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111 S1796 PCS: America's Healthy Future Act of 2009
U.S. Senate
2009-10-19
Pursuant to Title 17 Section 105 of the United States Code, this file is not subject to copyright protection and is in the public domain.
II
Calendar No. 184
111th CONGRESS
1st Session
S. 1796
[Report No. 111-89]
IN THE SENATE OF THE UNITED STATES
October 19, 2009
Mr. Baucus , from the Committee on Finance reported the following original bill; which was read twice and placed on the calendar
A BILL To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.
1.
Short title; table of contents
1.(a)
Short title This Act may be cited as the America's Healthy Future Act of 2009 .
1.(b)
Table of contents The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I - Health care coverage
Subtitle A - Insurance market reforms
Sec. 1001. Insurance market reforms in the individual and small group markets.
TITLE XXII - Health insurance coverage
Sec. 2200. Ensuring essential and affordable health benefits coverage for all Americans.
PART A - Insurance reforms
SUBPART 1 - Requirements in individual and small group markets
Sec. 2201. General requirements and definitions.
Sec. 2202. Prohibition on preexisting condition exclusions.
Sec. 2203. Guaranteed issue and renewal for insured plans.
Sec. 2204. Premium rating rules.
Sec. 2205. Use of uniform outline of coverage documents.
SUBPART 2 - Reforms relating to allocation of risks
Sec. 2211. Rating areas; pooling of risks; phase in of rating rules in small group markets.
Sec. 2212. Risk adjustment.
Sec. 2213. Establishment of transitional reinsurance program for individual markets in each State.
Sec. 2214. Establishment of risk corridors for plans in individual and small group markets.
Sec. 2215. Temporary high risk pools for individuals with preexisting conditions.
Sec. 2216. Reinsurance for retirees covered by employer-based plans.
SUBPART 3 - Preservation of right to maintain existing coverage
Sec. 2221. Grandfathered health benefits plans.
SUBPART 4 - Continued role of States
Sec. 2225. Continued State enforcement of insurance regulations.
Sec. 2226. Waiver of health insurance reform requirements.
Sec. 2227. Provisions relating to offering of plans in more than one State.
Sec. 2228. State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid.
SUBPART 5 - Other definitions and rules
Sec. 2230. Other definitions and rules.
Subtitle B - Exchanges and consumer assistance
Sec. 1101. Establishment of qualified health benefits plan exchanges.
PART B - Exchange and consumer assistance
SUBPART 1 - Individuals and small employers offered affordable choices
Sec. 2231. Rights and responsibilities regarding choice of coverage through exchange.
Sec. 2232. Qualified individuals and small employers; access limited to citizens and lawful residents.
SUBPART 2 - Establishment of exchanges
Sec. 2235. Establishment of exchanges by States.
Sec. 2236. Functions performed by Secretary, States, and exchanges.
Sec. 2237. Duties of the Secretary to facilitate exchanges.
Sec. 2238. Procedures for determining eligibility for exchange participation, premium credits and cost-sharing subsidies, and individual responsibility exemptions.
Sec. 2239. Streamlining of procedures for enrollment through an exchange and State Medicaid, CHIP, and health subsidy programs.
Sec. 1102. Encouraging meaningful use of electronic health records.
Subtitle C - Making coverage affordable
PART I - Essential benefits coverage
Sec. 1201. Provisions to ensure coverage of essential benefits.
PART C - Making coverage affordable
SUBPART 1 - Essential benefits coverage
Sec. 2241. Requirements for qualified health benefits plan.
Sec. 2242. Essential benefits package defined.
Sec. 2243. Levels of coverage.
Sec. 2244. Application of certain rules to plans in group markets.
Sec. 2245. Special rules relating to coverage of abortion services.
Sec. 1202. Application of State and Federal laws regarding abortion.
Sec. 1203. Application of emergency services laws.
PART II - Premium credits, cost-sharing subsidies, and small business credits
SUBPART A - Premium credits and cost-sharing subsidies
Sec. 1205. Refundable credit providing premium assistance for coverage under a qualified health benefits plan.
Sec. 36B. Refundable credit for coverage under a qualified health benefits plan.
Sec. 1206. Cost-sharing subsidies and advance payments of premium credits and cost-sharing subsidies.
SUBPART 2 - Premium credits and cost-sharing subsidies
Sec. 2246. Premium credits.
Sec. 2247. Cost-sharing subsidies for individuals enrolling in qualified health benefit plans.
Sec. 2248. Advance determination and payment of premium credits and cost-sharing subsidies.
Sec. 1207. Disclosures to carry out eligibility requirements for certain programs.
Sec. 1208. Premium credit and subsidy refunds and payments disregarded for Federal and Federally-assisted programs.
Sec. 1209. Fail-safe mechanism to prevent increase in Federal budget deficit.
SUBPART B - Credit for small employers
Sec. 1221. Credit for employee health insurance expenses of small businesses.
Sec. 45R. Employee health insurance expenses of small employers.
Subtitle D - Shared responsibility
PART I - Individual responsibility
Sec. 1301. Excise tax on individuals without essential health benefits coverage.
Chapter 48 - Maintenance of essential health benefits coverage
Sec. 5000A. Failure to maintain essential health benefits coverage.
Sec. 1302. Reporting of health insurance coverage.
SUBPART D - Information regarding health insurance coverage
Sec. 6055. Reporting of health insurance coverage.
PART II - Employer Responsibility
Sec. 1306. Employer shared responsibility requirement.
Sec. 4980H. Employer responsibility to provide health coverage.
Sec. 1307. Reporting of employer health insurance coverage.
Sec. 6056. Large employers required to report on health insurance coverage.
Subtitle E - Federal program for health care cooperatives
Sec. 1401. Establishment of Federal program for health care cooperatives.
PART D - Federal program for health care cooperatives
Sec. 2251. Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers.
Subtitle F - Transparency and accountability
Sec. 1501. Provisions ensuring transparency and accountability.
Sec. 2229. Requirements relating to transparency and accountability.
Sec. 1502. Reporting on utilization of premium dollars and standard hospital charges.
Sec. 1503. Development and utilization of uniform outline of coverage documents.
Sec. 1504. Development of standard definitions, personal scenarios, and annual personalized statements.
Subtitle G - Role of Public Programs
PART I - Medicaid Coverage for the Lowest Income Populations
Sec. 1601. Medicaid coverage for the lowest income populations.
Sec. 1602. Income eligibility for nonelderly determined using modified gross income.
Sec. 1603. Requirement to offer premium assistance for employer-sponsored insurance.
Sec. 1604. Payments to territories.
Sec. 1605. Medicaid Improvement Fund rescission.
PART II - Children's Health Insurance Program
Sec. 1611. Additional federal financial participation for CHIP.
Sec. 1612. Technical corrections.
PART III - Enrollment Simplification
Sec. 1621. Enrollment Simplification and coordination with State health insurance exchanges.
Sec. 1622. Permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations.
Sec. 1623. Promoting transparency in the development, implementation, and evaluation of Medicaid and CHIP waivers and section 1937 State plan amendments.
Sec. 1624. Standards and best practices to improve enrollment of vulnerable and underserved populations.
PART IV - Medicaid Services
Sec. 1631. Coverage for freestanding birth center services.
Sec. 1632. Concurrent care for children.
Sec. 1633. Funding to expand State Aging and Disability Resource Centers.
Sec. 1634. Community First Choice Option.
Sec. 1635. Protection for recipients of home and community-based services against spousal impoverishment.
Sec. 1636. Incentives for States to offer home and community-based services as a long-term care alternative to nursing homes.
Sec. 1636A. Removal of barriers to providing home and community-based services.
Sec. 1637. Money Follows the Person Rebalancing Demonstration.
Sec. 1638. Clarification of definition of medical assistance.
Sec. 1639. State eligibility option for family planning services.
Sec. 1640. Grants for school-based health centers.
Sec. 1641. Therapeutic foster care.
Sec. 1642. Sense of the Senate regarding long-term care.
PART V - Medicaid Prescription Drug Coverage
Sec. 1651. Prescription drug rebates.
Sec. 1652. Elimination of exclusion of coverage of certain drugs.
Sec. 1653. Providing adequate pharmacy reimbursement.
Sec. 1654. Study of barriers to appropriate utilization of generic medicine in federal health care programs.
PART VI - Medicaid Disproportionate Share Hospital (DSH) Payments
Sec. 1655. Disproportionate share hospital payments.
PART VII - Dual Eligibles
Sec. 1661. 5-year period for demonstration projects.
Sec. 1662. Providing Federal coverage and payment coordination for low-income Medicare beneficiaries.
PART VIII - Medicaid Quality
Sec. 1671. Adult health quality measures.
Sec. 1672. Payment Adjustment for Health Care-Acquired Conditions.
Sec. 1673. Demonstration project to evaluate integrated care around a hospitalization.
Sec. 1674. Medicaid Global Payment System Demonstration Project.
Sec. 1675. Pediatric Accountable Care Organization Demonstration Project.
Sec. 1676. Medicaid emergency psychiatric demonstration project.
PART IX - Improvements to the Medicaid and CHIP Payment and Access Commission (MACPAC)
Sec. 1681. MACPAC assessment of policies affecting all Medicaid beneficiaries.
PART X - American Indians and Alaska Natives
Sec. 1691. Special rules relating to Indians.
Sec. 1692. Elimination of sunset for reimbursement for all medicare part B services furnished by certain indian hospitals and clinics.
Subtitle H - Addressing Health Disparities
Sec. 1701. Standardized collection of data.
Sec. 1702. Required collection of data.
Sec. 1703. Data sharing and protection.
Sec. 1704. Inclusion of information about the importance of having a health care power of attorney in transition planning for children aging out of foster care and independent living programs.
Subtitle I - Maternal and child health services
Sec. 1801. Maternal, infant, and early childhood home visiting programs.
Sec. 1802. Support, education, and research for postpartum depression.
Sec. 1803. Personal responsibility education for adulthood training.
Sec. 1804. Restoration of funding for abstinence education.
Subtitle J - Programs of health promotion and disease prevention
Sec. 1901. Programs of health promotion and disease prevention.
Subtitle K - Elder Justice Act
Sec. 1911. Short title of subtitle.
Sec. 1912. Definitions.
Sec. 1913. Elder Justice.
Subtitle L - Provisions of General Application
Sec. 1921. Protecting Americans and ensuring taxpayer funds in government health care plans do not support or fund physician-assisted suicide; prohibition against discrimination on assisted suicide.
Sec. 1922. Protection of access to quality health care through the Department of Veterans Affairs and the Department of Defense.
Sec. 1923. Continued application of antitrust laws.
TITLE II - Promoting Disease Prevention and Wellness
Subtitle A - Medicare
Sec. 2001. Coverage of annual wellness visit providing a personalized prevention plan.
Sec. 2002. Removal of barriers to preventive services.
Sec. 2003. Evidence-based coverage of preventive services.
Sec. 2004. GAO study and report on medicare beneficiary access to vaccines.
Sec. 2005. Incentives for healthy lifestyles.
Subtitle B - Medicaid
Sec. 2101. Improving access to preventive services for eligible adults.
Sec. 2102. Coverage of comprehensive tobacco cessation services for pregnant women.
Sec. 2103. Incentives for healthy lifestyles.
Sec. 2104. State option to provide health homes for enrollees with chronic conditions.
Sec. 2105. Funding for Childhood Obesity Demonstration Project.
Sec. 2106. Public awareness of preventive and obesity-related services.
TITLE III - Improving the Quality and Efficiency of Health Care
Subtitle A - Transforming the Health Care Delivery System
PART I - Linking Payment to Quality Outcomes under the Medicare program
Sec. 3001. Hospital Value-Based purchasing program.
Sec. 3002. Improvements to the physician quality reporting system.
Sec. 3003. Improvements to the physician feedback program.
Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs.
Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.
Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities and home health agencies.
Sec. 3007. Value-based payment modifier under the physician fee schedule.
Sec. 3008. Payment adjustment for conditions acquired in hospitals.
PART II - Strengthening the Quality Infrastructure
Sec. 3011. National strategy.
Sec. 3012. Interagency Working Group on Health Care Quality.
Sec. 3013. Quality measure development.
Sec. 3014. Quality measure endorsement.
PART III - Encouraging Development of New Patient Care Models
Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation within CMS.
Sec. 3022. Medicare shared savings program.
Sec. 3023. National pilot program on payment bundling.
Sec. 3024. Independence at home pilot program.
Sec. 3025. Hospital readmissions reduction program.
Sec. 3026. Community-Based Care Transitions Program.
Sec. 3027. Extension of gainsharing demonstration.
PART IV - Strengthening primary care and other workforce improvements
Sec. 3031. Expanding access to primary care services and general surgery services.
Sec. 3031A. Medicare Federally qualified health center improvements.
Sec. 3032. Distribution of additional residency positions.
Sec. 3033. Counting resident time in outpatient settings and allowing flexibility for jointly operated residency training programs.
Sec. 3034. Rules for counting resident time for didactic and scholarly activities and other activities.
Sec. 3035. Preservation of resident cap positions from closed and acquired hospitals.
Sec. 3036. Workforce Advisory Committee.
Sec. 3037. Demonstration projects To address health professions workforce needs; extension of family-to-family health information centers.
Sec. 3038. Increasing teaching capacity.
Sec. 3039. Graduate nurse education demonstration program.
PART V - Health information technology
Sec. 3041. Free clinics and certified EHR technology.
Subtitle B - Improving Medicare for patients and Providers
PART I - Ensuring beneficiary access to physician care and other services
Sec. 3101. Increase in the physician payment update.
Sec. 3102. Extension of the work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee schedule.
Sec. 3103. Extension of exceptions process for Medicare therapy caps.
Sec. 3104. Extension of payment for technical component of certain physician pathology services.
Sec. 3105. Extension of ambulance add-ons.
Sec. 3106. Extension of certain payment rules for long-term care hospital services and of moratorium on the establishment of certain hospitals and facilities.
Sec. 3107. Extension of physician fee schedule mental health add-on.
Sec. 3108. Permitting physician assistants to order post-Hospital extended care services and to provide for recognition of attending physician assistants as attending physicians to serve hospice patients.
Sec. 3109. Recognition of certified diabetes educators as certified providers for purposes of Medicare diabetes outpatient self-management training services.
Sec. 3110. Exemption of certain pharmacies from accreditation requirements.
Sec. 3111. Part B special enrollment period for disabled TRICARE beneficiaries.
Sec. 3112. Payment for bone density tests.
Sec. 3113. Revision to the Medicare Improvement Fund.
Sec. 3114. Treatment of certain complex diagnostic laboratory tests.
Sec. 3115. Improved access for certified-midwife services.
Sec. 3116. Working Group on Access to Emergency Medical Care.
PART II - Rural protections
Sec. 3121. Extension of outpatient hold harmless provision.
Sec. 3122. Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas.
Sec. 3123. Extension of the Rural Community Hospital Demonstration Program.
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 3125. Temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals.
Sec. 3126. Improvements to the demonstration project on community health integration models in certain rural counties.
Sec. 3127. MedPAC study on adequacy of Medicare payments for health care providers serving in rural areas.
Sec. 3128. Technical correction related to critical access hospital services.
Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility program.
PART III - Improving payment accuracy
Sec. 3131. Payment adjustments for home health care.
Sec. 3132. Hospice reform.
Sec. 3133. Improvement to medicare disproportionate share hospital (DSH) payments.
Sec. 3134. Misvalued codes under the physician fee schedule.
Sec. 3135. Modification of equipment utilization factor for advanced imaging services.
Sec. 3136. Revision of payment for power-driven wheelchairs.
Sec. 3137. Hospital wage index improvement.
Sec. 3138. Treatment of certain cancer hospitals.
Sec. 3139. Payment for biosimilar biological products.
Sec. 3140. Public meeting and report on payment systems for new clinical laboratory diagnostic tests.
Sec. 3141. Medicare hospice concurrent care demonstration program.
Sec. 3142. Application of budget neutrality on a national basis in the calculation of the Medicare hospital wage index floor for each all-urban and rural state.
Sec. 3143. HHS study on urban Medicare-dependent hospitals.
Subtitle C - Provisions relating to part C
Sec. 3201. Medicare Advantage payment.
Sec. 3202. Benefit protection and simplification.
Sec. 3203. Application of coding intensity adjustment during MA payment transition.
Sec. 3204. Simplification of annual beneficiary election periods.
Sec. 3205. Extension for specialized MA plans for special needs individuals.
Sec. 3206. Extension of reasonable cost contracts.
Sec. 3207. Technical correction to MA private fee-for-service plans.
Sec. 3208. Making senior housing facility demonstration permanent.
Sec. 3209. Development of new standards for certain Medigap plans.
Subtitle D - Medicare part D improvements for prescription drug plans and MA-PD plans
Sec. 3301. Medicare prescription drug discount program for brand-Name drugs.
Sec. 3302. Improvement in determination of Medicare part D low-income benchmark premium.
Sec. 3303. Voluntary de minimus policy for subsidy eligible individuals under prescription drug plans and MA-PD plans.
Sec. 3304. Special rule for widows and widowers regarding eligibility for low-income assistance.
Sec. 3305. Improved information for subsidy eligible individuals reassigned to prescription drug plans and MA-PD plans.
Sec. 3306. Funding outreach and assistance for low-income programs.
Sec. 3307. Improving formulary requirements for prescription drug plans and MA-PD plans with respect to certain categories or classes of drugs.
Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries.
Sec. 3309. Simplification of plan information.
Sec. 3310. Limitation on removal or change of coverage of covered part D drugs under a formulary under a prescription drug plan or an MA-PD plan.
Sec. 3311. Elimination of cost sharing for certain dual eligible individuals.
Sec. 3312. Reducing wasteful dispensing of outpatient prescription drugs in long-term care facilities under prescription drug plans and MA-PD plans.
Sec. 3313. Improved Medicare prescription drug plan and MA-PD plan complaint system.
Sec. 3314. Uniform exceptions and appeals process for prescription drug plans and MA-PD plans.
Sec. 3315. Office of the Inspector General studies and reports.
Sec. 3316. HHS study and annual reports on coverage for dual eligibles.
Sec. 3317. 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.
Subtitle E - Ensuring Medicare sustainability
Sec. 3401. Revision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not already incorporate such improvements.
Sec. 3402. Temporary adjustment to the calculation of part B premiums.
Sec. 3403. Medicare Commission.
Sec. 3404. Ensuring medicare savings are kept in the medicare program.
Subtitle F - Comparative effectiveness research
Sec. 3501. Comparative effectiveness research.
Sec. 3502. Coordination with Federal coordinating council for comparative effectiveness research.
Sec. 3503. GAO report on national coverage determinations process.
Subtitle G - Administrative simplification
Sec. 3601. Administrative Simplification.
Subtitle H - Sense of the Senate regarding medical malpractice
Sec. 3701. Sense of the Senate regarding medical malpractice.
TITLE IV - Transparency and Program Integrity
Subtitle A - Limitation on Medicare exception to the prohibition on certain physician referrals for hospitals
Sec. 4001. Limitation on Medicare exception to the prohibition on certain physician referrals for hospitals.
Subtitle B - Physician Ownership and Other Transparency
Sec. 4101. Transparency reports and reporting of physician ownership or investment interests.
Sec. 4102. Disclosure requirements for in-office ancillary services exception to the prohibition on physician self-referral for certain imaging services.
Sec. 4103. Prescription drug sample transparency.
Subtitle C - Nursing home transparency and improvement
PART I - Improving transparency of information
Sec. 4201. Required disclosure of ownership and additional disclosable parties information.
Sec. 4202. Accountability requirements for skilled nursing facilities and nursing facilities.
Sec. 4203. Nursing home compare Medicare website.
Sec. 4204. Reporting of expenditures.
Sec. 4205. Standardized complaint form.
Sec. 4206. Ensuring staffing accountability.
Sec. 4207. GAO study and report on Five-Star Quality Rating System.
PART II - Targeting enforcement
Sec. 4211. Civil money penalties.
Sec. 4212. National independent monitor pilot program.
Sec. 4213. Notification of facility closure.
Sec. 4214. National demonstration projects on culture change and use of information technology in nursing homes.
PART III - Improving staff training
Sec. 4221. Dementia and abuse prevention training.
Subtitle D - Nationwide program for National and State background checks on direct patient access employees of long-term care facilities and providers
Sec. 4301. Nationwide program for National and State background checks on direct patient access employees of long-term care facilities and providers.
Subtitle E - Pharmacy Benefit Managers
Sec. 4401. Pharmacy benefit managers transparency requirements.
TITLE V - Fraud, Waste, and Abuse
Subtitle A - Medicare and Medicaid
Sec. 5001. Provider screening and other enrollment requirements under Medicare and Medicaid.
Sec. 5002. Enhanced Medicare and Medicaid program integrity provisions.
Sec. 5003. Elimination of duplication between the Healthcare Integrity and Protection Data Bank and the National Practitioner Data Bank.
Sec. 5004. Maximum period for submission of Medicare claims reduced to not more than 12 months.
Sec. 5005. Physicians who order items or services required to be Medicare enrolled physicians or eligible professionals.
Sec. 5006. Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse.
Sec. 5007. Face to face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment under Medicare.
Sec. 5008. Enhanced penalties.
Sec. 5009. Medicare self-referral disclosure protocol.
Sec. 5010. Adjustments to the Medicare durable medical equipment, prosthetics, orthotics, and supplies competitive acquisition program.
Sec. 5011. Expansion of the Recovery Audit Contractor (RAC) program.
Subtitle B - Additional Medicaid Provisions
Sec. 5101. Termination of provider participation under Medicaid if terminated under Medicare or other State plan.
Sec. 5102. Medicaid exclusion from participation relating to certain ownership, control, and management affiliations.
Sec. 5103. Billing agents, clearinghouses, or other alternate payees required to register under Medicaid.
Sec. 5104. Requirement to report expanded set of data elements under MMIS to detect fraud and abuse.
Sec. 5105. Prohibition on payments to institutions or entities located outside of the United States.
Sec. 5106. Overpayments.
Sec. 5107. Enhanced funding for program integrity activities.
Sec. 5108. Mandatory State use of national correct coding initiative.
Sec. 5109. General effective date.
TITLE VI - Revenue provisions
Subtitle A - Revenue offset provisions
Sec. 6001. Excise tax on high cost employer-sponsored health coverage.
Sec. 6002. Inclusion of cost of employer-sponsored health coverage on W-2.
Sec. 6003. Distributions for medicine qualified only if for prescribed drug or insulin.
Sec. 6004. Increase in additional tax on distributions from HSAs not used for qualified medical expenses.
Sec. 6005. Limitation on health flexible spending arrangements under cafeteria plans.
Sec. 6006. Expansion of information reporting requirements.
Sec. 6007. Additional requirements for charitable hospitals.
Sec. 6008. Imposition of annual fee on branded prescription pharmaceutical manufacturers and importers.
Sec. 6009. Imposition of annual fee on medical device manufacturers and importers.
Sec. 6010. Imposition of annual fee on health insurance providers.
Sec. 6011. Study and report of effect on veterans health care.
Sec. 6012. Elimination of deduction for expenses allocable to Medicare Part D subsidy.
Sec. 6013. Modification of itemized deduction for medical expenses.
Sec. 6014. Limitation on excessive remuneration paid by certain health insurance providers.
Subtitle B - Other provisions
Sec. 6021. Exclusion of health benefits provided by Indian tribal governments.
Sec. 6022. Establishment of simple cafeteria plans for small businesses.
Sec. 6023. Qualifying therapeutic discovery project credit.
I
Health care coverage
I|A
Insurance market reforms
I|A|1001.
Insurance market reforms in the individual and small group markets The Social Security Act ( 42 U.S.C. 301 et seq. ) is amended by adding at the end the following:
I|A|1001.XXII
Health insurance coverage
I|A|1001.XXII|2200.
Ensuring essential and affordable health benefits coverage for all Americans It is the purpose of this title to ensure that all Americans have access to affordable and essential health benefits coverage -
I|A|1001.XXII|2200.(1)
by requiring that all new health benefits plans offered to individuals and employees in the individual and small group markets be qualified health benefits plans that meet the insurance rating reforms and essential health benefits coverage requirements established under parts A and C;
I|A|1001.XXII|2200.(2)
by establishing State exchanges under part B that provide individuals and employees in the individual and small group markets greater access to qualified health benefits plans and to information concerning these health plans;
I|A|1001.XXII|2200.(3)
by making health benefits coverage more affordable by establishing premium credits and cost-sharing subsidies under part C for individuals enrolling in a health benefits plan through an exchange; and
I|A|1001.XXII|2200.(4)
by establishing the CO-OP program under part D to encourage the establishment of nonprofit health care cooperatives.
I|A|1001.XXII|A
Insurance reforms
I|A|1001.XXII|A|1
Requirements in individual and small group markets
I|A|1001.XXII|A|1|2201.
General requirements and definitions
I|A|1001.XXII|A|1|2201.(a)
New plans must be qualified health benefits plans Except as provided in subpart 3 (relating to preservation of existing coverage), each State shall provide that each health benefits plan which is offered in the individual or small group market within the State shall be a qualified health benefits plan.
I|A|1001.XXII|A|1|2201.(b)
Qualified health benefits plan For purposes of this title, a health benefits plan which is offered in the individual or small group market shall be a qualified health benefits plan with respect to a State if -
I|A|1001.XXII|A|1|2201.(b)(1)
the plan has in effect a certification (which may include a seal or other indication of approval) issued or recognized by the State that such plan meets the applicable requirements of -
I|A|1001.XXII|A|1|2201.(b)(1)(A)
this part (relating to requirements for insurance market reforms); and
I|A|1001.XXII|A|1|2201.(b)(1)(B)
part C (relating to requirements to make health insurance affordable); and
I|A|1001.XXII|A|1|2201.(b)(2)
the offeror of the plan -
I|A|1001.XXII|A|1|2201.(b)(2)(A)
is licensed by the State (and in good standing with the State) to offer a health benefits plan in the State; and
I|A|1001.XXII|A|1|2201.(b)(2)(B)
complies with such other requirements as the Secretary or the State may establish pursuant to this title for qualified health benefits plans.
I|A|1001.XXII|A|1|2201.(c)
Terms relating to health benefits plans In this title:
I|A|1001.XXII|A|1|2201.(c)(1)
Health benefits plan
I|A|1001.XXII|A|1|2201.(c)(1)(A)
In general The term health benefits plan means health insurance coverage and a group health plan.
I|A|1001.XXII|A|1|2201.(c)(1)(B)
Exception for self-insured plans and MEWAs Except to the extent specifically provided by this title, the term health benefits plan shall not include a group health plan or multiple employer welfare arrangement to the extent the plan is not subject to State insurance regulation under section 514 of the Employee Retirement Income Security Act of 1974.
I|A|1001.XXII|A|1|2201.(c)(2)
Health insurance coverage and issuer The terms health insurance coverage and health insurance issuer have the meanings given such terms by section 9832(b) of the Internal Revenue Code of 1986.
I|A|1001.XXII|A|1|2201.(c)(3)
Group health plan The term group health plan has the meaning given such term by section 5000(b) of such Code.
I|A|1001.XXII|A|1|2201.(c)(4)
Health benefits plan offeror The terms health benefits plan offeror and offeror mean in the case of -
I|A|1001.XXII|A|1|2201.(c)(4)(A)
health insurance coverage, the health insurance issuer offering the coverage; and
I|A|1001.XXII|A|1|2201.(c)(4)(B)
a group health plan -
I|A|1001.XXII|A|1|2201.(c)(4)(B)(i)
the plan sponsor; or
I|A|1001.XXII|A|1|2201.(c)(4)(B)(ii)
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 employer.
I|A|1001.XXII|A|1|2201.(d)
Definitions relating to markets In this title:
I|A|1001.XXII|A|1|2201.(d)(1)
Group market The term group market means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by an employer.
I|A|1001.XXII|A|1|2201.(d)(2)
Individual market The term individual market means the market for health insurance coverage offered to individuals other than in connection with a group health plan.
I|A|1001.XXII|A|1|2201.(d)(3)
Large and small group markets The terms large group market and small group market mean the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a large employer (as defined in section 2230(a)(1)) or by a small employer (as defined in section 2230(a)(2)), respectively.
I|A|1001.XXII|A|1|2202.
Prohibition on preexisting condition exclusions
I|A|1001.XXII|A|1|2202.(a)
Prohibition A health benefits plan shall be treated as a qualified health benefits plan only if the plan does not -
I|A|1001.XXII|A|1|2202.(a)(1)
impose any preexisting condition exclusion with respect to the plan; or
I|A|1001.XXII|A|1|2202.(a)(2)
otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent of an individual based on any health status-related factors in relation to the individual or dependent.
I|A|1001.XXII|A|1|2202.(b)
Preexisting condition exclusion For purposes of this section, the term preexisting condition exclusion means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.
I|A|1001.XXII|A|1|2202.(c)
Health status-related factors For purposes of this section, the term health status-related factors means health status, medical condition (including both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), and disability.
I|A|1001.XXII|A|1|2203.
Guaranteed issue and renewal for insured plans
I|A|1001.XXII|A|1|2203.(a)
In general Except as provided in this section, a health benefits plan shall be treated as a qualified health benefits plan only if the offeror of the plan -
I|A|1001.XXII|A|1|2203.(a)(1)
in the case of a plan offered -
I|A|1001.XXII|A|1|2203.(a)(1)(A)
in the individual market in a State, must accept every individual that applies for enrollment in the plan;
I|A|1001.XXII|A|1|2203.(a)(1)(B)
in the small group market in a State, must accept -
I|A|1001.XXII|A|1|2203.(a)(1)(B)(i)
every small employer in the State that applies for enrollment of its employees under the plan; and
I|A|1001.XXII|A|1|2203.(a)(1)(B)(ii)
every individual who is eligible to enroll in the plan by reason of a relationship to the employer as is determined -
I|A|1001.XXII|A|1|2203.(a)(1)(B)(ii)(I)
in accordance with the terms of such plan;
I|A|1001.XXII|A|1|2203.(a)(1)(B)(ii)(II)
as provided by the offeror under rules of the offeror that are uniformly applicable to small employers in the small group market within a State; and
I|A|1001.XXII|A|1|2203.(a)(1)(B)(ii)(III)
in accordance with all applicable State laws governing the offeror and the small group market; and
I|A|1001.XXII|A|1|2203.(a)(2)
must renew or continue in force coverage under the plan at the option of the individual or small employer, as applicable. An offeror of a plan shall not be treated as meeting the requirements of this subsection unless the plan also accepts, renews, or continues in force coverage of an individual who is eligible for enrollment in the plan by reason of their relationship to the named insured under the plan.
I|A|1001.XXII|A|1|2203.(b)
Special rules for guaranteed issue
I|A|1001.XXII|A|1|2203.(b)(1)
Enrollment Each offeror of a health benefits plan shall establish annual and special enrollment periods meeting the requirements of section 2236(d)(2) and may restrict enrollment described in subsection (a)(1) to such enrollment periods.
I|A|1001.XXII|A|1|2203.(b)(2)
Capacity limits For purposes of applying subsection (a)(1), if, as determined under regulations prescribed by the Secretary, a plan has a capacity limit, the plan may limit enrollment to that capacity limit but only if the plan selects individuals for enrollment on the basis of the order in which the individuals applied for enrollment and in a manner that does not discriminate in any manner prohibited under section 2202.
I|A|1001.XXII|A|1|2203.(c)
Guaranteed renewability For purposes of applying subsection (a)(2) -
I|A|1001.XXII|A|1|2203.(c)(1)
rescissions of coverage shall be treated in the same manner as non-renewals of coverage; and
I|A|1001.XXII|A|1|2203.(c)(2)
the premium rate at the time of renewal shall be determined using only the same categories of rate adjustment factors that were used at issue. The Secretary may prescribe rules for the application of paragraph (2) during any period during which the reforms under this subpart are being phased in by a State.
I|A|1001.XXII|A|1|2204.
Premium rating rules
I|A|1001.XXII|A|1|2204.(a)
In general A health benefits plan shall be treated as a qualified health benefits plan only if the premium rate charged for any benefit level of the plan may not vary except as provided in this section.
I|A|1001.XXII|A|1|2204.(b)
Limits based on specific ratios
I|A|1001.XXII|A|1|2204.(b)(1)
In general In the case of a health benefits plan offered in a rating area, the premium rate charged under the plan may vary only as provided in paragraphs (2) and (3).
I|A|1001.XXII|A|1|2204.(b)(2)
By family enrollment The premium rate may vary by family enrollment (such as variations within categories and compositions of families) so long as the ratio of the premium for the following types of enrollment to the premium for individual enrollment does not exceed the following ratios:
I|A|1001.XXII|A|1|2204.(b)(2)(A)
Individual, 1 to 1.
I|A|1001.XXII|A|1|2204.(b)(2)(B)
Adult with child, 1.8 to 1.
I|A|1001.XXII|A|1|2204.(b)(2)(C)
Two adults, 2 to 1.
I|A|1001.XXII|A|1|2204.(b)(2)(D)
Family, 3 to 1.
I|A|1001.XXII|A|1|2204.(b)(3)
Age and tobacco use Within any family enrollment category, the portion of the premium attributable to each individual covered by the health benefits plan in that category may vary as follows:
I|A|1001.XXII|A|1|2204.(b)(3)(A)
Limited age variation permitted By age (within the standard age bands established under subsection (c)) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 4 to 1.
I|A|1001.XXII|A|1|2204.(b)(3)(B)
Tobacco use By tobacco use so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 1.5 to 1.
I|A|1001.XXII|A|1|2204.(c)
Standard age categories The Secretary shall establish standard age bands between which premium rates may vary as provided in subsection (b)(3)(A).
I|A|1001.XXII|A|1|2204.(d)
Rule of construction Nothing in this section shall be construed to allow a health benefits plan to vary a premium rate on the basis of health status-related factors, gender, class of business, claims experience, or any other factor not described in subsection (b).
I|A|1001.XXII|A|1|2205.
Use of uniform outline of coverage documents A health benefits plan shall provide an outline of the plan's health insurance coverage meeting the standards of uniformity adopted by the Secretary under section 1503 of the America's Healthy Future Act of 2009 to -
I|A|1001.XXII|A|1|2205.(1)
an applicant at the time of application;
I|A|1001.XXII|A|1|2205.(2)
an enrollee at the time of enrollment; and
I|A|1001.XXII|A|1|2205.(3)
a policyholder or certificate holder of the plan at the time the policy is issued or the certificate is delivered.
I|A|1001.XXII|A|2
Reforms relating to allocation of risks
I|A|1001.XXII|A|2|2211.
Rating areas; pooling of risks; phase in of rating rules in small group markets
I|A|1001.XXII|A|2|2211.(a)
Rating areas
I|A|1001.XXII|A|2|2211.(a)(1)
In general Each State shall establish 1 or more rating areas within that State for purposes of applying the requirements of this title.
I|A|1001.XXII|A|2|2211.(a)(2)
Secretarial review The Secretary shall review the rating areas established by each State under subsection (a) to ensure the adequacy of such areas for purposes of carrying out the requirements of this title. If the Secretary determines a State's rating areas are not so adequate, the Secretary may establish rating areas for that State.
I|A|1001.XXII|A|2|2211.(b)
Single risk pool
I|A|1001.XXII|A|2|2211.(b)(1)
In general For purposes of applying the insurance reform requirements under subpart 1 -
I|A|1001.XXII|A|2|2211.(b)(1)(A)
Individual market The offeror of an insured qualified health benefits plan offered in the individual market in an area covered by an exchange shall consider all enrollees in the plan, including individuals who do not purchase such a plan through an exchange, to be members of a single risk pool.
I|A|1001.XXII|A|2|2211.(b)(1)(B)
Small group market The offeror of a qualified health benefits plan offered in the small group market in an area covered by an exchange shall consider all enrollees in the plan, including individuals who do not purchase such a plan through an exchange, to be members of a single risk pool.
I|A|1001.XXII|A|2|2211.(b)(2)
State election A State may elect to combine the individual and small group markets within the State for purposes of applying this subsection.
I|A|1001.XXII|A|2|2211.(c)
Phase in of insurance reform rules in small group market Upon request to, and approval by, the Secretary, each State shall phase in the application to the small group market of the insurance reform requirements under subpart 1 over a consecutive period of years (not greater than 5) beginning July 1, 2013.
I|A|1001.XXII|A|2|2212.
Risk adjustment
I|A|1001.XXII|A|2|2212.(a)
In general Each State shall adopt a risk adjustment model described in subsection (b) to implement procedures for the application of risk adjustment among qualified health benefit plans and grandfathered health benefits plans offered in both the individual and small group market. Such procedures shall apply to such qualified health benefit plans whether or not purchased through an exchange.
I|A|1001.XXII|A|2|2212.(b)
Risk adjustment models
I|A|1001.XXII|A|2|2212.(b)(1)
In general The Secretary shall establish 1 or more risk adjustment models for proper adjustments of premium amounts payable among offerors of qualified health benefits plans that take into account (in a manner specified by the Secretary) the differences in the risk characteristics of individuals and employers enrolled under the different plans so as to minimize the impact of adverse selection of enrollees among the plans.
I|A|1001.XXII|A|2|2212.(b)(2)
State option A State may -
I|A|1001.XXII|A|2|2212.(b)(2)(A)
adopt a risk adjustment model established under paragraph (1); or
I|A|1001.XXII|A|2|2212.(b)(2)(B)
establish its own risk adjustment model for purposes of subsection (a), but only if the State establishes to the satisfaction of the Secretary that such model will produce results substantially similar to the results of risk adjustment models established under paragraph (1) and will not increase costs to the Federal government.
I|A|1001.XXII|A|2|2212.(b)(3)
Operation of risk adjustment system A State may select an entity certified under subsection (c) to implement and operate its risk adjustment model under this section.
I|A|1001.XXII|A|2|2212.(c)
Certification of entities conducting risk adjustment The Secretary shall certify entities which the Secretary determines have the required expertise to implement the risk adjustment models adopted or established under subsection (b). The Secretary may not certify any entity which is a health benefits plan offeror or any entity owned or operated by such an offeror.
I|A|1001.XXII|A|2|2213.
Establishment of transitional reinsurance program for individual markets in each State
I|A|1001.XXII|A|2|2213.(a)
In general Each State shall, not later than July 1, 2013 -
I|A|1001.XXII|A|2|2213.(a)(1)
include in the Model Regulation, Federal standard, or State law or regulation the State adopts and has in effect under section 2225(a)(2) the provisions described in subsection (b); and
I|A|1001.XXII|A|2|2213.(a)(2)
establish (or enter into a contract with) 1 or more applicable reinsurance entities to carry out the reinsurance program under this section.
I|A|1001.XXII|A|2|2213.(b)
Model regulation
I|A|1001.XXII|A|2|2213.(b)(1)
In general In establishing the Model Regulation under section 2225 to carry out this part, the Secretary shall request the National Association of Insurance Commissioners (the NAIC ) to include provisions that enable States to establish and maintain a program under which -
I|A|1001.XXII|A|2|2213.(b)(1)(A)
the offerors of health benefits plans that are offered in the individual market are required to make payments to an applicable reinsurance entity for any plan year beginning in the 36-month period beginning July 1, 2013; and
I|A|1001.XXII|A|2|2213.(b)(1)(B)
the applicable reinsurance entity collects payments under subparagraph (A) and uses amounts so collected to make reinsurance payments to offerors of health benefits plans described in subparagraph (A) that cover high risk individuals for any plan year beginning in such 36-month period. If the NAIC does not include such provisions as part of the Model Regulation , the Secretary shall include such provisions in a Federal standard under section 2225(a)(1)(B).
I|A|1001.XXII|A|2|2213.(b)(2)
High-risk individual; payment amounts The following shall be included in the provisions under paragraph (1):
I|A|1001.XXII|A|2|2213.(b)(2)(A)
Determination of high-risk individuals The method by which individuals will be identified as high risk individuals for purposes of the reinsurance program established under this section. Such method shall provide for identification of individuals as high-risk individuals on the basis of -
I|A|1001.XXII|A|2|2213.(b)(2)(A)(i)
a list of at least 50 but not more than 100 medical conditions that are identified as high-risk conditions and that may be based on the identification of diagnostic and procedure codes that are indicative of individuals with pre-existing, high-risk conditions; or
I|A|1001.XXII|A|2|2213.(b)(2)(A)(ii)
any other comparable objective method of identification recommended by the American Academy of Actuaries.
I|A|1001.XXII|A|2|2213.(b)(2)(B)
Payment amount
I|A|1001.XXII|A|2|2213.(b)(2)(B)(i)
In general The formula for determining the amount of payments that will be paid to the offerors of health benefits plans that insure high-risk individuals. Such formula shall provide for the equitable allocation of available funds through reconciliation and may be designed -
I|A|1001.XXII|A|2|2213.(b)(2)(B)(i)(I)
to provide a schedule of payments that specifies the amount that will be paid for each of the conditions identified under subparagraph (A); or
I|A|1001.XXII|A|2|2213.(b)(2)(B)(i)(II)
to use any other comparable method for determining payment amounts that is recommended by the American Academy of Actuaries and that encourages the use of care coordination and care management programs for high risk conditions.
I|A|1001.XXII|A|2|2213.(b)(2)(B)(ii)
Coordination with cost-sharing and risk adjustment payments Such provisions shall provide methods to coordinate the payment system under this section with any cost-sharing requirements of a plan and the risk-adjustment program under section 2212.
I|A|1001.XXII|A|2|2213.(b)(3)
Determination of required contributions
I|A|1001.XXII|A|2|2213.(b)(3)(A)
In general The provisions under paragraph (1) shall include the method for determining the amount each offeror of a health benefits plan participating in the reinsurance program under this section is required to contribute under paragraph (1)(A) for each plan year beginning in the 36-month period beginning July 1, 2013. The contribution amount for any plan year may be based on the percentage of revenue of each offeror or on a specified amount per enrollee and may be required to be paid in advance or periodically throughout the plan year.
I|A|1001.XXII|A|2|2213.(b)(3)(B)
Specific requirements The method under this paragraph shall be designed so that -
I|A|1001.XXII|A|2|2213.(b)(3)(B)(i)
the contribution amount for each offeror proportionally reflects each offeror's fully insured commercial book of business for all major medical products and third party administration fees;
I|A|1001.XXII|A|2|2213.(b)(3)(B)(ii)
the contribution amount can include an additional amount to fund the administrative expenses of the applicable reinsurance entity;
I|A|1001.XXII|A|2|2213.(b)(3)(B)(iii)
subject to clause (iv), the aggregate contribution amounts for all States shall, based on the best estimates of the NAIC or the Secretary, whichever is applicable, and without regard to amounts described in clause (ii), equal $10,000,000,000 for plan years beginning in the 12-month period beginning July 1, 2013, $6,000,000,000 for plan years beginning in the 12-month period beginning July 1, 2014, and $4,000,000,000 for plan years beginning in the 12-month period beginning July 1, 2015; and
I|A|1001.XXII|A|2|2213.(b)(3)(B)(iv)
in addition to the aggregate contribution amounts under clause (iii), each offeror's contribution amount reflects its proportionate share of the $5,000,000,000 amount used to fund the retiree reinsurance program under section 2216. Nothing in this subparagraph shall be construed to preclude a State from collecting additional amounts from offerors on a voluntary basis.
I|A|1001.XXII|A|2|2213.(b)(4)
Expenditure of funds
I|A|1001.XXII|A|2|2213.(b)(4)(A)
In general Except as provided in subparagraph (B), the provisions under paragraph (1) shall provide that -
I|A|1001.XXII|A|2|2213.(b)(4)(A)(i)
the contribution amounts collected for any 12-month period may be allocated and used in any of the three 12-month periods for which amounts are collected based on the reinsurance needs of a particular period or to reflect experience in a prior period; and
I|A|1001.XXII|A|2|2213.(b)(4)(A)(ii)
amounts remaining unexpended as of June 30, 2016, may be used to make payments under any reinsurance program of a State in the individual market in effect in the 24-month period beginning on July 1, 2016.
I|A|1001.XXII|A|2|2213.(b)(4)(B)
Transfers to Secretary for retiree reinsurance The provisions under paragraph (1) shall provide that each applicable reinsurance entity shall transfer to the Secretary amounts collected that are allocable to amounts required to be collected under paragraph (3)(B)(iv).
I|A|1001.XXII|A|2|2213.(c)
Applicable reinsurance entity For purposes of this section -
I|A|1001.XXII|A|2|2213.(c)(1)
In general The term applicable reinsurance entity means a not-for-profit organization -
I|A|1001.XXII|A|2|2213.(c)(1)(A)
the purpose of which is to help stabilize premiums for coverage in the individual market in a State during the first 3 years of operation of an exchange for that market within the State when the risk of adverse selection related to new rating rules and market changes is greatest; and
I|A|1001.XXII|A|2|2213.(c)(1)(B)
the duties of which shall be to carry out the reinsurance program under this section by coordinating the funding and operation of the risk-spreading mechanisms designed to implement the reinsurance program.
I|A|1001.XXII|A|2|2213.(c)(2)
State discretion A State may have more than 1 applicable reinsurance entity to carry out the reinsurance program under this section within the State and 2 or more States may enter into agreements to provide for an applicable reinsurance entity to carry out such program in all such States.
I|A|1001.XXII|A|2|2213.(c)(3)
Entities are tax-exempt An applicable reinsurance entity established under this section shall be treated as an organization exempt from taxation under section 501(a) of the Internal Revenue Code of 1986. The preceding sentence shall not apply to the tax imposed by section 511 such Code (relating to tax on unrelated business taxable income of an exempt organization).
I|A|1001.XXII|A|2|2213.(d)
Coordination with State high-risk pools The State shall eliminate or modify any State high-risk pool to the extent necessary to carry out the reinsurance program established under this section. The State may coordinate the State high-risk pool with such program to the extent not inconsistent with the provisions of this section.
I|A|1001.XXII|A|2|2214.
Establishment of risk corridors for plans in individual and small group markets
I|A|1001.XXII|A|2|2214.(a)
In general The Secretary shall establish and administer a program of risk corridors for plan years beginning during the 36-month period beginning on July 1, 2013, under which a qualified health benefits plan offered in the individual or small group market may elect (before the beginning of such 36-month period) to participate in a payment adjustment system based on the ratio of the allowable costs of the plan to the plan's aggregate premiums. Such program shall be based on the program for regional participating provider organizations under part D of title XVIII.
I|A|1001.XXII|A|2|2214.(b)
Payment methodology
I|A|1001.XXII|A|2|2214.(b)(1)
Payments out The Secretary shall provide under the program established under subsection (a) that if -
I|A|1001.XXII|A|2|2214.(b)(1)(A)
a participating plan's allowable costs for any plan year are more than 103 percent but not more than 108 percent of the target amount, the Secretary shall pay to the plan an amount equal to 50 percent of the target amount in excess of 103 percent of the target amount; and
I|A|1001.XXII|A|2|2214.(b)(1)(B)
a participating plan's allowable costs for any plan year are more than 108 percent of the target amount, the Secretary shall pay to the plan an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of allowable costs in excess of 108 percent of the target amount.
I|A|1001.XXII|A|2|2214.(b)(2)
Payments in The Secretary shall provide under the program established under subsection (a) that if -
I|A|1001.XXII|A|2|2214.(b)(2)(A)
a participating plan's allowable costs for any plan year are less than 97 percent but not less than 92 percent of the target amount, the plan shall pay to the Secretary an amount equal to 50 percent of the excess of 97 percent of the target amount over the allowable costs; and
I|A|1001.XXII|A|2|2214.(b)(2)(B)
a participating plan's allowable costs for any plan year are less than 92 percent of the target amount, the plan shall pay to the Secretary an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of the excess of 92 percent of the target amount over the allowable costs.
I|A|1001.XXII|A|2|2214.(c)
Definitions In this section:
I|A|1001.XXII|A|2|2214.(c)(1)
Allowable costs
I|A|1001.XXII|A|2|2214.(c)(1)(A)
In general The amount of allowable costs of a plan for any year is an amount equal to the total costs (other than administrative costs) of the plan in providing benefits covered by the plan.
I|A|1001.XXII|A|2|2214.(c)(1)(B)
Reduction for risk adjustment and reinsurance payments Allowable costs shall be reduced by any risk adjustment and reinsurance payments received under section 2212 and 2213.
I|A|1001.XXII|A|2|2214.(c)(2)
Target amount The target amount of a plan for any year is an amount equal to the total premiums (including any premium credits or subsidies under any governmental program) reduced by the administrative costs of the plan.
I|A|1001.XXII|A|2|2215.
Temporary high risk pools for individuals with preexisting conditions
I|A|1001.XXII|A|2|2215.(a)
Establishment of high risk pools
I|A|1001.XXII|A|2|2215.(a)(1)
In general Not later than 1 year after the date of enactment of this title, the Secretary shall establish 1 or more high risk pools that -
I|A|1001.XXII|A|2|2215.(a)(1)(A)
provide to all eligible individuals health insurance coverage (or comparable coverage) that does not impose any preexisting condition exclusion with respect to such coverage for all eligible individuals; and
I|A|1001.XXII|A|2|2215.(a)(1)(B)
provide for health benefits coverage and premium rates described under subsection (b).
I|A|1001.XXII|A|2|2215.(a)(2)
Administration The Secretary may carry out this section -
I|A|1001.XXII|A|2|2215.(a)(2)(A)
directly; or
I|A|1001.XXII|A|2|2215.(a)(2)(B)
through agreements, grants, or contracts with States or other persons the Secretary determines appropriate.
I|A|1001.XXII|A|2|2215.(b)
Coverage and premium rates Except as provided in subsection (c)(2) -
I|A|1001.XXII|A|2|2215.(b)(1)
Coverage The Secretary shall provide that the health benefits coverage provided to an eligible individual through a high risk pool under this section shall -
I|A|1001.XXII|A|2|2215.(b)(1)(A)
consist of the essential benefits package described in section 2242; and
I|A|1001.XXII|A|2|2215.(b)(1)(B)
provide the bronze level of coverage described in section 2243(b)(1).
I|A|1001.XXII|A|2|2215.(b)(2)
Premium rates
I|A|1001.XXII|A|2|2215.(b)(2)(A)
In general Except as provided in subparagraph (B), the premium rate charged to an eligible individual enrolled in a high risk pool shall be equal to the standard premium rate for a health benefits plan providing the essential benefits package and bronze level of coverage described in paragraph (1).
I|A|1001.XXII|A|2|2215.(b)(2)(B)
Variation of premiums The Secretary may vary the premium under subparagraph (A) to the same extent, and in the same manner, as the offeror of a qualified health benefits plan may vary the premium for the plan under section 2204.
I|A|1001.XXII|A|2|2215.(c)
Funding; termination of authority
I|A|1001.XXII|A|2|2215.(c)(1)
In general There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to pay claims against (and administrative costs of) the high risk pool in excess of the premiums collected from eligible individuals enrolled in the high risk pool. Such funds shall be available without fiscal year limitation.
I|A|1001.XXII|A|2|2215.(c)(2)
Insufficient funds If the Secretary estimates for any fiscal year that the aggregate amounts available for payment of expenses of the high risk pool will be less than the amount of the expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficit, including reducing benefits, increasing premiums, or establishing waiting lists.
I|A|1001.XXII|A|2|2215.(c)(3)
Termination of authority
I|A|1001.XXII|A|2|2215.(c)(3)(A)
In general Except as provided in subparagraph (B), coverage of eligible individuals under a high risk pool shall terminate as of the end of June 30, 2013.
I|A|1001.XXII|A|2|2215.(c)(3)(B)
Transition to exchange The Secretary shall develop procedures to provide for the transition of eligible individuals enrolled in health insurance coverage offered through a high risk pool established under this section into qualified health benefits plans offered through an exchange. Such procedures shall ensure that there is no lapse in coverage with respect to the individual and may extend coverage after June 30, 2013, if the Secretary determines necessary to avoid such a lapse.
I|A|1001.XXII|A|2|2215.(d)
Eligible individual In this section, the term eligible individual means an individual who demonstrates to the satisfaction of the Secretary that the individual -
I|A|1001.XXII|A|2|2215.(d)(1)
has been denied health insurance coverage by reason of a preexisting condition (as defined in section 2202(b));
I|A|1001.XXII|A|2|2215.(d)(2)
has been uninsured for a continuous period of at least 6 months before the date of application for enrollment in a high risk pool;
I|A|1001.XXII|A|2|2215.(d)(3)
is not eligible for essential health benefits coverage (as defined in section 5000A(f)); and
I|A|1001.XXII|A|2|2215.(d)(4)
is an individual who is, and who is reasonably expected to be for the entire period of coverage, a citizen or national of the United States, an alien lawfully admitted to the United States for permanent residence, or an alien lawfully present in the United States.
I|A|1001.XXII|A|2|2216.
Reinsurance for retirees covered by employer-based plans
I|A|1001.XXII|A|2|2216.(a)
Administration
I|A|1001.XXII|A|2|2216.(a)(1)
In general Not later than 90 days after the date of enactment of this section, the Secretary shall establish a temporary reinsurance program to provide reimbursement to participating employment-based plans for a portion of the cost of providing health benefits to retirees during the period beginning on the date on which such program is established and ending on the date on which the Secretary estimates that applications for payments under this section will have been made that equal the funds made available under this section (reduced by any administrative costs of the program).
I|A|1001.XXII|A|2|2216.(a)(2)
Reference In this section:
I|A|1001.XXII|A|2|2216.(a)(2)(A)
Health benefits 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.
I|A|1001.XXII|A|2|2216.(a)(2)(B)
Employment-based plan The term employment-based plan means a group health benefits plan that -
I|A|1001.XXII|A|2|2216.(a)(2)(B)(i)
is -
I|A|1001.XXII|A|2|2216.(a)(2)(B)(i)(I)
maintained by one or more current or former employers (including without limitation any State or local government or political subdivision thereof), an employee organization, a voluntary employees' beneficiary association, or a committee or board of individuals appointed to administer such plan; or
I|A|1001.XXII|A|2|2216.(a)(2)(B)(i)(II)
a multiemployer plan (as defined in section 3(37) of the Employee Retirement Income Security Act of 1974); and
I|A|1001.XXII|A|2|2216.(a)(2)(B)(ii)
provides health benefits to retirees.
I|A|1001.XXII|A|2|2216.(a)(2)(C)
Retirees The term retirees means individuals who are age 55 and older but are not eligible for coverage under title XVIII of the Social Security Act, and who are not active employees of an employer maintaining, or currently contributing to, the employment-based plan or of any employer that has made substantial contributions to fund such plan.
I|A|1001.XXII|A|2|2216.(b)
Participation
I|A|1001.XXII|A|2|2216.(b)(1)
Employment-based plan eligibility A participating employment-based plan is an employment-based plan that -
I|A|1001.XXII|A|2|2216.(b)(1)(A)
meets the requirements of paragraph (2) with respect to benefits provided under the plan; and
I|A|1001.XXII|A|2|2216.(b)(1)(B)
submits 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.
I|A|1001.XXII|A|2|2216.(b)(2)
Plan requirements An employment-based plan meets the requirements of this paragraph if the plan -
I|A|1001.XXII|A|2|2216.(b)(2)(A)
provides benefits appropriate for individuals between the ages described in subsection (a)(2)(C) and that are certified as so appropriate by the Secretary;
I|A|1001.XXII|A|2|2216.(b)(2)(B)
implements programs and procedures to generate cost-savings with respect to participants with chronic and high-cost conditions; and
I|A|1001.XXII|A|2|2216.(b)(2)(C)
provides documentation of the actual cost of medical claims involved and for which reimbursement is sought under this section.
I|A|1001.XXII|A|2|2216.(c)
Payments
I|A|1001.XXII|A|2|2216.(c)(1)
Submission of claims
I|A|1001.XXII|A|2|2216.(c)(1)(A)
In general 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.
I|A|1001.XXII|A|2|2216.(c)(1)(B)
Basis for claims Claims submitted under paragraph (1) 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 the spouse, surviving spouse, or dependent of such retiree. In determining the amount of a 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 benefit. For purposes of determining the amount of any such claim, the costs paid by the retiree or the retiree's spouse, surviving spouse, or dependent in the form of deductibles, co-payments, or co-insurance shall be included in the amounts paid by the participating employment-based plan.
I|A|1001.XXII|A|2|2216.(c)(2)
Program payments 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 exceed $15,000, subject to the limits contained in paragraph (3).
I|A|1001.XXII|A|2|2216.(c)(3)
Limit To be eligible for reimbursement under the program, a claim submitted by a participating employment-based plan under paragraph (1) with respect to any individual shall not be less than $15,000 nor greater than $90,000. Such amounts shall be adjusted each fiscal year based on the percentage increase in the Medical Care Component of the Consumer Price Index for all urban consumers (rounded to the nearest multiple of $1,000) for the year involved.
I|A|1001.XXII|A|2|2216.(c)(4)
Use of payments Amounts paid to a participating employment-based plan under this subsection shall be used to lower costs for the plan. Such payments may be used to reduce premium costs for an entity described in subsection (a)(2)(B)(i) or to reduce premium contributions, co-payments, deductibles, co-insurance, or other out-of-pocket costs for plan participants. Such payments shall not be used as general revenues for an entity described in subsection (a)(2)(B)(i). The Secretary shall develop a mechanism to monitor the appropriate use of such payments by such entities.
I|A|1001.XXII|A|2|2216.(c)(5)
Payments not treated as income Payments received under this subsection shall not be included in determining the gross income of an entity described in subsection (a)(2)(B)(i) that is maintaining or currently contributing to a participating employment-based plan.
I|A|1001.XXII|A|2|2216.(c)(6)
Appeals The Secretary shall establish -
I|A|1001.XXII|A|2|2216.(c)(6)(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
I|A|1001.XXII|A|2|2216.(c)(6)(B)
procedures to protect against fraud, waste, and abuse under the program.
I|A|1001.XXII|A|2|2216.(d)
Audits The Secretary shall conduct annual audits of claims data submitted by participating employment-based plans under this section to ensure that such plans are in compliance with the requirements of this section.
I|A|1001.XXII|A|2|2216.(e)
Available funds
I|A|1001.XXII|A|2|2216.(e)(1)
In general The Secretary of the Treasury shall establish a separate account within the Treasury of the United States for deposit of amounts transferred to the Secretary of Health and Human Services under section 2213(b)(4)(B).
I|A|1001.XXII|A|2|2216.(e)(2)
Appropriations Amounts in the account are hereby appropriated for use by the Secretary in carrying out the program under this section.
I|A|1001.XXII|A|2|2216.(e)(3)
Limitations The Secretary has the authority to stop taking applications for participation in the program if applications will exceed amounts in the account.
I|A|1001.XXII|A|3
Preservation of right to maintain existing coverage
I|A|1001.XXII|A|3|2221.
Grandfathered health benefits plans
I|A|1001.XXII|A|3|2221.(a)
In general In the case of a grandfathered health benefits plan -
I|A|1001.XXII|A|3|2221.(a)(1)
nothing in this title shall be construed to require that an individual terminate coverage under the plan if such individual was enrolled in the plan as of the day before the effective date of this title;
I|A|1001.XXII|A|3|2221.(a)(2)
except as provided in subsection (b), the requirements of this part shall not apply to the plan; and
I|A|1001.XXII|A|3|2221.(a)(3)
the plan shall not be treated as a qualified health benefits plan for purposes of this title.
I|A|1001.XXII|A|3|2221.(b)
Application of rating rules in small group market Each State shall phase in the application of the insurance reform requirements under subpart 1 to grandfathered health benefits plans offered in the small group market within the State over a consecutive period of years (not greater than 5) beginning July 1, 2013.
I|A|1001.XXII|A|3|2221.(c)
Grandfathered health benefits plan In this title:
I|A|1001.XXII|A|3|2221.(c)(1)
In general The term grandfathered health benefits plan means any of the following that was offered and was in force and effect on the effective date of this title:
I|A|1001.XXII|A|3|2221.(c)(1)(A)
Health insurance coverage in the individual market.
I|A|1001.XXII|A|3|2221.(c)(1)(B)
A group health plan.
I|A|1001.XXII|A|3|2221.(c)(2)
Limited new enrollment
I|A|1001.XXII|A|3|2221.(c)(2)(A)
In general Except as provided in subparagraphs (B) and (C), a health benefits plan shall cease to be a grandfathered health benefits plan if it enrolls individuals who were not enrolled in the plan as of the day before the date described in paragraph (1).
I|A|1001.XXII|A|3|2221.(c)(2)(B)
Allowance for family members to join current coverage Family members of an individual enrolled in a health benefits plan as of the day before the date described in paragraph (1) may enroll in the plan on or after such date.
I|A|1001.XXII|A|3|2221.(c)(2)(C)
Allowance for new employees to join current plan A group health plan of an employer that provides coverage as of the day before the date described in paragraph (1) may provide for the enrolling of new employees (and their families) in such plan.
I|A|1001.XXII|A|3|2221.(c)(3)
Special rule for catastrophic plans If health insurance coverage offered and in force in the individual market as of the day before the effective of this title is actuarially equivalent to a catastrophic plan described in section 2243(c), such coverage shall be treated as a grandfathered health benefits plan for purposes of this section.
I|A|1001.XXII|A|4
Continued role of States
I|A|1001.XXII|A|4|2225.
Continued State enforcement of insurance regulations
I|A|1001.XXII|A|4|2225.(a)
In general
I|A|1001.XXII|A|4|2225.(a)(1)
Model regulation
I|A|1001.XXII|A|4|2225.(a)(1)(A)
In general The Secretary shall request the National Association of Insurance Commissioners (in this section referred to as the NAIC ) to, not later than 12 months after the date of enactment of this title, develop and promulgate a Model Regulation that implements the requirements set forth in this title for health benefit plans offered within a State. In developing and promulgating the Model Regulation, the NAIC shall consult with its members, health insurance issuers, consumer organizations, and such other individuals as the NAIC selects in a manner designed to ensure balanced representation among interested parties.
I|A|1001.XXII|A|4|2225.(a)(1)(B)
Secretarial action The Secretary shall include the Model Regulation established under paragraph (1) in the regulations prescribed by the Secretary to implement the requirements described in subparagraph (A). If the NAIC does not promulgate the Model Regulation within the 12-month period under subparagraph (A), the Secretary shall establish a Federal standard implementing such requirements.
I|A|1001.XXII|A|4|2225.(a)(2)
State action Each State that elects to apply the requirements set forth in this title to health benefit plans offered within the State shall, not later than July 1, 2013, adopt and have in effect -
I|A|1001.XXII|A|4|2225.(a)(2)(A)
the Model Regulation or Federal standard established under paragraph (1), whichever is applicable; or
I|A|1001.XXII|A|4|2225.(a)(2)(B)
a State law or regulation that the Secretary determines implements the requirements for health benefit plans offered within the State.
I|A|1001.XXII|A|4|2225.(a)(3)
Failure to implement provisions
I|A|1001.XXII|A|4|2225.(a)(3)(A)
In general If -
I|A|1001.XXII|A|4|2225.(a)(3)(A)(i)
a State does not elect to apply the requirements set forth in this title to health benefit plans offered within the State; or
I|A|1001.XXII|A|4|2225.(a)(3)(A)(ii)
the Secretary determines that an electing State has failed to adopt or substantially enforce the Model Regulation, Federal standard, or State law or regulations described in paragraph (2), whichever is applicable, with respect to health benefits plan offerors in the State, the Secretary shall implement and enforce such requirements insofar as they relate to the issuance, sale, renewal, and offering of health benefits plans in such State until such time as the Secretary determines the State has adopted and is substantially enforcing the requirements.
I|A|1001.XXII|A|4|2225.(a)(3)(B)
Enforcement authority The provisions of section 2722(b) of the Public Health Services Act shall apply to the enforcement under subparagraph (A) of the provisions of this part (without regard to any limitation on the application of those provisions to group health plans).
I|A|1001.XXII|A|4|2225.(a)(4)
Ratings reforms must apply uniformly to all offerors The Model Regulation, Federal standard, or State law and regulation implemented by a State under this subsection shall require that any standard or requirement adopted pursuant to this title (including any standard or requirement described in subsection (c) that offers more protection to consumers than the protection offered by any standard or requirement set forth in this title) shall be applied uniformly to all offerors of all health benefits plans in the individual or small group market, whichever is applicable.
I|A|1001.XXII|A|4|2225.(b)
State exchanges
I|A|1001.XXII|A|4|2225.(b)(1)
Exchanges for qualified plans
I|A|1001.XXII|A|4|2225.(b)(1)(A)
In general Subject to paragraph (2), not later than July 1, 2013, an electing State under subsection (a)(2) shall establish and have in operation 1 or more exchanges (including SHOP exchanges) meeting the requirements of part B with respect to the offering of qualified health benefits plans through the exchange.
I|A|1001.XXII|A|4|2225.(b)(1)(B)
Failure to establish If -
I|A|1001.XXII|A|4|2225.(b)(1)(B)(i)
a State is not an electing State under subsection (a)(2); or
I|A|1001.XXII|A|4|2225.(b)(1)(B)(ii)
an electing State does not establish the exchanges described in subparagraph (A) within 24 months after the date of enactment of this title (or the Secretary determines at the end of the 24-month period that the exchanges will not be operational by July 1, 2013), the Secretary shall enter into a contract with a nongovernmental entity to establish and operate the exchanges within the State.
I|A|1001.XXII|A|4|2225.(b)(2)
Interim exchanges Each electing State under subsection (a)(2) shall as soon as practicable establish the exchanges described in section 2235(e) for use by residents of the State during the period beginning January 1, 2010, and ending June 30, 2013. In the case of a State that is not an electing State under subsection (a)(2), or if the Secretary determines that the exchanges in an electing State will not be operational within a reasonable period of time after the date of enactment of this title, the Secretary shall enter into a contract with a nongovernmental entity to establish and operate the exchanges within the State during such period.
I|A|1001.XXII|A|4|2225.(c)
Continued applicability of State law with respect to health benefits plans
I|A|1001.XXII|A|4|2225.(c)(1)
In general Subject to paragraphs (2) and (3), this title shall not be construed to supersede any provision of State law which establishes, implements, or continues in effect any standard or requirement relating to health benefits plan offerors in connection with a health benefits plan that offers more protection to consumers than the protection offered by any standard or requirement set forth in this title. The standards or requirements referred to in the preceding sentence shall include standards or requirements relating to -
I|A|1001.XXII|A|4|2225.(c)(1)(A)
consumer protections, including claims grievance procedures, external review of claims determinations, oversight of insurance agent practices and training, and insurance market conduct;
I|A|1001.XXII|A|4|2225.(c)(1)(B)
premium rating reviews;
I|A|1001.XXII|A|4|2225.(c)(1)(C)
solvency and reserve requirements relating to the licensure of health insurance issuers operating in the State; and
I|A|1001.XXII|A|4|2225.(c)(1)(D)
the assessment of State-based premium taxes on health insurance issuers.
I|A|1001.XXII|A|4|2225.(c)(2)
Special rule for rating requirements For purposes of paragraph (1), in the case of the ratings requirements under section 2204, a State law shall not be treated as offering more protection to consumers than the protection offered by such requirements if the State law imposes ratios that are greater than the ratios specified in section 2204(b).
I|A|1001.XXII|A|4|2225.(c)(3)
Continued preemption with respect to group health plans Nothing in this part shall be construed to affect or modify the provisions of section 514 of the Employee Retirement Income Security Act of 1974 with respect to group health plans.
I|A|1001.XXII|A|4|2225.(d)
Automatic enrollment A State may institute a program to provide that offerors of qualified health benefit plans, small employers, and exchanges offering qualified health benefits plans in the individual and small group market within the State may automatically enroll individuals and employees in, or continue enrollment of individuals in, qualified health benefit plans where appropriate to ensure coverage of the individuals. Any automatic enrollment program shall include adequate notice and the opportunity for an individual or employee to opt out of any coverage the individual or employee were automatically enrolled in.
I|A|1001.XXII|A|4|2225.(e)
Claims review process Each State shall -
I|A|1001.XXII|A|4|2225.(e)(1)
require each offeror of a qualified health benefits plans offered through an exchange -
I|A|1001.XXII|A|4|2225.(e)(1)(A)
to provide an internal claims appeal process;
I|A|1001.XXII|A|4|2225.(e)(1)(B)
to provide notice in clear language and in the enrollee's primary language of available internal and external appeals processes and the availability of the ombudsman established under section 2229(a) to assist them with the appeals processes; and
I|A|1001.XXII|A|4|2225.(e)(1)(C)
to allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process;
I|A|1001.XXII|A|4|2225.(e)(2)
provide an external review process for such plans that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans; and
I|A|1001.XXII|A|4|2225.(e)(3)
ensure enrollees can seek judicial review through available Federal or State procedures.
I|A|1001.XXII|A|4|2225.(f)
Applicable State authority In this title, the term applicable State authority means the State insurance commissioner or official or officials designated by the State to enforce the requirements of this title for the State involved.
I|A|1001.XXII|A|4|2226.
Waiver of health insurance reform requirements
I|A|1001.XXII|A|4|2226.(a)
Application A State may apply to the Secretary for the waiver of all or any requirements under this title and section 5000A of the Internal Revenue Code of 1986 with respect to health insurance coverage within that State for plan years beginning on or after July 1, 2015. Such application shall -
I|A|1001.XXII|A|4|2226.(a)(1)
be filed at such time and in such manner as the Secretary may require; and
I|A|1001.XXII|A|4|2226.(a)(2)
contain such information as the Secretary may require, including -
I|A|1001.XXII|A|4|2226.(a)(2)(A)
a comprehensive description of the State legislation or program for implementing a plan meeting the requirements for a waiver under this section; and
I|A|1001.XXII|A|4|2226.(a)(2)(B)
a 10-year budget plan for such plan that is budget neutral for the Federal government.
I|A|1001.XXII|A|4|2226.(b)
Granting of waivers The Secretary may grant a request for a waiver under this section if the Secretary determines that -
I|A|1001.XXII|A|4|2226.(b)(1)
the State plan to provide health care coverage to its residents provides coverage that is at least as comprehensive as the coverage required under a qualified health benefits plan offered through exchanges established under this title; and
I|A|1001.XXII|A|4|2226.(b)(2)
the State plan to provide health care coverage to its residents will lower the growth in health care spending, will improve delivery system performance, will provide affordable choices for its citizens, will expand protection against excessive out-of-pocket spending, will provide coverage to the same number of uninsured as the provisions of this title will provide, and will not increase the Federal deficit.
I|A|1001.XXII|A|4|2226.(c)
Scope of waiver
I|A|1001.XXII|A|4|2226.(c)(1)
In general The Secretary shall determine the scope of a waiver granted to a State under this section, including which Federal laws and requirements will not apply to the State under the waiver.
I|A|1001.XXII|A|4|2226.(c)(2)
Limitation The Secretary may not waive under this section any Federal law or requirement that is not within the authority of the Secretary.
I|A|1001.XXII|A|4|2226.(d)
Determinations by Secretary
I|A|1001.XXII|A|4|2226.(d)(1)
Time for determination The Secretary shall make a determination under this section not later than 180 days after the receipt of an application from a State under subsection (a).
I|A|1001.XXII|A|4|2226.(d)(2)
Effect of determination
I|A|1001.XXII|A|4|2226.(d)(2)(A)
Granting of waivers If the Secretary determines to grant a waiver under this section, the Secretary shall notify the State involved of such determination and the terms and effectiveness of such waiver.
I|A|1001.XXII|A|4|2226.(d)(2)(B)
Denial of waiver If the Secretary determines a waiver should not be granted under this section, the Secretary shall notify the State involved, and the appropriate committees of Congress of such determination and the reasons therefor.
I|A|1001.XXII|A|4|2227.
Provisions relating to offering of plans in more than one State
I|A|1001.XXII|A|4|2227.(a)
Health care choice compacts
I|A|1001.XXII|A|4|2227.(a)(1)
In general The Secretary shall request the National Association of Insurance Commissioners to, no later than July 1, 2012, develop model rules for the creation of health care choice compacts under which 2 or more States may enter into an agreement under which -
I|A|1001.XXII|A|4|2227.(a)(1)(A)
1 or more qualified health benefits plans could be offered in the individual markets in all such States but, except as provided in subparagraph (B), only be subject to the laws and regulations of the State in which the plan was written or issued;
I|A|1001.XXII|A|4|2227.(a)(1)(B)
the offeror of any qualified health benefits plan to which the compact applies -
I|A|1001.XXII|A|4|2227.(a)(1)(B)(i)
would continue to be subject to market conduct, unfair trade practices, network adequacy, and consumer protection standards, including addressing disputes as to the performance of the contract, of the State in which the purchaser resides;
I|A|1001.XXII|A|4|2227.(a)(1)(B)(ii)
would be required to be licensed in each State in which it offers the plan under the compact or to submit to the jurisdiction of each such State with regard to the standards described in clause (i) (including allowing access to records as if the insurer were licensed in the State); and
I|A|1001.XXII|A|4|2227.(a)(1)(B)(iii)
must clearly notify consumers that the policy may not be subject to all the laws and regulations of the State in which the purchaser resides.
If the NAIC does not promulgate the model rules by July 1, 2012, the Secretary shall, not later than July 1, 2013, establish a Federal standard implementing such rules.
I|A|1001.XXII|A|4|2227.(a)(2)
State authority A State may not enter into an agreement under this subsection unless the State enacts a law after the date of the enactment of this title that specifically authorizes the State to enter into such agreements.
I|A|1001.XXII|A|4|2227.(a)(3)
Effective date A health care choice compact described in paragraph (1) shall not take effect before January 1, 2015.
I|A|1001.XXII|A|4|2227.(b)
Authority for nationwide plans
I|A|1001.XXII|A|4|2227.(b)(1)
In general Notwithstanding section 2225(c)(1), and except as provided in paragraph (2), if an offeror of a qualified health benefits plan in the individual or small group market meets the requirements of this subsection -
I|A|1001.XXII|A|4|2227.(b)(1)(A)
the offeror of the plan may offer the qualified health benefits plan in more than 1 State; and
I|A|1001.XXII|A|4|2227.(b)(1)(B)
any State law mandating benefit coverage by a health benefits plan shall not apply to the qualified health benefits plan.
I|A|1001.XXII|A|4|2227.(b)(2)
State opt-out A State may, by specific reference in a law enacted after the date of enactment of this title, provide that this subsection shall not apply to that State. Such opt-out shall be effective until such time as the State by law revokes it.
I|A|1001.XXII|A|4|2227.(b)(3)
Plan requirements An offeror meets the requirements of this subsection with respect to a qualified health benefits plan if -
I|A|1001.XXII|A|4|2227.(b)(3)(A)
the plan offers a benefits package that is uniform in each State in which the plan is offered and meets the requirements set forth in paragraph (3);
I|A|1001.XXII|A|4|2227.(b)(3)(B)
the offeror is licensed in each State in which it offers the plan and is subject in such State to the standards and requirements described in the last sentence of section 2225(c)(1);
I|A|1001.XXII|A|4|2227.(b)(3)(C)
the offeror meets all requirements of this title with respect to a qualified health benefits plan, including the requirement to offer the silver and gold levels of the plan in each exchange in the State for the market in which the plan is offered; and
I|A|1001.XXII|A|4|2227.(b)(3)(D)
the offeror determines the premiums for the plan in any State on the basis of the ratings rules in effect in that State for the ratings areas in which it is offered.
I|A|1001.XXII|A|4|2227.(b)(4)
Applicable regulations
I|A|1001.XXII|A|4|2227.(b)(4)(A)
In general The Secretary shall request the National Association of Insurance Commissioners to, no later than 2012, develop model rules for the offering of a qualified health benefits plans on a national basis. Such rules shall establish standards for -
I|A|1001.XXII|A|4|2227.(b)(4)(A)(i)
the implementation of benefit categories, taking into account how each benefit is offered in a majority of States; and
I|A|1001.XXII|A|4|2227.(b)(4)(A)(ii)
harmonization between applicable State authorities of State insurance regulations relating to filing of forms and the filing of premium rates. If the NAIC does not promulgate the model rules by December 31, 2012, the Secretary shall, not later than December 31, 2013, establish a Federal standard implementing such rules.
I|A|1001.XXII|A|4|2227.(b)(4)(B)
State action Each State (other than a State described in paragraph (2)) shall include the provisions described in subparagraph (A) in the Model Regulation, Federal standard, or State law or regulation the State adopts and has in effect under section 2225(a)(2).
I|A|1001.XXII|A|4|2228.
State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid
I|A|1001.XXII|A|4|2228.(a)
Establishment of program
I|A|1001.XXII|A|4|2228.(a)(1)
In general The Secretary shall establish a basic health program meeting the requirements of this section under which a State may enter into contracts to offer 1 or more standard health plans providing at least an essential benefits package described in section 2242 to eligible individuals in lieu of offering such individuals coverage through an exchange established under part B.
I|A|1001.XXII|A|4|2228.(a)(2)
Certifications as to benefit coverage and costs Such program shall provide that a State may not establish a basic health program under this section unless the State establishes to the satisfaction of the Secretary, and the Secretary certifies, that -
I|A|1001.XXII|A|4|2228.(a)(2)(A)
in the case of an eligible individual enrolled in a standard health plan offered through the program, the State provides -
I|A|1001.XXII|A|4|2228.(a)(2)(A)(i)
that the amount of the monthly premium an eligible individual is required to pay for coverage under the standard health plan for the individual and the individual's dependents does not exceed the amount of the monthly premium that the eligible individual would have been required to pay if the individual had enrolled in the applicable second lowest cost silver plan (as defined in section 36B(b)(3)(B) of the Internal Revenue Code of 1986) offered to the individual through an exchange; and
I|A|1001.XXII|A|4|2228.(a)(2)(A)(ii)
that the cost-sharing an eligible individual is required to pay under the standard health plan does not exceed -
I|A|1001.XXII|A|4|2228.(a)(2)(A)(ii)(I)
the cost-sharing required under a platinum plan in the case of an eligible individual with household income not in excess of 150 percent of the poverty line for the size of the family involved; and
I|A|1001.XXII|A|4|2228.(a)(2)(A)(ii)(II)
the cost-sharing required under a gold plan in the case of an eligible individual; and
I|A|1001.XXII|A|4|2228.(a)(2)(B)
the benefits provided under the standard health plans offered through the program cover at least benefits required under an essential benefits package described in section 2242. For purposes of subparagraph (A)(i), the amount of the monthly premium an individual is required to pay under either the standard health plan or the applicable second lowest cost silver plan shall be determined after reduction for any premium credits and premium subsidies allowable with respect to either plan.
I|A|1001.XXII|A|4|2228.(b)
Standard health plan In this section, the term standard heath plan means a health benefits plan that the State contracts with under this section -
I|A|1001.XXII|A|4|2228.(b)(1)
under which the only individuals eligible to enroll are eligible individuals;
I|A|1001.XXII|A|4|2228.(b)(2)
that provides at least an essential benefits package described in section 2242; and
I|A|1001.XXII|A|4|2228.(b)(3)
in the case of a plan that provides health insurance coverage offered by a health insurance issuer, that has a medical loss ratio of at least 85 percent.
I|A|1001.XXII|A|4|2228.(c)
Contracting process
I|A|1001.XXII|A|4|2228.(c)(1)
In general A State basic health program shall establish a competitive process for entering into contracts with standard health plans under subsection (a), including negotiation of premiums and cost-sharing and negotiation of benefits in addition to those required by an essential benefits package described in section 2242.
I|A|1001.XXII|A|4|2228.(c)(2)
Specific items to be considered A State shall, as part of its competitive process under paragraph (1), include at least the following:
I|A|1001.XXII|A|4|2228.(c)(2)(A)
Innovation Negotiation with offerors of a standard health plan for the inclusion of innovative features in the plan, including -
I|A|1001.XXII|A|4|2228.(c)(2)(A)(i)
care coordination and care management for enrollees, especially for those with chronic health conditions;
I|A|1001.XXII|A|4|2228.(c)(2)(A)(ii)
incentives for use of preventive services; and
I|A|1001.XXII|A|4|2228.(c)(2)(A)(iii)
the establishment of relationships between providers and patients that maximize patient involvement in health care decision-making, including providing incentives for appropriate utilization under the plan.
I|A|1001.XXII|A|4|2228.(c)(2)(B)
Health and resource differences Consideration of, and the making of suitable allowances for, differences in health care needs of enrollees and differences in local availability of, and access to, health care providers. Nothing in this subparagraph shall be construed as allowing discrimination on the basis of pre-existing condition or other health status-related factors.
I|A|1001.XXII|A|4|2228.(c)(2)(C)
Managed care Contracting with managed care systems, or with systems that offer as many of the attributes of managed care as are feasible in the local health care market.
I|A|1001.XXII|A|4|2228.(c)(2)(D)
Performance measures Establishing specific performance measures and standards for offerors of standard health plans that focus on quality of care and improved health outcomes, requiring such plan to report to the State with respect to the measures and standards, and making the performance and quality information available to enrollees in a useful form.
I|A|1001.XXII|A|4|2228.(c)(3)
Enhanced availability
I|A|1001.XXII|A|4|2228.(c)(3)(A)
Multiple plans A State shall, to the maximum extent feasible, seek to make multiple standard health plans available to eligible individuals within a State to ensure individuals have a choice of such plans.
I|A|1001.XXII|A|4|2228.(c)(3)(B)
Regional compacts A State may negotiate a regional compact with other States to include coverage of eligible individuals in all such States in agreements with offerors of standard health plans.
I|A|1001.XXII|A|4|2228.(c)(4)
Coordination with other State programs A State shall, to the maximum extent feasible, seek to coordinate the administration of, and provision of benefits under, its program under this section with the State medicaid program under title XIX, the State child health plan under title XXI, and other State-administered health programs to maximize the efficiency of such programs and to improve the continuity of care.
I|A|1001.XXII|A|4|2228.(d)
Transfer of funds to States
I|A|1001.XXII|A|4|2228.(d)(1)
In general If the Secretary determines that a State electing the application of this section meets the requirements of the program established under subsection (a), the Secretary shall transfer to the State for each fiscal year for which 1 or more standard health plans are operating within the State the amount determined under paragraph (3).
I|A|1001.XXII|A|4|2228.(d)(2)
Use of funds A State shall establish a trust for the deposit of the amounts received under paragraph (1) and amounts in the trust fund shall only be used to reduce the premiums and cost-sharing of, or to provide additional benefits for, eligible individuals enrolled in standard health plans within the State. Amounts in the trust fund, and expenditures of such amounts, shall not be included in determining the amount of any non-Federal funds for purposes of meeting any matching or expenditure requirement of any federally-funded program.
I|A|1001.XXII|A|4|2228.(d)(3)
Amount of payment
I|A|1001.XXII|A|4|2228.(d)(3)(A)
Secretarial determination
I|A|1001.XXII|A|4|2228.(d)(3)(A)(i)
In general The amount determined under this paragraph for any fiscal year is the amount the Secretary determines is equal to 85 percent of the credits under section 36B of the Internal Revenue Code of 1986, and the cost-sharing subsidies under section 2247, that would have been provided for the fiscal year to eligible individuals enrolled in standard health plans in the State if such eligible individuals were allowed to enroll in qualified health benefits plans through an exchange established under part B.
I|A|1001.XXII|A|4|2228.(d)(3)(A)(ii)
Specific requirements The Secretary shall make the determination under clause (i) on a per enrollee basis and shall take into account all relevant factors necessary to determine the value of the credits and subsidies that would have been provided to eligible individuals described in clause (i).
I|A|1001.XXII|A|4|2228.(d)(3)(B)
Corrections The Secretary shall adjust the payment for any fiscal year to reflect any error in the determinations under subparagraph (A) for any preceding fiscal year.
I|A|1001.XXII|A|4|2228.(d)(4)
Application of abortion coverage requirements The rules of section 2245 shall apply to a State basic health program, and to standard health plans offered through such program, in the same manner as such rules apply to qualified basic health benefits plans.
I|A|1001.XXII|A|4|2228.(e)
Eligible individual
I|A|1001.XXII|A|4|2228.(e)(1)
In general In this section, the term eligible individual means, with respect to any State, an individual -
I|A|1001.XXII|A|4|2228.(e)(1)(A)
who a resident of the State who is not eligible to enroll in the State's medicaid program under title XIX for benefits that at a minimum consist of the essential benefits package described in section 2242;
I|A|1001.XXII|A|4|2228.(e)(1)(B)
whose household income exceeds 133 percent but does not exceed 200 percent of the poverty line for the size of the family involved;
I|A|1001.XXII|A|4|2228.(e)(1)(C)
who is not eligible for essential health benefits coverage (as defined in section 5000A(f)) or is eligible for an employer-sponsored plan that is not affordable coverage (as determined under section 5000A(e)(2)); and
I|A|1001.XXII|A|4|2228.(e)(1)(D)
who has not attained age 65 as of the beginning of the plan year. Such term shall not include any individual who is not eligible under section 2232(c) to be covered by a qualified health benefits plan offered through an exchange.
I|A|1001.XXII|A|4|2228.(e)(2)
Eligible individuals may not use exchange An eligible individual shall not be treated as a qualified individual under section 2223 eligible for enrollment in a qualified health benefits plan offered through an exchange established under part B.
I|A|1001.XXII|A|4|2228.(f)
Secretarial oversight The Secretary shall each year conduct a review of each State program to ensure compliance with the requirements of this section, including ensuring that the State program meets -
I|A|1001.XXII|A|4|2228.(f)(1)
eligibility verification requirements for participation in the program;
I|A|1001.XXII|A|4|2228.(f)(2)
the requirements for use of Federal funds received by the program; and
I|A|1001.XXII|A|4|2228.(f)(3)
the quality and performance standards under this section.
I|A|1001.XXII|A|4|2228.(g)
Standard health plan offerors A State may provide that persons eligible to offer standard health plans under a basic health program established under this section may include a licensed health maintenance organization, a licensed health insurance insurer, or a network of health care providers established to offer services under the program.
I|A|1001.XXII|A|4|2228.(h)
Definitions Any term used in this section which is also used in section 36B of the Internal Revenue Code of 1986 shall have the meaning given such term by such section.
I|A|1001.XXII|A|5
Other definitions and rules
I|A|1001.XXII|A|5|2230.
Other definitions and rules
I|A|1001.XXII|A|5|2230.(a)
Employers In this title:
I|A|1001.XXII|A|5|2230.(a)(1)
Large employer The term large employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 101 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.
I|A|1001.XXII|A|5|2230.(a)(2)
Small employer The term small employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 100 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year. Unless an employer elects otherwise, if an employer is treated as a small employer for any plan year to which this title applies, then such employer shall continue to be treated as a small employer for any subsequent plan year even if the number of employees exceeds the number in effect under this subparagraph.
I|A|1001.XXII|A|5|2230.(a)(3)
State option to treat 50 employees as small In the case of plan years beginning before January 1, 2015, a State may elect to apply this subsection by substituting 51 employees for 101 employees in paragraph (1) and by substituting 50 employees for 100 employees in paragraph (2).
I|A|1001.XXII|A|5|2230.(a)(4)
Rules for determining employer size For purposes of this subsection -
I|A|1001.XXII|A|5|2230.(a)(4)(A)
Application of aggregation rule for employers All persons 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 as 1 employer.
I|A|1001.XXII|A|5|2230.(a)(4)(B)
Employers not in existence in preceding year In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.
I|A|1001.XXII|A|5|2230.(a)(4)(C)
Predecessors Any reference in this subsection to an employer shall include a reference to any predecessor of such employer.
I|A|1001.XXII|A|5|2230.(b)
Terms relating to plans In this title:
I|A|1001.XXII|A|5|2230.(b)(1)
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.
I|A|1001.XXII|A|5|2230.(b)(2)
Plan year The term plan year means -
I|A|1001.XXII|A|5|2230.(b)(2)(A)
with respect to a group health plan, a plan year as specified under such plan; or
I|A|1001.XXII|A|5|2230.(b)(2)(B)
with respect to another health benefits plan, the calendar year, the 12-month period beginning on July 1 of each year, or such other 12-month period as may be specified by the Secretary.
.
I|B
Exchanges and consumer assistance
I|B|1101.
Establishment of qualified health benefits plan exchanges
I|B|1101.(a)
In general Title XXII of the Social Security Act, as added by section 1001, is amended by adding at the end the following:
I|B|1101.(a)B
Exchange and consumer assistance
I|B|1101.(a)B|1
Individuals and small employers offered affordable choices
I|B|1101.(a)B|1|2231.
Rights and responsibilities regarding choice of coverage through exchange
I|B|1101.(a)B|1|2231.(a)
Right to enroll through an exchange
I|B|1101.(a)B|1|2231.(a)(1)
Qualified individuals Each qualified individual shall have the choice to enroll or to not enroll in a qualified health benefits plan offered through an exchange that is established under this title, that covers the State in which the individual resides, and that covers qualified health benefits plans in the individual market.
I|B|1101.(a)B|1|2231.(a)(2)
Qualified small employers
I|B|1101.(a)B|1|2231.(a)(2)(A)
In general In the case of a qualified small employer -
I|B|1101.(a)B|1|2231.(a)(2)(A)(i)
such employer may elect to offer to its employees qualified health benefits plans offered through an exchange that is established under this title, that covers the State in which the employees resides, and that covers qualified health benefits plans in the small group market; and
I|B|1101.(a)B|1|2231.(a)(2)(A)(ii)
each employee of such employer shall have the choice to enroll or to not enroll in a qualified health benefits plan offered through such exchange. If a qualified small employer elects to limit the qualified health benefits plans or levels of coverage under part C that employees may enroll in through such exchange, employees may only choose to enroll in those plans or plans in those levels.
I|B|1101.(a)B|1|2231.(a)(2)(B)
Self-insured plans If a qualified small employer offers its employees coverage under a self-insured health benefits plan, the employer may not offer its employees qualified health benefits plans through an exchange.
I|B|1101.(a)B|1|2231.(a)(3)
Members of Congress and Congressional staff required to participate in exchange
I|B|1101.(a)B|1|2231.(a)(3)(A)
In general Notwithstanding chapter 89 of title 5, United States Code, or any provision of this title -
I|B|1101.(a)B|1|2231.(a)(3)(A)(i)
each Member of Congress and Congressional employee shall be treated as a qualified individual entitled to the right under this paragraph to enroll in a qualified health benefits plan in the individual market offered through an exchange in the State in which the Member or employee resides; and
I|B|1101.(a)B|1|2231.(a)(3)(A)(ii)
any employer contribution under such chapter on behalf of the Member or employee may be paid only to the offeror of a qualified health benefits plan in which the Member or employee enrolled in through such exchange and not to the offeror of a plan offered through the Federal employees health benefit program under such chapter.
I|B|1101.(a)B|1|2231.(a)(3)(B)
Payments by Federal government The Secretary, in consultation with the Director of the Office of Personnel Management, shall establish procedures under which -
I|B|1101.(a)B|1|2231.(a)(3)(B)(i)
the employer contributions on behalf of a Member or Congressional employee are actuarially adjusted for age; and
I|B|1101.(a)B|1|2231.(a)(3)(B)(ii)
the employer contributions may be made directly to an exchange for payment to an offeror.
I|B|1101.(a)B|1|2231.(a)(3)(C)
Congressional employee In this paragraph, the term Congressional employee means an employee whose pay is disbursed by the Secretary of the Senate or the Clerk of the House of Representatives.
I|B|1101.(a)B|1|2231.(b)
Responsibility of offerors of qualified health benefits plans
I|B|1101.(a)B|1|2231.(b)(1)
All plans must be offered through an exchange An offeror of a qualified health benefits plan in a State -
I|B|1101.(a)B|1|2231.(b)(1)(A)
shall offer the plan through the exchange established by the State for the market in which the plan is being offered; and
I|B|1101.(a)B|1|2231.(b)(1)(B)
may offer such plan outside of an exchange.
I|B|1101.(a)B|1|2231.(b)(2)
Offerors must offer plans in silver and gold plans An offeror of a qualified health benefits plan in the individual or small group market within a State -
I|B|1101.(a)B|1|2231.(b)(2)(A)
shall offer within that market at least one qualified health benefits plan in the silver coverage level and at least one such plan in the gold coverage level; and
I|B|1101.(a)B|1|2231.(b)(2)(B)
may offer 1 or more qualified health benefits plan in the bronze and platinum coverage levels, a catastrophic plan described in section 2243(c), or a child-only plan described in section 2243(d).
I|B|1101.(a)B|1|2231.(c)
Responsibility of exchanges
I|B|1101.(a)B|1|2231.(c)(1)
In general Each exchange offering plans in the individual or small group market within a State shall offer all qualified health benefits plans in the State that are licensed by the State to be offered in that market.
I|B|1101.(a)B|1|2231.(c)(2)
Offering of stand-alone dental benefits
I|B|1101.(a)B|1|2231.(c)(2)(A)
In general Each exchange within a State shall allow an offeror of a health benefits plan that only provides limited scope dental benefits meeting the requirements of section 9832(c)(2)(A) of the Internal Revenue Code of 1986 to offer the plan through the exchange (either separately or in conjunction with a qualified health benefits plan) if the plan provides pediatric dental benefits meeting the requirements of 2242(b)(11) for individuals who have not attained the age of 21.
I|B|1101.(a)B|1|2231.(c)(2)(B)
Eligibility for credit and subsidy If an individual enrolls in both a qualified health benefits plan and a plan described in subparagraph (A) for any plan year, the portion of the premium for the plan described in subparagraph (A) that (under regulations prescribed by the Secretary) is properly allocable to individuals covered by the plan who have not attained the age of 21 before the beginning of the plan year shall be treated as a premium payable for a qualified health benefits plan for purposes of determining the amount of the premium credit under section 36B of such Code and cost-sharing subsidies under section 2237 with respect to the plan year.
I|B|1101.(a)B|1|2231.(d)
Enrollment through agents or brokers The Secretary shall establish procedures under which a State is required to allow agents or brokers -
I|B|1101.(a)B|1|2231.(d)(1)
to enroll individuals in any qualified health benefits plans in the individual or small group market as soon as the plan is offered through an exchange in the State; and
I|B|1101.(a)B|1|2231.(d)(2)
to assist individuals in applying for premium credits and cost-sharing subsidies for plans sold through an exchange.
I|B|1101.(a)B|1|2232.
Qualified individuals and small employers; access limited to citizens and lawful residents
I|B|1101.(a)B|1|2232.(a)
Qualified individuals In this title:
I|B|1101.(a)B|1|2232.(a)(1)
In general The term qualified individual means, with respect to an exchange, an individual who -
I|B|1101.(a)B|1|2232.(a)(1)(A)
is seeking to enroll in a qualified health benefits plan in the individual market offered through the exchange; and
I|B|1101.(a)B|1|2232.(a)(1)(B)
resides in the State that established the exchange.
I|B|1101.(a)B|1|2232.(a)(2)
Incarcerated individuals excluded An individual shall not be treated as a qualified individual if, at the time of enrollment, the individual is incarcerated, other than incarceration pending the disposition of charges.
I|B|1101.(a)B|1|2232.(b)
Qualified small employer In this title, the term qualified small employer means an employer that is a small employer that elects to make all full-time employees of such employer eligible for 1 or more qualified health benefits plans offered through an exchange established under this subtitle that offers qualified health benefits plans in the small group market.
I|B|1101.(a)B|1|2232.(c)
Access limited to lawful residents If an individual is not, or is not reasonably expected to be for the entire plan year for which enrollment is sought, a citizen or national of the United States, an alien lawfully admitted to the United States for permanent residence, or an alien lawfully present in the United States -
I|B|1101.(a)B|1|2232.(c)(1)
the individual shall not be treated as a qualified individual and may not be covered under a qualified health benefits plan in the individual market that is offered through an exchange; and
I|B|1101.(a)B|1|2232.(c)(2)
if the individual is an employee of a qualified small employer offering employees the opportunity to enroll in a qualified health benefits plan in the small group market through an exchange (or an individual bearing a relationship to such an employee that entitles such individual to coverage under such plan), the individual may not be covered under such plan.
I|B|1101.(a)B|2
Establishment of exchanges
I|B|1101.(a)B|2|2235.
Establishment of exchanges by States
I|B|1101.(a)B|2|2235.(a)
In general Each State shall, not later than July 1, 2013, establish -
I|B|1101.(a)B|2|2235.(a)(1)
an exchange for the State that is designed to facilitate the enrollment of qualified individuals in qualified health benefits plans offered in the individual market in the State; and
I|B|1101.(a)B|2|2235.(a)(2)
a Small Business Health Options Program (in this title referred to as a SHOP exchange ) that is designed to assist qualified small employers in facilitating the enrollment of their employees in qualified health benefits plans offered in either the individual or the small group market in the State.
I|B|1101.(a)B|2|2235.(b)
State flexibility
I|B|1101.(a)B|2|2235.(b)(1)
Merger of individual and SHOP exchanges A State may elect to provide only one exchange in the State for providing both exchange and SHOP exchange services to both qualified individuals and qualified small employers, but only if the exchange has separate resources to assist individuals and employers.
I|B|1101.(a)B|2|2235.(b)(2)
Regional exchanges An exchange or SHOP exchange may operate in more than 1 State if -
I|B|1101.(a)B|2|2235.(b)(2)(A)
each of the States agrees to the operation of the exchange in that State; and
I|B|1101.(a)B|2|2235.(b)(2)(B)
the Secretary approves of the operation of the exchange in all such States.
I|B|1101.(a)B|2|2235.(b)(3)
Authority to contract for exchange services
I|B|1101.(a)B|2|2235.(b)(3)(A)
Contract with sub-exchange Subject to such conditions and restrictions as the Secretary, in consultation with the Secretary of the Treasury, may prescribe under sections 2238 and 2248 -
I|B|1101.(a)B|2|2235.(b)(3)(A)(i)
In general A State may elect to authorize an exchange established by the State under this title to contract with an eligible entity to carry out 1 or more responsibilities of the exchange, including marketing and sale of qualified health benefits plans offered by the exchange, enrollment activities, broker relations, customer service, customer education, premium billing and collection, member advocacy with qualified health benefits plans, maintaining call center support, and performing the duties of the exchange under section 2238 in determining eligibility to participate in the exchange and to receive any credit or subsidy. An eligible entity may charge an additional fee to be used to pay the administrative and operational expenses of the entity.
I|B|1101.(a)B|2|2235.(b)(3)(A)(ii)
Eligible entity In this subparagraph, the term eligible entity means a person -
I|B|1101.(a)B|2|2235.(b)(3)(A)(ii)(I)
incorporated under, and subject to the laws of, 1 or more States;
I|B|1101.(a)B|2|2235.(b)(3)(A)(ii)(II)
that has demonstrated experience on a State or regional basis in the individual and small group health insurance and benefits coverage; and
I|B|1101.(a)B|2|2235.(b)(3)(A)(ii)(III)
that is not a health insurance issuer or that is treated under subsection (a) or (b) of section 52 as a member of the same controlled group of corporations (or under common control with) a health insurance issuer.
I|B|1101.(a)B|2|2235.(b)(3)(B)
Delegation to State medicaid agency A State may elect to authorize an exchange established by the State under this title to enter into an agreement with the State medicaid agency under title XIX to carry out the responsibilities of the exchange under this section in establishing the eligibility of individuals to participate in the exchange and to receive the premium credit under section 36B of the Internal Revenue Code of 1986 and the cost-sharing subsidy under section 2247. An exchange may enter into an agreement under this subparagraph only if the agreement meets requirements promulgated by the Secretary (after consultation with the Secretary of the Treasury) ensuring that the agreement lowers overall administrative costs and reduces the likelihood of eligibility errors and disruptions in coverage.
I|B|1101.(a)B|2|2235.(c)
Establishment of broker rate schedules Each State shall provide for the establishment of rate schedules for broker commissions paid by health benefits plans offered through an exchange.
I|B|1101.(a)B|2|2235.(d)
Offering of plans in large group market Beginning in 2017, each State may allow offerors of health benefits plans in the large group market in the State to offer the plans through an exchange. Nothing in this subsection shall be construed as requiring an offeror to offer such plans through an exchange.
I|B|1101.(a)B|2|2235.(e)
Interim exchanges before qualified plans
I|B|1101.(a)B|2|2235.(e)(1)
In general Each State shall, as soon as practicable after the date of enactment of this Act, establish an exchange through which enrollment in eligible health insurance coverage is offered for coverage during the period beginning January 1, 2010, and ending June 30, 2013. Each State may use the database established under paragraph (2)(C)(ii) in the operation of the exchange.
I|B|1101.(a)B|2|2235.(e)(2)
Eligible health insurance coverage In this subsection:
I|B|1101.(a)B|2|2235.(e)(2)(A)
In general The term eligible health insurance coverage means, with respect to any State, any health insurance coverage meeting the requirements of section 2244 which is offered -
I|B|1101.(a)B|2|2235.(e)(2)(A)(i)
by an issuer who is licensed to offer such coverage in that State; and
I|B|1101.(a)B|2|2235.(e)(2)(A)(ii)
in the individual or small group markets within the State.
I|B|1101.(a)B|2|2235.(e)(2)(B)
Exception for mini-medical plans Such term shall not include any health insurance coverage which, as determined under regulations prescribed by the Secretary, offers limited benefits or has a low annual limitation on the amount of benefits provided.
I|B|1101.(a)B|2|2235.(e)(2)(C)
Administration
I|B|1101.(a)B|2|2235.(e)(2)(C)(i)
In general The Secretary shall provide technical assistance to each State in establishing exchanges under this subsection.
I|B|1101.(a)B|2|2235.(e)(2)(C)(ii)
Database of plan offerings The Secretary, either directly or by grant or contract with a private entity, shall establish and maintain a database of health insurance coverage in the individual and small group markets. The Secretary shall ensure that individuals and small employers are able to access the information in the database that is specific to the State in which the individuals and employees reside.
I|B|1101.(a)B|2|2236.
Functions performed by Secretary, States, and exchanges
I|B|1101.(a)B|2|2236.(a)
Agreements to perform functions The Secretary shall enter into an agreement with each State (in this section referred to as the agreement ) setting forth which of the functions described in this section with respect to an exchange shall be performed by the Secretary, the State, or the exchange.
I|B|1101.(a)B|2|2236.(b)
Certification of plans The agreement shall provide for the State to establish procedures for the certification, recertification, and decertification of a health benefits plan as a qualified health benefits plan that meets the requirements of this title for offering the plan through exchanges within the State.
I|B|1101.(a)B|2|2236.(c)
Outreach and eligibility The agreement shall provide for the conduct of the following activities:
I|B|1101.(a)B|2|2236.(c)(1)
Outreach
I|B|1101.(a)B|2|2236.(c)(1)(A)
In general The establishment and carrying out of a plan to conduct outreach activities to inform and educate individuals and employers about the exchange, the annual open enrollment periods described in subsection (d)(2), and options for qualified health benefits plans offered through the exchange.
I|B|1101.(a)B|2|2236.(c)(1)(B)
Call centers The establishment and maintenance of call centers to provide information to, and answer questions from, individuals seeking to enroll in qualified health benefit plans through an exchange, including providing multilingual assistance and mailing of relevant information to individuals based on their inquiry and zip code.
I|B|1101.(a)B|2|2236.(c)(1)(C)
Internet portals The development of a model template for an Internet portal to be used to direct qualified individuals and qualified small employers to qualified health benefits plans, to assist individuals and employers in determining whether they are eligible to participate in an exchange or eligible for a premium credit or cost-sharing subsidy, and to present standardized information regarding qualified health benefits plans offered through an exchange to enable easier consumer choice. Such template shall include with respect to each qualified health benefits plan offered through the exchange in each rating area access to the uniform outline of coverage the plan is required to provide under section 2205 and to a copy of the plan's policy.
I|B|1101.(a)B|2|2236.(c)(1)(D)
Rating system The establishment of a rating system that would rate qualified health benefits plans offered through an exchange on the basis of the relative quality and price of plans in the same benefit level. The exchange shall include the quality rating in the information provided to individuals and employers through the Internet portal established under subparagraph (C).
I|B|1101.(a)B|2|2236.(c)(2)
Eligibility Subject to section 2238, the making of timely determinations as to whether -
I|B|1101.(a)B|2|2236.(c)(2)(A)
individuals or employers are qualified individuals or qualified small employers eligible to participate in the exchange; and
I|B|1101.(a)B|2|2236.(c)(2)(B)
an individual is disqualified from participation in the exchange or from receiving any premium credit or cost-sharing subsidy because the individual is not, or is not reasonably expected to be for the entire plan year for which enrollment is sought, a citizen or national of the United States, an alien lawfully admitted to the United States for permanent residence, or an alien lawfully present in the United States.
I|B|1101.(a)B|2|2236.(d)
Enrollment The agreement shall provide for the establishment and carrying out of an enrollment process which -
I|B|1101.(a)B|2|2236.(d)(1)
provides for enrollment in person, by mail, by telephone, or electronically, including -
I|B|1101.(a)B|2|2236.(d)(1)(A)
through enrollment in local hospitals and schools, State motor vehicle offices, local Social Security offices, locations operated by Indian tribes and tribal organizations, and any other accessible locations specified by the exchange; and
I|B|1101.(a)B|2|2236.(d)(1)(B)
through use of the call center and Web portal established under subsection (c)(1);
I|B|1101.(a)B|2|2236.(d)(2)
provides for -
I|B|1101.(a)B|2|2236.(d)(2)(A)
an initial open enrollment period from March 1, 2013, through May 31, 2013;
I|B|1101.(a)B|2|2236.(d)(2)(B)
annual open enrollment periods from March 1 through May 31 of subsequent calendar years;
I|B|1101.(a)B|2|2236.(d)(2)(C)
special enrollment periods specified in section 9801 of the Internal Revenue Code of 1986 and other special enrollment periods under circumstances similar to such periods under part D of title XVIII; and
I|B|1101.(a)B|2|2236.(d)(2)(D)
special monthly enrollment periods for Indians (as defined in section 4 of the Indian Health Care Improvement Act).
I|B|1101.(a)B|2|2236.(d)(3)
subject to section 2239 -
I|B|1101.(a)B|2|2236.(d)(3)(A)
establishes a uniform enrollment form that qualified individuals and qualified small businesses may use (either electronically or on paper) in enrolling in qualified health benefits plans offered through an exchange, and that takes into account criteria that the National Association of Insurance Commissioners develops and submits to the Secretary; and
I|B|1101.(a)B|2|2236.(d)(3)(B)
informs individuals of eligibility requirements for the medicaid program under title XIX, the CHIP program under title XXI, or any applicable State or local public program and refers individuals to such programs if a determination is made that the individuals are so eligible;
I|B|1101.(a)B|2|2236.(d)(4)
establishes standardized marketing requirements that are based on the standards used for Medicare Advantage plans and ensures that marketing practices with respect to qualified health benefits plans offered through the exchange meet the requirements; and
I|B|1101.(a)B|2|2236.(d)(5)
provides for a standardized format for presenting health benefits plan options in the exchange, including use of the uniform outline of coverage established under section 1503 of the America's Healthy Future Act of 2009 .
I|B|1101.(a)B|2|2236.(e)
Eligibility for credit and subsidy The agreement shall provide for the establishment and use of a calculator to determine the actual cost of coverage after application of any premium credit or cost-sharing subsidy and the carrying out of responsibilities under section 2248 with respect to the advance determination and payment of such credits or subsidies.
I|B|1101.(a)B|2|2236.(f)
Certification of exemption from individual responsibility excise tax Subject to section 2238, the agreement shall establish procedures for -
I|B|1101.(a)B|2|2236.(f)(1)
granting a certification attesting that, for purposes of the individual responsibility excise tax under section 5000A of the Internal Revenue Code of 1986, an individual is exempt from the individual requirement or from the tax imposed by such section because -
I|B|1101.(a)B|2|2236.(f)(1)(A)
there is no affordable qualified health benefits plan available through the exchange, or the individual's employer, covering the individual; or
I|B|1101.(a)B|2|2236.(f)(1)(B)
the individual meets the requirements for any other such exemption from the individual responsibility requirement or tax; and
I|B|1101.(a)B|2|2236.(f)(2)
transferring to the Secretary of the Treasury or the Secretary's delegate a list of the individuals who are so exempt. The Secretary shall establish the period for which any certification under this subsection is in effect.
I|B|1101.(a)B|2|2237.
Duties of the Secretary to facilitate exchanges
I|B|1101.(a)B|2|2237.(a)
Credit and subsidy determinations The Secretary and the Secretary of the Treasury shall carry out the responsibilities under section 2248 (relating to advance determination and payment of premium credit and cost-sharing subsidies) that are delegated specifically to the Secretary and the Secretary of the Treasury.
I|B|1101.(a)B|2|2237.(b)
SHOP exchange assistance The Secretary shall designate an office within the Department of Health and Human Services to provide technical assistance to States to facilitate the participation of qualified small businesses in SHOP exchanges.
I|B|1101.(a)B|2|2237.(c)
Funding of start-up costs
I|B|1101.(a)B|2|2237.(c)(1)
In general The Secretary shall pay to each State the amount the Secretary reasonably estimates to be the unreimbursed start-up costs for any exchange or SHOP exchange established within a State. The Secretary shall make separate payments for the start-up costs of the interim and permanent exchanges.
I|B|1101.(a)B|2|2237.(c)(2)
Operational costs No payments shall be made under this subsection for any operational costs of an exchange after the initial start-up is completed but an exchange may assess each qualified health benefits plan offered through the exchange its proportional share of such costs.
I|B|1101.(a)B|2|2238.
Procedures for determining eligibility for exchange participation, premium credits and cost-sharing subsidies, and individual responsibility exemptions
I|B|1101.(a)B|2|2238.(a)
In general The Secretary shall establish a program meeting the requirements of this section for determining -
I|B|1101.(a)B|2|2238.(a)(1)
whether an individual who is to be covered by a qualified health benefits plan offered through an exchange, or who is claiming a premium credit or cost-sharing subsidy, meets the requirements of sections 2236(c)(2)(B) and 2247(e) of this title and section 36B(e) of the Internal Revenue Code of 1986 that the individual be a citizen or national of the United States, an alien lawfully admitted to the United States for permanent residence, or an alien lawfully present in the United States;
I|B|1101.(a)B|2|2238.(a)(2)
in the case of an individual claiming a premium credit or cost-sharing subsidy under section 36B of such Code or section 2247 -
I|B|1101.(a)B|2|2238.(a)(2)(A)
whether the individual meets the income and coverage requirements of such sections; and
I|B|1101.(a)B|2|2238.(a)(2)(B)
the amount of the credit or subsidy;
I|B|1101.(a)B|2|2238.(a)(3)
whether an individual's coverage under an employer-sponsored health benefits plan is treated as unaffordable under sections 36B(c)(2)(C), 4980H(c)(2), and 5000A(e)(2); and
I|B|1101.(a)B|2|2238.(a)(4)
whether to grant a certification under section 2237(f) attesting that, for purposes of the individual responsibility excise tax under section 5000A of the Internal Revenue Code of 1986, an individual is entitled to an exemption from either the individual responsibility requirement or the tax imposed by such section.
I|B|1101.(a)B|2|2238.(b)
Information required to be provided by applicants
I|B|1101.(a)B|2|2238.(b)(1)
In general An applicant for enrollment in a qualified health benefits plan offered through an exchange shall provide -
I|B|1101.(a)B|2|2238.(b)(1)(A)
the name, address, and date of birth of each individual who is to be covered by the plan (in this subsection referred to as an enrollee ); and
I|B|1101.(a)B|2|2238.(b)(1)(B)
the information required by any of the following paragraphs that is applicable to an enrollee.
I|B|1101.(a)B|2|2238.(b)(2)
Citizenship or immigration status The following information shall be provided with respect to every enrollee:
I|B|1101.(a)B|2|2238.(b)(2)(A)
In the case of an enrollee whose eligibility is based on an attestation of citizenship of the enrollee, the enrollee's social security number.
I|B|1101.(a)B|2|2238.(b)(2)(B)
In the case of an individual whose eligibility is based on an attestation of the enrollee's immigration status, the enrollee's social security number (if applicable) and such identifying information with respect to the enrollee's immigration status as the Secretary, after consultation with the Secretary of Homeland Security, determines appropriate.
I|B|1101.(a)B|2|2238.(b)(3)
Eligibility and amount of credit or subsidy In the case of an enrollee with respect to whom a premium credit or cost-sharing subsidy under section 36B of such Code or section 2247 is being claimed, the following information:
I|B|1101.(a)B|2|2238.(b)(3)(A)
Information regarding income and family size The information described in section 6103(l)(21) for the taxable year ending with or within the second calendar year preceding the calendar year in which the plan year begins.
I|B|1101.(a)B|2|2238.(b)(3)(B)
Changes in circumstances The information described in section 2248(b)(2), including information with respect to individuals who were not required to file an income tax return for the taxable year described in subparagraph (A) or individuals who experienced changes in marital status or family size or significant reductions in income.
I|B|1101.(a)B|2|2238.(b)(4)
Employer-sponsored coverage In the case of an enrollee with respect to whom eligibility for a premium credit under section 36B of such Code or cost-sharing subsidy under section 2247, is being established on the basis that the enrollee's (or related individual's) employer is not treated under section 36B(c)(2)(C) of such Code as providing essential benefits coverage or affordable essential benefits coverage, the following information:
I|B|1101.(a)B|2|2238.(b)(4)(A)
The name, address, and employer identification number (if available) of the employer.
I|B|1101.(a)B|2|2238.(b)(4)(B)
Whether the enrollee or individual is a full-time employee and whether the employer provides such essential benefits coverage.
I|B|1101.(a)B|2|2238.(b)(4)(C)
If the employer provides such essential benefits coverage, the lowest cost option for the enrollee's or individual's enrollment status and the enrollee's or individual's required contribution (as defined in section 5000A(e)(2) of such Code) under the employer-sponsored plan.
I|B|1101.(a)B|2|2238.(b)(4)(D)
If an enrollee claims an employer's essential benefits coverage is unaffordable, the information described in paragraph (3).
I|B|1101.(a)B|2|2238.(b)(5)
Exemptions from individual responsibility requirements In the case of an individual who is seeking an exemption certificate under section 2237(f) from any requirement or tax imposed by section 5000A, the following information:
I|B|1101.(a)B|2|2238.(b)(5)(A)
In the case of an individual seeking exemption based on the individual's status as a member of an exempt religious sect or division, as a member of a health care sharing ministry, as an Indian, or as an individual eligible for a hardship exemption, such information as the Secretary shall prescribe.
I|B|1101.(a)B|2|2238.(b)(5)(B)
In the case of an individual seeking exemption based on the lack of affordable coverage or the individual's status as a taxpayer with household income less than 100 percent of the poverty line, the information described in paragraphs (3) and (4), as applicable.
I|B|1101.(a)B|2|2238.(c)
Verification of information contained in records of specific Federal officials
I|B|1101.(a)B|2|2238.(c)(1)
Information transferred to Secretary An exchange shall submit the information provided by an applicant under subsection (b) to the Secretary for verification in accordance with the requirements of this subsection and subsection (d).
I|B|1101.(a)B|2|2238.(c)(2)
Citizenship or immigration status
I|B|1101.(a)B|2|2238.(c)(2)(A)
Commissioner of Social Security The Secretary shall submit to the Commissioner of Social Security the following information for a determination as to whether the information provided is consistent with the information in the records of the Commissioner:
I|B|1101.(a)B|2|2238.(c)(2)(A)(i)
The name, date of birth, and social security number of each individual for whom such information was provided under subsection (b)(2).
I|B|1101.(a)B|2|2238.(c)(2)(A)(ii)
The attestation of an individual that the individual is a citizen.
I|B|1101.(a)B|2|2238.(c)(2)(B)
Secretary of Homeland Security
I|B|1101.(a)B|2|2238.(c)(2)(B)(i)
In general In the case of an individual -
I|B|1101.(a)B|2|2238.(c)(2)(B)(i)(I)
who attests that the individual is an alien lawfully admitted to the United States for permanent residence or an alien lawfully present in the United States; or
I|B|1101.(a)B|2|2238.(c)(2)(B)(i)(II)
who attests that the individual is a citizen but with respect to whom the Commissioner of Social Security has notified the Secretary under subsection (e)(3) that the attestation is inconsistent with information in the records maintained by the Commissioner; the Secretary shall submit to the Secretary of Homeland Security the information described in clause (ii) for a determination as to whether the information provided is consistent with the information in the records of the Secretary of Homeland Security.
I|B|1101.(a)B|2|2238.(c)(2)(B)(ii)
Information The information described in clause (ii) is the following:
I|B|1101.(a)B|2|2238.(c)(2)(B)(ii)(I)
The name, date of birth, and any identifying information with respect to the individual's immigration status provided under subsection (b)(2).
I|B|1101.(a)B|2|2238.(c)(2)(B)(ii)(II)
The attestation that the individual is an alien lawfully admitted to the United States for permanent residence or an alien lawfully present in the United States or in the case of an individual described in clause (i)(II), the attestation that the individual is a citizen.
I|B|1101.(a)B|2|2238.(c)(3)
Eligibility for credit and subsidy The Secretary shall submit the information described in subsection (b)(3)(A) provided under paragraph (3), (4), or (5) of subsection (b) to the Secretary of the Treasury for verification of household income and family size for purposes of eligibility.
I|B|1101.(a)B|2|2238.(c)(4)
Method The Secretary, in consultation with the Secretary of the Treasury, the Secretary of Homeland Security, and the Commissioner of Social Security, shall provide that verifications and determinations under this subsection shall be done -
I|B|1101.(a)B|2|2238.(c)(4)(A)
through use of an on-line system or otherwise for the electronic submission of, and response to, the information submitted under this subsection with respect to an applicant; or
I|B|1101.(a)B|2|2238.(c)(4)(B)
by determining the consistency of the information submitted with the information maintained in the records of the Secretary of the Treasury, the Secretary of Homeland Security, or the Commissioner of Social Security through such other method as is approved by the Secretary.
I|B|1101.(a)B|2|2238.(d)
Verification by Secretary In the case of information provided under subsection (b) that is not subject to verification under subsection (c), the Secretary shall verify the accuracy of such information in such manner as the Secretary determines appropriate, including delegating responsibility for verification to the exchange.
I|B|1101.(a)B|2|2238.(e)
Actions relating to verification
I|B|1101.(a)B|2|2238.(e)(1)
In general Each person to whom the Secretary provided information under subsection (c) shall report to the Secretary under the method established under subsection (c)(4) the results of its verification and the Secretary shall notify the exchange of such results. Each person to whom the Secretary provided information under subsection (d) shall report to the Secretary in such manner as the Secretary determines appropriate.
I|B|1101.(a)B|2|2238.(e)(2)
Verification
I|B|1101.(a)B|2|2238.(e)(2)(A)
Eligibility for enrollment and subsidies If information provided by an applicant under paragraphs (1), (2), (3), and (4) of subsection (b) is verified under subsections (c) and (d) -
I|B|1101.(a)B|2|2238.(e)(2)(A)(i)
the individual's eligibility to enroll through the exchange and to apply for premium credits and cost-sharing subsidies shall be satisfied; and
I|B|1101.(a)B|2|2238.(e)(2)(A)(ii)
the Secretary shall, if applicable, notify the Secretary of the Treasury under section 2248(c) of the amount of any advance payment to be made.
I|B|1101.(a)B|2|2238.(e)(2)(B)
Exemption from individual responsibility If information provided by an applicant under subsection (b)(5) is verified under subsections (c) and (d), the Secretary shall issue the certification of exemption described in section 2236(f).
I|B|1101.(a)B|2|2238.(e)(3)
Inconsistencies If the information provided by an applicant is inconsistent with information in the records maintained by persons under subsection (c) or is not verified under subsection (d), the Secretary shall notify the exchange and the exchange shall take the following actions:
I|B|1101.(a)B|2|2238.(e)(3)(A)
Reasonable effort The exchange shall make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors, by contacting the applicant to confirm the accuracy of the information, and by taking such additional actions as the Secretary, through regulation or other guidance, may identify.
I|B|1101.(a)B|2|2238.(e)(3)(B)
Notice and opportunity to correct In the case the inconsistency or inability to verify is not resolved under subparagraph (A), the exchange shall -
I|B|1101.(a)B|2|2238.(e)(3)(B)(i)
notify the applicant of such fact;
I|B|1101.(a)B|2|2238.(e)(3)(B)(ii)
provide the applicant with a reasonable period from the date on which the notice required under clause (i) is received by the applicant to either present satisfactory documentary evidence or resolve the inconsistency with the person verifying the information under subsection (c).
I|B|1101.(a)B|2|2238.(e)(4)
Specific actions
I|B|1101.(a)B|2|2238.(e)(4)(A)
Citizenship or immigration status If an inconsistency involving citizenship or immigration status with respect to any enrollee is unresolved under this subsection, the exchange shall notify the applicant that the enrollee is not eligible to participate in the exchange.
I|B|1101.(a)B|2|2238.(e)(4)(B)
Eligibility or amount of credit or subsidy If an inconsistency involving the eligibility for, or amount of, any credit or subsidy is unresolved under this subsection, the exchange shall notify the applicant of the amount (if any) of the credit or subsidy.
I|B|1101.(a)B|2|2238.(e)(4)(C)
Employer affordability If the Secretary notifies an exchange that an enrollee is eligible for a premium credit under section 36B of such Code or cost-sharing subsidy under section 2247 because the enrollee's (or related individual's) employer does not provide essential benefits coverage through an employer-sponsored plan or that the employer does provide that coverage but it is not affordable coverage, the exchange shall notify the employer of such fact and that the employer may be liable for the tax imposed by section 4980H with respect to an employee.
I|B|1101.(a)B|2|2238.(e)(4)(D)
Exemption In any case where the inconsistency involving, or inability to verify, information provided under subsection (b)(5) is not resolved, the exchange shall notify an applicant that no certification of exemption from any requirement or tax under section 5000A will be issued.
I|B|1101.(a)B|2|2238.(e)(4)(E)
Appeals process The exchange shall also notify each person receiving notice under this paragraph of the appeals processes established under subsection (f).
I|B|1101.(a)B|2|2238.(f)
Appeals and redeterminations
I|B|1101.(a)B|2|2238.(f)(1)
In general The Secretary, in consultation with the Secretary of the Treasury, the Secretary of Homeland Security, and the Commissioner of Social Security, shall establish procedures by which the Secretary or one of such other Federal officers -
I|B|1101.(a)B|2|2238.(f)(1)(A)
hears and makes decisions with respect to appeals of any determination under subsection (c); and
I|B|1101.(a)B|2|2238.(f)(1)(B)
redetermines eligibility on a periodic basis in appropriate circumstances.
I|B|1101.(a)B|2|2238.(f)(2)
Employer liability The Secretary shall establish a separate appeals process for employers who are notified under subsection (e)(4)(C) that the employer may be liable for the tax imposed by section 4980H with respect to an employee because of a determination that the employer does not provide essential benefits coverage through an employer-sponsored plan or that the employer does provide that coverage but it is not affordable coverage with respect to an employee. Such process shall provide an employer the opportunity to -
I|B|1101.(a)B|2|2238.(f)(2)(A)
present information to the exchange for review of the determination either by the exchange or the person making the determination, including evidence of the employer-sponsored plan and employer contributions to the plan; and
I|B|1101.(a)B|2|2238.(f)(2)(B)
have access to the data used to make the determination to the extent allowable by law. Such process shall be in addition to any rights of appeal the employer may have under subtitle F of the Internal Revenue Code of 1986.
I|B|1101.(a)B|2|2238.(g)
Confidentiality of applicant information Any person who receives information provided by an applicant under subsection (b), or receives information from a Federal agency under subsection (c), (d), or (e) shall -
I|B|1101.(a)B|2|2238.(g)(1)
use the information only for the purposes of, and to the extent necessary in, ensuring the efficient operation of the exchange, including verifying the eligibility of an individual to enroll through an exchange or to claim a premium credit or cost-sharing subsidy or the amount of the credit or subsidy; and
I|B|1101.(a)B|2|2238.(g)(2)
not disclose the information to any other person except as provided in this section.
I|B|1101.(a)B|2|2238.(h)
Penalties
I|B|1101.(a)B|2|2238.(h)(1)
False or fraudulent information
I|B|1101.(a)B|2|2238.(h)(1)(A)
Civil penalty If -
I|B|1101.(a)B|2|2238.(h)(1)(A)(i)
any person fails to provides correct information under subsection (b); and
I|B|1101.(a)B|2|2238.(h)(1)(A)(ii)
such failure is attributable to negligence or disregard of any rules or regulations of the Secretary, such person shall be subject, in addition to any other penalties that may be prescribed by law, to a civil penalty of not more than $25,000 with respect to any failures involving an application for a plan year. For purposes of this subparagraph, the terms negligence and disregard shall have the same meanings as when used in section 6662 of the Internal Revenue Code of 1986.
I|B|1101.(a)B|2|2238.(h)(1)(B)
Criminal penalty Any person who knowingly and willfully provides false or fraudulent information under subsection (b) shall be guilty of a felony, and upon conviction thereof, shall be fined not more than $250,000, imprisoned for not more than 5 years, or both.
I|B|1101.(a)B|2|2238.(h)(2)
Improper use or disclosure of information Any person who knowingly and willfully uses or discloses information in violation of subsection (g) shall be guilty of a felony, and upon conviction thereof, shall be fined not more than $25,000, imprisoned for not more than 5 years, or both.
I|B|1101.(a)B|2|2239.
Streamlining of procedures for enrollment through an exchange and State Medicaid, CHIP, and health subsidy programs
I|B|1101.(a)B|2|2239.(a)
In general The Secretary shall establish a system meeting the requirements of this section under which residents of each State may apply for enrollment in, receive a determination of eligibility for participation in, and continue participation in, applicable State health subsidy programs.
I|B|1101.(a)B|2|2239.(b)
Requirements relating to forms and notice
I|B|1101.(a)B|2|2239.(b)(1)
Requirements relating to forms
I|B|1101.(a)B|2|2239.(b)(1)(A)
In general The Secretary shall develop and provide to each State a single, streamlined form that -
I|B|1101.(a)B|2|2239.(b)(1)(A)(i)
may be used to apply for all applicable State health subsidy programs within the State;
I|B|1101.(a)B|2|2239.(b)(1)(A)(ii)
may be filed online, in person, by mail, or by telephone;
I|B|1101.(a)B|2|2239.(b)(1)(A)(iii)
may be filed with an exchange or with State officials operating one of the other applicable State health subsidy programs; and
I|B|1101.(a)B|2|2239.(b)(1)(A)(iv)
is structured to maximize an applicant's ability to complete the form satisfactorily, taking into account the characteristics of individuals who qualify for applicable State health subsidy programs.
I|B|1101.(a)B|2|2239.(b)(1)(B)
State authority to establish form A State may develop and use its own single, streamlined form as an alternative to the form developed under subparagraph (A) if the alternative form is consistent with standards promulgated by the Secretary under this section.
I|B|1101.(a)B|2|2239.(b)(1)(C)
Supplemental eligibility forms The Secretary may allow a State to use a supplemental or alternative form in the case of individuals who apply for eligibility that is not determined on the basis of the household income (as defined in section 36B of the Internal Revenue Code of 1986).
I|B|1101.(a)B|2|2239.(b)(2)
Notice The Secretary shall provide that an applicant filing a form under paragraph (1) shall receive notice of eligibility for an applicable State health subsidy program without any need to provide additional information or paperwork unless such information or paperwork is specifically required by law when information provided on the form is inconsistent with data used for the electronic verification under paragraph (3) or is otherwise insufficient to determine eligibility.
I|B|1101.(a)B|2|2239.(c)
Requirements relating to eligibility based on data exchanges
I|B|1101.(a)B|2|2239.(c)(1)
Development of secure interfaces Each State shall develop for all applicable State health subsidy programs a secure, electronic interface allowing an exchange of data (including information contained in the application forms described in subsection (b)) that allows a determination of eligibility for all such programs based on a single application. Such interface shall be compatible with the exchange method established for data verification under section 2238(c)(4).
I|B|1101.(a)B|2|2239.(c)(2)
Data matching program Each applicable State health subsidy program shall participate in a data matching arrangement for determining eligibility for participation in the program under paragraph (3) that -
I|B|1101.(a)B|2|2239.(c)(2)(A)
provides access to data described in paragraph (3);
I|B|1101.(a)B|2|2239.(c)(2)(B)
applies only to individuals who -
I|B|1101.(a)B|2|2239.(c)(2)(B)(i)
receive assistance from an applicable State health subsidy program; or
I|B|1101.(a)B|2|2239.(c)(2)(B)(ii)
apply for such assistance -
I|B|1101.(a)B|2|2239.(c)(2)(B)(ii)(I)
by filing a form described in subsection (b); or
I|B|1101.(a)B|2|2239.(c)(2)(B)(ii)(II)
by requesting a determination of eligibility and authorizing disclosure of the information described in paragraph (3) to applicable State health coverage subsidy programs for purposes of determining and establishing eligibility; and
I|B|1101.(a)B|2|2239.(c)(2)(C)
consistent with standards promulgated by the Secretary, including the privacy and data security safeguards described in section 1946 or that are otherwise applicable to such programs.
I|B|1101.(a)B|2|2239.(c)(3)
Determination of eligibility
I|B|1101.(a)B|2|2239.(c)(3)(A)
In general Each applicable State health subsidy program shall, to the maximum extent practicable -
I|B|1101.(a)B|2|2239.(c)(3)(A)(i)
establish, verify, and update eligibility for participation in the program using the data matching arrangement under paragraph (2); and
I|B|1101.(a)B|2|2239.(c)(3)(A)(ii)
determine such eligibility on the basis of reliable, third party data, including information described in sections 1137, 453(i), and 1942(a), obtained through such arrangement.
I|B|1101.(a)B|2|2239.(c)(3)(B)
Exception This paragraph shall not apply in circumstances with respect to which the Secretary determines that the administrative and other costs of use of the data matching arrangement under paragraph (2) outweigh its expected gains in accuracy, efficiency, and program participation.
I|B|1101.(a)B|2|2239.(c)(4)
Secretarial standards The Secretary shall, after consultation with persons in possession of the data to be matched and representatives of applicable State health subsidy programs, promulgate standards governing the timing, contents, and procedures for data matching described in this subsection. Such standards shall take into account administrative and other costs and the value of data matching to the establishment, verification, and updating of eligibility for applicable State health subsidy programs.
I|B|1101.(a)B|2|2239.(d)
Administrative authority
I|B|1101.(a)B|2|2239.(d)(1)
Agreements Subject to section 2238 and section 6103(l)(21) of the Internal Revenue Code of 1986 and any other requirement providing safeguards of privacy and data integrity, the Secretary may establish model agreements, and enter into agreements, for the sharing of data under this section.
I|B|1101.(a)B|2|2239.(d)(2)
Authority of exchange to contract out Nothing in this section shall be construed to -
I|B|1101.(a)B|2|2239.(d)(2)(A)
prohibit contractual arrangements through which a State medicaid agency determines eligibility for all applicable State health subsidy programs, but only if such agency complies with the Secretary's requirements ensuring reduced administrative costs, eligibility errors, and disruptions in coverage; or
I|B|1101.(a)B|2|2239.(d)(2)(B)
change any requirement under title XIX that eligibility for participation in a State's medicaid program must be determined by a public agency.
I|B|1101.(a)B|2|2239.(e)
Applicable State health subsidy program In this section, the term applicable State health subsidy program means -
I|B|1101.(a)B|2|2239.(e)(1)
the program under this title for the enrollment in qualified health benefits plans offered through an exchange, including the premium credits under section 36B of the Internal Revenue Code of 1986 and cost-sharing subsidies under section 2237;
I|B|1101.(a)B|2|2239.(e)(2)
a State medicaid program under title XIX;
I|B|1101.(a)B|2|2239.(e)(3)
a State children's health insurance program (CHIP) under title XXI; and
I|B|1101.(a)B|2|2239.(e)(4)
a State program under section 2228 establishing qualified basic health plans.
.
I|B|1101.(b)
Study of administration of employer responsibility
I|B|1101.(b)(1)
In general The Secretary of Health and Human Services shall, in consultation with the Secretary of the Treasury, conduct a study of the procedures that are necessary to ensure that in the administration of part B of subtitle A of title XXII of the Social Security Act (as added by this section) and section 4980H of the Internal Revenue Code of 1986 (as added by section 1306) that the following rights are protected:
I|B|1101.(b)(1)(A)
The rights of employees to preserve their right to confidentiality of their taxpayer return information and their right to enroll in a qualified basic health benefits plan through an exchange if an employer does not provide affordable coverage.
I|B|1101.(b)(1)(B)
The rights of employers to adequate due process and access to information necessary to accurately determine any tax imposed on employers.
I|B|1101.(b)(2)
Report Not later than July 1, 2012, the Secretary of Health and Human Services shall report the results of the study conducted under paragraph (1), including any recommendations for legislative changes, to the Committees on Finance and Health, Education, Labor and Pensions of the Senate and the Committees of Education and Labor and Ways and Means of the House of Representatives.
I|B|1102.
Encouraging meaningful use of electronic health records
I|B|1102.(a)
Study The Secretary of Health and Human Services shall conduct a study of methods that can be employed by qualified health benefits plans offered through an exchange to encourage increased meaningful use of electronic health records by health care providers, including -
I|B|1102.(a)(1)
payment systems established by qualified health benefit plans that provide higher rates of reimbursement for health care providers that engage in meaningful use of electronic health records; and
I|B|1102.(a)(2)
promotion of low-cost electronic health record software packages that are available for use by health care providers, including software packages that are available to health care providers through the Veterans Administration.
I|B|1102.(b)
Report
I|B|1102.(b)(1)
In General Not later than 24 months after the date of 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, including recommendations regarding the feasibility and effectiveness of payment systems established by qualified health benefit plans offered through an exchange to provide for higher rates of reimbursement for health care providers that engage in meaningful use of electronic health records.
I|B|1102.(b)(2)
Dissemination to exchanges Not later than 12 month after submitting the report under paragraph (1), the Secretary shall provide such report to any regional exchange or exchange established within a State.
I|C
Making coverage affordable
I|C|I
Essential benefits coverage
I|C|I|1201.
Provisions to ensure coverage of essential benefits Title XXII of the Social Security Act (as added by section 1001 and amended by section 1101) is amended by adding at the end the following:
I|C|I|1201.C
Making coverage affordable
I|C|I|1201.C|1
Essential benefits coverage
I|C|I|1201.C|1|2241.
Requirements for qualified health benefits plan A health benefits plan shall be treated as a qualified health benefits plan for purposes of this title only if -
I|C|I|1201.C|1|2241.(1)
the plan provides an essential benefits package described in section 2242;
I|C|I|1201.C|1|2241.(2)
subject to section 2243(c), the plan provides either the bronze, silver, gold, or platinum level of coverage described in section 2243; and
I|C|I|1201.C|1|2241.(3)
the offeror of the plan charges the same premium rate for the plan without regard to whether the plan is purchased through an exchange or whether the plan is purchased directly from the offeror or through an agent.
I|C|I|1201.C|1|2242.
Essential benefits package defined
I|C|I|1201.C|1|2242.(a)
In general In this division, the term essential benefits package means, with respect to any health benefits plan, coverage that -
I|C|I|1201.C|1|2242.(a)(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;
I|C|I|1201.C|1|2242.(a)(2)
limits cost-sharing for such covered health care items and services in accordance with subsection (c);
I|C|I|1201.C|1|2242.(a)(3)
meets the requirements with respect to specific items and services described in subsection (d); and
I|C|I|1201.C|1|2242.(a)(4)
does not impose any annual or lifetime limit on the coverage of such covered health care items and services.
I|C|I|1201.C|1|2242.(b)
Minimum services to be covered Subject to subsection (e), the items and services described in this subsection are the following:
I|C|I|1201.C|1|2242.(b)(1)
Hospitalization.
I|C|I|1201.C|1|2242.(b)(2)
Outpatient hospital and outpatient clinic services, including emergency department services.
I|C|I|1201.C|1|2242.(b)(3)
Professional services of physicians and other health professionals.
I|C|I|1201.C|1|2242.(b)(4)
Medical and surgical care.
I|C|I|1201.C|1|2242.(b)(5)
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.
I|C|I|1201.C|1|2242.(b)(6)
Prescription drugs.
I|C|I|1201.C|1|2242.(b)(7)
Rehabilitative and habilitative services.
I|C|I|1201.C|1|2242.(b)(8)
Mental health and substance use disorder services, including behavioral health treatment.
I|C|I|1201.C|1|2242.(b)(9)
Preventive services, including those services recommended with a grade of A or B by the United States Preventive Services Task Force and those vaccines recommended for use 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).
I|C|I|1201.C|1|2242.(b)(10)
Maternity benefits.
I|C|I|1201.C|1|2242.(b)(11)
Well baby and well child care and oral health, vision, and hearing services, equipment, and supplies for children under 21 years of age.
I|C|I|1201.C|1|2242.(c)
Requirements relating to cost-sharing
I|C|I|1201.C|1|2242.(c)(1)
No cost-sharing for preventive services There shall be no cost-sharing under an essential benefits package for preventive items and services described in subsection (b)(9).
I|C|I|1201.C|1|2242.(c)(2)
Annual limitation on cost-sharing
I|C|I|1201.C|1|2242.(c)(2)(A)
2013 The cost-sharing incurred under an essential benefits package with respect to self-only coverage or coverage other than self-only coverage for a plan year beginning in 2013 shall not exceed the dollar amounts in effect under section 223(c)(2)(A) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively, for taxable years beginning in 2013.
I|C|I|1201.C|1|2242.(c)(2)(B)
2014 and later In the case of any plan year beginning in a calendar year after 2013, the limitation under this paragraph shall -
I|C|I|1201.C|1|2242.(c)(2)(B)(i)
in the case of self-only coverage, be equal to the dollar amount under subparagraph (A) for self-only coverage, increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph (7) for the calendar year; and
I|C|I|1201.C|1|2242.(c)(2)(B)(ii)
in the case of other coverage, twice the amount in effect under clause (i). If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50.
I|C|I|1201.C|1|2242.(c)(3)
Annual limitation on deductibles for employer-sponsored plans
I|C|I|1201.C|1|2242.(c)(3)(A)
In general In the case of a health benefits plan offered in the small group market, the deductible under an essential benefits package shall not exceed -
I|C|I|1201.C|1|2242.(c)(3)(A)(i)
$2,000 in the case of a plan covering a single individual; and
I|C|I|1201.C|1|2242.(c)(3)(A)(ii)
$4,000 in the case of any other plan. The amounts under clauses (i) and (ii) may be increased by the maximum amount of reimbursement which is reasonably available to a participant under a flexible spending arrangement described in section 106(c)(2) of the Internal Revenue Code of 1986 (determined without regard to any salary reduction arrangement).
I|C|I|1201.C|1|2242.(c)(3)(B)
Indexing of limits In the case of any plan year beginning in a calendar year after 2013 -
I|C|I|1201.C|1|2242.(c)(3)(B)(i)
the dollar amount under subparagraph (A)(i) shall be increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph (7) for the calendar year; and
I|C|I|1201.C|1|2242.(c)(3)(B)(ii)
the dollar amount under subparagraph (A)(ii) shall be increased to an amount equal to twice the amount in effect under subparagraph (A)(i) for plan years beginning in the calendar year, determined after application of clause (i). If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50.
I|C|I|1201.C|1|2242.(c)(3)(C)
Limitations
I|C|I|1201.C|1|2242.(c)(3)(C)(i)
Actuarial value The limitation under this paragraph shall be applied in such a manner so as to not affect the actuarial value of any qualified health benefits plan, including a plan in the bronze level.
I|C|I|1201.C|1|2242.(c)(3)(C)(ii)
Catastrophic plan This paragraph shall not apply to a catastrophic plan described in section 2243(c).
I|C|I|1201.C|1|2242.(c)(4)
Parity within categories In the case of items and services described in paragraphs (1), (2), (3), and (5) of subsection (b), the cost-sharing incurred under an essential benefits package shall be the same for treatment of conditions within each such category of covered services.
I|C|I|1201.C|1|2242.(c)(5)
Special rule for value-based design
I|C|I|1201.C|1|2242.(c)(5)(A)
In general Paragraphs (1) and (4) shall not apply in the case of a health benefits plan for which a value-based design is used.
I|C|I|1201.C|1|2242.(c)(5)(B)
Value-based design For purposes of subparagraph (A), a value-based design is a methodology under which -
I|C|I|1201.C|1|2242.(c)(5)(B)(i)
clinically beneficial preventive screenings, lifestyle interventions, medications, immunizations, diagnostic tests and procedures, and treatments are identified; and
I|C|I|1201.C|1|2242.(c)(5)(B)(ii)
cost-sharing for items and services described in clause (i) is reduced or eliminated to reflect the high value and effectiveness of the items and services.
I|C|I|1201.C|1|2242.(c)(6)
Cost-sharing In this title, 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.
I|C|I|1201.C|1|2242.(c)(7)
Premium adjustment percentage For purposes of paragraphs (2)(B)(i) and (3)(B)(i), the premium adjustment percentage for any calendar year is the percentage (if any) by which the average per capita premium for health insurance coverage in the United States for the preceding calendar year (as estimated by the Secretary no later than October 1 of such preceding calendar year) exceeds such average per capita premium for 2012 (as determined by the Secretary).
I|C|I|1201.C|1|2242.(d)
Specific items and services
I|C|I|1201.C|1|2242.(d)(1)
Prescription drugs An essential benefits package shall at least meet the class and coverage requirements of part D of title XVIII of this Act with respect to prescription drugs.
I|C|I|1201.C|1|2242.(d)(2)
Mental health and substance use disorder services An essential benefits package shall at least meet the minimum standards required by Federal or State law for coverage of mental health and substance use disorder services, including ensuring that any financial requirements and treatment limitations applicable to such services comply with the requirements of section 9812(a) of the Internal Revenue Code of 1986 in the same manner as such requirements apply to a group health plan.
I|C|I|1201.C|1|2242.(d)(3)
Tobacco cessation programs If a health benefits plan varies its premium on the basis of tobacco use, an essential benefits package shall include coverage for tobacco cessation programs, including counseling and pharmacotherapy (involving either prescription or nonprescription drugs).
I|C|I|1201.C|1|2242.(d)(4)
Other items and services An essential benefits package shall include coverage of day surgery and related anaesthesia, diagnostic images and screening (including x-rays), and radiation and chemotherapy.
I|C|I|1201.C|1|2242.(d)(5)
Pediatric dental benefits If a health benefits plan described in section 2231(c)(2) (relating to stand-alone dental benefits plans) is offered through an exchange, another health benefits plan offered through such exchange shall not fail to be treated as a qualified health benefits plan solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required under subsection (b)(11).
I|C|I|1201.C|1|2242.(d)(6)
Special rules for emergency department services A health benefits plan shall not be treated as meeting the requirements of subsection (b)(2) to provide coverage for emergency department services unless the plan provides that -
I|C|I|1201.C|1|2242.(d)(6)(A)
coverage for such services will be provided without regard to any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services; and
I|C|I|1201.C|1|2242.(d)(6)(B)
if such services are provided out-of-network, any cost-sharing required by the plan does not exceed the cost-sharing that would be required if such services were provided in-network.
I|C|I|1201.C|1|2242.(e)
Specification and annual update
I|C|I|1201.C|1|2242.(e)(1)
In general Not later than July 1, 2012, the Secretary shall -
I|C|I|1201.C|1|2242.(e)(1)(A)
define the benefit categories established under subsection (b) for qualified health benefits plans offered in the individual market within a State; and
I|C|I|1201.C|1|2242.(e)(1)(B)
specify the covered treatments, items, and services within each of such categories. The Secretary shall establish such benefits coverage on the basis of the most recent medical evidence and information with respect to scientific advancement.
I|C|I|1201.C|1|2242.(e)(2)
Annual updates The Secretary shall annually update the benefits coverage determined under paragraph (1). The Secretary may address any gaps in access to coverage or changes in the evidence base by modifying or adding any category of benefits and covered treatments, items, and services.
I|C|I|1201.C|1|2242.(e)(3)
Limitation The Secretary shall ensure that the scope of the benefits coverage under this subsection is not more extensive than the scope of the benefits provided under a typical employer plan, as determined by the Secretary and certified by the Chief Actuary of the Centers for Medicare & Medicaid Services.
I|C|I|1201.C|1|2242.(e)(4)
Flexibility in plan design The Secretary shall allow flexibility in plan design to the extent such flexibility does not result in adverse selection.
I|C|I|1201.C|1|2242.(f)
Exchange requirement Each State shall ensure that at least 1 plan offered in each exchange established in the State shall offer qualified health benefits plans that are at least actuarially equivalent to the standard option Blue Cross Blue Shield plan offered under the Federal Employees Health Benefits Program chapter 89 of title 5, United States Code.
I|C|I|1201.C|1|2242.(g)
Payments to Federally-qualified health centers If any item or service covered by a qualified health benefits plan is provided by a Federally-qualified health center (as defined in section 1905(l)(2)(B)) to an enrollee of the plan, the offeror of the plan shall pay to the center for the item or service an amount that is not less than the amount of payment that would have been paid to the center under section 1902(bb) for such item or service.
I|C|I|1201.C|1|2243.
Levels of coverage
I|C|I|1201.C|1|2243.(a)
In general Except as provided in subsections (c) and (d), a health benefits plan shall provide a bronze, silver, gold, or platinum level of coverage.
I|C|I|1201.C|1|2243.(b)
Levels of coverage defined In this title, a health benefits plan providing an essential benefits package shall be assigned to 1 of the following levels of coverage:
I|C|I|1201.C|1|2243.(b)(1)
Bronze level A plan in the bronze level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 65 percent of the full actuarial value of the benefits provided under the essential benefits package.
I|C|I|1201.C|1|2243.(b)(2)
Silver level A plan in the silver level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 70 percent of the full actuarial value of the benefits provided under the essential benefits package.
I|C|I|1201.C|1|2243.(b)(3)
Gold level A plan in the gold level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 80 percent of the full actuarial value of the benefits provided under the essential benefits package.
I|C|I|1201.C|1|2243.(b)(4)
Platinum level A plan in the platinum level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 90 percent of the full actuarial value of the benefits provided under the essential benefits package.
I|C|I|1201.C|1|2243.(c)
Catastrophic plan for young individuals
I|C|I|1201.C|1|2243.(c)(1)
In general A health benefits plan not providing a bronze, silver, gold, or platinum level of coverage shall be treated as meeting the requirements of this section with respect to any plan year if -
I|C|I|1201.C|1|2243.(c)(1)(A)
except as provided in paragraph (3), the only individuals who are eligible to enroll in the plan are individuals who have not attained the age of 26 before the beginning of the plan year; and
I|C|I|1201.C|1|2243.(c)(1)(B)
the plan provides an essential benefits package meeting the requirements of section 2242, except that, subject to paragraph (2), the plan provides no benefits for any plan year until the individual has incurred cost-sharing expenses in an amount equal to the annual limitation in effect under section 2242(c)(2) for the plan year.
I|C|I|1201.C|1|2243.(c)(2)
Preventive services A health benefits plan shall not be treated as described in paragraph (1) unless the plan requires no cost-sharing with respect to preventive services described in section 2242(b)(9).
I|C|I|1201.C|1|2243.(c)(3)
Individuals without affordable coverage If an individual has a certification in effect for any plan year under section 2236(f) that the individual is exempt from the requirement under section 5000A of the Internal Revenue Code of 1986 by reason of section 5000A(e)(2), such individual shall be eligible to enroll for the plan year in a plan described in paragraph (1).
I|C|I|1201.C|1|2243.(d)
Child-only plans If an offeror offers a qualified health benefits plan in any level of coverage specified under this section, the offeror may also offer that plan in that level as a plan in which the only enrollees are individuals who, as of the beginning of a plan year -
I|C|I|1201.C|1|2243.(d)(1)
have not attained the age of 21; or
I|C|I|1201.C|1|2243.(d)(2)
have attained the age of 21 but are the dependent of another person.
I|C|I|1201.C|1|2243.(e)
Allowable variance A State may allow a de minimus variation in the actuarial valuations used in determining the level of coverage of a plan to account for differences in actuarial estimates.
I|C|I|1201.C|1|2243.(f)
Plan reference In this title, any reference to a bronze, silver, gold, or platinum plan shall be treated as a reference to a health benefits plan providing a bronze, silver, gold, or platinum level of coverage, as the case may be.
I|C|I|1201.C|1|2244.
Application of certain rules to plans in group markets
I|C|I|1201.C|1|2244.(a)
Annual and lifetime limits In the case of a health benefits plan offered in the large or small group market in a State, the State shall prohibit the plan for plan years beginning after 2009 from imposing unreasonable annual or lifetime limits (within the meaning of section 223 of the Internal Revenue Code of 1986) on enrollees in the plan. This subsection shall not apply to a grandfathered health benefits plan or to a qualified health benefits plan in the small group market.
I|C|I|1201.C|1|2244.(b)
Additional large group requirements In the case of a health benefits plan offered in the large group market in a State, the State shall require such plan for plan years beginning after June 30, 2013 -
I|C|I|1201.C|1|2244.(b)(1)
to meet the requirements of section 2243(c)(2) (relating to annual limits on cost-sharing); and
I|C|I|1201.C|1|2244.(b)(2)
to provide preventive items and services described in section 2243(b)(9) and except as provided in section 2243(c)(5), to require no cost-sharing for such items and services.
I|C|I|1201.C|1|2244.(c)
Auto enrollment Each State shall require any large employer that has more than 200 employees and that offers employees enrollment in 1 or more health benefits plans to automatically enroll new full-time employees in one of the plans and to continue the enrollment of current employees in a health benefits plan offered through the employer. Any automatic enrollment program shall include adequate notice and the opportunity for an employee to opt out of any coverage the individual was automatically enrolled in.
I|C|I|1201.C|1|2245.
Special rules relating to coverage of abortion services
I|C|I|1201.C|1|2245.(a)
Voluntary choice of coverage of abortion services
I|C|I|1201.C|1|2245.(a)(1)
In general Notwithstanding any other provision of this subpart and subject to paragraph (3) -
I|C|I|1201.C|1|2245.(a)(1)(A)
nothing in this subpart shall be construed to require a health benefits plan to provide coverage of services described in paragraph (2)(A) or (2)(B) as part of its essential benefits package for any plan year; and
I|C|I|1201.C|1|2245.(a)(1)(B)
the offeror of a health benefits plan shall determine whether or not the plan provides coverage of services described in paragraph (2)(A) or (2)(B) as part of such package for the plan year.
I|C|I|1201.C|1|2245.(a)(2)
Abortion services
I|C|I|1201.C|1|2245.(a)(2)(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.
I|C|I|1201.C|1|2245.(a)(2)(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.
I|C|I|1201.C|1|2245.(a)(3)
Assured availability of varied coverage through exchanges
I|C|I|1201.C|1|2245.(a)(3)(A)
In general The Secretary shall assure that with respect to qualified health benefits plans offered in any exchange established pursuant to this title -
I|C|I|1201.C|1|2245.(a)(3)(A)(i)
there is at least one such plan that provides coverage of services described in subparagraphs (A) and (B) of paragraph (2); and
I|C|I|1201.C|1|2245.(a)(3)(A)(ii)
there is at least one such plan that does not provide coverage of services described in paragraph (2)(A).
I|C|I|1201.C|1|2245.(a)(3)(B)
Special rules For purposes of subparagraph (A) -
I|C|I|1201.C|1|2245.(a)(3)(B)(i)
a plan shall be treated as described in subparagraph (A)(ii) if the plan does not provide coverage of services described in either paragraph (2)(A) or (2)(B); and
I|C|I|1201.C|1|2245.(a)(3)(B)(ii)
if a State has one exchange covering both the individual and small group markets, the Secretary shall meet the requirements of subparagraph (A) separately with respect to each such market.
I|C|I|1201.C|1|2245.(b)
Prohibition of use of Federal funds
I|C|I|1201.C|1|2245.(b)(1)
In general If a qualified health benefits plan provides coverage of services described in subsection (a)(2)(A), the offeror of the plan shall not use any amount attributable to any of the following for purposes of paying for such services:
I|C|I|1201.C|1|2245.(b)(1)(A)
The credit under section 36B(b) of the Internal Revenue Code of 1986 (and the amount of the advance payment of the credit under section 2248 of the Social Security Act).
I|C|I|1201.C|1|2245.(b)(1)(B)
Any cost-sharing subsidy under section 2247.
I|C|I|1201.C|1|2245.(b)(2)
Segregation of funds In the case of a plan to which paragraph (1) applies, the offeror of the plan shall, out of amounts not described in paragraph (1), segregate an amount equal to the actuarial amounts determined under paragraph (3) for all enrollees from the amounts described in paragraph (1).
I|C|I|1201.C|1|2245.(b)(3)
Actuarial value of optional service coverage
I|C|I|1201.C|1|2245.(b)(3)(A)
In general The Secretary shall estimate the basic per enrollee, per month cost, determined on an average actuarial basis, for including coverage under a qualified health benefits plan of the services described in subsection (a)(2)(A).
I|C|I|1201.C|1|2245.(b)(3)(B)
Considerations In making such estimate, the Secretary -
I|C|I|1201.C|1|2245.(b)(3)(B)(i)
may take into account the impact on overall costs of the inclusion of such coverage, but may not take into account any cost reduction estimated to result from such services, including prenatal care, delivery, or postnatal care;
I|C|I|1201.C|1|2245.(b)(3)(B)(ii)
shall estimate such costs as if such coverage were included for the entire population covered; and
I|C|I|1201.C|1|2245.(b)(3)(B)(iii)
may not estimate such a cost at less than $1 per enrollee, per month.
I|C|I|1201.C|1|2245.(c)
No discrimination on the basis of provision of abortion A qualified health benefits plan may not 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.
.
I|C|I|1202.
Application of State and Federal laws regarding abortion
I|C|I|1202.(a)
No preemption of State laws regarding abortion Nothing in this Act shall be construed to preempt or otherwise have any effect on State laws regarding the prohibition of (or requirement of) coverage, funding, or procedural requirements on abortions, including parental notification or consent for the performance of an abortion on a minor.
I|C|I|1202.(b)
No effect on Federal laws regarding abortion
I|C|I|1202.(b)(1)
In general Nothing in this Act shall be construed to have any effect on Federal laws regarding -
I|C|I|1202.(b)(1)(A)
conscience protection;
I|C|I|1202.(b)(1)(B)
willingness or refusal to provide abortion; and
I|C|I|1202.(b)(1)(C)
discrimination on the basis of the willingness or refusal to provide, pay for, cover, or refer for abortion or to provide or participate in training to provide abortion.
I|C|I|1202.(c)
No effect on Federal civil rights law Nothing in this section shall alter the rights and obligations of employees and employers under title VII of the Civil Rights Act of 1964.
I|C|I|1203.
Application of emergency services laws Nothing in this Act shall be construed to relieve any health care provider from providing emergency services as required by State or Federal law, including section 1867 of the Social Security Act (popularly known as EMTALA ).
I|C|II
Premium credits, cost-sharing subsidies, and small business credits
I|C|II|A
Premium credits and cost-sharing subsidies
I|C|II|A|1205.
Refundable credit providing premium assistance for coverage under a qualified health benefits plan
I|C|II|A|1205.(a)
In general Subpart C of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 (relating to refundable credits) is amended by inserting after section 36A the following new section:
I|C|II|A|1205.(a)36B.
Refundable credit for coverage under a qualified health benefits plan
I|C|II|A|1205.(a)36B.(a)
In general In the case of an applicable taxpayer, there shall be allowed as a credit against the tax imposed by this subtitle for any taxable year an amount equal to the premium assistance credit amount of the taxpayer for the taxable year.
I|C|II|A|1205.(a)36B.(b)
Premium assistance credit amount For purposes of this section -
I|C|II|A|1205.(a)36B.(b)(1)
In general The term premium assistance credit amount means, with respect to any taxable year, the sum of the premium assistance amounts determined under paragraph (2) with respect to all coverage months of the taxpayer occurring during the taxable year.
I|C|II|A|1205.(a)36B.(b)(2)
Premium assistance amount The premium assistance amount determined under this subsection with respect to any coverage month is the amount equal to the excess (if any) of -
I|C|II|A|1205.(a)36B.(b)(2)(A)
the lesser of -
I|C|II|A|1205.(a)36B.(b)(2)(A)(i)
the monthly premiums for such month for 1 or more qualified health benefits plans offered in the individual market within a State which cover the taxpayer, the taxpayer's spouse, or any dependent (as defined in section 152) of the taxpayer and which were enrolled in through an exchange established by the State under subpart B of title XXII of the Social Security Act, or
I|C|II|A|1205.(a)36B.(b)(2)(A)(ii)
the adjusted monthly premium for such month for the applicable second lowest cost silver plan with respect to the taxpayer, over
I|C|II|A|1205.(a)36B.(b)(2)(B)
an amount equal to 1/12 of the product of the applicable percentage and the taxpayer's household income for the taxable year.
I|C|II|A|1205.(a)36B.(b)(3)
Other terms and rules relating to premium assistance amounts For purposes of paragraph (2) -
I|C|II|A|1205.(a)36B.(b)(3)(A)
Applicable percentage
I|C|II|A|1205.(a)36B.(b)(3)(A)(i)
In general The applicable percentage with respect to any taxpayer for any taxable year is equal to 2 percent, increased by the number of percentage points (not greater than 10) which bears the same ratio to 10 percentage points as -
I|C|II|A|1205.(a)36B.(b)(3)(A)(i)(I)
the taxpayer's household income for the taxable year in excess of 100 percent of the poverty line for a family of the size involved, bears to
I|C|II|A|1205.(a)36B.(b)(3)(A)(i)(II)
an amount equal to 200 percent of the poverty line for a family of the size involved.
I|C|II|A|1205.(a)36B.(b)(3)(A)(ii)
Indexing In the case of taxable years beginning in any calendar year after 2013, the Secretary shall adjust the initial and final applicable percentages for the calendar year to reflect the excess of the rate of premium growth between the preceding calendar year and 2012 over the rate of income growth for such period.
I|C|II|A|1205.(a)36B.(b)(3)(B)
Applicable second lowest cost silver plan The applicable second lowest cost silver plan with respect to any applicable taxpayer is the second lowest cost silver plan in the individual market which -
I|C|II|A|1205.(a)36B.(b)(3)(B)(i)
is offered through the same exchange through which the qualified health benefits plans taken into account under paragraph (2)(A)(i) were offered, and
I|C|II|A|1205.(a)36B.(b)(3)(B)(ii)
in the case of -
I|C|II|A|1205.(a)36B.(b)(3)(B)(ii)(I)
an applicable taxpayer whose tax for the taxable year is determined under section 1(c) (relating to unmarried individuals other than surviving spouses and heads of households), provides self-only coverage, and
I|C|II|A|1205.(a)36B.(b)(3)(B)(ii)(II)
any other applicable taxpayer, provides family coverage.
If a taxpayer files a joint return and no credit is allowed under this section with respect to 1 of the spouses by reason of subsection (e), the taxpayer shall be treated as described in clause (ii)(I) unless a deduction is allowed under section 151 for the taxable year with respect to a dependent other than either spouse.
I|C|II|A|1205.(a)36B.(b)(3)(C)
Adjusted monthly premium The adjusted monthly premium for an applicable second lowest cost silver plan is the monthly premium which would have been charged for the plan if each individual covered under a qualified health benefits plan taken into account under paragraph (2)(A)(i) were covered by the plan and the premium was adjusted only for the age of each such individual in the manner allowed under section 2204 of the Social Security Act.
I|C|II|A|1205.(a)36B.(b)(4)
Reduction to eliminate Federal budget deficit The premium assistance credit amount (determined without regard to this paragraph) with respect to a month in a plan year for which a reduction is required in such amount under section 1209 of the America's Healthy Future Act of 2009 shall be reduced by the percentage specified in such section.
I|C|II|A|1205.(a)36B.(c)
Definition and rules relating to applicable taxpayers, coverage months, and qualified health benefits plan For purposes of this section -
I|C|II|A|1205.(a)36B.(c)(1)
Applicable taxpayer
I|C|II|A|1205.(a)36B.(c)(1)(A)
In general The term applicable taxpayer means, with respect to any taxable year, a taxpayer whose household income for the taxable year exceeds 100 percent (133 percent in the case of taxable years beginning in 2013) but does not exceed 400 percent of an amount equal to the poverty line for a family of the size involved.
I|C|II|A|1205.(a)36B.(c)(1)(B)
Special rule for certain individuals lawfully present in the United States In the case of any taxable year beginning after December 31, 2013, if -
I|C|II|A|1205.(a)36B.(c)(1)(B)(i)
a taxpayer has a household income which is not greater than 100 percent of an amount equal to the poverty line for a family of the size involved, and
I|C|II|A|1205.(a)36B.(c)(1)(B)(ii)
the taxpayer is an alien lawfully admitted to the United States for permanent residence, or an alien lawfully present in the United States, but is not eligible for the medicaid program under title XIX of the Social Security Act by reason of such alien status, the taxpayer shall be treated as an applicable taxpayer.
I|C|II|A|1205.(a)36B.(c)(1)(C)
Married couples must file joint return If the taxpayer is married (within the meaning of section 7703) at the close of the taxable year, the taxpayer shall be treated as an applicable taxpayer only if the taxpayer and the taxpayer's spouse file a joint return for the taxable year.
I|C|II|A|1205.(a)36B.(c)(1)(D)
Denial of credit to dependents No credit shall be allowed under this section to any individual with respect to whom a deduction under section 151 is allowable to another taxpayer for a taxable year beginning in the calendar year in which such individual's taxable year begins.
I|C|II|A|1205.(a)36B.(c)(2)
Coverage month For purposes of this subsection -
I|C|II|A|1205.(a)36B.(c)(2)(A)
In general The term coverage month means, with respect to an applicable taxpayer, any month if -
I|C|II|A|1205.(a)36B.(c)(2)(A)(i)
as of the first day of such month the taxpayer, the taxpayer's spouse, or any dependent of the taxpayer is covered by a qualified health benefits plan described in subsection (b)(2)(A)(i), and
I|C|II|A|1205.(a)36B.(c)(2)(A)(ii)
the premium for coverage under such plan for such month is paid by the taxpayer (or through advance payment of the credit under subsection (a) under section 2248 of the Social Security Act).
I|C|II|A|1205.(a)36B.(c)(2)(B)
Exception for essential health benefits coverage
I|C|II|A|1205.(a)36B.(c)(2)(B)(i)
In general The term coverage month shall not include any month with respect to an individual if for such month the individual is eligible for essential health benefits coverage other than eligibility for coverage under a qualified health benefits plan in the individual market offered through an exchange.
I|C|II|A|1205.(a)36B.(c)(2)(B)(ii)
Essential health benefits coverage The term essential health benefits coverage has the meaning given such term by section 5000A.
I|C|II|A|1205.(a)36B.(c)(2)(C)
Special rule for employer-sponsored essential coverage For purposes of subparagraph (B) -
I|C|II|A|1205.(a)36B.(c)(2)(C)(i)
Coverage must be affordable Except as provided in clause (iii), an employee shall not be treated as eligible for essential health benefits coverage if such coverage -
I|C|II|A|1205.(a)36B.(c)(2)(C)(i)(I)
consists of an eligible employer-sponsored plan (as defined in section 5000A(f)(2)) or a grandfathered health benefits plan maintained by the employee's employer, and
I|C|II|A|1205.(a)36B.(c)(2)(C)(i)(II)
the employee's required contribution (within the meaning of section 5000A(e)(2)) with respect to the plan exceeds 10 percent of the applicable taxpayer's household income. This clause shall also apply to an individual who is eligible to enroll in the plan by reason of a relationship the individual bears to the employee.
I|C|II|A|1205.(a)36B.(c)(2)(C)(ii)
Coverage must provide minimum value Except as provided in clause (iii), an employee shall not be treated as eligible for essential health benefits coverage if such coverage consists of an eligible employer-sponsored plan (as defined in section 5000A(f)(2)) or a grandfathered health benefits plan maintained by the employee's employer and the plan's share of the total allowed costs of benefits provided under the plan is less than 65 percent of such costs.
I|C|II|A|1205.(a)36B.(c)(2)(C)(iii)
Employee or family must not be covered under employer plan Clauses (i) and (ii) shall not apply if the employee (or any individual described in the last sentence of clause (i)) is covered under the eligible employer-sponsored plan or the grandfathered health benefits plan.
I|C|II|A|1205.(a)36B.(c)(2)(C)(iv)
Indexing In the case of plan years beginning in any calendar year after 2013, clause (i)(II) shall be applied by substituting for 10 percent a percentage equal to the sum of -
I|C|II|A|1205.(a)36B.(c)(2)(C)(iv)(I)
10 percent, plus
I|C|II|A|1205.(a)36B.(c)(2)(C)(iv)(II)
10 percent multiplied by the premium adjustment percentage (as defined in section 2242(c)(7) of the Social Security Act) for the calendar year.
I|C|II|A|1205.(a)36B.(c)(2)(D)
Special rule for medicaid individuals An individual shall not be treated as eligible for essential health benefits coverage if under title XIX of the Social Security Act the individual may elect to enroll in the medicaid program or in a qualified health benefits plan in the individual market through an exchange and elects to enroll in such plan even if under the medicaid program the individual receives coverage for items and services or cost-sharing which is provided under the medicaid program but not under such plan.
I|C|II|A|1205.(a)36B.(c)(3)
Definitions For purposes of this paragraph -
I|C|II|A|1205.(a)36B.(c)(3)(A)
Qualified health benefits plan The term qualified health benefits plan has the meaning given such term by section 2201(b) of the Social Security Act.
I|C|II|A|1205.(a)36B.(c)(3)(B)
Grandfathered health benefits plan The term grandfathered health benefits plan has the meaning given such term by section 2221 of the Social Security Act.
I|C|II|A|1205.(a)36B.(d)
Terms relating to income and families For purposes of this section -
I|C|II|A|1205.(a)36B.(d)(1)
Family size The family size involved with respect to any taxpayer shall be equal to the number of individuals for whom the taxpayer is allowed a deduction under section 151 (relating to allowance of deduction for personal exemptions) for the taxable year.
I|C|II|A|1205.(a)36B.(d)(2)
Household income
I|C|II|A|1205.(a)36B.(d)(2)(A)
In general The term household income means, with respect to any taxpayer, an amount equal to the sum of -
I|C|II|A|1205.(a)36B.(d)(2)(A)(i)
the modified gross income of the taxpayer, plus
I|C|II|A|1205.(a)36B.(d)(2)(A)(ii)
the aggregate modified gross incomes of all other individuals taken into account in determining the taxpayer's family size under paragraph (1).
I|C|II|A|1205.(a)36B.(d)(2)(B)
Modified gross income The term modified gross income means gross income -
I|C|II|A|1205.(a)36B.(d)(2)(B)(i)
decreased by the amount of any deduction allowable under paragraphs (1), (3), or (4) of section 62(a),
I|C|II|A|1205.(a)36B.(d)(2)(B)(ii)
increased by the amount of interest received or accrued during the taxable year which is exempt from tax imposed by this chapter, and
I|C|II|A|1205.(a)36B.(d)(2)(B)(iii)
determined without regard to sections 911, 931, and 933.
I|C|II|A|1205.(a)36B.(d)(3)
Poverty line
I|C|II|A|1205.(a)36B.(d)(3)(A)
In general The term poverty line has the meaning given that term in section 2110(c)(5) of the Social Security Act ( 42 U.S.C. 1397jj(c)(5) ).
I|C|II|A|1205.(a)36B.(d)(3)(B)
Poverty line used In the case of any qualified health benefits plan offered through an exchange for coverage during a taxable year beginning in a calendar year, the poverty line used shall be the most recently published poverty line as of the 1st day of the regular enrollment period for coverage during such calendar year.
I|C|II|A|1205.(a)36B.(e)
Rules for undocumented aliens
I|C|II|A|1205.(a)36B.(e)(1)
In general If any individual for whom the taxpayer is allowed a deduction under section 151 (relating to allowance of deduction for personal exemptions) for the taxable year is an undocumented alien -
I|C|II|A|1205.(a)36B.(e)(1)(A)
no credit shall be allowed under subsection (a) with respect to any portion of any premium taken into account under clause (i) or (ii) of subsection (b)(2)(A) which is attributable to the individual, and
I|C|II|A|1205.(a)36B.(e)(1)(B)
the individual shall not be taken into account in determining the family size involved but the individual's modified gross income shall be taken into account in determining household income.
I|C|II|A|1205.(a)36B.(e)(2)
Undocumented alien For purposes of this section -
I|C|II|A|1205.(a)36B.(e)(2)(A)
The term undocumented alien means an individual who is not, or who is reasonably not expected to be for the entire taxable year, a citizen or national of the United States, an alien lawfully admitted to the United States for permanent residence, or an alien lawfully present in the United States.
I|C|II|A|1205.(a)36B.(e)(2)(B)
Identification requirement An individual shall be treated as an undocumented alien unless the information required under section 2238(b)(2) of the Social Security Act has been provided with respect to such individual.
I|C|II|A|1205.(a)36B.(f)
Reconciliation of credit and advance credit
I|C|II|A|1205.(a)36B.(f)(1)
In general The amount of the credit allowed under this section for any taxable year shall be reduced (but not below zero) by the amount of any advance payment of such credit under section 2248 of the Social Security Act.
I|C|II|A|1205.(a)36B.(f)(2)
Excess advance payments
I|C|II|A|1205.(a)36B.(f)(2)(A)
In general If the advance payments to a taxpayer under section 2248 of the Social Security Act for a taxable year exceed the credit allowed by this section (determined without regard to paragraph (1)), the tax imposed by this chapter for the taxable year shall be increased by the amount of such excess.
I|C|II|A|1205.(a)36B.(f)(2)(B)
Limitation on increase where income less than 300 percent of poverty line In the case of an applicable taxpayer whose household income is less than 300 percent of the poverty line for the size of the family involved for the taxable year, the amount of the increase under subparagraph (A) shall in no event exceed $400 ($250 in the case of a taxpayer whose tax is determined under section 1(c) for the taxable year).
I|C|II|A|1205.(a)36B.(g)
Regulations The Secretary shall prescribe such regulations as may be necessary to carry out the provisions of this section, including regulations which provide for -
I|C|II|A|1205.(a)36B.(g)(1)
the coordination of the credit allowed under this section with the program for advance payment of the credit under section 2248 of the Social Security Act,
I|C|II|A|1205.(a)36B.(g)(2)
requirements for information required to be included on a return of tax with respect to the modified gross income of individuals other than the taxpayer, and
I|C|II|A|1205.(a)36B.(g)(3)
the application of subsection (f) where the filing status of the taxpayer for a taxable year is different from such status used for determining the advance payment of the credit.
.
I|C|II|A|1205.(b)
Disallowance of deduction Section 280C of the Internal Revenue Code of 1986 is amended by adding at the end the following new subsection:
I|C|II|A|1205.(b)(g)
Credit for health insurance premiums No deduction shall be allowed for the portion of the premiums paid by the taxpayer for coverage of 1 or more individuals under a qualified health benefits plan which is equal to the amount of the credit determined for the taxable year under section 36B(a) with respect to such premiums. .
I|C|II|A|1205.(c)
Treatment of failure to provide documentation as mathematical error Section 6213(g)(2) of the Internal Revenue Code of 1986 is amended by striking and at the end of subparagraph (M), by striking the period at the end of subparagraph (N) and inserting , and , and by inserting after subparagraph (N) the following new subparagraph:
I|C|II|A|1205.(c)(O)
the omission of identifying information described in section 2238(b)(1) of the Social Security Act and required under section 36B(e)(2)(B). .
I|C|II|A|1205.(d)
Study Not later than 5 years after the date of the enactment of this Act, the Secretary of the Treasury, in consultation with the Secretary of Health and Human Services, shall conduct a study of whether the percentage of household income used for purposes of section 36B(c)(2)(C) of the Internal Revenue Code of 1986 (as added by this section) is the appropriate level for determining whether employer-provided coverage is affordable for an employee and whether such level may be lowered without significantly increasing the costs to the Federal Government and reducing employer-provided coverage. The Secretary shall report the results of such study to the appropriate committees of Congress, including any recommendations for legislative changes.
I|C|II|A|1205.(e)
Conforming amendments
I|C|II|A|1205.(e)(1)
Paragraph (2) of section 1324(b) of title 31, United States Code, is amended by inserting 36B, after 36A, .
I|C|II|A|1205.(e)(2)
The table of sections for subpart C of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 is amended by inserting after the item relating to section 36A the following new item: Sec. 36B. Refundable credit for coverage under a qualified health benefits plan. .
I|C|II|A|1205.(f)
Effective date The amendments made by this section shall apply to taxable years beginning after December 31, 2012.
I|C|II|A|1206.
Cost-sharing subsidies and advance payments of premium credits and cost-sharing subsidies Title XXII of the Social Security Act (as added by section 1001 and amended by sections 1101 and 1201) is amended by adding at the end the following:
I|C|II|A|1206.2
Premium credits and cost-sharing subsidies
I|C|II|A|1206.2|2246.
Premium credits For refundable tax credit providing premium assistance for individuals with income less than 400 percent of the Federal poverty line, see section 36B of the Internal Revenue Code of 1986 (as added by section 1205 of the America's Healthy Future Act of 2009 ).
I|C|II|A|1206.2|2247.
Cost-sharing subsidies for individuals enrolling in qualified health benefit plans
I|C|II|A|1206.2|2247.(a)
In general In the case of an eligible insured enrolled in a qualified health benefits plan with respect to which a credit is allowed to the insured (or an applicable taxpayer on behalf of the insured) under section 36B of the Internal Revenue Code of 1986 -
I|C|II|A|1206.2|2247.(a)(1)
the Secretary shall notify the offeror of the plan of the eligible insured's eligibility for a reduction in cost-sharing under this section; and
I|C|II|A|1206.2|2247.(a)(2)
the offeror shall reduce the cost-sharing under the plan at the level and in the manner specified in subsection (c).
I|C|II|A|1206.2|2247.(b)
Eligible insured In this section, the term eligible insured means an individual -
I|C|II|A|1206.2|2247.(b)(1)
who enrolls in a qualified health benefits plan in the silver level of coverage in the individual market offered through an exchange under part B; and
I|C|II|A|1206.2|2247.(b)(2)
whose household income exceeds 100 percent (133 percent in the case of taxable years beginning in 2013) but does not exceed 400 percent of the poverty line for a family of the size involved. In the case of an individual described in section 36B(c)(1)(B) of the Internal Revenue Code of 1986 for any taxable year beginning after December 31, 2013, the individual shall be treated as having household income equal to 100 percent of such poverty line for purposes of applying this section.
I|C|II|A|1206.2|2247.(c)
Determination of reduction in cost-sharing
I|C|II|A|1206.2|2247.(c)(1)
Reduction in out-of-pocket limit The reduction in cost-sharing under this subsection shall first be achieved by reducing the applicable out-of pocket limit under section 2242(c)(2) in the case of -
I|C|II|A|1206.2|2247.(c)(1)(A)
an eligible insured whose household income is more than 100 percent but not more than 200 percent of the poverty line for a family of the size involved, by two-thirds;
I|C|II|A|1206.2|2247.(c)(1)(B)
an eligible insured whose household income is more than 200 percent but not more than 300 percent of the poverty line for a family of the size involved, by one-half; and
I|C|II|A|1206.2|2247.(c)(1)(C)
an eligible insured whose household income is more than 300 percent but not more than 400 percent of the poverty line for a family of the size involved, by one-third. The reduction under this paragraph shall not result in an increase in the plan's share of the total allowed costs of benefits provided under the plan above 80 percent (90 percent in the case of an eligible insured described in subparagraph (A)) of such costs
I|C|II|A|1206.2|2247.(c)(2)
Additional reduction for lower income insureds The Secretary shall establish procedures under which the offeror of a qualified health benefits plan to which this section applies shall further reduce cost-sharing under the plan in a manner sufficient to -
I|C|II|A|1206.2|2247.(c)(2)(A)
in the case of an eligible insured whose household income is not less than 100 percent but not more than 150 percent of the poverty line for a family of the size involved, increase the plan's share of the total allowed costs of benefits provided under the plan to 90 percent of such costs; and
I|C|II|A|1206.2|2247.(c)(2)(B)
in the case of an eligible insured whose household income is more than 150 percent but not more than 200 percent of the poverty line for a family of the size involved, increase the plan's share of the total allowed costs of benefits provided under the plan to 80 percent of such costs.
I|C|II|A|1206.2|2247.(c)(3)
Reduction to eliminate Federal budget deficit The reduction in cost-sharing under this section (determined without regard to this paragraph) with respect to a plan year for which a reduction is required in such amount under section 1209 of the America's Healthy Future Act of 2009 shall be reduced by the percentage specified in such section.
I|C|II|A|1206.2|2247.(c)(4)
Methods for providing subsidy
I|C|II|A|1206.2|2247.(c)(4)(A)
In general An offeror of a qualified health benefits plan making reductions under this subsection shall notify the Secretary of such reductions and the Secretary shall make periodic and timely payments to the offeror equal to the value of the reductions.
I|C|II|A|1206.2|2247.(c)(4)(B)
Capitated payments The Secretary may establish a capitated payment system to carry out the payment of subsidies under this section. Any such system shall take into account the value of the subsidies and make appropriate risk adjustments to such payments.
I|C|II|A|1206.2|2247.(d)
Special rules for Indians
I|C|II|A|1206.2|2247.(d)(1)
Indians under 300 percent of poverty If an individual enrolled in any qualified health benefits plan in the individual market through an exchange is an Indian (as defined in section 4 of the Indian Health Care Improvement Act) whose household income is not more than 300 percent of the poverty line for a family of the size involved, then, for purposes of this section -
I|C|II|A|1206.2|2247.(d)(1)(A)
such individual shall be treated as an eligible insured; and
I|C|II|A|1206.2|2247.(d)(1)(B)
the offeror of the plan shall eliminate any cost-sharing under the plan.
I|C|II|A|1206.2|2247.(d)(2)
Items or services furnished through Indian health providers If an Indian (as so defined) enrolled in a qualified health benefits plan is furnished an item or service directly by the Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization or through referral under contract health services -
I|C|II|A|1206.2|2247.(d)(2)(A)
no cost-sharing under the plan shall be imposed under the plan for such item or service; and
I|C|II|A|1206.2|2247.(d)(2)(B)
the offeror of the plan shall not reduce the payment to any such entity for such item or service by the amount of any cost-sharing that would be due from the Indian but for subparagraph (A).
I|C|II|A|1206.2|2247.(d)(3)
Payment The Secretary shall pay to the offeror of a qualified health benefits plan the amount necessary to reflect the increase in actuarial value of the plan required by reason of this subsection.
I|C|II|A|1206.2|2247.(e)
Rules for undocumented aliens
I|C|II|A|1206.2|2247.(e)(1)
In general In the case of an individual who is undocumented alien -
I|C|II|A|1206.2|2247.(e)(1)(A)
no cost-sharing reduction under this subsection shall apply with respect to any item or service provided to the individual; and
I|C|II|A|1206.2|2247.(e)(1)(B)
the individual shall not be taken into account in determining the family size involved but the individual's modified gross income shall be taken into account in determining household income.
I|C|II|A|1206.2|2247.(e)(2)
Identification requirement An individual shall be treated as an undocumented alien unless the information required under section 2238(b)(2) of the Social Security Act has been provided with respect to such individual.
I|C|II|A|1206.2|2247.(f)
Definitions and special rules In this section:
I|C|II|A|1206.2|2247.(f)(1)
In general Any term used in this section which is also used in section 36B of the Internal Revenue Code of 1986 shall have the meaning given such term by such section.
I|C|II|A|1206.2|2247.(f)(2)
Limitations on subsidy No subsidy shall be allowed under this section with respect to coverage for any month if such month would not be treated as a coverage month under section 36B(c)(2) of such Code.
I|C|II|A|1206.2|2248.
Advance determination and payment of premium credits and cost-sharing subsidies
I|C|II|A|1206.2|2248.(a)
In general The Secretary, in consultation with the Secretary of the Treasury, shall establish a program under which -
I|C|II|A|1206.2|2248.(a)(1)
upon request of an exchange, advance determinations are made under section 2238 with respect to the income eligibility of individuals enrolling in a qualified health benefits plan in the individual market through the exchange for the credit allowable under section 36B of the Internal Revenue Code of 1986 and the cost-sharing subsidy under section 2247;
I|C|II|A|1206.2|2248.(a)(2)
the Secretary notifies the exchange and the Secretary of the Treasury of the advance determinations; and
I|C|II|A|1206.2|2248.(a)(3)
the Secretary of the Treasury makes advance payments of such credit or subsidy to the offerors of the qualified health benefits plans in order to reduce the premiums payable by individuals eligible for such credit.
I|C|II|A|1206.2|2248.(b)
Advance determinations
I|C|II|A|1206.2|2248.(b)(1)
In general The Secretary shall provide under the program established under subsection (a) that advance determination of eligibility with respect to any individual shall be made -
I|C|II|A|1206.2|2248.(b)(1)(A)
during the annual open enrollment period applicable to the individual (or such other enrollment period as may be specified by the Secretary); and
I|C|II|A|1206.2|2248.(b)(1)(B)
on the basis of the individual's household income for the second taxable year preceding the taxable year in which enrollment through such enrollment period first takes effect.
I|C|II|A|1206.2|2248.(b)(2)
Changes in circumstances The Secretary shall provide procedures for making advance determinations on the basis of information other than that described in paragraph (1)(B) in cases where information included with an application form demonstrates substantial changes in income, changes in family size or other household circumstances, change in filing status, the filing of an application for unemployment benefits, or other significant changes affecting eligibility, including -
I|C|II|A|1206.2|2248.(b)(2)(A)
allowing an individual claiming a decrease of 20 percent or more in income, or filing an application for unemployment benefits, to have eligibility for the credit determined on the basis of household income for a later period or on the basis of the individual's estimate of such income for the taxable year; and
I|C|II|A|1206.2|2248.(b)(2)(B)
the determination of household income in cases where the taxpayer was not required to file a return of tax imposed by this chapter for the second preceding taxable year.
I|C|II|A|1206.2|2248.(c)
Payment of premium credits
I|C|II|A|1206.2|2248.(c)(1)
In general The Secretary shall notify the Secretary of the Treasury and the exchange through which the individual is enrolling of the advance determination under section 2238.
I|C|II|A|1206.2|2248.(c)(2)
Premium credit
I|C|II|A|1206.2|2248.(c)(2)(A)
In general The Secretary of the Treasury shall make the advance payment under this section of any credit allowed under section 36B of the Internal Revenue Code of 1986 to the offeror of a qualified health benefits plan on a monthly basis (or such other periodic basis as the Secretary may provide).
I|C|II|A|1206.2|2248.(c)(2)(B)
Offeror responsibilities An offeror of a qualified health benefits plan receiving an advance payment with respect to an individual enrolled in the plan shall -
I|C|II|A|1206.2|2248.(c)(2)(B)(i)
reduce the premium charged the insured for any period by the amount of the advance payment for the period;
I|C|II|A|1206.2|2248.(c)(2)(B)(ii)
notify the exchange and the Secretary of such reduction; and
I|C|II|A|1206.2|2248.(c)(2)(B)(iii)
in the case of any nonpayment of premiums by the insured -
I|C|II|A|1206.2|2248.(c)(2)(B)(iii)(I)
notify the Secretary of such nonpayment; and
I|C|II|A|1206.2|2248.(c)(2)(B)(iii)(II)
allow a 3-month grace period for nonpayment of premiums before discontinuing coverage.
I|C|II|A|1206.2|2248.(d)
Coordination with verification of lawful presence No advance payment shall be made under this section unless there has been a verification under section 2238 of the individual's citizenship or nationality or lawful presence in the United States.
.
I|C|II|A|1207.
Disclosures to carry out eligibility requirements for certain programs
I|C|II|A|1207.(a)
Disclosure of taxpayer return information and social security numbers
I|C|II|A|1207.(a)(1)
Taxpayer return information Subsection (l) of section 6103 of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph:
I|C|II|A|1207.(a)(1)(21)
Disclosure of return information to carry out eligibility requirements for certain programs
I|C|II|A|1207.(a)(1)(21)(A)
In general The Secretary, upon written request from the Secretary of Health and Human Services, shall disclose to officers, employees, and contractors of the Department of Health and Human Services return information of any taxpayer whose income is relevant in determining any credit under section 36B or any cost-sharing subsidy under section 2247 of the Social Security Act or eligibility for participation in a State medicaid program under title XIX of such Act, a State's children's health insurance program under title XXI of such Act, or a basic health program under section 2228 of such Act. Such return information shall be limited to -
I|C|II|A|1207.(a)(1)(21)(A)(i)
taxpayer identity information with respect to such taxpayer,
I|C|II|A|1207.(a)(1)(21)(A)(ii)
the filing status of such taxpayer,
I|C|II|A|1207.(a)(1)(21)(A)(iii)
the number of individuals for whom a deduction is allowed under section 151 with respect to the taxpayer (including the taxpayer and the taxpayer's spouse),
I|C|II|A|1207.(a)(1)(21)(A)(iv)
the modified gross income (as defined in section 36B) of such taxpayer and each of the other individuals included under clause (iii),
I|C|II|A|1207.(a)(1)(21)(A)(v)
such other information as is prescribed by the Secretary by regulation as might indicate whether the taxpayer is eligible for such credit or subsidy (and the amount thereof), and
I|C|II|A|1207.(a)(1)(21)(A)(vi)
the taxable year with respect to which the preceding information relates or, if applicable, the fact that such information is not available.
I|C|II|A|1207.(a)(1)(21)(B)
Information to exchange and State agencies The Secretary of Health and Human Services may disclose to an exchange established under title XXII of the Social Security Act or its contractors, or to a State agency administering a State program described in subparagraph (A) or its contractors, any inconsistency between the information provided by the exchange or State agency to the Secretary and the information provided to the Secretary under subparagraph (A).
I|C|II|A|1207.(a)(1)(21)(C)
Restriction on use of disclosed information Return information disclosed under subparagraph (A) or (B) may be used by officers, employees, and contractors of the Department of Health and Human Services, an exchange, or a State agency only for the purposes of, and to the extent necessary in -
I|C|II|A|1207.(a)(1)(21)(C)(i)
establishing eligibility for participation in the exchange, and verifying the appropriate amount of, any credit or subsidy described in subparagraph (A),
I|C|II|A|1207.(a)(1)(21)(C)(ii)
determining eligibility for participation in the State programs described in subparagraph (A).
.
I|C|II|A|1207.(a)(2)
Social Security numbers Section 205(c)(2)(C) of the Social Security Act is amended by adding at the end the following new clause:
I|C|II|A|1207.(a)(2)(x)
The Secretary of Health and Human Services, and the exchanges established under title XXII, are authorized to collect and use the names and social security account numbers of individuals as required to administer the provisions of, and the amendments made by, America's Healthy Future Act of 2009 . .
I|C|II|A|1207.(b)
Confidentiality and disclosure Paragraph (3) of section 6103(a) of such Code is amended by striking or (20) and inserting (20), or (21) .
I|C|II|A|1207.(c)
Procedures and recordkeeping related to disclosures Paragraph (4) of section 6103(p) of such Code is amended -
I|C|II|A|1207.(c)(1)
by inserting , or any entity described in subsection (l)(21), after or (20) in the matter preceding subparagraph (A),
I|C|II|A|1207.(c)(2)
by inserting or any entity described in subsection (l)(21), after or (o)(1)(A) in subparagraph (F)(ii), and
I|C|II|A|1207.(c)(3)
by inserting or any entity described in subsection (l)(21), after or (20) both places it appears in the matter after subparagraph (F).
I|C|II|A|1207.(d)
Unauthorized disclosure or inspection Paragraph (2) of section 7213(a) of such Code is amended by striking or (20) and inserting (20), or (21) .
I|C|II|A|1208.
Premium credit and subsidy refunds and payments disregarded for Federal and Federally-assisted programs For purposes of determining the eligibility of any individual for benefits or assistance, or the amount or extent of benefits or assistance, under any Federal program or under any State or local program financed in whole or in part with Federal funds -
I|C|II|A|1208.(1)
any credit or refund allowed or made to any individual by reason of section 36B of the Internal Revenue Code of 1986 (as added by section 1205) shall not be taken into account as income and shall not be taken into account as resources for the month of receipt and the following 2 months; and
I|C|II|A|1208.(2)
any cost-sharing subsidy payment or advance payment of the credit allowed under such section 36B that is made under section 2247 or 2248 of the Social Security Act (as added by section 1206) shall be treated as made to the qualified health benefits plan in which an individual is enrolled and not to that individual.
I|C|II|A|1209.
Fail-safe mechanism to prevent increase in Federal budget deficit
I|C|II|A|1209.(a)
Estimate and certification of effect of Act on budget deficit
I|C|II|A|1209.(a)(1)
In general The President shall include in the submission under section 1105 of title 31, United States Code, of the budget of the United States Government for fiscal year 2013 and each fiscal year thereafter an estimate of the budgetary effects for the fiscal year of the provisions of (and the amendments made by) this Act, based on the information available as of the date of such submission.
I|C|II|A|1209.(a)(2)
Certification The President shall include with the estimate under paragraph (1) for any fiscal year a certification as to whether the sum of the decreases in revenues and increases in outlays for the fiscal year by reason of the provisions of (and the amendments made by) this Act exceed (or do not exceed) the sum of the increases in revenues and decreases in outlays for the fiscal year by reason of the provisions and amendments.
I|C|II|A|1209.(b)
Effect of deficit If the President certifies an excess under subsection (a)(2) for any fiscal year -
I|C|II|A|1209.(b)(1)
the President shall include with the certification the percentage by which the credits allowable under section 36B of the Internal Revenue Code of 1986 and the cost-sharing subsidies under section 2247 of the Social Security Act must be reduced for plan years beginning during such fiscal year such that there is an aggregate decrease in the amount of such credits and subsidies equal to the amount of such excess; and
I|C|II|A|1209.(b)(2)
the President shall instruct the Secretary of Health and Human Services and the Secretary of the Treasury to reduce such credits and subsidies for such plan years by such percentage for purposes of applying section 36B(b)(4) of such Code and section 2247(c)(3) of such Act.
I|C|II|B
Credit for small employers
I|C|II|B|1221.
Credit for employee health insurance expenses of small businesses
I|C|II|B|1221.(a)
In general Subpart D of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 (relating to business-related credits) is amended by inserting after section 45Q the following:
I|C|II|B|1221.(a)45R.
Employee health insurance expenses of small employers
I|C|II|B|1221.(a)45R.(a)
General rule For purposes of section 38, in the case of an eligible small employer, the small employer health insurance credit determined under this section for any taxable year in the credit period is the amount determined under subsection (b).
I|C|II|B|1221.(a)45R.(b)
Health insurance credit amount Subject to subsection (c), the amount determined under this subsection with respect to any eligible small employer is equal to 50 percent (35 percent in the case of a tax-exempt eligible small employer) of the lesser of -
I|C|II|B|1221.(a)45R.(b)(1)
the aggregate amount of nonelective contributions the employer made on behalf of its employees during the taxable year under the arrangement described in subsection (d)(4) for premiums for qualified health benefits plans offered by the employer to its employees through an exchange, or
I|C|II|B|1221.(a)45R.(b)(2)
the aggregate amount of nonelective contributions which the employer would have made during the taxable year under the arrangement if each employee taken into account under paragraph (1) had enrolled in a qualified health benefits plan which had a premium equal to the average premium (as determined by the Secretary of Health and Human Services) for the small group market in the exchange through which the employee is eligible for coverage. In the case of a taxable year beginning in 2013, the credit determined under this section shall be determined only with respect to premiums for coverage after June 30, 2013.
I|C|II|B|1221.(a)45R.(c)
Limitations on credit
I|C|II|B|1221.(a)45R.(c)(1)
Phaseout of credit amount based on number of employees and average wages The amount of the credit determined under subsection (b) without regard to this subsection shall be reduced (but not below zero) by the sum of the following amounts:
I|C|II|B|1221.(a)45R.(c)(1)(A)
Such amount multiplied by a fraction the numerator of which is the total number of full-time equivalent employees of the employer in excess of 10 and the denominator of which is 15.
I|C|II|B|1221.(a)45R.(c)(1)(B)
Such amount multiplied by a fraction the numerator of which is the average annual wages of the employer in excess of the dollar amount in effect under subsection (d)(3)(B) and the denominator of which is $20,000.
I|C|II|B|1221.(a)45R.(c)(2)
State failure to adopt insurance rating reforms No credit shall be determined under this section with respect to contributions by the employer for any qualified health benefits plans purchased through an exchange for any month of coverage before the first month the State establishing the exchange has in effect the insurance rating reforms described in subtitle A of title XXII of the Social Security Act.
I|C|II|B|1221.(a)45R.(d)
Eligible small employer For purposes of this section -
I|C|II|B|1221.(a)45R.(d)(1)
In general The term eligible small employer means, with respect to any taxable year, an employer -
I|C|II|B|1221.(a)45R.(d)(1)(A)
which has no more than 25 full-time equivalent employees for the taxable year,
I|C|II|B|1221.(a)45R.(d)(1)(B)
the average annual wages of which do not exceed an amount equal to the amount in effect under paragraph (3)(B) for the taxable year plus $20,000, and
I|C|II|B|1221.(a)45R.(d)(1)(C)
which has in effect an arrangement described in paragraph (4).
I|C|II|B|1221.(a)45R.(d)(2)
Full-time equivalent employees
I|C|II|B|1221.(a)45R.(d)(2)(A)
In general The term full-time equivalent employees means a number of employees equal to the number determined by dividing -
I|C|II|B|1221.(a)45R.(d)(2)(A)(i)
the total number of hours for which wages were paid by the employer to employees during the taxable year, by
I|C|II|B|1221.(a)45R.(d)(2)(A)(ii)
2,080. Such number shall be rounded to the next lowest whole number if not otherwise a whole number.
I|C|II|B|1221.(a)45R.(d)(2)(B)
Excess hours not counted If an employee works in excess of 2,080 hours during any taxable year, such excess shall not be taken into account under subparagraph (A).
I|C|II|B|1221.(a)45R.(d)(2)(C)
Special rules The Secretary shall prescribe such regulations, rules, and guidance as may be necessary to apply this paragraph to employees who are not compensated on an hourly basis.
I|C|II|B|1221.(a)45R.(d)(3)
Average annual wages
I|C|II|B|1221.(a)45R.(d)(3)(A)
In general The average annual wages of an eligible small employer for any taxable year is the amount determined by dividing -
I|C|II|B|1221.(a)45R.(d)(3)(A)(i)
the aggregate amount of wages which were paid by the employer to employees during the taxable year, by
I|C|II|B|1221.(a)45R.(d)(3)(A)(ii)
the number of full-time equivalent employees of the employee determined under paragraph (2) for the taxable year. Such amount shall be rounded to the next lowest multiple of $1,000 if not otherwise such a multiple.
I|C|II|B|1221.(a)45R.(d)(3)(B)
Dollar amount For purposes of paragraph (1)(B) -
I|C|II|B|1221.(a)45R.(d)(3)(B)(i)
2010 The dollar amount in effect under this paragraph for taxable years beginning in 2010 is $20,000.
I|C|II|B|1221.(a)45R.(d)(3)(B)(ii)
Subsequent years In the case of a taxable year beginning in a calendar year after 2010, the dollar amount in effect under this paragraph shall be equal to $20,000, multiplied by the cost-of-living adjustment determined under section 1(f)(3) for the calendar year, determined by substituting calendar year 2009 for calendar year 1992 in subparagraph (B) thereof.
I|C|II|B|1221.(a)45R.(d)(4)
Contribution arrangement An arrangement is described in this paragraph if it requires an eligible small employer to make a nonelective contribution on behalf of each employee who enrolls in a qualified health benefits plan offered to employees by the employer through an exchange in an amount equal to a uniform percentage (not less than 50 percent) of the premium cost of the qualified health benefits plan.
I|C|II|B|1221.(a)45R.(d)(5)
Seasonal worker hours and wages not counted For purposes of this subsection -
I|C|II|B|1221.(a)45R.(d)(5)(A)
In general The number of hours worked by, and wages paid to, a seasonal worker of an employer shall not be taken into account in determining the full-time equivalent employees and average annual wages of the employer.
I|C|II|B|1221.(a)45R.(d)(5)(B)
Definition of seasonal worker The term seasonal worker means an individual who performs labor or services on a seasonal basis where, ordinarily, the employment pertains to or is of the kind exclusively performed at certain seasons or periods of the year and which, from its nature, may not be continuous or carried on throughout the year.
I|C|II|B|1221.(a)45R.(e)
Other rules and definitions For purposes of this section -
I|C|II|B|1221.(a)45R.(e)(1)
Employee
I|C|II|B|1221.(a)45R.(e)(1)(A)
Certain employees excluded The term employee shall not include -
I|C|II|B|1221.(a)45R.(e)(1)(A)(i)
an employee within the meaning of section 401(c)(1),
I|C|II|B|1221.(a)45R.(e)(1)(A)(ii)
any 2-percent shareholder (as defined in section 1372(b)) of an eligible small business which is an S corporation,
I|C|II|B|1221.(a)45R.(e)(1)(A)(iii)
any 5-percent owner (as defined in section 416(i)(1)(B)(i)) of an eligible small business, or
I|C|II|B|1221.(a)45R.(e)(1)(A)(iv)
any individual who bears any of the relationships described in subparagraphs (A) through (G) of section 152(d)(2) to, or is a dependent described in section 152(d)(2)(H) of, an individual described in clause (i), (ii), or (iii).
I|C|II|B|1221.(a)45R.(e)(1)(B)
Leased employees The term employee shall include a leased employee within the meaning of section 414(n).
I|C|II|B|1221.(a)45R.(e)(2)
Credit period The term credit period means, with respect to any eligible small employer, the 2-consecutive-taxable year period beginning with the 1st taxable year in which the employer (or any predecessor) offers 1 or more qualified health benefits plans to its employees through an exchange. If no credit is allowed to an employer (or predecessor) under this section by reason of subsection (c)(2) (relating to failure by States to adopt insurance rating reforms), the credit period with respect to the employer shall not begin until the 1st taxable year following the taxable year in which the State has in effect the insurance rating reforms described in such subsection.
I|C|II|B|1221.(a)45R.(e)(3)
Nonelective contribution The term nonelective contribution means an employer contribution other than an employer contribution pursuant to a salary reduction arrangement.
I|C|II|B|1221.(a)45R.(e)(4)
Wages The term wages has the meaning given such term by section 3121(a) (determined without regard to any dollar limitation contained in such section).
I|C|II|B|1221.(a)45R.(e)(5)
Aggregation and other rules made applicable
I|C|II|B|1221.(a)45R.(e)(5)(A)
Aggregation rules All employers treated as a single employer under subsection (b), (c), (m), or (o) of section 414 shall be treated as a single employer for purposes of this section.
I|C|II|B|1221.(a)45R.(e)(5)(B)
Other rules Rules similar to the rules of subsections (c), (d), and (e) of section 52 shall apply.
I|C|II|B|1221.(a)45R.(f)
Credit made available to tax-exempt eligible small employers
I|C|II|B|1221.(a)45R.(f)(1)
In general In the case of a tax-exempt eligible small employer, there shall be treated as a credit allowable under subpart C (and not allowable under this subpart) the lesser of - -
I|C|II|B|1221.(a)45R.(f)(1)(A)
the amount of the credit determined under this section with respect to such employer, or
I|C|II|B|1221.(a)45R.(f)(1)(B)
the amount of the payroll taxes of the employer during the calendar year in which the taxable year begins.
I|C|II|B|1221.(a)45R.(f)(2)
Tax-exempt eligible small employer For purposes of this section, the term tax-exempt eligible small employer means an eligible small employer which is any organization described in section 501(c) which is exempt from taxation under section 501(a).
I|C|II|B|1221.(a)45R.(f)(3)
Payroll taxes For purposes of this subsection -
I|C|II|B|1221.(a)45R.(f)(3)(A)
In general The term payroll taxes means -
I|C|II|B|1221.(a)45R.(f)(3)(A)(i)
amounts required to be withheld from the employees of the tax-exempt eligible small employer under section 3401(a),
I|C|II|B|1221.(a)45R.(f)(3)(A)(ii)
amounts required to be withheld from such employees under section 3101(b), and
I|C|II|B|1221.(a)45R.(f)(3)(A)(iii)
amounts of the taxes imposed on the tax-exempt eligible small employer under section 3111(b).
I|C|II|B|1221.(a)45R.(f)(3)(B)
Special rule A rule similar to the rule of section 24(d)(2)(C) shall apply for purposes of subparagraph (A).
I|C|II|B|1221.(a)45R.(g)
Application of section for calendar years 2011 and 2012 In the case of any taxable year beginning in 2011 or 2012, the following modifications to this section shall apply in determining the amount of the credit under subsection (a):
I|C|II|B|1221.(a)45R.(g)(1)
No credit period required The credit shall be determined without regard to whether the taxable year is in a credit period and for purposes of applying this section to taxable years beginning after 2012, no credit period shall be treated as beginning with a taxable year beginning before 2013.
I|C|II|B|1221.(a)45R.(g)(2)
Amount of credit The amount of the credit determined under subsection (b) shall be determined -
I|C|II|B|1221.(a)45R.(g)(2)(A)
by substituting 35 percent (25 percent in the case of a tax-exempt eligible small employer) for 50 percent (35 percent in the case of a tax-exempt eligible small employer) ,
I|C|II|B|1221.(a)45R.(g)(2)(B)
by reference to an eligible small employer's nonelective contributions for premiums paid for health insurance coverage (within the meaning of section 9832(b)(1)) of an employee, and
I|C|II|B|1221.(a)45R.(g)(2)(C)
by substituting for the average premium determined under subsection (b)(2) the amount the Secretary of Health and Human Services determines is the average premium for the small group market in the State in which the employer is offering health insurance coverage (or for such area within the State as is specified by the Secretary).
I|C|II|B|1221.(a)45R.(g)(3)
State rating reform limitation The limitation of paragraph (2) of subsection (c) shall not apply.
I|C|II|B|1221.(a)45R.(g)(4)
Contribution arrangement An arrangement shall not fail to meet the requirements of subsection (d)(4) solely because it provides for the offering of insurance outside of an exchange.
I|C|II|B|1221.(a)45R.(h)
Insurance definitions Any term used in this section which is also used in title XXII of the Social Security Act shall have the meaning given such term by such title.
I|C|II|B|1221.(a)45R.(i)
Regulations The Secretary shall prescribe such regulations as may be necessary to carry out the provisions of this section, including regulations to prevent the avoidance of the 2-year limit on the credit period through the use of successor entities and the avoidance of the limitations under paragraphs (1) and (2) of subsection (c) through the use of multiple entities.
.
I|C|II|B|1221.(b)
Credit to be part of general business credit Section 38(b) of the Internal Revenue Code of 1986 (relating to current year business credit) is amended by striking plus at the end of paragraph (34), by striking the period at the end of paragraph (35) and inserting , plus , and by inserting after paragraph (35) the following:
I|C|II|B|1221.(b)(36)
the small employer health insurance credit determined under section 45R. .
I|C|II|B|1221.(c)
Credit allowed against alternative minimum tax Section 38(c)(4)(B) of the Internal Revenue Code of 1986 (defining specified credits) is amended by redesignating clauses (vi), (vii), and (viii) as clauses (vii), (viii), and (ix), respectively, and by inserting after clause (v) the following new clause:
I|C|II|B|1221.(c)(vi)
the credit determined under section 45R, .
I|C|II|B|1221.(d)
Disallowance of deduction for certain expenses for which credit allowed
I|C|II|B|1221.(d)(1)
In general Section 280C of the Internal Revenue Code of 1986 (relating to disallowance of deduction for certain expenses for which credit allowed), as amended by section 1205(b), is amended by adding at the end the following new subsection:
I|C|II|B|1221.(d)(1)(h)
Credit for employee health insurance expenses of small employers No deduction shall be allowed for that portion of the premiums for qualified health benefits plans (as defined in section 2201(b) of the Social Security Act) paid by an employer which is equal to the amount of the credit determined under section 45R(a). .
I|C|II|B|1221.(d)(2)
Deduction for expiring credits Section 196(c) of such Code is amended by striking and at the end of paragraph (12), by striking the period at the end of paragraph (13) and inserting , and , and by adding at the end the following new paragraph:
I|C|II|B|1221.(d)(2)(14)
the small employer health insurance credit determined under section 45R(a). .
I|C|II|B|1221.(e)
Clerical amendment The table of sections for subpart D of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 is amended by adding at the end the following: Sec. 45R. Employee health insurance expenses of small employers. .
I|C|II|B|1221.(f)
Effective dates
I|C|II|B|1221.(f)(1)
In general The amendments made by this section shall apply to amounts paid or incurred in taxable years beginning after December 31, 2010.
I|C|II|B|1221.(f)(2)
Minimum tax The amendments made by subsection (c) shall apply to credits determined under section 45R of the Internal Revenue Code of 1986 in taxable years beginning after December 31, 2010, and to carrybacks of such credits.
I|D
Shared responsibility
I|D|I
Individual responsibility
I|D|I|1301.
Excise tax on individuals without essential health benefits coverage
I|D|I|1301.(a)
In general Subtitle D of the Internal Revenue Code of 1986 is amended by adding at the end the following new chapter:
I|D|I|1301.48
Maintenance of essential health benefits coverage Sec. 5000A. Failure to maintain essential health benefits coverage.
I|D|I|1301.48|5000A.
Failure to maintain essential health benefits coverage
I|D|I|1301.48|5000A.(a)
Requirement to maintain essential health benefits coverage If an individual is an applicable individual for any month beginning after June 30, 2013, the individual is required to be covered by essential health benefits coverage for such month.
I|D|I|1301.48|5000A.(b)
Imposition of tax
I|D|I|1301.48|5000A.(b)(1)
In general If an applicable individual fails to meet the requirement of subsection (a) for 1 or more months during any calendar year beginning after 2013, then, except as provided in subsection (d), there is hereby imposed a tax with respect to the individual in the amount determined under subsection (c).
I|D|I|1301.48|5000A.(b)(2)
Inclusion with income tax return Any tax imposed by this section with respect to any month shall be included with a taxpayer's return of tax imposed by chapter 1 for the taxable year which includes such month.
I|D|I|1301.48|5000A.(b)(3)
Liability for tax If an individual with respect to whom tax is imposed by this section for any month -
I|D|I|1301.48|5000A.(b)(3)(A)
is a dependent (as defined in section 152) of another taxpayer for the other taxpayer's taxable year including such month, such other taxpayer shall be liable for such tax, or
I|D|I|1301.48|5000A.(b)(3)(B)
files a joint return for the taxable year including such month, such individual and the spouse of such individual shall be jointly liable for such tax.
I|D|I|1301.48|5000A.(c)
Amount of tax
I|D|I|1301.48|5000A.(c)(1)
In general The tax determined under this subsection for any month with respect to any individual is an amount equal to 1/12 of the applicable dollar amount for the calendar year.
I|D|I|1301.48|5000A.(c)(2)
Dollar limitation The amount of the tax imposed by this section on any taxpayer for any taxable year with respect to all individuals for whom the taxpayer is liable under subsection (b)(3) shall not exceed an amount equal to twice the applicable dollar amount for the calendar year with or within which the taxable year ends.
I|D|I|1301.48|5000A.(c)(3)
Applicable dollar amount For purposes of paragraph (1) -
I|D|I|1301.48|5000A.(c)(3)(A)
In general Except as provided in subparagraph (B), the applicable dollar amount is $750.
I|D|I|1301.48|5000A.(c)(3)(B)
Phase in The applicable dollar amount is $200 for 2014, $400 for 2015, and $600 for 2016.
I|D|I|1301.48|5000A.(c)(3)(C)
Indexing of amount In the case of any calendar year beginning after 2017, the applicable dollar amount shall be equal to $750, increased by an amount equal to -
I|D|I|1301.48|5000A.(c)(3)(C)(i)
$750, multiplied by
I|D|I|1301.48|5000A.(c)(3)(C)(ii)
the cost-of-living adjustment determined under section 1(f)(3) for the calendar year, determined by substituting calendar year 2016 for calendar year 1992 in subparagraph (B) thereof. If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50.
I|D|I|1301.48|5000A.(c)(4)
Terms relating to income and families For purposes of this section -
I|D|I|1301.48|5000A.(c)(4)(A)
Family size The family size involved with respect to any taxpayer shall be equal to the number of individuals for whom the taxpayer is allowed a deduction under section 151 (relating to allowance of deduction for personal exemptions) for the taxable year.
I|D|I|1301.48|5000A.(c)(4)(B)
Household income The term household income means, with respect to any taxpayer, an amount equal to the sum of -
I|D|I|1301.48|5000A.(c)(4)(B)(i)
the modified gross income of the taxpayer, plus
I|D|I|1301.48|5000A.(c)(4)(B)(ii)
the aggregate modified gross incomes of all other individuals taken into account in determining the taxpayer's family size under paragraph (1).
I|D|I|1301.48|5000A.(c)(4)(C)
Modified gross income The term modified gross income means gross income -
I|D|I|1301.48|5000A.(c)(4)(C)(i)
decreased by the amount of any deduction allowable under paragraphs (1), (3), or (4) of section 62(a),
I|D|I|1301.48|5000A.(c)(4)(C)(ii)
increased by the amount of interest received or accrued during the taxable year which is exempt from tax imposed by this chapter, and
I|D|I|1301.48|5000A.(c)(4)(C)(iii)
determined without regard to sections 911, 931, and 933.
I|D|I|1301.48|5000A.(c)(4)(D)
Poverty line
I|D|I|1301.48|5000A.(c)(4)(D)(i)
In general The term poverty line has the meaning given that term in section 2110(c)(5) of the Social Security Act ( 42 U.S.C. 1397jj(c)(5) ).
I|D|I|1301.48|5000A.(c)(4)(D)(ii)
Poverty line used In the case of any taxable year ending with or within a calendar year, the poverty line used shall be the most recently published poverty line as of the 1st day of the such calendar year.
I|D|I|1301.48|5000A.(d)
Applicable individual For purposes of this section -
I|D|I|1301.48|5000A.(d)(1)
In general The term applicable individual means, with respect to any month, any individual who has attained the age of 18 before the beginning of the month other than an individual described in paragraph (2) or (3).
I|D|I|1301.48|5000A.(d)(2)
Religious exemptions
I|D|I|1301.48|5000A.(d)(2)(A)
Religious conscience exemption Such term shall not include any individual for any month if such individual has in effect an exemption under section 2236(f) of the Social Security Act which certifies that such individual is a member of a recognized religious sect or division thereof described in section 1402(g)(1) and an adherent of established tenets or teachings of such sect or division as described in such section.
I|D|I|1301.48|5000A.(d)(2)(B)
Health care sharing ministry
I|D|I|1301.48|5000A.(d)(2)(B)(i)
In general Such term shall not include any individual for any month if such individual is a member of a health care sharing ministry for the month.
I|D|I|1301.48|5000A.(d)(2)(B)(ii)
Health care sharing ministry The term health care sharing ministry means an organization -
I|D|I|1301.48|5000A.(d)(2)(B)(ii)(I)
which is described in section 501(c)(3) and is exempt from taxation under section 501(a),
I|D|I|1301.48|5000A.(d)(2)(B)(ii)(II)
members of which share a common set of ethical or religious beliefs and share medical expenses among members in accordance with those beliefs and without regard to the State in which a member resides or is employed,
I|D|I|1301.48|5000A.(d)(2)(B)(ii)(III)
members of which retain membership even after they develop a medical condition,
I|D|I|1301.48|5000A.(d)(2)(B)(ii)(IV)
which (or a predecessor of which) has been in existence at all times since December 31, 1999, and medical expenses of its members have been shared during the entire period of its existence, and
I|D|I|1301.48|5000A.(d)(2)(B)(ii)(V)
which conducts an annual audit which is performed by an independent certified public accounting firm in accordance with generally accepted accounting principles and which is made available to the public upon request.
I|D|I|1301.48|5000A.(d)(3)
Undocumented aliens Such term shall not include an individual for any month if for the month the individual is not a citizen or national of the United States, an alien lawfully admitted to the United States for permanent residence, or an alien lawfully present in the United States.
I|D|I|1301.48|5000A.(e)
Exemptions from tax No tax shall be imposed under subsection (a) with respect to -
I|D|I|1301.48|5000A.(e)(1)
Months during short coverage gaps Any month the last day of which occurred during a period in which the applicable individual was not covered by essential health benefits coverage for a period of less than 3 months.
I|D|I|1301.48|5000A.(e)(2)
Individuals who cannot afford coverage
I|D|I|1301.48|5000A.(e)(2)(A)
In general Any applicable individual if the applicable individual's required contribution for a calendar year exceeds 8 percent of such individual's household income for the second taxable year preceding the taxable year described in subsection (b)(2). For purposes of applying this subparagraph, the taxpayer's household income shall be increased by any exclusion from gross income for any portion of the required contribution made through a salary reduction arrangement.
I|D|I|1301.48|5000A.(e)(2)(B)
Required contribution For purposes of this paragraph, the term required contribution means -
I|D|I|1301.48|5000A.(e)(2)(B)(i)
in the case of an individual eligible to purchase health insurance coverage through an employer other than through an exchange, the portion of the annual premium which would be paid by the individual (without regard to whether paid through salary reduction or otherwise) for health insurance coverage which is the lowest cost coverage offered through the employer, or
I|D|I|1301.48|5000A.(e)(2)(B)(ii)
in the case of any individual not described in clause (i), the annual premium for the lowest cost bronze plan available in the individual market through the exchange in the State in which the individual resides (without regard to whether the individual is eligible to purchase a qualified health benefits plan through the exchange), reduced by the amount of the credit allowable under section 36B for the taxable year (determined as if the individual was covered by a qualified health benefits plan offered through the exchange for the entire taxable year).
I|D|I|1301.48|5000A.(e)(2)(C)
Special rule for individuals eligible for coverage through employee If an applicable individual is eligible for coverage through an employer by reason of a relationship to an employee, the determination under subparagraph (B)(i) shall be made by reference to the affordability of the coverage to the employee.
I|D|I|1301.48|5000A.(e)(2)(D)
Indexing In the case of plan years beginning in any calendar year after 2013, subparagraph (A) shall be applied by substituting for 8 percent the percentage the Secretary of Health and Human Services determines reflects the excess of the rate of premium growth between the preceding calendar year and 2012 over the rate of income growth for such period.
I|D|I|1301.48|5000A.(e)(3)
Taxpayers with income under 100 percent of poverty line Any applicable individual who has a household income for the for the second taxable year preceding the taxable year described in subsection (b)(2) which is less than 100 percent of the poverty line for the size of the family involved (determined in the same manner as under subsection (b)(4)).
I|D|I|1301.48|5000A.(e)(4)
Native Americans Any applicable individual who is an Indian as defined in section 4 of the Indian Health Care Improvement Act.
I|D|I|1301.48|5000A.(e)(5)
Hardships Any applicable individual who is determined by the Secretary to have suffered a hardship with respect to the capability to obtain coverage under a qualified health benefits plan.
I|D|I|1301.48|5000A.(f)
Essential health benefits coverage For purposes of this section -
I|D|I|1301.48|5000A.(f)(1)
In general The term essential health benefits coverage means any of the following:
I|D|I|1301.48|5000A.(f)(1)(A)
Qualified health benefits plan coverage Coverage under a qualified health benefits plan.
I|D|I|1301.48|5000A.(f)(1)(B)
Grandfathered health benefits plan Coverage under a grandfathered health benefits plan (as defined in section 2221(c) of the Social Security Act).
I|D|I|1301.48|5000A.(f)(1)(C)
Employer-sponsored plan Coverage under an eligible employer-sponsored plan.
I|D|I|1301.48|5000A.(f)(1)(D)
Medicare Coverage under part A of title XVIII of the Social Security Act.
I|D|I|1301.48|5000A.(f)(1)(E)
Medicaid Coverage for medical assistance under title XIX of the Social Security Act.
I|D|I|1301.48|5000A.(f)(1)(F)
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.
I|D|I|1301.48|5000A.(f)(1)(G)
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 Secretary of Health and Human Services in coordination with the Secretary to be not less than a level specified by the Secretary of Health and Human Services, based on the individual's priority for services as provided under section 1705(a) of such title.
I|D|I|1301.48|5000A.(f)(1)(H)
Federal employees coverage Coverage under the Federal employees health benefits program under chapter 89 of title 5, United States Code.
I|D|I|1301.48|5000A.(f)(1)(I)
Other coverage Such other health benefits coverage, such as a State health benefits risk pool or coverage while incarcerated, as the Secretary of Health and Human Services, in coordination with the Secretary, recognizes for purposes of this subsection.
I|D|I|1301.48|5000A.(f)(2)
Eligible employer-sponsored plan The term eligible employer-sponsored plan means, with respect to any employee, a health benefits plan (other than a grandfathered health benefits plan) offered by an employer to the employee, but only if -
I|D|I|1301.48|5000A.(f)(2)(A)
in the case of a small employer, the plan is a qualified health benefits plan, and
I|D|I|1301.48|5000A.(f)(2)(B)
in the case of a large employer plan, the plan meets the requirements of section 2244 of the Social Security Act.
I|D|I|1301.48|5000A.(f)(3)
Insurance-related terms Any term used in this section which is also used in title XXII of the Social Security Act shall have the same meaning as when used in such title.
I|D|I|1301.48|5000A.(g)
Modifications of subtitle F Notwithstanding any other provision of law -
I|D|I|1301.48|5000A.(g)(1)
Waiver of criminal and civil penalties and interest In the case of any failure by a taxpayer to timely pay any tax imposed by this section -
I|D|I|1301.48|5000A.(g)(1)(A)
such taxpayer shall not be subject to any criminal prosecution or penalty with respect to such failure, and
I|D|I|1301.48|5000A.(g)(1)(B)
no penalty, addition to tax, or interest shall be imposed with respect to such failure or such tax.
I|D|I|1301.48|5000A.(g)(2)
Limited collection actions permitted In the case of the assessment of any tax imposed by this section, the Secretary shall not take any action with respect to the collection of such tax other than -
I|D|I|1301.48|5000A.(g)(2)(A)
giving notice and demand for such tax under section 6303,
I|D|I|1301.48|5000A.(g)(2)(B)
crediting under section 6402(a) the amount of any overpayment of the taxpayer against such tax, and
I|D|I|1301.48|5000A.(g)(2)(C)
offsetting any payment owed by any Federal agency to the taxpayer against such tax under the Treasury offset program.
.
I|D|I|1301.(b)
Clerical amendment The table of chapters for subtitle D of the Internal Revenue Code of 1986 is amended by inserting after the item relating to chapter 47 the following new item: Chapter 48 - Maintenance of essential health benefits coverage .
I|D|I|1301.(c)
Study on affordable coverage
I|D|I|1301.(c)(1)
Study and report
I|D|I|1301.(c)(1)(A)
In general The Comptroller General shall conduct a study on the affordability of health insurance coverage, including -
I|D|I|1301.(c)(1)(A)(i)
the impact of the tax credit for qualified health insurance coverage of individuals under section 36B of the Internal Revenue Code of 1986 and the tax credit for employee health insurance expenses of small employers under section 45R of such Code on maintaining and expanding the health insurance coverage of individuals,
I|D|I|1301.(c)(1)(A)(ii)
the availability of affordable health benefits plans, and
I|D|I|1301.(c)(1)(A)(iii)
the ability of individuals to maintain essential health benefits coverage (as defined in section 5000A(f) of the Internal Revenue Code of 1986).
I|D|I|1301.(c)(1)(B)
Report Not later than February 1, 2014, the Comptroller General shall submit to the appropriate committees of Congress a report on the study conducted under subparagraph (A), together with legislative recommendations relating to the matters studied under such subparagraph.
I|D|I|1301.(c)(2)
Congressional consideration of recommendations
I|D|I|1301.(c)(2)(A)
Committee consideration of proposal; discharge; contingency for introduction Not later than April 1, 2014, the appropriate committees of Congress shall report legislation implementing the recommendations contained in the report described in paragraph (1)(B). If, with respect to the House involved, any such committee has not reported such legislation by such date, such committees shall be deemed to be discharged from further consideration of the proposal and any member of the House of Representatives or the Senate, respectively, may introduce legislation implementing the recommendations contained in the proposal and such legislation shall be placed on the appropriate calendar of the House involved.
I|D|I|1301.(c)(2)(B)
Expedited procedure
I|D|I|1301.(c)(2)(B)(i)
Consideration If legislation is reported out of committee or legislation is introduced under subparagraph (A), not later than 15 calendar days after the date on which a committee has been or could have been discharged from consideration of such legislation or such legislation is introduced, the Speaker of the House of Representatives, or the Speaker's designee, or the majority leader of the Senate, or the leader's designee, shall move to proceed to the consideration of the legislation. It shall also be in order for any member of the Senate or the House of Representatives, respectively, to move to proceed to the consideration of the legislation at any time after the conclusion of such 15-day period. All points of order against the legislation (and against consideration of the legislation) with the exception of points of order under the Congressional Budget Act of 1974 are waived. A motion to proceed to the consideration of the legislation is privileged in the Senate and highly privileged in the House of Representatives and is not debatable. The motion is not subject to amendment, to a motion to postpone consideration of the legislation, or to a motion to proceed to the consideration of other business. A motion to reconsider the vote by which the motion to proceed is agreed to or not agreed to shall not be in order. If the motion to proceed is agreed to, the Senate or the House of Representatives, as the case may be, shall immediately proceed to consideration of the legislation in accordance with the Standing Rules of the Senate or the House of Representatives, as the case may be, without intervening motion, order, or other business, and the resolution shall remain the unfinished business of the Senate or the House of Representatives, as the case may be, until disposed of.
I|D|I|1301.(c)(2)(B)(ii)
Consideration by other House If, before the passage by one House of the legislation that was introduced in such House, such House receives from the other House legislation as passed by such other House -
I|D|I|1301.(c)(2)(B)(ii)(I)
the legislation of the other House shall not be referred to a committee and shall immediately displace the legislation that was reported or introduced in the House in receipt of the legislation of the other House; and
I|D|I|1301.(c)(2)(B)(ii)(II)
the legislation of the other House shall immediately be considered by the receiving House under the same procedures applicable to legislation reported by or discharged from a committee or introduced under subparagraph (A). Upon disposition of legislation that is received by one House from the other House, it shall no longer be in order to consider the legislation that was reported or introduced in the receiving House.
I|D|I|1301.(c)(2)(B)(iii)
Senate limits on debate In the Senate, consideration of the legislation and on all debatable motions and appeals in connection therewith shall not exceed a total of 30 hours, which shall be divided equally between those favoring and those opposing the legislation. A motion further to limit debate on the legislation is in order and is not debatable. Any debatable motion or appeal is debatable for not to exceed 1 hour, to be divided equally between those favoring and those opposing the motion or appeal. All time used for consideration of the legislation, including time used for quorum calls and voting, shall be counted against the total 30 hours of consideration.
I|D|I|1301.(c)(2)(B)(iv)
Consideration in conference Immediately upon a final passage of the legislation that results in a disagreement between the two Houses of Congress with respect to the legislation, conferees shall be appointed and a conference convened. Not later than 15 days after the date on which conferees are appointed (excluding periods in which one or both Houses are in recess), the conferees shall file a report with the Senate and the House of Representatives resolving the differences between the Houses on the legislation. Notwithstanding any other rule of the Senate or the House of Representatives, it shall be in order to immediately consider a report of a committee of conference on the legislation filed in accordance with this subsection. Debate in the Senate and the House of Representatives on the conference report shall be limited to 10 hours, equally divided and controlled by the majority and minority leaders of the Senate or their designees and the Speaker of the House of Representatives and the minority leader of the House of Representatives or their designees. A vote on final passage of the conference report shall occur immediately at the conclusion or yielding back of all time for debate on the conference report.
I|D|I|1301.(c)(2)(C)
Rules of the Senate and House of Representatives This paragraph is enacted by Congress -
I|D|I|1301.(c)(2)(C)(i)
as an exercise of the rulemaking power of the Senate and House of Representatives, respectively, and is deemed to be part of the rules of each House, respectively, but applicable only with respect to the procedure to be followed in that House in the case of legislation under this section, and it supersedes other rules only to the extent that it is inconsistent with such rules; and
I|D|I|1301.(c)(2)(C)(ii)
with full recognition of the constitutional right of either House to change the rules (so far as they relate to the procedure of that House) at any time, in the same manner, and to the same extent as in the case of any other rule of that House.
I|D|I|1301.(c)(3)
Appropriate committees of Congress In this subsection, the term appropriate committees of Congress means the Committee on Ways and Means, the Committee on Education and Labor, and the Committee on Energy and Commerce of the House of Representatives and the Committee on Finance and the Committee on Health, Education, Labor and Pensions of the Senate.
I|D|I|1301.(d)
Effective date The amendments made by this section shall apply to taxable years ending after December 31, 2012.
I|D|I|1302.
Reporting of health insurance coverage
I|D|I|1302.(a)
In general Part III of subchapter A of chapter 61 of the Internal Revenue Code of 1986 is amended by inserting after subpart C the following new subpart:
I|D|I|1302.(a)D
Information regarding health insurance coverage Sec. 6055. Reporting of health insurance coverage.
I|D|I|1302.(a)D|6055.
Reporting of health insurance coverage
I|D|I|1302.(a)D|6055.(a)
In general Every person who provides essential health benefits coverage to an individual during a calendar year shall, at such time as the Secretary may prescribe, make a return described in subsection (b).
I|D|I|1302.(a)D|6055.(b)
Form and manner of return
I|D|I|1302.(a)D|6055.(b)(1)
In general A return is described in this subsection if such return -
I|D|I|1302.(a)D|6055.(b)(1)(A)
is in such form as the Secretary may prescribe, and
I|D|I|1302.(a)D|6055.(b)(1)(B)
contains -
I|D|I|1302.(a)D|6055.(b)(1)(B)(i)
the name, address and TIN of the primary insured and the name of each other individual obtaining coverage under the policy,
I|D|I|1302.(a)D|6055.(b)(1)(B)(ii)
the dates during which such individual was covered under essential health benefits coverage during the calendar year,
I|D|I|1302.(a)D|6055.(b)(1)(B)(iii)
the amount (if any) of any advance payment under section 2248 of the Social Security Act of any cost-sharing subsidy under section 2247 of such Act or of any premium credit under section 36B with respect to such coverage, and
I|D|I|1302.(a)D|6055.(b)(1)(B)(iv)
such other information as the Secretary may require.
I|D|I|1302.(a)D|6055.(b)(2)
Information relating to employer-provided coverage If essential health benefits coverage provided to an individual under subsection (a) consists of health insurance coverage of a health insurance issuer provided through a group health plan of an employer, a return described in this subsection shall include -
I|D|I|1302.(a)D|6055.(b)(2)(A)
the name, address, and employer identification number of the employer maintaining the plan,
I|D|I|1302.(a)D|6055.(b)(2)(B)
the portion of the premium (if any) required to be paid by the employer, and
I|D|I|1302.(a)D|6055.(b)(2)(C)
if the health insurance coverage is a qualified health benefits plan in the small group market offered through an exchange, such other information as the Secretary may require for administration of the credit under section 45R (relating to credit for employee health insurance expenses of small employers).
I|D|I|1302.(a)D|6055.(c)
Statements to be furnished to individuals with respect to whom information is reported
I|D|I|1302.(a)D|6055.(c)(1)
In general Every person required to make a return under subsection (a) shall furnish to each individual whose name is required to be set forth in such return a written statement showing -
I|D|I|1302.(a)D|6055.(c)(1)(A)
the name and address of the person required to make such return and the phone number of the information contact for such person, and
I|D|I|1302.(a)D|6055.(c)(1)(B)
the information required to be shown on the return with respect to such individual.
I|D|I|1302.(a)D|6055.(c)(2)
Time for furnishing statements The written statement required under paragraph (1) shall be furnished on or before January 31 of the year following the calendar year for which the return under subsection (a) was required to be made.
I|D|I|1302.(a)D|6055.(d)
Coverage provided by governmental units In the case of coverage provided by any governmental unit or any agency or instrumentality thereof, the officer or employee who enters into the agreement to provide such coverage (or the person appropriately designated for purposes of this section) shall make the returns and statements required by this section.
I|D|I|1302.(a)D|6055.(e)
Essential health benefits coverage For purposes of this section, the term essential health benefits coverage has the meaning given such term by section 5000A(f).
.
I|D|I|1302.(b)
Assessable penalties
I|D|I|1302.(b)(1)
Subparagraph (B) of section 6724(d)(1) of the Internal Revenue Code of 1986 (relating to definitions) is amended by striking or at the end of clause (xxii), by striking and at the end of clause (xxiii) and inserting or , and by inserting after clause (xxiii) the following new clause:
I|D|I|1302.(b)(1)(xxiv)
section 6055 (relating to returns relating to information regarding health insurance coverage), and .
I|D|I|1302.(b)(2)
Paragraph (2) of section 6724(d) of such Code is amended by striking or at the end of subparagraph (EE), by striking the period at the end of subparagraph (FF) and inserting , or and by inserting after subparagraph (FF) the following new subparagraph:
I|D|I|1302.(b)(2)(GG)
section 6055(c) (relating to statements relating to information regarding health insurance coverage). .
I|D|I|1302.(c)
Conforming amendment The table of subparts for part III of subchapter A of chapter 61 of such Code is amended by inserting after the item relating to subpart C the following new item: SUBPART D - Information regarding health insurance coverage .
I|D|I|1302.(d)
Effective date The amendments made by this section shall apply to calendar years beginning after 2012.
I|D|II
Employer Responsibility
I|D|II|1306.
Employer shared responsibility requirement
I|D|II|1306.(a)
In general Chapter 43 of the Internal Revenue Code of 1986 is amended by adding at the end the following:
I|D|II|1306.(a)4980H.
Employer responsibility to provide health coverage
I|D|II|1306.(a)4980H.(a)
Imposition of excise tax If -
I|D|II|1306.(a)4980H.(a)(1)
an applicable large employer fails to meet the health insurance coverage requirements of subsection (c) with respect to its full-time employees, and
I|D|II|1306.(a)4980H.(a)(2)
any such full-time employee of the employer is enrolled for any month during the period of such failure in a qualified health benefits plan with respect to which an applicable premium credit or cost-sharing subsidy is allowed or paid with respect to the employee, there is hereby imposed on such failure with respect to each such employee for each such month a tax in the amount determined under subsection (b).
I|D|II|1306.(a)4980H.(b)
Amount of tax
I|D|II|1306.(a)4980H.(b)(1)
In general The tax determined under this subsection with respect to a failure involving an employee for any month described in subsection (a)(2) shall be equal to 1/12 of the dollar amount which the Secretary of Health and Human Services determines (on the basis of the most recent data available) is equal to the sum of the average annual credit allowed under section 36B and the average annual cost-sharing subsidy under section 2247 of the Social Security Act for taxable years beginning in the calendar year preceding the calendar year in which such month occurs. In the case of a month occurring during 2013, the Secretary shall determine the average annual credit and subsidy on the basis of the aggregate amount of credits and subsidies (expressed as an annual amount) for which applicants were determined eligible during the initial open enrollment period under section 2237(d)(2)(A) of the Social Security Act.
I|D|II|1306.(a)4980H.(b)(2)
Overall limitation
I|D|II|1306.(a)4980H.(b)(2)(A)
In general The aggregate amount of tax determined under paragraph (1) with respect to all employees of an applicable large employer for any month shall not exceed 1/12 of the product of -
I|D|II|1306.(a)4980H.(b)(2)(A)(i)
$400, and
I|D|II|1306.(a)4980H.(b)(2)(A)(ii)
the average number of full-time employees of the employer on business days during the calendar year preceding the calendar year in which such month occurs (determined in the same manner as under subsection (d)(1)).
I|D|II|1306.(a)4980H.(b)(2)(B)
Indexing In the case of any calendar year after 2013, the $400 amount under subparagraph (A)(i) shall be increased by an amount equal to the product of -
I|D|II|1306.(a)4980H.(b)(2)(B)(i)
$400, and
I|D|II|1306.(a)4980H.(b)(2)(B)(ii)
the premium adjustment percentage (as defined in section 2242(c)(7) of the Social Security Act) for the calendar year. If the amount of any increase under this subparagraph is not a multiple of $10, such increase shall be rounded to the next lowest multiple of $10.
I|D|II|1306.(a)4980H.(c)
Health insurance coverage requirements For purposes of this section -
I|D|II|1306.(a)4980H.(c)(1)
In general An applicable large employer meets the health insurance coverage requirements of this subsection if the employer -
I|D|II|1306.(a)4980H.(c)(1)(A)
in the case of an employer in the small group market in a State, offers to its full-time employees (and their dependents) the opportunity to enroll in a qualified health benefits plan or a grandfathered health benefits plan, and
I|D|II|1306.(a)4980H.(c)(1)(B)
in the case of an employer in the large group market in a State, offers to its full-time employees (and their dependents) the opportunity to enroll in a group health plan meeting the requirements of section 2244 of the Social Security Act or a grandfathered health benefits plan.
I|D|II|1306.(a)4980H.(c)(2)
Exception where coverage is unaffordable or fails to provide minimum value An employer shall not be treated as meeting the requirements of this subsection with respect to any employee if -
I|D|II|1306.(a)4980H.(c)(2)(A)
the employee is eligible for the credit allowable under section 36B because the employee's required contribution under the plan described in paragraph (1) is determined to be unaffordable under section 36B(c)(2)(C), or
I|D|II|1306.(a)4980H.(c)(2)(B)
in the case of a plan (other than a qualified health benefits plan) offered under paragraph (1), the plan's share of the total allowed costs of benefits provided under the plan is less than 65 percent of such costs.
I|D|II|1306.(a)4980H.(d)
Definitions and special rules For purposes of this section -
I|D|II|1306.(a)4980H.(d)(1)
Applicable large employer
I|D|II|1306.(a)4980H.(d)(1)(A)
In general The term applicable large employer means, with respect to a calendar year, an employer who employed an average of at least 50 employees on business days during the preceding calendar year.
I|D|II|1306.(a)4980H.(d)(1)(B)
Rules for determining employer size For purposes of this paragraph -
I|D|II|1306.(a)4980H.(d)(1)(B)(i)
Application of aggregation rule for employers All persons 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 as 1 employer.
I|D|II|1306.(a)4980H.(d)(1)(B)(ii)
Employers not in existence in preceding year In the case of an employer which was not in existence throughout the preceding calendar year, the determination of whether such employer is an applicable large employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year.
I|D|II|1306.(a)4980H.(d)(1)(B)(iii)
Predecessors Any reference in this subsection to an employer shall include a reference to any predecessor of such employer.
I|D|II|1306.(a)4980H.(d)(2)
Applicable premium credit and cost-sharing subsidy The term applicable premium credit and cost-sharing subsidy means -
I|D|II|1306.(a)4980H.(d)(2)(A)
any premium credit allowed under section 36B (and any advance payment of the credit under section 2248 of the Social Security Act), and
I|D|II|1306.(a)4980H.(d)(2)(B)
any cost-sharing subsidy payment under section 2247 of such Act.
I|D|II|1306.(a)4980H.(d)(3)
Full-time employee
I|D|II|1306.(a)4980H.(d)(3)(A)
In general The term full-time employee means an employee who is employed on average at least 30 hours per week.
I|D|II|1306.(a)4980H.(d)(3)(B)
Special rules The Secretary shall prescribe such regulations, rules, and guidance as may be necessary to apply this paragraph to employees who are not compensated on an hourly basis.
I|D|II|1306.(a)4980H.(d)(4)
Other definitions Any term used in this section which is also used in title XXII of the Social Security Act shall have the same meaning as when used in such title.
I|D|II|1306.(a)4980H.(d)(5)
Tax nondeductible For denial of deduction for the tax imposed by this section, see section 275(a)(6).
I|D|II|1306.(a)4980H.(e)
Time for payment of tax The Secretary may provide for the payment of the tax imposed by this section on an annual, monthly, or other periodic basis as the Secretary may prescribe.
.
I|D|II|1306.(b)
Clerical amendment The table of sections for chapter 43 of such Code is amended by adding at the end the following new item: Sec. 4980H. Employer responsibility to provide health coverage. .
I|D|II|1306.(c)
Study and report of effect of tax on workers' wages
I|D|II|1306.(c)(1)
In general The Secretary of Labor shall conduct a study to determine whether employees' wages are reduced by reason of the application of the tax imposed under section 4980H of the Internal Revenue Code of 1986 (as added by the amendments made by this section). The Secretary shall make such determination on the basis of the National Compensation Survey published by the Bureau of Labor Statistics.
I|D|II|1306.(c)(2)
Report The Secretary shall report the results of the study under paragraph (1) to the Committee on Ways and Means of the House of Representatives and to the Committee on Finance of the Senate.
I|D|II|1306.(d)
Effective date The amendments made by this section shall apply to periods beginning after June 30, 2013.
I|D|II|1307.
Reporting of employer health insurance coverage
I|D|II|1307.(a)
In general Subpart D of part III of subchapter A of chapter 61 of the Internal Revenue Code of 1986, as added by section 1302, is amended by inserting after section 6055 the following new section:
I|D|II|1307.(a)6056.
Large employers required to report on health insurance coverage
I|D|II|1307.(a)6056.(a)
In general Every applicable large employer required to meet the requirements of section 4980H(c) with respect to its full-time employees during a calendar year shall, at such time as the Secretary may prescribe, make a return described in subsection (b).
I|D|II|1307.(a)6056.(b)
Form and manner of return A return is described in this subsection if such return -
I|D|II|1307.(a)6056.(b)(1)
is in such form as the Secretary may prescribe, and
I|D|II|1307.(a)6056.(b)(2)
contains -
I|D|II|1307.(a)6056.(b)(2)(A)
the name, date, and employer identification number of the employer,
I|D|II|1307.(a)6056.(b)(2)(B)
a certification as to whether the employer offers to its full-time employees (and their dependents) the opportunity to enroll in a health benefits plan or a grandfathered health benefits plan described in section 4980H(c) and applicable to the employer,
I|D|II|1307.(a)6056.(b)(2)(C)
if the employer certifies that the employer did offer to its full-time employees (and their dependents) the opportunity to so enroll -
I|D|II|1307.(a)6056.(b)(2)(C)(i)
the months during the calendar year for which coverage was available, and
I|D|II|1307.(a)6056.(b)(2)(C)(ii)
the monthly premium for the lowest cost option in each of the enrollment categories under each health benefits plan offered to employees,
I|D|II|1307.(a)6056.(b)(2)(D)
the name, address, and TIN of each full-time employee during the calendar year and the months (if any) during which such employee (and any dependents) were covered under any such health benefits plans and,
I|D|II|1307.(a)6056.(b)(2)(E)
such other information as the Secretary may require.
I|D|II|1307.(a)6056.(c)
Statements to be furnished to individuals with respect to whom information is reported
I|D|II|1307.(a)6056.(c)(1)
In general Every person required to make a return under subsection (a) shall furnish to each full-time employee whose name is required to be set forth in such return under subsection (b)(2)(D) a written statement showing -
I|D|II|1307.(a)6056.(c)(1)(A)
the name and address of the person required to make such return and the phone number of the information contact for such person, and
I|D|II|1307.(a)6056.(c)(1)(B)
the information required to be shown on the return with respect to such individual.
I|D|II|1307.(a)6056.(c)(2)
Time for furnishing statements The written statement required under paragraph (1) shall be furnished on or before January 31 of the year following the calendar year for which the return under subsection (a) was required to be made.
I|D|II|1307.(a)6056.(d)
Coordination with other requirements To the maximum extent feasible, the Secretary may provide that -
I|D|II|1307.(a)6056.(d)(1)
any return or statement required to be provided under this section may be provided as part of any return or statement required under section 6051 or 6055, and
I|D|II|1307.(a)6056.(d)(2)
in the case of an applicable large employer offering a health benefits plan of a health insurance issuer, the employer may enter into an agreement with the issuer to include information required under this section with the return and statement required to be provided by the issuer under section 6055.
I|D|II|1307.(a)6056.(e)
Coverage provided by governmental units In the case of any applicable large employer which is a governmental unit or any agency or instrumentality thereof, the person appropriately designated for purposes of this section shall make the returns and statements required by this section.
I|D|II|1307.(a)6056.(f)
Definitions For purposes of this section, any term used in this section which is also used in section 4980H shall have the meaning given such term by section 4980H.
.
I|D|II|1307.(b)
Assessable penalties
I|D|II|1307.(b)(1)
Subparagraph (B) of section 6724(d)(1) of the Internal Revenue Code of 1986 (relating to definitions), as amended by section 1302, is amended by striking or at the end of clause (xxiii), by striking and at the end of clause (xxiv) and inserting or , and by inserting after clause (xxiv) the following new clause:
I|D|II|1307.(b)(1)(xxv)
section 6056 (relating to returns relating to large employers required to report on health insurance coverage), and .
I|D|II|1307.(b)(2)
Paragraph (2) of section 6724(d) of such Code, as so amended, is amended by striking or at the end of subparagraph (FF), by striking the period at the end of subparagraph (GG) and inserting , or and by inserting after subparagraph (GG) the following new subparagraph:
I|D|II|1307.(b)(2)(HH)
section 6056(c) (relating to statements relating to large employers required to report on health insurance coverage). .
I|D|II|1307.(c)
Conforming amendment The table of sections for subpart D of part III of subchapter A of chapter 61 of such Code, as added by section 1302, is amended by adding at the end the following new item: Sec. 6056. Large employers required to report on health insurance coverage. .
I|D|II|1307.(d)
Effective date The amendments made by this section shall apply to periods beginning after June 30, 2013.
I|E
Federal program for health care cooperatives
I|E|1401.
Establishment of Federal program for health care cooperatives
I|E|1401.(a)
In general Title XXII of the Social Security Act (as added by section 1001 and amended by sections 1101 and 1201) is amended by adding at the end the following:
I|E|1401.(a)D
Federal program for health care cooperatives
I|E|1401.(a)D|2251.
Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers
I|E|1401.(a)D|2251.(a)
Establishment of program
I|E|1401.(a)D|2251.(a)(1)
In general The Secretary shall establish a program to carry out the purposes of this section to be known as the Consumer Operated and Oriented Plan (CO-OP) program.
I|E|1401.(a)D|2251.(a)(2)
Purpose It is the purpose of the CO-OP program to foster the creation of qualified nonprofit health insurance issuers to offer qualified health benefits plans in the individual and small group markets in the States in which the issuers are licensed to offer such plans.
I|E|1401.(a)D|2251.(b)
Loans and grants under the CO-OP program
I|E|1401.(a)D|2251.(b)(1)
In general The Secretary shall provide through the CO-OP program for the awarding to persons applying to become qualified nonprofit health insurance issuers of -
I|E|1401.(a)D|2251.(b)(1)(A)
loans to provide assistance to such person in meeting its start-up costs; and
I|E|1401.(a)D|2251.(b)(1)(B)
grants to provide assistance to such person in meeting any solvency requirements of States in which the person seeks to be licensed to issue qualified health benefits plans.
I|E|1401.(a)D|2251.(b)(2)
Requirements for awarding loans and grants
I|E|1401.(a)D|2251.(b)(2)(A)
In general In awarding loans and grants under the CO-OP program, the Secretary shall -
I|E|1401.(a)D|2251.(b)(2)(A)(i)
take into account the recommendations of the advisory board established under paragraph (3);
I|E|1401.(a)D|2251.(b)(2)(A)(ii)
give priority to applicants that will offer qualified health benefits plans on a Statewide basis, will utilize integrated care models, and have significant private support; and
I|E|1401.(a)D|2251.(b)(2)(A)(iii)
ensure that there is sufficient funding to establish at least 1 qualified nonprofit health insurance issuer in each State, except that nothing in this clause shall prohibit the Secretary from funding the establishment of multiple qualified nonprofit health insurance issuers in any State if the funding is sufficient to do so.
I|E|1401.(a)D|2251.(b)(2)(B)
States without issuers in program If no health insurance issuer applies to be a qualified nonprofit health insurance issuer within a State, the Secretary may use amounts appropriated under this section for the awarding of grants to encourage the establishment of a qualified nonprofit health insurance issuer within the State or the expansion of a qualified nonprofit health insurance issuer from another State to the State.
I|E|1401.(a)D|2251.(b)(2)(C)
Agreement
I|E|1401.(a)D|2251.(b)(2)(C)(i)
In general The Secretary shall require any person receiving a loan or grant under the CO-OP program to enter into an agreement with the Secretary which requires such person to meet (and to continue to meet) -
I|E|1401.(a)D|2251.(b)(2)(C)(i)(I)
any requirement under this section for such person to be treated as a qualified nonprofit health insurance issuer; and
I|E|1401.(a)D|2251.(b)(2)(C)(i)(II)
any requirements contained in the agreement for such person to receive such loan or grant.
I|E|1401.(a)D|2251.(b)(2)(C)(ii)
Restrictions on use of Federal funds The agreement shall include a requirement that no portion of the funds made available by any loan or grant under this section may be used -
I|E|1401.(a)D|2251.(b)(2)(C)(ii)(I)
for carrying on propaganda, or otherwise attempting, to influence legislation; or
I|E|1401.(a)D|2251.(b)(2)(C)(ii)(II)
for marketing. Nothing in this clause shall be construed to allow a person to take any action prohibited by section 501(c)(29) of the Internal Revenue Code of 1986.
I|E|1401.(a)D|2251.(b)(2)(C)(iii)
Failure to meet requirements If the Secretary determines that a person has failed to meet any requirement described in clause (i) or (ii) and has failed to correct such failure within a reasonable period of time of when the person first knows (or reasonably should have known) of such failure, such person shall repay to the Secretary an amount equal to the sum of -
I|E|1401.(a)D|2251.(b)(2)(C)(iii)(I)
110 percent of the aggregate amount of loans and grants received under this section; plus
I|E|1401.(a)D|2251.(b)(2)(C)(iii)(II)
interest on the aggregate amount of loans and grants received under this section for the period the loans or grants were outstanding. The Secretary shall notify the Secretary of the Treasury of any determination under this section of a failure that results in the termination of an issuer's tax-exempt status under section 501(c)(29) of such Code.
I|E|1401.(a)D|2251.(b)(2)(D)
Time for awarding loans and grants The Secretary shall not later than January 1, 2012, award the loans and grants under the CO-OP program and begin the distribution of amounts awarded under such loans and grants.
I|E|1401.(a)D|2251.(b)(3)
Advisory board
I|E|1401.(a)D|2251.(b)(3)(A)
In general The advisory board under this paragraph shall consist of 15 members appointed by the Comptroller General of the United States from among individuals with qualifications described in section 1805(c)(2).
I|E|1401.(a)D|2251.(b)(3)(B)
Rules relating to appointments
I|E|1401.(a)D|2251.(b)(3)(B)(i)
Standards Any individual appointed under subparagraph (A) shall meet ethics and conflict of interest standards protecting against insurance industry involvement and interference.
I|E|1401.(a)D|2251.(b)(3)(B)(ii)
Original appointments The original appointment of board members under subparagraph (A)(ii) shall be made no later than 3 months after the date of enactment of this title.
I|E|1401.(a)D|2251.(b)(3)(C)
Vacancy Any vacancy on the advisory board shall be filled in the same manner as the original appointment.
I|E|1401.(a)D|2251.(b)(3)(D)
Pay and reimbursement
I|E|1401.(a)D|2251.(b)(3)(D)(i)
No compensation for members of advisory board Except as provided in clause (ii), a member of the advisory board may not receive pay, allowances, or benefits by reason of their service on the board.
I|E|1401.(a)D|2251.(b)(3)(D)(ii)
Travel expenses Each member shall receive travel expenses, including per diem in lieu of subsistence under subchapter I of chapter 57 of title 5, United States Code.
I|E|1401.(a)D|2251.(b)(3)(E)
Application of FACA The Federal Advisory Committee Act (5 U.S.C. App.) shall apply to the advisory board, except that section 14 of such Act shall not apply.
I|E|1401.(a)D|2251.(b)(3)(F)
Termination The advisory board shall terminate on the earlier of the date that it completes its duties under this section or December 31, 2015.
I|E|1401.(a)D|2251.(c)
Qualified nonprofit health insurance issuer For purposes of this section -
I|E|1401.(a)D|2251.(c)(1)
In general The term qualified nonprofit health insurance issuer means a health insurance issuer that is an organization -
I|E|1401.(a)D|2251.(c)(1)(A)
that is organized under State law as a nonprofit, member corporation;
I|E|1401.(a)D|2251.(c)(1)(B)
substantially all of the activities of which consist of the issuance of qualified health benefits plans in the individual and small group markets in each State in which it is licensed to issue such plans; and
I|E|1401.(a)D|2251.(c)(1)(C)
that meets the other requirements of this subsection.
I|E|1401.(a)D|2251.(c)(2)
Certain organizations prohibited An organization shall not be treated as a qualified nonprofit health insurance issuer if -
I|E|1401.(a)D|2251.(c)(2)(A)
the organization or a related entity (or any predecessor of either) was a health insurance issuer on July 16, 2009; or
I|E|1401.(a)D|2251.(c)(2)(B)
the organization is sponsored by a State or local government, any political subdivision thereof, or any instrumentality of such government or political subdivision.
I|E|1401.(a)D|2251.(c)(3)
Governance requirements An organization shall not be treated as a qualified nonprofit health insurance issuer unless -
I|E|1401.(a)D|2251.(c)(3)(A)
the governance of the organization is subject to a majority vote of its members;
I|E|1401.(a)D|2251.(c)(3)(B)
its governing documents incorporate ethics and conflict of interest standards protecting against insurance industry involvement and interference; and
I|E|1401.(a)D|2251.(c)(3)(C)
as provided in regulations promulgated by the Secretary, the organization is required to operate with a strong consumer focus, including timeliness, responsiveness, and accountability to members.
I|E|1401.(a)D|2251.(c)(4)
Profits inure to benefit of members An organization shall not be treated as a qualified nonprofit health insurance issuer unless any profits made by the organization are required to be used to lower premiums, to improve benefits, or for other programs intended to improve the quality of health care delivered to its members.
I|E|1401.(a)D|2251.(c)(5)
Compliance with State insurance laws An organization shall not be treated as a qualified nonprofit health insurance issuer unless the organization meets all the requirements that other offerors of qualified health benefits are required to meet in any State where the issuer offers a qualified health benefits plan, including solvency and licensure requirements, rules on payments to providers, and compliance with network adequacy rules, rate and form filing rules, and any applicable State premium assessments.
I|E|1401.(a)D|2251.(c)(6)
Coordination with State insurance reforms An organization shall not be treated as a qualified nonprofit health insurance issuer unless the organization does not offer a health benefits plan in a State until that State has in effect the Model Regulation, Federal standard, or State law described in section 2225(a)(2).
I|E|1401.(a)D|2251.(d)
Establishment of private purchasing council
I|E|1401.(a)D|2251.(d)(1)
In general Qualified nonprofit health insurance issuers participating in the CO-OP program under this section may establish a private purchasing council to enter into collective purchasing arrangements for items and services that increase administrative and other cost efficiencies, including claims administration, administrative services, health information technology, and actuarial services.
I|E|1401.(a)D|2251.(d)(2)
Council may not set payment rates The private purchasing council established under paragraph (1) shall not set payment rates for health care facilities or providers participating in health insurance coverage provided by qualified nonprofit health insurance issuers.
I|E|1401.(a)D|2251.(d)(3)
Continued application of antitrust laws
I|E|1401.(a)D|2251.(d)(3)(A)
In general Nothing in this section shall be construed to limit the application of the antitrust laws to any private purchasing council (whether or not established under this subsection) or to any qualified nonprofit health insurance issuer participating in such a council.
I|E|1401.(a)D|2251.(d)(3)(B)
Antitrust laws For purposes of this subparagraph, the term antitrust laws has the meaning given the term in subsection (a) of the first section of the Clayton Act ( 15 U.S.C. 12(a) ). Such term also includes section 5 of the Federal Trade Commission Act ( 15 U.S.C. 45 ) to the extent that such section 5 applies to unfair methods of competition.
I|E|1401.(a)D|2251.(e)
Limitation on participation No representative of any Federal, State, or local government (or of any political subdivision or instrumentality thereof), and no representative of a person described in subsection (c)(2)(A), may serve on the board of directors of a qualified nonprofit health insurance issuer or with a private purchasing council established under subsection (d).
I|E|1401.(a)D|2251.(f)
Limitations on Secretary
I|E|1401.(a)D|2251.(f)(1)
In general The Secretary shall not -
I|E|1401.(a)D|2251.(f)(1)(A)
participate in any negotiations between 1 or more qualified nonprofit health insurance issuers (or a private purchasing council established under subsection (d)) and any health care facilities or providers, including any drug manufacturer, pharmacy, or hospital; and
I|E|1401.(a)D|2251.(f)(1)(B)
establish or maintain a price structure for reimbursement of any health benefits covered by such issuers.
I|E|1401.(a)D|2251.(f)(2)
Competition Nothing in this section shall be construed as authorizing the Secretary to interfere with the competitive nature of providing health benefits through qualified nonprofit health insurance issuers.
I|E|1401.(a)D|2251.(g)
State For purposes of this section, the term State means each of the 50 States and the District of Columbia.
I|E|1401.(a)D|2251.(h)
Appropriations There are hereby appropriated, out of any funds in the Treasury not otherwise appropriated, $6,000,000,000 to carry out this section.
.
I|E|1401.(b)
Tax exemption for qualified nonprofit health insurance issuer
I|E|1401.(b)(1)
In general Section 501(c) of the Internal Revenue Code of 1986 (relating to list of exempt organizations) is amended by adding at the end the following:
I|E|1401.(b)(1)(29)
CO-OP health insurance issuers
I|E|1401.(b)(1)(29)(A)
In general A qualified nonprofit health insurance issuer (within the meaning of section 2251 of the Social Security Act) which has received a loan or grant under the CO-OP program under such section, but only with respect to periods for which the issuer is in compliance with the requirements of such section and any agreement with respect to the loan or grant.
I|E|1401.(b)(1)(29)(B)
Conditions for exemption Subparagraph (A) shall apply to an organization only if -
I|E|1401.(b)(1)(29)(B)(i)
the organization has given notice to the Secretary, in such manner as the Secretary may by regulations prescribe, that it is applying for recognition of its status under this paragraph,
I|E|1401.(b)(1)(29)(B)(ii)
except as provided in section 2251(c)(4) of the Social Security Act, no part of the net earnings of which inures to the benefit of any private shareholder or individual,
I|E|1401.(b)(1)(29)(B)(iii)
no substantial part of the activities of which is carrying on propaganda, or otherwise attempting, to influence legislation, and
I|E|1401.(b)(1)(29)(B)(iv)
the organization does not participate in, or intervene in (including the publishing or distributing of statements), any political campaign on behalf of (or in opposition to) any candidate for public office.
.
I|E|1401.(b)(2)
Additional reporting requirement Section 6033 of such Code (relating to returns by exempt organizations) is amended by redesignating subsection (m) as subsection (n) and by inserting after subsection (l) the following:
I|E|1401.(b)(2)(m)
Additional information required from CO-OP insurers An organization described in section 501(c)(29) shall include on the return required under subsection (a) the following information:
I|E|1401.(b)(2)(m)(1)
The amount of the reserves required by each State in which the organization is licensed to issue qualified health benefits plans.
I|E|1401.(b)(2)(m)(2)
The amount of reserves on hand.
.
I|E|1401.(b)(3)
Application of tax on excess benefit transactions Section 4958(e)(1) of such Code (defining applicable tax-exempt organization) is amended by striking paragraph (3) or (4) and inserting paragraph (3), (4), or (29) .
I|E|1401.(c)
GAO Study and report
I|E|1401.(c)(1)
Study The Comptroller General of the General Accountability Office shall conduct an ongoing study on competition and market concentration in the health insurance market in the United States after the implementation of the reforms in such market under the provisions of, and the amendments made by, this Act. Such study shall include an analysis of new offerors of health insurance in such market.
I|E|1401.(c)(2)
Report The Comptroller General shall, not later than December 31 of each even-numbered year (beginning with 2014), report to the appropriate committees of the Congress the results of the study conducted under paragraph (1), including any recommendations for administrative or legislative changes the Comptroller General determines necessary or appropriate to increase competition in the health insurance market.
I|F
Transparency and accountability
I|F|1501.
Provisions ensuring transparency and accountability
I|F|1501.(a)
In general Title XXII of the Social Security Act, as added by subtitle A, is amended by adding at the end of subpart 4 of part A the following new section:
I|F|1501.(a)2229.
Requirements relating to transparency and accountability
I|F|1501.(a)2229.(a)
Ombudsmen Each State shall establish an ombudsmen program to address complaints related to health benefits plans issued within the State. Such program shall -
I|F|1501.(a)2229.(a)(1)
require each offeror of a health benefits plan within a State to provide an internal claims appeal process meeting the requirements of section 2226(e); and
I|F|1501.(a)2229.(a)(2)
authorize an individual covered by such a health benefits plan to have access to the services of an ombudsman -
I|F|1501.(a)2229.(a)(2)(A)
if such an internal appeal lasts more than 3 months or involves a life threatening issue; or
I|F|1501.(a)2229.(a)(2)(B)
to resolve problems with obtaining premium credits under section 36B of the Internal Revenue Code of 1986 or cost-sharing assistance under section 2247.
I|F|1501.(a)2229.(b)
Health insurance consumer assistance grants
I|F|1501.(a)2229.(b)(1)
In general Each State shall establish a program to provide grants to eligible entities to develop, support, and evaluate consumer assistance programs related to navigating options for health benefits plan coverage and selecting the appropriate health benefits plan coverage. Such program shall include a fair and open application process and shall attempt to ensure regional and geographic equity.
I|F|1501.(a)2229.(b)(2)
Data collection As a condition of receiving a grant under paragraph (1), an organization shall be required to collect and report data to the Secretary on the types of problems and inquiries encountered by consumers served by the consumer assistance programs.
I|F|1501.(a)2229.(b)(3)
Funding
I|F|1501.(a)2229.(b)(3)(A)
Initial funding There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $30,000,000 for the fiscal year 2014 to carry out this subsection. Such amount shall remain available without fiscal year limitation.
I|F|1501.(a)2229.(b)(3)(B)
Authorization for subsequent years There are authorized to be appropriated to the Secretary for each fiscal year following the fiscal year described in subparagraph (A) such sums as may be necessary to carry out this subsection.
I|F|1501.(a)2229.(b)(4)
Eligible entities In this section, the term eligible entity means any public, private, or not-for-profit consumer assistance organizations. Such term includes -
I|F|1501.(a)2229.(b)(4)(A)
any commercial fishing organization, any ranching or farming organization, or any other organization capable of conducting community-based health care outreach and enrollment assistance for workers who are hard to reach or employed in rural areas; and
I|F|1501.(a)2229.(b)(4)(B)
any Small Business Development Center that is capable of assisting small businesses in getting access to health benefits plans.
.
I|F|1501.(b)
Conforming amendment The table of sections for subpart 4 of part A of title XXII of the Social Security Act, as added by subtitle A, is amended by adding at the end the following new item: Sec. 2229. Requirements relating to transparency and accountability. .
I|F|1502.
Reporting on utilization of premium dollars and standard hospital charges
I|F|1502.(a)
Utilization of premium dollars
I|F|1502.(a)(1)
In general Each offeror of a health benefits plan offering health insurance coverage within the United States shall, with respect to each plan year beginning after December 31, 2009, report to the Secretary of Health and Human Services the percentage of the premiums collected for such coverage that are used to pay for items other than medical care.
I|F|1502.(a)(2)
Secretarial authority An offeror shall make the report under paragraph (1) at such time and in such manner as the Secretary of Health and Human Services may prescribe by regulations.
I|F|1502.(b)
Standard hospital charges Each hospital operating within the United States shall for each calendar year after 2009 establish (and update) a list of the hospital's standard charges for items and services provided by the hospital, including for each diagnosis-related group established under section 1886(d)(4) of the Social Security Act ( 42 U.S.C. 1395ww ).
I|F|1503.
Development and utilization of uniform outline of coverage documents
I|F|1503.(a)
In general The Secretary of Health and Human Services shall request the National Association of Insurance Commissioners (referred to, in this section as the NAIC ) to develop, and submit to the Secretary not later than 12 months after the date of enactment of this Act, standards for use by health insurance issuers in compiling and providing to enrollees an outline of coverage that accurately describes the coverage under the applicable health insurance plan. In developing such standards, the NAIC shall consult with a working group composed of representatives of consumer advocacy organizations, issuers of health insurance plans, and other qualified individuals.
I|F|1503.(b)
Requirements The standards for the outline of coverage developed under subsection (a) shall provide for the following:
I|F|1503.(b)(1)
Appearance The standards shall ensure that the outline of coverage is presented in a uniform format that does not exceed 4 pages in length and does not include print smaller than 12-point font.
I|F|1503.(b)(2)
Language The standards shall ensure that the language used is presented in a manner determined to be understandable by the average health plan enrollee.
I|F|1503.(b)(3)
Contents The standards shall ensure that the outline of coverage includes -
I|F|1503.(b)(3)(A)
the uniform definitions of standard insurance terms developed under section 1504;
I|F|1503.(b)(3)(B)
a description of the coverage, including dollar amounts for coverage of -
I|F|1503.(b)(3)(B)(i)
daily hospital room and board;
I|F|1503.(b)(3)(B)(ii)
miscellaneous hospital services;
I|F|1503.(b)(3)(B)(iii)
surgical services;
I|F|1503.(b)(3)(B)(iv)
anesthesia services;
I|F|1503.(b)(3)(B)(v)
physician services;
I|F|1503.(b)(3)(B)(vi)
prevention and wellness services;
I|F|1503.(b)(3)(B)(vii)
prescription drugs; and
I|F|1503.(b)(3)(B)(viii)
other benefits, as identified by the NAIC;
I|F|1503.(b)(3)(C)
the exceptions, reductions, and limitations on coverage;
I|F|1503.(b)(3)(D)
the cost-sharing provisions, including deductible, coinsurance, and co-payment obligations;
I|F|1503.(b)(3)(E)
the renewability and continuation of coverage provisions;
I|F|1503.(b)(3)(F)
a statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and
I|F|1503.(b)(3)(G)
a contact number for the consumer to call with additional questions and a web link where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained. For individual policies issued prior to January 1, 2014, the health insurance issuer will be deemed compliant with the web link requirement if the issuer makes a copy of the actual policy available upon request.
I|F|1503.(c)
Regulations
I|F|1503.(c)(1)
Submission If, not later than 12 months after the date of enactment of this Act, the NAIC submits to the Secretary of Health and Human Service the standards provided for under subsection (a), the Secretary shall, not later than 60 days after the date on which such standards are submitted, promulgate regulations to apply such standards to entities described in subsection (d)(3).
I|F|1503.(c)(2)
Failure to submit If the NAIC fails to submit to the Secretary the standards under subsection (a) within the 12-month period provided for in paragraph (1), the Secretary shall, not later than 90 days after the expiration of such 12-month period, promulgate regulations providing for the application of Federal standards for outlines of coverage to entities described in subsection (d)(3).
I|F|1503.(d)
Requirement to provide
I|F|1503.(d)(1)
In general Not later than 24 months after the date of enactment of this Act, each entity described in paragraph (3) shall deliver an outline of coverage pursuant to the standards promulgated by the Secretary under subsection (c) to -
I|F|1503.(d)(1)(A)
an applicant at the time of application;
I|F|1503.(d)(1)(B)
an enrollee at the time of enrollment; or
I|F|1503.(d)(1)(C)
a policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate.
I|F|1503.(d)(2)
Compliance An entity described in paragraph (3) is deemed in compliance with this section if the outline of coverage is provided in paper or electronic form.
I|F|1503.(d)(3)
Entities in general An entity described in this paragraph is -
I|F|1503.(d)(3)(A)
a health insurance issuer (including a group health plan) offering health insurance coverage within the United States (including carriers under the Federal Employee Health Benefits Program under chapter 89 of title 5, United States Code); and
I|F|1503.(d)(3)(B)
the Secretary with respect to coverage under the Medicare, Medicaid, and CHIP programs under titles XVIII, XIX, and XXI of the Social Security Act ( 42 U.S.C. 1395 , 1396, 1397aa et seq.).
I|F|1503.(e)
Preemption The standards promulgated under subsection (c) shall preempt any related State standards that require an outline of coverage.
I|F|1503.(f)
Failure to provide An entity described in subsection (d)(3) that willfully fails to provide the information required under this section shall be subject to a fine of not more than $1,000 for each such failure. Such failure with respect to each enrollee shall constitute a separate offense for purposes of this subsection.
I|F|1503.(g)
Definitions For purposes of this section, any term used in this section that is also used in title XXII of the Social Security Act shall have the same meaning as when used in such title.
I|F|1504.
Development of standard definitions, personal scenarios, and annual personalized statements
I|F|1504.(a)
Defining Insurance Terms
I|F|1504.(a)(1)
In general The Secretary of Health and Human Services shall, by regulations, provide for the development of standards for the definitions of terms used in health insurance coverage, including insurance-related terms (including the insurance-related terms described in paragraph (2)) and medical terms (including the medical terms described in paragraph (3)).
I|F|1504.(a)(2)
Insurance-related terms The insurance-related terms described in this paragraph are premium, deductible, co-insurance, co-payment, out-of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, UCR (usual, customary and reasonable) fees, excluded services, grievance and appeals, and such other terms as the Secretary determines are important to define so that consumers may compare health insurance coverage and understand the terms of their coverage.
I|F|1504.(a)(3)
Medical terms The medical terms described in this paragraph are hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as the Secretary determines are important to define so that consumers may compare the medical benefits offered by insurance health insurance and understand the extent of those medical benefits (or exceptions to those benefits).
I|F|1504.(b)
Coverage facts labels for patient claims scenarios The Secretary of Health and Human Services shall, by regulations, develop standards for coverage facts labels based on patient claims scenarios described in the regulations, which include information on estimated out-of-pocket cost-sharing and significant exclusions or benefit limits for such scenarios.
I|F|1504.(c)
Personalized statement The Secretary of Health and Human Services shall, by regulations, develop standards for an annual personalized statement that summarizes use of health care services and payment of claims with respect to an enrollee (and covered dependents) under health insurance coverage in the preceding year.
I|G
Role of Public Programs
I|G|I
Medicaid Coverage for the Lowest Income Populations
I|G|I|1601.
Medicaid coverage for the lowest income populations
I|G|I|1601.(a)
Coverage for individuals with income at or below 133 percent of the poverty line
I|G|I|1601.(a)(1)
Beginning 2014 Section 1902(a)(10)(A)(i) of the Social Security Act ( 42 U.S.C. 1396a ) is amended -
I|G|I|1601.(a)(1)(A)
by striking or at the end of subclause (VI);
I|G|I|1601.(a)(1)(B)
by adding or at the end of subclause (VII); and
I|G|I|1601.(a)(1)(C)
by inserting after subclause (VII) the following:
I|G|I|1601.(a)(1)(C)(VIII)
beginning January 1, 2014, who are under 65 years of age, not pregnant, and are not described in a previous subclause of this clause, and whose income (as determined under subsection (e)(14)) does not exceed 133 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved, subject to subsection (k); .
I|G|I|1601.(a)(2)
Coverage of, at a minimum, essential benefits; individuals with income exceeding 100, but less than 133 percent of the poverty line may elect subsidized exchange coverage instead of Medicaid Section 1902 of such Act ( 42 U.S.C. 1396a ) is amended by inserting after subsection (j) the following:
I|G|I|1601.(a)(2)(k)
I|G|I|1601.(a)(2)(k)(1)
The medical assistance provided to an individual described in subclause (VIII) of subsection (a)(10)(A)(i) shall consist of benchmark coverage described in section 1937(b)(1) or benchmark equivalent coverage described in section 1937(b)(2). Such medical assistance shall be provided subject to the requirements of section 1937, without regard to whether a State otherwise has elected the option to provide medical assistance through coverage under that section, unless an individual described in subclause (VIII) of subsection (a)(10)(A)(i) is also an individual for whom, under subparagraph (B) of section 1937(a)(2), the State may not require enrollment in benchmark coverage described in subsection (b)(1) of section 1937 or benchmark equivalent coverage described in subsection (b)(2) of that section, or the individual is a non-pregnant, non-elderly adult whose income exceeds 100, but does not exceed 133 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved, who has elected under section 1943(c) to enroll in a qualified health benefits plan through an exchange established by the State under section 2235.
.
I|G|I|1601.(a)(3)
Federal funding for cost of covering newly eligible individuals Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ), is amended -
I|G|I|1601.(a)(3)(A)
in subsection (b), in the first sentence, by inserting subsection (y) and before section 1933(d) ; and
I|G|I|1601.(a)(3)(B)
by adding at the end the following new subsection:
I|G|I|1601.(a)(3)(B)(y)
Increased FMAP for medical assistance for newly eligible mandatory individuals
I|G|I|1601.(a)(3)(B)(y)(1)
Amount of increase
I|G|I|1601.(a)(3)(B)(y)(1)(A)
Initial expansion period
I|G|I|1601.(a)(3)(B)(y)(1)(A)(i)
In general During the period that begins on January 1, 2014, and ends on December 31, 2018, notwithstanding subsection (b) and subject to subparagraphs (C) and (D) and section 1902(gg)(5), the Federal medical assistance percentage determined for a State that is one of the 50 States or the District of Columbia for each fiscal year quarter occurring during that period with respect to amounts expended for medical assistance for newly eligible individuals described in subclause (VIII) of section 1902(a)(10)(A)(i), shall be increased by the applicable percentage point increase specified in clause (ii) for the quarter and the State.
I|G|I|1601.(a)(3)(B)(y)(1)(A)(ii)
Applicable percentage point increase
I|G|I|1601.(a)(3)(B)(y)(1)(A)(ii)(I)
In general For purposes of clause (i), the applicable percentage point increase for a quarter is the following: For any fiscal year quarter occurring in the calendar year: If the State is an expansion State, the applicable percentage point increase is: If the State is not an expansion State, the applicable percentage point increase is: 2014 27.3 37.3 2015 28.3 36.3 2016 29.3 35.3 2017 30.3 34.3 2018 31.3 33.3
I|G|I|1601.(a)(3)(B)(y)(1)(A)(ii)(II)
Expansion state defined For purposes of the table in subclause (I), a State is an expansion State if, on the date of the enactment of the America's Healthy Future Act of 2009, the State offers health benefits coverage to parents and nonpregnant, childless adults whose income is at least 100 percent of the poverty line, that is not dependent on access to employer coverage or employment and is not limited to premium assistance, hospital-only benefits, a high deductible health plan (as defined in section 223(c)(2) of the Internal Revenue Code of 1986) purchased through a health savings account (as defined under section 223(d) of such Code), or alternative benefits under a demonstration program authorized under section 1938. A State that offers health benefits coverage to only parents or only nonpregnant childless adults described in the preceding sentence shall not be considered to be an expansion State.
I|G|I|1601.(a)(3)(B)(y)(1)(B)
2019 and succeeding years Beginning January 1, 2019, notwithstanding subsection (b) but subject to subparagraph (C), the Federal medical assistance percentage determined for a State that is one of the 50 States or the District of Columbia for each fiscal year quarter occurring during that period with respect to amounts expended for medical assistance for newly eligible individuals described in subclause (VIII) of section 1902(a)(10)(A)(i), shall be increased by 32.3 percentage points.
I|G|I|1601.(a)(3)(B)(y)(1)(C)
Limitation The Federal medical assistance percentage determined for a State under subparagraph (A) or (B) shall in no case be more than 95 percent.
I|G|I|1601.(a)(3)(B)(y)(1)(D)
High-need states Notwithstanding subparagraph (A), in the case of a high-need State, during the period that begins on January 1, 2014, and ends on December 31, 2018, the Federal medical assistance percentage determined for each fiscal year quarter occurring during that period with respect to amounts expended for medical assistance for newly eligible individuals described in subclause (VIII) of section 1902(a)(10)(A)(i), shall be equal to 100 percent. For purposes of the preceding sentence, the term high-need State means a State that is one of the 50 States or the District of Columbia, on the date of the enactment of the America's Healthy Future Act of 2009, has a total Medicaid enrollment under the State plan under this title and under any waiver of the plan that is below the national average for Medicaid enrollment as a percentage of State population, and for August 2009, has a seasonally-adjusted unemployment rate that is at least 12 percent, as determined by the Bureau of Labor Statistics of the Department of Labor.
I|G|I|1601.(a)(3)(B)(y)(2)
Definitions In this subsection:
I|G|I|1601.(a)(3)(B)(y)(2)(A)
Newly eligible The term newly eligible means, with respect to an individual described in subclause (VIII) of section 1902(a)(10)(A)(i), an individual who is not under 19 years of age (or such higher age as the State may have elected under section 1902(l)(1)(D)) and who, on the date of enactment of the America's Healthy Future Act of 2009, is not eligible under the State plan or under a waiver of the plan for full benefits or for benchmark coverage described in subparagraph (A), (B), or (C) of section 1937(b)(1) or benchmark equivalent coverage described in section 1937(b)(2) that has an aggregate actuarial value that is at least actuarially equivalent to benchmark coverage described in subparagraph (A), (B), or (C) of section 1937(b)(1), or is eligible but not enrolled (or is on a waiting list) for such benefits or coverage through a waiver under the plan that has a capped or limited enrollment that is full.
I|G|I|1601.(a)(3)(B)(y)(2)(B)
Full benefits The term full benefits means, with respect to an individual, medical assistance for all services covered under the State plan under this title that is not less in amount, duration, or scope, or is determined by the Secretary to be substantially equivalent, to the medical assistance available for an individual described in section 1902(a)(10)(A)(i).
.
I|G|I|1601.(a)(4)
State option to offer coverage earlier and presumptive eligibility; children required to have coverage for parents to be eligible Subsection (k) of section 1902 of the Social Security Act (as added by paragraph (2)), is amended by inserting after paragraph (1) the following:
I|G|I|1601.(a)(4)(2)
A State may elect through a State plan amendment to provide medical assistance to individuals described in subclause (VIII) of subsection (a)(10)(A)(i) beginning with the first day of any fiscal year quarter that begins on or after January 1, 2011, and before January 1, 2014. A State may elect to phase-in the extension of eligibility for medical assistance to such individuals based on income, so long as the State does not extend such eligibility to individuals described in such subclause with higher income before making individuals described in such subclause with lower income eligible for medical assistance.
I|G|I|1601.(a)(4)(3)
If the State has elected the option to provide for a period of presumptive eligibility under section 1920 or 1920A, the State may elect to provide for a period of presumptive eligibility for medical assistance (not to exceed 60 days) for individuals described in subclause (VIII) of subsection (a)(10)(A)(i) in the same manner as the State provides for such a period under that section, subject to such guidance as the Secretary shall establish.
I|G|I|1601.(a)(4)(4)
If an individual described in subclause (VIII) of subsection (a)(10)(A)(i) is the parent of a child who is under 19 years of age (or such higher age as the State may have elected under section 1902(l)(1)(D)) who is eligible for medical assistance under the State plan or under a waiver of such plan, the individual may not be enrolled under the State plan unless the individual's child is enrolled under the State plan or under a waiver of the plan or is enrolled in other health insurance coverage. For purposes of the preceding sentence, the term parent includes an individual treated as a caretaker relative for purposes of carrying out section 1931 and a noncustodial parent. .
I|G|I|1601.(a)(5)
Conforming amendments
I|G|I|1601.(a)(5)(A)
Section 1902(a)(10) of such Act ( 42 U.S.C. 1396a(a)(10) ) is amended in the matter following subparagraph (G), by striking and (XIV) and inserting (XIV) and by inserting and (XV) the medical assistance made available to an individual described in subparagraph (A)(i)(VIII) shall be limited to medical assistance described in subsection (k)(1) before the semicolon.
I|G|I|1601.(a)(5)(B)
Section 1902(l)(2)(C) of such Act ( 42 U.S.C. 1396a(l)(2)(C) ) is amended by striking 100 and inserting 133 .
I|G|I|1601.(a)(5)(C)
Section 1905(a) of such Act ( 42 U.S.C. 1396d(a) ) is amended in the matter preceding paragraph (1) -
I|G|I|1601.(a)(5)(C)(i)
by striking or at the end of clause (xii);
I|G|I|1601.(a)(5)(C)(ii)
by inserting or at the end of clause (xiii); and
I|G|I|1601.(a)(5)(C)(iii)
by inserting after clause (xiii) the following:
I|G|I|1601.(a)(5)(C)(iii)(xiv)
individuals described in section 1902(a)(10)(A)(i)(VIII), .
I|G|I|1601.(a)(5)(D)
Section 1903(f)(4) of such Act ( 42 U.S.C. 1396b(f)(4) ) is amended by inserting 1902(a)(10)(A)(i)(VIII), after 1902(a)(10)(A)(i)(VII), .
I|G|I|1601.(a)(5)(E)
Section 1937(a)(1)(B) of such Act ( 42 U.S.C. 1396u-7(a)(1)(B) ) is amended by inserting subclause (VIII) of section 1902(a)(10)(A)(i) or under after eligible under .
I|G|I|1601.(b)
Maintenance of medicaid income eligibility Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ) is amended -
I|G|I|1601.(b)(1)
in subsection (a) -
I|G|I|1601.(b)(1)(A)
by striking and at the end of paragraph (72);
I|G|I|1601.(b)(1)(B)
by striking the period at the end of paragraph (73) and inserting ; and ; and
I|G|I|1601.(b)(1)(C)
by inserting after paragraph (73) the following new paragraph:
I|G|I|1601.(b)(1)(C)(74)
provide for maintenance of effort under the State plan or under any waiver of the plan in accordance with subsection (gg). ; and
I|G|I|1601.(b)(2)
by adding at the end the following new subsection:
I|G|I|1601.(b)(2)(gg)
Maintenance of effort
I|G|I|1601.(b)(2)(gg)(1)
General requirement to maintain eligibility standards until state exchange is fully operational Subject to the succeeding paragraphs of this subsection, during the period that begins on the date of enactment of the America's Healthy Future Act of 2009 and ends on the date on which the Secretary determines that an exchange established by the State under section 2235 is fully operational, as a condition for receiving any Federal payments under section 1903(a) for calendar quarters occurring during such period, a State shall not have in effect eligibility standards, methodologies, or procedures under the State plan under this title or under any waiver of such plan that is in effect during that period, that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under the plan or waiver that are in effect on the date of enactment of the America's Healthy Future Act of 2009.
I|G|I|1601.(b)(2)(gg)(2)
Continuation of eligibility standards for adults with income at or below 133 percent of poverty until January 1, 2014 The requirement under paragraph (1) shall continue to apply to a State through December 31, 2013, with respect to the eligibility standards, methodologies, and procedures under the State plan under this title or under any waiver of such plan that are applicable to determining the eligibility for medical assistance of adults whose income does not exceed 133 percent of the poverty line (as defined in section 2110(c)(5)).
I|G|I|1601.(b)(2)(gg)(3)
Continuation of eligibility standards for children until October 1, 2019 The requirement under paragraph (1) shall continue to apply to a State through September 30, 2019, with respect to the eligibility standards, methodologies, and procedures under the State plan under this title or under any waiver of such plan that are applicable to determining the eligibility for medical assistance of any child who is under 19 years of age (or such higher age as the State may have elected under section 1902(l)(1)(D)).
I|G|I|1601.(b)(2)(gg)(4)
Nonapplication During the period that begins on January 1, 2011, and ends on December 31, 2013, the requirement under paragraph (1) shall not apply to a State with respect to nonpregnant, nondisabled adults who are eligible for medical assistance under the State plan or under a waiver of the plan at the option of the State and whose income exceeds 133 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved if, on or after December 31, 2010, the State certifies to the Secretary that, with respect to the State fiscal year during which the certification is made, the State has a budget deficit, or with respect to the succeeding State fiscal year, the State is projected to have a budget deficit. Upon submission of such a certification to the Secretary, the requirement under paragraph (1) shall not apply to the State with respect to any remaining portion of the period described in the preceding sentence.
I|G|I|1601.(b)(2)(gg)(5)
Additional federal financial participation
I|G|I|1601.(b)(2)(gg)(5)(A)
In general During the period that begins on October 1, 2013, and ends on September 30, 2019, notwithstanding section 1905(b), the Federal medical assistance percentage otherwise determined for a State under such section with respect to a fiscal year for amounts expended for medical assistance for individuals who are not newly eligible (as defined in section 1905(y)(2)(A)) individuals described in subclause (VIII) of section 1902(a)(10)(A)(i), shall -
I|G|I|1601.(b)(2)(gg)(5)(A)(i)
in the case of a State that is one of the 50 States or the District of Columbia, be increased by 0.15 percentage point; and
I|G|I|1601.(b)(2)(gg)(5)(A)(ii)
in the case of any other State, be increased by 0.075 percentage point.
I|G|I|1601.(b)(2)(gg)(5)(B)
Scope of application The increase in the Federal medical assistance percentage for a State under subparagraph (A) shall apply only for purposes of this title and shall not apply with respect to -
I|G|I|1601.(b)(2)(gg)(5)(B)(i)
disproportionate share hospital payments described in section 1923;
I|G|I|1601.(b)(2)(gg)(5)(B)(ii)
payments under title IV;
I|G|I|1601.(b)(2)(gg)(5)(B)(iii)
payments under title XXI; and
I|G|I|1601.(b)(2)(gg)(5)(B)(iv)
payments under this title that are based on the enhanced FMAP described in section 2105(b).
I|G|I|1601.(b)(2)(gg)(6)
Determination of compliance
I|G|I|1601.(b)(2)(gg)(6)(A)
States shall apply modified gross income A State's determination of income in accordance with subsection (e)(14) shall not be considered to be eligibility standards, methodologies, or procedures that are more restrictive than the standards, methodologies, or procedures in effect under the State plan or under a waiver of the plan on the date of enactment of the America's Healthy Future Act of 2009 for purposes of determining compliance with the requirements of paragraph (1), (2), or (3).
I|G|I|1601.(b)(2)(gg)(6)(B)
States may expand eligibility or move waivered populations into coverage under the State plan With respect to any period applicable under paragraph (1), (2), or (3), a State that applies eligibility standards, methodologies, or procedures under the State plan under this title or under any waiver of the plan that are less restrictive than the eligibility standards, methodologies, or procedures, applied under the State plan or under a waiver of the plan on the date of enactment of the America's Healthy Future Act of 2009, or that makes individuals who, on such date of enactment, are eligible for medical assistance under a waiver of the State plan, after such date of enactment eligible for medical assistance through a State plan amendment with an income eligibility level that is not less than the income eligibility level that applied under the waiver, or as a result of the application of subclause (VIII) of section 1902(a)(10)(A)(i), shall not be considered to have in effect eligibility standards, methodologies, or procedures that are more restrictive than the standards, methodologies, or procedures in effect under the State plan or under a waiver of the plan on the date of enactment of the America's Healthy Future Act of 2009 for purposes of determining compliance with the requirements of paragraph (1), (2), or (3).
.
I|G|I|1601.(c)
Medicaid benchmark benefits must consist of at least essential benefits Section 1937(b) of such Act ( 42 U.S.C. 1396u-7(b) ) is amended -
I|G|I|1601.(c)(1)
in paragraph (1), in the matter preceding subparagraph (A), by inserting subject to paragraphs (5) and (6), before each ;
I|G|I|1601.(c)(2)
in paragraph (2) -
I|G|I|1601.(c)(2)(A)
in the mater preceding subparagraph (A), by inserting subject to paragraphs (5) and (6) after subsection (a)(1), ;
I|G|I|1601.(c)(2)(B)
in subparagraph (A) -
I|G|I|1601.(c)(2)(B)(i)
by redesignating clauses (iv) and (v) as clauses (v) and (vi), respectively; and
I|G|I|1601.(c)(2)(B)(ii)
by inserting after clause (iii), the following:
I|G|I|1601.(c)(2)(B)(ii)(IV)
Coverage of prescription drugs. ; and
I|G|I|1601.(c)(2)(C)
in subparagraph (C) -
I|G|I|1601.(c)(2)(C)(i)
by striking clauses (i) and (ii); and
I|G|I|1601.(c)(2)(C)(ii)
by redesignating clauses (iii) and (iv) as clauses (i) and (ii), respectively; and
I|G|I|1601.(c)(3)
by adding at the end the following new paragraphs:
I|G|I|1601.(c)(3)(5)
Minimum standards Effective January 1, 2014, any benchmark benefit package under paragraph (1) or benchmark equivalent coverage under paragraph (2) must provide at least essential benefits described in section 2242 (as defined and specified annually by the Secretary in accordance with subsection (e) of that section).
I|G|I|1601.(c)(3)(6)
Mental health services parity
I|G|I|1601.(c)(3)(6)(A)
In general In the case of any benchmark benefit package under paragraph (1) or benchmark equivalent coverage under paragraph (2) that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan shall ensure that the financial requirements and treatment limitations applicable to such mental health or substance use disorder benefits comply with the requirements of section 2705(a) of the Public Health Service Act in the same manner as such requirements apply to a group health plan.
I|G|I|1601.(c)(3)(6)(B)
Deemed compliance Coverage provided with respect to an individual described in section 1905(a)(4)(B) and covered under the State plan under section 1902(a)(10)(A) of the services described in section 1905(a)(4)(B) (relating to early and periodic screening, diagnostic, and treatment services defined in section 1905(r)) and provided in accordance with section 1902(a)(43), shall be deemed to satisfy the requirements of subparagraph (A).
.
I|G|I|1601.(d)
Annual reports on medicaid enrollment
I|G|I|1601.(d)(1)
State reports Section 1902(a) of the Social Security Act ( 42 U.S.C. 1396a(a) ), as amended by subsection (b), is amended -
I|G|I|1601.(d)(1)(A)
by striking and at the end of paragraph (73);
I|G|I|1601.(d)(1)(B)
by striking the period at the end of paragraph (74) and inserting ; and ; and
I|G|I|1601.(d)(1)(C)
by inserting after paragraph (74) the following new paragraph:
I|G|I|1601.(d)(1)(C)(75)
provide that, beginning January 2015, and annually thereafter, the State shall submit a report to the Secretary that contains -
I|G|I|1601.(d)(1)(C)(75)(A)
the total number of newly enrolled individuals in the State plan or under a waiver of the plan for the fiscal year ending on September 30 of the preceding calendar year, disaggregated by population, including children, parents, nonpregnant childless adults, disabled individuals, elderly individuals, and such other categories or sub-categories of individuals eligible for medical assistance under the State plan or under a waiver of the plan as the Secretary may require; and
I|G|I|1601.(d)(1)(C)(75)(B)
a description of the outreach and enrollment processes used by the State during such fiscal year.
.
I|G|I|1601.(d)(2)
Reports to congress Beginning April 2015, and annually thereafter, the Secretary of Health and Human Services shall submit a report to the appropriate committees of Congress on the total new enrollment in Medicaid for the fiscal year ending on September 30 of the preceding calendar year on a national and State-by-State basis, and shall include in each such report such recommendations for administrative or legislative changes to improve enrollment in the Medicaid program as the Secretary determines appropriate.
I|G|I|1601.(e)
State option for coverage for individuals with income that exceeds 133 percent of the poverty line
I|G|I|1601.(e)(1)
Coverage as optional categorically needy group Section 1902 of the Social Security Act ( 42 U.S.C. 1396a ) is amended -
I|G|I|1601.(e)(1)(A)
in subsection (a)(10)(A)(ii) -
I|G|I|1601.(e)(1)(A)(i)
in subclause (XVIII), by striking or at the end;
I|G|I|1601.(e)(1)(A)(ii)
in subclause (XIX), by adding or at the end; and
I|G|I|1601.(e)(1)(A)(iii)
by adding at the end the following new subclause:
I|G|I|1601.(e)(1)(A)(iii)(XX)
beginning January 1, 2014, who are under 65 years of age and are not described in a previous subclause of this clause, and whose income (as determined under subsection (e)(14)) exceeds 133 percent of the poverty line (as defined in section 2110(c)(5)) applicable to a family of the size involved but does not exceed the highest income eligibility level established under the State plan or under a waiver of the plan, subject to subsection (hh); and
I|G|I|1601.(e)(1)(B)
by adding at the end the following new subsection:
I|G|I|1601.(e)(1)(B)(hh)
I|G|I|1601.(e)(1)(B)(hh)(1)
A State may elect to phase-in the extension of eligibility for medical assistance to individuals described in subclause (XX) of subsection (a)(10)(A)(ii) based on income, so long as the State does not extend such eligibility to individuals described in such subclause with higher income before making individuals described in such subclause with lower income eligible for medical assistance.
I|G|I|1601.(e)(1)(B)(hh)(2)
If the State has elected the option to provide for a period of presumptive eligibility under section 1920 or 1920A, the State may elect to provide for a period of presumptive eligibility for medical assistance (not to exceed 60 days) for individuals described in subclause (XX) of subsection (a)(10)(A)(ii) in the same manner as the State provides for such a period under that section, subject to such guidance as the Secretary shall establish.
I|G|I|1601.(e)(1)(B)(hh)(3)
If an individual described in subclause (XX) of subsection (a)(10)(A)(ii) is the parent of a child who is under 19 years of age (or such higher age as the State may have elected under section 1902(l)(1)(D)) who is eligible for medical assistance under the State plan or under a waiver of such plan, the individual may not be enrolled under the State plan unless the individual's child is enrolled under the State plan or under a waiver of the plan or is enrolled in other health insurance coverage. For purposes of the preceding sentence, the term parent includes an individual treated as a caretaker relative for purposes of carrying out section 1931 and a noncustodial parent.
.
I|G|I|1601.(e)(2)
Conforming amendments
I|G|I|1601.(e)(2)(A)
Section 1905(a) of such Act ( 42 U.S.C. 1396d(a) ), as amended by subsection (a)(5)(C), is amended in the matter preceding paragraph (1) -
I|G|I|1601.(e)(2)(A)(i)
by striking or at the end of clause (xiii);
I|G|I|1601.(e)(2)(A)(ii)
by inserting or at the end of clause (xiv); and
I|G|I|1601.(e)(2)(A)(iii)
by inserting after clause (xiv) the following:
I|G|I|1601.(e)(2)(A)(iii)(xv)
individuals described in section 1902(a)(10)(A)(ii)(XX), .
I|G|I|1601.(e)(2)(B)
Section 1903(f)(4) of such Act ( 42 U.S.C. 1396b(f)(4) ) is amended by inserting 1902(a)(10)(A)(ii)(XX), after 1902(a)(10)(A)(ii)(XIX), .
I|G|I|1602.
Income eligibility for nonelderly determined using modified gross income
I|G|I|1602.(a)
In general Section 1902(e) of the Social Security Act ( 42 U.S.C. 1396a(e) ) is amended by adding at the end the following:
I|G|I|1602.(a)(14)
Income determined using modified gross income
I|G|I|1602.(a)(14)(A)
In general Notwithstanding subsection (r) or any other provision of this title, except as provided in subparagraph (D), the modified gross income of an individual or family, as determined for purposes of allowing a premium credit assistance amount for the purchase of a qualified health benefits plan under section 36B of the Internal Revenue Code of 1986, shall be used for purposes of determining income eligibility for medical assistance under the State plan and under any waiver of such plan, and for any other purpose applicable under the plan or waiver for which a determination of income is required, including imposition of premiums and cost-sharing.
I|G|I|1602.(a)(14)(B)
No income or expense disregards No type of expense, block, or other income disregard shall be applied by a State in determining the modified gross income of an individual or family under the State plan or under a waiver of the plan.
I|G|I|1602.(a)(14)(C)
No assets test A State shall not apply any assets or resources test for purposes of determining the eligibility for medical assistance under the State plan or under a waiver of the plan of an individual or family.
I|G|I|1602.(a)(14)(D)
Exceptions
I|G|I|1602.(a)(14)(D)(i)
Individuals eligible because of other aid or assistance, elderly individuals, medically needy individuals, individuals eligible for medicare cost-sharing, and optional targeted low-income children Subparagraphs (A), (B), and (C) shall not apply to the determination of eligibility under the State plan or under a waiver for medical assistance for the following:
I|G|I|1602.(a)(14)(D)(i)(I)
Individuals who are eligible for medical assistance under the State plan or under a waiver of the plan on a basis that does not require a determination of income by the State agency administering the State plan or waiver, including as a result of eligibility for, or receipt of, other Federal or State aid or assistance, individuals who are eligible on the basis of receiving (or being treated as if receiving) supplemental security income benefits under title XVI, and individuals who are eligible as a result of being or being deemed to be a child in foster care under the responsibility of the State.
I|G|I|1602.(a)(14)(D)(i)(II)
Individuals who have attained age 65 or who are title II disability beneficiaries (as defined in section 1148(k)(3)).
I|G|I|1602.(a)(14)(D)(i)(III)
Individuals described in subsection (a)(10)(C).
I|G|I|1602.(a)(14)(D)(i)(IV)
Individuals described in any clause of subsection (a)(10)(E).
I|G|I|1602.(a)(14)(D)(i)(V)
Optional targeted low-income children described in section 1905(u)(2)(B).
I|G|I|1602.(a)(14)(D)(ii)
Express lane agency findings In the case of a State that elects the Express Lane option under paragraph (13), notwithstanding subparagraphs (A), (B), and (C), the State may rely on a finding made by an Express Lane agency in accordance with that paragraph relating to the income of an individual for purposes of determining the individual's eligibility for medical assistance under the State plan or under a waiver of the plan.
I|G|I|1602.(a)(14)(D)(iii)
Medicare prescription drug subsidies determinations Subparagraphs (A), (B), and (C) shall not apply to any determinations of eligibility for premium and cost-sharing subsidies under and in accordance with section 1860D-14 made by the State pursuant to section 1935(a)(2).
I|G|I|1602.(a)(14)(D)(iv)
Long-term care Subparagraphs (A), (B), and (C) shall not apply to any determinations of eligibility of individuals for purposes of medical assistance for services described in section 1917(c)(1)(C).
I|G|I|1602.(a)(14)(D)(v)
Grandfather of current enrollees until date of next regular redetermination An individual who, on July 1, 2013, is enrolled in the State plan or under a waiver of the plan and who would be determined ineligible for medical assistance solely because of the application of the modified gross income standard described in subparagraph (A), shall remain eligible for medical assistance under the State plan or waiver (and subject to the same premiums and cost-sharing as applied to the individual on that date) through March 31, 2014, or the date on which the individual's next regularly scheduled redetermination of eligibility is to occur, whichever is later.
I|G|I|1602.(a)(14)(E)
Limitation on secretarial authority The Secretary shall not waive compliance with the requirements of this paragraph except to the extent necessary to permit a State to coordinate eligibility requirements for dual eligible individuals (as defined in section 1915(h)(2)(B)) under the State plan or under a waiver of the plan and under title XVIII and individuals who require the level of care provided in a hospital, a nursing facility, or an intermediate care facility for the mentally retarded.
.
I|G|I|1602.(b)
Conforming amendment Section 1902(a)(17) of such Act ( 42 U.S.C. 1396a(a)(17) ) is amended by inserting (e)(14), before (l)(3) .
I|G|I|1602.(c)
Effective date The amendments made by subsections (a) and (b) take effect on July 1, 2013.
I|G|I|1603.
Requirement to offer premium assistance for employer-sponsored insurance
I|G|I|1603.(a)
In general Section 1906A of such Act ( 42 U.S.C. 1396e-1 ) is amended -
I|G|I|1603.(a)(1)
in subsection (a) -
I|G|I|1603.(a)(1)(A)
by striking may elect to and inserting shall ;
I|G|I|1603.(a)(1)(B)
by striking under age 19 ; and
I|G|I|1603.(a)(1)(C)
by inserting , in the case of an individual under age 19, after (and ;
I|G|I|1603.(a)(2)
in subsection (c), in the first sentence, by striking under age 19 ; and
I|G|I|1603.(a)(3)
in subsection (d)(2) -
I|G|I|1603.(a)(3)(A)
in the first sentence, by striking under age 19 ; and
I|G|I|1603.(a)(3)(B)
by striking the third sentence and inserting A State may not require, as a condition of an individual (or the individual's parent) being or remaining eligible for medical assistance under this title, that the individual (or the individual's parent) apply for enrollment in qualified employer-sponsored coverage under this section. .
I|G|I|1603.(b)
Conforming amendment The heading for section 1906A of such Act ( 42 U.S.C. 1396e-1 ) is amended by striking option for children .
I|G|I|1603.(c)
Effective date The amendments made by this section take effect on July 1, 2013.
I|G|I|1604.
Payments to territories
I|G|I|1604.(a)
Increase in limit on payments Section 1108(g) of the Social Security Act ( 42 U.S.C. 1308(g) ) is amended -
I|G|I|1604.(a)(1)
in paragraph (2), in the matter preceding subparagraph (A), by striking paragraph (3) and inserting paragraphs (3) and (5) ;
I|G|I|1604.(a)(2)
in paragraph (4), by striking and (3) and inserting (3), and (4) ; and
I|G|I|1604.(a)(3)
by adding at the end the following paragraph:
I|G|I|1604.(a)(3)(5)
Fiscal year 2011 and thereafter The amounts otherwise determined under this subsection for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa for the second, third, and fourth quarters of fiscal year 2011, and for each fiscal year after fiscal year 2011 (after the application of subsection (f) and the preceding paragraphs of this subsection), shall be increased by 30 percent. .
I|G|I|1604.(b)
Disregard of payments for mandatory expanded enrollment Section 1108(g)(4) of such Act ( 42 U.S.C. 1308(g) ) is amended -
I|G|I|1604.(b)(1)
by striking to fiscal years beginning and inserting "to -
I|G|I|1604.(b)(1)(A)
fiscal years beginning ;
I|G|I|1604.(b)(2)
by striking the period at the end and inserting ; and ; and
I|G|I|1604.(b)(3)
by adding at the end the following:
I|G|I|1604.(b)(3)(B)
fiscal years beginning with fiscal year 2014, payments made to Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, or American Samoa on the basis of the Federal medical assistance percentage as increased under section 1902(gg)(5), and payments made with respect to amounts expended for medical assistance for newly eligible (as defined in section 1905(y)(2)) nonpregnant childless adults who are eligible under subclause (VIII) of section 1902(a)(10)(A)(i) and whose income (as determined under section 1902(e)(14)) does not exceed (in the case of each such commonwealth and territory respectively) the income eligibility level in effect for that population under title XIX or under a waiver on the date of enactment of the America's Healthy Future Act of 2009, shall not be taken into account in applying subsection (f) (as increased in accordance with paragraphs (1), (2), (3), and (5) of this subsection) to such commonwealth or territory for such fiscal year. .
I|G|I|1604.(c)
Increased FMAP
I|G|I|1604.(c)(1)
In general The first sentence of section 1905(b) of the Social Security Act ( 42 U.S.C. 1396d(b) ) is amended by striking shall be 50 per centum and inserting shall be 55 percent .
I|G|I|1604.(c)(2)
Effective date The amendment made by paragraph (1) takes effect on January 1, 2011.
I|G|I|1605.
Medicaid Improvement Fund rescission
I|G|I|1605.(a)
Rescission Any amounts available to the Medicaid Improvement Fund established under section 1941 of the Social Security Act ( 42 U.S.C. 1396w-1 ) for any of fiscal years 2014 through 2018 that are available for expenditure from the Fund and that are not so obligated as of the date of the enactment of this Act are rescinded.
I|G|I|1605.(b)
Conforming amendments Section 1941(b)(1) of the Social Security Act ( 42 U.S.C. 1396w-1(b)(1) ) is amended -
I|G|I|1605.(b)(1)
in subparagraph (A), by striking $100,000,000 and inserting $0 ; and
I|G|I|1605.(b)(2)
in subparagraph (B), by striking $150,000,000 and inserting $0 .
I|G|II
Children's Health Insurance Program
I|G|II|1611.
Additional federal financial participation for CHIP
I|G|II|1611.(a)
In general Section 2105(b) of the Social Security Act ( 42 U.S.C. 1397ee(b) ) is amended by adding at the end the following: Notwithstanding the preceding sentence, during the period that begins on October 1, 2013, and ends on September 30, 2019, the enhanced FMAP determined for a State for a fiscal year (or for any portion of a fiscal year occurring during such period) shall be increased by 23 percentage points, but in no case shall exceed 100 percent. The increase in the enhanced FMAP under the preceding sentence shall not apply with respect to determining the payment to a State under subsection (a)(1) for expenditures described in subparagraph (D)(iv), paragraphs (8), (9), (11) of subsection (c), or clause (4) of the first sentence of section 1905(b). .
I|G|II|1611.(b)
Maintenance of effort Section 2105(d) of the Social Security Act ( 42 U.S.C. 1397ee(d) ) is amended by adding at the end the following:
I|G|II|1611.(b)(3)
Continuation of eligibility standards for children until October 1, 2019 During the period that begins on the date of enactment of the America's Healthy Future Act of 2009 and ends on September 30, 2019, a State shall not have in effect eligibility standards, methodologies, or procedures under its State child health plan (including any waiver under such plan) for children that are more restrictive than the eligibility standards, methodologies, or procedures, respectively, under such plan (or waiver) as in effect on the date of enactment of that Act. The preceding sentence shall not be construed as preventing a State during such period from -
I|G|II|1611.(b)(3)(A)
applying eligibility standards, methodologies, or procedures for children under the State child health plan or under any waiver of the plan that are less restrictive than the eligibility standards, methodologies, or procedures, respectively, for children under the plan or waiver that are in effect on the date of enactment of such Act; or
I|G|II|1611.(b)(3)(B)
imposing a limitation described in section 2112(b)(7) for a fiscal year in order to limit expenditures under the State child health plan to those for which Federal financial participation is available under this section for the fiscal year.
.
I|G|II|1611.(c)
No enrollment bonus payments for children enrolled after fiscal year 2013 Section 2105(a)(3)(F)(iii) of the Social Security Act ( 42 U.S.C. 1397ee(a)(3)(F)(iii) ) is amended by inserting or any children enrolled on or after October 1, 2013 before the period.
I|G|II|1611.(d)
Application of streamlined enrollment system Section 2107(e)(1) of the Social Security Act ( 42 U.S.C. 1397gg(e)(1) ) is amended by adding at the end the following:
I|G|II|1611.(d)(M)
Section 1943(b) (relating to coordination with State health insurance exchanges and the State Medicaid agency). .
I|G|II|1612.
Technical corrections
I|G|II|1612.(a)
CHIPRA Effective as if included in the enactment of the Children's Health Insurance Program Reauthorization Act of 2009 ( Public Law 111-3 ) (in this section referred to as CHIPRA ):
I|G|II|1612.(a)(1)
Section 2104(m) of the Social Security Act, as added by section 102 of CHIPRA, is amended -
I|G|II|1612.(a)(1)(A)
by redesignating paragraph (7) as paragraph (8); and
I|G|II|1612.(a)(1)(B)
by inserting after paragraph (6), the following:
I|G|II|1612.(a)(1)(B)(7)
Adjustment of fiscal years 2009 and 2010 allotments to account for changes in projected spending for certain previously approved expansion programs In the case of one of the 50 States or the District of Columbia that has an approved State plan amendment effective January 1, 2006, to provide child health assistance through the provision of benefits under the State plan under title XIX for children from birth through age 5 whose family income does not exceed 200 percent of the poverty line, the Secretary shall increase the allotments otherwise determined for the State for fiscal years 2009 and 2010 under paragraphs (1) and (2)(A)(i) in order to take into account changes in the projected total Federal payments to the State under this title for such fiscal years that are attributable to the provision of such assistance to such children. .
I|G|II|1612.(a)(2)
Section 605 of CHIPRA is amended by striking legal residents and insert lawfully residing in the United States .
I|G|II|1612.(a)(3)
Subclauses (I) and (II) of paragraph (3)(C)(i) of section 2105(a) of the Social Security Act ( 42 U.S.C. 1397ee(a)(3)(ii) ), as added by section 104 of CHIPRA, are each amended by striking , respectively .
I|G|II|1612.(a)(4)
Section 2105(a)(3)(E)(ii) of the Social Security Act ( 42 U.S.C. 1397ee(a)(3)(E)(ii) ), as added by section 104 of CHIPRA, is amended by striking subclause (IV).
I|G|II|1612.(a)(5)
Section 2105(c)(9)(B) of the Social Security Act ( 42 U.S.C. 1397e(c)(9)(B) ), as added by section 211(c)(1) of CHIPRA, is amended by striking section 1903(a)(3)(F) and inserting section 1903(a)(3)(G) .
I|G|II|1612.(a)(6)
Section 2109(b)(2)(B) of the Social Security Act ( 42 U.S.C. 1397ii(b)(2)(B) ), as added by section 602 of CHIPRA, is amended by striking the child population growth factor under section 2104(m)(5)(B) and inserting a high-performing State under section 2111(b)(3)(B) .
I|G|II|1612.(a)(7)
Section 211(a)(1)(B) of CHIPRA is amended -
I|G|II|1612.(a)(7)(A)
by striking is amended and all that follows through adding and inserting is amended by adding ; and
I|G|II|1612.(a)(7)(B)
by redesignating the new subparagraph to be added by such section to section 1903(a)(3) of the Social Security Act as a new subparagraph (H).
I|G|II|1612.(b)
ARRA Effective as if included in the enactment of section 5006(a) of division B of the American Recovery and Reinvestment Act of 2009 ( Public Law 111-5 ), the second sentence of section 1916A(a)(1) of the Social Security Act ( 42 U.S.C. 1396o-1(a)(1) ) is amended by striking or (i) and inserting , (i), or (j) .
I|G|III
Enrollment Simplification
I|G|III|1621.
Enrollment Simplification and coordination with State health insurance exchanges Title XIX of the Social Security Act ( 42 U.S.C. 1397aa et seq. ) is amended by adding at the end the following:
I|G|III|1621.1943.
Enrollment simplification and coordination with State health insurance exchanges
I|G|III|1621.1943.(a)
Condition for participation in medicaid As a condition of the State plan under this title and receipt of any Federal financial assistance under section 1903(a) for calendar quarters beginning after January 1, 2013, a State shall ensure that the requirements of subsections (b), (c), and (d) are met.
I|G|III|1621.1943.(b)
Enrollment simplification and coordination with state health insurance exchanges and chip
I|G|III|1621.1943.(b)(1)
In general A State shall establish procedures for -
I|G|III|1621.1943.(b)(1)(A)
enabling individuals, through an Internet website that meets the requirements of paragraph (4), to apply for medical assistance under the State plan or under a waiver of the plan, to be enrolled in the State plan or waiver, to renew their enrollment in the plan or waiver, and to consent to enrollment or reenrollment in the State plan through electronic signature;
I|G|III|1621.1943.(b)(1)(B)
enrolling, without any further determination by the State and through such website, individuals who are identified by an exchange established by the State under section 2235 as being eligible for -
I|G|III|1621.1943.(b)(1)(B)(i)
medical assistance under the State plan or under a waiver of the plan; or
I|G|III|1621.1943.(b)(1)(B)(ii)
child health assistance under the State child health plan under title XXI;
I|G|III|1621.1943.(b)(1)(C)
ensuring that individuals who apply for but are determined to be ineligible for medical assistance under the State plan or a waiver or ineligible for child health assistance under the State child health plan under title XXI, are able to apply for, and be enrolled in, coverage through such an exchange and, if applicable, obtain premium assistance for the purchase of a qualified health benefits plan under section 36B of the Internal Revenue Code of 1986 (and, if applicable, advance payment of such assistance under section 2248 of this Act), without having to submit an additional or separate application, and receive information regarding any other assistance or subsidies available for coverage obtained through the exchange;
I|G|III|1621.1943.(b)(1)(D)
ensuring that the State agency responsible for administering the State plan under this title (in this section referred to as the State Medicaid agency ), the State agency responsible for administering the State child health plan under title XXI (in this section referred to as the State CHIP agency ) and an exchange established by the State under section 2235 utilize a secure electronic interface sufficient to allow for a determination of an individual's eligibility for such medical assistance, child health assistance, or premium assistance, as appropriate; and
I|G|III|1621.1943.(b)(1)(E)
coordinating, for individuals who are enrolled in the State plan or under a waiver of the plan and who are also enrolled in a qualified health benefits plan offered through such an exchange, and for individuals who are enrolled in the State child health plan under title XXI and who are also enrolled in a qualified health benefits plan, the provision of medical assistance or child health assistance to such individuals with the coverage provided under the qualified health benefits plan in which they are enrolled.
I|G|III|1621.1943.(b)(2)
Agreements with state health insurance exchanges The State Medicaid agency and the State CHIP agency may enter into an agreement with an exchange established by the State under section 2235 under which the State Medicaid agency or State CHIP agency may determine whether a State resident is eligible for premium assistance for the purchase of a qualified health benefits plan under section 36B of the Internal Revenue Code of 1986 (and, if applicable, advance payment of such assistance under section 2248 of this Act), so long as the agreement meets such conditions and requirements as the Secretary of the Treasury may prescribe to reduce administrative costs and the likelihood of eligibility errors and disruptions in coverage.
I|G|III|1621.1943.(b)(3)
Streamlined enrollment system The State Medicaid agency and State CHIP agency shall participate in and comply with the requirements for the system established under section 2239 (relating to streamlined procedures for enrollment through an exchange, Medicaid, and CHIP).
I|G|III|1621.1943.(b)(4)
Enrollment website requirements The procedures established by State under paragraph (1) shall include establishing and having in operation, not later than January 1, 2013, an Internet website that is linked to any website of an exchange established by the State under section 2235 and to the State CHIP agency (if different from the State Medicaid agency) and allows an individual who is eligible for medical assistance under the State plan or under a waiver of the plan and who is eligible to receive premium credit assistance for the purchase of a qualified health benefits plan under section 36B of the Internal Revenue Code of 1986 to compare the benefits, premiums, and cost-sharing applicable to the individual under the State plan or waiver with the benefits, premiums, and cost-sharing available to the individual under a qualified health benefits plan offered through such an exchange, including, in the case of a child, the coverage that would be provided for the child through the State plan or waiver with the coverage that would be provided to the child through enrollment in family coverage under that plan and as supplemental coverage by the State under the State plan or waiver.
I|G|III|1621.1943.(b)(5)
Continued need for assessment for home and community-based services Nothing in paragraph (1) shall limit or modify the requirement that the State assess an individual for purposes of providing home and community-based services under the State plan or under any waiver of such plan for individuals described in subsection (a)(10)(A)(ii)(VI).
I|G|III|1621.1943.(c)
Option for certain medicaid-eligible populations to elect subsidized exchange coverage
I|G|III|1621.1943.(c)(1)
In general The State shall establish procedures to ensure that a non-pregnant, nonelderly adult whose income exceeds 100, but does not exceed 133 percent of the poverty line (as defined in section 2110(c)(5)) who is eligible for medical assistance under the State plan or under a waiver of the plan and who is eligible to receive premium assistance for the purchase of a qualified health benefits plan under section 36B of the Internal Revenue Code of 1986 (and advance payment of the assistance under section 2248 of this Act) is -
I|G|III|1621.1943.(c)(1)(A)
provided with the option to elect to enroll themselves, or if applicable, their family, in such a plan through an exchange established by the State under section 2235 instead of enrolling in the State plan under this title or a waiver of the plan and, in the case of the adult, to waive, as a result of making such an election, receipt of any medical assistance (including medical assistance for premiums and cost-sharing) under the State plan or waiver;
I|G|III|1621.1943.(c)(1)(B)
provided with -
I|G|III|1621.1943.(c)(1)(B)(i)
information, including through the State website established under section 1902(e)(15), comparing the benefits and cost-sharing that would be available under the State plan for the adult, and if applicable, the adult's family, with the benefits and cost-sharing available to the adult, and if applicable, the adult's family, through qualified health benefits plans offered through such an exchange (including with respect to the various levels of coverage available to the adult or family); and
I|G|III|1621.1943.(c)(1)(B)(ii)
an explanation of the key differences between the benefits and cost-sharing available for the adult, and if applicable, the adult's family, under the State plan or a waiver and the benefits and cost-sharing available to the adult or family through qualified health benefits plans offered through such an exchange for each of the levels of coverage available to the adult or family; and
I|G|III|1621.1943.(c)(1)(C)
if the adult elects to enroll themselves or their family in a plan through such an exchange, provided with assistance in selecting and enrolling in such a plan.
I|G|III|1621.1943.(c)(2)
Supplemental coverage, including EPSDT benefits, for children The State shall establish procedures to ensure that any child who is eligible for medical assistance under the State plan or under a waiver who is enrolled in a qualified health benefits plan through such an exchange is provided with supplemental coverage for items and services for which medical assistance is available under the State plan or waiver and for which benefits are not available under the qualified health benefits plan in which the child is enrolled, including services described in section 1905(a)(4)(B) (relating to early and periodic screening, diagnostic, and treatment services defined in section 1905(r)) and provided in accordance with the requirements of section 1902(a)(43) and medical assistance for premiums and cost-sharing imposed that exceed the amounts permitted under the State plan or waiver and to assure coordination of coverage for the child under the State plan or waiver and under the qualified health benefits plan in which the child is enrolled.
I|G|III|1621.1943.(c)(3)
Waiver of receipt of medical assistance for electing adults A nonpregnant, nonelderly adult whose income exceeds 100, but does not exceed 133 percent of the poverty line (as defined in section 2110(c)(5)) who elects to enroll in a qualified health benefits plan through an exchange established by the State under section 2235 shall waive, as a result of making such an election, being provided with medical assistance for themself (including medical assistance for premiums and cost-sharing) under the State plan or waiver while enrolled in the qualified health benefits plan.
I|G|III|1621.1943.(d)
State contribution for medicaid-eligible individuals electing coverage through a state exchange
I|G|III|1621.1943.(d)(1)
In general Each of the 50 States and the District of Columbia shall make an annual payment (beginning with 2014) to the Secretary equal to the sum of the following products determined with respect to each month of the preceding year for each population described in paragraph (2):
I|G|III|1621.1943.(d)(1)(A)
For each such month, the total number of individuals in the population eligible for medical assistance under the State plan or under a waiver of the plan for full benefits (as defined in section 1905(y)(2)(B)) who were enrolled in coverage through an exchange established by the State under section 2235 for any portion of the month.
I|G|III|1621.1943.(d)(1)(B)
Subject to paragraph (3), for each such month, the average cost of providing medical assistance for the population under the State plan or a waiver of the plan for the preceding year.
I|G|III|1621.1943.(d)(1)(C)
For each such month, the State percentage applicable under subsection (b) or (y) of section 1905 to expenditures for providing medical assistance to individuals within the population for that month.
I|G|III|1621.1943.(d)(2)
Populations described The populations described in this paragraph are the following:
I|G|III|1621.1943.(d)(2)(A)
Children.
I|G|III|1621.1943.(d)(2)(B)
Nondisabled, childless adults under age 65.
I|G|III|1621.1943.(d)(2)(C)
Nondisabled adults under age 65 who are parents.
I|G|III|1621.1943.(d)(2)(D)
Disabled, childless adults under age 65.
I|G|III|1621.1943.(d)(2)(E)
Disabled adults under age 65 who are parents.
I|G|III|1621.1943.(d)(3)
Average cost of medical assistance for children With respect to children, the average cost of providing medical assistance under the State plan or under a waiver of the plan for the preceding year shall be equal to the average cost of providing children under the State plan or waiver essential benefits described in section 2242 (as defined and specified by the Secretary for that year in accordance with subsection (e) of that section).
.
I|G|III|1622.
Permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations
I|G|III|1622.(a)
In general Section 1902(a)(47) of the Social Security Act ( 42 U.S.C. 1396a(a)(47) ) is amended -
I|G|III|1622.(a)(1)
by striking at the option of the State, provide and inserting "provide -
I|G|III|1622.(a)(1)(A)
at the option of the State, ;
I|G|III|1622.(a)(2)
by inserting and after the semicolon; and
I|G|III|1622.(a)(3)
by adding at the end the following:
I|G|III|1622.(a)(3)(B)
that any hospital that is a participating provider under the State plan may elect to be a qualified entity for purposes of determining, on the basis of preliminary information, whether any individual is eligible for medical assistance under the State plan or under a waiver of the plan for purposes of providing the individual with medical assistance during a presumptive eligibility period, in the same manner, and subject to the same requirements, as apply to the State options with respect to populations described in section 1920, 1920A, or 1920B (but without regard to whether the State has elected to provide for a presumptive eligibility period under any such sections), subject to such guidance as the Secretary shall establish; .
I|G|III|1622.(b)
Conforming amendment Section 1903(u)(1)(D)(v) of such Act ( 42 U.S.C. 1396b(u)(1)(D) v)) is amended -
I|G|III|1622.(b)(1)
by striking or for and inserting for ; and
I|G|III|1622.(b)(2)
by inserting before the period at the end the following: , or for medical assistance provided to an individual during a presumptive eligibility period resulting from a determination of presumptive eligibility made by a hospital that elects under section 1902(a)(47)(B) to be a qualified entity for such purpose .
I|G|III|1622.(c)
Effective date
I|G|III|1622.(c)(1)
Except as provided in paragraph (2), the amendment made by subsection (a) shall apply to services furnished on or after January 1, 2014, without regard to whether or not final regulations to carry out such amendment have been promulgated by such date.
I|G|III|1622.(c)(2)
In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendment made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.
I|G|III|1623.
Promoting transparency in the development, implementation, and evaluation of Medicaid and CHIP waivers and section 1937 State plan amendments
I|G|III|1623.(a)
Waiver transparency
I|G|III|1623.(a)(1)
In general Section 1115 of the Social Security Act ( 42 U.S.C. 1315 ) is amended by inserting after subsection (c) the following:
I|G|III|1623.(a)(1)(d)
In the case of any experimental, pilot, or demonstration project undertaken under subsection (a) to promote the objectives of title XIX or XXI in a State that would result in an impact on eligibility, enrollment, benefits, cost-sharing, or financing with respect to a State program under title XIX or XXI (in this subsection referred to as a Medicaid demonstration project and a CHIP demonstration project , respectively,) the following shall apply:
I|G|III|1623.(a)(1)(d)(1)
The Secretary may not approve a proposal for a Medicaid demonstration project, CHIP demonstration project, or a renewal of or an amendment to a previously approved Medicaid demonstration project or CHIP demonstration project unless the State requesting approval certifies that the following process was used to develop the proposal:
I|G|III|1623.(a)(1)(d)(1)(A)
At least 30 days prior to publication of the notice required under subparagraph (C), the State provided notice (which may have been accomplished by electronic mail) of the State's intent to develop the proposal to the medical care advisory committee established for the State for purposes of complying with section 1902(a)(4) and any individual or organization that requests or has requested such notice.
I|G|III|1623.(a)(1)(d)(1)(B)
Subsequent to providing the notice required under subparagraph (A) and prior to the notice required under subparagraph (C), the State convened at least 1 meeting of such medical care advisory committee at which the proposal and any modifications of the proposal were the primary items considered and discussed.
I|G|III|1623.(a)(1)(d)(1)(C)
At least 60 days prior to the date that the State submits the proposal to the Secretary, the State published for written comment (in accordance with the State's procedure for issuing regulations) a notice of the proposal that contained at least the following:
I|G|III|1623.(a)(1)(d)(1)(C)(i)
Information regarding how the public may submit comments to the State on the proposal.
I|G|III|1623.(a)(1)(d)(1)(C)(ii)
A statement of the State's projections regarding the likely effect and impact of the proposal on any individuals who are then eligible for, or receiving, medical assistance, child health assistance, or other health benefits coverage under a State program under title XIX or XXI and the State's assumptions on which such projections are based.
I|G|III|1623.(a)(1)(d)(1)(C)(iii)
A statement of the likely fiscal impact of the proposal, including all relevant calculations, showing how Federal and State spending on the project will compare to the amount of Federal and State funds that would have been expended had the project not been implemented.
I|G|III|1623.(a)(1)(d)(1)(D)
Concurrent with the publication of the notice required under subparagraph (C), the State -
I|G|III|1623.(a)(1)(d)(1)(D)(i)
posted the proposal (and any modifications of the proposal) on the State's official Medicaid or CHIP Internet website; and
I|G|III|1623.(a)(1)(d)(1)(D)(ii)
provided the notice required under subparagraph (B) (which may have been accomplished by electronic mail) to the medical care advisory committee referred to in subparagraph (A) and to any individual or organization that requested such notice.
I|G|III|1623.(a)(1)(d)(1)(E)
Not later than 30 days after publication of the notice required under subparagraph (C), the State convened at least 1 open meeting of the medical care advisory committee referred to in subparagraph (A), at which the proposal and any modifications of the proposal were the primary items considered and discussed.
I|G|III|1623.(a)(1)(d)(1)(F)
After publication of the notice required under subparagraph (C), the State -
I|G|III|1623.(a)(1)(d)(1)(F)(i)
held at least 2 public hearings on the proposal and any modifications of the proposal; and
I|G|III|1623.(a)(1)(d)(1)(F)(ii)
held the last such public hearing no more than 30 days before the State submitted the proposal to the Secretary.
I|G|III|1623.(a)(1)(d)(1)(G)
The State has a record of all public comments submitted in response to the notice required under subparagraph (B) or at any hearings or meetings required under this paragraph regarding the proposal.
I|G|III|1623.(a)(1)(d)(2)
A State shall include with any proposal submitted to the Secretary for a Medicaid demonstration project, CHIP demonstration project, or a renewal of or an amendment to a previously approved Medicaid demonstration project or CHIP demonstration project, the following:
I|G|III|1623.(a)(1)(d)(2)(A)
A detailed description of the public notice and input process used to develop the proposal in accordance with the requirements of paragraph (1).
I|G|III|1623.(a)(1)(d)(2)(B)
Copies of all notices required under paragraph (1).
I|G|III|1623.(a)(1)(d)(2)(C)
The dates of all meetings and hearings required under paragraph (1).
I|G|III|1623.(a)(1)(d)(2)(D)
A summary of the public comments received in response to the notices required under paragraph (1) or at any hearings or meetings required under that paragraph regarding the proposal and the State's response to the comments.
I|G|III|1623.(a)(1)(d)(2)(E)
A summary of any changes in the proposal that were made in response to the comments.
I|G|III|1623.(a)(1)(d)(2)(F)
A certification that the State complied with any applicable notification requirements with respect to Indian tribes during the development of the proposal in accordance with paragraph (1).
I|G|III|1623.(a)(1)(d)(3)
The Secretary shall return to a State without action any proposal for a Medicaid demonstration project, CHIP demonstration project, or a renewal of or an amendment to a previously approved Medicaid demonstration project or CHIP demonstration project, that fails to demonstrate compliance with the requirements of paragraphs (1) and (2).
I|G|III|1623.(a)(1)(d)(4)
With respect to all proposals for Medicaid demonstration projects, CHIP demonstration projects, or renewal of or amendments to a previously approved Medicaid or CHIP demonstration project, received by the Secretary the following shall apply:
I|G|III|1623.(a)(1)(d)(4)(A)
On or before the 10th day of each month, the Secretary shall publish a notice in the Federal Register identifying all of the proposals for such demonstration projects or amendments that were received by the Secretary during the preceding month.
I|G|III|1623.(a)(1)(d)(4)(B)
The notice required under subparagraph (A) shall provide information regarding the method by which comments on the proposals will be received from the public.
I|G|III|1623.(a)(1)(d)(4)(C)
Not later than 7 days after receipt of a proposal for a Medicaid demonstration project, CHIP demonstration project, or a renewal of or an amendment to a previously approved Medicaid or CHIP demonstration project, the Secretary shall -
I|G|III|1623.(a)(1)(d)(4)(C)(i)
provide notice (which may be accomplished by electronic mail) to any individual or organization that requests or has requested such notification;
I|G|III|1623.(a)(1)(d)(4)(C)(ii)
publish on the official Internet website of the Centers for Medicare & Medicaid Services a copy of the proposal, including any appendices or modifications of the proposal; and
I|G|III|1623.(a)(1)(d)(4)(C)(iii)
ensure that the information posted on the website is updated at least monthly to accurately reflect the current nature and status of the proposal.
I|G|III|1623.(a)(1)(d)(4)(D)
The Secretary shall provide for a period of not less than 30 days from the later of the date of publication of the notice required under subparagraph (A) that first identifies receipt of the proposal or the date on which an official Internet website containing the information required under subparagraph (C)(ii) with respect to the proposal is first published, in which written comments on the proposal may be submitted from all interested parties.
I|G|III|1623.(a)(1)(d)(4)(E)
After the completion of the public comment period required under subparagraph (D), if the Secretary intends to approve the proposal, as originally submitted or revised, the Secretary shall -
I|G|III|1623.(a)(1)(d)(4)(E)(i)
publish and post on the official Internet website for the Centers for Medicare & Medicaid Services the proposed terms and conditions for such approval and updated versions of the statements required to be published by the State under clauses (ii) and (iii) of paragraph (1)(C);
I|G|III|1623.(a)(1)(d)(4)(E)(ii)
provide at least a 15-day period for the submission of written comments from all interested parties on such proposed terms and conditions and such statements; and
I|G|III|1623.(a)(1)(d)(4)(E)(iii)
retain, and make available upon request, all comments received concerning the proposal, the terms and conditions for approval of the proposal, or the statements required to be published by the State under clauses (ii) and (iii) of paragraph (1)(C).
I|G|III|1623.(a)(1)(d)(4)(F)
In no event may the Secretary approve a proposal for a Medicaid or CHIP demonstration project or renewal of or an amendment to a previously approved Medicaid or CHIP demonstration project unless the Secretary determines that the proposal, renewal, or the amendment -
I|G|III|1623.(a)(1)(d)(4)(F)(i)
is based on a reasonable hypothesis which the Secretary has determined is likely to assist in promoting the objectives of title XIX or XXI; and
I|G|III|1623.(a)(1)(d)(4)(F)(ii)
will be evaluated no less frequently than every 3 years in accordance with paragraph (6).
I|G|III|1623.(a)(1)(d)(4)(G)
Not later than 3 business days after the approval of any proposal for a Medicaid demonstration project, CHIP demonstration project, or renewal of or amendment to a previously approved Medicaid or CHIP demonstration project, the Secretary shall post on the official Internet website for the Centers for Medicare & Medicaid Services the following:
I|G|III|1623.(a)(1)(d)(4)(G)(i)
The text of the approved Medicaid demonstration project, CHIP demonstration project, or renewal of or amendment to a previously approved Medicaid or CHIP demonstration project.
I|G|III|1623.(a)(1)(d)(4)(G)(ii)
A list identifying each provision of title XIX or XXI, and each regulation relating to either such title, for which compliance is waived under the approved demonstration project or amendment and any costs that would otherwise not be permitted that will be allowed under the demonstration project or amendment.
I|G|III|1623.(a)(1)(d)(4)(G)(iii)
The terms and conditions for approval of the demonstration project or amendment.
I|G|III|1623.(a)(1)(d)(4)(G)(iv)
The approval letter.
I|G|III|1623.(a)(1)(d)(4)(G)(v)
The operations protocol for the demonstration project or amendment.
I|G|III|1623.(a)(1)(d)(4)(G)(vi)
The evaluation design for the demonstration project or amendment.
I|G|III|1623.(a)(1)(d)(4)(G)(vii)
Any item required to be posted under this subparagraph that is not available within 3 business days of the approval of the demonstration project or amendment shall be posted as soon as the item becomes available,
I|G|III|1623.(a)(1)(d)(4)(H)
On or before the 10th day of each month the Secretary shall publish a notice in the Federal Register that identifies any proposals for Medicaid demonstration projects, CHIP demonstration projects, or renewal of or amendments to a previously approved Medicaid or CHIP demonstration project that were approved, denied, or returned to the State without action during the preceding month.
I|G|III|1623.(a)(1)(d)(4)(I)
The Secretary shall post on the official Internet website for the Centers for Medicare and Medicaid Services all quarterly reports submitted by the State (including data on whether the State is meeting its budget neutrality targets), evaluations, and other information the Secretary determines to be appropriate, on Medicaid or CHIP demonstration projects that are operational.
I|G|III|1623.(a)(1)(d)(5)
Any provision under title XIX or XXI, or under any regulation in effect that relates to either such title, that is not explicitly waived by the Secretary and identified in the list required under paragraph (4)(G)(ii) when approving the Medicaid demonstration project, CHIP demonstration project, or renewal of or amendment to any such demonstration project, is not waived and a State shall continue to comply with any such requirement.
I|G|III|1623.(a)(1)(d)(6)
I|G|III|1623.(a)(1)(d)(6)(A)
In the case of a proposal for a Medicaid demonstration project or CHIP demonstration project, the Secretary shall, by contract with a qualified research organization described in subparagraph (B), conduct an independent evaluation consistent with the evaluation criteria described in subparagraph (C) applicable to the individual project.
I|G|III|1623.(a)(1)(d)(6)(B)
A qualified research organization described in this subparagraph is an entity that the Secretary determines -
I|G|III|1623.(a)(1)(d)(6)(B)(i)
has staff with demonstrated expertise regarding Medicaid or CHIP beneficiaries, policies, and data systems (as applicable), and research design and methodology; and
I|G|III|1623.(a)(1)(d)(6)(B)(ii)
does not and did not in the past 24 months, by contract or subcontract, directly or indirectly, receive funds from the State that has proposed the demonstration project.
I|G|III|1623.(a)(1)(d)(6)(C)
The evaluation criteria described in this subparagraph shall include, but not be limited to, the following:
I|G|III|1623.(a)(1)(d)(6)(C)(i)
The use of services by beneficiaries under the project.
I|G|III|1623.(a)(1)(d)(6)(C)(ii)
The amount of out-of-pocket costs for health care services incurred by beneficiaries under the project.
I|G|III|1623.(a)(1)(d)(6)(C)(iii)
The extent to which special populations such as adults with disabilities, adults with chronic illness, and children with special health care needs are able to access needed health care services.
I|G|III|1623.(a)(1)(d)(6)(C)(iv)
If children are enrolled in the project, the extent to which such children are able to access early and periodic screening, diagnostic, and treatment services described in section 1905(r).
I|G|III|1623.(a)(1)(d)(6)(C)(v)
The level of satisfaction of beneficiaries under the project with respect to the accessibility, quality, and cost of care, including the extent to which beneficiaries under the project understand the choices of health care coverage available to them.
I|G|III|1623.(a)(1)(d)(6)(C)(vi)
The cost of health care services incurred by the State agency administering the project, whether through fee-for-service payments, premium payments, or otherwise.
I|G|III|1623.(a)(1)(d)(6)(C)(vii)
Administrative costs incurred by the State agency administering the project and by any administrative contractors.
I|G|III|1623.(a)(1)(d)(6)(D)
The Secretary shall not approve a proposal for a Medicaid demonstration project or a CHIP demonstration project, or a proposal for the extension of such a demonstration project, unless the State agency proposing to administer the demonstration project agrees to cooperate fully with the Secretary to the extent necessary to enable the Secretary to conduct the independent evaluation described in subparagraph (B) including collecting, verifying the accuracy of, and submitting to the organization on a timely basis data needed to conduct the independent evaluation.
I|G|III|1623.(a)(1)(d)(6)(E)
The State agency administering the project shall be allowed at least 30 days prior to publication of the independent evaluation to submit comments to the Secretary, and the State agency's comments shall be included in the results of the evaluation.
I|G|III|1623.(a)(1)(d)(6)(F)
The results of all evaluations conducted under this paragraph with respect to a Medicaid demonstration project or CHIP demonstration project shall be submitted to the Committee on Finance of the Senate and the Committee on Energy and Commerce of the House of Representatives not later than 6 months prior to the completion of the initial term of a demonstration project and shall thereafter be posted on the official Internet website of the Centers for Medicare & Medicaid Services.
I|G|III|1623.(a)(1)(d)(6)(G)
Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated to the Secretary, $4,500,000 for fiscal year 2010 and each fiscal year thereafter, for the purpose of carrying out the independent evaluations required under this paragraph. Amounts appropriated under this subparagraph for a fiscal year shall remain available until expended.
.
I|G|III|1623.(a)(2)
Rule of construction Nothing in the amendment made by subsection (a) shall be construed to -
I|G|III|1623.(a)(2)(A)
authorize the waiver of any provision of title XIX or XXI of the Social Security Act ( 42 U.S.C. 1396 et seq. , 1397aa et seq.) that is not otherwise authorized to be waived under such titles or under title XI of such Act ( 42 U.S.C. 1301 et seq. ) as of the date of enactment of this Act; or
I|G|III|1623.(a)(2)(B)
imply congressional approval of any experimental, pilot, or demonstration project affecting the Medicaid program under title XIX of the Social Security Act or the Children's health insurance program under title XXI of such Act that has been approved as of such date of enactment.
I|G|III|1623.(b)
Transparency for certain state plan amendments Section 1937 of such Act ( 42 U.S.C. 1396u-7 ) is amended by adding at the end the following:
I|G|III|1623.(b)(d)
State plan amendment approval requirements In the case of any State plan amendment proposed under subsection (a) that would limit the benefits eligible individuals would receive, the following shall apply:
I|G|III|1623.(b)(d)(1)
The Secretary may not approve a proposal for the amendment unless the State requesting approval certifies that the following process was used to develop the amendment:
I|G|III|1623.(b)(d)(1)(A)
Prior to publication of the notice required under subparagraph (B), the State -
I|G|III|1623.(b)(d)(1)(A)(i)
provided notice (which may have been accomplished by electronic mail) of the State's intent to develop the State plan amendment to the medical care advisory committee established for the State for purposes of complying with section 1902(a)(4) and any individual or organization that requests such notice; and
I|G|III|1623.(b)(d)(1)(A)(ii)
convened at least 1 meeting of such medical care advisory committee at which the State plan amendment was considered and discussed.
I|G|III|1623.(b)(d)(1)(B)
At least 60 days prior to the date that the State submits the State plan amendment to the Secretary, the State published for written comment (in accordance with the State's procedure for issuing regulations) a notice of the proposal that contains at least the following:
I|G|III|1623.(b)(d)(1)(B)(i)
Information regarding how the public may submit comments to the State on the State plan amendment.
I|G|III|1623.(b)(d)(1)(B)(ii)
A statement of the State's projections regarding the likely effect and impact of the proposal on any individuals who are eligible for, or receiving, medical assistance, under the State program under this title and the State's assumptions on which the projections are based.
I|G|III|1623.(b)(d)(1)(C)
Concurrent with the publication of the notice required under subparagraph (B), the State -
I|G|III|1623.(b)(d)(1)(C)(i)
posted the State plan amendment on the State's official Medicaid or CHIP Internet website; and
I|G|III|1623.(b)(d)(1)(C)(ii)
provided the notice (which may have been accomplished by electronic mail) to the medical care advisory committee referred to in subparagraph (A)(i) and to any individual or organization that requested such notice.
I|G|III|1623.(b)(d)(1)(D)
Not later than 30 days after publication of the notice required under subparagraph (B), the State convened at least 1 open meeting of the medical care advisory committee referred to in subparagraph (A)(i), at which the State plan amendment was considered and discussed.
I|G|III|1623.(b)(d)(2)
A State shall include with any State plan amendment submitted to the Secretary for approval the following:
I|G|III|1623.(b)(d)(2)(A)
A detailed description of the public notice and input process used to develop the State plan amendment in accordance with the requirements of paragraph (1).
I|G|III|1623.(b)(d)(2)(B)
Copies of all notices required under paragraph (1).
I|G|III|1623.(b)(d)(2)(C)
The dates of all meetings required under paragraph (1).
I|G|III|1623.(b)(d)(2)(D)
A certification that the State complied with any applicable notification requirements with respect to Indian tribes during the development of the proposal in accordance with paragraph (1).
I|G|III|1623.(b)(d)(3)
The Secretary shall return to a State without action any State plan amendment that fails to satisfy the requirements of paragraphs (1) and (2).
I|G|III|1623.(b)(d)(4)
With respect to all State plan amendments submitted for approval to the Secretary under this section the following shall apply:
I|G|III|1623.(b)(d)(4)(A)
On or before the 10th day of each month the Secretary shall publish a notice in the Federal Register identifying all the State plan amendments submitted for approval during the preceding month.
I|G|III|1623.(b)(d)(4)(B)
The notice required under subparagraph (A) shall provide information regarding the method by which comments on the proposals will be received from the public.
I|G|III|1623.(b)(d)(4)(C)
Not later than 7 days after submission of a State plan amendment for approval the Secretary shall -
I|G|III|1623.(b)(d)(4)(C)(i)
provide notice (which may be accomplished by electronic mail) to any individual or organization that has requested such notification; and
I|G|III|1623.(b)(d)(4)(C)(ii)
publish on the official Internet website of the Centers for Medicare & Medicaid Services a copy of the State plan amendment.
I|G|III|1623.(b)(d)(4)(D)
The Secretary shall provide for a period of not less than 30 days from the later of the date of publication of the notice required under subparagraph (A) that first identifies receipt of the State plan amendment or the date on which an official Internet website containing the information required under subparagraph (C)(ii) with respect to the State plan amendment is first published, in which written comments on the State plan amendment may be submitted from all interested parties.
I|G|III|1623.(b)(d)(4)(E)
On or before the 10th day of each month the Secretary shall publish a notice in the Federal Register that identifies any State plan amendments that were approved, denied, or returned to the State without action during the preceding month.
.
I|G|III|1623.(c)
Effective dates
I|G|III|1623.(c)(1)
Section 1115 requirements Subject to paragraph (2), the amendment made by subsection (a) shall take effect on the date of enactment of this Act and shall apply to -
I|G|III|1623.(c)(1)(A)
any proposal to conduct any experimental, pilot or demonstration project affecting the Medicaid program under title XIX of the Social Security Act or the State Children's Health Insurance Program under title XXI of such Act that is pending on the date of enactment or that is submitted to the Secretary after the date of enactment;
I|G|III|1623.(c)(1)(B)
any proposal to extend such a project that is pending on the date of enactment or that is submitted to the Secretary after the date of enactment; and
I|G|III|1623.(c)(1)(C)
any proposal to amend such a project that is pending on the date of enactment or that is submitted to the Secretary after the date of enactment.
I|G|III|1623.(c)(2)
Evaluation requirements applicable to new waivers The requirements of section 1115(d)(6) of the Social Security Act (relating to evaluation), as added by subsection (a), shall apply only to a proposal described in paragraph (1)(A) of this subsection.
I|G|III|1623.(c)(3)
Certain state plan amendments The amendment made by subsection (b) shall take effect on the date of enactment of this Act and shall apply to any State plan amendment for which approval is pending on the date of enactment or that is submitted to the Secretary of Health and Human Services for approval after the date of enactment of this Act.
I|G|III|1624.
Standards and best practices to improve enrollment of vulnerable and underserved populations
I|G|III|1624.(a)
In general Not later than April 1, 2011, the Secretary of Health and Human Services shall issue guidance to States regarding standards and best practices for conducting outreach to and enrolling vulnerable and underserved populations eligible for medical assistance under Medicaid under title XIX of the Social Security Act or for child health assistance under CHIP under title XXI of such Act, including children, unaccompanied homeless youth, children and youth with special health care needs, pregnant women, racial and ethnic minorities, rural populations, victims of abuse or trauma, individuals with mental health or substance-related disorders, and individuals with HIV/AIDS.
I|G|III|1624.(b)
Requirements
I|G|III|1624.(b)(1)
In general The guidance issued under subsection (a) shall -
I|G|III|1624.(b)(1)(A)
detail effective ways to inform vulnerable populations about coverage available under Medicaid and CHIP;
I|G|III|1624.(b)(1)(B)
identify ways to assist vulnerable populations to enroll in the programs;
I|G|III|1624.(b)(1)(C)
identify ways that application and enrollment barriers for such populations can be eliminated; and
I|G|III|1624.(b)(1)(D)
address specific methods for outreach and enrollment, including outstationing of eligibility workers, the Express Lane eligibility option, residency requirements, documentation of income and assets, presumptive eligibility, continuous eligibility, and automatic renewal.
I|G|III|1624.(b)(2)
Development and implementation The Secretary of Health and Human Services may use all available legal authority and shall work with appropriate stakeholders, including representatives of States and children's groups, to ensure that the guidance issued under subsection (a) is developed and implemented effectively.
I|G|III|1624.(b)(3)
Report to congress Not later than 2 years after the enactment of this Act and annually thereafter, the Secretary of Health and Human Services shall review and report to Congress on the progress made by States in implementing the standards and best practices identified in the guidance issued under subsection (a) and increasing the enrollment of vulnerable populations under Medicaid and CHIP.
I|G|IV
Medicaid Services
I|G|IV|1631.
Coverage for freestanding birth center services
I|G|IV|1631.(a)
In general Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ), is amended -
I|G|IV|1631.(a)(1)
in subsection (a) -
I|G|IV|1631.(a)(1)(A)
in paragraph (27), by striking and at the end;
I|G|IV|1631.(a)(1)(B)
by redesignating paragraph (28) as paragraph (29); and
I|G|IV|1631.(a)(1)(C)
by inserting after paragraph (27) the following new paragraph:
I|G|IV|1631.(a)(1)(C)(28)
freestanding birth center services (as defined in subsection (l)(3)(A)) and other ambulatory services that are offered by a freestanding birth center (as defined in subsection (l)(3)(B)) and that are otherwise included in the plan; and ; and
I|G|IV|1631.(a)(2)
in subsection (l), by adding at the end the following new paragraph:
I|G|IV|1631.(a)(2)(3)
I|G|IV|1631.(a)(2)(3)(A)
The term freestanding birth center services means services furnished to an individual at a freestanding birth center (as defined in subparagraph (B)) at such center.
I|G|IV|1631.(a)(2)(3)(B)
The term freestanding birth center means a health facility -
I|G|IV|1631.(a)(2)(3)(B)(i)
that is not a hospital;
I|G|IV|1631.(a)(2)(3)(B)(ii)
where childbirth is planned to occur away from the pregnant woman's residence;
I|G|IV|1631.(a)(2)(3)(B)(iii)
that is licensed or otherwise approved by the State to provide prenatal labor and delivery or postpartum care and other ambulatory services that are included in the plan; and
I|G|IV|1631.(a)(2)(3)(B)(iv)
that complies with such other requirements relating to the health and safety of individuals furnished services by the facility as the State shall establish.
I|G|IV|1631.(a)(2)(3)(C)
A State shall provide separate payments to providers administering prenatal labor and delivery or postpartum care in a freestanding birth center (as defined in subparagraph (B)), such as nurse midwives and other providers of services such as birth attendants recognized under State law, as determined appropriate by the Secretary. For purposes of the preceding sentence, the term birth attendant means an individual who is recognized or registered by the State involved to provide health care at childbirth and who provides such care within the scope of practice under which the individual is legally authorized to perform such care under State law (or the State regulatory mechanism provided by State law), regardless of whether the individual is under the supervision of, or associated with, a physician or other health care provider. Nothing in this subparagraph shall be construed as changing State law requirements applicable to a birth attendant.
.
I|G|IV|1631.(b)
Conforming amendment Section 1902(a)(10)(A) of the Social Security Act ( 42 U.S.C. 1396a(a)(10)(A) ), is amended in the matter preceding clause (i) by striking and (21) and inserting , (21), and (28) .
I|G|IV|1631.(c)
Effective date
I|G|IV|1631.(c)(1)
In general Except as provided in paragraph (2), the amendments made by this section shall take effect on the date of the enactment of this Act and shall apply to services furnished on or after such date.
I|G|IV|1631.(c)(2)
Exception if state legislation required In the case of a State plan for medical assistance under title XIX of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirement imposed by the amendments made by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of its failure to meet this additional requirement before the first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act. For purposes of the previous sentence, in the case of a State that has a 2-year legislative session, each year of such session shall be deemed to be a separate regular session of the State legislature.
I|G|IV|1632.
Concurrent care for children Section 1905(o)(1) of the Social Security Act ( 42 U.S.C. 1396d(o)(1) ) is amended -
I|G|IV|1632.(1)
in subparagraph (A), by striking subparagraph (B) and inserting subparagraphs (B) and (C) ; and
I|G|IV|1632.(2)
by adding at the end the following new subparagraph:
I|G|IV|1632.(2)(C)
A voluntary election to have payment made for hospice care for a child (as defined by the State) shall not constitute a waiver of any rights of the child to be provided with, or to have payment made under this title for, services that are related to the treatment of the child's condition for which a diagnosis of terminal illness has been made. .
I|G|IV|1633.
Funding to expand State Aging and Disability Resource Centers Out of any funds in the Treasury not otherwise appropriated, there is appropriated to the Secretary of Health and Human Services, acting through the Assistant Secretary for Aging, $10,000,000 for each of fiscal years 2010 through 2014, to carry out subsections (a)(20)(B)(iii) and (b)(8) of section 202 of the Older Americans Act of 1965 ( 42 U.S.C. 3012 ).
I|G|IV|1634.
Community First Choice Option Section 1915 of the Social Security Act ( 42 U.S.C. 1396n ) is amended by adding at the end the following:
I|G|IV|1634.(k)
State plan option to provide home and community-based attendant services and supports
I|G|IV|1634.(k)(1)
In general Subject to the succeeding provisions of this subsection, during the 5-year period that begins on January 1, 2014, a State may provide through a State plan amendment for the provision of medical assistance for home and community-based attendant services and supports for individuals who are eligible for medical assistance under the State plan whose income does not exceed 150 percent of the poverty line (as defined in section 2110(c)(5)) or, if greater, the income level applicable for an individual who has been determined to require an institutional level of care to be eligible for nursing facility services under the State plan and with respect to whom there has been a determination that, but for the provision of such services, the individuals would require the level of care provided in a hospital, a nursing facility, an intermediate care facility for the mentally retarded, or an institution for mental diseases, the cost of which could be reimbursed under the State plan, but only if the individual chooses to receive such home and community-based attendant services and supports, and only if the State meets the following requirements:
I|G|IV|1634.(k)(1)(A)
Availability The State shall make available home and community-based attendant services and supports to eligible individuals, as needed, to assist in accomplishing activities of daily living, instrumental activities of daily living, and health-related tasks through hands-on assistance, supervision, or cueing -
I|G|IV|1634.(k)(1)(A)(i)
under a person-centered plan of services and supports that is based on an assessment of functional need and that is agreed to in writing by the individual or, as appropriate, the individual's representative;
I|G|IV|1634.(k)(1)(A)(ii)
in a home or community setting, which does not include a nursing facility, institution for mental diseases, or an intermediate care facility for the mentally retarded;
I|G|IV|1634.(k)(1)(A)(iii)
under an agency-provider model or other model (as defined in paragraph (6)(C )); and
I|G|IV|1634.(k)(1)(A)(iv)
the furnishing of which -
I|G|IV|1634.(k)(1)(A)(iv)(I)
is selected, managed, and dismissed by the individual, or, as appropriate, with assistance from the individual's representative;
I|G|IV|1634.(k)(1)(A)(iv)(II)
is controlled, to the maximum extent possible, by the individual or where appropriate, the individual's representative, regardless of who may act as the employer of record; and
I|G|IV|1634.(k)(1)(A)(iv)(III)
provided by an individual who is qualified to provide such services, including family members (as defined by the Secretary).
I|G|IV|1634.(k)(1)(B)
Included services and supports In addition to assistance in accomplishing activities of daily living, instrumental activities of daily living, and health related tasks, the home and community-based attendant services and supports made available include -
I|G|IV|1634.(k)(1)(B)(i)
the acquisition, maintenance, and enhancement of skills necessary for the individual to accomplish activities of daily living, instrumental activities of daily living, and health related tasks;
I|G|IV|1634.(k)(1)(B)(ii)
back-up systems or mechanisms (such as the use of beepers or other electronic devices) to ensure continuity of services and supports; and
I|G|IV|1634.(k)(1)(B)(iii)
voluntary training on how to select, manage, and dismiss attendants.
I|G|IV|1634.(k)(1)(C)
Excluded services and supports Subject to subparagraph (D), the home and community-based attendant services and supports made available do not include -
I|G|IV|1634.(k)(1)(C)(i)
room and board costs for the individual;
I|G|IV|1634.(k)(1)(C)(ii)
special education and related services provided under the Individuals with Disabilities Education Act and vocational rehabilitation services provided under the Rehabilitation Act of 1973;
I|G|IV|1634.(k)(1)(C)(iii)
assistive technology devices and assistive technology services other than those under (1)(B)(ii);
I|G|IV|1634.(k)(1)(C)(iv)
medical supplies and equipment; or
I|G|IV|1634.(k)(1)(C)(v)
home modifications.
I|G|IV|1634.(k)(1)(D)
Permissible services and supports The home and community-based attendant services and supports may include -
I|G|IV|1634.(k)(1)(D)(i)
expenditures for transition costs such as rent and utility deposits, first month's rent and utilities, bedding, basic kitchen supplies, and other necessities required for an individual to make the transition from a nursing facility, institution for mental diseases, or intermediate care facility for the mentally retarded to a community-based home setting where the individual resides; and
I|G|IV|1634.(k)(1)(D)(ii)
expenditures relating to a need identified in an individual's person-centered plan of services that increase independence or substitute for human assistance, to the extent that expenditures would otherwise be made for the human assistance.
I|G|IV|1634.(k)(2)
Increased federal financial participation For purposes of payments to a State under section 1903(a)(1), with respect to amounts expended by the State to provide medical assistance under the State plan for home and community-based attendant services and supports to eligible individuals in accordance with this subsection during a fiscal year quarter occurring during the period described in paragraph (1), the Federal medical assistance percentage applicable to the State (as determined under sections 1905(b) and 1902(gg)(5)) shall be increased by 6 percentage points.
I|G|IV|1634.(k)(3)
State requirements In order for a State plan amendment to be approved under this subsection, the State shall -
I|G|IV|1634.(k)(3)(A)
develop and implement such amendment in collaboration with a Development and Implementation Council established by the State that includes a majority of members with disabilities, elderly individuals, and their representatives and consults and collaborates with such individuals;
I|G|IV|1634.(k)(3)(B)
provide consumer controlled home and community-based attendant services and supports to individuals on a statewide basis, in a manner that provides such services and supports in the most integrated setting appropriate to the individual's needs, and without regard to the individual's age, type or nature of disability, severity of disability, or the form of home and community-based attendant services and supports that the individual requires in order to lead an independent life;
I|G|IV|1634.(k)(3)(C)
with respect to expenditures during the first full fiscal year in which the State plan amendment is implemented, maintain or exceed the level of State expenditures for medical assistance that is provided under section 1905(a), section 1915, section 1115, or otherwise to individuals with disabilities or elderly individuals attributable to the preceding fiscal year;
I|G|IV|1634.(k)(3)(D)
establish and maintain a comprehensive, continuous quality assurance system with respect to community- based attendant services and supports that -
I|G|IV|1634.(k)(3)(D)(i)
includes standards for agency-based and other delivery models with respect to training, appeals for denials and reconsideration procedures of an individual plan, and other factors as determined by the Secretary;
I|G|IV|1634.(k)(3)(D)(ii)
incorporates feedback from consumers and their representatives, disability organizations, providers, families of disabled or elderly individuals, members of the community, and others and maximizes consumer independence and consumer control;
I|G|IV|1634.(k)(3)(D)(iii)
monitors the health and well-being of each individual who receives home and community-based attendant services and supports, including a process for the mandatory reporting, investigation, and resolution of allegations of neglect, abuse, or exploitation in connection with the provision of such services and supports; and
I|G|IV|1634.(k)(3)(D)(iv)
provides information about the provisions of the quality assurance required under clauses (i) through (iii) to each individual receiving such services; and
I|G|IV|1634.(k)(3)(E)
collect and report information, as determined necessary by the Secretary, for the purposes of approving the State plan amendment, providing Federal oversight, and conducting an evaluation under paragraph (5)(A), including data regarding how the State provides home and community-based attendant services and supports and other home and community-based services, the cost of such services and supports, and how the State provides individuals with disabilities who otherwise qualify for institutional care under the State plan or under a waiver the choice to instead receive home and community-based services in lieu of institutional care.
I|G|IV|1634.(k)(4)
Compliance with certain laws A State shall ensure that, regardless of whether the State uses an agency-provider model or other models to provide home and community-based attendant services and supports under a State plan amendment under this subsection, such services and supports are provided in accordance with the requirements of the Fair Labor Standards Act of 1938 and applicable Federal and State laws regarding -
I|G|IV|1634.(k)(4)(A)
withholding and payment of Federal and State income and payroll taxes;
I|G|IV|1634.(k)(4)(B)
the provision of unemployment and workers compensation insurance;
I|G|IV|1634.(k)(4)(C)
maintenance of general liability insurance; and
I|G|IV|1634.(k)(4)(D)
occupational health and safety.
I|G|IV|1634.(k)(5)
Evaluation, data collection, and report to congress
I|G|IV|1634.(k)(5)(A)
Evaluation The Secretary shall conduct an evaluation of the provision of home and community-based attendant services and supports under this subsection in order to determine the effectiveness of the provision of such services and supports in allowing the individuals receiving such services and supports to lead an independent life to the maximum extent possible; the impact on the physical and emotional health of the individuals who receive such services; and an comparative analysis of the costs of services provided under the State plan amendment under this subsection and those provided under institutional care in a nursing facility, institution for mental diseases, or an intermediate care facility for the mentally retarded.
I|G|IV|1634.(k)(5)(B)
Data collection The State shall provide the Secretary with the following information regarding the provision of home and community-based attendant services and supports under this subsection for each fiscal year for which such services and supports are provided:
I|G|IV|1634.(k)(5)(B)(i)
The number of individuals who are estimated to receive home and community-based attendant services and supports under this subsection during the fiscal year.
I|G|IV|1634.(k)(5)(B)(ii)
The number of individuals that received such services and supports during the preceding fiscal year.
I|G|IV|1634.(k)(5)(B)(iii)
The specific number of individuals served by type of disability, age, gender, education level, and employment status.
I|G|IV|1634.(k)(5)(B)(iv)
Whether the specific individuals have been previously served under any other home and community based services program under the State plan or under a waiver.
I|G|IV|1634.(k)(5)(C)
Reports Not later than -
I|G|IV|1634.(k)(5)(C)(i)
December 31, 2017, the Secretary shall submit to Congress and make available to the public an interim report on the findings of the evaluation under subparagraph (A); and
I|G|IV|1634.(k)(5)(C)(ii)
December 31, 2019, the Secretary shall submit to Congress and make available to the public a final report on the findings of the evaluation under subparagraph (A).
I|G|IV|1634.(k)(6)
Definitions In this subsection:
I|G|IV|1634.(k)(6)(A)
Activities of daily living The term activities of daily living includes tasks such as eating, toileting, grooming, dressing, bathing, and transferring.
I|G|IV|1634.(k)(6)(B)
Consumer controlled The term consumer controlled means a method of selecting and providing services and supports that allow the individual, or where appropriate, the individual's representative, maximum control of the home and community-based attendant services and supports, regardless of who acts as the employer of record.
I|G|IV|1634.(k)(6)(C)
Delivery models
I|G|IV|1634.(k)(6)(C)(i)
Agency-provider model The term agency-provider model means, with respect to the provision of home and community-based attendant services and supports for an individual, subject to paragraph (4), a method of providing consumer controlled services and supports under which entities contract for the provision of such services and supports.
I|G|IV|1634.(k)(6)(C)(ii)
Other models The term other models means, subject to paragraph (4), methods, other than an agency-provider model, for the provision of consumer controlled services and supports. Such models may include the provision of vouchers, direct cash payments, or use of a fiscal agent to assist in obtaining services.
I|G|IV|1634.(k)(6)(D)
Health-related tasks The term health-related tasks means specific tasks related to the needs of an individual, which can be delegated or assigned by licensed health-care professionals under State law to be performed by an attendant.
I|G|IV|1634.(k)(6)(E)
Individual's representative The term individual's representative means a parent, family member, guardian, advocate, or other authorized representative of an individual
I|G|IV|1634.(k)(6)(F)
Instrumental activities of daily living The term instrumental activities of daily living includes (but is not limited to) meal planning and preparation, managing finances, shopping for food, clothing, and other essential items, performing essential household chores, communicating by phone or other media, and traveling around and participating in the community.
.
I|G|IV|1635.
Protection for recipients of home and community-based services against spousal impoverishment During the 5-year period that begins on January 1, 2014, section 1924(h)(1)(A) of the Social Security Act ( 42 U.S.C. 1396r-5(h)(1)(A) ) shall be applied as though is eligible for medical assistance for home and community-based services provided under subsection (c), (d), or (i) of section 1915, under a waiver approved under section 1115, or who is eligible for such medical assistance by reason of being determined eligible under section 1902(a)(10)(C) or by reason of section 1902(f) or otherwise on the basis of a reduction of income based on costs incurred for medical or other remedial care, or who is eligible for medical assistance for home and community-based attendant services and supports under section 1915(k) were substituted in such section for (at the option of the State) is described in section 1902(a)(10)(A)(ii)(VI) .
I|G|IV|1636.
Incentives for States to offer home and community-based services as a long-term care alternative to nursing homes
I|G|IV|1636.(a)
State balancing incentive payments program Notwithstanding section 1905(b) of the Social Security Act ( 42 U.S.C. 1396d(b) ), in the case of a balancing incentive payment State, as defined in subsection (b), that meets the conditions described in subsection (c), during the balancing incentive period, the Federal medical assistance percentage determined for the State under section 1905(b) of such Act and increased under section 1902(gg)(5) shall be increased by the applicable percentage points determined under subsection (d) with respect to eligible medical assistance expenditures described in subsection (e).
I|G|IV|1636.(b)
Balancing incentive payment state A balancing incentive payment State is a State -
I|G|IV|1636.(b)(1)
in which less than 50 percent of the total expenditures for medical assistance under the State Medicaid program for fiscal year 2009 for long-term services and supports (as defined by the Secretary under subsection (f))(1)) are for non-institutionally-based long-term services and supports described in subsection (f)(1)(B);
I|G|IV|1636.(b)(2)
that submits an application and meets the conditions described in subsection (c); and
I|G|IV|1636.(b)(3)
that is selected by the Secretary to participate in the State balancing incentive payment program established under this section.
I|G|IV|1636.(c)
Conditions The conditions described in this subsection are the following:
I|G|IV|1636.(c)(1)
Application The State submits an application to the Secretary that includes, in addition to such other information as the Secretary shall require -
I|G|IV|1636.(c)(1)(A)
a proposed budget that details the State's plan to expand and diversify medical assistance for non-institutionally-based long-term services and supports described in subsection (f)(1)(B) under the State Medicaid program during the balancing incentive period and achieve the target spending percentage applicable to the State under paragraph (2), including through structural changes to how the State furnishes such assistance, such as through the establishment of a no wrong door - single entry point system , optional presumptive eligibility, case management services, and the use of core standardized assessment instruments, and that includes a description of the new or expanded offerings of such services that the State will provide and the projected costs of such services; and
I|G|IV|1636.(c)(1)(B)
in the case of a State that proposes to expand the provision of home and community-based services under its State Medicaid program through a State plan amendment under section 1915(i) of the Social Security Act, at the option of the State, an election to increase the income eligibility for such services from 150 percent of the poverty line to such higher percentage as the State may establish for such purpose, not to exceed 300 percent of the supplemental security income benefit rate established by section 1611(b)(1) of the Social Security Act ( 42 U.S.C. 1382(b)(1) ).
I|G|IV|1636.(c)(2)
Target spending percentages
I|G|IV|1636.(c)(2)(A)
In the case of a balancing incentive payment State in which less than 25 percent of the total expenditures for home and community-based services under the State Medicaid program for fiscal year 2009 are for such services, the target spending percentage for the State to achieve by not later than October 1, 2015, is that 25 percent of the total expenditures for home and community-based services under the State Medicaid program are for such services.
I|G|IV|1636.(c)(2)(B)
In the case of any other balancing incentive payment State, the target spending percentage for the State to achieve by not later than October 1, 2015, is that 50 percent of the total expenditures for home and community-based services under the State Medicaid program are for such services.
I|G|IV|1636.(c)(3)
Maintenance of eligibility requirements The State does not apply eligibility standards, methodologies, or procedures for determining eligibility for medical assistance for non-institutionally-based long-term services and supports described in subsection (f)(1)(B) under the State Medicaid program that are more restrictive than the eligibility standards, methodologies, or procedures in effect for such purposes on December 31, 2010.
I|G|IV|1636.(c)(4)
Use of additional funds The State agrees to use the additional Federal funds paid to the State as a result of this section only for purposes of providing new or expanded offerings of non-institutionally-based long-term services and supports described in subsection (f)(1)(B) under the State Medicaid program.
I|G|IV|1636.(c)(5)
Structural changes The State agrees to make, not later than the end of the 6-month period that begins on the date the State submits an application under this section, the following changes:
I|G|IV|1636.(c)(5)(A)
No wrong door - single entry point system Development of a statewide system to enable consumers to access all long-term services and supports through an agency, organization, coordinated network, or portal, in accordance with such standards as the State shall establish and that shall provide information regarding the availability of such services, how to apply for such services, and referral services for services and supports otherwise available in the community ; and determinations of financial and functional eligibility for such services and supports, or assistance with assessment processes for financial and functional eligibility.
I|G|IV|1636.(c)(5)(B)
Conflict-free case management services Conflict-free case management services to develop a service plan, arrange for services and supports, support the beneficiary (and, if appropriate, the beneficiary's caregivers) in directing the provision of services and supports, for the beneficiary, and conduct ongoing monitoring to assure that services and supports are delivered to meet the beneficiary's needs and achieve intended outcomes.
I|G|IV|1636.(c)(5)(C)
Core standardized assessment instruments Development of core standardized assessment instruments for determining eligibility for non-institutionally-based long-term services and supports described in subsection (f)(1)(B), which shall be used in a uniform manner throughout the State, to determine a beneficiary's needs for training, support services, medical care, transportation, and other services, and develop an individual service plan to address such needs.
I|G|IV|1636.(c)(6)
Data collection The State agrees to collect from providers of services and through such other means as the State determines appropriate the following data:
I|G|IV|1636.(c)(6)(A)
Services data Services data from providers of non-institutionally-based long-term services and supports described in subsection (f)(1)(B) on a per-beneficiary basis and in accordance with such standardized coding procedures as the State shall establish in consultation with the Secretary.
I|G|IV|1636.(c)(6)(B)
Quality data Quality data on a selected set of core quality measures agreed upon by the Secretary and the State that are linked to population-specific outcomes measures and accessible to providers.
I|G|IV|1636.(c)(6)(C)
Outcomes measures Outcomes measures data on a selected set of core population-specific outcomes measures agreed upon by the Secretary and the State that are accessible to providers and include -
I|G|IV|1636.(c)(6)(C)(i)
measures of beneficiary and family caregiver experience with providers;
I|G|IV|1636.(c)(6)(C)(ii)
measures of beneficiary and family caregiver satisfaction with services; and
I|G|IV|1636.(c)(6)(C)(iii)
measures for achieving desired outcomes appropriate to a specific beneficiary, including employment, participation in community life, health stability, and prevention of loss in function.
I|G|IV|1636.(d)
Applicable percentage points increase in FMAP The applicable percentage points increase is -
I|G|IV|1636.(d)(1)
in the case of a balancing incentive payment State subject to the target spending percentage described in subsection (c)(2)(A), 5 percentage points; and
I|G|IV|1636.(d)(2)
in the case of any other balancing incentive payment State, 2 percentage points.
I|G|IV|1636.(e)
Eligible medical assistance expenditures
I|G|IV|1636.(e)(1)
In general Subject to paragraph (2), medical assistance described in this subsection is medical assistance for non-institutionally-based long-term services and supports described in subsection (f)(1)(B) that is provided by a balancing incentive payment State under its State Medicaid program during the balancing incentive payment period.
I|G|IV|1636.(e)(2)
Limitation on payments In no case may the aggregate amount of payments made by the Secretary to balancing incentive payment States under this section during the balancing incentive period exceed $3,000,000,000.
I|G|IV|1636.(f)
Definitions In this section:
I|G|IV|1636.(f)(1)
Long-term services and supports defined The term long-term services and supports has the meaning given that term by Secretary and shall include the following (as defined with for purposes of State Medicaid programs under title XIX of the Social Security Act):
I|G|IV|1636.(f)(1)(A)
Institutionally-based long-term services and supports Services provided in an institution, including the following:
I|G|IV|1636.(f)(1)(A)(i)
Nursing facility services.
I|G|IV|1636.(f)(1)(A)(ii)
Services in an intermediate care facility for the mentally retarded described in subsection (a)(15) of section 1905 of such Act.
I|G|IV|1636.(f)(1)(B)
Non-institutionally-based long-term services and supports Services not provided in an institution, including the following:
I|G|IV|1636.(f)(1)(B)(i)
Home and community-based services provided under subsection (c), (d), or (i), of section 1915 of such Act or under a waiver under section 1115 of such Act.
I|G|IV|1636.(f)(1)(B)(ii)
Home health care services.
I|G|IV|1636.(f)(1)(B)(iii)
Personal care services.
I|G|IV|1636.(f)(1)(B)(iv)
Services described in subsection (a)(26) of section 1905 of such Act (relating to PACE program services).
I|G|IV|1636.(f)(1)(B)(v)
Self-directed personal assistance services described in section 1915(j) of such Act.
I|G|IV|1636.(f)(2)
Balancing incentive period The term balancing incentive period means the period that begins on October 1, 2011, and ends on September 30, 2015.
I|G|IV|1636.(f)(3)
Poverty line The term poverty line has the meaning given that term in section 2110(c)(5) of the Social Security Act ( 42 U.S.C. 1397jj(c)(5) ).
I|G|IV|1636.(f)(4)
State medicaid program The term State Medicaid program means the State program for medical assistance provided under a State plan under title XIX of the Social Security Act and under any waiver approved with respect to such State plan.
I|G|IV|1636A.
Removal of barriers to providing home and community-based services
I|G|IV|1636A.(a)
Oversight and assessment of the administration of home and community-based services The Secretary of Health and Human Services shall promulgate regulations to ensure that all States develop service systems that are designed to -
I|G|IV|1636A.(a)(1)
allocate resources for services in a manner that is responsive to the changing needs and choices of beneficiaries receiving non-institutionally-based long-term services and supports described in section 1936(f)(1)(B) (including such services and supports that are provided under programs other the State Medicaid program), and that provides strategies for beneficiaries receiving such services to maximize their independence;
I|G|IV|1636A.(a)(2)
provide the support and coordination needed for a beneficiary in need of such services (and their family caregivers or representative, if applicable) to design an individualized, self-directed, community-supported life; and
I|G|IV|1636A.(a)(3)
improve coordination among all providers of such services under federally and State-funded programs in order to -
I|G|IV|1636A.(a)(3)(A)
achieve a more consistent administration of policies and procedures across programs in relation to the provision of such services; and
I|G|IV|1636A.(a)(3)(B)
oversee and monitor all service system functions to assure -
I|G|IV|1636A.(a)(3)(B)(i)
coordination of, and effectiveness of, eligibility determinations and individual assessments; and
I|G|IV|1636A.(a)(3)(B)(ii)
development and service monitoring of a complaint system, a management system, a system to qualify and monitor providers, and systems for role-setting and individual budget determinations.
I|G|IV|1636A.(b)
Additional state options Section 1915(i) of the Social Security Act ( 42 U.S.C. 1396n(i) ) is amended by adding at the end the following new paragraphs:
I|G|IV|1636A.(b)(6)
State option to provide home and community-based services to individuals eligible for services under a waiver
I|G|IV|1636A.(b)(6)(A)
In general A State that provides home and community-based services in accordance with this subsection to individuals who satisfy the needs-based criteria for the receipt of such services established under paragraph (1)(A) may, in addition to continuing to provide such services to such individuals, elect to provide home and community-based services in accordance with the requirements of this paragraph to individuals who are eligible for home and community-based services under a waiver approved for the State under subsection (c), (d), or (e) or under section 1115 to provide such services, but only for those individuals whose income does not exceed 300 percent of the supplemental security income benefit rate established by section 1611(b)(1).
I|G|IV|1636A.(b)(6)(B)
Application of same requirements for individuals satisfying needs-based criteria Subject to subparagraph (C), a State shall provide home and community-based services to individuals under this paragraph in the same manner and subject to the same requirements as apply under the other paragraphs of this subsection to the provision of home and community-based services to individuals who satisfy the needs-based criteria established under paragraph (1)(A).
I|G|IV|1636A.(b)(6)(C)
Authority to offer different type, amount, duration, or scope of home and community-based services A State may offer home and community-based services to individuals under this paragraph that differ in type, amount, duration, or scope from the home and community-based services offered for individuals who satisfy the needs-based criteria established under paragraph (1)(A), so long as such services are within the scope of services described in paragraph (4)(B) of subsection (c) for which the Secretary has the authority to approve a waiver and do not include room or board.
I|G|IV|1636A.(b)(7)
State option to offer home and community-based services to specific, targeted populations
I|G|IV|1636A.(b)(7)(A)
In general A State may elect in a State plan amendment under this subsection to target the provision of home and community-based services under this subsection to specific populations and to differ the type, amount, duration, or scope of such services to such specific populations.
I|G|IV|1636A.(b)(7)(B)
5-year term
I|G|IV|1636A.(b)(7)(B)(i)
In general An election by a State under this paragraph shall be for a period of 5 years.
I|G|IV|1636A.(b)(7)(B)(ii)
Phase-in of services and eligibility permitted during initial 5-year period A State making an election under this paragraph may, during the first 5-year period for which the election is made, phase-in the enrollment of eligible individuals, or the provision of services to such individuals, or both, so long as all eligible individuals in the State for such services are enrolled, and all such services are provided, before the end of the initial 5-year period.
I|G|IV|1636A.(b)(7)(C)
Renewal An election by a State under this paragraph may be renewed for additional 5-year terms if the Secretary determines, prior to beginning of each such renewal period, that the State has -
I|G|IV|1636A.(b)(7)(C)(i)
adhered to the requirements of this subsection and paragraph in providing services under such an election; and
I|G|IV|1636A.(b)(7)(C)(ii)
met the State's objectives with respect to quality improvement and beneficiary outcomes.
.
I|G|IV|1636A.(c)
Removal of limitation on scope of services Paragraph (1) of section 1915(i) of the Social Security Act ( 42 U.S.C. 1396n(i) ), as amended by subsection (a), is amended by striking or such other services requested by the State as the Secretary may approve .
I|G|IV|1636A.(d)
Optional eligibility category To provide full medicaid benefits to individuals receiving home and community-based services under a State plan amendment
I|G|IV|1636A.(d)(1)
In general Section 1902(a)(10)(A)(ii) of the Social Security Act ( 42 U.S.C. 1396a(a)(10)(A)(ii) ), as amended by section 1639(a)(1), is amended -
I|G|IV|1636A.(d)(1)(A)
in subclause (XX), by striking or at the end;
I|G|IV|1636A.(d)(1)(B)
in subclause (XXI), by adding or at the end; and
I|G|IV|1636A.(d)(1)(C)
by inserting after subclause (XXI), the following new subclause:
I|G|IV|1636A.(d)(1)(C)(XXII)
who are eligible for home and community-based services under needs-based criteria established under paragraph (1)(A) of section 1915(i), or who are eligible for home and community-based services under paragraph (6) of such section, and who will receive home and community-based services pursuant to a State plan amendment under such subsection; .
I|G|IV|1636A.(d)(2)
Conforming amendments
I|G|IV|1636A.(d)(2)(A)
Section 1903(f)(4) of the Social Security Act ( 42 U.S.C. 1396b(f)(4) ), as amended by section 1639(a)(4)(B), is amended in the matter preceding subparagraph (A), by inserting 1902(a)(10)(A)(ii)(XXII), after 1902(a)(10)(A)(ii)(XXI), .
I|G|IV|1636A.(d)(2)(B)
Section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ) , as so amended, is amended in the matter preceding paragraph (1) -
I|G|IV|1636A.(d)(2)(B)(i)
in clause (xv), by striking or at the end;
I|G|IV|1636A.(d)(2)(B)(ii)
in clause (xvi), by adding or at the end; and
I|G|IV|1636A.(d)(2)(B)(iii)
by inserting after clause (xvi) the following new clause:
I|G|IV|1636A.(d)(2)(B)(iii)(xvii)
individuals who are eligible for home and community-based services under needs-based criteria established under paragraph (1)(A) of section 1915(i), or who are eligible for home and community-based services under paragraph (6) of such section, and who will receive home and community-based services pursuant to a State plan amendment under such subsection, .
I|G|IV|1636A.(e)
Elimination of option To limit number of eligible individuals or length of period for grandfathered individuals if eligibility criteria is modified Paragraph (1) of section 1915(i) of such Act ( 42 U.S.C. 1396n(i) ) is amended -
I|G|IV|1636A.(e)(1)
by striking subparagraph (C) and inserting the following:
I|G|IV|1636A.(e)(1)(C)
Projection of number of individuals to be provided home and community-based services The State submits to the Secretary, in such form and manner, and upon such frequency as the Secretary shall specify, the projected number of individuals to be provided home and community-based services. ; and
I|G|IV|1636A.(e)(2)
in subclause (II) of subparagraph (D)(ii), by striking to be eligible for such services for a period of at least 12 months beginning on the date the individual first received medical assistance for such services and inserting to continue to be eligible for such services after the effective date of the modification and until such time as the individual no longer meets the standard for receipt of such services under such pre-modified criteria .
I|G|IV|1636A.(f)
Elimination of option To waive statewideness; addition of option To waive comparability Paragraph (3) of section 1915(i) of such Act ( 42 U.S.C. 1396n(3) ) is amended by striking 1902(a)(1) (relating to statewideness) and inserting 1902(a)(10)(B) (relating to comparability) .
I|G|IV|1636A.(g)
Effective date The amendments made by subsections (b) through (f) take effect on the first day of the first fiscal year quarter that begins after the date of enactment of this Act.
I|G|IV|1637.
Money Follows the Person Rebalancing Demonstration
I|G|IV|1637.(a)
Extension of demonstration
I|G|IV|1637.(a)(1)
In general Section 6071(h) of the Deficit Reduction Act of 2005 ( 42 U.S.C. 1396a note) is amended -
I|G|IV|1637.(a)(1)(A)
in paragraph (1)(E), by striking fiscal year 2011 and inserting each of fiscal years 2011 through 2016 ; and
I|G|IV|1637.(a)(1)(B)
in paragraph (2), by striking 2011 and inserting 2016 .
I|G|IV|1637.(a)(2)
Evaluation Paragraphs (2) and (3) of section 6071(g) of such Act is amended are each amended by striking 2011 and inserting 2016 .
I|G|IV|1637.(b)
Reduction of institutional residency period
I|G|IV|1637.(b)(1)
In general Section 6071(b)(2) of the Deficit Reduction Act of 2005 ( 42 U.S.C. 1396a note) is amended -
I|G|IV|1637.(b)(1)(A)
in subparagraph (A)(i), by striking , for a period of not less than 6 months or for such longer minimum period, not to exceed 2 years, as may be specified by the State and inserting for a period of not less than 90 consecutive days ; and
I|G|IV|1637.(b)(1)(B)
by adding at the end the following: Any days that an individual resides in an institution on the basis of having been admitted solely for purposes of receiving short-term rehabilitative services for a period for which payment for such services is limited under title XVIII shall not be taken into account for purposes of determining the 90-day period required under subparagraph (A)(i). .
I|G|IV|1637.(b)(2)
Effective date The amendments made by this subsection take effect 30 days after the date of enactment of this Act.
I|G|IV|1638.
Clarification of definition of medical assistance Section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ) is amended by inserting or the care and services themselves, or both before (if provided in or after .
I|G|IV|1639.
State eligibility option for family planning services
I|G|IV|1639.(a)
Coverage as optional categorically needy group
I|G|IV|1639.(a)(1)
In general Section 1902(a)(10)(A)(ii) of the Social Security Act ( 42 U.S.C. 1396a(a)(10)(A)(ii) ), as amended by section 1601(e), is amended -
I|G|IV|1639.(a)(1)(A)
in subclause (XIX), by striking or at the end;
I|G|IV|1639.(a)(1)(B)
in subclause (XX), by adding or at the end; and
I|G|IV|1639.(a)(1)(C)
by adding at the end the following new subclause:
I|G|IV|1639.(a)(1)(C)(XXI)
who are described in subsection (ii) (relating to individuals who meet certain income standards); .
I|G|IV|1639.(a)(2)
Group described Section 1902 of such Act ( 42 U.S.C. 1396a ), as amended by section 1601(d), is amended by adding at the end the following new subsection:
I|G|IV|1639.(a)(2)(ii)
I|G|IV|1639.(a)(2)(ii)(1)
Individuals described in this subsection are individuals -
I|G|IV|1639.(a)(2)(ii)(1)(A)
whose income does not exceed an income eligibility level established by the State that does not exceed the highest income eligibility level established under the State plan under this title (or under its State child health plan under title XXI) for pregnant women; and
I|G|IV|1639.(a)(2)(ii)(1)(B)
who are not pregnant.
I|G|IV|1639.(a)(2)(ii)(2)
At the option of a State, individuals described in this subsection may include individuals who, had individuals applied on or before January 1, 2007, would have been made eligible pursuant to the standards and processes imposed by that State for benefits described in clause (XV) of the matter following subparagraph (G) of section subsection (a)(10) pursuant to a waiver granted under section 1115.
I|G|IV|1639.(a)(2)(ii)(3)
At the option of a State, for purposes of subsection (a)(17)(B), in determining eligibility for services under this subsection, the State may consider only the income of the applicant or recipient.
.
I|G|IV|1639.(a)(3)
Limitation on benefits Section 1902(a)(10) of the Social Security Act ( 42 U.S.C. 1396a(a)(10) ), as amended by section 1601(a)(5)(A), is amended in the matter following subparagraph (G) -
I|G|IV|1639.(a)(3)(A)
by striking and (XV) and inserting (XV) ; and
I|G|IV|1639.(a)(3)(B)
by inserting , and (XVI) the medical assistance made available to an individual described in subsection (ii) shall be limited to family planning services and supplies described in section 1905(a)(4)(C) including medical diagnosis and treatment services that are provided pursuant to a family planning service in a family planning setting before the semicolon.
I|G|IV|1639.(a)(4)
Conforming amendments
I|G|IV|1639.(a)(4)(A)
Section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ), as amended by section 1601(e)(2)(A), is amended in the matter preceding paragraph (1) -
I|G|IV|1639.(a)(4)(A)(i)
in clause (xiv), by striking or at the end;
I|G|IV|1639.(a)(4)(A)(ii)
in clause (xv), by adding or at the end; and
I|G|IV|1639.(a)(4)(A)(iii)
by inserting after clause (xv) the following:
I|G|IV|1639.(a)(4)(A)(iii)(xvi)
individuals described in section 1902(ii), .
I|G|IV|1639.(a)(4)(B)
Section 1903(f)(4) of such Act ( 42 U.S.C. 1396b(f)(4) ), as amended by section 1601(e)(2)(B), is amended by inserting 1902(a)(10)(A)(ii)(XXI), after 1902(a)(10)(A)(ii)(XX), .
I|G|IV|1639.(b)
Presumptive eligibility
I|G|IV|1639.(b)(1)
In general Title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. ) is amended by inserting after section 1920B the following:
I|G|IV|1639.(b)(1)1920C.
Presumptive eligibility for family planning services
I|G|IV|1639.(b)(1)1920C.(a)
State Option State plan approved under section 1902 may provide for making medical assistance available to an individual described in section 1902(ii) (relating to individuals who meet certain income eligibility standard) during a presumptive eligibility period. In the case of an individual described in section 1902(ii), such medical assistance shall be limited to family planning services and supplies described in 1905(a)(4)(C) and, at the State's option, medical diagnosis and treatment services that are provided in conjunction with a family planning service in a family planning setting.
I|G|IV|1639.(b)(1)1920C.(b)
Definitions For purposes of this section:
I|G|IV|1639.(b)(1)1920C.(b)(1)
Presumptive eligibility period The term presumptive eligibility period means, with respect to an individual described in subsection (a), the period that -
I|G|IV|1639.(b)(1)1920C.(b)(1)(A)
begins with the date on which a qualified entity determines, on the basis of preliminary information, that the individual is described in section 1902(ii); and
I|G|IV|1639.(b)(1)1920C.(b)(1)(B)
ends with (and includes) the earlier of -
I|G|IV|1639.(b)(1)1920C.(b)(1)(B)(i)
the day on which a determination is made with respect to the eligibility of such individual for services under the State plan; or
I|G|IV|1639.(b)(1)1920C.(b)(1)(B)(ii)
in the case of such an individual who does not file an application by the last day of the month following the month during which the entity makes the determination referred to in subparagraph (A), such last day.
I|G|IV|1639.(b)(1)1920C.(b)(2)
Qualified entity
I|G|IV|1639.(b)(1)1920C.(b)(2)(A)
In general Subject to subparagraph (B), the term qualified entity means any entity that -
I|G|IV|1639.(b)(1)1920C.(b)(2)(A)(i)
is eligible for payments under a State plan approved under this title; and
I|G|IV|1639.(b)(1)1920C.(b)(2)(A)(ii)
is determined by the State agency to be capable of making determinations of the type described in paragraph (1)(A).
I|G|IV|1639.(b)(1)1920C.(b)(2)(B)
Rule of construction Nothing in this paragraph shall be construed as preventing a State from limiting the classes of entities that may become qualified entities in order to prevent fraud and abuse.
I|G|IV|1639.(b)(1)1920C.(c)
Administration
I|G|IV|1639.(b)(1)1920C.(c)(1)
In general The State agency shall provide qualified entities with -
I|G|IV|1639.(b)(1)1920C.(c)(1)(A)
such forms as are necessary for an application to be made by an individual described in subsection (a) for medical assistance under the State plan; and
I|G|IV|1639.(b)(1)1920C.(c)(1)(B)
information on how to assist such individuals in completing and filing such forms.
I|G|IV|1639.(b)(1)1920C.(c)(2)
Notification requirements A qualified entity that determines under subsection (b)(1)(A) that an individual described in subsection (a) is presumptively eligible for medical assistance under a State plan shall -
I|G|IV|1639.(b)(1)1920C.(c)(2)(A)
notify the State agency of the determination within 5 working days after the date on which determination is made; and
I|G|IV|1639.(b)(1)1920C.(c)(2)(B)
inform such individual at the time the determination is made that an application for medical assistance is required to be made by not later than the last day of the month following the month during which the determination is made.
I|G|IV|1639.(b)(1)1920C.(c)(3)
Application for medical assistance In the case of an individual described in subsection (a) who is determined by a qualified entity to be presumptively eligible for medical assistance under a State plan, the individual shall apply for medical assistance by not later than the last day of the month following the month during which the determination is made.
I|G|IV|1639.(b)(1)1920C.(d)
Payment Notwithstanding any other provision of law, medical assistance that -
I|G|IV|1639.(b)(1)1920C.(d)(1)
is furnished to an individual described in subsection (a) -
I|G|IV|1639.(b)(1)1920C.(d)(1)(A)
during a presumptive eligibility period; and
I|G|IV|1639.(b)(1)1920C.(d)(1)(B)
by a entity that is eligible for payments under the State plan; and
I|G|IV|1639.(b)(1)1920C.(d)(2)
is included in the care and services covered by the State plan, shall be treated as medical assistance provided by such plan for purposes of clause (4) of the first sentence of section 1905(b).
.
I|G|IV|1639.(b)(2)
Conforming amendments
I|G|IV|1639.(b)(2)(A)
Section 1902(a)(47) of the Social Security Act ( 42 U.S.C. 1396a(a)(47) ), as amended by section 1622(a), is amended -
I|G|IV|1639.(b)(2)(A)(i)
in subparagraph (A), by inserting before the semicolon at the end the following: and provide for making medical assistance available to individuals described in subsection (a) of section 1920C during a presumptive eligibility period in accordance with such section ; and
I|G|IV|1639.(b)(2)(A)(ii)
in subparagraph (B), by striking or 1920B and inserting 1920B, or 1920C .
I|G|IV|1639.(b)(2)(B)
Section 1903(u)(1)(D)(v) of such Act ( 42 U.S.C. 1396b(u)(1)(D)(v) ), as amended by section 1622(b), is amended by inserting or for medical assistance provided to an individual described in subsection (a) of section 1920C during a presumptive eligibility period under such section, after 1920B during a presumptive eligibility period under such section, .
I|G|IV|1639.(c)
Clarification of coverage of family planning services and supplies Section 1937(b) of the Social Security Act ( 42 U.S.C. 1396u-7(b) ), as amended by section 1601(c), is amended by adding at the end the following:
I|G|IV|1639.(c)(7)
Coverage of family planning services and supplies Notwithstanding the previous provisions of this section, a State may not provide for medical assistance through enrollment of an individual with benchmark coverage or benchmark-equivalent coverage under this section unless such coverage includes for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section. .
I|G|IV|1639.(d)
Effective date The amendments made by this section take effect on the date of the enactment of this Act and shall apply to items and services furnished on or after such date.
I|G|IV|1640.
Grants for school-based health centers Title XIX of the Social Security Act ( 42 U.S.C. 1397aa et seq. ), as amended by section 1621, is amended by adding at the end the following:
I|G|IV|1640.1944.
Grants for school-based health centers
I|G|IV|1640.1944.(a)
Program The Secretary shall establish a program to award grants to eligible entities to support the operation of school-based health centers (as defined in section 2110(c)(9)).
I|G|IV|1640.1944.(b)
Eligibility To be eligible for a grant under this section, an entity shall -
I|G|IV|1640.1944.(b)(1)
be a school-based health center or a sponsoring facility (as defined in section 2110(c)(9)(B)) of a school-based health center; and
I|G|IV|1640.1944.(b)(2)
submit an application at such time, in such manner, and containing such information as the Secretary may require, including at a minimum an assurance that funds awarded under the grant shall not be used to provide any service that is not authorized or allowed by Federal, State, or local law.
I|G|IV|1640.1944.(c)
Preference In awarding grants under this section, the Secretary shall give preference to awarded grants for school-based health centers that serve a large population of children eligible for medical assistance under the State plan under this title or under a waiver of the plan or children eligible for child health assistance under the State child health plan under title XXI.
I|G|IV|1640.1944.(d)
Appropriations Out of any funds in the Treasury not otherwise appropriated, there is appropriated for each of fiscal years 2010 and 2011, $100,000,000 for the purpose of carrying out this section. Funds appropriated under this subsection shall remain available until expended.
.
I|G|IV|1641.
Therapeutic foster care Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ), as amended by sections 1601(a)(3) and 1636, is amended by adding at the end the following:
I|G|IV|1641.(aa)
I|G|IV|1641.(aa)(1)
Nothing in subsection (a) shall be construed as limiting a State from providing medical assistance for therapeutic foster care for children in foster care under the responsibility of the State in out-of-home placements.
I|G|IV|1641.(aa)(2)
The term therapeutic foster care means a foster care program that provides -
I|G|IV|1641.(aa)(2)(A)
to a child in foster care under the responsibility of the State -
I|G|IV|1641.(aa)(2)(A)(i)
structured daily activities that develop, improve, monitor, and reinforce age-appropriate social, communications, and behavioral skills;
I|G|IV|1641.(aa)(2)(A)(ii)
crisis intervention and crisis support services;
I|G|IV|1641.(aa)(2)(A)(iii)
medication monitoring;
I|G|IV|1641.(aa)(2)(A)(iv)
counseling; and
I|G|IV|1641.(aa)(2)(A)(v)
case management services; and
I|G|IV|1641.(aa)(2)(B)
specialized training for the foster parent and consultation with the foster parent on the management of children with mental illnesses and related health and developmental conditions.
.
I|G|IV|1642.
Sense of the Senate regarding long-term care
I|G|IV|1642.(a)
Findings The Senate makes the following findings:
I|G|IV|1642.(a)(1)
Nearly 2 decades have passed since Congress seriously considered long-term care reform. The United States Bipartisan Commission on Comprehensive Health Care, also know as the Pepper Commission , released its Call for Action blueprint for health reform in September 1990. In the 20 years since those recommendations were made, Congress has never acted on the report.
I|G|IV|1642.(a)(2)
In 1999, under the United States Supreme Court's decision in Olmstead v. L.C., 527 U.S. 581 (1999), individuals with disabilities have the right to choose to receive their long-term services and supports in the community, rather than in an institutional setting.
I|G|IV|1642.(a)(3)
Despite the Pepper Commission and Olmstead decision, the long-term care provided to our Nation‘s elderly and disabled has not improved. In fact, for many, it has gotten far worse.
I|G|IV|1642.(a)(4)
In 2007, 69 percent of Medicaid long-term care spending for elderly individuals and adults with physical disabilities paid for institutional services. Only 6 states spent 50 percent or more of their Medicaid long-term care dollars on home and community-based services for elderly individuals and adults with physical disabilities while ½ of the States spent less than 25 percent. This disparity continues even though, on average, it is estimated that Medicaid dollars can support nearly 3 elderly individuals and adults with physical disabilities in home and community-based services for every individual in a nursing home. Although every State has chosen to provide certain services under home and community-based waivers, these services are unevenly available within and across States, and reach a small percentage of eligible individuals.
I|G|IV|1642.(b)
Sense of the Senate It is the sense of the Senate that -
I|G|IV|1642.(b)(1)
during the 111th session of Congress, Congress should address long-term services and supports in a comprehensive way that guarantees elderly and disabled individuals the care they need; and
I|G|IV|1642.(b)(2)
long term services and supports should be made available in the community in addition to in institutions.
I|G|V
Medicaid Prescription Drug Coverage
I|G|V|1651.
Prescription drug rebates
I|G|V|1651.(a)
Increase in minimum rebate percentage for single source drugs and innovator multiple source drugs Section 1927(c)(1)(B) of the Social Security Act ( 42 U.S.C. 1396r-8(c)(1)(B) ) is amended -
I|G|V|1651.(a)(1)
in clause (i) -
I|G|V|1651.(a)(1)(A)
in subclause (IV), by striking and at the end;
I|G|V|1651.(a)(1)(B)
in subclause (V) -
I|G|V|1651.(a)(1)(B)(i)
by inserting and before January 1, 2010 after December 31, 1995, ; and
I|G|V|1651.(a)(1)(B)(ii)
by striking the period at the end and inserting ; and ; and
I|G|V|1651.(a)(1)(C)
by adding at the end the following new subclause:
I|G|V|1651.(a)(1)(C)(VI)
except as provided in clause (iii), after December 31, 2009, 23.1 percent. ; and
I|G|V|1651.(a)(2)
by adding at the end the following new clause:
I|G|V|1651.(a)(2)(iii)
Minimum rebate percentage for certain drugs
I|G|V|1651.(a)(2)(iii)(I)
In general In the case of a single source drug or an innovator multiple source drug described in subclause (II), the minimum rebate percentage for rebate periods specified in clause (i)(VI) is 17.1 percent.
I|G|V|1651.(a)(2)(iii)(II)
Drug described For purposes of subclause (I), a single source drug or an innovator multiple source drug described in this subclause is any of the following drugs:
I|G|V|1651.(a)(2)(iii)(aa)
A clotting factor for which a separate furnishing payment is made under section 1842(o)(5) and which is included on a list of such factors specified and updated regularly by the Secretary.
I|G|V|1651.(a)(2)(iii)(bb)
A drug approved by the Food and Drug Administration exclusively for pediatric indications.
.
I|G|V|1651.(b)
Increase in rebate for other drugs Section 1927(c)(3)(B) of such Act ( 42 U.S.C. 1396r-8(c)(3)(B) ) is amended -
I|G|V|1651.(b)(1)
in clause (i), by striking and at the end;
I|G|V|1651.(b)(2)
in clause (ii) -
I|G|V|1651.(b)(2)(A)
by inserting and before January 1, 2010, after December 31, 1993, ; and
I|G|V|1651.(b)(2)(B)
by striking the period and inserting ; and ; and
I|G|V|1651.(b)(3)
by adding at the end the following new clause:
I|G|V|1651.(b)(3)(iii)
after December 31, 2009, is 13 percent. .
I|G|V|1651.(c)
Extension of prescription drug discounts to enrollees of Medicaid managed care organizations
I|G|V|1651.(c)(1)
In general Section 1903(m)(2)(A) of such Act ( 42 U.S.C. 1396b(m)(2)(A) ) is amended -
I|G|V|1651.(c)(1)(A)
in clause (xi), by striking and at the end;
I|G|V|1651.(c)(1)(B)
in clause (xii), by striking the period at the end and inserting ; and ; and
I|G|V|1651.(c)(1)(C)
by adding at the end the following:
I|G|V|1651.(c)(1)(C)(xiii)
such contract provides that (I) covered outpatient drugs dispensed to individuals eligible for medical assistance who are enrolled with the entity shall be subject to the same rebate required by the agreement entered into under section 1927 as the State is subject to and that the State shall collect such rebates from manufacturers, (II) capitation rates paid to the entity shall be based on actual cost experience related to rebates and subject to the Federal regulations requiring actuarially sound rates, and (III) the entity shall report to the State, on such timely and periodic basis as specified by the Secretary, information on the total number of units of each dosage form and strength and package size by National Drug Code of each covered outpatient drug dispensed to individuals eligible for medical assistance who are enrolled with the entity and for which the entity is responsible for coverage of such drug under this subsection. .
I|G|V|1651.(c)(2)
Conforming amendments Section 1927 ( 42 U.S.C. 1396r-8 ) is amended -
I|G|V|1651.(c)(2)(A)
in subsection (d)(4), by inserting after subparagraph (E) the following:
I|G|V|1651.(c)(2)(A)(F)
Notwithstanding the preceding subparagraphs of this paragraph, any formulary established by medicaid managed care organization with a contract under section 1903(m) may be based on positive inclusion of drugs selected by a formulary committee consisting of physicians, pharmacists, and other individuals with appropriate clinical experience as long as drugs excluded from the formulary are available through prior authorization, as described in paragraph (5). ; and
I|G|V|1651.(c)(2)(B)
in subsection (j), by striking paragraph (1) and inserting the following:
I|G|V|1651.(c)(2)(B)(1)
Covered outpatient drugs are not subject to the requirements of this section if such drugs are -
I|G|V|1651.(c)(2)(B)(1)(A)
dispensed by health maintenance organizations, including Medicaid managed care organizations that contract under section 1903(m); and
I|G|V|1651.(c)(2)(B)(1)(B)
subject to discounts under section 340B of the Public Health Service Act.
.
I|G|V|1651.(d)
Additional rebate for new formulations of existing drugs
I|G|V|1651.(d)(1)
In general Section 1927(c)(2) of the Social Security Act ( 42 U.S.C. 1396r-8(c)(2) ) is amended by adding at the end the following new subparagraph:
I|G|V|1651.(d)(1)(C)
Treatment of new formulations
I|G|V|1651.(d)(1)(C)(i)
In general Except as provided in clause (ii), in the case of a drug that is a new formulation, such as an extended-release formulation, of a single source drug or an innovator multiple source drug, the rebate obligation with respect to the drug under this section shall be the amount computed under this section for the new formulation of the drug or, if greater, the product of -
I|G|V|1651.(d)(1)(C)(i)(I)
the average manufacturer price of the new formulation of the single source drug or innovator multiple source drug;
I|G|V|1651.(d)(1)(C)(i)(II)
the highest additional rebate (calculated as a percentage of average manufacturer price) under this section for any strength of the original single source drug or innovator multiple source drug; and
I|G|V|1651.(d)(1)(C)(i)(III)
the total number of units of each dosage form and strength of the new formulation paid for under the State plan in the rebate period (as reported by the State).
I|G|V|1651.(d)(1)(C)(ii)
No application to new formulations of orphan drugs Clause (i) shall not apply to a new formulation of a covered outpatient drug that is or has been designated under section 526 of the Federal Food, Drug, and Cosmetic Act ( 21 U.S.C. 360bb ) for a rare disease or condition, without regard to whether the period of market exclusivity for the drug under section 527 of such Act has expired or the specific indication for use of the drug.
.
I|G|V|1651.(d)(2)
Effective date The amendment made by paragraph (1) shall apply to drugs dispensed after December 31, 2009.
I|G|V|1651.(e)
Maximum rebate amount Section 1927(c)(2) of such Act ( 42 U.S.C. 1396r-8(c)(2) ), as amended by subsection (d), is amended by adding at the end the following new subparagraph:
I|G|V|1651.(e)(D)
Maximum rebate amount In no case shall the sum of the amounts applied under paragraph (1)(A)(ii) and this paragraph with respect to each dosage form and strength of a single source drug or an innovator multiple source drug for a rebate period beginning after December 31, 2009, exceed 100 percent of the average manufacturer price of the drug. .
I|G|V|1651.(f)
Conforming amendments
I|G|V|1651.(f)(1)
In general Section 340B of the Public Health Service Act ( 42 U.S.C. 256b ) is amended -
I|G|V|1651.(f)(1)(A)
in subsection (a)(2)(B)(i), by striking 1927(c)(4) and inserting 1927(c)(3) ; and
I|G|V|1651.(f)(1)(B)
by striking subsection (c); and
I|G|V|1651.(f)(1)(C)
redesignating subsection (d) as subsection (c).
I|G|V|1651.(f)(2)
Effective date The amendments made by this subsection take effect on January 1, 2010.
I|G|V|1652.
Elimination of exclusion of coverage of certain drugs
I|G|V|1652.(a)
In general Section 1927(d) of the Social Security Act ( 42 U.S.C. 1397r-8(d) ) is amended -
I|G|V|1652.(a)(1)
in paragraph (2) -
I|G|V|1652.(a)(1)(A)
by striking subparagraphs (E), (I), and (J), respectively; and
I|G|V|1652.(a)(1)(B)
by redesignating subparagraphs (F), (G), (H), and (K) as subparagraphs (E), (F), (G), and (H), respectively; and
I|G|V|1652.(a)(2)
by adding at the end the following new paragraph:
I|G|V|1652.(a)(2)(7)
Non-excludable drugs The following drugs or classes of drugs, or their medical uses, shall not be excluded from coverage:
I|G|V|1652.(a)(2)(7)(A)
Agents when used to promote smoking cessation.
I|G|V|1652.(a)(2)(7)(B)
Barbiturates.
I|G|V|1652.(a)(2)(7)(C)
Benzodiazepines.
.
I|G|V|1652.(b)
Effective date The amendments made by this section shall apply to services furnished on or after January 1, 2014.
I|G|V|1653.
Providing adequate pharmacy reimbursement
I|G|V|1653.(a)
Pharmacy reimbursement limits
I|G|V|1653.(a)(1)
In general Section 1927(e) of the Social Security Act ( 42 U.S.C. 1396r-8(e) ) is amended -
I|G|V|1653.(a)(1)(A)
in paragraph (4), by striking (or, effective January 1, 2007, two or more) ; and
I|G|V|1653.(a)(1)(B)
by striking paragraph (5) and inserting the following:
I|G|V|1653.(a)(1)(B)(5)
Use of AMP in Upper Payment Limits The Secretary shall calculate the Federal upper reimbursement limit established under paragraph (4) as no less than 175 percent of the weighted average (determined on the basis of utilization) of the most recently reported monthly average manufacturer prices for pharmaceutically and therapeutically equivalent multiple source drug products that are available for purchase by retail community pharmacies on a nationwide basis. The Secretary shall implement a smoothing process for average manufacturer prices. Such process shall be similar to the smoothing process used in determining the average sales price of a drug or biological under section 1847A. .
I|G|V|1653.(a)(2)
Definition of AMP Section 1927(k)(1) of such Act ( 42 U.S.C. 1396r-8(k)(1) ) is amended -
I|G|V|1653.(a)(2)(A)
in subparagraph (A), by striking by and all that follows through the period and inserting "by -
I|G|V|1653.(a)(2)(A)(i)
wholesalers for drugs distributed to retail community pharmacies; and
I|G|V|1653.(a)(2)(A)(ii)
retail community pharmacies that purchase drugs directly from the manufacturer. ; and
I|G|V|1653.(a)(2)(B)
by striking subparagraph (B) and inserting the following:
I|G|V|1653.(a)(2)(B)(B)
Exclusion of customary prompt pay discounts and other payments
I|G|V|1653.(a)(2)(B)(B)(i)
In general The average manufacturer price for a covered outpatient drug shall exclude -
I|G|V|1653.(a)(2)(B)(B)(i)(I)
customary prompt pay discounts extended to wholesalers;
I|G|V|1653.(a)(2)(B)(B)(i)(II)
bona fide service fees paid by manufacturers to wholesalers or retail community pharmacies, including (but not limited to) distribution service fees, inventory management fees, product stocking allowances, and fees associated with administrative services agreements and patient care programs (such as medication compliance programs and patient education programs);
I|G|V|1653.(a)(2)(B)(B)(i)(III)
reimbursement by manufacturers for recalled, damaged, expired, or otherwise unsalable returned goods, including (but not limited to) reimbursement for the cost of the goods and any reimbursement of costs associated with return goods handling and processing, reverse logistics, and drug destruction; and
I|G|V|1653.(a)(2)(B)(B)(i)(IV)
payments received from, and rebates or discounts provided to, pharmacy benefit managers, managed care organizations, health maintenance organizations, insurers, hospitals, clinics, mail order pharmacies, long term care providers, manufacturers, or any other entity that does not conduct business as a wholesaler or a retail community pharmacy.
I|G|V|1653.(a)(2)(B)(B)(ii)
Inclusion of other discounts and payments Notwithstanding clause (i), any other discounts, rebates, payments, or other financial transactions that are received by, paid by, or passed through to, retail community pharmacies shall be included in the average manufacturer price for a covered outpatient drug.
; and
I|G|V|1653.(a)(2)(C)
in subparagraph (C), by striking the retail pharmacy class of trade and inserting retail community pharmacies .
I|G|V|1653.(a)(3)
Definition of multiple source drug Section 1927(k)(7) of such Act ( 42 U.S.C. 1396r-8(k)(7) ) is amended -
I|G|V|1653.(a)(3)(A)
in subparagraph (A)(i)(III), by striking the State and inserting the United States ; and
I|G|V|1653.(a)(3)(B)
in subparagraph (C) -
I|G|V|1653.(a)(3)(B)(i)
in clause (i), by inserting and after the semicolon;
I|G|V|1653.(a)(3)(B)(ii)
in clause (ii), by striking ; and and inserting a period; and
I|G|V|1653.(a)(3)(B)(iii)
by striking clause (iii).
I|G|V|1653.(a)(4)
Definitions of retail community pharmacy; wholesaler Section 1927(k) of such Act ( 42 U.S.C. 1396r-8(k) ) is amended by adding at the end the following new paragraphs:
I|G|V|1653.(a)(4)(10)
Retail community pharmacy The term retail community pharmacy means an independent pharmacy, a chain pharmacy, a supermarket pharmacy, or a mass merchandiser pharmacy that is licensed as a pharmacy by the State and that dispenses medications to the general public at retail prices. Such term does not include a pharmacy that dispenses prescription medications to patients primarily through the mail, nursing home pharmacies, long-term care facility pharmacies, hospital pharmacies, clinics, charitable or not-for-profit pharmacies, government pharmacies, or pharmacy benefit managers.
I|G|V|1653.(a)(4)(11)
Wholesaler The term wholesaler means a drug wholesaler that is engaged in wholesale distribution of prescription drugs to retail community pharmacies, including (but not limited to) manufacturers, repackers, distributors, own-label distributors, private-label distributors, jobbers, brokers, warehouses (including manufacturer's and distributor's warehouses, chain drug warehouses, and wholesale drug warehouses) independent wholesale drug traders, and retail community pharmacies that conduct wholesale distributions. .
I|G|V|1653.(b)
Disclosure of price information to the public Section 1927(b)(3) of such Act ( 42 U.S.C. 1396r-8(b)(3) ) is amended -
I|G|V|1653.(b)(1)
in subparagraph (A) -
I|G|V|1653.(b)(1)(A)
in clause (i), in the matter preceding subclause (I), by inserting month of a after each ; and
I|G|V|1653.(b)(1)(B)
in the second sentence, by inserting (relating to the weighted average of the most recently reported monthly average manufacturer prices) after (D)(v) ; and
I|G|V|1653.(b)(2)
in subparagraph (D)(v), by striking average manufacturer prices and inserting the weighted average of the most recently reported monthly average manufacturer prices and the average retail survey price determined for each multiple source drug in accordance with subsection (f) .
I|G|V|1653.(c)
Clarification of application of survey of retail prices Section 1927(f)(1) of such Act ( 42 U.S.C. 1396r-8(b)(1) ) is amended -
I|G|V|1653.(c)(1)
in subparagraph (A)(i), by inserting with respect to a retail community pharmacy, before the determination ; and
I|G|V|1653.(c)(2)
in subparagraph (C)(ii), by striking retail pharmacies and inserting retail community pharmacies .
I|G|V|1653.(d)
Effective date The amendments made by this section shall take effect on the first day of the first calendar year quarter that begins at least 180 days after the date of enactment of this Act, without regard to whether or not final regulations to carry out such amendments have been promulgated by such date.
I|G|V|1654.
Study of barriers to appropriate utilization of generic medicine in federal health care programs
I|G|V|1654.(a)
Study The Comptroller General of the United States shall conduct a study of State laws that have a negative impact on generic drug utilization in Federal health care programs (as defined in section 1128B(f) of the Social Security Act (42 U.S.C. 1320a-7b(f))) due to restrictions such as (but not limited to) limits on pharmacists' ability to provide a generic drug substitute for a prescribed name brand drug and carve-outs of certain classes of drugs from generic substitution.
I|G|V|1654.(b)
Report Not later than April 1, 2012, the Comptroller General of the United States shall submit a report to Congress on the results of the study conducted under subsection (a).
I|G|VI
Medicaid Disproportionate Share Hospital (DSH) Payments
I|G|VI|1655.
Disproportionate share hospital payments
I|G|VI|1655.(a)
In general Section 1923(f) of the Social Security Act ( 42 U.S.C. 1396r-4(f) ) is amended -
I|G|VI|1655.(a)(1)
in paragraph (1), by striking and (3) and inserting , (3), and (7) ;
I|G|VI|1655.(a)(2)
in paragraph (3)(A), by striking paragraph (6) and inserting paragraphs (6) and (7) ;
I|G|VI|1655.(a)(3)
by redesignating paragraph (7) as paragraph (8); and
I|G|VI|1655.(a)(4)
by inserting after paragraph (6) the following new paragraph:
I|G|VI|1655.(a)(4)(7)
Reduction of state dsh allotments once reduction in uninsured threshold reached
I|G|VI|1655.(a)(4)(7)(A)
In general Subject to subparagraph (E), the DSH allotment for a State for fiscal years beginning with the fiscal year described in subparagraph (C) (with respect to the State), is equal to the DSH allotment that would be determined under this subsection for the State for the fiscal year without application of this paragraph (but after the application of subparagraph (D)), reduced by the applicable percentage determined for the State for the fiscal year under subparagraph (B).
I|G|VI|1655.(a)(4)(7)(B)
Applicable percentage For purposes of subparagraph (A), the applicable percentage for a State for a fiscal year is the following:
I|G|VI|1655.(a)(4)(7)(B)(i)
Uninsured reduction threshold fiscal year In the case of the first fiscal year described in subparagraph (C) with respect to the State -
I|G|VI|1655.(a)(4)(7)(B)(i)(I)
if the State is a low DSH State described in paragraph (5)(B), the applicable percentage is equal to 25 percent; and
I|G|VI|1655.(a)(4)(7)(B)(i)(II)
if the State is any other State, the applicable percentage is 50 percent.
I|G|VI|1655.(a)(4)(7)(B)(ii)
Subsequent fiscal years in which the percentage of uninsured decreases In the case of any fiscal year after the first fiscal year described in subparagraph (C) with respect to a State, if the Secretary determines on the basis of the most recent American Community Survey of the Bureau of the Census, that the percentage of uncovered individuals residing in the State is less than the percentage of such individuals determined for the State for the preceding fiscal year -
I|G|VI|1655.(a)(4)(7)(B)(ii)(I)
if the State is a low DSH State described in paragraph (5)(B), the applicable percentage is equal to the product of the amount by which the percentage of uncovered individuals for the fiscal year is less than the percentage of such individuals for the preceding fiscal year and 17.5 percent; and
I|G|VI|1655.(a)(4)(7)(B)(ii)(II)
if the State is any other State, the applicable percentage is equal to the product of the amount by which the percentage of uncovered individuals for the fiscal year is less than the percentage of such individuals for the preceding fiscal year and 35 percent.
I|G|VI|1655.(a)(4)(7)(C)
Fiscal year described For purposes of subparagraph (A), the fiscal year described in this subparagraph with respect to a State is the first fiscal year that occurs after fiscal year 2012 for which the Secretary determines, on the basis of the most recent American Community Survey of the Bureau of the Census, that the percentage of uncovered individuals residing in the State is at least 50 percent less than the percentage of such individuals determined for the State for fiscal year 2009.
I|G|VI|1655.(a)(4)(7)(D)
Exclusion of portions diverted for coverage expansions For purposes of applying the applicable percentage reduction under subparagraph (A) to the DSH allotment for a State for a fiscal year, the DSH allotment for a State that would be determined under this subsection for the State for the fiscal year without the application of this paragraph (and prior to any such reduction) shall not include any portion of the allotment for which the Secretary has approved the State's diversion to the costs of providing medical assistance or other health benefits coverage under a waiver that is in effect on July 2009.
I|G|VI|1655.(a)(4)(7)(E)
Minimum allotment In no event shall the DSH allotment determined for a State in accordance with this paragraph for fiscal year 2013 or any succeeding fiscal year be less than the amount equal to 35 percent of the DSH allotment determined for the State for fiscal year 2012 under this subsection (and after the application of this paragraph, if applicable), increased by the percentage change in the consumer price index for all urban consumers (all items, U.S. city average) for each previous fiscal year occurring before the fiscal year.
I|G|VI|1655.(a)(4)(7)(F)
Uncovered individuals In this paragraph, the term uncovered individuals means individuals with no health insurance (as defined in section 2791 of the Public Health Service Act) at any time during a year.
.
I|G|VI|1655.(b)
Effective date The amendments made by subsection (a) take effect on October 1, 2011.
I|G|VII
Dual Eligibles
I|G|VII|1661.
5-year period for demonstration projects
I|G|VII|1661.(a)
In general Section 1915(h) of the Social Security Act ( 42 U.S.C. 1396n(h) ) is amended -
I|G|VII|1661.(a)(1)
by inserting (1) after (h) ;
I|G|VII|1661.(a)(2)
by inserting , or a waiver described in paragraph (2) after (e) ; and
I|G|VII|1661.(a)(3)
by adding at the end the following new paragraph:
I|G|VII|1661.(a)(3)(2)
I|G|VII|1661.(a)(3)(2)(A)
Notwithstanding subsections (c)(3) and (d) (3), any waiver under subsection (b), (c), or (d), or a waiver under section 1115, that provides medical assistance for dual eligible individuals (including any such waivers under which non dual eligible individuals may be enrolled in addition to dual eligible individuals) may be conducted for a period of 5 years and, upon the request of the State, may be extended for additional 5-year periods unless the Secretary determines that for the previous waiver period the conditions for the waiver have not been met or it would no longer be cost-effective and efficient, or consistent with the purposes of this title, to extend the waiver.
I|G|VII|1661.(a)(3)(2)(B)
In this paragraph, the term dual eligible individual means an individual who is entitled to, or enrolled for, benefits under part A of title XVIII, or enrolled for benefits under part B of title XVIII, and is eligible for medical assistance under the State plan under this title or under a waiver of such plan.
.
I|G|VII|1661.(b)
Conforming amendments
I|G|VII|1661.(b)(1)
Section 1915 of such Act ( 42 U.S.C. 1396n ) is amended -
I|G|VII|1661.(b)(1)(A)
in subsection (b), by adding at the end the following new sentence: Subsection (h)(2) shall apply to a waiver under this subsection. ;
I|G|VII|1661.(b)(1)(B)
in subsection (c)(3), in the second sentence, by inserting (other than a waiver described in subsection (h)(2)) after A waiver under this subsection ;
I|G|VII|1661.(b)(1)(C)
in subsection (d)(3), in the second sentence, by inserting (other than a waiver described in subsection (h)(2)) after A waiver under this subsection .
I|G|VII|1661.(b)(2)
Section 1115 of such Act ( 42 U.S.C. 1315 ) is amended -
I|G|VII|1661.(b)(2)(A)
in subsection (e)(2), by inserting (5 years, in the case of a waiver described in section 1915(h)(2)) after 3 years ; and
I|G|VII|1661.(b)(2)(B)
in subsection (f)(6), by inserting (5 years, in the case of a waiver described in section 1915(h)(2)) after 3 years .
I|G|VII|1662.
Providing Federal coverage and payment coordination for low-income Medicare beneficiaries
I|G|VII|1662.(a)
Establishment of Federal coordinated health care office
I|G|VII|1662.(a)(1)
In general Not later than March 1, 2010, the Secretary of Health and Human Services (in this section referred to as the Secretary ) shall establish a Federal Coordinated Health Care Office.
I|G|VII|1662.(a)(2)
Establishment and reporting to CMS administrator The Federal Coordinated Health Care Office -
I|G|VII|1662.(a)(2)(A)
shall be established within the Centers for Medicare & Medicaid Services; and
I|G|VII|1662.(a)(2)(B)
have as the Office a Director who shall be appointed by, and be in direct line of authority to, the Administrator of the Centers for Medicare & Medicaid Services.
I|G|VII|1662.(b)
Purpose The purpose of the Federal Coordinated Health Care Office is to bring together officers and employees of the Medicare and Medicaid programs at the Centers for Medicare & Medicaid Services in order to -
I|G|VII|1662.(b)(1)
more effectively integrate benefits under the Medicare program under title XVIII of the Social Security Act and the Medicaid program under title XIX of such Act; and
I|G|VII|1662.(b)(2)
improve the coordination between the Federal Government and States for individuals eligible for benefits under both such programs in order to ensure that such individuals get full access to the items and services to which they are entitled under titles XVIII and XIX of the Social Security Act.
I|G|VII|1662.(c)
Goals The goals of the Federal Coordinated Health Care Office are as follows:
I|G|VII|1662.(c)(1)
Providing dual eligible individuals full access to the benefits to which such individuals are entitled under the Medicare and Medicaid programs.
I|G|VII|1662.(c)(2)
Simplifying the processes for dual eligible individuals to access the items and services they are entitled to under the Medicare and Medicaid programs.
I|G|VII|1662.(c)(3)
Improving the quality of health care and long-term services for dual eligible individuals.
I|G|VII|1662.(c)(4)
Increasing dual eligible individuals' understanding of and satisfaction with coverage under the Medicare and Medicaid programs.
I|G|VII|1662.(c)(5)
Eliminating regulatory conflicts between rules under the Medicare and Medicaid programs.
I|G|VII|1662.(c)(6)
Improving care continuity and ensuring safe and effective care transitions for dual eligible individuals.
I|G|VII|1662.(c)(7)
Eliminating cost-shifting between the Medicare and Medicaid program and among related health care providers.
I|G|VII|1662.(c)(8)
Improving the quality of performance of providers of services and suppliers under the Medicare and Medicaid programs.
I|G|VII|1662.(d)
Specific responsibilities The specific responsibilities of the Federal Coordinated Health Care Office are as follows:
I|G|VII|1662.(d)(1)
Providing States, specialized MA plans for special needs individuals (as defined in section 1859(b)(6) of the Social Security Act ( 42 U.S.C. 1395w-28(b)(6) )), physicians and other relevant entities or individuals with the education and tools necessary for developing programs that align benefits under the Medicare and Medicaid programs for dual eligible individuals.
I|G|VII|1662.(d)(2)
Supporting State efforts to coordinate and align acute care and long-term care services for dual eligible individuals with other items and services furnished under the Medicare program.
I|G|VII|1662.(d)(3)
Providing support for coordination of contracting and oversight by States and the Centers for Medicare & Medicaid Services with respect to the integration of the Medicare and Medicaid programs in a manner that is supportive of the goals described in paragraph (3).
I|G|VII|1662.(d)(4)
To consult and coordinate with the Medicare Payment Advisory Commission established under section 1805 of the Social Security Act ( 42 U.S.C. 1395b-6 ) and the Medicaid and CHIP Payment and Access Commission established under section 1900 of such Act ( 42 U.S.C. 1396 ) with respect to policies relating to the enrollment in, and provision of, benefits to dual eligible individuals under the Medicare program under title XVIII of the Social Security Act and the Medicaid program under title XIX of such Act.
I|G|VII|1662.(e)
Report The Secretary shall, as part of the budget transmitted under section 1105(a) of title 31, United States Code, submit to Congress an annual report containing recommendations for legislation that would improve care coordination and benefits for dual eligible individuals.
I|G|VII|1662.(f)
Dual eligible defined In this section, the term dual eligible individual means an individual who is entitled to, or enrolled for, benefits under part A of title XVIII of the Social Security Act, or enrolled for benefits under part B of title XVIII of such Act, and is eligible for medical assistance under a State plan under title XIX of such Act or under a waiver of such plan.
I|G|VIII
Medicaid Quality
I|G|VIII|1671.
Adult health quality measures Title XI of the Social Security Act ( 42 U.S.C. 1301 et seq. ), as amended by section 401 of the Children's Health Insurance Program Reauthorization Act of 2009 ( Public Law 111-3 ), is amended by inserting after section 1139A the following new section:
I|G|VIII|1671.1139B.
Adult health quality measures
I|G|VIII|1671.1139B.(a)
Development of core set of health care quality measures for adults eligible for benefits under Medicaid The Secretary shall identify and publish a recommended core set of adult health quality measures for Medicaid eligible adults in the same manner as the Secretary identifies and publishes a core set of child health quality measures under section 1139A, including with respect to identifying and publishing existing adult health quality measures that are in use under public and privately sponsored health care coverage arrangements, or that are part of reporting systems that measure both the presence and duration of health insurance coverage over time, that may be applicable to Medicaid eligible adults.
I|G|VIII|1671.1139B.(b)
Deadlines
I|G|VIII|1671.1139B.(b)(1)
Recommended Measures Not later than January 1, 2011, the Secretary shall identify and publish for comment a recommended core set of adult health quality measures for Medicaid eligible adults.
I|G|VIII|1671.1139B.(b)(2)
Dissemination Not later than January 1, 2012, the Secretary shall publish an initial core set of adult health quality measures that are applicable to Medicaid eligible adults.
I|G|VIII|1671.1139B.(b)(3)
Standardized Reporting Not later than January 1, 2013, the Secretary, in consultation with States, shall develop a standardized format for reporting information based on the initial core set of adult health quality measures and create procedures to encourage States to use such measures to voluntarily report information regarding the quality of health care for Medicaid eligible adults.
I|G|VIII|1671.1139B.(b)(4)
Reports to congress Not later than January 1, 2014, and every 3 years thereafter, the Secretary shall include in the report to Congress required under section 1139A(a)(6) information similar to the information required under that section with respect to the measures established under this section.
I|G|VIII|1671.1139B.(b)(5)
Establishment of Medicaid Quality Measurement Program
I|G|VIII|1671.1139B.(b)(5)(A)
In general Not later than 12 months after the release of the recommended core set of adult health quality measures under paragraph (1)), the Secretary shall establish a Medicaid Quality Measurement Program in the same manner as the Secretary establishes the pediatric quality measures program under section 1139A(b). The aggregate amount awarded by the Secretary for grants and contracts for the development, testing, and validation of emerging and innovative evidence-based measures under such program shall equal the aggregate amount awarded by the Secretary for grants under section 1139A(b)(4)(A)
I|G|VIII|1671.1139B.(b)(5)(B)
Revising, strengthening, and improving initial core measures Beginning not later than 24 months after the establishment of the Medicaid Quality Measurement Program, and annually thereafter, the Secretary shall publish recommended changes to the initial core set of adult health quality measures that shall reflect the results of the testing, validation, and consensus process for the development of adult health quality measures.
I|G|VIII|1671.1139B.(c)
Construction Nothing in this section shall be construed as supporting the restriction of coverage, under title XIX or XXI or otherwise, to only those services that are evidence-based, or in anyway limiting available services.
I|G|VIII|1671.1139B.(d)
Annual State Reports Regarding State-Specific Quality of Care Measures Applied Under Medicaid
I|G|VIII|1671.1139B.(d)(1)
Annual state reports Each State with a State plan or waiver approved under title XIX shall annually report (separately or as part of the annual report required under section 1139A(c)), to the Secretary on the -
I|G|VIII|1671.1139B.(d)(1)(A)
State-specific adult health quality measures applied by the State under the such plan, including measures described in subsection (a)(5); and
I|G|VIII|1671.1139B.(d)(1)(B)
State-specific information on the quality of health care furnished to Medicaid eligible adults under such plan, including information collected through external quality reviews of managed care organizations under section 1932 and benchmark plans under section 1937.
I|G|VIII|1671.1139B.(d)(2)
Publication Not later than September 30, 2014, and annually thereafter, the Secretary shall collect, analyze, and make publicly available the information reported by States under paragraph (1).
I|G|VIII|1671.1139B.(e)
Appropriation Out of any funds in the Treasury not otherwise appropriated, there is appropriated for each of fiscal years 2010 through 2014, $60,000,000 for the purpose of carrying out this section. Funds appropriated under this subsection shall remain available until expended.
.
I|G|VIII|1672.
Payment Adjustment for Health Care-Acquired Conditions
I|G|VIII|1672.(a)
In General The Secretary of Health and Human Services (in this subsection referred to as the Secretary ) shall conduct surveys to identify current State practices that prohibit payment for health care-acquired conditions and shall promulgate regulations, to be effective as of July 1, 2011, to prohibit payments to States under section 1903 of the Social Security Act for any amounts expended for providing medical assistance for such conditions. Such regulations shall ensure that a prohibition on payment for health care-acquired conditions shall not affect care or services provided to a Medicaid beneficiary.
I|G|VIII|1672.(b)
Health Care-Acquired Condition In this section. the term health care-acquired condition means a medical condition for which an individual was diagnosed that could be identified by a secondary diagnostic code described in section 1886(d)(4)(D)(iv) of the Social Security Act ( 42 U.S.C. 1395ww(d)(4)(D)(iv) ).
I|G|VIII|1672.(c)
Medicare Provisions In carrying out this section, the Secretary may elect to apply to State plans (or waivers) under title XIX of the Social Security Act the regulations promulgated pursuant to section 1886(d)(4)(D) of such Act ( 42 U.S.C. 1395ww(d)(4)(D) ) relating to the prohibition of payments based on the presence of a secondary diagnosis code specified by the Secretary in such regulations. The Secretary may exclude certain conditions identified under title XVIII of the Social Security Act for non-payment under title XIX of such Act when the Secretary finds the inclusion of such conditions to be inapplicable to beneficiaries under title XIX.
I|G|VIII|1673.
Demonstration project to evaluate integrated care around a hospitalization
I|G|VIII|1673.(a)
Authority to conduct project The Secretary of Health and Human Services (in this section referred to as the Secretary ) shall establish a demonstration project under title XIX of the Social Security Act to evaluate the use of bundled payments for the provision of integrated care for a Medicaid beneficiary -
I|G|VIII|1673.(a)(1)
with respect to an episode of care that includes a hospitalization; and
I|G|VIII|1673.(a)(2)
for concurrent physicians services provided during a hospitalization.
I|G|VIII|1673.(b)
Requirements The demonstration project shall be conducted in accordance with the following:
I|G|VIII|1673.(b)(1)
The demonstration project shall be conducted in up to 8 States, determined by the Secretary based on consideration of the potential to lower costs under the Medicaid program while improving care for Medicaid beneficiaries. A State selected to participate in the demonstration project may target the demonstration project to particular categories of beneficiaries, beneficiaries with particular diagnoses, or particular geographic regions of the State, but the Secretary shall insure that, as a whole, the demonstration project is, to the greatest extent possible, representative of the demographic and geographic composition of Medicaid beneficiaries nationally.
I|G|VIII|1673.(b)(2)
The demonstration project shall focus on conditions where there is evidence of an opportunity for providers of services and suppliers to improve the quality of care furnished to Medicaid beneficiaries while reducing total expenditures under the State Medicaid programs selected to participate, as determined by the Secretary.
I|G|VIII|1673.(b)(3)
A State selected to participate in the demonstration project shall specify the 1 or more episodes of care the State proposes to address in the project, the services to be included in the bundled payments, and the rationale for the selection of such episodes of care and services. The Secretary may modify the episodes of care as well as the services to be included in the bundled payments prior to or after approving the project. The Secretary may also vary such factors among the different States participating in the demonstration project.
I|G|VIII|1673.(b)(4)
The Secretary shall ensure that payments made under the demonstration project are adjusted for severity of illness and other characteristics of Medicaid beneficiaries within a category or having a diagnosis targeted as part of the demonstration project. States shall ensure that Medicaid beneficiaries are not liable for any additional cost sharing than if their care had not been subject to payment under the demonstration project.
I|G|VIII|1673.(b)(5)
Hospitals participating in the demonstration project shall have or establish robust discharge planning programs to ensure that Medicaid beneficiaries requiring post-acute care are appropriately placed in, or have ready access to, post-acute care settings.
I|G|VIII|1673.(b)(6)
The Secretary and each State selected to participate in the demonstration project shall ensure that the demonstration project does not result in the Medicaid beneficiaries whose care is subject to payment under the demonstration project being provided with less items and services for which medical assistance is provided under the State Medicaid program than the items and services for which medical assistance would have been provided to such beneficiaries under the State Medicaid program in the absence of the demonstration project.
I|G|VIII|1673.(c)
Waiver of provisions Notwithstanding section 1115(a) of the Social Security Act ( 42 U.S.C. 1315(a) ), the Secretary may waive such provisions of titles XIX, XVIII, and XI of that Act as may be necessary to accomplish the goals of the demonstration, ensure beneficiary access to acute and post-acute care, and maintain quality of care.
I|G|VIII|1673.(d)
Evaluation and report
I|G|VIII|1673.(d)(1)
Data Each State selected to participate in the demonstration project under this section shall provide to the Secretary, in such form and manner as the Secretary shall specify, relevant data necessary to monitor outcomes, costs, and quality, and evaluate the rationales for selection of the episodes of care and services specified by States under subsection (b)(3).
I|G|VIII|1673.(d)(2)
Report Not later than 1 year after the conclusion of the demonstration project, the Secretary shall submit a report to Congress on the results of the demonstration project.
I|G|VIII|1674.
Medicaid Global Payment System Demonstration Project
I|G|VIII|1674.(a)
In General The Secretary of Health and Human Services (referred to in this section as the Secretary ) shall, in coordination with the Innovation Center (as established under section 3021), establish the Medicaid Global Payment System Demonstration Project under which a participating State shall adjust the payments made to an eligible safety net hospital system or network from a fee-for-service payment structure to a global capitated payment model.
I|G|VIII|1674.(b)
Duration and Scope The demonstration project conducted under this section shall operate during a period of fiscal years 2010 through 2012. The Secretary shall select not more than 5 States to participate in the demonstration project.
I|G|VIII|1674.(c)
Eligible safety net hospital system or network For purposes of this section, the term eligible safety net hospital system or network means a large, safety net hospital system or network (as defined by the Secretary) that operates within a State selected by the Secretary under subsection (b).
I|G|VIII|1674.(d)
Evaluation
I|G|VIII|1674.(d)(1)
Testing The Innovation Center shall test and evaluate the demonstration project conducted under this section to examine any changes in health care quality outcomes and spending by the eligible safety net hospital systems or networks.
I|G|VIII|1674.(d)(2)
Budget Neutrality During the testing period under paragraph (1), any budget neutrality requirements under section 1115A(b)(3) of the Social Security Act (as added by section 3021) shall not be applicable.
I|G|VIII|1674.(d)(3)
Modification During the testing period under paragraph (1), the Secretary may, in the Secretary's discretion, modify or terminate the demonstration project conducted under this section.
I|G|VIII|1674.(e)
Report Not later than 12 months after the date of completion of the demonstration project under this section, the Secretary shall submit to Congress a report containing the results of the evaluation and testing conducted under subsection (d), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.
I|G|VIII|1674.(f)
Authorization of appropriations There are authorized to be appropriated such sums as are necessary to carry out this section.
I|G|VIII|1675.
Pediatric Accountable Care Organization Demonstration Project
I|G|VIII|1675.(a)
In General The Secretary of Health and Human Services (referred to in this section as the Secretary ) shall establish the Pediatric Accountable Care Organization Demonstration Project to authorize a participating State to allow pediatric medical providers that meet specified requirements to be recognized as an accountable care organization for purposes of receiving incentive payments (as described under subsection (d)), in the same manner as an accountable care organization is recognized and provided with incentive payments under section 1899 of the Social Security Act (as added by section 3022).
I|G|VIII|1675.(b)
Application A State that desires to participate in the demonstration project under this section shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.
I|G|VIII|1675.(c)
Requirements
I|G|VIII|1675.(c)(1)
Performance guidelines The Secretary, in consultation with the States and pediatric providers, shall establish guidelines to ensure that the quality of care delivered to individuals by a provider recognized as an accountable care organization under this section is not less than the quality of care that would have otherwise been provided to such individuals.
I|G|VIII|1675.(c)(2)
Savings requirement A participating State, in consultation with the Secretary, shall establish an annual minimal level of savings in expenditures for items and services covered under the Medicaid program under title XIX of the Social Security Act and the CHIP program under title XXI of such Act that must be reached by an accountable care organization in order for such organization to receive an incentive payment under subsection (d).
I|G|VIII|1675.(d)
Incentive payment An accountable care organization that meets the performance guidelines established by the Secretary under subsection (c)(1) and achieves savings greater than the annual minimal savings level established by the State under subsection (c)(2) shall receive an incentive payment for such year equal to a portion (as determined appropriate by the Secretary) of the amount of such excess savings. The Secretary may establish an annual cap on incentive payments for an accountable care organization.
I|G|VIII|1675.(e)
Authorization of appropriations There are authorized to be appropriated such sums as are necessary to carry out this section.
I|G|VIII|1676.
Medicaid emergency psychiatric demonstration project
I|G|VIII|1676.(a)
Authority To conduct demonstration project The Secretary of Health and Human Services (in this section referred to as the Secretary ) shall establish a demonstration project for up to 8 States under which an eligible State (as described in subsection (c)) shall provide reimbursement under the State Medicaid plan under title XIX of the Social Security Act to an institution for mental diseases (as defined in section 1905(i) of such Act) that is not publicly owned or operated and that is subject to the requirements of section 1867 of the Social Security Act ( 42 U.S.C. 1395dd ) for the provision of medical assistance available under such plan to an individual who -
I|G|VIII|1676.(a)(1)
has attained age 21, but has not attained age 65;
I|G|VIII|1676.(a)(2)
is eligible for medical assistance under such plan; and
I|G|VIII|1676.(a)(3)
requires such medical assistance to stabilize a psychiatric emergency medical condition, as evidenced by the expression of suicidal or homicidal thoughts or gestures determined dangerous to the individual or others.
I|G|VIII|1676.(b)
In-stay review The Secretary shall establish a mechanism for in-stay review to determine whether or not the patient has been stabilized (as defined in subsection (h)(5)). This mechanism shall commence before the third day of the inpatient stay. States participating in the demonstration project may manage the provision of these benefits under the project through utilization review, authorization, or management practices, or the application of medical necessity and appropriateness criteria applicable to behavioral health.
I|G|VIII|1676.(c)
Eligible state defined
I|G|VIII|1676.(c)(1)
Application Upon approval of an application submitted by a State described in paragraph (2), the State shall be an eligible State for purposes of conducting a demonstration project under this section.
I|G|VIII|1676.(c)(2)
State described States shall be selected by the Secretary in a manner so as to provide geographic diversity on the basis of the application to conduct a demonstration project under this section submitted by such States.
I|G|VIII|1676.(d)
Length of demonstration project The demonstration project established under this section shall be conducted for a period of 3 consecutive years.
I|G|VIII|1676.(e)
Limitations on federal funding
I|G|VIII|1676.(e)(1)
Appropriation
I|G|VIII|1676.(e)(1)(A)
In general Out of any funds in the Treasury not otherwise appropriated, there is appropriated to carry out this section, $75,000,000 for fiscal year 2010.
I|G|VIII|1676.(e)(1)(B)
Budget authority Subparagraph (A) constitutes budget authority in advance of appropriations Act and represents the obligation of the Federal Government to provide for the payment of the amounts appropriated under that subparagraph.
I|G|VIII|1676.(e)(2)
3-year availability Funds appropriated under paragraph (1) shall remain available for obligation through December 31, 2012.
I|G|VIII|1676.(e)(3)
Limitation on payments In no case may -
I|G|VIII|1676.(e)(3)(A)
the aggregate amount of payments made by the Secretary to eligible States under this section exceed $75,000,000; or
I|G|VIII|1676.(e)(3)(B)
payments be provided by the Secretary under this section after December 31, 2012.
I|G|VIII|1676.(e)(4)
Funds allocated to states The Secretary shall allocate funds to eligible States based on their applications and the availability of funds.
I|G|VIII|1676.(e)(5)
Payments to states The Secretary shall pay to each eligible State, from its allocation under paragraph (4), an amount each quarter equal to the Federal medical assistance percentage of expenditures in the quarter for medical assistance described in subsection (a).
I|G|VIII|1676.(f)
Reports
I|G|VIII|1676.(f)(1)
Annual progress reports The Secretary shall submit annual reports to Congress on the progress of the demonstration project conducted under this section.
I|G|VIII|1676.(f)(2)
Final report and recommendation An evaluation should be conducted of the demonstration project's impact on the functioning of the health and mental health service system and on individuals enrolled in the Medicaid program. This evaluation should include collection of baseline data for one-year prior to the initiation of the demonstration project as well as collection of data from matched comparison states not participating in the demonstration. The evaluation measures shall include the following:
I|G|VIII|1676.(f)(2)(A)
A determination, by State, as to whether the demonstration project resulted in increased access to inpatient mental health services under the Medicaid program and whether average length of stays were longer (or shorter) for individuals admitted under the demonstration project compared with individuals otherwise admitted in comparison sites.
I|G|VIII|1676.(f)(2)(B)
An analysis by State, regarding whether the demonstration project produced a significant reduction in emergency room visits for individuals eligible for assistance under the Medicaid program or in the duration of emergency room lengths of stay.
I|G|VIII|1676.(f)(2)(C)
An assessment of discharge planning by participating hospitals that ensures access to further (non-emergency) inpatient or residential care as well as continuity of care for those discharged to outpatient care.
I|G|VIII|1676.(f)(2)(D)
An assessment of the impact of the demonstration project on the costs of the full range of mental health services (including inpatient, emergency and ambulatory care) under the plan as contrasted with the comparison areas.
I|G|VIII|1676.(f)(2)(E)
Data on the percentage of consumers with Medicaid coverage who are admitted to inpatient facilities as a result of the demonstration project as compared to those admitted to these same facilities through other means.
I|G|VIII|1676.(f)(2)(F)
A recommendation regarding whether the demonstration project should be continued after December 31, 2012, and expanded on a national basis.
I|G|VIII|1676.(g)
Waiver authority
I|G|VIII|1676.(g)(1)
In general The Secretary shall waive the limitation of subdivision (B) following paragraph (28) of section 1905(a) of the Social Security Act ( 42 U.S.C. 1396d(a) ) (relating to limitations on payments for care or services for individuals under 65 years of age who are patients in an institution for mental diseases) for purposes of carrying out the demonstration project under this section.
I|G|VIII|1676.(g)(2)
Limited other waiver authority The Secretary may waive other requirements of titles XI and XIX of the Social Security Act (including the requirements of sections 1902(a)(1) (relating to statewideness) and 1902(1)(10)(B) (relating to comparability)) only to extent necessary to carry out the demonstration project under this section.
I|G|IX
Improvements to the Medicaid and CHIP Payment and Access Commission (MACPAC)
I|G|IX|1681.
MACPAC assessment of policies affecting all Medicaid beneficiaries
I|G|IX|1681.(a)
In general Section 1900 of the Social Security Act ( 42 U.S.C. 1396 ) is amended -
I|G|IX|1681.(a)(1)
in subsection (b) -
I|G|IX|1681.(a)(1)(A)
in paragraph (1) -
I|G|IX|1681.(a)(1)(A)(i)
in the paragraph heading, by inserting for all States before and annual ; and
I|G|IX|1681.(a)(1)(A)(ii)
in subparagraph (A), by striking children's ;
I|G|IX|1681.(a)(1)(A)(iii)
in subparagraph (B), by inserting , the Secretary, and States after Congress ;
I|G|IX|1681.(a)(1)(A)(iv)
in subparagraph (C), by striking March 1 and inserting March 15 ; and
I|G|IX|1681.(a)(1)(A)(v)
in subparagraph (D), by striking June 1 and inserting June 15 ;
I|G|IX|1681.(a)(1)(B)
in paragraph (2) -
I|G|IX|1681.(a)(1)(B)(i)
in subparagraph (A) -
I|G|IX|1681.(a)(1)(B)(i)(I)
in clause (i) -
I|G|IX|1681.(a)(1)(B)(i)(aa)
by inserting the efficient provision of after expenditures for ; and
I|G|IX|1681.(a)(1)(B)(i)(bb)
by striking hospital, skilled nursing facility, physician, Federally-qualified health center, rural health center, and other fees and inserting payments to medical, dental, and health professionals, hospitals, residential and long-term care providers, providers of home and community based services, Federally-qualified health centers and rural health clinics, managed care entities, and providers of other covered items and services ; and
I|G|IX|1681.(a)(1)(B)(i)(II)
in clause (iii), by inserting (including how such factors and methodologies enable such beneficiaries to obtain the services for which they are eligible, affect provider supply, and affect providers that serve a disproportionate share of low-income and other vulnerable populations) after beneficiaries ;
I|G|IX|1681.(a)(1)(B)(ii)
by redesignating subparagraphs (B) and (C) as subparagraphs (F) and (H), respectively;
I|G|IX|1681.(a)(1)(B)(iii)
by inserting after subparagraph (A), the following:
I|G|IX|1681.(a)(1)(B)(iii)(B)
Eligibility policies Medicaid and CHIP eligibility policies, including a determination of the degree to which Federal and State policies provide health care coverage to needy populations.
I|G|IX|1681.(a)(1)(B)(iii)(C)
Enrollment and retention processes Medicaid and CHIP enrollment and retention processes, including a determination of the degree to which Federal and State policies encourage the enrollment of individuals who are eligible for such programs and screen out individuals who are ineligible, while minimizing the share of program expenses devoted to such processes.
I|G|IX|1681.(a)(1)(B)(iii)(D)
Coverage policies Medicaid and CHIP benefit and coverage policies, including a determination of the degree to which Federal and State policies provide access to the services enrollees require to improve and maintain their health and functional status.
I|G|IX|1681.(a)(1)(B)(iii)(E)
Quality of care Medicaid and CHIP policies as they relate to the quality of care provided under those programs, including a determination of the degree to which Federal and State policies achieve their stated goals and interact with similar goals established by other purchasers of health care services. ;
I|G|IX|1681.(a)(1)(B)(iv)
by inserting after subparagraph (F) (as redesignated by clause (ii) of this subparagraph), the following:
I|G|IX|1681.(a)(1)(B)(iv)(G)
Interactions with Medicare and Medicaid Consistent with paragraph (11), the interaction of policies under Medicaid and the Medicare program under title XVIII, including with respect to how such interactions affect access to services, payments, and dual eligible individuals. and
I|G|IX|1681.(a)(1)(B)(v)
in subparagraph (H) (as so redesignated), by inserting and preventive, acute, and long-term services and supports after barriers ;
I|G|IX|1681.(a)(1)(C)
by redesignating paragraphs (3) through (9) as paragraphs (4) through (10), respectively;
I|G|IX|1681.(a)(1)(D)
by inserting after paragraph (2), the following new paragraph:
I|G|IX|1681.(a)(1)(D)(3)
Recommendations and reports of State-specific data MACPAC shall -
I|G|IX|1681.(a)(1)(D)(3)(A)
review national and State-specific Medicaid and CHIP data; and
I|G|IX|1681.(a)(1)(D)(3)(B)
submit reports and recommendations to Congress, the Secretary, and States based on such reviews.
;
I|G|IX|1681.(a)(1)(E)
in paragraph (4), as redesignated by subparagraph (C), by striking or any other problems and all that follows through the period and inserting , as well as other factors that adversely affect, or have the potential to adversely affect, access to care by, or the health care status of, Medicaid and CHIP beneficiaries. MACPAC shall include in the annual report required under paragraph (1)(D) a description of all such areas or problems identified with respect to the period addressed in the report. ;
I|G|IX|1681.(a)(1)(F)
in paragraph (5), as so redesignated, -
I|G|IX|1681.(a)(1)(F)(i)
in the paragraph heading, by inserting and regulations after reports ; and
I|G|IX|1681.(a)(1)(F)(ii)
by striking If and inserting the following:
I|G|IX|1681.(a)(1)(F)(ii)(A)
Certain secretarial reports If ; and
I|G|IX|1681.(a)(1)(F)(iii)
in the second sentence, by inserting and the Secretary after appropriate committees of Congress ; and
I|G|IX|1681.(a)(1)(F)(iv)
by adding at the end the following:
I|G|IX|1681.(a)(1)(F)(iv)(B)
Regulations MACPAC shall review Medicaid and CHIP regulations and may comment through submission of a report to the appropriate committees of Congress and the Secretary, on any such regulations that affect access, quality, or efficiency of health care. ;
I|G|IX|1681.(a)(1)(G)
in paragraph (10), as so redesignated, by inserting , and shall submit with any recommendations, a report on the Federal and State-specific budget consequences of the recommendations before the period; and
I|G|IX|1681.(a)(1)(H)
by adding at the end the following:
I|G|IX|1681.(a)(1)(H)(11)
Consultation and coordination with MedPAC
I|G|IX|1681.(a)(1)(H)(11)(A)
In general MACPAC shall regularly consult with the Medicare Payment Advisory Commission (in this paragraph referred to as MedPAC ) established under section 1805 in carrying out its duties under this section, particularly with respect to the issues specified in paragraph (2) as they relate to those Medicaid beneficiaries who are dually eligible for Medicaid and the Medicare program under title XVIII, adult Medicaid beneficiaries (who are not dually eligible for Medicare), and beneficiaries under Medicare. Responsibility for analysis of and recommendations to change Medicare policy regarding Medicare beneficiaries, including Medicare beneficiaries who are dually eligible for Medicare and Medicaid, shall rest with MedPAC.
I|G|IX|1681.(a)(1)(H)(11)(B)
Information sharing MACPAC and MedPAC shall have access to deliberations and records of the other such entity, respectively, upon the request of the other such entity.
I|G|IX|1681.(a)(1)(H)(12)
Consultation with states MACPAC shall regularly consult with States in carrying out its duties under this section, including with respect to developing processes for carrying out such duties, and shall ensure that input from States is taken into account and represented in MACPAC's recommendations and reports.
I|G|IX|1681.(a)(1)(H)(13)
Coordinate and consult with the Federal Coordinated Health Care Office MACPAC shall coordinate and consult with the Federal Coordinated Health Care Office established under section 1662 of the America's Healthy Future Act of 2009 before making any recommendations regarding dual eligible individuals.
I|G|IX|1681.(a)(1)(H)(14)
Programmatic oversight vested in the secretary MACPAC's authority to make recommendations in accordance with this section shall not affect, or be considered to duplicate, the Secretary's authority to carry out Federal responsibilities with respect to Medicaid and CHIP. ;
I|G|IX|1681.(a)(2)
in subsection (c)(2) -
I|G|IX|1681.(a)(2)(A)
by striking subparagraphs (A) and (B) and inserting the following:
I|G|IX|1681.(a)(2)(A)(A)
In general The membership of MACPAC shall include individuals who have had direct experience as enrollees or parents or caregivers of enrollees in Medicaid or CHIP and individuals with national recognition for their expertise in Federal safety net health programs, health finance and economics, actuarial science, health plans and integrated delivery systems, reimbursement for health care, health information technology, and other providers of health services, public health, and other related fields, who provide a mix of different professions, broad geographic representation, and a balance between urban and rural representation.
I|G|IX|1681.(a)(2)(A)(B)
Inclusion The membership of MACPAC shall include (but not be limited to) physicians, dentists, and other health professionals, employers, third-party payers, and individuals with expertise in the delivery of health services. Such membership shall also include representatives of children, pregnant women, the elderly, individuals with disabilities, caregivers, and dual eligible individuals, current or former representatives of State agencies responsible for administering Medicaid, and current or former representatives of State agencies responsible for administering CHIP. .
I|G|IX|1681.(a)(3)
in subsection (d)(2), by inserting and State after Federal ;
I|G|IX|1681.(a)(4)
in subsection (e)(1), in the first sentence, by inserting and, as a condition for receiving payments under sections 1903(a) and 2105(a), from any State agency responsible for administering Medicaid or CHIP, after United States ; and
I|G|IX|1681.(a)(5)
in subsection (f) -
I|G|IX|1681.(a)(5)(A)
in the subsection heading, by striking Authorization of appropriations and inserting Funding ;
I|G|IX|1681.(a)(5)(B)
in paragraph (1), by inserting (other than for fiscal year 2010) before in the same manner ; and
I|G|IX|1681.(a)(5)(C)
by adding at the end the following:
I|G|IX|1681.(a)(5)(C)(3)
Funding for fiscal year 2010
I|G|IX|1681.(a)(5)(C)(3)(A)
In general Out of any funds in the Treasury not otherwise appropriated, there is appropriated to MACPAC to carry out the provisions of this section for fiscal year 2010, $9,000,000.
I|G|IX|1681.(a)(5)(C)(3)(B)
Transfer of funds Notwithstanding section 2104(a)(13), from the amounts appropriated in such section for fiscal year 2010, $2,000,000 is hereby transferred and made available in such fiscal year to MACPAC to carry out the provisions of this section.
I|G|IX|1681.(a)(5)(C)(4)
Availability Amounts made available under paragraphs (2) and (3) to MACPAC to carry out the provisions of this section shall remain available until expended. .
I|G|IX|1681.(b)
Conforming MedPAC amendments Section 1805(b) of the Social Security Act ( 42 U.S.C. 1395b-6(b) ), is amended -
I|G|IX|1681.(b)(1)
in paragraph (1)(C), by striking March 1 of each year (beginning with 1998) and inserting March 15 ;
I|G|IX|1681.(b)(2)
in paragraph (1)(D), by inserting , and (beginning with 2012) containing an examination of the topics described in paragraph (9), to the extent feasible before the period; and
I|G|IX|1681.(b)(3)
by adding at the end the following:
I|G|IX|1681.(b)(3)(9)
Review and annual report on Medicaid and commercial trends The Commission shall review and report on aggregate trends in spending, utilization, and financial performance under the Medicaid program under title XIX and the private market for health care services with respect to providers for which, on an aggregate national basis, a significant portion of revenue or services is associated with the Medicaid program. Where appropriate, the Commission shall conduct such review in consultation with the Medicaid and CHIP Payment and Access Commission (MACPAC) established under section 1900.
I|G|IX|1681.(b)(3)(10)
Coordinate and consult with the Federal Coordinated Health Care Office The Commission shall coordinate and consult with the Federal Coordinated Health Care Office established under section 1662 of the America's Healthy Future Act of 2009 before making any recommendations regarding dual eligible individuals. .
I|G|X
American Indians and Alaska Natives
I|G|X|1691.
Special rules relating to Indians
I|G|X|1691.(a)
No cost-sharing for Indians with income at or below 300 percent of poverty enrolled in coverage through a State exchange For provisions prohibiting cost sharing for Indians enrolled in any qualified health benefits plan in the individual market through an exchange, see section 2247(d) of the Social Security Act.
I|G|X|1691.(b)
Payer of last resort Nothing in this Act or the amendments made by this Act shall affect the right of the United States, an Indian tribe, or a tribal organization to recover reimbursement from third parties for the costs of health services in accordance with section 206 of the Indian Health Care Improvement Act ( 42 U.S.C. 1621e ).
I|G|X|1691.(c)
Facilitating enrollment of Indians under the Express Lane option Section 1902(e)(13)(F)(ii) of the Social Security Act ( 42 U.S.C. 1396a(e)(13)(F)(ii) ) is amended -
I|G|X|1691.(c)(1)
in the clause heading, by inserting and Indian tribes and tribal organizations after agencies ; and
I|G|X|1691.(c)(2)
by adding at the end the following:
I|G|X|1691.(c)(2)(IV)
The Indian Health Service, an Indian Tribe, Tribal Organization, or Urban Indian Organization (as defined in section 1139(c)). .
I|G|X|1691.(d)
Technical corrections Section 1139(c) of the Social Security Act ( 42 U.S.C. 1320b-9(c) ) is amended by striking In this section and inserting For purposes of this section, title XIX, and title XXI .
I|G|X|1692.
Elimination of sunset for reimbursement for all medicare part B services furnished by certain indian hospitals and clinics
I|G|X|1692.(a)
Reimbursement for all Medicare part B services furnished by certain indian hospitals and clinics Section 1880(e)(1)(A) of the Social Security Act ( 42 U.S.C. 1395qq(e)(1)(A) ) is amended by striking during the 5-year period beginning on and inserting on or after .
I|G|X|1692.(b)
Effective date The amendments made by this section shall apply to items or services furnished on or after January 1, 2010.
I|H
Addressing Health Disparities
I|H|1701.
Standardized collection of data
I|H|1701.(a)
Uniform categories and collection requirements
I|H|1701.(a)(1)
Application of OMB standards for data collection and classification The Secretary of Health and Human Services, in consultation with the Director of the Office of Personnel Management, the Secretary of Defense, the Secretary of Veterans Affairs, and the head of other appropriate Federal agencies, shall establish procedures to ensure that, beginning January 1, 2011, all data collected under a Federal health care program (as defined in section 1128B(f) of the Social Security Act (42 U.S.C. 1320a-7b(f)) and under the health insurance program under chapter 89 of title 5, United States Code, on race, ethnicity, sex, and primary language, complies with the following:
I|H|1701.(a)(1)(A)
Office of Management and Budget Directive 15 (Standards for the Classification of Federal Data on Race and Ethnicity).
I|H|1701.(a)(1)(B)
Guidance for Federal agencies that collect or use aggregate data on race issued by the Office of Management and Budget.
I|H|1701.(a)(1)(C)
Guidance for Federal agencies for the allocation of multiple race responses for use in civil rights monitoring and enforcement issued by the Office of Management and Budget.
I|H|1701.(a)(2)
Access and treatment for individuals with disabilities Not later than January 1, 2012, the Secretary of Health and Human Services, in consultation with the Director of the Office of Personnel Management, the Secretary of Defense, the Secretary of Veterans Affairs, and the head of other appropriate Federal agencies, shall establish procedures for the Administrator of the Centers on Medicare & Medicaid Services to collect data under Federal health care programs (as so defined) and the health insurance program under chapter 89 of title 5, United States Code, in order to assess access to care and treatment for individuals with disabilities. Such procedures shall include surveying health care providers to identify -
I|H|1701.(a)(2)(A)
locations where individuals with disabilities access primary, acute (including intensive), and long-term care;
I|H|1701.(a)(2)(B)
the number of providers with accessible facilities and equipment to meet the needs of the individuals with disabilities; and
I|H|1701.(a)(2)(C)
the number of employees of health care providers trained in disability awareness and patient care of individuals with disabilities.
I|H|1701.(b)
Medicaid conforming amendments
I|H|1701.(b)(1)
State plan requirement Section 1902(a) of the Social Security Act ( 42 U.S.C. 1396a(a) ), as amended by section 1601(d), is amended -
I|H|1701.(b)(1)(A)
in paragraph (74), by striking and at the end;
I|H|1701.(b)(1)(B)
in paragraph (75), by striking the period at the end and inserting ; and ; and
I|H|1701.(b)(1)(C)
by inserting after paragraph (75) the following new paragraph:
I|H|1701.(b)(1)(C)(76)
provide that any data collected under the State plan meets the requirements of section 1701(a) of the America's Healthy Future Act of 2009. .
I|H|1701.(c)
CHIP conforming amendments Section 2108(e) of the Social Security Act ( 42 U.S.C. 1397hh(e) ) is amended by adding at the end the following new paragraph:
I|H|1701.(c)(7)
Data collected and reported in accordance with section 1701(a) of the America's Healthy Future Act of 2009, with respect to individuals enrolled in the State child health plan (and, in the case of enrollees under 19 years of age, their parents or legal guardians), including data regarding the primary language of such individuals, parents, and legal guardians. .
I|H|1702.
Required collection of data
I|H|1702.(a)
Population surveys and quality reporting Beginning January 1, 2012:
I|H|1702.(a)(1)
Federally-funded population surveys All federally funded population survey, including Current Population Surveys and American Community Surveys conducted by the Bureau of Labor Statistics and the Bureau of the Census, shall collect sufficient data relating to race, ethnicity, sex, primary language, and types of disability subgroups to generate statistically reliable estimates in studies comparing health disparities populations.
I|H|1702.(a)(2)
Quality reporting requirements Any reporting requirements imposed for purposes of measuring quality under a Federal health care program (as defined in section 1128B(f) of the such Act (42 U.S.C. 1320a-7b(f)) or under the health insurance program under chapter 89 of title 5, United States Code, shall include requirements for the collection of data on individuals receiving health care items or services under such programs by race, ethnicity, sex, primary language, and types of disability.
I|H|1702.(b)
Extending Medicare requirement to address health disparities data collection to Medicaid and CHIP Title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. ), as amended by section 1640 is amended by adding at the end the following new section:
I|H|1702.(b)1945.
Addressing health care disparities
I|H|1702.(b)1945.(a)
Evaluating Data Collection Approaches The Secretary shall evaluate approaches for the collection of data under this title and title XXI, to be performed in conjunction with existing quality reporting requirements and programs under this title and title XXI, that allow for the ongoing, accurate, and timely collection and evaluation of data on disparities in health care services and performance on the basis of race, ethnicity, sex, primary language, and types of disability. In conducting such evaluation, the Secretary shall consider the following objectives:
I|H|1702.(b)1945.(a)(1)
Protecting patient privacy.
I|H|1702.(b)1945.(a)(2)
Minimizing the administrative burdens of data collection and reporting on States, providers, and health plans participating under this title or title XXI.
I|H|1702.(b)1945.(a)(3)
Improving program data under this title and title XXI on race, ethnicity, sex, primary language, and types of disability.
I|H|1702.(b)1945.(b)
Reports to congress
I|H|1702.(b)1945.(b)(1)
Report on evaluation Not later than 18 months after the date of the enactment of this section, the Secretary shall submit to Congress a report on the evaluation conducted under subsection (a). Such report shall, taking into consideration the results of such evaluation -
I|H|1702.(b)1945.(b)(1)(A)
identify approaches (including defining methodologies) for identifying and collecting and evaluating data on health care disparities on the basis of race, ethnicity, sex, primary language, and types of disability for the programs under this title and title XXI; and
I|H|1702.(b)1945.(b)(1)(B)
include recommendations on the most effective strategies and approaches to reporting HEDIS quality measures as required under section 1852(e)(3) and other nationally recognized quality performance measures, as appropriate, on such bases.
I|H|1702.(b)1945.(b)(2)
Reports on data analyses Not later than 4 years after the date of the enactment of this section, and 4 years thereafter, the Secretary shall submit to Congress a report that includes recommendations for improving the identification of health care disparities for beneficiaries under this title and under title XXI based on analyses of the data collected under subsection (c).
I|H|1702.(b)1945.(c)
Implementing effective approaches Not later than 24 months after the date of the enactment of this section, the Secretary shall implement the approaches identified in the report submitted under subsection (b)(1) for the ongoing, accurate, and timely collection and evaluation of data on health care disparities on the basis of race, ethnicity, sex, primary language, and types of disability.
.
I|H|1703.
Data sharing and protection The Secretary of Health and Human Services, in consultation with the Director of the Office of Personnel Management, the Secretary of Defense, the Secretary of Veterans Affairs, and the head of other appropriate Federal agencies, shall establish procedures -
I|H|1703.(1)
for sharing data collected under a Federal health care program (as defined in section 1128B(f) of the such Act (42 U.S.C. 1320a-7b(f)) or under the health insurance program under chapter 89 of title 5, United States Code, on race, ethnicity, sex primary language, and type of disability, measures relating to such data, and analyses of such data, with other relevant Federal and State agencies including, within the Department of Health and Human Services, the Office of Minority Health, the Agency for Healthcare Research and Quality, the Centers for Disease Control and Prevention, and the Centers for Medicare & Medicaid Services; and
I|H|1703.(2)
establish procedures to ensure that all appropriate privacy and information security safeguards are used in the collection, analysis, and sharing of such data.
I|H|1704.
Inclusion of information about the importance of having a health care power of attorney in transition planning for children aging out of foster care and independent living programs
I|H|1704.(a)
Transition planning Section 475(5)(H) of the Social Security Act ( 42 U.S.C. 675(5)(H) ) is amended by inserting includes information about the importance of designating another individual to make health care treatment decisions on behalf of the child if the child becomes unable to participate in such decisions and the child does not have, or does not want, a relative who would otherwise be authorized under State law to make such decisions, and provides the child with the option to execute a health care power of attorney, health care proxy, or other similar document recognized under State law, after employment services, .
I|H|1704.(b)
Independent living education Section 477(b)(3) of such Act ( 42 U.S.C. 677(b)(3) ) is amended by adding at the end the following:
I|H|1704.(b)(K)
A certification by the chief executive officer of the State that the State will ensure that an adolescent participating in the program under this section are provided with education about the importance of designating another individual to make health care treatment decisions on behalf of the adolescent if the adolescent becomes unable to participate in such decisions and the adolescent does not have, or does not want, a relative who would otherwise be authorized under State law to make such decisions, whether a health care power of attorney, health care proxy, or other similar document is recognized under State law, and how to execute such a document if the adolescent wants to do so. .
I|H|1704.(c)
Health oversight and coordination plan Section 422(b)(15)(A) of such Act ( 42 U.S.C. 622(b)(15)(A) ) is amended -
I|H|1704.(c)(1)
in clause (v), by striking and at the end; and
I|H|1704.(c)(2)
by adding at the end the following:
I|H|1704.(c)(2)(vii)
steps to ensure that the components of the transition plan development process required under section 475(5)(H) that relate to the health care needs of children aging out of foster care, including the requirements to include options for health insurance, information about a health care power of attorney, health care proxy, or other similar document recognized under State law, and to provide the child with the option to execute such a document, are met; and .
I|H|1704.(d)
Effective date The amendments made by this section take effect on October 1, 2010.
I|I
Maternal and child health services
I|I|1801.
Maternal, infant, and early childhood home visiting programs Title V of the Social Security Act ( 42 U.S.C. 701 et seq. ) is amended by adding at the end the following new section:
I|I|1801.511.
Maternal, infant, and early childhood home visiting programs
I|I|1801.511.(a)
Purposes The purposes of this section are -
I|I|1801.511.(a)(1)
to strengthen and improve the programs and activities carried out under this title;
I|I|1801.511.(a)(2)
to improve coordination of services for at risk communities; and
I|I|1801.511.(a)(3)
to identify and provide comprehensive services to improve outcomes for families who reside in at risk communities.
I|I|1801.511.(b)
Requirement for all states to assess statewide needs and identify at risk communities
I|I|1801.511.(b)(1)
In general Not later than 6 months after the date of enactment of this section, each State shall, as a condition of receiving payments from an allotment for the State under section 502 for fiscal year 2011, conduct a statewide needs assessment (which shall be separate from the statewide needs assessment required under section 505(a)) that identifies -
I|I|1801.511.(b)(1)(A)
communities with concentrations of -
I|I|1801.511.(b)(1)(A)(i)
premature birth, low-birth weight infants, and infant mortality, including infant death due to neglect, or other indicators of at-risk prenatal, maternal, newborn, or child health;
I|I|1801.511.(b)(1)(A)(ii)
poverty;
I|I|1801.511.(b)(1)(A)(iii)
crime;
I|I|1801.511.(b)(1)(A)(iv)
domestic violence;
I|I|1801.511.(b)(1)(A)(v)
high rates of high-school drop-outs;
I|I|1801.511.(b)(1)(A)(vi)
substance abuse;
I|I|1801.511.(b)(1)(A)(vii)
unemployment; or
I|I|1801.511.(b)(1)(A)(viii)
child maltreatment;
I|I|1801.511.(b)(1)(B)
the quality and capacity of existing programs or initiatives for early childhood home visitation in the State including -
I|I|1801.511.(b)(1)(B)(i)
the number and types of individuals and families who are receiving services under such programs or initiatives;
I|I|1801.511.(b)(1)(B)(ii)
the gaps in early childhood home visitation in the State; and
I|I|1801.511.(b)(1)(B)(iii)
the extent to which such programs or initiatives are meeting the needs of eligible families described in subsection (k)(2); and
I|I|1801.511.(b)(1)(C)
the State's capacity for providing substance abuse treatment and counseling services to individuals and families in need of such treatment or services.
I|I|1801.511.(b)(2)
Coordination with other assessments In conducting the statewide needs assessment required under paragraph (1), the State shall coordinate with, and take into account, other appropriate needs assessments conducted by the State, as determined by the Secretary, including the needs assessment required under section 505(a) (both the most recently completed assessment and any such assessment in progress), the communitywide strategic planning and needs assessments conducted in accordance with section 640(g)(1)(C) of the Head Start Act, and the inventory of current unmet needs and current community-based and prevention-focused programs and activities to prevent child abuse and neglect, and other family resource services operating in the State required under section 205(3) of the Child Abuse Prevention and Treatment Act.
I|I|1801.511.(b)(3)
Submission to the secretary Each State shall submit to the Secretary, in such form and manner as the Secretary shall require -
I|I|1801.511.(b)(3)(A)
the results of the statewide needs assessment required under paragraph (1); and
I|I|1801.511.(b)(3)(B)
a description of how the State intends to address needs identified by the assessment, particularly with respect to communities identified under paragraph (1)(A), which may include applying for a grant to conduct an early childhood home visitation program in accordance with the requirements of this section.
I|I|1801.511.(c)
Grants for early childhood home visitation programs
I|I|1801.511.(c)(1)
Authority to make grants In addition to any other payments made under this title to a State, the Secretary shall make grants to eligible entities to enable the entities to deliver services under early childhood home visitation programs that satisfy the requirements of subsection (d) to eligible families in order to promote improvements in maternal and prenatal health, infant health, child health and development, parenting related to child development outcomes, school readiness, and the socioeconomic status of such families, and reductions in child abuse, neglect, and injuries.
I|I|1801.511.(c)(2)
Authority to use initial grant funds for planning or implementation An eligible entity that receives a grant under paragraph (1) may use a portion of the funds made available to the entity during the first 6 months of the period for which the grant is made for planning or implementation activities to assist with the establishment of early childhood home visitation programs that satisfy the requirements of subsection (d).
I|I|1801.511.(c)(3)
Grant duration The Secretary shall determine the period of years for which a grant is made to an eligible entity under paragraph (1).
I|I|1801.511.(d)
Requirements The requirements of this subsection for an early childhood home visitation program conducted with a grant made under this section are as follows:
I|I|1801.511.(d)(1)
Quantifiable, measurable improvement in benchmark areas
I|I|1801.511.(d)(1)(A)
In general The eligible entity establishes, subject to the approval of the Secretary, quantifiable, measurable 3- and 5-year benchmarks for demonstrating that the program results in improvements for the eligible families participating in the program in each of the following areas:
I|I|1801.511.(d)(1)(A)(i)
Improved maternal and newborn health.
I|I|1801.511.(d)(1)(A)(ii)
Prevention of child injuries and reduction of emergency department visits.
I|I|1801.511.(d)(1)(A)(iii)
Improvement in school readiness and achievement.
I|I|1801.511.(d)(1)(A)(iv)
Reduction in crime or domestic violence.
I|I|1801.511.(d)(1)(A)(v)
Improvements in family economic self-sufficiency.
I|I|1801.511.(d)(1)(A)(vi)
Improvements in the coordination and referrals for other community resources and supports.
I|I|1801.511.(d)(1)(B)
Demonstration of improvements after 3 years
I|I|1801.511.(d)(1)(B)(i)
Report to the secretary Not later than 30 days after the end of the 3rd year in which the eligible entity conducts the program, the entity submits to the Secretary a report demonstrating improvement in at least 4 of the areas specified in subparagraph (A).
I|I|1801.511.(d)(1)(B)(ii)
Corrective action plan If the report submitted by the eligible entity under clause (i) fails to demonstrate improvement in at least 4 of the areas specified in subparagraph (A), the entity shall develop and implement a plan to improve outcomes in each of the areas specified in subparagraph (A), subject to approval by the Secretary. The plan shall include provisions for the Secretary to monitor implementation of the plan and conduct continued oversight of the program, including through submission by the entity of regular reports to the Secretary.
I|I|1801.511.(d)(1)(B)(iii)
Technical assistance
I|I|1801.511.(d)(1)(B)(iii)(I)
In general The Secretary shall provide an eligible entity required to develop and implement an improvement plan under clause (ii) with technical assistance to develop and implement the plan. The Secretary may provide the technical assistance directly or through grants, contracts, or cooperative agreements.
I|I|1801.511.(d)(1)(B)(iii)(II)
Advisory panel The Secretary shall establish an advisory panel for purposes of obtaining recommendations regarding the technical assistance provided to entities in accordance with subclause (I).
I|I|1801.511.(d)(1)(B)(iv)
No improvement or failure to submit report If the Secretary determines after a period of time specified by the Secretary that an eligible entity implementing an improvement plan under clause (ii) has failed to demonstrate any improvement in the areas specified in subparagraph (A), or if the Secretary determines that an eligible entity has failed to submit the report required under clause (i), the Secretary shall terminate the entity's grant and may include any unexpended grant funds in grants made to nonprofit organizations under subsection (h)(2)(B).
I|I|1801.511.(d)(1)(C)
Final report Not later than December 31, 2014, the eligible entity shall submit a report to the Secretary demonstrating improvements (if any) in each of the areas specified in subparagraph (A).
I|I|1801.511.(d)(2)
Improvements in outcomes for individual families
I|I|1801.511.(d)(2)(A)
In general The program is designed, with respect to an eligible family participating in the program, to result in the participant outcomes described in subparagraph (B) that the eligible entity identifies on the basis of an individualized assessment of the family, are relevant for that family.
I|I|1801.511.(d)(2)(B)
Participant outcomes The participant outcomes described in this subparagraph are the following:
I|I|1801.511.(d)(2)(B)(i)
Improvements in prenatal, maternal, and newborn health, including improved pregnancy outcomes
I|I|1801.511.(d)(2)(B)(ii)
Improvements in child health and development, including the prevention of child injuries and maltreatment and improvements in cognitive, language, social-emotional, and physical developmental indicators.
I|I|1801.511.(d)(2)(B)(iii)
Improvements in parenting skills.
I|I|1801.511.(d)(2)(B)(iv)
Improvements in school readiness and child academic achievement.
I|I|1801.511.(d)(2)(B)(v)
Reductions in crime or domestic violence.
I|I|1801.511.(d)(2)(B)(vi)
Improvements in family economic self-sufficiency.
I|I|1801.511.(d)(2)(B)(vii)
Improvements in the coordination of referrals for, and the provision of, other community resources and supports for eligible families, consistent with State child welfare agency training.
I|I|1801.511.(d)(3)
Core components The program includes the following core components:
I|I|1801.511.(d)(3)(A)
Service delivery model or models
I|I|1801.511.(d)(3)(A)(i)
In general Subject to clause (ii), the program is conducted using 1 or more of the service delivery models described in item (aa) or (bb) of subclause (I) or in subclause (II) selected by the eligible entity:
I|I|1801.511.(d)(3)(A)(i)(I)
The model conforms to a clear consistent home visitation model that has been in existence for at least 3 years and is research-based, grounded in relevant empirically-based knowledge, linked to program determined outcomes, associated with a national organization or institution of higher education that has comprehensive home visitation program standards that ensure high quality service delivery and continuous program quality improvement, and has demonstrated significant, (and in the case of the service delivery model described in item (aa), sustained) positive outcomes, as described in the benchmark areas specified in paragraph (1)(A) and the participant outcomes described in paragraph (2)(B), when evaluated using well-designed and rigorous -
I|I|1801.511.(d)(3)(A)(i)(aa)
randomized controlled research designs, and the evaluation results have been published in a peer-reviewed journal; or
I|I|1801.511.(d)(3)(A)(i)(bb)
quasi-experimental research designs.
I|I|1801.511.(d)(3)(A)(i)(II)
The model conforms to a promising and new approach to achieving the benchmark areas specified in paragraph (1)(A) and the participant outcomes described in paragraph (2)(B), has been developed or identified by a national organization or institution of higher education, and will be evaluated through well-designed and rigorous process.
I|I|1801.511.(d)(3)(A)(ii)
Majority of grant funds used for evidence-based models An eligible entity shall use not more than 25 percent of the amount of the grant paid to the entity for a fiscal year for purposes of conducting a program using the service delivery model described in clause (i)(III).
I|I|1801.511.(d)(3)(A)(iii)
Criteria for evidence of effectiveness of models The Secretary shall establish criteria for evidence of effectiveness of the service delivery models (which may be tiered) and for assessing such evidence with respect to each such model. The Secretary shall ensure that the process for establishing the criteria is transparent and provides the opportunity for public comment.
I|I|1801.511.(d)(3)(B)
Additional requirements
I|I|1801.511.(d)(3)(B)(i)
The program adheres to a clear, consistent model that satisfies the requirements of being grounded in empirically-based knowledge related to home visiting and linked to the benchmark areas specified in paragraph (1)(A) and the participant outcomes described in paragraph (2)(B).
I|I|1801.511.(d)(3)(B)(ii)
The program employs well-trained and competent staff, as demonstrated by education or training, such as nurses, social workers, child development specialists, or other well-trained and competent staff, and provides ongoing and specific training on the model being delivered.
I|I|1801.511.(d)(3)(B)(iii)
The program maintains high quality supervision to establish home visitor competencies.
I|I|1801.511.(d)(3)(B)(iv)
The program demonstrates strong organizational capacity to implement the activities involved.
I|I|1801.511.(d)(3)(B)(v)
The program establishes appropriate linkages and referral networks to other community resources and supports for eligible families.
I|I|1801.511.(d)(3)(B)(vi)
The program monitors the fidelity of program implementation to ensure that services are delivered pursuant to the specified model.
I|I|1801.511.(d)(4)
Priority for serving high-risk populations The eligible entity gives priority to providing services under the program to the following:
I|I|1801.511.(d)(4)(A)
Eligible families who reside in communities in need of such services, as identified in the statewide needs assessment required under subsection (b)(1)(A).
I|I|1801.511.(d)(4)(B)
Low-income eligible families.
I|I|1801.511.(d)(4)(C)
Eligible families who are pregnant women who have not attained age 21.
I|I|1801.511.(d)(4)(D)
Eligible families that have a history of child abuse or neglect.
I|I|1801.511.(d)(4)(E)
Eligible families that have had interactions with child welfare services.
I|I|1801.511.(d)(4)(F)
Eligible families that have a history of substance abuse or need substance abuse treatment.
I|I|1801.511.(d)(4)(G)
Eligible families that have users of tobacco products in the home.
I|I|1801.511.(d)(4)(H)
Eligible families that are or have children with low student achievement.
I|I|1801.511.(d)(4)(I)
Eligible families with children with developmental delays or disabilities.
I|I|1801.511.(d)(4)(J)
Eligible families who, or that include individuals who, are serving or formerly served in the Armed Forces, including such families that have members of the Armed Forces who have had multiple deployments outside of the United States.
I|I|1801.511.(e)
Application requirements An eligible entity desiring a grant under this section shall submit an application to the Secretary for approval, in such manner as the Secretary may require, that includes the following:
I|I|1801.511.(e)(1)
A description of the populations to be served by the entity, including specific information regarding how the entity will serve high risk populations described in subsection (d)(4).
I|I|1801.511.(e)(2)
An assurance that the entity will give priority to serving low-income eligible families and eligible families who reside in at risk communities identified in the statewide needs assessment required under subsection (b)(1)(A).
I|I|1801.511.(e)(3)
The service delivery model or models described in subsection (d)(3)(A) that the entity will use under the program and the basis for the selection of the model or models.
I|I|1801.511.(e)(4)
A statement identifying how the selection of the populations to be served and the service delivery model or models that the entity will use under the program for such populations is consistent with the results of the statewide needs assessment conducted under subsection (b).
I|I|1801.511.(e)(5)
The quantifiable, measurable benchmarks established by the State to demonstrate that the program contributes to improvements in the areas specified in subsection (d)(1)(A).
I|I|1801.511.(e)(6)
An assurance that the entity will obtain and submit documentation or other appropriate evidence from the organization or entity that developed the service delivery model or models used under the program to verify that the program is implemented and services are delivered according to the model specifications.
I|I|1801.511.(e)(7)
Assurances that the entity will establish procedures to ensure that -
I|I|1801.511.(e)(7)(A)
the participation of each eligible family in the program is voluntary; and
I|I|1801.511.(e)(7)(B)
services are provided to an eligible family in accordance with the individual assessment for that family.
I|I|1801.511.(e)(8)
Assurances that the entity will -
I|I|1801.511.(e)(8)(A)
submit annual reports to the Secretary regarding the program and activities carried out under the program that include such information and data as the Secretary shall require; and
I|I|1801.511.(e)(8)(B)
participate in, and cooperate with, data and information collection necessary for the evaluation required under subsection (g)(2) and other research and evaluation activities carried out under subsection (h)(3).
I|I|1801.511.(e)(9)
A description of other State programs that include home visitation services, including, if applicable to the State, other programs carried out under this title with funds made available from allotments under section 502(c), programs funded under title IV, title II of the Child Abuse Prevention and Treatment Act (relating to community-based grants for the prevention of child abuse and neglect), and section 645A of the Head Start Act (relating to Early Head Start programs).
I|I|1801.511.(e)(10)
Other information as required by the Secretary.
I|I|1801.511.(f)
Maintenance of effort Funds provided to an eligible entity receiving a grant under this section shall supplement, and not supplant, funds from other sources for early childhood home visitation programs or initiatives.
I|I|1801.511.(g)
Evaluation
I|I|1801.511.(g)(1)
Independent, expert advisory panel The Secretary, in accordance with subsection (h)(1)(A), shall appoint an independent advisory panel consisting of experts in program evaluation and research, education, and early childhood programs -
I|I|1801.511.(g)(1)(A)
to review, and make recommendations on, the design and plan for the evaluation required under paragraph (2) within 1 year after the date of enactment of this section;
I|I|1801.511.(g)(1)(B)
to maintain and advise the Secretary regarding the progress of the evaluation; and
I|I|1801.511.(g)(1)(C)
to comment, if the panel so desires, on the report submitted under paragraph (3).
I|I|1801.511.(g)(2)
Authority to conduct evaluation On the basis of the recommendations of the advisory panel under paragraph (1), the Secretary shall, by grant, contract, or interagency agreement, conduct an evaluation of the statewide needs assessments submitted under subsection (b) and the grants made under subsections (c) and (h)(3)(B). The evaluation shall include -
I|I|1801.511.(g)(2)(A)
an analysis, on a State-by-State basis, of the results of such assessments, including indicators of maternal and prenatal health and infant health and mortality, and State actions in response to the assessments; and
I|I|1801.511.(g)(2)(B)
an assessment of -
I|I|1801.511.(g)(2)(B)(i)
the effect of early childhood home visitation programs on child and parent outcomes, including with respect to each of the benchmark areas specified in subsection (d)(1)(A) and the participant outcomes described in subsection (d)(2)(B);
I|I|1801.511.(g)(2)(B)(ii)
the effectiveness of such programs on different populations, including the extent to which the ability of programs to improve participant outcomes varies across programs and populations; and
I|I|1801.511.(g)(2)(B)(iii)
the potential for the activities conducted under such programs, if scaled broadly, to improve health care practices, eliminate health disparities, and improve health care system quality, efficiencies, and reduce costs.
I|I|1801.511.(g)(3)
Report Not later than March 31, 2015, the Secretary shall submit a report to Congress on the results of the evaluation conducted under paragraph (2) and shall make the report publicly available.
I|I|1801.511.(h)
Other provisions
I|I|1801.511.(h)(1)
Intra-agency collaboration The Secretary shall ensure that the Maternal and Child Health Bureau and the Administration for Children and Families collaborate with respect to all aspects of carrying out this section, including with respect to -
I|I|1801.511.(h)(1)(A)
reviewing and analyzing the statewide needs assessments required under subsection (b), the awarding and oversight of grants awarded under this section, the establishment of the advisory panels required under subsections (d)(1)(B)(iii)(II) and (g)(1), and the evaluation and report required under subsection (g); and
I|I|1801.511.(h)(1)(B)
consulting with other Federal agencies with responsibility for administering or evaluating programs that serve eligible families to coordinate and collaborate with respect to research related to such programs and families, including the Office of the Assistant Secretary for Planning and Evaluation of the Department of Health and Human Services, the Centers for Disease Control and Prevention, the National Institute of Child Health and Human Development of the National Institutes of Health, the Office of Juvenile Justice and Delinquency Prevention of the Department of Justice, and the Institute of Education Sciences of the Department of Education.
I|I|1801.511.(h)(2)
Grants to eligible entities that are not States
I|I|1801.511.(h)(2)(A)
Indian Tribes, Tribal Organizations, or Urban Indian Organizations The Secretary shall specify requirements for eligible entities that are Indian Tribes (or a consortium of Indian Tribes), Tribal Organizations, or Urban Indian Organizations to apply for and conduct an early childhood home visitation program with a grant under this section. Such requirements shall, to the greatest extent practicable, be consistent with the requirements applicable to eligible entities that are States and shall require an Indian Tribe (or consortium), Tribal Organization, or Urban Indian Organization to -
I|I|1801.511.(h)(2)(A)(i)
conduct a needs assessment similar to the assessment required for all States under subsection (b); and
I|I|1801.511.(h)(2)(A)(ii)
establish quantifiable, measurable 3- and 5-year benchmarks consistent with subsection (d)(1)(A).
I|I|1801.511.(h)(2)(B)
Nonprofit organizations If, as of the beginning of fiscal year 2012, a State has not applied and been approved for a grant under this section, the Secretary may use amounts appropriated under paragraph (1) of subsection (j) that are available for expenditure under paragraph (3) of that subsection to make a grant to an eligible entity that is a nonprofit organization described in subsection (k)(1)(B) to conduct an early childhood home visitation program in the State. The Secretary shall specify the requirements for such an organization to apply for and conduct the program which shall, to the greatest extent practicable, be consistent with the requirements applicable to eligible entities that are States and shall require the organization to -
I|I|1801.511.(h)(2)(B)(i)
carry out the program based on the needs assessment conducted by the State under subsection (b); and
I|I|1801.511.(h)(2)(B)(ii)
establish quantifiable, measurable 3- and 5-year benchmarks consistent with subsection (d)(1)(A).
I|I|1801.511.(h)(3)
Research and other evaluation activities
I|I|1801.511.(h)(3)(A)
In general The Secretary shall carry out a continuous program of research and evaluation activities in order to increase knowledge about the implementation and effectiveness of home visiting programs, using random assignment designs to the maximum extent feasible. The Secretary may carry out such activities directly, or through grants, cooperative agreements, or contracts.
I|I|1801.511.(h)(3)(B)
Requirements The Secretary shall ensure that -
I|I|1801.511.(h)(3)(B)(i)
evaluation of a specific program or project is conducted by persons or individuals not directly involved in the operation of such program or project; and
I|I|1801.511.(h)(3)(B)(ii)
the conduct of research and evaluation activities includes consultation with independent researchers, State officials, and developers and providers of home visiting programs on topics including research design and administrative data matching.
I|I|1801.511.(h)(4)
Report and recommendation Not later than December 31, 2015, the Secretary shall submit a report to Congress regarding the programs conducted with grants under this section. The report required under this paragraph shall include -
I|I|1801.511.(h)(4)(A)
information regarding the extent to which eligible entities receiving grants under this section demonstrated improvements in each of the areas specified in subsection (d)(1)(A);
I|I|1801.511.(h)(4)(B)
information regarding any technical assistance provided under subsection (d)(1)(B)(iii)(I), including the type of any such assistance provided; and
I|I|1801.511.(h)(4)(C)
recommendations for such legislative or administrative action as the Secretary determines appropriate.
I|I|1801.511.(i)
Application of other provisions of title
I|I|1801.511.(i)(1)
In general Except as provided in paragraph (2), the other provisions of this title shall not apply to a grant made under this section.
I|I|1801.511.(i)(2)
Exceptions The following provisions of this title shall apply to a grant made under this section to the same extent and in the same manner as such provisions apply to allotments made under section 502(c):
I|I|1801.511.(i)(2)(A)
Section 504(b)(6) (relating to prohibition on payments to excluded individuals and entities).
I|I|1801.511.(i)(2)(B)
Section 504(c) (relating to the use of funds for the purchase of technical assistance).
I|I|1801.511.(i)(2)(C)
Section 504(d) (relating to a limitation on administrative expenditures).
I|I|1801.511.(i)(2)(D)
Section 506 (relating to reports and audits), but only to the extent determined by the Secretary to be appropriate for grants made under this section.
I|I|1801.511.(i)(2)(E)
Section 507 (relating to penalties for false statements).
I|I|1801.511.(i)(2)(F)
Section 508 (relating to nondiscrimination).
I|I|1801.511.(i)(2)(G)
Section 509(a) (relating to the administration of the grant program).
I|I|1801.511.(j)
Appropriations
I|I|1801.511.(j)(1)
In general Out of any funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary to carry out this section -
I|I|1801.511.(j)(1)(A)
$100,000,000 for fiscal year 2010;
I|I|1801.511.(j)(1)(B)
$250,000,000 for fiscal year 2011;
I|I|1801.511.(j)(1)(C)
$350,000,000 for fiscal year 2012;
I|I|1801.511.(j)(1)(D)
$400,000,000 for fiscal year 2013; and
I|I|1801.511.(j)(1)(E)
$400,000,000 for fiscal year 2014.
I|I|1801.511.(j)(2)
Reservations Of the amount appropriated under this subsection for a fiscal year, the Secretary shall reserve -
I|I|1801.511.(j)(2)(A)
3 percent of such amount for purposes of making grants to eligible entities that are Indian Tribes (or a consortium of Indian Tribes), Tribal Organizations, or Urban Indian Organizations; and
I|I|1801.511.(j)(2)(B)
3 percent of such amount for purposes of carrying out subsections (d)(1)(B)(iii), (g), and (h)(3).
I|I|1801.511.(j)(3)
Availability Funds made available to an eligible entity under this section for a fiscal year shall remain available for expenditure by the eligible entity through the end of the second succeeding fiscal year after award. Any funds that are not expended by the eligible entity during the period in which the funds are available under the preceding sentence may be used for grants to nonprofit organizations under subsection (h)(2)(B).
I|I|1801.511.(k)
Definitions In this section:
I|I|1801.511.(k)(1)
Eligible entity
I|I|1801.511.(k)(1)(A)
In general The term eligible entity means a State, an Indian Tribe, Tribal Organization, or Urban Indian Organization, Puerto Rico, Guam, the Virgin Islands, the Northern Mariana Islands, and American Samoa.
I|I|1801.511.(k)(1)(B)
Nonprofit organizations Only for purposes of awarding grants under subsection (h)(2)(B), such term shall include a nonprofit organization with an established record of providing early childhood home visitation programs or initiatives in a State or several States.
I|I|1801.511.(k)(2)
Eligible family The term eligible family means -
I|I|1801.511.(k)(2)(A)
a woman who is pregnant, and the father of the child if the father is available; or
I|I|1801.511.(k)(2)(B)
a parent or primary caregiver of a child, including grandparents or other relatives of the child, and foster parents, who are serving as the child's primary caregiver from birth until entry into kindergarten, and including a noncustodial parent who has an ongoing relationship with, and at times provides physical care for, the child.
I|I|1801.511.(k)(3)
Indian tribe; tribal organization The terms Indian Tribe and Tribal Organization , and Urban Indian Organization have the meanings given such terms in section 4 of the Indian Health Care Improvement Act.
.
I|I|1802.
Support, education, and research for postpartum depression
I|I|1802.(a)
Definitions In this section:
I|I|1802.(a)(1)
The term postpartum condition means postpartum depression or postpartum psychosis.
I|I|1802.(a)(2)
The term Secretary means the Secretary of Health and Human Services.
I|I|1802.(b)
Research on postpartum conditions
I|I|1802.(b)(1)
Expansion and intensification of activities
I|I|1802.(b)(1)(A)
Continuation of activities The Secretary is encouraged to continue activities on postpartum conditions.
I|I|1802.(b)(1)(B)
Programs for Postpartum Conditions In carrying out subparagraph (A), the Secretary is encouraged to continue research to expand the understanding of the causes of, and treatments for, postpartum conditions. Activities under such subsection shall include conducting and supporting the following:
I|I|1802.(b)(1)(B)(i)
Basic research concerning the etiology and causes of the conditions.
I|I|1802.(b)(1)(B)(ii)
Epidemiological studies to address the frequency and natural history of the conditions and the differences among racial and ethnic groups with respect to the conditions.
I|I|1802.(b)(1)(B)(iii)
The development of improved screening and diagnostic techniques.
I|I|1802.(b)(1)(B)(iv)
Clinical research for the development and evaluation of new treatments.
I|I|1802.(b)(1)(B)(v)
Information and education programs for health care professionals and the public, which may include a coordinated national campaign to increase the awareness and knowledge of postpartum conditions. Activities under such a national campaign may -
I|I|1802.(b)(1)(B)(v)(I)
include public service announcements through television, radio, and other means; and
I|I|1802.(b)(1)(B)(v)(II)
focus on -
I|I|1802.(b)(1)(B)(v)(aa)
raising awareness about screening;
I|I|1802.(b)(1)(B)(v)(bb)
educating new mothers and their families about postpartum conditions to promote earlier diagnosis and treatment; and
I|I|1802.(b)(1)(B)(v)(cc)
ensuring that such education includes complete information concerning postpartum conditions, including its symptoms, methods of coping with the illness, and treatment resources.
I|I|1802.(b)(2)
Sense of Congress regarding longitudinal study of relative mental health consequences for women of resolving a pregnancy
I|I|1802.(b)(2)(A)
Sense of Congress It is the sense of Congress that the Director of the National Institute of Mental Health may conduct a nationally representative longitudinal study (during the period of fiscal years 2010 through 2019) of the relative mental health consequences for women of resolving a pregnancy (intended and unintended) in various ways, including carrying the pregnancy to term and parenting the child, carrying the pregnancy to term and placing the child for adoption, miscarriage, and having an abortion. This study may assess the incidence, timing, magnitude, and duration of the immediate and long-term mental health consequences (positive or negative) of these pregnancy outcomes.
I|I|1802.(b)(2)(B)
Report Subject to the completion of the study under subsection (a), beginning not later than 5 years after the date of the enactment of this Act, and periodically thereafter for the duration of the study, such Director may prepare and submit to the Congress reports on the findings of the study.
I|I|1802.(c)
Grants to provide services to individuals with a postpartum condition and their families Title V of the Social Security Act ( 42 U.S.C. 701 et seq. ), as amended by section 1801, is amended by adding at the end the following new section:
I|I|1802.(c)512.
Services to individuals with a postpartum condition and their families
I|I|1802.(c)512.(a)
In General In addition to any other payments made under this title to a State, the Secretary may make grants to eligible entities for projects for the establishment, operation, and coordination of effective and cost-efficient systems for the delivery of essential services to individuals with a postpartum condition and their families.
I|I|1802.(c)512.(b)
Certain activities To the extent practicable and appropriate, the Secretary shall ensure that projects funded under subsection (a) provide education and services with respect to the diagnosis and management of postpartum conditions. The Secretary may allow such projects to include the following:
I|I|1802.(c)512.(b)(1)
Delivering or enhancing outpatient and home-based health and support services, including case management and comprehensive treatment services for individuals with or at risk for postpartum conditions, and delivering or enhancing support services for their families.
I|I|1802.(c)512.(b)(2)
Delivering or enhancing inpatient care management services that ensure the well-being of the mother and family and the future development of the infant.
I|I|1802.(c)512.(b)(3)
Improving the quality, availability, and organization of health care and support services (including transportation services, attendant care, homemaker services, day or respite care, and providing counseling on financial assistance and insurance) for individuals with a postpartum condition and support services for their families.
I|I|1802.(c)512.(b)(4)
Providing education to new mothers and, as appropriate, their families about postpartum conditions to promote earlier diagnosis and treatment. Such education may include -
I|I|1802.(c)512.(b)(4)(A)
providing complete information on postpartum conditions, symptoms, methods of coping with the illness, and treatment resources; and
I|I|1802.(c)512.(b)(4)(B)
in the case of a grantee that is a State, hospital, or birthing facility -
I|I|1802.(c)512.(b)(4)(B)(i)
providing education to new mothers and fathers, and other family members as appropriate, concerning postpartum conditions before new mothers leave the health facility; and
I|I|1802.(c)512.(b)(4)(B)(ii)
ensuring that training programs regarding such education are carried out at the health facility.
I|I|1802.(c)512.(c)
Integration with other programs To the extent practicable and appropriate, the Secretary may integrate the grant program under this section with other grant programs carried out by the Secretary, including the program under section 330 of the Public Health Service Act.
I|I|1802.(c)512.(d)
Certain requirements A grant may be made under this section only if the applicant involved makes the following agreements:
I|I|1802.(c)512.(d)(1)
Not more than 5 percent of the grant will be used for administration, accounting, reporting, and program oversight functions.
I|I|1802.(c)512.(d)(2)
The grant will be used to supplement and not supplant funds from other sources related to the treatment of postpartum conditions.
I|I|1802.(c)512.(d)(3)
The applicant will abide by any limitations deemed appropriate by the Secretary on any charges to individuals receiving services pursuant to the grant. As deemed appropriate by the Secretary, such limitations on charges may vary based on the financial circumstances of the individual receiving services.
I|I|1802.(c)512.(d)(4)
The grant will not be expended to make payment for services authorized under subsection (a) to the extent that payment has been made, or can reasonably be expected to be made, with respect to such services -
I|I|1802.(c)512.(d)(4)(A)
under any State compensation program, under an insurance policy, or under any Federal or State health benefits program; or
I|I|1802.(c)512.(d)(4)(B)
by an entity that provides health services on a prepaid basis.
I|I|1802.(c)512.(d)(5)
The applicant will, at each site at which the applicant provides services funded under subsection (a), post a conspicuous notice informing individuals who receive the services of any Federal policies that apply to the applicant with respect to the imposition of charges on such individuals.
I|I|1802.(c)512.(d)(6)
For each grant period, the applicant will submit to the Secretary a report that describes how grant funds were used during such period.
I|I|1802.(c)512.(e)
Technical assistance The Secretary may provide technical assistance to entities seeking a grant under this section in order to assist such entities in complying with the requirements of this section.
I|I|1802.(c)512.(f)
Application of other provisions of title
I|I|1802.(c)512.(f)(1)
In general Except as provided in paragraph (2), the other provisions of this title shall not apply to a grant made under this section.
I|I|1802.(c)512.(f)(2)
Exceptions The following provisions of this title shall apply to a grant made under this section to the same extent and in the same manner as such provisions apply to allotments made under section 502(c):
I|I|1802.(c)512.(f)(2)(A)
Section 504(b)(6) (relating to prohibition on payments to excluded individuals and entities).
I|I|1802.(c)512.(f)(2)(B)
Section 504(c) (relating to the use of funds for the purchase of technical assistance).
I|I|1802.(c)512.(f)(2)(C)
Section 504(d) (relating to a limitation on administrative expenditures).
I|I|1802.(c)512.(f)(2)(D)
Section 506 (relating to reports and audits), but only to the extent determined by the Secretary to be appropriate for grants made under this section.
I|I|1802.(c)512.(f)(2)(E)
Section 507 (relating to penalties for false statements).
I|I|1802.(c)512.(f)(2)(F)
Section 508 (relating to nondiscrimination).
I|I|1802.(c)512.(f)(2)(G)
Section 509(a) (relating to the administration of the grant program).
I|I|1802.(c)512.(g)
Definitions In this section:
I|I|1802.(c)512.(g)(1)
The term eligible entity -
I|I|1802.(c)512.(g)(1)(A)
means a public or nonprofit private entity; and
I|I|1802.(c)512.(g)(1)(B)
includes a State or local government, public-private partnership, recipient of a grant under section 330H of the Public Health Service Act (relating to the Healthy Start Initiative), public or nonprofit private hospital, community-based organization, hospice, ambulatory care facility, community health center, migrant health center, public housing primary care center, or homeless health center.
I|I|1802.(c)512.(g)(2)
The term postpartum condition means postpartum depression or postpartum psychosis.
.
I|I|1802.(d)
General provisions
I|I|1802.(d)(1)
Authorization of appropriations To carry out this section and the amendment made by subsection (c), there are authorized to be appropriated, in addition to such other sums as may be available for such purpose -
I|I|1802.(d)(1)(A)
$3,000,000 for fiscal year 2010; and
I|I|1802.(d)(1)(B)
such sums as may be necessary for fiscal years 2011 and 2012.
I|I|1802.(d)(2)
Report by the Secretary
I|I|1802.(d)(2)(A)
Study The Secretary shall conduct a study on the benefits of screening for postpartum conditions.
I|I|1802.(d)(2)(B)
Report Not later than 2 years after the date of the enactment of this Act, the Secretary shall complete the study required by subparagraph (A) and submit a report to the Congress on the results of such study.
I|I|1802.(d)(3)
Limitation Notwithstanding any other provision of this section or the amendment made by subsection (c), the Secretary may not utilize amounts made available under this section or such amendment to carry out activities or programs that are duplicative of activities or programs that are already being carried out through the Department of Health and Human Services.
I|I|1803.
Personal responsibility education for adulthood training Title V of the Social Security Act ( 42 U.S.C. 701 et seq. ), as amended by sections 1801 and 1802(c), is amended by adding at the end the following:
I|I|1803.513.
Personal responsibility education for adulthood (PRE-adulthood) training
I|I|1803.513.(a)
Allotments to states
I|I|1803.513.(a)(1)
Amount
I|I|1803.513.(a)(1)(A)
In general For the purpose described in subsection (b), subject to the succeeding provisions of this section, for each of fiscal years 2010 through 2014, the Secretary shall allot to each State an amount equal to the product of -
I|I|1803.513.(a)(1)(A)(i)
the amount appropriated under subsection (f) for the fiscal year and available for allotments to States after the application of subsection (c); and
I|I|1803.513.(a)(1)(A)(ii)
the State youth population percentage determined under paragraph (2).
I|I|1803.513.(a)(1)(B)
Minimum allotment
I|I|1803.513.(a)(1)(B)(i)
In general Each State allotment under this paragraph for a fiscal year shall be at least $250,000.
I|I|1803.513.(a)(1)(B)(ii)
Pro rata adjustments The Secretary shall adjust on a pro rata basis the amount of the State allotments determined under this paragraph for a fiscal year to the extent necessary to comply with clause (i).
I|I|1803.513.(a)(1)(C)
Application required to access allotments
I|I|1803.513.(a)(1)(C)(i)
In general A State shall not be paid from its allotment for a fiscal year unless the State submits an application to the Secretary for the fiscal year and the Secretary approves the application (or requires changes to the application that the State satisfies) and meets such additional requirements as the Secretary may specify.
I|I|1803.513.(a)(1)(C)(ii)
Requirements The State application shall contain an assurance that the State has complied with the requirements of this section in preparing and submitting the application and shall include the following as well as such additional information as the Secretary may require:
I|I|1803.513.(a)(1)(C)(ii)(I)
Based on data from the Centers for Disease Control and Prevention National Center for Health Statistics, the most recent pregnancy rates for the State for youth ages 10 to 14 and youth ages 15 to 19 for which data are available, the most recent birth rates for such youth populations in the State for which data are available, and trends in those rates for the most recently preceding 5-year period for which such data are available.
I|I|1803.513.(a)(1)(C)(ii)(II)
State-established goals for reducing the pregnancy rates and birth rates for such youth populations.
I|I|1803.513.(a)(1)(C)(ii)(III)
A description of the State's plan for using the State allotments provided under this section to achieve such goals, especially among youth populations that are the most high-risk or vulnerable for pregnancies or otherwise have special circumstances, including youth in foster care, homeless youth, youth with HIV/AIDS, pregnant youth who are under 21 years of age, mothers who are under 21 years of age, and youth residing in areas with high birth rates for youth.
I|I|1803.513.(a)(2)
State youth population percentage
I|I|1803.513.(a)(2)(A)
In general For purposes of paragraph (1)(A)(ii), the State youth population percentage is, with respect to a State, the proportion (expressed as a percentage) of -
I|I|1803.513.(a)(2)(A)(i)
the number of individuals who have attained age 10 but not attained age 20 in the State; to
I|I|1803.513.(a)(2)(A)(ii)
the number of such individuals in all States.
I|I|1803.513.(a)(2)(B)
Determination of number of youth The number of individuals described in clauses (i) and (ii) of subparagraph (A) in a State shall be determined on the basis of the most recent Bureau of the Census data.
I|I|1803.513.(a)(3)
Availability of state allotments Subject to paragraph (4)(A), amounts allotted to a State pursuant to this subsection for a fiscal year shall remain available for expenditure by the State through the end of the second succeeding fiscal year.
I|I|1803.513.(a)(4)
Authority to award grants from state allotments to local organizations and entities in nonparticipating states
I|I|1803.513.(a)(4)(A)
Grants from unexpended allotments If a State does not submit an application under this section for fiscal year 2010 or 2011, the State shall no longer be eligible to submit an application to receive funds from the amounts allotted for the State for each of fiscal years 2010 through 2014 and such amounts shall be used by the Secretary to award grants under this paragraph for each of fiscal years 2012 through 2014. The Secretary also shall use any amounts from the allotments of States that submit applications under this section for a fiscal year that remain unexpended as of the end of the period in which the allotments are available for expenditure under paragraph (3) for awarding grants under this paragraph.
I|I|1803.513.(a)(4)(B)
3-year grants
I|I|1803.513.(a)(4)(B)(i)
In general The Secretary shall solicit applications to award 3-year grants in each of fiscal years 2012, 2013, and 2014 to local organizations and entities to conduct, consistent with subsection (b), programs and activities in States that do not submit an application for an allotment under this section for fiscal year 2010 or 2011.
I|I|1803.513.(a)(4)(B)(ii)
Faith-based organizations or consortia The Secretary may solicit and award grants under this paragraph to faith-based organizations or consortia, consistent with the requirements of section 1955 of the Public Health Service Act relating to a grant award to nongovernmental entities.
I|I|1803.513.(a)(4)(C)
Evaluation An organization or entity awarded a grant under this paragraph shall agree to participate in a rigorous Federal evaluation.
I|I|1803.513.(a)(5)
Maintenance of effort No payment shall be made to a State from the allotment determined for the State under this subsection or to a local organization or entity awarded a grant under paragraph (4), if the expenditure of non-federal funds by the State, organization, or entity for activities, programs, or initiatives for which amounts from allotments and grants under this subsection may be expended is less than the amount expended by the State, organization, or entity for such programs or initiatives for fiscal year 2009.
I|I|1803.513.(a)(6)
Data collection and reporting A State or local organization or entity receiving funds under this section shall cooperate with such requirements relating to the collection of data and information and reporting on outcomes regarding the programs and activities carried out with such funds, as the Secretary shall specify.
I|I|1803.513.(b)
Purpose
I|I|1803.513.(b)(1)
In general The purpose of an allotment under subsection (a)(1) to a State is to enable the State (or, in the case of grants made under subsection (a)(4)(B), to enable a local organization or entity) to carry out personal responsibility education for adulthood programs consistent with this subsection.
I|I|1803.513.(b)(2)
Personal responsibility education for adulthood programs
I|I|1803.513.(b)(2)(A)
In general In this section, the term personal responsibility education for adulthood program means a program that is designed to educate adolescents on -
I|I|1803.513.(b)(2)(A)(i)
both abstinence and contraception for the prevention of pregnancy and sexually transmitted infections, including HIV/AIDS, consistent with the requirements of subparagraph (B); and
I|I|1803.513.(b)(2)(A)(ii)
at least 3 of the adulthood preparation subjects described in subparagraph (C).
I|I|1803.513.(b)(2)(B)
Requirements The requirements of this subparagraph are the following:
I|I|1803.513.(b)(2)(B)(i)
The program replicates evidence-based effective programs or substantially incorporates elements of effective programs that have been proven on the basis of rigorous scientific research to change behavior, which means delaying sexual activity, increasing condom or contraceptive use for sexually active youth, or reducing pregnancy among youth.
I|I|1803.513.(b)(2)(B)(ii)
The program is medically-accurate and complete.
I|I|1803.513.(b)(2)(B)(iii)
The program includes activities to educate youth who are sexually active regarding responsible sexual behavior with respect to both abstinence and the use of contraception.
I|I|1803.513.(b)(2)(B)(iv)
The program places substantial emphasis on both abstinence and contraception for the prevention of pregnancy among youth and sexually transmitted infections.
I|I|1803.513.(b)(2)(B)(v)
The program provides age-appropriate information and activities.
I|I|1803.513.(b)(2)(B)(vi)
The information and activities carried out under the program are provided in the cultural context that is most appropriate for individuals in the particular population group to which they are directed.
I|I|1803.513.(b)(2)(C)
Adulthood preparation subjects The adulthood preparation subjects described in this subparagraph are the following:
I|I|1803.513.(b)(2)(C)(i)
Healthy relationships, such as positive self-esteem and relationship dynamics, friendships, dating, romantic involvement, marriage, and family interactions.
I|I|1803.513.(b)(2)(C)(ii)
Adolescent development, such as the development of healthy attitudes and values about adolescent growth and development, body image, racial and ethnic diversity, and other related subjects.
I|I|1803.513.(b)(2)(C)(iii)
Financial literacy.
I|I|1803.513.(b)(2)(C)(iv)
Parent-child communication.
I|I|1803.513.(b)(2)(C)(v)
Educational and career success, such as developing skills for employment preparation, job seeking, independent living, financial self-sufficiency, and workplace productivity.
I|I|1803.513.(b)(2)(C)(vi)
Healthy life skills, such as goal-setting, decision making, negotiation, communication and interpersonal skills, and stress management.
I|I|1803.513.(b)(2)(D)
Faith-based organizations A faith-based entity carrying out a program funded in whole or in part with funds made available under this section through a State allotment or a grant shall agree that information, activities, and services are carried out with funds made available to the entity from the allotment consistent with the requirements of section 1955 of the Public Health Service Act relating to a grant award to nongovernmental entities.
I|I|1803.513.(c)
Reservations of funds
I|I|1803.513.(c)(1)
Grants to implement innovative strategies From the amount appropriated under subsection (f) for the fiscal year, the Secretary shall reserve $10,000,000 of such amount for purposes of awarding grants to entities to implement innovative youth pregnancy prevention strategies and target services to high-risk, vulnerable, and culturally under-represented youth populations, including youth in foster care, homeless youth, youth with HIV/AIDS, pregnant women who are under 21 years of age and their partners, mothers who are under 21 years of age and their partners, and youth residing in areas with high birth rates for youth. An entity awarded a grant under this paragraph shall agree to participate in a rigorous Federal evaluation of the activities carried out with grant funds.
I|I|1803.513.(c)(2)
Other reservations From the amount appropriated under subsection (f) for the fiscal year that remains after the application of paragraph (1), the Secretary shall reserve the following amounts:
I|I|1803.513.(c)(2)(A)
Grants for indian tribes or tribal organizations The Secretary shall reserve 5 percent of such remainder for purposes of awarding grants to Indian tribes and tribal organizations in such manner, and subject to such requirements, as the Secretary, in consultation with Indian tribes and tribal organizations, determines appropriate.
I|I|1803.513.(c)(2)(B)
Secretarial responsibilities The Secretary shall reserve 10 percent of such remainder for expenditures by the Secretary for the following:
I|I|1803.513.(c)(2)(B)(i)
To award a grant to establish and operate a national teen pregnancy prevention resource center consistent with subparagraph (C).
I|I|1803.513.(c)(2)(B)(ii)
To conduct research, training, and technical assistance with respect to the programs and activities carried out with funds made available through allotments or grants made under this section.
I|I|1803.513.(c)(2)(B)(iii)
To evaluate the programs and activities carried out with funds made available through such allotments and grants.
I|I|1803.513.(c)(2)(C)
National teen pregnancy prevention resource center
I|I|1803.513.(c)(2)(C)(i)
In general The Secretary shall award a grant to a nationally recognized, nonpartisan, nonprofit organization that meets the requirements described in clause (ii) to establish and operate a national teen pregnancy prevention resource center (in this subparagraph referred to as the Resource Center ) to carry out the purpose and activities described in clause (iii).
I|I|1803.513.(c)(2)(C)(ii)
Requirements The requirements described in this clause are the following:
I|I|1803.513.(c)(2)(C)(ii)(I)
The organization has demonstrated experience working with and providing assistance to a broad range of individuals and entities to reduce teen pregnancy.
I|I|1803.513.(c)(2)(C)(ii)(II)
The organization is research-based and has comprehensive knowledge and data about teen pregnancy prevention strategies.
I|I|1803.513.(c)(2)(C)(iii)
Purpose and activities The Resource Center shall provide information and technical assistance to public and private entities seeking to reduce teen pregnancy rates through activities that include the following:
I|I|1803.513.(c)(2)(C)(iii)(I)
Synthesizing and disseminating research and information regarding effective and promising practices.
I|I|1803.513.(c)(2)(C)(iii)(II)
Developing and providing information on how to identify, select, and implement effective programs.
I|I|1803.513.(c)(2)(C)(iii)(III)
Linking organizations to existing resources, experts, and peers.
I|I|1803.513.(c)(2)(C)(iii)(IV)
Providing consultation and resources on a broad array of strategies and messages, including messages that focus on abstinence, contraception, responsible behavior and choices, family communication, relationships, and values.
I|I|1803.513.(c)(2)(C)(iv)
Collaboration with other organizations The organization operating the Resource Center shall collaborate with other entities that have expertise in the prevention of HIV and sexually transmitted infections, healthy relationships, financial literacy, and other topics addressed through the personal responsibility for adulthood educational programs to develop resources and materials, provide technical assistance to States, Indian tribes, and communities, and undertake other activities as necessary.
I|I|1803.513.(d)
Administration
I|I|1803.513.(d)(1)
In general The Secretary shall administer this section through the Assistant Secretary for the Administration for Children and Families within the Department of Health and Human Services.
I|I|1803.513.(d)(2)
Application of other provisions of title
I|I|1803.513.(d)(2)(A)
In general Except as provided in subparagraph (B), the other provisions of this title shall not apply to allotments or grants made under this section.
I|I|1803.513.(d)(2)(B)
Exceptions The following provisions of this title shall apply to allotments and grants made under this section to the same extent and in the same manner as such provisions apply to allotments made under section 502(c):
I|I|1803.513.(d)(2)(B)(i)
Section 504(b)(6) (relating to prohibition on payments to excluded individuals and entities).
I|I|1803.513.(d)(2)(B)(ii)
Section 504(c) (relating to the use of funds for the purchase of technical assistance).
I|I|1803.513.(d)(2)(B)(iii)
Section 504(d) (relating to a limitation on administrative expenditures).
I|I|1803.513.(d)(2)(B)(iv)
Section 506 (relating to reports and audits), but only to the extent determined by the Secretary to be appropriate for grants made under this section.
I|I|1803.513.(d)(2)(B)(v)
Section 507 (relating to penalties for false statements).
I|I|1803.513.(d)(2)(B)(vi)
Section 508 (relating to nondiscrimination).
I|I|1803.513.(e)
Definitions In this section:
I|I|1803.513.(e)(1)
Age-appropriate The term age-appropriate , with respect to the information in pregnancy prevention, means topics, messages, and teaching methods suitable to particular ages or age groups of children and adolescents, based on developing cognitive, emotional, and behavioral capacity typical for the age or age group.
I|I|1803.513.(e)(2)
Medically accurate and complete The term medically accurate and complete means verified or supported by the weight of research conducted in compliance with accepted scientific methods and -
I|I|1803.513.(e)(2)(A)
published in peer-reviewed journals, where applicable; or
I|I|1803.513.(e)(2)(B)
comprising information that leading professional organizations and agencies with relevant expertise in the field recognize as accurate, objective, and complete.
I|I|1803.513.(e)(3)
Indian tribes; tribal organizations The terms Indian tribe and Tribal organization have the meanings given such terms in section 4 of the Indian Health Care Improvement Act ( 25 U.S.C. 1603 )).
I|I|1803.513.(e)(4)
Youth The term youth means an individual who has attained age 10 but has not attained age 20.
I|I|1803.513.(f)
Appropriation For the purpose of carrying out this section, there is appropriated, out of any money in the Treasury not otherwise appropriated, $75,000,000 for each of fiscal years 2010 through 2014. Amounts appropriated under this subsection shall remain available until expended.
.
I|I|1804.
Restoration of funding for abstinence education Section 510 of the Social Security Act ( 42 U.S.C. 710 ) is amended -
I|I|1804.(1)
in subsection (a), by striking fiscal year 1998 and each subsequent fiscal year and inserting each of fiscal years 2010 through 2014 ; and
I|I|1804.(2)
in subsection (d) -
I|I|1804.(2)(A)
in the first sentence, by striking 1998 through 2003 and inserting 2010 through 2014 ; and
I|I|1804.(2)(B)
in the second sentence, by inserting (except that such appropriation shall be made on the date of enactment of the America's Healthy Future Act of 2009 in the case of fiscal year 2010) before the period.
I|J
Programs of health promotion and disease prevention
I|J|1901.
Programs of health promotion and disease prevention
I|J|1901.(a)
Internal Revenue Code of 1986 Section 9802 of the Internal Revenue Code of 1986 is amended -
I|J|1901.(a)(1)
by redesignating the second subsection (f) as subsection (g); and
I|J|1901.(a)(2)
by adding at the end the following:
I|J|1901.(a)(2)(h)
Programs of Health Promotion and Disease Prevention
I|J|1901.(a)(2)(h)(1)
Applicability The following shall apply with respect to a program of health promotion or disease prevention for purposes of subsection (b)(2)(B). Such programs shall be referred to as wellness programs .
I|J|1901.(a)(2)(h)(2)
Definition and general rule
I|J|1901.(a)(2)(h)(2)(A)
Definition For purposes of this subsection, a wellness program is any program designed to promote health or prevent disease, including a program designed to encourage individuals to adopt healthy behaviors.
I|J|1901.(a)(2)(h)(2)(B)
General rule For purposes of subsections (a)(2) and (b)(2) (which provide exceptions to the general prohibitions against discrimination based on a health factor for group health plan provisions that vary benefits (including cost-sharing mechanisms) or the premium or contribution for similarly situated individuals in connection with a wellness program that satisfies the requirements of this subsection), if none of the conditions for obtaining a reward under a wellness program are based on an individual satisfying a standard that is related to a health factor, under this subsection, such wellness program does not violate this section if participation in the program is made available to all similarly situated individuals. If any of the conditions for obtaining a reward under such a wellness program is based on an individual satisfying a standard that is related to a health factor, the wellness program shall not violate this section if the requirements of paragraph (4) of this section are satisfied.
I|J|1901.(a)(2)(h)(3)
Wellness programs not subject to requirements If none of the conditions for obtaining a reward under a wellness program are based on an individual satisfying a standard that is related to a health factor (or if a wellness program does not provide a reward), the wellness program shall not violate this section, if participation in the program is made available to all similarly situated individuals. Such programs need not satisfy the requirements of paragraph (4), if participation in the program is made available to all similarly situated individuals. Wellness programs described in this paragraph include the following:
I|J|1901.(a)(2)(h)(3)(A)
A program that reimburses all or part of the cost for memberships in a fitness center.
I|J|1901.(a)(2)(h)(3)(B)
A diagnostic testing program that provides a reward for participation and does not base any part of the reward on outcomes.
I|J|1901.(a)(2)(h)(3)(C)
A program that encourages preventive care through the waiver of the copayment or deductible requirement under a group health plan for the costs of, for example, prenatal care or well-baby visits.
I|J|1901.(a)(2)(h)(3)(D)
A program that reimburses employees for the costs of smoking cessation programs without regard to whether the employee quits smoking.
I|J|1901.(a)(2)(h)(3)(E)
A program that provides a reward to employees for attending a monthly health education seminar.
I|J|1901.(a)(2)(h)(4)
Wellness programs subject to requirements If any of the conditions for obtaining a reward under a wellness program is based on an individual satisfying a standard that is related to a health factor, the wellness program shall not violate this section if the requirements of this paragraph are satisfied.
I|J|1901.(a)(2)(h)(4)(A)
The reward for the wellness program, coupled with the reward for other wellness programs with respect to the plan that require satisfaction of a standard related to a health factor, shall not exceed 30 percent of the cost of employee-only coverage under the plan. However, if, in addition to employees, any class of dependents (such as spouses or spouses and dependent children) may participate in the wellness program, the reward shall not exceed 30 percent of the cost of the coverage in which an employee and any dependents are enrolled. For purposes of this paragraph, the cost of coverage shall be determined based on the total amount of employer and employee contributions for the benefit package under which the employee is (or the employee and any dependents are) receiving coverage. A reward may be in the form of a discount or rebate of a premium or contribution, a waiver of all or part of a cost-sharing mechanism (such as deductibles, copayments, or coinsurance), the absence of a surcharge, or the value of a benefit that would otherwise not be provided under the plan. The Secretaries of Labor, Health and Human Services, and the Treasury may increase the reward available under this subparagraph to up to 50 percent of the cost of coverage under the plan if such Secretaries determine that such an increase is appropriate.
I|J|1901.(a)(2)(h)(4)(B)
The wellness program shall be reasonably designed to promote health or prevent disease. A program satisfies this subparagraph if it has a reasonable chance of improving the health of or preventing disease in participating individuals and it is not overly burdensome, is not a subterfuge for discriminating based on a health factor, and is not highly suspect in the method chosen to promote health or prevent disease. At least once per year, each plan or issuer offering a wellness program shall evaluate the reasonableness of such program.
I|J|1901.(a)(2)(h)(4)(C)
The program shall give individuals eligible for the program the opportunity to qualify for the reward under the program at least once per year.
I|J|1901.(a)(2)(h)(4)(D)
I|J|1901.(a)(2)(h)(4)(D)(i)
The reward under the program shall be available to all similarly situated individuals.
I|J|1901.(a)(2)(h)(4)(D)(ii)
For purposes of clause (i), a reward is not available to all similarly situated individuals for a period unless the program allows -
I|J|1901.(a)(2)(h)(4)(D)(ii)(I)
a reasonable alternative standard (or waiver of the otherwise applicable standard) for obtaining the reward for any individual for whom, for that period, it is unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard; and
I|J|1901.(a)(2)(h)(4)(D)(ii)(II)
a reasonable alternative standard (or waiver of the otherwise applicable standard) for obtaining the reward for any individual for whom, for that period, it is medically inadvisable to attempt to satisfy the otherwise applicable standard.
I|J|1901.(a)(2)(h)(4)(D)(iii)
A plan or issuer may seek verification, such as a statement from an individual's physician, that a health factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard.
I|J|1901.(a)(2)(h)(4)(E)
I|J|1901.(a)(2)(h)(4)(E)(i)
The plan or issuer shall disclose in all plan materials describing the terms of the program the availability of a reasonable alternative standard (or the possibility of waiver of the otherwise applicable standard) required under subparagraph (D). If plan materials merely mention that a program is available, without describing its terms, such disclosure is not required.
I|J|1901.(a)(2)(h)(4)(E)(ii)
The following language, or similar language, may be used to satisfy the requirement of this subparagraph: If it is unreasonably difficult due to a medical condition for you to achieve the standards for the reward under this program, or if it is medically inadvisable for you to attempt to achieve the standards for the reward under this program, call us at [insert telephone number] and we will work with you to develop another way to qualify for the reward. .
I|J|1901.(a)(2)(h)(5)
Regulations The Secretaries of Labor, Health and Human Services, and the Treasury may promulgate regulations, as appropriate, to carry out this subsection.
I|J|1901.(a)(2)(h)(6)
Effective date This subsection shall take effect on the date of enactment of the America's Healthy Future Act of 2009.
I|J|1901.(a)(2)(h)(7)
Existing wellness programs During the period of time between the date of enactment of the America's Healthy Future Act of 2009 and the date on which the Secretaries of Labor, Health and Human Services, and the Treasury establish regulations to effectuate this subsection, a wellness program that was established prior to the date of enactment of the America's Healthy Future Act of 2009 may continue to operate in accordance with the requirements in effect on the day before such date of enactment.
.
I|J|1901.(b)
PHSA group market Section 2702(b) of the Public Health Service Act ( 42 U.S.C. 300gg-1(b) ) is amended by adding at the end the following:
I|J|1901.(b)(4)
Programs of health promotion and disease prevention The provisions of section 9802(h) of the Internal Revenue Code of 1986 shall apply to programs of health promotion and disease prevention offered through a group health plan or a health insurance issuer offering group health insurance coverage. .
I|J|1901.(c)
ERISA Section 702(b) of the Employee Retirement Income Security Act of 1974 ( 29 U.S.C. 1182(b) ) is amended by adding at the end the following:
I|J|1901.(c)(4)
Programs of health promotion and disease prevention The provisions of section 9802(h) of the Internal Revenue Code of 1986 shall apply to programs of health promotion and disease prevention offered through a group health plan or a health insurance issuer offering group health insurance coverage. .
I|J|1901.(d)
Application of wellness programs provisions to carriers providing Federal employee health benefits plans
I|J|1901.(d)(1)
In General Notwithstanding section 8906 of title 5, United States Code (including subsections (b)(1) and (b)(2) of such section), subsections (a), (b), and (c) of this section, including the amendments made by those subsections, (relating to wellness programs) shall apply to carriers entering into contracts under section 8902 of title 5, United States Code.
I|J|1901.(d)(2)
Proposals Carriers may submit separate proposals relating to voluntary wellness program offerings as part of the annual call for benefit and rate proposals to the Office of Personnel Management.
I|J|1901.(d)(3)
Effective date This subsection shall take effect on the date of enactment of this Act and shall apply to contracts entered into under section 8902 of title 5, United States Code, that take effect with respect to calendar years that begin more than 1 year after that date.
I|J|1901.(e)
State demonstration project Subpart 1 of part B of title XXVII of the Public Health Service Act ( 42 U.S.C. 300gg-41 et seq. ) is amended by adding at the end the following:
I|J|1901.(e)2746.
Wellness program demonstration project
I|J|1901.(e)2746.(a)
In general Not later than July 1, 2014, the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury, shall establish a 10-State demonstration project under which participating States shall apply the provisions of 9802(h) of the Internal Revenue Code of 1986 to programs of health promotion offered by a health insurance issuer that offers health insurance coverage in the individual market in such State.
I|J|1901.(e)2746.(b)
Expansion of demonstration project If the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury, determines that the demonstration project described in subsection (a) is effective, such Secretaries may, beginning on July 1, 2017 expand such demonstration project to include additional participating States.
I|J|1901.(e)2746.(c)
Requirements States that participate in the demonstration project under this section shall -
I|J|1901.(e)2746.(c)(1)
ensure that requirements of consumer protection are met in programs of health promotion in the individual market;
I|J|1901.(e)2746.(c)(2)
require verification from health insurance issuers that offer health insurance coverage in the individual market of such State that premium discounts -
I|J|1901.(e)2746.(c)(2)(A)
do not create undue burdens for individuals insured in the individual market;
I|J|1901.(e)2746.(c)(2)(B)
do not lead to cost shifting; and
I|J|1901.(e)2746.(c)(2)(C)
are not a subterfuge for discrimination; and
I|J|1901.(e)2746.(c)(3)
ensure that consumer data is protected in accordance with the requirements of section 264(c) of the Health Insurance Portability and Accountability Act of 1996 ( 42 U.S.C. 1320d-2 note).
I|J|1901.(e)2746.(d)
Existing programs of health promotion or disease prevention Nothing in this section shall preempt any State law related to programs of health promotion offered by a health insurance issuer that offers health insurance coverage in the individual market in such State that was established or adopted by State law on or after the date of enactment of this Act.
I|J|1901.(e)2746.(e)
Regulations The Secretaries of Health and Human Services and the Treasury may promulgate regulations, as appropriate, to carry out this section.
.
I|J|1901.(f)
Report
I|J|1901.(f)(1)
In general Not later than 3 years after the date of enactment of this Act, the Secretary of Health and Human Services, in consultation with the Secretary of the Treasury and the Secretary of Labor, shall submit a report to the appropriate committees of Congress concerning -
I|J|1901.(f)(1)(A)
the effectiveness of wellness programs (as defined in section 9802(h)(2) of the Internal Revenue Code of 1986, as added by subsection (a)) in promoting health and preventing disease;
I|J|1901.(f)(1)(B)
the impact of such wellness programs on the access to care and affordability of coverage for participants and non-participants of such programs;
I|J|1901.(f)(1)(C)
the impact of premium-based and cost-sharing incentives on participant behavior and the role of such programs in changing behavior; and
I|J|1901.(f)(1)(D)
the effectiveness of different types of rewards.
I|J|1901.(f)(2)
Data collection In preparing the report described in paragraph (1), the Secretaries shall gather relevant information from employers who provide employees with access to wellness programs, including State and Federal agencies.
I|K
Elder Justice Act
I|K|1911.
Short title of subtitle This subtitle may be cited as the Elder Justice Act of 2009 .
I|K|1912.
Definitions Except as otherwise specifically provided, any term that is defined in section 2011 of the Social Security Act (as added by section 1913(a)) and is used in this subtitle has the meaning given such term by such section.
I|K|1913.
Elder Justice
I|K|1913.(a)
Elder justice
I|K|1913.(a)(1)
In General Title XX of the Social Security Act ( 42 U.S.C. 1397 et seq. ) is amended -
I|K|1913.(a)(1)(A)
in the heading, by inserting and elder justice after social services ;
I|K|1913.(a)(1)(B)
by inserting before section 2001 the following:
I|K|1913.(a)(1)(B)A
Block grants to states for social services ; and
I|K|1913.(a)(1)(C)
by adding at the end the following:
I|K|1913.(a)(1)(C)B
Elder justice
I|K|1913.(a)(1)(C)B|2011.
Definitions In this subtitle:
I|K|1913.(a)(1)(C)B|2011.(1)
Abuse The term abuse means the knowing infliction of physical or psychological harm or the knowing deprivation of goods or services that are necessary to meet essential needs or to avoid physical or psychological harm.
I|K|1913.(a)(1)(C)B|2011.(2)
Adult protective services The term adult protective services means such services provided to adults as the Secretary may specify and includes services such as -
I|K|1913.(a)(1)(C)B|2011.(2)(A)
receiving reports of adult abuse, neglect, or exploitation;
I|K|1913.(a)(1)(C)B|2011.(2)(B)
investigating the reports described in subparagraph (A);
I|K|1913.(a)(1)(C)B|2011.(2)(C)
case planning, monitoring, evaluation, and other case work and services; and
I|K|1913.(a)(1)(C)B|2011.(2)(D)
providing, arranging for, or facilitating the provision of medical, social service, economic, legal, housing, law enforcement, or other protective, emergency, or support services.
I|K|1913.(a)(1)(C)B|2011.(3)
Caregiver The term caregiver means an individual who has the responsibility for the care of an elder, either voluntarily, by contract, by receipt of payment for care, or as a result of the operation of law, and means a family member or other individual who provides (on behalf of such individual or of a public or private agency, organization, or institution) compensated or uncompensated care to an elder who needs supportive services in any setting.
I|K|1913.(a)(1)(C)B|2011.(4)
Direct care The term direct care means care by an employee or contractor who provides assistance or long-term care services to a recipient.
I|K|1913.(a)(1)(C)B|2011.(5)
Elder The term elder means an individual age 60 or older.
I|K|1913.(a)(1)(C)B|2011.(6)
Elder justice The term elder justice means -
I|K|1913.(a)(1)(C)B|2011.(6)(A)
from a societal perspective, efforts to -
I|K|1913.(a)(1)(C)B|2011.(6)(A)(i)
prevent, detect, treat, intervene in, and prosecute elder abuse, neglect, and exploitation; and
I|K|1913.(a)(1)(C)B|2011.(6)(A)(ii)
protect elders with diminished capacity while maximizing their autonomy; and
I|K|1913.(a)(1)(C)B|2011.(6)(B)
from an individual perspective, the recognition of an elder's rights, including the right to be free of abuse, neglect, and exploitation.
I|K|1913.(a)(1)(C)B|2011.(7)
Eligible entity The term eligible entity means a State or local government agency, Indian tribe or tribal organization, or any other public or private entity that is engaged in and has expertise in issues relating to elder justice or in a field necessary to promote elder justice efforts.
I|K|1913.(a)(1)(C)B|2011.(8)
Exploitation The term exploitation means the fraudulent or otherwise illegal, unauthorized, or improper act or process of an individual, including a caregiver or fiduciary, that uses the resources of an elder for monetary or personal benefit, profit, or gain, or that results in depriving an elder of rightful access to, or use of, benefits, resources, belongings, or assets.
I|K|1913.(a)(1)(C)B|2011.(9)
Fiduciary The term fiduciary -
I|K|1913.(a)(1)(C)B|2011.(9)(A)
means a person or entity with the legal responsibility -
I|K|1913.(a)(1)(C)B|2011.(9)(A)(i)
to make decisions on behalf of and for the benefit of another person; and
I|K|1913.(a)(1)(C)B|2011.(9)(A)(ii)
to act in good faith and with fairness; and
I|K|1913.(a)(1)(C)B|2011.(9)(B)
includes a trustee, a guardian, a conservator, an executor, an agent under a financial power of attorney or health care power of attorney, or a representative payee.
I|K|1913.(a)(1)(C)B|2011.(10)
Grant The term grant includes a contract, cooperative agreement, or other mechanism for providing financial assistance.
I|K|1913.(a)(1)(C)B|2011.(11)
Guardianship The term guardianship means -
I|K|1913.(a)(1)(C)B|2011.(11)(A)
the process by which a State court determines that an adult individual lacks capacity to make decisions about self-care or property, and appoints another individual or entity known as a guardian, as a conservator, or by a similar term, as a surrogate decisionmaker;
I|K|1913.(a)(1)(C)B|2011.(11)(B)
the manner in which the court-appointed surrogate decisionmaker carries out duties to the individual and the court; or
I|K|1913.(a)(1)(C)B|2011.(11)(C)
the manner in which the court exercises oversight of the surrogate decisionmaker.
I|K|1913.(a)(1)(C)B|2011.(12)
Indian tribe
I|K|1913.(a)(1)(C)B|2011.(12)(A)
In general The term Indian tribe has the meaning given such term in section 4 of the Indian Self-Determination and Education Assistance Act ( 25 U.S.C. 450b ).
I|K|1913.(a)(1)(C)B|2011.(12)(B)
Inclusion of Pueblo and Rancheria The term Indian tribe includes any Pueblo or Rancheria.
I|K|1913.(a)(1)(C)B|2011.(13)
Law enforcement The term law enforcement means the full range of potential responders to elder abuse, neglect, and exploitation including -
I|K|1913.(a)(1)(C)B|2011.(13)(A)
police, sheriffs, detectives, public safety officers, and corrections personnel;
I|K|1913.(a)(1)(C)B|2011.(13)(B)
prosecutors;
I|K|1913.(a)(1)(C)B|2011.(13)(C)
medical examiners;
I|K|1913.(a)(1)(C)B|2011.(13)(D)
investigators; and
I|K|1913.(a)(1)(C)B|2011.(13)(E)
coroners.
I|K|1913.(a)(1)(C)B|2011.(14)
Long-term care
I|K|1913.(a)(1)(C)B|2011.(14)(A)
In general The term long-term care means supportive and health services specified by the Secretary for individuals who need assistance because the individuals have a loss of capacity for self-care due to illness, disability, or vulnerability.
I|K|1913.(a)(1)(C)B|2011.(14)(B)
Loss of capacity for self-care For purposes of subparagraph (A), the term loss of capacity for self-care means an inability to engage in 1 or more activities of daily living, including eating, dressing, bathing, management of one's financial affairs, and other activities the Secretary determines appropriate.
I|K|1913.(a)(1)(C)B|2011.(15)
Long-term care facility The term long-term care facility means a residential care provider that arranges for, or directly provides, long-term care.
I|K|1913.(a)(1)(C)B|2011.(16)
Neglect The term neglect means -
I|K|1913.(a)(1)(C)B|2011.(16)(A)
the failure of a caregiver or fiduciary to provide the goods or services that are necessary to maintain the health or safety of an elder; or
I|K|1913.(a)(1)(C)B|2011.(16)(B)
self-neglect.
I|K|1913.(a)(1)(C)B|2011.(17)
Nursing facility
I|K|1913.(a)(1)(C)B|2011.(17)(A)
In general The term nursing facility has the meaning given such term under section 1919(a).
I|K|1913.(a)(1)(C)B|2011.(17)(B)
Inclusion of skilled nursing facility The term nursing facility includes a skilled nursing facility (as defined in section 1819(a)).
I|K|1913.(a)(1)(C)B|2011.(18)
Self-neglect The term self-neglect means an adult's inability, due to physical or mental impairment or diminished capacity, to perform essential self-care tasks including -
I|K|1913.(a)(1)(C)B|2011.(18)(A)
obtaining essential food, clothing, shelter, and medical care;
I|K|1913.(a)(1)(C)B|2011.(18)(B)
obtaining goods and services necessary to maintain physical health, mental health, or general safety; or
I|K|1913.(a)(1)(C)B|2011.(18)(C)
managing one's own financial affairs.
I|K|1913.(a)(1)(C)B|2011.(19)
Serious bodily injury
I|K|1913.(a)(1)(C)B|2011.(19)(A)
In general The term serious bodily injury means an injury -
I|K|1913.(a)(1)(C)B|2011.(19)(A)(i)
involving extreme physical pain;
I|K|1913.(a)(1)(C)B|2011.(19)(A)(ii)
involving substantial risk of death;
I|K|1913.(a)(1)(C)B|2011.(19)(A)(iii)
involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; or
I|K|1913.(a)(1)(C)B|2011.(19)(A)(iv)
requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.
I|K|1913.(a)(1)(C)B|2011.(19)(B)
Criminal sexual abuse Serious bodily injury shall be considered to have occurred if the conduct causing the injury is conduct described in section 2241 (relating to aggravated sexual abuse) or 2242 (relating to sexual abuse) of title 18, United States Code, or any similar offense under State law.
I|K|1913.(a)(1)(C)B|2011.(20)
Social The term social , when used with respect to a service, includes adult protective services.
I|K|1913.(a)(1)(C)B|2011.(21)
State legal assistance developer The term State legal assistance developer means an individual described in section 731 of the Older Americans Act of 1965 .
I|K|1913.(a)(1)(C)B|2011.(22)
State long-term care ombudsman The term State Long-Term Care Ombudsman means the State Long-Term Care Ombudsman described in section 712(a)(2) of the Older Americans Act of 1965 .
I|K|1913.(a)(1)(C)B|2012.
General provisions
I|K|1913.(a)(1)(C)B|2012.(a)
Protection of Privacy In pursuing activities under this subtitle, the Secretary shall ensure the protection of individual health privacy consistent with the regulations promulgated under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 and applicable State and local privacy regulations.
I|K|1913.(a)(1)(C)B|2012.(b)
Rule of construction Nothing in this subtitle shall be construed to interfere with or abridge an elder's right to practice his or her religion through reliance on prayer alone for healing when this choice -
I|K|1913.(a)(1)(C)B|2012.(b)(1)
is contemporaneously expressed, either orally or in writing, with respect to a specific illness or injury which the elder has at the time of the decision by an elder who is competent at the time of the decision;
I|K|1913.(a)(1)(C)B|2012.(b)(2)
is previously set forth in a living will, health care proxy, or other advance directive document that is validly executed and applied under State law; or
I|K|1913.(a)(1)(C)B|2012.(b)(3)
may be unambiguously deduced from the elder's life history.
I|K|1913.(a)(1)(C)B|I
National Coordination of Elder Justice Activities and Research
I|K|1913.(a)(1)(C)B|I|A
Elder Justice Coordinating Council and Advisory Board on Elder Abuse, Neglect, and Exploitation
I|K|1913.(a)(1)(C)B|I|A|2021.
Elder Justice Coordinating Council
I|K|1913.(a)(1)(C)B|I|A|2021.(a)
Establishment There is established within the Office of the Secretary an Elder Justice Coordinating Council (in this section referred to as the Council ).
I|K|1913.(a)(1)(C)B|I|A|2021.(b)
Membership
I|K|1913.(a)(1)(C)B|I|A|2021.(b)(1)
In general The Council shall be composed of the following members:
I|K|1913.(a)(1)(C)B|I|A|2021.(b)(1)(A)
The Secretary (or the Secretary's designee).
I|K|1913.(a)(1)(C)B|I|A|2021.(b)(1)(B)
The Attorney General (or the Attorney General's designee).
I|K|1913.(a)(1)(C)B|I|A|2021.(b)(1)(C)
The head of each Federal department or agency or other governmental entity identified by the Chair referred to in subsection (d) as having responsibilities, or administering programs, relating to elder abuse, neglect, and exploitation.
I|K|1913.(a)(1)(C)B|I|A|2021.(b)(2)
Requirement Each member of the Council shall be an officer or employee of the Federal Government.
I|K|1913.(a)(1)(C)B|I|A|2021.(c)
Vacancies Any vacancy in the Council shall not affect its powers, but shall be filled in the same manner as the original appointment was made.
I|K|1913.(a)(1)(C)B|I|A|2021.(d)
Chair The member described in subsection (b)(1)(A) shall be Chair of the Council.
I|K|1913.(a)(1)(C)B|I|A|2021.(e)
Meetings The Council shall meet at least 2 times per year, as determined by the Chair.
I|K|1913.(a)(1)(C)B|I|A|2021.(f)
Duties
I|K|1913.(a)(1)(C)B|I|A|2021.(f)(1)
In general The Council shall make recommendations to the Secretary for the coordination of activities of the Department of Health and Human Services, the Department of Justice, and other relevant Federal, State, local, and private agencies and entities, relating to elder abuse, neglect, and exploitation and other crimes against elders.
I|K|1913.(a)(1)(C)B|I|A|2021.(f)(2)
Report Not later than the date that is 2 years after the date of enactment of the Elder Justice Act of 2009 and every 2 years thereafter, the Council shall submit to the Committee on Finance of the Senate and the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives a report that -
I|K|1913.(a)(1)(C)B|I|A|2021.(f)(2)(A)
describes the activities and accomplishments of, and challenges faced by -
I|K|1913.(a)(1)(C)B|I|A|2021.(f)(2)(A)(i)
the Council; and
I|K|1913.(a)(1)(C)B|I|A|2021.(f)(2)(A)(ii)
the entities represented on the Council; and
I|K|1913.(a)(1)(C)B|I|A|2021.(f)(2)(B)
makes such recommendations for legislation, model laws, or other action as the Council determines to be appropriate.
I|K|1913.(a)(1)(C)B|I|A|2021.(g)
Powers of the Council
I|K|1913.(a)(1)(C)B|I|A|2021.(g)(1)
Information from federal agencies Subject to the requirements of section 2012(a), the Council may secure directly from any Federal department or agency such information as the Council considers necessary to carry out this section. Upon request of the Chair of the Council, the head of such department or agency shall furnish such information to the Council.
I|K|1913.(a)(1)(C)B|I|A|2021.(g)(2)
Postal services The Council may use the United States mails in the same manner and under the same conditions as other departments and agencies of the Federal Government.
I|K|1913.(a)(1)(C)B|I|A|2021.(h)
Travel Expenses The members of the Council shall not receive compensation for the performance of services for the Council. The members shall be allowed travel expenses, including per diem in lieu of subsistence, at rates authorized for employees of agencies under subchapter I of chapter 57 of title 5, United States Code, while away from their homes or regular places of business in the performance of services for the Council. Notwithstanding section 1342 of title 31, United States Code, the Secretary may accept the voluntary and uncompensated services of the members of the Council.
I|K|1913.(a)(1)(C)B|I|A|2021.(i)
Detail of Government Employees Any Federal Government employee may be detailed to the Council without reimbursement, and such detail shall be without interruption or loss of civil service status or privilege.
I|K|1913.(a)(1)(C)B|I|A|2021.(j)
Status as Permanent Council Section 14 of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the Council.
I|K|1913.(a)(1)(C)B|I|A|2021.(k)
Authorization of appropriations There are authorized to be appropriated such sums as are necessary to carry out this section.
I|K|1913.(a)(1)(C)B|I|A|2022.
Advisory Board on Elder Abuse, Neglect, and Exploitation
I|K|1913.(a)(1)(C)B|I|A|2022.(a)
Establishment There is established a board to be known as the Advisory Board on Elder Abuse, Neglect, and Exploitation (in this section referred to as the Advisory Board ) to create short- and long-term multidisciplinary strategic plans for the development of the field of elder justice and to make recommendations to the Elder Justice Coordinating Council established under section 2021.
I|K|1913.(a)(1)(C)B|I|A|2022.(b)
Composition The Advisory Board shall be composed of 27 members appointed by the Secretary from among members of the general public who are individuals with experience and expertise in elder abuse, neglect, and exploitation prevention, detection, treatment, intervention, or prosecution.
I|K|1913.(a)(1)(C)B|I|A|2022.(c)
Solicitation of Nominations The Secretary shall publish a notice in the Federal Register soliciting nominations for the appointment of members of the Advisory Board under subsection (b).
I|K|1913.(a)(1)(C)B|I|A|2022.(d)
Terms
I|K|1913.(a)(1)(C)B|I|A|2022.(d)(1)
In general Each member of the Advisory Board shall be appointed for a term of 3 years, except that, of the members first appointed -
I|K|1913.(a)(1)(C)B|I|A|2022.(d)(1)(A)
9 shall be appointed for a term of 3 years;
I|K|1913.(a)(1)(C)B|I|A|2022.(d)(1)(B)
9 shall be appointed for a term of 2 years; and
I|K|1913.(a)(1)(C)B|I|A|2022.(d)(1)(C)
9 shall be appointed for a term of 1 year.
I|K|1913.(a)(1)(C)B|I|A|2022.(d)(2)
Vacancies
I|K|1913.(a)(1)(C)B|I|A|2022.(d)(2)(A)
In general Any vacancy on the Advisory Board shall not affect its powers, but shall be filled in the same manner as the original appointment was made.
I|K|1913.(a)(1)(C)B|I|A|2022.(d)(2)(B)
Filling unexpired term An individual chosen to fill a vacancy shall be appointed for the unexpired term of the member replaced.
I|K|1913.(a)(1)(C)B|I|A|2022.(d)(3)
Expiration of terms The term of any member shall not expire before the date on which the member's successor takes office.
I|K|1913.(a)(1)(C)B|I|A|2022.(e)
Election of Officers The Advisory Board shall elect a Chair and Vice Chair from among its members. The Advisory Board shall elect its initial Chair and Vice Chair at its initial meeting.
I|K|1913.(a)(1)(C)B|I|A|2022.(f)
Duties
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(1)
Enhance communication on promoting quality of, and preventing abuse, neglect, and exploitation in, Long-Term care The Advisory Board shall develop collaborative and innovative approaches to improve the quality of, including preventing abuse, neglect, and exploitation in, long-term care.
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(2)
Collaborative efforts to develop consensus around the management of certain quality-related factors
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(2)(A)
In general The Advisory Board shall establish multidisciplinary panels to address, and develop consensus on, subjects relating to improving the quality of long-term care. At least 1 such panel shall address, and develop consensus on, methods for managing resident-to-resident abuse in long-term care.
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(2)(B)
Activities conducted The multidisciplinary panels established under subparagraph (A) shall examine relevant research and data, identify best practices with respect to the subject of the panel, determine the best way to carry out those best practices in a practical and feasible manner, and determine an effective manner of distributing information on such subject.
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(3)
Report Not later than the date that is 18 months after the date of enactment of the Elder Justice Act of 2009 , and annually thereafter, the Advisory Board shall prepare and submit to the Elder Justice Coordinating Council, the Committee on Finance of the Senate, and the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives a report containing -
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(3)(A)
information on the status of Federal, State, and local public and private elder justice activities;
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(3)(B)
recommendations (including recommended priorities) regarding -
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(3)(B)(i)
elder justice programs, research, training, services, practice, enforcement, and coordination;
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(3)(B)(ii)
coordination between entities pursuing elder justice efforts and those involved in related areas that may inform or overlap with elder justice efforts, such as activities to combat violence against women and child abuse and neglect; and
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(3)(B)(iii)
activities relating to adult fiduciary systems, including guardianship and other fiduciary arrangements;
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(3)(C)
recommendations for specific modifications needed in Federal and State laws (including regulations) or for programs, research, and training to enhance prevention, detection, and treatment (including diagnosis) of, intervention in (including investigation of), and prosecution of elder abuse, neglect, and exploitation;
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(3)(D)
recommendations on methods for the most effective coordinated national data collection with respect to elder justice, and elder abuse, neglect, and exploitation; and
I|K|1913.(a)(1)(C)B|I|A|2022.(f)(3)(E)
recommendations for a multidisciplinary strategic plan to guide the effective and efficient development of the field of elder justice.
I|K|1913.(a)(1)(C)B|I|A|2022.(g)
Powers of the Advisory Board
I|K|1913.(a)(1)(C)B|I|A|2022.(g)(1)
Information from federal agencies Subject to the requirements of section 2012(a), the Advisory Board may secure directly from any Federal department or agency such information as the Advisory Board considers necessary to carry out this section. Upon request of the Chair of the Advisory Board, the head of such department or agency shall furnish such information to the Advisory Board.
I|K|1913.(a)(1)(C)B|I|A|2022.(g)(2)
Sharing of data and reports The Advisory Board may request from any entity pursuing elder justice activities under the Elder Justice Act of 2009 or an amendment made by that Act, any data, reports, or recommendations generated in connection with such activities.
I|K|1913.(a)(1)(C)B|I|A|2022.(g)(3)
Postal services The Advisory Board may use the United States mails in the same manner and under the same conditions as other departments and agencies of the Federal Government.
I|K|1913.(a)(1)(C)B|I|A|2022.(h)
Travel Expenses The members of the Advisory Board shall not receive compensation for the performance of services for the Advisory Board. The members shall be allowed travel expenses for up to 4 meetings per year, including per diem in lieu of subsistence, at rates authorized for employees of agencies under subchapter I of chapter 57 of title 5, United States Code, while away from their homes or regular places of business in the performance of services for the Advisory Board. Notwithstanding section 1342 of title 31, United States Code, the Secretary may accept the voluntary and uncompensated services of the members of the Advisory Board.
I|K|1913.(a)(1)(C)B|I|A|2022.(i)
Detail of Government Employees Any Federal Government employee may be detailed to the Advisory Board without reimbursement, and such detail shall be without interruption or loss of civil service status or privilege.
I|K|1913.(a)(1)(C)B|I|A|2022.(j)
Status as Permanent Advisory Committee Section 14 of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the advisory board.
I|K|1913.(a)(1)(C)B|I|A|2022.(k)
Authorization of appropriations There are authorized to be appropriated such sums as are necessary to carry out this section.
I|K|1913.(a)(1)(C)B|I|A|2023.
Research protections
I|K|1913.(a)(1)(C)B|I|A|2023.(a)
Guidelines The Secretary shall promulgate guidelines to assist researchers working in the area of elder abuse, neglect, and exploitation, with issues relating to human subject protections.
I|K|1913.(a)(1)(C)B|I|A|2023.(b)
Definition of legally authorized representative for application of regulations For purposes of the application of subpart A of part 46 of title 45, Code of Federal Regulations, to research conducted under this subpart, the term legally authorized representative means, unless otherwise provided by law, the individual or judicial or other body authorized under the applicable law to consent to medical treatment on behalf of another person.
I|K|1913.(a)(1)(C)B|I|A|2024.
Authorization of appropriations There are authorized to be appropriated to carry out this subpart -
I|K|1913.(a)(1)(C)B|I|A|2024.(1)
for fiscal year 2011, $6,500,000; and
I|K|1913.(a)(1)(C)B|I|A|2024.(2)
for each of fiscal years 2012 through 2014, $7,000,000.
I|K|1913.(a)(1)(C)B|I|B
Elder abuse, neglect, and exploitation forensic centers
I|K|1913.(a)(1)(C)B|I|B|2031.
Establishment and support of elder abuse, neglect, and Exploitation forensic Centers
I|K|1913.(a)(1)(C)B|I|B|2031.(a)
In general The Secretary, in consultation with the Attorney General, shall make grants to eligible entities to establish and operate stationary and mobile forensic centers, to develop forensic expertise regarding, and provide services relating to, elder abuse, neglect, and exploitation.
I|K|1913.(a)(1)(C)B|I|B|2031.(b)
Stationary forensic centers The Secretary shall make 4 of the grants described in subsection (a) to institutions of higher education with demonstrated expertise in forensics or commitment to preventing or treating elder abuse, neglect, or exploitation, to establish and operate stationary forensic centers.
I|K|1913.(a)(1)(C)B|I|B|2031.(c)
Mobile centers The Secretary shall make 6 of the grants described in subsection (a) to appropriate entities to establish and operate mobile forensic centers.
I|K|1913.(a)(1)(C)B|I|B|2031.(d)
Authorized Activities
I|K|1913.(a)(1)(C)B|I|B|2031.(d)(1)
Development of forensic markers and methodologies An eligible entity that receives a grant under this section shall use funds made available through the grant to assist in determining whether abuse, neglect, or exploitation occurred and whether a crime was committed and to conduct research to describe and disseminate information on -
I|K|1913.(a)(1)(C)B|I|B|2031.(d)(1)(A)
forensic markers that indicate a case in which elder abuse, neglect, or exploitation may have occurred; and
I|K|1913.(a)(1)(C)B|I|B|2031.(d)(1)(B)
methodologies for determining, in such a case, when and how health care, emergency service, social and protective services, and legal service providers should intervene and when the providers should report the case to law enforcement authorities.
I|K|1913.(a)(1)(C)B|I|B|2031.(d)(2)
Development of forensic expertise An eligible entity that receives a grant under this section shall use funds made available through the grant to develop forensic expertise regarding elder abuse, neglect, and exploitation in order to provide medical and forensic evaluation, therapeutic intervention, victim support and advocacy, case review, and case tracking.
I|K|1913.(a)(1)(C)B|I|B|2031.(d)(3)
Collection of evidence The Secretary, in coordination with the Attorney General, shall use data made available by grant recipients under this section to develop the capacity of geriatric health care professionals and law enforcement to collect forensic evidence, including collecting forensic evidence relating to a potential determination of elder abuse, neglect, or exploitation.
I|K|1913.(a)(1)(C)B|I|B|2031.(e)
Application To be eligible to receive a grant under this section, an entity shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require.
I|K|1913.(a)(1)(C)B|I|B|2031.(f)
Authorization of Appropriations There are authorized to be appropriated to carry out this section -
I|K|1913.(a)(1)(C)B|I|B|2031.(f)(1)
for fiscal year 2011, $4,000,000;
I|K|1913.(a)(1)(C)B|I|B|2031.(f)(2)
for fiscal year 2012, $6,000,000; and
I|K|1913.(a)(1)(C)B|I|B|2031.(f)(3)
for each of fiscal years 2013 and 2014, $8,000,000.
I|K|1913.(a)(1)(C)B|II
Programs To Promote Elder Justice
I|K|1913.(a)(1)(C)B|II|2041.
Enhancement of long-term care
I|K|1913.(a)(1)(C)B|II|2041.(a)
Grants and Incentives for Long-Term Care Staffing
I|K|1913.(a)(1)(C)B|II|2041.(a)(1)
In general The Secretary shall carry out activities, including activities described in paragraphs (2) and (3), to provide incentives for individuals to train for, seek, and maintain employment providing direct care in long-term care.
I|K|1913.(a)(1)(C)B|II|2041.(a)(2)
Specific programs to enhance training, recruitment, and retention of staff
I|K|1913.(a)(1)(C)B|II|2041.(a)(2)(A)
Coordination with secretary of labor to recruit and train long-term care staff The Secretary shall coordinate activities under this subsection with the Secretary of Labor in order to provide incentives for individuals to train for and seek employment providing direct care in long-term care.
I|K|1913.(a)(1)(C)B|II|2041.(a)(2)(B)
Career ladders and wage or benefit increases to increase staffing in long-term care
I|K|1913.(a)(1)(C)B|II|2041.(a)(2)(B)(i)
In general The Secretary shall make grants to eligible entities to carry out programs through which the entities -
I|K|1913.(a)(1)(C)B|II|2041.(a)(2)(B)(i)(I)
offer, to employees who provide direct care to residents of an eligible entity or individuals receiving community-based long-term care from an eligible entity, continuing training and varying levels of certification, based on observed clinical care practices and the amount of time the employees spend providing direct care; and
I|K|1913.(a)(1)(C)B|II|2041.(a)(2)(B)(i)(II)
provide, or make arrangements to provide, bonuses or other increased compensation or benefits to employees who achieve certification under such a program.
I|K|1913.(a)(1)(C)B|II|2041.(a)(2)(B)(ii)
Application To be eligible to receive a grant under this subparagraph, an eligible entity shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require (which may include evidence of consultation with the State in which the eligible entity is located with respect to carrying out activities funded under the grant).
I|K|1913.(a)(1)(C)B|II|2041.(a)(2)(B)(iii)
Authority to limit number of applicants Nothing in this subparagraph shall be construed as prohibiting the Secretary from limiting the number of applicants for a grant under this subparagraph.
I|K|1913.(a)(1)(C)B|II|2041.(a)(3)
Specific programs to improve management practices
I|K|1913.(a)(1)(C)B|II|2041.(a)(3)(A)
In general The Secretary shall make grants to eligible entities to enable the entities to provide training and technical assistance.
I|K|1913.(a)(1)(C)B|II|2041.(a)(3)(B)
Authorized activities An eligible entity that receives a grant under subparagraph (A) shall use funds made available through the grant to provide training and technical assistance regarding management practices using methods that are demonstrated to promote retention of individuals who provide direct care, such as -
I|K|1913.(a)(1)(C)B|II|2041.(a)(3)(B)(i)
the establishment of standard human resource policies that reward high performance, including policies that provide for improved wages and benefits on the basis of job reviews;
I|K|1913.(a)(1)(C)B|II|2041.(a)(3)(B)(ii)
the establishment of motivational and thoughtful work organization practices;
I|K|1913.(a)(1)(C)B|II|2041.(a)(3)(B)(iii)
the creation of a workplace culture that respects and values caregivers and their needs;
I|K|1913.(a)(1)(C)B|II|2041.(a)(3)(B)(iv)
the promotion of a workplace culture that respects the rights of residents of an eligible entity or individuals receiving community-based long-term care from an eligible entity and results in improved care for the residents or the individuals; and
I|K|1913.(a)(1)(C)B|II|2041.(a)(3)(B)(v)
the establishment of other programs that promote the provision of high quality care, such as a continuing education program that provides additional hours of training, including on-the-job training, for employees who are certified nurse aides.
I|K|1913.(a)(1)(C)B|II|2041.(a)(3)(C)
Application To be eligible to receive a grant under this paragraph, an eligible entity shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require (which may include evidence of consultation with the State in which the eligible entity is located with respect to carrying out activities funded under the grant).
I|K|1913.(a)(1)(C)B|II|2041.(a)(3)(D)
Authority to limit number of applicants Nothing in this paragraph shall be construed as prohibiting the Secretary from limiting the number of applicants for a grant under this paragraph.
I|K|1913.(a)(1)(C)B|II|2041.(a)(4)
Accountability measures The Secretary shall develop accountability measures to ensure that the activities conducted using funds made available under this subsection benefit individuals who provide direct care and increase the stability of the long-term care workforce.
I|K|1913.(a)(1)(C)B|II|2041.(a)(5)
Definitions In this subsection:
I|K|1913.(a)(1)(C)B|II|2041.(a)(5)(A)
Community-based long-term care The term community-based long-term care has the meaning given such term by the Secretary.
I|K|1913.(a)(1)(C)B|II|2041.(a)(5)(B)
Eligible entity The term eligible entity means the following:
I|K|1913.(a)(1)(C)B|II|2041.(a)(5)(B)(i)
A long-term care facility.
I|K|1913.(a)(1)(C)B|II|2041.(a)(5)(B)(ii)
A community-based long-term care entity (as defined by the Secretary).
I|K|1913.(a)(1)(C)B|II|2041.(b)
Certified EHR technology Grant Program
I|K|1913.(a)(1)(C)B|II|2041.(b)(1)
Grants authorized The Secretary is authorized to make grants to long-term care facilities for the purpose of assisting such entities in offsetting the costs related to purchasing, leasing, developing, and implementing certified EHR technology (as defined in section 1848(o)(4)) designed to improve patient safety and reduce adverse events and health care complications resulting from medication errors.
I|K|1913.(a)(1)(C)B|II|2041.(b)(2)
Use of grant funds Funds provided under grants under this subsection may be used for any of the following:
I|K|1913.(a)(1)(C)B|II|2041.(b)(2)(A)
Purchasing, leasing, and installing computer software and hardware, including handheld computer technologies.
I|K|1913.(a)(1)(C)B|II|2041.(b)(2)(B)
Making improvements to existing computer software and hardware.
I|K|1913.(a)(1)(C)B|II|2041.(b)(2)(C)
Making upgrades and other improvements to existing computer software and hardware to enable e-prescribing.
I|K|1913.(a)(1)(C)B|II|2041.(b)(2)(D)
Providing education and training to eligible long-term care facility staff on the use of such technology to implement the electronic transmission of prescription and patient information.
I|K|1913.(a)(1)(C)B|II|2041.(b)(3)
Application
I|K|1913.(a)(1)(C)B|II|2041.(b)(3)(A)
In general To be eligible to receive a grant under this subsection, a long-term care facility shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require (which may include evidence of consultation with the State in which the long-term care facility is located with respect to carrying out activities funded under the grant).
I|K|1913.(a)(1)(C)B|II|2041.(b)(3)(B)
Authority to limit number of applicants Nothing in this subsection shall be construed as prohibiting the Secretary from limiting the number of applicants for a grant under this subsection.
I|K|1913.(a)(1)(C)B|II|2041.(b)(4)
Participation in state health exchanges A long-term care facility that receives a grant under this subsection shall, where available, participate in activities conducted by a State or a qualified State-designated entity (as defined in section 3013(f) of the Public Health Service Act) under a grant under section 3013 of the Public Health Service Act to coordinate care and for other purposes determined appropriate by the Secretary.
I|K|1913.(a)(1)(C)B|II|2041.(b)(5)
Accountability measures The Secretary shall develop accountability measures to ensure that the activities conducted using funds made available under this subsection help improve patient safety and reduce adverse events and health care complications resulting from medication errors.
I|K|1913.(a)(1)(C)B|II|2041.(c)
Adoption of Standards for Transactions Involving Clinical Data by Long-Term Care Facilities
I|K|1913.(a)(1)(C)B|II|2041.(c)(1)
Standards and compatibility The Secretary shall adopt electronic standards for the exchange of clinical data by long-term care facilities, including, where available, standards for messaging and nomenclature. Standards adopted by the Secretary under the preceding sentence shall be compatible with standards established under part C of title XI, standards established under subsections (b)(2)(B)(i) and (e)(4) of section 1860D-4, standards adopted under section 3004 of the Public Health Service Act, and general health information technology standards.
I|K|1913.(a)(1)(C)B|II|2041.(c)(2)
Electronic submission of data to the secretary
I|K|1913.(a)(1)(C)B|II|2041.(c)(2)(A)
In general Not later than 10 years after the date of enactment of the Elder Justice Act of 2009 , the Secretary shall have procedures in place to accept the optional electronic submission of clinical data by long-term care facilities pursuant to the standards adopted under paragraph (1).
I|K|1913.(a)(1)(C)B|II|2041.(c)(2)(B)
Rule of construction Nothing in this subsection shall be construed to require a long-term care facility to submit clinical data electronically to the Secretary.
I|K|1913.(a)(1)(C)B|II|2041.(c)(3)
Regulations The Secretary shall promulgate regulations to carry out this subsection. Such regulations shall require a State, as a condition of the receipt of funds under this part, to conduct such data collection and reporting as the Secretary determines are necessary to satisfy the requirements of this subsection.
I|K|1913.(a)(1)(C)B|II|2041.(d)
Authorization of Appropriations There are authorized to be appropriated to carry out this section -
I|K|1913.(a)(1)(C)B|II|2041.(d)(1)
for fiscal year 2011, $20,000,000;
I|K|1913.(a)(1)(C)B|II|2041.(d)(2)
for fiscal year 2012, $17,500,000; and
I|K|1913.(a)(1)(C)B|II|2041.(d)(3)
for each of fiscal years 2013 and 2014, $15,000,000.
I|K|1913.(a)(1)(C)B|II|2042.
Adult protective services functions and grant programs
I|K|1913.(a)(1)(C)B|II|2042.(a)
Secretarial responsibilities
I|K|1913.(a)(1)(C)B|II|2042.(a)(1)
In general The Secretary shall ensure that the Department of Health and Human Services -
I|K|1913.(a)(1)(C)B|II|2042.(a)(1)(A)
provides funding authorized by this part to State and local adult protective services offices that investigate reports of the abuse, neglect, and exploitation of elders;
I|K|1913.(a)(1)(C)B|II|2042.(a)(1)(B)
collects and disseminates data annually relating to the abuse, exploitation, and neglect of elders in coordination with the Department of Justice;
I|K|1913.(a)(1)(C)B|II|2042.(a)(1)(C)
develops and disseminates information on best practices regarding, and provides training on, carrying out adult protective services;
I|K|1913.(a)(1)(C)B|II|2042.(a)(1)(D)
conducts research related to the provision of adult protective services; and
I|K|1913.(a)(1)(C)B|II|2042.(a)(1)(E)
provides technical assistance to States and other entities that provide or fund the provision of adult protective services, including through grants made under subsections (b) and (c).
I|K|1913.(a)(1)(C)B|II|2042.(a)(2)
Authorization of appropriations There are authorized to be appropriated to carry out this subsection, $3,000,000 for fiscal year 2011 and $4,000,000 for each of fiscal years 2012 through 2014.
I|K|1913.(a)(1)(C)B|II|2042.(b)
Grants To enhance the provision of adult protective services
I|K|1913.(a)(1)(C)B|II|2042.(b)(1)
Establishment There is established an adult protective services grant program under which the Secretary shall annually award grants to States in the amounts calculated under paragraph (2) for the purposes of enhancing adult protective services provided by States and local units of government.
I|K|1913.(a)(1)(C)B|II|2042.(b)(2)
Amount of payment
I|K|1913.(a)(1)(C)B|II|2042.(b)(2)(A)
In general Subject to the availability of appropriations and subparagraphs (B) and (C), the amount paid to a State for a fiscal year under the program under this subsection shall equal the amount appropriated for that year to carry out this subsection multiplied by the percentage of the total number of elders who reside in the United States who reside in that State.
I|K|1913.(a)(1)(C)B|II|2042.(b)(2)(B)
Guaranteed minimum payment amount
I|K|1913.(a)(1)(C)B|II|2042.(b)(2)(B)(i)
50 states Subject to clause (ii), if the amount determined under subparagraph (A) for a State for a fiscal year is less than 0.75 percent of the amount appropriated for such year, the Secretary shall increase such determined amount so that the total amount paid under this subsection to the State for the year is equal to 0.75 percent of the amount so appropriated.
I|K|1913.(a)(1)(C)B|II|2042.(b)(2)(B)(ii)
Territories In the case of a State other than 1 of the 50 States, clause (i) shall be applied as if each reference to 0.75 were a reference to 0.1 .
I|K|1913.(a)(1)(C)B|II|2042.(b)(2)(C)
Pro rata reductions The Secretary shall make such pro rata reductions to the amounts described in subparagraph (A) as are necessary to comply with the requirements of subparagraph (B).
I|K|1913.(a)(1)(C)B|II|2042.(b)(3)
Authorized activities
I|K|1913.(a)(1)(C)B|II|2042.(b)(3)(A)
Adult protective services Funds made available pursuant to this subsection may only be used by States and local units of government to provide adult protective services and may not be used for any other purpose.
I|K|1913.(a)(1)(C)B|II|2042.(b)(3)(B)
Use by agency Each State receiving funds pursuant to this subsection shall provide such funds to the agency or unit of State government having legal responsibility for providing adult protective services within the State.
I|K|1913.(a)(1)(C)B|II|2042.(b)(3)(C)
Supplement not supplant Each State or local unit of government shall use funds made available pursuant to this subsection to supplement and not supplant other Federal, State, and local public funds expended to provide adult protective services in the State.
I|K|1913.(a)(1)(C)B|II|2042.(b)(4)
State reports Each State receiving funds under this subsection shall submit to the Secretary, at such time and in such manner as the Secretary may require, a report on the number of elders served by the grants awarded under this subsection.
I|K|1913.(a)(1)(C)B|II|2042.(b)(5)
Authorization of appropriations There are authorized to be appropriated to carry out this subsection, $100,000,000 for each of fiscal years 2011 through 2014.
I|K|1913.(a)(1)(C)B|II|2042.(c)
State Demonstration Programs
I|K|1913.(a)(1)(C)B|II|2042.(c)(1)
Establishment The Secretary shall award grants to States for the purposes of conducting demonstration programs in accordance with paragraph (2).
I|K|1913.(a)(1)(C)B|II|2042.(c)(2)
Demonstration programs Funds made available pursuant to this subsection may be used by States and local units of government to conduct demonstration programs that test -
I|K|1913.(a)(1)(C)B|II|2042.(c)(2)(A)
training modules developed for the purpose of detecting or preventing elder abuse;
I|K|1913.(a)(1)(C)B|II|2042.(c)(2)(B)
methods to detect or prevent financial exploitation of elders;
I|K|1913.(a)(1)(C)B|II|2042.(c)(2)(C)
methods to detect elder abuse;
I|K|1913.(a)(1)(C)B|II|2042.(c)(2)(D)
whether training on elder abuse forensics enhances the detection of elder abuse by employees of the State or local unit of government; or
I|K|1913.(a)(1)(C)B|II|2042.(c)(2)(E)
other matters relating to the detection or prevention of elder abuse.
I|K|1913.(a)(1)(C)B|II|2042.(c)(3)
Application To be eligible to receive a grant under this subsection, a State shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require.
I|K|1913.(a)(1)(C)B|II|2042.(c)(4)
State reports Each State that receives funds under this subsection shall submit to the Secretary a report at such time, in such manner, and containing such information as the Secretary may require on the results of the demonstration program conducted by the State using funds made available under this subsection.
I|K|1913.(a)(1)(C)B|II|2042.(c)(5)
Authorization of appropriations There are authorized to be appropriated to carry out this subsection, $25,000,000 for each of fiscal years 2011 through 2014.
I|K|1913.(a)(1)(C)B|II|2043.
Long-term care ombudsman program grants and training
I|K|1913.(a)(1)(C)B|II|2043.(a)
Grants To support the long-term care ombudsman program
I|K|1913.(a)(1)(C)B|II|2043.(a)(1)
In general The Secretary shall make grants to eligible entities with relevant expertise and experience in abuse and neglect in long-term care facilities or long-term care ombudsman programs and responsibilities, for the purpose of -
I|K|1913.(a)(1)(C)B|II|2043.(a)(1)(A)
improving the capacity of State long-term care ombudsman programs to respond to and resolve complaints about abuse and neglect;
I|K|1913.(a)(1)(C)B|II|2043.(a)(1)(B)
conducting pilot programs with State long-term care ombudsman offices or local ombudsman entities; and
I|K|1913.(a)(1)(C)B|II|2043.(a)(1)(C)
providing support for such State long-term care ombudsman programs and such pilot programs (such as through the establishment of a national long-term care ombudsman resource center).
I|K|1913.(a)(1)(C)B|II|2043.(a)(2)
Authorization of appropriations There are authorized to be appropriated to carry out this subsection -
I|K|1913.(a)(1)(C)B|II|2043.(a)(2)(A)
for fiscal year 2011, $5,000,000;
I|K|1913.(a)(1)(C)B|II|2043.(a)(2)(B)
for fiscal year 2012, $7,500,000; and
I|K|1913.(a)(1)(C)B|II|2043.(a)(2)(C)
for each of fiscal years 2013 and 2014, $10,000,000.
I|K|1913.(a)(1)(C)B|II|2043.(b)
Ombudsman training programs
I|K|1913.(a)(1)(C)B|II|2043.(b)(1)
In general The Secretary shall establish programs to provide and improve ombudsman training with respect to elder abuse, neglect, and exploitation for national organizations and State long-term care ombudsman programs.
I|K|1913.(a)(1)(C)B|II|2043.(b)(2)
Authorization of appropriations There are authorized to be appropriated to carry out this subsection, for each of fiscal years 2011 through 2014, $10,000,000.
I|K|1913.(a)(1)(C)B|II|2044.
Provision of information regarding, and evaluations of, elder justice programs
I|K|1913.(a)(1)(C)B|II|2044.(a)
Provision of Information To be eligible to receive a grant under this part, an applicant shall agree -
I|K|1913.(a)(1)(C)B|II|2044.(a)(1)
except as provided in paragraph (2), to provide the eligible entity conducting an evaluation under subsection (b) of the activities funded through the grant with such information as the eligible entity may require in order to conduct such evaluation; or
I|K|1913.(a)(1)(C)B|II|2044.(a)(2)
in the case of an applicant for a grant under section 2041(b), to provide the Secretary with such information as the Secretary may require to conduct an evaluation or audit under subsection (c).
I|K|1913.(a)(1)(C)B|II|2044.(b)
Use of Eligible Entities To Conduct Evaluations
I|K|1913.(a)(1)(C)B|II|2044.(b)(1)
Evaluations required Except as provided in paragraph (2), the Secretary shall -
I|K|1913.(a)(1)(C)B|II|2044.(b)(1)(A)
reserve a portion (not less than 2 percent) of the funds appropriated with respect to each program carried out under this part; and
I|K|1913.(a)(1)(C)B|II|2044.(b)(1)(B)
use the funds reserved under subparagraph (A) to provide assistance to eligible entities to conduct evaluations of the activities funded under each program carried out under this part.
I|K|1913.(a)(1)(C)B|II|2044.(b)(2)
Certified EHR technology grant program not included The provisions of this subsection shall not apply to the certified EHR technology grant program under section 2041(b).
I|K|1913.(a)(1)(C)B|II|2044.(b)(3)
Authorized activities A recipient of assistance described in paragraph (1)(B) shall use the funds made available through the assistance to conduct a validated evaluation of the effectiveness of the activities funded under a program carried out under this part.
I|K|1913.(a)(1)(C)B|II|2044.(b)(4)
Applications To be eligible to receive assistance under paragraph (1)(B), an entity shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require, including a proposal for the evaluation.
I|K|1913.(a)(1)(C)B|II|2044.(b)(5)
Reports Not later than a date specified by the Secretary, an eligible entity receiving assistance under paragraph (1)(B) shall submit to the Secretary, the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives, and the Committee on Finance of the Senate a report containing the results of the evaluation conducted using such assistance together with such recommendations as the entity determines to be appropriate.
I|K|1913.(a)(1)(C)B|II|2044.(c)
Evaluations and Audits of Certified EHR technology Grant Program by the Secretary
I|K|1913.(a)(1)(C)B|II|2044.(c)(1)
Evaluations The Secretary shall conduct an evaluation of the activities funded under the certified EHR technology grant program under section 2041(b). Such evaluation shall include an evaluation of whether the funding provided under the grant is expended only for the purposes for which it is made.
I|K|1913.(a)(1)(C)B|II|2044.(c)(2)
Audits The Secretary shall conduct appropriate audits of grants made under section 2041(b).
I|K|1913.(a)(1)(C)B|II|2045.
Report Not later than October 1, 2014, the Secretary shall submit to the Elder Justice Coordinating Council established under section 2021, the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives, and the Committee on Finance of the Senate a report -
I|K|1913.(a)(1)(C)B|II|2045.(1)
compiling, summarizing, and analyzing the information contained in the State reports submitted under subsections (b)(4) and (c)(4) of section 2042; and
I|K|1913.(a)(1)(C)B|II|2045.(2)
containing such recommendations for legislative or administrative action as the Secretary determines to be appropriate.
.
I|K|1913.(a)(2)
Option for State plan under program for temporary assistance for needy families
I|K|1913.(a)(2)(A)
In general Section 402(a)(1)(B) of the Social Security Act ( 42 U.S.C. 602(a)(1)(B) ) is amended by adding at the end the following new clause:
I|K|1913.(a)(2)(A)(v)
The document shall indicate whether the State intends to assist individuals to train for, seek, and maintain employment -
I|K|1913.(a)(2)(A)(v)(I)
providing direct care in a long-term care facility (as such terms are defined under section 2011); or
I|K|1913.(a)(2)(A)(v)(II)
in other occupations related to elder care determined appropriate by the State for which the State identifies an unmet need for service personnel, and, if so, shall include an overview of such assistance.
.
I|K|1913.(a)(2)(B)
Effective date The amendment made by subparagraph (A) shall take effect on January 1, 2011.
I|K|1913.(b)
Protecting residents of long-term care facilities
I|K|1913.(b)(1)
National training institute for surveyors
I|K|1913.(b)(1)(A)
In general The Secretary of Health and Human Services shall enter into a contract with an entity for the purpose of establishing and operating a National Training Institute for Federal and State surveyors. Such Institute shall provide and improve the training of surveyors with respect to investigating allegations of abuse, neglect, and misappropriation of property in programs and long-term care facilities that receive payments under title XVIII or XIX of the Social Security Act.
I|K|1913.(b)(1)(B)
Activities carried out by the Institute The contract entered into under subparagraph (A) shall require the Institute established and operated under such contract to carry out the following activities:
I|K|1913.(b)(1)(B)(i)
Assess the extent to which State agencies use specialized surveyors for the investigation of reported allegations of abuse, neglect, and misappropriation of property in such programs and long-term care facilities.
I|K|1913.(b)(1)(B)(ii)
Evaluate how the competencies of surveyors may be improved to more effectively investigate reported allegations of such abuse, neglect, and misappropriation of property, and provide feedback to Federal and State agencies on the evaluations conducted.
I|K|1913.(b)(1)(B)(iii)
Provide a national program of training, tools, and technical assistance to Federal and State surveyors on investigating reports of such abuse, neglect, and misappropriation of property.
I|K|1913.(b)(1)(B)(iv)
Develop and disseminate information on best practices for the investigation of such abuse, neglect, and misappropriation of property.
I|K|1913.(b)(1)(B)(v)
Assess the performance of State complaint intake systems, in order to ensure that the intake of complaints occurs 24 hours per day, 7 days a week (including holidays).
I|K|1913.(b)(1)(B)(vi)
To the extent approved by the Secretary of Health and Human Services, provide a national 24 hours per day, 7 days a week (including holidays), back-up system to State complaint intake systems in order to ensure optimum national responsiveness to complaints of such abuse, neglect, and misappropriation of property.
I|K|1913.(b)(1)(B)(vii)
Analyze and report annually on the following:
I|K|1913.(b)(1)(B)(vii)(I)
The total number and sources of complaints of such abuse, neglect, and misappropriation of property.
I|K|1913.(b)(1)(B)(vii)(II)
The extent to which such complaints are referred to law enforcement agencies.
I|K|1913.(b)(1)(B)(vii)(III)
General results of Federal and State investigations of such complaints.
I|K|1913.(b)(1)(B)(viii)
Conduct a national study of the cost to State agencies of conducting complaint investigations of skilled nursing facilities and nursing facilities under sections 1819 and 1919, respectively, of the Social Security Act ( 42 U.S.C. 1395i-3 ; 1396r), and making recommendations to the Secretary of Health and Human Services with respect to options to increase the efficiency and cost-effectiveness of such investigations.
I|K|1913.(b)(1)(C)
Authorization There are authorized to be appropriated to carry out this paragraph, for the period of fiscal years 2011 through 2014, $12,000,000.
I|K|1913.(b)(2)
Grants to State survey agencies
I|K|1913.(b)(2)(A)
In general The Secretary of Health and Human Services shall make grants to State agencies that perform surveys of skilled nursing facilities or nursing facilities under sections 1819 or 1919, respectively, of the Social Security Act ( 42 U.S.C. 1395i-3 ; 1395r).
I|K|1913.(b)(2)(B)
Use of funds A grant awarded under subparagraph (A) shall be used for the purpose of designing and implementing complaint investigations systems that -
I|K|1913.(b)(2)(B)(i)
promptly prioritize complaints in order to ensure a rapid response to the most serious and urgent complaints;
I|K|1913.(b)(2)(B)(ii)
respond to complaints with optimum effectiveness and timeliness; and
I|K|1913.(b)(2)(B)(iii)
optimize the collaboration between local authorities, consumers, and providers, including -
I|K|1913.(b)(2)(B)(iii)(I)
such State agency;
I|K|1913.(b)(2)(B)(iii)(II)
the State Long-Term Care Ombudsman;
I|K|1913.(b)(2)(B)(iii)(III)
local law enforcement agencies;
I|K|1913.(b)(2)(B)(iii)(IV)
advocacy and consumer organizations;
I|K|1913.(b)(2)(B)(iii)(V)
State aging units;
I|K|1913.(b)(2)(B)(iii)(VI)
Area Agencies on Aging; and
I|K|1913.(b)(2)(B)(iii)(VII)
other appropriate entities.
I|K|1913.(b)(2)(C)
Authorization There are authorized to be appropriated to carry out this paragraph, for each of fiscal years 2011 through 2014, $5,000,000.
I|K|1913.(b)(3)
Reporting of crimes in federally funded long-Term Care Facilities Part A of title XI of the Social Security Act ( 42 U.S.C. 1301 et seq. ), as amended by sections 1611(c), is amended by inserting after section 1150A the following new section:
I|K|1913.(b)(3)1150B.
Reporting to law enforcement of crimes occurring in federally funded long-Term care facilities
I|K|1913.(b)(3)1150B.(a)
Determination and Notification
I|K|1913.(b)(3)1150B.(a)(1)
Determination The owner or operator of each long-term care facility that receives Federal funds under this Act shall annually determine whether the facility received at least $10,000 in such Federal funds during the preceding year.
I|K|1913.(b)(3)1150B.(a)(2)
Notification If the owner or operator determines under paragraph (1) that the facility received at least $10,000 in such Federal funds during the preceding year, such owner or operator shall annually notify each covered individual (as defined in paragraph (3)) of that individual's obligation to comply with the reporting requirements described in subsection (b).
I|K|1913.(b)(3)1150B.(a)(3)
Covered individual defined In this section, the term covered individual means each individual who is an owner, operator, employee, manager, agent, or contractor of a long-term care facility that is the subject of a determination described in paragraph (1).
I|K|1913.(b)(3)1150B.(b)
Reporting Requirements
I|K|1913.(b)(3)1150B.(b)(1)
In general Each covered individual shall report to the Secretary and 1 or more law enforcement entities for the political subdivision in which the facility is located any reasonable suspicion of a crime (as defined by the law of the applicable political subdivision) against any individual who is a resident of, or is receiving care from, the facility.
I|K|1913.(b)(3)1150B.(b)(2)
Timing If the events that cause the suspicion -
I|K|1913.(b)(3)1150B.(b)(2)(A)
result in serious bodily injury, the individual shall report the suspicion immediately, but not later than 2 hours after forming the suspicion; and
I|K|1913.(b)(3)1150B.(b)(2)(B)
do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion.
I|K|1913.(b)(3)1150B.(c)
Penalties
I|K|1913.(b)(3)1150B.(c)(1)
In general If a covered individual violates subsection (b) -
I|K|1913.(b)(3)1150B.(c)(1)(A)
the covered individual shall be subject to a civil money penalty of not more than $200,000; and
I|K|1913.(b)(3)1150B.(c)(1)(B)
the Secretary may make a determination in the same proceeding to exclude the covered individual from participation in any Federal health care program (as defined in section 1128B(f)).
I|K|1913.(b)(3)1150B.(c)(2)
Increased harm If a covered individual violates subsection (b) and the violation exacerbates the harm to the victim of the crime or results in harm to another individual -
I|K|1913.(b)(3)1150B.(c)(2)(A)
the covered individual shall be subject to a civil money penalty of not more than $300,000; and
I|K|1913.(b)(3)1150B.(c)(2)(B)
the Secretary may make a determination in the same proceeding to exclude the covered individual from participation in any Federal health care program (as defined in section 1128B(f)).
I|K|1913.(b)(3)1150B.(c)(3)
Excluded individual During any period for which a covered individual is classified as an excluded individual under paragraph (1)(B) or (2)(B), a long-term care facility that employs such individual shall be ineligible to receive Federal funds under this Act.
I|K|1913.(b)(3)1150B.(c)(4)
Extenuating circumstances
I|K|1913.(b)(3)1150B.(c)(4)(A)
In general The Secretary may take into account the financial burden on providers with underserved populations in determining any penalty to be imposed under this subsection.
I|K|1913.(b)(3)1150B.(c)(4)(B)
Underserved population defined In this paragraph, the term underserved population means the population of an area designated by the Secretary as an area with a shortage of elder justice programs or a population group designated by the Secretary as having a shortage of such programs. Such areas or groups designated by the Secretary may include -
I|K|1913.(b)(3)1150B.(c)(4)(B)(i)
areas or groups that are geographically isolated (such as isolated in a rural area);
I|K|1913.(b)(3)1150B.(c)(4)(B)(ii)
racial and ethnic minority populations; and
I|K|1913.(b)(3)1150B.(c)(4)(B)(iii)
populations underserved because of special needs (such as language barriers, disabilities, alien status, or age).
I|K|1913.(b)(3)1150B.(d)
Additional Penalties for Retaliation
I|K|1913.(b)(3)1150B.(d)(1)
In general A long-term care facility may not -
I|K|1913.(b)(3)1150B.(d)(1)(A)
discharge, demote, suspend, threaten, harass, or deny a promotion or other employment-related benefit to an employee, or in any other manner discriminate against an employee in the terms and conditions of employment because of lawful acts done by the employee; or
I|K|1913.(b)(3)1150B.(d)(1)(B)
file a complaint or a report against a nurse or other employee with the appropriate State professional disciplinary agency because of lawful acts done by the nurse or employee, for making a report, causing a report to be made, or for taking steps in furtherance of making a report pursuant to subsection (b)(1).
I|K|1913.(b)(3)1150B.(d)(2)
Penalties for retaliation If a long-term care facility violates subparagraph (A) or (B) of paragraph (1) the facility shall be subject to a civil money penalty of not more than $200,000 or the Secretary may classify the entity as an excluded entity for a period of 2 years pursuant to section 1128(b), or both.
I|K|1913.(b)(3)1150B.(d)(3)
Requirement to post notice Each long-term care facility shall post conspicuously in an appropriate location a sign (in a form specified by the Secretary) specifying the rights of employees under this section. Such sign shall include a statement that an employee may file a complaint with the Secretary against a long-term care facility that violates the provisions of this subsection and information with respect to the manner of filing such a complaint.
I|K|1913.(b)(3)1150B.(e)
Procedure The provisions of section 1128A (other than subsections (a) and (b) and the second sentence of subsection (f)) shall apply to a civil money penalty or exclusion under this section in the same manner as such provisions apply to a penalty or proceeding under section 1128A(a).
I|K|1913.(b)(3)1150B.(f)
Definitions In this section, the terms elder justice , long-term care facility , and law enforcement have the meanings given those terms in section 2011.
.
I|K|1913.(c)
National nurse aide registry
I|K|1913.(c)(1)
Definition of nurse aide In this subsection, the term nurse aide has the meaning given that term in sections 1819(b)(5)(F) and 1919(b)(5)(F) of the Social Security Act ( 42 U.S.C. 1395i-3(b)(5)(F) ; 1396r(b)(5)(F)).
I|K|1913.(c)(2)
Study and report
I|K|1913.(c)(2)(A)
In general The Secretary, in consultation with appropriate government agencies and private sector organizations, shall conduct a study on establishing a national nurse aide registry.
I|K|1913.(c)(2)(B)
Areas evaluated The study conducted under this subsection shall include an evaluation of -
I|K|1913.(c)(2)(B)(i)
who should be included in the registry;
I|K|1913.(c)(2)(B)(ii)
how such a registry would comply with Federal and State privacy laws and regulations;
I|K|1913.(c)(2)(B)(iii)
how data would be collected for the registry;
I|K|1913.(c)(2)(B)(iv)
what entities and individuals would have access to the data collected;
I|K|1913.(c)(2)(B)(v)
how the registry would provide appropriate information regarding violations of Federal and State law by individuals included in the registry;
I|K|1913.(c)(2)(B)(vi)
how the functions of a national nurse aide registry would be coordinated with the nationwide program for national and State background checks on direct patient access employees of long-term care facilities and providers under section 4301; and
I|K|1913.(c)(2)(B)(vii)
how the information included in State nurse aide registries developed and maintained under sections 1819(e)(2) and 1919(e)(2) of the Social Security Act ( 42 U.S.C. 1395i-3(e)(2) ; 1396r(e)(2)(2)) would be provided as part of a national nurse aide registry.
I|K|1913.(c)(2)(C)
Considerations In conducting the study and preparing the report required under this subsection, the Secretary shall take into consideration the findings and conclusions of relevant reports and other relevant resources, including the following:
I|K|1913.(c)(2)(C)(i)
The Department of Health and Human Services Office of Inspector General Report, Nurse Aide Registries: State Compliance and Practices (February 2005).
I|K|1913.(c)(2)(C)(ii)
The General Accounting Office (now known as the Government Accountability Office) Report, Nursing Homes: More Can Be Done to Protect Residents from Abuse (March 2002).
I|K|1913.(c)(2)(C)(iii)
The Department of Health and Human Services Office of the Inspector General Report, Nurse Aide Registries: Long-Term Care Facility Compliance and Practices (July 2005).
I|K|1913.(c)(2)(C)(iv)
The Department of Health and Human Services Health Resources and Services Administration Report, Nursing Aides, Home Health Aides, and Related Health Care Occupations - National and Local Workforce Shortages and Associated Data Needs (2004) (in particular with respect to chapter 7 and appendix F).
I|K|1913.(c)(2)(C)(v)
The 2001 Report to CMS from the School of Rural Public Health, Texas A&M University, Preventing Abuse and Neglect in Nursing Homes: The Role of Nurse Aide Registries.
I|K|1913.(c)(2)(C)(vi)
Information included in State nurse aide registries developed and maintained under sections 1819(e)(2) and 1919(e)(2) of the Social Security Act ( 42 U.S.C. 1395i-3(e)(2) ; 1396r(e)(2)(2)).
I|K|1913.(c)(2)(D)
Report Not later than 18 months after the date of enactment of this Act, the Secretary shall submit to the Elder Justice Coordinating Council established under section 2021 of the Social Security Act, as added by section 1805(a), the Committee on Finance of the Senate, and the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives a report containing the findings and recommendations of the study conducted under this paragraph.
I|K|1913.(c)(2)(E)
Funding limitation Funding for the study conducted under this subsection shall not exceed $500,000.
I|K|1913.(c)(3)
Congressional action After receiving the report submitted by the Secretary under paragraph (2)(D), the Committee on Finance of the Senate and the Committee on Ways and Means and the Committee on Energy and Commerce of the House of Representatives shall, as they deem appropriate, take action based on the recommendations contained in the report.
I|K|1913.(c)(4)
Authorization of appropriations There are authorized to be appropriated such sums as are necessary for the purpose of carrying out this subsection.
I|K|1913.(d)
Conforming amendments
I|K|1913.(d)(1)
Title XX Title XX of the Social Security Act ( 42 U.S.C. 1397 et seq. ), as amended by section 1913(a), is amended -
I|K|1913.(d)(1)(A)
in the heading of section 2001, by striking title and inserting subtitle ; and
I|K|1913.(d)(1)(B)
in subtitle 1, by striking this title each place it appears and inserting this subtitle .
I|K|1913.(d)(2)
Title IV Title IV of the Social Security Act ( 42 U.S.C. 601 et seq. ) is amended -
I|K|1913.(d)(2)(A)
in section 404(d) -
I|K|1913.(d)(2)(A)(i)
in paragraphs (1)(A), (2)(A), and (3)(B), by inserting subtitle 1 of before title XX each place it appears;
I|K|1913.(d)(2)(A)(ii)
in the heading of paragraph (2), by inserting subtitle 1 of before title XX ; and
I|K|1913.(d)(2)(A)(iii)
in the heading of paragraph (3)(B), by inserting subtitle 1 of before title XX ; and
I|K|1913.(d)(2)(B)
in sections 422(b), 471(a)(4), 472(h)(1), and 473(b)(2), by inserting subtitle 1 of before title XX each place it appears.
I|K|1913.(d)(3)
Title XI Title XI of the Social Security Act ( 42 U.S.C. 1301 et seq. ) is amended -
I|K|1913.(d)(3)(A)
in section 1128(h)(3) -
I|K|1913.(d)(3)(A)(i)
by inserting subtitle 1 of before title XX ; and
I|K|1913.(d)(3)(A)(ii)
by striking such title and inserting such subtitle ; and
I|K|1913.(d)(3)(B)
in section 1128A(i)(1), by inserting subtitle 1 of before title XX .
I|L
Provisions of General Application
I|L|1921.
Protecting Americans and ensuring taxpayer funds in government health care plans do not support or fund physician-assisted suicide; prohibition against discrimination on assisted suicide
I|L|1921.(a)
Protecting Americans and ensuring taxpayer funds in government health care plans do not support or fund physician-assisted suicide The Federal Government, and any State or local government or health care provider that receives Federal financial assistance under this Act (or under an amendment made by this Act) or any health plan created under this Act (or under an amendment made by this Act), shall not pay for or reimburse any health care entity to provide for any health care item or service furnished for the purpose of causing, or for the purpose of assisting in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.
I|L|1921.(b)
Prohibition against discrimination on assisted suicide
I|L|1921.(b)(1)
In general The Federal Government, and any State or local government or health care provider that receives Federal financial assistance under this Act (or under an amendment made by this Act) or any health plan created under this Act (or under an amendment made by this Act), may not subject an individual or institutional health care entity to discrimination on the basis that the entity does not provide any health care item or service furnished for the purpose of causing, or for the purpose of assisting in causing, the death of any individual, such as by assisted suicide, euthanasia, or mercy killing.
I|L|1921.(b)(2)
Administration The Office for Civil Rights of the Department of Health and Human Services is designated to receive complaints of discrimination based on this subsection.
I|L|1921.(c)
Construction and treatment of certain services Nothing in subsection (a) or (b) shall be construed to apply to or to affect any limitation relating to -
I|L|1921.(c)(1)
the withholding or withdrawing of medical treatment or medical care;
I|L|1921.(c)(2)
the withholding or withdrawing of nutrition or hydration;
I|L|1921.(c)(3)
abortion; or
I|L|1921.(c)(4)
the use of an item, good, benefit, or service furnished for the purpose of alleviating pain or discomfort, even if such use may increase the risk of death, so long as such item, good, benefit, or service is not also furnished for the purpose of causing, or the purpose of assisting in causing, death, for any reason.
I|L|1921.(d)
Definition In this section, the term health care entity includes an individual physician or other health care professional, a hospital, a provider-sponsored organization, a health maintenance organization, a health insurance plan, or any other kind of health care facility, organization, or plan.
I|L|1922.
Protection of access to quality health care through the Department of Veterans Affairs and the Department of Defense
I|L|1922.(a)
Health care through Department of Veterans Affairs Nothing is in this Act shall be construed to prohibit, limit, or otherwise penalize veterans and dependents eligible for health care through the Department of Veterans Affairs under the laws administered by the Secretary of Veterans Affairs from receiving timely access to quality health care in any facility of the Department or from any non-Department health care provider through which the Secretary provides health care.
I|L|1922.(b)
Health care through Department of Defense
I|L|1922.(b)(1)
In general Nothing is in this Act shall be construed to prohibit, limit, or otherwise penalize eligible beneficiaries from receiving timely access to quality health care in any military medical treatment facility or under the TRICARE program.
I|L|1922.(b)(2)
Definitions In this subsection:
I|L|1922.(b)(2)(A)
The term eligible beneficiaries means covered beneficiaries (as defined in section 1072(5) of title 10, United States Code) for purposes of eligible for mental and dental care under chapter 55 of title 10, United States Code.
I|L|1922.(b)(2)(B)
The term TRICARE program has the meaning given that term in section 1072(7) of title 10, United States Code.
I|L|1923.
Continued application of antitrust laws Nothing in this Act shall be construed to modify, impair, or supersede the operation of any of the antitrust laws. For the purposes of this Act, the term antitrust laws has the meaning given such term in subsection (a) of the first section of the Clayton Act ( 15 U.S.C. 12(a) ). Such term also includes section 5 of the Federal Trade Commission Act ( 15 U.S.C. 45 ) to the extent that such section 5 applies to unfair methods of competition.
II
Promoting Disease Prevention and Wellness
II|A
Medicare
II|A|2001.
Coverage of annual wellness visit providing a personalized prevention plan
II|A|2001.(a)
Coverage of personalized prevention plan services
II|A|2001.(a)(1)
In general Section 1861(s)(2) of the Social Security Act ( 42 U.S.C. 1395x(s)(2) ) is amended -
II|A|2001.(a)(1)(A)
in subparagraph (DD), by striking and at the end;
II|A|2001.(a)(1)(B)
in subparagraph (EE), by adding and at the end; and
II|A|2001.(a)(1)(C)
by adding at the end the following new subparagraph:
II|A|2001.(a)(1)(FF)
personalized prevention plan services (as defined in subsection (hhh)); .
II|A|2001.(a)(2)
Conforming amendments Clauses (i) and (ii) of section 1861(s)(2)(K) of the Social Security Act ( 42 U.S.C. 1395x(s)(2)(K) ) are each amended by striking subsection (ww)(1) and inserting subsections (ww)(1) and (hhh) .
II|A|2001.(b)
Personalized prevention plan services defined Section 1861 of the Social Security Act ( 42 U.S.C. 1395x ) is amended by adding at the end the following new subsection:
II|A|2001.(b)(hhh)
Annual Wellness Visit
II|A|2001.(b)(hhh)(1)
The term personalized prevention plan services means the creation of a plan for an individual -
II|A|2001.(b)(hhh)(1)(A)
that includes a health risk assessment (that meets the guidelines established by the Secretary under paragraph (5)(A)) of the individual that is completed prior to or as part of the same visit with a health professional described in paragraph (4); and
II|A|2001.(b)(hhh)(1)(B)
that -
II|A|2001.(b)(hhh)(1)(B)(i)
takes into account the results of the health risk assessment;
II|A|2001.(b)(hhh)(1)(B)(ii)
contains the elements described in paragraph (2); and
II|A|2001.(b)(hhh)(1)(B)(iii)
may contain the elements described in paragraph (3).
II|A|2001.(b)(hhh)(2)
Subject to paragraph (5)(H), the elements described in this paragraph are the following:
II|A|2001.(b)(hhh)(2)(A)
The establishment of, or an update to, the individual's medical and family history.
II|A|2001.(b)(hhh)(2)(B)
The establishment of, or an update to, the following:
II|A|2001.(b)(hhh)(2)(B)(i)
A screening schedule for the next 5 to 10 years, as appropriate, based on recommendations of the United States Preventive Services Task Force and the individual's health status, screening history, and age-appropriate preventive services covered under this title.
II|A|2001.(b)(hhh)(2)(B)(ii)
A list of risk factors and conditions that are of concern with respect to the individual, development of a strategy to improve health status through lifestyle or other interventions that emphasize primary prevention, and recommendations for appropriate programs and informational resources for reducing or eliminating such risk factors and conditions.
II|A|2001.(b)(hhh)(2)(B)(iii)
A list of risk factors and conditions for which secondary or tertiary prevention interventions are recommended or are underway, and a list of treatment options and their associated risks and benefits.
II|A|2001.(b)(hhh)(2)(B)(iv)
A list of all medications currently prescribed for the individual.
II|A|2001.(b)(hhh)(2)(B)(v)
A list of all providers of services and suppliers regularly involved in providing care to the individual.
II|A|2001.(b)(hhh)(2)(C)
The furnishing of personalized health advice and a referral, as appropriate, to health education or preventive counseling services aimed at reducing identified risk factors, or community-based lifestyle interventions to reduce health risks and promote wellness, including weight loss, physical activity, smoking cessation, and nutrition.
II|A|2001.(b)(hhh)(2)(D)
A measurement of height, weight, body mass index (or waist circumference, if appropriate), and blood pressure.
II|A|2001.(b)(hhh)(2)(E)
Any other element determined appropriate by the Secretary.
II|A|2001.(b)(hhh)(3)
Subject to paragraph (5)(H), the elements described in this paragraph are the following:
II|A|2001.(b)(hhh)(3)(A)
Referral for additional testing related to a diagnosis of a possible chronic condition.
II|A|2001.(b)(hhh)(3)(B)
In the case of an individual with a diagnosed chronic condition, referral for or review of the available treatment options.
II|A|2001.(b)(hhh)(3)(C)
The furnishing of or referral for any preventive services described in subparagraphs (A) and (B) of subsection (ddd)(3).
II|A|2001.(b)(hhh)(3)(D)
Cognitive impairment assessment.
II|A|2001.(b)(hhh)(3)(E)
Any other element determined appropriate by the Secretary.
II|A|2001.(b)(hhh)(4)
A health professional described in this paragraph is -
II|A|2001.(b)(hhh)(4)(A)
a physician;
II|A|2001.(b)(hhh)(4)(B)
a practitioner described in clause (i) of section 1842(b)(18)(C); or
II|A|2001.(b)(hhh)(4)(C)
a medical professional (including a health educator, registered dietitian, or nutrition professional) or a team of medical professionals, as determined appropriate by the Secretary, under the supervision of a physician.
II|A|2001.(b)(hhh)(5)
II|A|2001.(b)(hhh)(5)(A)
For purposes of paragraph (1)(A), the Secretary, not later than 1 year after the date of enactment of the America's Healthy Future Act of 2009, shall establish publicly available guidelines for health risk assessments. Such guidelines shall be developed in consultation with relevant groups and entities and shall provide that a health risk assessment -
II|A|2001.(b)(hhh)(5)(A)(i)
identify chronic diseases, modifiable risk factors, and urgent health needs of the individual; and
II|A|2001.(b)(hhh)(5)(A)(ii)
may be furnished -
II|A|2001.(b)(hhh)(5)(A)(ii)(I)
through an interactive telephonic or web-based program that meets the standards established under subparagraph (D);
II|A|2001.(b)(hhh)(5)(A)(ii)(II)
during an encounter with a health care professional; or
II|A|2001.(b)(hhh)(5)(A)(ii)(III)
through any other means the Secretary determines appropriate to maximize accessibility and ease of use by beneficiaries, while ensuring the privacy of such beneficiaries.
II|A|2001.(b)(hhh)(5)(B)
The Secretary may coordinate with community-based entities (including State Health Insurance Programs, Area Agencies on Aging, Aging and Disability Resource Centers, and the Administration on Aging) to -
II|A|2001.(b)(hhh)(5)(B)(i)
ensure that health risk assessments are accessible to beneficiaries; and
II|A|2001.(b)(hhh)(5)(B)(ii)
provide appropriate support for the completion of health risk assessments by beneficiaries.
II|A|2001.(b)(hhh)(5)(C)
The Secretary shall establish procedures to make beneficiaries and providers aware of the requirement that a beneficiary complete a health risk assessment prior to or at the same time as receiving personalized prevention plan services.
II|A|2001.(b)(hhh)(5)(D)
Not later than 1 year after the date of enactment of the America's Healthy Future Act of 2009, the Secretary shall establish standards for interactive telephonic or web-based programs used to furnish health risk assessments under subparagraph (A)(ii)(I).
II|A|2001.(b)(hhh)(5)(E)
To the extent practicable, the Secretary shall encourage the use of, integration with, and coordination of health information technology (including use of technology that is compatible with electronic medical records and personal health records) and may experiment with the use of personalized technology to aid in the management of and adherence to provider recommendations in order to improve the health status of beneficiaries.
II|A|2001.(b)(hhh)(5)(F)
A beneficiary shall be eligible to receive personalized prevention plan services under this subsection provided that the beneficiary has not received such services within the preceding 12-month period. During the period of 12 months after the date that the beneficiary's first coverage begins under part B, payment shall be made under such part for only one of the following services:
II|A|2001.(b)(hhh)(5)(F)(i)
An initial preventive physical examination (as defined under subsection (ww)(1)).
II|A|2001.(b)(hhh)(5)(F)(ii)
Personalized prevention plan services provided under this subsection.
II|A|2001.(b)(hhh)(5)(G)
II|A|2001.(b)(hhh)(5)(G)(i)
Not later than 1 year after the date of enactment of the America's Healthy Future Act of 2009, the Secretary shall develop and make available to the public a health risk assessment model. Such model shall meet the guidelines under subparagraph (A) and may be used to meet the requirement under paragraph (1)(A).
II|A|2001.(b)(hhh)(5)(G)(ii)
Any health risk assessment that meets the guidelines under subparagraph (A) and is approved by the Secretary may be used to meet the requirement under paragraph (1)(A).
II|A|2001.(b)(hhh)(5)(H)
II|A|2001.(b)(hhh)(5)(H)(i)
Subject to clause (ii), the Secretary shall issue guidance that -
II|A|2001.(b)(hhh)(5)(H)(i)(I)
identifies elements under paragraphs (2) and (3) that are not required to be provided to a beneficiary during each annual visit; and
II|A|2001.(b)(hhh)(5)(H)(i)(II)
establishes a yearly schedule for appropriate provision of such elements.
II|A|2001.(b)(hhh)(5)(H)(ii)
Personalized prevention plan services that are provided to a beneficiary within the period of 12 months after the date that such beneficiary's first coverage period begins under part B shall be required to include any elements included under paragraphs (2) and (3).
.
II|A|2001.(c)
Payment and Elimination of Cost-Sharing
II|A|2001.(c)(1)
Payment and elimination of coinsurance Section 1833(a)(1) of the Social Security Act ( 42 U.S.C. 1395l(a)(1) ) is amended -
II|A|2001.(c)(1)(A)
in subparagraph (N), by inserting other than personalized prevention plan services (as defined in section 1861(hhh)(1)) after (as defined in section 1848(j)(3)) ;
II|A|2001.(c)(1)(B)
by striking and before (W) ; and
II|A|2001.(c)(1)(C)
by inserting before the semicolon at the end the following: , and (X) with respect to personalized prevention plan services (as defined in section 1861(hhh)(1)), the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under the payment basis determined under section 1848 .
II|A|2001.(c)(2)
Payment under physician fee schedule Section 1848(j)(3) of the Social Security Act ( 42 U.S.C. 1395w-4(j)(3) ) is amended by inserting (2)(FF) (including administration of the health risk assessment) , after (2)(EE), .
II|A|2001.(c)(3)
Elimination of coinsurance in outpatient hospital settings
II|A|2001.(c)(3)(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 and diagnostic mammography and inserting , diagnostic mammography, or personalized prevention plan services (as defined in section 1861(hhh)(1)) .
II|A|2001.(c)(3)(B)
Conforming amendments Section 1833(a)(2) of the Social Security Act ( 42 U.S.C. 1395l(a)(2) ) is amended -
II|A|2001.(c)(3)(B)(i)
in subparagraph (F), by striking and at the end;
II|A|2001.(c)(3)(B)(ii)
in subparagraph (G)(ii), by striking the comma at the end and inserting ; and ; and
II|A|2001.(c)(3)(B)(iii)
by inserting after subparagraph (G)(ii) the following new subparagraph:
II|A|2001.(c)(3)(B)(iii)(H)
with respect to personalized prevention plan services (as defined in section 1861(hhh)(1)) furnished by an outpatient department of a hospital, the amount determined under paragraph (1)(X), .
II|A|2001.(c)(4)
Waiver of application of deductible The first sentence of section 1833(b) of the Social Security Act ( 42 U.S.C. 1395l(b) ) is amended -
II|A|2001.(c)(4)(A)
by striking and before (9) ; and
II|A|2001.(c)(4)(B)
by inserting before the period the following: , and (10) such deductible shall not apply with respect to personalized prevention plan services (as defined in section 1861(hhh)(1)) .
II|A|2001.(d)
Frequency Limitation Section 1862(a) of the Social Security Act ( 42 U.S.C. 1395y(a) ) is amended -
II|A|2001.(d)(1)
in paragraph (1) -
II|A|2001.(d)(1)(A)
in subparagraph (N), by striking and at the end;
II|A|2001.(d)(1)(B)
in subparagraph (O), by striking the semicolon at the end and inserting , and ; and
II|A|2001.(d)(1)(C)
by adding at the end the following new subparagraph:
II|A|2001.(d)(1)(C)(P)
in the case of personalized prevention plan services (as defined in section 1861(hhh)(1)), which are performed more frequently than is covered under such section; ; and
II|A|2001.(d)(2)
in paragraph (7), by striking or (K) and inserting (K), or (P) .
II|A|2001.(e)
Effective Date The amendments made by this section shall apply to services furnished on or after January 1, 2011.
II|A|2002.
Removal of barriers to preventive services
II|A|2002.(a)
Definition of preventive services Section 1861(ddd) of the Social Security Act ( 42 U.S.C. 1395x(ddd) ) is amended -
II|A|2002.(a)(1)
in the heading, by inserting ; preventive services after services ;
II|A|2002.(a)(2)
in paragraph (1), by striking not otherwise described in this title and inserting not described in subparagraph (A) or (C) of paragraph (3) ; and
II|A|2002.(a)(3)
by adding at the end the following new paragraph:
II|A|2002.(a)(3)(3)
The term preventive services means the following:
II|A|2002.(a)(3)(3)(A)
The screening and preventive services described in subsection (ww)(2) (other than the service described in subparagraph (M) of such subsection).
II|A|2002.(a)(3)(3)(B)
An initial preventive physical examination (as defined in subsection (ww)).
II|A|2002.(a)(3)(3)(C)
Personalized prevention plan services (as defined in subsection (hhh)(1)).
.
II|A|2002.(b)
Coinsurance
II|A|2002.(b)(1)
General application
II|A|2002.(b)(1)(A)
In general Section 1833(a)(1) of the Social Security Act ( 42 U.S.C. 1395l(a)(1) ), as amended by section 2001(c)(1), is amended -
II|A|2002.(b)(1)(A)(i)
in subparagraph (T), by inserting (or 100 percent if such services are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual) after 80 percent ;
II|A|2002.(b)(1)(A)(ii)
in subparagraph (W) -
II|A|2002.(b)(1)(A)(ii)(I)
in clause (i), by inserting (if such subparagraph were applied, by substituting 100 percent for 80 percent ) after subparagraph (D) ; and
II|A|2002.(b)(1)(A)(ii)(II)
in clause (ii), by striking 80 percent and inserting 100 percent ;
II|A|2002.(b)(1)(A)(iii)
by striking and before (X) ; and
II|A|2002.(b)(1)(A)(iv)
by inserting before the semicolon at the end the following: , and (Y) with respect to preventive services described in subparagraphs (A) and (B) of section 1861(ddd)(3) that are appropriate for the individual and, in the case of such services described in subparagraph (A), are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population, the amount paid shall be 100 percent of the lesser of the actual charge for the services or the amount determined under the fee schedule that applies to such services under this part .
II|A|2002.(b)(2)
Elimination of coinsurance in outpatient hospital settings
II|A|2002.(b)(2)(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) ), as amended by section 2001(c)(3)(A), is amended -
II|A|2002.(b)(2)(A)(i)
by striking or before personalized prevention plan services ; and
II|A|2002.(b)(2)(A)(ii)
by inserting before the period the following: , or preventive services described in subparagraphs (A) and (B) of section 1861(ddd)(3) that are appropriate for the individual and, in the case of such services described in subparagraph (A), are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population .
II|A|2002.(b)(2)(B)
Conforming amendments Section 1833(a)(2) of the Social Security Act ( 42 U.S.C. 1395l(a)(2) ), as amended by section 2001(c)(3)(B), is amended -
II|A|2002.(b)(2)(B)(i)
in subparagraph (G)(ii), by striking and after the semicolon at the end;
II|A|2002.(b)(2)(B)(ii)
in subparagraph (H), by striking the comma at the end and inserting ; and ; and
II|A|2002.(b)(2)(B)(iii)
by inserting after subparagraph (H) the following new subparagraph:
II|A|2002.(b)(2)(B)(iii)(I)
with respect to preventive services described in subparagraphs (A) and (B) of section 1861(ddd)(3) that are appropriate for the individual and are furnished by an outpatient department of a hospital and, in the case of such services described in subparagraph (A), are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population, the amount determined under paragraph (1)(W) or (1)(Y), .
II|A|2002.(c)
Waiver of application of deductible for preventive services and colorectal cancer screening tests Section 1833(b) of the Social Security Act ( 42 U.S.C. 1395l(b) ), as amended by section 2001(c)(4) is amended -
II|A|2002.(c)(1)
in paragraph (1), by striking items and services described in section 1861(s)(10)(A) and inserting preventive services described in subparagraph (A) of section 1861(ddd)(3) that are recommended with a grade of A or B by the United States Preventive Services Task Force for any indication or population and are appropriate for the individual. ; and
II|A|2002.(c)(2)
by adding at the end the following new sentence: Paragraph (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. .
II|A|2002.(d)
Effective date The amendments made by this section shall apply to items and services furnished on or after January 1, 2011.
II|A|2003.
Evidence-based coverage of preventive services
II|A|2003.(a)
Authority To modify or eliminate coverage of certain preventive services
II|A|2003.(a)(1)
In general Section 1834 of the Social Security Act ( 42 U.S.C. 1395m ) is amended by adding at the end the following new subsection:
II|A|2003.(a)(1)(n)
Authority To modify or eliminate coverage of certain preventive services Notwithstanding any other provision of this title, effective beginning on January 1, 2010, if the Secretary determines appropriate, the Secretary may -
II|A|2003.(a)(1)(n)(1)
modify -
II|A|2003.(a)(1)(n)(1)(A)
the coverage of any preventive service described in subparagraph (A) of section 1861(ddd)(3) to the extent that such modification is consistent with the recommendations of the United States Preventive Services Task Force; and
II|A|2003.(a)(1)(n)(1)(B)
the services included in the initial preventive physical examination described in subparagraph (B) of such section; and
II|A|2003.(a)(1)(n)(2)
provide that no payment shall be made under this title for a preventive service described in subparagraph (A) of such section that is not recommended with a grade of A, B, C, or I by such Task Force.
.
II|A|2003.(a)(2)
Construction Nothing in the amendment made by paragraph (1) shall be construed to affect the coverage of diagnostic or treatment services under title XVIII of the Social Security Act.
II|A|2003.(b)
Support for outreach and education regarding preventive services
II|A|2003.(b)(1)
Funding
II|A|2003.(b)(1)(A)
In general Out of any funds in the Treasury not otherwise appropriated, there are appropriated for fiscal year 2010, $15,000,000 to the Centers for Medicare & Medicaid Services Program Management Account for the purposes described in subparagraph (B). Amounts appropriated under this subparagraph shall -
II|A|2003.(b)(1)(A)(i)
be disbursed to such Account on January 1, 2010; and
II|A|2003.(b)(1)(A)(ii)
remain available until expended.
II|A|2003.(b)(1)(B)
Purposes described The purposes described in this subparagraph are as follows:
II|A|2003.(b)(1)(B)(i)
To conduct education and outreach activities to Medicare beneficiaries and health care providers regarding the coverage of preventive services (as defined in section 1861(ddd)(3) of the Social Security Act, as added by section 2002(a)) under the Medicare program under title XVIII of such Act in order to encourage optimal utilization of such services.
II|A|2003.(b)(1)(B)(ii)
To coordinate such education and outreach activities with community-based entities, including State Health Insurance Programs, Area Agencies on Aging, and Aging and Disability Resource Centers, that are carrying out the activities described in section 1861(hhh)(5)(B) of the Social Security Act, as added by section 2001(b).
II|A|2003.(b)(1)(C)
Activity support Out of the amounts appropriated under subparagraph (A), the Secretary may provide support and assistance for activities conducted by community-based entities as described under subparagraph (B)(ii).
II|A|2003.(b)(2)
HHS study and report to Congress
II|A|2003.(b)(2)(A)
Study The Secretary of Health and Human Services shall conduct a study on preventive services under the Medicare program. Such study shall include an analysis of -
II|A|2003.(b)(2)(A)(i)
the implementation of the amendments made by section 101(a) of the Medicare Improvements for Patients and Providers Act of 2008 ( Public Law 110-275 ; 122 Stat. 2496), including a description of plans to add coverage of additional preventive services pursuant to such amendments; and
II|A|2003.(b)(2)(A)(ii)
the implementation of the education and outreach activities under paragraph (1)(B).
II|A|2003.(b)(2)(B)
Report 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 on the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.
II|A|2003.(b)(2)(C)
Funding Out of the amounts appropriated under paragraph (1)(A), an amount not greater than $1,000,000 shall be made available to carry out this paragraph.
II|A|2003.(b)(3)
GAO study and report to Congress
II|A|2003.(b)(3)(A)
Study The Comptroller General of the United States shall conduct a study on existing efforts by the Secretary of Health and Human Services to improve utilization of preventive services under the Medicare program, including primary, secondary, and tertiary services and the use of health information technology to coordinate such services. Such study shall include an analysis of -
II|A|2003.(b)(3)(A)(i)
the utilization of and payment for preventive services under the Medicare program; and
II|A|2003.(b)(3)(A)(ii)
whether barriers to optimal utilization of and access to such services exist and if so, what are those barriers.
II|A|2003.(b)(3)(B)
Report Not later than 2 years after the date of the enactment of this Act, the Comptroller General of the United States shall submit to Congress a report on the study conducted under subparagraph (A), together with recommendations for -
II|A|2003.(b)(3)(B)(i)
improving access to, and utilization and coordination of, primary, secondary, and tertiary preventive services under the Medicare program, with an emphasis on the most costly chronic conditions affecting Medicare population; and
II|A|2003.(b)(3)(B)(ii)
such legislation and administrative action as the Comptroller General determines appropriate.
II|A|2003.(b)(3)(C)
Funding Out of any funds in the Treasury not otherwise appropriated, there are appropriated $2,000,000 to carry out this paragraph. Amounts appropriated under this subparagraph shall remain available until expended.
II|A|2004.
GAO study and report on medicare beneficiary access to vaccines
II|A|2004.(a)
Study The Comptroller General of the United States (in this section referred to as the Comptroller General ) shall conduct a study on the ability of Medicare beneficiaries who were 65 years of age or older to access routinely recommended vaccines covered under the prescription drug program under part D of title XVIII of the Social Security Act over the period since the establishment of such program. Such study shall include the following:
II|A|2004.(a)(1)
An analysis and determination of -
II|A|2004.(a)(1)(A)
the number of Medicare beneficiaries who were 65 years of age or older and were eligible for a routinely recommended vaccination that was covered under part D;
II|A|2004.(a)(1)(B)
the number of such beneficiaries who actually received a routinely recommended vaccination that was covered under part D; and
II|A|2004.(a)(1)(C)
any barriers to access by such beneficiaries to routinely recommended vaccinations that were covered under part D.
II|A|2004.(a)(2)
A summary of the findings and recommendations by government agencies, departments, and advisory bodies (as well as relevant professional organizations) on the impact of coverage under part D of routinely recommended adult immunizations for access to such immunizations by Medicare beneficiaries.
II|A|2004.(b)
Report Not later than June 1, 2010, the Comptroller General shall submit to the appropriate committees of jurisdiction of the House of Representatives and the Senate a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.
II|A|2004.(c)
Funding Out of any funds in the Treasury not otherwise appropriated, there are appropriated $1,000,000 for fiscal year 2010 to carry out this section.
II|A|2005.
Incentives for healthy lifestyles
II|A|2005.(a)
Medicare demonstration project
II|A|2005.(a)(1)
Establishment
II|A|2005.(a)(1)(A)
In general The Secretary shall establish and implement a demonstration project under title XVIII of the Social Security Act to test programs that provide incentives to Medicare beneficiaries to reduce their risk of avoidable health outcomes that are associated with lifestyle choices, including smoking, exercise, and diet.
II|A|2005.(a)(1)(B)
Evidence review Prior to the establishment of the demonstration project, the Secretary shall review the available evidence, literature, best practices, and resources relevant to the Medicare population that are related to -
II|A|2005.(a)(1)(B)(i)
programs that promote a healthy lifestyle and reduce health risk factors; and
II|A|2005.(a)(1)(B)(ii)
providing individuals with incentives for participating in such programs.
II|A|2005.(a)(2)
Duration and scope
II|A|2005.(a)(2)(A)
Duration The Secretary shall conduct the demonstration project for an initial period of 3 years, beginning not later than July 1, 2010, with authority to continue for an additional 2 years any program or program component that is determined to be effective under the interim evaluation and report described under subsection (b).
II|A|2005.(a)(2)(B)
Scope
II|A|2005.(a)(2)(B)(i)
In general The Secretary shall select not more than 10 sites to conduct the programs described in paragraph (3), and may select such sites in coordination with other community-based programs that are oriented towards promoting healthy lifestyles, reducing risk factors, and reducing the impact of chronic diseases (including programs conducted by the Administration on Aging, the Centers for Disease Control and Prevention, and the Agency for Healthcare Research and Quality).
II|A|2005.(a)(2)(B)(ii)
Selection In selecting sites to participate in the demonstration project, the Secretary shall select -
II|A|2005.(a)(2)(B)(ii)(I)
not less than 2 sites that are located in rural areas; and
II|A|2005.(a)(2)(B)(ii)(II)
not less than 2 sites that serve a minority community (including Native American communities).
II|A|2005.(a)(2)(B)(iii)
Preference In selecting sites to participate in the demonstration project, the Secretary may give preference to organizations that have demonstrated experience in designing and implementing programs that provide incentives to adults to make healthy lifestyle choices.
II|A|2005.(a)(3)
Program described The Secretary shall select programs that are evidence-based and designed to help Medicare beneficiaries make healthy lifestyle choices to reduce their health risks, including -
II|A|2005.(a)(3)(A)
ceasing use of tobacco products;
II|A|2005.(a)(3)(B)
controlling or reducing their weight;
II|A|2005.(a)(3)(C)
controlling or lowering their cholesterol;
II|A|2005.(a)(3)(D)
lowering their blood pressure;
II|A|2005.(a)(3)(E)
learning strategies to avoid the onset of diabetes or, in the case of a diabetic, improving the management of such condition;
II|A|2005.(a)(3)(F)
reducing the risks of falls; and
II|A|2005.(a)(3)(G)
other approaches as determined by the Secretary.
II|A|2005.(a)(4)
Monitoring participation and measuring outcomes Each participating site shall establish a system to -
II|A|2005.(a)(4)(A)
monitor participation by Medicare beneficiaries in programs described in paragraph (3); and
II|A|2005.(a)(4)(B)
validate changes in health risks and outcomes, including adoption and maintenance of healthy behaviors by Medicare beneficiaries participating in such programs; and
II|A|2005.(a)(4)(C)
establish standards and health status targets for Medicare beneficiaries participating in such programs and measure the degree to which such standards and targets are met.
II|A|2005.(b)
Evaluations and reports
II|A|2005.(b)(1)
In general
II|A|2005.(b)(1)(A)
Independent evaluations The Secretary shall provide for an interim and final independent evaluation of the demonstration project that shall assess -
II|A|2005.(b)(1)(A)(i)
the extent to which participating Medicare beneficiaries achieved the program goals described in subsection (a)(3); and
II|A|2005.(b)(1)(A)(ii)
any impact on utilization of health services and costs to the Medicare program as compared to the cost of the programs conducted under the demonstration project.
II|A|2005.(b)(1)(B)
Interim determination Not later than July 1, 2013, the Secretary shall make a determination, pursuant to subsection (a)(2)(A), as to any programs or program components that should be extended through July 1, 2015.
II|A|2005.(b)(2)
Interim report Not later than January 1, 2014, the Secretary shall submit to Congress an interim report on the demonstration project. The interim report shall include -
II|A|2005.(b)(2)(A)
a preliminary evaluation of the effectiveness of the programs or program components conducted through the demonstration project; and
II|A|2005.(b)(2)(B)
a description of any programs or program components that have been extended under paragraph (1)(B).
II|A|2005.(b)(3)
Final report Not later than January 1, 2016, the Secretary shall submit to Congress a final report on the demonstration project that includes the results of the independent evaluation required under paragraph (1), together with recommendations for such legislation and administrative action as the Secretary determines appropriate, including a recommendation as to any programs conducted under the demonstration project that should be extended or expanded.
II|A|2005.(c)
No effect on eligibility for, or amount of, other benefits Any incentives provided to a Medicare beneficiary participating in the demonstration project shall not be taken into account for purposes of determining the beneficiary's eligibility for, or amount of, benefits under the Medicare program or any other program funded in whole or in part with Federal funds.
II|A|2005.(d)
Funding
II|A|2005.(d)(1)
In General Out of any funds in the Treasury not otherwise appropriated, there are appropriated $15,000,000 for each of fiscal years 2010 through 2015 to the Centers for Medicare & Medicaid Services Program Management Account to carry out the demonstration project. Amounts appropriated under this paragraph shall remain available until expended.
II|A|2005.(d)(2)
Use of certain funds Out of the amounts appropriated under paragraph (1), an amount not greater than $5,000,000 shall be made available to design, implement, and evaluate programs conducted under the demonstration project, with such amount to remain available until expended.
II|A|2005.(e)
Administration Chapter 35 of title 44, United States Code shall not apply to the selection, testing, and evaluation of programs, or the expansion of such programs, under this section.
II|A|2005.(f)
Definitions In this section:
II|A|2005.(f)(1)
Demonstration project The term "demonstration project" means the demonstration project conducted under this section.
II|A|2005.(f)(2)
Medicare beneficiary The term Medicare beneficiary means an individual who is entitled to benefits under part A of title XVIII of the Social Security Act and enrolled under part B of such title.
II|A|2005.(f)(3)
Secretary The term Secretary means the Secretary of Health and Human Services.
II|B
Medicaid
II|B|2101.
Improving access to preventive services for eligible adults
II|B|2101.(a)
Clarification of inclusion of services Section 1905(a)(13) of the Social Security Act ( 42 U.S.C. 1396d(a)(13) ) is amended to read as follows:
II|B|2101.(a)(13)
other diagnostic, screening, preventive, and rehabilitative services, including -
II|B|2101.(a)(13)(A)
any clinical preventive services that are assigned a grade of A or B by the United States Preventive Services Task Force;
II|B|2101.(a)(13)(B)
with respect to an adult individual, approved vaccines 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) and their administration; and
II|B|2101.(a)(13)(C)
any medical or remedial services (provided in a facility, a home, or other setting) recommended by a physician or other licensed practitioner of the healing arts within the scope of their practice under State law, for the maximum reduction of physical or mental disability and restoration of an individual to the best possible functional level;
.
II|B|2101.(b)
Increased fmap Section 1905(b) of the Social Security Act ( 42 U.S.C. 1396d(b) ), as amended by sections 1601(a)(3)(A) and 1604(c)(1), is amended in the first sentence -
II|B|2101.(b)(1)
by striking , and (4) and inserting , (4) ; and
II|B|2101.(b)(2)
by inserting before the period the following: , and (5) in the case of a State that provides medical assistance for services and vaccines described in subparagraphs (A) and (B) of subsection (a)(13), and prohibits cost-sharing for such services and vaccines, the Federal medical assistance percentage, as determined under this subsection and subsection (y) (without regard to paragraph (1)(C) of such subsection), shall be increased by 1 percentage point with respect to medical assistance for such services and vaccines and for items and services described in subsection (a)(4)(D) .
II|B|2101.(c)
Effective Date The amendments made under this section shall take effect on January 1, 2013.
II|B|2102.
Coverage of comprehensive tobacco cessation services for pregnant women
II|B|2102.(a)
Requiring coverage of counseling and pharmacotherapy for cessation of tobacco use by pregnant women Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ), as amended by sections 1601(a)(3)(B), 1636, and 1642, is further amended -
II|B|2102.(a)(1)
in subsection (a)(4) -
II|B|2102.(a)(1)(A)
by striking and before (C) ; and
II|B|2102.(a)(1)(B)
by inserting before the semicolon at the end the following new subparagraph: ; and (D) counseling and pharmacotherapy for cessation of tobacco use by pregnant women (as defined in subsection (bb)) ; and
II|B|2102.(a)(2)
by adding at the end the following:
II|B|2102.(a)(2)(bb)
II|B|2102.(a)(2)(bb)(1)
For purposes of this title, the term counseling and pharmacotherapy for cessation of tobacco use by pregnant women means diagnostic, therapy, and counseling services and pharmacotherapy (including the coverage of prescription and nonprescription tobacco cessation agents approved by the Food and Drug Administration) for cessation of tobacco use by pregnant women who use tobacco products or who are being treated for tobacco use that is furnished -
II|B|2102.(a)(2)(bb)(1)(A)
by or under the supervision of a physician; or
II|B|2102.(a)(2)(bb)(1)(B)
by any other health care professional who -
II|B|2102.(a)(2)(bb)(1)(B)(i)
is legally authorized to furnish such services under State law (or the State regulatory mechanism provided by State law) of the State in which the services are furnished; and
II|B|2102.(a)(2)(bb)(1)(B)(ii)
is authorized to receive payment for other services under this title or is designated by the Secretary for this purpose.
II|B|2102.(a)(2)(bb)(2)
Subject to paragraph (3), such term is limited to -
II|B|2102.(a)(2)(bb)(2)(A)
services recommended with respect to pregnant women in Treating Tobacco Use and Dependence: 2008 Update: A Clinical Practice Guideline , published by the Public Health Service in May 2008, or any subsequent modification of such Guideline; and
II|B|2102.(a)(2)(bb)(2)(B)
such other services that the Secretary recognizes to be effective for cessation of tobacco use by pregnant women.
II|B|2102.(a)(2)(bb)(3)
Such term shall not include coverage for drugs or biologicals that are not otherwise covered under this title.
.
II|B|2102.(b)
Exception from optional restriction under medicaid prescription drug coverage Section 1927(d)(2)(F) of the Social Security Act ( 42 U.S.C. 1396r-8(d)(2)(F) ), as redesignated by section 1652(a), is amended by inserting before the period at the end the following: , except, in the case of pregnant women when recommended in accordance with the Guideline referred to in section 1905(bb)(2)(A), agents approved by the Food and Drug Administration under the over-the-counter monograph process for purposes of promoting, and when used to promote, tobacco cessation .
II|B|2102.(c)
Removal of Cost-Sharing for counseling and pharmacotherapy for cessation of tobacco use by pregnant women
II|B|2102.(c)(1)
General cost-sharing limitations Section 1916 of the Social Security Act ( 42 U.S.C. 1396o ) is amended in each of subsections (a)(2)(B) and (b)(2)(B) by inserting , and counseling and pharmacotherapy for cessation of tobacco use by pregnant women (as defined in section 1905(bb)) and covered outpatient drugs (as defined in subsection (k)(2) of section 1927 and including nonprescription drugs described in subsection (d)(2) of such section) that are prescribed for purposes of promoting, and when used to promote, tobacco cessation by pregnant women in accordance with the Guideline referred to in section 1905(bb)(2)(A) after complicate the pregnancy .
II|B|2102.(c)(2)
Application to alternative cost-sharing Section 1916A(b)(3)(B)(iii) of such Act ( 42 U.S.C. 1396o-1(b)(3)(B)(iii) ) is amended by inserting , and counseling and pharmacotherapy for cessation of tobacco use by pregnant women (as defined in section 1905(bb)) after complicate the pregnancy .
II|B|2102.(d)
Effective date The amendments made by this section shall take effect on October 1, 2010.
II|B|2103.
Incentives for healthy lifestyles
II|B|2103.(a)
Initiatives
II|B|2103.(a)(1)
Establishment
II|B|2103.(a)(1)(A)
In General The Secretary shall award grants to States to carry out initiatives to provide incentives to Medicaid beneficiaries who -
II|B|2103.(a)(1)(A)(i)
successfully participate in a program described in paragraph (3); and
II|B|2103.(a)(1)(A)(ii)
upon completion of such participation, demonstrate changes in health risk and outcomes, including the adoption and maintenance of healthy behaviors by meeting specific targets (as described in subsection (c)(2)).
II|B|2103.(a)(1)(B)
Purpose The purpose of the initiatives under this section is to test approaches that may encourage behavior modification and determine scalable solutions.
II|B|2103.(a)(2)
Duration
II|B|2103.(a)(2)(A)
Initiation of program; resources The Secretary shall awards grants to States beginning on January 1, 2011, or beginning on the date on which the Secretary develops program criteria, whichever is earlier. The Secretary shall develop program criteria for initiatives under this section using relevant evidence-based research and resources, including the Guide to Community Preventive Services, the Guide to Clinical Preventive Services, and the National Registry of Evidence-Based Programs and Practices.
II|B|2103.(a)(2)(B)
Duration of program A State awarded a grant to carry out initiatives under this section shall carry out such initiatives within the 5-year period beginning on January 1, 2011, or beginning on the date on which the Secretary develops program criteria, whichever is earlier. Initiatives under this section shall be carried out by a State for a period of not less than 3 years.
II|B|2103.(a)(3)
Program described
II|B|2103.(a)(3)(A)
In general A program described in this paragraph is a comprehensive, evidence-based, widely available, and easily accessible program, proposed by the State and approved by the Secretary, that is designed and uniquely suited to address the needs of Medicaid beneficiaries and has demonstrated success in helping individuals achieve one or more of the following:
II|B|2103.(a)(3)(A)(i)
Ceasing use of tobacco products.
II|B|2103.(a)(3)(A)(ii)
Controlling or reducing their weight.
II|B|2103.(a)(3)(A)(iii)
Lowering their cholesterol.
II|B|2103.(a)(3)(A)(iv)
Lowering their blood pressure.
II|B|2103.(a)(3)(A)(v)
Avoiding the onset of diabetes or, in the case of a diabetic, improving the management of that condition.
II|B|2103.(a)(3)(B)
Co-morbidities A program under this section may also address co-morbidities (including depression) that are related to any of the conditions described in subparagraph (A).
II|B|2103.(a)(3)(C)
Waiver authority The Secretary may waive the requirements of sections 1902(a)(1) (relating to statewideness) and 1902(a)(10)(B) (relating to comparability) of the Social Security Act for a State awarded a grant to conduct an initiative under this section and shall ensure that a State makes any program described in subparagraph (A) widely available and accessible to Medicaid beneficiaries in the State.
II|B|2103.(a)(3)(D)
Flexibility in implementation A State may enter into arrangements with providers participating in Medicaid, community-based organizations, faith-based organizations, public-private partnerships, Indian tribes, or similar entities or organizations to carry out programs described in subparagraph (A).
II|B|2103.(a)(4)
Application Following the development of program criteria by the Secretary, a State may submit an application, in such manner and containing such information as the Secretary may require, that shall include a proposal for programs described in paragraph (3)(A) and a plan to make Medicaid beneficiaries and providers participating in Medicaid who reside in the State aware and informed about such programs.
II|B|2103.(b)
Education and outreach campaign
II|B|2103.(b)(1)
State awareness The Secretary shall conduct an outreach and education campaign to make States aware of the grants under this section.
II|B|2103.(b)(2)
Provider and beneficiary education A State awarded a grant to conduct an initiative under this section shall conduct an outreach and education campaign to make Medicaid beneficiaries and providers participating in Medicaid who reside in the State aware of the programs described in subsection (a)(3) that are to be carried out by the State under the grant.
II|B|2103.(c)
Monitoring A State awarded a grant to conduct an initiative under this section shall develop and implement a system to -
II|B|2103.(c)(1)
monitor Medicaid beneficiary participation in the program and validate changes in health risk and outcomes with clinical data, including the adoption and maintenance of health behaviors by such beneficiaries;
II|B|2103.(c)(2)
to the extent practicable, establish standards and health status targets for Medicaid beneficiaries participating in the program and measure the degree to which such standards and targets are met;
II|B|2103.(c)(3)
evaluate the effectiveness of the program and provide the Secretary with such evaluations;
II|B|2103.(c)(4)
report to the Secretary on processes that have been developed and lessons learned from the program; and
II|B|2103.(c)(5)
report on preventive services as part of reporting on quality measures for Medicaid managed care programs.
II|B|2103.(d)
Independent assessments
II|B|2103.(d)(1)
In general The Secretary shall provide for an independent assessment of the initiatives carried out under this section.
II|B|2103.(d)(2)
State reporting A State awarded a grant to carry out initiatives under this section shall submit reports to the Secretary, on a semi-annual basis, regarding the programs that are supported by the grant funds. Such report shall include information, as specified by the Secretary, regarding -
II|B|2103.(d)(2)(A)
the specific uses of the grant funds;
II|B|2103.(d)(2)(B)
an assessment of program implementation and lessons learned from the programs;
II|B|2103.(d)(2)(C)
an assessment of quality improvements and clinical outcomes under such programs; and
II|B|2103.(d)(2)(D)
estimates of cost savings resulting from such programs.
II|B|2103.(d)(3)
Initial report Not later than January 1, 2014, the Secretary shall submit to Congress an initial report on such initiatives based on information provided by States through reports required under paragraph (2). The initial report shall include an interim evaluation of the effectiveness of the initiatives carried out with grants awarded under this section and a recommendation regarding whether funding for expanding or extending the initiatives should be extended beyond January 1, 2016.
II|B|2103.(d)(4)
Final report Not later than July 1, 2016, the Secretary shall submit to Congress a final report on the program that includes the results of the independent assessment required under paragraph (1), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.
II|B|2103.(e)
No effect on eligibility for, or amount of, other benefits Any incentives provided to a Medicaid beneficiary participating in a program described in subsection (a)(3) shall not be taken into account for purposes of determining the beneficiary's eligibility for, or amount of, benefits under any program funded in whole or in part with Federal funds.
II|B|2103.(f)
Funding Out of any funds in the Treasury not otherwise appropriated, there are appropriated for the 5-year period beginning on January 1, 2011, $100,000,000 to the Secretary to carry out this section. Amounts appropriated under this subsection shall remain available until expended.
II|B|2103.(g)
Definitions In this section:
II|B|2103.(g)(1)
Medicaid beneficiary The term Medicaid beneficiary means an individual who is eligible for medical assistance under a State plan or waiver under title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. ) and is enrolled in such plan or waiver.
II|B|2103.(g)(2)
Secretary The term Secretary means the Secretary of Health and Human Services.
II|B|2103.(g)(3)
State The term State has the meaning given that term for purposes of title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. ).
II|B|2104.
State option to provide health homes for enrollees with chronic conditions
II|B|2104.(a)
State plan amendment Title XIX of the Social Security Act ( 42 U.S.C. 1396a et seq. ), as amended by sections 1621, 1640, and 1702(b), is amended by adding at the end the following new section:
II|B|2104.(a)1946.
State option to provide coordinated care through a health home for individuals with chronic conditions
II|B|2104.(a)1946.(a)
In general Notwithstanding section 1902(a)(1) (relating to statewideness), section 1902(a)(10)(B) (relating to comparability), and any other provision of this title for which the Secretary determines it is necessary to waive in order to implement this section, beginning January 1, 2011, a State, at its option as a State plan amendment, may provide for medical assistance under this title to eligible individuals with chronic conditions who select a designated provider as the individual's health home for purposes of providing the individual with health home services.
II|B|2104.(a)1946.(b)
Health home qualification standards The Secretary shall establish standards for qualification as a designated provider (as described under subsection (h)(3)) for the purpose of being eligible to be a health home for purposes of this section.
II|B|2104.(a)1946.(c)
Payments
II|B|2104.(a)1946.(c)(1)
In general A State shall provide a designated provider, or a team of health care professionals operating with such a provider, with payments for the provision of health home services to each eligible individual with chronic conditions that selects the provider as the individual's health home. Payments made to a designated provider or a team for such services shall be treated as medical assistance for purposes of section 1903(a), except that, during the first 8 fiscal year quarters that the State plan amendment is in effect, the Federal medical assistance percentage applicable to such payments shall be equal to 90 percent.
II|B|2104.(a)1946.(c)(2)
Methodology
II|B|2104.(a)1946.(c)(2)(A)
In general The State shall specify in the State plan amendment the methodology the State will use for determining payment for the provision of health home services. Such methodology for determining payment -
II|B|2104.(a)1946.(c)(2)(A)(i)
may be tiered to reflect, with respect to each eligible individual with chronic conditions provided such services by a designated provider or a team of health care professionals operating with such a provider, the severity or number of each such individual's chronic conditions or the specific capabilities of the provider or team; and
II|B|2104.(a)1946.(c)(2)(A)(ii)
shall be established consistent with section 1902(a)(30)(A).
II|B|2104.(a)1946.(c)(2)(B)
Alternate models of payment The methodology for determining payment for provision of health home services under this section shall not be limited to a per-member per-month basis and may provide (as proposed by the State and subject to approval by the Secretary) for alternate models of payment.
II|B|2104.(a)1946.(c)(3)
Planning grants The Secretary may award planning grants to States for purposes of developing a State plan amendment under this section. A State awarded a planning grant shall contribute an amount equal to the State percentage determined under section 1905(b) (without regard to section 5001 of Public Law 111-5 ) for each fiscal year for which the grant is awarded. The total amount of payments made to States under this paragraph shall not exceed $25,000,000.
II|B|2104.(a)1946.(d)
Hospital referrals A State shall include in the State plan amendment a requirement for hospitals that are participating providers under the State plan or a waiver of such plan to establish procedures for referring any eligible individuals with chronic conditions who seek or need treatment in a hospital emergency department to designated providers.
II|B|2104.(a)1946.(e)
Coordination A State shall consult and coordinate, as appropriate, with the Substance Abuse and Mental Health Services Administration in addressing issues regarding the prevention and treatment of mental illness and substance abuse among eligible individuals with chronic conditions.
II|B|2104.(a)1946.(f)
Monitoring A State shall include in the State plan amendment -
II|B|2104.(a)1946.(f)(1)
a methodology for tracking avoidable hospital readmissions and calculating savings that result from improved chronic care coordination and management under this section; and
II|B|2104.(a)1946.(f)(2)
a proposal for use of health information technology in providing health home services under this section and improving service delivery and coordination across the care continuum (including the use of wireless patient technology to improve coordination and management of care and patient adherence to recommendations made by their provider).
II|B|2104.(a)1946.(g)
Report on quality measures As a condition for receiving payment for health home services provided to an eligible individual with chronic conditions, a designated provider shall report to the State, in accordance with such requirements as the Secretary shall specify, on all applicable measures for determining the quality of such services. When appropriate and feasible, a designated provider shall use health information technology in providing the State with such information.
II|B|2104.(a)1946.(h)
Definitions In this section:
II|B|2104.(a)1946.(h)(1)
Eligible individual with chronic conditions
II|B|2104.(a)1946.(h)(1)(A)
In general Subject to subparagraph (B), the term eligible individual with chronic conditions means an individual who -
II|B|2104.(a)1946.(h)(1)(A)(i)
is eligible for medical assistance under the State plan or under a waiver of such plan; and
II|B|2104.(a)1946.(h)(1)(A)(ii)
has at least -
II|B|2104.(a)1946.(h)(1)(A)(ii)(I)
2 chronic conditions;
II|B|2104.(a)1946.(h)(1)(A)(ii)(II)
1 chronic condition and is at risk of having a second chronic condition; or
II|B|2104.(a)1946.(h)(1)(A)(ii)(III)
1 serious and persistent mental health condition.
II|B|2104.(a)1946.(h)(1)(B)
Rule of construction Nothing in this paragraph shall prevent the Secretary from establishing higher levels as to the number or severity of chronic or mental health conditions for purposes of determining eligibility for receipt of health home services under this section.
II|B|2104.(a)1946.(h)(2)
Chronic condition The term chronic condition has the meaning given that term by the Secretary and shall include, but is not limited to, the following:
II|B|2104.(a)1946.(h)(2)(A)
A mental health condition.
II|B|2104.(a)1946.(h)(2)(B)
Substance abuse.
II|B|2104.(a)1946.(h)(2)(C)
Asthma.
II|B|2104.(a)1946.(h)(2)(D)
Diabetes.
II|B|2104.(a)1946.(h)(2)(E)
Heart disease.
II|B|2104.(a)1946.(h)(2)(F)
Being overweight, as evidenced by having a Body Mass Index (BMI) over 25.
II|B|2104.(a)1946.(h)(3)
Designated provider The term designated provider means a physician, clinical practice or clinical group practice, rural clinic, community health center, community mental health center, home health agency, or any other entity or provider (including pediatricians and obstetricians) that is determined by the State and approved by the Secretary to be qualified to be a health home for eligible individuals with chronic conditions on the basis of documentation evidencing that the physician, practice, or clinic -
II|B|2104.(a)1946.(h)(3)(A)
has the systems and infrastructure in place to provide health home services; and
II|B|2104.(a)1946.(h)(3)(B)
satisfies the qualification standards established by the Secretary under subsection (b).
II|B|2104.(a)1946.(h)(4)
Health home The term health home means a designated provider (including a provider that operates in coordination with a team of health care professionals) selected by an eligible individual with chronic conditions to provide health home services.
II|B|2104.(a)1946.(h)(5)
Health home services
II|B|2104.(a)1946.(h)(5)(A)
In general The term health home services means comprehensive and timely high-quality services described in subparagraph (B) that are provided by a designated provider or a team of health care professionals (as described in subparagraph (C)) operating with such a provider.
II|B|2104.(a)1946.(h)(5)(B)
Services described The services described in this subparagraph are -
II|B|2104.(a)1946.(h)(5)(B)(i)
comprehensive care management;
II|B|2104.(a)1946.(h)(5)(B)(ii)
care coordination and health promotion;
II|B|2104.(a)1946.(h)(5)(B)(iii)
comprehensive transitional care, including appropriate follow-up, from inpatient to other settings;
II|B|2104.(a)1946.(h)(5)(B)(iv)
patient and family support;
II|B|2104.(a)1946.(h)(5)(B)(v)
referral to community and social support services, if relevant; and
II|B|2104.(a)1946.(h)(5)(B)(vi)
use of health information technology to link services, as feasible and appropriate.
II|B|2104.(a)1946.(h)(5)(C)
Team of health care professionals described A team of health care professionals described in this subparagraph is a team of professionals (as described in the State plan amendment) that may -
II|B|2104.(a)1946.(h)(5)(C)(i)
include physicians and other professionals, such as a nurse care coordinator, nutritionist, social worker, behavioral health professional, or any professionals deemed appropriate by the State; and
II|B|2104.(a)1946.(h)(5)(C)(ii)
be free standing, virtual, or based at a hospital, community health center, community mental health center, rural clinic, clinical practice or clinical group practice, academic health center, or any entity deemed appropriate by the State and approved by the Secretary.
.
II|B|2104.(b)
Evaluation
II|B|2104.(b)(1)
Independent evaluation
II|B|2104.(b)(1)(A)
In general Not later than January 1, 2013, the Secretary shall enter into a contract with an independent entity or organization to conduct an evaluation and assessment of the States that have elected the option to provide coordinated care through a health home for Medicaid beneficiaries with chronic conditions under section 1946 of the Social Security Act (as added by subsection (a)) for the purpose of determining the effect of such option on reducing hospital admissions, emergency room visits, and admissions to skilled nursing facilities.
II|B|2104.(b)(1)(B)
Evaluation report Not later than January 1, 2017, the Secretary shall report to Congress on the evaluation and assessment conducted under subparagraph (A).
II|B|2104.(b)(2)
Survey and interim report
II|B|2104.(b)(2)(A)
In General Not later than January 1, 2014, the Secretary of Health and Human Services shall survey States that have elected the option under section 1946 of the Social Security Act (as added by subsection (a)) and report to Congress on the nature, extent, and use of such option, particularly as it pertains to -
II|B|2104.(b)(2)(A)(i)
hospital admission rates;
II|B|2104.(b)(2)(A)(ii)
chronic disease management;
II|B|2104.(b)(2)(A)(iii)
coordination of care for individuals with chronic conditions;
II|B|2104.(b)(2)(A)(iv)
assessment of program implementation;
II|B|2104.(b)(2)(A)(v)
processes and lessons learned (as described in subparagraph (B));
II|B|2104.(b)(2)(A)(vi)
assessment of quality improvements and clinical outcomes under such option; and
II|B|2104.(b)(2)(A)(vii)
estimates of cost savings.
II|B|2104.(b)(2)(B)
Implementation reporting A State that has elected the option under section 1946 of the Social Security Act (as added by subsection (a)) shall report to the Secretary, as necessary, on processes that have been developed and lessons learned regarding provision of coordinated care through a health home for Medicaid beneficiaries with chronic conditions under such option.
II|B|2105.
Funding for Childhood Obesity Demonstration Project Section 1139A(e)(8) of the Social Security Act (42 U.S.C. 1320b-9a(e)(8)) is amended to read as follows:
II|B|2105.(8)
Appropriation Out of any funds in the Treasury not otherwise appropriated, there is appropriated to carry out this subsection, $25,000,000 for the period of fiscal years 2010 through 2014. .
II|B|2106.
Public awareness of preventive and obesity-related services
II|B|2106.(a)
Information to States The Secretary of Health and Human Services shall provide guidance and relevant information to States and health care providers regarding preventive and obesity-related services that are available to Medicaid enrollees, including obesity screening and counseling for children and adults.
II|B|2106.(b)
Information to enrollees Each State shall design a public awareness campaign to educate Medicaid enrollees regarding availability and coverage of such services, with the goal of reducing incidences of obesity.
II|B|2106.(c)
Report Not later than January 1, 2011, and every 3 years thereafter through January 1, 2017, the Secretary of Health and Human Services shall report to Congress on the status and effectiveness of efforts under subsections (a) and (b), including summaries of the States' efforts to increase awareness of coverage of obesity-related services.
III
Improving the Quality and Efficiency of Health Care
III|A
Transforming the Health Care Delivery System
III|A|I
Linking Payment to Quality Outcomes under the Medicare program
III|A|I|3001.
Hospital Value-Based purchasing program
III|A|I|3001.(a)
Program
III|A|I|3001.(a)(1)
In general Section 1886 of the Social Security Act ( 42 U.S.C. 1395ww ), as amended by section 4102(a) of the HITECH Act ( Public Law 111-5 ), is amended by adding at the end the following new subsection:
III|A|I|3001.(a)(1)(o)
Hospital Value-Based purchasing program
III|A|I|3001.(a)(1)(o)(1)
Establishment
III|A|I|3001.(a)(1)(o)(1)(A)
In general Subject to the succeeding provisions of this subsection, the Secretary shall establish a hospital value-based purchasing program (in this subsection referred to as the Program ) under which value-based incentive payments are made in a fiscal year to hospitals that meet the performance standards under paragraph (3) for the performance period for such fiscal year (as established under paragraph (4)).
III|A|I|3001.(a)(1)(o)(1)(B)
Program to begin in fiscal year 2013 The Program shall apply to payments for discharges occurring on or after October 1, 2012.
III|A|I|3001.(a)(1)(o)(1)(C)
Applicability of program to hospitals
III|A|I|3001.(a)(1)(o)(1)(C)(i)
In general For purposes of this subsection, subject to clause (ii), the term hospital means a subsection (d) hospital (as defined in subsection (d)(1)(B)).
III|A|I|3001.(a)(1)(o)(1)(C)(ii)
Exclusions The term hospital shall not include, with respect to a fiscal year, a hospital -
III|A|I|3001.(a)(1)(o)(1)(C)(ii)(I)
that is subject to the payment reduction under subsection (b)(3)(B)(viii)(I) for such fiscal year;
III|A|I|3001.(a)(1)(o)(1)(C)(ii)(II)
for which, during the performance period for such fiscal year, the Secretary has cited deficiencies that pose immediate jeopardy to the health or safety of patients;
III|A|I|3001.(a)(1)(o)(1)(C)(ii)(III)
for which there are not a minimum number (as determined by the Secretary) of measures that apply to the hospital for the performance period for such fiscal year; or
III|A|I|3001.(a)(1)(o)(1)(C)(ii)(IV)
for which there are not a minimum number (as determined by the Secretary) of cases for the measures that apply to the hospital for the performance period for such fiscal year.
III|A|I|3001.(a)(1)(o)(1)(C)(iii)
Independent analysis For purposes of determining the minimum numbers under subclauses (III) and (IV) of clause (ii), the Secretary shall have conducted an independent analysis of what numbers are appropriate.
III|A|I|3001.(a)(1)(o)(2)
Measures
III|A|I|3001.(a)(1)(o)(2)(A)
In general The Secretary shall select measures for purposes of the Program. Such measures shall be selected from the measures specified under subsection (b)(3)(B)(viii).
III|A|I|3001.(a)(1)(o)(2)(B)
Requirements
III|A|I|3001.(a)(1)(o)(2)(B)(i)
For fiscal year 2013 For value-based incentive payments made with respect to discharges occurring during fiscal year 2013, the Secretary shall ensure the following:
III|A|I|3001.(a)(1)(o)(2)(B)(i)(I)
Conditions or procedures Measures are selected under subparagraph (A) that cover at least the following 5 specific conditions or procedures:
III|A|I|3001.(a)(1)(o)(2)(B)(i)(aa)
Acute myocardial infarction (AMI).
III|A|I|3001.(a)(1)(o)(2)(B)(i)(bb)
Heart failure.
III|A|I|3001.(a)(1)(o)(2)(B)(i)(cc)
Pneumonia.
III|A|I|3001.(a)(1)(o)(2)(B)(i)(dd)
Surgeries, as measured by the Surgical Care Improvement Project (formerly referred to as Surgical Infection Prevention for discharges occurring before July 2006).
III|A|I|3001.(a)(1)(o)(2)(B)(i)(ee)
Healthcare-associated infections, as measured by the prevention metrics and targets established in the HHS Action Plan to Prevent Healthcare-Associated Infections (or any successor plan) of the Department of Health and Human Services.
III|A|I|3001.(a)(1)(o)(2)(B)(i)(II)
HCAHPS Measures selected under subparagraph (A) shall be related to the Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS).
III|A|I|3001.(a)(1)(o)(2)(B)(ii)
Inclusion of efficiency measures For value-based incentive payments made with respect to discharges occurring during fiscal year 2014 or a subsequent fiscal year, the Secretary shall ensure that measures selected under subparagraph (A) include efficiency measures, including measures of Medicare spending per beneficiary . Such measures shall be adjusted for factors such as age, sex, race, severity of illness, and other factors that the Secretary determines appropriate.
III|A|I|3001.(a)(1)(o)(2)(C)
Limitations
III|A|I|3001.(a)(1)(o)(2)(C)(i)
Time requirement for prior reporting and notice The Secretary may not select a measure under subparagraph (A) for use under the Program with respect to a performance period for a fiscal year (as established under paragraph (4)) unless such measure has been specified under subsection (b)(3)(B)(viii) and included on the Hospital Compare Internet website for at least 1 year prior to the beginning of such performance period.
III|A|I|3001.(a)(1)(o)(2)(C)(ii)
Measure not applicable unless hospital furnishes services appropriate to the measure A measure selected under subparagraph (A) shall not apply to a hospital if such hospital does not furnish services appropriate to such measure.
III|A|I|3001.(a)(1)(o)(2)(D)
Replacing measures Subclause (VI) of subsection (b)(3)(B)(viii) shall apply to measures selected under subparagraph (A) in the same manner as such subclause applies to measures selected under such subsection.
III|A|I|3001.(a)(1)(o)(3)
Performance standards
III|A|I|3001.(a)(1)(o)(3)(A)
Establishment The Secretary shall establish performance standards with respect to measures selected under paragraph (2) for a performance period for a fiscal year (as established under paragraph (4)).
III|A|I|3001.(a)(1)(o)(3)(B)
Achievement and improvement The performance standards established under subparagraph (A) shall include levels of achievement and improvement.
III|A|I|3001.(a)(1)(o)(3)(C)
Timing The Secretary shall establish and announce the performance standards under subparagraph (A) not later than 60 days prior to the beginning of the performance period for the fiscal year involved.
III|A|I|3001.(a)(1)(o)(3)(D)
Considerations in establishing standards In establishing performance standards with respect to measures under this paragraph, the Secretary shall take into account appropriate factors, such as -
III|A|I|3001.(a)(1)(o)(3)(D)(i)
practical experience with the measures involved, including whether a significant proportion of hospitals failed to meet the performance standard during previous performance periods;
III|A|I|3001.(a)(1)(o)(3)(D)(ii)
historical performance standards;
III|A|I|3001.(a)(1)(o)(3)(D)(iii)
improvement rates; and
III|A|I|3001.(a)(1)(o)(3)(D)(iv)
the opportunity for continued improvement.
III|A|I|3001.(a)(1)(o)(4)
Performance period For purposes of the Program, the Secretary shall establish the performance period for a fiscal year. Such performance period shall begin and end prior to the beginning of such fiscal year.
III|A|I|3001.(a)(1)(o)(5)
Hospital performance score
III|A|I|3001.(a)(1)(o)(5)(A)
In general Subject to subparagraph (B), the Secretary shall develop a methodology for assessing the total performance of each hospital based on performance standards with respect to the measures selected under paragraph (2) for a performance period (as established under paragraph (4)). Using such methodology, the Secretary shall provide for an assessment (in this subsection referred to as the hospital performance score ) for each hospital for each performance period.
III|A|I|3001.(a)(1)(o)(5)(B)
Application
III|A|I|3001.(a)(1)(o)(5)(B)(i)
Appropriate distribution The Secretary shall ensure that the application of the methodology developed under subparagraph (A) results in an appropriate distribution of value-based incentive payments under paragraph (6) among hospitals achieving different levels of hospital performance scores, with hospitals achieving the highest hospital performance scores receiving the largest value-based incentive payments.
III|A|I|3001.(a)(1)(o)(5)(B)(ii)
Higher of achievement or improvement The methodology developed under subparagraph (A) shall provide that the hospital performance score is determined using the higher of its achievement or improvement score for each measure.
III|A|I|3001.(a)(1)(o)(5)(B)(iii)
Weights The methodology developed under subparagraph (A) shall provide for the assignment of weights for categories of measures as the Secretary determines appropriate.
III|A|I|3001.(a)(1)(o)(5)(B)(iv)
No minimum performance standard The Secretary shall not set a minimum performance standard in determining the hospital performance score for any hospital.
III|A|I|3001.(a)(1)(o)(5)(B)(v)
Reflection of measures applicable to the hospital The hospital performance score for a hospital shall reflect the measures that apply to the hospital.
III|A|I|3001.(a)(1)(o)(6)
Calculation of value-based incentive payments
III|A|I|3001.(a)(1)(o)(6)(A)
In general In the case of a hospital that the Secretary determines meets (or exceeds) the performance standards under paragraph (3) for the performance period for a fiscal year (as established under paragraph (4)), the Secretary shall increase the base operating DRG payment amount (as defined in paragraph (7)(D)), as determined after application of paragraph (7)(B)(i), for a hospital for each discharge occurring in such fiscal year by the value-based incentive payment amount.
III|A|I|3001.(a)(1)(o)(6)(B)
Value-Based incentive payment amount The value-based incentive payment amount for each discharge of a hospital in a fiscal year shall be equal to the product of -
III|A|I|3001.(a)(1)(o)(6)(B)(i)
the base operating DRG payment amount (as defined in paragraph (7)(D)) for the discharge for the hospital for such fiscal year; and
III|A|I|3001.(a)(1)(o)(6)(B)(ii)
the value-based incentive payment percentage specified under subparagraph (C) for the hospital for such fiscal year.
III|A|I|3001.(a)(1)(o)(6)(C)
Value-based incentive payment percentage
III|A|I|3001.(a)(1)(o)(6)(C)(i)
In general The Secretary shall specify a value-based incentive payment percentage for a hospital for a fiscal year.
III|A|I|3001.(a)(1)(o)(6)(C)(ii)
Requirements In specifying the value-based incentive payment percentage for each hospital for a fiscal year under clause (i), the Secretary shall ensure that -
III|A|I|3001.(a)(1)(o)(6)(C)(ii)(I)
such percentage is based on the hospital performance score of the hospital under paragraph (5); and
III|A|I|3001.(a)(1)(o)(6)(C)(ii)(II)
the total amount of value-based incentive payments under this paragraph to all hospitals in such fiscal year is equal to the total amount available for value-based incentive payments for such fiscal year under paragraph (7)(A), as estimated by the Secretary.
III|A|I|3001.(a)(1)(o)(7)
Funding for Value-Based incentive payments
III|A|I|3001.(a)(1)(o)(7)(A)
Amount The total amount available for value-based incentive payments under paragraph (6) for all hospitals for a fiscal year shall be equal to the total amount of reduced payments for all hospitals under subparagraph (B) for such fiscal year, as estimated by the Secretary.
III|A|I|3001.(a)(1)(o)(7)(B)
Adjustment to payments
III|A|I|3001.(a)(1)(o)(7)(B)(i)
In general The Secretary shall reduce the base operating DRG payment amount (as defined in subparagraph (D)) for a hospital for each discharge in a fiscal year (beginning with fiscal year 2013) by an amount equal to the applicable percent (as defined in subparagraph (C)) of the base operating DRG payment amount for the discharge for the hospital for such fiscal year. The Secretary shall make such reductions for all hospitals in the fiscal year involved, regardless of whether or not the hospital has been determined by the Secretary to have earned a value-based incentive payment under paragraph (6) for such fiscal year.
III|A|I|3001.(a)(1)(o)(7)(B)(ii)
No effect on other payments Payments described in items (aa) and (bb) of subparagraph (D)(i)(II) for a hospital shall be determined as if this subsection had not been enacted.
III|A|I|3001.(a)(1)(o)(7)(C)
Applicable percent defined For purposes of subparagraph (B), the term applicable percent means -
III|A|I|3001.(a)(1)(o)(7)(C)(i)
with respect to fiscal year 2013, 1.0 percent;
III|A|I|3001.(a)(1)(o)(7)(C)(ii)
with respect to fiscal year 2014, 1.25 percent;
III|A|I|3001.(a)(1)(o)(7)(C)(iii)
with respect to fiscal year 2015, 1.5 percent;
III|A|I|3001.(a)(1)(o)(7)(C)(iv)
with respect to fiscal year 2016, 1.75 percent; and
III|A|I|3001.(a)(1)(o)(7)(C)(v)
with respect to fiscal year 2017 and succeeding fiscal years, 2 percent.
III|A|I|3001.(a)(1)(o)(7)(D)
Base operating DRG payment amount defined
III|A|I|3001.(a)(1)(o)(7)(D)(i)
In general Except as provided in clause (ii), in this subsection, the term base operating DRG payment amount means, with respect to a hospital for a fiscal year -
III|A|I|3001.(a)(1)(o)(7)(D)(i)(I)
the payment amount that would otherwise be made under subsection (d) for a discharge if this subsection did not apply; reduced by
III|A|I|3001.(a)(1)(o)(7)(D)(i)(II)
any portion of such payment amount that is attributable to -
III|A|I|3001.(a)(1)(o)(7)(D)(i)(aa)
payments under paragraphs (5)(A), (5)(B), (5)(F), and (12) of subsection (d); and
III|A|I|3001.(a)(1)(o)(7)(D)(i)(bb)
such other payments under subsection (d) determined appropriate by the Secretary.
III|A|I|3001.(a)(1)(o)(7)(D)(ii)
Special rules for certain hospitals
III|A|I|3001.(a)(1)(o)(7)(D)(ii)(I)
Sole community hospitals and medicare-dependent, small rural hospitals In the case of a medicare-dependent, small rural hospital (with respect to discharges occurring during fiscal year 2012 and 2013) or a sole community hospital, in applying subparagraph (A)(i), the payment amount that would otherwise be made under subsection (d) shall be determined without regard to subparagraphs (I) and (L) of subsection (b)(3) and subparagraphs (D) and (G) of subsection (d)(5).
III|A|I|3001.(a)(1)(o)(7)(D)(ii)(II)
Hospitals paid under section 1814 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.
III|A|I|3001.(a)(1)(o)(8)
Announcement of net result of adjustments Under the Program, the Secretary shall, not later than 60 days prior to the fiscal year involved, inform each hospital of the adjustments to payments to the hospital for discharges occurring in such fiscal year under paragraphs (6) and (7)(B)(i).
III|A|I|3001.(a)(1)(o)(9)
No effect in subsequent fiscal years The value-based incentive payment under paragraph (6) and the payment reduction under paragraph (7)(B)(i) shall each apply only with respect to the fiscal year involved, and the Secretary shall not take into account such value-based incentive payment or payment reduction in making payments to a hospital under this section in a subsequent fiscal year.
III|A|I|3001.(a)(1)(o)(10)
Public reporting
III|A|I|3001.(a)(1)(o)(10)(A)
Hospital specific information
III|A|I|3001.(a)(1)(o)(10)(A)(i)
In general The Secretary shall make information available to the public regarding the performance of individual hospitals under the Program, including -
III|A|I|3001.(a)(1)(o)(10)(A)(i)(I)
the performance of the hospital with respect to each measure that applies to the hospital;
III|A|I|3001.(a)(1)(o)(10)(A)(i)(II)
the performance of the hospital with respect to each condition or procedure; and
III|A|I|3001.(a)(1)(o)(10)(A)(i)(III)
the hospital performance score assessing the total performance of the hospital.
III|A|I|3001.(a)(1)(o)(10)(A)(ii)
Opportunity to review and submit corrections The Secretary shall ensure that a hospital has the opportunity to review, and submit corrections for, the information to be made public with respect to the hospital under clause (i) prior to such information being made public.
III|A|I|3001.(a)(1)(o)(10)(A)(iii)
Website Such information shall be posted on the Hospital Compare Internet website in an easily understandable format.
III|A|I|3001.(a)(1)(o)(10)(B)
Aggregate information The Secretary shall periodically post on the Hospital Compare Internet website aggregate information on the Program, including -
III|A|I|3001.(a)(1)(o)(10)(B)(i)
the number of hospitals receiving value-based incentive payments under paragraph (6) and the range and total amount of such value-based incentive payments; and
III|A|I|3001.(a)(1)(o)(10)(B)(ii)
the number of hospitals receiving less than the maximum value-based incentive payment available to the hospital for the fiscal year involved and the range and amount of such payments.
III|A|I|3001.(a)(1)(o)(11)
Implementation
III|A|I|3001.(a)(1)(o)(11)(A)
Appeals The Secretary shall establish a process by which hospitals may appeal the calculation of a hospital's performance assessment with respect to the performance standards established under paragraph (3)(A) and the hospital performance score under paragraph (5). The Secretary shall ensure that such process provides for resolution of such appeals in a timely manner.
III|A|I|3001.(a)(1)(o)(11)(B)
Limitation on review Except as provided in subparagraph (A), there shall be no administrative or judicial review under section 1869, section 1878, or otherwise of the following:
III|A|I|3001.(a)(1)(o)(11)(B)(i)
The methodology used to determine the amount of the value-based incentive payment under paragraph (6) and the determination of such amount.
III|A|I|3001.(a)(1)(o)(11)(B)(ii)
The determination of the amount of funding available for such value-based incentive payments under paragraph (7)(A) and the payment reduction under paragraph (7)(B)(i).
III|A|I|3001.(a)(1)(o)(11)(B)(iii)
The establishment of the performance standards under paragraph (3) and the performance period under paragraph (4).
III|A|I|3001.(a)(1)(o)(11)(B)(iv)
The measures specified under subsection (b)(3)(B)(viii) and the measures selected under paragraph (2).
III|A|I|3001.(a)(1)(o)(11)(B)(v)
The methodology developed under paragraph (5) that is used to calculate hospital performance scores and the calculation of such scores.
III|A|I|3001.(a)(1)(o)(11)(B)(vi)
The validation methodology specified in subsection (b)(3)(B)(viii)(XI).
III|A|I|3001.(a)(1)(o)(11)(C)
Consultation with small hospitals The Secretary shall consult with small rural and urban hospitals on the application of the Program to such hospitals.
III|A|I|3001.(a)(1)(o)(12)
Promulgation of regulations The Secretary shall promulgate regulations to carry out the Program, including the selection of measures under paragraph (2), the methodology developed under paragraph (5) that is used to calculate hospital performance scores, and the methodology used to determine the amount of value-based incentive payments under paragraph (6).
.
III|A|I|3001.(a)(2)
Amendments for reporting of hospital quality information Section 1886(b)(3)(B)(viii) of the Social Security Act ( 42 U.S.C. 1395ww(b)(3)(B)(viii) ) is amended -
III|A|I|3001.(a)(2)(A)
in subclause (II), by adding at the end the following sentence: The Secretary may require hospitals to submit data on measures that are not used for the determination of value-based incentive payments under subsection (o). ;
III|A|I|3001.(a)(2)(B)
in subclause (V), by striking beginning with fiscal year 2008 and inserting for fiscal years 2008 through 2012 ;
III|A|I|3001.(a)(2)(C)
in subclause (VII), in the first sentence, by striking data submitted and inserting information regarding measures submitted ; and
III|A|I|3001.(a)(2)(D)
by adding at the end the following new subclauses:
III|A|I|3001.(a)(2)(D)(VIII)
Effective for payments beginning with fiscal year 2013, with respect to quality measures for outcomes of care, the Secretary shall provide for such risk adjustment as the Secretary determines to be appropriate to maintain incentives for hospitals to treat patients with severe illnesses or conditions.
III|A|I|3001.(a)(2)(D)(IX)
Effective for payments beginning with fiscal year 2013, each measure specified by the Secretary under this clause shall be endorsed under paragraph (1) of section 1890C(f) or used as a result of a determination under paragraph (2) of such section.
III|A|I|3001.(a)(2)(D)(X)
To the extent practicable, the Secretary shall, with input from consensus organizations and other stakeholders, take steps to ensure that the measures specified by the Secretary under this clause are coordinated and aligned with quality measures applicable to -
III|A|I|3001.(a)(2)(D)(aa)
physicians under section 1848(k); and
III|A|I|3001.(a)(2)(D)(bb)
other providers of services and suppliers under this title.
III|A|I|3001.(a)(2)(D)(XI)
The Secretary shall establish a process to validate measures specified under this clause as appropriate. Such process shall include the auditing of a number of randomly selected hospitals sufficient to ensure validity of the reporting program under this clause as a whole and shall provide a hospital with an opportunity to appeal the validation of measures reported by such hospital. .
III|A|I|3001.(a)(3)
Website improvements Section 1886(b)(3)(B) of the Social Security Act ( 42 U.S.C. 1395ww(b)(3)(B) ), as amended by section 4102(b) of the HITECH Act ( Public Law 111-5 ), is amended by adding at the end the following new clause:
III|A|I|3001.(a)(3)(ix)
III|A|I|3001.(a)(3)(ix)(I)
The Secretary shall develop standard Internet website reports tailored to meet the needs of various stakeholders such as hospitals, patients, researchers, and policymakers. The Secretary shall seek input from such stakeholders in determining the type of information that is useful and the formats that best facilitate the use of the information.
III|A|I|3001.(a)(3)(ix)(II)
The Secretary shall modify the Hospital Compare Internet website to make the use and navigation of that website readily available to individuals accessing it.
.
III|A|I|3001.(a)(4)
GAO study and report
III|A|I|3001.(a)(4)(A)
Study The Comptroller General of the United States shall conduct a study on the performance of the hospital value-based purchasing program established under section 1886(o) of the Social Security Act, as added by paragraph (1). Such study shall include an analysis of the impact of such program on -
III|A|I|3001.(a)(4)(A)(i)
the quality of care furnished to Medicare beneficiaries, including diverse Medicare beneficiary populations (such as diverse in terms of race, ethnicity, and socioeconomic status);
III|A|I|3001.(a)(4)(A)(ii)
expenditures under the Medicare program, including any reduced expenditures under Part A of title XVIII of such Act that are attributable to the improvement in the delivery of inpatient hospital services by reason of such hospital value-based purchasing program;
III|A|I|3001.(a)(4)(A)(iii)
the quality performance among safety net hospitals and any barriers such hospitals face in meeting the performance standards applicable under such hospital value-based purchasing program; and
III|A|I|3001.(a)(4)(A)(iv)
the quality performance among small rural and small urban hospitals and any barriers such hospitals face in meeting the performance standards applicable under such hospital value-based purchasing program.
III|A|I|3001.(a)(4)(B)
Reports
III|A|I|3001.(a)(4)(B)(i)
Interim report Not later than October 1, 2015, the Comptroller General of the United States shall submit to Congress an interim report containing the results of the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.
III|A|I|3001.(a)(4)(B)(ii)
Final report Not later than July 1, 2017, the Comptroller General of the United States shall submit to Congress a report containing the results of the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.
III|A|I|3001.(a)(5)
HHS study and report
III|A|I|3001.(a)(5)(A)
Study The Secretary of Health and Human Services shall conduct a study on the performance of the hospital value-based purchasing program established under section 1886(o) of the Social Security Act, as added by paragraph (1). Such study shall include an analysis -
III|A|I|3001.(a)(5)(A)(i)
of ways to improve the hospital value-based purchasing program and ways to address any unintended consequences that may occur as a result of such program;
III|A|I|3001.(a)(5)(A)(ii)
of whether the hospital value-based purchasing program resulted in lower spending under the Medicare program under title XVIII of such Act or other financial savings to hospitals;
III|A|I|3001.(a)(5)(A)(iii)
the appropriateness of the Medicare program sharing in any savings generated through the hospital value-based purchasing program; and
III|A|I|3001.(a)(5)(A)(iv)
any other area determined appropriate by the Secretary.
III|A|I|3001.(a)(5)(B)
Report Not later than January 1, 2016, the Secretary of Health and Human Services shall submit to Congress a report containing the results of the study conducted under subparagraph (A), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.
III|A|I|3001.(b)
Value-Based purchasing demonstration programs
III|A|I|3001.(b)(1)
Value-Based purchasing demonstration program for inpatient critical access hospitals
III|A|I|3001.(b)(1)(A)
Establishment
III|A|I|3001.(b)(1)(A)(i)
In general Not later than 2 years after the date of enactment of this Act, the Secretary of Health and Human Services (in this subsection referred to as the Secretary ) shall establish a demonstration program under which the Secretary establishes a value-based purchasing program under the Medicare program under title XVIII of the Social Security Act for critical access hospitals (as defined in paragraph (1) of section 1861(mm) of such Act ( 42 U.S.C. 1395x(mm) )) with respect to inpatient critical access hospital services (as defined in paragraph (2) of such section) in order to test innovative methods of measuring and rewarding quality health care furnished by such hospitals.
III|A|I|3001.(b)(1)(A)(ii)
Duration The demonstration program under this paragraph shall be conducted for a 3-year period.
III|A|I|3001.(b)(1)(A)(iii)
Sites The Secretary shall conduct the demonstration program under this paragraph at an appropriate number (as determined by the Secretary) of critical access hospitals. The Secretary shall ensure that such hospitals are representative of the spectrum of such hospitals that participate in the Medicare program.
III|A|I|3001.(b)(1)(B)
Waiver authority The Secretary may waive such requirements of titles XI and XVIII of the Social Security Act as may be necessary to carry out the demonstration program under this paragraph.
III|A|I|3001.(b)(1)(C)
Report Not later than 18 months after the completion of the demonstration program under this paragraph, the Secretary shall submit to Congress a report on the demonstration program together with -
III|A|I|3001.(b)(1)(C)(i)
recommendations on the establishment of a permanent value-based purchasing program under the Medicare program for critical access hospitals with respect to inpatient critical access hospital services; and
III|A|I|3001.(b)(1)(C)(ii)
recommendations for such other legislation and administrative action as the Secretary determines appropriate.
III|A|I|3001.(b)(2)
Value-Based purchasing demonstration program for hospitals excluded from hospital Value-Based purchasing program as a result of insufficient numbers of measures and cases
III|A|I|3001.(b)(2)(A)
Establishment
III|A|I|3001.(b)(2)(A)(i)
In general Not later than 2 years after the date of enactment of this Act, the Secretary shall establish a demonstration program under which the Secretary establishes a value-based purchasing program under the Medicare program under title XVIII of the Social Security Act for applicable hospitals (as defined in clause (ii)) with respect to inpatient hospital services (as defined in section 1861(b) of the Social Security Act ( 42 U.S.C. 1395x(b) )) in order to test innovative methods of measuring and rewarding quality health care furnished by such hospitals.
III|A|I|3001.(b)(2)(A)(ii)
Applicable hospital defined For purposes of this paragraph, the term applicable hospital means a hospital described in subclause (III) or (IV) of section 1886(o)(1)(C)(ii) of the Social Security Act, as added by subsection (a)(1).
III|A|I|3001.(b)(2)(A)(iii)
Duration The demonstration program under this paragraph shall be conducted for a 3-year period.
III|A|I|3001.(b)(2)(A)(iv)
Sites The Secretary shall conduct the demonstration program under this paragraph at an appropriate number (as determined by the Secretary) of applicable hospitals. The Secretary shall ensure that such hospitals are representative of the spectrum of such hospitals that participate in the Medicare program.
III|A|I|3001.(b)(2)(B)
Waiver authority The Secretary may waive such requirements of titles XI and XVIII of the Social Security Act as may be necessary to carry out the demonstration program under this paragraph.
III|A|I|3001.(b)(2)(C)
Report Not later than 18 months after the completion of the demonstration program under this paragraph, the Secretary shall submit to Congress a report on the demonstration program together with -
III|A|I|3001.(b)(2)(C)(i)
recommendations on the establishment of a permanent value-based purchasing program under the Medicare program for applicable hospitals with respect to inpatient hospital services; and
III|A|I|3001.(b)(2)(C)(ii)
recommendations for such other legislation and administrative action as the Secretary determines appropriate.
III|A|I|3002.
Improvements to the physician quality reporting system
III|A|I|3002.(a)
Extension Section 1848(m) of the Social Security Act ( 42 U.S.C. 1395w-4(m) ) is amended -
III|A|I|3002.(a)(1)
in paragraph (1) -
III|A|I|3002.(a)(1)(A)
in subparagraph (A), in the matter preceding clause (i), by striking 2010 and inserting 2012 ; and
III|A|I|3002.(a)(1)(B)
in subparagraph (B) -
III|A|I|3002.(a)(1)(B)(i)
in clause (i), by striking and at the end;
III|A|I|3002.(a)(1)(B)(ii)
in clause (ii), by striking the period at the end and inserting a semicolon; and
III|A|I|3002.(a)(1)(B)(iii)
by adding at the end the following new clauses:
III|A|I|3002.(a)(1)(B)(iii)(iii)
for 2011, 1.0 percent; and
III|A|I|3002.(a)(1)(B)(iii)(iv)
for 2012, 0.5 percent. ;
III|A|I|3002.(a)(2)
in paragraph (3) -
III|A|I|3002.(a)(2)(A)
in subparagraph (A), in the matter preceding clause (i), by inserting (or, for purposes of subsection (a)(8), for the quality reporting period for the year) after reporting period ; and
III|A|I|3002.(a)(2)(B)
in subparagraph (C)(i), by inserting , or, for purposes of subsection (a)(8), for a quality reporting period for the year after (a)(5), for a reporting period for a year ;
III|A|I|3002.(a)(3)
in paragraph (5)(E)(iv), by striking subsection (a)(5)(A) and inserting paragraphs (5)(A) and (8)(A) of subsection (a) ; and
III|A|I|3002.(a)(4)
in paragraph (6)(C) -
III|A|I|3002.(a)(4)(A)
in clause (i)(II), by striking , 2009, 2010, and 2011 and inserting and subsequent years ; and
III|A|I|3002.(a)(4)(B)
in clause (iii) -
III|A|I|3002.(a)(4)(B)(i)
by inserting (a)(8) after (a)(5) ; and
III|A|I|3002.(a)(4)(B)(ii)
by striking under subparagraph (D)(iii) of such subsection and inserting under subsection (a)(5)(D)(iii) or the quality reporting period under subsection (a)(8)(D)(iii), respectively .
III|A|I|3002.(b)
Incentive payment adjustment for quality reporting Section 1848(a) of the Social Security Act ( 42 U.S.C. 1395w-4(a) ) is amended by adding at the end the following new paragraph:
III|A|I|3002.(b)(8)
Incentives for quality reporting
III|A|I|3002.(b)(8)(A)
Adjustment
III|A|I|3002.(b)(8)(A)(i)
In general With respect to covered professional services furnished by an eligible professional during 2013 or any subsequent year, if the eligible professional does not satisfactorily submit data on quality measures for covered professional services for the quality reporting period for the year (as determined under subsection (m)(3)(A)), the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraphs (3), (5), and (7), but without regard to this paragraph).
III|A|I|3002.(b)(8)(A)(ii)
Applicable percent For purposes of clause (i), the term applicable percent means -
III|A|I|3002.(b)(8)(A)(ii)(I)
for 2013, 98.5 percent; and
III|A|I|3002.(b)(8)(A)(ii)(II)
for 2014 and each subsequent year, 98 percent.
III|A|I|3002.(b)(8)(B)
Application
III|A|I|3002.(b)(8)(B)(i)
Physician reporting system rules Paragraphs (5), (6), and (8) of subsection (k) shall apply for purposes of this paragraph in the same manner as they apply for purposes of such subsection.
III|A|I|3002.(b)(8)(B)(ii)
Incentive payment validation rules Clauses (ii) and (iii) of subsection (m)(5)(D) shall apply for purposes of this paragraph in a similar manner as they apply for purposes of such subsection.
III|A|I|3002.(b)(8)(C)
Definitions For purposes of this paragraph:
III|A|I|3002.(b)(8)(C)(i)
Eligible professional; covered professional services The terms eligible professional and covered professional services have the meanings given such terms in subsection (k)(3).
III|A|I|3002.(b)(8)(C)(ii)
Physician reporting system The term physician reporting system means the system established under subsection (k).
III|A|I|3002.(b)(8)(C)(iii)
Quality reporting period The term quality reporting period means, with respect to a year, a period specified by the Secretary.
.
III|A|I|3002.(c)
Additional mechanism for determining satisfactory and successful reporting Section 1848(m)(3) of the Social Security Act ( 42 U.S.C. 1395w-4(m)(3) ) is amended by adding at the end the following new subparagraph:
III|A|I|3002.(c)(E)
Additional mechanism for satisfactory and successful reporting of measures
III|A|I|3002.(c)(E)(i)
In general Not later than January 1, 2011, the Secretary shall establish and have in place a process under which an eligible professional shall be treated as satisfactorily submitting data on quality measures under subparagraph (A) and as meeting the requirement described in subparagraph (B)(ii) for covered professional services for reporting periods for 2 consecutive years (or, for purposes of subsection (a)(5), for reporting periods for 2 consecutive years, or, for purposes of subsection (a)(8), for quality reporting periods for 2 consecutive years) if, during the reporting period of the first of such years, the eligible professional -
III|A|I|3002.(c)(E)(i)(I)
participates in a program described in clause (ii); and
III|A|I|3002.(c)(E)(i)(II)
completes a qualified MOC practice assessment.
III|A|I|3002.(c)(E)(ii)
Program described A program described in this clause is a qualified American Board of Medical Specialties Maintenance of Certification program (commonly referred to as a Maintenance of Certification program or MOC ) or an equivalent program (as determined by the Secretary) that -
III|A|I|3002.(c)(E)(ii)(I)
satisfactorily submits data through the mechanism described in subsection (k)(4) on quality measures under subparagraph (A) with respect to the eligible professional for the reporting period for the first year of such 2 consecutive years (as determined as determined by the Secretary); and
III|A|I|3002.(c)(E)(ii)(II)
submits to the Secretary (in accordance with procedures established by the Secretary under clause (iv)(II)) the information described in clause (iv)(I).
III|A|I|3002.(c)(E)(iii)
Qualified MOC practice assessment For purposes of clauses (i)(II), the term qualified MOC practice assessment means an assessment of a physician's practice that includes an initial assessment of an eligible professional's practice, is designed to demonstrate the eligible professional's use of evidence-based medicine, and would seek to improve quality of care through follow-up assessments.
III|A|I|3002.(c)(E)(iv)
Information described and establishment of procedures
III|A|I|3002.(c)(E)(iv)(I)
Information described The information described in this subclause is the methods, measures, and data used under a program described in clause (ii) or a qualified MOC practice assessment under clause (iii).
III|A|I|3002.(c)(E)(iv)(II)
Procedures The Secretary, in consultation with programs described in clause (ii), shall establish procedures for the submission of information under clause (ii). Such procedures shall ensure that the information described in subclause (I) allows for innovation and appropriateness with respect to the specialty of the eligible professional.
.
III|A|I|3002.(d)
Integration of physician quality reporting and EHR reporting Section 1848(m) of the Social Security Act ( 42 U.S.C. 1395w-4(m) ) is amended by adding at the end the following new paragraph:
III|A|I|3002.(d)(7)
Integration of physician quality reporting and EHR reporting Not later than January 1, 2012, the Secretary shall develop a plan to integrate 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:
III|A|I|3002.(d)(7)(A)
The selection of measures, the reporting of which would both demonstrate -
III|A|I|3002.(d)(7)(A)(i)
meaningful use of an electronic health record for purposes of subsection (o); and
III|A|I|3002.(d)(7)(A)(ii)
quality of care furnished to an individual.
III|A|I|3002.(d)(7)(B)
Such other activities as specified by the Secretary.
.
III|A|I|3002.(e)
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:
III|A|I|3002.(e)(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. .
III|A|I|3002.(f)
Appeals Such section is further amended -
III|A|I|3002.(f)(1)
in subparagraph (E), by striking There shall and inserting Except as provided in subparagraph (I), there shall ; and
III|A|I|3002.(f)(2)
by adding at the end the following new subparagraph:
III|A|I|3002.(f)(2)(I)
Informal appeals process The Secretary shall, by not later than January 1, 2011, establish and have in place an informal process for eligible professionals to seek a review of the determination that an eligible professional did not satisfactorily submit data on quality measures under this subsection. .
III|A|I|3003.
Improvements to the physician feedback program
III|A|I|3003.(a)
Improvements
III|A|I|3003.(a)(1)
In general Section 1848(n) of the Social Security Act ( 42 U.S.C. 1395w-4(n) ) is amended -
III|A|I|3003.(a)(1)(A)
in paragraph (1) -
III|A|I|3003.(a)(1)(A)(i)
in subparagraph (A) -
III|A|I|3003.(a)(1)(A)(i)(I)
by striking general . - The Secretary and inserting " general . -
III|A|I|3003.(a)(1)(A)(i)(I)(i)
Establishment The Secretary ;
III|A|I|3003.(a)(1)(A)(i)(II)
in clause (i), as added by clause (i), by striking the Program ) and all that follows through the period at the end of the second sentence and inserting the Program ). ; and
III|A|I|3003.(a)(1)(A)(i)(III)
by adding at the end the following new clauses:
III|A|I|3003.(a)(1)(A)(i)(III)(ii)
Reports on resources The Secretary shall use claims data under this title (and may use other data) to provide confidential reports to physicians (and, as determined appropriate by the Secretary, to groups of physicians) that measure the resources involved in furnishing care to individuals under this title.
III|A|I|3003.(a)(1)(A)(i)(III)(iii)
Inclusion of certain information If determined appropriate by the Secretary, the Secretary may include information on the quality of care furnished to individuals under this title by the physician (or group of physicians) in such reports. ; and
III|A|I|3003.(a)(1)(A)(ii)
in subparagraph (B), by striking subparagraph (A) and inserting subparagraph (A)(ii) ;
III|A|I|3003.(a)(1)(B)
in paragraph (4) -
III|A|I|3003.(a)(1)(B)(i)
in the heading, by inserting initial after focus ; and
III|A|I|3003.(a)(1)(B)(ii)
in the matter preceding subparagraph (A), by inserting initial after focus the ;
III|A|I|3003.(a)(1)(C)
in paragraph (6), by adding at the end the following new sentence: For adjustments for reports on utilization under paragraph (9), see subparagraph (D) of such paragraph. ; and
III|A|I|3003.(a)(1)(D)
by adding at the end the following new paragraphs:
III|A|I|3003.(a)(1)(D)(9)
Reports on utilization
III|A|I|3003.(a)(1)(D)(9)(A)
Development of episode grouper
III|A|I|3003.(a)(1)(D)(9)(A)(i)
In general The Secretary shall develop an episode grouper that combines separate but clinically related items and services into an episode of care for an individual, as appropriate.
III|A|I|3003.(a)(1)(D)(9)(A)(ii)
Timeline for development The episode grouper described in subparagraph (A) shall be developed by not later than January 1, 2012.
III|A|I|3003.(a)(1)(D)(9)(A)(iii)
Public availability The Secretary shall make the details of the episode grouper described in subparagraph (A) available to the public.
III|A|I|3003.(a)(1)(D)(9)(A)(iv)
Endorsement The Secretary shall seek endorsement of the episode grouper described in subparagraph (A) by the entity with a contract under section 1890(a).
III|A|I|3003.(a)(1)(D)(9)(B)
Reports on utilization Effective beginning with 2012, the Secretary shall provide reports to physicians that compare, as determined appropriate by the Secretary, patterns of resource use of the individual physician to such patterns of other physicians.
III|A|I|3003.(a)(1)(D)(9)(C)
Analysis of data The Secretary shall, for purposes of preparing reports under this paragraph, establish methodologies as appropriate, such as to -
III|A|I|3003.(a)(1)(D)(9)(C)(i)
attribute episodes of care, in whole or in part, to physicians;
III|A|I|3003.(a)(1)(D)(9)(C)(ii)
identify appropriate physicians for purposes of comparison under subparagraph (B); and
III|A|I|3003.(a)(1)(D)(9)(C)(iii)
aggregate episodes of care attributed to a physician under clause (i) into a composite measure per individual.
III|A|I|3003.(a)(1)(D)(9)(D)
Data adjustment In preparing reports under this paragraph, the Secretary shall make appropriate adjustments, including adjustments -
III|A|I|3003.(a)(1)(D)(9)(D)(i)
to account for differences in socio-economic and demographic characteristics, ethnicity, and health status of individuals (such as to recognize that less healthy individuals may require more intensive interventions); and
III|A|I|3003.(a)(1)(D)(9)(D)(ii)
to eliminate the effect of geographic adjustments in payment rates (as described in subsection (e)).
III|A|I|3003.(a)(1)(D)(9)(E)
Public availability of methodology The Secretary shall make available to the public -
III|A|I|3003.(a)(1)(D)(9)(E)(i)
the methodologies established under subparagraph (C);
III|A|I|3003.(a)(1)(D)(9)(E)(ii)
information regarding any adjustments made to data under subparagraph (D); and
III|A|I|3003.(a)(1)(D)(9)(E)(iii)
aggregate reports with respect to physicians.
III|A|I|3003.(a)(1)(D)(9)(F)
Definition of physician In this paragraph:
III|A|I|3003.(a)(1)(D)(9)(F)(i)
In general The term physician has the meaning given that term in section 1861(r)(1).
III|A|I|3003.(a)(1)(D)(9)(F)(ii)
Treatment of groups Such term includes, as the Secretary determines appropriate, a group of physicians.
III|A|I|3003.(a)(1)(D)(9)(G)
Limitations on review There shall be no administrative or judicial review under section 1869, section 1878, or otherwise or otherwise of the establishment of the methodology under subparagraph (C), including the determination of an episode of care under such methodology.
III|A|I|3003.(a)(1)(D)(10)
Coordination with other Value-Based purchasing reforms The Secretary shall coordinate the Program with the value-based payment modifier established under subsection (p) and, as the Secretary determines appropriate, other similar provisions of this title. .
III|A|I|3003.(a)(2)
Conforming amendment Section 1890(b) of the Social Security Act ( 42 U.S.C. 1395aaa(b) ) is amended by adding at the end the following new paragraph:
III|A|I|3003.(a)(2)(6)
Review and endorsement of episode grouper under the physician feedback program The entity shall provide for the review and, as appropriate, the endorsement of the episode grouper developed by the Secretary under section 1848(n)(9)(A). Such review shall be conducted on an expedited basis. .
III|A|I|3003.(b)
Incentives for avoiding excess Utilization Section 1848(a) of the Social Security Act ( 42 U.S.C. 1395w-4(a) ), as amended by section 3002(b), is amended by adding at the end the following new paragraph:
III|A|I|3003.(b)(9)
Incentive for avoiding excess utilization
III|A|I|3003.(b)(9)(A)
In general With respect to physicians' services furnished by an applicable physician on or after January 1, 2014, the fee schedule amount for such services furnished by the applicable physician during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be 95 percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraphs (3), (5), (7), and (8), but without regard to this paragraph).
III|A|I|3003.(b)(9)(B)
Applicable physician In this paragraph:
III|A|I|3003.(b)(9)(B)(i)
In general The term applicable physician means a physician which the Secretary determines is at or above the 90th percentile of resource use (or, if applicable, the standard measure of utilization specified under subparagraph (C)) with respect to a composite measure per individual, such as the composite measure under the methodology established under subsection (n)(9)(C)(iii).
III|A|I|3003.(b)(9)(B)(ii)
Definition of physician In this paragraph:
III|A|I|3003.(b)(9)(B)(ii)(I)
In general The term physician has the meaning given that term in section 1861(r)(1).
III|A|I|3003.(b)(9)(B)(ii)(II)
Treatment of groups Such term includes, as the Secretary determines appropriate, a group of physicians.
III|A|I|3003.(b)(9)(C)
Authority to revise standard measure of resource use for determining applicable physicians With respect to physicians' services furnished by an applicable physician on or after January 1, 2020, the Secretary may substitute a standard measure of resource use, such as deviation from the national mean, (as specified by the Secretary) for the percentile of resource use described in subparagraph (B)(i).
III|A|I|3003.(b)(9)(D)
Reporting period In this paragraph, the term reporting period means a period specified by the Secretary.
III|A|I|3003.(b)(9)(E)
Limitations on review There shall be no administrative or judicial review under section 1869, section 1878, or otherwise or otherwise of -
III|A|I|3003.(b)(9)(E)(i)
the determination of any incentive payment under subparagraph (A);
III|A|I|3003.(b)(9)(E)(ii)
the determination of who is an applicable physician under subparagraph (B)(i), including the specification and application of the standard measure of utilization under subparagraph (C); and
III|A|I|3003.(b)(9)(E)(iii)
the specification of the reporting period under subparagraph (D).
.
III|A|I|3004.
Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs
III|A|I|3004.(a)
Long-term care hospitals Section 1886(m) of the Social Security Act (42 U. S.C. 1395ww(m)), as amended by section 3401(c), is amended by adding at the end the following new paragraph:
III|A|I|3004.(a)(5)
Quality reporting
III|A|I|3004.(a)(5)(A)
Reduction in update for failure to report Under the system described in paragraph (1), for rate year 2014 and each subsequent rate year, in the case of a long-term care hospital that does not submit data to the Secretary in accordance with subparagraph (C) with respect to such a rate year, the update for payments for discharges occurring during such rate year shall be reduced by 2 percentage points.
III|A|I|3004.(a)(5)(B)
Noncumulative application Any reduction under subparagraph (A) shall apply only with respect to the rate year involved and the Secretary shall not take into account such reduction in computing the payment amount under the system described in paragraph (1) for a subsequent rate year.
III|A|I|3004.(a)(5)(C)
Submission of quality data For rate year 2014 and each subsequent rate year, each long-term care hospital shall submit to the Secretary data on quality measures specified under subparagraph (D). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph.
III|A|I|3004.(a)(5)(D)
Quality measures
III|A|I|3004.(a)(5)(D)(i)
In general The quality measures specified under this subparagraph shall be such measures selected by the Secretary from measures that have been endorsed under paragraph (1) of section 1890C(f) or used as a result of a determination under paragraph (2) of such section.
III|A|I|3004.(a)(5)(D)(ii)
Time frame Not later than October 1, 2012, the Secretary shall publish the measures selected under this subparagraph that will be applicable with respect to rate year 2014.
III|A|I|3004.(a)(5)(E)
Public availability of data submitted The Secretary shall establish procedures for making data submitted under subparagraph (C) available to the public. Such procedures shall ensure that a long-term care hospital has the opportunity to review the data that is to be made public with respect to the hospital prior to such data being made public. The Secretary shall report quality measures that relate to services furnished in inpatient settings in long-term care hospitals on the Internet website of the Centers for Medicare & Medicaid Services.
.
III|A|I|3004.(b)
Inpatient rehabilitation hospitals Section 1886(j) of the Social Security Act ( 42 U.S.C. 1395ww(j) ) is amended -
III|A|I|3004.(b)(1)
by redesignating paragraph (7) as paragraph (8); and
III|A|I|3004.(b)(2)
by inserting after paragraph (6) the following new paragraph:
III|A|I|3004.(b)(2)(7)
Quality reporting
III|A|I|3004.(b)(2)(7)(A)
Reduction in update for failure to report For purposes of fiscal year 2014 and each subsequent fiscal year, in the case of a rehabilitation facility that does not submit data to the Secretary in accordance with subparagraph (C) with respect to such a fiscal year, the increase factor to be applied under paragraph (3)(C) for payments for discharges occurring during such fiscal year shall be reduced by 2 percentage points.
III|A|I|3004.(b)(2)(7)(B)
Noncumulative application Any reduction under subparagraph (A) shall apply only with respect to the fiscal year involved and the Secretary shall not take into account such reduction in computing the payment amount under this subsection for a subsequent fiscal year.
III|A|I|3004.(b)(2)(7)(C)
Submission of quality data For fiscal year 2014 and each subsequent rate year, each rehabilitation facility shall submit to the Secretary data on quality measures specified under subparagraph (D). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph.
III|A|I|3004.(b)(2)(7)(D)
Quality measures
III|A|I|3004.(b)(2)(7)(D)(i)
In general The quality measures specified under this subparagraph shall be such measures selected by the Secretary from measures that have been endorsed under paragraph (1) of section 1890C(f) or used as a result of a determination under paragraph (2) of such section.
III|A|I|3004.(b)(2)(7)(D)(ii)
Time frame Not later than October 1, 2012, the Secretary shall publish the measures selected under this subparagraph that will be applicable with respect to fiscal year 2014.
III|A|I|3004.(b)(2)(7)(E)
Public availability of data submitted The Secretary shall establish procedures for making data submitted under subparagraph (C) available to the public. Such procedures shall ensure that a rehabilitation facility has the opportunity to review the data that is to be made public with respect to the facility prior to such data being made public. The Secretary shall report quality measures that relate to services furnished in inpatient settings in rehabilitation facilities on the Internet website of the Centers for Medicare & Medicaid Services.
.
III|A|I|3004.(c)
Hospice programs Section 1814(i) of the Social Security Act ( 42 U.S.C. 1395f(i) ) is amended -
III|A|I|3004.(c)(1)
by redesignating paragraph (5) as paragraph (6); and
III|A|I|3004.(c)(2)
by inserting after paragraph (4) the following new paragraph:
III|A|I|3004.(c)(2)(5)
Quality reporting
III|A|I|3004.(c)(2)(5)(A)
Reduction in update for failure to report For purposes of fiscal year 2014 and each subsequent fiscal year, in the case of a hospice program that does not submit data to the Secretary in accordance with subparagraph (C) with respect to such a fiscal year, the market basket percentage increase to be applied under clause (ii) or (iii) of paragraph (1)(C), as applicable, for payments for routine home care and other services included in hospice care furnished during such fiscal year shall be reduced by 2 percentage points.
III|A|I|3004.(c)(2)(5)(B)
Noncumulative application Any reduction under subparagraph (A) shall apply only with respect to the fiscal year involved and the Secretary shall not take into account such reduction in computing the payment amount under this subsection for a subsequent fiscal year.
III|A|I|3004.(c)(2)(5)(C)
Submission of quality data For fiscal year 2014 and each subsequent fiscal year, each hospice program shall submit to the Secretary data on quality measures specified under subparagraph (D). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph.
III|A|I|3004.(c)(2)(5)(D)
Quality measures
III|A|I|3004.(c)(2)(5)(D)(i)
In general The quality measures specified under this subparagraph shall be such measures selected by the Secretary from measures that have been endorsed under paragraph (1) of section 1890C(f) or used as a result of a determination under paragraph (2) of such section.
III|A|I|3004.(c)(2)(5)(D)(ii)
Time frame Not later than October 1, 2012, the Secretary shall publish the measures selected under this subparagraph that will be applicable with respect to fiscal year 2014.
III|A|I|3004.(c)(2)(5)(E)
Public availability of data submitted The Secretary shall establish procedures for making data submitted under subparagraph (C) available to the public. Such procedures shall ensure that a hospice program has the opportunity to review the data that is to be made public with respect to the hospice program prior to such data being made public. The Secretary shall report quality measures that relate to hospice care provided by hospice programs on the Internet website of the Centers for Medicare & Medicaid Services.
.
III|A|I|3005.
Quality reporting for PPS-exempt cancer hospitals Section 1866 of the Social Security Act ( 42 U.S.C. 1395cc ) is amended -
III|A|I|3005.(1)
in subsection (a)(1) -
III|A|I|3005.(1)(A)
in subparagraph (U), by striking and at the end;
III|A|I|3005.(1)(B)
in subparagraph (V), by striking the period at the end and inserting , and ; and
III|A|I|3005.(1)(C)
by adding at the end the following new subparagraph:
III|A|I|3005.(1)(C)(W)
in the case of a hospital described in section 1886(d)(1)(B)(v), to report quality data to the Secretary in accordance with subsection (k). ; and
III|A|I|3005.(2)
by adding at the end the following new subsection:
III|A|I|3005.(2)(k)
Quality reporting by cancer hospitals
III|A|I|3005.(2)(k)(1)
In general For purposes of fiscal year 2014 and each subsequent fiscal year, a hospital described in section 1886(d)(1)(B)(v) shall submit data to the Secretary in accordance with paragraph (2) with respect to such a fiscal year.
III|A|I|3005.(2)(k)(2)
Submission of quality data For fiscal year 2014 and each subsequent fiscal year, each hospital described in such section shall submit to the Secretary data on quality measures specified under paragraph (3). Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this subparagraph.
III|A|I|3005.(2)(k)(3)
Quality measures
III|A|I|3005.(2)(k)(3)(A)
In general The quality measures specified under this subparagraph shall be such measures selected by the Secretary from measures that have been endorsed under paragraph (1) of section 1890C(f) or used as a result of a determination under paragraph (2) of such section.
III|A|I|3005.(2)(k)(3)(C)
Time frame Not later than October 1, 2012, the Secretary shall publish the measures selected under this paragraph that will be applicable with respect to fiscal year 2014.
III|A|I|3005.(2)(k)(4)
Public availability of data submitted The Secretary shall establish procedures for making data submitted under paragraph (4) available to the public. Such procedures shall ensure that a hospital described in section 1886(d)(1)(B)(v) has the opportunity to review the data that is to be made public with respect to the hospital prior to such data being made public. The Secretary shall report quality measures of process, structure, outcome, patients' perspective on care, efficiency, and costs of care that relate to services furnished in such hospitals on the Internet website of the Centers for Medicare & Medicaid Services.
.
III|A|I|3006.
Plans for a Value-Based purchasing program for skilled nursing facilities and home health agencies
III|A|I|3006.(a)
Skilled nursing facilities
III|A|I|3006.(a)(1)
In general The Secretary of Health and Human Services (in this section referred to as the Secretary ) shall develop a plan to implement a value-based purchasing program for payments under the Medicare program under title XVIII of the Social Security Act for skilled nursing facilities (as defined in section 1819(a) of such Act ( 42 U.S.C. 1395i-3(a) )).
III|A|I|3006.(a)(2)
Details In developing the plan under paragraph (1), the Secretary shall consider the following issues:
III|A|I|3006.(a)(2)(A)
The ongoing development, selection, and modification process for measures (as selected from measures that are endorsed under paragraph (1) of section 1890C(f) or used as a result of a determination under paragraph (2) of such section), to the extent feasible and practicable, of all dimensions of quality and efficiency in skilled nursing facilities.
III|A|I|3006.(a)(2)(B)
The reporting, collection, and validation of quality data.
III|A|I|3006.(a)(2)(C)
The structure of value-based payment adjustments, including the determination of thresholds or improvements in quality that would substantiate a payment adjustment, the size of such payments, and the sources of funding for the value-based bonus payments.
III|A|I|3006.(a)(2)(D)
Methods for the public disclosure of information on the performance of skilled nursing facilities.
III|A|I|3006.(a)(2)(E)
Any other issues determined appropriate by the Secretary.
III|A|I|3006.(a)(3)
Consultation In developing the plan under paragraph (1), the Secretary shall -
III|A|I|3006.(a)(3)(A)
consult with relevant affected parties; and
III|A|I|3006.(a)(3)(B)
consider experience with such demonstrations that the Secretary determines are relevant to the value-based purchasing program described in paragraph (1).
III|A|I|3006.(a)(4)
Report to congress Not later than October 1, 2011, the Secretary shall submit to Congress a report containing the plan developed under paragraph (1).
III|A|I|3006.(b)
Home health agencies
III|A|I|3006.(b)(1)
In general The Secretary of Health and Human Services (in this section referred to as the Secretary ) shall develop a plan to implement a value-based purchasing program for payments under the Medicare program under title XVIII of the Social Security Act for home health agencies (as defined in section 1861(o) of such Act ( 42 U.S.C. 1395x(o) )).
III|A|I|3006.(b)(2)
Details In developing the plan under paragraph (1), the Secretary shall consider the following issues:
III|A|I|3006.(b)(2)(A)
The ongoing development, selection, and modification process for measures (as selected from measures that are endorsed under paragraph (1) of section 1890C(f) or used as a result of a determination under paragraph (2) of such section), to the extent feasible and practicable, of all dimensions of quality and efficiency in home health agencies.
III|A|I|3006.(b)(2)(B)
The reporting, collection, and validation of quality data.
III|A|I|3006.(b)(2)(C)
The structure of value-based payment adjustments, including the determination of thresholds or improvements in quality that would substantiate a payment adjustment, the size of such payments, and the sources of funding for the value-based bonus payments.
III|A|I|3006.(b)(2)(D)
Methods for the public disclosure of information on the performance of home health agencies.
III|A|I|3006.(b)(2)(E)
Any other issues determined appropriate by the Secretary.
III|A|I|3006.(b)(3)
Consultation In developing the plan under paragraph (1), the Secretary shall -
III|A|I|3006.(b)(3)(A)
consult with relevant affected parties; and
III|A|I|3006.(b)(3)(B)
consider experience with such demonstrations that the Secretary determines are relevant to the value-based purchasing program described in paragraph (1).
III|A|I|3006.(b)(4)
Report to congress Not later than October 1, 2010, the Secretary shall submit to Congress a report containing the plan developed under paragraph (1).
III|A|I|3007.
Value-based payment modifier under the physician fee schedule Section 1848 of the Social Security Act ( 42 U.S.C. 1395w-4 ) is amended -
III|A|I|3007.(1)
in subsection (b)(1), by inserting subject to subsection (p), after 1998, .
III|A|I|3007.(2)
by adding at the end the following new subsection:
III|A|I|3007.(2)(p)
Establishment of value-based payment modifier
III|A|I|3007.(2)(p)(1)
In general The Secretary shall establish a payment modifier that provides for differential payment to a physician or a group of physicians under the fee schedule established under subsection (b) based upon the quality of care furnished compared to cost (as determined under paragraphs (2) and (3), respectively) during a performance period. Such payment modifier shall be separate from the geographic adjustment factors established under subsection (e).
III|A|I|3007.(2)(p)(2)
Quality
III|A|I|3007.(2)(p)(2)(A)
In general For purposes of paragraph (1), quality of care shall be evaluated, to the extent practicable, based on a composite of measures of the quality of care furnished (as established by the Secretary under subparagraph (B)).
III|A|I|3007.(2)(p)(2)(B)
Measures
III|A|I|3007.(2)(p)(2)(B)(i)
The Secretary shall establish appropriate measures of the quality of care furnished by a physician or group of physicians to individuals enrolled under this part, such as measures that reflect health outcomes. Such measures shall be risk adjusted as determined appropriate by the Secretary.
III|A|I|3007.(2)(p)(2)(B)(ii)
The Secretary shall seek endorsement of the measures established under this subparagraph by the entity with a contract under section 1890(a).
III|A|I|3007.(2)(p)(3)
Costs For purposes of paragraph (1), costs shall be evaluated, to the extent practicable, based on a composite of appropriate measures of costs established by the Secretary (such as the composite measure under the methodology established under subsection (n)(9)(C)(iii)) that eliminate the effect of geographic adjustments in payment rates (as described in subsection (e)), and take into account risk factors (such as socio-economic and demographic characteristics, ethnicity, and health status of individuals (such as to recognize that less healthy individuals may require more intensive interventions) and other factors determined appropriate by the Secretary.
III|A|I|3007.(2)(p)(4)
Implementation
III|A|I|3007.(2)(p)(4)(A)
Publication of measures, dates of implementation, performance period Not later than January 1, 2012, the Secretary shall publish the following:
III|A|I|3007.(2)(p)(4)(A)(i)
The measures of quality of care and costs established under paragraphs (2) and (3), respectively.
III|A|I|3007.(2)(p)(4)(A)(ii)
The dates for implementation of the payment modifier (as determined under subparagraph (B)).
III|A|I|3007.(2)(p)(4)(A)(iii)
The initial performance period (as specified under subparagraph (B)(ii)).
III|A|I|3007.(2)(p)(4)(B)
Deadlines for implementation
III|A|I|3007.(2)(p)(4)(B)(i)
Initial implementation Subject to the preceding provisions of this subparagraph, the Secretary shall begin implementing the payment modifier established under this subsection through the rulemaking process during 2013 for the physician fee schedule established under subsection (b).
III|A|I|3007.(2)(p)(4)(B)(ii)
Initial performance period
III|A|I|3007.(2)(p)(4)(B)(ii)(I)
In general The Secretary shall specify an initial performance period for application of the payment modifier established under this subsection with respect to 2015.
III|A|I|3007.(2)(p)(4)(B)(ii)(II)
Provision of information during initial performance period During the initial performance period, the Secretary shall, to the extent practicable, provide information to physicians and groups of physicians about the quality of care furnished by the physician or group of physicians to individuals enrolled under this part compared to cost (as determined under paragraphs (2) and (3), respectively) with respect to the performance period.
III|A|I|3007.(2)(p)(4)(B)(iii)
Application The Secretary shall apply the payment modifier established under this subsection for items and services furnished -
III|A|I|3007.(2)(p)(4)(B)(iii)(I)
beginning on January 1, 2015, with respect to specific physicians and groups of physicians the Secretary determines appropriate; and
III|A|I|3007.(2)(p)(4)(B)(iii)(II)
beginning not later than January 1, 2017, with respect to all physicians and groups of physicians.
III|A|I|3007.(2)(p)(4)(C)
Budget neutrality The payment modifier established under this subsection shall be implemented in a budget neutral manner.
III|A|I|3007.(2)(p)(5)
Systems-based care The Secretary shall, as appropriate, apply the payment modifier established under this subsection in a manner that promotes systems-based care.
III|A|I|3007.(2)(p)(6)
Consideration of special circumstances of certain providers In applying the payment modifier under this subsection, the Secretary shall, as appropriate, take into account the special circumstances of physicians or groups of physicians in rural areas and other underserved communities.
III|A|I|3007.(2)(p)(7)
Application For purposes of the initial application of the payment modifier established under this subsection during the period beginning on January 1, 2015, and ending on December 31, 2016, the term physician has the meaning given such term in section 1861(r). On or after January 1, 2017, the Secretary may apply this subsection to eligible professionals (as defined in subsection (k)(3)(B)) as the Secretary determines appropriate.
III|A|I|3007.(2)(p)(8)
Definitions For purposes of this subsection:
III|A|I|3007.(2)(p)(8)(A)
Costs The term costs means expenditures per individual as determined appropriate by the Secretary. In making the determination under the preceding sentence, the Secretary may take into account the amount of growth in expenditures per individual for a physician compared to the amount of such growth for other physicians.
III|A|I|3007.(2)(p)(8)(B)
Performance period The term performance period means a period specified by the Secretary.
III|A|I|3007.(2)(p)(9)
Coordination with other value-based purchasing reforms The Secretary shall coordinate the value-based payment modifier established under this subsection with the Physician Feedback Program under subsection (n) and, as the Secretary determines appropriate, other similar provisions of this title.
III|A|I|3007.(2)(p)(10)
Limitations on review There shall be no administrative or judicial review under section 1869, section 1878, or otherwise or otherwise of -
III|A|I|3007.(2)(p)(10)(A)
the establishment of the value-based payment modifier under this subsection;
III|A|I|3007.(2)(p)(10)(B)
the evaluation of quality of care under paragraph (2), including the establishment of appropriate measures of the quality of care under paragraph (2)(B);
III|A|I|3007.(2)(p)(10)(C)
the evaluation of costs under paragraph (3), including the establishment of appropriate measures of costs under such paragraph;
III|A|I|3007.(2)(p)(10)(D)
the dates for implementation of the value-based payment modifier;
III|A|I|3007.(2)(p)(10)(E)
the specification of the initial performance period and any other performance period under paragraphs (4)(B)(ii) and (8)(B), respectively;
III|A|I|3007.(2)(p)(10)(F)
the application of the value-based payment modifier under paragraph (7); and
III|A|I|3007.(2)(p)(10)(G)
the determination of costs under paragraph (8)(A).
.
III|A|I|3008.
Payment adjustment for conditions acquired in hospitals Section 1886 of the Social Security Act ( 42 U.S.C. 1395ww ), as amended by section 3001, is amended by adding at the end the following new subsection:
III|A|I|3008.(p)
Adjustment to hospital payments for hospital acquired conditions
III|A|I|3008.(p)(1)
In general In order to provide an incentive for applicable hospitals to reduce hospital acquired conditions under this title, with respect to discharges from an applicable hospital occurring during fiscal year 2015 or a subsequent fiscal year, the amount of payment under this section or section 1814(b)(3), as applicable, for such discharges during the fiscal year shall be equal to 99 percent of the amount of payment that would otherwise apply to such discharges under this section or section 1814(b)(3) (determined after the application of subsections (n), (o), and (q) and section 1814(l)(3) but without regard to this subsection).
III|A|I|3008.(p)(2)
Applicable hospitals
III|A|I|3008.(p)(2)(A)
In general For purposes of this subsection, the term applicable hospital means a subsection (d) hospital that meets the criteria described in subparagraph (B).
III|A|I|3008.(p)(2)(B)
Criteria described
III|A|I|3008.(p)(2)(B)(i)
In general The criteria described in this subparagraph, with respect to a subsection (d) hospital, is that the subsection (d) hospital is in the top quartile of all subsection (d) hospitals, relative to the national average, of hospital acquired conditions during the applicable period, as determined by the Secretary.
III|A|I|3008.(p)(2)(B)(ii)
Risk adjustment In carrying out clause (i), the Secretary shall establish and apply an appropriate risk adjustment methodology.
III|A|I|3008.(p)(3)
Hospital acquired conditions For purposes of this subsection, the term hospital acquired condition means a condition identified for purposes of subsection (d)(4)(D)(iv) that an individual acquires during a stay in an applicable hospital, as determined by the Secretary.
III|A|I|30