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The text of the bill below is as of Mar 22, 2010 (Passed Congress).

This is the Senate's health care bill. The bill started off with text regarding an unrelated matter but the Senate is co-opted this bill as a vehicle for passage of their reform and changed the text in whole to the health care bill. They do this because the Constitution requires all revenue bills to start in the House, and their health reform plan involves revenue. So they have chosen to work off of a bill that started in the House, even if that bill is unrelated.

H.R.3590

One Hundred Eleventh Congress

of the

United States of America

AT THE SECOND SESSION

Begun and held at the City of Washington on Tuesday,

the fifth day of January, two thousand and ten

An Act

Entitled The Patient Protection and Affordable Care Act.

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) Short Title- This Act may be cited as the ‘Patient Protection and Affordable Care 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--Immediate Improvements in Health Care Coverage for All Americans

Sec. 1001. Amendments to the Public Health Service Act.

‘PART A--Individual and Group Market Reforms

‘subpart ii--improving coverage

‘Sec. 2711. No lifetime or annual limits.

‘Sec. 2712. Prohibition on rescissions.

‘Sec. 2713. Coverage of preventive health services.

‘Sec. 2714. Extension of dependent coverage.

‘Sec. 2715. Development and utilization of uniform explanation of coverage documents and standardized definitions.

‘Sec. 2716. Prohibition of discrimination based on salary.

‘Sec. 2717. Ensuring the quality of care.

‘Sec. 2718. Bringing down the cost of health care coverage.

‘Sec. 2719. Appeals process.

Sec. 1002. Health insurance consumer information. Sec. 1003. Ensuring that consumers get value for their dollars. Sec. 1004. Effective dates.

Subtitle B--Immediate Actions to Preserve and Expand Coverage

Sec. 1101. Immediate access to insurance for uninsured individuals with a preexisting condition. Sec. 1102. Reinsurance for early retirees. Sec. 1103. Immediate information that allows consumers to identify affordable coverage options. Sec. 1104. Administrative simplification. Sec. 1105. Effective date.

Subtitle C--Quality Health Insurance Coverage for All Americans

PART I--Health Insurance Market Reforms

Sec. 1201. Amendment to the Public Health Service Act.

‘subpart i--general reform

‘Sec. 2704. Prohibition of preexisting condition exclusions or other discrimination based on health status.

‘Sec. 2701. Fair health insurance premiums.

‘Sec. 2702. Guaranteed availability of coverage.

‘Sec. 2703. Guaranteed renewability of coverage.

‘Sec. 2705. Prohibiting discrimination against individual participants and beneficiaries based on health status.

‘Sec. 2706. Non-discrimination in health care.

‘Sec. 2707. Comprehensive health insurance coverage.

‘Sec. 2708. Prohibition on excessive waiting periods.

PART II--Other Provisions

Sec. 1251. Preservation of right to maintain existing coverage. Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers and group health plans. Sec. 1253. Effective dates.

Subtitle D--Available Coverage Choices for All Americans

PART I--Establishment of Qualified Health Plans

Sec. 1301. Qualified health plan defined. Sec. 1302. Essential health benefits requirements. Sec. 1303. Special rules. Sec. 1304. Related definitions.

PART II--Consumer Choices and Insurance Competition Through Health Benefit Exchanges

Sec. 1311. Affordable choices of health benefit plans. Sec. 1312. Consumer choice. Sec. 1313. Financial integrity.

PART III--State Flexibility Relating to Exchanges

Sec. 1321. State flexibility in operation and enforcement of Exchanges and related requirements. Sec. 1322. Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers. Sec. 1323. Community health insurance option. Sec. 1324. Level playing field.

PART IV--State Flexibility to Establish Alternative Programs

Sec. 1331. State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid. Sec. 1332. Waiver for State innovation. Sec. 1333. Provisions relating to offering of plans in more than one State.

PART V--Reinsurance and Risk Adjustment

Sec. 1341. Transitional reinsurance program for individual and small group markets in each State. Sec. 1342. Establishment of risk corridors for plans in individual and small group markets. Sec. 1343. Risk adjustment.

Subtitle E--Affordable Coverage Choices for All Americans

PART I--Premium Tax Credits and Cost-sharing Reductions

subpart a--premium tax credits and cost-sharing reductions

Sec. 1401. Refundable tax credit providing premium assistance for coverage under a qualified health plan. Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans.

subpart b--eligibility determinations

Sec. 1411. Procedures for determining eligibility for Exchange participation, premium tax credits and reduced cost-sharing, and individual responsibility exemptions. Sec. 1412. Advance determination and payment of premium tax credits and cost-sharing reductions. Sec. 1413. Streamlining of procedures for enrollment through an exchange and State Medicaid, CHIP, and health subsidy programs. Sec. 1414. Disclosures to carry out eligibility requirements for certain programs. Sec. 1415. Premium tax credit and cost-sharing reduction payments disregarded for Federal and Federally-assisted programs.

PART II--Small Business Tax Credit

Sec. 1421. Credit for employee health insurance expenses of small businesses.

Subtitle F--Shared Responsibility for Health Care

PART I--Individual Responsibility

Sec. 1501. Requirement to maintain minimum essential coverage. Sec. 1502. Reporting of health insurance coverage.

PART II--Employer Responsibilities

Sec. 1511. Automatic enrollment for employees of large employers. Sec. 1512. Employer requirement to inform employees of coverage options. Sec. 1513. Shared responsibility for employers. Sec. 1514. Reporting of employer health insurance coverage. Sec. 1515. Offering of Exchange-participating qualified health plans through cafeteria plans.

Subtitle G--Miscellaneous Provisions

Sec. 1551. Definitions. Sec. 1552. Transparency in government. Sec. 1553. Prohibition against discrimination on assisted suicide. Sec. 1554. Access to therapies. Sec. 1555. Freedom not to participate in Federal health insurance programs. Sec. 1556. Equity for certain eligible survivors. Sec. 1557. Nondiscrimination. Sec. 1558. Protections for employees. Sec. 1559. Oversight. Sec. 1560. Rules of construction. Sec. 1561. Health information technology enrollment standards and protocols. Sec. 1562. Conforming amendments. Sec. 1563. Sense of the Senate promoting fiscal responsibility.

TITLE II--ROLE OF PUBLIC PROGRAMS

Subtitle A--Improved Access to Medicaid

Sec. 2001. Medicaid coverage for the lowest income populations. Sec. 2002. Income eligibility for nonelderly determined using modified gross income. Sec. 2003. Requirement to offer premium assistance for employer-sponsored insurance. Sec. 2004. Medicaid coverage for former foster care children. Sec. 2005. Payments to territories. Sec. 2006. Special adjustment to FMAP determination for certain States recovering from a major disaster. Sec. 2007. Medicaid Improvement Fund rescission.

Subtitle B--Enhanced Support for the Children’s Health Insurance Program

Sec. 2101. Additional federal financial participation for CHIP. Sec. 2102. Technical corrections.

Subtitle C--Medicaid and CHIP Enrollment Simplification

Sec. 2201. Enrollment Simplification and coordination with State Health Insurance Exchanges. Sec. 2202. Permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations.

Subtitle D--Improvements to Medicaid Services

Sec. 2301. Coverage for freestanding birth center services. Sec. 2302. Concurrent care for children. Sec. 2303. State eligibility option for family planning services. Sec. 2304. Clarification of definition of medical assistance.

Subtitle E--New Options for States to Provide Long-Term Services and Supports

Sec. 2401. Community First Choice Option. Sec. 2402. Removal of barriers to providing home and community-based services. Sec. 2403. Money Follows the Person Rebalancing Demonstration. Sec. 2404. Protection for recipients of home and community-based services against spousal impoverishment. Sec. 2405. Funding to expand State Aging and Disability Resource Centers. Sec. 2406. Sense of the Senate regarding long-term care.

Subtitle F--Medicaid Prescription Drug Coverage

Sec. 2501. Prescription drug rebates. Sec. 2502. Elimination of exclusion of coverage of certain drugs. Sec. 2503. Providing adequate pharmacy reimbursement.

Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments

Sec. 2551. Disproportionate share hospital payments.

Subtitle H--Improved Coordination for Dual Eligible Beneficiaries

Sec. 2601. 5-year period for demonstration projects. Sec. 2602. Providing Federal coverage and payment coordination for dual eligible beneficiaries.

Subtitle I--Improving the Quality of Medicaid for Patients and Providers

Sec. 2701. Adult health quality measures. Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions. Sec. 2703. State option to provide health homes for enrollees with chronic conditions. Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization. Sec. 2705. Medicaid Global Payment System Demonstration Project. Sec. 2706. Pediatric Accountable Care Organization Demonstration Project. Sec. 2707. Medicaid emergency psychiatric demonstration project.

Subtitle J--Improvements to the Medicaid and CHIP Payment and Access Commission (MACPAC)

Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries.

Subtitle K--Protections for American Indians and Alaska Natives

Sec. 2901. Special rules relating to Indians. Sec. 2902. Elimination of sunset for reimbursement for all medicare part B services furnished by certain indian hospitals and clinics.

Subtitle L--Maternal and Child Health Services

Sec. 2951. Maternal, infant, and early childhood home visiting programs. Sec. 2952. Support, education, and research for postpartum depression. Sec. 2953. Personal responsibility education. Sec. 2954. Restoration of funding for abstinence education. Sec. 2955. Inclusion of information about the importance of having a health care power of attorney in transition planning for children aging out of foster care and independent living programs.

TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE

Subtitle A--Transforming the Health Care Delivery System

PART I--Linking Payment to Quality Outcomes Under the Medicare Program

Sec. 3001. Hospital Value-Based purchasing program. Sec. 3002. Improvements to the physician quality reporting system. Sec. 3003. Improvements to the physician feedback program. Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs. Sec. 3005. Quality reporting for PPS-exempt cancer hospitals. Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities and home health agencies. Sec. 3007. Value-based payment modifier under the physician fee schedule. Sec. 3008. Payment adjustment for conditions acquired in hospitals.

PART II--National Strategy to Improve Health Care Quality

Sec. 3011. National strategy. Sec. 3012. Interagency Working Group on Health Care Quality. Sec. 3013. Quality measure development. Sec. 3014. Quality measurement. Sec. 3015. Data collection; public reporting.

PART III--Encouraging Development of New Patient Care Models

Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation within CMS. Sec. 3022. Medicare shared savings program. Sec. 3023. National pilot program on payment bundling. Sec. 3024. Independence at home demonstration program. Sec. 3025. Hospital readmissions reduction program. Sec. 3026. Community-Based Care Transitions Program. Sec. 3027. Extension of gainsharing demonstration.

Subtitle B--Improving Medicare for Patients and Providers

PART I--Ensuring Beneficiary Access to Physician Care and Other Services

Sec. 3101. Increase in the physician payment update. Sec. 3102. Extension of the work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee schedule. Sec. 3103. Extension of exceptions process for Medicare therapy caps. Sec. 3104. Extension of payment for technical component of certain physician pathology services. Sec. 3105. Extension of ambulance add-ons. Sec. 3106. Extension of certain payment rules for long-term care hospital services and of moratorium on the establishment of certain hospitals and facilities. Sec. 3107. Extension of physician fee schedule mental health add-on. Sec. 3108. Permitting physician assistants to order post-Hospital extended care services. Sec. 3109. Exemption of certain pharmacies from accreditation requirements. Sec. 3110. Part B special enrollment period for disabled TRICARE beneficiaries. Sec. 3111. Payment for bone density tests. Sec. 3112. Revision to the Medicare Improvement Fund. Sec. 3113. Treatment of certain complex diagnostic laboratory tests. Sec. 3114. Improved access for certified nurse-midwife services.

PART II--Rural Protections

Sec. 3121. Extension of outpatient hold harmless provision. Sec. 3122. Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas. Sec. 3123. Extension of the Rural Community Hospital Demonstration Program. Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program. Sec. 3125. Temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals. Sec. 3126. Improvements to the demonstration project on community health integration models in certain rural counties. Sec. 3127. MedPAC study on adequacy of Medicare payments for health care providers serving in rural areas. Sec. 3128. Technical correction related to critical access hospital services. Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility program.

PART III--Improving Payment Accuracy

Sec. 3131. Payment adjustments for home health care. Sec. 3132. Hospice reform. Sec. 3133. Improvement to medicare disproportionate share hospital (DSH) payments. Sec. 3134. Misvalued codes under the physician fee schedule. Sec. 3135. Modification of equipment utilization factor for advanced imaging services. Sec. 3136. Revision of payment for power-driven wheelchairs. Sec. 3137. Hospital wage index improvement. Sec. 3138. Treatment of certain cancer hospitals. Sec. 3139. Payment for biosimilar biological products. Sec. 3140. Medicare hospice concurrent care demonstration program. Sec. 3141. Application of budget neutrality on a national basis in the calculation of the Medicare hospital wage index floor. Sec. 3142. HHS study on urban Medicare-dependent hospitals. Sec. 3143. Protecting home health benefits.

Subtitle C--Provisions Relating to Part C

Sec. 3201. Medicare Advantage payment. Sec. 3202. Benefit protection and simplification. Sec. 3203. Application of coding intensity adjustment during MA payment transition. Sec. 3204. Simplification of annual beneficiary election periods. Sec. 3205. Extension for specialized MA plans for special needs individuals. Sec. 3206. Extension of reasonable cost contracts. Sec. 3207. Technical correction to MA private fee-for-service plans. Sec. 3208. Making senior housing facility demonstration permanent. Sec. 3209. Authority to deny plan bids. Sec. 3210. Development of new standards for certain Medigap plans.

Subtitle D--Medicare Part D Improvements for Prescription Drug Plans and MA-PD Plans

Sec. 3301. Medicare coverage gap discount program. Sec. 3302. Improvement in determination of Medicare part D low-income benchmark premium. Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals under prescription drug plans and MA-PD plans. Sec. 3304. Special rule for widows and widowers regarding eligibility for low-income assistance. Sec. 3305. Improved information for subsidy eligible individuals reassigned to prescription drug plans and MA-PD plans. Sec. 3306. Funding outreach and assistance for low-income programs. Sec. 3307. Improving formulary requirements for prescription drug plans and MA-PD plans with respect to certain categories or classes of drugs. Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries. Sec. 3309. Elimination of cost sharing for certain dual eligible individuals. Sec. 3310. Reducing wasteful dispensing of outpatient prescription drugs in long-term care facilities under prescription drug plans and MA-PD plans. Sec. 3311. Improved Medicare prescription drug plan and MA-PD plan complaint system. Sec. 3312. Uniform exceptions and appeals process for prescription drug plans and MA-PD plans. Sec. 3313. Office of the Inspector General studies and reports. Sec. 3314. Including costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the annual out-of-pocket threshold under part D. Sec. 3315. Immediate reduction in coverage gap in 2010.

Subtitle E--Ensuring Medicare Sustainability

Sec. 3401. Revision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not already incorporate such improvements. Sec. 3402. Temporary adjustment to the calculation of part B premiums. Sec. 3403. Independent Medicare Advisory Board.

Subtitle F--Health Care Quality Improvements

Sec. 3501. Health care delivery system research; Quality improvement technical assistance. Sec. 3502. Establishing community health teams to support the patient-centered medical home. Sec. 3503. Medication management services in treatment of chronic disease. Sec. 3504. Design and implementation of regionalized systems for emergency care. Sec. 3505. Trauma care centers and service availability. Sec. 3506. Program to facilitate shared decisionmaking. Sec. 3507. Presentation of prescription drug benefit and risk information. Sec. 3508. Demonstration program to integrate quality improvement and patient safety training into clinical education of health professionals. Sec. 3509. Improving women’s health. Sec. 3510. Patient navigator program. Sec. 3511. Authorization of appropriations.

Subtitle G--Protecting and Improving Guaranteed Medicare Benefits

Sec. 3601. Protecting and improving guaranteed Medicare benefits. Sec. 3602. No cuts in guaranteed benefits.

TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH

Subtitle A--Modernizing Disease Prevention and Public Health Systems

Sec. 4001. National Prevention, Health Promotion and Public Health Council. Sec. 4002. Prevention and Public Health Fund. Sec. 4003. Clinical and community preventive services. Sec. 4004. Education and outreach campaign regarding preventive benefits.

Subtitle B--Increasing Access to Clinical Preventive Services

Sec. 4101. School-based health centers. Sec. 4102. Oral healthcare prevention activities. Sec. 4103. Medicare coverage of annual wellness visit providing a personalized prevention plan. Sec. 4104. Removal of barriers to preventive services in Medicare. Sec. 4105. Evidence-based coverage of preventive services in Medicare. Sec. 4106. Improving access to preventive services for eligible adults in Medicaid. Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant women in Medicaid. Sec. 4108. Incentives for prevention of chronic diseases in medicaid.

Subtitle C--Creating Healthier Communities

Sec. 4201. Community transformation grants. Sec. 4202. Healthy aging, living well; evaluation of community-based prevention and wellness programs for Medicare beneficiaries. Sec. 4203. Removing barriers and improving access to wellness for individuals with disabilities. Sec. 4204. Immunizations. Sec. 4205. Nutrition labeling of standard menu items at chain restaurants. Sec. 4206. Demonstration project concerning individualized wellness plan. Sec. 4207. Reasonable break time for nursing mothers.

Subtitle D--Support for Prevention and Public Health Innovation

Sec. 4301. Research on optimizing the delivery of public health services. Sec. 4302. Understanding health disparities: data collection and analysis. Sec. 4303. CDC and employer-based wellness programs. Sec. 4304. Epidemiology-Laboratory Capacity Grants. Sec. 4305. Advancing research and treatment for pain care management. Sec. 4306. Funding for Childhood Obesity Demonstration Project.

Subtitle E--Miscellaneous Provisions

Sec. 4401. Sense of the Senate concerning CBO scoring. Sec. 4402. Effectiveness of Federal health and wellness initiatives.

TITLE V--HEALTH CARE WORKFORCE

Subtitle A--Purpose and Definitions

Sec. 5001. Purpose. Sec. 5002. Definitions.

Subtitle B--Innovations in the Health Care Workforce

Sec. 5101. National health care workforce commission. Sec. 5102. State health care workforce development grants. Sec. 5103. Health care workforce assessment.

Subtitle C--Increasing the Supply of the Health Care Workforce

Sec. 5201. Federally supported student loan funds. Sec. 5202. Nursing student loan program. Sec. 5203. Health care workforce loan repayment programs. Sec. 5204. Public health workforce recruitment and retention programs. Sec. 5205. Allied health workforce recruitment and retention programs. Sec. 5206. Grants for State and local programs. Sec. 5207. Funding for National Health Service Corps. Sec. 5208. Nurse-managed health clinics. Sec. 5209. Elimination of cap on commissioned corps. Sec. 5210. Establishing a Ready Reserve Corps.

Subtitle D--Enhancing Health Care Workforce Education and Training

Sec. 5301. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship. Sec. 5302. Training opportunities for direct care workers. Sec. 5303. Training in general, pediatric, and public health dentistry. Sec. 5304. Alternative dental health care providers demonstration project. Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric education. Sec. 5306. Mental and behavioral health education and training grants. Sec. 5307. Cultural competency, prevention, and public health and individuals with disabilities training. Sec. 5308. Advanced nursing education grants. Sec. 5309. Nurse education, practice, and retention grants. Sec. 5310. Loan repayment and scholarship program. Sec. 5311. Nurse faculty loan program. Sec. 5312. Authorization of appropriations for parts B through D of title VIII. Sec. 5313. Grants to promote the community health workforce. Sec. 5314. Fellowship training in public health. Sec. 5315. United States Public Health Sciences Track.

Subtitle E--Supporting the Existing Health Care Workforce

Sec. 5401. Centers of excellence. Sec. 5402. Health care professionals training for diversity. Sec. 5403. Interdisciplinary, community-based linkages. Sec. 5404. Workforce diversity grants. Sec. 5405. Primary care extension program.

Subtitle F--Strengthening Primary Care and Other Workforce Improvements

Sec. 5501. Expanding access to primary care services and general surgery services. Sec. 5502. Medicare Federally qualified health center improvements. Sec. 5503. Distribution of additional residency positions. Sec. 5504. Counting resident time in nonprovider settings. Sec. 5505. Rules for counting resident time for didactic and scholarly activities and other activities. Sec. 5506. Preservation of resident cap positions from closed hospitals. Sec. 5507. Demonstration projects To address health professions workforce needs; extension of family-to-family health information centers. Sec. 5508. Increasing teaching capacity. Sec. 5509. Graduate nurse education demonstration.

Subtitle G--Improving Access to Health Care Services

Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs). Sec. 5602. Negotiated rulemaking for development of methodology and criteria for designating medically underserved populations and health professions shortage areas. Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services for Children Program. Sec. 5604. Co-locating primary and specialty care in community-based mental health settings. Sec. 5605. Key National indicators.

Subtitle H--General Provisions

Sec. 5701. Reports.

TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY

Subtitle A--Physician Ownership and Other Transparency

Sec. 6001. Limitation on Medicare exception to the prohibition on certain physician referrals for hospitals. Sec. 6002. Transparency reports and reporting of physician ownership or investment interests. Sec. 6003. Disclosure requirements for in-office ancillary services exception to the prohibition on physician self-referral for certain imaging services. Sec. 6004. Prescription drug sample transparency. Sec. 6005. Pharmacy benefit managers transparency requirements.

Subtitle B--Nursing Home Transparency and Improvement

PART I--Improving Transparency of Information

Sec. 6101. Required disclosure of ownership and additional disclosable parties information. Sec. 6102. Accountability requirements for skilled nursing facilities and nursing facilities. Sec. 6103. Nursing home compare Medicare website. Sec. 6104. Reporting of expenditures. Sec. 6105. Standardized complaint form. Sec. 6106. Ensuring staffing accountability. Sec. 6107. GAO study and report on Five-Star Quality Rating System.

PART II--Targeting Enforcement

Sec. 6111. Civil money penalties. Sec. 6112. National independent monitor demonstration project. Sec. 6113. Notification of facility closure. Sec. 6114. National demonstration projects on culture change and use of information technology in nursing homes.

PART III--Improving Staff Training

Sec. 6121. Dementia and abuse prevention training.

Subtitle C--Nationwide Program for National and State Background Checks on Direct Patient Access Employees of Long-term Care Facilities and Providers

Sec. 6201. Nationwide program for National and State background checks on direct patient access employees of long-term care facilities and providers.

Subtitle D--Patient-Centered Outcomes Research

Sec. 6301. Patient-Centered Outcomes Research. Sec. 6302. Federal coordinating council for comparative effectiveness research.

Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions

Sec. 6401. Provider screening and other enrollment requirements under Medicare, Medicaid, and CHIP. Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions. Sec. 6403. Elimination of duplication between the Healthcare Integrity and Protection Data Bank and the National Practitioner Data Bank. Sec. 6404. Maximum period for submission of Medicare claims reduced to not more than 12 months. Sec. 6405. Physicians who order items or services required to be Medicare enrolled physicians or eligible professionals. Sec. 6406. Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse. Sec. 6407. Face to face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment under Medicare. Sec. 6408. Enhanced penalties. Sec. 6409. Medicare self-referral disclosure protocol. Sec. 6410. Adjustments to the Medicare durable medical equipment, prosthetics, orthotics, and supplies competitive acquisition program. Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program.

Subtitle F--Additional Medicaid Program Integrity Provisions

Sec. 6501. Termination of provider participation under Medicaid if terminated under Medicare or other State plan. Sec. 6502. Medicaid exclusion from participation relating to certain ownership, control, and management affiliations. Sec. 6503. Billing agents, clearinghouses, or other alternate payees required to register under Medicaid. Sec. 6504. Requirement to report expanded set of data elements under MMIS to detect fraud and abuse. Sec. 6505. Prohibition on payments to institutions or entities located outside of the United States. Sec. 6506. Overpayments. Sec. 6507. Mandatory State use of national correct coding initiative. Sec. 6508. General effective date.

Subtitle G--Additional Program Integrity Provisions

Sec. 6601. Prohibition on false statements and representations. Sec. 6602. Clarifying definition. Sec. 6603. Development of model uniform report form. Sec. 6604. Applicability of State law to combat fraud and abuse. Sec. 6605. Enabling the Department of Labor to issue administrative summary cease and desist orders and summary seizures orders against plans that are in financially hazardous condition. Sec. 6606. MEWA plan registration with Department of Labor. Sec. 6607. Permitting evidentiary privilege and confidential communications.

Subtitle H--Elder Justice Act

Sec. 6701. Short title of subtitle. Sec. 6702. Definitions. Sec. 6703. Elder Justice.

Subtitle I--Sense of the Senate Regarding Medical Malpractice

Sec. 6801. Sense of the Senate regarding medical malpractice.

TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES

Subtitle A--Biologics Price Competition and Innovation

Sec. 7001. Short title. Sec. 7002. Approval pathway for biosimilar biological products. Sec. 7003. Savings.

Subtitle B--More Affordable Medicines for Children and Underserved Communities

Sec. 7101. Expanded participation in 340B program. Sec. 7102. Improvements to 340B program integrity. Sec. 7103. GAO study to make recommendations on improving the 340B program.

TITLE VIII--CLASS ACT

Sec. 8001. Short title of title. Sec. 8002. Establishment of national voluntary insurance program for purchasing community living assistance services and support.

TITLE IX--REVENUE PROVISIONS

Subtitle A--Revenue Offset Provisions

Sec. 9001. Excise tax on high cost employer-sponsored health coverage. Sec. 9002. Inclusion of cost of employer-sponsored health coverage on W-2. Sec. 9003. Distributions for medicine qualified only if for prescribed drug or insulin. Sec. 9004. Increase in additional tax on distributions from HSAs and Archer MSAs not used for qualified medical expenses. Sec. 9005. Limitation on health flexible spending arrangements under cafeteria plans. Sec. 9006. Expansion of information reporting requirements. Sec. 9007. Additional requirements for charitable hospitals. Sec. 9008. Imposition of annual fee on branded prescription pharmaceutical manufacturers and importers. Sec. 9009. Imposition of annual fee on medical device manufacturers and importers. Sec. 9010. Imposition of annual fee on health insurance providers. Sec. 9011. Study and report of effect on veterans health care. Sec. 9012. Elimination of deduction for expenses allocable to Medicare Part D subsidy. Sec. 9013. Modification of itemized deduction for medical expenses. Sec. 9014. Limitation on excessive remuneration paid by certain health insurance providers. Sec. 9015. Additional hospital insurance tax on high-income taxpayers. Sec. 9016. Modification of section 833 treatment of certain health organizations. Sec. 9017. Excise tax on elective cosmetic medical procedures.

Subtitle B--Other Provisions

Sec. 9021. Exclusion of health benefits provided by Indian tribal governments. Sec. 9022. Establishment of simple cafeteria plans for small businesses. Sec. 9023. Qualifying therapeutic discovery project credit.

TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

Subtitle A--Provisions Relating to Title I

Sec. 10101. Amendments to subtitle A. Sec. 10102. Amendments to subtitle B. Sec. 10103. Amendments to subtitle C. Sec. 10104. Amendments to subtitle D. Sec. 10105. Amendments to subtitle E. Sec. 10106. Amendments to subtitle F. Sec. 10107. Amendments to subtitle G. Sec. 10108. Free choice vouchers. Sec. 10109. Development of standards for financial and administrative transactions.

Subtitle B--Provisions Relating to Title II

PART I--Medicaid and CHIP

Sec. 10201. Amendments to the Social Security Act and title II of this Act. Sec. 10202. Incentives for States to offer home and community-based services as a long-term care alternative to nursing homes. Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and other CHIP-related provisions.

PART II--Support for Pregnant and Parenting Teens and Women

Sec. 10211. Definitions. Sec. 10212. Establishment of pregnancy assistance fund. Sec. 10213. Permissible uses of Fund. Sec. 10214. Appropriations.

PART III--Indian Health Care Improvement

Sec. 10221. Indian health care improvement.

Subtitle C--Provisions Relating to Title III

Sec. 10301. Plans for a Value-Based purchasing program for ambulatory surgical centers. Sec. 10302. Revision to national strategy for quality improvement in health care. Sec. 10303. Development of outcome measures. Sec. 10304. Selection of efficiency measures. Sec. 10305. Data collection; public reporting. Sec. 10306. Improvements under the Center for Medicare and Medicaid Innovation. Sec. 10307. Improvements to the Medicare shared savings program. Sec. 10308. Revisions to national pilot program on payment bundling. Sec. 10309. Revisions to hospital readmissions reduction program. Sec. 10310. Repeal of physician payment update. Sec. 10311. Revisions to extension of ambulance add-ons. Sec. 10312. Certain payment rules for long-term care hospital services and moratorium on the establishment of certain hospitals and facilities. Sec. 10313. Revisions to the extension for the rural community hospital demonstration program. Sec. 10314. Adjustment to low-volume hospital provision. Sec. 10315. Revisions to home health care provisions. Sec. 10316. Medicare DSH. Sec. 10317. Revisions to extension of section 508 hospital provisions. Sec. 10318. Revisions to transitional extra benefits under Medicare Advantage. Sec. 10319. Revisions to market basket adjustments. Sec. 10320. Expansion of the scope of, and additional improvements to, the Independent Medicare Advisory Board. Sec. 10321. Revision to community health teams. Sec. 10322. Quality reporting for psychiatric hospitals. Sec. 10323. Medicare coverage for individuals exposed to environmental health hazards. Sec. 10324. Protections for frontier States. Sec. 10325. Revision to skilled nursing facility prospective payment system. Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare providers. Sec. 10327. Improvements to the physician quality reporting system. Sec. 10328. Improvement in part D medication therapy management (MTM) programs. Sec. 10329. Developing methodology to assess health plan value. Sec. 10330. Modernizing computer and data systems of the Centers for Medicare & Medicaid services to support improvements in care delivery. Sec. 10331. Public reporting of performance information. Sec. 10332. Availability of medicare data for performance measurement. Sec. 10333. Community-based collaborative care networks. Sec. 10334. Minority health. Sec. 10335. Technical correction to the hospital value-based purchasing program. Sec. 10336. GAO study and report on Medicare beneficiary access to high-quality dialysis services.

Subtitle D--Provisions Relating to Title IV

Sec. 10401. Amendments to subtitle A. Sec. 10402. Amendments to subtitle B. Sec. 10403. Amendments to subtitle C. Sec. 10404. Amendments to subtitle D. Sec. 10405. Amendments to subtitle E. Sec. 10406. Amendment relating to waiving coinsurance for preventive services. Sec. 10407. Better diabetes care. Sec. 10408. Grants for small businesses to provide comprehensive workplace wellness programs. Sec. 10409. Cures Acceleration Network. Sec. 10410. Centers of Excellence for Depression. Sec. 10411. Programs relating to congenital heart disease. Sec. 10412. Automated Defibrillation in Adam’s Memory Act. Sec. 10413. Young women’s breast health awareness and support of young women diagnosed with breast cancer.

Subtitle E--Provisions Relating to Title V

Sec. 10501. Amendments to the Public Health Service Act, the Social Security Act, and title V of this Act. Sec. 10502. Infrastructure to Expand Access to Care. Sec. 10503. Community Health Centers and the National Health Service Corps Fund. Sec. 10504. Demonstration project to provide access to affordable care.

Subtitle F--Provisions Relating to Title VI

Sec. 10601. Revisions to limitation on medicare exception to the prohibition on certain physician referrals for hospitals. Sec. 10602. Clarifications to patient-centered outcomes research. Sec. 10603. Striking provisions relating to individual provider application fees. Sec. 10604. Technical correction to section 6405. Sec. 10605. Certain other providers permitted to conduct face to face encounter for home health services. Sec. 10606. Health care fraud enforcement. Sec. 10607. State demonstration programs to evaluate alternatives to current medical tort litigation. Sec. 10608. Extension of medical malpractice coverage to free clinics. Sec. 10609. Labeling changes.

Subtitle G--Provisions Relating to Title VIII

Sec. 10801. Provisions relating to title VIII.

Subtitle H--Provisions Relating to Title IX

Sec. 10901. Modifications to excise tax on high cost employer-sponsored health coverage. Sec. 10902. Inflation adjustment of limitation on health flexible spending arrangements under cafeteria plans. Sec. 10903. Modification of limitation on charges by charitable hospitals. Sec. 10904. Modification of annual fee on medical device manufacturers and importers. Sec. 10905. Modification of annual fee on health insurance providers. Sec. 10906. Modifications to additional hospital insurance tax on high-income taxpayers. Sec. 10907. Excise tax on indoor tanning services in lieu of elective cosmetic medical procedures. Sec. 10908. Exclusion for assistance provided to participants in State student loan repayment programs for certain health professionals. Sec. 10909. Expansion of adoption credit and adoption assistance programs.

TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

Subtitle A--Immediate Improvements in Health Care Coverage for All Americans

SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.

Part A 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 inserting the following:

‘PART A--INDIVIDUAL AND GROUP MARKET REFORMS’;

(2) by redesignating sections 2704 through 2707 as sections 2725 through 2728, respectively; (3) by redesignating sections 2711 through 2713 as sections 2731 through 2733, respectively; (4) by redesignating sections 2721 through 2723 as sections 2735 through 2737, respectively; and (5) by inserting after section 2702, the following:

‘Subpart II--Improving Coverage

‘SEC. 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-- ‘(1) lifetime limits on the dollar value of benefits for any participant or beneficiary; or ‘(2) unreasonable annual limits (within the meaning of section 223 of the Internal Revenue Code of 1986) on the dollar value of benefits for any participant or beneficiary. ‘(b) Per Beneficiary Limits- Subsection (a) shall not be construed to prevent a group health plan or health insurance coverage that is not required to provide essential health benefits under section 1302(b) of the Patient Protection and Affordable Care Act from placing annual or lifetime per beneficiary limits on specific covered benefits to the extent that such limits are otherwise permitted under Federal or State law.

‘SEC. 2712. PROHIBITION ON RESCISSIONS. ‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage involved, except that this section 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 plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 2702(c) or 2742(b).

‘SEC. 2713. 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, at a minimum provide coverage for and shall not impose any cost sharing requirements 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. ‘(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph. ‘(5) for the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009. Nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by such Task Force. ‘(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. ‘(c) Value-based Insurance Design- The Secretary may develop guidelines to permit a group health plan and a health insurance issuer offering group or individual health insurance coverage to utilize value-based insurance designs.

‘SEC. 2714. 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 (who is not married) 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). ‘(c) Rule of Construction- Nothing in this section shall be construed to modify the definition of ‘dependent’ as used in the Internal Revenue Code of 1986 with respect to the tax treatment of the cost of coverage.

‘SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM EXPLANATION OF COVERAGE DOCUMENTS AND STANDARDIZED DEFINITIONS. ‘(a) In General- Not later than 12 months after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary shall develop standards for use by a group health plan and a health insurance issuer offering group or individual health insurance coverage, in compiling and providing to enrollees a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the applicable plan or coverage. In developing such standards, the Secretary shall consult with the National Association of Insurance Commissioners (referred to in this section as the ‘NAIC’), 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. ‘(b) Requirements- The standards for the summary of benefits and coverage developed under subsection (a) shall provide for the following: ‘(1) APPEARANCE- The standards shall ensure that the summary of benefits and coverage is presented in a uniform format that does not exceed 4 pages in length and does not include print smaller than 12-point font. ‘(2) LANGUAGE- The standards shall ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee. ‘(3) CONTENTS- The standards shall ensure that the summary of benefits and coverage includes-- ‘(A) uniform definitions of standard insurance terms and medical terms (consistent with subsection (g)) so that consumers may compare health insurance coverage and understand the terms of coverage (or exception to such coverage); ‘(B) a description of the coverage, including cost sharing for-- ‘(i) each of the categories of the essential health benefits described in subparagraphs (A) through (J) of section 1302(b)(1) of the Patient Protection and Affordable Care Act; and ‘(ii) other benefits, as identified by the Secretary; ‘(C) the exceptions, reductions, and limitations on coverage; ‘(D) the cost-sharing provisions, including deductible, coinsurance, and co-payment obligations; ‘(E) the renewability and continuation of coverage provisions; ‘(F) a coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing, such scenarios to be based on recognized clinical practice guidelines; ‘(G) a statement of whether the plan or coverage-- ‘(i) provides minimum essential coverage (as defined under section 5000A(f) of the Internal Revenue Code 1986); and ‘(ii) ensures that the plan or coverage share of the total allowed costs of benefits provided under the plan or coverage is not less than 60 percent of such costs; ‘(H) a statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and ‘(I) a contact number for the consumer to call with additional questions and an Internet web address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained. ‘(c) Periodic Review and Updating- The Secretary shall periodically review and update, as appropriate, the standards developed under this section. ‘(d) Requirement To Provide- ‘(1) IN GENERAL- Not later than 24 months after the date of enactment of the Patient Protection and Affordable Care Act, each entity described in paragraph (3) shall provide, prior to any enrollment restriction, a summary of benefits and coverage explanation pursuant to the standards developed by the Secretary under subsection (a) to-- ‘(A) an applicant at the time of application; ‘(B) an enrollee prior to the time of enrollment or reenrollment, as applicable; and ‘(C) a policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate. ‘(2) COMPLIANCE- An entity described in paragraph (3) is deemed to be in compliance with this section if the summary of benefits and coverage described in subsection (a) is provided in paper or electronic form. ‘(3) ENTITIES IN GENERAL- An entity described in this paragraph is-- ‘(A) a health insurance issuer (including a group health plan that is not a self-insured plan) offering health insurance coverage within the United States; or ‘(B) in the case of a self-insured group health plan, the plan sponsor or designated administrator of the plan (as such terms are defined in section 3(16) of the Employee Retirement Income Security Act of 1974). ‘(4) NOTICE OF MODIFICATIONS- If a group health plan or health insurance issuer makes any material modification in any of the terms of the plan or coverage involved (as defined for purposes of section 102 of the Employee Retirement Income Security Act of 1974) that is not reflected in the most recently provided summary of benefits and coverage, the plan or issuer shall provide notice of such modification to enrollees not later than 60 days prior to the date on which such modification will become effective. ‘(e) Preemption- The standards developed under subsection (a) shall preempt any related State standards that require a summary of benefits and coverage that provides less information to consumers than that required to be provided under this section, as determined by the Secretary. ‘(f) Failure To Provide- An entity described in subsection (d)(3) that willfully fails to provide the information required under this section shall be subject to a fine of not more than $1,000 for each such failure. Such failure with respect to each enrollee shall constitute a separate offense for purposes of this subsection. ‘(g) Development of Standard Definitions- ‘(1) IN GENERAL- The Secretary shall, by regulation, provide for the development of standards for the definitions of terms used in health insurance coverage, including the insurance-related terms described in paragraph (2) and the medical terms described in paragraph (3). ‘(2) INSURANCE-RELATED TERMS- The insurance-related terms described in this paragraph are premium, deductible, co-insurance, co-payment, out-of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, UCR (usual, customary and reasonable) fees, excluded services, grievance and appeals, and such other terms as the Secretary determines are important to define so that consumers may compare health insurance coverage and understand the terms of their coverage. ‘(3) MEDICAL TERMS- The medical terms described in this paragraph are hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as the Secretary determines are important to define so that consumers may compare the medical benefits offered by health insurance and understand the extent of those medical benefits (or exceptions to those benefits).

‘SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON SALARY. ‘(a) In General- The plan sponsor of a group health plan (other than a self-insured plan) 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 or otherwise establish eligibility rules that have the effect of discriminating in favor of higher wage employees. ‘(b) Limitation- Subsection (a) shall not be construed to prohibit a plan sponsor 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 similarly situated employees with a higher hourly or annual compensation.

‘SEC. 2717. ENSURING THE QUALITY OF CARE. ‘(a) Quality Reporting- ‘(1) IN GENERAL- Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary, in consultation with experts in health care quality and stakeholders, shall develop reporting requirements for use by a group health plan, and a health insurance issuer offering group or individual health insurance coverage, with respect to plan or coverage benefits and health care provider reimbursement structures that-- ‘(A) improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model as defined for purposes of section 3602 of the Patient Protection and Affordable Care Act, for treatment or services under the plan or coverage; ‘(B) implement 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) implement 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) implement wellness and health promotion activities. ‘(2) REPORTING REQUIREMENTS- ‘(A) IN GENERAL- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall annually submit to the Secretary, and to enrollees under the plan or coverage, a report on whether the benefits under the plan or coverage satisfy the elements described in subparagraphs (A) through (D) of paragraph (1). ‘(B) TIMING OF REPORTS- A report under subparagraph (A) shall be made available to an enrollee under the plan or coverage during each open enrollment period. ‘(C) AVAILABILITY OF REPORTS- The Secretary shall make reports submitted under subparagraph (A) available to the public through an Internet website. ‘(D) PENALTIES- In developing the reporting requirements under paragraph (1), the Secretary may develop and impose appropriate penalties for non-compliance with such requirements. ‘(E) EXCEPTIONS- In developing the reporting requirements under paragraph (1), the Secretary may provide for exceptions to such requirements for group health plans and health insurance issuers that substantially meet the goals of this section. ‘(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 offers 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) Regulations- Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary shall promulgate regulations that provide criteria for determining whether a reimbursement structure is described in subsection (a). ‘(d) Study and Report- Not later than 180 days after the date on which regulations are promulgated under subsection (c), the Government Accountability Office shall review such regulations and 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.

‘SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE. ‘(a) Clear Accounting for Costs- A health insurance issuer offering group or individual health insurance coverage shall, with respect to each plan year, submit to the Secretary a report concerning the percentage of total premium revenue that such coverage expends-- ‘(1) on reimbursement for clinical services provided to enrollees under such coverage; ‘(2) for activities that improve health care quality; and ‘(3) on all other non-claims costs, including an explanation of the nature of such costs, and excluding State taxes and licensing or regulatory fees. The Secretary shall make reports received under this section available to the public on the Internet website of the Department of Health and Human Services. ‘(b) Ensuring That Consumers Receive Value for Their Premium Payments- ‘(1) REQUIREMENT TO PROVIDE VALUE FOR PREMIUM PAYMENTS- A health insurance issuer offering group or individual health insurance coverage shall, with respect to each plan year, provide an annual rebate to each enrollee under such coverage, on a pro rata basis, in an amount that is equal to the amount by which premium revenue expended by the issuer on activities described in subsection (a)(3) exceeds-- ‘(A) with respect to a health insurance issuer offering coverage in the group market, 20 percent, or such lower percentage as a State may by regulation determine; or ‘(B) with respect to a health insurance issuer offering coverage in the individual market, 25 percent, or such lower percentage as a State may by regulation determine, except that such percentage shall be adjusted to the extent the Secretary determines that the application of such percentage with a State may destabilize the existing individual market in such State. ‘(2) CONSIDERATION IN SETTING PERCENTAGES- In determining the percentages under paragraph (1), a State shall seek to ensure adequate participation by health insurance issuers, competition in the health insurance market in the State, and value for consumers so that premiums are used for clinical services and quality improvements. ‘(3) TERMINATION- The provisions of this subsection shall have no force or effect after December 31, 2013. ‘(c) Standard Hospital Charges- Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospital’s standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886(d)(4) of the Social Security Act. ‘(d) Definitions- The Secretary, in consultation with the National Association of Insurance Commissions, shall establish uniform definitions for the activities reported under subsection (a).

‘SEC. 2719. APPEALS PROCESS. ‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimum-- ‘(1) have in effect an internal claims appeal process; ‘(2) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes; ‘(3) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process; and ‘(4) provide an external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans.’.

SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION.

Part C of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-91 et seq.) is amended by adding at the end the following:

‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION. ‘(a) In General- The Secretary shall award grants to States to enable such States (or the Exchanges operating in such States) to establish, expand, or provide support for-- ‘(1) offices of health insurance consumer assistance; or ‘(2) health insurance ombudsman programs. ‘(b) Eligibility- ‘(1) IN GENERAL- To be eligible to receive a grant, a State shall designate an independent office of health insurance consumer assistance, or an ombudsman, 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 office of health insurance consumer assistance or health insurance ombudsman shall-- ‘(1) assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the group health plan or health insurance issuer involved and providing information about the external appeal process; ‘(2) collect, track, and quantify problems and inquiries encountered by consumers; ‘(3) educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage; ‘(4) assist consumers with enrollment in a group health plan or health insurance coverage by providing information, referral, and assistance; and ‘(5) resolve problems with obtaining premium tax credits under section 36B of the Internal Revenue Code of 1986. ‘(d) Data Collection- As a condition of receiving a grant under subsection (a), an office of health insurance consumer assistance or ombudsman program shall be required to collect and report data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to identify areas where more enforcement action is necessary and shall share such information with State insurance regulators, the Secretary of Labor, and the Secretary of the Treasury for use in the enforcement activities of such agencies. ‘(e) Funding- ‘(1) INITIAL FUNDING- There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $30,000,000 for the first fiscal year for which this section applies to carry out this section. Such amount shall remain available without fiscal year limitation. ‘(2) AUTHORIZATION FOR SUBSEQUENT YEARS- There is authorized to be appropriated to the Secretary for each fiscal year following the fiscal year described in paragraph (1), such sums as may be necessary to carry out this section.’.

SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS.

Part C of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-91 et seq.), as amended by section 1002, is further amended by adding at the end the following:

‘SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS. ‘(a) Initial Premium Review Process- ‘(1) IN GENERAL- The Secretary, in conjunction with States, shall establish a process for the annual review, beginning with the 2010 plan year and subject to subsection (b)(2)(A), of unreasonable increases in premiums for health insurance coverage. ‘(2) JUSTIFICATION AND DISCLOSURE- The process established under paragraph (1) shall require health insurance issuers to submit to the Secretary and the relevant State a justification for an unreasonable premium increase prior to the implementation of the increase. Such issuers shall prominently post such information on their Internet websites. The Secretary shall ensure the public disclosure of information on such increases and justifications for all health insurance issuers. ‘(b) Continuing Premium Review Process- ‘(1) INFORMING SECRETARY OF PREMIUM INCREASE PATTERNS- As a condition of receiving a grant under subsection (c)(1), a State, through its Commissioner of Insurance, shall-- ‘(A) provide the Secretary with information about trends in premium increases in health insurance coverage in premium rating areas in the State; and ‘(B) make recommendations, as appropriate, to the State Exchange about whether particular health insurance issuers should be excluded from participation in the Exchange based on a pattern or practice of excessive or unjustified premium increases. ‘(2) MONITORING BY SECRETARY OF PREMIUM INCREASES- ‘(A) IN GENERAL- Beginning with plan years beginning in 2014, the Secretary, in conjunction with the States and consistent with the provisions of subsection (a)(2), shall monitor premium increases of health insurance coverage offered through an Exchange and outside of an Exchange. ‘(B) CONSIDERATION IN OPENING EXCHANGE- In determining under section 1312(f)(2)(B) of the Patient Protection and Affordable Care Act whether to offer qualified health plans in the large group market through an Exchange, the State shall take into account any excess of premium growth outside of the Exchange as compared to the rate of such growth inside the Exchange. ‘(c) Grants in Support of Process- ‘(1) PREMIUM REVIEW GRANTS DURING 2010 THROUGH 2014- The Secretary shall carry out a program to award grants to States during the 5-year period beginning with fiscal year 2010 to assist such States in carrying out subsection (a), including-- ‘(A) in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage; and ‘(B) in providing information and recommendations to the Secretary under subsection (b)(1). ‘(2) FUNDING- ‘(A) IN GENERAL- Out of all funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary $250,000,000, to be available for expenditure for grants under paragraph (1) and subparagraph (B). ‘(B) FURTHER AVAILABILITY FOR INSURANCE REFORM AND CONSUMER PROTECTION- If the amounts appropriated under subparagraph (A) are not fully obligated under grants under paragraph (1) by the end of fiscal year 2014, any remaining funds shall remain available to the Secretary for grants to States for planning and implementing the insurance reforms and consumer protections under part A. ‘(C) ALLOCATION- The Secretary shall establish a formula for determining the amount of any grant to a State under this subsection. Under such formula-- ‘(i) the Secretary shall consider the number of plans of health insurance coverage offered in each State and the population of the State; and ‘(ii) no State qualifying for a grant under paragraph (1) shall receive less than $1,000,000, or more than $5,000,000 for a grant year.’.

SEC. 1004. EFFECTIVE DATES.

(a) In General- Except as provided for 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 6 months after the date of enactment of this Act, except that the amendments made by sections 1002 and 1003 shall become effective for fiscal years beginning with fiscal year 2010. (b) Special Rule- The amendments made by sections 1002 and 1003 shall take effect on the date of enactment of this Act.

Subtitle B--Immediate Actions to Preserve and Expand Coverage

SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED INDIVIDUALS WITH A PREEXISTING CONDITION.

(a) In General- Not later than 90 days after the date of enactment of this Act, the Secretary shall establish a temporary high risk health insurance pool program to provide health insurance coverage for eligible individuals during the period beginning on the date on which such program is established and ending on January 1, 2014. (b) Administration- (1) IN GENERAL- The Secretary may carry out the program under this section directly or through contracts to eligible entities. (2) ELIGIBLE ENTITIES- To be eligible for a contract under paragraph (1), an entity shall-- (A) be a State or nonprofit private entity; (B) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require; and (C) agree to utilize contract funding to establish and administer a qualified high risk pool for eligible individuals. (3) MAINTENANCE OF EFFORT- To be eligible to enter into a contract with the Secretary under this subsection, a State shall agree not to reduce the annual amount the State expended for the operation of one or more State high risk pools during the year preceding the year in which such contract is entered into. (c) Qualified High Risk Pool- (1) IN GENERAL- Amounts made available under this section shall be used to establish a qualified high risk pool that meets the requirements of paragraph (2). (2) REQUIREMENTS- A qualified high risk pool meets the requirements of this paragraph if such pool-- (A) provides to all eligible individuals health insurance coverage that does not impose any preexisting condition exclusion with respect to such coverage; (B) provides health insurance coverage-- (i) in which the issuer’s share of the total allowed costs of benefits provided under such coverage is not less than 65 percent of such costs; and (ii) that has an out of pocket limit not greater than the applicable amount described in section 223(c)(2) of the Internal Revenue Code of 1986 for the year involved, except that the Secretary may modify such limit if necessary to ensure the pool meets the actuarial value limit under clause (i); (C) ensures that with respect to the premium rate charged for health insurance coverage offered to eligible individuals through the high risk pool, such rate shall-- (i) except as provided in clause (ii), vary only as provided for under section 2701 of the Public Health Service Act (as amended by this Act and notwithstanding the date on which such amendments take effect); (ii) vary on the basis of age by a factor of not greater than 4 to 1; and (iii) be established at a standard rate for a standard population; and (D) meets any other requirements determined appropriate by the Secretary. (d) Eligible Individual- An individual shall be deemed to be an eligible individual for purposes of this section if such individual-- (1) is a citizen or national of the United States or is lawfully present in the United States (as determined in accordance with section 1411); (2) has not been covered under creditable coverage (as defined in section 2701(c)(1) of the Public Health Service Act as in effect on the date of enactment of this Act) during the 6-month period prior to the date on which such individual is applying for coverage through the high risk pool; and (3) has a pre-existing condition, as determined in a manner consistent with guidance issued by the Secretary. (e) Protection Against Dumping Risk by Insurers- (1) IN GENERAL- The Secretary shall establish criteria for determining whether health insurance issuers and employment-based health plans have discouraged an individual from remaining enrolled in prior coverage based on that individual’s health status. (2) SANCTIONS- An issuer or employment-based health plan shall be responsible for reimbursing the program under this section for the medical expenses incurred by the program for an individual who, based on criteria established by the Secretary, the Secretary finds was encouraged by the issuer to disenroll from health benefits coverage prior to enrolling in coverage through the program. The criteria shall include at least the following circumstances: (A) In the case of prior coverage obtained through an employer, the provision by the employer, group health plan, or the issuer of money or other financial consideration for disenrolling from the coverage. (B) In the case of prior coverage obtained directly from an issuer or under an employment-based health plan-- (i) the provision by the issuer or plan of money or other financial consideration for disenrolling from the coverage; or (ii) in the case of an individual whose premium for the prior coverage exceeded the premium required by the program (adjusted based on the age factors applied to the prior coverage)-- (I) the prior coverage is a policy that is no longer being actively marketed (as defined by the Secretary) by the issuer; or (II) the prior coverage is a policy for which duration of coverage form issue or health status are factors that can be considered in determining premiums at renewal. (3) CONSTRUCTION- Nothing in this subsection shall be construed as constituting exclusive remedies for violations of criteria established under paragraph (1) or as preventing States from applying or enforcing such paragraph or other provisions under law with respect to health insurance issuers. (f) Oversight- The Secretary shall establish-- (1) an appeals process to enable individuals to appeal a determination under this section; and (2) procedures to protect against waste, fraud, and abuse. (g) Funding; Termination of Authority- (1) IN GENERAL- There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to pay claims against (and the administrative costs of) the high risk pool under this section that are in excess of the amount of premiums collected from eligible individuals enrolled in the high risk pool. Such funds shall be available without fiscal year limitation. (2) INSUFFICIENT FUNDS- If the Secretary estimates for any fiscal year that the aggregate amounts available for the payment of the expenses of the high risk pool will be less than the actual amount of such expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficit. (3) TERMINATION OF AUTHORITY- (A) IN GENERAL- Except as provided in subparagraph (B), coverage of eligible individuals under a high risk pool in a State shall terminate on January 1, 2014. (B) TRANSITION TO EXCHANGE- The Secretary shall develop procedures to provide for the transition of eligible individuals enrolled in health insurance coverage offered through a high risk pool established under this section into qualified health plans offered through an Exchange. Such procedures shall ensure that there is no lapse in coverage with respect to the individual and may extend coverage after the termination of the risk pool involved, if the Secretary determines necessary to avoid such a lapse. (4) LIMITATIONS- The Secretary has the authority to stop taking applications for participation in the program under this section to comply with the funding limitation provided for in paragraph (1). (5) RELATION TO STATE LAWS- The standards established under this section shall supersede any State law or regulation (other than State licensing laws or State laws relating to plan solvency) with respect to qualified high risk pools which are established in accordance with this section.

SEC. 1102. REINSURANCE FOR EARLY RETIREES.

(a) Administration- (1) IN GENERAL- Not later than 90 days after the date of enactment of this Act, 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 insurance coverage to early 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 January 1, 2014. (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 early retirees. (C) EARLY RETIREES- The term ‘early 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- A participating employment-based plan is an employment-based plan that-- (A) meets the requirements of paragraph (2) with respect to health benefits provided under the plan; and (B) submits to the Secretary an application for participation in the program, at such time, in such manner, and containing such information as the Secretary shall require. (2) EMPLOYMENT-BASED HEALTH BENEFITS- An employment-based plan meets the requirements of this paragraph if the plan-- (A) implements programs and procedures to generate cost-savings with respect to participants with chronic and high-cost conditions; (B) provides documentation of the actual cost of medical claims involved; and (C) is certified 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 subparagraph (A) shall be based on the actual amount expended by the participating employment-based plan involved within the plan year for the health benefits provided to an early 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 early 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) Funding- There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to carry out the program under this section. Such funds shall be available without fiscal year limitation. (f) Limitation- The Secretary has the authority to stop taking applications for participation in the program based on the availability of funding under subsection (e).

SEC. 1103. IMMEDIATE INFORMATION THAT ALLOWS CONSUMERS TO IDENTIFY AFFORDABLE COVERAGE OPTIONS.

(a) Internet Portal to Affordable Coverage Options- (1) IMMEDIATE ESTABLISHMENT- Not later than July 1, 2010, the Secretary, in consultation with the States, shall establish a mechanism, including an Internet website, through which a resident of any State may identify affordable health insurance coverage options in that State. (2) CONNECTING TO AFFORDABLE COVERAGE- An Internet website established under paragraph (1) shall, to the extent practicable, provide ways for residents of any State to receive information on at least the following coverage options: (A) Health insurance coverage offered by health insurance issuers, other than coverage that provides reimbursement only for the treatment or mitigation of-- (i) a single disease or condition; or (ii) an unreasonably limited set of diseases or conditions (as determined by the Secretary); (B) Medicaid coverage under title XIX of the Social Security Act. (C) Coverage under title XXI of the Social Security Act. (D) A State health benefits high risk pool, to the extent that such high risk pool is offered in such State; and (E) Coverage under a high risk pool under section 1101. (b) Enhancing Comparative Purchasing Options- (1) IN GENERAL- Not later than 60 days after the date of enactment of this Act, the Secretary shall develop a standardized format to be used for the presentation of information relating to the coverage options described in subsection (a)(2). Such format shall, at a minimum, require the inclusion of information on the percentage of total premium revenue expended on nonclinical costs (as reported under section 2718(a) of the Public Health Service Act), eligibility, availability, premium rates, and cost sharing with respect to such coverage options and be consistent with the standards adopted for the uniform explanation of coverage as provided for in section 2715 of the Public Health Service Act. (2) USE OF FORMAT- The Secretary shall utilize the format developed under paragraph (1) in compiling information concerning coverage options on the Internet website established under subsection (a). (c) Authority To Contract- The Secretary may carry out this section through contracts entered into with qualified entities.

SEC. 1104. ADMINISTRATIVE SIMPLIFICATION.

(a) Purpose of Administrative Simplification- Section 261 of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d note) is amended-- (1) by inserting ‘uniform’ before ‘standards’; and (2) by inserting ‘and to reduce the clerical burden on patients, health care providers, and health plans’ before the period at the end. (b) Operating Rules for Health Information Transactions- (1) DEFINITION OF OPERATING RULES- Section 1171 of the Social Security Act (42 U.S.C. 1320d) is amended by adding at the end the following: ‘(9) OPERATING RULES- The term ‘operating rules’ means the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications as adopted for purposes of this part.’. (2) TRANSACTION STANDARDS; OPERATING RULES AND COMPLIANCE- Section 1173 of the Social Security Act (42 U.S.C. 1320d-2) is amended-- (A) in subsection (a)(2), by adding at the end the following new subparagraph: ‘(J) Electronic funds transfers.’; (B) in subsection (a), by adding at the end the following new paragraph: ‘(4) REQUIREMENTS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS- ‘(A) IN GENERAL- The standards and associated operating rules adopted by the Secretary shall-- ‘(i) to the extent feasible and appropriate, enable determination of an individual’s eligibility and financial responsibility for specific services prior to or at the point of care; ‘(ii) be comprehensive, requiring minimal augmentation by paper or other communications; ‘(iii) provide for timely acknowledgment, response, and status reporting that supports a transparent claims and denial management process (including adjudication and appeals); and ‘(iv) describe all data elements (including reason and remark codes) in unambiguous terms, require that such data elements be required or conditioned upon set values in other fields, and prohibit additional conditions (except where necessary to implement State or Federal law, or to protect against fraud and abuse). ‘(B) REDUCTION OF CLERICAL BURDEN- In adopting standards and operating rules for the transactions referred to under paragraph (1), the Secretary shall seek to reduce the number and complexity of forms (including paper and electronic forms) and data entry required by patients and providers.’; and (C) by adding at the end the following new subsections: ‘(g) Operating Rules- ‘(1) IN GENERAL- The Secretary shall adopt a single set of operating rules for each transaction referred to under subsection (a)(1) with the goal of creating as much uniformity in the implementation of the electronic standards as possible. Such operating rules shall be consensus-based and reflect the necessary business rules affecting health plans and health care providers and the manner in which they operate pursuant to standards issued under Health Insurance Portability and Accountability Act of 1996. ‘(2) OPERATING RULES DEVELOPMENT- In adopting operating rules under this subsection, the Secretary shall consider recommendations for operating rules developed by a qualified nonprofit entity that meets the following requirements: ‘(A) The entity focuses its mission on administrative simplification. ‘(B) The entity demonstrates a multi-stakeholder and consensus-based process for development of operating rules, including representation by or participation from health plans, health care providers, vendors, relevant Federal agencies, and other standard development organizations. ‘(C) The entity has a public set of guiding principles that ensure the operating rules and process are open and transparent, and supports nondiscrimination and conflict of interest policies that demonstrate a commitment to open, fair, and nondiscriminatory practices. ‘(D) The entity builds on the transaction standards issued under Health Insurance Portability and Accountability Act of 1996. ‘(E) The entity allows for public review and updates of the operating rules. ‘(3) REVIEW AND RECOMMENDATIONS- The National Committee on Vital and Health Statistics shall-- ‘(A) advise the Secretary as to whether a nonprofit entity meets the requirements under paragraph (2); ‘(B) review the operating rules developed and recommended by such nonprofit entity; ‘(C) determine whether such operating rules represent a consensus view of the health care stakeholders and are consistent with and do not conflict with other existing standards; ‘(D) evaluate whether such operating rules are consistent with electronic standards adopted for health information technology; and ‘(E) submit to the Secretary a recommendation as to whether the Secretary should adopt such operating rules. ‘(4) IMPLEMENTATION- ‘(A) IN GENERAL- The Secretary shall adopt operating rules under this subsection, by regulation in accordance with subparagraph (C), following consideration of the operating rules developed by the non-profit entity described in paragraph (2) and the recommendation submitted by the National Committee on Vital and Health Statistics under paragraph (3)(E) and having ensured consultation with providers. ‘(B) ADOPTION REQUIREMENTS; EFFECTIVE DATES- ‘(i) ELIGIBILITY FOR A HEALTH PLAN AND HEALTH CLAIM STATUS- The set of operating rules for eligibility for a health plan and health claim status transactions shall be adopted not later than July 1, 2011, in a manner ensuring that such operating rules are effective not later than January 1, 2013, and may allow for the use of a machine readable identification card. ‘(ii) ELECTRONIC FUNDS TRANSFERS AND HEALTH CARE PAYMENT AND REMITTANCE ADVICE- The set of operating rules for electronic funds transfers and health care payment and remittance advice transactions shall-- ‘(I) allow for automated reconciliation of the electronic payment with the remittance advice; and ‘(II) be adopted not later than July 1, 2012, in a manner ensuring that such operating rules are effective not later than January 1, 2014. ‘(iii) HEALTH CLAIMS OR EQUIVALENT ENCOUNTER INFORMATION, ENROLLMENT AND DISENROLLMENT IN A HEALTH PLAN, HEALTH PLAN PREMIUM PAYMENTS, REFERRAL CERTIFICATION AND AUTHORIZATION- The set of operating rules for health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization transactions shall be adopted not later than July 1, 2014, in a manner ensuring that such operating rules are effective not later than January 1, 2016. ‘(C) EXPEDITED RULEMAKING- The Secretary shall promulgate an interim final rule applying any standard or operating rule recommended by the National Committee on Vital and Health Statistics pursuant to paragraph (3). The Secretary shall accept and consider public comments on any interim final rule published under this subparagraph for 60 days after the date of such publication. ‘(h) Compliance- ‘(1) HEALTH PLAN CERTIFICATION- ‘(A) ELIGIBILITY FOR A HEALTH PLAN, HEALTH CLAIM STATUS, ELECTRONIC FUNDS TRANSFERS, HEALTH CARE PAYMENT AND REMITTANCE ADVICE- Not later than December 31, 2013, a health plan shall file a statement with the Secretary, in such form as the Secretary may require, certifying that the data and information systems for such plan are in compliance with any applicable standards (as described under paragraph (7) of section 1171) and associated operating rules (as described under paragraph (9) of such section) for electronic funds transfers, eligibility for a health plan, health claim status, and health care payment and remittance advice, respectively. ‘(B) HEALTH CLAIMS OR EQUIVALENT ENCOUNTER INFORMATION, ENROLLMENT AND DISENROLLMENT IN A HEALTH PLAN, HEALTH PLAN PREMIUM PAYMENTS, HEALTH CLAIMS ATTACHMENTS, REFERRAL CERTIFICATION AND AUTHORIZATION- Not later than December 31, 2015, a health plan shall file a statement with the Secretary, in such form as the Secretary may require, certifying that the data and information systems for such plan are in compliance with any applicable standards and associated operating rules for health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, health claims attachments, and referral certification and authorization, respectively. A health plan shall provide the same level of documentation to certify compliance with such transactions as is required to certify compliance with the transactions specified in subparagraph (A). ‘(2) DOCUMENTATION OF COMPLIANCE- A health plan shall provide the Secretary, in such form as the Secretary may require, with adequate documentation of compliance with the standards and operating rules described under paragraph (1). A health plan shall not be considered to have provided adequate documentation and shall not be certified as being in compliance with such standards, unless the health plan-- ‘(A) demonstrates to the Secretary that the plan conducts the electronic transactions specified in paragraph (1) in a manner that fully complies with the regulations of the Secretary; and ‘(B) provides documentation showing that the plan has completed end-to-end testing for such transactions with their partners, such as hospitals and physicians. ‘(3) SERVICE CONTRACTS- A health plan shall be required to ensure that any entities that provide services pursuant to a contract with such health plan shall comply with any applicable certification and compliance requirements (and provide the Secretary with adequate documentation of such compliance) under this subsection. ‘(4) CERTIFICATION BY OUTSIDE ENTITY- The Secretary may designate independent, outside entities to certify that a health plan has complied with the requirements under this subsection, provided that the certification standards employed by such entities are in accordance with any standards or operating rules issued by the Secretary. ‘(5) COMPLIANCE WITH REVISED STANDARDS AND OPERATING RULES- ‘(A) IN GENERAL- A health plan (including entities described under paragraph (3)) shall file a statement with the Secretary, in such form as the Secretary may require, certifying that the data and information systems for such plan are in compliance with any applicable revised standards and associated operating rules under this subsection for any interim final rule promulgated by the Secretary under subsection (i) that-- ‘(i) amends any standard or operating rule described under paragraph (1) of this subsection; or ‘(ii) establishes a standard (as described under subsection (a)(1)(B)) or associated operating rules (as described under subsection (i)(5)) for any other financial and administrative transactions. ‘(B) DATE OF COMPLIANCE- A health plan shall comply with such requirements not later than the effective date of the applicable standard or operating rule. ‘(6) AUDITS OF HEALTH PLANS- The Secretary shall conduct periodic audits to ensure that health plans (including entities described under paragraph (3)) are in compliance with any standards and operating rules that are described under paragraph (1) or subsection (i)(5). ‘(i) Review and Amendment of Standards and Operating Rules- ‘(1) ESTABLISHMENT- Not later than January 1, 2014, the Secretary shall establish a review committee (as described under paragraph (4)). ‘(2) EVALUATIONS AND REPORTS- ‘(A) HEARINGS- Not later than April 1, 2014, and not less than biennially thereafter, the Secretary, acting through the review committee, shall conduct hearings to evaluate and review the adopted standards and operating rules established under this section. ‘(B) REPORT- Not later than July 1, 2014, and not less than biennially thereafter, the review committee shall provide recommendations for updating and improving such standards and operating rules. The review committee shall recommend a single set of operating rules per transaction standard and maintain the goal of creating as much uniformity as possible in the implementation of the electronic standards. ‘(3) INTERIM FINAL RULEMAKING- ‘(A) IN GENERAL- Any recommendations to amend adopted standards and operating rules that have been approved by the review committee and reported to the Secretary under paragraph (2)(B) shall be adopted by the Secretary through promulgation of an interim final rule not later than 90 days after receipt of the committee’s report. ‘(B) PUBLIC COMMENT- ‘(i) PUBLIC COMMENT PERIOD- The Secretary shall accept and consider public comments on any interim final rule published under this paragraph for 60 days after the date of such publication. ‘(ii) EFFECTIVE DATE- The effective date of any amendment to existing standards or operating rules that is adopted through an interim final rule published under this paragraph shall be 25 months following the close of such public comment period. ‘(4) REVIEW COMMITTEE- ‘(A) DEFINITION- For the purposes of this subsection, the term ‘review committee’ means a committee chartered by or within the Department of Health and Human services that has been designated by the Secretary to carry out this subsection, including-- ‘(i) the National Committee on Vital and Health Statistics; or ‘(ii) any appropriate committee as determined by the Secretary. ‘(B) COORDINATION OF HIT STANDARDS- In developing recommendations under this subsection, the review committee shall ensure coordination, as appropriate, with the standards that support the certified electronic health record technology approved by the Office of the National Coordinator for Health Information Technology. ‘(5) OPERATING RULES FOR OTHER STANDARDS ADOPTED BY THE SECRETARY- The Secretary shall adopt a single set of operating rules (pursuant to the process described under subsection (g)) for any transaction for which a standard had been adopted pursuant to subsection (a)(1)(B). ‘(j) Penalties- ‘(1) PENALTY FEE- ‘(A) IN GENERAL- Not later than April 1, 2014, and annually thereafter, the Secretary shall assess a penalty fee (as determined under subparagraph (B)) against a health plan that has failed to meet the requirements under subsection (h) with respect to certification and documentation of compliance with-- ‘(i) the standards and associated operating rules described under paragraph (1) of such subsection; and ‘(ii) a standard (as described under subsection (a)(1)(B)) and associated operating rules (as described under subsection (i)(5)) for any other financial and administrative transactions. ‘(B) FEE AMOUNT- Subject to subparagraphs (C), (D), and (E), the Secretary shall assess a penalty fee against a health plan in the amount of $1 per covered life until certification is complete. The penalty shall be assessed per person covered by the plan for which its data systems for major medical policies are not in compliance and shall be imposed against the health plan for each day that the plan is not in compliance with the requirements under subsection (h). ‘(C) ADDITIONAL PENALTY FOR MISREPRESENTATION- A health plan that knowingly provides inaccurate or incomplete information in a statement of certification or documentation of compliance under subsection (h) shall be subject to a penalty fee that is double the amount that would otherwise be imposed under this subsection. ‘(D) ANNUAL FEE INCREASE- The amount of the penalty fee imposed under this subsection shall be increased on an annual basis by the annual percentage increase in total national health care expenditures, as determined by the Secretary. ‘(E) PENALTY LIMIT- A penalty fee assessed against a health plan under this subsection shall not exceed, on an annual basis-- ‘(i) an amount equal to $20 per covered life under such plan; or ‘(ii) an amount equal to $40 per covered life