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HR 3200 IHRHCommentsClose CommentsPermalink

111th CONGRESSCommentsClose CommentsPermalink

1st SessionCommentsClose CommentsPermalink

H. R. 3200CommentsClose CommentsPermalink

To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.CommentsClose CommentsPermalink

IN THE HOUSE OF REPRESENTATIVESCommentsClose CommentsPermalink

July 14, 2009CommentsClose CommentsPermalink

Mr. DINGELL (for himself, Mr. RANGEL, Mr. WAXMAN, Mr. GEORGE MILLER of California, Mr. STARK, Mr. PALLONE, and Mr. ANDREWS) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Labor, Oversight and Government Reform, and the Budget, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concernedCommentsClose CommentsPermalink

A BILLCommentsClose CommentsPermalink

To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.CommentsClose CommentsPermalink

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, CommentsClose CommentsPermalink

SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, AND SUBTITLES.

(a) Short Title- This Act may be cited as the ‘America’s Affordable Health Choices Act of 2009’. CommentsClose CommentsPermalink





(b) Table of Divisions, Titles, and Subtitles- This Act is divided into divisions, titles, and subtitles as follows: CommentsClose CommentsPermalink

DIVISION A--AFFORDABLE HEALTH CARE CHOICES

TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS CommentsClose CommentsPermalink





Subtitle A--General Standards CommentsClose CommentsPermalink





Subtitle B--Standards Guaranteeing Access to Affordable Coverage CommentsClose CommentsPermalink





Subtitle C--Standards Guaranteeing Access to Essential Benefits CommentsClose CommentsPermalink





Subtitle D--Additional Consumer Protections CommentsClose CommentsPermalink





Subtitle E--Governance CommentsClose CommentsPermalink





Subtitle F--Relation to Other Requirements; Miscellaneous CommentsClose CommentsPermalink





Subtitle G--Early Investments CommentsClose CommentsPermalink





TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS CommentsClose CommentsPermalink





Subtitle A--Health Insurance Exchange CommentsClose CommentsPermalink





Subtitle B--Public Health Insurance Option CommentsClose CommentsPermalink





Subtitle C--Individual Affordability Credits CommentsClose CommentsPermalink





Subtitle D--Health Insurance Cooperatives CommentsClose CommentsPermalink





TITLE III--SHARED RESPONSIBILITY CommentsClose CommentsPermalink





Subtitle A--Individual Responsibility Subtitle B--Employer Responsibility Subtitle A--Individual Responsibility CommentsClose CommentsPermalink





Subtitle B--Employer Responsibility CommentsClose CommentsPermalink





TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 CommentsClose CommentsPermalink





Subtitle A--Shared Responsibility CommentsClose CommentsPermalink





Subtitle B--Credit for Small Business Employee Health Coverage Expenses CommentsClose CommentsPermalink





Subtitle C--Disclosures To Carry Out Health Insurance Exchange Subsidies CommentsClose CommentsPermalink





Subtitle D--Other Revenue Provisions CommentsClose CommentsPermalink

DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

TITLE I--IMPROVING HEALTH CARE VALUE CommentsClose CommentsPermalink





Subtitle A--Provisions Related to Medicare Part A CommentsClose CommentsPermalink





Subtitle B--Provisions Related to Part BMedicare Part B CommentsClose CommentsPermalink





Subtitle C--Provisions Related to Medicare Parts A and B CommentsClose CommentsPermalink





Subtitle D--Medicare Advantage Reforms CommentsClose CommentsPermalink





Subtitle E--Improvements to Medicare Part D CommentsClose CommentsPermalink





Subtitle F--Medicare Rural Access Protections CommentsClose CommentsPermalink





TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS CommentsClose CommentsPermalink





Subtitle A--Improving and Simplifying Financial Assistance for Low Income Medicare Beneficiaries CommentsClose CommentsPermalink





Subtitle B--Reducing Health Disparities CommentsClose CommentsPermalink





Subtitle C--Miscellaneous Improvements CommentsClose CommentsPermalink





TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND COORDINATED CARE CommentsClose CommentsPermalink





TITLE IV--QUALITY CommentsClose CommentsPermalink





Subtitle A--Comparative Effectiveness Research CommentsClose CommentsPermalink





Subtitle B--Nursing Home Transparency Subtitle B--Nursing Home Transparency CommentsClose CommentsPermalink





Subtitle C--Quality Measurements CommentsClose CommentsPermalink





Subtitle D--Physician Payments Sunshine Provision CommentsClose CommentsPermalink





Subtitle E--Public Reporting on Health Care-Associated Infections CommentsClose CommentsPermalink





TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION CommentsClose CommentsPermalink





TITLE VI--PROGRAM INTEGRITY CommentsClose CommentsPermalink





Subtitle A--Increased Funding To Fight Waste, Fraud, and Abuse CommentsClose CommentsPermalink





Subtitle B--Enhanced Penalties for Fraud and Abuse CommentsClose CommentsPermalink





Subtitle C--Enhanced Program and Provider Protections CommentsClose CommentsPermalink





Subtitle D--Access to Information Needed To Prevent Fraud, Waste, and Abuse CommentsClose CommentsPermalink





TITLE VII--MEDICAID AND CHIP CommentsClose CommentsPermalink





Subtitle A--Medicaid and Health Reform CommentsClose CommentsPermalink





Subtitle B--Prevention Subtitle C--Access Subtitle D--Coverage Subtitle B--Prevention CommentsClose CommentsPermalink





Subtitle C--Access CommentsClose CommentsPermalink





Subtitle D--Coverage CommentsClose CommentsPermalink





Subtitle E--Financing CommentsClose CommentsPermalink





Subtitle F--Waste, Fraud, and Abuse CommentsClose CommentsPermalink





Subtitle G--Puerto Rico and the Territoriesayments to the Territories CommentsClose CommentsPermalink





Subtitle H--Miscellaneous CommentsClose CommentsPermalink





TITLE VIII--REVENUE-RELATED PROVISIONS CommentsClose CommentsPermalink





TITLE IX--MISCELLANEOUS PROVISIONS CommentsClose CommentsPermalink

DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

TITLE I--COMMUNITY HEALTH CENTERS CommentsClose CommentsPermalink





TITLE II--WORKFORCE CommentsClose CommentsPermalink





Subtitle A--Primary Care Workforce CommentsClose CommentsPermalink





Subtitle B--Nursing Workforce CommentsClose CommentsPermalink





Subtitle C--Public Health Workforce CommentsClose CommentsPermalink





Subtitle D--Adapting Workforce to Evolving Health System Needs CommentsClose CommentsPermalink





TITLE III--PREVENTION AND WELLNESS CommentsClose CommentsPermalink





TITLE IV--QUALITY AND SURVEILLANCE CommentsClose CommentsPermalink





TITLE V--OTHER PROVISIONS CommentsClose CommentsPermalink





Subtitle A--Drug Discount for Rural and Other Hospitals CommentsClose CommentsPermalink





Subtitle B--School-Based Health Clinics Subtitle C--National Medical Device Registry Subtitle D--Grants for Comprehensive Programs To Provide Education to Nurses and Create a Pipeline to Nursing Subtitle B--Programs CommentsClose CommentsPermalink





Subtitle C--Food and Drug Administration CommentsClose CommentsPermalink





Subtitle D--Community Living Assistance Services and Supports CommentsClose CommentsPermalink





Subtitle E--States Failing To Adhere to Certain Employment ObligationMiscellaneous CommentsClose CommentsPermalink

DIVISION A--AFFORDABLE HEALTH CARE CHOICES CommentsClose CommentsPermalink

SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS.

(a) Purpose- CommentsClose CommentsPermalink





(1) IN GENERAL- The purpose of this division is to provide affordable, quality health care for all Americans and reduce the growth in health care spending. CommentsClose CommentsPermalink





(2) BUILDING ON CURRENT SYSTEM- This division achieves this purpose by building on what works in today’s health care system, while repairing the aspects that are broken. CommentsClose CommentsPermalink





(3) INSURANCE REFORMS- This division-- CommentsClose CommentsPermalink





(A) enacts strong insurance market reforms; CommentsClose CommentsPermalink





(B) creates a new Health Insurance Exchange, with a public health insurance option alongside private plans and cooperatives under subtitle D of title II; CommentsClose CommentsPermalink





(C) includes sliding scale affordability credits; and CommentsClose CommentsPermalink





(D) initiates shared responsibility among workers, employers, and the government; CommentsClose CommentsPermalink





so that all Americans have coverage of essential health benefits. CommentsClose CommentsPermalink





(4) HEALTH DELIVERY REFORM- This division institutes health delivery system reforms both to increase quality and to reduce growth in health spending so that health care becomes more affordable for businesses, families, and government. CommentsClose CommentsPermalink





(b) Table of Contents of Division- The table of contents of this division is as follows: CommentsClose CommentsPermalink





Sec. 100. Purpose; table of contents of division; general definitions. CommentsClose CommentsPermalink

TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

Subtitle A--General Standards

Sec. 101. Requirements reforming health insurance marketplace. CommentsClose CommentsPermalink





Sec. 102. Protecting the choice to keep current coverage. CommentsClose CommentsPermalink

Subtitle B--Standards Guaranteeing Access to Affordable Coverage

Sec. 111. Prohibiting pre-existing condition exclusions. CommentsClose CommentsPermalink





Sec. 112. Guaranteed issue and renewal for insured plans. CommentsClose CommentsPermalink





Sec. 113. Insurance rating rules. CommentsClose CommentsPermalink





Sec. 114. Nondiscrimination in benefits; parity in mental health and substance abuse disorder benefits. CommentsClose CommentsPermalink





Sec. 115. Ensuring adequacy of provider networks. CommentsClose CommentsPermalink





Sec. 116. Ensuring value and lower premiums. CommentsClose CommentsPermalink

Subtitle C--Standards Guaranteeing Access to Essential Benefits

Sec. 121. Coverage of essential benefits package. CommentsClose CommentsPermalink





Sec. 122. Essential benefits package defined. CommentsClose CommentsPermalink





Sec. 123. Health Benefits Advisory Committee. CommentsClose CommentsPermalink





Sec. 124. Process for adoption of recommendations; adoption of benefit standards. CommentsClose CommentsPermalink





Sec. 125. Prohibition of discrimination in health care services based on religious or spiritual content. CommentsClose CommentsPermalink

Subtitle D--Additional Consumer Protections

Sec. 131. Requiring fair marketing practices by health insurers. CommentsClose CommentsPermalink





Sec. 132. Requiring fair grievance and appeals mechanisms. CommentsClose CommentsPermalink





Sec. 133. Requiring information transparency and plan disclosure. CommentsClose CommentsPermalink





Sec. 134. Application to qualified health benefits plans not offered through the Health Insurance Exchange. CommentsClose CommentsPermalink





Sec. 135. Timely payment of claims. CommentsClose CommentsPermalink





Sec. 136. Standardized rules for coordination and subrogation of benefits. CommentsClose CommentsPermalink





Sec. 137. Application of administrative simplification. CommentsClose CommentsPermalink





Sec. 138. Information on end-of-life planning. CommentsClose CommentsPermalink





Sec. 139. Utilization review activities. CommentsClose CommentsPermalink





Sec. 139A. Internal appeals procedures. CommentsClose CommentsPermalink





Sec. 139B. External appeals procedures. CommentsClose CommentsPermalink

Subtitle E--Governance

Sec. 141. Health Choices Administration; Health Choices Commissioner. CommentsClose CommentsPermalink





Sec. 142. Duties and authority of Commissioner. CommentsClose CommentsPermalink





Sec. 143. Consultation and coordination. CommentsClose CommentsPermalink





Sec. 144. Health Insurance Ombudsman. CommentsClose CommentsPermalink

Subtitle F--Relation to Other Requirements; Miscellaneous

Sec. 151. Relation to other requirements. CommentsClose CommentsPermalink





Sec. 152. Prohibiting discrimination in health care. CommentsClose CommentsPermalink





Sec. 153. Whistleblower protection. CommentsClose CommentsPermalink





Sec. 154. Construction regarding collective bargaining. CommentsClose CommentsPermalink





Sec. 155. Severability. CommentsClose CommentsPermalink





Sec. 156. Application of State and Federal laws regarding abortion. CommentsClose CommentsPermalink





Sec. 157. Non-discrimination on abortion and respect for rights of conscience. CommentsClose CommentsPermalink

Subtitle G--Early Investments

Sec. 161. Ensuring value and lower premiums. CommentsClose CommentsPermalink





Sec. 162. Ending health insurance rescission abuse. CommentsClose CommentsPermalink





Sec. 163. Ending health insurance denials and delays of necessary treatment for children with deformities. CommentsClose CommentsPermalink





Sec. 164. Administrative simplification. CommentsClose CommentsPermalink





Sec. 1645. Expansion of electronic transactions in medicare. CommentsClose CommentsPermalink





Sec. 166. Reinsurance program for retirees. CommentsClose CommentsPermalink





Sec. 167. Limitations on preexisting condition exclusions in group health plans and health insurance coverage in the group and individual markets in advance of applicability of new prohibition of preexisting condition exclusions. CommentsClose CommentsPermalink

TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

Subtitle A--Health Insurance Exchange

Sec. 201. Establishment of Health Insurance Exchange; outline of duties; definitions. CommentsClose CommentsPermalink





Sec. 202. Exchange-eligible individuals and employers. CommentsClose CommentsPermalink





Sec. 203. Benefits package levels. CommentsClose CommentsPermalink





Sec. 204. Contracts for the offering of Exchange-participating health benefits plans. CommentsClose CommentsPermalink





Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plans. CommentsClose CommentsPermalink





Sec. 206. Other functions. CommentsClose CommentsPermalink





Sec. 207. Health Insurance Exchange Trust Fund. CommentsClose CommentsPermalink





Sec. 208. Optional operation of State-based health insurance exchanges. CommentsClose CommentsPermalink





Sec. 209. Limitation on premium increases under Exchange-participating health benefits plans. CommentsClose CommentsPermalink

Subtitle B--Public Health Insurance Option

Sec. 221. Establishment and administration of a public health insurance option as an Exchange-qualified health benefits plan. CommentsClose CommentsPermalink





Sec. 222. Premiums and financing. CommentsClose CommentsPermalink





Sec. 223. PNegotiated payment rates for items and services. CommentsClose CommentsPermalink





Sec. 224. Modernized payment initiatives and delivery system reform. CommentsClose CommentsPermalink





Sec. 225. Provider participation. CommentsClose CommentsPermalink





Sec. 226. Application of fraud and abuse provisions. CommentsClose CommentsPermalink





Sec. 227. Application of HIPAA insurance requirements. CommentsClose CommentsPermalink





Sec. 228. Application of health information privacy, security, and electronic transaction requirements. CommentsClose CommentsPermalink





Sec. 229. Enrollment in public health insurance option is voluntary. CommentsClose CommentsPermalink

Subtitle C--Individual Affordability Credits

Sec. 241. Availability through Health Insurance Exchange. CommentsClose CommentsPermalink





Sec. 242. Affordable credit eligible individual. CommentsClose CommentsPermalink





Sec. 243. Affordable premium credit. CommentsClose CommentsPermalink





Sec. 244. Affordability cost-sharing credit. CommentsClose CommentsPermalink





Sec. 245. Income determinations. CommentsClose CommentsPermalink





Sec. 246. No Federal payment for undocumented aliens. CommentsClose CommentsPermalink

TITLE III--SHARED RESPONSIBILITY

Subtitle A--Individual Responsibility

Sec. 301. Individual responsibility. CommentsClose CommentsPermalink

Subtitle B--Employer Responsibility

Part 1--Health Coverage Participation Requirements

Sec. 311. Health coverage participation requirements. CommentsClose CommentsPermalink





Sec. 312. Employer responsibility to contribute towards employee and dependent coverage. CommentsClose CommentsPermalink





Sec. 313. Employer contributions in lieu of coverage. CommentsClose CommentsPermalink





Sec. 314. Authority related to improper steering. CommentsClose CommentsPermalink

Part 2--Satisfaction of Health Coverage Participation Requirements

Sec. 321. Satisfaction of health coverage participation requirements under the Employee Retirement Income Security Act of 1974. CommentsClose CommentsPermalink





Sec. 322. Satisfaction of health coverage participation requirements under the Internal Revenue Code of 1986. CommentsClose CommentsPermalink





Sec. 323. Satisfaction of health coverage participation requirements under the Public Health Service Act. CommentsClose CommentsPermalink





Sec. 324. Additional rules relating to health coverage participation requirements. CommentsClose CommentsPermalink

TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986

Subtitle A--Shared Responsibility

Part 1--Individual Responsibility

Sec. 401. Tax on individuals without acceptable health care coverage. CommentsClose CommentsPermalink

Part 2--Employer Responsibility

Sec. 411. Election to satisfy health coverage participation requirements. CommentsClose CommentsPermalink





Sec. 412. Responsibilities of nonelecting employers. CommentsClose CommentsPermalink

Subtitle B--Credit for Small Business Employee Health Coverage Expenses

Sec. 421. Credit for small business employee health coverage expenses. CommentsClose CommentsPermalink

Subtitle C--Disclosures To Carry Out Health Insurance Exchange Subsidies

Sec. 431. Disclosures to carry out health insurance exchange subsidies. CommentsClose CommentsPermalink

Subtitle D--Other Revenue Provisions

Part 1--General Provisions

Sec. 441. Surcharge on high income individuals. CommentsClose CommentsPermalink





Sec. 442. Delay in application of worldwide allocation of interest. CommentsClose CommentsPermalink

Part 2--Prevention of Tax Avoidance

Sec. 451. Limitation on treaty benefits for certain deductible payments. CommentsClose CommentsPermalink





Sec. 452. Codification of economic substance doctrine. CommentsClose CommentsPermalink





Sec. 453. Penalties for underpayments. CommentsClose CommentsPermalink





(c) General Definitions- Except as otherwise provided, in this division: CommentsClose CommentsPermalink





(1) ACCEPTABLE COVERAGE- The term ‘acceptable coverage’ has the meaning given such term in section 202(d)(2). CommentsClose CommentsPermalink





(2) BASIC PLAN- The term ‘basic plan’ has the meaning given such term in section 203(c). CommentsClose CommentsPermalink





(3) COMMISSIONER- The term ‘Commissioner’ means the Health Choices Commissioner established under section 141. CommentsClose CommentsPermalink





(4) COST-SHARING- The term ‘cost-sharing’ includes deductibles, coinsurance, copayments, and similar charges but does not include premiums or any network payment differential for covered services or spending for non-covered services. CommentsClose CommentsPermalink





(5) DEPENDENT- The term ‘dependent’ has the meaning given such term by the Commissioner and includes a spouse. CommentsClose CommentsPermalink





(6) EMPLOYMENT-BASED HEALTH PLAN- The term ‘employment-based health plan’-- CommentsClose CommentsPermalink





(A) means a group health plan (as defined in section 733(a)(1) of the Employee Retirement Income Security Act of 1974); and CommentsClose CommentsPermalink





(B) includes such a plan that is the following: CommentsClose CommentsPermalink





(i) FEDERAL, STATE, AND TRIBAL GOVERNMENTAL PLANS- A governmental plan (as defined in section 3(32) of the Employee Retirement Income Security Act of 1974), including a health benefits plan offered under chapter 89 of title 5, United States Code. CommentsClose CommentsPermalink





(ii) CHURCH PLANS- A church plan (as defined in section 3(33) of the Employee Retirement Income Security Act of 1974). CommentsClose CommentsPermalink





(7) ENHANCED PLAN- The term ‘enhanced plan’ has the meaning given such term in section 203(c). CommentsClose CommentsPermalink





(8) ESSENTIAL BENEFITS PACKAGE- The term ‘essential benefits package’ is defined in section 122(a). CommentsClose CommentsPermalink





(9) FAMILY- The term ‘family’ means an individual and includes the individual’s dependents. CommentsClose CommentsPermalink





(10) FEDERAL POVERTY LEVEL; FPL- The terms ‘Federal poverty level’ and ‘FPL’ have the meaning given the term ‘poverty line’ in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. CommentsClose CommentsPermalink





(11) HEALTH BENEFITS PLAN- The terms ‘health benefits plan’ means health insurance coverage and an employment-based health plan and includes the public health insurance option.(12) HEALTH INSURANCE COVERAGE; HEALTH INSURANCE and cooperatives under subtitle D of title II. CommentsClose CommentsPermalink





(12) HEALTH INSURANCE COVERAGE; HEALTH INSURANCE ISSUER- The terms ‘health insurance coverage’ and ‘health insurance issuer’ have the meanings given such terms in section 2791 of the Public Health Service Act. CommentsClose CommentsPermalink





(13) HEALTH INSURANCE EXCHANGE- The term ‘Health Insurance Exchange’ means the Health Insurance Exchange established under section 201. CommentsClose CommentsPermalink





(14) MEDICAID- The term ‘Medicaid’ means a State plan under title XIX of the Social Security Act (whether or not the plan is operating under a waiver under section 1115 of such Act). CommentsClose CommentsPermalink





(15) MEDICARE- The term ‘Medicare’ means the health insurance programs under title XVIII of the Social Security Act. CommentsClose CommentsPermalink





(16) PLAN SPONSOR- The term ‘plan sponsor’ has the meaning given such term in section 3(16)(B) of the Employee Retirement Income Security Act of 1974. CommentsClose CommentsPermalink





(17) PLAN YEAR- The term ‘plan year’ means-- CommentsClose CommentsPermalink





(A) with respect to an employment-based health plan, a plan year as specified under such plan; or CommentsClose CommentsPermalink





(B) with respect to a health benefits plan other than an employment-based health plan, a 12-month period as specified by the Commissioner. CommentsClose CommentsPermalink





(18) PREMIUM PLAN; PREMIUM-PLUS PLAN- The terms ‘premium plan’ and ‘premium-plus plan’ have the meanings given such terms in section 203(c). CommentsClose CommentsPermalink





(19) QHBP OFFERING ENTITY- The terms ‘QHBP offering entity’ means, with respect to a health benefits plan that is-- CommentsClose CommentsPermalink





(A) a group health plan (as defined, subject to subsection (d), in section 733(a)(1) of the Employee Retirement Income Security Act of 1974), the plan sponsor in relation to such group health plan, except that, in the case of a plan maintained jointly by 1 or more employers and 1 or more employee organizations and with respect to which an employer is the primary source of financing, such term means such employer; CommentsClose CommentsPermalink





(B) health insurance coverage, the health insurance issuer offering the coverage;(C) the public health, including a cooperative under subtitle D of title II; CommentsClose CommentsPermalink





(C) the public health insurance option, the Secretary of Health and Human Services; CommentsClose CommentsPermalink





(D) a non-Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the State or political subdivision of a State (or agency or instrumentality of such State or subdivision) which establishes or maintains such plan; or CommentsClose CommentsPermalink





(E) a Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the appropriate Federal official. CommentsClose CommentsPermalink





(20) QUALIFIED HEALTH BENEFITS PLAN- The term ‘qualified health benefits plan’ means a health benefits plan that meets the requirements for such a plan under title I and includes the public health insurance option.(21) PUBLIC HEALTH INSURANCE and cooperatives under subtitle D of title II. CommentsClose CommentsPermalink





(21) PUBLIC HEALTH INSURANCE OPTION- The term ‘public health insurance option’ means the public health insurance option as provided under subtitle B of title II. CommentsClose CommentsPermalink





(22) SERVICE AREA; PREMIUM RATING AREA- The terms ‘service area’ and ‘premium rating area’ mean with respect to health insurance coverage-- CommentsClose CommentsPermalink





(A) offered other than through the Health Insurance Exchange, such an area as established by the QHBP offering entity of such coverage in accordance with applicable State law; and CommentsClose CommentsPermalink





(B) offered through the Health Insurance Exchange, such an area as established by such entity in accordance with applicable State law and applicable rules of the Commissioner for Exchange-participating health benefits plans. CommentsClose CommentsPermalink





(23) STATE- The term ‘State’ means the 50 States and the District of Columbia. CommentsClose CommentsPermalink





(24) STATE MEDICAID AGENCY- The term ‘State Medicaid agency’ means, with respect to a Medicaid plan, the single State agency responsible for administering such plan under title XIX of the Social Security Act. CommentsClose CommentsPermalink





(25) Y1, Y2, ETC.- The terms ‘Y1’ , ‘Y2’, ‘Y3’, ‘Y4’, ‘Y5’, and similar subsequently numbered terms, mean 2013 and subsequent years, respectively. CommentsClose CommentsPermalink

TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS CommentsClose CommentsPermalink

Subtitle A--General Standards CommentsClose CommentsPermalink

SEC. 101. REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE.

(a) Purpose- The purpose of this title is to establish standards to ensure that new health insurance coverage and employment-based health plans that are offered meet standards guaranteeing access to affordable coverage, essential benefits, and other consumer protections. CommentsClose CommentsPermalink





(b) Requirements for Qualified Health Benefits Plans- On or after the first day of Y1, a health benefits plan shall not be a qualified health benefits plan under this division unless the plan meets the applicable requirements of the following subtitles for the type of plan and plan year involved: CommentsClose CommentsPermalink





(1) Subtitle B (relating to affordable coverage). CommentsClose CommentsPermalink





(2) Subtitle C (relating to essential benefits). CommentsClose CommentsPermalink





(3) Subtitle D (relating to consumer protection). CommentsClose CommentsPermalink





(c) Terminology- In this division: CommentsClose CommentsPermalink





(1) ENROLLMENT IN EMPLOYMENT-BASED HEALTH PLANS- An individual shall be treated as being ‘enrolled’ in an employment-based health plan if the individual is a participant or beneficiary (as such terms are defined in section 3(7) and 3(8), respectively, of the Employee Retirement Income Security Act of 1974) in such plan. CommentsClose CommentsPermalink





(2) INDIVIDUAL AND GROUP HEALTH INSURANCE COVERAGE- The terms ‘individual health insurance coverage’ and ‘group health insurance coverage’ mean health insurance coverage offered in the individual market or large or small group market, respectively, as defined in section 2791 of the Public Health Service Act. CommentsClose CommentsPermalink

SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.

(a) Grandfathered Health Insurance Coverage Defined- Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term ‘grandfathered health insurance coverage’ means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met: CommentsClose CommentsPermalink





(1) LIMITATION ON NEW ENROLLMENT- CommentsClose CommentsPermalink





(A) IN GENERAL- Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1. CommentsClose CommentsPermalink





(B) DEPENDENT COVERAGE PERMITTED- Subparagraph (A) shall not affect the subsequent enrollment of a dependent of an individual who is covered as of such first day. CommentsClose CommentsPermalink





(2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS- Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1. CommentsClose CommentsPermalink





(3) RESTRICTIONS ON PREMIUM INCREASES- The issuer cannot vary the percentage increase in the premium for a risk group of enrollees in specific grandfathered health insurance coverage without changing the premium for all enrollees in the same risk group at the same rate, as specified by the Commissioner. CommentsClose CommentsPermalink





(b) Grace Period for Current Employment-based Health Plans- CommentsClose CommentsPermalink





(1) GRACE PERIOD- CommentsClose CommentsPermalink





(A) IN GENERAL- The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 101, including the essential benefit package requirement under section 121. CommentsClose CommentsPermalink





(B) EXCEPTION FOR LIMITED BENEFITS PLANS- Subparagraph (A) shall not apply to an employment-based health plan in which the coverage consists only of one or more of the following: CommentsClose CommentsPermalink





(i) Any coverage described in section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009 (Public LawL 111-5). CommentsClose CommentsPermalink





(ii) Excepted benefits (as defined in section 733(c) of the Employee Retirement Income Security Act of 1974), including coverage under a specified disease or illness policy described in paragraph (3)(A) of such section. CommentsClose CommentsPermalink





(iii) Such other limited benefits as the Commissioner may specify. CommentsClose CommentsPermalink





In no case shall an employment-based health plan in which the coverage consists only of one or more of the coverage or benefits described in clauses (i) through (iii) be treated as acceptable coverage under this division CommentsClose CommentsPermalink





(2) TRANSITIONAL TREATMENT AS ACCEPTABLE COVERAGE- During the grace period specified in paragraph (1)(A), an employment-based health plan that is described in such paragraph shall be treated as acceptable coverage under this division. CommentsClose CommentsPermalink





(c) Limitation on Individual Health Insurance Coverage- CommentsClose CommentsPermalink





(1) IN GENERAL- Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan. CommentsClose CommentsPermalink





(2) SEPARATE, EXCEPTED COVERAGE PERMITTED- Excepted benefits (as defined in section 2791(c) of the Public Health Service Act) are not included within the definition of health insurance coverage. Nothing in paragraph (1) shall prevent the offering, other than through the Health Insurance Exchange, of excepted benefits so long as it is offered and priced separately from health insurance coverage. CommentsClose CommentsPermalink





(3) STAND-ALONE DENTAL AND VISION COVERAGE PERMITTED- Nothing in this division shall be construed-- CommentsClose CommentsPermalink





(A) to prevent the offering of a stand-alone plans that offer coverage of excepted benefits described in section 2791(c)(2)(A) of the Public Health Service Act (relating to limited scope dental or vision benefits)for individuals and families from a State licensed dental and vision carrier; or CommentsClose CommentsPermalink





(B) as applying requirements for a qualified health benefits plan to such stand-alone plans that is offered and priced separately from a qualified health benefits plan. CommentsClose CommentsPermalink

Subtitle B--Standards Guaranteeing Access to Affordable Coverage CommentsClose CommentsPermalink

SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS.

A qualified health benefits plan may not impose any pre-existing condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any health status-related factors (as defined in section 2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent. CommentsClose CommentsPermalink

SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS.

The requirements of sections 2711 (other than subsections (c) and (e)) and 2712 (other than paragraphs (3), and (6) of subsection (b) and subsection (e)) of the Public Health Service Act, relating to guaranteed availability and renewability of health insurance coverage, shall apply to individuals and employers in all individual and group health insurance coverage, whether offered to individuals or employers through the Health Insurance Exchange, through any employment-based health plan, or otherwise, and shall apply to the public health insurance option, in the same manner as such sections apply to employers and health insurance coverage offered in the small group market, except that such section 2712(b)(1) shall apply only if, before nonrenewal or discontinuation of coverage, the issuer has provided the enrollee with notice of non-payment of premiums and there is a grace period during which the enrollees has an opportunity to correct such nonpayment. Rescissions of such coverage shall be prohibited except in cases of fraud as defined in sections 2712(b)(2) of such Act. CommentsClose CommentsPermalink

SEC. 113. INSURANCE RATING RULES.

(a) In General- The premium rate charged for an insured qualified health benefits plan and for coverage under the public health insurance option may not vary except as follows: CommentsClose CommentsPermalink





(1) LIMITED AGE VARIATION PERMITTED- By age (within such age categories as the Commissioner shall specify) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1. CommentsClose CommentsPermalink





(2) BY AREA- By premium rating area (as permitted by State insurance regulators or, in the case of Exchange-participating health benefits plans, as specified by the Commissioner in consultation with such regulators). CommentsClose CommentsPermalink





(3) BY FAMILY ENROLLMENT- By family enrollment (such as variations within categories and compositions of families) so long as the ratio of the premium for family enrollment (or enrollments) to the premium for individual enrollment is uniform, as specified under State law and consistent with rules of the Commissioner. CommentsClose CommentsPermalink





(b) Actuarial Value of Optional Service Coverage- CommentsClose CommentsPermalink





(1) IN GENERAL- The Commissioner shall estimate the basic per enrollee, per month cost, determined on an average actuarial basis, for including coverage under a basic plan of the services described in section 122(d)(4)(A). CommentsClose CommentsPermalink





(2) CONSIDERATIONS- In making such estimate the Commissioner-- CommentsClose CommentsPermalink





(A) may take into account the impact on overall costs of the inclusion of such coverage, but may not take into account any cost reduction estimated to result from such services, including prenatal care, delivery, or postnatal care; CommentsClose CommentsPermalink





(B) shall estimate such costs as if such coverage were included for the entire population covered; and CommentsClose CommentsPermalink





(C) may not estimate such a cost at less than $1 per enrollee, per month. CommentsClose CommentsPermalink





(c) Study and Reports- CommentsClose CommentsPermalink





(1) STUDY- The Commissioner, in coordination with the Secretary of Health and Human Services and the Secretary of Labor, shall conduct a study of the large group insured and self-insured employer health care markets. Such study shall examine the following: CommentsClose CommentsPermalink





(A) The types of employers by key characteristics, including size, that purchase insured products versus those that self-insure. CommentsClose CommentsPermalink





(B) The similarities and differences between typical insured and self-insured health plans. CommentsClose CommentsPermalink





(C) The financial solvency and capital reserve levels of employers that self-insure by employer size. CommentsClose CommentsPermalink





(D) The risk of self-insured employers not being able to pay obligations or otherwise becoming financially insolvent. CommentsClose CommentsPermalink





(E) The extent to which rating rules are likely to cause adverse selection in the large group market or to encourage small and mid size employers to self-insure CommentsClose CommentsPermalink





(2) REPORTS- Not later than 18 months after the date of the enactment of this Act, the Commissioner shall submit to Congress and the applicable agencies a report on the study conducted under paragraph (1). Such report shall include any recommendations the Commissioner deems appropriate to ensure that the law does not provide incentives for small and mid-size employers to self-insure or create adverse selection in the risk pools of large group insurers and self-insured employers. Not later than 18 months after the first day of Y1, the Commissioner shall submit to Congress and the applicable agencies an updated report on such study, including updates on such recommendations. CommentsClose CommentsPermalink

SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.

(a) Nondiscrimination in Benefits- A qualified health benefits plan (including the public health insurance option) shall comply with standards established by the Commissioner to prohibit discrimination in health benefits or benefit structures for qualifying health benefits plans, building from sections 702 of Employee Retirement Income Security Act of 1974, 2702 of the Public Health Service Act, and section 9802 of the Internal Revenue Code of 1986. CommentsClose CommentsPermalink





(b) Parity in Mental Health and Substance Abuse Disorder Benefits- To the extent such provisions are not superceded by or inconsistent with subtitle C, the provisions of section 2705 (other than subsections (a)(1), (a)(2), and (c)) of section 2705 of the Public Health Service Act shall apply to a qualified health benefits plan, regardless of whether it is offered in the individual or group market, in the same manner as such provisions apply to health insurance coverage offered in the large group market. CommentsClose CommentsPermalink

SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.

(a) In General- A qualified health benefits plan that(including the public health insurance option) that uses a provider network for items and services shall meet such standards respecting provider networks as the Commissioner may establish to assure the adequacy of such networks in ensuring enrollee access to such items and services and transparency in the cost-sharing differentials between in-network coverage and out-of-network coverage. CommentsClose CommentsPermalink





(b) Provider Network Defined- In this division, the term ‘provider network’ means the providers with respect to which covered benefits, treatments, and services are available under a health benefits plan. CommentsClose CommentsPermalink

SEC. 116. ENSURING VALUE AND LOWER PREMIUMS.

(a) In General- A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment sufficient to meet such loss ratio. CommentsClose CommentsPermalink





(b) Building on Interim Rules- In implementing subsection (a), the Commissioner shall build on the definition and methodology developed by the Secretary of Health and Human Services under the amendments made by section 161 for determining how to calculate the medical loss ratio. Such methodology shall be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by QHBP offering entities, competition in the health insurance market in and out of the Health Insurance Exchange, and value for consumers so that their premiums are used for services. CommentsClose CommentsPermalink

Subtitle C--Standards Guaranteeing Access to Essential Benefits CommentsClose CommentsPermalink

SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.

(a) In General- A qualified health benefits plan shall provide coverage that at least meets the benefit standards adopted under section 124 for the essential benefits package described in section 122 for the plan year involved. CommentsClose CommentsPermalink





(b) Choice of Coverage- CommentsClose CommentsPermalink





(1) NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of a qualified health benefits plan that is not an Exchange-participating health benefits plan, such plan may offer such coverage in addition to the essential benefits package as the QHBP offering entity may specify. CommentsClose CommentsPermalink





(2) EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of an Exchange-participating health benefits plan, such plan is required under section 203 to provide specified levels of benefits and, in the case of a plan offering a premium-plus level of benefits, provide additional benefits. CommentsClose CommentsPermalink





(3) CONTINUATION OF OFFERING OF SEPARATE EXCEPTED BENEFITS COVERAGE- Nothing in this division shall be construed as affecting the offering of health benefits in the form of excepted benefits (described in section 102(b)(1)(B)(ii)) if such benefits are offered under a separate policy, contract, or certificate of insurance. CommentsClose CommentsPermalink





(c) No Restrictions on Coverage Unrelated to Clinical Appropriateness- A qualified health benefits plan may not impose any restriction (other than cost-sharing) unrelated to clinical appropriateness on the coverage of the health care items and services. CommentsClose CommentsPermalink

SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.

(a) In General- In this division, the term ‘essential benefits package’ means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that-- CommentsClose CommentsPermalink





(1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice; CommentsClose CommentsPermalink





(2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c); CommentsClose CommentsPermalink





(3) does not impose any annual or lifetime limit on the coverage of covered health care items and services; CommentsClose CommentsPermalink





(4) complies with section 115(a) (relating to network adequacy); and CommentsClose CommentsPermalink





(5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage. CommentsClose CommentsPermalink





(b) Minimum Services Tto Be Covered- TSubject to subsection (d), the items and services described in this subsection are the following: CommentsClose CommentsPermalink





(1) Hospitalization. CommentsClose CommentsPermalink





(2) Outpatient hospital and outpatient clinic services, including emergency department services. CommentsClose CommentsPermalink





(3) Professional services of physicians and other health professionals. CommentsClose CommentsPermalink





(4) Such services, equipment, and supplies incident to the services of a physician’s or a health professional’s delivery of care in institutional settings, physician offices, patients’ homes or place of residence, or other settings, as appropriate. CommentsClose CommentsPermalink





(5) Prescription drugs. CommentsClose CommentsPermalink





(6) Rehabilitative and habilitative services. CommentsClose CommentsPermalink





(7) Mental health and substance use disorder services, including behavioral health treatments. CommentsClose CommentsPermalink





(8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention. CommentsClose CommentsPermalink





(9) Maternity care. CommentsClose CommentsPermalink





(10) Well baby and well child care; treatment of a congenital or developmental deformity, disease, or injury; and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age. CommentsClose CommentsPermalink





(c) Requirements Relating to Cost-sharing and Minimum Actuarial Value- CommentsClose CommentsPermalink





(1) NO COST-SHARING FOR PREVENTIVE SERVICES- There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care. CommentsClose CommentsPermalink





(2) ANNUAL LIMITATION- CommentsClose CommentsPermalink





(A) ANNUAL LIMITATION- The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B). CommentsClose CommentsPermalink





(B) APPLICABLE LEVEL- The applicable level specified in this subparagraph for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year. CommentsClose CommentsPermalink





(C) USE OF COPAYMENTS- In establishing cost-sharing levels for basic, enhanced, and premium plans under this subsection, the Secretary shall, to the maximum extent possible, use only copayments and not coinsurance. CommentsClose CommentsPermalink





(3) MINIMUM ACTUARIAL VALUE- CommentsClose CommentsPermalink





(A) IN GENERAL- The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B). CommentsClose CommentsPermalink





(B) REFERENCE BENEFITS PACKAGE DESCRIBED- The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed. CommentsClose CommentsPermalink





(d) Abortion Coverage Prohibited as Part of Minimum Benefits Package- CommentsClose CommentsPermalink





(1) PROHIBITION OF REQUIRED COVERAGE- The Health Benefits Advisory Committee may not recommend under section 123(b) and the Secretary may not adopt in standards under section 124(b), the services described in paragraph (4)(A) or (4)(B) as part of the essential benefits package and the Commissioner may not require such services for qualified health benefits plans to participate in the Health Insurance Exchange. CommentsClose CommentsPermalink





(2) VOLUNTARY CHOICE OF COVERAGE BY PLAN- In the case of a qualified health benefits plan, the plan is not required (or prohibited) under this Act from providing coverage of services described in paragraph (4)(A) or (4)(B) and the QHBP offering entity shall determine whether such coverage is provided. CommentsClose CommentsPermalink





(3) COVERAGE UNDER PUBLIC HEALTH INSURANCE OPTION- The public health insurance option shall provide coverage for services described in paragraph (4)(B). Nothing in this Act shall be construed as preventing the public health insurance option from providing for or prohibiting coverage of services described in paragraph (4)(A). CommentsClose CommentsPermalink





(4) ABORTION SERVICES- CommentsClose CommentsPermalink





(A) ABORTIONS FOR WHICH PUBLIC FUNDING IS PROHIBITED- The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is not permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. CommentsClose CommentsPermalink





(B) ABORTIONS FOR WHICH PUBLIC FUNDING IS ALLOWED- The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. CommentsClose CommentsPermalink





(e) Stand-alone Coverage- CommentsClose CommentsPermalink





(1) NO APPLICATION TO ADULT COVERAGE- Nothing in this subtitle shall be construed as requiring an individual who is 21 years of age or older to be provided stand-alone dental-only or vision-only coverage. CommentsClose CommentsPermalink





(2) TREATMENT OF COMBINED COVERAGE- The combination of stand-alone coverage described in paragraph (1) and a qualified health benefits plan without coverage of such oral and vision services shall be treated as satisfying the essential benefits package under this division. CommentsClose CommentsPermalink

SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.

(a) Establishment- CommentsClose CommentsPermalink





(1) IN GENERAL- There is established a private-public advisory committee which shall be a panel of medical and other experts to be known as the Health Benefits Advisory Committee to recommend covered benefits and essential, enhanced, and premium plans. CommentsClose CommentsPermalink





(2) CHAIR- The Surgeon General shall be a member and the chair of the Health Benefits Advisory Committee. CommentsClose CommentsPermalink





(3) MEMBERSHIP- The Health Benefits Advisory Committee shall be composed of the following members, in addition to the Surgeon General: CommentsClose CommentsPermalink





(A) 9 members who are not Federal employees or officers and who are appointed by the President. CommentsClose CommentsPermalink





(B) 9 members who are not Federal employees or officers and who are appointed by the Comptroller General of the United States in a manner similar to the manner in which the Comptroller General appoints members to the Medicare Payment Advisory Commission under section 1805(c) of the Social Security Act. CommentsClose CommentsPermalink





(C) Such even number of members (not to exceed 8) who are Federal employees and officers, as the President may appoint. CommentsClose CommentsPermalink





Such initial appointments shall be made not later than 60 days after the date of the enactment of this Act. CommentsClose CommentsPermalink





(4) TERMS- Each member of the Health Benefits Advisory Committee shall serve a 3-year term on the Committee, except that the terms of the initial members shall be adjusted in order to provide for a staggered term of appointment for all such members. CommentsClose CommentsPermalink





(5) PARTICIPATION- The membership of the Health Benefits Advisory Committee shall at least reflect providers, consumer representatives, employers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities, representatives of relevant governmental agencies. and at least one practicing physician or other health professional and an expert on children’s health and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of such Committee. Not less than 25 percent of the members of the Committee shall be practicing health care practitioners who, as of the date of their appointment, practice in a rural area and who have practiced in a rural area for at least the 5-year period preceding such date. CommentsClose CommentsPermalink





(b) Duties- CommentsClose CommentsPermalink





(1) RECOMMENDATIONS ON BENEFIT STANDARDS- The Health Benefits Advisory Committee shall recommend to the Secretary of Health and Human Services (in this subtitle referred to as the ‘Secretary’) benefit standards (as defined in paragraph (4)), and periodic updates to such standards. In developing such recommendations, the Committee shall take into account innovation in health care and consider how such standards could reduce health disparities. CommentsClose CommentsPermalink





(2) DEADLINE- The Health Benefits Advisory Committee shall recommend initial benefit standards to the Secretary not later than 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink





(3) PUBLIC INPUT- The Health Benefits Advisory Committee shall allow for public input as a part of developing recommendations under this subsection. CommentsClose CommentsPermalink





(4) BENEFIT STANDARDS DEFINED- In this subtitle, the term ‘benefit standards’ means standards respecting-- CommentsClose CommentsPermalink





(A) the essential benefits package described in section 122, including categories of covered treatments, items and services within benefit classes, and cost-sharing consistent with subsection (d) of such section; and CommentsClose CommentsPermalink





(B) the cost-sharing levels for enhanced plans and premium plans (as provided under section 203(c)) consistent with paragraph (5). CommentsClose CommentsPermalink





(5) LEVELS OF COST-SHARING FOR ENHANCED AND PREMIUM PLANS- CommentsClose CommentsPermalink





(A) ENHANCED PLAN- The level of cost-sharing for enhanced plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 85 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B). CommentsClose CommentsPermalink





(B) PREMIUM PLAN- The level of cost-sharing for premium plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 95 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B). CommentsClose CommentsPermalink





(c) Operations- CommentsClose CommentsPermalink





(1) PER DIEM PAY- Each member of the Health Benefits Advisory Committee shall receive travel expenses, including per diem in accordance with applicable provisions under subchapter I of chapter 57 of title 5, United States Code, and shall otherwise serve without additional pay. CommentsClose CommentsPermalink





(2) MEMBERS NOT TREATED AS FEDERAL EMPLOYEES- Members of the Health Benefits Advisory Committee shall not be considered employees of the Federal government solely by reason of any service on the Committee. CommentsClose CommentsPermalink





(3) APPLICATION OF FACA- The Federal Advisory Committee Act (5 U.S.C. App.), other than section 14, shall apply to the Health Benefits Advisory Committee. CommentsClose CommentsPermalink





(d) Publication- The Secretary shall provide for publication in the Federal Register and the posting on the Internet website of the Department of Health and Human Services of all recommendations made by the Health Benefits Advisory Committee under this section. CommentsClose CommentsPermalink

SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION OF BENEFIT STANDARDS.

(a) Process for Adoption of Recommendations- CommentsClose CommentsPermalink





(1) REVIEW OF RECOMMENDED STANDARDS- Not later than 45 days after the date of receipt of benefit standards recommended under section 123 (including such standards as modified under paragraph (2)(B)), the Secretary shall review such standards and shall determine whether to propose adoption of such standards as a package. CommentsClose CommentsPermalink





(2) DETERMINATION TO ADOPT STANDARDS- If the Secretary determines-- CommentsClose CommentsPermalink





(A) to propose adoption of benefit standards so recommended as a package, the Secretary shall, by regulation undersection 553 of title 5, United States Code, propose adoption such standards; or CommentsClose CommentsPermalink





(B) not to propose adoption of such standards as a package, the Secretary shall notify the Health Benefits Advisory Committee in writing of such determination and the reasons for not proposing the adoption of such recommendation and provide the Committee with a further opportunity to modify its previous recommendations and submit new recommendations to the Secretary on a timely basis. CommentsClose CommentsPermalink





(3) CONTINGENCY- If, because of the application of paragraph (2)(B), the Secretary would otherwise be unable to propose initial adoption of such recommended standards by the deadline specified in subsection (b)(1), the Secretary shall, by regulation undersection 553 of title 5, United States Code, propose adoption of initial benefit standards by such deadline. CommentsClose CommentsPermalink





(4) PUBLICATION- The Secretary shall provide for publication in the Federal Register of all determinations made by the Secretary under this subsection. CommentsClose CommentsPermalink





(b) Adoption of Standards- CommentsClose CommentsPermalink





(1) INITIAL STANDARDS- Not later than 18 months after the date of the enactment of this Act, the Secretary shall, through the rulemaking process consistent with subsection (a), adopt an initial set of benefit standards. CommentsClose CommentsPermalink





(2) PERIODIC UPDATING STANDARDS- Under subsection (a), the Secretary shall provide for the periodic updating of the benefit standards previously adopted under this section. CommentsClose CommentsPermalink





(3) REQUIREMENT- The Secretary may not adopt any benefit standards for an essential benefits package or for level of cost-sharing that are inconsistent with the requirements for such a package or level under sections 122 (including subsection (d)) and 123(b)(5). CommentsClose CommentsPermalink

Subtitle D--Additional Consumer Protections CommentsClose CommentsPermalink

SEC. 131. REQUIRING FAIR MARKETING PRACTICES BY HEALTH INSURERS.

The Commissioner shall establish uniform marketing standards that all insured QHBP offering entities shall meet. CommentsClose CommentsPermalink

SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.

(a) In General- A QHBP offering entity shall provide for timely grievance and appeals mechanisms that the Commissioner shall establish.

(b) Internal Claims and Appeals Process- Under a qualified health benefits plan the QHBP offering entity shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70246) and shall update such process in accordance with any standards that the Commissioner may establish.

(c) External Review Process-

(1) IN GENERAL- The Commissioner shall establish an external review process (including procedures for expedited reviews of urgent claims) that provides for an impartial, independent, and de novo review of denied claims under this division.

(2) REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS- A determination made, with respect to a qualified health benefits plan offered by a QHBP offering entity, under the external review process established under this subsection shall be binding on the plan and the entity.

(d) Construction- Nothing in this section shall be construed as affecting the availability of judicial review under State law for adverse decisions under subsection (b) or (c), subject to section 151as the Commissioner shall establish consistent with sections 139 through 139B. CommentsClose CommentsPermalink

SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE.

(a) Accurate and Timely Disclosure- CommentsClose CommentsPermalink





(1) IN GENERAL- A qualified health benefits plan (including the public health insurance option) shall comply with standards established by the Commissioner for the accurate and timely disclosure of plan documents, plan terms and conditions, claims payment policies and practices, periodic financial disclosure, data on enrollment, data on disenrollment, data on the number of claims denials, data on rating practices, information on cost-sharing and payments with respect to any out-of-network coverage, and other information as determined appropriate by the Commissioner. The Commissioner shall require that such disclosure be provided in plain language. CommentsClose CommentsPermalink





(2) PLAIN LANGUAGE- In this subsection, the term ‘plain language’ means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is clean, concise, well-organized, and follows other best practices of plain language writing. CommentsClose CommentsPermalink





(3) GUIDANCE- The Commissioner shall develop and issue guidance on best practices of plain language writing. CommentsClose CommentsPermalink





(b) Contracting Reimbursement- A qualified health benefits plan shall comply with standards established by the Commissioner to ensure(including the public health insurance option) shall comply with standards established by the Commissioner to ensure transparency to each health care provider relating to reimbursement arrangements between such plan and such provider. CommentsClose CommentsPermalink





(c) Advance Notice of Plan Changes- A change in a qualified health benefits plan shall not be made without such reasonable and timely advance notice to enrollees of such change(including the public health insurance option) shall not be made without such reasonable and timely advance notice to enrollees of such change. CommentsClose CommentsPermalink





(d) Pharmacy Benefit Managers Transparency Requirements- CommentsClose CommentsPermalink





(1) IN GENERAL- Notwithstanding any other provision of law, a qualified health benefits plan shall enter into a contract with a pharmacy benefit managers (in this subsection referred to as a ‘PBM’) to manage the prescription drug coverage provided under such plan, or to control the costs of such prescription drug coverage, only if as a condition of such contract the PBM is required to provide at least annually to the Commissioner and to the QHBP offering entity offering such plan the following information: CommentsClose CommentsPermalink





(A) Information on the volume of prescriptions under the contract that are filled via mail order and at retail pharmacies. CommentsClose CommentsPermalink





(B) An estimate of aggregate average payments under the contract, per prescription (weighted by prescription volume), made to mail order and retail pharmacists, and the average amount, per prescription, that the PBM was paid by the plan for prescriptions filled at mail order and retail pharmacists. CommentsClose CommentsPermalink





(C) An estimate of the aggregate average payment per prescription (weighted by prescription volume) under the contract received from pharmaceutical manufacturers, including all rebates, discounts, prices concessions, or administrative, and other payments from pharmaceutical manufacturers, and a description of the types of payments, and the amount of these payments that were shared with the plan, and a description of the percentage of prescriptions for which the PBM received such payments. CommentsClose CommentsPermalink





(D) Information on the overall percentage of generic drugs dispensed under the contract at retail and mail order pharmacies, and the percentage of cases in which a generic drug is dispensed when available. CommentsClose CommentsPermalink





(E) Information on the percentage and number of cases under the contract in which individuals were switched from a prescribed drug that was less expensive to a drug that was more expensive, the rationale for these switches, and a description of the PBM policies governing such switches. CommentsClose CommentsPermalink





(2) CONFIDENTIALITY OF INFORMATION- Notwithstanding any other provision of law, information disclosed by a PBM to the Commissioner or a QHBP offering entity under this subsection is confidential and shall not be disclosed by the Commissioner or the QHBP offering entity in a form which discloses the identity of a specific PBM or prices charged by such PBM or a specific retailer, manufacturer, or wholesaler, except-- CommentsClose CommentsPermalink





(A) as the Commissioner determines to be necessary to carry out this subsection; CommentsClose CommentsPermalink





(B) to permit the Comptroller General to review the information provided; CommentsClose CommentsPermalink





(C) to permit the Director of the Congressional Budget Office to review the information provided; and CommentsClose CommentsPermalink





(D) to permit the Commissioner to disclose industry-wide aggregate or average information to be used in assessing the overall impact of PBMs on prescription drug prices and spending. CommentsClose CommentsPermalink

SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS PLANS NOT OFFERED THROUGH THE HEALTH INSURANCE EXCHANGE.

The requirements of the previous provisions of this subtitle shall apply to qualified health benefits plans that are not being offered through the Health Insurance Exchange only to the extent specified by the Commissioner. CommentsClose CommentsPermalink

SEC. 135. TIMELY PAYMENT OF CLAIMS.

A QHBP offering entity shall comply with the requirements of section 1857(f) of the Social Security Act with respect to a qualified health benefits plan it offers in the same manner an Medicare Advantage organization is required to comply with such requirements with respect to a Medicare Advantage plan it offers under part C of Medicare. CommentsClose CommentsPermalink

SEC. 136. STANDARDIZED RULES FOR COORDINATION AND SUBROGATION OF BENEFITS.

The Commissioner shall establish standards for the coordination and subrogation of benefits and reimbursement of payments in cases involving individuals and multiple plan coverage. CommentsClose CommentsPermalink

SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICATION.

A QHBP offering entity is required to comply with standards for electronic financial and administrative transactions under section 1173A of the Social Security Act, and the operating rules under section 1173B of such Act, as added by section 163(a). CommentsClose CommentsPermalink

Subtitle E--Governance CommentsClose CommentsPermalink

SEC. 141. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES COMMISSIONER.

(a) In General- There is hereby established, as an independent agency in the executive branch of the Government, a Health Choices Administration (in this division referred to as the ‘Administration’). CommentsClose CommentsPermalink





(b) Commissioner- CommentsClose CommentsPermalink





(1) IN GENERAL- The Administration shall be headed by a Health Choices Commissioner (in this division referred to as the ‘Commissioner’) who shall be appointed by the President, by and with the advice and consent of the Senate. CommentsClose CommentsPermalink





(2) COMPENSATION; ETC- The provisions of paragraphs (2), (5), and (7) of subsection (a) (relating to compensation, terms, general powers, rulemaking, and delegation) of section 702 of the Social Security Act (42 U.S.C. 902) shall apply to the Commissioner and the Administration in the same manner as such provisions apply to the Commissioner of Social Security and the Social Security Administration. CommentsClose CommentsPermalink

SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER.

(a) Duties- The Commissioner is responsible for carrying out the following functions under this division: CommentsClose CommentsPermalink





(1) QUALIFIED PLAN STANDARDS- The establishment of qualified health benefits plan standards under this title, including the enforcement of such standards in coordination with State insurance regulators and the Secretaries of Labor and the Treasury. CommentsClose CommentsPermalink





(2) HEALTH INSURANCE EXCHANGE- The establishment and operation of a Health Insurance Exchange under subtitle A of title II. CommentsClose CommentsPermalink





(3) INDIVIDUAL AFFORDABILITY CREDITS- The administration of individual affordability credits under subtitle C of title II, including determination of eligibility for such credits. CommentsClose CommentsPermalink





(4) ADDITIONAL FUNCTIONS- Such additional functions as may be specified in this division. CommentsClose CommentsPermalink





(b) Promoting Accountability- CommentsClose CommentsPermalink





(1) IN GENERAL- The Commissioner shall undertake activities in accordance with this subtitle to promote accountability of QHBP offering entities in meeting Federal health insurance requirements, regardless of whether such accountability is with respect to qualified health benefits plans offered through the Health Insurance Exchange or outside of such Exchange. CommentsClose CommentsPermalink





(2) COMPLIANCE EXAMINATION AND AUDITS- CommentsClose CommentsPermalink





(A) IN GENERAL- The commissioner shall, in coordination with States, conduct audits of qualified health benefits plan compliance with Federal requirements. Such audits may include random compliance audits and targeted audits in response to complaints or other suspected non-compliance. CommentsClose CommentsPermalink





(B) RECOUPMENT OF COSTS IN CONNECTION WITH EXAMINATION AND AUDITS- The Commissioner is authorized to recoup from qualified health benefits plans reimbursement for the costs of such examinations and audit of such QHBP offering entities. CommentsClose CommentsPermalink





(c) Data Collection- The Commissioner shall collect data for purposes of carrying out the Commissioner’s duties, including for purposes of promoting quality and value, protecting consumers, and addressing disparities in health and health care and may share such data with the Secretary of Health and Human Services. CommentsClose CommentsPermalink





(d) Sanctions Authority- CommentsClose CommentsPermalink





(1) IN GENERAL- In the case that the Commissioner determines that a QHBP offering entity violates a requirement of this title, the Commissioner may, in coordination with State insurance regulators and the Secretary of Labor, provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph (2). CommentsClose CommentsPermalink





(2) REMEDIES- The remedies described in this paragraph, with respect to a qualified health benefits plan offered by a QHBP offering entity, are-- CommentsClose CommentsPermalink





(A) civil money penalties of not more than the amount that would be applicable under similar circumstances for similar violations under section 1857(g) of the Social Security Act; CommentsClose CommentsPermalink





(B) suspension of enrollment of individuals under such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Commissioner is satisfied that the basis for such determination has been corrected and is not likely to recur; CommentsClose CommentsPermalink





(C) in the case of an Exchange-participating health benefits plan, suspension of payment to the entity under the Health Insurance Exchange for individuals enrolled in such plan after the date the Commissioner notifies the entity of a determination under paragraph (1) and until the Secretary is satisfied that the basis for such determination has been corrected and is not likely to recur; or CommentsClose CommentsPermalink





(D) working with State insurance regulators to terminate plans for repeated failure by the offering entity to meet the requirements of this title. CommentsClose CommentsPermalink





(e) Standard Definitions of Insurance and Medical Terms- The Commissioner shall provide for the development of standards for the definitions of terms used in health insurance coverage, including insurance-related terms. CommentsClose CommentsPermalink





(f) Efficiency in Administration- The Commissioner shall issue regulations for the effective and efficient administration of the Health Insurance Exchange and affordability credits under subtitle C, including, with respect to the determination of eligibility for affordability credits, the use of personnel who are employed in accordance with the requirements of title 5, United States Code, to carry out the duties of the Commissioner or, in the case of sections 208 and 241(b)(2), the use of State personnel who are employed in accordance with standards prescribed by the Office of Personnel Management pursuant to section 208 of the Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728). CommentsClose CommentsPermalink

SEC. 143. CONSULTATION AND COORDINATION.

(a) Consultation- In carrying out the Commissioner’s duties under this division, the Commissioner, as appropriate, shall consult with at least with the following: CommentsClose CommentsPermalink





(1) The National Association of Insurance Commissioners, State attorneys general, and State insurance regulators, including concerning the standards for insured qualified health benefits plans under this title and enforcement of such standards. CommentsClose CommentsPermalink





(2) Appropriate State agencies, specifically concerning the administration of individual affordability credits under subtitle C of title II and the offering of Exchange-participating health benefits plans, to Medicaid eligible individuals under subtitle A of such title. CommentsClose CommentsPermalink





(3) Other appropriate Federal agencies. CommentsClose CommentsPermalink





(4) Indian tribes and tribal organizations. CommentsClose CommentsPermalink





(5) The National Association of Insurance Commissioners for purposes of using model guidelines established by such association for purposes of subtitles B and D. CommentsClose CommentsPermalink





(b) Coordination- CommentsClose CommentsPermalink





(1) IN GENERAL- In carrying out the functions of the Commissioner, including with respect to the enforcement of the provisions of this division, the Commissioner shall work in coordination with existing Federal and State entities to the maximum extent feasible consistent with this division and in a manner that prevents conflicts of interest in duties and ensures effective enforcement. CommentsClose CommentsPermalink





(2) UNIFORM STANDARDS- The Commissioner, in coordination with such entities, shall seek to achieve uniform standards that adequately protect consumers in a manner that does not unreasonably affect employers and insurers. CommentsClose CommentsPermalink

SEC. 144. HEALTH INSURANCE OMBUDSMAN.

(a) In General- The Commissioner shall appoint within the Health Choices Administration a Qualified Health Benefits Plan Ombudsman who shall have expertise and experience in the fields of health care and education of (and assistance to) individuals. CommentsClose CommentsPermalink





(b) Duties- The Qualified Health Benefits Plan Ombudsman shall, in a linguistically appropriate manner-- CommentsClose CommentsPermalink





(1) receive complaints, grievances, and requests for information submitted by individuals; CommentsClose CommentsPermalink





(2) provide assistance with respect to complaints, grievances, and requests referred to in paragraph (1), including-- CommentsClose CommentsPermalink





(A) helping individuals determine the relevant information needed to seek an appeal of a decision or determination; CommentsClose CommentsPermalink





(B) assistance to such individuals with any problems arising from disenrollment from such a plan; CommentsClose CommentsPermalink





(C) assistance to such individuals in choosing a qualified health benefits plan in which to enroll; and CommentsClose CommentsPermalink





(D) assistance to such individuals in presenting information under subtitle C (relating to affordability credits); and CommentsClose CommentsPermalink





(3) submit annual reports to Congress and the Commissioner that describe the activities of the Ombudsman and that include such recommendations for improvement in the administration of this division as the Ombudsman determines appropriate. The Ombudsman shall not serve as an advocate for any increases in payments or new coverage of services, but may identify issues and problems in payment or coverage policies. CommentsClose CommentsPermalink

Subtitle F--Relation to Other Requirements; Miscellaneous CommentsClose CommentsPermalink

SEC. 151. RELATION TO OTHER REQUIREMENTS.

(a) Coverage Not Offered Through Exchange- CommentsClose CommentsPermalink





(1) IN GENERAL- In the case of health insurance coverage not offered through the Health Insurance Exchange (whether or not offered in connection with an employment-based health plan), and in the case of employment-based health plans, the requirements of this title do not supercede any requirements applicable under titles XXII and XXVII of the Public Health Service Act, parts 6 and 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, or State law, except insofar as such requirements prevent the application of a requirement of this division, as determined by the Commissioner. CommentsClose CommentsPermalink





(2) CONSTRUCTION- Nothing in paragraph (1) shall be construed as affecting the application of section 514 of the Employee Retirement Income Security Act of 1974. CommentsClose CommentsPermalink





(b) Coverage Offered Through Exchange- CommentsClose CommentsPermalink





(1) IN GENERAL- In the case of health insurance coverage offered through the Health Insurance Exchange-- CommentsClose CommentsPermalink





(A) the requirements of this title do not supercede any requirements (including requirements relating to genetic information nondiscrimination and mental health) applicable under title XXVII of the Public Health Service Act or under State law, except insofar as such requirements prevent the application of a requirement of this division, as determined by the Commissioner; and CommentsClose CommentsPermalink





(B) individual rights and remedies under State laws shall apply. CommentsClose CommentsPermalink





(2) CONSTRUCTION- In the case of coverage described in paragraph (1), nothing in such paragraph shall be construed as preventing the application of rights and remedies under State laws with respect to any requirement referred to in paragraph (1)(A). CommentsClose CommentsPermalink

SEC. 152. PROHIBITING DISCRIMINATION IN HEALTH CARE.

(a) In General- Except as otherwise explicitly permitted by this Act and by subsequent regulations consistent with this Act, all health care and related services (including insurance coverage and public health activities) covered by this Act shall be provided without regard to personal characteristics extraneous to the provision of high quality health care or related services. CommentsClose CommentsPermalink





(b) Implementation- To implement the requirement set forth in subsection (a), the Secretary of Health and Human Services shall, not later than 18 months after the date of the enactment of this Act, promulgate such regulations as are necessary or appropriate to insure that all health care and related services (including insurance coverage and public health activities) covered by this Act are provided (whether directly or through contractual, licensing, or other arrangements) without regard to personal characteristics extraneous to the provision of high quality health care or related services. CommentsClose CommentsPermalink

SEC. 153. WHISTLEBLOWER PROTECTION.

(a) Retaliation Prohibited- No employer may discharge any employee or otherwise discriminate against any employee with respect to his compensation, terms, conditions, or other privileges of employment because the employee (or any person acting pursuant to a request of the employee)-- CommentsClose CommentsPermalink





(1) provided, caused to be provided, or is about to provide or cause to be provided to the employer, the Federal Government, or the attorney general of a State information relating to any violation of, or any act or omission the employee reasonably believes to be a violation of any provision of this Act or any order, rule, or regulation promulgated under this Act; CommentsClose CommentsPermalink





(2) testified or is about to testify in a proceeding concerning such violation; CommentsClose CommentsPermalink





(3) assisted or participated or is about to assist or participate in such a proceeding; or CommentsClose CommentsPermalink





(4) objected to, or refused to participate in, any activity, policy, practice, or assigned task that the employee (or other such person) reasonably believed to be in violation of any provision of this Act or any order, rule, or regulation promulgated under this Act. CommentsClose CommentsPermalink





(b) Enforcement Action- An employee covered by this section who alleges discrimination by an employer in violation of subsection (a) may bring an action governed by the rules, procedures, legal burdens of proof, and remedies set forth in section 40(b) of the Consumer Product Safety Act (15 U.S.C. 2087(b)). CommentsClose CommentsPermalink





(c) Employer Defined- As used in this section, the term ‘employer’ means any person (including one or more individuals, partnerships, associations, corporations, trusts, professional membership organization including a certification, disciplinary, or other professional body, unincorporated organizations, nongovernmental organizations, or trustees) engaged in profit or nonprofit business or industry whose activities are governed by this Act, and any agent, contractor, subcontractor, grantee, or consultant of such person. CommentsClose CommentsPermalink





(d) Rule of Construction- The rule of construction set forth insection 20109(h) of title 49, United States Code, shall also apply to this section. CommentsClose CommentsPermalink

SEC. 154. CONSTRUCTION REGARDING COLLECTIVE BARGAINING.

Nothing in this division shall be construed to alter of supercede any statutory or other obligation to engage in collective bargaining over the terms and conditions of employment related to health care. CommentsClose CommentsPermalink

SEC. 155. SEVERABILITY.

If any provision of this Act, or any application of such provision to any person or circumstance, is held to be unconstitutional, the remainder of the provisions of this Act and the application of the provision to any other person or circumstance shall not be affected. CommentsClose CommentsPermalink

Subtitle G--Early Investments CommentsClose CommentsPermalink

SEC. 161. ENSURING VALUE AND LOWER PREMIUMS.

(a) Group Health Insurance Coverage- Title XXVII of the Public Health Service Act is amended by inserting after section 2713 the following new section: CommentsClose CommentsPermalink

‘SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.

‘(a) In General- Each health insurance issuer that offers health insurance coverage in the small or large group market shall provide that for any plan year in which the coverage has a medical loss ratio below a level specified by the Secretary, the issuer shall provide in a manner specified by the Secretary for rebates to enrollees of payment sufficient to meet such loss ratio. Such methodology shall be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by issuers, competition in the health insurance market, and value for consumers so that their premiums are used for services. CommentsClose CommentsPermalink





‘(b) Uniform Definitions- The Secretary shall establish a uniform definition of medical loss ratio and methodology for determining how to calculate the medical loss ratio. Such methodology shall be designed to take into account the special circumstances of smaller plans, different types of plans, and newer plans.’. CommentsClose CommentsPermalink





(b) Individual Health Insurance Coverage- Such title is further amended by inserting after section 2753 the following new section: CommentsClose CommentsPermalink

‘SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.

‘The provisions of section 2714 shall apply to health insurance coverage offered in the individual market in the same manner as such provisions apply to health insurance coverage offered in the small or large group market.’. CommentsClose CommentsPermalink





(c) Immediate Implementation- The amendments made by this section shall apply in the group and individual market for plan years beginning on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 162. ENDING HEALTH INSURANCE RESCISSION ABUSE.

(a) Clarification Regarding Application of Guaranteed Renewability of Individual Health Insurance Coverage- Section 2742 of the Public Health Service Act (42 U.S.C. 300gg-42) is amended-- CommentsClose CommentsPermalink





(1) in its heading, by inserting ‘and continuation in force, including prohibition of rescission,’ after ‘guaranteed renewability’; and CommentsClose CommentsPermalink





(2) in subsection (a), by inserting ‘, including without rescission,’ after ‘continue in force’. CommentsClose CommentsPermalink





(b) Secretarial Guidance Regarding Rescissions- Section 2742 of such Act (42 U.S.C. 300gg-42) is amended by adding at the end the following: CommentsClose CommentsPermalink





‘(f) Rescission- A health insurance issuer may rescind health insurance coverage only upon clear and convincing evidence of fraud described in subsection (b)(2). The Secretary, no later than July 1, 2010, shall issue guidance implementing this requirement, including procedures for independent, external third party review.’. CommentsClose CommentsPermalink





(c) Opportunity for Independent, External Third Party Review in Certain Cases- Subpart 1 of part B of title XXVII of such Act (42 U.S.C. 300gg-41 et seq.) is amended by adding at the end the following: CommentsClose CommentsPermalink

‘SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD PARTY REVIEW IN CASES OF RESCISSION.

‘(a) Notice and Review Right- If a health insurance issuer determines to rescind health insurance coverage for an individual in the individual market, before such rescission may take effect the issuer shall provide the individual with notice of such proposed rescission and an opportunity for a review of such determination by an independent, external third party under procedures specified by the Secretary under section 2742(f). CommentsClose CommentsPermalink





‘(b) Independent Determination- If the individual requests such review by an independent, external third party of a rescission of health insurance coverage, the coverage shall remain in effect until such third party determines that the coverage may be rescinded under the guidance issued by the Secretary under section 2742(f).’. CommentsClose CommentsPermalink





(d) Effective Date- The amendments made by this section shall apply on and after October 1, 2010, with respect to health insurance coverage issued before, on, or after such date. CommentsClose CommentsPermalink

SEC. 163. ENDING HEALTH INSURANCE DENIALS AND DELAYS OF NECESSARY TREATMENT FOR CHILDREN WITH DEFORMITIES.

SEC. 164. ADMINISTRATIVE SIMPLIFICATION.

(a) Standardizing Electronic Administrative Transactions- CommentsClose CommentsPermalink





(1) IN GENERAL- Part C of title XI of the Social Security Act (42 U.S.C. 1320d et seq.) is amended by inserting after section 1173 the following new sections: CommentsClose CommentsPermalink

‘SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE TRANSACTIONS.

‘(a) Standards for Financial and Administrative Transactions- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall adopt and regularly update standards consistent with the goals described in paragraph (2). CommentsClose CommentsPermalink





‘(2) GOALS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS- The goals for standards under paragraph (1) are that such standards shall-- CommentsClose CommentsPermalink





‘(A) be unique with no conflicting or redundant standards; CommentsClose CommentsPermalink





‘(B) be authoritative, permitting no additions or constraints for electronic transactions, including companion guides; CommentsClose CommentsPermalink





‘(C) be comprehensive, efficient and robust, requiring minimal augmentation by paper transactions or clarification by further communications; CommentsClose CommentsPermalink





‘(D) enable the real-time (or near real-time) determination of an individual’s financial responsibility at the point of service and, to the extent possible, prior to service, including whether the individual is eligible for a specific service with a specific physician at a specific facility, which may include utilization of a machine-readable health plan beneficiary identification card; CommentsClose CommentsPermalink





‘(E) enable, where feasible, near real-time adjudication of claims; CommentsClose CommentsPermalink





‘(F) provide for timely acknowledgment, response, and status reporting applicable to any electronic transaction deemed appropriate by the Secretary; CommentsClose CommentsPermalink





‘(G) describe all data elements (such as reason and remark codes) in unambiguous terms, not permit optional fields, require that data elements be either required or conditioned upon set values in other fields, and prohibit additional conditions; and CommentsClose CommentsPermalink





‘(H) harmonize all common data elements across administrative and clinical transaction standards. CommentsClose CommentsPermalink





‘(3) TIME FOR ADOPTION- Not later than 2 years after the date of implementation of the X12 Version 5010 transaction standards implemented under this part, the Secretary shall adopt standards under this section. CommentsClose CommentsPermalink





‘(4) REQUIREMENTS FOR SPECIFIC STANDARDS- The standards under this section shall be developed, adopted, and enforced so as to-- CommentsClose CommentsPermalink





‘(A) clarify, refine, complete, and expand, as needed, the standards required under section 1173; CommentsClose CommentsPermalink





‘(B) require paper versions of standardized transactions to comply with the same standards as to data content such that a fully compliant, equivalent electronic transaction can be populated from the data from a paper version; CommentsClose CommentsPermalink





‘(C) enable electronic funds transfers, in order to allow automated reconciliation with the related health care payment and remittance advice; CommentsClose CommentsPermalink





‘(D) require timely and transparent claim and denial management processes, including tracking, adjudication, and appeal processing; CommentsClose CommentsPermalink





‘(E) require the use of a standard electronic transaction with which health care providers may quickly and efficiently enroll with a health plan to conduct the other electronic transactions provided for in this part; and CommentsClose CommentsPermalink





‘(F) provide for other requirements relating to administrative simplification as identified by the Secretary, in consultation with stakeholders. CommentsClose CommentsPermalink





‘(5) BUILDING ON EXISTING STANDARDS- In developing the standards under this section, the Secretary shall build upon existing and planned standards. CommentsClose CommentsPermalink





‘(6) IMPLEMENTATION AND ENFORCEMENT- Not later than 6 months after the date of the enactment of this section, the Secretary shall submit to the appropriate committees of Congress a plan for the implementation and enforcement, by not later than 5 years after such date of enactment, of the standards under this section. Such plan shall include-- CommentsClose CommentsPermalink





‘(A) a process and timeframe with milestones for developing the complete set of standards; CommentsClose CommentsPermalink





‘(B) an expedited upgrade program for continually developing and approving additions and modifications to the standards as often as annually to improve their quality and extend their functionality to meet evolving requirements in health care; CommentsClose CommentsPermalink





‘(C) programs to provide incentives for, and ease the burden of, implementation for certain health care providers, with special consideration given to such providers serving rural or underserved areas and ensure coordination with standards, implementation specifications, and certification criteria being adopted under the HITECH Act; CommentsClose CommentsPermalink





‘(D) programs to provide incentives for, and ease the burden of, health care providers who volunteer to participate in the process of setting standards for electronic transactions; CommentsClose CommentsPermalink





‘(E) an estimate of total funds needed to ensure timely completion of the implementation plan; and CommentsClose CommentsPermalink





‘(F) an enforcement process that includes timely investigation of complaints, random audits to ensure compliance, civil monetary and programmatic penalties for non-compliance consistent with existing laws and regulations, and a fair and reasonable appeals process building off of enforcement provisions under this part. CommentsClose CommentsPermalink





‘(b) Limitations on Use of Data- Nothing in this section shall be construed to permit the use of information collected under this section in a manner that would adversely affect any individual. CommentsClose CommentsPermalink





‘(c) Protection of Data- The Secretary shall ensure (through the promulgation of regulations or otherwise) that all data collected pursuant to subsection (a) are-- CommentsClose CommentsPermalink





‘(1) used and disclosed in a manner that meets the HIPAA privacy and security law (as defined in section 3009(a)(2) of the Public Health Service Act), including any privacy or security standard adopted under section 3004 of such Act; and CommentsClose CommentsPermalink





‘(2) protected from all inappropriate internal use by any entity that collects, stores, or receives the data, including use of such data in determinations of eligibility (or continued eligibility) in health plans, and from other inappropriate uses, as defined by the Secretary. CommentsClose CommentsPermalink

‘SEC. 1173B. OPERATING RULES.

‘(a) In General- The Secretary shall adopt operating rules for each transaction described in section 1173(a)(2) of the Social Security Act (42 U.S.C. 1320d-2(a)) CommentsClose CommentsPermalink





‘(b) Operating Rules Development- In adopting such rules, the Secretary shall take into account the development of operating rules that have been developed by a nonprofit entity that meets the following criteria: CommentsClose CommentsPermalink





‘(1) The entity focuses its mission on administrative simplification. CommentsClose CommentsPermalink





‘(2) The entity demonstrates a established multi-stakeholder process that creates consensus based operating rules using a voting policy with balanced representation by the critical stakeholders (including health plans and health care providers) so that no one group dominates the entity and shall include others such as standards development organizations, and relevant Federal agencies. CommentsClose CommentsPermalink





‘(3) The entity has in place a public set of guiding principles that ensure the operating rules and process are open and transparent. CommentsClose CommentsPermalink





‘(4) The entity shall coordinate its activities with the HIT Policy Committee and the HIT Standards Committee (established under title XXX of the Public Health Service Act) and complements the efforts of the Office of the National Healthcare Coordinator and its related health information exchange goals. CommentsClose CommentsPermalink





‘(5) The entity incorporates national standards, including the transaction standards issued under Health Insurance Portability and Accountability Act of 1996. CommentsClose CommentsPermalink





‘(6) The entity uses existing market research and proven best practices. CommentsClose CommentsPermalink





‘(7) The entity has a set of measures that allow for the evaluation of their market impact and public reporting of aggregate stakeholder impact. CommentsClose CommentsPermalink





‘(8) The entity supports nondiscrimination and conflict of interest policies that demonstrate a commitment to open, fair, and nondiscriminatory practices. CommentsClose CommentsPermalink





‘(9) The entity allows for public reviews and updates of the operating rules. CommentsClose CommentsPermalink





‘(c) Implementation- The Secretary shall adopt operating rules under this section, by regulation or otherwise, only after taking into account the rules developed by the entity under subsection (b) and having ensured consultation with providers. The first set of operating rules for the transactions for eligibility for health plan and health claims status under this section shall be adopted not later than October 1, 2011, in a manner such that such set of rules is effective beginning not later than January 1, 2013. The second set of operating rules for the remainder of the transactions described in section 1173(a)(2) of the Social Security Act (42 U.S.C. 1320d-2(a)) shall be adopted not later than October 1, 2012, in a manner such that such set of rules is effective beginning not later than January 1, 2014.’. CommentsClose CommentsPermalink





(2) DEFINITIONS- Section 1171 of such Act (42 U.S.C. 1320d) is amended-- CommentsClose CommentsPermalink





(A) in paragraph (7), by striking ‘with reference to’ and all that follows and inserting ‘with reference to a transaction or data element of health information in section 1173 means implementation specifications, certification criteria, operating rules, messaging formats, codes, and code sets adopted or established by the Secretary for the electronic exchange and use of information.’; and CommentsClose CommentsPermalink





(B) by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(9) OPERATING RULES- The term ‘operating rules’ means business rules for using and processing transactions. Operating rules should address the following: CommentsClose CommentsPermalink





‘(A) Requirements for data content using available and established national standards. CommentsClose CommentsPermalink





‘(B) Infrastructure requirements that establish best practices for streamlining data flow to yield timely execution of transactions. CommentsClose CommentsPermalink





‘(C) Policies defining the transaction related rights and responsibilities for entities that are transmitting or receiving data.’. CommentsClose CommentsPermalink





(3) CONFORMING AMENDMENT- Section 1179(a) of such Act (42 U.S.C. 1320d-8(a)) is amended, in the matter before paragraph (1)-- CommentsClose CommentsPermalink





(A) by inserting ‘on behalf of an individual’ after ‘1978)’; and CommentsClose CommentsPermalink





(B) by inserting ‘on behalf of an individual’ after ‘for a financial institution.’’. CommentsClose CommentsPermalink





(b) Standards for Claims Attachments and Coordination of Benefits - CommentsClose CommentsPermalink





(1) STANDARD FOR HEALTH CLAIMS ATTACHMENTS- Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall promulgate a final rule to establish a standard for health claims attachment transaction described in section 1173(a)(2)(B) of the Social Security Act (42 U.S.C. 1320d-2(a)(2)(B)) and coordination of benefits. CommentsClose CommentsPermalink





(2) REVISION IN PROCESSING PAYMENT TRANSACTIONS BY FINANCIAL INSTITUTIONS- CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1179 of the Social Security Act (42 U.S.C. 1320d-8) is amended, in the matter before paragraph (1)-- CommentsClose CommentsPermalink





(i) by striking ‘or is engaged’ and inserting ‘and is engaged’; and CommentsClose CommentsPermalink





(ii) by inserting ‘(other than as a business associate for a covered entity)’ after ‘for a financial institution’. CommentsClose CommentsPermalink





(B) EFFECTIVE DATE- The amendments made by paragraph (1) shall apply to transactions occurring on or after such date (not later than 6 months after the date of the enactment of this Act) as the Secretary of Health and Human Services shall specify. CommentsClose CommentsPermalink





(c) Unique Health Plan Identifier- Not later than 2 years after the date of the enactment of this Act, the Secretary of Health and Human Services shall promulgate a final rule to establish a unique health plan identifier described in section 1173(b) of the Social Security Act (42 U.S.C. 1320d-2(b)) based on the input of the National Committee of Vital and Health Statistics and consultation with health plans. The Secretary may do so on an interim final basis and effective not later than October 1, 2012. CommentsClose CommentsPermalink

SEC. 1645. EXPANSION OF ELECTRONIC TRANSACTIONS IN MEDICARE.

SEC. 166. REINSURANCE PROGRAM FOR RETIREES.

(a) Establishment- CommentsClose CommentsPermalink





(1) IN GENERAL- Not later than 90 days after the date of the enactment of this Act, the Secretary of Health and Human Services shall establish a temporary reinsurance program (in this section referred to as the ‘reinsurance program’) to provide reimbursement to assist participating employment-based plans with the cost of providing health benefits to retirees and to eligible spouses, surviving spouses and dependents of such retirees. CommentsClose CommentsPermalink





(2) DEFINITIONS- For purposes of this section: CommentsClose CommentsPermalink





(A) The term ‘eligible employment-based plan’ means a group health benefits plan that-- CommentsClose CommentsPermalink





(i) is maintained by one or more employers, former employers or employee associations, or a voluntary employees’ beneficiary association, or a committee or board of individuals appointed to administer such plan, and CommentsClose CommentsPermalink





(ii) provides health benefits to retirees. CommentsClose CommentsPermalink





(B) The term ‘health benefits’ means medical, surgical, hospital, prescription drug, and such other benefits as shall be determined by the Secretary, whether self-funded or delivered through the purchase of insurance or otherwise. CommentsClose CommentsPermalink





(C) The term ‘participating employment-based plan’ means an eligible employment-based plan that is participating in the reinsurance program. CommentsClose CommentsPermalink





(D) The term ‘retiree’ means, with respect to a participating employment-benefit plan, an individual who-- CommentsClose CommentsPermalink





(i) is 55 years of age or older; CommentsClose CommentsPermalink





(ii) is not eligible for coverage under title XVIII of the Social Security Act; and CommentsClose CommentsPermalink





(iii) is not an active employee of an employer maintaining the plan or of any employer that makes or has made substantial contributions to fund such plan. CommentsClose CommentsPermalink





(E) The term ‘Secretary’ means Secretary of Health and Human Services. CommentsClose CommentsPermalink





(b) Participation- To be eligible to participate in the reinsurance program, an eligible employment-based plan shall submit to the Secretary an application for participation in the program, at such time, in such manner, and containing such information as the Secretary shall require. CommentsClose CommentsPermalink





(c) Payment- CommentsClose CommentsPermalink





(1) SUBMISSION OF CLAIMS- CommentsClose CommentsPermalink





(A) IN GENERAL- Under the reinsurance program, a participating employment-based plan shall submit claims for reimbursement to the Secretary which shall contain documentation of the actual costs of the items and services for which each claim is being submitted. CommentsClose CommentsPermalink





(B) BASIS FOR CLAIMS- Each claim submitted under subparagraph (A) shall be based on the actual amount expended by the participating employment-based plan involved within the plan year for the appropriate employment based health benefits provided to a retiree or to the spouse, surviving spouse, or dependent of a retiree. In determining the amount of any claim for purposes of this subsection, the participating employment-based plan shall take into account any negotiated price concessions (such as discounts, direct or indirect subsidies, rebates, and direct or indirect remunerations) obtained by such plan with respect to such health benefits. For purposes of calculating the amount of any claim, the costs paid by the retiree or by the spouse, surviving spouse, or dependent of the retiree in the form of deductibles, co-payments, and co-insurance shall be included along with the amounts paid by the participating employment-based plan. CommentsClose CommentsPermalink





(2) PROGRAM PAYMENTS AND LIMIT- If the Secretary determines that a participating employment-based plan has submitted a valid claim under paragraph (1), the Secretary shall reimburse such plan for 80 percent of that portion of the costs attributable to such claim that exceeds $15,000, but is less than $90,000. Such amounts shall be adjusted each year based on the percentage increase in the medical care component of the Consumer Price Index (rounded to the nearest multiple of $1,000) for the year involved. CommentsClose CommentsPermalink





(3) USE OF PAYMENTS- Amounts paid to a participating employment-based plan under this subsection shall be used to lower the costs borne directly by the participants and beneficiaries for health benefits provided under such plan in the form of premiums, co-payments, deductibles, co-insurance, or other out-of-pocket costs. Such payments shall not be used to reduce the costs of an employer maintaining the participating employment-based plan. The Secretary shall develop a mechanism to monitor the appropriate use of such payments by such plans. CommentsClose CommentsPermalink





(4) APPEALS AND PROGRAM PROTECTIONS- The Secretary shall establish-- CommentsClose CommentsPermalink





(A) an appeals process to permit participating employment-based plans to appeal a determination of the Secretary with respect to claims submitted under this section; and CommentsClose CommentsPermalink





(B) procedures to protect against fraud, waste, and abuse under the program. CommentsClose CommentsPermalink





(5) AUDITS- The Secretary shall conduct annual audits of claims data submitted by participating employment-based plans under this section to ensure that they are in compliance with the requirements of this section. CommentsClose CommentsPermalink





(d) Retiree Reserve Trust Fund- CommentsClose CommentsPermalink





(1) ESTABLISHMENT- CommentsClose CommentsPermalink





(A) IN GENERAL- There is established in the Treasury of the United States a trust fund to be known as the ‘Retiree Reserve Trust Fund’ (referred to in this section as the ‘Trust Fund’), that shall consist of such amounts as may be appropriated or credited to the Trust Fund as provided for in this subsection to enable the Secretary to carry out the reinsurance program. Such amounts shall remain available until expended. CommentsClose CommentsPermalink





(B) FUNDING- There are hereby appropriated to the Trust Fund, out of any moneys in the Treasury not otherwise appropriated, an amount requested by the Secretary as necessary to carry out this section, except that the total of all such amounts requested shall not exceed $10,000,000,000. CommentsClose CommentsPermalink





(C) APPROPRIATIONS FROM THE TRUST FUND- CommentsClose CommentsPermalink





(i) IN GENERAL- Amounts in the Trust Fund are appropriated to provide funding to carry out the reinsurance program and shall be used to carry out such program. CommentsClose CommentsPermalink





(ii) BUDGETARY IMPLICATIONS- Amounts appropriated under clause (i), and outlays flowing from such appropriations, shall not be taken into account for purposes of any budget enforcement procedures including allocations under section 302(a) and (b) of the Balanced Budget and Emergency Deficit Control Act and budget resolutions for fiscal years during which appropriations are made from the Trust Fund. CommentsClose CommentsPermalink





(iii) LIMITATION TO AVAILABLE FUNDS- The Secretary has the authority to stop taking applications for participation in the program or take such other steps in reducing expenditures under the reinsurance program in order to ensure that expenditures under the reinsurance program do not exceed the funds available under this subsection. CommentsClose CommentsPermalink

TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS CommentsClose CommentsPermalink

Subtitle A--Health Insurance Exchange CommentsClose CommentsPermalink

SEC. 201. ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE; OUTLINE OF DUTIES; DEFINITIONS.

(a) Establishment- There is established within the Health Choices Administration and under the direction of the Commissioner a Health Insurance Exchange in order to facilitate access of individuals and employers, through a transparent process, to a variety of choices of affordable, quality health insurance coverage, including a public health insurance option. CommentsClose CommentsPermalink





(b) Outline of Duties of Commissioner- In accordance with this subtitle and in coordination with appropriate Federal and State officials as provided under section 143(b), the Commissioner shall-- CommentsClose CommentsPermalink





(1) under section 204 establish standards for, accept bids from, and negotiate and enter into contracts with, QHBP offering entities for the offering of health benefits plans through the Health Insurance Exchange, with different levels of benefits required under section 203, and including with respect to oversight and enforcement; CommentsClose CommentsPermalink





(2) under section 205 facilitate outreach and enrollment in such plans of Exchange-eligible individuals and employers described in section 202; and CommentsClose CommentsPermalink





(3) conduct such activities related to the Health Insurance Exchange as required, including establishment of a risk pooling mechanism under section 206 and consumer protections under subtitle D of title I. CommentsClose CommentsPermalink





(c) Exchange-participating Health Benefits Plan Defined- In this division, the term ‘Exchange-participating health benefits plan’ means a qualified health benefits plan that is offered through the Health Insurance Exchange. CommentsClose CommentsPermalink

SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.

(a) Access to Coverage- IExcept as provided in subsection (i) and in accordance with this section, all individuals are eligible to obtain coverage through enrollment in an Exchange-participating health benefits plan offered through the Health Insurance Exchange unless such individuals are enrolled in another qualified health benefits plan or other acceptable coverage. CommentsClose CommentsPermalink





(b) Definitions- In this division: CommentsClose CommentsPermalink





(1) EXCHANGE-ELIGIBLE INDIVIDUAL- The term ‘Exchange-eligible individual’ means an individual who is eligible under this section to be enrolled through the Health Insurance Exchange in an Exchange-participating health benefits plan and, with respect to family coverage, includes dependents of such individual. CommentsClose CommentsPermalink





(2) EXCHANGE-ELIGIBLE EMPLOYER- The term ‘Exchange-eligible employer’ means an employer that is eligible under this section to enroll through the Health Insurance Exchange employees of the employer (and their dependents) in Exchange-eligible health benefits plans. CommentsClose CommentsPermalink





(3) EMPLOYMENT-RELATED DEFINITIONS- The terms ‘employer’, ‘employee’, ‘full-time employee’, and ‘part-time employee’ have the meanings given such terms by the Commissioner for purposes of this division. CommentsClose CommentsPermalink





(c) Transition- Individuals and employers shall only be eligible to enroll or participate in the Health Insurance Exchange in accordance with the following transition schedule: CommentsClose CommentsPermalink





(1) FIRST YEAR- In Y1 (as defined in section 100(c))-- CommentsClose CommentsPermalink





(A) individuals described in subsection (d)(1), including individuals described in paragraphs (3) and (4) of subsection (d); and CommentsClose CommentsPermalink





(B) smallest employers described in subsection (e)(1). CommentsClose CommentsPermalink





(2) SECOND YEAR- In Y2-- CommentsClose CommentsPermalink





(A) individuals and employers described in paragraph (1); and CommentsClose CommentsPermalink





(B) smaller employers described in subsection (e)(2). CommentsClose CommentsPermalink





(3) THIRD AND SUBSEQUENT YEARS- In Y3 and subsequent years-- CommentsClose CommentsPermalink





(A) individuals and employers described in paragraph (2); and CommentsClose CommentsPermalink





(B) larger employers as permitted by the Commissioner under subsection (e)(3). CommentsClose CommentsPermalink





(d) Individuals- CommentsClose CommentsPermalink





(1) INDIVIDUAL DESCRIBED- Subject to the succeeding provisions of this subsection, an individual described in this paragraph is an individual who-- CommentsClose CommentsPermalink





(A) is not enrolled in coverage described in subparagraphs (C) through (F) of paragraph (2); and CommentsClose CommentsPermalink





(B) is not enrolled in coverage as a full-time employee (or as a dependent of such an employee) under a group health plan if the coverage and an employer contribution under the plan meet the requirements of section 312. CommentsClose CommentsPermalink





For purposes of subparagraph (B), in the case of an individual who is self-employed, who has at least 1 employee, and who meets the requirements of section 312, such individual shall be deemed a full-time employee described in such subparagraph. CommentsClose CommentsPermalink





(2) ACCEPTABLE COVERAGE- For purposes of this division, the term ‘acceptable coverage’ means any of the following: CommentsClose CommentsPermalink





(A) QUALIFIED HEALTH BENEFITS PLAN COVERAGE- Coverage under a qualified health benefits plan. CommentsClose CommentsPermalink





(B) GRANDFATHERED HEALTH INSURANCE COVERAGE; COVERAGE UNDER CURRENT GROUP HEALTH PLAN- Coverage under a grandfathered health insurance coverage (as defined in subsection (a) of section 102) or under a current group health plan (described in subsection (b) of such section). CommentsClose CommentsPermalink





(C) MEDICARE- Coverage under part A of title XVIII of the Social Security Act. CommentsClose CommentsPermalink





(D) MEDICAID- Coverage for medical assistance under title XIX of the Social Security Act, excluding such coverage that is only available because of the application of subsection (u), (z), or (aa) of section 1902 of such Act CommentsClose CommentsPermalink





.(E) MEMBERS OF THE ARMED FORCES AND DEPENDENTS (INCLUDING TRICARE)- Coverage under chapter 55 of title 10, United States Code, including similar coverage furnished under section 1781 of title 38 of such Code. CommentsClose CommentsPermalink





(F) VA- Coverage under the veteran’s health care program under chapter 17 of title 38, United States Code, but only if the coverage for the individual involved is determined by the Commissioner in coordination with the Secretary of Treasury to be not less than a level specified by the Commissioner and Secretary of Veteran’s Affairs, in coordination with the Secretary of Treasury, based on the individual’s priority for services as provided under section 1705(a) of such title. CommentsClose CommentsPermalink





(G) OTHER COVERAGE- Such other health benefits coverage, such as a State health benefits risk pool, as the Commissioner, in coordination with the Secretary of the Treasury, recognizes for purposes of this paragraph. CommentsClose CommentsPermalink





The Commissioner shall make determinations under this paragraph in coordination with the Secretary of the Treasury. CommentsClose CommentsPermalink





(3) TREATMENT OF CERTAIN NON-TRADITIONAL MEDICAID ELIGIBLE INDIVIDUALS- An individual who is a non-traditional Medicaid eligible individual (as defined in section 205(e)(4)(C)) in a State may be an Exchange-eligible individual if the individual was enrolled in a qualified health benefits plan, grandfathered health insurance coverage, or current group health plan during the 6 months before the individual became a non-traditional Medicaid eligible individual. During the period in which such an individual has chosen to enroll in an Exchange-participating health benefits plan, the individual is not also eligible for medical assistance under Medicaid. CommentsClose CommentsPermalink





(4) CONTINUING ELIGIBILITY PERMITTED- CommentsClose CommentsPermalink





(A) IN GENERAL- Except as provided in subparagraph (B), once an individual qualifies as an Exchange-eligible individual under this subsection (including as an employee or dependent of an employee of an Exchange-eligible employer) and enrolls under an Exchange-participating health benefits plan through the Health Insurance Exchange, the individual shall continue to be treated as an Exchange-eligible individual until the individual is no longer enrolled with an Exchange-participating health benefits plan. CommentsClose CommentsPermalink





(B) EXCEPTIONS- CommentsClose CommentsPermalink





(i) IN GENERAL- Subparagraph (A) shall not apply to an individual once the individual becomes eligible for coverage-- CommentsClose CommentsPermalink





(I) under part A of the Medicare program; CommentsClose CommentsPermalink





(II) under the Medicaid program as a Medicaid eligible individual, except as permitted under paragraph (3) or clause (ii); or CommentsClose CommentsPermalink





(III) in such other circumstances as the Commissioner may provide. CommentsClose CommentsPermalink





(ii) TRANSITION PERIOD- In the case described in clause (i)(II), the Commissioner shall permit the individual to continue treatment under subparagraph (A) until such limited time as the Commissioner determines it is administratively feasible, consistent with minimizing disruption in the individual’s access to health care. CommentsClose CommentsPermalink





(e) Employers- CommentsClose CommentsPermalink





(1) SMALLEST EMPLOYER- Subject to paragraph (4), smallest employers described in this paragraph are employers with 10 or fewer employees. CommentsClose CommentsPermalink





(2) SMALLER EMPLOYERS- Subject to paragraph (4), smaller employers described in this paragraph are employers that are not smallest employers described in paragraph (1) and have 20 or fewer employees. CommentsClose CommentsPermalink





(3) LARGER EMPLOYERS- CommentsClose CommentsPermalink





(A) IN GENERAL- Beginning with Y3, the Commissioner may permit employers not described in paragraph (1) or (2) to be Exchange-eligible employers. CommentsClose CommentsPermalink





(B) PHASE-IN- In applying subparagraph (A), the Commissioner may phase-in the application of such subparagraph based on the number of full-time employees of an employer and such other considerations as the Commissioner deems appropriate. CommentsClose CommentsPermalink





(4) CONTINUING ELIGIBILITY- Once an employer is permitted to be an Exchange-eligible employer under this subsection and enrolls employees through the Health Insurance Exchange, the employer shall continue to be treated as an Exchange-eligible employer for each subsequent plan year regardless of the number of employees involved unless and until the employer meets the requirement of section 311(a) through paragraph (1) of such section by offering a group health plan and not through offering an Exchange-participating health benefits plan. CommentsClose CommentsPermalink





(5) EMPLOYER PARTICIPATION AND CONTRIBUTIONS- CommentsClose CommentsPermalink





(A) SATISFACTION OF EMPLOYER RESPONSIBILITY- For any year in which an employer is an Exchange-eligible employer, such employer may meet the requirements of section 312 with respect to employees of such employer by offering such employees the option of enrolling with Exchange-participating health benefits plans through the Health Insurance Exchange consistent with the provisions of subtitle B of title III. CommentsClose CommentsPermalink





(B) EMPLOYEE CHOICE- Any employee offered Exchange-participating health benefits plans by the employer of such employee under subparagraph (A) may choose coverage under any such plan. That choice includes, with respect to family coverage, coverage of the dependents of such employee. CommentsClose CommentsPermalink





(6) AFFILIATED GROUPS- Any employer which is part of a group of employers who are treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated, for purposes of this subtitle, as a single employer. CommentsClose CommentsPermalink





(7) OTHER COUNTING RULES- The Commissioner shall establish rules relating to how employees are counted for purposes of carrying out this subsection. CommentsClose CommentsPermalink





(f) Special Situation Authority- The Commissioner shall have the authority to establish such rules as may be necessary to deal with special situations with regard to uninsured individuals and employers participating as Exchange-eligible individuals and employers, such as transition periods for individuals and employers who gain, or lose, Exchange-eligible participation status, and to establish grace periods for premium payment. CommentsClose CommentsPermalink





(g) Surveys of Individuals and Employers- The Commissioner shall provide for periodic surveys of Exchange-eligible individuals and employers concerning satisfaction of such individuals and employers with the Health Insurance Exchange and Exchange-participating health benefits plans. CommentsClose CommentsPermalink





(h) Exchange Access Study- CommentsClose CommentsPermalink





(1) IN GENERAL- The Commissioner shall conduct a study of access to the Health Insurance Exchange for individuals and for employers, including individuals and employers who are not eligible and enrolled in Exchange-participating health benefits plans. The goal of the study is to determine if there are significant groups and types of individuals and employers who are not Exchange -eligible individuals or employers, but who would have improved benefits and affordability if made eligible for coverage in the Exchange. CommentsClose CommentsPermalink





(2) ITEMS INCLUDED IN STUDY- Such study also shall examine-- CommentsClose CommentsPermalink





(A) the terms, conditions, and affordability of group health coverage offered by employers and QHBP offering entities outside of the Exchange compared to Exchange-participating health benefits plans; and CommentsClose CommentsPermalink





(B) the affordability-test standard for access of certain employed individuals to coverage in the Health Insurance Exchange. CommentsClose CommentsPermalink





(3) REPORT- Not later than January 1 of Y3, in Y6, and thereafter, the Commissioner shall submit to Congress on the study conducted under this subsection and shall include in such report recommendations regarding changes in standards for Exchange eligibility for for individuals and employersindividuals and employers. CommentsClose CommentsPermalink





(i) Exception for Veterans and Members of Armed Forces- Notwithstanding any other provision of this Act, an individual with acceptable coverage described in subparagraph (E) or (F) of subsection (d)(2) is eligible to obtain coverage through enrollment in an Exchange-participating health benefits plan offered through the Health Insurance Exchange. CommentsClose CommentsPermalink





(j) Department of Veterans Affairs and Department of Defense Health Programs- Nothing in this section shall be construed as affecting any authority under title 38, United States Code, or chapter 55 of title 10, United States Code. CommentsClose CommentsPermalink





(k) Report on Comparable Coverage for CHIP Children; Special Rule for CHIP Children- CommentsClose CommentsPermalink





(1) REPORT- No later than December 31, 2011, the Secretary of Health and Human Services shall submit to Congress a report that compares the benefits packages offered in 2011 to an average State child health plan under title XXI of the Social Security Act and to the benefit standards adopted under section 124 for the essential benefits package and the affordability credits under subtitle C. CommentsClose CommentsPermalink





(2) CERTIFICATION OF SECRETARY- Notwithstanding the previous provisions of this section, no child who would be eligible for coverage under title XXI of the Social Security Act shall be enrolled in an Exchange participating health benefits plan until the Secretary of Health and Human Services has certified, based on the findings in the report under paragraph (1) and changes made pursuant to the recommendations in the report, if any, that the coverage (as described in section 121(a)) is at least comparable to the coverage provided to children under an average State child health plan under such title as in effect in 2011. CommentsClose CommentsPermalink

SEC. 203. BENEFITS PACKAGE LEVELS.

(a) In General- The Commissioner shall specify the benefits to be made available under Exchange-participating health benefits plans during each plan year, consistent with subtitle C of title I and this section. CommentsClose CommentsPermalink





(b) Limitation on Health Benefits Plans Offered by Offering Entities- The Commissioner may not enter into a contract with a QHBP offering entity under section 204(c) for the offering of an Exchange-participating health benefits plan in a service area unless the following requirements are met: CommentsClose CommentsPermalink





(1) REQUIRED OFFERING OF BASIC PLAN- The entity offers only one basic plan for such service area. CommentsClose CommentsPermalink





(2) OPTIONAL OFFERING OF ENHANCED PLAN- If and only if the entity offers a basic plan for such service area, the entity may offer one enhanced plan for such area. CommentsClose CommentsPermalink





(3) OPTIONAL OFFERING OF PREMIUM PLAN- If and only if the entity offers an enhanced plan for such service area, the entity may offer one premium plan for such area. CommentsClose CommentsPermalink





(4) OPTIONAL OFFERING OF PREMIUM-PLUS PLANS- If and only if the entity offers a premium plan for such service area, the entity may offer one or more premium-plus plans for such area. CommentsClose CommentsPermalink





All such plans may be offered under a single contract with the Commissioner. CommentsClose CommentsPermalink





(c) Specification of Benefit Levels for Plans- CommentsClose CommentsPermalink





(1) IN GENERAL- The Commissioner shall establish the following standards consistent with this subsection and title I: CommentsClose CommentsPermalink





(A) BASIC, ENHANCED, AND PREMIUM PLANS- Standards for 3 levels of Exchange-participating health benefits plans: basic, enhanced, and premium (in this division referred to as a ‘basic plan’, ‘enhanced plan’, and ‘premium plan’, respectively). CommentsClose CommentsPermalink





(B) PREMIUM-PLUS PLAN BENEFITS- Standards for additional benefits that may be offered, consistent with this subsection and subtitle C of title I, under a premium plan (such a plan with additional benefits referred to in this division as a ‘premium-plus plan’) . CommentsClose CommentsPermalink





(2) BASIC PLAN- CommentsClose CommentsPermalink





(A) IN GENERAL- A basic plan shall offer the essential benefits package required under title I for a qualified health benefits plan. CommentsClose CommentsPermalink





(B) TIERED COST-SHARING FOR AFFORDABLE CREDIT ELIGIBLE INDIVIDUALS- In the case of an affordable credit eligible individual (as defined in section 242(a)(1)) enrolled in an Exchange-participating health benefits plan, the benefits under a basic plan are modified to provide for the reduced cost-sharing for the income tier applicable to the individual under section 244(c). CommentsClose CommentsPermalink





(3) ENHANCED PLAN- An enhanced plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided under title I consistent with section 123(b)(5)(A). CommentsClose CommentsPermalink





(4) PREMIUM PLAN- A premium plan shall offer, in addition to the level of benefits under the basic plan, a lower level of cost-sharing as provided under title I consistent with section 123(b)(5)(B). CommentsClose CommentsPermalink





(5) PREMIUM-PLUS PLAN- A premium-plus plan is a premium plan that also provides additional benefits, such as adult oral health and vision care, approved by the Commissioner. The portion of the premium that is attributable to such additional benefits shall be separately specified. CommentsClose CommentsPermalink





(6) RANGE OF PERMISSIBLE VARIATION IN COST-SHARING- The Commissioner shall establish a permissible range of variation of cost-sharing for each basic, enhanced, and premium plan, except with respect to any benefit for which there is no cost-sharing permitted under the essential benefits package. Such variation shall permit a variation of not more than plus (or minus) 10 percent in cost-sharing with respect to each benefit category specified under section 122. CommentsClose CommentsPermalink





(d) Treatment of State Benefit Mandates- Insofar as a State requires a health insurance issuer offering health insurance coverage to include benefits beyond the essential benefits package, such requirement shall continue to apply to an Exchange-participating health benefits plan, if the State has entered into an arrangement satisfactory to the Commissioner to reimburse the Commissioner for the amount of any net increase in affordability premium credits under subtitle C as a result of an increase in premium in basic plans as a result of application of such requirement. CommentsClose CommentsPermalink





(e) Rules Regarding Coverage of and Affordability Credits for Specified Services- CommentsClose CommentsPermalink





(1) ASSURED AVAILABILITY OF VARIED COVERAGE THROUGH THE HEALTH INSURANCE EXCHANGE- The Commissioner shall assure that, of the Exchange participating health benefits plan offered in each premium rating area of the Health Insurance Exchange-- CommentsClose CommentsPermalink





(A) there is at least one such plan that provides coverage of services described in subparagraphs (A) and (B) of section 122(d)(4); and CommentsClose CommentsPermalink





(B) there is at least one such plan that does not provide coverage of services described in section 122(d)(4)(A) which plan may also be one that does not provide coverage of services described in section 122(d)(4)(B). CommentsClose CommentsPermalink





(2) SEGREGATION OF FUNDS- If a qualified health benefits plan provides coverage of services described in section 122(d)(4)(A), the plan shall provide assurances satisfactory to the Commissioner that-- CommentsClose CommentsPermalink





(A) any affordability credits provided under subtitle C of title II are not used for purposes of paying for such services; and CommentsClose CommentsPermalink





(B) only premium amounts attributable to the actuarial value described in section 113(b) are used for such purpose. CommentsClose CommentsPermalink

SEC. 204. CONTRACTS FOR THE OFFERING OF EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.

(a) Contracting Duties- In carrying out section 201(b)(1) and consistent with this subtitle: CommentsClose CommentsPermalink





(1) OFFERING ENTITY AND PLAN STANDARDS- The Commissioner shall-- CommentsClose CommentsPermalink





(A) establish standards necessary to implement the requirements of this title and title I for-- CommentsClose CommentsPermalink





(i) QHBP offering entities for the offering of an Exchange-participating health benefits plan; and CommentsClose CommentsPermalink





(ii) for Exchange-participating health benefits plans; and CommentsClose CommentsPermalink





(B) certify QHBP offering entities and qualified health benefits plans as meeting such standards and requirements of this title and title I for purposes of this subtitle. CommentsClose CommentsPermalink





(2) SOLICITING AND NEGOTIATING BIDS; CONTRACTS- The Commissioner shall-- CommentsClose CommentsPermalink





(A) solicit bids from QHBP offering entities for the offering of Exchange-participating health benefits plans; CommentsClose CommentsPermalink





(B) based upon a review of such bids, negotiate with such entities for the offering of such plans; and CommentsClose CommentsPermalink





(C) enter into contracts with such entities for the offering of such plans through the Health Insurance Exchange under terms (consistent with this title) negotiated between the Commissioner and such entities. CommentsClose CommentsPermalink





(3) FAR NOT APPLICABLE- The provisions of the Federal Acquisition Regulation shall not apply to contracts between the Commissioner and QHBP offering entities for the offering of Exchange-participating health benefits plans under this title. CommentsClose CommentsPermalink





(b) Standards for QHBP Offering Entities Tto Offer Exchange-Pparticipating Health Benefits Plans- The standards established under subsection (a)(1)(A) shall require that, in order for a QHBP offering entity to offer an Exchange-participating health benefits plan, the entity must meet the following requirements: CommentsClose CommentsPermalink





(1) LICENSED- The entity shall be licensed to offer health insurance coverage under State law for each State in which it is offering such coverage. CommentsClose CommentsPermalink





(2) DATA REPORTING- The entity shall provide for the reporting of such information as the Commissioner may specify, including information necessary to administer the risk pooling mechanism described in section 206(b) and information to address disparities in health and health care. CommentsClose CommentsPermalink





(3) IMPLEMENTING AFFORDABILITY CREDITS- The entity shall provide for implementation of the affordability credits provided for enrollees under subtitle C, including the reduction in cost-sharing under section 244(c). CommentsClose CommentsPermalink





(4) ENROLLMENT- The entity shall accept all enrollments under this subtitle, subject to such exceptions (such as capacity limitations) in accordance with the requirements under title I for a qualified health benefits plan. The entity shall notify the Commissioner if the entity projects or anticipates reaching such a capacity limitation that would result in a limitation in enrollment. CommentsClose CommentsPermalink





(5) RISK POOLING PARTICIPATION- The entity shall participate in such risk pooling mechanism as the Commissioner establishes under section 206(b). CommentsClose CommentsPermalink





(6) ESSENTIAL COMMUNITY PROVIDERS- With respect to the basic plan offered by the entity, the entity shall contract for outpatient services with covered entities (as defined in section 340B(a)(4) of the Public Health Service Act, as in effect as of July 1, 2009). The Commissioner shall specify the extent to which and manner in which the previous sentence shall apply in the case of a basic plan with respect to which the Commissioner determines provides substantially all benefits through a health maintenance organization, as defined in section 2791(b)(3) of the Public Health Service Act. CommentsClose CommentsPermalink





(7) CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES AND COMMUNICATIONS- The entity shall provide for culturally and linguistically appropriate communication and health services. CommentsClose CommentsPermalink





(8) ADDITIONAL REQUIREMENTS- The entity shall comply with other applicable requirements of this title, as specified by the Commissioner, which shall include standards regarding billing and collection practices for premiums and related grace periods and which may include standards to ensure that the entity does not use coercive practices to force providers not to contract with other entities offering coverage through the Health Insurance Exchange. CommentsClose CommentsPermalink





(c) Contracts- CommentsClose CommentsPermalink





(1) BID APPLICATION- To be eligible to enter into a contract under this section, a QHBP offering entity shall submit to the Commissioner a bid at such time, in such manner, and containing such information as the Commissioner may require. CommentsClose CommentsPermalink





(2) TERM- Each contract with a QHBP offering entity under this section shall be for a term of not less than one year, but may be made automatically renewable from term to term in the absence of notice of termination by either party. CommentsClose CommentsPermalink





(3) ENFORCEMENT OF NETWORK ADEQUACY- In the case of a health benefits plan of a QHBP offering entity that uses a provider network, the contract under this section with the entity shall provide that if-- CommentsClose CommentsPermalink





(A) the Commissioner determines that such provider network does not meet such standards as the Commissioner shall establish under section 115; and CommentsClose CommentsPermalink





(B) an individual enrolled in such plan receives an item or service from a provider that is not within such network; CommentsClose CommentsPermalink





then any cost-sharing for such item or service shall be equal to the amount of such cost-sharing that would be imposed if such item or service was furnished by a provider within such network. CommentsClose CommentsPermalink





(4) OVERSIGHT AND ENFORCEMENT RESPONSIBILITIES- The Commissioner shall establish processes, in coordination with State insurance regulators, to oversee, monitor, and enforce applicable requirements of this title with respect to QHBP offering entities offering Exchange-participating health benefits plans and such plans, including the marketing of such plans. Such processes shall include the following: CommentsClose CommentsPermalink





(A) GRIEVANCE AND COMPLAINT MECHANISMS- The Commissioner shall establish, in coordination with State insurance regulators, a process under which Exchange-eligible individuals and employers may file complaints concerning violations of such standards. CommentsClose CommentsPermalink





(B) ENFORCEMENT- In carrying out authorities under this division relating to the Health Insurance Exchange, the Commissioner may impose one or more of the intermediate sanctions described in section 142(c). CommentsClose CommentsPermalink





(C) TERMINATION- CommentsClose CommentsPermalink





(i) IN GENERAL- The Commissioner may terminate a contract with a QHBP offering entity under this section for the offering of an Exchange-participating health benefits plan if such entity fails to comply with the applicable requirements of this title. Any determination by the Commissioner to terminate a contract shall be made in accordance with formal investigation and compliance procedures established by the Commissioner under which-- CommentsClose CommentsPermalink





(I) the Commissioner provides the entity with the reasonable opportunity to develop and implement a corrective action plan to correct the deficiencies that were the basis of the Commissioner’s determination; and CommentsClose CommentsPermalink





(II) the Commissioner provides the entity with reasonable notice and opportunity for hearing (including the right to appeal an initial decision) before terminating the contract. CommentsClose CommentsPermalink





(ii) EXCEPTION FOR IMMINENT AND SERIOUS RISK TO HEALTH- Clause (i) shall not apply if the Commissioner determines that a delay in termination, resulting from compliance with the procedures specified in such clause prior to termination, would pose an imminent and serious risk to the health of individuals enrolled under the qualified health benefits plan of the QHBP offering entity. CommentsClose CommentsPermalink





(D) CONSTRUCTION- Nothing in this subsection shall be construed as preventing the application of other sanctions under subtitle E of title I with respect to an entity for a violation of such a requirement. CommentsClose CommentsPermalink





(d) No Discrimination on the Basis of Provision of Abortion- No Exchange participating health benefits plan may discriminate against any individual health care provider or health care facility because of its willingness or unwillingness to provide, pay for, provide coverage of, or refer for abortions. CommentsClose CommentsPermalink

SEC. 205. OUTREACH AND ENROLLMENT OF EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS IN EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.

(a) In General- CommentsClose CommentsPermalink





(1) OUTREACH- The Commissioner shall conduct outreach activities consistent with subsection (c), including through use of appropriate entities as described in paragraph (43) of such subsection, to inform and educate individuals and employers about the Health Insurance Exchange and Exchange-participating health benefits plan options. Such outreach shall include outreach specific to vulnerable populations, such as children, individuals with disabilities, individuals with mental illness, and individuals with other cognitive impairments. CommentsClose CommentsPermalink





(2) ELIGIBILITY- The Commissioner shall make timely determinations of whether individuals and employers are Exchange-eligible individuals and employers (as defined in section 202). CommentsClose CommentsPermalink





(3) ENROLLMENT- The Commissioner shall establish and carry out an enrollment process for Exchange-eligible individuals and employers, including at community locations, in accordance with subsection (b). CommentsClose CommentsPermalink





(b) Enrollment Process- CommentsClose CommentsPermalink





(1) IN GENERAL- The Commissioner shall establish a process consistent with this title for enrollments in Exchange-participating health benefits plans. Such process shall provide for enrollment through means such as the mail, by telephone, electronically, and in person. CommentsClose CommentsPermalink





(2) ENROLLMENT PERIODS- CommentsClose CommentsPermalink





(A) OPEN ENROLLMENT PERIOD- The Commissioner shall establish an annual open enrollment period during which an Exchange-eligible individual or employer may elect to enroll in an Exchange-participating health benefits plan for the following plan year and an enrollment period for affordability credits under subtitle C. Such periods shall be during September through November of each year, or such other time that would maximize timeliness of income verification for purposes of such subtitle. The open enrollment period shall not be less than 30 days. CommentsClose CommentsPermalink





(B) SPECIAL ENROLLMENT- The Commissioner shall also provide for special enrollment periods to take into account special circumstances of individuals and employers, such as an individual who-- CommentsClose CommentsPermalink





(i) loses acceptable coverage; CommentsClose CommentsPermalink





(ii) experiences a change in marital or other dependent status; CommentsClose CommentsPermalink





(iii) moves outside the service area of the Exchange-participating health benefits plan in which the individual is enrolled; or CommentsClose CommentsPermalink





(iv) experiences a significant change in income. CommentsClose CommentsPermalink





(C) ENROLLMENT INFORMATION- The Commissioner shall provide for the broad dissemination of information to prospective enrollees on the enrollment process, including before each open enrollment period. In carrying out the previous sentence, the Commissioner may work with other appropriate entities to facilitate such provision of information. CommentsClose CommentsPermalink





(3) AUTOMATIC ENROLLMENT FOR NON-MEDICAID ELIGIBLE INDIVIDUALS- CommentsClose CommentsPermalink





(A) IN GENERAL- The Commissioner shall provide for a process under which individuals who are Exchange-eligible individuals described in subparagraph (B) are automatically enrolled under an appropriate Exchange-participating health benefits plan. Such process may involve a random assignment or some other form of assignment that takes into account the health care providers used by the individual involved or such other relevant factors as the Commissioner may specify. CommentsClose CommentsPermalink





(B) SUBSIDIZED INDIVIDUALS DESCRIBED- An individual described in this subparagraph is an Exchange-eligible individual who is either of the following: CommentsClose CommentsPermalink





(i) AFFORDABILITY CREDIT ELIGIBLE INDIVIDUALS- The individual-- CommentsClose CommentsPermalink





(I) has applied for, and been determined eligible for, affordability credits under subtitle C; CommentsClose CommentsPermalink





(II) has not opted out from receiving such affordability credit; and CommentsClose CommentsPermalink





(III) does not otherwise enroll in another Exchange-participating health benefits plan. CommentsClose CommentsPermalink





(ii) INDIVIDUALS ENROLLED IN A TERMINATED PLAN- The individual is enrolled in an Exchange-participating health benefits plan that is terminated (during or at the end of a plan year) and who does not otherwise enroll in another Exchange-participating health benefits plan. CommentsClose CommentsPermalink





(4) DIRECT PAYMENT OF PREMIUMS TO PLANS- Under the enrollment process, individuals enrolled in an Exchange-partcipating health benefits plan shall pay such plans icipating health benefits plan shall pay such plans directly, and not through the Commissioner or the Health Insurance Exchange. CommentsClose CommentsPermalink





(c) Coverage Information and Assistance- CommentsClose CommentsPermalink





(1) COVERAGE INFORMATION- The Commissioner shall provide for the broad dissemination of information on Exchange-participating health benefits plans offered under this title. Such information shall be provided in a comparative manner, and shall include information on benefits, premiums, cost-sharing, quality, provider networks, and consumer satisfaction. CommentsClose CommentsPermalink





(2) CONSUMER ASSISTANCE WITH CHOICE- To provide assistance to Exchange-eligible individuals and employers, the Commissioner shall-- CommentsClose CommentsPermalink





(A) provide for the operation of a toll-free telephone hotline to respond to requests for assistance and maintain an Internet website through which individuals may obtain information on coverage under Exchange-participating health benefits plans and file complaints; CommentsClose CommentsPermalink





(B) develop and disseminate information to Exchange-eligible enrollees on their rights and responsibilities; CommentsClose CommentsPermalink





(C) assist Exchange-eligible individuals in selecting Exchange-participating health benefits plans and obtaining benefits through such plans; and CommentsClose CommentsPermalink





(D) ensure that the Internet website described in subparagraph (A) and the information described in subparagraph (B) is developed using plain language (as defined in section 133(a)(2)). CommentsClose CommentsPermalink





(3) USE OF OTHER ENTITIES- In carrying out this subsection, the Commissioner may work with other appropriate entities to facilitate the dissemination of information under this subsection and to provide assistance as described in paragraph (2). CommentsClose CommentsPermalink





(d) Special Duties Related to Medicaid and CHIP- CommentsClose CommentsPermalink





(1) COVERAGE FOR CERTAIN NEWBORNS- CommentsClose CommentsPermalink





(A) IN GENERAL- In the case of a child born in the United States who at the time of birth is not otherwise covered under acceptable coverage, for the period of time beginning on the date of birth and ending on the date the child otherwise is covered under acceptable coverage (or, if earlier, the end of the month in which the 60-day period, beginning on the date of birth, ends), the child shall be deemed-- CommentsClose CommentsPermalink





(i) to be a non-traditional Medicaid eligible individual (as defined in subsection (e)(5)) for purposes of this division and Medicaid; and CommentsClose CommentsPermalink





(ii) to have elected to enroll in Medicaid through the application of paragraph (3). CommentsClose CommentsPermalink





(B) EXTENDED TREATMENT AS TRADITIONAL MEDICAID ELIGIBLE INDIVIDUAL- In the case of a child described in subparagraph (A) who at the end of the period referred to in such subparagraph is not otherwise covered under acceptable coverage, the child shall be deemed (until such time as the child obtains such coverage or the State otherwise makes a determination of the child’s eligibility for medical assistance under its Medicaid plan pursuant to section 1943(c)(1) of the Social Security Act) to be a traditional Medicaid eligible individual described in section 1902(l)(1)(B) of such Act. CommentsClose CommentsPermalink





(2) CHIP TRANSITION- A child who, as of the day before the first day of Y1, is eligible for child health assistance under title XXI of the Social Security Act (including a child receiving coverage under an arrangement described in section 2101(a)(2) of such Act) is deemed as of such first day to be an Exchange-eligible individual unless the individual is a traditional Medicaid eligible individual as of such day. CommentsClose CommentsPermalink





(3) AUTOMATIC ENROLLMENT OF MEDICAID ELIGIBLE INDIVIDUALS INTO MEDICAID- The Commissioner shall provide for a process under which an individual who is described in section 202(d)(3) and has not elected to enroll in an Exchange-participating health benefits plan is automatically enrolled under Medicaid. CommentsClose CommentsPermalink





(4) NOTIFICATIONS- The Commissioner shall notify each State in Y1 and for purposes of section 1902(gg)(1) of the Social Security Act (as added by section 1703(a)) whether the Health Insurance Exchange can support enrollment of children described in paragraph (2) in such State in such year. CommentsClose CommentsPermalink





(e) Medicaid Coverage for Medicaid Eligible Individuals- CommentsClose CommentsPermalink





(1) IN GENERAL- CommentsClose CommentsPermalink





(A) CHOICE FOR LIMITED EXCHANGE-ELIGIBLE INDIVIDUALS- As part of the enrollment process under subsection (b), the Commissioner shall provide the option, in the case of an Exchange-eligible individual described in section 202(d)(3), for the individual to elect to enroll under Medicaid instead of under an Exchange-participating health benefits plan. Such an individual may change such election during an enrollment period under subsection (b)(2). CommentsClose CommentsPermalink





(B) MEDICAID ENROLLMENT OBLIGATION- An Exchange eligible individual may apply, in the manner described in section 241(b)(1), for a determination of whether the individual is a Medicaid-eligible individual. If the individual is determined to be so eligible, the Commissioner, through the Medicaid memorandum of understanding, shall provide for the enrollment of the individual under the State Medicaid plan in accordance with the Medicaid memorandum of understanding under paragraph (4). In the case of such an enrollment, the State shall provide for the same periodic redetermination of eligibility under Medicaid as would otherwise apply if the individual had directly applied for medical assistance to the State Medicaid agency. CommentsClose CommentsPermalink





(2) NON-TRADITIONAL MEDICAID ELIGIBLE INDIVIDUALS- In the case of a non-traditional Medicaid eligible individual described in section 202(d)(3) who elects to enroll under Medicaid under paragraph (1)(A), the Commissioner shall provide for the enrollment of the individual under the State Medicaid plan in accordance with the Medicaid memorandum of understanding under paragraph (43). CommentsClose CommentsPermalink





(3) COORDINATED ENROLLMENT WITH STATE THROUGH MEMORANDUM OF UNDERSTANDING- The Commissioner, in consultation with the Secretary of Health and Human Services, shall enter into a memorandum of understanding with each State (each in this division referred to as a ‘Medicaid memorandum of understanding’) with respect to coordinating enrollment of individuals in Exchange-participating health benefits plans and under the State’s Medicaid program consistent with this section and to otherwise coordinate the implementation of the provisions of this division with respect to the Medicaid program. Such memorandum shall permit the exchange of information consistent with the limitations described in section 1902(a)(7) of the Social Security Act. Nothing in this section shall be construed as permitting such memorandum to modify or vitiate any requirement of a State Medicaid plan. CommentsClose CommentsPermalink





(4) MEDICAID ELIGIBLE INDIVIDUALS- For purposes of this division: CommentsClose CommentsPermalink





(A) MEDICAID ELIGIBLE INDIVIDUAL- The term ‘Medicaid eligible individual’ means an individual who is eligible for medical assistance under Medicaid. CommentsClose CommentsPermalink





(B) TRADITIONAL MEDICAID ELIGIBLE INDIVIDUAL- The term ‘traditional Medicaid eligible individual’ means a Medicaid eligible individual other than an individual who is-- CommentsClose CommentsPermalink





(i) a Medicaid eligible individual by reason of the application of subclause (VIII) of section 1902(a)(10)(A)(i) of the Social Security Act; or CommentsClose CommentsPermalink





(ii) a childless adult not described in section 1902(a)(10)(A) or (C) of such Act (as in effect as of the day before the date of the enactment of this Act). CommentsClose CommentsPermalink





(C) NON-TRADITIONAL MEDICAID ELIGIBLE INDIVIDUAL- The term ‘non-traditional Medicaid eligible individual’ means a Medicaid eligible individual who is not a traditional Medicaid eligible individual. CommentsClose CommentsPermalink





(f) Effective Culturally and Linguistically Appropriate Communication- In carrying out this section, the Commissioner shall establish effective methods for communicating in plain language and a culturally and linguistically appropriate manner. CommentsClose CommentsPermalink





(g) Role for Enrollment Agents and Brokers- Nothing in this division shall be construed to affect the role of enrollment agents and brokers under State law, including with regard to the enrollment of individuals and employers in qualified health benefits plans including the public health insurance option. CommentsClose CommentsPermalink

SEC. 206. OTHER FUNCTIONS.

(a) Coordination of Affordability Credits- The Commissioner shall coordinate the distribution of affordability premium and cost-sharing credits under subtitle C to QHBP offering entities offering Exchange-participating health benefits plans. CommentsClose CommentsPermalink





(b) Coordination of Risk Pooling- The Commissioner shall establish a mechanism whereby there is an adjustment made of the premium amounts payable among QHBP offering entities offering Exchange-participating health benefits plans of premiums collected for such plans that takes into account (in a manner specified by the Commissioner) the differences in the risk characteristics of individuals and employers enrolled under the different Exchange-participating health benefits plans offered by such entities so as to minimize the impact of adverse selection of enrollees among the plans offered by such entities. CommentsClose CommentsPermalink





(c) Special Inspector General for the Health Insurance Exchange- CommentsClose CommentsPermalink





(1) ESTABLISHMENT; APPOINTMENT- There is hereby established the Office of the Special Inspector General for the Health Insurance Exchange, to be headed by a Special Inspector General for the Health Insurance Exchange (in this subsection referred to as the ‘Special Inspector General’) to be appointed by the President, by and with the advice and consent of the Senate. The nomination of an individual as Special Inspector General shall be made as soon as practicable after the establishment of the program under this subtitle. CommentsClose CommentsPermalink





(2) DUTIES- The Special Inspector General shall-- CommentsClose CommentsPermalink





(A) conduct, supervise, and coordinate audits, evaluations and investigations of the Health Insurance Exchange to protect the integrity of the Health Insurance Exchange, as well as the health and welfare of participants in the Exchange; CommentsClose CommentsPermalink





(B) report both to the Commissioner and to the Congress regarding program and management problems and recommendations to correct them; CommentsClose CommentsPermalink





(C) have other duties (described in paragraphs (2) and (3) of section 121 of division A ofPublic Law 110-343) in relation to the duties described in the previous subparagraphs; and CommentsClose CommentsPermalink





(D) have the authorities provided in section 6 of the Inspector General Act of 1978 in carrying out duties under this paragraph. CommentsClose CommentsPermalink





(3) APPLICATION OF OTHER SPECIAL INSPECTOR GENERAL PROVISIONS- The provisions of subsections (b) (other than paragraphs (1) and (3)), (d) (other than paragraph (1)), and (e) of section 121 of division A of the Emergency Economic Stabilization Act of 2009 (Public Law 110-343) shall apply to the Special Inspector General under this subsection in the same manner as such provisions apply to the Special Inspector General under such section. CommentsClose CommentsPermalink





(4) REPORTS- Not later than one year after the confirmation of the Special Inspector General, and annually thereafter, the Special Inspector General shall submit to the appropriate committees of Congress a report summarizing the activities of the Special Inspector General during the one year period ending on the date such report is submitted. CommentsClose CommentsPermalink





(5) TERMINATION- The Office of the Special Inspector General shall terminate five years after the date of the enactment of this Act. CommentsClose CommentsPermalink

SEC. 207. HEALTH INSURANCE EXCHANGE TRUST FUND.

(a) Establishment of Health Insurance Exchange Trust Fund- There is created within the Treasury of the United States a trust fund to be known as the ‘Health Insurance Exchange Trust Fund’ (in this section referred to as the ‘Trust Fund’), consisting of such amounts as may be appropriated or credited to the Trust Fund under this section or any other provision of law. CommentsClose CommentsPermalink





(b) Payments From Trust Fund- The Commissioner shall pay from time to time from the Trust Fund such amounts as the Commissioner determines are necessary to make payments to operate the Health Insurance Exchange, including payments under subtitle C (relating to affordability credits). CommentsClose CommentsPermalink





(c) Transfers to Trust Fund- CommentsClose CommentsPermalink





(1) DEDICATED PAYMENTS- There is hereby appropriated to the Trust Fund amounts equivalent to the following: CommentsClose CommentsPermalink





(A) TAXES ON INDIVIDUALS NOT OBTAINING ACCEPTABLE COVERAGE- The amounts received in the Treasury under section 59B of the Internal Revenue Code of 1986 (relating to requirement of health insurance coverage for individuals). CommentsClose CommentsPermalink





(B) EMPLOYMENT TAXES ON EMPLOYERS NOT PROVIDING ACCEPTABLE COVERAGE- The amounts received in the Treasury under section 3111(c) of the Internal Revenue Code of 1986 (relating to employers electing to not provide health benefits). CommentsClose CommentsPermalink





(C) EXCISE TAX ON FAILURES TO MEET CERTAIN HEALTH COVERAGE REQUIREMENTS- The amounts received in the Treasury under section 4980H(b) (relating to excise tax with respect to failure to meet health coverage participation requirements). CommentsClose CommentsPermalink





(2) APPROPRIATIONS TO COVER GOVERNMENT CONTRIBUTIONS- There are hereby appropriated, out of any moneys in the Treasury not otherwise appropriated, to the Trust Fund, an amount equivalent to the amount of payments made from the Trust Fund under subsection (b) plus such amounts as are necessary reduced by the amounts deposited under paragraph (1). CommentsClose CommentsPermalink





(d) Application of Certain Rules- Rules similar to the rules of subchapter B of chapter 98 of the Internal Revenue Code of 1986 shall apply with respect to the Trust Fund. CommentsClose CommentsPermalink

SEC. 208. OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE EXCHANGES.

(a) In General- If-- CommentsClose CommentsPermalink





(1) a State (or group of States, subject to the approval of the Commissioner) applies to the Commissioner for approval of a State-based Health Insurance Exchange to operate in the State (or group of States); and CommentsClose CommentsPermalink





(2) the Commissioner approves such State-based Health Insurance Exchange, CommentsClose CommentsPermalink





then, subject to subsections (c) and (d), the State-based Health Insurance Exchange shall operate, instead of the Health Insurance Exchange, with respect to such State (or group of States). The Commissioner shall approve a State-based Health Insurance Exchange if it meets the requirements for approval under subsection (b). CommentsClose CommentsPermalink





(b) Requirements for Approval- CommentsClose CommentsPermalink





(1) IN GENERAL- The Commissioner may not approve a State-based Health Insurance Exchange under this section unless the following requirements are met: CommentsClose CommentsPermalink





(1A) The State-based Health Insurance Exchange must demonstrate the capacity to and provide assurances satisfactory to the Commissioner that the State-based Health Insurance Exchange will carry out the functions specified for the Health Insurance Exchange in the State (or States) involved, including-- CommentsClose CommentsPermalink





(Ai) negotiating and contracting with QHBP offering entities for the offering of Exchange-participating health benefits plan, which satisfy the standards and requirements of this title and title I; CommentsClose CommentsPermalink





(Bii) enrolling Exchange-eligible individuals and employers in such State in such plans; CommentsClose CommentsPermalink





(Ciii) the establishment of sufficient local offices to meet the needs of Exchange-eligible individuals and employers; CommentsClose CommentsPermalink





(Div) administering affordability credits under subtitle B using the same methodologies (and at least the same income verification methods) as would otherwise apply under such subtitle and at a cost to the Federal Government which does exceed the cost to the Federal Government if this section did not apply; and CommentsClose CommentsPermalink





(Ev) enforcement activities consistent with federal requirements. CommentsClose CommentsPermalink





(2B) There is no more than one Health Insurance Exchange operating with respect to any one State. CommentsClose CommentsPermalink





(3C) The State provides assurances satisfactory to the Commissioner that approval of such an Exchange will not result in any net increase in expenditures to the Federal Government. CommentsClose CommentsPermalink





(4D) The State provides for reporting of such information as the Commissioner determines and assurances satisfactory to the Commissioner that it will vigorously enforce violations of applicable requirements. CommentsClose CommentsPermalink





(5) Such other requirements as the Commissioner may specify.(c) E) The State is eligible to receive an incentive payment for enacting and implementing medical liability reforms as specified in subsection (g). CommentsClose CommentsPermalink





(F) Such other requirements as the Commissioner may specify. CommentsClose CommentsPermalink





(2) PRESUMPTION FOR CERTAIN STATE-OPERATED EXCHANGES- CommentsClose CommentsPermalink





(A) IN GENERAL- In the case of a State operating an Exchange prior to January 1, 2010 that seeks to operate the State-based Health Insurance Exchange under this section, the Commissioner shall presume that such Exchange meets the standards under this section unless the Commissioner determines, after completion of the process established under subparagraph (B), that the Exchange does not comply with such standards. CommentsClose CommentsPermalink





(B) PROCESS- The Commissioner shall establish a process to work with a State described in subparagraph (A) to provide assistance necessary to assure that the State’s Exchange comes into compliance with the standards for approval under this section. CommentsClose CommentsPermalink





(c) Ceasing Operation- CommentsClose CommentsPermalink





(1) IN GENERAL- A State-based Health Insurance Exchange may, at the option of each State involved, and only after providing timely and reasonable notice to the Commissioner, cease operation as such an Exchange, in which case the Health Insurance Exchange shall operate, instead of such State-based Health Insurance Exchange, with respect to such State (or States). CommentsClose CommentsPermalink





(2) TERMINATION; HEALTH INSURANCE EXCHANGE RESUMPTION OF FUNCTIONS- The Commissioner may terminate the approval (for some or all functions) of a State-based Health Insurance Exchange under this section if the Commissioner determines that such Exchange no longer meets the requirements of subsection (b) or is no longer capable of carrying out such functions in accordance with the requirements of this subtitle. In lieu of terminating such approval, the Commissioner may temporarily assume some or all functions of the State-based Health Insurance Exchange until such time as the Commissioner determines the State-based Health Insurance Exchange meets such requirements of subsection (b) and is capable of carrying out such functions in accordance with the requirements of this subtitle. CommentsClose CommentsPermalink





(3) EFFECTIVENESS- The ceasing or termination of a State-based Health Insurance Exchange under this subsection shall be effective in such time and manner as the Commissioner shall specify. CommentsClose CommentsPermalink





(d) Retention of Authority- CommentsClose CommentsPermalink





(1) AUTHORITY RETAINED- Enforcement authorities of the Commissioner shall be retained by the Commissioner. CommentsClose CommentsPermalink





(2) DISCRETION TO RETAIN ADDITIONAL AUTHORITY- The Commissioner may specify functions of the Health Insurance Exchange that-- CommentsClose CommentsPermalink





(A) may not be performed by a State-based Health Insurance Exchange under this section; or CommentsClose CommentsPermalink





(B) may be performed by the Commissioner and by such a State-based Health Insurance Exchange. CommentsClose CommentsPermalink





(e) References- In the case of a State-based Health Insurance Exchange, except as the Commissioner may otherwise specify under subsection (d), any references in this subtitle to the Health Insurance Exchange or to the Commissioner in the area in which the State-based Health Insurance Exchange operates shall be deemed a reference to the State-based Health Insurance Exchange and the head of such Exchange, respectively. CommentsClose CommentsPermalink





(f) Funding- In the case of a State-based Health Insurance Exchange, there shall be assistance provided for the operation of such Exchange in the form of a matching grant with a State share of expenditures required. CommentsClose CommentsPermalink





(g) Medical Liability Alternatives- CommentsClose CommentsPermalink





(1) PURPOSES- The purposes of this subsection are-- CommentsClose CommentsPermalink





(A) to ensure quality healthcare is readily available by providing an alternative framework to reduce the costs of defensive medicine and allow victims of malpractice to be fairly compensated; and CommentsClose CommentsPermalink





(B) to do the above without limiting attorneys fees or imposing caps on damages. CommentsClose CommentsPermalink





(2) INCENTIVE PAYMENTS FOR MEDICAL LIABILITY REFORM- CommentsClose CommentsPermalink





(A) IN GENERAL- Each State is eligible to receive an incentive payment, in an amount determined by the Secretary subject to the availability of appropriations, if the State enacts after the date of the enactment of this subsection, and is implementing, an alternative medical liability law that complies with this subsection. CommentsClose CommentsPermalink





(B) DETERMINATION BY SECRETARY- The Secretary shall determine that a State’s alternative medical liability law complies with this subsection if the Secretary is satisfied that the State-- CommentsClose CommentsPermalink





(i) has enacted and is currently implementing that law; and CommentsClose CommentsPermalink





(ii) that law is effective. CommentsClose CommentsPermalink





(C) CONSIDERATIONS FOR DETERMINATION- In making a determination of the effectiveness of a law, the Secretary shall consider whether the law-- CommentsClose CommentsPermalink





(i) makes the medical liability system more reliable through prevention of or prompt and fair resolution of disputes; CommentsClose CommentsPermalink





(ii) encourages the disclosure of health care errors; and CommentsClose CommentsPermalink





(iii) maintains access to affordable liability insurance. CommentsClose CommentsPermalink





(D) OPTIONAL CONTENTS OF ALTERNATIVE MEDICAL LIABILITY LAW- An alternative medical liability law shall contain any one or a combination of the following litigation alternatives: CommentsClose CommentsPermalink





(i) Certificate of Merit. CommentsClose CommentsPermalink





(ii) Early offer. CommentsClose CommentsPermalink





(E) USE OF INCENTIVE PAYMENTS- The State shall use an incentive payment received under this subsection to improve health care in that State. CommentsClose CommentsPermalink





(3) APPLICATION- Each State seeking an incentive payment under this subsection shall submit to the Secretary an application, at such time, in such manner, and containing such information as the Secretary may require. CommentsClose CommentsPermalink





(4) TECHNICAL ASSISTANCE- The Secretary may provide technical assistance to the States applying for or awarded an incentive payment under this subsection. CommentsClose CommentsPermalink





(5) REPORTS- Beginning not later than one year after the date of the enactment of this subsection, the Secretary shall submit to Congress an annual report on the progress States have made in adopting and implementing alternative medical liability laws that comply with this subsection. Such reports shall contain sufficient documentation regarding the effectiveness of such laws to enable an objective comparative analysis of them. CommentsClose CommentsPermalink





(6) RULEMAKING- The Secretary may make rules to carry out this subsection. CommentsClose CommentsPermalink





(7) DEFINITION- In this subsection-- CommentsClose CommentsPermalink





(A) the term ‘Secretary’ means the Secretary of Health and Human Services; and CommentsClose CommentsPermalink





(B) the term ‘State’ includes the District of Columbia, Puerto Rico, and each other territory or possession of the United States. CommentsClose CommentsPermalink





(8) AUTHORIZATION OF APPROPRIATIONS- There are authorized to be appropriated to carry out this subsection such sums as may be necessary, to remain available until expended. CommentsClose CommentsPermalink

Subtitle B--Public Health Insurance Option CommentsClose CommentsPermalink

SEC. 221. ESTABLISHMENT AND ADMINISTRATION OF A PUBLIC HEALTH INSURANCE OPTION AS AN EXCHANGE-QUALIFIED HEALTH BENEFITS PLAN.

(a) Establishment- For years beginning with Y1, the Secretary of Health and Human Services (in this subtitle referred to as the ‘Secretary’) shall provide for the offering of an Exchange-participating health benefits plan (in this division referred to as the ‘public health insurance option’) that ensures choice, competition, and stability of affordable, high quality coverage throughout the United States in accordance with this subtitle. In designing the option, the Secretary’s primary responsibility is to create a low-cost plan without compriomising quality or access to care. CommentsClose CommentsPermalink





(b) Offering as an Exchange-participating Health Benefits Plan- CommentsClose CommentsPermalink





(1) EXCLUSIVE TO THE EXCHANGE- The public health insurance option shall only be made available through the Health Insurance Exchange. CommentsClose CommentsPermalink





(2) ENSURING A LEVEL PLAYING FIELD- Consistent with this subtitle, the public health insurance option shall comply with requirements that are applicable under this title to an Exchange-participating health benefits plan, including requirements related to benefits, benefit levels, provider networks, notices, consumer protections, and cost sharing. CommentsClose CommentsPermalink





(3) PROVISION OF BENEFIT LEVELS- The public health insurance option-- CommentsClose CommentsPermalink





(A) shall offer basic, enhanced, and premium plans; and CommentsClose CommentsPermalink





(B) may offer premium-plus plans. CommentsClose CommentsPermalink





(c) Administrative Contracting- The Secretary may enter into contracts for the purpose of performing administrative functions (including functions described in subsection (a)(4) of section 1874A of the Social Security Act) with respect to the public health insurance option in the same manner as the Secretary may enter into contracts under subsection (a)(1) of such section. The Secretary has the same authority with respect to the public health insurance option as the Secretary has under subsections (a)(1) and (b) of section 1874A of the Social Security Act with respect to title XVIII of such Act. Contracts under this subsection shall not involve the transfer of insurance risk to such entity. CommentsClose CommentsPermalink





(d) Ombudsman- The Secretary shall establish an office of the ombudsman for the public health insurance option which shall have duties with respect to the public health insurance option similar to the duties of the Medicare Beneficiary Ombudsman under section 1808(c)(2) of the Social Security Act. CommentsClose CommentsPermalink





(e) Data Collection- The Secretary shall collect such data as may be required to establish premiums and payment rates for the public health insurance option and for other purposes under this subtitle, including to improve quality and to reduce racial, ethnic, and other disparities in health and health care. CommentsClose CommentsPermalink





(f) Treatment of Public Health Insurance Option- With respect to the public health insurance option, the Secretary shall be treated as a QHBP offering entity offering an Exchange-participating health benefits plan. CommentsClose CommentsPermalink





(g) Access to Federal Courts- The provisions of Medicare (and related provisions of title II of the Social Security Act) relating to access of Medicare beneficiaries to Federal courts for the enforcement of rights under Medicare, including with respect to amounts in controversy, shall apply to the public health insurance option and individuals enrolled under such option under this title in the same manner as such provisions apply to Medicare and Medicare beneficiaries. CommentsClose CommentsPermalink

SEC. 222. PREMIUMS AND FINANCING.

(a) Establishment of Premiums- CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary shall establish geographically-adjusted premium rates for the public health insurance option in a manner-- CommentsClose CommentsPermalink





(A) that complies with the premium rules established by the Commissioner under section 113 for Exchange-participating health benefit plans; and CommentsClose CommentsPermalink





(B) at a level sufficient to fully finance the costs of-- CommentsClose CommentsPermalink





(i) health benefits provided by the public health insurance option; and CommentsClose CommentsPermalink





(ii) administrative costs related to operating the public health insurance option. CommentsClose CommentsPermalink





(2) CONTINGENCY MARGIN- In establishing premium rates under paragraph (1), the Secretary shall include an appropriate amount for a contingency margin (which shall be not less than 90 days of estimated claims). Before setting such appropriate amount for years starting with Y3, the Secretary shall solicit a recommendation on such amount from the American Academy of Actuaries. CommentsClose CommentsPermalink





(b) Account- CommentsClose CommentsPermalink





(1) ESTABLISHMENT- There is established in the Treasury of the United States an Account for the receipts and disbursements attributable to the operation of the public health insurance option, including the start-up funding under paragraph (2). Section 1854(g) of the Social Security Act shall apply to receipts described in the previous sentence in the same manner as such section applies to payments or premiums described in such section. CommentsClose CommentsPermalink





(2) START-UP FUNDING- CommentsClose CommentsPermalink





(A) IN GENERAL- In order to provide for the establishment of the public health insurance option there is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $2,000,000,000. In order to provide for initial claims reserves before the collection of premiums, there is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, such sums as necessary to cover 90 days worth of claims reserves based on projected enrollment. CommentsClose CommentsPermalink





(B) AMORTIZATION OF START-UP FUNDING- The Secretary shall provide for the repayment of the startup funding provided under subparagraph (A) to the Treasury in an amortized manner over the 10-year period beginning with Y1. CommentsClose CommentsPermalink





(C) LIMITATION ON FUNDING- Nothing in this section shall be construed as authorizing any additional appropriations to the Account, other than such amounts as are otherwise provided with respect to other Exchange-participating health benefits plans. CommentsClose CommentsPermalink





(3) NO BAILOUTS- In no case shall the public health insurance option receive any Federal funds for purposes of insolvency in any manner similar to the manner in which entities receive Federal funding under the Troubled Assets Relief Program of the Secretary of the Treasury. CommentsClose CommentsPermalink

SEC. 223. NEGOTIATED PAYMENT RATES FOR ITEMS AND SERVICES.

(a) Rates Established by SecretaryNegotiation of Payment Rates- CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary shall establish payment rates for the public health insurance option for services and health care providers consistent with this section and may change such payment rates in accordance withnegotiate payment rates for the public health insurance option for services and health care providers consistent with this section and section 224. CommentsClose CommentsPermalink





(2) INITIAL PAYMENT RULES-

(A) IN GENERAL- Except as provided in subparagraph (B) and subsection (b)(1), during Y1, Y2, and Y3, the Secretary shall base the payment rates under this section for services and providers described in paragraph (1) on the payment rates for similar services and providers under parts A and B of Medicare.

(B) EXCEPTIONS-

(i) Practitioners’ SERVICES- Payment rates for practitioners’ services otherwise established under the fee schedule under section 1848 of the Social Security Act shall be applied without regard to the provisions under subsection (f) of such section and the update under subsection (d)(4) under such section for a year as applied under this paragraph shall be not less than 1 percent.

(ii) ADJUSTMENTS- The Secretary may determine the extent to which Medicare adjustments applicable to base payment rates under parts A and B of Medicare shall apply under this subtitle.

(3) FOR NEW SERVICESMANNER OF NEGOTIATION- The Secretary shall modify payment rates described in paragraph (2) in order to accommodate payments for services, such as well-child visits, that are not otherwise covered under Medicarenegotiate such rates in a manner that results in payment rates that are not lower, in the aggregate, than rates under title XVIII of the Social Security Act, and not higher, in the aggregate, than the average rates paid by other QHBP offering entities for services and health care providers. CommentsClose CommentsPermalink




(3) INNOVATIVE PAYMENT METHODS- Nothing in this subsection shall be construed as preventing the use of innovative payment methods such as those described in section 224 in connection with the negotiation of payment rates under this subsection. CommentsClose CommentsPermalink





(4) PRESCRIPTION DRUGS- Payment rates under this section for prescription drugs that are not paid for under part A or part B of Medicare shall be at rates negotiated by the Secretary.

(b) Incentives for Participating Providers-

Notwithstanding any other provision of law, the Secretary shall establish a particular formulary for prescription drugs under the public health insurance option. CommentsClose CommentsPermalink




(b) Establishment of a Provider Network- CommentsClose CommentsPermalink





(1) IN GENERAL- Health care providers (including physicians and hospitals) participating in Medicare are participating providers in the public health insurance option unless they opt out in a process established by the Secretary consistent with this subsection. CommentsClose CommentsPermalink





(2) REQUIREMENTS FOR OPT-OUT PROCESS- Under the process established under paragraph (1)INITIAL INCENTIVE PERIOD-

(A) IN GENERAL- The Secretary shall provide, in the case of services described in subparagraph (B) furnished during Y1, Y2, and Y3, for payment rates that are 5 percent greater than the rates established under subsection (a).

(B) SERVICES DESCRIBED- The services described in this subparagraph are items and professional services, under the public health insurance option by a physician or other health care practitioner-- CommentsClose CommentsPermalink




(A) providers described in such subparagraph shall be provided at least a 1-year period prior to the first day of Y1 to opt out of participating in the public health insurance option; CommentsClose CommentsPermalink





(B) no provider shall be subject to a penalty for not participating in the public health insurance option; CommentsClose CommentsPermalink





(C) the Secretary shall include information on how providers participating in Medicare who participates in both Medicare and the public health insurance option.

(C) SPECIAL RULES- A pediatrician and any other health care practitioner who is a type of practitioner that does not typically participate in Medicare (as determined by the Secretary) shall also be eligible for the increased payment rates under subparagraph (A).

(2) SUBSEQUENT PERIODS- Beginning with Y4 and for subsequent years, the Secretary shall continue to use an administrative process to set such rates in order to promote payment accuracy, to ensure adequate beneficiary access to providers, and to promote affordablility and the efficient delivery of medical care consistent with section 221(a). Such rates shall not be set at levels expected to increase overall medical costs under the option beyond what would be expected if the process under subsection (a)(2) and paragraph (1) of this subsection were continued.

(3) ESTABLISHMENT OF A PROVIDER NETWORK- Health care providers participating under Medicare are participating providerschose to opt out of participating in the public health insurance option unless they opt out in a process established by the Secretary.

(c) Administrative Process for Setting Rates- Chapter 5 of title 5, United States Code shall apply to the process for the initial establishment of payment rates under this section but not to the specific methodology for establishing such rates or the calculation of such rates.

(d) Construction- Nothing in this subtitle shall be construed as limiting the Secretary’s authority to correct for payments that are excessive or deficient, taking into account the provisions of section 221(a) and the amounts paid for similar health care providers and services under other Exchange-participating health benefits plans.

(e) Construction- Nothing in this subtitle shall be construed as affecting the authority of the Secretary to establish payment rates, including payments to provide for the more efficient delivery of services, such as the initiatives provided for under section 224.

(f) may opt back in; and CommentsClose CommentsPermalink




(D) there shall be an annual enrollment period in which providers may decide whether to participate in the public health insurance option. CommentsClose CommentsPermalink





(3) RULEMAKING- Not later than 18 months before the first day of Y1, the Secretary shall promulgate rules (pursuant to notice and comment) for the process described in paragraph (1). CommentsClose CommentsPermalink





(c) Limitations on Review- There shall be no administrative or judicial review of a payment rate or methodology established under this section or under section 224. CommentsClose CommentsPermalink

SEC. 224. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM REFORM.

(a) In General- For plan years beginning with Y1, the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value-based purchasing, bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers. CommentsClose CommentsPermalink





(b) Requirements for Innovative Payments- The Secretary shall design and implement the payment mechanisms and policies under this section in a manner that-- CommentsClose CommentsPermalink





(1) seeks to-- CommentsClose CommentsPermalink





(A) improve health outcomes; CommentsClose CommentsPermalink





(B) reduce health disparities (including racial, ethnic, and other disparities); CommentsClose CommentsPermalink





(C) provide efficent and affordable care;(D) address geographic ient and affordable care; CommentsClose CommentsPermalink





(D) address geographic variation in the provision of health services; or CommentsClose CommentsPermalink





(E) prevent or manage chronic illness; and CommentsClose CommentsPermalink





(2) promotes care that is integrated, patient-centered, quality, and efficient. CommentsClose CommentsPermalink





(c) Encouraging the Use of High Value Services- To the extent allowed by the benefit standards applied to all Exchange-participating health benefits plans, the public health insurance option may modify cost sharing and payment rates to encourage the use of services that promote health and value. CommentsClose CommentsPermalink





(d) Promotion of Delivery System Reform- The Secretary shall monitor and evaluate the progress of payment and delivery system reforms under this section and shall seek to implement such reforms subject to the following: CommentsClose CommentsPermalink





(1) To the extent that the Secretary finds a payment and delivery system reform successful in improving quality and reducing costs, the Secretary shall implement such reform on as large a geographic scale as practical and economical. CommentsClose CommentsPermalink





(2) The Secretary may delay the implementation of such a reform in geographic areas in which such implementation would place the public health insurance option at a competitive disadvantage. CommentsClose CommentsPermalink





(3) The Secretary may prioritize implementation of such a reform in high cost geographic areas or otherwise in order to reduce total program costs or to promote high value care. CommentsClose CommentsPermalink





(e) Non-uniformity Permitted- Nothing in this subtitle shall prevent the Secretary from varying payments based on different payment structure models (such as accountable care organizations and medical homes) under the public health insurance option for different geographic areas. CommentsClose CommentsPermalink

SEC. 225. PROVIDER PARTICIPATION.

(a) In General- The Secretary shall establish conditions of participation for health care providers under the public health insurance option. CommentsClose CommentsPermalink





(b) Licensure or Certification- The Secretary shall not allow a health care provider to participate in the public health insurance option unless such provider is appropriately licensed or certified under State law. CommentsClose CommentsPermalink





(c) Payment Terms for Providers-

(1) PHYSICIANS- The Secretary shall provide for the annual participation of physicians under the public health insurance option, for which payment may be made for services furnished during the year, in one of 2 classes:

(A) PREFERRED PHYSICIANS- Those physicians who agree to accept the payment rate established under section 223 (without regard to cost-sharing) as the payment in full.

(B) PARTICIPATING, NON-PREFERRED PHYSICIANS- Those physicians who agree not to impose charges (in relation to the payment rate described in section 223 for such physicians) that exceed the ratio permitted under section 1848(g)(2)(C) of the Social Security Act.

(2) OTHER PROVIDERS- The Secretary shall provide The Secretary shall establish terms and conditions for the participation (on an annual or other basis specified by the Secretary) of health care providers (other than physicians) under the public health insurance option under which payment shall only be available if the provider agrees to accept the payment rate established under section 223 (without regard to cost-sharing) as the payment in full.(d) physicians and other health care providers under the public health insurance option, for which payment may be made for services furnished during the year. CommentsClose CommentsPermalink




(d) Exclusion of Certain Providers- The Secretary shall exclude from participation under the public health insurance option a health care provider that is excluded from participation in a Federal health care program (as defined in section 1128B(f) of the Social Security Act). CommentsClose CommentsPermalink

SEC. 226. APPLICATION OF FRAUD AND ABUSE PROVISIONS.

Provisions of law (other than criminal law provisions) identified by the Secretary by regulation, in consultation with the Inspector General of the Department of Health and Human Services, that impose sanctions with respect to waste, fraud, and abuse under Medicare, such as the False Claims Act (31 U.S.C. 3729 et seq.), shall also apply to the public health insurance option. CommentsClose CommentsPermalink

Subtitle C--Individual Affordability Credits CommentsClose CommentsPermalink

SEC. 241. AVAILABILITY THROUGH HEALTH INSURANCE EXCHANGE.

(a) In General- Subject to the succeeding provisions of this subtitle, in the case of an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan-- CommentsClose CommentsPermalink





(1) the individual shall be eligible for, in accordance with this subtitle, affordability credits consisting of-- CommentsClose CommentsPermalink





(A) an affordability premium credit under section 243 to be applied against the premium for the Exchange-participating health benefits plan in which the individual is enrolled; and CommentsClose CommentsPermalink





(B) an affordability cost-sharing credit under section 244 to be applied as a reduction of the cost-sharing otherwise applicable to such plan; and CommentsClose CommentsPermalink





(2) the Commissioner shall pay the QHBP offering entity that offers such plan from the Health Insurance Exchange Trust Fund the aggregate amount of affordability credits for all affordable credit eligible individuals enrolled in such plan. CommentsClose CommentsPermalink





(b) Application- CommentsClose CommentsPermalink





(1) IN GENERAL- An Exchange eligible individual may apply to the Commissioner through the Health Insurance Exchange or through another entity under an arrangement made with the Commissioner, in a form and manner specified by the Commissioner. The Commissioner through the Health Insurance Exchange or through another public entity under an arrangement made with the Commissioner shall make a determination as to eligibility of an individual for affordability credits under this subtitle. The Commissioner shall establish a process whereby, on the basis of information otherwise available, individuals may be deemed to be affordable credit eligible individuals. In carrying this subtitle, the Commissioner shall establish effective methods that ensure that individuals with limited English proficiency are able to apply for affordability credits. CommentsClose CommentsPermalink





(2) USE OF STATE MEDICAID AGENCIES- If the Commissioner determines that a State Medicaid agency has the capacity to make a determination of eligibility for affordability credits under this subtitle and under the same standards as used by the Commissioner, under the Medicaid memorandum of understanding (as defined in section 205(c)(4))-- CommentsClose CommentsPermalink





(A) the State Medicaid agency is authorized to conduct such determinations for any Exchange-eligible individual who requests such a determination; and CommentsClose CommentsPermalink





(B) the Commissioner shall reimburse the State Medicaid agency for the costs of conducting such determinations. CommentsClose CommentsPermalink





(3) MEDICAID SCREEN AND ENROLL OBLIGATION- In the case of an application made under paragraph (1), there shall be a determination of whether the individual is a Medicaid-eligible individual. If the individual is determined to be so eligible, the Commissioner, through the Medicaid memorandum of understanding, shall provide for the enrollment of the individual under the State Medicaid plan in accordance with the Medicaid memorandum of understanding. In the case of such an enrollment, the State shall provide for the same periodic redetermination of eligibility under Medicaid as would otherwise apply if the individual had directly applied for medical assistance to the State Medicaid agency. CommentsClose CommentsPermalink





(c) Use of Affordability Credits- CommentsClose CommentsPermalink





(1) IN GENERAL- In Y1 and Y2 an affordable credit eligible individual may use an affordability credit only with respect to a basic plan. CommentsClose CommentsPermalink





(2) FLEXIBILITY IN PLAN ENROLLMENT AUTHORIZED- Beginning with Y3, the Commissioner shall establish a process to allow an affordability credit to be used for enrollees in enhanced or premium plans. In the case of an affordable credit eligible individual who enrolls in an enhanced or premium plan, the individual shall be responsible for any difference between the premium for such plan and the affordable credit amount otherwise applicable if the individual had enrolled in a basic plan. CommentsClose CommentsPermalink





(3) PROHIBITION OF USE OF PUBLIC FUNDS FOR ABORTION COVERAGE- An affordability credit may not be used for payment for services described in section 122(d)(4)(A). CommentsClose CommentsPermalink





(d) Access to Data- In carrying out this subtitle, the Commissioner shall request from the Secretary of the Treasury consistent with section 6103 of the Internal Revenue Code of 1986 such information as may be required to carry out this subtitle. CommentsClose CommentsPermalink





(e) No Cash Rebates- In no case shall an affordable credit eligible individual receive any cash payment as a result of the application of this subtitle. CommentsClose CommentsPermalink

SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.

(a) Definition- CommentsClose CommentsPermalink





(1) IN GENERAL- For purposes of this division, the term ‘affordable credit eligible individual’ means, subject to subsection (b), an individual who is lawfully present in a State in the United States (other than as a nonimmigrant described in a subparagraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act)-- CommentsClose CommentsPermalink





(A) who is enrolled under an Exchange-participating health benefits plan and is not enrolled under such plan as an employee (or dependent of an employee) through an employer qualified health benefits plan that meets the requirements of section 312; CommentsClose CommentsPermalink





(B) with family income below 400 percent of the Federal poverty level for a family of the size involved; and CommentsClose CommentsPermalink





(C) who is not a Medicaid eligible individual, other than an individual described in section 202(d)(3) or an individual during a transition period under section 202(d)(4)(B)(ii). CommentsClose CommentsPermalink





(2) TREATMENT OF FAMILY- Except as the Commissioner may otherwise provide, members of the same family who are affordable credit eligible individuals shall be treated as a single affordable credit individual eligible for the applicable credit for such a family under this subtitle. CommentsClose CommentsPermalink





(3) EQUAL TREATMENT OF CERTAIN EMPLOYED INDIVIDUALS- CommentsClose CommentsPermalink





(A) IN GENERAL- For purposes of applying this section with respect to an individual who is an employee of an employer that has an annual payroll (for the preceding calendar year) which does not exceed $750,000 and that makes the contribution which would be required under section 313(a) if the table specified in subparagraph (B) were substituted for the table specified in section 313(b)(1) (and if, in applying section 313(b)(2), $750,000 were substituted for $400,000), such individual shall be treated in the same manner as an employee of an employer that makes the contribution described in section 313(a) (without regard to this paragraph). CommentsClose CommentsPermalink





(B) TABLE- The table specified in this subparagraph is the following: CommentsClose CommentsPermalink

(b) Limitations on Employee and Dependent Disqualification- CommentsClose CommentsPermalink





(1) IN GENERAL- Subject to paragraph (2), the term ‘affordable credit eligible individual’ does not include a full-time employee of an employer if the employer offers the employee coverage (for the employee and dependents) as a full-time employee under a group health plan if the coverage and employer contribution under the plan meet the requirements of section 312. CommentsClose CommentsPermalink





(2) EXCEPTIONS- CommentsClose CommentsPermalink





(A) FOR CERTAIN FAMILY CIRCUMSTANCES- The Commissioner shall establish such exceptions and special rules in the case described in paragraph (1) as may be appropriate in the case of a divorced or separated individual or such a dependent of an employee who would otherwise be an affordable credit eligible individual. CommentsClose CommentsPermalink





(B) FOR UNAFFORDABLE EMPLOYER COVERAGE- Beginning in Y2, in the case of full-time employees for which the cost of the employee premium for coverage under a group health plan would exceed 112 percent of current family income (determined by the Commissioner on the basis of verifiable documentation and without regard to section 245), paragraph (1) shall not apply. CommentsClose CommentsPermalink





(c) Income Defined- CommentsClose CommentsPermalink





(1) IN GENERAL- In this title, the term ‘income’ means modified adjusted gross income (as defined in section 59B of the Internal Revenue Code of 1986). CommentsClose CommentsPermalink





(2) STUDY OF INCOME DISREGARDS- The Commissioner shall conduct a study that examines the application of income disregards for purposes of this subtitle. Not later than the first day of Y2, the Commissioner shall submit to Congress a report on such study and shall include such recommendations as the Commissioner determines appropriate. CommentsClose CommentsPermalink





(d) Clarification of Treatment of Affordability Credits- Affordability credits under this subtitle shall not be treated, for purposes of title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, to be a benefit provided under section 403 of such title. CommentsClose CommentsPermalink

SEC. 243. AFFORDABLE PREMIUM CREDIT.

(a) In General- The affordability premium credit under this section for an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan is in an amount equal to the amount (if any) by which the premium for the plan (or, if less, the reference premium amount specified in subsection (c)), exceeds the affordable premium amount specified in subsection (b) for the individual. CommentsClose CommentsPermalink





(b) Affordable Premium Amount- CommentsClose CommentsPermalink





(1) IN GENERAL- The affordable premium amount specified in this subsection for an individual for monthly premium in a plan year shall be equal to 1/12 of the product of-- CommentsClose CommentsPermalink





(A) the premium percentage limit specified in paragraph (2) for the individual based upon the individual’s family income for the plan year; and CommentsClose CommentsPermalink





(B) the individual’s family income for such plan year. CommentsClose CommentsPermalink





(2) PREMIUM PERCENTAGE LIMITS BASED ON TABLE- The Commissioner shall establish premium percentage limits so that for individuals whose family income is within an income tier specified in the table in subsection (d) such percentage limits shall increase, on a sliding scale in a linear manner, from the initial premium percentage to the final premium percentage specified in such table for such income tier. CommentsClose CommentsPermalink





(c) Reference Premium Amount- The reference premium amount specified in this subsection for a plan year for an individual in a premium rating area is equal to the average premium for the 3 basic plans in the area for the plan year with the lowest premium levels. In computing such amount the Commissioner may exclude plans with extremely limited enrollments. CommentsClose CommentsPermalink





(d) Table of Premium Percentage Limits and Actuarial Value Percentages Based on Income Tier- CommentsClose CommentsPermalink





(1) IN GENERAL- For purposes of this subtitle, subject to paragraphs (3) and (4), the table specified in this subsection is as follows: CommentsClose CommentsPermalink

--------------------------------------------------------------------------------  CommentsClose CommentsPermalink

The initial premium percentage is-- The final premium percentage is-- The actuarial value percentage is--CommentsClose CommentsPermalink

--------------------------------------------------------------------------------  CommentsClose CommentsPermalink

133% through 150%                                1.5%                              3.0%                                 97% CommentsClose CommentsPermalink

150% through 200%                                3.0%                              5.5%                                 93% CommentsClose CommentsPermalink

200% through 250%                                5.5%                                78%                                 85% CommentsClose CommentsPermalink

250% through 300%                                  78%                               910%                                 78% CommentsClose CommentsPermalink

300% through 350%                                 9%                               10%                               11%                                 72% CommentsClose CommentsPermalink

350% through 400%                                 10%                               11%                               12%                                 70% CommentsClose CommentsPermalink

--------------------------------------------------------------------------------  CommentsClose CommentsPermalink

(2) SPECIAL RULES- For purposes of applying the table under paragraph (1)-- CommentsClose CommentsPermalink





(A) FOR LOWEST LEVEL OF INCOME- In the case of an individual with income that does not exceed 133 percent of FPL, the individual shall be considered to have income that is 133 percent% of FPL. CommentsClose CommentsPermalink





(B) APPLICATION OF HIGHER ACTUARIAL VALUE PERCENTAGE AT TIER TRANSITION POINTS- If two actuarial value percentages may be determined with respect to an individual, the actuarial value percentage shall be the higher of such percentages. CommentsClose CommentsPermalink





(3) INDEXING- For years after Y1, the Commissioner shall adjust the initial and final premium percentages to maintain the ratio of governmental to enrollee shares of premiums over time, for each income tier identified in the table in paragraph (1). CommentsClose CommentsPermalink





(4) CONTINGENT ADJUSTMENT FOR ADDITIONAL SAVINGS- CommentsClose CommentsPermalink





(A) IN GENERAL- Before the beginning of each year beginning with Y2-- CommentsClose CommentsPermalink





(i) the Chief Actuary of the Centers of Medicare & Medicaid Services shall estimate the amount of savings in the previous year under this division resulting from the application of the provisions described in subparagraph (B) and shall report such estimate to the Commissioner; and CommentsClose CommentsPermalink





(ii) the Commissioner, based upon such estimate, shall provide for an appropriate increase in the initial and final premium percentages in the table specified in paragraph (1) in a manner that is designed to result in an increase in aggregate affordability credits equivalent to the amount so estimated. CommentsClose CommentsPermalink





(B) PROVISIONS DESCRIBED- The provisions described in this subparagraph are as follows: CommentsClose CommentsPermalink





(i) FORMULARY UNDER PUBLIC OPTION- Section 223(a)(4). CommentsClose CommentsPermalink





(ii) PBM TRANSPARENCY- Section 133(d). CommentsClose CommentsPermalink





(iii) ACO IN MEDICAID- Section 1730. CommentsClose CommentsPermalink





(iv) ADMINISTRATIVE SIMPLIFICATION- CommentsClose CommentsPermalink





(I) Section 1173A of the Social Security Act, as added by section 163(a)(1). CommentsClose CommentsPermalink





(II) Section 163(c). CommentsClose CommentsPermalink





(III) Section 164. CommentsClose CommentsPermalink





(v) LIMITATION ON PREMIUM INCREASES IN EXCHANGE-PARTICIPATING PLANS- Section 209. CommentsClose CommentsPermalink





(vi) NEGOTIATION OF LOWER PART D DRUG PRICES- Section 1186. CommentsClose CommentsPermalink

SEC. 244. AFFORDABILITY COST-SHARING CREDIT.

(a) In General- The affordability cost-sharing credit under this section for an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan is in the form of the cost-sharing reduction described in subsection (b) provided under this section for the income tier in which the individual is classified based on the individual’s family income. CommentsClose CommentsPermalink





(b) Cost-sharing Reductions- The Commissioner shall specify a reduction in cost-sharing amounts and the annual limitation on cost-sharing specified in section 122(c)(2)(B) under a basic plan for each income tier specified in the table under section 243(d), with respect to a year, in a manner so that, as estimated by the Commissioner, the actuarial value of the coverage with such reduced cost-sharing amounts (and the reduced annual cost-sharing limit) is equal to the actuarial value percentage (specified in the table under section 243(d) for the income tier involved) of the full actuarial value if there were no cost-sharing imposed under the plan. CommentsClose CommentsPermalink





(c) Determination and Payment of Cost-sharing Affordability Credit- In the case of an affordable credit eligible individual in a tier enrolled in an Exchange-participating health benefits plan offered by a QHBP offering entity, the Commissioner shall provide for payment to the offering entity of an amount equivalent to the increased actuarial value of the benefits under the plan provided under section 203(c)(2)(B) resulting from the reduction in cost-sharing described in subsection (b). CommentsClose CommentsPermalink

SEC. 245. INCOME DETERMINATIONS.

(a) In General- In applying this subtitle for an affordability credit for an individual for a plan year, the individual’s income shall be the income (as defined in section 242(c)) for the individual for the most recent taxable year (as determined in accordance with rules of the Commissioner). The Federal poverty level applied shall be such level in effect as of the date of the application. CommentsClose CommentsPermalink





(b) Program Integrity; Income Verification Procedures- CommentsClose CommentsPermalink





(1) PROGRAM INTEGRITY- The Commissioner shall take such steps as may be appropriate to ensure the accuracy of determinations and redeterminations under this subtitle. CommentsClose CommentsPermalink





(2) INCOME VERIFICATION- CommentsClose CommentsPermalink





(A) IN GENERAL- Upon an initial application of an individual for an affordability credit under this subtitle (or in applying section 242(b)) or upon an application for a change in the affordability credit based upon a significant change in family income described in subparagraph (A)-- CommentsClose CommentsPermalink





(i) the Commissioner shall request from the Secretary of the Treasury the disclosure to the Commissioner of such information as may be permitted to verify the information contained in such application; and CommentsClose CommentsPermalink





(ii) the Commissioner shall use the information so disclosed to verify such information. CommentsClose CommentsPermalink





(B) ALTERNATIVE PROCEDURES- The Commissioner shall establish procedures for the verification of income for purposes of this subtitle if no income tax return is available for the most recent completed tax year. CommentsClose CommentsPermalink





(c) Special Rules- CommentsClose CommentsPermalink





(1) CHANGES IN INCOME AS A PERCENT OF FPL- In the case that an individual’s income (expressed as a percentage of the Federal poverty level for a family of the size involved) for a plan year is expected (in a manner specified by the Commissioner) to be significantly different from the income (as so expressed) used under subsection (a), the Commissioner shall establish rules requiring an individual to report, consistent with the mechanism established under paragraph (2), significant changes in such income (including a significant change in family composition) to the Commissioner and requiring the substitution of such income for the income otherwise applicable. CommentsClose CommentsPermalink





(2) REPORTING OF SIGNIFICANT CHANGES IN INCOME- The Commissioner shall establish rules under which an individual determined to be an affordable credit eligible individual would be required to inform the Commissioner when there is a significant change in the family income of the individual (expressed as a percentage of the FPL for a family of the size involved) and of the information regarding such change. Such mechanism shall provide for guidelines that specify the circumstances that qualify as a significant change, the verifiable information required to document such a change, and the process for submission of such information. If the Commissioner receives new information from an individual regarding the family income of the individual, the Commissioner shall provide for a redetermination of the individual’s eligibility to be an affordable credit eligible individual. CommentsClose CommentsPermalink





(3) TRANSITION FOR CHIP- In the case of a child described in section 2025(d)(2), the Commissioner shall establish rules under which the family income of the child is deemed to be no greater than the family income of the child as most recently determined before Y1 by the State under title XXI of the Social Security Act. CommentsClose CommentsPermalink





(4) STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF FPL- CommentsClose CommentsPermalink





The Commissioner shall(A) IN GENERAL- The Commissioner shall examine the feasibility and implication of adjusting the application of the Federal poverty level under this subtitle for different geographic areas so as to reflect the variations in cost-of-living among different areas within the United States. If the Commissioner determines that an adjustment is feasible, the study should include a methodology to make such an adjustment. Not later than the first day of Y2, the Commissioner shall submit to Congress a report on such study and shall include such recommendations as the Commissioner determines appropriate. CommentsClose CommentsPermalink





(B) INCLUSION OF TERRITORIES- CommentsClose CommentsPermalink





(i) IN GENERAL- The Commissioner shall ensure that the study under subparagraph (A) covers the territories of the United States and that special attention is paid to the disparity that exists among poverty levels and the cost of living in such territories and to the impact of such disparity on efforts to expand health coverage and ensure health care. CommentsClose CommentsPermalink





(ii) TERRITORIES DEFINED- In this subparagraph, the term ‘territories of the United States’ includes the Commonwealth of Puerto Rico, the United States Virgin Islands, Guam, the Northern Mariana Islands, and any other territory or possession of the United States. CommentsClose CommentsPermalink





(d) Penalties for Misrepresentation- In the case of an individual intentionally misrepresents family income or the individual fails (without regard to intent) to disclose to the Commissioner a significant change in family income under subsection (c) in a manner that results in the individual becoming an affordable credit eligible individual when the individual is not or in the amount of the affordability credit exceeding the correct amount-- CommentsClose CommentsPermalink





(1) the individual is liable for repayment of the amount of the improper affordability credit; ;and CommentsClose CommentsPermalink





(2) in the case of such an intentional misrepresentation or other egregious circumstances specified by the Commissioner, the Commissioner may impose an additional penalty. CommentsClose CommentsPermalink

SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.

Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States. CommentsClose CommentsPermalink

TITLE III--SHARED RESPONSIBILITY CommentsClose CommentsPermalink

Subtitle A--Individual Responsibility CommentsClose CommentsPermalink

SEC. 301. INDIVIDUAL RESPONSIBILITY.

For an individual’s responsibility to obtain acceptable coverage, see section 59B of the Internal Revenue Code of 1986 (as added by section 401 of this Act). CommentsClose CommentsPermalink

Subtitle B--Employer Responsibility CommentsClose CommentsPermalink

PART 1--HEALTH COVERAGE PARTICIPATION REQUIREMENTS

SEC. 311. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

An employer meets the requirements of this section if such employer does all of the following: CommentsClose CommentsPermalink





(1) OFFER OF COVERAGE- The employer offers each employee individual and family coverage under a qualified health benefits plan (or under a current employment-based health plan (within the meaning of section 102(b))) in accordance with section 312. CommentsClose CommentsPermalink





(2) CONTRIBUTION TOWARDS COVERAGE- If an employee accepts such offer of coverage, the employer makes timely contributions towards such coverage in accordance with section 312. CommentsClose CommentsPermalink





(3) CONTRIBUTION IN LIEU OF COVERAGE- Beginning with Y2, if an employee declines such offer but otherwise obtains coverage in an Exchange-participating health benefits plan (other than by reason of being covered by family coverage as a spouse or dependent of the primary insured), the employer shall make a timely contribution to the Health Insurance Exchange with respect to each such employee in accordance with section 313. CommentsClose CommentsPermalink

SEC. 312. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARDS EMPLOYEE AND DEPENDENT COVERAGE.

(a) In General- An employer meets the requirements of this section with respect to an employee if the following requirements are met: CommentsClose CommentsPermalink





(1) OFFERING OF COVERAGE- The employer offers the coverage described in section 311(1) either through an Exchange-participating health benefits plan or other than through such a plan. CommentsClose CommentsPermalink





(2) EMPLOYER REQUIRED CONTRIBUTION- The employer timely pays to the issuer of such coverage an amount not less than the employer required contribution specified in subsection (b) for such coverage. CommentsClose CommentsPermalink





(3) PROVISION OF INFORMATION- The employer provides the Health Choices Commissioner, the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable, with such information as the Commissioner may require to ascertain compliance with the requirements of this section. CommentsClose CommentsPermalink





(4) AUTOENROLLMENT OF EMPLOYEES- The employer provides for autoenrollment of the employee in accordance with subsection (c). CommentsClose CommentsPermalink





(b) Reduction of Employee Premiums Through Minimum Employer Contribution- CommentsClose CommentsPermalink





(1) FULL-TIME EMPLOYEES- The minimum employer contribution described in this subsection for coverage of a full-time employee (and, if any, the employee’s spouse and qualifying children (as defined in section 152(c) of the Internal Revenue Code of 1986) under a qualified health benefits plan (or current employment-based health plan) is equal to-- CommentsClose CommentsPermalink





(A) in case of individual coverage, not less than 72.5 percent of the applicable premium (as defined in section 4980B(f)(4) of such Code, subject to paragraph (2)) of the lowest cost plan offered by the employer that is a qualified health benefits plan (or is such current employment-based health plan); and CommentsClose CommentsPermalink





(B) in the case of family coverage which includes coverage of such spouse and children, not less 65 percent of such applicable premium of such lowest cost plan. CommentsClose CommentsPermalink





(2) APPLICABLE PREMIUM FOR EXCHANGE COVERAGE- In this subtitle, the amount of the applicable premium of the lowest cost plan with respect to coverage of an employee under an Exchange-participating health benefits plan is the reference premium amount under section 243(c) for individual coverage (or, if elected, family coverage) for the premium rating area in which the individual or family resides. CommentsClose CommentsPermalink





(3) MINIMUM EMPLOYER CONTRIBUTION FOR EMPLOYEES OTHER THAN FULL-TIME EMPLOYEES- In the case of coverage for an employee who is not a full-time employee, the amount of the minimum employer contribution under this subsection shall be a proportion (as determined in accordance with rules of the Health Choices Commissioner, the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable) of the minimum employer contribution under this subsection with respect to a full-time employee that reflects the proportion of-- CommentsClose CommentsPermalink





(A) the average weekly hours of employment of the employee by the employer, to CommentsClose CommentsPermalink





(B) the minimum weekly hours specified by the Commissioner for an employee to be a full-time employee. CommentsClose CommentsPermalink





(4) SALARY REDUCTIONS NOT TREATED AS EMPLOYER CONTRIBUTIONS- For purposes of this section, any contribution on behalf of an employee with respect to which there is a corresponding reduction in the compensation of the employee shall not be treated as an amount paid by the employer. CommentsClose CommentsPermalink





(c) Automatic Enrollment for Employer Sponsored Health Benefits- CommentsClose CommentsPermalink





(1) IN GENERAL- The requirement of this subsection with respect to an employer and an employee is that the employer automatically enroll suchs employee into the employment-based health benefits plan for individual coverage under the plan option with the lowest applicable employee premium. CommentsClose CommentsPermalink





(2) OPT-OUT- In no case may an employer automatically enroll an employee in a plan under paragraph (1) if such employee makes an affirmative election to opt out of such plan or to elect coverage under an employment-based health benefits plan offered by such employer. An employer shall provide an employee with a 30-day period to make such an affirmative election before the employer may automatically enroll the employee in such a plan. CommentsClose CommentsPermalink





(3) NOTICE REQUIREMENTS- CommentsClose CommentsPermalink





(A) IN GENERAL- Each employer described in paragraph (1) who automatically enrolls an employee into a plan as described in such paragraph shall provide the employees, within a reasonable period before the beginning of each plan year (or, in the case of new employees, within a reasonable period before the end of the enrollment period for such a new employee), written notice of the employees’ rights and obligations relating to the automatic enrollment requirement under such paragraph. Such notice must be comprehensive and understood by the average employee to whom the automatic enrollment requirement applies. CommentsClose CommentsPermalink





(B) INCLUSION OF SPECIFIC INFORMATION- The written notice under subparagraph (A) must explain an employee’s right to opt out of being automatically enrolled in a plan and in the case that more than one level of benefits or employee premium level is offered by the employer involved, the notice must explain which level of benefits and employee premium level the employee will be automatically enrolled in the absence of an affirmative election by the employee. CommentsClose CommentsPermalink

SEC. 313. EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE.

(a) In General- A contribution is made in accordance with this section with respect to an employee if such contribution is equal to an amount equal to 8 percent of the average wages paid by the employer during the period of enrollment (determined by taking into account all employees of the employer and in such manner as the Commissioner provides, including rules providing for the appropriate aggregation of related employers). Any such contribution-- CommentsClose CommentsPermalink





(1) shall be paid to the Health Choices Commissioner for deposit into the Health Insurance Exchange Trust Fund, and CommentsClose CommentsPermalink





(2) shall not be applied against the premium of the employee under the Exchange-participating health benefits plan in which the employee is enrolled. CommentsClose CommentsPermalink





(b) Special Rules for Small Employers- CommentsClose CommentsPermalink





(1) IN GENERAL- In the case of any employer who is a small employer for any calendar year, subsection (a) shall be applied by substituting the applicable percentage determined in accordance with the following table for ‘8 percent’: CommentsClose CommentsPermalink

--------------------------------------------------------------------------------  CommentsClose CommentsPermalink

--------------------------------------------------------------------------------  CommentsClose CommentsPermalink

If the annual payroll of such employer for the preceding calendar year: The applicable percentage is: CommentsClose CommentsPermalink

Does not exceed $250,000                            0 percent CommentsClose CommentsPermalink

Exceeds $250,000, but does not exceed $300,000                            2 percent CommentsClose CommentsPermalink

Exceeds $300,000, but does not exceed $350,000                            4 percent CommentsClose CommentsPermalink

Exceeds $350,000, but does not exceed $400,000                            6 percent CommentsClose CommentsPermalink

--------------------------------------------------------------------------------  CommentsClose CommentsPermalink

(2) SMALL EMPLOYER- For purposes of this subsection, the term ‘small employer’ means any employer for any calendar year if the annual payroll of such employer for the preceding calendar year does not exceed $400,000. CommentsClose CommentsPermalink





(3) ANNUAL PAYROLL- For purposes of this paragraph, the term ‘annual payroll’ means, with respect to any employer for any calendar year, the aggregate wages paid by the employer during such calendar year. CommentsClose CommentsPermalink





(4) AGGREGATION RULES- Related employers and predecessors shall be treated as a single employer for purposes of this subsection. CommentsClose CommentsPermalink

SEC. 314. AUTHORITY RELATED TO IMPROPER STEERING.

The Health Choices Commissioner (in coordination with the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury) shall have authority to set standards for determining whether employers or insurers are undertaking any actions to affect the risk pool within the Health Insurance Exchange by inducing individuals to decline coverage under a qualified health benefits plan (or current employment-based health plan (within the meaning of section 102(b))) offered by the employer and instead to enroll in an Exchange-participating health benefits plan. An employer violating such standards shall be treated as not meeting the requirements of this section. CommentsClose CommentsPermalink

PART 2--SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS

SEC. 321. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS UNDER THE EMPLOYEE RETIREMENT INCOME SECURITY ACT OF 1974.

(a) In General- Subtitle B of title I of the Employee Retirement Income Security Act of 1974 is amended by adding at the end the following new part:

‘PART 8--NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS

‘SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

‘(a) In General- An employer may make an election with the Secretary to be subject to the health coverage participation requirements.

‘(b) Time and Manner- An election under subsection (a) may be made at such time and in such form and manner as the Secretary may prescribe.

‘SEC. 802. TREATMENT OF COVERAGE RESULTING FROM ELECTION.

‘(a) In General- If an employer makes an election to the Secretary under section 801--

‘(1) such election shall be treated as the establishment and maintenance of a group health plan (as defined in section 733(a)) for purposes of this title, subject to section 151 of the America’s Affordable Health Choices Act of 2009, and

‘(2) the health coverage participation requirements shall be deemed to be included as terms and conditions of such plan.

‘(b) Periodic Investigations To Discover Noncompliance- The Secretary shall regularly audit a representative sampling of employers and group health plans and conduct investigations and other activities under section 504 with respect to such sampling of plans so as to discover noncompliance with the health coverage participation requirements in connection with such plans. The Secretary shall communicate findings of noncompliance made by the Secretary under this subsection to the Secretary of the Treasury and the Health Choices Commissioner. The Secretary shall take such timely enforcement action as appropriate to achieve compliance.

‘SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

‘For purposes of this part, the term ‘health coverage participation requirements’ means the requirements of part 1 of subtitle B of title III of division A of America’s Affordable Health Choices Act of 2009 (as in effect on the date of the enactment of such Act).

‘SEC. 804. RULES FOR APPLYING REQUIREMENTS.

‘(a) Affiliated Groups- In the case of any employer which is part of a group of employers who are treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986, the election under section 801 shall be made by such employer as the Secretary may provide. Any such election, once made, shall apply to all members of such group.

‘(b) Separate Elections- Under regulations prescribed by the Secretary, separate elections may be made under section 801 with respect to--

‘(1) separate lines of business, and

‘(2) full-time employees and employees who are not full-time employees.

‘SEC. 805. TERMINATION OF ELECTION IN CASES OF SUBSTANTIAL NONCOMPLIANCE.

‘The Secretary may terminate the election of any employer under section 801 if the Secretary (in coordination with the Health Choices Commissioner) determines that such employer is in substantial noncompliance with the health coverage participation requirements and shall refer any such determination to the Secretary of the Treasury as appropriate.

‘SEC. 806. REGULATIONS.

‘The Secretary may promulgate such regulations as may be necessary or appropriate to carry out the provisions of this part, in accordance with section 324(a) of the America’s Affordable Health Choices Act of 2009. The Secretary may promulgate any interim final rules as the Secretary determines are appropriate to carry out this part.’.

(b) Enforcement of Health Coverage Participation Requirements- Section 502 of such Act (29 U.S.C. 1132) is amended--

(1) in subsection (a)(6), by striking ‘paragraph’ and all that follows through ‘subsection (c)’ and inserting ‘paragraph (2), (4), (5), (6), (7), (8), (9), (10), or (11) of subsection (c)’; and

(2) in subsection (c), by redesignating the second paragraph (10) as paragraph (12) and by inserting after the first paragraph (10) the following new paragraph:

‘(11) HEALTH COVERAGE PARTICIPATION REQUIREMENTS-

‘(A) CIVIL PENALTIES- In the case of any employer who fails (during any period with respect to which an election under section 801(a) is in effect) to satisfy the health coverage participation requirements with respect to any employee, the Secretary may assess a civil penalty against the employer of $100 for each day in the period beginning on the date such failure first occurs and ending on the date such failure is corrected.

‘(B) HEALTH COVERAGE PARTICIPATION REQUIREMENTS- For purposes of this paragraph, the term ‘health coverage participation requirements’ has the meaning provided in section 803.

‘(C) LIMITATIONS ON AMOUNT OF PENALTY-

‘(i) PENALTY NOT TO APPLY WHERE FAILURE NOT DISCOVERED EXERCISING REASONABLE DILIGENCE- No penalty shall be assessed under subparagraph (A) with respect to any failure during any period for which it is established to the satisfaction of the Secretary that the employer did not know, or exercising reasonable diligence would not have known, that such failure existed.

‘(ii) PENALTY NOT TO APPLY TO FAILURES CORRECTED WITHIN 30 DAYS- No penalty shall be assessed under subparagraph (A) with respect to any failure if--

‘(I) such failure was due to reasonable cause and not to willful neglect, and

‘(II) such failure is corrected during the 30-day period beginning on the 1st date that the employer knew, or exercising reasonable diligence would have known, that such failure existed.

‘(iii) OVERALL LIMITATION FOR UNINTENTIONAL FAILURES- In the case of failures which are due to reasonable cause and not to willful neglect, the penalty assessed under subparagraph (A) for failures during any 1-year period shall not exceed the amount equal to the lesser of--

‘(I) 10 percent of the aggregate amount paid or incurred by the employer (or predecessor employer) during the preceding 1-year period for group health plans, or

‘(II) $500,000.

‘(D) ADVANCE NOTIFICATION OF FAILURE PRIOR TO ASSESSMENT- Before a reasonable time prior to the assessment of any penalty under this paragraph with respect to any failure by an employer, the Secretary shall inform the employer in writing of such failure and shall provide the employer information regarding efforts and procedures which may be undertaken by the employer to correct such failure.

‘(E) COORDINATION WITH EXCISE TAX- Under regulations prescribed in accordance with section 324 of the America’s Affordable Health Choices Act of 2009, the Secretary and the Secretary of the Treasury shall coordinate the assessment of penalties under this section in connection with failures to satisfy health coverage participation requirements with the imposition of excise taxes on such failures under section 4980H(b) of the Internal Revenue Code of 1986 so as to avoid duplication of penalties with respect to such failures.

‘(F) DEPOSIT OF PENALTY COLLECTED- Any amount of penalty collected under this paragraph shall be deposited as miscellaneous receipts in the Treasury of the United States.’.

(c) Clerical Amendments- The table of contents in section 1 of such Act is amended by inserting after the item relating to section 734 the following new items:

‘Part 8--National Health Coverage Participation Requirements

‘Sec. 801. Election of employer to be subject to national health coverage participation requirements.

‘Sec. 802. Treatment of coverage resulting from election.

‘Sec. 803. Health coverage participation requirements.

‘Sec. 804. Rules for applying requirements.

‘Sec. 805. Termination of election in cases of substantial noncompliance.

‘Sec. 806. Regulations.’.

(d) Effective Date- The amendments made by this section shall apply to periods beginning after December 31, 2012.

SEC. 322. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS UNDER THE INTERNAL REVENUE CODE OF 1986.

(a) Failure To Elect, or Substantially Comply With, Health Coverage Participation Requirements- For employment tax on employers who fail to elect, or substantially comply with, the health coverage participation requirements described in part 1, see section 3111(c) of the Internal Revenue Code of 1986 (as added by section 412 of this Act).

(b) Other Failures- For excise tax on other failures of electing employers to comply with such requirements, see section 4980H of the Internal Revenue Code of 1986 (as added by section 411 of this Act).

SEC. 323. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS UNDER THE PUBLIC HEALTH SERVICE ACT.

(a) In General- Part C of title XXVII of the Public Health Service Act is amended by adding at the end the following new section: CommentsClose CommentsPermalink

‘SEC. 2793. NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

‘(a) Election of Employer Tto Be Subject to National Health Coverage Participation Requirements- CommentsClose CommentsPermalink





‘(1) IN GENERAL- An employer may make an election with the Secretary to be subject to the health coverage participation requirements. CommentsClose CommentsPermalink





‘(2) TIME AND MANNER- An election under paragraph (1) may be made at such time and in such form and manner as the Secretary may prescribe. CommentsClose CommentsPermalink





‘(b) Treatment of Coverage Resulting From Election- CommentsClose CommentsPermalink





‘(1) IN GENERAL- If an employer makes an election to the Secretary under subsection (a)-- CommentsClose CommentsPermalink





‘(A) such election shall be treated as the establishment and maintenance of a group health plan for purposes of this title, subject to section 151 of the America’s Affordable Health Choices Act of 2009, and CommentsClose CommentsPermalink





‘(B) the health coverage participation requirements shall be deemed to be included as terms and conditions of such plan. CommentsClose CommentsPermalink





‘(2) PERIODIC INVESTIGATIONS TO DETERMINE COMPLIANCE WITH HEALTH COVERAGE PARTICIPATION REQUIREMENTS- The Secretary shall regularly audit a representative sampling of employers and conduct investigations and other activities with respect to such sampling of employers so as to discover noncompliance with the health coverage participation requirements in connection with such employers (during any period with respect to which an election under subsection (a) is in effect). The Secretary shall communicate findings of noncompliance made by the Secretary under this subsection to the Secretary of the Treasury and the Health Choices Commissioner. The Secretary shall take such timely enforcement action as appropriate to achieve compliance. CommentsClose CommentsPermalink





‘(c) Health Coverage Participation Requirements- For purposes of this section, the term ‘health coverage participation requirements’ means the requirements of part 1 of subtitle B of title III of division A of the America’s Affordable Health Choices Act of 2009 (as in effect on the date of the enactment of this section). CommentsClose CommentsPermalink





‘(d) Separate Elections- Under regulations prescribed by the Secretary, separate elections may be made under subsection (a) with respect to full-time employees and employees who are not full-time employees. CommentsClose CommentsPermalink





‘(e) Termination of Election in Cases of Substantial Noncompliance- The Secretary may terminate the election of any employer under subsection (a) if the Secretary (in coordination with the Health Choices Commissioner) determines that such employer is in substantial noncompliance with the health coverage participation requirements and shall refer any such determination to the Secretary of the Treasury as appropriate. CommentsClose CommentsPermalink





‘(f) Enforcement of Health Coverage Participation Requirements- CommentsClose CommentsPermalink





‘(1) CIVIL PENALTIES- In the case of any employer who fails (during any period with respect to which the election under subsection (a) is in effect) to satisfy the health coverage participation requirements with respect to any employee, the Secretary may assess a civil penalty against the employer of $100 for each day in the period beginning on the date such failure first occurs and ending on the date such failure is corrected. CommentsClose CommentsPermalink





‘(2) LIMITATIONS ON AMOUNT OF PENALTY- CommentsClose CommentsPermalink





‘(A) PENALTY NOT TO APPLY WHERE FAILURE NOT DISCOVERED EXERCISING REASONABLE DILIGENCE- No penalty shall be assessed under paragraph (1) with respect to any failure during any period for which it is established to the satisfaction of the Secretary that the employer did not know, or exercising reasonable diligence would not have known, that such failure existed. CommentsClose CommentsPermalink





‘(B) PENALTY NOT TO APPLY TO FAILURES CORRECTED WITHIN 30 DAYS- No penalty shall be assessed under paragraph (1) with respect to any failure if-- CommentsClose CommentsPermalink





‘(i) such failure was due to reasonable cause and not to willful neglect, and CommentsClose CommentsPermalink





‘(ii) such failure is corrected during the 30-day period beginning on the 1st date that the employer knew, or exercising reasonable diligence would have known, that such failure existed. CommentsClose CommentsPermalink





‘(C) OVERALL LIMITATION FOR UNINTENTIONAL FAILURES- In the case of failures which are due to reasonable cause and not to willful neglect, the penalty assessed under paragraph (1) for failures during any 1-year period shall not exceed the amount equal to the lesser of-- CommentsClose CommentsPermalink





‘(i) 10 percent of the aggregate amount paid or incurred by the employer (or predecessor employer) during the preceding taxable year for group health plans, or CommentsClose CommentsPermalink





‘(ii) $500,000. CommentsClose CommentsPermalink





‘(3) ADVANCE NOTIFICATION OF FAILURE PRIOR TO ASSESSMENT- Before a reasonable time prior to the assessment of any penalty under paragraph (1) with respect to any failure by an employer, the Secretary shall inform the employer in writing of such failure and shall provide the employer information regarding efforts and procedures which may be undertaken by the employer to correct such failure. CommentsClose CommentsPermalink





‘(4) ACTIONS TO ENFORCE ASSESSMENTS- The Secretary may bring a civil action in any District Court of the United States to collect any civil penalty under this subsection. CommentsClose CommentsPermalink





‘(5) COORDINATION WITH EXCISE TAX- Under regulations prescribed in accordance with section 324 of the America’s Affordable Health Choices Act of 2009, the Secretary and the Secretary of the Treasury shall coordinate the assessment of penalties under paragraph (1) in connection with failures to satisfy health coverage participation requirements with the imposition of excise taxes on such failures under section 4980H(b) of the Internal Revenue Code of 1986 so as to avoid duplication of penalties with respect to such failures. CommentsClose CommentsPermalink





‘(6) DEPOSIT OF PENALTY COLLECTED- Any amount of penalty collected under this subsection shall be deposited as miscellaneous receipts in the Treasury of the United States. CommentsClose CommentsPermalink





‘(g) Regulations- The Secretary may promulgate such regulations as may be necessary or appropriate to carry out the provisions of this section, in accordance with section 324(a) of the America’s Affordable Health Choices Act of 2009. The Secretary may promulgate any interim final rules as the Secretary determines are appropriate to carry out this section.’. CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by subsection (a) shall apply to periods beginning after December 31, 2012. CommentsClose CommentsPermalink

SEC. 324. ADDITIONAL RULES RELATING TO HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

(a) Assuring Coordination- The officers consisting of the Secretary of Labor, the Secretary of the Treasury, the Secretary of Health and Human Services, and the Health Choices Commissioner shall ensure, through the execution of an interagency memorandum of understanding among such officers, that-- CommentsClose CommentsPermalink





(1) regulations, rulings, and interpretations issued by such officers relating to the same matter over which two or more of such officers have responsibility under subpart B of part 6 of subtitle B of title I of the Employee Retirement Income Security Act of 1974, section 4980H of the Internal Revenue Code of 1986, and section 2793 of the Public Health Service Act are administered so as to have the same effect at all times; and CommentsClose CommentsPermalink





(2) coordination of policies relating to enforcing the same requirements through such officers in order to have a coordinated enforcement strategy that avoids duplication of enforcement efforts and assigns priorities in enforcement. CommentsClose CommentsPermalink





(b) Multiemployer Plans- In the case of a group health plan that is a multiemployer plan (as defined in section 3(37) of the Employee Retirement Income Security Act of 1974), the regulations prescribed in accordance with subsection (a) by the officers referred to in subsection (a) shall provide for the application of the health coverage participation requirements to the plan sponsor and contributing sponsors of such plan. CommentsClose CommentsPermalink

DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS CommentsClose CommentsPermalink

SEC. 1001. TABLE OF CONTENTS OF DIVISION.

The table of contents for this division is as follows: CommentsClose CommentsPermalink

DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

Sec. 1001. Table of contents of division. CommentsClose CommentsPermalink

TITLE I--IMPROVING HEALTH CARE VALUE

Subtitle A--Provisions Related to Medicare Part A

Part 1--Market Basket Updates

Sec. 1101. Skilled nursing facility payment update. CommentsClose CommentsPermalink





Sec. 1102. Inpatient rehabilitation facility payment update. CommentsClose CommentsPermalink





Sec. 1103. Incorporating productivity improvements into market basket updates that do not already incorporate such improvements. CommentsClose CommentsPermalink

Part 2--Other Medicare Part A Provisions

Sec. 1111. Payments to skilled nursing facilities. CommentsClose CommentsPermalink





Sec. 1112. Medicare DSH report and payment adjustments in response to coverage expansion. CommentsClose CommentsPermalink

Subtitle B--Provisions Related to Medicare Part B

Part 1--Physicians’ Services

Sec. 1121. Sustainable growth rate reform. CommentsClose CommentsPermalink





Sec. 1122. Misvalued codes under the physician fee schedule. CommentsClose CommentsPermalink





Sec. 1123. Payments for efficient areas. CommentsClose CommentsPermalink





Sec. 1124. Modifications to the Physician Quality Reporting Initiative (PQRI). CommentsClose CommentsPermalink





Sec. 1125. Adjustment to Medicare payment localities. CommentsClose CommentsPermalink





Sec. 1126. Resource-based feedback program for physicians in Medicare. CommentsClose CommentsPermalink

Part 2--Market Basket Updates

Sec. 1131. Incorporating productivity improvements into market basket updates that do not already incorporate such improvements. CommentsClose CommentsPermalink

Part 3--Other Provisions

Sec. 1141. Rental and purchase of power-driven wheelchairs. CommentsClose CommentsPermalink





Sec. 1141A. Election to take ownership, or to decline ownership, of a certain item of complex durable medical equipment after the 13-month capped rental period ends. CommentsClose CommentsPermalink





Sec. 1142. Extension of payment rule for brachytherapy. CommentsClose CommentsPermalink





Sec. 1143. Home infusion therapy report to congress. CommentsClose CommentsPermalink





Sec. 1144. Require ambulatory surgical centers (ASCs) to submit cost data and other data. CommentsClose CommentsPermalink





Sec. 1145. Treatment of certain cancer hospitals. CommentsClose CommentsPermalink





Sec. 1146. Medicare Improvement Fund. CommentsClose CommentsPermalink





Sec. 1147. Payment for imaging services. CommentsClose CommentsPermalink





Sec. 1148. Durable medical equipment program improvements. CommentsClose CommentsPermalink





Sec. 1149. MedPAC study and report on bone mass measurement. CommentsClose CommentsPermalink





Sec. 1149A. Exclusion of customary prompt pay discounts extended to wholesalers from manufacturer’s average sales price for payments for drugs and biologicals under Medicare part B. CommentsClose CommentsPermalink





Sec. 1149B. Timely access to postmastectomy items. CommentsClose CommentsPermalink





Sec. 1149C. Moratorium on Medicare reductions in payment rates for certain interventional pain management procedures covered under the ASC fee schedule. CommentsClose CommentsPermalink





Sec. 1149D. Medicare coverage of services of qualified respiratory therapists performed under the general supervision of a physician. CommentsClose CommentsPermalink

Subtitle C--Provisions Related to Medicare Parts A and B

Sec. 1151. Reducing potentially preventable hospital readmissions. CommentsClose CommentsPermalink





Sec. 1152. Post acute care services payment reform plan and bundling pilot program. CommentsClose CommentsPermalink





Sec. 1153. Home health payment update for 2010. CommentsClose CommentsPermalink





Sec. 1154. Payment adjustments for home health care. CommentsClose CommentsPermalink





Sec. 1155. Incorporating productivity improvements into market basket update for home health services. CommentsClose CommentsPermalink





Sec. 1156. Limitation on Medicare exceptions to the prohibition on certain physician referrals made to hospitals. CommentsClose CommentsPermalink





Sec. 1157. Institute of Medicine study of geographic adjustment factors under Medicare. CommentsClose CommentsPermalink





Sec. 1158. Revision of Medicare payment systems to address geographic inequities. CommentsClose CommentsPermalink

Subtitle D--Medicare Advantage Reforms

Part 1--Payment and Administration

Sec. 1161. Phase-in of payment based on fee-for-service costs. CommentsClose CommentsPermalink





Sec. 1162. Quality bonus payments. CommentsClose CommentsPermalink





Sec. 1163. Extension of Secretarial coding intensity adjustment authority. CommentsClose CommentsPermalink





Sec. 1164. Simplification of annual beneficiary election periods. CommentsClose CommentsPermalink





Sec. 1165. Extension of reasonable cost contracts. CommentsClose CommentsPermalink





Sec. 1166. Limitation of waiver authority for employer group plans. CommentsClose CommentsPermalink





Sec. 1167. Improving risk adjustment for payments. CommentsClose CommentsPermalink





Sec. 1168. Elimination of MA Regional Plan Stabilization Fund. CommentsClose CommentsPermalink





Sec. 1169. Study regarding the effects of calculating Medicare Advantage payment rates on a regional average of Medicare fee for service rates. CommentsClose CommentsPermalink

Part 2--Beneficiary Protections and Anti-Fraud

Sec. 1171. Limitation on cost-sharing for individual health services. CommentsClose CommentsPermalink





Sec. 1172. Continuous open enrollment for enrollees in plans with enrollment suspension. CommentsClose CommentsPermalink





Sec. 1173. Information for beneficiaries on MA plan administrative costs. CommentsClose CommentsPermalink





Sec. 1174. Strengthening audit authority. CommentsClose CommentsPermalink





Sec. 1175. Authority to deny plan bids. CommentsClose CommentsPermalink

Part 3--Treatment of Special Needs Plans

Sec. 1176. Limitation on enrollment outside open enrollment period of individuals into chronic care specialized MA plans for special needs individuals. CommentsClose CommentsPermalink





Sec. 1177. Extension of authority of special needs plans to restrict enrollment. CommentsClose CommentsPermalink

Subtitle E--Improvements to Medicare Part D

Sec. 1181. Elimination of coverage gap. CommentsClose CommentsPermalink





Sec. 1182. Discounts for certain part D drugs in original coverage gap. CommentsClose CommentsPermalink





Sec. 1183. Repeal of provision relating to submission of claims by pharmacies located in or contracting with long-term care facilities. CommentsClose CommentsPermalink





Sec. 1184. 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. CommentsClose CommentsPermalink





Sec. 1185. Permitting mid-year changes in enrollment for formulary changes that adversely impact an enrollee. CommentsClose CommentsPermalink





Sec. 1186. Negotiation of lower covered part D drug prices on behalf of Medicare beneficiaries. CommentsClose CommentsPermalink





Sec. 1187. State certification prior to waiver of licensure requirements under Medicare prescription drug program. CommentsClose CommentsPermalink

Subtitle F--Medicare Rural Access Protections

Sec. 1191. Telehealth expansion and enhancements. CommentsClose CommentsPermalink





Sec. 1192. Extension of outpatient hold harmless provision. CommentsClose CommentsPermalink





Sec. 1193. Extension of section 508 hospital reclassifications. CommentsClose CommentsPermalink





Sec. 1194. Extension of geographic floor for work. CommentsClose CommentsPermalink





Sec. 1195. Extension of payment for technical component of certain physician pathology services. CommentsClose CommentsPermalink





Sec. 1196. Extension of ambulance add-ons. CommentsClose CommentsPermalink





Sec. 1197. Ensuring proportional representation of interests of rural areas on MedPAC. CommentsClose CommentsPermalink

TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS

Subtitle A--Improving and Simplifying Financial Assistance for Low Income Medicare Beneficiaries

Sec. 1201. Improving assets tests for Medicare Savings Program and low-income subsidy program. CommentsClose CommentsPermalink





Sec. 1202. Elimination of part D cost-sharing for certain non-institutionalized full-benefit dual eligible individuals. CommentsClose CommentsPermalink





Sec. 1203. Eliminating barriers to enrollment. CommentsClose CommentsPermalink





Sec. 1204. Enhanced oversight relating to reimbursements for retroactive low income subsidy enrollment. CommentsClose CommentsPermalink





Sec. 1205. Intelligent assignment in enrollment. CommentsClose CommentsPermalink





Sec. 1206. Special enrollment period and automatic enrollment process for certain subsidy eligible individuals. CommentsClose CommentsPermalink





Sec. 1207. Application of MA premiums prior to rebate in calculation of low income subsidy benchmark. CommentsClose CommentsPermalink

Subtitle B--Reducing Health Disparities

Sec. 1221. Ensuring effective communication in Medicare. CommentsClose CommentsPermalink





Sec. 1222. Demonstration to promote access for Medicare beneficiaries with limited -English proficiency by providing reimbursement for culturally and linguistically appropriate services. CommentsClose CommentsPermalink





Sec. 1223. IOM report on impact of language access services. CommentsClose CommentsPermalink





Sec. 1224. Definitions. CommentsClose CommentsPermalink

Subtitle C--Miscellaneous Improvements

Sec. 1231. Extension of therapy caps exceptions process. CommentsClose CommentsPermalink





Sec. 1232. Extended months of coverage of immunosuppressive drugs for kidney transplant patients and other renal dialysis provisions. CommentsClose CommentsPermalink





Sec. 1233. Advance care planning consultation. CommentsClose CommentsPermalink





Sec. 1234. Part B special enrollment period and waiver of limited enrollment penalty for TRICARE beneficiaries. CommentsClose CommentsPermalink





Sec. 1235. Exception for use of more recent tax year in case of gains from sale of primary residence in computing part B income-related premium. CommentsClose CommentsPermalink





Sec. 1236. Demonstration program on use of patient decisions aids. CommentsClose CommentsPermalink

TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND COORDINATED CARE

Sec. 1301. Accountable Care Organization pilot program. CommentsClose CommentsPermalink





Sec. 1302. Medical home pilot program. CommentsClose CommentsPermalink





Sec. 1303. Payment incentive for Independence at home pilot program. CommentsClose CommentsPermalink





Sec. 1304. Payment incentive for selected primary care services. CommentsClose CommentsPermalink





Sec. 13045. Increased reimbursement rate for certified nurse-midwives. CommentsClose CommentsPermalink





Sec. 13056. Coverage and waiver of cost-sharing for preventive services. CommentsClose CommentsPermalink





Sec. 13067. Waiver of deductible for colorectal cancer screening tests regardless of coding, subsequent diagnosis, or ancillary tissue removal. CommentsClose CommentsPermalink





Sec. 13078. Excluding clinical social worker services from coverage under the mMedicare skilled nursing facility prospective payment system and consolidated payment. CommentsClose CommentsPermalink





Sec. 13089. Coverage of marriage and family therapist services and mental health counselor services. CommentsClose CommentsPermalink





Sec. 130910. Extension of physician fee schedule mental health add-on. CommentsClose CommentsPermalink





Sec. 13101. Expanding access to vaccines. CommentsClose CommentsPermalink





Sec. 1312. Recognition of certified diabetes educators as certified providers for purposes of Medicare diabetes outpatient self-management training services. CommentsClose CommentsPermalink

TITLE IV--QUALITY

Subtitle A--Comparative Effectiveness Research

Sec. 1401. Comparative effectiveness research. CommentsClose CommentsPermalink

Subtitle B--Nursing Home Transparency

Part 1--Improving Transparency of Information on Skilled Nursing Facilities and Nursing Facilities

Sec. 1411. Required disclosure of ownership and additional disclosable parties information. CommentsClose CommentsPermalink





Sec. 1412. Accountability requirements. CommentsClose CommentsPermalink





Sec. 1413. Nursing home compare Medicare website. CommentsClose CommentsPermalink





Sec. 1414. Reporting of expenditures. CommentsClose CommentsPermalink





Sec. 1415. Standardized complaint form. CommentsClose CommentsPermalink





Sec. 1416. Ensuring staffing accountability. CommentsClose CommentsPermalink

Part 2--Targeting Enforcement

Sec. 1421. Civil money penalties. CommentsClose CommentsPermalink





Sec. 1422. National independent monitor pilot program. CommentsClose CommentsPermalink





Sec. 1423. Notification of facility closure. CommentsClose CommentsPermalink

Part 3--Improving Staff Training

Sec. 1431. Dementia and abuse prevention training. CommentsClose CommentsPermalink





Sec. 1432. Study and report on training required for certified nurse aides and supervisory staff. CommentsClose CommentsPermalink





Sec. 1433. Qualification of director of food services of a Medicaid nursing facility. CommentsClose CommentsPermalink

Subtitle C--Quality Measurements

Sec. 1441. Establishment of national priorities for quality improvement. CommentsClose CommentsPermalink





Sec. 1442. Development of new quality measures; GAO evaluation of data collection process for quality measurement. CommentsClose CommentsPermalink





Sec. 1443. Multi-stakeholder pre-stakeholder prerulemaking input into selection of quality measures. CommentsClose CommentsPermalink





Sec. 1444. Application of quality measures. CommentsClose CommentsPermalink





Sec. 1445. Consensus-based entity funding. CommentsClose CommentsPermalink





Sec. 1446. Quality indicators for care of people with Alzheimer’s disease. CommentsClose CommentsPermalink





Sec. 1447. Study on five star quality rating system. CommentsClose CommentsPermalink

Subtitle D--Physician Payments Sunshine Provision

Sec. 1451. Reports on financial relationships between manufacturers and distributors of covered drugs, devices, biologicals, or medical supplies under Medicare, Medicaid, or CHIP and physicians and other health care entities and between physicians and other health care entities. CommentsClose CommentsPermalink

Subtitle E--Public Reporting on Health Care-Associated Infections

Sec. 1461. Requirement for public reporting by hospitals and ambulatory surgical centers on health care-associated infections. CommentsClose CommentsPermalink

TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION

Sec. 1501. Distribution of unused residency positions. CommentsClose CommentsPermalink





Sec. 1502. Increasing training in nonprovider settings. CommentsClose CommentsPermalink





Sec. 1503. Rules for counting resident time for didactic and scholarly activities and other activities. CommentsClose CommentsPermalink





Sec. 1504. Preservation of resident cap positions from closed hospitals. CommentsClose CommentsPermalink





Sec. 1505. Improving accountability for approved medical residency training. CommentsClose CommentsPermalink

TITLE VI--PROGRAM INTEGRITY

Subtitle A--Increased Funding To Fight Waste, Fraud, and Abuse

Sec. 1601. Increased funding and flexibility to fight fraud and abuse. CommentsClose CommentsPermalink

Subtitle B--Enhanced Penalties for Fraud and Abuse

Sec. 1611. Enhanced penalties for false statements on provider or supplier enrollment applications. CommentsClose CommentsPermalink





Sec. 1612. Enhanced penalties for submission of false statements material to a false claim. CommentsClose CommentsPermalink





Sec. 1613. Enhanced penalties for delaying inspections. CommentsClose CommentsPermalink





Sec. 1614. Enhanced hospice program safeguards. CommentsClose CommentsPermalink





Sec. 1615. Enhanced penalties for individuals excluded from program participation. CommentsClose CommentsPermalink





Sec. 1616. Enhanced penalties for provision of false information by Medicare Advantage and part D plans. CommentsClose CommentsPermalink





Sec. 1617. Enhanced penalties for Medicare Advantage and part D marketing violations. CommentsClose CommentsPermalink





Sec. 1618. Enhanced penalties for obstruction of program audits. CommentsClose CommentsPermalink





Sec. 1619. Exclusion of certain individuals and entities from participation in Medicare and State health care programs. CommentsClose CommentsPermalink

Subtitle C--Enhanced Program and Provider Protections

Sec. 1631. Enhanced CMS program protection authority. CommentsClose CommentsPermalink





Sec. 1632. Enhanced Medicare, Medicaid, and CHIP program disclosure requirements relating to previous affiliations. CommentsClose CommentsPermalink





Sec. 1633. Required inclusion of payment modifier for certain evaluation and management services. CommentsClose CommentsPermalink





Sec. 1634. Evaluations and reports required under Medicare Integrity Program. CommentsClose CommentsPermalink





Sec. 1635. Require providers and suppliers to adopt programs to reduce waste, fraud, and abuse. CommentsClose CommentsPermalink





Sec. 1636. Maximum period for submission of Medicare claims reduced to not more than 12 months. CommentsClose CommentsPermalink





Sec. 1637. Physicians who order durable medical equipment or home health services required to be Medicare -enrolled physicians or eligible professionals. CommentsClose CommentsPermalink





Sec. 1638. Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse. CommentsClose CommentsPermalink





Sec. 1639. Face to -to-face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment under Medicare. CommentsClose CommentsPermalink





Sec. 1640. Extension of testimonial subpoena authority to program exclusion investigations. CommentsClose CommentsPermalink





Sec. 1641. Required repayments of Medicare and Medicaid overpayments. CommentsClose CommentsPermalink





Sec. 1642. Expanded application of hardship waivers for OIG exclusions to beneficiaries of any Federal health care program. CommentsClose CommentsPermalink





Sec. 1643. Access to certain information on renal dialysis facilities. CommentsClose CommentsPermalink





Sec. 1644. Billing agents, clearinghouses, or other alternate payees required to register under Medicare. CommentsClose CommentsPermalink





Sec. 1645. Conforming civil monetary penalties to False Claims Act amendments. CommentsClose CommentsPermalink

Subtitle D--Access to Information Needed To Prevent Fraud, Waste, and Abuse

Sec. 1651. Access to Information Necessary to Identify Fraud, Waste, and Ainformation necessary to identify fraud, waste, and abuse. CommentsClose CommentsPermalink





Sec. 1652. Elimination of duplication between the Healthcare Integrity and Protection Data Bank and the National Practitioner Data Bank. CommentsClose CommentsPermalink





Sec. 1653. Compliance with HIPAA privacy and security standards. CommentsClose CommentsPermalink

TITLE VII--MEDICAID AND CHIP

Subtitle A--Medicaid and Health Reform

Sec. 1701. Eligibility for individuals with income below 133 1/3 percent of the Federal poverty level. CommentsClose CommentsPermalink





Sec. 1702. Requirements and special rules for certain Medicaid eligible individuals. CommentsClose CommentsPermalink





Sec. 1703. CHIP and Medicaid maintenance of effort.

Sec. 1704. Reduction in Medicaid DSH3. CHIP and Medicaid maintenance of eligibility. CommentsClose CommentsPermalink




Sec. 1704. Reduction in Medicaid DSH. CommentsClose CommentsPermalink





Sec. 1705. Expanded outstationing. CommentsClose CommentsPermalink

Subtitle B--Prevention

Sec. 1711. Required coverage of preventive services. CommentsClose CommentsPermalink





Sec. 1712. Tobacco cessation. CommentsClose CommentsPermalink





Sec. 1713. Optional coverage of nurse home visitation services. CommentsClose CommentsPermalink





Sec. 1714. State eligibility option for family planning services. CommentsClose CommentsPermalink

Subtitle C--Access

Sec. 1721. Payments to primary care practitioners. CommentsClose CommentsPermalink





Sec. 1722. Medical home pilot program. CommentsClose CommentsPermalink





Sec. 1723. Translation or interpretation services. CommentsClose CommentsPermalink





Sec. 1724. Optional coverage for freestanding birth center services. CommentsClose CommentsPermalink





Sec. 1725. Inclusion of public health clinics under the vaccines for children program. CommentsClose CommentsPermalink





Sec. 1726. Requiring coverage of services of podiatrists. CommentsClose CommentsPermalink





Sec. 1726A. Requiring coverage of services of optometrists. CommentsClose CommentsPermalink





Sec. 1727. Therapeutic foster care. CommentsClose CommentsPermalink





Sec. 1728. Assuring adequate payment levels for services. CommentsClose CommentsPermalink





Sec. 1729. Preserving Medicaid coverage for youths upon release from public institutions. CommentsClose CommentsPermalink





Sec. 1730. Quality measures for maternity and adult health services under Medicaid and CHIP. CommentsClose CommentsPermalink





Sec. 1730A. Accountable care organization pilot program. CommentsClose CommentsPermalink

Subtitle D--Coverage

Sec. 1731. Optional mMedicaid coverage of low-income HIV-infected individuals. CommentsClose CommentsPermalink





Sec. 1732. Extending transitional Medicaid Assistance (TMA). CommentsClose CommentsPermalink





Sec. 1733. Requirement of 12-month continuous coverage under certain CHIP programs. CommentsClose CommentsPermalink





Sec. 1734. Preventing the application under CHIP of coverage waiting periods for certain children. CommentsClose CommentsPermalink





Sec. 1735. Adult day health care services. CommentsClose CommentsPermalink





Sec. 1736. Medicaid coverage for citizens of Freely Associated States. CommentsClose CommentsPermalink





Sec. 1737. Continuing requirement of Medicaid coverage of nonemergency transportation to medically necessary services. CommentsClose CommentsPermalink





Sec. 1738. State option to disregard certain income in providing continued Medicaid coverage for certain individuals with extremely high prescription costs. CommentsClose CommentsPermalink

Subtitle E--Financing

Sec. 1741. Payments to pharmacists. CommentsClose CommentsPermalink





Sec. 1742. Prescription drug rebates. CommentsClose CommentsPermalink





Sec. 1743. Extension of prescription drug discounts to enrollees of mMedicaid managed care organizations. CommentsClose CommentsPermalink





Sec. 1744. Payments for graduate medical education. CommentsClose CommentsPermalink





Sec. 1745. Report on Medicaid payments. CommentsClose CommentsPermalink





Sec. 1746. Reviews of Medicaid. CommentsClose CommentsPermalink





Sec. 1747. Extension of delay in managed care organization provider tax elimination. CommentsClose CommentsPermalink

Subtitle F--Waste, Fraud, and Abuse

Sec. 1751. Health- care acquired conditions. CommentsClose CommentsPermalink





Sec. 1752. Evaluations and reports required under Medicaid Integrity Program. CommentsClose CommentsPermalink





Sec. 1753. Require providers and suppliers to adopt programs to reduce waste, fraud, and abuse. CommentsClose CommentsPermalink





Sec. 1754. Overpayments. CommentsClose CommentsPermalink





Sec. 1755. Managed Care Ocare organizations. CommentsClose CommentsPermalink





Sec. 1756. Termination of provider participation under Medicaid and CHIP if terminated under Medicare or other State plan or child health plan. CommentsClose CommentsPermalink





Sec. 1757. Medicaid and CHIP exclusion from participation relating to certain ownership, control, and management affiliations. CommentsClose CommentsPermalink





Sec. 1758. Requirement to report expanded set of data elements under MMIS to detect fraud and abuse. CommentsClose CommentsPermalink





Sec. 1759. Billing agents, clearinghouses, or other alternate payees required to register under Medicaid. CommentsClose CommentsPermalink





Sec. 1760. Denial of payments for litigation-related misconduct. CommentsClose CommentsPermalink





Sec. 1761. Mandatory State use of national correct coding initiative. CommentsClose CommentsPermalink

Subtitle G--Puerto Rico andayments to the Territories

Sec. 1771. Puerto Rico andayment to territories. CommentsClose CommentsPermalink

Subtitle H--Miscellaneous

Sec. 1781. Technical corrections. CommentsClose CommentsPermalink





Sec. 1782. Extension of QI program. CommentsClose CommentsPermalink





Sec. 1783. Outreach and enrollment of Medicaid and CHIP eligible individuals. CommentsClose CommentsPermalink





Sec. 1784. Prohibitions on Federal Medicaid and CHIP payment for undocumented aliens. CommentsClose CommentsPermalink





Sec. 1785. Demonstration project for stabilization of emergency medical conditions by nonpublicly owned or operated institutions for mental diseases. CommentsClose CommentsPermalink

TITLE VIII--REVENUE-RELATED PROVISIONS

Sec. 1801. Disclosures to facilitate identification of individuals likely to be ineligible for the low-income assistance under the Medicare prescription drug program to assist Social Security Administration’s outreach to eligible individuals. CommentsClose CommentsPermalink





Sec. 1802. Comparative Effectiveness Research Trust Fund; financing for Trust Fund. CommentsClose CommentsPermalink

TITLE IX--MISCELLANEOUS PROVISIONS

Sec. 1901. Repeal of trigger provision. CommentsClose CommentsPermalink





Sec. 1902. Repeal of comparative cost adjustment (CCA) program. CommentsClose CommentsPermalink





Sec. 1903. Extension of gainsharing demonstration. CommentsClose CommentsPermalink





Sec. 1904. Grants to States for quality home visitation programs for families with young children and families expecting children. CommentsClose CommentsPermalink





Sec. 1905. Improved coordination and protection for dual eligibles. CommentsClose CommentsPermalink





TITLE I--IMPROVING HEALTH CARE VALUE

Subtitle A--Provisions Related to Medicare Part A

PART 1--MARKET BASKET UPDATESSEC. 1101. SKILLED NURSING FACILITY PAYMENT UPDATE.

(a) In General- Section 1888(e)(4)(E)(ii) of the Social Security Act (42 U.S.C. 1395yy(e)(4)(E)(ii)) is amended--

(1) in subclause (III), by striking ‘and’ at the end;

(2) by redesignating subclause (IV) as subclause (VI); and

(3) by inserting after subclause (III) the following new subclauses:

‘(IV) for each of fiscal years 2004 through 2009, the rate computed for the previous fiscal year increased by the skilled nursing facility market basket percentage change for the fiscal year involved;

‘(V) for fiscal year 2010, the rate computed for the previous fiscal year; and’.

(b) Delayed Effective Date- Section 1888(e)(4)(E)(ii)(V) of the Social Security Act, as inserted by subsection (a)(3), shall not apply to payment for days before January 1, 2010.

SEC. 1102. INPATIENT REHABILITATION FACILITY PAYMENT UPDATE.

(a) In General- Section 1886(j)(3)(C) of the Social Security Act (42 U.S.C. 1395ww(j)(3)(C)) is amended by striking ‘and 2009’ and inserting ‘through 2010’.

(b) Delayed Effective Date- The amendment made by subsection (a) shall not apply to payment units occurring before January 1, 2010.

SEC. 1103. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET UPDATES THAT DO NOT ALREADY INCORPORATE SUCH IMPROVEMENTS.

(a) Inpatient Acute Hospitals- Section 1886(b)(3)(B) of the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)) is amended--

(1) in clause (iii)--

(A) by striking ‘(iii) For purposes of this subparagraph,’ and inserting ‘(iii)(I) For purposes of this subparagraph, subject to the productivity adjustment described in subclause (II),’; and

(B) by adding at the end the following new subclause:

‘(II) The productivity adjustment described in this subclause, with respect to an increase or change for a fiscal year or year or cost reporting period, or other annual period, is a productivity offset equal to the percentage change in the 10-year moving average of annual economy-wide private nonfarm business multi-factor productivity (as recently published before the promulgation of such increase for the year or period involved). Except as otherwise provided, any reference to the increase described in this clause shall be a reference to the percentage increase described in subclause (I) minus the percentage change under this subclause.’;

(2) in the first sentence of clause (viii)(I), by inserting ‘(but not below zero)’ after ‘shall be reduced’; and

(3) in the first sentence of clause (ix)(I)--

(A) by inserting ‘(determined without regard to clause (iii)(II)’ after ‘clause (i)’ the second time it appears; and

(B) by inserting ‘(but not below zero)’ after ‘reduced’.

(b) Skilled Nursing Facilities- Section 1888(e)(5)(B) of such Act (42 U.S.C. 1395yy(e)(5)(B)) is amended by inserting ‘subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II)’ after ‘as calculated by the Secretary’.

(c) Long-Term Care Hospitals- Section 1886(m) of the Social Security Act (42 U.S.C. 1395ww(m)) is amended by adding at the end the following new paragraph:

‘(3) PRODUCTIVITY ADJUSTMENT- In implementing the system described in paragraph (1) for discharges occurring during the rate year ending in 2010 or any subsequent rate year for a hospital, to the extent that an annual percentage increase factor applies to a base rate for such discharges for the hospital, such factor shall be subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II).’.

(d) Inpatient Rehabilitation Facilities- The second sentence of section 1886(j)(3)(C) of the Social Security Act (42 U.S.C. 1395ww(j)(3)(C)) is amended by inserting ‘(subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II))’ after ‘appropriate percentage increase’.

(e) Psychiatric Hospitals- Section 1886 of the Social Security Act (42 U.S.C. 1395ww) is amended by adding at the end the following new subsection:

‘(o) Prospective Payment for Psychiatric Hospitals-

‘(1) REFERENCE TO ESTABLISHMENT AND IMPLEMENTATION OF SYSTEM- For provisions related to the establishment and implementation of a prospective payment system for payments under this title for inpatient hospital services furnished by psychiatric hospitals (as described in clause (i) of subsection (d)(1)(B)) and psychiatric units (as described in the matter following clause (v) of such subsection), see section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999.

‘(2) PRODUCTIVITY ADJUSTMENT- In implementing the system described in paragraph (1) for discharges occurring during the rate year ending in 2011 or any subsequent rate year for a psychiatric hospital or unit described in such paragraph, to the extent that an annual percentage increase factor applies to a base rate for such discharges for the hospital or unit, respectively, such factor shall be subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II).’.

(f) Hospice Care- Subclause (VII) of section 1814(i)(1)(C)(ii) of the Social Security Act (42 U.S.C. 1395f(i)(1)(C)(ii)) is amended by inserting after ‘the market basket percentage increase’ the following: ‘(which is subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II))’.

(g) Effective Date- The amendments made by subsections (a), (b), (d), and (f) shall apply to annual increases effected for fiscal years beginning with fiscal year 2010.

PART 2--OTHER MEDICARE PART A PROVISIONSSEC. 1111. PAYMENTS TO SKILLED NURSING FACILITIES.

(a) Change in Recalibration Factor-

(1) ANALYSIS- The Secretary of Health and Human Services shall conduct, using calendar year 2006 claims data, an initial analysis comparing total payments under title XVIII of the Social Security Act for skilled nursing facility services under the RUG-53 and under the RUG-44 classification systems.

(2) ADJUSTMENT IN RECALIBRATION FACTOR- Based on the initial analysis under paragraph (1), the Secretary shall adjust the case mix indexes under section 1888(e)(4)(G)(i) of the Social Security Act (42 U.S.C. 1395yy(e)(4)(G)(i)) for fiscal year 2010 by the appropriate recalibration factor as proposed in the proposed rule for Medicare skilled nursing facilities issued by such Secretary on May 12, 2009 (74 Federal Register 22214 et seq.).

(b) Change in Payment for Nontherapy Ancillary (NTA) Services and Therapy Services-

(1) CHANGES UNDER CURRENT SNF CLASSIFICATION SYSTEM-

(A) IN GENERAL- Subject to subparagraph (B), the Secretary of Health and Human Services shall, under the system for payment of skilled nursing facility services under section 1888(e) of the Social Security Act (42 U.S.C. 1395yy(e)), increase payment by 10 percent for non-therapy ancillary services (as specified by the Secretary in the notice issued on November 27, 1998 (63 Federal Register 65561 et seq.)) and shall decrease payment for the therapy case mix component of such rates by 5.5 percent.

(B) EFFECTIVE DATE- The changes in payment described in subparagraph (A) shall apply for days on or after January 1, 2010, and until the Secretary implements an alternative case mix classification system for payment of skilled nursing facility services under section 1888(e) of the Social Security Act (42 U.S.C. 1395yy(e)).

(C) IMPLEMENTATION- Notwithstanding any other provision of law, the Secretary may implement by program instruction or otherwise the provisions of this paragraph.

(2) CHANGES UNDER A FUTURE SNF CASE MIX CLASSIFICATION SYSTEM-

(A) ANALYSIS-

(i) IN GENERAL- The Secretary of Health and Human Services shall analyze payments for non-therapy ancillary services under a future skilled nursing facility classification system to ensure the accuracy of payment for non-therapy ancillary services. Such analysis shall consider use of appropriate indicators which may include age, physical and mental status, ability to perform activities of daily living, prior nursing home stay, broad RUG category, and a proxy for length of stay.

(ii) APPLICATION- Such analysis shall be conducted in a manner such that the future skilled nursing facility classification system is implemented to apply to services furnished during a fiscal year beginning with fiscal year 2011.

(B) CONSULTATION- In conducting the analysis under subparagraph (A), the Secretary shall consult with interested parties, including the Medicare Payment Advisory Commission and other interested stakeholders, to identify appropriate predictors of nontherapy ancillary costs.

(C) RULEMAKING- The Secretary shall include the result of the analysis under subparagraph (A) in the fiscal year 2011 rulemaking cycle for purposes of implementation beginning for such fiscal year.

(D) IMPLEMENTATION- Subject to subparagraph (E) and consistent with subparagraph (A)(ii), the Secretary shall implement changes to payments for non-therapy ancillary services (which may include a separate rate component for non-therapy ancillary services and may include use of a model that predicts payment amounts applicable for non-therapy ancillary services) under such future skilled nursing facility services classification system as the Secretary determines appropriate based on the analysis conducted pursuant to subparagraph (A).

(E) BUDGET NEUTRALITY- The Secretary shall implement changes described in subparagraph (D) in a manner such that the estimated expenditures under such future skilled nursing facility services classification system for a fiscal year beginning with fiscal year 2011 with such changes would be equal to the estimated expenditures that would otherwise occur under title XVIII of the Social Security Act under such future skilled nursing facilit Sec. 1906. Standardized marketing requirements under the Medicare Advantage and Medicare prescription drug programs. CommentsClose CommentsPermalink




Sec. 1907. NAIC recommendations on the establishment of standardized benefit packages for Medicare Advantage plans and prescription drug plans. CommentsClose CommentsPermalink





Sec. 1908. Application of emergency services classification system for such year without such changes.

(c) Outlier Policy for NTA and Therapy- Section 1888(e) of the Social Security Act (42 U.S.C. 1395yy(e)) is amended by adding at the end the following new paragraph:

‘(13) OUTLIERS FOR NTA AND THERAPY-

‘(A) IN GENERAL- With respect to outliers because of unusual variations in the type or amount of medically necessary care, beginning with October 1, 2010, the Secretary--

‘(i) shall provide for an addition or adjustment to the payment amount otherwise made under this section with respect to non-therapy ancillary services in the case of such outliers; and

‘(ii) may provide for such an addition or adjustment to the payment amount otherwise made under this section with respect to therapy services in the case of such outliers.

‘(B) OUTLIERS BASED ON AGGREGATE COSTS- Outlier adjustments or additional payments described in subparagraph (A) shall be based on aggregate costs during a stay in a skilled nursing facility and not on the number of days in such stay.

‘(C) BUDGET NEUTRALITY- The Secretary shall reduce estimated payments that would otherwise be made under the prospective payment system under this subsection with respect to a fiscal year by 2 percent. The total amount of the additional payments or payment adjustments for outliers made under this paragraph with respect to a fiscal year may not exceed 2 percent of the total payments projected or estimated to be made based on the prospective payment system under this subsection for the fiscal year.’.

(d) Conforming Amendments- Section 1888(e)(8) of such Act (42 U.S.C. 1395yy(e)(8)) is amended--

(1) in subparagraph (A), by inserting ‘and adjustment under section 1111(b) of the America’s Affordable Health Choices Act of 2009;

(2) in subparagraph (B), by striking ‘and’;

(3) in subparagraph (C), by striking the period and inserting ‘; and’; and

(4) by adding at the end the following new subparagraph:

‘(D) the establishment of outliers under paragraph (13).’.

SEC. 1112. MEDICARE DSH REPORT AND PAYMENT ADJUSTMENTS IN RESPONSE TO COVERAGE EXPANSION.

(a) DSH Report-

(1) IN GENERAL- Not later than January 1, 2016, the Secretary of Health and Human Services shall submit to Congress a report on Medicare DSH taking into account the impact of the health care reforms carried out under division A in reducing the number of uninsured individuals. The report shall include recommendations relating to the following:

(A) The appropriate amount, targeting, and distribution of Medicare DSH to compensate for higher Medicare costs associated with serving low-income beneficiaries (taking into account variations in the empirical justification for Medicare DSH attributable to hospital characteristics, including bed size), consistent with the original intent of Medicare DSH.

(B) The appropriate amount, targeting, and distribution of Medicare DSH to hospitals given their continued uncompensated care costs, to the extent such costs remain.

(2) COORDINATION WITH MEDICAID DSH REPORT- The Secretary shall coordinate the report under this subsection with the report on Medicaid DSH under section 1704(a).

(b) Payment Adjustments in Response to Coverage Expansion-

(1) IN GENERAL- If there is a significant decrease in the national rate of uninsurance as a result of this Act (as determined under paragraph (2)(A)), then the Secretary of Health and Human Services shall, beginning in fiscal year 2017, implement the following adjustments to Medicare DSH:

(A) The amount of Medicare DSH shall be adjusted based on the recommendations of the report under subsection (a)(1)(A) and shall take into account variations in the empirical justification for Medicare DSH attributable to hospital characteristics, including bed size.

(B) Subject to paragraph (3), increase Medicare DSH for a hospital by an additional amount that is based on the amount of uncompensated care provided by the hospital based on criteria for uncompensated care as determined by the Secretary, which shall exclude bad debt.

(2) SIGNIFICANT DECREASE IN NATIONAL RATE OF UNINSURANCE AS A RESULT OF THIS ACT- For purposes of this subsection--

(A) IN GENERAL- There is a ‘significant decrease in the national rate of uninsurance as a result of this Act’ if there is a decrease in the national rate of uninsurance (as defined in subparagraph (B)) from 2012 to 2014 that exceeds 8 percentage points.

(B) NATIONAL RATE OF UNINSURANCE DEFINED- The term ‘national rate of uninsurance’ means, for a year, such rate for the under-65 population for the year as determined and published by the Bureau of the Census in its Current Population Survey in or about September of the succeeding year.

(3) UNCOMPENSATED CARE INCREASE-

(A) COMPUTATION OF DSH SAVINGS- For each fiscal year (beginning with fiscal year 2017), the Secretary shall estimate the aggregate reduction in Medicare DSH that will result from the adjustment under paragraph (1)(A).

(B) STRUCTURE OF PAYMENT INCREASE- The Secretary shall compute the increase in Medicare DSH under paragraph (1)(B) for a fiscal year in accordance with a formula established by the Secretary that provides that--

(i) the aggregate amount of such increase for the fiscal year does not exceed 50 percent of the aggregate reduction in Medicare DSH estimated by the Secretary for such fiscal year; and

(ii) hospitals with higher levels of uncompensated care receive a greater increase.

(c) Medicare DSH- In this section, the term ‘Medicare DSH’ means adjustments in payments under section 1886(d)(5)(F) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(F)) for inpatient hospital services furnished by disproportionate share hospitals.

laws. CommentsClose CommentsPermalink




Sec. 1909. Nationwide program for national and State background checks on direct patient access employees of long-term care facilities and providers. CommentsClose CommentsPermalink





Sec. 1910. Establishment of Center for Medicare and Medicaid Payment Innovation within CMS. CommentsClose CommentsPermalink

Subtitle B--Provisions Related to Medicare Part B CommentsClose CommentsPermalink

PART 1--PHYSICIANS’ SERVICES

SEC. 1121. SUSTAINABLE GROWTH RATE REFORM.

(a) Transitional Update for 2010- Section 1848(d) of the Social Security Act (42 U.S.C. 1395w-4(d)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(10) UPDATE FOR 2010- The update to the single conversion factor established in paragraph (1)(C) for 2010 shall be the percentage increase in the MEI (as defined in section 1842(i)(3)) for that year.’. CommentsClose CommentsPermalink





(b) Rebasing SGR Using 2009; Limitation on Cumulative Adjustment Period- Section 1848(d)(4) of such Act (42 U.S.C. 1395w-4(d)(4)) is amended-- CommentsClose CommentsPermalink





(1) in subparagraph (B), by striking ‘subparagraph (D)’ and inserting ‘subparagraphs (D) and (G)’; and CommentsClose CommentsPermalink





(2) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(G) REBASING USING 2009 FOR FUTURE UPDATE ADJUSTMENTS- In determining the update adjustment factor under subparagraph (B) for 2011 and subsequent years-- CommentsClose CommentsPermalink





‘(i) the allowed expenditures for 2009 shall be equal to the amount of the actual expenditures for physicians’ services during 2009; and CommentsClose CommentsPermalink





‘(ii) the reference in subparagraph (B)(ii)(I) to ‘April 1, 1996’ shall be treated as a reference to ‘January 1, 2009 (or, if later, the first day of the fifth year before the year involved)’.’. CommentsClose CommentsPermalink





(c) Limitation on Physicians’ Services Included in Target Growth Rate Computation to Services Covered Under Physician Fee Schedule- Effective for services furnished on or after January 1, 2009, section 1848(f)(4)(A) of such Act is amended by striking ‘(such as clinical’ and all that follows through ‘in a physician’s office’ and inserting ‘for which payment under this part is made under the fee schedule under this section, for services for practitioners described in section 1842(b)(18)(C) on a basis related to such fee schedule, or for services described in section 1861(p) (other than such services when furnished in the facility of a provider of services)’. CommentsClose CommentsPermalink





(d) Establishment of Separate Target Growth Rates for Categories of Services- CommentsClose CommentsPermalink





(1) ESTABLISHMENT OF SERVICE CATEGORIES- Subsection (j) of section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(5) SERVICE CATEGORIES- For services furnished on or after January 1, 2009, each of the following categories of physicians’ services (as defined in paragraph (3)) shall be treated as a separate ‘service category’: CommentsClose CommentsPermalink





‘(A) Evaluation and management services that are procedure codes (for services covered under this title) for-- CommentsClose CommentsPermalink





‘(i) services in the category designated Evaluation and Management in the Health Care Common Procedure Coding System (established by the Secretary under subsection (c)(5) as of December 31, 2009, and as subsequently modified by the Secretary); and CommentsClose CommentsPermalink





‘(ii) preventive services (as defined in section 1861(iii)) for which payment is made under this section. CommentsClose CommentsPermalink





‘(B) All other services not described in subparagraph (A). CommentsClose CommentsPermalink





Service categories established under this paragraph shall apply without regard to the specialty of the physician furnishing the service.’. CommentsClose CommentsPermalink





(2) ESTABLISHMENT OF SEPARATE CONVERSION FACTORS FOR EACH SERVICE CATEGORY- Subsection (d)(1) of section 1848 of the Social Security Act (42 U.S.C. 1395w-4) is amended-- CommentsClose CommentsPermalink





(A) in subparagraph (A)-- CommentsClose CommentsPermalink





(i) by designating the sentence beginning ‘The conversion factor’ as clause (i) with the heading ‘APPLICATION OF SINGLE CONVERSION FACTOR- ’ and with appropriate indentation; CommentsClose CommentsPermalink





(ii) by striking ‘The conversion factor’ and inserting ‘Subject to clause (ii), the conversion factor’; and CommentsClose CommentsPermalink





(iii) by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(ii) APPLICATION OF MULTIPLE CONVERSION FACTORS BEGINNING WITH 2011- CommentsClose CommentsPermalink





‘(I) IN GENERAL- In applying clause (i) for years beginning with 2011, separate conversion factors shall be established for each service category of physicians’ services (as defined in subsection (j)(5)) and any reference in this section to a conversion factor for such years shall be deemed to be a reference to the conversion factor for each of such categories. CommentsClose CommentsPermalink





‘(II) INITIAL CONVERSION FACTORS- Such factors for 2011 shall be based upon the single conversion factor for the previous year multiplied by the update established under paragraph (11) for such category for 2011. CommentsClose CommentsPermalink





‘(III) UPDATING OF CONVERSION FACTORS- Such factor for a service category for a subsequent year shall be based upon the conversion factor for such category for the previous year and adjusted by the update established for such category under paragraph (11) for the year involved.’; and CommentsClose CommentsPermalink





(B) in subparagraph (D), by striking ‘other physicians’ services’ and inserting ‘for physicians’ services described in the service category described in subsection (j)(5)(B)’. CommentsClose CommentsPermalink





(3) ESTABLISHING UPDATES FOR CONVERSION FACTORS FOR SERVICE CATEGORIES- Section 1848(d) of the Social Security Act (42 U.S.C. 1395w-4(d)), as amended by subsection (a), is amended-- CommentsClose CommentsPermalink





(A) in paragraph (4)(C)(iii), by striking ‘The allowed’ and inserting ‘Subject to paragraph (11)(B), the allowed’; and CommentsClose CommentsPermalink





(B) by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(11) UPDATES FOR SERVICE CATEGORIES BEGINNING WITH 2011- CommentsClose CommentsPermalink





‘(A) IN GENERAL- In applying paragraph (4) for a year beginning with 2011, the following rules apply: CommentsClose CommentsPermalink





‘(i) APPLICATION OF SEPARATE UPDATE ADJUSTMENTS FOR EACH SERVICE CATEGORY- Pursuant to paragraph (1)(A)(ii)(I), the update shall be made to the conversion factor for each service category (as defined in subsection (j)(5)) based upon an update adjustment factor for the respective category and year and the update adjustment factor shall be computed, for a year, separately for each service category. CommentsClose CommentsPermalink





‘(ii) COMPUTATION OF ALLOWED AND ACTUAL EXPENDITURES BASED ON SERVICE CATEGORIES- In computing the prior year adjustment component and the cumulative adjustment component under clauses (i) and (ii) of paragraph (4)(B), the following rules apply: CommentsClose CommentsPermalink





‘(I) APPLICATION BASED ON SERVICE CATEGORIES- The allowed expenditures and actual expenditures shall be the allowed and actual expenditures for the service category, as determined under subparagraph (B). CommentsClose CommentsPermalink





‘(II) APPLICATION OF CATEGORY SPECIFIC TARGET GROWTH RATE- The growth rate applied under clause (ii)(II) of such paragraph shall be the target growth rate for the service category involved under subsection (f)(5). CommentsClose CommentsPermalink





‘(B) DETERMINATION OF ALLOWED EXPENDITURES- In applying paragraph (4) for a year beginning with 2010, notwithstanding subparagraph (C)(iii) of such paragraph, the allowed expenditures for a service category for a year is an amount computed by the Secretary as follows: CommentsClose CommentsPermalink





‘(i) FOR 2010- For 2010: CommentsClose CommentsPermalink





‘(I) TOTAL 2009 ACTUAL EXPENDITURES FOR ALL SERVICES INCLUDED IN SGR COMPUTATION FOR EACH SERVICE CATEGORY- Compute total actual expenditures for physicians’ services (as defined in subsection (f)(4)(A)) for 2009 for each service category. CommentsClose CommentsPermalink





‘(II) INCREASE BY GROWTH RATE TO OBTAIN 2010 ALLOWED EXPENDITURES FOR SERVICE CATEGORY- Compute allowed expenditures for the service category for 2010 by increasing the allowed expenditures for the service category for 2009 computed under subclause (I) by the target growth rate for such service category under subsection (f) for 2010. CommentsClose CommentsPermalink





‘(ii) FOR SUBSEQUENT YEARS- For a subsequent year, take the amount of allowed expenditures for such category for the preceding year (under clause (i) or this clause) and increase it by the target growth rate determined under subsection (f) for such category and year.’. CommentsClose CommentsPermalink





(4) APPLICATION OF SEPARATE TARGET GROWTH RATES FOR EACH CATEGORY- CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1848(f) of the Social Security Act (42 U.S.C. 1395w-4(f)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(5) APPLICATION OF SEPARATE TARGET GROWTH RATES FOR EACH SERVICE CATEGORY BEGINNING WITH 2010- The target growth rate for a year beginning with 2010 shall be computed and applied separately under this subsection for each service category (as defined in subsection (j)(5)) and shall be computed using the same method for computing the target growth rate except that the factor described in paragraph (2)(C) for-- CommentsClose CommentsPermalink





‘(A) the service category described in subsection (j)(5)(A) shall be increased by 0.02; and CommentsClose CommentsPermalink





‘(B) the service category described in subsection (j)(5)(B) shall be increased by 0.01.’. CommentsClose CommentsPermalink





(B) USE OF TARGET GROWTH RATES- Section 1848 of such Act is further amended-- CommentsClose CommentsPermalink





(i) in subsection (d)-- CommentsClose CommentsPermalink





(I) in paragraph (1)(E)(ii), by inserting ‘or target’ after ‘sustainable’; and CommentsClose CommentsPermalink





(II) in paragraph (4)(B)(ii)(II), by inserting ‘or target’ after ‘sustainable’; and CommentsClose CommentsPermalink





(ii) in the heading of subsection (f), by inserting ‘and Target Growth Rate’ after ‘Sustainable Growth Rate’; CommentsClose CommentsPermalink





(iii) in subsection (f)(1)-- CommentsClose CommentsPermalink





(I) by striking ‘and’ at the end of subparagraph (A); CommentsClose CommentsPermalink





(II) in subparagraph (B), by inserting ‘before 2010’ after ‘each succeeding year’ and by striking the period at the end and inserting ‘; and’; and CommentsClose CommentsPermalink





(III) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(C) November 1 of each succeeding year the target growth rate for such succeeding year and each of the 2 preceding years.’; and CommentsClose CommentsPermalink





(iv) in subsection (f)(2), in the matter before subparagraph (A), by inserting after ‘beginning with 2000’ the following: ‘and ending with 2009’. CommentsClose CommentsPermalink





(e) Application to Accountable Care Organization Pilot Program- In applying the target growth rate under subsections (d) and (f) of section 1848 of the Social Security Act to services furnished by a practitioner to beneficiaries who are attributable to an accountable care organization under the pilot program provided under section 1866D of such Act, the Secretary of Health and Human Services shall develop, not later than January 1, 2012, for application beginning with 2012, a method that-- CommentsClose CommentsPermalink





(1) allows each such organization to have its own expenditure targets and updates for such practitioners, with respect to beneficiaries who are attributable to that organization, that are consistent with the methodologies described in such subsection (f); and CommentsClose CommentsPermalink





(2) provides that the target growth rate applicable to other physicians shall not apply to such physicians to the extent that the physicians’ services are furnished through the accountable care organization. CommentsClose CommentsPermalink





In applying paragraph (1), the Secretary of Health and Human Services may apply the difference in the update under such paragraph on a claim-by-claim or lump sum basis and such a payment shall be taken into account under the pilot program. CommentsClose CommentsPermalink

SEC. 1122. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE.

(a) In General- Section 1848(c)(2) of the Social Security Act (42 U.S.C. 1395w-4(c)(2)) is amended by adding at the end the following new subparagraphs: CommentsClose CommentsPermalink





‘(K) POTENTIALLY MISVALUED CODES- CommentsClose CommentsPermalink





‘(i) IN GENERAL- The Secretary shall-- CommentsClose CommentsPermalink





‘(I) periodically identify services as being potentially misvalued using criteria specified in clause (ii); and CommentsClose CommentsPermalink





‘(II) review and make appropriate adjustments to the relative values established under this paragraph for services identified as being potentially misvalued under subclause (I). CommentsClose CommentsPermalink





‘(ii) IDENTIFICATION OF POTENTIALLY MISVALUED CODES- For purposes of identifying potentially misvalued services pursuant to clause (i)(I), the Secretary shall examine (as the Secretary determines to be appropriate) codes (and families of codes as appropriate) for which there has been the fastest growth; codes (and families of codes as appropriate) that have experienced substantial changes in practice expenses; codes for new technologies or services within an appropriate period (such as three years) after the relative values are initially established for such codes; multiple codes that are frequently billed in conjunction with furnishing a single service; codes with low relative values, particularly those that are often billed multiple times for a single treatment; codes which have not been subject to review since the implementation of the RBRVS (the so-called ‘Harvard-valued codes’); and such other codes determined to be appropriate by the Secretary. CommentsClose CommentsPermalink





‘(iii) REVIEW AND ADJUSTMENTS- CommentsClose CommentsPermalink





‘(I) The Secretary may use existing processes to receive recommendations on the review and appropriate adjustment of potentially misvalued services described clause (i)(II). CommentsClose CommentsPermalink





‘(II) The Secretary may conduct surveys, other data collection activities, studies, or other analyses as the Secretary determines to be appropriate to facilitate the review and appropriate adjustment described in clause (i)(II). CommentsClose CommentsPermalink





‘(III) The Secretary may use analytic contractors to identify and analyze services identified under clause (i)(I), conduct surveys or collect data, and make recommendations on the review and appropriate adjustment of services described in clause (i)(II). CommentsClose CommentsPermalink





‘(IV) The Secretary may coordinate the review and appropriate adjustment described in clause (i)(II) with the periodic review described in subparagraph (B). CommentsClose CommentsPermalink





‘(V) As part of the review and adjustment described in clause (i)(II), including with respect to codes with low relative values described in clause (ii), the Secretary may make appropriate coding revisions (including using existing processes for consideration of coding changes) which may include consolidation of individual services into bundled codes for payment under the fee schedule under subsection (b). CommentsClose CommentsPermalink





‘(VI) The provisions of subparagraph (B)(ii)(II) shall apply to adjustments to relative value units made pursuant to this subparagraph in the same manner as such provisions apply to adjustments under subparagraph (B)(ii)(II). CommentsClose CommentsPermalink





‘(L) VALIDATING RELATIVE VALUE UNITS- CommentsClose CommentsPermalink





‘(i) IN GENERAL- The Secretary shall establish a process to validate relative value units under the fee schedule under subsection (b). CommentsClose CommentsPermalink





‘(ii) COMPONENTS AND ELEMENTS OF WORK- The process described in clause (i) may include validation of work elements (such as time, mental effort and professional judgment, technical skill and physical effort, and stress due to risk) involved with furnishing a service and may include validation of the pre, post, and intra-service components of work. CommentsClose CommentsPermalink





‘(iii) SCOPE OF CODES- The validation of work relative value units shall include a sampling of codes for services that is the same as the codes listed under subparagraph (K)(ii) CommentsClose CommentsPermalink





.‘(iv) METHODS- The Secretary may conduct the validation under this subparagraph using methods described in subclauses (I) through (V) of subparagraph (K)(iii) as the Secretary determines to be appropriate. CommentsClose CommentsPermalink





‘(v) ADJUSTMENTS- The Secretary shall make appropriate adjustments to the work relative value units under the fee schedule under subsection (b). The provisions of subparagraph (B)(ii)(II) shall apply to adjustments to relative value units made pursuant to this subparagraph in the same manner as such provisions apply to adjustments under subparagraph (B)(ii)(II).’. CommentsClose CommentsPermalink





(b) Implementation- CommentsClose CommentsPermalink





(1) FUNDING- For purposes of carrying out the provisions of subparagraphs (K) and (L) of 1848(c)(2) of the Social Security Act, as added by subsection (a), in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services for the Center for Medicare & Medicaid Services Program Management Account $20,000,000 for fiscal year 2010 and each subsequent fiscal year. Amounts appropriated under this paragraph for a fiscal year shall be available until expended. CommentsClose CommentsPermalink





(2) ADMINISTRATION- CommentsClose CommentsPermalink





(A) Chapter 35 of title 44, United States Code and the provisions of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to this section or the amendment made by this section. CommentsClose CommentsPermalink





(B) Notwithstanding any other provision of law, the Secretary may implement subparagraphs (K) and (L) of 1848(c)(2) of the Social Security Act, as added by subsection (a), by program instruction or otherwise. CommentsClose CommentsPermalink





(C) Section 4505(d) of the Balanced Budget Act of 1997 is repealed. CommentsClose CommentsPermalink





(D) Except for provisions related to confidentiality of information, the provisions of the Federal Acquisition Regulation shall not apply to this section or the amendment made by this section. CommentsClose CommentsPermalink





(3) FOCUSING CMS RESOURCES ON POTENTIALLY OVERVALUED CODES- Section 1868(a) of the Social Security Act (42 U.S.C. 1395ee(a)) is repealed. CommentsClose CommentsPermalink

SEC. 1123. PAYMENTS FOR EFFICIENT AREAS.

Section 1833 of the Social Security Act (42 U.S.C. 1395l) is amended by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(x) Incentive Payments for Efficient Areas- CommentsClose CommentsPermalink





‘(1) IN GENERAL- In the case of services furnished under the physician fee schedule under section 1848 on or after January 1, 2011, and before January 1, 2013, by a supplier that is paid under such fee schedule in an efficient area (as identified under paragraph (2)), in addition to the amount of payment that would otherwise be made for such services under this part, there also shall be paid (on a monthly or quarterly basis) an amount equal to 5 percent of the payment amount for the services under this part. CommentsClose CommentsPermalink





‘(2) IDENTIFICATION OF EFFICIENT AREAS- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Based upon available data, the Secretary shall identify those counties or equivalent areas in the United States in the lowest fifth percentile of utilization based on per capita spending under this part and part A for services provided in the most recent year for which data are available as of the date of the enactment of this subsection, as standardized to eliminate the effect of geographic adjustments in payment rates. CommentsClose CommentsPermalink





‘(B) IDENTIFICATION OF COUNTIES WHERE SERVICE IS FURNISHED- For purposes of.- For purposes of paying the additional amount specified in paragraph (1), if the Secretary uses the 5-digit postal ZIP Code where the service is furnished, the dominant county of the postal ZIP Code (as determined by the United States Postal Service, or otherwise) shall be used to determine whether the postal ZIP Code is in a county described in subparagraph (A). CommentsClose CommentsPermalink





‘(C) LIMITATION ON REVIEW- There shall be no administrative or judicial review under section 1869, 1878, or otherwise, respecting-- CommentsClose CommentsPermalink





‘(i) the identification of a county or other area under subparagraph (A); or CommentsClose CommentsPermalink





‘(ii) the assignment of a postal ZIP Code to a county or other area under subparagraph (B). CommentsClose CommentsPermalink





‘(D) PUBLICATION OF LIST OF COUNTIES; POSTING ON WEBSITE- With respect to a year for which a county or area is identified under this paragraph, the Secretary shall identify such counties or areas as part of the proposed and final rule to implement the physician fee schedule under section 1848 for the applicable year. The Secretary shall post the list of counties identified under this paragraph on the Internet website of the Centers for Medicare & Medicaid Services.’. CommentsClose CommentsPermalink

SEC. 1124. MODIFICATIONS TO THE PHYSICIAN QUALITY REPORTING INITIATIVE (PQRI).

(a) Feedback- Section 1848(m)(5) of the Social Security Act (42 U.S.C. 1395w-4(m)(5)) is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(H) FEEDBACK- The Secretary shall provide timely feedback to eligible professionals on the performance of the eligible professional with respect to satisfactorily submitting data on quality measures under this subsection.’. CommentsClose CommentsPermalink





(b) Appeals- Such section is further amended-- CommentsClose CommentsPermalink





(1) in subparagraph (E), by striking ‘There shall be’ and inserting ‘Subject to subparagraph (I), there shall be’; and CommentsClose CommentsPermalink





(2) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(I) INFORMAL APPEALS PROCESS- Notwithstanding subparagraph (E), by not later than January 1, 2011, the Secretary shall establish and have in place an informal process for eligible professionals to appeal the determination that an eligible professional did not satisfactorily submit data on quality measures under this subsection.’. CommentsClose CommentsPermalink





(c) Integration of Physician Quality Reporting and EHR Reporting- Section 1848(m) of such Act is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(7) INTEGRATION OF PHYSICIAN QUALITY REPORTING AND EHR REPORTING- Not later than January 1, 2012, the Secretary shall develop a plan to integrate clinical reporting on quality measures under this subsection with reporting requirements under subsection (o) relating to the meaningful use of electronic health records. Such integration shall consist of the following: CommentsClose CommentsPermalink





‘(A) The development of measures, the reporting of which would both demonstrate-- CommentsClose CommentsPermalink





‘(i) meaningful use of an electronic health record for purposes of subsection (o); and CommentsClose CommentsPermalink





‘(ii) clinical quality of care furnished to an individual. CommentsClose CommentsPermalink





‘(B) The collection of health data to identify deficiencies in the quality and coordination of care for individuals eligible for benefits under this part. CommentsClose CommentsPermalink





‘(C) Such other activities as specified by the Secretary.’. CommentsClose CommentsPermalink





(d) Extension of Incentive Payments- Section 1848(m)(1) of such Act (42 U.S.C. 1395w-4(m)(1)) is amended-- CommentsClose CommentsPermalink





(1) in subparagraph (A), by striking ‘2010’ and inserting ‘2012’; and CommentsClose CommentsPermalink





(2) in subparagraph (B)(ii), by striking ‘2009 and 2010’ and inserting ‘for each of the years 2009 through each of the years 2009 through 2012’. CommentsClose CommentsPermalink

SEC. 1125. ADJUSTMENT TO MEDICARE PAYMENT LOCALITIES.

(a) In General- Section 1848(e) of the Social Security Act (42 U.S.C.1395w-4(e)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(6) TRANSITION TO USE OF MSAS AS FEE SCHEDULE AREAS IN CALIFORNIA- CommentsClose CommentsPermalink





‘(A) IN GENERAL- CommentsClose CommentsPermalink





‘(i) REVISION- Subject to clause (ii) and notwithstanding the previous provisions of this subsection, for services furnished on or after January 1, 2011, the Secretary shall revise the fee schedule areas used for payment under this section applicable to the State of California using the Metropolitan Statistical Area (MSA) iterative Geographic Adjustment Factor methodology as follows: CommentsClose CommentsPermalink





‘(I) The Secretary shall configure the physician fee schedule areas using the Core-Based Statistical Areas-Metropolitan Statistical Areas (each in this paragraph referred to as an ‘MSA’), as defined by the Director of the Office of Management and Budget, as the basis for the fee schedule areas. The Secretary shall employ an iterative process to transition fee schedule areas. First, the Secretary shall list all MSAs within the State by Geographic Adjustment Factor described in paragraph (2) (in this paragraph referred to as a ‘GAF’) in descending order. In the first iteration, the Secretary shall compare the GAF of the highest cost MSA in the State to the weighted-average GAF of the group of remaining MSAs in the State. If the ratio of the GAF of the highest cost MSA to the weighted-average GAF of the rest of State is 1.05 or greater then the highest cost MSA becomes a separate fee schedule area. CommentsClose CommentsPermalink





‘(II) In the next iteration, the Secretary shall compare the MSA of the second-highest GAF to the weighted-average GAF of the group of remaining MSAs. If the ratio of the second-highest MSA’s GAF to the weighted-average of the remaining lower cost MSAs is 1.05 or greater, the second-highest MSA becomes a separate fee schedule area. The iterative process continues until the ratio of the GAF of the highest-cost remaining MSA to the weighted-average of the remaining lower-cost MSAs is less than 1.05, and the remaining group of lower cost MSAs form a single fee schedule area,. If two MSAs have identical GAFs, they shall be combined in the iterative comparison. CommentsClose CommentsPermalink





‘(ii) TRANSITION- For services furnished on or after January 1, 2011, and before January 1, 2016, in the State of California, after calculating the work, practice expense, and malpractice geographic indices described in clauses (i), (ii), and (iii) of paragraph (1)(A) that would otherwise apply through application of this paragraph, the Secretary shall increase any such index to the county-based fee schedule area value on December 31, 2009, if such index would otherwise be less than the value on January 1, 2010. CommentsClose CommentsPermalink





‘(B) SUBSEQUENT REVISIONS- CommentsClose CommentsPermalink





‘(i) PERIODIC REVIEW AND ADJUSTMENTS IN FEE SCHEDULE AREAS- Subsequent to the process outlined in paragraph (1)(C), not less often than every three years, the Secretary shall review and update the California Rest-of-State fee schedule area using MSAs as defined by the Director of the Office of Management and Budget and the iterative methodology described in subparagraph (A)(i). CommentsClose CommentsPermalink





‘(ii) LINK WITH GEOGRAPHIC INDEX DATA REVISION- The revision described in clause (i) shall be made effective concurrently with the application of the periodic review of the adjustment factors required under paragraph (1)(C) for California for 2012 and subsequent periods. Upon request, the Secretary shall make available to the public any county-level or MSA derived data used to calculate the geographic practice cost index. CommentsClose CommentsPermalink





‘(C) REFERENCES TO FEE SCHEDULE AREAS- Effective for services furnished on or after January 1, 2010, for the State of California, any reference in this section to a fee schedule area shall be deemed a reference to an MSA in the State.’. CommentsClose CommentsPermalink





(b) Conforming Amendment to Definition of Fee Schedule Area- Section 1848(j)(2) of the Social Security Act (42 U.S.C. 1395w(j)(2)) is amended by striking ‘The term’ and inserting ‘Except as provided in subsection (e)(6)(C), the term’. CommentsClose CommentsPermalink

PART 2--MARKET BASKET UPDATES

SEC. 1131. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET UPDATES THAT DO NOT ALREADY INCORPORATE SUCH IMPROVEMENTS.

(a) Outpatient Hospitals- CommentsClose CommentsPermalink





(1) IN GENERAL- The first sentence of section 1833(t)(3)(C)(iv) of the Social Security Act (42 U.S.C. 1395l(t)(3)(C)(iv)) is amended-- CommentsClose CommentsPermalink





(A) by inserting ‘(which is subject to the productivity adjustment described in subclause (II) of such section)’ after ‘1886(b)(3)(B)(iii)’; and CommentsClose CommentsPermalink





(B) by inserting ‘(but not below 0)’ after ‘reduced’. CommentsClose CommentsPermalink





(2) EFFECTIVE DATE- The amendments made by paragraph (1) shall apply to increase factors for services furnished in years beginning with 2010. CommentsClose CommentsPermalink





(b) Ambulance Services- Section 1834(l)(3)(B) of such Act (42 U.S.C. 1395m(l)(3)(B))) is amended by inserting before the period at the end the following: ‘and, in the case of years beginning with 2010, subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II)’. CommentsClose CommentsPermalink





(c) Ambulatory Surgical Center Services- Section 1833(i)(2)(D) of such Act (42 U.S.C. 1395l(i)(2)(D)) is amended-- CommentsClose CommentsPermalink





(1) by redesignating clause (v) as clause (vi); and CommentsClose CommentsPermalink





(2) by inserting after clause (iv) the following new clause: CommentsClose CommentsPermalink





‘(v) In implementing the system described in clause (i), for services furnished during 2010 or any subsequent year, to the extent that an annual percentage change factor applies, such factor shall be subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II).’. CommentsClose CommentsPermalink





(d) Laboratory Services- Section 1833(h)(2)(A) of such Act (42 U.S.C. 1395l(h)(2)(A)) is amended-- CommentsClose CommentsPermalink





(1) in clause (i), by striking ‘for each of years 2009 throughthe years 2009 through 2013’ and inserting ‘for 2009’; and CommentsClose CommentsPermalink





(2) clause (ii)-- CommentsClose CommentsPermalink





(A) by striking ‘and’ at the end of subclause (III); CommentsClose CommentsPermalink





(B) by striking the period at the end of subclause (IV) and inserting ‘; and’; and CommentsClose CommentsPermalink





(C) by adding at the end the following new subclause: CommentsClose CommentsPermalink





‘(V) the annual adjustment in the fee schedules determined under clause (i) for years beginning with 2010 shall be subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II).’. CommentsClose CommentsPermalink





(e) Certain Durable Medical Equipment- Section 1834(a)(14) of such Act (42 U.S.C. 1395m(a)(14)) is amended-- CommentsClose CommentsPermalink





(1) in subparagraph (K), by inserting before the semicolon at the end the following: ‘, subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II)’; CommentsClose CommentsPermalink





(2) in subparagraph (L)(i), by inserting after ‘June 2013,’ the following: ‘subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II),’; CommentsClose CommentsPermalink





(3) in subparagraph (L)(ii), by inserting after ‘June 2013’ the following: ‘, subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II)’; and CommentsClose CommentsPermalink





(4) in subparagraph (M), by inserting before the period at the end the following: ‘, subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II)’. CommentsClose CommentsPermalink

PART 3--OTHER PROVISIONS

SEC. 1141. RENTAL AND PURCHASE OF POWER-DRIVEN WHEELCHAIRS.

(a) In General- Section 1834(a)(7)(A)(iii) of the Social Security Act (42 U.S.C. 1395m(a)(7)(A)(iii)) is amended-- CommentsClose CommentsPermalink





(1) in the heading, by inserting ‘CERTAIN COMPLEX REHABILITATIVE’ after ‘OPTION FOR’; and CommentsClose CommentsPermalink





(2) by striking ‘power-driven wheelchair’ and inserting ‘complex rehabilitative power-driven wheelchair recognized by the Secretary as classified within group 3 or higher’. CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by subsection (a) shall take effect on January 1, 2011, and shall apply to power-driven wheelchairs furnished on or after such date. Such amendments shall not apply to contracts entered into under section 1847 of the Social Security Act (42 U.S.C. 1395w-3) pursuant to a bid submitted under such section before October 1, 2010, under subsection (a)(1)(B)(i)(I) of such section. CommentsClose CommentsPermalink

SEC. 1141A. ELECTION TO TAKE OWNERSHIP, OR TO DECLINE OWNERSHIP, OF A CERTAIN ITEM OF COMPLEX DURABLE MEDICAL EQUIPMENT AFTER THE 13-MONTH CAPPED RENTAL PERIOD ENDS.

SEC. 1142. EXTENSION OF PAYMENT RULE FOR BRACHYTHERAPY.

Section 1833(t)(16)(C) of the Social Security Act (42 U.S.C. 1395l(t)(16)(C)), as amended by section 142 of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275), is amended by striking, the first place it appears, ‘January 1, 2010’ and inserting ‘January 1, 2012’. CommentsClose CommentsPermalink

SEC. 1143. HOME INFUSION THERAPY REPORT TO CONGRESS.

Not later than 12 months after the date of enactment of this Act, the Medicare Payment Advisory Commission shall submit to Congress a report on the following: CommentsClose CommentsPermalink





(1) The scope of coverage for home infusion therapy in the fee-for-service Medicare program under title XVIII of the Social Security Act, Medicare Advantage under part C of such title, the veteran’s health care program under chapter 17 of title 38, United States Code, and among private payers, including an analysis of the scope of services provided by home infusion therapy providers to their patients in such programs. CommentsClose CommentsPermalink





(2) The benefits and costs of providing such coverage under the Medicare program, including a calculation of the potential savings achieved through avoided or shortened hospital and nursing home stays as a result of Medicare coverage of home infusion therapy. CommentsClose CommentsPermalink





(3) An assessment of sources of data on the costs of home infusion therapy that might be used to construct payment mechanisms in the Medicare program. CommentsClose CommentsPermalink





(4) Recommendations, if any, on the structure of a payment system under the Medicare program for home infusion therapy, including an analysis of the payment methodologies used under Medicare Advantage plans and private health plans for the provision of home infusion therapy and their applicability to the Medicare program. CommentsClose CommentsPermalink

SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS (ASCS) TO SUBMIT COST DATA AND OTHER DATA.

(a) Cost Reporting- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1833(i) of the Social Security Act (42 U.S.C. 1395l(i)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(8) The Secretary shall require, as a condition of the agreement described in section 1832(a)(2)(F)(i), the submission of such cost report as the Secretary may specify, taking into account the requirements for such reports under section 1815 in the case of a hospital.’. CommentsClose CommentsPermalink





(2) DEVELOPMENT OF COST REPORT- Not later than 3 years after the date of the enactment of this Act, the Secretary of Health and Human Services shall develop a cost report form for use under section 1833(i)(8) of the Social Security Act, as added by paragraph (1). CommentsClose CommentsPermalink





(3) AUDIT REQUIREMENT- The Secretary shall provide for periodic auditing of cost reports submitted under section 1833(i)(8) of the Social Security Act, as added by paragraph (1). CommentsClose CommentsPermalink





(4) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to agreements applicable to cost reporting periods beginning 18 months after the date the Secretary develops the cost report form under paragraph (2). CommentsClose CommentsPermalink





(b) Additional Data on Quality- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1833(i)(7) of such Act (42 U.S.C. 1395l(i)(7)) is amended-- CommentsClose CommentsPermalink





(A) in subparagraph (B), by inserting ‘subject to subparagraph (C),’ after ‘may otherwise provide,’; and CommentsClose CommentsPermalink





(B) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(C) Under subparagraph (B) the Secretary shall require the reporting of such additional data relating to quality of services furnished in an ambulatory surgical facility, including data on health care associated infections, as the Secretary may specify.’. CommentsClose CommentsPermalink





(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall to reporting for years beginning with 2012. CommentsClose CommentsPermalink

SEC. 1145. TREATMENT OF CERTAIN CANCER HOSPITALS.

Section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(18) AUTHORIZATION OF ADJUSTMENT FOR CANCER HOSPITALS- CommentsClose CommentsPermalink





‘(A) STUDY- The Secretary shall conduct a study to determine if, under the system under this subsection, costs incurred by hospitals described in section 1886(d)(1)(B)(v) with respect to ambulatory payment classification groups exceed those costs incurred by other hospitals furnishing services under this subsection (as determined appropriate by the Secretary). CommentsClose CommentsPermalink





‘(B) AUTHORIZATION OF ADJUSTMENT- Insofar as the Secretary determines under subparagraph (A) that costs incurred by hospitals described in section 1886(d)(1)(B)(v) exceed those costs incurred by other hospitals furnishing services under this subsection, the Secretary shall provide for an appropriate adjustment under paragraph (2)(E) to reflect those higher costs effective for services furnished on or after January 1, 2011.’. CommentsClose CommentsPermalink

SEC. 1146. MEDICARE IMPROVEMENT FUND.

Section 1898(b)(1)(A) of the Social Security Act (42 U.S.C. 1395iii(b)(1)(A)) is amended to read as follows: CommentsClose CommentsPermalink





‘(A) the period beginning with fiscal year 2011 and ending with fiscal year 2019, $8,000,000,000; and’. CommentsClose CommentsPermalink

SEC. 1147. PAYMENT FOR IMAGING SERVICES.

(a) Adjustment in Practice Expense to Reflect Higher Presumed Utilization- Section 1848 of the Social Security Act (42 U.S.C. 1395w) is amended-- CommentsClose CommentsPermalink





(1) in subsection (b)(4)-- CommentsClose CommentsPermalink





(A) in subparagraph (B), by striking ‘subparagraph (A)’ and inserting ‘this paragraph’; and CommentsClose CommentsPermalink





(B) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(C) ADJUSTMENT IN PRACTICE EXPENSE TO REFLECT HIGHER PRESUMED UTILIZATION- In computing the number of practice expense relative value units under subsection (c)(2)(C)(ii) with respect to advanced diagnostic imaging services (as defined in section 1834(e)(1)(B)) , the Secretary shall adjust such number of units so it reflects a 75 percent (rather than 50 percent) presumed rate of utilization of imaging equipment.’; and CommentsClose CommentsPermalink





(2) in subsection (c)(2)(B)(v)(II), by inserting ‘AND OTHER PROVISIONS’ after ‘OPD PAYMENT CAP’. CommentsClose CommentsPermalink





(b) Adjustment in Technical Component ‘discount’ on Single-session Imaging to Consecutive Body Parts- Section 1848(b)(4) of such Act is further amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(D) ADJUSTMENT IN TECHNICAL COMPONENT DISCOUNT ON SINGLE-SESSION IMAGING INVOLVING CONSECUTIVE BODY PARTS- The Secretary shall increase the reduction in expenditures attributable to the multiple procedure payment reduction applicable to the technical component for imaging under the final rule published by the Secretary in the Federal Register on November 21, 2005 (part 405 of title 42, Code of Federal Regulations) from 25 percent to 50 percent.’. CommentsClose CommentsPermalink





(c) Effective Date- Except as otherwise provided, this section, and the amendments made by this section, shall apply to services furnished on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 1148. DURABLE MEDICAL EQUIPMENT PROGRAM IMPROVEMENTS.

(a) Waiver of Surety Bond Requirement- Section 1834(a)(16) of the Social Security Act (42 U.S.C. 1395m(a)(16)) is amended by adding at the end the following: ‘The requirement for a surety bond described in subparagraph (B) shall not apply in the case of a pharmacy (i) that has been enrolled under section 1866(j) as a supplier of durable medical equipment, prosthetics, orthotics, and supplies and has been issued (which may include renewal of) a provider number (as described in the first sentence of this paragraph) for at least 5 years, and (ii) for which a final adverse action (as defined in section 424.57(a) of title 42, Code of Federal Regulations) has never been imposed.’. CommentsClose CommentsPermalink





(b) Ensuring Supply of Oxygen Equipment - CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1834(a)(5)(F) of the Social Security Act (42 U.S.C. 1395m(a)(5)(F)) is amended-- CommentsClose CommentsPermalink





(A) in clause (ii), by striking ‘After the’ and inserting ‘Except as provided in clause (iii), after the’; and CommentsClose CommentsPermalink





(B) by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(iii) CONTINUATION OF SUPPLY- In the case of a supplier furnishing such equipment to an individual under this subsection as of the 27th month of the 36 months described in clause (i), the supplier furnishing such equipment as of such month shall continue to furnish such equipment to such individual (either directly or though arrangements with other suppliers of such equipment) during any subsequent period of medical need for the remainder of the reasonable useful lifetime of the equipment, as determined by the Secretary, regardless of the location of the individual, unless another supplier has accepted responsibility for continuing to furnish such equipment during the remainder of such period.’. CommentsClose CommentsPermalink





(2) EFFECTIVE DATE- The amendments made by paragraph (1) shall take effect as of the date of the enactment of this Act and shall apply to the furnishing of equipment to individuals for whom the 27th month of a continuous period of use of oxygen equipment described in section 1834(a)(5)(F) of the Social Security Act occurs on or after July 1, 2010. CommentsClose CommentsPermalink





(c) Treatment of Current Accreditation Applications- Section 1834(a)(20)(F) of such Act (42 U.S.C. 1395m(a)(20)(F)) is amended-- CommentsClose CommentsPermalink





(1) in clause (i)-- CommentsClose CommentsPermalink





(A) by striking ‘clause (ii)’ and inserting ‘clauses (ii) and (iii)’; and CommentsClose CommentsPermalink





(B) by striking ‘and’ at the end; CommentsClose CommentsPermalink





(2) by striking the period at the end of clause (ii)(II) and by inserting ‘; and’; and CommentsClose CommentsPermalink





(3) by adding at the end the following: CommentsClose CommentsPermalink





‘(iii) the requirement for accreditation described in clause (i) shall not apply for purposes of supplying diabetic testing supplies, canes, and crutches in the case of a pharmacy that is enrolled under section 1866(j) as a supplier of durable medical equipment, prosthetics, orthotics, and supplies. CommentsClose CommentsPermalink





Any supplier that has submitted an application for accreditation before August 1, 2009, shall be deemed as meeting applicable standards and accreditation requirement under this subparagraph until such time as the independent accreditation organization takes action on the supplier’s application.’. CommentsClose CommentsPermalink





(d) Restoring 36-Mmonth Oxygen Rental Period in Case of Supplier Bankruptcy for Certain Individuals- Section 1834(a)(5)(F) of such Act (42 U.S.C. 1395m(a)(5)(F)) is amended by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(iiiv) EXCEPTION FOR BANKRUPTCY- If a supplier of oxygen to an individual is declared bankrupt and its assets are liquidated and at the time of such declaration and liquidation more than 24 months of rental payments have been made, the individual may begin under this subparagraph a new 36-month rental period with another supplier of oxygen.’. CommentsClose CommentsPermalink





(e) Payment Adjustment- Section 1834(a)(14)(K) of such Act (42 U.S.C. 1395m(a)(14)(K)), as amended by section 1131(e), is amended by inserting before the semicolon at the end the following: ‘, -0.5 percent’. CommentsClose CommentsPermalink

SEC. 1149. MEDPAC STUDY AND REPORT ON BONE MASS MEASUREMENT.

(a) In General- The Medicare Payment Advisory Commission shall conduct a study regarding bone mass measurement, including computed tomography, duel-energy x-ray absorptriometry, and vertebral fracture assessment. The study shall focus on the following: CommentsClose CommentsPermalink





(1) An assessment of the adequacy of Medicare payment rates for such services, taking into account costs of acquiring the necessary equipment, professional work time, and practice expense costs. CommentsClose CommentsPermalink





(2) The impact of Medicare payment changes since 2006 on beneficiary access to bone mass measurement benefits in general and in rural and minority communities specifically. CommentsClose CommentsPermalink





(3) A review of the clinically appropriate and recommended use among Medicare beneficiaries and how usage rates among such beneficiaries compares to such recommendations. CommentsClose CommentsPermalink





(4) In conjunction with the findings under (3), recommendations, if necessary, regarding methods for reaching appropriate use of bone mass measurement studies among Medicare beneficiaries. CommentsClose CommentsPermalink





(b) Report- The Commission shall submit a report to the Congress, not later than 9 months after the date of the enactment of this Act, containing a description of the results of the study conducted under subsection (a) and the conclusions and recommendations, if any, regarding each of the issues described in paragraphs (1), (2), (3), (3) and (4) of such subsection. CommentsClose CommentsPermalink

SEC. 1149A. EXCLUSION OF CUSTOMARY PROMPT PAY DISCOUNTS EXTENDED TO WHOLESALERS FROM MANUFACTURER’S AVERAGE SALES PRICE FOR PAYMENTS FOR DRUGS AND BIOLOGICALS UNDER MEDICARE PART B.

Subtitle C--Provisions Related to Medicare Parts A and B CommentsClose CommentsPermalink

SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS.

(a) Hospitals- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1886 of the Social Security Act (42 U.S.C. 1395ww), as amended by section 1103(a), is amended by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(p) Adjustment to Hospital Payments for Excess Readmissions- CommentsClose CommentsPermalink





‘(1) IN GENERAL- With respect to payment for discharges from an applicable hospital (as defined in paragraph (5)(C)) occurring during a fiscal year beginning on or after October 1, 2011, in order to account for excess readmissions in the hospital, the Secretary shall reduce the payments that would otherwise be made to such hospital under subsection (d) (or section 1814(b)(3), as the case may be) for such a discharge by an amount equal to the product of-- CommentsClose CommentsPermalink





‘(A) the base operating DRG payment amount (as defined in paragraph (2)) for the discharge; and CommentsClose CommentsPermalink





‘(B) the adjustment factor (described in paragraph (3)(A)) for the hospital for the fiscal year. CommentsClose CommentsPermalink





‘(2) BASE OPERATING DRG PAYMENT AMOUNT- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Except as provided in subparagraph (B), for purposes of this subsection, the term ‘base operating DRG payment amount’ means, with respect to a hospital for a fiscal year, the payment amount that would otherwise be made under subsection (d) for a discharge if this subsection did not apply, reduced by any portion of such amount that is attributable to payments under subparagraphs (B) and (F) of paragraph (5). CommentsClose CommentsPermalink





‘(B) ADJUSTMENTS- For purposes of subparagraph (A), in the case of a hospital that is paid under section 1814(b)(3), the term ‘base operating DRG payment amount’ means the payment amount under such section. CommentsClose CommentsPermalink





‘(3) ADJUSTMENT FACTOR- CommentsClose CommentsPermalink





‘(A) IN GENERAL- For purposes of paragraph (1), the adjustment factor under this paragraph for an applicable hospital for a fiscal year is equal to the greater of-- CommentsClose CommentsPermalink





‘(i) the ratio described in subparagraph (B) for the hospital for the applicable period (as defined in paragraph (5)(D)) for such fiscal year; or CommentsClose CommentsPermalink





‘(ii) the floor adjustment factor specified in subparagraph (C). CommentsClose CommentsPermalink





‘(B) RATIO- The ratio described in this subparagraph for a hospital for an applicable period is equal to 1 minus the ratio of-- CommentsClose CommentsPermalink





‘(i) the aggregate payments for excess readmissions (as defined in paragraph (4)(A)) with respect to an applicable hospital for the applicable period; and CommentsClose CommentsPermalink





‘(ii) the aggregate payments for all discharges (as defined in paragraph (4)(B)) with respect to such applicable hospital for such applicable period. CommentsClose CommentsPermalink





‘(C) FLOOR ADJUSTMENT FACTOR- For purposes of subparagraph (A), the floor adjustment factor specified in this subparagraph for-- CommentsClose CommentsPermalink





‘(i) fiscal year 2012 is 0.99; CommentsClose CommentsPermalink





‘(ii) fiscal year 2013 is 0.98; CommentsClose CommentsPermalink





‘(iii) fiscal year 2014 is 0.97; or CommentsClose CommentsPermalink





‘(iv) a subsequent fiscal year is 0.95. CommentsClose CommentsPermalink





‘(4) AGGREGATE PAYMENTS, EXCESS READMISSION RATIO DEFINED- For purposes of this subsection: CommentsClose CommentsPermalink





‘(A) AGGREGATE PAYMENTS FOR EXCESS READMISSIONS- The term ‘aggregate payments for excess readmissions’ means, for a hospital for a fiscal year, the sum, for applicable conditions (as defined in paragraph (5)(A)), of the product, for each applicable condition, of-- CommentsClose CommentsPermalink





‘(i) the base operating DRG payment amount for such hospital for such fiscal year for such condition; CommentsClose CommentsPermalink





‘(ii) the number of admissions for such condition for such hospital for such fiscal year; and CommentsClose CommentsPermalink





‘(iii) the excess readmissions ratio (as defined in subparagraph (C)) for such hospital for the applicable period for such fiscal year minus 1. CommentsClose CommentsPermalink





‘(B) AGGREGATE PAYMENTS FOR ALL DISCHARGES- The term ‘aggregate payments for all discharges’ means, for a hospital for a fiscal year, the sum of the base operating DRG payment amounts for all discharges for all conditions from such hospital for such fiscal year. CommentsClose CommentsPermalink





‘(C) EXCESS READMISSION RATIO- CommentsClose CommentsPermalink





‘(i) IN GENERAL- Subject to clauses (ii) and (iii), the term ‘excess readmissions ratio’ means, with respect to an applicable condition for a hospital for an applicable period, the ratio (but not less than 1.0) of-- CommentsClose CommentsPermalink





‘(I) the risk adjusted readmissions based on actual readmissions, as determined consistent with a readmission measure methodology that has been endorsed under paragraph (5)(A)(ii)(I), for an applicable hospital for such condition with respect to the applicable period; to CommentsClose CommentsPermalink





‘(II) the risk adjusted expected readmissions (as determined consistent with such a methodology) for such hospital for such condition with respect to such applicable period. CommentsClose CommentsPermalink





‘(ii) EXCLUSION OF CERTAIN READMISSIONS- For purposes of clause (i), with respect to a hospital, excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number (as determined by the Secretary) of discharges for such applicable condition for the applicable period and such hospital. CommentsClose CommentsPermalink





‘(iii) ADJUSTMENT- In order to promote a reduction over time in the overall rate of readmissions for applicable conditions, the Secretary may provide, beginning with discharges for fiscal year 2014, for the determination of the excess readmissions ratio under subparagraph (C) to be based on a ranking of hospitals by readmission ratios (from lower to higher readmission ratios) normalized to a benchmark that is lower than the 50th percentile. CommentsClose CommentsPermalink





‘(5) DEFINITIONS- For purposes of this subsection: CommentsClose CommentsPermalink





‘(A) APPLICABLE CONDITION- The term ‘applicable condition’ means, subject to subparagraph (B), a condition or procedure selected by the Secretary among conditions and procedures for which-- CommentsClose CommentsPermalink





‘(i) readmissions (as defined in subparagraph (E)) that represent conditions or procedures that are high volume or high expenditures under this title (or other criteria specified by the Secretary); and CommentsClose CommentsPermalink





‘(ii) measures of such readmissions-- CommentsClose CommentsPermalink





‘(I) have been endorsed by the entity with a contract under section 1890(a); and CommentsClose CommentsPermalink





‘(II) such endorsed measures have appropriate exclusions for readmissions that are unrelated to the prior discharge (such as a planned readmission or transfer to another applicable hospital). CommentsClose CommentsPermalink





‘(B) EXPANSION OF APPLICABLE CONDITIONS- Beginning with fiscal year 2013, the Secretary shall expand the applicable conditions beyond the 3 conditions for which measures have been endorsed as described in subparagraph (A)(ii)(I) as of the date of the enactment of this subsection to the additional 4 conditions that have been so identified by the Medicare Payment Advisory Commission in its report to Congress in June 2007 and to other conditions and procedures which may include an all-condition measure of readmissions, as determined appropriate by the Secretary. In expanding such applicable conditions, the Secretary shall seek the endorsement described in subparagraph (A)(ii)(I) but may apply such measures without such an endorsement. CommentsClose CommentsPermalink





‘(C) APPLICABLE HOSPITAL- The term ‘applicable hospital’ means a subsection (d) hospital or a hospital that is paid under section 1814(b)(3). CommentsClose CommentsPermalink





‘(D) APPLICABLE PERIOD- The term ‘applicable period’ means, with respect to a fiscal year, such period as the Secretary shall specify for purposes of determining excess readmissions. CommentsClose CommentsPermalink





‘(E) READMISSION- The term ‘readmission’ means, in the case of an individual who is discharged from an applicable hospital, the admission of the individual to the same or another applicable hospital within a time period specified by the Secretary from the date of such discharge. Insofar as the discharge relates to an applicable condition for which there is an endorsed measure described in subparagraph (A)(ii)(I), such time period (such as 30 days) shall be consistent with the time period specified for such measure. CommentsClose CommentsPermalink





‘(6) LIMITATIONS ON REVIEW- There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of-- CommentsClose CommentsPermalink





‘(A) the determination of base operating DRG payment amounts; CommentsClose CommentsPermalink





‘(B) the methodology for determining the adjustment factor under paragraph (3), including excess readmissions ratio under paragraph (4)(C), aggregate payments for excess readmissions under paragraph (4)(A), and aggregate payments for all discharges under paragraph (4)(B), and applicable periods and applicable conditions under paragraph (5); CommentsClose CommentsPermalink





‘(C) the measures of readmissions as described in paragraph (5)(A)(ii); and CommentsClose CommentsPermalink





‘(D) the determination of a targeted hospital under paragraph (8)(B)(i), the increase in payment under paragraph (8)(B)(ii), the aggregate cap under paragraph (8)(C)(i), the hospital-specific limit under paragraph (8)(C)(ii), and the form of payment made by the Secretary under paragraph (8)(D). CommentsClose CommentsPermalink





‘(7) MONITORING INAPPROPRIATE CHANGES IN ADMISSIONS PRACTICES- The Secretary shall monitor the activities of applicable hospitals to determine if such hospitals have taken steps to avoid patients at risk in order to reduce the likelihood of increasing readmissions for applicable conditions. If the Secretary determines that such a hospital has taken such a step, after notice to the hospital and opportunity for the hospital to undertake action to alleviate such steps, the Secretary may impose an appropriate sanction. CommentsClose CommentsPermalink





‘(8) ASSISTANCE TO CERTAIN HOSPITALS- CommentsClose CommentsPermalink





‘(A) IN GENERAL- For purposes of providing funds to applicable hospitals to take steps described in subparagraph (E) to address factors that may impact readmissions of individuals who are discharged from such a hospital, for fiscal years beginning on or after October 1, 2011, the Secretary shall make a payment adjustment for a hospital described in subparagraph (B), with respect to each such fiscal year, by a percent estimated by the Secretary to be consistent with subparagraph (C). CommentsClose CommentsPermalink





‘(B) TARGETED HOSPITALS- Subparagraph (A) shall apply to an applicable hospital that-- CommentsClose CommentsPermalink





‘(i) received (or, in the case of an 1814(b)(3) hospital, otherwise would have been eligible to receive) $10,000,000 or more in disproportionate share payments using the latest available data as estimated by the Secretary; and CommentsClose CommentsPermalink





‘(ii) provides assurances satisfactory to the Secretary that the increase in payment under this paragraph shall be used for purposes described in subparagraph (E). CommentsClose CommentsPermalink





‘(C) CAPS- CommentsClose CommentsPermalink





‘(i) AGGREGATE CAP- The aggregate amount of the payment adjustment under this paragraph for a fiscal year shall not exceed 5 percent of the estimated difference in the spending that would occur for such fiscal year with and without application of the adjustment factor described in paragraph (3) and applied pursuant to paragraph (1). CommentsClose CommentsPermalink





‘(ii) HOSPITAL-SPECIFIC LIMIT- The aggregate amount of the payment adjustment for a hospital under this paragraph shall not exceed the estimated difference in spending that would occur for such fiscal year for such hospital with and without application of the adjustment factor described in paragraph (3) and applied pursuant to paragraph (1). CommentsClose CommentsPermalink





‘(D) FORM OF PAYMENT- The Secretary may make the additional payments under this paragraph on a lump sum basis, a periodic basis, a claim by claim basis, or otherwise. CommentsClose CommentsPermalink





‘(E) USE OF ADDITIONAL PAYMENT- Funding under this paragraph shall be used by targeted hospitals for transitional care activities designed to address the patient noncompliance issues that result in higher than normal readmission rates, such as one or more of the following: CommentsClose CommentsPermalink





‘(i) Providing care coordination services to assist in transitions from the targeted hospital to other settings. CommentsClose CommentsPermalink





‘(ii) Hiring translators and interpreters. CommentsClose CommentsPermalink





‘(iii) Increasing services offered by discharge planners. CommentsClose CommentsPermalink





‘(iv) Ensuring that individuals receive a summary of care and medication orders upon discharge. CommentsClose CommentsPermalink





‘(v) Developing a quality improvement plan to assess and remedy preventable readmission rates. CommentsClose CommentsPermalink





‘(vi) Assigning discharged individuals to a medical home. CommentsClose CommentsPermalink





‘(vii) Doing other activities as determined appropriate by the Secretary. CommentsClose CommentsPermalink





‘(F) GAO REPORT ON USE OF FUNDS- Not later than 3 years after the date on which funds are first made available under this paragraph, the Comptroller General of the United States shall submit to Congress a report on the use of such funds. CommentsClose CommentsPermalink





‘(G) DISPROPORTIONATE SHARE HOSPITAL PAYMENT- In this paragraph, the term ‘disproportionate share hospital payment’ means an additional payment amount under subsection (d)(5)(F).’. CommentsClose CommentsPermalink





(b) Application to Critical Access Hospitals- Section 1814(l) of the Social Security Act (42 U.S.C. 1395f(l)) is amended-- CommentsClose CommentsPermalink





(1) in paragraph (5)-- CommentsClose CommentsPermalink





(A) by striking ‘and’ at the end of subparagraph (C); CommentsClose CommentsPermalink





(B) by striking the period at the end of subparagraph (D) and inserting ‘; and’; CommentsClose CommentsPermalink





(C) by inserting at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(E) Tthe methodology for determining the adjustment factor under paragraph (5), including the determination of aggregate payments for actual and expected readmissions, applicable periods, applicable conditions and measures of readmissions.’; and CommentsClose CommentsPermalink





(D) by redesignating such paragraph as paragraph (6); and CommentsClose CommentsPermalink





(2) by inserting after paragraph (4) the following new paragraph: CommentsClose CommentsPermalink





‘(5) The adjustment factor described in section 1886(p)(3) shall apply to payments with respect to a critical access hospital with respect to a cost reporting period beginning in fiscal year 2012 and each subsequent fiscal year (after application of paragraph (4) of this subsection) in a manner similar to the manner in which such section applies with respect to a fiscal year to an applicable hospital as described in section 1886(p)(2).’. CommentsClose CommentsPermalink





(c) Post Acute Care Providers- CommentsClose CommentsPermalink





(1) INTERIM POLICY- CommentsClose CommentsPermalink





(A) IN GENERAL- With respect to a readmission to an applicable hospital or a critical access hospital (as described in section 1814(l) of the Social Security Act) from a post acute care provider (as defined in paragraph (3)) and such a readmission is not governed by section 412.531 of title 42, Code of Federal Regulations, if the claim submitted by such a post-acute care provider under title XVIII of the Social Security Act indicates that the individual was readmitted to a hospital from such a post-acute care provider or admitted from home and under the care of a home health agency within 30 days of an initial discharge from an applicable hospital or critical access hospital, the payment under such title on such claim shall be the applicable percent specified in subparagraph (B) of the payment that would otherwise be made under the respective payment system under such title for such post-acute care provider if this subsection did not apply. CommentsClose CommentsPermalink





(B) APPLICABLE PERCENT DEFINED- For purposes of subparagraph (A), the applicable percent is-- CommentsClose CommentsPermalink





(i) for fiscal or rate year 2012 is 0.996; CommentsClose CommentsPermalink





(ii) for fiscal or rate year 2013 is 0.993; and CommentsClose CommentsPermalink





(iii) for fiscal or rate year 2014 is 0.99. CommentsClose CommentsPermalink





(C) EFFECTIVE DATE- Subparagraph (1) shall apply to discharges or services furnished (as the case may be with respect to the applicable post acute care provider) on or after the first day of the fiscal year or rate year, beginning on or after October 1, 2011, with respect to the applicable post acute care provider. CommentsClose CommentsPermalink





(2) DEVELOPMENT AND APPLICATION OF PERFORMANCE MEASURES- CommentsClose CommentsPermalink





(A) IN GENERAL- The Secretary of Health and Human Services shall develop appropriate measures of readmission rates for post acute care providers. The Secretary shall seek endorsement of such measures by the entity with a contract under section 1890(a) of the Social Security Act but may adopt and apply such measures under this paragraph without such an endorsement. The Secretary shall expand such measures in a manner similar to the manner in which applicable conditions are expanded under paragraph (5)(B) of section 1886(p) of the Social Security Act, as added by subsection (a). CommentsClose CommentsPermalink





(B) IMPLEMENTATION- The Secretary shall apply, on or after October 1, 2014, with respect to post acute care providers, policies similar to the policies applied with respect to applicable hospitals and critical access hospitals under the amendments made by subsection (a). The provisions of paragraph (1) shall apply with respect to any period on or after October 1, 2014, and before such application date described in the previous sentence in the same manner as such provisions apply with respect to fiscal or rate year 2014. CommentsClose CommentsPermalink





(C) MONITORING AND PENALTIES- The provisions of paragraph (7) of such section 1886(p) shall apply to providers under this paragraph in the same manner as they apply to hospitals under such section. CommentsClose CommentsPermalink





(3) DEFINITIONS- For purposes of this subsection: CommentsClose CommentsPermalink





(A) POST ACUTE CARE PROVIDER- The term ‘post acute care provider’ means-- CommentsClose CommentsPermalink





(i) a skilled nursing facility (as defined in section 1819(a) of the Social Security Act); CommentsClose CommentsPermalink





(ii) an inpatient rehabilitation facility (described in section 1886(h)(1)(A) of such Act); CommentsClose CommentsPermalink





(iii) a home health agency (as defined in section 1861(o) of such Act); and CommentsClose CommentsPermalink





(iv) a long term care hospital (as defined in section 1861(ccc) of such Act). CommentsClose CommentsPermalink





(B) OTHER TERMS - The terms ‘applicable condition’, ‘applicable hospital’, and ‘readmission’ have the meanings given such terms in section 1886(p)(5) of the Social Security Act, as added by subsection (a)(1). CommentsClose CommentsPermalink





(d) Physicians- CommentsClose CommentsPermalink





(1) STUDY- The Secretary of Health and Human Services shall conduct a study to determine how the readmissions policy described in the previous subsections could be applied to physicians. CommentsClose CommentsPermalink





(2) CONSIDERATIONS- In conducting the study, the Secretary shall consider approaches such as-- CommentsClose CommentsPermalink





(A) creating a new code (or codes) and payment amount (or amounts) under the fee schedule in section 1848 of the Social Security Act (in a budget neutral manner) for services furnished by an appropriate physician who sees an individual within the first week after discharge from a hospital or critical access hospital; CommentsClose CommentsPermalink





(B) developing measures of rates of readmission for individuals treated by physicians; CommentsClose CommentsPermalink





(C) applying a payment reduction for physicians who treat the patient during the initial admission that results in a readmission; and CommentsClose CommentsPermalink





(D) methods for attributing payments or payment reductions to the appropriate physician or physicians. CommentsClose CommentsPermalink





(3) REPORT- The Secretary shall issue a public report on such study not later than the date that is one year after the date of the enactment of this Act. CommentsClose CommentsPermalink





(e) Funding- For purposes of carrying out the provisions of this section, in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services for the Center for Medicare & Medicaid Services Program Management Account $25,000,000 for each fiscal year beginning with 2010. Amounts appropriated under this subsection for a fiscal year shall be available until expended. CommentsClose CommentsPermalink

SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM PLAN AND BUNDLING PILOT PROGRAM.

(a) Plan- CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall develop a detailed plan to reform payment for post acute care (PAC) services under the Medicare program under title XVIII of the Social Security Act (in this section referred to as the ‘Medicare program)’. The goals of such payment reform are to-- CommentsClose CommentsPermalink





(A) improve the coordination, quality, and efficiency of such services; and CommentsClose CommentsPermalink





(B) improve outcomes for individuals such as reducing the need for readmission to hospitals from providers of such services. CommentsClose CommentsPermalink





(2) BUNDLING POST ACUTE SERVICES- The plan described in paragraph (1) shall include detailed specifications for a bundled payment for post acute services (in this section referred to as the ‘post acute care bundle’), and may include other approaches determined appropriate by the Secretary. CommentsClose CommentsPermalink





(3) POST ACUTE SERVICES- For purposes of this section, the term ‘post acute services’ means services for which payment may be made under the Medicare program that are furnished by skilled nursing facilities, inpatient rehabilitation facilities, long term care hospitals, hospital based outpatient rehabilitation facilities and home health agencies to an individual after discharge of such individual from a hospital, and such other services determined appropriate by the Secretary. CommentsClose CommentsPermalink





(b) Details- The plan described in subsection (a)(1) shall include consideration of the following issues: CommentsClose CommentsPermalink





(1) The nature of payments under a post acute care bundle, including the type of provider or entity to whom payment should be made, the scope of activities and services included in the bundle, whether payment for physicians’ services should be included in the bundle, and the period covered by the bundle. CommentsClose CommentsPermalink





(2) Whether the payment should be consolidated with the payment under the inpatient prospective system under section 1886 of the Social Security Act (in this section referred to as MS-DRGs) or a separate payment should be established for such bundle, and if a separate payment is established, whether it should be made only upon use of post acute care services or for every discharge. CommentsClose CommentsPermalink





(3) Whether the bundle should be applied across all categories of providers of inpatient services (including critical access hospitals) and post acute care services or whether it should be limited to certain categories of providers, services, or discharges, such as high volume or high cost MS-DRGs. CommentsClose CommentsPermalink





(4) The extent to which payment rates could be established to achieve offsets for efficiencies that could be expected to be achieved with a bundle payment, whether such rates should be established on a national basis or for different geographic areas, should vary according to discharge, case mix, outliers, and geographic differences in wages or other appropriate adjustments, and how to update such rates. CommentsClose CommentsPermalink





(5) The nature of protections needed for individuals under a system of bundled payments to ensure that individuals receive quality care, are furnished the level and amount of services needed as determined by an appropriate assessment instrument, are offered choice of provider, and the extent to which transitional care services would improve quality of care for individuals and the functioning of a bundled post-acute system. CommentsClose CommentsPermalink





(6) The nature of relationships that may be required between hospitals and providers of post acute care services to facilitate bundled payments, including the application of gainsharing, anti-referral, anti-kickback, and anti-trust laws. CommentsClose CommentsPermalink





(7) Quality measures that would be appropriate for reporting by hospitals and post acute providers (such as measures that assess changes in functional status and quality measures appropriate for each type of post acute services provider including how the reporting of such quality measures could be coordinated with other reporting of such quality measures by such providers otherwise required). CommentsClose CommentsPermalink





(8) How cost-sharing for a post acute care bundle should be treated relative to current rules for cost-sharing for inpatient hospital, home health, skilled nursing facility, and other services. CommentsClose CommentsPermalink





(9) How other programmatic issues should be treated in a post acute care bundle, including rules specific to various types of post-acute providers such as the post-acute transfer policy, three-day hospital stay to qualify for services furnished by skilled nursing facilities, and the coordination of payments and care under the Medicare program and the Medicaid program. CommentsClose CommentsPermalink





(10) Such other issues as the Secretary deems appropriate. CommentsClose CommentsPermalink





(c) Consultations and Analysis- CommentsClose CommentsPermalink





(1) CONSULTATION WITH STAKEHOLDERS- In developing the plan under subsection (a)(1), the Secretary shall consult with relevant stakeholders and shall consider experience with such research studies and demonstrations that the Secretary determines appropriate. CommentsClose CommentsPermalink





(2) ANALYSIS AND DATA COLLECTION- In developing such plan, the Secretary shall-- CommentsClose CommentsPermalink





(A) analyze the issues described in subsection (b) and other issues that the Secretary determines appropriate; CommentsClose CommentsPermalink





(B) analyze the impacts (including geographic impacts) of post acute service reform approaches, including bundling of such services on individuals, hospitals, post acute care providers, and physicians; CommentsClose CommentsPermalink





(C) use existing data (such as data submitted on claims) and collect such data as the Secretary determines are appropriate to develop such plan required in this section; and CommentsClose CommentsPermalink





(D) if patient functional status measures are appropriate for the analysis, to the extent practical, build upon the CARE tool being developed pursuant to section 5008 of the Deficit Reduction Act of 2005. CommentsClose CommentsPermalink





(d) Administration- CommentsClose CommentsPermalink





(1) FUNDING- For purposes of carrying out the provisions of this section, in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary for the Center for Medicare & Medicaid Services Program Management Account $15,000,000 for each of the fiscal years 2010 through 2012. Amounts appropriated under this paragraph for a fiscal year shall be available until expended. CommentsClose CommentsPermalink





(2) EXPEDITED DATA COLLECTION- Chapter 35 of title 44, United States Code shall not apply to this section. CommentsClose CommentsPermalink





(e) Public Reports- CommentsClose CommentsPermalink





(1) INTERIM REPORTS- The Secretary shall issue interim public reports on a periodic basis on the plan described in subsection (a)(1), the issues described in subsection (b), and impact analyses as the Secretary determines appropriate. CommentsClose CommentsPermalink





(2) FINAL REPORT- Not later than the date that is 3 years after the date of the enactment of this Act, the Secretary shall issue a final public report on such plan, including analysis of issues described in subsection (b) and impact analyses. CommentsClose CommentsPermalink





(f) Conversion of Acute Care Episode Demonstration to Pilot Program and Expansion Tto Include Post Acute Services- CommentsClose CommentsPermalink





(1) IN GENERAL- Part E of title XVIII of the Social Security Act is amended by inserting after section 1866C the following new section: CommentsClose CommentsPermalink

‘SEC. 1866D. CONVERSION OF ACUTE CARE EPISODE DEMONSTRATION TO PILOT PROGRAM AND EXPANSION TO INCLUDE POST ACUTE SERVICES

.‘‘Sec. 1866D. (a) In General- By not later than January 1, 2011, the Secretary shall, for the purpose of promoting the use of bundled payments to promote efficient and high quality delivery of care-- CommentsClose CommentsPermalink





‘(1) convert the acute care episode demonstration program conducted under section 1866C to a pilot program; and CommentsClose CommentsPermalink





‘(2) subject to subsection (c), expand such program as so converted to include post acute services and such other services the Secretary determines to be appropriate, which may include transitional services. CommentsClose CommentsPermalink





‘(b) Scope- The pilot program under subsection (a) may include additional geographic areas and additional conditions which account for significant program spending, as defined by the Secretary. Nothing in this subsection shall be construed as limiting the number of hospital and physician groups or the number of hospitalSecretary shall set specific goals for the number of acute and post-acute provider groups that may participate in the pilot program.‘(c) bundling test sites under the pilot program to ensure that the pilot program is of sufficient size and scope to-- CommentsClose CommentsPermalink





‘(1) test the approaches under the pilot program in a variety of settings, including urban, rural, and underserved areas; CommentsClose CommentsPermalink





‘(2) include geographic areas and additional conditions that account for significant program spending, as defined by the Secretary; and CommentsClose CommentsPermalink





‘(3) subject to subsection (d), disseminate the pilot program rapidly on a national basis. CommentsClose CommentsPermalink





To the extent that the Secretary finds inpatient and post-acute care bundling to be successful in improving quality and reducing costs, the Secretary shall implement such mechanisms and reforms under the pilot program on as large a geographic scale as practical and economical, consistent with subsection (e). CommentsClose CommentsPermalink





‘(c) Limitation- The Secretary shall only expand the pilot program under subsection (a)(2) if the Secretary finds that-- CommentsClose CommentsPermalink





‘(1) the demonstration program under section 1866C and pilot program under this section maintain or increase the quality of care received by individuals enrolled under this title; and CommentsClose CommentsPermalink





‘(2) such demonstration program and pilot program reduce program expenditures and, based on the certification under subsection (d), that the expansion of such pilot program would result in estimated spending that would be less than what spending would otherwise be in the absence of this section. CommentsClose CommentsPermalink





‘(d) Certification- For purposes of subsection (c), the Chief Actuary of the Centers for Medicare & Medicaid Services shall certify whether expansion of the pilot program under this section would result in estimated spending that would be less than what spending would otherwise be in the absence of this section. CommentsClose CommentsPermalink





‘(e) Voluntary Participation- Nothing in this paragraph shall be construed as requiring the participation of an entity in the pilot program under this section.’. CommentsClose CommentsPermalink





(2) CONFORMING AMENDMENT- Section 1866C(b) of the Social Security Act (42 U.S.C. 1395cc-3(b)) is amended by striking ‘The Secretary’ and inserting ‘Subject to section 1866D, the Secretary’. CommentsClose CommentsPermalink

SEC. 1153. HOME HEALTH PAYMENT UPDATE FOR 2010.

Section 1895(b)(3)(B)(ii) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(B)(ii)) is amended-- CommentsClose CommentsPermalink





(1) in subclause (IV), by striking ‘and’; CommentsClose CommentsPermalink





(2) by redesignating subclause (V) as subclause (VII); and CommentsClose CommentsPermalink





(3) by inserting after subclause (IV) the following new subclauses: CommentsClose CommentsPermalink





‘(V) 2007, 2008, and 2009, subject to clause (v), the home health market basket percentage increase; CommentsClose CommentsPermalink





‘(VI) 2010, subject to clause (v), 0 percent; and’. CommentsClose CommentsPermalink

SEC. 1154. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE.

(a) Acceleration of Adjustment for Case Mix Changes- Section 1895(b)(3)(B) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amended-- CommentsClose CommentsPermalink





(1) in clause (iv), by striking ‘Insofar as’ and inserting ‘Subject to clause (vi), insofar as’; and CommentsClose CommentsPermalink





(2) by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(vi) SPECIAL RULE FOR CASE MIX CHANGES FOR 2011- CommentsClose CommentsPermalink





‘(I) IN GENERAL- With respect to the case mix adjustments established in section 484.220(a) of title 42, Code of Federal Regulations, the Secretary shall apply, in 2010, the adjustment established in paragraph (3) of such section for 2011, in addition to applying the adjustment established in paragraph (2) for 2010. CommentsClose CommentsPermalink





‘(II) CONSTRUCTION- Nothing in this clause shall be construed as limiting the amount of adjustment for case mix for 2010 or 2011 if more recent data indicate an appropriate adjustment that is greater than the amount established in the section described in subclause (I).’. CommentsClose CommentsPermalink





(b) Rebasing Home Health Prospective Payment Amount- Section 1895(b)(3)(A) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(A)) is amended-- CommentsClose CommentsPermalink





(1) in clause (i)-- CommentsClose CommentsPermalink





(A) in subclause (III), by inserting ‘and before 2011’ after ‘after the period described in subclause (II)’; and CommentsClose CommentsPermalink





(B) by inserting after subclause (III) the following new subclauses: CommentsClose CommentsPermalink





‘(IV) Subject to clause (iii)(I), for 2011, such amount (or amounts) shall be adjusted by a uniform percentage determined to be appropriate by the Secretary based on analysis of factors such as changes in the average number and types of visits in an episode, the change in intensity of visits in an episode, growth in cost per episode, and other factors that the Secretary considers to be relevant. CommentsClose CommentsPermalink





‘(V) Subject to clause (iii)(II), for a year after 2011, such a amount (or amounts) shall be equal to the amount (or amounts) determined under this clause for the previous year, updated under subparagraph (B).’; and CommentsClose CommentsPermalink





(2) by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(iii) SPECIAL RULE IN CASE OF INABILITY TO EFFECT TIMELY REBASING- CommentsClose CommentsPermalink





‘(I) APPLICATION OF PROXY AMOUNT FOR 2011- If the Secretary is not able to compute the amount (or amounts) under clause (i)(IV) so as to permit, on a timely basis, the application of such clause for 2011, the Secretary shall substitute for such amount (or amounts) 95 percent of the amount (or amounts) that would otherwise be specified under clause (i)(III) if it applied for 2011. CommentsClose CommentsPermalink





‘(II) ADJUSTMENT FOR SUBSEQUENT YEARS BASED ON DATA- If the Secretary applies subclause (I), the Secretary before July 1, 2011, shall compare the amount (or amounts) applied under such subclause with the amount (or amounts) that should have been applied under clause (i)(IV). The Secretary shall decrease or increase the prospective payment amount (or amounts) under clause (i)(V) for 2012 (or, at the Secretary’s discretion, over a period of several years beginning with 2012) by the amount (if any) by which the amount (or amounts) applied under subclause (I) is greater or less, respectively, than the amount (or amounts) that should have been applied under clause (i)(IV).’. CommentsClose CommentsPermalink

SEC. 1155. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET UPDATE FOR HOME HEALTH SERVICES.

(a) In General- Section 1895(b)(3)(B) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amended-- CommentsClose CommentsPermalink





(1) in clause (iii), by inserting ‘(including being subject to the productivity adjustment described in section 1886(b)(3)(B)(iii)(II))’ after ‘in the same manner’; and CommentsClose CommentsPermalink





(2) in clause (v)(I), by inserting ‘(but not below 0)’ after ‘reduced’. CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) shall apply to home health market basket percentage increases for years beginning with 2010. CommentsClose CommentsPermalink

SEC. 1156. LIMITATION ON MEDICARE EXCEPTIONS TO THE PROHIBITION ON CERTAIN PHYSICIAN REFERRALS MADE TO HOSPITALS.

(a) In General- Section 1877 of the Social Security Act (42 U.S.C. 1395nn) is amended-- CommentsClose CommentsPermalink





(1) in subsection (d)(2)-- CommentsClose CommentsPermalink





(A) in subparagraph (A), by striking ‘and’ at the end; CommentsClose CommentsPermalink





(B) in subparagraph (B), by striking the period at the end and inserting ‘; and’; and CommentsClose CommentsPermalink





(C) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(C) in the case where the entity is a hospital, the hospital meets the requirements of paragraph (3)(D).’; CommentsClose CommentsPermalink





(2) in subsection (d)(3)-- CommentsClose CommentsPermalink





(A) in subparagraph (B), by striking ‘and’ at the end; CommentsClose CommentsPermalink





(B) in subparagraph (C), by striking the period at the end and inserting ‘; and’; and CommentsClose CommentsPermalink





(C) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(D) the hospital meets the requirements described in subsection (i)(1).’; CommentsClose CommentsPermalink





(3) by amending subsection (f) to read as follows: CommentsClose CommentsPermalink





‘(f) Reporting and Disclosure Requirements- CommentsClose CommentsPermalink





‘(1) IN GENERAL- Each entity providing covered items or services for which payment may be made under this title shall provide the Secretary with the information concerning the entity’s ownership, investment, and compensation arrangements, including-- CommentsClose CommentsPermalink





‘(A) the covered items and services provided by the entity, and CommentsClose CommentsPermalink





‘(B) the names and unique physician identification numbers of all physicians with an ownership or investment interest (as described in subsection (a)(2)(A)), or with a compensation arrangement (as described in subsection (a)(2)(B)), in the entity, or whose immediate relatives have such an ownership or investment interest or who have such a compensation relationship with the entity. CommentsClose CommentsPermalink





Such information shall be provided in such form, manner, and at such times as the Secretary shall specify. The requirement of this subsection shall not apply to designated health services provided outside the United States or to entities which the Secretary determines provide services for which payment may be made under this title very infrequently. CommentsClose CommentsPermalink





‘(2) REQUIREMENTS FOR HOSPITALS WITH PHYSICIAN OWNERSHIP OR INVESTMENT- In the case of a hospital that meets the requirements described in subsection (i)(1), the hospital shall-- CommentsClose CommentsPermalink





‘(A) submit to the Secretary an initial report, and periodic updates at a frequency determined by the Secretary, containing a detailed description of the identity of each physician owner and physician investor and any other owners or investors of the hospital; CommentsClose CommentsPermalink





‘(B) require that any referring physician owner or investor discloses to the individual being referred, by a time that permits the individual to make a meaningful decision regarding the receipt of services, as determined by the Secretary, the ownership or investment interest, as applicable, of such referring physician in the hospital; and CommentsClose CommentsPermalink





‘(C) disclose the fact that the hospital is partially or wholly owned by one or more physicians or has one or more physician investors-- CommentsClose CommentsPermalink





‘(i) on any public website for the hospital; and CommentsClose CommentsPermalink





‘(ii) in any public advertising for the hospital. CommentsClose CommentsPermalink





The information to be reported or disclosed under this paragraph shall be provided in such form, manner, and at such times as the Secretary shall specify. The requirements of this paragraph shall not apply to designated health services furnished outside the United States or to entities which the Secretary determines provide services for which payment may be made under this title very infrequently. CommentsClose CommentsPermalink





‘(3) PUBLICATION OF INFORMATION- The Secretary shall publish, and periodically update, the information submitted by hospitals under paragraph (2)(A) on the public Internet website of the Centers for Medicare & Medicaid Services.’; CommentsClose CommentsPermalink





(4) by amending subsection (g)(5) to read as follows: CommentsClose CommentsPermalink





‘(5) FAILURE TO REPORT OR DISCLOSE INFORMATION- CommentsClose CommentsPermalink





‘(A) REPORTING- Any person who is required, but fails, to meet a reporting requirement of paragraphs (1) and (2)(A) of subsection (f) is subject to a civil money penalty of not more than $10,000 for each day for which reporting is required to have been made. CommentsClose CommentsPermalink





‘(B) DISCLOSURE- Any physician who is required, but fails, to meet a disclosure requirement of subsection (f)(2)(B) or a hospital that is required, but fails, to meet a disclosure requirement of subsection (f)(2)(C) is subject to a civil money penalty of not more than $10,000 for each case in which disclosure is required to have been made. CommentsClose CommentsPermalink





‘(C) APPLICATION- The provisions of section 1128A (other than the first sentence of subsection (a) and other than subsection (b)) shall apply to a civil money penalty under subparagraphs (A) and (B) in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).’; and CommentsClose CommentsPermalink





(5) by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(i) Requirements Tto Qualify for Rural Provider and Hospital Ownership Exceptions to Self-referral Prohibition- CommentsClose CommentsPermalink





‘(1) REQUIREMENTS DESCRIBED- For purposes of subsection (d)(3)(D), the requirements described in this paragraph are as follows: CommentsClose CommentsPermalink





‘(A) PROVIDER AGREEMENT- The hospital had-- CommentsClose CommentsPermalink





‘(i) physician ownership or investment on January 1, 2009; and CommentsClose CommentsPermalink





‘(ii) a provider agreement under section 1866 in effect on such date. CommentsClose CommentsPermalink





‘(B) PROHIBITION ON PHYSICIAN OWNERSHIP OR INVESTMENT- The percentage of the total value of the ownership or investment interests held in the hospital, or in an entity whose assets include the hospital, by physician owners or investors in the aggregate does not exceed such percentage as of the date of enactment of this subsection. CommentsClose CommentsPermalink





‘(C) PROHIBITION ON EXPANSION OF FACILITY CAPACITY- Except as provided in paragraph (2), the number of operating rooms, procedure rooms, or beds of the hospital at any time on or after the date of the enactment of this subsection are no greater than the number of operating rooms, procedure rooms, or beds, respectively, as of such date. CommentsClose CommentsPermalink





‘(D) ENSURING BONA FIDE OWNERSHIP AND INVESTMENT- CommentsClose CommentsPermalink





‘(i) Any ownership or investment interests that the hospital offers to a physician are not offered on more favorable terms than the terms offered to a person who is not in a position to refer patients or otherwise generate business for the hospital. CommentsClose CommentsPermalink





‘(ii) The hospital (or any investors in the hospital) does not directly or indirectly provide loans or financing for any physician owner or investor in the hospital. CommentsClose CommentsPermalink





‘(iii) The hospital (or any investors in the hospital) does not directly or indirectly guarantee a loan, make a payment toward a loan, or otherwise subsidize a loan, for any physician owner or investor or group of physician owners or investors that is related to acquiring any ownership or investment interest in the hospital. CommentsClose CommentsPermalink





‘(iv) Ownership or investment returns are distributed to each owner or investor in the hospital in an amount that is directly proportional to the ownership or investment interest of such owner or investor in the hospital. CommentsClose CommentsPermalink





‘(v) The investment interest of the owner or investor is directly proportional to the owner’s or investor’s capital contributions made at the time the ownership or investment interest is obtained. CommentsClose CommentsPermalink





‘(vi) Physician owners and investors do not receive, directly or indirectly, any guaranteed receipt of or right to purchase other business interests related to the hospital, including the purchase or lease of any property under the control of other owners or investors in the hospital or located near the premises of the hospital. CommentsClose CommentsPermalink





‘(vii) The hospital does not offer a physician owner or investor the opportunity to purchase or lease any property under the control of the hospital or any other owner or investor in the hospital on more favorable terms than the terms offered to a person that is not a physician owner or investor. CommentsClose CommentsPermalink





‘(viii) The hospital does not condition any physician ownership or investment interests either directly or indirectly on the physician owner or investor making or influencing referrals to the hospital or otherwise generating business for the hospital. CommentsClose CommentsPermalink





‘(E) PATIENT SAFETY- In the case of a hospital that does not offer emergency services, the hospital has the capacity to-- CommentsClose CommentsPermalink





‘(i) provide assessment and initial treatment for medical emergencies; and CommentsClose CommentsPermalink





‘(ii) if the hospital lacks additional capabilities required to treat the emergency involved, refer and transfer the patient with the medical emergency to a hospital with the required capability. CommentsClose CommentsPermalink





‘(F) LIMITATION ON APPLICATION TO CERTAIN CONVERTED FACILITIES- The hospital was not converted from an ambulatory surgical center to a hospital on or after the date of enactment of this subsection. CommentsClose CommentsPermalink





‘(2) EXCEPTION TO PROHIBITION ON EXPANSION OF FACILITY CAPACITY- CommentsClose CommentsPermalink





‘(A) PROCESS- CommentsClose CommentsPermalink





‘(i) ESTABLISHMENT- The Secretary shall establish and implement a process under which a hospital may apply for an exception from the requirement under paragraph (1)(C). CommentsClose CommentsPermalink





‘(ii) OPPORTUNITY FOR COMMUNITY INPUT- The process under clause (i) shall provide persons and entities in the community in which the hospital applying for an exception is located with the opportunity to provide input with respect to the application. CommentsClose CommentsPermalink





‘(iii) TIMING FOR IMPLEMENTATION- The Secretary shall implement the process under clause (i) on the date that is one month after the promulgation of regulations described in clause (iv). CommentsClose CommentsPermalink





‘(iv) REGULATIONS- Not later than the first day of the month beginning 18 months after the date of the enactment of this subsection, the Secretary shall promulgate regulations to carry out the process under clause (i). The Secretary may issue such regulations as interim final regulations. CommentsClose CommentsPermalink





‘(B) FREQUENCY- The process described in subparagraph (A) shall permit a hospital to apply for an exception up to once every 2 years. CommentsClose CommentsPermalink





‘(C) PERMITTED INCREASE- CommentsClose CommentsPermalink





‘(i) IN GENERAL- Subject to clause (ii) and subparagraph (D), a hospital granted an exception under the process described in subparagraph (A) may increase the number of operating rooms, procedure rooms, or beds of the hospital above the baseline number of operating rooms, procedure rooms, or beds, respectively, of the hospital (or, if the hospital has been granted a previous exception under this paragraph, above the number of operating rooms, procedure rooms, or beds, respectively, of the hospital after the application of the most recent increase under such an exception). CommentsClose CommentsPermalink





‘(ii) 100 PERCENT INCREASE LIMITATION- The Secretary shall not permit an increase in the number of operating rooms, procedure rooms, or beds of a hospital under clause (i) to the extent such increase would result in the number of operating rooms, procedure rooms, or beds of the hospital exceeding 200 percent of the baseline number of operating rooms, procedure rooms, or beds of the hospital. CommentsClose CommentsPermalink





‘(iii) BASELINE NUMBER OF OPERATING ROOMS, PROCEDURE ROOMS, OR BEDS- In this paragraph, the term ‘baseline number of operating rooms, procedure rooms, or beds’ means the number of operating rooms, procedure rooms, or beds of a hospital as of the date of enactment of this subsection. CommentsClose CommentsPermalink





‘(D) INCREASE LIMITED TO FACILITIES ON THE MAIN CAMPUS OF THE HOSPITAL- Any increase in the number of operating rooms, procedure rooms, or beds of a hospital pursuant to this paragraph may only occur in facilities on the main campus of the hospital. CommentsClose CommentsPermalink





‘(E) CONDITIONS FOR APPROVAL OF AN INCREASE IN FACILITY CAPACITY- The Secretary may grant an exception under the process described in subparagraph (A) only to a hospital-- CommentsClose CommentsPermalink





‘(i) that is located in a county in which the percentage increase in the population during the most recent 5-year period for which data are available is estimated to be at least 150 percent of the percentage increase in the population growth of the State in which the hospital is located during that period, as estimated by Bureau of the Census and available to the Secretary; CommentsClose CommentsPermalink





‘(ii) whose annual percent of total inpatient admissions that represent inpatient admissions under the program under title XIX is estimated to be equal to or greater than the average percent with respect to such admissions for all hospitals located in the county in which the hospital is located; CommentsClose CommentsPermalink





‘(iii) that does not discriminate against beneficiaries of Federal health care programs and does not permit physicians practicing at the hospital to discriminate against such beneficiaries; CommentsClose CommentsPermalink





‘(iv) that is located in a State in which the average bed capacity in the State is estimated to be less than the national average bed capacity; CommentsClose CommentsPermalink





‘(v) that has an average bed occupancy rate that is estimated to be greater than the average bed occupancy rate in the State in which the hospital is located; and CommentsClose CommentsPermalink





‘(vi) that meets other conditions as determined by the Secretary. CommentsClose CommentsPermalink





‘(F) PROCEDURE ROOMS- In this subsection, the term ‘procedure rooms’ includes rooms in which catheterizations, angiographies, angiograms, and endoscopies are furnished, but such term shall not include emergency rooms or departments (except for rooms in which catheterizations, angiographies, angiograms, and endoscopies are furnished). CommentsClose CommentsPermalink





‘(G) PUBLICATION OF FINAL DECISIONS- Not later than 120 days after receiving a complete application under this paragraph, the Secretary shall publish on the public Internet website of the Centers for Medicare & Medicaid Services the final decision with respect to such application. CommentsClose CommentsPermalink





‘(H) LIMITATION ON REVIEW- There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the exception process under this paragraph, including the establishment of such process, and any determination made under such process. CommentsClose CommentsPermalink





‘(3) PHYSICIAN OWNER OR INVESTOR DEFINED- For purposes of this subsection and subsection (f)(2), the term ‘physician owner or investor’ means a physician (or an immediate family member of such physician) with a direct or an indirect ownership or investment interest in the hospital. CommentsClose CommentsPermalink





‘(4) PATIENT SAFETY REQUIREMENT- In the case of a hospital to which the requirements of paragraph (1) apply, insofar as the hospital admits a patient and does not have any physician available on the premises 24 hours per day, 7 days per week, before admitting the patient-- CommentsClose CommentsPermalink





‘(A) the hospital shall disclose such fact to the patient; and CommentsClose CommentsPermalink





‘(B) following such disclosure, the hospital shall receive from the patient a signed acknowledgment that the patient understands such fact. CommentsClose CommentsPermalink





‘(5) CLARIFICATION- Nothing in this subsection shall be construed as preventing the Secretary from terminating a hospital’s provider agreement if the hospital is not in compliance with regulations pursuant to section 1866.’. CommentsClose CommentsPermalink





(b) Verifying Compliance- The Secretary of Health and Human Services shall establish policies and procedures to verify compliance with the requirements described in subsections (i)(1) and (i)(4) of section 1877 of the Social Security Act, as added by subsection (a)(5). The Secretary may use unannounced site reviews of hospitals and audits to verify compliance with such requirements. CommentsClose CommentsPermalink





(c) Implementation- CommentsClose CommentsPermalink





(1) FUNDING- For purposes of carrying out the amendments made by subsection (a) and the provisions of subsection (b), in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated there are appropriated to the Secretary of Health and Human Services for the Centers for Medicare & Medicaid Services Program Management Account $5,000,000 for each fiscal year beginning with fiscal year 2010. Amounts appropriated under this paragraph for a fiscal year shall be available until expended. CommentsClose CommentsPermalink





(2) ADMINISTRATION- Chapter 35 of title 44, United States Code, shall not apply to the amendments made by subsection (a) and the provisions of subsection (b). CommentsClose CommentsPermalink

SEC. 1157. INSTITUTE OF MEDICINE STUDY OF GEOGRAPHIC ADJUSTMENT FACTORS UNDER MEDICARE.

(a) In General- The Secretary of Health and Human Services shall enter into a contract with the Institute of Medicine of the National Academy of Science to conduct a comprehensive empirical study, and provide recommendations as appropriate, on the accuracy of the geographic adjustment factors established under sections 1848(e) and 1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395w-4(e), 11395ww(d)(3)). CommentsClose CommentsPermalink





(b) Matters Included- Such study shall include an evaluation and assessment of the following with respect to such adjustment factors: CommentsClose CommentsPermalink





(1) Empirical validity of the adjustment factors. CommentsClose CommentsPermalink





(2) Methodology used to determine the adjustment factors. CommentsClose CommentsPermalink





(3) Measures used for the adjustment factors, taking into account-- CommentsClose CommentsPermalink





(A) timeliness of data and frequency of revisions to such data; CommentsClose CommentsPermalink





(B) sources of data and the degree to which such data are representative of costs; and CommentsClose CommentsPermalink





(C) operational costs of providers who participate in Medicare. CommentsClose CommentsPermalink





(c) Evaluation- Such study shall, within the context of the United States health care marketplace, evaluate and consider the following: CommentsClose CommentsPermalink





(1) The effect of the adjustment factors on the level and distribution of the health care workforce and resources, including-- CommentsClose CommentsPermalink





(A) recruitment and retention that takes into account workforce mobility between urban and rural areas; CommentsClose CommentsPermalink





(B) ability of hospitals and other facilities to maintain an adequate and skilled workforce; and CommentsClose CommentsPermalink





(C) patient access to providers and needed medical technologies. CommentsClose CommentsPermalink





(2) The effect of the adjustment factors on population health and quality of care. CommentsClose CommentsPermalink





(3) The effect of the adjustment factors on the ability of providers to furnish efficient, high value care. CommentsClose CommentsPermalink





(d) Report- The contract under subsection (a) shall provide for the Institute of Medicine to submit, not later than one year after the date of the enactment of this Act, to the Secretary and the Congress a report containing results and recommendations of the study conducted under this section. CommentsClose CommentsPermalink





(e) Funding- There are authorized to be appropriated to carry out this section such sums as may be necessary. CommentsClose CommentsPermalink

SEC. 1158. REVISION OF MEDICARE PAYMENT SYSTEMS TO ADDRESS GEOGRAPHIC INEQUITIES.(a) In General- The Secretary of Health and Human Services, taking into account the recommendations made in the report under section 1157(d), shall include in the proposed rules published to implement changes to payment systems for physicians and hospitals under sections 1848(e) and 1886(d)(3)(E), respectively, of the Social Security Act, proposals to revise geographic adjustment factors for such payment systems for services furnished under the Medicare program. Such proposed rules shall be published in the rulemaking period immediately following submission of .

(a) In General- Taking into account the recommendations described in the report under section 1157(d), and notwithstanding the geographic adjustments that would otherwise apply under sections 1848(e) and 1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395w-4(e), 1395ww(d)(3)(E)), the Secretary of Health and Human Services shall include in proposed rules applicable to the rulemaking cycle for payment systems for physicians’ services and inpatient hospital services under sections 1848 and 1886(d) of such Act, respectively, proposals (as the Secretary determines to be appropriate) to revise the geographic adjustment factors used in such systems. Such proposals shall be contained in the next rulemaking cycle following the submission to the Secretary of the report under section 1157(d). CommentsClose CommentsPermalink





(b) Payment Adjustments- CommentsClose CommentsPermalink





(1) FUNDING FOR IMPROVEMENTS- In making any changes to the geographic adjustment factors in accordance with subsection (a), the Secretary shall use funds made available for such purposesThe Secretary shall use funds as provided under subsection (c) in making changes to the geographic adjustment factors pursuant to subsection (a). In making such changes to such geographic adjustment factors, the Secretary shall ensure that the estimated increased expenditures resulting from such changes does not exceed the amounts provided under subsection (c). CommentsClose CommentsPermalink





(2) ENSURING FAIRNESS- In carrying out this subsection, the Secretary shall not change payment rates to be less than they would have been had this section not been enactedreduce the geographic adjustment below the factor that applied for such payment system in the payment year before such changes. CommentsClose CommentsPermalink





(c) Funding- Amounts in the Medicare Improvement Fund under section 1898 of the Social Security Act (42 U.S.C. 1395iii), as amended by section 1146, shall be available to the Secretary to make changes to the geographic adjustments factors established under sections 1848(e) and 1886(d)(3)(E) of the Social Security Act. For such purpose, such funds shall be available for expenditure for services as described in subsections (a) and (b) with respect to services furnished before January1, 2014, and shall not exceed the total amounts available under such Fund for such period. No more than one-half of such amounts shall be available for expenditure for 1, 2014. No more than one-half of such amounts shall be available with respect to services furnished in any one payment year. CommentsClose CommentsPermalink

Subtitle D--Medicare Advantage Reforms CommentsClose CommentsPermalink

PART 1--PAYMENT AND ADMINISTRATION

SEC. 1161. PHASE-IN OF PAYMENT BASED ON FEE-FOR-SERVICE COSTS.

Section 1853 of the Social Security Act (42 U.S.C. 1395w-23) is amended-- CommentsClose CommentsPermalink





(1) in subsection (j)(1)(A)-- CommentsClose CommentsPermalink





(A) by striking ‘beginning with 2007’ and inserting ‘for 2007, 2008, 2009, and 2010’; and CommentsClose CommentsPermalink





(B) by inserting after ‘(k)(1)’ the following: ‘, or, beginning with 2011, 1/12 of the blended benchmark amount determined under subsection (n)(1)’; and CommentsClose CommentsPermalink





(2) by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(n) Determination of Blended Benchmark Amount- CommentsClose CommentsPermalink





‘(1) IN GENERAL- For purposes of subsection (j), subject to paragraphs (3) and (4), the term ‘blended benchmark amount’ means for an area-- CommentsClose CommentsPermalink





‘(A) for 2011 the sum of-- CommentsClose CommentsPermalink





‘(i) 2/3 of the applicable amount (as defined in subsection (k)) for the area and year; and CommentsClose CommentsPermalink





‘(ii) 1/3 of the amount specified in paragraph (2) for the area and year; CommentsClose CommentsPermalink





‘(B) for 2012 the sum of-- CommentsClose CommentsPermalink





‘(i) 1/3 of the applicable amount for the area and year; and CommentsClose CommentsPermalink





‘(ii) 2/3 of the amount specified in paragraph (2) for the area and year; and CommentsClose CommentsPermalink





‘(C) for a subsequent year the amount specified in paragraph (2) for the area and year. CommentsClose CommentsPermalink





‘(2) SPECIFIED AMOUNT- The amount specified in this paragraph for an area and year is the amount specified in subsection (c)(1)(D)(i) for the area and year adjusted (in a manner specified by the Secretary) to take into account the phase-out in the indirect costs of medical education from capitation rates described in subsection (k)(4). CommentsClose CommentsPermalink





‘(3) FEE-FOR-SERVICE PAYMENT FLOOR- In no case shall the blended benchmark amount for an area and year be less than the amount specified in paragraph (2). CommentsClose CommentsPermalink





‘(4) EXCEPTION FOR PACE PLANS- This subsection shall not apply to payments to a PACE program under section 1894.’. CommentsClose CommentsPermalink

SEC. 1162. QUALITY BONUS PAYMENTS.

(a) In General- Section 1853 of the Social Security Act (42 U.S.C. 1395w-23), as amended by section 1161, is amended-- CommentsClose CommentsPermalink





(1) in subsection (j), by inserting ‘subject to subsection (o),’ after ‘For purposes of this part,’; and CommentsClose CommentsPermalink





(2) by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(o) Quality Based Payment Adjustment- CommentsClose CommentsPermalink





‘(1) HIGH QUALITY PLAN ADJUSTMENT- For years beginning with 2011, in the case of a Medicare Advantage plan that is identified (under paragraph (3)(E)(ii)) as a high quality MA plan with respect to the year, the blended benchmark amount under subsection (n)(1) shall be increased-- CommentsClose CommentsPermalink





‘(A) for 2011, by 1.0 percent; CommentsClose CommentsPermalink





‘(B) for 2012, by 2.0 percent; and CommentsClose CommentsPermalink





‘(C) for a subsequent year, by 3.0 percent. CommentsClose CommentsPermalink





‘(2) IMPROVED QUALITY PLAN ADJUSTMENT- For years beginning with 2011, in the case of a Medicare Advantage plan that is identified (under paragraph (3)(E)(iii)) as an improved quality MA plan with respect to the year, blended benchmark amount under subsection (n)(1) shall be increased-- CommentsClose CommentsPermalink





‘(A) for 2011, by 0.33 percent; CommentsClose CommentsPermalink





‘(B) for 2012, by 0.66 percent; and CommentsClose CommentsPermalink





‘(C) for a subsequent year, by 1.0 percent. CommentsClose CommentsPermalink





‘(3) DETERMINATIONS OF QUALITY- CommentsClose CommentsPermalink





‘(A) QUALITY PERFORMANCE- The Secretary shall provide for the computation of a quality performance score for each Medicare Advantage plan to be applied for each year beginning with 2010. CommentsClose CommentsPermalink





‘(B) COMPUTATION OF SCORE- CommentsClose CommentsPermalink





‘(i) FOR YEARS BEFORE 2014- For years before 2014, the quality performance score for a Medicare Advantage plan shall be computed based on a blend (as designated by the Secretary) of the plan’s performance on-- CommentsClose CommentsPermalink





‘(I) HEDIS effectiveness of care quality measures; CommentsClose CommentsPermalink





‘(II) CAHPS quality measures; and CommentsClose CommentsPermalink





‘(III) such other measures of clinical quality as the Secretary may specify. CommentsClose CommentsPermalink





Such measures shall be risk-adjusted as the Secretary deems appropriate. CommentsClose CommentsPermalink





‘(ii) ESTABLISHMENT OF OUTCOME-BASED MEASURES- By not later than for 2013 the Secretary shall implement reporting requirements for quality under this section on measures selected under clause (iii) that reflect the outcomes of care experienced by individuals enrolled in Medicare Advantage plans (in addition to measures described in clause (i)). Such measures may include-- CommentsClose CommentsPermalink





‘(I) measures of rates of admission and readmission to a hospital; CommentsClose CommentsPermalink





‘(II) measures of prevention quality, such as those established by the Agency for Healthcare Research and Quality (that include hospital admission rates for specified conditions); CommentsClose CommentsPermalink





‘(III) measures of patient mortality and morbidity following surgery; CommentsClose CommentsPermalink





‘(IV) measures of health functioning (such as limitations on activities of daily living) and survival for patients with chronic diseases; CommentsClose CommentsPermalink





‘(V) measures of patient safety; and CommentsClose CommentsPermalink





‘(VI) other measure of outcomes and patient quality of life as determined by the Secretary. CommentsClose CommentsPermalink





Such measures shall be risk-adjusted as the Secretary deems appropriate. In determining the quality measures to be used under this clause, the Secretary shall take into consideration the recommendations of the Medicare Payment Advisory Commission in its report to Congress under section 168 of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) and shall provide preference to measures collected on and comparable to measures used in measuring quality under parts A and B. CommentsClose CommentsPermalink





‘(iii) RULES FOR SELECTION OF MEASURES- The Secretary shall select measures for purposes of clause (ii) consistent with the following: CommentsClose CommentsPermalink





‘(I) The Secretary shall provide preference to clinical quality measures that have been endorsed by the entity with a contract with the Secretary under section 1890(a). CommentsClose CommentsPermalink





‘(II) Prior to any measure being selected under this clause, the Secretary shall publish in the Federal Register such measure and provide for a period of public comment on such measure. CommentsClose CommentsPermalink





‘(iv) TRANSITIONAL USE OF BLEND- For payments for 2014 and 2015, the Secretary may compute the quality performance score for a Medicare Advantage plan based on a blend of the measures specified in clause (i) and the measures described in clause (ii) and selected under clause (iii). CommentsClose CommentsPermalink





‘(v) USE OF QUALITY OUTCOMES MEASURES- For payments beginning with 2016, the preponderance of measures used under this paragraph shall be quality outcomes measures described in clause (ii) and selected under clause (iii). CommentsClose CommentsPermalink





‘(C) DATA USED IN COMPUTING SCORE- Such score for application for-- CommentsClose CommentsPermalink





‘(i) payments in 2011 shall be based on quality performance data for plans for 2009; and CommentsClose CommentsPermalink





‘(ii) payments in 2012 and a subsequent year shall be based on quality performance data for plans for the second preceding year. CommentsClose CommentsPermalink





‘(D) REPORTING OF DATA- Each Medicare Advantage organization shall provide for the reporting to the Secretary of quality performance data described in subparagraph (B) (in order to determine a quality performance score under this paragraph) in such time and manner as the Secretary shall specify. CommentsClose CommentsPermalink





‘(E) RANKING OF PLANS- CommentsClose CommentsPermalink





‘(i) INITIAL RANKING- Based on the quality performance score described in subparagraph (B) achieved with respect to a year, the Secretary shall rank plan performance-- CommentsClose CommentsPermalink





‘(I) from highest to lowest based on absolute scores; and CommentsClose CommentsPermalink





‘(II) from highest to lowest based on percentage improvement in the score for the plan from the previous year. CommentsClose CommentsPermalink





A plan which does not report quality performance data under subparagraph (D) shall be counted, for purposes of such ranking, as having the lowest plan performance and lowest percentage improvement. CommentsClose CommentsPermalink





‘(ii) IDENTIFICATION OF HIGH QUALITY PLANS IN TOP QUINTILE BASED ON PROJECTED ENROLLMENT- The Secretary shall, based on the scores for each plan under clause (i)(I) and the Secretary’s projected enrollment for each plan and subject to clause (iv), identify those Medicare Advantage plans with the highest score that, based upon projected enrollment, are projected to include in the aggregate 20 percent of the total projected enrollment for the year. For purposes of this subsection, a plan so identified shall be referred to in this subsection as a ‘high quality MA plan’. CommentsClose CommentsPermalink





‘(iii) IDENTIFICATION OF IMPROVED QUALITY PLANS IN TOP QUINTILE BASED ON PROJECTED ENROLLMENT- The Secretary shall, based on the percentage improvement score for each plan under clause (i)(II) and the Secretary’s projected enrollment for each plan and subject to clause (iv), identify those Medicare Advantage plans with the greatest percentage improvement score that, based upon projected enrollment, are projected to include in the aggregate 20 percent of the total projected enrollment for the year. For purposes of this subsection, a plan so identified that is not a high quality plan for the year shall be referred to in this subsection as an ‘improved quality MA plan’. CommentsClose CommentsPermalink





‘(iv) AUTHORITY TO DISQUALIFY CERTAIN PLANS- In applying clauses (ii) and (iii), the Secretary may determine not to identify a Medicare Advantage plan if the Secretary has identified deficiencies in the plan’s compliance with rules for such plans under this part. CommentsClose CommentsPermalink





‘(F) NOTIFICATION- The Secretary, in the annual announcement required under subsection (b)(1)(B) in 2011 and each succeeding year, shall notify the Medicare Advantage organization that is offering a high quality plan or an improved quality plan of such identification for the year and the quality performance payment adjustment for such plan for the year. The Secretary shall provide for publication on the website for the Medicare program of the information described in the previous sentence.’. CommentsClose CommentsPermalink

SEC. 1163. EXTENSION OF SECRETARIAL CODING INTENSITY ADJUSTMENT AUTHORITY.

Section 1853(a)(1)(C)(ii) of the Social Security Act (42 U.S.C. 1395w-23(a)(1)(C)(ii)) is amended-- CommentsClose CommentsPermalink





(1) in the matter before subclause (I), by striking ‘through 2010’ and inserting ‘and each subsequent year’; and CommentsClose CommentsPermalink





(2) in subclause (II)-- CommentsClose CommentsPermalink





(A) by inserting ‘periodically’ before ‘conduct an analysis’; CommentsClose CommentsPermalink





(B) by inserting ‘on a timely basis’ after ‘are incorporated’; and CommentsClose CommentsPermalink





(C) by striking ‘only for 2008, 2009, and 2010’ and inserting ‘for 2008 and subsequent years’. CommentsClose CommentsPermalink

SEC. 1164. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION PERIODS.

(a) 2 Week Processing Period for Annual Enrollment Period (AEP)- Paragraph (3)(B) of section 1851(e) of the Social Security Act (42 U.S.C. 1395w-21(e)) is amended-- CommentsClose CommentsPermalink





(1) by striking ‘and’ at the end of clause (iii); CommentsClose CommentsPermalink





(2) in clause (iv)-- CommentsClose CommentsPermalink





(A) by striking ‘and succeeding years’ and inserting ‘, 2008, 2009, and 2010’; and CommentsClose CommentsPermalink





(B) by striking the period at the end and inserting ‘; and’; and CommentsClose CommentsPermalink





(3) by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(v) with respect to 2011 and succeeding years, the period beginning on November 1 and ending on December 15 of the year before such year.’. CommentsClose CommentsPermalink





(b) Elimination of 3-month Additional Open Enrollment Period (OEP)- Effective for plan years beginning with 2011, paragraph (2) of such section is amended by striking subparagraph (C). CommentsClose CommentsPermalink

SEC. 1165. EXTENSION OF REASONABLE COST CONTRACTS.

Section 1876(h)(5)(C) of the Social Security Act (42 U.S.C. 1395mm(h)(5)(C)) is amended-- CommentsClose CommentsPermalink





(1) in clause (ii), by striking ‘January 1, 2010’ and inserting ‘January 1, 2012’; and CommentsClose CommentsPermalink





(2) in clause (iii), by striking ‘the service area for the year’ and inserting ‘the portion of the plan’s service area for the year that is within the service area of a reasonable cost reimbursement contract’. CommentsClose CommentsPermalink

SEC. 1166. LIMITATION OF WAIVER AUTHORITY FOR EMPLOYER GROUP PLANS.

(a) In General- The first sentence of paragraph (2) of section 1857(i) of the Social Security Act (42 U.S.C. 1395w-27(i)) is amended by inserting before the period at the end the following: ‘, but only if 90 percent of the Medicare Advantage eligible individuals enrolled under such plan reside in a county in which the MA organization offers an MA local plan’. CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) shall apply for plan years beginning on or after January 1, 2011, and shall not apply to plans which were in effect as of December 31, 2010. CommentsClose CommentsPermalink

SEC. 1167. IMPROVING RISK ADJUSTMENT FOR PAYMENTS.

(a) Report to Congress- Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a report that evaluates the adequacy of the risk adjustment system under section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395-23(a)(1)(C)) in predicting costs for beneficiaries with chronic or co-morbid conditions, beneficiaries dually-eligible for Medicare and Medicaid, and non-Medicaid eligible low-income beneficiaries; and the need and feasibility of including further gradations of diseases or conditions and multiple years of beneficiary data. CommentsClose CommentsPermalink





(b) Improvements to Risk Adjustment- Not later than January 1, 2012, the Secretary shall implement necessary improvements to the risk adjustment system under section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395-23(a)(1)(C)), taking into account the evaluation under subsection (a). CommentsClose CommentsPermalink

SEC. 1168. ELIMINATION OF MA REGIONAL PLAN STABILIZATION FUND.

(a) In General- Section 1858 of the Social Security Act (42 U.S.C. 1395w-27a) is amended by striking subsection (e). CommentsClose CommentsPermalink





(b) Transition- Any amount contained in the MA Regional Plan Stabilization Fund as of the date of the enactment of this Act shall be transferred to the Federal Supplementary Medical Insurance Trust Fund. CommentsClose CommentsPermalink

PART 2--BENEFICIARY PROTECTIONS AND ANTI-FRAUD

SEC. 1171. LIMITATION ON COST-SHARING FOR INDIVIDUAL HEALTH SERVICES.

(a) In General- Section 1852(a)(1) of the Social Security Act (42 U.S.C. 1395w-22(a)(1)) is amended-- CommentsClose CommentsPermalink





(1) in subparagraph (A), by inserting before the period at the end the following: ‘with cost-sharing that is no greater (and may be less) than the cost-sharing that would otherwise be imposed under such program option’; CommentsClose CommentsPermalink





(2) in subparagraph (B)(i), by striking ‘or an actuarially equivalent level of cost-sharing as determined in this part’; and CommentsClose CommentsPermalink





(3) by amending clause (ii) of subparagraph (B) to read as follows: CommentsClose CommentsPermalink





‘(ii) PERMITTING USE OF FLAT COPAYMENT OR PER DIEM RATE- Nothing in clause (i) shall be construed as prohibiting a Medicare Advantage plan from using a flat copayment or per diem rate, in lieu of the cost-sharing that would be imposed under part A or B, so long as the amount of the cost-sharing imposed does not exceed the amount of the cost-sharing that would be imposed under the respective part if the individual were not enrolled in a plan under this part.’. CommentsClose CommentsPermalink





(b) Limitation for Dual Eligibles and Qualified Medicare Beneficiaries- Section 1852(a) of such Act is amended by adding at the end the following new paragraph:‘(7) LIMITATION ON to read as follows: CommentsClose CommentsPermalink





‘(7) LIMITATION ON COST-SHARING FOR DUAL ELIGIBLES AND QUALIFIED MEDICARE BENEFICIARIES- In the case of a individual who is a full-benefit dual eligible individual (as defined in section 1935(c)(6)) or a qualified medicare beneficiary (as defined in section 1905(p)(1)) who is enrolled in a Medicare Advantage plan, the plan may not impose cost-sharing that exceeds the amount of cost-sharing that would be permitted with respect to the individual under this title and title XIX if the individual were not enrolled with such plan.’. CommentsClose CommentsPermalink





(c) Effective Dates- CommentsClose CommentsPermalink





(1) The amendments made by subsection (a) shall apply to plan years beginning on or after January 1, 2011. CommentsClose CommentsPermalink





(2) The amendments made by subsection (b) shall apply to plan years beginning on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 1172. CONTINUOUS OPEN ENROLLMENT FOR ENROLLEES IN PLANS WITH ENROLLMENT SUSPENSION.

Section 1851(e)(4) of the Social Security Act (42 U.S.C. 1395w(e)(4)) is amended-- CommentsClose CommentsPermalink





(1) in subparagraph (C), by striking at the end ‘or’; CommentsClose CommentsPermalink





(2) in subparagraph (D)-- CommentsClose CommentsPermalink





(A) by inserting ‘, taking into account the health or well-being of the individual’ before the period; and CommentsClose CommentsPermalink





(B) by redesignating such subparagraph as subparagraph (E); and CommentsClose CommentsPermalink





(3) by inserting after subparagraph (C) the following new subparagraph: CommentsClose CommentsPermalink





‘(D) the individual is enrolled in an MA plan and enrollment in the plan is suspended under paragraph (2)(B) or (3)(C) of section 1857(g) because of a failure of the plan to meet applicable requirements; or’. CommentsClose CommentsPermalink

SEC. 1173. INFORMATION FOR BENEFICIARIES ON MA PLAN ADMINISTRATIVE COSTS.

(a) Disclosure of Medical Loss Ratios and Other Expense Data- Section 1851 of the Social Security Act (42 U.S.C. 1395w-21), as previously amended by this subtitle, is amended by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(p) Publication of Medical Loss Ratios and Other Cost-related Information- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall publish, not later than November 1 of each year (beginning with 2011), for each MA plan contract, the medical loss ratio of the plan in the previous year. CommentsClose CommentsPermalink





‘(2) SUBMISSION OF DATA- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Each MA organization shall submit to the Secretary, in a form and manner specified by the Secretary, data necessary for the Secretary to publish the medical loss ratio on a timely basis. CommentsClose CommentsPermalink





‘(B) DATA FOR 2010 AND 2011- The data submitted under subparagraph (A) for 2010 and for 2011 shall be consistent in content with the data reported as part of the MA plan bid in June 2009 for 2010. CommentsClose CommentsPermalink





‘(C) USE OF STANDARDIZED ELEMENTS AND DEFINITIONS- The data to be submitted under subparagraph (A) relating to medical loss ratio for a year, beginning with 2012, shall be submitted based on the standardized elements and definitions developed under paragraph (3). CommentsClose CommentsPermalink





‘(3) DEVELOPMENT OF DATA REPORTING STANDARDS- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall develop and implement standardized data elements and definitions for reporting under this subsection, for contract years beginning with 2012, of data necessary for the calculation of the medical loss ratio for MA plans. Not later than December 31, 2010, the Secretary shall publish a report describing the elements and definitions so developed. CommentsClose CommentsPermalink





‘(B) CONSULTATION- The Secretary shall consult with the Health Choices Commissioner, representatives of MA organizations, experts on health plan accounting systems, and representatives of the National Association of Insurance Commissioners, in the development of such data elements and definitions. CommentsClose CommentsPermalink





‘(4) MEDICAL LOSS RATIO TO BE DEFINED- For purposes of this part, the term ‘medical loss ratio’ has the meaning given such term by the Secretary, taking into account the meaning given such term by the Health Choices Commissioner under section 116 of the America’s Affordable Health Choices Act of 2009.’. CommentsClose CommentsPermalink





(b) Minimum Medical Loss Ratio- Section 1857(e) of the Social Security Act (42 U.S.C. 1395w-27(e)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(4) REQUIREMENT FOR MINIMUM MEDICAL LOSS RATIO- If the Secretary determines for a contract year (beginning with 2014) that an MA plan has failed to have a medical loss ratio (as defined in section 1851(p)(4)) of at least .85-- CommentsClose CommentsPermalink





‘(A) the Secretary shall require the Medicare Advantage organization offering the plan to give enrollees a rebate (in the second succeeding contract year) of premiums under this part (or part B or part D, if applicable) by such amount as would provide for a benefits ratio of at least .85; CommentsClose CommentsPermalink





‘(B) for 3 consecutive contract years, the Secretary shall not permit the enrollment of new enrollees under the plan for coverage during the second succeeding contract year; and CommentsClose CommentsPermalink





‘(C) the Secretary shall terminate the plan contract if the plan fails to have such a medical loss ratio for 5 consecutive contract years.’. CommentsClose CommentsPermalink

SEC. 1174. STRENGTHENING AUDIT AUTHORITY.

(a) For Part C Payments Risk Adjustment- Section 1857(d)(1) of the Social Security Act (42 U.S.C. 1395w-27(d)(1)) is amended by inserting after ‘section 1858(c))’ the following: ‘, and data submitted with respect to risk adjustment under section 1853(a)(3)’. CommentsClose CommentsPermalink





(b) Enforcement of Audits and Deficiencies- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1857(e) of such Act, as amended by section 1173, is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(5) ENFORCEMENT OF AUDITS AND DEFICIENCIES- CommentsClose CommentsPermalink





‘(A) INFORMATION IN CONTRACT- The Secretary shall require that each contract with an MA organization under this section shall include terms that inform the organization of the provisions in subsection (d). CommentsClose CommentsPermalink





‘(B) ENFORCEMENT AUTHORITY- The Secretary is authorized, in connection with conducting audits and other activities under subsection (d), to take such actions, including pursuit of financial recoveries, necessary to address deficiencies identified in such audits or other activities.’. CommentsClose CommentsPermalink





(2) APPLICATION UNDER PART D- For provision applying the amendment made by paragraph (1) to prescription drug plans under part D, see section 1860D-12(b)(3)(D) of the Social Security Act. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall take effect on the date of the enactment of this Act and shall apply to audits and activities conducted for contract years beginning on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 1175. AUTHORITY TO DENY PLAN BIDS.

(a) In General- Section 1854(a)(5) of the Social Security Act (42 U.S.C. 1395w-24(a)(5)) is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(C) REJECTION OF BIDS- Nothing in this section shall be construed as requiring the Secretary to accept any or every bid by an MA organization under this subsection.’. CommentsClose CommentsPermalink





(b) Application Under Part D- Section 1860D-11(d) of such Act (42 U.S.C. 1395w-111(d)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(3) REJECTION OF BIDS- Paragraph (5)(C) of section 1854(a) shall apply with respect to bids under this section in the same manner as it applies to bids by an MA organization under such section.’. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall apply to bids for contract years beginning on or after January 1, 2011. CommentsClose CommentsPermalink

PART 3--TREATMENT OF SPECIAL NEEDS PLANS

SEC. 1176. LIMITATION ON ENROLLMENT OUTSIDE OPEN ENROLLMENT PERIOD OF INDIVIDUALS INTO CHRONIC CARE SPECIALIZED MA PLANS FOR SPECIAL NEEDS INDIVIDUALS.

Section 1859(f)(4) of the Social Security Act (42 U.S.C. 1395w-28(f)(4)) is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(C) The plan does not enroll an individual on or after January 1, 2011, other than during an annual, coordinated open enrollment period or when at the time of the diagnosis of the disease or condition that qualifies the individual as an individual described in subsection (b)(6)(B)(iii).’. CommentsClose CommentsPermalink

SEC. 1177. EXTENSION OF AUTHORITY OF SPECIAL NEEDS PLANS TO RESTRICT ENROLLMENT.

(a) In General- Section 1859(f)(1) of the Social Security Act (42 U.S.C. 1395w-28(f)(1)) is amended by striking ‘January 1, 2011’ and inserting ‘January 1, 2013 (or January 1, 2016, in the case of a plan described in section 1177(b)(1) of the America’s Affordable Health Choices Act of 2009)’. CommentsClose CommentsPermalink





(b) Grandfathering of Certain Plans- CommentsClose CommentsPermalink





(1) PLANS DESCRIBED- For purposes of section 1859(f)(1) of the Social Security Act (42 U.S.C. 1395w-28(f)(1)), a plan described in this paragraph is a plan that had a contract with a State that had a State program to operate an integrated Medicaid-Medicare program that had been approved by the Centers for Medicare & Medicaid Services as of January 1, 2004. CommentsClose CommentsPermalink





(2) ANALYSIS; REPORT- The Secretary of Health and Human Services shall provide, through a contract with an independent health services evaluation organization, for an analysis of the plans described in paragraph (1) with regard to the impact of such plans on cost, quality of care, patient satisfaction, and other subjects as specified by the Secretary. Not later than December 31, 2011, the Secretary shall submit to Congress a report on such analysis and shall include in such report such recommendations with regard to the treatment of such plans as the Secretary deems appropriate. CommentsClose CommentsPermalink

Subtitle E--Improvements to Medicare Part D CommentsClose CommentsPermalink

SEC. 1181. ELIMINATION OF COVERAGE GAP.

(a) In General- Section 1860D-2(b) of such Act (42 U.S.C. 1395w-102(b)) is amended-- CommentsClose CommentsPermalink





(1) in paragraph (3)(A), by striking ‘paragraph (4)’ and inserting ‘paragraphs (4) and (7)’; CommentsClose CommentsPermalink





(2) in paragraph (4)(B)(i), by inserting ‘subject to paragraph (7),’ after ‘purposes of this part,’; and CommentsClose CommentsPermalink





(3) by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(7) PHASED-IN ELIMINATION OF COVERAGE GAP- CommentsClose CommentsPermalink





‘(A) IN GENERAL- For each year beginning with 2011, the Secretary shall consistent with this paragraph progressively increase the initial coverage limit (described in subsection (b)(3)) and decrease the annual out-of-pocket threshold from the amounts otherwise computed until there is a continuation of coverage from the initial coverage limit for expenditures incurred through the total amount of expenditures at which benefits are available under paragraph (4). CommentsClose CommentsPermalink





‘(B) INCREASE IN INITIAL COVERAGE LIMIT- For a year beginning with 2011, the initial coverage limit otherwise computed without regard to this paragraph shall be increased by 1/2 of the cumulative phase-in percentage (as defined in subparagraph (D)(ii) for the year) times the out-of-pocket gap amount (as defined in subparagraph (E)) for the year. CommentsClose CommentsPermalink





‘(C) DECREASE IN ANNUAL OUT-OF-POCKET THRESHOLD- For a year beginning with 2011, the annual out-of-pocket threshold otherwise computed without regard to this paragraph shall be decreased by 1/2 of the cumulative phase-in percentage of the out-of-pocket gap amount for the year multiplied by 1.75. CommentsClose CommentsPermalink





‘(D) PHASE-IN- For purposes of this paragraph: CommentsClose CommentsPermalink





‘(i) ANNUAL PHASE-IN PERCENTAGE- The term ‘annual phase-in percentage’ means-- CommentsClose CommentsPermalink





‘(I) for 2011, 13 percent; CommentsClose CommentsPermalink





‘(II) for 2012, 2013, 2014, and 2015, 5 percent; CommentsClose CommentsPermalink





‘(III) for 2016 through 2018, 7.5 percent; and CommentsClose CommentsPermalink





‘(IV) for 2019 and each subsequent year, 10 percent. CommentsClose CommentsPermalink





‘(ii) CUMULATIVE PHASE-IN PERCENTAGE- The term ‘cumulative phase-in percentage’ means for a year the sum of the annual phase-in percentage for the year and the annual phase-in percentages for each previous year beginning with 2011, but in no case more than 100 percent. CommentsClose CommentsPermalink





‘(E) OUT-OF-POCKET GAP AMOUNT- For purposes of this paragraph, the term ‘out-of-pocket gap amount’ means for a year the amount by which-- CommentsClose CommentsPermalink





‘(i) the annual out-of-pocket threshold specified in paragraph (4)(B) for the year (as determined as if this paragraph did not apply), exceeds CommentsClose CommentsPermalink





‘(ii) the sum of-- CommentsClose CommentsPermalink





‘(I) the annual deductible under paragraph (1) for the year; and CommentsClose CommentsPermalink





‘(II) 1/4 of the amount by which the initial coverage limit under paragraph (3) for the year (as determined as if this paragraph did not apply) exceeds such annual deductible.’. CommentsClose CommentsPermalink





(b) Requiring Drug Manufacturers Tto Provide Drug Rebates for Full-Bbenefit Dual Eligibles- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1860D-2 of the Social Security Act (42 U.S.C. 1396r-8) is amended-- CommentsClose CommentsPermalink





(A) in subsection (e)(1), in the matter before subparagraph (A), by inserting ‘and subsection (f)’ after ‘this subsection’; and CommentsClose CommentsPermalink





(B) by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(f) Prescription Drug Rebate Agreement for Full-Bbenefit Dual Eligible Individuals- CommentsClose CommentsPermalink





‘(1) IN GENERAL- In this part, the term ‘covered part D drug’ does not include any drug or biologic that is manufactured by a manufacturer that has not entered into and have in effect a rebate agreement described in paragraph (2). CommentsClose CommentsPermalink





‘(2) REBATE AGREEMENT- A rebate agreement under this subsection shall require the manufacturer to provide to the Secretary a rebate for each rebate period (as defined in paragraph (6)(B)) ending after December 31, 2010, in the amount specified in paragraph (3) for any covered part D drug of the manufacturer dispensed after December 31, 2010, to any full-benefit dual eligible individual (as defined in paragraph (6)(A)) for which payment was made by a PDP sponsor under part D or a MA organization under part C for such period. Such rebate shall be paid by the manufacturer to the Secretary not later than 30 days after the date of receipt of the information described in section 1860D-12(b)(7), including as such section is applied under section 1857(f)(3). CommentsClose CommentsPermalink





‘(3) REBATE FOR FULL-BENEFIT DUAL ELIGIBLE MEDICARE DRUG PLAN ENROLLEES- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The amount of the rebate specified under this paragraph for a manufacturer for a rebate period, with respect to each dosage form and strength of any covered part D drug provided by such manufacturer and dispensed to a full-benefit dual eligible individual, shall be equal to the product of-- CommentsClose CommentsPermalink





‘(i) the total number of units of such dosage form and strength of the drug so provided and dispensed for which payment was made by a PDP sponsor under part D or a MA organization under part C for the rebate period (as reported under section 1860D-12(b)(7), including as such section is applied under section 1857(f)(3)); and CommentsClose CommentsPermalink





‘(ii) the amount (if any) by which-- CommentsClose CommentsPermalink





‘(I) the Medicaid rebate amount (as defined in subparagraph (B)) for such form, strength, and period, exceeds CommentsClose CommentsPermalink





‘(II) the average Medicare drug program full-benefit dual eligible rebate amount (as defined in subparagraph (C)) for such form, strength, and period. CommentsClose CommentsPermalink





‘(B) MEDICAID REBATE AMOUNT- For purposes of this paragraph, the term ‘Medicaid rebate amount’ means, with respect to each dosage form and strength of a covered part D drug provided by the manufacturer for a rebate period-- CommentsClose CommentsPermalink





‘(i) in the case of a single source drug or an innovator multiple source drug, the amount specified in paragraph (1)(A)(ii) of section 1927(bc) plus the amount, if any, specified in paragraph (2)(A)(ii) of such section, for such form, strength, and period; or CommentsClose CommentsPermalink





‘(ii) in the case of any other covered outpatient drug, the amount specified in paragraph (3)(A)(i) of such section for such form, strength, and period. CommentsClose CommentsPermalink





‘(C) AVERAGE MEDICARE DRUG PROGRAM FULL-BENEFIT DUAL ELIGIBLE REBATE AMOUNT- For purposes of this subsection, the term ‘average Medicare drug program full-benefit dual eligible rebate amount’ means, with respect to each dosage form and strength of a covered part D drug provided by a manufacturer for a rebate period, the sum, for all PDP sponsors under part D and MA organizations administering a MA-PD plan under part C, of-- CommentsClose CommentsPermalink





‘(i) the product, for each such sponsor or organization, of-- CommentsClose CommentsPermalink





‘(I) the sum of all rebates, discounts, or other price concessions (not taking into account any rebate provided under paragraph (2) for such dosage form and strength of the drug dispensed, calculated on a per-unit basis, but only to the extent that any such rebate, discount, or other price concession applies equally to drugs dispensed to full-benefit dual eligible Medicare drug plan enrollees and drugs dispensed to PDP and MA-PD enrollees who are not full-benefit dual eligible individuals; and CommentsClose CommentsPermalink





‘(II) the number of the units of such dosage and strength of the drug dispensed during the rebate period to full-benefit dual eligible individuals enrolled in the prescription drug plans administered by the PDP sponsor or the MA-PD plans administered by the MA-PD organization; divided by CommentsClose CommentsPermalink





‘(ii) the total number of units of such dosage and strength of the drug dispensed during the rebate period to full-benefit dual eligible individuals enrolled in all prescription drug plans administered by PDP sponsors and all MA-PD plans administered by MA-PD organizations. CommentsClose CommentsPermalink





‘(4) LENGTH OF AGREEMENT- The provisions of paragraph (4) of section 1927(b) (other than clauses (iv) and (v) of subparagraph (B)) shall apply to rebate agreements under this subsection in the same manner as such paragraph applies to a rebate agreement under such section. CommentsClose CommentsPermalink





‘(5) OTHER TERMS AND CONDITIONS- The Secretary shall establish other terms and conditions of the rebate agreement under this subsection, including terms and conditions related to compliance, that are consistent with this subsection. CommentsClose CommentsPermalink





‘(6) DEFINITIONS- In this subsection and section 1860D-12(b)(7): CommentsClose CommentsPermalink





‘(A) FULL-BENEFIT DUAL ELIGIBLE INDIVIDUAL- The term ‘full-benefit dual eligible individual’ has the meaning given such term in section 1935(c)(6). CommentsClose CommentsPermalink





‘(B) REBATE PERIOD- The term ‘rebate period’ has the meaning given such term in section 1927(k)(8).’. CommentsClose CommentsPermalink





(2) REPORTING REQUIREMENT FOR THE DETERMINATION AND PAYMENT OF REBATES BY MANUFACTURES RELATED TO REBATE FOR FULL-BENEFIT DUAL ELIGIBLE MEDICARE DRUG PLAN ENROLLEES- CommentsClose CommentsPermalink





(A) REQUIREMENTS FOR PDP SPONSORS- Section 1860D-12(b) of the Social Security Act (42 U.S.C. 1395w-112(b)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(7) REPORTING REQUIREMENT FOR THE DETERMINATION AND PAYMENT OF REBATES BY MANUFACTURERS RELATED TO REBATE FOR FULL-BENEFIT DUAL ELIGIBLE MEDICARE DRUG PLAN ENROLLEES- CommentsClose CommentsPermalink





‘(A) IN GENERAL- For purposes of the rebate under section 1860D-2(f) for contract years beginning on or after January 1, 2011, each contract entered into with a PDP sponsor under this part with respect to a prescription drug plan shall require that the sponsor comply with subparagraphs (B) and (C). CommentsClose CommentsPermalink





‘(B) REPORT FORM AND CONTENTS- Not later than 60 days after the end of each rebate period (as defined in section 1860D-2(f)(6)(B)) within such a contract year to which such section applies, a PDP sponsor of a prescription drug plan under this part shall report to each manufacturer-- CommentsClose CommentsPermalink





‘(i) information (by National Drug Code number) on the total number of units of each dosage, form, and strength of each drug of such manufacturer dispensed to full-benefit dual eligible Medicare drug plan enrollees under any prescription drug plan operated by the PDP sponsor during the rebate period; CommentsClose CommentsPermalink





‘(ii) information on the price discounts, price concessions, and rebates for such drugs for such form, strength, and period; CommentsClose CommentsPermalink





‘(iii) information on the extent to which such price discounts, price concessions, and rebates apply equally to full-benefit dual eligible Medicare drug plan enrollees and PDP enrollees who are not full-benefit dual eligible Medicare drug plan enrollees; and CommentsClose CommentsPermalink





‘(iv) any additional information that the Secretary determines is necessary to enable the Secretary to calculate the average Medicare drug program full-benefit dual eligible rebate amount (as defined in paragraph (3)(C) of such section), and to determine the amount of the rebate required under this section, for such form, strength, and period. CommentsClose CommentsPermalink





Such report shall be in a form consistent with a standard reporting format established by the Secretary. CommentsClose CommentsPermalink





‘(C) SUBMISSION TO SECRETARY- Each PDP sponsor shall promptly transmit a copy of the information reported under subparagraph (B) to the Secretary for the purpose of audit oversight and evaluation. CommentsClose CommentsPermalink





‘(D) CONFIDENTIALITY OF INFORMATION- The provisions of subparagraph (D) of section 1927(b)(3), relating to confidentiality of information, shall apply to information reported by PDP sponsors under this paragraph in the same manner that such provisions apply to information disclosed by manufacturers or wholesalers under such section, except-- CommentsClose CommentsPermalink





‘(i) that any reference to ‘this section’ in clause (i) of such subparagraph shall be treated as being a reference to this section; CommentsClose CommentsPermalink





‘(ii) the reference to the Director of the Congressional Budget Office in clause (iii) of such subparagraph shall be treated as including a reference to the Medicare Payment Advisory Commission; and CommentsClose CommentsPermalink





‘(iii) clause (iv) of such subparagraph shall not apply. CommentsClose CommentsPermalink





‘(E) OVERSIGHT- Information reported under this paragraph may be used by the Inspector General of the Department of Health and Human Services for the statutorily authorized purposes of audit, investigation, and evaluations. CommentsClose CommentsPermalink





‘(F) PENALTIES FOR FAILURE TO PROVIDE TIMELY INFORMATION AND PROVISION OF FALSE INFORMATION- In the case of a PDP sponsor-- CommentsClose CommentsPermalink





‘(i) that fails to provide information required under subparagraph (B) on a timely basis, the sponsor is subject to a civil money penalty in the amount of $10,000 for each day in which such information has not been provided; or CommentsClose CommentsPermalink





‘(ii) that knowingly (as defined in section 1128A(i)) provides false information under such subparagraph, the sponsor is subject to a civil money penalty in an amount not to exceed $100,000 for each item of false information. CommentsClose CommentsPermalink





Such civil money penalties are in addition to other penalties as may be prescribed by law. The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under this subparagraph in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).’. CommentsClose CommentsPermalink





(B) APPLICATION TO MA ORGANIZATIONS- Section 1857(f)(3) of the Social Security Act (42 U.S.C. 1395w-27(f)(3)) is amended by adding at the end the following: CommentsClose CommentsPermalink





‘(D) REPORTING REQUIREMENT RELATED TO REBATE FOR FULL-BENEFIT DUAL ELIGIBLE MEDICARE DRUG PLAN ENROLLEES- Section 1860D-12(b)(7).’. CommentsClose CommentsPermalink





(3) DEPOSIT OF REBATES INTO MEDICARE PRESCRIPTION DRUG ACCOUNT- Section 1860D-16(c) of such Act (42 U.S.C. 1395w-116(c)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(6) REBATE FOR FULL-BENEFIT DUAL ELIGIBLE MEDICARE DRUG PLAN ENROLLEES- Amounts paid under a rebate agreement under section 1860D-2(f) shall be deposited into the Account and shall be used to pay for all or part of the gradual elimination of the coverage gap under section 1860D-2(b)(7).’. CommentsClose CommentsPermalink

SEC. 1182. DISCOUNTS FOR CERTAIN PART D DRUGS IN ORIGINAL COVERAGE GAP.

Section 1860D-2 of the Social Security Act (42 U.S.C. 1395w-102), as amended by section 1181(a), is amended-- CommentsClose CommentsPermalink





(1) in subsection (b)(4)(C)(ii), by inserting ‘subject to subsection (g)(2)(C),’ after ‘(ii)’; CommentsClose CommentsPermalink





(2) in subsection (e)(1), in the matter before subparagraph (A), by striking ‘subsection (f)’ and inserting ‘subsections (f) and (g)’ after ‘this subsection’; and CommentsClose CommentsPermalink





(3) by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(g) Requirement for Manufacturer Discount Agreement for Certain Qualifying Drugs- CommentsClose CommentsPermalink





‘(1) IN GENERAL- In this part, the term ‘covered part D drug’ does not include any drug or biologic that is manufactured by a manufacturer that has not entered into and have in effect for all qualifying drugs (as defined in paragraph (5)(A)) a discount agreement described in paragraph (2). CommentsClose CommentsPermalink





‘(2) DISCOUNT AGREEMENT- CommentsClose CommentsPermalink





‘(A) PERIODIC DISCOUNTS- A discount agreement under this paragraph shall require the manufacturer involved to provide, to each PDP sponsor with respect to a prescription drug plan or each MA organization with respect to each MA-PD plan, a discount in an amount specified in paragraph (3) for qualifying drugs (as defined in paragraph (5)(A)) of the manufacturer dispensed to a qualifying enrollee after December 31, 2010, insofar as the individual is in the original gap in coverage (as defined in paragraph (5)(E)). CommentsClose CommentsPermalink





‘(B) DISCOUNT AGREEMENT- Insofar as not inconsistent with this subsection, the Secretary shall establish terms and conditions of such agreement, including terms and conditions relating to compliance, similar to the terms and conditions for rebate agreements under paragraphs (2), (3), and (4) of section 1927(b), except that-- CommentsClose CommentsPermalink





‘(i) discounts shall be applied under this subsection to prescription drug plans and MA-PD plans instead of State plans under title XIX; CommentsClose CommentsPermalink





‘(ii) PDP sponsors and MA organizations shall be responsible, instead of States, for provision of necessary utilization information to drug manufacturers; and CommentsClose CommentsPermalink





‘(iii) sponsors and MA organizations shall be responsible for reporting information on drug-component negotiated price, instead of other manufacturer prices. CommentsClose CommentsPermalink





‘(C) COUNTING DISCOUNT TOWARD TRUE OUT-OF-POCKET COSTS- Under the discount agreement, in applying subsection (b)(4), with regard to subparagraph (C)(i) of such subsection, if a qualified enrollee purchases the qualified drug insofar as the enrollee is in an actual gap of coverage (as defined in paragraph (5)(D)), the amount of the discount under the agreement shall be treated and counted as costs incurred by the plan enrollee. CommentsClose CommentsPermalink





‘(3) DISCOUNT AMOUNT- The amount of the discount specified in this paragraph for a discount period for a plan is equal to 50 percent of the amount of the drug-component negotiated price (as defined in paragraph (5)(C)) for qualifying drugs for the period involved. CommentsClose CommentsPermalink





‘(4) ADDITIONAL TERMS- In the case of a discount provided under this subsection with respect to a prescription drug plan offered by a PDP sponsor or an MA-PD plan offered by an MA organization, if a qualified enrollee purchases the qualified drug-- CommentsClose CommentsPermalink





‘(A) insofar as the enrollee is in an actual gap of coverage (as defined in paragraph (5)(D)), the sponsor or plan shall provide the discount to the enrollee at the time the enrollee pays for the drug; and CommentsClose CommentsPermalink





‘(B) insofar as the enrollee is in the portion of the original gap in coverage (as defined in paragraph (5)(E)) that is not in the actual gap in coverage, the discount shall not be applied against the negotiated price (as defined in subsection (d)(1)(B)) for the purpose of calculating the beneficiary payment. CommentsClose CommentsPermalink





‘(5) DEFINITIONS- In this subsection: CommentsClose CommentsPermalink





‘(A) QUALIFYING DRUG- The term ‘qualifying drug’ means, with respect to a prescription drug plan or MA-PD plan, a drug or biological product that-- CommentsClose CommentsPermalink





‘(i)(I) is a drug produced or distributed under an original new drug application approved by the Food and Drug Administration, including a drug product marketed by any cross-licensed producers or distributors operating under the new drug application; CommentsClose CommentsPermalink





‘(II) is a drug that was originally marketed under an original new drug application approved by the Food and Drug Administration; or CommentsClose CommentsPermalink





‘(III) is a biological product as approved under Ssection 351(a) of the Public Health Services Act; CommentsClose CommentsPermalink





‘(ii) is covered under the formulary of the plan; and CommentsClose CommentsPermalink





‘(iii) is dispensed to an individual who is in the original gap in coverage. CommentsClose CommentsPermalink





‘(B) QUALIFYING ENROLLEE- The term ‘qualifying enrollee’ means an individual enrolled in a prescription drug plan or MA-PD plan other than such an individual who is a subsidy-eligible individual (as defined in section 1860D-14(a)(3)). CommentsClose CommentsPermalink





‘(C) DRUG-COMPONENT NEGOTIATED PRICE- The term ‘drug-component negotiated price’ means, with respect to a qualifying drug, the negotiated price (as defined in subsection (d)(1)(B)), as determined without regard to any dispensing fee, of the drug under the prescription drug plan or MA-PD plan involved. CommentsClose CommentsPermalink





‘(D) ACTUAL GAP IN COVERAGE- The term ‘actual gap in coverage’ means the gap in prescription drug coverage that occurs between the initial coverage limit (as modified under subparagraph (B) of subsection (b)(7)) and the annual out-of-pocket threshold (as modified under subparagraph (C) of such subsection). CommentsClose CommentsPermalink





‘(E) ORIGINAL GAP IN COVERAGE- The term ‘original in gap coverage’ means the gap in prescription drug coverage that would occur between the initial coverage limit (described in subsection (b)(3)) and the annual out-of-pocket threshold (as defined in subsection (b)(4))(B(B)) if subsection (b)(7) did not apply.’. CommentsClose CommentsPermalink

SEC. 1183. REPEAL OF PROVISION RELATING TO SUBMISSION OF CLAIMS BY PHARMACIES LOCATED IN OR CONTRACTING WITH LONG-TERM CARE FACILITIES.

(a) Part D Submission- Section 1860D-12(b) of the Social Security Act (42 U.S.C. 1395w-112(b)), as amended by section 172(a)(1) of Public Law 110-275, is amended by striking paragraph (5) and redesignating paragraph (6) and paragraph (7), as added by section 1181(b)(2), as paragraph (5) and paragraph (6), respectively. CommentsClose CommentsPermalink





(b) Submission to MA-PD Plans- Section 1857(f)(3) of the Social Security Act (42 U.S.C. 1395w-27(f)(3)), as added by section 171(b) of Public Law 110-275 and amended by section 172(a)(2) of such Public Law, is amended by striking subparagraph (B) and redesignating subparagraph and section 1181 of this Act, is amended by striking subparagraph (B) and redesignating subparagraphs (C) as subparagraph (B)nd (D) as subparagraphs (B) and (C), respectively. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall apply for contract years beginning with 2010. CommentsClose CommentsPermalink

SEC. 1184. INCLUDING COSTS INCURRED BY AIDS DRUG ASSISTANCE PROGRAMS AND INDIAN HEALTH SERVICE IN PROVIDING PRESCRIPTION DRUGS TOWARD THE ANNUAL OUT-OF-POCKET THRESHOLD UNDER PART D.

(a) In General- Section 1860D-2(b)(4)(C) of the Social Security Act (42 U.S.C. 1395w-102(b)(4)(C)) is amended-- CommentsClose CommentsPermalink





(1) in clause (i), by striking ‘and’ at the end; CommentsClose CommentsPermalink





(2) in clause (ii)-- CommentsClose CommentsPermalink





(A) by striking ‘such costs shall be treated as incurred only if’ and inserting ‘subject to clause (iii), such costs shall be treated as incurred only if’; CommentsClose CommentsPermalink





(B) by striking ‘, under section 1860D-14, or under a State Pharmaceutical Assistance Program’; and CommentsClose CommentsPermalink





(C) by striking the period at the end and inserting ‘; and’; and CommentsClose CommentsPermalink





(3) by inserting after clause (ii) the following new clause: CommentsClose CommentsPermalink





‘(iii) such costs shall be treated as incurred and shall not be considered to be reimbursed under clause (ii) if such costs are borne or paid-- CommentsClose CommentsPermalink





‘(I) under section 1860D-14; CommentsClose CommentsPermalink





‘(II) under a State Pharmaceutical Assistance Program; CommentsClose CommentsPermalink





‘(III) by the Indian Health Service, an Indian tribe or tribal organization, or an urban Indian organization (as defined in section 4 of the Indian Health Care Improvement Act); or CommentsClose CommentsPermalink





‘(IV) under an AIDS Drug Assistance Program under part B of title XXVI of the Public Health Service Act.’. CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by subsection (a) shall apply to costs incurred on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 1185. PERMITTING MID-YEAR CHANGES IN ENROLLMENT FOR FORMULARY CHANGES THAT ADVERSELY IMPACT AN ENROLLEE.

(a) In General- Section 1860D-1(b)(3) of the Social Security Act (42 U.S.C. 1395w-101(b)(3)) is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(F) CHANGE IN FORMULARY RESULTING IN INCREASE IN COST-SHARING- CommentsClose CommentsPermalink





‘(i) IN GENERAL- Except as provided in clause (ii), in the case of an individual enrolled in a prescription drug plan (or MA-PD plan) who has been prescribed and is using a covered part D drug while so enrolled, if the formulary of the plan is materially changed (other than at the end of a contract year) so to reduce the coverage (or increase the cost-sharing) of the drug under the plan. CommentsClose CommentsPermalink





‘(ii) EXCEPTION- Clause (i) shall not apply in the case that a drug is removed from the formulary of a plan because of a recall or withdrawal of the drug issued by the Food and Drug Administration, because the drug is replaced with a generic drug that is a therapeutic equivalent, or because of utilization management applied to-- CommentsClose CommentsPermalink





‘(I) a drug whose labeling includes a boxed warning required by the Food and Drug Administration under section 210.57(c)(1) of title 21, Code of Federal Regulations (or a successor regulation); or CommentsClose CommentsPermalink





‘(II) a drug required under subsection (c)(2) of section 505-1 of the Federal Food, Drug, and Cosmetic Act to have a Risk Evaluation and Management Strategy that includes elements under subsection (f) of such section.’. CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) shall apply to contract years beginning on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 1186. NEGOTIATION OF LOWER COVERED PART D DRUG PRICES ON BEHALF OF MEDICARE BENEFICIARIES.

Subtitle F--Medicare Rural Access Protections CommentsClose CommentsPermalink

SEC. 1191. TELEHEALTH EXPANSION AND ENHANCEMENTS.(a) .

(a) Additional Telehealth Site- CommentsClose CommentsPermalink





(1) IN GENERAL- Paragraph (4)(C)(ii) of section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) is amended by adding at the end the following new subclause: CommentsClose CommentsPermalink





‘(IX) A renal dialysis facility.’ CommentsClose CommentsPermalink





(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to services furnished on or after January 1, 2011. CommentsClose CommentsPermalink





(b) Telehealth Advisory Committee- CommentsClose CommentsPermalink





(1) ESTABLISHMENT- Section 1868 of the Social Security Act (42 U.S.C. 1395ee) is amended-- CommentsClose CommentsPermalink





(A) in the heading, by adding at the end the following: ‘TELEHEALTH ADVISORY COMMITTEE’; and CommentsClose CommentsPermalink





(B) by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(c) Telehealth Advisory Committee- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall appoint a Telehealth Advisory Committee (in this subsection referred to as the ‘Advisory Committee’) to make recommendations to the Secretary on policies of the Centers for Medicare & Medicaid Services regarding telehealth services as established under section 1834(m), including the appropriate addition or deletion of services (and HCPCS codes) to those specified in paragraphs (4)(F)(i) and (4)(F)(ii) of such section and for authorized payment under paragraph (1) of such section. CommentsClose CommentsPermalink





‘(2) MEMBERSHIP; TERMS- CommentsClose CommentsPermalink





‘(A) MEMBERSHIP- CommentsClose CommentsPermalink





‘(i) IN GENERAL- The Advisory Committee shall be composed of 9 members, to be appointed by the Secretary, of whom-- CommentsClose CommentsPermalink





‘(I) 5 shall be practicing physicians; CommentsClose CommentsPermalink





‘(II) 2 shall be practicing non-physician health care practitioners; and CommentsClose CommentsPermalink





‘(III) 2 shall be administrators of telehealth programs. CommentsClose CommentsPermalink





‘(ii) REQUIREMENTS FOR APPOINTING MEMBERS- In appointing members of the Advisory Committee, the Secretary shall-- CommentsClose CommentsPermalink





‘(I) ensure that each member has prior experience with the practice of telemedicine or telehealth; CommentsClose CommentsPermalink





‘(II) give preference to individuals who are currently providing telemedicine or telehealth services or who are involved in telemedicine or telehealth programs; CommentsClose CommentsPermalink





‘(III) ensure that the membership of the Advisory Committee represents a balance of specialties and geographic regions; and CommentsClose CommentsPermalink





‘(IV) take into account the recommendations of stakeholders. CommentsClose CommentsPermalink





‘(B) TERMS- The members of the Advisory Committee shall serve for such term as the Secretary may specify. CommentsClose CommentsPermalink





‘(C) CONFLICTS OF INTEREST- An advisory committee member may not participate with respect to a particular matter considered in an advisory committee meeting if such member (or an immediate family member of such member) has a financial interest that could be affected by the advice given to the Secretary with respect to such matter. CommentsClose CommentsPermalink





‘(3) MEETINGS- The Advisory Committee shall meet twice each calendar year and at such other times as the Secretary may provide. CommentsClose CommentsPermalink





‘(4) PERMANENT COMMITTEE- Section 14 of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the Advisory Committee.’ CommentsClose CommentsPermalink





(2) FOLLOWING RECOMMENDATIONS- Section 1834(m)(4)(F) of such Act (42 U.S.C. 1395m(m)(4)(F)) is amended by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(iii) RECOMMENDATIONS OF THE TELEHEALTH ADVISORY COMMITTEE- In making determinations under clauses (i) and (ii), the Secretary shall take into account the recommendations of the Telehealth Advisory Committee (established under section 1868(c)) when adding or deleting services (and HCPCS codes) and in establishing policies of the Centers for Medicare & Medicaid Services regarding the delivery of telehealth services. If the Secretary does not implement such a recommendation, the Secretary shall publish in the Federal Register a statement regarding the reason such recommendation was not implemented.’ CommentsClose CommentsPermalink





(3) WAIVER OF ADMINISTRATIVE LIMITATION- The Secretary of Health and Human Services shall establish the Telehealth Advisory Committee under the amendment made by paragraph (1) notwithstanding any limitation that may apply to the number of advisory committees that may be established (within the Department of Health and Human Services or otherwise). CommentsClose CommentsPermalink

SEC. 1192. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION.

Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 1395l(t)(7)(D)(i)) is amended-- CommentsClose CommentsPermalink





(1) in subclause (II)-- CommentsClose CommentsPermalink





(A) in the first sentence, by striking CommentsClose CommentsPermalink

131‘2010’ and inserting ‘2012’; andCommentsClose CommentsPermalink

(B) in the second sentence, by striking ‘or 2009’ and inserting ‘, 2009, 2010, or 2011’; and CommentsClose CommentsPermalink





(2) in subclause (III), by striking ‘January 1, 2010’ and inserting ‘January 1, 2012’. CommentsClose CommentsPermalink

SEC. 1193. EXTENSION OF SECTION 508 HOSPITAL RECLASSIFICATIONS.

Subsection (a) of section 106 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395 note), as amended by section 117 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173) and section 124 of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275), is amended by striking ‘September 30, 2009’ and inserting ‘September 30, 2011’. CommentsClose CommentsPermalink

SEC. 1194. EXTENSION OF GEOGRAPHIC FLOOR FOR WORK.

Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-4(e)(1)(E)) is amended by striking ‘before January 1, 2010’ and inserting ‘before January 1, 2012’. CommentsClose CommentsPermalink

SEC. 1195. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF CERTAIN PHYSICIAN PATHOLOGY SERVICES.

Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (as enacted into law by section 1(a)(6) ofPublic Law 106-554), as amended by section 732 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (42 U.S.C. 1395w-4 note), section 104 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 110-173), and section 136 of the Medicare Improvements for Patients and Providers Act of 1008 (Public Law 110-275), is amended by striking ‘and 2009’ and inserting ‘2009, 2010, and 2011’. CommentsClose CommentsPermalink

SEC. 1196. EXTENSION OF AMBULANCE ADD-ONS.

(a) In General- Section 1834(l)(13) of the Social Security Act (42 U.S.C. 1395m(l)(13)) is amended-- CommentsClose CommentsPermalink





(1) in subparagraph (A)-- CommentsClose CommentsPermalink





(A) in the matter preceding clause (i), by striking ‘before January 1, 2010’ and inserting ‘before January 1, 2012’; and CommentsClose CommentsPermalink





(B) in each of clauses (i) and (ii), by striking ‘before January 1, 2010’ and inserting ‘before January 1, 2012’. CommentsClose CommentsPermalink





(b) Air Ambulance Improvements- Section 146(b)(1) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) is amended by striking ‘ending on December 31, 2009’ and inserting ‘ending on December 31, 2011’. CommentsClose CommentsPermalink

TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS CommentsClose CommentsPermalink

Subtitle A--Improving and Simplifying Financial Assistance for Low Income Medicare Beneficiaries CommentsClose CommentsPermalink

SEC. 1201. IMPROVING ASSETS TESTS FOR MEDICARE SAVINGS PROGRAM AND LOW-INCOME SUBSIDY PROGRAM.

(a) Application of Highest Level Permitted Under LIS to All Subsidy Eligible Individuals- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1860D-14(a)(1) of the Social Security Act (42 U.S.C. 1395w-114(a)(1)) is amended in the matter before subparagraph (A), by inserting ‘(or, beginning with 2012, paragraph (3)(E))’ after ‘paragraph (3)(D)’. CommentsClose CommentsPermalink





(2) ANNUAL INCREASE IN LIS RESOURCE TEST- Section 1860D-14(a)(3)(E)(i) of such Act (42 U.S.C. 1395w-114(a)(3)(E)(i)) is amended-- CommentsClose CommentsPermalink





(A) by striking ‘and’ at the end of subclause (I); CommentsClose CommentsPermalink





(B) in subclause (II), by inserting ‘(before 2012)’ after ‘subsequent year’; CommentsClose CommentsPermalink





(C) by striking the period at the end of subclause (II) and inserting a semicolon; CommentsClose CommentsPermalink





(D) by inserting after subclause (II) the following new subclauses: CommentsClose CommentsPermalink





‘(III) for 2012, $17,000 (or $34,000 in the case of the combined value of the individual’s assets or resources and the assets or resources of the individual’s spouse); and CommentsClose CommentsPermalink





‘(IV) for a subsequent year, the dollar amounts specified in this subclause (or subclause (III)) for the previous year increased by the annual percentage increase in the consumer price index (all items; U.S. city average) as of September of such previous year.’; and CommentsClose CommentsPermalink





(E) in the last sentence, by inserting ‘or (IV)’ after ‘subclause (II)’. CommentsClose CommentsPermalink





(3) APPLICATION OF LIS TEST UNDER MEDICARE SAVINGS PROGRAM- Section 1905(p)(1)(C) of such Act (42 U.S.C. 1396d(p)(1)(C)) is amended-- CommentsClose CommentsPermalink





(A) by striking ‘effective beginning with January 1, 2010’ and inserting ‘effective for the period beginning with January 1, 2010, and ending with December 31, 2011’; and CommentsClose CommentsPermalink





(B) by inserting before the period at the end the following: ‘or, effective beginning with January 1, 2012, whose resources (as so determined) do not exceed the maximum resource level applied for the year under subparagraph (E) of section 1860D-14(a)(3) (determined without regard to the life insurance policy exclusion provided under subparagraph (G) of such section) applicable to an individual or to the individual and the individual’s spouse (as the case may be)’. CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by subsection (a) shall apply to eligibility determinations for income-related subsidies and medicare cost-sharing furnished for periods beginning on or after January 1, 2012. CommentsClose CommentsPermalink

SEC. 1202. ELIMINATION OF PART D COST-SHARING FOR CERTAIN NON-INSTITUTIONALIZED FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS.

(a) In General- Section 1860D-14(a)(1)(D)(i) of the Social Security Act (42 U.S.C. 1395w-114(a)(1)(D)(i)) is amended-- CommentsClose CommentsPermalink





(1) by striking ‘INSTITUTIONALIZED INDIVIDUALS- In’ and inserting ‘ELIMINATION OF COST-SHARING FOR CERTAIN FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS- CommentsClose CommentsPermalink





‘(I) INSTITUTIONALIZED INDIVIDUALS- In’; and CommentsClose CommentsPermalink





(2) by adding at the end the following new subclause: CommentsClose CommentsPermalink





‘(II) CERTAIN OTHER INDIVIDUALS- In the case of an individual who is a full-benefit dual eligible individual and with respect to whom there has been a determination that but for the provision of home and community based care (whether under section 1915, 1932, or under a waiver under section 1115) the individual would require the level of care provided in a hospital or a nursing facility or intermediate care facility for the mentally retarded the cost of which could be reimbursed under the State plan under title XIX, the elimination of any beneficiary coinsurance described in section 1860D-2(b)(2) (for all amounts through the total amount of expenditures at which benefits are available under section 1860D-2(b)(4)).’. CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by subsection (a) shall apply to drugs dispensed on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 1203. ELIMINATING BARRIERS TO ENROLLMENT.

(a) Administrative Verification of Income and Resources Under the Low-income Subsidy Program- CommentsClose CommentsPermalink





(1) IN GENERAL- Clause (iii) of section 1860D-14(a)(3)(E) of the Social Security Act (42 U.S.C. 1395w-114(a)(3)(E)) is amended to read as follows: CommentsClose CommentsPermalink





‘(iii) CERTIFICATION OF INCOME AND RESOURCES- For purposes of applying this section-- CommentsClose CommentsPermalink





‘(I) an individual shall be permitted to apply on the basis of self-certification of income and resources; and CommentsClose CommentsPermalink





‘(II) matters attested to in the application shall be subject to appropriate methods of verification without the need of the individual to provide additional documentation, except in extraordinary situations as determined by the Commissioner.’. CommentsClose CommentsPermalink





(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply beginning January 1, 2010. CommentsClose CommentsPermalink





(b) Disclosures Tto Facilitate Identification of Individuals Likely Tto Be Ineligible for the Low-income Assistance Under the Medicare Prescription Drug Program Tto Assist Social Security Administration’s Outreach to Eligible Individuals- For provision authorizing disclosure of return information to facilitate identification of individuals likely to be ineligible for low-income subsidies under Medicare prescription drug program, see section 1801. CommentsClose CommentsPermalink

SEC. 1204. ENHANCED OVERSIGHT RELATING TO REIMBURSEMENTS FOR RETROACTIVE LOW INCOME SUBSIDY ENROLLMENT.

(a) In General- In the case of a retroactive LIS enrollment beneficiary who is enrolled under a prescription drug plan under part D of title XVIII of the Social Security Act (or an MA-PD plan under part C of such title), the beneficiary (or any eligible third party) is entitled to reimbursement by the plan for covered drug costs incurred by the beneficiary during the retroactive coverage period of the beneficiary in accordance with subsection (b) and in the case of such a beneficiary described in subsection (c)(4)(A)(i), such reimbursement shall be made automatically by the plan upon receipt of appropriate notice the beneficiary is eligible for assistance described in such subsection (c)(4)(A)(i) without further information required to be filed with the plan by the beneficiary. CommentsClose CommentsPermalink





(b) Administrative Requirements Relating to Reimbursements- CommentsClose CommentsPermalink





(1) LINE-ITEM DESCRIPTION- Each reimbursement made by a prescription drug plan or MA-PD plan under subsection (a) shall include a line-item description of the items for which the reimbursement is made. CommentsClose CommentsPermalink





(2) TIMING OF REIMBURSEMENTS- A prescription drug plan or MA-PD plan must make a reimbursement under subsection (a) to a retroactive LIS enrollment beneficiary, with respect to a claim, not later than 45 days after-- CommentsClose CommentsPermalink





(A) in the case of a beneficiary described in subsection (c)(4)(A)(i), the date on which the plan receives notice from the Secretary that the beneficiary is eligible for assistance described in such subsection; or CommentsClose CommentsPermalink





(B) in the case of a beneficiary described in subsection (c)(4)(A)(ii), the date on which the beneficiary files the claim with the plan. CommentsClose CommentsPermalink





(3) REPORTING REQUIREMENT- For each month beginning with January 2011, each prescription drug plan and each MA-PD plan shall report to the Secretary the following: CommentsClose CommentsPermalink





(A) The number of claims the plan has readjudicated during the month due to a beneficiary becoming retroactively eligible for subsidies available under section 1860D-14 of the Social Security Act. CommentsClose CommentsPermalink





(B) The total value of the readjudicated claim amount for the month. CommentsClose CommentsPermalink





(C) The Medicare Health Insurance Claims Number of beneficiaries for whom claims were readjudicated. CommentsClose CommentsPermalink





(D) For the claims described in subparagraphs (A) and (B), an attestation to the Administrator of the Centers for Medicare & Medicaid Services of the total amount of reimbursement the plan has provided to beneficiaries for premiums and cost-sharing that the beneficiary overpaid for which the plan received payment from the Centers for Medicare & Medicaid Services. CommentsClose CommentsPermalink





(c) Definitions- For purposes of this section: CommentsClose CommentsPermalink





(1) COVERED DRUG COSTS- The term ‘covered drug costs’ means, with respect to a retroactive LIS enrollment beneficiary enrolled under a prescription drug plan under part D of title XVIII of the Social Security Act (or an MA-PD plan under part C of such title), the amount by which-- CommentsClose CommentsPermalink





(A) the costs incurred by such beneficiary during the retroactive coverage period of the beneficiary for covered part D drugs, premiums, and cost-sharing under such title; exceeds CommentsClose CommentsPermalink





(B) such costs that would have been incurred by such beneficiary during such period if the beneficiary had been both enrolled in the plan and recognized by such plan as qualified during such period for the low income subsidy under section 1860D-14 of the Social Security Act to which the individual is entitled. CommentsClose CommentsPermalink





(2) ELIGIBLE THIRD PARTY- The term ‘eligible third party’ means, with respect to a retroactive LIS enrollment beneficiary, an organization or other third party that is owed payment on behalf of such beneficiary for covered drug costs incurred by such beneficiary during the retroactive coverage period of such beneficiary. CommentsClose CommentsPermalink





(3) RETROACTIVE COVERAGE PERIOD- The term ‘retroactive coverage period’ means-- CommentsClose CommentsPermalink





(A) with respect to a retroactive LIS enrollment beneficiary described in paragraph (4)(A)(i), the period-- CommentsClose CommentsPermalink





(i) beginning on the effective date of the assistance described in such paragraph for which the individual is eligible; and CommentsClose CommentsPermalink





(ii) ending on the date the plan effectuates the status of such individual as so eligible; and CommentsClose CommentsPermalink





(B) with respect to a retroactive LIS enrollment beneficiary described in paragraph (4)(A)(ii), the period-- CommentsClose CommentsPermalink





(i) beginning on the date the individual is both entitled to benefits under part A, or enrolled under part B, of title XVIII of the Social Security Act and eligible for medical assistance under a State plan under title XIX of such Act; and CommentsClose CommentsPermalink





(ii) ending on the date the plan effectuates the status of such individual as a full-benefit dual eligible individual (as defined in section 1935(c)(6) of such Act). CommentsClose CommentsPermalink





(4) RETROACTIVE LIS ENROLLMENT BENEFICIARY- CommentsClose CommentsPermalink





(A) IN GENERAL- The term ‘retroactive LIS enrollment beneficiary’ means an individual who-- CommentsClose CommentsPermalink





(i) is enrolled in a prescription drug plan under part D of title XVIII of the Social Security Act (or an MA-PD plan under part C of such title) and subsequently becomes eligible as a full-benefit dual eligible individual (as defined in section 1935(c)(6) of such Act), an individual receiving a low-income subsidy under section 1860D-14 of such Act, an individual receiving assistance under the Medicare Savings Program implemented under clauses (i), (iii), and (iv) of section 1902(a)(10)(E) of such Act, or an individual receiving assistance under the supplemental security income program under section 1611 of such Act; or CommentsClose CommentsPermalink





(ii) subject to subparagraph (B)(i), is a full-benefit dual eligible individual (as defined in section 1935(c)(6) of such Act) who is automatically enrolled in such a plan under section 1860D-1(b)(1)(C) of such Act. CommentsClose CommentsPermalink





(B) EXCEPTION FOR BENEFICIARIES ENROLLED IN RFP PLAN- CommentsClose CommentsPermalink





(i) IN GENERAL- In no case shall an individual described in subparagraph (A)(ii) include an individual who is enrolled, pursuant to a RFP contract described in clause (ii), in a prescription drug plan offered by the sponsor of such plan awarded such contract. CommentsClose CommentsPermalink





(ii) RFP CONTRACT DESCRIBED- The RFP contract described in this section is a contract entered into between the Secretary and a sponsor of a prescription drug plan pursuant to the Centers for Medicare & Medicaid Services’ request for proposals issued on February 17, 2009, relating to Medicare part D retroactive coverage for certain low income beneficiaries, or a similar subsequent request for proposals. CommentsClose CommentsPermalink

SEC. 1205. INTELLIGENT ASSIGNMENT IN ENROLLMENT.

(a) In General- Section 1860D-1(b)(1)(C) of the Social Security Act (42 U.S.C. 1395w-101(b)(1)(C)) is amended by adding after ‘PDP region’ the following: ‘or through use of an intelligent assignment process that is designed to maximize the access of such individual to necessary prescription drugs while minimizing costs to such individual and to the program under this part to the greatest extent possible. In the case the Secretary enrolls such individuals through use of an intelligent assignment process, such process shall take into account the extent to which prescription drugs necessary for the individual are covered in the case of a PDP sponsor of a prescription drug plan that uses a formulary, the use of prior authorization or other restrictions on access to coverage of such prescription drugs by such a sponsor, and the overall quality of a prescription drug plan as measured by quality ratings established by the Secretary.’ CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) shall take effect for contract years beginning with 2012. CommentsClose CommentsPermalink

SEC. 1206. SPECIAL ENROLLMENT PERIOD AND AUTOMATIC ENROLLMENT PROCESS FOR CERTAIN SUBSIDY ELIGIBLE INDIVIDUALS.

(a) Special Enrollment Period- Section 1860D-1(b)(3)(D) of the Social Security Act (42 U.S.C. 1395w-101(b)(3)(D)) is amended to read as follows: CommentsClose CommentsPermalink





‘(D) SUBSIDY ELIGIBLE INDIVIDUALS- In the case of an individual (as determined by the Secretary) who is determined under subparagraph (B) of section 1860D-14(a)(3) to be a subsidy eligible individual.’. CommentsClose CommentsPermalink





(b) Automatic Enrollment- Section 1860D-1(b)(1) of the Social Security Act (42 U.S.C. 1395w-101(b)(1)) is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(D) SPECIAL RULE FOR SUBSIDY ELIGIBLE INDIVIDUALS- The process established under subparagraph (A) shall include, in the case of an individual described in section 1860D-1(b)(3)(D) who fails to enroll in a prescription paragraph (3)(D) who fails to enroll in a prescription drug plan or an MA-PD plan during the special enrollment established under such section applicable to such individual, the application of the assignment process described in subparagraph (C) to such individual in the same manner as such assignment process applies to a part D eligible individual described in such subparagraph (C). Nothing in the previous sentence shall prevent an individual described in such sentence from declining enrollment in a plan determined appropriate by the Secretary (or in the program under this part) or from changing such enrollment.’. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall apply to subsidy determinations made for months beginning with January 2011. CommentsClose CommentsPermalink

SEC. 1207. APPLICATION OF MA PREMIUMS PRIOR TO REBATE IN CALCULATION OF LOW INCOME SUBSIDY BENCHMARK.

(a) In General- Section 1860D-14(b)(2)(B)(iii) of the Social Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) is amended by inserting before the period the following: ‘before the application of the monthly rebate computed under section 1854(b)(1)(C)(i) for that plan and year involved’. CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) shall apply to subsidy determinations made for months beginning with January 2011. CommentsClose CommentsPermalink

Subtitle B--Reducing Health Disparities CommentsClose CommentsPermalink

SEC. 1221. ENSURING EFFECTIVE COMMUNICATION IN MEDICARE.

(a) Ensuring Effective Communication by the Centers for Medicare & Medicaid Services- CommentsClose CommentsPermalink





(1) STUDY ON MEDICARE PAYMENTS FOR LANGUAGE SERVICES- The Secretary of Health and Human Services shall conduct a study that examines the extent to which Medicare service providers utilize, offer, or make available language services for beneficiaries who are limited English proficient and ways that Medicare should develop payment systems for language services. CommentsClose CommentsPermalink





(2) ANALYSES- The study shall include an analysis of each of the following: CommentsClose CommentsPermalink





(A) How to develop and structure appropriate payment systems for language services for all Medicare service providers. CommentsClose CommentsPermalink





(B) The feasibility of adopting a payment methodology for on-site interpreters, including interpreters who work as independent contractors and interpreters who work for agencies that provide on-site interpretation, pursuant to which such interpreters could directly bill Medicare for services provided in support of physician office services for an LEP Medicare patient. CommentsClose CommentsPermalink





(C) The feasibility of Medicare contracting directly with agencies that provide off-site interpretation including telephonic and video interpretation pursuant to which such contractors could directly bill Medicare for the services provided in support of physician office services for an LEP Medicare patient. CommentsClose CommentsPermalink





(D) The feasibility of modifying the existing Medicare resource-based relative value scale (RBRVS) by using adjustments (such as multipliers or add-ons) when a patient is LEP. CommentsClose CommentsPermalink





(E) How each of options described in a previous paragraph would be funded and how such funding would affect physician payments, a physician’s practice, and beneficiary cost-sharing. CommentsClose CommentsPermalink





(F) The extent to which providers under parts A and B of title XVIII of the Social Security Act, MA organizations offering Medicare Advantage plans under part C of such title and PDP sponsors of a prescription drug plan under part D of such title utilize, offer, or make available language services for beneficiaries with limited English proficiency. CommentsClose CommentsPermalink





(G) The nature and type of language services provided by States under title XIX of the Social Security Act and the extent to which such services could be utilized by beneficiaries and providers under title XVIII of such Act. CommentsClose CommentsPermalink





(3) VARIATION IN PAYMENT SYSTEM DESCRIBED- The payment systems described in paragraph (2)(A) may allow variations based upon types of service providers, available delivery methods, and costs for providing language services including such factors as-- CommentsClose CommentsPermalink





(A) the type of language services provided (such as provision of health care or health care related services directly in a non-English language by a bilingual provider or use of an interpreter); CommentsClose CommentsPermalink





(B) type of interpretation services provided (such as in-person, telephonic, video interpretation); CommentsClose CommentsPermalink





(C) the methods and costs of providing language services (including the costs of providing language services with internal staff or through contract with external independent contractors or agencies, or both); CommentsClose CommentsPermalink





(D) providing services for languages not frequently encountered in the United States; and CommentsClose CommentsPermalink





(E) providing services in rural areas. CommentsClose CommentsPermalink





(4) REPORT- The Secretary shall submit a report on the study conducted under subsection (a) to appropriate committees of Congress not later than 12 months after the date of the enactment of this Act. CommentsClose CommentsPermalink





(5) EXEMPTION FROM PAPERWORK REDUCTION ACT- Chapter 35 of title 44, United States Code (commonly known as the ‘Paperwork Reduction Act’ ), shall not apply for purposes of carrying out this subsection. CommentsClose CommentsPermalink





(6) AUTHORIZATION OF APPROPRIATIONS- There is authorized to be appropriated to carry out this subsection such sums as are necessary. CommentsClose CommentsPermalink





(b) Health Plans- Section 1857(g)(1) of the Social Security Act (42 U.S.C. 1395w-27(g)(1)) is amended-- CommentsClose CommentsPermalink





(1) by striking ‘or’ at the end of subparagraph (F); CommentsClose CommentsPermalink





(2) by adding ‘or’ at the end of subparagraph (G); and CommentsClose CommentsPermalink





(3) by inserting after subparagraph (G) the following new subparagraph: CommentsClose CommentsPermalink





‘(H) fails substantially to provide language services to limited English proficient beneficiaries enrolled in the plan that are required under law;’. CommentsClose CommentsPermalink

SEC. 1222. DEMONSTRATION TO PROMOTE ACCESS FOR MEDICARE BENEFICIARIES WITH LIMITED -ENGLISH PROFICIENCY BY PROVIDING REIMBURSEMENT FOR CULTURALLY AND LINGUISTICALLY APPROPRIATE SERVICES.

(a) In General- Not later than 6 months after the date of the completion of the study described in section 1221(a), the Secretary, acting through the Centers for Medicare & Medicaid Services and the Center for Medicare and Medicaid Payment Innovation established under section 1115A of the Social Security Act (as added by section 1910) and consistent with the applicable provisions of such section, shall carry out a demonstration program under which the Secretary shall award not fewer than 24 3-year grants to eligible Medicare service providers (as described in subsection (b)(1)) to improve effective communication between such providers and Medicare beneficiaries who are living in communities where racial and ethnic minorities, including populations that face language barriers, are underserved with respect to such services. In designing and carrying out the demonstration the Secretary shall take into consideration the results of the study conducted under section 1221(a) and adjust, as appropriate, the distribution of grants so as to better target Medicare beneficiaries who are in the greatest need of language services. The Secretary shall not authorize a grant larger than $500,000 over three years for any grantee. CommentsClose CommentsPermalink





(b) Eligibility; Priority- CommentsClose CommentsPermalink





(1) ELIGIBILITY- To be eligible to receive a grant under subsection (a) an entity shall-- CommentsClose CommentsPermalink





(A) be-- CommentsClose CommentsPermalink





(i) a provider of services under part A of title XVIII of the Social Security Act; CommentsClose CommentsPermalink





(ii) a service provider under part B of such title; CommentsClose CommentsPermalink





(iii) a part C organization offering a Medicare part C plan under part C of such title; or CommentsClose CommentsPermalink





(iv) a PDP sponsor of a prescription drug plan under part D of such title; and CommentsClose CommentsPermalink





(B) prepare and submit to the Secretary an application, at such time, in such manner, and accompanied by such additional information as the Secretary may require. CommentsClose CommentsPermalink





(2) PRIORITY- CommentsClose CommentsPermalink





(A) DISTRIBUTION- To the extent feasible, in awarding grants under this section, the Secretary shall award-- CommentsClose CommentsPermalink





(i) at least 6 grants to providers of services described in paragraph (1)(A)(i); CommentsClose CommentsPermalink





(ii) at least 6 grants to service providers described in paragraph (1)(A)(ii); CommentsClose CommentsPermalink





(iii) at least 6 grants to organizations described in paragraph (1)(A)(iii); and CommentsClose CommentsPermalink





(iv) at least 6 grants to sponsors described in paragraph (1)(A)(iv). CommentsClose CommentsPermalink





(B) FOR COMMUNITY ORGANIZATIONS- The Secretary shall give priority to applicants that have developed partnerships with community organizations or with agencies with experience in language access. CommentsClose CommentsPermalink





(C) VARIATION IN GRANTEES- The Secretary shall also ensure that the grantees under this section represent, among other factors, variations in-- CommentsClose CommentsPermalink





(i) different types of language services provided and of service providers and organizations under parts A through D of title XVIII of the Social Security Act; CommentsClose CommentsPermalink





(ii) languages needed and their frequency of use; CommentsClose CommentsPermalink





(iii) urban and rural settings; CommentsClose CommentsPermalink





(iv) at least two geographic regions, as defined by the Secretary; and CommentsClose CommentsPermalink





(v) at least two large metropolitan statistical areas with diverse populations. CommentsClose CommentsPermalink





(c) Use of Funds- CommentsClose CommentsPermalink





(1) IN GENERAL- A grantee shall use grant funds received under this section to pay for the provision of competent language services to Medicare beneficiaries who are limited -English proficient. Competent interpreter services may be provided through on-site interpretation, telephonic interpretation, or video interpretation or direct provision of health care or health care related services by a bilingual health care provider. A grantee may use bilingual providers, staff, or contract interpreters. A grantee may use grant funds to pay for competent translation services. A grantee may use up to 10 percent of the grant funds to pay for administrative costs associated with the provision of competent language services and for reporting required under subsection (e). CommentsClose CommentsPermalink





(2) ORGANIZATIONS- Grantees that are part C organizations or PDP sponsors must ensure that their network providers receive at least 50 percent of the grant funds to pay for the provision of competent language services to Medicare beneficiaries who are limited -English proficient, including physicians and pharmacies. CommentsClose CommentsPermalink





(3) DETERMINATION OF PAYMENTS FOR LANGUAGE SERVICES- Payments to grantees shall be calculated based on the estimated numbers of limited English-English proficient Medicare beneficiaries in a grantee’s service area utilizing-- CommentsClose CommentsPermalink





(A) data on the numbers of limited English-English proficient individuals who speak English less than ‘very well’ from the most recently available data from the Bureau of the Census or other State-based study the Secretary determines likely to yield accurate data regarding the number of such individuals served by the grantee; or CommentsClose CommentsPermalink





(B) the grantee’s own data if the grantee routinely collects data on Medicare beneficiaries’ primary language in a manner determined by the Secretary to yield accurate data and such data shows greater numbers of limited English-English proficient individuals than the data listed in subparagraph (A). CommentsClose CommentsPermalink





(4) LIMITATIONS- CommentsClose CommentsPermalink





(A) REPORTING- Payments shall only be provided under this section to grantees that report their costs of providing language services as required under subsection (e) and may be modified annually at the discretion of the Secretary. If a grantee fails to provide the reports under such section for the first year of a grant, the Secretary may terminate the grant and solicit applications from new grantees to participate in the subsequent two years of the demonstration program. CommentsClose CommentsPermalink





(B) TYPE OF SERVICES- CommentsClose CommentsPermalink





(i) IN GENERAL- Subject to clause (ii), payments shall be provided under this section only to grantees that utilize competent bilingual staff or competent interpreter or translation services which-- CommentsClose CommentsPermalink





(I) if the grantee operates in a State that has statewide health care interpreter standards, meet the State standards currently in effect; or CommentsClose CommentsPermalink





(II) if the grantee operates in a State that does not have statewide health care interpreter standards, utilizes competent interpreters who follow the National Council on Interpreting in Health Care’s Code of Ethics and Standards of Practice. CommentsClose CommentsPermalink





(ii) EXEMPTIONS- The requirements of clause (i) shall not apply-- CommentsClose CommentsPermalink





(I) in the case of a Medicare beneficiary who is limited -English proficient (who has been informed in the beneficiary’s primary language of the availability of free interpreter and translation services) and who requests the use of family, friends, or other persons untrained in interpretation or translation and the grantee documents the request in the beneficiary’s record; and CommentsClose CommentsPermalink





(II) in the case of a medical emergency where the delay directly associated with obtaining a competent interpreter or translation services would jeopardize the health of the patient. CommentsClose CommentsPermalink





Nothing in clause (ii)(II) shall be construed to exempt emergency rooms or similar entities that regularly provide health care services in medical emergencies from having in place systems to provide competent interpreter and translation services without undue delay. CommentsClose CommentsPermalink





(d) Assurances- Grantees under this section shall-- CommentsClose CommentsPermalink





(1) ensure that appropriate clinical and support staff receive ongoing education and training in linguistically appropriate service delivery; CommentsClose CommentsPermalink





(2) ensure the linguistic competence of bilingual providers; CommentsClose CommentsPermalink





(3) offer and provide appropriate language services at no additional charge to each patient with limited -English proficiency at all points of contact, in a timely manner during all hours of operation; CommentsClose CommentsPermalink





(4) notify Medicare beneficiaries of their right to receive language services in their primary language; CommentsClose CommentsPermalink





(5) post signage in the languages of the commonly encountered group or groups present in the service area of the organization; and CommentsClose CommentsPermalink





(6) ensure that-- CommentsClose CommentsPermalink





(A) primary language data are collected for recipients of language services; and CommentsClose CommentsPermalink





(B) consistent with the privacy protections provided under the regulations promulgated pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d-2 note), if the recipient of language services is a minor or is incapacitated, the primary language of the parent or legal guardian is collected and utilized. CommentsClose CommentsPermalink





(e) Reporting Requirements- Grantees under this section shall provide the Secretary with reports at the conclusion of the each year of a grant under this section. Each report shall include at least the following information: CommentsClose CommentsPermalink





(1) The number of Medicare beneficiaries to whom language services are provided. CommentsClose CommentsPermalink





(2) The languages of those Medicare beneficiaries. CommentsClose CommentsPermalink





(3) The types of language services provided (such as provision of services directly in non-English language by a bilingual health care provider or use of an interpreter). CommentsClose CommentsPermalink





(4) Type of interpretation (such as in-person, telephonic, or video interpretation). CommentsClose CommentsPermalink





(5) The methods of providing language services (such as staff or contract with external independent contractors or agencies). CommentsClose CommentsPermalink





(6) The length of time for each interpretation encounter. CommentsClose CommentsPermalink





(7) The costs of providing language services (which may be actual or estimated, as determined by the Secretary). CommentsClose CommentsPermalink





(f) No Cost Sharing- Limited -English proficient Medicare beneficiaries shall not have to pay cost-sharing or co-pays for language services provided through this demonstration program. CommentsClose CommentsPermalink





(g) Evaluation and Report- The Secretary shall conduct an evaluation of the demonstration program under this section and shall submit to the appropriate committees of Congress a report not later than 1 year after the completion of the program. The report shall include the following: CommentsClose CommentsPermalink





(1) An analysis of the patient outcomes and costs of furnishing care to the limited -English proficient Medicare beneficiaries participating in the project as compared to such outcomes and costs for limited-English proficient Medicare beneficiaries not participating. CommentsClose CommentsPermalink





(2) The effect of delivering culturally and linguistically appropriate services on beneficiary access to care, utilization of services, efficiency and cost-effectiveness of health care delivery, patient satisfaction, and select health outcomes. CommentsClose CommentsPermalink





(3) Recommendations, if any, regarding the extension of such project to the entire Medicare program. CommentsClose CommentsPermalink





(h) General Provisions- Nothing in this section shall be construed to limit otherwise existing obligations of recipients of Federal financial assistance under title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000(d) et seq.) or any other statute. CommentsClose CommentsPermalink





(i) Authorization of Appropriations- There are authorized to be appropriated to carry out this section $16,000,000 for each fiscal year of the demonstration program. CommentsClose CommentsPermalink

SEC. 1223. IOM REPORT ON IMPACT OF LANGUAGE ACCESS SERVICES.

(a) In General- The Secretary of Health and Human Services shall enter into an arrangement with the Institute of Medicine under which the Institute will prepare and publish, not later than 3 years after the date of the enactment of this Act, a report on the impact of language access services on the health and health care of limited English-English proficient populations. CommentsClose CommentsPermalink





(b) Contents- Such report shall include-- CommentsClose CommentsPermalink





(1) recommendations on the development and implementation of policies and practices by health care organizations and providers for limited -English proficient patient populations; CommentsClose CommentsPermalink





(2) a description of the effect of providing language access services on quality of health care and access to care and reduced medical error; and CommentsClose CommentsPermalink





(3) a description of the costs associated with or savings related to provision of language access services. CommentsClose CommentsPermalink

SEC. 1224. DEFINITIONS.

In this subtitle: CommentsClose CommentsPermalink





(1) BILINGUAL- The term ‘bilingual’ with respect to an individual means a person who has sufficient degree of proficiency in two languages and can ensure effective communication can occur in both languages. CommentsClose CommentsPermalink





(2) COMPETENT INTERPRETER SERVICES- The term ‘competent interpreter services’ means a trans-language rendition of a spoken message in which the interpreter comprehends the source language and can speak comprehensively in the target language to convey the meaning intended in the source language. The interpreter knows health and health-related terminology and provides accurate interpretations by choosing equivalent expressions that convey the best matching and meaning to the source language and captures, to the greatest possible extent, all nuances intended in the source message. CommentsClose CommentsPermalink





(3) COMPETENT TRANSLATION SERVICES- The term ‘competent translation services’ means a trans-language rendition of a written document in which the translator comprehends the source language and can write comprehensively in the target language to convey the meaning intended in the source language. The translator knows health and health-related terminology and provides accurate translations by choosing equivalent expressions that convey the best matching and meaning to the source language and captures, to the greatest possible extent, all nuances intended in the source document. CommentsClose CommentsPermalink





(4) EFFECTIVE COMMUNICATION- The term ‘effective communication’ means an exchange of information between the provider of health care or health care-related services and the limited -English proficient recipient of such services that enables limited -English proficient individuals to access, understand, and benefit from health care or health care-related services. CommentsClose CommentsPermalink





(5) INTERPRETING/INTERPRETATION- The terms ‘interpreting’ and ‘interpretation’ mean the transmission of a spoken message from one language into another, faithfully, accurately, and objectively. CommentsClose CommentsPermalink





(6) HEALTH CARE SERVICES- The term ‘health care services’ means services that address physical as well as mental health conditions in all care settings. CommentsClose CommentsPermalink





(7) HEALTH CARE-RELATED SERVICES- The term ‘health care-related services’ means human or social services programs or activities that provide access, referrals or links to health care. CommentsClose CommentsPermalink





(8) LANGUAGE ACCESS- The term ‘language access’ means the provision of language services to an LEP individual designed to enhance that individual’s access to, understanding of or benefit from health care or health care-related services. CommentsClose CommentsPermalink





(9) LANGUAGE SERVICES- The term ‘language services’ means provision of health care services directly in a non-English language, interpretation, translation, and non-English signage. CommentsClose CommentsPermalink





(10) LIMITED -ENGLISH PROFICIENT- The term ‘limited -English proficient’ or ‘LEP’ with respect to an individual means an individual who speaks a primary language other than English and who cannot speak, read, write or understand the English language at a level that permits the individual to effectively communicate with clinical or nonclinical staff at an entity providing health care or health care related services. CommentsClose CommentsPermalink





(11) MEDICARE BENEFICIARY- The term ‘Medicare beneficiary’ means an individual entitled to benefits under part A of title XVIII of the Social Security Act or enrolled under part B of such title. CommentsClose CommentsPermalink





(12) MEDICARE PROGRAM- The term ‘Medicare program’ means the programs under parts A through D of title XVIII of the Social Security Act. CommentsClose CommentsPermalink





(13) SERVICE PROVIDER- The term ‘service provider’ includes all suppliers, providers of services, or entities under contract to provide coverage, items or services under any part of title XVIII of the Social Security Act. CommentsClose CommentsPermalink

Subtitle C--Miscellaneous Improvements CommentsClose CommentsPermalink

SEC. 1231. EXTENSION OF THERAPY CAPS EXCEPTIONS PROCESS.

Section 1833(g)(5) of the Social Security Act (42 U.S.C. 1395l(g)(5)), as amended by section 141 of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275), is amended by striking ‘December 31, 2009’ and inserting ‘December 31, 2011’. CommentsClose CommentsPermalink

SEC. 1232. EXTENDED MONTHS OF COVERAGE OF IMMUNOSUPPRESSIVE DRUGS FOR KIDNEY TRANSPLANT PATIENTS AND OTHER RENAL DIALYSIS PROVISIONS.

(a) Provision of Appropriate Coverage of Immunosuppressive Drugs Under the Medicare Program for Kidney Transplant Recipients- CommentsClose CommentsPermalink





(1) CONTINUED ENTITLEMENT TO IMMUNOSUPPRESSIVE DRUGS- CommentsClose CommentsPermalink





(A) KIDNEY TRANSPLANT RECIPIENTS- Section 226A(b)(2) of the Social Security Act (42 U.S.C. 426-1(b)(2)) is amended by inserting ‘(except for coverage of immunosuppressive drugs under section 1861(s)(2)(J))’ before ‘, with the thirty-sixth month’. CommentsClose CommentsPermalink





(B) APPLICATION- Section 1836 of such Act (42 U.S.C. 1395o) is amended-- CommentsClose CommentsPermalink





(i) by striking ‘Every individual who’ and inserting ‘(a) IN GENERAL- Every individual who’; and CommentsClose CommentsPermalink





(ii) by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(b) Special Rules Applicable to Individuals Only Eligible for Coverage of Immunosuppressive Drugs- CommentsClose CommentsPermalink





‘(1) IN GENERAL- In the case of an individual whose eligibility for benefits under this title has ended on or after January 1, 2012, except for the coverage of immunosuppressive drugs by reason of section 226A(b)(2), the following rules shall apply: CommentsClose CommentsPermalink





‘(A) The individual shall be deemed to be enrolled under this part for purposes of receiving coverage of such drugs. CommentsClose CommentsPermalink





‘(B) The individual shall be responsible for providing for payment of the portion of the premium under section 1839 which is not covered under the Medicare savings program (as defined in section 1144(c)(7)) in order to receive such coverage. CommentsClose CommentsPermalink





‘(C) The provision of such drugs shall be subject to the application of-- CommentsClose CommentsPermalink





‘(i) the deductible under section 1833(b); and CommentsClose CommentsPermalink





‘(ii) the coinsurance amount applicable for such drugs (as determined under this part). CommentsClose CommentsPermalink





‘(D) If the individual is an inpatient of a hospital or other entity, the individual is entitled to receive coverage of such drugs under this part. CommentsClose CommentsPermalink





‘(2) ESTABLISHMENT OF PROCEDURES IN ORDER TO IMPLEMENT COVERAGE- The Secretary shall establish procedures for-- CommentsClose CommentsPermalink





‘(A) identifying individuals that are entitled to coverage of immunosuppressive drugs by reason of section 226A(b)(2); and CommentsClose CommentsPermalink





‘(B) distinguishing such individuals from individuals that are enrolled under this part for the complete package of benefits under this part.’. CommentsClose CommentsPermalink





(C) TECHNICAL AMENDMENT TO CORRECT DUPLICATE SUBSECTION DESIGNATION- Subsection (dc) of section 226A of such Act (42 U.S.C. 426-1), as added by section 201(a)(3)(D)(ii) of the Social Security Independence and Program Improvements Act of 1994 (Public Law 103-296; 108 Stat. 1497), is redesignated as subsection (d). CommentsClose CommentsPermalink





(2) EXTENSION OF SECONDARY PAYER REQUIREMENTS FOR ESRD BENEFICIARIES- Section 1862(b)(1)(C) of such Act (42 U.S.C. 1395y(b)(1)(C)) is amended by adding at the end the following new sentence: ‘With regard to immunosuppressive drugs furnished on or after the date of the enactment of the America’s Affordable Health Choices Act of 2009, this subparagraph shall be applied without regard to any time limitation.’. CommentsClose CommentsPermalink





(b) Medicare Coverage for ESRD Patients- Section 1881 of such Act is further amended-- CommentsClose CommentsPermalink





(1) in subsection (b)(14)(B)(iii), by inserting ‘, including oral drugs that are not the oral equivalent of an intravenous drug (such as oral phosphate binders and calcimimetics),’ after ‘other drugs and biologicals’; CommentsClose CommentsPermalink





(2) in subsection (b)(14)(E)(ii)-- CommentsClose CommentsPermalink





(A) in the first sentence-- CommentsClose CommentsPermalink





(i) by striking ‘a one-time election to be excluded from the phase-in’ and inserting ‘an election, with respect to 2011, 2012, or 2013, to be excluded from the phase-in (or the remainder of the phase-in)’; and CommentsClose CommentsPermalink





(ii) by adding at the end the following: before the period at the end the following: ‘for such year and for each subsequent year during the phase-in described in clause (i)’; and CommentsClose CommentsPermalink





(B) in the second sentence-- CommentsClose CommentsPermalink





(i) by striking ‘January 1, 2011’ and inserting ‘the first date of such year’; and CommentsClose CommentsPermalink





(ii) by inserting ‘and at a time’ after ‘form and manner’; and CommentsClose CommentsPermalink





(3) in subsection (h)(4)(E), by striking ‘lesser’ and inserting ‘greater’. CommentsClose CommentsPermalink

SEC. 1233. ADVANCE CARE PLANNING CONSULTATION.

(a) Medicare- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended-- CommentsClose CommentsPermalink





(A) in subsection (s)(2)-- CommentsClose CommentsPermalink





(i) by striking ‘and’ at the end of subparagraph (DD); CommentsClose CommentsPermalink





(ii) by adding ‘and’ at the end of subparagraph (EE); and CommentsClose CommentsPermalink





(iii) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(FF) advance care planning consultation (as defined in subsection (hhh)(1));’; and CommentsClose CommentsPermalink





(B) by adding at the end the following new subsection: CommentsClose CommentsPermalink

‘Advance Care Planning Consultation

‘(hhh)(1) Subject to paragraphs (3) and (4), the term ‘advance care planning consultation’ means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years. Such consultation shall include the following: CommentsClose CommentsPermalink





‘(A) An explanation by the practitioner of advance care planning, including key questions and considerations, important steps, and suggested people to talk to. CommentsClose CommentsPermalink





‘(B) An explanation by the practitioner of advance directives, including living wills and durable powers of attorney, and their uses. CommentsClose CommentsPermalink





‘(C) An explanation by the practitioner of the role and responsibilities of a health care proxy. CommentsClose CommentsPermalink





‘(D) The provision by the practitioner of a list of national and State-specific resources to assist consumers and their families with advance care planning, including the national toll-free hotline, the advance care planning clearinghouses, and State legal service organizations (including those funded through the Older Americans Act of 1965). CommentsClose CommentsPermalink





‘(E) An explanation by the practitioner of the continuum of end-of-life services and supports available, including palliative care and hospice, and benefits for such services and supports that are available under this title. CommentsClose CommentsPermalink





‘(F)(i) Subject to clause (ii), an explanation of orders regarding life sustaining treatment or similar orders, which shall include-- CommentsClose CommentsPermalink





‘(I) the reasons why the development of such an order is beneficial to the individual and the individual’s family and the individual’s family and thereasons why such an order should be updated periodically as the health of the individual changes; CommentsClose CommentsPermalink





‘(II) the information needed for an individual or legal surrogate to make informed decisions regarding the completion of such an order; and CommentsClose CommentsPermalink





‘(III) the identification of resources that an individual may use to determine the requirements of the State in which such individual resides so that the treatment wishes of that individual will be carried out if the individual is unable to communicate those wishes, including requirements regarding the designation of a surrogate decisionmaker (also known as a health care proxy). CommentsClose CommentsPermalink





‘(ii) The Secretary shall limit the requirement for explanations under clause (i) to consultations furnished in a State-- CommentsClose CommentsPermalink





‘(I) in which all legal barriers have been addressed for enabling orders for life sustaining treatment to constitute a set of medical orders respected across all care settings; and CommentsClose CommentsPermalink





‘(II) that has in effect a program for orders for life sustaining treatment described in clause (iii). CommentsClose CommentsPermalink





‘(iii) A program for orders for life sustaining treatment for a States described in this clause is a program that-- CommentsClose CommentsPermalink





‘(I) ensures such orders are standardized and uniquely identifiable throughout the State; CommentsClose CommentsPermalink





‘(II) distributes or makes accessible such orders to physicians and other health professionals that (acting within the scope of the professional’s authority under State law) may sign orders for life sustaining treatment; CommentsClose CommentsPermalink





‘(III) provides training for health care professionals across the continuum of care about the goals and use of orders for life sustaining treatment; and CommentsClose CommentsPermalink





‘(IV) is guided by a coalition of stakeholders includes representatives from emergency medical services, emergency department physicians or nurses, state long-term care association, state medical association, state surveyors, agency responsible for senior services, state department of health, state hospital association, home health association, state bar association, and state hospice association. CommentsClose CommentsPermalink





‘(2) A practitioner described in this paragraph is-- CommentsClose CommentsPermalink





‘(A) a physician (as defined in subsection (r)(1)); and CommentsClose CommentsPermalink





‘(B) a nurse practitioner or physician’s assistant who has the authority under State law to sign orders for life sustaining treatments. CommentsClose CommentsPermalink





‘(3)(A) An initial preventive physical examination under subsection (WW), including any related discussion during such examination, shall not be considered an advance care planning consultation for purposes of applying the 5-year limitation under paragraph (1). CommentsClose CommentsPermalink





‘(B) An advance care planning consultation with respect to an individual may be conducted more frequently than provided under paragraph (1) if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a skilled nursing facility, a long-term care facility (as defined by the Secretary), or a hospice program. CommentsClose CommentsPermalink





‘(4) A consultation under this subsection may include the formulation of an order regarding life sustaining treatment or a similar order. CommentsClose CommentsPermalink





‘(5)(A) For purposes of this section, the term ‘order regarding life sustaining treatment’ means, with respect to an individual, an actionable medical order relating to the treatment of that individual that-- CommentsClose CommentsPermalink





‘(i) is signed and dated by a physician (as defined in subsection (r)(1)) or another health care professional (as specified by the Secretary and who is acting within the scope of the professional’s authority under State law in signing such an order, including a nurse practitioner or physician assistant) and is in a form that permits it to stay with the individual and be followed by health care professionals and providers across the continuum of care; CommentsClose CommentsPermalink





‘(ii) effectively communicates the individual’s preferences regarding life sustaining treatment, including an indication of the treatment and care desired by the individual; CommentsClose CommentsPermalink





‘(iii) is uniquely identifiable and standardized within a given locality, region, or State (as identified by the Secretary); and CommentsClose CommentsPermalink





‘(iv) may incorporate any advance directive (as defined in section 1866(f)(3)) if executed by the individual. CommentsClose CommentsPermalink





‘(B) The level of treatment indicated under subparagraph (A)(ii) may range from an indication for full treatment to an indication to limit some or all or specified interventions. Such indicated levels of treatment may include indications respecting, among other items-- CommentsClose CommentsPermalink





‘(i) the intensity of medical intervention if the patient is pulse less, apneic, or has serious cardiac or pulmonary problems; CommentsClose CommentsPermalink





‘(ii) the individual’s desire regarding transfer to a hospital or remaining at the current care setting; CommentsClose CommentsPermalink





‘(iii) the use of antibiotics; and CommentsClose CommentsPermalink





‘(iv) the use of artificially administered nutrition and hydration.’. CommentsClose CommentsPermalink





(2) PAYMENT- Section 1848(j)(3) of such Act (42 U.S.C. 1395w-4(j)(3)) is amended by inserting ‘(2)(FF),’ after ‘(2)(EE),’. CommentsClose CommentsPermalink





(3) FREQUENCY LIMITATION- Section 1862(a) of such Act (42 U.S.C. 1395y(a)) is amended-- CommentsClose CommentsPermalink





(A) in paragraph (1)-- CommentsClose CommentsPermalink





(i) in subparagraph (N), by striking ‘and’ at the end; CommentsClose CommentsPermalink





(ii) in subparagraph (O) by striking the semicolon at the end and inserting ‘, and’; and CommentsClose CommentsPermalink





(iii) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(P) in the case of advance care planning consultations (as defined in section 1861(hhh)(1)), which are performed more frequently than is covered under such section;’; and CommentsClose CommentsPermalink





(B) in paragraph (7), by striking ‘or (K)’ and inserting ‘(K), or (P)’. CommentsClose CommentsPermalink





(4) EFFECTIVE DATE- The amendments made by this subsection shall apply to consultations furnished on or after January 1, 2011. CommentsClose CommentsPermalink





(b) Expansion of Physician Quality Reporting Initiative for End of Life Care- CommentsClose CommentsPermalink





(1) Physician’S QUALITY REPORTING INITIATIVE- Section 1848(k)(2) of the Social Security Act (42 U.S.C. 1395w-4(k)(2)) is amended by adding at the end the following new paragraphs:‘(3subparagraph: CommentsClose CommentsPermalink





‘(E) Physician’S QUALITY REPORTING INITIATIVE- CommentsClose CommentsPermalink





‘(Ai) IN GENERAL- For purposes of reporting data on quality measures for covered professional services furnished during 2011 and any subsequent year, to the extent that measures are available, the Secretary shall include quality measures on end of life care and advanced care planning that have been adopted or endorsed by a consensus-based organization, if appropriate. Such measures shall measure both the creation of and adherence to orders for life-sustaining treatment. CommentsClose CommentsPermalink





‘(Bii) PROPOSED SET OF MEASURES- The Secretary shall publish in the Federal Register proposed quality measures on end of life care and advanced care planning that the Secretary determines are described in subparagraph (A) and would be appropriate for eligible professionals to use to submit data to the Secretary. The Secretary shall provide for a period of public comment on such set of measures before finalizing such proposed measures.’. CommentsClose CommentsPermalink





(c) Inclusion of Information in Medicare & You Handbook- CommentsClose CommentsPermalink





(1) MEDICARE & YOU HANDBOOK- CommentsClose CommentsPermalink





(A) IN GENERAL- Not later than 1 year after the date of the enactment of this Act, the Secretary of Health and Human Services shall update the online version of the Medicare & You Handbook to include the following: CommentsClose CommentsPermalink





(i) An explanation of advance care planning and advance directives, including-- CommentsClose CommentsPermalink





(I) living wills; CommentsClose CommentsPermalink





(II) durable power of attorney; CommentsClose CommentsPermalink





(III) orders of life-sustaining treatment; and CommentsClose CommentsPermalink





(IV) health care proxies. CommentsClose CommentsPermalink





(ii) A description of Federal and State resources available to assist individuals and their families with advance care planning and advance directives, including-- CommentsClose CommentsPermalink





(I) available State legal service organizations to assist individuals with advance care planning, including those organizations that receive funding pursuant to the Older Americans Act of 1965 (42 U.S.C. 93001 et seq.); CommentsClose CommentsPermalink





(II) website links or addresses for State-specific advance directive forms; and CommentsClose CommentsPermalink





(III) any additional information, as determined by the Secretary. CommentsClose CommentsPermalink





(B) UPDATE OF PAPER AND SUBSEQUENT VERSIONS- The Secretary shall include the information described in subparagraph (A) in all paper and electronic versions of the Medicare & You Handbook that are published on or after the date that is 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink

SEC. 1234. PART B SPECIAL ENROLLMENT PERIOD AND WAIVER OF LIMITED ENROLLMENT PENALTY FOR TRICARE BENEFICIARIES.

(a) Part B Special Enrollment Period- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1837 of the Social Security Act (42 U.S.C. 1395p) is amended by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(l)(1) In the case of any individual who is a covered beneficiary (as defined insection 1072(5) of title 10, United States Code) at the time the individual is entitled to hospital insurance benefits under part A under section 226(b) or section 226A and who is eligible to enroll but who has elected not to enroll (or to be deemed enrolled) during the individual’s initial enrollment period, there shall be a special enrollment period described in paragraph (2). CommentsClose CommentsPermalink





‘(2) The special enrollment period described in this paragraph, with respect to an individual, is the 12-month period beginning on the day after the last day of the initial enrollment period of the individual or, if later, the 12-month period beginning with the month the individual is notified of enrollment under this section. CommentsClose CommentsPermalink





‘(3) In the case of an individual who enrolls during the special enrollment period provided under paragraph (1), the coverage period under this part shall begin on the first day of the month in which the individual enrolls or, at the option of the individual, on the first day of the second month following the last month of the individual’s initial enrollment period. CommentsClose CommentsPermalink





‘(4) The Secretary of Defense shall establish a method for identifying individuals described in paragraph (1) and providing notice to them of their eligibility for enrollment during the special enrollment period described in paragraph (2).’. CommentsClose CommentsPermalink





(2) EFFECTIVE DATE- The amendment made by paragraph (1) shall apply to elections made on or after the date of the enactment of this Act. CommentsClose CommentsPermalink





(b) Waiver of Increase of Premium- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1839(b) of the Social Security Act (42 U.S.C. 1395r(b)) is amended by striking ‘section 1837(i)(4)’ and inserting ‘subsection (i)(4) or (l) of section 1837’. CommentsClose CommentsPermalink





(2) EFFECTIVE DATE- CommentsClose CommentsPermalink





(A) IN GENERAL- The amendment made by paragraph (1) shall apply with respect to elections made on or after the date of the enactment of this Act. CommentsClose CommentsPermalink





(B) REBATES FOR CERTAIN DISABLED AND ESRD BENEFICIARIES- CommentsClose CommentsPermalink





(i) IN GENERAL- With respect to premiums for months on or after January 2005 and before the month of the enactment of this Act, no increase in the premium shall be effected for a month in the case of any individual who is a covered beneficiary (as defined insection 1072(5) of title 10, United States Code) at the time the individual is entitled to hospital insurance benefits under part A of title XVIII of the Social Security Act under section 226(b) or 226A of such Act, and who is eligible to enroll, but who has elected not to enroll (or to be deemed enrolled), during the individual’s initial enrollment period, and who enrolls under this part within the 12-month period that begins on the first day of the month after the month of notification of entitlement under this part. CommentsClose CommentsPermalink





(ii) CONSULTATION WITH DEPARTMENT OF DEFENSE- The Secretary of Health and Human Services shall consult with the Secretary of Defense in identifying individuals described in this paragraph. CommentsClose CommentsPermalink





(iii) REBATES- The Secretary of Health and Human Services shall establish a method for providing rebates of premium increases paid for months on or after January 1, 2005, and before the month of the enactment of this Act for which a penalty was applied and collected. CommentsClose CommentsPermalink

SEC. 1235. EXCEPTION FOR USE OF MORE RECENT TAX YEAR IN CASE OF GAINS FROM SALE OF PRIMARY RESIDENCE IN COMPUTING PART B INCOME-RELATED PREMIUM.

(a) In General- Section 1839(i)(4)(C)(ii)(II) of the Social Security Act (42 U.S.C. 1395r(i)(4)(C)(ii)(II)) is amended by inserting ‘sale of primary residence,’ after ‘divorce of such individual,’. CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) shall apply to premiums and payments for years beginning with 2011. CommentsClose CommentsPermalink

SEC. 1236. DEMONSTRATION PROGRAM ON USE OF PATIENT DECISIONS AIDS.

(a) In General- The Secretary of Health and Human Services, acting through the Center for Medicare and Medicaid Payment Innovation established under section 1115A of the Social Security Act (as added by section 1910) and consistent with the applicable provisions of such section, shall establish a shared decision making demonstration program (in this subsection referred to as the ‘program’) under the Medicare program using patient decision aids to meet the objective of improving the understanding by Medicare beneficiaries of their medical treatment options, as compared to comparable Medicare beneficiaries who do not participate in a shared decision making process using patient decision aids. CommentsClose CommentsPermalink





(b) Sites- CommentsClose CommentsPermalink





(1) ENROLLMENT- The Secretary shall enroll in the program not more than 30 eligible providers who have experience in implementing, and have invested in the necessary infrastructure to implement, shared decision making using patient decision aids. CommentsClose CommentsPermalink





(2) APPLICATION- An eligible provider seeking to participate in the program shall submit to the Secretary an application at such time and containing such information as the Secretary may require. CommentsClose CommentsPermalink





(3) PREFERENCE- In enrolling eligible providers in the program, the Secretary shall give preference to eligible providers that-- CommentsClose CommentsPermalink





(A) have documented experience in using patient decision aids for the conditions identified by the Secretary and in using shared decision making; CommentsClose CommentsPermalink





(B) have the necessary information technology infrastructure to collect the information required by the Secretary for reporting purposes; and CommentsClose CommentsPermalink





(C) are trained in how to use patient decision aids and shared decision making. CommentsClose CommentsPermalink





(c) Follow-up Counseling Visit- CommentsClose CommentsPermalink





(1) IN GENERAL- An eligible provider participating in the program shall routinely schedule Medicare beneficiaries for a counseling visit after the viewing of such a patient decision aid to answer any questions the beneficiary may have with respect to the medical care of the condition involved and to assist the beneficiary in thinking through how their preferences and concerns relate to their medical care. CommentsClose CommentsPermalink





(2) PAYMENT FOR FOLLOW-UP COUNSELING VISIT- The Secretary shall establish procedures for making payments for such counseling visits provided to Medicare beneficiaries under the program. Such procedures shall provide for the establishment-- CommentsClose CommentsPermalink





(A) of a code (or codes) to represent such services; and CommentsClose CommentsPermalink





(B) of a single payment amount for such service that includes the professional time of the health care provider and a portion of the reasonable costs of the infrastructure of the eligible provider such as would be made under the applicable payment systems to that provider for similar covered services. CommentsClose CommentsPermalink





(d) Costs of Aids- An eligible provider participating in the program shall be responsible for the costs of selecting, purchasing, and incorporating such patient decision aids into the provider’s practice, and reporting data on quality and outcome measures under the program. CommentsClose CommentsPermalink





(e) Funding- The Secretary shall provide for the transfer from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 of the Social Security Act (42 U.S.C. 1395t) of such funds as are necessary for the costs of carrying out the program. CommentsClose CommentsPermalink





(f) Waiver Authority- The Secretary may waive such requirements of titles XI and XVIII of the Social Security Act (42 U.S.C. 1301 et seq. and 1395 et seq.) as may be necessary for the purpose of carrying out the program. CommentsClose CommentsPermalink





(g) Report- Not later than 12 months after the date of completion of the program, the Secretary shall submit to Congress a report on such program, together with recommendations for such legislation and administrative action as the Secretary determines to be appropriate. The final report shall include an evaluation of the impact of the use of the program on health quality, utilization of health care services, and on improving the quality of life of such beneficiaries. CommentsClose CommentsPermalink





(h) Definitions- In this section: CommentsClose CommentsPermalink





(1) ELIGIBLE PROVIDER- The term ‘eligible provider’ means the following: CommentsClose CommentsPermalink





(A) A primary care practice. CommentsClose CommentsPermalink





(B) A specialty practice. CommentsClose CommentsPermalink





(C) A multispecialty group practice. CommentsClose CommentsPermalink





(D) A hospital. CommentsClose CommentsPermalink





(E) A rural health clinic. CommentsClose CommentsPermalink





(F) A fFederally qualified health center (as defined in section 1861(aa)(4) of the Social Security Act (42 U.S.C. 1395x(aa)(4)). CommentsClose CommentsPermalink





(G) An integrated delivery system. CommentsClose CommentsPermalink





(H) A State cooperative entity that includes the State government and at least one other health care provider which is set up for the purpose of testing shared decision making and patient decision aids. CommentsClose CommentsPermalink





(2) PATIENT DECISION AID- The term ‘patient decision aid’ means an educational tool (such as the Internet, a video, or a pamphlet) that helps patients (or, if appropriate, the family caregiver of the patient) understand and communicate their beliefs and preferences related to their treatment options, and to decide with their health care provider what treatments are best for them based on their treatment options, scientific evidence, circumstances, beliefs, and preferences. CommentsClose CommentsPermalink





(3) SHARED DECISION MAKING- The term ‘shared decision making’ means a collaborative process between patient and clinician that engages the patient in decision making, provides patients with information about trade-offs among treatment options, and facilitates the incorporation of patient preferences and values into the medical plan. CommentsClose CommentsPermalink

TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND COORDINATED CARE CommentsClose CommentsPermalink

SEC. 1301. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM.

Title XVIII of the Social Security Act is amended by inserting after section 1866CD, as added by section 1152(f) of this Act, the following new section: CommentsClose CommentsPermalink

‘ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM

‘Sec. 1866DE. (a) Establishment- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall conduct a pilot program (in this section referred to as the ‘pilot program’) to test different payment incentive models, including (to the extent practicable) the specific payment incentive models described in subsection (c), designed to reduce the growth of expenditures and improve health outcomes in the provision of items and services under this title to applicable beneficiaries (as defined in subsection (d)) by qualifying accountable care organizations (as defined in subsection (b)(1)) in order to-- CommentsClose CommentsPermalink





‘(1A) promote accountability for a patient population and coordinate items and services under parts A and B; CommentsClose CommentsPermalink





‘(2B) encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery; and CommentsClose CommentsPermalink





‘(3C) reward physician practices and other physician organizational models for the provision of high quality and efficient health care services. CommentsClose CommentsPermalink





‘(b)2) SCOPE- The Secretary shall set specific goals for the number of accountable care organizations, participating practitioners, and patients served in the initial tests under the pilot program to ensure that the pilot program is of sufficient size and scope to-- CommentsClose CommentsPermalink





‘(A) test the approach involved in a variety of settings, including urban, rural, and underserved areas; and CommentsClose CommentsPermalink





‘(B) subject to subsection (f)(1), disseminate such approach rapidly on a national basis. CommentsClose CommentsPermalink





To the extent that the Secretary finds a qualifying accountable care organization model to be successful in improving quality and reducing costs, the Secretary shall attempt to attract at least 10 percent of all eligible providers to act as accountable care organizations and implement such mechanisms and reforms within 5 years after the date of the enactment of this section. If the Secretary further finds such accountable care organization models to be successful, the Secretary shall seek to implement such mechanisms and reforms on as large a geographic scale as practical and economical. CommentsClose CommentsPermalink





‘(b) Qualifying Accountable Care Organizations (ACOs)- CommentsClose CommentsPermalink





‘(1) QUALIFYING ACO DEFINED- In this section: CommentsClose CommentsPermalink





‘(A) IN GENERAL- The terms ‘qualifying accountable care organization’ and ‘qualifying ACO’ mean a group of physicians or other physician organizational model (as defined in subparagraph (D)) that-- CommentsClose CommentsPermalink





‘(i) is organized at least in part for the purpose of providing physicians’ services; and CommentsClose CommentsPermalink





‘(ii) meets such criteria as the Secretary determines to be appropriate to participate in the pilot program, including the criteria specified in paragraph (2). CommentsClose CommentsPermalink





‘(B) INCLUSION OF OTHER PROVIDERS- Nothing in this subsection shall be construed as preventing a qualifying ACO from including a hospital or any other provider of services or supplier furnishing items or services for which payment may be made under this title that is affiliated with the ACO under an arrangement structured so that such provider or supplier participates in the pilot program and shares in any incentive payments under the pilot program. CommentsClose CommentsPermalink





‘(C) PHYSICIAN- The term ‘physician’ includes, except as the Secretary may otherwise provide, any individual who furnishes services for which payment may be made as physicians’ services. CommentsClose CommentsPermalink





‘(D) OTHER PHYSICIAN ORGANIZATIONAL MODEL- The term ‘other physician organization model’ means, with respect to a qualifying ACO any model of organization under which physicians enter into agreements with other providers for the purposes of participation in the pilot program in order to provide high quality and efficient health care services and share in any incentive payments under such program CommentsClose CommentsPermalink





.‘(E) OTHER SERVICES- Nothing in this paragraph shall be construed as preventing a qualifying ACO from furnishing items or services, for which payment may not be made under this title, for purposes of achieving performance goals under the pilot program. CommentsClose CommentsPermalink





‘(2) QUALIFYING CRITERIA- The following are criteria described in this paragraph for an organized group of physicians to be a qualifying ACO: CommentsClose CommentsPermalink





‘(A) The group has a legal structure that would allow the group to receive and distribute incentive payments under this section. CommentsClose CommentsPermalink





‘(B) The group includes a sufficient number of primary care physicians (regardless of specialty) for the applicable beneficiaries for whose care the group is accountable (as determined by the Secretary). CommentsClose CommentsPermalink





‘(C) The group reports on quality measures in such form, manner, and frequency as specified by the Secretary (which may be for the group, for providers of services and suppliers, or both). CommentsClose CommentsPermalink





‘(D) The group reports to the Secretary (in a form, manner and frequency as specified by the Secretary) such data as the Secretary determines appropriate to monitor and evaluate the pilot program. CommentsClose CommentsPermalink





‘(E) The group provides notice to applicable beneficiaries regarding the pilot program (as determined appropriate by the Secretary). CommentsClose CommentsPermalink





‘(F) The group contributes to a best practices network or website, that shall be maintained by the Secretary for the purpose of sharing strategies on quality improvement, care coordination, and efficiency that the groups believe are effective. CommentsClose CommentsPermalink





‘(G) The group utilizes patient-centered processes of care, including those that emphasize patient and caregiver involvement in planning and monitoring of ongoing care management plan. CommentsClose CommentsPermalink





‘(H) The group meets other criteria determined to be appropriate by the Secretary. CommentsClose CommentsPermalink





‘(c) Specific Payment Incentive Models- The specific payment incentive models described in this subsection are the following: CommentsClose CommentsPermalink





‘(1) PERFORMANCE TARGET MODEL- Under the performance target model under this paragraph (in this paragraph referred to as the ‘performance target model’): CommentsClose CommentsPermalink





‘(A) IN GENERAL- A qualifying ACO qualifies to receive an incentive payment if expenditures for applicable beneficiaries are less than a target spending level or a target rate of growth. The incentive payment shall be made only if savings are greater than would result from normal variation in expenditures for items and services covered under parts A and B. CommentsClose CommentsPermalink





‘(B) COMPUTATION OF PERFORMANCE TARGET- CommentsClose CommentsPermalink





‘(i) IN GENERAL- The Secretary shall establish a performance target for each qualifying ACO comprised of a base amount (described in clause (ii)) increased to the current year by an adjustment factor (described in clause (iii)). Such a target may be established on a per capita basis, as the Secretary determines to be appropriate. CommentsClose CommentsPermalink





‘(ii) BASE AMOUNT- For purposes of clause (i), the base amount in this subparagraph is equal to the average total payments (or allowed charges) under parts A and B (and may include part D, if the Secretary determines appropriate) for applicable beneficiaries for whom the qualifying ACO furnishes items and services in a base period determined by the Secretary. Such base amount may be determined on a per capita basis. CommentsClose CommentsPermalink





‘(iii) ADJUSTMENT FACTOR- For purposes of clause (i), the adjustment factor in this clause may equal an annual per capita amount that reflects changes in expenditures from the period of the base amount to the current year that would represent an appropriate performance target for applicable beneficiaries (as determined by the Secretary). Such adjustment factor may be determined as an amount or rate, may be determined on a national, regional, local, or organization-specific basis, and may be determined on a per capita basis. Such adjustment factor also may be adjusted for risk as determined appropriate by the Secretary. CommentsClose CommentsPermalink





‘(iv) REBASING- Under this model the Secretary shall periodically rebase the base expenditure amount described in clause (ii). CommentsClose CommentsPermalink





‘(C) MEETING TARGET- CommentsClose CommentsPermalink





‘(i) IN GENERAL- Subject to clause (ii), a qualifying ACO that meet or exceeds annual quality and performance targets for a year shall receive an incentive payment for such year equal to a portion (as determined appropriate by the Secretary) of the amount by which payments under this title for such year relative are estimated to be below the performance target for such year, as determined by the Secretary. The Secretary may establish a cap on incentive payments for a year for a qualifying ACO. CommentsClose CommentsPermalink





‘(ii) LIMITATION- The Secretary shall limit incentive payments to each qualifying ACO under this paragraph as necessary to ensure that the aggregate expenditures with respect to applicable beneficiaries for such ACOs under this title (inclusive of incentive payments described in this subparagraph) do not exceed the amount that the Secretary estimates would be expended for such ACO for such beneficiaries if the pilot program under this section were not implemented. CommentsClose CommentsPermalink





‘(D) REPORTING AND OTHER REQUIREMENTS- In carrying out such model, the Secretary may (as the Secretary determines to be appropriate) incorporate reporting requirements, incentive payments, and penalties related to the physician quality reporting initiative (PQRI), electronic prescribing, electronic health records, and other similar initiatives under section 1848, and may use alternative criteria than would otherwise apply under such section for determining whether to make such payments. The incentive payments described in this subparagraph shall not be included in the limit described in subparagraph (C)(ii) or in the performance target model described in this paragraph. CommentsClose CommentsPermalink





‘(2) PARTIAL CAPITATION MODEL- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to subparagraph (B), a partial capitation model described in this paragraph (in this paragraph referred to as a ‘partial capitation model’) is a model in which a qualifying ACO would be at financial risk for some, but not all, of the items and services covered under parts A and B, such as at risk for some or all physicians’ services or all items and services under part B. The Secretary may limit a partial capitation model to ACOs that are highly integrated systems of care and to ACOs capable of bearing risk, as determined to be appropriate by the Secretary. CommentsClose CommentsPermalink





‘(B) NO ADDITIONAL PROGRAM EXPENDITURES- Payments to a qualifying ACO for applicable beneficiaries for a year under the partial capitation model shall be established in a manner that does not result in spending more for such ACO for such beneficiaries than would otherwise be expended for such ACO for such beneficiaries for such year if the pilot program were not implemented, as estimated by the Secretary. CommentsClose CommentsPermalink





‘(3) OTHER PAYMENT MODELS- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to subparagraph (B), the Secretary may develop other payment models that meet the goals of this pilot program to improve quality and efficiency. CommentsClose CommentsPermalink





‘(B) NO ADDITIONAL PROGRAM EXPENDITURES- Subparagraph (B) of paragraph (2) shall apply to a payment model under subparagraph (A) in a similar manner as such subparagraph (B) applies to the payment model under paragraph (2). CommentsClose CommentsPermalink





‘(d) Applicable Beneficiaries- CommentsClose CommentsPermalink





‘(1) IN GENERAL- In this section, the term ‘applicable beneficiary’ means, with respect to a qualifying ACO, an individual who-- CommentsClose CommentsPermalink





‘(A) is enrolled under part B and entitled to benefits under part A; CommentsClose CommentsPermalink





‘(B) is not enrolled in a Medicare Advantage plan under part C or a PACE program under section 1894; and CommentsClose CommentsPermalink





‘(C) meets such other criteria as the Secretary determines appropriate, which may include criteria relating to frequency of contact with physicians in the ACO CommentsClose CommentsPermalink





.‘(2) FOLLOWING APPLICABLE BENEFICIARIES- The Secretary may monitor data on expenditures and quality of services under this title after an applicable beneficiary discontinues receiving services under this title through a qualifying ACO. CommentsClose CommentsPermalink





‘(e) Implementation- CommentsClose CommentsPermalink





‘(1) STARTING DATE- The pilot program shall begin no later than January 1, 2012. An agreement with a qualifying ACO under the pilot program may cover a multi-year period of between 3 and 5 years. CommentsClose CommentsPermalink





‘(2) WAIVER- The Secretary may waive such provisions of this title (including section 1877) and title XI in the manner the Secretary determines necessary in order implement the pilot program. CommentsClose CommentsPermalink





‘(3) PERFORMANCE RESULTS REPORTS- The Secretary shall report performance results to qualifying ACOs under the pilot program at least annually. CommentsClose CommentsPermalink





‘(4) LIMITATIONS ON REVIEW- There shall be no administrative or judicial review under section 1869, section 1878, or otherwise of-- CommentsClose CommentsPermalink





‘(A) the elements, parameters, scope, and duration of the pilot program; CommentsClose CommentsPermalink





‘(B) the selection of qualifying ACOs for the pilot program; CommentsClose CommentsPermalink





‘(C) the establishment of targets, measurement of performance, determinations with respect to whether savings have been achieved and the amount of savings; CommentsClose CommentsPermalink





‘(D) determinations regarding whether, to whom, and in what amounts incentive payments are paid; and CommentsClose CommentsPermalink





‘(E) decisions about the extension of the program under subsection (g), expansion of the program under subsection (h) or extensions under subsection (i). CommentsClose CommentsPermalink





‘(5) ADMINISTRATION- Chapter 35 of title 44, United States Code shall not apply to this section. CommentsClose CommentsPermalink





‘(f) Evaluation; Monitoring- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall evaluate the payment incentive model for each qualifying ACO under the pilot program to assess impacts on beneficiaries, providers of services, suppliers and the program under this title. The Secretary shall make such evaluation publicly available within 60 days of the date of completion of such report. CommentsClose CommentsPermalink





‘(2) MONITORING- The Inspector General of the Department of Health and Human Services shall provide for monitoring of the operation of ACOs under the pilot program with regard to violations of section 1877 (popularly known as the ‘Stark law’). CommentsClose CommentsPermalink





‘(g) Extension of Pilot Agreement With Successful Organizations- CommentsClose CommentsPermalink





‘(1) REPORTS TO CONGRESS- Not later than 2 years after the date the first agreement is entered into under this section, and biennially thereafter for six years, the Secretary shall submit to Congress and make publicly available a report on the use of authorities under the pilot program. Each report shall address the impact of the use of those authorities on expenditures, access, and quality under this title. CommentsClose CommentsPermalink





‘(2) EXTENSION- Subject to the report provided under paragraph (1), with respect to a qualifying ACO, the Secretary may extend the duration of the agreement for such ACO under the pilot program as the Secretary determines appropriate if-- CommentsClose CommentsPermalink





‘(A) the ACO receives incentive payments with respect to any of the first 4 years of the pilot agreement and is consistently meeting quality standards; or CommentsClose CommentsPermalink





‘(B) the ACO is consistently exceeding quality standards and is not increasing spending under the program. CommentsClose CommentsPermalink





‘(3) TERMINATION- The Secretary may terminate an agreement with a qualifying ACO under the pilot program if such ACO did not receive incentive payments or consistently failed to meet quality standards in any of the first 3 years under the program. CommentsClose CommentsPermalink





‘(h) Expansion to Additional ACOs- CommentsClose CommentsPermalink





‘(1) TESTING AND REFINEMENT OF PAYMENT INCENTIVE MODELS- Subject to the evaluation described in subsection (f), the Secretary may enter into agreements under the pilot program with additional qualifying ACOs to further test and refine payment incentive models with respect to qualifying ACOs. CommentsClose CommentsPermalink





‘(2) EXPANDING USE OF SUCCESSFUL MODELS TO PROGRAM IMPLEMENTATION- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to subparagraph (B), the Secretary may issue regulations to implement, on a permanent basis, 1 or more models if, and to the extent that, such models are beneficial to the program under this title, as determined by the Secretary. CommentsClose CommentsPermalink





‘(B) CERTIFICATION- The Chief Actuary of the Centers for Medicare & Medicaid Services shall certify that 1 or more of such models described in subparagraph (A) would result in estimated spending that would be less than what spending would otherwise be estimated to be in the absence of such expansion. CommentsClose CommentsPermalink





‘(i) Treatment of Physician Group Practice Demonstration- CommentsClose CommentsPermalink





‘(1) EXTENSION- The Secretary may enter in to an agreement with a qualifying ACO under the demonstration under section 1866A, subject to rebasing and other modifications deemed appropriate by the Secretary, until the pilot program under this section is operational. CommentsClose CommentsPermalink





‘(2) TRANSITION- For purposes of extension of an agreement with a qualifying ACO under subsection (g)(2), the Secretary shall treat receipt of an incentive payment for a year by an organization under the physician group practice demonstration pursuant to section 1866A as a year for which an incentive payment is made under such subsection, as long as such practice group practice organization meets the criteria under subsection (b)(2). CommentsClose CommentsPermalink





‘(j) Additional Provisions- CommentsClose CommentsPermalink





‘(1) AUTHORITY FOR SEPARATE INCENTIVE ARRANGEMENTS- The Secretary may create separate incentive arrangements (including using multiple years of data, varying thresholds, varying shared savings amounts, and varying shared savings limits) for different categories of qualifying ACOs to reflect natural variations in data availability, variation in average annual attributable expenditures, program integrity, and other matters the Secretary deems appropriate. CommentsClose CommentsPermalink





‘(2) ENCOURAGEMENT OF PARTICIPATION OF SMALLER ORGANIZATIONS- In order to encourage the participation of smaller accountable care organizations under the pilot program, the Secretary may limit a qualifying ACO’s exposure to high cost patients under the program. CommentsClose CommentsPermalink





‘(3) TREATMENT OF HIGH-COST BENEFICIARIES WITH CHRONIC DISEASES- Nothing in this section shall be construed as preventing a qualifying ACO from entering into an arrangement with an Independence at Home Medical Practice or from providing home based services for the treatment of beneficiaries who are eligible for that program. CommentsClose CommentsPermalink





‘(4) INVOLVEMENT IN PRIVATE PAYER ARRANGEMENTS- Nothing in this section shall be construed as preventing qualifying ACOs participating in the pilot program from negotiating similar contracts with private payers. CommentsClose CommentsPermalink





‘(45) ANTIDISCRIMINATION LIMITATION- The Secretary shall not enter into an agreement with an entity to provide health care items or services under the pilot program, or with an entity to administer the program, unless such entity guarantees that it will not deny, limit, or condition the coverage or provision of benefits under the program, for individuals eligible to be enrolled under such program, based on any health status-related factor described in section 2702(a)(1) of the Public Health Service Act. CommentsClose CommentsPermalink





‘(56) CONSTRUCTION- Nothing in this section shall be construed to compel or require an organization to use an organization-specific target growth rate for an accountable care organization under this section for purposes of section 1848. CommentsClose CommentsPermalink





‘(67) FUNDING- For purposes of administering and carrying out the pilot program, other than for payments for items and services furnished under this title and incentive payments under subsection (c)(1), in addition to funds otherwise appropriated, there are appropriated to the Secretary for the Center for Medicare & Medicaid Services Program Management Account $25,000,000 for each of fiscal years 2010 through 2014 and $20,000,000 for fiscal year 2015. Amounts appropriated under this paragraph for a fiscal year shall be available until expended.’. CommentsClose CommentsPermalink

SEC. 1302. MEDICAL HOME PILOT PROGRAM.

(a) In General- Title XVIII of the Social Security Act is amended by inserting after section 1866DE, as inserted by section 1301, the following new section: CommentsClose CommentsPermalink

‘MEDICAL HOME PILOT PROGRAM

‘Sec. 1866EF. (a) Establishment and Medical Home Models- CommentsClose CommentsPermalink





‘(1) ESTABLISHMENT OF PILOT PROGRAM- The Secretary shall establish a medical home pilot program (in this section referred to as the ‘pilot program’) for the purpose of evaluating the feasibility and advisability of reimbursing qualified patient-centered medical homes for furnishing medical home services (as defined under subsection (b)(1)) to high need beneficiaries (as defined in subsection (d)(1)(C)) and to targeted high need beneficiaries (as defined in subsection (c)(1)(C)). CommentsClose CommentsPermalink





‘(2) SCOPE- Subject to subsection (g), the pilot program shall includeSecretary shall set specific goals for the number of practices and communities, and the number of patients served, under the pilot program in the initial tests to ensure that the pilot program is of sufficient size and scope to-- CommentsClose CommentsPermalink





‘(A) test the approach involved in a variety of settings, including urban, rural, and underserved areas; and CommentsClose CommentsPermalink





‘(B) subject to subsection (e)(1), disseminate such approach rapidly on a national basis. CommentsClose CommentsPermalink





To the extent that the Secretary finds a medical home model to be successful in improving quality and reducing costs, the Secretary shall implement such mechanisms and reforms on as large a geographic scale as practical and economical. CommentsClose CommentsPermalink





‘(3) MODELS OF MEDICAL HOMES IN THE PILOT PROGRAM- The pilot program shall evaluate each of the following medical home models: CommentsClose CommentsPermalink





‘(A) INDEPENDENT PATIENT-CENTERED MEDICAL HOME MODEL- Independent patient-centered medical home model under subsection (c). CommentsClose CommentsPermalink





‘(B) COMMUNITY-BASED MEDICAL HOME MODEL- Community-based medical home model under subsection (d). CommentsClose CommentsPermalink





‘(4) PARTICIPATION OF NURSE PRACTITIONERS AND PHYSICIAN ASSISTANTS- CommentsClose CommentsPermalink





‘(A) Nothing in this section shall be construed as preventing a nurse practitioner from leading a patient centered medical home so long as-- CommentsClose CommentsPermalink





‘(i) all the requirements of this section are met; and CommentsClose CommentsPermalink





‘(ii) the nurse practitioner is acting consistently with State law. CommentsClose CommentsPermalink





‘(B) Nothing in this section shall be construed as preventing a physician assistant from participating in a patient centered medical home so long as-- CommentsClose CommentsPermalink





‘(i) all the requirements of this section are met; and CommentsClose CommentsPermalink





‘(ii) the physician assistant is acting consistently with State law. CommentsClose CommentsPermalink





‘(b) Definitions- For purposes of this section: CommentsClose CommentsPermalink





‘(1) PATIENT-CENTERED MEDICAL HOME SERVICES- The term ‘patient-centered medical home services’ means services that-- CommentsClose CommentsPermalink





‘(A) provide beneficiaries with direct and ongoing access to a primary care or principal care by a physician or nurse practitioner who accepts responsibility for providing first contact, continuous and comprehensive care to such beneficiary; CommentsClose CommentsPermalink





‘(B) coordinate the care provided to a beneficiary by a team of individuals at the practice level across office, institutional and home settings led by a primary care or principal care physician or nurse practitioner, as needed and appropriate; CommentsClose CommentsPermalink





‘(C) provide for all the patient’s health care needs or take responsibility for appropriately arranging care with other qualified providers for all stages of life; CommentsClose CommentsPermalink





‘(D) provide continuous access to care and communication with participating beneficiaries; CommentsClose CommentsPermalink





‘(E) provide support for patient self-management, proactive and regular patient monitoring, support for family caregivers, use patient-centered processes, and coordination with community resources; CommentsClose CommentsPermalink





‘(F) integrate readily accessible, clinically useful information on participating patients that enables the practice to treat such patients comprehensively and systematically; and CommentsClose CommentsPermalink





‘(G) implement evidence-based guidelines and apply such guidelines to the identified needs of beneficiaries over time and with the intensity needed by such beneficiaries. CommentsClose CommentsPermalink





‘(2) PRIMARY CARE- The term ‘primary care’ means health care that is provided by a physician or nurse practitioner, nurse practitioner, or physician assistant who practices in the field of family medicine, general internal medicine, geriatric medicine, or pediatric medicine. CommentsClose CommentsPermalink





‘(3) PRINCIPAL CARE- The term ‘principal care’ means integrated, accessible health care that is provided by a physician who is a medical subspecialist that addresses the majority of the personal health care needs of patients with chronic conditions requiring the subspecialist’s expertise, and for whom the subspecialist assumes care management. CommentsClose CommentsPermalink





‘(c) Independent Patient-Ccentered Medical Home Model- CommentsClose CommentsPermalink





‘(1) IN GENERAL- CommentsClose CommentsPermalink





‘(A) PAYMENT AUTHORITY- Under the independent patient-centered medical home model under this subsection, the Secretary shall make payments for medical home services furnished by an independent patient-centered medical home (as defined in subparagraph (B)) pursuant to paragraph (3)(B) for a targeted high need beneficiaries (as defined in subparagraph (C)). CommentsClose CommentsPermalink





‘(B) INDEPENDENT PATIENT-CENTERED MEDICAL HOME DEFINED- In this section, the term ‘independent patient-centered medical home’ means a physician-directed or nurse-practitioner-directed practice that is qualified under paragraph (2) as-- CommentsClose CommentsPermalink





‘(i) providing beneficiaries with patient-centered medical home services; and CommentsClose CommentsPermalink





‘(ii) meets such other requirements as the Secretary may specify. CommentsClose CommentsPermalink





‘(C) TARGETED HIGH NEED BENEFICIARY DEFINED- For purposes of this subsection, the term ‘targeted high need beneficiary’ means a high need beneficiary who, based on a risk score as specified by the Secretary, is generally within the upper 50th percentile of Medicare beneficiaries. CommentsClose CommentsPermalink





‘(D) BENEFICIARY ELECTION TO PARTICIPATE- The Secretary shall determine an appropriate method of ensuring that beneficiaries have agreed to participate in the pilot program. CommentsClose CommentsPermalink





‘(E) IMPLEMENTATION- The pilot program under this subsection shall begin no later than 6 months after the date of the enactment of this section. CommentsClose CommentsPermalink





‘(2) STANDARD SETTING AND QUALIFICATION PROCESS FOR PATIENT-CENTERED MEDICAL HOMES- The Secretary shall review alternative models for standard setting and qualification, and shall establish a process-- CommentsClose CommentsPermalink





‘(A) to establish standards to enable medical practices to qualify as patient-centered medical homes; and CommentsClose CommentsPermalink





‘(B) to initially provide for the review and certification of medical practices as meeting such standards. CommentsClose CommentsPermalink





‘(3) PAYMENT- CommentsClose CommentsPermalink





‘(A) ESTABLISHMENT OF METHODOLOGY- The Secretary shall establish a methodology for the payment for medical home services furnished by independent patient-centered medical homes. Under such methodology, the Secretary shall adjust payments to medical homes based on beneficiary risk scores to ensure that higher payments are made for higher risk beneficiaries. CommentsClose CommentsPermalink





‘(B) PER BENEFICIARY PER MONTH PAYMENTS- Under such payment methodology, the Secretary shall pay independent patient-centered medical homes a monthly fee for each targeted high need beneficiary who consents to receive medical home services through such medical home. CommentsClose CommentsPermalink





‘(C) PROSPECTIVE PAYMENT- The fee under subparagraph (B) shall be paid on a prospective basis. CommentsClose CommentsPermalink





‘(D) AMOUNT OF PAYMENT- In determining the amount of such fee, the Secretary shall consider the following: CommentsClose CommentsPermalink





‘(i) The clinical work and practice expenses involved in providing the medical home services provided by the independent patient-centered medical home (such as providing increased access, care coordination, population disease management, and teaching self-care skills for managing chronic illnesses) for which payment is not made under this title as of the date of the enactment of this section. CommentsClose CommentsPermalink





‘(ii) Allow for differential payments based on capabilities of the independent patient-centered medical home. CommentsClose CommentsPermalink





‘(iii) Use appropriate risk-adjustment in determining the amount of the per beneficiary per month payment under this paragraph in a manner that ensures that higher payments are made for higher risk beneficiaries. CommentsClose CommentsPermalink





‘(4) ENCOURAGING PARTICIPATION OF VARIETY OF PRACTICES- The pilot program under this subsection shall be designed to include the participation of physicians in practices with fewer than 10 full-time equivalent physicians, as well as physicians in larger practices, particularly in underserved and rural areas, as well as federally qualified community health centers, and rural health centers. CommentsClose CommentsPermalink





‘(5) NO DUPLICATION IN PILOT PARTICIPATION- A physician in a group practice that participates in the accountable care organization pilot program under section 1866D shall not be eligible to participate in the pilot program under this subsection, unless the pilot program under this section has been implemented on a permanent basis under subsection (e)(3). CommentsClose CommentsPermalink





‘(d) Community-Bbased Medical Home Model- CommentsClose CommentsPermalink





‘(1) IN GENERAL- CommentsClose CommentsPermalink





‘(A) AUTHORITY FOR PAYMENTS- Under the community-based medical home model under this subsection (in this section referred to as the ‘CBMH model’), the Secretary shall make payments for the furnishing of medical home services by a community-based medical home (as defined in subparagraph (B)) pursuant to paragraph (5)(B) for high need beneficiaries. CommentsClose CommentsPermalink





‘(B) COMMUNITY-BASED MEDICAL HOME DEFINED- In this section, the term ‘community-based medical home’ means a nonprofit community-based or State-based organization that is certified under paragraph (2) as meeting the following requirements: CommentsClose CommentsPermalink





‘(i) The organization provides beneficiaries with medical home services. CommentsClose CommentsPermalink





‘(ii) The organization provides medical home services under the supervision of and in close collaboration with the primary care or principal care physician or nurse practitioner, nurse practitioner, or physician assistant designated by the beneficiary as his or her community-based medical home provider. CommentsClose CommentsPermalink





‘(iii) The organization employs community health workers, including nurses or other non-physician practitioners, lay health workers, or other persons as determined appropriate by the Secretary, that assist the primary or principal care physician or nurse practitioner, nurse practitioner, or physician assistant in chronic care management activities such as teaching self-care skills for managing chronic illnesses, transitional care services, care plan setting, medication therapy management services for patients with multiple chronic diseases, or help beneficiaries access the health care and community-based resources in their local geographic area. CommentsClose CommentsPermalink





‘(iv) The organization meets such other requirements as the Secretary may specify. CommentsClose CommentsPermalink





‘(C) HIGH NEED BENEFICIARY- In this section, the term ‘high need beneficiary’ means an individual who requires regular medical monitoring, advising, or treatment, including such an individual with cognitive impairment that leads to functional impairment. CommentsClose CommentsPermalink





‘(2) QUALIFICATION PROCESS FOR COMMUNITY-BASED MEDICAL HOMES- The Secretary shall establish a process-- CommentsClose CommentsPermalink





‘(A) for the initial qualification of community-based or State-based organizations as community-based medical homes; and CommentsClose CommentsPermalink





‘(B) to provide for the review and qualification of such community-based and State-based organizations pursuant to criteria established by the Secretary. CommentsClose CommentsPermalink





‘(3) DURATION- The pilot program for community-based medical homes under this subsection shall start no later than 2 years after the date of the enactment of this section. Each demonstration site under the pilot program shall operate for a period of up to 5 years after the initial implementation phase, without regard to the receipt of a initial implementation funding under subsection (i). CommentsClose CommentsPermalink





‘(4) PREFERENCE- In selecting sites for the CBMH model, the Secretary shall seek to eliminate racial, ethnic, gender, and geographic health disparities and may give preference to-- CommentsClose CommentsPermalink





‘(A) applications from geographic areas that propose to coordinate health care services for chronically ill beneficiaries across a variety of health care settings, such as primary care physician practices with fewer than 10 physicians, specialty physicians, nurse practitioner practices, Federally qualified health centers, rural health clinics, and other settings; CommentsClose CommentsPermalink





‘(B) applications that include other payors that furnish medical home services for chronically ill patients covered by such payors; and CommentsClose CommentsPermalink





‘(C) applications from States that propose to use the medical home model to coordinate health care services for individuals enrolled under this title, individuals enrolled under title XIX, and full-benefit dual eligible individuals (as defined in section 1935(c)(6)) with chronic diseases across a variety of health care settings. CommentsClose CommentsPermalink





‘(5) PAYMENTS- CommentsClose CommentsPermalink





‘(A) ESTABLISHMENT OF METHODOLOGY- The Secretary shall establish a methodology for the payment for medical home services furnished under the CBMH model. CommentsClose CommentsPermalink





‘(B) PER BENEFICIARY PER MONTH PAYMENTS- Under such payment methodology, the Secretary shall make two separate monthly payments for each high need beneficiary who consents to receive medical home services through such medical home, as follows: CommentsClose CommentsPermalink





‘(i) PAYMENT TO COMMUNITY-BASED ORGANIZATION- One monthly payment to a community-based or State-based organization. CommentsClose CommentsPermalink





‘(ii) PAYMENT TO PRIMARY OR PRINCIPAL CARE PRACTICE- One monthly payment to the primary or principal care practice for such beneficiary. CommentsClose CommentsPermalink





‘(C) PROSPECTIVE PAYMENT- The payments under subparagraph (B) shall be paid on a prospective basis. CommentsClose CommentsPermalink





‘(D) AMOUNT OF PAYMENT- In determining the amount of such payment, the Secretary shall consider the following: CommentsClose CommentsPermalink





‘(i) The clinical work and practice expenses involved in providing the medical home services provided by the community-based medical home (such as providing increased access, care coordination, care plan setting, population disease management, and teaching self-care skills for managing chronic illnesses) for which payment is not made under this title as of the date of the enactment of this section. CommentsClose CommentsPermalink





‘(ii) Use appropriate risk-adjustment in determining the amount of the per beneficiary per month payment under this paragraph. CommentsClose CommentsPermalink





‘(6) INITIAL IMPLEMENTATION FUNDING- The Secretary may make available initial implementation funding to a community based or State-based organization or a State that is participating in the pilot program under this subsection. Such organization shall provide the Secretary with a detailed implementation plan that includes how such funds will be used. The Secretary shall select a territory of the United States as one of the locations in which to implement the pilot program under this subsection. CommentsClose CommentsPermalink





‘(e) Expansion of Program- CommentsClose CommentsPermalink





‘(1) EVALUATION OF COST AND QUALITY- The Secretary shall evaluate the pilot program to determine-- CommentsClose CommentsPermalink





‘(A) the extent to which medical homes result in-- CommentsClose CommentsPermalink





‘(i) improvement in the quality and coordination of health care services, particularly with regard to the care of complex patients; CommentsClose CommentsPermalink





‘(ii) improvement in reducing health disparities; CommentsClose CommentsPermalink





‘(iii) reductions in preventable hospitalizations; CommentsClose CommentsPermalink





‘(iv) prevention of readmissions; CommentsClose CommentsPermalink





‘(v) reductions in emergency room visits; CommentsClose CommentsPermalink





‘(vi) improvement in health outcomes, including patient functional status where applicable; CommentsClose CommentsPermalink





‘(vii) improvement in patient satisfaction; CommentsClose CommentsPermalink





‘(viii) improved efficiency of care such as reducing duplicative diagnostic tests and laboratory tests; and CommentsClose CommentsPermalink





‘(ix) reductions in health care expenditures; and CommentsClose CommentsPermalink





‘(B) the feasability and advisability of reimbursing medical homes for medical home services under this title on a permanent basis. CommentsClose CommentsPermalink





‘(2) REPORT- Not later than 60 days after the date of completion of the evaluation under paragraph (1), the Secretary shall submit to Congress and make available to the public a report on the findings of the evaluation under paragraph (1). CommentsClose CommentsPermalink





‘(3) EXPANSION OF PROGRAM- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to the results of the evaluation under paragraph (1) and subparagraph (B), the Secretary may issue regulations to implement, on a permanent basis, one or more models, if, and to the extent that such model or models, are beneficial to the program under this title, including that such implementation will improve quality of care, as determined by the Secretary. CommentsClose CommentsPermalink





‘(B) CERTIFICATION REQUIREMENT- The Secretary may not issue such regulations unless the Chief Actuary of the Centers for Medicare & Medicaid Services certifies that the expansion of the components of the pilot program described in subparagraph (A) would result in estimated spending under this title that would be no more than the level of spending that the Secretary estimates would otherwise be spent under this title in the absence of such expansion. CommentsClose CommentsPermalink





‘(f) Administrative Provisions- CommentsClose CommentsPermalink





‘(1) NO DUPLICATION IN PAYMENTS- During any month, the Secretary may not make payments under this section under more than one model or through more than one medical home under any model for the furnishing of medical home services to an individual. CommentsClose CommentsPermalink





‘(2) NO EFFECT ON PAYMENT FOR EVALUATION AND MANAGEMENT SERVICES- Payments made under this section are in addition to, and have no effect on the amount of, payment for evaluation and management services made under this title CommentsClose CommentsPermalink





.‘(3) ADMINISTRATION- Chapter 35 of title 44, United States Code shall not apply to this section. CommentsClose CommentsPermalink





‘(g) Funding- CommentsClose CommentsPermalink





‘(1) OPERATIONAL COSTS- For purposes of administering and carrying out the pilot program (including the design, implementation, technical assistance for and evaluation of such program), in addition to funds otherwise available, there shall be transferred from the Federal Supplementary Medical Insurance Trust Fund under section 1841 to the Secretary for the Centers for Medicare & Medicaid Services Program Management Account $6,000,000 for each of fiscal years 2010 through 2014. Amounts appropriated under this paragraph for a fiscal year shall be available until expended. CommentsClose CommentsPermalink





‘(2) PATIENT-CENTERED MEDICAL HOME SERVICES- In addition to funds otherwise available, there shall be available to the Secretary for the Centers for Medicare & Medicaid Services, from the Federal Supplementary Medical Insurance Trust Fund under section 1841-- CommentsClose CommentsPermalink





‘(A) $200,000,000 for each of fiscal years 2010 through 2014 for payments for medical home services under subsection (c)(3); and CommentsClose CommentsPermalink





‘(B) $125,000,000 for each of fiscal years 2012 through 2016, for payments under subsection (d)(5). CommentsClose CommentsPermalink





Amounts available under this paragraph for a fiscal year shall be available until expended. CommentsClose CommentsPermalink





‘(3) INITIAL IMPLEMENTATION- In addition to funds otherwise available, there shall be available to the Secretary for the Centers for Medicare & Medicaid Services, from the Federal Supplementary Medical Insurance Trust Fund under section 1841, $2,500,000 for each of fiscal years 2010 through 2012, under subsection (d)(6). Amounts available under this paragraph for a fiscal year shall be available until expended. CommentsClose CommentsPermalink





‘(h) Treatment of TRHCA Medicare Medical Home Demonstration Funding- CommentsClose CommentsPermalink





‘(1) In addition to funds otherwise available for payment of medical home services under subsection (c)(3), there shall also be available the amount provided in subsection (g) of section 204 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395b-1 note). CommentsClose CommentsPermalink





‘(2) Notwithstanding section 1302(c) of the America’s Affordable Health Choices Act of 2009, in addition to funds provided in paragraph (1) and subsection (g)(2)(A), the funding for medical home services that would otherwise have been available if such section 204 medical home demonstration had been implemented (without regard to subsection (g) of such section) shall be available to the independent patient-centered medical home model described in subsection (c).’. CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by this section shall apply to services furnished on or after the date of the enactment of this Act. CommentsClose CommentsPermalink





(c) Conforming Repeal- Section 204 of division B of the Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395b-1 note), as amended by section 133(a)(2) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275), is repealed. CommentsClose CommentsPermalink

SEC. 1303. INDEPENDENCE AT HOME PILOT PROGRAM.

SEC. 1304. PAYMENT INCENTIVE FOR SELECTED PRIMARY CARE SERVICES.

(a) In General- Section 1833 of the Social Security Act is amended by inserting after subsection (o) the following new subsection: CommentsClose CommentsPermalink





‘(p) Primary Care Payment Incentives- CommentsClose CommentsPermalink





‘(1) IN GENERAL- In the case of primary care services (as defined in paragraph (2)) furnished on or after January 1, 2011, by a primary care practitioner (as defined in paragraph (3)) for which amounts are payable under section 1848, in addition to the amount otherwise paid under this part there shall also be paid to the practitioner (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6)) (on a monthly or quarterly basis) from the Federal Supplementary Medical Insurance Trust Fund an amount equal 5 percent (or 10 percent if the practitioner predominately furnishes such services in an area that is designated (under section 332(a)(1)(A) of the Public Health Service Act) as a primary care health professional shortage area. CommentsClose CommentsPermalink





‘(2) PRIMARY CARE SERVICES DEFINED- In this subsection, the term ‘primary care services’-- CommentsClose CommentsPermalink





‘(A) means services which are evaluation and management services as defined in section 1848(j)(5)(A); and CommentsClose CommentsPermalink





‘(B) includes services furnished by another health care professional that would be described in subparagraph (A) if furnished by a physician. CommentsClose CommentsPermalink





‘(3) PRIMARY CARE PRACTITIONER DEFINED- In this subsection, the term ‘primary care practitioner’-- CommentsClose CommentsPermalink





‘(A) means a physician or other health care practitioner (including a nurse practitioner) who-- CommentsClose CommentsPermalink





‘(i) specializes in family medicine, general internal medicine, general pediatrics, geriatrics, or obstetrics and gynecology; and CommentsClose CommentsPermalink





‘(ii) has allowed charges for primary care services that account for at least 50 percent of the physician’s or practitioner’s total allowed charges under section 1848, as determined by the Secretary for the most recent period for which data are available; and CommentsClose CommentsPermalink





‘(B) includes a physician assistant who is under the supervision of a practitionerhysician described in subparagraph (A). CommentsClose CommentsPermalink





‘(4) LIMITATION ON REVIEW- There shall be no administrative or judicial review under section 1869, section 1878, or otherwise, respecting-- CommentsClose CommentsPermalink





‘(A) any determination or designation under this subsection; CommentsClose CommentsPermalink





‘(B) the identification of services as primary care services under this subsection; and CommentsClose CommentsPermalink





‘(C) the identification of a practitioner as a primary care practitioner under this subsection. CommentsClose CommentsPermalink





‘(5) COORDINATION WITH OTHER PAYMENTS- CommentsClose CommentsPermalink





‘(A) WITH OTHER PRIMARY CARE INCENTIVES- The provisions of this subsection shall not be taken into account in applying subsections (m) and (u) and any payment under such subsections shall not be taken into account in computing payments under this subsection. CommentsClose CommentsPermalink





‘(B) WITH QUALITY INCENTIVES- Payments under this subsection shall not be taken into account in determining the amounts that would otherwise be paid under this part for purposes of section 1834(g)(2)(B).’. CommentsClose CommentsPermalink





(b) Conforming Amendments- CommentsClose CommentsPermalink





(1) Section 1833(m) of such Act (42 U.S.C. 1395l(m)) is amended by redesignating paragraph (4) as paragraph (5) and by inserting after paragraph (3) the following new paragraph: CommentsClose CommentsPermalink





‘(4) The provisions of this subsection shall not be taken into account in applying subsections (m) or (u) and any payment under such subsections shall not be taken into account in computing payments under this subsection.’. CommentsClose CommentsPermalink





(2) Section 1848(m)(5)(B) of such Act (42 U.S.C. 1395w-4(m)(5)(B)) is amended by inserting ‘, (p),’ after ‘(m)’. CommentsClose CommentsPermalink





(3) Section 1848(o)(1)(B)(iv) of such Act (42 U.S.C. 1395w-4(o)(1)(B)(iv)) is amended by inserting ‘primary care’ before ‘health professional shortage area’. CommentsClose CommentsPermalink

SEC. 13045. INCREASED REIMBURSEMENT RATE FOR CERTIFIED NURSE-MIDWIVES.

(a) In General- Section 1833(a)(1)(K) of the Social Security Act (42 U.S.C.1395l(a)(1)(K)) is amended by striking ‘(but in no event’ and all that follows through ‘performed by a physician)’. CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) shall apply to services furnished on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 13056. COVERAGE AND WAIVER OF COST-SHARING FOR PREVENTIVE SERVICES.

(a) Medicare Covered Preventive Services Defined- Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by section 1235(a)(23(a), is amended by adding at the end the following new subsection: CommentsClose CommentsPermalink

‘Medicare Covered Preventive Services

‘(iii)(1) Subject to the succeeding provisions of this subsection, the term ‘Medicare covered preventive services’ means the following: CommentsClose CommentsPermalink





‘(A) Prostate cancer screening tests (as defined in subsection (oo)). CommentsClose CommentsPermalink





‘(B) Colorectal cancer screening tests (as defined in subsection (pp) and when applicable as described in section 1305). CommentsClose CommentsPermalink





‘(C) Diabetes outpatient self-management training services (as defined in subsection (qq)). CommentsClose CommentsPermalink





‘(D) Screening for glaucoma for certain individuals (as described in subsection (s)(2)(U)). CommentsClose CommentsPermalink





‘(E) Medical nutrition therapy services for certain individuals (as described in subsection (s)(2)(V)). CommentsClose CommentsPermalink





‘(F) An initial preventive physical examination (as defined in subsection (ww)). CommentsClose CommentsPermalink





‘(G) Cardiovascular screening blood tests (as defined in subsection (xx)(1)). CommentsClose CommentsPermalink





‘(H) Diabetes screening tests (as defined in subsection (yy)). CommentsClose CommentsPermalink





‘(I) Ultrasound screening for abdominal aortic aneurysm for certain individuals (as described in described in subsection (s)(2)(AA)). CommentsClose CommentsPermalink





‘(J) Pneumococcal and influenza vaccines and their administration (as described in subsection (s)(10)(A)) and hepatitis B vaccine and its administration for certain individuals (as described in subsection (s)(10)(B)). CommentsClose CommentsPermalink





‘(K) Screening mammography (as defined in subsection (jj)). CommentsClose CommentsPermalink





‘(L) Screening pap smear and screening pelvic exam (as defined in subsection (nn)). CommentsClose CommentsPermalink





‘(M) Bone mass measurement (as defined in subsection (rr)). CommentsClose CommentsPermalink





‘(N) Kidney disease education services (as defined in subsection (ggg)). CommentsClose CommentsPermalink





‘(O) Additional preventive services (as defined in subsection (ddd)). CommentsClose CommentsPermalink





‘(2) With respect to specific Medicare covered preventive services, the limitations and conditions described in the provisions referenced in paragraph (1) with respect to such services shall apply.’. CommentsClose CommentsPermalink





(b) Payment and Elimination of Cost-sharing- CommentsClose CommentsPermalink





(1) IN GENERAL- CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1833(a) of the Social Security Act (42 U.S.C. 1395l(a)) is amended by adding after and below paragraph (9) the following: CommentsClose CommentsPermalink





‘With respect to Medicare covered preventive services, in any case in which the payment rate otherwise provided under this part is computed as a percent of less than 100 percent of an actual charge, fee schedule rate, or other rate, such percentage shall be increased to 100 percent.’. CommentsClose CommentsPermalink





(B) APPLICATION TO SIGMOIDOSCOPIES AND COLONOSCOPIES- Section 1834(d) of such Act (42 U.S.C. 1395m(d)) is amended-- CommentsClose CommentsPermalink





(i) in paragraph (2)(C), by amending clause (ii) to read as follows: CommentsClose CommentsPermalink





‘(ii) NO COINSURANCE- In the case of a beneficiary who receives services described in clause (i), there shall be no coinsurance applied.’; and CommentsClose CommentsPermalink





(ii) in paragraph (3)(C), by amending clause (ii) to read as follows: CommentsClose CommentsPermalink





‘(ii) NO COINSURANCE- In the case of a beneficiary who receives services described in clause (i), there shall be no coinsurance applied.’. CommentsClose CommentsPermalink





(2) ELIMINATION OF COINSURANCE IN OUTPATIENT HOSPITAL SETTINGS- CommentsClose CommentsPermalink





(A) EXCLUSION FROM OPD FEE SCHEDULE- Section 1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 1395l(t)(1)(B)(iv)) is amended by striking ‘screening mammography (as defined in section 1861(jj)) and diagnostic mammography’ and inserting ‘diagnostic mammograms and Medicare covered preventive services (as defined in section 1861(iii)(1))’. CommentsClose CommentsPermalink





(B) CONFORMING AMENDMENTS- Section 1833(a)(2) of the Social Security Act (42 U.S.C. 1395l(a)(2)) is amended-- CommentsClose CommentsPermalink





(i) in subparagraph (F), by striking ‘and’ after the semicolon at the end; CommentsClose CommentsPermalink





(ii) in subparagraph (G)(ii), by adding ‘and’ at the , by adding ‘and’ at the end; and CommentsClose CommentsPermalink





(iii) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(H) with respect to additional preventive services (as defined in section 1861(ddd)) furnished by an outpatient department of a hospital, the amount determined under paragraph (1)(W);’. CommentsClose CommentsPermalink





(3) WAIVER OF APPLICATION OF DEDUCTIBLE FOR ALL PREVENTIVE SERVICES- The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is amended-- CommentsClose CommentsPermalink





(A) in clause (1), by striking ‘items and services described in section 1861(s)(10)(A)’ and inserting ‘Medicare covered preventive services (as defined in section 1861(iii))’;

(B) by inserting ‘and’ before ‘(4)’; and

(C) by striking clauses (5) through (8) and CommentsClose CommentsPermalink




(B) by striking clause (5) and all that follows through ‘(9)’ and inserting ‘and (5)’. CommentsClose CommentsPermalink





(4) APPLICATION TO PROVIDERS OF SERVICES- Section 1866(a)(2)(A)(ii) of such Act (42 U.S.C. 1395cc(a)(2)(A)(ii)) is amended by inserting ‘other than for Medicare covered preventive services and’ after ‘for such items and services (’. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall apply to services furnished on or after January 1, 2011. CommentsClose CommentsPermalink





SEC. 1306 (d) Report to Congress on Barriers to Preventive Services- Not later than 12 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall report to Congress on Medicare beneficiary barriers, such as physician referral requirements or being a part of the Welcome to Medicare Physical Exam, to abdominal aortic aneurysm screening and other preventative services as approved by the U.S. Preventive Services Task Force. Furthermore, using existing educational resources, the Secretary shall make educating patients and physicians regarding the risk factors for an abdominal aortic aneurysm and when beneficiaries should be screened, a priority. CommentsClose CommentsPermalink

SEC. 1307. WAIVER OF DEDUCTIBLE FOR COLORECTAL CANCER SCREENING TESTS REGARDLESS OF CODING, SUBSEQUENT DIAGNOSIS, OR ANCILLARY TISSUE REMOVAL.

(a) In General- Section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)), as amended by section 13056(b)(3), is amended by adding at the end the following new sentence: ‘Clause (1) of the first sentence of this subsection shall apply with respect to a colorectal cancer screening test regardless of the code that is billed for the establishment of a diagnosis as a result of the test, or for the removal of tissue or other matter or other procedure that is furnished in connection with, as a result of, and in the same clinical encounter as, the screening test.’. CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) shall apply to items and services furnished on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 13078. EXCLUDING CLINICAL SOCIAL WORKER SERVICES FROM COVERAGE UNDER THE MEDICARE SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM AND CONSOLIDATED PAYMENT.

(a) In General- Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting ‘clinical social worker services,’ after ‘qualified psychologist services,’. CommentsClose CommentsPermalink





(b) Conforming Amendment- Section 1861(hh)(2) of the Social Security Act (42 U.S.C. 1395x(hh)(2)) is amended by striking ‘and other than services furnished to an inpatient of a skilled nursing facility which the facility is required to provide as a requirement for participation’. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall apply to items and services furnished on or after July 1, 2010. CommentsClose CommentsPermalink

SEC. 13089. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES AND MENTAL HEALTH COUNSELOR SERVICES.

(a) Coverage of Marriage and Family Therapist Services- CommentsClose CommentsPermalink





(1) COVERAGE OF SERVICES- Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as amended by section 12353, is amended-- CommentsClose CommentsPermalink





(A) in subparagraph (EE), by striking ‘and’ at the end; CommentsClose CommentsPermalink





(B) in subparagraph (FF), by adding ‘and’ at the end; and CommentsClose CommentsPermalink





(C) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(GG) marriage and family therapist services (as defined in subsection (jjj));’. CommentsClose CommentsPermalink





(2) DEFINITION- Section 1861 of the Social Security Act (42 U.S.C. 1395x), as amended by sections 1235 and 13053 and 1306, is amended by adding at the end the following new subsection: CommentsClose CommentsPermalink

‘Marriage and Family Therapist Services

‘(jjj)(1) The term ‘marriage and family therapist services’ means services performed by a marriage and family therapist (as defined in paragraph (2)) for the diagnosis and treatment of mental illnesses, which the marriage and family therapist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services. CommentsClose CommentsPermalink





‘(2) The term ‘marriage and family therapist’ means an individual who-- CommentsClose CommentsPermalink





‘(A) possesses a master’s or doctoral degree which qualifies for licensure or certification as a marriage and family therapist pursuant to State law; CommentsClose CommentsPermalink





‘(B) after obtaining such degree has performed at least 2 years of clinical supervised experience in marriage and family therapy; and CommentsClose CommentsPermalink





‘(C) is licensed or certified as a marriage and family therapist in the State in which marriage and family therapist services are performed.’. CommentsClose CommentsPermalink





(3) PROVISION FOR PAYMENT UNDER PART B- Section 1832(a)(2)(B) of the Social Security Act (42 U.S.C. 1395k(a)(2)(B)) is amended by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(v) marriage and family therapist services;’. CommentsClose CommentsPermalink





(4) AMOUNT OF PAYMENT- CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended-- CommentsClose CommentsPermalink





(i) by striking ‘and’ before ‘(W)’; and CommentsClose CommentsPermalink





(ii) by inserting before the semicolon at the end the following: ‘, and (X) with respect to marriage and family therapist services under section 1861(s)(2)(GG), the amounts paid shall be 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for payment of a psychologist under clause (L)’. CommentsClose CommentsPermalink





(B) DEVELOPMENT OF CRITERIA WITH RESPECT TO CONSULTATION WITH A HEALTH CARE PROFESSIONAL- The Secretary of Health and Human Services shall, taking into consideration concerns for patient confidentiality, develop criteria with respect to payment for marriage and family therapist services for which payment may be made directly to the marriage and family therapist under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) under which such a therapist must agree to consult with a patient’s attending or primary care physician or nurse practitioner in accordance with such criteria. CommentsClose CommentsPermalink





(5) EXCLUSION OF MARRIAGE AND FAMILY THERAPIST SERVICES FROM SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM- Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 13078(a), is amended by inserting ‘marriage and family therapist services (as defined in subsection (jjj)(1)),’ after ‘clinical social worker services,’. CommentsClose CommentsPermalink





(6) COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES PROVIDED IN RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS- Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by striking ‘or by a clinical social worker (as defined in subsection (hh)(1)),’ and inserting ‘, by a clinical social worker (as defined in subsection (hh)(1)), or by a marriage and family therapist (as defined in subsection (jjj)(2)),’. CommentsClose CommentsPermalink





(7) INCLUSION OF MARRIAGE AND FAMILY THERAPISTS AS PRACTITIONERS FOR ASSIGNMENT OF CLAIMS- Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is amended by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(vii) A marriage and family therapist (as defined in section 1861(jjj)(2)).’. CommentsClose CommentsPermalink





(b) Coverage of Mental Health Counselor Services- CommentsClose CommentsPermalink





(1) COVERAGE OF SERVICES- Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)), as previously amended, is further amended-- CommentsClose CommentsPermalink





(A) in subparagraph (FF), by striking ‘and’ at the end; CommentsClose CommentsPermalink





(B) in subparagraph (GG), by inserting ‘and’ at the end; and CommentsClose CommentsPermalink





(C) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(HH) mental health counselor services (as defined in subsection (kkk)(1));’. CommentsClose CommentsPermalink





(2) DEFINITION- Section 1861 of the Social Security Act (42 U.S.C. 1395x), as previously amended, is amended by adding at the end the following new subsection: CommentsClose CommentsPermalink

‘Mental Health Counselor Services

‘(kkk)(1) The term ‘mental health counselor services’ means services performed by a mental health counselor (as defined in paragraph (2)) for the diagnosis and treatment of mental illnesses which the mental health counselor is legally authorized to perform under State law (or the State regulatory mechanism provided by the State law) of the State in which such services are performed, as would otherwise be covered if furnished by a physician or as incident to a physician’s professional service, but only if no facility or other provider charges or is paid any amounts with respect to the furnishing of such services. CommentsClose CommentsPermalink





‘(2) The term ‘mental health counselor’ means an individual who-- CommentsClose CommentsPermalink





‘(A) possesses a master’s or doctor’s degree which qualifies the individual for licensure or certification for the practice of mental health counseling in the State in which the services are performed; CommentsClose CommentsPermalink





‘(B) after obtaining such a degree has performed at least 2 years of supervised mental health counselor practice; and CommentsClose CommentsPermalink





‘(C) is licensed or certified as a mental health counselor or professional counselor by the State in which the services are performed.’. CommentsClose CommentsPermalink





(3) PROVISION FOR PAYMENT UNDER PART B- Section 1832(a)(2)(B) of the Social Security Act (42 U.S.C. 1395k(a)(2)(B)), as amended by subsection (a)(3), is further amended-- CommentsClose CommentsPermalink





(A) by striking ‘and’ at the end of clause (iv); CommentsClose CommentsPermalink





(B) by adding ‘and’ at the end of clause (v); and CommentsClose CommentsPermalink





(C) by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(vi) mental health counselor services; and’. CommentsClose CommentsPermalink





(4) AMOUNT OF PAYMENT- CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)), as amended by subsection (a), is further amended-- CommentsClose CommentsPermalink





(i) by striking ‘and’ before ‘(X)’; and CommentsClose CommentsPermalink





(ii) by inserting before the semicolon at the end the following: ‘, and (Y), with respect to mental health counselor services under section 1861(s)(2)(HH), the amounts paid shall be 80 percent of the lesser of the actual charge for the services or 75 percent of the amount determined for payment of a psychologist under clause (L)’. CommentsClose CommentsPermalink





(B) DEVELOPMENT OF CRITERIA WITH RESPECT TO CONSULTATION WITH A PHYSICIAN- The Secretary of Health and Human Services shall, taking into consideration concerns for patient confidentiality, develop criteria with respect to payment for mental health counselor services for which payment may be made directly to the mental health counselor under part B of title XVIII of the Social Security Act (42 U.S.C. 1395j et seq.) under which such a counselor must agree to consult with a patient’s attending or primary care physician in accordance with such criteria. CommentsClose CommentsPermalink





(5) EXCLUSION OF MENTAL HEALTH COUNSELOR SERVICES FROM SKILLED NURSING FACILITY PROSPECTIVE PAYMENT SYSTEM- Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 13078(a) and subsection (a), is amended by inserting ‘mental health counselor services (as defined in section 1861(kkk)(1)),’ after ‘marriage and family therapist services (as defined in subsection (jjj)(1)),’. CommentsClose CommentsPermalink





(6) COVERAGE OF MENTAL HEALTH COUNSELOR SERVICES PROVIDED IN RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS- Section 1861(aa)(1)(B) of the Social Security Act (42 U.S.C. 1395x(aa)(1)(B)), as amended by subsection (a), is amended by striking ‘or by a marriage and family therapist (as defined in subsection (jjj)(2)),’ and inserting ‘by a marriage and family therapist (as defined in subsection (jjj)(2)), or a mental health counselor (as defined in subsection (kkk)(2)),’. CommentsClose CommentsPermalink





(7) INCLUSION OF MENTAL HEALTH COUNSELORS AS PRACTITIONERS FOR ASSIGNMENT OF CLAIMS- Section 1842(b)(18)(C) of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended by subsection (a)(7), is amended by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(viii) A mental health counselor (as defined in section 1861(kkk)(2)).’. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall apply to items and services furnished on or after January 1, 2011. CommentsClose CommentsPermalink

SEC. 130910. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH ADD-ON.

Section 138(a)(1) of the Medicare Improvements for Patients and Providers Act of 2008 (Public Law 110-275) is amended by striking ‘December 31, 2009’ and inserting ‘December 31, 2011’. CommentsClose CommentsPermalink

SEC. 13101. EXPANDING ACCESS TO VACCINES.

(a) In General- Paragraph (10) of section 1861(s) of the Social Security Act (42 U.S.C. 1395w(s)) is amended to read as follows: CommentsClose CommentsPermalink





‘(10) federally recommended vaccines (as defined in subsection (lll)) and their respective administration;’. CommentsClose CommentsPermalink





(b) Federally Recommended Vaccines Defined- Section 1861 of such Act, as previously amended, is further amended by adding at the end the following new subsection: CommentsClose CommentsPermalink

‘Federally Recommended Vaccines

‘(lll) The term ‘federally recommended vaccine’ means an approved vaccine recommended by the Advisory Committee on Immunization Practices (an advisory committee established by the Secretary, acting through the Director of the Centers for Disease Control and Prevention).’. CommentsClose CommentsPermalink





(c) Conforming Amendments- CommentsClose CommentsPermalink





(1) Section 1833 of such Act (42 U.S.C. 1395l) is amended, in each of subsections (a)(1)(B), (a)(2)(G), (a)(3)(A), and (b)(1) (as amended by section 1305(b)), by striking ‘1861(s)(10)(A)’ or ‘1861(s)(10)(Bby striking ‘1861(s)(10)(A)’ and inserting ‘1861(s)(10)’ each place it appears. CommentsClose CommentsPermalink





(2) Section 1842(o)(1)(A)(iv) of such Act (42 U.S.C. 1395u(o)(1)(A)(iv)) is amended-- CommentsClose CommentsPermalink





(A) by striking ‘subparagraph (A) or (B) of’; and CommentsClose CommentsPermalink





(B) by inserting before the period the following: ‘and before January 1, 2011, and influenza vaccines furnished on or after January 1, 2011’. CommentsClose CommentsPermalink





(3) Section 1847A(c)(6) of such Act (42 U.S.C. 1395w-3a(c)(6)) is amended by striking subparagraph (G) and inserting the following: CommentsClose CommentsPermalink





‘(G) IMPLEMENTATION- Chapter 35 of title 44, United States Code shall not apply to manufacturer provision of information pursuant to section 1927(b)(3)(A)(iii) for purposes of implementation of this section.’. CommentsClose CommentsPermalink





(4) Section 1860D-2(e)(1)(B) of such Act (42 U.S.C. 1395w-102(e)(1)(B)) is amended by striking ‘such term includes a vaccine’ and all that follows through ‘its administration) and’. CommentsClose CommentsPermalink





(5) Section 1861(ww)(2)(A) of such Act (42 U.S.C. 1395x(ww)(2)(A))) is amended by striking ‘Pneumococcal, influenza, and hepatitis B vaccine and administration’ and inserting ‘Federally recommended vaccines (as defined in subsection (lll)) and their respective administration’. CommentsClose CommentsPermalink





(6) Section 1861(iii)(1) of such Act, as added by section 13056(a), is amended by amending subparagraph (J) to read as follows: CommentsClose CommentsPermalink





‘(J) Federally recommended vaccines (as defined in subsection (lll)) and their respective administration.’. CommentsClose CommentsPermalink





(7) Section 1927(b)(3)(A)(iii) of such Act (42 U.S.C. 1396r-8(b)(3)(A)(iii)) is amended, in the matter following subclause (III), by inserting ‘(A)(iv) (including influenza vaccines furnished on or after January 1, 2011),’ after ‘described in subparagraph.’(d) Effective ’ CommentsClose CommentsPermalink





(d) Effective Dates- The amendments made by-- CommentsClose CommentsPermalink





(1) this section (other than by subsection (c)(7)) shall apply to vaccines administered on or after January 1, 2011; and CommentsClose CommentsPermalink





(2) by subsection (c)(7) shall apply to calendar quarters beginning on or after January 1, 2010. CommentsClose CommentsPermalink

TITLE IV--QUALITY CommentsClose CommentsPermalink

Subtitle A--Comparative Effectiveness Research CommentsClose CommentsPermalink

SEC. 1401. COMPARATIVE EFFECTIVENESS RESEARCH.

(a) In General- tTitle XI of the Social Security Act is amended by adding at the end the following new part: CommentsClose CommentsPermalink

‘Part D--Comparative Effectiveness Research

‘COMPARATIVE EFFECTIVENESS RESEARCH

‘Sec. 1181. (a) Center for Comparative Effectiveness Research Established- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall establish within the Agency for Healthcare Research and Quality a Center for Comparative Effectiveness Research (in this section referred to as the ‘Center’) to conduct, support, and synthesize research (including research conducted or supported under section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003) with respect to the outcomes, effectiveness, and appropriateness of health care services and procedures in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically. CommentsClose CommentsPermalink





‘(2) DUTIES- The Center shall-- CommentsClose CommentsPermalink





‘(A) conduct, support, and synthesize research relevant to the comparative effectiveness of the full spectrum of health care items, services and systems, including pharmaceuticals, medical devices, medical and surgical procedures, and other medical interventions; CommentsClose CommentsPermalink





‘(B) conduct and support systematic reviews of clinical research, including original research conducted subsequent to the date of the enactment of this section; CommentsClose CommentsPermalink





‘(C) continuously develop rigorous scientific methodologies for conducting comparative effectiveness studies, and use such methodologies appropriately; CommentsClose CommentsPermalink





‘(D) submit to the Comparative Effectiveness Research Commission, the Secretary, and Congress appropriate relevant reports described in subsection (d)(2); and CommentsClose CommentsPermalink





‘(E) encourage, as appropriate, the development and use of clinical registries and the development of clinical effectiveness research data networks from electronic health records, post marketing drug and medical device surveillance efforts, and other forms of electronic health data. CommentsClose CommentsPermalink





‘(3) POWERS- CommentsClose CommentsPermalink





‘(A) OBTAINING OFFICIAL DATA- The Center may secure directly from any department or agency of the United States information necessary to enable it to carry out this section. Upon request of the Center, the head of that department or agency shall furnish that information to the Center on an agreed upon schedule. CommentsClose CommentsPermalink





‘(B) DATA COLLECTION- In order to carry out its functions, the Center shall-- CommentsClose CommentsPermalink





‘(i) utilize existing information, both published and unpublished, where possible, collected and assessed either by its own staff or under other arrangements made in accordance with this section, CommentsClose CommentsPermalink





‘(ii) carry out, or award grants or contracts for, original research and experimentation, where existing information is inadequate, and CommentsClose CommentsPermalink





‘(iii) adopt procedures allowing any interested party to submit information for the use by the Center and Commission under subsection (b) in making reports and recommendations. CommentsClose CommentsPermalink





‘(C) ACCESS OF GAO TO INFORMATION- The Comptroller General shall have unrestricted access to all deliberations, records, and nonproprietary data of the Center and Commission under subsection (b), immediately upon request. CommentsClose CommentsPermalink





‘(D) PERIODIC AUDIT- The Center and Commission under subsection (b) shall be subject to periodic audit by the Comptroller General. CommentsClose CommentsPermalink





‘(b) Oversight by Comparative Effectiveness Research Commission- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall establish an independent Comparative Effectiveness Research Commission (in this section referred to as the ‘Commission’) to oversee and evaluate the activities carried out by the Center under subsection (a), subject to the authority of the Secretary, to ensure such activities result in highly credible research and information resulting from such research. CommentsClose CommentsPermalink





‘(2) DUTIES- The Commission shall-- CommentsClose CommentsPermalink





‘(A) determine national priorities for research described in subsection (a) and in making such determinations consult with a broad array of public and private stakeholders, including patients and health care providers and payers; CommentsClose CommentsPermalink





‘(B) monitor the appropriateness of use of the CERTF described in subsection (g) with respect to the timely production of comparative effectiveness research determined to be a national priority under subparagraph (A); CommentsClose CommentsPermalink





‘(C) identify highly credible research methods and standards of evidence for such research to be considered by the Center; CommentsClose CommentsPermalink





‘(D) review the methodologies developed by the center under subsection (a)(2)(C); CommentsClose CommentsPermalink





‘(E) not later than one year after the date of the enactment of this section, enter into an arrangement under which the Institute of Medicine of the National Academy of Sciences shall conduct an evaluation and report on standards of evidence for such research; CommentsClose CommentsPermalink





‘(F) support forums to increase stakeholder awareness and permit stakeholder feedback on the efforts of the Center to advance methods and standards that promote highly credible research; CommentsClose CommentsPermalink





‘(G) make recommendations for policies that would allow for public access of data produced under this section, in accordance with appropriate privacy and proprietary practices, while ensuring that the information produced through such data is timely and credible; CommentsClose CommentsPermalink





‘(H) appoint a clinical perspective advisory panel for each research priority determined under subparagraph (A), which shall consult with patients and advise the Center on research questions, methods, and evidence gaps in terms of clinical outcomes for the specific research inquiry to be examined with respect to such priority to ensure that the information produced from such research is clinically relevant to decisions made by clinicians and patients at the point of care; CommentsClose CommentsPermalink





‘(I) make recommendations for the priority for periodic reviews of previous comparative effectiveness research and studies conducted by the Center under subsection (a); CommentsClose CommentsPermalink





‘(J) routinely review processes of the Center with respect to such research to confirm that the information produced by such research is objective, credible, consistent with standards of evidence established under this section, and developed through a transparent process that includes consultations with appropriate stakeholders; and CommentsClose CommentsPermalink





‘(K) make recommendations to the center for the broad dissemination of the findings of research conducted and supported under this section that enables clinicians, patients, consumers, and payers to make more informed health care decisions that improve quality and value. CommentsClose CommentsPermalink





‘(3) COMPOSITION OF COMMISSION- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The members of the Commission shall consist of-- CommentsClose CommentsPermalink





‘(i) the Director of the Agency for Healthcare Research and Quality; CommentsClose CommentsPermalink





‘(ii) the Chief Medical Officer of the Centers for Medicare & Medicaid Services; and CommentsClose CommentsPermalink





‘(iii) 15 additional members who shall represent broad constituencies of stakeholders including clinicians, patients, researchers, third-party payers, consumers of Federal and State beneficiary programs. CommentsClose CommentsPermalink





Of such members, at least 9 shall be practicing physicians, health care practitioners, consumers, or patients. CommentsClose CommentsPermalink





‘(B) QUALIFICATIONS- CommentsClose CommentsPermalink





‘(i) DIVERSE REPRESENTATION OF PERSPECTIVES- The members of the Commission shall represent a broad range of perspectives and shall collectively have experience in the following areas: CommentsClose CommentsPermalink





‘(I) Epidemiology. CommentsClose CommentsPermalink





‘(II) Health services research. CommentsClose CommentsPermalink





‘(III) Bioethics. CommentsClose CommentsPermalink





‘(IV) Decision sciences. CommentsClose CommentsPermalink





‘(V) Health disparities. CommentsClose CommentsPermalink





‘(VI) Economics. CommentsClose CommentsPermalink





‘(ii) DIVERSE REPRESENTATION OF HEALTH CARE COMMUNITY- At least one member shall represent each of the following health care communities: CommentsClose CommentsPermalink





‘(I) Patients. CommentsClose CommentsPermalink





‘(II) Health care consumers. CommentsClose CommentsPermalink





‘(III) Practicing Physicians, including surgeons. CommentsClose CommentsPermalink





‘(IV) Other health care practitioners engaged in clinical care. CommentsClose CommentsPermalink





‘(V) Employers. CommentsClose CommentsPermalink





‘(VI) Public payers. CommentsClose CommentsPermalink





‘(VII) Insurance plans. CommentsClose CommentsPermalink





‘(VIII) Clinical researchers who conduct research on behalf of pharmaceutical or device manufacturers. CommentsClose CommentsPermalink





‘(C) LIMITATION- No more than 3 of the Members of the Commission may be representatives of pharmaceutical or device manufacturers and such representatives shall be clinical researchers described under subparagraph (B)(ii)(VIII). CommentsClose CommentsPermalink





‘(4) APPOINTMENT- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall appoint the members of the Commission. CommentsClose CommentsPermalink





‘(B) CONSULTATION- In considering candidates for appointment to the Commission, the Secretary may consult with the Government Accountability Office and the Institute of Medicine of the National Academy of Sciences. CommentsClose CommentsPermalink





‘(5) CHAIRMAN; VICE CHAIRMAN- The Secretary shall designate a member of the Commission, at the time of appointment of the member, as Chairman and a member as Vice Chairman for that term of appointment, except that in the case of vacancy of the Chairmanship or Vice Chairmanship, the Secretary may designate another member for the remainder of that member’s term. The Chairman shall serve as an ex officio member of the National Advisory Council of the Agency for Health Care Research and Quality under section 931(c)(3)(B) of the Public Health Service Act. CommentsClose CommentsPermalink





‘(6) TERMS- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Except as provided in subparagraph (B), each member of the Commission shall be appointed for a term of 4 years. CommentsClose CommentsPermalink





‘(B) TERMS OF INITIAL APPOINTEES- Of the members first appointed-- CommentsClose CommentsPermalink





‘(i) 8 shall be appointed for a term of 4 years; and CommentsClose CommentsPermalink





‘(ii) 7 shall be appointed for a term of 3 years. CommentsClose CommentsPermalink





‘(7) COORDINATION- To enhance effectiveness and coordination, the Secretary is encouraged, to the greatest extent possible, to seek coordination between the Commission and the National Advisory Council of the Agency for Healthcare Research and Quality. CommentsClose CommentsPermalink





‘(8) CONFLICTS OF INTEREST- CommentsClose CommentsPermalink





‘(A) IN GENERAL- In appointing the members of the Commission or a clinical perspective advisory panel described in paragraph (2)(H), the Secretary or the Commission, respectively, shall take into consideration any financial interest (as defined in subparagraph (D)), consistent with this paragraph, and develop a plan for managing any identified conflicts. CommentsClose CommentsPermalink





‘(B) EVALUATION AND CRITERIA- When considering an appointment to the Commission or a clinical perspective advisory panel described paragraph (2)(H) the Secretary or the Commission shall review the expertise of the individual and the financial disclosure report filed by the individual pursuant to the Ethics in Government Act of 1978 for each individual under consideration for the appointment, so as to reduce the likelihood that an appointed individual will later require a written determination as referred to insection 208(b)(1) of title 18, United States Code, a written certification as referred to in section 208(b)(3) of title 18, United States Code, or a waiver as referred to in subparagraph (D)(iii) for service on the Commission at a meeting of the Commission. CommentsClose CommentsPermalink





‘(C) DISCLOSURES; PROHIBITIONS ON PARTICIPATION; WAIVERS- CommentsClose CommentsPermalink





‘(i) DISCLOSURE OF FINANCIAL INTEREST- Prior to a meeting of the Commission or a clinical perspective advisory panel described in paragraph (2)(H) regarding a ‘particular matter’ (as that term is used insection 208 of title 18, United States Code), each member of the Commission or the clinical perspective advisory panel who is a full-time Government employee or special Government employee shall disclose to the Secretary financial interests in accordance with subsection (b) of such section 208. CommentsClose CommentsPermalink





‘(ii) PROHIBITIONS ON PARTICIPATION- Except as provided under clause (iii), a member of the Commission or a clinical perspective advisory panel described in paragraph (2)(H) may not participate with respect to a particular matter considered in meeting of the Commission or the clinical perspective advisory panel if such member (or an immediate family member of such member) has a financial interest that could be affected by the advice given to the Secretary with respect to such matter, excluding interests exempted in regulations issued by the Director of the Office of Government Ethics as too remote or inconsequential to affect the integrity of the services of the Government officers or employees to which such regulations apply. CommentsClose CommentsPermalink





‘(iii) WAIVER- If the Secretary determines it necessary to afford the Commission or a clinical perspective advisory panel described in paragraph 2(H) essential expertise, the Secretary may grant a waiver of the prohibition in clause (ii) to permit a member described in such subparagraph to-- CommentsClose CommentsPermalink





‘(I) participate as a non-voting member with respect to a particular matter considered in a Commission or a clinical perspective advisory panel meeting; or CommentsClose CommentsPermalink





‘(II) participate as a voting member with respect to a particular matter considered in a Commission or a clinical perspective advisory panel meeting. CommentsClose CommentsPermalink





‘(iv) LIMITATION ON WAIVERS AND OTHER EXCEPTIONS- CommentsClose CommentsPermalink





‘(I) DETERMINATION OF ALLOWABLE EXCEPTIONS FOR THE COMMISSION- The number of waivers granted to members of the Commission cannot exceed one-half of the total number of members for the Commission. CommentsClose CommentsPermalink





‘(II) PROHIBITION ON VOTING STATUS ON CLINICAL PERSPECTIVE ADVISORY PANELS- No voting member of any clinical perspective advisory panel shall be in receipt of a waiver. No more than two nonvoting members of any clinical perspective advisory panel shall receive a waiver. CommentsClose CommentsPermalink





‘(D) FINANCIAL INTEREST DEFINED- For purposes of this paragraph, the term ‘financial interest’ means a financial interest undersection 208(a) of title 18, United States Code. CommentsClose CommentsPermalink





‘(9) COMPENSATION- While serving on the business of the Commission (including travel time), a member of the Commission shall be entitled to compensation at the per diem equivalent of the rate provided for level IV of the Executive Schedule undersection 5315 of title 5, United States Code; and while so serving away from home and the member’s regular place of business, a member may be allowed travel expenses, as authorized by the Director of the Commission. CommentsClose CommentsPermalink





‘(10) AVAILABILITY OF REPORTS- The Commission shall transmit to the Secretary a copy of each report submitted under this subsection and shall make such reports available to the public. CommentsClose CommentsPermalink





‘(11) DIRECTOR AND STAFF; EXPERTS AND CONSULTANTS- Subject to such review as the Secretary deems necessary to assure the efficient administration of the Commission, the Commission may-- CommentsClose CommentsPermalink





‘(A) appoint an Executive Director (subject to the approval of the Secretary) and such other personnel as Federal employees undersection 2105 of title 5, United States Code, as may be necessary to carry out its duties (without regard to the provisions of title 5, United States Code, governing appointments in the competitive service); CommentsClose CommentsPermalink





‘(B) seek such assistance and support as may be required in the performance of its duties from appropriate Federal departments and agencies; CommentsClose CommentsPermalink





‘(C) enter into contracts or make other arrangements, as may be necessary for the conduct of the work of the Commission (without regard to section 3709 of the Revised Statutes (41 U.S.C. 5)); CommentsClose CommentsPermalink





‘(D) make advance, progress, and other payments which relate to the work of the Commission; CommentsClose CommentsPermalink





‘(E) provide transportation and subsistence for persons serving without compensation; and CommentsClose CommentsPermalink





‘(F) prescribe such rules and regulations as it deems necessary with respect to the internal organization and operation of the Commission. CommentsClose CommentsPermalink





‘(c) Research Requirements- Any research conducted, supported, or synthesized under this section shall meet the following requirements: CommentsClose CommentsPermalink





‘(1) ENSURING TRANSPARENCY, CREDIBILITY, AND ACCESS- CommentsClose CommentsPermalink





‘(A) The establishment of the agenda and conduct of the research shall be insulated from inappropriate political or stakeholder influence. CommentsClose CommentsPermalink





‘(B) Methods of conducting such research shall be scientifically based. CommentsClose CommentsPermalink





‘(C) All aspects of the prioritization of research, conduct of the research, and development of conclusions based on the research shall be transparent to all stakeholders. CommentsClose CommentsPermalink





‘(D) The process and methods for conducting such research shall be publicly documented and available to all stakeholders. CommentsClose CommentsPermalink





‘(E) Throughout the process of such research, the Center shall provide opportunities for all stakeholders involved to review and provide public comment on the methods and findings of such research. CommentsClose CommentsPermalink





‘(2) USE OF CLINICAL PERSPECTIVE ADVISORY PANELS- The research shall meet a national research priority determined under subsection (b)(2)(A) and shall consider advice given to the Center by the clinical perspective advisory panel for the national research priority. CommentsClose CommentsPermalink





‘(3) STAKEHOLDER INPUT- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Commission shall consult with patients, health care providers, health care consumer representatives, and other appropriate stakeholders with an interest in the research through a transparent process recommended by the Commission. CommentsClose CommentsPermalink





‘(B) SPECIFIC AREAS OF CONSULTATION- Consultation shall include where deemed appropriate by the Commission-- CommentsClose CommentsPermalink





‘(i) recommending research priorities and questions; CommentsClose CommentsPermalink





‘(ii) recommending research methodologies; and CommentsClose CommentsPermalink





‘(iii) advising on and assisting with efforts to disseminate research findings. CommentsClose CommentsPermalink





‘(C) OMBUDSMAN- The Secretary shall designate a patient ombudsman. The ombudsman shall-- CommentsClose CommentsPermalink





‘(i) serve as an available point of contact for any patients with an interest in proposed comparative effectiveness studies by the Center; and CommentsClose CommentsPermalink





‘(ii) ensure that any comments from patients regarding proposed comparative effectiveness studies are reviewed by the Commission. CommentsClose CommentsPermalink





‘(4) TAKING INTO ACCOUNT POTENTIAL DIFFERENCES- Research shall-- CommentsClose CommentsPermalink





‘(A) be designed, as appropriate, to take into account the potential for differences in the effectiveness of health care items and services used with various subpopulations such as racial and ethnic minorities, women, different age groups (including children, adolescents, adults, and seniors), and individuals with different comorbidities; and‘(B)-- CommentsClose CommentsPermalink





‘(B) seek, as feasible and appropriate, to include members of such subpopulations as subjects in the research. CommentsClose CommentsPermalink





‘(d) Public Access to Comparative Effectiveness Information- CommentsClose CommentsPermalink





‘(1) IN GENERAL- Not later than 90 days after receipt by the Center or Commission, as applicable, of a relevant report described in paragraph (2) made by the Center, Commission, or clinical perspective advisory panel under this section, appropriate information contained in such report shall be posted on the official public Internet site of the Center and of the Commission, as applicable. CommentsClose CommentsPermalink





‘(2) RELEVANT REPORTS DESCRIBED- For purposes of this section, a relevant report is each of the following submitted by the Center or a grantee or contractor of the Center: CommentsClose CommentsPermalink





‘(A) Any interim or progress reports as deemed appropriate by the Secretary. CommentsClose CommentsPermalink





‘(B) Stakeholder comments. CommentsClose CommentsPermalink





‘(C) A final report. CommentsClose CommentsPermalink





‘(e) Dissemination and Incorporation of Comparative Effectiveness Information- CommentsClose CommentsPermalink





‘(1) DISSEMINATION- The Center shall provide for the dissemination of appropriate findings produced by research supported, conducted, or synthesized under this section to health care providers, patients, vendors of health information technology focused on clinical decision support, appropriate professional associations, and Federal and private health plans, and other relevant stakeholders. In disseminating such findings the Center shall-- CommentsClose CommentsPermalink





‘(A) convey findings of research so that they are comprehensible and useful to patients and providers in making health care decisions; CommentsClose CommentsPermalink





‘(B) discuss findings and other considerations specific to certain sub-populations, risk factors, and comorbidities as appropriate; CommentsClose CommentsPermalink





‘(C) include considerations such as limitations of research and what further research may be needed, as appropriate; CommentsClose CommentsPermalink





‘(D) not include any data that the dissemination of which would violate the privacy of research participants or violate any confidentiality agreements made with respect to the use of data under this section; and CommentsClose CommentsPermalink





‘(E) assist the users of health information technology focused on clinical decision support to promote the timely incorporation of such findings into clinical practices and promote the ease of use of such incorporation. CommentsClose CommentsPermalink





‘(2) DISSEMINATION PROTOCOLS AND STRATEGIES- The Center shall develop protocols and strategies for the appropriate dissemination of research findings in order to ensure effective communication of findings and the use and incorporation of such findings into relevant activities for the purpose of informing higher quality and more effective and efficient decisions regarding medical items and services. In developing and adopting such protocols and strategies, the Center shall consult with stakeholders concerning the types of dissemination that will be most useful to the end users of information and may provide for the utilization of multiple formats for conveying findings to different audiences, including dissemination to individuals with limited English proficiency. CommentsClose CommentsPermalink





‘(f) Reports to Congress- CommentsClose CommentsPermalink





‘(1) ANNUAL REPORTS- Beginning not later than one year after the date of the enactment of this section, the Director of the Agency of Healthcare Research and Quality and the Commission shall submit to Congress an annual report on the activities of the Center and the Commission, as well as the research, conducted under this section. Each such report shall include a discussion of the Center’s compliance with subsection (c)(B)(44)(B), including any reasons for lack of complicance with such subsection. CommentsClose CommentsPermalink





‘(2) RECOMMENDATION FOR FAIR SHARE PER CAPITA AMOUNT FOR ALL-PAYER FINANCING- Beginning not later than December 31, 2011, the Secretary shall submit to Congress an annual recommendation for a fair share per capita amount described in subsection (c)(1) of section 9511 of the Internal Revenue Code of 1986 for purposes of funding the CERTF under such section. CommentsClose CommentsPermalink





‘(3) ANALYSIS AND REVIEW- Not later than December 31, 2013, the Secretary, in consultation with the Commission, shall submit to Congress a report on all activities conducted or supported under this section as of such date. Such report shall include an evaluation of the overall costs of such activities and an analysis of the backlog of any research proposals approved by the Commission but not funded. CommentsClose CommentsPermalink





‘(g) Funding of Comparative Effectiveness Research- For fiscal year 2010 and each subsequent fiscal year, amounts in the Comparative Effectiveness Research Trust Fund (referred to in this section as the ‘CERTF’) under section 9511 of the Internal Revenue Code of 1986 shall be available, without the need for further appropriations and without fiscal year limitation, to the Secretary to carry out this section. CommentsClose CommentsPermalink





‘(h) Construction- Nothing in this section shall be construed to permit the Commission or the Center to mandate coverage, reimbursement, or other policies for any public or private payer. CommentsClose CommentsPermalink





‘(i) Research Not To Be Used To Deny or Ration Care- In no case may any research conducted, supported, or developed by the Center, the Commission, or the Federal Coordinating Council for Comparative Effectiveness Research be used by the federal government to deny or ration care. CommentsClose CommentsPermalink





‘(j) Application of Federally Funded Clinical Comparative Effectiveness Research- The Centers for Medicare & Medicaid Services may not use Federally funded clinical comparative effectiveness research data under this section to make coverage determinations for medical treatments, services, or items under title XVIII on the basis of cost. CommentsClose CommentsPermalink





‘(k) Conditions on Recommendations of Standards or Protocols- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The work performed by the Commission or the Center shall be based upon consultation with, and review by, the specialty colleges and academies of medicine to determine best practices within their field of specialty. Any recommendations made or best practices developed by the Commission or the Center -- CommentsClose CommentsPermalink





‘(A) shall be based upon evidence-based medicine; and CommentsClose CommentsPermalink





‘(B) shall not violate standards and protocols of clinical excellence of the specialty colleges and academies. CommentsClose CommentsPermalink





‘(2) DEFINITIONS- For purposes of this subsection: CommentsClose CommentsPermalink





‘(A) SPECIALTY COLLEGES AND ACADEMIES OF MEDICINE- The term ‘specialty colleges and academies of medicine’ means the trade associations and professional membership societies that represent physicians based on the field of medicine in which each such physician practices or is board certified. CommentsClose CommentsPermalink





‘(B) STANDARDS AND PROTOCOLS OF CLINICAL EXCELLENCE- The term ‘standards and protocols of clinical excellence’ means clinical or practice guidelines that consist of a set of directions or principles that is based on evidence and is designed to assist a health care practitioner with decisions about appropriate diagnostic, therapeutic, or other clinical procedures for specific clinical circumstances.’. CommentsClose CommentsPermalink





(b) Comparative Effectiveness Research Trust Fund; Financing for the Trust Fund- For provision establishing a Comparative Effectiveness Research Trust Fund and financing such Trust Fund, see section 1802. CommentsClose CommentsPermalink

Subtitle B--Nursing Home Transparency CommentsClose CommentsPermalink

PART 1--IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING FACILITIES AND NURSING FACILITIES

SEC. 1411. REQUIRED DISCLOSURE OF OWNERSHIP AND ADDITIONAL DISCLOSABLE PARTIES INFORMATION.

(a) In General- Section 1124 of the Social Security Act (42 U.S.C. 1320a-3) is amended by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(c) Required Disclosure of Ownership and Additional Disclosable Parties Information- CommentsClose CommentsPermalink





‘(1) DISCLOSURE- A facility (as defined in paragraph (7)(B)) shall have the information described in paragraph (3) available-- CommentsClose CommentsPermalink





‘(A) during the period beginning on the date of the enactment of this subsection and ending on the date such information is made available to the public under section 1411(b) of the America’s Affordable Health Choices Act of 2009, for submission to the Secretary, the Inspector General of the Department of Health and Human Services, the State in which the facility is located, and the State long-term care ombudsman in the case where the Secretary, the Inspector General, the State, or the State long-term care ombudsman requests such information; and CommentsClose CommentsPermalink





‘(B) beginning on the effective date of the final regulations promulgated under paragraph (4)(A), for reporting such information in accordance with such final regulations. CommentsClose CommentsPermalink





Nothing in subparagraph (A) shall be construed as authorizing a facility to dispose of or delete information described in such subparagraph after the effective date of the final regulations promulgated under paragraph (4)(A). CommentsClose CommentsPermalink





‘(2) PUBLIC AVAILABILITY OF INFORMATION- During the period described in paragraph (1)(A), a facility shall-- CommentsClose CommentsPermalink





‘(A) make the information described in paragraph (3) available to the public upon request and update such information as may be necessary to reflect changes in such information; and CommentsClose CommentsPermalink





‘(B) post a notice of the availability of such information in the lobby of the facility in a prominent manner. CommentsClose CommentsPermalink





‘(3) INFORMATION DESCRIBED- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The following information is described in this paragraph: CommentsClose CommentsPermalink





‘(i) The information described in subsections (a) and (b), subject to subparagraph (C). CommentsClose CommentsPermalink





‘(ii) The identity of and information on-- CommentsClose CommentsPermalink





‘(I) each member of the governing body of the facility, including the name, title, and period of service of each such member; CommentsClose CommentsPermalink





‘(II) each person or entity who is an officer, director, member, partner, trustee, or managing employee of the facility, including the name, title, and date of start of service of each such person or entity; and CommentsClose CommentsPermalink





‘(III) each person or entity who is an additional disclosable party of the facility. CommentsClose CommentsPermalink





‘(iii) The organizational structure of each person and entity described in subclauses (II) and (III) of clause (ii) and a description of the relationship of each such person or entity to the facility and to one another. CommentsClose CommentsPermalink





‘(B) SPECIAL RULE WHERE INFORMATION IS ALREADY REPORTED OR SUBMITTED- To the extent that information reported by a facility to the Internal Revenue Service on Form 990, information submitted by a facility to the Securities and Exchange Commission, or information otherwise submitted to the Secretary or any other Federal agency contains the information described in clauses (i), (ii), or (iii) of subparagraph (A), the Secretary may allow, to the extent practicable, such Form or such information to meet the requirements of paragraph (1) and to be submitted in a manner specified by the Secretary. CommentsClose CommentsPermalink





‘(C) SPECIAL RULE- In applying subparagraph (A)(i)-- CommentsClose CommentsPermalink





‘(i) with respect to subsections (a) and (b), ‘ownership or control interest’ shall include direct or indirect interests, including such interests in intermediate entities; and CommentsClose CommentsPermalink





‘(ii) subsection (a)(3)(A)(ii) shall include the owner of a whole or part interest in any mortgage, deed of trust, note, or other obligation secured, in whole or in part, by the entity or any of the property or assets thereof, if the interest is equal to or exceeds 5 percent of the total property or assets of the entirety. CommentsClose CommentsPermalink





‘(4) REPORTING- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Not later than the date that is 2 years after the date of the enactment of this subsection, the Secretary shall promulgate regulations requiring, effective on the date that is 90 days after the date on which such final regulations are published in the Federal Register, a facility to report the information described in paragraph (3) to the Secretary in a standardized format, and such other regulations as are necessary to carry out this subsection. Such final regulations shall ensure that the facility certifies, as a condition of participation and payment under the program under title XVIII or XIX, that the information reported by the facility in accordance with such final regulations is accurate and current. CommentsClose CommentsPermalink





‘(B) GUIDANCE- The Secretary shall provide guidance and technical assistance to States on how to adopt the standardized format under subparagraph (A). CommentsClose CommentsPermalink





‘(5) NO EFFECT ON EXISTING REPORTING REQUIREMENTS- Nothing in this subsection shall reduce, diminish, or alter any reporting requirement for a facility that is in effect as of the date of the enactment of this subsection. CommentsClose CommentsPermalink





‘(6) DEFINITIONS- In this subsection: CommentsClose CommentsPermalink





‘(A) ADDITIONAL DISCLOSABLE PARTY- The term ‘additional disclosable party’ means, with respect to a facility, any person or entity who-- CommentsClose CommentsPermalink





‘(i) exercises operational, financial, or managerial control over the facility or a part thereof, or provides policies or procedures for any of the operations of the facility, or provides financial or cash management services to the facility; CommentsClose CommentsPermalink





‘(ii) leases or subleases real property to the facility, or owns a whole or part interest equal to or exceeding 5 percent of the total value of such real property; CommentsClose CommentsPermalink





‘(iii) lends funds or provides a financial guarantee to the facility in an amount which is equal to or exceeds $50,000; or CommentsClose CommentsPermalink





‘(iv) provides management or administrative services, clinical consulting services, or accounting or financial services to the facility. CommentsClose CommentsPermalink





‘(B) FACILITY- The term ‘facility’ means a disclosing entity which is-- CommentsClose CommentsPermalink





‘(i) a skilled nursing facility (as defined in section 1819(a)); or CommentsClose CommentsPermalink





‘(ii) a nursing facility (as defined in section 1919(a)). CommentsClose CommentsPermalink





‘(C) MANAGING EMPLOYEE- The term ‘managing employee’ means, with respect to a facility, an individual (including a general manager, business manager, administrator, director, or consultant) who directly or indirectly manages, advises, or supervises any element of the practices, finances, or operations of the facility. CommentsClose CommentsPermalink





‘(D) ORGANIZATIONAL STRUCTURE- The term ‘organizational structure’ means, in the case of-- CommentsClose CommentsPermalink





‘(i) a corporation, the officers, directors, and shareholders of the corporation who have an ownership interest in the corporation which is equal to or exceeds 5 percent; CommentsClose CommentsPermalink





‘(ii) a limited liability company, the members and managers of the limited liability company (including, as applicable, what percentage each member and manager has of the ownership interest in the limited liability company); CommentsClose CommentsPermalink





‘(iii) a general partnership, the partners of the general partnership; CommentsClose CommentsPermalink





‘(iv) a limited partnership, the general partners and any limited partners of the limited partnership who have an ownership interest in the limited partnership which is equal to or exceeds 10 percent; CommentsClose CommentsPermalink





‘(v) a trust, the trustees of the trust; CommentsClose CommentsPermalink





‘(vi) an individual, contact information for the individual; and CommentsClose CommentsPermalink





‘(vii) any other person or entity, such information as the Secretary determines appropriate.’. CommentsClose CommentsPermalink





(b) Public Availability of Information- CommentsClose CommentsPermalink





(1) IN GENERAL- Not later than the date that is 1 year after the date on which the final regulations promulgated under section 1124(c)(4)(A) of the Social Security Act, as added by subsection (a), are published in the Federal Register, the information reported in accordance with such final regulations shall be made available to the public in accordance with procedures established by the Secretary. CommentsClose CommentsPermalink





(2) DEFINITIONS- In this subsection: CommentsClose CommentsPermalink





(A) NURSING FACILITY- The term ‘nursing facility’ has the meaning given such term in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)). CommentsClose CommentsPermalink





(B) SECRETARY- The term ‘Secretary’ means the Secretary of Health and Human Services. CommentsClose CommentsPermalink





(C) SKILLED NURSING FACILITY- The term ‘skilled nursing facility’ has the meaning given such term in section 1819(a) of the Social Security Act (42 U.S.C. 1395i-3(a)). CommentsClose CommentsPermalink





(c) Conforming Amendments- CommentsClose CommentsPermalink





(1) SKILLED NURSING FACILITIES- Section 1819(d)(1) of the Social Security Act (42 U.S.C. 1395i-3(d)(1)) is amended by striking subparagraph (B) and redesignating subparagraph (C) as subparagraph (B). CommentsClose CommentsPermalink





(2) NURSING FACILITIES- Section 1919(d)(1) of the Social Security Act (42 U.S.C. 1396r(d)(1)) is amended by striking subparagraph (B) and redesignating subparagraph (C) as subparagraph (B). CommentsClose CommentsPermalink

SEC. 1412. ACCOUNTABILITY REQUIREMENTS.

(a) Effective Compliance and Ethics Programs- CommentsClose CommentsPermalink





(1) SKILLED NURSING FACILITIES- Section 1819(d)(1) of the Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by section 1411(c)(1), is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(C) COMPLIANCE AND ETHICS PROGRAMS- CommentsClose CommentsPermalink





‘(i) REQUIREMENT- On or after the date that is 36 months after the date of the enactment of this subparagraph, a skilled nursing facility shall, with respect to the entity that operates the facility (in this subparagraph referred to as the ‘operating organization’ or ‘organization’), have in operation a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under this Act and in promoting quality of care consistent with regulations developed under clause (ii). CommentsClose CommentsPermalink





‘(ii) DEVELOPMENT OF REGULATIONS- CommentsClose CommentsPermalink





‘(I) IN GENERAL- Not later than the date that is 2 years after such date of the enactment, the Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall promulgate regulations for an effective compliance and ethics program for operating organizations, which may include a model compliance program. CommentsClose CommentsPermalink





‘(II) DESIGN OF REGULATIONS- Such regulations with respect to specific elements or formality of a program may vary with the size of the organization, such that larger organizations should have a more formal and rigorous program and include established written policies defining the standards and procedures to be followed by its employees. Such requirements shall specifically apply to the corporate level management of multi-unit nursing home chains. CommentsClose CommentsPermalink





‘(III) EVALUATION- Not later than 3 years after the date of promulgation of regulations under this clause, the Secretary shall complete an evaluation of the compliance and ethics programs required to be established under this subparagraph. Such evaluation shall determine if such programs led to changes in deficiency citations, changes in quality performance, or changes in other metrics of resident quality of care. The Secretary shall submit to Congress a report on such evaluation and shall include in such report such recommendations regarding changes in the requirements for such programs as the Secretary determines appropriate. CommentsClose CommentsPermalink





‘(iii) REQUIREMENTS FOR COMPLIANCE AND ETHICS PROGRAMS- In this subparagraph, the term ‘compliance and ethics program’ means, with respect to a skilled nursing facility, a program of the operating organization that-- CommentsClose CommentsPermalink





‘(I) has been reasonably designed, implemented, and enforced so that it generally will be effective in preventing and detecting criminal, civil, and administrative violations under this Act and in promoting quality of care; and CommentsClose CommentsPermalink





‘(II) includes at least the required components specified in clause (iv). CommentsClose CommentsPermalink





‘(iv) REQUIRED COMPONENTS OF PROGRAM- The required components of a compliance and ethics program of an organization are the following: CommentsClose CommentsPermalink





‘(I) The organization must have established compliance standards and procedures to be followed by its employees, contractors, and other agents that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under this Act. CommentsClose CommentsPermalink





‘(II) Specific individuals within high-level personnel of the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures and have sufficient resources and authority to assure such compliance. CommentsClose CommentsPermalink





‘(III) The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in criminal, civil, and administrative violations under this Act. CommentsClose CommentsPermalink





‘(IV) The organization must have taken steps to communicate effectively its standards and procedures to all employees and other agents, such as by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required. CommentsClose CommentsPermalink





‘(V) The organization must have taken reasonable steps to achieve compliance with its standards, such as by utilizing monitoring and auditing systems reasonably designed to detect criminal, civil, and administrative violations under this Act by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents could report violations by others within the organization without fear of retribution. CommentsClose CommentsPermalink





‘(VI) The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense. CommentsClose CommentsPermalink





‘(VII) After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including repayment of any funds to which it was not entitled and any necessary modification to its program to prevent and detect criminal, civil, and administrative violations under this Act. CommentsClose CommentsPermalink





‘(VIII) The organization must periodically undertake reassessment of its compliance program to identify changes necessary to reflect changes within the organization and its facilities. CommentsClose CommentsPermalink





‘(v) COORDINATION- The provisions of this subparagraph shall apply with respect to a skilled nursing facility in lieu of section 1874(d).’. CommentsClose CommentsPermalink





(2) NURSING FACILITIES- Section 1919(d)(1) of the Social Security Act (42 U.S.C. 1396r(d)(1)), as amended by section 1411(c)(2), is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(C) COMPLIANCE AND ETHICS PROGRAM- CommentsClose CommentsPermalink





‘(i) REQUIREMENT- On or after the date that is 36 months after the date of the enactment of this subparagraph, a nursing facility shall, with respect to the entity that operates the facility (in this subparagraph referred to as the ‘operating organization’ or ‘organization’), have in operation a compliance and ethics program that is effective in preventing and detecting criminal, civil, and administrative violations under this Act and in promoting quality of care consistent with regulations developed under clause (ii). CommentsClose CommentsPermalink





‘(ii) DEVELOPMENT OF REGULATIONS- CommentsClose CommentsPermalink





‘(I) IN GENERAL- Not later than the date that is 2 years after such date of the enactment, the Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall develop regulations for an effective compliance and ethics program for operating organizations, which may include a model compliance program. CommentsClose CommentsPermalink





‘(II) DESIGN OF REGULATIONS- Such regulations with respect to specific elements or formality of a program may vary with the size of the organization, such that larger organizations should have a more formal and rigorous program and include established written policies defining the standards and procedures to be followed by its employees. Such requirements may specifically apply to the corporate level management of multi-unit nursing home chains. CommentsClose CommentsPermalink





‘(III) EVALUATION- Not later than 3 years after the date of promulgation of regulations under this clause the Secretary shall complete an evaluation of the compliance and ethics programs required to be established under this subparagraph. Such evaluation shall determine if such programs led to changes in deficiency citations, changes in quality performance, or changes in other metrics of resident quality of care. The Secretary shall submit to Congress a report on such evaluation and shall include in such report such recommendations regarding changes in the requirements for such programs as the Secretary determines appropriate. CommentsClose CommentsPermalink





‘(iii) REQUIREMENTS FOR COMPLIANCE AND ETHICS PROGRAMS- In this subparagraph, the term ‘compliance and ethics program’ means, with respect to a nursing facility, a program of the operating organization that-- CommentsClose CommentsPermalink





‘(I) has been reasonably designed, implemented, and enforced so that it generally will be effective in preventing and detecting criminal, civil, and administrative violations under this Act and in promoting quality of care; and CommentsClose CommentsPermalink





‘(II) includes at least the required components specified in clause (iv). CommentsClose CommentsPermalink





‘(iv) REQUIRED COMPONENTS OF PROGRAM- The required components of a compliance and ethics program of an organization are the following: CommentsClose CommentsPermalink





‘(I) The organization must have established compliance standards and procedures to be followed by its employees and other agents that are reasonably capable of reducing the prospect of criminal, civil, and administrative violations under this Act. CommentsClose CommentsPermalink





‘(II) Specific individuals within high-level personnel of the organization must have been assigned overall responsibility to oversee compliance with such standards and procedures and has sufficient resources and authority to assure such compliance. CommentsClose CommentsPermalink





‘(III) The organization must have used due care not to delegate substantial discretionary authority to individuals whom the organization knew, or should have known through the exercise of due diligence, had a propensity to engage in criminal, civil, and administrative violations under this Act. CommentsClose CommentsPermalink





‘(IV) The organization must have taken steps to communicate effectively its standards and procedures to all employees and other agents, such as by requiring participation in training programs or by disseminating publications that explain in a practical manner what is required. CommentsClose CommentsPermalink





‘(V) The organization must have taken reasonable steps to achieve compliance with its standards, such as by utilizing monitoring and auditing systems reasonably designed to detect criminal, civil, and administrative violations under this Act by its employees and other agents and by having in place and publicizing a reporting system whereby employees and other agents could report violations by others within the organization without fear of retribution. CommentsClose CommentsPermalink





‘(VI) The standards must have been consistently enforced through appropriate disciplinary mechanisms, including, as appropriate, discipline of individuals responsible for the failure to detect an offense. CommentsClose CommentsPermalink





‘(VII) After an offense has been detected, the organization must have taken all reasonable steps to respond appropriately to the offense and to prevent further similar offenses, including repayment of any funds to which it was not entitled and any necessary modification to its program to prevent and detect criminal, civil, and administrative violations under this Act. CommentsClose CommentsPermalink





‘(VIII) The organization must periodically undertake reassessment of its compliance program to identify changes necessary to reflect changes within the organization and its facilities. CommentsClose CommentsPermalink





‘(v) COORDINATION- The provisions of this subparagraph shall apply with respect to a nursing facility in lieu of section 1902(a)(77).’. CommentsClose CommentsPermalink





(b) Quality Assurance and Performance Improvement Program- CommentsClose CommentsPermalink





(1) SKILLED NURSING FACILITIES- Section 1819(b)(1)(B) of the Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended-- CommentsClose CommentsPermalink





(A) by striking ‘ASSURANCE’ and inserting ‘ASSURANCE AND QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT PROGRAM’; CommentsClose CommentsPermalink





(B) by designating the matter beginning with ‘A skilled nursing facility’ as a clause (i) with the heading ‘IN GENERAL- ’ and the appropriate indentation; CommentsClose CommentsPermalink





and(C (C) in clause (i) (as so designated by subparagraph (B)), by redesignating clauses (i) and (ii) as subclauses (I) and (II), respectively; and CommentsClose CommentsPermalink





(D) by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(ii) QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT PROGRAM- CommentsClose CommentsPermalink





‘(I) IN GENERAL- Not later than December 31, 2011, the Secretary shall establish and implement a quality assurance and performance improvement program (in this clause referred to as the ‘QAPI program’) for skilled nursing facilities, including multi-unit chains of such facilities. Under the QAPI program, the Secretary shall establish standards relating to such facilities and provide technical assistance to such facilities on the development of best practices in order to meet such standards. Not later than 1 year after the date on which the regulations are promulgated under subclause (II), a skilled nursing facility must submit to the Secretary a plan for the facility to meet such standards and implement such best practices, including how to coordinate the implementation of such plan with quality assessment and assurance activities conducted under clause (i). CommentsClose CommentsPermalink





‘(II) REGULATIONS- The Secretary shall promulgate regulations to carry out this clause.’. CommentsClose CommentsPermalink





(2) NURSING FACILITIES- Section 1919(b)(1)(B) of the Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended-- CommentsClose CommentsPermalink





(A) by striking ‘ASSURANCE’ and inserting ‘ASSURANCE AND QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT PROGRAM’; CommentsClose CommentsPermalink





(B) by designating the matter beginning with ‘A nursing facility’ as a clause (i) with the heading ‘IN GENERAL- ’ and the appropriate indentation; and CommentsClose CommentsPermalink





(C) by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(ii) QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT PROGRAM- CommentsClose CommentsPermalink





‘(I) IN GENERAL- Not later than December 31, 2011, the Secretary shall establish and implement a quality assurance and performance improvement program (in this clause referred to as the ‘QAPI program’) for nursing facilities, including multi-unit chains of such facilities. Under the QAPI program, the Secretary shall establish standards relating to such facilities and provide technical assistance to such facilities on the development of best practices in order to meet such standards. Not later than 1 year after the date on which the regulations are promulgated under subclause (II), a nursing facility must submit to the Secretary a plan for the facility to meet such standards and implement such best practices, including how to coordinate the implementation of such plan with quality assessment and assurance activities conducted under clause (i). CommentsClose CommentsPermalink





‘(II) REGULATIONS- The Secretary shall promulgate regulations to carry out this clause.’. CommentsClose CommentsPermalink





(3) PROPOSAL TO REVISE QUALITY ASSURANCE AND PERFORMANCE IMPROVEMENT PROGRAMS- The Secretary shall include in the proposed rule published under section 1888(e) of the Social Security Act (42 U.S.C. 1395yy(e)(5)(A)) for the subsequent fiscal year to the extent otherwise authorized under section 1819(b)(1)(B) or 1819(d)(1)(C) of the Social Security Act or other statutory or regulatory authority, one or more proposals for skilled nursing facilities to modify and strengthen quality assurance and performance improvement programs in such facilities. At the time of publication of such proposed rule and to the extent otherwise authorized under section 1919(b)(1)(B) or 1919(d)(1)(C) of such Act or other regulatory authority. CommentsClose CommentsPermalink





(4) FACILITY PLAN- Not later than 1 year after the date on which the regulations are promulgated under subclause (II) of clause (ii) of sections 1819(b)(1)(B) and 1919(b)(1)(B) of the Social Security Act, as added by paragraphs (1) and (2), a skilled nursing facility and a nursing facility must submit to the Secretary a plan for the facility to meet the standards under such regulations and implement such best practices, including how to coordinate the implementation of such plan with quality assessment and assurance activities conducted under clause (i) of such sections. CommentsClose CommentsPermalink





(c) GAO Study on Nursing Facility Undercapitalization- CommentsClose CommentsPermalink





(1) IN GENERAL- The Comptroller General of the United States shall conduct a study that examines the following: CommentsClose CommentsPermalink





(A) The extent to which corporations that own or operate large numbers of nursing facilities, taking into account ownership type (including private equity and control interests), are undercapitalizing such facilities. CommentsClose CommentsPermalink





(B) The effects of such undercapitalization on quality of care, including staffing and food costs, at such facilities. CommentsClose CommentsPermalink





(C) Options to address such undercapitalization, such as requirements relating to surety bonds, liability insurance, or minimum capitalization. CommentsClose CommentsPermalink





(2) REPORT- Not later than 18 months after the date of the enactment of this Act, the Comptroller General shall submit to Congress a report on the study conducted under paragraph (1). CommentsClose CommentsPermalink





(3) NURSING FACILITY- In this subsection, the term ‘nursing facility’ includes a skilled nursing facility. CommentsClose CommentsPermalink

SEC. 1413. NURSING HOME COMPARE MEDICARE WEBSITE.

(a) Skilled Nursing Facilities- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1819 of the Social Security Act (42 U.S.C. 1395i-3) is amended-- CommentsClose CommentsPermalink





(A) by redesignating subsection (i) as subsection (j); and CommentsClose CommentsPermalink





(B) by inserting after subsection (h) the following new subsection: CommentsClose CommentsPermalink





‘(i) Nursing Home Compare Website- CommentsClose CommentsPermalink





‘(1) INCLUSION OF ADDITIONAL INFORMATION- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall ensure that the Department of Health and Human Services includes, as part of the information provided for comparison of nursing homes on the official Internet website of the Federal Government for Medicare beneficiaries (commonly referred to as the ‘Nursing Home Compare’ Medicare website) (or a successor website), the following information in a manner that is prominent, easily accessible, readily understandable to consumers of long-term care services, and searchable: CommentsClose CommentsPermalink





‘(i) Information that is reported to the Secretary under section 1124(c)(4). CommentsClose CommentsPermalink





‘(ii) Information on the ‘Special Focus Facility program’ (or a successor program) established by the Centers for Medicare and Medicaid Services, according to procedures established by the Secretary. Such procedures shall provide for the inclusion of information with respect to, and the names and locations of, those facilities that, since the previous quarter-- CommentsClose CommentsPermalink





‘(I) were newly enrolled in the program; CommentsClose CommentsPermalink





‘(II) are enrolled in the program and have failed to significantly improve; CommentsClose CommentsPermalink





‘(III) are enrolled in the program and have significantly improved; CommentsClose CommentsPermalink





‘(IV) have graduated from the program; and CommentsClose CommentsPermalink





‘(V) have closed voluntarily or no longer participate under this title. CommentsClose CommentsPermalink





‘(iii) Staffing data for each facility (including resident census data and data on the hours of care provided per resident per day) based on data submitted under subsection (b)(8)(C), including information on staffing turnover and tenure, in a format that is clearly understandable to consumers of long-term care services and allows such consumers to compare differences in staffing between facilities and State and national averages for the facilities. Such format shall include-- CommentsClose CommentsPermalink





‘(I) concise explanations of how to interpret the data (such as a plain English explanation of data reflecting ‘nursing home staff hours per resident day’); CommentsClose CommentsPermalink





‘(II) differences in types of staff (such as training associated with different categories of staff); CommentsClose CommentsPermalink





‘(III) the relationship between nurse staffing levels and quality of care; and CommentsClose CommentsPermalink





‘(IV) an explanation that appropriate staffing levels vary based on patient case mix. CommentsClose CommentsPermalink





‘(iv) Links to State Internet websites with information regarding State survey and certification programs, links to Form 2567 State inspection reports (or a successor form) on such websites, information to guide consumers in how to interpret and understand such reports, and the facility plan of correction or other response to such report. CommentsClose CommentsPermalink





‘(v) The standardized complaint form developed under subsection (f)(8), including explanatory material on what complaint forms are, how they are used, and how to file a complaint with the State survey and certification program and the State long-term care ombudsman program. CommentsClose CommentsPermalink





‘(vi) Summary information on the number, type, severity, and outcome of substantiated complaints. CommentsClose CommentsPermalink





‘(vii) The number of adjudicated instances of criminal violations by employees of a a nursing facility-- CommentsClose CommentsPermalink





‘(I) that were committed inside the facility; CommentsClose CommentsPermalink





‘(II) with respect to such instances of violations or crimes committed inside of the facility that were the violations or crimes of abuse, neglect, and exploitation, criminal sexual abuse, or other violations or crimes that resulted in serious bodily injury; and CommentsClose CommentsPermalink





‘(III) the number of civil monetary penalties levied against the facility, employees, contractors, and other agents. CommentsClose CommentsPermalink





‘(B) DEADLINE FOR PROVISION OF INFORMATION- CommentsClose CommentsPermalink





‘(i) IN GENERAL- Except as provided in clause (ii), the Secretary shall ensure that the information described in subparagraph (A) is included on such website (or a successor website) not later than 1 year after the date of the enactment of this subsection. CommentsClose CommentsPermalink





‘(ii) EXCEPTION- The Secretary shall ensure that the information described in subparagraph (A)(i) and (A)(iii) is included on such website (or a successor website) not later than the date on which the requirements under section 1124(c)(4) and subsection (b)(8)(C)(ii) are implemented. CommentsClose CommentsPermalink





‘(2) REVIEW AND MODIFICATION OF WEBSITE- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall establish a process-- CommentsClose CommentsPermalink





‘(i) to review the accuracy, clarity of presentation, timeliness, and comprehensiveness of information reported on such website as of the day before the date of the enactment of this subsection; and CommentsClose CommentsPermalink





‘(ii) not later than 1 year after the date of the enactment of this subsection, to modify or revamp such website in accordance with the review conducted under clause (i). CommentsClose CommentsPermalink





‘(B) CONSULTATION- In conducting the review under subparagraph (A)(i), the Secretary shall consult with-- CommentsClose CommentsPermalink





‘(i) State long-term care ombudsman programs; CommentsClose CommentsPermalink





‘(ii) consumer advocacy groups; CommentsClose CommentsPermalink





‘(iii) provider stakeholder groups; and CommentsClose CommentsPermalink





‘(iv) any other representatives of programs or groups the Secretary determines appropriate.’. CommentsClose CommentsPermalink





(2) TIMELINESS OF SUBMISSION OF SURVEY AND CERTIFICATION INFORMATION- CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1819(g)(5) of the Social Security Act (42 U.S.C. 1395i-3(g)(5)) is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(E) SUBMISSION OF SURVEY AND CERTIFICATION INFORMATION TO THE SECRETARY- In order to improve the timeliness of information made available to the public under subparagraph (A) and provided on the Nursing Home Compare Medicare website under subsection (i), each State shall submit information respecting any survey or certification made respecting a skilled nursing facility (including any enforcement actions taken by the State) to the Secretary not later than the date on which the State sends such information to the facility. The Secretary shall use the information submitted under the preceding sentence to update the information provided on the Nursing Home Compare Medicare website as expeditiously as practicable but not less frequently than quarterly.’. CommentsClose CommentsPermalink





(B) EFFECTIVE DATE- The amendment made by this paragraph shall take effect 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink





(3) SPECIAL FOCUS FACILITY PROGRAM- Section 1819(f) of such Act is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(8) SPECIAL FOCUS FACILITY PROGRAM- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall conduct a special focus facility program for enforcement of requirements for skilled nursing facilities that the Secretary has identified as having substantially failed to meet applicable requirement of this Act. CommentsClose CommentsPermalink





‘(B) PERIODIC SURVEYS- Under such program the Secretary shall conduct surveys of each facility in the program not less than once every 6 months.’. CommentsClose CommentsPermalink





(b) Nursing Facilities- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1919 of the Social Security Act (42 U.S.C. 1396r) is amended-- CommentsClose CommentsPermalink





(A) by redesignating subsection (i) as subsection (j); and CommentsClose CommentsPermalink





(B) by inserting after subsection (h) the following new subsection: CommentsClose CommentsPermalink





‘(i) Nursing Home Compare Website- CommentsClose CommentsPermalink





‘(1) INCLUSION OF ADDITIONAL INFORMATION- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall ensure that the Department of Health and Human Services includes, as part of the information provided for comparison of nursing homes on the official Internet website of the Federal Government for Medicare beneficiaries (commonly referred to as the ‘Nursing Home Compare’ Medicare website) (or a successor website), the following information in a manner that is prominent, easily accessible, readily understandable to consumers of long-term care services, and searchable: CommentsClose CommentsPermalink





‘(i) Staffing data for each facility (including resident census data and data on the hours of care provided per resident per day) based on data submitted under subsection (b)(8)(C)(ii), including information on staffing turnover and tenure, in a format that is clearly understandable to consumers of long-term care services and allows such consumers to compare differences in staffing between facilities and State and national averages for the facilities. Such format shall include-- CommentsClose CommentsPermalink





‘(I) concise explanations of how to interpret the data (such as plain English explanation of data reflecting ‘nursing home staff hours per resident day’); CommentsClose CommentsPermalink





‘(II) differences in types of staff (such as training associated with different categories of staff); CommentsClose CommentsPermalink





‘(III) the relationship between nurse staffing levels and quality of care; and CommentsClose CommentsPermalink





‘(IV) an explanation that appropriate staffing levels vary based on patient case mix. CommentsClose CommentsPermalink





‘(ii) Links to State Internet websites with information regarding State survey and certification programs, links to Form 2567 State inspection reports (or a successor form) on such websites, information to guide consumers in how to interpret and understand such reports, and the facility plan of correction or other response to such report. CommentsClose CommentsPermalink





‘(iii) The standardized complaint form developed under subsection (f)(10), including explanatory material on what complaint forms are, how they are used, and how to file a complaint with the State survey and certification program and the State long-term care ombudsman program. CommentsClose CommentsPermalink





‘(iv) Summary information on the number, type, severity, and outcome of substantiated complaints. CommentsClose CommentsPermalink





‘(v) The number of adjudicated instances of criminal violations by employees of a nursing facility-- CommentsClose CommentsPermalink





‘(I) that were committed inside of the facility; and CommentsClose CommentsPermalink





‘(II) with respect to such instances of violations or crimes committed outside of the facility, that were the violations or crimes that resulted in the serious bodily injury of an elder. CommentsClose CommentsPermalink





‘(B) DEADLINE FOR PROVISION OF INFORMATION- CommentsClose CommentsPermalink





‘(i) IN GENERAL- Except as provided in clause (ii), the Secretary shall ensure that the information described in subparagraph (A) is included on such website (or a successor website) not later than 1 year after the date of the enactment of this subsection. CommentsClose CommentsPermalink





‘(ii) EXCEPTION- The Secretary shall ensure that the information described in subparagraph (A)(i) and (A)(iii) is included on such website (or a successor website) not later than the date on which the requirements under section 1124(c)(4) and subsection (b)(8)(C)(ii) are implemented. CommentsClose CommentsPermalink





‘(2) REVIEW AND MODIFICATION OF WEBSITE- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall establish a process-- CommentsClose CommentsPermalink





‘(i) to review the accuracy, clarity of presentation, timeliness, and comprehensiveness of information reported on such website as of the day before the date of the enactment of this subsection; and CommentsClose CommentsPermalink





‘(ii) not later than 1 year after the date of the enactment of this subsection, to modify or revamp such website in accordance with the review conducted under clause (i). CommentsClose CommentsPermalink





‘(B) CONSULTATION- In conducting the review under subparagraph (A)(i), the Secretary shall consult with-- CommentsClose CommentsPermalink





‘(i) State long-term care ombudsman programs; CommentsClose CommentsPermalink





‘(ii) consumer advocacy groups; CommentsClose CommentsPermalink





‘(iii) provider stakeholder groups; CommentsClose CommentsPermalink





‘(iv) skilled nursing facility employees and their representatives; and CommentsClose CommentsPermalink





‘(v) any other representatives of programs or groups the Secretary determines appropriate.’. CommentsClose CommentsPermalink





(2) TIMELINESS OF SUBMISSION OF SURVEY AND CERTIFICATION INFORMATION- CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1919(g)(5) of the Social Security Act (42 U.S.C. 1396r(g)(5)) is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(E) SUBMISSION OF SURVEY AND CERTIFICATION INFORMATION TO THE SECRETARY- In order to improve the timeliness of information made available to the public under subparagraph (A) and provided on the Nursing Home Compare Medicare website under subsection (i), each State shall submit information respecting any survey or certification made respecting a nursing facility (including any enforcement actions taken by the State) to the Secretary not later than the date on which the State sends such information to the facility. The Secretary shall use the information submitted under the preceding sentence to update the information provided on the Nursing Home Compare Medicare website as expeditiously as practicable but not less frequently than quarterly.’. CommentsClose CommentsPermalink





(B) EFFECTIVE DATE- The amendment made by this paragraph shall take effect 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink





(3) SPECIAL FOCUS FACILITY PROGRAM- Section 1919(f) of such Act is amended by adding at the end of the following new paragraph: CommentsClose CommentsPermalink





‘(10) SPECIAL FOCUS FACILITY PROGRAM- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall conduct a special focus facility program for enforcement of requirements for nursing facilities that the Secretary has identified as having substantially failed to meet applicable requirements of this Act. CommentsClose CommentsPermalink





‘(B) PERIODIC SURVEYS- Under such program the Secretary shall conduct surveys of each facility in the program not less often than once every 6 months.’. CommentsClose CommentsPermalink





(c) Availability of Reports on Surveys, Certifications, and Complaint Investigations- CommentsClose CommentsPermalink





(1) SKILLED NURSING FACILITIES- Section 1819(d)(1) of the Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by sections 1411 and 1412, is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(D) AVAILABILITY OF SURVEY, CERTIFICATION, AND COMPLAINT INVESTIGATION REPORTS- A skilled nursing facility must-- CommentsClose CommentsPermalink





‘(i) have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years available for any individual to review upon request; and CommentsClose CommentsPermalink





‘(ii) post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. CommentsClose CommentsPermalink





The facility shall not make available under clause (i) identifying information about complainants or residents.’. CommentsClose CommentsPermalink





(2) NURSING FACILITIES- Section 1919(d)(1) of the Social Security Act (42 U.S.C. 1396r(d)(1)), as amended by sections 1411 and 1412, is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(D) AVAILABILITY OF SURVEY, CERTIFICATION, AND COMPLAINT INVESTIGATION REPORTS- A nursing facility must-- CommentsClose CommentsPermalink





‘(i) have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years available for any individual to review upon request; and CommentsClose CommentsPermalink





‘(ii) post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. CommentsClose CommentsPermalink





The facility shall not make available under clause (i) identifying information about complainants or residents.’. CommentsClose CommentsPermalink





(3) EFFECTIVE DATE- The amendments made by this subsection shall take effect 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink





(d) Guidance to States on Form 2567 State Inspection Reports and Complaint Investigation Reports- CommentsClose CommentsPermalink





(1) GUIDANCE- The Secretary of Health and Human Services (in this subtitle referred to as the ‘Secretary’) shall provide guidance to States on how States can establish electronic links to Form 2567 State inspection reports (or a successor form), complaint investigation reports, and a facility’s plan of correction or other response to such Form 2567 State inspection reports (or a successor form) on the Internet website of the State that provides information on skilled nursing facilities and nursing facilities and the Secretary shall, if possible, include such information on Nursing Home Compare. CommentsClose CommentsPermalink





(2) REQUIREMENT- Section 1902(a)(9) of the Social Security Act (42 U.S.C. 1396a(a)(9)) is amended-- CommentsClose CommentsPermalink





(A) by striking ‘and’ at the end of subparagraph (B); CommentsClose CommentsPermalink





(B) by striking the semicolon at the end of subparagraph (C) and inserting ‘, and’; and CommentsClose CommentsPermalink





(C) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(D) that the State maintain a consumer-oriented website providing useful information to consumers regarding all skilled nursing facilities and all nursing facilities in the State, including for each facility, Form 2567 State inspection reports (or a successor form), complaint investigation reports, the facility’s plan of correction, and such other information that the State or the Secretary considers useful in assisting the public to assess the quality of long term care options and the quality of care provided by individual facilities;’. CommentsClose CommentsPermalink





(3) DEFINITIONS- In this subsection: CommentsClose CommentsPermalink





(A) NURSING FACILITY- The term ‘nursing facility’ has the meaning given such term in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)). CommentsClose CommentsPermalink





(B) SECRETARY- The term ‘Secretary’ means the Secretary of Health and Human Services. CommentsClose CommentsPermalink





(C) SKILLED NURSING FACILITY- The term ‘skilled nursing facility’ has the meaning given such term in section 1819(a) of the Social Security Act (42 U.S.C. 1395i-3(a)). CommentsClose CommentsPermalink

SEC. 1414. REPORTING OF EXPENDITURES.

Section 1888 of the Social Security Act (42 U.S.C. 1395yy) is amended by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(f) Reporting of Direct Care Expenditures- CommentsClose CommentsPermalink





‘(1) IN GENERAL- For cost reports submitted under this title for cost reporting periods beginning on or after the date that is 3 years after the date of the enactment of this subsection, skilled nursing facilities shall separately report expenditures for wages and benefits for direct care staff (breaking out (at a minimum) registered nurses, licensed professional nurses, certified nurse assistants, and other medical and therapy staff). CommentsClose CommentsPermalink





‘(2) MODIFICATION OF FORM- The Secretary, in consultation with private sector accountants experienced with skilled nursing facility cost reports, shall redesign such reports to meet the requirement of paragraph (1) not later than 1 year after the date of the enactment of this subsection. CommentsClose CommentsPermalink





‘(3) CATEGORIZATION BY FUNCTIONAL ACCOUNTS- Not later than 30 months after the date of the enactment of this subsection, the Secretary, working in consultation with the Medicare Payment Advisory Commission, the Inspector General of the Department of Health and Human Services, and other expert parties the Secretary determines appropriate, shall take the expenditures listed on cost reports, as modified under paragraph (1), submitted by skilled nursing facilities and categorize such expenditures, regardless of any source of payment for such expenditures, for each skilled nursing facility into the following functional accounts on an annual basis: CommentsClose CommentsPermalink





‘(A) Spending on direct care services (including nursing, therapy, and medical services). CommentsClose CommentsPermalink





‘(B) Spending on indirect care (including housekeeping and dietary services). CommentsClose CommentsPermalink





‘(C) Capital assets (including building and land costs). CommentsClose CommentsPermalink





‘(D) Administrative services costs. CommentsClose CommentsPermalink





‘(4) AVAILABILITY OF INFORMATION SUBMITTED- The Secretary shall establish procedures to make information on expenditures submitted under this subsection readily available to interested parties upon request, subject to such requirements as the Secretary may specify under the procedures established under this paragraph.’. CommentsClose CommentsPermalink

SEC. 1415. STANDARDIZED COMPLAINT FORM.

(a) Skilled Nursing Facilities- CommentsClose CommentsPermalink





(1) DEVELOPMENT BY THE SECRETARY- Section 1819(f) of the Social Security Act (42 U.S.C. 1395i-3(f)), as amended by section 1413(a)(3), is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(9) STANDARDIZED COMPLAINT FORM- The Secretary shall develop a standardized complaint form for use by a resident (or a person acting on the resident’s behalf) in filing a complaint with a State survey and certification agency and a State long-term care ombudsman program with respect to a skilled nursing facility.’. CommentsClose CommentsPermalink





(2) STATE REQUIREMENTS- Section 1819(e) of the Social Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(6) COMPLAINT PROCESSES AND WHISTLE-BLOWER PROTECTION- CommentsClose CommentsPermalink





‘(A) COMPLAINT FORMS- The State must make the standardized complaint form developed under subsection (f)(9) available upon request to-- CommentsClose CommentsPermalink





‘(i) a resident of a skilled nursing facility; CommentsClose CommentsPermalink





‘(ii) any person acting on the resident’s behalf; and CommentsClose CommentsPermalink





‘(iii) any person who works at a skilled nursing facility or is a representative of such a worker. CommentsClose CommentsPermalink





‘(B) COMPLAINT RESOLUTION PROCESS- The State must establish a complaint resolution process in order to ensure that a resident, the legal representative of a resident of a skilled nursing facility, or other responsible party is not retaliated against if the resident, legal representative, or responsible party has complained, in good faith, about the quality of care or other issues relating to the skilled nursing facility, that the legal representative of a resident of a skilled nursing facility or other responsible party is not denied access to such resident or otherwise retaliated against if such representative party has complained, in good faith, about the quality of care provided by the facility or other issues relating to the facility, and that a person who works at a skilled nursing facility is not retaliated against if the worker has complained, in good faith, about quality of care or services or an issue relating to the quality of care or services provided at the facility, whether the resident, legal representative, other responsible party, or worker used the form developed under subsection (f)(9) or some other method for submitting the complaint. Such complaint resolution process shall include-- CommentsClose CommentsPermalink





‘(i) procedures to assure accurate tracking of complaints received, including notification to the complainant that a complaint has been received; CommentsClose CommentsPermalink





‘(ii) procedures to determine the likely severity of a complaint and for the investigation of the complaint; CommentsClose CommentsPermalink





‘(iii) deadlines for responding to a complaint and for notifying the complainant of the outcome of the investigation; and CommentsClose CommentsPermalink





‘(iv) procedures to ensure that the identity of the complainant will be kept confidential. CommentsClose CommentsPermalink





‘(C) WHISTLEBLOWER PROTECTION- CommentsClose CommentsPermalink





‘(i) PROHIBITION AGAINST RETALIATION- No person who works at a skilled nursing facility may be penalized, discriminated, or retaliated against with respect to any aspect of employment, including discharge, promotion, compensation, terms, conditions, or privileges of employment, or have a contract for services terminated, because the person (or anyone acting at the person’s request) complained, in good faith, about the quality of care or services provided by a nursing facility or about other issues relating to quality of care or services, whether using the form developed under subsection (f)(9) or some other method for submitting the complaint. CommentsClose CommentsPermalink





‘(ii) RETALIATORY REPORTING- A skilled nursing facility may not file a complaint or a report against a person who works (or has worked at the facility with the appropriate State professional disciplinary agency because the person (or anyone acting at the person’s request) complained in good faith, as described in clause (i). CommentsClose CommentsPermalink





‘(iii) COMMENCEMENT OF ACTION- Any person who believes the person has been penalized, discriminated , or retaliated against or had a contract for services terminated in violation of clause (i) or against whom a complaint has been filed in violation of clause (ii) may bring an action at law or equity in the appropriate district court of the United States, which shall have jurisdiction over such action without regard to the amount in controversy or the citizenship of the parties, and which shall have jurisdiction to grant complete relief, including, but not limited to, injunctive relief (such as reinstatement, compensatory damages (which may include reimbursement of lost wages, compensation, and benefits), costs of litigation (including reasonable attorney and expert witness fees), exemplary damages where appropriate, and such other relief as the court deems just and proper. CommentsClose CommentsPermalink





‘(iv) RIGHTS NOT WAIVABLE- The rights protected by this paragraph may not be diminished by contract or other agreement, and nothing in this paragraph shall be construed to diminish any greater or additional protection provided by Federal or State law or by contract or other agreement. CommentsClose CommentsPermalink





‘(v) REQUIREMENT TO POST NOTICE OF EMPLOYEE RIGHTS- Each skilled nursing facility shall post conspicuously in an appropriate location a sign (in a form specified by the Secretary) specifying the rights of persons under this paragraph and including a statement that an employee may file a complaint with the Secretary against a skilled nursing facility that violates the provisions of this paragraph and information with respect to the manner of filing such a complaint. CommentsClose CommentsPermalink





‘(D) RULE OF CONSTRUCTION- Nothing in this paragraph shall be construed as preventing a resident of a skilled nursing facility (or a person acting on the resident’s behalf) from submitting a complaint in a manner or format other than by using the standardized complaint form developed under subsection (f)(9) (including submitting a complaint orally). CommentsClose CommentsPermalink





‘(E) GOOD FAITH DEFINED- For purposes of this paragraph, an individual shall be deemed to be acting in good faith with respect to the filing of a complaint if the individual reasonably believes-- CommentsClose CommentsPermalink





‘(i) the information reported or disclosed in the complaint is true; and CommentsClose CommentsPermalink





‘(ii) the violation of this title has occurred or may occur in relation to such information.’. CommentsClose CommentsPermalink





(b) Nursing Facilities- CommentsClose CommentsPermalink





(1) DEVELOPMENT BY THE SECRETARY- Section 1919(f) of the Social Security Act (42 U.S.C. 1395i-3(f)), as amended by section 1413(b), is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(11) STANDARDIZED COMPLAINT FORM- The Secretary shall develop a standardized complaint form for use by a resident (or a person acting on the resident’s behalf) in filing a complaint with a State survey and certification agency and a State long-term care ombudsman program with respect to a nursing facility.’. CommentsClose CommentsPermalink





(2) STATE REQUIREMENTS- Section 1919(e) of the Social Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(8) COMPLAINT PROCESSES AND WHISTLEBLOWER PROTECTION- CommentsClose CommentsPermalink





‘(A) COMPLAINT FORMS- The State must make the standardized complaint form developed under subsection (f)(11) available upon request to-- CommentsClose CommentsPermalink





‘(i) a resident of a nursing facility; CommentsClose CommentsPermalink





‘(ii) any person acting on the resident’s behalf; and CommentsClose CommentsPermalink





‘(iii) any person who works at a nursing facility or a representative of such a worker. CommentsClose CommentsPermalink





‘(B) COMPLAINT RESOLUTION PROCESS- The State must establish a complaint resolution process in order to ensure that a resident, the legal representative of a resident of a nursing facility, or other responsible party is not retaliated against if the resident, legal representative, or responsible party has complained, in good faith, about the quality of care or other issues relating to the nursing facility, that the legal representative of a resident of a nursing facility or other responsible party is not denied access to such resident or otherwise retaliated against if such representative party has complained, in good faith, about the quality of care provided by the facility or other issues relating to the facility, and that a person who works at a nursing facility is not retaliated against if the worker has complained, in good faith, about quality of care or services or an issue relating to the quality of care or services provided at the facility, whether the resident, legal representative, other responsible party, or worker used the form developed under subsection (f)(11) or some other method for submitting the complaint. Such complaint resolution process shall include-- CommentsClose CommentsPermalink





‘(i) procedures to assure accurate tracking of complaints received, including notification to the complainant that a complaint has been received; CommentsClose CommentsPermalink





‘(ii) procedures to determine the likely severity of a complaint and for the investigation of the complaint; CommentsClose CommentsPermalink





‘(iii) deadlines for responding to a complaint and for notifying the complainant of the outcome of the investigation; and CommentsClose CommentsPermalink





‘(iv) procedures to ensure that the identity of the complainant will be kept confidential. CommentsClose CommentsPermalink





‘(C) WHISTLEBLOWER PROTECTION- CommentsClose CommentsPermalink





‘(i) PROHIBITION AGAINST RETALIATION- No person who works at a nursing facility may be penalized, discriminated, or retaliated against with respect to any aspect of employment, including discharge, promotion, compensation, terms, conditions, or privileges of employment, or have a contract for services terminated, because the person (or anyone acting at the person’s request) complained, in good faith, about the quality of care or services provided by a nursing facility or about other issues relating to quality of care or services, whether using the form developed under subsection (f)(11) or some other method for submitting the complaint. CommentsClose CommentsPermalink





‘(ii) RETALIATORY REPORTING- A nursing facility may not file a complaint or a report against a person who works (or has worked at the facility with the appropriate State professional disciplinary agency because the person (or anyone acting at the person’s request) complained in good faith, as described in clause (i). CommentsClose CommentsPermalink





‘(iii) COMMENCEMENT OF ACTION- Any person who believes the person has been penalized, discriminated, or retaliated against or had a contract for services terminated in violation of clause (i) or against whom a complaint has been filed in violation of clause (ii) may bring an action at law or equity in the appropriate district court of the United States, which shall have jurisdiction over such action without regard to the amount in controversy or the citizenship of the parties, and which shall have jurisdiction to grant complete relief, including, but not limited to, injunctive relief (such as reinstatement, compensatory damages (which may include reimbursement of lost wages, compensation, and benefits), costs of litigation (including reasonable attorney and expert witness fees), exemplary damages where appropriate, and such other relief as the court deems just and proper. CommentsClose CommentsPermalink





‘(iv) RIGHTS NOT WAIVABLE- The rights protected by this paragraph may not be diminished by contract or other agreement, and nothing in this paragraph shall be construed to diminish any greater or additional protection provided by Federal or State law or by contract or other agreement. CommentsClose CommentsPermalink





‘(v) REQUIREMENT TO POST NOTICE OF EMPLOYEE RIGHTS- Each nursing facility shall post conspicuously in an appropriate location a sign (in a form specified by the Secretary) specifying the rights of persons under this paragraph and including a statement that an employee may file a complaint with the Secretary against a nursing facility that violates the provisions of this paragraph and information with respect to the manner of filing such a complaint. CommentsClose CommentsPermalink





‘(D) RULE OF CONSTRUCTION- Nothing in this paragraph shall be construed as preventing a resident of a nursing facility (or a person acting on the resident’s behalf) from submitting a complaint in a manner or format other than by using the standardized complaint form developed under subsection (f)(11) (including submitting a complaint orally). CommentsClose CommentsPermalink





‘(E) GOOD FAITH DEFINED- For purposes of this paragraph, an individual shall be deemed to be acting in good faith with respect to the filing of a complaint if the individual reasonably believes-- CommentsClose CommentsPermalink





‘(i) the information reported or disclosed in the complaint is true; and CommentsClose CommentsPermalink





‘(ii) the violation of this title has occurred or may occur in relation to such information.’. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall take effect 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink

SEC. 1416. ENSURING STAFFING ACCOUNTABILITY.

(a) Skilled Nursing Facilities- Section 1819(b)(8) of the Social Security Act (42 U.S.C. 1395i-3(b)(8)) is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(C) SUBMISSION OF STAFFING INFORMATION BASED ON PAYROLL DATA IN A UNIFORM FORMAT- Beginning not later than 2 years after the date of the enactment of this subparagraph, and after consulting with State long-term care ombudsman programs, consumer advocacy groups, provider stakeholder groups, employees and their representatives, and other parties the Secretary deems appropriate, the Secretary shall require a skilled nursing facility to electronically submit to the Secretary direct care staffing information (including information with respect to agency and contract staff) based on payroll and other verifiable and auditable data in a uniform format (according to specifications established by the Secretary in consultation with such programs, groups, and parties). Such specifications shall require that the information submitted under the preceding sentence-- CommentsClose CommentsPermalink





‘(i) specify the category of work a certified employee performs (such as whether the employee is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other medical personnel); CommentsClose CommentsPermalink





‘(ii) include resident census data and information on resident case mix; CommentsClose CommentsPermalink





‘(iii) include a regular reporting schedule; and CommentsClose CommentsPermalink





‘(iv) include information on employee turnover and tenure and on the hours of care provided by each category of certified employees referenced in clause (i) per resident per day. CommentsClose CommentsPermalink





Nothing in this subparagraph shall be construed as preventing the Secretary from requiring submission of such information with respect to specific categories, such as nursing staff, before other categories of certified employees. Information under this subparagraph with respect to agency and contract staff shall be kept separate from information on employee staffing.’. CommentsClose CommentsPermalink





(b) Nursing Facilities- Section 1919(b)(8) of the Social Security Act (42 U.S.C. 1396r(b)(8)) is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(C) SUBMISSION OF STAFFING INFORMATION BASED ON PAYROLL DATA IN A UNIFORM FORMAT- Beginning not later than 2 years after the date of the enactment of this subparagraph, and after consulting with State long-term care ombudsman programs, consumer advocacy groups, provider stakeholder groups, employees and their representatives, and other parties the Secretary deems appropriate, the Secretary shall require a nursing facility to electronically submit to the Secretary direct care staffing information (including information with respect to agency and contract staff) based on payroll and other verifiable and auditable data in a uniform format (according to specifications established by the Secretary in consultation with such programs, groups, and parties). Such specifications shall require that the information submitted under the preceding sentence-- CommentsClose CommentsPermalink





‘(i) specify the category of work a certified employee performs (such as whether the employee is a registered nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other medical personnel); CommentsClose CommentsPermalink





‘(ii) include resident census data and information on resident case mix; CommentsClose CommentsPermalink





‘(iii) include a regular reporting schedule; and CommentsClose CommentsPermalink





‘(iv) include information on employee turnover and tenure and on the hours of care provided by each category of certified employees referenced in clause (i) per resident per day. CommentsClose CommentsPermalink





Nothing in this subparagraph shall be construed as preventing the Secretary from requiring submission of such information with respect to specific categories, such as nursing staff, before other categories of certified employees. Information under this subparagraph with respect to agency and contract staff shall be kept separate from information on employee staffing.’. CommentsClose CommentsPermalink

PART 2--TARGETING ENFORCEMENT

SEC. 1421. CIVIL MONEY PENALTIES.

(a) Skilled Nursing Facilities- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1819(h)(2)(B)(ii) of the Social Security Act (42 U.S.C. 1395i-3(h)(2)(B)(ii)) is amended to read as follows: CommentsClose CommentsPermalink





‘(ii) AUTHORITY WITH RESPECT TO CIVIL MONEY PENALTIES- CommentsClose CommentsPermalink





‘(I) AMOUNT- The Secretary may impose a civil money penalty in the applicable per instance or per day amount (as defined in subclause (II) and (III)) for each day or instance, respectively, of noncompliance (as determined appropriate by the Secretary). CommentsClose CommentsPermalink





‘(II) APPLICABLE PER INSTANCE AMOUNT- In this clause, the term ‘applicable per instance amount’ means-- CommentsClose CommentsPermalink

‘(aa) in the case where the deficiency is found to be a direct proximate cause of death of a resident of the facility, an amount not to exceed $100,000; CommentsClose CommentsPermalink

‘(bb) in each case of a deficiency where the facility is cited for actual harm or immediate jeopardy, an amount not less than $3,050 and not more than $25,000; and CommentsClose CommentsPermalink

‘(cc) in each case of any other deficiency, an amount not less than $250 and not to exceed $3050. CommentsClose CommentsPermalink

‘(III) APPLICABLE PER DAY AMOUNT- In this clause, the term ‘applicable per day amount’ means-- CommentsClose CommentsPermalink

‘(aa) in each case of a deficiency where the facility is cited for actual harm or immediate jeopardy, an amount not less than $3,050 and not more than $25,000;, and CommentsClose CommentsPermalink

‘(bb) in each case of any other deficiency, an amount not less than $250 and not to exceed $3,050. CommentsClose CommentsPermalink

‘(IV) REDUCTION OF CIVIL MONEY PENALTIES IN CERTAIN CIRCUMSTANCES- Subject to subclauses (V) and (VI), in the case where a facility self-reports and promptly corrects a deficiency for which a penalty was imposed under this clause not later than 10 calendar days after the date of such imposition, the Secretary may reduce the amount of the penalty imposed by not more than 50 percent. CommentsClose CommentsPermalink





‘(V) PROHIBITION ON REDUCTION FOR CERTAIN DEFICIENCIES- CommentsClose CommentsPermalink

‘(aa) REPEAT DEFICIENCIES- The Secretary may not reduce under subclause (IV) the amount of a penalty if the deficiency is a repeat deficiency. CommentsClose CommentsPermalink

‘(bb) CERTAIN OTHER DEFICIENCIES- The Secretary may not reduce under subclause (IV) the amount of a penalty if the penalty is imposed for a deficiency described in subclause (II)(aa) or (III)(aa) and the actual harm or widespread harm immediately jeopardizes the health or safety of a resident or residents of the facility, or if the penalty is imposed for a deficiency described in subclause (II)(bb). CommentsClose CommentsPermalink

‘(VI) LIMITATION ON AGGREGATE REDUCTIONS- The aggregate reduction in a penalty under subclause (IV) may not exceed 35 percent on the basis of self-reporting, on the basis of a waiver or an appeal (as provided for under regulations under section 488.436 of title 42, Code of Federal Regulations), or on the basis of both. CommentsClose CommentsPermalink





‘(VII) COLLECTION OF CIVIL MONEY PENALTIES- In the case of a civil money penalty imposed under this clause, the Secretary-- CommentsClose CommentsPermalink

‘(aa) subject to item (cc), shall, not later than 30 days after the date of imposition of the penalty, provide the opportunity for the facility to participate in an independent informal dispute resolution process which generates a written record prior to the collection of such penalty, but such opportunity shall not affect the responsibility of the State survey agency for making final recommendations for such penalties; CommentsClose CommentsPermalink

‘(bb) in the case where the penalty is imposed for each day of noncompliance, shall not impose a penalty for any day during the period beginning on the initial day of the imposition of the penalty and ending on the day on which the informal dispute resolution process under item (aa) is completed; CommentsClose CommentsPermalink

‘(cc) may provide for the collection of such civil money penalty and the placement of such amounts collected in an escrow account under the direction of the Secretary on the earlier of the date on which the informal dispute resolution process under item (aa) is completed or the date that is 90 days after the date of the imposition of the penalty; CommentsClose CommentsPermalink

‘(dd) may provide that such amounts collected are kept in such account pending the resolution of any subsequent appeals; CommentsClose CommentsPermalink

‘(ee) in the case where the facility successfully appeals the penalty, may provide for the return of such amounts collected (plus interest) to the facility; and CommentsClose CommentsPermalink

‘(ff) in the case where all such appeals are unsuccessful, may provide that some portion of such amounts collected may be used to support activities that benefit residents, including assistance to support and protect residents of a facility that closes (voluntarily or involuntarily) or is decertified (including offsetting costs of relocating residents to home and community-based settings or another facility), projects that support resident and family councils and other consumer involvement in assuring quality care in facilities, and facility improvement initiatives approved by the Secretary (including joint training of facility staff and surveyors, technical assistance for facilities under quality assurance programs, the appointment of temporary management, and other activities approved by the Secretary). CommentsClose CommentsPermalink

‘(VIII) PROCEDURE- The provisions of section 1128A (other than subsections (a) and (b) and except to the extent that such provisions require a hearing prior to the imposition of a civil money penalty) shall apply to a civil money penalty under this clause in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).’. CommentsClose CommentsPermalink





(2) CONFORMING AMENDMENT- The second sentence of section 1819(h)(5) of the Social Security Act (42 U.S.C. 1395i-3(h)(5)) is amended by inserting ‘(ii),’after ‘(i),’. CommentsClose CommentsPermalink





(b) Nursing Facilities- CommentsClose CommentsPermalink





(1) PENALTIES IMPOSED BY THE STATE- CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1919(h)(2) of the Social Security Act (42 U.S.C. 1396r(h)(2)) is amended-- CommentsClose CommentsPermalink





(i) in subparagraph (A)(ii), by striking the first sentence and inserting the following: ‘A civil money penalty in accordance with subparagraph (G).’; and CommentsClose CommentsPermalink





(ii) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(G) CIVIL MONEY PENALTIES- CommentsClose CommentsPermalink





‘(i) IN GENERAL- The State may impose a civil money penalty under subparagraph (A)(ii) in the applicable per instance or per day amount (as defined in subclause (II) and (III)) for each day or instance, respectively, of noncompliance (as determined appropriate by the Secretary). CommentsClose CommentsPermalink





‘(ii) APPLICABLE PER INSTANCE AMOUNT- In this subparagraph, the term ‘applicable per instance amount’ means-- CommentsClose CommentsPermalink





‘(I) in the case where the deficiency is found to be a direct proximate cause of death of a resident of the facility, an amount not to exceed $100,000;. CommentsClose CommentsPermalink





‘(II) in each case of a deficiency where the facility is cited for actual harm or immediate jeopardy, an amount not less than $3,050 and not more than $25,000; and CommentsClose CommentsPermalink





‘(III) in each case of any other deficiency, an amount not less than $250 and not to exceed $3,050. CommentsClose CommentsPermalink





‘(iii) APPLICABLE PER DAY AMOUNT- In this subparagraph, the term ‘applicable per day amount’ means-- CommentsClose CommentsPermalink





‘(I) in each case of a deficiency where the facility is cited for actual harm or immediate jeopardy, an amount not less than $3,050 and not more than $25,000; and CommentsClose CommentsPermalink





‘(II) in each case of any other deficiency, an amount not less than $250 and not to exceed $3,050. CommentsClose CommentsPermalink





‘(iv) REDUCTION OF CIVIL MONEY PENALTIES IN CERTAIN CIRCUMSTANCES- Subject to clauses (v) and (vi), in the case where a facility self-reports and promptly corrects a deficiency for which a penalty was imposed under subparagraph (A)(ii) not later than 10 calendar days after the date of such imposition, the State may reduce the amount of the penalty imposed by not more than 50 percent. CommentsClose CommentsPermalink





‘(v) PROHIBITION ON REDUCTION FOR CERTAIN DEFICIENCIES- CommentsClose CommentsPermalink





‘(I) REPEAT DEFICIENCIES- The State may not reduce under clause (iv) the amount of a penalty if the State had reduced a penalty imposed on the facility in the preceding year under such clause with respect to a repeat deficiency. CommentsClose CommentsPermalink





‘(II) CERTAIN OTHER DEFICIENCIES- The State may not reduce under clause (iv) the amount of a penalty if the penalty is imposed for a deficiency described in clause (ii)(II) or (iii)(I) and the actual harm or widespread harm that immediately jeopardizes the health or safety of a resident or residents of the facility, or if the penalty is imposed for a deficiency described in clause (ii)(I). CommentsClose CommentsPermalink





‘(III) LIMITATION ON AGGREGATE REDUCTIONS- The aggregate reduction in a penalty under clause (iv) may not exceed 35 percent on the basis of self-reporting, on the basis of a waiver or an appeal (as provided for under regulations under section 488.436 of title 42, Code of Federal Regulations), or on the basis of both. CommentsClose CommentsPermalink





‘(ivvi) COLLECTION OF CIVIL MONEY PENALTIES- In the case of a civil money penalty imposed under subparagraph (A)(ii), the State-- CommentsClose CommentsPermalink





‘(I) subject to subclause (III), shall, not later than 30 days after the date of imposition of the penalty, provide the opportunity for the facility to participate in an independent informal dispute resolution process which generates a written record prior to the collection of such penalty, but such opportunity shall not affect the responsibility of the State survey agency for making final recommendations for such penalties; CommentsClose CommentsPermalink





‘(II) in the case where the penalty is imposed for each day of noncompliance, shall not impose a penalty for any day during the period beginning on the initial day of the imposition of the penalty and ending on the day on which the informal dispute resolution process under subclause (I) is completed; CommentsClose CommentsPermalink





‘(III) may provide for the collection of such civil money penalty and the placement of such amounts collected in an escrow account under the direction of the State on the earlier of the date on which the informal dispute resolution process under subclause (I) is completed or the date that is 90 days after the date of the imposition of the penalty; CommentsClose CommentsPermalink





‘(IV) may provide that such amounts collected are kept in such account pending the resolution of any subsequent appeals; CommentsClose CommentsPermalink





‘(V) in the case where the facility successfully appeals the penalty, may provide for the return of such amounts collected (plus interest) to the facility; and CommentsClose CommentsPermalink





‘(VI) in the case where all such appeals are unsuccessful, may provide that such funds collected shall be used for the purposes described in the second sentence of subparagraph (A)(ii).’. CommentsClose CommentsPermalink





(B) CONFORMING AMENDMENT- The second sentence of section 1919(h)(2)(A)(ii) of the Social Security Act (42 U.S.C. 1396r(h)(2)(A)(ii)) is amended by inserting before the period at the end the following: ‘, and some portion of such funds may be used to support activities that benefit residents, including assistance to support and protect residents of a facility that closes (voluntarily or involuntarily) or is decertified (including offsetting costs of relocating residents to home and community-based settings or another facility), projects that support resident and family councils and other consumer involvement in assuring quality care in facilities, and facility improvement initiatives approved by the Secretary (including joint training of facility staff and surveyors, providing technical assistance to facilities under quality assurance programs, the appointment of temporary management, and other activities approved by the Secretary)’. CommentsClose CommentsPermalink





(2) PENALTIES IMPOSED BY THE SECRETARY- CommentsClose CommentsPermalink





(A) IN GENERAL- Section 1919(h)(3)(C)(ii) of the Social Security Act (42 U.S.C. 1396r(h)(3)(C)) is amended to read as follows: CommentsClose CommentsPermalink





‘(ii) AUTHORITY WITH RESPECT TO CIVIL MONEY PENALTIES- CommentsClose CommentsPermalink





‘(I) AMOUNT- Subject to subclause (II), the Secretary may impose a civil money penalty in an amount not to exceed $10,000 for each day or each instance of noncompliance (as determined appropriate by the Secretary). CommentsClose CommentsPermalink





‘(II) REDUCTION OF CIVIL MONEY PENALTIES IN CERTAIN CIRCUMSTANCES- Subject to subclause (III), in the case where a facility self-reports and promptly corrects a deficiency for which a penalty was imposed under this clause not later than 10 calendar days after the date of such imposition, the Secretary may reduce the amount of the penalty imposed by not more than 50 percent. CommentsClose CommentsPermalink





‘(III) PROHIBITION ON REDUCTION FOR REPEAT DEFICIENCIES- The Secretary may not reduce the amount of a penalty under subclause (II) if the Secretary had reduced a penalty imposed on the facility in the preceding year under such subclause with respect to a repeat deficiency. CommentsClose CommentsPermalink





‘(IV) COLLECTION OF CIVIL MONEY PENALTIES- In the case of a civil money penalty imposed under this clause, the Secretary-- CommentsClose CommentsPermalink

‘(aa) subject to item (bb), shall, not later than 30 days after the date of imposition of the penalty, provide the opportunity for the facility to participate in an independent informal dispute resolution process which generates a written record prior to the collection of such penalty; CommentsClose CommentsPermalink

‘(bb) in the case where the penalty is imposed for each day of noncompliance, shall not impose a penalty for any day during the period beginning on the initial day of the imposition of the penalty and ending on the day on which the informal dispute resolution process under item (aa) is completed; CommentsClose CommentsPermalink

‘(cc) may provide for the collection of such civil money penalty and the placement of such amounts collected in an escrow account under the direction of the Secretary on the earlier of the date on which the informal dispute resolution process under item (aa) is completed or the date that is 90 days after the date of the imposition of the penalty; CommentsClose CommentsPermalink

‘(dd) may provide that such amounts collected are kept in such account pending the resolution of any subsequent appeals; CommentsClose CommentsPermalink

‘(ee) in the case where the facility successfully appeals the penalty, may provide for the return of such amounts collected (plus interest) to the facility; and CommentsClose CommentsPermalink

‘(ff) in the case where all such appeals are unsuccessful, may provide that some portion of such amounts collected may be used to support activities that benefit residents, including assistance to support and protect residents of a facility that closes (voluntarily or involuntarily) or is decertified (including offsetting costs of relocating residents to home and community-based settings or another facility), projects that support resident and family councils and other consumer involvement in assuring quality care in facilities, and facility improvement initiatives approved by the Secretary (including joint training of facility staff and surveyors, technical assistance for facilities under quality assurance programs, the appointment of temporary management, and other activities approved by the Secretary). CommentsClose CommentsPermalink

‘(V) PROCEDURE- The provisions of section 1128A (other than subsections (a) and (b) and except to the extent that such provisions require a hearing prior to the imposition of a civil money penalty) shall apply to a civil money penalty under this clause in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).’. CommentsClose CommentsPermalink





(B) CONFORMING AMENDMENT- Section 1919(h)(8) of the Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is amended by inserting ‘and in paragraph (3)(C)(ii)’ after ‘paragraph (2)(A)’. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall take effect 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink

SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PROGRAM.

(a) Establishment- CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary, in consultation with the Inspector General of the Department of Health and Human Services, shall establish a pilot program (in this section referred to as the ‘pilot program’) to develop, test, and implement use of an independent monitor to oversee interstate and large intrastate chains of skilled nursing facilities and nursing facilities. CommentsClose CommentsPermalink





(2) SELECTION- The Secretary shall select chains of skilled nursing facilities and nursing facilities described in paragraph (1) to participate in the pilot program from among those chains that submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require. CommentsClose CommentsPermalink





(3) DURATION- The Secretary shall conduct the pilot program for a two-year period. CommentsClose CommentsPermalink





(4) IMPLEMENTATION- The Secretary shall implement the pilot program not later than one year after the date of the enactment of this Act. CommentsClose CommentsPermalink





(b) Requirements- The Secretary shall evaluate chains selected to participate in the pilot program based on criteria selected by the Secretary, including where evidence suggests that one or more facilities of the chain are experiencing serious safety and quality of care problems. Such criteria may include the evaluation of a chain that includes one or more facilities participating in the ‘Special Focus Facility’ program (or a successor program) or one or more facilities with a record of repeated serious safety and quality of care deficiencies. CommentsClose CommentsPermalink





(c) Responsibilities of the Independent Monitor- An independent monitor that enters into a contract with the Secretary to participate in the conduct of such program shall-- CommentsClose CommentsPermalink





(1) conduct periodic reviews and prepare root-cause quality and deficiency analyses of a chain to assess if facilities of the chain are in compliance with State and Federal laws and regulations applicable to the facilities; CommentsClose CommentsPermalink





(2) undertake sustained oversight of the chain, whether publicly or privately held, to involve the owners of the chain and the principal business partners of such owners in facilitating compliance by facilities of the chain with State and Federal laws and regulations applicable to the facilities; CommentsClose CommentsPermalink





(3) analyze the management structure, distribution of expenditures, and nurse staffing levels of facilities of the chain in relation to resident census, staff turnover rates, and tenure; CommentsClose CommentsPermalink





(4) report findings and recommendations with respect to such reviews, analyses, and oversight to the chain and facilities of the chain, to the Secretary and to relevant States; and CommentsClose CommentsPermalink





(5) publish the results of such reviews, analyses, and oversight. CommentsClose CommentsPermalink





(d) Implementation of Recommendations- CommentsClose CommentsPermalink





(1) RECEIPT OF FINDING BY CHAIN- Not later than 10 days after receipt of a finding of an independent monitor under subsection (c)(4), a chain participating in the pilot program shall submit to the independent monitor a report-- CommentsClose CommentsPermalink





(A) outlining corrective actions the chain will take to implement the recommendations in such report; or CommentsClose CommentsPermalink





(B) indicating that the chain will not implement such recommendations and why it will not do so. CommentsClose CommentsPermalink





(2) RECEIPT OF REPORT BY INDEPENDENT MONITOR- Not later than 10 days after the date of receipt of a report submitted by a chain under paragraph (1), an independent monitor shall finalize its recommendations and submit a report to the chain and facilities of the chain, the Secretary, and the State (or States) involved, as appropriate, containing such final recommendations. CommentsClose CommentsPermalink





(e) Cost of Appointment- A chain shall be responsible for a portion of the costs associated with the appointment of independent monitors under the pilot program. The chain shall pay such portion to the Secretary (in an amount and in accordance with procedures established by the Secretary). CommentsClose CommentsPermalink





(f) Waiver Authority- The Secretary may waive such requirements of titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as may be necessary for the purpose of carrying out the pilot program. CommentsClose CommentsPermalink





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





(h) Definitions- In this section: CommentsClose CommentsPermalink





(1) FACILITY- The term ‘facility’ means a skilled nursing facility or a nursing facility. CommentsClose CommentsPermalink





(2) NURSING FACILITY- The term ‘nursing facility’ has the meaning given such term in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)). CommentsClose CommentsPermalink





(3) SECRETARY- The term ‘Secretary’ means the Secretary of Health and Human Services, acting through the Assistant Secretary for Planning and Evaluation. CommentsClose CommentsPermalink





(4) SKILLED NURSING FACILITY- The term ‘skilled nursing facility’ has the meaning given such term in section 1819(a) of the Social Security Act (42 U.S.C. 1395(a)). CommentsClose CommentsPermalink





(i) Evaluation and Report- CommentsClose CommentsPermalink





(1) EVALUATION- The Inspector General of the Department of Health and Human Services shall evaluate the pilot program. Such evaluation shall-- CommentsClose CommentsPermalink





(A) determine whether the independent monitor program should be established on a permanent basis; and CommentsClose CommentsPermalink





(B) if the Inspector General determines that the independent monitor program should be established on a permanent basis, recommend appropriate procedures and mechanisms for such establishment. CommentsClose CommentsPermalink





(2) REPORT- Not later than 180 days after the completion of the pilot program, the Inspector General shall submit to Congress and the Secretary a report containing the results of the evaluation conducted under paragraph (1), together with recommendations for such legislation and administrative action as the Inspector General determines appropriate. CommentsClose CommentsPermalink

SEC. 1423. NOTIFICATION OF FACILITY CLOSURE.

(a) Skilled Nursing Facilities- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1819(c) of the Social Security Act (42 U.S.C. 1395i-3(c)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(7) NOTIFICATION OF FACILITY CLOSURE- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Any individual who is the administrator of a skilled nursing facility must-- CommentsClose CommentsPermalink





‘(i) submit to the Secretary, the State long-term care ombudsman, residents of the facility, and the legal representatives of such residents or other responsible parties, written notification of an impending closure-- CommentsClose CommentsPermalink





‘(I) subject to subclause (II), not later than the date that is 60 days prior to the date of such closure; and CommentsClose CommentsPermalink





‘(II) in the case of a facility where the Secretary terminates the facility’s participation under this title, not later than the date that the Secretary determines appropriate; CommentsClose CommentsPermalink





‘(ii) ensure that the facility does not admit any new residents on or after the date on which such written notification is submitted; and CommentsClose CommentsPermalink





‘(iii) include in the notice a plan for the transfer and adequate relocation of the residents of the facility by a specified date prior to closure that has been approved by the State, including assurances that the residents will be transferred to the most appropriate facility or other setting in terms of quality, services, and location, taking into consideration the needs and best interests of each resident. CommentsClose CommentsPermalink





‘(B) RELOCATION- CommentsClose CommentsPermalink





‘(i) IN GENERAL- The State shall ensure that, before a facility closes, all residents of the facility have been successfully relocated to another facility or an alternative home and community-based setting. CommentsClose CommentsPermalink





‘(ii) CONTINUATION OF PAYMENTS UNTIL RESIDENTS RELOCATED- The Secretary may, as the Secretary determines appropriate, continue to make payments under this title with respect to residents of a facility that has submitted a notification under subparagraph (A) during the period beginning on the date such notification is submitted and ending on the date on which the resident is successfully relocated.’. CommentsClose CommentsPermalink





(2) CONFORMING AMENDMENTS- Section 1819(h)(4) of the Social Security Act (42 U.S.C. 1395i-3(h)(4)) is amended-- CommentsClose CommentsPermalink





(A) in the first sentence, by striking ‘the Secretary shall terminate’ and inserting ‘the Secretary, subject to subsection (c)(7), shall terminate’; and CommentsClose CommentsPermalink





(B) in the second sentence, by striking ‘subsection (c)(2)’ and inserting ‘paragraphs (2) and (7) of subsection (c)’. CommentsClose CommentsPermalink





(b) Nursing Facilities- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1919(c) of the Social Security Act (42 U.S.C. 1396r(c)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(9) NOTIFICATION OF FACILITY CLOSURE- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Any individual who is an administrator of a nursing facility must-- CommentsClose CommentsPermalink





‘(i) submit to the Secretary, the State long-term care ombudsman, residents of the facility, and the legal representatives of such residents or other responsible parties, written notification of an impending closure-- CommentsClose CommentsPermalink





‘(I) subject to subclause (II), not later than the date that is 60 days prior to the date of such closure; and CommentsClose CommentsPermalink





‘(II) in the case of a facility where the Secretary terminates the facility’s participation under this title, not later than the date that the Secretary determines appropriate; CommentsClose CommentsPermalink





‘(ii) ensure that the facility does not admit any new residents on or after the date on which such written notification is submitted; and CommentsClose CommentsPermalink





‘(iii) include in the notice a plan for the transfer and adequate relocation of the residents of the facility by a specified date prior to closure that has been approved by the State, including assurances that the residents will be transferred to the most appropriate facility or other setting in terms of quality, services, and location, taking into consideration the needs and best interests of each resident. CommentsClose CommentsPermalink





‘(B) RELOCATION- CommentsClose CommentsPermalink





‘(i) IN GENERAL- The State shall ensure that, before a facility closes, all residents of the facility have been successfully relocated to another facility or an alternative home and community-based setting. CommentsClose CommentsPermalink





‘(ii) CONTINUATION OF PAYMENTS UNTIL RESIDENTS RELOCATED- The Secretary may, as the Secretary determines appropriate, continue to make payments under this title with respect to residents of a facility that has submitted a notification under subparagraph (A) during the period beginning on the date such notification is submitted and ending on the date on which the resident is successfully relocated.’. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall take effect 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink

PART 3--IMPROVING STAFF TRAINING

SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING.

(a) Skilled Nursing Facilities- Section 1819(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(I)) is amended by inserting ‘(including, in the case of initial training and, if the Secretary determines appropriate, in the case of ongoing training, dementia management training and resident abuse prevention training)’ after ‘curriculum’. CommentsClose CommentsPermalink





(b) Nursing Facilities- Section 1919(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is amended by inserting ‘(including, in the case of initial training and, if the Secretary determines appropriate, in the case of ongoing training, dementia management training and resident abuse prevention training)’ after ‘curriculum’. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by this section shall take effect 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink

SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED FOR CERTIFIED NURSE AIDES AND SUPERVISORY STAFF.

(a) Study- CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary shall conduct a study on the content of training for certified nurse aides and supervisory staff of skilled nursing facilities and nursing facilities. The study shall include an analysis of the following: CommentsClose CommentsPermalink





(A) Whether the number of initial training hours for certified nurse aides required under sections 1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) of the Social Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(II); 1396r(f)(2)(A)(i)(II)) should be increased from 75 and, if so, what the required number of initial training hours should be, including any recommendations for the content of such training (including training related to dementia). CommentsClose CommentsPermalink





(B) Whether requirements for ongoing training under such sections 1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) should be increased from 12 hours per year, including any recommendations for the content of such training. CommentsClose CommentsPermalink





(2) CONSULTATION- In conducting the analysis under paragraph (1)(A), the Secretary shall consult with States that, as of the date of the enactment of this Act, require more than 75 hours of training for certified nurse aides. CommentsClose CommentsPermalink





(3) DEFINITIONS- In this section: CommentsClose CommentsPermalink





(A) NURSING FACILITY- The term ‘nursing facility’ has the meaning given such term in section 1919(a) of the Social Security Act (42 U.S.C. 1396r(a)). CommentsClose CommentsPermalink





(B) SECRETARY- The term ‘Secretary’ means the Secretary of Health and Human Services, acting through the Assistant Secretary for Planning and Evaluation. CommentsClose CommentsPermalink





(C) SKILLED NURSING FACILITY- The term ‘skilled nursing facility’ has the meaning given such term in section 1819(a) of the Social Security Act (42 U.S.C. 1395(a)). CommentsClose CommentsPermalink





(b) Report- Not later than 2 years after the date of the enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Secretary determines appropriate. CommentsClose CommentsPermalink

Subtitle C--Quality Measurements CommentsClose CommentsPermalink

SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR QUALITY IMPROVEMENT.

Title XI of the Social Security Act, as amended by section 1401(a), is further amended by adding at the end the following new part: CommentsClose CommentsPermalink

‘Part E--Quality Improvement

‘ESTABLISHMENT OF NATIONAL PRIORITIES FOR PERFORMANCE IMPROVEMENT

‘Sec. 1191. (a) ESTABLISHMENT OF NATIONAL PRIORITIES BY THE SECRETARYstablishment of National Priorities by the Secretary- The Secretary shall establish and periodically update, not less frequently than triennially, national priorities for performance improvement. CommentsClose CommentsPermalink





‘(b) Recommendations for National Priorities- In establishing and updating national priorities under subsection (a), the Secretary shall solicit and consider recommendations from multiple outside stakeholders. CommentsClose CommentsPermalink





‘(c) Considerations in Setting National Priorities- With respect to such priorities, the Secretary shall ensure that priority is given to areas in the delivery of health care services in the United States that-- CommentsClose CommentsPermalink





‘(1) contribute to a large burden of disease, including those that address the health care provided to patients with prevalent, high-cost chronic diseases; CommentsClose CommentsPermalink





‘(2) have the greatest potential to decrease morbidity and mortality in this country, including those that are designed to eliminate harm to patients; CommentsClose CommentsPermalink





‘(3) have the greatest potential for improving the performance, affordability, and patient-centeredness of health care, including those due to variations in care; CommentsClose CommentsPermalink





‘(4) address health disparities across groups and areas; and CommentsClose CommentsPermalink





‘(5) have the potential for rapid improvement due to existing evidence, standards of care or other reasons. CommentsClose CommentsPermalink





‘(d) Definitions- In this part: CommentsClose CommentsPermalink





‘(1) CONSENSUS-BASED ENTITY- The term ‘consensus-based entity’ means an entity with a contract with the Secretary under section 1890. CommentsClose CommentsPermalink





‘(2) QUALITY MEASURE- The term ‘quality measure’ means a national consensus standard for measuring the performance and improvement of population health, or of institutional providers of services, physicians, and other health care practitioners in the delivery of health care services. CommentsClose CommentsPermalink





‘(e) Funding- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841 (in such proportion as the Secretary determines appropriate), of $2,000,000, for the activities under this section for each of the fiscal years 2010 through 2014. CommentsClose CommentsPermalink





‘(2) AUTHORIZATION OF APPROPRIATIONS- For purposes of carrying out the provisions of this section, in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services $2,000,000 for each of the fiscal years 2010 through 2014.’. CommentsClose CommentsPermalink

SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; GAO EVALUATION OF DATA COLLECTION PROCESS FOR QUALITY MEASUREMENT.

Part E of title XI of the Social Security Act, as added by section 1441, is amended by adding at the end the following new sections: CommentsClose CommentsPermalink

‘SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES.

‘(a) Agreements With Qualified Entities- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall enter into agreements with qualified entities to develop quality measures for the delivery of health care services in the United States. CommentsClose CommentsPermalink





‘(2) FORM OF AGREEMENTS- The Secretary may carry out paragraph (1) by contract, grant, or otherwise. CommentsClose CommentsPermalink





‘(3) RECOMMENDATIONS OF CONSENSUS-BASED ENTITY- In carrying out this section, the Secretary shall-- CommentsClose CommentsPermalink





‘(A) seek public input; and CommentsClose CommentsPermalink





‘(B) take into consideration recommendations of the consensus-based entity with a contract with the Secretary under section 1890(a). CommentsClose CommentsPermalink





‘(b) Determination of Areas Where Quality Measures Are Required- Consistent with the national priorities established under this part and with the programs administered by the Centers for Medicare & Medicaid Services and in consultation with other relevant Federal agencies, the Secretary shall determine areas in which quality measures for assessing health care services in the United States are needed. CommentsClose CommentsPermalink





‘(c) Development of Quality Measures- CommentsClose CommentsPermalink





‘(1) PATIENT-CENTERED AND POPULATION-BASED MEASURES- Quality measures developed under agreements under subsection (a) shall be designed-- CommentsClose CommentsPermalink





‘(A) to assess outcomes, presence of impairment, and functional status of patients; CommentsClose CommentsPermalink





‘(B) to assess the continuity and coordination of care and care transitions for patients across providers and health care settings, including end of life care; CommentsClose CommentsPermalink





‘(C) to assess patient experience and patient engagement; CommentsClose CommentsPermalink





‘(D) to assess the safety, effectiveness, and timeliness of care; CommentsClose CommentsPermalink





‘(E) to assess health disparities including those associated with individual race, ethnicity, age, gender, place of residence or language; CommentsClose CommentsPermalink





‘(F) to assess the efficiency and resource use in the provision of care; CommentsClose CommentsPermalink





‘(G) to the extent feasible, to be collected as part of health information technologies supporting better delivery of health care services; CommentsClose CommentsPermalink





‘(H) to be available free of charge to users for the use of such measures; and CommentsClose CommentsPermalink





‘(I) to assess delivery of health care services to individuals regardless of age. CommentsClose CommentsPermalink





‘(2) AVAILABILITY OF MEASURES- The Secretary shall make quality measures developed under this section available to the public. CommentsClose CommentsPermalink





‘(3) TESTING OF PROPOSED MEASURES- The Secretary may use amounts made available under subsection (f) to fund the testing of proposed quality measures by qualified entities. Testing funded under this paragraph shall include testing of the feasibility and usability of proposed measures. CommentsClose CommentsPermalink





‘(4) UPDATING OF ENDORSED MEASURES- The Secretary may use amounts made available under subsection (f) to fund the updating (and testing, if applicable) by consensus-based entities of quality measures that have been previously endorsed by such an entity as new evidence is developed, in a manner consistent with section 1890(b)(3). CommentsClose CommentsPermalink





‘(d) Qualified Entities- Before entering into agreements with a qualified entity, the Secretary shall ensure that the entity is a public, nonprofit or academic institution with technical expertise in the area of health quality measurement. CommentsClose CommentsPermalink





‘(e) Application for Grant- A grant may be made under this section only if an application for the grant is submitted to the Secretary and the application is in such form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this section. CommentsClose CommentsPermalink





‘(f) Funding- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841 (in such proportion as the Secretary determines appropriate), of $25,000,000, to the Secretary for purposes of carrying out this section for each of the fiscal years 2010 through 2014. CommentsClose CommentsPermalink





‘(2) AUTHORIZATION OF APPROPRIATIONS- For purposes of carrying out the provisions of this section, in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services $25,000,000 for each of the fiscal years 2010 through 2014. CommentsClose CommentsPermalink

‘SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROCESS FOR QUALITY MEASUREMENT.

‘(a) GAO Evaluations- The Comptroller General of the United States shall conduct periodic evaluations of the implementation of the data collection processes for quality measures used by the Secretary. CommentsClose CommentsPermalink





‘(b) Considerations- In carrying out the evaluation under subsection (a), the Comptroller General shall determine-- CommentsClose CommentsPermalink





‘(1) whether the system for the collection of data for quality measures provides for validation of data as relevant and scientifically credible; CommentsClose CommentsPermalink





‘(2) whether data collection efforts under the system use the most efficient and cost-effective means in a manner that minimizes administrative burden on persons required to collect data and that adequately protects the privacy of patients’ personal health information and provides data security; CommentsClose CommentsPermalink





‘(3) whether standards under the system provide for an appropriate opportunity for physicians and other clinicians and institutional providers of services to review and correct findings; and CommentsClose CommentsPermalink





‘(4) the extent to which quality measures are consistent with section 1192(c)(1) or result in direct or indirect costs to users of such measures. CommentsClose CommentsPermalink





‘(c) Report- The Comptroller General shall submit reports to Congress and to the Secretary containing a description of the findings and conclusions of the results of each such evaluation.’. CommentsClose CommentsPermalink

SEC. 1443. MULTI-STAKEHOLDER PRE-STAKEHOLDER PRERULEMAKING INPUT INTO SELECTION OF QUALITY MEASURES.

Section 1808 of the Social Security Act (42 U.S.C. 1395b-9) is amended by adding at the end the following new subsection: CommentsClose CommentsPermalink





‘(d) Multi-stakeholder Pre-rulemaking Input Into Selection of Quality Measures- CommentsClose CommentsPermalink





‘(1) LIST OF MEASURES- Not later than December 1 before each year (beginning with 2011), the Secretary shall make public a list of measures being considered for selection for quality measurement by the Secretary in rulemaking with respect to payment systems under this title beginning in the payment year beginning in such year and for payment systems beginning in the calendar year following such year, as the case may be. CommentsClose CommentsPermalink





‘(2) CONSULTATION ON SELECTION OF ENDORSED QUALITY MEASURES- A consensus-based entity that has entered into a contract under section 1890 shall, as part of such contract, convene multi-stakeholder groups to provide recommendations on the selection of individual or composite quality measures, for use in reporting performance information to the public or for use in public health care programs. CommentsClose CommentsPermalink





‘(3) MULTI-STAKEHOLDER INPUT- Not later than February 1 of each year (beginning with 2011), the consensus-based entity described in paragraph (2) shall transmit to the Secretary the recommendations of multi-stakeholder groups provided under paragraph (2). Such recommendations shall be included in the transmissions the consensus-based entity makes to the Secretary under the contract provided for under section 1890. CommentsClose CommentsPermalink





‘(4) REQUIREMENT FOR TRANSPARENCY IN PROCESS- CommentsClose CommentsPermalink





‘(A) IN GENERAL- In convening multi-stakeholder groups under paragraph (2) with respect to the selection of quality measures, the consensus-based entity described in such paragraph shall provide for an open and transparent process for the activities conducted pursuant to such convening. CommentsClose CommentsPermalink





‘(B) SELECTION OF ORGANIZATIONS PARTICIPATING IN MULTI-STAKEHOLDER GROUPS- The process under paragraph (2) shall ensure that the selection of representatives of multi-stakeholder groups includes provision for public nominations for, and the opportunity for public comment on, such selection. CommentsClose CommentsPermalink





‘(5) USE OF INPUT- The respective proposed rule shall contain a summary of the recommendations made by the multi-stakeholder groups under paragraph (2), as well as other comments received regarding the proposed measures, and the extent to which such proposed rule follows such recommendations and the rationale for not following such recommendations. CommentsClose CommentsPermalink





‘(6) MULTI-STAKEHOLDER GROUPS- For purposes of this subsection, the term ‘multi-stakeholder groups’ means, with respect to a quality measure, a voluntary collaborative of organizations representing persons interested in or affected by the use of such quality measure, such as the following: CommentsClose CommentsPermalink





‘(A) Hospitals and other institutional providers. CommentsClose CommentsPermalink





‘(B) Physicians. CommentsClose CommentsPermalink





‘(C) Health care quality alliances. CommentsClose CommentsPermalink





‘(D) Nurses and other health care practitioners. CommentsClose CommentsPermalink





‘(E) Health plans. CommentsClose CommentsPermalink





‘(F) Patient advocates and consumer groups. CommentsClose CommentsPermalink





‘(G) Employers. CommentsClose CommentsPermalink





‘(H) Public and private purchasers of health care items and services. CommentsClose CommentsPermalink





‘(I) Labor organizations. CommentsClose CommentsPermalink





‘(J) Relevant departments or agencies of the United States. CommentsClose CommentsPermalink





‘(K) Biopharmaceutical companies and manufacturers of medical devices. CommentsClose CommentsPermalink





‘(L) Licensing, credentialing, and accrediting bodies. CommentsClose CommentsPermalink





‘(7) FUNDING- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall provide for the transfer, from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841 (in such proportion as the Secretary determines appropriate), of $1,000,000, to the Secretary for purposes of carrying out this subsection for each of the fiscal years 2010 through 2014. CommentsClose CommentsPermalink





‘(B) AUTHORIZATION OF APPROPRIATIONS- For purposes of carrying out the provisions of this subsection, in addition to funds otherwise available, out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary of Health and Human Services $1,000,000 for each of the fiscal years 2010 through 2014.’. CommentsClose CommentsPermalink

SEC. 1444. APPLICATION OF QUALITY MEASURES.

(a) Inpatient Hospital Services- Section 1886(b)(3)(B) of such Act (42 U.S.C. 1395ww(b)(3)(B)) is amended by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(x)(I) Subject to subclause (II), for purposes of reporting data on quality measures for inpatient hospital services furnished during fiscal year 2012 and each subsequent fiscal year, the quality measures specified under clause (viii) shall be measures selected by the Secretary from measures that have been endorsed by the entity with a contract with the Secretary under section 1890(a). CommentsClose CommentsPermalink





‘(II) In the case of a specified area or medical topic determined appropriate by the Secretary for which a feasible and practical quality measure has not been endorsed by the entity with a contract under section 1890(a), the Secretary may specify a measure that is not so endorsed as long as due consideration is given to measures that have been endorsed or adopted by a consensus organization identified by the Secretary. The Secretary shall submit such a non-endorsed measure to the entity for consideration for endorsement. If the entity considers but does not endorse such a measure and if the Secretary does not phase-out use of such measure, the Secretary shall include the rationale for continued use of such a measure in rulemaking.’. CommentsClose CommentsPermalink





(b) Outpatient Hospital Services- Section 1833(t)(17) of such Act (42 U.S.C. 1395l(t)(17)) is amended by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(F) USE OF ENDORSED QUALITY MEASURES- The provisions of clause (x) of section 1886(b)(3)(C) shall apply to quality measures for covered OPD services under this paragraph in the same manner as such provisions apply to quality measures for inpatient hospital services.’. CommentsClose CommentsPermalink





(c) Physicians’ Services- Section 1848(k)(2)(C)(ii) of such Act (42 U.S.C. 1395w-4(k)(2)(C)(ii)) is amended by adding at the end the following: ‘The Secretary shall submit such a non-endorsed measure to the entity for consideration for endorsement. If the entity considers but does not endorse such a measure and if the Secretary does not phase-out use of such measure, the Secretary shall include the rationale for continued use of such a measure in rulemaking.’. CommentsClose CommentsPermalink





(d) Renal Dialysis Services- Section 1881(h)(2)(B)(ii) of such Act (42 U.S.C. 1395rr(h)(2)(B)(ii)) is amended by adding at the end the following: ‘The Secretary shall submit such a non-endorsed measure to the entity for consideration for endorsement. If the entity considers but does not endorse such a measure and if the Secretary does not phase-out use of such measure, the Secretary shall include the rationale for continued use of such a measure in rulemaking.’. CommentsClose CommentsPermalink





(e) Endorsement of Standards- Section 1890(b)(2) of the Social Security Act (42 U.S.C. 1395aaa(b)(2)) is amended by adding after and below subparagraph (B) the following: CommentsClose CommentsPermalink





‘If the entity does not endorse a measure, such entity shall explain the reasons and provide suggestions about changes to such measure that might make it a potentially endorsable measure.’. CommentsClose CommentsPermalink





(f) Effective Date- Except as otherwise provided, the amendments made by this section shall apply to quality measures applied for payment years beginning with 2012 or fiscal year 2012, as the case may be. CommentsClose CommentsPermalink

SEC. 1445. CONSENSUS-BASED ENTITY FUNDING.

Section 1890(d) of the Social Security Act (42 U.S.C. 1395aaa(d)) is amended by striking ‘for each of fiscal years 2009 through 2012’ and inserting ‘for fiscal year 2009, and $12,000,000 for each of the fiscal years 2010 through 2012.’’. CommentsClose CommentsPermalink

Subtitle D--Physician Payments Sunshine Provision CommentsClose CommentsPermalink

SEC. 1451. REPORTS ON FINANCIAL RELATIONSHIPS BETWEEN MANUFACTURERS AND DISTRIBUTORS OF COVERED DRUGS, DEVICES, BIOLOGICALS, OR MEDICAL SUPPLIES UNDER MEDICARE, MEDICAID, OR CHIP AND PHYSICIANS AND OTHER HEALTH CARE ENTITIES AND BETWEEN PHYSICIANS AND OTHER HEALTH CARE ENTITIES.

(a) In General- Part A of title XI of the Social Security Act (42 U.S.C. 1301 et seq.), as amended by section 1631(a), is further amended by inserting after section 1128G the following new section: CommentsClose CommentsPermalink

‘SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS’ FINANCIAL RELATIONSHIPS WITH MANUFACTURERS AND DISTRIBUTORS OF COVERED DRUGS, DEVICES, BIOLOGICALS, OR MEDICAL SUPPLIES UNDER MEDICARE, MEDICAID, OR CHIP AND WITH ENTITIES THAT BILL FOR SERVICES UNDER MEDICARE.

‘(a) Reporting of Payments or Other Transfers of Value- CommentsClose CommentsPermalink





‘(1) IN GENERAL- Except as provided in this subsection, not later than March 31, 2011, and annually thereafter, each applicable manufacturer or distributor that provides a payment or other transfer of value to a covered recipient, or to an entity or individual at the request of or designated on behalf of a covered recipient, shall submit to the Secretary, in such electronic form as the Secretary shall require, the following information with respect to the preceding calendar year: CommentsClose CommentsPermalink





‘(A) With respect to the covered recipient, the recipient’s name, business address, physician specialty, and national provider identifier. CommentsClose CommentsPermalink





‘(B) With respect to the payment or other transfer of value, other than a drug sample-- CommentsClose CommentsPermalink





‘(i) its value and date; CommentsClose CommentsPermalink





‘(ii) the name of the related drug, device, or supply, if available; and CommentsClose CommentsPermalink





‘(iii) a description of its form, indicated (as appropriate for all that apply) as-- CommentsClose CommentsPermalink





‘(I) cash or a cash equivalent; CommentsClose CommentsPermalink





‘(II) in-kind items or services; CommentsClose CommentsPermalink





‘(III) stock, a stock option, or any other ownership interest, dividend, profit, or other return on investment; or CommentsClose CommentsPermalink





‘(IV) any other form (as defined by the Secretary). CommentsClose CommentsPermalink





‘(C) With respect to a drug sample, the name, number, date, and dosage units of the sample. CommentsClose CommentsPermalink





‘(2) AGGREGATE REPORTING- Information submitted by an applicable manufacturer or distributor under paragraph (1) shall include the aggregate amount of all payments or other transfers of value provided by the manufacturer or distributor to covered recipients (and to entities or individuals at the request of or designated on behalf of a covered recipient) during the year involved, including all payments and transfers of value regardless of whether such payments or transfer of value were individually disclosed. CommentsClose CommentsPermalink





‘(3) SPECIAL RULE FOR CERTAIN PAYMENTS OR OTHER TRANSFERS OF VALUE- In the case where an applicable manufacturer or distributor provides a payment or other transfer of value to an entity or individual at the request of or designated on behalf of a covered recipient, the manufacturer or distributor shall disclose that payment or other transfer of value under the name of the covered recipient. CommentsClose CommentsPermalink





‘(4) DELAYED REPORTING FOR PAYMENTS MADE PURSUANT TO PRODUCT DEVELOPMENT AGREEMENTS- In the case of a payment or other transfer of value made to a covered recipient by an applicable manufacturer or distributor pursuant to a product development agreement for services furnished in connection with the development of a new drug, device, biological, or medical supply, the applicable manufacturer or distributor may report the value and recipient of such payment or other transfer of value in the first reporting period under this subsection in the next reporting deadline after the earlier of the following: CommentsClose CommentsPermalink





‘(A) The date of the approval or clearance of the covered drug, device, biological, or medical supply by the Food and Drug Administration. CommentsClose CommentsPermalink





‘(B) Two calendar years after the date such payment or other transfer of value was made. CommentsClose CommentsPermalink





‘(5) DELAYED REPORTING FOR PAYMENTS MADE PURSUANT TO CLINICAL INVESTIGATIONS- In the case of a payment or other transfer of value made to a covered recipient by an applicable manufacturer or distributor in connection with a clinical investigation regarding a new drug, device, biological, or medical supply, the applicable manufacturer or distributor may report as required under this section in the next reporting period under this subsection after the earlier of the following: CommentsClose CommentsPermalink





‘(A) The date that the clinical investigation is registered on the website maintained by the National Institutes of Health pursuant to section 671 of the Food and Drug Administration Amendments Act of 2007. CommentsClose CommentsPermalink





‘(B) Two calendar years after the date such payment or other transfer of value was made. CommentsClose CommentsPermalink





‘(6) CONFIDENTIALITY- Information described in paragraph (4) or (5) shall be considered confidential and shall not be subject to disclosure undersection 552 of title 5, United States Code, or any other similar Federal, State, or local law, until or after the date on which the information is made available to the public under such paragraph. CommentsClose CommentsPermalink





‘(b) Reporting of Ownership Interest by Physicians in Hospitals and Other Entities That Bill Medicare- Not later than March 31 of each year (beginning with 2011), each hospital or other health care entity (not including a Medicare Advantage organization) that bills the Secretary under part A or part B of title XVIII for services shall report on the ownership shares (other than ownership shares described in section 1877(c)) of each physician who, directly or indirectly, owns an interest in the entity. In this subsection, the term ‘physician’ includes a physician’s immediate family members (as defined for purposes of section 1877(a)). CommentsClose CommentsPermalink





‘(c) Public Availability- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall establish procedures to ensure that, not later than September 30, 2011, and on June 30 of each year beginning thereafter, the information submitted under subsections (a) and (b), other than information regard drug samples, with respect to the preceding calendar year is made available through an Internet website that-- CommentsClose CommentsPermalink





‘(A) is searchable and is in a format that is clear and understandable; CommentsClose CommentsPermalink





‘(B) contains information that is presented by the name of the applicable manufacturer or distributor, the name of the covered recipient, the business address of the covered recipient, the specialty (if applicable) of the covered recipient, the value of the payment or other transfer of value, the date on which the payment or other transfer of value was provided to the covered recipient, the form of the payment or other transfer of value, indicated (as appropriate) under subsection (a)(1)(B)(ii), the nature of the payment or other transfer of value, indicated (as appropriate) under subsection (a)(1)(B)(iii), and the name of the covered drug, device, biological, or medical supply, as applicable; CommentsClose CommentsPermalink





‘(C) contains information that is able to be easily aggregated and downloaded; CommentsClose CommentsPermalink





‘(D) contains a description of any enforcement actions taken to carry out this section, including any penalties imposed under subsection (d), during the preceding year; CommentsClose CommentsPermalink





‘(E) contains background information on industry-physician relationships; CommentsClose CommentsPermalink





‘(F) in the case of information submitted with respect to a payment or other transfer of value described in subsection (a)(5), lists such information separately from the other information submitted under subsection (a) and designates such separately listed information as funding for clinical research; CommentsClose CommentsPermalink





‘(G) contains any other information the Secretary determines would be helpful to the average consumer; and CommentsClose CommentsPermalink





‘(H) provides the covered recipient an opportunity to submit corrections to the information made available to the public with respect to the covered recipient. CommentsClose CommentsPermalink





‘(2) ACCURACY OF REPORTING- The accuracy of the information that is submitted under subsections (a) and (b) and made available under paragraph (1) shall be the responsibility of the applicable manufacturer or distributor of a covered drug, device, biological, or medical supply reporting under subsection (a) or hospital or other health care entity reporting physician ownership under subsection (b). The Secretary shall establish procedures to ensure that the covered recipient is provided with an opportunity to submit corrections to the manufacturer, distributor, hospital, or other entity reporting under subsection (a) or (b) with regard to information made public with respect to the covered recipient and, under such procedures, the corrections shall be transmitted to the Secretary. CommentsClose CommentsPermalink





‘(3) SPECIAL RULE FOR DRUG SAMPLES- Information relating to drug samples provided under subsection (a) shall not be made available to the public by the Secretary but may be made available outside the Department of Health and Human Services by the Secretary for research or legitimate business purposes pursuant to data use agreements. CommentsClose CommentsPermalink





‘(4) SPECIAL RULE FOR NATIONAL PROVIDER IDENTIFIERS- Information relating to national provider identifiers provided under subsection (a) shall not be made available to the public by the Secretary but may be made available outside the Department of Health and Human Services by the Secretary for research or legitimate business purposes pursuant to data use agreements. CommentsClose CommentsPermalink





‘(d) Penalties for Noncompliance- CommentsClose CommentsPermalink





‘(1) FAILURE TO REPORT- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to subparagraph (B), except as provided in paragraph (2), any applicable manufacturer or distributor that fails to submit information required under subsection (a) in a timely manner in accordance with regulations promulgated to carry out such subsection, and any hospital or other entity that fails to submit information required under subsection (b) in a timely manner in accordance with regulations promulgated to carry out such subsection shall be subject to a civil money penalty of not less than $1,000, but not more than $10,000, for each payment or other transfer of value or ownership or investment interest not reported as required under such subsection. Such penalty shall be imposed and collected in the same manner as civil money penalties under subsection (a) of section 1128A are imposed and collected under that section. CommentsClose CommentsPermalink





‘(B) LIMITATION- The total amount of civil money penalties imposed under subparagraph (A) with respect to each annual submission of information under subsection (a) by an applicable manufacturer or distributor or other entity shall not exceed $150,000. CommentsClose CommentsPermalink





‘(2) KNOWING FAILURE TO REPORT- CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to subparagraph (B), any applicable manufacturer or distributor that knowingly fails to submit information required under subsection (a) in a timely manner in accordance with regulations promulgated to carry out such subsection and any hospital or other entity that fails to submit information required under subsection (b) in a timely manner in accordance with regulations promulgated to carry out such subsection, shall be subject to a civil money penalty of not less than $10,000, but not more than $100,000, for each payment or other transfer of value or ownership or investment interest not reported as required under such subsection. Such penalty shall be imposed and collected in the same manner as civil money penalties under subsection (a) of section 1128A are imposed and collected under that section. CommentsClose CommentsPermalink





‘(B) LIMITATION- The total amount of civil money penalties imposed under subparagraph (A) with respect to each annual submission of information under subsection (a) or (b) by an applicable manufacturer, distributor, or entity shall not exceed $1,000,000, or, if greater, 0.1 percentage of the total annual revenues of the manufacturer, distributor, or entity. CommentsClose CommentsPermalink





‘(3) USE OF FUNDS- Funds collected by the Secretary as a result of the imposition of a civil money penalty under this subsection shall be used to carry out this section. CommentsClose CommentsPermalink





‘(4) ENFORCEMENT THROUGH STATE ATTORNEYS GENERAL- The attorney general of a State, after providing notice to the Secretary of an intent to proceed under this paragraph in a specific case and providing the Secretary with an opportunity to bring an action under this subsection and the Secretary declining such opportunity, may proceed under this subsection against a manufacturer or distributor in the State. CommentsClose CommentsPermalink





‘(e) Annual Report to Congress- Not later than April 1 of each year beginning with 2011, the Secretary shall submit to Congress a report that includes the following: CommentsClose CommentsPermalink





‘(1) The information submitted under this section during the preceding year, aggregated for each applicable manufacturer or distributor of a covered drug, device, biological, or medical supply that submitted such information during such year. CommentsClose CommentsPermalink





‘(2) A description of any enforcement actions taken to carry out this section, including any penalties imposed under subsection (d), during the preceding year. CommentsClose CommentsPermalink





‘(f) Definitions- In this section: CommentsClose CommentsPermalink





‘(1) APPLICABLE MANUFACTURER; APPLICABLE DISTRIBUTOR- The term ‘applicable manufacturer’ means a manufacturer of a covered drug, device, biological, or medical supply, and the term ‘applicable distributor’ means a distributor of a covered drug, device, or medical supply. CommentsClose CommentsPermalink





‘(2) CLINICAL INVESTIGATION- The term ‘clinical investigation’ means any experiment involving one or more human subjects, or materials derived from human subjects, in which a drug or device is administered, dispensed, or used. CommentsClose CommentsPermalink





‘(3) COVERED DRUG, DEVICE, BIOLOGICAL, OR MEDICAL SUPPLY- The term ‘covered’ means, with respect to a drug, device, biological, or medical supply, such a drug, device, biological, or medical supply for which payment is available under title XVIII or a State plan under title XIX or XXI (or a waiver of such a plan). CommentsClose CommentsPermalink





‘(4) COVERED RECIPIENT- The term ‘covered recipient’ means the following: CommentsClose CommentsPermalink





‘(A) A physician. CommentsClose CommentsPermalink





‘(B) A physician group practice. CommentsClose CommentsPermalink





‘(C) Any other prescriber of a covered drug, device, biological, or medical supply. CommentsClose CommentsPermalink





‘(D) A pharmacy or pharmacist. CommentsClose CommentsPermalink





‘(E) A health insurance issuer, group health plan, or other entity offering a health benefits plan, including any employee of such an issuer, plan, or entity. CommentsClose CommentsPermalink





‘(F) A pharmacy benefit manager, including any employee of such a manager. CommentsClose CommentsPermalink





‘(G) A hospital. CommentsClose CommentsPermalink





‘(H) A medical school. CommentsClose CommentsPermalink





‘(I) A sponsor of a continuing medical education program. CommentsClose CommentsPermalink





‘(J) A patient advocacy or disease specific group. CommentsClose CommentsPermalink





‘(K) A organization of health care professionals. CommentsClose CommentsPermalink





‘(L) A biomedical researcher. CommentsClose CommentsPermalink





‘(M) A group purchasing organization. CommentsClose CommentsPermalink





‘(5) DISTRIBUTOR OF A COVERED DRUG, DEVICE, OR MEDICAL SUPPLY- The term ‘distributor of a covered drug, device, or medical supply’ means any entity which is engaged in the marketing or distribution of a covered drug, device, or medical supply (or any subsidiary of or entity affiliated with such entity), but does not include a wholesale pharmaceutical distributor. CommentsClose CommentsPermalink





‘(6) EMPLOYEE- The term ‘employee’ has the meaning given such term in section 1877(h)(2). CommentsClose CommentsPermalink





‘(7) KNOWINGLY- The term ‘knowingly’ has the meaning given such term insection 3729(b) of title 31, United States Code. CommentsClose CommentsPermalink





‘(8) MANUFACTURER OF A COVERED DRUG, DEVICE, BIOLOGICAL, OR MEDICAL SUPPLY- The term ‘manufacturer of a covered drug, device, biological, or medical supply’ means any entity which is engaged in the production, preparation, propagation, compounding, conversion, processing, marketing, or distribution of a covered drug, device, biological, or medical supply (or any subsidiary of or entity affiliated with such entity). CommentsClose CommentsPermalink





‘(9) PAYMENT OR OTHER TRANSFER OF VALUE- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The term ‘payment or other transfer of value’ means a transfer of anything of value for or of any of the following: CommentsClose CommentsPermalink





‘(i) Gift, food, or entertainment. CommentsClose CommentsPermalink





‘(ii) Travel or trip. CommentsClose CommentsPermalink





‘(iii) Honoraria. CommentsClose CommentsPermalink





‘(iv) Research funding or grant. CommentsClose CommentsPermalink





‘(v) Education or conference funding. CommentsClose CommentsPermalink





‘(vi) Consulting fees. CommentsClose CommentsPermalink





‘(vii) Ownership or investment interest and royalties or license fee. CommentsClose CommentsPermalink





‘(B) INCLUSIONS- Subject to subparagraph (C), the term ‘payment or other transfer of value’ includes any compensation, gift, honorarium, speaking fee, consulting fee, travel, services, dividend, profit distribution, stock or stock option grant, or any ownership or investment interest held by a physician in a manufacturer (excluding a dividend or other profit distribution from, or ownership or investment interest in, a publicly traded security or mutual fund (as described in section 1877(c))). CommentsClose CommentsPermalink





‘(C) EXCLUSIONS- The term ‘payment or other transfer of value’ does not include the following: CommentsClose CommentsPermalink





‘(i) Any payment or other transfer of value provided by an applicable manufacturer or distributor to a covered recipient where the amount transferred to, requested by, or designated on behalf of the covered recipient does not exceed $5. CommentsClose CommentsPermalink





‘(ii) The loan of a covered device for a short-term trial period, not to exceed 90 days, to permit evaluation of the covered device by the covered recipient. CommentsClose CommentsPermalink





‘(iii) Items or services provided under a contractual warranty, including the replacement of a covered device, where the terms of the warranty are set forth in the purchase or lease agreement for the covered device. CommentsClose CommentsPermalink





‘(iv) A transfer of anything of value to a covered recipient when the covered recipient is a patient and not acting in the professional capacity of a covered recipient. CommentsClose CommentsPermalink





‘(v) In-kind items used for the provision of charity care. CommentsClose CommentsPermalink





‘(vi) A dividend or other profit distribution from, or ownership or investment interest in, a publicly traded security and mutual fund (as described in section 1877(c)). CommentsClose CommentsPermalink





‘(vii) Compensation paid by a manufacturer or distributor of a covered drug, device, biological, or medical supply to a covered recipient who is directly employed by and works solely for such manufacturer or distributor. CommentsClose CommentsPermalink





‘(viii) Any discount or cash rebate. CommentsClose CommentsPermalink





‘(10) PHYSICIAN- The term ‘physician’ has the meaning given that term in section 1861(r). For purposes of this section, such term does not include a physician who is an employee of the applicable manufacturer that is required to submit information under subsection (a). CommentsClose CommentsPermalink





‘(g) Annual Reports to States- Not later than April 1 of each year beginning with 2011, the Secretary shall submit to States a report that includes a summary of the information submitted under subsections (a) and (d) during the preceding year with respect to covered recipients or other hospitals and entities in the State. CommentsClose CommentsPermalink





‘(h) Relation to State Laws- CommentsClose CommentsPermalink





‘(1) IN GENERAL- Effective on January 1, 2011, subject to paragraph (2), the provisions of this section shall preempt any law or regulation of a State or of a political subdivision of a State that requires an applicable manufacturer and applicable distributor (as such terms are defined in subsection (f)) to disclose or report, in any format, the type of information (described in subsection (a)) regarding a payment or other transfer of value provided by the manufacturer to a covered recipient (as so defined). CommentsClose CommentsPermalink





‘(2) NO PREEMPTION OF ADDITIONAL REQUIREMENTS- Paragraph (1) shall not preempt any law or regulation of a State or of a political subdivision of a State that requires any of the following: CommentsClose CommentsPermalink





‘(A) The disclosure or reporting of information not of the type required to be disclosed or reported under this section. CommentsClose CommentsPermalink





‘(B) The disclosure or reporting, in any format, of the type of information required to be disclosed or reported under this section to a Federal, State, or local governmental agency for public health surveillance, investigation, or other public health purposes or health oversight purposes. CommentsClose CommentsPermalink





‘(C) The discovery or admissibility of information described in this section in a criminal, civil, or administrative proceeding.’. CommentsClose CommentsPermalink





(b) Availability of Information From the Disclosure of Financial Relationship Report (DFRR)- The Secretary of Health and Human Services shall submit to Congress a report on the full results of the Disclosure of Physician Financial Relationships surveys required pursuant to section 5006 of the Deficit Reduction Act of 2005. Such report shall be submitted to Congress not later than the date that is 6 months after the date such surveys are collected and shall be made publicly available on an Internet website of the Department of Health and Human Services. CommentsClose CommentsPermalink

Subtitle E--Public Reporting on Health Care-Associated Infections CommentsClose CommentsPermalink

SEC. 1461. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND AMBULATORY SURGICAL CENTERS ON HEALTH CARE-ASSOCIATED INFECTIONS.

(a) In General- Title XI of the Social Security Act is amended by inserting after section 1138 the following section: CommentsClose CommentsPermalink

‘SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND AMBULATORY SURGICAL CENTERS ON HEALTH CARE-ASSOCIATED INFECTIONS.

‘(a) Reporting Requirement- CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall provide that a hospital (as defined in subsection (g)) or ambulatory surgical center meeting the requirements of titles XVIII or XIX may participate in the programs established under such titles (pursuant to the applicable provisions of law, including sections 1866(a)(1) and 1832(a)(1)(F)(i)) only if, in accordance with this section, the hospital or center reports such information on health care-associated infections that develop in the hospital or center (and such demographic information associated with such infections) as the Secretary specifies. CommentsClose CommentsPermalink





‘(2) REPORTING PROTOCOLS- Such information shall be reported in accordance with reporting protocols established by the Secretary through the Director of the Centers for Disease Control and Prevention (in this section referred to as the ‘CDC’) and to the National Healthcare Safety Network of the CDC or under such another reporting system of such Centers as determined appropriate by the Secretary in consultation with such Director. CommentsClose CommentsPermalink





‘(3) COORDINATION WITH HIT- The Secretary, through the Director of the CDC and the Office of the National Coordinator for Health Information Technology, shall ensure that the transmission of information under this subsection is coordinated with systems established under the HITECH Act, where appropriate. CommentsClose CommentsPermalink





‘(4) PROCEDURES TO ENSURE THE VALIDITY OF INFORMATION- The Secretary shall establish procedures regarding the validity of the information submitted under this subsection in order to ensure that such information is appropriately compared across hospitals and centers. Such procedures shall address failures to report as well as errors in reporting. CommentsClose CommentsPermalink





‘(5) IMPLEMENTATION- Not later than 1 year after the date of enactment of this section, the Secretary, through the Director of CDC, shall promulgate regulations to carry out this section. CommentsClose CommentsPermalink





‘(b) Public Posting of Information- The Secretary shall promptly post, on the official public Internet site of the Department of Health and Human Services, the information reported under subsection (a). Such information shall be set forth in a manner that allows for the comparison of information on health care-associated infections-- CommentsClose CommentsPermalink





‘(1) among hospitals and ambulatory surgical centers; and CommentsClose CommentsPermalink





‘(2) by demographic information. CommentsClose CommentsPermalink





‘(c) Annual Report to Congress- On an annual basis the Secretary shall submit to the Congress a report that summarizes each of the following: CommentsClose CommentsPermalink





‘(1) The number and types of health care-associated infections reported under subsection (a) in hospitals and ambulatory surgical centers during such year. CommentsClose CommentsPermalink





‘(2) Factors that contribute to the occurrence of such infections, including health care worker immunization rates. CommentsClose CommentsPermalink





‘(3) Based on the most recent information available to the Secretary on the composition of the professional staff of hospitals and ambulatory surgical centers, the number of certified infection control professionals on the staff of hospitals and ambulatory surgical centers. CommentsClose CommentsPermalink





‘(4) The total increases or decreases in health care costs that resulted from increases or decreases in the rates of occurrence of each such type of infection during such year. CommentsClose CommentsPermalink





‘(5) Recommendations, in coordination with the Center for Quality Improvement established under section 931 of the Public Health Service Act, for best practices to eliminate the rates of occurrence of each such type of infection in hospitals and ambulatory surgical centers. CommentsClose CommentsPermalink





‘(d) Non-preemption of State Laws- Nothing in this section shall be construed as preempting or otherwise affecting any provision of State law relating to the disclosure of information on health care-associated infections or patient safety procedures for a hospital or ambulatory surgical center. CommentsClose CommentsPermalink





‘(e) Health Care-associated Infection- For purposes of this section: CommentsClose CommentsPermalink





‘(1) IN GENERAL- The term ‘health care-associated infection’ means an infection that develops in a patient who has received care in any institutional setting where health care is delivered and is related to receiving health care. CommentsClose CommentsPermalink





‘(2) RELATED TO RECEIVING HEALTH CARE- The term ‘related to receiving health care’, with respect to an infection, means that the infection was not incubating or present at the time health care was provided. CommentsClose CommentsPermalink





‘(f) Application to Critical Access Hospitals- For purposes of this section, the term ‘hospital’ includes a critical access hospital, as defined in section 1861(mm)(1).’. CommentsClose CommentsPermalink





(b) Effective Date- With respect to section 1138A of the Social Security Act (as inserted by subsection (a) of this section), the requirement under such section that hospitals and ambulatory surgical centers submit reports takes effect on such date (not later than 2 years after the date of the enactment of this Act) as the Secretary of Health and Human Services shall specify. In order to meet such deadline, the Secretary may implement such section through guidance or other instructions. CommentsClose CommentsPermalink





(c) GAO Report- Not later than 18 months after the date of the enactment of this Act, the Comptroller General of the United States shall submit to Congress a report on the program established under section 1138A of the Social Security Act, as inserted by subsection (a). Such report shall include an analysis of the appropriateness of the types of information required for submission, compliance with reporting requirements, the success of the validity procedures established, and any conflict or overlap between the reporting required under such section and any other reporting systems mandated by either the States or the Federal Government. CommentsClose CommentsPermalink





(d) Report on Additional Data- Not later than 18 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to the Congress a report on the appropriateness of expanding the requirements under such section to include additional information (such as health care worker immunization rates), in order to improve health care quality and patient safety. CommentsClose CommentsPermalink

TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION CommentsClose CommentsPermalink

SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSITIONS.

(a) In General- Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)) is amended-- CommentsClose CommentsPermalink





(1) in paragraph (4)(F)(i), by striking ‘paragraph (7)’ and inserting ‘paragraphs (7) and (8)’; CommentsClose CommentsPermalink





(2) in paragraph (4)(H)(i), by striking ‘paragraph (7)’ and inserting ‘paragraphs (7) and (8)’; CommentsClose CommentsPermalink





(3) in paragraph (7)(E), by inserting ‘and paragraph (8)’ after ‘this paragraph’; and CommentsClose CommentsPermalink





(4) by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(8) ADDITIONAL REDISTRIBUTION OF UNUSED RESIDENCY POSITIONS- CommentsClose CommentsPermalink





‘(A) REDUCTIONS IN LIMIT BASED ON UNUSED POSITIONS- CommentsClose CommentsPermalink





‘(i) PROGRAMS SUBJECT TO REDUCTION- If a hospital’s reference resident level (specified in clause (ii)) is less than the otherwise applicable resident limit (as defined in subparagraph (C)(ii)), effective for portions of cost reporting periods occurring on or after July 1, 2011, the otherwise applicable resident limit shall be reduced by 90 percent of the difference between such otherwise applicable resident limit and such reference resident level. CommentsClose CommentsPermalink





‘(ii) REFERENCE RESIDENT LEVEL- CommentsClose CommentsPermalink





‘(I) IN GENERAL- Except as otherwise provided in a subsequent subclause, the reference resident level specified in this clause for a hospital is the highest resident level for any of the 3 most recent cost reporting periods (ending before the date of the enactment of this paragraph) of the hospital for which a cost report has been settled (or, if not, submitted (subject to audit)), as determined by the Secretary. CommentsClose CommentsPermalink





‘(II) USE OF MOST RECENT ACCOUNTING PERIOD TO RECOGNIZE EXPANSION OF EXISTING PROGRAMS- If a hospital submits a timely request to increase its resident level due to an expansion, or planned expansion, of an existing residency training program that is not reflected on the most recent settled or submitted cost report, after audit and subject to the discretion of the Secretary, subject to subclause (IV), the reference resident level for such hospital is the resident level that includes the additional residents attributable to such expansion or establishment, as determined by the Secretary. The Secretary is authorized to determine an alternative reference resident level for a hospital that submitted to the Secretary a timely request, before the start of the 2009-2010 academic year, for an increase in its reference resident level due to a planned expansion. CommentsClose CommentsPermalink





‘(III) SPECIAL PROVIDER AGREEMENT- In the case of a hospital described in paragraph (4)(H)(v), the reference resident level specified in this clause is the limitation applicable under subclause (I) of such paragraph. CommentsClose CommentsPermalink





‘(IV) PREVIOUS REDISTRIBUTION- The reference resident level specified in this clause for a hospital shall be increased to the extent required to take into account an increase in resident positions made available to the hospital under paragraph (7)(B) that are not otherwise taken into account under a previous subclause. CommentsClose CommentsPermalink





‘(iii) AFFILIATION- The provisions of clause (i) shall be applied to hospitals which are members of the same affiliated group (as defined by the Secretary under paragraph (4)(H)(ii)) and to the extent the hospitals can demonstrate that they are filling any additional resident slots allocated to other hospitals through an affiliation agreement, the Secretary shall adjust the determination of available slots accordingly, or which the Secretary otherwise has permitted the resident positions (under section 402 of the Social Security Amendments of 1967) to be aggregated for purposes of applying the resident position limitations under this subsection. CommentsClose CommentsPermalink





‘(B) REDISTRIBUTION- CommentsClose CommentsPermalink





‘(i) IN GENERAL- The Secretary shall increase the otherwise applicable resident limit for each qualifying hospital that submits an application under this subparagraph by such number as the Secretary may approve for portions of cost reporting periods occurring on or after July 1, 2011. The estimated aggregate number of increases in the otherwise applicable resident limit under this subparagraph may not exceed the Secretary’s estimate of the aggregate reduction in such limits attributable to subparagraph (A). CommentsClose CommentsPermalink





‘(ii) REQUIREMENTS FOR QUALIFYING HOSPITALS- A hospital is not a qualifying hospital for purposes of this paragraph unless the following requirements are met: CommentsClose CommentsPermalink





‘(I) MAINTENANCE OF PRIMARY CARE RESIDENT LEVEL- The hospital maintains the number of primary care residents at a level that is not less than the base level of primary care residents increased by the number of additional primary care resident positions provided to the hospital under this subparagraph. For purposes of this subparagraph, the ‘base level of primary care residents’ for a hospital is the level of such residents as of a base period (specified by the Secretary), determined without regard to whether such positions were in excess of the otherwise applicable resident limit for such period but taking into account the application of subclauses (II) and (III) of subparagraph (A)(ii). CommentsClose CommentsPermalink





‘(II) DEDICATED ASSIGNMENT OF ADDITIONAL RESIDENT POSITIONS TO PRIMARY CARE- The hospital assigns all such additional resident positions for primary care residents. CommentsClose CommentsPermalink





‘(III) ACCREDITATION- The hospital’s residency programs in primary care are fully accredited or, in the case of a residency training program not in operation as of the base year, the hospital is actively applying for such accreditation for the program for such additional resident positions (as determined by the Secretary). CommentsClose CommentsPermalink





‘(iii) CONSIDERATIONS IN REDISTRIBUTION- In determining for which qualifying hospitals the increase in the otherwise applicable resident limit is provided under this subparagraph, the Secretary shall take into account the demonstrated likelihood of the hospital filling the positions within the first 3 cost reporting periods beginning on or after July 1, 2011, made available under this subparagraph, as determined by the Secretary. CommentsClose CommentsPermalink





‘(iv) PRIORITY FOR CERTAIN HOSPITALS- In determining for which qualifying hospitals the increase in the otherwise applicable resident limit is provided under this subparagraph, the Secretary shall distribute the increase to qualifying hospitals based on the following criteria: CommentsClose CommentsPermalink





‘(I) The Secretary shall give preference to hospitals that had a reduction in resident training positions under subparagraph (A). CommentsClose CommentsPermalink





‘(II) The Secretary shall give preference to hospitals with 3-year primary care residency training programs, such as family practice and general internal medicine. CommentsClose CommentsPermalink





‘(III) The Secretary shall give preference to hospitals insofar as they have in effect formal arrangements (as determined by the Secretary) that place greater emphasis upon training in Federally qualified health centers, rural health clinics, and other nonprovider settings, and to hospitals that receive additional payments under subsection (d)(5)(F) and emphasize training in an outpatient department. CommentsClose CommentsPermalink





‘(IV) The Secretary shall give preference to hospitals with a number of positions (as of July 1, 2009) in excess of the otherwise applicable resident limit for such period. CommentsClose CommentsPermalink





‘(V) The Secretary shall give preference to hospitals that place greater emphasis upon training in a health professional shortage area (designated under section 332 of the Public Health Service Act) or a health professional needs area (designated under section 2211 of such Act). CommentsClose CommentsPermalink





‘(VI) The Secretary shall give preference to hospitals in States that have low resident-to-population ratios (including a greater preference for those States with lower resident-to-population ratios). CommentsClose CommentsPermalink





‘(v) LIMITATION- In no case shall more than 20 full-time equivalent additional residency positions be made available under this subparagraph with respect to any hospital. CommentsClose CommentsPermalink





‘(vi) APPLICATION OF PER RESIDENT AMOUNTS FOR PRIMARY CARE- With respect to additional residency positions in a hospital attributable to the increase provided under this subparagraph, the approved FTE resident amounts are deemed to be equal to the hospital per resident amounts for primary care and nonprimary care computed under paragraph (2)(D) for that hospital. CommentsClose CommentsPermalink





‘(vi) DISTRIBUTION- The Secretary shall distribute the increase in resident training positions to qualifying hospitals under this subparagraph not later than July 1, 2011. CommentsClose CommentsPermalink





‘(C) RESIDENT LEVEL AND LIMIT DEFINED- In this paragraph: CommentsClose CommentsPermalink





‘(i) The term ‘resident level’ has the meaning given such term in paragraph (7)(C)(i). CommentsClose CommentsPermalink





‘(ii) The term ‘otherwise applicable resident limit’ means, with respect to a hospital, the limit otherwise applicable under subparagraphs (F)(i) and (H) of paragraph (4) on the resident level for the hospital determined without regard to this paragraph but taking into account paragraph (7)(A). CommentsClose CommentsPermalink





‘(D) MAINTENANCE OF PRIMARY CARE RESIDENT LEVEL- In carrying out this paragraph, the Secretary shall require hospitals that receive additional resident positions under subparagraph (B)-- CommentsClose CommentsPermalink





‘(i) to maintain records, and periodically report to the Secretary, on the number of primary care residents in its residency training programs; and CommentsClose CommentsPermalink





‘(ii) as a condition of payment for a cost reporting period under this subsection for such positions, to maintain the level of such positions at not less than the sum of-- CommentsClose CommentsPermalink





‘(I) the base level of primary care resident positions (as determined under subparagraph (B)(ii)(I)) before receiving such additional positions; and CommentsClose CommentsPermalink





‘(II) the number of such additional positions.’. CommentsClose CommentsPermalink





(b) IME- CommentsClose CommentsPermalink





(1) IN GENERAL- Section 1886(d)(5)(B)(v) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the seconthird sentence, is amended-- CommentsClose CommentsPermalink





(A) by striking ‘subsection (h)(7)’ and inserting ‘subsections (h)(7) and (h)(8)’; and CommentsClose CommentsPermalink





(B) by striking ‘it applies’ and inserting ‘they apply’. CommentsClose CommentsPermalink





(2) CONFORMING PROVISION- Section 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by adding at the end the following clause: CommentsClose CommentsPermalink





‘(x) For discharges occurring on or after July 1, 2011, insofar as an additional payment amount under this subparagraph is attributable to resident positions distributed to a hospital under subsection (h)(8)(B), the indirect teaching adjustment factor shall be computed in the same manner as provided under clause (ii) with respect to such resident positions.’. CommentsClose CommentsPermalink





(c) Conforming Amendment- Section 422(b)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173) is amended by striking ‘section 1886(h)(7)’ and all that follows and inserting ‘paragraphs (7) and (8) of subsection (h) of section 1886 of the Social Security Act.’. CommentsClose CommentsPermalink

SEC. 1502. INCREASING TRAINING IN NONPROVIDER SETTINGS.

(a) Direct GME- Section 1886(h)(4)(E) of the Social Security Act (42 U.S.C. 1395ww(h)) is amended-- CommentsClose CommentsPermalink





(1) by designating the first sentence as a clause (i) with the heading ‘IN GENERAL’ and appropriate indentation;(2) by striking- ’ and appropriate indentation; CommentsClose CommentsPermalink





(2) by striking ‘shall be counted and that all the time’ and inserting ‘shall be counted and that-- CommentsClose CommentsPermalink





‘(I) effective for cost reporting periods beginning before July 1, 2009, all the time’; CommentsClose CommentsPermalink





(3) in subclause (I), as inserted by paragraph (1), by striking the period at the end and inserting ‘; and’; and CommentsClose CommentsPermalink





(A) by inserting after subclause (I), as so inserted, the following: CommentsClose CommentsPermalink





‘(II) effective for cost reporting periods beginning on or after July 1, 2009, all the time so spent by a resident shall be counted towards the determination of full-time equivalency, without regard to the setting in which the activities are performed, if the hospital incurs the costs of the stipends and fringe benefits of the resident during the time the resident spends in that setting. CommentsClose CommentsPermalink





Any hospital claiming under this subparagraph for time spent in a nonprovider setting shall maintain and make available to the Secretary records regarding the amount of such time and such amount in comparison with amounts of such time in such base year as the Secretary shall specify.’. CommentsClose CommentsPermalink





(b) IME- Section 1886(d)(5)(B)(iv) of the Social Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amended-- CommentsClose CommentsPermalink





(1) by striking ‘(iv) Effective for discharges occurring on or after October 1, 1997’ and inserting ‘(iv)(I) Effective for discharges occurring on or after October 1, 1997, and before July 1, 2009’; and CommentsClose CommentsPermalink





(2) by inserting after subclause (I), as inserted by paragraph (1), the following new subclause: CommentsClose CommentsPermalink





‘(II) Effective for discharges occurring on or after July 1, 2009, all the time spent by an intern or resident in patient care activities at an entity in a nonprovider setting shall be counted towards the determination of full-time equivalency if the hospital incurs the costs of the stipends and fringe benefits of the intern or resident during the time the intern or resident spends in that setting.’. CommentsClose CommentsPermalink





(c) OIG Study on Impact on Training- The Inspector General of the Department of Health and Human Services shall analyze the data collected by the Secretary of Health and Human Services from the records made available to the Secretary under section 1886(h)(4)(E) of the Social Security Act, as amended by subsection (a), in order to assess the extent to which there is an increase in time spent by medical residents in training in nonprovider settings as a result of the amendments made by this section. Not later than 4 years after the date of the enactment of this Act, the Inspector General shall submit a report to Congress on such analysis and assessment. CommentsClose CommentsPermalink





(d) Demonstration Project for Approved Teaching Health Centers- CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary of Health and Human Services shall conduct a demonstration project under which an approved teaching health center (as defined in paragraph (3)) would be eligible for payment under subsections (h) and (k) of section 1886 of the Social Security Act (42 U.S.C. 1395ww) of amounts for its own direct costs of graduate medical education activities for primary care residents, as well as for the direct costs of graduate medical education activities of its contracting hospital for such residents, in a manner similar to the manner in which such payments would be made to a hospital if the hospital were to operate such a program. CommentsClose CommentsPermalink





(2) CONDITIONS- Under the demonstration project-- CommentsClose CommentsPermalink





(A) an approved teaching health center shall contract with an accredited teaching hospital to carry out the inpatient responsibilities of the primary care residency program of the hospital involved and is responsible for payment to the hospital for the hospital’s costs of the salary and fringe benefits for residents in the program; CommentsClose CommentsPermalink





(B) the number of primary care residents of the center shall not count against the contracting hospital’s resident limit; and CommentsClose CommentsPermalink





(C) the contracting hospital shall agree not to diminish the number of residents in its primary care residency training program. CommentsClose CommentsPermalink





(3) APPROVED TEACHING HEALTH CENTER DEFINED- In this subsection, the term ‘approved teaching health center’ means a nonprovider setting, such as a Federally qualified health center or rural health clinic (as defined in section 1861(aa) of the Social Security Act), that develops and operates an accredited primary care residency program for which funding would be available if it were operated by a hospital. CommentsClose CommentsPermalink

SEC. 1503. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND SCHOLARLY ACTIVITIES AND OTHER ACTIVITIES.

(a) Direct GME- Section 1886(h) of the Social Security Act (42 U.S.C. 1395ww(h)) is amended-- CommentsClose CommentsPermalink





(1) in paragraph (4)(E), as amended by section 1502(a)-- CommentsClose CommentsPermalink





(A) in clause (i), by striking ‘Such rules’ and inserting ‘Subject to clause (ii), such rules’; and CommentsClose CommentsPermalink





(B) by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(ii) TREATMENT OF CERTAIN NONPROVIDER AND DIDACTIC ACTIVITIES- Such rules shall provide that all time spent by an intern or resident in an approved medical residency training program in a nonprovider setting that is primarily engaged in furnishing patient care (as defined in paragraph (5)(K)) in nonpatient care activities, such as didactic conferences and seminars, but not including research not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall be counted toward the determination of full-time equivalency.’; CommentsClose CommentsPermalink





(2) in paragraph (4), by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(I) TREATMENT OF CERTAIN TIME IN APROVED MEDICAL RESIDENCY TRAINING PROGRAM- In determining the hospital’s number of full-time equivalent residents for purposes of this subsection, all the time that is spent by an intern or resident in an approved medical residency training program on vacation, sick leave, or other approved leave, as such time is defined by the Secretary, and that does not prolong the total time the resident is participating in the approved program beyond the normal duration of the program shall be counted toward the determination of full-time equivalency.’; and CommentsClose CommentsPermalink





(3) in paragraph (5), by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(K) NONPROVIDER SETTING THAT IS PRIMARILY ENGAGED IN FURNISHING PATIENT CARE- The term ‘nonprovider setting that is primarily engaged in furnishing patient care’ means a nonprovider setting in which the primary activity is the care and treatment of patients, as defined by the Secretary.’. CommentsClose CommentsPermalink





(b) IME Determinations- Section 1886(d)(5)(B) of such Act (42 U.S.C. 1395ww(d)(5)(B)), as amended by section 1501(b), is amended by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(xi)(I) The provisions of subparagraph (I) of subsection (h)(4) shall apply under this subparagraph in the same manner as they apply under such subsection. CommentsClose CommentsPermalink





‘(II) In determining the hospital’s number of full-time equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in an approved medical residency training program in nonpatient care activities, such as didactic conferences and seminars, as such time and activities are defined by the Secretary, that occurs in the hospital shall be counted toward the determination of full-time equivalency if the hospital-- CommentsClose CommentsPermalink





‘(aa) is recognized as a subsection (d) hospital; CommentsClose CommentsPermalink





‘(bb) is recognized as a subsection (d) Puerto Rico hospital; CommentsClose CommentsPermalink





‘(cc) is reimbursed under a reimbursement system authorized under section 1814(b)(3); or CommentsClose CommentsPermalink





‘(dd) is a provider-based hospital outpatient department. CommentsClose CommentsPermalink





‘(III) In determining the hospital’s number of full-time equivalent residents for purposes of this subparagraph, all the time spent by an intern or resident in an approved medical residency training program in research activities that are not associated with the treatment or diagnosis of a particular patient, as such time and activities are defined by the Secretary, shall not be counted toward the determination of full-time equivalency.’. CommentsClose CommentsPermalink





(c) Effective Dates; Application- CommentsClose CommentsPermalink





(1) IN GENERAL- Except as otherwise provided, the Secretary of Health and Human Services shall implement the amendments made by this section in a manner so as to apply to cost reporting periods beginning on or after January 1, 1983. CommentsClose CommentsPermalink





(2) DIRECT GME- Section 1886(h)(4)(E)(ii) of the Social Security Act, as added by subsection (a)(1)(B), shall apply to cost reporting periods beginning on or after July 1, 2008. CommentsClose CommentsPermalink





(3) IME- Section 1886(d)(5)(B)(x)(III) of the Social Security Act, as added by subsection (b), shall apply to cost reporting periods beginning on or after October 1, 2001. Such section, as so added, shall not give rise to any inference on how the law in effect prior to such date should be interpreted. CommentsClose CommentsPermalink





(4) APPLICATION- The amendments made by this section shall not be applied in a manner that requires reopening of any settled hospital cost reports as to which there is not a jurisdictionally proper appeal pending as of the date of the enactment of this Act on the issue of payment for indirect costs of medical education under section 1886(d)(5)(B) of the Social Security Act or for direct graduate medical education costs under section 1886(h) of such Act. CommentsClose CommentsPermalink

SEC. 1504. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED HOSPITALS.

(a) Direct GME- Section 1886(h)(4)(H) of the Social Security Act (42 U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at the end the following new clause: CommentsClose CommentsPermalink





‘(vi) REDISTRIBUTION OF RESIDENCY SLOTS AFTER A HOSPITAL CLOSES- CommentsClose CommentsPermalink





‘(I) IN GENERAL- The Secretary shall, by regulation, establish a process consistent with subclauses (II) and (III) under which, in the case where a hospital (other than a hospital described in clause (v)) with an approved medical residency program in a State closes on or after the date that is 2 years before the date of the enactment of this clause, the Secretary shall increase the otherwise applicable resident limit under this paragraph for other hospitals in the State in accordance with this clause. CommentsClose CommentsPermalink





‘(II) PROCESS FOR HOSPITALS IN CERTAIN AREAS- In determining for which hospitals the increase in the otherwise applicable resident limit described in subclause (I) is provided, the Secretary shall establish a process to provide for such increase to one or more hospitals located in the State. Such process shall take into consideration the recommendations submitted to the Secretary by the senior health official (as designated by the chief executive officer of such State) if such recommendations are submitted not later than 180 days after the date of the hospital closure involved (or, in the case of a hospital that closed after the date that is 2 years before the date of the enactment of this clause, 180 days after such date of enactment). CommentsClose CommentsPermalink





‘(III) LIMITATION- The estimated aggregate number of increases in the otherwise applicable resident limits for hospitals under this clause shall be equal to the estimated number of resident positions in the approved medical residency programs that closed on or after the date described in subclause (I).’. CommentsClose CommentsPermalink





(b) No Effect on Temporary FTE Cap Adjustments- The amendments made by this section shall not effect any temporary adjustment to a hospital’s FTE cap under section 413.79(h) of title 42, Code of Federal Regulations (as in effect on the date of enactment of this Act) and shall not affect the application of section 1886(h)(4)(H)(v) of the Social Security Act. CommentsClose CommentsPermalink





(c) Conforming Amendments- CommentsClose CommentsPermalink





(1) Section 422(b)(2) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108-173), as amended by section 1501(c), is amended by striking ‘(7) and’ and inserting ‘(4)(H)(vi), (7), and’. CommentsClose CommentsPermalink





(2) Section 1886(h)(7)(E) of the Social Security Act (42 U.S.C. 1395ww(h)(7)(E)) is amended by inserting ‘or under paragraph (4)(H)(vi)’ after ‘under this paragraph’. CommentsClose CommentsPermalink

SEC. 1505. IMPROVING ACCOUNTABILITY FOR APPROVED MEDICAL RESIDENCY TRAINING.

(a) Specification of Goals for Approved Medical Residency Training Programs- Section 1886(h)(1) of the Social Security Act (42 U.S.C. 1395ww(h)(1)) is amended-- CommentsClose CommentsPermalink





(1) by designating the matter beginning with ‘Notwithstanding’ as a subparagraph (A) with the heading ‘IN GENERAL- ’ and with appropriate indentation; and CommentsClose CommentsPermalink





(2) by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(B) GOALS AND ACCOUNTABILITY FOR APPROVED MEDICAL RESIDENCY TRAINING PROGRAMS- The goals of medical residency training programs are to foster a physician workforce so that physicians are trained to be able to do the following: CommentsClose CommentsPermalink





‘(i) Work effectively in various health care delivery settings, such as nonprovider settings. CommentsClose CommentsPermalink





‘(ii) Coordinate patient care within and across settings relevant to their specialties. CommentsClose CommentsPermalink





‘(iii) Understand the relevant cost and value of various diagnostic and treatment options. CommentsClose CommentsPermalink





‘(iv) Work in inter-professional teams and multi-disciplinary team-based models in provider and nonprovider settings to enhance safety and improve quality of patient care. CommentsClose CommentsPermalink





‘(v) Be knowledgeable in methods of identifying systematic errors in health care delivery and in implementing systematic solutions in case of such errors, including experience and participation in continuous quality improvement projects to improve health outcomes of the population the physicians serve. CommentsClose CommentsPermalink





‘(vi) Be meaningful EHR users (as determined under section 1848(o)(2)) in the delivery of care and in improving the quality of the health of the community and the individuals that the hospital serves.’ CommentsClose CommentsPermalink





(b) GAO Study on Evaluation of Training Programs- CommentsClose CommentsPermalink





(1) IN GENERAL- The Comptroller General of the United States shall conduct a study to evaluate the extent to which medical residency training programs-- CommentsClose CommentsPermalink





(A) are meeting the goals described in section 1886(h)(1)(B) of the Social Security Act, as added by subsection (a), in a range of residency programs, including primary care and other specialties; and CommentsClose CommentsPermalink





(B) have the appropriate faculty expertise to teach the topics required to achieve such goals. CommentsClose CommentsPermalink





(2) REPORT- Not later than 18 months after the date of the enactment of this Act, the Comptroller General shall submit to Congress a report on such study and shall include in such report recommendations as to how medical residency training programs could be further encouraged to meet such goals through means such as-- CommentsClose CommentsPermalink





(A) development of curriculum requirements; and CommentsClose CommentsPermalink





(B) assessment of the accreditation processes of the Accreditation Council for Graduate Medical Education and the American Osteopathic Association and effectiveness of those processes in accrediting medical residency programs that meet the goals referred to in paragraph (1)(A). CommentsClose CommentsPermalink

TITLE VI--PROGRAM INTEGRITY CommentsClose CommentsPermalink

Subtitle A--Increased Funding To Fight Waste, Fraud, and Abuse CommentsClose CommentsPermalink

SEC. 1601. INCREASED FUNDING AND FLEXIBILITY TO FIGHT FRAUD AND ABUSE.

(a) In General- Section 1817(k) of the Social Security Act (42 U.S.C. 1395i(k)) is amended-- CommentsClose CommentsPermalink





(1) by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(7) ADDITIONAL FUNDING- In addition to the funds otherwise appropriated to the Account from the Trust Fund under paragraphs (3) and (4) and for purposes described in paragraphs (3)(C) and (4)(A), there are hereby appropriated an additional $100,000,000 to such Account from such Trust Fund for each fiscal year beginning with 2011. The funds appropriated under this paragraph shall be allocated in the same proportion as the total funding appropriated with respect to paragraphs (3)(A) and (4)(A) was allocated with respect to fiscal year 2010, and shall be available without further appropriation until expended.’. CommentsClose CommentsPermalink





(2) in paragraph (4)(A)-- CommentsClose CommentsPermalink





(A) by inserting ‘for activities described in paragraph (3)(C) and’ after ‘necessary’; and CommentsClose CommentsPermalink





(B) by inserting ‘until expended’ after ‘appropriation’. CommentsClose CommentsPermalink





(b) Flexibility in Pursuing Fraud and Abuse- Section 1893(a) of the Social Security Act (42 U.S.C. 1395ddd(a)) is amended by inserting ‘, or otherwise,’ after ‘entities’. CommentsClose CommentsPermalink

Subtitle B--Enhanced Penalties for Fraud and Abuse CommentsClose CommentsPermalink

SEC. 1611. ENHANCED PENALTIES FOR FALSE STATEMENTS ON PROVIDER OR SUPPLIER ENROLLMENT APPLICATIONS.

(a) In General- Section 1128A(a) of the Social Security Act (42 U.S.C. 1320a-7a(a)) is amended-- CommentsClose CommentsPermalink





(1) in paragraph (1)(D), by striking all that follows ‘in which the person was excluded’ and inserting ‘under Federal law from the Federal health care program under which the claim was made, or’; CommentsClose CommentsPermalink





(2) by striking ‘or’ at the end of paragraph (6); CommentsClose CommentsPermalink





(3) in paragraph (7), by inserting at the end ‘or’; CommentsClose CommentsPermalink





(4) by inserting after paragraph (7) the following new paragraph: CommentsClose CommentsPermalink





‘(8) knowingly makes or causes to be made any false statement, omission, or misrepresentation of a material fact in any application, agreement, bid, or contract to participate or enroll as a provider of services or supplier under a Federal health care program, including managed care organizations under title XIX, Medicare Advantage organizations under part C of title XVIII, prescription drug plan sponsors under part D of title XVIII, and entities that apply to participate as providers of services or suppliers in such managed care organizations and such plans;’; CommentsClose CommentsPermalink





(5) in the matter following paragraph (8), as inserted by paragraph (4), by striking ‘or in cases under paragraph (7), $50,000 for each such act)’ and inserting ‘in cases under paragraph (7), $50,000 for each such act, or in cases under paragraph (8), $50,000 for each false statement, omission, or misrepresentation of a material fact)’; and CommentsClose CommentsPermalink





(6) in the second sentence, by striking ‘for a lawful purpose)’ and inserting ‘for a lawful purpose, or in cases under paragraph (8), an assessment of not more than 3 times the amount claimed as the result of the false statement, omission, or misrepresentation of material fact claimed by a provider of services or supplier whose application to participate contained such false statement, omission, or misrepresentation)’. CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by subsection (a) shall apply to acts committed on or after January 1, 2010. CommentsClose CommentsPermalink

SEC. 1612. ENHANCED PENALTIES FOR SUBMISSION OF FALSE STATEMENTS MATERIAL TO A FALSE CLAIM.

(a) In General- Section 1128A(a) of the Social Security Act (42 U.S.C. 1320a-7a(a)), as amended by section 1611, is further amended-- CommentsClose CommentsPermalink





(1) in paragraph (7), by striking ‘or’ at the end; CommentsClose CommentsPermalink





(2) in paragraph (8), by inserting ‘or’ at the end; and CommentsClose CommentsPermalink





(3) by inserting after paragraph (8), the following new paragraph: CommentsClose CommentsPermalink





‘(9) knowingly makes, uses, or causes to be made or used, a false record or statement material to a false or fraudulent claim for payment for items and services furnished under a Federal health care program;’; and CommentsClose CommentsPermalink





(4) in the matter following paragraph (9), as inserted by paragraph (3)-- CommentsClose CommentsPermalink





(A) by striking ‘or in cases under paragraph (8)’ and inserting ‘in cases under paragraph (8)’; and CommentsClose CommentsPermalink





(B) by striking ‘a material fact)’ and inserting ‘a material fact, in cases under paragraph (9), $50,000 for each false record or statement)’. CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by subsection (a) shall apply to acts committed on or after January 1, 2010. CommentsClose CommentsPermalink

SEC. 1613. ENHANCED PENALTIES FOR DELAYING INSPECTIONS.

(a) In General- Section 1128A(a) of the Social Security Act (42 U.S.C. 1320a-7a(a)), as amended by sections 1611 and 1612, is further amended-- CommentsClose CommentsPermalink





(1) in paragraph (8), by striking ‘or’ at the end; CommentsClose CommentsPermalink





(2) in paragraph (9), by inserting ‘or’ at the end; CommentsClose CommentsPermalink





(3) by inserting after paragraph (9) the following new paragraph: CommentsClose CommentsPermalink





‘(10) fails to grant timely access, upon reasonable request (as defined by the Secretary in regulations), to the Inspector General of the Department of Health and Human Services, for the purpose of audits, investigations, evaluations, or other statutory functions of the Inspector General of the Department of Health and Human Services;’; and CommentsClose CommentsPermalink





(4) in the matter following paragraph (10), as inserted by paragraph (3)--

(A) by striking ‘or’ after ‘$50,000 for each such act,’; and

(B) by inserting ‘, or in , by inserting ‘, or in cases under paragraph (10), $15,000 for each day of the failure described in such paragraph’ after ‘false record or statement’. CommentsClose CommentsPermalink




(b) Ensuring Timely Inspections Relating to Contracts With MA Organizations- Section 1857(d)(2) of such Act (42 U.S.C. 1395w-27(d)(2)) is amended-- CommentsClose CommentsPermalink





(1) in subparagraph (A), by inserting ‘timely’ before ‘inspect’; and CommentsClose CommentsPermalink





(2) in subparagraph (B), by inserting ‘timely’ before ‘audit and inspect’. CommentsClose CommentsPermalink





(c) Effective Date- The amendments made by subsection (a) shall apply to violations committed on or after January 1, 2010. CommentsClose CommentsPermalink

SEC. 1614. ENHANCED HOSPICE PROGRAM SAFEGUARDS.

(a) Medicare- Part A of title XVIII of the Social Security Act is amended by inserting after section 1819 the following new section: CommentsClose CommentsPermalink

‘SEC. 1819A. ASSURING QUALITY OF CARE IN HOSPICE CARE.

‘(a) In General- If the Secretary determines on the basis of a survey or otherwise, that a hospice program that is certified for participation under this title has demonstrated a substandard quality of care and failed to meet such other requirements as the Secretary may find necessary in the interest of the health and safety of the individuals who are provided care and services by the agency or organization involved and determines-- CommentsClose CommentsPermalink





‘(1) that the deficiencies involved immediately jeopardize the health and safety of the individuals to whom the program furnishes items and services, the Secretary shall take immediate action to remove the jeopardy and correct the deficiencies through the remedy specified in subsection (b)(2)(A)(iii) or terminate the certification of the program, and may provide, in addition, for 1 or more of the other remedies described in subsection (b)(2)(A); or CommentsClose CommentsPermalink





‘(2) that the deficiencies involved do not immediately jeopardize the health and safety of the individuals to whom the program furnishes items and services, the Secretary may-- CommentsClose CommentsPermalink





‘(A) impose intermediate sanctions developed pursuant to subsection (b), in lieu of terminating the certification of the program; and CommentsClose CommentsPermalink





‘(B) if, after such a period of intermediate sanctions, the program is still not in compliance with such requirements, the Secretary shall terminate the certification of the program. CommentsClose CommentsPermalink





If the Secretary determines that a hospice program that is certified for participation under this title is in compliance with such requirements but, as of a previous period, was not in compliance with such requirements, the Secretary may provide for a civil money penalty under subsection (b)(2)(A)(i) for the days in which it finds that the program was not in compliance with such requirements. CommentsClose CommentsPermalink





‘(b) Intermediate Sanctions- CommentsClose CommentsPermalink





‘(1) DEVELOPMENT AND IMPLEMENTATION- The Secretary shall develop and implement, by not later than July 1, 2012-- CommentsClose CommentsPermalink





‘(A) a range of intermediate sanctions to apply to hospice programs under the conditions described in subsection (a), and CommentsClose CommentsPermalink





‘(B) appropriate procedures for appealing determinations relating to the imposition of such sanctions. CommentsClose CommentsPermalink





‘(2) SPECIFIED SANCTIONS- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The intermediate sanctions developed under paragraph (1) may include-- CommentsClose CommentsPermalink





‘(i) civil money penalties in an amount not to exceed $10,000 for each day of noncompliance or, in the case of a per instance penalty applied by the Secretary, not to exceed $25,000, CommentsClose CommentsPermalink





‘(ii) denial of all or part of the payments to which a hospice program would otherwise be entitled under this title with respect to items and services furnished by a hospice program on or after the date on which the Secretary determines that intermediate sanctions should be imposed pursuant to subsection (a)(2), CommentsClose CommentsPermalink





‘(iii) the appointment of temporary management to oversee the operation of the hospice program and to protect and assure the health and safety of the individuals under the care of the program while improvements are made, CommentsClose CommentsPermalink





‘(iv) corrective action plans, and CommentsClose CommentsPermalink





‘(v) in-service training for staff. CommentsClose CommentsPermalink





The provisions of section 1128A (other than subsections (a) and (b)) shall apply to a civil money penalty under clause (i) in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a). The temporary management under clause (iii) shall not be terminated until the Secretary has determined that the program has the management capability to ensure continued compliance with all requirements referred to in that clause. CommentsClose CommentsPermalink





‘(B) CLARIFICATION- The sanctions specified in subparagraph (A) are in addition to sanctions otherwise available under State or Federal law and shall not be construed as limiting other remedies, including any remedy available to an individual at common law. CommentsClose CommentsPermalink





‘(C) COMMENCEMENT OF PAYMENT- A denial of payment under subparagraph (A)(ii) shall terminate when the Secretary determines that the hospice program no longer demonstrates a substandard quality of care and meets such other requirements as the Secretary may find necessary in the interest of the health and safety of the individuals who are provided care and services by the agency or organization involved. CommentsClose CommentsPermalink





‘(3) SECRETARIAL AUTHORITY- The Secretary shall develop and implement, by not later than July 1, 2011, specific procedures with respect to the conditions under which each of the intermediate sanctions developed under paragraph (1) is to be applied, including the amount of any fines and the severity of each of these sanctions. Such procedures shall be designed so as to minimize the time between identification of deficiencies and imposition of these sanctions and shall provide for the imposition of incrementally more severe fines for repeated or uncorrected deficiencies.’. CommentsClose CommentsPermalink





(b) Application to Medicaid- Section 1905(o) of the Social Security Act (42 U.S.C. 1396d(o)) is amended by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(4) The provisions of section 1819A shall apply to a hospice program providing hospice care under this title in the same manner as such provisions apply to a hospice program providing hospice care under title XVIII.’. CommentsClose CommentsPermalink





(c) Application to CHIP- Title XXI of the Social Security Act is amended by adding at the end the following new section: CommentsClose CommentsPermalink

‘SEC. 2114. ASSURING QUALITY OF CARE IN HOSPICE CARE.

‘The provisions of section 1819A shall apply to a hospice program providing hospice care under this title in the same manner such provisions apply to a hospice program providing hospice care under title XVIII.’. CommentsClose CommentsPermalink

SEC. 1615. ENHANCED PENALTIES FOR INDIVIDUALS EXCLUDED FROM PROGRAM PARTICIPATION.

(a) In General- Section 1128A(a) of the Social Security Act (42 U.S.C. 1320a-7a(a)), as amended by the previous sections, is further amended-- CommentsClose CommentsPermalink





(1) by striking ‘or’ at the end of paragraph (9); CommentsClose CommentsPermalink





(2) by inserting ‘or’ at the end of paragraph (10); CommentsClose CommentsPermalink





(3) by inserting after paragraph (10) the following new paragraph: CommentsClose CommentsPermalink





‘(11) orders or prescribes an item or service, including without limitation home health care, diagnostic and clinical lab tests, prescription drugs, durable medical equipment, ambulance services, physical or occupational therapy, or any other item or service, during a period when the person has been excluded from participation in a Federal health care program, and the person knows or should know that a claim for such item or service will be presented to such a program;’; and CommentsClose CommentsPermalink





(4) in the matter following paragraph (11), as inserted by paragraph (2), by striking ‘$15,000 for each day of the failure described in such 3), by striking ‘or in cases under paragraph (10), $15,000 for each day of the failure described in such paragraph’ and inserting‘$15,000 for each day of the failure described in such ‘in cases under paragraph (10), $15,000 for each day of the failure described in such paragraph, or in cases under paragraph (11), $50,000 for each order or prescription for an item or service by an excluded individual’. CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by subsection (a) shall apply to violations committed on or after January 1, 2010. CommentsClose CommentsPermalink

SEC. 1616. ENHANCED PENALTIES FOR PROVISION OF FALSE INFORMATION BY MEDICARE ADVANTAGE AND PART D PLANS.

(a) In General- Section 1857(g)(2)(A) of the Social Security Act (42 U.S.C. 1395w--27(g)(2)(A)) is amended by inserting ‘except with respect to a determination under subparagraph (E), an assessment of not more than 3 times the amount claimed by such plan or plan sponsor based upon the misrepresentation or falsified information involved,’ after ‘for each such determination,’. CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) shall apply to violations committed on or after January 1, 2010. CommentsClose CommentsPermalink

SEC. 1617. ENHANCED PENALTIES FOR MEDICARE ADVANTAGE AND PART D MARKETING VIOLATIONS.

(a) In General- Section 1857(g)(1) of the Social Security Act (42 U.S.C. 1395w--27(g)(1)), as amended by section 1221(b), is amended-- CommentsClose CommentsPermalink





(1) in subparagraph (G), by striking ‘or’ at the end; CommentsClose CommentsPermalink





(2) by inserting after subparagraph (H) the following new subparagraphs: CommentsClose CommentsPermalink





‘(I) except as provided under subparagraph (C) or (D) of section 1860D-1(b)(1), enrolls an individual in any plan under this part without the prior consent of the individual or the designee of the individual; CommentsClose CommentsPermalink





‘(J) transfers an individual enrolled under this part from one plan to another without the prior consent of the individual or the designee of the individual or solely for the purpose of earning a commission; CommentsClose CommentsPermalink





‘(K) fails to comply with marketing restrictions described in subsections (h) and (j) of section 1851 or applicable implementing regulations or guidance; or CommentsClose CommentsPermalink





‘(L) employs or contracts with any individual or entity who engages in the conduct described in subparagraphs (A) through (K) of this paragraph;’; and CommentsClose CommentsPermalink





(3) by adding at the end the following new sentence: ‘The Secretary may provide, in addition to any other remedies authorized by law, for any of the remedies described in paragraph (2), if the Secretary determines that any employee or agent of such organization, or any provider or supplier who contracts with such organization, has engaged in any conduct described in subparagraphs (A) through (L) of this paragraph.’ CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by subsection (a) shall apply to violations committed on or after January 1, 2010. CommentsClose CommentsPermalink

SEC. 1618. ENHANCED PENALTIES FOR OBSTRUCTION OF PROGRAM AUDITS.

(a) In General- Section 1128(b)(2) of the Social Security Act (42 U.S.C. 1320a-7(b)(2)) is amended-- CommentsClose CommentsPermalink





(1) in the heading, by inserting ‘OR AUDIT’ after ‘INVESTIGATION’; and CommentsClose CommentsPermalink





(2) by striking ‘investigation into’ and all that follows through the period and inserting ‘investigation or audit related to--’ CommentsClose CommentsPermalink





‘(iA) any offense described in paragraph (1) or in subsection (a); or CommentsClose CommentsPermalink





‘(iiB) the use of funds received, directly or indirectly, from any Federal health care program (as defined in section 1128B(f)).’. CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by subsection (a) shall apply to violations committed on or after January 1, 2010. CommentsClose CommentsPermalink

SEC. 1619. EXCLUSION OF CERTAIN INDIVIDUALS AND ENTITIES FROM PARTICIPATION IN MEDICARE AND STATE HEALTH CARE PROGRAMS.

(a) In General- Section 1128(c) of the Social Security Act, as previously amended by this division, is further amended-- CommentsClose CommentsPermalink