIFIED HEALTH PLANS.
(a) IN GENERAL.—In the case of an eligible insured
25 enrolled in a qualified health plan—
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1
2
(1) the Secretary shall notify the issuer of the
plan of such eligibility; and
3
(2) the issuer shall reduce the cost-sharing
4
under the plan at the level and in the manner speci-
5
fied in subsection (c).
6
(b) ELIGIBLE INSURED.—In this section, the term
7 ‘‘eligible insured’’ means an individual—
8
(1) who enrolls in a qualified health plan in the
9
silver level of coverage in the individual market of-
10
fered through an Exchange; and
11
(2) whose household income exceeds 100 per-
12
cent but does not exceed 400 percent of the poverty
13
line for a family of the size involved.
14 In the case of an individual described in section
15 36B(c)(1)(B) of the Internal Revenue Code of 1986, the
16 individual shall be treated as having household income
17 equal to 100 percent for purposes of applying this section.
18
19
(c) DETERMINATION
OF
REDUCTION
IN
COST-SHAR-
ING.—
20
(1) REDUCTION
21
(A) IN
IN OUT-OF-POCKET LIMIT.—
GENERAL.—The
reduction in cost-
22
sharing under this subsection shall first be
23
achieved by reducing the applicable out-of pock-
24
et limit under section 1302(c)(1) in the case
25
of—
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1
(i) an eligible insured whose household
2
income is more than 100 percent but not
3
more than 200 percent of the poverty line
4
for a family of the size involved, by two-
5
thirds;
6
(ii) an eligible insured whose house-
7
hold income is more than 200 percent but
8
not more than 300 percent of the poverty
9
line for a family of the size involved, by
10
one-half; and
11
(iii) an eligible insured whose house-
12
hold income is more than 300 percent but
13
not more than 400 percent of the poverty
14
line for a family of the size involved, by
15
one-third.
16
(B)
17
18
COORDINATION
WITH
ACTUARIAL
VALUE LIMITS.—
(i) IN
GENERAL.—The
Secretary shall
19
ensure the reduction under this paragraph
20
shall not result in an increase in the plan’s
21
share of the total allowed costs of benefits
22
provided under the plan above—
23
(I) 90 percent in the case of an
24
eligible insured described in para-
25
graph (2)(A);
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(II) 80 percent in the case of an
2
eligible insured described in para-
3
graph (2)(B); and
4
(III) 70 percent in the case of an
5
eligible insured described in clause (ii)
6
or (iii) of subparagraph (A).
7
(ii)
ADJUSTMENT.—The
Secretary
8
shall adjust the out-of pocket limits under
9
paragraph (1) if necessary to ensure that
10
such limits do not cause the respective ac-
11
tuarial values to exceed the levels specified
12
in clause (i).
13
(2) ADDITIONAL
REDUCTION FOR LOWER IN-
14
COME INSUREDS.—The
15
cedures under which the issuer of a qualified health
16
plan to which this section applies shall further re-
17
duce cost-sharing under the plan in a manner suffi-
18
cient to—
Secretary shall establish pro-
19
(A) in the case of an eligible insured whose
20
household income is not less than 100 percent
21
but not more than 150 percent of the poverty
22
line for a family of the size involved, increase
23
the plan’s share of the total allowed costs of
24
benefits provided under the plan to 90 percent
25
of such costs; and
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(B) in the case of an eligible insured whose
2
household income is more than 150 percent but
3
not more than 200 percent of the poverty line
4
for a family of the size involved, increase the
5
plan’s share of the total allowed costs of bene-
6
fits provided under the plan to 80 percent of
7
such costs.
8
(3) METHODS
9
(A) IN
FOR REDUCING COST-SHARING.—
GENERAL.—An
issuer of a qualified
10
health plan making reductions under this sub-
11
section shall notify the Secretary of such reduc-
12
tions and the Secretary shall make periodic and
13
timely payments to the issuer equal to the value
14
of the reductions.
15
(B) CAPITATED
PAYMENTS.—The
Sec-
16
retary may establish a capitated payment sys-
17
tem to carry out the payment of cost-sharing
18
reductions under this section. Any such system
19
shall take into account the value of the reduc-
20
tions and make appropriate risk adjustments to
21
such payments.
22
(4) ADDITIONAL
BENEFITS.—If
a qualified
23
health plan under section 1302(b)(5) offers benefits
24
in addition to the essential health benefits required
25
to be provided by the plan, or a State requires a
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qualified health plan under section 1311(d)(3)(B) to
2
cover benefits in addition to the essential health ben-
3
efits required to be provided by the plan, the reduc-
4
tions in cost-sharing under this section shall not
5
apply to such additional benefits.
6
(5) SPECIAL
RULE FOR PEDIATRIC DENTAL
7
PLANS.—If
8
health plan and a plan described in section
9
1311(d)(2)(B)(ii)(I) for any plan year, subsection
10
(a) shall not apply to that portion of any reduction
11
in cost-sharing under subsection (c) that (under reg-
12
ulations prescribed by the Secretary) is properly al-
13
locable to pediatric dental benefits which are in-
14
cluded in the essential health benefits required to be
15
provided by a qualified health plan under section
16
1302(b)(1)(J).
17
(d) SPECIAL RULES FOR INDIANS.—
18
an individual enrolls in both a qualified
(1) INDIANS
UNDER 300 PERCENT OF POV-
19
ERTY.—If
20
health plan in the individual market through an Ex-
21
change is an Indian (as defined in section 4(d) of
22
the Indian Self-Determination and Education Assist-
23
ance Act (25 U.S.C. 450b(d))) whose household in-
24
come is not more than 300 percent of the poverty
an individual enrolled in any qualified
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1
line for a family of the size involved, then, for pur-
2
poses of this section—
3
4
5
(A) such individual shall be treated as an
eligible insured; and
(B) the issuer of the plan shall eliminate
6
any cost-sharing under the plan.
7
(2) ITEMS
OR SERVICES FURNISHED THROUGH
8
INDIAN HEALTH PROVIDERS.—If
9
defined) enrolled in a qualified health plan is fur-
10
nished an item or service directly by the Indian
11
Health Service, an Indian Tribe, Tribal Organiza-
12
tion, or Urban Indian Organization or through refer-
13
ral under contract health services—
an Indian (as so
14
(A) no cost-sharing under the plan shall be
15
imposed under the plan for such item or serv-
16
ice; and
17
(B) the issuer of the plan shall not reduce
18
the payment to any such entity for such item
19
or service by the amount of any cost-sharing
20
that would be due from the Indian but for sub-
21
paragraph (A).
22
(3) PAYMENT.—The Secretary shall pay to the
23
issuer of a qualified health plan the amount nec-
24
essary to reflect the increase in actuarial value of
25
the plan required by reason of this subsection.
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(e) RULES
FOR
INDIVIDUALS NOT LAWFULLY
2 PRESENT.—
3
4
(1) IN
GENERAL.—If
an individual who is an el-
igible insured is not lawfully present—
5
(A) no cost-sharing reduction under this
6
section shall apply with respect to the indi-
7
vidual; and
8
(B) for purposes of applying this section,
9
the determination as to what percentage a tax-
10
payer’s household income bears to the poverty
11
level for a family of the size involved shall be
12
made under one of the following methods:
13
(i) A method under which—
14
(I) the taxpayer’s family size is
15
determined by not taking such indi-
16
viduals into account, and
17
(II) the taxpayer’s household in-
18
come is equal to the product of the
19
taxpayer’s household income (deter-
20
mined without regard to this sub-
21
section) and a fraction—
22
(aa) the numerator of which
23
is the poverty line for the tax-
24
payer’s family size determined
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after application of subclause (I),
2
and
3
(bb)
the
denominator
of
4
which is the poverty line for the
5
taxpayer’s family size determined
6
without regard to subclause (I).
7
(ii) A comparable method reaching the
8
same result as the method under clause (i).
9
(2) LAWFULLY
PRESENT.—For
purposes of this
10
section, an individual shall be treated as lawfully
11
present only if the individual is, and is reasonably
12
expected to be for the entire period of enrollment for
13
which the cost-sharing reduction under this section
14
is being claimed, a citizen or national of the United
15
States or an alien lawfully present in the United
16
States.
17
(3) SECRETARIAL
AUTHORITY.—The
Secretary,
18
in consultation with the Secretary of the Treasury,
19
shall prescribe rules setting forth the methods by
20
which calculations of family size and household in-
21
come are made for purposes of this subsection. Such
22
rules shall be designed to ensure that the least bur-
23
den is placed on individuals enrolling in qualified
24
health plans through an Exchange and taxpayers eli-
25
gible for the credit allowable under this section.
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1
(f) DEFINITIONS
AND
SPECIAL RULES.—In this sec-
2 tion:
3
(1) IN
GENERAL.—Any
term used in this sec-
4
tion which is also used in section 36B of the Inter-
5
nal Revenue Code of 1986 shall have the meaning
6
given such term by such section.
7
(2) LIMITATIONS
ON REDUCTION.—No
cost-
8
sharing reduction shall be allowed under this section
9
with respect to coverage for any month unless the
10
month is a coverage month with respect to which a
11
credit is allowed to the insured (or an applicable tax-
12
payer on behalf of the insured) under section 36B
13
of such Code.
14
(3) DATA
USED FOR ELIGIBILITY.—Any
deter-
15
mination under this section shall be made on the
16
basis of the taxable year for which the advance de-
17
termination is made under section 1412 and not the
18
taxable year for which the credit under section 36B
19
of such Code is allowed.
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1
Subpart B—Eligibility Determinations
2
SEC. 1411. PROCEDURES FOR DETERMINING ELIGIBILITY
3
FOR EXCHANGE PARTICIPATION, PREMIUM
4
TAX CREDITS AND REDUCED COST-SHARING ,
5
AND INDIVIDUAL RESPONSIBILITY EXEMP-
6
TIONS.
7
(a) ESTABLISHMENT
OF
PROGRAM.—The Secretary
8 shall establish a program meeting the requirements of this
9 section for determining—
10
(1) whether an individual who is to be covered
11
in the individual market by a qualified health plan
12
offered through an Exchange, or who is claiming a
13
premium tax credit or reduced cost-sharing, meets
14
the requirements of sections 1312(f)(3), 1402(e),
15
and 1412(d) of this title and section 36B(e) of the
16
Internal Revenue Code of 1986 that the individual
17
be a citizen or national of the United States or an
18
alien lawfully present in the United States;
19
(2) in the case of an individual claiming a pre-
20
mium tax credit or reduced cost-sharing under sec-
21
tion 36B of such Code or section 1402—
22
(A) whether the individual meets the in-
23
come and coverage requirements of such sec-
24
tions; and
25
26
(B) the amount of the tax credit or reduced cost-sharing;
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1
(3) whether an individual’s coverage under an
2
employer-sponsored health benefits plan is treated as
3
unaffordable
4
5000A(e)(2); and
under
sections
36B(c)(2)(C)
and
5
(4) whether to grant a certification under sec-
6
tion 1311(d)(4)(H) attesting that, for purposes of
7
the individual responsibility requirement under sec-
8
tion 5000A of the Internal Revenue Code of 1986,
9
an individual is entitled to an exemption from either
10
the individual responsibility requirement or the pen-
11
alty imposed by such section.
12
(b) INFORMATION REQUIRED
TO
BE PROVIDED
BY
13 APPLICANTS.—
14
(1) IN
GENERAL.—An
applicant for enrollment
15
in a qualified health plan offered through an Ex-
16
change in the individual market shall provide—
17
(A) the name, address, and date of birth of
18
each individual who is to be covered by the plan
19
(in this subsection referred to as an ‘‘enrollee’’);
20
and
21
(B) the information required by any of the
22
following paragraphs that is applicable to an
23
enrollee.
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1
(2) CITIZENSHIP
OR IMMIGRATION STATUS.—
2
The following information shall be provided with re-
3
spect to every enrollee:
4
(A) In the case of an enrollee whose eligi-
5
bility is based on an attestation of citizenship of
6
the enrollee, the enrollee’s social security num-
7
ber.
8
(B) In the case of an individual whose eli-
9
gibility is based on an attestation of the enroll-
10
ee’s immigration status, the enrollee’s social se-
11
curity number (if applicable) and such identi-
12
fying information with respect to the enrollee’s
13
immigration status as the Secretary, after con-
14
sultation with the Secretary of Homeland Secu-
15
rity, determines appropriate.
16
(3) ELIGIBILITY
AND AMOUNT OF TAX CREDIT
17
OR REDUCED COST-SHARING.—In
18
rollee with respect to whom a premium tax credit or
19
reduced cost-sharing under section 36B of such
20
Code or section 1402 is being claimed, the following
21
information:
22
(A) INFORMATION
the case of an en-
REGARDING
INCOME
23
AND FAMILY SIZE.—The
24
in section 6103(l)(21) for the taxable year end-
25
ing with or within the second calendar year pre-
information described
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1
ceding the calendar year in which the plan year
2
begins.
3
(B) CHANGES
IN CIRCUMSTANCES.—The
4
information described in section 1412(b)(2), in-
5
cluding information with respect to individuals
6
who were not required to file an income tax re-
7
turn for the taxable year described in subpara-
8
graph (A) or individuals who experienced
9
changes in marital status or family size or sig-
10
nificant reductions in income.
11
(4) EMPLOYER-SPONSORED
COVERAGE.—In
the
12
case of an enrollee with respect to whom eligibility
13
for a premium tax credit under section 36B of such
14
Code or cost-sharing reduction under section 1402 is
15
being established on the basis that the enrollee’s (or
16
related individual’s) employer is not treated under
17
section 36B(c)(2)(C) of such Code as providing min-
18
imum essential coverage or affordable minimum es-
19
sential coverage, the following information:
20
(A) The name, address, and employer iden-
21
tification number (if available) of the employer.
22
(B) Whether the enrollee or individual is a
23
full-time employee and whether the employer
24
provides such minimum essential coverage.
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1
(C) If the employer provides such min-
2
imum essential coverage, the lowest cost option
3
for the enrollee’s or individual’s enrollment sta-
4
tus and the enrollee’s or individual’s required
5
contribution (within the meaning of section
6
5000A(e)(1)(B) of such Code) under the em-
7
ployer-sponsored plan.
8
(D) If an enrollee claims an employer’s
9
minimum essential coverage is unaffordable, the
10
information described in paragraph (3).
11
If an enrollee changes employment or obtains addi-
12
tional employment while enrolled in a qualified
13
health plan for which such credit or reduction is al-
14
lowed, the enrollee shall notify the Exchange of such
15
change or additional employment and provide the in-
16
formation described in this paragraph with respect
17
to the new employer.
18
(5) EXEMPTIONS
FROM INDIVIDUAL RESPONSI-
19
BILITY REQUIREMENTS.—In
20
vidual who is seeking an exemption certificate under
21
section 1311(d)(4)(H) from any requirement or pen-
22
alty imposed by section 5000A, the following infor-
23
mation:
the case of an indi-
24
(A) In the case of an individual seeking ex-
25
emption based on the individual’s status as a
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1
member of an exempt religious sect or division,
2
as a member of a health care sharing ministry,
3
as an Indian, or as an individual eligible for a
4
hardship exemption, such information as the
5
Secretary shall prescribe.
6
(B) In the case of an individual seeking ex-
7
emption based on the lack of affordable cov-
8
erage or the individual’s status as a taxpayer
9
with household income less than 100 percent of
10
the poverty line, the information described in
11
paragraphs (3) and (4), as applicable.
12
(c) VERIFICATION
OF
INFORMATION CONTAINED
IN
13 RECORDS OF SPECIFIC FEDERAL OFFICIALS.—
14
(1)
15
RETARY.—An
16
tion provided by an applicant under subsection (b)
17
to the Secretary for verification in accordance with
18
the requirements of this subsection and subsection
19
(d).
20
21
INFORMATION
TRANSFERRED
TO
SEC-
Exchange shall submit the informa-
(2) CITIZENSHIP
OR IMMIGRATION STATUS.—
(A) COMMISSIONER
OF
SOCIAL
SECU-
22
RITY.—The
23
missioner of Social Security the following infor-
24
mation for a determination as to whether the
Secretary shall submit to the Com-
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1
information provided is consistent with the in-
2
formation in the records of the Commissioner:
3
(i) The name, date of birth, and social
4
security number of each individual for
5
whom such information was provided
6
under subsection (b)(2).
7
(ii) The attestation of an individual
8
that the individual is a citizen.
9
(B) SECRETARY
10
11
12
OF
HOMELAND
SECU-
RITY.—
(i) IN
GENERAL.—In
the case of an
individual—
13
(I) who attests that the indi-
14
vidual is an alien lawfully present in
15
the United States; or
16
(II) who attests that the indi-
17
vidual is a citizen but with respect to
18
whom the Commissioner of Social Se-
19
curity has notified the Secretary
20
under subsection (e)(3) that the attes-
21
tation is inconsistent with information
22
in the records maintained by the
23
Commissioner;
24
the Secretary shall submit to the Secretary
25
of Homeland Security the information de-
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1
scribed in clause (ii) for a determination as
2
to whether the information provided is con-
3
sistent with the information in the records
4
of the Secretary of Homeland Security.
5
6
(ii) INFORMATION.—The information
described in clause (ii) is the following:
7
(I) The name, date of birth, and
8
any identifying information with re-
9
spect to the individual’s immigration
10
status
11
(b)(2).
provided
under
subsection
12
(II) The attestation that the indi-
13
vidual is an alien lawfully present in
14
the United States or in the case of an
15
individual described in clause (i)(II),
16
the attestation that the individual is a
17
citizen.
18
(3) ELIGIBILITY
FOR TAX CREDIT AND COST-
19
SHARING REDUCTION.—The
20
the information described in subsection (b)(3)(A)
21
provided under paragraph (3), (4), or (5) of sub-
22
section (b) to the Secretary of the Treasury for
23
verification of household income and family size for
24
purposes of eligibility.
25
(4) METHODS.—
Secretary shall submit
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1
(A) IN
GENERAL.—The
Secretary, in con-
2
sultation with the Secretary of the Treasury,
3
the Secretary of Homeland Security, and the
4
Commissioner of Social Security, shall provide
5
that verifications and determinations under this
6
subsection shall be done—
7
(i) through use of an on-line system
8
or otherwise for the electronic submission
9
of, and response to, the information sub-
10
mitted under this subsection with respect
11
to an applicant; or
12
(ii) by determining the consistency of
13
the information submitted with the infor-
14
mation maintained in the records of the
15
Secretary of the Treasury, the Secretary of
16
Homeland Security, or the Commissioner
17
of Social Security through such other
18
method as is approved by the Secretary.
19
(B) FLEXIBILITY.—The Secretary may
20
modify the methods used under the program es-
21
tablished by this section for the Exchange and
22
verification of information if the Secretary de-
23
termines such modifications would reduce the
24
administrative costs and burdens on the appli-
25
cant, including allowing an applicant to request
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1
the Secretary of the Treasury to provide the in-
2
formation described in paragraph (3) directly to
3
the Exchange or to the Secretary. The Sec-
4
retary shall not make any such modification un-
5
less the Secretary determines that any applica-
6
ble requirements under this section and section
7
6103 of the Internal Revenue Code of 1986
8
with respect to the confidentiality, disclosure,
9
maintenance, or use of information will be met.
10
(d) VERIFICATION
BY
SECRETARY.—In the case of
11 information provided under subsection (b) that is not re12 quired under subsection (c) to be submitted to another
13 person for verification, the Secretary shall verify the accu14 racy of such information in such manner as the Secretary
15 determines appropriate, including delegating responsibility
16 for verification to the Exchange.
17
18
(e) ACTIONS RELATING TO VERIFICATION.—
(1) IN
GENERAL.—Each
person to whom the
19
Secretary provided information under subsection (c)
20
shall report to the Secretary under the method es-
21
tablished under subsection (c)(4) the results of its
22
verification and the Secretary shall notify the Ex-
23
change of such results. Each person to whom the
24
Secretary provided information under subsection (d)
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1
shall report to the Secretary in such manner as the
2
Secretary determines appropriate.
3
4
(2) VERIFICATION.—
(A) ELIGIBILITY
FOR ENROLLMENT AND
5
PREMIUM TAX CREDITS AND COST-SHARING RE-
6
DUCTIONS.—If
7
plicant under paragraphs (1), (2), (3), and (4)
8
of subsection (b) is verified under subsections
9
(c) and (d)—
information provided by an ap-
10
(i) the individual’s eligibility to enroll
11
through the Exchange and to apply for
12
premium tax credits and cost-sharing re-
13
ductions shall be satisfied; and
14
(ii) the Secretary shall, if applicable,
15
notify the Secretary of the Treasury under
16
section 1412(c) of the amount of any ad-
17
vance payment to be made.
18
(B) EXEMPTION
FROM INDIVIDUAL RE-
19
SPONSIBILITY.—If
20
applicant under subsection (b)(5) is verified
21
under subsections (c) and (d), the Secretary
22
shall issue the certification of exemption de-
23
scribed in section 1311(d)(4)(H).
24
(3) INCONSISTENCIES
25
information provided by an
INVOLVING ATTESTATION
OF CITIZENSHIP OR LAWFUL PRESENCE.—If
the in-
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1
formation provided by any applicant under sub-
2
section (b)(2) is inconsistent with information in the
3
records maintained by the Commissioner of Social
4
Security or Secretary of Homeland Security, which-
5
ever is applicable, the applicant’s eligibility will be
6
determined in the same manner as an individual’s
7
eligibility under the medicaid program is determined
8
under section 1902(ee) of the Social Security Act (as
9
in effect on January 1, 2010).
10
11
12
(4) INCONSISTENCIES
INVOLVING OTHER IN-
FORMATION.—
(A) IN
GENERAL.—If
the information pro-
13
vided by an applicant under subsection (b)
14
(other than subsection (b)(2)) is inconsistent
15
with information in the records maintained by
16
persons under subsection (c) or is not verified
17
under subsection (d), the Secretary shall notify
18
the Exchange and the Exchange shall take the
19
following actions:
20
(i) REASONABLE
EFFORT.—The
Ex-
21
change shall make a reasonable effort to
22
identify and address the causes of such in-
23
consistency,
24
graphical or other clerical errors, by con-
25
tacting the applicant to confirm the accu-
including
through
typo-
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1
racy of the information, and by taking
2
such additional actions as the Secretary,
3
through regulation or other guidance, may
4
identify.
5
(ii) NOTICE
AND OPPORTUNITY TO
6
CORRECT.—In
7
or inability to verify is not resolved under
8
subparagraph (A), the Exchange shall—
9
10
the case the inconsistency
(I) notify the applicant of such
fact;
11
(II) provide the applicant an op-
12
portunity to either present satisfac-
13
tory documentary evidence or resolve
14
the inconsistency with the person
15
verifying the information under sub-
16
section (c) or (d) during the 90-day
17
period beginning the date on which
18
the notice required under subclause
19
(I) is sent to the applicant.
20
The Secretary may extend the 90-day pe-
21
riod under subclause (II) for enrollments
22
occurring during 2014.
23
(B) SPECIFIC
24
ACTIONS
NOT
INVOLVING
CITIZENSHIP OR LAWFUL PRESENCE.—
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1
(i) IN
GENERAL.—Except
as provided
2
in paragraph (3), the Exchange shall, dur-
3
ing any period before the close of the pe-
4
riod under subparagraph (A)(ii)(II), make
5
any determination under paragraphs (2),
6
(3), and (4) of subsection (a) on the basis
7
of the information contained on the appli-
8
cation.
9
(ii) ELIGIBILITY
OR
AMOUNT
OF
10
CREDIT OR REDUCTION.—If
11
ency involving the eligibility for, or amount
12
of, any premium tax credit or cost-sharing
13
reduction is unresolved under this sub-
14
section as of the close of the period under
15
subparagraph (A)(ii)(II), the Exchange
16
shall notify the applicant of the amount (if
17
any) of the credit or reduction that is de-
18
termined on the basis of the records main-
19
tained by persons under subsection (c).
20
(iii) EMPLOYER
an inconsist-
AFFORDABILITY.—If
21
the Secretary notifies an Exchange that an
22
enrollee is eligible for a premium tax credit
23
under section 36B of such Code or cost-
24
sharing reduction under section 1402 be-
25
cause the enrollee’s (or related individ-
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283
1
ual’s) employer does not provide minimum
2
essential coverage through an employer-
3
sponsored plan or that the employer does
4
provide that coverage but it is not afford-
5
able coverage, the Exchange shall notify
6
the employer of such fact and that the em-
7
ployer may be liable for the payment as-
8
sessed under section 4980H of such Code.
9
(iv) EXEMPTION.—In any case where
10
the inconsistency involving, or inability to
11
verify, information provided under sub-
12
section (b)(5) is not resolved as of the
13
close of the period under subparagraph
14
(A)(ii)(II), the Exchange shall notify an
15
applicant that no certification of exemption
16
from any requirement or payment under
17
section 5000A of such Code will be issued.
18
(C) APPEALS
PROCESS.—The
Exchange
19
shall also notify each person receiving notice
20
under this paragraph of the appeals processes
21
established under subsection (f).
22
(f) APPEALS AND REDETERMINATIONS.—
23
(1) IN
GENERAL.—The
Secretary, in consulta-
24
tion with the Secretary of the Treasury, the Sec-
25
retary of Homeland Security, and the Commissioner
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1
of Social Security, shall establish procedures by
2
which the Secretary or one of such other Federal of-
3
ficers—
4
(A) hears and makes decisions with respect
5
to appeals of any determination under sub-
6
section (e); and
7
(B) redetermines eligibility on a periodic
8
basis in appropriate circumstances.
9
(2) EMPLOYER
10
(A) IN
LIABILITY.—
GENERAL.—The
Secretary shall es-
11
tablish a separate appeals process for employers
12
who are notified under subsection (e)(4)(C) that
13
the employer may be liable for a tax imposed by
14
section 4980H of the Internal Revenue Code of
15
1986 with respect to an employee because of a
16
determination that the employer does not pro-
17
vide minimum essential coverage through an
18
employer-sponsored plan or that the employer
19
does provide that coverage but it is not afford-
20
able coverage with respect to an employee. Such
21
process shall provide an employer the oppor-
22
tunity to—
23
(i) present information to the Ex-
24
change for review of the determination ei-
25
ther by the Exchange or the person mak-
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1
ing the determination, including evidence
2
of the employer-sponsored plan and em-
3
ployer contributions to the plan; and
4
(ii) have access to the data used to
5
make the determination to the extent al-
6
lowable by law.
7
Such process shall be in addition to any rights
8
of appeal the employer may have under subtitle
9
F of such Code.
10
(B) CONFIDENTIALITY.—Notwithstanding
11
any provision of this title (or the amendments
12
made by this title) or section 6103 of the Inter-
13
nal Revenue Code of 1986, an employer shall
14
not be entitled to any taxpayer return informa-
15
tion with respect to an employee for purposes of
16
determining whether the employer is subject to
17
the penalty under section 4980H of such Code
18
with respect to the employee, except that—
19
(i) the employer may be notified as to
20
the name of an employee and whether or
21
not the employee’s income is above or
22
below the threshold by which the afford-
23
ability of an employer’s health insurance
24
coverage is measured; and
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1
(ii) this subparagraph shall not apply
2
to an employee who provides a waiver (at
3
such time and in such manner as the Sec-
4
retary may prescribe) authorizing an em-
5
ployer to have access to the employee’s tax-
6
payer return information.
7
8
9
(g) CONFIDENTIALITY
OF
APPLICANT INFORMA-
GENERAL.—An
applicant for insurance
TION.—
(1) IN
10
coverage or for a premium tax credit or cost-sharing
11
reduction shall be required to provide only the infor-
12
mation strictly necessary to authenticate identity,
13
determine eligibility, and determine the amount of
14
the credit or reduction.
15
(2) RECEIPT
OF INFORMATION.—Any
person
16
who receives information provided by an applicant
17
under subsection (b) (whether directly or by another
18
person at the request of the applicant), or receives
19
information from a Federal agency under subsection
20
(c), (d), or (e), shall—
21
(A) use the information only for the pur-
22
poses of, and to the extent necessary in, ensur-
23
ing the efficient operation of the Exchange, in-
24
cluding verifying the eligibility of an individual
25
to enroll through an Exchange or to claim a
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1
premium tax credit or cost-sharing reduction or
2
the amount of the credit or reduction; and
3
(B) not disclose the information to any
4
other person except as provided in this section.
5
6
(h) PENALTIES.—
(1) FALSE
OR FRAUDULENT INFORMATION.—
7
(A) CIVIL
8
(i) IN
PENALTY.—
GENERAL.—If—
9
(I) any person fails to provides
10
correct information under subsection
11
(b); and
12
(II) such failure is attributable to
13
negligence or disregard of any rules or
14
regulations of the Secretary,
15
such person shall be subject, in addition to
16
any other penalties that may be prescribed
17
by law, to a civil penalty of not more than
18
$25,000 with respect to any failures involv-
19
ing an application for a plan year. For
20
purposes of this subparagraph, the terms
21
‘‘negligence’’ and ‘‘disregard’’ shall have
22
the same meanings as when used in section
23
6662 of the Internal Revenue Code of
24
1986.
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1
(ii)
REASONABLE
CAUSE
EXCEP-
2
TION.—No
3
clause (i) if the Secretary determines that
4
there was a reasonable cause for the fail-
5
ure and that the person acted in good
6
faith.
7
(B)
8
TIONS.—Any
9
fully provides false or fraudulent information
10
under subsection (b) shall be subject, in addi-
11
tion to any other penalties that may be pre-
12
scribed by law, to a civil penalty of not more
13
than $250,000.
14
(2) IMPROPER
penalty shall be imposed under
KNOWING
AND
WILLFUL
VIOLA-
person who knowingly and will-
USE OR DISCLOSURE OF INFOR-
15
MATION.—Any
16
uses or discloses information in violation of sub-
17
section (g) shall be subject, in addition to any other
18
penalties that may be prescribed by law, to a civil
19
penalty of not more than $25,000.
20
person who knowingly and willfully
(3) LIMITATIONS
ON LIENS AND LEVIES.—The
21
Secretary (or, if applicable, the Attorney General of
22
the United States) shall not—
23
(A) file notice of lien with respect to any
24
property of a person by reason of any failure to
25
pay the penalty imposed by this subsection; or
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289
1
2
3
4
5
(B) levy on any such property with respect
to such failure.
(i) STUDY
OF
ADMINISTRATION
OF
EMPLOYER RE-
SPONSIBILITY.—
(1) IN
GENERAL.—The
Secretary of Health and
6
Human Services shall, in consultation with the Sec-
7
retary of the Treasury, conduct a study of the proce-
8
dures that are necessary to ensure that in the ad-
9
ministration of this title and section 4980H of the
10
Internal Revenue Code of 1986 (as added by section
11
1513) that the following rights are protected:
12
(A) The rights of employees to preserve
13
their right to confidentiality of their taxpayer
14
return information and their right to enroll in
15
a qualified health plan through an Exchange if
16
an employer does not provide affordable cov-
17
erage.
18
(B) The rights of employers to adequate
19
due process and access to information necessary
20
to accurately determine any payment assessed
21
on employers.
22
(2) REPORT.—Not later than January 1, 2013,
23
the Secretary of Health and Human Services shall
24
report the results of the study conducted under
25
paragraph (1), including any recommendations for
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1
legislative changes, to the Committees on Finance
2
and Health, Education, Labor and Pensions of the
3
Senate and the Committees of Education and Labor
4
and Ways and Means of the House of Representa-
5
tives.
6
SEC. 1412. ADVANCE DETERMINATION AND PAYMENT OF
7
PREMIUM TAX CREDITS AND COST-SHARING
8
REDUCTIONS.
9
(a) IN GENERAL.—The Secretary, in consultation
10 with the Secretary of the Treasury, shall establish a pro11 gram under which—
12
(1) upon request of an Exchange, advance de-
13
terminations are made under section 1411 with re-
14
spect to the income eligibility of individuals enrolling
15
in a qualified health plan in the individual market
16
through the Exchange for the premium tax credit al-
17
lowable under section 36B of the Internal Revenue
18
Code of 1986 and the cost-sharing reductions under
19
section 1402;
20
21
22
(2) the Secretary notifies—
(A) the Exchange and the Secretary of the
Treasury of the advance determinations; and
23
(B) the Secretary of the Treasury of the
24
name and employer identification number of
25
each employer with respect to whom 1 or more
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291
1
employee of the employer were determined to be
2
eligible for the premium tax credit under sec-
3
tion 36B of the Internal Revenue Code of 1986
4
and the cost-sharing reductions under section
5
1402 because—
6
7
(i) the employer did not provide minimum essential coverage; or
8
(ii) the employer provided such min-
9
imum essential coverage but it was deter-
10
mined under section 36B(c)(2)(C) of such
11
Code to either be unaffordable to the em-
12
ployee or not provide the required min-
13
imum actuarial value; and
14
(3) the Secretary of the Treasury makes ad-
15
vance payments of such credit or reductions to the
16
issuers of the qualified health plans in order to re-
17
duce the premiums payable by individuals eligible for
18
such credit.
19
(b) ADVANCE DETERMINATIONS.—
20
(1) IN
GENERAL.—The
Secretary shall provide
21
under the program established under subsection (a)
22
that advance determination of eligibility with respect
23
to any individual shall be made—
24
(A) during the annual open enrollment pe-
25
riod applicable to the individual (or such other
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1
enrollment period as may be specified by the
2
Secretary); and
3
(B) on the basis of the individual’s house-
4
hold income for the most recent taxable year for
5
which the Secretary, after consultation with the
6
Secretary of the Treasury, determines informa-
7
tion is available.
8
(2) CHANGES
IN CIRCUMSTANCES.—The
Sec-
9
retary shall provide procedures for making advance
10
determinations on the basis of information other
11
than that described in paragraph (1)(B) in cases
12
where information included with an application form
13
demonstrates substantial changes in income, changes
14
in family size or other household circumstances,
15
change in filing status, the filing of an application
16
for unemployment benefits, or other significant
17
changes affecting eligibility, including—
18
(A) allowing an individual claiming a de-
19
crease of 20 percent or more in income, or fil-
20
ing an application for unemployment benefits,
21
to have eligibility for the credit determined on
22
the basis of household income for a later period
23
or on the basis of the individual’s estimate of
24
such income for the taxable year; and
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1
(B) the determination of household income
2
in cases where the taxpayer was not required to
3
file a return of tax imposed by this chapter for
4
the second preceding taxable year.
5
6
7
(c) PAYMENT
SHARING
OF
PREMIUM TAX CREDITS
AND
COST-
REDUCTIONS.—
(1) IN
GENERAL.—The
Secretary shall notify
8
the Secretary of the Treasury and the Exchange
9
through which the individual is enrolling of the ad-
10
11
12
vance determination under section 1411.
(2) PREMIUM
(A) IN
TAX CREDIT.—
GENERAL.—The
Secretary of the
13
Treasury shall make the advance payment
14
under this section of any premium tax credit al-
15
lowed under section 36B of the Internal Rev-
16
enue Code of 1986 to the issuer of a qualified
17
health plan on a monthly basis (or such other
18
periodic basis as the Secretary may provide).
19
(B) ISSUER
RESPONSIBILITIES.—An
issuer
20
of a qualified health plan receiving an advance
21
payment with respect to an individual enrolled
22
in the plan shall—
23
(i) reduce the premium charged the
24
insured for any period by the amount of
25
the advance payment for the period;
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1
(ii) notify the Exchange and the Sec-
2
retary of such reduction;
3
(iii) include with each billing state-
4
ment the amount by which the premium
5
for the plan has been reduced by reason of
6
the advance payment; and
7
(iv) in the case of any nonpayment of
8
premiums by the insured—
9
(I) notify the Secretary of such
10
nonpayment; and
11
(II) allow a 3-month grace period
12
for nonpayment of premiums before
13
discontinuing coverage.
14
(3) COST-SHARING
REDUCTIONS.—The
Sec-
15
retary shall also notify the Secretary of the Treasury
16
and the Exchange under paragraph (1) if an ad-
17
vance payment of the cost-sharing reductions under
18
section 1402 is to be made to the issuer of any
19
qualified health plan with respect to any individual
20
enrolled in the plan. The Secretary of the Treasury
21
shall make such advance payment at such time and
22
in such amount as the Secretary specifies in the no-
23
tice.
24
(d) NO FEDERAL PAYMENTS
FOR INDIVIDUALS
NOT
25 LAWFULLY PRESENT.—Nothing in this subtitle or the
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1 amendments made by this subtitle allows Federal pay2 ments, credits, or cost-sharing reductions for individuals
3 who are not lawfully present in the United States.
4
(e) STATE FLEXIBILITY.—Nothing in this subtitle or
5 the amendments made by this subtitle shall be construed
6 to prohibit a State from making payments to or on behalf
7 of an individual for coverage under a qualified health plan
8 offered through an Exchange that are in addition to any
9 credits or cost-sharing reductions allowable to the indi10 vidual under this subtitle and such amendments.
11
SEC. 1413. STREAMLINING OF PROCEDURES FOR ENROLL-
12
MENT THROUGH AN EXCHANGE AND STATE
13
MEDICAID, CHIP, AND HEALTH SUBSIDY PRO-
14
GRAMS.
15
(a) IN GENERAL.—The Secretary shall establish a
16 system meeting the requirements of this section under
17 which residents of each State may apply for enrollment
18 in, receive a determination of eligibility for participation
19 in, and continue participation in, applicable State health
20 subsidy programs. Such system shall ensure that if an in21 dividual applying to an Exchange is found through screen22 ing to be eligible for medical assistance under the State
23 medicaid plan under title XIX, or eligible for enrollment
24 under a State children’s health insurance program
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1 (CHIP) under title XXI of such Act, the individual is en2 rolled for assistance under such plan or program.
3
4
5
6
(b) REQUIREMENTS RELATING
TO
FORMS
AND
NO -
TICE.—
(1) REQUIREMENTS
(A) IN
RELATING TO FORMS.—
GENERAL.—The
Secretary shall de-
7
velop and provide to each State a single,
8
streamlined form that—
9
(i) may be used to apply for all appli-
10
cable State health subsidy programs within
11
the State;
12
13
(ii) may be filed online, in person, by
mail, or by telephone;
14
(iii) may be filed with an Exchange or
15
with State officials operating one of the
16
other applicable State health subsidy pro-
17
grams; and
18
(iv) is structured to maximize an ap-
19
plicant’s ability to complete the form satis-
20
factorily, taking into account the charac-
21
teristics of individuals who qualify for ap-
22
plicable State health subsidy programs.
23
(B) STATE
AUTHORITY
TO
ESTABLISH
24
FORM.—A
25
single, streamlined form as an alternative to the
State may develop and use its own
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1
form developed under subparagraph (A) if the
2
alternative form is consistent with standards
3
promulgated by the Secretary under this sec-
4
tion.
5
(C)
6
FORMS.—The
7
use a supplemental or alternative form in the
8
case of individuals who apply for eligibility that
9
is not determined on the basis of the household
10
income (as defined in section 36B of the Inter-
11
nal Revenue Code of 1986).
12
(2) NOTICE.—The Secretary shall provide that
13
an applicant filing a form under paragraph (1) shall
14
receive notice of eligibility for an applicable State
15
health subsidy program without any need to provide
16
additional information or paperwork unless such in-
17
formation or paperwork is specifically required by
18
law when information provided on the form is incon-
19
sistent with data used for the electronic verification
20
under paragraph (3) or is otherwise insufficient to
21
determine eligibility.
22
(c) REQUIREMENTS RELATING
SUPPLEMENTAL
ELIGIBILITY
Secretary may allow a State to
TO
ELIGIBILITY
23 BASED ON DATA EXCHANGES.—
24
25
(1) DEVELOPMENT
OF SECURE INTERFACES.—
Each State shall develop for all applicable State
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1
health subsidy programs a secure, electronic inter-
2
face allowing an exchange of data (including infor-
3
mation contained in the application forms described
4
in subsection (b)) that allows a determination of eli-
5
gibility for all such programs based on a single ap-
6
plication. Such interface shall be compatible with the
7
method established for data verification under sec-
8
tion 1411(c)(4).
9
(2) DATA
MATCHING PROGRAM.—Each
applica-
10
ble State health subsidy program shall participate in
11
a data matching arrangement for determining eligi-
12
bility for participation in the program under para-
13
graph (3) that—
14
15
16
17
(A) provides access to data described in
paragraph (3);
(B) applies only to individuals who—
(i) receive assistance from an applica-
18
ble State health subsidy program; or
19
(ii) apply for such assistance—
20
21
(I) by filing a form described in
subsection (b); or
22
(II) by requesting a determina-
23
tion of eligibility and authorizing dis-
24
closure of the information described in
25
paragraph (3) to applicable State
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1
health coverage subsidy programs for
2
purposes of determining and estab-
3
lishing eligibility; and
4
(C) consistent with standards promulgated
5
by the Secretary, including the privacy and data
6
security safeguards described in section 1942 of
7
the Social Security Act or that are otherwise
8
applicable to such programs.
9
(3) DETERMINATION
10
(A) IN
OF ELIGIBILITY.—
GENERAL.—Each
applicable State
11
health subsidy program shall, to the maximum
12
extent practicable—
13
(i) establish, verify, and update eligi-
14
bility for participation in the program
15
using the data matching arrangement
16
under paragraph (2); and
17
(ii) determine such eligibility on the
18
basis of reliable, third party data, includ-
19
ing information described in sections 1137,
20
453(i), and 1942(a) of the Social Security
21
Act, obtained through such arrangement.
22
(B) EXCEPTION.—This paragraph shall
23
not apply in circumstances with respect to
24
which the Secretary determines that the admin-
25
istrative and other costs of use of the data
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1
matching arrangement under paragraph (2)
2
outweigh its expected gains in accuracy, effi-
3
ciency, and program participation.
4
(4) SECRETARIAL
STANDARDS.—The
Secretary
5
shall, after consultation with persons in possession
6
of the data to be matched and representatives of ap-
7
plicable State health subsidy programs, promulgate
8
standards governing the timing, contents, and proce-
9
dures for data matching described in this subsection.
10
Such standards shall take into account administra-
11
tive and other costs and the value of data matching
12
to the establishment, verification, and updating of
13
eligibility for applicable State health subsidy pro-
14
grams.
15
(d) ADMINISTRATIVE AUTHORITY.—
16
(1) AGREEMENTS.—Subject to section 1411
17
and section 6103(l)(21) of the Internal Revenue
18
Code of 1986 and any other requirement providing
19
safeguards of privacy and data integrity, the Sec-
20
retary may establish model agreements, and enter
21
into agreements, for the sharing of data under this
22
section.
23
(2) AUTHORITY
24
OUT.—Nothing
25
to—
OF EXCHANGE TO CONTRACT
in this section shall be construed
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1
(A)
prohibit
contractual
arrangements
2
through which a State medicaid agency deter-
3
mines eligibility for all applicable State health
4
subsidy programs, but only if such agency com-
5
plies with the Secretary’s requirements ensuring
6
reduced administrative costs, eligibility errors,
7
and disruptions in coverage; or
8
(B) change any requirement under title
9
XIX that eligibility for participation in a
10
State’s medicaid program must be determined
11
by a public agency.
12
13
(e) APPLICABLE STATE HEALTH SUBSIDY PROGRAM.—In
this section, the term ‘‘applicable State health
14 subsidy program’’ means—
15
(1) the program under this title for the enroll-
16
ment in qualified health plans offered through an
17
Exchange, including the premium tax credits under
18
section 36B of the Internal Revenue Code of 1986
19
and cost-sharing reductions under section 1402;
20
21
22
23
24
25
(2) a State medicaid program under title XIX
of the Social Security Act;
(3) a State children’s health insurance program
(CHIP) under title XXI of such Act; and
(4) a State program under section 1331 establishing qualified basic health plans.
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1
SEC. 1414. DISCLOSURES TO CARRY OUT ELIGIBILITY RE-
2
3
4
5
QUIREMENTS FOR CERTAIN PROGRAMS.
(a) DISCLOSURE
TION AND
OF
TAXPAYER RETURN INFORMA-
SOCIAL SECURITY NUMBERS.—
(1) TAXPAYER
RETURN INFORMATION.—Sub-
6
section (l) of section 6103 of the Internal Revenue
7
Code of 1986 is amended by adding at the end the
8
following new paragraph:
9
‘‘(21) DISCLOSURE
OF RETURN INFORMATION
10
TO CARRY OUT ELIGIBILITY REQUIREMENTS FOR
11
CERTAIN PROGRAMS.—
12
‘‘(A) IN
GENERAL.—The
Secretary, upon
13
written request from the Secretary of Health
14
and Human Services, shall disclose to officers,
15
employees, and contractors of the Department
16
of Health and Human Services return informa-
17
tion of any taxpayer whose income is relevant
18
in determining any premium tax credit under
19
section 36B or any cost-sharing reduction
20
under section 1402 of the Patient Protection
21
and Affordable Care Act or eligibility for par-
22
ticipation in a State medicaid program under
23
title XIX of the Social Security Act, a State’s
24
children’s health insurance program under title
25
XXI of the Social Security Act, or a basic
26
health program under section 1331 of Patient
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1
Protection and Affordable Care Act. Such re-
2
turn information shall be limited to—
3
4
5
6
‘‘(i)
taxpayer
identity
information
with respect to such taxpayer,
‘‘(ii) the filing status of such taxpayer,
7
‘‘(iii) the number of individuals for
8
whom a deduction is allowed under section
9
151 with respect to the taxpayer (including
10
the taxpayer and the taxpayer’s spouse),
11
‘‘(iv) the modified gross income (as
12
defined in section 36B) of such taxpayer
13
and each of the other individuals included
14
under clause (iii) who are required to file
15
a return of tax imposed by chapter 1 for
16
the taxable year,
17
‘‘(v) such other information as is pre-
18
scribed by the Secretary by regulation as
19
might indicate whether the taxpayer is eli-
20
gible for such credit or reduction (and the
21
amount thereof), and
22
‘‘(vi) the taxable year with respect to
23
which the preceding information relates or,
24
if applicable, the fact that such informa-
25
tion is not available.
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1
‘‘(B) INFORMATION
TO EXCHANGE AND
2
STATE AGENCIES.—The
Secretary of Health
3
and Human Services may disclose to an Ex-
4
change established under the Patient Protection
5
and Affordable Care Act or its contractors, or
6
to a State agency administering a State pro-
7
gram described in subparagraph (A) or its con-
8
tractors, any inconsistency between the infor-
9
mation provided by the Exchange or State
10
agency to the Secretary and the information
11
provided to the Secretary under subparagraph
12
(A).
13
‘‘(C) RESTRICTION
ON USE OF DISCLOSED
14
INFORMATION.—Return
information disclosed
15
under subparagraph (A) or (B) may be used by
16
officers, employees, and contractors of the De-
17
partment of Health and Human Services, an
18
Exchange, or a State agency only for the pur-
19
poses of, and to the extent necessary in—
20
‘‘(i) establishing eligibility for partici-
21
pation in the Exchange, and verifying the
22
appropriate amount of, any credit or re-
23
duction described in subparagraph (A),
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1
‘‘(ii) determining eligibility for partici-
2
pation in the State programs described in
3
subparagraph (A).’’.
4
(2)
SOCIAL
SECURITY
NUMBERS.—Section
5
205(c)(2)(C) of the Social Security Act is amended
6
by adding at the end the following new clause:
7
‘‘(x) The Secretary of Health and
8
Human Services, and the Exchanges estab-
9
lished under section 1311 of the Patient
10
Protection and Affordable Care Act, are
11
authorized to collect and use the names
12
and social security account numbers of in-
13
dividuals as required to administer the pro-
14
visions of, and the amendments made by,
15
the such Act.’’.
16
(b) CONFIDENTIALITY
AND
DISCLOSURE.—Para-
17 graph (3) of section 6103(a) of such Code is amended by
18 striking ‘‘or (20)’’ and inserting ‘‘(20), or (21)’’.
19
20
(c) PROCEDURES
TO
AND
RECORDKEEPING RELATED
DISCLOSURES.—Paragraph (4) of section 6103(p) of
21 such Code is amended—
22
(1) by inserting ‘‘, or any entity described in
23
subsection (l)(21),’’ after ‘‘or (20)’’ in the matter
24
preceding subparagraph (A),
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1
(2) by inserting ‘‘or any entity described in sub-
2
section (l)(21),’’ after ‘‘or (o)(1)(A)’’ in subpara-
3
graph (F)(ii), and
4
(3) by inserting ‘‘or any entity described in sub-
5
section (l)(21),’’ after ‘‘or (20)’’ both places it ap-
6
pears in the matter after subparagraph (F).
7
(d) UNAUTHORIZED DISCLOSURE
OR INSPECTION.—
8 Paragraph (2) of section 7213(a) of such Code is amended
9 by striking ‘‘or (20)’’ and inserting ‘‘(20), or (21)’’.
10
SEC. 1415. PREMIUM TAX CREDIT AND COST-SHARING RE-
11
DUCTION
12
FEDERAL AND FEDERALLY-ASSISTED PRO-
13
GRAMS.
14
PAYMENTS
DISREGARDED
FOR
For purposes of determining the eligibility of any in-
15 dividual for benefits or assistance, or the amount or extent
16 of benefits or assistance, under any Federal program or
17 under any State or local program financed in whole or in
18 part with Federal funds—
19
(1) any credit or refund allowed or made to any
20
individual by reason of section 36B of the Internal
21
Revenue Code of 1986 (as added by section 1401)
22
shall not be taken into account as income and shall
23
not be taken into account as resources for the month
24
of receipt and the following 2 months; and
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1
(2) any cost-sharing reduction payment or ad-
2
vance payment of the credit allowed under such sec-
3
tion 36B that is made under section 1402 or 1412
4
shall be treated as made to the qualified health plan
5
in which an individual is enrolled and not to that in-
6
dividual.
7
PART II—SMALL BUSINESS TAX CREDIT
8
SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE
9
10
EXPENSES OF SMALL BUSINESSES.
(a) IN GENERAL.—Subpart D of part IV of sub-
11 chapter A of chapter 1 of the Internal Revenue Code of
12 1986 (relating to business-related credits) is amended by
13 inserting after section 45Q the following:
14
15
16
‘‘SEC. 45R. EMPLOYEE HEALTH INSURANCE EXPENSES OF
SMALL EMPLOYERS.
‘‘(a) GENERAL RULE.—For purposes of section 38,
17 in the case of an eligible small employer, the small em18 ployer health insurance credit determined under this sec19 tion for any taxable year in the credit period is the amount
20 determined under subsection (b).
21
‘‘(b) HEALTH INSURANCE CREDIT AMOUNT.—Sub-
22 ject to subsection (c), the amount determined under this
23 subsection with respect to any eligible small employer is
24 equal to 50 percent (35 percent in the case of a tax-exempt
25 eligible small employer) of the lesser of—
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1
‘‘(1) the aggregate amount of nonelective con-
2
tributions the employer made on behalf of its em-
3
ployees during the taxable year under the arrange-
4
ment described in subsection (d)(4) for premiums
5
for qualified health plans offered by the employer to
6
its employees through an Exchange, or
7
‘‘(2) the aggregate amount of nonelective con-
8
tributions which the employer would have made dur-
9
ing the taxable year under the arrangement if each
10
employee taken into account under paragraph (1)
11
had enrolled in a qualified health plan which had a
12
premium equal to the average premium (as deter-
13
mined by the Secretary of Health and Human Serv-
14
ices) for the small group market in the rating area
15
in which the employee enrolls for coverage.
16
‘‘(c) PHASEOUT
17 NUMBER
OF
OF
EMPLOYEES
CREDIT AMOUNT BASED
AND
ON
AVERAGE WAGES.—The
18 amount of the credit determined under subsection (b)
19 without regard to this subsection shall be reduced (but not
20 below zero) by the sum of the following amounts:
21
‘‘(1) Such amount multiplied by a fraction the
22
numerator of which is the total number of full-time
23
equivalent employees of the employer in excess of 10
24
and the denominator of which is 15.
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1
‘‘(2) Such amount multiplied by a fraction the
2
numerator of which is the average annual wages of
3
the employer in excess of the dollar amount in effect
4
under subsection (d)(3)(B) and the denominator of
5
which is such dollar amount.
6
‘‘(d) ELIGIBLE SMALL EMPLOYER.—For purposes of
7 this section—
8
9
10
11
12
‘‘(1) IN
GENERAL.—The
term ‘eligible small
employer’ means, with respect to any taxable year,
an employer—
‘‘(A) which has no more than 25 full-time
equivalent employees for the taxable year,
13
‘‘(B) the average annual wages of which do
14
not exceed an amount equal to twice the dollar
15
amount in effect under paragraph (3)(B) for
16
the taxable year, and
17
‘‘(C) which has in effect an arrangement
18
described in paragraph (4).
19
‘‘(2) FULL-TIME
20
‘‘(A) IN
EQUIVALENT EMPLOYEES.—
GENERAL.—The
term ‘full-time
21
equivalent employees’ means a number of em-
22
ployees equal to the number determined by di-
23
viding—
24
‘‘(i) the total number of hours of serv-
25
ice for which wages were paid by the em-
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310
1
ployer to employees during the taxable
2
year, by
3
‘‘(ii) 2,080.
4
Such number shall be rounded to the next low-
5
est whole number if not otherwise a whole num-
6
ber.
7
‘‘(B) EXCESS
HOURS NOT COUNTED.—If
8
an employee works in excess of 2,080 hours of
9
service during any taxable year, such excess
10
shall not be taken into account under subpara-
11
graph (A).
12
‘‘(C) HOURS
OF SERVICE.—The
Secretary,
13
in consultation with the Secretary of Labor,
14
shall prescribe such regulations, rules, and
15
guidance as may be necessary to determine the
16
hours of service of an employee, including rules
17
for the application of this paragraph to employ-
18
ees who are not compensated on an hourly
19
basis.
20
‘‘(3) AVERAGE
21
‘‘(A) IN
ANNUAL WAGES.—
GENERAL.—The
average annual
22
wages of an eligible small employer for any tax-
23
able year is the amount determined by divid-
24
ing—
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1
‘‘(i) the aggregate amount of wages
2
which were paid by the employer to em-
3
ployees during the taxable year, by
4
‘‘(ii) the number of full-time equiva-
5
lent employees of the employee determined
6
under paragraph (2) for the taxable year.
7
Such amount shall be rounded to the next low-
8
est multiple of $1,000 if not otherwise such a
9
multiple.
10
‘‘(B) DOLLAR
11
paragraph (1)(B)—
12
‘‘(i) 2011,
AMOUNT.—For
purposes of
2012, AND 2013.—The
dollar
13
amount in effect under this paragraph for
14
taxable years beginning in 2011, 2012, or
15
2013 is $20,000.
16
‘‘(ii) SUBSEQUENT
YEARS.—In
the
17
case of a taxable year beginning in a cal-
18
endar year after 2013, the dollar amount
19
in effect under this paragraph shall be
20
equal to $20,000, multiplied by the cost-of-
21
living adjustment determined under section
22
1(f)(3) for the calendar year, determined
23
by substituting ‘calendar year 2012’ for
24
‘calendar year 1992’ in subparagraph (B)
25
thereof.
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1
‘‘(4) CONTRIBUTION
ARRANGEMENT.—An
ar-
2
rangement is described in this paragraph if it re-
3
quires an eligible small employer to make a nonelec-
4
tive contribution on behalf of each employee who en-
5
rolls in a qualified health plan offered to employees
6
by the employer through an exchange in an amount
7
equal to a uniform percentage (not less than 50 per-
8
cent) of the premium cost of the qualified health
9
plan.
10
‘‘(5) SEASONAL
WORKER HOURS AND WAGES
11
NOT COUNTED.—For
purposes of this subsection—
12
‘‘(A) IN
GENERAL.—The
number of hours
13
of service worked by, and wages paid to, a sea-
14
sonal worker of an employer shall not be taken
15
into account in determining the full-time equiv-
16
alent employees and average annual wages of
17
the employer unless the worker works for the
18
employer on more than 120 days during the
19
taxable year.
20
‘‘(B) DEFINITION
OF SEASONAL WORK-
21
ER.—The
22
er who performs labor or services on a seasonal
23
basis as defined by the Secretary of Labor, in-
24
cluding workers covered by section 500.20(s)(1)
25
of title 29, Code of Federal Regulations and re-
term ‘seasonal worker’ means a work-
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313
1
tail workers employed exclusively during holiday
2
seasons.
3
‘‘(e) OTHER RULES
DEFINITIONS.—For pur-
AND
4 poses of this section—
5
‘‘(1) EMPLOYEE.—
6
‘‘(A) CERTAIN
7
8
9
EMPLOYEES EXCLUDED.—
The term ‘employee’ shall not include—
‘‘(i) an employee within the meaning
of section 401(c)(1),
10
‘‘(ii) any 2-percent shareholder (as de-
11
fined in section 1372(b)) of an eligible
12
small business which is an S corporation,
13
‘‘(iii) any 5-percent owner (as defined
14
in section 416(i)(1)(B)(i)) of an eligible
15
small business, or
16
‘‘(iv) any individual who bears any of
17
the relationships described in subpara-
18
graphs
19
152(d)(2) to, or is a dependent described
20
in section 152(d)(2)(H) of, an individual
21
described in clause (i), (ii), or (iii).
22
‘‘(B) LEASED
(A)
through
(G)
of
EMPLOYEES.—The
section
term
23
‘employee’ shall include a leased employee with-
24
in the meaning of section 414(n).
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1
‘‘(2) CREDIT
PERIOD.—The
term ‘credit period’
2
means, with respect to any eligible small employer,
3
the 2-consecutive-taxable year period beginning with
4
the 1st taxable year in which the employer (or any
5
predecessor) offers 1 or more qualified health plans
6
to its employees through an Exchange.
7
‘‘(3) NONELECTIVE
CONTRIBUTION.—The
term
8
‘nonelective contribution’ means an employer con-
9
tribution other than an employer contribution pursu-
10
ant to a salary reduction arrangement.
11
‘‘(4) WAGES.—The term ‘wages’ has the mean-
12
ing given such term by section 3121(a) (determined
13
without regard to any dollar limitation contained in
14
such section).
15
16
17
‘‘(5) AGGREGATION
AND OTHER RULES MADE
APPLICABLE.—
‘‘(A) AGGREGATION
RULES.—All
employ-
18
ers treated as a single employer under sub-
19
section (b), (c), (m), or (o) of section 414 shall
20
be treated as a single employer for purposes of
21
this section.
22
‘‘(B) OTHER
RULES.—Rules
similar to the
23
rules of subsections (c), (d), and (e) of section
24
52 shall apply.
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1
2
3
‘‘(f) CREDIT MADE AVAILABLE TO TAX-EXEMPT ELIGIBLE
SMALL EMPLOYERS.—
‘‘(1) IN
GENERAL.—In
the case of a tax-exempt
4
eligible small employer, there shall be treated as a
5
credit allowable under subpart C (and not allowable
6
under this subpart) the lesser of—
7
‘‘(A) the amount of the credit determined
8
under this section with respect to such em-
9
ployer, or
10
‘‘(B) the amount of the payroll taxes of the
11
employer during the calendar year in which the
12
taxable year begins.
13
‘‘(2)
14
PLOYER.—For
15
‘tax-exempt eligible small employer’ means an eligi-
16
ble small employer which is any organization de-
17
scribed in section 501(c) which is exempt from tax-
18
ation under section 501(a).
19
20
21
22
TAX-EXEMPT
ELIGIBLE
SMALL
EM-
purposes of this section, the term
‘‘(3) PAYROLL
TAXES.—For
purposes of this
subsection—
‘‘(A) IN
GENERAL.—The
term ‘payroll
taxes’ means—
23
‘‘(i) amounts required to be withheld
24
from the employees of the tax-exempt eligi-
25
ble small employer under section 3401(a),
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1
‘‘(ii) amounts required to be withheld
2
from
3
3101(b), and
such
employees
under
section
4
‘‘(iii) amounts of the taxes imposed on
5
the tax-exempt eligible small employer
6
under section 3111(b).
7
‘‘(B) SPECIAL
RULE.—A
rule similar to
8
the rule of section 24(d)(2)(C) shall apply for
9
purposes of subparagraph (A).
10
‘‘(g) APPLICATION
11 YEARS 2011, 2012,
OF
AND
SECTION
FOR
CALENDAR
2013.—In the case of any tax-
12 able year beginning in 2011, 2012, or 2013, the following
13 modifications to this section shall apply in determining the
14 amount of the credit under subsection (a):
15
‘‘(1) NO
CREDIT
PERIOD
REQUIRED.—The
16
credit shall be determined without regard to whether
17
the taxable year is in a credit period and for pur-
18
poses of applying this section to taxable years begin-
19
ning after 2013, no credit period shall be treated as
20
beginning with a taxable year beginning before
21
2014.
22
‘‘(2) AMOUNT
OF CREDIT.—The
amount of the
23
credit determined under subsection (b) shall be de-
24
termined—
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1
‘‘(A) by substituting ‘35 percent (25 per-
2
cent in the case of a tax-exempt eligible small
3
employer)’ for ‘50 percent (35 percent in the
4
case of a tax-exempt eligible small employer)’,
5
‘‘(B) by reference to an eligible small em-
6
ployer’s nonelective contributions for premiums
7
paid for health insurance coverage (within the
8
meaning of section 9832(b)(1)) of an employee,
9
and
10
‘‘(C) by substituting for the average pre-
11
mium determined under subsection (b)(2) the
12
amount the Secretary of Health and Human
13
Services determines is the average premium for
14
the small group market in the State in which
15
the employer is offering health insurance cov-
16
erage (or for such area within the State as is
17
specified by the Secretary).
18
‘‘(3) CONTRIBUTION
ARRANGEMENT.—An
ar-
19
rangement shall not fail to meet the requirements of
20
subsection (d)(4) solely because it provides for the
21
offering of insurance outside of an Exchange.
22
‘‘(h) INSURANCE DEFINITIONS.—Any term used in
23 this section which is also used in the Public Health Service
24 Act or subtitle A of title I of the Patient Protection and
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318
1 Affordable Care Act shall have the meaning given such
2 term by such Act or subtitle.
3
‘‘(i) REGULATIONS.—The Secretary shall prescribe
4 such regulations as may be necessary to carry out the pro5 visions of this section, including regulations to prevent the
6 avoidance of the 2-year limit on the credit period through
7 the use of successor entities and the avoidance of the limi8 tations under subsection (c) through the use of multiple
9 entities.’’.
10
(b) CREDIT
TO
BE PART
OF
GENERAL BUSINESS
11 CREDIT.—Section 38(b) of the Internal Revenue Code of
12 1986 (relating to current year business credit) is amended
13 by striking ‘‘plus’’ at the end of paragraph (34), by strik14 ing the period at the end of paragraph (35) and inserting
15 ‘‘, plus’’, and by inserting after paragraph (35) the fol16 lowing:
17
‘‘(36) the small employer health insurance cred-
18
it determined under section 45R.’’.
19
(c) CREDIT ALLOWED AGAINST ALTERNATIVE MIN-
20
IMUM
TAX.—Section 38(c)(4)(B) of the Internal Revenue
21 Code of 1986 (defining specified credits) is amended by
22 redesignating clauses (vi), (vii), and (viii) as clauses (vii),
23 (viii), and (ix), respectively, and by inserting after clause
24 (v) the following new clause:
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1
‘‘(vi) the credit determined under sec-
2
3
tion 45R,’’.
(d) DISALLOWANCE
OF
DEDUCTION
FOR
CERTAIN
4 EXPENSES FOR WHICH CREDIT ALLOWED.—
5
(1) IN
GENERAL.—Section
280C of the Internal
6
Revenue Code of 1986 (relating to disallowance of
7
deduction for certain expenses for which credit al-
8
lowed), as amended by section 1401(b), is amended
9
by adding at the end the following new subsection:
10
‘‘(h) CREDIT
11 EXPENSES
OF
FOR
EMPLOYEE HEALTH INSURANCE
SMALL EMPLOYERS.—No deduction shall
12 be allowed for that portion of the premiums for qualified
13 health plans (as defined in section 1301(a) of the Patient
14 Protection and Affordable Care Act), or for health insur15 ance coverage in the case of taxable years beginning in
16 2011, 2012, or 2013, paid by an employer which is equal
17 to the amount of the credit determined under section
18 45R(a) with respect to the premiums.’’.
19
(2) DEDUCTION
FOR EXPIRING CREDITS.—Sec-
20
tion 196(c) of such Code is amended by striking
21
‘‘and’’ at the end of paragraph (12), by striking the
22
period at the end of paragraph (13) and inserting ‘‘,
23
and’’, and by adding at the end the following new
24
paragraph:
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1
‘‘(14) the small employer health insurance cred-
2
it determined under section 45R(a).’’.
3
(e) CLERICAL AMENDMENT.—The table of sections
4 for subpart D of part IV of subchapter A of chapter 1
5 of the Internal Revenue Code of 1986 is amended by add6 ing at the end the following:
‘‘Sec. 45R. Employee health insurance expenses of small employers.’’.
7
(f) EFFECTIVE DATES.—
8
(1) IN
GENERAL.—The
amendments made by
9
this section shall apply to amounts paid or incurred
10
in taxable years beginning after December 31, 2010.
11
(2) MINIMUM
TAX.—The
amendments made by
12
subsection (c) shall apply to credits determined
13
under section 45R of the Internal Revenue Code of
14
1986 in taxable years beginning after December 31,
15
2010, and to carrybacks of such credits.
17
Subtitle F—Shared Responsibility
for Health Care
18
PART I—INDIVIDUAL RESPONSIBILITY
19
SEC. 1501. REQUIREMENT TO MAINTAIN MINIMUM ESSEN-
16
20
21
TIAL COVERAGE.
(a) FINDINGS.—Congress makes the following find-
22 ings:
23
(1) IN
GENERAL.—The
individual responsibility
24
requirement provided for in this section (in this sub-
25
section referred to as the ‘‘requirement’’) is commer-
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1
cial and economic in nature, and substantially af-
2
fects interstate commerce, as a result of the effects
3
described in paragraph (2).
4
(2) EFFECTS
ON THE NATIONAL ECONOMY AND
5
INTERSTATE COMMERCE.—The
6
this paragraph are the following:
effects described in
7
(A) The requirement regulates activity that
8
is commercial and economic in nature: economic
9
and financial decisions about how and when
10
health care is paid for, and when health insur-
11
ance is purchased.
12
(B) Health insurance and health care serv-
13
ices are a significant part of the national econ-
14
omy. National health spending is projected to
15
increase from $2,500,000,000,000, or 17.6 per-
16
cent
17
$4,700,000,000,000 in 2019. Private health in-
18
surance
19
$854,000,000,000 in 2009, and pays for med-
20
ical supplies, drugs, and equipment that are
21
shipped in interstate commerce. Since most
22
health insurance is sold by national or regional
23
health insurance companies, health insurance is
24
sold in interstate commerce and claims pay-
25
ments flow through interstate commerce.
of
the
economy,
spending
is
in
projected
2009
to
to
be
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1
(C) The requirement, together with the
2
other provisions of this Act, will add millions of
3
new consumers to the health insurance market,
4
increasing the supply of, and demand for,
5
health care services. According to the Congres-
6
sional Budget Office, the requirement will in-
7
crease the number and share of Americans who
8
are insured.
9
(D) The requirement achieves near-uni-
10
versal coverage by building upon and strength-
11
ening the private employer-based health insur-
12
ance system, which covers 176,000,000 Ameri-
13
cans nationwide. In Massachusetts, a similar re-
14
quirement has strengthened private employer-
15
based coverage: despite the economic downturn,
16
the number of workers offered employer-based
17
coverage has actually increased.
18
(E) Half of all personal bankruptcies are
19
caused in part by medical expenses. By signifi-
20
cantly increasing health insurance coverage, the
21
requirement, together with the other provisions
22
of this Act, will improve financial security for
23
families.
24
(F) Under the Employee Retirement In-
25
come Security Act of 1974 (29 U.S.C. 1001 et
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1
seq.), the Public Health Service Act (42 U.S.C.
2
201 et seq.), and this Act, the Federal Govern-
3
ment has a significant role in regulating health
4
insurance which is in interstate commerce.
5
(G) Under sections 2704 and 2705 of the
6
Public Health Service Act (as added by section
7
1201 of this Act), if there were no requirement,
8
many individuals would wait to purchase health
9
insurance until they needed care. By signifi-
10
cantly increasing health insurance coverage, the
11
requirement, together with the other provisions
12
of this Act, will minimize this adverse selection
13
and broaden the health insurance risk pool to
14
include healthy individuals, which will lower
15
health insurance premiums. The requirement is
16
essential to creating effective health insurance
17
markets in which improved health insurance
18
products that are guaranteed issue and do not
19
exclude coverage of pre-existing conditions can
20
be sold.
21
(H) Administrative costs for private health
22
insurance, which were $90,000,000,000 in
23
2006, are 26 to 30 percent of premiums in the
24
current individual and small group markets. By
25
significantly increasing health insurance cov-
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1
erage and the size of purchasing pools, which
2
will increase economies of scale, the require-
3
ment, together with the other provisions of this
4
Act, will significantly reduce administrative
5
costs and lower health insurance premiums.
6
The requirement is essential to creating effec-
7
tive health insurance markets that do not re-
8
quire underwriting and eliminate its associated
9
administrative costs.
10
(3) SUPREME
COURT
RULING.—In
United
11
States v. South-Eastern Underwriters Association
12
(322 U.S. 533 (1944)), the Supreme Court of the
13
United States ruled that insurance is interstate com-
14
merce subject to Federal regulation.
15
(b) IN GENERAL.—Subtitle D of the Internal Rev-
16 enue Code of 1986 is amended by adding at the end the
17 following new chapter:
18
‘‘CHAPTER 48—MAINTENANCE OF
19
MINIMUM ESSENTIAL COVERAGE
‘‘Sec. 5000A. Requirement to maintain minimum essential coverage.
20
‘‘SEC. 5000A. REQUIREMENT TO MAINTAIN MINIMUM ES-
21
SENTIAL COVERAGE.
22
23
‘‘(a) REQUIREMENT
TIAL
TO
MAINTAIN MINIMUM ESSEN-
COVERAGE.—An applicable individual shall for each
24 month beginning after 2013 ensure that the individual,
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1 and any dependent of the individual who is an applicable
2 individual, is covered under minimum essential coverage
3 for such month.
4
5
‘‘(b) SHARED RESPONSIBILITY PAYMENT.—
‘‘(1) IN
GENERAL.—If
an applicable individual
6
fails to meet the requirement of subsection (a) for
7
1 or more months during any calendar year begin-
8
ning after 2013, then, except as provided in sub-
9
section (d), there is hereby imposed a penalty with
10
respect to the individual in the amount determined
11
under subsection (c).
12
‘‘(2) INCLUSION
WITH RETURN.—Any
penalty
13
imposed by this section with respect to any month
14
shall be included with a taxpayer’s return under
15
chapter 1 for the taxable year which includes such
16
month.
17
‘‘(3) PAYMENT
OF PENALTY.—If
an individual
18
with respect to whom a penalty is imposed by this
19
section for any month—
20
‘‘(A) is a dependent (as defined in section
21
152) of another taxpayer for the other tax-
22
payer’s taxable year including such month, such
23
other taxpayer shall be liable for such penalty,
24
or
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1
‘‘(B) files a joint return for the taxable
2
year including such month, such individual and
3
the spouse of such individual shall be jointly lia-
4
ble for such penalty.
5
‘‘(c) AMOUNT OF PENALTY.—
6
‘‘(1) IN
GENERAL.—The
penalty determined
7
under this subsection for any month with respect to
8
any individual is an amount equal to 1⁄12 of the ap-
9
plicable dollar amount for the calendar year.
10
‘‘(2) DOLLAR
LIMITATION.—The
amount of the
11
penalty imposed by this section on any taxpayer for
12
any taxable year with respect to all individuals for
13
whom the taxpayer is liable under subsection (b)(3)
14
shall not exceed an amount equal to 300 percent the
15
applicable dollar amount (determined without regard
16
to paragraph (3)(C)) for the calendar year with or
17
within which the taxable year ends.
18
19
20
‘‘(3) APPLICABLE
DOLLAR AMOUNT.—For
pur-
poses of paragraph (1)—
‘‘(A) IN
GENERAL.—Except
as provided in
21
subparagraphs (B) and (C), the applicable dol-
22
lar amount is $750.
23
24
‘‘(B) PHASE
IN.—The
applicable dollar
amount is $95 for 2014 and $350 for 2015.
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1
‘‘(C) SPECIAL
2
UNDER AGE 18.—If
3
not attained the age of 18 as of the beginning
4
of a month, the applicable dollar amount with
5
respect to such individual for the month shall
6
be equal to one-half of the applicable dollar
7
amount for the calendar year in which the
8
month occurs.
9
RULE
FOR
INDIVIDUALS
an applicable individual has
‘‘(D) INDEXING
OF AMOUNT.—In
the case
10
of any calendar year beginning after 2016, the
11
applicable dollar amount shall be equal to $750,
12
increased by an amount equal to—
13
‘‘(i) $750, multiplied by
14
‘‘(ii) the cost-of-living adjustment de-
15
termined under section 1(f)(3) for the cal-
16
endar year, determined by substituting
17
‘calendar year 2015’ for ‘calendar year
18
1992’ in subparagraph (B) thereof.
19
If the amount of any increase under clause (i)
20
is not a multiple of $50, such increase shall be
21
rounded to the next lowest multiple of $50.
22
‘‘(4) TERMS
23
24
25
LIES.—For
RELATING TO INCOME AND FAMI-
purposes of this section—
‘‘(A) FAMILY
SIZE.—The
family size in-
volved with respect to any taxpayer shall be
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1
equal to the number of individuals for whom
2
the taxpayer is allowed a deduction under sec-
3
tion 151 (relating to allowance of deduction for
4
personal exemptions) for the taxable year.
5
‘‘(B) HOUSEHOLD
INCOME.—The
term
6
‘household income’ means, with respect to any
7
taxpayer for any taxable year, an amount equal
8
to the sum of—
9
10
‘‘(i) the modified gross income of the
taxpayer, plus
11
12
‘‘(ii) the aggregate modified gross incomes of all other individuals who—
13
‘‘(I) were taken into account in
14
determining the taxpayer’s family size
15
under paragraph (1), and
16
‘‘(II) were required to file a re-
17
turn of tax imposed by section 1 for
18
the taxable year.
19
‘‘(C)
MODIFIED
GROSS
INCOME.—The
20
term ‘modified gross income’ means gross in-
21
come—
22
‘‘(i) decreased by the amount of any
23
deduction allowable under paragraph (1),
24
(3), (4), or (10) of section 62(a),
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1
‘‘(ii) increased by the amount of inter-
2
est received or accrued during the taxable
3
year which is exempt from tax imposed by
4
this chapter, and
5
‘‘(iii) determined without regard to
6
sections 911, 931, and 933.
7
‘‘(D) POVERTY
8
‘‘(i) IN
LINE.—
GENERAL.—The
term ‘poverty
9
line’ has the meaning given that term in
10
section 2110(c)(5) of the Social Security
11
Act (42 U.S.C. 1397jj(c)(5)).
12
‘‘(ii) POVERTY
LINE USED.—In
the
13
case of any taxable year ending with or
14
within a calendar year, the poverty line
15
used shall be the most recently published
16
poverty line as of the 1st day of such cal-
17
endar year.
18
‘‘(d) APPLICABLE INDIVIDUAL.—For purposes of this
19 section—
20
‘‘(1) IN
GENERAL.—The
term ‘applicable indi-
21
vidual’ means, with respect to any month, an indi-
22
vidual other than an individual described in para-
23
graph (2), (3), or (4).
24
‘‘(2) RELIGIOUS
EXEMPTIONS.—
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1
‘‘(A)
RELIGIOUS
CONSCIENCE
EXEMP-
2
TION.—Such
3
vidual for any month if such individual has in
4
effect
5
1311(d)(4)(H) of the Patient Protection and
6
Affordable Care Act which certifies that such
7
individual is a member of a recognized religious
8
sect or division thereof described in section
9
1402(g)(1) and an adherent of established te-
10
nets or teachings of such sect or division as de-
11
scribed in such section.
12
‘‘(B) HEALTH
13
an
term shall not include any indi-
exemption
‘‘(i) IN
under
section
CARE SHARING MINISTRY.—
GENERAL.—Such
term shall
14
not include any individual for any month if
15
such individual is a member of a health
16
care sharing ministry for the month.
17
‘‘(ii) HEALTH
CARE SHARING MIN-
18
ISTRY.—The
19
ministry’ means an organization—
term ‘health care sharing
20
‘‘(I) which is described in section
21
501(c)(3) and is exempt from taxation
22
under section 501(a),
23
‘‘(II) members of which share a
24
common set of ethical or religious be-
25
liefs and share medical expenses
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1
among members in accordance with
2
those beliefs and without regard to
3
the State in which a member resides
4
or is employed,
5
‘‘(III) members of which retain
6
membership even after they develop a
7
medical condition,
8
‘‘(IV) which (or a predecessor of
9
which) has been in existence at all
10
times since December 31, 1999, and
11
medical expenses of its members have
12
been shared continuously and without
13
interruption since at least December
14
31, 1999, and
15
‘‘(V) which conducts an annual
16
audit which is performed by an inde-
17
pendent certified public accounting
18
firm in accordance with generally ac-
19
cepted
20
which is made available to the public
21
upon request.
22
‘‘(3) INDIVIDUALS
accounting
principles
and
NOT LAWFULLY PRESENT.—
23
Such term shall not include an individual for any
24
month if for the month the individual is not a citizen
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1
or national of the United States or an alien lawfully
2
present in the United States.
3
‘‘(4) INCARCERATED
INDIVIDUALS.—Such
term
4
shall not include an individual for any month if for
5
the month the individual is incarcerated, other than
6
incarceration pending the disposition of charges.
7
‘‘(e) EXEMPTIONS.—No penalty shall be imposed
8 under subsection (a) with respect to—
9
10
11
‘‘(1) INDIVIDUALS
WHO CANNOT AFFORD COV-
ERAGE.—
‘‘(A) IN
GENERAL.—Any
applicable indi-
12
vidual for any month if the applicable individ-
13
ual’s required contribution (determined on an
14
annual basis) for coverage for the month ex-
15
ceeds 8 percent of such individual’s household
16
income for the taxable year described in section
17
1412(b)(1)(B) of the Patient Protection and
18
Affordable Care Act. For purposes of applying
19
this subparagraph, the taxpayer’s household in-
20
come shall be increased by any exclusion from
21
gross income for any portion of the required
22
contribution made through a salary reduction
23
arrangement.
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1
‘‘(B)
REQUIRED
CONTRIBUTION.—For
2
purposes of this paragraph, the term ‘required
3
contribution’ means—
4
‘‘(i) in the case of an individual eligi-
5
ble to purchase minimum essential cov-
6
erage consisting of coverage through an el-
7
igible-employer-sponsored plan, the portion
8
of the annual premium which would be
9
paid by the individual (without regard to
10
whether paid through salary reduction or
11
otherwise) for self-only coverage, or
12
‘‘(ii) in the case of an individual eligi-
13
ble only to purchase minimum essential
14
coverage described in subsection (f)(1)(C),
15
the annual premium for the lowest cost
16
bronze plan available in the individual
17
market through the Exchange in the State
18
in the rating area in which the individual
19
resides (without regard to whether the in-
20
dividual purchased a qualified health plan
21
through the Exchange), reduced by the
22
amount of the credit allowable under sec-
23
tion 36B for the taxable year (determined
24
as if the individual was covered by a quali-
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1
fied health plan offered through the Ex-
2
change for the entire taxable year).
3
‘‘(C) SPECIAL
RULES FOR INDIVIDUALS
4
RELATED TO EMPLOYEES.—For
5
subparagraph (B)(i), if an applicable individual
6
is eligible for minimum essential coverage
7
through an employer by reason of a relationship
8
to an employee, the determination shall be
9
made by reference to the affordability of the
10
purposes of
coverage to the employee.
11
‘‘(D) INDEXING.—In the case of plan years
12
beginning in any calendar year after 2014, sub-
13
paragraph (A) shall be applied by substituting
14
for ‘8 percent’ the percentage the Secretary of
15
Health and Human Services determines reflects
16
the excess of the rate of premium growth be-
17
tween the preceding calendar year and 2013
18
over the rate of income growth for such period.
19
‘‘(2) TAXPAYERS
WITH
INCOME
UNDER
100
20
PERCENT OF POVERTY LINE.—Any
21
vidual for any month during a calendar year if the
22
individual’s household income for the taxable year
23
described in section 1412(b)(1)(B) of the Patient
24
Protection and Affordable Care Act is less than 100
25
percent of the poverty line for the size of the family
applicable indi-
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1
involved (determined in the same manner as under
2
subsection (b)(4)).
3
‘‘(3) MEMBERS
OF INDIAN TRIBES.—Any
appli-
4
cable individual for any month during which the in-
5
dividual is a member of an Indian tribe (as defined
6
in section 45A(c)(6)).
7
8
9
‘‘(4)
MONTHS
DURING
SHORT
COVERAGE
GAPS.—
‘‘(A) IN
GENERAL.—Any
month the last
10
day of which occurred during a period in which
11
the applicable individual was not covered by
12
minimum essential coverage for a continuous
13
period of less than 3 months.
14
15
‘‘(B) SPECIAL
RULES.—For
purposes of
applying this paragraph—
16
‘‘(i) the length of a continuous period
17
shall be determined without regard to the
18
calendar years in which months in such pe-
19
riod occur,
20
‘‘(ii) if a continuous period is greater
21
than the period allowed under subpara-
22
graph (A), no exception shall be provided
23
under this paragraph for any month in the
24
period, and
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1
‘‘(iii) if there is more than 1 contin-
2
uous period described in subparagraph (A)
3
covering months in a calendar year, the ex-
4
ception provided by this paragraph shall
5
only apply to months in the first of such
6
periods.
7
The Secretary shall prescribe rules for the col-
8
lection of the penalty imposed by this section in
9
cases where continuous periods include months
10
in more than 1 taxable year.
11
‘‘(5) HARDSHIPS.—Any applicable individual
12
who for any month is determined by the Secretary
13
of Health and Human Services under section
14
1311(d)(4)(H) to have suffered a hardship with re-
15
spect to the capability to obtain coverage under a
16
qualified health plan.
17
‘‘(f) MINIMUM ESSENTIAL COVERAGE.—For pur-
18 poses of this section—
19
20
21
22
‘‘(1) IN
GENERAL.—The
term ‘minimum essen-
tial coverage’ means any of the following:
‘‘(A)
GOVERNMENT
GRAMS.—Coverage
SPONSORED
PRO-
under—
23
‘‘(i) the Medicare program under part
24
A of title XVIII of the Social Security Act,
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337
1
2
‘‘(ii) the Medicaid program under title
XIX of the Social Security Act,
3
4
‘‘(iii) the CHIP program under title
XXI of the Social Security Act,
5
‘‘(iv) the TRICARE for Life program,
6
‘‘(v) the veteran’s health care program
7
under chapter 17 of title 38, United States
8
Code, or
9
‘‘(vi) a health plan under section
10
2504(e) of title 22, United States Code
11
(relating to Peace Corps volunteers).
12
‘‘(B) EMPLOYER-SPONSORED
PLAN.—Cov-
13
erage under an eligible employer-sponsored
14
plan.
15
‘‘(C) PLANS
IN
THE
INDIVIDUAL
16
KET.—Coverage
17
the individual market within a State.
18
19
20
MAR-
under a health plan offered in
‘‘(D) GRANDFATHERED
HEALTH PLAN.—
Coverage under a grandfathered health plan.
‘‘(E)
OTHER
COVERAGE.—Such
other
21
health benefits coverage, such as a State health
22
benefits risk pool, as the Secretary of Health
23
and Human Services, in coordination with the
24
Secretary, recognizes for purposes of this sub-
25
section.
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1
‘‘(2) ELIGIBLE
EMPLOYER-SPONSORED PLAN.—
2
The term ‘eligible employer-sponsored plan’ means,
3
with respect to any employee, a group health plan or
4
group health insurance coverage offered by an em-
5
ployer to the employee which is—
6
‘‘(A) a governmental plan (within the
7
meaning of section 2791(d)(8) of the Public
8
Health Service Act), or
9
‘‘(B) any other plan or coverage offered in
10
the small or large group market within a State.
11
Such term shall include a grandfathered health plan
12
described in paragraph (1)(D) offered in a group
13
market.
14
‘‘(3) EXCEPTED
BENEFITS NOT TREATED AS
15
MINIMUM ESSENTIAL COVERAGE.—The
16
imum essential coverage’ shall not include health in-
17
surance coverage which consists of coverage of ex-
18
cepted benefits—
term ‘min-
19
‘‘(A) described in paragraph (1) of sub-
20
section (c) of section 2791 of the Public Health
21
Service Act; or
22
‘‘(B) described in paragraph (2), (3), or
23
(4) of such subsection if the benefits are pro-
24
vided under a separate policy, certificate, or
25
contract of insurance.
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1
‘‘(4) INDIVIDUALS
RESIDING OUTSIDE UNITED
2
STATES OR RESIDENTS OF TERRITORIES.—Any
3
plicable individual shall be treated as having min-
4
imum essential coverage for any month—
ap-
5
‘‘(A) if such month occurs during any pe-
6
riod described in subparagraph (A) or (B) of
7
section 911(d)(1) which is applicable to the in-
8
dividual, or
9
‘‘(B) if such individual is a bona fide resi-
10
dent of any possession of the United States (as
11
determined under section 937(a)) for such
12
month.
13
‘‘(5) INSURANCE-RELATED
TERMS.—Any
term
14
used in this section which is also used in title I of
15
the Patient Protection and Affordable Care Act shall
16
have the same meaning as when used in such title.
17
‘‘(g) ADMINISTRATION AND PROCEDURE.—
18
‘‘(1) IN
GENERAL.—The
penalty provided by
19
this section shall be paid upon notice and demand by
20
the Secretary, and except as provided in paragraph
21
(2), shall be assessed and collected in the same man-
22
ner as an assessable penalty under subchapter B of
23
chapter 68.
24
‘‘(2) SPECIAL
25
other provision of law—
RULES.—Notwithstanding
any
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1
‘‘(A) WAIVER
OF CRIMINAL PENALTIES.—
2
In the case of any failure by a taxpayer to time-
3
ly pay any penalty imposed by this section, such
4
taxpayer shall not be subject to any criminal
5
prosecution or penalty with respect to such fail-
6
ure.
7
8
‘‘(B) LIMITATIONS
IES.—The
ON LIENS AND LEV-
Secretary shall not—
9
‘‘(i) file notice of lien with respect to
10
any property of a taxpayer by reason of
11
any failure to pay the penalty imposed by
12
this section, or
13
14
15
‘‘(ii) levy on any such property with
respect to such failure.’’.
(c) CLERICAL AMENDMENT.—The table of chapters
16 for subtitle D of the Internal Revenue Code of 1986 is
17 amended by inserting after the item relating to chapter
18 47 the following new item:
‘‘CHAPTER 48—MAINTENANCE
19
OF
MINIMUM ESSENTIAL COVERAGE.’’.
(d) EFFECTIVE DATE.—The amendments made by
20 this section shall apply to taxable years ending after De21 cember 31, 2013.
22
SEC. 1502. REPORTING OF HEALTH INSURANCE COVERAGE.
23
(a) IN GENERAL.—Part III of subchapter A of chap-
24 ter 61 of the Internal Revenue Code of 1986 is amended
25 by inserting after subpart C the following new subpart:
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1
‘‘Subpart D—Information Regarding Health
2
Insurance Coverage
‘‘Sec. 6055. Reporting of health insurance coverage.
3
4
5
‘‘SEC. 6055. REPORTING OF HEALTH INSURANCE COVERAGE.
‘‘(a) IN GENERAL.—Every person who provides min-
6 imum essential coverage to an individual during a calendar
7 year shall, at such time as the Secretary may prescribe,
8 make a return described in subsection (b).
9
10
11
12
13
14
‘‘(b) FORM AND MANNER OF RETURN.—
‘‘(1) IN
GENERAL.—A
return is described in
this subsection if such return—
‘‘(A) is in such form as the Secretary may
prescribe, and
‘‘(B) contains—
15
‘‘(i) the name, address and TIN of
16
the primary insured and the name and
17
TIN of each other individual obtaining cov-
18
erage under the policy,
19
‘‘(ii) the dates during which such indi-
20
vidual was covered under minimum essen-
21
tial coverage during the calendar year,
22
‘‘(iii) in the case of minimum essential
23
coverage which consists of health insurance
24
coverage, information concerning—
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1
‘‘(I) whether or not the coverage
2
is a qualified health plan offered
3
through
4
under section 1311 of the Patient
5
Protection and Affordable Care Act,
6
and
an
Exchange
established
7
‘‘(II) in the case of a qualified
8
health plan, the amount (if any) of
9
any advance payment under section
10
1412 of the Patient Protection and
11
Affordable Care Act of any cost-shar-
12
ing reduction under section 1402 of
13
such Act or of any premium tax credit
14
under section 36B with respect to
15
such coverage, and
16
‘‘(iv) such other information as the
17
18
Secretary may require.
‘‘(2) INFORMATION
RELATING TO EMPLOYER-
19
PROVIDED COVERAGE.—If
20
erage provided to an individual under subsection (a)
21
consists of health insurance coverage of a health in-
22
surance issuer provided through a group health plan
23
of an employer, a return described in this subsection
24
shall include—
minimum essential cov-
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1
‘‘(A) the name, address, and employer
2
identification number of the employer maintain-
3
ing the plan,
4
‘‘(B) the portion of the premium (if any)
5
required to be paid by the employer, and
6
‘‘(C) if the health insurance coverage is a
7
qualified health plan in the small group market
8
offered through an Exchange, such other infor-
9
mation as the Secretary may require for admin-
10
istration of the credit under section 45R (relat-
11
ing to credit for employee health insurance ex-
12
penses of small employers).
13
‘‘(c) STATEMENTS
14
UALS
15
PORTED.—
16
WITH RESPECT
‘‘(1) IN
TO
TO
BE FURNISHED
TO
INDIVID-
WHOM INFORMATION IS RE-
GENERAL.—Every
person required to
17
make a return under subsection (a) shall furnish to
18
each individual whose name is required to be set
19
forth in such return a written statement showing—
20
‘‘(A) the name and address of the person
21
required to make such return and the phone
22
number of the information contact for such per-
23
son, and
24
25
‘‘(B) the information required to be shown
on the return with respect to such individual.
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1
‘‘(2) TIME
FOR FURNISHING STATEMENTS.—
2
The written statement required under paragraph (1)
3
shall be furnished on or before January 31 of the
4
year following the calendar year for which the return
5
under subsection (a) was required to be made.
6
‘‘(d) COVERAGE PROVIDED
BY
GOVERNMENTAL
7 UNITS.—In the case of coverage provided by any govern8 mental unit or any agency or instrumentality thereof, the
9 officer or employee who enters into the agreement to pro10 vide such coverage (or the person appropriately designated
11 for purposes of this section) shall make the returns and
12 statements required by this section.
13
‘‘(e) MINIMUM ESSENTIAL COVERAGE.—For pur-
14 poses of this section, the term ‘minimum essential cov15 erage’ has the meaning given such term by section
16 5000A(f).’’.
17
(b) ASSESSABLE PENALTIES.—
18
(1) Subparagraph (B) of section 6724(d)(1) of
19
the Internal Revenue Code of 1986 (relating to defi-
20
nitions) is amended by striking ‘‘or’’ at the end of
21
clause (xxii), by striking ‘‘and’’ at the end of clause
22
(xxiii) and inserting ‘‘or’’, and by inserting after
23
clause (xxiii) the following new clause:
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1
‘‘(xxiv) section 6055 (relating to re-
2
turns relating to information regarding
3
health insurance coverage), and’’.
4
(2) Paragraph (2) of section 6724(d) of such
5
Code is amended by striking ‘‘or’’ at the end of sub-
6
paragraph (EE), by striking the period at the end
7
of subparagraph (FF) and inserting ‘‘, or’’ and by
8
inserting after subparagraph (FF) the following new
9
subparagraph:
10
‘‘(GG) section 6055(c) (relating to state-
11
ments relating to information regarding health
12
insurance coverage).’’.
13
(c) NOTIFICATION
OF
NONENROLLMENT.—Not later
14 than June 30 of each year, the Secretary of the Treasury,
15 acting through the Internal Revenue Service and in con16 sultation with the Secretary of Health and Human Serv17 ices, shall send a notification to each individual who files
18 an individual income tax return and who is not enrolled
19 in minimum essential coverage (as defined in section
20 5000A of the Internal Revenue Code of 1986). Such noti21 fication shall contain information on the services available
22 through the Exchange operating in the State in which
23 such individual resides.
24
(d) CONFORMING AMENDMENT.—The table of sub-
25 parts for part III of subchapter A of chapter 61 of such
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1 Code is amended by inserting after the item relating to
2 subpart C the following new item:
‘‘SUBPART
3
D—INFORMATION REGARDING HEALTH INSURANCE COVERAGE’’.
(e) EFFECTIVE DATE.—The amendments made by
4 this section shall apply to calendar years beginning after
5 2013.
6
PART II—EMPLOYER RESPONSIBILITIES
7
SEC. 1511. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF
8
9
LARGE EMPLOYERS.
The Fair Labor Standards Act of 1938 is amended
10 by inserting after section 18 (29 U.S.C. 218) the fol11 lowing:
12
13
14
‘‘SEC. 18A. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF
LARGE EMPLOYERS.
‘‘In accordance with regulations promulgated by the
15 Secretary, an employer to which this Act applies that has
16 more than 200 full-time employees and that offers employ17 ees enrollment in 1 or more health benefits plans shall
18 automatically enroll new full-time employees in one of the
19 plans offered (subject to any waiting period authorized by
20 law) and to continue the enrollment of current employees
21 in a health benefits plan offered through the employer.
22 Any automatic enrollment program shall include adequate
23 notice and the opportunity for an employee to opt out of
24 any coverage the individual or employee were automati25 cally enrolled in. Nothing in this section shall be construed
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1 to supersede any State law which establishes, implements,
2 or continues in effect any standard or requirement relating
3 to employers in connection with payroll except to the ex4 tent that such standard or requirement prevents an em5 ployer from instituting the automatic enrollment program
6 under this section.’’.
7
8
9
SEC. 1512. EMPLOYER REQUIREMENT TO INFORM EMPLOYEES OF COVERAGE OPTIONS.
The Fair Labor Standards Act of 1938 is amended
10 by inserting after section 18A (as added by section 1513)
11 the following:
12
13
‘‘SEC. 18B. NOTICE TO EMPLOYEES.
‘‘(a) IN GENERAL.—In accordance with regulations
14 promulgated by the Secretary, an employer to which this
15 Act applies, shall provide to each employee at the time
16 of hiring (or with respect to current employees, not later
17 than March 1, 2013), written notice—
18
‘‘(1) informing the employee of the existence of
19
an Exchange, including a description of the services
20
provided by such Exchange, and the manner in
21
which the employee may contact the Exchange to re-
22
quest assistance;
23
‘‘(2) if the employer plan’s share of the total al-
24
lowed costs of benefits provided under the plan is
25
less than 60 percent of such costs, that the employee
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1
may be eligible for a premium tax credit under sec-
2
tion 36B of the Internal Revenue Code of 1986 and
3
a cost sharing reduction under section 1402 of the
4
Patient Protection and Affordable Care Act if the
5
employee purchases a qualified health plan through
6
the Exchange; and
7
‘‘(3) if the employee purchases a qualified
8
health plan through the Exchange, the employee will
9
lose the employer contribution (if any) to any health
10
benefits plan offered by the employer and that all or
11
a portion of such contribution may be excludable
12
from income for Federal income tax purposes.
13
‘‘(b) EFFECTIVE DATE.—Subsection (a) shall take
14 effect with respect to employers in a State beginning on
15 March 1, 2013.’’.
16
17
SEC. 1513. SHARED RESPONSIBILITY FOR EMPLOYERS.
(a) IN GENERAL.—Chapter 43 of the Internal Rev-
18 enue Code of 1986 is amended by adding at the end the
19 following:
20
‘‘SEC. 4980H. SHARED RESPONSIBILITY FOR EMPLOYERS
21
REGARDING HEALTH COVERAGE.
22
‘‘(a) LARGE EMPLOYERS NOT OFFERING HEALTH
23 COVERAGE.—If—
24
‘‘(1) any applicable large employer fails to offer
25
to its full-time employees (and their dependents) the
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1
opportunity to enroll in minimum essential coverage
2
under an eligible employer-sponsored plan (as de-
3
fined in section 5000A(f)(2)) for any month, and
4
‘‘(2) at least one full-time employee of the ap-
5
plicable large employer has been certified to the em-
6
ployer under section 1411 of the Patient Protection
7
and Affordable Care Act as having enrolled for such
8
month in a qualified health plan with respect to
9
which an applicable premium tax credit or cost-shar-
10
ing reduction is allowed or paid with respect to the
11
employee,
12 then there is hereby imposed on the employer an assess13 able payment equal to the product of the applicable pay14 ment amount and the number of individuals employed by
15 the employer as full-time employees during such month.
16
‘‘(b) LARGE EMPLOYERS WITH WAITING PERIODS
17 EXCEEDING 30 DAYS.—
18
‘‘(1) IN
GENERAL.—In
the case of any applica-
19
ble large employer which requires an extended wait-
20
ing period to enroll in any minimum essential cov-
21
erage under an employer-sponsored plan (as defined
22
in section 5000A(f)(2)), there is hereby imposed on
23
the employer an assessable payment, in the amount
24
specified in paragraph (2), for each full-time em-
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1
ployee of the employer to whom the extended waiting
2
period applies.
3
‘‘(2) AMOUNT.—For purposes of paragraph (1),
4
the amount specified in this paragraph for a full-
5
time employee is—
6
‘‘(A) in the case of an extended waiting pe-
7
riod which exceeds 30 days but does not exceed
8
60 days, $400, and
9
‘‘(B) in the case of an extended waiting pe-
10
riod which exceeds 60 days, $600.
11
‘‘(3) EXTENDED
WAITING PERIOD.—The
term
12
‘extended waiting period’ means any waiting period
13
(as defined in section 2701(b)(4) of the Public
14
Health Service Act) which exceeds 30 days.
15
‘‘(c) LARGE EMPLOYERS OFFERING COVERAGE
16 WITH EMPLOYEES WHO QUALIFY
FOR
PREMIUM TAX
17 CREDITS OR COST-SHARING REDUCTIONS.—
18
‘‘(1) IN
GENERAL.—If—
19
‘‘(A) an applicable large employer offers to
20
its full-time employees (and their dependents)
21
the opportunity to enroll in minimum essential
22
coverage under an eligible employer-sponsored
23
plan (as defined in section 5000A(f)(2)) for any
24
month, and
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1
‘‘(B) 1 or more full-time employees of the
2
applicable large employer has been certified to
3
the employer under section 1411 of the Patient
4
Protection and Affordable Care Act as having
5
enrolled for such month in a qualified health
6
plan with respect to which an applicable pre-
7
mium tax credit or cost-sharing reduction is al-
8
lowed or paid with respect to the employee,
9
then there is hereby imposed on the employer an as-
10
sessable payment equal to the product of the number
11
of full-time employees of the applicable large em-
12
ployer described in subparagraph (B) for such
13
month and 400 percent of the applicable payment
14
amount.
15
‘‘(2) OVERALL
LIMITATION.—The
aggregate
16
amount of tax determined under paragraph (1) with
17
respect to all employees of an applicable large em-
18
ployer for any month shall not exceed the product of
19
the applicable payment amount and the number of
20
individuals employed by the employer as full-time
21
employees during such month.
22
‘‘(d) DEFINITIONS
23 poses of this section—
AND
SPECIAL RULES.—For pur-
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1
‘‘(1) APPLICABLE
AMOUNT.—The
PAYMENT
2
term ‘applicable payment amount’ means, with re-
3
spect to any month, 1⁄12 of $750.
4
‘‘(2) APPLICABLE
5
‘‘(A) IN
LARGE EMPLOYER.—
GENERAL.—The
term ‘applicable
6
large employer’ means, with respect to a cal-
7
endar year, an employer who employed an aver-
8
age of at least 50 full-time employees on busi-
9
ness days during the preceding calendar year.
10
11
12
‘‘(B) EXEMPTION
FOR CERTAIN EMPLOY-
ERS.—
‘‘(i) IN
GENERAL.—An
employer shall
13
not be considered to employ more than 50
14
full-time employees if—
15
‘‘(I) the employer’s workforce ex-
16
ceeds 50 full-time employees for 120
17
days or fewer during the calendar
18
year, and
19
‘‘(II) the employees in excess of
20
50 employed during such 120-day pe-
21
riod were seasonal workers.
22
‘‘(ii)
DEFINITION
OF
SEASONAL
23
WORKERS.—The
24
means a worker who performs labor or
25
services on a seasonal basis as defined by
term ‘seasonal worker’
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1
the Secretary of Labor, including workers
2
covered by section 500.20(s)(1) of title 29,
3
Code of Federal Regulations and retail
4
workers employed exclusively during holi-
5
day seasons.
6
‘‘(C) RULES
7
SIZE.—For
FOR DETERMINING EMPLOYER
purposes of this paragraph—
8
‘‘(i) APPLICATION
9
RULE FOR EMPLOYERS.—All
OF AGGREGATION
persons treat-
10
ed as a single employer under subsection
11
(b), (c), (m), or (o) of section 414 of the
12
Internal Revenue Code of 1986 shall be
13
treated as 1 employer.
14
‘‘(ii) EMPLOYERS
15
IN PRECEDING YEAR.—In
16
employer which was not in existence
17
throughout the preceding calendar year,
18
the determination of whether such em-
19
ployer is an applicable large employer shall
20
be based on the average number of employ-
21
ees that it is reasonably expected such em-
22
ployer will employ on business days in the
23
current calendar year.
NOT IN EXISTENCE
the case of an
24
‘‘(iii) PREDECESSORS.—Any reference
25
in this subsection to an employer shall in-
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1
clude a reference to any predecessor of
2
such employer.
3
‘‘(3) APPLICABLE
PREMIUM TAX CREDIT AND
4
COST-SHARING REDUCTION.—The
5
premium tax credit and cost-sharing reduction’
6
means—
7
8
term ‘applicable
‘‘(A) any premium tax credit allowed under
section 36B,
9
‘‘(B) any cost-sharing reduction under sec-
10
tion 1402 of the Patient Protection and Afford-
11
able Care Act, and
12
‘‘(C) any advance payment of such credit
13
or reduction under section 1412 of such Act.
14
‘‘(4) FULL-TIME
15
‘‘(A) IN
EMPLOYEE.—
GENERAL.—The
term ‘full-time
16
employee’ means an employee who is employed
17
on average at least 30 hours of service per
18
week.
19
‘‘(B) HOURS
OF SERVICE.—The
Secretary,
20
in consultation with the Secretary of Labor,
21
shall prescribe such regulations, rules, and
22
guidance as may be necessary to determine the
23
hours of service of an employee, including rules
24
for the application of this paragraph to employ-
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1
ees who are not compensated on an hourly
2
basis.
3
‘‘(5) INFLATION
4
‘‘(A) IN
ADJUSTMENT.—
GENERAL.—In
the case of any cal-
5
endar year after 2014, each of the dollar
6
amounts in subsection (b)(2) and (d)(1) shall
7
be increased by an amount equal to the product
8
of—
9
‘‘(i) such dollar amount, and
10
‘‘(ii) the premium adjustment percent-
11
age (as defined in section 1302(c)(4) of
12
the Patient Protection and Affordable Care
13
Act) for the calendar year.
14
‘‘(B) ROUNDING.—If the amount of any
15
increase under subparagraph (A) is not a mul-
16
tiple of $10, such increase shall be rounded to
17
the next lowest multiple of $10.
18
‘‘(6) OTHER
DEFINITIONS.—Any
term used in
19
this section which is also used in the Patient Protec-
20
tion and Affordable Care Act shall have the same
21
meaning as when used in such Act.
22
‘‘(7) TAX
NONDEDUCTIBLE.—For
denial of de-
23
duction for the tax imposed by this section, see sec-
24
tion 275(a)(6).
25
‘‘(e) ADMINISTRATION AND PROCEDURE.—
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1
‘‘(1) IN
GENERAL.—Any
assessable payment
2
provided by this section shall be paid upon notice
3
and demand by the Secretary, and shall be assessed
4
and collected in the same manner as an assessable
5
penalty under subchapter B of chapter 68.
6
‘‘(2) TIME
FOR PAYMENT.—The
Secretary may
7
provide for the payment of any assessable payment
8
provided by this section on an annual, monthly, or
9
other periodic basis as the Secretary may prescribe.
10
‘‘(3) COORDINATION
WITH CREDITS, ETC..—
11
The Secretary shall prescribe rules, regulations, or
12
guidance for the repayment of any assessable pay-
13
ment (including interest) if such payment is based
14
on the allowance or payment of an applicable pre-
15
mium tax credit or cost-sharing reduction with re-
16
spect to an employee, such allowance or payment is
17
subsequently disallowed, and the assessable payment
18
would not have been required to be made but for
19
such allowance or payment.’’.
20
(b) CLERICAL AMENDMENT.—The table of sections
21 for chapter 43 of such Code is amended by adding at the
22 end the following new item:
‘‘Sec. 4980H. Shared responsibility for employers regarding health coverage.’’.
23
(c) STUDY
AND
24 WORKERS’ WAGES.—
REPORT
OF
EFFECT
OF
TAX
ON
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1
(1) IN
GENERAL.—The
Secretary of Labor shall
2
conduct a study to determine whether employees’
3
wages are reduced by reason of the application of
4
the assessable payments under section 4980H of the
5
Internal Revenue Code of 1986 (as added by the
6
amendments made by this section). The Secretary
7
shall make such determination on the basis of the
8
National Compensation Survey published by the Bu-
9
reau of Labor Statistics.
10
(2) REPORT.—The Secretary shall report the
11
results of the study under paragraph (1) to the
12
Committee on Ways and Means of the House of
13
Representatives and to the Committee on Finance of
14
the Senate.
15
(d) EFFECTIVE DATE.—The amendments made by
16 this section shall apply to months beginning after Decem17 ber 31, 2013.
18
19
20
SEC. 1514. REPORTING OF EMPLOYER HEALTH INSURANCE
COVERAGE.
(a) IN GENERAL.—Subpart D of part III of sub-
21 chapter A of chapter 61 of the Internal Revenue Code of
22 1986, as added by section 1502, is amended by inserting
23 after section 6055 the following new section:
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1
‘‘SEC. 6056. LARGE EMPLOYERS REQUIRED TO REPORT ON
2
HEALTH INSURANCE COVERAGE.
3
‘‘(a) IN GENERAL.—Every applicable large employer
4 required to meet the requirements of section 4980H with
5 respect to its full-time employees during a calendar year
6 shall, at such time as the Secretary may prescribe, make
7 a return described in subsection (b).
8
‘‘(b) FORM
AND
MANNER
OF
RETURN.—A return is
9 described in this subsection if such return—
10
11
12
13
14
‘‘(1) is in such form as the Secretary may prescribe, and
‘‘(2) contains—
‘‘(A) the name, date, and employer identification number of the employer,
15
‘‘(B) a certification as to whether the em-
16
ployer offers to its full-time employees (and
17
their dependents) the opportunity to enroll in
18
minimum essential coverage under an eligible
19
employer-sponsored plan (as defined in section
20
5000A(f)(2)),
21
‘‘(C) if the employer certifies that the em-
22
ployer did offer to its full-time employees (and
23
their dependents) the opportunity to so enroll—
24
‘‘(i) the length of any waiting period
25
(as defined in section 2701(b)(4) of the
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1
Public Health Service Act) with respect to
2
such coverage,
3
‘‘(ii) the months during the calendar
4
year for which coverage under the plan was
5
available,
6
‘‘(iii) the monthly premium for the
7
lowest cost option in each of the enroll-
8
ment categories under the plan, and
9
‘‘(iv) the applicable large employer’s
10
share of the total allowed costs of benefits
11
provided under the plan,
12
‘‘(D) the number of full-time employees for
13
each month during the calendar year,
14
‘‘(E) the name, address, and TIN of each
15
full-time employee during the calendar year and
16
the months (if any) during which such employee
17
(and any dependents) were covered under any
18
such health benefits plans, and
19
‘‘(F) such other information as the Sec-
20
21
retary may require.
‘‘(c) STATEMENTS
22
UALS
23
PORTED.—
24
25
WITH RESPECT
‘‘(1) IN
TO
TO
BE FURNISHED
TO
INDIVID-
WHOM INFORMATION IS RE-
GENERAL.—Every
person required to
make a return under subsection (a) shall furnish to
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1
each full-time employee whose name is required to
2
be set forth in such return under subsection
3
(b)(2)(E) a written statement showing—
4
‘‘(A) the name and address of the person
5
required to make such return and the phone
6
number of the information contact for such per-
7
son, and
8
‘‘(B) the information required to be shown
9
on the return with respect to such individual.
10
‘‘(2) TIME
FOR FURNISHING STATEMENTS.—
11
The written statement required under paragraph (1)
12
shall be furnished on or before January 31 of the
13
year following the calendar year for which the return
14
under subsection (a) was required to be made.
15
‘‘(d)
16
COORDINATION
MENTS.—To
WITH
OTHER
REQUIRE-
the maximum extent feasible, the Secretary
17 may provide that—
18
‘‘(1) any return or statement required to be
19
provided under this section may be provided as part
20
of any return or statement required under section
21
6051 or 6055, and
22
‘‘(2) in the case of an applicable large employer
23
offering health insurance coverage of a health insur-
24
ance issuer, the employer may enter into an agree-
25
ment with the issuer to include information required
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1
under this section with the return and statement re-
2
quired to be provided by the issuer under section
3
6055.
4
‘‘(e) COVERAGE PROVIDED
BY
GOVERNMENTAL
5 UNITS.—In the case of any applicable large employer
6 which is a governmental unit or any agency or instrumen7 tality thereof, the person appropriately designated for pur8 poses of this section shall make the returns and state9 ments required by this section.
10
‘‘(f) DEFINITIONS.—For purposes of this section, any
11 term used in this section which is also used in section
12 4980H shall have the meaning given such term by section
13 4980H.’’.
14
(b) ASSESSABLE PENALTIES.—
15
(1) Subparagraph (B) of section 6724(d)(1) of
16
the Internal Revenue Code of 1986 (relating to defi-
17
nitions), as amended by section 1502, is amended by
18
striking ‘‘or’’ at the end of clause (xxiii), by striking
19
‘‘and’’ at the end of clause (xxiv) and inserting ‘‘or’’,
20
and by inserting after clause (xxiv) the following
21
new clause:
22
‘‘(xxv) section 6056 (relating to re-
23
turns relating to large employers required
24
to report on health insurance coverage),
25
and’’.
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1
(2) Paragraph (2) of section 6724(d) of such
2
Code, as so amended, is amended by striking ‘‘or’’
3
at the end of subparagraph (FF), by striking the pe-
4
riod at the end of subparagraph (GG) and inserting
5
‘‘, or’’ and by inserting after subparagraph (GG) the
6
following new subparagraph:
7
‘‘(HH) section 6056(c) (relating to state-
8
ments relating to large employers required to
9
report on health insurance coverage).’’.
10
(c) CONFORMING AMENDMENT.—The table of sec-
11 tions for subpart D of part III of subchapter A of chapter
12 61 of such Code, as added by section 1502, is amended
13 by adding at the end the following new item:
‘‘Sec. 6056. Large employers required to report on health insurance coverage.’’.
14
(d) EFFECTIVE DATE.—The amendments made by
15 this section shall apply to periods beginning after Decem16 ber 31, 2013.
17
SEC.
1515.
OFFERING
OF
EXCHANGE-PARTICIPATING
18
QUALIFIED HEALTH PLANS THROUGH CAFE-
19
TERIA PLANS.
20
(a) IN GENERAL.—Subsection (f) of section 125 of
21 the Internal Revenue Code of 1986 is amended by adding
22 at the end the following new paragraph:
23
24
‘‘(3)
CERTAIN
EXCHANGE-PARTICIPATING
QUALIFIED HEALTH PLANS NOT QUALIFIED.—
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1
‘‘(A) IN
GENERAL.—The
term ‘qualified
2
benefit’ shall not include any qualified health
3
plan (as defined in section 1301(a) of the Pa-
4
tient Protection and Affordable Care Act) of-
5
fered through an Exchange established under
6
section 1311 of such Act.
7
‘‘(B) EXCEPTION
FOR EXCHANGE-ELIGI-
8
BLE EMPLOYERS.—Subparagraph
9
apply with respect to any employee if such em-
10
ployee’s employer is a qualified employer (as de-
11
fined in section 1312(f)(2) of the Patient Pro-
12
tection and Affordable Care Act) offering the
13
employee the opportunity to enroll through such
14
an Exchange in a qualified health plan in a
15
group market.’’.
16
(A) shall not
(b) CONFORMING AMENDMENTS.—Subsection (f) of
17 section 125 of such Code is amended—
18
(1) by striking ‘‘For purposes of this section,
19
the term’’ and inserting ‘‘For purposes of this sec-
20
tion—
21
‘‘(1) IN GENERAL.—The term’’, and
22
23
(2) by striking ‘‘Such term shall not include’’
and inserting the following:
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1
‘‘(2) LONG-TERM
CARE INSURANCE NOT QUALI-
2
FIED.—The
3
clude’’.
4
(c) EFFECTIVE DATE.—The amendments made by
term ‘qualified benefit’ shall not in-
5 this section shall apply to taxable years beginning after
6 December 31, 2013.
7
8
9
10
Subtitle G—Miscellaneous
Provisions
SEC. 1551. DEFINITIONS.
Unless specifically provided for otherwise, the defini-
11 tions contained in section 2791 of the Public Health Serv12 ice Act (42 U.S.C. 300gg-91) shall apply with respect to
13 this title.
14
15
SEC. 1552. TRANSPARENCY IN GOVERNMENT.
Not later than 30 days after the date of enactment
16 of this Act, the Secretary of Health and Human Services
17 shall publish on the Internet website of the Department
18 of Health and Human Services, a list of all of the authori19 ties provided to the Secretary under this Act (and the
20 amendments made by this Act).
21
22
23
SEC. 1553. PROHIBITION AGAINST DISCRIMINATION ON ASSISTED SUICIDE.
(a) IN GENERAL.—The Federal Government, and
24 any State or local government or health care provider that
25 receives Federal financial assistance under this Act (or
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1 under an amendment made by this Act) or any health plan
2 created under this Act (or under an amendment made by
3 this Act), may not subject an individual or institutional
4 health care entity to discrimination on the basis that the
5 entity does not provide any health care item or service fur6 nished for the purpose of causing, or for the purpose of
7 assisting in causing, the death of any individual, such as
8 by assisted suicide, euthanasia, or mercy killing.
9
(b) DEFINITION.—In this section, the term ‘‘health
10 care entity’’ includes an individual physician or other
11 health care professional, a hospital, a provider-sponsored
12 organization, a health maintenance organization, a health
13 insurance plan, or any other kind of health care facility,
14 organization, or plan.
15
(c) CONSTRUCTION
AND
TREATMENT
OF
CERTAIN
16 SERVICES.—Nothing in subsection (a) shall be construed
17 to apply to, or to affect, any limitation relating to—
18
19
20
21
(1) the withholding or withdrawing of medical
treatment or medical care;
(2) the withholding or withdrawing of nutrition
or hydration;
22
(3) abortion; or
23
(4) the use of an item, good, benefit, or service
24
furnished for the purpose of alleviating pain or dis-
25
comfort, even if such use may increase the risk of
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1
death, so long as such item, good, benefit, or service
2
is not also furnished for the purpose of causing, or
3
the purpose of assisting in causing, death, for any
4
reason.
5
(d) ADMINISTRATION.—The Office for Civil Rights of
6 the Department of Health and Human Services is des7 ignated to receive complaints of discrimination based on
8 this section.
9
10
SEC. 1554. ACCESS TO THERAPIES.
Notwithstanding any other provision of this Act, the
11 Secretary of Health and Human Services shall not pro12 mulgate any regulation that—
13
(1) creates any unreasonable barriers to the
14
ability of individuals to obtain appropriate medical
15
care;
16
17
(2) impedes timely access to health care services;
18
(3) interferes with communications regarding a
19
full range of treatment options between the patient
20
and the provider;
21
(4) restricts the ability of health care providers
22
to provide full disclosure of all relevant information
23
to patients making health care decisions;
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1
(5) violates the principles of informed consent
2
and the ethical standards of health care profes-
3
sionals; or
4
(6) limits the availability of health care treat-
5
ment for the full duration of a patient’s medical
6
needs.
7
SEC. 1555. FREEDOM NOT TO PARTICIPATE IN FEDERAL
8
HEALTH INSURANCE PROGRAMS.
9
No individual, company, business, nonprofit entity, or
10 health insurance issuer offering group or individual health
11 insurance coverage shall be required to participate in any
12 Federal health insurance program created under this Act
13 (or any amendments made by this Act), or in any Federal
14 health insurance program expanded by this Act (or any
15 such amendments), and there shall be no penalty or fine
16 imposed upon any such issuer for choosing not to partici17 pate in such programs.
18
19
SEC. 1556. EQUITY FOR CERTAIN ELIGIBLE SURVIVORS.
(a) REBUTTABLE PRESUMPTION.—Section 411(c)(4)
20 of the Black Lung Benefits Act (30 U.S.C. 921(c)(4)) is
21 amended by striking the last sentence.
22
(b) CONTINUATION
OF
BENEFITS.—Section 422(l) of
23 the Black Lung Benefits Act (30 U.S.C. 932(l)) is amend24 ed by striking ‘‘, except with respect to a claim filed under
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1 this part on or after the effective date of the Black Lung
2 Benefits Amendments of 1981’’.
3
(c) EFFECTIVE DATE.—The amendments made by
4 this section shall apply with respect to claims filed under
5 part B or part C of the Black Lung Benefits Act (30
6 U.S.C. 921 et seq., 931 et seq.) after January 1, 2005,
7 that are pending on or after the date of enactment of this
8 Act.
9
10
SEC. 1557. NONDISCRIMINATION.
(a) IN GENERAL.—Except as otherwise provided for
11 in this title (or an amendment made by this title), an indi12 vidual shall not, on the ground prohibited under title VI
13 of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.),
14 title IX of the Education Amendments of 1972 (20 U.S.C.
15 1681 et seq.), the Age Discrimination Act of 1975 (42
16 U.S.C. 6101 et seq.), or section 504 of the Rehabilitation
17 Act of 1973 (29 U.S.C. 794), be excluded from participa18 tion in, be denied the benefits of, or be subjected to dis19 crimination under, any health program or activity, any
20 part of which is receiving Federal financial assistance, in21 cluding credits, subsidies, or contracts of insurance, or
22 under any program or activity that is administered by an
23 Executive Agency or any entity established under this title
24 (or amendments). The enforcement mechanisms provided
25 for and available under such title VI, title IX, section 504,
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1 or such Age Discrimination Act shall apply for purposes
2 of violations of this subsection.
3
(b) CONTINUED APPLICATION OF LAWS.—Nothing in
4 this title (or an amendment made by this title) shall be
5 construed to invalidate or limit the rights, remedies, proce6 dures, or legal standards available to individuals aggrieved
7 under title VI of the Civil Rights Act of 1964 (42 U.S.C.
8 2000d et seq.), title VII of the Civil Rights Act of 1964
9 (42 U.S.C. 2000e et seq.), title IX of the Education
10 Amendments of 1972 (20 U.S.C. 1681 et seq.), section
11 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794),
12 or the Age Discrimination Act of 1975 (42 U.S.C. 611
13 et seq.), or to supersede State laws that provide additional
14 protections against discrimination on any basis described
15 in subsection (a).
16
(c) REGULATIONS.—The Secretary may promulgate
17 regulations to implement this section.
18
19
SEC. 1558. PROTECTIONS FOR EMPLOYEES.
The Fair Labor Standards Act of 1938 is amended
20 by inserting after section 18B (as added by section 1512)
21 the following:
22
23
‘‘SEC. 18C. PROTECTIONS FOR EMPLOYEES.
‘‘(a) PROHIBITION.—No employer shall discharge or
24 in any manner discriminate against any employee with re25 spect to his or her compensation, terms, conditions, or
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1 other privileges of employment because the employee (or
2 an individual acting at the request of the employee) has—
3
‘‘(1) received a credit under section 36B of the
4
Internal Revenue Code of 1986 or a subsidy under
5
section 1402 of this Act;
6
‘‘(2) provided, caused to be provided, or is
7
about to provide or cause to be provided to the em-
8
ployer, the Federal Government, or the attorney
9
general of a State information relating to any viola-
10
tion of, or any act or omission the employee reason-
11
ably believes to be a violation of, any provision of
12
this title (or an amendment made by this title);
13
14
15
16
‘‘(3) testified or is about to testify in a proceeding concerning such violation;
‘‘(4) assisted or participated, or is about to assist or participate, in such a proceeding; or
17
‘‘(5) objected to, or refused to participate in,
18
any activity, policy, practice, or assigned task that
19
the employee (or other such person) reasonably be-
20
lieved to be in violation of any provision of this title
21
(or amendment), or any order, rule, regulation,
22
standard, or ban under this title (or amendment).
23
‘‘(b) COMPLAINT PROCEDURE.—
24
25
‘‘(1) IN
GENERAL.—An
employee who believes
that he or she has been discharged or otherwise dis-
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1
criminated against by any employer in violation of
2
this section may seek relief in accordance with the
3
procedures, notifications, burdens of proof, remedies,
4
and statutes of limitation set forth in section
5
2087(b) of title 15, United States Code.
6
‘‘(2) NO
LIMITATION ON RIGHTS.—Nothing
in
7
this section shall be deemed to diminish the rights,
8
privileges, or remedies of any employee under any
9
Federal or State law or under any collective bar-
10
gaining agreement. The rights and remedies in this
11
section may not be waived by any agreement, policy,
12
form, or condition of employment.’’.
13
14
SEC. 1559. OVERSIGHT.
The Inspector General of the Department of Health
15 and Human Services shall have oversight authority with
16 respect to the administration and implementation of this
17 title as it relates to such Department.
18
19
SEC. 1560. RULES OF CONSTRUCTION.
(a) NO EFFECT
ON
ANTITRUST LAWS.—Nothing in
20 this title (or an amendment made by this title) shall be
21 construed to modify, impair, or supersede the operation
22 of any of the antitrust laws. For the purposes of this sec23 tion, the term ‘‘antitrust laws’’ has the meaning given
24 such term in subsection (a) of the first section of the Clay25 ton Act, except that such term includes section 5 of the
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1 Federal Trade Commission Act to the extent that such
2 section 5 applies to unfair methods of competition.
3
(b) RULE
OF
CONSTRUCTION REGARDING HAWAII’S
4 PREPAID HEALTH CARE ACT.—Nothing in this title (or
5 an amendment made by this title) shall be construed to
6 modify or limit the application of the exemption for Ha7 waii’s Prepaid Health Care Act (Haw. Rev. Stat. §§ 3938 1 et seq.) as provided for under section 514(b)(5) of the
9 Employee Retirement Income Security Act of 1974 (29
10 U.S.C. 1144(b)(5)).
11
(c) STUDENT HEALTH INSURANCE PLANS.—Nothing
12 in this title (or an amendment made by this title) shall
13 be construed to prohibit an institution of higher education
14 (as such term is defined for purposes of the Higher Edu15 cation Act of 1965) from offering a student health insur16 ance plan, to the extent that such requirement is otherwise
17 permitted under applicable Federal, State or local law.
18
(d) NO EFFECT
ON
EXISTING REQUIREMENTS.—
19 Nothing in this title (or an amendment made by this title,
20 unless specified by direct statutory reference) shall be con21 strued to modify any existing Federal requirement con22 cerning the State agency responsible for determining eligi23 bility for programs identified in section 1413.
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1
SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLL-
2
MENT STANDARDS AND PROTOCOLS.
3
Title XXX of the Public Health Service Act (42
4 U.S.C. 300jj et seq.) is amended by adding at the end
5 the following:
6
‘‘Subtitle C—Other Provisions
7
‘‘SEC. 3021. HEALTH INFORMATION TECHNOLOGY ENROLL-
8
9
10
MENT STANDARDS AND PROTOCOLS.
‘‘(a) IN GENERAL.—
‘‘(1) STANDARDS
AND PROTOCOLS.—Not
later
11
than 180 days after the date of enactment of this
12
title, the Secretary, in consultation with the HIT
13
Policy Committee and the HIT Standards Com-
14
mittee, shall develop interoperable and secure stand-
15
ards and protocols that facilitate enrollment of indi-
16
viduals in Federal and State health and human serv-
17
ices programs, as determined by the Secretary.
18
‘‘(2) METHODS.—The Secretary shall facilitate
19
enrollment in such programs through methods deter-
20
mined appropriate by the Secretary, which shall in-
21
clude providing individuals and third parties author-
22
ized by such individuals and their designees notifica-
23
tion of eligibility and verification of eligibility re-
24
quired under such programs.
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1
‘‘(b) CONTENT.—The standards and protocols for
2 electronic enrollment in the Federal and State programs
3 described in subsection (a) shall allow for the following:
4
‘‘(1) Electronic matching against existing Fed-
5
eral and State data, including vital records, employ-
6
ment history, enrollment systems, tax records, and
7
other data determined appropriate by the Secretary
8
to serve as evidence of eligibility and in lieu of
9
paper-based documentation.
10
‘‘(2) Simplification and submission of electronic
11
documentation, digitization of documents, and sys-
12
tems verification of eligibility.
13
‘‘(3) Reuse of stored eligibility information (in-
14
cluding documentation) to assist with retention of el-
15
igible individuals.
16
‘‘(4) Capability for individuals to apply, recer-
17
tify and manage their eligibility information online,
18
including at home, at points of service, and other
19
community-based locations.
20
‘‘(5) Ability to expand the enrollment system to
21
integrate new programs, rules, and functionalities, to
22
operate at increased volume, and to apply stream-
23
lined verification and eligibility processes to other
24
Federal and State programs, as appropriate.
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1
‘‘(6) Notification of eligibility, recertification,
2
and other needed communication regarding eligi-
3
bility, which may include communication via email
4
and cellular phones.
5
‘‘(7) Other functionalities necessary to provide
6
eligibles with streamlined enrollment process.
7
‘‘(c) APPROVAL
AND
NOTIFICATION.—With respect
8 to any standard or protocol developed under subsection (a)
9 that has been approved by the HIT Policy Committee and
10 the HIT Standards Committee, the Secretary—
11
12
‘‘(1) shall notify States of such standards or
protocols; and
13
‘‘(2) may require, as a condition of receiving
14
Federal funds for the health information technology
15
investments, that States or other entities incorporate
16
such standards and protocols into such investments.
17
‘‘(d) GRANTS
18
19
PRIATE
FOR
IMPLEMENTATION
OF
APPRO-
ENROLLMENT HIT.—
‘‘(1) IN
GENERAL.—The
Secretary shall award
20
grant to eligible entities to develop new, and adapt
21
existing, technology systems to implement the HIT
22
enrollment standards and protocols developed under
23
subsection (a) (referred to in this subsection as ‘ap-
24
propriate HIT technology’).
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1
2
3
4
‘‘(2) ELIGIBLE
ENTITIES.—To
be eligible for a
grant under this subsection, an entity shall—
‘‘(A) be a State, political subdivision of a
State, or a local governmental entity; and
5
‘‘(B) submit to the Secretary an applica-
6
tion at such time, in such manner, and con-
7
taining—
8
‘‘(i) a plan to adopt and implement
9
appropriate enrollment technology that in-
10
cludes—
11
‘‘(I) proposed reduction in main-
12
tenance costs of technology systems;
13
‘‘(II) elimination or updating of
14
legacy systems; and
15
‘‘(III) demonstrated collaboration
16
with other entities that may receive a
17
grant under this section that are lo-
18
cated in the same State, political sub-
19
division, or locality;
20
‘‘(ii) an assurance that the entity will
21
share such appropriate enrollment tech-
22
nology in accordance with paragraph (4);
23
and
24
25
‘‘(iii) such other information as the
Secretary may require.
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1
‘‘(3) SHARING.—
2
‘‘(A) IN
GENERAL.—The
Secretary shall
3
ensure that appropriate enrollment HIT adopt-
4
ed under grants under this subsection is made
5
available to other qualified State, qualified po-
6
litical subdivisions of a State, or other appro-
7
priate qualified entities (as described in sub-
8
paragraph (B)) at no cost.
9
‘‘(B) QUALIFIED
ENTITIES.—The
Sec-
10
retary shall determine what entities are quali-
11
fied to receive enrollment HIT under subpara-
12
graph (A), taking into consideration the rec-
13
ommendations of the HIT Policy Committee
14
and the HIT Standards Committee.’’.
15
16
SEC. 1562. CONFORMING AMENDMENTS.
(a) APPLICABILITY.—Section 2735 of the Public
17 Health Service Act (42 U.S.C. 300gg-21), as so redesig18 nated by section 1001(4), is amended—
19
(1) by striking subsection (a);
20
(2) in subsection (b)—
21
22
23
(A) in paragraph (1), by striking ‘‘1
through 3’’ and inserting ‘‘1 and 2’’; and
(B) in paragraph (2)—
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1
(i) in subparagraph (A), by striking
2
‘‘subparagraph (D)’’ and inserting ‘‘sub-
3
paragraph (D) or (E)’’;
4
5
(ii) by striking ‘‘1 through 3’’ and inserting ‘‘1 and 2’’; and
6
(iii) by adding at the end the fol-
7
lowing:
8
‘‘(E) ELECTION
NOT APPLICABLE.—The
9
election described in subparagraph (A) shall not
10
be available with respect to the provisions of
11
subpart 1.’’;
12
(3) in subsection (c), by striking ‘‘1 through 3
13
shall not apply to any group’’ and inserting ‘‘1 and
14
2 shall not apply to any individual coverage or any
15
group’’; and
16
(4) in subsection (d)—
17
(A) in paragraph (1), by striking ‘‘1
18
through 3 shall not apply to any group’’ and in-
19
serting ‘‘1 and 2 shall not apply to any indi-
20
vidual coverage or any group’’;
21
(B) in paragraph (2)—
22
(i) in the matter preceding subpara-
23
graph (A), by striking ‘‘1 through 3 shall
24
not apply to any group’’ and inserting ‘‘1
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1
and 2 shall not apply to any individual cov-
2
erage or any group’’; and
3
(ii) in subparagraph (C), by inserting
4
‘‘or, with respect to individual coverage,
5
under any health insurance coverage main-
6
tained by the same health insurance
7
issuer’’; and
8
(C) in paragraph (3), by striking ‘‘any
9
group’’ and inserting ‘‘any individual coverage
10
11
or any group’’.
(b) DEFINITIONS.—Section 2791(d) of the Public
12 Health Service Act (42 U.S.C. 300gg-91(d)) is amended
13 by adding at the end the following:
14
‘‘(20) QUALIFIED
HEALTH PLAN.—The
term
15
‘qualified health plan’ has the meaning given such
16
term in section 1301(a) of the Patient Protection
17
and Affordable Care Act.
18
‘‘(21)
EXCHANGE.—The
term
‘Exchange’
19
means an American Health Benefit Exchange estab-
20
lished under section 1311 of the Patient Protection
21
and Affordable Care Act.’’.
22
(c) TECHNICAL
AND
CONFORMING AMENDMENTS.—
23 Title XXVII of the Public Health Service Act (42 U.S.C.
24 300gg et seq.) is amended—
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1
2
3
(1) in section 2704 (42 U.S.C. 300gg), as so
redesignated by section 1201(2)—
(A) in subsection (c)—
4
(i) in paragraph (2), by striking
5
‘‘group health plan’’ each place that such
6
term appears and inserting ‘‘group or indi-
7
vidual health plan’’; and
8
(ii) in paragraph (3)—
9
(I) by striking ‘‘group health in-
10
surance’’ each place that such term
11
appears and inserting ‘‘group or indi-
12
vidual health insurance’’; and
13
(II) in subparagraph (D), by
14
striking ‘‘small or large’’ and insert-
15
ing ‘‘individual or group’’;
16
(B) in subsection (d), by striking ‘‘group
17
health insurance’’ each place that such term ap-
18
pears and inserting ‘‘group or individual health
19
insurance’’; and
20
(C) in subsection (e)(1)(A), by striking
21
‘‘group health insurance’’ and inserting ‘‘group
22
or individual health insurance’’;
23
(2) by striking the second heading for subpart
24
2 of part A (relating to other requirements);
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1
2
(3) in section 2725 (42 U.S.C. 300gg-4), as so
redesignated by section 1001(2)—
3
(A) in subsection (a), by striking ‘‘health
4
insurance issuer offering group health insur-
5
ance coverage’’ and inserting ‘‘health insurance
6
issuer offering group or individual health insur-
7
ance coverage’’;
8
(B) in subsection (b)—
9
(i) by striking ‘‘health insurance
10
issuer offering group health insurance cov-
11
erage in connection with a group health
12
plan’’ in the matter preceding paragraph
13
(1) and inserting ‘‘health insurance issuer
14
offering group or individual health insur-
15
ance coverage’’; and
16
(ii) in paragraph (1), by striking
17
‘‘plan’’ and inserting ‘‘plan or coverage’’;
18
(C) in subsection (c)—
19
(i) in paragraph (2), by striking
20
‘‘group health insurance coverage offered
21
by a health insurance issuer’’ and inserting
22
‘‘health insurance issuer offering group or
23
individual health insurance coverage’’; and
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1
(ii) in paragraph (3), by striking
2
‘‘issuer’’ and inserting ‘‘health insurance
3
issuer’’; and
4
(D) in subsection (e), by striking ‘‘health
5
insurance issuer offering group health insur-
6
ance coverage’’ and inserting ‘‘health insurance
7
issuer offering group or individual health insur-
8
ance coverage’’;
9
(4) in section 2726 (42 U.S.C. 300gg-5), as so
10
redesignated by section 1001(2)—
11
(A) in subsection (a), by striking ‘‘(or
12
health insurance coverage offered in connection
13
with such a plan)’’ each place that such term
14
appears and inserting ‘‘or a health insurance
15
issuer offering group or individual health insur-
16
ance coverage’’;
17
(B) in subsection (b), by striking ‘‘(or
18
health insurance coverage offered in connection
19
with such a plan)’’ each place that such term
20
appears and inserting ‘‘or a health insurance
21
issuer offering group or individual health insur-
22
ance coverage’’; and
23
(C) in subsection (c)—
24
(i) in paragraph (1), by striking ‘‘(and
25
group health insurance coverage offered in
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1
connection with a group health plan)’’ and
2
inserting ‘‘and a health insurance issuer
3
offering group or individual health insur-
4
ance coverage’’;
5
(ii) in paragraph (2), by striking ‘‘(or
6
health insurance coverage offered in con-
7
nection with such a plan)’’ each place that
8
such term appears and inserting ‘‘or a
9
health insurance issuer offering group or
10
individual health insurance coverage’’;
11
(5) in section 2727 (42 U.S.C. 300gg-6), as so
12
redesignated by section 1001(2), by striking ‘‘health
13
insurance issuers providing health insurance cov-
14
erage in connection with group health plans’’ and in-
15
serting ‘‘and health insurance issuers offering group
16
or individual health insurance coverage’’;
17
18
(6) in section 2728 (42 U.S.C. 300gg-7), as so
redesignated by section 1001(2)—
19
(A) in subsection (a), by striking ‘‘health
20
insurance coverage offered in connection with
21
such plan’’ and inserting ‘‘individual health in-
22
surance coverage’’;
23
24
25
(B) in subsection (b)—
(i) in paragraph (1), by striking ‘‘or a
health
insurance
issuer
that
provides
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1
health insurance coverage in connection
2
with a group health plan’’ and inserting
3
‘‘or a health insurance issuer that offers
4
group or individual health insurance cov-
5
erage’’;
6
(ii) in paragraph (2), by striking
7
‘‘health insurance coverage offered in con-
8
nection with the plan’’ and inserting ‘‘indi-
9
vidual health insurance coverage’’; and
10
(iii) in paragraph (3), by striking
11
‘‘health insurance coverage offered by an
12
issuer in connection with such plan’’ and
13
inserting ‘‘individual health insurance cov-
14
erage’’;
15
(C) in subsection (c), by striking ‘‘health
16
insurance issuer providing health insurance cov-
17
erage in connection with a group health plan’’
18
and inserting ‘‘health insurance issuer that of-
19
fers group or individual health insurance cov-
20
erage’’; and
21
(D) in subsection (e)(1), by striking
22
‘‘health insurance coverage offered in connec-
23
tion with such a plan’’ and inserting ‘‘individual
24
health insurance coverage’’;
25
(7) by striking the heading for subpart 3;
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1
2
3
4
5
6
(8) in section 2731 (42 U.S.C. 300gg-11), as so
redesignated by section 1001(3)—
(A) by striking the section heading and all
that follows through subsection (b);
(B) in subsection (c)—
(i) in paragraph (1)—
7
(I) in the matter preceding sub-
8
paragraph (A), by striking ‘‘small
9
group’’ and inserting ‘‘group and indi-
10
11
vidual’’; and
(II) in subparagraph (B)—
12
(aa) in the matter preceding
13
clause (i), by inserting ‘‘and indi-
14
viduals’’ after ‘‘employers’’;
15
(bb) in clause (i), by insert-
16
ing ‘‘or any additional individ-
17
uals’’ after ‘‘additional groups’’;
18
and
19
(cc) in clause (ii), by strik-
20
ing ‘‘without regard to the claims
21
experience of those employers
22
and their employees (and their
23
dependents) or any health status-
24
related factor relating to such’’
25
and inserting ‘‘and individuals
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1
without regard to the claims ex-
2
perience of those individuals, em-
3
ployers and their employees (and
4
their dependents) or any health
5
status-related factor relating to
6
such individuals’’; and
7
(ii) in paragraph (2), by striking
8
‘‘small group’’ and inserting ‘‘group or in-
9
dividual’’;
10
(C) in subsection (d)—
11
(i) by striking ‘‘small group’’ each
12
place that such appears and inserting
13
‘‘group or individual’’; and
14
(ii) in paragraph (1)(B)—
15
(I) by striking ‘‘all employers’’
16
and inserting ‘‘all employers and indi-
17
viduals’’;
18
(II) by striking ‘‘those employ-
19
ers’’ and inserting ‘‘those individuals,
20
employers’’; and
21
(III) by striking ‘‘such employ-
22
ees’’ and inserting ‘‘such individuals,
23
employees’’;
24
(D) by striking subsection (e);
25
(E) by striking subsection (f); and
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1
(F) by transferring such section (as
2
amended by this paragraph) to appear at the
3
end of section 2702 (as added by section
4
1001(4));
5
(9) in section 2732 (42 U.S.C. 300gg-12), as so
6
7
8
9
redesignated by section 1001(3)—
(A) by striking the section heading and all
that follows through subsection (a);
(B) in subsection (b)—
10
(i) in the matter preceding paragraph
11
(1), by striking ‘‘group health plan in the
12
small or large group market’’ and inserting
13
‘‘health insurance coverage offered in the
14
group or individual market’’;
15
(ii) in paragraph (1), by inserting ‘‘,
16
or individual, as applicable,’’ after ‘‘plan
17
sponsor’’;
18
(iii) in paragraph (2), by inserting ‘‘,
19
or individual, as applicable,’’ after ‘‘plan
20
sponsor’’; and
21
22
23
(iv) by striking paragraph (3) and inserting the following:
‘‘(3) VIOLATION
OF PARTICIPATION OR CON-
24
TRIBUTION RATES.—In
25
plan, the plan sponsor has failed to comply with a
the case of a group health
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388
1
material plan provision relating to employer con-
2
tribution or group participation rules, pursuant to
3
applicable State law.’’;
4
5
(C) in subsection (c)—
(i) in paragraph (1)—
6
(I) in the matter preceding sub-
7
paragraph (A), by striking ‘‘group
8
health insurance coverage offered in
9
the small or large group market’’ and
10
inserting ‘‘group or individual health
11
insurance coverage’’;
12
(II) in subparagraph (A), by in-
13
serting ‘‘or individual, as applicable,’’
14
after ‘‘plan sponsor’’;
15
(III) in subparagraph (B)—
16
(aa) by inserting ‘‘or indi-
17
vidual, as applicable,’’ after ‘‘plan
18
sponsor’’; and
19
(bb) by inserting ‘‘or indi-
20
vidual
21
erage’’; and
22
(IV) in subparagraph (C), by in-
23
serting ‘‘or individuals, as applicable,’’
24
after ‘‘those sponsors’’; and
25
(ii) in paragraph (2)(A)—
health
insurance
cov-
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1
(I) in the matter preceding clause
2
(i), by striking ‘‘small group market
3
or the large group market, or both
4
markets,’’ and inserting ‘‘individual or
5
group market, or all markets,’’; and
6
(II) in clause (i), by inserting ‘‘or
7
individual, as applicable,’’ after ‘‘plan
8
sponsor’’; and
9
(D) by transferring such section (as
10
amended by this paragraph) to appear at the
11
end of section 2703 (as added by section
12
1001(4));
13
(10) in section 2733 (42 U.S.C. 300gg-13), as
14
15
so redesignated by section 1001(4)—
(A) in subsection (a)—
16
(i) in the matter preceding paragraph
17
(1), by striking ‘‘small employer’’ and in-
18
serting ‘‘small employer or an individual’’;
19
(ii) in paragraph (1), by inserting ‘‘,
20
or individual, as applicable,’’ after ‘‘em-
21
ployer’’ each place that such appears; and
22
(iii) in paragraph (2), by striking
23
‘‘small employer’’ and inserting ‘‘employer,
24
or individual, as applicable,’’;
25
(B) in subsection (b)—
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390
1
(i) in paragraph (1)—
2
(I) in the matter preceding sub-
3
paragraph (A), by striking ‘‘small em-
4
ployer’’ and inserting ‘‘employer, or
5
individual, as applicable,’’;
6
7
8
9
10
(II) in subparagraph (A), by adding ‘‘and’’ at the end;
(III) by striking subparagraphs
(B) and (C); and
(IV) in subparagraph (D)—
11
(aa) by inserting ‘‘, or indi-
12
vidual, as applicable,’’ after ‘‘em-
13
ployer’’; and
14
(bb) by redesignating such
15
subparagraph as subparagraph
16
(B);
17
(ii) in paragraph (2)—
18
(I) by striking ‘‘small employers’’
19
each place that such term appears
20
and inserting ‘‘employers, or individ-
21
uals, as applicable,’’; and
22
(II) by striking ‘‘small employer’’
23
and inserting ‘‘employer, or indi-
24
vidual, as applicable,’’; and
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391
1
(C) by redesignating such section (as
2
amended by this paragraph) as section 2709
3
and transferring such section to appear after
4
section 2708 (as added by section 1001(5));
5
(11) by redesignating subpart 4 as subpart 2;
6
(12) in section 2735 (42 U.S.C. 300gg-21), as
7
so redesignated by section 1001(4)—
8
(A) by striking subsection (a);
9
(B) by striking ‘‘subparts 1 through 3’’
10
each place that such appears and inserting
11
‘‘subpart 1’’;
12
(C)
by
redesignating
subsections
(b)
13
through (e) as subsections (a) through (d), re-
14
spectively; and
15
(D) by redesignating such section (as
16
amended by this paragraph) as section 2722;
17
(13) in section 2736 (42 U.S.C. 300gg-22), as
18
19
so redesignated by section 1001(4)—
(A) in subsection (a)—
20
(i) in paragraph (1), by striking
21
‘‘small or large group markets’’ and insert-
22
ing ‘‘individual or group market’’; and
23
(ii) in paragraph (2), by inserting ‘‘or
24
individual health insurance coverage’’ after
25
‘‘group health plans’’;
O:\BAI\BAI09M01.xml [file 1 of 9]
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392
1
(B) in subsection (b)(1)(B), by inserting
2
‘‘individual health insurance coverage or’’ after
3
‘‘respect to’’; and
4
(C) by redesignating such section (as
5
amended by this paragraph) as section 2723;
6
(14) in section 2737(a)(1) (42 U.S.C. 300gg-
7
8
9
10
23), as so redesignated by section 1001(4)—
(A) by inserting ‘‘individual or’’ before
‘‘group health insurance’’; and
(B)
by
redesignating
such
section(as
11
amended by this paragraph) as section 2724;
12
(15) in section 2762 (42 U.S.C. 300gg-62)—
13
14
15
16
17
(A) in the section heading by inserting
‘‘AND
APPLICATION’’
before the period; and
(B) by adding at the end the following:
‘‘(c) APPLICATION OF PART A PROVISIONS.—
‘‘(1) IN
GENERAL.—The
provisions of part A
18
shall apply to health insurance issuers providing
19
health insurance coverage in the individual market
20
in a State as provided for in such part.
21
‘‘(2) CLARIFICATION.—To the extent that any
22
provision of this part conflicts with a provision of
23
part A with respect to health insurance issuers pro-
24
viding health insurance coverage in the individual
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393
1
market in a State, the provisions of such part A
2
shall apply.’’; and
3
4
5
6
7
(16) in section 2791(e) (42 U.S.C. 300gg91(e))—
(A) in paragraph (2), by striking ‘‘51’’ and
inserting ‘‘101’’; and
(B) in paragraph (4)—
8
(i) by striking ‘‘at least 2’’ each place
9
that such appears and inserting ‘‘at least
10
11
12
13
1’’; and
(ii) by striking ‘‘50’’ and inserting
‘‘100’’.
(d) APPLICATION.—Notwithstanding any other provi-
14 sion of the Patient Protection and Affordable Care Act,
15 nothing in such Act (or an amendment made by such Act)
16 shall be construed to—
17
(1) prohibit (or authorize the Secretary of
18
Health and Human Services to promulgate regula-
19
tions that prohibit) a group health plan or health in-
20
surance issuer from carrying out utilization manage-
21
ment techniques that are commonly used as of the
22
date of enactment of this Act; or
23
24
(2) restrict the application of the amendments
made by this subtitle.
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1
(e) TECHNICAL AMENDMENT
TO THE
2 RETIREMENT INCOME SECURITY ACT
OF
EMPLOYEE
1974.—Subpart
3 B of part 7 of subtitle A of title I of the Employee Retire4 ment Income Security Act of 1974 (29 U.S.C. 1181 et.
5 seq.) is amended, by adding at the end the following:
6
7
‘‘SEC. 715. ADDITIONAL MARKET REFORMS.
‘‘(a) GENERAL RULE.—Except as provided in sub-
8 section (b)—
9
‘‘(1) the provisions of part A of title XXVII of
10
the Public Health Service Act (as amended by the
11
Patient Protection and Affordable Care Act) shall
12
apply to group health plans, and health insurance
13
issuers providing health insurance coverage in con-
14
nection with group health plans, as if included in
15
this subpart; and
16
‘‘(2) to the extent that any provision of this
17
part conflicts with a provision of such part A with
18
respect to group health plans, or health insurance
19
issuers providing health insurance coverage in con-
20
nection with group health plans, the provisions of
21
such part A shall apply.
22
‘‘(b) EXCEPTION.—Notwithstanding subsection (a),
23 the provisions of sections 2716 and 2718 of title XXVII
24 of the Public Health Service Act (as amended by the Pa25 tient Protection and Affordable Care Act) shall not apply
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395
1 with respect to self-insured group health plans, and the
2 provisions of this part shall continue to apply to such
3 plans as if such sections of the Public Health Service Act
4 (as so amended) had not been enacted.’’.
5
(f) TECHNICAL AMENDMENT
6 REVENUE CODE
OF
TO THE
INTERNAL
1986.—Subchapter B of chapter 100
7 of the Internal Revenue Code of 1986 is amended by add8 ing at the end the following:
9
10
‘‘SEC. 9815. ADDITIONAL MARKET REFORMS.
‘‘(a) GENERAL RULE.—Except as provided in sub-
11 section (b)—
12
‘‘(1) the provisions of part A of title XXVII of
13
the Public Health Service Act (as amended by the
14
Patient Protection and Affordable Care Act) shall
15
apply to group health plans, and health insurance
16
issuers providing health insurance coverage in con-
17
nection with group health plans, as if included in
18
this subchapter; and
19
‘‘(2) to the extent that any provision of this
20
subchapter conflicts with a provision of such part A
21
with respect to group health plans, or health insur-
22
ance issuers providing health insurance coverage in
23
connection with group health plans, the provisions of
24
such part A shall apply.
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1
‘‘(b) EXCEPTION.—Notwithstanding subsection (a),
2 the provisions of sections 2716 and 2718 of title XXVII
3 of the Public Health Service Act (as amended by the Pa4 tient Protection and Affordable Care Act) shall not apply
5 with respect to self-insured group health plans, and the
6 provisions of this subchapter shall continue to apply to
7 such plans as if such sections of the Public Health Service
8 Act (as so amended) had not been enacted.’’.
12
TITLE II—ROLE OF PUBLIC
PROGRAMS
Subtitle A—Improved Access to
Medicaid
13
SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME
9
10
11
14
POPULATIONS.
15
16
17
(a) COVERAGE
OR
FOR
INDIVIDUALS WITH INCOME
AT
BELOW 133 PERCENT OF THE POVERTY LINE.—
(1)
BEGINNING
2014.—Section
18
1902(a)(10)(A)(i) of the Social Security Act (42
19
U.S.C. 1396a) is amended—
20
21
22
23
24
25
(A) by striking ‘‘or’’ at the end of subclause (VI);
(B) by adding ‘‘or’’ at the end of subclause
(VII); and
(C) by inserting after subclause (VII) the
following:
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1
‘‘(VIII) beginning January 1,
2
2014, who are under 65 years of age,
3
not pregnant, not entitled to, or en-
4
rolled for, benefits under part A of
5
title XVIII, or enrolled for benefits
6
under part B of title XVIII, and are
7
not described in a previous subclause
8
of this clause, and whose income (as
9
determined under subsection (e)(14))
10
does not exceed 133 percent of the
11
poverty line (as defined in section
12
2110(c)(5)) applicable to a family of
13
the size involved, subject to subsection
14
(k);’’.
15
(2) PROVISION
16
17
OF AT LEAST MINIMUM ESSEN-
TIAL COVERAGE.—
(A) IN
GENERAL.—Section
1902 of such
18
Act (42 U.S.C. 1396a) is amended by inserting
19
after subsection (j) the following:
20
‘‘(k)(1) The medical assistance provided to an indi-
21 vidual described in subclause (VIII) of subsection
22 (a)(10)(A)(i) shall consist of benchmark coverage de23 scribed in section 1937(b)(1) or benchmark equivalent
24 coverage described in section 1937(b)(2). Such medical as25 sistance shall be provided subject to the requirements of
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398
1 section 1937, without regard to whether a State otherwise
2 has elected the option to provide medical assistance
3 through coverage under that section, unless an individual
4 described in subclause (VIII) of subsection (a)(10)(A)(i)
5 is also an individual for whom, under subparagraph (B)
6 of section 1937(a)(2), the State may not require enroll7 ment in benchmark coverage described in subsection
8 (b)(1) of section 1937 or benchmark equivalent coverage
9 described in subsection (b)(2) of that section.’’.
10
(B) CONFORMING
AMENDMENT.—Section
11
1903(i) of the Social Security Act, as amended
12
by section 6402(c), is amended—
13
14
(i) in paragraph (24), by striking ‘‘or’’
at the end;
15
16
(ii) in paragraph (25), by striking the
period and inserting ‘‘; or’’; and
17
18
(iii) by adding at the end the following:
19
‘‘(26) with respect to any amounts expended for
20
medical assistance for individuals described in sub-
21
clause (VIII) of subsection (a)(10)(A)(i) other than
22
medical assistance provided through benchmark cov-
23
erage described in section 1937(b)(1) or benchmark
24
equivalent
25
1937(b)(2).’’.
coverage
described
in
section
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399
1
(3) FEDERAL
FUNDING FOR COST OF COVERING
2
NEWLY ELIGIBLE INDIVIDUALS.—Section
3
the Social Security Act (42 U.S.C. 1396d), is
4
amended—
1905 of
5
(A) in subsection (b), in the first sentence,
6
by inserting ‘‘subsection (y) and’’ before ‘‘sec-
7
tion 1933(d)’’; and
8
(B) by adding at the end the following new
9
subsection:
10
11
‘‘(y) INCREASED FMAP
FOR
FOR
MEDICAL ASSISTANCE
NEWLY ELIGIBLE MANDATORY INDIVIDUALS.—
12
‘‘(1) AMOUNT
13
‘‘(A) 100
OF INCREASE.—
PERCENT FMAP.—During
the pe-
14
riod that begins on January 1, 2014, and ends
15
on December 31, 2016, notwithstanding sub-
16
section (b), the Federal medical assistance per-
17
centage determined for a State that is one of
18
the 50 States or the District of Columbia for
19
each fiscal year occurring during that period
20
with respect to amounts expended for medical
21
assistance for newly eligible individuals de-
22
scribed
23
1902(a)(10)(A)(i) shall be equal to 100 percent.
24
in
subclause
‘‘(B) 2017
(VIII)
AND 2018.—
of
section
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400
1
‘‘(i) IN
GENERAL.—During
the period
2
that begins on January 1, 2017, and ends
3
on December 31, 2018, notwithstanding
4
subsection (b) and subject to subparagraph
5
(D), the Federal medical assistance per-
6
centage determined for a State that is one
7
of the 50 States or the District of Colum-
8
bia for each fiscal year occurring during
9
that period with respect to amounts ex-
10
pended for medical assistance for newly eli-
11
gible individuals described in subclause
12
(VIII) of section 1902(a)(10)(A)(i), shall
13
be increased by the applicable percentage
14
point increase specified in clause (ii) for
15
the quarter and the State.
16
‘‘(ii) APPLICABLE
17
PERCENTAGE POINT
INCREASE.—
18
‘‘(I) IN
GENERAL.—For
purposes
19
of clause (i), the applicable percentage
20
point increase for a quarter is the fol-
21
lowing:
‘‘For any fiscal year
quarter occurring in
the calendar year:
If the State is an expansion State, the
applicable percentage point increase
is:
If the State is not an
expansion State, the
applicable percentage point increase is:
2017
30.3
34.3
2018
31.3
33.3
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401
1
‘‘(II)
EXPANSION
STATE
DE-
2
FINED.—For
3
subclause (I), a State is an expansion
4
State if, on the date of the enactment
5
of the Patient Protection and Afford-
6
able Care Act, the State offers health
7
benefits coverage statewide to parents
8
and
9
whose income is at least 100 percent
10
of the poverty line, that is not depend-
11
ent on access to employer coverage,
12
employer contribution, or employment
13
and is not limited to premium assist-
14
ance, hospital-only benefits, a high de-
15
ductible health plan, or alternative
16
benefits under a demonstration pro-
17
gram authorized under section 1938.
18
A State that offers health benefits
19
coverage to only parents or only non-
20
pregnant childless adults described in
21
the preceding sentence shall not be
22
considered to be an expansion State.
23
‘‘(C) 2019
purposes of the table in
nonpregnant,
childless
adults
AND SUCCEEDING YEARS.—Be-
24
ginning January 1, 2019, notwithstanding sub-
25
section (b) but subject to subparagraph (D),
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402
1
the Federal medical assistance percentage de-
2
termined for a State that is one of the 50
3
States or the District of Columbia for each fis-
4
cal year quarter occurring during that period
5
with respect to amounts expended for medical
6
assistance for newly eligible individuals de-
7
scribed
8
1902(a)(10)(A)(i), shall be increased by 32.3
9
percentage points.
in
subclause
(VIII)
of
section
10
‘‘(D) LIMITATION.—The Federal medical
11
assistance percentage determined for a State
12
under subparagraph (B) or (C) shall in no case
13
be more than 95 percent.
14
‘‘(2) DEFINITIONS.—In this subsection:
15
‘‘(A) NEWLY
ELIGIBLE.—The
term ‘newly
16
eligible’ means, with respect to an individual de-
17
scribed
18
1902(a)(10)(A)(i), an individual who is not
19
under 19 years of age (or such higher age as
20
the State may have elected) and who, on the
21
date of enactment of the Patient Protection and
22
Affordable Care Act, is not eligible under the
23
State plan or under a waiver of the plan for full
24
benefits or for benchmark coverage described in
25
subparagraph (A), (B), or (C) of section
in
subclause
(VIII)
of
section
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403
1
1937(b)(1) or benchmark equivalent coverage
2
described in section 1937(b)(2) that has an ag-
3
gregate actuarial value that is at least actuari-
4
ally equivalent to benchmark coverage described
5
in subparagraph (A), (B), or (C) of section
6
1937(b)(1), or is eligible but not enrolled (or is
7
on a waiting list) for such benefits or coverage
8
through a waiver under the plan that has a
9
capped or limited enrollment that is full.
10
‘‘(B) FULL
BENEFITS.—The
term ‘full
11
benefits’ means, with respect to an individual,
12
medical assistance for all services covered under
13
the State plan under this title that is not less
14
in amount, duration, or scope, or is determined
15
by the Secretary to be substantially equivalent,
16
to the medical assistance available for an indi-
17
vidual described in section 1902(a)(10)(A)(i).’’.
18
(4) STATE
OPTIONS TO OFFER COVERAGE EAR-
19
LIER AND PRESUMPTIVE ELIGIBILITY; CHILDREN
20
REQUIRED TO HAVE COVERAGE FOR PARENTS TO BE
21
ELIGIBLE.—
22
(A) IN
GENERAL.—Subsection
(k) of sec-
23
tion 1902 of the Social Security Act (as added
24
by paragraph (2)), is amended by inserting
25
after paragraph (1) the following:
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404
1
‘‘(2) Beginning with the first day of any fiscal year
2 quarter that begins on or after January 1, 2011, and be3 fore January 1, 2014, a State may elect through a State
4 plan amendment to provide medical assistance to individ5 uals who would be described in subclause (VIII) of sub6 section (a)(10)(A)(i) if that subclause were effective before
7 January 1, 2014. A State may elect to phase-in the exten8 sion of eligibility for medical assistance to such individuals
9 based on income, so long as the State does not extend
10 such eligibility to individuals described in such subclause
11 with higher income before making individuals described in
12 such subclause with lower income eligible for medical as13 sistance.
14
‘‘(3) If an individual described in subclause (VIII) of
15 subsection (a)(10)(A)(i) is the parent of a child who is
16 under 19 years of age (or such higher age as the State
17 may have elected) who is eligible for medical assistance
18 under the State plan or under a waiver of such plan
19 (under that subclause or under a State plan amendment
20 under paragraph (2), the individual may not be enrolled
21 under the State plan unless the individual’s child is en22 rolled under the State plan or under a waiver of the plan
23 or is enrolled in other health insurance coverage. For pur24 poses of the preceding sentence, the term ‘parent’ includes
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405
1 an individual treated as a caretaker relative for purposes
2 of carrying out section 1931.’’.
3
(B) PRESUMPTIVE
ELIGIBILITY.—Section
4
1920 of the Social Security Act (42 U.S.C.
5
1396r–1) is amended by adding at the end the
6
following:
7
‘‘(e) If the State has elected the option to provide
8 a presumptive eligibility period under this section or sec9 tion 1920A, the State may elect to provide a presumptive
10 eligibility period (as defined in subsection (b)(1)) for indi11 viduals who are eligible for medical assistance under
12 clause (i)(VIII) of subsection (a)(10)(A) or section 1931
13 in the same manner as the State provides for such a pe14 riod under this section or section 1920A, subject to such
15 guidance as the Secretary shall establish.’’.
16
(5) CONFORMING
AMENDMENTS.—
17
(A) Section 1902(a)(10) of such Act (42
18
U.S.C. 1396a(a)(10)) is amended in the matter
19
following subparagraph (G), by striking ‘‘and
20
(XIV)’’ and inserting ‘‘(XIV)’’ and by inserting
21
‘‘and (XV) the medical assistance made avail-
22
able to an individual described in subparagraph
23
(A)(i)(VIII) shall be limited to medical assist-
24
ance described in subsection (k)(1)’’ before the
25
semicolon.
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406
1
(B) Section 1902(l)(2)(C) of such Act (42
2
U.S.C. 1396a(l)(2)(C)) is amended by striking
3
‘‘100’’ and inserting ‘‘133’’.
4
(C) Section 1905(a) of such Act (42
5
U.S.C. 1396d(a)) is amended in the matter pre-
6
ceding paragraph (1)—
7
8
(i) by striking ‘‘or’’ at the end of
clause (xii);
9
10
(ii) by inserting ‘‘or’’ at the end of
clause (xiii); and
11
12
13
14
(iii) by inserting after clause (xiii) the
following:
‘‘(xiv)
individuals
described
in
section
1902(a)(10)(A)(i)(VIII),’’.
15
(D) Section 1903(f)(4) of such Act (42
16
U.S.C. 1396b(f)(4)) is amended by inserting
17
‘‘1902(a)(10)(A)(i)(VIII),’’
18
‘‘1902(a)(10)(A)(i)(VII),’’.
after
19
(E) Section 1937(a)(1)(B) of such Act (42
20
U.S.C. 1396u–7(a)(1)(B)) is amended by in-
21
serting
22
1902(a)(10)(A)(i) or under’’ after ‘‘eligible
23
under’’.
‘‘subclause
(VIII)
of
section
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407
1
2
(b) MAINTENANCE
BILITY.—Section
OF
MEDICAID INCOME ELIGI-
1902 of the Social Security Act (42
3 U.S.C. 1396a) is amended—
4
(1) in subsection (a)—
5
6
(A) by striking ‘‘and’’ at the end of paragraph (72);
7
8
(B) by striking the period at the end of
paragraph (73) and inserting ‘‘; and’’; and
9
(C) by inserting after paragraph (73) the
10
following new paragraph:
11
‘‘(74) provide for maintenance of effort under
12
the State plan or under any waiver of the plan in
13
accordance with subsection (gg).’’; and
14
(2) by adding at the end the following new sub-
15
section:
16
‘‘(gg) MAINTENANCE OF EFFORT.—
17
‘‘(1) GENERAL
REQUIREMENT
TO
MAINTAIN
18
ELIGIBILITY STANDARDS UNTIL STATE EXCHANGE IS
19
FULLY OPERATIONAL.—Subject
20
paragraphs of this subsection, during the period that
21
begins on the date of enactment of the Patient Pro-
22
tection and Affordable Care Act and ends on the
23
date on which the Secretary determines that an Ex-
24
change established by the State under section 1311
25
of the Patient Protection and Affordable Care Act is
to the succeeding
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408
1
fully operational, as a condition for receiving any
2
Federal payments under section 1903(a) for cal-
3
endar quarters occurring during such period, a State
4
shall not have in effect eligibility standards, meth-
5
odologies, or procedures under the State plan under
6
this title or under any waiver of such plan that is
7
in effect during that period, that are more restrictive
8
than the eligibility standards, methodologies, or pro-
9
cedures, respectively, under the plan or waiver that
10
are in effect on the date of enactment of the Patient
11
Protection and Affordable Care Act.
12
‘‘(2) CONTINUATION
OF ELIGIBILITY STAND-
13
ARDS FOR CHILDREN UNTIL OCTOBER 1, 2019.—The
14
requirement under paragraph (1) shall continue to
15
apply to a State through September 30, 2019, with
16
respect to the eligibility standards, methodologies,
17
and procedures under the State plan under this title
18
or under any waiver of such plan that are applicable
19
to determining the eligibility for medical assistance
20
of any child who is under 19 years of age (or such
21
higher age as the State may have elected).
22
‘‘(3) NONAPPLICATION.—During the period
23
that begins on January 1, 2011, and ends on De-
24
cember 31, 2013, the requirement under paragraph
25
(1) shall not apply to a State with respect to non-
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409
1
pregnant, nondisabled adults who are eligible for
2
medical assistance under the State plan or under a
3
waiver of the plan at the option of the State and
4
whose income exceeds 133 percent of the poverty
5
line (as defined in section 2110(c)(5)) applicable to
6
a family of the size involved if, on or after December
7
31, 2010, the State certifies to the Secretary that,
8
with respect to the State fiscal year during which
9
the certification is made, the State has a budget def-
10
icit, or with respect to the succeeding State fiscal
11
year, the State is projected to have a budget deficit.
12
Upon submission of such a certification to the Sec-
13
retary, the requirement under paragraph (1) shall
14
not apply to the State with respect to any remaining
15
portion of the period described in the preceding sen-
16
tence.
17
‘‘(4) DETERMINATION
OF COMPLIANCE.—
18
‘‘(A) STATES
19
GROSS INCOME.—A
20
come in accordance with subsection (e)(14)
21
shall not be considered to be eligibility stand-
22
ards, methodologies, or procedures that are
23
more restrictive than the standards, methodolo-
24
gies, or procedures in effect under the State
25
plan or under a waiver of the plan on the date
SHALL
APPLY
MODIFIED
State’s determination of in-
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410
1
of enactment of the Patient Protection and Af-
2
fordable Care Act for purposes of determining
3
compliance with the requirements of paragraph
4
(1), (2), or (3).
5
‘‘(B) STATES
MAY EXPAND ELIGIBILITY OR
6
MOVE WAIVERED POPULATIONS INTO COVERAGE
7
UNDER THE STATE PLAN.—With
8
period applicable under paragraph (1), (2), or
9
(3), a State that applies eligibility standards,
10
methodologies, or procedures under the State
11
plan under this title or under any waiver of the
12
plan that are less restrictive than the eligibility
13
standards, methodologies, or procedures, ap-
14
plied under the State plan or under a waiver of
15
the plan on the date of enactment of the Pa-
16
tient Protection and Affordable Care Act, or
17
that makes individuals who, on such date of en-
18
actment, are eligible for medical assistance
19
under a waiver of the State plan, after such
20
date of enactment eligible for medical assistance
21
through a State plan amendment with an in-
22
come eligibility level that is not less than the in-
23
come eligibility level that applied under the
24
waiver, or as a result of the application of sub-
25
clause (VIII) of section 1902(a)(10)(A)(i), shall
respect to any
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411
1
not be considered to have in effect eligibility
2
standards, methodologies, or procedures that
3
are more restrictive than the standards, meth-
4
odologies, or procedures in effect under the
5
State plan or under a waiver of the plan on the
6
date of enactment of the Patient Protection and
7
Affordable Care Act for purposes of deter-
8
mining compliance with the requirements of
9
paragraph (1), (2), or (3).’’.
10
11
(c) MEDICAID BENCHMARK BENEFITS MUST CONSIST OF AT
LEAST MINIMUM ESSENTIAL COVERAGE.—
12 Section 1937(b) of such Act (42 U.S.C. 1396u–7(b)) is
13 amended—
14
(1) in paragraph (1), in the matter preceding
15
subparagraph (A), by inserting ‘‘subject to para-
16
graphs (5) and (6),’’ before ‘‘each’’;
17
(2) in paragraph (2)—
18
(A) in the matter preceding subparagraph
19
(A), by inserting ‘‘subject to paragraphs (5)
20
and (6)’’ after ‘‘subsection (a)(1),’’;
21
(B) in subparagraph (A)—
22
(i) by redesignating clauses (iv) and
23
(v) as clauses (vi) and (vii), respectively;
24
and
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S.L.C.
412
1
2
(ii) by inserting after clause (iii), the
following:
3
‘‘(iv) Coverage of prescription drugs.
4
‘‘(v) Mental health services.’’; and
5
(C) in subparagraph (C)—
6
(i) by striking clauses (i) and (ii); and
7
(ii) by redesignating clauses (iii) and
8
(iv) as clauses (i) and (ii), respectively; and
9
(3) by adding at the end the following new
10
11
paragraphs:
‘‘(5) MINIMUM
STANDARDS.—Effective
January
12
1, 2014, any benchmark benefit package under para-
13
graph (1) or benchmark equivalent coverage under
14
paragraph (2) must provide at least essential health
15
benefits as described in section 1302(b) of the Pa-
16
tient Protection and Affordable Care Act.
17
‘‘(6) MENTAL
18
‘‘(A) IN
HEALTH SERVICES PARITY.—
GENERAL.—In
the case of any
19
benchmark benefit package under paragraph
20
(1) or benchmark equivalent coverage under
21
paragraph (2) that is offered by an entity that
22
is not a medicaid managed care organization
23
and that provides both medical and surgical
24
benefits and mental health or substance use dis-
25
order benefits, the entity shall ensure that the
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413
1
financial requirements and treatment limita-
2
tions applicable to such mental health or sub-
3
stance use disorder benefits comply with the re-
4
quirements of section 2705(a) of the Public
5
Health Service Act in the same manner as such
6
requirements apply to a group health plan.
7
‘‘(B)
DEEMED
COMPLIANCE.—Coverage
8
provided with respect to an individual described
9
in section 1905(a)(4)(B) and covered under the
10
State plan under section 1902(a)(10)(A) of the
11
services described in section 1905(a)(4)(B) (re-
12
lating to early and periodic screening, diag-
13
nostic, and treatment services defined in section
14
1905(r)) and provided in accordance with sec-
15
tion 1902(a)(43), shall be deemed to satisfy the
16
requirements of subparagraph (A).’’.
17
18
19
(d) ANNUAL REPORTS
ON
MEDICAID ENROLL-
MENT.—
(1) STATE
REPORTS.—Section
1902(a) of the
20
Social Security Act (42 U.S.C. 1396a(a)), as amend-
21
ed by subsection (b), is amended—
22
23
24
25
(A) by striking ‘‘and’’ at the end of paragraph (73);
(B) by striking the period at the end of
paragraph (74) and inserting ‘‘; and’’; and
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414
1
(C) by inserting after paragraph (74) the
2
following new paragraph:
3
‘‘(75) provide that, beginning January 2015,
4
and annually thereafter, the State shall submit a re-
5
port to the Secretary that contains—
6
‘‘(A) the total number of enrolled and
7
newly enrolled individuals in the State plan or
8
under a waiver of the plan for the fiscal year
9
ending on September 30 of the preceding cal-
10
endar year, disaggregated by population, includ-
11
ing children, parents, nonpregnant childless
12
adults, disabled individuals, elderly individuals,
13
and such other categories or sub-categories of
14
individuals eligible for medical assistance under
15
the State plan or under a waiver of the plan as
16
the Secretary may require;
17
‘‘(B) a description, which may be specified
18
by population, of the outreach and enrollment
19
processes used by the State during such fiscal
20
year; and
21
‘‘(C) any other data reporting determined
22
necessary by the Secretary to monitor enroll-
23
ment and retention of individuals eligible for
24
medical assistance under the State plan or
25
under a waiver of the plan.’’.
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415
1
(2) REPORTS
TO CONGRESS.—Beginning
April
2
2015, and annually thereafter, the Secretary of
3
Health and Human Services shall submit a report to
4
the appropriate committees of Congress on the total
5
enrollment and new enrollment in Medicaid for the
6
fiscal year ending on September 30 of the preceding
7
calendar year on a national and State-by-State
8
basis, and shall include in each such report such rec-
9
ommendations
for
administrative
or
legislative
10
changes to improve enrollment in the Medicaid pro-
11
gram as the Secretary determines appropriate.
12
(e) STATE OPTION FOR COVERAGE FOR INDIVIDUALS
13 WITH INCOME THAT EXCEEDS 133 PERCENT
OF THE
14 POVERTY LINE.—
15
(1) COVERAGE
16
NEEDY GROUP.—Section
17
Act (42 U.S.C. 1396a) is amended—
18
19
20
21
22
23
24
AS OPTIONAL CATEGORICALLY
1902 of the Social Security
(A) in subsection (a)(10)(A)(ii)—
(i) in subclause (XVIII), by striking
‘‘or’’ at the end;
(ii) in subclause (XIX), by adding
‘‘or’’ at the end; and
(iii) by adding at the end the following new subclause:
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416
1
‘‘(XX)
beginning
January
1,
2
2014, who are under 65 years of age
3
and are not described in or enrolled
4
under a previous subclause of this
5
clause, and whose income (as deter-
6
mined under subsection (e)(14)) ex-
7
ceeds 133 percent of the poverty line
8
(as defined in section 2110(c)(5)) ap-
9
plicable to a family of the size in-
10
volved but does not exceed the highest
11
income
12
under the State plan or under a waiv-
13
er of the plan, subject to subsection
14
(hh);’’ and
15
level
established
(B) by adding at the end the following new
16
17
eligibility
subsection:
‘‘(hh)(1) A State may elect to phase-in the extension
18 of eligibility for medical assistance to individuals described
19 in subclause (XX) of subsection (a)(10)(A)(ii) based on
20 the categorical group (including nonpregnant childless
21 adults) or income, so long as the State does not extend
22 such eligibility to individuals described in such subclause
23 with higher income before making individuals described in
24 such subclause with lower income eligible for medical as25 sistance.
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417
1
‘‘(2) If an individual described in subclause (XX) of
2 subsection (a)(10)(A)(ii) is the parent of a child who is
3 under 19 years of age (or such higher age as the State
4 may have elected) who is eligible for medical assistance
5 under the State plan or under a waiver of such plan, the
6 individual may not be enrolled under the State plan unless
7 the individual’s child is enrolled under the State plan or
8 under a waiver of the plan or is enrolled in other health
9 insurance coverage. For purposes of the preceding sen10 tence, the term ‘parent’ includes an individual treated as
11 a caretaker relative for purposes of carrying out section
12 1931.’’.
13
(2) CONFORMING
AMENDMENTS.—
14
(A) Section 1905(a) of such Act (42
15
U.S.C. 1396d(a)), as amended by subsection
16
(a)(5)(C), is amended in the matter preceding
17
paragraph (1)—
18
19
(i) by striking ‘‘or’’ at the end of
clause (xiii);
20
21
(ii) by inserting ‘‘or’’ at the end of
clause (xiv); and
22
23
24
25
(iii) by inserting after clause (xiv) the
following:
‘‘(xv)
individuals
1902(a)(10)(A)(ii)(XX),’’.
described
in
section
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418
1
(B) Section 1903(f)(4) of such Act (42
2
U.S.C. 1396b(f)(4)) is amended by inserting
3
‘‘1902(a)(10)(A)(ii)(XX),’’
4
‘‘1902(a)(10)(A)(ii)(XIX),’’.
after
5
(C) Section 1920(e) of such Act (42
6
U.S.C. 1396r–1(e)), as added by subsection
7
(a)(4)(B), is amended by inserting ‘‘or clause
8
(ii)(XX)’’ after ‘‘clause (i)(VIII)’’.
9
10
11
SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETERMINED USING MODIFIED GROSS INCOME.
(a) IN GENERAL.—Section 1902(e) of the Social Se-
12 curity Act (42 U.S.C. 1396a(e)) is amended by adding at
13 the end the following:
14
‘‘(14) INCOME
15
GROSS INCOME.—
16
‘‘(A) IN
DETERMINED USING MODIFIED
GENERAL.—Notwithstanding
sub-
17
section (r) or any other provision of this title,
18
except as provided in subparagraph (D), for
19
purposes of determining income eligibility for
20
medical assistance under the State plan or
21
under any waiver of such plan and for any
22
other purpose applicable under the plan or
23
waiver for which a determination of income is
24
required, including with respect to the imposi-
25
tion of premiums and cost-sharing, a State
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419
1
shall use the modified gross income of an indi-
2
vidual and, in the case of an individual in a
3
family greater than 1, the household income of
4
such family. A State shall establish income eli-
5
gibility thresholds for populations to be eligible
6
for medical assistance under the State plan or
7
a waiver of the plan using modified gross in-
8
come and household income that are not less
9
than the effective income eligibility levels that
10
applied under the State plan or waiver on the
11
date of enactment of the Patient Protection and
12
Affordable Care Act. For purposes of complying
13
with the maintenance of effort requirements
14
under subsection (gg) during the transition to
15
modified gross income and household income, a
16
State shall, working with the Secretary, estab-
17
lish an equivalent income test that ensures indi-
18
viduals eligible for medical assistance under the
19
State plan or under a waiver of the plan on the
20
date of enactment of the Patient Protection and
21
Affordable Care Act, do not lose coverage under
22
the State plan or under a waiver of the plan.
23
The Secretary may waive such provisions of this
24
title and title XXI as are necessary to ensure
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420
1
that States establish income and eligibility de-
2
termination systems that protect beneficiaries.
3
‘‘(B) NO
4
REGARDS.—No
5
income disregard shall be applied by a State to
6
determine income eligibility for medical assist-
7
ance under the State plan or under any waiver
8
of such plan or for any other purpose applicable
9
under the plan or waiver for which a determina-
10
11
INCOME
OR
EXPENSE
DIS-
type of expense, block, or other
tion of income is required.
‘‘(C) NO
ASSETS TEST.—A
State shall not
12
apply any assets or resources test for purposes
13
of determining eligibility for medical assistance
14
under the State plan or under a waiver of the
15
plan.
16
17
‘‘(D) EXCEPTIONS.—
‘‘(i) INDIVIDUALS
ELIGIBLE BECAUSE
18
OF OTHER AID OR ASSISTANCE, ELDERLY
19
INDIVIDUALS, MEDICALLY NEEDY INDIVID-
20
UALS,
21
MEDICARE
22
graphs (A), (B), and (C) shall not apply to
23
the determination of eligibility under the
24
State plan or under a waiver for medical
25
assistance for the following:
AND
INDIVIDUALS
ELIGIBLE
FOR
COST-SHARING.—Subpara-
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421
1
‘‘(I) Individuals who are eligible
2
for medical assistance under the State
3
plan or under a waiver of the plan on
4
a basis that does not require a deter-
5
mination of income by the State agen-
6
cy administering the State plan or
7
waiver, including as a result of eligi-
8
bility for, or receipt of, other Federal
9
or State aid or assistance, individuals
10
who are eligible on the basis of receiv-
11
ing (or being treated as if receiving)
12
supplemental security income benefits
13
under title XVI, and individuals who
14
are eligible as a result of being or
15
being deemed to be a child in foster
16
care under the responsibility of the
17
State.
18
19
‘‘(II) Individuals who have attained age 65.
20
‘‘(III) Individuals who qualify for
21
medical assistance under the State
22
plan or under any waiver of such plan
23
on the basis of being blind or disabled
24
(or being treated as being blind or
25
disabled) without regard to whether
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422
1
the individual is eligible for supple-
2
mental security income benefits under
3
title XVI on the basis of being blind
4
or disabled and including an indi-
5
vidual who is eligible for medical as-
6
sistance on the basis of section
7
1902(e)(3).
8
9
10
‘‘(IV) Individuals described in
subsection (a)(10)(C).
‘‘(V) Individuals described in any
11
clause of subsection (a)(10)(E).
12
‘‘(ii) EXPRESS
LANE AGENCY FIND-
13
INGS.—In
14
the Express Lane option under paragraph
15
(13), notwithstanding subparagraphs (A),
16
(B), and (C), the State may rely on a find-
17
ing made by an Express Lane agency in
18
accordance with that paragraph relating to
19
the income of an individual for purposes of
20
determining the individual’s eligibility for
21
medical assistance under the State plan or
22
under a waiver of the plan.
23
‘‘(iii) MEDICARE
the case of a State that elects
PRESCRIPTION DRUG
24
SUBSIDIES
25
graphs (A), (B), and (C) shall not apply to
DETERMINATIONS.—Subpara-
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1
any determinations of eligibility for pre-
2
mium and cost-sharing subsidies under
3
and in accordance with section 1860D–14
4
made by the State pursuant to section
5
1935(a)(2).
6
‘‘(iv) LONG-TERM
CARE.—Subpara-
7
graphs (A), (B), and (C) shall not apply to
8
any determinations of eligibility of individ-
9
uals for purposes of medical assistance for
10
nursing facility services, a level of care in
11
any institution equivalent to that of nurs-
12
ing facility services, home or community-
13
based services furnished under a waiver or
14
State plan amendment under section 1915
15
or a waiver under section 1115, and serv-
16
ices described in section 1917(c)(1)(C)(ii).
17
‘‘(v) GRANDFATHER
OF CURRENT EN-
18
ROLLEES UNTIL DATE OF NEXT REGULAR
19
REDETERMINATION.—An
20
on January 1, 2014, is enrolled in the
21
State plan or under a waiver of the plan
22
and who would be determined ineligible for
23
medical assistance solely because of the ap-
24
plication of the modified gross income or
25
household income standard described in
individual who,
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1
subparagraph (A), shall remain eligible for
2
medical assistance under the State plan or
3
waiver (and subject to the same premiums
4
and cost-sharing as applied to the indi-
5
vidual on that date) through March 31,
6
2014, or the date on which the individual’s
7
next regularly scheduled redetermination of
8
eligibility is to occur, whichever is later.
9
‘‘(E) TRANSITION
PLANNING AND OVER-
10
SIGHT.—Each
11
retary for the Secretary’s approval the income
12
eligibility thresholds proposed to be established
13
using modified gross income and household in-
14
come, the methodologies and procedures to be
15
used to determine income eligibility using modi-
16
fied gross income and household income and, if
17
applicable, a State plan amendment establishing
18
an optional eligibility category under subsection
19
(a)(10)(A)(ii)(XX). To the extent practicable,
20
the State shall use the same methodologies and
21
procedures for purposes of making such deter-
22
minations as the State used on the date of en-
23
actment of the Patient Protection and Afford-
24
able Care Act. The Secretary shall ensure that
25
the income eligibility thresholds proposed to be
State shall submit to the Sec-
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1
established using modified gross income and
2
household income, including under the eligibility
3
category
4
(a)(10)(A)(ii)(XX), and the methodologies and
5
procedures proposed to be used to determine in-
6
come eligibility, will not result in children who
7
would have been eligible for medical assistance
8
under the State plan or under a waiver of the
9
plan on the date of enactment of the Patient
10
Protection and Affordable Care Act no longer
11
being eligible for such assistance.
12
established
‘‘(F) LIMITATION
under
subsection
ON SECRETARIAL AU-
13
THORITY.—The
14
pliance with the requirements of this paragraph
15
except to the extent necessary to permit a State
16
to coordinate eligibility requirements for dual
17
eligible individuals (as defined in section
18
1915(h)(2)(B)) under the State plan or under
19
a waiver of the plan and under title XVIII and
20
individuals who require the level of care pro-
21
vided in a hospital, a nursing facility, or an in-
22
termediate care facility for the mentally re-
23
tarded.
24
25
Secretary shall not waive com-
‘‘(G) DEFINITIONS
INCOME
AND
OF MODIFIED GROSS
HOUSEHOLD
INCOME.—In
this
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1
paragraph, the terms ‘modified gross income’
2
and ‘household income’ have the meanings
3
given such terms in section 36B(d)(2) of the
4
Internal Revenue Code of 1986.
5
‘‘(H) CONTINUED
APPLICATION OF MED-
6
ICAID RULES REGARDING POINT-IN-TIME IN-
7
COME AND SOURCES OF INCOME.—The
8
ment under this paragraph for States to use
9
modified gross income and household income to
10
determine income eligibility for medical assist-
11
ance under the State plan or under any waiver
12
of such plan and for any other purpose applica-
13
ble under the plan or waiver for which a deter-
14
mination of income is required shall not be con-
15
strued as affecting or limiting the application
16
of—
require-
17
‘‘(i) the requirement under this title
18
and under the State plan or a waiver of
19
the plan to determine an individual’s in-
20
come as of the point in time at which an
21
application for medical assistance under
22
the State plan or a waiver of the plan is
23
processed; or
24
‘‘(ii) any rules established under this
25
title or under the State plan or a waiver of
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1
the plan regarding sources of countable in-
2
come.’’.
3
(b)
CONFORMING
AMENDMENT.—Section
4 1902(a)(17) of such Act (42 U.S.C. 1396a(a)(17)) is
5 amended by inserting ‘‘(e)(14),’’ before ‘‘(l)(3)’’.
6
(c) EFFECTIVE DATE.—The amendments made by
7 subsections (a) and (b) take effect on January 1, 2014.
8
SEC. 2003. REQUIREMENT TO OFFER PREMIUM ASSIST-
9
ANCE FOR EMPLOYER-SPONSORED INSUR-
10
11
ANCE.
(a) IN GENERAL.—Section 1906A of such Act (42
12 U.S.C. 1396e–1) is amended—
13
14
15
(1) in subsection (a)—
(A) by striking ‘‘may elect to’’ and inserting ‘‘shall’’;
16
(B) by striking ‘‘under age 19’’; and
17
(C) by inserting ‘‘, in the case of an indi-
18
vidual under age 19,’’ after ‘‘(and’’;
19
(2) in subsection (c), in the first sentence, by
20
21
22
23
24
striking ‘‘under age 19’’; and
(3) in subsection (d)—
(A) in paragraph (2)—
(i) in the first sentence, by striking
‘‘under age 19’’; and
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1
(ii) by striking the third sentence and
2
inserting ‘‘A State may not require, as a
3
condition of an individual (or the individ-
4
ual’s parent) being or remaining eligible
5
for medical assistance under this title, that
6
the individual (or the individual’s parent)
7
apply for enrollment in qualified employer-
8
sponsored coverage under this section.’’;
9
and
10
(B) in paragraph (3), by striking ‘‘the par-
11
ent of an individual under age 19’’ and insert-
12
ing ‘‘an individual (or the parent of an indi-
13
vidual)’’; and
14
(4) in subsection (e), by striking ‘‘under age
15
19’’ each place it appears.
16
(b) CONFORMING AMENDMENT.—The heading for
17 section 1906A of such Act (42 U.S.C. 1396e–1) is amend18 ed by striking ‘‘OPTION FOR CHILDREN’’.
19
(c) EFFECTIVE DATE.—The amendments made by
20 this section take effect on January 1, 2014.
21
22
23
SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER
CARE CHILDREN.
(a) IN GENERAL.—Section 1902(a)(10)(A)(i) of the
24 Social Security Act (42 U.S.C. 1396a), as amended by
25 section 2001(a)(1), is amended—
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1
2
3
4
5
6
(1) by striking ‘‘or’’ at the end of subclause
(VII);
(2) by adding ‘‘or’’ at the end of subclause
(VIII); and
(3) by inserting after subclause (VIII) the following:
7
‘‘(IX) who were in foster care
8
under the responsibility of a State for
9
more than 6 months (whether or not
10
consecutive) but are no longer in such
11
care, who are not described in any of
12
subclauses (I) through (VII) of this
13
clause, and who are under 25 years of
14
age;’’.
15
16
(b) OPTION
BILITY.—Section
TO
PROVIDE PRESUMPTIVE ELIGI-
1920(e) of such Act (42 U.S.C. 1396r–
17 1(e)), as added by section 2001(a)(4)(B) and amended by
18 section 2001(e)(2)(C), is amended by inserting ‘‘, clause
19 (i)(IX),’’ after ‘‘clause (i)(VIII)’’.
20
(c) CONFORMING AMENDMENTS.—
21
(1) Section 1903(f)(4) of such Act (42 U.S.C.
22
1396b(f)(4)), as amended by section 2001(a)(5)(D),
23
is amended by inserting ‘‘1902(a)(10)(A)(i)(IX),’’
24
after ‘‘1902(a)(10)(A)(i)(VIII),’’.
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1
(2) Section 1937(a)(2)(B)(viii) of such Act (42
2
U.S.C. 1396u–7(a)(2)(B)(viii)) is amended by in-
3
serting ‘‘, or the individual qualifies for medical as-
4
sistance
5
1902(a)(10)(A)(i)(IX)’’ before the period.
6
(d) EFFECTIVE DATE.—The amendments made by
on
the
basis
of
section
7 this section take effect on January 1, 2019.
8
9
SEC. 2005. PAYMENTS TO TERRITORIES.
(a) INCREASE
IN
LIMIT
ON
PAYMENTS.—Section
10 1108(g) of the Social Security Act (42 U.S.C. 1308(g))
11 is amended—
12
(1) in paragraph (2), in the matter preceding
13
subparagraph (A), by striking ‘‘paragraph (3)’’ and
14
inserting ‘‘paragraphs (3) and (5)’’;
15
16
17
18
19
(2) in paragraph (4), by striking ‘‘and (3)’’ and
inserting ‘‘(3), and (4)’’; and
(3) by adding at the end the following paragraph:
‘‘(5) FISCAL
YEAR 2011 AND THEREAFTER.—
20
The amounts otherwise determined under this sub-
21
section for Puerto Rico, the Virgin Islands, Guam,
22
the Northern Mariana Islands, and American Samoa
23
for the second, third, and fourth quarters of fiscal
24
year 2011, and for each fiscal year after fiscal year
25
2011 (after the application of subsection (f) and the
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1
preceding paragraphs of this subsection), shall be in-
2
creased by 30 percent.’’.
3
(b) DISREGARD
4
PANDED
OF
PAYMENTS
FOR
MANDATORY EX-
ENROLLMENT.—Section 1108(g)(4) of such Act
5 (42 U.S.C. 1308(g)(4)) is amended—
6
7
8
9
10
11
(1) by striking ‘‘to fiscal years beginning’’ and
inserting ‘‘to—
‘‘(A) fiscal years beginning’’;
(2) by striking the period at the end and inserting ‘‘; and’’; and
(3) by adding at the end the following:
12
‘‘(B) fiscal years beginning with fiscal year
13
2014, payments made to Puerto Rico, the Vir-
14
gin Islands, Guam, the Northern Mariana Is-
15
lands, or American Samoa with respect to
16
amounts expended for medical assistance for
17
newly eligible (as defined in section 1905(y)(2))
18
nonpregnant childless adults who are eligible
19
under
20
1902(a)(10)(A)(i) and whose income (as deter-
21
mined under section 1902(e)(14)) does not ex-
22
ceed (in the case of each such commonwealth
23
and territory respectively) the income eligibility
24
level in effect for that population under title
25
XIX or under a waiver on the date of enact-
subclause
(VIII)
of
section
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1
ment of the Patient Protection and Affordable
2
Care Act, shall not be taken into account in ap-
3
plying subsection (f) (as increased in accord-
4
ance with paragraphs (1), (2), (3), and (5) of
5
this subsection) to such commonwealth or terri-
6
tory for such fiscal year.’’.
7
(c) INCREASED FMAP.—
8
(1) IN
GENERAL.—The
first sentence of section
9
1905(b) of the Social Security Act (42 U.S.C.
10
1396d(b)) is amended by striking ‘‘shall be 50 per
11
centum’’ and inserting ‘‘shall be 55 percent’’.
12
(2) EFFECTIVE
DATE.—The
amendment made
13
by paragraph (1) takes effect on January 1, 2011.
14
SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINA-
15
TION FOR CERTAIN STATES RECOVERING
16
FROM A MAJOR DISASTER.
17
Section 1905 of the Social Security Act (42 U.S.C.
18 1396d),
as
amended
by
sections
2001(a)(3)
and
19 2001(b)(2), is amended—
20
(1) in subsection (b), in the first sentence, by
21
striking ‘‘subsection (y)’’ and inserting ‘‘subsections
22
(y) and (aa)’’; and
23
24
(2) by adding at the end the following new subsection:
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1
‘‘(aa)(1) Notwithstanding subsection (b), beginning
2 January 1, 2011, the Federal medical assistance percent3 age for a fiscal year for a disaster-recovery FMAP adjust4 ment State shall be equal to the following:
5
‘‘(A) In the case of the first fiscal year (or part
6
of a fiscal year) for which this subsection applies to
7
the State, the Federal medical assistance percentage
8
determined for the fiscal year without regard to this
9
subsection and subsection (y), increased by 50 per-
10
cent of the number of percentage points by which
11
the Federal medical assistance percentage deter-
12
mined for the State for the fiscal year without re-
13
gard to this subsection and subsection (y), is less
14
than the Federal medical assistance percentage de-
15
termined for the State for the preceding fiscal year
16
after the application of only subsection (a) of section
17
5001 of Public Law 111–5 (if applicable to the pre-
18
ceding fiscal year) and without regard to this sub-
19
section, subsection (y), and subsections (b) and (c)
20
of section 5001 of Public Law 111–5.
21
‘‘(B) In the case of the second or any suc-
22
ceeding fiscal year for which this subsection applies
23
to the State, the Federal medical assistance percent-
24
age determined for the preceding fiscal year under
25
this subsection for the State, increased by 25 per-
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1
cent of the number of percentage points by which
2
the Federal medical assistance percentage deter-
3
mined for the State for the fiscal year without re-
4
gard to this subsection and subsection (y), is less
5
than the Federal medical assistance percentage de-
6
termined for the State for the preceding fiscal year
7
under this subsection.
8
‘‘(2) In this subsection, the term ‘disaster-recovery
9 FMAP adjustment State’ means a State that is one of
10 the 50 States or the District of Columbia, for which, at
11 any time during the preceding 7 fiscal years, the President
12 has declared a major disaster under section 401 of the
13 Robert T. Stafford Disaster Relief and Emergency Assist14 ance Act and determined as a result of such disaster that
15 every county or parish in the State warrant individual and
16 public assistance or public assistance from the Federal
17 Government under such Act and for which—
18
‘‘(A) in the case of the first fiscal year (or part
19
of a fiscal year) for which this subsection applies to
20
the State, the Federal medical assistance percentage
21
determined for the State for the fiscal year without
22
regard to this subsection and subsection (y), is less
23
than the Federal medical assistance percentage de-
24
termined for the State for the preceding fiscal year
25
after the application of only subsection (a) of section
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1
5001 of Public Law 111–5 (if applicable to the pre-
2
ceding fiscal year) and without regard to this sub-
3
section, subsection (y), and subsections (b) and (c)
4
of section 5001 of Public Law 111–5, by at least 3
5
percentage points; and
6
‘‘(B) in the case of the second or any suc-
7
ceeding fiscal year for which this subsection applies
8
to the State, the Federal medical assistance percent-
9
age determined for the State for the fiscal year with-
10
out regard to this subsection and subsection (y), is
11
less than the Federal medical assistance percentage
12
determined for the State for the preceding fiscal
13
year under this subsection by at least 3 percentage
14
points.
15
‘‘(3) The Federal medical assistance percentage de-
16 termined for a disaster-recovery FMAP adjustment State
17 under paragraph (1) shall apply for purposes of this title
18 (other than with respect to disproportionate share hospital
19 payments described in section 1923 and payments under
20 this title that are based on the enhanced FMAP described
21 in 2105(b)) and shall not apply with respect to payments
22 under title IV (other than under part E of title IV) or
23 payments under title XXI.’’.
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1
2
SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION.
(a) RESCISSION.—Any amounts available to the Med-
3 icaid Improvement Fund established under section 1941
4 of the Social Security Act (42 U.S.C. 1396w–1) for any
5 of fiscal years 2014 through 2018 that are available for
6 expenditure from the Fund and that are not so obligated
7 as of the date of the enactment of this Act are rescinded.
8
(b)
CONFORMING
AMENDMENTS.—Section
9 1941(b)(1) of the Social Security Act (42 U.S.C. 1396w–
10 1(b)(1)) is amended—
11
12
13
14
(1)
in
subparagraph
(A),
by
striking
‘‘$100,000,000’’ and inserting ‘‘$0’’; and
(2)
in
subparagraph
(B),
by
striking
‘‘$150,000,000’’ and inserting ‘‘$0’’.
17
Subtitle B—Enhanced Support for
the Children’s Health Insurance
Program
18
SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPA-
15
16
19
20
TION FOR CHIP.
(a) IN GENERAL.—Section 2105(b) of the Social Se-
21 curity Act (42 U.S.C. 1397ee(b)) is amended by adding
22 at the end the following: ‘‘Notwithstanding the preceding
23 sentence, during the period that begins on October 1,
24 2013, and ends on September 30, 2019, the enhanced
25 FMAP determined for a State for a fiscal year (or for
26 any portion of a fiscal year occurring during such period)
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1 shall be increased by 23 percentage points, but in no case
2 shall exceed 100 percent. The increase in the enhanced
3 FMAP under the preceding sentence shall not apply with
4 respect to determining the payment to a State under sub5 section (a)(1) for expenditures described in subparagraph
6 (D)(iv), paragraphs (8), (9), (11) of subsection (c), or
7 clause (4) of the first sentence of section 1905(b).’’.
8
9
(b) MAINTENANCE OF EFFORT.—
(1) IN
GENERAL.—Section
2105(d) of the So-
10
cial Security Act (42 U.S.C. 1397ee(d)) is amended
11
by adding at the end the following:
12
13
14
‘‘(3) CONTINUATION
OF ELIGIBILITY STAND-
ARDS FOR CHILDREN UNTIL OCTOBER 1, 2019.—
‘‘(A) IN
GENERAL.—During
the period
15
that begins on the date of enactment of the Pa-
16
tient Protection and Affordable Care Act and
17
ends on September 30, 2019, a State shall not
18
have in effect eligibility standards, methodolo-
19
gies, or procedures under its State child health
20
plan (including any waiver under such plan) for
21
children (including children provided medical
22
assistance for which payment is made under
23
section 2105(a)(1)(A)) that are more restrictive
24
than the eligibility standards, methodologies, or
25
procedures, respectively, under such plan (or
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1
waiver) as in effect on the date of enactment of
2
that Act. The preceding sentence shall not be
3
construed as preventing a State during such pe-
4
riod from—
5
‘‘(i) applying eligibility standards,
6
methodologies, or procedures for children
7
under the State child health plan or under
8
any waiver of the plan that are less restric-
9
tive than the eligibility standards, meth-
10
odologies, or procedures, respectively, for
11
children under the plan or waiver that are
12
in effect on the date of enactment of such
13
Act; or
14
‘‘(ii) imposing a limitation described
15
in section 2112(b)(7) for a fiscal year in
16
order to limit expenditures under the State
17
child health plan to those for which Fed-
18
eral financial participation is available
19
under this section for the fiscal year.
20
‘‘(B) ASSURANCE
OF
EXCHANGE
COV-
21
ERAGE FOR TARGETED LOW-INCOME CHILDREN
22
UNABLE TO BE PROVIDED CHILD HEALTH AS-
23
SISTANCE AS A RESULT OF FUNDING SHORT-
24
FALLS.—In
25
under section 2104 are insufficient to provide
the event that allotments provided
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1
coverage to all children who are eligible to be
2
targeted low-income children under the State
3
child health plan under this title, a State shall
4
establish procedures to ensure that such chil-
5
dren are provided coverage through an Ex-
6
change established by the State under section
7
1311 of the Patient Protection and Affordable
8
Care Act.’’.
9
(2) CONFORMING
AMENDMENT TO TITLE XXI
10
MEDICAID
11
2105(d)(1) of the Social Security Act (42 U.S.C.
12
1397ee(d)(1)) is amended by adding before the pe-
13
riod
14
1902(e)(14)’’.
15
(c) NO ENROLLMENT BONUS PAYMENTS
16
DREN
‘‘,
MAINTENANCE
except
as
OF
required
EFFORT.—Section
under
section
FOR
CHIL-
ENROLLED AFTER FISCAL YEAR 2013.—Section
17 2105(a)(3)(F)(iii) of the Social Security Act (42 U.S.C.
18 1397ee(a)(3)(F)(iii)) is amended by inserting ‘‘or any chil19 dren enrolled on or after October 1, 2013’’ before the pe20 riod.
21
22
23
(d) INCOME ELIGIBILITY DETERMINED USING MODIFIED
GROSS INCOME.—
(1)
STATE
PLAN
REQUIREMENT.—Section
24
2102(b)(1)(B) of the Social Security Act (42 U.S.C.
25
1397bb(b)(1)(B)) is amended—
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1
2
(A) in clause (iii), by striking ‘‘and’’ after
the semicolon;
3
4
(B) in clause (iv), by striking the period
and inserting ‘‘; and’’; and
5
(C) by adding at the end the following:
6
‘‘(v) shall, beginning January 1, 2014,
7
use modified gross income and household
8
income (as defined in section 36B(d)(2) of
9
the Internal Revenue Code of 1986) to de-
10
termine eligibility for child health assist-
11
ance under the State child health plan or
12
under any waiver of such plan and for any
13
other purpose applicable under the plan or
14
waiver for which a determination of income
15
is required, including with respect to the
16
imposition of premiums and cost-sharing,
17
consistent with section 1902(e)(14).’’.
18
(2)
CONFORMING
AMENDMENT.—Section
19
2107(e)(1) of the Social Security Act (42 U.S.C.
20
1397gg(e)(1)) is amended—
21
(A) by redesignating subparagraphs (E)
22
through (L) as subparagraphs (F) through (M),
23
respectively; and
24
25
(B) by inserting after subparagraph (D),
the following:
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1
‘‘(E) Section 1902(e)(14) (relating to in-
2
come determined using modified gross income
3
and household income).’’.
4
(e) APPLICATION
OF
STREAMLINED ENROLLMENT
5 SYSTEM.—Section 2107(e)(1) of the Social Security Act
6 (42 U.S.C. 1397gg(e)(1)), as amended by subsection
7 (d)(2), is amended by adding at the end the following:
8
‘‘(N) Section 1943(b) (relating to coordi-
9
nation with State Exchanges and the State
10
Medicaid agency).’’.
11
(f) CHIP ELIGIBILITY
12
FOR
13
REGARDS.—Notwithstanding
MEDICAID
AS A
FOR
RESULT
OF
CHILDREN INELIGIBLE
ELIMINATION
OF
DIS-
any other provision of law,
14 a State shall treat any child who is determined to be ineli15 gible for medical assistance under the State Medicaid plan
16 or under a waiver of the plan as a result of the elimination
17 of the application of an income disregard based on expense
18 or type of income, as required under section 1902(e)(14)
19 of the Social Security Act (as added by this Act), as a
20 targeted low-income child under section 2110(b) (unless
21 the child is excluded under paragraph (2) of that section)
22 and shall provide child health assistance to the child under
23 the State child health plan (whether implemented under
24 title XIX or XXI, or both, of the Social Security Act).
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1
2
SEC. 2102. TECHNICAL CORRECTIONS.
(a) CHIPRA.—Effective as if included in the enact-
3 ment of the Children’s Health Insurance Program Reau4 thorization Act of 2009 (Public Law 111–3) (in this sec5 tion referred to as ‘‘CHIPRA’’):
6
(1) Section 2104(m) of the Social Security Act,
7
as added by section 102 of CHIPRA, is amended—
8
(A) by redesignating paragraph (7) as
9
10
paragraph (8); and
(B) by inserting after paragraph (6), the
11
following:
12
‘‘(7) ADJUSTMENT
OF FISCAL YEAR 2010 AL-
13
LOTMENTS TO ACCOUNT FOR CHANGES IN PRO-
14
JECTED SPENDING FOR CERTAIN PREVIOUSLY AP-
15
PROVED EXPANSION PROGRAMS.—For
16
recalculating the fiscal year 2010 allotment, in the
17
case of one of the 50 States or the District of Co-
18
lumbia that has an approved State plan amendment
19
effective January 1, 2006, to provide child health as-
20
sistance through the provision of benefits under the
21
State plan under title XIX for children from birth
22
through age 5 whose family income does not exceed
23
200 percent of the poverty line, the Secretary shall
24
increase the allotment by an amount that would be
25
equal to the Federal share of expenditures that
26
would have been claimed at the enhanced FMAP
purposes of
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1
rate rather than the Federal medical assistance per-
2
centage matching rate for such population.’’.
3
(2) Section 605 of CHIPRA is amended by
4
striking ‘‘legal residents’’ and insert ‘‘lawfully resid-
5
ing in the United States’’.
6
(3) Subclauses (I) and (II) of paragraph
7
(3)(C)(i) of section 2105(a) of the Social Security
8
Act (42 U.S.C. 1397ee(a)(3)(ii)), as added by sec-
9
tion 104 of CHIPRA, are each amended by striking
10
‘‘, respectively’’.
11
(4) Section 2105(a)(3)(E)(ii) of the Social Se-
12
curity Act (42 U.S.C. 1397ee(a)(3)(E)(ii)), as added
13
by section 104 of CHIPRA, is amended by striking
14
subclause (IV).
15
(5) Section 2105(c)(9)(B) of the Social Security
16
Act (42 U.S.C. 1397e(c)(9)(B)), as added by section
17
211(c)(1) of CHIPRA, is amended by striking ‘‘sec-
18
tion
19
1903(a)(3)(G)’’.
1903(a)(3)(F)’’
and
inserting
‘‘section
20
(6) Section 2109(b)(2)(B) of the Social Secu-
21
rity Act (42 U.S.C. 1397ii(b)(2)(B)), as added by
22
section 602 of CHIPRA, is amended by striking
23
‘‘the child population growth factor under section
24
2104(m)(5)(B)’’ and inserting ‘‘a high-performing
25
State under section 2111(b)(3)(B)’’.
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444
1
(7) Section 2110(c)(9)(B)(v) of the Social Secu-
2
rity Act (42 U.S.C. 1397jj(c)(9)(B)(v)), as added by
3
section 505(b) of CHIPRA, is amended by striking
4
‘‘school or school system’’ and inserting ‘‘local edu-
5
cational agency (as defined under section 9101 of
6
the Elementary and Secondary Education Act of
7
1965’’.
8
9
(8) Section 211(a)(1)(B) of CHIPRA is amended—
10
(A) by striking ‘‘is amended’’ and all that
11
follows through ‘‘adding’’ and inserting ‘‘is
12
amended by adding’’; and
13
(B) by redesignating the new subpara-
14
graph to be added by such section to section
15
1903(a)(3) of the Social Security Act as a new
16
subparagraph (H).
17
(b) ARRA.—Effective as if included in the enactment
18 of section 5006(a) of division B of the American Recovery
19 and Reinvestment Act of 2009 (Public Law 111–5), the
20 second sentence of section 1916A(a)(1) of the Social Secu21 rity Act (42 U.S.C. 1396o–1(a)(1)) is amended by striking
22 ‘‘or (i)’’ and inserting ‘‘, (i), or (j)’’.
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2
Subtitle C—Medicaid and CHIP
Enrollment Simplification
3
SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINA-
4
TION WITH STATE HEALTH INSURANCE EX-
5
CHANGES.
1
6
Title XIX of the Social Security Act (42 U.S.C.
7 1397aa et seq.) is amended by adding at the end the fol8 lowing:
9
‘‘SEC. 1943. ENROLLMENT SIMPLIFICATION AND COORDI-
10
NATION WITH STATE HEALTH INSURANCE EX-
11
CHANGES.
12
13
‘‘(a) CONDITION
ICAID.—As
FOR
PARTICIPATION
IN
MED-
a condition of the State plan under this title
14 and receipt of any Federal financial assistance under sec15 tion 1903(a) for calendar quarters beginning after Janu16 ary 1, 2014, a State shall ensure that the requirements
17 of subsection (b) is met.
18
19
‘‘(b) ENROLLMENT SIMPLIFICATION
TION
AND
COORDINA-
WITH STATE HEALTH INSURANCE EXCHANGES AND
20 CHIP.—
21
22
‘‘(1) IN
GENERAL.—A
State shall establish pro-
cedures for—
23
‘‘(A) enabling individuals, through an
24
Internet website that meets the requirements of
25
paragraph (4), to apply for medical assistance
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1
under the State plan or under a waiver of the
2
plan, to be enrolled in the State plan or waiver,
3
to renew their enrollment in the plan or waiver,
4
and to consent to enrollment or reenrollment in
5
the State plan through electronic signature;
6
‘‘(B) enrolling, without any further deter-
7
mination by the State and through such
8
website, individuals who are identified by an
9
Exchange established by the State under sec-
10
tion 1311 of the Patient Protection and Afford-
11
able Care Act as being eligible for—
12
‘‘(i) medical assistance under the
13
State plan or under a waiver of the plan;
14
or
15
‘‘(ii) child health assistance under the
16
State child health plan under title XXI;
17
‘‘(C) ensuring that individuals who apply
18
for but are determined to be ineligible for med-
19
ical assistance under the State plan or a waiver
20
or ineligible for child health assistance under
21
the State child health plan under title XXI, are
22
screened for eligibility for enrollment in quali-
23
fied health plans offered through such an Ex-
24
change and, if applicable, premium assistance
25
for the purchase of a qualified health plan
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447
1
under section 36B of the Internal Revenue
2
Code of 1986 (and, if applicable, advance pay-
3
ment of such assistance under section 1412 of
4
the Patient Protection and Affordable Care
5
Act), and, if eligible, enrolled in such a plan
6
without having to submit an additional or sepa-
7
rate application, and that such individuals re-
8
ceive information regarding reduced cost-shar-
9
ing for eligible individuals under section 1402
10
of the Patient Protection and Affordable Care
11
Act, and any other assistance or subsidies avail-
12
able for coverage obtained through the Ex-
13
change;
14
‘‘(D) ensuring that the State agency re-
15
sponsible for administering the State plan
16
under this title (in this section referred to as
17
the ‘State Medicaid agency’), the State agency
18
responsible for administering the State child
19
health plan under title XXI (in this section re-
20
ferred to as the ‘State CHIP agency’) and an
21
Exchange established by the State under sec-
22
tion 1311 of the Patient Protection and Afford-
23
able Care Act utilize a secure electronic inter-
24
face sufficient to allow for a determination of
25
an individual’s eligibility for such medical as-
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448
1
sistance, child health assistance, or premium
2
assistance, and enrollment in the State plan
3
under this title, title XXI, or a qualified health
4
plan, as appropriate;
5
‘‘(E) coordinating, for individuals who are
6
enrolled in the State plan or under a waiver of
7
the plan and who are also enrolled in a quali-
8
fied health plan offered through such an Ex-
9
change, and for individuals who are enrolled in
10
the State child health plan under title XXI and
11
who are also enrolled in a qualified health plan,
12
the provision of medical assistance or child
13
health assistance to such individuals with the
14
coverage provided under the qualified health
15
plan in which they are enrolled, including serv-
16
ices described in section 1905(a)(4)(B) (relating
17
to early and periodic screening, diagnostic, and
18
treatment services defined in section 1905(r))
19
and provided in accordance with the require-
20
ments of section 1902(a)(43); and
21
‘‘(F) conducting outreach to and enrolling
22
vulnerable and underserved populations eligible
23
for medical assistance under this title XIX or
24
for child health assistance under title XXI, in-
25
cluding
children,
unaccompanied
homeless
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449
1
youth, children and youth with special health
2
care needs, pregnant women, racial and ethnic
3
minorities, rural populations, victims of abuse
4
or trauma, individuals with mental health or
5
substance-related disorders, and individuals
6
with HIV/AIDS.
7
‘‘(2) AGREEMENTS
8
SURANCE EXCHANGES.—The
9
and the State CHIP agency may enter into an
10
agreement with an Exchange established by the
11
State under section 1311 of the Patient Protection
12
and Affordable Care Act under which the State
13
Medicaid agency or State CHIP agency may deter-
14
mine whether a State resident is eligible for pre-
15
mium assistance for the purchase of a qualified
16
health plan under section 36B of the Internal Rev-
17
enue Code of 1986 (and, if applicable, advance pay-
18
ment of such assistance under section 1412 of the
19
Patient Protection and Affordable Care Act), so long
20
as the agreement meets such conditions and require-
21
ments as the Secretary of the Treasury may pre-
22
scribe to reduce administrative costs and the likeli-
23
hood of eligibility errors and disruptions in coverage.
24
25
‘‘(3) STREAMLINED
WITH STATE HEALTH IN-
State Medicaid agency
ENROLLMENT SYSTEM.—
The State Medicaid agency and State CHIP agency
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450
1
shall participate in and comply with the require-
2
ments for the system established under section 1413
3
of the Patient Protection and Affordable Care Act
4
(relating to streamlined procedures for enrollment
5
through an Exchange, Medicaid, and CHIP).
6
‘‘(4) ENROLLMENT
WEBSITE REQUIREMENTS.—
7
The procedures established by State under para-
8
graph (1) shall include establishing and having in
9
operation, not later than January 1, 2014, an Inter-
10
net website that is linked to any website of an Ex-
11
change established by the State under section 1311
12
of the Patient Protection and Affordable Care Act
13
and to the State CHIP agency (if different from the
14
State Medicaid agency) and allows an individual who
15
is eligible for medical assistance under the State
16
plan or under a waiver of the plan and who is eligi-
17
ble to receive premium credit assistance for the pur-
18
chase of a qualified health plan under section 36B
19
of the Internal Revenue Code of 1986 to compare
20
the benefits, premiums, and cost-sharing applicable
21
to the individual under the State plan or waiver with
22
the benefits, premiums, and cost-sharing available to
23
the individual under a qualified health plan offered
24
through such an Exchange, including, in the case of
25
a child, the coverage that would be provided for the
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451
1
child through the State plan or waiver with the cov-
2
erage that would be provided to the child through
3
enrollment in family coverage under that plan and
4
as supplemental coverage by the State under the
5
State plan or waiver.
6
‘‘(5) CONTINUED
NEED FOR ASSESSMENT FOR
7
HOME AND COMMUNITY-BASED SERVICES.—Nothing
8
in paragraph (1) shall limit or modify the require-
9
ment that the State assess an individual for pur-
10
poses of providing home and community-based serv-
11
ices under the State plan or under any waiver of
12
such plan for individuals described in subsection
13
(a)(10)(A)(ii)(VI).’’.
14
SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMP-
15
TIVE
16
ALL MEDICAID ELIGIBLE POPULATIONS.
17
ELIGIBILITY
DETERMINATIONS
FOR
(a) IN GENERAL.—Section 1902(a)(47) of the Social
18 Security Act (42 U.S.C. 1396a(a)(47)) is amended—
19
20
21
(1) by striking ‘‘at the option of the State, provide’’ and inserting ‘‘provide—
‘‘(A) at the option of the State,’’;
22
(2) by inserting ‘‘and’’ after the semicolon; and
23
(3) by adding at the end the following:
24
‘‘(B) that any hospital that is a partici-
25
pating provider under the State plan may elect
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452
1
to be a qualified entity for purposes of deter-
2
mining, on the basis of preliminary information,
3
whether any individual is eligible for medical as-
4
sistance under the State plan or under a waiver
5
of the plan for purposes of providing the indi-
6
vidual with medical assistance during a pre-
7
sumptive eligibility period, in the same manner,
8
and subject to the same requirements, as apply
9
to the State options with respect to populations
10
described in section 1920, 1920A, or 1920B
11
(but without regard to whether the State has
12
elected to provide for a presumptive eligibility
13
period under any such sections), subject to such
14
guidance as the Secretary shall establish;’’.
15
(b)
CONFORMING
16 1903(u)(1)(D)(v)
of
such
AMENDMENT.—Section
Act
(42
U.S.C.
17 1396b(u)(1)(D)v)) is amended—
18
19
(1) by striking ‘‘or for’’ and inserting ‘‘for’’;
and
20
(2) by inserting before the period at the end the
21
following: ‘‘, or for medical assistance provided to an
22
individual during a presumptive eligibility period re-
23
sulting from a determination of presumptive eligi-
24
bility made by a hospital that elects under section
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1
1902(a)(47)(B) to be a qualified entity for such pur-
2
pose’’.
3
(c) EFFECTIVE DATE.—The amendments made by
4 this section take effect on January 1, 2014, and apply to
5 services furnished on or after that date.
7
Subtitle D—Improvements to
Medicaid Services
8
SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER
6
9
10
SERVICES.
(a) IN GENERAL.—Section 1905 of the Social Secu-
11 rity Act (42 U.S.C. 1396d), is amended—
12
13
14
15
16
17
(1) in subsection (a)—
(A) in paragraph (27), by striking ‘‘and’’
at the end;
(B) by redesignating paragraph (28) as
paragraph (29); and
(C) by inserting after paragraph (27) the
18
following new paragraph:
19
‘‘(28) freestanding birth center services (as de-
20
fined in subsection (l)(3)(A)) and other ambulatory
21
services that are offered by a freestanding birth cen-
22
ter (as defined in subsection (l)(3)(B)) and that are
23
otherwise included in the plan; and’’; and
24
25
(2) in subsection (l), by adding at the end the
following new paragraph:
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1
‘‘(3)(A) The term ‘freestanding birth center services’
2 means services furnished to an individual at a freestanding
3 birth center (as defined in subparagraph (B)) at such cen4 ter.
5
‘‘(B) The term ‘freestanding birth center’ means a
6 health facility—
7
‘‘(i) that is not a hospital;
8
‘‘(ii) where childbirth is planned to occur away
9
from the pregnant woman’s residence;
10
‘‘(iii) that is licensed or otherwise approved by
11
the State to provide prenatal labor and delivery or
12
postpartum care and other ambulatory services that
13
are included in the plan; and
14
‘‘(iv) that complies with such other require-
15
ments relating to the health and safety of individuals
16
furnished services by the facility as the State shall
17
establish.
18
‘‘(C) A State shall provide separate payments to pro-
19 viders administering prenatal labor and delivery or
20 postpartum care in a freestanding birth center (as defined
21 in subparagraph (B)), such as nurse midwives and other
22 providers of services such as birth attendants recognized
23 under State law, as determined appropriate by the Sec24 retary. For purposes of the preceding sentence, the term
25 ‘birth attendant’ means an individual who is recognized
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455
1 or registered by the State involved to provide health care
2 at childbirth and who provides such care within the scope
3 of practice under which the individual is legally authorized
4 to perform such care under State law (or the State regu5 latory mechanism provided by State law), regardless of
6 whether the individual is under the supervision of, or asso7 ciated with, a physician or other health care provider.
8 Nothing in this subparagraph shall be construed as chang9 ing State law requirements applicable to a birth attend10 ant.’’.
11
(b)
CONFORMING
AMENDMENT.—Section
12 1902(a)(10)(A) of the Social Security Act (42 U.S.C.
13 1396a(a)(10)(A)), is amended in the matter preceding
14 clause (i) by striking ‘‘and (21)’’ and inserting ‘‘, (21),
15 and (28)’’.
16
17
(c) EFFECTIVE DATE.—
(1) IN
GENERAL.—Except
as provided in para-
18
graph (2), the amendments made by this section
19
shall take effect on the date of the enactment of this
20
Act and shall apply to services furnished on or after
21
such date.
22
(2) EXCEPTION
IF STATE LEGISLATION RE-
23
QUIRED.—In
24
sistance under title XIX of the Social Security Act
25
which the Secretary of Health and Human Services
the case of a State plan for medical as-
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1
determines requires State legislation (other than leg-
2
islation appropriating funds) in order for the plan to
3
meet the additional requirement imposed by the
4
amendments made by this section, the State plan
5
shall not be regarded as failing to comply with the
6
requirements of such title solely on the basis of its
7
failure to meet this additional requirement before
8
the first day of the first calendar quarter beginning
9
after the close of the first regular session of the
10
State legislature that begins after the date of the en-
11
actment of this Act. For purposes of the previous
12
sentence, in the case of a State that has a 2-year
13
legislative session, each year of such session shall be
14
deemed to be a separate regular session of the State
15
legislature.
16
17
SEC. 2302. CONCURRENT CARE FOR CHILDREN.
(a) IN GENERAL.—Section 1905(o)(1) of the Social
18 Security Act (42 U.S.C. 1396d(o)(1)) is amended—
19
(1) in subparagraph (A), by striking ‘‘subpara-
20
graph (B)’’ and inserting ‘‘subparagraphs (B) and
21
(C)’’; and
22
(2) by adding at the end the following new sub-
23
paragraph:
24
‘‘(C) A voluntary election to have payment made for
25 hospice care for a child (as defined by the State) shall
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457
1 not constitute a waiver of any rights of the child to be
2 provided with, or to have payment made under this title
3 for, services that are related to the treatment of the child’s
4 condition for which a diagnosis of terminal illness has been
5 made.’’.
6
(b) APPLICATION
CHIP.—Section 2110(a)(23) of
TO
7 the Social Security Act (42 U.S.C. 1397jj(a)(23)) is
8 amended by inserting ‘‘(concurrent, in the case of an indi9 vidual who is a child, with care related to the treatment
10 of the child’s condition with respect to which a diagnosis
11 of terminal illness has been made’’ after ‘‘hospice care’’.
12
SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLAN-
13
14
NING SERVICES.
(a)
COVERAGE
AS
OPTIONAL
CATEGORICALLY
15 NEEDY GROUP.—
16
(1) IN
GENERAL.—Section
17
of
18
1396a(a)(10)(A)(ii)),
19
2001(e), is amended—
20
21
22
23
24
25
the
Social
Security
as
1902(a)(10)(A)(ii)
Act
amended
(42
U.S.C.
by
section
(A) in subclause (XIX), by striking ‘‘or’’ at
the end;
(B) in subclause (XX), by adding ‘‘or’’ at
the end; and
(C) by adding at the end the following new
subclause:
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1
‘‘(XXI) who are described in sub-
2
section (ii) (relating to individuals
3
who meet certain income standards);’’.
4
(2) GROUP
DESCRIBED.—Section
1902 of such
5
Act (42 U.S.C. 1396a), as amended by section
6
2001(d), is amended by adding at the end the fol-
7
lowing new subsection:
8
‘‘(ii)(1) Individuals described in this subsection are
9 individuals—
10
‘‘(A) whose income does not exceed an in-
11
come eligibility level established by the State
12
that does not exceed the highest income eligi-
13
bility level established under the State plan
14
under this title (or under its State child health
15
plan under title XXI) for pregnant women; and
16
‘‘(B) who are not pregnant.
17
‘‘(2) At the option of a State, individuals de-
18
scribed in this subsection may include individuals
19
who, had individuals applied on or before January 1,
20
2007, would have been made eligible pursuant to the
21
standards and processes imposed by that State for
22
benefits described in clause (XV) of the matter fol-
23
lowing subparagraph (G) of section subsection
24
(a)(10) pursuant to a waiver granted under section
25
1115.
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1
‘‘(3) At the option of a State, for purposes of
2
subsection (a)(17)(B), in determining eligibility for
3
services under this subsection, the State may con-
4
sider only the income of the applicant or recipient.’’.
5
(3)
LIMITATION
ON
BENEFITS.—Section
6
1902(a)(10) of the Social Security Act (42 U.S.C.
7
1396a(a)(10)),
8
2001(a)(5)(A), is amended in the matter following
9
subparagraph (G)—
10
11
as
amended
by
section
(A) by striking ‘‘and (XV)’’ and inserting
‘‘(XV)’’; and
12
(B) by inserting ‘‘, and (XVI) the medical
13
assistance made available to an individual de-
14
scribed in subsection (ii) shall be limited to
15
family planning services and supplies described
16
in section 1905(a)(4)(C) including medical di-
17
agnosis and treatment services that are pro-
18
vided pursuant to a family planning service in
19
a family planning setting’’ before the semicolon.
20
(4) CONFORMING
AMENDMENTS.—
21
(A) Section 1905(a) of the Social Security
22
Act (42 U.S.C. 1396d(a)), as amended by sec-
23
tion 2001(e)(2)(A), is amended in the matter
24
preceding paragraph (1)—
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1
2
(i) in clause (xiv), by striking ‘‘or’’ at
the end;
3
4
(ii) in clause (xv), by adding ‘‘or’’ at
the end; and
5
6
(iii) by inserting after clause (xv) the
following:
7
‘‘(xvi) individuals described in section
8
1902(ii),’’.
9
(B) Section 1903(f)(4) of such Act (42
10
U.S.C. 1396b(f)(4)), as amended by section
11
2001(e)(2)(B),
12
‘‘1902(a)(10)(A)(ii)(XXI),’’
13
‘‘1902(a)(10)(A)(ii)(XX),’’.
14
15
is
amended
by
inserting
after
(b) PRESUMPTIVE ELIGIBILITY.—
(1) IN
GENERAL.—Title
XIX of the Social Se-
16
curity Act (42 U.S.C. 1396 et seq.) is amended by
17
inserting after section 1920B the following:
18
19
20
‘‘PRESUMPTIVE
ELIGIBILITY FOR FAMILY PLANNING
SERVICES
‘‘SEC. 1920C. (a) STATE OPTION.—State plan ap-
21 proved under section 1902 may provide for making med22 ical assistance available to an individual described in sec23 tion 1902(ii) (relating to individuals who meet certain in24 come eligibility standard) during a presumptive eligibility
25 period. In the case of an individual described in section
26 1902(ii), such medical assistance shall be limited to family
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461
1 planning services and supplies described in 1905(a)(4)(C)
2 and, at the State’s option, medical diagnosis and treat3 ment services that are provided in conjunction with a fam4 ily planning service in a family planning setting.
5
6
‘‘(b) DEFINITIONS.—For purposes of this section:
‘‘(1) PRESUMPTIVE
ELIGIBILITY PERIOD.—The
7
term ‘presumptive eligibility period’ means, with re-
8
spect to an individual described in subsection (a),
9
the period that—
10
‘‘(A) begins with the date on which a
11
qualified entity determines, on the basis of pre-
12
liminary information, that the individual is de-
13
scribed in section 1902(ii); and
14
15
‘‘(B) ends with (and includes) the earlier
of—
16
‘‘(i) the day on which a determination
17
is made with respect to the eligibility of
18
such individual for services under the State
19
plan; or
20
‘‘(ii) in the case of such an individual
21
who does not file an application by the last
22
day of the month following the month dur-
23
ing which the entity makes the determina-
24
tion referred to in subparagraph (A), such
25
last day.
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1
‘‘(2) QUALIFIED
2
‘‘(A) IN
ENTITY.—
GENERAL.—Subject
to subpara-
3
graph (B), the term ‘qualified entity’ means
4
any entity that—
5
‘‘(i) is eligible for payments under a
6
State plan approved under this title; and
7
‘‘(ii) is determined by the State agen-
8
cy to be capable of making determinations
9
of the type described in paragraph (1)(A).
10
‘‘(B) RULE
OF CONSTRUCTION.—Nothing
11
in this paragraph shall be construed as pre-
12
venting a State from limiting the classes of en-
13
tities that may become qualified entities in
14
order to prevent fraud and abuse.
15
‘‘(c) ADMINISTRATION.—
16
17
‘‘(1) IN
GENERAL.—The
State agency shall pro-
vide qualified entities with—
18
‘‘(A) such forms as are necessary for an
19
application to be made by an individual de-
20
scribed in subsection (a) for medical assistance
21
under the State plan; and
22
‘‘(B) information on how to assist such in-
23
dividuals in completing and filing such forms.
24
‘‘(2) NOTIFICATION
25
fied
entity
that
REQUIREMENTS.—A
determines
under
quali-
subsection
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1
(b)(1)(A) that an individual described in subsection
2
(a) is presumptively eligible for medical assistance
3
under a State plan shall—
4
‘‘(A) notify the State agency of the deter-
5
mination within 5 working days after the date
6
on which determination is made; and
7
‘‘(B) inform such individual at the time
8
the determination is made that an application
9
for medical assistance is required to be made by
10
not later than the last day of the month fol-
11
lowing the month during which the determina-
12
tion is made.
13
‘‘(3)
APPLICATION
FOR
MEDICAL
ASSIST-
14
ANCE.—In
15
subsection (a) who is determined by a qualified enti-
16
ty to be presumptively eligible for medical assistance
17
under a State plan, the individual shall apply for
18
medical assistance by not later than the last day of
19
the month following the month during which the de-
20
termination is made.
21
‘‘(d) PAYMENT.—Notwithstanding any other provi-
the case of an individual described in
22 sion of law, medical assistance that—
23
24
‘‘(1) is furnished to an individual described in
subsection (a)—
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1
2
3
‘‘(A) during a presumptive eligibility period; and
‘‘(B) by a entity that is eligible for pay-
4
ments under the State plan; and
5
‘‘(2) is included in the care and services covered
6
by the State plan,
7 shall be treated as medical assistance provided by such
8 plan for purposes of clause (4) of the first sentence of
9 section 1905(b).’’.
10
(2) CONFORMING
AMENDMENTS.—
11
(A) Section 1902(a)(47) of the Social Se-
12
curity Act (42 U.S.C. 1396a(a)(47)), as amend-
13
ed by section 2202(a), is amended—
14
(i) in subparagraph (A), by inserting
15
before the semicolon at the end the fol-
16
lowing: ‘‘and provide for making medical
17
assistance available to individuals described
18
in subsection (a) of section 1920C during
19
a presumptive eligibility period in accord-
20
ance with such section’’; and
21
(ii) in subparagraph (B), by striking
22
‘‘or 1920B’’ and inserting ‘‘1920B, or
23
1920C’’.
24
(B) Section 1903(u)(1)(D)(v) of such Act
25
(42 U.S.C. 1396b(u)(1)(D)(v)), as amended by
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1
section 2202(b), is amended by inserting ‘‘or
2
for medical assistance provided to an individual
3
described in subsection (a) of section 1920C
4
during a presumptive eligibility period under
5
such section,’’ after ‘‘1920B during a presump-
6
tive eligibility period under such section,’’.
7
8
(c) CLARIFICATION
NING
SERVICES
AND
OF
COVERAGE
OF
FAMILY PLAN-
SUPPLIES.—Section 1937(b) of the
9 Social Security Act (42 U.S.C. 1396u–7(b)), as amended
10 by section 2001(c), is amended by adding at the end the
11 following:
12
‘‘(7) COVERAGE
OF FAMILY PLANNING SERV-
13
ICES AND SUPPLIES.—Notwithstanding
14
provisions of this section, a State may not provide
15
for medical assistance through enrollment of an indi-
16
vidual with benchmark coverage or benchmark-equiv-
17
alent coverage under this section unless such cov-
18
erage includes for any individual described in section
19
1905(a)(4)(C), medical assistance for family plan-
20
ning services and supplies in accordance with such
21
section.’’.
22
(d) EFFECTIVE DATE.—The amendments made by
the previous
23 this section take effect on the date of the enactment of
24 this Act and shall apply to items and services furnished
25 on or after such date.
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1
SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL AS-
2
3
SISTANCE.
Section 1905(a) of the Social Security Act (42 U.S.C.
4 1396d(a)) is amended by inserting ‘‘or the care and serv5 ices themselves, or both’’ before ‘‘(if provided in or after’’.
8
Subtitle E—New Options for States
to Provide Long-Term Services
and Supports
9
SEC. 2401. COMMUNITY FIRST CHOICE OPTION.
6
7
10
Section 1915 of the Social Security Act (42 U.S.C.
11 1396n) is amended by adding at the end the following:
12
‘‘(k) STATE PLAN OPTION
TO
PROVIDE HOME
13 COMMUNITY-BASED ATTENDANT SERVICES
14
15
AND
AND
SUP-
PORTS.—
‘‘(1) IN
GENERAL.—Subject
to the succeeding
16
provisions of this subsection, beginning October 1,
17
2010, a State may provide through a State plan
18
amendment for the provision of medical assistance
19
for home and community-based attendant services
20
and supports for individuals who are eligible for
21
medical assistance under the State plan whose in-
22
come does not exceed 150 percent of the poverty line
23
(as defined in section 2110(c)(5)) or, if greater, the
24
income level applicable for an individual who has
25
been determined to require an institutional level of
26
care to be eligible for nursing facility services under
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1
the State plan and with respect to whom there has
2
been a determination that, but for the provision of
3
such services, the individuals would require the level
4
of care provided in a hospital, a nursing facility, an
5
intermediate care facility for the mentally retarded,
6
or an institution for mental diseases, the cost of
7
which could be reimbursed under the State plan, but
8
only if the individual chooses to receive such home
9
and community-based attendant services and sup-
10
ports, and only if the State meets the following re-
11
quirements:
12
‘‘(A)
AVAILABILITY.—The
State
shall
13
make available home and community-based at-
14
tendant services and supports to eligible indi-
15
viduals, as needed, to assist in accomplishing
16
activities of daily living, instrumental activities
17
of daily living, and health-related tasks through
18
hands-on assistance, supervision, or cueing—
19
‘‘(i) under a person-centered plan of
20
services and supports that is based on an
21
assessment of functional need and that is
22
agreed to in writing by the individual or,
23
as appropriate, the individual’s representa-
24
tive;
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1
‘‘(ii) in a home or community setting,
2
which does not include a nursing facility,
3
institution for mental diseases, or an inter-
4
mediate care facility for the mentally re-
5
tarded;
6
‘‘(iii) under an agency-provider model
7
or other model (as defined in paragraph
8
(6)(C )); and
9
‘‘(iv) the furnishing of which—
10
‘‘(I) is selected, managed, and
11
dismissed by the individual, or, as ap-
12
propriate, with assistance from the in-
13
dividual’s representative;
14
‘‘(II) is controlled, to the max-
15
imum extent possible, by the indi-
16
vidual or where appropriate, the indi-
17
vidual’s representative, regardless of
18
who may act as the employer of
19
record; and
20
‘‘(III) provided by an individual
21
who is qualified to provide such serv-
22
ices, including family members (as de-
23
fined by the Secretary).
24
25
‘‘(B)
PORTS.—In
INCLUDED
SERVICES
AND
SUP-
addition to assistance in accom-
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469
1
plishing activities of daily living, instrumental
2
activities of daily living, and health related
3
tasks, the home and community-based attend-
4
ant services and supports made available in-
5
clude—
6
‘‘(i) the acquisition, maintenance, and
7
enhancement of skills necessary for the in-
8
dividual to accomplish activities of daily
9
living, instrumental activities of daily liv-
10
ing, and health related tasks;
11
‘‘(ii) back-up systems or mechanisms
12
(such as the use of beepers or other elec-
13
tronic devices) to ensure continuity of serv-
14
ices and supports; and
15
‘‘(iii) voluntary training on how to se-
16
lect, manage, and dismiss attendants.
17
‘‘(C) EXCLUDED
SERVICES
AND
SUP-
18
PORTS.—Subject
19
home and community-based attendant services
20
and supports made available do not include—
21
22
to subparagraph (D), the
‘‘(i) room and board costs for the individual;
23
‘‘(ii) special education and related
24
services provided under the Individuals
25
with Disabilities Education Act and voca-
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470
1
tional
2
under the Rehabilitation Act of 1973;
rehabilitation
services
provided
3
‘‘(iii) assistive technology devices and
4
assistive technology services other than
5
those under (1)(B)(ii);
6
7
8
9
‘‘(iv) medical supplies and equipment;
or
‘‘(v) home modifications.
‘‘(D) PERMISSIBLE
SERVICES AND SUP-
10
PORTS.—The
11
tendant services and supports may include—
home and community-based at-
12
‘‘(i) expenditures for transition costs
13
such as rent and utility deposits, first
14
month’s rent and utilities, bedding, basic
15
kitchen supplies, and other necessities re-
16
quired for an individual to make the tran-
17
sition from a nursing facility, institution
18
for mental diseases, or intermediate care
19
facility for the mentally retarded to a com-
20
munity-based home setting where the indi-
21
vidual resides; and
22
‘‘(ii) expenditures relating to a need
23
identified in an individual’s person-cen-
24
tered plan of services that increase inde-
25
pendence or substitute for human assist-
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471
1
ance, to the extent that expenditures would
2
otherwise be made for the human assist-
3
ance.
4
‘‘(2) INCREASED
FEDERAL FINANCIAL PARTICI-
5
PATION.—For
6
under section 1903(a)(1), with respect to amounts
7
expended by the State to provide medical assistance
8
under the State plan for home and community-based
9
attendant services and supports to eligible individ-
10
uals in accordance with this subsection during a fis-
11
cal year quarter occurring during the period de-
12
scribed in paragraph (1), the Federal medical assist-
13
ance percentage applicable to the State (as deter-
14
mined under section 1905(b)) shall be increased by
15
6 percentage points.
16
purposes of payments to a State
‘‘(3) STATE
REQUIREMENTS.—In
order for a
17
State plan amendment to be approved under this
18
subsection, the State shall—
19
‘‘(A) develop and implement such amend-
20
ment in collaboration with a Development and
21
Implementation Council established by the
22
State that includes a majority of members with
23
disabilities, elderly individuals, and their rep-
24
resentatives and consults and collaborates with
25
such individuals;
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1
‘‘(B) provide consumer controlled home
2
and community-based attendant services and
3
supports to individuals on a statewide basis, in
4
a manner that provides such services and sup-
5
ports in the most integrated setting appropriate
6
to the individual’s needs, and without regard to
7
the individual’s age, type or nature of disability,
8
severity of disability, or the form of home and
9
community-based attendant services and sup-
10
ports that the individual requires in order to
11
lead an independent life;
12
‘‘(C) with respect to expenditures during
13
the first full fiscal year in which the State plan
14
amendment is implemented, maintain or exceed
15
the level of State expenditures for medical as-
16
sistance that is provided under section 1905(a),
17
section 1915, section 1115, or otherwise to indi-
18
viduals with disabilities or elderly individuals
19
attributable to the preceding fiscal year;
20
‘‘(D) establish and maintain a comprehen-
21
sive, continuous quality assurance system with
22
respect to community- based attendant services
23
and supports that—
24
‘‘(i) includes standards for agency-
25
based and other delivery models with re-
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473
1
spect to training, appeals for denials and
2
reconsideration procedures of an individual
3
plan, and other factors as determined by
4
the Secretary;
5
‘‘(ii) incorporates feedback from con-
6
sumers and their representatives, disability
7
organizations, providers, families of dis-
8
abled or elderly individuals, members of
9
the community, and others and maximizes
10
consumer independence and consumer con-
11
trol;
12
‘‘(iii) monitors the health and well-
13
being of each individual who receives home
14
and community-based attendant services
15
and supports, including a process for the
16
mandatory reporting, investigation, and
17
resolution of allegations of neglect, abuse,
18
or exploitation in connection with the pro-
19
vision of such services and supports; and
20
‘‘(iv) provides information about the
21
provisions of the quality assurance re-
22
quired under clauses (i) through (iii) to
23
each individual receiving such services; and
24
‘‘(E) collect and report information, as de-
25
termined necessary by the Secretary, for the
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1
purposes of approving the State plan amend-
2
ment, providing Federal oversight, and con-
3
ducting an evaluation under paragraph (5)(A),
4
including data regarding how the State provides
5
home and community-based attendant services
6
and supports and other home and community-
7
based services, the cost of such services and
8
supports, and how the State provides individ-
9
uals with disabilities who otherwise qualify for
10
institutional care under the State plan or under
11
a waiver the choice to instead receive home and
12
community-based services in lieu of institutional
13
care.
14
‘‘(4) COMPLIANCE
WITH CERTAIN LAWS.—A
15
State shall ensure that, regardless of whether the
16
State uses an agency-provider model or other models
17
to provide home and community-based attendant
18
services and supports under a State plan amend-
19
ment under this subsection, such services and sup-
20
ports are provided in accordance with the require-
21
ments of the Fair Labor Standards Act of 1938 and
22
applicable Federal and State laws regarding—
23
24
‘‘(A) withholding and payment of Federal
and State income and payroll taxes;
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1
2
3
4
5
6
7
‘‘(B) the provision of unemployment and
workers compensation insurance;
‘‘(C) maintenance of general liability insurance; and
‘‘(D) occupational health and safety.
‘‘(5) EVALUATION,
DATA COLLECTION, AND RE-
PORT TO CONGRESS.—
8
‘‘(A) EVALUATION.—The Secretary shall
9
conduct an evaluation of the provision of home
10
and community-based attendant services and
11
supports under this subsection in order to de-
12
termine the effectiveness of the provision of
13
such services and supports in allowing the indi-
14
viduals receiving such services and supports to
15
lead an independent life to the maximum extent
16
possible; the impact on the physical and emo-
17
tional health of the individuals who receive such
18
services; and an comparative analysis of the
19
costs of services provided under the State plan
20
amendment under this subsection and those
21
provided under institutional care in a nursing
22
facility, institution for mental diseases, or an
23
intermediate care facility for the mentally re-
24
tarded.
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1
‘‘(B) DATA
COLLECTION.—The
State shall
2
provide the Secretary with the following infor-
3
mation regarding the provision of home and
4
community-based attendant services and sup-
5
ports under this subsection for each fiscal year
6
for which such services and supports are pro-
7
vided:
8
‘‘(i) The number of individuals who
9
are estimated to receive home and commu-
10
nity-based attendant services and supports
11
under this subsection during the fiscal
12
year.
13
‘‘(ii) The number of individuals that
14
received such services and supports during
15
the preceding fiscal year.
16
‘‘(iii) The specific number of individ-
17
uals served by type of disability, age, gen-
18
der, education level, and employment sta-
19
tus.
20
‘‘(iv) Whether the specific individuals
21
have been previously served under any
22
other home and community based services
23
program under the State plan or under a
24
waiver.
25
‘‘(C) REPORTS.—Not later than—
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1
‘‘(i) December 31, 2013, the Sec-
2
retary shall submit to Congress and make
3
available to the public an interim report on
4
the findings of the evaluation under sub-
5
paragraph (A); and
6
‘‘(ii) December 31, 2015, the Sec-
7
retary shall submit to Congress and make
8
available to the public a final report on the
9
findings of the evaluation under subpara-
10
11
12
graph (A).
‘‘(6) DEFINITIONS.—In this subsection:
‘‘(A) ACTIVITIES
OF DAILY LIVING.—The
13
term ‘activities of daily living’ includes tasks
14
such as eating, toileting, grooming, dressing,
15
bathing, and transferring.
16
‘‘(B) CONSUMER
CONTROLLED.—The
term
17
‘consumer controlled’ means a method of select-
18
ing and providing services and supports that
19
allow the individual, or where appropriate, the
20
individual’s representative, maximum control of
21
the home and community-based attendant serv-
22
ices and supports, regardless of who acts as the
23
employer of record.
24
‘‘(C) DELIVERY
MODELS.—
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1
‘‘(i) AGENCY-PROVIDER
MODEL.—The
2
term ‘agency-provider model’ means, with
3
respect to the provision of home and com-
4
munity-based attendant services and sup-
5
ports for an individual, subject to para-
6
graph (4), a method of providing consumer
7
controlled services and supports under
8
which entities contract for the provision of
9
such services and supports.
10
‘‘(ii)
OTHER
MODELS.—The
term
11
‘other models’ means, subject to paragraph
12
(4), methods, other than an agency-pro-
13
vider model, for the provision of consumer
14
controlled services and supports. Such
15
models may include the provision of vouch-
16
ers, direct cash payments, or use of a fiscal
17
agent to assist in obtaining services.
18
‘‘(D)
HEALTH-RELATED
TASKS.—The
19
term ‘health-related tasks’ means specific tasks
20
related to the needs of an individual, which can
21
be delegated or assigned by licensed health-care
22
professionals under State law to be performed
23
by an attendant.
24
25
‘‘(E) INDIVIDUAL’S
REPRESENTATIVE.—
The term ‘individual’s representative’ means a
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1
parent, family member, guardian, advocate, or
2
other authorized representative of an individual
3
‘‘(F) INSTRUMENTAL
ACTIVITIES OF DAILY
4
LIVING.—The
5
daily living’ includes (but is not limited to) meal
6
planning and preparation, managing finances,
7
shopping for food, clothing, and other essential
8
items, performing essential household chores,
9
communicating by phone or other media, and
10
traveling around and participating in the com-
11
munity.’’.
12
SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME
13
14
15
term ‘instrumental activities of
AND COMMUNITY-BASED SERVICES.
(a) OVERSIGHT
TRATION OF
HOME
AND
AND
ASSESSMENT
OF THE
ADMINIS-
COMMUNITY-BASED SERVICES.—
16 The Secretary of Health and Human Services shall pro17 mulgate regulations to ensure that all States develop serv18 ice systems that are designed to—
19
(1) allocate resources for services in a manner
20
that is responsive to the changing needs and choices
21
of beneficiaries receiving non-institutionally-based
22
long-term services and supports (including such
23
services and supports that are provided under pro-
24
grams other the State Medicaid program), and that
25
provides strategies for beneficiaries receiving such
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1
services to maximize their independence, including
2
through the use of client-employed providers;
3
(2) provide the support and coordination needed
4
for a beneficiary in need of such services (and their
5
family caregivers or representative, if applicable) to
6
design an individualized, self-directed, community-
7
supported life; and
8
(3) improve coordination among, and the regu-
9
lation of, all providers of such services under feder-
10
ally and State-funded programs in order to—
11
(A) achieve a more consistent administra-
12
tion of policies and procedures across programs
13
in relation to the provision of such services; and
14
(B) oversee and monitor all service system
15
functions to assure—
16
(i) coordination of, and effectiveness
17
of, eligibility determinations and individual
18
assessments;
19
(ii) development and service moni-
20
toring of a complaint system, a manage-
21
ment system, a system to qualify and mon-
22
itor providers, and systems for role-setting
23
and individual budget determinations; and
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1
(iii) an adequate number of qualified
2
direct care workers to provide self-directed
3
personal assistance services.
4
(b) ADDITIONAL STATE OPTIONS.—Section 1915(i)
5 of the Social Security Act (42 U.S.C. 1396n(i)) is amend6 ed by adding at the end the following new paragraphs:
7
‘‘(6) STATE
OPTION TO PROVIDE HOME AND
8
COMMUNITY-BASED SERVICES TO INDIVIDUALS ELI-
9
GIBLE FOR SERVICES UNDER A WAIVER.—
10
‘‘(A) IN
GENERAL.—A
State that provides
11
home and community-based services in accord-
12
ance with this subsection to individuals who
13
satisfy the needs-based criteria for the receipt
14
of such services established under paragraph
15
(1)(A) may, in addition to continuing to provide
16
such services to such individuals, elect to pro-
17
vide home and community-based services in ac-
18
cordance with the requirements of this para-
19
graph to individuals who are eligible for home
20
and community-based services under a waiver
21
approved for the State under subsection (c),
22
(d), or (e) or under section 1115 to provide
23
such services, but only for those individuals
24
whose income does not exceed 300 percent of
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1
the supplemental security income benefit rate
2
established by section 1611(b)(1).
3
‘‘(B) APPLICATION
OF
SAME
REQUIRE-
4
MENTS FOR INDIVIDUALS SATISFYING NEEDS-
5
BASED
6
(C), a State shall provide home and community-
7
based services to individuals under this para-
8
graph in the same manner and subject to the
9
same requirements as apply under the other
10
paragraphs of this subsection to the provision
11
of home and community-based services to indi-
12
viduals who satisfy the needs-based criteria es-
13
tablished under paragraph (1)(A).
14
CRITERIA.—Subject
‘‘(C) AUTHORITY
to subparagraph
TO OFFER DIFFERENT
15
TYPE, AMOUNT, DURATION, OR SCOPE OF HOME
16
AND
17
may offer home and community-based services
18
to individuals under this paragraph that differ
19
in type, amount, duration, or scope from the
20
home and community-based services offered for
21
individuals who satisfy the needs-based criteria
22
established under paragraph (1)(A), so long as
23
such services are within the scope of services
24
described in paragraph (4)(B) of subsection (c)
25
for which the Secretary has the authority to ap-
COMMUNITY-BASED
SERVICES.—A
State
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1
prove a waiver and do not include room or
2
board.
3
‘‘(7) STATE
OPTION TO OFFER HOME AND COM-
4
MUNITY-BASED SERVICES TO SPECIFIC, TARGETED
5
POPULATIONS.—
6
‘‘(A) IN
GENERAL.—A
State may elect in
7
a State plan amendment under this subsection
8
to target the provision of home and community-
9
based services under this subsection to specific
10
populations and to differ the type, amount, du-
11
ration, or scope of such services to such specific
12
populations.
13
‘‘(B) 5-YEAR
14
‘‘(i) IN
TERM.—
GENERAL.—An
election by a
15
State under this paragraph shall be for a
16
period of 5 years.
17
‘‘(ii) PHASE-IN
OF SERVICES AND ELI-
18
GIBILITY PERMITTED DURING INITIAL 5-
19
YEAR PERIOD.—A
20
tion under this paragraph may, during the
21
first 5-year period for which the election is
22
made, phase-in the enrollment of eligible
23
individuals, or the provision of services to
24
such individuals, or both, so long as all eli-
25
gible individuals in the State for such serv-
State making an elec-
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484
1
ices are enrolled, and all such services are
2
provided, before the end of the initial 5-
3
year period.
4
‘‘(C) RENEWAL.—An election by a State
5
under this paragraph may be renewed for addi-
6
tional 5-year terms if the Secretary determines,
7
prior to beginning of each such renewal period,
8
that the State has—
9
‘‘(i) adhered to the requirements of
10
this subsection and paragraph in providing
11
services under such an election; and
12
‘‘(ii) met the State’s objectives with
13
respect to quality improvement and bene-
14
ficiary outcomes.’’.
15
(c) REMOVAL
16
ICES.—Paragraph
OF
LIMITATION
ON
SCOPE
OF
SERV-
(1) of section 1915(i) of the Social Se-
17 curity Act (42 U.S.C. 1396n(i)), as amended by sub18 section (a), is amended by striking ‘‘or such other services
19 requested by the State as the Secretary may approve’’.
20
(d) OPTIONAL ELIGIBILITY CATEGORY TO PROVIDE
21 FULL MEDICAID BENEFITS
22 HOME
AND
TO
INDIVIDUALS RECEIVING
COMMUNITY-BASED SERVICES UNDER
A
23 STATE PLAN AMENDMENT.—
24
25
(1) IN
of
the
GENERAL.—Section
Social
Security
1902(a)(10)(A)(ii)
Act
(42
U.S.C.
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485
1
1396a(a)(10)(A)(ii)),
2
2304(a)(1), is amended—
3
4
5
6
7
8
as
amended
by
section
(A) in subclause (XX), by striking ‘‘or’’ at
the end;
(B) in subclause (XXI), by adding ‘‘or’’ at
the end; and
(C) by inserting after subclause (XXI), the
following new subclause:
9
‘‘(XXII) who are eligible for
10
home and community-based services
11
under needs-based criteria established
12
under paragraph (1)(A) of section
13
1915(i), or who are eligible for home
14
and community-based services under
15
paragraph (6) of such section, and
16
who will receive home and community-
17
based services pursuant to a State
18
plan amendment under such sub-
19
section;’’.
20
(2) CONFORMING
AMENDMENTS.—
21
(A) Section 1903(f)(4) of the Social Secu-
22
rity Act (42 U.S.C. 1396b(f)(4)), as amended
23
by section 2304(a)(4)(B), is amended in the
24
matter preceding subparagraph (A), by insert-
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486
1
ing
2
‘‘1902(a)(10)(A)(ii)(XXI),’’.
‘‘1902(a)(10)(A)(ii)(XXII),’’
after
3
(B) Section 1905(a) of the Social Security
4
Act (42 U.S.C. 1396d(a)), as so amended, is
5
amended in the matter preceding paragraph
6
(1)—
7
8
9
10
11
12
(i) in clause (xv), by striking ‘‘or’’ at
the end;
(ii) in clause (xvi), by adding ‘‘or’’ at
the end; and
(iii) by inserting after clause (xvi) the
following new clause:
13
‘‘(xvii) individuals who are eligible for home and
14
community-based services under needs-based criteria
15
established under paragraph (1)(A) of section
16
1915(i), or who are eligible for home and commu-
17
nity-based services under paragraph (6) of such sec-
18
tion, and who will receive home and community-
19
based services pursuant to a State plan amendment
20
under such subsection,’’.
21
(e) ELIMINATION
OF
22 ELIGIBLE INDIVIDUALS
OPTION TO LIMIT NUMBER
OR
LENGTH
OF
PERIOD
OF
FOR
23 GRANDFATHERED INDIVIDUALS IF ELIGIBILITY CRITERIA
24 IS MODIFIED.—Paragraph (1) of section 1915(i) of such
25 Act (42 U.S.C. 1396n(i)) is amended—
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1
2
(1) by striking subparagraph (C) and inserting
the following:
3
‘‘(C) PROJECTION
OF NUMBER OF INDI-
4
VIDUALS TO BE PROVIDED HOME AND COMMU-
5
NITY-BASED SERVICES.—The
6
the Secretary, in such form and manner, and
7
upon such frequency as the Secretary shall
8
specify, the projected number of individuals to
9
be provided home and community-based serv-
State submits to
10
ices.’’; and
11
(2) in subclause (II) of subparagraph (D)(ii),
12
by striking ‘‘to be eligible for such services for a pe-
13
riod of at least 12 months beginning on the date the
14
individual first received medical assistance for such
15
services’’ and inserting ‘‘to continue to be eligible for
16
such services after the effective date of the modifica-
17
tion and until such time as the individual no longer
18
meets the standard for receipt of such services under
19
such pre-modified criteria’’.
20
(f)
ELIMINATION
OF
21 STATEWIDENESS; ADDITION
22
PARABILITY.—Paragraph
OF
OPTION
TO
WAIVE
OPTION TO WAIVE COM-
(3) of section 1915(i) of such
23 Act (42 U.S.C. 1396n(3)) is amended by striking
24 ‘‘1902(a)(1) (relating to statewideness)’’ and inserting
25 ‘‘1902(a)(10)(B) (relating to comparability)’’.
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1
(g) EFFECTIVE DATE.—The amendments made by
2 subsections (b) through (f) take effect on the first day of
3 the first fiscal year quarter that begins after the date of
4 enactment of this Act.
5
SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING
6
7
DEMONSTRATION.
(a) EXTENSION OF DEMONSTRATION.—
8
9
10
(1) IN
GENERAL.—Section
6071(h) of the Def-
icit Reduction Act of 2005 (42 U.S.C. 1396a note)
is amended—
11
(A) in paragraph (1)(E), by striking ‘‘fis-
12
cal year 2011’’ and inserting ‘‘each of fiscal
13
years 2011 through 2016’’; and
14
(B) in paragraph (2), by striking ‘‘2011’’
15
and inserting ‘‘2016’’.
16
(2) EVALUATION.—Paragraphs (2) and (3) of
17
section 6071(g) of such Act is amended are each
18
amended by striking ‘‘2011’’ and inserting ‘‘2016’’.
19
(b) REDUCTION
20
21
OF
INSTITUTIONAL RESIDENCY PE-
RIOD.—
(1) IN
GENERAL.—Section
6071(b)(2) of the
22
Deficit Reduction Act of 2005 (42 U.S.C. 1396a
23
note) is amended—
24
(A) in subparagraph (A)(i), by striking ‘‘,
25
for a period of not less than 6 months or for
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489
1
such longer minimum period, not to exceed 2
2
years, as may be specified by the State’’ and in-
3
serting ‘‘for a period of not less than 90 con-
4
secutive days’’; and
5
(B) by adding at the end the following:
6
‘‘Any days that an individual resides in an institu-
7
tion on the basis of having been admitted solely for
8
purposes of receiving short-term rehabilitative serv-
9
ices for a period for which payment for such services
10
is limited under title XVIII shall not be taken into
11
account for purposes of determining the 90-day pe-
12
riod required under subparagraph (A)(i).’’.
13
(2) EFFECTIVE
DATE.—The
amendments made
14
by this subsection take effect 30 days after the date
15
of enactment of this Act.
16
SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND
17
COMMUNITY-BASED
18
SPOUSAL IMPOVERISHMENT.
19
SERVICES
AGAINST
During the 5-year period that begins on January 1,
20 2014, section 1924(h)(1)(A) of the Social Security Act (42
21 U.S.C. 1396r–5(h)(1)(A)) shall be applied as though ‘‘is
22 eligible for medical assistance for home and community23 based services provided under subsection (c), (d), or (i)
24 of section 1915, under a waiver approved under section
25 1115, or who is eligible for such medical assistance by rea-
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490
1 son
of
being
determined
eligible
under
section
2 1902(a)(10)(C) or by reason of section 1902(f) or other3 wise on the basis of a reduction of income based on costs
4 incurred for medical or other remedial care, or who is eligi5 ble for medical assistance for home and community-based
6 attendant services and supports under section 1915(k)’’
7 were substituted in such section for ‘‘(at the option of the
8 State) is described in section 1902(a)(10)(A)(ii)(VI)’’.
9
SEC. 2405. FUNDING TO EXPAND STATE AGING AND DIS-
10
11
ABILITY RESOURCE CENTERS.
Out of any funds in the Treasury not otherwise ap-
12 propriated, there is appropriated to the Secretary of
13 Health and Human Services, acting through the Assistant
14 Secretary for Aging, $10,000,000 for each of fiscal years
15 2010
through
2014,
to
carry
out
subsections
16 (a)(20)(B)(iii) and (b)(8) of section 202 of the Older
17 Americans Act of 1965 (42 U.S.C. 3012).
18
SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM
19
20
CARE.
(a) FINDINGS.—The Senate makes the following
21 findings:
22
(1) Nearly 2 decades have passed since Con-
23
gress seriously considered long-term care reform.
24
The United States Bipartisan Commission on Com-
25
prehensive Health Care, also know as the ‘‘Pepper
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491
1
Commission’’, released its ‘‘Call for Action’’ blue-
2
print for health reform in September 1990. In the
3
20 years since those recommendations were made,
4
Congress has never acted on the report.
5
(2) In 1999, under the United States Supreme
6
Court’s decision in Olmstead v. L.C., 527 U.S. 581
7
(1999), individuals with disabilities have the right to
8
choose to receive their long-term services and sup-
9
ports in the community, rather than in an institu-
10
tional setting.
11
(3)
Despite
the
Pepper
Commission
and
12
Olmstead decision, the long-term care provided to
13
our Nation‘s elderly and disabled has not improved.
14
In fact, for many, it has gotten far worse.
15
(4) In 2007, 69 percent of Medicaid long-term
16
care spending for elderly individuals and adults with
17
physical disabilities paid for institutional services.
18
Only 6 states spent 50 percent or more of their
19
Medicaid long-term care dollars on home and com-
20
munity-based services for elderly individuals and
21
adults with physical disabilities while
22
States spent less than 25 percent. This disparity
23
continues even though, on average, it is estimated
24
that Medicaid dollars can support nearly 3 elderly
25
individuals and adults with physical disabilities in
⁄
12
of the
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492
1
home and community-based services for every indi-
2
vidual in a nursing home. Although every State has
3
chosen to provide certain services under home and
4
community-based waivers, these services are un-
5
evenly available within and across States, and reach
6
a small percentage of eligible individuals.
7
(b) SENSE
OF THE
SENATE.—It is the sense of the
8 Senate that—
9
(1) during the 111th session of Congress, Con-
10
gress should address long-term services and supports
11
in a comprehensive way that guarantees elderly and
12
disabled individuals the care they need; and
13
(2) long term services and supports should be
14
made available in the community in addition to in
15
institutions.
16
17
18
Subtitle F—Medicaid Prescription
Drug Coverage
SEC. 2501. PRESCRIPTION DRUG REBATES.
19
20
(a) INCREASE
FOR
IN
MINIMUM REBATE PERCENTAGE
SINGLE SOURCE DRUGS
AND INNOVATOR
MULTIPLE
21 SOURCE DRUGS.—
22
(1) IN
GENERAL.—Section
1927(c)(1)(B) of the
23
Social Security Act (42 U.S.C. 1396r–8(c)(1)(B)) is
24
amended—
25
(A) in clause (i)—
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493
1
2
(i) in subclause (IV), by striking
‘‘and’’ at the end;
3
(ii) in subclause (V)—
4
(I) by inserting ‘‘and before Jan-
5
uary 1, 2010’’ after ‘‘December 31,
6
1995,’’; and
7
(II) by striking the period at the
8
end and inserting ‘‘; and’’; and
9
(iii) by adding at the end the fol-
10
lowing new subclause:
11
‘‘(VI)
except
as
provided
in
12
clause (iii), after December 31, 2009,
13
23.1 percent.’’; and
14
15
16
17
18
(B) by adding at the end the following new
clause:
‘‘(iii) MINIMUM
REBATE PERCENTAGE
FOR CERTAIN DRUGS.—
‘‘(I) IN
GENERAL.—In
the case
19
of a single source drug or an inno-
20
vator multiple source drug described
21
in subclause (II), the minimum rebate
22
percentage for rebate periods specified
23
in clause (i)(VI) is 17.1 percent.
24
25
‘‘(II)
DRUG
DESCRIBED.—For
purposes of subclause (I), a single
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1
source drug or an innovator multiple
2
source drug described in this sub-
3
clause is any of the following drugs:
4
‘‘(aa) A clotting factor for
5
which a separate furnishing pay-
6
ment is made under section
7
1842(o)(5) and which is included
8
on a list of such factors specified
9
and updated regularly by the
10
Secretary.
11
‘‘(bb) A drug approved by
12
the Food and Drug Administra-
13
tion exclusively for pediatric indi-
14
cations.’’.
15
(2) RECAPTURE
OF TOTAL SAVINGS DUE TO IN-
16
CREASE.—Section
17
U.S.C. 1396r–8(b)(1)) is amended by adding at the
18
end the following new subparagraph:
19
20
21
1927(b)(1) of such Act (42
‘‘(C) SPECIAL
RULE FOR INCREASED MIN-
IMUM REBATE PERCENTAGE.—
‘‘(i) IN
GENERAL.—In
addition to the
22
amounts applied as a reduction under sub-
23
paragraph (B), for rebate periods begin-
24
ning on or after January 1, 2010, during
25
a fiscal year, the Secretary shall reduce
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495
1
payments to a State under section 1903(a)
2
in the manner specified in clause (ii), in an
3
amount equal to the product of—
4
‘‘(I) 100 percent minus the Fed-
5
eral medical assistance percentage ap-
6
plicable to the rebate period for the
7
State; and
8
‘‘(II) the amounts received by the
9
State under such subparagraph that
10
are attributable (as estimated by the
11
Secretary based on utilization and
12
other data) to the increase in the min-
13
imum rebate percentage effected by
14
the amendments made by subsections
15
(a)(1), (b), and (d) of section 2501 of
16
the Patient Protection and Affordable
17
Care Act, taking into account the ad-
18
ditional drugs included under the
19
amendments made by subsection (c)
20
of section 2501 of such Act.
21
The Secretary shall adjust such payment
22
reduction for a calendar quarter to the ex-
23
tent the Secretary determines, based upon
24
subsequent utilization and other data, that
25
the reduction for such quarter was greater
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1
or less than the amount of payment reduc-
2
tion that should have been made.
3
‘‘(ii) MANNER
OF PAYMENT REDUC-
4
TION.—The
5
tion under clause (i) for a State for a
6
quarter shall be deemed an overpayment to
7
the State under this title to be disallowed
8
against the State’s regular quarterly draw
9
for all Medicaid spending under section
10
1903(d)(2). Such a disallowance is not
11
subject to a reconsideration under section
12
1116(d).’’.
13
(b) INCREASE
IN
amount of the payment reduc-
REBATE
FOR
OTHER DRUGS.—Sec-
14 tion 1927(c)(3)(B) of such Act (42 U.S.C. 1396r–
15 8(c)(3)(B)) is amended—
16
(1) in clause (i), by striking ‘‘and’’ at the end;
17
(2) in clause (ii)—
18
19
(A) by inserting ‘‘and before January 1,
2010,’’ after ‘‘December 31, 1993,’’; and
20
(B) by striking the period and inserting ‘‘;
21
and’’; and
22
(3) by adding at the end the following new
23
24
25
clause:
‘‘(iii) after December 31, 2009, is 13
percent.’’.
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1
(c) EXTENSION
2
TO
3
ZATIONS.—
4
ENROLLEES
(1) IN
OF
OF
PRESCRIPTION DRUG DISCOUNTS
MEDICAID MANAGED CARE ORGANI-
GENERAL.—Section
1903(m)(2)(A) of
5
such Act (42 U.S.C. 1396b(m)(2)(A)) is amended—
6
(A) in clause (xi), by striking ‘‘and’’ at the
7
8
9
10
end;
(B) in clause (xii), by striking the period
at the end and inserting ‘‘; and’’; and
(C) by adding at the end the following:
11
‘‘(xiii) such contract provides that (I)
12
covered outpatient drugs dispensed to indi-
13
viduals eligible for medical assistance who
14
are enrolled with the entity shall be subject
15
to the same rebate required by the agree-
16
ment entered into under section 1927 as
17
the State is subject to and that the State
18
shall collect such rebates from manufactur-
19
ers, (II) capitation rates paid to the entity
20
shall be based on actual cost experience re-
21
lated to rebates and subject to the Federal
22
regulations requiring actuarially sound
23
rates, and (III) the entity shall report to
24
the State, on such timely and periodic
25
basis as specified by the Secretary in order
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498
1
to include in the information submitted by
2
the State to a manufacturer and the Sec-
3
retary under section 1927(b)(2)(A), infor-
4
mation on the total number of units of
5
each dosage form and strength and pack-
6
age size by National Drug Code of each
7
covered outpatient drug dispensed to indi-
8
viduals eligible for medical assistance who
9
are enrolled with the entity and for which
10
the entity is responsible for coverage of
11
such drug under this subsection (other
12
than covered outpatient drugs that under
13
subsection (j)(1) of section 1927 are not
14
subject to the requirements of that section)
15
and such other data as the Secretary de-
16
termines necessary to carry out this sub-
17
section.’’.
18
19
20
(2) CONFORMING
AMENDMENTS.—Section
1927
(42 U.S.C. 1396r–8) is amended—
(A) in subsection (b)—
21
(i) in paragraph (1)(A), in the first
22
sentence, by inserting ‘‘, including such
23
drugs dispensed to individuals enrolled
24
with a medicaid managed care organization
25
if the organization is responsible for cov-
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499
1
erage of such drugs’’ before the period;
2
and
3
(ii) in paragraph (2)(A), by inserting
4
‘‘including such information reported by
5
each medicaid managed care organization,’’
6
after ‘‘for which payment was made under
7
the plan during the period,’’; and
8
(B) in subsection (j), by striking para-
9
graph (1) and inserting the following:
10
‘‘(1) Covered outpatient drugs are not subject
11
to the requirements of this section if such drugs
12
are—
13
‘‘(A) dispensed by health maintenance or-
14
ganizations, including Medicaid managed care
15
organizations
16
1903(m); and
17
under
section
340B of the Public Health Service Act.’’.
19
21
contract
‘‘(B) subject to discounts under section
18
20
that
(d) ADDITIONAL REBATE
OF
FOR
NEW FORMULATIONS
EXISTING DRUGS.—
(1) IN
GENERAL.—Section
1927(c)(2) of the
22
Social Security Act (42 U.S.C. 1396r–8(c)(2)) is
23
amended by adding at the end the following new
24
subparagraph:
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1
2
3
‘‘(C) TREATMENT
OF
NEW
FORMULA-
TIONS.—
‘‘(i) IN
GENERAL.—Except
as pro-
4
vided in clause (ii), in the case of a drug
5
that is a new formulation, such as an ex-
6
tended-release formulation, of a single
7
source drug or an innovator multiple
8
source drug, the rebate obligation with re-
9
spect to the drug under this section shall
10
be the amount computed under this section
11
for the new formulation of the drug or, if
12
greater, the product of—
13
‘‘(I) the average manufacturer
14
price for each dosage form and
15
strength of the new formulation of the
16
single source drug or innovator mul-
17
tiple source drug;
18
‘‘(II) the highest additional re-
19
bate (calculated as a percentage of av-
20
erage manufacturer price) under this
21
section for any strength of the origi-
22
nal single source drug or innovator
23
multiple source drug; and
24
‘‘(III) the total number of units
25
of each dosage form and strength of
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501
1
the new formulation paid for under
2
the State plan in the rebate period (as
3
reported by the State).
4
‘‘(ii) NO
APPLICATION TO NEW FOR-
5
MULATIONS OF ORPHAN DRUGS.—Clause
6
(i) shall not apply to a new formulation of
7
a covered outpatient drug that is or has
8
been designated under section 526 of the
9
Federal Food, Drug, and Cosmetic Act (21
10
U.S.C. 360bb) for a rare disease or condi-
11
tion, without regard to whether the period
12
of market exclusivity for the drug under
13
section 527 of such Act has expired or the
14
specific indication for use of the drug.’’.
15
(2) EFFECTIVE
DATE.—The
amendment made
16
by paragraph (1) shall apply to drugs that are paid
17
for by a State after December 31, 2009.
18
(e)
MAXIMUM
REBATE
AMOUNT.—Section
19 1927(c)(2) of such Act (42 U.S.C. 1396r–8(c)(2)), as
20 amended by subsection (d), is amended by adding at the
21 end the following new subparagraph:
22
‘‘(D) MAXIMUM
REBATE AMOUNT.—In
no
23
case shall the sum of the amounts applied
24
under paragraph (1)(A)(ii) and this paragraph
25
with respect to each dosage form and strength
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502
1
of a single source drug or an innovator multiple
2
source drug for a rebate period beginning after
3
December 31, 2009, exceed 100 percent of the
4
average manufacturer price of the drug.’’.
5
6
(f) CONFORMING AMENDMENTS.—
(1) IN
GENERAL.—Section
340B of the Public
7
Health Service Act (42 U.S.C. 256b) is amended—
8
(A) in subsection (a)(2)(B)(i), by striking
9
‘‘1927(c)(4)’’ and inserting ‘‘1927(c)(3)’’; and
10
(B) by striking subsection (c); and
11
(C) redesignating subsection (d) as sub-
12
section (c).
13
(2) EFFECTIVE
DATE.—The
amendments made
14
by this subsection take effect on January 1, 2010.
15
SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF
16
17
CERTAIN DRUGS.
(a) IN GENERAL.—Section 1927(d) of the Social Se-
18 curity Act (42 U.S.C. 1397r–8(d)) is amended—
19
20
21
(1) in paragraph (2)—
(A) by striking subparagraphs (E), (I),
and (J), respectively; and
22
(B) by redesignating subparagraphs (F),
23
(G), (H), and (K) as subparagraphs (E), (F),
24
(G), and (H), respectively; and
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503
1
2
(2) by adding at the end the following new
paragraph:
3
‘‘(7) NON-EXCLUDABLE
DRUGS.—The
following
4
drugs or classes of drugs, or their medical uses, shall
5
not be excluded from coverage:
6
‘‘(A) Agents when used to promote smok-
7
ing cessation, including agents approved by the
8
Food and Drug Administration under the over-
9
the-counter monograph process for purposes of
10
promoting, and when used to promote, tobacco
11
cessation.
12
‘‘(B) Barbiturates.
13
‘‘(C) Benzodiazepines.’’.
14
(b) EFFECTIVE DATE.—The amendments made by
15 this section shall apply to services furnished on or after
16 January 1, 2014.
17
SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSE-
18
19
MENT.
(a) PHARMACY REIMBURSEMENT LIMITS.—
20
(1) IN
GENERAL.—Section
1927(e) of the So-
21
cial Security Act (42 U.S.C. 1396r–8(e)) is amend-
22
ed—
23
24
(A) in paragraph (4), by striking ‘‘(or, effective January 1, 2007, two or more)’’; and
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1
(B) by striking paragraph (5) and insert-
2
ing the following:
3
‘‘(5) USE
OF AMP IN UPPER PAYMENT LIM-
4
ITS.—The
5
upper reimbursement limit established under para-
6
graph (4) as no less than 175 percent of the weight-
7
ed average (determined on the basis of utilization) of
8
the most recently reported monthly average manu-
9
facturer prices for pharmaceutically and therapeuti-
10
cally equivalent multiple source drug products that
11
are available for purchase by retail community phar-
12
macies on a nationwide basis. The Secretary shall
13
implement a smoothing process for average manu-
14
facturer prices. Such process shall be similar to the
15
smoothing process used in determining the average
16
sales price of a drug or biological under section
17
1847A.’’.
18
Secretary shall calculate the Federal
(2) DEFINITION
OF AMP.—Section
1927(k)(1)
19
of such Act (42 U.S.C. 1396r–8(k)(1)) is amend-
20
ed—
21
(A) in subparagraph (A), by striking ‘‘by’’
22
and all that follows through the period and in-
23
serting ‘‘by—
24
25
‘‘(i) wholesalers for drugs distributed
to retail community pharmacies; and
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505
1
‘‘(ii) retail community pharmacies
2
that purchase drugs directly from the man-
3
ufacturer.’’; and
4
(B) by striking subparagraph (B) and in-
5
6
7
8
9
10
11
12
serting the following:
‘‘(B) EXCLUSION
OF CUSTOMARY PROMPT
PAY DISCOUNTS AND OTHER PAYMENTS.—
‘‘(i) IN
GENERAL.—The
average man-
ufacturer price for a covered outpatient
drug shall exclude—
‘‘(I) customary prompt pay discounts extended to wholesalers;
13
‘‘(II) bona fide service fees paid
14
by manufacturers to wholesalers or re-
15
tail community pharmacies, including
16
(but not limited to) distribution serv-
17
ice fees, inventory management fees,
18
product stocking allowances, and fees
19
associated with administrative services
20
agreements and patient care programs
21
(such as medication compliance pro-
22
grams and patient education pro-
23
grams);
24
‘‘(III) reimbursement by manu-
25
facturers for recalled, damaged, ex-
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1
pired, or otherwise unsalable returned
2
goods, including (but not limited to)
3
reimbursement for the cost of the
4
goods and any reimbursement of costs
5
associated with return goods handling
6
and processing, reverse logistics, and
7
drug destruction; and
8
‘‘(IV) payments received from,
9
and rebates or discounts provided to,
10
pharmacy benefit managers, managed
11
care organizations, health mainte-
12
nance organizations, insurers, hos-
13
pitals, clinics, mail order pharmacies,
14
long term care providers, manufactur-
15
ers, or any other entity that does not
16
conduct business as a wholesaler or a
17
retail community pharmacy.
18
‘‘(ii)
INCLUSION
OF
OTHER
DIS-
19
COUNTS
20
standing clause (i), any other discounts,
21
rebates, payments, or other financial trans-
22
actions that are received by, paid by, or
23
passed through to, retail community phar-
24
macies shall be included in the average
AND
PAYMENTS.—Notwith-
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1
manufacturer price for a covered out-
2
patient drug.’’; and
3
(C) in subparagraph (C), by striking ‘‘the
4
retail pharmacy class of trade’’ and inserting
5
‘‘retail community pharmacies’’.
6
(3)
DEFINITION
OF
7
DRUG.—Section
8
1396r–8(k)(7)) is amended—
MULTIPLE
SOURCE
1927(k)(7) of such Act (42 U.S.C.
9
(A) in subparagraph (A)(i)(III), by strik-
10
ing ‘‘the State’’ and inserting ‘‘the United
11
States’’; and
12
13
14
15
16
17
18
(B) in subparagraph (C)—
(i) in clause (i), by inserting ‘‘and’’
after the semicolon;
(ii) in clause (ii), by striking ‘‘; and’’
and inserting a period; and
(iii) by striking clause (iii).
(4) DEFINITIONS
OF RETAIL COMMUNITY PHAR-
19
MACY; WHOLESALER.—Section
20
(42 U.S.C. 1396r–8(k)) is amended by adding at the
21
end the following new paragraphs:
22
‘‘(10) RETAIL
1927(k) of such Act
COMMUNITY
PHARMACY.—The
23
term ‘retail community pharmacy’ means an inde-
24
pendent pharmacy, a chain pharmacy, a super-
25
market pharmacy, or a mass merchandiser phar-
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508
1
macy that is licensed as a pharmacy by the State
2
and that dispenses medications to the general public
3
at retail prices. Such term does not include a phar-
4
macy that dispenses prescription medications to pa-
5
tients primarily through the mail, nursing home
6
pharmacies, long-term care facility pharmacies, hos-
7
pital pharmacies, clinics, charitable or not-for-profit
8
pharmacies, government pharmacies, or pharmacy
9
benefit managers.
10
‘‘(11) WHOLESALER.—The term ‘wholesaler’
11
means a drug wholesaler that is engaged in whole-
12
sale distribution of prescription drugs to retail com-
13
munity pharmacies, including (but not limited to)
14
manufacturers, repackers, distributors, own-label
15
distributors, private-label distributors, jobbers, bro-
16
kers, warehouses (including manufacturer’s and dis-
17
tributor’s warehouses, chain drug warehouses, and
18
wholesale drug warehouses) independent wholesale
19
drug traders, and retail community pharmacies that
20
conduct wholesale distributions.’’.
21
(b) DISCLOSURE
OF
PRICE INFORMATION
TO THE
22 PUBLIC.—Section 1927(b)(3) of such Act (42 U.S.C.
23 1396r–8(b)(3)) is amended—
24
(1) in subparagraph (A)—
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1
2
(A) in the first sentence, by inserting after
clause (iii) the following:
3
‘‘(iv) not later than 30 days after the
4
last day of each month of a rebate period
5
under the agreement, on the manufactur-
6
er’s total number of units that are used to
7
calculate the monthly average manufac-
8
turer price for each covered outpatient
9
drug;’’; and
10
(B) in the second sentence, by inserting
11
‘‘(relating to the weighted average of the most
12
recently reported monthly average manufacturer
13
prices)’’ after ‘‘(D)(v)’’; and
14
(2) in subparagraph (D)(v), by striking ‘‘aver-
15
age manufacturer prices’’ and inserting ‘‘the weight-
16
ed average of the most recently reported monthly av-
17
erage manufacturer prices and the average retail
18
survey price determined for each multiple source
19
drug in accordance with subsection (f)’’.
20
(c) CLARIFICATION
OF
APPLICATION
OF
SURVEY
OF
21 RETAIL PRICES.—Section 1927(f)(1) of such Act (42
22 U.S.C. 1396r–8(b)(1)) is amended—
23
(1) in subparagraph (A)(i), by inserting ‘‘with
24
respect to a retail community pharmacy,’’ before
25
‘‘the determination’’; and
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510
1
(2) in subparagraph (C)(ii), by striking ‘‘retail
2
pharmacies’’ and inserting ‘‘retail community phar-
3
macies’’.
4
(d) EFFECTIVE DATE.—The amendments made by
5 this section shall take effect on the first day of the first
6 calendar year quarter that begins at least 180 days after
7 the date of enactment of this Act, without regard to
8 whether or not final regulations to carry out such amend9 ments have been promulgated by such date.
12
Subtitle G—Medicaid Disproportionate Share Hospital (DSH)
Payments
13
SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAY-
10
11
14
15
MENTS.
(a) IN GENERAL.—Section 1923(f) of the Social Se-
16 curity Act (42 U.S.C. 1396r–4(f)) is amended—
17
18
19
20
21
22
23
24
(1) in paragraph (1), by striking ‘‘and (3)’’ and
inserting ‘‘, (3), and (7)’’;
(2) in paragraph (3)(A), by striking ‘‘paragraph
(6)’’ and inserting ‘‘paragraphs (6) and (7)’’;
(3) by redesignating paragraph (7) as paragraph (8); and
(4) by inserting after paragraph (6) the following new paragraph:
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1
‘‘(7) REDUCTION
2
ONCE
3
REACHED.—
4
REDUCTION
‘‘(A) IN
OF STATE DSH ALLOTMENTS
IN
UNINSURED
GENERAL.—Subject
THRESHOLD
to subpara-
5
graph (E), the DSH allotment for a State for
6
fiscal years beginning with the fiscal year de-
7
scribed in subparagraph (C) (with respect to
8
the State), is equal to—
9
‘‘(i) in the case of the first fiscal year
10
described in subparagraph (C) with respect
11
to a State, the DSH allotment that would
12
be determined under this subsection for
13
the State for the fiscal year without appli-
14
cation of this paragraph (but after the ap-
15
plication of subparagraph (D)), reduced by
16
the applicable percentage determined for
17
the State for the fiscal year under sub-
18
paragraph (B)(i); and
19
‘‘(ii) in the case of any subsequent fis-
20
cal year with respect to the State, the
21
DSH allotment determined under this
22
paragraph for the State for the preceding
23
fiscal year, reduced by the applicable per-
24
centage determined for the State for the
25
fiscal year under subparagraph (B)(ii).
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1
‘‘(B)
APPLICABLE
PERCENTAGE.—For
2
purposes of subparagraph (A), the applicable
3
percentage for a State for a fiscal year is the
4
following:
5
‘‘(i) UNINSURED
REDUCTION THRESH-
6
OLD FISCAL YEAR.—In
7
fiscal year described in subparagraph (C)
8
with respect to the State—
the case of the first
9
‘‘(I) if the State is a low DSH
10
State described in paragraph (5)(B),
11
the applicable percentage is equal to
12
25 percent; and
13
‘‘(II) if the State is any other
14
State, the applicable percentage is 50
15
percent.
16
‘‘(ii) SUBSEQUENT
FISCAL YEARS IN
17
WHICH THE PERCENTAGE OF UNINSURED
18
DECREASES.—In
19
year after the first fiscal year described in
20
subparagraph (C) with respect to a State,
21
if the Secretary determines on the basis of
22
the most recent American Community Sur-
23
vey of the Bureau of the Census, that the
24
percentage of uncovered individuals resid-
25
ing in the State is less than the percentage
the case of any fiscal
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1
of such individuals determined for the
2
State for the preceding fiscal year—
3
‘‘(I) if the State is a low DSH
4
State described in paragraph (5)(B),
5
the applicable percentage is equal to
6
the product of the percentage reduc-
7
tion in uncovered individuals for the
8
fiscal year from the preceding fiscal
9
year and 25 percent; and
10
‘‘(II) if the State is any other
11
State, the applicable percentage is
12
equal to the product of the percentage
13
reduction in uncovered individuals for
14
the fiscal year from the preceding fis-
15
cal year and 50 percent.
16
‘‘(C) FISCAL
YEAR DESCRIBED.—For
pur-
17
poses of subparagraph (A), the fiscal year de-
18
scribed in this subparagraph with respect to a
19
State is the first fiscal year that occurs after
20
fiscal year 2012 for which the Secretary deter-
21
mines, on the basis of the most recent Amer-
22
ican Community Survey of the Bureau of the
23
Census, that the percentage of uncovered indi-
24
viduals residing in the State is at least 45 per-
25
cent less than the percentage of such individ-
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514
1
uals determined for the State for fiscal year
2
2009.
3
‘‘(D) EXCLUSION
OF PORTIONS DIVERTED
4
FOR COVERAGE EXPANSIONS.—For
5
applying the applicable percentage reduction
6
under subparagraph (A) to the DSH allotment
7
for a State for a fiscal year, the DSH allotment
8
for a State that would be determined under this
9
subsection for the State for the fiscal year with-
10
out the application of this paragraph (and prior
11
to any such reduction) shall not include any
12
portion of the allotment for which the Secretary
13
has approved the State’s diversion to the costs
14
of providing medical assistance or other health
15
benefits coverage under a waiver that is in ef-
16
fect on July 2009.
17
‘‘(E) MINIMUM
purposes of
ALLOTMENT.—In
no event
18
shall the DSH allotment determined for a State
19
in accordance with this paragraph for fiscal
20
year 2013 or any succeeding fiscal year be less
21
than the amount equal to 35 percent of the
22
DSH allotment determined for the State for fis-
23
cal year 2012 under this subsection (and after
24
the application of this paragraph, if applicable),
25
increased by the percentage change in the con-
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1
sumer price index for all urban consumers (all
2
items, U.S. city average) for each previous fis-
3
cal year occurring before the fiscal year.
4
‘‘(F) UNCOVERED
INDIVIDUALS.—In
this
5
paragraph, the term ‘uncovered individuals’
6
means individuals with no health insurance cov-
7
erage at any time during a year (as determined
8
by the Secretary based on the most recent data
9
available).’’.
10
(b) EFFECTIVE DATE.—The amendments made by
11 subsection (a) take effect on October 1, 2011.
14
Subtitle H—Improved Coordination for Dual Eligible Beneficiaries
15
SEC.
12
13
16
17
2601.
5-YEAR
PERIOD
FOR
DEMONSTRATION
PROJECTS.
(a) IN GENERAL.—Section 1915(h) of the Social Se-
18 curity Act (42 U.S.C. 1396n(h)) is amended—
19
(1) by inserting ‘‘(1)’’ after ‘‘(h)’’;
20
(2) by inserting ‘‘, or a waiver described in
21
22
paragraph (2)’’ after ‘‘(e)’’; and
(3) by adding at the end the following new
23
paragraph:
24
‘‘(2)(A) Notwithstanding subsections (c)(3) and (d)
25 (3), any waiver under subsection (b), (c), or (d), or a waiv-
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516
1 er under section 1115, that provides medical assistance
2 for dual eligible individuals (including any such waivers
3 under which non dual eligible individuals may be enrolled
4 in addition to dual eligible individuals) may be conducted
5 for a period of 5 years and, upon the request of the State,
6 may be extended for additional 5-year periods unless the
7 Secretary determines that for the previous waiver period
8 the conditions for the waiver have not been met or it would
9 no longer be cost-effective and efficient, or consistent with
10 the purposes of this title, to extend the waiver.
11
‘‘(B) In this paragraph, the term ‘dual eligible indi-
12 vidual’ means an individual who is entitled to, or enrolled
13 for, benefits under part A of title XVIII, or enrolled for
14 benefits under part B of title XVIII, and is eligible for
15 medical assistance under the State plan under this title
16 or under a waiver of such plan.’’.
17
18
19
(b) CONFORMING AMENDMENTS.—
(1) Section 1915 of such Act (42 U.S.C.
1396n) is amended—
20
(A) in subsection (b), by adding at the end
21
the following new sentence: ‘‘Subsection (h)(2)
22
shall apply to a waiver under this subsection.’’;
23
(B) in subsection (c)(3), in the second sen-
24
tence, by inserting ‘‘(other than a waiver de-
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517
1
scribed in subsection (h)(2))’’ after ‘‘A waiver
2
under this subsection’’;
3
(C) in subsection (d)(3), in the second sen-
4
tence, by inserting ‘‘(other than a waiver de-
5
scribed in subsection (h)(2))’’ after ‘‘A waiver
6
under this subsection’’.
7
(2) Section 1115 of such Act (42 U.S.C. 1315)
8
is amended—
9
(A) in subsection (e)(2), by inserting ‘‘(5
10
years, in the case of a waiver described in sec-
11
tion 1915(h)(2))’’ after ‘‘3 years’’; and
12
(B) in subsection (f)(6), by inserting ‘‘(5
13
years, in the case of a waiver described in sec-
14
tion 1915(h)(2))’’ after ‘‘3 years’’.
15
SEC. 2602. PROVIDING FEDERAL COVERAGE AND PAYMENT
16
COORDINATION FOR DUAL ELIGIBLE BENE-
17
FICIARIES.
18
(a) ESTABLISHMENT
OF
FEDERAL COORDINATED
19 HEALTH CARE OFFICE.—
20
(1) IN
GENERAL.—Not
later than March 1,
21
2010, the Secretary of Health and Human Services
22
(in this section referred to as the ‘‘Secretary’’) shall
23
establish a Federal Coordinated Health Care Office.
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1
(2) ESTABLISHMENT
2
ADMINISTRATOR.—The
3
Care Office—
4
5
AND REPORTING TO CMS
Federal Coordinated Health
(A) shall be established within the Centers
for Medicare & Medicaid Services; and
6
(B) have as the Office a Director who shall
7
be appointed by, and be in direct line of author-
8
ity to, the Administrator of the Centers for
9
Medicare & Medicaid Services.
10
(b) PURPOSE.—The purpose of the Federal Coordi-
11 nated Health Care Office is to bring together officers and
12 employees of the Medicare and Medicaid programs at the
13 Centers for Medicare & Medicaid Services in order to—
14
(1) more effectively integrate benefits under the
15
Medicare program under title XVIII of the Social
16
Security Act and the Medicaid program under title
17
XIX of such Act; and
18
(2) improve the coordination between the Fed-
19
eral Government and States for individuals eligible
20
for benefits under both such programs in order to
21
ensure that such individuals get full access to the
22
items and services to which they are entitled under
23
titles XVIII and XIX of the Social Security Act.
24
(c) GOALS.—The goals of the Federal Coordinated
25 Health Care Office are as follows:
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1
(1) Providing dual eligible individuals full ac-
2
cess to the benefits to which such individuals are en-
3
titled under the Medicare and Medicaid programs.
4
(2) Simplifying the processes for dual eligible
5
individuals to access the items and services they are
6
entitled to under the Medicare and Medicaid pro-
7
grams.
8
9
(3) Improving the quality of health care and
long-term services for dual eligible individuals.
10
(4) Increasing dual eligible individuals’ under-
11
standing of and satisfaction with coverage under the
12
Medicare and Medicaid programs.
13
14
(5) Eliminating regulatory conflicts between
rules under the Medicare and Medicaid programs.
15
(6) Improving care continuity and ensuring safe
16
and effective care transitions for dual eligible indi-
17
viduals.
18
(7) Eliminating cost-shifting between the Medi-
19
care and Medicaid program and among related
20
health care providers.
21
(8) Improving the quality of performance of
22
providers of services and suppliers under the Medi-
23
care and Medicaid programs.
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1
(d) SPECIFIC RESPONSIBILITIES.—The specific re-
2 sponsibilities of the Federal Coordinated Health Care Of3 fice are as follows:
4
(1) Providing States, specialized MA plans for
5
special needs individuals (as defined in section
6
1859(b)(6) of the Social Security Act (42 U.S.C.
7
1395w–28(b)(6))), physicians and other relevant en-
8
tities or individuals with the education and tools nec-
9
essary for developing programs that align benefits
10
under the Medicare and Medicaid programs for dual
11
eligible individuals.
12
(2) Supporting State efforts to coordinate and
13
align acute care and long-term care services for dual
14
eligible individuals with other items and services fur-
15
nished under the Medicare program.
16
(3) Providing support for coordination of con-
17
tracting and oversight by States and the Centers for
18
Medicare & Medicaid Services with respect to the in-
19
tegration of the Medicare and Medicaid programs in
20
a manner that is supportive of the goals described
21
in paragraph (3).
22
(4) To consult and coordinate with the Medi-
23
care Payment Advisory Commission established
24
under section 1805 of the Social Security Act (42
25
U.S.C. 1395b–6) and the Medicaid and CHIP Pay-
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1
ment and Access Commission established under sec-
2
tion 1900 of such Act (42 U.S.C. 1396) with respect
3
to policies relating to the enrollment in, and provi-
4
sion of, benefits to dual eligible individuals under the
5
Medicare program under title XVIII of the Social
6
Security Act and the Medicaid program under title
7
XIX of such Act.
8
(5) To study the provision of drug coverage for
9
new full-benefit dual eligible individuals (as defined
10
in section 1935(c)(6) of the Social Security Act (42
11
U.S.C. 1396u–5(c)(6)), as well as to monitor and re-
12
port annual total expenditures, health outcomes, and
13
access to benefits for all dual eligible individuals.
14
(e) REPORT.—The Secretary shall, as part of the
15 budget transmitted under section 1105(a) of title 31,
16 United States Code, submit to Congress an annual report
17 containing recommendations for legislation that would im18 prove care coordination and benefits for dual eligible indi19 viduals.
20
(f) DUAL ELIGIBLE DEFINED.—In this section, the
21 term ‘‘dual eligible individual’’ means an individual who
22 is entitled to, or enrolled for, benefits under part A of title
23 XVIII of the Social Security Act, or enrolled for benefits
24 under part B of title XVIII of such Act, and is eligible
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1 for medical assistance under a State plan under title XIX
2 of such Act or under a waiver of such plan.
5
Subtitle I—Improving the Quality
of Medicaid for Patients and
Providers
6
SEC. 2701. ADULT HEALTH QUALITY MEASURES.
3
4
7
Title XI of the Social Security Act (42 U.S.C. 1301
8 et seq.), as amended by section 401 of the Children’s
9 Health Insurance Program Reauthorization Act of 2009
10 (Public Law 111-3), is amended by inserting after section
11 1139A the following new section:
12
‘‘SEC. 1139B. ADULT HEALTH QUALITY MEASURES.
13
‘‘(a) DEVELOPMENT OF CORE SET OF HEALTH CARE
14 QUALITY MEASURES
15
FITS
FOR
ADULTS ELIGIBLE
FOR
BENE-
UNDER MEDICAID.—The Secretary shall identify
16 and publish a recommended core set of adult health qual17 ity measures for Medicaid eligible adults in the same man18 ner as the Secretary identifies and publishes a core set
19 of child health quality measures under section 1139A, in20 cluding with respect to identifying and publishing existing
21 adult health quality measures that are in use under public
22 and privately sponsored health care coverage arrange23 ments, or that are part of reporting systems that measure
24 both the presence and duration of health insurance cov-
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1 erage over time, that may be applicable to Medicaid eligi2 ble adults.
3
4
‘‘(b) DEADLINES.—
‘‘(1) RECOMMENDED
MEASURES.—Not
later
5
than January 1, 2011, the Secretary shall identify
6
and publish for comment a recommended core set of
7
adult health quality measures for Medicaid eligible
8
adults.
9
‘‘(2) DISSEMINATION.—Not later than January
10
1, 2012, the Secretary shall publish an initial core
11
set of adult health quality measures that are appli-
12
cable to Medicaid eligible adults.
13
‘‘(3) STANDARDIZED
REPORTING.—Not
later
14
than January 1, 2013, the Secretary, in consultation
15
with States, shall develop a standardized format for
16
reporting information based on the initial core set of
17
adult health quality measures and create procedures
18
to encourage States to use such measures to volun-
19
tarily report information regarding the quality of
20
health care for Medicaid eligible adults.
21
‘‘(4) REPORTS
TO CONGRESS.—Not
later than
22
January 1, 2014, and every 3 years thereafter, the
23
Secretary shall include in the report to Congress re-
24
quired under section 1139A(a)(6) information simi-
25
lar to the information required under that section
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1
with respect to the measures established under this
2
section.
3
‘‘(5) ESTABLISHMENT
4
MEASUREMENT PROGRAM.—
5
‘‘(A) IN
OF MEDICAID QUALITY
GENERAL.—Not
later than 12
6
months after the release of the recommended
7
core set of adult health quality measures under
8
paragraph (1)), the Secretary shall establish a
9
Medicaid Quality Measurement Program in the
10
same manner as the Secretary establishes the
11
pediatric quality measures program under sec-
12
tion 1139A(b). The aggregate amount awarded
13
by the Secretary for grants and contracts for
14
the development, testing, and validation of
15
emerging and innovative evidence-based meas-
16
ures under such program shall equal the aggre-
17
gate amount awarded by the Secretary for
18
grants under section 1139A(b)(4)(A)
19
‘‘(B) REVISING,
STRENGTHENING, AND IM-
20
PROVING INITIAL CORE MEASURES.—Beginning
21
not later than 24 months after the establish-
22
ment of the Medicaid Quality Measurement
23
Program, and annually thereafter, the Sec-
24
retary shall publish recommended changes to
25
the initial core set of adult health quality meas-
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1
ures that shall reflect the results of the testing,
2
validation, and consensus process for the devel-
3
opment of adult health quality measures.
4
‘‘(c) CONSTRUCTION.—Nothing in this section shall
5 be construed as supporting the restriction of coverage,
6 under title XIX or XXI or otherwise, to only those services
7 that are evidence-based, or in anyway limiting available
8 services.
9
‘‘(d) ANNUAL STATE REPORTS REGARDING STATE-
10 SPECIFIC QUALITY
OF
CARE MEASURES APPLIED UNDER
11 MEDICAID.—
12
‘‘(1) ANNUAL
STATE REPORTS.—Each
State
13
with a State plan or waiver approved under title
14
XIX shall annually report (separately or as part of
15
the annual report required under section 1139A(c)),
16
to the Secretary on the—
17
‘‘(A) State-specific adult health quality
18
measures applied by the State under the such
19
plan, including measures described in sub-
20
section (a)(5); and
21
‘‘(B) State-specific information on the
22
quality of health care furnished to Medicaid eli-
23
gible adults under such plan, including informa-
24
tion collected through external quality reviews
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1
of managed care organizations under section
2
1932 and benchmark plans under section 1937.
3
‘‘(2) PUBLICATION.—Not later than September
4
30, 2014, and annually thereafter, the Secretary
5
shall collect, analyze, and make publicly available the
6
information reported by States under paragraph (1).
7
‘‘(e) APPROPRIATION.—Out of any funds in the
8 Treasury not otherwise appropriated, there is appro9 priated for each of fiscal years 2010 through 2014,
10 $60,000,000 for the purpose of carrying out this section.
11 Funds appropriated under this subsection shall remain
12 available until expended.’’.
13
14
15
SEC. 2702. PAYMENT ADJUSTMENT FOR HEALTH CARE-ACQUIRED CONDITIONS.
(a) IN GENERAL.—The Secretary of Health and
16 Human Services (in this subsection referred to as the
17 ‘‘Secretary’’) shall identify current State practices that
18 prohibit payment for health care-acquired conditions and
19 shall incorporate the practices identified, or elements of
20 such practices, which the Secretary determines appro21 priate for application to the Medicaid program in regula22 tions. Such regulations shall be effective as of July 1,
23 2011, and shall prohibit payments to States under section
24 1903 of the Social Security Act for any amounts expended
25 for providing medical assistance for health care-acquired
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1 conditions specified in the regulations. The regulations
2 shall ensure that the prohibition on payment for health
3 care-acquired conditions shall not result in a loss of access
4 to care or services for Medicaid beneficiaries.
5
(b) HEALTH CARE-ACQUIRED CONDITION.—In this
6 section. the term ‘‘health care-acquired condition’’ means
7 a medical condition for which an individual was diagnosed
8 that could be identified by a secondary diagnostic code de9 scribed in section 1886(d)(4)(D)(iv) of the Social Security
10 Act (42 U.S.C. 1395ww(d)(4)(D)(iv)).
11
(c) MEDICARE PROVISIONS.—In carrying out this
12 section, the Secretary shall apply to State plans (or waiv13 ers) under title XIX of the Social Security Act the regula14 tions promulgated pursuant to section 1886(d)(4)(D) of
15 such Act (42 U.S.C. 1395ww(d)(4)(D)) relating to the
16 prohibition of payments based on the presence of a sec17 ondary diagnosis code specified by the Secretary in such
18 regulations, as appropriate for the Medicaid program. The
19 Secretary may exclude certain conditions identified under
20 title XVIII of the Social Security Act for non-payment
21 under title XIX of such Act when the Secretary finds the
22 inclusion of such conditions to be inapplicable to bene23 ficiaries under title XIX.
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1
SEC. 2703. STATE OPTION TO PROVIDE HEALTH HOMES
2
FOR
3
TIONS.
4
ENROLLEES
WITH
CHRONIC
CONDI-
(a) STATE PLAN AMENDMENT.—Title XIX of the So-
5 cial Security Act (42 U.S.C. 1396a et seq.), as amended
6 by sections 2201 and 2305, is amended by adding at the
7 end the following new section:
8
9
10
11
‘‘SEC. 1945. STATE OPTION
NATED
UALS
CARE THROUGH
A
TO
PROVIDE COORDI-
HEALTH HOME
FOR
INDIVID-
WITH CHRONIC CONDITIONS.—
‘‘(a)
12 1902(a)(1)
IN
GENERAL.—Notwithstanding
(relating
to
statewideness),
section
section
13 1902(a)(10)(B) (relating to comparability), and any other
14 provision of this title for which the Secretary determines
15 it is necessary to waive in order to implement this section,
16 beginning January 1, 2011, a State, at its option as a
17 State plan amendment, may provide for medical assistance
18 under this title to eligible individuals with chronic condi19 tions who select a designated provider (as described under
20 subsection (h)(5)), a team of health care professionals (as
21 described under subsection (h)(6)) operating with such a
22 provider, or a health team (as described under subsection
23 (h)(7)) as the individual’s health home for purposes of
24 providing the individual with health home services.
25
‘‘(b) HEALTH HOME QUALIFICATION STANDARDS.—
26 The Secretary shall establish standards for qualification
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1 as a designated provider for the purpose of being eligible
2 to be a health home for purposes of this section.
3
4
‘‘(c) PAYMENTS.—
‘‘(1) IN
GENERAL.—A
State shall provide a des-
5
ignated provider, a team of health care professionals
6
operating with such a provider, or a health team
7
with payments for the provision of health home serv-
8
ices to each eligible individual with chronic condi-
9
tions that selects such provider, team of health care
10
professionals, or health team as the individual’s
11
health home. Payments made to a designated pro-
12
vider, a team of health care professionals operating
13
with such a provider, or a health team for such serv-
14
ices shall be treated as medical assistance for pur-
15
poses of section 1903(a), except that, during the
16
first 8 fiscal year quarters that the State plan
17
amendment is in effect, the Federal medical assist-
18
ance percentage applicable to such payments shall be
19
equal to 90 percent.
20
21
‘‘(2) METHODOLOGY.—
‘‘(A) IN
GENERAL.—The
State shall speci-
22
fy in the State plan amendment the method-
23
ology the State will use for determining pay-
24
ment for the provision of health home services.
25
Such methodology for determining payment—
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1
‘‘(i) may be tiered to reflect, with re-
2
spect to each eligible individual with chron-
3
ic conditions provided such services by a
4
designated provider, a team of health care
5
professionals operating with such a pro-
6
vider, or a health team, as well as the se-
7
verity or number of each such individual’s
8
chronic conditions or the specific capabili-
9
ties of the provider, team of health care
10
11
professionals, or health team; and
‘‘(ii) shall be established consistent
12
with section 1902(a)(30)(A).
13
‘‘(B) ALTERNATE
MODELS OF PAYMENT.—
14
The methodology for determining payment for
15
provision of health home services under this
16
section shall not be limited to a per-member
17
per-month basis and may provide (as proposed
18
by the State and subject to approval by the
19
Secretary) for alternate models of payment.
20
‘‘(3) PLANNING
21
‘‘(A) IN
GRANTS.—
GENERAL.—Beginning
January 1,
22
2011, the Secretary may award planning grants
23
to States for purposes of developing a State
24
plan amendment under this section. A planning
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1
grant awarded to a State under this paragraph
2
shall remain available until expended.
3
‘‘(B)
STATE
CONTRIBUTION.—A
State
4
awarded a planning grant shall contribute an
5
amount equal to the State percentage deter-
6
mined under section 1905(b) (without regard to
7
section 5001 of Public Law 111–5) for each fis-
8
cal year for which the grant is awarded.
9
‘‘(C) LIMITATION.—The total amount of
10
payments made to States under this paragraph
11
shall not exceed $25,000,000.
12
‘‘(d) HOSPITAL REFERRALS.—A State shall include
13 in the State plan amendment a requirement for hospitals
14 that are participating providers under the State plan or
15 a waiver of such plan to establish procedures for referring
16 any eligible individuals with chronic conditions who seek
17 or need treatment in a hospital emergency department to
18 designated providers.
19
‘‘(e) COORDINATION.—A State shall consult and co-
20 ordinate, as appropriate, with the Substance Abuse and
21 Mental Health Services Administration in addressing
22 issues regarding the prevention and treatment of mental
23 illness and substance abuse among eligible individuals with
24 chronic conditions.
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1
‘‘(f) MONITORING.—A State shall include in the State
2 plan amendment—
3
‘‘(1) a methodology for tracking avoidable hos-
4
pital readmissions and calculating savings that re-
5
sult from improved chronic care coordination and
6
management under this section; and
7
‘‘(2) a proposal for use of health information
8
technology in providing health home services under
9
this section and improving service delivery and co-
10
ordination across the care continuum (including the
11
use of wireless patient technology to improve coordi-
12
nation and management of care and patient adher-
13
ence to recommendations made by their provider).
14
‘‘(g) REPORT
ON
QUALITY MEASURES.—As a condi-
15 tion for receiving payment for health home services pro16 vided to an eligible individual with chronic conditions, a
17 designated provider shall report to the State, in accord18 ance with such requirements as the Secretary shall specify,
19 on all applicable measures for determining the quality of
20 such services. When appropriate and feasible, a designated
21 provider shall use health information technology in pro22 viding the State with such information.
23
24
25
‘‘(h) DEFINITIONS.—In this section:
‘‘(1) ELIGIBLE
CONDITIONS.—
INDIVIDUAL
WITH
CHRONIC
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1
‘‘(A) IN
GENERAL.—Subject
to subpara-
2
graph (B), the term ‘eligible individual with
3
chronic conditions’ means an individual who—
4
‘‘(i) is eligible for medical assistance
5
under the State plan or under a waiver of
6
such plan; and
7
‘‘(ii) has at least—
8
‘‘(I) 2 chronic conditions;
9
‘‘(II) 1 chronic condition and is
10
at risk of having a second chronic
11
condition; or
12
‘‘(III) 1 serious and persistent
13
mental health condition.
14
‘‘(B) RULE
OF CONSTRUCTION.—Nothing
15
in this paragraph shall prevent the Secretary
16
from establishing higher levels as to the number
17
or severity of chronic or mental health condi-
18
tions for purposes of determining eligibility for
19
receipt of health home services under this sec-
20
tion.
21
‘‘(2) CHRONIC
CONDITION.—The
term ‘chronic
22
condition’ has the meaning given that term by the
23
Secretary and shall include, but is not limited to, the
24
following:
25
‘‘(A) A mental health condition.
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1
‘‘(B) Substance use disorder.
2
‘‘(C) Asthma.
3
‘‘(D) Diabetes.
4
‘‘(E) Heart disease.
5
‘‘(F) Being overweight, as evidenced by
6
having a Body Mass Index (BMI) over 25.
7
‘‘(3) HEALTH
HOME.—The
term ‘health home’
8
means a designated provider (including a provider
9
that operates in coordination with a team of health
10
care professionals) or a health team selected by an
11
eligible individual with chronic conditions to provide
12
health home services.
13
‘‘(4) HEALTH
14
‘‘(A) IN
HOME SERVICES.—
GENERAL.—The
term ‘health
15
home services’ means comprehensive and timely
16
high-quality services described in subparagraph
17
(B) that are provided by a designated provider,
18
a team of health care professionals operating
19
with such a provider, or a health team.
20
21
‘‘(B) SERVICES
DESCRIBED.—The
services
described in this subparagraph are—
22
‘‘(i) comprehensive care management;
23
‘‘(ii) care coordination and health pro-
24
motion;
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1
‘‘(iii) comprehensive transitional care,
2
including appropriate follow-up, from inpa-
3
tient to other settings;
4
5
6
7
‘‘(iv) patient and family support (including authorized representatives);
‘‘(v) referral to community and social
support services, if relevant; and
8
‘‘(vi) use of health information tech-
9
nology to link services, as feasible and ap-
10
propriate.
11
‘‘(5) DESIGNATED
PROVIDER.—The
term ‘des-
12
ignated provider’ means a physician, clinical practice
13
or clinical group practice, rural clinic, community
14
health center, community mental health center,
15
home health agency, or any other entity or provider
16
(including pediatricians, gynecologists, and obstetri-
17
cians) that is determined by the State and approved
18
by the Secretary to be qualified to be a health home
19
for eligible individuals with chronic conditions on the
20
basis of documentation evidencing that the physi-
21
cian, practice, or clinic—
22
23
‘‘(A) has the systems and infrastructure in
place to provide health home services; and
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1
‘‘(B) satisfies the qualification standards
2
established by the Secretary under subsection
3
(b).
4
‘‘(6)
TEAM
OF
HEALTH
CARE
PROFES-
5
SIONALS.—The
6
sionals’ means a team of health professionals (as de-
7
scribed in the State plan amendment) that may—
term ‘team of health care profes-
8
‘‘(A) include physicians and other profes-
9
sionals, such as a nurse care coordinator, nutri-
10
tionist, social worker, behavioral health profes-
11
sional, or any professionals deemed appropriate
12
by the State; and
13
‘‘(B) be free standing, virtual, or based at
14
a hospital, community health center, community
15
mental health center, rural clinic, clinical prac-
16
tice or clinical group practice, academic health
17
center, or any entity deemed appropriate by the
18
State and approved by the Secretary.
19
‘‘(7) HEALTH
TEAM.—The
term ‘health team’
20
has the meaning given such term for purposes of
21
section 3502 of the Patient Protection and Afford-
22
able Care Act.’’.
23
(b) EVALUATION.—
24
(1) INDEPENDENT
EVALUATION.—
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1
(A) IN
GENERAL.—The
Secretary shall
2
enter into a contract with an independent entity
3
or organization to conduct an evaluation and
4
assessment of the States that have elected the
5
option to provide coordinated care through a
6
health home for Medicaid beneficiaries with
7
chronic conditions under section 1945 of the
8
Social Security Act (as added by subsection (a))
9
for the purpose of determining the effect of
10
such option on reducing hospital admissions,
11
emergency room visits, and admissions to
12
skilled nursing facilities.
13
(B) EVALUATION
REPORT.—Not
later than
14
January 1, 2017, the Secretary shall report to
15
Congress on the evaluation and assessment con-
16
ducted under subparagraph (A).
17
(2) SURVEY
18
(A) IN
AND INTERIM REPORT.—
GENERAL.—Not
later than January
19
1, 2014, the Secretary of Health and Human
20
Services shall survey States that have elected
21
the option under section 1945 of the Social Se-
22
curity Act (as added by subsection (a)) and re-
23
port to Congress on the nature, extent, and use
24
of such option, particularly as it pertains to—
25
(i) hospital admission rates;
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1
(ii) chronic disease management;
2
(iii) coordination of care for individ-
3
uals with chronic conditions;
4
5
(iv) assessment of program implementation;
6
7
(v) processes and lessons learned (as
described in subparagraph (B));
8
(vi) assessment of quality improve-
9
ments and clinical outcomes under such
10
option; and
11
12
(vii) estimates of cost savings.
(B)
IMPLEMENTATION
REPORTING.—A
13
State that has elected the option under section
14
1945 of the Social Security Act (as added by
15
subsection (a)) shall report to the Secretary, as
16
necessary, on processes that have been devel-
17
oped and lessons learned regarding provision of
18
coordinated care through a health home for
19
Medicaid beneficiaries with chronic conditions
20
under such option.
21
SEC. 2704. DEMONSTRATION PROJECT TO EVALUATE INTE-
22
GRATED CARE AROUND A HOSPITALIZATION.
23
24
25
(a) AUTHORITY TO CONDUCT PROJECT.—
(1) IN
GENERAL.—The
Secretary of Health and
Human Services (in this section referred to as the
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539
1
‘‘Secretary’’) shall establish a demonstration project
2
under title XIX of the Social Security Act to evalu-
3
ate the use of bundled payments for the provision of
4
integrated care for a Medicaid beneficiary—
5
6
7
(A) with respect to an episode of care that
includes a hospitalization; and
(B) for concurrent physicians services pro-
8
vided during a hospitalization.
9
(2) DURATION.—The demonstration project
10
shall begin on January 1, 2012, and shall end on
11
December 31, 2016.
12
(b) REQUIREMENTS.—The demonstration project
13 shall be conducted in accordance with the following:
14
(1) The demonstration project shall be con-
15
ducted in up to 8 States, determined by the Sec-
16
retary based on consideration of the potential to
17
lower costs under the Medicaid program while im-
18
proving care for Medicaid beneficiaries. A State se-
19
lected to participate in the demonstration project
20
may target the demonstration project to particular
21
categories of beneficiaries, beneficiaries with par-
22
ticular diagnoses, or particular geographic regions of
23
the State, but the Secretary shall insure that, as a
24
whole, the demonstration project is, to the greatest
25
extent possible, representative of the demographic
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540
1
and geographic composition of Medicaid beneficiaries
2
nationally.
3
(2) The demonstration project shall focus on
4
conditions where there is evidence of an opportunity
5
for providers of services and suppliers to improve the
6
quality of care furnished to Medicaid beneficiaries
7
while reducing total expenditures under the State
8
Medicaid programs selected to participate, as deter-
9
mined by the Secretary.
10
(3) A State selected to participate in the dem-
11
onstration project shall specify the 1 or more epi-
12
sodes of care the State proposes to address in the
13
project, the services to be included in the bundled
14
payments, and the rationale for the selection of such
15
episodes of care and services. The Secretary may
16
modify the episodes of care as well as the services
17
to be included in the bundled payments prior to or
18
after approving the project. The Secretary may also
19
vary such factors among the different States partici-
20
pating in the demonstration project.
21
(4) The Secretary shall ensure that payments
22
made under the demonstration project are adjusted
23
for severity of illness and other characteristics of
24
Medicaid beneficiaries within a category or having a
25
diagnosis targeted as part of the demonstration
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1
project. States shall ensure that Medicaid bene-
2
ficiaries are not liable for any additional cost sharing
3
than if their care had not been subject to payment
4
under the demonstration project.
5
(5) Hospitals participating in the demonstration
6
project shall have or establish robust discharge plan-
7
ning programs to ensure that Medicaid beneficiaries
8
requiring post-acute care are appropriately placed in,
9
or have ready access to, post-acute care settings.
10
(6) The Secretary and each State selected to
11
participate in the demonstration project shall ensure
12
that the demonstration project does not result in the
13
Medicaid beneficiaries whose care is subject to pay-
14
ment under the demonstration project being pro-
15
vided with less items and services for which medical
16
assistance is provided under the State Medicaid pro-
17
gram than the items and services for which medical
18
assistance would have been provided to such bene-
19
ficiaries under the State Medicaid program in the
20
absence of the demonstration project.
21
(c) WAIVER
OF
PROVISIONS.—Notwithstanding sec-
22 tion 1115(a) of the Social Security Act (42 U.S.C.
23 1315(a)), the Secretary may waive such provisions of titles
24 XIX, XVIII, and XI of that Act as may be necessary to
25 accomplish the goals of the demonstration, ensure bene-
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1 ficiary access to acute and post-acute care, and maintain
2 quality of care.
3
(d) EVALUATION AND REPORT.—
4
(1) DATA.—Each State selected to participate
5
in the demonstration project under this section shall
6
provide to the Secretary, in such form and manner
7
as the Secretary shall specify, relevant data nec-
8
essary to monitor outcomes, costs, and quality, and
9
evaluate the rationales for selection of the episodes
10
of care and services specified by States under sub-
11
section (b)(3).
12
(2) REPORT.—Not later than 1 year after the
13
conclusion of the demonstration project, the Sec-
14
retary shall submit a report to Congress on the re-
15
sults of the demonstration project.
16
17
18
SEC. 2705. MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION PROJECT.
(a) IN GENERAL.—The Secretary of Health and
19 Human Services (referred to in this section as the ‘‘Sec20 retary’’) shall, in coordination with the Center for Medi21 care and Medicaid Innovation (as established under sec22 tion 1115A of the Social Security Act, as added by section
23 3021 of this Act), establish the Medicaid Global Payment
24 System Demonstration Project under which a partici25 pating State shall adjust the payments made to an eligible
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1 safety net hospital system or network from a fee-for-serv2 ice payment structure to a global capitated payment
3 model.
4
(b) DURATION
AND
SCOPE.—The demonstration
5 project conducted under this section shall operate during
6 a period of fiscal years 2010 through 2012. The Secretary
7 shall select not more than 5 States to participate in the
8 demonstration project.
9
(c) ELIGIBLE SAFETY NET HOSPITAL SYSTEM
OR
10 NETWORK.—For purposes of this section, the term ‘‘eligi11 ble safety net hospital system or network’’ means a large,
12 safety net hospital system or network (as defined by the
13 Secretary) that operates within a State selected by the
14 Secretary under subsection (b).
15
(d) EVALUATION.—
16
(1) TESTING.—The Innovation Center shall test
17
and evaluate the demonstration project conducted
18
under this section to examine any changes in health
19
care quality outcomes and spending by the eligible
20
safety net hospital systems or networks.
21
(2) BUDGET
NEUTRALITY.—During
the testing
22
period under paragraph (1), any budget neutrality
23
requirements under section 1115A(b)(3) of the So-
24
cial Security Act (as so added) shall not be applica-
25
ble.
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1
(3) MODIFICATION.—During the testing period
2
under paragraph (1), the Secretary may, in the Sec-
3
retary’s discretion, modify or terminate the dem-
4
onstration project conducted under this section.
5
(e) REPORT.—Not later than 12 months after the
6 date of completion of the demonstration project under this
7 section, the Secretary shall submit to Congress a report
8 containing the results of the evaluation and testing con9 ducted under subsection (d), together with recommenda10 tions for such legislation and administrative action as the
11 Secretary determines appropriate.
12
(f) AUTHORIZATION
OF
APPROPRIATIONS.—There
13 are authorized to be appropriated such sums as are nec14 essary to carry out this section.
15
16
17
18
SEC. 2706. PEDIATRIC ACCOUNTABLE CARE ORGANIZATION
DEMONSTRATION PROJECT.
(a) AUTHORITY TO CONDUCT DEMONSTRATION.—
(1) IN
GENERAL.—The
Secretary of Health and
19
Human Services (referred to in this section as the
20
‘‘Secretary’’) shall establish the Pediatric Account-
21
able Care Organization Demonstration Project to
22
authorize a participating State to allow pediatric
23
medical providers that meet specified requirements
24
to be recognized as an accountable care organization
25
for purposes of receiving incentive payments (as de-
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1
scribed under subsection (d)), in the same manner
2
as an accountable care organization is recognized
3
and provided with incentive payments under section
4
1899 of the Social Security Act (as added by section
5
3022).
6
(2) DURATION.—The demonstration project
7
shall begin on January 1, 2012, and shall end on
8
December 31, 2016.
9
(b) APPLICATION.—A State that desires to partici-
10 pate in the demonstration project under this section shall
11 submit to the Secretary an application at such time, in
12 such manner, and containing such information as the Sec13 retary may require.
14
15
(c) REQUIREMENTS.—
(1) PERFORMANCE
GUIDELINES.—The
Sec-
16
retary, in consultation with the States and pediatric
17
providers, shall establish guidelines to ensure that
18
the quality of care delivered to individuals by a pro-
19
vider recognized as an accountable care organization
20
under this section is not less than the quality of care
21
that would have otherwise been provided to such in-
22
dividuals.
23
(2) SAVINGS
REQUIREMENT.—A
participating
24
State, in consultation with the Secretary, shall es-
25
tablish an annual minimal level of savings in expend-
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1
itures for items and services covered under the Med-
2
icaid program under title XIX of the Social Security
3
Act and the CHIP program under title XXI of such
4
Act that must be reached by an accountable care or-
5
ganization in order for such organization to receive
6
an incentive payment under subsection (d).
7
(3) MINIMUM
PARTICIPATION PERIOD.—A
pro-
8
vider desiring to be recognized as an accountable
9
care organization under the demonstration project
10
shall enter into an agreement with the State to par-
11
ticipate in the project for not less than a 3-year pe-
12
riod.
13
(d) INCENTIVE PAYMENT.—An accountable care or-
14 ganization that meets the performance guidelines estab15 lished by the Secretary under subsection (c)(1) and
16 achieves savings greater than the annual minimal savings
17 level established by the State under subsection (c)(2) shall
18 receive an incentive payment for such year equal to a por19 tion (as determined appropriate by the Secretary) of the
20 amount of such excess savings. The Secretary may estab21 lish an annual cap on incentive payments for an account22 able care organization.
23
(e) AUTHORIZATION
OF
APPROPRIATIONS.—There
24 are authorized to be appropriated such sums as are nec25 essary to carry out this section.
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1
SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC DEM-
2
3
ONSTRATION PROJECT.
(a) AUTHORITY TO CONDUCT DEMONSTRATION
4 PROJECT.—The Secretary of Health and Human Services
5 (in this section referred to as the ‘‘Secretary’’) shall estab6 lish a demonstration project under which an eligible State
7 (as described in subsection (c)) shall provide payment
8 under the State Medicaid plan under title XIX of the So9 cial Security Act to an institution for mental diseases that
10 is not publicly owned or operated and that is subject to
11 the requirements of section 1867 of the Social Security
12 Act (42 U.S.C. 1395dd) for the provision of medical as13 sistance available under such plan to individuals who—
14
15
16
17
18
(1) have attained age 21, but have not attained
age 65;
(2) are eligible for medical assistance under
such plan; and
(3) require such medical assistance to stabilize
19
an emergency medical condition.
20
(b) STABILIZATION REVIEW.—A State shall specify
21 in its application described in subsection (c)(1) establish
22 a mechanism for how it will ensure that institutions par23 ticipating in the demonstration will determine whether or
24 not such individuals have been stabilized (as defined in
25 subsection (h)(5)) . This mechanism shall commence be26 fore the third day of the inpatient stay. States partici-
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1 pating in the demonstration project may manage the pro2 vision of services for the stabilization of medical emer3 gency conditions through utilization review, authorization,
4 or management practices, or the application of medical ne5 cessity and appropriateness criteria applicable to behav6 ioral health.
7
8
9
10
(c) ELIGIBLE STATE DEFINED.—
(1) IN
GENERAL.—An
eligible State is a State
that has made an application and has been selected
pursuant to paragraphs (2) and (3).
11
(2) APPLICATION.—A State seeking to partici-
12
pate in the demonstration project under this section
13
shall submit to the Secretary, at such time and in
14
such format as the Secretary requires, an applica-
15
tion that includes such information, provisions, and
16
assurances, as the Secretary may require.
17
(3) SELECTION.—A State shall be determined
18
eligible for the demonstration by the Secretary on a
19
competitive basis among States with applications
20
meeting the requirements of paragraph (1). In se-
21
lecting State applications for the demonstration
22
project, the Secretary shall seek to achieve an appro-
23
priate national balance in the geographic distribu-
24
tion of such projects.
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1
(d) LENGTH
DEMONSTRATION PROJECT.—The
OF
2 demonstration project established under this section shall
3 be conducted for a period of 3 consecutive years.
4
5
(e) LIMITATIONS ON FEDERAL FUNDING.—
(1) APPROPRIATION.—
6
(A) IN
GENERAL.—Out
of any funds in the
7
Treasury not otherwise appropriated, there is
8
appropriated
9
$75,000,000 for fiscal year 2011.
10
to
carry
(B) BUDGET
out
this
section,
AUTHORITY.—Subparagraph
11
(A) constitutes budget authority in advance of
12
appropriations Act and represents the obliga-
13
tion of the Federal Government to provide for
14
the payment of the amounts appropriated under
15
that subparagraph.
16
(2)
5-YEAR
AVAILABILITY.—Funds
appro-
17
priated under paragraph (1) shall remain available
18
for obligation through December 31, 2015.
19
20
(3) LIMITATION
ON PAYMENTS.—In
no case
may—
21
(A) the aggregate amount of payments
22
made by the Secretary to eligible States under
23
this section exceed $75,000,000; or
24
25
(B) payments be provided by the Secretary
under this section after December 31, 2015.
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1
(4) FUNDS
ALLOCATED TO STATES.—Funds
2
shall be allocated to eligible States on the basis of
3
criteria, including a State’s application and the
4
availability of funds, as determined by the Secretary.
5
(5) PAYMENTS
TO
STATES.—The
Secretary
6
shall pay to each eligible State, from its allocation
7
under paragraph (4), an amount each quarter equal
8
to the Federal medical assistance percentage of ex-
9
penditures in the quarter for medical assistance de-
10
scribed in subsection (a). As a condition of receiving
11
payment, a State shall collect and report informa-
12
tion, as determined necessary by the Secretary, for
13
the purposes of providing Federal oversight and con-
14
ducting an evaluation under subsection (f)(1).
15
(f) EVALUATION AND REPORT TO CONGRESS.—
16
(1) EVALUATION.—The Secretary shall conduct
17
an evaluation of the demonstration project in order
18
to determine the impact on the functioning of the
19
health and mental health service system and on indi-
20
viduals enrolled in the Medicaid program and shall
21
include the following:
22
(A) An assessment of access to inpatient
23
mental health services under the Medicaid pro-
24
gram; average lengths of inpatient stays; and
25
emergency room visits.
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1
2
(B) An assessment of discharge planning
by participating hospitals.
3
(C) An assessment of the impact of the
4
demonstration project on the costs of the full
5
range of mental health services (including inpa-
6
tient, emergency and ambulatory care).
7
(D) An analysis of the percentage of con-
8
sumers with Medicaid coverage who are admit-
9
ted to inpatient facilities as a result of the dem-
10
onstration project as compared to those admit-
11
ted to these same facilities through other
12
means.
13
(E) A recommendation regarding whether
14
the demonstration project should be continued
15
after December 31, 2013, and expanded on a
16
national basis.
17
(2) REPORT.—Not later than December 31,
18
2013, the Secretary shall submit to Congress and
19
make available to the public a report on the findings
20
of the evaluation under paragraph (1).
21
(g) WAIVER AUTHORITY.—
22
(1) IN
GENERAL.—The
Secretary shall waive
23
the limitation of subdivision (B) following paragraph
24
(28) of section 1905(a) of the Social Security Act
25
(42 U.S.C. 1396d(a)) (relating to limitations on pay-
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1
ments for care or services for individuals under 65
2
years of age who are patients in an institution for
3
mental diseases) for purposes of carrying out the
4
demonstration project under this section.
5
(2) LIMITED
OTHER WAIVER AUTHORITY.—The
6
Secretary may waive other requirements of titles XI
7
and XIX of the Social Security Act (including the
8
requirements of sections 1902(a)(1) (relating to
9
statewideness) and 1902(1)(10)(B) (relating to com-
10
parability)) only to extent necessary to carry out the
11
demonstration project under this section.
12
(h) DEFINITIONS.—In this section:
13
(1) EMERGENCY
MEDICAL
CONDITION.—The
14
term ‘‘emergency medical condition’’ means, with re-
15
spect to an individual, an individual who expresses
16
suicidal or homicidal thoughts or gestures, if deter-
17
mined dangerous to self or others.
18
(2) FEDERAL
MEDICAL ASSISTANCE PERCENT-
19
AGE.—The
20
centage’’ has the meaning given that term with re-
21
spect to a State under section 1905(b) of the Social
22
Security Act (42 U.S.C. 1396d(b)).
23
24
term ‘‘Federal medical assistance per-
(3) INSTITUTION
FOR MENTAL DISEASES.—The
term ‘‘institution for mental diseases’’ has the mean-
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553
1
ing given to that term in section 1905(i) of the So-
2
cial Security Act (42 U.S.C. 1396d(i)).
3
(4) MEDICAL
ASSISTANCE.—The
term ‘‘medical
4
assistance’’ has the meaning given that term in sec-
5
tion 1905(a) of the Social Security Act (42 U.S.C.
6
1396d(a)).
7
(5)
STABILIZED.—The
term
‘‘stabilized’’
8
means, with respect to an individual, that the emer-
9
gency medical condition no longer exists with respect
10
to the individual and the individual is no longer dan-
11
gerous to self or others.
12
(6) STATE.—The term ‘‘State’’ has the mean-
13
ing given that term for purposes of title XIX of the
14
Social Security Act (42 U.S.C. 1396 et seq.).
18
Subtitle J—Improvements to the
Medicaid and CHIP Payment
and
Access
Commission
(MACPAC)
19
SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING
20
ALL MEDICAID BENEFICIARIES.
15
16
17
21
(a) IN GENERAL.—Section 1900 of the Social Secu-
22 rity Act (42 U.S.C. 1396) is amended—
23
24
(1) in subsection (b)—
(A) in paragraph (1)—
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1
(i) in the paragraph heading, by in-
2
serting ‘‘FOR
3
ANNUAL’’;
4
5
ALL STATES’’
before ‘‘AND
and
(ii) in subparagraph (A), by striking
‘‘children’s’’;
6
(iii) in subparagraph (B), by inserting
7
‘‘, the Secretary, and States’’ after ‘‘Con-
8
gress’’;
9
(iv) in subparagraph (C), by striking
10
‘‘March 1’’ and inserting ‘‘March 15’’; and
11
(v) in subparagraph (D), by striking
12
‘‘June 1’’ and inserting ‘‘June 15’’;
13
(B) in paragraph (2)—
14
(i) in subparagraph (A)—
15
(I) in clause (i)—
16
(aa) by inserting ‘‘the effi-
17
cient provision of’’ after ‘‘expend-
18
itures for’’; and
19
(bb) by striking ‘‘hospital,
20
skilled nursing facility, physician,
21
Federally-qualified health center,
22
rural health center, and other
23
fees’’ and inserting ‘‘payments to
24
medical, dental, and health pro-
25
fessionals, hospitals, residential
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1
and long-term care providers,
2
providers of home and commu-
3
nity based services, Federally-
4
qualified health centers and rural
5
health clinics, managed care enti-
6
ties, and providers of other cov-
7
ered items and services’’; and
8
(II) in clause (iii), by inserting
9
‘‘(including how such factors and
10
methodologies
11
ficiaries to obtain the services for
12
which they are eligible, affect provider
13
supply, and affect providers that serve
14
a disproportionate share of low-income
15
and other vulnerable populations)’’
16
after ‘‘beneficiaries’’;
17
(ii) by redesignating subparagraphs
18
(B) and (C) as subparagraphs (F) and
19
(H), respectively;
20
enable
such
bene-
(iii) by inserting after subparagraph
21
(A), the following:
22
‘‘(B)
ELIGIBILITY
POLICIES.—Medicaid
23
and CHIP eligibility policies, including a deter-
24
mination of the degree to which Federal and
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1
State policies provide health care coverage to
2
needy populations.
3
‘‘(C) ENROLLMENT
AND RETENTION PROC-
4
ESSES.—Medicaid
5
retention processes, including a determination
6
of the degree to which Federal and State poli-
7
cies encourage the enrollment of individuals
8
who are eligible for such programs and screen
9
out individuals who are ineligible, while mini-
10
mizing the share of program expenses devoted
11
to such processes.
12
and CHIP enrollment and
‘‘(D) COVERAGE
POLICIES.—Medicaid
and
13
CHIP benefit and coverage policies, including a
14
determination of the degree to which Federal
15
and State policies provide access to the services
16
enrollees require to improve and maintain their
17
health and functional status.
18
‘‘(E) QUALITY
OF CARE.—Medicaid
and
19
CHIP policies as they relate to the quality of
20
care provided under those programs, including
21
a determination of the degree to which Federal
22
and State policies achieve their stated goals and
23
interact with similar goals established by other
24
purchasers of health care services.’’;
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1
(iv) by inserting after subparagraph
2
(F) (as redesignated by clause (ii) of this
3
subparagraph), the following:
4
‘‘(G) INTERACTIONS
WITH MEDICARE AND
5
MEDICAID.—Consistent
6
the interaction of policies under Medicaid and
7
the Medicare program under title XVIII, in-
8
cluding with respect to how such interactions
9
affect access to services, payments, and dual el-
10
with paragraph (11),
igible individuals.’’ and
11
(v) in subparagraph (H) (as so redes-
12
ignated), by inserting ‘‘and preventive,
13
acute, and long-term services and sup-
14
ports’’ after ‘‘barriers’’;
15
(C)
by
redesignating
paragraphs
(3)
16
through (9) as paragraphs (4) through (10), re-
17
spectively;
18
(D) by inserting after paragraph (2), the
19
following new paragraph:
20
‘‘(3) RECOMMENDATIONS
21
22
23
AND
STATE-SPECIFIC DATA.—MACPAC
REPORTS
OF
shall—
‘‘(A) review national and State-specific
Medicaid and CHIP data; and
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1
‘‘(B) submit reports and recommendations
2
to Congress, the Secretary, and States based on
3
such reviews.’’;
4
(E) in paragraph (4), as redesignated by
5
subparagraph (C), by striking ‘‘or any other
6
problems’’ and all that follows through the pe-
7
riod and inserting ‘‘, as well as other factors
8
that adversely affect, or have the potential to
9
adversely affect, access to care by, or the health
10
care status of, Medicaid and CHIP bene-
11
ficiaries. MACPAC shall include in the annual
12
report required under paragraph (1)(D) a de-
13
scription of all such areas or problems identi-
14
fied with respect to the period addressed in the
15
report.’’;
16
17
(F) in paragraph (5), as so redesignated,—
18
(i) in the paragraph heading, by in-
19
serting ‘‘AND
20
PORTS’’;
21
after ‘‘RE-
and
(ii) by striking ‘‘If’’ and inserting the
22
following:
23
‘‘(A) CERTAIN
24
REGULATIONS’’
If’’; and
SECRETARIAL REPORTS.—
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1
(iii) in the second sentence, by insert-
2
ing ‘‘and the Secretary’’ after ‘‘appropriate
3
committees of Congress’’; and
4
(iv) by adding at the end the fol-
5
lowing:
6
‘‘(B) REGULATIONS.—MACPAC shall re-
7
view Medicaid and CHIP regulations and may
8
comment through submission of a report to the
9
appropriate committees of Congress and the
10
Secretary, on any such regulations that affect
11
access, quality, or efficiency of health care.’’;
12
(G) in paragraph (10), as so redesignated,
13
by inserting ‘‘, and shall submit with any rec-
14
ommendations, a report on the Federal and
15
State-specific budget consequences of the rec-
16
ommendations’’ before the period; and
17
18
19
20
(H) by adding at the end the following:
‘‘(11)
CONSULTATION
AND
COORDINATION
WITH MEDPAC.—
‘‘(A) IN
GENERAL.—MACPAC
shall con-
21
sult with the Medicare Payment Advisory Com-
22
mission (in this paragraph referred to as
23
‘MedPAC’) established under section 1805 in
24
carrying out its duties under this section, as ap-
25
propriate and particularly with respect to the
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1
issues specified in paragraph (2) as they relate
2
to those Medicaid beneficiaries who are dually
3
eligible for Medicaid and the Medicare program
4
under title XVIII, adult Medicaid beneficiaries
5
(who are not dually eligible for Medicare), and
6
beneficiaries under Medicare. Responsibility for
7
analysis of and recommendations to change
8
Medicare
9
ficiaries, including Medicare beneficiaries who
10
are dually eligible for Medicare and Medicaid,
11
shall rest with MedPAC.
12
‘‘(B) INFORMATION
policy
regarding
Medicare
bene-
SHARING.—MACPAC
13
and MedPAC shall have access to deliberations
14
and records of the other such entity, respec-
15
tively, upon the request of the other such enti-
16
ty.
17
‘‘(12)
CONSULTATION
WITH
STATES.—
18
MACPAC shall regularly consult with States in car-
19
rying out its duties under this section, including
20
with respect to developing processes for carrying out
21
such duties, and shall ensure that input from States
22
is taken into account and represented in MACPAC’s
23
recommendations and reports.
24
‘‘(13) COORDINATE
25
AND CONSULT WITH THE
FEDERAL COORDINATED HEALTH CARE OFFICE.—
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1
MACPAC shall coordinate and consult with the Fed-
2
eral Coordinated Health Care Office established
3
under section 2081 of the Patient Protection and
4
Affordable Care Act before making any rec-
5
ommendations regarding dual eligible individuals.
6
‘‘(14) PROGRAMMATIC
7
THE SECRETARY.—MACPAC’s
8
recommendations in accordance with this section
9
shall not affect, or be considered to duplicate, the
10
Secretary’s authority to carry out Federal respon-
11
sibilities with respect to Medicaid and CHIP.’’;
12
13
14
15
OVERSIGHT VESTED IN
authority to make
(2) in subsection (c)(2)—
(A) by striking subparagraphs (A) and (B)
and inserting the following:
‘‘(A) IN
GENERAL.—The
membership of
16
MACPAC shall include individuals who have
17
had direct experience as enrollees or parents or
18
caregivers of enrollees in Medicaid or CHIP and
19
individuals with national recognition for their
20
expertise in Federal safety net health programs,
21
health finance and economics, actuarial science,
22
health plans and integrated delivery systems,
23
reimbursement for health care, health informa-
24
tion technology, and other providers of health
25
services, public health, and other related fields,
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1
who provide a mix of different professions,
2
broad geographic representation, and a balance
3
between urban and rural representation.
4
‘‘(B) INCLUSION.—The membership of
5
MACPAC shall include (but not be limited to)
6
physicians, dentists, and other health profes-
7
sionals, employers, third-party payers, and indi-
8
viduals with expertise in the delivery of health
9
services. Such membership shall also include
10
representatives of children, pregnant women,
11
the elderly, individuals with disabilities, care-
12
givers, and dual eligible individuals, current or
13
former representatives of State agencies respon-
14
sible for administering Medicaid, and current or
15
former representatives of State agencies respon-
16
sible for administering CHIP.’’.
17
(3) in subsection (d)(2), by inserting ‘‘and
18
State’’ after ‘‘Federal’’;
19
(4) in subsection (e)(1), in the first sentence, by
20
inserting ‘‘and, as a condition for receiving payments
21
under sections 1903(a) and 2105(a), from any State
22
agency responsible for administering Medicaid or
23
CHIP,’’ after ‘‘United States’’; and
24
(5) in subsection (f)—
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1
(A) in the subsection heading, by striking
2
‘‘AUTHORIZATION
3
inserting ‘‘FUNDING’’;
OF
APPROPRIATIONS’’ and
4
(B) in paragraph (1), by inserting ‘‘(other
5
than for fiscal year 2010)’’ before ‘‘in the same
6
manner’’; and
7
8
9
(C) by adding at the end the following:
‘‘(3) FUNDING
‘‘(A) IN
FOR FISCAL YEAR 2010.—
GENERAL.—Out
of any funds in
10
the Treasury not otherwise appropriated, there
11
is appropriated to MACPAC to carry out the
12
provisions of this section for fiscal year 2010,
13
$9,000,000.
14
‘‘(B) TRANSFER
OF
FUNDS.—Notwith-
15
standing
16
amounts appropriated in such section for fiscal
17
year 2010, $2,000,000 is hereby transferred
18
and made available in such fiscal year to
19
MACPAC to carry out the provisions of this
20
section.
21
‘‘(4) AVAILABILITY.—Amounts made available
22
under paragraphs (2) and (3) to MACPAC to carry
23
out the provisions of this section shall remain avail-
24
able until expended.’’.
section
2104(a)(13),
from
the
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564
1
(b) CONFORMING MEDPAC AMENDMENTS.—Section
2 1805(b) of the Social Security Act (42 U.S.C. 1395b–
3 6(b)), is amended—
4
(1) in paragraph (1)(C), by striking ‘‘March 1
5
of each year (beginning with 1998)’’ and inserting
6
‘‘March 15’’;
7
(2) in paragraph (1)(D), by inserting ‘‘, and
8
(beginning with 2012) containing an examination of
9
the topics described in paragraph (9), to the extent
10
feasible’’ before the period; and
11
(3) by adding at the end the following:
12
‘‘(9) REVIEW
AND ANNUAL REPORT ON MED-
13
ICAID AND COMMERCIAL TRENDS.—The
14
shall review and report on aggregate trends in
15
spending, utilization, and financial performance
16
under the Medicaid program under title XIX and
17
the private market for health care services with re-
18
spect to providers for which, on an aggregate na-
19
tional basis, a significant portion of revenue or serv-
20
ices is associated with the Medicaid program. Where
21
appropriate, the Commission shall conduct such re-
22
view in consultation with the Medicaid and CHIP
23
Payment and Access Commission established under
24
section 1900 (in this section referred to as
25
‘MACPAC’).
Commission
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1
‘‘(10) COORDINATE
AND CONSULT WITH THE
2
FEDERAL COORDINATED HEALTH CARE OFFICE.—
3
The Commission shall coordinate and consult with
4
the Federal Coordinated Health Care Office estab-
5
lished under section 2081 of the Patient Protection
6
and Affordable Care Act before making any rec-
7
ommendations regarding dual eligible individuals.
8
9
‘‘(11) INTERACTION
CARE.—The
OF MEDICAID AND MEDI-
Commission
shall
consult
with
10
MACPAC in carrying out its duties under this sec-
11
tion, as appropriate. Responsibility for analysis of
12
and recommendations to change Medicare policy re-
13
garding Medicare beneficiaries, including Medicare
14
beneficiaries who are dually eligible for Medicare and
15
Medicaid, shall rest with the Commission. Responsi-
16
bility for analysis of and recommendations to change
17
Medicaid policy regarding Medicaid beneficiaries, in-
18
cluding Medicaid beneficiaries who are dually eligible
19
for
20
MACPAC.’’.
Medicare
and
Medicaid,
shall
rest
with
22
Subtitle K—Protections for American Indians and Alaska Natives
23
SEC. 2901. SPECIAL RULES RELATING TO INDIANS.
21
24
25
(a) NO COST-SHARING
AT OR
FOR
BELOW 300 PERCENT
OF
INDIANS WITH INCOME
POVERTY ENROLLED
IN
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566
1 COVERAGE THROUGH
A
STATE EXCHANGE.—For provi-
2 sions prohibiting cost sharing for Indians enrolled in any
3 qualified health plan in the individual market through an
4 Exchange, see section 1402(d) of the Patient Protection
5 and Affordable Care Act.
6
(b) PAYER
OF
LAST RESORT.—Health programs op-
7 erated by the Indian Health Service, Indian tribes, tribal
8 organizations, and Urban Indian organizations (as those
9 terms are defined in section 4 of the Indian Health Care
10 Improvement Act (25 U.S.C. 1603)) shall be the payer
11 of last resort for services provided by such Service, tribes,
12 or organizations to individuals eligible for services through
13 such programs, notwithstanding any Federal, State, or
14 local law to the contrary.
15
16
(c) FACILITATING ENROLLMENT
THE
EXPRESS
LANE
OF INDIANS
UNDER
OPTION.—Section
17 1902(e)(13)(F)(ii) of the Social Security Act (42 U.S.C.
18 1396a(e)(13)(F)(ii)) is amended—
19
(1) in the clause heading, by inserting ‘‘AND
20
DIAN TRIBES AND TRIBAL ORGANIZATIONS’’
21
‘‘AGENCIES’’; and
22
IN-
after
(2) by adding at the end the following:
23
‘‘(IV) The Indian Health Service,
24
an Indian Tribe, Tribal Organization,
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567
1
or Urban Indian Organization (as de-
2
fined in section 1139(c)).’’.
3
(d) TECHNICAL CORRECTIONS.—Section 1139(c) of
4 the Social Security Act (42 U.S.C. 1320b–9(c)) is amend5 ed by striking ‘‘In this section’’ and inserting ‘‘For pur6 poses of this section, title XIX, and title XXI’’.
7
SEC. 2902. ELIMINATION OF SUNSET FOR REIMBURSEMENT
8
FOR ALL MEDICARE PART B SERVICES FUR-
9
NISHED BY CERTAIN INDIAN HOSPITALS AND
10
CLINICS.
11
(a) REIMBURSEMENT
12 SERVICES FURNISHED
13
AND
BY
FOR
ALL MEDICARE PART B
CERTAIN INDIAN HOSPITALS
CLINICS.—Section 1880(e)(1)(A) of the Social Secu-
14 rity Act (42 U.S.C. 1395qq(e)(1)(A)) is amended by strik15 ing ‘‘during the 5-year period beginning on’’ and inserting
16 ‘‘on or after’’.
17
(b) EFFECTIVE DATE.—The amendments made by
18 this section shall apply to items or services furnished on
19 or after January 1, 2010.
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2
Subtitle L—Maternal and Child
Health Services
3
SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD
1
4
5
HOME VISITING PROGRAMS.
Title V of the Social Security Act (42 U.S.C. 701
6 et seq.) is amended by adding at the end the following
7 new section:
8
‘‘SEC. 511. MATERNAL, INFANT, AND EARLY CHILDHOOD
9
HOME VISITING PROGRAMS.
10
‘‘(a) PURPOSES.—The purposes of this section are—
11
‘‘(1) to strengthen and improve the programs
12
13
14
and activities carried out under this title;
‘‘(2) to improve coordination of services for at
risk communities; and
15
‘‘(3) to identify and provide comprehensive
16
services to improve outcomes for families who reside
17
in at risk communities.
18
‘‘(b) REQUIREMENT
19 STATEWIDE NEEDS
20
21
AND
FOR
ALL STATES
IDENTIFY
AT
TO
ASSESS
RISK COMMU-
NITIES.—
‘‘(1) IN
GENERAL.—Not
later than 6 months
22
after the date of enactment of this section, each
23
State shall, as a condition of receiving payments
24
from an allotment for the State under section 502
25
for fiscal year 2011, conduct a statewide needs as-
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569
1
sessment (which shall be separate from the statewide
2
needs assessment required under section 505(a))
3
that identifies—
4
‘‘(A) communities with concentrations of—
5
‘‘(i) premature birth, low-birth weight
6
infants, and infant mortality, including in-
7
fant death due to neglect, or other indica-
8
tors of at-risk prenatal, maternal, newborn,
9
or child health;
10
‘‘(ii) poverty;
11
‘‘(iii) crime;
12
‘‘(iv) domestic violence;
13
‘‘(v) high rates of high-school drop-
14
outs;
15
‘‘(vi) substance abuse;
16
‘‘(vii) unemployment; or
17
‘‘(viii) child maltreatment;
18
‘‘(B) the quality and capacity of existing
19
programs or initiatives for early childhood home
20
visitation in the State including—
21
‘‘(i) the number and types of individ-
22
uals and families who are receiving services
23
under such programs or initiatives;
24
25
‘‘(ii) the gaps in early childhood home
visitation in the State; and
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570
1
‘‘(iii) the extent to which such pro-
2
grams or initiatives are meeting the needs
3
of eligible families described in subsection
4
(k)(2); and
5
‘‘(C) the State’s capacity for providing
6
substance abuse treatment and counseling serv-
7
ices to individuals and families in need of such
8
treatment or services.
9
‘‘(2) COORDINATION
WITH
OTHER
ASSESS-
10
MENTS.—In
11
ment required under paragraph (1), the State shall
12
coordinate with, and take into account, other appro-
13
priate needs assessments conducted by the State, as
14
determined by the Secretary, including the needs as-
15
sessment required under section 505(a) (both the
16
most recently completed assessment and any such
17
assessment in progress), the communitywide stra-
18
tegic planning and needs assessments conducted in
19
accordance with section 640(g)(1)(C) of the Head
20
Start Act, and the inventory of current unmet needs
21
and current community-based and prevention-fo-
22
cused programs and activities to prevent child abuse
23
and neglect, and other family resource services oper-
24
ating in the State required under section 205(3) of
25
the Child Abuse Prevention and Treatment Act.
conducting the statewide needs assess-
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571
1
‘‘(3) SUBMISSION
TO THE SECRETARY.—Each
2
State shall submit to the Secretary, in such form
3
and manner as the Secretary shall require—
4
‘‘(A) the results of the statewide needs as-
5
sessment required under paragraph (1); and
6
‘‘(B) a description of how the State in-
7
tends to address needs identified by the assess-
8
ment, particularly with respect to communities
9
identified under paragraph (1)(A), which may
10
include applying for a grant to conduct an early
11
childhood home visitation program in accord-
12
ance with the requirements of this section.
13
14
15
‘‘(c) GRANTS
TION
FOR
EARLY CHILDHOOD HOME VISITA-
PROGRAMS.—
‘‘(1) AUTHORITY
TO MAKE GRANTS.—In
addi-
16
tion to any other payments made under this title to
17
a State, the Secretary shall make grants to eligible
18
entities to enable the entities to deliver services
19
under early childhood home visitation programs that
20
satisfy the requirements of subsection (d) to eligible
21
families in order to promote improvements in mater-
22
nal and prenatal health, infant health, child health
23
and development, parenting related to child develop-
24
ment outcomes, school readiness, and the socio-
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572
1
economic status of such families, and reductions in
2
child abuse, neglect, and injuries.
3
‘‘(2) AUTHORITY
TO USE INITIAL GRANT FUNDS
4
FOR PLANNING OR IMPLEMENTATION.—An
5
entity that receives a grant under paragraph (1)
6
may use a portion of the funds made available to the
7
entity during the first 6 months of the period for
8
which the grant is made for planning or implementa-
9
tion activities to assist with the establishment of
10
early childhood home visitation programs that sat-
11
isfy the requirements of subsection (d).
12
‘‘(3) GRANT
DURATION.—The
eligible
Secretary shall
13
determine the period of years for which a grant is
14
made to an eligible entity under paragraph (1).
15
‘‘(4) TECHNICAL
ASSISTANCE.—The
Secretary
16
shall provide an eligible entity that receives a grant
17
under paragraph (1) with technical assistance in ad-
18
ministering programs or activities conducted in
19
whole or in part with grant funds.
20
‘‘(d) REQUIREMENTS.—The requirements of this sub-
21 section for an early childhood home visitation program
22 conducted with a grant made under this section are as
23 follows:
24
‘‘(1) QUANTIFIABLE,
25
MENT IN BENCHMARK AREAS.—
MEASURABLE IMPROVE-
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573
1
‘‘(A) IN
GENERAL.—The
eligible entity es-
2
tablishes, subject to the approval of the Sec-
3
retary, quantifiable, measurable 3- and 5-year
4
benchmarks for demonstrating that the pro-
5
gram results in improvements for the eligible
6
families participating in the program in each of
7
the following areas:
8
9
‘‘(i) Improved maternal and newborn
health.
10
‘‘(ii) Prevention of child injuries, child
11
abuse, neglect, or maltreatment, and re-
12
duction of emergency department visits.
13
14
15
16
17
18
‘‘(iii) Improvement in school readiness
and achievement.
‘‘(iv) Reduction in crime or domestic
violence.
‘‘(v) Improvements in family economic
self-sufficiency.
19
‘‘(vi) Improvements in the coordina-
20
tion and referrals for other community re-
21
sources and supports.
22
‘‘(B) DEMONSTRATION
23
24
25
OF IMPROVEMENTS
AFTER 3 YEARS.—
‘‘(i) REPORT
TO THE SECRETARY.—
Not later than 30 days after the end of the
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S.L.C.
574
1
3rd year in which the eligible entity con-
2
ducts the program, the entity submits to
3
the Secretary a report demonstrating im-
4
provement in at least 4 of the areas speci-
5
fied in subparagraph (A).
6
‘‘(ii) CORRECTIVE
ACTION PLAN.—If
7
the report submitted by the eligible entity
8
under clause (i) fails to demonstrate im-
9
provement in at least 4 of the areas speci-
10
fied in subparagraph (A), the entity shall
11
develop and implement a plan to improve
12
outcomes in each of the areas specified in
13
subparagraph (A), subject to approval by
14
the Secretary. The plan shall include provi-
15
sions for the Secretary to monitor imple-
16
mentation of the plan and conduct contin-
17
ued oversight of the program, including
18
through submission by the entity of reg-
19
ular reports to the Secretary.
20
‘‘(iii) TECHNICAL
21
‘‘(I) IN
ASSISTANCE.—
GENERAL.—The
Sec-
22
retary shall provide an eligible entity
23
required to develop and implement an
24
improvement plan under clause (ii)
25
with technical assistance to develop
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S.L.C.
575
1
and implement the plan. The Sec-
2
retary may provide the technical as-
3
sistance directly or through grants,
4
contracts, or cooperative agreements.
5
‘‘(II)
ADVISORY
PANEL.—The
6
Secretary shall establish an advisory
7
panel for purposes of obtaining rec-
8
ommendations regarding the technical
9
assistance provided to entities in ac-
10
cordance with subclause (I).
11
‘‘(iv) NO
IMPROVEMENT OR FAILURE
12
TO SUBMIT REPORT.—If
13
termines after a period of time specified by
14
the Secretary that an eligible entity imple-
15
menting an improvement plan under clause
16
(ii) has failed to demonstrate any improve-
17
ment in the areas specified in subpara-
18
graph (A), or if the Secretary determines
19
that an eligible entity has failed to submit
20
the report required under clause (i), the
21
Secretary shall terminate the entity’s grant
22
and may include any unexpended grant
23
funds in grants made to nonprofit organi-
24
zations under subsection (h)(2)(B).
the Secretary de-
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576
1
‘‘(C) FINAL
REPORT.—Not
later than De-
2
cember 31, 2015, the eligible entity shall sub-
3
mit a report to the Secretary demonstrating im-
4
provements (if any) in each of the areas speci-
5
fied in subparagraph (A).
6
‘‘(2) IMPROVEMENTS
7
8
IN OUTCOMES FOR INDI-
VIDUAL FAMILIES.—
‘‘(A) IN
GENERAL.—The
program is de-
9
signed, with respect to an eligible family partici-
10
pating in the program, to result in the partici-
11
pant outcomes described in subparagraph (B)
12
that the eligible entity identifies on the basis of
13
an individualized assessment of the family, are
14
relevant for that family.
15
‘‘(B) PARTICIPANT
OUTCOMES.—The
par-
16
ticipant outcomes described in this subpara-
17
graph are the following:
18
‘‘(i) Improvements in prenatal, mater-
19
nal, and newborn health, including im-
20
proved pregnancy outcomes
21
‘‘(ii) Improvements in child health
22
and development, including the prevention
23
of child injuries and maltreatment and im-
24
provements in cognitive, language, social-
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577
1
emotional, and physical developmental indi-
2
cators.
3
4
‘‘(iii)
ness and child academic achievement.
‘‘(v) Reductions in crime or domestic
violence.
9
10
parenting
‘‘(iv) Improvements in school readi-
7
8
in
skills.
5
6
Improvements
‘‘(vi) Improvements in family economic self-sufficiency.
11
‘‘(vii) Improvements in the coordina-
12
tion of referrals for, and the provision of,
13
other community resources and supports
14
for eligible families, consistent with State
15
child welfare agency training.
16
17
18
19
20
‘‘(3) CORE
COMPONENTS.—The
program in-
cludes the following core components:
‘‘(A) SERVICE
DELIVERY MODEL OR MOD-
ELS.—
‘‘(i) IN
GENERAL.—Subject
to clause
21
(ii), the program is conducted using 1 or
22
more of the service delivery models de-
23
scribed in item (aa) or (bb) of subclause
24
(I) or in subclause (II) selected by the eli-
25
gible entity:
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1
‘‘(I) The model conforms to a
2
clear consistent home visitation model
3
that has been in existence for at least
4
3 years and is research-based, ground-
5
ed
6
knowledge, linked to program deter-
7
mined outcomes, associated with a na-
8
tional organization or institution of
9
higher education that has comprehen-
10
sive home visitation program stand-
11
ards that ensure high quality service
12
delivery and continuous program qual-
13
ity
14
onstrated significant, (and in the case
15
of the service delivery model described
16
in item (aa), sustained) positive out-
17
comes, as described in the benchmark
18
areas specified in paragraph (1)(A)
19
and the participant outcomes de-
20
scribed in paragraph (2)(B), when
21
evaluated using well-designed and rig-
22
orous—
in
relevant
improvement,
empirically-based
and
has
dem-
23
‘‘(aa) randomized controlled
24
research designs, and the evalua-
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579
1
tion results have been published
2
in a peer-reviewed journal; or
3
‘‘(bb) quasi-experimental re-
4
search designs.
5
‘‘(II) The model conforms to a
6
promising
7
achieving the benchmark areas speci-
8
fied in paragraph (1)(A) and the par-
9
ticipant outcomes described in para-
10
graph (2)(B), has been developed or
11
identified by a national organization
12
or institution of higher education, and
13
will be evaluated through well-de-
14
signed and rigorous process.
15
‘‘(ii) MAJORITY
and
new
OF
approach
GRANT
to
FUNDS
16
USED FOR EVIDENCE-BASED MODELS.—An
17
eligible entity shall use not more than 25
18
percent of the amount of the grant paid to
19
the entity for a fiscal year for purposes of
20
conducting a program using the service de-
21
livery model described in clause (i)(II).
22
‘‘(iii) CRITERIA
FOR EVIDENCE OF EF-
23
FECTIVENESS OF MODELS.—The
24
shall establish criteria for evidence of effec-
25
tiveness of the service delivery models and
Secretary
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580
1
shall ensure that the process for estab-
2
lishing the criteria is transparent and pro-
3
vides the opportunity for public comment.
4
‘‘(B) ADDITIONAL
REQUIREMENTS.—
5
‘‘(i) The program adheres to a clear,
6
consistent model that satisfies the require-
7
ments of being grounded in empirically-
8
based knowledge related to home visiting
9
and linked to the benchmark areas speci-
10
fied in paragraph (1)(A) and the partici-
11
pant outcomes described in paragraph
12
(2)(B) related to the purposes of the pro-
13
gram.
14
‘‘(ii)
The
program
employs
well-
15
trained and competent staff, as dem-
16
onstrated by education or training, such as
17
nurses, social workers, educators, child de-
18
velopment specialists, or other well-trained
19
and competent staff, and provides ongoing
20
and specific training on the model being
21
delivered.
22
‘‘(iii) The program maintains high
23
quality supervision to establish home vis-
24
itor competencies.
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581
1
‘‘(iv)
The
program
demonstrates
2
strong organizational capacity to imple-
3
ment the activities involved.
4
‘‘(v) The program establishes appro-
5
priate linkages and referral networks to
6
other community resources and supports
7
for eligible families.
8
‘‘(vi) The program monitors the fidel-
9
ity of program implementation to ensure
10
that services are delivered pursuant to the
11
specified model.
12
‘‘(4) PRIORITY
FOR SERVING HIGH-RISK POPU-
13
LATIONS.—The
14
viding services under the program to the following:
15
‘‘(A) Eligible families who reside in com-
16
munities in need of such services, as identified
17
in the statewide needs assessment required
18
under subsection (b)(1)(A).
eligible entity gives priority to pro-
19
‘‘(B) Low-income eligible families.
20
‘‘(C) Eligible families who are pregnant
21
women who have not attained age 21.
22
‘‘(D) Eligible families that have a history
23
of child abuse or neglect or have had inter-
24
actions with child welfare services.
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582
1
‘‘(E) Eligible families that have a history
2
of substance abuse or need substance abuse
3
treatment.
4
5
6
7
8
9
‘‘(F) Eligible families that have users of
tobacco products in the home.
‘‘(G) Eligible families that are or have children with low student achievement.
‘‘(H) Eligible families with children with
developmental delays or disabilities.
10
‘‘(I) Eligible families who, or that include
11
individuals who, are serving or formerly served
12
in the Armed Forces, including such families
13
that have members of the Armed Forces who
14
have had multiple deployments outside of the
15
United States.
16
‘‘(e) APPLICATION REQUIREMENTS.—An eligible en-
17 tity desiring a grant under this section shall submit an
18 application to the Secretary for approval, in such manner
19 as the Secretary may require, that includes the following:
20
‘‘(1) A description of the populations to be
21
served by the entity, including specific information
22
regarding how the entity will serve high risk popu-
23
lations described in subsection (d)(4).
24
‘‘(2) An assurance that the entity will give pri-
25
ority to serving low-income eligible families and eligi-
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583
1
ble families who reside in at risk communities identi-
2
fied in the statewide needs assessment required
3
under subsection (b)(1)(A).
4
‘‘(3) The service delivery model or models de-
5
scribed in subsection (d)(3)(A) that the entity will
6
use under the program and the basis for the selec-
7
tion of the model or models.
8
‘‘(4) A statement identifying how the selection
9
of the populations to be served and the service deliv-
10
ery model or models that the entity will use under
11
the program for such populations is consistent with
12
the results of the statewide needs assessment con-
13
ducted under subsection (b).
14
‘‘(5) The quantifiable, measurable benchmarks
15
established by the State to demonstrate that the
16
program contributes to improvements in the areas
17
specified in subsection (d)(1)(A).
18
‘‘(6) An assurance that the entity will obtain
19
and submit documentation or other appropriate evi-
20
dence from the organization or entity that developed
21
the service delivery model or models used under the
22
program to verify that the program is implemented
23
and services are delivered according to the model
24
specifications.
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584
1
2
3
4
‘‘(7) Assurances that the entity will establish
procedures to ensure that—
‘‘(A) the participation of each eligible family in the program is voluntary; and
5
‘‘(B) services are provided to an eligible
6
family in accordance with the individual assess-
7
ment for that family.
8
‘‘(8) Assurances that the entity will—
9
‘‘(A) submit annual reports to the Sec-
10
retary regarding the program and activities car-
11
ried out under the program that include such
12
information and data as the Secretary shall re-
13
quire; and
14
‘‘(B) participate in, and cooperate with,
15
data and information collection necessary for
16
the evaluation required under subsection (g)(2)
17
and other research and evaluation activities car-
18
ried out under subsection (h)(3).
19
‘‘(9) A description of other State programs that
20
include home visitation services, including, if appli-
21
cable to the State, other programs carried out under
22
this title with funds made available from allotments
23
under section 502(c), programs funded under title
24
IV, title II of the Child Abuse Prevention and Treat-
25
ment Act (relating to community-based grants for
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585
1
the prevention of child abuse and neglect), and sec-
2
tion 645A of the Head Start Act (relating to Early
3
Head Start programs).
4
‘‘(10) Other information as required by the Sec-
5
retary.
6
‘‘(f) MAINTENANCE
OF
EFFORT.—Funds provided to
7 an eligible entity receiving a grant under this section shall
8 supplement, and not supplant, funds from other sources
9 for early childhood home visitation programs or initiatives.
10
‘‘(g) EVALUATION.—
11
‘‘(1)
12
PANEL.—The
13
section (h)(1)(A), shall appoint an independent advi-
14
sory panel consisting of experts in program evalua-
15
tion and research, education, and early childhood de-
16
velopment—
INDEPENDENT,
EXPERT
ADVISORY
Secretary, in accordance with sub-
17
‘‘(A) to review, and make recommendations
18
on, the design and plan for the evaluation re-
19
quired under paragraph (2) within 1 year after
20
the date of enactment of this section;
21
22
23
24
‘‘(B) to maintain and advise the Secretary
regarding the progress of the evaluation; and
‘‘(C) to comment, if the panel so desires,
on the report submitted under paragraph (3).
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1
‘‘(2) AUTHORITY
TO CONDUCT EVALUATION.—
2
On the basis of the recommendations of the advisory
3
panel under paragraph (1), the Secretary shall, by
4
grant, contract, or interagency agreement, conduct
5
an evaluation of the statewide needs assessments
6
submitted under subsection (b) and the grants made
7
under subsections (c) and (h)(3)(B). The evaluation
8
shall include—
9
‘‘(A) an analysis, on a State-by-State
10
basis, of the results of such assessments, in-
11
cluding indicators of maternal and prenatal
12
health and infant health and mortality, and
13
State actions in response to the assessments;
14
and
15
‘‘(B) an assessment of—
16
‘‘(i) the effect of early childhood home
17
visitation programs on child and parent
18
outcomes, including with respect to each of
19
the benchmark areas specified in sub-
20
section (d)(1)(A) and the participant out-
21
comes described in subsection (d)(2)(B);
22
‘‘(ii) the effectiveness of such pro-
23
grams on different populations, including
24
the extent to which the ability of programs
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587
1
to improve participant outcomes varies
2
across programs and populations; and
3
‘‘(iii) the potential for the activities
4
conducted under such programs, if scaled
5
broadly, to improve health care practices,
6
eliminate health disparities, and improve
7
health care system quality, efficiencies, and
8
reduce costs.
9
‘‘(3) REPORT.—Not later than March 31, 2015,
10
the Secretary shall submit a report to Congress on
11
the results of the evaluation conducted under para-
12
graph (2) and shall make the report publicly avail-
13
able.
14
‘‘(h) OTHER PROVISIONS.—
15
‘‘(1)
INTRA-AGENCY
COLLABORATION.—The
16
Secretary shall ensure that the Maternal and Child
17
Health Bureau and the Administration for Children
18
and Families collaborate with respect to carrying out
19
this section, including with respect to—
20
‘‘(A) reviewing and analyzing the statewide
21
needs assessments required under subsection
22
(b), the awarding and oversight of grants
23
awarded under this section, the establishment
24
of the advisory panels required under sub-
25
sections (d)(1)(B)(iii)(II) and (g)(1), and the
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588
1
evaluation and report required under subsection
2
(g); and
3
‘‘(B) consulting with other Federal agen-
4
cies with responsibility for administering or
5
evaluating programs that serve eligible families
6
to coordinate and collaborate with respect to re-
7
search related to such programs and families,
8
including the Office of the Assistant Secretary
9
for Planning and Evaluation of the Department
10
of Health and Human Services, the Centers for
11
Disease Control and Prevention, the National
12
Institute of Child Health and Human Develop-
13
ment of the National Institutes of Health, the
14
Office of Juvenile Justice and Delinquency Pre-
15
vention of the Department of Justice, and the
16
Institute of Education Sciences of the Depart-
17
ment of Education.
18
‘‘(2) GRANTS
19
20
TO ELIGIBLE ENTITIES THAT ARE
NOT STATES.—
‘‘(A) INDIAN
TRIBES, TRIBAL ORGANIZA-
21
TIONS, OR URBAN INDIAN ORGANIZATIONS.—
22
The Secretary shall specify requirements for eli-
23
gible entities that are Indian Tribes (or a con-
24
sortium of Indian Tribes), Tribal Organiza-
25
tions, or Urban Indian Organizations to apply
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589
1
for and conduct an early childhood home visita-
2
tion program with a grant under this section.
3
Such requirements shall, to the greatest extent
4
practicable, be consistent with the requirements
5
applicable to eligible entities that are States
6
and shall require an Indian Tribe (or consor-
7
tium), Tribal Organization, or Urban Indian
8
Organization to—
9
‘‘(i) conduct a needs assessment simi-
10
lar to the assessment required for all
11
States under subsection (b); and
12
‘‘(ii) establish quantifiable, measur-
13
able 3- and 5-year benchmarks consistent
14
with subsection (d)(1)(A).
15
‘‘(B) NONPROFIT
ORGANIZATIONS.—If,
as
16
of the beginning of fiscal year 2012, a State
17
has not applied or been approved for a grant
18
under this section, the Secretary may use
19
amounts appropriated under paragraph (1) of
20
subsection (j) that are available for expenditure
21
under paragraph (3) of that subsection to make
22
a grant to an eligible entity that is a nonprofit
23
organization described in subsection (k)(1)(B)
24
to conduct an early childhood home visitation
25
program in the State. The Secretary shall speci-
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590
1
fy the requirements for such an organization to
2
apply for and conduct the program which shall,
3
to the greatest extent practicable, be consistent
4
with the requirements applicable to eligible enti-
5
ties that are States and shall require the orga-
6
nization to—
7
‘‘(i) carry out the program based on
8
the needs assessment conducted by the
9
State under subsection (b); and
10
‘‘(ii) establish quantifiable, measur-
11
able 3- and 5-year benchmarks consistent
12
with subsection (d)(1)(A).
13
14
15
‘‘(3) RESEARCH
AND OTHER EVALUATION AC-
TIVITIES.—
‘‘(A) IN
GENERAL.—The
Secretary shall
16
carry out a continuous program of research and
17
evaluation activities in order to increase knowl-
18
edge about the implementation and effective-
19
ness of home visiting programs, using random
20
assignment designs to the maximum extent fea-
21
sible. The Secretary may carry out such activi-
22
ties directly, or through grants, cooperative
23
agreements, or contracts.
24
25
‘‘(B)
REQUIREMENTS.—The
shall ensure that—
Secretary
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591
1
‘‘(i) evaluation of a specific program
2
or project is conducted by persons or indi-
3
viduals not directly involved in the oper-
4
ation of such program or project; and
5
‘‘(ii) the conduct of research and eval-
6
uation activities includes consultation with
7
independent researchers, State officials,
8
and developers and providers of home vis-
9
iting programs on topics including research
10
11
design and administrative data matching.
‘‘(4) REPORT
AND
RECOMMENDATION.—Not
12
later than December 31, 2015, the Secretary shall
13
submit a report to Congress regarding the programs
14
conducted with grants under this section. The report
15
required under this paragraph shall include—
16
‘‘(A) information regarding the extent to
17
which eligible entities receiving grants under
18
this section demonstrated improvements in each
19
of the areas specified in subsection (d)(1)(A);
20
‘‘(B) information regarding any technical
21
assistance
22
(d)(1)(B)(iii)(I), including the type of any such
23
assistance provided; and
provided
under
subsection
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592
1
‘‘(C) recommendations for such legislative
2
or administrative action as the Secretary deter-
3
mines appropriate.
4
‘‘(i) APPLICATION
OF
OTHER PROVISIONS
OF
5 TITLE.—
6
‘‘(1) IN
GENERAL.—Except
as provided in para-
7
graph (2), the other provisions of this title shall not
8
apply to a grant made under this section.
9
‘‘(2) EXCEPTIONS.—The following provisions of
10
this title shall apply to a grant made under this sec-
11
tion to the same extent and in the same manner as
12
such provisions apply to allotments made under sec-
13
tion 502(c):
14
‘‘(A) Section 504(b)(6) (relating to prohi-
15
bition on payments to excluded individuals and
16
entities).
17
‘‘(B) Section 504(c) (relating to the use of
18
funds for the purchase of technical assistance).
19
‘‘(C) Section 504(d) (relating to a limita-
20
tion on administrative expenditures).
21
‘‘(D) Section 506 (relating to reports and
22
audits), but only to the extent determined by
23
the Secretary to be appropriate for grants made
24
under this section.
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593
1
2
‘‘(E) Section 507 (relating to penalties for
false statements).
3
‘‘(F)
4
discrimination).
5
6
7
8
Section
508
(relating
to
non-
‘‘(G) Section 509(a) (relating to the administration of the grant program).
‘‘(j) APPROPRIATIONS.—
‘‘(1) IN
GENERAL.—Out
of any funds in the
9
Treasury not otherwise appropriated, there are ap-
10
propriated to the Secretary to carry out this sec-
11
tion—
12
‘‘(A) $100,000,000 for fiscal year 2010;
13
‘‘(B) $250,000,000 for fiscal year 2011;
14
‘‘(C) $350,000,000 for fiscal year 2012;
15
‘‘(D) $400,000,000 for fiscal year 2013;
16
17
and
‘‘(E) $400,000,000 for fiscal year 2014.
18
‘‘(2) RESERVATIONS.—Of the amount appro-
19
priated under this subsection for a fiscal year, the
20
Secretary shall reserve—
21
‘‘(A) 3 percent of such amount for pur-
22
poses of making grants to eligible entities that
23
are Indian Tribes (or a consortium of Indian
24
Tribes), Tribal Organizations, or Urban Indian
25
Organizations; and
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594
1
‘‘(B) 3 percent of such amount for pur-
2
poses of carrying out subsections (d)(1)(B)(iii),
3
(g), and (h)(3).
4
‘‘(3) AVAILABILITY.—Funds made available to
5
an eligible entity under this section for a fiscal year
6
shall remain available for expenditure by the eligible
7
entity through the end of the second succeeding fis-
8
cal year after award. Any funds that are not ex-
9
pended by the eligible entity during the period in
10
which the funds are available under the preceding
11
sentence may be used for grants to nonprofit organi-
12
zations under subsection (h)(2)(B).
13
‘‘(k) DEFINITIONS.—In this section:
14
15
‘‘(1) ELIGIBLE
‘‘(A) IN
ENTITY.—
GENERAL.—The
term ‘eligible en-
16
tity’ means a State, an Indian Tribe, Tribal Or-
17
ganization, or Urban Indian Organization,
18
Puerto Rico, Guam, the Virgin Islands, the
19
Northern
20
Samoa.
21
Mariana
Islands,
‘‘(B) NONPROFIT
and
American
ORGANIZATIONS.—Only
22
for purposes of awarding grants under sub-
23
section (h)(2)(B), such term shall include a
24
nonprofit organization with an established
25
record of providing early childhood home visita-
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595
1
tion programs or initiatives in a State or sev-
2
eral States.
3
‘‘(2) ELIGIBLE
4
5
6
FAMILY.—The
term ‘eligible
family’ means—
‘‘(A) a woman who is pregnant, and the father of the child if the father is available; or
7
‘‘(B) a parent or primary caregiver of a
8
child, including grandparents or other relatives
9
of the child, and foster parents, who are serving
10
as the child’s primary caregiver from birth to
11
kindergarten entry, and including a noncusto-
12
dial parent who has an ongoing relationship
13
with, and at times provides physical care for,
14
the child.
15
‘‘(3) INDIAN
TRIBE; TRIBAL ORGANIZATION.—
16
The terms ‘Indian Tribe’ and ‘Tribal Organization’,
17
and ‘Urban Indian Organization’ have the meanings
18
given such terms in section 4 of the Indian Health
19
Care Improvement Act.’’.
20
21
22
23
SEC. 2952. SUPPORT, EDUCATION, AND RESEARCH FOR
POSTPARTUM DEPRESSION.
(a) RESEARCH ON POSTPARTUM CONDITIONS.—
(1) EXPANSION
AND INTENSIFICATION OF AC-
24
TIVITIES.—The
25
Services (in this subsection and subsection (c) re-
Secretary of Health and Human
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596
1
ferred to as the ‘‘Secretary’’) is encouraged to con-
2
tinue
3
postpartum psychosis (in this subsection and sub-
4
section (c) referred to as ‘‘postpartum conditions’’),
5
including research to expand the understanding of
6
the causes of, and treatments for, postpartum condi-
7
tions. Activities under this paragraph shall include
8
conducting and supporting the following:
9
10
activities
on
postpartum
depression
or
(A) Basic research concerning the etiology
and causes of the conditions.
11
(B) Epidemiological studies to address the
12
frequency and natural history of the conditions
13
and the differences among racial and ethnic
14
groups with respect to the conditions.
15
16
17
18
(C) The development of improved screening and diagnostic techniques.
(D) Clinical research for the development
and evaluation of new treatments.
19
(E) Information and education programs
20
for health care professionals and the public,
21
which may include a coordinated national cam-
22
paign to increase the awareness and knowledge
23
of postpartum conditions. Activities under such
24
a national campaign may—
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597
1
(i) include public service announce-
2
ments through television, radio, and other
3
means; and
4
(ii) focus on—
5
(I)
6
raising
awareness
about
screening;
7
(II) educating new mothers and
8
their families about postpartum condi-
9
tions to promote earlier diagnosis and
10
treatment; and
11
(III) ensuring that such edu-
12
cation includes complete information
13
concerning postpartum conditions, in-
14
cluding its symptoms, methods of cop-
15
ing with the illness, and treatment re-
16
sources.
17
(2) SENSE
OF CONGRESS REGARDING LONGITU-
18
DINAL STUDY OF RELATIVE MENTAL HEALTH CON-
19
SEQUENCES FOR WOMEN OF RESOLVING A PREG-
20
NANCY.—
21
(A) SENSE
OF CONGRESS.—It
is the sense
22
of Congress that the Director of the National
23
Institute of Mental Health may conduct a na-
24
tionally representative longitudinal study (dur-
25
ing the period of fiscal years 2010 through
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598
1
2019) of the relative mental health con-
2
sequences for women of resolving a pregnancy
3
(intended and unintended) in various ways, in-
4
cluding carrying the pregnancy to term and
5
parenting the child, carrying the pregnancy to
6
term and placing the child for adoption, mis-
7
carriage, and having an abortion. This study
8
may assess the incidence, timing, magnitude,
9
and duration of the immediate and long-term
10
mental health consequences (positive or nega-
11
tive) of these pregnancy outcomes.
12
(B) REPORT.—Subject to the completion
13
of the study under subsection (a), beginning not
14
later than 5 years after the date of the enact-
15
ment of this Act, and periodically thereafter for
16
the duration of the study, such Director may
17
prepare and submit to the Congress reports on
18
the findings of the study.
19
(b) GRANTS
20 WITH
21
A
TO
PROVIDE SERVICES
POSTPARTUM CONDITION
LIES.—Title
TO INDIVIDUALS
AND
THEIR FAMI-
V of the Social Security Act (42 U.S.C. 701
22 et seq.), as amended by section 2951, is amended by add23 ing at the end the following new section:
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599
1
‘‘SEC.
512.
SERVICES
TO
INDIVIDUALS
WITH
A
2
POSTPARTUM CONDITION AND THEIR FAMI-
3
LIES.
4
‘‘(a) IN GENERAL.—In addition to any other pay-
5 ments made under this title to a State, the Secretary may
6 make grants to eligible entities for projects for the estab7 lishment, operation, and coordination of effective and cost8 efficient systems for the delivery of essential services to
9 individuals with or at risk for postpartum conditions and
10 their families.
11
‘‘(b) CERTAIN ACTIVITIES.—To the extent prac-
12 ticable and appropriate, the Secretary shall ensure that
13 projects funded under subsection (a) provide education
14 and services with respect to the diagnosis and manage15 ment of postpartum conditions for individuals with or at
16 risk for postpartum conditions and their families. The Sec17 retary may allow such projects to include the following:
18
‘‘(1) Delivering or enhancing outpatient and
19
home-based health and support services, including
20
case management and comprehensive treatment
21
services.
22
‘‘(2) Delivering or enhancing inpatient care
23
management services that ensure the well-being of
24
the mother and family and the future development
25
of the infant.
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600
1
‘‘(3) Improving the quality, availability, and or-
2
ganization of health care and support services (in-
3
cluding transportation services, attendant care,
4
homemaker services, day or respite care, and pro-
5
viding counseling on financial assistance and insur-
6
ance).
7
‘‘(4) Providing education about postpartum
8
conditions to promote earlier diagnosis and treat-
9
ment. Such education may include—
10
‘‘(A) providing complete information on
11
postpartum conditions, symptoms, methods of
12
coping with the illness, and treatment re-
13
sources; and
14
15
‘‘(B) in the case of a grantee that is a
State, hospital, or birthing facility—
16
‘‘(i) providing education to new moth-
17
ers and fathers, and other family members
18
as appropriate, concerning postpartum
19
conditions before new mothers leave the
20
health facility; and
21
‘‘(ii) ensuring that training programs
22
regarding such education are carried out
23
at the health facility.
24
‘‘(c) INTEGRATION WITH OTHER PROGRAMS.—To
25 the extent practicable and appropriate, the Secretary may
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601
1 integrate the grant program under this section with other
2 grant programs carried out by the Secretary, including the
3 program under section 330 of the Public Health Service
4 Act.
5
‘‘(d) REQUIREMENTS.—The Secretary shall establish
6 requirements for grants made under this section that in7 clude a limit on the amount of grants funds that may be
8 used for administration, accounting, reporting, or program
9 oversight functions and a requirement for each eligible en10 tity that receives a grant to submit, for each grant period,
11 a report to the Secretary that describes how grant funds
12 were used during such period.
13
‘‘(e) TECHNICAL ASSISTANCE.—The Secretary may
14 provide technical assistance to entities seeking a grant
15 under this section in order to assist such entities in com16 plying with the requirements of this section.
17
‘‘(f) APPLICATION
OF
OTHER PROVISIONS
OF
18 TITLE.—
19
‘‘(1) IN
GENERAL.—Except
as provided in para-
20
graph (2), the other provisions of this title shall not
21
apply to a grant made under this section.
22
‘‘(2) EXCEPTIONS.—The following provisions of
23
this title shall apply to a grant made under this sec-
24
tion to the same extent and in the same manner as
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S.L.C.
602
1
such provisions apply to allotments made under sec-
2
tion 502(c):
3
‘‘(A) Section 504(b)(6) (relating to prohi-
4
bition on payments to excluded individuals and
5
entities).
6
‘‘(B) Section 504(c) (relating to the use of
7
funds for the purchase of technical assistance).
8
‘‘(C) Section 504(d) (relating to a limita-
9
tion on administrative expenditures).
10
‘‘(D) Section 506 (relating to reports and
11
audits), but only to the extent determined by
12
the Secretary to be appropriate for grants made
13
under this section.
14
15
‘‘(E) Section 507 (relating to penalties for
false statements).
16
‘‘(F)
17
discrimination).
18
19
20
21
22
23
Section
508
(relating
to
non-
‘‘(G) Section 509(a) (relating to the administration of the grant program).
‘‘(g) DEFINITIONS.—In this section:
‘‘(1) The term ‘eligible entity’—
‘‘(A) means a public or nonprofit private
entity; and
24
‘‘(B) includes a State or local government,
25
public-private partnership, recipient of a grant
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S.L.C.
603
1
under section 330H of the Public Health Serv-
2
ice Act (relating to the Healthy Start Initia-
3
tive), public or nonprofit private hospital, com-
4
munity-based organization, hospice, ambulatory
5
care facility, community health center, migrant
6
health center, public housing primary care cen-
7
ter, or homeless health center.
8
‘‘(2) The term ‘postpartum condition’ means
9
10
11
postpartum depression or postpartum psychosis.’’.
(c) GENERAL PROVISIONS.—
(1) AUTHORIZATION
OF APPROPRIATIONS.—To
12
carry out this section and the amendment made by
13
subsection (b), there are authorized to be appro-
14
priated, in addition to such other sums as may be
15
available for such purpose—
16
(A) $3,000,000 for fiscal year 2010; and
17
(B) such sums as may be necessary for fis-
18
cal years 2011 and 2012.
19
(2) REPORT
BY THE SECRETARY.—
20
(A) STUDY.—The Secretary shall conduct
21
a study on the benefits of screening for
22
postpartum conditions.
23
(B) REPORT.—Not later than 2 years after
24
the date of the enactment of this Act, the Sec-
25
retary shall complete the study required by sub-
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1
paragraph (A) and submit a report to the Con-
2
gress on the results of such study.
3
4
SEC. 2953. PERSONAL RESPONSIBILITY EDUCATION.
Title V of the Social Security Act (42 U.S.C. 701
5 et seq.), as amended by sections 2951 and 2952(c), is
6 amended by adding at the end the following:
7
8
‘‘SEC. 513. PERSONAL RESPONSIBILITY EDUCATION.
‘‘(a) ALLOTMENTS TO STATES.—
9
‘‘(1) AMOUNT.—
10
‘‘(A) IN
GENERAL.—For
the purpose de-
11
scribed in subsection (b), subject to the suc-
12
ceeding provisions of this section, for each of
13
fiscal years 2010 through 2014, the Secretary
14
shall allot to each State an amount equal to the
15
product of—
16
‘‘(i) the amount appropriated under
17
subsection (f) for the fiscal year and avail-
18
able for allotments to States after the ap-
19
plication of subsection (c); and
20
‘‘(ii) the State youth population per-
21
centage determined under paragraph (2).
22
‘‘(B) MINIMUM
23
‘‘(i) IN
ALLOTMENT.—
GENERAL.—Each
State allot-
24
ment under this paragraph for a fiscal
25
year shall be at least $250,000.
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1
‘‘(ii) PRO
RATA ADJUSTMENTS.—The
2
Secretary shall adjust on a pro rata basis
3
the amount of the State allotments deter-
4
mined under this paragraph for a fiscal
5
year to the extent necessary to comply with
6
clause (i).
7
‘‘(C) APPLICATION
8
ALLOTMENTS.—
9
‘‘(i) IN
REQUIRED TO ACCESS
GENERAL.—A
State shall not
10
be paid from its allotment for a fiscal year
11
unless the State submits an application to
12
the Secretary for the fiscal year and the
13
Secretary approves the application (or re-
14
quires changes to the application that the
15
State satisfies) and meets such additional
16
requirements as the Secretary may specify.
17
‘‘(ii) REQUIREMENTS.—The State ap-
18
plication shall contain an assurance that
19
the State has complied with the require-
20
ments of this section in preparing and sub-
21
mitting the application and shall include
22
the following as well as such additional in-
23
formation as the Secretary may require:
24
‘‘(I) Based on data from the
25
Centers for Disease Control and Pre-
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606
1
vention National Center for Health
2
Statistics, the most recent pregnancy
3
rates for the State for youth ages 10
4
to 14 and youth ages 15 to 19 for
5
which data are available, the most re-
6
cent birth rates for such youth popu-
7
lations in the State for which data are
8
available, and trends in those rates
9
for the most recently preceding 5-year
10
period for which such data are avail-
11
able.
12
‘‘(II) State-established goals for
13
reducing the pregnancy rates and
14
birth rates for such youth populations.
15
‘‘(III)
A
description
of
the
16
State’s plan for using the State allot-
17
ments provided under this section to
18
achieve such goals, especially among
19
youth populations that are the most
20
high-risk or vulnerable for pregnancies
21
or
22
cumstances, including youth in foster
23
care, homeless youth, youth with HIV/
24
AIDS, pregnant youth who are under
25
21 years of age, mothers who are
otherwise
have
special
cir-
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1
under 21 years of age, and youth re-
2
siding in areas with high birth rates
3
for youth.
4
5
6
‘‘(2) STATE
YOUTH
POPULATION
PERCENT-
AGE.—
‘‘(A) IN
GENERAL.—For
purposes of para-
7
graph (1)(A)(ii), the State youth population
8
percentage is, with respect to a State, the pro-
9
portion (expressed as a percentage) of—
10
‘‘(i) the number of individuals who
11
have attained age 10 but not attained age
12
20 in the State; to
13
‘‘(ii) the number of such individuals in
14
all States.
15
‘‘(B) DETERMINATION
OF
NUMBER
OF
16
YOUTH.—The
17
in clauses (i) and (ii) of subparagraph (A) in a
18
State shall be determined on the basis of the
19
most recent Bureau of the Census data.
20
‘‘(3) AVAILABILITY
number of individuals described
OF STATE ALLOTMENTS.—
21
Subject to paragraph (4)(A), amounts allotted to a
22
State pursuant to this subsection for a fiscal year
23
shall remain available for expenditure by the State
24
through the end of the second succeeding fiscal year.
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1
‘‘(4) AUTHORITY
TO
AWARD
GRANTS
FROM
2
STATE ALLOTMENTS TO LOCAL ORGANIZATIONS AND
3
ENTITIES IN NONPARTICIPATING STATES.—
4
‘‘(A) GRANTS
FROM UNEXPENDED ALLOT-
5
MENTS.—If
6
tion under this section for fiscal year 2010 or
7
2011, the State shall no longer be eligible to
8
submit an application to receive funds from the
9
amounts allotted for the State for each of fiscal
10
years 2010 through 2014 and such amounts
11
shall be used by the Secretary to award grants
12
under this paragraph for each of fiscal years
13
2012 through 2014. The Secretary also shall
14
use any amounts from the allotments of States
15
that submit applications under this section for
16
a fiscal year that remain unexpended as of the
17
end of the period in which the allotments are
18
available for expenditure under paragraph (3)
19
for awarding grants under this paragraph.
a State does not submit an applica-
20
‘‘(B) 3-YEAR
21
‘‘(i) IN
GRANTS.—
GENERAL.—The
Secretary
22
shall solicit applications to award 3-year
23
grants in each of fiscal years 2012, 2013,
24
and 2014 to local organizations and enti-
25
ties to conduct, consistent with subsection
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1
(b), programs and activities in States that
2
do not submit an application for an allot-
3
ment under this section for fiscal year
4
2010 or 2011.
5
‘‘(ii) FAITH-BASED
ORGANIZATIONS
6
OR CONSORTIA.—The
7
and award grants under this paragraph to
8
faith-based organizations or consortia.
9
‘‘(C) EVALUATION.—An organization or
10
entity awarded a grant under this paragraph
11
shall agree to participate in a rigorous Federal
12
evaluation.
13
‘‘(5) MAINTENANCE
Secretary may solicit
OF EFFORT.—No
payment
14
shall be made to a State from the allotment deter-
15
mined for the State under this subsection or to a
16
local organization or entity awarded a grant under
17
paragraph (4), if the expenditure of non-federal
18
funds by the State, organization, or entity for activi-
19
ties, programs, or initiatives for which amounts from
20
allotments and grants under this subsection may be
21
expended is less than the amount expended by the
22
State, organization, or entity for such programs or
23
initiatives for fiscal year 2009.
24
25
‘‘(6) DATA
COLLECTION AND REPORTING.—A
State or local organization or entity receiving funds
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610
1
under this section shall cooperate with such require-
2
ments relating to the collection of data and informa-
3
tion and reporting on outcomes regarding the pro-
4
grams and activities carried out with such funds, as
5
the Secretary shall specify.
6
‘‘(b) PURPOSE.—
7
‘‘(1) IN
GENERAL.—The
purpose of an allot-
8
ment under subsection (a)(1) to a State is to enable
9
the State (or, in the case of grants made under sub-
10
section (a)(4)(B), to enable a local organization or
11
entity) to carry out personal responsibility education
12
programs consistent with this subsection.
13
14
15
‘‘(2) PERSONAL
RESPONSIBILITY
EDUCATION
PROGRAMS.—
‘‘(A) IN
GENERAL.—In
this section, the
16
term ‘personal responsibility education pro-
17
gram’ means a program that is designed to
18
educate adolescents on—
19
‘‘(i) both abstinence and contraception
20
for the prevention of pregnancy and sexu-
21
ally transmitted infections, including HIV/
22
AIDS, consistent with the requirements of
23
subparagraph (B); and
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1
‘‘(ii) at least 3 of the adulthood prep-
2
aration subjects described in subparagraph
3
(C).
4
‘‘(B) REQUIREMENTS.—The requirements
5
of this subparagraph are the following:
6
‘‘(i) The program replicates evidence-
7
based effective programs or substantially
8
incorporates elements of effective programs
9
that have been proven on the basis of rig-
10
orous scientific research to change behav-
11
ior, which means delaying sexual activity,
12
increasing condom or contraceptive use for
13
sexually active youth, or reducing preg-
14
nancy among youth.
15
16
‘‘(ii) The program is medically-accurate and complete.
17
‘‘(iii) The program includes activities
18
to educate youth who are sexually active
19
regarding responsible sexual behavior with
20
respect to both abstinence and the use of
21
contraception.
22
‘‘(iv) The program places substantial
23
emphasis on both abstinence and contra-
24
ception for the prevention of pregnancy
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612
1
among youth and sexually transmitted in-
2
fections.
3
4
‘‘(v) The program provides age-appropriate information and activities.
5
‘‘(vi) The information and activities
6
carried out under the program are pro-
7
vided in the cultural context that is most
8
appropriate for individuals in the par-
9
ticular population group to which they are
10
directed.
11
‘‘(C)
ADULTHOOD
PREPARATION
SUB-
12
JECTS.—The
13
described in this subparagraph are the fol-
14
lowing:
adulthood preparation subjects
15
‘‘(i) Healthy relationships, such as
16
positive self-esteem and relationship dy-
17
namics, friendships, dating, romantic in-
18
volvement, marriage, and family inter-
19
actions.
20
‘‘(ii) Adolescent development, such as
21
the development of healthy attitudes and
22
values about adolescent growth and devel-
23
opment, body image, racial and ethnic di-
24
versity, and other related subjects.
25
‘‘(iii) Financial literacy.
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1
‘‘(iv) Parent-child communication.
2
‘‘(v) Educational and career success,
3
such as developing skills for employment
4
preparation, job seeking, independent liv-
5
ing, financial self-sufficiency, and work-
6
place productivity.
7
‘‘(vi) Healthy life skills, such as goal-
8
setting, decision making, negotiation, com-
9
munication and interpersonal skills, and
10
11
12
stress management.
‘‘(c) RESERVATIONS OF FUNDS.—
‘‘(1) GRANTS
TO
IMPLEMENT
INNOVATIVE
13
STRATEGIES.—From
14
subsection (f) for the fiscal year, the Secretary shall
15
reserve $10,000,000 of such amount for purposes of
16
awarding grants to entities to implement innovative
17
youth pregnancy prevention strategies and target
18
services to high-risk, vulnerable, and culturally
19
under-represented
20
youth in foster care, homeless youth, youth with
21
HIV/AIDS, pregnant women who are under 21 years
22
of age and their partners, mothers who are under 21
23
years of age and their partners, and youth residing
24
in areas with high birth rates for youth. An entity
25
awarded a grant under this paragraph shall agree to
the amount appropriated under
youth
populations,
including
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1
participate in a rigorous Federal evaluation of the
2
activities carried out with grant funds.
3
‘‘(2)
OTHER
RESERVATIONS.—From
the
4
amount appropriated under subsection (f) for the
5
fiscal year that remains after the application of
6
paragraph (1), the Secretary shall reserve the fol-
7
lowing amounts:
8
9
‘‘(A) GRANTS
FOR
INDIAN
TRIBAL ORGANIZATIONS.—The
TRIBES
OR
Secretary shall
10
reserve 5 percent of such remainder for pur-
11
poses of awarding grants to Indian tribes and
12
tribal organizations in such manner, and sub-
13
ject to such requirements, as the Secretary, in
14
consultation with Indian tribes and tribal orga-
15
nizations, determines appropriate.
16
17
‘‘(B) SECRETARIAL
RESPONSIBILITIES.—
‘‘(i) RESERVATION
OF FUNDS.—The
18
Secretary shall reserve 10 percent of such
19
remainder for expenditures by the Sec-
20
retary for the activities described in
21
clauses (ii) and (iii).
22
‘‘(ii) PROGRAM
SUPPORT.—The
Sec-
23
retary shall provide, directly or through a
24
competitive grant process, research, train-
25
ing and technical assistance, including dis-
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615
1
semination of research and information re-
2
garding effective and promising practices,
3
providing consultation and resources on a
4
broad array of teen pregnancy prevention
5
strategies, including abstinence and contra-
6
ception, and developing resources and ma-
7
terials to support the activities of recipi-
8
ents of grants and other State, tribal, and
9
community organizations working to re-
10
duce teen pregnancy. In carrying out such
11
functions, the Secretary shall collaborate
12
with a variety of entities that have exper-
13
tise in the prevention of teen pregnancy,
14
HIV and sexually transmitted infections,
15
healthy relationships, financial literacy,
16
and other topics addressed through the
17
personal responsibility education programs.
18
‘‘(iii) EVALUATION.—The Secretary
19
shall evaluate the programs and activities
20
carried out with funds made available
21
through allotments or grants under this
22
section.
23
24
25
‘‘(d) ADMINISTRATION.—
‘‘(1) IN
GENERAL.—The
Secretary shall admin-
ister this section through the Assistant Secretary for
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1
the Administration for Children and Families within
2
the Department of Health and Human Services.
3
4
5
‘‘(2) APPLICATION
OF OTHER PROVISIONS OF
TITLE.—
‘‘(A) IN
GENERAL.—Except
as provided in
6
subparagraph (B), the other provisions of this
7
title shall not apply to allotments or grants
8
made under this section.
9
‘‘(B) EXCEPTIONS.—The following provi-
10
sions of this title shall apply to allotments and
11
grants made under this section to the same ex-
12
tent and in the same manner as such provisions
13
apply to allotments made under section 502(c):
14
‘‘(i) Section 504(b)(6) (relating to
15
prohibition on payments to excluded indi-
16
viduals and entities).
17
‘‘(ii) Section 504(c) (relating to the
18
use of funds for the purchase of technical
19
assistance).
20
‘‘(iii) Section 504(d) (relating to a
21
limitation on administrative expenditures).
22
‘‘(iv) Section 506 (relating to reports
23
and audits), but only to the extent deter-
24
mined by the Secretary to be appropriate
25
for grants made under this section.
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1
‘‘(v) Section 507 (relating to penalties
2
for false statements).
3
‘‘(vi) Section 508 (relating to non-
4
discrimination).
5
‘‘(e) DEFINITIONS.—In this section:
6
‘‘(1) AGE-APPROPRIATE.—The term ‘age-appro-
7
priate’, with respect to the information in pregnancy
8
prevention, means topics, messages, and teaching
9
methods suitable to particular ages or age groups of
10
children and adolescents, based on developing cog-
11
nitive, emotional, and behavioral capacity typical for
12
the age or age group.
13
‘‘(2) MEDICALLY
ACCURATE AND COMPLETE.—
14
The term ‘medically accurate and complete’ means
15
verified or supported by the weight of research con-
16
ducted in compliance with accepted scientific meth-
17
ods and—
18
19
‘‘(A) published in peer-reviewed journals,
where applicable; or
20
‘‘(B) comprising information that leading
21
professional organizations and agencies with
22
relevant expertise in the field recognize as accu-
23
rate, objective, and complete.
24
‘‘(3)
25
TIONS.—The
INDIAN
TRIBES;
TRIBAL
ORGANIZA-
terms ‘Indian tribe’ and ‘Tribal organi-
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1
zation’ have the meanings given such terms in sec-
2
tion 4 of the Indian Health Care Improvement Act
3
(25 U.S.C. 1603)).
4
‘‘(4) YOUTH.—The term ‘youth’ means an indi-
5
vidual who has attained age 10 but has not attained
6
age 20.
7
‘‘(f) APPROPRIATION.—For the purpose of carrying
8 out this section, there is appropriated, out of any money
9 in the Treasury not otherwise appropriated, $75,000,000
10 for each of fiscal years 2010 through 2014. Amounts ap11 propriated under this subsection shall remain available
12 until expended.’’.
13
14
15
SEC. 2954. RESTORATION OF FUNDING FOR ABSTINENCE
EDUCATION.
Section 510 of the Social Security Act (42 U.S.C.
16 710) is amended—
17
(1) in subsection (a), by striking ‘‘fiscal year
18
1998 and each subsequent fiscal year’’ and inserting
19
‘‘each of fiscal years 2010 through 2014’’; and
20
(2) in subsection (d)—
21
(A) in the first sentence, by striking ‘‘1998
22
through 2003’’ and inserting ‘‘2010 through
23
2014’’; and
24
(B) in the second sentence, by inserting
25
‘‘(except that such appropriation shall be made
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619
1
on the date of enactment of the Patient Protec-
2
tion and Affordable Care Act in the case of fis-
3
cal year 2010)’’ before the period.
4
SEC. 2955. INCLUSION OF INFORMATION ABOUT THE IM-
5
PORTANCE
6
POWER OF ATTORNEY IN TRANSITION PLAN-
7
NING FOR CHILDREN AGING OUT OF FOSTER
8
CARE AND INDEPENDENT LIVING PROGRAMS.
9
(a) TRANSITION PLANNING.—Section 475(5)(H) of
OF
HAVING
A
HEALTH
CARE
10 the Social Security Act (42 U.S.C. 675(5)(H)) is amended
11 by inserting ‘‘includes information about the importance
12 of designating another individual to make health care
13 treatment decisions on behalf of the child if the child be14 comes unable to participate in such decisions and the child
15 does not have, or does not want, a relative who would oth16 erwise be authorized under State law to make such deci17 sions, and provides the child with the option to execute
18 a health care power of attorney, health care proxy, or
19 other similar document recognized under State law,’’ after
20 ‘‘employment services,’’.
21
(b) INDEPENDENT LIVING EDUCATION.—Section
22 477(b)(3) of such Act (42 U.S.C. 677(b)(3)) is amended
23 by adding at the end the following:
24
‘‘(K) A certification by the chief executive
25
officer of the State that the State will ensure
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1
that an adolescent participating in the program
2
under this section are provided with education
3
about the importance of designating another in-
4
dividual to make health care treatment deci-
5
sions on behalf of the adolescent if the adoles-
6
cent becomes unable to participate in such deci-
7
sions and the adolescent does not have, or does
8
not want, a relative who would otherwise be au-
9
thorized under State law to make such deci-
10
sions, whether a health care power of attorney,
11
health care proxy, or other similar document is
12
recognized under State law, and how to execute
13
such a document if the adolescent wants to do
14
so.’’.
15
(c)
HEALTH
OVERSIGHT
AND
COORDINATION
16 PLAN.—Section 422(b)(15)(A) of such Act (42 U.S.C.
17 622(b)(15)(A)) is amended—
18
19
20
(1) in clause (v), by striking ‘‘and’’ at the end;
and
(2) by adding at the end the following:
21
‘‘(vii) steps to ensure that the compo-
22
nents of the transition plan development
23
process required under section 475(5)(H)
24
that relate to the health care needs of chil-
25
dren aging out of foster care, including the
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1
requirements to include options for health
2
insurance, information about a health care
3
power of attorney, health care proxy, or
4
other similar document recognized under
5
State law, and to provide the child with the
6
option to execute such a document, are
7
met; and’’.
8
(d) EFFECTIVE DATE.—The amendments made by
9 this section take effect on October 1, 2010.
14
TITLE
III—IMPROVING
THE
QUALITY AND EFFICIENCY OF
HEALTH CARE
Subtitle A—Transforming the
Health Care Delivery System
15
PART I—LINKING PAYMENT TO QUALITY
16
OUTCOMES UNDER THE MEDICARE PROGRAM
17
SEC. 3001. HOSPITAL VALUE-BASED PURCHASING PRO-
10
11
12
13
18
GRAM.
19
(a) PROGRAM.—
20
(1) IN
GENERAL.—Section
1886 of the Social
21
Security Act (42 U.S.C. 1395ww), as amended by
22
section 4102(a) of the HITECH Act (Public Law
23
111–5), is amended by adding at the end the fol-
24
lowing new subsection:
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1
2
3
4
‘‘(o) HOSPITAL VALUE-BASED PURCHASING PROGRAM.—
‘‘(1) ESTABLISHMENT.—
‘‘(A) IN
GENERAL.—Subject
to the suc-
5
ceeding provisions of this subsection, the Sec-
6
retary shall establish a hospital value-based
7
purchasing program (in this subsection referred
8
to as the ‘Program’) under which value-based
9
incentive payments are made in a fiscal year to
10
hospitals that meet the performance standards
11
under paragraph (3) for the performance period
12
for such fiscal year (as established under para-
13
graph (4)).
14
‘‘(B) PROGRAM
TO BEGIN IN FISCAL YEAR
15
2013.—The
16
for discharges occurring on or after October 1,
17
2012.
18
19
20
Program shall apply to payments
‘‘(C) APPLICABILITY
OF PROGRAM TO HOS-
PITALS.—
‘‘(i) IN
GENERAL.—For
purposes of
21
this subsection, subject to clause (ii), the
22
term ‘hospital’ means a subsection (d) hos-
23
pital (as defined in subsection (d)(1)(B)).
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1
‘‘(ii) EXCLUSIONS.—The term ‘hos-
2
pital’ shall not include, with respect to a
3
fiscal year, a hospital—
4
‘‘(I) that is subject to the pay-
5
ment
6
(b)(3)(B)(viii)(I) for such fiscal year;
7
‘‘(II) for which, during the per-
8
formance period for such fiscal year,
9
the Secretary has cited deficiencies
10
that pose immediate jeopardy to the
11
health or safety of patients;
reduction
under
subsection
12
‘‘(III) for which there are not a
13
minimum number (as determined by
14
the Secretary) of measures that apply
15
to the hospital for the performance
16
period for such fiscal year; or
17
‘‘(IV) for which there are not a
18
minimum number (as determined by
19
the Secretary) of cases for the meas-
20
ures that apply to the hospital for the
21
performance period for such fiscal
22
year.
23
‘‘(iii) INDEPENDENT
ANALYSIS.—For
24
purposes of determining the minimum
25
numbers under subclauses (III) and (IV)
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1
of clause (ii), the Secretary shall have con-
2
ducted an independent analysis of what
3
numbers are appropriate.
4
‘‘(iv) EXEMPTION.—In the case of a
5
hospital
6
1814(b)(3), the Secretary may exempt
7
such hospital from the application of this
8
subsection if the State which is paid under
9
such section submits an annual report to
10
the Secretary describing how a similar pro-
11
gram in the State for a participating hos-
12
pital or hospitals achieves or surpasses the
13
measured results in terms of patient health
14
outcomes and cost savings established
15
under this subsection.
that
16
‘‘(2) MEASURES.—
17
‘‘(A) IN
is
paid
GENERAL.—The
under
section
Secretary shall
18
select measures for purposes of the Program.
19
Such measures shall be selected from the meas-
20
ures specified under subsection (b)(3)(B)(viii).
21
22
‘‘(B) REQUIREMENTS.—
‘‘(i) FOR
FISCAL
YEAR
2013.—For
23
value-based incentive payments made with
24
respect to discharges occurring during fis-
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1
cal year 2013, the Secretary shall ensure
2
the following:
3
‘‘(I)
CONDITIONS
OR
PROCE-
4
DURES.—Measures
5
subparagraph (A) that cover at least
6
the following 5 specific conditions or
7
procedures:
8
9
are selected under
‘‘(aa) Acute myocardial infarction (AMI).
10
‘‘(bb) Heart failure.
11
‘‘(cc) Pneumonia.
12
‘‘(dd) Surgeries, as meas-
13
ured by the Surgical Care Im-
14
provement Project (formerly re-
15
ferred to as ‘Surgical Infection
16
Prevention’ for discharges occur-
17
ring before July 2006).
18
‘‘(ee) Healthcare-associated
19
infections, as measured by the
20
prevention metrics and targets
21
established in the HHS Action
22
Plan to Prevent Healthcare-Asso-
23
ciated Infections (or any suc-
24
cessor plan) of the Department
25
of Health and Human Services.
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1
‘‘(II) HCAHPS.—Measures se-
2
lected under subparagraph (A) shall
3
be related to the Hospital Consumer
4
Assessment of Healthcare Providers
5
and Systems survey (HCAHPS).
6
‘‘(ii)
INCLUSION
OF
EFFICIENCY
7
MEASURES.—For
8
payments made with respect to discharges
9
occurring during fiscal year 2014 or a sub-
10
sequent fiscal year, the Secretary shall en-
11
sure that measures selected under subpara-
12
graph (A) include efficiency measures, in-
13
cluding measures of ‘Medicare spending
14
per beneficiary’. Such measures shall be
15
adjusted for factors such as age, sex, race,
16
severity of illness, and other factors that
17
the Secretary determines appropriate.
18
‘‘(C) LIMITATIONS.—
19
‘‘(i) TIME
value-based
incentive
REQUIREMENT FOR PRIOR
20
REPORTING AND NOTICE.—The
21
may not select a measure under subpara-
22
graph (A) for use under the Program with
23
respect to a performance period for a fiscal
24
year (as established under paragraph (4))
25
unless such measure has been specified
Secretary
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627
1
under subsection (b)(3)(B)(viii) and in-
2
cluded on the Hospital Compare Internet
3
website for at least 1 year prior to the be-
4
ginning of such performance period.
5
‘‘(ii) MEASURE
NOT APPLICABLE UN-
6
LESS HOSPITAL FURNISHES SERVICES AP-
7
PROPRIATE TO THE MEASURE.—A
8
selected under subparagraph (A) shall not
9
apply to a hospital if such hospital does
10
not furnish services appropriate to such
11
measure.
12
‘‘(D) REPLACING
measure
MEASURES.—Subclause
13
(VI) of subsection (b)(3)(B)(viii) shall apply to
14
measures selected under subparagraph (A) in
15
the same manner as such subclause applies to
16
measures selected under such subsection.
17
‘‘(3) PERFORMANCE
18
‘‘(A)
STANDARDS.—
ESTABLISHMENT.—The
Secretary
19
shall establish performance standards with re-
20
spect to measures selected under paragraph (2)
21
for a performance period for a fiscal year (as
22
established under paragraph (4)).
23
24
‘‘(B)
MENT.—The
ACHIEVEMENT
AND
IMPROVE-
performance standards established
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628
1
under subparagraph (A) shall include levels of
2
achievement and improvement.
3
‘‘(C) TIMING.—The Secretary shall estab-
4
lish and announce the performance standards
5
under subparagraph (A) not later than 60 days
6
prior to the beginning of the performance pe-
7
riod for the fiscal year involved.
8
9
‘‘(D) CONSIDERATIONS
STANDARDS.—In
IN ESTABLISHING
establishing
performance
10
standards with respect to measures under this
11
paragraph, the Secretary shall take into ac-
12
count appropriate factors, such as—
13
‘‘(i) practical experience with the
14
measures involved, including whether a sig-
15
nificant proportion of hospitals failed to
16
meet the performance standard during pre-
17
vious performance periods;
18
‘‘(ii) historical performance standards;
19
‘‘(iii) improvement rates; and
20
‘‘(iv) the opportunity for continued
21
22
improvement.
‘‘(4) PERFORMANCE
PERIOD.—For
purposes of
23
the Program, the Secretary shall establish the per-
24
formance period for a fiscal year. Such performance
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629
1
period shall begin and end prior to the beginning of
2
such fiscal year.
3
4
‘‘(5) HOSPITAL
‘‘(A) IN
PERFORMANCE SCORE.—
GENERAL.—Subject
to subpara-
5
graph (B), the Secretary shall develop a meth-
6
odology for assessing the total performance of
7
each hospital based on performance standards
8
with respect to the measures selected under
9
paragraph (2) for a performance period (as es-
10
tablished under paragraph (4)). Using such
11
methodology, the Secretary shall provide for an
12
assessment (in this subsection referred to as the
13
‘hospital performance score’) for each hospital
14
for each performance period.
15
16
‘‘(B) APPLICATION.—
‘‘(i) APPROPRIATE
DISTRIBUTION.—
17
The Secretary shall ensure that the appli-
18
cation of the methodology developed under
19
subparagraph (A) results in an appropriate
20
distribution of value-based incentive pay-
21
ments under paragraph (6) among hos-
22
pitals achieving different levels of hospital
23
performance scores, with hospitals achiev-
24
ing the highest hospital performance scores
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630
1
receiving the largest value-based incentive
2
payments.
3
‘‘(ii) HIGHER
OF ACHIEVEMENT OR
4
IMPROVEMENT.—The
5
oped under subparagraph (A) shall provide
6
that the hospital performance score is de-
7
termined using the higher of its achieve-
8
ment or improvement score for each meas-
9
ure.
10
‘‘(iii)
methodology devel-
WEIGHTS.—The
methodology
11
developed under subparagraph (A) shall
12
provide for the assignment of weights for
13
categories of measures as the Secretary de-
14
termines appropriate.
15
‘‘(iv) NO
MINIMUM
PERFORMANCE
16
STANDARD.—The
17
minimum performance standard in deter-
18
mining the hospital performance score for
19
any hospital.
20
Secretary shall not set a
‘‘(v) REFLECTION
OF MEASURES AP-
21
PLICABLE TO THE HOSPITAL.—The
22
pital performance score for a hospital shall
23
reflect the measures that apply to the hos-
24
pital.
hos-
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631
1
2
3
‘‘(6) CALCULATION
OF VALUE-BASED INCEN-
TIVE PAYMENTS.—
‘‘(A) IN
GENERAL.—In
the case of a hos-
4
pital that the Secretary determines meets (or
5
exceeds) the performance standards under para-
6
graph (3) for the performance period for a fis-
7
cal year (as established under paragraph (4)),
8
the Secretary shall increase the base operating
9
DRG payment amount (as defined in paragraph
10
(7)(D)), as determined after application of
11
paragraph (7)(B)(i), for a hospital for each dis-
12
charge occurring in such fiscal year by the
13
value-based incentive payment amount.
14
‘‘(B) VALUE-BASED
INCENTIVE PAYMENT
15
AMOUNT.—The
16
amount for each discharge of a hospital in a fis-
17
cal year shall be equal to the product of—
value-based incentive payment
18
‘‘(i) the base operating DRG payment
19
amount (as defined in paragraph (7)(D))
20
for the discharge for the hospital for such
21
fiscal year; and
22
‘‘(ii) the value-based incentive pay-
23
ment percentage specified under subpara-
24
graph (C) for the hospital for such fiscal
25
year.
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632
1
2
‘‘(C) VALUE-BASED
INCENTIVE PAYMENT
PERCENTAGE.—
3
‘‘(i) IN
GENERAL.—The
Secretary
4
shall specify a value-based incentive pay-
5
ment percentage for a hospital for a fiscal
6
year.
7
‘‘(ii) REQUIREMENTS.—In specifying
8
the value-based incentive payment percent-
9
age for each hospital for a fiscal year
10
under clause (i), the Secretary shall ensure
11
that—
12
‘‘(I) such percentage is based on
13
the hospital performance score of the
14
hospital under paragraph (5); and
15
‘‘(II) the total amount of value-
16
based incentive payments under this
17
paragraph to all hospitals in such fis-
18
cal year is equal to the total amount
19
available for value-based incentive
20
payments for such fiscal year under
21
paragraph (7)(A), as estimated by the
22
Secretary.
23
24
‘‘(7) FUNDING
PAYMENTS.—
FOR VALUE-BASED INCENTIVE
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633
1
‘‘(A) AMOUNT.—The total amount avail-
2
able for value-based incentive payments under
3
paragraph (6) for all hospitals for a fiscal year
4
shall be equal to the total amount of reduced
5
payments for all hospitals under subparagraph
6
(B) for such fiscal year, as estimated by the
7
Secretary.
8
‘‘(B) ADJUSTMENT
9
‘‘(i) IN
TO PAYMENTS.—
GENERAL.—The
Secretary
10
shall reduce the base operating DRG pay-
11
ment amount (as defined in subparagraph
12
(D)) for a hospital for each discharge in a
13
fiscal year (beginning with fiscal year
14
2013) by an amount equal to the applica-
15
ble percent (as defined in subparagraph
16
(C)) of the base operating DRG payment
17
amount for the discharge for the hospital
18
for such fiscal year. The Secretary shall
19
make such reductions for all hospitals in
20
the fiscal year involved, regardless of
21
whether or not the hospital has been deter-
22
mined by the Secretary to have earned a
23
value-based incentive payment under para-
24
graph (6) for such fiscal year.
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634
1
‘‘(ii) NO
2
MENTS.—Payments
3
and (bb) of subparagraph (D)(i)(II) for a
4
hospital shall be determined as if this sub-
5
section had not been enacted.
6
‘‘(C) APPLICABLE
EFFECT
ON
OTHER
PAY-
described in items (aa)
PERCENT DEFINED.—
7
For purposes of subparagraph (B), the term
8
‘applicable percent’ means—
9
10
‘‘(i) with respect to fiscal year 2013,
1.0 percent;
11
12
‘‘(ii) with respect to fiscal year 2014,
1.25 percent;
13
14
‘‘(iii) with respect to fiscal year 2015,
1.5 percent;
15
16
‘‘(iv) with respect to fiscal year 2016,
1.75 percent; and
17
‘‘(v) with respect to fiscal year 2017
18
and succeeding fiscal years, 2 percent.
19
‘‘(D) BASE
20
AMOUNT DEFINED.—
21
‘‘(i) IN
OPERATING
DRG
GENERAL.—Except
PAYMENT
as pro-
22
vided in clause (ii), in this subsection, the
23
term
24
amount’ means, with respect to a hospital
25
for a fiscal year—
‘base
operating
DRG
payment
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635
1
‘‘(I) the payment amount that
2
would otherwise be made under sub-
3
section (d) (determined without re-
4
gard to subsection (q)) for a discharge
5
if this subsection did not apply; re-
6
duced by
7
‘‘(II) any portion of such pay-
8
ment amount that is attributable to—
9
‘‘(aa) payments under para-
10
graphs (5)(A), (5)(B), (5)(F),
11
and (12) of subsection (d); and
12
‘‘(bb) such other payments
13
under subsection (d) determined
14
appropriate by the Secretary.
15
‘‘(ii) SPECIAL
16
HOSPITALS.—
17
‘‘(I)
RULES FOR CERTAIN
SOLE
COMMUNITY
HOS-
18
PITALS AND MEDICARE-DEPENDENT,
19
SMALL
20
case of a medicare-dependent, small
21
rural hospital (with respect to dis-
22
charges occurring during fiscal year
23
2012 and 2013) or a sole community
24
hospital, in applying subparagraph
25
(A)(i), the payment amount that
RURAL
HOSPITALS.—In
the
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636
1
would otherwise be made under sub-
2
section (d) shall be determined with-
3
out regard to subparagraphs (I) and
4
(L) of subsection (b)(3) and subpara-
5
graphs (D) and (G) of subsection
6
(d)(5).
7
‘‘(II) HOSPITALS
PAID
UNDER
8
SECTION 1814.—In
9
pital that is paid under section
10
1814(b)(3), the term ‘base operating
11
DRG payment amount’ means the
12
payment amount under such section.
13
‘‘(8) ANNOUNCEMENT
the case of a hos-
OF NET RESULT OF AD-
14
JUSTMENTS.—Under
15
shall, not later than 60 days prior to the fiscal year
16
involved, inform each hospital of the adjustments to
17
payments to the hospital for discharges occurring in
18
such fiscal year under paragraphs (6) and (7)(B)(i).
19
‘‘(9) NO
the Program, the Secretary
EFFECT
IN
SUBSEQUENT
FISCAL
20
YEARS.—The
21
paragraph (6) and the payment reduction under
22
paragraph (7)(B)(i) shall each apply only with re-
23
spect to the fiscal year involved, and the Secretary
24
shall not take into account such value-based incen-
25
tive payment or payment reduction in making pay-
value-based incentive payment under
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S.L.C.
637
1
ments to a hospital under this section in a subse-
2
quent fiscal year.
3
4
5
‘‘(10) PUBLIC
REPORTING.—
‘‘(A) HOSPITAL
‘‘(i) IN
SPECIFIC INFORMATION.—
GENERAL.—The
Secretary
6
shall make information available to the
7
public regarding the performance of indi-
8
vidual hospitals under the Program, in-
9
cluding—
10
‘‘(I) the performance of the hos-
11
pital with respect to each measure
12
that applies to the hospital;
13
‘‘(II) the performance of the hos-
14
pital with respect to each condition or
15
procedure; and
16
‘‘(III) the hospital performance
17
score assessing the total performance
18
of the hospital.
19
‘‘(ii) OPPORTUNITY
TO REVIEW AND
20
SUBMIT
21
shall ensure that a hospital has the oppor-
22
tunity to review, and submit corrections
23
for, the information to be made public with
24
respect to the hospital under clause (i)
CORRECTIONS.—The
Secretary
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638
1
prior to such information being made pub-
2
lic.
3
‘‘(iii)
WEBSITE.—Such
information
4
shall be posted on the Hospital Compare
5
Internet website in an easily understand-
6
able format.
7
‘‘(B)
AGGREGATE
INFORMATION.—The
8
Secretary shall periodically post on the Hospital
9
Compare Internet website aggregate informa-
10
11
tion on the Program, including—
‘‘(i) the number of hospitals receiving
12
value-based
13
paragraph (6) and the range and total
14
amount of such value-based incentive pay-
15
ments; and
incentive
payments
under
16
‘‘(ii) the number of hospitals receiving
17
less than the maximum value-based incen-
18
tive payment available to the hospital for
19
the fiscal year involved and the range and
20
amount of such payments.
21
‘‘(11) IMPLEMENTATION.—
22
‘‘(A) APPEALS.—The Secretary shall es-
23
tablish a process by which hospitals may appeal
24
the calculation of a hospital’s performance as-
25
sessment with respect to the performance
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639
1
standards established under paragraph (3)(A)
2
and the hospital performance score under para-
3
graph (5). The Secretary shall ensure that such
4
process provides for resolution of such appeals
5
in a timely manner.
6
‘‘(B) LIMITATION
ON REVIEW.—Except
as
7
provided in subparagraph (A), there shall be no
8
administrative or judicial review under section
9
1869, section 1878, or otherwise of the fol-
10
lowing:
11
‘‘(i) The methodology used to deter-
12
mine the amount of the value-based incen-
13
tive payment under paragraph (6) and the
14
determination of such amount.
15
‘‘(ii) The determination of the amount
16
of funding available for such value-based
17
incentive
18
(7)(A) and the payment reduction under
19
paragraph (7)(B)(i).
payments
under
paragraph
20
‘‘(iii) The establishment of the per-
21
formance standards under paragraph (3)
22
and the performance period under para-
23
graph (4).
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640
1
‘‘(iv) The measures specified under
2
subsection (b)(3)(B)(viii) and the measures
3
selected under paragraph (2).
4
‘‘(v) The methodology developed under
5
paragraph (5) that is used to calculate
6
hospital performance scores and the cal-
7
culation of such scores.
8
‘‘(vi)
9
The
validation
methodology
specified in subsection (b)(3)(B)(viii)(XI).
10
‘‘(C) CONSULTATION
WITH SMALL HOS-
11
PITALS.—The
12
rural and urban hospitals on the application of
13
the Program to such hospitals.
14
‘‘(12) PROMULGATION
Secretary shall consult with small
OF REGULATIONS.—The
15
Secretary shall promulgate regulations to carry out
16
the Program, including the selection of measures
17
under paragraph (2), the methodology developed
18
under paragraph (5) that is used to calculate hos-
19
pital performance scores, and the methodology used
20
to determine the amount of value-based incentive
21
payments under paragraph (6).’’.
22
(2) AMENDMENTS
FOR REPORTING OF HOS-
23
PITAL
24
1886(b)(3)(B)(viii) of the Social Security Act (42
25
U.S.C. 1395ww(b)(3)(B)(viii)) is amended—
QUALITY
INFORMATION.—Section
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S.L.C.
641
1
(A) in subclause (II), by adding at the end
2
the following sentence: ‘‘The Secretary may re-
3
quire hospitals to submit data on measures that
4
are not used for the determination of value-
5
based incentive payments under subsection
6
(o).’’;
7
(B) in subclause (V), by striking ‘‘begin-
8
ning with fiscal year 2008’’ and inserting ‘‘for
9
fiscal years 2008 through 2012’’;
10
(C) in subclause (VII), in the first sen-
11
tence, by striking ‘‘data submitted’’ and insert-
12
ing ‘‘information regarding measures sub-
13
mitted’’; and
14
15
16
(D) by adding at the end the following new
subclauses:
‘‘(VIII) Effective for payments beginning with fiscal
17 year 2013, with respect to quality measures for outcomes
18 of care, the Secretary shall provide for such risk adjust19 ment as the Secretary determines to be appropriate to
20 maintain incentives for hospitals to treat patients with se21 vere illnesses or conditions.
22
‘‘(IX)(aa) Subject to item (bb), effective for payments
23 beginning with fiscal year 2013, each measure specified
24 by the Secretary under this clause shall be endorsed by
25 the entity with a contract under section 1890(a).
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642
1
‘‘(bb) In the case of a specified area or medical topic
2 determined appropriate by the Secretary for which a fea3 sible and practical measure has not been endorsed by the
4 entity with a contract under section 1890(a), the Sec5 retary may specify a measure that is not so endorsed as
6 long as due consideration is given to measures that have
7 been endorsed or adopted by a consensus organization
8 identified by the Secretary.
9
‘‘(X) To the extent practicable, the Secretary shall,
10 with input from consensus organizations and other stake11 holders, take steps to ensure that the measures specified
12 by the Secretary under this clause are coordinated and
13 aligned with quality measures applicable to—
14
‘‘(aa) physicians under section 1848(k); and
15
‘‘(bb) other providers of services and suppliers
16
under this title.
17
‘‘(XI) The Secretary shall establish a process to vali-
18 date measures specified under this clause as appropriate.
19 Such process shall include the auditing of a number of
20 randomly selected hospitals sufficient to ensure validity of
21 the reporting program under this clause as a whole and
22 shall provide a hospital with an opportunity to appeal the
23 validation of measures reported by such hospital.’’.
24
25
(3)
WEBSITE
IMPROVEMENTS.—Section
1886(b)(3)(B) of the Social Security Act (42 U.S.C.
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1
1395ww(b)(3)(B)), as amended by section 4102(b)
2
of the HITECH Act (Public Law 111–5), is amend-
3
ed by adding at the end the following new clause:
4
‘‘(x)(I) The Secretary shall develop standard Internet
5 website reports tailored to meet the needs of various stake6 holders such as hospitals, patients, researchers, and pol7 icymakers. The Secretary shall seek input from such
8 stakeholders in determining the type of information that
9 is useful and the formats that best facilitate the use of
10 the information.
11
‘‘(II) The Secretary shall modify the Hospital Com-
12 pare Internet website to make the use and navigation of
13 that website readily available to individuals accessing it.’’.
14
(4) GAO
STUDY AND REPORT.—
15
(A) STUDY.—The Comptroller General of
16
the United States shall conduct a study on the
17
performance of the hospital value-based pur-
18
chasing program established under section
19
1886(o) of the Social Security Act, as added by
20
paragraph (1). Such study shall include an
21
analysis of the impact of such program on—
22
(i) the quality of care furnished to
23
Medicare beneficiaries, including diverse
24
Medicare beneficiary populations (such as
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644
1
diverse in terms of race, ethnicity, and so-
2
cioeconomic status);
3
(ii) expenditures under the Medicare
4
program, including any reduced expendi-
5
tures under Part A of title XVIII of such
6
Act that are attributable to the improve-
7
ment in the delivery of inpatient hospital
8
services by reason of such hospital value-
9
based purchasing program;
10
(iii) the quality performance among
11
safety net hospitals and any barriers such
12
hospitals face in meeting the performance
13
standards applicable under such hospital
14
value-based purchasing program; and
15
(iv) the quality performance among
16
small rural and small urban hospitals and
17
any barriers such hospitals face in meeting
18
the
19
under such hospital value-based purchasing
20
program.
21
(B) REPORTS.—
22
(i) INTERIM
performance
standards
REPORT.—Not
applicable
later than
23
October 1, 2015, the Comptroller General
24
of the United States shall submit to Con-
25
gress an interim report containing the re-
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645
1
sults of the study conducted under sub-
2
paragraph (A), together with recommenda-
3
tions for such legislation and administra-
4
tive action as the Comptroller General de-
5
termines appropriate.
6
(ii) FINAL
REPORT.—Not
later than
7
July 1, 2017, the Comptroller General of
8
the United States shall submit to Congress
9
a report containing the results of the study
10
conducted under subparagraph (A), to-
11
gether with recommendations for such leg-
12
islation and administrative action as the
13
Comptroller General determines appro-
14
priate.
15
(5) HHS
STUDY AND REPORT.—
16
(A) STUDY.—The Secretary of Health and
17
Human Services shall conduct a study on the
18
performance of the hospital value-based pur-
19
chasing program established under section
20
1886(o) of the Social Security Act, as added by
21
paragraph (1). Such study shall include an
22
analysis—
23
(i) of ways to improve the hospital
24
value-based purchasing program and ways
25
to address any unintended consequences
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1
that may occur as a result of such pro-
2
gram;
3
(ii) of whether the hospital value-
4
based purchasing program resulted in
5
lower spending under the Medicare pro-
6
gram under title XVIII of such Act or
7
other financial savings to hospitals;
8
(iii) the appropriateness of the Medi-
9
care program sharing in any savings gen-
10
erated through the hospital value-based
11
purchasing program; and
12
(iv) any other area determined appro-
13
priate by the Secretary.
14
(B) REPORT.—Not later than January 1,
15
2016, the Secretary of Health and Human
16
Services shall submit to Congress a report con-
17
taining the results of the study conducted under
18
subparagraph (A), together with recommenda-
19
tions for such legislation and administrative ac-
20
tion as the Secretary determines appropriate.
21
(b) VALUE-BASED PURCHASING DEMONSTRATION
22 PROGRAMS.—
23
(1) VALUE-BASED
PURCHASING
DEMONSTRA-
24
TION PROGRAM FOR INPATIENT CRITICAL ACCESS
25
HOSPITALS.—
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2
(A) ESTABLISHMENT.—
(i) IN
GENERAL.—Not
later than 2
3
years after the date of enactment of this
4
Act, the Secretary of Health and Human
5
Services (in this subsection referred to as
6
the ‘‘Secretary’’) shall establish a dem-
7
onstration program under which the Sec-
8
retary establishes a value-based purchasing
9
program under the Medicare program
10
under title XVIII of the Social Security
11
Act for critical access hospitals (as defined
12
in paragraph (1) of section 1861(mm) of
13
such Act (42 U.S.C. 1395x(mm))) with re-
14
spect to inpatient critical access hospital
15
services (as defined in paragraph (2) of
16
such section) in order to test innovative
17
methods of measuring and rewarding qual-
18
ity and efficient health care furnished by
19
such hospitals.
20
(ii) DURATION.—The demonstration
21
program under this paragraph shall be
22
conducted for a 3-year period.
23
(iii) SITES.—The Secretary shall con-
24
duct the demonstration program under this
25
paragraph at an appropriate number (as
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1
determined by the Secretary) of critical ac-
2
cess hospitals. The Secretary shall ensure
3
that such hospitals are representative of
4
the spectrum of such hospitals that partici-
5
pate in the Medicare program.
6
(B) WAIVER
AUTHORITY.—The
Secretary
7
may waive such requirements of titles XI and
8
XVIII of the Social Security Act as may be nec-
9
essary to carry out the demonstration program
10
11
under this paragraph.
(C)
BUDGET
NEUTRALITY
REQUIRE-
12
MENT.—In
13
gram under this section, the Secretary shall en-
14
sure that the aggregate payments made by the
15
Secretary do not exceed the amount which the
16
Secretary would have paid if the demonstration
17
program under this section was not imple-
18
mented.
conducting the demonstration pro-
19
(D) REPORT.—Not later than 18 months
20
after the completion of the demonstration pro-
21
gram under this paragraph, the Secretary shall
22
submit to Congress a report on the demonstra-
23
tion program together with—
24
(i) recommendations on the establish-
25
ment of a permanent value-based pur-
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1
chasing program under the Medicare pro-
2
gram for critical access hospitals with re-
3
spect to inpatient critical access hospital
4
services; and
5
(ii) recommendations for such other
6
legislation and administrative action as the
7
Secretary determines appropriate.
8
(2) VALUE-BASED
PURCHASING
DEMONSTRA-
9
TION PROGRAM FOR HOSPITALS EXCLUDED FROM
10
HOSPITAL VALUE-BASED PURCHASING PROGRAM AS
11
A RESULT OF INSUFFICIENT NUMBERS OF MEAS-
12
URES AND CASES.—
13
(A) ESTABLISHMENT.—
14
(i) IN
GENERAL.—Not
later than 2
15
years after the date of enactment of this
16
Act, the Secretary shall establish a dem-
17
onstration program under which the Sec-
18
retary establishes a value-based purchasing
19
program under the Medicare program
20
under title XVIII of the Social Security
21
Act for applicable hospitals (as defined in
22
clause (ii)) with respect to inpatient hos-
23
pital
24
1861(b) of the Social Security Act (42
25
U.S.C. 1395x(b))) in order to test innova-
services
(as
defined
in
section
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1
tive methods of measuring and rewarding
2
quality and efficient health care furnished
3
by such hospitals.
4
(ii)
5
FINED.—For
6
the term ‘‘applicable hospital’’ means a
7
hospital described in subclause (III) or
8
(IV) of section 1886(o)(1)(C)(ii) of the So-
9
cial Security Act, as added by subsection
10
APPLICABLE
HOSPITAL
DE-
purposes of this paragraph,
(a)(1).
11
(iii) DURATION.—The demonstration
12
program under this paragraph shall be
13
conducted for a 3-year period.
14
(iv) SITES.—The Secretary shall con-
15
duct the demonstration program under this
16
paragraph at an appropriate number (as
17
determined by the Secretary) of applicable
18
hospitals. The Secretary shall ensure that
19
such hospitals are representative of the
20
spectrum of such hospitals that participate
21
in the Medicare program.
22
(B) WAIVER
AUTHORITY.—The
Secretary
23
may waive such requirements of titles XI and
24
XVIII of the Social Security Act as may be nec-
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651
1
essary to carry out the demonstration program
2
under this paragraph.
3
(C)
BUDGET
NEUTRALITY
REQUIRE-
4
MENT.—In
5
gram under this section, the Secretary shall en-
6
sure that the aggregate payments made by the
7
Secretary do not exceed the amount which the
8
Secretary would have paid if the demonstration
9
program under this section was not imple-
10
conducting the demonstration pro-
mented.
11
(D) REPORT.—Not later than 18 months
12
after the completion of the demonstration pro-
13
gram under this paragraph, the Secretary shall
14
submit to Congress a report on the demonstra-
15
tion program together with—
16
(i) recommendations on the establish-
17
ment of a permanent value-based pur-
18
chasing program under the Medicare pro-
19
gram for applicable hospitals with respect
20
to inpatient hospital services; and
21
(ii) recommendations for such other
22
legislation and administrative action as the
23
Secretary determines appropriate.
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1
2
3
SEC. 3002. IMPROVEMENTS TO THE PHYSICIAN QUALITY
REPORTING SYSTEM.
(a) EXTENSION.—Section 1848(m) of the Social Se-
4 curity Act (42 U.S.C. 1395w–4(m)) is amended—
5
(1) in paragraph (1)—
6
(A) in subparagraph (A), in the matter
7
preceding clause (i), by striking ‘‘2010’’ and in-
8
serting ‘‘2014’’; and
9
(B) in subparagraph (B)—
10
11
(i) in clause (i), by striking ‘‘and’’ at
the end;
12
(ii) in clause (ii), by striking the pe-
13
riod at the end and inserting a semicolon;
14
and
15
16
(iii) by adding at the end the following new clauses:
17
‘‘(iii) for 2011, 1.0 percent; and
18
‘‘(iv) for 2012, 2013, and 2014, 0.5
19
20
percent.’’;
(2) in paragraph (3)—
21
(A) in subparagraph (A), in the matter
22
preceding clause (i), by inserting ‘‘(or, for pur-
23
poses of subsection (a)(8), for the quality re-
24
porting period for the year)’’ after ‘‘reporting
25
period’’; and
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1
(B) in subparagraph (C)(i), by inserting ‘‘,
2
or, for purposes of subsection (a)(8), for a qual-
3
ity reporting period for the year’’ after ‘‘(a)(5),
4
for a reporting period for a year’’;
5
(3) in paragraph (5)(E)(iv), by striking ‘‘sub-
6
section (a)(5)(A)’’ and inserting ‘‘paragraphs (5)(A)
7
and (8)(A) of subsection (a)’’; and
8
(4) in paragraph (6)(C)—
9
(A) in clause (i)(II), by striking ‘‘, 2009,
10
2010, and 2011’’ and inserting ‘‘and subse-
11
quent years’’; and
12
(B) in clause (iii)—
13
(i)
14
‘‘(a)(5)’’; and
by
inserting
‘‘(a)(8)’’
after
15
(ii) by striking ‘‘under subparagraph
16
(D)(iii) of such subsection’’ and inserting
17
‘‘under subsection (a)(5)(D)(iii) or the
18
quality reporting period under subsection
19
(a)(8)(D)(iii), respectively’’.
20
21
(b) INCENTIVE PAYMENT ADJUSTMENT
ITY
FOR
QUAL-
REPORTING.—Section 1848(a) of the Social Security
22 Act (42 U.S.C. 1395w–4(a)) is amended by adding at the
23 end the following new paragraph:
24
25
‘‘(8) INCENTIVES
FOR QUALITY REPORTING.—
‘‘(A) ADJUSTMENT.—
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1
‘‘(i) IN
GENERAL.—With
respect to
2
covered professional services furnished by
3
an eligible professional during 2015 or any
4
subsequent year, if the eligible professional
5
does not satisfactorily submit data on qual-
6
ity measures for covered professional serv-
7
ices for the quality reporting period for the
8
year (as determined under subsection
9
(m)(3)(A)), the fee schedule amount for
10
such services furnished by such profes-
11
sional during the year (including the fee
12
schedule amount for purposes of deter-
13
mining a payment based on such amount)
14
shall be equal to the applicable percent of
15
the fee schedule amount that would other-
16
wise apply to such services under this sub-
17
section (determined after application of
18
paragraphs (3), (5), and (7), but without
19
regard to this paragraph).
20
‘‘(ii)
APPLICABLE
PERCENT.—For
21
purposes of clause (i), the term ‘applicable
22
percent’ means—
23
‘‘(I) for 2015, 98.5 percent; and
24
‘‘(II) for 2016 and each subse-
25
quent year, 98 percent.
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1
‘‘(B) APPLICATION.—
2
‘‘(i) PHYSICIAN
REPORTING SYSTEM
3
RULES.—Paragraphs
(5), (6), and (8) of
4
subsection (k) shall apply for purposes of
5
this paragraph in the same manner as they
6
apply for purposes of such subsection.
7
‘‘(ii) INCENTIVE
PAYMENT
VALIDA-
8
TION RULES.—Clauses
9
section (m)(5)(D) shall apply for purposes
10
of this paragraph in a similar manner as
11
they apply for purposes of such subsection.
12
‘‘(C) DEFINITIONS.—For purposes of this
13
14
(ii) and (iii) of sub-
paragraph:
‘‘(i) ELIGIBLE
PROFESSIONAL; COV-
15
ERED
16
terms ‘eligible professional’ and ‘covered
17
professional services’ have the meanings
18
given such terms in subsection (k)(3).
19
PROFESSIONAL
‘‘(ii)
PHYSICIAN
SERVICES.—The
REPORTING
SYS-
20
TEM.—The
21
tem’ means the system established under
22
subsection (k).
23
24
term ‘physician reporting sys-
‘‘(iii) QUALITY
REPORTING PERIOD.—
The term ‘quality reporting period’ means,
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1
with respect to a year, a period specified
2
by the Secretary.’’.
3
(c) MAINTENANCE
4
(1) IN
OF
CERTIFICATION PROGRAMS.—
GENERAL.—Section
1848(k)(4) of the
5
Social Security Act (42 U.S.C. 1395w–4(k)(4)) is
6
amended by inserting ‘‘or through a Maintenance of
7
Certification program operated by a specialty body
8
of the American Board of Medical Specialties that
9
meets the criteria for such a registry’’ after ‘‘Data-
10
base)’’.
11
(2) EFFECTIVE
DATE.—The
amendment made
12
by paragraph (1) shall apply for years after 2010.
13
(d) INTEGRATION
14
ING AND
OF
PHYSICIAN QUALITY REPORT-
EHR REPORTING.—Section 1848(m) of the So-
15 cial Security Act (42 U.S.C. 1395w–4(m)) is amended by
16 adding at the end the following new paragraph:
17
‘‘(7) INTEGRATION
OF PHYSICIAN QUALITY RE-
18
PORTING AND EHR REPORTING.—Not
19
January 1, 2012, the Secretary shall develop a plan
20
to integrate reporting on quality measures under
21
this subsection with reporting requirements under
22
subsection (o) relating to the meaningful use of elec-
23
tronic health records. Such integration shall consist
24
of the following:
later than
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657
1
2
‘‘(A) The selection of measures, the reporting of which would both demonstrate—
3
‘‘(i) meaningful use of an electronic
4
health record for purposes of subsection
5
(o); and
6
‘‘(ii) quality of care furnished to an
7
individual.
8
‘‘(B) Such other activities as specified by
9
10
the Secretary.’’.
(e) FEEDBACK.—Section 1848(m)(5) of the Social
11 Security Act (42 U.S.C. 1395w–4(m)(5)) is amended by
12 adding at the end the following new subparagraph:
13
‘‘(H) FEEDBACK.—The Secretary shall
14
provide timely feedback to eligible professionals
15
on the performance of the eligible professional
16
with respect to satisfactorily submitting data on
17
quality measures under this subsection.’’.
18
(f) APPEALS.—Such section is further amended—
19
(1) in subparagraph (E), by striking ‘‘There
20
shall’’ and inserting ‘‘Except as provided in subpara-
21
graph (I), there shall’’; and
22
23
24
25
(2) by adding at the end the following new subparagraph:
‘‘(I) INFORMAL
APPEALS PROCESS.—The
Secretary shall, by not later than January 1,
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1
2011, establish and have in place an informal
2
process for eligible professionals to seek a re-
3
view of the determination that an eligible pro-
4
fessional did not satisfactorily submit data on
5
quality measures under this subsection.’’.
6
7
8
SEC. 3003. IMPROVEMENTS TO THE PHYSICIAN FEEDBACK
PROGRAM.
(a) IN GENERAL.—Section 1848(n) of the Social Se-
9 curity Act (42 U.S.C. 1395w–4(n)) is amended—
10
11
12
13
(1) in paragraph (1)—
(A) in subparagraph (A)—
(i) by striking ‘‘GENERAL.—The Secretary’’ and inserting ‘‘GENERAL.—
14
‘‘(i)
15
retary’’;
ESTABLISHMENT.—The
Sec-
16
(ii) in clause (i), as added by clause
17
(i), by striking ‘‘the ‘Program’)’’ and all
18
that follows through the period at the end
19
of the second sentence and inserting ‘‘the
20
‘Program’).’’; and
21
(iii) by adding at the end the fol-
22
lowing new clauses:
23
‘‘(ii) REPORTS
ON RESOURCES.—The
24
Secretary shall use claims data under this
25
title (and may use other data) to provide
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659
1
confidential reports to physicians (and, as
2
determined appropriate by the Secretary,
3
to groups of physicians) that measure the
4
resources involved in furnishing care to in-
5
dividuals under this title.
6
‘‘(iii) INCLUSION
OF CERTAIN INFOR-
7
MATION.—If
8
the Secretary, the Secretary may include
9
information on the quality of care fur-
10
nished to individuals under this title by the
11
physician (or group of physicians) in such
12
reports.’’; and
13
(B) in subparagraph (B), by striking ‘‘sub-
14
paragraph (A)’’ and inserting ‘‘subparagraph
15
(A)(ii)’’;
16
(2) in paragraph (4)—
17
18
19
determined appropriate by
(A) in the heading, by inserting ‘‘INITIAL’’
after ‘‘FOCUS’’; and
(B) in the matter preceding subparagraph
20
(A), by inserting ‘‘initial’’ after ‘‘focus the’’;
21
(3) in paragraph (6), by adding at the end the
22
following new sentence: ‘‘For adjustments for re-
23
ports on utilization under paragraph (9), see sub-
24
paragraph (D) of such paragraph.’’; and
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1
2
3
4
5
6
(4) by adding at the end the following new
paragraphs:
‘‘(9) REPORTS
ON UTILIZATION.—
‘‘(A) DEVELOPMENT
OF EPISODE GROUP-
ER.—
‘‘(i) IN
GENERAL.—The
Secretary
7
shall develop an episode grouper that com-
8
bines separate but clinically related items
9
and services into an episode of care for an
10
11
individual, as appropriate.
‘‘(ii)
TIMELINE
FOR
DEVELOP-
12
MENT.—The
13
subparagraph (A) shall be developed by not
14
later than January 1, 2012.
15
‘‘(iii)
episode grouper described in
PUBLIC
AVAILABILITY.—The
16
Secretary shall make the details of the epi-
17
sode grouper described in subparagraph
18
(A) available to the public.
19
‘‘(iv) ENDORSEMENT.—The Secretary
20
shall seek endorsement of the episode
21
grouper described in subparagraph (A) by
22
the entity with a contract under section
23
1890(a).
24
‘‘(B) REPORTS
25
ON UTILIZATION.—Effec-
tive beginning with 2012, the Secretary shall
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1
provide reports to physicians that compare, as
2
determined appropriate by the Secretary, pat-
3
terns of resource use of the individual physician
4
to such patterns of other physicians.
5
‘‘(C) ANALYSIS
OF DATA.—The
Secretary
6
shall, for purposes of preparing reports under
7
this paragraph, establish methodologies as ap-
8
propriate, such as to—
9
10
‘‘(i) attribute episodes of care, in
whole or in part, to physicians;
11
‘‘(ii) identify appropriate physicians
12
for purposes of comparison under subpara-
13
graph (B); and
14
‘‘(iii) aggregate episodes of care at-
15
tributed to a physician under clause (i)
16
into a composite measure per individual.
17
‘‘(D) DATA
ADJUSTMENT.—In
preparing
18
reports under this paragraph, the Secretary
19
shall make appropriate adjustments, including
20
adjustments—
21
‘‘(i) to account for differences in so-
22
cioeconomic and demographic characteris-
23
tics, ethnicity, and health status of individ-
24
uals (such as to recognize that less healthy
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1
individuals may require more intensive
2
interventions); and
3
‘‘(ii) to eliminate the effect of geo-
4
graphic adjustments in payment rates (as
5
described in subsection (e)).
6
‘‘(E) PUBLIC
7
OLOGY.—The
8
the public—
9
10
AVAILABILITY OF METHOD-
Secretary shall make available to
‘‘(i) the methodologies established
under subparagraph (C);
11
‘‘(ii) information regarding any ad-
12
justments made to data under subpara-
13
graph (D); and
14
‘‘(iii) aggregate reports with respect
15
to physicians.
16
‘‘(F) DEFINITION
17
18
OF PHYSICIAN.—In
this
paragraph:
‘‘(i) IN
GENERAL.—The
term ‘physi-
19
cian’ has the meaning given that term in
20
section 1861(r)(1).
21
‘‘(ii) TREATMENT
OF GROUPS.—Such
22
term includes, as the Secretary determines
23
appropriate, a group of physicians.
24
‘‘(G) LIMITATIONS
25
ON
REVIEW.—There
shall be no administrative or judicial review
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1
under section 1869, section 1878, or otherwise
2
of the establishment of the methodology under
3
subparagraph (C), including the determination
4
of an episode of care under such methodology.
5
‘‘(10) COORDINATION
WITH
OTHER
VALUE-
6
BASED PURCHASING REFORMS.—The
7
coordinate the Program with the value-based pay-
8
ment modifier established under subsection (p) and,
9
as the Secretary determines appropriate, other simi-
Secretary shall
10
lar provisions of this title.’’.
11
(b) CONFORMING AMENDMENT.—Section 1890(b) of
12 the Social Security Act (42 U.S.C. 1395aaa(b)) is amend13 ed by adding at the end the following new paragraph:
14
‘‘(6) REVIEW
AND ENDORSEMENT OF EPISODE
15
GROUPER UNDER THE PHYSICIAN FEEDBACK PRO-
16
GRAM.—The
17
as appropriate, the endorsement of the episode
18
grouper developed by the Secretary under section
19
1848(n)(9)(A). Such review shall be conducted on an
20
expedited basis.’’.
21
entity shall provide for the review and,
SEC. 3004. QUALITY REPORTING FOR LONG-TERM CARE
22
HOSPITALS,
23
HOSPITALS, AND HOSPICE PROGRAMS.
24
(a)
LONG-TERM
INPATIENT
CARE
REHABILITATION
HOSPITALS.—Section
25 1886(m) of the Social Security Act (42 U.S.C.
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664
1 1395ww(m)), as amended by section 3401(c), is amended
2 by adding at the end the following new paragraph:
3
4
5
‘‘(5) QUALITY
REPORTING.—
‘‘(A) REDUCTION
IN UPDATE FOR FAILURE
TO REPORT.—
6
‘‘(i) IN
GENERAL.—Under
the system
7
described in paragraph (1), for rate year
8
2014 and each subsequent rate year, in the
9
case of a long-term care hospital that does
10
not submit data to the Secretary in accord-
11
ance with subparagraph (C) with respect
12
to such a rate year, any annual update to
13
a standard Federal rate for discharges for
14
the hospital during the rate year, and after
15
application of paragraph (3), shall be re-
16
duced by 2 percentage points.
17
‘‘(ii) SPECIAL
RULE.—The
application
18
of this subparagraph may result in such
19
annual update being less than 0.0 for a
20
rate year, and may result in payment rates
21
under the system described in paragraph
22
(1) for a rate year being less than such
23
payment rates for the preceding rate year.
24
‘‘(B)
25
NONCUMULATIVE
APPLICATION.—
Any reduction under subparagraph (A) shall
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1
apply only with respect to the rate year involved
2
and the Secretary shall not take into account
3
such reduction in computing the payment
4
amount under the system described in para-
5
graph (1) for a subsequent rate year.
6
‘‘(C) SUBMISSION
OF QUALITY DATA.—For
7
rate year 2014 and each subsequent rate year,
8
each long-term care hospital shall submit to the
9
Secretary data on quality measures specified
10
under subparagraph (D). Such data shall be
11
submitted in a form and manner, and at a time,
12
specified by the Secretary for purposes of this
13
subparagraph.
14
15
‘‘(D) QUALITY
‘‘(i) IN
MEASURES.—
GENERAL.—Subject
to clause
16
(ii), any measure specified by the Secretary
17
under this subparagraph must have been
18
endorsed by the entity with a contract
19
under section 1890(a).
20
‘‘(ii) EXCEPTION.—In the case of a
21
specified area or medical topic determined
22
appropriate by the Secretary for which a
23
feasible and practical measure has not
24
been endorsed by the entity with a contract
25
under section 1890(a), the Secretary may
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1
specify a measure that is not so endorsed
2
as long as due consideration is given to
3
measures that have been endorsed or
4
adopted by a consensus organization iden-
5
tified by the Secretary.
6
‘‘(iii) TIME
FRAME.—Not
later than
7
October 1, 2012, the Secretary shall pub-
8
lish the measures selected under this sub-
9
paragraph that will be applicable with re-
10
spect to rate year 2014.
11
‘‘(E) PUBLIC
AVAILABILITY OF DATA SUB-
12
MITTED.—The
13
dures for making data submitted under sub-
14
paragraph (C) available to the public. Such pro-
15
cedures shall ensure that a long-term care hos-
16
pital has the opportunity to review the data
17
that is to be made public with respect to the
18
hospital prior to such data being made public.
19
The Secretary shall report quality measures
20
that relate to services furnished in inpatient
21
settings in long-term care hospitals on the
22
Internet website of the Centers for Medicare &
23
Medicaid Services.’’.
Secretary shall establish proce-
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1
(b) INPATIENT REHABILITATION HOSPITALS.—Sec-
2 tion 1886(j) of the Social Security Act (42 U.S.C.
3 1395ww(j)) is amended—
4
5
6
(1) by redesignating paragraph (7) as paragraph (8); and
(2) by inserting after paragraph (6) the fol-
7
lowing new paragraph:
8
‘‘(7) QUALITY
9
10
11
REPORTING.—
‘‘(A) REDUCTION
IN UPDATE FOR FAILURE
TO REPORT.—
‘‘(i) IN
GENERAL.—For
purposes of
12
fiscal year 2014 and each subsequent fiscal
13
year, in the case of a rehabilitation facility
14
that does not submit data to the Secretary
15
in accordance with subparagraph (C) with
16
respect to such a fiscal year, after deter-
17
mining the increase factor described in
18
paragraph (3)(C), and after application of
19
paragraph (3)(D), the Secretary shall re-
20
duce such increase factor for payments for
21
discharges occurring during such fiscal
22
year by 2 percentage points.
23
‘‘(ii) SPECIAL
RULE.—The
application
24
of this subparagraph may result in the in-
25
crease factor described in paragraph (3)(C)
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668
1
being less than 0.0 for a fiscal year, and
2
may result in payment rates under this
3
subsection for a fiscal year being less than
4
such payment rates for the preceding fiscal
5
year.
6
‘‘(B)
NONCUMULATIVE
APPLICATION.—
7
Any reduction under subparagraph (A) shall
8
apply only with respect to the fiscal year in-
9
volved and the Secretary shall not take into ac-
10
count such reduction in computing the payment
11
amount under this subsection for a subsequent
12
fiscal year.
13
‘‘(C) SUBMISSION
OF QUALITY DATA.—For
14
fiscal year 2014 and each subsequent rate year,
15
each rehabilitation facility shall submit to the
16
Secretary data on quality measures specified
17
under subparagraph (D). Such data shall be
18
submitted in a form and manner, and at a time,
19
specified by the Secretary for purposes of this
20
subparagraph.
21
22
‘‘(D) QUALITY
‘‘(i) IN
MEASURES.—
GENERAL.—Subject
to clause
23
(ii), any measure specified by the Secretary
24
under this subparagraph must have been
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669
1
endorsed by the entity with a contract
2
under section 1890(a).
3
‘‘(ii) EXCEPTION.—In the case of a
4
specified area or medical topic determined
5
appropriate by the Secretary for which a
6
feasible and practical measure has not
7
been endorsed by the entity with a contract
8
under section 1890(a), the Secretary may
9
specify a measure that is not so endorsed
10
as long as due consideration is given to
11
measures that have been endorsed or
12
adopted by a consensus organization iden-
13
tified by the Secretary.
14
‘‘(iii) TIME
FRAME.—Not
later than
15
October 1, 2012, the Secretary shall pub-
16
lish the measures selected under this sub-
17
paragraph that will be applicable with re-
18
spect to fiscal year 2014.
19
‘‘(E) PUBLIC
AVAILABILITY OF DATA SUB-
20
MITTED.—The
21
dures for making data submitted under sub-
22
paragraph (C) available to the public. Such pro-
23
cedures shall ensure that a rehabilitation facil-
24
ity has the opportunity to review the data that
25
is to be made public with respect to the facility
Secretary shall establish proce-
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670
1
prior to such data being made public. The Sec-
2
retary shall report quality measures that relate
3
to services furnished in inpatient settings in re-
4
habilitation facilities on the Internet website of
5
the Centers for Medicare & Medicaid Services.’’.
6
(c) HOSPICE PROGRAMS.—Section 1814(i) of the So-
7 cial Security Act (42 U.S.C. 1395f(i)) is amended—
8
9
10
(1) by redesignating paragraph (5) as paragraph (6); and
(2) by inserting after paragraph (4) the fol-
11
lowing new paragraph:
12
‘‘(5) QUALITY
13
14
15
REPORTING.—
‘‘(A) REDUCTION
IN UPDATE FOR FAILURE
TO REPORT.—
‘‘(i) IN
GENERAL.—For
purposes of
16
fiscal year 2014 and each subsequent fiscal
17
year, in the case of a hospice program that
18
does not submit data to the Secretary in
19
accordance with subparagraph (C) with re-
20
spect to such a fiscal year, after deter-
21
mining the market basket percentage in-
22
crease under paragraph (1)(C)(ii)(VII) or
23
paragraph (1)(C)(iii), as applicable, and
24
after application of paragraph (1)(C)(iv),
25
with respect to the fiscal year, the Sec-
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671
1
retary shall reduce such market basket
2
percentage increase by 2 percentage points.
3
‘‘(ii) SPECIAL
RULE.—The
application
4
of this subparagraph may result in the
5
market basket percentage increase under
6
paragraph (1)(C)(ii)(VII) or paragraph
7
(1)(C)(iii), as applicable, being less than
8
0.0 for a fiscal year, and may result in
9
payment rates under this subsection for a
10
fiscal year being less than such payment
11
rates for the preceding fiscal year.
12
‘‘(B)
NONCUMULATIVE
APPLICATION.—
13
Any reduction under subparagraph (A) shall
14
apply only with respect to the fiscal year in-
15
volved and the Secretary shall not take into ac-
16
count such reduction in computing the payment
17
amount under this subsection for a subsequent
18
fiscal year.
19
‘‘(C) SUBMISSION
OF QUALITY DATA.—For
20
fiscal year 2014 and each subsequent fiscal
21
year, each hospice program shall submit to the
22
Secretary data on quality measures specified
23
under subparagraph (D). Such data shall be
24
submitted in a form and manner, and at a time,
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1
specified by the Secretary for purposes of this
2
subparagraph.
3
4
‘‘(D) QUALITY
‘‘(i) IN
MEASURES.—
GENERAL.—Subject
to clause
5
(ii), any measure specified by the Secretary
6
under this subparagraph must have been
7
endorsed by the entity with a contract
8
under section 1890(a).
9
‘‘(ii) EXCEPTION.—In the case of a
10
specified area or medical topic determined
11
appropriate by the Secretary for which a
12
feasible and practical measure has not
13
been endorsed by the entity with a contract
14
under section 1890(a), the Secretary may
15
specify a measure that is not so endorsed
16
as long as due consideration is given to
17
measures that have been endorsed or
18
adopted by a consensus organization iden-
19
tified by the Secretary.
20
‘‘(iii) TIME
FRAME.—Not
later than
21
October 1, 2012, the Secretary shall pub-
22
lish the measures selected under this sub-
23
paragraph that will be applicable with re-
24
spect to fiscal year 2014.
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1
‘‘(E) PUBLIC
AVAILABILITY OF DATA SUB-
2
MITTED.—The
3
dures for making data submitted under sub-
4
paragraph (C) available to the public. Such pro-
5
cedures shall ensure that a hospice program has
6
the opportunity to review the data that is to be
7
made public with respect to the hospice pro-
8
gram prior to such data being made public. The
9
Secretary shall report quality measures that re-
10
late to hospice care provided by hospice pro-
11
grams on the Internet website of the Centers
12
for Medicare & Medicaid Services.’’.
13
14
15
Secretary shall establish proce-
SEC. 3005. QUALITY REPORTING FOR PPS-EXEMPT CANCER
HOSPITALS.
Section 1866 of the Social Security Act (42 U.S.C.
16 1395cc) is amended—
17
18
19
20
21
22
23
(1) in subsection (a)(1)—
(A) in subparagraph (U), by striking
‘‘and’’ at the end;
(B) in subparagraph (V), by striking the
period at the end and inserting ‘‘, and’’; and
(C) by adding at the end the following new
subparagraph:
24
‘‘(W) in the case of a hospital described in
25
section 1886(d)(1)(B)(v), to report quality data
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674
1
to the Secretary in accordance with subsection
2
(k).’’; and
3
(2) by adding at the end the following new sub-
4
section:
5
‘‘(k)
6
7
QUALITY
REPORTING
BY
CANCER
HOS-
PITALS.—
‘‘(1) IN
GENERAL.—For
purposes of fiscal year
8
2014 and each subsequent fiscal year, a hospital de-
9
scribed in section 1886(d)(1)(B)(v) shall submit
10
data to the Secretary in accordance with paragraph
11
(2) with respect to such a fiscal year.
12
‘‘(2) SUBMISSION
OF QUALITY DATA.—For
fis-
13
cal year 2014 and each subsequent fiscal year, each
14
hospital described in such section shall submit to the
15
Secretary data on quality measures specified under
16
paragraph (3). Such data shall be submitted in a
17
form and manner, and at a time, specified by the
18
Secretary for purposes of this subparagraph.
19
‘‘(3) QUALITY
20
‘‘(A) IN
MEASURES.—
GENERAL.—Subject
to subpara-
21
graph (B), any measure specified by the Sec-
22
retary under this paragraph must have been en-
23
dorsed by the entity with a contract under sec-
24
tion 1890(a).
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1
‘‘(B) EXCEPTION.—In the case of a speci-
2
fied area or medical topic determined appro-
3
priate by the Secretary for which a feasible and
4
practical measure has not been endorsed by the
5
entity with a contract under section 1890(a),
6
the Secretary may specify a measure that is not
7
so endorsed as long as due consideration is
8
given to measures that have been endorsed or
9
adopted by a consensus organization identified
10
11
by the Secretary.
‘‘(C) TIME
FRAME.—Not
later than Octo-
12
ber 1, 2012, the Secretary shall publish the
13
measures selected under this paragraph that
14
will be applicable with respect to fiscal year
15
2014.
16
‘‘(4) PUBLIC
AVAILABILITY
OF
DATA
SUB-
17
MITTED.—The
18
for making data submitted under paragraph (4)
19
available to the public. Such procedures shall ensure
20
that a hospital described in section 1886(d)(1)(B)(v)
21
has the opportunity to review the data that is to be
22
made public with respect to the hospital prior to
23
such data being made public. The Secretary shall re-
24
port quality measures of process, structure, outcome,
25
patients’ perspective on care, efficiency, and costs of
Secretary shall establish procedures
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S.L.C.
676
1
care that relate to services furnished in such hos-
2
pitals on the Internet website of the Centers for
3
Medicare & Medicaid Services.’’.
4
SEC. 3006. PLANS FOR A VALUE-BASED PURCHASING PRO-
5
GRAM FOR SKILLED NURSING FACILITIES
6
AND HOME HEALTH AGENCIES.
7
8
(a) SKILLED NURSING FACILITIES.—
(1) IN
GENERAL.—The
Secretary of Health and
9
Human Services (in this section referred to as the
10
‘‘Secretary’’) shall develop a plan to implement a
11
value-based purchasing program for payments under
12
the Medicare program under title XVIII of the So-
13
cial Security Act for skilled nursing facilities (as de-
14
fined in section 1819(a) of such Act (42 U.S.C.
15
1395i–3(a))).
16
(2) DETAILS.—In developing the plan under
17
paragraph (1), the Secretary shall consider the fol-
18
lowing issues:
19
(A) The ongoing development, selection,
20
and modification process for measures (includ-
21
ing under section 1890 of the Social Security
22
Act (42 U.S.C. 1395aaa) and section 1890A
23
such Act, as added by section 3014), to the ex-
24
tent feasible and practicable, of all dimensions
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677
1
of quality and efficiency in skilled nursing fa-
2
cilities.
3
(i) IN
GENERAL.—Subject
to clause
4
(ii), any measure specified by the Secretary
5
under subparagraph (A)(iii) must have
6
been endorsed by the entity with a contract
7
under section 1890(a).
8
(ii) EXCEPTION.—In the case of a
9
specified area or medical topic determined
10
appropriate by the Secretary for which a
11
feasible and practical measure has not
12
been endorsed by the entity with a contract
13
under section 1890(a), the Secretary may
14
specify a measure that is not so endorsed
15
as long as due consideration is given to
16
measures that have been endorsed or
17
adopted by a consensus organization iden-
18
tified by the Secretary.
19
(B) The reporting, collection, and valida-
20
tion of quality data.
21
(C) The structure of value-based payment
22
adjustments, including the determination of
23
thresholds or improvements in quality that
24
would substantiate a payment adjustment, the
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1
size of such payments, and the sources of fund-
2
ing for the value-based bonus payments.
3
(D) Methods for the public disclosure of
4
information on the performance of skilled nurs-
5
ing facilities.
6
(E) Any other issues determined appro-
7
priate by the Secretary.
8
(3) CONSULTATION.—In developing the plan
9
under paragraph (1), the Secretary shall—
10
11
(A) consult with relevant affected parties;
and
12
(B) consider experience with such dem-
13
onstrations that the Secretary determines are
14
relevant to the value-based purchasing program
15
described in paragraph (1).
16
(4) REPORT
TO CONGRESS.—Not
later than Oc-
17
tober 1, 2011, the Secretary shall submit to Con-
18
gress a report containing the plan developed under
19
paragraph (1).
20
(b) HOME HEALTH AGENCIES.—
21
(1) IN
GENERAL.—The
Secretary of Health and
22
Human Services (in this section referred to as the
23
‘‘Secretary’’) shall develop a plan to implement a
24
value-based purchasing program for payments under
25
the Medicare program under title XVIII of the So-
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679
1
cial Security Act for home health agencies (as de-
2
fined in section 1861(o) of such Act (42 U.S.C.
3
1395x(o))).
4
(2) DETAILS.—In developing the plan under
5
paragraph (1), the Secretary shall consider the fol-
6
lowing issues:
7
(A) The ongoing development, selection,
8
and modification process for measures (includ-
9
ing under section 1890 of the Social Security
10
Act (42 U.S.C. 1395aaa) and section 1890A
11
such Act, as added by section 3014), to the ex-
12
tent feasible and practicable, of all dimensions
13
of quality and efficiency in home health agen-
14
cies.
15
16
(B) The reporting, collection, and validation of quality data.
17
(C) The structure of value-based payment
18
adjustments, including the determination of
19
thresholds or improvements in quality that
20
would substantiate a payment adjustment, the
21
size of such payments, and the sources of fund-
22
ing for the value-based bonus payments.
23
(D) Methods for the public disclosure of
24
information on the performance of home health
25
agencies.
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1
(E) Any other issues determined appro-
2
priate by the Secretary.
3
(3) CONSULTATION.—In developing the plan
4
under paragraph (1), the Secretary shall—
5
6
(A) consult with relevant affected parties;
and
7
(B) consider experience with such dem-
8
onstrations that the Secretary determines are
9
relevant to the value-based purchasing program
10
described in paragraph (1).
11
(4) REPORT
TO CONGRESS.—Not
later than Oc-
12
tober 1, 2011, the Secretary shall submit to Con-
13
gress a report containing the plan developed under
14
paragraph (1).
15
SEC. 3007. VALUE-BASED PAYMENT MODIFIER UNDER THE
16
17
PHYSICIAN FEE SCHEDULE.
Section 1848 of the Social Security Act (42 U.S.C.
18 1395w–4) is amended—
19
20
21
(1) in subsection (b)(1), by inserting ‘‘subject
to subsection (p),’’ after ‘‘1998,’’; and
(2) by adding at the end the following new sub-
22
section:
23
‘‘(p) ESTABLISHMENT
24 MODIFIER.—
OF
VALUE-BASED PAYMENT
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681
1
‘‘(1) IN
GENERAL.—The
Secretary shall estab-
2
lish a payment modifier that provides for differential
3
payment to a physician or a group of physicians
4
under the fee schedule established under subsection
5
(b) based upon the quality of care furnished com-
6
pared to cost (as determined under paragraphs (2)
7
and (3), respectively) during a performance period.
8
Such payment modifier shall be separate from the
9
geographic adjustment factors established under
10
subsection (e).
11
‘‘(2) QUALITY.—
12
‘‘(A) IN
GENERAL.—For
purposes of para-
13
graph (1), quality of care shall be evaluated, to
14
the extent practicable, based on a composite of
15
measures of the quality of care furnished (as
16
established by the Secretary under subpara-
17
graph (B)).
18
‘‘(B) MEASURES.—
19
‘‘(i) The Secretary shall establish ap-
20
propriate measures of the quality of care
21
furnished by a physician or group of physi-
22
cians to individuals enrolled under this
23
part, such as measures that reflect health
24
outcomes. Such measures shall be risk ad-
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682
1
justed as determined appropriate by the
2
Secretary.
3
‘‘(ii) The Secretary shall seek endorse-
4
ment of the measures established under
5
this subparagraph by the entity with a
6
contract under section 1890(a).
7
‘‘(3) COSTS.—For purposes of paragraph (1),
8
costs shall be evaluated, to the extent practicable,
9
based on a composite of appropriate measures of
10
costs established by the Secretary (such as the com-
11
posite measure under the methodology established
12
under subsection (n)(9)(C)(iii)) that eliminate the
13
effect of geographic adjustments in payment rates
14
(as described in subsection (e)), and take into ac-
15
count risk factors (such as socioeconomic and demo-
16
graphic characteristics, ethnicity, and health status
17
of individuals (such as to recognize that less healthy
18
individuals may require more intensive interventions)
19
and other factors determined appropriate by the
20
Secretary.
21
‘‘(4) IMPLEMENTATION.—
22
‘‘(A) PUBLICATION
OF MEASURES, DATES
23
OF
24
RIOD.—Not
25
Secretary shall publish the following:
IMPLEMENTATION,
PERFORMANCE
PE-
later than January 1, 2012, the
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1
‘‘(i) The measures of quality of care
2
and costs established under paragraphs (2)
3
and (3), respectively.
4
‘‘(ii) The dates for implementation of
5
the payment modifier (as determined under
6
subparagraph (B)).
7
‘‘(iii) The initial performance period
8
(as specified under subparagraph (B)(ii)).
9
‘‘(B)
10
11
DEADLINES
FOR
IMPLEMENTA-
TION.—
‘‘(i) INITIAL
IMPLEMENTATION.—Sub-
12
ject to the preceding provisions of this sub-
13
paragraph, the Secretary shall begin imple-
14
menting the payment modifier established
15
under this subsection through the rule-
16
making process during 2013 for the physi-
17
cian fee schedule established under sub-
18
section (b).
19
20
21
‘‘(ii)
INITIAL
PERFORMANCE
PE-
GENERAL.—The
Sec-
RIOD.—
‘‘(I) IN
22
retary shall specify an initial perform-
23
ance period for application of the pay-
24
ment modifier established under this
25
subsection with respect to 2015.
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1
‘‘(II) PROVISION
OF
INFORMA-
2
TION DURING INITIAL PERFORMANCE
3
PERIOD.—During
4
ance period, the Secretary shall, to
5
the extent practicable, provide infor-
6
mation to physicians and groups of
7
physicians about the quality of care
8
furnished by the physician or group of
9
physicians
to
the initial perform-
individuals
enrolled
10
under this part compared to cost (as
11
determined under paragraphs (2) and
12
(3), respectively) with respect to the
13
performance period.
14
‘‘(iii) APPLICATION.—The Secretary
15
shall apply the payment modifier estab-
16
lished under this subsection for items and
17
services furnished—
18
‘‘(I) beginning on January 1,
19
2015, with respect to specific physi-
20
cians and groups of physicians the
21
Secretary determines appropriate; and
22
‘‘(II) beginning not later than
23
January 1, 2017, with respect to all
24
physicians and groups of physicians.
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1
‘‘(C) BUDGET
NEUTRALITY.—The
pay-
2
ment modifier established under this subsection
3
shall be implemented in a budget neutral man-
4
ner.
5
‘‘(5) SYSTEMS-BASED
CARE.—The
Secretary
6
shall, as appropriate, apply the payment modifier es-
7
tablished under this subsection in a manner that
8
promotes systems-based care.
9
‘‘(6)
CONSIDERATION
OF
SPECIAL
CIR-
10
CUMSTANCES OF CERTAIN PROVIDERS.—In
11
the payment modifier under this subsection, the Sec-
12
retary shall, as appropriate, take into account the
13
special circumstances of physicians or groups of phy-
14
sicians in rural areas and other underserved commu-
15
nities.
applying
16
‘‘(7) APPLICATION.—For purposes of the initial
17
application of the payment modifier established
18
under this subsection during the period beginning on
19
January 1, 2015, and ending on December 31,
20
2016, the term ‘physician’ has the meaning given
21
such term in section 1861(r). On or after January
22
1, 2017, the Secretary may apply this subsection to
23
eligible professionals (as defined in subsection
24
(k)(3)(B)) as the Secretary determines appropriate.
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1
2
‘‘(8) DEFINITIONS.—For purposes of this subsection:
3
‘‘(A) COSTS.—The term ‘costs’ means ex-
4
penditures per individual as determined appro-
5
priate by the Secretary. In making the deter-
6
mination under the preceding sentence, the Sec-
7
retary may take into account the amount of
8
growth in expenditures per individual for a phy-
9
sician compared to the amount of such growth
10
11
for other physicians.
‘‘(B) PERFORMANCE
PERIOD.—The
term
12
‘performance period’ means a period specified
13
by the Secretary.
14
‘‘(9) COORDINATION
WITH
OTHER
VALUE-
15
BASED PURCHASING REFORMS.—The
16
coordinate the value-based payment modifier estab-
17
lished under this subsection with the Physician
18
Feedback Program under subsection (n) and, as the
19
Secretary determines appropriate, other similar pro-
20
visions of this title.
21
‘‘(10) LIMITATIONS
Secretary shall
ON REVIEW.—There
shall
22
be no administrative or judicial review under section
23
1869, section 1878, or otherwise of—
24
25
‘‘(A) the establishment of the value-based
payment modifier under this subsection;
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1
‘‘(B) the evaluation of quality of care
2
under paragraph (2), including the establish-
3
ment of appropriate measures of the quality of
4
care under paragraph (2)(B);
5
‘‘(C) the evaluation of costs under para-
6
graph (3), including the establishment of appro-
7
priate measures of costs under such paragraph;
8
‘‘(D) the dates for implementation of the
9
value-based payment modifier;
10
‘‘(E) the specification of the initial per-
11
formance period and any other performance pe-
12
riod under paragraphs (4)(B)(ii) and (8)(B),
13
respectively;
14
15
‘‘(F) the application of the value-based
payment modifier under paragraph (7); and
16
17
18
‘‘(G) the determination of costs under
paragraph (8)(A).’’.
SEC. 3008. PAYMENT ADJUSTMENT FOR CONDITIONS AC-
19
20
QUIRED IN HOSPITALS.
(a) IN GENERAL.—Section 1886 of the Social Secu-
21 rity Act (42 U.S.C. 1395ww), as amended by section
22 3001, is amended by adding at the end the following new
23 subsection:
24
‘‘(p) ADJUSTMENT
TO
HOSPITAL PAYMENTS
25 HOSPITAL ACQUIRED CONDITIONS.—
FOR
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1
‘‘(1) IN
GENERAL.—In
order to provide an in-
2
centive for applicable hospitals to reduce hospital ac-
3
quired conditions under this title, with respect to
4
discharges from an applicable hospital occurring
5
during fiscal year 2015 or a subsequent fiscal year,
6
the amount of payment under this section or section
7
1814(b)(3), as applicable, for such discharges during
8
the fiscal year shall be equal to 99 percent of the
9
amount of payment that would otherwise apply to
10
such discharges under this section or section
11
1814(b)(3) (determined after the application of sub-
12
sections (o) and (q) and section 1814(l)(4) but with-
13
out regard to this subsection).
14
‘‘(2) APPLICABLE
15
‘‘(A) IN
HOSPITALS.—
GENERAL.—For
purposes of this
16
subsection, the term ‘applicable hospital’ means
17
a subsection (d) hospital that meets the criteria
18
described in subparagraph (B).
19
20
‘‘(B) CRITERIA
‘‘(i) IN
DESCRIBED.—
GENERAL.—The
criteria de-
21
scribed in this subparagraph, with respect
22
to a subsection (d) hospital, is that the
23
subsection (d) hospital is in the top quar-
24
tile of all subsection (d) hospitals, relative
25
to the national average, of hospital ac-
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689
1
quired conditions during the applicable pe-
2
riod, as determined by the Secretary.
3
‘‘(ii) RISK
ADJUSTMENT.—In
carrying
4
out clause (i), the Secretary shall establish
5
and apply an appropriate risk adjustment
6
methodology.
7
‘‘(C) EXEMPTION.—In the case of a hos-
8
pital that is paid under section 1814(b)(3), the
9
Secretary may exempt such hospital from the
10
application of this subsection if the State which
11
is paid under such section submits an annual
12
report to the Secretary describing how a similar
13
program in the State for a participating hos-
14
pital or hospitals achieves or surpasses the
15
measured results in terms of patient health out-
16
comes and cost savings established under this
17
subsection.
18
‘‘(3) HOSPITAL
ACQUIRED CONDITIONS.—For
19
purposes of this subsection, the term ‘hospital ac-
20
quired condition’ means a condition identified for
21
purposes of subsection (d)(4)(D)(iv) and any other
22
condition determined appropriate by the Secretary
23
that an individual acquires during a stay in an ap-
24
plicable hospital, as determined by the Secretary.
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1
‘‘(4) APPLICABLE
PERIOD.—In
this subsection,
2
the term ‘applicable period’ means, with respect to
3
a fiscal year, a period specified by the Secretary.
4
‘‘(5) REPORTING
TO HOSPITALS.—Prior
to fis-
5
cal year 2015 and each subsequent fiscal year, the
6
Secretary shall provide confidential reports to appli-
7
cable hospitals with respect to hospital acquired con-
8
ditions of the applicable hospital during the applica-
9
ble period.
10
11
12
‘‘(6) REPORTING
HOSPITAL SPECIFIC INFORMA-
TION.—
‘‘(A) IN
GENERAL.—The
Secretary shall
13
make information available to the public re-
14
garding hospital acquired conditions of each ap-
15
plicable hospital.
16
‘‘(B) OPPORTUNITY
TO REVIEW AND SUB-
17
MIT CORRECTIONS.—The
Secretary shall ensure
18
that an applicable hospital has the opportunity
19
to review, and submit corrections for, the infor-
20
mation to be made public with respect to the
21
hospital under subparagraph (A) prior to such
22
information being made public.
23
‘‘(C) WEBSITE.—Such information shall be
24
posted on the Hospital Compare Internet
25
website in an easily understandable format.
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1
‘‘(7) LIMITATIONS
ON REVIEW.—There
shall be
2
no administrative or judicial review under section
3
1869, section 1878, or otherwise of the following:
4
5
6
7
8
9
‘‘(A) The criteria described in paragraph
(2)(A).
‘‘(B) The specification of hospital acquired
conditions under paragraph (3).
‘‘(C) The specification of the applicable period under paragraph (4).
10
‘‘(D) The provision of reports to applicable
11
hospitals under paragraph (5) and the informa-
12
tion made available to the public under para-
13
graph (6).’’.
14
(b) STUDY
AND
REPORT
ON
EXPANSION
15 HEALTHCARE ACQUIRED CONDITIONS POLICY
TO
OF
OTHER
16 PROVIDERS.—
17
(1) STUDY.—The Secretary of Health and
18
Human Services shall conduct a study on expanding
19
the healthcare acquired conditions policy under sub-
20
section (d)(4)(D) of section 1886 of the Social Secu-
21
rity Act (42 U.S.C. 1395ww) to payments made to
22
other facilities under the Medicare program under
23
title XVIII of the Social Security Act, including such
24
payments made to inpatient rehabilitation facilities,
25
long-term care hospitals (as described in sub-
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692
1
section(d)(1)(B)(iv) of such section), hospital out-
2
patient departments, and other hospitals excluded
3
from the inpatient prospective payment system
4
under such section, skilled nursing facilities, ambula-
5
tory surgical centers, and health clinics. Such study
6
shall include an analysis of how such policies could
7
impact quality of patient care, patient safety, and
8
spending under the Medicare program.
9
(2) REPORT.—Not later than January 1, 2012,
10
the Secretary shall submit to Congress a report con-
11
taining the results of the study conducted under
12
paragraph (1), together with recommendations for
13
such legislation and administrative action as the
14
Secretary determines appropriate.
15
PART II—NATIONAL STRATEGY TO IMPROVE
16
HEALTH CARE QUALITY
17
18
SEC. 3011. NATIONAL STRATEGY.
Title III of the Public Health Service Act (42 U.S.C.
19 241 et seq.) is amended by adding at the end the fol20 lowing:
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1
‘‘PART S—HEALTH CARE QUALITY PROGRAMS
2
‘‘Subpart I—National Strategy for Quality
3
Improvement in Health Care
4
‘‘SEC. 399HH. NATIONAL STRATEGY FOR QUALITY IM-
5
6
PROVEMENT IN HEALTH CARE.
‘‘(a) ESTABLISHMENT
OF
NATIONAL STRATEGY
AND
7 PRIORITIES.—
8
‘‘(1) NATIONAL
STRATEGY.—The
Secretary,
9
through a transparent collaborative process, shall es-
10
tablish a national strategy to improve the delivery of
11
health care services, patient health outcomes, and
12
population health.
13
14
‘‘(2) IDENTIFICATION
‘‘(A) IN
OF PRIORITIES.—
GENERAL.—The
Secretary shall
15
identify national priorities for improvement in
16
developing the strategy under paragraph (1).
17
‘‘(B)
REQUIREMENTS.—The
Secretary
18
shall ensure that priorities identified under sub-
19
paragraph (A) will—
20
‘‘(i) have the greatest potential for im-
21
proving the health outcomes, efficiency,
22
and patient-centeredness of health care for
23
all populations, including children and vul-
24
nerable populations;
25
‘‘(ii) identify areas in the delivery of
26
health care services that have the potential
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1
for rapid improvement in the quality and
2
efficiency of patient care;
3
‘‘(iii) address gaps in quality, effi-
4
ciency, comparative effectiveness informa-
5
tion, and health outcomes measures and
6
data aggregation techniques;
7
8
‘‘(iv) improve Federal payment policy
to emphasize quality and efficiency;
9
‘‘(v) enhance the use of health care
10
data to improve quality, efficiency, trans-
11
parency, and outcomes;
12
‘‘(vi) address the health care provided
13
to patients with high-cost chronic diseases;
14
‘‘(vii) improve research and dissemi-
15
nation of strategies and best practices to
16
improve patient safety and reduce medical
17
errors, preventable admissions and re-
18
admissions, and health care-associated in-
19
fections;
20
‘‘(viii) reduce health disparities across
21
health disparity populations (as defined in
22
section 485E) and geographic areas; and
23
24
‘‘(ix) address other areas as determined appropriate by the Secretary.
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1
‘‘(C)
CONSIDERATIONS.—In
identifying
2
priorities under subparagraph (A), the Sec-
3
retary shall take into consideration the rec-
4
ommendations submitted by the entity with a
5
contract under section 1890(a) of the Social Se-
6
curity Act and other stakeholders.
7
‘‘(D) COORDINATION
WITH STATE AGEN-
8
CIES.—The
9
nate, and consult with State agencies respon-
10
sible for administering the Medicaid program
11
under title XIX of the Social Security Act and
12
the Children’s Health Insurance Program under
13
title XXI of such Act with respect to developing
14
and disseminating strategies, goals, models, and
15
timetables that are consistent with the national
16
priorities identified under subparagraph (A).
17
18
Secretary shall collaborate, coordi-
‘‘(b) STRATEGIC PLAN.—
‘‘(1) IN
GENERAL.—The
national strategy shall
19
include a comprehensive strategic plan to achieve the
20
priorities described in subsection (a).
21
‘‘(2) REQUIREMENTS.—The strategic plan shall
22
include provisions for addressing, at a minimum, the
23
following:
24
‘‘(A) Coordination among agencies within
25
the Department, which shall include steps to
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1
minimize duplication of efforts and utilization
2
of common quality measures, where available.
3
Such common quality measures shall be meas-
4
ures identified by the Secretary under section
5
1139A or 1139B of the Social Security Act or
6
endorsed under section 1890 of such Act.
7
8
‘‘(B) Agency-specific strategic plans to
achieve national priorities.
9
‘‘(C) Establishment of annual benchmarks
10
for each relevant agency to achieve national pri-
11
orities.
12
‘‘(D) A process for regular reporting by
13
the agencies to the Secretary on the implemen-
14
tation of the strategic plan.
15
‘‘(E) Strategies to align public and private
16
payers with regard to quality and patient safety
17
efforts.
18
‘‘(F) Incorporating quality improvement
19
and measurement in the strategic plan for
20
health information technology required by the
21
American Recovery and Reinvestment Act of
22
2009 (Public Law 111–5).
23
‘‘(c) PERIODIC UPDATE
OF
NATIONAL STRATEGY.—
24 The Secretary shall update the national strategy not less
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697
1 than annually. Any such update shall include a review of
2 short- and long-term goals.
3
‘‘(d) SUBMISSION
AND
AVAILABILITY
OF
NATIONAL
4 STRATEGY AND UPDATES.—
5
‘‘(1) DEADLINE
FOR INITIAL SUBMISSION OF
6
NATIONAL STRATEGY.—Not
7
2011, the Secretary shall submit to the relevant
8
committees of Congress the national strategy de-
9
scribed in subsection (a).
10
‘‘(2) UPDATES.—
11
‘‘(A) IN
later than January 1,
GENERAL.—The
Secretary shall
12
submit to the relevant committees of Congress
13
an annual update to the strategy described in
14
paragraph (1).
15
‘‘(B)
INFORMATION
SUBMITTED.—Each
16
update submitted under subparagraph (A) shall
17
include—
18
‘‘(i) a review of the short- and long-
19
term goals of the national strategy and any
20
gaps in such strategy;
21
‘‘(ii) an analysis of the progress, or
22
lack of progress, in meeting such goals and
23
any barriers to such progress;
24
‘‘(iii) the information reported under
25
section 1139A of the Social Security Act,
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1
consistent with the reporting requirements
2
of such section; and
3
‘‘(iv) in the case of an update required
4
to be submitted on or after January 1,
5
2014, the information reported under sec-
6
tion 1139B(b)(4) of the Social Security
7
Act, consistent with the reporting require-
8
ments of such section.
9
‘‘(C) SATISFACTION
OF OTHER REPORTING
10
REQUIREMENTS.—Compliance
11
ments of clauses (iii) and (iv) of subparagraph
12
(B) shall satisfy the reporting requirements
13
under sections 1139A(a)(6) and 1139B(b)(4),
14
respectively, of the Social Security Act.
15
‘‘(e)
HEALTH
CARE
with the require-
QUALITY
INTERNET
16 WEBSITE.—Not later than January 1, 2011, the Sec17 retary shall create an Internet website to make public in18 formation regarding—
19
‘‘(1) the national priorities for health care qual-
20
ity improvement established under subsection (a)(2);
21
‘‘(2) the agency-specific strategic plans for
22
health care quality described in subsection (b)(2)(B);
23
and
24
25
‘‘(3) other information, as the Secretary determines to be appropriate.’’.
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1
2
3
SEC. 3012. INTERAGENCY WORKING GROUP ON HEALTH
CARE QUALITY.
(a) IN GENERAL.—The President shall convene a
4 working group to be known as the Interagency Working
5 Group on Health Care Quality (referred to in this section
6 as the ‘‘Working Group’’).
7
(b) GOALS.—The goals of the Working Group shall
8 be to achieve the following:
9
(1) Collaboration, cooperation, and consultation
10
between Federal departments and agencies with re-
11
spect to developing and disseminating strategies,
12
goals, models, and timetables that are consistent
13
with the national priorities identified under section
14
399HH(a)(2) of the Public Health Service Act (as
15
added by section 3011).
16
(2) Avoidance of inefficient duplication of qual-
17
ity improvement efforts and resources, where prac-
18
ticable, and a streamlined process for quality report-
19
ing and compliance requirements.
20
(3) Assess alignment of quality efforts in the
21
public sector with private sector initiatives.
22
(c) COMPOSITION.—
23
24
25
26
(1) IN
GENERAL.—The
Working Group shall be
composed of senior level representatives of—
(A) the Department of Health and Human
Services;
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1
2
(B) the Centers for Medicare & Medicaid
Services;
3
(C) the National Institutes of Health;
4
(D) the Centers for Disease Control and
5
Prevention;
6
(E) the Food and Drug Administration;
7
(F) the Health Resources and Services Ad-
8
9
10
11
12
13
14
15
16
ministration;
(G) the Agency for Healthcare Research
and Quality;
(H) the Office of the National Coordinator
for Health Information Technology;
(I) the Substance Abuse and Mental
Health Services Administration;
(J) the Administration for Children and
Families;
17
(K) the Department of Commerce;
18
(L) the Office of Management and Budget;
19
(M) the United States Coast Guard;
20
(N) the Federal Bureau of Prisons;
21
(O) the National Highway Traffic Safety
22
Administration;
23
(P) the Federal Trade Commission;
24
(Q) the Social Security Administration;
25
(R) the Department of Labor;
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1
2
(S) the United States Office of Personnel
Management;
3
(T) the Department of Defense;
4
(U) the Department of Education;
5
(V) the Department of Veterans Affairs;
6
(W) the Veterans Health Administration;
7
and
8
(X) any other Federal agencies and de-
9
partments with activities relating to improving
10
health care quality and safety, as determined by
11
the President.
12
(2) CHAIR
AND VICE-CHAIR.—
13
(A) CHAIR.—The Working Group shall be
14
chaired by the Secretary of Health and Human
15
Services.
16
(B) VICE
CHAIR.—Members
of the Work-
17
ing Group, other than the Secretary of Health
18
and Human Services, shall serve as Vice Chair
19
of the Group on a rotating basis, as determined
20
by the Group.
21
(d) REPORT
TO
CONGRESS.—Not later than Decem-
22 ber 31, 2010, and annually thereafter, the Working Group
23 shall submit to the relevant Committees of Congress, and
24 make public on an Internet website, a report describing
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1 the progress and recommendations of the Working Group
2 in meeting the goals described in subsection (b).
3
4
SEC. 3013. QUALITY MEASURE DEVELOPMENT.
(a) PUBLIC HEALTH SERVICE ACT.—Title IX of the
5 Public Health Service Act (42 U.S.C. 299 et seq.) is
6 amended—
7
(1) by redesignating part D as part E;
8
(2) by redesignating sections 931 through 938
9
10
11
as sections 941 through 948, respectively;
(3) in section 948(1), as so redesignated, by
striking ‘‘931’’ and inserting ‘‘941’’; and
12
(4) by inserting after section 926 the following:
13
‘‘PART D—HEALTH CARE QUALITY
14
IMPROVEMENT
15
‘‘Subpart I—Quality Measure Development
16
17
‘‘SEC. 931. QUALITY MEASURE DEVELOPMENT.
‘‘(a) QUALITY MEASURE.—In this subpart, the term
18 ‘quality measure’ means a standard for measuring the per19 formance and improvement of population health or of
20 health plans, providers of services, and other clinicians in
21 the delivery of health care services.
22
‘‘(b) IDENTIFICATION OF QUALITY MEASURES.—
23
‘‘(1) IDENTIFICATION.—The Secretary, in con-
24
sultation with the Director of the Agency for
25
Healthcare Research and Quality and the Adminis-
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1
trator of the Centers for Medicare & Medicaid Serv-
2
ices, shall identify, not less often than triennially,
3
gaps where no quality measures exist and existing
4
quality measures that need improvement, updating,
5
or expansion, consistent with the national strategy
6
under section 399HH, to the extent available, for
7
use in Federal health programs. In identifying such
8
gaps and existing quality measures that need im-
9
provement, the Secretary shall take into consider-
10
ation—
11
‘‘(A) the gaps identified by the entity with
12
a contract under section 1890(a) of the Social
13
Security Act and other stakeholders;
14
‘‘(B) quality measures identified by the pe-
15
diatric quality measures program under section
16
1139A of the Social Security Act; and
17
‘‘(C) quality measures identified through
18
the Medicaid Quality Measurement Program
19
under section 1139B of the Social Security Act.
20
‘‘(2) PUBLICATION.—The Secretary shall make
21
available to the public on an Internet website a re-
22
port on any gaps identified under paragraph (1) and
23
the process used to make such identification.
24
‘‘(c) GRANTS
25
URE
OR
DEVELOPMENT.—
CONTRACTS
FOR
QUALITY MEAS-
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1
‘‘(1) IN
GENERAL.—The
Secretary shall award
2
grants, contracts, or intergovernmental agreements
3
to eligible entities for purposes of developing, im-
4
proving, updating, or expanding quality measures
5
identified under subsection (b).
6
‘‘(2) PRIORITIZATION
IN THE DEVELOPMENT
7
OF QUALITY MEASURES.—In
8
tracts, or agreements under this subsection, the Sec-
9
retary shall give priority to the development of qual-
10
11
12
awarding grants, con-
ity measures that allow the assessment of—
‘‘(A) health outcomes and functional status
of patients;
13
‘‘(B) the management and coordination of
14
health care across episodes of care and care
15
transitions for patients across the continuum of
16
providers, health care settings, and health
17
plans;
18
‘‘(C) the experience, quality, and use of in-
19
formation provided to and used by patients,
20
caregivers, and authorized representatives to in-
21
form decisionmaking about treatment options,
22
including the use of shared decisionmaking
23
tools and preference sensitive care (as defined
24
in section 936);
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1
2
‘‘(D) the meaningful use of health information technology;
3
‘‘(E) the safety, effectiveness, patient-
4
centeredness, appropriateness, and timeliness of
5
care;
6
‘‘(F) the efficiency of care;
7
‘‘(G) the equity of health services and
8
health disparities across health disparity popu-
9
lations (as defined in section 485E) and geo-
10
graphic areas;
11
‘‘(H) patient experience and satisfaction;
12
‘‘(I) the use of innovative strategies and
13
methodologies identified under section 933; and
14
‘‘(J) other areas determined appropriate by
15
the Secretary.
16
‘‘(3) ELIGIBLE
ENTITIES.—To
be eligible for a
17
grant or contract under this subsection, an entity
18
shall—
19
‘‘(A) have demonstrated expertise and ca-
20
pacity in the development and evaluation of
21
quality measures;
22
23
‘‘(B) have adopted procedures to include in
the quality measure development process—
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1
‘‘(i) the views of those providers or
2
payers whose performance will be assessed
3
by the measure; and
4
‘‘(ii) the views of other parties who
5
also will use the quality measures (such as
6
patients, consumers, and health care pur-
7
chasers);
8
‘‘(C) collaborate with the entity with a con-
9
tract under section 1890(a) of the Social Secu-
10
rity Act and other stakeholders, as practicable,
11
and the Secretary so that quality measures de-
12
veloped by the eligible entity will meet the re-
13
quirements to be considered for endorsement by
14
the entity with a contract under such section
15
1890(a);
16
17
‘‘(D) have transparent policies regarding
governance and conflicts of interest; and
18
‘‘(E) submit an application to the Sec-
19
retary at such time and in such manner, as the
20
Secretary may require.
21
‘‘(4) USE
OF FUNDS.—An
entity that receives
22
a grant, contract, or agreement under this sub-
23
section shall use such award to develop quality
24
measures that meet the following requirements:
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707
1
‘‘(A) Such measures support measures re-
2
quired to be reported under the Social Security
3
Act, where applicable, and in support of gaps
4
and existing quality measures that need im-
5
provement, as described in subsection (b)(1)(A).
6
‘‘(B) Such measures support measures de-
7
veloped under section 1139A of the Social Secu-
8
rity Act and the Medicaid Quality Measurement
9
Program under section 1139B of such Act,
10
where applicable.
11
‘‘(C) To the extent practicable, data on
12
such quality measures is able to be collected
13
using health information technologies.
14
15
16
17
18
‘‘(D) Each quality measure is free of
charge to users of such measure.
‘‘(E) Each quality measure is publicly
available on an Internet website.
‘‘(d) OTHER ACTIVITIES
BY THE
SECRETARY.—The
19 Secretary may use amounts available under this section
20 to update and test, where applicable, quality measures en21 dorsed by the entity with a contract under section 1890(a)
22 of the Social Security Act or adopted by the Secretary.
23
‘‘(e) COORDINATION
OF
GRANTS.—The Secretary
24 shall ensure that grants or contracts awarded under this
25 section are coordinated with grants and contracts awarded
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708
1 under sections 1139A(5) and 1139B(4)(A) of the Social
2 Security Act.’’.
3
(b) SOCIAL SECURITY ACT.—Section 1890A of the
4 Social Security Act, as added by section 3014(b), is
5 amended by adding at the end the following new sub6 section:
7
‘‘(e) DEVELOPMENT
OF
QUALITY MEASURES.—The
8 Administrator of the Center for Medicare & Medicaid
9 Services shall through contracts develop quality measures
10 (as determined appropriate by the Administrator) for use
11 under this Act. In developing such measures, the Adminis12 trator shall consult with the Director of the Agency for
13 Healthcare Research and Quality.’’.
14
(c) FUNDING.—There are authorized to be appro-
15 priated to the Secretary of Health and Human Services
16 to carry out this section, $75,000,000 for each of fiscal
17 years 2010 through 2014. Of the amounts appropriated
18 under the preceding sentence in a fiscal year, not less than
19 50 percent of such amounts shall be used pursuant to sub20 section (e) of section 1890A of the Social Security Act,
21 as added by subsection (b), with respect to programs
22 under such Act. Amounts appropriated under this sub23 section for a fiscal year shall remain available until ex24 pended.
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709
1
2
3
SEC. 3014. QUALITY MEASUREMENT.
(a) NEW DUTIES
FOR
CONSENSUS-BASED ENTITY.—
(1) MULTI-STAKEHOLDER
GROUP INPUT.—Sec-
4
tion 1890(b) of the Social Security Act (42 U.S.C.
5
1395aaa(b)), as amended by section 3003, is amend-
6
ed by adding at the end the following new para-
7
graphs:
8
9
‘‘(7)
CONVENING
MULTI-STAKEHOLDER
GROUPS.—
10
‘‘(A) IN
GENERAL.—The
entity shall con-
11
vene multi-stakeholder groups to provide input
12
on—
13
‘‘(i) the selection of quality measures
14
described
15
among—
16
17
in
subparagraph
(B),
from
‘‘(I) such measures that have
been endorsed by the entity; and
18
‘‘(II) such measures that have
19
not been considered for endorsement
20
by such entity but are used or pro-
21
posed to be used by the Secretary for
22
the collection or reporting of quality
23
measures; and
24
‘‘(ii) national priorities (as identified
25
under section 399HH of the Public Health
26
Service Act) for improvement in population
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710
1
health and in the delivery of health care
2
services for consideration under the na-
3
tional strategy established under section
4
399HH of the Public Health Service Act.
5
‘‘(B) QUALITY
6
‘‘(i) IN
MEASURES.—
GENERAL.—Subject
to clause
7
(ii), the quality measures described in this
8
subparagraph are quality measures—
9
‘‘(I) for use pursuant to sections
10
1814(i)(5)(D),
11
1833(t)(17),
12
1866(k)(3),
13
1886(b)(3)(B)(viii),
14
1886(m)(5)(D),
15
1895(b)(3)(B)(v);
1833(i)(7),
1848(k)(2)(C),
1881(h)(2)(A)(iii),
1886(j)(7)(D),
1886(o)(2),
and
16
‘‘(II) for use in reporting per-
17
formance information to the public;
18
and
19
‘‘(III) for use in health care pro-
20
grams other than for use under this
21
Act.
22
‘‘(ii) EXCLUSION.—Data sets (such as
23
the outcome and assessment information
24
set for home health services and the min-
25
imum data set for skilled nursing facility
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711
1
services) that are used for purposes of
2
classification systems used in establishing
3
payment rates under this title shall not be
4
quality measures described in this subpara-
5
graph.
6
‘‘(C) REQUIREMENT
7
8
FOR TRANSPARENCY
IN PROCESS.—
‘‘(i)
IN
GENERAL.—In
convening
9
multi-stakeholder groups under subpara-
10
graph (A) with respect to the selection of
11
quality measures, the entity shall provide
12
for an open and transparent process for
13
the activities conducted pursuant to such
14
convening.
15
‘‘(ii) SELECTION
OF ORGANIZATIONS
16
PARTICIPATING
17
GROUPS.—The
18
(i) shall ensure that the selection of rep-
19
resentatives comprising such groups pro-
20
vides for public nominations for, and the
21
opportunity for public comment on, such
22
selection.
23
‘‘(D) MULTI-STAKEHOLDER
IN
MULTI-STAKEHOLDER
process described in clause
GROUP
DE-
24
FINED.—In
25
stakeholder group’ means, with respect to a
this paragraph, the term ‘multi-
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S.L.C.
712
1
quality measure, a voluntary collaborative of or-
2
ganizations representing a broad group of
3
stakeholders interested in or affected by the use
4
of such quality measure.
5
‘‘(8) TRANSMISSION
OF MULTI-STAKEHOLDER
6
INPUT.—Not
7
(beginning with 2012), the entity shall transmit to
8
the Secretary the input of multi-stakeholder groups
9
provided under paragraph (7).’’.
10
later than February 1 of each year
(2) ANNUAL
REPORT.—Section
11
of
12
1395aaa(b)(5)(A)) is amended—
the
13
14
15
16
17
18
Social
Security
Act
1890(b)(5)(A)
(42
U.S.C.
(A) in clause (ii), by striking ‘‘and’’ at the
end;
(B) in clause (iii), by striking the period at
the end and inserting a semicolon; and
(C) by adding at the end the following new
clauses:
19
‘‘(iv) gaps in endorsed quality meas-
20
ures, which shall include measures that are
21
within priority areas identified by the Sec-
22
retary under the national strategy estab-
23
lished under section 399HH of the Public
24
Health Service Act, and where quality
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713
1
measures are unavailable or inadequate to
2
identify or address such gaps;
3
‘‘(v) areas in which evidence is insuffi-
4
cient to support endorsement of quality
5
measures in priority areas identified by the
6
Secretary under the national strategy es-
7
tablished under section 399HH of the
8
Public Health Service Act and where tar-
9
geted research may address such gaps; and
10
‘‘(vi) the matters described in clauses
11
(i) and (ii) of paragraph (7)(A).’’.
12
(b) MULTI-STAKEHOLDER GROUP INPUT INTO SE-
13
LECTION OF
QUALITY MEASURES.—Title XVIII of the So-
14 cial Security Act (42 U.S.C. 1395 et seq.) is amended by
15 inserting after section 1890 the following:
16
17
‘‘QUALITY
MEASUREMENT
‘‘SEC. 1890A. (a) MULTI-STAKEHOLDER GROUP
18 INPUT INTO SELECTION
OF
QUALITY MEASURES.—The
19 Secretary shall establish a pre-rulemaking process under
20 which the following steps occur with respect to the selec21 tion
of
quality
measures
described
in
section
22 1890(b)(7)(B):
23
‘‘(1) INPUT.—Pursuant to section 1890(b)(7),
24
the entity with a contract under section 1890 shall
25
convene multi-stakeholder groups to provide input to
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S.L.C.
714
1
the Secretary on the selection of quality measures
2
described in subparagraph (B) of such paragraph.
3
‘‘(2) PUBLIC
AVAILABILITY OF MEASURES CON-
4
SIDERED FOR SELECTION.—Not
5
ber 1 of each year (beginning with 2011), the Sec-
6
retary shall make available to the public a list of
7
quality measures described in section 1890(b)(7)(B)
8
that the Secretary is considering under this title.
9
‘‘(3) TRANSMISSION
later than Decem-
OF MULTI-STAKEHOLDER
10
INPUT.—Pursuant
11
than February 1 of each year (beginning with
12
2012), the entity shall transmit to the Secretary the
13
input of multi-stakeholder groups described in para-
14
graph (1).
15
to section 1890(b)(8), not later
‘‘(4) CONSIDERATION
OF MULTI-STAKEHOLDER
16
INPUT.—The
17
the input from multi-stakeholder groups described in
18
paragraph (1) in selecting quality measures de-
19
scribed in section 1890(b)(7)(B) that have been en-
20
dorsed by the entity with a contract under section
21
1890 and measures that have not been endorsed by
22
such entity.
23
Secretary shall take into consideration
‘‘(5) RATIONALE
FOR USE OF QUALITY MEAS-
24
URES.—The
25
Register the rationale for the use of any quality
Secretary shall publish in the Federal
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S.L.C.
715
1
measure described in section 1890(b)(7)(B) that has
2
not been endorsed by the entity with a contract
3
under section 1890.
4
‘‘(6) ASSESSMENT
OF IMPACT.—Not
later than
5
March 1, 2012, and at least once every three years
6
thereafter, the Secretary shall—
7
‘‘(A) conduct an assessment of the quality
8
impact of the use of endorsed measures de-
9
scribed in section 1890(b)(7)(B); and
10
11
12
‘‘(B) make such assessment available to
the public.
‘‘(b) PROCESS
FOR
DISSEMINATION
OF
MEASURES
13 USED BY THE SECRETARY.—
14
‘‘(1) IN
GENERAL.—The
Secretary shall estab-
15
lish a process for disseminating quality measures
16
used by the Secretary. Such process shall include the
17
following:
18
‘‘(A) The incorporation of such measures,
19
where applicable, in workforce programs, train-
20
ing curricula, and any other means of dissemi-
21
nation determined appropriate by the Secretary.
22
‘‘(B) The dissemination of such quality
23
measures through the national strategy devel-
24
oped under section 399HH of the Public Health
25
Service Act.
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716
1
‘‘(2) EXISTING
METHODS.—To
the extent prac-
2
ticable, the Secretary shall utilize and expand exist-
3
ing dissemination methods in disseminating quality
4
measures under the process established under para-
5
graph (1).
6
‘‘(c) REVIEW
OF
QUALITY MEASURES USED
BY THE
7 SECRETARY.—
8
‘‘(1) IN
GENERAL.—The
Secretary shall—
9
‘‘(A) periodically (but in no case less often
10
than once every 3 years) review quality meas-
11
ures described in section 1890(b)(7)(B); and
12
13
‘‘(B) with respect to each such measure,
determine whether to—
14
15
‘‘(i) maintain the use of such measure; or
16
‘‘(ii) phase out such measure.
17
‘‘(2) CONSIDERATIONS.—In conducting the re-
18
view under paragraph (1), the Secretary shall take
19
steps to—
20
21
‘‘(A) seek to avoid duplication of measures
used; and
22
‘‘(B) take into consideration current inno-
23
vative methodologies and strategies for quality
24
improvement practices in the delivery of health
25
care services that represent best practices for
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S.L.C.
717
1
such quality improvement and measures en-
2
dorsed by the entity with a contract under sec-
3
tion 1890 since the previous review by the Sec-
4
retary.
5
‘‘(d) RULE
OF
CONSTRUCTION.—Nothing in this sec-
6 tion shall preclude a State from using the quality meas7 ures identified under sections 1139A and 1139B.’’.
8
(c) FUNDING.—For purposes of carrying out the
9 amendments made by this section, the Secretary shall pro10 vide for the transfer, from the Federal Hospital Insurance
11 Trust Fund under section 1817 of the Social Security Act
12 (42 U.S.C. 1395i) and the Federal Supplementary Med13 ical Insurance Trust Fund under section 1841 of such Act
14 (42 U.S.C. 1395t), in such proportion as the Secretary
15 determines appropriate, of $20,000,000, to the Centers for
16 Medicare & Medicaid Services Program Management Ac17 count for each of fiscal years 2010 through 2014.
18 Amounts transferred under the preceding sentence shall
19 remain available until expended.
20
21
SEC. 3015. DATA COLLECTION; PUBLIC REPORTING.
Title III of the Public Health Service Act (42 U.S.C.
22 241 et seq.), as amended by section 3011, is further
23 amended by adding at the end the following:
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718
1
‘‘SEC. 399II. COLLECTION AND ANALYSIS OF DATA FOR
2
3
QUALITY AND RESOURCE USE MEASURES.
‘‘(a) IN GENERAL.—The Secretary shall collect and
4 aggregate consistent data on quality and resource use
5 measures from information systems used to support health
6 care delivery to implement the public reporting of perform7 ance information, as described in section 399JJ, and may
8 award grants or contracts for this purpose. The Secretary
9 shall ensure that such collection, aggregation, and analysis
10 systems span an increasingly broad range of patient popu11 lations, providers, and geographic areas over time.
12
13
14
‘‘(b) GRANTS
OR
CONTRACTS
FOR
DATA COLLEC-
TION.—
‘‘(1) IN
GENERAL.—The
Secretary may award
15
grants or contracts to eligible entities to support
16
new, or improve existing, efforts to collect and ag-
17
gregate quality and resource use measures described
18
under subsection (c).
19
‘‘(2) ELIGIBLE
ENTITIES.—To
be eligible for a
20
grant or contract under this subsection, an entity
21
shall—
22
‘‘(A) be—
23
‘‘(i) a multi-stakeholder entity that co-
24
ordinates the development of methods and
25
implementation plans for the consistent re-
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
719
1
porting of summary quality and cost infor-
2
mation;
3
‘‘(ii) an entity capable of submitting
4
such summary data for a particular popu-
5
lation and providers, such as a disease reg-
6
istry, regional collaboration, health plan
7
collaboration,
8
source; or
or
other
population-wide
9
‘‘(iii) a Federal Indian Health Service
10
program or a health program operated by
11
an Indian tribe (as defined in section 4 of
12
the Indian Health Care Improvement Act);
13
‘‘(B) promote the use of the systems that
14
provide data to improve and coordinate patient
15
care;
16
‘‘(C) support the provision of timely, con-
17
sistent quality and resource use information to
18
health care providers, and other groups and or-
19
ganizations as appropriate, with an opportunity
20
for providers to correct inaccurate measures;
21
and
22
‘‘(D) agree to report, as determined by the
23
Secretary, measures on quality and resource use
24
to the public in accordance with the public re-
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
720
1
porting
2
399JJ.
3
process
established
under
section
‘‘(c) CONSISTENT DATA AGGREGATION.—The Sec-
4 retary may award grants or contracts under this section
5 only to entities that enable summary data that can be inte6 grated and compared across multiple sources. The Sec7 retary shall provide standards for the protection of the se8 curity and privacy of patient data.
9
‘‘(d) MATCHING FUNDS.—The Secretary may not
10 award a grant or contract under this section to an entity
11 unless the entity agrees that it will make available (di12 rectly or through contributions from other public or pri13 vate entities) non-Federal contributions toward the activi14 ties to be carried out under the grant or contract in an
15 amount equal to $1 for each $5 of Federal funds provided
16 under the grant or contract. Such non-Federal matching
17 funds may be provided directly or through donations from
18 public or private entities and may be in cash or in-kind,
19 fairly evaluated, including plant, equipment, or services.
20
‘‘(e) AUTHORIZATION
OF
APPROPRIATIONS.—To
21 carry out this section, there are authorized to be appro22 priated such sums as may be necessary for fiscal years
23 2010 through 2014.
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721
1
‘‘SEC. 399JJ. PUBLIC REPORTING OF PERFORMANCE IN-
2
3
FORMATION.
‘‘(a)
DEVELOPMENT
PERFORMANCE
OF
4 WEBSITES.—The Secretary shall make available to the
5 public, through standardized Internet websites, perform6 ance information summarizing data on quality measures.
7 Such information shall be tailored to respond to the dif8 fering needs of hospitals and other institutional health
9 care providers, physicians and other clinicians, patients,
10 consumers, researchers, policymakers, States, and other
11 stakeholders, as the Secretary may specify.
12
‘‘(b) INFORMATION
ON
CONDITIONS.—The perform-
13 ance information made publicly available on an Internet
14 website, as described in subsection (a), shall include infor15 mation regarding clinical conditions to the extent such in16 formation is available, and the information shall, where
17 appropriate,
be
provider-specific
and
sufficiently
18 disaggregated and specific to meet the needs of patients
19 with different clinical conditions.
20
21
‘‘(c) CONSULTATION.—
‘‘(1) IN
GENERAL.—In
carrying out this sec-
22
tion, the Secretary shall consult with the entity with
23
a contract under section 1890(a) of the Social Secu-
24
rity Act, and other entities, as appropriate, to deter-
25
mine the type of information that is useful to stake-
26
holders and the format that best facilitates use of
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S.L.C.
722
1
the reports and of performance reporting Internet
2
websites.
3
‘‘(2) CONSULTATION
WITH STAKEHOLDERS.—
4
The entity with a contract under section 1890(a) of
5
the Social Security Act shall convene multi-stake-
6
holder groups, as described in such section, to review
7
the design and format of each Internet website made
8
available under subsection (a) and shall transmit to
9
the Secretary the views of such multi-stakeholder
10
groups with respect to each such design and format.
11
‘‘(d) COORDINATION.—Where appropriate, the Sec-
12 retary shall coordinate the manner in which data are pre13 sented through Internet websites described in subsection
14 (a) and for public reporting of other quality measures by
15 the Secretary, including such quality measures under title
16 XVIII of the Social Security Act.
17
‘‘(e) AUTHORIZATION
OF
APPROPRIATIONS.—To
18 carry out this section, there are authorized to be appro19 priated such sums as may be necessary for fiscal years
20 2010 through 2014.’’.
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723
1
PART III—ENCOURAGING DEVELOPMENT OF
2
NEW PATIENT CARE MODELS
3
SEC. 3021. ESTABLISHMENT OF CENTER FOR MEDICARE
4
5
AND MEDICAID INNOVATION WITHIN CMS.
(a) IN GENERAL.—Title XI of the Social Security Act
6 is amended by inserting after section 1115 the following
7 new section:
8
9
‘‘CENTER
FOR MEDICARE AND MEDICAID INNOVATION
‘‘SEC. 1115A. (a) CENTER
FOR
MEDICARE
AND
10 MEDICAID INNOVATION ESTABLISHED.—
11
‘‘(1) IN
GENERAL.—There
is created within the
12
Centers for Medicare & Medicaid Services a Center
13
for Medicare and Medicaid Innovation (in this sec-
14
tion referred to as the ‘CMI’) to carry out the duties
15
described in this section. The purpose of the CMI is
16
to test innovative payment and service delivery mod-
17
els to reduce program expenditures under the appli-
18
cable titles while preserving or enhancing the quality
19
of care furnished to individuals under such titles. In
20
selecting such models, the Secretary shall give pref-
21
erence to models that also improve the coordination,
22
quality, and efficiency of health care services fur-
23
nished to applicable individuals defined in paragraph
24
(4)(A).
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724
1
‘‘(2) DEADLINE.—The Secretary shall ensure
2
that the CMI is carrying out the duties described in
3
this section by not later than January 1, 2011.
4
‘‘(3) CONSULTATION.—In carrying out the du-
5
ties under this section, the CMI shall consult rep-
6
resentatives of relevant Federal agencies, and clin-
7
ical and analytical experts with expertise in medicine
8
and health care management. The CMI shall use
9
open door forums or other mechanisms to seek input
10
11
12
13
from interested parties.
‘‘(4) DEFINITIONS.—In this section:
‘‘(A) APPLICABLE
INDIVIDUAL.—The
term
‘applicable individual’ means—
14
‘‘(i) an individual who is entitled to,
15
or enrolled for, benefits under part A of
16
title XVIII or enrolled for benefits under
17
part B of such title;
18
‘‘(ii) an individual who is eligible for
19
medical assistance under title XIX, under
20
a State plan or waiver; or
21
‘‘(iii) an individual who meets the cri-
22
teria of both clauses (i) and (ii).
23
‘‘(B) APPLICABLE
TITLE.—The
term ‘ap-
24
plicable title’ means title XVIII, title XIX, or
25
both.
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725
1
2
‘‘(b) TESTING OF MODELS (PHASE I).—
‘‘(1) IN
GENERAL.—The
CMI shall test pay-
3
ment and service delivery models in accordance with
4
selection criteria under paragraph (2) to determine
5
the effect of applying such models under the applica-
6
ble title (as defined in subsection (a)(4)(B)) on pro-
7
gram expenditures under such titles and the quality
8
of care received by individuals receiving benefits
9
under such title.
10
11
‘‘(2) SELECTION
‘‘(A) IN
OF MODELS TO BE TESTED.—
GENERAL.—The
Secretary shall
12
select models to be tested from models where
13
the Secretary determines that there is evidence
14
that the model addresses a defined population
15
for which there are deficits in care leading to
16
poor clinical outcomes or potentially avoidable
17
expenditures. The models selected under the
18
preceding sentence may include the models de-
19
scribed in subparagraph (B).
20
‘‘(B) OPPORTUNITIES.—The models de-
21
scribed in this subparagraph are the following
22
models:
23
‘‘(i) Promoting broad payment and
24
practice reform in primary care, including
25
patient-centered medical home models for
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S.L.C.
726
1
high-need applicable individuals, medical
2
homes that address women’s unique health
3
care needs, and models that transition pri-
4
mary care practices away from fee-for-serv-
5
ice based reimbursement and toward com-
6
prehensive payment or salary-based pay-
7
ment.
8
‘‘(ii) Contracting directly with groups
9
of providers of services and suppliers to
10
promote innovative care delivery models,
11
such as through risk-based comprehensive
12
payment or salary-based payment.
13
‘‘(iii) Utilizing geriatric assessments
14
and comprehensive care plans to coordinate
15
the care (including through interdiscipli-
16
nary teams) of applicable individuals with
17
multiple chronic conditions and at least
18
one of the following:
19
20
21
‘‘(I) An inability to perform 2 or
more activities of daily living.
‘‘(II) Cognitive impairment, in-
22
cluding dementia.
23
‘‘(iv) Promote care coordination be-
24
tween providers of services and suppliers
25
that transition health care providers away
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S.L.C.
727
1
from fee-for-service based reimbursement
2
and toward salary-based payment.
3
‘‘(v) Supporting care coordination for
4
chronically-ill applicable individuals at high
5
risk of hospitalization through a health in-
6
formation technology-enabled provider net-
7
work that includes care coordinators, a
8
chronic disease registry, and home tele-
9
health technology.
10
‘‘(vi) Varying payment to physicians
11
who order advanced diagnostic imaging
12
services
13
1834(e)(1)(B)) according to the physi-
14
cian’s adherence to appropriateness criteria
15
for the ordering of such services, as deter-
16
mined in consultation with physician spe-
17
cialty groups and other relevant stake-
18
holders.
(as
defined
in
section
19
‘‘(vii) Utilizing medication therapy
20
management services, such as those de-
21
scribed in section 935 of the Public Health
22
Service Act.
23
‘‘(viii) Establishing community-based
24
health teams to support small-practice
25
medical homes by assisting the primary
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728
1
care practitioner in chronic care manage-
2
ment, including patient self-management,
3
activities.
4
‘‘(ix) Assisting applicable individuals
5
in making informed health care choices by
6
paying providers of services and suppliers
7
for using patient decision-support tools, in-
8
cluding tools that meet the standards de-
9
veloped
and
identified
under
section
10
936(c)(2)(A) of the Public Health Service
11
Act, that improve applicable individual and
12
caregiver understanding of medical treat-
13
ment options.
14
‘‘(x) Allowing States to test and
15
evaluate fully integrating care for dual eli-
16
gible individuals in the State, including the
17
management and oversight of all funds
18
under the applicable titles with respect to
19
such individuals.
20
‘‘(xi) Allowing States to test and
21
evaluate systems of all-payer payment re-
22
form for the medical care of residents of
23
the State, including dual eligible individ-
24
uals.
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729
1
‘‘(xii) Aligning nationally recognized,
2
evidence-based guidelines of cancer care
3
with payment incentives under title XVIII
4
in the areas of treatment planning and fol-
5
low-up care planning for applicable individ-
6
uals described in clause (i) or (iii) of sub-
7
section (a)(4)(A) with cancer, including the
8
identification of gaps in applicable quality
9
measures.
10
‘‘(xiii)
Improving
post-acute
care
11
through continuing care hospitals that
12
offer inpatient rehabilitation, long-term
13
care hospitals, and home health or skilled
14
nursing care during an inpatient stay and
15
the 30 days immediately following dis-
16
charge.
17
‘‘(xiv) Funding home health providers
18
who offer chronic care management serv-
19
ices to applicable individuals in cooperation
20
with interdisciplinary teams.
21
‘‘(xv) Promoting improved quality and
22
reduced cost by developing a collaborative
23
of high-quality, low-cost health care insti-
24
tutions that is responsible for—
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730
1
‘‘(I)
developing,
documenting,
2
and disseminating best practices and
3
proven care methods;
4
‘‘(II) implementing such best
5
practices and proven care methods
6
within
7
onstrate
8
quality and efficiency; and
such
institutions
further
to
dem-
improvements
in
9
‘‘(III) providing assistance to
10
other health care institutions on how
11
best to employ such best practices and
12
proven
13
health care quality and lower costs.
14
‘‘(xvi) Facilitate inpatient care, in-
15
cluding intensive care, of hospitalized ap-
16
plicable individuals at their local hospital
17
through the use of electronic monitoring by
18
specialists, including intensivists and crit-
19
ical care specialists, based at integrated
20
health systems.
care
methods
to
improve
21
‘‘(xvii) Promoting greater efficiencies
22
and timely access to outpatient services
23
(such as outpatient physical therapy serv-
24
ices) through models that do not require a
25
physician or other health professional to
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S.L.C.
731
1
refer the service or be involved in estab-
2
lishing the plan of care for the service,
3
when such service is furnished by a health
4
professional who has the authority to fur-
5
nish the service under existing State law.
6
‘‘(xviii)
Establishing
comprehensive
7
payments to Healthcare Innovation Zones,
8
consisting of groups of providers that in-
9
clude a teaching hospital, physicians, and
10
other clinical entities, that, through their
11
structure, operations, and joint-activity de-
12
liver a full spectrum of integrated and
13
comprehensive health care services to ap-
14
plicable individuals while also incorporating
15
innovative methods for the clinical training
16
of future health care professionals.
17
‘‘(C) ADDITIONAL
FACTORS FOR CONSID-
18
ERATION.—In
19
under subparagraph (A), the CMI may consider
20
the following additional factors:
selecting models for testing
21
‘‘(i) Whether the model includes a
22
regular process for monitoring and updat-
23
ing patient care plans in a manner that is
24
consistent with the needs and preferences
25
of applicable individuals.
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732
1
‘‘(ii) Whether the model places the ap-
2
plicable individual, including family mem-
3
bers and other informal caregivers of the
4
applicable individual, at the center of the
5
care team of the applicable individual.
6
‘‘(iii) Whether the model provides for
7
in-person contact with applicable individ-
8
uals.
9
‘‘(iv) Whether the model utilizes tech-
10
nology, such as electronic health records
11
and patient-based remote monitoring sys-
12
tems, to coordinate care over time and
13
across settings.
14
‘‘(v) Whether the model provides for
15
the maintenance of a close relationship be-
16
tween care coordinators, primary care
17
practitioners, specialist physicians, commu-
18
nity-based organizations, and other pro-
19
viders of services and suppliers.
20
‘‘(vi) Whether the model relies on a
21
team-based approach to interventions, such
22
as comprehensive care assessments, care
23
planning, and self-management coaching.
24
‘‘(vii) Whether, under the model, pro-
25
viders of services and suppliers are able to
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733
1
share information with patients, caregivers,
2
and other providers of services and sup-
3
pliers on a real time basis.
4
‘‘(3) BUDGET
5
‘‘(A)
NEUTRALITY.—
INITIAL
PERIOD.—The
Secretary
6
shall not require, as a condition for testing a
7
model under paragraph (1), that the design of
8
such model ensure that such model is budget
9
neutral initially with respect to expenditures
10
under the applicable title.
11
‘‘(B) TERMINATION
OR MODIFICATION.—
12
The Secretary shall terminate or modify the de-
13
sign and implementation of a model unless the
14
Secretary determines (and the Chief Actuary of
15
the Centers for Medicare & Medicaid Services,
16
with respect to program spending under the ap-
17
plicable title, certifies), after testing has begun,
18
that the model is expected to—
19
‘‘(i) improve the quality of care (as
20
determined by the Administrator of the
21
Centers for Medicare & Medicaid Services)
22
without increasing spending under the ap-
23
plicable title;
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734
1
‘‘(ii) reduce spending under the appli-
2
cable title without reducing the quality of
3
care; or
4
5
‘‘(iii) improve the quality of care and
reduce spending.
6
Such termination may occur at any time after
7
such testing has begun and before completion of
8
the testing.
9
‘‘(4) EVALUATION.—
10
‘‘(A) IN
GENERAL.—The
Secretary shall
11
conduct an evaluation of each model tested
12
under this subsection. Such evaluation shall in-
13
clude an analysis of—
14
‘‘(i) the quality of care furnished
15
under the model, including the measure-
16
ment of patient-level outcomes and patient-
17
centeredness criteria determined appro-
18
priate by the Secretary; and
19
‘‘(ii) the changes in spending under
20
the applicable titles by reason of the
21
model.
22
‘‘(B) INFORMATION.—The Secretary shall
23
make the results of each evaluation under this
24
paragraph available to the public in a timely
25
fashion and may establish requirements for
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S.L.C.
735
1
States and other entities participating in the
2
testing of models under this section to collect
3
and report information that the Secretary de-
4
termines is necessary to monitor and evaluate
5
such models.
6
‘‘(c) EXPANSION
OF
MODELS (PHASE II).—Taking
7 into account the evaluation under subsection (b)(4), the
8 Secretary may, through rulemaking, expand (including im9 plementation on a nationwide basis) the duration and the
10 scope of a model that is being tested under subsection (b)
11 or a demonstration project under section 1866C, to the
12 extent determined appropriate by the Secretary, if—
13
14
‘‘(1) the Secretary determines that such expansion is expected to—
15
16
‘‘(A) reduce spending under applicable title
without reducing the quality of care; or
17
‘‘(B) improve the quality of care and re-
18
duce spending; and
19
‘‘(2) the Chief Actuary of the Centers for Medi-
20
care & Medicaid Services certifies that such expan-
21
sion would reduce program spending under applica-
22
ble titles.
23
‘‘(d) IMPLEMENTATION.—
24
25
‘‘(1) WAIVER
AUTHORITY.—The
Secretary may
waive such requirements of titles XI and XVIII and
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
736
1
of
2
1903(m)(2)(A)(iii) as may be necessary solely for
3
purposes of carrying out this section with respect to
4
testing models described in subsection (b).
5
sections
1902(a)(1),
‘‘(2) LIMITATIONS
1902(a)(13),
ON REVIEW.—There
and
shall be
6
no administrative or judicial review under section
7
1869, section 1878, or otherwise of—
8
9
10
11
‘‘(A) the selection of models for testing or
expansion under this section;
‘‘(B) the selection of organizations, sites,
or participants to test those models selected;
12
‘‘(C) the elements, parameters, scope, and
13
duration of such models for testing or dissemi-
14
nation;
15
16
‘‘(D) determinations regarding budget neutrality under subsection (b)(3);
17
‘‘(E) the termination or modification of the
18
design and implementation of a model under
19
subsection (b)(3)(B); and
20
‘‘(F) determinations about expansion of
21
the duration and scope of a model under sub-
22
section (c), including the determination that a
23
model is not expected to meet criteria described
24
in paragraph (1) or (2) of such subsection.
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737
1
‘‘(3) ADMINISTRATION.—Chapter 35 of title 44,
2
United States Code, shall not apply to the testing
3
and evaluation of models or expansion of such mod-
4
els under this section.
5
‘‘(e) APPLICATION
TO
CHIP.—The Center may carry
6 out activities under this section with respect to title XXI
7 in the same manner as provided under this section with
8 respect to the program under the applicable titles.
9
‘‘(f) FUNDING.—
10
‘‘(1) IN
GENERAL.—There
are appropriated,
11
from amounts in the Treasury not otherwise appro-
12
priated—
13
‘‘(A) $5,000,000 for the design, implemen-
14
tation, and evaluation of models under sub-
15
section (b) for fiscal year 2010;
16
‘‘(B) $10,000,000,000 for the activities
17
initiated under this section for the period of fis-
18
cal years 2011 through 2019; and
19
‘‘(C) the amount described in subpara-
20
graph (B) for the activities initiated under this
21
section for each subsequent 10-year fiscal pe-
22
riod (beginning with the 10-year fiscal period
23
beginning with fiscal year 2020).
24
Amounts appropriated under the preceding sentence
25
shall remain available until expended.
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S.L.C.
738
1
‘‘(2)
USE
OF
CERTAIN
FUNDS.—Out
of
2
amounts appropriated under subparagraphs (B) and
3
(C) of paragraph (1), not less than $25,000,000
4
shall be made available each such fiscal year to de-
5
sign, implement, and evaluate models under sub-
6
section (b).
7
‘‘(g) REPORT
TO
CONGRESS.—Beginning in 2012,
8 and not less than once every other year thereafter, the
9 Secretary shall submit to Congress a report on activities
10 under this section. Each such report shall describe the
11 models tested under subsection (b), including the number
12 of individuals described in subsection (a)(4)(A)(i) and of
13 individuals described in subsection (a)(4)(A)(ii) partici14 pating in such models and payments made under applica15 ble titles for services on behalf of such individuals, any
16 models chosen for expansion under subsection (c), and the
17 results from evaluations under subsection (b)(4). In addi18 tion, each such report shall provide such recommendations
19 as the Secretary determines are appropriate for legislative
20 action to facilitate the development and expansion of suc21 cessful payment models.’’.
22
(b) MEDICAID CONFORMING AMENDMENT.—Section
23 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)),
24 as amended by section 8002(b), is amended—
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S.L.C.
739
1
2
3
4
5
6
(1) in paragraph (81), by striking ‘‘and’’ at the
end;
(2) in paragraph (82), by striking the period at
the end and inserting ‘‘; and’’; and
(3) by inserting after paragraph (82) the following new paragraph:
7
‘‘(83) provide for implementation of the pay-
8
ment models specified by the Secretary under section
9
1115A(c) for implementation on a nationwide basis
10
unless the State demonstrates to the satisfaction of
11
the Secretary that implementation would not be ad-
12
ministratively feasible or appropriate to the health
13
care delivery system of the State.’’.
14
(c) REVISIONS
15
ONSTRATION
TO
HEALTH CARE QUALITY DEM-
PROGRAM.—Subsections (b) and (f) of sec-
16 tion 1866C of the Social Security Act (42 U.S.C. 1395cc–
17 3) are amended by striking ‘‘5-year’’ each place it appears.
18
19
SEC. 3022. MEDICARE SHARED SAVINGS PROGRAM.
Title XVIII of the Social Security Act (42 U.S.C.
20 1395 et seq.) is amended by adding at the end the fol21 lowing new section:
22
23
24
‘‘SHARED
SAVINGS PROGRAM
‘‘SEC. 1899. (a) ESTABLISHMENT.—
‘‘(1) IN
GENERAL.—Not
later than January 1,
25
2012, the Secretary shall establish a shared savings
26
program (in this section referred to as the ‘pro-
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
740
1
gram’) that promotes accountability for a patient
2
population and coordinates items and services under
3
parts A and B, and encourages investment in infra-
4
structure and redesigned care processes for high
5
quality and efficient service delivery. Under such
6
program—
7
‘‘(A) groups of providers of services and
8
suppliers meeting criteria specified by the Sec-
9
retary may work together to manage and co-
10
ordinate care for Medicare fee-for-service bene-
11
ficiaries through an accountable care organiza-
12
tion (referred to in this section as an ‘ACO’);
13
and
14
‘‘(B) ACOs that meet quality performance
15
standards established by the Secretary are eligi-
16
ble to receive payments for shared savings
17
under subsection (d)(2).
18
19
‘‘(b) ELIGIBLE ACOS.—
‘‘(1) IN
GENERAL.—Subject
to the succeeding
20
provisions of this subsection, as determined appro-
21
priate by the Secretary, the following groups of pro-
22
viders of services and suppliers which have estab-
23
lished a mechanism for shared governance are eligi-
24
ble to participate as ACOs under the program under
25
this section:
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S.L.C.
741
1
2
3
4
‘‘(A) ACO professionals in group practice
arrangements.
‘‘(B) Networks of individual practices of
ACO professionals.
5
‘‘(C) Partnerships or joint venture ar-
6
rangements between hospitals and ACO profes-
7
sionals.
8
9
‘‘(D) Hospitals employing ACO professionals.
10
‘‘(E) Such other groups of providers of
11
services and suppliers as the Secretary deter-
12
mines appropriate.
13
‘‘(2) REQUIREMENTS.—An ACO shall meet the
14
following requirements:
15
‘‘(A) The ACO shall be willing to become
16
accountable for the quality, cost, and overall
17
care of the Medicare fee-for-service beneficiaries
18
assigned to it.
19
‘‘(B) The ACO shall enter into an agree-
20
ment with the Secretary to participate in the
21
program for not less than a 3-year period (re-
22
ferred to in this section as the ‘agreement pe-
23
riod’).
24
‘‘(C) The ACO shall have a formal legal
25
structure that would allow the organization to
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S.L.C.
742
1
receive and distribute payments for shared sav-
2
ings under subsection (d)(2) to participating
3
providers of services and suppliers.
4
‘‘(D) The ACO shall include primary care
5
ACO professionals that are sufficient for the
6
number of Medicare fee-for-service beneficiaries
7
assigned to the ACO under subsection (c). At a
8
minimum, the ACO shall have at least 5,000
9
such beneficiaries assigned to it under sub-
10
section (c) in order to be eligible to participate
11
in the ACO program.
12
‘‘(E) The ACO shall provide the Secretary
13
with such information regarding ACO profes-
14
sionals participating in the ACO as the Sec-
15
retary determines necessary to support the as-
16
signment of Medicare fee-for-service bene-
17
ficiaries to an ACO, the implementation of
18
quality and other reporting requirements under
19
paragraph (3), and the determination of pay-
20
ments for shared savings under subsection
21
(d)(2).
22
‘‘(F) The ACO shall have in place a leader-
23
ship and management structure that includes
24
clinical and administrative systems.
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S.L.C.
743
1
‘‘(G) The ACO shall define processes to
2
promote evidence-based medicine and patient
3
engagement, report on quality and cost meas-
4
ures, and coordinate care, such as through the
5
use of telehealth, remote patient monitoring,
6
and other such enabling technologies.
7
‘‘(H) The ACO shall demonstrate to the
8
Secretary that it meets patient-centeredness cri-
9
teria specified by the Secretary, such as the use
10
of patient and caregiver assessments or the use
11
of individualized care plans.
12
‘‘(3) QUALITY
13
14
AND
OTHER
REPORTING
RE-
QUIREMENTS.—
‘‘(A) IN
GENERAL.—The
Secretary shall
15
determine appropriate measures to assess the
16
quality of care furnished by the ACO, such as
17
measures of—
18
‘‘(i) clinical processes and outcomes;
19
‘‘(ii) patient and, where practicable,
20
caregiver experience of care; and
21
‘‘(iii) utilization (such as rates of hos-
22
pital admissions for ambulatory care sen-
23
sitive conditions).
24
‘‘(B)
25
REPORTING
REQUIREMENTS.—An
ACO shall submit data in a form and manner
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S.L.C.
744
1
specified by the Secretary on measures the Sec-
2
retary determines necessary for the ACO to re-
3
port in order to evaluate the quality of care fur-
4
nished by the ACO. Such data may include care
5
transitions across health care settings, including
6
hospital discharge planning and post-hospital
7
discharge follow-up by ACO professionals, as
8
the Secretary determines appropriate.
9
‘‘(C)
QUALITY
PERFORMANCE
STAND-
10
ARDS.—The
11
performance standards to assess the quality of
12
care furnished by ACOs. The Secretary shall
13
seek to improve the quality of care furnished by
14
ACOs over time by specifying higher standards,
15
new measures, or both for purposes of assessing
16
such quality of care.
Secretary shall establish quality
17
‘‘(D)
18
MENTS.—The
19
determines appropriate, incorporate reporting
20
requirements and incentive payments related to
21
the
22
(PQRI) under section 1848, including such re-
23
quirements and such payments related to elec-
24
tronic prescribing, electronic health records,
25
and other similar initiatives under section 1848,
OTHER
REPORTING
REQUIRE-
Secretary may, as the Secretary
physician
quality
reporting
initiative
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
745
1
and may use alternative criteria than would
2
otherwise apply under such section for deter-
3
mining whether to make such payments. The
4
incentive payments described in the preceding
5
sentence shall not be taken into consideration
6
when calculating any payments otherwise made
7
under subsection (d).
8
‘‘(4) NO
9
DUPLICATION IN PARTICIPATION IN
SHARED SAVINGS PROGRAMS.—A
provider of services
10
or supplier that participates in any of the following
11
shall not be eligible to participate in an ACO under
12
this section:
13
‘‘(A) A model tested or expanded under
14
section 1115A that involves shared savings
15
under this title, or any other program or dem-
16
onstration project that involves such shared
17
savings.
18
19
20
‘‘(B) The independence at home medical
practice pilot program under section 1866E.
‘‘(c) ASSIGNMENT
21 BENEFICIARIES
TO
OF
MEDICARE FEE-FOR-SERVICE
ACOS.—The Secretary shall deter-
22 mine an appropriate method to assign Medicare fee-for23 service beneficiaries to an ACO based on their utilization
24 of primary care services provided under this title by an
25 ACO professional described in subsection (h)(1)(A).
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746
1
‘‘(d) PAYMENTS AND TREATMENT OF SAVINGS.—
2
‘‘(1) PAYMENTS.—
3
‘‘(A) IN
GENERAL.—Under
the program,
4
subject to paragraph (3), payments shall con-
5
tinue to be made to providers of services and
6
suppliers participating in an ACO under the
7
original Medicare fee-for-service program under
8
parts A and B in the same manner as they
9
would otherwise be made except that a partici-
10
pating ACO is eligible to receive payment for
11
shared savings under paragraph (2) if—
12
‘‘(i) the ACO meets quality perform-
13
ance standards established by the Sec-
14
retary under subsection (b)(3); and
15
‘‘(ii) the ACO meets the requirement
16
under subparagraph (B)(i).
17
‘‘(B) SAVINGS
18
19
REQUIREMENT AND BENCH-
MARK.—
‘‘(i) DETERMINING
SAVINGS.—In
each
20
year of the agreement period, an ACO
21
shall be eligible to receive payment for
22
shared savings under paragraph (2) only if
23
the estimated average per capita Medicare
24
expenditures under the ACO for Medicare
25
fee-for-service beneficiaries for parts A and
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S.L.C.
747
1
B services, adjusted for beneficiary charac-
2
teristics, is at least the percent specified by
3
the Secretary below the applicable bench-
4
mark under clause (ii). The Secretary shall
5
determine the appropriate percent de-
6
scribed in the preceding sentence to ac-
7
count for normal variation in expenditures
8
under this title, based upon the number of
9
Medicare fee-for-service beneficiaries as-
10
11
signed to an ACO.
‘‘(ii)
ESTABLISH
AND
UPDATE
12
BENCHMARK.—The
13
mate a benchmark for each agreement pe-
14
riod for each ACO using the most recent
15
available 3 years of per-beneficiary expend-
16
itures for parts A and B services for Medi-
17
care fee-for-service beneficiaries assigned
18
to the ACO. Such benchmark shall be ad-
19
justed for beneficiary characteristics and
20
such other factors as the Secretary deter-
21
mines appropriate and updated by the pro-
22
jected absolute amount of growth in na-
23
tional per capita expenditures for parts A
24
and B services under the original Medicare
25
fee-for-service program, as estimated by
Secretary shall esti-
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S.L.C.
748
1
the Secretary. Such benchmark shall be
2
reset at the start of each agreement pe-
3
riod.
4
‘‘(2) PAYMENTS
FOR SHARED SAVINGS.—Sub-
5
ject to performance with respect to the quality per-
6
formance standards established by the Secretary
7
under subsection (b)(3), if an ACO meets the re-
8
quirements under paragraph (1), a percent (as de-
9
termined appropriate by the Secretary) of the dif-
10
ference between such estimated average per capita
11
Medicare expenditures in a year, adjusted for bene-
12
ficiary characteristics, under the ACO and such
13
benchmark for the ACO may be paid to the ACO as
14
shared savings and the remainder of such difference
15
shall be retained by the program under this title.
16
The Secretary shall establish limits on the total
17
amount of shared savings that may be paid to an
18
ACO under this paragraph.
19
‘‘(3) MONITORING
AVOIDANCE OF AT-RISK PA-
20
TIENTS.—If
21
has taken steps to avoid patients at risk in order to
22
reduce the likelihood of increasing costs to the ACO
23
the Secretary may impose an appropriate sanction
24
on the ACO, including termination from the pro-
25
gram.
the Secretary determines that an ACO
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749
1
‘‘(4) TERMINATION.—The Secretary may termi-
2
nate an agreement with an ACO if it does not meet
3
the quality performance standards established by the
4
Secretary under subsection (b)(3).
5
‘‘(e) ADMINISTRATION.—Chapter 35 of title 44,
6 United States Code, shall not apply to the program.
7
‘‘(f) WAIVER AUTHORITY.—The Secretary may waive
8 such requirements of sections 1128A and 1128B and title
9 XVIII of this Act as may be necessary to carry out the
10 provisions of this section.
11
‘‘(g) LIMITATIONS
ON
REVIEW.—There shall be no
12 administrative or judicial review under section 1869, sec13 tion 1878, or otherwise of—
14
15
‘‘(1) the specification of criteria under subsection (a)(1)(B);
16
‘‘(2) the assessment of the quality of care fur-
17
nished by an ACO and the establishment of perform-
18
ance standards under subsection (b)(3);
19
20
‘‘(3) the assignment of Medicare fee-for-service
beneficiaries to an ACO under subsection (c);
21
‘‘(4) the determination of whether an ACO is
22
eligible for shared savings under subsection (d)(2)
23
and the amount of such shared savings, including
24
the determination of the estimated average per cap-
25
ita Medicare expenditures under the ACO for Medi-
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750
1
care fee-for-service beneficiaries assigned to the ACO
2
and the average benchmark for the ACO under sub-
3
section (d)(1)(B);
4
‘‘(5) the percent of shared savings specified by
5
the Secretary under subsection (d)(2) and any limit
6
on the total amount of shared savings established by
7
the Secretary under such subsection; and
8
9
10
‘‘(6) the termination of an ACO under subsection (d)(4).
‘‘(h) DEFINITIONS.—In this section:
11
‘‘(1) ACO
12
professional’ means—
13
14
PROFESSIONAL.—The
term ‘ACO
‘‘(A) a physician (as defined in section
1861(r)(1)); and
15
‘‘(B) a practitioner described in section
16
1842(b)(18)(C)(i).
17
‘‘(2) HOSPITAL.—The term ‘hospital’ means a
18
subsection (d) hospital (as defined in section
19
1886(d)(1)(B)).
20
‘‘(3)
21
FICIARY.—The
22
ficiary’ means an individual who is enrolled in the
23
original Medicare fee-for-service program under
24
parts A and B and is not enrolled in an MA plan
MEDICARE
FEE-FOR-SERVICE
BENE-
term ‘Medicare fee-for-service bene-
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751
1
under part C, an eligible organization under section
2
1876, or a PACE program under section 1894.’’.
3
SEC. 3023. NATIONAL PILOT PROGRAM ON PAYMENT BUN-
4
5
DLING.
Title XVIII of the Social Security Act, as amended
6 by section 3021, is amended by inserting after section
7 1886C the following new section:
8
9
10
‘‘NATIONAL
PILOT PROGRAM ON PAYMENT BUNDLING
‘‘SEC. 1866D. (a) IMPLEMENTATION.—
‘‘(1) IN
GENERAL.—The
Secretary shall estab-
11
lish a pilot program for integrated care during an
12
episode of care provided to an applicable beneficiary
13
around a hospitalization in order to improve the co-
14
ordination, quality, and efficiency of health care
15
services under this title.
16
17
‘‘(2) DEFINITIONS.—In this section:
‘‘(A)
APPLICABLE
BENEFICIARY.—The
18
term ‘applicable beneficiary’ means an indi-
19
vidual who—
20
‘‘(i) is entitled to, or enrolled for, ben-
21
efits under part A and enrolled for benefits
22
under part B of such title, but not enrolled
23
under part C or a PACE program under
24
section 1894; and
25
26
‘‘(ii) is admitted to a hospital for an
applicable condition.
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1
‘‘(B) APPLICABLE
CONDITION.—The
term
2
‘applicable condition’ means 1 or more of 8 con-
3
ditions selected by the Secretary. In selecting
4
conditions under the preceding sentence, the
5
Secretary shall take into consideration the fol-
6
lowing factors:
7
‘‘(i) Whether the conditions selected
8
include a mix of chronic and acute condi-
9
tions.
10
‘‘(ii) Whether the conditions selected
11
include a mix of surgical and medical con-
12
ditions.
13
‘‘(iii) Whether a condition is one for
14
which there is evidence of an opportunity
15
for providers of services and suppliers to
16
improve the quality of care furnished while
17
reducing total expenditures under this
18
title.
19
20
‘‘(iv) Whether a condition has significant variation in—
21
22
‘‘(I) the number of readmissions;
and
23
‘‘(II) the amount of expenditures
24
for post-acute care spending under
25
this title.
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753
1
‘‘(v) Whether a condition is high-vol-
2
ume and has high post-acute care expendi-
3
tures under this title.
4
‘‘(vi) Which conditions the Secretary
5
determines are most amenable to bundling
6
across the spectrum of care given practice
7
patterns under this title.
8
‘‘(C) APPLICABLE
9
SERVICES.—The
term
‘applicable services’ means the following:
10
‘‘(i) Acute care inpatient services.
11
‘‘(ii) Physicians’ services delivered in
12
and outside of an acute care hospital set-
13
ting.
14
15
‘‘(iii) Outpatient hospital services, including emergency department services.
16
‘‘(iv) Post-acute care services, includ-
17
ing home health services, skilled nursing
18
services, inpatient rehabilitation services,
19
and inpatient hospital services furnished by
20
a long-term care hospital.
21
‘‘(v) Other services the Secretary de-
22
termines appropriate.
23
‘‘(D) EPISODE
24
25
‘‘(i) IN
OF CARE.—
GENERAL.—Subject
to clause
(ii), the term ‘episode of care’ means, with
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754
1
respect to an applicable condition and an
2
applicable beneficiary, the period that in-
3
cludes—
4
‘‘(I) the 3 days prior to the ad-
5
mission of the applicable beneficiary
6
to a hospital for the applicable condi-
7
tion;
8
‘‘(II) the length of stay of the ap-
9
plicable beneficiary in such hospital;
10
and
11
‘‘(III) the 30 days following the
12
discharge of the applicable beneficiary
13
from such hospital.
14
‘‘(ii) ESTABLISHMENT
OF PERIOD BY
15
THE SECRETARY.—The
16
propriate, may establish a period (other
17
than the period described in clause (i)) for
18
an episode of care under the pilot program.
19
‘‘(E) PHYSICIANS’
Secretary, as ap-
SERVICES.—The
term
20
‘physicians’ services’ has the meaning given
21
such term in section 1861(q).
22
‘‘(F) PILOT
PROGRAM.—The
term ‘pilot
23
program’ means the pilot program under this
24
section.
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1
‘‘(G) PROVIDER
OF SERVICES.—The
term
2
‘provider of services’ has the meaning given
3
such term in section 1861(u).
4
‘‘(H) READMISSION.—The term ‘readmis-
5
sion’ has the meaning given such term in sec-
6
tion 1886(q)(5)(E).
7
‘‘(I) SUPPLIER.—The term ‘supplier’ has
8
the meaning given such term in section
9
1861(d).
10
‘‘(3) DEADLINE
FOR IMPLEMENTATION.—The
11
Secretary shall establish the pilot program not later
12
than January 1, 2013.
13
‘‘(b) DEVELOPMENTAL PHASE.—
14
‘‘(1) DETERMINATION
OF
PATIENT
ASSESS-
15
MENT INSTRUMENT.—The
16
which patient assessment instrument (such as the
17
Continuity
18
(CARE) tool) shall be used under the pilot program
19
to evaluate the applicable condition of an applicable
20
beneficiary for purposes of determining the most
21
clinically appropriate site for the provision of post-
22
acute care to the applicable beneficiary.
23
Assessment
‘‘(2) DEVELOPMENT
Secretary shall determine
Record
and
Evaluation
OF QUALITY MEASURES
24
FOR AN EPISODE OF CARE AND FOR POST-ACUTE
25
CARE.—
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1
‘‘(A) IN
GENERAL.—The
Secretary, in con-
2
sultation with the Agency for Healthcare Re-
3
search and Quality and the entity with a con-
4
tract under section 1890(a) of the Social Secu-
5
rity Act, shall develop quality measures for use
6
in the pilot program—
7
‘‘(i) for episodes of care; and
8
‘‘(ii) for post-acute care.
9
‘‘(B) SITE-NEUTRAL
POST-ACUTE
CARE
10
QUALITY
11
developed under subparagraph (A)(ii) shall be
12
site-neutral.
13
MEASURES.—Any
‘‘(C) COORDINATION
quality measures
WITH QUALITY MEAS-
14
URE DEVELOPMENT AND ENDORSEMENT PRO-
15
CEDURES.—The
16
development of quality measures under sub-
17
paragraph (A) is done in a manner that is con-
18
sistent with the measures developed and en-
19
dorsed under section 1890 and 1890A that are
20
applicable to all post-acute care settings.
21
Secretary shall ensure that the
‘‘(c) DETAILS.—
22
‘‘(1) DURATION.—
23
‘‘(A) IN
GENERAL.—Subject
to subpara-
24
graph (B), the pilot program shall be conducted
25
for a period of 5 years.
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757
1
‘‘(B) EXTENSION.—The Secretary may ex-
2
tend the duration of the pilot program for pro-
3
viders of services and suppliers participating in
4
the pilot program as of the day before the end
5
of the 5-year period described in subparagraph
6
(A), for a period determined appropriate by the
7
Secretary, if the Secretary determines that such
8
extension will result in improving or not reduc-
9
ing the quality of patient care and reducing
10
spending under this title.
11
‘‘(2) PARTICIPATING
12
13
PROVIDERS OF SERVICES
AND SUPPLIERS.—
‘‘(A) IN
GENERAL.—An
entity comprised
14
of providers of services and suppliers, including
15
a hospital, a physician group, a skilled nursing
16
facility, and a home health agency, who are oth-
17
erwise participating under this title, may sub-
18
mit an application to the Secretary to provide
19
applicable services to applicable individuals
20
under this section.
21
‘‘(B)
REQUIREMENTS.—The
Secretary
22
shall develop requirements for entities to par-
23
ticipate in the pilot program under this section.
24
Such requirements shall ensure that applicable
25
beneficiaries have an adequate choice of pro-
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758
1
viders of services and suppliers under the pilot
2
program.
3
‘‘(3) PAYMENT
4
5
‘‘(A) IN
METHODOLOGY.—
GENERAL.—
‘‘(i) ESTABLISHMENT
OF
PAYMENT
6
METHODS.—The
7
payment methods for the pilot program for
8
entities participating in the pilot program.
9
Such payment methods may include bun-
10
dled payments and bids from entities for
11
episodes of care. The Secretary shall make
12
payments to the entity for services covered
13
under this section.
14
‘‘(ii) NO
Secretary shall develop
ADDITIONAL PROGRAM EX-
15
PENDITURES.—Payments
16
tion for applicable items and services under
17
this title (including payment for services
18
described in subparagraph (B)) for appli-
19
cable beneficiaries for a year shall be es-
20
tablished in a manner that does not result
21
in spending more for such entity for such
22
beneficiaries than would otherwise be ex-
23
pended for such entity for such bene-
24
ficiaries for such year if the pilot program
under this sec-
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759
1
were not implemented, as estimated by the
2
Secretary.
3
‘‘(B) INCLUSION
OF CERTAIN SERVICES.—
4
A payment methodology tested under the pilot
5
program shall include payment for the fur-
6
nishing of applicable services and other appro-
7
priate services, such as care coordination, medi-
8
cation reconciliation, discharge planning, transi-
9
tional care services, and other patient-centered
10
activities as determined appropriate by the Sec-
11
retary.
12
13
14
‘‘(C) BUNDLED
‘‘(i) IN
PAYMENTS.—
GENERAL.—A
bundled pay-
ment under the pilot program shall—
15
‘‘(I) be comprehensive, covering
16
the costs of applicable services and
17
other appropriate services furnished to
18
an individual during an episode of
19
care (as determined by the Secretary);
20
and
21
‘‘(II) be made to the entity which
22
is participating in the pilot program.
23
‘‘(ii) REQUIREMENT
FOR PROVISION
24
OF APPLICABLE SERVICES AND OTHER AP-
25
PROPRIATE SERVICES.—Applicable
services
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760
1
and other appropriate services for which
2
payment is made under this subparagraph
3
shall be furnished or directed by the entity
4
which is participating in the pilot program.
5
‘‘(D) PAYMENT
FOR
POST-ACUTE
CARE
6
SERVICES AFTER THE EPISODE OF CARE.—The
7
Secretary shall establish procedures, in the case
8
where an applicable beneficiary requires contin-
9
ued post-acute care services after the last day
10
of the episode of care, under which payment for
11
such services shall be made.
12
‘‘(4) QUALITY
13
‘‘(A) IN
MEASURES.—
GENERAL.—The
Secretary shall
14
establish quality measures (including quality
15
measures of process, outcome, and structure)
16
related to care provided by entities participating
17
in the pilot program. Quality measures estab-
18
lished under the preceding sentence shall in-
19
clude measures of the following:
20
‘‘(i) Functional status improvement.
21
‘‘(ii) Reducing rates of avoidable hos-
22
23
24
pital readmissions.
‘‘(iii) Rates of discharge to the community.
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761
1
2
‘‘(iv) Rates of admission to an emergency room after a hospitalization.
3
4
‘‘(v) Incidence of health care acquired
infections.
5
‘‘(vi) Efficiency measures.
6
‘‘(vii)
7
of
patient-
centeredness of care.
8
9
Measures
‘‘(viii) Measures of patient perception
of care.
10
‘‘(ix) Other measures, including meas-
11
ures of patient outcomes, determined ap-
12
propriate by the Secretary.
13
‘‘(B) REPORTING
14
15
ON
QUALITY
MEAS-
URES.—
‘‘(i) IN
GENERAL.—A
entity shall sub-
16
mit data to the Secretary on quality meas-
17
ures established under subparagraph (A)
18
during each year of the pilot program (in
19
a form and manner, subject to clause (iii),
20
specified by the Secretary).
21
‘‘(ii) SUBMISSION
OF DATA THROUGH
22
ELECTRONIC
23
extent practicable, the Secretary shall
24
specify that data on measures be sub-
25
mitted under clause (i) through the use of
HEALTH
RECORD.—To
the
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762
1
an qualified electronic health record (as de-
2
fined in section 3000(13) of the Public
3
Health Service Act (42 U.S.C. 300jj–
4
11(13)) in a manner specified by the Sec-
5
retary.
6
‘‘(d) WAIVER.—The Secretary may waive such provi-
7 sions of this title and title XI as may be necessary to carry
8 out the pilot program.
9
‘‘(e) INDEPENDENT EVALUATION
AND
REPORTS
ON
10 PILOT PROGRAM.—
11
‘‘(1) INDEPENDENT
EVALUATION.—The
Sec-
12
retary shall conduct an independent evaluation of
13
the pilot program, including the extent to which the
14
pilot program has—
15
16
‘‘(A) improved quality measures established under subsection (c)(4)(A);
17
‘‘(B) improved health outcomes;
18
‘‘(C) improved applicable beneficiary access
19
20
21
22
to care; and
‘‘(D) reduced spending under this title.
‘‘(2) REPORTS.—
‘‘(A) INTERIM
REPORT.—Not
later than 2
23
years after the implementation of the pilot pro-
24
gram, the Secretary shall submit to Congress a
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1
report on the initial results of the independent
2
evaluation conducted under paragraph (1).
3
‘‘(B) FINAL
REPORT.—Not
later than 3
4
years after the implementation of the pilot pro-
5
gram, the Secretary shall submit to Congress a
6
report on the final results of the independent
7
evaluation conducted under paragraph (1).
8
‘‘(f) CONSULTATION.—The Secretary shall consult
9 with representatives of small rural hospitals, including
10 critical
access
hospitals
(as
defined
in
section
11 1861(mm)(1)), regarding their participation in the pilot
12 program. Such consultation shall include consideration of
13 innovative methods of implementing bundled payments in
14 hospitals described in the preceding sentence, taking into
15 consideration any difficulties in doing so as a result of the
16 low volume of services provided by such hospitals.
17
18
‘‘(g) IMPLEMENTATION PLAN.—
‘‘(1) IN
GENERAL.—Not
later than January 1,
19
2016, the Secretary shall submit a plan for the im-
20
plementation of an expansion of the pilot program if
21
the Secretary determines that such expansion will
22
result in improving or not reducing the quality of
23
patient care and reducing spending under this title.
24
‘‘(h) ADMINISTRATION.—Chapter 35 of title 44,
25 United States Code, shall not apply to the selection, test-
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1 ing, and evaluation of models or the expansion of such
2 models under this section.’’.
3
4
5
SEC. 3024. INDEPENDENCE AT HOME DEMONSTRATION
PROGRAM.
Title XVIII of the Social Security Act is amended by
6 inserting after section 1866D, as inserted by section 3023,
7 the following new section:
8
‘‘INDEPENDENCE
AT HOME MEDICAL PRACTICE
9
DEMONSTRATION PROGRAM
10
‘‘SEC. 1866D. (a) ESTABLISHMENT.—
11
‘‘(1) IN
GENERAL.—The
Secretary shall con-
12
duct a demonstration program (in this section re-
13
ferred to as the ‘demonstration program’) to test a
14
payment incentive and service delivery model that
15
utilizes physician and nurse practitioner directed
16
home-based primary care teams designed to reduce
17
expenditures and improve health outcomes in the
18
provision of items and services under this title to ap-
19
plicable beneficiaries (as defined in subsection (d)).
20
‘‘(2) REQUIREMENT.—The demonstration pro-
21
gram shall test whether a model described in para-
22
graph (1), which is accountable for providing com-
23
prehensive, coordinated, continuous, and accessible
24
care to high-need populations at home and coordi-
25
nating health care across all treatment settings, re-
26
sults in—
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1
‘‘(A) reducing preventable hospitalizations;
2
‘‘(B) preventing hospital readmissions;
3
‘‘(C) reducing emergency room visits;
4
‘‘(D) improving health outcomes commen-
5
surate with the beneficiaries’ stage of chronic
6
illness;
7
‘‘(E) improving the efficiency of care, such
8
as by reducing duplicative diagnostic and lab-
9
oratory tests;
10
‘‘(F) reducing the cost of health care serv-
11
ices covered under this title; and
12
‘‘(G) achieving beneficiary and family care-
13
giver satisfaction.
14
‘‘(b) INDEPENDENCE
15
16
17
18
AT
HOME MEDICAL PRAC-
‘‘(1) INDEPENDENCE
AT HOME MEDICAL PRAC-
TICE.—
TICE DEFINED.—In
‘‘(A) IN
this section:
GENERAL.—The
term ‘independ-
19
ence at home medical practice’ means a legal
20
entity that—
21
‘‘(i) is comprised of an individual phy-
22
sician or nurse practitioner or group of
23
physicians and nurse practitioners that
24
provides care as part of a team that in-
25
cludes physicians, nurses, physician assist-
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S.L.C.
766
1
ants, pharmacists, and other health and
2
social services staff as appropriate who
3
have experience providing home-based pri-
4
mary care to applicable beneficiaries, make
5
in-home visits, and are available 24 hours
6
per day, 7 days per week to carry out
7
plans of care that are tailored to the indi-
8
vidual beneficiary’s chronic conditions and
9
designed to achieve the results in sub-
10
section (a);
11
‘‘(ii) is organized at least in part for
12
the purpose of providing physicians’ serv-
13
ices;
14
‘‘(iii) has documented experience in
15
providing home-based primary care serv-
16
ices to high-cost chronically ill bene-
17
ficiaries, as determined appropriate by the
18
Secretary;
19
‘‘(iv) furnishes services to at least 200
20
applicable beneficiaries (as defined in sub-
21
section (d)) during each year of the dem-
22
onstration program;
23
24
‘‘(v) has entered into an agreement
with the Secretary;
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767
1
‘‘(vi) uses electronic health informa-
2
tion systems, remote monitoring, and mo-
3
bile diagnostic technology; and
4
‘‘(vii) meets such other criteria as the
5
Secretary determines to be appropriate to
6
participate in the demonstration program.
7
The entity shall report on quality measures (in
8
such form, manner, and frequency as specified
9
by the Secretary, which may be for the group,
10
for providers of services and suppliers, or both)
11
and report to the Secretary (in a form, manner,
12
and frequency as specified by the Secretary)
13
such data as the Secretary determines appro-
14
priate to monitor and evaluate the demonstra-
15
tion program.
16
‘‘(B) PHYSICIAN.—The term ‘physician’ in-
17
cludes, except as the Secretary may otherwise
18
provide, any individual who furnishes services
19
for which payment may be made as physicians’
20
services and has the medical training or experi-
21
ence to fulfill the physician’s role described in
22
subparagraph (A)(i).
23
‘‘(2) PARTICIPATION
OF NURSE PRACTITIONERS
24
AND PHYSICIAN ASSISTANTS.—Nothing
25
tion shall be construed to prevent a nurse practi-
in this sec-
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1
tioner or physician assistant from participating in,
2
or leading, a home-based primary care team as part
3
of an independence at home medical practice if—
4
5
‘‘(A) all the requirements of this section
are met;
6
‘‘(B) the nurse practitioner or physician
7
assistant, as the case may be, is acting con-
8
sistent with State law; and
9
‘‘(C) the nurse practitioner or physician
10
assistant has the medical training or experience
11
to fulfill the nurse practitioner or physician as-
12
sistant role described in paragraph (1)(A)(i).
13
‘‘(3) INCLUSION
OF PROVIDERS AND PRACTI-
14
TIONERS.—Nothing
15
strued as preventing an independence at home med-
16
ical practice from including a provider of services or
17
a participating practitioner described in section
18
1842(b)(18)(C) that is affiliated with the practice
19
under an arrangement structured so that such pro-
20
vider of services or practitioner participates in the
21
demonstration program and shares in any savings
22
under the demonstration program.
23
‘‘(4) QUALITY
in this subsection shall be con-
AND
PERFORMANCE
STAND-
24
ARDS.—The
25
ance standards for independence at home medical
Secretary shall develop quality perform-
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769
1
practices participating in the demonstration pro-
2
gram.
3
‘‘(c) PAYMENT METHODOLOGY.—
4
‘‘(1) ESTABLISHMENT
OF TARGET SPENDING
5
LEVEL.—The
6
annual spending target, for the amount the Sec-
7
retary estimates would have been spent in the ab-
8
sence of the demonstration, for items and services
9
covered under parts A and B furnished to applicable
10
beneficiaries for each qualifying independence at
11
home medical practice under this section. Such
12
spending targets shall be determined on a per capita
13
basis. Such spending targets shall include a risk cor-
14
ridor that takes into account normal variation in ex-
15
penditures for items and services covered under
16
parts A and B furnished to such beneficiaries with
17
the size of the corridor being related to the number
18
of applicable beneficiaries furnished services by each
19
independence at home medical practice. The spend-
20
ing targets may also be adjusted for other factors as
21
the Secretary determines appropriate.
22
Secretary shall establish an estimated
‘‘(2) INCENTIVE
PAYMENTS.—Subject
to per-
23
formance on quality measures, a qualifying inde-
24
pendence at home medical practice is eligible to re-
25
ceive an incentive payment under this section if ac-
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770
1
tual expenditures for a year for the applicable bene-
2
ficiaries it enrolls are less than the estimated spend-
3
ing target established under paragraph (1) for such
4
year. An incentive payment for such year shall be
5
equal to a portion (as determined by the Secretary)
6
of the amount by which actual expenditures (includ-
7
ing incentive payments under this paragraph) for
8
applicable beneficiaries under parts A and B for
9
such year are estimated to be less than 5 percent
10
less than the estimated spending target for such
11
year, as determined under paragraph (1).
12
‘‘(d) APPLICABLE BENEFICIARIES.—
13
‘‘(1) DEFINITION.—In this section, the term
14
‘applicable beneficiary’ means, with respect to a
15
qualifying independence at home medical practice,
16
an individual who the practice has determined—
17
18
‘‘(A) is entitled to benefits under part A
and enrolled for benefits under part B;
19
‘‘(B) is not enrolled in a Medicare Advan-
20
tage plan under part C or a PACE program
21
under section 1894;
22
‘‘(C) has 2 or more chronic illnesses, such
23
as congestive heart failure, diabetes, other de-
24
mentias designated by the Secretary, chronic
25
obstructive pulmonary disease, ischemic heart
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771
1
disease,
2
neurodegenerative diseases, and other diseases
3
and conditions designated by the Secretary
4
which result in high costs under this title;
5
6
stroke,
Alzheimer’s
Disease
and
‘‘(D) within the past 12 months has had a
nonelective hospital admission;
7
‘‘(E) within the past 12 months has re-
8
ceived acute or subacute rehabilitation services;
9
‘‘(F) has 2 or more functional depend-
10
encies requiring the assistance of another per-
11
son (such as bathing, dressing, toileting, walk-
12
ing, or feeding); and
13
‘‘(G) meets such other criteria as the Sec-
14
retary determines appropriate.
15
‘‘(2) PATIENT
ELECTION TO PARTICIPATE.—
16
The Secretary shall determine an appropriate meth-
17
od of ensuring that applicable beneficiaries have
18
agreed to enroll in an independence at home medical
19
practice under the demonstration program. Enroll-
20
ment in the demonstration program shall be vol-
21
untary.
22
‘‘(3) BENEFICIARY
ACCESS
TO
SERVICES.—
23
Nothing in this section shall be construed as encour-
24
aging physicians or nurse practitioners to limit ap-
25
plicable beneficiary access to services covered under
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772
1
this title and applicable beneficiaries shall not be re-
2
quired to relinquish access to any benefit under this
3
title as a condition of receiving services from an
4
independence at home medical practice.
5
‘‘(e) IMPLEMENTATION.—
6
‘‘(1) STARTING
DATE.—The
demonstration pro-
7
gram shall begin no later than January 1, 2012. An
8
agreement with an independence at home medical
9
practice under the demonstration program may
10
11
cover not more than a 3-year period.
‘‘(2) NO
PHYSICIAN
DUPLICATION
IN
DEM-
12
ONSTRATION PARTICIPATION.—The
13
not pay an independence at home medical practice
14
under this section that participates in section 1899.
15
‘‘(3) NO
Secretary shall
BENEFICIARY DUPLICATION IN DEM-
16
ONSTRATION PARTICIPATION.—The
17
ensure that no applicable beneficiary enrolled in an
18
independence at home medical practice under this
19
section is participating in the programs under sec-
20
tion 1899.
Secretary shall
21
‘‘(4) PREFERENCE.—In approving an independ-
22
ence at home medical practice, the Secretary shall
23
give preference to practices that are—
24
25
‘‘(A) located in high-cost areas of the
country;
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S.L.C.
773
1
‘‘(B) have experience in furnishing health
2
care services to applicable beneficiaries in the
3
home; and
4
‘‘(C) use electronic medical records, health
5
information technology, and individualized plans
6
of care.
7
‘‘(5) LIMITATION
ON NUMBER OF PRACTICES.—
8
In selecting qualified independence at home medical
9
practices to participate under the demonstration pro-
10
gram, the Secretary shall limit the number of such
11
practices so that the number of applicable bene-
12
ficiaries that may participate in the demonstration
13
program does not exceed 10,000.
14
‘‘(6) WAIVER.—The Secretary may waive such
15
provisions of this title and title XI as the Secretary
16
determines necessary in order to implement the dem-
17
onstration program.
18
‘‘(7) ADMINISTRATION.—Chapter 35 of title 44,
19
United States Code, shall not apply to this section.
20
‘‘(f) EVALUATION AND MONITORING.—
21
‘‘(1) IN
GENERAL.—The
Secretary shall evalu-
22
ate each independence at home medical practice
23
under the demonstration program to assess whether
24
the practice achieved the results described in sub-
25
section (a).
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774
1
‘‘(2)
MONITORING
APPLICABLE
BENE-
2
FICIARIES.—The
3
penditures and quality of services under this title
4
after an applicable beneficiary discontinues receiving
5
services under this title through a qualifying inde-
6
pendence at home medical practice.
7
‘‘(g) REPORTS
Secretary may monitor data on ex-
TO
CONGRESS.—The Secretary shall
8 conduct an independent evaluation of the demonstration
9 program and submit to Congress a final report, including
10 best practices under the demonstration program. Such re11 port shall include an analysis of the demonstration pro12 gram on coordination of care, expenditures under this
13 title, applicable beneficiary access to services, and the
14 quality of health care services provided to applicable bene15 ficiaries.
16
‘‘(h) FUNDING.—For purposes of administering and
17 carrying out the demonstration program, other than for
18 payments for items and services furnished under this title
19 and incentive payments under subsection (c), in addition
20 to funds otherwise appropriated, there shall be transferred
21 to the Secretary for the Center for Medicare & Medicaid
22 Services Program Management Account from the Federal
23 Hospital Insurance Trust Fund under section 1817 and
24 the Federal Supplementary Medical Insurance Trust
25 Fund under section 1841 (in proportions determined ap-
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S.L.C.
775
1 propriate by the Secretary) $5,000,000 for each of fiscal
2 years 2010 through 2015. Amounts transferred under this
3 subsection for a fiscal year shall be available until ex4 pended.
5
6
‘‘(i) TERMINATION.—
‘‘(1) MANDATORY
TERMINATION.—The
Sec-
7
retary shall terminate an agreement with an inde-
8
pendence at home medical practice if—
9
‘‘(A) the Secretary estimates or determines
10
that such practice will not receive an incentive
11
payment for the second of 2 consecutive years
12
under the demonstration program; or
13
‘‘(B) such practice fails to meet quality
14
standards during any year of the demonstration
15
program.
16
‘‘(2) PERMISSIVE
TERMINATION.—The
Sec-
17
retary may terminate an agreement with an inde-
18
pendence at home medical practice for such other
19
reasons determined appropriate by the Secretary.’’.
20
SEC. 3025. HOSPITAL READMISSIONS REDUCTION PRO-
21
22
GRAM.
(a) IN GENERAL.—Section 1886 of the Social Secu-
23 rity Act (42 U.S.C. 1395ww), as amended by sections
24 3001 and 3008, is amended by adding at the end the fol25 lowing new subsection:
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776
1
2
‘‘(q) HOSPITAL READMISSIONS REDUCTION PROGRAM.—
3
‘‘(1) IN
GENERAL.—With
respect to payment
4
for discharges from an applicable hospital (as de-
5
fined in paragraph (5)(C)) occurring during a fiscal
6
year beginning on or after October 1, 2012, in order
7
to account for excess readmissions in the hospital,
8
the Secretary shall reduce the payments that would
9
otherwise be made to such hospital under subsection
10
(d) (or section 1814(b)(3), as the case may be) for
11
such a discharge by an amount equal to the product
12
of—
13
‘‘(A) the base operating DRG payment
14
amount (as defined in paragraph (2)) for the
15
discharge; and
16
‘‘(B) the adjustment factor (described in
17
paragraph (3)(A)) for the hospital for the fiscal
18
year.
19
‘‘(2) BASE
20
21
OPERATING DRG PAYMENT AMOUNT
DEFINED.—
‘‘(A) IN
GENERAL.—Except
as provided in
22
subparagraph (B), in this subsection, the term
23
‘base operating DRG payment amount’ means,
24
with respect to a hospital for a fiscal year—
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S.L.C.
777
1
‘‘(i) the payment amount that would
2
otherwise be made under subsection (d)
3
(determined without regard to subsection
4
(o)) for a discharge if this subsection did
5
not apply; reduced by
6
‘‘(ii) any portion of such payment
7
amount that is attributable to payments
8
under paragraphs (5)(A), (5)(B), (5)(F),
9
and (12) of subsection (d).
10
11
‘‘(B) SPECIAL
RULES FOR CERTAIN HOS-
PITALS.—
12
‘‘(i) SOLE
COMMUNITY
HOSPITALS
13
AND
14
RURAL HOSPITALS.—In
15
care-dependent, small rural hospital (with
16
respect to discharges occurring during fis-
17
cal years 2012 and 2013) or a sole com-
18
munity hospital, in applying subparagraph
19
(A)(i), the payment amount that would
20
otherwise be made under subsection (d)
21
shall be determined without regard to sub-
22
paragraphs (I) and (L) of subsection
23
(b)(3) and subparagraphs (D) and (G) of
24
subsection (d)(5).
MEDICARE-DEPENDENT,
SMALL
the case of a medi-
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778
1
‘‘(ii) HOSPITALS
PAID UNDER SEC-
2
TION 1814.—In
3
is paid under section 1814(b)(3), the Sec-
4
retary may exempt such hospitals provided
5
that States paid under such section submit
6
an annual report to the Secretary describ-
7
ing how a similar program in the State for
8
a
9
achieves or surpasses the measured results
10
in terms of patient health outcomes and
11
cost savings established herein with respect
12
to this section.
the case of a hospital that
participating
13
‘‘(3) ADJUSTMENT
14
‘‘(A) IN
hospital
or
hospitals
FACTOR.—
GENERAL.—For
purposes of para-
15
graph (1), the adjustment factor under this
16
paragraph for an applicable hospital for a fiscal
17
year is equal to the greater of—
18
‘‘(i) the ratio described in subpara-
19
graph (B) for the hospital for the applica-
20
ble period (as defined in paragraph (5)(D))
21
for such fiscal year; or
22
23
‘‘(ii) the floor adjustment factor specified in subparagraph (C).
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779
1
‘‘(B) RATIO.—The ratio described in this
2
subparagraph for a hospital for an applicable
3
period is equal to 1 minus the ratio of—
4
‘‘(i) the aggregate payments for ex-
5
cess readmissions (as defined in paragraph
6
(4)(A)) with respect to an applicable hos-
7
pital for the applicable period; and
8
‘‘(ii) the aggregate payments for all
9
discharges
(as
defined
in
paragraph
10
(4)(B)) with respect to such applicable
11
hospital for such applicable period.
12
‘‘(C) FLOOR
ADJUSTMENT FACTOR.—For
13
purposes of subparagraph (A), the floor adjust-
14
ment factor specified in this subparagraph
15
for—
16
‘‘(i) fiscal year 2013 is 0.99;
17
‘‘(ii) fiscal year 2014 is 0.98; or
18
‘‘(iii) fiscal year 2015 and subsequent
19
20
fiscal years is 0.97.
‘‘(4) AGGREGATE
PAYMENTS, EXCESS READMIS-
21
SION RATIO DEFINED.—For
22
section:
23
‘‘(A) AGGREGATE
purposes of this sub-
PAYMENTS FOR EXCESS
24
READMISSIONS.—The
25
for excess readmissions’ means, for a hospital
term ‘aggregate payments
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780
1
for an applicable period, the sum, for applicable
2
conditions (as defined in paragraph (5)(A)), of
3
the product, for each applicable condition, of—
4
‘‘(i) the base operating DRG payment
5
amount for such hospital for such applica-
6
ble period for such condition;
7
‘‘(ii) the number of admissions for
8
such condition for such hospital for such
9
applicable period; and
10
‘‘(iii) the excess readmissions ratio (as
11
defined in subparagraph (C)) for such hos-
12
pital for such applicable period minus 1.
13
‘‘(B) AGGREGATE
PAYMENTS FOR ALL DIS-
14
CHARGES.—The
15
all discharges’ means, for a hospital for an ap-
16
plicable period, the sum of the base operating
17
DRG payment amounts for all discharges for
18
all conditions from such hospital for such appli-
19
cable period.
20
21
term ‘aggregate payments for
‘‘(C) EXCESS
‘‘(i) IN
READMISSION RATIO.—
GENERAL.—Subject
to clause
22
(ii), the term ‘excess readmissions ratio’
23
means, with respect to an applicable condi-
24
tion for a hospital for an applicable period,
25
the ratio (but not less than 1.0) of—
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781
1
‘‘(I) the risk adjusted readmis-
2
sions based on actual readmissions, as
3
determined consistent with a readmis-
4
sion measure methodology that has
5
been
6
(5)(A)(ii)(I), for an applicable hospital
7
for such condition with respect to
8
such applicable period; to
9
endorsed
under
paragraph
‘‘(II) the risk adjusted expected
10
readmissions
11
sistent with such a methodology) for
12
such hospital for such condition with
13
respect to such applicable period.
14
‘‘(ii) EXCLUSION
(as
determined
OF
CERTAIN
con-
RE-
15
ADMISSIONS.—For
16
with respect to a hospital, excess readmis-
17
sions shall not include readmissions for an
18
applicable condition for which there are
19
fewer than a minimum number (as deter-
20
mined by the Secretary) of discharges for
21
such applicable condition for the applicable
22
period and such hospital.
23
24
purposes of clause (i),
‘‘(5) DEFINITIONS.—For purposes of this subsection:
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782
1
‘‘(A) APPLICABLE
CONDITION.—The
term
2
‘applicable condition’ means, subject to sub-
3
paragraph (B), a condition or procedure se-
4
lected by the Secretary among conditions and
5
procedures for which—
6
‘‘(i) readmissions (as defined in sub-
7
paragraph (E)) that represent conditions
8
or procedures that are high volume or high
9
expenditures under this title (or other cri-
10
teria specified by the Secretary); and
11
‘‘(ii) measures of such readmissions—
12
‘‘(I) have been endorsed by the
13
entity with a contract under section
14
1890(a); and
15
‘‘(II) such endorsed measures
16
have exclusions for readmissions that
17
are unrelated to the prior discharge
18
(such as a planned readmission or
19
transfer to another applicable hos-
20
pital).
21
‘‘(B) EXPANSION
OF APPLICABLE CONDI-
22
TIONS.—Beginning
23
Secretary shall, to the extent practicable, ex-
24
pand the applicable conditions beyond the 3
25
conditions for which measures have been en-
with fiscal year 2015, the
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S.L.C.
783
1
dorsed as described in subparagraph (A)(ii)(I)
2
as of the date of the enactment of this sub-
3
section to the additional 4 conditions that have
4
been identified by the Medicare Payment Advi-
5
sory Commission in its report to Congress in
6
June 2007 and to other conditions and proce-
7
dures as determined appropriate by the Sec-
8
retary. In expanding such applicable conditions,
9
the Secretary shall seek the endorsement de-
10
scribed in subparagraph (A)(ii)(I) but may
11
apply such measures without such an endorse-
12
ment in the case of a specified area or medical
13
topic determined appropriate by the Secretary
14
for which a feasible and practical measure has
15
not been endorsed by the entity with a contract
16
under section 1890(a) as long as due consider-
17
ation is given to measures that have been en-
18
dorsed or adopted by a consensus organization
19
identified by the Secretary.
20
‘‘(C) APPLICABLE
HOSPITAL.—The
term
21
‘applicable hospital’ means a subsection (d) hos-
22
pital or a hospital that is paid under section
23
1814(b)(3), as the case may be.
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784
1
‘‘(D) APPLICABLE
PERIOD.—The
term ‘ap-
2
plicable period’ means, with respect to a fiscal
3
year, such period as the Secretary shall specify.
4
‘‘(E) READMISSION.—The term ‘readmis-
5
sion’ means, in the case of an individual who is
6
discharged from an applicable hospital, the ad-
7
mission of the individual to the same or another
8
applicable hospital within a time period speci-
9
fied by the Secretary from the date of such dis-
10
charge. Insofar as the discharge relates to an
11
applicable condition for which there is an en-
12
dorsed measure described in subparagraph
13
(A)(ii)(I), such time period (such as 30 days)
14
shall be consistent with the time period speci-
15
fied for such measure.
16
‘‘(6) REPORTING
17
18
HOSPITAL SPECIFIC INFORMA-
TION.—
‘‘(A) IN
GENERAL.—The
Secretary shall
19
make information available to the public re-
20
garding readmission rates of each subsection
21
(d) hospital under the program.
22
‘‘(B) OPPORTUNITY
TO REVIEW AND SUB-
23
MIT CORRECTIONS.—The
Secretary shall ensure
24
that a subsection (d) hospital has the oppor-
25
tunity to review, and submit corrections for, the
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785
1
information to be made public with respect to
2
the hospital under subparagraph (A) prior to
3
such information being made public.
4
‘‘(C) WEBSITE.—Such information shall be
5
posted on the Hospital Compare Internet
6
website in an easily understandable format.
7
‘‘(7) LIMITATIONS
ON REVIEW.—There
shall be
8
no administrative or judicial review under section
9
1869, section 1878, or otherwise of the following:
10
11
‘‘(A) The determination of base operating
DRG payment amounts.
12
‘‘(B) The methodology for determining the
13
adjustment factor under paragraph (3), includ-
14
ing excess readmissions ratio under paragraph
15
(4)(C), aggregate payments for excess readmis-
16
sions under paragraph (4)(A), and aggregate
17
payments for all discharges under paragraph
18
(4)(B), and applicable periods and applicable
19
conditions under paragraph (5).
20
‘‘(C) The measures of readmissions as de-
21
scribed in paragraph (5)(A)(ii).
22
‘‘(8)
23
24
25
READMISSION
RATES
FOR
ALL
PA-
TIENTS.—
‘‘(A) CALCULATION
OF
READMISSION.—
The Secretary shall calculate readmission rates
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S.L.C.
786
1
for all patients (as defined in subparagraph
2
(D)) for a specified hospital (as defined in sub-
3
paragraph (D)(ii)) for an applicable condition
4
(as defined in paragraph (5)(B)) and other con-
5
ditions deemed appropriate by the Secretary for
6
an applicable period (as defined in paragraph
7
(5)(D)) in the same manner as used to cal-
8
culate such readmission rates for hospitals with
9
respect to this title and posted on the CMS
10
11
Hospital Compare website.
‘‘(B) POSTING
OF HOSPITAL SPECIFIC ALL
12
PATIENT READMISSION RATES.—The
13
shall make information on all patient readmis-
14
sion rates calculated under subparagraph (A)
15
available on the CMS Hospital Compare website
16
in a form and manner determined appropriate
17
by the Secretary. The Secretary may also make
18
other information determined appropriate by
19
the Secretary available on such website.
20
21
‘‘(C) HOSPITAL
Secretary
SUBMISSION OF ALL PA-
TIENT DATA.—
22
‘‘(i) Except as provided for in clause
23
(ii), each specified hospital (as defined in
24
subparagraph (D)(ii)) shall submit to the
25
Secretary, in a form, manner and time
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S.L.C.
787
1
specified by the Secretary, data and infor-
2
mation determined necessary by the Sec-
3
retary for the Secretary to calculate the all
4
patient readmission rates described in sub-
5
paragraph (A).
6
‘‘(ii) Instead of a specified hospital
7
submitting to the Secretary the data and
8
information described in clause (i), such
9
data and information may be submitted to
10
the Secretary, on behalf of such a specified
11
hospital, by a state or an entity determined
12
appropriate by the Secretary.
13
‘‘(D) DEFINITIONS.—For purposes of this
14
paragraph:
15
‘‘(i) The term ‘all patients’ means pa-
16
tients who are treated on an inpatient
17
basis and discharged from a specified hos-
18
pital (as defined in clause (ii)).
19
‘‘(ii) The term ‘specified hospital’
20
means a subsection (d) hospital, hospitals
21
described in clauses (i) through (v) of sub-
22
section (d)(1)(B) and, as determined fea-
23
sible and appropriate by the Secretary,
24
other hospitals not otherwise described in
25
this subparagraph.’’.
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1
(b) QUALITY IMPROVEMENT.—Part S of title III of
2 the Public Health Service Act, as amended by section
3 3015, is further amended by adding at the end the fol4 lowing:
5
‘‘SEC. 399KK. QUALITY IMPROVEMENT PROGRAM FOR HOS-
6
PITALS WITH A HIGH SEVERITY ADJUSTED
7
READMISSION RATE.
8
9
‘‘(a) ESTABLISHMENT.—
‘‘(1) IN
GENERAL.—Not
later than 2 years
10
after the date of enactment of this section, the Sec-
11
retary shall make available a program for eligible
12
hospitals to improve their readmission rates through
13
the use of patient safety organizations (as defined in
14
section 921(4)).
15
‘‘(2) ELIGIBLE
HOSPITAL DEFINED.—In
this
16
subsection, the term ‘eligible hospital’ means a hos-
17
pital that the Secretary determines has a high rate
18
of risk adjusted readmissions for the conditions de-
19
scribed in section 1886(q)(8)(A) of the Social Secu-
20
rity Act and has not taken appropriate steps to re-
21
duce such readmissions and improve patient safety
22
as evidenced through historically high rates of re-
23
admissions, as determined by the Secretary.
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789
1
‘‘(3) RISK
ADJUSTMENT.—The
Secretary shall
2
utilize appropriate risk adjustment measures to de-
3
termine eligible hospitals.
4
‘‘(b) REPORT
TO THE
SECRETARY.—As determined
5 appropriate by the Secretary, eligible hospitals and patient
6 safety organizations working with those hospitals shall re7 port to the Secretary on the processes employed by the
8 hospital to improve readmission rates and the impact of
9 such processes on readmission rates.’’.
10
11
12
SEC. 3026. COMMUNITY-BASED CARE TRANSITIONS PROGRAM.
(a) IN GENERAL.—The Secretary shall establish a
13 Community-Based Care Transitions Program under which
14 the Secretary provides funding to eligible entities that fur15 nish improved care transition services to high-risk Medi16 care beneficiaries.
17
(b) DEFINITIONS.—In this section:
18
(1) ELIGIBLE
19
ty’’ means the following:
ENTITY.—The
term ‘‘eligible enti-
20
(A) A subsection (d) hospital (as defined in
21
section 1886(d)(1)(B) of the Social Security
22
Act (42 U.S.C. 1395ww(d)(1)(B))) identified by
23
the Secretary as having a high readmission
24
rate, such as under section 1886(q) of the So-
25
cial Security Act, as added by section 3025.
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S.L.C.
790
1
(B) An appropriate community-based orga-
2
nization that provides care transition services
3
under this section across a continuum of care
4
through arrangements with subsection (d) hos-
5
pitals (as so defined) to furnish the services de-
6
scribed in subsection (c)(2)(B)(i) and whose
7
governing body includes sufficient representa-
8
tion of multiple health care stakeholders (in-
9
cluding consumers).
10
(2) HIGH-RISK
MEDICARE BENEFICIARY.—The
11
term ‘‘high-risk Medicare beneficiary’’ means a
12
Medicare beneficiary who has attained a minimum
13
hierarchical condition category score, as determined
14
by the Secretary, based on a diagnosis of multiple
15
chronic conditions or other risk factors associated
16
with a hospital readmission or substandard transi-
17
tion into post-hospitalization care, which may in-
18
clude 1 or more of the following:
19
(A) Cognitive impairment.
20
(B) Depression.
21
(C) A history of multiple readmissions.
22
(D) Any other chronic disease or risk fac-
23
tor as determined by the Secretary.
24
(3)
25
MEDICARE
BENEFICIARY.—The
term
‘‘Medicare beneficiary’’ means an individual who is
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S.L.C.
791
1
entitled to benefits under part A of title XVIII of
2
the Social Security Act (42 U.S.C. 1395 et seq.) and
3
enrolled under part B of such title, but not enrolled
4
under part C of such title.
5
6
(4) PROGRAM.—The term ‘‘program’’ means
the program conducted under this section.
7
(5) READMISSION.—The term ‘‘readmission’’
8
has the meaning given such term in section
9
1886(q)(5)(E) of the Social Security Act, as added
10
11
by section 3025.
(6) SECRETARY.—The term ‘‘Secretary’’ means
12
the Secretary of Health and Human Services.
13
(c) REQUIREMENTS.—
14
(1) DURATION.—
15
(A) IN
GENERAL.—The
program shall be
16
conducted for a 5-year period, beginning Janu-
17
ary 1, 2011.
18
(B) EXPANSION.—The Secretary may ex-
19
pand the duration and the scope of the pro-
20
gram, to the extent determined appropriate by
21
the Secretary, if the Secretary determines (and
22
the Chief Actuary of the Centers for Medicare
23
& Medicaid Services, with respect to spending
24
under this title, certifies) that such expansion
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S.L.C.
792
1
would reduce spending under this title without
2
reducing quality.
3
(2) APPLICATION;
4
(A) IN
PARTICIPATION.—
GENERAL.—
5
(i) APPLICATION.—An eligible entity
6
seeking to participate in the program shall
7
submit an application to the Secretary at
8
such time, in such manner, and containing
9
such information as the Secretary may re-
10
quire.
11
(ii) PARTNERSHIP.—If an eligible en-
12
tity is a hospital, such hospital shall enter
13
into a partnership with a community-based
14
organization to participate in the program.
15
(B) INTERVENTION
PROPOSAL.—Subject
16
to subparagraph (C), an application submitted
17
under subparagraph (A)(i) shall include a de-
18
tailed proposal for at least 1 care transition
19
intervention, which may include the following:
20
(i) Initiating care transition services
21
for a high-risk Medicare beneficiary not
22
later than 24 hours prior to the discharge
23
of the beneficiary from the eligible entity.
24
(ii) Arranging timely post-discharge
25
follow-up services to the high-risk Medicare
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S.L.C.
793
1
beneficiary to provide the beneficiary (and,
2
as appropriate, the primary caregiver of
3
the beneficiary) with information regarding
4
responding to symptoms that may indicate
5
additional health problems or a deterio-
6
rating condition.
7
(iii) Providing the high-risk Medicare
8
beneficiary (and, as appropriate, the pri-
9
mary caregiver of the beneficiary) with as-
10
sistance to ensure productive and timely
11
interactions between patients and post-
12
acute and outpatient providers.
13
(iv) Assessing and actively engaging
14
with a high-risk Medicare beneficiary (and,
15
as appropriate, the primary caregiver of
16
the beneficiary) through the provision of
17
self-management support and relevant in-
18
formation that is specific to the bene-
19
ficiary’s condition.
20
(v) Conducting comprehensive medica-
21
tion review and management (including, if
22
appropriate, counseling and self-manage-
23
ment support).
24
(C) LIMITATION.—A care transition inter-
25
vention proposed under subparagraph (B) may
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S.L.C.
794
1
not include payment for services required under
2
the discharge planning process described in sec-
3
tion 1861(ee) of the Social Security Act (42
4
U.S.C. 1395x(ee)).
5
(3) SELECTION.—In selecting eligible entities to
6
participate in the program, the Secretary shall give
7
priority to eligible entities that—
8
(A) participate in a program administered
9
by the Administration on Aging to provide con-
10
current care transitions interventions with mul-
11
tiple hospitals and practitioners; or
12
(B) provide services to medically under-
13
served populations, small communities, and
14
rural areas.
15
(d) IMPLEMENTATION.—Notwithstanding any other
16 provision of law, the Secretary may implement the provi17 sions of this section by program instruction or otherwise.
18
(e) WAIVER AUTHORITY.—The Secretary may waive
19 such requirements of titles XI and XVIII of the Social
20 Security Act as may be necessary to carry out the pro21 gram.
22
(f) FUNDING.—For purposes of carrying out this sec-
23 tion, the Secretary of Health and Human Services shall
24 provide for the transfer, from the Federal Hospital Insur25 ance Trust Fund under section 1817 of the Social Secu-
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S.L.C.
795
1 rity Act (42 U.S.C. 1395i) and the Federal Supple2 mentary Medical Insurance Trust Fund under section
3 1841 of such Act (42 U.S.C. 1395t), in such proportion
4 as the Secretary determines appropriate, of $500,000,000,
5 to the Centers for Medicare & Medicaid Services Program
6 Management Account for the period of fiscal years 2011
7 through 2015. Amounts transferred under the preceding
8 sentence shall remain available until expended.
9
SEC. 3027. EXTENSION OF GAINSHARING DEMONSTRATION.
10
(a) IN GENERAL.—Subsection (d)(3) of section 5007
11 of the Deficit Reduction Act of 2005 (Public Law 109–
12 171) is amended by inserting ‘‘(or September 30, 2011,
13 in the case of a demonstration project in operation as of
14 October 1, 2008)’’ after ‘‘December 31, 2009’’.
15
(b) FUNDING.—
16
(1) IN
GENERAL.—Subsection
(f)(1) of such
17
section is amended by inserting ‘‘and for fiscal year
18
2010, $1,600,000,’’ after ‘‘$6,000,000,’’.
19
(2) AVAILABILITY.—Subsection (f)(2) of such
20
section is amended by striking ‘‘2010’’ and inserting
21
‘‘2014 or until expended’’.
22
(c) REPORTS.—
23
24
(1) QUALITY
IMPROVEMENT AND SAVINGS.—
Subsection (e)(3) of such section is amended by
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S.L.C.
796
1
striking ‘‘December 1, 2008’’ and inserting ‘‘March
2
31, 2011’’.
3
(2) FINAL
REPORT.—Subsection
(e)(4) of such
4
section is amended by striking ‘‘May 1, 2010’’ and
5
inserting ‘‘March 31, 2013’’.
7
Subtitle B—Improving Medicare
for Patients and Providers
8
PART I—ENSURING BENEFICIARY ACCESS TO
9
PHYSICIAN CARE AND OTHER SERVICES
6
10
SEC. 3101. INCREASE IN THE PHYSICIAN PAYMENT UPDATE.
11
Section 1848(d) of the Social Security Act (42 U.S.C.
12 1395w–4(d)) is amended by adding at the end the fol13 lowing new paragraph:
14
15
‘‘(10) UPDATE
‘‘(A) IN
FOR 2010.—
GENERAL.—Subject
to paragraphs
16
(7)(B), (8)(B), and (9)(B), in lieu of the update
17
to the single conversion factor established in
18
paragraph (1)(C) that would otherwise apply
19
for 2010, the update to the single conversion
20
factor shall be 0.5 percent.
21
‘‘(B) NO
EFFECT ON COMPUTATION OF
22
CONVERSION FACTOR FOR 2011 AND SUBSE-
23
QUENT YEARS.—The
24
this subsection shall be computed under para-
conversion factor under
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
797
1
graph (1)(A) for 2011 and subsequent years as
2
if subparagraph (A) had never applied.’’.
3
SEC. 3102. EXTENSION OF THE WORK GEOGRAPHIC INDEX
4
FLOOR AND REVISIONS TO THE PRACTICE
5
EXPENSE GEOGRAPHIC ADJUSTMENT UNDER
6
THE MEDICARE PHYSICIAN FEE SCHEDULE.
7
(a) EXTENSION
OF
WORK GPCI FLOOR.—Section
8 1848(e)(1)(E) of the Social Security Act (42 U.S.C.
9 1395w–4(e)(1)(E)) is amended by striking ‘‘before Janu10 ary 1, 2010’’ and inserting ‘‘before January 1, 2011’’.
11
12
(b) PRACTICE EXPENSE GEOGRAPHIC ADJUSTMENT
FOR
2010
AND
SUBSEQUENT YEARS.—Section 1848(e)(1)
13 of the Social Security Act (42 U.S.C. 1395w4(e)(1)) is
14 amended—
15
16
17
18
19
(1) in subparagraph (A), by striking ‘‘and (G)’’
and inserting ‘‘(G), and (H)’’; and
(2) by adding at the end the following new subparagraph:
‘‘(H) PRACTICE
20
ADJUSTMENT
21
YEARS.—
22
FOR
‘‘(i) FOR
EXPENSE
2010
AND
2010.—Subject
GEOGRAPHIC
SUBSEQUENT
to clause (iii),
23
for services furnished during 2010, the em-
24
ployee wage and rent portions of the prac-
25
tice expense geographic index described in
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
798
1
subparagraph (A)(i) shall reflect 3⁄4 of the
2
difference between the relative costs of em-
3
ployee wages and rents in each of the dif-
4
ferent fee schedule areas and the national
5
average of such employee wages and rents.
6
‘‘(ii) FOR
2011.—Subject
to clause
7
(iii), for services furnished during 2011,
8
the employee wage and rent portions of the
9
practice expense geographic index de-
10
scribed in subparagraph (A)(i) shall reflect
11
12
12
costs of employee wages and rents in each
13
of the different fee schedule areas and the
14
national average of such employee wages
15
and rents.
16
⁄ of the difference between the relative
‘‘(iii) HOLD
HARMLESS.—The
practice
17
expense portion of the geographic adjust-
18
ment factor applied in a fee schedule area
19
for services furnished in 2010 or 2011
20
shall not, as a result of the application of
21
clause (i) or (ii), be reduced below the
22
practice expense portion of the geographic
23
adjustment factor under subparagraph
24
(A)(i) (as calculated prior to the applica-
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
799
1
tion of such clause (i) or (ii), respectively)
2
for such area for such year.
3
‘‘(iv) ANALYSIS.—The Secretary shall
4
analyze current methods of establishing
5
practice expense geographic adjustments
6
under subparagraph (A)(i) and evaluate
7
data that fairly and reliably establishes
8
distinctions in the costs of operating a
9
medical practice in the different fee sched-
10
ule areas. Such analysis shall include an
11
evaluation of the following:
12
‘‘(I) The feasibility of using ac-
13
tual data or reliable survey data devel-
14
oped by medical organizations on the
15
costs of operating a medical practice,
16
including office rents and non-physi-
17
cian staff wages, in different fee
18
schedule areas.
19
‘‘(II) The office expense portion
20
of the practice expense geographic ad-
21
justment described in subparagraph
22
(A)(i), including the extent to which
23
types of office expenses are deter-
24
mined in local markets instead of na-
25
tional markets.
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S.L.C.
800
1
‘‘(III) The weights assigned to
2
each of the categories within the prac-
3
tice expense geographic adjustment
4
described in subparagraph (A)(i).
5
‘‘(v) REVISION
FOR 2012 AND SUBSE-
6
QUENT YEARS.—As
a result of the analysis
7
described in clause (iv), the Secretary
8
shall, not later than January 1, 2012,
9
make appropriate adjustments to the prac-
10
tice expense geographic adjustment de-
11
scribed in subparagraph (A)(i) to ensure
12
accurate geographic adjustments across fee
13
schedule areas, including—
14
‘‘(I) basing the office rents com-
15
ponent and its weight on office ex-
16
penses that vary among fee schedule
17
areas; and
18
‘‘(II) considering a representative
19
range of professional and non-profes-
20
sional personnel employed in a med-
21
ical office based on the use of the
22
American Community Survey data or
23
other reliable data for wage adjust-
24
ments.
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S.L.C.
801
1
Such adjustments shall be made without
2
regard to adjustments made pursuant to
3
clauses (i) and (ii) and shall be made in a
4
budget neutral manner.’’.
5
6
7
SEC. 3103. EXTENSION OF EXCEPTIONS PROCESS FOR
MEDICARE THERAPY CAPS.
Section 1833(g)(5) of the Social Security Act (42
8 U.S.C. 1395l(g)(5)) is amended by striking ‘‘December
9 31, 2009’’ and inserting ‘‘December 31, 2010’’.
10
SEC. 3104. EXTENSION OF PAYMENT FOR TECHNICAL COM-
11
PONENT OF CERTAIN PHYSICIAN PATHOL-
12
OGY SERVICES.
13
Section 542(c) of the Medicare, Medicaid, and
14 SCHIP Benefits Improvement and Protection Act of 2000
15 (as enacted into law by section 1(a)(6) of Public Law 106–
16 554), as amended by section 732 of the Medicare Prescrip17 tion Drug, Improvement, and Modernization Act of 2003
18 (42 U.S.C. 1395w–4 note), section 104 of division B of
19 the Tax Relief and Health Care Act of 2006 (42 U.S.C.
20 1395w–4 note), section 104 of the Medicare, Medicaid,
21 and SCHIP Extension Act of 2007 (Public Law 110–
22 173), and section 136 of the Medicare Improvements for
23 Patients and Providers Act of 2008 (Public Law 110–
24 275), is amended by striking ‘‘and 2009’’ and inserting
25 ‘‘2009, and 2010’’.
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
802
1
2
SEC. 3105. EXTENSION OF AMBULANCE ADD-ONS.
(a) GROUND AMBULANCE.—Section 1834(l)(13)(A)
3 of the Social Security Act (42 U.S.C. 1395m(l)(13)(A))
4 is amended—
5
(1) in the matter preceding clause (i)—
6
(A) by striking ‘‘2007, and for’’ and in-
7
serting ‘‘2007, for’’; and
8
(B) by striking ‘‘2010’’ and inserting
9
‘‘2010, and for such services furnished on or
10
after April 1, 2010, and before January 1,
11
2011,’’; and
12
(2) in each of clauses (i) and (ii), by inserting
13
‘‘, and on or after April 1, 2010, and before January
14
1, 2011’’ after ‘‘January 1, 2010’’ each place it ap-
15
pears.
16
(b) AIR AMBULANCE.—Section 146(b)(1) of the
17 Medicare Improvements for Patients and Providers Act of
18 2008 (Public Law 110–275) is amended by striking ‘‘De19 cember 31, 2009’’ and inserting ‘‘December 31, 2009, and
20 during the period beginning on April 1, 2010, and ending
21 on January 1, 2011’’.
22
(c)
SUPER
RURAL
AMBULANCE.—Section
23 1834(l)(12)(A) of the Social Security Act (42 U.S.C.
24 1395m(l)(12)(A)) is amended by striking ‘‘2010’’ and in25 serting ‘‘2010, and on or after April 1, 2010, and before
26 January 1, 2011’’.
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803
1
SEC. 3106. EXTENSION OF CERTAIN PAYMENT RULES FOR
2
LONG-TERM CARE HOSPITAL SERVICES AND
3
OF MORATORIUM ON THE ESTABLISHMENT
4
OF CERTAIN HOSPITALS AND FACILITIES.
5
(a) EXTENSION
OF
CERTAIN PAYMENT RULES.—
6 Section 114(c) of the Medicare, Medicaid, and SCHIP Ex7 tension Act of 2007 (42 U.S.C. 1395ww note), as amend8 ed by section 4302(a) of the American Recovery and Rein9 vestment Act (Public Law 111–5), is further amended by
10 striking ‘‘3-year period’’ each place it appears and insert11 ing ‘‘4-year period’’.
12
(b)
EXTENSION
OF
MORATORIUM.—Section
13 114(d)(1) of such Act (42 U.S.C. 1395ww note), in the
14 matter preceding subparagraph (A), is amended by strik15 ing ‘‘3-year period’’ and inserting ‘‘4-year period’’.
16
SEC. 3107. EXTENSION OF PHYSICIAN FEE SCHEDULE MEN-
17
18
TAL HEALTH ADD-ON.
Section 138(a)(1) of the Medicare Improvements for
19 Patients and Providers Act of 2008 (Public Law 110–275)
20 is amended by striking ‘‘December 31, 2009’’ and insert21 ing ‘‘December 31, 2010’’.
22
SEC. 3108. PERMITTING PHYSICIAN ASSISTANTS TO ORDER
23
24
POST-HOSPITAL EXTENDED CARE SERVICES.
(a) ORDERING POST-HOSPITAL EXTENDED CARE
25 SERVICES.—
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S.L.C.
804
1
(1) IN
GENERAL.—Section
1814(a)(2) of the
2
Social Security Act (42 U.S.C. 1395f(a)(2)), in the
3
matter preceding subparagraph (A), is amended by
4
striking ‘‘or clinical nurse specialist’’ and inserting
5
‘‘, a clinical nurse specialist, or a physician assistant
6
(as those terms are defined in section 1861(aa)(5))’’
7
after ‘‘nurse practitioner’’.
8
(2)
CONFORMING
AMENDMENT.—Section
9
1814(a) of the Social Security Act (42 U.S.C.
10
1395f(a)) is amended, in the second sentence, by
11
striking ‘‘or clinical nurse specialist’’ and inserting
12
‘‘clinical nurse specialist, or physician assistant’’
13
after ‘‘nurse practitioner,’’.
14
(b) EFFECTIVE DATE.—The amendments made by
15 this section shall apply to items and services furnished on
16 or after January 1, 2011.
17
18
19
SEC. 3109. EXEMPTION OF CERTAIN PHARMACIES FROM
ACCREDITATION REQUIREMENTS.
(a) IN GENERAL.—Section 1834(a)(20) of the Social
20 Security Act (42 U.S.C. 1395m(a)(20)), as added by sec21 tion 154(b)(1)(A) of the Medicare Improvements for Pa22 tients and Providers Act of 2008 (Public Law 100–275),
23 is amended—
24
(1) in subparagraph (F)(i)—
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
805
1
2
(A) by inserting ‘‘and subparagraph (G)’’
after ‘‘clause (ii)’’; and
3
(B) by inserting ‘‘, except that the Sec-
4
retary shall not require a pharmacy to have
5
submitted to the Secretary such evidence of ac-
6
creditation prior to January 1, 2011’’ before
7
the semicolon at the end; and
8
(2) by adding at the end the following new sub-
9
10
11
12
paragraph:
‘‘(G) APPLICATION
OF ACCREDITATION RE-
QUIREMENT TO CERTAIN PHARMACIES.—
‘‘(i) IN
GENERAL.—With
respect to
13
items and services furnished on or after
14
January 1, 2011, in implementing quality
15
standards under this paragraph—
16
‘‘(I) subject to subclause (II), in
17
applying such standards and the ac-
18
creditation requirement of subpara-
19
graph (F)(i) with respect to phar-
20
macies described in clause (ii) fur-
21
nishing such items and services, such
22
standards and accreditation require-
23
ment shall not apply to such phar-
24
macies; and
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
806
1
‘‘(II) the Secretary may apply to
2
such pharmacies an alternative ac-
3
creditation requirement established by
4
the Secretary if the Secretary deter-
5
mines such alternative accreditation
6
requirement is more appropriate for
7
such pharmacies.
8
‘‘(ii)
PHARMACIES
DESCRIBED.—A
9
pharmacy described in this clause is a
10
pharmacy that meets each of the following
11
criteria:
12
‘‘(I) The total billings by the
13
pharmacy for such items and services
14
under this title are less than 5 percent
15
of total pharmacy sales, as determined
16
based on the average total pharmacy
17
sales for the previous 3 calendar
18
years, 3 fiscal years, or other yearly
19
period specified by the Secretary.
20
‘‘(II) The pharmacy has been en-
21
rolled under section 1866(j) as a sup-
22
plier of durable medical equipment,
23
prosthetics, orthotics, and supplies,
24
has been issued (which may include
25
the renewal of) a provider number for
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S.L.C.
807
1
at least 5 years, and for which a final
2
adverse action (as defined in section
3
424.57(a) of title 42, Code of Federal
4
Regulations) has not been imposed in
5
the past 5 years.
6
‘‘(III) The pharmacy submits to
7
the Secretary an attestation, in a
8
form and manner, and at a time,
9
specified by the Secretary, that the
10
pharmacy meets the criteria described
11
in subclauses (I) and (II). Such attes-
12
tation shall be subject to section 1001
13
of title 18, United States Code.
14
‘‘(IV) The pharmacy agrees to
15
submit materials as requested by the
16
Secretary, or during the course of an
17
audit conducted on a random sample
18
of pharmacies selected annually, to
19
verify that the pharmacy meets the
20
criteria described in subclauses (I)
21
and (II). Materials submitted under
22
the preceding sentence shall include a
23
certification by an accountant on be-
24
half of the pharmacy or the submis-
25
sion of tax returns filed by the phar-
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
808
1
macy during the relevant periods, as
2
requested by the Secretary.’’.
3
(b) ADMINISTRATION.—Notwithstanding any other
4 provision of law, the Secretary may implement the amend5 ments made by subsection (a) by program instruction or
6 otherwise.
7
(c) RULE
OF
CONSTRUCTION.—Nothing in the provi-
8 sions of or amendments made by this section shall be con9 strued as affecting the application of an accreditation re10 quirement for pharmacies to qualify for bidding in a com11 petitive acquisition area under section 1847 of the Social
12 Security Act (42 U.S.C. 1395w–3).
13
SEC. 3110. PART B SPECIAL ENROLLMENT PERIOD FOR DIS-
14
ABLED TRICARE BENEFICIARIES.
15
16
(a) IN GENERAL.—
(1) IN
GENERAL.—Section
1837 of the Social
17
Security Act (42 U.S.C. 1395p) is amended by add-
18
ing at the end the following new subsection:
19
‘‘(l)(1) In the case of any individual who is a covered
20 beneficiary (as defined in section 1072(5) of title 10,
21 United States Code) at the time the individual is entitled
22 to part A under section 226(b) or section 226A and who
23 is eligible to enroll but who has elected not to enroll (or
24 to be deemed enrolled) during the individual’s initial en-
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S.L.C.
809
1 rollment period, there shall be a special enrollment period
2 described in paragraph (2).
3
‘‘(2) The special enrollment period described in this
4 paragraph, with respect to an individual, is the 12-month
5 period beginning on the day after the last day of the initial
6 enrollment period of the individual or, if later, the 127 month period beginning with the month the individual is
8 notified of enrollment under this section.
9
‘‘(3) In the case of an individual who enrolls during
10 the special enrollment period provided under paragraph
11 (1), the coverage period under this part shall begin on the
12 first day of the month in which the individual enrolls, or,
13 at the option of the individual, the first month after the
14 end of the individual’s initial enrollment period.
15
‘‘(4) An individual may only enroll during the special
16 enrollment period provided under paragraph (1) one time
17 during the individual’s lifetime.
18
‘‘(5) The Secretary shall ensure that the materials
19 relating to coverage under this part that are provided to
20 an individual described in paragraph (1) prior to the indi21 vidual’s initial enrollment period contain information con22 cerning the impact of not enrolling under this part, includ23 ing the impact on health care benefits under the
24 TRICARE program under chapter 55 of title 10, United
25 States Code.
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810
1
‘‘(6) The Secretary of Defense shall collaborate with
2 the Secretary of Health and Human Services and the
3 Commissioner of Social Security to provide for the accu4 rate identification of individuals described in paragraph
5 (1). The Secretary of Defense shall provide such individ6 uals with notification with respect to this subsection. The
7 Secretary of Defense shall collaborate with the Secretary
8 of Health and Human Services and the Commissioner of
9 Social Security to ensure appropriate follow up pursuant
10 to any notification provided under the preceding sen11 tence.’’.
12
(2) EFFECTIVE
DATE.—The
amendment made
13
by paragraph (1) shall apply to elections made with
14
respect to initial enrollment periods that end after
15
the date of the enactment of this Act.
16
(b) WAIVER
OF
INCREASE
OF
PREMIUM.—Section
17 1839(b) of the Social Security Act (42 U.S.C. 1395r(b))
18 is amended by striking ‘‘section 1837(i)(4)’’ and inserting
19 ‘‘subsection (i)(4) or (l) of section 1837’’.
20
SEC. 3111. PAYMENT FOR BONE DENSITY TESTS.
21
(a) PAYMENT.—
22
(1) IN
23
24
GENERAL.—Section
1848 of the Social
Security Act (42 U.S.C. 1395w–4) is amended—
(A) in subsection (b)—
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1
(i) in paragraph (4)(B), by inserting
2
‘‘, and for 2010 and 2011, dual-energy x-
3
ray absorptiometry services (as described
4
in paragraph (6))’’ before the period at the
5
end; and
6
7
8
(ii) by adding at the end the following
new paragraph:
‘‘(6) TREATMENT
OF BONE MASS SCANS.—For
9
dual-energy x-ray absorptiometry services (identified
10
in 2006 by HCPCS codes 76075 and 76077 (and
11
any succeeding codes)) furnished during 2010 and
12
2011, instead of the payment amount that would
13
otherwise be determined under this section for such
14
years, the payment amount shall be equal to 70 per-
15
cent of the product of—
16
17
18
19
‘‘(A) the relative value for the service (as
determined in subsection (c)(2)) for 2006;
‘‘(B) the conversion factor (established
under subsection (d)) for 2006; and
20
‘‘(C) the geographic adjustment factor (es-
21
tablished under subsection (e)(2)) for the serv-
22
ice for the fee schedule area for 2010 and 2011,
23
respectively.’’; and
24
(B) in subsection (c)(2)(B)(iv)—
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1
(i) in subclause (II), by striking
2
‘‘and’’ at the end;
3
(ii) in subclause (III), by striking the
4
period at the end and inserting ‘‘; and’’;
5
and
6
(iii) by adding at the end the fol-
7
lowing new subclause:
8
‘‘(IV) subsection (b)(6) shall not
9
be taken into account in applying
10
clause (ii)(II) for 2010 or 2011.’’.
11
(2) IMPLEMENTATION.—Notwithstanding any
12
other provision of law, the Secretary may implement
13
the amendments made by paragraph (1) by program
14
instruction or otherwise.
15
(b) STUDY
AND
REPORT
BY THE
INSTITUTE
OF
16 MEDICINE.—
17
(1) IN
GENERAL.—The
Secretary of Health and
18
Human Services is authorized to enter into an
19
agreement with the Institute of Medicine of the Na-
20
tional Academies to conduct a study on the ramifica-
21
tions of Medicare payment reductions for dual-en-
22
ergy x-ray absorptiometry (as described in section
23
1848(b)(6) of the Social Security Act, as added by
24
subsection (a)(1)) during 2007, 2008, and 2009 on
25
beneficiary access to bone mass density tests.
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1
(2) REPORT.—An agreement entered into under
2
paragraph (1) shall provide for the Institute of Med-
3
icine to submit to the Secretary and to Congress a
4
report containing the results of the study conducted
5
under such paragraph.
6
SEC. 3112. REVISION TO THE MEDICARE IMPROVEMENT
7
8
FUND.
Section 1898(b)(1)(A) of the Social Security Act (42
9 U.S.C.
1395iii)
is
amended
by
striking
10 ‘‘$22,290,000,000’’ and inserting ‘‘$0’’.
11
12
13
14
SEC. 3113. TREATMENT OF CERTAIN COMPLEX DIAGNOSTIC
LABORATORY TESTS.
(a) DEMONSTRATION PROJECT.—
(1) IN
GENERAL.—The
Secretary of Health and
15
Human Services (in this section referred to as the
16
‘‘Secretary’’) shall conduct a demonstration project
17
under part B title XVIII of the Social Security Act
18
under which separate payments are made under
19
such part for complex diagnostic laboratory tests
20
provided to individuals under such part. Under the
21
demonstration project, the Secretary shall establish
22
appropriate payment rates for such tests.
23
24
(2) COVERED
COMPLEX DIAGNOSTIC LABORA-
TORY TEST DEFINED.—In
this section, the term
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1
‘‘complex diagnostic laboratory test’’ means a diag-
2
nostic laboratory test—
3
(A) that is an analysis of gene protein ex-
4
pression, topographic genotyping, or a cancer
5
chemotherapy sensitivity assay;
6
(B) that is determined by the Secretary to
7
be a laboratory test for which there is not an
8
alternative test having equivalent performance
9
characteristics;
10
(C) which is billed using a Health Care
11
Procedure Coding System (HCPCS) code other
12
than a not otherwise classified code under such
13
Coding System;
14
(D) which is approved or cleared by the
15
Food and Drug Administration or is covered
16
under title XVIII of the Social Security Act;
17
and
18
(E) is described in section 1861(s)(3) of
19
the
20
1395x(s)(3)).
21
(3) SEPARATE
Social
Security
PAYMENT
Act
(42
U.S.C.
DEFINED.—In
this
22
section, the term ‘‘separate payment’’ means direct
23
payment to a laboratory (including a hospital-based
24
or independent laboratory) that performs a complex
25
diagnostic laboratory test with respect to a specimen
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815
1
collected from an individual during a period in which
2
the individual is a patient of a hospital if the test
3
is performed after such period of hospitalization and
4
if separate payment would not otherwise be made
5
under title XVIII of the Social Security Act by rea-
6
son of sections 1862(a)(14) and 1866(a)(1)(H)(i) of
7
the such Act (42 U.S.C. 1395y(a)(14); 42 U.S.C.
8
1395cc(a)(1)(H)(i)).
9
(b) DURATION.—Subject to subsection (c)(2), the
10 Secretary shall conduct the demonstration project under
11 this section for the 2-year period beginning on July 1,
12 2011.
13
(c) PAYMENTS
AND
LIMITATION.—Payments under
14 the demonstration project under this section shall—
15
(1) be made from the Federal Supplemental
16
Medical Insurance Trust Fund under section 1841
17
of the Social Security Act (42 U.S.C. 1395t); and
18
19
(2) may not exceed $100,000,000.
(d) REPORT.—Not later than 2 years after the com-
20 pletion of the demonstration project under this section, the
21 Secretary shall submit to Congress a report on the project.
22 Such report shall include—
23
(1) an assessment of the impact of the dem-
24
onstration project on access to care, quality of care,
25
health outcomes, and expenditures under title XVIII
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816
1
of the Social Security Act (including any savings
2
under such title); and
3
(2) such recommendations as the Secretary de-
4
termines appropriate.
5
(e) IMPLEMENTATION FUNDING.—For purposes of
6 administering this section (including preparing and sub7 mitting the report under subsection (d)), the Secretary
8 shall provide for the transfer, from the Federal Supple9 mental Medical Insurance Trust Fund under section 1841
10 of the Social Security Act (42 U.S.C. 1395t), to the Cen11 ters for Medicare & Medicaid Services Program Manage12 ment Account, of $5,000,000. Amounts transferred under
13 the preceding sentence shall remain available until ex14 pended.
15
16
17
SEC. 3114. IMPROVED ACCESS FOR CERTIFIED NURSE-MIDWIFE SERVICES.
Section 1833(a)(1)(K) of the Social Security Act (42
18 U.S.C. 1395l(a)(1)(K)) is amended by inserting ‘‘(or 100
19 percent for services furnished on or after January 1,
20 2011)’’ after ‘‘1992, 65 percent’’.
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817
1
PART II—RURAL PROTECTIONS
2
SEC. 3121. EXTENSION OF OUTPATIENT HOLD HARMLESS
3
4
PROVISION.
(a) IN GENERAL.—Section 1833(t)(7)(D)(i) of the
5 Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)) is
6 amended—
7
8
9
10
(1) in subclause (II)—
(A) in the first sentence, by striking
‘‘2010’’and inserting ‘‘2011’’; and
(B) in the second sentence, by striking ‘‘or
11
2009’’ and inserting ‘‘, 2009, or 2010’’; and
12
(2) in subclause (III), by striking ‘‘January 1,
13
2010’’ and inserting ‘‘January 1, 2011’’.
14
(b) PERMITTING ALL SOLE COMMUNITY HOSPITALS
15 TO BE ELIGIBLE
FOR
HOLD HARMLESS.—Section
16 1833(t)(7)(D)(i)(III) of the Social Security Act (42
17 U.S.C. 1395l(t)(7)(D)(i)(III)) is amended by adding at
18 the end the following new sentence: ‘‘In the case of covered
19 OPD services furnished on or after January 1, 2010, and
20 before January 1, 2011, the preceding sentence shall be
21 applied without regard to the 100-bed limitation.’’.
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818
1
SEC. 3122. EXTENSION OF MEDICARE REASONABLE COSTS
2
PAYMENTS FOR CERTAIN CLINICAL DIAG-
3
NOSTIC LABORATORY TESTS FURNISHED TO
4
HOSPITAL
5
AREAS.
6
PATIENTS
IN
CERTAIN
RURAL
Section 416(b) of the Medicare Prescription Drug,
7 Improvement, and Modernization Act of 2003 (42 U.S.C.
8 1395l–4), as amended by section 105 of division B of the
9 Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395l
10 note) and section 107 of the Medicare, Medicaid, and
11 SCHIP Extension Act of 2007 (42 U.S.C. 1395l note),
12 is amended by inserting ‘‘or during the 1-year period be13 ginning on July 1, 2010’’ before the period at the end.
14
SEC. 3123. EXTENSION OF THE RURAL COMMUNITY HOS-
15
16
PITAL DEMONSTRATION PROGRAM.
(a) ONE-YEAR EXTENSION.—Section 410A of the
17 Medicare Prescription Drug, Improvement, and Mod18 ernization Act of 2003 (Public Law 108–173; 117 Stat.
19 2272) is amended by adding at the end the following new
20 subsection:
21
‘‘(g) ONE-YEAR EXTENSION
OF
DEMONSTRATION
GENERAL.—Subject
to the succeeding
22 PROGRAM.—
23
‘‘(1) IN
24
provisions of this subsection, the Secretary shall con-
25
duct the demonstration program under this section
26
for an additional 1-year period (in this section re-
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S.L.C.
819
1
ferred to as the ‘1-year extension period’) that be-
2
gins on the date immediately following the last day
3
of the initial 5-year period under subsection (a)(5).
4
‘‘(2)
EXPANSION
OF
DEMONSTRATION
5
STATES.—Notwithstanding
6
the 1-year extension period, the Secretary shall ex-
7
pand the number of States with low population den-
8
sities determined by the Secretary under such sub-
9
section to 20. In determining which States to include
10
in such expansion, the Secretary shall use the same
11
criteria and data that the Secretary used to deter-
12
mine the States under such subsection for purposes
13
of the initial 5-year period.
14
‘‘(3) INCREASE
subsection (a)(2), during
IN MAXIMUM NUMBER OF HOS-
15
PITALS
16
PROGRAM.—Notwithstanding
17
ing the 1-year extension period, not more than 30
18
rural community hospitals may participate in the
19
demonstration program under this section.
20
PARTICIPATING
‘‘(4) NO
AFFECT
IN
ON
THE
DEMONSTRATION
subsection (a)(4), dur-
HOSPITALS
IN
DEM-
21
ONSTRATION PROGRAM ON DATE OF ENACTMENT.—
22
In the case of a rural community hospital that is
23
participating in the demonstration program under
24
this section as of the last day of the initial 5-year
25
period, the Secretary shall provide for the continued
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820
1
participation of such rural community hospital in
2
the demonstration program during the 1-year exten-
3
sion period unless the rural community hospital
4
makes an election, in such form and manner as the
5
Secretary may specify, to discontinue such participa-
6
tion.’’.
7
(b) CONFORMING AMENDMENTS.—Subsection (a)(5)
8 of section 410A of the Medicare Prescription Drug, Im9 provement, and Modernization Act of 2003 (Public Law
10 108–173; 117 Stat. 2272) is amended by inserting ‘‘(in
11 this section referred to as the ‘initial 5-year period’) and,
12 as provided in subsection (g), for the 1-year extension pe13 riod’’ after ‘‘5-year period’’.
14
(c) TECHNICAL AMENDMENTS.—
15
(1) Subsection (b) of section 410A of the Medi-
16
care Prescription Drug, Improvement, and Mod-
17
ernization Act of 2003 (Public Law 108–173; 117
18
Stat. 2272) is amended—
19
20
(A) in paragraph (1)(B)(ii), by striking
‘‘2)’’ and inserting ‘‘2))’’; and
21
(B) in paragraph (2), by inserting ‘‘cost’’
22
before ‘‘reporting period’’ the first place such
23
term appears in each of subparagraphs (A) and
24
(B).
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821
1
(2) Subsection (f)(1) of section 410A of the
2
Medicare Prescription Drug, Improvement, and
3
Modernization Act of 2003 (Public Law 108–173;
4
117 Stat. 2272) is amended—
5
(A) in subparagraph (A)(ii), by striking
6
‘‘paragraph (2)’’ and inserting ‘‘subparagraph
7
(B)’’; and
8
(B) in subparagraph (B), by striking
9
‘‘paragraph (1)(B)’’ and inserting ‘‘subpara-
10
11
12
13
graph (A)(ii)’’.
SEC. 3124. EXTENSION OF THE MEDICARE-DEPENDENT
HOSPITAL (MDH) PROGRAM.
(a) EXTENSION
OF
PAYMENT METHODOLOGY.—Sec-
14 tion 1886(d)(5)(G) of the Social Security Act (42 U.S.C.
15 1395ww(d)(5)(G)) is amended—
16
17
18
(1) in clause (i), by striking ‘‘October 1, 2011’’
and inserting ‘‘October 1, 2012’’; and
(2) in clause (ii)(II), by striking ‘‘October 1,
19
2011’’ and inserting ‘‘October 1, 2012’’.
20
(b) CONFORMING AMENDMENTS.—
21
(1) EXTENSION
OF TARGET AMOUNT.—Section
22
1886(b)(3)(D) of the Social Security Act (42 U.S.C.
23
1395ww(b)(3)(D)) is amended—
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S.L.C.
822
1
(A) in the matter preceding clause (i), by
2
striking ‘‘October 1, 2011’’ and inserting ‘‘Oc-
3
tober 1, 2012’’; and
4
(B) in clause (iv), by striking ‘‘through fis-
5
cal year 2011’’ and inserting ‘‘through fiscal
6
year 2012’’.
7
(2) PERMITTING
8
CLASSIFICATION.—Section
9
bus Budget Reconciliation Act of 1993 (42 U.S.C.
10
1395ww note) is amended by striking ‘‘through fis-
11
cal year 2011’’ and inserting ‘‘through fiscal year
12
2012’’.
13
HOSPITALS TO DECLINE RE-
13501(e)(2) of the Omni-
SEC. 3125. TEMPORARY IMPROVEMENTS TO THE MEDICARE
14
INPATIENT
15
MENT FOR LOW-VOLUME HOSPITALS.
16
Section 1886(d)(12) of the Social Security Act (42
HOSPITAL
PAYMENT
ADJUST-
17 U.S.C. 1395ww(d)(12)) is amended—
18
19
(1) in subparagraph (A), by inserting ‘‘or (D)’’
after ‘‘subparagraph (B)’’;
20
(2) in subparagraph (B), in the matter pre-
21
ceding clause (i), by striking ‘‘The Secretary’’ and
22
inserting ‘‘For discharges occurring in fiscal years
23
2005 through 2010 and for discharges occurring in
24
fiscal year 2013 and subsequent fiscal years, the
25
Secretary’’;
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1
(3) in subparagraph (C)(i)—
2
(A) by inserting ‘‘(or, with respect to fiscal
3
years 2011 and 2012, 15 road miles)’’ after
4
‘‘25 road miles’’; and
5
(B) by inserting ‘‘(or, with respect to fiscal
6
years 2011 and 2012, 1,500 discharges of indi-
7
viduals entitled to, or enrolled for, benefits
8
under part A)’’ after ‘‘800 discharges’’; and
9
(4) by adding at the end the following new sub-
10
11
paragraph:
‘‘(D) TEMPORARY
APPLICABLE PERCENT-
12
AGE INCREASE.—For
13
fiscal years 2011 and 2012, the Secretary shall
14
determine an applicable percentage increase for
15
purposes of subparagraph (A) using a contin-
16
uous linear sliding scale ranging from 25 per-
17
cent for low-volume hospitals with 200 or fewer
18
discharges of individuals entitled to, or enrolled
19
for, benefits under part A in the fiscal year to
20
0 percent for low-volume hospitals with greater
21
than 1,500 discharges of such individuals in the
22
fiscal year.’’.
discharges occurring in
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S.L.C.
824
1
SEC.
3126.
IMPROVEMENTS
TO
THE
DEMONSTRATION
2
PROJECT ON COMMUNITY HEALTH INTEGRA-
3
TION MODELS IN CERTAIN RURAL COUNTIES.
4
(a) REMOVAL OF LIMITATION ON NUMBER OF ELIGI-
5
BLE
COUNTIES SELECTED.—Subsection (d)(3) of section
6 123 of the Medicare Improvements for Patients and Pro7 viders Act of 2008 (42 U.S.C. 1395i–4 note) is amended
8 by striking ‘‘not more than 6’’.
9
(b) REMOVAL
OF
REFERENCES
10 CLINIC SERVICES
AND INCLUSION OF
11
OF
ICES IN
SCOPE
TO
RURAL HEALTH
PHYSICIANS’ SERV-
DEMONSTRATION PROJECT.—Such
12 section 123 is amended—
13
14
15
16
17
(1) in subsection (d)(4)(B)(i)(3), by striking
subclause (III); and
(2) in subsection (j)—
(A) in paragraph (8), by striking subparagraph (B) and inserting the following:
18
‘‘(B) Physicians’ services (as defined in
19
section 1861(q) of the Social Security Act (42
20
U.S.C. 1395x(q)).’’;
21
(B) by striking paragraph (9); and
22
(C) by redesignating paragraph (10) as
23
paragraph (9).
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1
SEC. 3127. MEDPAC STUDY ON ADEQUACY OF MEDICARE
2
PAYMENTS FOR HEALTH CARE PROVIDERS
3
SERVING IN RURAL AREAS.
4
(a) STUDY.—The Medicare Payment Advisory Com-
5 mission shall conduct a study on the adequacy of pay6 ments for items and services furnished by providers of
7 services and suppliers in rural areas under the Medicare
8 program under title XVIII of the Social Security Act (42
9 U.S.C. 1395 et seq.). Such study shall include an analysis
10 of—
11
(1) any adjustments in payments to providers
12
of services and suppliers that furnish items and
13
services in rural areas;
14
15
(2) access by Medicare beneficiaries to items
and services in rural areas;
16
(3) the adequacy of payments to providers of
17
services and suppliers that furnish items and serv-
18
ices in rural areas; and
19
(4) the quality of care furnished in rural areas.
20
(b) REPORT.—Not later than January 1, 2011, the
21 Medicare Payment Advisory Commission shall submit to
22 Congress a report containing the results of the study con23 ducted under subsection (a). Such report shall include rec24 ommendations on appropriate modifications to any adjust25 ments in payments to providers of services and suppliers
26 that furnish items and services in rural areas, together
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826
1 with recommendations for such legislation and administra2 tive action as the Medicare Payment Advisory Commission
3 determines appropriate.
4
5
6
SEC. 3128. TECHNICAL CORRECTION RELATED TO CRITICAL ACCESS HOSPITAL SERVICES.
(a) IN GENERAL.—Subsections (g)(2)(A) and (l)(8)
7 of section 1834 of the Social Security Act (42 U.S.C.
8 1395m) are each amended by inserting ‘‘101 percent of’’
9 before ‘‘the reasonable costs’’.
10
(b) EFFECTIVE DATE.—The amendments made by
11 subsection (a) shall take effect as if included in the enact12 ment of section 405(a) of the Medicare Prescription Drug,
13 Improvement, and Modernization Act of 2003 (Public Law
14 108–173; 117 Stat. 2266).
15
16
17
SEC. 3129. EXTENSION OF AND REVISIONS TO MEDICARE
RURAL HOSPITAL FLEXIBILITY PROGRAM.
(a) AUTHORIZATION.—Section 1820(j) of the Social
18 Security Act (42 U.S.C. 1395i–4(j)) is amended—
19
20
(1) by striking ‘‘2010, and for’’ and inserting
‘‘2010, for’’; and
21
(2) by inserting ‘‘and for making grants to all
22
States under subsection (g), such sums as may be
23
necessary in each of fiscal years 2011 and 2012, to
24
remain available until expended’’ before the period
25
at the end.
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1
(b) USE
OF
FUNDS.—Section 1820(g)(3) of the So-
2 cial Security Act (42 U.S.C. 1395i–4(g)(3)) is amended—
3
(1) in subparagraph (A), by inserting ‘‘and to
4
assist such hospitals in participating in delivery sys-
5
tem reforms under the provisions of and amend-
6
ments made by the Patient Protection and Afford-
7
able Care Act, such as value-based purchasing pro-
8
grams, accountable care organizations under section
9
1899, the National pilot program on payment bun-
10
dling under section 1866D, and other delivery sys-
11
tem reform programs determined appropriate by the
12
Secretary’’ before the period at the end; and
13
14
15
(2) in subparagraph (E)—
(A) by striking ‘‘, and to offset’’ and inserting ‘‘, to offset’’; and
16
(B) by inserting ‘‘and to participate in de-
17
livery system reforms under the provisions of
18
and amendments made by the Patient Protec-
19
tion and Affordable Care Act, such as value-
20
based purchasing programs, accountable care
21
organizations under section 1899, the National
22
pilot program on payment bundling under sec-
23
tion 1866D, and other delivery system reform
24
programs determined appropriate by the Sec-
25
retary’’ before the period at the end.
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1
(c) EFFECTIVE DATE.—The amendments made by
2 this section shall apply to grants made on or after January
3 1, 2010.
4
PART III—IMPROVING PAYMENT ACCURACY
5
SEC. 3131. PAYMENT ADJUSTMENTS FOR HOME HEALTH
6
7
8
9
CARE.
(a) REBASING HOME HEALTH PROSPECTIVE PAYMENT
AMOUNT.—
(1) IN
GENERAL.—Section
1895(b)(3)(A) of the
10
Social Security Act (42 U.S.C. 1395fff(b)(3)(A)) is
11
amended—
12
(A) in clause (i)(III), by striking ‘‘For pe-
13
riods’’ and inserting ‘‘Subject to clause (iii), for
14
periods’’; and
15
16
17
18
19
(B) by adding at the end the following new
clause:
‘‘(iii) ADJUSTMENT
FOR
2013
AND
SUBSEQUENT YEARS.—
‘‘(I) IN
GENERAL.—Subject
to
20
subclause (II), for 2013 and subse-
21
quent years, the amount (or amounts)
22
that would otherwise be applicable
23
under clause (i)(III) shall be adjusted
24
by a percentage determined appro-
25
priate by the Secretary to reflect such
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829
1
factors as changes in the number of
2
visits in an episode, the mix of serv-
3
ices in an episode, the level of inten-
4
sity of services in an episode, the av-
5
erage cost of providing care per epi-
6
sode, and other factors that the Sec-
7
retary considers to be relevant. In
8
conducting the analysis under the pre-
9
ceding sentence, the Secretary may
10
consider differences between hospital-
11
based and freestanding agencies, be-
12
tween for-profit and nonprofit agen-
13
cies, and between the resource costs of
14
urban and rural agencies. Such ad-
15
justment shall be made before the up-
16
date under subparagraph (B) is ap-
17
plied for the year.
18
‘‘(II)
TRANSITION.—The
Sec-
19
retary shall provide for a 4-year
20
phase-in (in equal increments) of the
21
adjustment under subclause (I), with
22
such adjustment being fully imple-
23
mented for 2016. During each year of
24
such phase-in, the amount of any ad-
25
justment under subclause (I) for the
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
830
1
year may not exceed 3.5 percent of
2
the amount (or amounts) applicable
3
under clause (i)(III) as of the date of
4
enactment of the Patient Protection
5
and Affordable Care Act.’’.
6
(2) MEDPAC
STUDY AND REPORT.—
7
(A) STUDY.—The Medicare Payment Advi-
8
sory Commission shall conduct a study on the
9
implementation of the amendments made by
10
paragraph (1). Such study shall include an
11
analysis of the impact of such amendments
12
on—
13
(i) access to care;
14
(ii) quality outcomes;
15
(iii) the number of home health agen-
16
cies; and
17
(iv) rural agencies, urban agencies,
18
for-profit agencies, and nonprofit agencies.
19
(B) REPORT.—Not later than January 1,
20
2015, the Medicare Payment Advisory Commis-
21
sion shall submit to Congress a report on the
22
study conducted under subparagraph (A), to-
23
gether with recommendations for such legisla-
24
tion and administrative action as the Commis-
25
sion determines appropriate.
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S.L.C.
831
1
(b)
PROGRAM-SPECIFIC
OUTLIER
CAP.—Section
2 1895(b) of the Social Security Act (42 U.S.C. 1395fff(b))
3 is amended—
4
(1) in paragraph (3)(C), by striking ‘‘the aggre-
5
gate’’ and all that follows through the period at the
6
end and inserting ‘‘5 percent of the total payments
7
estimated to be made based on the prospective pay-
8
ment system under this subsection for the period.’’;
9
and
10
11
(2) in paragraph (5)—
(A) by striking ‘‘OUTLIERS.—The Sec-
12
retary’’
13
‘‘OUTLIERS.—
14
15
and
‘‘(A) IN
inserting
the
following:
GENERAL.—Subject
to subpara-
graph (B), the Secretary’’;
16
(B) in subparagraph (A), as added by sub-
17
paragraph (A), by striking ‘‘5 percent’’ and in-
18
serting ‘‘2.5 percent’’; and
19
20
21
(C) by adding at the end the following new
subparagraph:
‘‘(B) PROGRAM
SPECIFIC OUTLIER CAP.—
22
The estimated total amount of additional pay-
23
ments or payment adjustments made under
24
subparagraph (A) with respect to a home health
25
agency for a year (beginning with 2011) may
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
832
1
not exceed an amount equal to 10 percent of
2
the estimated total amount of payments made
3
under this section (without regard to this para-
4
graph) with respect to the home health agency
5
for the year.’’.
6
(c) APPLICATION
OF THE
MEDICARE RURAL HOME
7 HEALTH ADD-ON POLICY.—Section 421 of the Medicare
8 Prescription Drug, Improvement, and Modernization Act
9 of 2003 (Public Law 108–173; 117 Stat. 2283), as
10 amended by section 5201(b) of the Deficit Reduction Act
11 of 2005 (Public Law 109–171; 120 Stat. 46), is amend12 ed—
13
14
15
(1) in the section heading, by striking ‘‘ONEYEAR’’
and inserting ‘‘TEMPORARY’’; and
(2) in subsection (a)—
16
17
(A) by striking ‘‘, and episodes’’ and inserting ‘‘, episodes’’;
18
(B) by inserting ‘‘and episodes and visits
19
ending on or after April 1, 2010, and before
20
January 1, 2016,’’ after ‘‘January 1, 2007,’’;
21
and
22
(C) by inserting ‘‘(or, in the case of epi-
23
sodes and visits ending on or after April 1,
24
2010, and before January 1, 2016, 3 percent)’’
25
before the period at the end.
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833
1
(d) STUDY
AND
REPORT
ON THE
2 HOME HEALTH PAYMENT REFORMS
3
4
SURE
DEVELOPMENT
IN
ORDER
TO
OF
EN -
ACCESS TO CARE AND QUALITY SERVICES.—
(1) IN
GENERAL.—The
Secretary of Health and
5
Human Services (in this section referred to as the
6
‘‘Secretary’’) shall conduct a study to evaluate the
7
costs and quality of care among efficient home
8
health agencies relative to other such agencies in
9
providing ongoing access to care and in treating
10
Medicare beneficiaries with varying severity levels of
11
illness. Such study shall include an analysis of the
12
following:
13
(A) Methods to revise the home health pro-
14
spective payment system under section 1895 of
15
the Social Security Act (42 U.S.C. 1395fff) to
16
more accurately account for the costs related to
17
patient severity of illness or to improving bene-
18
ficiary access to care, including—
19
20
(i) payment adjustments for services
that may be under- or over-valued;
21
(ii) necessary changes to reflect the
22
resource use relative to providing home
23
health services to low-income Medicare
24
beneficiaries or Medicare beneficiaries liv-
25
ing in medically underserved areas;
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
834
1
(iii) ways the outlier payment may be
2
improved to more accurately reflect the
3
cost of treating Medicare beneficiaries with
4
high severity levels of illness;
5
(iv) the role of quality of care incen-
6
tives and penalties in driving provider and
7
patient behavior;
8
9
10
(v) improvements in the application of
a wage index; and
(vi) other areas determined appro-
11
priate by the Secretary.
12
(B) The validity and reliability of re-
13
sponses on the OASIS instrument with par-
14
ticular emphasis on questions that relate to
15
higher payment under the home health prospec-
16
tive payment system and higher outcome scores
17
under Home Care Compare.
18
(C) Additional research or payment revi-
19
sions under the home health prospective pay-
20
ment system that may be necessary to set the
21
payment rates for home health services based
22
on costs of high-quality and efficient home
23
health agencies or to improve Medicare bene-
24
ficiary access to care.
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S.L.C.
835
1
(D) A timetable for implementation of any
2
appropriate changes based on the analysis of
3
the matters described in subparagraphs (A),
4
(B), and (C).
5
(E) Other areas determined appropriate by
6
the Secretary.
7
(2) CONSIDERATIONS.—In conducting the study
8
under paragraph (1), the Secretary shall consider
9
whether certain factors should be used to measure
10
patient severity of illness and access to care, such
11
as—
12
13
(A) population density and relative patient
access to care;
14
(B) variations in service costs for providing
15
care to individuals who are dually eligible under
16
the Medicare and Medicaid programs;
17
(C) the presence of severe or chronic dis-
18
eases, as evidenced by multiple, discontinuous
19
home health episodes;
20
(D) poverty status, as evidenced by the re-
21
ceipt of Supplemental Security Income under
22
title XVI of the Social Security Act;
23
(E) the absence of caregivers;
24
(F) language barriers;
25
(G) atypical transportation costs;
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S.L.C.
836
1
(H) security costs; and
2
(I) other factors determined appropriate by
3
the Secretary.
4
(3) REPORT.—Not later than March 1, 2011,
5
the Secretary shall submit to Congress a report on
6
the study conducted under paragraph (1), together
7
with recommendations for such legislation and ad-
8
ministrative action as the Secretary determines ap-
9
propriate.
10
(4) CONSULTATIONS.—In conducting the study
11
under paragraph (1) and preparing the report under
12
paragraph (3), the Secretary shall consult with—
13
14
15
16
17
18
19
20
21
22
23
24
(A) stakeholders representing home health
agencies;
(B) groups representing Medicare beneficiaries;
(C) the Medicare Payment Advisory Commission;
(D) the Inspector General of the Department of Health and Human Services; and
(E) the Comptroller General of the United
States.
SEC. 3132. HOSPICE REFORM.
(a) HOSPICE CARE PAYMENT REFORMS.—
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S.L.C.
837
1
(1) IN
GENERAL.—Section
1814(i) of the Social
2
Security Act (42 U.S.C. 1395f(i)), as amended by
3
section 3004(c), is amended—
4
5
6
(A) by redesignating paragraph (6) as
paragraph (7); and
(B) by inserting after paragraph (5) the
7
following new paragraph:
8
‘‘(6)(A) The Secretary shall collect additional
9
data and information as the Secretary determines
10
appropriate to revise payments for hospice care
11
under this subsection pursuant to subparagraph (D)
12
and for other purposes as determined appropriate by
13
the Secretary. The Secretary shall begin to collect
14
such data by not later than January 1, 2011.
15
‘‘(B) The additional data and information to be
16
collected under subparagraph (A) may include data
17
and information on—
18
‘‘(i) charges and payments;
19
‘‘(ii) the number of days of hospice care
20
which are attributable to individuals who are
21
entitled to, or enrolled for, benefits under part
22
A; and
23
24
‘‘(iii) with respect to each type of service
included in hospice care—
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S.L.C.
838
1
2
‘‘(I) the number of days of hospice
care attributable to the type of service;
3
4
‘‘(II) the cost of the type of service;
and
5
‘‘(III) the amount of payment for the
6
type of service;
7
‘‘(iv) charitable contributions and other
8
9
10
11
12
revenue of the hospice program;
‘‘(v) the number of hospice visits;
‘‘(vi) the type of practitioner providing the
visit; and
‘‘(vii) the length of the visit and other
13
basic information with respect to the visit.
14
‘‘(C) The Secretary may collect the additional
15
data and information under subparagraph (A) on
16
cost reports, claims, or other mechanisms as the
17
Secretary determines to be appropriate.
18
‘‘(D)(i) Notwithstanding the preceding para-
19
graphs of this subsection, not earlier than October
20
1, 2013, the Secretary shall, by regulation, imple-
21
ment revisions to the methodology for determining
22
the payment rates for routine home care and other
23
services included in hospice care under this part, as
24
the Secretary determines to be appropriate. Such re-
25
visions may be based on an analysis of data and in-
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
839
1
formation collected under subparagraph (A). Such
2
revisions may include adjustments to per diem pay-
3
ments that reflect changes in resource intensity in
4
providing such care and services during the course
5
of the entire episode of hospice care.
6
‘‘(ii) Revisions in payment implemented pursu-
7
ant to clause (i) shall result in the same estimated
8
amount of aggregate expenditures under this title
9
for hospice care furnished in the fiscal year in which
10
such revisions in payment are implemented as would
11
have been made under this title for such care in
12
such fiscal year if such revisions had not been imple-
13
mented.
14
‘‘(E) The Secretary shall consult with hospice
15
programs and the Medicare Payment Advisory Com-
16
mission regarding the additional data and informa-
17
tion to be collected under subparagraph (A) and the
18
payment revisions under subparagraph (D).’’.
19
(2)
CONFORMING
AMENDMENTS.—Section
20
1814(i)(1)(C) of the Social Security Act (42 U.S.C.
21
1395f(i)(1)(C)) is amended—
22
(A) in clause (ii)—
23
(i) in the matter preceding subclause
24
(I), by inserting ‘‘(before the first fiscal
25
year in which the payment revisions de-
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
840
1
scribed in paragraph (6)(D) are imple-
2
mented)’’ after ‘‘subsequent fiscal year’’;
3
and
4
(ii) in subclause (VII), by inserting
5
‘‘(before the first fiscal year in which the
6
payment revisions described in paragraph
7
(6)(D) are implemented), subject to clause
8
(iv),’’ after ‘‘subsequent fiscal year’’; and
9
(B) by adding at the end the following new
10
clause:
11
‘‘(iii) With respect to routine home
12
care and other services included in hospice
13
care furnished during fiscal years subse-
14
quent to the first fiscal year in which pay-
15
ment revisions described in paragraph
16
(6)(D) are implemented, the payment rates
17
for such care and services shall be the pay-
18
ment rates in effect under this clause dur-
19
ing the preceding fiscal year increased by,
20
subject to clause (iv), the market basket
21
percentage increase (as defined in section
22
1886(b)(3)(B)(iii)) for the fiscal year.’’.
23
24
(b) ADOPTION
GIBILITY
OF
MEDPAC HOSPICE PROGRAM ELI-
RECERTIFICATION RECOMMENDATIONS.—Sec-
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S.L.C.
841
1 tion 1814(a)(7) of the Social Security Act (42 U.S.C.
2 1395f(a)(7)) is amended—
3
4
5
6
7
(1) in subparagraph (B), by striking ‘‘and’’ at
the end; and
(2) by adding at the end the following new subparagraph:
‘‘(D) on and after January 1, 2011—
8
‘‘(i) a hospice physician or nurse prac-
9
titioner has a face-to-face encounter with
10
the individual to determine continued eligi-
11
bility of the individual for hospice care
12
prior to the 180th-day recertification and
13
each subsequent recertification under sub-
14
paragraph (A)(ii) and attests that such
15
visit took place (in accordance with proce-
16
dures established by the Secretary); and
17
‘‘(ii) in the case of hospice care pro-
18
vided an individual for more than 180 days
19
by a hospice program for which the num-
20
ber of such cases for such program com-
21
prises more than a percent (specified by
22
the Secretary) of the total number of such
23
cases for all programs under this title, the
24
hospice care provided to such individual is
25
medically reviewed (in accordance with
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
842
1
procedures established by the Secretary);
2
and’’.
3
SEC.
3133.
IMPROVEMENT
TO
MEDICARE
DISPROPOR-
4
TIONATE SHARE HOSPITAL (DSH) PAYMENTS.
5
Section 1886 of the Social Security Act (42 U.S.C.
6 1395ww), as amended by sections 3001, 3008, and 3025,
7 is amended—
8
(1) in subsection (d)(5)(F)(i), by striking
9
‘‘For’’ and inserting ‘‘Subject to subsection (r), for’’;
10
11
and
(2) by adding at the end the following new sub-
12
section:
13
‘‘(r) ADJUSTMENTS
14
TO
MEDICARE DSH PAY-
MENTS.—
15
‘‘(1)
16
MENTS.—For
17
fiscal year, instead of the amount of dispropor-
18
tionate share hospital payment that would otherwise
19
be made under subsection (d)(5)(F) to a subsection
20
(d) hospital for the fiscal year, the Secretary shall
21
pay to the subsection (d) hospital 25 percent of such
22
amount (which represents the empirically justified
23
amount for such payment, as determined by the
24
Medicare Payment Advisory Commission in its
25
March 2007 Report to the Congress).
EMPIRICALLY
JUSTIFIED
DSH
PAY-
fiscal year 2015 and each subsequent
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
843
1
‘‘(2) ADDITIONAL
PAYMENT.—In
addition to
2
the payment made to a subsection (d) hospital under
3
paragraph (1), for fiscal year 2015 and each subse-
4
quent fiscal year, the Secretary shall pay to such
5
subsection (d) hospitals an additional amount equal
6
to the product of the following factors:
7
8
‘‘(A) FACTOR
ONE.—A
factor equal to the
difference between—
9
‘‘(i) the aggregate amount of pay-
10
ments that would be made to subsection
11
(d) hospitals under subsection (d)(5)(F) if
12
this subsection did not apply for such fis-
13
cal year (as estimated by the Secretary);
14
and
15
‘‘(ii) the aggregate amount of pay-
16
ments that are made to subsection (d) hos-
17
pitals under paragraph (1) for such fiscal
18
year (as so estimated).
19
‘‘(B) FACTOR
20
TWO.—
‘‘(i) FISCAL
YEARS 2015, 2016, AND
21
2017.—For
22
and 2017, a factor equal to 1 minus the
23
percent change (divided by 100) in the per-
24
cent of individuals under the age of 65 who
each of fiscal years 2015, 2016,
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
844
1
are uninsured, as determined by comparing
2
the percent of such individuals—
3
‘‘(I) who are uninsured in 2012,
4
the last year before coverage expan-
5
sion under the Patient Protection and
6
Affordable Care Act (as calculated by
7
the Secretary based on the most re-
8
cent estimates available from the Di-
9
rector of the Congressional Budget
10
Office before a vote in either House
11
on such Act that, if determined in the
12
affirmative, would clear such Act for
13
enrollment); and
14
‘‘(II) who are uninsured in the
15
most recent period for which data is
16
available (as so calculated).
17
‘‘(ii)
18
YEARS.—For
19
subsequent fiscal year, a factor equal to 1
20
minus the percent change (divided by 100)
21
in the percent of individuals who are unin-
22
sured, as determined by comparing the
23
percent of individuals—
2018
AND
SUBSEQUENT
fiscal year 2018 and each
24
‘‘(I) who are uninsured in 2012
25
(as estimated by the Secretary, based
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
845
1
on data from the Census Bureau or
2
other sources the Secretary deter-
3
mines appropriate, and certified by
4
the Chief Actuary of the Centers for
5
Medicare & Medicaid Services); and
6
‘‘(II) who are uninsured in the
7
most recent period for which data is
8
available (as so estimated and cer-
9
tified).
10
‘‘(C) FACTOR
THREE.—A
factor equal to
11
the percent, for each subsection (d) hospital,
12
that represents the quotient of—
13
‘‘(i) the amount of uncompensated
14
care for such hospital for a period selected
15
by the Secretary (as estimated by the Sec-
16
retary, based on appropriate data (includ-
17
ing, in the case where the Secretary deter-
18
mines that alternative data is available
19
which is a better proxy for the costs of
20
subsection (d) hospitals for treating the
21
uninsured, the use of such alternative
22
data)); and
23
‘‘(ii) the aggregate amount of uncom-
24
pensated care for all subsection (d) hos-
25
pitals that receive a payment under this
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
846
1
subsection for such period (as so esti-
2
mated, based on such data).
3
‘‘(3) LIMITATIONS
ON REVIEW.—There
shall be
4
no administrative or judicial review under section
5
1869, section 1878, or otherwise of the following:
6
‘‘(A) Any estimate of the Secretary for
7
purposes of determining the factors described in
8
paragraph (2).
9
10
11
12
13
‘‘(B) Any period selected by the Secretary
for such purposes.’’.
SEC. 3134. MISVALUED CODES UNDER THE PHYSICIAN FEE
SCHEDULE.
(a) IN GENERAL.—Section 1848(c)(2) of the Social
14 Security Act (42 U.S.C. 1395w–4(c)(2)) is amended by
15 adding at the end the following new subparagraphs:
16
17
18
‘‘(K) POTENTIALLY
‘‘(i) IN
MISVALUED CODES.—
GENERAL.—The
Secretary
shall—
19
‘‘(I) periodically identify services
20
as being potentially misvalued using
21
criteria specified in clause (ii); and
22
‘‘(II) review and make appro-
23
priate adjustments to the relative val-
24
ues established under this paragraph
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
847
1
for services identified as being poten-
2
tially misvalued under subclause (I).
3
‘‘(ii)
IDENTIFICATION
OF
POTEN-
4
TIALLY MISVALUED CODES.—For
purposes
5
of identifying potentially misvalued services
6
pursuant to clause (i)(I), the Secretary
7
shall examine (as the Secretary determines
8
to be appropriate) codes (and families of
9
codes as appropriate) for which there has
10
been the fastest growth; codes (and fami-
11
lies of codes as appropriate) that have ex-
12
perienced substantial changes in practice
13
expenses; codes for new technologies or
14
services within an appropriate period (such
15
as 3 years) after the relative values are ini-
16
tially established for such codes; multiple
17
codes that are frequently billed in conjunc-
18
tion with furnishing a single service; codes
19
with low relative values, particularly those
20
that are often billed multiple times for a
21
single treatment; codes which have not
22
been subject to review since the implemen-
23
tation of the RBRVS (the so-called ‘Har-
24
vard-valued codes’); and such other codes
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
848
1
determined to be appropriate by the Sec-
2
retary.
3
4
‘‘(iii) REVIEW
AND ADJUSTMENTS.—
‘‘(I) The Secretary may use ex-
5
isting
6
ommendations on the review and ap-
7
propriate adjustment of potentially
8
misvalued services described in clause
9
(i)(II).
processes
to
receive
rec-
10
‘‘(II) The Secretary may conduct
11
surveys, other data collection activi-
12
ties, studies, or other analyses as the
13
Secretary determines to be appro-
14
priate to facilitate the review and ap-
15
propriate
16
clause (i)(II).
adjustment
described
in
17
‘‘(III) The Secretary may use
18
analytic contractors to identify and
19
analyze
20
clause (i)(I), conduct surveys or col-
21
lect data, and make recommendations
22
on the review and appropriate adjust-
23
ment of services described in clause
24
(i)(II).
services
identified
under
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
849
1
‘‘(IV) The Secretary may coordi-
2
nate the review and appropriate ad-
3
justment described in clause (i)(II)
4
with the periodic review described in
5
subparagraph (B).
6
‘‘(V) As part of the review and
7
adjustment described in clause (i)(II),
8
including with respect to codes with
9
low relative values described in clause
10
(ii), the Secretary may make appro-
11
priate
12
using existing processes for consider-
13
ation of coding changes) which may
14
include consolidation of individual
15
services into bundled codes for pay-
16
ment under the fee schedule under
17
subsection (b).
coding
revisions
(including
18
‘‘(VI) The provisions of subpara-
19
graph (B)(ii)(II) shall apply to adjust-
20
ments to relative value units made
21
pursuant to this subparagraph in the
22
same manner as such provisions apply
23
to adjustments under subparagraph
24
(B)(ii)(II).
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850
1
‘‘(L)
2
UNITS.—
3
VALIDATING
‘‘(i) IN
RELATIVE
GENERAL.—The
VALUE
Secretary
4
shall establish a process to validate relative
5
value units under the fee schedule under
6
subsection (b).
7
‘‘(ii) COMPONENTS
AND
ELEMENTS
8
OF
9
clause (i) may include validation of work
10
elements (such as time, mental effort and
11
professional judgment, technical skill and
12
physical effort, and stress due to risk) in-
13
volved with furnishing a service and may
14
include validation of the pre-, post-, and
15
intra-service components of work.
16
WORK.—The
‘‘(iii) SCOPE
process
described
OF CODES.—The
in
valida-
17
tion of work relative value units shall in-
18
clude a sampling of codes for services that
19
is the same as the codes listed under sub-
20
paragraph (K)(ii).
21
‘‘(iv) METHODS.—The Secretary may
22
conduct the validation under this subpara-
23
graph using methods described in sub-
24
clauses (I) through (V) of subparagraph
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S.L.C.
851
1
(K)(iii) as the Secretary determines to be
2
appropriate.
3
‘‘(v) ADJUSTMENTS.—The Secretary
4
shall make appropriate adjustments to the
5
work relative value units under the fee
6
schedule under subsection (b). The provi-
7
sions of subparagraph (B)(ii)(II) shall
8
apply to adjustments to relative value units
9
made pursuant to this subparagraph in the
10
same manner as such provisions apply to
11
adjustments
12
(B)(ii)(II).’’.
13
14
under
subparagraph
(b) IMPLEMENTATION.—
(1) ADMINISTRATION.—
15
(A) Chapter 35 of title 44, United States
16
Code and the provisions of the Federal Advisory
17
Committee Act (5 U.S.C. App.) shall not apply
18
to this section or the amendment made by this
19
section.
20
(B) Notwithstanding any other provision of
21
law, the Secretary may implement subpara-
22
graphs (K) and (L) of 1848(c)(2) of the Social
23
Security Act, as added by subsection (a), by
24
program instruction or otherwise.
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S.L.C.
852
1
(C) Section 4505(d) of the Balanced
2
Budget Act of 1997 is repealed.
3
(D) Except for provisions related to con-
4
fidentiality of information, the provisions of the
5
Federal Acquisition Regulation shall not apply
6
to this section or the amendment made by this
7
section.
8
(2) FOCUSING
9
CMS
RESOURCES
TIALLY OVERVALUED CODES.—Section
ON
POTEN-
1868(a) of
10
the Social Security Act (42 U.S.C. 1395ee(a)) is re-
11
pealed.
12
SEC. 3135. MODIFICATION OF EQUIPMENT UTILIZATION
13
FACTOR FOR ADVANCED IMAGING SERVICES.
14
15
(a) ADJUSTMENT
FLECT
IN
PRACTICE EXPENSE
TO
RE -
HIGHER PRESUMED UTILIZATION.—Section 1848
16 of the Social Security Act (42 U.S.C. 1395w–4) is amend17 ed—
18
(1) in subsection (b)(4)—
19
(A) in subparagraph (B), by striking ‘‘sub-
20
paragraph (A)’’ and inserting ‘‘this paragraph’’;
21
and
22
23
(B) by adding at the end the following new
subparagraph:
24
25
‘‘(C) ADJUSTMENT
TO
REFLECT
HIGHER
IN PRACTICE EXPENSE
PRESUMED
UTILIZA-
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S.L.C.
853
1
TION.—Consistent
2
computing the number of practice expense rel-
3
ative value units under subsection (c)(2)(C)(ii)
4
with respect to advanced diagnostic imaging
5
services (as defined in section 1834(e)(1)(B))
6
furnished on or after January 1, 2010, the Sec-
7
retary shall adjust such number of units so it
8
reflects—
with the methodology for
9
‘‘(i) in the case of services furnished
10
on or after January 1, 2010, and before
11
January 1, 2013, a 65 percent (rather
12
than 50 percent) presumed rate of utiliza-
13
tion of imaging equipment;
14
‘‘(ii) in the case of services furnished
15
on or after January 1, 2013, and before
16
January 1, 2014, a 70 percent (rather
17
than 50 percent) presumed rate of utiliza-
18
tion of imaging equipment; and
19
‘‘(iii) in the case of services furnished
20
on or after January 1, 2014, a 75 percent
21
(rather than 50 percent) presumed rate of
22
utilization of imaging equipment.’’; and
23
(2) in subsection (c)(2)(B)(v), by adding at the
24
end the following new subclauses:
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S.L.C.
854
1
‘‘(III) CHANGE
IN
PRESUMED
2
UTILIZATION LEVEL OF CERTAIN AD-
3
VANCED DIAGNOSTIC IMAGING SERV-
4
ICES FOR 2010 THROUGH 2012.—Effec-
5
tive for fee schedules established be-
6
ginning with 2010 and ending with
7
2012, reduced expenditures attrib-
8
utable to the presumed rate of utiliza-
9
tion of imaging equipment of 65 per-
10
cent under subsection (b)(4)(C)(i) in-
11
stead of a presumed rate of utilization
12
of such equipment of 50 percent.
13
‘‘(IV) CHANGE
IN
PRESUMED
14
UTILIZATION LEVEL OF CERTAIN AD-
15
VANCED DIAGNOSTIC IMAGING SERV-
16
ICES
17
schedules established for 2013, re-
18
duced expenditures attributable to the
19
presumed rate of utilization of imag-
20
ing equipment of 70 percent under
21
subsection (b)(4)(C)(ii) instead of a
22
presumed rate of utilization of such
23
equipment of 50 percent.
24
‘‘(V) CHANGE
25
FOR
LIZATION
2013.—Effective
LEVEL
for fee
IN PRESUMED UTIOF
CERTAIN
AD-
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S.L.C.
855
1
VANCED DIAGNOSTIC IMAGING SERV-
2
ICES
3
YEARS.—Effective
4
established beginning with 2014, re-
5
duced expenditures attributable to the
6
presumed rate of utilization of imag-
7
ing equipment of 75 percent under
8
subsection (b)(4)(C)(iii) instead of a
9
presumed rate of utilization of such
10
11
12
FOR
2014
AND
SUBSEQUENT
for fee schedules
equipment of 50 percent.’’.
(b) ADJUSTMENT
COUNT’’ ON
IN
TECHNICAL COMPONENT ‘‘DIS-
SINGLE-SESSION IMAGING
TO
CONSECUTIVE
13 BODY PARTS.—Section 1848 of the Social Security Act
14 (42 U.S.C. 1395w–4), as amended by subsection (a), is
15 amended—
16
17
18
(1) in subsection (b)(4), by adding at the end
the following new subparagraph:
‘‘(D) ADJUSTMENT
IN TECHNICAL COMPO-
19
NENT DISCOUNT ON SINGLE-SESSION IMAGING
20
INVOLVING CONSECUTIVE BODY PARTS.—For
21
services furnished on or after July 1, 2010, the
22
Secretary shall increase the reduction in pay-
23
ments attributable to the multiple procedure
24
payment reduction applicable to the technical
25
component for imaging under the final rule
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
856
1
published by the Secretary in the Federal Reg-
2
ister on November 21, 2005 (part 405 of title
3
42, Code of Federal Regulations) from 25 per-
4
cent to 50 percent.’’; and
5
(2) in subsection (c)(2)(B)(v), by adding at the
6
end the following new subclause:
7
‘‘(VI)
ADDITIONAL
8
PAYMENT
9
PROCEDURES.—Effective
FOR
MULTIPLE
REDUCED
IMAGING
for
fee
10
schedules established beginning with
11
2010 (but not applied for services fur-
12
nished prior to July 1, 2010), reduced
13
expenditures attributable to the in-
14
crease in the multiple procedure pay-
15
ment reduction from 25 to 50 percent
16
(as
17
(b)(4)(D)).’’.
18
19
(c) ANALYSIS
TERS FOR
BY THE
described
in
CHIEF ACTUARY
subsection
OF THE
CEN-
MEDICARE & MEDICAID SERVICES.—Not later
20 than January 1, 2013, the Chief Actuary of the Centers
21 for Medicare & Medicaid Services shall make publicly
22 available an analysis of whether, for the period of 2010
23 through 2019, the cumulative expenditure reductions
24 under title XVIII of the Social Security Act that are at-
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
857
1 tributable to the adjustments under the amendments made
2 by this section are projected to exceed $3,000,000,000.
3
SEC. 3136. REVISION OF PAYMENT FOR POWER-DRIVEN
4
5
WHEELCHAIRS.
(a) IN GENERAL.—Section 1834(a)(7)(A) of the So-
6 cial Security Act (42 U.S.C. 1395m(a)(7)(A)) is amend7 ed—
8
(1) in clause (i)—
9
10
(A) in subclause (II), by inserting ‘‘subclause (III) and’’ after ‘‘Subject to’’; and
11
12
(B) by adding at the end the following new
subclause:
13
‘‘(III)
14
POWER-DRIVEN
15
purposes of payment for power-driven
16
wheelchairs, subclause (II) shall be
17
applied by substituting ‘15 percent’
18
and ‘6 percent’ for ‘10 percent’ and
19
‘7.5 percent’, respectively.’’; and
20
SPECIAL
WHEELCHAIRS.—For
(A) in the heading, by inserting ‘‘COM-
22
PLEX, REHABILITATIVE’’
23
EN’’;
25
FOR
(2) in clause (iii)—
21
24
RULE
before ‘‘POWER-DRIV-
and
(B) by inserting ‘‘complex, rehabilitative’’
before ‘‘power-driven’’.
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S.L.C.
858
1
(b)
TECHNICAL
AMENDMENT.—Section
2 1834(a)(7)(C)(ii)(II) of the Social Security Act (42 U.S.C.
3 1395m(a)(7)(C)(ii)(II)) is amended by striking ‘‘(A)(ii)
4 or’’.
5
6
(c) EFFECTIVE DATE.—
(1) IN
GENERAL.—Subject
to paragraph (2),
7
the amendments made by subsection (a) shall take
8
effect on January 1, 2011, and shall apply to power-
9
driven wheelchairs furnished on or after such date.
10
(2) APPLICATION
TO COMPETITIVE BIDDING.—
11
The amendments made by subsection (a) shall not
12
apply to payment made for items and services fur-
13
nished pursuant to contracts entered into under sec-
14
tion 1847 of the Social Security Act (42 U.S.C.
15
1395w–3) prior to January 1, 2011, pursuant to the
16
implementation of subsection (a)(1)(B)(i)(I) of such
17
section 1847.
18
19
20
21
SEC. 3137. HOSPITAL WAGE INDEX IMPROVEMENT.
(a) EXTENSION
OF
SECTION 508 HOSPITAL RECLAS-
SIFICATIONS.—
(1) IN
GENERAL.—Subsection
(a) of section
22
106 of division B of the Tax Relief and Health Care
23
Act of 2006 (42 U.S.C. 1395 note), as amended by
24
section 117 of the Medicare, Medicaid, and SCHIP
25
Extension Act of 2007 (Public Law 110–173) and
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S.L.C.
859
1
section 124 of the Medicare Improvements for Pa-
2
tients and Providers Act of 2008 (Public Law 110–
3
275), is amended by striking ‘‘September 30, 2009’’
4
and inserting ‘‘September 30, 2010’’.
5
(2) USE
OF PARTICULAR WAGE INDEX IN FIS-
6
CAL YEAR 2010.—For
7
the amendment made by this subsection during fis-
8
cal year 2010, the Secretary shall use the hospital
9
wage index that was promulgated by the Secretary
10
in the Federal Register on August 27, 2009 (74
11
Fed. Reg. 43754), and any subsequent corrections.
12
(b) PLAN
13
14
PITAL
FOR
purposes of implementation of
REFORMING
THE
MEDICARE HOS-
WAGE INDEX SYSTEM.—
(1) IN
GENERAL.—Not
later than December 31,
15
2011, the Secretary of Health and Human Services
16
(in this section referred to as the ‘‘Secretary’’) shall
17
submit to Congress a report that includes a plan to
18
reform the hospital wage index system under section
19
1886 of the Social Security Act.
20
(2) DETAILS.—In developing the plan under
21
paragraph (1), the Secretary shall take into account
22
the goals for reforming such system set forth in the
23
Medicare Payment Advisory Commission June 2007
24
report entitled ‘‘Report to Congress: Promoting
25
Greater Efficiency in Medicare’’, including estab-
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
860
1
lishing a new hospital compensation index system
2
that—
3
(A) uses Bureau of Labor Statistics data,
4
or other data or methodologies, to calculate rel-
5
ative wages for each geographic area involved;
6
(B) minimizes wage index adjustments be-
7
tween and within metropolitan statistical areas
8
and statewide rural areas;
9
(C) includes methods to minimize the vola-
10
tility of wage index adjustments that result
11
from implementation of policy, while maintain-
12
ing budget neutrality in applying such adjust-
13
ments;
14
(D) takes into account the effect that im-
15
plementation of the system would have on
16
health care providers and on each region of the
17
country;
18
(E) addresses issues related to occupa-
19
tional mix, such as staffing practices and ratios,
20
and any evidence on the effect on quality of
21
care or patient safety as a result of the imple-
22
mentation of the system; and
23
(F) provides for a transition.
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S.L.C.
861
1
(3) CONSULTATION.—In developing the plan
2
under paragraph (1), the Secretary shall consult
3
with relevant affected parties.
4
(c) USE
5
MINING
OF
PARTICULAR CRITERIA
FOR
DETER-
RECLASSIFICATIONS.—Notwithstanding any other
6 provision of law, in making decisions on applications for
7 reclassification of a subsection (d) hospital (as defined in
8 paragraph (1)(B) of section 1886(d) of the Social Security
9 Act (42 U.S.C. 1395ww(d)) for the purposes described in
10 paragraph (10)(D)(v) of such section for fiscal year 2011
11 and each subsequent fiscal year (until the first fiscal year
12 beginning on or after the date that is 1 year after the
13 Secretary of Health and Human Services submits the re14 port to Congress under subsection (b)), the Geographic
15 Classification Review Board established under paragraph
16 (10) of such section shall use the average hourly wage
17 comparison criteria used in making such decisions as of
18 September 30, 2008. The preceding sentence shall be ef19 fected in a budget neutral manner.
20
21
SEC. 3138. TREATMENT OF CERTAIN CANCER HOSPITALS.
Section 1833(t) of the Social Security Act (42 U.S.C.
22 1395l(t)) is amended by adding at the end the following
23 new paragraph:
24
25
‘‘(18) AUTHORIZATION
CANCER HOSPITALS.—
OF ADJUSTMENT FOR
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
862
1
‘‘(A) STUDY.—The Secretary shall conduct
2
a study to determine if, under the system under
3
this subsection, costs incurred by hospitals de-
4
scribed in section 1886(d)(1)(B)(v) with respect
5
to ambulatory payment classification groups ex-
6
ceed those costs incurred by other hospitals fur-
7
nishing services under this subsection (as deter-
8
mined appropriate by the Secretary). In con-
9
ducting the study under this subparagraph, the
10
Secretary shall take into consideration the cost
11
of drugs and biologicals incurred by such hos-
12
pitals.
13
‘‘(B) AUTHORIZATION
OF ADJUSTMENT.—
14
Insofar as the Secretary determines under sub-
15
paragraph (A) that costs incurred by hospitals
16
described in section 1886(d)(1)(B)(v) exceed
17
those costs incurred by other hospitals fur-
18
nishing services under this subsection, the Sec-
19
retary shall provide for an appropriate adjust-
20
ment under paragraph (2)(E) to reflect those
21
higher costs effective for services furnished on
22
or after January 1, 2011.’’.
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S.L.C.
863
1
2
3
SEC. 3139. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS.
(a) IN GENERAL.—Section 1847A of the Social Secu-
4 rity Act (42 U.S.C. 1395w–3a) is amended—
5
(1) in subsection (b)—
6
(A) in paragraph (1)—
7
(i) in subparagraph (A), by striking
8
‘‘or’’ at the end;
9
(ii) in subparagraph (B), by striking
10
the period at the end and inserting ‘‘; or’’;
11
and
12
(iii) by adding at the end the fol-
13
lowing new subparagraph:
14
‘‘(C) in the case of a biosimilar biological
15
product (as defined in subsection (c)(6)(H)),
16
the amount determined under paragraph (8).’’;
17
and
18
(B) by adding at the end the following new
19
paragraph:
20
‘‘(8) BIOSIMILAR
BIOLOGICAL PRODUCT.—The
21
amount specified in this paragraph for a biosimilar
22
biological product described in paragraph (1)(C) is
23
the sum of—
24
‘‘(A) the average sales price as determined
25
using the methodology described under para-
26
graph (6) applied to a biosimilar biological
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
864
1
product for all National Drug Codes assigned to
2
such product in the same manner as such para-
3
graph is applied to drugs described in such
4
paragraph; and
5
‘‘(B) 6 percent of the amount determined
6
under paragraph (4) for the reference biological
7
product (as defined in subsection (c)(6)(I)).’’;
8
and
9
(2) in subsection (c)(6), by adding at the end
10
11
the following new subparagraph:
‘‘(H) BIOSIMILAR
BIOLOGICAL PRODUCT.—
12
The term ‘biosimilar biological product’ means
13
a biological product approved under an abbre-
14
viated application for a license of a biological
15
product that relies in part on data or informa-
16
tion in an application for another biological
17
product licensed under section 351 of the Pub-
18
lic Health Service Act.
19
‘‘(I) REFERENCE
BIOLOGICAL PRODUCT.—
20
The term ‘reference biological product’ means
21
the biological product licensed under such sec-
22
tion 351 that is referred to in the application
23
described in subparagraph (H) of the biosimilar
24
biological product.’’.
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S.L.C.
865
1
(b) EFFECTIVE DATE.—The amendments made by
2 subsection (a) shall apply to payments for biosimilar bio3 logical products beginning with the first day of the second
4 calendar quarter after enactment of legislation providing
5 for a biosimilar pathway (as determined by the Secretary).
6
SEC. 3140. MEDICARE HOSPICE CONCURRENT CARE DEM-
7
8
9
ONSTRATION PROGRAM.
(a) ESTABLISHMENT.—
(1) IN
GENERAL.—The
Secretary of Health and
10
Human Services (in this section referred to as the
11
‘‘Secretary’’) shall establish a Medicare Hospice
12
Concurrent Care demonstration program at partici-
13
pating hospice programs under which Medicare
14
beneficiaries are furnished, during the same period,
15
hospice care and any other items or services covered
16
under title XVIII of the Social Security Act (42
17
U.S.C. 1395 et seq.) from funds otherwise paid
18
under such title to such hospice programs.
19
(2) DURATION.—The demonstration program
20
under this section shall be conducted for a 3-year
21
period.
22
(3) SITES.—The Secretary shall select not more
23
than 15 hospice programs at which the demonstra-
24
tion program under this section shall be conducted.
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S.L.C.
866
1
Such hospice programs shall be located in urban and
2
rural areas.
3
(b) INDEPENDENT EVALUATION AND REPORTS.—
4
(1) INDEPENDENT
EVALUATION.—The
Sec-
5
retary shall provide for the conduct of an inde-
6
pendent evaluation of the demonstration program
7
under this section. Such independent evaluation
8
shall determine whether the demonstration program
9
has improved patient care, quality of life, and cost-
10
effectiveness for Medicare beneficiaries participating
11
in the demonstration program.
12
(2) REPORTS.—The Secretary shall submit to
13
Congress a report containing the results of the eval-
14
uation conducted under paragraph (1), together with
15
such recommendations as the Secretary determines
16
appropriate.
17
(c) BUDGET NEUTRALITY.—With respect to the 3-
18 year period of the demonstration program under this sec19 tion, the Secretary shall ensure that the aggregate expend20 itures under title XVIII for such period shall not exceed
21 the aggregate expenditures that would have been expended
22 under such title if the demonstration program under this
23 section had not been implemented.
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S.L.C.
867
1
SEC. 3141. APPLICATION OF BUDGET NEUTRALITY ON A NA-
2
TIONAL BASIS IN THE CALCULATION OF THE
3
MEDICARE HOSPITAL WAGE INDEX FLOOR.
4
In the case of discharges occurring on or after Octo-
5 ber 1, 2010, for purposes of applying section 4410 of the
6 Balanced Budget Act of 1997 (42 U.S.C. 1395ww note)
7 and paragraph (h)(4) of section 412.64 of title 42, Code
8 of Federal Regulations, the Secretary of Health and
9 Human Services shall administer subsection (b) of such
10 section 4410 and paragraph (e) of such section 412.64
11 in the same manner as the Secretary administered such
12 subsection (b) and paragraph (e) for discharges occurring
13 during fiscal year 2008 (through a uniform, national ad14 justment to the area wage index).
15
16
17
18
SEC. 3142. HHS STUDY ON URBAN MEDICARE-DEPENDENT
HOSPITALS.
(a) STUDY.—
(1) IN
GENERAL.—The
Secretary of Health and
19
Human Services (in this section referred to as the
20
‘‘Secretary’’) shall conduct a study on the need for
21
an additional payment for urban Medicare-depend-
22
ent hospitals for inpatient hospital services under
23
section 1886 of the Social Security Act (42 U.S.C.
24
1395ww). Such study shall include an analysis of—
25
(A) the Medicare inpatient margins of
26
urban Medicare-dependent hospitals, as com-
O:\MAL\MAL09863.xml [file 3 of 9]
S.L.C.
868
1
pared to other hospitals which receive 1 or more
2
additional payments or adjustments under such
3
section (including those payments or adjust-
4
ments described in paragraph (2)(A)); and
5
(B) whether payments to medicare-depend-
6
ent, small rural hospitals under subsection
7
(d)(5)(G) of such section should be applied to
8
urban Medicare-dependent hospitals.
9
(2) URBAN
MEDICARE-DEPENDENT HOSPITAL
10
DEFINED.—For
11
‘‘urban Medicare-dependent hospital’’ means a sub-
12
section (d) hospital (as defined in subsection
13
(d)(1)(B) of such section) that—
purposes of this section, the term
14
(A) does not receive any additional pay-
15
ment or adjustment under such section, such as
16
payments for indirect medical education costs
17
under subsection (d)(5)(B) of such section, dis-
18
proportionate share payments under subsection
19
(d)(5)(A) of such section, payments to a rural
20
referral center under subsection (d)(5)(C) of
21
such section, payments to a critical access hos-
22
pital under section 1814(l) of such Act (42
23
U.S.C. 1395f(l)), payments to a sole community
24
hospital under subsection (d)(5)(D) of such sec-
25
tion 1886, or payments to a medicare-depend-
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S.L.C.
869
1
ent, small rural hospital under subsection
2
(d)(5)(G) of such section 1886; and
3
(B) for which more than 60 percent of its
4
inpatient days or discharges during 2 of the 3
5
most recently audited cost reporting periods for
6
which the Secretary has a settled cost report
7
were attributable to inpatients entitled to bene-
8
fits under part A of title XVIII of such Act.
9
(b) REPORT.—Not later than 9 months after the date
10 of enactment of this Act, the Secretary shall submit to
11 Congress a report containing the results of the study con12 ducted under subsection (a), together with recommenda13 tions for such legislation and administrative