S. 1679 (111th): Affordable Health Choices Act

111th Congress, 2009–2010. Text as of Sep 17, 2009 (Placed on Calendar in the Senate).

Status & Summary | PDF | Source: GPO

II

Calendar No. 161

111th CONGRESS

1st Session

S. 1679

IN THE SENATE OF THE UNITED STATES

September 17, 2009

, from the Committee on Health, Education, Labor, and Pensions reported the following original bill; which was read twice and placed on the calendar

A BILL

To make quality, affordable health care available to all Americans, reduce costs, improve health care quality, enhance disease prevention, and strengthen the health care workforce.

1.

Short title; table of contents

(a)

Short title

This Act may be cited as the Affordable Health Choices Act.

(b)

Table of contents

The table of contents of this Act is as follows:

Sec. 1. Short title; table of contents.

TITLE I—Quality, affordable health care for all Americans

Subtitle A—Effective coverage for all Americans

PART I—Provisions applicable to the individual and group markets

Sec. 101. Amendment to the Public Health Service Act.

PART A—Individual and group market reforms

SUBPART 1—General reform

Sec. 2705. Prohibition of preexisting condition exclusions or other discrimination based on health status.

Sec. 2701. Fair insurance coverage.

Sec. 2702. Guaranteed availability of coverage.

Sec. 2703. Guaranteed renewability of coverage.

Sec. 2704. Increasing the Transparency of Health Care Costs and Regulatory Fees.

Sec. 2706. Prohibiting discrimination against individual participants and beneficiaries based on health status.

Sec. 2707. Ensuring the quality of care.

Sec. 2708. Coverage of preventive health services.

Sec. 2709. Coverage of Preventive Women’s Health Services.

Sec. 2710. Extension of dependent coverage.

Sec. 2711. No lifetime or annual limits.

Sec. 2712. Notification by plans not providing minimum qualifying coverage.

Sec. 2713. Non-discrimination in health care.

PART II—Provision applicable to the group market

Sec. 121. Amendment to the Public Health Service Act.

Sec. 2720A. Prohibition of discrimination based on salary.

PART III—Other provisions

Sec. 131. No changes to existing coverage.

Sec. 132. Applicability.

Sec. 133. Conforming amendments.

Sec. 134. Savings.

Sec. 135. Effective dates.

Subtitle B—Available coverage for all Americans

Sec. 141. Building on the success of the Federal Employees Health Benefits Program and the health benefits program of most large employers so all Americans have affordable health benefit choices.

Sec. 142. Affordable health choices for all Americans.

TITLE XXXI—Affordable health choices for all Americans

Subtitle A—Affordable choices

Sec. 3101. Affordable choices of health benefit plans.

Sec. 3102. Financial integrity.

Sec. 3103. Program design.

Sec. 3104. Allowing State flexibility.

Sec. 3105. Navigators.

Sec. 3106. Community health insurance option.

Sec. 3107. Application of same laws to private plans and the community health insurance option.

Sec. 3108. Participation of professionals on certain health-related commissions.

Sec. 3109. Health insurance consumer assistance grants.

Sec. 143. Freedom not to participate in Federal health insurance programs.

Subtitle C—Affordable coverage for all Americans

Sec. 151. Support for affordable health coverage.

Subtitle B—Making coverage affordable

Sec. 3111. Support for affordable health coverage.

Sec. 3112. Small business health options program credit.

Sec. 152. Program integrity.

Subtitle D—Shared responsibility for health care

Sec. 161. Individual responsibility.

Sec. 162. Notification on the availability of affordable health choices.

Sec. 163. Shared responsibility of employers.

Sec. 3115. Shared responsibility of employers.

Sec. 3116. Definitions.

Subtitle E—Improving access to health care services

Sec. 171. Spending for Federally Qualified Health Centers (FQHCs).

Sec. 172. Other provisions.

Sec. 173. Negotiated rulemaking for development of methodology and criteria for designating medically underserved populations and health professions shortage areas.

Sec. 174. Equity for certain eligible survivors.

Sec. 175. Reauthorization of the Wakefield Emergency Medical Services for Children Program.

Sec. 176. Co-locating primary and specialty care in community-based mental health settings.

Subtitle F—Making health care more affordable for retirees

Sec. 181. Reinsurance for retirees.

Subtitle G—Improving the Use of Health Information Technology for Enrollment; Miscellaneous Provisions

Sec. 185. Health information technology enrollment standards and protocols.

Sec. 186. Rule of construction regarding Hawaii's Prepaid Health Care Act.

Sec. 187. Key National indicators.

Sec. 188. Study and report on rates of preventable diseases in new Medicare enrollees.

Sec. 189. Transparency in government.

Sec. 189A. Preserving the solvency of Medicare and Social Security.

Sec. 189B. Prohibition against discrimination on assisted suicide.

Sec. 189C. Access to therapies.

Sec. 189D. Freedom not to participate in Federal health insurance programs.

Subtitle H—CLASS Act

Sec. 190. Short title of subtitle.

Sec. 191. Establishment of national voluntary insurance program for purchasing community living assistance services and support.

TITLE XXXII—Community Living Assistance Services and Supports

Sec. 3201. Purpose.

Sec. 3202. Definitions.

Sec. 3203. CLASS Independence Benefit Plan.

Sec. 3204. Enrollment and disenrollment requirements.

Sec. 3205. Benefits.

Sec. 3206. CLASS Independence Fund.

Sec. 3207. CLASS Independence Advisory Council.

Sec. 3208. Regulations; annual report.

Sec. 3209. Inspector General's report.

Sec. 3210. Tax treatment of program.

TITLE II—Improving the quality and efficiency of health care

Subtitle A—National strategy to improve health care quality

Sec. 201. National strategy.

Sec. 202. Interagency Working Group on Health Care Quality.

Sec. 203. Quality measure development.

Sec. 204. Quality measure endorsement; public reporting; data collection.

Sec. 205. Collection and analysis of data for quality and resource use measures.

Subtitle B—Health care quality improvements

Sec. 211. Health care delivery system research; Quality improvement technical assistance.

Sec. 212. Grants to establish community health teams to support the patient-centered medical home.

Sec. 213. Grants to implement medication management services in treatment of chronic disease.

Sec. 214. Design and implementation of regionalized systems for emergency care.

Sec. 215. Trauma care centers and service availability.

Sec. 216. Reducing and reporting hospital readmissions.

Sec. 217. Program to facilitate shared decisionmaking.

Sec. 218. Presentation of prescription drug benefit and risk information.

Sec. 219. Center for health outcomes research and evaluation.

Sec. 220. Demonstration program to integrate quality improvement and patient safety training into clinical education of health professionals.

Sec. 221. Office of women's health.

Sec. 222. Administrative simplification.

Sec. 223. Patient navigator program.

Sec. 224. Authorization of appropriations.

Subtitle C—Civil and criminal penalties for acts involving Federal health care programs; exception to limitation on certain physician referrals

Sec. 231. Safe harbors to antikickback civil penalties and criminal penalties for provision of health information technology and training services.

Sec. 232. Exception to limitation on certain physician referrals (under Stark) for provision of health information technology and training services to health care professionals.

Sec. 233. Rules of construction regarding use of consortia.

TITLE III—Improving the health of the American people

Subtitle A—Modernizing disease prevention and public health systems

Sec. 301. National Prevention, Health Promotion and Public Health Council.

Sec. 302. Prevention and Public Health Fund.

Sec. 303. Clinical and Community Preventive Services.

Sec. 304. Education and outreach campaign regarding preventive benefits.

Subtitle B—Increasing access to clinical preventive services

Sec. 311. Right choices program.

Sec. 312. School-based health clinics.

Sec. 313. Oral healthcare prevention activities.

Sec. 314. Oral health improvement.

Subtitle C—Creating healthier communities

Sec. 321. Community transformation grants.

Sec. 322. Healthy aging, living well.

Sec. 323. Wellness for individuals with disabilities.

Sec. 324. Immunizations.

Sec. 325. Nutrition labeling of standard menu items at chain restaurants and of articles of food sold from vending machines.

Sec. 326. Encouraging employer-sponsored wellness programs.

Sec. 327. Demonstration project concerning individualized wellness plan.

Sec. 328. Reasonable break time for nursing mothers.

Subtitle D—Support for prevention and public health innovation

Sec. 331. Research on optimizing the delivery of public health services.

Sec. 332. Understanding health disparities: data collection and analysis.

Sec. 333. Health impact assessments.

Sec. 334. CDC and employer-based wellness programs.

Sec. 335. Epidemiology-Laboratory Capacity Grants.

Sec. 336. Federal messaging on health promotion and disease prevention.

Subtitle E—Advancing research and treatment for pain care management

Sec. 341. Institute of Medicine Conference on Pain.

Sec. 342. Pain research at National Institutes of Health.

Sec. 343. Pain care education and training.

Sec. 344. Public awareness campaign on pain management.

Subtitle F—Coordinated environmental public health network

Sec. 351. Amendment to the Public Health Service Act.

Subtitle G—Miscellaneous provisions

Sec. 361. Sense of the Senate concerning CBO scoring.

Sec. 362. Effectiveness of Federal health and wellness initiatives.

TITLE IV—Health care workforce

Subtitle A—Purpose and definitions

Sec. 401. Purpose.

Sec. 402. Definitions.

Subtitle B—Innovations in the health care workforce

Sec. 411. National health care workforce commission.

Sec. 412. State health care workforce development grants.

Sec. 413. Health care workforce program assessment.

Subtitle C—Increasing the supply of the health care workforce

Sec. 421. Federally supported student loan funds.

Sec. 422. Nursing student loan program.

Sec. 423. Health care workforce loan repayment programs.

Sec. 424. Public health workforce recruitment and retention programs.

Sec. 425. Allied health workforce recruitment and retention programs.

Sec. 426. Grants for State and local programs.

Sec. 427. Funding for National Health Service Corps.

Sec. 428. Nurse-managed health clinics.

Sec. 429. Elimination of cap on commissioned corps.

Sec. 430. Establishing a Ready Reserve Corps.

Subtitle D—Enhancing health care workforce education and training

Sec. 431. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship.

Sec. 432. Training opportunities for direct care workers.

Sec. 433. Training in general, pediatric, and public health dentistry.

Sec. 434. Alternative dental health care providers demonstration project.

Sec. 435. Geriatric education and training; career awards; comprehensive geriatric education.

Sec. 436. Mental and behavioral health education and training grants.

Sec. 437. Cultural competency, prevention and public health and individuals with disabilities training.

Sec. 438. Advanced nursing education grants.

Sec. 439. Nurse education, practice, and retention grants.

Sec. 440. Loan repayment and scholarship program.

Sec. 441. Nurse faculty loan program.

Sec. 442. Authorization of appropriations for parts B through D of title VIII.

Sec. 443. Grants to promote the community health workforce.

Sec. 444. Youth public health program.

Sec. 445. Fellowship training in public health.

Sec. 446. United States Public Health Sciences Track.

Subtitle E—Supporting the Existing Health Care Workforce

Sec. 451. Centers of excellence.

Sec. 452. Health care professionals training for diversity.

Sec. 453. Interdisciplinary, community-based linkages.

Sec. 454. Workforce diversity grants.

Sec. 455. Primary care extension program.

Sec. 456. Definition of economic hardship.

Subtitle F—General Provisions

Sec. 461. Reports.

TITLE V—Preventing fraud and abuse

Subtitle A—Establishment of New Health and Human Services and Department of Justice Health Care Fraud Positions

Sec. 501. Health and Human Services Senior Advisor.

Sec. 502. Department of Justice Position.

Sec. 503. Reports to Congress.

Sec. 504. Fraud, waste, and abuse commission.

Subtitle B—Health Care Program Integrity Coordinating Council

Sec. 511. Establishment.

Subtitle C—False Statements and Representations

Sec. 521. Prohibition on false statements and representations.

Subtitle D—Federal health care offense

Sec. 531. Clarifying definition.

Subtitle E—Uniformity in fraud and abuse reporting

Sec. 541. Development of model uniform report form.

Subtitle F—Applicability of State law to combat fraud and abuse

Sec. 551. Applicability of State law to combat fraud and abuse.

Subtitle G—Enabling the Department of Labor to issue administrative summary cease and desist orders and summary seizures orders against plans that are in financially hazardous condition

Sec. 561. Enabling the Department of Labor to issue administrative summary cease and desist orders and summary seizures orders against plans that are in financially hazardous condition.

Subtitle H—Requiring Multiple Employer Welfare Arrangement (MEWA) plans to file a registration form with the Department of Labor prior to enrolling anyone in the plan

Sec. 571. MEWA plan registration with Department of Labor.

Subtitle I—Permitting evidentiary privilege and confidential communications

Sec. 581. Permitting evidentiary privilege and confidential communications.

TITLE VI—Improving access to innovative medical therapies

Subtitle A—Biologics price competition and innovation

Sec. 601. Short title.

Sec. 602. Approval pathway for biosimilar biological products.

Sec. 603. Savings.

Subtitle B—More affordable medicines for children and underserved communities

Sec. 611. Expanded participation in 340B program.

Sec. 612. Improvements to 340B program integrity.

Sec. 613. GAO study to make recommendations on improving the 340B program.

I

Quality, affordable health care for all Americans

A

Effective coverage for all Americans

I

Provisions applicable to the individual and group markets

101.

Amendment to the Public Health Service Act

Part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended—

(1)

by striking the part heading and heading for subpart 1 and inserting the following:

A

Individual and group market reforms

1

General reform

;

(2)

in section 2701 (42 U.S.C. 300gg)—

(A)

by striking the section heading and subsection (a) and inserting the following:

2705.

Prohibition of preexisting condition exclusions or other discrimination based on health status

(a)

In general

A group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage.

; and

(B)

by transferring the remainder of section so as to appear after the section 2704 as added by paragraph (5);

(3)

in section 2702 (42 U.S.C. 300gg-1)—

(A)

by striking the section heading and all that follows through subsection (a)—

(B)

in subsection (b)—

(i)

by striking health insurance issuer offering health insurance coverage in connection with a group health plan each place that such appears and inserting health insurance issuer offering group or individual health insurance coverage; and

(ii)

in paragraph (2)(A)—

(I)

by inserting or individual after employer; and

(II)

by inserting or individual health coverage, as the case may be before the semicolon;

(C)

by redesignating subsections (b) through (f) as subsections (e) through (i), respectively; and

(D)

by transferring the remainder of such section to appear at the end of section 2706 (as added by paragraph (5));

(4)

by redesignating existing sections 2704 through 2707 and sections 2711 through 2713 as sections 2717 through 2720 and sections 2714 through 2716, respectively; and

(5)

by inserting after the subpart heading (as added by paragraph (1)) the following:

2701.

Fair insurance coverage

(a)

In general

With respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual or small group market—

(1)

such rate shall vary with respect to the particular plan or coverage involved only by—

(A)

family structure;

(B)

community rating area;

(C)

the actuarial value of the benefit;

(D)

age, except that such rate shall not vary by more than 2 to 1;

(E)

tobacco use, except that such rate shall not vary by more than 1.5 to 1; and

(F)

adherence to or participation in a reasonably designed program of health promotion and disease prevention, if such a program is offered by the employer that is the sponsor of the coverage involved; and

(2)

such rate shall not vary with respect to the particular plan or coverage involved by health status-related factors, gender, class of business, claims experience, industry, or any other factor not described in paragraph (1), except that group health plans and health insurance issuers offering group health insurance coverage may establish premium discounts or rebates for modifying otherwise applicable copayments or deductibles in return for adherence to or participation in reasonably designed programs of health promotion or disease prevention.

(b)

Community rating area

Taking into account the applicable recommendations of the National Association of Insurance Commissioners, the Secretary shall by regulation establish a minimum size for community rating areas for purposes of this section, which, for areas contained in a Metropolitan Statistical Area, shall not be smaller than such area.

2702.

Guaranteed availability of coverage

(a)

Issuance of coverage in the individual and group market

Subject to subsections (b) through (e), each health insurance issuer that offers health insurance coverage in the individual or group market in a State must accept every employer and individual in the State that applies for such coverage.

(b)

Enrollment

(1)

Restriction

A health insurance issuer described in subsection (a) may restrict enrollment in coverage described in such subsection to open or special enrollment periods.

(2)

Establishment

A health insurance issuer described in subsection (a) shall, in accordance with the regulations promulgated under paragraph (3), establish special enrollment periods for qualifying events (under section 603 of the Employee Retirement Income Security Act of 1974).

(3)

Regulations

Not later than 1 year after the date of enactment of this section, the Secretary shall promulgate regulations with respect to enrollment periods under paragraphs (1) and (2).

2703.

Guaranteed renewability of coverage

(a)

In general

Except as provided in this section, if a health insurance issuer offers health insurance coverage in the individual or group market, the issuer must renew or continue in force such coverage at the option of the plan sponsor or the individual, as applicable.

(b)

Prohibition on rescissions

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such coverage once the plan involved has been issued, except that this subsection shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the coverage. Coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 2702(c) or 2742(b).

2704.

Increasing the Transparency of Health Care Costs and Regulatory Fees

(a)

Clear accounting for costs

A health insurance issuer offering group or individual health insurance coverage shall publicly report (in a manner to be established by the Secretary through regulation) the percentage of total premium revenue that such coverage expends—

(1)

on reimbursement for clinical services provided to enrollees under such plan or coverage;

(2)

for activities that improve health care quality;

(3)

on taxes, license, or regulatory fee costs, and the cost of any surcharge imposed by the Gateway under title XXXI; and

(4)

on all other non-claims costs, including an explanation of the nature of such costs and an itemized list of costs associated with compliance with the Affordable Health Choices Act.

(b)

Definition

In this section, the term activities to improve health care quality means activities described in section 2707.

(c)

Processes and methods

The Secretary shall develop a methodology for calculating the percentages described in subsection (a). Such methodology may provide for a requirement that a report described in subsection (a) include an actuarial certification of the information included in such report.

2706.

Prohibiting discrimination against individual participants and beneficiaries based on health status

(a)

In general

A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan or coverage based on any of the following health status-related factors in relation to the individual or a dependent of the individual:

(1)

Health status.

(2)

Medical condition (including both physical and mental illnesses).

(3)

Claims experience.

(4)

Receipt of health care.

(5)

Medical history.

(6)

Genetic information.

(7)

Evidence of insurability (including conditions arising out of acts of domestic violence).

(8)

Disability.

(9)

Any other health status-related factor determined appropriate by the Secretary.

(b)

Programs of health promotion or disease prevention

(1)

General provisions

(A)

General rule

For purposes of paragraph (2)(B), a program of health promotion or disease prevention (referred to in this subsection as a wellness program) shall be a program offered by an employer that is designed to promote health or prevent disease that meets the applicable requirements of this subsection.

(B)

No conditions based on health status factor

If none of the conditions for obtaining a premium discount or rebate or other reward for participation in a wellness program is based on an individual satisfying a standard that is related to a health status factor, such wellness program shall not violate this section if participation in the program is made available to all similarly situated individuals and the requirements of paragraph (2) are complied with.

(C)

Conditions based on health status factor

If any of the conditions for obtaining a premium discount or rebate or other reward for participation in a wellness program is based on an individual satisfying a standard that is related to a health status factor, such wellness program shall not violate this section if the requirements of paragraph (3) are complied with.

(2)

Wellness programs not subject to requirements

If none of the conditions for obtaining a premium discount or rebate or other reward under a wellness program as described in paragraph (1)(B) are based on an individual satisfying a standard that is related to a health status factor (or if such a wellness program does not provide such a reward), the wellness program shall not violate this section if participation in the program is made available to all similarly situated individuals. The following programs shall not have to comply with the requirements of paragraph (3) if participation in the program is made available to all similarly situated individuals:

(A)

A program that reimburses all or part of the cost for memberships in a fitness center.

(B)

A diagnostic testing program that provides a reward for participation and does not base any part of the reward on outcomes.

(C)

A program that encourages preventive care related to a health condition through the waiver of the copayment or deductible requirement under an individual or group health plan for the costs of certain items or services related to a health condition (such as prenatal care or well-baby visits).

(D)

A program that reimburses individuals for the costs of smoking cessation programs without regard to whether the individual quits smoking.

(E)

A program that provides a reward to individuals for attending a periodic health education seminar.

(3)

Wellness programs subject to requirements

If any of the conditions for obtaining a premium discount, rebate, or reward under a wellness program as described in paragraph (1)(C) is based on an individual satisfying a standard that is related to a health status factor, the wellness program shall not violate this section if the following requirements are complied with:

(A)

The reward for the wellness program, together with the reward for other wellness programs with respect to the plan that requires satisfaction of a standard related to a health status factor, shall not exceed 30 percent of the cost of employee-only coverage under the plan. If, in addition to employees or individuals, any class of dependents (such as spouses or spouses and dependent children) may participate fully in the wellness program, such reward shall not exceed 30 percent of the cost of the coverage in which an employee or individual 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 if the Secretaries determine that such an increase is appropriate.

(B)

The wellness program shall be reasonably designed to promote health or prevent disease. A program complies with the preceding sentence if the program 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 status factor, and is not highly suspect in the method chosen to promote health or prevent disease. The plan or issuer shall evaluate the program’s reasonableness at least once per year.

(C)

The plan shall give individuals eligible for the program the opportunity to qualify for the reward under the program at least once each year.

(D)

The full reward under the wellness program shall be made available to all similarly situated individuals. For such purpose, among other things:

(i)

The reward is not available to all similarly situated individuals for a period unless the wellness program allows—

(I)

for 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

(II)

for 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.

(ii)

If reasonable under the circumstances, the plan or issuer may seek verification, such as a statement from an individual’s physician, that a health status factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard.

(E)

The plan or issuer involved shall disclose in all plan materials describing the terms of the wellness 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 disclose that such a program is available, without describing its terms, the disclosure under this subparagraph shall not be required.

(c)

Existing programs

Nothing in this section shall prohibit a program of health promotion or disease prevention that was established prior to the date of enactment of this section and applied with all applicable regulations, and that is operating on such date, from continuing to be carried out for as long as such regulations remain in effect.

(d)

Regulations

Nothing in this section shall be construed as prohibiting the Secretaries of Labor, Health and Human Services, or the Treasury from promulgating regulations in connection with this section.

2707.

Ensuring the quality of care

(a)

In general

Except as provided in subsection (c), a group health plan and a health insurance issuer offering group or individual health insurance coverage shall develop and implement a reimbursement structure for making payments to health care providers that provides incentives for—

(1)

the provision of high quality health care under the plan or coverage in a manner that includes—

(A)

the implementation of case management, care coordination, chronic disease management, and medication and care compliance activities that includes the use of the medical home model as defined in section 212 of the Affordable Health Choices Act for treatment or services under the plan or coverage;

(B)

the implementation of activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post-discharge reinforcement by an appropriate health care professional;

(C)

the implementation of activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage;

(D)

the implementation of wellness and health promotion activities;

(E)

child health measures under section 1139A of the Social Security Act; and

(F)

culturally and linguistically appropriate care, as defined by the Secretary; and

(2)

payment policies that substantially reflects the payment policy of the Medicare program under title XVIII of the Social Security Act and the Children's Health Insurance Program under title XXI of such Act with respect to any generally implemented incentive policy to promote high quality health care, except that in order that no plan or issuer be forced to deny patients medical care needed to prevent their deaths or preserve or restore their health, no plan or issuer shall be prohibited from providing payment for a treatment or diagnostic procedure it chooses to cover, unless such treatment or procedure has been determined to be unsafe or dangerous or capable of neither preventing the patient's death nor preserving or restoring the patient's health.

(b)

Wellness and prevention programs

For purposes of subsection (a)(1)(D), wellness and health promotion activities may include personalized wellness and prevention services, which are coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager, or a health, wellness or prevention services organization that conducts health risk assessments or offer ongoing face-to-face, telephonic or web-based intervention efforts for each of the program’s participants, and which may include the following wellness and prevention efforts:

(1)

Smoking cessation.

(2)

Weight management.

(3)

Stress management.

(4)

Physical fitness.

(5)

Nutrition.

(6)

Heart disease prevention.

(7)

Healthy lifestyle support.

(8)

Diabetes prevention.

(c)

Exceptions

In promulgating regulations under subsection (d), the Secretary may provide for exceptions to the requirements of subsection (a) for insurers that substantially meet the goals of this section.

(d)

Regulations

Not later than 180 days after the date of enactment of the Affordable Health Choices Act, the Secretary shall promulgate regulations—

(1)

that define the term generally implemented for purposes of subsection (a)(2);

(2)

that require the expiration of a minimum period of time between the date on which a policy is generally implemented for purposes of subsection (a)(2) and the date on which such policy shall apply with respect to health insurance coverage offered in the individual or group market; and

(3)

that provide criteria for determining whether a payment policy is described in subsection (a).

(e)

Study and report

Not later than 180 days after the date of enactment of the Affordable Health Choices Act, the Government Accountability Office shall conduct a study and submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives a report regarding the impact the activities under this section have had on the quality and cost of health care.

2708.

Coverage of preventive health services

(a)

In general

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost sharing requirements (other than minimal cost sharing in accordance with guidelines developed by the Secretary) for—

(1)

evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force;

(2)

immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and

(3)

with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration.

(b)

Interval

(1)

In general

The Secretary shall establish a minimum interval between the date on which a recommendation described in subsection (a)(1) or (a)(2) or a guideline under subsection (a)(3) is issued and the plan year with respect to which the requirement described in subsection (a) is effective with respect to the service described in such recommendation or guideline.

(2)

Minimum

The interval described in paragraph (1) shall not be less than 1 year.

2709.

Coverage of Preventive Women’s Health Services

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for, and shall not impose any cost sharing requirements (other than minimal cost sharing in accordance with guidelines developed by the Secretary) for, with respect to women (including pregnant women and individuals of child bearing age), such additional preventive care and screenings not covered under section 2708 as provided for in guidelines supported by the Health Resources and Services Administration.

2710.

Extension of dependent coverage

(a)

In general

A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child until the child turns 26 years of age. Nothing in this section shall require a health plan or a health insurance issuer described in the preceding sentence to make coverage available for a child of a child receiving dependent coverage.

(b)

Regulations

The Secretary shall promulgate regulations to define the dependents to which coverage shall be made available under subsection (a).

2711.

No lifetime or annual limits

(a)

In general

A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish lifetime or annual limits on the dollar value of benefits for any participant or beneficiary.

(b)

Preventing fraud and abuse

This section shall not apply until the date on which the Secretary certifies that enacting this section will not result in undue proliferation of fraud and abuse, especially with regard to durable medical equipment.

2712.

Notification by plans not providing minimum qualifying coverage

(a)

In general

Not later than 1 year after the date on which the Secretary establishes criteria with respect to minimum qualifying coverage under section 3103, a group health plan and a health insurance issuer offering group or individual health insurance coverage that fails to provide such minimum qualifying coverage shall notify, in such manner as may be required by the Secretary, enrollees and prospective enrollees in such plan or coverage of such failure prior to enrollment or re-enrollment.

(b)

Modifications

If the Secretary modifies the criteria with respect to minimum qualifying coverage under section 3103, a group health plan or health insurance issuer that fails to provide such modified minimum qualifying coverage shall provide the notice required under subsection (a) within 60 days of the date of such modification.

2713.

Non-discrimination in health care

A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that provider's license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures.

.

II

Provision applicable to the group market

121.

Amendment to the Public Health Service Act

Subpart 2 of part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-4 et seq.) is amended by adding at the end the following:

2720A.

Prohibition of discrimination based on salary

(a)

In general

A group health plan and a health insurance issuer offering group health insurance coverage may not establish rules relating to the health insurance coverage eligibility (including continued eligibility) of any full-time employee under the terms of the plan that are based on the total hourly or annual salary of the employee.

(b)

Limitation

Subsection (a) shall not be construed to prohibit a group health plan or health insurance issuer from establishing contribution requirements for enrollment in the plan or coverage that provide for the payment by employees with lower hourly or annual compensation of a lower dollar or percentage contribution than the payment required of a similarly situated employees with a higher hourly or annual compensation.

.

III

Other provisions

131.

No changes to existing coverage

(a)

Option to retain current insurance coverage

(1)

In general

Nothing in this Act (or an amendment made by this Act) shall be construed to require that an individual terminate coverage under a group health plan or health insurance coverage in which such individual was enrolled prior to the date of enactment of this title.

(2)

Continuation of coverage

With respect to a group health plan or health insurance coverage in which an individual was enrolled prior to the date of enactment of this title, this subtitle (and the amendments made by this subtitle) shall not apply to such plan or coverage, regardless of whether the individual renews such coverage after such date of enactment.

(b)

Allowance for family members to join current coverage

With respect to a group health plan or health insurance coverage in which an individual was enrolled prior to the date of enactment of this title and which is renewed after such date, family members of such individual shall be permitted to enroll in such plan or coverage if such enrollment is permitted under the terms of the plan in effect as of such date of enactment.

(c)

Allowance for new employees to join current plan

A group health plan that provides coverage on the date of enactment of this Act may provide for the enrolling of new employees (and their families) in such plan, and this subtitle (and the amendments made by this subtitle) shall not apply with respect to such plan and such new employees (and their families).

(d)

No additional benefit

Subsections (b) and (c) shall only apply to individuals described in such subsections and the family members of such individuals (as provided for in such subsections).

(e)

Limitation

Subsections (a) through (d) shall not apply to any group health plan or health insurance coverage that has been modified to a significant extent with respect to covered benefits or cost sharing requirements after the date of enactment of this Act. The Secretary shall by regulation establish criteria to determine whether a plan or health insurance coverage has been modified to a significant extent under the preceding sentence, except that any coverage amendment made pursuant to an agreement between an employer or an individual and a health insurance issuer relating to the coverage which amends the coverage solely to conform to any requirement added by this Act (or amendments to this Act) shall not be treated as a significant modification.

(f)

Effect on collective bargaining agreements

In the case of health insurance coverage maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers that was ratified before the date of enactment of this title, the provisions of this subtitle (and the amendments made by this subtitle) shall not apply until the date on which the last of the collective bargaining agreements relating to the coverage terminates. Any coverage amendment made pursuant to a collective bargaining agreement relating to the coverage which amends the coverage solely to conform to any requirement added by this subtitle (or amendments) shall not be treated as a termination of such collective bargaining agreement.

(g)

Risk adjustment

The provisions of section 3101(c)(6) of the Public Health Service Act (as added by section 142) shall not apply to a group health plan or health insurance coverage to which this section applies.

132.

Applicability

Section 2721 of the Public Health Service Act (42 U.S.C. 300gg-21) is amended—

(1)

by striking subsection (a);

(2)

in subsection (b)—

(A)

in paragraph (1), by striking 1 through 3 and inserting 1 and 2; and

(B)

in paragraph (2)—

(i)

in subparagraph (A), by striking subparagraph (D) and inserting subparagraph (D) or (E);

(ii)

by striking 1 through 3 and inserting 1 and 2; and

(iii)

by adding at the end the following:

(E)

Election not applicable

The election described in subparagraph (A) shall not be available with respect to the provisions of subpart 1.

;

(3)

in subsection (c), by striking 1 through 3 shall not apply to any group and inserting 1 and 2 shall not apply to any individual coverage or any group; and

(4)

in subsection (d)—

(A)

in paragraph (1), by striking 1 through 3 shall not apply to any group and inserting 1 and 2 shall not apply to any individual coverage or any group;

(B)

in paragraph (2)—

(i)

in the matter preceding subparagraph (A), by striking 1 through 3 shall not apply to any group and inserting 1 and 2 shall not apply to any individual coverage or any group; and

(ii)

in subparagraph (C), by inserting or, with respect to individual coverage, under any health insurance coverage maintained by the same health insurance issuer; and

(C)

in paragraph (3), by striking any group and inserting any individual coverage or any group.

133.

Conforming amendments

(a)

Public Health Service Act

Title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended—

(1)

in section 2705 (42 U.S.C. 300gg), as so redesignated by section 101(2)—

(A)

in subsection (c)—

(i)

in paragraph (2), by striking group health plan each place that such appears and inserting group or individual health plan; and

(ii)

in paragraph (3)—

(I)

by striking group health insurance each place that such appears and inserting group or individual health insurance; and

(II)

in subparagraph (D), by striking small or large and inserting individual or group;

(B)

in subsection (d), by striking group health insurance each place that such appears and inserting group or individual health insurance; and

(C)

in subsection (e)(1)(A), by striking group health insurance and inserting group or individual health insurance;

(2)

by striking the heading for subpart 2 of part A;

(3)

in section 2717 (42 U.S.C. 300gg-4), as so redesignated—

(A)

in subsection (a), by striking health insurance issuer offering group health insurance coverage and inserting health insurance issuer offering group or individual health insurance coverage;

(B)

in subsection (b)—

(i)

by striking health insurance issuer offering group health insurance coverage in connection with a group health plan in the matter preceding paragraph (1) and inserting health insurance issuer offering group or individual health insurance coverage; and

(ii)

in paragraph (1), by striking plan and inserting plan or coverage;

(C)

in subsection (c)—

(i)

in paragraph (2), by striking group health insurance coverage offered by a health insurance issuer and inserting health insurance issuer offering group or individual health insurance coverage; and

(ii)

in paragraph (3), by striking issuer and inserting health insurance issuer; and

(D)

in subsection (e), by striking health insurance issuer offering group health insurance coverage and inserting health insurance issuer offering group or individual health insurance coverage;

(4)

in section 2718 (42 U.S.C. 300gg-5), as so redesignated—

(A)

in subsection (a), by striking (or health insurance coverage offered in connection with such a plan) each place that such appears and inserting or a health insurance issuer offering group or individual health insurance coverage;

(B)

in subsection (b), by striking (or health insurance coverage offered in connection with such a plan) each place that such appears and inserting or a health insurance issuer offering group or individual health insurance coverage; and

(C)

in subsection (c)—

(i)

in paragraph (1), by striking (and group health insurance coverage offered in connection with a group health plan) and inserting and a health insurance issuer offering group or individual health insurance coverage;

(ii)

in paragraph (2), by striking (or health insurance coverage offered in connection with such a plan) each place that such appears and inserting or a health insurance issuer offering group or individual health insurance coverage;

(5)

in section 2719 (42 U.S.C. 300gg-6), as so redesignated, by striking health insurance issuers providing health insurance coverage in connection with group health plans and inserting and health insurance issuers offering group or individual health insurance coverage;

(6)

in section 2720 (42 U.S.C. 300gg-7), as so redesignated—

(A)

in subsection (a), by striking health insurance coverage offered in connection with such plan and inserting individual health insurance coverage;

(B)

in subsection (b)—

(i)

in paragraph (1), by striking or a health insurance issuer that provides health insurance coverage in connection with a group health plan and inserting or a health insurance issuer that offers group or individual health insurance coverage;

(ii)

in paragraph (2), by striking health insurance coverage offered in connection with the plan and inserting individual health insurance coverage; and

(iii)

in paragraph (3), by striking health insurance coverage offered by an issuer in connection with such plan and inserting individual health insurance coverage;

(C)

in subsection (c), by striking health insurance issuer providing health insurance coverage in connection with a group health plan and inserting health insurance issuer that offers group or individual health insurance coverage; and

(D)

in subsection (e)(1), by striking health insurance coverage offered in connection with such a plan and inserting individual health insurance coverage;

(7)

by striking the heading for subpart 3;

(8)

in section 2714 (42 U.S.C. 300gg-11), as so redesignated—

(A)

by striking the section heading and all that follows through subsection (b);

(B)

in subsection (c)—

(i)

in paragraph (1)—

(I)

in the matter preceding subparagraph (A), by striking small group and inserting group and individual; and

(II)

in subparagraph (B)—

(aa)

in the matter preceding clause (i), by inserting and individuals after employers;

(bb)

in clause (i), by inserting or any additional individuals after additional groups; and

(cc)

in clause (ii), by striking without regard to the claims experience of those employers and their employees (and their dependents) or any health status-related factor relating to such and inserting and individuals without regard to the claims experience of those individuals, employers and their employees (and their dependents) or any health status-related factor relating to such individuals; and

(ii)

in paragraph (2), by striking small group and inserting group or individual;

(C)

in subsection (d)—

(i)

by striking small group each place that such appears and inserting group or individual; and

(ii)

in paragraph (1)(B)—

(I)

by striking all employers and inserting all employers and individuals;

(II)

by striking those employers and inserting those individuals, employers; and

(III)

by striking such employees and inserting such individuals, employees;

(D)

by striking subsection (e);

(E)

by striking subsection (f); and

(F)

by transferring the remainder of such section to appear at the end of section 2702 (as added by section 101(5));

(9)

in section 2715 (42 U.S.C. 300gg-12), as so redesignated—

(A)

by striking the section heading and all that follows through subsection (a);

(B)

in subsection (b)—

(i)

in the matter preceding paragraph (1), by striking group health plan in the small or large group market and inserting health insurance coverage offered in the group or individual market;

(ii)

in paragraph (1), by inserting , or individual, as applicable, after plan sponsor;

(iii)

in paragraph (2), by inserting , or individual, as applicable, after plan sponsor; and

(iv)

by striking paragraph (3) and inserting the following:

(3)

Violation of participation or contribution rates

In the case of a group health plan, the plan sponsor has failed to comply with a material plan provision relating to employer contribution or group participation rules, pursuant to applicable State law.

;

(C)

in subsection (c)—

(i)

in paragraph (1)—

(I)

in the matter preceding subparagraph (A), by striking group health insurance coverage offered in the small or large group market and inserting group or individual health insurance coverage;

(II)

in subparagraph (A), by inserting or individual, as applicable, after plan sponsor;

(III)

in subparagraph (B)—

(aa)

by inserting or individual, as applicable, after plan sponsor; and

(bb)

by inserting or individual health insurance coverage; and

(IV)

in subparagraph (C), by inserting or individuals, as applicable, after those sponsors; and

(ii)

in paragraph (2)(A)—

(I)

in the matter preceding clause (i), by striking small group market or the large group market, or both markets, and inserting individual or group market, or all markets,; and

(II)

in clause (i), by inserting or individual, as applicable, after plan sponsor; and

(D)

by transferring the remainder of such section to appear at the end of section 2703 (as added by section 101(5));

(10)

in section 2716 (42 U.S.C. 300gg-13), as so redesignated—

(A)

in subsection (a)—

(i)

in the matter preceding paragraph (1), by striking small employer and inserting small employer or an individual;

(ii)

in paragraph (1), by inserting , or individual, as applicable, after employer each place that such appears; and

(iii)

in paragraph (2), by striking small employer and inserting employer, or individual, as applicable,;

(B)

in subsection (b)—

(i)

in paragraph (1)—

(I)

in the matter preceding subparagraph (A), by striking small employer and inserting employer, or individual, as applicable,;

(II)

in subparagraph (A), by adding and at the end;

(III)

by striking subparagraphs (B) and (C); and

(IV)

in subparagraph (D)—

(aa)

by inserting , or individual, as applicable, after employer; and

(bb)

by redesignating such subparagraph as subparagraph (B);

(ii)

in paragraph (2)—

(I)

by striking small employers each place that such appears and inserting employers, or individuals, as applicable,; and

(II)

by striking small employer and inserting employer, or individual, as applicable,; and

(C)

by redesignating such section as section 2712 and transferring such section to appear after section 2711 (as added by section 101(5));

(11)

by redesignating subpart 4 as subpart 2;

(12)

in section 2721 (42 U.S.C. 300gg-21)—

(A)

by striking subsection (a);

(B)

by striking subparts 1 through 3 each place that such appears and inserting subpart 1; and

(C)

by redesignating subsections (b) through (e) as subsections (a) through (d), respectively;

(13)

in section 2722 (42 U.S.C. 300gg-22)—

(A)

in subsection (a)—

(i)

in paragraph (1), by striking small or large group markets and inserting individual or group market; and

(ii)

in paragraph (2), by inserting or individual health insurance coverage after group health plans; and

(B)

in subsection (b)(1)(B), by inserting individual health insurance coverage or after respect to; and

(14)

in section 2723(a)(1) (42 U.S.C. 300gg-23), by inserting individual or before group health insurance.

(b)

Applicability

Notwithstanding any other provision of the Affordable Health Choices Act, nothing in such Act (or an amendment made by such Act) shall be construed to—

(1)

authorize the Secretary of Health and Human Services to promulgate regulations that prohibit a group health plan or health insurance issuer from carrying out utilization management techniques that are commonly used as of the date of enactment of this section; or

(2)

restrict the application of the amendments made by this subtitle.

(c)

Technical amendment to the Employee Retirement Income Security Act of 1974

Subpart B of part 7 of subtitle A of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1181 et. seq.) is amended, by adding at the end the following:

715.

Additional market reforms

(a)

General rule

Except as provided in subsection (b)—

(1)

the provisions of subpart 1 of part A of title XXVII of the Public Health Service Act (as amended by the Affordable Health Choices Act) shall apply to group health plans, and health insurance issuers providing health insurance coverage in connection with group health plans, as if included in this subpart; and

(2)

to the extent that any provision of this part conflicts with a provision of such subpart 1 with respect to group health plans, or health insurance issuers providing health insurance coverage in connection with group health plans, the provisions of such subpart 1 shall apply.

(b)

Exception

Notwithstanding subsection (a), the provisions of sections 2701, 2702, and 2704 of title XXVII of the Public Health Service Act (as amended by the Affordable Health Choices Act) shall not apply with respect to self-insured group health plans, and the provisions of this part shall continue to apply to such plans as if such sections of the Public Health Service Act (as so amended) had not been enacted.

.

(d)

Technical amendment to the Internal Revenue Code of 1986

Subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following:

9815.

Additional market reforms

(a)

General rule

Except as provided in subsection (b)—

(1)

the provisions of subpart 1 of part A of title XXVII of the Public Health Service Act (as amended by the Affordable Health Choices Act) shall apply to group health plans, and health insurance issuers providing health insurance coverage in connection with group health plans, as if included in this subchapter; and

(2)

to the extent that any provision of this subchapter conflicts with a provision of such subpart 1 with respect to group health plans, or health insurance issuers providing health insurance coverage in connection with group health plans, the provisions of such subpart 1 shall apply.

(b)

Exception

Notwithstanding subsection (a), the provisions of sections 2701, 2702, and 2704 of title XXVII of the Public Health Service Act (as amended by the Affordable Health Choices Act) shall not apply with respect to self-insured group health plans, and the provisions of this subchapter shall continue to apply to such plans as if such sections of the Public Health Service Act (as so amended) had not been enacted.

.

134.

Savings

(a)

Determination

The Secretary of the Treasury, in consultation with the Secretary of Health and Human Services, shall for each fiscal year determine the amount of savings to the Federal Government as a result of the enactment of this subtitle.

(b)

Use

Notwithstanding any other provision of this subtitle (or an amendment made by this subtitle), the savings to the Federal Government generated as a result of the enactment of this subtitle shall be used for deficit reduction.

135.

Effective dates

(a)

Applicability

Except as otherwise provided in subsection (b), this subtitle (and the amendments made by this subtitle) shall become effective for plan years beginning on or after the date that is 1 year after the date of enactment of this Act.

(b)

Delayed applicability

Sections 2701, 2702, 2705, and 2706 of the Public Health Service Act (as added by section 101) shall become effective with respect to group health plans or health insurance coverage offered in a State on the date on which such State becomes a participating or establishing State under section 3104 of the Public Health Service Act (as added by section 142).

B

Available coverage for all Americans

141.

Building on the success of the Federal Employees Health Benefits Program and the health benefits program of most large employers so all americans have affordable health benefit choices

(a)

Findings

The Senate finds that—

(1)

the Federal employees health benefits program under chapter 89 of title 5, United States Code, allows Members of Congress, and section 514 of the Employee Retirement Income Security Act of 1974 allows large employers, to have affordable choices among competing health benefit plans;

(2)

the Federal employees health benefits program ensures that the health benefit plans available to Members of Congress meet minimum standards of quality and effectiveness;

(3)

millions of Americans have no meaningful choice in health benefits, because health benefit plans are either unavailable or unaffordable; and

(4)

all Americans should have the same kinds of meaningful choices of health benefit plans that Members of Congress, as Federal employees, enjoy through the Federal employees health benefits program.

(b)

Sense of the Senate

It is the sense of the Senate that Congress should establish a means for all Americans to enjoy affordable choices in health benefit plans, in the same manner that Members of Congress have such choices through the Federal employees health benefits program.

142.

Affordable health choices for all americans

(a)

Purpose

It is the purpose of this section to facilitate the establishment of Affordable Health Benefit Gateways in each State, with appropriate flexibility for States in establishing and administering the Gateways.

(b)

American Health Benefit Gateways

The Public Health Service Act ( 42 U.S.C. 201 et seq.) is amended by adding at the end the following:

XXXI

Affordable health choices for all americans

A

Affordable choices

3101.

Affordable choices of health benefit plans

(a)

Assistance to States to establish american health benefit gateways

(1)

Planning and establishment grants

Not later than 60 days after the date of enactment of this section (or as soon as practicable thereafter), the Secretary shall make awards, from amounts appropriated under paragraph (5), to States in the amount specified in paragraph (2) for the uses described in paragraph (3).

(2)

Amount specified

(A)

Total determined

For each fiscal year, the Secretary shall determine the total amount that the Secretary will make available for grants under this subsection.

(B)

State amount

For each State that is awarded a grant under paragraph (1), the amount of such grants shall be based on a formula established by the Secretary under which each State shall receive an award in an amount that is based on the following two components:

(i)

A minimum amount for each State.

(ii)

An additional amount based on population.

The Secretary shall ensure that the aggregate amount awarded to all States under clause (i) is not less than 60 percent of the aggregate amount awarded to all States under this subparagraph.
(3)

Use of funds

A State shall use amounts awarded under this subsection for activities (including planning activities) related to establishing an American Health Benefit Gateway, as described in subsection (b).

(4)

Renewability of grant

(A)

In general

The Secretary may renew a grant awarded under paragraph (1) if the State recipient of such grant—

(i)

is making progress, as determined by the Secretary, toward—

(I)

establishing a Gateway; and

(II)

implementing the reforms described in subtitle A of title I of the Affordable Health Choices Act; and

(ii)

is meeting such other benchmarks as the Secretary may establish.

(B)

Limitation

If a State is an establishing State or a participating State (as defined in section 3104), such State shall not be eligible for a grant renewal under subparagraph (A) as of the second fiscal year following the date on which such State was deemed to be an establishing State or a participating State.

(5)

Authorization of appropriations

There are authorized to be appropriated such sums as may be necessary to carry out this subsection in each of fiscal years 2009 through 2014.

(b)

American Health Benefit Gateways

An American Health Benefit Gateway (referred to in this title as a Gateway) means a mechanism that—

(1)

facilitates the purchase of health insurance coverage and related insurance products through the Gateway at an affordable price by qualified individuals and qualified employers and reduces the cost of health care; and

(2)

meets the requirements of subsection (c).

(c)

Requirements

(1)

Establishment

A Gateway shall be a governmental agency or nonprofit entity that is established by—

(A)

a State, in the case of an establishing State (as described in section 3104); or

(B)

the Secretary, in the case of a participating State (as described in section 3104).

(2)

Offering of coverage

(A)

In general

A Gateway shall make available qualified health plans to qualified individuals and qualified employers.

(B)

Inclusion

In making available coverage pursuant to subparagraph (A), a Gateway shall include a community health insurance option (as described in section 3106).

(C)

Limitation

A Gateway may not make available any health plan or other health insurance coverage that is not a qualified health plan.

(D)

Allowance to offer

A Gateway may make available a qualified health plan notwithstanding any provision of law that may require benefits other than the essential health benefits specified under section 3103(a).

(E)

States may require additional benefits

Subject to the requirements of subparagraph (F), a State may require that a qualified health plan offered in such State offer benefits in addition to the essential health benefits described in section 3103(a).

(F)

Additional benefits

(i)

No additional Federal cost

A requirement by a State under subparagraph (E) that a qualified health plan cover benefits in addition to the essential health benefits required shall not affect the amount of a credit provided under section 3111 with respect to such plan.

(ii)

State must assume cost

A State shall make payments to or on behalf of an eligible individual to defray the cost of any additional benefits described in subparagraph (E).

(3)

Functions

A Gateway shall, at a minimum—

(A)

establish procedures for the certification, recertification, and decertification, consistent with guidelines developed by the Secretary under subsection (m), of health plans as qualified health plans;

(B)

develop and make available tools to allow consumers to receive accurate and culturally and linguistically appropriate information on—

(i)

expected premiums and out of pocket expenses (taking into account any credits for which such individual is eligible under section 3111);

(ii)

the availability of in-network and out-of-network providers;

(iii)

the costs of any surcharge assessed under paragraph (4);

(iv)

data, by plan, that reflects the frequency with which preventive services rated A or B by the U.S. Preventive Services Task Force or recommended by the Advisory Committee on Immunization Practices are utilized by enrollees, a comparison of such data to the average frequency with which such preventive services are utilized by enrollees across all qualified health plans, and whether such preventive services are utilized by enrollees as frequently as recommended;

(v)

medical loss ratios, as reported under section 2704(a);

(vi)

any quality measures for health plan performance endorsed under section 399JJ; and

(vii)

such other matters relating to consumer costs and expected experience under the plan as a Gateway may determine necessary;

(C)

utilize the administrative simplification measures and standards developed under section 222 of the Affordable Health Choices Act;

(D)

enter into agreements, to the extent determined appropriate by the Gateway, with navigators, as described in section 3105;

(E)

facilitate the purchase of coverage for long-term services and supports;

(F)

collect, analyze, and respond to complaints and concerns from enrollees regarding coverage provided through the Gateway;

(G)

provide for the operation of a toll-free telephone hotline to respond to requests for assistance; and

(H)

maintain an Internet website through which enrollees and prospective enrollees of qualified health plans may obtain standardized comparative information on such plans.

(4)

Surcharges

(A)

In general

A Gateway may assess a surcharge on all health insurance issuers offering qualified health plans through the Gateway to pay for the administrative and operational expenses of the Gateway.

(B)

Limitation

A surcharge described in subparagraph (A) may not exceed 4 percent of the premiums collected by a qualified health plan.

(C)

Further limitation

No funds collected through a Gateway surcharge for administrative and operational expenses may be used for staff retreats, promotional giveaways, excessive executive compensation, or promotion of Federal or State legislative and regulatory modifications.

(5)

Risk adjustment payment

(A)

Establishing and participating States

(i)

Low actuarial risk plans

Using the criteria and methods developed under subparagraph (B), each establishing State or participating State (as defined in section 3104) shall assess a charge on health plans and health insurance issuers (with respect to health insurance coverage) described in subparagraph (C) if the actuarial risk of the enrollees of such plans or coverage for a year is less than the average actuarial risk of all enrollees in all plans or coverage in such State for such year that are not self-insured group health plans (which are subject to the provisions of the Employee Retirement Income Security Act of 1974).

(ii)

High actuarial risk plans

Using the criteria and methods developed under subparagraph (B), each establishing State or participating State (as defined in section 3104) shall provide a payment to health plans and health insurance issuers (with respect to health insurance coverage) described in subparagraph (C) if the actuarial risk of the enrollees of such plans or coverage for a year is greater than the average actuarial risk of all enrollees in all plans and coverage in such State for such year that are not self-insured group health plans (which are subject to the provisions of the Employee Retirement Income Security Act of 1974).

(B)

Criteria and methods

The Secretary, in consultation with States, shall establish criteria and methods to be used in carrying out the risk adjustment activities under this paragraph. The Secretary may utilize criteria and methods similar to the criteria and methods utilized under part C or D of title XVIII of the Social Security Act.

(C)

Scope

A health plan or a health insurance issuer is described in this subparagraph if such health plan or health insurance issuer provides coverage for an individual or for an employer group the size of which does not exceed—

(i)

in the case of an employer with its primary place of business located in an establishing State, the criteria relating to the size of employers established by such State as described in section 3116(a)(2)(A)(ii)(I); or

(ii)

in the case of an employer with its primary place of business located in a participating State, the criteria relating to the size of employers established by the Secretary as described in section 3116(a)(2)(A)(ii)(II).

(6)

Facilitating Enrollment

(A)

In general

A Gateway shall (through, to the extent practicable, the use of information technology) implement policies and procedures to—

(i)

facilitate the identification of individuals who lack qualifying coverage; and

(ii)

assist such individuals in enrolling in—

(I)

a qualified health plan that is affordable and available to such individual, if such individual is a qualified individual;

(II)

the medicaid program under title XIX of the Social Security Act, if such individual is eligible for such program;

(III)

the CHIP program under title XXI of the Social Security Act, if such individual is eligible for such program; or

(IV)

other Federal programs in which such individual is eligible to participate.

(B)

Choice for individuals eligible for CHIP

A qualified individual who is eligible for the Children's Health Insurance Program under title XXI of the Social Security Act may elect to enroll in such program or in a qualified health plan. Where such individual is a minor child, such election shall be made by the parent or guardian of such child.

(C)

Oversight

The Secretary shall oversee the implementation of subparagraph (A)(ii) to ensure that individuals are assisted to enroll in the program most appropriate under such subparagraph for each such individual.

(D)

Accessibility of materials

Any materials used by a Gateway to carry out this paragraph shall be provided in a form and manner calculated to be understood by individuals who may apply to be enrollees in a qualified health plan, taking into account potential language barriers and disabilities of individuals.

(7)

Consultation

A Gateway shall consult with stakeholders relevant to carrying out the activities under this subsection, including—

(A)

educated health care consumers who are enrollees in qualified health plans;

(B)

individuals and entities with experience in facilitating enrollment in qualified health plans;

(C)

representatives of small businesses and self-employed individuals;

(D)

State Medicaid offices; and

(E)

advocates for enrolling hard to reach populations.

(8)

Standards and protocols

(A)

In general

The Secretary, in consultation with the Office of the National Coordinator for Health Information Technology, shall develop interoperable, secure, scalable, and reusable standards and protocols that facilitate enrollment of individuals in Federal and State health and human services programs.

(B)

Coordination

The Secretary shall facilitate enrollment of individuals in programs described in subparagraph (A) through methods which shall include—

(i)

electronic matching against existing Federal and State data to serve as evidence of eligibility and digital documentation in lieu of paper-based documentation;

(ii)

capability for individuals to apply, recertify, and manage eligibility information online, including conducting real-time queries against databases for existing eligibility prior to submitting applications; and

(iii)

other functionalities necessary to provide eligible individuals with a streamlined enrollment process.

(C)

Assistance

The Secretary shall award grants to enhance community-based enrollment to—

(i)

States to assist such States in—

(I)

contracting with qualified technology vendors to develop or acquire electronic enrollment software systems;

(II)

contracting with community and consumer focused nonprofit organizations with experience working with consumers, including the uninsured and the underinsured, to establish Statewide helplines for enrollment assistance and referrals; and

(III)

establishing public education campaigns through grants to qualifying organizations for the design and implementation of public education campaigns targeting uninsured and traditionally underserved communities; and

(ii)

community-based organizations for infrastructure and training to establish electronic assistance programs.

(9)

Notification

With respect to the standards and protocols developed under paragraph (8), the Secretary—

(A)

shall notify States of such standards and protocols; and

(B)

may require, as a condition of receiving Federal funds, that States or other entities incorporate such standards and protocols into such investments.

(10)

Publication of costs

A Gateway shall publish the average costs of income or other taxes, licensing or regulatory fees, and any surcharges imposed by the Gateway, and the administrative costs of such Gateway, on an Internet website to educate consumers on such costs. Such information shall also include monies lost to waste, fraud, and abuse.

(d)

Certification

A Gateway may certify a health plan as a qualified health plan if—

(1)

such health plan meets the requirements of subsection (m);

(2)

the Gateway determines that making available such health plan through such Gateway is in the interests of qualified individuals and qualified employers in the States or States in which such Gateway operates, except that the Gateway may not exclude a health plan—

(A)

on the basis that such plan is a fee-for-service plan;

(B)

through the imposition of premium price controls; or

(C)

on the basis that the plan provides treatments necessary to prevent patients' deaths in circumstances the Gateway determines are inappropriate or to costly; and

(3)

the Gateway determines that the plan has not established a pattern or practice under which benefits covered by the plan are denied to covered individuals on the basis of the individuals' age or expected length of life or of the individuals' present or predicted disability, degree of medical dependency, or quality of life.

(e)

Guidance

The Secretary shall develop guidance that may be used by a Gateway to carry out the activities described in this section.

(f)

Flexibility

(1)

Regional or other interstate Gateways

A Gateway may operate in more than one State, provided that each State in which such Gateway operates permits such operation.

(2)

Subsidiary Gateways

A State may establish one or more subsidiary Gateway, provided that—

(A)

each such Gateway serves a geographically distinct area; and

(B)

the area served by each such Gateway is at least as large as a community rating area described in section 2701.

(g)

No limitation on contracting based on abortion

No individual health care provider or health care facility may be excluded from contracting with a health insurance issuer participating in the Gateway on the basis that the provider or facility performs abortions or the provider or facility refuses to perform abortions, except in an emergency, if performing abortions is contrary to the religious or moral beliefs of the provider or facility.

(h)

Portals to State Gateway

The Secretary shall establish a mechanism, including an Internet website, through which a resident of any State may identify any Gateway operating in such State.

(i)

Choice

(1)

Qualified individuals

A qualified individual may enroll in any qualified health plan available to such individual.

(2)

Qualified employers

(A)

Employer may specify tier

A qualified employer may provide support for coverage of employees under a qualified health plan by selecting any tier of cost sharing described in section 3111(a)(1).

(B)

Employee may choose plans within a tier

Each employee of a qualified employer may choose to enroll in a qualified health plan that offers coverage at the tier of cost sharing selected by an employer, as described in subparagraph (A).

(3)

Self-employed individuals

(A)

Deeming

An individual who is self-employed (as defined in section 401(c)(1) of the Internal Revenue Code of 1986) shall be deemed to be a qualified employer unless such individual notifies the applicable Gateway that such individual elects to be considered a qualified individual.

(B)

Eligibility

In the case of a self-employed individual making the election described in subparagraph (A)—

(i)

the income of such individual for purposes of section 3111 shall be deemed to be the total business income of such individual;

(ii)

premium payments made by such individual to a qualified health plan shall not be treated as employer-provided coverage under section 106(a) of the Internal Revenue Code of 1986; and

(iii)

the individual shall not be eligible for a credit under section 3112.

(j)

Payment of premiums by qualified individuals

A qualified individual enrolled in any qualified health plan may pay any applicable premium owed by such individual to the health insurance issuer issuing such qualified health plan.

(k)

Single risk pool

(1)

Individual market

A health insurance issuer shall consider all enrollees in an individual plan, including individuals who do not purchase such a plan through the Gateway, to be members of a single risk pool.

(2)

Group health insurance policies

A health insurance issuer shall consider all enrollees in a small group health plan, other than a self-insured group health plan, including individuals who do not purchase such a plan through the Gateway, to be members of a single risk pool.

(l)

Empowering consumer choice

(1)

Continued operation of market outside Gateways

Nothing in this title shall be construed to prohibit a health insurance issuer from offering a health insurance policy or providing coverage under such policy to a qualified individual where such policy is not a qualified health plan. Nothing in this title shall be construed to prohibit a qualified individual from enrolling in a health insurance plan where such plan is not a qualified health plan.

(2)

Continued operation of state benefit requirements

Nothing in this title shall be construed to terminate, abridge, or limit the operation of any requirement under State law with respect to any policy or plan that is not a qualified health plan to offer benefits required under State law.

(3)

Voluntary nature of a gateway

(A)

Choice to enroll or not to enroll

Nothing in this title shall be construed to restrict the choice of a qualified individual to enroll or not to enroll in a qualified health plan or to participate in a Gateway.

(B)

Prohibition against compelled enrollment

Nothing in this title shall be construed to compel an individual to enroll in a qualified health plan or to participate in a Gateway.

(m)

Criteria for certification

(1)

In general

The Secretary shall, by regulation, establish criteria for certification of health plans as qualified health plans. Such criteria shall require that, to be certified, a plan—

(A)

not employ marketing practices that have the effect of discouraging the enrollment in such plan by individuals with significant health needs;

(B)

employ methods to ensure that insurance products are simple, comparable, and structured for ease of consumer choice;

(C)

ensure a wide choice of providers (in a manner consistent with applicable network adequacy provisions under section 2702(c));

(D)

include within health insurance plan networks those essential community providers, where available, that serve predominately low-income, medically-underserved individuals, such as health care providers defined in section 340B(a)(4) of the Public Health Service Act and providers described in section 1927(c)(1)(D)(i)(IV) of the Social Security Act as set forth by section 221 of Public Law 111-8;

(E)

make available to individuals enrolled in, or seeking to enroll in, such plan a detailed description of—

(i)

benefits offered, including maximums, limitations (including differential cost-sharing for out of network services), exclusions and other benefit limitations;

(ii)

the service area;

(iii)

required premiums;

(iv)

cost-sharing requirements;

(v)

the manner in which enrollees access providers; and

(vi)

the grievance and appeals procedures;

(F)

provide coverage for at least the essential health care benefits established under section 3103(a);

(G)(i)

is accredited by the National Committee for Quality Assurance or by any other entity recognized by the Secretary for the accreditation of health insurance issuers or plans; or

(ii)

receives such accreditation within a period established by a Gateway for such accreditation that is applicable to all qualified health plans;

(H)

implement a quality improvement strategy described in subsection (n)(1);

(I)

have adequate procedures in place for appeals of coverage determinations;

(J)

may not establish a benefit design that is likely to substantially discourage enrollment by certain qualified individuals in such plan; and

(K)

report to the applicable Gateway data on any quality measures for health plan performance endorsed under section 399JJ.

(2)

Request to National Association of Insurance Commissioners

The Secretary shall request the National Association of Insurance Commissioners to develop and submit to the Secretary model criteria for the certification of qualified health plans, that address the elements described in subparagraphs (A) through (K) of paragraph (1). In developing such criteria, the National Association of Insurance Commissioners shall consult with appropriate Federal agencies, consumer representatives, insurance carriers, and other stakeholders.

(3)

Required consideration

If the model criteria described in paragraph (2) are submitted to the Secretary by the date that is 9 months after the date on which a request is made under such paragraph, the Secretary shall consider such model criteria in promulgating the regulations under paragraph (1).

(4)

Rule of construction

Nothing in paragraph (1)(D) shall be construed to require a qualified health plan to contract with a provider described in such paragraph if such provider refuses to accept the generally applicable payment rates of such plan.

(n)

Rewarding Quality Through Market-Based Incentives

(1)

Strategy described

A strategy described in this paragraph is a payment structure that provides increased reimbursement or other incentives for—

(A)

improving health outcomes through the implementation of activities that shall include quality reporting, effective case management, care coordination, chronic disease management, medication and care compliance initiatives, including through the use of the medical home model as defined in section 212 of the Affordable Health Choices Act, for treatment or services under the plan or coverage;

(B)

the implementation of activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional;

(C)

the implementation of activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; and

(D)

the implementation of wellness and health promotion activities.

(2)

Guidelines

The Secretary, in consultation with experts in health care quality and stakeholders, shall develop guidelines concerning the matters described in paragraph (1).

(3)

Requirements

The guidelines developed under paragraph (2) shall require the periodic reporting to the applicable Gateway of the activities that a qualified health plan has conducted to implement a strategy described in paragraph (1).

(o)

No interference with State regulatory authority

Nothing in this title shall be construed to preempt any State law that does not prevent the application of the provisions of this title.

(p)

Quality improvement

(1)

Enhancing patient safety

Beginning on January 1, 2012 a qualified health plan may contract with—

(A)

a hospital with greater than 50 beds only if such hospital—

(i)

utilizes a patient safety evaluation system as described in part C of title IX; and

(ii)

implements a mechanism to ensure that each patient receives a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; or

(B)

a health care provider if such provider implements such mechanisms to improve health care quality as the Secretary may by regulation require.

(2)

Exceptions

The Secretary may establish reasonable exceptions to the requirements described in paragraph (1).

(3)

Adjustment

The Secretary may by regulation adjust the number of beds described in paragraph (1)(A).

(q)

Continued applicability of mental health parity

Section 2716 shall apply to qualified health plans in the same manner and to the same extent as such section applies to health insurance issuers and group health plans.

(r)

Promotion of informed choice of health insurance coverage

(1)

In general

The Secretary shall develop standards for use by health insurance issuers offering health insurance coverage through the Gateway in the individual or group market in compiling and providing to enrollees a summary of benefits explanation that accurately represents the benefits and coverage provided by the issuer under each of its applicable health insurance products. In developing such standards, the Secretary shall consult with the National Association of Insurance Commissioners, a working group composed of representatives of health insurance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals.

(2)

Requirements

The standards for the summary of benefits explanation developed under paragraph (1) shall provide for the following:

(A)

Appearance

The standards shall ensure that the summary is presented in a uniform format.

(B)

Language

The standards shall ensure that the language used in the summary is presented in a manner determined to be understandable by the average health plan enrollee.

(C)

Contents

The standards shall ensure that the summary includes the following:

(i)

Information determined to be essential to a consumer’s understanding of the applicable health insurance plan benefits.

(ii)

Uniform definitions of standard insurance terms including premium, deductible, co-insurance, co-payment, out-of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, usual, customary and reasonable fees, excluded services, grievance and appeals, prior authorization, precertification, and such other terms as determined by the Secretary so that consumers may compare health insurance coverage and understand the terms of coverage.

(iii)

Uniform definitions of medical terms including 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 determined by the Secretary so that consumers may compare the medical benefits and understand the extent of those medical benefits (or exceptions to those benefits).

(iv)

A statement of whether the plan meets minimum qualifying coverage (when effective under section 3103.)

(v)

Examples to illustrate common benefits scenarios, including scenarios that illustrate the health care needs of pregnancy and of at least several serious or chronic medical conditions.

(vi)

Illustrations that enhance consumer understanding of the explanation.

(3)

Requirement to provide

Not later than 12 months after the Secretary develops standards under paragraph (1), each health insurance issuer offering health insurance coverage through the Gateway shall, prior to any enrollment restriction, provide annually to enrollees and potential enrollees a summary of benefits explanation pursuant to the standards developed by the Secretary under paragraph (1)

(4)

Preemption

The standards developed under paragraph (1) shall preempt any related State standards that require summary of benefits health plan explanations that provide less information to consumers, as determined by the Secretary.

(5)

Failure to provide

A health insurance issuer that willfully fails to provide the information required under this subsection 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 paragraph.

(6)

Application

The provisions of this subsection shall apply to health insurance coverage offered through the Gateway. The Secretary shall evaluate the impact on consumers of expanding the application of the provisions of this subsection to additional health insurance issuers.

(s)

Disclosure of information

(1)

In general

In connection with the offering of any health insurance coverage in the individual or group market through a Gateway, a health insurance issuer—

(A)

shall disclose to such individual or employer as part of its solicitation and sales materials, the information described in paragraph (2);

(B)

shall disclose to such individual or employer enrolled in such plan any change and an explanation of such change with respect to the information described in paragraph (2) with reasonable and timely advance notice with respect to such change;

(C)

upon the request of such individual or employer, shall provide the information described in paragraph (2); and

(D)

shall disclose such information as the Secretary may require in order to ensure compliance with consumer protection provisions under this title.

(2)

Information described

(A)

In general

Subject to subparagraph (C), with respect to a health insurance issuer offering health insurance coverage in the individual or group market through a Gateway, information disclosed under this paragraph shall include—

(i)

the provisions of such coverage concerning the issuer’s right to change premium rates, co-payments, in- and out-of-provider networks, or any other information as determined by the Secretary; and

(ii)

the benefits and premiums available under all health insurance coverage for which an individual or employers is qualified.

(B)

Form of information

Information shall be provided under this paragraph in a manner determined to be understandable by the average employer or individual and shall be sufficient to reasonably inform such employer or individual of their rights and obligations under the health insurance coverage involved.

(C)

Exception

Information described under this paragraph shall not include information that is proprietary or trade secret information.

3102.

Financial integrity

(a)

Accounting for expenditures

(1)

In general

A Gateway shall keep an accurate accounting of all activities, receipts, and expenditures and shall annually submit to the Secretary a report concerning such accountings.

(2)

Investigations

The Secretary may investigate the affairs of a Gateway, may examine the properties and records of a Gateway, and may require periodical reports in relation to activities undertaken by a Gateway. A Gateway shall fully cooperate in any investigation conducted under this paragraph.

(3)

Audits

A Gateway shall be subject to annual audits by the Secretary.

(4)

Pattern of abuse

If the Secretary determines that a Gateway or a State has engaged in serious misconduct with respect to compliance with the requirements of, or carrying out activities required under, this title, the Secretary may rescind from payments otherwise due to such State involved under this or any other Act administered by the Secretary an amount not to exceed 1 percent of such payments per year until corrective actions are taken by the State that are determined to be adequate by the Secretary.

(5)

Protections against fraud and abuse

With respect to activities carried out under this title, the Secretary shall provide for the efficient and non-discriminatory administration of Gateway activities and implement any measure or procedure that—

(A)

the Secretary determines is appropriate to reduce fraud and abuse in the administration of this title; and

(B)

the Secretary has authority to implement under this title or any other Act;

(6)

Application of the False Claims Act

(A)

In general

Payments made by, through, or in connection with a Gateway are subject to the False Claims Act (31 U.S.C. 3729 et seq.) if those payments include any Federal funds. Compliance with the requirements of this Act concerning eligibility for a health insurance issuer to participate in the Gateway shall be a material condition of an issuer’s entitlement to receive payments, including subsidy payments, through the Gateway.

(B)

Damages

Notwithstanding paragraph (1) of section 3729(a) of title 31, United States Code, and subject to paragraph (2) of such section, the civil penalty assessed under the False Claims Act on any person found liable under such Act as described in subparagraph (A) shall be increased by not less than 3 times and not more than 6 times the amount of damages which the Government sustains because of the act of that person.

(b)

GAO oversight

Not later than 5 years after the date of enactment of this section, the Comptroller General shall conduct an ongoing study of Gateway activities and the enrollees in qualified health plans offered through Gateways. Such study shall review—

(1)

the operations and administration of Gateways, including surveys and reports of qualified health plans offered through Gateways and on the experience of such plans (including data on enrollees in Gateways and individuals purchasing health insurance coverage outside of Gateways), the expenses of Gateways, claims statistics relating to qualified health plans, complaints data relating to such plans, and the manner in which Gateways meets their goals;

(2)

any significant observations regarding the utilization and adoption of Gateways;

(3)

where appropriate, recommendations for improvements in the operations or policies of Gateways; and

(4)

how many physicians, by area and specialty, are not taking or accepting new patients enrolled in Federal Government health care programs, and the adequacy of provider networks of Federal Government health care programs.

3103.

Program design

(a)

Program design

(1)

In general

The Secretary shall establish the following:

(A)

Subject to paragraph (2), the essential health care benefits eligible for credits under section 3111, where such benefits shall include at least the following general categories:

(i)

Ambulatory patient services.

(ii)

Emergency services.

(iii)

Hospitalization.

(iv)

Maternity and newborn care.

(v)

Mental health and substance abuse services.

(vi)

Prescription drugs.

(vii)

Rehabilitative and habilitative services and devices.

(viii)

Laboratory services.

(ix)

Preventive and wellness services.

(x)

Pediatric services, including oral and vision care.

(B)

The criteria that coverage must meet to be considered minimum qualifying coverage.

(C)

The conditions under which coverage shall be considered affordable and available coverage for individuals and families at different income levels.

(D)

The essential benefits provided for in subparagraph (A) shall include a requirement that there be non-discrimination in health care in a manner that, with respect to an individual who is eligible for medical or surgical care under a qualified health plan offered through a Gateway, prohibits the Administrator of the Gateway, or a qualified health plan offered through the Gateway, from denying such individual benefits for religious or spiritual health care, except that such religious or spiritual health care shall be an expense eligible for deduction as a medical care expense as determined by Internal Revenue Service Rulings interpreting section 213(d) of the Internal Revenue Code of 1986 as of January 1, 2009.

(2)

Limitation

The Secretary shall ensure that the scope of the essential health benefits under paragraph (1)(A) is equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary.

(3)

Certification

In establishing the essential health benefits described in paragraph (1)(A), the Secretary shall submit a report to the appropriate committees of Congress containing a certification from the Chief Actuary of the Centers for Medicare & Medicaid Services that such essential health benefits meet the limitation described in paragraph (2).

(b)

National Independent Commission on Essential Health Care Benefits

(1)

Establishment

There is established a temporary advisory commission to be known as the National Independent Commission on Essential Health Care Benefits (in this section referred to as the Commission).

(2)

Duties

The Commission shall:

(A)

Review and analyze the benefits offered under typical employer-sponsored health plans, and State laws requiring coverage of specified items and services in the individual and group insurance markets.

(B)

Hold public hearings, meetings, or other public listening sessions not less than 3 times to take testimony and receive such evidence as the Commission considers advisable to carry out activities under this section.

(C)

Make recommendations to the Secretary regarding the specific items and services that should be included in the essential heath care benefits package eligible for credits under section 3111.

(3)

Considerations

The Commission shall consider—

(A)

the clinical appropriateness and effectiveness of the benefits covered;

(B)

the affordability of the benefits covered;

(C)

the financial protection of enrollees against high healthcare expenses;

(D)

access to necessary healthcare services, including primary and preventive health services;

(E)

existing State laws that require coverage of health care items or services in the individual and group markets; and

(F)

the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet the actuarial limitations described in subsection (a)(2).

(4)

Membership

(A)

Number and appointment

The Commission shall be composed of 17 members to be appointed by the Secretary.

(B)

Qualifications

(i)

In general

The membership of the Commission shall include individuals with national recognition for their expertise in clinical medicine, primary and preventive health care, integrative medicine, and actuarial science and health plan benefit design.

(ii)

Inclusion

The membership of the Commission shall include an expert in actuarial science and health plan benefit design, a health care provider, a patient or consumer advocate, a representative of labor organizations representing workers, an employer, a third-party payer, a health services researcher, an individual skilled in the conduct and interpretation of the biomedical and health sciences, an individual with expertise in pediatric health care, and an individual with expertise in outcomes and effectiveness research and technology assessment.

(C)

Chairman

The Secretary shall designate a member of the Commission who is an expert in actuarial science and health plan benefit design, at the time of appointment of such member, as Chairman.

(D)

Meetings

The Commission shall meet at the call of the Chairman. Advance notice of such meetings shall be published in the Federal Register and the meetings shall be open to the public.

(E)

Ethical disclosures

The Secretary shall establish a system for public disclosure by members of the Commission of financial and other potential conflicts of interest relating to such members.

(F)

Deadline for appointment

Members of the Commission shall be appointed by not later than 45 days after the date of enactment of this title.

(G)

Terms of appointment

The term of any appointment under subparagraph (A) to the Commission shall be for the life of the Commission.

(H)

Compensation

Members of the Commission shall receive no additional pay, allowances, or benefits by reason of their service on the Commission.

(I)

Expenses

Each member of the Commission shall receive travel expenses and per diem in lieu of subsistence in accordance with sections 5702 and 5703 of title 5, United States Code.

(5)

Staff and support services

(A)

Executive director

(i)

Appointment

The Secretary shall appoint an executive director of the Commission.

(ii)

Compensation

The executive director of the Commission shall be paid the rate of basic pay for level V of the Executive Schedule.

(iii)

Staff

With the approval of the Commission, the executive director may appoint such personnel as the executive director considers appropriate.

(iv)

Applicability of civil service laws

The staff of the Commission shall be appointed without regard to the provisions of title 5, United States Code, governing appointments in the competitive service, and shall be paid without regard to the provisions of chapter 51 and subchapter III of chapter 53 of such title (relating to classification and General Schedule pay rates).

(v)

Experts and consultants

With the approval of the Commission, the executive director may procure temporary and intermittent services under section 3109(b) of title 5, United States Code.

(6)

Powers

(A)

Cost estimates by office of management and budget and office of the chief actuary of the centers for medicare & medicare services

The Director of the Office of Management and Budget or the Chief Actuary of the Centers for Medicare & Medicaid Services, or both, shall provide to the Commission, upon the request of the Commission, such cost estimates as the Commission determines to be necessary to carry out its duties under this section.

(B)

Technical assistance

Upon the request of the Commission, the head of a Federal agency or its representatives, including representatives of the Office of Personnel Management, shall provide such technical assistance to the Commission as the Commission determines to be necessary to carry out its duties under this section.

(C)

Obtaining information

The Commission may secure directly from any Federal agency information necessary to enable it to carry out its duties, if the information may be disclosed under section 552 of title 5, United States Code.

(D)

Public input

The Commission shall adopt procedures allowing any interested party to submit information for the Commission’s use in making reports and recommendations.

(7)

Report

Not later than 6 months after the date of enactment of this title, the Commission shall submit a report to the Secretary and Congress which shall contain a detailed statement of only those recommendations, findings, and conclusions of the Commission that receive the approval of at least 12 members of the Commission. The Secretary shall provide for publication in the Federal Register and the posting on an appropriate Internet website of the report and recommendations of the Commission.

(8)

Termination

The Commission shall terminate on the date that is 30 days after the date on which the report is submitted under subsection (7).

(9)

Authorization of appropriations

There are authorized to be appropriated to carry out this subsection, $1,500,000.

(c)

Required elements for consideration

(1)

Essential health care benefits

In establishing the essential health benefits under subsection (a)(1)(A), the Secretary shall—

(A)

consider the report and recommendations of the Commission established under subsection (b);

(B)

ensure that such essential health benefits reflect an appropriate balance among the categories described in such subsection, so that benefits are not unduly weighted toward any category;

(C)

not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;

(D)

take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups;

(E)

ensure that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individuals' age or expected length of life or of the individuals' present or predicted disability, degree of medical dependency, or quality of life; and

(F)

review the essential health benefits under subsection (a)(1)(A) not less than annually, and provide a report to Congress and the public that contains—

(i)

an assessment of whether enrollees are facing any difficulty accessing needed services for reasons of coverage or cost;

(ii)

an assessment of whether the essential benefits package needs to be modified or updated to account for changes in medical evidence or scientific advancement;

(iii)

information on how the benefit package will be modified to address any such gaps in access or changes in the evidence base; and

(iv)

an assessment of the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet actuarial limitations described in subsection (a)(2).

(2)

Minimum qualifying coverage

In establishing the criteria described in subsection (a)(1)(B), the Secretary—

(A)

shall—

(i)

exclude from meeting such criteria any coverage that—

(I)

provides reimbursement for the treatment or mitigation of—

(aa)

a single disease or condition; or

(bb)

an unreasonably limited set of diseases or conditions; or

(II)

has an out of pocket limit that exceeds the amount described in section 223(c)(2) of the Internal Revenue Code of 1986 for the year involved; and

(ii)

establish such criteria (taking into account the requirements established under clause (i)) in a manner that results in the least practicable disruption of the health care marketplace, consistent with the goals and activities under this title; and

(B)

may provide for the application of different criteria (except with respect to the limitation described in subparagraph (A)(i)(II)) with respect to young adults.

(3)

Affordable coverage

The Secretary shall establish a standard under which coverage is defined to be unaffordable only if the premium paid by the individual is greater than 12.5 percent of the adjusted gross income of the individual involved. Beginning with calendar years after 2013, the Secretary shall adjust the percentage described in this paragraph by an amount that is equal to the percentage increase or decrease in the medical care component of the Consumer Price Index for all urban consumers (U.S. city average) during the preceding calendar year.

3104.

Allowing State flexibility

(a)

Optional State establishment of Gateway

During the 4-year period following the date of enactment of this section, a State may—

(1)(A)

establish a Gateway;

(B)

adopt the insurance reform provisions as provided for in subtitle A of title I of the Affordable Health Choices Act (and the amendments made by such title); and

(C)

agree to make employers that are State or local governments subject to sections 162 and 163 of the Affordable Health Choices Act.

(2)(A)

request that the Secretary operate (for a minimum period of 5 years) a Gateway in such State;

(B)

adopt the insurance reform provisions as provided for in subtitle A of title I of the Affordable Health Choices Act (and the amendments made by such subtitle); and

(C)

agree to make employers that are State or local governments subject to sections 162 and 163 of the Affordable Health Choices Act; or

(3)

elect not to take the actions described in paragraph (1) or (2).

(b)

Establishing States

(1)

In general

If the Secretary determines that a State has taken the actions described in subsection (a)(1), any resident of that State who is an eligible individual shall be eligible for credits under section 3111 beginning on the date that is 60 days after the date of such determination.

(2)

Continued review

The Secretary shall establish procedures to ensure continued review by the Secretary of the compliance of a State with the requirements of subsection (a). If the Secretary determines that a State has failed to maintain compliance with such requirements, the Secretary may revoke the determination under paragraph (1).

(3)

Deeming

A State that is the subject of a positive determination by the Secretary under paragraph (1) (unless such determination is revoked under paragraph (2)) shall be deemed to be an establishing State beginning on the date that is 60 days after the date of such determination.

(c)

Request for the Secretary to establish a Gateway

(1)

In general

In the case of a State that makes the request described in subsection (a)(2), the Secretary shall determine whether the State has enacted and has in effect the insurance reforms provided for in subtitle A of title I of the Affordable Health Choices Act.

(2)

Operation of Gateway

(A)

Positive determination

If the Secretary determines that the State has enacted and has in effect the insurance reforms described in paragraph (1), the Secretary shall establish a Gateway in such State as soon as practicable after making such determination.

(B)

Negative determination

If the Secretary determines that the State has not enacted or does not have in effect the insurance reforms described in paragraph (1), the Secretary shall establish a Gateway in such State as soon as practicable after the Secretary determines that such State has enacted and has in effect such reforms.

(3)

Participating State

The State shall be deemed to be a participating State on the date on which the Gateway established by the Secretary is in effect in such State.

(4)

Eligibility

Any resident of a State described in paragraph (3) who is an eligible individual shall be eligible for credits under section 3111 beginning on the date that is 60 days after the date on which such Gateway is established in such State.

(d)

Federal fallback in the case of States that refuse to improve health care coverage

(1)

In general

Upon the expiration of the 4-year period following the date of enactment of this section, in the case of a State that is not otherwise a participating State or an establishing State—

(A)

the Secretary shall establish and operate a Gateway in such State;

(B)

the insurance reform provisions provided for in subtitle A of title I of the Affordable Health Choices Act shall become effective in such State, notwithstanding any contrary provision of State law;

(C)

the State shall be deemed to be a participating State; and

(D)

the residents of that State who are eligible individuals shall be eligible for credits under section 3111 beginning on the date that is 60 days after the date on which such Gateway is established, if the State agrees to make employers that are State or local governments subject to sections 162 and 163 of the Affordable Health Choices Act.

(2)

Eligibility of individuals for credits

With respect to a State that makes the election described in subsection (a)(3), the residents of such State shall not be eligible for credits under section 3111 until such State becomes a participating State under paragraph (1).

3105.

Navigators

(a)

In general

The Secretary shall award grants to establishing or participating States to enable such States (or the Gateways operating in such States) to enter into agreements with private and public entities under which such entities will serve as navigators in accordance with this section.

(b)

Eligibility

(1)

In general

To be eligible to enter into an agreement under subsection (a), an entity shall demonstrate that the entity has existing relationships with, or could readily establish relationships with, employers and employees, consumers (including the uninsured and the underinsured), or self-employed individuals, likely to be qualified to enroll in a qualified health plan.

(2)

Types

Entities described in paragraph (1) may include trade, industry and professional associations, commercial fishing industry organizations, ranching and farming organizations, community and consumer-focused nonprofit groups, chambers of commerce, unions, small business development centers, other licensed insurance agents and brokers, and other entities that the Secretary determines to be capable of carrying out the duties described in subsection (c).

(c)

Duties

An entity that serves as a navigator under an agreement under subsection (a) shall—

(1)

conduct public education activities to raise awareness of the program under this title;

(2)

distribute fair and impartial information concerning enrollment in qualified health plans, and the availability of credits under section 3111;

(3)

facilitate enrollment in a qualified health plan;

(4)

provide referrals to the appropriate State agency or agencies for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage; and

(5)

provide information in a manner determined by the Secretary to be culturally and linguistically appropriate to the needs of the population served by the Gateway.

(d)

Standards

(1)

In general

The Secretary shall establish standards for navigators under this section, including provisions to ensure that any private or public entity that is selected as a navigator is qualified, and licensed if appropriate, to engage in the navigator activities described in this section and to avoid conflicts of interest. Under such standards, a navigator shall not—

(A)

be a health insurance issuer; or

(B)

receive any consideration directly or indirectly from any health insurance issuer in connection with the participation of any employer in the program under this title or the enrollment of any qualified individual or qualified employer in a qualified health plan.

(2)

Fair and impartial information and services

The Secretary, in collaboration with States, shall develop guidelines regarding the duties described in subsection (c).

3106.

Community health insurance option

(a)

Voluntary nature

(1)

No requirement for health care providers to participate

Nothing in this section shall be construed to require a health care provider to participate in a community health insurance option, or to impose any penalty for non-participation.

(2)

No requirement for individuals to join

Nothing in this section shall be construed to require an individual to participate in a community health insurance option, or to impose any penalty for non-participation.

(b)

Establishment of community health insurance option

(1)

Establishment

The Secretary shall establish a community health insurance option to offer, through each Gateway established under this title, health care coverage that provides value, choice, competition, and stability of affordable, high quality coverage throughout the United States.

(2)

Community health insurance option

In this section, the term community health insurance option means health insurance coverage that—

(A)

except as specifically provided for in this section, complies with the requirements for being a qualified health plan;

(B)

provides high value for the premium charged;

(C)

reduces administrative costs and promotes administrative simplification for beneficiaries;

(D)

promotes high quality clinical care;

(E)

provides high quality customer service to beneficiaries;

(F)

offers a wide choice of providers; and

(G)

complies with State laws (if any), except as otherwise provided for in this title, relating to—

(i)

guaranteed renewal;

(ii)

rating;

(iii)

preexisting conditions;

(iv)

non-discrimination;

(v)

quality improvement and reporting;

(vi)

fraud and abuse;

(vii)

solvency and financial requirements;

(viii)

market conduct;

(ix)

prompt payment;

(x)

appeals and grievances;

(xi)

privacy and confidentiality;

(xii)

licensure; and

(xiii)

benefit plan material or information.

(3)

Essential health benefits

(A)

General rule

Except as provided in subparagraph (B), a community health insurance option offered under this section shall provide coverage only for the essential health benefits described in section 3103.

(B)

States may offer additional benefits

A State may require that a community health insurance option offered in such State offer benefits in addition to the essential health benefits required under subparagraph (A).

(C)

Credits

(i)

In general

An individual enrolled in a community health insurance option under this section shall be eligible for credits under section 3111 in the same manner as an individual who is enrolled in a qualified health plan.

(ii)

No additional Federal cost

A requirement by a State under subparagraph (B) that a community health insurance option cover benefits in addition to the essential health benefits required under subparagraph (A) shall not affect the amount of a credit provided under section 3111 with respect to such plan.

(D)

State must assume cost

A State shall make payments to or on behalf of an eligible individual to defray the cost of any additional benefits described in subparagraph (B).

(E)

Ensuring Access to All Services

Nothing in this Act shall prohibit an individual enrolled in a community health insurance option from paying out-of-pocket the full cost of any item or service not included as an essential health benefit or otherwise covered as a benefit by a health plan. Nothing in this Act shall prohibit any type of medical provider from accepting an out-of-pocket payment from an individual enrolled in a community health insurance option for a service otherwise not included as an essential health benefit.

(F)

Protecting Access to End of Life Care

A community health insurance option offered under this section shall be prohibited from limiting access to end of life care.

(4)

Cost sharing

A community health insurance option shall offer coverage at each of the cost sharing tiers described in section 3111(a).

(5)

Premiums

(A)

Premiums sufficient to cover costs

The Secretary shall set premium rates in an amount sufficient to cover expected costs (including claims and administrative costs) using methods in general use by qualified health plans.

(B)

Applicable rules

The provisions of title XXVII relating to premiums shall apply to community health insurance options under this section, including modified community rating provisions under section 2701.

(C)

Collection of data

The Secretary shall collect data as necessary to set premium rates under subparagraph (A).

(D)

Contingency margin

In establishing premium rates under subparagraph (A), the Secretary shall include an appropriate amount for a contingency margin.

(6)

Reimbursement rates

(A)

Negotiated rates

The Secretary shall negotiate rates for the reimbursement of health care providers for benefits covered under a community health insurance option.

(B)

Limitation

The rates described in subparagraph (A) shall not be higher, in aggregate, than the average reimbursement rates paid by health insurance issuers offering qualified health plans through the Gateway.

(C)

Innovation

Subject to the limits contained in subparagraph (A), a State Advisory Council established or designated under subsection (d) may develop or encourage the use of innovative payment policies that promote quality, efficiency and savings to consumers.

(D)

Physician negotiated rates

Nothing in this paragraph shall prohibit the application of a State law that permits physicians to jointly negotiate with health plans. In such State, physicians may jointly negotiate with a community health insurance option concerning rates paid by the option.

(7)

Solvency and consumer protection

(A)

Solvency

The Secretary shall establish a Federal solvency standard to be applied with respect to a community health insurance option. A community health insurance option shall also be subject to the solvency standard of each State in which such community health insurance option is offered.

(B)

Minimum required

In establishing the standard described under subparagraph (A), the Secretary shall require a reserve fund that shall be equal to at least the dollar value of the incurred but not reported claims of a community health insurance option.

(C)

Consumer protections

The consumer protection laws of a State shall apply to a community health insurance option.

(8)

Requirements established in partnership with insurance commissioners

(A)

In general

The Secretary, in collaboration with the National Association of Insurance Commissioners (in this paragraph referred to as the NAIC), may promulgate regulations to establish additional requirements for a community health insurance option.

(B)

Applicability

Any requirement promulgated under subparagraph (A) shall be applicable to such option beginning 90 days after the date on which the regulation involved becomes final.

(9)

Ombudsman

In establishing community health insurance options, the Secretary shall establish an ombudsman or similar mechanism to provide assistance to consumers with respect to disputes, grievances, or appeals.

(c)

Start-up Fund

(1)

Establishment of fund

(A)

In general

There is established in the Treasury of the United States a trust fund to be known as the Health Benefit Plan Start-Up Fund (referred to in this section as the Start-Up Fund), that shall consist of such amounts as may be appropriated or credited to the Start-Up Fund as provided for in this subsection to provide loans for the initial operations of a community health insurance option. Such amounts shall remain available until expended.

(B)

Funding

There is hereby appropriated to the Start-Up Fund, out of any moneys in the Treasury not otherwise appropriated an amount requested by the Secretary of Health and Human Services as necessary to—

(i)

pay the start-up costs associated with the initial operations of a community health insurance option;

(ii)

pay the costs of making payments on claims submitted during the period that is not more than 90 days from the date on which such option is offered; and

(iii)

make payments under paragraph (3).

(2)

Use of Start-Up fund

The Secretary shall use amounts contained in the Start-Up Fund to make payments (subject to the repayment requirements in paragraph (5)) for the purposes described in paragraph (1)(B).

(3)

Risk corridor payments

(A)

In general

In any case in which the Secretary has entered into a contract with a contracting administrator, the Secretary shall use amounts contained in the Start-Up Fund to make risk corridor payments to such administrator during the 2-year period beginning on the date on which such administrator enters into a contract under subsection (e). Such payments shall be based on the risk corridors in effect during fiscal years 2006 and 2007 for making payments under section 1860D-15(e) of the Social Security Act.

(B)

Subsequent year

In years after the expiration of the period referred to in subparagraph (A), the Secretary may extend or increase the risk corridors and payments provided for under subparagraph (A).

(C)

Amount used to reduce costs

The Secretary shall deposit any payments received from a contracting administrator under subparagraph (A) into the Start-Up Fund.

(4)

Pass through of rebates

The Secretary may establish procedures for reducing the amount of payments to a contracting administrator to take into account any rebates or price concessions.

(5)

Repayment

(A)

In general

A community health insurance option shall be required to repay the Secretary of the Treasury (on such terms as the Secretary may require) for any payments made under paragraph (1)(B) by the date that is not later than 10 years after the date on which the payment is made. The Secretary may require the payment of interest with respect to such repayments at rates that do not exceed the market interest rate (as determined by the Secretary).

(B)

Sanctions in case of for-profit conversion

In any case in which the Secretary enters into a contract with a qualified entity for the offering of a community health insurance option and such entity is determined to be a for-profit entity by the Secretary, such entity shall be—

(i)

immediately liable to the Secretary for any payments received by such entity from the Start-Up Fund; and

(ii)

permanently ineligible to offer a qualified health plan.

(d)

State advisory council

(1)

Establishment

A State shall establish or designate a public or non-profit private entity to serve as the State Advisory Council to provide recommendations to the Secretary on the operations and policies of a community health insurance option in the State. Such Council shall provide recommendations on at least the following:

(A)

policies and procedures to integrate quality improvement and cost containment mechanisms into the health care delivery system;

(B)

mechanisms to facilitate public awareness of the availability of a community health insurance option; and

(C)

alternative payment structures under a community health insurance option for health care providers that encourage quality improvement and cost control.

(2)

Members

The members of the State Advisory Council shall be representatives of the public and shall include educated health care consumers and providers.

(3)

Applicability of recommendations

The Secretary may apply the recommendations of a State Advisory Council to a community health insurance option that State, in any other State, or in all States.

(e)

Authority to contract; terms of contract

(1)

Authority

(A)

In general

The Secretary may enter into a contract or contracts with one or more qualified entities for the purpose of performing administrative functions (including functions described in subsection (a)(4) of section 1874A of the Social Security Act) with respect to a community health insurance option in the same manner as the Secretary may enter into contracts under subsection (a)(1) of such section. The Secretary shall have the same authority with respect to a community health insurance option under this section as the Secretary has under subsections (a)(1) and (b) of section 1874A of the Social Security Act with respect to title XVIII of such Act.

(B)

Requirements apply

If the Secretary enters into a contract with a qualified entity to offer a community health insurance option, under such contract such entity—

(i)

shall meet the criteria established under paragraph (2); and

(ii)

shall receive an administrative fee under paragraph (7).

(C)

Limitation

Contracts under this subsection shall not involve the transfer of insurance risk to the contracting administrator.

(D)

Reference

An entity with which the Secretary has entered into a contract under this paragraph shall be referred to as a contracting administrator.

(2)

Qualified entity

To be qualified to be selected by the Secretary to offer a community health insurance option, an entity shall—

(A)

meet the criteria established under section 1874A(a)(2) of the Social Security Act;

(B)

be a nonprofit entity for purposes of offering such option;

(C)

meet the solvency standards applicable under subsection (b)(7);

(D)

be eligible to offer health insurance or health benefits coverage;

(E)

meet quality standards specified by the Secretary;

(F)

have in place effective procedures to control fraud, abuse, and waste; and

(G)

meet such other requirements as the Secretary may impose.

“Procedures described under subparagraph (F) shall include the implementation of procedures to use beneficiary identifiers to identify individuals entitled to benefits so that such an individual’s social security account number is not used, and shall also include procedures for the use of technology (including front-end, prepayment intelligent data-matching technology similar to that used by hedge funds, investment funds, and banks) to provide real-time data analysis of claims for payment under this title to identify and investigate unusual billing or order practices under this title that could indicate fraud or abuse.
(3)

Term

A contract provided for under paragraph (1) shall be for a term of at least 5 years but not more than 10 years, as determined by the Secretary. At the end of each such term, the Secretary shall conduct a competitive bidding process for the purposes of renewing existing contracts or selecting new qualified entities with which to enter into contracts under such paragraph.

(4)

Limitation

A contract may not be renewed under this subsection unless the Secretary determines that the contracting administrator has met performance requirements established by the Secretary in the areas described in paragraph (7)(B).

(5)

Audits

The Inspector General shall conduct periodic audits with respect to contracting administrators under this subsection to ensure that the administrator involved is in compliance with this section.

(6)

Revocation

A contract awarded under this subsection shall be revoked by the Secretary or the Inspector General only after notice to the contracting administrator involved and an opportunity for a hearing. The Secretary may revoke such contract if the Secretary determines that such administrator has engaged in fraud, deception, waste, abuse of power, negligence, mismanagement of taxpayer dollars, or gross mismanagement. An entity that has had a contract revoked under this paragraph shall not be qualified to enter into a subsequent contract under this subsection.

(7)

Fee for administration

(A)

In general

The Secretary shall pay the contracting administrator a fee for the management, administration, and delivery of the benefits under this section.

(B)

Requirement for high quality administration

The Secretary may increase the fee described in subparagraph (A) by not more than 10 percent, or reduce the fee described in subparagraph (A) by not more than 50 percent, based on the extent to which the contracting administrator, in the determination of the Secretary, meets performance requirements established by the Secretary, in at least the following areas:

(i)

Maintaining low premium costs and low cost sharing requirements, provided that such requirements are consistent with section 3111(a).

(ii)

Reducing administrative costs and promoting administrative simplification for beneficiaries.

(iii)

Promoting high quality clinical care.

(iv)

Providing high quality customer service to beneficiaries.

(C)

Non-renewal

The Secretary may not renew a contract to offer a community health insurance option under this section with any contracting entity that has been assessed more than one reduction under subparagraph (B) during the contract period.

(8)

Limitation

Notwithstanding the terms of a contract under this subsection, the Secretary shall negotiate the reimbursement rates for purposes of subsection (b)(6).

(f)

Report by HHS and insolvency warnings

(1)

In general

On an annual basis, the Secretary shall conduct a study on the solvency of a community health insurance option and submit to Congress a report describing the results of such study.

(2)

Result

If, in any year, the result of the study under paragraph (1) is that a community health insurance option is insolvent, such result shall be treated as a community health insurance option solvency warning.

(3)

Submission of plan and procedure

(A)

In general

If there is a community health insurance option solvency warning under paragraph (2) made in a year, the President shall submit to Congress, within the 15-day period beginning on the date of the budget submission to Congress under section 1105(a) of title 31, United States Code, for the succeeding year, proposed legislation to respond to such warning.

(B)

Procedure

In the case of a legislative proposal submitted by the President pursuant to subparagraph (A), such proposal shall be considered by Congress using the same procedures described under sections 803 and 804 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 that shall be used for a medicare funding warning.

(g)

Marketing parity

In a facility controlled by the Federal Government, or by a State, where marketing or promotional materials related to a community health insurance option are made available to the public, making available marketing or promotional materials relating to private health insurance plans shall not be prohibited. Such materials include informational pamphlets, guidebooks, enrollment forms, or other materials determined reasonable for display.

(h)

Authorization of appropriations

There is authorized to be appropriated, such sums as may be necessary to carry out this section.

3107.

Application of same laws to private plans and the community health insurance option

(a)

In general

Notwithstanding any other provision of law, any health insurance coverage offered by a private health insurance issuer shall not be subject to any Federal or State law described in subsection (b) if a community health insurance option under section 3106 is not subject to such law.

(b)

Laws described

The Federal and State laws described in this subsection are those Federal and State laws relating to—

(1)

guaranteed renewal;

(2)

rating;

(3)

preexisting conditions;

(4)

non-discrimination;

(5)

quality improvement and reporting;

(6)

fraud and abuse;

(7)

solvency and financial requirements;

(8)

market conduct;

(9)

prompt payment;

(10)

appeals and grievances;

(11)

privacy and confidentiality;

(12)

licensure; and

(13)

benefit plan material or information.

3108.

Participation of professionals on certain health-related commissions

The membership of any council, committee, or other advisory body which the Secretary uses to inform official decision-making related to coverage of, or payment for, medical procedures, conditions, or care, shall have as its participants professionals who hold medical degrees from accredited American universities or colleges and have active clinical practice. Such advisory entities shall be composed of not less than one-third of such professionals.

3109.

Health insurance consumer assistance grants

(a)

In general

The Secretary shall award grants to establishing or participating States to enable such States (or the Gateways operating in such States) to establish, expand, or provide support for offices of health insurance consumer assistance.

(b)

Eligibility

(1)

In general

To be eligible to receive a grant, a State shall designate an office of health insurance consumer assistance that, directly or in coordination with State health insurance regulators and consumer assistance organizations, receives and responds to inquiries and complaints concerning health insurance coverage with respect to Federal health insurance requirements and under State law.

(2)

Criteria

A State that receives a grant under this section shall comply with criteria established by the Secretary for carrying out activities under such grant.

(c)

Duties

The State-designated office of health insurance consumer assistance shall—

(1)

assist with the filing of complaints and appeals, including filing appeals with a qualified health plan’s internal appeal or grievance process and providing information about the external appeal process;

(2)

track consumer complaints, quantify such complaints, and regularly report such complaints to the State Gateway or the Secretary, as necessary;

(3)

educate consumers on their rights and responsibilities with respect to qualified health plans; and

(4)

assist consumers with enrollment in a qualified health plan by providing information, referral, and assistance, in collaboration with navigators under section 3105.

(d)

Authorization of appropriations

There is authorized to be appropriated to carry out this section, $20,000,000 for fiscal year 2010, and such sums as may be necessary for each fiscal year thereafter.

.

143.

Freedom not to participate in Federal health insurance programs

(a)

Requirement

Notwithstanding any other provision of law, on the date of enactment of this Act, all Members of Congress and congressional staff shall enroll in a Federal health insurance program—

(1)

created under this Act (or an amendment made by this Act); or

(2)

offered through a Gateway established under this Act (or an amendment made by this Act).

(b)

Definitions

In this section:

(1)

Member of Congress

The term Member of Congress means any member of the House of Representatives or the Senate.

(2)

Congressional staff

The term congressional staff means all full-time and part-time employees employed by the official office of a Member of Congress, whether in Washington, DC or outside of Washington, DC.

C

Affordable coverage for all Americans

151.

Support for affordable health coverage

(a)

In general

Title XXXI of the Public Health Service Act, as added by section 142(a), is amended by inserting after subtitle A the following:

B

Making coverage affordable

3111.

Support for affordable health coverage

(a)

Cost sharing for a basic plan

(1)

Basic plan

The Secretary shall establish at least the following tiers of cost sharing for eligible individuals:

(A)

A tier for a basic plan in which—

(i)

a qualified health plan shall, on average, provide reimbursement for 76 percent of the total allowed costs of the benefit provided; and

(ii)

the out of pocket limitation for the plan shall not be greater than the out of pocket limitation applicable under section 223(c)(2) of the Internal Revenue Code of 1986.

(B)

A tier in which—

(i)

the average reimbursement percentage is equal to the reimbursement percentage of the basic plan increased by 8 percentage points; and

(ii)

the dollar value of the out of pocket limitation shall not be greater than 50 percent of the dollar value of the out of pocket limitation of the basic plan.

(C)

A tier in which—

(i)

the average reimbursement percentage is equal to the reimbursement percentage of the basic plan increased by 17 percentage points; and

(ii)

the dollar value of the out of pocket limitation shall not be greater than 20 percent of the dollar value of the out of pocket limitation of the basic plan.

(2)

Out of pocket

For purposes of this section, the term out of pocket shall include all expenditures for covered qualified medical expenses (as provided for with respect to high deductible health plans under section 223(d)(2) of the Internal Revenue Code of 1986).

(b)

Payment of credits

(1)

In general

The Secretary shall, with respect to an eligible individual (as defined in section 3116(a)(1)) and on behalf of such individual, pay a premium credit to the Gateway through which the individual is enrolled in the qualified health plan involved. Such Gateway shall remit an amount equal to such credit to the qualified health plan in which such individual is enrolled.

(2)

Amount

(A)

In general

Subject to the indexing provision described in paragraph (6), and the limitation described in paragraph (4), the amount of an annual credit with respect to an eligible individual under paragraph (1) shall be an amount determined by the Secretary so that the eligible individual involved is not required to pay in the case of an individual with an adjusted gross income equal to 400 percent of the poverty line for a family of the size involved, an amount that exceeds 12.5 percent of such individual's income for the year involved.

(B)

Reductions based on income

The amount that an eligible individual is required to pay under subparagraph (A) shall be ratably reduced to 1 percent of income in the case of an eligible individual with an adjusted gross income equal to 150 percent of the poverty line for a family of the size involved for the year.

(3)

Simplified schedule

The Secretary may establish a schedule of premium credits under this subsection in dollar amounts to simplify the administration of this section so long as any such schedule does not significantly change the value of the premium credits described in paragraph (2).

(4)

Limitation of credits

(A)

In general

A credit under paragraph (1) may not exceed the lesser of the amount of the reference premium for the individual involved or the premium of the qualified health plan in which such individual is enrolled.

(B)

Reference premium

In this section, the term reference premium means—

(i)

with respect to an individual enrolling in coverage whose adjusted gross income does not exceed 200 percent of the poverty line for a family of the size involved for the year, the weighted average annual premium of the 3 lowest cost qualified health plans that—

(I)

meet the criteria for cost sharing and out of pocket limits described in subsection (a)(1)(C); and

(II)

are offered in the community rating area in which the individual resides;

(ii)

with respect to an individual enrolling in coverage whose adjusted gross income exceeds 200, but does not exceed 300, percent of the poverty line for a family of the size involved for the year, the weighted average annual premium of the 3 lowest cost qualified health plans that—

(I)

meet the criteria for cost sharing and out of pocket limits described in subsection (a)(1)(B); and

(II)

are offered in the community rating area in which the individual resides; and

(iii)

with respect to an individual enrolling in coverage whose adjusted gross income exceeds 300, but does not exceed 400, percent of the poverty line for a family of the size involved for the year, the weighted average annual premium of the 3 lowest cost qualified health plans that—

(I)

meet the criteria for cost sharing and out of pocket limits described in subsection (a)(1)(A); and

(II)

are offered in the community rating area in which the individual resides.

(C)

Individuals allowed to enroll in any plan

Nothing in this section shall be construed to prohibit a qualified individual from enrolling in any qualified health plan.

(D)

Limitation

In determining the 3 lowest cost health plans for purposes of this paragraph, the community health insurance option shall not be considered.

(5)

Method of calculation

(A)

Calculation of credit based on essential health care benefits

In the case of a qualified health plan that provides reimbursement for benefits that are not included in the essential health benefits established by the Secretary under section 3103(a)(1)(A), the reference premium shall be determined for purposes of paragraph (2) without regard to such reimbursement.

(B)

Risk adjustment

The reference premium shall be adjusted to account for premium differences based on age, family size, and geographic variation.

(C)

Rule in case of fewer plans

In any case in which there are less than 3 qualified health plans offered in the community rating area in which the individual resides, the determinations made under paragraph (2) shall be based on the number of such qualified plans that are actually offered in the area.

(6)

Indexing

Beginning with calendar years after 2013, the percentages described in paragraph (2) that specify the portion of the reference premium that an individual or family is responsible for paying shall be annually adjusted by a percentage that is equal to the percentage increase or decrease in the medical care component of the Consumer Price Index for all urban consumers (U.S. city average) during the preceding calendar year.

(c)

State flexibility

A State may make payments to or on behalf of an eligible individual that are greater than the amounts required under this section.

(d)

Eligibility determinations

(1)

Rule for eligibility determinations

The Secretary shall, by regulation, establish rules and procedures for—

(A)

the submission of applications during the fourth quarter of the calendar year involved for payments under this section, including the electronic submission of documents necessary for application and enrollment;

(B)

making determinations with respect to the eligibility of individuals submitting applications under subparagraph (A) for payments under this section and informing individuals of such determinations, including verifying income through the use of data contained in the tax returns of applicants for such credits;

(C)

making determinations of adjusted gross income in cases where the individual applicant was not required to file a tax return for the taxable year involved;

(D)

resolving appeals of such determinations;

(E)

redetermining eligibility on a periodic basis; and

(F)

making payments under this section.

(2)

Determination of eligibility

For purposes of paragraph (1), the Secretary shall establish rules that permit eligibility to be determined based on—

(A)

the applicant’s adjusted gross income for the second preceding taxable year; or

(B)

in the case of an individual who is seeking payment under this section based on claiming a significant decrease in adjusted gross income—

(i)

the applicant’s adjusted gross income for the most recent period otherwise practicable; or

(ii)

the applicant’s declaration of estimated annual adjusted gross income for the year involved.

(3)

Determining eligibility

(A)

Authority of the Secretary

(i)

In general

The Secretary shall have the authority to make determinations (including redeterminations) with respect to the eligibility of individuals submitting applications for credits under this section. The Secretary shall verify, through the Internal Revenue Service or using the income and eligibility verification system utilized for purposes of the Medicaid program under section 1137 of the Social Security Act, the income data received from individuals submitting applications for credits under this section.

(ii)

Authority to use tax returns

To be eligible to receive a credit under this section, an individual shall—

(I)

authorize the disclosure of the tax return information of the individual as provided for in section 6103(l)(21) of the Internal Revenue Code; or

(II)

with respect to individuals who do not file a tax return for the year involved—

(aa)

provide satisfactory documentation of adjusted gross income, as determined by the Secretary, which may include a prior year Federal income tax return; and

(bb)

authorize the disclosure to the Secretary of such information as may be required from the Internal Revenue Service to verify that such individual has not filed a tax return for the year involved.

(iii)

Stringency

The verification requirements with respect to individuals described in clause (ii)(II) shall be at least as stringent as those required under section 1137 of the Social Security Act.

(B)

Delegation of authority

Except under the conditions described in subparagraph (D), the Secretary shall delegate to a Gateway (and, upon request from such State or States, to the State or States in which such Gateway operates) the authority to carry out the activities described in subparagraph (A). The Gateway may consult with the Internal Revenue Service to verify income data received from individuals submitting applications for credits under this section.

(C)

Requirement for consistency

A Gateway (and, as applicable, the State or States in which such Gateway operates) shall carry out the activities described in subparagraph (B) in a manner that is consistent with the regulations promulgated under paragraph (1).

(D)

Revocation of authority

If the Secretary determines that a Gateway (or the State or States in which such Gateway operates) is carrying out the activities described in subparagraph (A) in a manner that is substantially inconsistent with the regulations promulgated under paragraph (1), the Secretary may, after notice and opportunity for a hearing, revoke the delegation of authority under subparagraph (A). If the Secretary revokes the delegation of authority, the references to a Gateway in subparagraph (E) and (F) shall be deemed to be references to the Secretary.

(E)

Requirement to report change in status

(i)

In general

An individual who has been determined to be eligible for credits under this section shall notify the Gateway of any changes that may affect such eligibility in a manner specified by the Secretary.

(ii)

Redetermination

If the Gateway receives a notice from an individual under clause (i), the Gateway shall promptly redetermine the individual’s eligibility for payments.

(F)

Termination of payments

The Gateway shall terminate payments on behalf of an individual (after providing notice to the individual) if—

(i)

the individual fails to provide information for purposes of subparagraph (E)(i) on a timely basis; or

(ii)

the Gateway determines that the individual is no longer eligible for such payments.

(G)

Territorial tax authorities

With respect to determinations of eligibility for, or payment of, credits under this section that require the use of information maintained by a tax authority of a United States territory, the Secretary shall make such determination in coordination with such authority under rules and procedures that are similar to the rules and procedures applied to determinations made where such information is obtained from the Internal Revenue Service.

(4)

Application

(A)

Methods

The process established under paragraph (1)(A) shall permit applications in person, by mail, telephone, or the Internet.

(B)

Form and contents

An application under paragraph (1)(A) shall be in such form and manner as specified by the Secretary, and may require documentation.

(C)

Submission

An application under paragraph (1)(A) may be submitted to the Gateway, or to a State agency for a determination under this section.

(D)

Assistance

A Gateway, or a State agency under this section, shall assist individuals in the filing of applications under paragraph (1)(A).

(5)

Reconciliation

(A)

Filing of statement

In the case of an individual who has received payments under this section for a year and who is claiming a significant decrease (as determined by the Secretary) in adjusted gross income from such year, such individual shall file with the Secretary an income reconciliation statement, at such time, in such manner, and containing such information as the Secretary may require.

(B)

Reconciliation

(i)

In general

Based on and using the adjusted gross income reported in the statement filed by an individual under subparagraph (A), the Secretary shall compute the amount of payments that should have been provided on behalf of the individual for the year involved.

(ii)

Overpayment of payments

(I)

In general

Subject to the limitation in subclause (II), if the amount of payments provided on behalf of an individual for a year under this section was significantly greater (as determined by the Secretary) than the amount computed under clause (i), the individual shall be liable to the Secretary for such excess amount. The Secretary may establish methods under which such liability may be assessed through a reduction in the amount of any credit otherwise applicable under this section with respect to such individual.

(II)

Limitation

With respect to any individual described in subclause (I) who had a verified adjusted gross income that did not exceed 400 percent of the poverty line for a family of the size involved for such year, the amount of any repayment under such subclause (I) shall not exceed—

(aa)

$250 for an individual who filed an individual tax return for such year; or

(bb)

$400 for an individual who filed a joint tax return for such year.

Any such individual with a adjusted gross income that exceeds 400 percent of the poverty line for a family of the size involved for such year shall repay the entire amount so received.
(iii)

Underpayment of payments

If the amount of payments provided to an individual for a year under this section was less than the amount computed under clause (i), the Secretary shall pay to the individual the amount of such deficit. The Secretary may establish methods under which such payments may be provided through an increase in the amount of any credit otherwise applicable under this section with respect to such individual.

(iv)

Coordination with IRS

The Secretary shall coordinate with the Secretary of the Treasury to develop procedures to enable the Internal Revenue Service to administer this subparagraph with respect to the collection of overpayments.

(C)

Failure to file

In the case of an individual who fails to file a statement for a year as required under subparagraph (A), the individual shall not be eligible for further payments until such statement is filed. The Secretary shall waive the application of this subparagraph if the individual establishes, to the satisfaction of the Secretary, good cause for the failure to file the statement on a timely basis.

(D)

Determinations

The Secretary shall make determinations with respect to statements submitted under this paragraph based on income data from the most recent tax return filed by the individual.

(6)

Determinations made with respect to same taxable years

In making determinations under this section with respect to adjusted gross income as compared to the poverty line, the Secretary shall ensure that the poverty line data used relates to the same taxable year for which the adjusted gross income is determined.

(7)

Outreach

The Gateway shall conduct culturally and linguistically appropriate outreach activities to provide information to individuals that may potentially be eligible for payments under this section. Such activities shall include information on the application process with respect to such payments.

(e)

Exclusion from income

Amounts received by an individual under this section shall not be considered as income, and shall not be taken into account in determining assets or resources for purposes of determining the eligibility of such individual, or any other 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.

(f)

Conflict

A Gateway may not establish rules that conflict with or prevent the application of regulations promulgated by the Secretary under this title.

(g)

No Federal funding

Nothing in this title shall allow Federal payments for individuals who are not lawfully present in the United States.

(h)

Appropriation

Out of any funds in the Treasury of the United States not otherwise appropriated, there are appropriated such sums as may be necessary to carry out this section for each fiscal year.

3112.

Small business health options program credit

(a)

Calculation of credit

For each calendar year beginning in calendar year 2010, in the case of an employer that is a qualified small employer, out of any funds in the Treasury of the United States not otherwise appropriated, the Secretary shall make a payment to such qualified small employer in the amount described in subsection (b).

(b)

General credit amount

For purposes of this section:

(1)

In general

The credit amount described in this subsection shall be the product of—

(A)

the applicable amount specified in paragraph (2);

(B)

the employer size factor specified in paragraph (3); and

(C)

the percentage of year factor specified in paragraph (4).

(2)

Applicable amount

For purposes of paragraph (1):

(A)

In general

The applicable amount shall be equal to—

(i)

$1,000 for each employee of the employer who receives self-only health insurance coverage through the employer;

(ii)

$2,000 for each employee of the employer who receives family health insurance coverage through the employer; and

(iii)

$1,500 for each employee of the employer who receives health insurance coverage for two adults or one adult and one or more children through the employer.

(B)

Bonus for payment of greater percentage of premiums

The applicable amount specified in subparagraph (A) shall be increased by $200 in the case of subparagraph (A)(i), $400 in the case of subparagraph (A)(ii), and $300 in the case of subparagraph (A)(iii), for each additional 10 percent of the qualified employee health insurance expenses exceeding 60 percent which are paid by the qualified small employer.

(3)

Employer size factor

For purposes of paragraph (1), the employer size factor shall be the percentage determined in accordance with the following:

(A)

With respect to an employer with 10 or fewer employees, the percentage shall be 100 percent.

(B)

With respect to an employer with more than 10, but not more than 20, full-time employees, the percentage shall be 80 percent.

(C)

With respect to an employer with more than 20, but not more than 30, full-time employees, the percentage shall be 50 percent.

(D)

With respect to an employer with more than 30, but not more than 40, full-time employees, the percentage shall be 40 percent.

(E)

With respect to an employer with more than 40, but not more than 50, full-time employees, the percentage shall be 20 percent.

(F)

With respect to an employer with more than 50 full-time employees, the percentage shall be 0 percent.

(4)

Percentage of year factor

For purposes of paragraph (1), the percentage of year factor shall be equal to the ratio of—

(A)

the number of months during the year for which the employer paid or incurred at least 60 percent of the qualified employee health insurance expenses of such employer; and

(B)

12.

(c)

Definitions and special rules

For purposes of this section:

(1)

Qualified small employer

(A)

In general

The term qualified small employer means an employer (as defined in section 3(d) of the Fair Labor Standards Act of 1938 and including self-employed individuals) that—

(i)

pays or incurs at least 60 percent of the qualified employee health insurance expenses of such employer, or who is self-employed; and

(ii)

was—

(I)

an employer that—

(aa)

employed an average of 50 or fewer full-time employees during the preceding taxable year; and

(bb)

had an average wage of less than $50,000 for full time employees in the preceding taxable year; or

(II)

a self-employed individual that—

(aa)

had not less than $5,000 in net earnings;

(bb)

had not greater than $50,000 in net earnings; and

(cc)

has elected not to receive a credit under section 3111.

(B)

Limitation

An employer may not receive a credit under this section for more than 1 period of not more than 3 consecutive years.

(2)

Qualified employee health insurance expenses

(A)

In general

The term qualified employee health insurance expenses means any amount paid by an employer or an employee of such employer for health insurance coverage to the extent such amount is for coverage—

(i)

provided to any employee (as defined in section 3(e) of the Fair Labor Standards Act of 1938), or

(ii)

for a self-employed individual.

(B)

Exception for amounts paid under salary reduction arrangements

No amount paid or incurred for health insurance coverage pursuant to a salary reduction arrangement shall be taken into account for purposes of subparagraph (A).

(3)

Full-time employee

The term full time employee means, with respect to any period, an employee (as defined in section 3(e) of the Fair Labor Standards Act of 1938) of an employer if the average number of hours worked by such employee in the preceding taxable year for such employer was at least 40 hours per week.

(d)

Inflation adjustment

(1)

In general

For each calendar year after 2010, the dollar amounts specified in subsections (b)(2)(A), (b)(2)(B), and (c)(1)(A)(ii) (after the application of this paragraph) shall be the amounts in effect in the preceding calendar year or, if greater, the product of—

(A)

the corresponding dollar amount specified in such subsection; and

(B)

the ratio of the index of wage inflation (as determined by the Bureau of Labor Statistics) for August of the preceding calendar year to such index of wage inflation for August of 2008.

(2)

Rounding

If any amount determined under paragraph (1) is not a multiple of $100, such amount shall be rounded to the next lowest multiple of $100.

(e)

Application of certain rules in determination of employer size

For purposes of this section:

(1)

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.

(2)

Employers not in existence in preceding year

In the case of an employer which was not in existence for the full preceding taxable year, the determination of whether such employer meets the requirements of this section shall be based on the average number of full-time employees that it is reasonably expected such employer will employ on business days in the employer’s first full taxable year.

(3)

Predecessors

Any reference in this subsection to an employer shall include a reference to any predecessor of such employer.

.

152.

Program integrity

(a)

In general

Subsection (l) of section 6103 of the Internal Revenue Code of 1986 is amended by adding at the end the following new paragraph:

(21)

Voluntary authorization for income verification

(A)

Voluntary authorization

The Secretary shall provide a mechanism for each taxpayer to indicate whether such taxpayer authorizes the Secretary to disclose to the Secretary of Health and Human Services (or, pursuant to a delegation described in subsection (d)(4)(B), to a State or a Gateway (as defined in section 3101 of the Public Health Service Act) return information of a taxpayer who may be eligible for credits under section 3111 of the Public Health Service Act.

(B)

Provision of information

If a taxpayer authorizes the disclosure described in subparagraph (A), the Secretary shall disclose to the Secretary of Health and Human Services (or, pursuant to a delegation described in subsection (d)(4)(B), to a State or a Gateway) the minimum necessary amount of information necessary to establish whether such individual is eligible for credits under section 3111 of the Public Health Service Act.

(C)

Restriction on use of disclosed information

Return information disclosed under subparagraph (A) may be used by the Secretary (or, pursuant to a delegation described in subsection (d)(4)(B), a State or a Gateway) only for the purposes of, and to the extent necessary in, establishing the appropriate amount of any payments under section 3111 of the Public Health Service Act.

.

(b)

Collection of amounts

Section 6305(a) of the Internal Revenue Code of 1986 is amended by inserting or under section 3111 of the Public Health Service Act after Social Security Act.

(c)

Conforming amendments

(1)

Paragraph (3) of section 6103(a) of such Code is amended by striking or (20) and inserting (20), or (21).

(2)

Paragraph (4) of section 6103(p) of such Code is amended by striking (l)(10), (16), (18), (19), or (20) each place it appears and inserting (l)(10), (16), (18), (19), (20), or (21).

(3)

Paragraph (2) of section 7213(a) of such Code is amended by striking or (20) and inserting (20), or (21).

D

Shared responsibility for health care

161.

Individual responsibility

(a)

Payments

(1)

In general

Subchapter A of chapter 1 of the Internal Revenue Code of 1986 (relating to determination of tax liability) is amended by adding at the end the following new part:

VIII

Shared responsibility payments

Sec. 59B. Shared responsibility payments.

59B.

Shared responsibility payments

(a)

Requirement

Every individual shall ensure that such individual, and each dependent of such individual, is covered under qualifying coverage at all times during the taxable year.

(b)

Payment

(1)

In general

(A)

In general

In the case of any individual who did not have in effect qualifying coverage (as defined in section 3116 of the Public Health Service Act) for any month during the taxable year, there is hereby imposed for the taxable year, in addition to any other amount imposed by this subtitle, an amount equal to the amount established under paragraph (2).

(B)

Rule for dependents

Any amount to be imposed under this subsection with respect to an individual described in subparagraph (A) that is a dependent (as defined in section 152) of another taxpayer shall be imposed—

(i)

except in any case described in clause (ii), upon the taxpayer on whom such individual is a dependent; or

(ii)

in any case in which the taxpayer with respect to whom such individual is a dependent files a joint return, jointly upon the taxpayer and the spouse of the taxpayer.

(C)

Limitation

The maximum amount imposed under this paragraph with respect to any taxpayer shall not exceed 4 times the amount determined under paragraph (2)(D).

(2)

Amount established

(A)

Requirement to establish

Not later than June 30 of each calendar year, the Secretary, in consultation with the Secretary of Health and Human Services and with the States, shall establish an amount for purposes of paragraph (1).

(B)

Effective date

The amount established under subparagraph (A) shall be effective with respect to the taxable year following the date on which the amount under subparagraph (A) is established.

(C)

Required consideration

Subject to the limitation described in subparagraph (D), in establishing the amount under subparagraph (A), the Secretary shall seek to establish the minimum practicable amount that can accomplish the goal of enhancing participation in qualifying coverage (as so defined).

(D)

Limitation

(i)

In general

Subject to an adjustment under clause (ii), the amount established under this subparagraph is $750.

(ii)

Inflation adjustment

Beginning with taxable years after 2011, the amount described in clause (i) shall be adjusted by the Secretary by notice, published in the Federal Register, for each fiscal year to reflect the total percentage change that occurred in the medical care component of the Consumer Price Index for all urban consumers (all items; U.S. city average) during the preceding calendar year.

(c)

Exemptions

Subsection (b) shall not apply to any individual—

(1)

with respect to any month if such month occurs during any period in which such individual did not have qualifying coverage (as so defined) for a period of less than 90 days,

(2)

who is a resident of a State that is not a participating State or an establishing State (as such terms are defined in section 3104 of the Public Health Service Act),

(3)

who is an Indian as defined in section 4 of the Indian Health Care Improvement Act,

(4)

for whom affordable health care coverage is not available (as such terms are defined by the Secretary of Health and Human Services under section 3103 of the Public Health Service Act), or

(5)

described in section 3116(a)(4)(C) of the Public Health Service Act.

(d)

Coordination with other provisions

(1)

Not treated as tax for certain purposes

The amount imposed by this section shall not be treated as a tax imposed by this chapter for purposes of determining—

(A)

the amount of any credit allowable under this chapter, or

(B)

the amount of the minimum tax imposed by section 55.

(2)

Treatment under subtitle F

For purposes of subtitle F, the amount imposed by this section shall be treated as if it were a tax imposed by section 1.

(3)

Section 15 not to apply

Section 15 shall not apply to the amount imposed by this section.

(4)

Section not to affect liability of possessions, etc

This section shall not apply for purposes of determining liability to any possession of the United States. For purposes of section 932 and 7654, the amount imposed under this section shall not be treated as a tax imposed by this chapter.

(e)

Uses

Amounts collected under this section shall be dedicated to premium credits established under section 3111 of the Public Health Service Act.

(f)

Regulations

The Secretary may prescribe such regulations as may be appropriate to carry out the purposes of this section.

.

(2)

Clerical amendment

The table of parts for subchapter A of chapter 1 of such Code is amended by adding at the end the following new item:

PART VIII—Shared responsibility payments

.

(3)

Effective date

The amendments made by this section shall apply to taxable years beginning after December 31, 2011.

(b)

Reporting of health insurance coverage

(1)

In general

Part III of subchapter A of chapter 61 of the Internal Revenue Code of 1986 is amended by inserting after subpart B the following new subpart:

D

Information regarding health insurance coverage

Sec. 6055. Reporting of health insurance coverage.

6055.

Reporting of health insurance coverage

(a)

In general

Every person who provides health insurance that is qualifying coverage shall make a return described in subsection (b).

(b)

Form and manner of return

A return is described in this subsection if such return—

(1)

is in such form as the Secretary prescribes,

(2)

contains—

(A)

the name, address, and taxpayer identification number of each individual who is covered under health insurance that is qualifying coverage provided by such person, and

(B)

the number of months during the calendar year during which each such individual was covered under such health insurance, and

(3)

such other information as the Secretary may prescribe.

(c)

Statements to be furnished to individuals with respect to whom information is reported

(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—

(A)

the name, address, and phone number of the information contact of the person required to make such return, and

(B)

the number of months during the calendar year during which such individual was covered under health insurance that is qualifying coverage provided by such person.

(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.

(d)

Qualifying coverage

For purposes of this section, the term qualifying coverage has the meaning given such term under section 3116 of the Public Health Service Act.

.

(2)

Conforming amendments

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—Health insurance coverage

.

(3)

Effective date

The amendments made by this section shall apply to taxable years beginning after December 31, 2011.

(c)

Notification of nonenrollment

Not later than June 30 of each year, the Secretary of the Treasury, acting through the Internal Revenue Service and in consultation with the Secretary of Health and Human Services, shall send a notification each individual who files an individual income tax return and who is not enrolled in qualifying coverage (as defined in section 3116 of the Public Health Service Act). Such notification shall contain information on the services available through the Gateway (if any) operating in the State in which such individual resides.

162.

Notification on the availability of affordable health choices

The Fair Labor Standards Act of 1938 is amended by inserting after section 18 (29 U.S.C. 218) the following:

18A.

Notice to employees

(a)

In general

In accordance with regulations promulgated by the Secretary, an employer to which this Act applies, shall provide to each employee at the time of hiring (or with respect to current employees, within 90 days of the date on which a State becomes an establishing or participating State under section 3104 of the Public Health Service Act), written notice informing the employee of the existence of the American Health Benefits Gateway, including a description of the services provided by such Gateway and the manner in which the employee may contact the Gateway to request assistance.

(b)

Effective date

Subsection (a) shall take effect with respect to employers in a State beginning 90 days after the date on which the State becomes an establishing or participating State under section 3104 of the Public Health Service. Act.

.

163.

Shared responsibility of employers

Subtitle B of title XXXI of the Public Health Service Act, as amended by section 151, is further amended by adding at the end the following:

3115.

Shared responsibility of employers

(a)

Employees not offered coverage

An employer shall make a payment to the Secretary in the amount described in subsection (b) with respect to each employee—

(1)

who is not offered qualifying coverage by such employer during each month where such employee is not offered qualifying coverage; or

(2)

on behalf of whom such employer is not contributing at least 60 percent of the monthly premiums for such coverage for each such month.

(b)

Amount

(1)

In general

The annual amount described in this subsection shall be equal to $750 for each full-time employee described in subsection (a). Such amount shall be pro-rated with respect to each month in which subsection (a) applies with respect to an employee.

(2)

Pro rata application for part-time employees

The provisions of paragraph (1) shall apply with respect to part-time employees employed by the employer, except that the annual payment amount described in such paragraph shall be reduced to $375 for each part-time employee.

(3)

Application

The provisions of this subsection shall only apply with respect to the number of employees employed by the employer in excess of 25 employees.

(c)

Procedures

The Secretary shall develop procedures for making determinations with respect to qualifying coverage and for making the payments required under subsection (a). Such procedures shall provide for the making of payments on a quarterly basis.

(d)

Use of funds

Amounts shall be collected under subsection (a) and be available for obligation only to the extent and in the amount provided in advance in appropriations Acts. Such amounts are authorized to remain available until expended.

(e)

Inflation adjustment

Beginning with calendar years after 2013, the amounts described in subsection (b) shall be adjusted by the Secretary by notice, published in the Federal Register, for each fiscal year to reflect the total percentage change that occurred in the medical care component of the Consumer Price Index for all urban consumers (all items; U.S. city average) during the preceding calendar year.

(f)

Exemption for small employers

(1)

In general

For purposes of this section, the term employer means an employer that employs more than 25 employees on business days during the preceding calendar year. An employer shall not be considered to employ more than 25 employees if—

(A)

the employer's workforce exceeds 25 employees for 120 days or fewer during the calendar year; and

(B)

the employees employed during such 120-day period were seasonal workers.

(2)

Definition of seasonal workers

In this subsection, 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.

(3)

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.

(4)

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.

(5)

Predecessors

Any reference in this subsection to an employer shall include a reference to any predecessor of such employer.

(g)

Authority to certify

The Secretary, in collaboration with the Secretary of the Treasury and the Secretary of Labor, shall establish procedures for determining the number of employees of employers who are not offered qualifying coverage.

(h)

Independent contractors

For purposes of determining whether an employer is subject to this section, any individual who qualifies as an independent contractor under Federal law and who is retained by such employer shall not be counted when determining the number of employees employed by the employer.

(i)

Regulations

The Secretary, in consultation with the Secretary of Labor, shall promulgate such regulations as may be appropriate to carry out activities under this section.

(j)

Effective date

This section shall apply with respect to an employer beginning in the calendar year in which the State in which the employer is located becomes an establishing State or a participating State.

3116.

Definitions

(a)

In general

In this title:

(1)

Eligible individual

The term eligible individual means an individual who is—

(A)

a citizen or national of the United States or an alien lawfully admitted to the United States for permanent residence or an alien lawfully present in the United States;

(B)

a qualified individual;

(C)

enrolled in a qualified health plan; and

(D)

not receiving full benefits coverage under a State child health plan under title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.) (or full benefits coverage under a demonstration project funded through such title XXI).

(2)

Qualified employer

(A)

In general

The term qualified employer means an employer that—

(i)

elects to make all full-time employees of such employer eligible for a qualified health plan; and

(ii)
(I)

in the case of an employer that elects to make its employees eligible for qualified health plans in an establishing State—

(aa)

employs fewer than the number of employees specified in subparagraph (B); and

(bb)

meets criteria established by the State; or

(II)

in the case of an employer that elects to make its employees eligible for qualified health plans in a participating State—

(aa)

employs fewer than the number of employees specified in subparagraph (B); and

(bb)

meets criteria established by the Secretary.

(B)

Number of employees

(i)

Establishment

(I)

By state

In the case of an establishing State, such State may by regulation establish the number of employees described in subparagraph (A)(ii)(I)(aa) but such number may not be less than 50.

(II)

By the secretary

In the case of a participating State, the Secretary may by regulation establish the number of employees described in subparagraph (A)(ii)(II)(aa) but such number may not be less than 50.

(ii)

Default

If a State or the Secretary does not establish the number described in subclause (I) or (II), respectively, of clause (i), such number shall be 50.

(C)

Continuation of participation

A qualified employer that is enrolled in a qualified health plan and that experiences an increase in the number of employees of such employer such that the number of employees of such employer exceeds the number specified in subparagraph (B)(i) or subparagraph (B)(ii), as applicable, shall, notwithstanding such increase, continue to be considered a qualified employer for purposes of this title, provided that such employer remains enrolled in a qualified health plan.

(3)

Qualified health plan

(A)

In general

The term qualified health plan means health plan that—

(i)

has in effect a certification (which may include a seal or other indication of approval) that such plan meets the criteria for certification described in section 3101(m) issued or recognized by each Gateway through which such plan is offered; and

(ii)

is offered by a health insurance issuer that—

(I)

is licensed and in good standing to offer health insurance coverage in each State in which such issuer offers health insurance coverage under this title;

(II)

agrees to offer at least one qualified health plan in the tier described in section 3111(a)(1)(A) and at least one plan in the tier described in section 3111(a)(1)(B);

(III)

complies with the regulations developed by the Secretary under section 3101(m) and such other requirements as an applicable Gateway may establish; and

(IV)

agrees to pay any surcharge assessed under section 3101(c)(4).

(B)

Inclusion of community health insurance option

Any reference in this title to a qualified health plan shall be deemed to include a community health insurance option, unless specifically provided for otherwise.

(4)

Qualified individual

(A)

In general

The term qualified individual means an individual who is—

(i)

residing in a participating State or an establishing State (as defined in section 3104);

(ii)

not incarcerated, except an individual in custody pending the disposition of charges;

(iii)

not entitled to coverage under the Medicare program under part A of title XVIII of the Social Security Act;

(iv)

not enrolled in coverage under the Medicare program under part B of title XVIII of the Social Security Act or under part C of such title; and

(v)

not eligible for coverage under—

(I)

the Medicaid program under a State plan under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), or under a waiver under section 1115 of such Act;

(II)

the TRICARE program under chapter 55 of title 10, United States Code (as defined in section 1072(7) of such title);

(III)

the Federal employees health benefits program under chapter 89 of title 5, United States Code; or

(IV)

employer-sponsored coverage (except as provided under subparagraph (B)).

(B)

Employees without affordable coverage

An individual who is eligible for employer-sponsored coverage shall be deemed to be a qualified individual under subparagraph (A) only if such coverage—

(i)

does not meet the criteria established under section 3103 for minimum qualifying coverage; or

(ii)

is not affordable (as such term is defined by the Secretary under section 3103) for such employee.

(C)

Individuals at less than 150 percent of poverty

An individual with an adjusted gross income that does not exceed 150 percent of the poverty line for a family of the size involved shall not be considered a qualified individual for purposes of this title.

(5)

Qualifying coverage

The term qualifying coverage means—

(A)

a group health plan or health insurance coverage—

(i)

that an individual is enrolled in on the date of enactment of this title; or

(ii)

that is described in clause (i) and that is renewed by an enrollee as provided for in section 131 of the Affordable Health Choices Act;

(B)

a group health plan or health insurance coverage that—

(i)

is not described in subparagraph (A); and

(ii)

meets or exceeds the criteria for minimum qualifying coverage (as defined in section 3103);

(C)

Medicare coverage under parts A and B of title XVIII of the Social Security Act or under part C of such title;

(D)

Medicaid coverage under a State plan under title XIX of the Social Security Act (or under a waiver under section 1115 of such Act), other than coverage consisting solely of benefits under section 1928 of such Act;

(E)

coverage under title XXI of the Social Security Act;

(F)

coverage under the TRICARE program under chapter 55 of title 10, United States Code;

(G)

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 to be not less than the coverage provided under a qualified health plan, based on the individual’s priority for services as provided under section 1705(a) of such title;

(H)

coverage under the Federal employees health benefits program under chapter 89 of title 5, United States Code;

(I)

a State health benefits high risk pool;

(J)

a health benefit plan under section 2504(e) of title 22, United States Code; or

(K)

coverage under a qualified health plan.

For purposes of this paragraph, an individual shall be deemed to have qualifying coverage if such individual is an individual described in section 1402(e) or (g) of the Internal Revenue Code of 1986.
(6)

Adjusted gross income

The term adjusted gross income with respect to an individual has the meaning given such term for purposes of section 62(a) of the Internal Revenue Code of 1986.

(7)

Educated health care consumer

The term educated health care consumer means an individual who is knowledgeable about the health care system, and has background or experience in making informed decisions regarding health, medical, and scientific matters.

(b)

Incorporation of additional definitions

Unless specifically provided for otherwise, the definitions contained in section 2791 shall apply with respect to this title.

.

E

Improving access to health care services

171.

Spending for Federally Qualified Health Centers (FQHCs)

(a)

In general

Section 330(r) of the Public Health Service Act (42 U.S.C. 254b(r)) is amended by striking paragraph (1) and inserting the following:

(1)

General amounts for grants

For the purpose of carrying out this section, in addition to the amounts authorized to be appropriated under subsection (d), there is authorized to be appropriated the following:

(A)

For fiscal year 2010, $2,988,821,592.

(B)

For fiscal year 2011, $3,862,107,440.

(C)

For fiscal year 2012, $4,990,553,440.

(D)

For fiscal year 2013, $6,448,713,307.

(E)

For fiscal year 2014, $7,332,924,155.

(F)

For fiscal year 2015, $8,332,924,155.

(G)

For fiscal year 2016, and each subsequent fiscal year, the amount appropriated for the preceding fiscal year adjusted by the product of—

(i)

one plus the average percentage increase in costs incurred per patient served; and

(ii)

one plus the average percentage increase in the total number of patients served.

.

(b)

Rule of construction

Section 330(r) of the Public Health Service Act (42 U.S.C. 254b(r)) is amended by adding at the end the following:

(4)

Rule of construction with respect to rural health clinics

(A)

In general

Nothing in this section shall be construed to prevent a community health center from contracting with a Federally certified rural health clinic (as defined in section 1861(aa)(2) of the Social Security Act), a low-volume hospital (as defined for purposes of section 1886 of such Act), a critical access hospital, a sole community hospital (as defined for purposes of section 1886(d)(5)(D)(iii) of such Act), or a medicare-dependent share hospital (as defined for purposes of section 1886(d)(5)(G)(iv) of such Act) for the delivery of primary health care services that are available at the clinic or hospital to individuals who would otherwise be eligible for free or reduced cost care if that individual were able to obtain that care at the community health center. Such services may be limited in scope to those primary health care services available in that clinic or hospitals.

(B)

Assurances

In order for a clinic or hospital to receive funds under this section through a contract with a community health center under subparagraph (A), such clinic or hospital shall establish policies to ensure—

(i)

nondiscrimination based on the ability of a patient to pay; and

(ii)

the establishment of a sliding fee scale for low-income patients.

.

172.

Other provisions

(a)

Settings for service delivery

Section 330(a)(1) of the Public Health Service Act (42 U.S.C. 254b(a)(1)) is amended by adding at the end the following: Required primary health services and additional health services may be provided either at facilities directly operated by the center or at any other inpatient or outpatient settings determined appropriate by the center to meet the needs of its patents..

(b)

Location of service delivery sites

Section 330(a) of the Public Health Service Act (42 U.S.C. 254b(a)) is amended by adding at the end the following:

(3)

Considerations

(A)

Location of sites

Subject to subparagraph (B), a center shall not be required to locate its service facility or facilities within a designated medically underserved area in order to serve either the residents of its catchment area or a special medically underserved population comprised of migratory and seasonal agricultural workers, the homeless, or residents of public housing, if that location is determined by the center to be reasonably accessible to and appropriate to meet the needs of the medically underserved residents of the center’s catchment area or the special medically underserved population, in accordance with subparagraphs (A) and (J) of subsection (k)(3).

(B)

Location within another center's area

The Secretary may permit applicants for grants under this section to propose the location of a service delivery site within another center’s catchment area if the applicant demonstrates sufficient unmet need in such area and can otherwise justify the need for additional Federal resources in the catchment area. In determining whether to approve such a proposal, the Secretary shall take into consideration whether collaboration between the two centers exists, or whether the applicant has made reasonable attempts to establish such collaboration, and shall consider any comments timely submitted by the affected center concerning the potential impact of the proposal on the availability or accessibility of services the affected center currently provides or the financial viability of the affected center.

.

(c)

Affiliation agreements

Section 330(k)(3)(B) of the Public Health Service Act (42 U.S.C. 254b(k)(3)(B)) is amended by inserting before the semicolon the following: , including contractual arrangements as appropriate, while maintaining full compliance with the requirements of this section, including the requirements of subparagraph (H) concerning the composition and authorities of the center’s governing board, and, except as otherwise provided in clause (ii) of such subparagraph, ensuring full autonomy of the center over policies, direction, and operations related to health care delivery, personnel, finances, and quality assurance.

(d)

Governance requirements

Section 330(k)(3) of the Public Health Service Act (42 U.S.C. 254b(k)(3)) is amended—

(1)

in subparagraph (H)—

(A)

in clause (ii), strike ; and and inserting , except that in the case of a public center (as defined in the second sentence of this paragraph), the public entity may retain authority to establish financial and personnel policies for the center; and;

(B)

in clause (iii), by adding and at the end; and

(C)

by inserting after clause (iii) the following:

(iv)

in the case of a co-applicant with a public entity, meets the requirements of clauses (i) and (ii);

; and

(2)

in the second sentence, by inserting before the period the following: that is governed by a board that satisfies the requirements of subparagraph (H) or that jointly applies (or has applied) for funding with a co-applicant board that meets such requirements.

(e)

Adjustment in center's operating plan and budget

Section 330(k)(3)(I)(i) of the Public Health Service Act (42 U.S.C. 254b(k)(3)(I)(i)) is amended by adding before the semicolon the following: , which may be modified by the center at any time during the fiscal year involved if such modifications do not require additional grant funds, do not compromise the availability or accessibility of services currently provided by the center, and otherwise meet the conditions of subsection (a)(3)(B), except that any such modifications that do not comply with this clause, as determined by the health center, shall be submitted to the Secretary for approval.

(f)

Joint purchasing arrangements for reduced cost

Section 330(l) of the Public Health Service Act (42 U.S.C. 254b(l)) is amended—

(1)

by striking The Secretary and inserting the following:

(1)

In general

The Secretary

; and

(2)

by adding at the end the following:

(2)

Assistance with supplies and services costs

The Secretary, directly or through grants or contracts, may carry out projects to establish and administer arrangements under which the costs of providing the supplies and services needed for the operation of federally qualified health centers are reduced through collaborative efforts of the centers, through making purchases that apply to multiple centers, or through such other methods as the Secretary determines to be appropriate.

.

(g)

Opportunity To Correct Material Failure Regarding Grant Conditions

Section 330(e) of the Public Health Service Act (42 U.S.C. 254b(e)) is amended by adding at the end the following:

(6)

Opportunity to Correct Material Failure Regarding Grant Conditions

If the Secretary finds that a center materially fails to meet any requirement (except for any requirements waived by the Secretary) necessary to qualify for its grant under this subsection, the Secretary shall provide the center with an opportunity to achieve compliance (over a period of up to 1 year from making such finding) before terminating the center's grant. A center may appeal and obtain an impartial review of any Secretarial determination made with respect to a grant under this subsection, or may appeal and receive a fair hearing on any Secretarial determination involving termination of the center's grant entitlement, modification of the center's service area, termination of a medically underserved population designation within the center's service area, disallowance of any grant expenditures, or a significant reduction in a center's grant amount.

.

173.

Negotiated rulemaking for development of methodology and criteria for designating medically underserved populations and health professions shortage areas

(a)

Establishment

(1)

In general

The Secretary of Health and Human Services (in this section referred to as the Secretary) shall establish, through a negotiated rulemaking process under subchapter 3 of chapter 5 of title 5, United States Code, a comprehensive methodology and criteria for designation of—

(A)

medically underserved populations in accordance with section 330(b)(3) of the Public Health Service Act (42 U.S.C. 254b(b)(3));

(B)

health professions shortage areas under section 332 of the Public Health Service Act (42 U.S.C. 254e).

(2)

Factors to consider

In establishing the methodology and criteria under paragraph (1), the Secretary—

(A)

shall consult with relevant stakeholders who will be significantly affected by a rule (such as national, State and regional organizations representing affected entities), State health offices, community organizations, health centers and other affected entities, and other interested parties; and

(B)

shall take into account—

(i)

the timely availability and appropriateness of data used to determine a designation to potential applicants for such designations;

(ii)

the impact of the methodology and criteria on communities of various types and on health centers and other safety net providers;

(iii)

the degree of ease or difficulty that will face potential applicants for such designations in securing the necessary data; and

(iv)

the extent to which the methodology accurately measures various barriers that confront individuals and population groups in seeking health care services.

(b)

Publication of notice

In carrying out the rulemaking process under this subsection, the Secretary shall publish the notice provided for under section 564(a) of title 5, United States Code, by not later than 45 days after the date of the enactment of this Act.

(c)

Target date for publication of rule

As part of the notice under subsection (b), and for purposes of this subsection, the target date for publication, as referred to in section 564(a)(5) of title 5, United Sates Code, shall be July 1, 2010.

(d)

Appointment of negotiated rulemaking committee and facilitator

The Secretary shall provide for—

(1)

the appointment of a negotiated rulemaking committee under section 565(a) of title 5, United States Code, by not later than 30 days after the end of the comment period provided for under section 564(c) of such title; and

(2)

the nomination of a facilitator under section 566(c) of such title 5 by not later than 10 days after the date of appointment of the committee.

(e)

Preliminary committee report

The negotiated rulemaking committee appointed under subsection (d) shall report to the Secretary, by not later than April 1, 2010, regarding the committee's progress on achieving a consensus with regard to the rulemaking proceeding and whether such consensus is likely to occur before one month before the target date for publication of the rule. If the committee reports that the committee has failed to make significant progress toward such consensus or is unlikely to reach such consensus by the target date, the Secretary may terminate such process and provide for the publication of a rule under this section through such other methods as the Secretary may provide.

(f)

Final committee report

If the committee is not terminated under subsection (e), the rulemaking committee shall submit a report containing a proposed rule by not later than one month before the target publication date.

(g)

Interim final effect

The Secretary shall publish a rule under this section in the Federal Register by not later than the target publication date. Such rule shall be effective and final immediately on an interim basis, but is subject to change and revision after public notice and opportunity for a period (of not less than 90 days) for public comment. In connection with such rule, the Secretary shall specify the process for the timely review and approval of applications for such designations pursuant to such rules and consistent with this section.

(h)

Publication of rule after public comment

The Secretary shall provide for consideration of such comments and republication of such rule by not later than 1 year after the target publication date.

174.

Equity for certain eligible survivors

(a)

Rebuttable presumption

Section 411(c)(4) of the Black Lung Benefits Act (30 U.S.C. 921(c)(4)) is amended by striking the last sentence.

(b)

Continuation of benefits

Section 422(l) of the Black Lung Benefits Act (30 U.S.C. 932(l)) is amended by striking , except with respect to a claim filed under this part on or after the effective date of the Black Lung Benefits Amendments of 1981.

(c)

Effective date

The amendments made by this section shall apply with respect to claims filed under part B or part C of the Black Lung Benefits Act (30 U.S.C. 921 et seq., 931 et seq.) after January 1, 2005, that are pending on or after the date of enactment of this Act.

175.

Reauthorization of the Wakefield Emergency Medical Services for Children Program

Section 1910 of the Public Health Service Act (42 U.S.C. 300w–9) is amended—

(1)

in subsection (a), by striking 3-year period (with an optional 4th year and inserting 4-year period (with an optional 5th year; and

(2)

in subsection (d)—

(A)

by striking and such sums and inserting such sums; and

(B)

by inserting before the period the following: , $25,000,000 for fiscal year 2010, $26,250,000 for fiscal year 2011, $27,562,500 for fiscal year 2012, $28,940,625 for fiscal year 2013, and $30,387,656 for fiscal year 2014.

176.

Co-locating primary and specialty care in community-based mental health settings

Subpart 3 of part B of title V of the Public Health Service Act (42 U.S.C. 290bb-31 et seq.) is amended by adding at the end the following:

520K.

Grants for co-locating primary and specialty care in community-based mental health settings

(a)

Definitions

In this section:

(1)

Eligible entity

The term eligible entity means a qualified community mental health program defined under section 1913(b)(1).

(2)

Special populations

The term special populations refers to the following 3 groups:

(A)

Children and adolescents with mental and emotional disturbances who have co-occurring primary care conditions and chronic diseases.

(B)

Adults with mental illnesses who have co-occurring primary care conditions and chronic diseases.

(C)

Older adults with mental illnesses who have co-occurring primary care conditions and chronic diseases.

(b)

Program authorized

The Secretary, acting through the Administrator of the Substance Abuse and Mental Health Services Administration and in coordination with the Director of the Health Resources and Services Administration, shall award grants to eligible entities to establish demonstration projects for the provision of coordinated and integrated services to special populations through the co-location of primary and specialty care services in community-based mental and behavioral health settings.

(c)

Application

To be eligible to receive a grant under this section, an eligible entity shall submit an application to the Administrator at such time, in such manner, and accompanied by such information as the Administrator may require. Each such application shall include—

(1)

an assessment of the primary care needs of the patients served by the eligible entity and a description of how the eligible entity will address such needs; and

(2)

a description of partnerships, cooperative agreements, or other arrangements with local primary care providers, including community health centers, to provide services to special populations.

(d)

Use of funds

(1)

In general

For the benefit of special populations, an eligible entity shall use funds awarded under this section for—

(A)

the provision, by qualified primary care professionals on a reasonable cost basis, of—

(i)

primary care services on site at the eligible entity;

(ii)

diagnostic and laboratory services; or

(iii)

adult and pediatric eye, ear, and dental screenings;

(B)

reasonable costs associated with medically necessary referrals to qualified specialty care professionals as well as to other coordinators of care or, if permitted by the terms of the grant, for the provision, by qualified specialty care professionals on a reasonable cost basis on site at the eligible entity;

(C)

information technology required to accommodate the clinical needs of primary and specialty care professionals; or

(D)

facility improvements or modifications needed to bring primary and specialty care professionals on site at the eligible entity.

(2)

Limitation

Not to exceed 15 percent of grant funds may be used for activities described in subparagraphs (C) and (D) of paragraph (1).

(e)

Geographic distribution

The Secretary shall ensure that grants awarded under this section are equitably distributed among the geographical regions of the United States and between urban and rural populations.

(f)

Evaluation

Not later than 3 months after a grant or cooperative agreement awarded under this section expires, an eligible entity shall submit to the Secretary the results of an evaluation to be conducted by the entity concerning the effectiveness of the activities carried out under the grant or agreement.

(g)

Report

Not later than 5 years after the date of enactment of this section, the Secretary shall prepare and submit to the appropriate committees of Congress a report that shall evaluate the activities funded under this section. The report shall include an evaluation of the impact of co-locating primary and specialty care in community mental and behavioral health settings on overall patient health status and recommendations on whether or not the demonstration program under this section should be made permanent.

(h)

Authorization of appropriations

There are authorized to be appropriated to carry out this section, $50,000,0000 for fiscal year 2010 and such sums as may be necessary for each of fiscal years 2011 through 2014.

.

F

Making health care more affordable for retirees

181.

Reinsurance for retirees

(a)

Administration

(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 whose primary residence is located in any State that is not a participating State or an establishing State (as described in section 3104) for a portion of the cost of providing health insurance coverage to retirees (and to the eligible spouses, surviving spouses, and dependents of such retirees) during the period beginning on the date on which such program is established and ending on the date on which such State becomes a participating State or an establishing State.

(2)

Reference

In this section:

(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.

(B)

Employment-based plan

The term employment-based plan means a group health benefits plan that—

(i)

is—

(I)

maintained by one or more current or former employers (including without limitation any State or local government or political subdivision thereof), employee organization, a voluntary employees’ beneficiary association, or a committee or board of individuals appointed to administer such plan; or

(II)

a multiemployer plan (as defined in section 3(37) of the Employee Retirement Income Security Act of 1974); and

(ii)

provides health benefits to retirees.

(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.

(b)

Participation

(1)

Employment-based plan eligibility

To be eligible to participate in the program established under this section, an employment-based plan (as defined in subsection (a)(2) and referred to in this section as a participating employment-based plan shall—

(A)

provide employment-based health plan benefits; and

(B)

submit to the Secretary an application for participation in the program, at such time, in such manner, and containing such information as the Secretary shall require.

(2)

Appropriate employment-based health benefits

Appropriate employment-based health benefits described in this paragraph shall—

(A)

meet the requirements established under section 3103(a)(1)(B);

(B)

implement programs and procedures to generate cost-savings with respect to participants with chronic and high-cost conditions;

(C)

provide documentation of the actual cost of medical claims involved; and

(D)

be certified as appropriate by the Secretary.

(c)

Payments

(1)

Submission of claims

(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.

(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.

(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).

(3)

Limit

To be eligible for reimbursement under the program, a claim submitted by a participating employment-based plan 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.

(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.

(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.

(6)

Appeals

The Secretary shall establish—

(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

(B)

procedures to protect against fraud, waste, and abuse under the program.

(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.

(e)

Retiree reserve trust fund

(1)

Establishment of trust fund

(A)

In general

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

(B)

Funding

There are hereby appropriated to the Trust Fund, out of any moneys in the Treasury not otherwise appropriated an amount requested by the Secretary of Health and Human Services as necessary to carry out this section, except that the total of all such amounts requested shall not exceed $10,000,000,000.

(C)

Appropriations from the trust fund

Amounts in the Trust Fund may be appropriated to provide funding to carry out this program under this section

(2)

Use of trust fund

The Secretary shall use amounts contained in the Trust Fund to carry out the program under this section.

(3)

Limitations

The Secretary has the authority to stop taking applications for participation in the program to comply with the funding limit provided for in paragraph (1)(B).

G

Improving the Use of Health Information Technology for Enrollment; Miscellaneous Provisions

185.

Health information technology enrollment standards and protocols

Title XXX of the Public Health Service Act (42 U.S.C. 300jj et seq.) is amended by adding at the end the following:

C

Other provisions

3021.

Health information technology enrollment standards and protocols

(a)

In general

(1)

Standards and protocols

Not later than 180 days after the date of enactment of this title, the Secretary, in consultation with the HIT Policy Committee and the HIT Standards Committee, shall develop interoperable and secure standards and protocols that facilitate enrollment of individuals in Federal and State health and human services programs, as determined by the Secretary.

(2)

Methods

The Secretary shall facilitate enrollment in such programs through methods determined appropriate by the Secretary, which shall include providing individuals and third parties authorized by such individuals and their designees notification of eligibility and verification of eligibility required under such programs.

(b)

Content

The standards and protocols for electronic enrollment in the Federal and State programs described in subsection (a) shall allow for the following:

(1)

Electronic matching against existing Federal and State data, including vital records, employment history, enrollment systems, tax records, and other data determined appropriate by the Secretary to serve as evidence of eligibility and in lieu of paper-based documentation.

(2)

Simplification and submission of electronic documentation, digitization of documents, and systems verification of eligibility.

(3)

Reuse of stored eligibility information (including documentation) to assist with retention of eligible individuals.

(4)

Capability for individuals to apply, recertify and manage their eligibility information online, including at home, at points of service, and other community-based locations.

(5)

Ability to expand the enrollment system to integrate new programs, rules, and functionalities, to operate at increased volume, and to apply streamlined verification and eligibility processes to other Federal and State programs, as appropriate.

(6)

Notification of eligibility, recertification, and other needed communication regarding eligibility, which may include communication via email and cellular phones.

(7)

Other functionalities necessary to provide eligibles with streamlined enrollment process.

(c)

Approval and notification

With respect to any standard or protocol developed under subsection (a) that has been approved by the HIT Policy Committee and the HIT Standards Committee, the Secretary—

(1)

shall notify States of such standards or protocols; and

(2)

may require, as a condition of receiving Federal funds for the health information technology investments, that States or other entities incorporate such standards and protocols into such investments.

(d)

Grants for implementation of appropriate enrollment HIT

(1)

In general

The Secretary shall award grant to eligible entities to develop new, and adapt existing, technology systems to implement the HIT enrollment standards and protocols developed under subsection (a) (referred to in this subsection as appropriate HIT technology).

(2)

Eligible entities

To be eligible for a grant under this subsection, an entity shall—

(A)

be a State, political subdivision of a State, or a local governmental entity; and

(B)

submit to the Secretary an application at such time, in such manner, and containing—

(i)

a plan to adopt and implement appropriate enrollment technology that includes—

(I)

proposed reduction in maintenance costs of technology systems;

(II)

elimination or updating of legacy systems; and

(III)

demonstrated collaboration with other entities that may receive a grant under this section that are located in the same State, political subdivision, or locality;

(ii)

an assurance that the entity will share such appropriate enrollment technology in accordance with paragraph (4); and

(iii)

such other information as the Secretary may require.

(3)

Sharing

(A)

In general

The Secretary shall ensure that appropriate enrollment HIT adopted under grants under this subsection is made available to other qualified State, qualified political subdivisions of a State, or other appropriate qualified entities (as described in subparagraph (B)) at no cost.

(B)

Qualified entities

The Secretary shall determine what entities are qualified to receive enrollment HIT under subparagraph (A), taking into consideration the recommendations of the HIT Policy Committee and the HIT Standards Committee.

.

186.

Rule of construction regarding Hawaii's Prepaid Health Care Act

Nothing in this title (or an amendment made by this title) shall be construed to modify or limit the application of the exemption for Hawaii's Prepaid Health Care Act (Haw. Rev. Stat. §§ 393-1 et seq.) as provided for under section 514(b)(5) of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1144(b)(5)).

187.

Key National indicators

(a)

Definitions

In this section:

(1)

Academy

The term Academy means the National Academy of Sciences.

(2)

Commission

The term Commission means the Commission on Key National Indicators established under subsection (b).

(3)

Institute

The term Institute means a Key National Indicators Institute as designated under subsection (c)(3).

(b)

Commission on Key National Indicators

(1)

Establishment

There is established a Commission on Key National Indicators.

(2)

Membership

(A)

Number and appointment

The Commission shall be composed of 8 members, to be appointed equally by the majority and minority leaders of the Senate and the Speaker and minority leader of the House of Representatives.

(B)

Prohibited appointments

Members of the Commission shall not include Members of Congress or other elected Federal, State, or local government officials.

(C)

Qualifications

In making appointments under subparagraph (A), the majority and minority leaders of the Senate and the Speaker and minority leader of the House of Representatives shall appoint individuals who have shown a dedication to improving civic dialogue and decision-making through the wide use of scientific evidence and factual information.

(D)

Period of appointment

Each member of the Commission shall be appointed for a 2-year term, except that 1 initial appointment shall be for 3 years. Any vacancies shall not affect the power and duties of the Commission but shall be filled in the same manner as the original appointment and shall last only for the remainder of that term.

(E)

Date

Members of the Commission shall be appointed by not later than 30 days after the date of enactment of this Act.

(F)

Initial organizing period

–Not later than 60 days after the date of enactment of this Act, the Commission shall develop and implement a schedule for completion of the review and reports required under subsection (d).

(G)

Co-chairpersons

The Commission shall select 2 Co-Chairpersons from among its members.

(c)

Duties of the Commission

(1)

In general

The Commission shall—

(A)

conduct comprehensive oversight of a newly established key national indicators system consistent with the purpose described in this subsection;

(B)

make recommendations on how to improve the key national indicators system;

(C)

coordinate with Federal Government users and information providers to assure access to relevant and quality data; and

(D)

enter into contracts with the Academy.

(2)

Reports

(A)

Annual report to Congress

Not later than 1 year after the selection of the 2 Co-Chairpersons of the Commission, and each subsequent year thereafter, the Commission shall prepare and submit to the appropriate Committees of Congress and the President a report that contains a detailed statement of the recommendations, findings, and conclusions of the Commission on the activities of the Academy and a designated Institute related to the establishment of a Key National Indicator System.

(B)

Annual report to the academy

(i)

In general

Not later than 6 months after the selection of the 2 Co-Chairpersons of the Commission, and each subsequent year thereafter, the Commission shall prepare and submit to the Academy and a designated Institute a report making recommendations concerning potential issue areas and key indicators to be included in the Key National Indicators.

(ii)

Limitation

The Commission shall not have the authority to direct the Academy or, if established, the Institute, to adopt, modify, or delete any key indicators.

(3)

Contract with the national academy of sciences

(A)

In general

–As soon as practicable after the selection of the 2 Co-Chairpersons of the Commission, the Co-Chairpersons shall enter into an arrangement with the National Academy of Sciences under which the Academy shall—

(i)

review available public and private sector research on the selection of a set of key national indicators;

(ii)

determine how best to establish a key national indicator system for the United States, by either creating its own institutional capability or designating an independent private nonprofit organization as an Institute to implement a key national indicator system;

(iii)

if the Academy designates an independent Institute under clause (ii), provide scientific and technical advice to the Institute and create an appropriate governance mechanism that balances Academy involvement and the independence of the Institute; and

(iv)

provide an annual report to the Commission addressing scientific and technical issues related to the key national indicator system and, if established, the Institute, and governance of the Institute’s budget and operations.

(B)

Participation

In executing the arrangement under subparagraph (A), the National Academy of Sciences shall convene a multi-sector, multi-disciplinary process to define major scientific and technical issues associated with developing, maintaining, and evolving a Key National Indicator System and, if an Institute is established, to provide it with scientific and technical advice.

(C)

Establishment of a key national indicator system

(i)

In general

In executing the arrangement under subparagraph (A), the National Academy of Sciences shall enable the establishment of a key national indicator system by—

(I)

creating its own institutional capability; or

(II)

partnering with an independent private nonprofit organization as an Institute to implement a key national indicator system.

(ii)

Institute

If the Academy designates an Institute under clause (i)(II), such Institute shall be a non-profit entity (as defined for purposes of section 501(c)(3) of the Internal Revenue Code of 1986) with an educational mission, a governance structure that emphasizes independence, and characteristics that make such entity appropriate for establishing a key national indicator system.

(iii)

Responsibilities

Either the Academy or the Institute designated under clause (i)(II) shall be responsible for the following:

(I)

Identifying and selecting issue areas to be represented by the key national indicators.

(II)

Identifying and selecting the measures used for key national indicators within the issue areas under subclause (I).

(III)

Identifying and selecting data to populate the key national indicators described under subclause (II).

(IV)

Designing, publishing, and maintaining a public website that contains a freely accessible database allowing public access to the key national indicators.

(V)

Developing a quality assurance framework to ensure rigorous and independent processes and the selection of quality data.

(VI)

Developing a budget for the construction and management of a sustainable, adaptable, and evolving key national indicator system that reflects all Commission funding of Academy and, if an Institute is established, Institute activities.

(VII)

Reporting annually to the Commission regarding its selection of issue areas, key indicators, data, and progress toward establishing a web-accessible database.

(VIII)

Responding directly to the Commission in response to any Commission recommendations and to the Academy regarding any inquiries by the Academy.

(iv)

Governance

Upon the establishment of a key national indicator system, the Academy shall create an appropriate governance mechanism that incorporates advisory and control functions. If an Institute is designated under clause (i)(II), the governance mechanism shall balance appropriate Academy involvement and the independence of the Institute.

(v)

Modification and changes

The Academy shall retain the sole discretion, at any time, to alter its approach to the establishment of a key national indicator system or, if an Institute is designated under clause (i)(II), to alter any aspect of its relationship with the Institute or to designate a different non-profit entity to serve as the Institute.

(vi)

Construction

Nothing in this section shall be construed to limit the ability of the Academy or the Institute designated under clause (i)(II) to receive private funding for activities related to the establishment of a key national indicator system.

(D)

Annual report

As part of the arrangement under subparagraph (A), the National Academy of Sciences shall, not later than 270 days after the date of enactment of this Act, and annually thereafter, submit to the Co-Chairpersons of the Commission a report that contains the findings and recommendations of the Academy.

(d)

Government Accountability Office study and report

(1)

GAO study

The Comptroller General of the United States shall conduct a study of previous work conducted by all public agencies, private organizations, or foreign countries with respect to best practices for a key national indicator system. The study shall be submitted to the appropriate authorizing committees of Congress.

(2)

GAO financial audit

If an Institute is established under this section, the Comptroller General shall conduct an annual audit of the financial statements of the Institute, in accordance with generally accepted government auditing standards and submit a report on such audit to the Commission and the appropriate authorizing committees of Congress.

(3)

GAO programmatic review

The Comptroller General of the United States shall conduct programmatic assessments of the Institute established under this section as determined necessary by the Comptroller General and report the findings to the Commission and to the appropriate authorizing committees of Congress.

(e)

Authorization of appropriations

(1)

In general

–There are authorized to be appropriated to carry out the purposes of this section, $10,000,000 for fiscal year 2010, and $7,500,000 for each of fiscal year 2011 through 2018.

(2)

Availability

–Amounts appropriated under paragraph (1) shall remain available until expended.

188.

Study and report on rates of preventable diseases in new Medicare enrollees

(a)

Study

(1)

In general

The Comptroller General of the United States (in this section referred to as the Comptroller General) shall conduct a study on—

(A)

whether applicable new Medicare enrollees exhibit higher than expected rates of preventable disease when compared to the entire population of new Medicare enrollees or another appropriate statistical baseline; and

(B)

if applicable new Medicare enrollees exhibit such a higher than expected rate of preventable disease, whether such rate is related to the failure of the enrollee's previous private health insurance issuer to promote, cover, or adequately pay for preventive health benefits.

(2)

Applicable new Medicare enrollee

In this section, the term applicable new Medicare enrollee means an individual—

(A)

who is entitled to, or enrolled for, benefits under part A of title XVII of the Social Security Act (42 U.S.C. 1395 et seq.) or enrolled for benefits under part B of such title on or after the date of enactment of this Act; and

(B)

who was covered by private health insurance or Medicaid or other Federal Government health programs (as of the day before the date of such entitlement or enrollment).

(b)

Report

Not later than 3 years after the date on which at least 5 Gateways under title XXXI of the Public Health Service Act, as added by section 142, are operating in the United States, the Comptroller General shall submit to Congress a report containing the results of the study conducted under subsection (a), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.

189.

Transparency in government

Not later than 30 days after the date of enactment of this Act, the Secretary of Health and Human Services shall publish on the Internet website of the Department of Health and Human Services, a list of all of the authorities provided to the Secretary under this Act (and the amendments made by this Act).

189A.

Preserving the solvency of Medicare and Social Security

Nothing in this Act (or an amendment made by this Act) shall be carried out in a manner that threatens the solvency of Medicare or Social Security programs.

189B.

Prohibition against discrimination on assisted suicide

(a)

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.

(b)

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.

(c)

Construction and treatment of certain services

Nothing in subsection (a) shall be construed to apply to or to affect any limitation relating to—

(1)

the withholding or withdrawing of medical treatment or medical care;

(2)

the withholding or withdrawing of nutrition or hydration;

(3)

abortion; or

(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.

(d)

Administration

The Office for Civil Rights of the Department of Health and Human Services is designated to receive complaints of discrimination based on this section.

189C.

Access to therapies

Notwithstanding any other provision of the Affordable Health Choices Act, the Secretary of Health and Human Services shall not promulgate any regulation that—

(1)

creates any unreasonable barriers to the ability of individuals to obtain appropriate medical care;

(2)

impedes timely access to health care services;

(3)

interferes with communications regarding a full range of treatment options between the patient and the provider;

(4)

restricts the ability of health care providers to provide full disclosure of all relevant information to patients making health care decisions;

(5)

violates the principles of informed consent and the ethical standards of health care professionals; or

(6)

limits the availability of health care treatment for the full duration of a patient’s medical needs.

189D.

Freedom not to participate in Federal health insurance programs

No individual, company, business, nonprofit entity, or health insurer offering group or individual health insurance shall be required to participate in any Federal health insurance program created under this Act (or any amendments made by this Act), or in any Federal health insurance program expanded by this Act (or any such amendments), and there shall be no penalty or fine imposed upon any such insurer for choosing not to participate in such programs.

H

CLASS Act

190.

Short title of subtitle

This subtitle may be cited as the Community Living Assistance Services and Supports Act or the CLASS Act.

191.

Establishment of national voluntary insurance program for purchasing community living assistance services and support

(a)

Establishment of CLASS program

(1)

In general

The Public Health Service Act (42 U.S.C. 201 et seq.), as amended by section 143, is amended by adding at the end the following:

XXXII

Community Living Assistance Services and Supports

3201.

Purpose

The purpose of this title is to establish a national voluntary insurance program for purchasing community living assistance services and supports in order to—

(1)

provide individuals with functional limitations with tools that will allow them to maintain their personal and financial independence and live in the community through a new financing strategy for community living assistance services and supports;

(2)

establish an infrastructure that will help address the Nation's community living assistance services and supports needs;

(3)

alleviate burdens on family caregivers; and

(4)

address institutional bias by providing a financing mechanism that supports personal choice and independence to live in the community.

3202.

Definitions

In this title:

(1)

Active enrollee

The term active enrollee means an individual who is enrolled in the CLASS program in accordance with section 3204 and who has paid any premiums due to maintain such enrollment.

(2)

Actively employed

The term actively employed means an individual who—

(A)

is reporting for work at the individual's usual place of employment or at another location to which the individual is required to travel because of the individual's employment (or in the case of an individual who is a member of the uniformed services, is on active duty and is physically able to perform the duties of the individual's position); and

(B)

is able to perform all the usual and customary duties of the individual's employment on the individual's regular work schedule.

(3)

Activities of daily living

The term activities of daily living means each of the following activities specified in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986:

(A)

Eating.

(B)

Toileting.

(C)

Transferring.

(D)

Bathing.

(E)

Dressing.

(F)

Continence.

(4)

CLASS program

The term CLASS program means the program established under this title.

(5)

Disability determination service

The term Disability Determination Service means, with respect to each State, the entity that has an agreement with the Commissioner of Social Security to make disability determinations for purposes of title II or XVI of the Social Security Act (42 U.S.C. 401 et seq., 1381 et seq.).

(6)

Eligible beneficiary

(A)

In general

The term eligible beneficiary means any individual who is an active enrollee in the CLASS program and, as of the date described in subparagraph (B)—

(i)

has paid premiums for enrollment in such program for at least 60 months;

(ii)

has earned, for each calendar year that occurs during the first 60 months for which the individual has paid premiums for enrollment in the program, at least an amount equal to the amount of wages and self-employment income which an individual must have in order to be credited with a quarter of coverage under section 213(d) of the Social Security Act for that year; and

(iii)

has paid premiums for enrollment in such program for at least 24 consecutive months, if a lapse in premium payments of more than 3 months has occurred during the period that begins on the date of the individual's enrollment and ends on the date of such determination.

(B)

Date described

For purposes of subparagraph (A), the date described in this subparagraph is the date on which the individual is determined to have a functional limitation described in section 3203(a)(1)(C) that is expected to last for a continuous period of more than 90 days.

(C)

Regulations

The Secretary shall promulgate regulations specifying exceptions to the minimum earnings requirements under subparagraph (A)(ii) for purposes of being considered an eligible beneficiary for certain populations.

(7)

Hospital; nursing facility; intermediate care facility for the mentally retarded; institution for mental diseases

The terms hospital, nursing facility, intermediate care facility for the mentally retarded, and institution for mental diseases have the meanings given such terms for purposes of Medicaid.

(8)

CLASS Independence Advisory Council

The term CLASS Independence Advisory Council or Council means the Advisory Council established under section 3207 to advise the Secretary.

(9)

CLASS Independence Benefit Plan

The term CLASS Independence Benefit Plan means the benefit plan developed and designated by the Secretary in accordance with section 3203.

(10)

CLASS Independence Fund

The term CLASS Independence Fund or Fund means the fund established under section 3206.

(11)

Medicaid

The term Medicaid means the program established under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.).

(12)

Protection and advocacy system

The term Protection and Advocacy System means the system for each State established under section 143 of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (42 U.S.C. 15043).

3203.

CLASS Independence Benefit Plan

(a)

Process for development

(1)

In general

The Secretary, in consultation with appropriate actuaries and other experts, shall develop at least 3 actuarially sound benefit plans as alternatives for consideration for designation by the Secretary as the CLASS Independence Benefit Plan under which eligible beneficiaries shall receive benefits under this title. Each of the plan alternatives developed shall be designed to provide eligible beneficiaries with the benefits described in section 3205 consistent with the following requirements:

(A)

Premiums

Beginning with the first year of the CLASS program, and for each year thereafter, the Secretary shall establish all premiums to be paid by enrollees for the year based on an actuarial analysis of the 75-year costs of the program that ensures solvency throughout such 75-year period.

(B)

Vesting period

A 5-year vesting period for eligibility for benefits.

(C)

Benefit triggers

A benefit trigger for provision of benefits that requires a determination that an individual has a functional limitation, as certified by a licensed health care practitioner, described in any of the following clauses that is expected to last for a continuous period of more than 90 days:

(i)

The individual is determined to be unable to perform at least the minimum number (which may be 2 or 3) of activities of daily living as are required under the plan for the provision of benefits without substantial assistance (as defined by the Secretary) from another individual.

(ii)

The individual requires substantial supervision to protect the individual from threats to health and safety due to substantial cognitive impairment.

(iii)

The individual has a level of functional limitation similar (as determined under regulations prescribed by the Secretary) to the level of functional limitation described in clause (i) or (ii).

(D)

Cash benefit

Payment of a cash benefit that satisfies the following requirements:

(i)

Minimum required amount

The benefit amount provides an eligible beneficiary with not less than an average of $50 per day (as determined based on the reasonably expected distribution of beneficiaries receiving benefits at various benefit levels).

(ii)

Amount scaled to functional ability

The benefit amount is varied based on a scale of functional ability, with not less than 2, and not more than 6, benefit level amounts.

(iii)

Daily or weekly

The benefit is paid on a daily or weekly basis.

(iv)

No lifetime or aggregate limit

The benefit is not subject to any lifetime or aggregate limit.

(E)

Coordination with supplemental coverage obtained through the Exchange

The benefits allow for coordination with any supplemental coverage purchased through a Gateway established under section 3101.

(2)

Review and recommendation by the CLASS Independence Advisory Council

The CLASS Independence Advisory Council shall—

(A)

evaluate the alternative benefit plans developed under paragraph (1); and

(B)

recommend for designation as the CLASS Independence Benefit Plan for offering to the public the plan that the Council determines best balances price and benefits to meet enrollees’ needs in an actuarially sound manner, while optimizing the probability of the long-term sustainability of the CLASS program.

(3)

Designation by the Secretary

Not later than October 1, 2012, the Secretary, taking into consideration the recommendation of the CLASS Independence Advisory Council under paragraph (2)(B), shall designate a benefit plan as the CLASS Independence Benefit Plan. The Secretary shall publish such designation, along with details of the plan and the reasons for the selection by the Secretary, in a final rule that allows for a period of public comment.

(b)

Additional premium requirements

(1)

Adjustment of premiums

(A)

In general

Except as provided in subparagraphs (B), (C), (D), and (E), the amount of the monthly premium determined for an individual upon such individual's enrollment in the CLASS program shall remain the same for as long as the individual is an active enrollee in the program.

(B)

Recalculated premium if required for program solvency

(i)

In general

Subject to clause (ii), if the Secretary determines, based on the most recent report of the Board of Trustees of the CLASS Independence Fund, the advice of the CLASS Independence Advisory Council, and the annual report of the Inspector General of the Department of Health and Human Services, and waste, fraud, and abuse, or such other information as the Secretary determines appropriate, that the monthly premiums and income to the CLASS Independence Fund for a year are projected to be insufficient with respect to the 20-year period that begins with that year, the Secretary shall adjust the monthly premiums for individuals enrolled in the CLASS program as necessary.

(ii)

Exemption from increase

Any increase in a monthly premium imposed as result of a determination described in clause (i) shall not apply with respect to the monthly premium of any active enrollee who—

(I)

has attained age 65;

(II)

has paid premiums for enrollment in the program for at least 20 years; and

(III)

is not actively employed.

(C)

Recalculated premium if reenrollment after more than a 3-month lapse

(i)

In general

The reenrollment of an individual after a 90-day period during which the individual failed to pay the monthly premium required to maintain the individual's enrollment in the CLASS program shall be treated as an initial enrollment for purposes of age-adjusting the premium for enrollment in the program.

(ii)

Credit for prior months if reenrolled within 5 years

An individual who reenrolls in the CLASS program after such a 90-day period and before the end of the 5-year period that begins with the first month for which the individual failed to pay the monthly premium required to maintain the individual's enrollment in the program shall be—

(I)

credited with any months of paid premiums that accrued prior to the individual's lapse in enrollment; and

(II)

notwithstanding the total amount of any such credited months, required to satisfy section 3202(6)(A)(ii) before being eligible to receive benefits.

(D)

Penalty for reenollment after 5-year lapse

In the case of an individual who reenrolls in the CLASS program after the end of the 5-year period described in subparagraph (C)(ii), the monthly premium required for the individual shall be the age-adjusted premium that would be applicable to an initially enrolling individual who is the same age as the reenrolling individual, increased by the greater of—

(i)

an amount that the Secretary determines is actuarially sound for each month that occurs during the period that begins with the first month for which the individual failed to pay the monthly premium required to maintain the individual's enrollment in the CLASS program and ends with the month preceding the month in which the reenollment is effective; or

(ii)

1 percent of the applicable age-adjusted premium for each such month occurring in such period.

(2)

Administrative expenses

In determining the monthly premiums for the CLASS program the Secretary, in coordination with the Commissioner of Social Security, may factor in costs for administering the program, not to exceed—

(A)

in the case of the first 5 years in which the program is in effect under this title, an amount equal to 3 percent of all premiums paid during each such year; and

(B)

in the case of subsequent years, an amount equal to 5 percent of the total amount of all expenditures (including benefits paid) under this title with respect to that year.

(3)

No underwriting requirements

No underwriting (other than on the basis of age in accordance with paragraph (2)) shall be used to—

(A)

determine the monthly premium for enrollment in the CLASS program; or

(B)

prevent an individual from enrolling in the program.

3204.

Enrollment and disenrollment requirements

(a)

Automatic enrollment

(1)

In general

Subject to paragraph (2), the Secretary, in coordination with the Secretary of the Treasury, shall establish procedures under which each individual described in subsection (c) shall be automatically enrolled in the CLASS program by an employer of such individual in the same manner as an employer may elect to automatically enroll employees in a plan under section 401(k), 403(b), or 457 of the Internal Revenue Code of 1986.

(2)

Alternative enrollment procedures

The procedures established under paragraph (1) shall provide for an alternative enrollment process for an individual described in subsection (c) in the case of such an individual—

(A)

who is self-employed;

(B)

who has more than 1 employer;

(C)

whose employer does not elect to participate in the automatic enrollment process established by the Secretary; or

(D)

who is a spouse described in subsection (c)(2) of who is not subject to automatic enrollment.

(3)

Administration

(A)

In general

The Secretary and the Secretary of the Treasury shall, by regulation, establish procedures to—

(i)

ensure that an individual is not automatically enrolled in the CLASS program by more than 1 employer; and

(ii)

allow for an individual's employer to deduct a premium for a spouse described in subsection (c)(1)(B) who is not subject to automatic enrollment.

(B)

Form

Enrollment in the CLASS program shall be made in such manner as the Secretary may prescribe in order to ensure ease of administration.

(b)

Election to opt-out

An individual described in subsection (c) may elect to waive enrollment in the CLASS program at any time in such form and manner as the Secretary and the Secretary of the Treasury shall prescribe.

(c)

Individual described

For purposes of enrolling in the CLASS program, an individual described in this paragraph is—

(1)

an individual—

(A)

who has attained age 18;

(B)

who—

(i)

receives wages on which there is imposed a tax under section 3201(a) of the Internal Revenue Code of 1986; or

(ii)

derives self-employment income on which there is imposed a tax under section 1401(a) of the Internal Revenue Code of 1986;

(C)

who is actively employed; and

(D)

who is not—

(i)

a patient in a hospital or nursing facility, an intermediate care facility for the mentally retarded, or an institution for mental diseases and receiving medical assistance under Medicaid; or

(ii)

confined in a jail, prison, other penal institution or correctional facility, or by court order pursuant to conviction of a criminal offense or in connection with a verdict or finding described in section 202(x)(1)(A)(ii) of the Social Security Act (42 U.S.C. 402(x)(1)(A)(ii)); or

(2)

the spouse of an individual described in paragraph (1) and who would be an individual so described but for subparagraph (B) or (C) of that paragraph.

(d)

Rule of construction

Nothing in this title shall be construed as requiring an active enrollee to continue to satisfy subparagraph (B) or (C) of subsection (c)(1) in order to maintain enrollment in the CLASS program.

(e)

Payment

(1)

Payroll deduction

An amount equal to the monthly premium for the enrollment in the CLASS program of an individual shall be deducted from the wages or self-employment income of such individual in accordance with such procedures as the Secretary, in coordination with the Secretary of the Treasury, shall establish for employers who elect to deduct and withhold such premiums on behalf of enrolled employees.

(2)

Alternative payment mechanism

The Secretary, in coordination with the Secretary of the Treasury, shall establish alternative procedures for the payment of monthly premiums by an individual enrolled in the CLASS program—

(A)

who does not have an employer who elects to deduct and withhold premiums in accordance with subparagraph (A); or

(B)

who does not earn wages or derive self-employment income.

(f)

Transfer of premiums collected

(1)

In general

During each calendar year the Secretary of the Treasury shall deposit into the CLASS Independence Fund a total amount equal, in the aggregate, to 100 percent of the premiums collected during that year.

(2)

Transfers based on estimates

The amount deposited pursuant to paragraph (1) shall be transferred in at least monthly payments to the CLASS Independence Fund on the basis of estimates by the Secretary and certified to the Secretary of the Treasury of the amounts collected in accordance with subparagraphs (A) and (B) of paragraph (5). Proper adjustments shall be made in amounts subsequently transferred to the Fund to the extent prior estimates were in excess of, or were less than, actual amounts collected.

(g)

Other enrollment and disenrollment opportunities

The Secretary, in coordination with the Secretary of the Treasury, shall establish procedures under which—

(1)

an individual who, in the year of the individual's initial eligibility to enroll in the CLASS program, has elected to waive enrollment in the program, is eligible to elect to enroll in the program, in such form and manner as the Secretaries shall establish, only during an open enrollment period established by the Secretaries that is specific to the individual and that may not occur more frequently than biennially after the date on which the individual first elected to waive enrollment in the program; and

(2)

an individual shall only be permitted to disenroll from the program during an annual disenrollment period established by the Secretaries and in such form and manner as the Secretaries shall establish.

3205.

Benefits

(a)

Determination of eligibility

(1)

Application for receipt of benefits

The Secretary, in coordination with the Commissioner of Social Security, shall establish procedures under which an active enrollee shall apply for receipt of benefits under the CLASS Independence Benefit Plan.

(2)

Eligibility assessments

(A)

In general

Not later than January 1, 2012, the Secretary shall enter into agreements with—

(i)

the Disability Determination Service for each State to provide for eligibility assessments of active enrollees who apply for receipt of benefits;

(ii)

the Protection and Advocacy System for each State to provide advocacy services in accordance with subsection (d); and

(iii)

public and private entities to provide advice and assistance counseling in accordance with subsection (e).

(B)

Regulations

The Secretary, in coordination with the Commissioner of Social Security, shall promulgate regulations to develop an expedited eligibility determination process, as certified by a licensed health care practitioner, an appeals process, and a redetermination process, as certified by a licensed health care practitioner, including whether an applicant is eligible for a cash benefit under the program and if so, the amount of the cash benefit (in accordance the sliding scale established under the plan).

(C)

Presumptive eligibility for certain institutionalized enrollees planning to discharge

An active enrollee shall be deemed presumptively eligible if the enrollee—

(i)

has applied for, and attests is eligible for, the maximum cash benefit available under the sliding scale established under the CLASS Independence Benefit Plan;

(ii)

is a patient in a hospital (but only if the hospitalization is for long-term care), nursing facility, intermediate care facility for the mentally retarded, or an institution for mental diseases; and

(iii)

is in the process of, or about to being the process of, planning to discharge from the hospital, facility, or institution, or within 60 days from the date of discharge from the hospital, facility, or institution.

(D)

Appeals

The Secretary shall establish procedures under which an applicant for benefits under the CLASS Independence Benefit Plan shall be guaranteed the right to appeal an adverse determination.

(b)

Benefits

An eligible beneficiary shall receive the following benefits under the CLASS Independence Benefit Plan:

(1)

Cash benefit

A cash benefit established by the Secretary in accordance with the requirements of section 3203(a)(1)(D) that—

(A)

the first year in which beneficiaries receive the benefits under the plan, is not less than the average dollar amount specified in clause (i) of such section; and

(B)

for any subsequent year, is not less than the average per day dollar limit applicable under this subparagraph for the preceding year, increased by the percentage increase in the consumer price index for all urban consumers (U.S. city average) over the previous year.

(2)

Advocacy services

Advocacy services in accordance with subsection (d).

(3)

Advice and assistance counseling

Advice and assistance counseling in accordance with subsection (e).

(4)

Administrative expenses

Advocacy services and advise and assistance counseling services under paragraphs (2) and (3) of this subsection shall be included as administrative expenses under section 3203(b)(3).

(c)

Payment of benefits

(1)

Life independence account

(A)

In general

The Secretary shall establish procedures for administering the provision of benefits to eligible beneficiaries under the CLASS Independence Benefit Plan, including the payment of the cash benefit for the beneficiary into a Life Independence Account established by the Secretary on behalf of each eligible beneficiary.

(B)

Use of cash benefits

Cash benefits paid into a Life Independence Account of an eligible beneficiary shall be used to purchase nonmedical services and supports that the beneficiary needs to maintain his or her independence at home or in another residential setting of their choice in the community, including (but not limited to) home modifications, assistive technology, accessible transportation, homemaker services, respite care, personal assistance services, home care aides, and nursing support. Nothing in the preceding sentence shall prevent an eligible beneficiary from using cash benefits paid into a Life Independence Account for obtaining assistance with decision making concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives or other written instructions recognized under State law, such as a living will or durable power of attorney for health care, in the case that an injury or illness causes the individual to be unable to make health care decisions.

(C)

Electronic management of funds

The Secretary shall establish procedures for—

(i)

crediting an account established on behalf of a beneficiary with the beneficiary's cash daily benefit;

(ii)

allowing the beneficiary to access such account through debit cards; and

(iii)

accounting for withdrawals by the beneficiary from such account.

(D)

Primary payor rules for beneficiaries who are enrolled in medicaid

In the case of an eligible beneficiary who is enrolled in Medicaid, the following payment rules shall apply:

(i)

Institutionalized beneficiary

If the beneficiary is a patient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or an institution for mental diseases, the beneficiary shall retain an amount equal to 5 percent of the beneficiary's daily or weekly cash benefit (as applicable) (which shall be in addition to the amount of the beneficiary's personal needs allowance provided under Medicaid), and the remainder of such benefit shall be applied toward the facility's cost of providing the beneficiary's care, and Medicaid shall provide secondary coverage for such care.

(ii)

Beneficiaries receiving home and community-based services

(I)

50 percent of benefit retained by beneficiary

Subject to subclause (II), if a beneficiary is receiving medical assistance under Medicaid for home and community based services, the beneficiary shall retain an amount equal to 50 percent of the beneficiary's daily or weekly cash benefit (as applicable), and the remainder of the daily or weekly cash benefit shall be applied toward the cost to the State of providing such assistance (and shall not be used to claim Federal matching funds under Medicaid), and Medicaid shall provide secondary coverage for the remainder of any costs incurred in providing such assistance.

(II)

Requirement for state offset

A State shall be paid the remainder of a beneficiary's daily or weekly cash benefit under subclause (I) only if the State home and community-based waiver under section 1115 of the Social Security Act (42 U.S.C. 1315) or subsection (c) or (d) of section 1915 of such Act (42 U.S.C. 1396n), or the State plan amendment under subsection (i) of such section does not include a waiver of the requirements of section 1902(a)(1) of the Social Security Act (relating to statewideness) or of section 1902(a)(10)(B) of such Act (relating to comparability) and the State offers at a minimum case management services, personal care services, habilitation services, and respite care under such a waiver or State plan amendment.

(III)

Definition of home and community-based services

In this clause, the term home and community-based services means any services which may be offered under a home and community-based waiver authorized for a State under section 1115 of the Social Security Act (42 U.S.C. 1315) or subsection (c) or (d) of section 1915 of such Act (42 U.S.C. 1396n) or under a State plan amendment under subsection (i) of such section.

(iii)

Beneficiaries enrolled in programs of all-inclusive care for the elderly (pace)

(I)

In general

Subject to subclause (II), if a beneficiary is receiving medical assistance under Medicaid for PACE program services under section 1934 of the Social Security Act (42 U.S.C. 1396u–4), the beneficiary shall retain an amount equal to 50 percent of the beneficiary's daily or weekly cash benefit (as applicable), and the remainder of the daily or weekly cash benefit shall be applied toward the cost to the State of providing such assistance (and shall not be used to claim Federal matching funds under Medicaid), and Medicaid shall provide secondary coverage for the remainder of any costs incurred in providing such assistance.

(II)

Institutionalized recipients of pace program services

If a beneficiary receiving assistance under Medicaid for PACE program services is a patient in a hospital, nursing facility, intermediate care facility for the mentally retarded, or an institution for mental diseases, the beneficiary shall be treated as in institutionalized beneficiary under clause (i).

(2)

Authorized representatives

(A)

In general

The Secretary shall establish procedures to allow access to a beneficiary's cash benefits by an authorized representative of the eligible beneficiary on whose behalf such benefits are paid.

(B)

Quality assurance and protection against fraud and abuse

The procedures established under subparagraph (A) shall ensure that authorized representatives of eligible beneficiaries comply with standards of conduct established by the Secretary, including standards requiring that such representatives provide quality services on behalf of such beneficiaries, do not have conflicts of interest, and do not misuse benefits paid on behalf of such beneficiaries or otherwise engage in fraud or abuse.

(3)

Commencement of benefits

Benefits shall be paid to, or on behalf of, an eligible beneficiary beginning with the first month in which an application for such benefits is approved.

(4)

Rollover option for lump-sum payment

An eligible beneficiary may elect to—

(A)

defer payment of their daily or weekly benefit and to rollover any such deferred benefits from month-to-month, but not from year-to-year; and

(B)

receive a lump-sum payment of such deferred benefits in an amount that may not exceed the lesser of—

(i)

the total amount of the accrued deferred benefits; or

(ii)

the applicable annual benefit.

(5)

Period for determination of annual benefits

(A)

In general

The applicable period for determining with respect to an eligible beneficiary the applicable annual benefit and the amount of any accrued deferred benefits is the 12-month period that commences with the first month in which the beneficiary began to receive such benefits, and each 12-month period thereafter.

(B)

Inclusion of increased benefits

The Secretary shall establish procedures under which cash benefits paid to an eligible beneficiary that increase or decrease as a result of a change in the functional status of the beneficiary before the end of a 12-month benefit period shall be included in the determination of the applicable annual benefit paid to the eligible beneficiary.

(C)

Recoupment of unpaid, accrued benefits

(i)

In general

The Secretary, in coordination with the Secretary of the Treasury, shall recoup any accrued benefits in the event of—

(I)

the death of a beneficiary; or

(II)

the failure of a beneficiary to elect under paragraph (4)(B) to receive such benefits as a lump-sum payment before the end of the 12-month period in which such benefits accrued.

(ii)

Payment into class independence fund

Any benefits recouped in accordance with clause (i) shall be paid into the CLASS Independence Fund and used in accordance with section 3206.

(6)

Requirement to recertify eligibility for receipt of benefits

An eligible beneficiary shall periodically, as determined by the Secretary, in coordination with the Commissioner of Social Security—

(A)

recertify by submission of medical evidence the beneficiary's continued eligibility for receipt of benefits; and

(B)

submit records of expenditures attributable to the aggregate cash benefit received by the beneficiary during the preceding year.

(7)

Supplement, not supplant other health care benefits

Subject to the Medicaid payment rules under paragraph (1)(D), benefits received by an eligible beneficiary shall supplement, but not supplant, other health care benefits for which the beneficiary is eligible under Medicaid or any other Federally funded program that provides health care benefits or assistance.

(d)

Advocacy services

An agreement entered into under subsection (a)(2)(A)(ii) shall require the Protection and Advocacy System for the State to—

(1)

assign, as needed, an advocacy counselor to each eligible beneficiary that is covered by such agreement and who shall provide an eligible beneficiary with—

(A)

information regarding how to access the appeals process established for the program;

(B)

assistance with respect to the annual recertification and notification required under subsection (c)(6); and

(C)

such other assistance with obtaining services as the Secretary, by regulation, shall require; and

(2)

ensure that the System and such counselors comply with the requirements of subsection (h).

(e)

Advice and assistance counseling

An agreement entered into under subsection (a)(2)(A)(iii) shall require the entity to assign, as requested by an eligible beneficiary that is covered by such agreement, an advice and assistance counselor who shall provide an eligible beneficiary with information regarding—

(1)

accessing and coordinating long-term services and supports in the most integrated setting;

(2)

possible eligibility for other benefits and services;

(3)

development of a service and support plan;

(4)

information about programs established under the Assistive Technology Act of 1998 and the services offered under such programs;

(5)

available assistance with decision making concerning medical care, including the right to accept or refuse medical or surgical treatment and the right to formulate advance directives or other written instructions recognized under State law, such as a living will or durable power of attorney for health care, in the case that an injury or illness causes the individual to be unable to make health care decisions; and

(6)

such other services as the Secretary, by regulation, may require.

(f)

No effect on eligibility for other benefits

Benefits paid to an eligible beneficiary under the CLASS program shall be disregarded for purposes of determining or continuing the beneficiary's eligibility for receipt of benefits under any other Federal, State, or locally funded assistance program, including benefits paid under titles II, XVI, XVIII, XIX, or XXI of the Social Security Act (42 U.S.C. 401 et seq., 1381 et seq., 1395 et seq., 1396 et seq., 1397aa et seq.), under the laws administered by the Secretary of Veterans Affairs, under low-income housing assistance programs, or under the supplemental nutrition assistance program established under the Food and Nutrition Act of 2008 (7 U.S.C. 2011 et seq.).

(g)

Rule of construction

Nothing in this title shall be construed as prohibiting benefits paid under the CLASS Independence Benefit Plan from being used to compensate a family caregiver for providing community living assistance services and supports to an eligible beneficiary.

(h)

Protection against conflict of interests

The Secretary shall establish procedures to ensure that the Disability Determination Service and Protection and Advocacy System for a State, advocacy counselors for eligible beneficiaries, and any other entities that provide services to active enrollees and eligible beneficiaries under the CLASS program comply with the following:

(1)

If the entity provides counseling or planning services, such services are provided in a manner that fosters the best interests of the active enrollee or beneficiary.

(2)

The entity has established operating procedures that are designed to avoid or minimize conflicts of interest between the entity and an active enrollee or beneficiary.

(3)

The entity provides information about all services and options available to the active enrollee or beneficiary, to the best of its knowledge, including services available through other entities or providers.

(4)

The entity assists the active enrollee or beneficiary to access desired services, regardless of the provider.

(5)

The entity reports the number of active enrollees and beneficiaries provided with assistance by age, disability, and whether such enrollees and beneficiaries received services from the entity or another entity.

(6)

If the entity provides counseling or planning services, the entity ensures that an active enrollee or beneficiary is informed of any financial interest that the entity has in a service provider.

(7)

The entity provides an active enrollee or beneficiary with a list of available service providers that can meet the needs of the active enrollee or beneficiary.

The Secretary shall establish the procedures under this subsection that apply to the Disability Determination Service in coordination with the Commissioner of Social Security.
3206.

CLASS Independence Fund

(a)

Establishment of CLASS Independence Fund

There is established in the Treasury of the United States a trust fund to be known as the CLASS Independence Fund. The Secretary of the Treasury shall serve as Managing Trustee of such Fund. The Fund shall consist of all amounts derived from payments into the Fund under sections 3204(f) and 3205(c)(5)(C)(ii), and remaining after investment of such amounts under subsection (b), including additional amounts derived as income from such investments. The amounts held in the Fund are appropriated and shall remain available without fiscal year limitation—

(1)

to be held for investment on behalf of individuals enrolled in the CLASS program;

(2)

to pay the administrative expenses related to the Fund and to investment under subsection (b); and

(3)

to pay cash benefits to eligible beneficiaries under the CLASS Independence Benefit Plan.

(b)

Investment of fund balance

The Secretary of the Treasury shall invest and manage the CLASS Independence Fund in the same manner, and to the same extent, as the Federal Supplementary Medical Insurance Trust Fund may be invested and managed under subsections (c), (d), and (e) of section 1841(d) of the Social Security Act (42 U.S.C. 1395t).

(c)

Lock-Box protection

(1)

In general

Notwithstanding any other provision of law, it shall not be in order in the Senate or the House of Representatives to consider any measure that would authorize the payment or use of amounts in the Fund for any purpose other than a purpose authorized under this title.

(2)

60-vote waiver required in the senate

(A)

In general

Paragraph (1) may be waived or suspended in the Senate only by the affirmative vote of 3/5 of the Members, duly chosen and sworn.

(B)

Appeals

(i)

Procedure

Appeals in the Senate from the decisions of the Chair relating to subparagraph (A) shall be limited to 1 hour, to be equally divided between, and controlled by, the mover and the manager of the measure that would authorize the payment or use of amounts in the Fund for a purpose other than a purpose authorized under this title.

(ii)

60-votes required

An affirmative vote of 3/5 of the Members, duly chosen and sworn, shall be required in the Senate to sustain an appeal of the ruling of the Chair on a point of order raised in relation to subparagraph (A).

(3)

Rules of the senate and house of representatives

This subsection is enacted by Congress—

(A)

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 a measure described in paragraph (1), and it supersedes other rules only to the extent that it is inconsistent with such rules; and

(B)

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.

(d)

Board of Trustees

(1)

In general

With respect to the CLASS Independence Fund, there is hereby created a body to be known as the Board of Trustees of the CLASS Independence Fund (hereinafter in this section referred to as the Board of Trustees) composed of the Commissioner of Social Security, the Secretary of the Treasury, the Secretary of Labor, and the Secretary of Health and Human Services, all ex officio, and of two members of the public (both of whom may not be from the same political party), who shall be nominated by the President for a term of 4 years and subject to confirmation by the Senate. A member of the Board of Trustees serving as a member of the public and nominated and confirmed to fill a vacancy occurring during a term shall be nominated and confirmed only for the remainder of such term. An individual nominated and confirmed as a member of the public may serve in such position after the expiration of such member's term until the earlier of the time at which the member's successor takes office or the time at which a report of the Board is first issued under paragraph (2) after the expiration of the member's term. The Secretary of the Treasury shall be the Managing Trustee of the Board of Trustees. The Board of Trustees shall meet not less frequently than once each calendar year. A person serving on the Board of Trustees shall not be considered to be a fiduciary and shall not be personally liable for actions taken in such capacity with respect to the Trust Fund.

(2)

Duties

(A)

In general

It shall be the duty of the Board of Trustees to do the following:

(i)

Hold the CLASS Independence Fund.

(ii)

Report to the Congress not later than the first day of April of each year on the operation and status of the CLASS Independence Fund during the preceding fiscal year and on its expected operation and status during the current fiscal year and the next 2 fiscal years.

(iii)

Report immediately to the Congress whenever the Board is of the opinion that the amount of the CLASS Independence Fund is not actuarially sound in regards to the projections under section 3203(b)(2)(B)(i).

(iv)

Review the general policies followed in managing the CLASS Independence Fund, and recommend changes in such policies, including necessary changes in the provisions of law which govern the way in which the CLASS Independence Fund is to be managed.

(B)

Report

The report provided for in subparagraph (A)(ii) shall—

(i)

include—

(I)

a statement of the assets of, and the disbursements made from, the CLASS Independence Fund during the preceding fiscal year;

(II)

an estimate of the expected income to, and disbursements to be made from, the CLASS Independence Fund during the current fiscal year and each of the next 2 fiscal years;

(III)

a statement of the actuarial status of the CLASS Independence Fund for the current fiscal year, each of the next 2 fiscal years, and as projected over the 75-year period beginning with the current fiscal year;

(IV)

an actuarial opinion by the Chief Actuary of the Social Security Administration certifying that the techniques and methodologies used are generally accepted within the actuarial profession and that the assumptions and cost estimates used are reasonable; and

(V)

an opinion by the Commissioner of Social Security that the Disability Determination Service personnel are not over burdened by the additional requirements of the CLASS program; and

(ii)

be printed as a House document of the session of the Congress to which the report is made.

(C)

Recommendations

If the Board of Trustees determines that enrollment trends and expected future benefit claims on the CLASS Independence Fund are not actuarially sound in regards to the projections under section 3203(b)(2)(B)(i) and are unlikely to be resolved with reasonable premium increases or through other means, the Board of Trustees shall include in the report provided for in subparagraph (A)(ii) recommendations for such legislative action as the Board of Trustees determine to be appropriate, including whether to adjust monthly premiums or impose a temporary moratorium on new enrollments.

3207.

CLASS Independence Advisory Council

(a)

Establishment

There is hereby created an Advisory Committee to be known as the CLASS Independence Advisory Council.

(b)

Membership

(1)

In general

The CLASS Independence Advisory Council shall be composed of not more than 15 individuals, not otherwise in the employ of the United States—

(A)

who shall be appointed by the President without regard to the civil service laws and regulations; and

(B)

a majority of whom shall be representatives of individuals who participate or are likely to participate in the CLASS program, and shall include representatives of older and younger workers, individuals with disabilities, family caregivers of individuals who require services and supports to maintain their independence at home or in another residential setting of their choice in the community, individuals with expertise in long-term care or disability insurance, actuarial science, economics, and other relevant disciplines, as determined by the Secretary.

(2)

Terms

(A)

In general

The members of the CLASS Independence Advisory Council shall serve overlapping terms of 3 years (unless appointed to fill a vacancy occurring prior to the expiration of a term, in which case the individual shall serve for the remainder of the term).

(B)

Limitation

A member shall not be eligible to serve for more than 2 consecutive terms.

(3)

Chair

The President shall, from time to time, appoint one of the members of the CLASS Independence Advisory Council to serve as the Chair.

(c)

Duties

The CLASS Independence Advisory Council shall advise the Secretary on matters of general policy in the administration of the CLASS program established under this title and in the formulation of regulations under this title including with respect to—

(1)

the development of the CLASS Independence Benefit Plan under section 3203; and

(2)

the determination of monthly premiums under such plan.

(d)

Application of FACA

The Federal Advisory Committee Act (5 U.S.C. App.), other than section 14 of that Act, shall apply to the CLASS Independence Advisory Council.

(e)

Authorization of appropriations

(1)

In general

There are authorized to be appropriated to the CLASS Independence Advisory Council to carry out its duties under this section, such sums as may be necessary for fiscal year 2011 and for each fiscal year thereafter.

(2)

Availability

Any sums appropriated under the authorization contained in this section shall remain available, without fiscal year limitation, until expended.

3208.

Regulations; annual report

(a)

Regulations

The Secretary shall promulgate such regulations as are necessary to carry out the CLASS program in accordance with this title. Such regulations shall include provisions to prevent fraud and abuse under the program.

(b)

Annual report

Beginning January 1, 2014, the Secretary shall submit an annual report to Congress on the CLASS program. Each report shall include the following:

(1)

The total number of enrollees in the program.

(2)

The total number of eligible beneficiaries during the fiscal year.

(3)

The total amount of cash benefits provided during the fiscal year.

(4)

A description of instances of fraud or abuse identified during the fiscal year.

(5)

Recommendations for such administrative or legislative action as the Secretary determines is necessary to improve the program or to prevent the occurrence of fraud or abuse.

3209.

Inspector General's report

The Inspector General of the Department of Health and Human Services shall submit an annual report to the Secretary and Congress relating to the overall progress of the CLASS program and of the existence of waste, fraud, and abuse in the CLASS program. Each such report shall include findings in the following areas:

(1)

The eligibility determination process.

(2)

The provision of cash benefits.

(3)

Quality assurance and protection against waste, fraud, and abuse.

(4)

Recouping of unpaid and accrued benefits.

3210.

Tax treatment of program

The CLASS program shall be treated for purposes of the Internal Revenue Code of 1986 in the same manner as a qualified long-term care insurance contract for qualified long-term care services.

.

(2)

Conforming amendments to medicaid

Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as amended by section 5006(e)(2)(A) of division B of Public Law 111–5, is amended—

(A)

in paragraph (72), by striking and at the end;

(B)

in paragraph (73)(B), by striking the period and inserting ; and; and

(C)

by inserting after paragraph (73) the following:

(74)

provide that the State will comply with such regulations regarding the application of primary and secondary payor rules with respect to individuals who are eligible for medical assistance under this title and are eligible beneficiaries under the CLASS program established under title XXXII of the Public Health Service Act as the Secretary shall establish.

.

(b)

Assurance of adequate infrastructure for the provision of personal care attendant workers

Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as amended by subsection (a)(2), is amended—

(1)

in paragraph (73)(B), by striking and at the end;

(2)

in paragraph (74), by striking the period at the end and inserting ; and; and

(3)

by inserting after paragraph (74), the following:

(75)

provide that, not later than 2 years after the date of enactment of the Community Living Assistance Services and Supports Act, each State shall—

(A)

assess the extent to which entities such as providers of home care, home health services, home and community service providers, public authorities created to provide personal care services to individuals eligible for medical assistance under the State plan, and nonprofit organizations, are serving or have the capacity to serve as fiscal agents for, employers of, and providers of employment-related benefits for, personal care attendant workers who provide personal care services to individuals receiving benefits under the CLASS program established under title XXXII of the Public Health Service Act, including in rural and underserved areas;

(B)

designate or create such entities to serve as fiscal agents for, employers of, and providers of employment-related benefits for, such workers to ensure an adequate supply of the workers for individuals receiving benefits under the CLASS program, including in rural and underserved areas; and

(C)

ensure that the designation or creation of such entities will not negatively alter or impede existing programs, models, methods, or administration of service delivery that provide for consumer controlled or self-directed home and community services and further ensure that such entities will not impede the ability of individuals to direct and control their home and community services, including the ability to select, manage, dismiss, co-employ, or employ such workers or inhibit such individuals from relying on family members for the provision of personal care services.

.

(c)

Personal care attendants workforce advisory panel

(1)

Establishment

Not later than 90 days after the date of enactment of this Act, the Secretary of Health and Human Services shall establish a Personal Care Attendants Workforce Advisory Panel for the purpose of examining and advising the Secretary and Congress on workforce issues related to personal care attendant workers, including with respect to the adequacy of the number of such workers, the salaries, wages, and benefits of such workers, and access to the services provided by such workers.

(2)

Membership

In appointing members to the Personal Care Attendants Workforce Advisory Panel, the Secretary shall ensure that such members include the following:

(A)

Individuals with disabilities of all ages.

(B)

Senior individuals.

(C)

Representatives of individuals with disabilities.

(D)

Representatives of senior individuals.

(E)

Representatives of workforce and labor organizations.

(F)

Representatives of home and community-based service providers.

(G)

Representatives of assisted living providers.

(d)

Inclusion of information on supplemental coverage in the national clearinghouse for long-term care information; extension of funding

Section 6021(d) of the Deficit Reduction Act of 2005 (42 U.S.C. 1396p note) is amended—

(1)

in paragraph (2)(A)—

(A)

in clause (ii), by striking and at the end;

(B)

in clause (iii), by striking the period at the end and inserting ; and; and

(C)

by adding at the end the following:

(iv)

include information regarding the CLASS program established under title XXXII of the Public Health Service Act and coverage available for purchase through a Gateway established under section 3101 of such Act that is supplemental coverage to the benefits provided under a CLASS Independence Benefit Plan under that program.

; and

(2)

in paragraph (3), by striking 2010 and inserting 2015.

(e)

Effective date

The amendments made by subsections (a), (b), and (d) take effect on January 1, 2011.

II

Improving the quality and efficiency of health care

A

National strategy to improve health care quality

201.

National strategy

(a)

In general

Title III of the Public Health Service Act (42 U.S.C. 241 et seq.) is amended by adding at the end the following:

S

Health care quality programs

I

National Strategy for Quality Improvement in Health Care

399HH.

National Strategy for Quality Improvement in Health Care

(a)

Establishment of national strategy and priorities

(1)

National strategy

The Secretary, through a transparent collaborative process, shall establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health.

(2)

Identification of priorities

(A)

In general

The Secretary shall identify national priorities for improvement in developing the strategy under paragraph (1).

(B)

Requirements

The Secretary shall ensure that priorities identified under subparagraph (A) will—

(i)

address the health care provided to patients with high-cost chronic diseases;

(ii)

improve the design, development, demonstration, dissemination, and adoption of infrastructure and innovative methodologies and strategies for quality improvement in the delivery of health care services that represent best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health care-associated infections;

(iii)

have the greatest potential for improving the health outcomes, efficiency, and patient-centeredness of health care;

(iv)

reduce health disparities across health disparity populations (as defined by section 485E) and geographic areas;

(v)

address gaps in quality and health outcomes measures, comparative effectiveness information, and data aggregation techniques, including the use of data registries;

(vi)

identify areas in the delivery of health care services that have the potential for rapid improvement in the quality of patient care;

(vii)

improve Federal payment policy to emphasize quality;

(viii)

enhance the use of health care data to improve quality, transparency, and outcomes; and

(ix)

address other areas as determined appropriate by the Secretary.

(C)

Considerations

In identifying priorities under subparagraph (A), the Secretary shall take into consideration—

(i)

the recommendations submitted by qualified consensus-based entities as required under section 399JJ; and

(ii)

the recommendations of the Interagency Working Group on Health Care Quality established under section 202 of the Affordable Health Choices Act.

(b)

Strategic plan

(1)

In general

The national strategy shall include a comprehensive strategic plan to achieve the priorities described in subsection (a).

(2)

Requirements

The strategic plan shall include provisions for addressing, at a minimum, the following:

(A)

Coordination among agencies within the Department, which shall include steps to minimize duplication of efforts and utilization of common quality measures, where available. Such common quality measures shall be measures endorsed under section 399JJ.

(B)

Agency-specific strategic plans to achieve national priorities.

(C)

Establishment of annual benchmarks for each relevant agency to achieve national priorities.

(D)

A process for regular reporting by the agencies to the Secretary on the implementation of the strategic plan.

(E)

Use of common incentives among public and private payers with regard to quality and patient safety efforts.

(F)

Incorporating quality improvement and measurement in the strategic plan for health information technology required by the American Recovery and Reinvestment Act of 2009 (Public Law 111–5).

(c)

Periodic update of national strategy

The Secretary shall update the national strategy not less than triennially. Any such update shall include a review of short- and long-term goals.

(d)

Submission and availability of national strategy

The Secretary shall transmit to the relevant Committees of Congress the national strategy and updates to such strategy.

(e)

Public reporting

(1)

Annual national health care quality report card

Not later than January 31, 2011, and annually thereafter, the Secretary shall publish a national health care quality report card, which shall include—

(A)

the considerations for national priorities described in subsection (a)(2);

(B)

an analysis of the progress of the strategic plans under subsection (b)(2)(B) in achieving the national priorities under subsection (a)(2), and any gaps in such strategic plans;

(C)

the extent to which private sector strategies have informed Federal quality improvement efforts; and

(D)

a summary of consumer and provider feedback regarding quality improvement practices.

(2)

Website

Not later than July 1, 2010, the Director shall create an Internet website to make public information regarding—

(A)

the national priorities for health care quality improvement established under subsection (a)(2);

(B)

the agency-specific strategic plans for health care quality described in subsection (b)(2)(B);

(C)

the annual national health care quality report card described in paragraph (1); and

(D)

other information, as the Secretary determines to be appropriate.

.

(b)

Agency quality review

(1)

In general

Each relevant agency within the Department of Health and Human Services shall review the statutory authority, regulations, policies, and procedures of such agency, as in effect on the date of enactment of this title, for purposes of determining whether there are any deficiencies or inconsistencies that prohibit full compliance with the intent, purposes, and provisions of this title (and the amendments made by this title).

(2)

Proposals

Each agency described in paragraph (1) shall, not later than July 1, 2010, submit to the Secretary of Health and Human Services a proposal of the measures as may be necessary to bring the authority, regulations, policies, and procedures of such agency into conformity with the intent, purposes, and provisions of the this title (and the amendments made by this title).

202.

Interagency Working Group on Health Care Quality

(a)

In general

The President shall convene a working group to be known as the Interagency Working Group on Health Care Quality (referred to in this section as the Working Group).

(b)

Goals

The goals of the Working Group shall be to achieve the following:

(1)

Collaboration, cooperation, and consultation between Federal departments and agencies with respect to developing and disseminating strategies, goals, models, and timetables that are consistent with the national priorities identified under section 399HH(a)(2) of the Public Health Service Act (as added by section 201).

(2)

Avoidance of inefficient duplication of quality improvement efforts and resources, where practicable, and a streamlined process for quality reporting and compliance requirements.

(c)

Composition

(1)

In general

The Working Group shall be composed of senior level representatives of—

(A)

the Department of Health and Human Services;

(B)

the Department of Labor;

(C)

the United States Office of Personnel Management;

(D)

the Department of Defense;

(E)

the Department of Education;

(F)

the Department of Veterans Affairs; and

(G)

any other Federal agencies and departments with activities relating to improving health care quality and safety, as determined by the President.

(2)

Chair and vice-chair

(A)

Chair

The Working Group shall be chaired by the Secretary of Health and Human Services.

(B)

Vice-chair

Members of the Working Group, other than the Secretary of Health and Human Services, shall serve as Vice Chair of the Group on a rotating basis, as determined by the Group.

(d)

Report to congress

Not later than December 31, 2010, and annually thereafter, the Working Group shall submit to the relevant Committees of Congress, and make public on an Internet website, a report describing the progress and recommendations of the Working Group in meeting the goals described in subsection (b).

203.

Quality measure development

Title IX of the Public Health Service Act (42 U.S.C. 299 et seq.) is amended—

(1)

by redesignating part D as part E;

(2)

by redesignating sections 931 through 938 as sections 941 through 948, respectively;

(3)

in section 948(1), as so redesignated, by striking 931 and inserting 941; and

(4)

by inserting after section 926 the following:

D

Health care quality improvement

I

Quality measure development

931.

Quality measure development

(a)

Quality measure

In this subpart, the term quality measure means a standard for measuring the performance and improvement of population health or of health plans, providers of services, and other clinicians in the delivery of health care services.

(b)

Identification of quality measures

(1)

Identification

The Director shall identify, not less often than biennially, gaps where no quality measures exist, or where existing quality measures need improvement, updating, or expansion, consistent with the national strategy under section 399HH, for use in programs authorized under this Act. In identifying such gaps, the Director shall take into consideration the gaps identified by a qualified consensus-based entity under section 399JJ.

(2)

Publication

The Director shall make available to the public on an Internet website a report on any gaps identified under paragraph (1) and the process used to make such identification.

(c)

Grants or contracts for quality measure development

(1)

In general

The Director shall award grants, contracts, or intergovernmental agreements to eligible entities for purposes of developing, improving, updating, or expanding quality measures identified under subsection (b).

(2)

Prioritization in the Development of Quality Measures

In awarding grants, contracts, or agreements under this subsection, the Director shall give priority to the development of quality measures that allow the assessment of—

(A)

health outcomes and functional status of patients;

(B)

the continuity, management, and coordination of health care and care transitions, including episodes of care, for patients across the continuum of providers, health care settings, and health plans;

(C)

patient, caregiver, and authorized representative experience, quality and relevance of information provided to patients, caregivers, and authorized representatives, and use of information by patients, caregivers, and authorized representatives to inform decisionmaking about treatment options and, where appropriate, palliative care;

(D)

the safety, effectiveness, and timeliness of care;

(E)

health disparities across health disparity populations (as defined in section 485E) and geographic areas;

(F)

the appropriate use of health care resources and services; or

(G)

use of innovative strategies and methodologies identified under section 933.

(3)

Eligible entities

To be eligible for a grant or contract under this subsection, an entity shall—

(A)

have demonstrated expertise and capacity in the development and evaluation of quality measures;

(B)

have adopted procedures to include in the quality measure development process—

(i)

the views of those providers or payers whose performance will be assessed by the measure; and

(ii)

the views of other parties who also will use the quality measures (such as patients, consumers, and health care purchasers);

(C)

collaborate with a qualified consensus-based entity (as defined in section 399JJ), as practicable, and the Secretary so that quality measures developed by the eligible entity will meet the requirements to be considered for endorsement by such qualified consensus-based entity;

(D)

have transparent policies regarding conflicts of interest; and

(E)

submit an application to the Director at such time and in such manner, as the Director may require.

(4)

Use of funds

An entity that receives a grant, contract, or agreement under this subsection shall use such award to develop quality measures that meet the following requirements:

(A)

Such measures build upon measures developed under section 1139A of Social Security Act, where applicable.

(B)

To the extent practicable, data on such quality measures is able to be collected using health information technologies.

(C)

Each quality measure is free of charge to users of such measure.

(D)

Each quality measure is publicly available on an Internet website.

(d)

Other activities by the Director

The Director may use amounts available under this section to update and test, where applicable, quality measures endorsed by a qualified consensus-based entity (as defined in section 399JJ) or adopted by the Secretary.

(e)

Funding

There are authorized to be appropriated to carry out this section, $75,000,000 for each of fiscal years 2010 through 2014.

.

204.

Quality measure endorsement; public reporting; data collection

Title III of the Public Health Service Act (42 U.S.C. 241 et seq.), as amended by section 201, is further amended by adding at the end the following:

II

Health care quality programs

399JJ.

Quality measure endorsement

(a)

Definitions

In this subpart:

(1)

Qualified consensus-based entity

The term qualified consensus-based entity means an entity with a contract with the Secretary under section 1890 of the Social Security Act.

(2)

Quality measure

The term quality measure means a standard for measuring the performance and improvement of population health or of health plans, providers of services, and other clinicians in the delivery of health care services.

(3)

Multi-stakeholder group

The term multi-stakeholder group means, with respect to a quality measure, a voluntary collaborative of organizations representing a broad group of stakeholders interested in or affected by the use of such quality measure.

(b)

Grants and contracts

A qualified consensus-based entity may receive a grant or contract under this subsection to—

(1)

make recommendations to the Secretary for national priorities for performance improvement in population health and in the delivery of health care services;

(2)

identify gaps in endorsed quality measures, which shall include measures that—

(A)

are within priority areas identified by the Secretary under the national strategy established under section 399HH;

(B)

assess common care episodes, patient health outcomes, processes, efficiency, cost, and appropriate use of health care services and resources and address health disparities across health disparity populations (as defined in section 485E) and geographic areas; or

(C)

assess use of innovative methodologies and strategies for quality improvement practices in the delivery of health care services that represent best practices for such quality improvement identified in section 933;

(3)

identify and endorse quality measures, including measures that address gaps identified in paragraph (2);

(4)

update endorsed quality measures at least every 3 years;

(5)

make endorsed quality measures publicly available and have a plan for broad-based dissemination of endorsed measures; and

(6)

transmit endorsed quality measures to the Secretary.

(c)

Annual reports

(1)

In general

A qualified consensus-based entity that receives a grant or contract under this section shall provide a report to the Secretary not less than annually—

(A)

of where gaps (as described in subsection (b)(2)) exist and where quality measures are unavailable or inadequate to identify or address such gaps; and

(B)

regarding areas in which evidence is insufficient to support endorsement of quality measures in priority areas identified by the Secretary under the national strategy established under section 399HH and where targeted research may address such gaps.

(2)

Impact of quality measures

A qualified consensus-based entity that receives a grant or contract under this section shall provide a report to the Secretary not less than annually regarding the economic and quality impact of the use of endorsed measures.

(d)

Priorities for performance improvement

(1)

Recommendation for national priorities

A qualified consensus-based entity that receives a grant or contract under this section shall evaluate evidence and convene multi-stakeholder groups to make recommendations to the Secretary for national priorities for performance improvement in population health and in the delivery of health care services for consideration under the national strategy established under section 399HH. The qualified consensus-based entity shall make such recommendations not less frequently than triennially.

(2)

Requirements for transparency in process

(A)

In general

In convening multi-stakeholder groups under paragraph (1) with respect to recommendations for national priorities, the qualified consensus-based entity shall provide for an open and transparent process for the activities conducted pursuant to such convening.

(B)

Selection of organizations participating in multi-stakeholder groups

The process under subparagraph (A) shall ensure that the selection of representatives comprising such groups provides for public nominations for, and the opportunity for public comment on, such selection.

(3)

Considerations in recommending priorities

In making recommendations under paragraph (1), the qualified consensus-based entity shall ensure that priority is given to areas in the delivery of health care services for all populations including children, and other vulnerable populations that—

(A)

address the health care provided to patients with prevalent, high-cost chronic diseases;

(B)

improve the design, development, demonstration, and adoption of infrastructure and innovative methodologies and strategies for quality improvement practices in the delivery of health care services, including those that improve patient safety and reduce medical errors, readmissions, and health care-associated infections;

(C)

have the greatest potential for improving the health outcomes, efficiency, and patient-centeredness of health care;

(D)

reduce health disparities across populations (as defined in section 485E) and geographic areas;

(E)

address gaps in quality and health outcomes measures, comparative effectiveness information, and data aggregation techniques, including the use of data registries;

(F)

identify areas in the delivery of health care services that have the potential for rapid improvement in the quality of patient care; and

(G)

address the appropriate use of health care technology, resources and services.

(e)

Process for consultation of stakeholder groups

(1)

Consultation of selection of endorsed quality measures

A qualified consensus-based entity that receives a grant or contract under this section shall convene multi-stakeholder groups to provide guidance on the selection of individual or composite quality measures, for use in reporting performance information to the public or for use in Federal health programs, from among—

(A)

such measures that have been endorsed by the qualified consensus-based entity (under section 1890(b) of the Social Security Act or otherwise); and

(B)

such measures that have not been considered for endorsement by the qualified consensus-based entity but are used or proposed to be used by the Secretary under subsection (f)(2) under laws under the jurisdiction of the Secretary that require the collection or reporting of quality measures.

(2)

Transmission of multi-stakeholder guidance

The qualified consensus-based entity shall transmit to the Secretary the guidance of multi-stakeholder groups provided under paragraph (1).

(3)

Requirement for transparency in process

(A)

In general

In convening multi-stakeholder groups under paragraph (1) with respect to the selection of quality measures, the qualified consensus-based entity shall provide for an open and transparent process for the activities conducted pursuant to such convening.

(B)

Selection of organizations participating in multi-stakeholder groups

The process under subparagraph (A) shall ensure that the selection of representatives comprising such groups provides for public nominations for, and the opportunity for public comment on, such selection.

(f)

Coordination of use of quality measures

(1)

Endorsed quality measures

The Secretary may make a determination under regulation or otherwise to use a quality measure described in subsection (e)(1)(A) only after taking into account the guidance of multi-stakeholder groups under subsection (e)(2).

(2)

Use of interim measures

(A)

In general

The Secretary may make a determination, by regulation or otherwise, to use a quality measure that has not been endorsed as described in subsection (e)(1)(A), provided that the Secretary—

(i)

in a timely manner, transmits the measure to the qualified consensus-based entity for consideration for endorsement and for the multi-stakeholder consultation process under subsection (e)(1);

(ii)

publishes in the Federal Register the rationale for the use of the measure; and

(iii)

phases out use of the measure upon a decision of the qualified consensus-based entity not to endorse the measure, contingent on availability of an adequate alternative endorsed measure (as determined by the Secretary), taking into account guidance from multi-stakeholder consultation process under subsection (e)(1).

(B)

No adequate alternative

If an adequate alternative endorsed measure is not available, the Secretary shall support the development of such an alternative endorsed measure, as described in section 931.

(3)

Requirement of coordination with entity

(A)

Requirement for notification of entity of deadline for recommendations for quality measures in proposed regulations

For each notice of proposed rulemaking to implement the collection or reporting of data on quality measures as described in section 399LL, the Secretary shall establish a process for the regular provision of advance notice to the qualified consensus-based entity of the date certain by which recommendations of the entity with respect to quality measures must be submitted to the Secretary for consideration in the development of such specified regulation.

(B)

Timely notice

Under the process established under subparagraph (A), notice shall be given to the qualified consensus-based entity not less than 120 days before the date certain referred to in subparagraph (A).

(C)

Publication of description of entity recommendations and responses

In publishing a specified regulation, the Secretary shall include a description of each recommendation of the qualified consensus-based entity with respect to quality measures and shall include responses of the Secretary to each such recommendation.

(D)

Definition

In this paragraph, the term specified regulation means a notice of proposed rulemaking to implement the collection or reporting of data on quality measures as described in section 399LL.

(4)

Effective date

This subsection shall apply with respect to determinations or requirements by the Secretary for the use of quality measures made on or after the date of enactment of the Affordable Health Choices Act.

(g)

Review of quality measures used by the Secretary

(1)

In general

Not less than once every 3 years, the Secretary shall review quality measures used by the Secretary and, with respect to each such measure, shall determine whether to—

(A)

maintain the use of such measure; or

(B)

phase out such measure.

(2)

Considerations

In conducting the review under paragraph (1), the Secretary shall—

(A)

seek to avoid duplication of measures used; and

(B)

take into consideration current innovative methodologies and strategies for quality improvement practices in the delivery of health care services that represent best practices for such quality improvement and measures endorsed by a qualified consensus-based entity since the previous review by the Secretary.

(h)

Process for dissemination of measures used by the Secretary

The Secretary shall establish a process for disseminating quality measures used by the Secretary. Such process shall include the incorporation of such measures, where applicable, in workforce programs, training curricula, payment programs, and any other means of dissemination determined by the Secretary. The Secretary shall establish a process to disseminate such quality measures through the Interagency Working Group established under section 202 of the Affordable Health Choices Act.

(i)

Funding

To carry out this section there are authorized to be appropriated $50,000,000 for each of fiscal years for 2010 through 2014.

399KK.

Public reporting of performance information

(a)

Reporting of quality measures

(1)

In general

(A)

Reporting system

Not later than 5 years after the date of enactment of the Affordable Health Choices Act, and after notice and opportunity for public comment, the Secretary shall implement a system for the reporting on quality measures that protect patient privacy and, where appropriate—

(i)

assess health outcomes and functional status of patients;

(ii)

assess the continuity and coordination of care and care transitions, including episodes of care, for patients across the continuum of providers and health care settings;

(iii)

assess patient experience and patient, caregiver, and family engagement;

(iv)

assess the safety, effectiveness, and timeliness of care; and

(v)

assess health disparities (as defined by section 485E) across populations and geographic areas.

(2)

Form and manner

The data submitted under the system implemented under paragraph (1) shall be in a form and manner specified by the Secretary.

(3)

Measures described

The quality measures described in paragraph (1) shall—

(A)

be risk adjusted, taking into account differences in patient health status, patient characteristics, and geographic location, as appropriate;

(B)

be valid, reliable, evidence-based, feasible to collect, and actionable by providers, payers and consumers, as appropriate;

(C)

minimize the burden of collection and reporting such measures; and

(D)

be consistent with the national strategy established by the Secretary under section 399HH.

(b)

Development of performance websites

The Secretary shall make available to the public performance information summarizing data on quality measures collected in subsection (a) through a series of standardized Internet websites tailored to respond to the differing needs of hospitals and other institutional providers and services, physicians and other clinicians, patients, consumers, researchers, policymakers, States, and such other stakeholders as the Secretary may specify.

(c)

Design

Each standardized Internet website made available under subsection (b) shall be designed to make the use and navigation of that website readily available to individuals accessing it. The Secretary shall develop a flexible format to meet the differing needs of the various stakeholders and shall modify the website to permit a user to easily customize queries.

(d)

Information on conditions

Performance information made publicly available on a standardized Internet website under subsection (b) shall be presented by, but not limited to, clinical condition to the extent such information is available, and the information presented shall, where appropriate, be provider-specific and sufficiently disaggregated and specific to meet the needs of patients with different clinical conditions.

(e)

Consultation

The Secretary shall carry out this section in collaboration with a qualified consensus-based entity under section 399JJ to determine the type of information that is useful to stakeholders and the format that best facilitates use of the reports and of performance reporting Internet websites. The qualified consensus-based entity shall convene multi-stakeholder groups as provided in section 399JJ to review the design and format of each Internet website made available under subsection (b) and shall transmit to the Secretary the views of such multi-stakeholder groups with respect to each such design and format.

399LL.

Evaluation of data collection process for quality measurement

(a)

GAO Evaluations

The Comptroller General of the United States shall conduct periodic evaluations of the implementation of the data collection processes for quality measures used by the Secretary.

(b)

Considerations

In carrying out the evaluation under subsection (a), the Comptroller General shall determine—

(1)

whether the system for the collection of data for quality measures provides for validation of data as relevant, fair, and scientifically credible;

(2)

whether data collection efforts under the system use the most efficient and cost-effective means in a manner that minimizes administrative burden on persons required to collect data and that adequately protects the privacy of patients’ personal health information and provides data security;

(3)

whether standards under the system provide for an opportunity for physicians and other clinicians and institutional providers of services to review and correct findings; and

(4)

the extent to which quality measures—

(A)

assess health outcomes and functional status of patients;

(B)

assess the continuity and coordination of care and care transitions, including episodes of care, for patients across the continuum of providers, age, and health care settings;

(C)

assess patient experience and patient, caregiver, and family engagement;

(D)

assess the safety, effectiveness, and timeliness of care;

(E)

assess health disparities across health disparity populations (as defined by section 485E) and geographic areas;

(F)

address the appropriate use of health care resources and services;

(G)

are designed to be collected as part of health information technologies supporting better delivery of health care services;

(H)

result in direct or indirect costs to users of such measures; and

(I)

provide utility to both the care of individuals and the management of population health.

(c)

Report

The Comptroller General shall submit reports to Congress and to the Secretary containing a description of the findings and conclusions of the results of each such evaluation.

.

205.

Collection and analysis of data for quality and resource use measures

(a)

In general

Part S of title III of the Public Health Service Act, as amended by section 204, is further amended by adding at the end the following:

399MM.

Collection and analysis of data for quality and resource use measures

(a)

Purpose

The purpose of this section is to provide for the development of reports based on Federal health care data and private data that is publicly available or is provided by the entity making the request for the report in order to—

(1)

improve the quality and efficiency of health care and advance health care research;

(2)

enhance the education and awareness of consumers for evaluating health care services; and

(3)

provide the public with reports on national, regional, and provider- and supplier-specific performance, which may be in a provider- or supplier-identifiable format.

(b)

Establishment of process

The Secretary shall establish a process to collect, and validate, aggregate data on quality measures described in section 399JJ to facilitate public reporting described in section 399KK. Such process shall—

(1)

be developed based on guidance of a broad-based, public-private collaboration;

(2)

employ methods that are scientifically sound and feasible to implement nationwide through the use of consistent methods for the collection, analysis, and reporting of quality and resource use measures;

(3)

over time, where feasible, build on expanding availability of health information technology and other data systems that are directly used to improve and coordinate patient care;

(4)

allow for the integration of data on quality of care and resource use from a range of data sources used by providers and patients to coordinate and improve care, including public sources, private sources, and public-private collaborations;

(5)

be implemented in accordance with an aggressive timeline to be established by the Secretary based on the technical and practical feasibility of measures and related data systems; and

(6)

utilize clinical and claims data to evaluate the quality and efficiency of health care.

(c)

Data collection, aggregation, and analysis

The Secretary shall ensure the collection and aggregation of consistent data on quality and resource use measures from information systems used to support health care delivery to implement the public reporting of performance information as described in section 399KK. The Secretary shall ensure that such collection, aggregation, and analysis systems span an increasingly broad range of patient populations, providers, and geographic areas over time.

(d)

Grants and contracts for data collection

(1)

In general

The Secretary shall award grants or contracts to eligible entities to support the collection and aggregation of quality and resource use measures described under subsection (c).

(2)

Eligible entities

To be eligible for a grant or contract under this subsection, an entity shall—

(A)
(i)

be a multi-stakeholder entity that coordinates the development of methods and implementation plans for the consistent reporting of summary quality and cost information;

(ii)

be an entity capable of submitting such summary data for a particular population and providers, such as a disease registry, regional collaboration, health plan collaboration, or other population-wide source; or

(iii)

be a Federal Indian Health Service program or a health program operated by an Indian Tribe (as defined in section 4 of the Indian Health Care Improvement Act);

(B)

promote the use of the systems that provide data to improve and coordinate patient care;

(C)

support the provision of timely, consistent quality and resource use information to health care providers, and other groups and organizations as appropriate, with an opportunity for providers to correct inaccurate measures; and

(D)

support the provision of consistent measures on quality and resource use to the public in accordance with the process established by the Secretary under subsection (b).

(3)

Consistent data aggregation

The Secretary shall award funding under this subsection only to entities enabling summary data that can be integrated and compared across multiple sources. The Secretary shall also provide standards for the protection of the security and privacy of patient data.

(e)

Pilot programs to develop, validate, and improve methods used to support the nationwide quality measurement and reporting strategy

(1)

In general

(A)

Development, validation, and improvement methods

The Secretary shall support the development, validation, implementation, and refinement of nationally consistent methods used to support quality measurement and reporting under section 399KK.

(B)

Grants and contracts

The Secretary may award grants or contracts to eligible quality data entities to carry out subparagraph (A).

(2)

Eligible quality data entities

To be eligible for a grant or contract under this subsection, a quality data entity shall—

(A)

be a public or private organization with expertise and experience in large-scale health care data aggregation, integration, analysis, or reporting; and

(B)

support the implementation of quality measurement and reporting under section 399KK, including the production of data that can be combined and compared with equivalent information from other entities involved in supporting the delivery of care.

(f)

Grants and contracts for data analysis

(1)

Federal health care data

In this subsection:

(A)

In general

Subject to subparagraph (B), the term Federal health care data means—

(i)

deidentified enrollment data and deidentified claims data maintained by the Secretary or entities under programs, contracts, grants, or memoranda of understanding administered by the Secretary; and

(ii)

where feasible, other deidentified enrollment data and deidentified claims data maintained by the Federal Government or entities under contract with the Federal Government.

(B)

Exception

The term Federal health care data includes data relating to programs administered by the Secretary under the Social Security Act only to the extent that the disclosure of such data is authorized or required under such Act.

(2)

Awards

The Secretary shall award contracts to eligible entities to support the analysis of quality and resource use measures described under subsection (c).

(3)

Eligible entities

(A)

Qualifications

The Secretary shall enter into a contract with an entity under paragraph (2) only if the Secretary determines that the entity—

(i)

has the research capability to conduct and complete reports under this subsection;

(ii)

has in place—

(I)

an information technology infrastructure to support the database of Federal health care data that is to be disclosed to the entity; and

(II)

operational standards to provide security for such database;

(iii)

has experience with, and expertise on, the development of reports on health care quality and efficiency; and

(iv)

has a significant business presence in the United States.

(B)

Contract requirements

Each contract with an entity under paragraph (2) shall contain the following requirements:

(i)

Ensuring beneficiary privacy

(I)

HIPAA

The entity shall meet the requirements imposed on a covered entity for purposes of applying part C of title XI and all regulatory provisions promulgated thereunder, including regulations (relating to privacy) adopted pursuant to the authority of the Secretary under section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note).

(II)

Other statutory protections

The entity shall be required to refrain from disclosing data that could be withheld by the Secretary under section 552 of title 5, United States Code, or whose disclosure by the Secretary would violate section 552a of such title.

(ii)

Proprietary information

The entity shall provide assurances that the entity will not disclose any negotiated price concessions, such as discounts, direct or indirect subsidies, rebates, and direct or indirect remunerations, obtained by health care providers or suppliers or health care plans, or any other proprietary cost information.

(iii)

Disclosure

The entity shall disclose—

(I)

any financial, reporting, or contractual relationship between the entity and any health care provider or supplier or health care plan; and

(II)

if applicable, the fact that the entity is managed, controlled, or operated by any health care provider or supplier or health care plan.

(iv)

Component of another organization

If the entity is a component of another organization—

(I)

the entity shall maintain Federal health care data and reports separately from the rest of the organization and establish appropriate security measures to maintain the confidentiality and privacy of the Federal health care data and reports; and

(II)

the entity shall not make an unauthorized disclosure to the rest of the organization of Federal health care data or reports in breach of such confidentiality and privacy requirement.

(v)

Termination or nonrenewal

If a contract under this subsection is terminated or not renewed, the following requirements shall apply:

(I)

Confidentiality and privacy protections

The entity shall continue to comply with the confidentiality and privacy requirements under this subsection with respect to all Federal health care data disclosed to the entity and each report developed by the entity.

(II)

Disposition of data and reports

The entity shall—

(aa)

return to the Secretary all Federal health care data disclosed to the entity and each report developed by the entity; or

(bb)

if returning the Federal health care data and reports is not practicable, destroy the reports and Federal health care data.

(vi)

Risk adjustment

The entity shall ensure that the methodology used to develop a report under paragraph (4) shall include acceptable risk adjustment and case-mix adjustment developed in consultation with providers.

(C)

Competitive procedures

Competitive procedures (as defined in section 4(5) of the Federal Procurement Policy Act) shall be used to enter into contracts under paragraph (2).

(D)

Review of contract in event of a merger or acquisition

The Secretary shall review the contract with an entity receiving a contract under this subsection in the event of a merger or acquisition of the entity in order to ensure that the requirements under this subsection will continue to be met.

(4)

Procedures for the development of reports

Notwithstanding section 552(b)(6) or 552a(b) of title 5, United States Code, subject to paragraph (1)(B), not later than 12 months after the date of enactment of this section, the Secretary, in accordance with the purpose described in subsection (a), shall establish and implement procedures under which an entity may submit a request to an entity with a contract under this subsection to develop a report based on—

(A)

Federal health care data disclosed to the entity under paragraph (5); and

(B)

private data that is publicly available or is provided to the entity by the entity making the request for the report.

(5)

Access to Federal Health Care Data

(A)

In general

The procedures established under paragraph (4) shall provide for the secure disclosure of Federal health care data to each entity with a contract under paragraph (2).

(B)

Update information

Not less than every 6 months, the Secretary shall update the information disclosed under subparagraph (A) to each such entity.

(g)

Public reporting of quality resource use measures at the provider, group, system, regional, and other levels

The Secretary shall make aggregated data, and reports developed under subsection (f), on quality and resource use measures collected under this section available to health care providers and the public through the process described in 399KK.

(h)

Research access to health care data and reporting on performance

The Secretary shall permit researchers that meet criteria used to evaluate the appropriateness of the release data for research purposes (as established by the Secretary) to—

(1)

have access to Federal health care data (as defined in subsection (f)); and

(2)

report on the performance of health care providers and suppliers, including reporting in a provider- or supplier-identifiable format.

(i)

Authorization of appropriations

There are authorized to be appropriated to carry out this section $90,000,000 for each of fiscal years 2010 through 2014.

.

(b)

HIT Policy Committee

Section 3002(b)(2)(B) of the Public Health Service Act (42 U.S.C. 300jj–12(b)(2)(B)) is amended by adding at the end the following:

(ix)

The use of certified electronic health records to collect and report quality measures accepted by the Secretary.

.

B

Health care quality improvements

211.

Health care delivery system research; Quality improvement technical assistance

Part D of title IX of the Public Health Service Act, as amended by section 203, is further amended by adding at the end the following:

II

Health care quality improvement programs

933.

Health care delivery system research

(a)

Purpose

The purposes of this section are to—

(1)

enable the Director to identify, develop, evaluate, disseminate, and provide training in innovative methodologies and strategies for quality improvement practices in the delivery of health care services that represent best practices (referred to as best practices) in health care quality, safety, and value; and

(2)

ensure that the Director is accountable for implementing a model to pursue such research in a collaborative manner with other related Federal agencies.

(b)

Establishment of Center

There is established within the Agency the Patient Safety Research Center (referred to in this section as the Center).

(c)

General functions of Center

The Center shall—

(1)

carry out its functions using research from a variety of disciplines, which may include epidemiology, health services, sociology, psychology, human factors engineering, biostatistics, health economics, clinical research, and health informatics;

(2)

conduct or support activities for activities identified in subsection (a), and for—

(A)

best practices for quality improvement practices in the delivery of health care services; and

(B)

that include changes in processes of care and the redesign of systems used by providers that will reliably result in intended health outcomes, improve patient safety, and reduce medical errors (such as skill development for health care providers in team-based health care delivery and rapid cycle process improvement) and facilitate adoption of improved workflow;

(3)

identify health care providers, including health care systems, single institutions, and individual providers, that—

(A)

deliver consistently high-quality, efficient health care services (as determined by the Secretary); and

(B)

employ best practices that are adaptable and scalable to diverse health care settings or effective in improving care across diverse settings;

(4)

assess research, evidence, and knowledge about what strategies and methodologies are most effective in improving health care delivery;

(5)

find ways to translate such information rapidly and effectively into practice, and document the sustainability of those improvements;

(6)

create strategies for quality improvement through the development of tools, methodologies, and interventions that can successfully reduce variations in the delivery of health care;

(7)

identify, measure, and improve organizational, human, or other causative factors, including those related to the culture and system design of a health care organization, that contribute to the success and sustainability of specific quality improvement and patient safety strategies;

(8)

provide for the development of best practices in the delivery of health care services that—

(A)

have a high likelihood of success, based on structured review of empirical evidence;

(B)

are specified with sufficient detail of the individual processes, steps, training, skills, and knowledge required for implementation and incorporation into workflow of health care practitioners in a variety of settings;

(C)

are designed to be readily adapted by health care providers in a variety of settings; and

(D)

where applicable, assist health care providers in working with other health care providers across the continuum of care and in engaging patients and their families in improving the care and patient health outcomes;

(9)

provide for the funding of the activities of organizations with recognized expertise and excellence in improving the delivery of health care services, including children's health care, by involving multiple disciplines, managers of health care entities, broad development and training, patients, caregivers and families, and frontline health care workers, including activities for the examination of strategies to share best quality improvement practices and to promote excellence in the delivery of health care services; and

(10)

build capacity at the State and community level to lead quality and safety efforts through education, training, and mentoring programs to carry out the activities under paragraphs (1) through (9).

(d)

Research Functions of Center

(1)

In general

The Center shall support, such as through a contract or other mechanism, research on health care delivery system improvement and the development of tools to facilitate adoption of best practices that improve the quality, safety, and efficiency of health care delivery services. Such support may include establishing a Quality Improvement Network Research Program for the purpose of testing, scaling, and disseminating of interventions to improve quality and efficiency in health care. Recipients of funding under the Program may include national, State, multi-State, or multi-site quality improvement networks.

(2)

Research requirements

The research conducted pursuant to paragraph (1) shall—

(A)

address the priorities identified by the Secretary in the national strategic plan established under section 399HH;

(B)

identify areas in which evidence is insufficient to identify strategies and methodologies, taking into consideration areas of insufficient evidence identified by a qualified consensus-based entity in the report required under section 399JJ;

(C)

address concerns identified by health care institutions and providers and communicated through the Center pursuant to subsection (e);

(D)

reduce preventable morbidity, mortality, and associated costs of morbidity and mortality by building capacity for patient safety research;

(E)

support the discovery of processes for the reliable, safe, efficient, and responsive delivery of health care, taking into account discoveries from clinical research and comparative effectiveness research;

(F)

be designed to help improve health care quality and is tested in practice-based settings;

(G)

allow communication of research findings and translate evidence into practice recommendations that are adaptable to a variety of settings, and which, as soon as practicable after the establishment of the Center, shall include—

(i)

the implementation of a national application of Intensive Care Unit improvement projects relating to the adult (including geriatric), pediatric, and neonatal patient populations;

(ii)

practical methods for addressing health care associated infections, including Methicillin–Resistant Staphylococcus Aureus and Vancomycin–Resistant Entercoccus infections and other emerging infections; and

(iii)

practical methods for reducing preventable hospital admissions and readmissions;

(H)

expand demonstration projects for improving the quality of children’s health care and the use of health information technology, such as through Pediatric Quality Improvement Collaboratives and Learning Networks, consistent with provisions of section 1139A of the Social Security Act for assessing and improving quality, where applicable;

(I)

identify and mitigate hazards by—

(i)

analyzing events reported to patient safety reporting systems and patient safety organizations; and

(ii)

using the results of such analyses to develop scientific methods of response to such events;

(J)

include the conduct of systematic reviews of existing practices that improve the quality, safety, and efficiency of health care delivery, as well as new research on improving such practices; and

(K)

include the examination of how to measure and evaluate the progress of quality and patient safety activities.

(e)

Dissemination of research findings

(1)

Public availability

The Director shall make the research findings of the Center available to the public through multiple media and appropriate formats to reflect the varying needs of health care providers and consumers and diverse levels of health literacy.

(2)

Linkage to health information technology

The Secretary shall ensure that research findings and results generated by the Center are shared with the Office of the National Coordinator of Health Information Technology and used to inform the activities of the health information technology extension program under section 3012, as well as any relevant standards, certification criteria, or implementation specifications.

(f)

Prioritization

The Director shall identify and regularly update a list of processes or systems on which to focus research and dissemination activities of the Center, taking into account—

(1)

cost to Federal health programs;

(2)

consumer assessment of health care experience;

(3)

provider assessment of such processes or systems and opportunities to minimize distress and injury to the health care workforce;

(4)

potential impact of such processes or systems on health status and function of patients, including vulnerable populations including children;

(5)

areas of insufficient evidence identified under subsection (d)(2)(B); and

(6)

the evolution of meaningful use of health information technology, as defined in section 3000.

(g)

Funding

There is authorized to be appropriated to carry out this section $20,000,000 for fiscal years 2010 through 2014.

934.

Quality improvement technical assistance and implementation

(a)

In general

The Director, through the Patient Safety Research Center established in section 933 (referred to in this section as the Center), shall award—

(1)

technical assistance grants or contracts to eligible entities to provide technical support to institutions that deliver health care and health care providers so that such institutions and providers understand, adapt, and implement the models and practices identified in the research conducted by the Center, including the Quality Improvement Networks Research Program; and

(2)

implementation grants or contracts to eligible entities to implement the models and practices described under paragraph (1).

(b)

Eligible entities

(1)

Technical assistance award

To be eligible to receive a technical assistance grant or contract under subsection (a)(1), an entity—

(A)

may be a health care provider, health care provider association, professional society, health care worker organization, Indian health organization, quality improvement organization, patient safety organization, local quality improvement collaborative, the Joint Commission, academic health center, university, physician-based research network, primary care extension program established under section 399V, a Federal Indian Health Service program or a health program operated by an Indian Tribe (as defined in section 4 of the Indian Health Care Improvement Act), or any other entity identified by the Secretary; and

(B)

shall have demonstrated expertise in providing information and technical support and assistance to health care providers regarding quality improvement.

(2)

Implementation award

To be eligible to receive an implementation grant or contract under subsection (a)(2), an entity—

(A)

may be a hospital or other health care provider or consortium or providers, as determined by the Secretary; and

(B)

shall have demonstrated expertise in providing information and technical support and assistance to health care providers regarding quality improvement.

(c)

Application

(1)

Technical assistance award

To receive a technical assistance grant or contract under subsection (a)(1), an eligible entity shall submit an application to the Secretary at such time, in such manner, and containing—

(A)

a plan for a sustainable business model that may include a system of—

(i)

charging fees to institutions and providers that receive technical support from the entity; and

(ii)

reducing or eliminating such fees for such institutions and providers that serve low-income populations; and

(B)

such other information as the Director may require.

(2)

Implementation award

To receive a grant or contract under subsection (a)(2), an eligible entity shall submit an application to the Secretary at such time, in such manner, and containing—

(A)

a plan for implementation of a model or practice identified in the research conducted by the Center including—

(i)

financial cost, staffing requirements, and timeline for implementation; and

(ii)

pre- and projected post-implementation quality measure performance data in targeted improvement areas identified by the Secretary; and

(B)

such other information as the Director may require.

(d)

Matching funds

The Director may not award a grant or contract under this section to an entity unless the entity agrees that it will make available (directly or through contributions from other public or private entities) non-Federal contributions toward the activities to be carried out under the grant or contract in an amount equal to $1 for each $5 of Federal funds provided under the grant or contract. Such non-Federal matching funds may be provided directly or through donations from public or private entities and may be in cash or in-kind, fairly evaluated, including plant, equipment, or services.

(e)

Evaluation

(1)

In general

The Director shall evaluate the performance of each entity that receives a grant or contract under this section. The evaluation of an entity shall include a study of—

(A)

the success of such entity in achieving the implementation, by the health care institutions and providers assisted by such entity, of the models and practices identified in the research conducted by the Center under section 933;

(B)

the perception of the health care institutions and providers assisted by such entity regarding the value of the entity; and

(C)

where practicable, better patient health outcomes and lower cost resulting from the assistance provided by such entity.

(2)

Effect of evaluation

Based on the outcome of the evaluation of the entity under paragraph (1), the Director shall determine whether to renew a grant or contract with such entity under this section.

(f)

Coordination

The entities that receive a grant or contract under this section shall coordinate with health information technology regional extension centers under section 3012(c) and the primary care extension program established under section 399V regarding the dissemination of quality improvement, system delivery reform, and best practices information.

.

212.

Grants to establish community health teams to support the patient-centered medical home

(a)

In general

The Secretary of Health and Human Services (referred to in this section as the Secretary) shall establish a program to provide grants to eligible entities to establish community-based interdisciplinary, interprofessional teams (referred to in this section as health teams) to support primary care practices, including obstetrics and gynecology practices, within the hospital service areas served by the eligible entities. Grants shall be used to—

(1)

establish health teams to provide support services to primary care providers; and

(2)

provide capitated payments to primary care providers as determined by the Secretary.

(b)

Eligible entities

To be eligible to receive a grant under subsection (a), an entity shall—

(1)
(A)

be a State or State-designated entity; or

(B)

be an Indian Tribe or tribal organization, as defined in section 4 of the Indian Health Care Improvement Act;

(2)

submit a plan for achieving long-term financial sustainability within 3 years;

(3)

submit a plan for incorporating prevention initiatives and patient education and care management resources into the delivery of health care that is integrated with community-based prevention and treatment resources, where available;

(4)

ensure that the health team established by the entity includes an interdisciplinary, interprofessional team of health care providers, as determined by the Secretary; such team may include medical specialists, nurses, nutritionists, dieticians, social workers, behavioral and mental health providers (including substance use disorder prevention and treatment providers), doctors of chiropractic, licensed complementary and alternative medicine practitioners, and physicians' assistants; and

(5)

submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require.

(c)

Requirements for health teams

A health team established pursuant to a grant under subsection (a) shall—

(1)

establish contractual agreements with primary care providers to provide support services;

(2)

support patient-centered medical homes, defined as mode of care that includes—

(A)

personal physicians;

(B)

whole person orientation;

(C)

coordinated and integrated care;

(D)

safe and high quality care though evidence-informed medicine, appropriate use of health information technology, and continuous quality improvements;

(E)

expanded access to care; and

(F)

payment that recognizes added value from additional components of patient-centered care;

(3)

collaborate with local primary care providers and existing State and community based resources to coordinate disease prevention, chronic disease management, transitioning between health care providers and settings and case management for patients, including children, with priority given to those amenable to prevention and with chronic diseases or conditions identified by the Secretary;

(4)

in collaboration with local health care providers, develop and implement interdisciplinary, interprofessional care plans that integrate clinical and community preventive and health promotion services for patients, including children, with a priority given to those amenable to prevention and with chronic diseases or conditions identified by the Secretary;

(5)

incorporate health care providers, patients, caregivers, and authorized representatives in program design and oversight;

(6)

provide support necessary for local primary care providers to—

(A)

coordinate and provide access to high-quality health care services;

(B)

coordinate and provide access to preventive and health promotion services;

(C)

provide access to appropriate specialty care and inpatient services;

(D)

provide quality-driven, cost-effective, culturally appropriate, and patient- and family-centered health care;

(E)

provide access to pharmacist-delivered medication management services, including medication reconciliation;

(F)

provide coordination of the appropriate use of complementary and alternative (CAM) services to those who request such services;

(G)

promote effective strategies for treatment planning, monitoring health outcomes and resource use, sharing information, treatment decision support, and organizing care to avoid duplication of service and other medical management approaches intended to improve quality and value of health care services;

(H)

provide local access to the continuum of health care services in the most appropriate setting, including access to individuals that implement the care plans of patients and coordinate care, such as integrative health care practitioners;

(I)

collect and report data that permits evaluation of the success of the collaborative effort on patient outcomes, including collection of data on patient experience of care, and identification of areas for improvement; and

(J)

establish a coordinated system of early identification and referral for children at risk for developmental or behavioral problems such as through the use of infolines, health information technology, or other means as determined by the Secretary;

(7)

provide 24-hour care management and support during transitions in care settings including—

(A)

a transitional care program that provides onsite visits from the care coordinator, assists with the development of discharge plans and medication reconciliation upon admission to and discharge from the hospitals, nursing home, or other institution setting;

(B)

discharge planning and counseling support to providers, patients, caregivers, and authorized representatives;

(C)

assuring that post-discharge care plans include medication management, as appropriate;

(D)

referrals for mental and behavioral health services, which may include the use of infolines; and

(E)

transitional health care needs from adolescence to adulthood;

(8)

serve as a liaison to community prevention and treatment programs;

(9)

demonstrate a capacity to implement and maintain health information technology that meets the requirements of certified EHR technology (as defined in section 3000 of the Public Health Service Act (42 U.S.C. 300jj)) to facilitate coordination among members of the applicable care team and affiliated primary care practices; and

(10)

where applicable, report to the Secretary information on quality measures used under section 399JJ of the Public Health Service Act.

(d)

Requirement for primary care providers

A provider who contracts with a care team shall—

(1)

provide a care plan to the care team for each patient participant;

(2)

provide access to participant health records; and

(3)

meet regularly with the care team to ensure integration of care.

(e)

Reporting to Secretary

An entity that receives a grant under subsection (a) shall submit to the Secretary a report that describes and evaluates, as requested by the Secretary, the activities carried out by the entity under subsection (c).

(f)

Definition of primary care

In this section, the term primary care means the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.

213.

Grants to implement medication management services in treatment of chronic disease

Title IX of the Public Health Service Act (42 U.S.C. 299 et seq.), as amended by section 211, is further amended by inserting after section 934 the following:

935.

Grants to implement medication management services in treatment of chronic diseases

(a)

In general

The Secretary, acting through the Patient Safety Research Center established in section 933 (referred to in this section as the Center), shall establish a program to provide grants to eligible entities to implement medication management (referred to in this section as MTM) services provided by licensed pharmacists, as a collaborative, multidisciplinary, inter-professional approach to the treatment of chronic diseases for targeted individuals, to improve the quality of care and reduce overall cost in the treatment of such diseases. The Secretary shall commence the grant program not later than May 1, 2010.

(b)

Eligible entities

To be eligible to receive a grant under subsection (a), an entity shall—

(1)

provide a setting appropriate for MTM services, as recommended by the experts described in subsection (e);

(2)

submit to the Secretary a plan for achieving long-term financial sustainability;

(3)

where applicable, submit a plan for coordinating MTM services through local community health teams established in section 212 of the Affordable Health Choices Act or in collaboration with primary care extension programs established in section 399V;

(4)

submit a plan for meeting the requirements under subsection (c); and

(5)

submit to the Secretary such other information as the Secretary may require.

(c)

MTM services to targeted individuals

The MTM services provided with the assistance of a grant awarded under subsection (a) shall, as allowed by State law including applicable collaborative pharmacy practice agreements, include—

(1)

performing or obtaining necessary assessments of the health and functional status of each patient receiving such MTM services;

(2)

formulating a medication treatment plan according to therapeutic goals agreed upon by the prescriber and the patient or caregiver or authorized representative of the patient;

(3)

selecting, initiating, modifying, recommending changes to, or administering medication therapy;

(4)

monitoring, which may include access to, ordering, or performing laboratory assessments, and evaluating the response of the patient to therapy, including safety and effectiveness;

(5)

performing an initial comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events, quarterly targeted medication reviews for ongoing monitoring, and additional followup interventions on a schedule developed collaboratively with the prescriber;

(6)

documenting the care delivered and communicating essential information about such care, including a summary of the medication review, and the recommendations of the pharmacist to other appropriate health care providers of the patient in a timely fashion;

(7)

providing education and training designed to enhance the understanding and appropriate use of the medications by the patient, caregiver, and other authorized representative;

(8)

providing information, support services, and resources and strategies designed to enhance patient adherence with therapeutic regimens;

(9)

coordinating and integrating MTM services within the broader health care management services provided to the patient; and

(10)

such other patient care services allowed under pharmacist scopes of practice in use in other Federal programs that have implemented MTM services.

(d)

Targeted individuals

MTM services provided by licensed pharmacists under a grant awarded under subsection (a) shall be offered to targeted individuals who—

(1)

take 4 or more prescribed medications (including over-the-counter medications and dietary supplements);

(2)

take any high risk medications;

(3)

have 2 or more chronic diseases, as identified by the Secretary; or

(4)

have undergone a transition of care, or other factors, as determined by the Secretary, that are likely to create a high risk of medication-related problems.

(e)

Consultation with experts

In designing and implementing MTM services provided under grants awarded under subsection (a), the Secretary shall consult with Federal, State, private, public-private, and academic entities, pharmacy and pharmacist organizations, health care organizations, consumer advocates, chronic disease groups, and other stakeholders involved with the research, dissemination, and implementation of pharmacist-delivered MTM services, as the Secretary determines appropriate. The Secretary, in collaboration with this group, shall determine whether it is possible to incorporate rapid cycle process improvement concepts in use in other Federal programs that have implemented MTM services.

(f)

Reporting to the Secretary

An entity that receives a grant under subsection (a) shall submit to the Secretary a report that describes and evaluates, as requested by the Secretary, the activities carried out under subsection (c), including quality measures endorsed under 399JJ, as determined by the Secretary.

(g)

Evaluation and report

The Secretary shall submit to the relevant committees of Congress a report which shall—

(1)

assess the clinical effectiveness of pharmacist-provided services under the MTM services program, as compared to usual care, including an evaluation of whether enrollees maintained better health with fewer hospitalizations and emergency room visits than similar patients not enrolled in the program;

(2)

assess changes in overall health care resource use by targeted individuals;

(3)

assess patient and prescriber satisfaction with MTM services;

(4)

assess the impact of patient-cost sharing requirements on medication adherence and recommendations for modifications;

(5)

identify and evaluate other factors that may impact clinical and economic outcomes, including demographic characteristics, clinical characteristics, and health services use of the patient, as well as characteristics of the regimen, pharmacy benefit, and MTM services provided; and

(6)

evaluate the extent to which participating pharmacists who maintain a dispensing role have a conflict of interest in the provision of MTM services, and if such conflict is found, provide recommendations on how such a conflict might be appropriately addressed.

(h)

Grant to fund development of performance measures

Secretary may, through the quality measure development program under section 931 of the Public Health Service Act, award grants or contracts to eligible entities for the purpose of funding the development of performance measures that assess the use and effectiveness of medication therapy management services.

.

214.

Design and implementation of regionalized systems for emergency care

(a)

In general

Title XII of the Public Health Service Act (42 U.S.C. 300d et seq.) is amended—

(1)

in section 1203—

(A)

in the section heading, by inserting for Trauma Systems after Grants; and

(B)

in subsection (a), by striking Administrator of the Health Resources and Services Administration and inserting Assistant Secretary for Preparedness and Response;

(2)

by inserting after section 1203 the following:

1204.

Competitive grants for regionalized systems for emergency care response

(a)

In general

The Secretary, acting through the Assistant Secretary for Preparedness and Response, shall award not fewer than 4 multiyear contracts or competitive grants to eligible entities to support pilot projects that design, implement, and evaluate innovative models of regionalized, comprehensive, and accountable emergency care and trauma systems.

(b)

Eligible entity; region

In this section:

(1)

Eligible entity

The term eligible entity means—

(A)

a State or a partnership of 1 or more States and 1 or more local governments; or

(B)

an Indian Tribe (as defined in section 4 of the Indian Health Care Improvement Act) or a partnership of 1 or more Indian Tribes.

(2)

Region

The term region means an area within a State, an area that lies within multiple States, or a similar area (such as a multicounty area), as determined by the Secretary.

(3)

Emergency services

The term emergency services includes acute, prehospital, and trauma care.

(c)

Pilot projects

The Secretary shall award a contract or grant under subsection (a) to an eligible entity that proposes a pilot project to design, implement, and evaluate an emergency medical and trauma system that—

(1)

coordinates with public health and safety services, emergency medical services, medical facilities, trauma centers, and other entities in a region to develop an approach to emergency medical and trauma system access throughout the region, including 9–1–1 Public Safety Answering Points and emergency medical dispatch;

(2)

includes a mechanism, such as a regional medical direction or transport communications system, that operates throughout the region to ensure that the patient is taken to the medically appropriate facility (whether an initial facility or a higher-level facility) in a timely fashion;

(3)

allows for the tracking of prehospital and hospital resources, including inpatient bed capacity, emergency department capacity, trauma center capacity, on-call specialist coverage, ambulance diversion status, and the coordination of such tracking with regional communications and hospital destination decisions; and

(4)

includes a consistent region-wide prehospital, hospital, and interfacility data management system that—

(A)

submits data to the National EMS Information System, the National Trauma Data Bank, and others;

(B)

reports data to appropriate Federal and State databanks and registries; and

(C)

contains information sufficient to evaluate key elements of prehospital care, hospital destination decisions, including initial hospital and interfacility decisions, and relevant health outcomes of hospital care.

(d)

Application

(1)

In general

An eligible entity that seeks a contract or grant described in subsection (a) shall submit to the Secretary an application at such time and in such manner as the Secretary may require.

(2)

Application information

Each application shall include—

(A)

an assurance from the eligible entity that the proposed system—

(i)

has been coordinated with the applicable State Office of Emergency Medical Services (or equivalent State office);

(ii)

includes consistent indirect and direct medical oversight of prehospital, hospital, and interfacility transport throughout the region;

(iii)

coordinates prehospital treatment and triage, hospital destination, and interfacility transport throughout the region;

(iv)

includes a categorization or designation system for special medical facilities throughout the region that is integrated with transport and destination protocols;

(v)

includes a regional medical direction, patient tracking, and resource allocation system that supports day-to-day emergency care and surge capacity and is integrated with other components of the national and State emergency preparedness system; and

(vi)

addresses pediatric concerns related to integration, planning, preparedness, and coordination of emergency medical services for infants, children and adolescents; and

(B)

such other information as the Secretary may require.

(e)

Requirement of matching funds

(1)

In general

The Secretary may not make a grant under this section unless the State (or consortia of States) involved agrees, with respect to the costs to be incurred by the State (or consortia) in carrying out the purpose for which such grant was made, to make available non-Federal contributions (in cash or in kind under paragraph (2)) toward such costs in an amount equal to not less than $1 for each $3 of Federal funds provided in the grant. Such contributions may be made directly or through donations from public or private entities.

(2)

Non-Federal contributions

Non-Federal contributions required in paragraph (1) may be in cash or in kind, fairly evaluated, including equipment or services (and excluding indirect or overhead costs). Amounts provided by the Federal Government, or services assisted or subsidized to any significant extent by the Federal Government, may not be included in determining the amount of such non-Federal contributions.

(f)

Priority

The Secretary shall give priority for the award of the contracts or grants described in subsection (a) to any eligible entity that serves a population in a medically underserved area (as defined in section 330(b)(3)).

(g)

Report

Not later than 90 days after the completion of a pilot project under subsection (a), the recipient of such contract or grant described in shall submit to the Secretary a report containing the results of an evaluation of the program, including an identification of—

(1)

the impact of the regional, accountable emergency care and trauma system on patient health outcomes for various critical care categories, such as trauma, stroke, cardiac emergencies, neurological emergencies, and pediatric emergencies;

(2)

the system characteristics that contribute to the effectiveness and efficiency of the program (or lack thereof);

(3)

methods of assuring the long-term financial sustainability of the emergency care and trauma system;

(4)

the State and local legislation necessary to implement and to maintain the system;

(5)

the barriers to developing regionalized, accountable emergency care and trauma systems, as well as the methods to overcome such barriers; and

(6)

recommendations on the utilization of available funding for future regionalization efforts.

(h)

Dissemination of findings

The Secretary shall, as appropriate, disseminate to the public and to the appropriate Committees of the Congress, the information contained in a report made under subsection (g).

; and

(3)

in section 1232—

(A)

in subsection (a), by striking appropriated and all that follows through the period at the end and inserting appropriated $24,000,000 for each of fiscal years 2010 through 2014.; and

(B)

by inserting after subsection (c) the following:

(d)

Authority

For the purpose of carrying out parts A through C, beginning on the date of enactment of the Affordable Health Choices Act, the Secretary shall transfer authority in administering grants and related authorities under such parts from the Administrator of the Health Resources and Services Administration to the Assistant Secretary for Preparedness and Response.

.

(b)

Support for emergency medicine research

Part H of title IV of the Public Health Service Act (42 U.S.C. 289 et seq.) is amended by inserting after the section 498C the following:

498D.

Support for emergency medicine research

(a)

Emergency medical research

The Secretary shall support Federal programs administered by the National Institutes of Health, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, the Centers for Disease Control and Prevention, and other agencies involved in improving the emergency care system to expand and accelerate research in emergency medical care systems and emergency medicine, including—

(1)

the basic science of emergency medicine;

(2)

the model of service delivery and the components of such models that contribute to enhanced patient health outcomes;

(3)

the translation of basic scientific research into improved practice; and

(4)

the development of timely and efficient delivery of health services.

(b)

Pediatric emergency medical research

The Secretary shall support Federal programs administered by the National Institutes of Health, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, the Centers for Disease Control and Prevention, and other agencies to coordinate and expand research in pediatric emergency medical care systems and pediatric emergency medicine, including—

(1)

an examination of the gaps and opportunities in pediatric emergency care research and a strategy for the optimal organization and funding of such research;

(2)

the role of pediatric emergency services as an integrated component of the overall health system;

(3)

system-wide pediatric emergency care planning, preparedness, coordination, and funding;

(4)

pediatric training in professional education; and

(5)

research in pediatric emergency care, specifically on the efficacy, safety, and health outcomes of medications used for infants, children, and adolescents in emergency care settings in order to improve patient safety.

(c)

Impact research

The Secretary shall support research to determine the estimated economic impact of, and savings that result from, the implementation of coordinated emergency care systems.

(d)

Authorization of appropriations

There are authorized to be appropriated to carry out this section such sums as may be necessary for each of fiscal years 2010 through 2014.

.

215.

Trauma care centers and service availability

(a)

Trauma care centers

(1)

Grants for trauma care centers

Section 1241 of the Public Health Service Act (42 U.S.C. 300d–41) is amended by striking subsections (a) and (b) and inserting the following:

(a)

In general

The Secretary shall establish 3 programs to award grants to qualified public, nonprofit, Indian Health Service, Indian tribal, and urban Indian trauma centers—

(1)

to assist in defraying substantial uncompensated care costs;

(2)

to further the core missions of such trauma centers, including by addressing costs associated with patient stabilization and transfer, trauma education and outreach, coordination with local and regional trauma systems, essential personnel and other fixed costs, and expenses associated with employee and non-employee physician services; and

(3)

to provide emergency relief to ensure the continued and future availability of trauma services.

(b)

Minimum qualifications of trauma centers

(1)

Participation in trauma care system operating under certain professional guidelines

Except as provided in paragraph (2), the Secretary may not award a grant to a trauma center under subsection (a) unless the trauma center is a participant in a trauma system that substantially complies with section 1213.

(2)

Exemption

Paragraph (1) shall not apply to trauma centers that are located in States with no existing trauma care system.

(3)

Qualification for substantial uncompensated care costs

The Secretary shall award substantial uncompensated care grants under subsection (a)(1) only to trauma centers meeting at least 1 of the criteria in 1 of the following 3 categories:

(A)

Category A

The criteria for category A are as follows:

(i)

At least 40 percent of the visits in the emergency department of the hospital in which the trauma center is located were charity or self-pay patients.

(ii)

At least 50 percent of the visits in such emergency department were Medicaid (under title XIX of the Social Security Act (42 U.S.C. 1396 et seq.)) and charity and self-pay patients combined.

(B)

Category B

The criteria for category B are as follows:

(i)

At least 35 percent of the visits in the emergency department were charity or self-pay patients.

(ii)

At least 50 percent of the visits in the emergency department were Medicaid and charity and self-pay patients combined.

(C)

Category C

The criteria for category C are as follows:

(i)

At least 20 percent of the visits in the emergency department were charity or self-pay patients.

(ii)

At least 30 percent of the visits in the emergency department were Medicaid and charity and self-pay patients combined.

(4)

Trauma centers in 1115 waiver States

Notwithstanding paragraph (3), the Secretary may award a substantial uncompensated care grant to a trauma center under subsection (a)(1) if the trauma center qualifies for funds under a Low Income Pool or Safety Net Care Pool established through a waiver approved under section 1115 of the Social Security Act (42 U.S.C. 1315).

(5)

Designation

The Secretary may not award a grant to a trauma center unless such trauma center is verified by the American College of Surgeons or designated by an equivalent State or local agency.

(c)

Additional requirements

The Secretary may not award a grant to a trauma center under subsection (a)(1) unless such trauma center—

(1)

submits to the Secretary a plan satisfactory to the Secretary that demonstrates a continued commitment to serving trauma patients regardless of their ability to pay; and

(2)

has policies in place to assist patients who cannot pay for part or all of the care they receive, including a sliding fee scale, and to ensure fair billing and collection practices.

.

(2)

Considerations in making grants

Section 1242 of the Public Health Service Act (42 U.S.C. 300d–42) is amended by striking subsections (a) and (b) and inserting the following:

(a)

Substantial Uncompensated Care Awards

(1)

In general

The Secretary shall establish an award basis for each eligible trauma center for grants under section 1241(a)(1) according to the percentage described in paragraph (2), subject to the requirements of section 1241(b)(3).

(2)

Percentages

The applicable percentages are as follows:

(A)

With respect to a category A trauma center, 100 percent of the uncompensated care costs.

(B)

With respect to a category B trauma center, not more than 75 percent of the uncompensated care costs.

(C)

With respect to a category C trauma center, not more than 50 percent of the uncompensated care costs.

(b)

Core mission awards

(1)

In general

In awarding grants under section 1241(a)(2), the Secretary shall—

(A)

reserve 25 percent of the amount allocated for core mission awards for Level III and Level IV trauma centers; and

(B)

reserve 25 percent of the amount allocated for core mission awards for large urban Level I and II trauma centers—

(i)

that have at least 1 graduate medical education fellowship in trauma or trauma related specialties for which demand is exceeding supply;

(ii)

for which—

(I)

annual uncompensated care costs exceed $10,000,000; or

(II)

at least 20 percent of emergency department visits are charity or self-pay or Medicaid patients; and

(iii)

that are not eligible for substantial uncompensated care awards under section 1241(a)(1).

(c)

Emergency awards

In awarding grants under section 1241(a)(3), the Secretary shall—

(1)

give preference to any application submitted by a trauma center that provides trauma care in a geographic area in which the availability of trauma care has significantly decreased or will significantly decrease if the center is forced to close or downgrade service or growth in demand for trauma services exceeds capacity; and

(2)

reallocate any emergency awards funds not obligated due to insufficient, or a lack of qualified, applications to the significant uncompensated care award program.

.

(3)

Certain agreements

Section 1243 of the Public Health Service Act (42 U.S.C. 300d–43) is amended by striking subsections (a), (b), and (c) and inserting the following:

(a)

Maintenance of financial support

The Secretary may require a trauma center receiving a grant under section 1241(a) to maintain access to trauma services at comparable levels to the prior year during the grant period .

(b)

Trauma care registry

The Secretary may require the trauma center receiving a grant under section 1241(a) to provide data to a national and centralized registry of trauma cases, in accordance with guidelines developed by the American College of Surgeons, and as the Secretary may otherwise require.

.

(4)

General provisions

Section 1244 of the Public Health Service Act (42 U.S.C. 300d–44) is amended by striking subsections (a), (b), and (c) and inserting the following:

(a)

Application

The Secretary may not award a grant to a trauma center under section 1241(a) unless such center submits an application for the grant to the Secretary and the application is in such form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this part.

(b)

Limitation on duration of support

The period during which a trauma center receives payments under a grant under section 1241(a)(3) shall be for 3 fiscal years, except that the Secretary may waive such requirement for a center and authorize such center to receive such payments for 1 additional fiscal year.

(c)

Limitation on amount of grant

Notwithstanding section 1242(a), a grant under section 1241 may not be made in an amount exceeding $2,000,000 for each fiscal year.

(d)

Eligibility

Except as provided in section 1242(b)(1)(B)(iii), acquisition of, or eligibility for, a grant under section 1241(a) shall not preclude a trauma center from being eligible for other grants described in such section.

(e)

Funding distribution

Of the total amount appropriated for a fiscal year under section 1245, 70 percent shall be used for substantial uncompensated care awards under section 1241(a)(1), 20 percent shall be used for core mission awards under section 1241(a)(2), and 10 percent shall be used for emergency awards under section 1241(a)(3).

(f)

Minimum allowance

Notwithstanding subsection (e), if the amount appropriated for a fiscal year under section 1245 is less than $25,000,000, all available funding for such fiscal year shall be used for substantial uncompensated care awards under section 1241(a)(1).

(g)

Substantial uncompensated care award distribution and proportional share

Notwithstanding section 1242(a), of the amount appropriated for substantial uncompensated care grants for a fiscal year, the Secretary shall—

(1)

make available—

(A)

50 percent of such funds for category A trauma center grantees;

(B)

35 percent of such funds for category B trauma center grantees; and

(C)

15 percent of such funds for category C trauma center grantees; and

(2)

provide available funds within each category in a manner proportional to the award basis specified in section 1242(a)(2) to each eligible trauma center.

(h)

Report

Beginning 2 years after the date of enactment of the Affordable Health Choices Act, and every 2 years thereafter, the Secretary shall biennially report to Congress regarding the status of the grants made under section 1241 and on the overall financial stability of trauma centers.

.

(5)

Authorization of appropriations

Section 1245 of the Public Health Service Act (42 U.S.C. 300d–45) is amended to read as follows:

1245.

Authorization of appropriations

For the purpose of carrying out this part, there are authorized to be appropriated $100,000,000 for fiscal year 2009, and such sums as may be necessary for each of fiscal years 2010 through 2015. Such authorization of appropriations is in addition to any other authorization of appropriations or amounts that are available for such purpose.

.

(6)

Definition

Part D of title XII of the Public Health Service Act (42 U.S.C. 300d–41 et seq.) is amended by adding at the end the following:

1246.

Definition

In this part, the term uncompensated care costs means unreimbursed costs from serving self-pay, charity, or Medicaid patients, without regard to payment under section 1923 of the Social Security Act, all of which are attributable to emergency care and trauma care, including costs related to subsequent inpatient admissions to the hospital.

.

(b)

Trauma service availability

Title XII of the Public Health Service Act (42 U.S.C. 300d et seq.) is amended by adding at the end the following:

H

Trauma service availability

1281.

Grants to States

(a)

Establishment

To promote universal access to trauma care services provided by trauma centers and trauma-related physician specialties, the Secretary shall provide funding to States to enable such States to award grants to eligible entities for the purposes described in this section.

(b)

Awarding of grants by States

Each State may award grants to eligible entities within the State for the purposes described in subparagraph (d).

(c)

Eligibility

(1)

In general

To be eligible to receive a grant under subsection (b) an entity shall—

(A)

be—

(i)

a public or nonprofit trauma center or consortium thereof that meets that requirements of paragraphs (1), (2), and (5) of section 1241(b);

(ii)

a safety net public or nonprofit trauma center that meets the requirements of paragraphs (1) through (5) of section 1241(b); or

(iii)

a hospital in an underserved area (as defined by the State) that seeks to establish new trauma services; and

(B)

submit to the State an application at such time, in such manner, and containing such information as the State may require.

(2)

Limitation

A State shall use at least 40 percent of the amount available to the State under this part for a fiscal year to award grants to safety net trauma centers described in paragraph (1)(A)(ii).

(d)

Use of funds

The recipient of a grant under subsection (b) shall carry out 1 or more of the following activities consistent with subsection (b):

(1)

Providing trauma centers with funding to support physician compensation in trauma-related physician specialties where shortages exist in the region involved, with priority provided to safety net trauma centers described in subsection (c)(1)(A)(ii).

(2)

Providing for individual safety net trauma center fiscal stability and costs related to having service that is available 24 hours a day, 7 days a week, with priority provided to safety net trauma centers described in subsection (c)(1)(A)(ii) located in urban, border, and rural areas.

(3)

Reducing trauma center overcrowding at specific trauma centers related to throughput of trauma patients.

(4)

Establishing new trauma services in underserved areas as defined by the State.

(5)

Enhancing collaboration between trauma centers and other hospitals and emergency medical services personnel related to trauma service availability.

(6)

Making capital improvements to enhance access and expedite trauma care, including providing helipads and associated safety infrastructure.

(7)

Enhancing trauma surge capacity at specific trauma centers.

(8)

Ensuring expedient receipt of trauma patients transported by ground or air to the appropriate trauma center.

(9)

Enhancing interstate trauma center collaboration.

(e)

Limitation

(1)

In general

A State may use not more than 20 percent of the amount available to the State under this part for a fiscal year for administrative costs associated with awarding grants and related costs.

(2)

Maintenance of effort

The Secretary may not provide funding to a State under this part unless the State agrees that such funds will be used to supplement and not supplant State funding otherwise available for the activities and costs described in this part.

(f)

Distribution of funds

The following shall apply with respect to grants provided in this part:

(1)

Less than $10,000,000

If the amount of appropriations for this part in a fiscal year is less than $10,000,000, the Secretary shall divide such funding evenly among only those States that have 1 or more trauma centers eligible for funding under section 1241(b)(3)(A).

(2)

Less than $20,000,000

If the amount of appropriations in a fiscal year is less than $20,000,000, the Secretary shall divide such funding evenly among only those States that have 1 or more trauma centers eligible for funding under subparagraphs (A) and (B) of section 1241(b)(3).

(3)

Less than $30,000,000

If the amount of appropriations for this part in a fiscal year is less than $30,000,000, the Secretary shall divide such funding evenly among only those States that have 1 or more trauma centers eligible for funding under section 1241(b)(3).

(4)

$30,000,000 or more

If the amount of appropriations for this part in a fiscal year is $30,000,000 or more, the Secretary shall divide such funding evenly among all States.

1282.

Authorization of appropriations

For the purpose of carrying out this part, there is authorized to be appropriated $100,000,000 for each of fiscal years 2010 through 2015.

.

216.

Reducing and reporting hospital readmissions

(a)

In general

Part S of title III of the Public Health Service Act, as amended by section 205, is further amended by adding at the end the following:

399NN.

Readmissions

(a)

Purpose

The purpose of this section is to improve the quality and value of inpatient hospital services in order to—

(1)

improve the coordination of care; and

(2)

appropriately reduce inefficiency and waste, such as unnecessary hospital readmissions, in the care furnished.

(b)

Information gathering and analysis

Beginning 2010, the Secretary shall analyze and calculate hospital-specific and national applicable readmissions rates based on subsection (e). In developing criteria and carrying out this section, the Secretary shall consider the unique characters of rural and low-volume hospitals (including critical access hospitals).

(c)

Disclosure

(1)

In general

Beginning in 2011, the Secretary shall establish procedures to provide for the confidential disclosure to hospitals receiving funds under this Act of information on hospital-specific and national applicable readmission rates described in subsection (b).

(2)

Public disclosure of information

Not later than 2 years after the date of enactment of this section, the Secretary shall make the information on the rates of applicable readmission rates and other statistical information of hospital receiving funds under this Act disclosed under paragraph (1) publicly available in a form and manner determined appropriate by the Secretary.

(3)

Report

Not later than 180 days after the date of enactment of this section, the Secretary shall submit to Congress a report that contains—

(A)

a summary of the implementation of the procedures under paragraph (1);

(B)

a plan for the public disclosure of information under paragraph (2); and

(C)

recommendations for such legislation or administrative action as the Secretary determines appropriate.

(d)

Applicable readmission defined

(1)

In general

In this section, the term applicable readmission means a readmission—

(A)

selected by the Secretary under subsection (e));

(B)

that occurs within a time interval (as specified under subsection (f)) following a discharge from a hospital; and

(C)

which is for a condition or procedure selected under subsection (g).

(2)

Determination of applicability to readmissions to certain hospitals

The Secretary shall determine whether the term applicable readmission includes readmissions to the same hospital as the prior discharge or readmissions to any hospital.

(e)

Selection of readmissions

Not later 6 months after the date of enactment of this section, the Secretary, in consultation with appropriate representatives of the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality, shall, for each of the conditions or procedures selected under subsection (g), select readmissions that meet each of the following requirements:

(1)

The readmission could reasonably have been prevented by the provision of care consistent with evidence-based guidelines during the prior admission or the post discharge follow-up period.

(2)

The readmission is for a condition or procedure related to the care provided during the prior admission or post discharge follow-up period, which includes a readmission for the following:

(A)

The same condition or procedure as the prior discharge.

(B)

An infection or other complication of care.

(C)

A condition or procedure indicative of a failed surgical intervention.

(D)

Other conditions or procedures as determined appropriate by the Secretary.

(f)

Specification of time interval

The Secretary shall specify a time interval, of not less than 7 days and not more than 30 days, between the prior discharge and applicable readmission for purposes of this section.

(g)

Selection of conditions or procedures

(1)

In general

Not later than 6 months after the date of enactment of this section, the Secretary shall select at least 2 conditions or procedures which meet each of the following requirements:

(A)

Such conditions or procedures have a high volume.

(B)

For the time interval specified under subsection (f), such conditions or procedures have a relatively high rate of occurrence of subsequent readmissions described in subsection (f), as compared to all other conditions or procedures.

(2)

Expansion of conditions or procedures selected

The Secretary shall expand the list of readmission conditions analyzed under this section to include at least 8 conditions with the highest volume and highest rate of readmissions. At least one of the conditions selected shall be a condition prevalent in geriatric patients.

(h)

Quality improvement program for hospitals with a high severity adjusted readmission rate

(1)

Establishment

(A)

In general

Not later than 2 years after the date of enactment of this section, the Secretary shall establish a program for eligible hospitals to improve their readmission rates through the use of patient safety organizations (as defined in section 921(4)).

(B)

Eligible hospital defined

In this subsection, the term eligible hospital means a hospital which the Secretary determines (based on the most recent available historical data) has a severity adjusted readmission rate for the conditions described in subsection (g) among the highest 25 percent of all hospitals nationally.

(C)

Risk adjustment

The Secretary shall utilize appropriate risk adjustment measures to determine eligible hospitals.

(2)

Report to the Secretary

Eligible hospitals and patient safety organizations working with those hospitals shall report to the Secretary on the processes employed by the hospital to improve readmission rates and the impact of such processes on readmission rates.

.

(b)

GAO study and report

(1)

Study

The Comptroller General of the United States shall conduct a study on the impact of section 399NN of the Public Health Service Act, as added by subsection (a), on—

(A)

care furnished to consumers;

(B)

expenditures under Federal health programs; and

(C)

the cost and quality of care furnished by hospitals.

(2)

Report

Not later than January 1, 2013, the Comptroller General of the United States shall submit to Congress a report on the study conducted under paragraph (1), together with recommendations for such legislation and administrative action as the Comptroller General determines appropriate.

(c)

Study by IOM

(1)

In general

The Secretary of Health and Human Services shall seek to enter into an agreement with the Institute of Medicine to submit to Congress, not later than 1 year after the date of enactment of this Act, a report on recommendations on how to reduce unnecessary hospital readmissions. Such report shall also include recommendations on how to develop a coordinated care plan for patients being discharged from the hospital.

(2)

Authorization

For the purpose of carrying out this subsection, there is authorized to be appropriated such sums as may be necessary for fiscal year 2010.

217.

Program to facilitate shared decisionmaking

Part D of title IX of the Public Health Service Act, as amended by section 213, is further amended by adding at the end the following:

936.

Program to facilitate shared decisionmaking

(a)

Purpose

The purpose of this section is to facilitate collaborative processes between patients, caregivers or authorized representatives, and clinicians that engages the patient, caregiver or authorized representative in decisionmaking, provides patients, caregivers or authorized representatives with information about trade-offs among treatment options, and facilitates the incorporation of patient preferences and values into the medical plan.

(b)

Definitions

In this section:

(1)

Patient decision aid

The term patient decision aid means an educational tool that helps patients, caregivers or authorized representatives understand and communicate their beliefs and preferences related to their treatment options, and to decide with their health care provider what treatments are best for them based on their treatment options, scientific evidence, circumstances, beliefs, and preferences.

(2)

Preference sensitive care

The term preference sensitive care means medical care for which the clinical evidence does not clearly support one treatment option such that the appropriate course of treatment depends on the values of the patient or the preferences of the patient, caregivers or authorized representatives regarding the benefits, harms and scientific evidence for each treatment option, the use of such care should depend on the informed patient choice among clinically appropriate treatment options.

(c)

Establishment of independent standards for patient decision aids for preference sensitive care

(1)

Contract with entity to establish standards and certify patient decision aids

(A)

In general

For purposes of supporting consensus-based standards for patient decision aids for preference sensitive care and a certification process for patient decision aids for use in the Federal health programs and by other interested parties, the Secretary shall have in effect a contract with the qualified consensus-based entity identified in section 399JJ. Such contract shall provide that the entity perform the duties described in paragraph (2).

(B)

Timing for first contract

As soon as practicable after the date of the enactment of this section, the Secretary shall enter into the first contract under subparagraph (A).

(C)

Period of contract

A contract under subparagraph (A) shall be for a period of 18 months (except such contract may be renewed after a subsequent bidding process).

(2)

Duties

The following duties are described in this paragraph:

(A)

Develop and identify standards for patient decision aids

The entity shall synthesize evidence and convene a broad range of experts and key stakeholders to develop and identify consensus-based standards to evaluate patient decision aids for preference sensitive care.

(B)

Endorse patient decision aids

The entity shall review patient decision aids and develop a certification process whether patient decision aids meet the standards developed and identified under subparagraph (A). The entity shall give priority to the review and certification of patient decision aids for preference sensitive care.

(d)

Program to Develop, Update and Patient Decision Aids to Assist Health Care Providers and Patients

(1)

In general

The Secretary, acting through the Director, and in coordination with heads of other relevant agencies, such as the Director of the Centers for Disease Control and Prevention and the Director of the National Institutes of Health, shall establish a program to award grants or contracts—

(A)

to develop, update, and produce patient decision aids for preference sensitive care to assist health care providers in educating patients, caregivers, and authorized representatives concerning the relative safety, relative effectiveness (including possible health outcomes and impact on functional status), and relative cost of treatment or, where appropriate, palliative care options;

(B)

to test such materials to ensure such materials are balanced and evidence based in aiding health care providers and patients, caregivers, and authorized representatives to make informed decisions about patient care and can be easily incorporated into a broad array of practice settings; and

(C)

to educate providers on the use of such materials, including through academic curricula.

(2)

Requirements for patient decision aids

Patient decision aids developed and produced pursuant to a grant or contract under paragraph (1)—

(A)

shall be designed to engage patients, caregivers, and authorized representatives in informed decisionmaking with health care providers;

(B)

shall present up-to-date clinical evidence about the risks and benefits of treatment options in a form and manner that is age-appropriate and can be adapted for patients, caregivers, and authorized representatives from a variety of cultural and educational backgrounds to reflect the varying needs of consumers and diverse levels of health literacy;

(C)

shall, where appropriate, explain why there is a lack of evidence to support one treatment option over another; and

(D)

shall address health care decisions across the age span, including those affecting vulnerable populations including children.

(3)

Distribution

The Director shall ensure that patient decision aids produced with grants or contracts under this section are available to the public.

(4)

Nonduplication of efforts

The Director shall ensure that the activities under this section of the Agency and other agencies, including the Centers for Disease Control and Prevention and the National Institutes of Health, are free of unnecessary duplication of effort.

(e)

Grants to support shared decision making implementation

(1)

In general

The Secretary shall establish a program to provide for the phased-in development, implementation, and evaluation of shared decisionmaking using patient decision aids to meet the objective of improving the understanding of patients of their medical treatment options.

(2)

Shared decisionmaking resource centers

(A)

In general

The Secretary shall provide grants for the establishment and support of Shared Decision Making Resource Centers (referred to in this subsection as Centers) to provide technical assistance to providers and to develop and disseminate best practices and other information to support and accelerate adoption, implementation, and effective use of patient decision aids and shared decision making by providers.

(B)

Objectives

The objective of a Center is to enhance and promote the adoption of patient decision aids and shared decisionmaking through—

(i)

providing assistance to eligible providers with the implementation and effective use of, and training on, patient decision aids; and

(ii)

the dissemination of best practices and research on the implementation and effective use of patient decision aids.

(3)

Shared decisionmaking participation grants

(A)

In general

The Secretary shall provide grants to health care providers for the development and implementation of shared decisionmaking techniques.

(B)

Preference

In order to facilitate the use of best practices, the Secretary shall provide a preference in making grants under this subsection to health care providers who participate in training by Shared Decision Making Resource Centers or comparable training.

(C)

Limitation

Funds under this paragraph shall not be used to purchase or implement use of patient decision aids other than those certified under the process identified in subsection (c).

(4)

Guidance

The Secretary may issue guidance to eligible grantees under this subsection on the use of patient decision aids.

(5)

Quality Measures

(A)

In general

The Secretary shall measure the quality of shared decisionmaking. For purposes of making such measurements, the Secretary shall select quality measures as described in section 399JJ.

(B)

Reporting data on measures

A provider receiving a grant under this subsection shall report to the Secretary data on quality measures selected under subparagraph (A) in accordance with procedures established by the Secretary.

(C)

Feedback on measures

The Secretary shall provide confidential reports to eligible providers receiving a grant under this section on the performance of the eligible provider on quality measures selected by the Secretary under subparagraph (A), the aggregate performance of all eligible providers participating in the program, and any improvements in such performance. Such reports shall be made publicly available not less than 3 years after the date of enactment of this section.

(D)

Grant to fund development of performance measures

The Director may, through the quality measure development program under section 931, award grants or contracts to eligible entities to fund development of performance measures which assess the use by health care providers of shared decisionmaking processes or patient decision aids.

(E)

Contents of report

Each report submitted under this paragraph shall—

(i)

include an assessment of—

(I)

quality measures selected under subparagraph (A);

(II)

patient and health care provider satisfaction with regard to activities carried out under this paragraph;

(III)

utilization of medical services for patients of providers receiving a grant under this paragraph and other patients as determined appropriate by the Secretary;

(IV)

appropriate utilization of shared decisionmaking by providers receiving a grant under this paragraph; and

(V)

the costs to providers participating of selecting, purchasing, and incorporating approved patient decision aids and meeting reporting requirements under this paragraph; and

(ii)

identify the characteristics of individual eligible providers that are most effective in implementing shared decisionmaking under the applicable phase of the program.

(f)

Funding

For purposes of carrying out this section there are authorized to be appropriated such sums as may be necessary for fiscal year 2010 and each subsequent fiscal year.

.

218.

Presentation of prescription drug benefit and risk information

(a)

In general

The Secretary of Health and Human Services (referred to in this section as the Secretary), acting through the Commissioner of Food and Drugs, shall determine whether the addition of quantitative summaries of the benefits and risks of prescription drugs in a standardized format (such as a table or drug facts box) to the promotional labeling or print advertising of such drugs would improve health care decisionmaking by clinicians and patients and consumers.

(b)

Review and consultation

In making the determination under subsection (a), the Secretary shall review all available scientific evidence and research on decisionmaking and social and cognitive psychology and consult with drug manufacturers, clinicians, patients and consumers, experts in health literacy, representatives of racial and ethnic minorities, and experts in women’s and pediatric health.

(c)

Report

Not later than 1 year after the date of enactment of this Act, the Secretary shall submit to Congress a report that provides—

(1)

the determination by the Secretary under subsection (a); and

(2)

the reasoning and analysis underlying that determination.

(d)

Authority

If the Secretary determines under subsection (a) that the addition of quantitative summaries of the benefits and risks of prescription drugs in a standardized format (such as a table or drug facts box) to the promotional labeling or print advertising of such drugs would improve health care decision-making by clinicians and patients and consumers, then the Secretary, not later than 3 years after the date of submission of the report under subsection (c), shall promulgate proposed regulations as necessary to implement such format.

(e)

Clarification

Nothing in this section shall be construed to restrict the existing authorities of the Secretary with respect to benefit and risk information.

219.

Center for health outcomes research and evaluation

Part D of title IX of the Public Health Service Act, as amended by section 217, is further amended by adding at the end the following:

937.

Center for health outcomes research and evaluation

(a)

Establishment

The Secretary shall establish within the Agency the Center for Health Outcomes Research and Evaluation (referred to in this section as the Center) to collect, conduct, support, and synthesize research with respect to comparing health outcomes, effectiveness, and appropriateness of health care services and procedures in order to identify the manner in which diseases, disorders, and other health conditions can most effectively and appropriately be prevented, diagnosed, treated, and managed clinically.

(b)

Duties

The Center shall—

(1)

coordinate, conduct, support, and synthesize research relevant to the comparative health outcomes and effectiveness of the full spectrum of health care treatments, including pharmaceuticals, medical devices, medical and surgical procedures, screening and diagnostics, behavioral health care, oral health, and other health interventions;

(2)

coordinate, conduct, and support systematic reviews of clinical research, including original research conducted subsequent to the date of the enactment of this section;

(3)

coordinate, conduct, support, and synthesize research that—

(A)

identifies which treatment is most effective and least toxic for each individual given each individual's genetic makeup and coexisting conditions; and

(B)

reduces treatment disparities, among ethnic and racial minorities, children, and vulnerable populations;

(4)

use a broad range of methodologies, including randomized controlled clinical trials, observational studies and other approaches;

(5)

create informational tools that organize, synthesize, and disseminate research findings to providers, patients, and public and private payers;

(6)

develop a publicly available resource database that collects and contains high-quality, independent evidence to inform healthcare decisionmaking, which shall include reliable evidence from government and non-government sources;

(7)

submit to the Secretary, and Congress appropriate relevant reports described in subsection (h);

(8)

encourage, as appropriate, the development and use of clinical registries and the development of health outcomes research data networks from electronic health records, post marketing drug and medical device surveillance efforts, and other forms of electronic health data; and

(9)

not later than one year after the date of the enactment of this section, develop minimum methodological standards to be used when conducting studies of comparative health outcomes and value (and procedures for use of such standards) in order to help ensure accurate and effective comparisons and assessments of treatment options, and update such standards at least biennially.

(c)

Powers

(1)

Obtaining official data

The Center may secure directly from any department or agency of the United States information necessary to enable the Center to carry out this section. Upon request of the Center, the head of that department or agency shall furnish that information to the Center on an agreed upon schedule.

(2)

Data collection

In order to carry out its functions, the Center shall—

(A)

utilize existing information, both published and unpublished, where possible, collected and assessed either by the staff of the Center or under other arrangements made in accordance with this section;

(B)

carry out, or award grants or contracts for, original research and experimentation, where existing information is inadequate;

(C)

adopt procedures allowing any interested party to submit information for use by the Center or the Advisory Counsel under subsection (d) in making reports and recommendations; and

(D)

comply with any existing data privacy standards applicable to the Center.

(3)

Periodic audit

–The Center shall be subject to periodic audit by the Comptroller General.

(d)

Advisory Council

(1)

In general

To ensure transparency, the Secretary shall establish through the Agency’s National Advisory Council, an advisory council (referred to in this section as the Council) that includes representatives from the scientific research, patient, provider, and health industry communities.

(2)

Composition of council

(A)

In general

The members of the Council shall consist of—

(i)

2 ex officio members who shall be—

(I)

the Director; and

(II)

the Chief Medical Officer of the Centers for Medicare & Medicaid Services; and

(ii)

19 additional members who shall represent broad constituencies of stakeholders.

(B)

Qualifications

(i)

Diverse representation of perspectives

The members of the Council shall represent a broad range of perspectives and shall collectively have experience in the following areas:

(I)

Epidemiology.

(II)

Health services research.

(III)

Bioethics.

(IV)

Communication and decision sciences.

(V)

Health economics.

(VI)

Safe use of medical products.

(VII)

The practice of medicine.

(ii)

Diverse representation of health care community

At least one member shall represent each of the following health care communities:

(I)

Consumers.

(II)

Practicing physicians, including surgeons.

(III)

Nurses.

(IV)

State licensed practitioners and other health care professionals.

(V)

Employers.

(VI)

Public payers.

(VII)

Insurance plans.

(VIII)

Clinical researchers who conduct research on behalf of pharmaceutical or device manufacturers.

(IX)

Clinical researchers who conduct research related to personalized medicine.

(X)

Clinical researchers who conduct research related to reducing health disparities.

(3)

Appointment

The Secretary or the Secretary’s designee shall appoint the members of the Council.

(4)

Terms

(A)

In general

–Except as provided in subparagraph (B), each member of the Council shall be appointed for a term of 4 years.

(B)

Terms of initial appointees

–Of the members first appointed—

(i)

10 shall be appointed for a term of 4 years; and

(ii)

9 shall be appointed for a term of 2 years.

(5)

Conflicts of interest

–In appointing the members of the Council, the Secretary shall take into consideration any financial conflicts of interest.

(e)

Rare disease research

In the case of a research study of a rare disease, the Secretary shall appoint a clinical expert advisory panel for purposes of assisting in the design of such research study and determining the feasibility of recruiting for and conducting such research study.

(f)

Expert advisory panels

The Center may appoint expert advisory panels to advise the Center and the agency, instrumentality, or entity conducting the research regarding the research question involved and the research design or protocol, including important patient subgroups and other parameters of the research. Such expert advisory panels may include individuals with experience in the relevant topic, project, or category for which the panel is established, including practicing and research clinicians and relevant specialists and subspecialists.

(g)

Research requirements

Any research conducted, supported, or synthesized under this section shall meet the following requirements:

(1)

Ensuring transparency, credibility, and access

The establishment of the agenda and conduct of the research shall be insulated from undue political or stakeholder influence, in accordance with the following:

(A)

Methods of conducting such research shall be scientifically based and take into account scientific advances in personalized medicine and reduces treatment disparities that include ethnic and racial minorities and children.

(B)

All aspects of the prioritization of research, conduct of the research, and development of conclusions based on the research shall be transparent to all stakeholders.

(C)

The process and methods for conducting such research shall be publicly documented and available to all stakeholders.

(D)

The Center shall establish a process for stakeholders involved to review and provide comment on the methods and findings of such research.

(2)

Stakeholder input

The priorities of the research, the research, and the dissemination of the research shall involve the consultation of patients, health care providers, experts in wellness and health promotion, and health care consumer representatives through transparent mechanisms recommended by the Council.

(h)

Public access to health outcomes information

(1)

In general

To the extent practicable, not later than 180 days after receipt by the Center of a relevant report described in paragraph (2), appropriate information contained in such report shall be posted on the official public Internet site of the Center, as applicable.

(2)

Relevant reports described

For purposes of this section, a relevant report is each of the following submitted by a grantee or contractor of the Center:

(A)

An interim progress report.

(B)

A draft final report that is available to stakeholders for review.

(C)

Stakeholder comments and response to same.

(D)

A final progress report on new research submitted for publication by a peer review journal.

(E)

A final report.

(3)

Benefit to subpopulations

All reports described in paragraph (2) shall assess whether the research demonstrates a benefit of the therapy with respect to a specific subpopulation of individuals, even if the outcome of the research demonstrates that, on average, with respect to the general population, the clinical benefits of the treatment do not exceed the harm.

(i)

Access by congress and the counsel to Center information

The Secretary shall establish a process for the Center to share with Congress reports and non-proprietary data of the Center.

(j)

Dissemination, incorporation, and feedback of information

(1)

Dissemination

The Center shall provide for the dissemination of findings produced by research supported, conducted, or synthesized under this section to health care providers, patients, vendors of health information technology focused on clinical decision support, appropriate professional associations, and Federal and private health plans. Center reports and recommendations shall not be construed as mandates for payment, coverage, or treatment.

(2)

Incorporation

The Center shall assist users of health information technology focused on clinical decision support to promote the timely incorporation of the findings described in paragraph (1) into clinical practices and to promote the ease of use of such incorporation.

(3)

Feedback

The Center shall establish a process to receive feedback from providers, patients, vendors of health information technology focused on clinical decision support, appropriate professional associations, and Federal and private health plans about the value of the information disseminated under this section.

(k)

Reports to congress

(1)

Annual reports

Beginning not later than one year after the date of enactment of this section, the Director shall submit to Congress an annual report on the activities of the Center and the Council, and the research conducted, under this section.

(2)

Analysis and review

Not later than December 31, 2011, the Secretary, shall submit to Congress a report on all activities conducted or supported under this section as of such date. Such report shall—

(A)

include an evaluation of the impact from such activities, the overall costs of such activities, and an analysis of the backlog of any research proposals approved but not funded; and

(B)

address whether Congress should expand the responsibilities of the Center to include studies of the effectiveness of various aspects of the health care delivery system, including health plans and delivery models, such as health plan features, benefit designs and performance, and the ways in which health services are organized, managed, and delivered.

.

220.

Demonstration program to integrate quality improvement and patient safety training into clinical education of health professionals

(a)

In general

The Secretary may award grants to eligible entities or consortia under this section to carry out demonstration projects to develop and implement academic curricula that integrates quality improvement and patient safety in the clinical education of health professionals. Such awards shall be made on a competitive basis and pursuant to peer review.

(b)

Eligibility

To be eligible to receive a grant under subsection (a), an entity or consortium shall—

(1)

submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require;

(2)

be or include—

(A)

a health professions school;

(B)

a school of public health;

(C)

a school of social work;

(D)

a school of nursing;

(E)

a school of pharmacy;

(F)

an institution with a graduate medical education program; or

(G)

a school of health care administration;

(3)

collaborate in the development of curricula described in subsection (a) with an organization that accredits such school or institution;

(4)

provide for the collection of data regarding the effectiveness of the demonstration project; and

(5)

provide matching funds in accordance with subsection (c).

(c)

Matching funds

(1)

In general

The Secretary may award a grant to an entity or consortium under this section only if the entity or consortium agrees to make available non-Federal contributions toward the costs of the program to be funded under the grant in an amount that is not less than $1 for each $5 of Federal funds provided under the grant.

(2)

Determination of amount contributed

Non-Federal contributions under paragraph (1) may be in cash or in kind, fairly evaluated, including equipment or services. Amounts provided by the Federal Government, or services assisted or subsidized to any significant extent by the Federal Government, may not be included in determining the amount of such contributions.

(d)

Evaluation

The Secretary shall take such action as may be necessary to evaluate the projects funded under this section and publish, make publicly available, and disseminate the results of such evaluations on as wide a basis as is practicable.

(e)

Reports

Not later than 2 years after the date of enactment of this section, and annually thereafter, the Secretary shall submit to the Committee on Health, Education, Labor, and Pensions and the Committee on Finance of the Senate and the Committee on Energy and Commerce and the Committee on Ways and Means of the House of Representatives a report that—

(1)

describes the specific projects supported under this section; and

(2)

contains recommendations for Congress based on the evaluation conducted under subsection (d).

221.

Office of women's health

(a)

Health and Human Services office on women's health

(1)

Establishment

Part A of title II of the Public Health Service Act (42 U.S.C. 202 et seq.) is amended by adding at the end the following:

229.

Health and Human Services Office on Women’s Health

(a)

Establishment of office

There is established within the Office of the Secretary, an Office on Women’s Health (referred to in this section as the Office). The Office shall be headed by a Deputy Assistant Secretary for Women’s Health who may report to the Secretary.

(b)

Duties

The Secretary, acting through the Office, with respect to the health concerns of women, shall—

(1)

establish short-range and long-range goals and objectives within the Department of Health and Human Services and, as relevant and appropriate, coordinate with other appropriate offices on activities within the Department that relate to disease prevention, health promotion, service delivery, research, and public and health care professional education, for issues of particular concern to women throughout their lifespan;

(2)

provide expert advice and consultation to the Secretary concerning scientific, legal, ethical, and policy issues relating to women’s health;

(3)

monitor the Department of Health and Human Services’ offices, agencies, and regional activities regarding women’s health and identify needs regarding the coordination of activities, including intramural and extramural multidisciplinary activities;

(4)

establish a Department of Health and Human Services Coordinating Committee on Women’s Health, which shall be chaired by the Deputy Assistant Secretary for Women’s Health and composed of senior level representatives from each of the agencies and offices of the Department of Health and Human Services;

(5)

establish a National Women’s Health Information Center to—

(A)

facilitate the exchange of information regarding matters relating to health information, health promotion, preventive health services, research advances, and education in the appropriate use of health care;

(B)

facilitate access to such information;

(C)

assist in the analysis of issues and problems relating to the matters described in this paragraph; and

(D)

provide technical assistance with respect to the exchange of information (including facilitating the development of materials for such technical assistance);

(6)

coordinate efforts to promote women’s health programs and policies with the private sector; and

(7)

through publications and any other means appropriate, provide for the exchange of information between the Office and recipients of grants, contracts, and agreements under subsection (c), and between the Office and health professionals and the general public.

(c)

Grants and contracts regarding duties

(1)

Authority

In carrying out subsection (b), the Secretary may make grants to, and enter into cooperative agreements, contracts, and interagency agreements with, public and private entities, agencies, and organizations.

(2)

Evaluation and dissemination

The Secretary shall directly or through contracts with public and private entities, agencies, and organizations, provide for evaluations of projects carried out with financial assistance provided under paragraph (1) and for the dissemination of information developed as a result of such projects.

(d)

Reports

Not later than 1 year after the date of enactment of this section, and every second year thereafter, the Secretary shall prepare and submit to the appropriate committees of Congress a report describing the activities carried out under this section during the period for which the report is being prepared.

(e)

Authorization of appropriations

For the purpose of carrying out this section, there are authorized to be appropriated such sums as may be necessary for each of the fiscal years 2010 through 2014.

.

(2)

Transfer of functions

There are transferred to the Office on Women’s Health (established under section 229 of the Public Health Service Act, as added by this section), all functions exercised by the Office on Women’s Health of the Public Health Service prior to the date of enactment of this section, including all personnel and compensation authority, all delegation and assignment authority, and all remaining appropriations. All orders, determinations, rules, regulations, permits, agreements, grants, contracts, certificates, licenses, registrations, privileges, and other administrative actions that—

(A)

have been issued, made, granted, or allowed to become effective by the President, any Federal agency or official thereof, or by a court of competent jurisdiction, in the performance of functions transferred under this paragraph; and

(B)

are in effect at the time this section takes effect, or were final before the date of enactment of this section and are to become effective on or after such date,

shall continue in effect according to their terms until modified, terminated, superseded, set aside, or revoked in accordance with law by the President, the Secretary, or other authorized official, a court of competent jurisdiction, or by operation of law.
(b)

Centers for disease control and prevention office of women’s health

Part A of title III of the Public Health Service Act (42 U.S.C. 241 et seq.) is amended by adding at the end the following:

310A.

Centers for disease control and prevention office of women’s health

(a)

Establishment

There is established within the Office of the Director of the Centers for Disease Control and Prevention, an office to be known as the Office of Women’s Health (referred to in this section as the Office). The Office shall be headed by a director who shall be appointed by the Director of such Centers.

(b)

Purpose

The Director of the Office shall—

(1)

report to the Director of the Centers for Disease Control and Prevention on the current level of the Centers’ activity regarding women’s health conditions across, where appropriate, age, biological, and sociocultural c