[Congressional Record Volume 156, Number 43 (Sunday, March 21, 2010)]
[House]
[Pages H1891-H2169]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]

[[Page H1891]]

Senate

The Senate was not in session today. Its next meeting will be held on 
Monday, March 22, 2010, at 2 p.m.





House of Representatives

Sunday, March 21, 2010

SENATE AMENDMENTS TO H.R. 3590, SERVICE MEMBERS HOME OWNERSHIP TAX ACT 
OF 2009, AND H.R. 4872, HEALTH CARE AND EDUCATION RECONCILIATION ACT OF 
                            2010--Continued
                              {time}  2145

  Mr. CAMP. Mr. Speaker, for the purposes of a unanimous consent 
request, I yield to the gentleman from Texas (Mr. Hall).
  (Mr. HALL of Texas asked and was given permission to revise and 
extend his remarks.)
  Mr. HALL of Texas. Mr. Speaker, I rise in opposition to this flawed 
health care bill.
  Mr. CAMP. Mr. Speaker, for the purpose of a unanimous consent 
request, I yield to the gentlewoman from North Carolina (Ms. Foxx).
  (Ms. FOXX asked and was given permission to revise and extend her 
remarks.)
  Ms. FOXX. Mr. Speaker, I rise in opposition to this flawed health 
bill.
  Mr. CAMP. For the purpose of a unanimous consent request, I yield to 
the gentleman from New York (Mr. King).
  (Mr. KING of New York asked and was given permission to revise and 
extend his remarks.)
  Mr. KING of New York. Mr. Speaker, I rise in opposition to this 
flawed health care bill.
  Mr. CAMP. Mr. Speaker, I yield 4 minutes to the distinguished 
gentleman from Virginia (Mr. Cantor), the Republican whip.
  Mr. CANTOR. Mr. Speaker, all of us in this body, Republicans and 
Democrats alike, care about Americans' health care, but many of us from 
both sides of the aisle don't care for this trillion dollar overhaul. 
And the fact is, the majority of Americans don't care for it either.
  Sadly, Mr. Speaker, the only bipartisanship we've seen surrounding 
this overhaul has been in opposition to it, and there's a reason for 
that. Health care is a very personal issue, and this overhaul will 
impact every man, woman, and child in this country. It will even affect 
future generations that have not yet been born.
  Mr. Speaker, this overhaul will have a huge impact on our parents, 
our spouses, and our kids. This is something that they'll be paying for 
for the rest of their lives. And for too long, Mr. Speaker, the 
majority in this body and the President of the United States have 
refused to listen to the American people.
  So, Mr. Speaker, I have a message for those Americans. We hear you. 
We hear you loud and clear, because we believe this government must 
stop spending money that it doesn't have, and this trillion dollar 
overhaul will do the opposite.
  We believe that this government must stop piling debt upon our 
children and grandchildren, and this trillion dollar overhaul will do 
the opposite.
  We believe that this government must stop raising taxes on small 
businesses and families, and, Mr. Speaker, this trillion dollar 
overhaul will do the opposite.
  We believe that America is the land of innovation and that government 
must stop crippling job creators and entrepreneurs with oppressive 
mandates and taxes, and this trillion dollar overhaul will do the 
opposite.
  Mr. Speaker, we believe that in America our government must not force 
those who fundamentally object to abortion to have to pay for it, and 
this trillion dollar overhaul does the opposite.
  And we believe in building upon what works in our current health 
care, Mr. Speaker, so that doctors in America can continue to provide 
the best care in the world, and this trillion dollar overhaul does the 
opposite.
  And, Mr. Speaker, we believe that families and patients should have 
the freedom and the right to choose the doctors they want, and this 
trillion dollar overhaul will begin to take that freedom away.
  Mr. Speaker, if there's one thing that the American people have 
learned over the past year, it's that we are truly at a critical time 
in this country. We are at a crossroads.
  This trillion dollar health care overhaul before us today has caused 
a lot of fear and uncertainty. It's the latest part of an agenda that 
is being forced upon the American people that attempts to seize more 
control over the economy and our lives.
  The choices we make on deficit spending, higher taxes, energy 
security, and health care, they're all important. They're important 
because they will all determine what kind of country we want to be.

[[Page H1892]]

  The SPEAKER pro tempore (Mr. Obey). The time of the gentleman has 
expired.
  Mr. CAMP. I yield the gentleman 30 additional seconds.
  Mr. CANTOR. Mr. Speaker, the choice before us is very clear. The 
choice is whether we want to become a country that is unrecognizable, 
or one that will fulfill the American Dream so that we remain the most 
secure and most prosperous, freest country in the history of the world.
  Mr. Speaker, I urge my colleagues today to listen to the people and 
vote ``no'' against this legislation.
  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to Mr. Ackerman of New York.
  (Mr. ACKERMAN asked and was given permission to revise and extend his 
remarks.)
  Mr. ACKERMAN. I rise in enthusiastic support of this historic, 
important bill.
  The SPEAKER pro tempore. The gentleman will be charged.
  Mr. SPRATT. For purposes of another unanimous consent request, I 
yield to the gentlelady from California (Ms. Waters).
  (Ms. WATERS asked and was given permission to revise and extend her 
remarks.)
  Ms. WATERS. Mr. Speaker, I rise in support of this bill.
  Our health care system is broken; no one can deny it.
  Every day, millions of Americans go without needed health care 
because they have no insurance. Some of these people work for small 
businesses and other employers that do not provide insurance. Some of 
them lost their insurance when they lost their jobs. Some of them were 
denied coverage by insurance companies because of a pre-existing 
condition. And some of them simply could not afford the escalating 
premiums. Even for people with health insurance, a devastating accident 
or illness can be very expensive. The cost of health care is the number 
one reason for bankruptcies in America.
  So we cannot afford inaction. Today, we have a clear choice--to start 
to fix the broken health care system--or to do nothing.
  However, this bill is not perfect. I would like to have seen included 
measures such as a public health insurance option like Medicare that 
would compete with the private insurance plans and a single national 
insurance exchange where people could purchase the health plan of their 
choice instead of separate state-based exchanges with different 
standards. I believe these measures would be more effective at 
containing costs and creating competition for the insurance industry.
  I am also concerned that this bill should not be used to limit the 
right of women to reproductive choice. Despite the President's 
Executive Order, attempting to codify existing law under the so-called 
Hyde Amendment, it is not clear that the Senate bill does not go beyond 
the Hyde amendment.
  Nevertheless, I have decided to support H.R. 3590, together with the 
improvements included in H.R. 4872, because it will make health care 
more affordable and more accessible for thousands of my constituents 
and millions of Americans. By passing this legislation today we are 
taking a critically important step in the right direction.
  According to an analysis by the House Energy and Commerce Committee, 
this health care reform bill will benefit California's 35th District in 
the following ways:
  Improve coverage for 281,000 residents with health insurance.
  Extend coverage to 125,500 residents who lack insurance.
  Guarantee that 21,200 residents with pre-existing conditions can 
obtain coverage.
  Allow 58,000 young adults to obtain coverage on their parents' 
insurance plans.
  Give tax credits and other assistance to up to 157,000 families and 
15,100 small businesses to help them afford coverage.
  Improve Medicare for 62,000 beneficiaries, including reducing the 
costs of prescription drugs and closing the donut hole.
  Protect 1,100 families from bankruptcy due to unaffordable health 
care costs.
  Provide millions of dollars in new funding for 10 community health 
centers.
  Reduce the cost of uncompensated care for hospitals and other health 
care providers by $15 million annually.
  Many provisions of the bill will kick in immediately. Insurance 
companies will no longer be able to take away a person's insurance 
because the person gets sick, an unfair practice known as rescission. 
It will immediately prevent insurance companies from denying coverage 
to children with pre-existing conditions, and eventually end 
discrimination against anyone with a pre-existing condition. It will 
immediately allow young people the ability to remain on their parents' 
insurance until age 26. It will immediately help seniors pay for 
prescription drugs and eventually eliminate the donut hole completely. 
And it will extend tax credits to small businesses so that they can 
provide health insurance to their employees.
  Over the next few years, the bill will extend coverage to 32 million 
Americans, or 95 percent of the population, providing affordability 
credits for individuals who cannot afford to purchase health insurance 
on their own.
  Improving our health care system is essential to setting us on the 
right path to healthier lives, renewed American innovation, and a 
stronger, more stable American economy. I urge my colleagues to support 
this bill and expand access to health care for families and small 
businesses throughout the United States of America.
  Mr. SPRATT. For purposes of a unanimous consent request, I yield to 
Mr. Driehaus from Ohio.
  (Mr. DRIEHAUS asked and was given permission to revise and extend his 
remarks.)
  Mr. DRIEHAUS. Mr. Speaker, I rise in support of this health care 
legislation.
  Mr. SPRATT. Mr. Speaker, I now yield 1 minute to the gentlelady from 
Minnesota (Ms. McCollum).
  Ms. McCOLLUM. Mr. Speaker, beyond the walls of this Capitol, there 
are millions of Americans who can't afford health insurance and they 
live in fear of getting sick. Millions more are discriminated against 
by insurance companies because they have preexisting medical 
conditions.
  In my own life, as a child and as an adult, I've lived without health 
insurance. A dear, dear niece of mine has a preexisting condition that 
makes her uninsurable.
  Passing health insurance reform is not a political game. It's 
personal. It's about real people's lives. When we pass this bill, we 
will save lives. Families will be protected. Millions of Americans will 
no longer live in fear.
  Today I will vote to end discrimination against people with 
preexisting conditions. Today I will vote to extend health care to 32 
million Americans. And when this bill becomes law, health care security 
will finally become a reality for the American people.
  Mr. CAMP. Mr. Speaker, at this time I will yield to the gentleman 
from California for the purpose of a unanimous consent request.
  Mr. DANIEL E. LUNGREN of California. Mr. Speaker, because of 
confusion over its legal effect, I ask unanimous consent that the text 
of President Obama's Executive order referring to abortion funding, 
that it be considered as a freestanding amendment to the text of H.R. 
3590 and we be allowed to vote on it separately.
  The SPEAKER pro tempore. The Chair cannot entertain such a request 
unless it has been cleared.


                        Parliamentary Inquiries

  Mr. DANIEL E. LUNGREN of California. Mr. Speaker, parliamentary 
inquiry.
  The SPEAKER pro tempore. The gentleman will state his parliamentary 
inquiry.
  Mr. DANIEL E. LUNGREN of California. Mr. Speaker, is such unanimous 
consent request, is it, in fact, in order under the rules of the House?
  The SPEAKER pro tempore. The Chair has indicated that requests for 
these matters must be cleared.
  The Chair is not obligated to instruct Members on the rules of the 
House.
  Mr. DANIEL E. LUNGREN of California. Mr. Speaker, with respect, may I 
make a further inquiry, Mr. Speaker?
  The SPEAKER pro tempore. The gentleman may inquire.
  Mr. DANIEL E. LUNGREN of California. Would that request, if it were 
cleared, be considered germane to the bill under consideration?
  The SPEAKER pro tempore. The Chair will not respond to hypotheticals.
  Mr. DANIEL E. LUNGREN of California. Mr. Speaker, additional 
parliamentary inquiry.
  The SPEAKER pro tempore. The gentleman may proceed.
  Mr. DANIEL E. LUNGREN of California. When I am informed that it must 
be cleared, do I understand that to mean it must be cleared by the 
Speaker or the majority leader?
  The SPEAKER pro tempore. Leadership on both sides must clear these 
matters. I'm sure the gentleman knows that.
  Mr. DANIEL E. LUNGREN of California. I thank the Speaker.
  Mr. CAMP. Mr. Speaker, I reserve my time.

[[Page H1893]]

  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to the gentlewoman from Ohio (Ms. Kaptur).
  (Ms. KAPTUR asked and was given permission to revise and extend her 
remarks.)
  Ms. KAPTUR. Mr. Speaker, I rise in support of affordable health 
insurance for all Americans.
  I rise in support of this historic legislation because affordable 
health care is really about life--about a healthier and more secure 
life for all Americans.
  This is about life--the life of a senior who can't afford 
prescription drugs, or a mother carrying a new life waiting to be born.
  This legislation says every American has the right to the dignity of 
a healthy life. Nothing more, nothing less. Its promise is true for all 
citizens, of all ages, from all walks of life. In that respect, it is 
profoundly American.
  It is most certainly about the millions of citizens in our nation who 
run small businesses and about their employees--who after all these 
years comprise over half the uninsured in our nation. These businesses 
embody the hopes and dreams of life in America. They are the engines of 
job growth, but after all these decades, they are treated like second 
class citizens.
  This bill is about women and children--the millions of women who have 
no health care and the millions of children who are born frail and weak 
because their mothers have no access to prenatal care and their fathers 
have no insurance. The March of Dimes tells us that every year, more 
than half a million American children are born underweight, one out of 
every eight children born premature, malnourished, and so many with 
disability. That should not happen in America. Our nation's insurance 
programs aren't meeting the market nor the promise of America.
  This legislation will help millions of women obtain health coverage 
and thus reduce abortion by enhancing broad coverage options for 
women's and children's health. It will vastly improve preventive care, 
more than double funds available to community health centers (including 
obstetric and gynecological care), and move America fully into this 
21st century. No woman, no woman--including poor women, pregnant women, 
working women, single women, and nursing women--will be denied health 
insurance coverage.
  Mr. Speaker, the best anti-abortion bill we can pass is one that 
gives women and children a real chance through health insurance 
coverage that allows fragile life to come to term. This bill does that. 
It gives hope, to every family, to every woman to every child yet to be 
born. It says you have a right to be born. It provides for prenatal 
care during a woman's pregnancy, preventive care for newborns, funding 
to help pregnant and parenting teens and college students with 
assistance for basic necessities, as well as adoption tax credits. No 
family, no mother, no father will ever have to question again whether 
they can afford to bring a conceived child to term
  This bill is about a better life for seniors, too. By closing the 
doughnut hole, it makes sure they can afford the medicine they need to 
live healthy, independent lives.
  As the costs of insurance have risen, emptying the wallets of our 
neighbors, almost one in three Americans (87 million of our fellow 
citizens) went without health insurance for some period last year. We 
can do better in America.
  There is so much shifting in the marketplace, it is becoming less 
stable and reliable. Thousands more of our citizens are losing their 
insurance because they have lost their jobs as the unemployment 
epidemic rages throughout our nation.
  Even those with insurance, no matter how expensive or robust it might 
be, learn their coverage is not guaranteed nor continuous nor quality. 
Millions of hardworking Americans are denied coverage; charged an 
impossibly higher rate, or discriminated against because of a pre-
existing condition. Family employer-sponsored health insurance 
increased 119 percent over the last decade. Small business premiums 
alone have risen 129 percent. Without reform, rates are projected to 
increase to $23,842 on average by 2020. This simply cannot continue; 
the system is broken.

  I can identify with the tens of millions of our fellow citizens who 
have no health insurance, over half of whom are either small business 
owners or their employees. When my brother, Steve, and I were growing 
up, our beloved, hardworking father, ``Kappy,'' had three heart 
attacks. He made the gut-wrenching decision to sell our small family 
market to go to work in an auto plant for one reason: to get health 
insurance for his wife, Anastasia, and their two children. He didn't 
even care about himself. I shall never forget that piercing experience: 
it is the story of millions upon millions of our fellow citizens 
excluded, priced out or eliminated from the insurance market place. In 
our parents' memory, the best jobs bill I can vote is one that takes 
the health insurance anxiety off the backs of small businesspeople 
across our nation. I do so today in our parents' memory.
  I have listened closely to the concerns of citizens in Ohio's Ninth 
Congressional District. There is passion on both sides. Some claim this 
legislation is unconstitutional. I respectfully disagree. To accept 
that argument is to say that Social Security is unconstitutional, or 
Medicare is unconstitutional, or veterans' benefits are 
unconstitutional, or the interstate highway system is unconstitutional. 
I believe that argument would tear apart the fabric of our Republic.
  Affordable health insurance reform is necessary to provide greater 
competition among available plans to cut the costs of doing business, 
reduce the share of government expenditures spent on health care, help 
our companies to be more competitive in the world market, unleash the 
entrepreneurial talents of the American people, and give peace of mind 
to the middle class, our seniors and others that everything they have 
worked for will not be taken away if they get sick.
  I have been touched by stories from constituents and I rise today in 
support of this historic bill for them:
  David owns a small business. In 1999, he offered health insurance to 
his 15 employees. Over the course of the next decade, his insurance 
premiums skyrocketed and he had to let some employees go. By 2007 he 
was down to three employees and could no longer provide insurance for 
them--or himself. Now uninsured, he recently suffered a heart attack. 
Health care expenses forced him to file for bankruptcy. Sad to say, his 
case is not all that unusual--health care costs are the leading cause 
of bankruptcy in America.
  Jeff changed jobs and was required to obtain different health 
insurance while his wife was mid-term in a pregnancy. The pregnancy was 
high risk, the birth was problematic, and the insurer, a ``health 
maintenance organization,'' an HMO, denied coverage not only for the 
mother's labor and delivery, but also their baby's conditions at birth.
  Lillian will reach her allowable Part D private drug plan coverage in 
March. She cannot afford to pay for her medicines, so she never climbs 
out of the ``doughnut hole'' to obtain coverage again. As a result, she 
will quit taking her prescription drugs for nine months, until the new 
year starts. As a result, she has been hospitalized.
  Mary has suffered from bipolar disorder since her twenties. She is 
now in her fifties. She is married, with a family. She has experienced 
many exacerbations of her illness and resulting hospitalizations. She 
reached the insurer's lifetime maximum when in her early forties. Since 
then, her family has had to pay her expenses.
  Susan is the director of a nonprofit organization that serves 
homeless families. The organization offers health insurance to 
employees, but the premium increase this year was 49%. Now the agency 
must choose between dropping insurance as an employee benefit or 
reducing services to the vulnerable families it serves. Meanwhile, the 
insurer posted record profits last year.

  Bob and Catherine were married for 53 years and raised six children. 
Catherine developed a chronic debilitating illness which worsened over 
time. Bob took care of her at home for nine years, using all of their 
savings and having to sell their house.
  Cassandra is a12-year-old girl with juvenile diabetes. Since her 
diagnosis as a toddler, her parents have been unable to obtain health 
care coverage even though they could afford to pay for it. They must 
pay all her health expenses out of pocket. They live in a small 
apartment.
  Aaron is 14. He has a failing liver and has needed a liver transplant 
for five years. His mom could not work because she had to care for him. 
The family has no health care coverage. Though the hospital absorbed 
much of the cost for his care and treatment, the family held 
fundraisers through the years to pay for his transplant and the health 
care which has subsequently followed. All of us are familiar with the 
spaghetti dinners, and benefit dances, and silent auctions to help 
families in similar circumstances. Heroic compassionate people rise to 
the occasion in communities across our nation, but often it simply is 
not enough.
  For too long, the health of our nation has dwindled--indeed the U.S. 
ranks behind over a dozen major nations in health outcomes--while the 
pockets of the insurance giants have thickened. Insurance companies 
raise rates and deny coverage to pay their CEOs excessive salaries and 
bonuses. WellCare and Aetna's executives, for example, received between 
$18 and $23 million dollars alone in 2008. Despite wanting to increase 
premiums recently for individuals by 39 percent, WellPoint's 
executives, which is an insurance provider in the state of Ohio where I 
represent, received over $8.6 million.
  Our seniors have compromised prescription drugs for necessary 
groceries, while the insurance and pharmaceutical industries have made 
record profits. Hard working families

[[Page H1894]]

have watched their savings plummet and their homes foreclosed after 
unexpected illnesses. Women with breast cancer, men with heart disease 
and children with leukemia or childhood diabetes have been flat-out 
denied health insurance coverage for pre-existing conditions or 
reaching insurance policy caps.
  With the mounting economic strain on American families and the rising 
costs of health insurance to workers, businesses and the federal 
budget, the status quo has proven itself unsustainable, fiscally 
irresponsible and morally unacceptable. The time has come for this 
historical change. The bill before us pays for itself and actually 
brings revenues back to the health system as a result of the 
combination of added competition and better use of the health dollar. I 
stand in support of its promise to the American people--the promise of 
a better and healthier life for all in this blessed land.
  Mr. SPRATT. Also for purposes of a unanimous consent request, I yield 
to Mrs. Dahlkemper from Pennsylvania.
  (Mrs. DAHLKEMPER asked and was given permission to revise and extend 
her remarks.)
  Mrs. DAHLKEMPER. Mr. Speaker, I rise in support of this health care 
legislation.
  Mr. SPRATT. I now yield 1\1/2\ minutes to the gentlewoman from 
Connecticut (Ms. DeLauro).
  Ms. DeLAURO. Mr. Speaker, I rise in support of this historic 
legislation, arguably the most important vote we here today will ever 
take in this Chamber.
  Today fulfills a promise made 100 years ago by Theodore Roosevelt 
when he first called for comprehensive health insurance reform. It 
fulfills a promise made by Franklin Roosevelt to our parents, our 
grandparents, our great grandparents in 1944. President Richard Nixon 
also labored and lost on this national mission. And President Bill 
Clinton, too, tried to climb this mountain.
  Today's legislation builds on the great achievements of Social 
Security and Medicare, those big changes that we all take for granted, 
regardless of party. And yes, they, too, were characterized as 
socialist government takeovers.
  And today we have a chance to make health insurance affordable for 
people and for small businesses that ends the power of the insurance 
companies to deny them coverage, increase their rates and, yes, drop 
them when they get sick. Enough.
  This reform law allows 32 million of our citizens to get insurance, a 
moral imperative. It closes the doughnut hole in prescription drugs for 
seniors, and women will no longer have to pay more for their insurance, 
a long overdue reckoning.
  I am humbled by the opportunity to cast a vote for this historic 
change.
  Mr. CAMP. Mr. Speaker, I yield myself 2 minutes.
  We've heard a lot of discussion tonight about this bill and how it's 
been characterized. Let me just read a few quotes from my friends on 
the Democratic side who've characterized this bill.
  A Democrat from North Carolina says: There is no question that our 
current health care system is broken and that we need to make 
significant reforms to improve it in an equitable, fiscally 
responsible, and sustainable manner. In my opinion, the bill as written 
does not meet those criteria.
  A Democrat from Tennessee says: After thorough and careful review of 
the legislation, I am unconvinced that the long-term trend of rising 
health care costs is adequately addressed and am, therefore, unable to 
support the legislation.
  A Democrat from New Mexico said: I do not believe that the bill does 
enough to contain costs.
  A Democrat from North Carolina says: Health care reform is needed, 
but the bill before us is too expensive, does not adequately address 
rising medical costs and skyrocketing insurance premiums, and tries to 
do too much too soon. We simply cannot afford to create a new Federal 
bureaucracy that costs nearly $1 trillion when our national debt is $12 
trillion and there is no plan in place to address it. I will not vote 
for it.
  Another Democrat from Virginia says: I have spoken with countless 
small business owners, families, medical professionals, and average 
citizens across Virginia, and it becomes very clear that this bill is 
not the right solution for Virginia's health care challenges.
  On and on and on again. This is not the right bill for America. This 
costs $1 trillion, raises a half a trillion in taxes, and cuts Medicare 
by half a trillion dollars. Vote ``no'' on this bill.

                              {time}  2200

  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to the gentlelady from New York (Mrs. Lowey).
  (Mrs. LOWEY asked and was given permission to revise and extend her 
remarks.)
  Mrs. LOWEY. I rise in strong support of this bill.
  Mr. Speaker, I rise in support of enacting historic health care 
reform.
  Over the past fifteen months, I have held countless meetings with 
community organizations, small business owners, senior citizens, 
doctors, nurses, and patients, joined public forums and community 
meetings, and held telephone town halls. It is clear to me the status 
quo is unsustainable. Without action, individuals would continue to be 
denied coverage and care, more families would go into bankruptcy due to 
the costs of care, and businesses would continue to struggle to cover 
their employees.
  Some benefits will be evident almost immediately after this bill is 
signed. The most egregious practices of insurance companies, like 
denying coverage for children due to pre-existing conditions and 
dropping coverage when patients become sick, will be illegal. Small 
businesses will gain tax credits to provide affordable insurance to 
their employees. Senior citizens will benefit from immediate steps to 
close the Medicare prescription drug ``donut hole.''
  I have heard hundreds of personal stories. A social worker in Ardsley 
earning $53,000 per year whose out-of-pocket insurance premium just 
increased by $110 to $831 per month. Or the man from White Plains who 
was denied life saving cancer medication by his insurance company until 
my intervention. The small business owner from Ossining whose premium 
costs increased 40 percent this year.
  I want to assure you that:
  Medicare benefits will be strengthened by closing the prescription 
drug ``donut hole,'' eliminating charges for preventive care, and 
extending the solvency of the Medicare Trust Fund.
  The vast majority of families in Westchester and Rockland Counties 
will see absolutely no change in their income taxes due to this bill. I 
fought to protect our region, and I continue my work to index federal 
taxes to cost of living, which would help residents in our expensive 
area.
  Small businesses with fewer than 50 employees are exempt from 
employer requirements and some will immediately be offered tax credits 
to provide coverage for their employees.
  This legislation will not provide taxpayer funding for abortion, and 
in fact I am not pleased with new obstacles to reproductive health 
care.
  And finally, this bill will reduce the federal deficit by more than 
$143 billion in the first ten years and more than $1.2 trillion in the 
second ten years after passage.
  Instead of passing the House bill, the Senate adopted a flawed bill 
that I will support for the sole purpose of immediately making 
improvements through reconciliation to help American families and 
businesses.
  Although the legislation we passed this week is not perfect, it will 
rein in skyrocketing insurance premiums for families, prevent the worst 
practices of the insurance industry, help 30 million uninsured 
Americans gain access to care, allow insured Americans to keep their 
coverage if they like it, help small businesses afford coverage for 
their employees, allow children up to 26 years old to stay on their 
parents' plans and protect Medicare for senior citizens.
  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to the gentleman from New Jersey (Mr. Payne).
  (Mr. PAYNE asked and was given permission to revise and extend his 
remarks.)
  Mr. PAYNE. Mr. Speaker, I rise in support of this great health care 
reform bill.
  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to the gentleman from Florida (Mr. Grayson).
  (Mr. GRAYSON asked and was given permission to revise and extend his 
remarks.)
  Mr. GRAYSON. I rise in support of this bill.
  Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request, 
I yield to the gentleman from Georgia (Mr. Bishop).

[[Page H1895]]

  (Mr. BISHOP of Georgia asked and was given permission to revise and 
extend his remarks.)
  Mr. BISHOP of Georgia. I rise in support of this historic health care 
reform bill.
  Mr. SPRATT. Mr. Speaker, can you tell me how much time is remaining 
on my side?
  The SPEAKER pro tempore. There are 2\1/4\ minutes remaining for the 
gentleman from South Carolina.
  Mr. SPRATT. Mr. Speaker, I yield 1\1/4\ minutes to the gentleman from 
New Jersey (Mr. Andrews).
  (Mr. ANDREWS asked and was given permission to revise and extend his 
remarks.)
  Mr. ANDREWS. Mr. Speaker, our friends on the other side of the aisle 
have asked frequently tonight what kind of country are we. They've 
asked exactly the right question. Tomorrow when a person is denied a 
job because she has breast cancer or is charged higher premiums because 
he has asthma, what kind of country will we be? Tomorrow when a senior 
citizen has enough money in her checking account to pay the utility 
bill or her prescription bill but not both, what kind of country will 
we be? When a person who tonight is scrubbing floors or pumping gas or 
waiting on tables tomorrow tries to go to buy a health insurance policy 
for herself or her children, what kind of country will we be?
  For Social Security, we gave decency for seniors. In Medicare, we 
gave compassion for seniors. In the Civil Rights Act, we gave equality 
for all Americans. Tonight, we will give justice and decency. That's 
the kind of country that we will be.
  Mr. CAMP. Mr. Speaker, at this time I yield 1 minute to the 
distinguished minority leader, the gentleman from Ohio (Mr. Boehner).
  Mr. BOEHNER. Mr. Speaker and my colleagues, I rise tonight with a sad 
and heavy heart. Today we should be standing together reflecting on a 
year of bipartisanship and working to answer our country's call and 
their challenge to address the rising costs of health insurance in our 
country.
  Today, this body, this institution, enshrined in the first article of 
the Constitution by our Founding Fathers as a sign of the importance 
they placed on this House, should be looking with pride on this 
legislation and our work.
  But it is not so.
  No, today we're standing here looking at a health care bill that no 
one in this body believes is satisfactory. Today we stand here amidst 
the wreckage of what was once the respect and honor that this House was 
held in by our fellow citizens. And we all know why it is so. We have 
failed to listen to America. And we have failed to reflect the will of 
our constituents. And when we fail to reflect that will, we fail 
ourselves, and we fail our country.
  Look at this bill. Ask yourself, do you really believe that if you 
like the health plan that you have that you can keep it? No, you can't. 
You can't say that.
  In this economy, with this unemployment, with our desperate need for 
jobs and economic growth, is this really the time to raise taxes, to 
create bureaucracies, and burden every job creator in our land? The 
answer is no.
  Can you go home and tell your senior citizens that these cuts in 
Medicare will not limit their access to doctors or further weaken the 
program instead of strengthening it? No, you cannot.
  Can you go home and tell your constituents with confidence that this 
bill respects the sanctity of all human life and that it won't allow 
for taxpayer funding of abortions for the first time in 30 years? No, 
you cannot.
  And look at how this bill was written. Can you say it was done 
openly, with transparency and accountability? Without backroom deals 
and struck behind closed doors hidden from the people? Hell, no, you 
can't.
  Have you read the bill? Have you read the reconciliation bill? Have 
you read the manager' s amendment? Hell, no, you haven't.


                Announcement by the Speaker Pro Tempore

  The SPEAKER pro tempore. Both sides would do well to remember the 
dignity of the House.
  Mr. BOEHNER. Mr. Speaker, in a few minutes we will cast some of the 
most consequential votes that any of us will ever cast in this Chamber. 
The decision we make will affect every man, woman, and child in this 
Nation for generations to come. If we're going to vote to defy the will 
of the American people, then we ought to have the courage to stand 
before them and announce our votes, one at a time.
  I sent a letter to the Speaker this week asking that the ``call of 
the roll'' be ordered for this vote. Madam Speaker, I ask you, will 
you, in the interest of this institution, grant my request?
  Will you, Mr. Speaker, grant my request that we have a call of the 
roll?
  The SPEAKER pro tempore. Is the gentleman asking a rhetorical 
question?
  Mr. BOEHNER. Mr. Speaker, will you grant my request that we have a 
call of the roll?
  The SPEAKER pro tempore. Under clause 2(a) of rule XX, a record vote 
is conducted by electronic device unless the Speaker directs otherwise.
  MR. BOEHNER. And you, Mr. Speaker, will you grant that request?
  The SPEAKER pro tempore. The Chair will decide at the time the 
question is ripe. This is not it.
  Mr. BOEHNER. My colleagues, this is the People's House.
  When we came here, we each swore an oath to uphold and abide by the 
Constitution as representatives of the people. But the process here is 
broken. The institution is broken. And as a result, this bill is not 
what the American people need nor what our constituents want.
  Americans are out there making sacrifices and struggling to make a 
better future for their kids, and over the last year as the damn-the-
torpedoes outline of this legislation became more clear, millions of 
Americans lifted their voices and many, for the first time, asking us 
to slow down, not to try to cram through more than this system could 
handle, not to spend money that we didn't have. In this time of 
recession, they wanted us to focus on jobs, not more spending, not more 
government, and certainly not more taxes.
  But what they see today frightens them. They're frightened because 
they don't know what comes next. They're disgusted because what they 
see is one political party closing out the other from what should be a 
national solution. And they're angry. They're angry that no matter how 
they engage in this debate, this body moves forward against their will.
  Shame on us. Shame on this body. Shame on each and every one of you 
who substitutes your will and your desires above those of your fellow 
countrymen.
  Around this Chamber, looking upon us are the lawgivers from Moses, to 
Gaius, to Blackstone, to Thomas Jefferson. By our actions today, we 
disgrace their values. We break the ties of history in this Chamber. We 
break our trust with America.
  When I handed the Speaker the gavel in 2007, I said this: ``This is 
the People's House. And the moment a majority forgets it, it starts 
writing itself a ticket to minority status.''
  If we pass this bill, there will be no turning back. It will be the 
last straw for the American people. In a democracy, you can only ignore 
the will of the people for so long and get away with it. And if we defy 
the will of our fellow citizens and pass this bill, we're going to be 
held to account by those who have placed us in their trust. We will 
have shattered those bonds of trust.
  I beg you, I beg each and every one of you on both sides of the 
aisle: Do not further strike at the heart of this country and this 
institution with arrogance, for surely you will not strike with 
impunity.
  I ask each of you to vow to never let this happen again--this 
process, this defiance of our citizens. It's not too late to begin to 
restore the bonds of trust with our Nation and return comity to this 
institution.
  And so join me. Join me in voting against this bill so that we can 
come together, together anew and addressing the challenge of health 
care in a manner that brings credit to this body and brings credit to 
the ideals of this Nation, and most importantly, that reflects the will 
of the American people.

                              {time}  2215

  Mr. SPRATT. Mr. Speaker, I yield 1 minute to the gentlewoman from 
California, who has led the way in this quest for health care reform 
and tirelessly, persistently, she has brought us to this moment of the 
decision, the

[[Page H1896]]

gentlewoman from California, the Speaker of the House, Ms. Pelosi.
  Ms. PELOSI. Thank you, my colleagues. I thank the gentleman for 
yielding. I thank all of you for bringing us to this moment.
  Mr. Speaker, it is with great humility and with great pride that 
tonight we will make history for our country and progress for the 
American people. Just think, we will be joining those who established 
Social Security, Medicare, and now tonight health care for all 
Americans.
  In doing so, we will honor the vows of our Founders, who, in the 
Declaration of Independence, said that we are endowed by our Creator 
with certain inalienable rights and among these are life, liberty, and 
the pursuit of happiness.
  This legislation will lead to healthier lives, more liberty to pursue 
hopes and dreams and happiness for the American people. This is an 
American proposal that honors the traditions of our country.
  We would not be here tonight for sure without the extraordinary 
leadership and vision of President Barack Obama. We thank him for his 
unwavering commitment to health care for all Americans. This began over 
a year ago under his leadership in the American Recovery and 
Reinvestment Act where we had very significant investments in science, 
technology, and innovation for health care reform.
  It continued in the President's budget a few months later, a budget 
which was a statement of our national values, which allocated resources 
that were part of our value system and in a way that stabilized our 
economy, created jobs, lowered taxes for the middle class and did so 
and reduced the deficit and did so in a way that had pillars of 
investment, including education and health care reform.
  Health care reform and education equal opportunity for the American 
people. This legislation tonight, if I had one word to describe it, 
would be opportunity with its investments in education and health care 
as a continuation of the President's budget.
  We all know, and it's been said over and over again, that our economy 
needs something new, a jolt, and I believe that this legislation will 
unleash tremendous entrepreneurial power into our economy. Imagine a 
society and an economy where a person could change jobs without losing 
health insurance, where they could be self-employed or start a small 
business.
  Imagine an economy where people could follow their passions and their 
talent without having to worry that their children would not have 
health insurance, that if they had a child with diabetes who was 
bipolar or preexisting medical condition in their family, that they 
would be job locked. Under this bill, their entrepreneurial spirit will 
be unleashed.
  We all know that the present health care system and health insurance 
system in our country is unsustainable. We simply cannot afford it. It 
doesn't work for enough people in terms of delivery of service, and it 
is bankrupting the country with the upward spiral of increasing medical 
cost. The best action that we can take on behalf of America's family 
budgets and on behalf of the Federal budget is to pass health care 
reform.
  The best action we can take to strengthen Medicare and improve care 
and benefits for our seniors is to pass this legislation tonight, pass 
health care reform. The best action we can do to create jobs and 
strengthen our economic security is pass health care reform.
  The best action we can take to keep America competitive, ignite 
innovation, again, unleash entrepreneurial spirit is to pass health 
care reform.
  With this action tonight, with this health care reform, 32 million 
more Americans will have health care insurance and those who have 
insurance now will be spared of being at the mercy of the health 
insurance industry with their obscene increases in premiums, their 
rescinding of policies at the time of illness, their cutting off of 
policies even if you have been fully paying but become sick. The list 
goes on and on about the health care reforms that are in this 
legislation: insure 32 million more people, make it more affordable for 
the middle class, end insurance company discrimination on preexisting 
conditions, improve care and benefits under Medicare and extending 
Medicare solvency for almost a decade, creating a healthier America 
through prevention, through wellness and innovation, create 4 million 
jobs in the life of the bill and doing all of that by saving the 
taxpayer $1.3 trillion.
  Another Speaker, Tip O'Neill, once said, All politics is local. I say 
tonight that when it comes to health care for all Americans, all 
politics is personal. It's personal for the family that wrote to me, 
who had to choose between buying groceries and seeing a doctor. It's 
personal to the family that was refused coverage because their child 
had a preexisting condition, no coverage, the child got worse, sicker.
  It's personal for women. After we pass this bill, being a woman will 
no longer be a preexisting medical condition.

  It's personal for the senior gentleman whom I met in Michigan who 
told me about his wife who had been bedridden for 16 years. He told me 
he didn't know how he was going to be able to pay his medical bills. As 
I said to you before, I saw a grown man cry. He was worried that he 
might lose his home, that they might lose their home because of his 
medical bills and he didn't know how he was going to pay them and, most 
of all, he was too embarrassed to tell his children and ask them for 
help. How many times have you heard a story like that?
  It's personal for millions of families who have gone into bankruptcy 
under the weight of rising health care costs, and so many, many, many--
a high percentage of the bankruptcy in our country--are caused by 
medical bills that people cannot pay. It's personal for 45,000 
Americans and families who have lost a loved one each year because they 
didn't and couldn't get health insurance.
  That is why we are proud and also humble today to act with the 
support of millions of Americans who recognize the urgency of passing 
health care reform and more than 350 organizations representing 
Americans of every age, every background, every part of the country who 
have endorsed this legislation. Our coalition ranges from AARP who said 
that our legislation ``improves efforts to crack down on fraud and 
waste in Medicare, strengthening the program for today's seniors and 
future generations.'' I repeat: ``improves efforts to crack down on 
fraud and waste in Medicare, strengthening the program for today's 
seniors and future generations.''
  To the American Medical Association, the Catholic Health Association, 
the United Methodist Church and Voices for America's Children, from A 
to Z, they are sending a clear message to Members of Congress, say 
``yes'' to health care reform.
  We have also reached this historic moment because of the 
extraordinary leadership and hard work and dedication of all of the 
Members of Congress, but I want to especially recognize our esteemed 
Chairs, Mr. Waxman, Mr. Rangel, Mr. Levin, Mr. Miller, Mr. Spratt, Ms. 
Slaughter, for bringing this bill to the floor today. Let us 
acknowledge them.
  I want to acknowledge the staff of the committees and of the 
leadership. They have done a remarkable job, dazzling us with their 
knowledge and their know-how.
  I would like to thank on my own staff Amy Rosenbaum, Wendell Primus 
and Arshi Siddiqui.
  Now I will close by saying it wouldn't be possible to talk about 
health care without acknowledging the great leadership of Senator 
Edward Kennedy, who made health care his life's work. In a letter to 
President Obama before he passed away--he left a letter to be read 
after he died--Senator Kennedy wrote that access to health care was 
``the great unfinished business of our society.'' That is, until today.
  After more than a year of debate and, by the way, the legislation 
that will go forth from here has over 200 Republican amendments, and 
while it may not get Republican votes and be bipartisan in that 
respect, it is bipartisan in having over 200 Republican amendments.
  After a year of debate and hearing the calls of millions of 
Americans, we have come to this historic moment. Today we have the 
opportunity to complete the great unfinished business of our society 
and pass health insurance reform for all Americans. That is a right and 
not a privilege.

[[Page H1897]]

  In that same letter to the President, Senator Kennedy wrote, What is 
at stake? He said at stake are not just the details of policy, but the 
character of our country. Americans will look back on this day as one 
in which we honored the character of our country and honored our 
commitment to our Nation's Founders for a commitment to life, liberty 
and the pursuit of happiness.
  As our colleague, John Lewis, has said, we may not have chosen the 
time, but the time has chosen us. We have been given this country, an 
opportunity to stay right up there with, again, Social Security, 
Medicare, health care for all Americans.
  I urge my colleagues to join together in passing health insurance 
reform, making history and restoring the American Dream. I urge an 
``aye'' vote.

                              {time}  2230


                Announcement By the Speaker Pro Tempore

  The SPEAKER pro tempore. The Chair will again remind all persons in 
the gallery that they are here as guests of the House, and that any 
manifestation of approval or disapproval of proceedings or other 
audible conversation is in violation of the rules of the House.
  Mr. AL GREEN of Texas. Mr. Speaker, I am proud to support H.R. 4872, 
the Reconciliation Act of 2010 and the healthcare reform package that 
its passage will complete.
  Today, the House of Representatives has been given the opportunity to 
take a concrete and powerful step toward completing the work of 
reforming our healthcare system that began decades ago. For much of the 
last year, my colleagues and I have debated many ways in which we could 
work to lower costs, improve the quality of care and expand coverage. 
What we pass today will begin to achieve all three.
  In the wake of the financial crisis that has devastated our economy, 
concerns of our nation's deficit are well-placed and wholly 
appropriate. Despite what many of its opponents would argue, the 
passage of this healthcare reform package will reduce the national 
deficit by an estimated $1.3 trillion over the next 20 years according 
to the Congressional Budget Office.
  Through the course of this debate, we have seen misinformation about 
healthcare reform instill fear into the hearts of the American people. 
We have seen the distortion of truth breed uncertainty about whether 
healthcare reform will be to the benefit of our country. Despite all of 
the debate, and at times confusion, there remains one incontrovertible 
truth: the cost of inaction, when our country spends nearly $2.5 
trillion a year on healthcare, over 45 million Americans are without 
health insurance, and 45,000 people die every year due to lack of 
health insurance, is simply too great.
  The time for debate has ended. The question we are faced with is 
quite simple: do we act to shift the course of this country towards 
affordable, quality healthcare, or do we continue down the path of 
unsustainable costs and squander this historic opportunity to bring 
about meaningful change in the lives of the American people?
  I am proud to vote in favor of this giant step toward putting 
Americans in control of their health care and I look forward to this 
legislation being signed into law so that we may move forward with this 
much needed reform.
  Mr. SMITH of Texas. Mr. Speaker, Republicans and Democrats agree on 
the need for health insurance to cover those who cannot afford it. But 
this legislation is the wrong way.
  The health care bill is built on the shifting sands of higher 
premiums, increased taxes and reduced benefits. Such a foundation 
cannot last and will be washed away by the American people in the 
November election.
  A majority of the American people want to choose their own health 
care plan, not have the government do it for them. Under this bill, 
many health care decisions will be made by federal employees, not 
patients and their doctors. The result will be less care at higher 
cost.
  Mr. PUTNAM. Mr. Speaker, at the end of this term, I will have served 
in Congress for 10 years. I have had the privilege of participating in 
countless debates--from war resolutions and trade policies to the 
aftermath of the 9/11 attacks--and working with Members of Congress on 
both sides of the aisle on some of America's greatest challenges.
  We now stand on the floor of the House of Representatives to address 
one of today's greatest challenges in America--healthcare reform. While 
this may be one of the more complicated issues we are faced with, the 
goals--in my mind--are simple. We need to lower the cost of healthcare, 
while expanding healthcare coverage to more individuals. To accomplish 
this, I have advocated for policies like allowing small businesses to 
pool together and form association health plans, providing incentives 
for wellness programs and healthy life decisions, making reforms to our 
medical malpractice laws, and allowing individuals to purchase 
insurance across state lines. These policies are far-reaching, free-
market based, and--most of all--don't require new government 
bureaucracies. Unfortunately, they all lost out to a partisan process 
of backroom deals that have tainted this proposal and further 
undermined the already low esteem in which the people we serve hold in 
this institution.
  Ever since the first 2,000 page healthcare bill was dropped on my 
desk just prior to the vote in November, I have listened to 
Floridians--from parents and patients to doctors and seniors--who 
understand that healthcare is just too dynamic to be taken over by a 
stale, cold federal government. They understand that we don't need to 
model our healthcare system on those systems across the globe who envy 
our quality of care, technology, and research investment. We don't need 
some agency to make decisions about our family's healthcare that has 
the efficiency of FEMA and the compassion of the drivers license 
office. While we do have some aspects of our system that need to be 
improved, Floridians understand we should address them in a manner that 
actually solves the problem--not having government destroy the 
innovation that comes from competition. Madam Speaker, they understand 
this, but Congress clearly doesn't.
  The misguided policies we are voting on today are sadly coupled with 
the broken process they followed to get here. The measure we will vote 
on hasn't seen a single legislative committee, bi-partisan negotiation, 
or open process. Like anything with such an impact to the American 
people, this legislation deserves the scrutiny of the legislative 
process and the challenges that may come with amendments and committee 
debate. In short, this measure deserves a public vetting to arrive at 
the best possible outcome.
  Had our founders seen the process this healthcare debate has taken, 
they simply would not have recognized it as the House of 
Representatives they envisioned. Would they have supported a process 
that didn't even include the committees responsible for healthcare? 
Would they have appreciated gimmicks that only budget analysts would 
understand in order to ensure a certain overall cost? Could they 
explain  why a student loan bill was mysteriously attached to a massive 
healthcare reform proposal or why Congress decided to give one state a 
better deal than the rest of the country? Could they have ever imagined 
a Congress that is only willing to dedicate two hours of debate to a 
measure that spends $1 trillion?

  Our schoolchildren are taught the way an idea becomes law and that as 
an elected Representative, I have the ability to amend this legislation 
on their behalf and spend days debating every provision that may have 
been included. They know they deserve a process that allows their 
representative to have a seat at the drafting table, not one where the 
bill is dropped on his desk just prior to a vote. Even the most casual 
observer of this process and this bill's journey would find it 
unrecognizable from our most basic understanding of civics and 
representative democracy.
  When the outcome of this vote became more important than the product 
itself, taxpayers lost. When the legislative process became an 
afterthought to salvaging a presidency, taxpayers lost. When debate was 
sacrificed for special deals, taxpayers lost.
  Madam Speaker, this process is a disservice and has birthed a flawed 
product that restrains patient freedom and choice, burdens future 
generations with debt, undermines a competitive business model for 
medicine and, most tragically, will reduce the most innovative 
diagnostics and treatment on Earth to the lowest common bureaucratic 
denominator.
  Time and again, the government proves inefficient and obsolete in 
changing times with rapidly emerging technologies. In medicine, that is 
a recipe for obsolescence, archaic approaches, and delayed treatments 
that costs lives and weakens the human condition.
  While I do not hold up the current health care model as perfect--I do 
observe the quality of the treatment options, the daily miracles made 
possible by world-class technology guided by well-trained health care 
professionals, and the range of options in large and small towns alike 
as evidence that the American model is far superior to the cumbersome, 
one-size-fits-all models that are found in nations like Canada and the 
UK whose citizens frequently flee to our nation to find the quality 
care they believe is not available in their own countries.
  Tonight's vote against this bill is cast on behalf of patients and 
doctors, taxpayers and citizens who value innovation, competition, and 
the spirit of the individual that has created the American experience 
and built this great nation into the envy of the world.
  While we can and must do more to improve access and affordability, we 
shouldn't sacrifice all we are as a nation for the security of mediocre 
medicine, bureaucratically administered.

[[Page H1898]]

  Mr. PAULSEN. Mr. Speaker, this body is nearing what will be a 
defining vote for the future of our nation.
  While Majority Leadership continued the arm twisting until enough 
members would vote for the bill, the voice of the American people got 
louder.
  They have made it clear they do not want this bill. My constituents, 
by a margin of over 3 to 1, have told me they don't like this plan--and 
with good reason.
  This bill will cost nearly 1 trillion dollars in the next decade 
alone--and the true cost of this bill will surely go higher as 
entitlement spending soars and other provisions are fully phased in.
  The bill is loaded with job-killing tax increases--and an Associated 
Press analysis said health care premiums will actually go up under this 
plan.
  The bill will also allow the IRS to verify if you have ``acceptable'' 
health care coverage and fine you if you don't!
  This bill will cut $500 billion from Medicare and in turn use that 
money for new entitlement spending. And history has shown entitlement 
spending goes up, not down, over time. With our current entitlement 
programs already headed for insolvency, why on earth would you 
exacerbate the problem?
  I would be remiss if I didn't mention that this legislation also 
negatively impacts our Nation's veterans. It betrays the promise that 
this county made to honor their sacrifice by failing to cover millions 
of beneficiaries including dependents, widows, survivors and orphans.
  The VFW has expressed their opposition to this bill and this body 
should not pass any bill that negatively impacts our veterans. Those 
families who have proudly served this country deserve better.
  Finally, the legislation contains a $20-billion tax on American 
medical manufacturers. This tax--which will hit manufacturers of 
technologies now common in modern medicine such as pacemakers, stents 
and MRI scanners--will be levied against many medical device 
manufacturers in my home state of Minnesota. In the end, this will harm 
jobs and cause patients to pay more for fewer medical technologies--the 
exact opposite of what we need.
  I believe this Nation needs real, bipartisan health care reform the 
American people can support. This bill should be set aside and replaced 
with common sense measures that will actually lower costs for everyone.
  Ms. LINDA T. SANCHEZ of California. Mr. Speaker, whether all 
Americans should have access to quality health care at a reasonable 
price is a question a century old. First raised by Teddy Roosevelt in 
1912, then repeated by FDR, Harry Truman, and later presidents, the 
question almost answers itself. No nation can be strong whose citizens 
are sick and poor. To improve our economy, to care for our people, to 
fix our expensive and broken healthcare system, the time is now.
  Truman argued that the principal reason why people could not receive 
the care they needed in 1946 was that they could not afford to pay for 
it. At the time, the cost of health care accounted for 4 percent of the 
nation's income. Today, the reason people don't receive care most 
likely remains its unaffordability, but the aggregate cost of health 
care has since risen to 16 percent of the nation's income.
  Having grown up in a working family of seven kids, I know how 
important health insurance is. My parents couldn't predict which of us 
might break a leg, need our tonsils out, or worse, but they could 
predict that without insurance, they couldn't pay to get us the care we 
needed. There is no reason that hard working Americans should be priced 
out of needed healthcare.
  Without doubt, this is not a perfect bill. It does not contain strong 
employer responsibility provisions or a public plan to provide real 
competition to private insurers. It cuts DSH payments for hospitals too 
much. It benefits states that have left some of their poorest citizens 
out of Medicaid without rewarding states like California that have been 
doing the right thing all along.
  It contains an Independent Payment Advisory Board, which would 
severely limit Congressional oversight of the Medicare program and 
place authority within the executive branch, without Congressional 
oversight, judicial review, or state or community input. It also does 
something no bill has ever done before--prohibits undocumented 
immigrants from spending their own money to buy private health 
insurance within an insurance exchange or marketplace.
  But the bill's strength--that it makes health insurance accessible 
and affordable for more than 30 million Americans who currently lack 
insurance--is so much more important than its weaknesses.
  After fifteen months of hearings, meetings, debates, and ideas, the 
time has come for Congress to act to make healthcare better for all 
Americans.
  I take this vote after much thought and consideration, not for any 
politician, but for my constituents who are anxious about whether they 
will be able to afford care for themselves and their children when they 
need it. For a nation as wealthy as America to have tens of millions of 
people without health insurance is shameful.
  Even those who have insurance fear losing their jobs, and with it 
their insurance. Some are concerned that they will reach their annual 
or lifetime caps on coverage. Others are anxious that their insurance 
companies will simply drop them as soon as they get sick.
  This bill, which my constituents have told me this Nation desperately 
needs, will address a number of shortcomings in our current system.
  In our current system, those who have insurance pay more to subsidize 
care for those who don't have insurance. This bill changes that by 
requiring everyone to have basic health coverage. Everyone has a stake 
in improving public health. Currently, the uninsured don't get 
preventive care, and once they're sick, they wind up in the most 
expensive place to get treatment--the emergency room. The large number 
of uninsured distorts our system, acting as a hidden tax on the 
insured. This bill repeals that hidden tax.
  In our current system, those with pre-existing conditions are 
discriminated against. No child asks to be born with muscular 
dystrophy, juvenile diabetes, asthma, or Down Syndrome. Yet current law 
allows insurance companies to deny or limit their coverage. This bill 
fixes that injustice, protecting our children, and ensuring they can 
access coverage for life.
  In our current system, some women pay twice as much as men for 
insurance simply because they are women. This bill will change that so 
insurance companies will treat all people equally.
  In our current system, Americans who work just as long and just as 
hard as their fellow citizens often lack insurance simply because they 
work for a small company instead of a large one. This bill addresses 
that too, by creating generous tax credits to small businesses to make 
insurance more affordable, and by creating affordability credits to 
help self-employed folks buy insurance at an affordable price in an 
insurance marketplace.
  In our current system, healthcare costs are skyrocketing out of 
control. This bill will help rein in costs by paying doctors for 
quality, not quantity, and actually reduces the budget deficit, making 
our Nation more fiscally stable.
  Oh, and one more thing, in our current system, millions of Americans 
like their doctors and insurance companies. This bill allows you to 
keep them. Millions of Americans will see no change in this bill except 
for the added peace of mind that occurs when you are no longer at the 
mercy of an insurance company that can drop or deny coverage at the 
drop of a hat.
  And I haven't even mentioned the improvements to Medicare: closing 
the donut hole, eliminating co-payments on preventive tests, and 
reducing fraud and waste to extend the life of the Medicare Trust Fund.
  Yes, anyone who looks at this bill can find something wrong with it. 
But I can't remember the last time I voted on a perfect bill here in 
Congress. Just about every bill can be improved in one way or another.
  On balance, this bill does what I came to Washington to do: to give a 
voice to average working people, whose voices are too often drowned out 
by the voices of moneyed interests.
  Because I believe this bill would make America a stronger, more 
stable, healthier, fairer, and more just Nation, I vote yes.
  Mr. CONYERS. Mr. Speaker, I rise today in strong support of the 
American people's call to pass health reform, and I urge this body to 
pass this historic bill.
  We are here at this moment, principally, because of one number: 45 
million. These are the uninsured Americans, many of whom have lost 
their job and their health insurance in the worst economic downturn 
since the Great Depression. Today's vote on this imperfect legislation 
is necessary because our fellow citizens desperately need access to 
affordable comprehensive health care services. This legislation will 
give them that foot in the door and pave the way for greater future 
reforms.
  America remains the only nation in the industrialized world where 
health care is a for-profit corporate enterprise, where approximately 
45,000 uninsured people die each year from lack of coverage, and over 1 
million people go bankrupt each year.
  Let me be clear. This is not a perfect bill. I would have preferred a 
different approach that covered more people. But let me address those 
who oppose this bill. Tomorrow, they are going to wake up and our 
democracy will still stand. We will continue to live in the greatest 
country with the hardest working, most patriotic, freedom-loving 
citizens on the planet.
  The real impact of the bill will be felt tomorrow when:
  Insurance companies can no longer drop a person's coverage once they 
become sick;

[[Page H1899]]

  The average senior citizen will gain an additional $1,727 in 
prescription drug coverage; and
  Our children cannot be denied coverage based on pre-existing 
conditions and will be covered under our policies until they are 26.
  When health reform is fully enacted, approximately 31 million 
additional Americans will have access to health insurance, with 15 
million of them receiving care via an improved Medicaid.
  Don't let anyone fool you--Medicare will be strengthened by this 
bill. The only Medicare cuts in this bill are the billions in corporate 
welfare subsidies to health insurance companies that provide minimal 
benefit to seniors. The bill takes this wasteful spending and applies 
these funds to benefit consumers, not insurance companies. Medicare 
will become more affordable, offer more comprehensive benefits, and 
continue to provide peace of mind to America's seniors for years to 
come.
  We will not end our efforts to improve our health system with the 
passage of this bill. Just as we have improved Medicare and Social 
Security, so too will we strengthen this initial package of reforms.
  Members of the Senate Leadership have made it clear they will revisit 
the idea of a public health insurance plan this year. I call on my 
fellow progressives to hold firm in our insistence on such a vote. The 
health insurance monopolies fear the competition an efficient not-for-
profit public health insurance plan would provide and that is exactly 
why we must have an up or down vote on this proposal.
  I support a public health option because I fundamentally believe in 
the value of public health insurance. For this reason, I remain an 
ardent supporter of universal single-payer health care. This system has 
successfully provided quality, affordable, and cost-effective health 
care wherever implemented, whether with Medicare, the U.S. military, 
Europe, Taiwan, or Japan.
  Adoption of a single-payer system is the only long-term means to 
eliminate the
corporate-medical-industrial-complex which threatens to undermine our 
health system with continued rising costs and an insatiable desire to 
pass costs onto already burdened citizens. For-profit investor-owned 
hospitals, prescription drug companies, and medical device 
manufacturers are just as culpable as the health insurance industry and 
future reforms must seek to address the profits-first mindset that 
prevails in these industries.
  If this bill passes, we should celebrate it. Tomorrow we will begin 
the work to make it better--to truly secure health care as a human 
right.
  Mr. HOEKSTRA. Mr. Speaker, I rise today to vehemently object to the 
government takeover of health care.
  It is bad social policy, bad public policy and bad fiscal policy for 
the United States.
  The health care bills we will vote on today are estimated to cost 
more than $1 trillion, will expand government bureaucracy, permit 
taxpayer-funded abortions, increase taxes and cut Medicare. 
Additionally, it includes egregious sweetheart deals such as the 
``Cornhusker Kickback'' for Nebraska, ``Gator Aid'' for Florida and the 
``Louisiana Purchase.''
  My home state of Michigan alone will be forced to pay $710 million 
annually for new Medicaid enrollees, money the state does not have to 
spare. It is verging on denying the state's ability to regulate health 
care programs and insurance and encroach on its sovereignty in doing 
so.
  Every American is personally impacted by health care. As such over 
the last year Michigan residents and all Americans have voiced their 
opposition with the health care proposals in Congress. It is 
disheartening to see that Congress is blatantly ignoring the voice of 
the public.
  The U.S. health care system remains the best in the world, but still 
needs reform. Reform can be achieved by targeted measures such as 
allowing insurance competition across state lines and creating high-
risk pools of money for states to support those with pre-existing 
conditions.
  I had hoped that we could work in a bipartisan manner to achieve 
reform of health care, but Republicans were not allowed a seat at the 
table.
  We do not need the federal government to take over one-sixth of the 
American economy, and saddle states like Michigan with mandates, tax 
increases and debt.
  Mr. Speaker, in Michigan a situation has developed in which home 
health car providers have been forced to pay union dues to state 
because they accept federal dollars.
  How can we be sure that the same will not happen to medical 
practitioners who will be forced into a government-run system?
  Additionally, I am concerned that the reconciliation bill that we 
will vote upon today will completely federalize student lending, 
leading to lost jobs, tax increases and the elimination of choice.
  Mr. Speaker, I will be voting against the bills, and I respectfully 
submit my remarks for the Record.
  Mr. COBLE. Mr. Speaker, I rise in opposition to the proposed 
government takeover of our health care system.
  I have not come at this decision lightly. Although a small portion of 
my constituents support this proposal, the vast majority want nothing 
to do with it. Clearly there are areas of our health care system that 
need to be improved. That being said, this bill is a complete overhaul 
of the system.
  Make no mistake about it. This bill will put the government in 
control of our health care. It is a train wreck waiting to occur and 
considering our current economic morass, we need no train wrecks.
  It is with the best interests of all of my constituents, their 
children and future generations that I will oppose this legislation.
  Mr. POSEY. Mr. Speaker, I rise to express my strong objections to the 
health care legislation, H.R. 3950, and the unprecedented, process 
through which it is being considered. The overwhelming majority of 
Americans are telling Washington through their letters, calls and every 
poll that they don't want this bill. Nearly eight in ten of my 
constituents who have contacted me on this issue have asked that I vote 
against the bill.
  Social Security is already unsustainable. Medicare is unsustainable. 
Medicaid is unsustainable and reimbursements are already so low that 
few doctors will even see Medicaid patients. These programs have tens 
of trillions of dollars in unfunded liabilities. Rather than fix these 
problems, the bill before us makes them worse. This bill takes over 
$500 billion out of Medicare and spends it on this new health care 
plan. It adds millions of new enrollees to Medicaid--already one of the 
fastest growing federal and state budget line items. H.R. 3950 takes 
over $53 billion out of the Social Security Trust Fund and spends it on 
this new health care plan. And, they say that this bill will save the 
taxpayers money.
  The American people have figured it out and that is why they want 
this particular piece of legislation stopped. It's not that they don't 
want health care reform; it's just that they don't want this particular 
bill. No one is suggesting that the status quo is acceptable. In fact, 
I have cosponsored more than a dozen health care bills aimed at fixing 
the problems with our current system. I suggested in a meeting with the 
Secretary of Health and Human Services Kathleen Sebelius, that we move 
forward with those things upon which we can reach agreement--like 
addressing preexisting conditions and ending the practice of insurance 
companies dropping coverage for someone when they get sick. 
Unfortunately, she rejected that offer.
  I want to talk just briefly about the cost of this bill. On Thursday, 
a preliminary Congressional Budget Office, CBO, cost estimate of the 
bill was released. But that budget included a number of gimmicks that 
hide the real costs of health care reform legislation. I believe the 
American people want and deserve honest budgeting because once the 
smoke and mirrors are removed, they will have to pay the costs of this 
bill.
  Let's look at why we have the differences. It is important to 
remember that the CBO can only estimate the costs of the specific 
language that is presented to them. An analysis of the costs of the 
bill that was released by the Senate Budget Committee found that after 
you remove the budget gimmicks, this bill increases the budget deficit 
by nearly $600 billion in the first 10 years and $1.6 trillion over the 
second 10 years. This is a far cry from the preliminary budget estimate 
from the CBO, which put the net effect of the bill at reducing the 
deficit by $118 billion over 10 years. So, what causes this 
discrepancy?
  What are some of the reasons for the differences? CBO does not 
include in its calculation the $53 billion that is borrowed from Social 
Security to pay for H.R. 3950. CBO assumes these monies will not have 
to be repaid to the Social Security Trust Fund.
  Likewise, the bill includes over $500 billion in cuts to Medicare 
program and assumes that future Congresses will allow these cuts to be 
fully implemented. Anyone remotely familiar with Congress knows that 
time and again Congress has stepped in to stop such Medicare cuts and 
may well do so again in the future. Thus to assume that Medicare will 
be cut by nearly $500 billion is simply not realistic. Furthermore, 
rather than take these Medicare savings and spend them elsewhere, these 
funds could have been used to help secure the long-term solvency of 
Medicare.

  This bill creates a new long-term care entitlement benefit, known as 
the CLASS Act. This bill collects $70 billion more in premiums than it 
will pay out in benefits over the first 10 years of the program. Rather 
than keep this $70 billion in the Trust Fund to pay future benefits, 
H.R. 3950 takes the money out of this trust fund and uses it to pay the 
costs of H.R. 3950.

[[Page H1900]]

  H.R. 3950 creates dozens of new programs; however, the CB0 cost 
estimate does not include any costs associated with these programs. The 
Senate Budget Committee estimates the 10-year costs of these programs 
at $114 billion.
  Medicare also faces more than a $200 billion shortfall in the amount 
of funding needed to pay physicians. It would have been appropriate to 
use the Medicare savings in H.R. 3950 to fix this problem. However, 
H.R. 3950 leaves in place the 21 percent cut in payments to doctors. 
Speaker Pelosi has said that we can expect another bill to come to the 
House floor in a few weeks that fixes this shortfall. The cost of that 
bill will simply be added to the deficit and no one will have to pay 
for it.
  So, rather than saving $118 billion over 10 years as CBO estimates, 
the real costs will be hundreds of billions of dollars in deficit 
spending in just the first 10 years. Between 2020 and 2029 the debt 
rises even more.
  Our nation has lost millions of jobs since January of 2008. To 
restore these jobs, our nation would have to create 250,000 jobs per 
month for each of the next 5 years. Hundreds of billions of dollars in 
new taxes on small business and new costly mandates included in H.R. 
3950 will only result in the loss of additional jobs and it will make 
it harder for businesses to hire new employees. In fact, it is 
estimated that this bill may result in the loss of more than 2 million 
additional jobs.
  Not only does this bill have a costly impact on businesses, but it 
imposes tens of billions of dollars in unfunded mandates on the states. 
Our state budgets are already stretched thin and governors and state 
legislatures are cutting tens of billions of dollars just to balance 
their budgets--something many states are required to do, but not 
Washington. This bill makes that task harder for the states and will 
ultimately result in higher taxes on individuals and businesses.
  H.R. 3950 lacks sufficient protections to ensure that American 
taxpayers are not forced to pay for the health care of millions of 
illegal immigrants.
  I am further concerned that this bill fails to include protections, 
passed earlier this year in the House, that would ensure that taxpayer 
money is not used to pay for elective abortions. This bill also lacks 
sufficient conscience protections to ensure that health care providers, 
doctors, nurses, hospitals, and health plans are not required to 
participate or in any way support elective abortions.
  Never before has Congress considered a bill that so fundamentally 
changes the relationship between the people and the government.
  This bill gives the federal government unprecedented powers. H.R. 
3950 empowers government panels to make coverage determinations. It 
also creates the Independent Medicare Advisory Board, IMAB, which is 
given broad authority to make cuts in Medicare.
  Over 4,000 times in this bill, the word ``shall'' appears, and 
``shall'' indicates a federal mandate. In more than a dozen places, the 
bill provides that there will be ``no administrative or judicial 
review'' of a federal bureaucrat's decision.
  It has been said that: ``A democracy cannot exist as a permanent form 
of government . . . It can only exist until the voters discover they 
can vote themselves largess from the public treasury. From that moment 
on, the majority usually votes for the candidates promising them the 
most benefits. Therefore the average age of the world's greatest 
civilizations has been about 200 years. These nations have progressed 
through this sequence: From bondage to spiritual faith; from spiritual 
faith to great courage; from courage to liberty; from liberty to 
abundance; from abundance to selfishness; from selfishness to apathy; 
from apathy to dependence; from dependency back again into bondage.''
  This bill vastly expands the powers of the Internal Revenue Service, 
IRS. If this bill becomes law, the IRS may have to hire up to 16,500 
additional employees just to enforce all the new taxes and penalties. 
The bill empowers the IRS to: (1) verify that Americans have 
government-approved health care coverage; (2) fine Americans up to 
$2,085 or 2 percent of income (whichever 'is greater) for the failure 
to purchase a government-approved plan; (3) confiscate tax refunds; and 
(4) increase audits.
  Finally, I would be remiss if I did not express my deep 
disappointment with the process that has characterized this debate and 
the manner in which this legislation has been written. I come from the 
sunshine state, where we have very strict laws about transparency and 
openness in government--a process that is seriously lacking in 
Washington.
  The House considered a bill in three committees last summer. A 
handful of Republican amendments were adopted in those committees. 
Unfortunately, when the bill was rewritten behind closed doors before 
coming to the House floor in November; those amendments were removed 
from the bill. When the House considered this bill in November 2009, 
over 200 amendments were filed to be offered, but the leaders in the 
majority allowed only one amendment to be voted on.
  Likewise the Senate bill was written behind closed doors and no 
amendments were allowed to be offered when it was considered in the 
Senate in December 2009. It includes special earmarks meant to secure 
the votes of particular Senators. Now we are debating that bill today, 
and once again no amendments are allowed to be offered.
  We are also debating a new bill drafted by the majority in the House 
that purports to make changes to the Senate bill. Again, this bill was 
drafted behind closed doors over the last few days and includes yet 
again more special provisions intended to secure particular votes. 
Yesterday, at the House Rules Committee, Republicans presented over 80 
amendments that they wanted to offer to this bill, but not a single one 
allowed an up or down vote.
  Mr. Speaker, is it any wonder that the American people have so much 
disdain for Washington and this body? This is a sad day characterized 
by a lack of openness and transparency. The American people deserve 
better.
  Mr. KANJORSKI. Mr. Speaker, today I voted for legislation designed to 
improve the affordability and accessibility of health care. Americans 
already spend more on health care than the people of any other nation. 
If we take no action, health care costs are expected to double over the 
next 10 years, just as they have over the last 10 years. It is not the 
bill I would have written if it were up to me alone, but it is the best 
we can do at this time.
  This was one of the most difficult votes I have ever cast, primarily 
because there is a great deal of confusion about what this bill will 
do. Over the last year, many people throughout Northeastern 
Pennsylvania have taken the time to voice their thoughts on this health 
care reform bill, and I have taken each voice into consideration. I 
have heard the desperate pleas from people who have been sick and can 
no longer obtain any insurance. I have heard from small business owners 
who struggle to pay the premiums for their employees. I have also heard 
from a sizable number of my constituents who fear they will lose 
fundamental freedoms if this bill becomes law. From my careful review 
of the legislation, I have come to the conclusion that this fear is 
unfounded.
  Democracy requires the consent of the governed, but that consent 
needs to be informed with facts, not the widespread misinformation 
which has permeated the national conversation about this legislation. I 
had hoped that the House and Senate would conduct a conference 
committee to iron out the differences between the House and Senate 
bills televised by C-SPAN so that the American people would have an 
opportunity to understand the provisions included in this very complex 
bill. It is important to set the record straight between facts and 
myths.
  This bill does not empower the federal government to take over health 
care. In fact, this bill preserves the employment-based private 
insurance delivery system upon which a majority of working Americans 
relies for insurance coverage. It allows participants to choose the 
health insurance plan that best fits individual and family needs by 
creating a marketplace of insurance plans, resembling the Federal 
Employees Health Program used by all federal workers, including Members 
of Congress. The bill attempts to rein in those private insurers by 
prohibiting their most egregious abuses: denying coverage for 
individuals with pre-existing medical conditions, imposing a lifetime 
cap on medical care, and limiting the ability of individuals to change 
jobs without the fear of losing insurance coverage. It will also enable 
young adults to stay on their parents' insurance until age 26.
  If people currently have health insurance, whether it is through an 
employer or another means, their coverage will not change. If anything, 
their premiums are expected to decrease because there will be more 
people in the insurance pool. But, if people are unsatisfied with their 
insurance, they will have the capabilities to switch to a plan that 
best fits their needs.
  Senior citizens have expressed a great deal of worry that they will 
be denied services if this bill becomes law. In fact, seniors will 
experience better coverage for their prescription drug costs and will 
have no out of pocket costs for preventive care. In addition, this 
legislation reduces excessive payments to private insurance companies 
that administer Medicare Advantage Plans and applies those savings to 
the bill. It also works to reduce waste, fraud, and abuse in the 
Medicare program, which will help strengthen the program. As a result 
of this legislation, the non-partisan Congressional Budget Office (CBO) 
estimates that the solvency of the Medicare program will be extended by 
more than 9 years.
  This bill will help save American families money and prevent health 
care costs from bankrupting our country. The U.S. spent 16 percent of 
its gross domestic product, GDP,

[[Page H1901]]

on health care in 2008, more than any other industrialized country. CBO 
estimates that number will rise to 25 percent without changes to 
federal law. CBO also estimates that this bill will reduce the deficit 
by $138 billion over the 2010-2019 period.
  Many of my friends who oppose abortion have expressed concern that 
their tax dollars could be used to pay for abortions. I have been 
assured that this is not the case, and I am pleased that President 
Obama intends to issue an executive order to clarify that no funds in 
the bill will be used for abortion. Moreover, I will continue to remain 
vigilant to ensure that the Hyde Amendment, which prevents federal 
funding of abortion, remains the law of the land.
  I was greatly disturbed when the student loan legislation was hastily 
attached to the health care reform bill at the last minute because of 
the impact it would have on the 1,100 Sallie Mae workers in my 
district. Yesterday, Education Secretary Arne Duncan assured me that he 
will use all of the tools at his disposal to help ensure that these 
workers will remain employed.
  I thank the many Northeastern Pennsylvanians who have shared their 
thoughts with me on this important legislation over the past few 
months. When you are sick, the last thing you should have to worry 
about is how to pay the bills. Insurance is supposed to relieve this 
worry, but instead the current system has made that worry worse. Today, 
we are working to reverse this course.
  Mr. GALLEGLY. Mr. Speaker, if Congress wants to remove fraud and 
abuse from the healthcare system, it can start by overturning this 
bill.
  The Congressional Budget Office released an updated analysis of H.R. 
4872. According to the Congressional Budget Office, this bill will cost 
taxpayers $1 trillion. The analysis also confirmed that this bill will 
raise healthcare premiums $2,100 more a year for millions of families 
than if Speaker Pelosi had left healthcare alone.
  It also reaffirmed that as many as 9 million people now enrolled in 
employer-based plans will lose their coverage.
  At a time when our military men and women are fighting terrorists 
around the world, the national commander of the Veterans of Foreign 
Wars urged Congress to vote the bill down because it does not protect 
veteran healthcare plans.
  At a time when unemployment has hit a record 11.6 percent in Ventura 
County and 10.4 percent in Santa Barbara County, Speaker Pelosi's bill 
adds $569.2 billion of additional taxes onto the backs of American 
families and $52 billion on struggling employers.
  It hurts seniors with $200 billion in cuts to Medicare Advantage and 
raids Medicare and Social Security to fund the new mandate and hide the 
true cost of the bill.
  This bill must be overturned before the bulk of its provisions take 
effect in 2014. I support real reform that reduces premiums, reduces 
government spending and protects the doctor-patient relationship.
  I cosponsored a bill that would provide real reform, but Speaker 
Pelosi will not allow a vote on it. It includes:
  Allowing small businesses to band together to purchase health 
insurance for employees and use their combined bargaining power to 
negotiate better health benefits at lower prices.
  Reforming medical liability laws to discourage unnecessary and 
frivolous lawsuits, which only drive up prices for everyone and force 
doctors to practice defensive medicine.
  Removing unnecessary regulations that prevent health insurance 
companies from operating across state lines--which will provide the 
competition without government-run health care.
  Establishing high-risk pools to help people with pre-existing 
conditions find affordable insurance.
  I and many of my colleagues believe issues of portability, increasing 
costs and rescinding coverage must be addressed. However, in doing so, 
we must also protect a patient's right to choose the best coverage for 
him or herself in a vibrant, competitive marketplace, not force 
Americans into a one-size-fits-all government-run program designed by 
Speaker Pelosi.
  Mr. YOUNG of Florida. Mr. Speaker, four and a half months ago when 
the House first considered health care reform legislation I voted 
against it saying that it did not represent good public policy.
  Nothing in the package of legislation we will consider today and 
tonight changes my mind. It is still not good public policy, it was not 
considered under an open process envisioned by the drafters of our 
Constitution, and it will drive up--not down--the cost of health 
insurance and medical care for individuals.
  This bill cuts Medicare by $523.5 billion. This cannot do anything 
but compromise the quality and availability of care for older Americans 
who depend upon the program for their medical care. The Chief Actuary 
for the Centers for Medicare and Medicaid Services confirmed that in 
December when he advised Congress that ``providers for whom Medicare 
constitutes a substantive portion of their business could find it 
difficult to remain profitable and, absent legislative intervention, 
might end their participation in the program (possibly jeopardizing 
access to care for beneficiaries).''
  A large percentage of my constituents in the 10th Congressional 
District rely on Medicare for their health care coverage and a large 
number of medical providers in my area care for a high percentage of 
Medicare patients. In a survey I sent to every registered voter last 
fall in my Congressional District, and to which more than 31,500 
responded, 83 percent of the respondents said they were opposed to 
paying for health care reform by cutting billions from the Medicare 
program. They are concerned about the cuts in this legislation for 
inpatient and outpatient hospital services, inpatient rehabilitation 
services, long term care facilities, skilled nursing programs, hospice 
services, kidney dialysis facilities, and medical laboratory services.
  If this is not of concern enough to our nation's seniors, the 
legislation we consider today cuts $200 billion from the Medicare 
Advantage program, through which an estimated 47,000 residents of the 
10th Congressional District receive their medical care. The Chief 
Actuary for Medicare has said that cuts of this magnitude would force 
more than 60 percent of these Medicare Advantage beneficiaries from the 
program. Nationally, that totals 4.8 million Americans who would lose 
their current coverage.
  Despite the fact that this legislation makes draconian cuts in 
Medicare, it will increase, not decrease, overall federal spending on 
health care. The non-partisan Congressional Budget Office (CBO) 
estimates that overall federal spending on health care will increase by 
$390 billion over 10 years. This is at a time when proponents of this 
legislation say it will save money.
  Supporters of this legislation also tout the expansion in health 
insurance coverage they claim it will bring about. However, this 
expansion is due in large part to increasing the Medicaid rolls. In 
fact, the CBO estimates that of the 32 million newly insured Americans 
under this legislation, half, or 16 million, will receive their 
insurance through the federally and state sponsored Medicaid program. 
At the same time, millions of people will be enrolled in subsidized 
plans on the government run health insurance exchanges and millions 
will lose their employer sponsored health insurance.
  Mr. Speaker, the majority of people I represent like the health care 
coverage they currently have and do not believe this legislation will 
improve the quality of their coverage. In my Town Hall by mail survey 
last fall, 73 percent of those who responded said they are satisfied 
with their current coverage and 70 percent say this legislation would 
not improve the quality of their coverage. Furthermore, 75 percent say 
Congress should not raise taxes to pay for this legislation and 74 
percent say individuals should not be required to purchase health 
insurance.

  Many constituents have also expressed their grave concerns about the 
insertion of the federal government into the precious patient-doctor 
relationship. A perfect example of this is the creation of 159 new 
boards, bureaucracies, and programs created in the 2,733 page health 
care bill.
  For example, in an effort to keep Medicare spending below targeted 
levels the legislation creates the Independent Medicare Advisory Board. 
This new entity will be required to submit recommendations to Congress 
to keep Medicare spending below targeted levels. This could result in 
additional coverage decisions being made by unelected bureaucrats 
largely or exclusively on cost grounds.
  Few issues have divided the American people as much as this health 
care debate and given the interest and passion they have shown on this 
matter demands that we give it serious consideration with a lot less 
politics. Many of us have suggested that we start with legislation in 
areas that we all agree we can fix now. That includes lowering health 
insurance costs by allowing small businesses and individuals to pool 
together in lower priced plans, requiring the coverage of individuals 
with serious pre-existing medical conditions, prohibiting insurance 
companies from canceling policies for those who become sick, 
prohibiting insurance companies from imposing arbitrary spending caps 
for policyholders, allowing families to purchase health insurance 
policies across state lines, closing the Medicare Part D doughnut hole, 
and providing for medical liability tort reform which the Congressional 
Budget Office says would save $54 billion over 10 years in large part 
due to lower medical malpractice premiums and the reduction of 
defensive medicine practices.
  In addition to Medicare cuts, the authors of this legislation pay for 
new big government programs by raising federal taxes by $569 billion 
over a ten year period. Many of those taxes will impact middle class 
families. These are families who will pay a penalty if they choose not 
to carry health insurance, the owners of small businesses who will pay 
a penalty

[[Page H1902]]

if they do not provide health insurance for their employees, a sales 
tax on medical devices, a tax on prescription drugs, and a tax on 
health insurance premiums.
  This bill also violates the President's promise that if you like your 
insurance you can keep it. In addition to the 4.8 million seniors who 
will lose their coverage under the Medicare Advantage program, the CBO 
estimates that another 8 to 9 million people would lose their employer 
based coverage when their employers choose to drop their coverage or 
shift their coverage to the new subsidized policies on the health care 
exchange.
  This legislation would also contradict the President's promise that 
the cost of health care coverage would go down. Instead, the CBO 
estimates that the enactment of this legislation will raise private 
health insurance premiums from 10 to 13 percent.
  Mr. Speaker, most Presidents make it a practice of trying to bring 
the country together in the face of difficult issues. We did this in 
bipartisan fashion when it came to ensuring the financial solvency of 
the Social Security system, reforming our nation's welfare programs, 
and in engaging in an international war on terrorism. Yet this 
administration has sought to do it their way whether the country agreed 
or not.
  Tonight we are faced with legislation that affects every American, 
every American family, and every American business. The decision we 
make tonight could be irreversible and the changes to the Senate passed 
bill that are promised tonight may never take place. This is no way to 
conduct our nation's business. It engenders no level of confidence in 
the people who elected us to serve them.
  Mrs. CAPPS. Mr. Speaker, I rise in strong support of passing 
comprehensive health care reform legislation.
  This moment has been a long time coming. I've worked on health care 
since coming to Congress and passing comprehensive reform has always 
been a major goal of mine.
  I've met with and listened to my constituents, along with countless 
doctors, nurses, hospital administrators, researchers, and other health 
care experts. They know that America's health care system has many 
wonderful aspects: it can provide the most cutting edge care, cure 
diseases thought fatal only a few years ago, and devise new and 
exciting drugs, devices and treatments with mind numbing speed.
  But we also know our health care system's problems are legion. 
Coverage is erratic, incomplete and can evaporate without notice; costs 
are out of control for consumers, businesses and taxpayers; and health 
outcomes are actually better in dozens of countries that spend far less 
per capita than we do.
  The legislation before us addresses these problems and will help 
ensure that affordable, quality health care is always available to all 
Americans.
  The most trumpeted aspect of the bill is the coverage it would 
provide to some 32 million Americans who are currently uninsured, 
including an estimated 92,000 citizens in my own district. Passing this 
legislation is a matter of life or death for them as an estimated 
45,000 Americans die every year because they lack health care 
insurance. In addition, the uninsured are much more likely to forego 
primary care and delay other health care services leading to the 
development of otherwise preventable disease, requiring much more 
invasive and costly treatments.
  The bill expands Medicaid to provide coverage for more very low 
income individuals, and sets up state exchanges that will serve as 
marketplaces for individuals and small businesses to buy affordable 
health plans. The bill provides assistance to some individuals to 
purchase coverage and tax credits to small businesses so that they can 
provide health insurance to their employees. And it lets young adults 
stay on their parents' plans until age 26. These new mechanisms and 
support systems should provide coverage to the vast majority of today's 
uninsured, improving both the physical and financial health of millions 
of our fellow citizens.
  But, perhaps just as important, the bill offers critical protection 
for those already with health insurance. Today, insurance companies 
often drop consumers if they get sick, refuse coverage for so-called 
pre-existing conditions, and put annual and lifetime limits on a 
consumer's coverage. This bill puts an end to those unfair practices. A 
wife's diagnosis of cancer or a child's serious accident shouldn't be 
the cause for a family losing health insurance just when it is needed 
most.
  Those currently with coverage will also benefit through lowered 
insurance premiums. The Congressional Budget Office says premiums will 
be 14 to 20 percent lower per policy holder. Furthermore, the 
nonpartisan Robert Wood Johnson Foundation estimates that without 
health care reform individuals and families would see their health 
insurance premiums rise by as much as 79 percent over the next decade. 
That is unaffordable, unsustainable and just one of the many reasons we 
must enact this legislation.
  The bill also makes significant investments to train our next 
generation of doctors, nurses and allied-health professionals. This is 
critical because today's current shortages of nurses and doctors would 
only be exacerbated as we bring millions of new regular patients into 
the system without the appropriate investment in our health care 
workforce.
  The legislation will also make it much easier to access preventive 
health care services by eliminating co-pays for important recommended 
screenings such as those for heart disease or cervical cancer.
  Mr. Speaker, I've been hearing a lot from senior citizens concerned 
about what our health care reform proposal would mean for them.
  The bill will close Medicare's prescription drug ``donut hole,'' 
which in my Congressional district affects nearly 9,000 beneficiaries. 
It is unfair that policyholders should have to pay insurance premiums 
while receiving no coverage. The legislation before us today will give 
seniors who fall into the donut hole a $250 rebate this year, 50 
percent discounts on brand name drugs when they fall into the donut 
hole beginning next year, and completely close the donut hole by 2020. 
In addition to closing the donut hole, we take steps to crack down on 
fraud, waste and abuse which will extend the solvency of the Medicare 
Trust Fund by 9 years, according to CBO.
  Finally, this bill is the largest deficit reduction measure in a 
generation. According to CBO enactment of this legislation is projected 
to reduce the federal deficit by $130 billion by 2020 and by over $1.2 
trillion during the following decade. Earlier this year, the 
Democratic-led Congress reinstated tough ``pay-go'' budget rules the 
Republican-led Congress had allowed to lapse in 2003 and this health 
care bill is a reflection of our determination to bring our federal 
books back into balance as they were prior to the Bush Administration.
  Mr. Speaker, I will not argue this is a perfect bill because it is 
not. Most problematically, it lacks a public option, which would make 
the insurance market more competitive, ensure the greatest possible 
choice for consumers and bring down health care costs even more than 
the bill does already. I am also deeply disappointed the bill contains 
inappropriate language that may restrict a woman's access to 
reproductive health services.
  But I'm also not one to let the perfect be the enemy of the good and 
in this case, we have legislation that is very good and deserves our 
favorable consideration.
  I urge my colleagues to do the same.
  Mr. HOLT. Mr. Speaker, I rise today to support the health reform 
package we are debating today. It is an important, very beneficial step 
in America's history.
  I see the need for this legislation when I meet with my constituents, 
read their letters, and talk with them on the phone. A woman from 
Pennington, New Jersey called me yesterday. She was concerned that she 
would lose her job due to state budget cuts in New Jersey, which would 
mean that she would lose her health coverage as well. She told me her 
worries about finding affordable coverage while she looks for a new job 
and tries to keep food on her table. To complicate her situation, she 
has a pre-existing condition. This means that even if she could afford 
health care, it is possible she could be denied due to her pre-existing 
condition.
  This woman's story is not unique. At a roundtable in Trenton, a 
spouse of a cancer patient told me that when she and her husband came 
home from the hospital after one extensive treatment, they returned to 
foot-high stacks of insurance paperwork and $150,000 of out-of-pocket 
charges for her husband's needed care. A self-employed woman from East 
Brunswick wrote to me to let me know she pays $2,000 a month for her 
family's coverage and still sometimes has to pay out-of-pocket to see 
physicians.
  I vote for health reform to help middle-class women and men just like 
these hardworking New Jerseyans, who play by the rules and still find 
health coverage out of reach.
  Once reform goes into effect, families and small businesses will have 
more control over their own health care.
  Families with health insurance through their employers would benefit 
from caps on yearly out-of-pocket costs. Seniors would find that 
Medicare not only remains intact, but is improved--recipients would 
receive free preventive care and better primary care. Small businesses 
would have more health insurance options and additional support for 
their health insurance expenses. Patients with diseases such as 
diabetes or cancer would be able to obtain insurance without being 
turned away because of their pre-existing condition.
  The benefits of this health reform would be felt immediately upon 
enactment of the health insurance reform package. For example, small 
business owners who provide insurance for their employees would receive 
tax credits, families would no longer face annual or lifetime caps on 
their insurance benefits, and

[[Page H1903]]

seniors with high prescription drug costs would receive $250 of 
additional assistance in their Medicare prescription drug plan.
  The health reform package would do all these things while reducing 
the deficit by $138 billion for the first ten years and by $1.2 
trillion in the next ten years.
  Today's vote is the culmination of over a century of debate about 
health reform. Since Teddy Roosevelt ran for President in 1912, our 
nation has been debating how to ensure that sick Americans can access 
the care they need. This Congress has been debating this health reform 
legislation in one of the most thorough processes in recent memory. 
During the past few years, the House of Representatives has held 79 
bipartisan hearings on health insurance reform, debated 239 amendments, 
and heard from 181 witnesses.
  The vote today brings this extensive process to a close at least here 
in the house, finally passing health reform legislation that will 
provide secure coverage to all Americans, ensure families have stable 
costs, and improve Medicare for our seniors.
  I urge my colleagues to vote in favor of this health reform package 
to provide health security to our nation's families and small 
businesses.
  Mr. McCLINTOCK. Mr. Speaker, I rise in opposition to this flawed 
health care bill. Under the provisions of this bill, Americans will be 
required by federal law to purchase health insurance policies that 
include every mandate imposed by the new federal health czar and will 
face federal fines and even imprisonment if they refuse. And they will 
pay for them through a combination of higher taxes, higher premiums or 
lower wages.
  The proposition that Congress has the power to order Americans to 
purchase insurance--or any other product--is contrary to the 
fundamental concept of individual liberty and antithetical to the 
takings clause of the Fifth Amendment. If this precedent were to be 
upheld, the federal government will have assumed authority over every 
aspect of individual choice in the care of ourselves and our families 
and can logically be extended to what foods we choose or to what 
physical activities we engage in. Nor is this brave new doctrine 
limited to health care. Once the precedent is established that 
government may usurp individual decisions in the marketplace, what 
limitation remains on its power to order any other of our decisions as 
consumers?
  Fortunately, the Constitution still protects our freedom from such 
usurpations. It will fall to the Supreme Court to hold this act 
accountable to the Constitution and it will fall to ``We the People'' 
to hold those responsible for it accountable at the polls.
  Mr. HERGER. Mr. Speaker, the ``Reconciliation Act of 2010,'' written 
behind closed doors and published just a few days ago, does nothing to 
improve the Senate health care bill. It is simply more of the same: 
higher taxes on investment and job creation, more cuts to Medicare to 
pay for the new government health care program, and more special 
backroom deals reflecting the Majority's determination to pass this 
bill by any means necessary.
  The reconciliation bill raises the Medicare payroll tax and, for the 
first time in history, applies it to unearned income. This tax hike is 
aimed squarely at small businesses and is sure to result in the loss of 
even more jobs. Even worse, Congress is once again raiding the Medicare 
and Social Security Trust Funds to pay for other programs.
  The reconciliation bill also contains higher cuts to Medicare 
Advantage--over $200 billion in all. If this passes, it is the end of 
Medicare Advantage as we know it. Senior citizens in many parts of the 
country will no longer be able to choose their Medicare plan. Once 
again, these cuts have nothing to do with solving Medicare's long-term 
budget problems. They are greasing the skids for the new government 
health care program.
  Not only does the reconciliation bill leave in place many of the 
backroom deals included in the Senate bill, it adds several new ones, 
including a special tax exemption for union multiemployer health plans 
and extra Medicare money for hospitals and physicians in certain parts 
of the country. The American people have repeatedly expressed outrage 
at the special deals that are being made behind closed doors, yet the 
Democratic Majority still refuses to listen.
  One of the most serious concerns I have heard from my constituents is 
that the Senate government health care bill will lead to rationing. 
Unfortunately, the Rules Committee refused to make in order my 
amendment to ensure that the new comparative effectiveness research 
board established by the Senate bill cannot be used as a basis for 
cost-based coverage denials. The Majority has repeatedly refused to 
include an ironclad guarantee that Medicare will not start rationing 
access to life-saving treatments because of their cost. The 
reconciliation bill also leaves intact a new Independent Payment 
Advisory Board of unelected bureaucrats that will have the power to 
change Medicare payment policies without congressional approval, and 
that cannot be repealed without a supermajority vote of the House and 
Senate. This board is charged not only with issuing recommendations, 
but also implementing Medicare policy. It is the ultimate embodiment of 
government-run health care where decisions about access to innovative 
new drugs, treatments and therapies are decided not by patients and 
doctors and a functioning marketplace, but by unresponsive and 
unaccountable bureaucrats working to contain costs.
  In a final touch of irony for a Majority that has repeatedly insisted 
that they are not aiming for a government takeover of health care, this 
reconciliation bill incorporates a complete government takeover of the 
private student loan industry. The Majority's rationale for this policy 
is that the current policy of government subsidies for private 
businesses is not controlling costs and has become too expensive. The 
Congressional Budget Office has already told us that the Senate health 
care bill will cause individual private insurance premiums to rise 
faster than they would under current law. It is difficult to imagine 
that a government-industry cartel will be any more efficient for health 
insurance than it was for student loans. After a few years of this 
policy, will Democrats again conclude that costs are out of control and 
the government must take over?
  The House should reject both the Senate government health care bill 
and this reconciliation bill that only makes things worse.
  Mr. FRANKS of Arizona. Mr. Speaker, today I resolutely intend to vote 
against H.R. 3590 and H.R. 4872, the imposition of government-run 
health care on the American people.
  It appears that Democrats in this majority are determined to shove 
this bill down the throats of the American people with not even a 
single Republican vote. Never has such sweeping legislation--taking 
over fully one-sixth of our economy--been done with a purely partisan 
vote. Therefore, whatever ill comes from this bill, history should 
record that Democrats alone chose the path of socialism over the 
highway of freedom. Let future generations hold them accountable.
  My first reason for voting against this bill will be the conviction 
in my heart that I will be voting to protect my children, their 
contemporaries, and generations to come from being forced to live under 
the socialist ideal of a bill that will dim the light of freedom and 
suppress many of the hopes they might have otherwise had.
  I vote against this bill because it is my deepest conviction that its 
cost will grow to threaten the entire economy of the United States in 
the years to come. In every corner of the planet, in every corridor of 
history, socialized medicine has always cost more, not less. Every 
government health care program the United States has ever implemented 
has cost many times the amount that was first predicted.
  I am fundamentally convinced that the costs of this bill will so 
overwhelmingly outpace present predictions that Congress will have no 
choice but to drastically alter its provisions in the future.
  I also intend to vote against this bill because of the provisions in 
it that will increase the killing of unborn children in the name of 
health care. Nothing so completely destroys the notion that this bill 
is about compassion than the arrogant and cruel disenfranchisement of 
those helpless unborn children who have no voice in this twisted and 
corrupt process.
  It is also my conviction that this bill will reduce the quality of 
the greatest health care system in the world, and that many of those 
who support it today will be its victims tomorrow.
  Ultimately, this bill is about robbing America of one of its greatest 
distinctives: freedom of the individual. It's about robbing the 
American citizen of power, and putting it in the hands of left-wing 
bureaucrats and elitists who think they know more about running 
people's lives than the people themselves do.
  Finally, I vote against this bill because I believe one day America 
will look back and see what a tragic mistake that it was. It is my hope 
that when that occurs, my children and my children's children will know 
that it was my deepest desire to protect their freedom as faithfully as 
my father protected mine.
  Mrs. SCHMIDT. Mr. Speaker, I rise in opposition to both the Patient 
Protection and Affordable Care and the Health Care and Education 
Reconciliation Acts. Most likely, this package of bills will pass 
tonight without a single Republican vote. It did not have to be this 
way.
  There is bipartisan consensus that our health care system is in need 
of real reform. President Obama is correct when he says that the costs 
associated with our current health care system are unsustainable. Too 
many of my constituents are struggling to provide coverage for their 
families and employees. The ever-rising costs of medical coverage have 
left too many Americans without the means to purchase the health 
insurance that many of us take for granted. Individuals with pre-
existing medical conditions are often unable to purchase insurance at 
all. And, people should not

[[Page H1904]]

be forced to remain in a job they hate just for the health insurance 
benefits.
  We can begin to right these wrongs and others, as well. But, we do 
not need to destroy a system that has given us the best doctors and 
hospitals in the world and put us on the cutting edge of life-saving 
technology and pharmaceuticals. Unfortunately, the package of bills we 
are considering today, will actually increase premiums and ration care. 
People will be forced out of their current coverage--whether they like 
it or not. The bills will stifle economic growth and cost jobs. They 
actually manage to cut Medicare by a half-trillion dollars, yet make 
our entitlement crisis even more urgent. And, perhaps worst of all, it 
allows federal funding for abortions for the first time in 34 years.
  The President is fond of saying that Americans have been fighting for 
this type of healthcare reform for a hundred years. That might be true 
for some Americans. However, over the last nine months, we have all had 
the opportunity to hear from the vast majority of Americans. We have 
heard from them in a number of different ways--rallies at the Capitol, 
letters, phone calls, and, yes, town hall meetings throughout all of 
our districts. Their message is clear. If you were listening this 
weekend, you would have heard it summed up at rallies at the Capitol--
``Kill the Bill.'' They fear government involvement in their medical 
decisions. They fear a future of higher taxes and debt heaped on their 
children and grandchildren. They fear a bill that rations care. And, 
they are tired of the backroom deals and politics as usual. Worse than 
all of these, they are afraid of a government too arrogant to listen to 
what they have to say.
  The House of Representatives is the people's house. We have a duty to 
listen to what the American people are telling us. There is still time 
to listen and defeat this flawed and dangerous bill.
  Mr. MANZULLO. Mr. Speaker, the President's $1 trillion health care 
bill is a job-killing disaster that will slap Americans with massive 
tax increases and Medicare cuts immediately while delaying the bulk of 
the health care benefits until 2014. This is not health care reform; 
this is an unprecedented and unnecessary government takeover employing 
some of the highest and cruelest tax increases and perhaps the broadest 
expansion of the power of the federal government in history. It didn't 
have to be this way. I do support health care reform. Bipartisan 
alternatives exist that would make health care more affordable and 
accessible for the uninsured without having to wait four years for 
benefits.
  Here are just a few of the most egregious policies within the 
President's massive government takeover of health care. H.R. 3590 would 
increase taxes on Americans by $569 billion, including a new $210 
billion 2.9 percent ``Medicare'' tax on investment income; cut Medicare 
benefits for seniors by $530 billion; increase Americans' health 
insurance premiums $2,100 by 2014, according to the non-partisan 
Congressional Budget Office; put another 3 to 5 million Americans on 
the unemployment lines due to the heavy mandates that require employers 
to provide health care coverage to their employees and families whether 
they can afford it or not; require the Internal Revenue Service (IRS) 
to hire up to 16,500 additional workers to enforce all the new tax 
penalties on Americans who can not afford to purchase health insurance; 
and puts another 16 million Americans on Medicaid, a struggling program 
that pays such low reimbursement rates that 121 Walgreens stores in 
Washington announced last week they would no longer accept Medicaid for 
prescriptions. This bill will burden states with additional Medicaid 
share costs. The State of Illinois, already facing a $12 billion budget 
deficit with plans to cut $1.3 billion from local school funding, would 
have to pay at least $1.8 billion in additional Medicaid sharing costs 
to cover the additional enrollments. To add insult to injury, this bill 
makes Americans wait until 2014 to receive the bulk of the benefits. In 
fact, the ban on preexisting conditions does not kick in until 2014 for 
adults.
  This bill implements tax increases and Medicare cuts immediately, but 
delays most of the benefit provisions for four years. However, when you 
look at the first 10 years of benefits, the estimated true cost will be 
$2.6 trillion. And that does not even include the nearly $1 trillion of 
additional spending that was either pulled out of the bill to be dealt 
with later or the result of correcting double counting cuts in 
unrelated programs.
  Plus, H.R. 3590 would not have a true firewall of protection to 
prevent federal tax dollars from paying for abortions. According to a 
Quinnipiac University survey released on December 22, 2009, 72 percent 
of Americans said they oppose allowing abortions to be paid for with 
public funds under any new health care system created by the 
government. Thus, because a ``reconciliation'' bill cannot solve this 
particular issue due to the fact that it is not directly a budget 
issue, the President has promised to issue an executive order to ban 
federal funding of abortion. However, an Executive Order cannot trump 
the language in this bill that would become law, if passed. In 1952, 
the Supreme Court struck down President Truman's executive order during 
the Korean War that assumed federal control of certain domestic steel 
mills due to labor unrest because it was an unconstitutional exercise 
of lawmaking authority reserved to Congress. In 1996, the District of 
Columbia Court of Appeals struck down an executive order issued by 
President Clinton which authorized sanctions on federal contractors 
that permanently replaced workers who went on strike because it 
superseded existing law guaranteeing the right of employers the right 
to hire permanent replacement workers. Finally, the Supreme Court 
struck down an executive order issued by President G.W. Bush because 
Congress, in enacting a statutory military commissions system, had 
impliedly prohibited the President's invocation of military commission 
jurisdiction over a terrorist detainee.

  I also want to expand upon what I believe to be one of the cruelest 
elements of this bill. As if raising taxes on struggling families and 
their employers, cutting benefits for seniors, growing the IRS 
enforcement police by thousands, and further jeopardizing the budgets 
of all states in the union was not cruel enough, this bill creates a 
new 2.9 percent tax on life-saving medical devices like the titanium 
brace that was inserted into the spine of my wife after a cancerous 
tumor shattered one of her vertebrae. That medical device saved my wife 
from the wheelchair. The authors of this bill believe that life-saving 
medical devices should be nearly three percent more expensive. I fail 
to understand how we make health care more affordable by pursuing 
policies that intentionally make health care more expensive.
  As the former Chairman of the House Small Business Committee, I have 
long supported legislation that would help small employers purchase 
health insurance for their employees and their families. Of the 47 
million uninsured Americans, 57 percent work for small employers who 
cannot afford to offer them health insurance. I support two bipartisan 
solutions that would go a long way to reduce the number of uninsured in 
America. First, Congress should pass H.R. 2360, the Small Business 
Health Options Program Act of 2009 (SHOP Act) as a stand-alone bill. 
H.R. 2360 would allow small employers to purchase health insurance at 
reduced group rates through national associations while still following 
state rules. I am one of 60 bipartisan cosponsors of H.R. 2360, which 
also enjoys support from the liberal Service Employees International 
Union (SEIU), the AARP, and the conservative National Federation of 
Independent Business (NFIB). A companion bill in the Senate was 
authored by my fellow Illinoisan, Senator Dick Durbin, and enjoys 
similar bipartisan support.
  Second, Congress should also pass H.R. 1470, the Equity for Our 
Nation's Self-Employed Act of 2009. This bill would let small employers 
pay for their health insurance before they pay their Social Security 
and Medicare tax liabilities, giving them the same deduction as large 
employers. The self-employed pay on average $12,106 annually for family 
health care coverage, and H.R. 1470 would save them $1,852 a year, 
according to the Kaiser Foundation. I am one of 48 bipartisan co-
sponsors of H.R. 1470.
  These bills would dramatically reduce the costs of health insurance 
for small employers so they can better afford to provide coverage for 
their employees and their families. And they will reduce the rolls of 
the uninsured without increasing taxes, killing jobs, forcing Americans 
into a government-run program, and burdening our children and 
grandchildren with even more debt.
  Mr. Speaker, I also support making the following four changes to 
America's health care system. First, we need to reform our out-of-
control medical liability system. Medical malpractice insurance 
continues to surge, skyrocketing health care costs and forcing doctors 
and other medical professionals to practice ``defensive medicine,'' 
which entails ordering costly and often unnecessary tests to cover all 
the bases from lawsuits. I am a cosponsor of the HEALTH Act (H.R. 1086) 
that would fully compensate victims for medical injuries but place 
reasonable caps on punitive and non-economic damages that often inflate 
the awards and contribute to out-of-control liability and health care 
costs.
  Second, we need to expand tax-free availability to Health Savings 
Accounts (HSAs). HSAs allow small business owners to offer more 
affordable high-deductible health insurance plans to their employees 
and make tax-deductible contributions to employee savings accounts to 
allow their employees to build equity and assume personal control of 
their health care needs. Congress should increase the tax deductibility 
for these insurance plans.
  Third, we need to preserve high-quality health care through America's 
community health centers. I am a strong supporter of continued funding 
of our community health center system, which provides high-quality 
health

[[Page H1905]]

care to America's low-income families. The district I am privileged to 
represent has one of the model community health centers in America, the 
Crusader Clinic in Rockford, which serves more than 40,000 needy 
patients in northern Illinois each year.
  Finally, we need to create refundable tax credits to help low-income 
Americans purchase health insurance. Low-income children are already 
covered through the federal State Children's Health Insurance Program 
(SCHIP), and I support refundable tax credits to help low-income adults 
purchase health insurance.
  Mr. Speaker, this bill today will increase taxes, cut Medicare, raise 
health care premiums, and put millions more Americans on the 
unemployment lines. And amazingly, most of the benefits--including the 
ban on pre-existing conditions for adults--will not be available for 
another four years. We should instead be pursuing the bipartisan 
reforms that would make health care more affordable and accessible to 
Americans now, and not make them wait four years for assistance. This 
bill is certainly not the type of health care reform Americans deserve.
  Ms. KILPATRICK of Michigan. Mr. Speaker, I rise today in support of 
H.R. 4872, the Health Care and Education Affordability Reconciliation 
Act. I urge all my colleagues to support this bill because it will 
improve the accessibility and affordability of health care for millions 
of Americans.
  Today, there are more than 44 million Americans who lack health care 
insurance. We must ensure that the needs of these Americans are met. 
This bill will help us begin to do just that.
  While we in Congress have deliberated and debated the costs, 
challenges, and consequences of health care reform, millions of 
Americans continue to sacrifice, struggle, and suffer. Hundreds of 
people have sent me letters and e-mails, called and visited my office, 
and participated in town hall meetings to express their opinions. The 
majority of my constituents want and need health care reform. Many are 
unemployed and struggling to maintain their health care insurance while 
trying to make sure that there is food on the table, that they have 
shelter, and that their lights, gas, and water are on. Others are 
dealing with increases in health care premiums that continue to rise at 
the will of insurance companies. Still others are trying to get 
adequate treatment for serious illnesses and to pay for the medicines 
that can help them.
  I am a strong supporter of the single payer health care plan. I also 
support a strong public option. I support this bill because it begins 
the process of universal health care coverage for all Americans.
  This measure expands coverage to 32 million more people, or more than 
95% of Americans, while lowering health care costs over the long term. 
It prevents insurance companies from discriminating based on pre-
existing conditions, health status, and gender. It creates health 
insurance exchanges--competitive marketplaces where individuals and 
small businesses can buy affordable health care coverage--and offers 
premium tax credits and cost-sharing to low and middle income 
Americans, providing families and small businesses with the largest tax 
cut for health care in history. It also invests in Community Health 
Centers to expand access to health care in communities where it is 
needed most. The bill also empowers the Department of Health and Human 
Services (HHS) and state insurance commissioners to conduct annual 
reviews of new plans demanding unjustified, egregious premium 
increases.
  This bill puts patients and doctors in charge of their health care--
not health insurance companies. Children can no longer be discriminated 
against because of preexisting conditions. Seniors will no longer have 
to pay deductibles and co-pays. There will be free mandatory preventive 
health care provided for all under all health care plans. Plus, there 
will be a ban on lifetime coverage limits under this bill.
  The bill cuts taxes to small businesses to help small employers pay 
for health care coverage for their employees. Small businesses will 
have tax credits and vouchers so as to be able to afford health care 
coverage for their employees.
  The bill makes key investments in Medicaid and children's health. It 
expands eligibility for Medicaid to include all non-elderly Americans 
with income below 133% of the Federal Poverty Level and provides fair 
assistance to states to help cover the costs of these new Medicaid 
populations. The measure also maintains current funding levels for the 
Children's Health Insurance Program (CHIP) through fiscal year 2015 and 
increases payments to primary care doctors in Medicaid.
  The Health Care and Education Affordability Reconciliation Act 
strengthens Medicare. It adds at least nine years to the solvency of 
the Medicare Hospital Insurance Fund, fills the Medicare prescription 
drug donut hole, improves Medicare payments for primary care, and 
reduces overpayments to private Medicare Advantage plans. It 
also provides new, free annual wellness visits; eliminates out-of-
pocket copayments for preventive benefits under Medicare, such as 
cancer and diabetes screenings; and provides better chronic care, with 
doctors collaborating to provide patient-centered care for the 80% of 
older Americans who have at least one chronic medical condition, such 
as high blood pressure or diabetes. The bill also encourages 
reimbursing health care providers on the basis of volume instead of 
value by including a number of proposals aimed at moving away from the 
``a la carte'' Medicare fee-for-service system toward paying for 
quality and value, while reducing costs for America's seniors.

  This legislation reins in the abuse by health insurance companies of 
arbitrarily increasing premiums and stops insurance companies from 
dropping individuals from policies when people get sick and need health 
care insurance. If you change or lose your job, you will still have 
health care coverage. When you enter a hospital, you and your family 
can rest assured, knowing that your policy will cover the costs 
associated with your health care.
  Last, this legislation demonstrates fiscal sensibility and 
responsibility. It will reduce the deficit by $138 billion over the 
next decade, with an additional $1.2 trillion in additional deficit 
reduction in the following decade. The bill tightens current health tax 
incentives, collects industry fees, institutes modest excise taxes, and 
slightly increases the Medicare Hospital Insurance tax for individuals 
who earn more than $200,000 and couples who earn more than $250,000. It 
includes a fee on insurance companies that sell high cost health 
insurance plans to promote smarter, more cost-effective health coverage 
choices and changes health care tax incentives by increasing penalties 
on nonqualified distributions from health savings accounts, capping 
federal saving account contributions, and standardizing the definition 
of qualified medical expenses. The cost of health care reform under 
this legislation is fully paid for, in large part, by eliminating 
waste, fraud, abuse, and excessive profits for private insurers.
  As Democrats promised the American people, this bill is fully paid 
for. This legislation is the single largest deficit reduction tool in 
the history of our country. It is not balanced on the backs of our 
children and our grandchildren.
  My family and my faith provide the foundation for my commitment to 
service. I am honored and humbled to represent the people of the 13th 
Congressional District. As Members of Congress, we serve others. 
Through this service, we often provide people with the tools and 
resources they want and need. Our service not only changes us for the 
better by giving our lives meaning and fulfillment, but it also creates 
positive change in the lives of others. Like a raindrop in a river, our 
service creates ripples that leave an indelible impact on all those it 
touches.
  Today, we will make history by finishing what many Congresses before 
us started. The debate has gone on long enough. The American people 
want action. We must reject the status quo. We must stand up and do 
what is right. We must be a voice for the voiceless, give hope to the 
hopeless, and provide help to the helpless by supporting health care 
reform now.
  Let us be the light in the darkness by voting in support of the 
Health Care and Education Affordability Reconciliation Act. It will 
give much needed assistance to millions of Americans by making health 
care affordable for the middle class, providing security for our 
seniors, and guaranteeing access to health insurance for the uninsured. 
It is common sense for the common good, and I urge all my colleagues to 
vote yes on this historic measure.
  Mr. LARSON of Connecticut. Mr. Speaker, I rise on this momentous day 
in support of this historic legislation. Just as our predecessors stood 
up for the American people to pass Social Security and Medicare, today 
we affirm our commitment to families across this country by passing 
comprehensive health care reform. Today, Democrats are once again 
showing whose side they are on, the side of the American people.
  While my colleagues on the other side of the aisle like to focus on 
those who are against this effort, I've heard from too many of my own 
constituents whose stories exemplify why we need health reform and 
encouraged me to support this bill.
  Constituents like Jody from Bristol. Jody and her family had to 
downgrade their health insurance after their premiums jumped 30% in one 
year. Just a few months later Jody was diagnosed with Crohn's disease. 
After 12 months her medical debt was more than $30,000. Now, even after 
she has insurance, she is struggling to pay off the $35,000 in credit 
card bills her family amassed to pay her health care.
  It's in stories like these, of people facing severe financial 
difficulty because of medical debt, being denied coverage because of a 
pre-existing condition, or losing their coverage when they get sick 
that creates the moral imperative to right these wrongs. In this bill 
we

[[Page H1906]]

will cap out of pocket costs, end discrimination based on pre-existing 
health conditions, and end the practice of insurance rescissions.
  The American people may not like the complicated legal language of 
the bill or the messy process it takes in Washington to get historic 
acts accomplished. But after this bill is signed the parent whose 
children have been denied coverage because of a pre-existing condition 
will be able to get health insurance for them; young adults will no 
longer have to fear being without coverage because they will be able to 
stay on their parent's insurance; seniors will get relief from 
skyrocketing prescription drug prices; and small businesses will get 
tax breaks for offering their employees health.
  Once this bill is signed, this country will be stronger, the economy 
will be stronger and the American people will be stronger than ever 
before. I thank the Speaker and my Democratic colleagues for their 
efforts on behalf of the American people and urge my colleagues to 
support this legislation.
  Mr. GARAMENDI. Mr. Speaker, today, Democrats in the House of 
Representatives voted to form a more perfect union. By expanding health 
care coverage to 32 million Americans, we are continuing the proud 
American tradition of promoting justice, ensuring the general welfare, 
and broadening access to life, liberty, and the pursuit of happiness.
  Republican leaders in the 1930s said Social Security would lead to 
``the lash of the dictator'' and in the 1960s said Medicare would lead 
to grandparents telling stories of ``what it once was like in America 
when men were free.'' Yet with time, Social Security and Medicare 
became incredibly popular services cherished by most Americans. A 
broader consensus emerged, and a more perfect union was formed. I am 
confident that the same will soon be said about today's health care 
reform bill.
  When the people get past the slogans, the fear tactics, and the gross 
distortions, what they find in this legislation is a series of ideas 
widely popular and aligned with the best of American values. This is 
the second largest deficit reduction bill in 20 years. In my district, 
9,000 people with preexisting conditions will finally be able to have 
access to insurance. 96,000 seniors will see their Medicare improved 
with significant prescription drug discounts and free preventative 
screenings. 106,000 families will receive tax credits to make their 
coverage more affordable. 52,000 young adults will be able to attain 
coverage through their parents' insurance. 13,100 small business owners 
will receive significant tax rebates. 1,400 families will avoid 
bankruptcy. A similar story exists in every corner of this great 
country.
  In the fight to extend health coverage to every man, woman, and 
child, this bill is an incredibly important beginning. But it's still 
just a beginning. ``A more perfect union'' implies that the progress of 
the American experience is never complete. Each subsequent generation 
is expected to pick up the torch and continue on our long road toward 
positive change. Today the House of Representatives bestowed upon this 
great nation the most historic health reform since Medicare. I am proud 
to have voted ``yes'' for health care reform. I won't live to see a 
perfect union, but it is a tremendous honor to see a more perfect union 
formed before my eyes.
  Mr. OBERSTAR. Mr. Speaker, today the House of Representatives crosses 
a historic threshold in the evolution of social justice, quality of 
life, equity of health service delivery, and a worthy legacy for our 
children, with passage of comprehensive health care reform legislation.
  Our Nation enjoys the best, but the most expensive health care in the 
world. The comprehensive health care legislation under consideration 
will preserve what works best in our health care system and make that 
system more efficient and affordable.
  In Minnesota and throughout the Nation, citizens will quickly see the 
benefits of this legislation that includes important consumer 
protections to reduce the power of health insurance companies. You will 
have greater control of your health care decisions. This bill will 
assure that no one's current health care can be dropped. No one will be 
forced out of the health care they now hold. No one will be denied 
coverage because of a previously existing condition. No one's health 
insurance will be dropped because of lifetime caps; no one can be 
denied when they need their health insurance the most. People will be 
able to retain their health insurance if they change jobs.
  For seniors, the legislation closes the doughnut hole that has 
existed for five years, which will save seniors thousands of dollars in 
prescription drug costs. Young adults will be able to stay on their 
parents' policy until age 26.
  If we fail to provide health care for all of our citizens, we all 
will pay higher taxes and higher health insurance premiums because we 
eventually pay for ``sick care'' rather than make the wise investments 
in the promotion of preventive health care.
  This health care legislation, which assures that all Americans will 
be able to have and to keep health insurance, is central to our 
economic recovery and to balancing our federal budget.
  To be sure, this health care reform legislation will not cure every 
shortcoming in our health care system, but unquestionably the status 
quo is unacceptable and unaffordable. For far too long, too many 
citizens have been denied essential health care, and our commitment to 
fundamental justice demands that we make affordable access available to 
every American.
  This health care legislation will provide numerous benefits for 
Minnesota and the Nation. Importantly, this legislation expands access 
to health care to more than 32 million Americans. This expansion of 
health care will be achieved without increasing the federal deficit. 
The nonpartisan Congressional Budget Office has objectively analyzed 
the legislation and has determined that its enactment will reduce the 
deficit by $143 billion over the first decade and more than $1.2 
trillion over the second decade. The health care legislation is fully 
financed by ending the excessive subsides in the Medicare Advantage 
program and by additional changes in Medicare reimbursement that will 
make Medicare more efficient without reducing essential Medicare 
benefits; it will expand the solvency of the Medicare Trust Fund by an 
additional seven years.
  This health care legislation also includes important improvements in 
rural health care for Minnesota and the Nation. I was concerned that 
the original House health care bill did not incorporate a number of 
necessary reforms to expand access in rural America. I am pleased to 
report that the health care legislation under consideration not only 
expands health insurance coverage in rural America, but it also 
promotes the training and placement of health care professionals in 
rural areas. I am also very pleased that this legislation addresses the 
longstanding geographic disparity in Medicare reimbursement. Northland 
health care providers have been greatly disadvantaged by unfair 
Medicare reimbursement, and this legislation closes that gap and moves 
us inexorably toward payment parity with the rest of the country.
  Just as the Hippocratic oath requires that medical providers adhere 
to the admonition of ``First, do no harm,'' the same is true for 
legislators, and this legislation, while not perfect, will implement 
significant and positive changes in the delivery of health care.
  This is especially true with regard to vulnerable women and unborn 
children. I am confident that abortion will not be funded in this 
legislation. Current law dating back to October 12, 1979 (Public Law 
96-86), has contained a federal prohibition on the use of federal funds 
for abortion in community health centers. Conscience clause protections 
that have existed in the past, that are in effect today, will remain in 
effect in the future. The legislation also prohibits the use of federal 
tax credits and cost-sharing assistance to pay for abortion. I am very 
pleased that President Obama has prepared and will issue an Executive 
Order upon enactment to reaffirm the enforcement of current law that 
prevents the use of federal funds for abortion.
  Today, we keep faith with the American people. Today we ensure that 
quality, affordable health care is available to everyone to this 
generation and generations to come.
  Support this bill.
  Mr. TOWNS. Mr. Speaker, I would like to clarify several points in 
Section 1334 of H.R. 3590, regarding the Office of Personnel 
Management's authority to provide oversight and set premiums of multi-
State plans.
  OPM, of course, has administered the Federal Employees Health 
Benefits Program for over 50 years, and that program has served as a 
model for the Exchanges envisioned under this legislation. In 
administering the FEHB Program, OPM has been able to address the 
problem of uniformity of benefits and requirements across State lines 
using its authority under 8902(m) of Title 5. Section 1334(a)(4) of the 
Senate-passed bill states that ``the Director shall implement this 
subsection in a manner similar to the manner in which the Director 
implements the . . . Federal employees health benefit program under 
chapter 89 of title 5, United States Code''. The intent of this 
provision is that OPM oversee multi-State health plans in the same 
manner in which oversight is provided under the FEHB Program for the 
purposes of uniformity of health insurance plans. OPM should exercise 
this authority, as it does in the FEHBP, to ensure that multi-State 
plans offer uniform benefits, negotiate premiums with multi-State 
plans, and require these plans to set aside a certain amount of reserve 
funds. Moreover, it is imperative that OPM issue rules and guidelines 
as necessary to effectively and efficiently administer the multi-State 
plans, including for uniform adjudication procedures for disputes 
involving the multi-state plans.
  Another issue that requires clarification is the interaction between 
the Secretary of Health and Human Services and the Director

[[Page H1907]]

of OPM. The legislation gives the Secretary broad authority to issue 
regulations governing the operation of State Exchanges. Any rule or 
regulation governing plans offered on State Exchanges would affect 
OPM's administration of the multi-State plans, which will also be 
offered on the Exchanges. There are overlapping responsibilities 
between HHS and OPM with regard to the multi-State plans offered on 
State Exchanges. The legislation envisions that the Secretary of HHS 
will coordinate and consult with the Director of OPM on any policy 
decisions that would affect the administration of multi-State plans. 
This joint effort is essential to ensuring the proper operation of the 
multi-State program as envisioned by Section 1334.
  Under section 1334, OPM is directed to ensure that sufficient 
resources are allocated to the ongoing administration of the FEHBP. The 
intent of this provision is to ensure that essential resources are not 
pulled away from FEHBP in order to start up the new program created by 
this bill. However, where greater efficiencies can be found from the 
administration of both programs jointly, we would expect OPM to adopt 
that approach.
  Lastly, section 2714 of H.R. 3590 would allow unmarried adult 
children to remain on their parent's plan up to the age of 26. Congress 
intends that this mandate apply to individual FEHB plans in their 
capacity as private health insurers and to the FEHBP as a group health 
plan. This Congressional Budget Office incorporated this interpretation 
of section 2714 in preparing its cost estimate of the legislation. 
Given the economic conditions in country, this is an important reform 
that will help families across the country, including the families of 
federal employees and retirees. I am pleased to support this provision 
as one of many reforms that will improve health care coverage for low 
and middle income Americans.
  Mr. BOUCHER. Mr. Speaker, health care reform is needed. More than 36 
million American citizens do not have health insurance, and millions 
more are underinsured and cannot afford to pay for the medical care 
they need. Those who have health insurance are finding that health care 
costs and health insurance premiums are rapidly rising. In fact, health 
insurance premiums are increasing 3.5 times faster than the rate of 
increase in family incomes.
  This status quo is unsustainable, and finding a way for everyone to 
afford health insurance is necessary to benefit both the uninsured and 
those who have insurance. It is also essential that health insurance 
reform control health care costs and prevent rapid increases in health 
insurance premiums. But reform legislation must also ensure that the 
residents of my district in Southwest Virginia continue to have access 
to the high quality health care services that are now delivered 
locally.
  After reading and carefully reviewing the legislation, I oppose 
passage of the health care measure before the House today. My concern 
largely centers on the dramatic reductions in Medicare funding required 
by the legislation. Over the next 10 years, the bill requires that 
Medicare funding be reduced by $450 billion. In fact, in April of this 
year, doctors in our region and across the nation will have their 
Medicare payments reduced by 21 percent. Over the next several years, 
additional reductions in payments to doctors will occur. Other health 
care providers will also experience substantial reductions in their 
Medicare reimbursements. These Medicare payment reductions are fully 
accommodated by and expected to occur in order to achieve the $450 
billion Medicare payment reduction required by the reform legislation.
  The population of the Ninth Congressional District is more elderly 
than in the typical congressional district. Most senior citizens in our 
region depend upon Medicare to pay their medical bills. Therefore, 
these Medicare funding cuts will be far more harmful to the population 
of our region than to the population of the typical congressional 
district. The dramatic cuts in Medicare funding that would be required 
by the health reform bill would adversely affect the quality of health 
care for senior citizens and other Medicare recipients.
  Because Medicare is paying less, doctors, hospitals and other health 
care providers would increase charges to patients who have health 
insurance to make up for what they are not receiving from Medicare. 
This cost shifting of some substantial portion of the Medicare cuts 
would raise health insurance premiums for those who have insurance.
  While it is important that means be found to enable everyone, 
including those who are currently uninsured, to be able to afford 
health insurance, achieving that goal cannot occur at the expense of 
people who are currently insured. Having concluded that these dramatic 
Medicare cuts would both decrease the quality of health care that is 
delivered to our region's senior citizens and result in increases in 
health insurance premiums for the currently insured, I simply cannot 
lend my support to passage of the bill.
  I am also concerned about the unsavory deal-making that occurred in 
the United States Senate when the health care bill was considered in 
December. Some states received special benefits at the expense of other 
states. While the measure before the House today removes several of the 
special benefits, others remain and were not removed by the 
legislation. For example, the states of Louisiana, Tennessee, 
Connecticut and Montana have each received special benefits in the 
health care reform legislation not made available to other states. I 
simply cannot countenance this kind of deal-making which goes well 
beyond the bounds of normal legislative negotiations.
  In my view, the legislation does not do enough to eliminate the 
historical disparity in Medicare funding between urban areas and rural 
areas under which rural areas receive less than the urban regions of 
the country. There is no justification for Medicare paying less for 
medical procedures performed in our region than in the cities.
  The bill also fails to achieve the tort reform which is necessary to 
control health care costs. Virginia's tort reform law, which was 
adopted when I was a member of the Virginia General Assembly, has 
worked well, and I have urged that it be a model for national 
application. Unfortunately, the reform bill fails to include this 
needed provision.
  I deeply regret that the legislation does not have a bipartisan 
foundation. On a matter of this scope, affecting every American 
citizen, the best ideas of both political parties should be drawn upon 
in crafting balanced legislation that well serves the public interest. 
That did not happen as the reform bill was constructed.
  Reform is needed, but the measure being debated in the House today 
falls short. Because of massive funding reductions for Medicare, it 
would adversely affect the quality of care received by Southwest 
Virginia senior citizens. It would result in health insurance premium 
increases for those who have insurance. It contains unacceptable 
special benefits for some states at the expense of the others. It does 
not correct the unwarranted disparities in Medicare reimbursements that 
penalize rural areas. It does not contain meaningful tort reform, and 
it lacks the necessary bipartisan foundation.
  The reform legislation contains many helpful provisions; however, in 
my view its shortcomings outweigh its merits. I will cast my vote 
accordingly.
  Mr. PRICE of North Carolina. Mr. Speaker, ``once to every man and 
nation,'' wrote the great abolitionist poet James Russell Lowell, 
``comes the moment to decide.''
  Mr. Speaker, there are moments in history when it becomes clear that 
we simply cannot wait any longer to do what is right. When we have the 
opportunity to take a significant step to make our country better, the 
sort of opportunity that comes only a few times in a lifetime. We face 
such a moment tonight.
  Our health insurance system is falling far short of the American 
peoples' basic needs. It isn't working for families, who have seen 
their insurance premiums increase 75 percent over the past decade, 
while their earnings have risen only 14 percent. It isn't working for 
young adults, whose parents' policies stop covering them in their early 
twenties in most states, as if people that age don't need health 
insurance. It isn't working for people who have pre-existing conditions 
and can't find affordable coverage. It isn't working for the countless 
Americans whose coverage has been revoked when they get sick and need 
it most. And it isn't working for small business owners who want to 
provide coverage for their employees but can't access the low group 
rates that insurance companies willingly negotiate with large 
employers.
  Over the past year, I have attended numerous town hall meetings and 
roundtable discussions. I have met personally with doctors and 
patients, parents and children, seniors and students, business owners 
and employees. I have read thousands of letters and emails from 
constituents about this critical issue.
  In the course of these conversations, I have heard a rich and diverse 
range of views on the current state of our nation's health care system, 
but one conclusion has been shared by almost everyone: The status quo 
is unacceptable.
  Our current system penalizes the sick. It sells young people short. 
It puts small businesses--the primary engine of job creation in our 
country--at a competitive disadvantage. And instead of medicine, it 
offers seniors the Medicare doughnut hole.
  Why, then, would we continue to accept it? Particularly when we have 
before us a carefully crafted bill that directly addresses the system's 
flaws, preserves its strengths, and sets us on the path to meeting 
longer-term challenges.
  The time for reform is now.
  In an effort to defeat this bill, some of my colleagues have 
fabricated claims about ``death panels'' and damage to Medicare. They 
have raised the specter of ``socialism'' and ``government takeovers'' 
when they know quite well that this bill leaves the provision of

[[Page H1908]]

care, and most insurance, in the private sector. They urge us to 
``start over,'' but when challenged to come up with an alternative, 
they produced a plan that leaves insurance discrimination in place as 
well as tens of millions of uninsured.
  Reform will save money for employees, business owners, and taxpayers. 
It will end insurance company abuses. It will let young people stay on 
their parents' policies until age 27. It will extend coverage to 95 
percent of Americans. It expands community health centers and increases 
the number of primary care doctors and nurses. And it will end the 
hidden tax that the insured pay every month in the form of higher 
premiums.
  If my colleagues don't want to take my word for it, ask some of the 
people--right in their own backyards--who have lived through it 
firsthand. Ask David Swanson, whose insurance company raised the 
premium for his daughter's coverage 54 percent when she turned 17. Ask 
Blake Anderson, a small business owner who cannot afford coverage for 
his four employees. Ask Libbie Hough, who fears her 18-year-old 
daughter won't be able to find insurance when she finishes college 
because of a genetic disorder. Or ask the thousands of Americans who 
think they have good coverage until they get sick and hit annual or 
lifetime benefit caps, or lose their jobs.
  Mr. Speaker, the American people have waited long enough. We face an 
historic decision tonight, one that will resonate throughout our 
country, as have Social Security and Medicare, for decades to come. Let 
us seize the moment for the people we were elected to serve, and for 
future generations.
  Mr. RAHALL. Mr. Speaker, throughout my career of public service, 
there have been a few critical challenges that have remained at the top 
of my priority list; protecting our coal miners and our coal jobs and 
the need to provide our people with access to affordable, quality 
health care.
  Across southern West Virginia, especially in rural areas where senior 
populations are high, that challenge has been particularly daunting, 
because so many health insurance companies have been increasingly 
putting high profit margins above all else, even the compassionate 
treatment of the sick and the elderly.
  I have consistently spoken out against the abuses of and mistreatment 
by huge, for-profit health insurance companies. And I have advocated 
for competition, recognizing that it is good for consumers and drives 
down prices for all buyers, while driving up quality of service.
  At the same time, I have consistently stood against the use of 
federal funds to pay for abortions--a stand I took again when I worked 
to have anti-abortion language included in the original House-passed 
health care bill. That was, in fact, one of many issues that I heard a 
lot about from West Virginians in recent months and that I successfully 
pressed to have addressed in the House bill.
  With the Executive Order strengthening the life protections in this 
bill, we have achieved a firm anchor for the protection of life in this 
country, reflecting the principles of the Hyde Amendment, no federal 
funding for abortions. Administrative chipping away and mischief will 
be held at bay with this order throughout this administration. Future 
administrations should be held to this standard.
  Health care is a deeply personal issue for all Americans. But it is 
also true that there are no people in the world more personally 
generous than Americans when it comes to helping the ill and the 
injured.
  I understand people's frustrations and concerns over coal, jobs, our 
economy. The rhetoric about health care this year has been emotional, 
at times angry, and, ultimately divisive. Much of the legitimate debate 
has been undermined by millions of dollars in advertising, underwritten 
by massive health insurance companies interested only in protecting 
their record profits and lucrative salaries. The result has been a 
polarized public and a polarized Congress.
  But underlying the most contentious, most calculatingly advertised 
issues, there can be found common ground. Certainly the status quo--
where honest, hardworking parents are forced into bankruptcy to afford 
lifesaving treatments for their child and where longtime, loyal workers 
lose their health care coverage along with their jobs during tough 
economic times--does not comport with American values.
  One of my constituents, Fred Long, is a Vietnam veteran and a proud 
West Virginian who has long had private health insurance. Fred, blessed 
with good health, needed his insurance little until he was 63 years old 
when he had to have cataracts removed from both eyes.
  Fred's brother was born with cerebral palsy. His problems were 
covered by SSI and Medicaid. He, too, had cataracts removed, but 
because of Medicaid, it did not cost his family a dime.
  The two brothers had the same procedure, used the same hospital, and 
same doctor, yet Fred's surgery cost him $3,099.36 despite Fred's $480 
a month health insurance premiums.
  Mr. Long closed his letter to me with this:
  ``. . . how many thousands of dollars have been paid in insurance 
premiums over the years . . . I don't know if this will be of any help 
in changing the thinking of those that can't see where national health 
care would benefit the working man.
  ``The insurance companies could have done this, collected from those 
that weren't sick and paid the heath care cost for those that were 
sick, just like the government helped my brother when he needed it. He 
is on Medicare now and I just hope I can get by the next few years when 
I can sign up for Medicare. (Sincerely, Fred Long)''
  Mr. Long's personal story echoes so many others I have heard from all 
across southern West Virginia--this is just one of the reasons I 
believe health care reform is necessary.
  We must end the polarization of America and find that common ground 
for the common good. The health care system as it currently exists is 
not sustainable for the long-term and this Nation has a host of serious 
challenges that cry out for attention--jobs for our people, renewed 
transportation funding for our highways, expansion of our technology, 
and diversification of our economy.
  Unfortunately, as long as the needs of the people can be subverted by 
special interests, financed by donors who operate in secrecy without 
any accountability to the American public, I worry that we will see 
little more than the same polarization that has dominated this Nation 
for months.
  Free speech is a wonderful American right that must be protected. But 
much of the speech we have been witnessing of late has been anything 
but free. It has been well-financed by special interests whose hands 
are in the pockets of political operatives, and their motivation is not 
the preservation of health care for our citizens, but, instead, the 
preservation of power for themselves. Worse still, to the degree that 
these operatives are able to bend government to suit their own 
purposes, you can be sure that others will line up to use the same 
tactics for their own good.
  This is bad for West Virginia. And it is bad for our Nation.
  Throughout my years of hard work for the people of West Virginia, I 
have worked with Republicans, Democrats, and Independents alike, always 
focused on the needs of southern West Virginia and the Nation. In all 
that time, I have used my experience, honesty, and integrity to sustain 
jobs for our coal miners, to ensure their health and safety and that of 
their homes and their families. I have fought to expand our job base 
and to build improved infrastructure, to advance technology, ensure 
veterans care, improve education, and protect our God-given natural 
resources, including the unborn.
  Today, I call for an end to the polarization. We must put away our 
personal interests, set aside our differences, and do the People's 
work. We must come together for the common good, using common sense.
  Ms. SUTTON. Mr. Speaker, every year 45,000 people in this country die 
because they do not have insurance coverage, and in this great nation 
it should not be that way. And, on this day, in this moment, we have 
been called to stand up and vote to put an end to that sad reality.
  This is the moment when we will finally take the long-overdue step of 
ending the unconscionable practices of the insurance companies, who 
through their greed and disregard have enjoyed record profits even as 
American families have suffered, sometimes fatally because of their 
actions.
  I support this legislation because it will put a stop to the 
discriminatory practices by insurance companies that deny care based on 
pre-existing conditions and impose outrageous premium increases on 
American families.
  I support this legislation because it will cap out-of-pocket expenses 
that insurance companies impose on our constituents forcing many into 
bankruptcy when they or their children are stricken by illness or 
injury.
  I support this legislation because it is a vote to stop insurance 
companies from inflicting lifetime caps on people who have paid for 
insurance, only to find that it was not there for them when they needed 
it most.
  I support this legislation, because it will strengthen the solvency 
of Medicare, lower drug costs and close the donut hole for our seniors, 
and has the support of the AARP.
  This legislation will make health insurance more affordable and 
accessible for small businesses and individuals.
  This legislation will finally curb the perpetual, skyrocketing costs 
of health care that have been drowning far too many American families 
for far too long.
  This measure will reduce our deficit by more than $1.3 trillion in 
the next two decades.
  I support this legislation because within the 13th District of Ohio, 
which I am so honored to serve, it will improve coverage for 420,000 of 
my constituents with health insurance.

[[Page H1909]]

  It will give tax credits and other assistance to up to 154,000 
families and 13,200 small businesses to help them afford coverage.
  It will improve Medicare for 107,000 beneficiaries, including closing 
the donut hole. ``It will extend coverage to 33,500 uninsured residents 
of the 13th District.
  It will guarantee that 9,000 residents with pre-existing conditions 
can obtain coverage.
  It will protect 1,700 families from bankruptcy due to unaffordable 
health care costs. ``It will allow 45,000 young adults to obtain 
coverage on their parents'' insurance plans.
  It will help support 3 community health centers in the 13th District 
and reduce the cost of uncompensated care for hospitals and other 
health care providers by $34 million annually.
  For all of these reasons, this is the day, this is the moment, and I 
am honored to support this health care measure.
  Ms. VELAZQUEZ. Mr. Speaker, for too long, working families have lived 
in fear that they are just one illness away from financial ruin. For 
too long, the men and women in my home state of New York have watched 
their premiums skyrocket, with family rates up 97 percent in the last 
decade. For too long, Latinos have been left behind, suffering the 
highest uninsured rate of any other community. Tonight, it is time to 
say enough.
  It is time to say enough to the discriminatory policies that charge 
women and minorities more money for the same services. It is time to 
say enough to a system that has pushed more than 2.5 million New 
Yorkers over the brink and into the ranks of the uninsured. And it is 
time to say enough to a status quo that robs Americans of the peace of 
mind that can only come from knowing this--they, and they alone, are in 
charge of their own well-being.
  Mr. Speaker, this bill gives every American that autonomy. For the 
Latino community, it delivers coverage to 8.8 million people. In my 
home district, it improves options for 324,000 residents, and expands 
care to 86,000 more. For 16,000 people with preexisting conditions, it 
allows them to buy affordable health plans right away, promising them: 
Never again. Never again can you be denied coverage. And for 4,300 of 
my district's seniors paying full price for prescription drugs, it 
closes the Medicare donut hole.
  Meanwhile, this bill invests in New York's network of community 
health centers. In my district alone, 33 clinics will see critical 
improvements, meaning more options for the men and women of Brooklyn, 
Queens and the Lower East Side. And at the end of the day, Mr. Speaker, 
isn't that what this legislation is all about--options?
  The Patient Protection and Affordable Care Act will deliver better 
choices--not just for New Yorkers, but for all Americans. With the 
passage of health care reform, we are finally answering a decades-long 
cry for help. We are finally empowering the American people with 
quality, affordable options that put them in the driver's seat, and I 
urge support of this landmark legislation.
  Mr. BISHOP of Georgia. Mr. Speaker, I have decided to support the 
health reform legislation because it represents an historic opportunity 
to make health care more accessible and affordable now and into the 
future. I base this decision not on what is popular, but on what I 
believe is in the best interest for Georgia's Second Congressional 
District both in the short- and long-term.
  Throughout this process, I have solicited the views of people both 
supporting and opposing health care reform. I have heard from doctors 
and patients, small business owners and the CEOs of large corporations, 
as well as residents of rural and urban areas. I also have heard from 
the healthy and the sick, the young and the old, and the rich and the 
poor. I thank each of you who shared your views with me, and I have 
listened to your opinions.
  In my district there are more than 83,000 uninsured residents who 
will receive health insurance coverage under this bill. There are 
14,500 uninsured individuals who have a pre-existing medical condition 
such as cancer, heart disease, and diabetes and who will now no longer 
be denied affordable health insurance coverage. In addition, there are 
12,100 small business owners in my district who will qualify for tax 
credits to help employees afford health care.
  My district is also home to 96,000 senior citizens who will benefit 
from a stronger Medicare program whose solvency is extended to 2026. 
There are 6,600 Medicare beneficiaries who will now be able to afford 
their prescription drugs with the closure of the Part D 'donut hole.' 
And, through the health care reform bill, 181,000 households in 
Southwest Georgia could qualify for tax credits to purchase health 
insurance through Medicaid, employer sponsored insurance, or other 
acceptable coverage. For these people and for millions of Americans 
like them, I have decided to support the health care reform bill.
  Some people have asked how I could be a fiscally conservative Blue 
Dog Democrat and still support the health reform bill. I do not know 
how I could be a Blue Dog Democrat and not support this bill. According 
to the nonpartisan Congressional Budget Office, the bill will reduce 
the deficit by $138 billion over the next 10 years and $1.2 trillion in 
the decade after that. It includes tough provisions attacking waste and 
fraud in the Medicare and Medicaid programs, including some proposed by 
Republicans. It will slow the growth in health care costs that are 
becoming an increasing burden on families, businesses, and governments. 
And the legislation will benefit rural America by boosting mandatory 
funding for community health centers by $11 billion over five years and 
making significant investments in the training of primary care doctors.
  This bill is not perfect. We cannot, however, let the perfect be the 
enemy of the good. Nor can we allow fear, misinformation, political 
motivation and partisanship to prevent us from taking the necessary 
steps to improve our health care system. I believe that we have a moral 
obligation to ensure that all Americans, regardless of race, ethnicity, 
geography, or income, receive the health care they need to lead healthy 
and productive lives.
  As a man of faith, I know that Jesus taught us to provide and care 
for others, especially the `least of these' who often have few 
advocates. In addition, when I ask myself, `What would Jesus do if he 
represented the Second Congressional district, and had the opportunity 
to vote to enable more than 32 million uninsured Americans to receive 
health insurance?' I believe He would take care of this immediate need 
of the people--not let them fend for themselves while we start over or 
do nothing. This legislation goes a long way toward living up to this 
moral principle, and I am proud to support it.
  Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I rise to claim time 
in support of the Reconciliation Bill and the Senate amendments to the 
Patient Protection and Affordable Care Act.
  Health care in the United States has degraded in accessibility and 
quality to the extent that we are a nation in crisis. Change is needed 
to truly make progress toward a healthier America, and the time for 
change is now.
  We are the closest in 60 years of legislative efforts to provide 
access to health care for all Americans. We must pass this legislation 
for the people.
  It is time to place compassion and dignity over corporate greed.
  My experiences as a legislator--and as a nurse--have provided a 
unique vantage point from which to discuss this issue. I have seen 
first-hand the state of affairs of our health care system.
  We cannot sustain the current system as premiums rise, prescription 
prices soar, and medical bankruptcies increase as services decline.
  Texas leads the Nation in uninsured, including the highest rate of 
uninsured children, and I am here today to stand up for my constituents 
who desperately seek access to care.
  Thousands of families are crushed by the growing cost of health care. 
This legislation reins in health care costs for families and businesses 
and reduces the deficit.
  We have come to a point where we must choose consumers over insurance 
companies. Insurance companies have held the public hostage for many 
years, controlling and rationing care. It is time to give citizens the 
right to control their own health care.
  I stand in strong support of the legislation and urge my colleagues 
to do the same.
  Mr. HALL of Texas. Mr. Speaker, as we enter the most important and 
eventful week of the thirty years I've been up here--I think of the 
consequences of the votes we will cast--both Republican and Democrat.
  When we passed the health bill on this very floor--the Democrats--
with a 40 vote advantage on the House Floor--passed H.R. 3962 with a 5 
vote advantage--which showed that the outrageous health bill had been 
lessened in severity in the Commerce Committee--and was softened up 
enough for the Senate to kill it. Then, a series of Senators negotiated 
gifts they were not entitled to--each receiving a different 
consideration--into being the coveted 60th vote. If we take the Floor 
back--I would favor subpoenaing those who may have made the overtures 
to compare it to the law of bribery or corrupt deals. I would send the 
results to the Federal and State Prosecutors. The bribery penalty as 
set out in 18 U.S. Code Section 203 ``is imprisonment for not more than 
a year and a civil fine of not more than $50,000 for each violation.'' 
I consider offering a bribe--for a personal benefit--as worse than 
accepting one; let's clean up the United States Congress--and listen to 
our people whose only request is to take back our country.
  Webster's Dictionary defines ``bribe'' as money or favor given or 
promised to a person in a position of trust to influence their judgment 
or conduct.
  Mr. MARIO DIAZ-BALART of Florida. Mr. Speaker, I rise today to 
express my strong opposition to the eventual government takeover of 
health care that took place on the floor of the House today.

[[Page H1910]]

  Though I strongly believe that America needs health care reform, I 
cannot in good conscience cast a vote for a bill that will take our 
country down the path of bankruptcy.
  This deeply flawed legislation raids Medicare, which faces insolvency 
in 2017, by over half a trillion dollars in order to create a massive 
new entitlement program. It raises taxes on our families and small 
businesses by over half a trillion dollars. It will lead to increases 
in insurance premiums, increase overall spending on health care by over 
$200 billion and will result in job losses. This bill will also 
increase the national debt and deficit, leaving our children and 
grandchildren to pay the price.
  Today Democrat leadership abused and manipulated the legislative 
process for political gain, in an effort to force an eventual 
government takeover of health care that the American people do not 
want. This legislation was drafted in secret and is loaded with 
backroom deals for certain Members of Congress and special interests. 
The American people need, demand and deserve health care reform that 
will increase access, improve quality and lower costs. What the 
American people do not want is this ill-conceived legislation that will 
bankrupt our country and leave a lasting negative impact on generations 
to come.
  Nothing is more sacred in this country then our freedom and 
democracy. These are the fundamental principles that make America the 
greatest country in the world, and I cannot and will not vote for 
legislation that jeopardizes the freedom, democracy, prosperity and 
opportunity of future generations of Americans.
  Mr. COSTELLO. Mr. Speaker, we meet today for what will truly be a 
historic debate and vote on national health care reform. Like the 
passage of Social Security in 1935 and Medicare in 1965, it is sure to 
be one of a handful of votes that will stand the test of time as of 
great national significance. Also like those votes, the public debate 
surrounding national health care reform has engendered great passion on 
both sides, often generating more heat than light, but instructive all 
the same, as we must listen to all viewpoints as we contemplate major 
changes that will affect the entire country.
  Today's vote is a major milestone in what has been a decades-long 
effort to ensure access to quality health care for all Americans. In my 
district, 34,000 people are uninsured and use the hospital emergency 
room for treatment. Nine thousand people have a pre-existing condition 
that precludes them from getting insurance. Meanwhile, health insurance 
premiums have increased 131 percent over the last decade while wages 
have gone up only 38 percent. While the process over the last 14 months 
to develop health care reform legislation has been far from perfect, it 
is undeniable that our current health care system is broken, and we 
must take action to fix it. Toward this goal, I will vote in support of 
H.R. 3590 and H.R. 4872.
  This has been the hardest decision regarding a vote I have had to 
make during my service in the House of Representatives. During that 
time, I have strived to serve the people I represent with diligence and 
integrity, while remaining true to my core individual beliefs.
  One of those core beliefs is my support of protecting the unborn. I 
along with Congressman Bart Stupak (D-MI) and other pro-life Democrats 
have worked hard through the passage of the House bill and since the 
passage of the Senate bill to ensure that current law Hyde amendment 
abortion restrictions are applied to the final legislation. However, we 
were successful in convincing President Obama--a pro-choice President--
to issue an executive order that clearly states that the Hyde amendment 
will apply to the bill. This is a highly significant act. In addition, 
a colloquy on the House floor clearly stated that this is the intent of 
Congress. With these changes, I believe we have accomplished our goal. 
This belief is shared by the Catholic Health Association, NETWORK--a 
national Catholic social justice lobby, the Catholic Sisters--60 
Catholic women religious leaders representing 59,000 Catholic Nuns, and 
Democrats for Life.
  I stated that I would not vote for the Senate-passed bill in its 
current form. With the presidential executive order approving the Hyde 
abortion language and the fact that H.R. 4872 eliminates the 
``Cornhusker Kickback'' and other state-specific promises, combined 
with assurances from the Senate that H.R. 4872 will pass that body, I 
feel I can now support the Senate bill as amended.
  The fact is that this may be our last best chance to address a health 
care system that is unsustainable, that is spending $1 billion annually 
on medical costs for the uninsured while insurance premiums rise 
uncontrollably. Our current system is grossly inefficient and 
jeopardizes our future economic health. This legislation will insure 32 
million additional Americans, eliminate pre-existing condition 
restrictions, allow for the interstate sale of health insurance, 
eliminate lifetime caps on insurance benefits, allow dependent children 
to stay on their parents' insurance until age 26, and improve health 
care for seniors, all while reducing our budget deficit by $138 billion 
over the next 10 years, and by $1.2 trillion over the next 10.
  While the legislation will allow those that have health insurance to 
keep it, it will also end the fear that so many uninsured Americans 
have of becoming sick--of having to use their life savings or declare 
bankruptcy to pay for a medical emergency. It can be the difference 
that allows the disabled to live with dignity, and provides workers the 
confidence to reach their maximum professional potential.
  Mr. Speaker, after much deliberation, it is clear to me that we must 
take this opportunity to improve the provision of health care in our 
country. While it is a difficult thing to do, it is unquestionably the 
right thing to do, and I am confident that history will reflect this 
fact.
  Mr. GOODLATTE. Mr. Speaker, nearly two months ago President Obama 
stood here before the Members of the House of Representatives, the 
Senate, the Supreme Court Justices, his own Cabinet Members and 
millions of Americans who were watching on television to deliver his 
first State of the Union address. In that speech he declared that as 
economic uncertainty continues to plague our Nation the government must 
focus on policies that promote economic growth and job creation. My how 
things have changed in just two short months.
  Congress should be working to reduce the tax and regulatory burdens 
that hinder small businesses and ultimately overall economic growth and 
job creation. Instead, over the loud objections of a majority of 
Americans, the Majority continues to advance their health care reform 
proposal which sets the tone for a Washington takeover of the health 
care system. This legislation which contains a multitude of new federal 
regulations, mandates, new big government programs, and a significant 
increase in federal spending and debt, will be extremely detrimental to 
American businesses and particularly our small businesses, which will 
make job losses even worse.
  The legislation includes over $569 billion in tax increases and over 
$523 billion in Medicare cuts. This includes $52 billion in new taxes 
on employers, including small businesses, that cannot afford to provide 
health coverage or that don't offer coverage. The effect of this type 
of tax, similar to a payroll tax increase, would ultimately fall 
squarely on workers in the form of lower wages or reduced employment. 
Additionally, the legislation includes $17 billion in new taxes on 
Americans who do not comply with the individual insurance mandate which 
is sure to further stifle economic growth.
  In fact, 130 economists from all across the country sent President 
Obama a letter explaining how this legislation is a job-killer. In 
their letter, the economists stated that the insurance mandate and the 
tax increases, among other things, will ``constrict economic growth and 
reduce employment'' while ``increasing spending on health care and 
increasing the cost of health coverage''.
  That is why I strongly support an alternative proposal which allows 
for the purchase of health insurance across state lines, allows 
individuals and small businesses to join large pools to get more 
competitive rates, provides tort reform to cut down the high cost of 
defensive medicine, allows full tax deductibility of health insurance 
premiums, portability of health insurance and protection against pre-
existing condition exclusions. In addition, I support health insurance 
tax credits for individuals and families who don't have access to 
employer-based health insurance, increasing the number of community 
health centers, and encouraging the use of health information 
technology to achieve greater efficiencies.
  Congress should not be pushing this government takeover of health 
care that will inflict even more harm on our Nation's economy, making 
job losses even worse. Instead Congress must focus on strategies that 
help Americans obtain the best quality health care at the least cost, 
and ensure that the government fosters increased access to quality care 
based on individual choice, not by taking away choices from people on 
the grounds that government knows best.
  Mr. SMITH of New Jersey. Mr. Speaker, for those of us who recognize 
abortion as lethal violence against children and the exploitation of 
women, nothing less than a comprehensive prohibition on public funding, 
promotion and facilitation of elective abortion in any federal health 
program, including the bill under consideration today, satisfies the 
demands of social justice.
  The Stupak-Pitts Amendment which passed 240-194-1 ensures that not 
some, but all the elements of the Hyde amendment applies to the 
programs that are both authorized and appropriated in this bill.
  By now, I trust that all members fully understand that because 
programs in Obamacare are both authorized and appropriated in this 
legislation, the actual Hyde Amendment has no legal affect. It only 
affects Labor HHS not this massive expansion of government funded 
health care.

[[Page H1911]]

  Regrettably the language that emerged from the Senate is weak, 
duplicitous and ineffective, not by accident, but by design. It will 
open up the floodgates of public funding for abortion in a myriad of 
programs resulting in more dead babies and wounded moms than would 
otherwise have been the case.
  Because abortion methods dismember, decapitate, crush, poison, starve 
to death and induce premature labor, pro-life Members of Congress, and 
according to every reputable poll, significant majorities of Americans 
want no complicity whatsoever in this evil. Obamacare forces us to be 
complicit.
  Abortion hurts women's health and puts future children subsequently 
born to women who aborted at significant risk. At least 102 studies 
show significant psychological harm, major depression and elevated 
suicide risk in women who abort.
  Recently, the Times of London reported that, ``[S]enior . . . 
psychiatrists say that new evidence has uncovered a clear link between 
abortion and mental illness in women with no previous history of 
psychological problems.'' They found, ``that women who have had 
abortions have twice the level of psychological problems and three 
times the level of depression as women who have given birth or who have 
never been pregnant . . .''
  In 2006, a comprehensive New Zealand study found that 78.6 percent of 
the 15-18 year olds who had abortions displayed symptoms of major 
depression as compared to 31 percent of their peers. The study also 
found that 27 percent of the 21-25 year old women who had abortions had 
suicidal idealizations compared to 8 percent of those who did not have 
an abortion.
  At least 28 studies--including three in 2009--show that abortion 
increases the risk of breast cancer by some 30-40 percent or more yet 
the abortion industry has largely succeeded in suppressing these facts. 
Abortion isn't safe for subsequent children born to women who have had 
an abortion. At least 113 studies show a significant association 
between abortion and subsequent premature births. For example a study 
by researchers Shah and Zoe showed a 36 percent increased risk for 
preterm birth after one abortion and a staggering 93 percent increased 
risk after two.

  Similarly, the risk of subsequent children being born with low birth 
weight increases by 35 percent after one and 72 percent after two or 
more abortions. Another study shows the risk increases 9 times after a 
woman has had three abortions.
  What does this mean for her children? Preterm birth is the leading 
cause of infant mortality in the industrialized world after congenital 
anomalies. Preterm infants have a greater risk of suffering from 
chronic lung disease, sensory deficits, cerebral palsy, cognitive 
impairments and behavior problems. Low birth weight is similarly 
associated with neonatal mortality and morbidity.
  Unlike both the Hyde Amendment and what would be the effect of the 
Stupak-Pitts amendment, the Senate passed bill permits health care 
plans and policies funded with tax credits to pay for abortion, so long 
as the issuer of the federally subsided plan collects a new, 
congressionally mandated fee from every enrollee in that plan to pay 
for other peoples abortions. Requiring the segregation of funds into 
allocation accounts--a mere bookkeeping exercise touted by some as an 
improvement to the new pro-abortion funding scheme--does absolutely 
nothing to protect any victims--baby or mother--from publically funded 
abortion.
  The Senate passed bill creates a new Community Health Center fund and 
appropriates at least $7 billion for Community Health Centers (CHC). 
Again recognizing that the Hyde Amendment does not apply to this bill 
and absent enactment of the Stupak-Pitts amendment, it is clear that 
the 1,250 CHC clinics (among the most effective means of reaching the 
poor and underserved with basic health care) will likely be compelled 
either by the Obama Administration or the courts or both to fund 
abortion on demand at CHC sites. There is no statutory protection 
against this abuse in the Senate-passed bill.
  Additionally, under the federal employee health benefits plan, which 
includes Members of Congress, since 1984, no funds may be used for 
abortion or the administrative expenses in connection with any health 
plans that provide any benefit or coverage for abortions or even the 
administrative expense, except in the case of rape, incest or to 
protect the life of the mother.
  The Office of Personnel Management (OPM) administers the program.
  The Senate-passed bill on the other hand creates a huge new program 
administered by OPM that would manage two or more new multi-state or 
national health plans. The bill stipulates that at least one plan not 
pay for abortion. Which only begs to question: what about the other new 
multi-state plans administered by OPM? Why can those federally 
administered plans include funding abortion on demand? This represents 
a radical departure from current policy.
  Additionally, other appropriated funds in the bill have no Hyde/
Stupak-Pitts type protections either including $5 billion for a 
temporary high risk health insurance fund and $6 billion in grants and 
loans for health cover co-ops. Pro-life members who vote for this bill 
will roll the dice on this one.
  When the bill left the House, it contained the Hyde-Weldon language 
protecting health care providers who refuse to participate in abortion 
against discrimination by government entities. The Senate passed bill 
instead only includes more narrow text that prevents discrimination by 
a ``qualified health plan'' on the Exchange. This narrow language was 
included in the House bill, but without the additional protections 
against discrimination by federal and state governmental entities, pro-
life health care providers are not fully protected.

  Then there's the Mikulski Amendment, Sec. 2713, which empowers the 
HHS Secretary with broad new authority to compel private health care 
plans in America to cover ``preventable'' services. When Senator Ben 
Nelson suggested that abortion not be included in the so-called 
preventative services mandate, Ms. Mikulski said no--raising a serious 
red flag that abortion is being postured as ``preventable abortion 
service in the future''--after all, abortion prevents a live birth.
  Abortion as preventative health care isn't new.
  And as far back as 1976, Dr. Willard Cates, Jr. and Dr. David Grimes, 
then with CDC, presented a paper to a Planned Parenthood meeting, 
entitled: Abortion as a Treatment for Unintended Pregnancy: The Number 
Two Sexually Transmitted ``Disease''. To call pregnancy sexually 
transmitted disease; to call abortion a treatment or a means of 
prevention for this ``disease'' is barbaric.
  Abortion isn't health care--preventative or otherwise.
  Mr. Speaker, we live in an age of ultrasound imaging--the ultimate 
window to the womb and its occupant. We are in the midst of a fetal 
health care revolution, an explosion of benign innovative interventions 
designed to diagnose, treat and cure disease or illness any unborn 
child may be suffering.
  Unborn children are society's youngest and most vulnerable patients. 
Obamacare should do them no harm. Tragically, it does the worst harm of 
all. It kills them.
  Mr. FILNER. Mr. Speaker, I rise in support of this bill and I would 
like to take the opportunity to remind America's veterans that the plan 
will not affect the VA health care system. I continue to work in 
concert with leaders in the House of Representatives to ensure that 
veterans receive the world-class health care services they have so 
bravely earned.
  Let me be clear: enrolled veterans meet the individual responsibility 
requirements under the bill to maintain quality health coverage.
  I firmly believe all of our citizens should have access to health 
care. I am proud that Congress has crafted a plan to bring stability 
and security to Americans who have insurance today, and affordable 
coverage to those who do not. This plan, however, will not jeopardize 
the current health care services and benefits provided by VA. We will 
keep our promise to our Nation's heroes of the past, present, and 
future.
  I was pleased to sign a letter with House Armed Services Chairman Ike 
Shelton, House Ways & Means Chairman Sander Levin, House Education & 
Labor Chairman George Miller, and House Energy and Commerce Chairman 
Henry Waxman affirming that current health care reform legislation does 
not undermine or change the Department of Veterans Affairs mandate to 
provide comprehensive health care to veterans. I would like to submit 
this letter, along with statements from the Vietnam Veterans of America 
and AMVETS and a statement from General Eric Shinseki, Secretary of the 
VA, affirming this fact for the Record.

                                Congress of the United States,

                                   Washington, DC, March 21, 2010.
     Hon. Louise Slaughter,
     Committee on Rules, The Capitol,
     Washington, DC.
       Dear Chairwoman Slaughter: The House Democratic leadership 
     asked our committees to review HR 3590 and HR 4872 to assess 
     the impact of the bills on the health care provided by the 
     Department of Defense and the Department of Veterans Affairs. 
     Our reviews of HR 3590 and HR 4872 lead us to believe that 
     the intent of the bills was never to undermine or change the 
     Department of Defense and Department of Veterans Affairs 
     operation of their health care programs or interfere with the 
     care that our service members receive under TRICARE. However, 
     we commit to look into this issue further to ensure that no 
     unintended consequences may arise and to take any legislative 
     action that may be necessary.
       HR 3590, as drafted, does not specifically mention that 
     TRICARE coverage meets the individual responsibility 
     requirement. but such coverage would satisfy the requirements 
     of this bill. To affirm that this is the case, the U.S. House 
     of Representatives unanimously passed HR 4887, the TRICARE

[[Page H1912]]

     Affirmation Act, which provides assurances to the American 
     people that care provided to those in the military and their 
     families, as well as military retirees under age 65 and their 
     families, would indeed meet the requirement for coverage.
       The members of our nation's military sacrifice much to 
     defend us all. We commit to these dedicated service members 
     and their families as well as our veterans that we will 
     protect the quality healthcare they receive,
           Sincerely,
     Bob Filner,
       Chairman, Committee on Veterans' Affairs.
     George Miller,
       Chairman, Committee on Education and Labor.
     Henry Waxman,
       Chairman, Committee on Energy and Commerce.
     Ike Skelton,
       Chairman, Committee on Armed Services.
     Sander Levin,
       Chairman, Committee on Ways and Means.
                                  ____

                                                   March 21, 2010.

 Vietnam Veterans of America Applauds Passage of Skelton Bill Ensuring 
  Protection of TRICARE, VA Health Care, and CHAMPUS; Decries ``Scare 
                               Tactics''

       Washington, DC.--`` We thank and applaud passage of H.R. 
     4887 yesterday in the House of Representatives, by a vote of 
     403-0. Passage of this bill ensures that health care programs 
     for veterans, active duty military, retired military, and 
     their families/survivors will not be affected negatively by 
     the pending health care reform legislation.'' said John 
     Rowan, National President of Vietnam Veterans of America 
     (VVA).
       ``It is unfortunate that some continue to raise what is now 
     is even more clearly a false alarm that is apparently meant 
     to frighten veterans and their families in order to prompt 
     them to oppose the pending legislation. While there is 
     legitimate debate as to whether or not the pending health 
     care measures should become law, VVA does not appreciate 
     spreading rumors that are not accurate by any political 
     partisan from any point of the political spectrum,'' 
     continued Rowan.
       ``Last summer there was a similar incident, also involving 
     partisans in the health care reform debate, that VVA soundly 
     condemned. We said then: ``It is our hope that sane minds 
     reject fear-mongering, and that veterans recognize these 
     scare tactics for what they are,'' Rowan said. Rowan 
     concluded by saying: ``VVA has always worked hard for justice 
     for veterans of all generations, and their families. We have 
     always, and will continue to, work with public officials 
     representing all political parties and points of view. Issues 
     affecting veterans and their families are not, should not, 
     and must not become partisan footballs to bat around. VVA 
     decries any effort, by anyone, that would do just that.''
                                  ____



                               Department of Veterans Affairs,

                                                   March 21, 2010.

              Statement from VA Secretary Eric K. Shinseki

       As Secretary of Veterans Affairs, I accepted the solemn 
     responsibility to uphold our sacred trust with our nation's 
     Veterans. Fears that Veterans health care and TRICARE will be 
     undermined by the health reform legislation are unfounded. I 
     am confident that the legislation being voted on today will 
     provide the protections afforded our nation's Veterans and 
     the health care they have earned through their service. The 
     President and I stand firm in our commitment to those who 
     serve and have served in our armed forces. We pledge to 
     continue to provide the men and women in uniform and our 
     Veterans the high quality health care they have earned.
       President Obama has strongly supported Veterans and their 
     needs, specifically health care needs, on every major issue 
     for these past 14 months--advance appropriations, new GI Bill 
     implementation, new Agent Orange presumptions for three 
     additional diseases, new Gulf War Illness presumptions for 
     nine additional diseases, and a 16% budget increase in 2010 
     for the Department of Veterans Affairs, that is the largest 
     in over 30 years, and which has been followed by a 2011 VA 
     budget request that increases that record budget by an 
     additional 7.6%.
       To give our Veterans further assurance that health reform 
     legislation will not affect their health care systems, the 
     Chairmen of five House committees, including Veterans Affairs 
     Chairman Bob Filner and Armed Services Chairman Ike Skelton, 
     have just issued a joint letter reaffirming that the health 
     reform legislation as written would protect those receiving 
     care through all TRICARE and Department of Veterans Affairs 
     programs.
                                  ____


      AMVETS Applauds Skelton Bill To Protect Military Health Care

       Lanham, Md. March 21, 2010--AMVETS leaders applauded the 
     passing of H.R. 4887, introduced by Rep. Ike Skelton, D-Mo., 
     that will protect specific health care benefits of military 
     veterans, members of the Armed Forces and their families.
       AMVETS National Legislative Director Raymond Kelly said 
     Sunday that AMVETS leaders have always understood the intent 
     of H.R. 3590: The Patient Protection and Affordable Care Act, 
     and believed it would not compromise the health care benefits 
     of American Veterans.
       ``AMVETS continues to share the opinion of Department of 
     Veterans Affairs Secretary Eric Shinseki and other VA and 
     Department of Defense leaders that health care reform 
     legislation does not threaten the veterans' community,'' said 
     Kelley. ``The successful passing of Rep. Skelton's 
     legislation only solidifies our belief and erases any and all 
     doubt of potential harm.''
       Kelly said AMVETS will continue to monitor the debate to 
     ensure the Senate version of H.R. 4887 also passes.
  Ms. HIRONO. Mr. Speaker, today we take a stand for hard-working 
middle class families who deserve a better value for their health care 
dollar. We take a stand for better health care for America's seniors. 
We take a stand for those who have been denied insurance coverage 
because of a preexisting condition or whose insurance is rescinded when 
they need it most.
  This has been a difficult debate. There are strong, personal feelings 
about the issue of health care, because it affects all of us. This 
makes it even more important that we focus on the substance of health 
care reform, rather than engage in demagoguery, name calling, and 
worse. Republicans and Democrats alike know that our health care system 
is broken and not sustainable. Our country spends more on health care 
than any other developed country and we fall far below these other 
countries in the health of our people.
  H.R. 4872 and the Senate health care reform bill, H.R. 3590, are not 
perfect, but they are a step in the right direction. The health 
insurance reform measure achieves the three key goals of affordability 
for the middle class, accessibility for all Americans, and 
accountability for the insurance industry.
  More than 350 organizations support the health insurance reform 
legislation that we are voting on today. They include: the American 
Medical Association, AARP, Catholic Health Association, Main Street 
Alliance, Federation of American Hospitals, National Association of 
Public Hospitals and Health Systems, American College of Physicians, 
Paralyzed Veterans of America, American Heart Association, American 
Cancer Society Cancer Action Network, American Diabetes Association, 
American Nurses Association, Families USA, National Committee to 
Preserve Social Security and Medicare, National Women's Law Center, 
Consumer Federation of America, and the Consumers Union.
  Once this bill is passed, Americans will see immediate benefits: 
seniors will start to see immediate relief from high prescription 
prices with a $250 rebate for Medicare beneficiaries who hit the donut 
hole; preventative services and immunizations will be free under 
Medicare right away--eliminating co-payments for preventative services 
and exempting preventative services from deductibles; and small 
businesses that provide coverage to their employees will be eligible 
for a tax credit of up to 35% of premiums. The bill will also ban 
insurers from denying coverage to children with pre-existing conditions 
and eliminates lifetime limits and restrictive annual limits on 
coverage.
  These are real reforms yielding real benefits to people who are not 
getting their money's worth from the current system. It will soon be 
much harder to mischaracterize what this effort to change the health 
care system has been about once reform is enacted and the benefits 
accrue.
  I was appalled at the news that my colleagues John Lewis, Andre 
Carson, Emanuel Cleaver, and Barney Frank were verbally insulted and in 
one instance spat on by anti-health care reform protestors yesterday.
  The ugliness that this behavior exemplified reminded me of why ``Live 
Aloha'' is more than a motto to us in Hawaii. The Hawaiian word aloha, 
has deep meaning in my state; it is far more than hello or goodbye. To 
``Live Aloha'' is to also have respect for yourself and respect for 
others, especially those with whom we disagree. To treat each other 
with decency--not hatred, or racism, or bigotry--is to ``Live Aloha.'' 
I'm proud to represent a state where we strive toward that ideal.
  My office has taken many calls and received many emails and letters 
on health care reform. A call that my office received on Friday was 
particularly heartfelt. It was from a woman on the island of Kauai who 
called to tell me that she and her 93 year-old friend both wanted me to 
stay strong and to vote in support of health care reform. I mention 
this particular call because it reminded me of the people and places I 
represent, who I fight for every day, and what this health care debate 
is all about.
  In his recent address to the Democratic Caucus, President Barack 
Obama quoted President Abraham Lincoln who said, ``I am not bound to 
win, but I'm bound to be true. I'm not bound to succeed, but I'm bound 
to live up to what light I have.'' This bill calls us to be true to the 
millions of Americans who want and need enlightened health care reform. 
It is a privilege to vote for H.R. 4872.

[[Page H1913]]

  Mr. ISRAEL. Mr. Speaker, I rise in support of this bill for one 
fundamental reason. It is-simply the right thing to do. Not for my 
Party, not for the President, not for the Speaker, not for me. But for 
the people I represent. The middle class and working families; the 
backbones of our economy--small businesses--challenged by rising health 
costs.
  Few debates have been as long and as passionate as this one. Since 
last August I have heard the strong voices on both sides of this issue. 
I have listened to the angry chants of opponents of the bill at Town 
Hall meetings. I have read the mail from people who insist this is a 
march towards socialism, that it is a dangerous experiment, that it 
involves government death panels who will deny senior citizens the 
life-saving health care they need. I have watched protesters march 
outside my district office on Long Island. I have seen the repugnant 
signs here in Washington comparing health care to the Holocaust.
  I have seen and heard it all. But I have also heard others. They are 
the average Long Islanders--not rich, not poor, but usually somewhere 
in between--who live in quiet desperation and concern.
  The small business owner on Long Island who told me he just received 
a 22 percent increase in health insurance premiums and agonizes at the 
prospect of either scaling back the care he provides his workers or 
scaling back the workers he pays. Under this bill, his business will 
receive a tax credit to help him provide insurance to his workers. And 
he will be able to shop for competitive rates and services in a new 
market-driven ``Health Insurance Exchange.''
  The woman who thought health care worked pretty well for her, until 
her daughter was diagnosed with breast cancer. She's been forced to 
deal with high medical costs to care for her daughter. But, under this 
bill, she will not have to worry about an insurance company that 
refuses to pay for her chemotherapy.
  The middle class family with two kids just out of college who are 
having trouble finding a job that provides health insurance. Under this 
bill, those young adults can get coverage on their parents' plans until 
they turn 26.
  The retired plumber on the block where I live. One day he came to my 
house. I thought he wanted to debate this bill with me. Instead, he 
said: ``I wish you would pass this now. Don't these people know that if 
they lose their jobs they lose their health care?''
  And just yesterday, Mr. Speaker, a small business owner called me 
with concerns and plentiful questions about the legislation we will 
vote on today. After I explained it, he said: ``There's been too much 
confusion about this bill. I wish it had been explained.''
  He is right. This bill has changed in over a year of debate. 
Sometimes in an effort to accept bipartisan recommendations. Sometimes 
to reduce its cost. While one side has had the responsibility to 
improve the bill, the other side has taken the opportunity to brand it 
with mischaracterizations. But now the ink is dry, Mr. Speaker. And the 
dry ink of this bill represents the best hope to protect the middle 
class and working families I represent. The small business owner in 
East Northport who now has a level playing field when shopping for 
insurance. The family in Sayville who can now keep a child insured 
until the age of twenty-six. The senior in Deer Park whose drug costs 
will be covered. The accountant in Huntington who lost his job but will 
be able to shop for affordable health care.
  This bill will improve coverage for 485,000 of my constituents with 
coverage through their employer, give tax credits to as many as 81,000 
families and 21,000 small businesses to make health care affordable in 
my district, and extend coverage to 29,000 uninsured residents of the 
towns I represent.
  This bill will reduce our debt. Yesterday, the Congressional Budget 
Office certified that the bill is fully funded and will actually reduce 
federal deficits by $143 billion in the first ten years and over a 
trillion dollars in the next ten.
  This bill is an urgent reversal from eight years of ignoring the 
crisis. Between 2000 and 2008, health insurance premiums doubled, 
insurance company profits quadrupled, and an additional 6 million 
Americans became uninsured. As a result, the leading cause of personal 
bankruptcy today is unpaid medical bills. Without action, these trends 
will grow worse.
  These are the middle class families and businesses that have always 
expanded our economy. But rising health costs and insecurity have 
undermined the middle class. This bill will provide them with the basic 
security they need to do what they've always done: build our economy.
  This vote is no different than the 1965 vote for Medicare. Back then, 
when one-quarter of American seniors were living in poverty and wracked 
with un-payable medical bills, there were loud voices that said, ``do 
nothing'' and ``start over'' and ``vote no.'' Public opinion was 
skeptical then. Had I been in Congress in 1965, and the choice was 
voting for Medicare and risking my seat, or voting against Medicare and 
saving my seat, I would have voted for Medicare. It became the back 
bone of economic security for our senior citizens and helped build a 
middle class with economic security. This is no different. No less 
necessary. No less historic.
  Mr. STARK. Mr. Speaker, This is a historic day. We have worked to 
enact health reform in America for decades. President Johnson took a 
major step when he signed Medicare into law in 1965 and guaranteed 
every American age sixty-five and over quality, affordable health care. 
Forty-five years later, we are about to extend that guarantee to all 
Americans.
  It isn't the bill I would have written. However when it comes to 
legislating health insurance reform in America, we will not get 
everything each of us want. This bill is a compromise that bridges the 
differences among us.
  I am proud to support this legislation and urge my colleagues to do 
the same.
  This bill builds a solid foundation. It will:
  Extend coverage to 95 percent of all Americans.
  Assure affordability of health insurance by providing tax credits and 
cost-sharing assistance to families up to 400 percent of poverty.
  Halt abuses of the health insurance industry--forcing them to compete 
on quality, not just their ability to avoid covering needed health 
services.
  Guarantee a standard benefit package for all Americans with an annual 
cap on out-of-pocket spending. No family should go bankrupt because of 
medical expenses.
  Create a new marketplace, called an Exchange, where people will be 
able to comparison shop among health insurance plans.
  Require that insurance plans spend at least a certain percentage of 
their premium dollars on benefits and end discrimination by health 
status, gender, occupation.
  Help senior citizens by filling the Republican Medicare prescription 
drug donut hole--ensuring that Medicare beneficiaries will be able to 
afford their medications year-round.
  We are joined in support of this legislation by a coalition of 
patients, doctors, nurses, hospitals, businesses, labor unions, 
children's advocates and senior citizens.
  President Obama has worked tirelessly to achieve this goal and he 
deserves much of the credit.
  There are components I wish had turned out differently and I pledge 
to continue working to improve them. In particular, I have some 
concerns about Medicare.
  I oppose the inclusion the Independent Payment Advisory Commission, 
called IPAB. Some of my colleagues support this Commission because it 
shields them from having to take tough votes when it comes to cutting 
Medicare provider payments. It's my experience that Congress always 
does what is needed to protect and strengthen the Medicare program. 
IPAB is a dangerous provision. By statute, this Commission would be 
required to hold Medicare spending to an arbitrary and unrealistic 
growth rate. It is a mindless-rate cutting machine that sets the 
program up for unsustainable cuts. That will endanger the health of 
America's seniors and people with disabilities. It is an unprecedented 
abrogation of Congressional authority to an unelected, unaccountable 
body of so-called experts. I intend to work tirelessly to mitigate the 
damage that will be caused by IPAB.
  I am pleased that this legislation reduces government overpayments to 
private health insurance plans in Medicare and that our reconciliation 
negotiations improved on those savings. It still should eliminate the 
overpayments. I support the choice of private plans in Medicare, but I 
don't support wasting taxpayer dollars on corporate subsidies to 
achieve that goal. Plans that can meet or beat Medicare should be 
allowed to participate. Those that can't should be excluded. We've got 
more work to be done here.
  We also lost a provision in the House bill that ensured Medicare 
beneficiaries in private plans would never pay higher cost-sharing for 
Medicare services than if they were enrolled in traditional Medicare. 
I'll be working with the Administration to see that they move forward 
with steps in their authority to resolve that disparity.
  I am disappointed in the lack of a public health insurance option. 
This provision fell victim to the strength of the insurance industry 
lobby. It would have saved taxpayers money, enhanced competition, and 
increased efficiencies. That it isn't in this bill does not mean it 
can't be added in the future.
  These flaws are what one must expect when bringing a bill through the 
US Congress that touches more than one-sixth of our economy. In the 
past, we've allowed health reform to fail because of similar 
imperfections. We, can't let that happen now.
  Our vote today will determine whether we finally provide affordable, 
quality health care to all Americans. I am proud to rise in support of 
this legislation, and I urge my colleagues to join me in voting yes.
  Mr. PIERLUISI. Mr. Speaker, I rise so that the record will reflect 
the following point about the Medicare Advantage program and its 
application in Puerto Rico. For a variety of reasons, relatively few 
Medicare beneficiaries in

[[Page H1914]]

Puerto Rico are enrolled in Part B. The Medicare Payment Advisory 
Commission (MedPac) has determined that, as a result, fee-for-service 
reimbursement rates for providers on the Island are artifically low and 
unstable. Over the past year, I have worked with the House Committee on 
Ways and Means to examine ways to address this problem. In the report 
accompanying the health care reform bill it approved, the Committee 
candidly acknowledged the problem and urged CMS to use its existing 
authority to adjust the reimbursement rates in Puerto Rico. I strongly 
supported this language and believe it is still operative. Working with 
Committee leadership and my colleagues, I will do everything within my 
power to ensure that CMS uses its current authority to make certain 
that reimbursement rates to MA providers in Puerto Rico are fair.
  The language included in the House Ways and Means Committee report 
is:
  The phase-down of MA payments to FFS costs applies equally to all 50 
states and the territories, however, Puerto Rico is a unique situation 
that the Committee expects that the Secretary will use authority under 
current law to examine. Specifically, very few Medicare beneficiaries 
in Puerto Rico choose to enroll in Part B; instead, MA plans buy down 
the Part B premium for enrollees and therefore many Medicare 
beneficiaries enroll in MA to receive all of their Medicare services.
  With only a small population enrolled in Part B through traditional 
Medicare, the county FFS expenditures calculated by the Secretary are 
artificially low and unstable from year-to-year. Therefore, the 
Committee expects that when calculating county FFS rates in Puerto 
Rico, the Secretary will use utilization and expenditure data from MA 
plans under current authority and adjust these rates and risk scores 
appropriately.
  Mr. SMITH of Texas. Mr. Speaker, by a 12-point margin, Americans say 
the Administration's health care plan is a ``bad idea,'' according to a 
new NBC News/Wall Street Journal survey.
  And the number of people who call the health plan a ``bad idea'' has 
reached a new high.
  But you won't hear about this from the national media--not even NBC, 
who conducted the poll. During a report about the survey on NBC's 
Nightly News, anchor Brian Williams failed to mention this finding.
  Other polls show even greater opposition to the Administration's 
plan. According to Investor's Business Daily, Americans want Congress 
to ``start fresh'' by 61 percent to 32 percent.
  NBC and the national media should give the American people the facts 
about health care, not hide them.
  Mr. POE of Texas. Mr. Speaker, in a new survey of doctors published 
by The New England Journal of Medicine--nearly half of all primary care 
physicians said they may leave the medical profession if Obama-care 
passes.
  Doctors are getting railroaded out of practice now. Medicare doesn't 
pay the cost to keep their doors open. The new healthcare scheme makes 
it worse. Some doctors who can stay in business won't see Medicare 
patients anymore. They can't afford it.
  More patients and fewer physicians will cause long lines and 
rationing for our senior citizens.
  Government-run Medicare already denies claims twice as much as 
private insurance. But when Medicare denies coverage for a procedure--
you can't pay for it with your own money. The procedure--not the 
coverage--but the procedure is denied under Medicare. That's government 
rationing.
  Passing the healthcare bill would only make those problems worse.
  Government-run healthcare has the competence of FEMA, the efficiency 
of the Post Office, and the compassion of the IRS. It is not fit for a 
free people.
  And that's just the way it is.
  Mr. PETRI. Mr. Speaker, I rise in opposition to H.R. 3590 and H.R. 
4872. I certainly agree that it is time to fix the health care system 
in the United States so that all Americans have access to quality, 
affordable health care. However, the path we are considering takes us 
in the entirely wrong direction. And this reconciliation bill only 
makes worse the Senate amendment considered by the House today. 
Overall, it will break the bank because it is filled with budget 
gimmicks to hide its true cost. It imposes over $500 billion in new 
taxes as our fragile economy struggles towards recovery. It makes 
significant cuts to Medicare, including to Medicare Advantage Plans 
which will surely eliminate or reduce benefits to the 216,000 
beneficiaries in Wisconsin. It gives the government unprecedented 
authority over the regulation of health insurance, which will lead to 
increased costs for those who currently have health insurance.
  We need the right reforms to eliminate waste throughout the system 
and reward high quality low-cost care. We should be choosing approaches 
which give consumers incentives to use their health care dollars 
wisely. Instead, we are going in the opposite direction by turning 
decisions over to government bureaucrats.
  Instead of getting everybody into the old, dysfunctional system and 
then figuring out how to pay for it, we should emphasize advances in 
efficiency so that more people will be able to afford their health 
care, and the government will be better able to take care of the rest. 
Unfortunately, the majority in Congress has committed us to a path 
which will make the right reforms much harder to achieve.
  Despite the fact that I will vote against both bills, I do want to 
express my support for provisions in H.R. 4872 that make changes to the 
federal student loan program. This bill eliminates the Federal Family 
Education Loan (FFEL) Program and moves the origination of all federal 
student loans to the Direct Loan Program. For over two decades I have 
championed the Direct Loan Program as the most efficient, stable, and 
cost effective federal student loan program. The change to 100 percent 
direct lending marks an important step forward for students, parents, 
and taxpayers.
  Currently we have two federal student loan programs that provide the 
exact same student loans to borrowers, and schools choose to 
participate in either one or the other. The FFEL Program uses private 
capital to fund student loans but receives a federal subsidy to ensure 
a guaranteed rate of return. The federal government also provides a 
guarantee on these loans. Thus, if a student defaults, taxpayers are on 
the hook, not the private lender. The Direct Loan Program uses the 
proceeds from the wholesale auction of Treasury securities to the 
private sector to fund loans to students, and all servicing and bill 
collection is handled by private companies operating through 
performance-based contracts. The loans are delivered to students 
through the same system that universities use to disburse Pell Grants.

  I first became interested in student loan reform in the early 1980s 
when the head of the Wisconsin higher education agency convinced me 
that the FFEL program was wildly costly to the government. I introduced 
the first direct loan proposal in 1983 and almost ten years later won 
approval of a pilot program to test the direct loan program at hundreds 
of schools nationwide, including Marquette University in my state of 
Wisconsin. A year later, I successfully worked with President Clinton 
to authorize the Direct Loan Program.
  Over the years, there has been unanimous agreement about the 
excessive costs of the FFEL program compared to the Direct Loan Program 
when studied by the Congressional Budget Office (CBO), the U.S. 
Government Accountability Office (GAO), and the Office of Management 
and Budget (OMB) and the Treasury Department under both Presidents 
Clinton and Bush. Most recently, the Congressional Budget Office 
reported that a switch to all direct lending would save taxpayers $61 
billion over ten years.
  Besides being more expensive for the taxpayers, the FFEL program has 
also been plagued by fraud and abuse which further illustrates the 
drawbacks of this program for students and taxpayers. For instance, 
last Congress it was found that from 2001 to 2006 nonprofit lenders 
illegally claimed, according to one estimate, over $1 billion in 
improper taxpayers subsidies by knowingly manipulating a loophole in 
the law. And then there was the ``pay for play'' scandal in which it 
was revealed that colleges and administrators received special favors, 
benefits and kickbacks from lenders in exchange for steering students 
to their loans.
  The FFEL program has also been proven to be unreliable. In 2008, 
because of the turmoil in the credit markets, Congress passed emergency 
legislation to temporarily allow lenders access to Treasury funds so 
they could continue to make loans. Between the Direct Loan Program and 
an emergency program, the federal government now funds $8.80 of every 
$10 in federal student lending activity. Over the past year, hundreds 
of schools have switched to the Direct Loan Program. They report smooth 
and easy transitions to the program and satisfaction with the service. 
In fact, according to Student Lending Analytics, only two percent of 
schools surveyed indicated they had not taken the steps necessary to 
originate direct loans.
  By moving to 100 percent direct lending we are not favoring 
government over the private markets, there is no ``takeover'' here. 
Eliminating guaranteed loans in favor of direct loans means replacing a 
wasteful program with one that is more cost effective and in the 
interests of students and taxpayers. So, while I must vote against this 
bill due to the ill-conceived health care provisions, I strongly 
support the switch to 100 percent direct lending.
  Mr. HASTINGS of Florida. Mr. Speaker, we are on the brink of passing 
a bill that will lay the foundation for comprehensive health care 
reform. We have discussed and debated various aspects of this bill for 
over a year. Now, it is time to act.
  Developing and executing major reform efforts has never been easy or 
pretty. Violent

[[Page H1915]]

and divisive debates waged when Congress was considering legislation 
that instituted Medicare.
  And yet, few would dispute that this program is essential to 
delivering quality health care to some of our Nation's most vulnerable 
communities--the elderly and disabled.
  Like reform efforts of the past, the health care reform bill has been 
met with blind criticisms and incessant fear mongering. Amazingly, some 
of my colleagues talk about horrific scenarios that will result from 
passing the bill and ignore the horrific conditions that people are 
enduring right now. They don't speak for me. They don't speak for the 
161,000 uninsured Floridians in my district, and they don't speak for 
people who know that this bill is fiscally responsible and takes a 
multifaceted approach to improving our health care system.
  Every single day, people are forced to choose between paying their 
mortgage or financing costly life-saving treatments. Every single day, 
seniors are forced to choose between buying food or buying their 
medication. Every single day, people are dying prematurely because they 
don't have regular access to health care services. You can't tell me 
that these people don't want or need health care reform.
  Mr. Speaker, health care reform boils down to whether you believe 
that 47 million uninsured Americans is an unfortunate but acceptable 
fact, or an injustice that must be addressed.
  Achieving comprehensive health care reform requires a uniquely 
American approach that preserves what works and introduces new elements 
that will allow us to meet 21st century needs and goals. This reform 
bill does just that. I urge my colleagues to vote in support of this 
historic bill and ensure that our fellow Americans have access to 
affordable and high quality health care.
  Mr. BACA. Mr. Speaker, I stand today in strong support of the health 
care reform the American people so desperately need.
  American families and small businesses--not insurance companies--
deserve control over their health care decisions.
  The bill we are debating today will:
  Lower insurance costs--and hold insurance companies accountable.
  End denial of coverage for pre-existing conditions.
  Provide coverage to 32 million uninsured Americans.
  Close the Medicare Doughnut Hole--so seniors will be able to afford 
the coverage they need.
  Eliminate waste in our current system--and lower the deficit by $138 
billion over 10 years; and $1.2 trillion over the next 20 years.
  And allow young adults to stay on their parents' insurance coverage 
until the age of 26.
  Health care reform is an issue that affects every single American--
but is especially important to our Hispanic American community.
  Forty-one percent of Hispanics over the age of 18 lack health 
coverage. We must do better--and with this bill--we will.
  Twenty-one percent of older Hispanics suffer from diabetes--compared 
to only 14 percent of non-Hispanic whites.
  The preventive care this bill provides will lower this disparity.
  This truly is a historic time.
  In 1935 we passed Social Security. In 1965, we passed Medicare.
  Today--we pass a health care reform that will save millions of 
lives--shrink our deficit, and put our nation on a path to prosperity.
  We must move past the hate, the fear, and the lies that have 
dominated this debate, and get the job done for the American people.
  I urge my colleagues to vote for this bill and pass health care 
reform that we need now and for generations to come.
  Ms. BERKLEY. Mr. Speaker, I rise today in support of health care 
reform.
  While not perfect, this bill addresses key obstacles that continue to 
plague the system. The cost of health care premiums is skyrocketing out 
of control, creating an atmosphere where only insurance companies can 
and will prosper and prevail. Without this reform, our individual 
citizens and businesses will continue to be devastated by unsustainable 
costs or barriers to coverage.
  This bill would increase access for those who have been denied 
insurance in the past, either because they can't afford it, have a pre-
existing condition, or have been dropped from coverage after getting 
sick. It would provide financial assistance to working families to make 
their health care costs affordable and it would provide businesses with 
tax credits for providing health care for their employees.
  In my district, this bill would extend coverage to 155,500 uninsured 
residents, guarantee that 26,200 residents with pre-existing conditions 
can obtain coverage, reduce the cost of uncompensated care for 
hospitals and other health care providers by $74 million annually, and 
allow 63,000 young adults to obtain coverage on their parents' 
insurance plans.
  I believe it is my duty to fight for the health, well-being and 
protection of the citizens I represent. While this package does not 
contain all the reforms needed, it provides a framework of very 
positive first steps that will achieve a great deal for Nevada 
families. There is no doubt that more must be done, but I believe this 
is a step in the right direction. I urge my colleagues to vote yes on 
this legislation.
  Mr. PLATTS. Mr. Speaker, all members of Congress agree that the 
status quo in health care is unacceptable and that we must act to make 
affordable, quality health care accessible for all Americans. The 
legislation before us today, however, is the wrong solution. Simply 
put, it is bad public policy.
  Throughout the debate on health care reform, I have emphasized that 
Congress must be certain to adhere to the physician's principle of 
``First, do no harm.'' Unfortunately, the Senate-passed health care 
bill (H.R. 3590) and reconciliation legislation (H.R. 4278) that we are 
considering today will do significant harm.
  A primary focus of health care reform must be on bringing down the 
rapidly rising cost of health care and health insurance. Instead, the 
legislation before us today costs over $1 trillion in the first 10 
years. When fully implemented, the proposed plan's costs will total 
more than $200 billion per year. That's $2 trillion in additional 
health care-related costs over the course of the plan's first full 
decade of implementation. Once the budgetary gimmicks are stripped 
away, the legislation before us will increase the overall budget 
deficit dramatically.
  According to the Congressional Budget Office (CBO), the proposed 
legislation will do significant additional harm as well. CBO analysis 
concludes that health insurance premiums in the individual market will 
increase by 10-13%, Medicare will be cut by more than $500 billion, 
taxes will increase by $579 billion, and millions of Americans will 
ultimately be forced off private health insurance plans into 
government-run plans.
  Countless new taxes are included in the proposed health care 
legislation. For example, new taxes would be imposed on: individuals 
without health insurance; employers, whether they provide health 
insurance for their employees or not; certain employer-provided health 
insurance plans, more and more of them over time; medical devices, like 
wheelchairs and walkers; investment income; Flexible Spending Accounts; 
and health insurers and pharmaceutical companies, taxes that are likely 
to be passed along to their customers.
  The proposed legislation's cuts to Medicare will detrimentally impact 
millions of senior citizens. For example, CBO estimates that, as 
drafted, the cuts to Medicare Advantage funding will result in 
approximately 4.8 million seniors losing access to such plans. Plans in 
which they chose to enroll.
  Mr. Speaker, the process by which we are considering these bills is 
also wrong. Ordinarily, the reconciliation process is used to pass 
legislation making changes in existing federal programs or taxes. The 
reconciliation legislation under consideration today will make changes 
to a health care bill that has yet to even be enacted. Importantly, 
there is no guarantee that the reconciliation bill will be passed in 
the Senate. This means that the House would be effectively trusting 
that the Senate health care bill will be ``fixed'' by the 
reconciliation process, even as the Senate health care bill is approved 
by the House and becomes law.
  The entire health care reform legislative process has been tainted by 
proposals offered along the way to gain votes--like the infamous 
``Cornhusker Kickback,'' as well as special provisions for other states 
that have undermined confidence in the final product. Similarly, the 
House leadership's initial plan of using a ``deem-and-pass'' 
legislative tactic--enacting the Senate bill into law without a 
straight up-or-down vote--greatly diminished the American people's 
trust in this legislation's provisions.
  Rather than enacting the legislation before us today, Congress should 
restart the process and enact common sense health care reforms that 
have bipartisan support. Reforms such as small business health 
insurance pools, medical malpractice liability reform, tax credits and 
deductions for health care expenses, and insurance reforms addressing 
the issues of pre-existing conditions and wrongful coverage termination 
will better ensure access to affordable, quality health care for all 
Americans, while also adhering to the physician's principle of ``First, 
do no harm.''
  Mr. COOPER. Mr. Speaker. I woke up this Sunday morning, said my 
prayers, and finally decided that I will vote ``yes'' on health care 
reform.
  Having heard from tens of thousands of Middle Tennesseans on all 
sides of the issue (including the flood of messages in the last few 
days and hours), and having spent months studying the various bills, I 
know that America must improve its health care system because it is 
unsustainable. This legislation will make it better.

[[Page H1916]]

  Any decision of this magnitude must be made very carefully, after 
weighing every concern. We Nashvillians are proud of our outstanding 
health care community that makes us ``the nation's health care industry 
capital.'' Given our community's expertise, it is interesting to note 
that:
  Every Nashville hospital strongly supports the legislation, whether 
it's St. Thomas, Vanderbilt (both University and Hospital), Centennial, 
Meharry Medical School, Nashville General, Summit, Skyline, or Southern 
Hills.
  A majority of physicians who contacted me support the legislation 
and, although the Tennessee Medical Association opposes it, the TMA's 
national organization, the conservative American Medical Association, 
supports it.
  A majority of local nurses support the legislation, along with the 
American Nurses Association.
  Despite media controversy regarding abortion, the Catholic Health 
Association, Catholics United, and groups representing 59,000 Catholic 
Sisters support the legislation.
  The largest Nashville and national senior organization, AARP, 
supports the legislation.
  It means a lot to me that so many local people who know so much about 
health care agree with my decision.
  Of course, there are plenty of people who disagree who are also very 
knowledgeable about health care, and I have great respect for their 
opinions. I've learned a lot from their views. Several of their 
suggested improvements are already in the legislation. You may be 
surprised that many of these critics want the legislation to do more, 
not less. Having taught health policy at Vanderbilt's business school 
for many years, I can easily point out many flaws in the legislation 
myself, both substantive and procedural. I have been working hard in 
Congress to eliminate those flaws. For example, yesterday we were able 
to force a clear, up-or-down vote on today's legislation instead of 
using the parliamentary maneuver that was favored by some in my own 
party.
  Let me make clear that I respect the advocacy of those who are 
opposed to the legislation. They actually help me make sure that more 
people in Congress do their homework and pay attention to America's 
financial problems. They are strengthening our democracy with their 
voices.
  The bottom line is that this legislation offers the only realistic 
hope that most Americans have for getting a fair deal in today's 
private health insurance markets. This is not a government takeover of 
those markets, but a way to encourage better private-market 
competition. In the future, private insurance companies should compete 
to keep us healthy, not drop us from coverage. Tens of millions of 
Americans will benefit immediately from reform of these insurance 
markets. Thousands of lives will literally be saved due to the greater 
affordability of health insurance. This is as major a public health 
accomplishment as reducing car wrecks or finding a cure for a dread 
disease. One of the lives saved could be yours.
  My health insurance is Tennessee Blue Cross/Blue Shield (just like I 
had when I was a small businessman in Nashville) but, as a Congressman, 
I am able to purchase it as part of a large pool, an exchange. I want 
every American to have the same purchasing power. No matter what your 
insurance company is, most Tennesseans are only one illness away, one 
pink slip away, or one premium hike away from being mistreated by 
current insurance practices: discrimination against pre-existing 
conditions, arbitrary premium pricing, and last-minute rescission of 
coverage when you need it most. This legislation will cover 32 million 
hardworking, middle-class Americans who are left out in the cold by 
today's insurance practices. Rival legislation only attempts to cover 3 
million uninsured people, or less than 10% of the problem. America can, 
and must, do better.
  The financial issues involved are just as important as the coverage 
issues, as I pointed out in my remarks at the President's bipartisan 
summit on health care at Blair House in February. Will improved 
coverage increase the deficit, either short-term or long-term? And will 
this legislation start containing the explosion in health costs that 
threaten our economy but do not improve our health?
  Although CBO claims that the legislation will reduce deficits in the 
first ten years by over $100 billion, and by over $1 trillion after 
that, you don't have to believe CBO to realize that, even if you assume 
zero deficit reduction, this is a huge improvement in the policymaking 
of recent years. In plain English, this bill is paid for, and may even 
save big money. Should these projections prove faulty, there are fail-
safe mechanisms within the legislation that, with public support, 
should correct any budget problems. I proudly voted against the 2003 
Medicare drug bill because it did not even attempt to pay for itself. 
That one bill (which very few constituents complained about) added $600 
billion to the short-term deficit and as much as $7.8 trillion in the 
out years. Fiscal conservatives have much more reason to protest that 
legislation than this.
  There is a legitimate concern about whether the so-called ``doc fix'' 
should have been included in this legislation. It is not. That issue is 
the result of the 1997 Balanced Budget Act formula that limits the 
growth of physician reimbursement under Medicare. Since 1997, some 
doctors have been able to increase their reimbursement more than 
others, but all are now threatened with a 21 percent cut. This is a 
$320 billion problem over the next 10 years, and a $4.2 trillion 
problem in the out years. Unless this issue is resolved, it could have 
more deficit impact than all of health reform. I think that we must 
figure out a way to pay for the ``doc fix'' now, not add it to the 
deficit. If you really care about the deficit, watch how your elected 
officials vote on this key issue.
  This legislation does not do enough to contain medical inflation, but 
it makes a good start because it contains the largest proposed savings 
in health costs in history, $600 billion over ten years. To make these 
savings stick, we will all have to be vigilant because every health 
care provider will immediately be asking for Congress to reduce or even 
reverse those savings. For those who sincerely want Congress to have 
more backbone on these issues, the answer is to support more savings 
now by asking for tougher follow-on legislation. You won't achieve more 
savings by encouraging Congress to slouch away from its 
responsibilities today.
  There are many talking heads on television who claim to want more 
cuts, but their immediate plan is to do nothing. Today the official 
Republican Party position is to scare seniors about Medicare and, 
despite a blizzard of words, do nothing. They are behaving as badly as 
the Democratic Party used to behave when scaring Social Security 
recipients. If history is any guide, America only has the political 
will to face up to these issues every 15 years, and, when we did 
address them, Congress did not make much progress. Neither political 
party will tell you that the real cost of delaying reform is roughly 
$16 billion a day. That's my estimate, based on accrual accounting, of 
the financial harm being done to America by a failure to resolve these 
problems on a timely basis. Waiting too long to pass reform could be as 
terrible a fiscal tragedy as waiting too long to treat cancer. Of 
course, the pundits have no way of paying for the delay, and the fiscal 
harm, that they foster. The opportunity cost of endless arguments may 
even be greater than the cost of solving the problems themselves!
  Opponents of today's reform also claim to have a better plan. I'd 
love to see it. I am thoroughly familiar with their legislative ideas 
because I have been working in a bipartisan way on these issues for 
many years. They simply do not have a better plan today that could 
garner more than a handful of votes, and, given their track record, are 
not likely to ever present one. There is no magic wand. For example, 
I've tried for many years to promote the bipartisan Healthy Americans 
Act, H.R. 1321. We ended up with only a handful of cosponsors. Another 
example is my friend Rep. Paul Ryan's (R-WI) interesting plan that has 
made him the darling of The Wall Street Journal. His bill, H.R. 4529, 
has exactly 13 cosponsors. You need at least 216 votes to get anything 
accomplished. As intriguing as some of these ideas are, they are not a 
solution, especially when the meter is ticking at about $16 billion a 
day.
  There is a lot of rhetoric about which political party is more 
sincere about deficit reduction. The facts are that the last Democratic 
president to have a balanced budget was Bill Clinton, just ten years 
ago. The last Republican president to have a balanced budget was 
Herbert Hoover, almost eighty years ago. Today's Congress has finally 
passed into law important ``pay-as-you-go'' legislation that will force 
Washington to start living within its means. Budget experts think that 
this is the single most important step toward getting our fiscal house 
in order. Blue Dog Democrats, of which I am a member, forced this 
improvement in budgeting.
  The President has created a bipartisan Fiscal Responsibility 
Commission that will help Washington face up to its deficit problems. 
The President is doing his best to implement my bipartisan legislation 
on this issue, legislation that the Senate failed to pass because seven 
Republican senators (who are original cosponsors) voted against their 
own bill! None of these important steps toward fiscal sanity was 
allowed under the previous Administration. In fact, the previous Vice 
President, Dick Cheney, was famous for saying, ``Deficits don't 
matter.'' He could not have been more mistaken.
  Regardless of what happens to this legislation today, America cannot 
afford to ignore the growing crisis in financing today's medical 
system. In the future, we need to focus on these issues every year, not 
every 15 years. Passage of this legislation is absolutely certain to do 
that. Flaws will need to be corrected, adjustments made, new ideas 
explored. I have a list ready. Just as continual advances in medicine 
must be made, continual advancements

[[Page H1917]]

in delivery of medical care must be made. Both types of advancements 
save lives. It is better when the private sector makes these 
improvements but, when the private sector fails, then government should 
help the private-sector, not run their businesses for them.
  I am well aware of the fact that this is a big vote, and perhaps a 
career-limiting decision. But I think most folks back home want me to 
do what is right, not just what's temporarily popular. That's what my 
90-year-old mother taught me. I've made tough votes before and been 
proven right. Against united Republican opposition, I voted for the 
1993 Clinton budget that put America on the path to the longest 
economic recovery in history. Against united Republican leadership, I 
voted against the 2003 Medicare drug bill that was the largest unfunded 
expansion of entitlement programs in history. And against united 
Republican opposition, I voted for the House health reform bill in 
November of 2009 that enabled us to vote on the much better Senate 
measure today.
  I have the honor of representing the Hermitage District. Our greatest 
hero, Andrew Jackson, said ``One man with courage is a majority.'' I 
sure hope he was right.
  Mr. TOWNS. Mr. Speaker, today the House of Representatives is 
preparing to vote on historic health insurance reform legislation, H.R. 
4872, the Health Care and Education Affordability Reconciliation Act. 
We have spent more than a year debating this important bill that will 
provide 32 million Americans health insurance. In my home district, New 
York's 10th Congressional District, access to affordable health 
insurance will make a tremendous difference in the lives of men and 
women who have been burdened by the escalating costs of health care.
  We can no longer wait to stem the rising tide of the uninsured and 
underinsured, implement important reforms to prevent insurers from 
discriminating against persons with pre-existing conditions and enact 
important measures to rein in costs.
  When this bill is signed into law, millions of Americans who do not 
have health care today will finally walk the pathway to coverage. 
American families will no longer face bankruptcy when a loved one gets 
ill and seniors will finally get relief from the high cost of 
prescription drugs due to our expanded coverage under Medicare Part D.
  Importantly, we are doing all of this without adding one penny to the 
federal deficit. In fact, this bill will reduce our federal debt by 
$143 billion over the next ten years, and hundreds of billions more in 
the years thereafter.
  Health insurance reform is an issue I have been committed to 
throughout my long congressional career. We have been close to this day 
before, but this time, at long last, I am confident we will see this 
legislation signed into law.
  Mr. Speaker, I thank my colleagues who supported this bill.
  Mr. ACKERMAN. Mr. Speaker, I rise on this historic day in strong 
support of the Health Care and Education Affordability Reconciliation 
Act of 2010, H.R. 4872.
  Let me be perfectly clear: all Americans should have access to 
affordable and quality health-care coverage. For too long, drastically 
needed health-insurance reform has been delayed. I'm proud that the 
overdue reform of our health-care insurance system has finally begun. 
Many of us, including Members of Congress, enjoy excellent health-care 
coverage. But far too many people have inadequate coverage, including 
over 70,000 of my constituents who are completely uninsured. And for 
those of us with coverage, the status quo is unsustainable and costly: 
Without health insurance reform, the insurance premium for an average 
family is expected to rise from $13,000 today to $24,000 in less than a 
decade. Mr. Speaker, my constituents want reduced costs, more choices 
and expanded coverage.
  I support this landmark legislation because it changes the way that 
insurance companies currently ration medical care: The legislation we 
are about to pass would require all plans to eliminate coverage denials 
because of pre-existing conditions, eliminate dropping coverage when 
individuals become sick, eliminate annual and lifetime caps on how much 
can be spent on care, and eliminate exorbitant out-of-pocket expenses. 
Opponents of this bill would rather have the big health-insurance 
companies dictate the rules. But I think all Americans deserve these 
basic protections from their health-insurance plans, and these 
important guarantees will improve the coverage for nearly all those who 
already have insurance--even those Americans who are extremely 
satisfied with their current plans.
  The Act starts with what works well in today's health care system and 
fixes the parts that are broken. No one has to give up the health care 
they enjoy today--everyone can keep their current health plan, doctors 
and hospitals. New state marketplaces called exchanges will allow 
uninsured individuals to shop among a large number of private plans 
with a core set of benefits. For the first time ever, American 
families--even those who keep their current health insurance--will 
benefit from no longer having to worry about losing health coverage 
because of a new or lost job. The bill finally brings the type of 
health insurance reform that Americans need and deserve.
  Many opposed to comprehensive health insurance claim there are no 
immediate benefits to these bills; that somehow nothing happens until 
the exchanges are set up. Mr. Speaker, here are just some of the 
immediate benefits that take effect this very year: small businesses 
will receive tax credits for offering health insurance to their 
employees; seniors who fall within the infamous Medicare prescription-
drug donut hole will receive a $250 rebate; people who have been denied 
health-care coverage because of a pre-existing condition will be able 
to get affordable coverage through temporary high-risk pools; children 
will no longer be callously denied coverage because of a pre-existing 
condition; annual limits and lifetime limits on the cost of care will 
start to be prohibited; and also this year, insurance companies will no 
longer be able to take away an individual's coverage because they get 
sick.
  Mr. Speaker, unfortunately, the previous Administration and the 
former leadership of the House of Representatives never acknowledged 
the moral or economic costs we pay every day for our failure to make 
health coverage affordable and accessible for everyone. Today, that 
ends. Today we recognize that more people with good coverage saves 
lives and saves costs. Today we unequivocally state that people should 
not have to go bankrupt to pay their medical bills. And today we 
finally realize that no one should have to go to an emergency room just 
to receive routine medical care. I am proud to be voting today to make 
sure that health-care insurance reform is putting these essential 
principles into action.
  So, Mr. Speaker, I urge all my colleagues to support the Health Care 
and Education Affordability Reconciliation Act of 2010, H.R. 4872 so 
that all Americans will have access to health care.
  Mr. ANDREWS. Mr. Speaker, I rise today in support of millions of 
individuals throughout our country who are working for small businesses 
which are in PEO arrangements. The clear objective of this legislation 
is to create incentives for health care coverage and not to provide 
disincentives. I would like to clarify that for purposes of the 
application of section 2716 of the Public Health Service Act 
(Prohibition on Discrimination in Favor of Highly Compensated 
Individuals) and Internal Revenue Code section 45R (Credit for Employee 
Health Insurance Expenses of Small Businesses), to any health plans 
sponsored by a professional employer organization (PEO) or a PEO client 
organization, the rules would be applied to each client organization 
separately and eligibility for the small business tax credits would 
also apply to each client organization separately, and not at the PEO 
level.
  Mr. KIRK. Mr. Speaker, I rise today in opposition to H.R. 3590, the 
Senate Health Care bill. I strongly support reforms to lower the cost 
of health insurance and cover Americans with pre-existing conditions. 
That is why I authored the Medical Rights and Reform Act, H.R. 3790. 
Under our centrist Reform Act, we cover Americans with pre-existing 
conditions and advance three major reforms:
  (1) The Medical Rights Act: Under our bill, Congress shall make no 
law interfering with the personal decisions that you make with your 
doctor,
  (2) Lawsuit Reform: By applying the lawsuit reforms (recently 
eliminated in Illinois) similar to successful California reforms, we 
could reduce defensive medicine, saving over $200 billion annually, and
  (3) Granting Americans Interstate Rights: Our bill grants the right 
to all Americans to buy health coverage from any state in the union, 
especially if you find a plan that is less expensive or more flexible 
for your family or small business. This improves choice and competition 
for each American.
  Unfortunately, the Congressional leadership will not permit a debate 
on our bill. Instead, the House will only allow one vote on the health 
care bill adopted by the Senate.
  Under the Senate bill, the Congress will increase spending by $1.2 
trillion, including $940 billion for new subsidies, $144 billion for 
new mandates, $70 billion to administer the bill and $41 billion in 
unrelated spending. To attempt to pay for the bill, Congress will raise 
taxes, cut Medicare and borrow a historic amount of money. To pass the 
Senate, the bill also included the ``Louisiana Purchase'', ``Cornhusker 
Kickback'' and ``Gatoraide'' that advantaged Louisiana, Nebraska and 
Florida over the people of Illinois.
  The bill imposes 12 new federal taxes, imposing over $500 billion in 
new payments to the government, including over $23 billion in taxes on 
the people of Illinois. Among the new taxes is a new ``Individual 
Mandate Tax'' (IMT) of $2,250 per household or 2 percent of

[[Page H1918]]

household income. The bill increases the Medicare payroll tax and does 
not adjust this for inflation. Therefore, like the infamous Alternative 
Minimum Tax (AMT), the new Medicare tax will soon reach most middle 
class families as inflation pushes more Americans into its bracket.
  The bill also increases the capital gains tax. Most economists worry 
that too many businesses plan for the short-term, hurting long-term 
economic growth. That is why investments which are held for longer 
periods of time pay a lower capital gains tax. The Senate bill reverses 
this wise policy by imposing a new 3.8 percent tax on capital gains, 
raising the rate from 15 percent to 23.8 percent by 2013.
  Both Americans for Tax Reform and the Heritage Foundation estimated 
that the new taxes and Medicare cuts in the bill would cost over 
600,000 job opportunities per year or an estimated 26,042 fewer 
Illinois jobs. The bill also has a number of budget gimmicks to hide 
spending. Once the Social Security Trust Fund, long-term health care 
and student loan gimmicks are removed, the bill adds $755 billion to 
the federal deficit or $2,460 in new debt for each man, woman, and 
child.
  Here is a look at the estimated national job losses under the bill:

------------------------------------------------------------------------
                           Sector                                Jobs
------------------------------------------------------------------------
Agriculture, forestry, fishing and hunting..................      -5,441
Mining......................................................      -5,478
Construction................................................     -43,316
Manufacturing...............................................    -105,229
Wholesale trade.............................................     -47,663
Retail trade................................................     -84,339
Transportation and warehousing..............................     -36,806
Utilities...................................................      -5,271
Information.................................................     -26,342
Financial Activities........................................     -77,269
Professional and business services..........................    -132,596
Educational services........................................     -32,102
Leisure and hospitality.....................................     -49,682
Other services..............................................     -46,564
------------------------------------------------------------------------
    Total...................................................    -698,098
------------------------------------------------------------------------

  Half of all people employed in Illinois work in a small business and 
over 80 percent of job losses during this Great Recession have been 
from small business employers. Nevertheless, this legislation requires 
the federal government to levy a new $52 billion tax on small 
businesses, even though unemployment now tops 12 percent in Illinois. 
The bill begins a new $2,000 tax on small business with over 50 
employees. Over 21,600 small businesses in Illinois could be subject to 
this new tax. This tax applies to part-time as well as full-time 
workers. The follow-up Reconciliation Bill also includes an 
unprecedented extension of the Medicare tax to all non-wage income.
  The legislation stands for the principle that we should cut senior 
health care under Medicare to fund a new entitlement spending program. 
Over 40 million seniors depend on Medicare for their health care. Under 
the Senate bill, the federal government would cut over $500 billion 
from Medicare. This includes cutting over $200 billion from Medicare 
Advantage, cancelling the Medicare choice of over 120,000 Illinois 
seniors.
  Here is a summary of the Medicare cuts:

------------------------------------------------------------------------
 
------------------------------------------------------------------------
Medicare Advantage........................  $202 billion.
Home Health...............................  39 billion.
Medicare Part B...........................  25 billion.
Hospital DSH Payments.....................  25 billion.
Medicare Part D...........................  10 billion.
Medical Imaging...........................  1 billion.
Preventative Services.....................  700 million.
Durable Medical Equipment.................  1 billion.
Power-Driven Wheelchairs..................  800 million.
Hospice...................................  100 million.
Medicare Improvement Fund.................  20 billion.
Medigap...................................  100 million.
------------------------------------------------------------------------
    Total.................................  $523 billion.
------------------------------------------------------------------------

  While the American people overwhelmingly want to lower health 
insurance costs, the bill increases costs because it requires Americans 
to buy health insurance that include new mandates for coverage. 
According to the Administration, individual insurance premiums will 
increase by 10 percent for over 600,000 people in Illinois. On average, 
Illinois individuals currently pay $2,499 annually for insurance. Under 
the bill, costs will go up at least $150 a month to a level of $4,299 
annually.
  On March 4, the Chicago Tribune reported that for ``more than half-
million consumers in individual health plans, base rates will go up 
from 8.5 percent to more than 60 percent.'' The non-partisan 
Congressional Budget Office reported that the bill's provisions that 
double the tax on health insurers, drug makers and medical devices will 
all be passed on to patients in the form of higher health costs and 
rising insurance premiums.
  Under the federal Medicaid program for the poor, states must pay half 
of all costs. As you know, the State of Illinois has one of the highest 
deficits of any state, totaling over $12 billion. Spending on the 
Illinois Medicaid program rose 65 percent from $8 billion in 2001 to 
$13 billion in 2008 to now cover 2.4 million people. Under the Senate 
Health Care bill, Illinois would have to cover an additional 400,000 
people, adding an additional $1 billion to the state's deficit over 
five years.
  Health care under Medicaid is already deteriorating. Over 9,000 
doctors in Illinois refuse to accept Medicaid patients (28 percent 
nationwide), in part because it takes Illinois over 100 days to pay for 
services.
  About the only jobs created by the legislation would be at the IRS. 
According to the nonpartisan Congressional Budget Office, the IRS would 
need to hire over 16,000 people--over 700 just in Illinois--to audit 
the American people and impose the new taxes and mandates of the bill. 
New IRS agents would verify if you have acceptable authority, fine you 
up to 2 percent of your income for failure to prove that you have 
purchased ``minimum essential coverage,'' confiscate your tax refund 
and conduct audits. Under the bill, nearly half of the new individual 
mandate taxes will be paid by Americans earning less than $66,150 for a 
family of four.
  I will vote against this legislation because it costs Illinois jobs, 
raises taxes and deepens the debt our children must one day pay. I wish 
that we could adopt a more modest set of reforms that do not have such 
harsh consequences for our economy.
  In the coming days, I will outline policies and legislation that will 
reduce spending, lower the debt and prevent new taxes on the American 
people. While we did not prevail in this contest, I will continue to 
work and ensure a strong economy and bright future for every Illinois 
citizen.
  Mr. GRIJALVA. Mr. Speaker, after a long battle for this Nation's 
health care reform, my decision to vote in favor of this bill was 
ultimately made, not by myself, but by the people I represent.
  This bill is a beginning to the end of an abusive system:
  It is a beginning to provide the people of our great Nation access 
the most basic health care services;
  It is a beginning to stop insurance companies from reaping benefits 
at the cost of the sick, injured, poor and dying people in our Nation;
  It is a beginning to making our health care system one that we can be 
proud of--
  One that includes everyone regardless of their social status;
  One that treats people equal regardless of their age, race or gender;
  One that makes sure our children are treated properly and that our 
parents will be provided for in the future; and
  It finally provides reauthorization of Indian Health Care.
  Every day I am flooded by groups, businesses and individuals that can 
no longer bear the abuses from our current health care system. I want 
to share of few of their reasons for supporting this bill:
  The National Committee to Preserve Social Security and Medicare 
states:

       The bill preserves and improves Medicare for current and 
     future beneficiaries. Because of our strong commitment to 
     Medicare, we support the health reform currently before 
     Congress. Indeed, we consider it to be vital for preserving 
     and protecting Medicare. On behalf of the seniors you 
     represent, we ask that you commit to supporting health reform 
     as well.

  Catholic Sisters for Healthcare Reform states:

       We have witnessed firsthand the impact of our national 
     health care crisis, particularly its impact on women, 
     children and people who are poor. We see the toll on families 
     who have delayed seeking care due to a lack of health 
     insurance coverage or lack of funds with which to pay high 
     deductibles and co-pays. We have counseled and prayed with 
     men, women and children who have been denied health care 
     coverage by insurance companies. We have witnessed early and 
     avoidable deaths because of delayed medical treatment.

  American Nurses Association states:

       We understand the cost of inaction--our patients can no 
     longer afford to wait. The uninsured and underinsured 
     continue to delay or forgo much-needed care; they continue to 
     arrive in the emergency rooms across the country for 
     conditions that could have been easily prevented with access 
     to primary care--we are all paying a high price for inaction.

  My dear friend, Karen, from the National Breast Cancer Coalition came 
to me and poured her heart out on behalf of the millions of women 
battling cancer, this vote is for you. The National Breast Cancer 
Coalition states:

       For women who are battling breast cancer, health care 
     reform will mean accessing potentially life-saving treatment 
     and not losing their health insurance coverage if they lose 
     their job. For their families, it means not being driven into 
     bankruptcy when the person they love has been diagnosed with 
     breast cancer, must contend with a recurrence of the disease, 
     or struggle with equally life threatening complications. For 
     the tens of thousands of women who will be diagnosed with 
     breast cancer today and in the future, enacting health care 
     reform will mean being able to focus their energy on battling 
     the disease, not fighting with their insurance company. We 
     cannot delay any longer.

  United States Hispanic Chamber of Commerce states:


[[Page H1919]]


       As business owners, we know well the concept of opportunity 
     cost. The rate of premium growth has become such a burden to 
     our businesses that we are required to support this 
     compromise rather than see premiums double, or triple, once 
     again as they have done this decade. As organizations that 
     believe in free market solutions, this decision was not taken 
     lightly. But, the fact remains that the small business 
     components in this compromise bill will provide real relief--
     a small business exchange that pools risk while respecting 
     the free market and tax credits to incentivize those 
     businesses that are just within reach of providing health 
     care to their workers.

  While these groups and the American people understand this bill is 
the beginning of reforming our system, I can assure you it is not the 
end.
  I will continue to fight for a public entity to be part of our 
system.
  I will continue to fight for immigrants to be treated fairly in our 
Nation, and I will argue the grave economic impacts of leaving these 
people out of our system.
  I will continue to fight for stricter control of the pharmaceutical 
companies to force them to negotiate prices instead of dictating them.
  And above all I will not stop, I will continue to push to make our 
system more efficient and more equitable--this is only the beginning.
  I would like to end with a quote from my dear friend that we lost 
during the mist of this battle, who I feel has been our guiding light.
  Ted Kennedy said:

       The battle to achieve Medicare for All will not be easy. 
     Powerful interests will strongly oppose it, because they 
     profit immensely from the status quo. Right wing forces will 
     unleash false attack ads ranting against socialized medicine 
     and government-run health care.

  Ted--we will not give up--this is the beginning.
  Mr. FRELINGHUYSEN. Mr. Speaker, at the outset, let me be very clear: 
I support health care reform. I just do not support Speaker Nancy 
Pelosi's version of health care reform.
  With respect to controlling costs for New Jersey's families, changing 
insurance company practices and making coverage more available to more 
Americans, the status quo is simply unacceptable. We can, and we must, 
do better, but not at the expense of millions of American families who 
are worried about a government takeover of their health care decisions!
  With that said, the health care package before the House today is 
wrong on both process and policy.
  On process, the American people know instinctively that a change as 
historic as this will only be successful with full engagement of the 
American people and bipartisan support in Congress. However, from the 
beginning, Speaker Nancy Pelosi and Senate Majority Leader Harry Reid 
adopted a `go-it-alone' strategy and refused to consider Republican 
ideas in any significant way. Indeed, the Majority today is even 
refusing to listen to the very valid concerns of the American people.
  In addition, this legislation, and all the versions that preceded it, 
were drafted behind closed doors at the White House or in Capitol 
backrooms, with no transparency whatsoever as to which organizations 
were participating and benefitting! In fact, the Majority had to be 
`shamed' into releasing the contents of the bill 72 hours before a vote 
to allow Republicans and the American people to review its contents.
  To add insult to injury, the President and Speaker Pelosi decided to 
use the budget 'reconciliation' process solely to deny the Senate 
Minority the ability to use its traditional practice of the filibuster 
to block passage of harmful legislation such as this.
  Madame Speaker, the process the Majority has used is shameful, but 
the policy they seek to impose is downright harmful.
  Once again, I state without hesitation that I support health reform. 
However, I cannot support this proposal.
  First, this package contains over $523 billion in job-killing, higher 
taxes. I cannot think of a worse time to tax families and small 
businessmen and women than in the middle of a serious recession.
  The American people need to understand the destructive nature of this 
bill: $17 billion in new taxes on Americans who do not obey the bill's 
requirement that individuals must buy health insurance whether they 
want to or not, and $52 billion in new taxes on employers that do not 
provide health coverage deemed ``acceptable'' or ``affordable'' by 
Washington-based government bureaucrats. This provision alone may force 
the IRS to hire another 16,000 agents and auditors to enforce 
compliance with the new law.
  In addition, the bill contains new taxes on capital gains, dividends 
and interest that will further stifle economic growth and job creation. 
The Medicare tax on capital gains, dividends, and other investment 
income gets bigger, magnifying the destructive power of the tax. The 
bill increases the tax from 2.9 percent to 3.8 percent and for the 
first time, this tax will be extended beyond wages to include interest, 
dividends, capital gains, annuities, royalties, home sales and rents. 
This new tax will be particularly damaging to New Jersey's seniors, 
many of whom depend on such income to survive.
  Second, this package contains over $569 billion in total cuts to 
Medicare.
  These reductions include $202.3 billion from seniors' Medicare health 
plans, including massive cuts targeting the extra benefits and reduced 
cost-sharing seniors receive through Medicare Advantage. 148,000 
seniors in New Jersey, including over 35,000 in my Congressional 
District enjoy the benefits of this innovative program. The 
Congressional Budget Office predicts that three million seniors 
nationwide currently receiving health benefits through these Medicare 
plans will be dropped.
  But the Medicare cuts go deeper. The bill slashes $156 billion from 
hospitals, including long-term care hospitals, skilled nursing 
facilities, Ambulatory Surgical Centers, hospice, ambulances, dialysis 
facilities, labs and durable medical equipment (DME) suppliers.
  The package also contains $40 billion in cuts to home health 
reimbursements and $22 billion in additional cuts to hospitals by 
slashing reimbursements designed to assist hospitals that serve low-
income patients. In addition, $65.7 billion in money will be taken from 
seniors in the form of higher premiums.
  My colleagues, I am also shocked that the Majority has not protected 
our men and women in uniform, military retirees and veterans who could 
be affected by the new law. The Senate-passed health care bill omitted 
protections for military health plans that were included in the House 
bill.
  Specifically, the Senate language does not appear to give the 
Department of Veterans' Affairs (VA) health care system specific 
protection from interference by other government agencies administering 
the various authorities contained in the massive bill, as it pertains 
to ``minimum essential coverage.''
  Further, the final bills would leave it up to bureaucrats at the 
Department of the Treasury to determine whether TRICARE meets the 
minimum standards under the bill's individual health insurance mandate. 
If that bureaucrat decides against TRICARE, service members and their 
families would have to buy some other health coverage or pay a penalty.
  Our men and women in uniform, and our veterans, have earned the best 
health care available. They need to know that they will continue to 
receive this same level of care. It is truly regrettable that, in a 
bill stuffed with `backroom' deals and special `arrangements', this 
group of American heroes is denied the consideration they earn on the 
battlefield each and every day.
  Mr. Speaker, this bill is also notable for what it does not contain. 
There is no medical lawsuit reform. It fails to promote portability of 
coverage. It does not allow insurance companies to sell their policies 
across state lines. It fails to recognize the value of Association 
Health Plans, which permit small businesses to pool their risk in order 
to secure lower insurance rates. The bill does not expand Health 
Savings Accounts which millions of families use to provide protection 
against catastrophic illness or injury. The package also does very 
little to enhance medical training for doctors, nurses and technicians. 
If we are going to expand coverage for tens of millions of Americans, 
we need to increase graduation rates in these critical medical 
professions.
  I would also add that this bill completely ignores the ongoing crisis 
in Medicare reimbursement rates for doctors. My colleagues, the 
question is not whether you can choose your doctor under the Pelosi 
health care proposal, but whether your doctor will choose you! Many 
doctors in New Jersey are already questioning their participation in 
the Medicare program, putting in greater jeopardy our seniors' access 
to care. Does the Majority actually believe that the pending 22-percent 
reimbursement reduction will not cause more doctors to `opt out' of 
Medicare?
  Mr. Speaker, I end this statement where I started: I support health 
care reform. The status quo is unacceptable and I would welcome the 
opportunity to work with anyone who will work with me to draft and pass 
single, individual bills that promote portability of coverage, allow 
individuals to buy health care across state lines, cover people with 
preexisting conditions, improve access to Health Savings Accounts, and 
enact `junk lawsuit' reform, among other actions to bring down the cost 
of coverage for New Jersey families and businesses.
  We can do better than this process and this package. America's future 
economic and security freedoms depend on it.
  Mr. TAYLOR. Mr. Speaker, I voted against H.R. 3962, the Affordable 
Health Care for America Act, on November 7, 2009 and I will continue to 
oppose this legislation in the House. The House passed the bill by a 
vote of 220-215. During House consideration, I voted for the Stupak 
amendment, which prohibits federal funds from paying for abortions

[[Page H1920]]

or from subsidizing health insurance plans that would cover abortions. 
The House passed the Stupak amendment by a vote of 240-194.
  Taxpayers cannot afford a new federal health insurance program. The 
government already provides Medicare, Medicaid, and other programs to 
provide medical care for senior citizens, people with disabilities, and 
others who have substantial medical needs. Our nation also has an 
obligation to provide medical coverage for veterans, active-duty 
military and their dependents, National Guard and Reserve personnel, 
and military retirees. With the national debt in excess of $12 trillion 
and projected to grow far into the future, I believe that Congress 
should focus on fulfilling the promises that have already been made 
rather than make new promises that we cannot afford.
  There are several ways to make health care more efficient without 
increasing costs and without creating a whole new government program.
  I strongly support efforts to allow the government to use their 
purchasing power to negotiate directly with drug manufacturers when 
buying prescription drugs for beneficiaries enrolled in the Medicare 
Part D Program. Negotiating prices with insurance companies would help 
to ensure that taxpayers are paying the best available price and that 
tax dollars are spent wisely without reducing coverage or affecting the 
individuals enrolled in Medicare Part D. In 2008, the government spent 
about $49 billion on Medicare Part D drugs. If the government could 
save even 10% by negotiating directly with drug companies, taxpayers 
would save nearly $4.9 billion.
  The government should purchase generic drugs instead of more 
expensive alternatives, unless the prescribing physician says that a 
name brand drug is medically necessary. On average, generic drugs cost 
1/10th of the cost of their name brand equivalent.
  I am a cosponsor of H.R. 1583, legislation to repeal the insurance 
industry's antitrust exemption. The health care bill that passed the 
House included a repeal of antitrust laws only for the health care 
industry. While this is important, I firmly believe that repealing 
antitrust laws from the entire insurance industry would force insurers 
to compete with one another in a competitive market on the basis of 
price, service, and value. I strongly supported the bill that passed in 
the House which repealed the exemption of antitrust laws for the health 
care insurance industry.
  I am also in favor of proposals that would allow individuals to 
continue to be covered under their parents' insurance plan until they 
reach the age of 27.
  I would like to remind you that I do not support creating a whole new 
health care program, but I do support smaller reforms to make the 
current system more effective for taxpayers and consumers. Again, I 
voted against the health care bill that passed the House, and I will 
oppose this bill.
  Mr. MORAN of Virginia. Mr. Speaker, today we will define who we are--
as Americans, and as Democrats or Republicans.
  No Republican will vote for this bill because they say they want a 
smaller government, lower taxes, and less spending.
  Democrats, on the other hand, believe that America's government can 
be fiscally responsible and also play an essential role in helping 
America achieve its true greatness.
  We know that America is a lesser Nation when we have to pay twice 
what other countries citizens' pay for health care, while we live 
shorter and less healthy lives; We are a lesser nation when millions of 
America's families lose their homes and life savings because a loved 
one gets seriously sick.
  We know that we can reduce the suffering of our people, while 
lengthening and bettering their lives. And because we know this, we 
have a responsibility to change it.
  As with Social Security and Medicare and Civil Rights legislation, it 
is now time for another step in our historic progress toward greatness. 
That's why we chose public service and why we, as Democrats, will pass 
this bill today.
  The SPEAKER pro tempore. Under the rule, all time for debate has 
expired.
  Mr. SPRATT. Mr. Speaker, pursuant to House Resolution 1203, I call up 
the bill (H.R. 3590) to amend the Internal Revenue Code of 1986 to 
modify the first-time homebuyers credit in the case of members of the 
Armed Forces and certain other Federal employees, and for other 
purposes, with the Senate amendments thereto, and I have a motion at 
the desk.
  The Clerk read the title of the bill.
  The SPEAKER pro tempore. The Clerk will designate the Senate 
amendments.
  The text of the Senate amendments is as follows:

       Senate amendments:
       Strike all after the enacting clause and insert the 
     following:

     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.

[[Page H1921]]

       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.

[[Page H1922]]

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.

[[Page H1923]]

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.

[[Page H1924]]

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.

[[Page H1925]]

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;
       ``(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; and
       ``(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

[[Page H1926]]

     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

[[Page H1927]]

       ``(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.

[[Page H1928]]

       (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).

[[Page H1929]]

     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

[[Page H1930]]

     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 under the 
     plan if such plan has knowingly provided inaccurate or 
     incomplete information (as described under subparagraph (C)).
       ``(F) Determination of covered individuals.--The Secretary 
     shall determine the number of covered lives under a health 
     plan based upon the most recent statements and filings that 
     have been submitted by such plan to the Securities and 
     Exchange Commission.
       ``(2) Notice and dispute procedure.--The Secretary shall 
     establish a procedure for assessment of penalty fees under 
     this subsection that provides a health plan with reasonable 
     notice and a dispute resolution procedure prior to provision 
     of a notice of assessment by the Secretary of the Treasury 
     (as described under paragraph (4)(B)).
       ``(3) Penalty fee report.--Not later than May 1, 2014, and 
     annually thereafter, the Secretary shall provide the 
     Secretary of the Treasury with a report identifying those 
     health plans that have been assessed a penalty fee under this 
     subsection.
       ``(4) Collection of penalty fee.--
       ``(A) In general.--The Secretary of the Treasury, acting 
     through the Financial Management Service, shall administer 
     the collection of penalty fees from health plans that have 
     been identified by the Secretary in the penalty fee report 
     provided under paragraph (3).
       ``(B) Notice.--Not later than August 1, 2014, and annually 
     thereafter, the Secretary of the Treasury shall provide 
     notice to each health plan that has been assessed a penalty 
     fee by the Secretary under this subsection. Such notice shall 
     include the amount of the penalty fee assessed by the 
     Secretary and the due date for payment of such fee to the 
     Secretary of the Treasury (as described in subparagraph (C)).
       ``(C) Payment due date.--Payment by a health plan for a 
     penalty fee assessed under this subsection shall be made to 
     the Secretary of the Treasury not later than November 1, 
     2014, and annually thereafter.
       ``(D) Unpaid penalty fees.--Any amount of a penalty fee 
     assessed against a health plan under this subsection for 
     which payment has not been made by the due date provided 
     under subparagraph (C) shall be--
       ``(i) increased by the interest accrued on such amount, as 
     determined pursuant to the underpayment rate established 
     under section 6621 of the Internal Revenue Code of 1986; and
       ``(ii) treated as a past-due, legally enforceable debt owed 
     to a Federal agency for purposes of section 6402(d) of the 
     Internal Revenue Code of 1986.
       ``(E) Administrative fees.--Any fee charged or allocated 
     for collection activities conducted by the Financial 
     Management Service will be passed on to a health plan on a 
     pro-rata basis and added to any penalty fee collected from 
     the plan.''.
       (c) Promulgation of Rules.--
       (1) Unique health plan identifier.--The Secretary shall 
     promulgate a final rule to establish a unique health plan 
     identifier (as described in section 1173(b) of the Social 
     Security Act (42 U.S.C. 1320d-2(b))) based on the input of 
     the National Committee on Vital and Health Statistics. The 
     Secretary may do so on an interim final basis and such rule 
     shall be effective not later than October 1, 2012.
       (2) Electronic funds transfer.--The Secretary shall 
     promulgate a final rule to establish a standard for 
     electronic funds transfers (as described in section 
     1173(a)(2)(J) of the Social Security Act, as added by 
     subsection (b)(2)(A)). The Secretary may do so on an interim 
     final basis and shall adopt such standard not later than 
     January 1, 2012, in a manner ensuring that such standard is 
     effective not later than January 1, 2014.
       (3) Health claims attachments.--The Secretary shall 
     promulgate a final rule to establish

[[Page H1931]]

     a transaction standard and a single set of associated 
     operating rules for health claims attachments (as described 
     in section 1173(a)(2)(B) of the Social Security Act (42 
     U.S.C. 1320d-2(a)(2)(B))) that is consistent with the X12 
     Version 5010 transaction standards. The Secretary may do so 
     on an interim final basis and shall adopt a transaction 
     standard and a single set of associated operating rules not 
     later than January 1, 2014, in a manner ensuring that such 
     standard is effective not later than January 1, 2016.
       (d) Expansion of Electronic Transactions in Medicare.--
     Section 1862(a) of the Social Security Act (42 U.S.C. 
     1395y(a)) is amended--
       (1) in paragraph (23), by striking the ``or'' at the end;
       (2) in paragraph (24), by striking the period and inserting 
     ``; or''; and
       (3) by inserting after paragraph (24) the following new 
     paragraph:
       ``(25) not later than January 1, 2014, for which the 
     payment is other than by electronic funds transfer (EFT) or 
     an electronic remittance in a form as specified in ASC X12 
     835 Health Care Payment and Remittance Advice or subsequent 
     standard.''.

     SEC. 1105. EFFECTIVE DATE.

       This subtitle shall take effect on the date of enactment of 
     this Act.

    Subtitle C--Quality Health Insurance Coverage for All Americans

                PART I--HEALTH INSURANCE MARKET REFORMS

     SEC. 1201. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT.

       Part A of title XXVII of the Public Health Service Act (42 
     U.S.C. 300gg et seq.), as amended by section 1001, is further 
     amended--
       (1) by striking the heading for subpart 1 and inserting the 
     following:

                     ``Subpart I--General Reform'';

       (2)(A) in section 2701 (42 U.S.C. 300gg), by striking the 
     section heading and subsection (a) and inserting the 
     following:

     ``SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS 
                   OR OTHER DISCRIMINATION BASED ON HEALTH STATUS.

       ``(a) In General.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage may not impose any preexisting condition 
     exclusion with respect to such plan or coverage.''; and
       (B) by transferring such section (as amended by 
     subparagraph (A)) so as to appear after the section 2703 
     added by paragraph (4);
       (3)(A) in section 2702 (42 U.S.C. 300gg-1)--
       (i) by striking the section heading and all that follows 
     through subsection (a);
       (ii) in subsection (b)--
       (I) by striking ``health insurance issuer offering health 
     insurance coverage in connection with a group health plan'' 
     each place that such appears and inserting ``health insurance 
     issuer offering group or individual health insurance 
     coverage''; and
       (II) in paragraph (2)(A)--

       (aa) by inserting ``or individual'' after ``employer''; and
       (bb) by inserting ``or individual health coverage, as the 
     case may be'' before the semicolon; and

       (iii) in subsection (e)--
       (I) by striking ``(a)(1)(F)'' and inserting ``(a)(6)'';
       (II) by striking ``2701'' and inserting ``2704''; and
       (III) by striking ``2721(a)'' and inserting ``2735(a)''; 
     and
       (B) by transferring such section (as amended by 
     subparagraph (A)) to appear after section 2705(a) as added by 
     paragraph (4); and
       (4) by inserting after the subpart heading (as added by 
     paragraph (1)) the following:

     ``SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS.

       ``(a) Prohibiting Discriminatory Premium Rates.--
       ``(1) In general.--With respect to the premium rate charged 
     by a health insurance issuer for health insurance coverage 
     offered in the individual or small group market--
       ``(A) such rate shall vary with respect to the particular 
     plan or coverage involved only by--
       ``(i) whether such plan or coverage covers an individual or 
     family;
       ``(ii) rating area, as established in accordance with 
     paragraph (2);
       ``(iii) age, except that such rate shall not vary by more 
     than 3 to 1 for adults (consistent with section 2707(c)); and
       ``(iv) tobacco use, except that such rate shall not vary by 
     more than 1.5 to 1; and
       ``(B) such rate shall not vary with respect to the 
     particular plan or coverage involved by any other factor not 
     described in subparagraph (A).
       ``(2) Rating area.--
       ``(A) In general.--Each State shall establish 1 or more 
     rating areas within that State for purposes of applying the 
     requirements of this title.
       ``(B) Secretarial review.--The Secretary shall review the 
     rating areas established by each State under subparagraph (A) 
     to ensure the adequacy of such areas for purposes of carrying 
     out the requirements of this title. If the Secretary 
     determines a State's rating areas are not adequate, or that a 
     State does not establish such areas, the Secretary may 
     establish rating areas for that State.
       ``(3) Permissible age bands.--The Secretary, in 
     consultation with the National Association of Insurance 
     Commissioners, shall define the permissible age bands for 
     rating purposes under paragraph (1)(A)(iii).
       ``(4) Application of variations based on age or tobacco 
     use.--With respect to family coverage under a group health 
     plan or health insurance coverage, the rating variations 
     permitted under clauses (iii) and (iv) of paragraph (1)(A) 
     shall be applied based on the portion of the premium that is 
     attributable to each family member covered under the plan or 
     coverage.
       ``(5) Special rule for large group market.--If a State 
     permits health insurance issuers that offer coverage in the 
     large group market in the State to offer such coverage 
     through the State Exchange (as provided for under section 
     1312(f)(2)(B) of the Patient Protection and Affordable Care 
     Act), the provisions of this subsection shall apply to all 
     coverage offered in such market in the State.

     ``SEC. 2702. GUARANTEED AVAILABILITY OF COVERAGE.

       ``(a) Guaranteed Issuance of Coverage in the Individual and 
     Group Market.--Subject to subsections (b) through (e), each 
     health insurance issuer that offers health insurance coverage 
     in the individual or group market in a State must accept 
     every employer and individual in the State that applies for 
     such coverage.
       ``(b) Enrollment.--
       ``(1) Restriction.--A health insurance issuer described in 
     subsection (a) may restrict enrollment in coverage described 
     in such subsection to open or special enrollment periods.
       ``(2) Establishment.--A health insurance issuer described 
     in subsection (a) shall, in accordance with the regulations 
     promulgated under paragraph (3), establish special enrollment 
     periods for qualifying events (under section 603 of the 
     Employee Retirement Income Security Act of 1974).
       ``(3) Regulations.--The Secretary shall promulgate 
     regulations with respect to enrollment periods under 
     paragraphs (1) and (2).

     ``SEC. 2703. GUARANTEED RENEWABILITY OF COVERAGE.

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

     ``SEC. 2705. PROHIBITING DISCRIMINATION AGAINST INDIVIDUAL 
                   PARTICIPANTS AND BENEFICIARIES BASED ON HEALTH 
                   STATUS.

       ``(a) In General.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage may not establish rules for eligibility 
     (including continued eligibility) of any individual to enroll 
     under the terms of the plan or coverage based on any of the 
     following health status-related factors in relation to the 
     individual or a dependent of the individual:
       ``(1) Health status.
       ``(2) Medical condition (including both physical and mental 
     illnesses).
       ``(3) Claims experience.
       ``(4) Receipt of health care.
       ``(5) Medical history.
       ``(6) Genetic information.
       ``(7) Evidence of insurability (including conditions 
     arising out of acts of domestic violence).
       ``(8) Disability.
       ``(9) Any other health status-related factor determined 
     appropriate by the Secretary.
       ``(j) Programs of Health Promotion or Disease Prevention.--
       ``(1) General provisions.--
       ``(A) General rule.--For purposes of subsection (b)(2)(B), 
     a program of health promotion or disease prevention (referred 
     to in this subsection as a `wellness program') shall be a 
     program offered by an employer that is designed to promote 
     health or prevent disease that meets the applicable 
     requirements of this subsection.
       ``(B) No conditions based on health status factor.--If none 
     of the conditions for obtaining a premium discount or rebate 
     or other reward for participation in a wellness program is 
     based on an individual satisfying a standard that is related 
     to a health status factor, such wellness program shall not 
     violate this section if participation in the program is made 
     available to all similarly situated individuals and the 
     requirements of paragraph (2) are complied with.
       ``(C) Conditions based on health status factor.--If any of 
     the conditions for obtaining a premium discount or rebate or 
     other reward for participation in a wellness program is based 
     on an individual satisfying a standard that is related to a 
     health status factor, such wellness program shall not violate 
     this section if the requirements of paragraph (3) are 
     complied with.
       ``(2) Wellness programs not subject to requirements.--If 
     none of the conditions for obtaining a premium discount or 
     rebate or other reward under a wellness program as described 
     in paragraph (1)(B) are based on an individual satisfying a 
     standard that is related to a health status factor (or if 
     such a wellness program does not provide such a reward), the 
     wellness program shall not violate this section if 
     participation in the program is made available to all 
     similarly situated individuals. The following programs shall 
     not have to comply with the requirements of paragraph (3) if 
     participation in the program is made available to all 
     similarly situated individuals:
       ``(A) A program that reimburses all or part of the cost for 
     memberships in a fitness center.
       ``(B) A diagnostic testing program that provides a reward 
     for participation and does not base any part of the reward on 
     outcomes.
       ``(C) A program that encourages preventive care related to 
     a health condition through the waiver of the copayment or 
     deductible requirement under group health plan for the costs 
     of certain items or services related to a health condition 
     (such as prenatal care or well-baby visits).
       ``(D) A program that reimburses individuals for the costs 
     of smoking cessation programs without regard to whether the 
     individual quits smoking.
       ``(E) A program that provides a reward to individuals for 
     attending a periodic health education seminar.
       ``(3) Wellness programs subject to requirements.--If any of 
     the conditions for obtaining a premium discount, rebate, or 
     reward

[[Page H1932]]

     under a wellness program as described in paragraph (1)(C) is 
     based on an individual satisfying a standard that is related 
     to a health status factor, the wellness program shall not 
     violate this section if the following requirements are 
     complied with:
       ``(A) The reward for the wellness program, together with 
     the reward for other wellness programs with respect to the 
     plan that requires satisfaction of a standard related to a 
     health status factor, shall not exceed 30 percent of the cost 
     of employee-only coverage under the plan. If, in addition to 
     employees or individuals, any class of dependents (such as 
     spouses or spouses and dependent children) may participate 
     fully in the wellness program, such reward shall not exceed 
     30 percent of the cost of the coverage in which an employee 
     or individual and any dependents are enrolled. For purposes 
     of this paragraph, the cost of coverage shall be determined 
     based on the total amount of employer and employee 
     contributions for the benefit package under which the 
     employee is (or the employee and any dependents are) 
     receiving coverage. A reward may be in the form of a discount 
     or rebate of a premium or contribution, a waiver of all or 
     part of a cost-sharing mechanism (such as deductibles, 
     copayments, or coinsurance), the absence of a surcharge, or 
     the value of a benefit that would otherwise not be provided 
     under the plan. The Secretaries of Labor, Health and Human 
     Services, and the Treasury may increase the reward available 
     under this subparagraph to up to 50 percent of the cost of 
     coverage if the Secretaries determine that such an increase 
     is appropriate.
       ``(B) The wellness program shall be reasonably designed to 
     promote health or prevent disease. A program complies with 
     the preceding sentence if the program has a reasonable chance 
     of improving the health of, or preventing disease in, 
     participating individuals and it is not overly burdensome, is 
     not a subterfuge for discriminating based on a health status 
     factor, and is not highly suspect in the method chosen to 
     promote health or prevent disease.
       ``(C) The plan shall give individuals eligible for the 
     program the opportunity to qualify for the reward under the 
     program at least once each year.
       ``(D) The full reward under the wellness program shall be 
     made available to all similarly situated individuals. For 
     such purpose, among other things:
       ``(i) The reward is not available to all similarly situated 
     individuals for a period unless the wellness program allows--

       ``(I) for a reasonable alternative standard (or waiver of 
     the otherwise applicable standard) for obtaining the reward 
     for any individual for whom, for that period, it is 
     unreasonably difficult due to a medical condition to satisfy 
     the otherwise applicable standard; and
       ``(II) for a reasonable alternative standard (or waiver of 
     the otherwise applicable standard) for obtaining the reward 
     for any individual for whom, for that period, it is medically 
     inadvisable to attempt to satisfy the otherwise applicable 
     standard.

       ``(ii) If reasonable under the circumstances, the plan or 
     issuer may seek verification, such as a statement from an 
     individual's physician, that a health status factor makes it 
     unreasonably difficult or medically inadvisable for the 
     individual to satisfy or attempt to satisfy the otherwise 
     applicable standard.
       ``(E) The plan or issuer involved shall disclose in all 
     plan materials describing the terms of the wellness program 
     the availability of a reasonable alternative standard (or the 
     possibility of waiver of the otherwise applicable standard) 
     required under subparagraph (D). If plan materials disclose 
     that such a program is available, without describing its 
     terms, the disclosure under this subparagraph shall not be 
     required.
       ``(k) Existing Programs.--Nothing in this section shall 
     prohibit a program of health promotion or disease prevention 
     that was established prior to the date of enactment of this 
     section and applied with all applicable regulations, and that 
     is operating on such date, from continuing to be carried out 
     for as long as such regulations remain in effect.
       ``(l) Wellness Program Demonstration Project.--
       ``(1) In general.--Not later than July 1, 2014, the 
     Secretary, in consultation with the Secretary of the Treasury 
     and the Secretary of Labor, shall establish a 10-State 
     demonstration project under which participating States shall 
     apply the provisions of subsection (j) to programs of health 
     promotion offered by a health insurance issuer that offers 
     health insurance coverage in the individual market in such 
     State.
       ``(2) Expansion of demonstration project.--If the 
     Secretary, in consultation with the Secretary of the Treasury 
     and the Secretary of Labor, determines that the demonstration 
     project described in paragraph (1) is effective, such 
     Secretaries may, beginning on July 1, 2017 expand such 
     demonstration project to include additional participating 
     States.
       ``(3) Requirements.--
       ``(A) Maintenance of coverage.--The Secretary, in 
     consultation with the Secretary of the Treasury and the 
     Secretary of Labor, shall not approve the participation of a 
     State in the demonstration project under this section unless 
     the Secretaries determine that the State's project is 
     designed in a manner that--
       ``(i) will not result in any decrease in coverage; and
       ``(ii) will not increase the cost to the Federal Government 
     in providing credits under section 36B of the Internal 
     Revenue Code of 1986 or cost-sharing assistance under section 
     1402 of the Patient Protection and Affordable Care Act.
       ``(B) Other requirements.--States that participate in the 
     demonstration project under this subsection--
       ``(i) may permit premium discounts or rebates or the 
     modification of otherwise applicable copayments or 
     deductibles for adherence to, or participation in, a 
     reasonably designed program of health promotion and disease 
     prevention;
       ``(ii) shall ensure that requirements of consumer 
     protection are met in programs of health promotion in the 
     individual market;
       ``(iii) shall require verification from health insurance 
     issuers that offer health insurance coverage in the 
     individual market of such State that premium discounts--

       ``(I) do not create undue burdens for individuals insured 
     in the individual market;
       ``(II) do not lead to cost shifting; and
       ``(III) are not a subterfuge for discrimination;

       ``(iv) shall ensure that consumer data is protected in 
     accordance with the requirements of section 264(c) of the 
     Health Insurance Portability and Accountability Act of 1996 
     (42 U.S.C. 1320d-2 note); and
       ``(v) shall ensure and demonstrate to the satisfaction of 
     the Secretary that the discounts or other rewards provided 
     under the project reflect the expected level of participation 
     in the wellness program involved and the anticipated effect 
     the program will have on utilization or medical claim costs.
       ``(m) Report.--
       ``(1) In general.--Not later than 3 years after the date of 
     enactment of the Patient Protection and Affordable Care Act, 
     the Secretary, in consultation with the Secretary of the 
     Treasury and the Secretary of Labor, shall submit a report to 
     the appropriate committees of Congress concerning--
       ``(A) the effectiveness of wellness programs (as defined in 
     subsection (j)) in promoting health and preventing disease;
       ``(B) the impact of such wellness programs on the access to 
     care and affordability of coverage for participants and non-
     participants of such programs;
       ``(C) the impact of premium-based and cost-sharing 
     incentives on participant behavior and the role of such 
     programs in changing behavior; and
       ``(D) the effectiveness of different types of rewards.
       ``(2) Data collection.--In preparing the report described 
     in paragraph (1), the Secretaries shall gather relevant 
     information from employers who provide employees with access 
     to wellness programs, including State and Federal agencies.
       ``(n) Regulations.--Nothing in this section shall be 
     construed as prohibiting the Secretaries of Labor, Health and 
     Human Services, or the Treasury from promulgating regulations 
     in connection with this section.

     ``SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.

       ``(a) Providers.--A group health plan and a health 
     insurance issuer offering group or individual health 
     insurance coverage shall not discriminate with respect to 
     participation under the plan or coverage against any health 
     care provider who is acting within the scope of that 
     provider's license or certification under applicable State 
     law. This section shall not require that a group health plan 
     or health insurance issuer contract with any health care 
     provider willing to abide by the terms and conditions for 
     participation established by the plan or issuer. Nothing in 
     this section shall be construed as preventing a group health 
     plan, a health insurance issuer, or the Secretary from 
     establishing varying reimbursement rates based on quality or 
     performance measures.
       ``(b) Individuals.--The provisions of section 1558 of the 
     Patient Protection and Affordable Care Act (relating to non-
     discrimination) shall apply with respect to a group health 
     plan or health insurance issuer offering group or individual 
     health insurance coverage.

     ``SEC. 2707. COMPREHENSIVE HEALTH INSURANCE COVERAGE.

       ``(a) Coverage for Essential Health Benefits Package.--A 
     health insurance issuer that offers health insurance coverage 
     in the individual or small group market shall ensure that 
     such coverage includes the essential health benefits package 
     required under section 1302(a) of the Patient Protection and 
     Affordable Care Act.
       ``(b) Cost-sharing Under Group Health Plans.--A group 
     health plan shall ensure that any annual cost-sharing imposed 
     under the plan does not exceed the limitations provided for 
     under paragraphs (1) and (2) of section 1302(c).
       ``(c) Child-only Plans.--If a health insurance issuer 
     offers health insurance coverage in any level of coverage 
     specified under section 1302(d) of the Patient Protection and 
     Affordable Care Act, the issuer shall also offer such 
     coverage in that level as a plan in which the only enrollees 
     are individuals who, as of the beginning of a plan year, have 
     not attained the age of 21.
       ``(d) Dental Only.--This section shall not apply to a plan 
     described in section 1302(d)(2)(B)(ii)(I).

     ``SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS.

       ``A group health plan and a health insurance issuer 
     offering group or individual health insurance coverage shall 
     not apply any waiting period (as defined in section 
     2704(b)(4)) that exceeds 90 days.''.

                       PART II--OTHER PROVISIONS

     SEC. 1251. PRESERVATION OF RIGHT TO MAINTAIN EXISTING 
                   COVERAGE.

       (a) No Changes to Existing Coverage.--
       (1) In general.--Nothing in this Act (or an amendment made 
     by this Act) shall be construed to require that an individual 
     terminate coverage under a group health plan or health 
     insurance coverage in which such individual was enrolled on 
     the date of enactment of this Act.
       (2) Continuation of coverage.--With respect to a group 
     health plan or health insurance coverage in which an 
     individual was enrolled on the date of enactment of this Act, 
     this subtitle and subtitle A (and the amendments made by such 
     subtitles) shall not apply to such plan or

[[Page H1933]]

     coverage, regardless of whether the individual renews such 
     coverage after such date of enactment.
       (b) Allowance for Family Members To Join Current 
     Coverage.--With respect to a group health plan or health 
     insurance coverage in which an individual was enrolled on the 
     date of enactment of this Act and which is renewed after such 
     date, family members of such individual shall be permitted to 
     enroll in such plan or coverage if such enrollment is 
     permitted under the terms of the plan in effect as of such 
     date of enactment.
       (c) Allowance for New Employees To Join Current Plan.--A 
     group health plan that provides coverage on the date of 
     enactment of this Act may provide for the enrolling of new 
     employees (and their families) in such plan, and this 
     subtitle and subtitle A (and the amendments made by such 
     subtitles) shall not apply with respect to such plan and such 
     new employees (and their families).
       (d) Effect on Collective Bargaining Agreements.--In the 
     case of health insurance coverage maintained pursuant to one 
     or more collective bargaining agreements between employee 
     representatives and one or more employers that was ratified 
     before the date of enactment of this Act, the provisions of 
     this subtitle and subtitle A (and the amendments made by such 
     subtitles) shall not apply until the date on which the last 
     of the collective bargaining agreements relating to the 
     coverage terminates. Any coverage amendment made pursuant to 
     a collective bargaining agreement relating to the coverage 
     which amends the coverage solely to conform to any 
     requirement added by this subtitle or subtitle A (or 
     amendments) shall not be treated as a termination of such 
     collective bargaining agreement.
       (e) Definition.--In this title, the term ``grandfathered 
     health plan'' means any group health plan or health insurance 
     coverage to which this section applies.

     SEC. 1252. RATING REFORMS MUST APPLY UNIFORMLY TO ALL HEALTH 
                   INSURANCE ISSUERS AND GROUP HEALTH PLANS.

       Any standard or requirement adopted by a State pursuant to 
     this title, or any amendment made by this title, shall be 
     applied uniformly to all health plans in each insurance 
     market to which the standard and requirements apply. The 
     preceding sentence shall also apply to a State standard or 
     requirement relating to the standard or requirement required 
     by this title (or any such amendment) that is not the same as 
     the standard or requirement but that is not preempted under 
     section 1321(d).

     SEC. 1253. EFFECTIVE DATES.

       This subtitle (and the amendments made by this subtitle) 
     shall become effective for plan years beginning on or after 
     January 1, 2014.

        Subtitle D--Available Coverage Choices for All Americans

            PART I--ESTABLISHMENT OF QUALIFIED HEALTH PLANS

     SEC. 1301. QUALIFIED HEALTH PLAN DEFINED.

       (a) Qualified Health Plan.--In this title:
       (1) In general.--The term ``qualified health plan'' means a 
     health plan that--
       (A) has in effect a certification (which may include a seal 
     or other indication of approval) that such plan meets the 
     criteria for certification described in section 1311(c) 
     issued or recognized by each Exchange through which such plan 
     is offered;
       (B) provides the essential health benefits package 
     described in section 1302(a); and
       (C) is offered by a health insurance issuer that--
       (i) is licensed and in good standing to offer health 
     insurance coverage in each State in which such issuer offers 
     health insurance coverage under this title;
       (ii) agrees to offer at least one qualified health plan in 
     the silver level and at least one plan in the gold level in 
     each such Exchange;
       (iii) agrees to charge the same premium rate for each 
     qualified health plan of the issuer without regard to whether 
     the plan is offered through an Exchange or whether the plan 
     is offered directly from the issuer or through an agent; and
       (iv) complies with the regulations developed by the 
     Secretary under section 1311(d) and such other requirements 
     as an applicable Exchange may establish.
       (2) Inclusion of co-op plans and community health insurance 
     option.--Any reference in this title to a qualified health 
     plan shall be deemed to include a qualified health plan 
     offered through the CO-OP program under section 1322 or a 
     community health insurance option under section 1323, unless 
     specifically provided for otherwise.
       (b) Terms Relating to Health Plans.--In this title:
       (1) Health plan.--
       (A) In general.--The term ``health plan'' means health 
     insurance coverage and a group health plan.
       (B) Exception for self-insured plans and mewas.--Except to 
     the extent specifically provided by this title, the term 
     ``health plan'' shall not include a group health plan or 
     multiple employer welfare arrangement to the extent the plan 
     or arrangement is not subject to State insurance regulation 
     under section 514 of the Employee Retirement Income Security 
     Act of 1974.
       (2) Health insurance coverage and issuer.--The terms 
     ``health insurance coverage'' and ``health insurance issuer'' 
     have the meanings given such terms by section 2791(b) of the 
     Public Health Service Act.
       (3) Group health plan.--The term ``group health plan'' has 
     the meaning given such term by section 2791(a) of the Public 
     Health Service Act.

     SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.

       (a) Essential Health Benefits Package.--In this title, the 
     term ``essential health benefits package'' means, with 
     respect to any health plan, coverage that--
       (1) provides for the essential health benefits defined by 
     the Secretary under subsection (b);
       (2) limits cost-sharing for such coverage in accordance 
     with subsection (c); and
       (3) subject to subsection (e), provides either the bronze, 
     silver, gold, or platinum level of coverage described in 
     subsection (d).
       (b) Essential Health Benefits.--
       (1) In general.--Subject to paragraph (2), the Secretary 
     shall define the essential health benefits, except that such 
     benefits shall include at least the following general 
     categories and the items and services covered within the 
     categories:
       (A) Ambulatory patient services.
       (B) Emergency services.
       (C) Hospitalization.
       (D) Maternity and newborn care.
       (E) Mental health and substance use disorder services, 
     including behavioral health treatment.
       (F) Prescription drugs.
       (G) Rehabilitative and habilitative services and devices.
       (H) Laboratory services.
       (I) Preventive and wellness services and chronic disease 
     management.
       (J) Pediatric services, including oral and vision care.
       (2) Limitation.--
       (A) In general.--The Secretary shall ensure that the scope 
     of the essential health benefits under paragraph (1) is equal 
     to the scope of benefits provided under a typical employer 
     plan, as determined by the Secretary. To inform this 
     determination, the Secretary of Labor shall conduct a survey 
     of employer-sponsored coverage to determine the benefits 
     typically covered by employers, including multiemployer 
     plans, and provide a report on such survey to the Secretary.
       (B) Certification.--In defining the essential health 
     benefits described in paragraph (1), and in revising the 
     benefits under paragraph (4)(H), the Secretary shall submit a 
     report to the appropriate committees of Congress containing a 
     certification from the Chief Actuary of the Centers for 
     Medicare & Medicaid Services that such essential health 
     benefits meet the limitation described in paragraph (2).
       (3) Notice and hearing.--In defining the essential health 
     benefits described in paragraph (1), and in revising the 
     benefits under paragraph (4)(H), the Secretary shall provide 
     notice and an opportunity for public comment.
       (4) Required elements for consideration.--In defining the 
     essential health benefits under paragraph (1), the Secretary 
     shall--
       (A) ensure that such essential health benefits reflect an 
     appropriate balance among the categories described in such 
     subsection, so that benefits are not unduly weighted toward 
     any category;
       (B) not make coverage decisions, determine reimbursement 
     rates, establish incentive programs, or design benefits in 
     ways that discriminate against individuals because of their 
     age, disability, or expected length of life;
       (C) take into account the health care needs of diverse 
     segments of the population, including women, children, 
     persons with disabilities, and other groups;
       (D) ensure that health benefits established as essential 
     not be subject to denial to individuals against their wishes 
     on the basis of the individuals' age or expected length of 
     life or of the individuals' present or predicted disability, 
     degree of medical dependency, or quality of life;
       (E) provide that a qualified health plan shall not be 
     treated as providing coverage for the essential health 
     benefits described in paragraph (1) unless the plan provides 
     that--
       (i) coverage for emergency department services will be 
     provided without imposing any requirement under the plan for 
     prior authorization of services or any limitation on coverage 
     where the provider of services does not have a contractual 
     relationship with the plan for the providing of services that 
     is more restrictive than the requirements or limitations that 
     apply to emergency department services received from 
     providers who do have such a contractual relationship with 
     the plan; and
       (ii) if such services are provided out-of-network, the 
     cost-sharing requirement (expressed as a copayment amount or 
     coinsurance rate) is the same requirement that would apply if 
     such services were provided in-network;
       (F) provide that if a plan described in section 
     1311(b)(2)(B)(ii) (relating to stand-alone dental benefits 
     plans) is offered through an Exchange, another health plan 
     offered through such Exchange shall not fail to be treated as 
     a qualified health plan solely because the plan does not 
     offer coverage of benefits offered through the stand-alone 
     plan that are otherwise required under paragraph (1)(J); and
       (G) periodically review the essential health benefits under 
     paragraph (1), and provide a report to Congress and the 
     public that contains--
       (i) an assessment of whether enrollees are facing any 
     difficulty accessing needed services for reasons of coverage 
     or cost;
       (ii) an assessment of whether the essential health benefits 
     needs to be modified or updated to account for changes in 
     medical evidence or scientific advancement;
       (iii) information on how the essential health benefits will 
     be modified to address any such gaps in access or changes in 
     the evidence base;
       (iv) an assessment of the potential of additional or 
     expanded benefits to increase costs and the interactions 
     between the addition or expansion of benefits and reductions 
     in existing benefits to meet actuarial limitations described 
     in paragraph (2); and
       (H) periodically update the essential health benefits under 
     paragraph (1) to address any gaps in access to coverage or 
     changes in the evidence base the Secretary identifies in the 
     review conducted under subparagraph (G).

[[Page H1934]]

       (5) Rule of construction.--Nothing in this title shall be 
     construed to prohibit a health plan from providing benefits 
     in excess of the essential health benefits described in this 
     subsection.
       (c) Requirements Relating to Cost-Sharing.--
       (1) Annual limitation on cost-sharing.--
       (A) 2014.--The cost-sharing incurred under a health plan 
     with respect to self-only coverage or coverage other than 
     self-only coverage for a plan year beginning in 2014 shall 
     not exceed the dollar amounts in effect under section 
     223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for 
     self-only and family coverage, respectively, for taxable 
     years beginning in 2014.
       (B) 2015 and later.--In the case of any plan year beginning 
     in a calendar year after 2014, the limitation under this 
     paragraph shall--
       (i) in the case of self-only coverage, be equal to the 
     dollar amount under subparagraph (A) for self-only coverage 
     for plan years beginning in 2014, increased by an amount 
     equal to the product of that amount and the premium 
     adjustment percentage under paragraph (4) for the calendar 
     year; and
       (ii) in the case of other coverage, twice the amount in 
     effect under clause (i).
     If the amount of any increase under clause (i) is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.
       (2) Annual limitation on deductibles for employer-sponsored 
     plans.--
       (A) In general.--In the case of a health plan offered in 
     the small group market, the deductible under the plan shall 
     not exceed--
       (i) $2,000 in the case of a plan covering a single 
     individual; and
       (ii) $4,000 in the case of any other plan.

     The amounts under clauses (i) and (ii) may be increased by 
     the maximum amount of reimbursement which is reasonably 
     available to a participant under a flexible spending 
     arrangement described in section 106(c)(2) of the Internal 
     Revenue Code of 1986 (determined without regard to any salary 
     reduction arrangement).
       (B) Indexing of limits.--In the case of any plan year 
     beginning in a calendar year after 2014--
       (i) the dollar amount under subparagraph (A)(i) shall be 
     increased by an amount equal to the product of that amount 
     and the premium adjustment percentage under paragraph (4) for 
     the calendar year; and
       (ii) the dollar amount under subparagraph (A)(ii) shall be 
     increased to an amount equal to twice the amount in effect 
     under subparagraph (A)(i) for plan years beginning in the 
     calendar year, determined after application of clause (i).

     If the amount of any increase under clause (i) is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.
       (C) Actuarial value.--The limitation under this paragraph 
     shall be applied in such a manner so as to not affect the 
     actuarial value of any health plan, including a plan in the 
     bronze level.
       (D) Coordination with preventive limits.--Nothing in this 
     paragraph shall be construed to allow a plan to have a 
     deductible under the plan apply to benefits described in 
     section 2713 of the Public Health Service Act.
       (3) Cost-sharing.--In this title--
       (A) In general.--The term ``cost-sharing'' includes--
       (i) deductibles, coinsurance, copayments, or similar 
     charges; and
       (ii) any other expenditure required of an insured 
     individual which is a qualified medical expense (within the 
     meaning of section 223(d)(2) of the Internal Revenue Code of 
     1986) with respect to essential health benefits covered under 
     the plan.
       (B) Exceptions.--Such term does not include premiums, 
     balance billing amounts for non-network providers, or 
     spending for non-covered services.
       (4) Premium adjustment percentage.--For purposes of 
     paragraphs (1)(B)(i) and (2)(B)(i), the premium adjustment 
     percentage for any calendar year is the percentage (if any) 
     by which the average per capita premium for health insurance 
     coverage in the United States for the preceding calendar year 
     (as estimated by the Secretary no later than October 1 of 
     such preceding calendar year) exceeds such average per capita 
     premium for 2013 (as determined by the Secretary).
       (d) Levels of Coverage.--
       (1) Levels of coverage defined.--The levels of coverage 
     described in this subsection are as follows:
       (A) Bronze level.--A plan in the bronze level shall provide 
     a level of coverage that is designed to provide benefits that 
     are actuarially equivalent to 60 percent of the full 
     actuarial value of the benefits provided under the plan.
       (B) Silver level.--A plan in the silver level shall provide 
     a level of coverage that is designed to provide benefits that 
     are actuarially equivalent to 70 percent of the full 
     actuarial value of the benefits provided under the plan.
       (C) Gold level.--A plan in the gold level shall provide a 
     level of coverage that is designed to provide benefits that 
     are actuarially equivalent to 80 percent of the full 
     actuarial value of the benefits provided under the plan.
       (D) Platinum level.--A plan in the platinum level shall 
     provide a level of coverage that is designed to provide 
     benefits that are actuarially equivalent to 90 percent of the 
     full actuarial value of the benefits provided under the plan.
       (2) Actuarial value.--
       (A) In general.--Under regulations issued by the Secretary, 
     the level of coverage of a plan shall be determined on the 
     basis that the essential health benefits described in 
     subsection (b) shall be provided to a standard population 
     (and without regard to the population the plan may actually 
     provide benefits to).
       (B) Employer contributions.--The Secretary may issue 
     regulations under which employer contributions to a health 
     savings account (within the meaning of section 223 of the 
     Internal Revenue Code of 1986) may be taken into account in 
     determining the level of coverage for a plan of the employer.
       (C) Application.--In determining under this title, the 
     Public Health Service Act, or the Internal Revenue Code of 
     1986 the percentage of the total allowed costs of benefits 
     provided under a group health plan or health insurance 
     coverage that are provided by such plan or coverage, the 
     rules contained in the regulations under this paragraph shall 
     apply.
       (3) Allowable variance.--The Secretary shall develop 
     guidelines to provide for a de minimis variation in the 
     actuarial valuations used in determining the level of 
     coverage of a plan to account for differences in actuarial 
     estimates.
       (4) Plan reference.--In this title, any reference to a 
     bronze, silver, gold, or platinum plan shall be treated as a 
     reference to a qualified health plan providing a bronze, 
     silver, gold, or platinum level of coverage, as the case may 
     be.
       (e) Catastrophic Plan.--
       (1) In general.--A health plan not providing a bronze, 
     silver, gold, or platinum level of coverage shall be treated 
     as meeting the requirements of subsection (d) with respect to 
     any plan year if--
       (A) the only individuals who are eligible to enroll in the 
     plan are individuals described in paragraph (2); and
       (B) the plan provides--
       (i) except as provided in clause (ii), the essential health 
     benefits determined under subsection (b), except that the 
     plan provides no benefits for any plan year until the 
     individual has incurred cost-sharing expenses in an amount 
     equal to the annual limitation in effect under subsection 
     (c)(1) for the plan year (except as provided for in section 
     2713); and
       (ii) coverage for at least three primary care visits.
       (2) Individuals eligible for enrollment.--An individual is 
     described in this paragraph for any plan year if the 
     individual--
       (A) has not attained the age of 30 before the beginning of 
     the plan year; or
       (B) has a certification in effect for any plan year under 
     this title that the individual is exempt from the requirement 
     under section 5000A of the Internal Revenue Code of 1986 by 
     reason of--
       (i) section 5000A(e)(1) of such Code (relating to 
     individuals without affordable coverage); or
       (ii) section 5000A(e)(5) of such Code (relating to 
     individuals with hardships).
       (3) Restriction to individual market.--If a health 
     insurance issuer offers a health plan described in this 
     subsection, the issuer may only offer the plan in the 
     individual market.
       (f) Child-only Plans.--If a qualified health plan is 
     offered through the Exchange in any level of coverage 
     specified under subsection (d), the issuer shall also offer 
     that plan through the Exchange in that level as a plan in 
     which the only enrollees are individuals who, as of the 
     beginning of a plan year, have not attained the age of 21, 
     and such plan shall be treated as a qualified health plan.

     SEC. 1303. SPECIAL RULES.

       (a) Special Rules Relating to Coverage of Abortion 
     Services.--
       (1) Voluntary choice of coverage of abortion services.--
       (A) In general.--Notwithstanding any other provision of 
     this title (or any amendment made by this title), and subject 
     to subparagraphs (C) and (D)--
       (i) nothing in this title (or any amendment made by this 
     title), shall be construed to require a qualified health plan 
     to provide coverage of services described in subparagraph 
     (B)(i) or (B)(ii) as part of its essential health benefits 
     for any plan year; and
       (ii) the issuer of a qualified health plan shall determine 
     whether or not the plan provides coverage of services 
     described in subparagraph (B)(i) or (B)(ii) as part of such 
     benefits for the plan year.
       (B) Abortion services.--
       (i) Abortions for which public funding is prohibited.--The 
     services described in this clause are abortions for which the 
     expenditure of Federal funds appropriated for the Department 
     of Health and Human Services is not permitted, based on the 
     law as in effect as of the date that is 6 months before the 
     beginning of the plan year involved.
       (ii) Abortions for which public funding is allowed.--The 
     services described in this clause are abortions for which the 
     expenditure of Federal funds appropriated for the Department 
     of Health and Human Services is permitted, based on the law 
     as in effect as of the date that is 6 months before the 
     beginning of the plan year involved.
       (C) Prohibition on federal funds for abortion services in 
     community health insurance option.--
       (i) Determination by secretary.--The Secretary may not 
     determine, in accordance with subparagraph (A)(ii), that the 
     community health insurance option established under section 
     1323 shall provide coverage of services described in 
     subparagraph (B)(i) as part of benefits for the plan year 
     unless the Secretary--

       (I) assures compliance with the requirements of paragraph 
     (2);
       (II) assures, in accordance with applicable provisions of 
     generally accepted accounting requirements, circulars on 
     funds management of the Office of Management and Budget, and 
     guidance on accounting of the Government Accountability 
     Office, that no Federal funds are used for such coverage; and
       (III) notwithstanding section 1323(e)(1)(C) or any other 
     provision of this title, takes all necessary steps to assure 
     that the United States does not bear the insurance risk for a 
     community health insurance option's coverage of services 
     described in subparagraph (B)(i).

       (ii) State requirement.--If a State requires, in addition 
     to the essential health benefits required under section 
     1323(b)(3) (A), coverage of

[[Page H1935]]

     services described in subparagraph (B)(i) for enrollees of a 
     community health insurance option offered in such State, the 
     State shall assure that no funds flowing through or from the 
     community health insurance option, and no other Federal 
     funds, pay or defray the cost of providing coverage of 
     services described in subparagraph (B)(i). The United States 
     shall not bear the insurance risk for a State's required 
     coverage of services described in subparagraph (B)(i).
       (iii) Exceptions.--Nothing in this subparagraph shall apply 
     to coverage of services described in subparagraph (B)(ii) by 
     the community health insurance option. Services described in 
     subparagraph (B)(ii) shall be covered to the same extent as 
     such services are covered under title XIX of the Social 
     Security Act.
       (D) Assured availability of varied coverage through 
     exchanges.--
       (i) In general.--The Secretary shall assure that with 
     respect to qualified health plans offered in any Exchange 
     established pursuant to this title--

       (I) there is at least one such plan that provides coverage 
     of services described in clauses (i) and (ii) of subparagraph 
     (B); and
       (II) there is at least one such plan that does not provide 
     coverage of services described in subparagraph (B)(i).

       (ii) Special rules.--For purposes of clause (i)--

       (I) a plan shall be treated as described in clause (i)(II) 
     if the plan does not provide coverage of services described 
     in either subparagraph (B)(i) or (B)(ii); and
       (II) if a State has one Exchange covering more than 1 
     insurance market, the Secretary shall meet the requirements 
     of clause (i) separately with respect to each such market.

       (2) Prohibition on the use of federal funds.--
       (A) In general.--If a qualified health plan provides 
     coverage of services described in paragraph (1)(B)(i), the 
     issuer of the plan shall not use any amount attributable to 
     any of the following for purposes of paying for such 
     services:
       (i) The credit under section 36B of the Internal Revenue 
     Code of 1986 (and the amount (if any) of the advance payment 
     of the credit under section 1412 of the Patient Protection 
     and Affordable Care Act).
       (ii) Any cost-sharing reduction under section 1402 of 
     thePatient Protection and Affordable Care Act (and the amount 
     (if any) of the advance payment of the reduction under 
     section 1412 of the Patient Protection and Affordable Care 
     Act).
       (B) Segregation of funds.--In the case of a plan to which 
     subparagraph (A) applies, the issuer of the plan shall, out 
     of amounts not described in subparagraph (A), segregate an 
     amount equal to the actuarial amounts determined under 
     subparagraph (C) for all enrollees from the amounts described 
     in subparagraph (A).
       (C) Actuarial value of optional service coverage.--
       (i) In general.--The Secretary shall estimate the basic per 
     enrollee, per month cost, determined on an average actuarial 
     basis, for including coverage under a qualified health plan 
     of the services described in paragraph (1)(B)(i).
       (ii) Considerations.--In making such estimate, the 
     Secretary--

       (I) may take into account the impact on overall costs of 
     the inclusion of such coverage, but may not take into account 
     any cost reduction estimated to result from such services, 
     including prenatal care, delivery, or postnatal care;
       (II) shall estimate such costs as if such coverage were 
     included for the entire population covered; and
       (III) may not estimate such a cost at less than $1 per 
     enrollee, per month.

       (3) Provider conscience protections.--No individual health 
     care provider or health care facility may be discriminated 
     against because of a willingness or an unwillingness, if 
     doing so is contrary to the religious or moral beliefs of the 
     provider or facility, to provide, pay for, provide coverage 
     of, or refer for abortions.
       (b) Application of State and Federal Laws Regarding 
     Abortion.--
       (1) No preemption of state laws regarding abortion.--
     Nothing in this Act shall be construed to preempt or 
     otherwise have any effect on State laws regarding the 
     prohibition of (or requirement of) coverage, funding, or 
     procedural requirements on abortions, including parental 
     notification or consent for the performance of an abortion on 
     a minor.
       (2) No effect on federal laws regarding abortion.--
       (A) In general.--Nothing in this Act shall be construed to 
     have any effect on Federal laws regarding--
       (i) conscience protection;
       (ii) willingness or refusal to provide abortion; and
       (iii) discrimination on the basis of the willingness or 
     refusal to provide, pay for, cover, or refer for abortion or 
     to provide or participate in training to provide abortion.
       (3) No effect on federal civil rights law.--Nothing in this 
     subsection shall alter the rights and obligations of 
     employees and employers under title VII of the Civil Rights 
     Act of 1964.
       (c) Application of Emergency Services Laws.--Nothing in 
     this Act shall be construed to relieve any health care 
     provider from providing emergency services as required by 
     State or Federal law, including section 1867 of the Social 
     Security Act (popularly known as ``EMTALA'').

     SEC. 1304. RELATED DEFINITIONS.

       (a) Definitions Relating to Markets.--In this title:
       (1) Group market.--The term ``group market'' means the 
     health insurance market under which individuals obtain health 
     insurance coverage (directly or through any arrangement) on 
     behalf of themselves (and their dependents) through a group 
     health plan maintained by an employer.
       (2) Individual market.--The term ``individual market'' 
     means the market for health insurance coverage offered to 
     individuals other than in connection with a group health 
     plan.
       (3) Large and small group markets.--The terms ``large group 
     market'' and ``small group market'' mean the health insurance 
     market under which individuals obtain health insurance 
     coverage (directly or through any arrangement) on behalf of 
     themselves (and their dependents) through a group health plan 
     maintained by a large employer (as defined in subsection 
     (b)(1)) or by a small employer (as defined in subsection 
     (b)(2)), respectively.
       (b) Employers.--In this title:
       (1) Large employer.--The term ``large employer'' means, in 
     connection with a group health plan with respect to a 
     calendar year and a plan year, an employer who employed an 
     average of at least 101 employees on business days during the 
     preceding calendar year and who employs at least 1 employee 
     on the first day of the plan year.
       (2) Small employer.--The term ``small employer'' means, in 
     connection with a group health plan with respect to a 
     calendar year and a plan year, an employer who employed an 
     average of at least 1 but not more than 100 employees on 
     business days during the preceding calendar year and who 
     employs at least 1 employee on the first day of the plan 
     year.
       (3) State option to treat 50 employees as small.--In the 
     case of plan years beginning before January 1, 2016, a State 
     may elect to apply this subsection by substituting ``51 
     employees'' for ``101 employees'' in paragraph (1) and by 
     substituting ``50 employees'' for ``100 employees'' in 
     paragraph (2).
       (4) Rules for determining employer size.--For purposes of 
     this subsection--
       (A) Application of aggregation rule for employers.--All 
     persons treated as a single employer under subsection (b), 
     (c), (m), or (o) of section 414 of the Internal Revenue Code 
     of 1986 shall be treated as 1 employer.
       (B) Employers not in existence in preceding year.--In the 
     case of an employer which was not in existence throughout the 
     preceding calendar year, the determination of whether such 
     employer is a small or large employer shall be based on the 
     average number of employees that it is reasonably expected 
     such employer will employ on business days in the current 
     calendar year.
       (C) Predecessors.--Any reference in this subsection to an 
     employer shall include a reference to any predecessor of such 
     employer.
       (D) Continuation of participation for growing small 
     employers.--If--
       (i) a qualified employer that is a small employer makes 
     enrollment in qualified health plans offered in the small 
     group market available to its employees through an Exchange; 
     and
       (ii) the employer ceases to be a small employer by reason 
     of an increase in the number of employees of such employer;
     the employer shall continue to be treated as a small employer 
     for purposes of this subtitle for the period beginning with 
     the increase and ending with the first day on which the 
     employer does not make such enrollment available to its 
     employees.
       (c) Secretary.--In this title, the term ``Secretary'' means 
     the Secretary of Health and Human Services.
       (d) State.--In this title, the term ``State'' means each of 
     the 50 States and the District of Columbia.

  PART II--CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH 
                           BENEFIT EXCHANGES

     SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.

       (a) Assistance to States to Establish American Health 
     Benefit Exchanges.--
       (1) Planning and establishment grants.--There shall be 
     appropriated to the Secretary, out of any moneys in the 
     Treasury not otherwise appropriated, an amount necessary to 
     enable the Secretary to make awards, not later than 1 year 
     after the date of enactment of this Act, to States in the 
     amount specified in paragraph (2) for the uses described in 
     paragraph (3).
       (2) Amount specified.--For each fiscal year, the Secretary 
     shall determine the total amount that the Secretary will make 
     available to each State for grants under this subsection.
       (3) Use of funds.--A State shall use amounts awarded under 
     this subsection for activities (including planning 
     activities) related to establishing an American Health 
     Benefit Exchange, as described in subsection (b).
       (4) Renewability of grant.--
       (A) In general.--Subject to subsection (d)(4), the 
     Secretary may renew a grant awarded under paragraph (1) if 
     the State recipient of such grant--
       (i) is making progress, as determined by the Secretary, 
     toward--

       (I) establishing an Exchange; and
       (II) implementing the reforms described in subtitles A and 
     C (and the amendments made by such subtitles); and

       (ii) is meeting such other benchmarks as the Secretary may 
     establish.
       (B) Limitation.--No grant shall be awarded under this 
     subsection after January 1, 2015.
       (5) Technical assistance to facilitate participation in 
     shop exchanges.--The Secretary shall provide technical 
     assistance to States to facilitate the participation of 
     qualified small businesses in such States in SHOP Exchanges.
       (b) American Health Benefit Exchanges.--
       (1) In general.--Each State shall, not later than January 
     1, 2014, establish an American Health Benefit Exchange 
     (referred to in this title as an ``Exchange'') for the State 
     that--
       (A) facilitates the purchase of qualified health plans;

[[Page H1936]]

       (B) provides for the establishment of a Small Business 
     Health Options Program (in this title referred to as a ``SHOP 
     Exchange'') that is designed to assist qualified employers in 
     the State who are small employers in facilitating the 
     enrollment of their employees in qualified health plans 
     offered in the small group market in the State; and
       (C) meets the requirements of subsection (d).
       (2) Merger of individual and shop exchanges.--A State may 
     elect to provide only one Exchange in the State for providing 
     both Exchange and SHOP Exchange services to both qualified 
     individuals and qualified small employers, but only if the 
     Exchange has adequate resources to assist such individuals 
     and employers.
       (c) Responsibilities of the Secretary.--
       (1) In general.--The Secretary shall, by regulation, 
     establish criteria for the certification of health plans as 
     qualified health plans. Such criteria shall require that, to 
     be certified, a plan shall, at a minimum--
       (A) meet marketing requirements, and not employ marketing 
     practices or benefit designs that have the effect of 
     discouraging the enrollment in such plan by individuals with 
     significant health needs;
       (B) ensure a sufficient choice of providers (in a manner 
     consistent with applicable network adequacy provisions under 
     section 2702(c) of the Public Health Service Act), and 
     provide information to enrollees and prospective enrollees on 
     the availability of in-network and out-of-network providers;
       (C) include within health insurance plan networks those 
     essential community providers, where available, that serve 
     predominately low-income, medically-underserved individuals, 
     such as health care providers defined in section 340B(a)(4) 
     of the Public Health Service Act and providers described in 
     section 1927(c)(1)(D)(i)(IV) of the Social Security Act as 
     set forth by section 221 of Public Law 111-8, except that 
     nothing in this subparagraph shall be construed to require 
     any health plan to provide coverage for any specific medical 
     procedure;
       (D)(i) be accredited with respect to local performance on 
     clinical quality measures such as the Healthcare 
     Effectiveness Data and Information Set, patient experience 
     ratings on a standardized Consumer Assessment of Healthcare 
     Providers and Systems survey, as well as consumer access, 
     utilization management, quality assurance, provider 
     credentialing, complaints and appeals, network adequacy and 
     access, and patient information programs by any entity 
     recognized by the Secretary for the accreditation of health 
     insurance issuers or plans (so long as any such entity has 
     transparent and rigorous methodological and scoring 
     criteria); or
       (ii) receive such accreditation within a period established 
     by an Exchange for such accreditation that is applicable to 
     all qualified health plans;
       (E) implement a quality improvement strategy described in 
     subsection (g)(1);
       (F) utilize a uniform enrollment form that qualified 
     individuals and qualified employers may use (either 
     electronically or on paper) in enrolling in qualified health 
     plans offered through such Exchange, and that takes into 
     account criteria that the National Association of Insurance 
     Commissioners develops and submits to the Secretary;
       (G) utilize the standard format established for presenting 
     health benefits plan options; and
       (H) provide information to enrollees and prospective 
     enrollees, and to each Exchange in which the plan is offered, 
     on any quality measures for health plan performance endorsed 
     under section 399JJ of the Public Health Service Act, as 
     applicable.
       (2) Rule of construction.--Nothing in paragraph (1)(C) 
     shall be construed to require a qualified health plan to 
     contract with a provider described in such paragraph if such 
     provider refuses to accept the generally applicable payment 
     rates of such plan.
       (3) Rating system.--The Secretary shall develop a rating 
     system that would rate qualified health plans offered through 
     an Exchange in each benefits level on the basis of the 
     relative quality and price. The Exchange shall include the 
     quality rating in the information provided to individuals and 
     employers through the Internet portal established under 
     paragraph (4).
       (4) Enrollee satisfaction system.--The Secretary shall 
     develop an enrollee satisfaction survey system that would 
     evaluate the level of enrollee satisfaction with qualified 
     health plans offered through an Exchange, for each such 
     qualified health plan that had more than 500 enrollees in the 
     previous year. The Exchange shall include enrollee 
     satisfaction information in the information provided to 
     individuals and employers through the Internet portal 
     established under paragraph (5) in a manner that allows 
     individuals to easily compare enrollee satisfaction levels 
     between comparable plans.
       (5) Internet portals.--The Secretary shall--
       (A) continue to operate, maintain, and update the Internet 
     portal developed under section 1103(a) and to assist States 
     in developing and maintaining their own such portal; and
       (B) make available for use by Exchanges a model template 
     for an Internet portal that may be used to direct qualified 
     individuals and qualified employers to qualified health 
     plans, to assist such individuals and employers in 
     determining whether they are eligible to participate in an 
     Exchange or eligible for a premium tax credit or cost-sharing 
     reduction, and to present standardized information (including 
     quality ratings) regarding qualified health plans offered 
     through an Exchange to assist consumers in making easy health 
     insurance choices.

     Such template shall include, with respect to each qualified 
     health plan offered through the Exchange in each rating area, 
     access to the uniform outline of coverage the plan is 
     required to provide under section 2716 of the Public Health 
     Service Act and to a copy of the plan's written policy.
       (6) Enrollment periods.--The Secretary shall require an 
     Exchange to provide for--
       (A) an initial open enrollment, as determined by the 
     Secretary (such determination to be made not later than July 
     1, 2012);
       (B) annual open enrollment periods, as determined by the 
     Secretary for calendar years after the initial enrollment 
     period;
       (C) special enrollment periods specified in section 9801 of 
     the Internal Revenue Code of 1986 and other special 
     enrollment periods under circumstances similar to such 
     periods under part D of title XVIII of the Social Security 
     Act; and
       (D) special monthly enrollment periods for Indians (as 
     defined in section 4 of the Indian Health Care Improvement 
     Act).
       (d) Requirements.--
       (1) In general.--An Exchange shall be a governmental agency 
     or nonprofit entity that is established by a State.
       (2) Offering of coverage.--
       (A) In general.--An Exchange shall make available qualified 
     health plans to qualified individuals and qualified 
     employers.
       (B) Limitation.--
       (i) In general.--An Exchange may not make available any 
     health plan that is not a qualified health plan.
       (ii) Offering of stand-alone dental benefits.--Each 
     Exchange within a State shall allow an issuer of a plan that 
     only provides limited scope dental benefits meeting the 
     requirements of section 9832(c)(2)(A) of the Internal Revenue 
     Code of 1986 to offer the plan through the Exchange (either 
     separately or in conjunction with a qualified health plan) if 
     the plan provides pediatric dental benefits meeting the 
     requirements of section 1302(b)(1)(J)).
       (3) Rules relating to additional required benefits.--
       (A) In general.--Except as provided in subparagraph (B), an 
     Exchange may make available a qualified health plan 
     notwithstanding any provision of law that may require 
     benefits other than the essential health benefits specified 
     under section 1302(b).
       (B) States may require additional benefits.--
       (i) In general.--Subject to the requirements of clause 
     (ii), a State may require that a qualified health plan 
     offered in such State offer benefits in addition to the 
     essential health benefits specified under section 1302(b).
       (ii) State must assume cost.--A State shall make payments 
     to or on behalf of an individual eligible for the premium tax 
     credit under section 36B of the Internal Revenue Code of 1986 
     and any cost-sharing reduction under section 1402 to defray 
     the cost to the individual of any additional benefits 
     described in clause (i) which are not eligible for such 
     credit or reduction under section 36B(b)(3)(D) of such Code 
     and section 1402(c)(4).
       (4) Functions.--An Exchange shall, at a minimum--
       (A) implement procedures for the certification, 
     recertification, and decertification, consistent with 
     guidelines developed by the Secretary under subsection (c), 
     of health plans as qualified health plans;
       (B) provide for the operation of a toll-free telephone 
     hotline to respond to requests for assistance;
       (C) maintain an Internet website through which enrollees 
     and prospective enrollees of qualified health plans may 
     obtain standardized comparative information on such plans;
       (D) assign a rating to each qualified health plan offered 
     through such Exchange in accordance with the criteria 
     developed by the Secretary under subsection (c)(3);
       (E) utilize a standardized format for presenting health 
     benefits plan options in the Exchange, including the use of 
     the uniform outline of coverage established under section 
     2715 of the Public Health Service Act;
       (F) in accordance with section 1413, inform individuals of 
     eligibility requirements for the medicaid program under title 
     XIX of the Social Security Act, the CHIP program under title 
     XXI of such Act, or any applicable State or local public 
     program and if through screening of the application by the 
     Exchange, the Exchange determines that such individuals are 
     eligible for any such program, enroll such individuals in 
     such program;
       (G) establish and make available by electronic means a 
     calculator to determine the actual cost of coverage after the 
     application of any premium tax credit under section 36B of 
     the Internal Revenue Code of 1986 and any cost-sharing 
     reduction under section 1402;
       (H) subject to section 1411, grant a certification 
     attesting that, for purposes of the individual responsibility 
     penalty under section 5000A of the Internal Revenue Code of 
     1986, an individual is exempt from the individual requirement 
     or from the penalty imposed by such section because--
       (i) there is no affordable qualified health plan available 
     through the Exchange, or the individual's employer, covering 
     the individual; or
       (ii) the individual meets the requirements for any other 
     such exemption from the individual responsibility requirement 
     or penalty;
       (I) transfer to the Secretary of the Treasury--
       (i) a list of the individuals who are issued a 
     certification under subparagraph (H), including the name and 
     taxpayer identification number of each individual;
       (ii) the name and taxpayer identification number of each 
     individual who was an employee of an employer but who was 
     determined to be eligible for the premium tax credit under 
     section 36B of the Internal Revenue Code of 1986 because--

       (I) the employer did not provide minimum essential 
     coverage; or
       (II) the employer provided such minimum essential coverage 
     but it was determined under

[[Page H1937]]

     section 36B(c)(2)(C) of such Code to either be unaffordable 
     to the employee or not provide the required minimum actuarial 
     value; and

       (iii) the name and taxpayer identification number of each 
     individual who notifies the Exchange under section 1411(b)(4) 
     that they have changed employers and of each individual who 
     ceases coverage under a qualified health plan during a plan 
     year (and the effective date of such cessation);
       (J) provide to each employer the name of each employee of 
     the employer described in subparagraph (I)(ii) who ceases 
     coverage under a qualified health plan during a plan year 
     (and the effective date of such cessation); and
       (K) establish the Navigator program described in subsection 
     (i).
       (5) Funding limitations.--
       (A) No federal funds for continued operations.--In 
     establishing an Exchange under this section, the State shall 
     ensure that such Exchange is self-sustaining beginning on 
     January 1, 2015, including allowing the Exchange to charge 
     assessments or user fees to participating health insurance 
     issuers, or to otherwise generate funding, to support its 
     operations.
       (B) Prohibiting wasteful use of funds.--In carrying out 
     activities under this subsection, an Exchange shall not 
     utilize any funds intended for the administrative and 
     operational expenses of the Exchange for staff retreats, 
     promotional giveaways, excessive executive compensation, or 
     promotion of Federal or State legislative and regulatory 
     modifications.
       (6) Consultation.--An Exchange shall consult with 
     stakeholders relevant to carrying out the activities under 
     this section, including--
       (A) health care consumers who are enrollees in qualified 
     health plans;
       (B) individuals and entities with experience in 
     facilitating enrollment in qualified health plans;
       (C) representatives of small businesses and self-employed 
     individuals;
       (D) State Medicaid offices; and
       (E) advocates for enrolling hard to reach populations.
       (7) Publication of costs.--An Exchange shall publish the 
     average costs of licensing, regulatory fees, and any other 
     payments required by the Exchange, and the administrative 
     costs of such Exchange, on an Internet website to educate 
     consumers on such costs. Such information shall also include 
     monies lost to waste, fraud, and abuse.
       (e) Certification.--
       (1) In general.--An Exchange may certify a health plan as a 
     qualified health plan if--
       (A) such health plan meets the requirements for 
     certification as promulgated by the Secretary under 
     subsection (c)(1); and
       (B) the Exchange determines that making available such 
     health plan through such Exchange is in the interests of 
     qualified individuals and qualified employers in the State or 
     States in which such Exchange operates, except that the 
     Exchange may not exclude a health plan--
       (i) on the basis that such plan is a fee-for-service plan;
       (ii) through the imposition of premium price controls; or
       (iii) on the basis that the plan provides treatments 
     necessary to prevent patients' deaths in circumstances the 
     Exchange determines are inappropriate or too costly.
       (2) Premium considerations.--The Exchange shall require 
     health plans seeking certification as qualified health plans 
     to submit a justification for any premium increase prior to 
     implementation of the increase. Such plans shall prominently 
     post such information on their websites. The Exchange may 
     take this information, and the information and the 
     recommendations provided to the Exchange by the State under 
     section 2794(b)(1) of the Public Health Service Act (relating 
     to patterns or practices of excessive or unjustified premium 
     increases), into consideration when determining whether to 
     make such health plan available through the Exchange. The 
     Exchange shall take into account any excess of premium growth 
     outside the Exchange as compared to the rate of such growth 
     inside the Exchange, including information reported by the 
     States.
       (f) Flexibility.--
       (1) Regional or other interstate exchanges.--An Exchange 
     may operate in more than one State if--
       (A) each State in which such Exchange operates permits such 
     operation; and
       (B) the Secretary approves such regional or interstate 
     Exchange.
       (2) Subsidiary exchanges.--A State may establish one or 
     more subsidiary Exchanges if--
       (A) each such Exchange serves a geographically distinct 
     area; and
       (B) the area served by each such Exchange is at least as 
     large as a rating area described in section 2701(a) of the 
     Public Health Service Act.
       (3) Authority to contract.--
       (A) In general.--A State may elect to authorize an Exchange 
     established by the State under this section to enter into an 
     agreement with an eligible entity to carry out 1 or more 
     responsibilities of the Exchange.
       (B) Eligible entity.--In this paragraph, the term 
     ``eligible entity'' means--
       (i) a person--

       (I) incorporated under, and subject to the laws of, 1 or 
     more States;
       (II) that has demonstrated experience on a State or 
     regional basis in the individual and small group health 
     insurance markets and in benefits coverage; and
       (III) that is not a health insurance issuer or that is 
     treated under subsection (a) or (b) of section 52 of the 
     Internal Revenue Code of 1986 as a member of the same 
     controlled group of corporations (or under common control 
     with) as a health insurance issuer; or

       (ii) the State medicaid agency under title XIX of the 
     Social Security Act.
       (g) Rewarding Quality Through Market-Based Incentives.--
       (1) Strategy described.--A strategy described in this 
     paragraph is a payment structure that provides increased 
     reimbursement or other incentives for--
       (A) improving health outcomes through the implementation of 
     activities that shall include quality reporting, effective 
     case management, care coordination, chronic disease 
     management, medication and care compliance initiatives, 
     including through the use of the medical home model, for 
     treatment or services under the plan or coverage;
       (B) the implementation of activities to prevent hospital 
     readmissions through a comprehensive program for hospital 
     discharge that includes patient-centered education and 
     counseling, comprehensive discharge planning, and post 
     discharge reinforcement by an appropriate health care 
     professional;
       (C) the implementation of activities to improve patient 
     safety and reduce medical errors through the appropriate use 
     of best clinical practices, evidence based medicine, and 
     health information technology under the plan or coverage; and
       (D) the implementation of wellness and health promotion 
     activities.
       (2) Guidelines.--The Secretary, in consultation with 
     experts in health care quality and stakeholders, shall 
     develop guidelines concerning the matters described in 
     paragraph (1).
       (3) Requirements.--The guidelines developed under paragraph 
     (2) shall require the periodic reporting to the applicable 
     Exchange of the activities that a qualified health plan has 
     conducted to implement a strategy described in paragraph (1).
       (h) Quality Improvement.--
       (1) Enhancing patient safety.--Beginning on January 1, 
     2015, a qualified health plan may contract with--
       (A) a hospital with greater than 50 beds only if such 
     hospital--
       (i) utilizes a patient safety evaluation system as 
     described in part C of title IX of the Public Health Service 
     Act; and
       (ii) implements a mechanism to ensure that each patient 
     receives a comprehensive program for hospital discharge that 
     includes patient-centered education and counseling, 
     comprehensive discharge planning, and post discharge 
     reinforcement by an appropriate health care professional; or
       (B) a health care provider only if such provider implements 
     such mechanisms to improve health care quality as the 
     Secretary may by regulation require.
       (2) Exceptions.--The Secretary may establish reasonable 
     exceptions to the requirements described in paragraph (1).
       (3) Adjustment.--The Secretary may by regulation adjust the 
     number of beds described in paragraph (1)(A).
       (i) Navigators.--
       (1) In general.--An Exchange shall establish a program 
     under which it awards grants to entities described in 
     paragraph (2) to carry out the duties described in paragraph 
     (3).
       (2) Eligibility.--
       (A) In general.--To be eligible to receive a grant under 
     paragraph (1), an entity shall demonstrate to the Exchange 
     involved that the entity has existing relationships, or could 
     readily establish relationships, with employers and 
     employees, consumers (including uninsured and underinsured 
     consumers), or self-employed individuals likely to be 
     qualified to enroll in a qualified health plan.
       (B) Types.--Entities described in subparagraph (A) may 
     include trade, industry, and professional associations, 
     commercial fishing industry organizations, ranching and 
     farming organizations, community and consumer-focused 
     nonprofit groups, chambers of commerce, unions, small 
     business development centers, other licensed insurance agents 
     and brokers, and other entities that--
       (i) are capable of carrying out the duties described in 
     paragraph (3);
       (ii) meet the standards described in paragraph (4); and
       (iii) provide information consistent with the standards 
     developed under paragraph (5).
       (3) Duties.--An entity that serves as a navigator under a 
     grant under this subsection shall--
       (A) conduct public education activities to raise awareness 
     of the availability of qualified health plans;
       (B) distribute fair and impartial information concerning 
     enrollment in qualified health plans, and the availability of 
     premium tax credits under section 36B of the Internal Revenue 
     Code of 1986 and cost-sharing reductions under section 1402;
       (C) facilitate enrollment in qualified health plans;
       (D) provide referrals to any applicable office of health 
     insurance consumer assistance or health insurance ombudsman 
     established under section 2793 of the Public Health Service 
     Act, or any other appropriate State agency or agencies, for 
     any enrollee with a grievance, complaint, or question 
     regarding their health plan, coverage, or a determination 
     under such plan or coverage; and
       (E) provide information in a manner that is culturally and 
     linguistically appropriate to the needs of the population 
     being served by the Exchange or Exchanges.
       (4) Standards.--
       (A) In general.--The Secretary shall establish standards 
     for navigators under this subsection, including provisions to 
     ensure that any private or public entity that is selected as 
     a navigator is qualified, and licensed if appropriate, to 
     engage in the navigator activities described in this 
     subsection and to avoid conflicts of interest. Under such 
     standards, a navigator shall not--
       (i) be a health insurance issuer; or

[[Page H1938]]

       (ii) receive any consideration directly or indirectly from 
     any health insurance issuer in connection with the enrollment 
     of any qualified individuals or employees of a qualified 
     employer in a qualified health plan.
       (5) Fair and impartial information and services.--The 
     Secretary, in collaboration with States, shall develop 
     standards to ensure that information made available by 
     navigators is fair, accurate, and impartial.
       (6) Funding.--Grants under this subsection shall be made 
     from the operational funds of the Exchange and not Federal 
     funds received by the State to establish the Exchange.
       (j) Applicability of Mental Health Parity.--Section 2726 of 
     the Public Health Service Act shall apply to qualified health 
     plans in the same manner and to the same extent as such 
     section applies to health insurance issuers and group health 
     plans.
       (k) Conflict.--An Exchange may not establish rules that 
     conflict with or prevent the application of regulations 
     promulgated by the Secretary under this subtitle.

     SEC. 1312. CONSUMER CHOICE.

       (a) Choice.--
       (1) Qualified individuals.--A qualified individual may 
     enroll in any qualified health plan available to such 
     individual.
       (2) Qualified employers.--
       (A) Employer may specify level.--A qualified employer may 
     provide support for coverage of employees under a qualified 
     health plan by selecting any level of coverage under section 
     1302(d) to be made available to employees through an 
     Exchange.
       (B) Employee may choose plans within a level.--Each 
     employee of a qualified employer that elects a level of 
     coverage under subparagraph (A) may choose to enroll in a 
     qualified health plan that offers coverage at that level.
       (b) Payment of Premiums by Qualified Individuals.--A 
     qualified individual enrolled in any qualified health plan 
     may pay any applicable premium owed by such individual to the 
     health insurance issuer issuing such qualified health plan.
       (c) Single Risk Pool.--
       (1) Individual market.--A health insurance issuer shall 
     consider all enrollees in all health plans (other than 
     grandfathered health plans) offered by such issuer in the 
     individual market, including those enrollees who do not 
     enroll in such plans through the Exchange, to be members of a 
     single risk pool.
       (2) Small group market.--A health insurance issuer shall 
     consider all enrollees in all health plans (other than 
     grandfathered health plans) offered by such issuer in the 
     small group market, including those enrollees who do not 
     enroll in such plans through the Exchange, to be members of a 
     single risk pool.
       (3) Merger of markets.--A State may require the individual 
     and small group insurance markets within a State to be merged 
     if the State determines appropriate.
       (4) State law.--A State law requiring grandfathered health 
     plans to be included in a pool described in paragraph (1) or 
     (2) shall not apply.
       (d) Empowering Consumer Choice.--
       (1) Continued operation of market outside exchanges.--
     Nothing in this title shall be construed to prohibit--
       (A) a health insurance issuer from offering outside of an 
     Exchange a health plan to a qualified individual or qualified 
     employer; and
       (B) a qualified individual from enrolling in, or a 
     qualified employer from selecting for its employees, a health 
     plan offered outside of an Exchange.
       (2) Continued operation of state benefit requirements.--
     Nothing in this title shall be construed to terminate, 
     abridge, or limit the operation of any requirement under 
     State law with respect to any policy or plan that is offered 
     outside of an Exchange to offer benefits.
       (3) Voluntary nature of an exchange.--
       (A) Choice to enroll or not to enroll.--Nothing in this 
     title shall be construed to restrict the choice of a 
     qualified individual to enroll or not to enroll in a 
     qualified health plan or to participate in an Exchange.
       (B) Prohibition against compelled enrollment.--Nothing in 
     this title shall be construed to compel an individual to 
     enroll in a qualified health plan or to participate in an 
     Exchange.
       (C) Individuals allowed to enroll in any plan.--A qualified 
     individual may enroll in any qualified health plan, except 
     that in the case of a catastrophic plan described in section 
     1302(e), a qualified individual may enroll in the plan only 
     if the individual is eligible to enroll in the plan under 
     section 1302(e)(2).
       (D) Members of congress in the exchange.--
       (i) Requirement.--Notwithstanding any other provision of 
     law, after the effective date of this subtitle, the only 
     health plans that the Federal Government may make available 
     to Members of Congress and congressional staff with respect 
     to their service as a Member of Congress or congressional 
     staff shall be health plans that are--

       (I) created under this Act (or an amendment made by this 
     Act); or
       (II) offered through an Exchange established under this Act 
     (or an amendment made by this Act).

       (ii) Definitions.--In this section:

       (I) Member of congress.--The term ``Member of Congress'' 
     means any member of the House of Representatives or the 
     Senate.
       (II) Congressional staff.--The term ``congressional staff'' 
     means all full-time and part-time employees employed by the 
     official office of a Member of Congress, whether in 
     Washington, DC or outside of Washington, DC.

       (4) No penalty for transferring to minimum essential 
     coverage outside exchange.--An Exchange, or a qualified 
     health plan offered through an Exchange, shall not impose any 
     penalty or other fee on an individual who cancels enrollment 
     in a plan because the individual becomes eligible for minimum 
     essential coverage (as defined in section 5000A(f) of the 
     Internal Revenue Code of 1986 without regard to paragraph 
     (1)(C) or (D) thereof) or such coverage becomes affordable 
     (within the meaning of section 36B(c)(2)(C) of such Code).
       (e) Enrollment Through Agents or Brokers.--The Secretary 
     shall establish procedures under which a State may allow 
     agents or brokers--
       (1) to enroll individuals in any qualified health plans in 
     the individual or small group market as soon as the plan is 
     offered through an Exchange in the State; and
       (2) to assist individuals in applying for premium tax 
     credits and cost-sharing reductions for plans sold through an 
     Exchange.

     Such procedures may include the establishment of rate 
     schedules for broker commissions paid by health benefits 
     plans offered through an exchange.
       (f) Qualified Individuals and Employers; Access Limited to 
     Citizens and Lawful Residents.--
       (1) Qualified individuals.--In this title:
       (A) In general.--The term ``qualified individual'' means, 
     with respect to an Exchange, an individual who--
       (i) is seeking to enroll in a qualified health plan in the 
     individual market offered through the Exchange; and
       (ii) resides in the State that established the Exchange 
     (except with respect to territorial agreements under section 
     1312(f)).
       (B) Incarcerated individuals excluded.--An individual shall 
     not be treated as a qualified individual if, at the time of 
     enrollment, the individual is incarcerated, other than 
     incarceration pending the disposition of charges.
       (2) Qualified employer.--In this title:
       (A) In general.--The term ``qualified employer'' means a 
     small employer that elects to make all full-time employees of 
     such employer eligible for 1 or more qualified health plans 
     offered in the small group market through an Exchange that 
     offers qualified health plans.
       (B) Extension to large groups.--
       (i) In general.--Beginning in 2017, each State may allow 
     issuers of health insurance coverage in the large group 
     market in the State to offer qualified health plans in such 
     market through an Exchange. Nothing in this subparagraph 
     shall be construed as requiring the issuer to offer such 
     plans through an Exchange.
       (ii) Large employers eligible.--If a State under clause (i) 
     allows issuers to offer qualified health plans in the large 
     group market through an Exchange, the term ``qualified 
     employer'' shall include a large employer that elects to make 
     all full-time employees of such employer eligible for 1 or 
     more qualified health plans offered in the large group market 
     through the Exchange.
       (3) Access limited to lawful residents.--If an individual 
     is not, or is not reasonably expected to be for the entire 
     period for which enrollment is sought, a citizen or national 
     of the United States or an alien lawfully present in the 
     United States, the individual shall not be treated as a 
     qualified individual and may not be covered under a qualified 
     health plan in the individual market that is offered through 
     an Exchange.

     SEC. 1313. FINANCIAL INTEGRITY.

       (a) Accounting for Expenditures.--
       (1) In general.--An Exchange shall keep an accurate 
     accounting of all activities, receipts, and expenditures and 
     shall annually submit to the Secretary a report concerning 
     such accountings.
       (2) Investigations.--The Secretary, in coordination with 
     the Inspector General of the Department of Health and Human 
     Services, may investigate the affairs of an Exchange, may 
     examine the properties and records of an Exchange, and may 
     require periodic reports in relation to activities undertaken 
     by an Exchange. An Exchange shall fully cooperate in any 
     investigation conducted under this paragraph.
       (3) Audits.--An Exchange shall be subject to annual audits 
     by the Secretary.
       (4) Pattern of abuse.--If the Secretary determines that an 
     Exchange or a State has engaged in serious misconduct with 
     respect to compliance with the requirements of, or carrying 
     out of activities required under, this title, the Secretary 
     may rescind from payments otherwise due to such State 
     involved under this or any other Act administered by the 
     Secretary an amount not to exceed 1 percent of such payments 
     per year until corrective actions are taken by the State that 
     are determined to be adequate by the Secretary.
       (5) Protections against fraud and abuse.--With respect to 
     activities carried out under this title, the Secretary shall 
     provide for the efficient and non-discriminatory 
     administration of Exchange activities and implement any 
     measure or procedure that--
       (A) the Secretary determines is appropriate to reduce fraud 
     and abuse in the administration of this title; and
       (B) the Secretary has authority to implement under this 
     title or any other Act.
       (6) Application of the false claims act.--
       (A) In general.--Payments made by, through, or in 
     connection with an Exchange are subject to the False Claims 
     Act (31 U.S.C. 3729 et seq.) if those payments include any 
     Federal funds. Compliance with the requirements of this Act 
     concerning eligibility for a health insurance issuer to 
     participate in the Exchange shall be a material condition of 
     an issuer's entitlement to receive payments, including 
     payments of premium tax credits and cost-sharing reductions, 
     through the Exchange.
       (B) Damages.--Notwithstanding paragraph (1) of section 
     3729(a) of title 31, United States

[[Page H1939]]

     Code, and subject to paragraph (2) of such section, the civil 
     penalty assessed under the False Claims Act on any person 
     found liable under such Act as described in subparagraph (A) 
     shall be increased by not less than 3 times and not more than 
     6 times the amount of damages which the Government sustains 
     because of the act of that person.
       (b) GAO Oversight.--Not later than 5 years after the first 
     date on which Exchanges are required to be operational under 
     this title, the Comptroller General shall conduct an ongoing 
     study of Exchange activities and the enrollees in qualified 
     health plans offered through Exchanges. Such study shall 
     review--
       (1) the operations and administration of Exchanges, 
     including surveys and reports of qualified health plans 
     offered through Exchanges and on the experience of such plans 
     (including data on enrollees in Exchanges and individuals 
     purchasing health insurance coverage outside of Exchanges), 
     the expenses of Exchanges, claims statistics relating to 
     qualified health plans, complaints data relating to such 
     plans, and the manner in which Exchanges meet their goals;
       (2) any significant observations regarding the utilization 
     and adoption of Exchanges;
       (3) where appropriate, recommendations for improvements in 
     the operations or policies of Exchanges; and
       (4) how many physicians, by area and specialty, are not 
     taking or accepting new patients enrolled in Federal 
     Government health care programs, and the adequacy of provider 
     networks of Federal Government health care programs.

           PART III--STATE FLEXIBILITY RELATING TO EXCHANGES

     SEC. 1321. STATE FLEXIBILITY IN OPERATION AND ENFORCEMENT OF 
                   EXCHANGES AND RELATED REQUIREMENTS.

       (a) Establishment of Standards.--
       (1) In general.--The Secretary shall, as soon as 
     practicable after the date of enactment of this Act, issue 
     regulations setting standards for meeting the requirements 
     under this title, and the amendments made by this title, with 
     respect to--
       (A) the establishment and operation of Exchanges (including 
     SHOP Exchanges);
       (B) the offering of qualified health plans through such 
     Exchanges;
       (C) the establishment of the reinsurance and risk 
     adjustment programs under part V; and
       (D) such other requirements as the Secretary determines 
     appropriate.

     The preceding sentence shall not apply to standards for 
     requirements under subtitles A and C (and the amendments made 
     by such subtitles) for which the Secretary issues regulations 
     under the Public Health Service Act.
       (2) Consultation.--In issuing the regulations under 
     paragraph (1), the Secretary shall consult with the National 
     Association of Insurance Commissioners and its members and 
     with health insurance issuers, consumer organizations, and 
     such other individuals as the Secretary selects in a manner 
     designed to ensure balanced representation among interested 
     parties.
       (b) State Action.--Each State that elects, at such time and 
     in such manner as the Secretary may prescribe, to apply the 
     requirements described in subsection (a) shall, not later 
     than January 1, 2014, adopt and have in effect--
       (1) the Federal standards established under subsection (a); 
     or
       (2) a State law or regulation that the Secretary determines 
     implements the standards within the State.
       (c) Failure To Establish Exchange or Implement 
     Requirements.--
       (1) In general.--If--
       (A) a State is not an electing State under subsection (b); 
     or
       (B) the Secretary determines, on or before January 1, 2013, 
     that an electing State--
       (i) will not have any required Exchange operational by 
     January 1, 2014; or
       (ii) has not taken the actions the Secretary determines 
     necessary to implement--

       (I) the other requirements set forth in the standards under 
     subsection (a); or
       (II) the requirements set forth in subtitles A and C and 
     the amendments made by such subtitles;

     the Secretary shall (directly or through agreement with a 
     not-for-profit entity) establish and operate such Exchange 
     within the State and the Secretary shall take such actions as 
     are necessary to implement such other requirements.
       (2) Enforcement authority.--The provisions of section 
     2736(b) of the Public Health Services Act shall apply to the 
     enforcement under paragraph (1) of requirements of subsection 
     (a)(1) (without regard to any limitation on the application 
     of those provisions to group health plans).
       (d) No Interference With State Regulatory Authority.--
     Nothing in this title shall be construed to preempt any State 
     law that does not prevent the application of the provisions 
     of this title.
       (e) Presumption for Certain State-Operated Exchanges.--
       (1) In general.--In the case of a State operating an 
     Exchange before January 1, 2010, and which has insured a 
     percentage of its population not less than the percentage of 
     the population projected to be covered nationally after the 
     implementation of this Act, that seeks to operate an Exchange 
     under this section, the Secretary shall presume that such 
     Exchange meets the standards under this section unless the 
     Secretary determines, after completion of the process 
     established under paragraph (2), that the Exchange does not 
     comply with such standards.
       (2) Process.--The Secretary shall establish a process to 
     work with a State described in paragraph (1) to provide 
     assistance necessary to assist the State's Exchange in coming 
     into compliance with the standards for approval under this 
     section.

     SEC. 1322. FEDERAL PROGRAM TO ASSIST ESTABLISHMENT AND 
                   OPERATION OF NONPROFIT, MEMBER-RUN HEALTH 
                   INSURANCE ISSUERS.

       (a) Establishment of Program.--
       (1) In general.--The Secretary shall establish a program to 
     carry out the purposes of this section to be known as the 
     Consumer Operated and Oriented Plan (CO-OP) program.
       (2) Purpose.--It is the purpose of the CO-OP program to 
     foster the creation of qualified nonprofit health insurance 
     issuers to offer qualified health plans in the individual and 
     small group markets in the States in which the issuers are 
     licensed to offer such plans.
       (b) Loans and Grants Under the CO-OP Program.--
       (1) In general.--The Secretary shall provide through the 
     CO-OP program for the awarding to persons applying to become 
     qualified nonprofit health insurance issuers of--
       (A) loans to provide assistance to such person in meeting 
     its start-up costs; and
       (B) grants to provide assistance to such person in meeting 
     any solvency requirements of States in which the person seeks 
     to be licensed to issue qualified health plans.
       (2) Requirements for awarding loans and grants.--
       (A) In general.--In awarding loans and grants under the CO-
     OP program, the Secretary shall--
       (i) take into account the recommendations of the advisory 
     board established under paragraph (3);
       (ii) give priority to applicants that will offer qualified 
     health plans on a Statewide basis, will utilize integrated 
     care models, and have significant private support; and
       (iii) ensure that there is sufficient funding to establish 
     at least 1 qualified nonprofit health insurance issuer in 
     each State, except that nothing in this clause shall prohibit 
     the Secretary from funding the establishment of multiple 
     qualified nonprofit health insurance issuers in any State if 
     the funding is sufficient to do so.
       (B) States without issuers in program.--If no health 
     insurance issuer applies to be a qualified nonprofit health 
     insurance issuer within a State, the Secretary may use 
     amounts appropriated under this section for the awarding of 
     grants to encourage the establishment of a qualified 
     nonprofit health insurance issuer within the State or the 
     expansion of a qualified nonprofit health insurance issuer 
     from another State to the State.
       (C) Agreement.--
       (i) In general.--The Secretary shall require any person 
     receiving a loan or grant under the CO-OP program to enter 
     into an agreement with the Secretary which requires such 
     person to meet (and to continue to meet)--

       (I) any requirement under this section for such person to 
     be treated as a qualified nonprofit health insurance issuer; 
     and
       (II) any requirements contained in the agreement for such 
     person to receive such loan or grant.

       (ii) Restrictions on use of federal funds.--The agreement 
     shall include a requirement that no portion of the funds made 
     available by any loan or grant under this section may be 
     used--

       (I) for carrying on propaganda, or otherwise attempting, to 
     influence legislation; or
       (II) for marketing.

     Nothing in this clause shall be construed to allow a person 
     to take any action prohibited by section 501(c)(29) of the 
     Internal Revenue Code of 1986.
       (iii) Failure to meet requirements.--If the Secretary 
     determines that a person has failed to meet any requirement 
     described in clause (i) or (ii) and has failed to correct 
     such failure within a reasonable period of time of when the 
     person first knows (or reasonably should have known) of such 
     failure, such person shall repay to the Secretary an amount 
     equal to the sum of--

       (I) 110 percent of the aggregate amount of loans and grants 
     received under this section; plus
       (II) interest on the aggregate amount of loans and grants 
     received under this section for the period the loans or 
     grants were outstanding.

     The Secretary shall notify the Secretary of the Treasury of 
     any determination under this section of a failure that 
     results in the termination of an issuer's tax-exempt status 
     under section 501(c)(29) of such Code.
       (D) Time for awarding loans and grants.--The Secretary 
     shall not later than July 1, 2013, award the loans and grants 
     under the CO-OP program and begin the distribution of amounts 
     awarded under such loans and grants.
       (3) Advisory board.--
       (A) In general.--The advisory board under this paragraph 
     shall consist of 15 members appointed by the Comptroller 
     General of the United States from among individuals with 
     qualifications described in section 1805(c)(2) of the Social 
     Security Act.
       (B) Rules relating to appointments.--
       (i) Standards.--Any individual appointed under subparagraph 
     (A) shall meet ethics and conflict of interest standards 
     protecting against insurance industry involvement and 
     interference.
       (ii) Original appointments.--The original appointment of 
     board members under subparagraph (A)(ii) shall be made no 
     later than 3 months after the date of enactment of this Act.
       (C) Vacancy.--Any vacancy on the advisory board shall be 
     filled in the same manner as the original appointment.
       (D) Pay and reimbursement.--
       (i) No compensation for members of advisory board.--Except 
     as provided in clause (ii), a member of the advisory board 
     may not receive pay, allowances, or benefits by reason of 
     their service on the board.
       (ii) Travel expenses.--Each member shall receive travel 
     expenses, including per diem in lieu

[[Page H1940]]

     of subsistence under subchapter I of chapter 57 of title 5, 
     United States Code.
       (E) Application of faca.--The Federal Advisory Committee 
     Act (5 U.S.C. App.) shall apply to the advisory board, except 
     that section 14 of such Act shall not apply.
       (F) Termination.--The advisory board shall terminate on the 
     earlier of the date that it completes its duties under this 
     section or December 31, 2015.
       (c) Qualified Nonprofit Health Insurance Issuer.--For 
     purposes of this section--
       (1) In general.--The term ``qualified nonprofit health 
     insurance issuer'' means a health insurance issuer that is an 
     organization--
       (A) that is organized under State law as a nonprofit, 
     member corporation;
       (B) substantially all of the activities of which consist of 
     the issuance of qualified health plans in the individual and 
     small group markets in each State in which it is licensed to 
     issue such plans; and
       (C) that meets the other requirements of this subsection.
       (2) Certain organizations prohibited.--An organization 
     shall not be treated as a qualified nonprofit health 
     insurance issuer if--
       (A) the organization or a related entity (or any 
     predecessor of either) was a health insurance issuer on July 
     16, 2009; or
       (B) the organization is sponsored by a State or local 
     government, any political subdivision thereof, or any 
     instrumentality of such government or political subdivision.
       (3) Governance requirements.--An organization shall not be 
     treated as a qualified nonprofit health insurance issuer 
     unless--
       (A) the governance of the organization is subject to a 
     majority vote of its members;
       (B) its governing documents incorporate ethics and conflict 
     of interest standards protecting against insurance industry 
     involvement and interference; and
       (C) as provided in regulations promulgated by the 
     Secretary, the organization is required to operate with a 
     strong consumer focus, including timeliness, responsiveness, 
     and accountability to members.
       (4) Profits inure to benefit of members.--An organization 
     shall not be treated as a qualified nonprofit health 
     insurance issuer unless any profits made by the organization 
     are required to be used to lower premiums, to improve 
     benefits, or for other programs intended to improve the 
     quality of health care delivered to its members.
       (5) Compliance with state insurance laws.--An organization 
     shall not be treated as a qualified nonprofit health 
     insurance issuer unless the organization meets all the 
     requirements that other issuers of qualified health plans are 
     required to meet in any State where the issuer offers a 
     qualified health plan, including solvency and licensure 
     requirements, rules on payments to providers, and compliance 
     with network adequacy rules, rate and form filing rules, any 
     applicable State premium assessments and any other State law 
     described in section 1324(b).
       (6) Coordination with state insurance reforms.--An 
     organization shall not be treated as a qualified nonprofit 
     health insurance issuer unless the organization does not 
     offer a health plan in a State until that State has in effect 
     (or the Secretary has implemented for the State) the market 
     reforms required by part A of title XXVII of the Public 
     Health Service Act (as amended by subtitles A and C of this 
     Act).
       (d) Establishment of Private Purchasing Council.--
       (1) In general.--Qualified nonprofit health insurance 
     issuers participating in the CO-OP program under this section 
     may establish a private purchasing council to enter into 
     collective purchasing arrangements for items and services 
     that increase administrative and other cost efficiencies, 
     including claims administration, administrative services, 
     health information technology, and actuarial services.
       (2) Council may not set payment rates.--The private 
     purchasing council established under paragraph (1) shall not 
     set payment rates for health care facilities or providers 
     participating in health insurance coverage provided by 
     qualified nonprofit health insurance issuers.
       (3) Continued application of antitrust laws.--
       (A) In general.--Nothing in this section shall be construed 
     to limit the application of the antitrust laws to any private 
     purchasing council (whether or not established under this 
     subsection) or to any qualified nonprofit health insurance 
     issuer participating in such a council.
       (B) Antitrust laws.--For purposes of this subparagraph, the 
     term ``antitrust laws'' has the meaning given the term in 
     subsection (a) of the first section of the Clayton Act (15 
     U.S.C. 12(a)). Such term also includes section 5 of the 
     Federal Trade Commission Act (15 U.S.C. 45) to the extent 
     that such section 5 applies to unfair methods of competition.
       (e) Limitation on Participation.--No representative of any 
     Federal, State, or local government (or of any political 
     subdivision or instrumentality thereof), and no 
     representative of a person described in subsection (c)(2)(A), 
     may serve on the board of directors of a qualified nonprofit 
     health insurance issuer or with a private purchasing council 
     established under subsection (d).
       (f) Limitations on Secretary.--
       (1) In general.--The Secretary shall not--
       (A) participate in any negotiations between 1 or more 
     qualified nonprofit health insurance issuers (or a private 
     purchasing council established under subsection (d)) and any 
     health care facilities or providers, including any drug 
     manufacturer, pharmacy, or hospital; and
       (B) establish or maintain a price structure for 
     reimbursement of any health benefits covered by such issuers.
       (2) Competition.--Nothing in this section shall be 
     construed as authorizing the Secretary to interfere with the 
     competitive nature of providing health benefits through 
     qualified nonprofit health insurance issuers.
       (g) Appropriations.--There are hereby appropriated, out of 
     any funds in the Treasury not otherwise appropriated, 
     $6,000,000,000 to carry out this section.
       (h) Tax Exemption for Qualified Nonprofit Health Insurance 
     Issuer.--
       (1) In general.--Section 501(c) of the Internal Revenue 
     Code of 1986 (relating to list of exempt organizations) is 
     amended by adding at the end the following:
       ``(29) CO-OP health insurance issuers.--
       ``(A) In general.--A qualified nonprofit health insurance 
     issuer (within the meaning of section 1322 of the Patient 
     Protection and Affordable Care Act) which has received a loan 
     or grant under the CO-OP program under such section, but only 
     with respect to periods for which the issuer is in compliance 
     with the requirements of such section and any agreement with 
     respect to the loan or grant.
       ``(B) Conditions for exemption.--Subparagraph (A) shall 
     apply to an organization only if--
       ``(i) the organization has given notice to the Secretary, 
     in such manner as the Secretary may by regulations prescribe, 
     that it is applying for recognition of its status under this 
     paragraph,
       ``(ii) except as provided in section 1322(c)(4) of the 
     Patient Protection and Affordable Care Act, no part of the 
     net earnings of which inures to the benefit of any private 
     shareholder or individual,
       ``(iii) no substantial part of the activities of which is 
     carrying on propaganda, or otherwise attempting, to influence 
     legislation, and
       ``(iv) the organization does not participate in, or 
     intervene in (including the publishing or distributing of 
     statements), any political campaign on behalf of (or in 
     opposition to) any candidate for public office.''.
       (2) Additional reporting requirement.--Section 6033 of such 
     Code (relating to returns by exempt organizations) is amended 
     by redesignating subsection (m) as subsection (n) and by 
     inserting after subsection (l) the following:
       ``(m) Additional Information Required From CO-OP 
     Insurers.--An organization described in section 501(c)(29) 
     shall include on the return required under subsection (a) the 
     following information:
       ``(1) The amount of the reserves required by each State in 
     which the organization is licensed to issue qualified health 
     plans.
       ``(2) The amount of reserves on hand.''.
       (3) Application of tax on excess benefit transactions.--
     Section 4958(e)(1) of such Code (defining applicable tax-
     exempt organization) is amended by striking ``paragraph (3) 
     or (4)'' and inserting ``paragraph (3), (4), or (29)''.
       (i) GAO Study and Report.--
       (1) Study.--The Comptroller General of the General 
     Accountability Office shall conduct an ongoing study on 
     competition and market concentration in the health insurance 
     market in the United States after the implementation of the 
     reforms in such market under the provisions of, and the 
     amendments made by, this Act. Such study shall include an 
     analysis of new issuers of health insurance in such market.
       (2) Report.--The Comptroller General shall, not later than 
     December 31 of each even-numbered year (beginning with 2014), 
     report to the appropriate committees of the Congress the 
     results of the study conducted under paragraph (1), including 
     any recommendations for administrative or legislative changes 
     the Comptroller General determines necessary or appropriate 
     to increase competition in the health insurance market.

     SEC. 1323. COMMUNITY HEALTH INSURANCE OPTION.

       (a) Voluntary Nature.--
       (1) No requirement for health care providers to 
     participate.--Nothing in this section shall be construed to 
     require a health care provider to participate in a community 
     health insurance option, or to impose any penalty for non-
     participation.
       (2) No requirement for individuals to join.--Nothing in 
     this section shall be construed to require an individual to 
     participate in a community health insurance option, or to 
     impose any penalty for non-participation.
       (3) State opt out.--
       (A) In general.--A State may elect to prohibit Exchanges in 
     such State from offering a community health insurance option 
     if such State enacts a law to provide for such prohibition.
       (B) Termination of opt out.--A State may repeal a law 
     described in subparagraph (A) and provide for the offering of 
     such an option through the Exchange.
       (b) Establishment of Community Health Insurance Option.--
       (1) Establishment.--The Secretary shall establish a 
     community health insurance option to offer, through the 
     Exchanges established under this title (other than Exchanges 
     in States that elect to opt out as provided for in subsection 
     (a)(3)), health care coverage that provides value, choice, 
     competition, and stability of affordable, high quality 
     coverage throughout the United States.
       (2) Community health insurance option.--In this section, 
     the term ``community health insurance option'' means health 
     insurance coverage that--
       (A) except as specifically provided for in this section, 
     complies with the requirements for being a qualified health 
     plan;
       (B) provides high value for the premium charged;
       (C) reduces administrative costs and promotes 
     administrative simplification for beneficiaries;
       (D) promotes high quality clinical care;
       (E) provides high quality customer service to 
     beneficiaries;
       (F) offers a sufficient choice of providers; and
       (G) complies with State laws (if any), except as otherwise 
     provided for in this title, relating to the laws described in 
     section 1324(b).

[[Page H1941]]

       (3) Essential health benefits.--
       (A) General rule.--Except as provided in subparagraph (B), 
     a community health insurance option offered under this 
     section shall provide coverage only for the essential health 
     benefits described in section 1302(b).
       (B) States may offer additional benefits.--Nothing in this 
     section shall preclude a State from requiring that benefits 
     in addition to the essential health benefits required under 
     subparagraph (A) be provided to enrollees of a community 
     health insurance option offered in such State.
       (C) Credits.--
       (i) In general.--An individual enrolled in a community 
     health insurance option under this section shall be eligible 
     for credits under section 36B of the Internal Revenue Code of 
     1986 in the same manner as an individual who is enrolled in a 
     qualified health plan.
       (ii) No additional federal cost.--A requirement by a State 
     under subparagraph (B) that benefits in addition to the 
     essential health benefits required under subparagraph (A) be 
     provided to enrollees of a community health insurance option 
     shall not affect the amount of a premium tax credit provided 
     under section 36B of the Internal Revenue Code of 1986 with 
     respect to such plan.
       (D) State must assume cost.--A State shall make payments to 
     or on behalf of an eligible individual to defray the cost of 
     any additional benefits described in subparagraph (B).
       (E) Ensuring access to all services.--Nothing in this Act 
     shall prohibit an individual enrolled in a community health 
     insurance option from paying out-of-pocket the full cost of 
     any item or service not included as an essential health 
     benefit or otherwise covered as a benefit by a health plan. 
     Nothing in subparagraph (B) shall prohibit any type of 
     medical provider from accepting an out-of-pocket payment from 
     an individual enrolled in a community health insurance option 
     for a service otherwise not included as an essential health 
     benefit.
       (F) Protecting access to end of life care.--A community 
     health insurance option offered under this section shall be 
     prohibited from limiting access to end of life care.
       (4) Cost sharing.--A community health insurance option 
     shall offer coverage at each of the levels of coverage 
     described in section 1302(d).
       (5) Premiums.--
       (A) Premiums sufficient to cover costs.--The Secretary 
     shall establish geographically adjusted premium rates in an 
     amount sufficient to cover expected costs (including claims 
     and administrative costs) using methods in general use by 
     qualified health plans.
       (B) Applicable rules.--The provisions of title XXVII of the 
     Public Health Service Act relating to premiums shall apply to 
     community health insurance options under this section, 
     including modified community rating provisions under section 
     2701 of such Act.
       (C) Collection of data.--The Secretary shall collect data 
     as necessary to set premium rates under subparagraph (A).
       (D) National pooling.--Notwithstanding any other provision 
     of law, the Secretary may treat all enrollees in community 
     health insurance options as members of a single pool.
       (E) Contingency margin.--In establishing premium rates 
     under subparagraph (A), the Secretary shall include an 
     appropriate amount for a contingency margin.
       (6) Reimbursement rates.--
       (A) Negotiated rates.--The Secretary shall negotiate rates 
     for the reimbursement of health care providers for benefits 
     covered under a community health insurance option.
       (B) Limitation.--The rates described in subparagraph (A) 
     shall not be higher, in aggregate, than the average 
     reimbursement rates paid by health insurance issuers offering 
     qualified health plans through the Exchange.
       (C) Innovation.--Subject to the limits contained in 
     subparagraph (A), a State Advisory Council established or 
     designated under subsection (d) may develop or encourage the 
     use of innovative payment policies that promote quality, 
     efficiency and savings to consumers.
       (7) Solvency and consumer protection.--
       (A) Solvency.--The Secretary shall establish a Federal 
     solvency standard to be applied with respect to a community 
     health insurance option. A community health insurance option 
     shall also be subject to the solvency standard of each State 
     in which such community health insurance option is offered.
       (B) Minimum required.--In establishing the standard 
     described under subparagraph (A), the Secretary shall require 
     a reserve fund that shall be equal to at least the dollar 
     value of the incurred but not reported claims of a community 
     health insurance option.
       (C) Consumer protections.--The consumer protection laws of 
     a State shall apply to a community health insurance option.
       (8) Requirements established in partnership with insurance 
     commissioners.--
       (A) In general.--The Secretary, in collaboration with the 
     National Association of Insurance Commissioners (in this 
     paragraph referred to as the ``NAIC''), may promulgate 
     regulations to establish additional requirements for a 
     community health insurance option.
       (B) Applicability.--Any requirement promulgated under 
     subparagraph (A) shall be applicable to such option beginning 
     90 days after the date on which the regulation involved 
     becomes final.
       (c) Start-up Fund.--
       (1) Establishment of fund.--
       (A) In general.--There is established in the Treasury of 
     the United States a trust fund to be known as the ``Health 
     Benefit Plan Start-Up Fund'' (referred to in this section as 
     the ``Start-Up Fund''), that shall consist of such amounts as 
     may be appropriated or credited to the Start-Up Fund as 
     provided for in this subsection to provide loans for the 
     initial operations of a community health insurance option. 
     Such amounts shall remain available until expended.
       (B) Funding.--There is hereby appropriated to the Start-Up 
     Fund, out of any moneys in the Treasury not otherwise 
     appropriated an amount requested by the Secretary of Health 
     and Human Services as necessary to--
       (i) pay the start-up costs associated with the initial 
     operations of a community health insurance option; and
       (ii) pay the costs of making payments on claims submitted 
     during the period that is not more than 90 days from the date 
     on which such option is offered.
       (2) Use of start-up fund.--The Secretary shall use amounts 
     contained in the Start-Up Fund to make payments (subject to 
     the repayment requirements in paragraph (4)) for the purposes 
     described in paragraph (1)(B).
       (3) Pass through of rebates.--The Secretary may establish 
     procedures for reducing the amount of payments to a 
     contracting administrator to take into account any rebates or 
     price concessions.
       (4) Repayment.--
       (A) In general.--A community health insurance option shall 
     be required to repay the Secretary of the Treasury (on such 
     terms as the Secretary may require) for any payments made 
     under paragraph (1)(B) by the date that is not later than 9 
     years after the date on which the payment is made. The 
     Secretary may require the payment of interest with respect to 
     such repayments at rates that do not exceed the market 
     interest rate (as determined by the Secretary).
       (B) Sanctions in case of for-profit conversion.--In any 
     case in which the Secretary enters into a contract with a 
     qualified entity for the offering of a community health 
     insurance option and such entity is determined to be a for-
     profit entity by the Secretary, such entity shall be--
       (i) immediately liable to the Secretary for any payments 
     received by such entity from the Start-Up Fund; and
       (ii) permanently ineligible to offer a qualified health 
     plan.
       (d) State Advisory Council.--
       (1) Establishment.--A State (other than a State that elects 
     to opt out as provided for in subsection (a)(3)) shall 
     establish or designate a public or non-profit private entity 
     to serve as the State Advisory Council to provide 
     recommendations to the Secretary on the operations and 
     policies of a community health insurance option in the State. 
     Such Council shall provide recommendations on at least the 
     following:
       (A) policies and procedures to integrate quality 
     improvement and cost containment mechanisms into the health 
     care delivery system;
       (B) mechanisms to facilitate public awareness of the 
     availability of a community health insurance option; and
       (C) alternative payment structures under a community health 
     insurance option for health care providers that encourage 
     quality improvement and cost control.
       (2) Members.--The members of the State Advisory Council 
     shall be representatives of the public and shall include 
     health care consumers and providers.
       (3) Applicability of recommendations.--The Secretary may 
     apply the recommendations of a State Advisory Council to a 
     community health insurance option in that State, in any other 
     State, or in all States.
       (e) Authority To Contract; Terms of Contract.--
       (1) Authority.--
       (A) In general.--The Secretary may enter into a contract or 
     contracts with one or more qualified entities for the purpose 
     of performing administrative functions (including functions 
     described in subsection (a)(4) of section 1874A of the Social 
     Security Act) with respect to a community health insurance 
     option in the same manner as the Secretary may enter into 
     contracts under subsection (a)(1) of such section. The 
     Secretary shall have the same authority with respect to a 
     community health insurance option under this section as the 
     Secretary has under subsections (a)(1) and (b) of section 
     1874A of the Social Security Act with respect to title XVIII 
     of such Act.
       (B) Requirements apply.--If the Secretary enters into a 
     contract with a qualified entity to offer a community health 
     insurance option, under such contract such entity--
       (i) shall meet the criteria established under paragraph 
     (2); and
       (ii) shall receive an administrative fee under paragraph 
     (7).
       (C) Limitation.--Contracts under this subsection shall not 
     involve the transfer of insurance risk to the contracting 
     administrator.
       (D) Reference.--An entity with which the Secretary has 
     entered into a contract under this paragraph shall be 
     referred to as a ``contracting administrator''.
       (2) Qualified entity.--To be qualified to be selected by 
     the Secretary to offer a community health insurance option, 
     an entity shall--
       (A) meet the criteria established under section 1874A(a)(2) 
     of the Social Security Act;
       (B) be a nonprofit entity for purposes of offering such 
     option;
       (C) meet the solvency standards applicable under subsection 
     (b)(7);
       (D) be eligible to offer health insurance or health 
     benefits coverage;
       (E) meet quality standards specified by the Secretary;
       (F) have in place effective procedures to control fraud, 
     abuse, and waste; and
       (G) meet such other requirements as the Secretary may 
     impose.

     Procedures described under subparagraph (F) shall include the 
     implementation of procedures to use beneficiary identifiers 
     to identify individuals entitled to benefits so that such an 
     individual's social security account number is not used,

[[Page H1942]]

     and shall also include procedures for the use of technology 
     (including front-end, prepayment intelligent data-matching 
     technology similar to that used by hedge funds, investment 
     funds, and banks) to provide real-time data analysis of 
     claims for payment under this title to identify and 
     investigate unusual billing or order practices under this 
     title that could indicate fraud or abuse.
       (3) Term.--A contract provided for under paragraph (1) 
     shall be for a term of at least 5 years but not more than 10 
     years, as determined by the Secretary. At the end of each 
     such term, the Secretary shall conduct a competitive bidding 
     process for the purposes of renewing existing contracts or 
     selecting new qualified entities with which to enter into 
     contracts under such paragraph.
       (4) Limitation.--A contract may not be renewed under this 
     subsection unless the Secretary determines that the 
     contracting administrator has met performance requirements 
     established by the Secretary in the areas described in 
     paragraph (7)(B).
       (5) Audits.--The Inspector General shall conduct periodic 
     audits with respect to contracting administrators under this 
     subsection to ensure that the administrator involved is in 
     compliance with this section.
       (6) Revocation.--A contract awarded under this subsection 
     shall be revoked by the Secretary, upon the recommendation of 
     the Inspector General, only after notice to the contracting 
     administrator involved and an opportunity for a hearing. The 
     Secretary may revoke such contract if the Secretary 
     determines that such administrator has engaged in fraud, 
     deception, waste, abuse of power, negligence, mismanagement 
     of taxpayer dollars, or gross mismanagement. An entity that 
     has had a contract revoked under this paragraph shall not be 
     qualified to enter into a subsequent contract under this 
     subsection.
       (7) Fee for administration.--
       (A) In general.--The Secretary shall pay the contracting 
     administrator a fee for the management, administration, and 
     delivery of the benefits under this section.
       (B) Requirement for high quality administration.--The 
     Secretary may increase the fee described in subparagraph (A) 
     by not more than 10 percent, or reduce the fee described in 
     subparagraph (A) by not more than 50 percent, based on the 
     extent to which the contracting administrator, in the 
     determination of the Secretary, meets performance 
     requirements established by the Secretary, in at least the 
     following areas:
       (i) Maintaining low premium costs and low cost sharing 
     requirements, provided that such requirements are consistent 
     with section 1302.
       (ii) Reducing administrative costs and promoting 
     administrative simplification for beneficiaries.
       (iii) Promoting high quality clinical care.
       (iv) Providing high quality customer service to 
     beneficiaries.
       (C) Non-renewal.--The Secretary may not renew a contract to 
     offer a community health insurance option under this section 
     with any contracting entity that has been assessed more than 
     one reduction under subparagraph (B) during the contract 
     period.
       (8) Limitation.--Notwithstanding the terms of a contract 
     under this subsection, the Secretary shall negotiate the 
     reimbursement rates for purposes of subsection (b)(6).
       (f) Report by HHS and Insolvency Warnings.--
       (1) In general.--On an annual basis, the Secretary shall 
     conduct a study on the solvency of a community health 
     insurance option and submit to Congress a report describing 
     the results of such study.
       (2) Result.--If, in any year, the result of the study under 
     paragraph (1) is that a community health insurance option is 
     insolvent, such result shall be treated as a community health 
     insurance option solvency warning.
       (3) Submission of plan and procedure.--
       (A) In general.--If there is a community health insurance 
     option solvency warning under paragraph (2) made in a year, 
     the President shall submit to Congress, within the 15-day 
     period beginning on the date of the budget submission to 
     Congress under section 1105(a) of title 31, United States 
     Code, for the succeeding year, proposed legislation to 
     respond to such warning.
       (B) Procedure.--In the case of a legislative proposal 
     submitted by the President pursuant to subparagraph (A), such 
     proposal shall be considered by Congress using the same 
     procedures described under sections 803 and 804 of the 
     Medicare Prescription Drug, Improvement, and Modernization 
     Act of 2003 that shall be used for a medicare funding 
     warning.
       (g) Marketing Parity.--In a facility controlled by the 
     Federal Government, or by a State, where marketing or 
     promotional materials related to a community health insurance 
     option are made available to the public, making available 
     marketing or promotional materials relating to private health 
     insurance plans shall not be prohibited. Such materials 
     include informational pamphlets, guidebooks, enrollment 
     forms, or other materials determined reasonable for display.
       (h) Authorization of Appropriations.--There is authorized 
     to be appropriated such sums as may be necessary to carry out 
     this section.

     SEC. 1324. LEVEL PLAYING FIELD.

       (a) In General.--Notwithstanding any other provision of 
     law, any health insurance coverage offered by a private 
     health insurance issuer shall not be subject to any Federal 
     or State law described in subsection (b) if a qualified 
     health plan offered under the Consumer Operated and Oriented 
     Plan program under section 1322, a community health insurance 
     option under section 1323, or a nationwide qualified health 
     plan under section 1333(b), is not subject to such law.
       (b) Laws Described.--The Federal and State laws described 
     in this subsection are those Federal and State laws relating 
     to--
       (1) guaranteed renewal;
       (2) rating;
       (3) preexisting conditions;
       (4) non-discrimination;
       (5) quality improvement and reporting;
       (6) fraud and abuse;
       (7) solvency and financial requirements;
       (8) market conduct;
       (9) prompt payment;
       (10) appeals and grievances;
       (11) privacy and confidentiality;
       (12) licensure; and
       (13) benefit plan material or information.

      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.

       (a) Establishment of Program.--
       (1) In general.--The Secretary shall establish a basic 
     health program meeting the requirements of this section under 
     which a State may enter into contracts to offer 1 or more 
     standard health plans providing at least the essential health 
     benefits described in section 1302(b) to eligible individuals 
     in lieu of offering such individuals coverage through an 
     Exchange.
       (2) Certifications as to benefit coverage and costs.--Such 
     program shall provide that a State may not establish a basic 
     health program under this section unless the State 
     establishes to the satisfaction of the Secretary, and the 
     Secretary certifies, that--
       (A) in the case of an eligible individual enrolled in a 
     standard health plan offered through the program, the State 
     provides--
       (i) that the amount of the monthly premium an eligible 
     individual is required to pay for coverage under the standard 
     health plan for the individual and the individual's 
     dependents does not exceed the amount of the monthly premium 
     that the eligible individual would have been required to pay 
     (in the rating area in which the individual resides) if the 
     individual had enrolled in the applicable second lowest cost 
     silver plan (as defined in section 36B(b)(3)(B) of the 
     Internal Revenue Code of 1986) offered to the individual 
     through an Exchange; and
       (ii) that the cost-sharing an eligible individual is 
     required to pay under the standard health plan does not 
     exceed--

       (I) the cost-sharing required under a platinum plan in the 
     case of an eligible individual with household income not in 
     excess of 150 percent of the poverty line for the size of the 
     family involved; and
       (II) the cost-sharing required under a gold plan in the 
     case of an eligible individual not described in subclause 
     (I); and

       (B) the benefits provided under the standard health plans 
     offered through the program cover at least the essential 
     health benefits described in section 1302(b).

     For purposes of subparagraph (A)(i), the amount of the 
     monthly premium an individual is required to pay under either 
     the standard health plan or the applicable second lowest cost 
     silver plan shall be determined after reduction for any 
     premium tax credits and cost-sharing reductions allowable 
     with respect to either plan.
       (b) Standard Health Plan.--In this section, the term 
     ``standard heath plan'' means a health benefits plan that the 
     State contracts with under this section--
       (1) under which the only individuals eligible to enroll are 
     eligible individuals;
       (2) that provides at least the essential health benefits 
     described in section 1302(b); and
       (3) in the case of a plan that provides health insurance 
     coverage offered by a health insurance issuer, that has a 
     medical loss ratio of at least 85 percent.
       (c) Contracting Process.--
       (1) In general.--A State basic health program shall 
     establish a competitive process for entering into contracts 
     with standard health plans under subsection (a), including 
     negotiation of premiums and cost-sharing and negotiation of 
     benefits in addition to the essential health benefits 
     described in section 1302(b).
       (2) Specific items to be considered.--A State shall, as 
     part of its competitive process under paragraph (1), include 
     at least the following:
       (A) Innovation.--Negotiation with offerors of a standard 
     health plan for the inclusion of innovative features in the 
     plan, including--
       (i) care coordination and care management for enrollees, 
     especially for those with chronic health conditions;
       (ii) incentives for use of preventive services; and
       (iii) the establishment of relationships between providers 
     and patients that maximize patient involvement in health care 
     decision-making, including providing incentives for 
     appropriate utilization under the plan.
       (B) Health and resource differences.--Consideration of, and 
     the making of suitable allowances for, differences in health 
     care needs of enrollees and differences in local availability 
     of, and access to, health care providers. Nothing in this 
     subparagraph shall be construed as allowing discrimination on 
     the basis of pre-existing conditions or other health status-
     related factors.
       (C) Managed care.--Contracting with managed care systems, 
     or with systems that offer as many of the attributes of 
     managed care as are feasible in the local health care market.
       (D) Performance measures.--Establishing specific 
     performance measures and standards for issuers of standard 
     health plans that focus on quality of care and improved 
     health outcomes, requiring such plans to report to the State 
     with respect to the measures and standards, and making the 
     performance and quality information available to enrollees in 
     a useful form.

[[Page H1943]]

       (3) Enhanced availability.--
       (A) Multiple plans.--A State shall, to the maximum extent 
     feasible, seek to make multiple standard health plans 
     available to eligible individuals within a State to ensure 
     individuals have a choice of such plans.
       (B) Regional compacts.--A State may negotiate a regional 
     compact with other States to include coverage of eligible 
     individuals in all such States in agreements with issuers of 
     standard health plans.
       (4) Coordination with other state programs.--A State shall 
     seek to coordinate the administration of, and provision of 
     benefits under, its program under this section with the State 
     medicaid program under title XIX of the Social Security Act, 
     the State child health plan under title XXI of such Act, and 
     other State-administered health programs to maximize the 
     efficiency of such programs and to improve the continuity of 
     care.
       (d) Transfer of Funds to States.--
       (1) In general.--If the Secretary determines that a State 
     electing the application of this section meets the 
     requirements of the program established under subsection (a), 
     the Secretary shall transfer to the State for each fiscal 
     year for which 1 or more standard health plans are operating 
     within the State the amount determined under paragraph (3).
       (2) Use of funds.--A State shall establish a trust for the 
     deposit of the amounts received under paragraph (1) and 
     amounts in the trust fund shall only be used to reduce the 
     premiums and cost-sharing of, or to provide additional 
     benefits for, eligible individuals enrolled in standard 
     health plans within the State. Amounts in the trust fund, and 
     expenditures of such amounts, shall not be included in 
     determining the amount of any non-Federal funds for purposes 
     of meeting any matching or expenditure requirement of any 
     federally-funded program.
       (3) Amount of payment.--
       (A) Secretarial determination.--
       (i) In general.--The amount determined under this paragraph 
     for any fiscal year is the amount the Secretary determines is 
     equal to 85 percent of the premium tax credits under section 
     36B of the Internal Revenue Code of 1986, and the cost-
     sharing reductions under section 1402, that would have been 
     provided for the fiscal year to eligible individuals enrolled 
     in standard health plans in the State if such eligible 
     individuals were allowed to enroll in qualified health plans 
     through an Exchange established under this subtitle.
       (ii) Specific requirements.--The Secretary shall make the 
     determination under clause (i) on a per enrollee basis and 
     shall take into account all relevant factors necessary to 
     determine the value of the premium tax credits and cost-
     sharing reductions that would have been provided to eligible 
     individuals described in clause (i), including the age and 
     income of the enrollee, whether the enrollment is for self-
     only or family coverage, geographic differences in average 
     spending for health care across rating areas, the health 
     status of the enrollee for purposes of determining risk 
     adjustment payments and reinsurance payments that would have 
     been made if the enrollee had enrolled in a qualified health 
     plan through an Exchange, and whether any reconciliation of 
     the credit or cost-sharing reductions would have occurred if 
     the enrollee had been so enrolled. This determination shall 
     take into consideration the experience of other States with 
     respect to participation in an Exchange and such credits and 
     reductions provided to residents of the other States, with a 
     special focus on enrollees with income below 200 percent of 
     poverty.
       (iii) Certification.--The Chief Actuary of the Centers for 
     Medicare & Medicaid Services, in consultation with the Office 
     of Tax Analysis of the Department of the Treasury, shall 
     certify whether the methodology used to make determinations 
     under this subparagraph, and such determinations, meet the 
     requirements of clause (ii). Such certifications shall be 
     based on sufficient data from the State and from comparable 
     States about their experience with programs created by this 
     Act.
       (B) Corrections.--The Secretary shall adjust the payment 
     for any fiscal year to reflect any error in the 
     determinations under subparagraph (A) for any preceding 
     fiscal year.
       (4) Application of special rules.--The provisions of 
     section 1303 shall apply to a State basic health program, and 
     to standard health plans offered through such program, in the 
     same manner as such rules apply to qualified health plans.
       (e) Eligible Individual.--
       (1) In general.--In this section, the term ``eligible 
     individual'' means, with respect to any State, an 
     individual--
       (A) who a resident of the State who is not eligible to 
     enroll in the State's medicaid program under title XIX of the 
     Social Security Act for benefits that at a minimum consist of 
     the essential health benefits described in section 1302(b);
       (B) whose household income exceeds 133 percent but does not 
     exceed 200 percent of the poverty line for the size of the 
     family involved;
       (C) who is not eligible for minimum essential coverage (as 
     defined in section 5000A(f) of the Internal Revenue Code of 
     1986) or is eligible for an employer-sponsored plan that is 
     not affordable coverage (as determined under section 
     5000A(e)(2) of such Code); and
       (D) who has not attained age 65 as of the beginning of the 
     plan year.

     Such term shall not include any individual who is not a 
     qualified individual under section 1312 who is eligible to be 
     covered by a qualified health plan offered through an 
     Exchange.
       (2) Eligible individuals may not use exchange.--An eligible 
     individual shall not be treated as a qualified individual 
     under section 1312 eligible for enrollment in a qualified 
     health plan offered through an Exchange established under 
     section 1311.
       (f) Secretarial Oversight.--The Secretary shall each year 
     conduct a review of each State program to ensure compliance 
     with the requirements of this section, including ensuring 
     that the State program meets--
       (1) eligibility verification requirements for participation 
     in the program;
       (2) the requirements for use of Federal funds received by 
     the program; and
       (3) the quality and performance standards under this 
     section.
       (g) Standard Health Plan Offerors.--A State may provide 
     that persons eligible to offer standard health plans under a 
     basic health program established under this section may 
     include a licensed health maintenance organization, a 
     licensed health insurance insurer, or a network of health 
     care providers established to offer services under the 
     program.
       (h) Definitions.--Any term used in this section which is 
     also used in section 36B of the Internal Revenue Code of 1986 
     shall have the meaning given such term by such section.

     SEC. 1332. WAIVER FOR STATE INNOVATION.

       (a) Application.--
       (1) In general.--A State may apply to the Secretary for the 
     waiver of all or any requirements described in paragraph (2) 
     with respect to health insurance coverage within that State 
     for plan years beginning on or after January 1, 2017. Such 
     application shall--
       (A) be filed at such time and in such manner as the 
     Secretary may require;
       (B) contain such information as the Secretary may require, 
     including--
       (i) a comprehensive description of the State legislation 
     and program to implement a plan meeting the requirements for 
     a waiver under this section; and
       (ii) a 10-year budget plan for such plan that is budget 
     neutral for the Federal Government; and
       (C) provide an assurance that the State has enacted the law 
     described in subsection (b)(2).
       (2) Requirements.--The requirements described in this 
     paragraph with respect to health insurance coverage within 
     the State for plan years beginning on or after January 1, 
     2014, are as follows:
       (A) Part I of subtitle D.
       (B) Part II of subtitle D.
       (C) Section 1402.
       (D) Sections 36B, 4980H, and 5000A of the Internal Revenue 
     Code of 1986.
       (3) Pass through of funding.--With respect to a State 
     waiver under paragraph (1), under which, due to the structure 
     of the State plan, individuals and small employers in the 
     State would not qualify for the premium tax credits, cost-
     sharing reductions, or small business credits under sections 
     36B of the Internal Revenue Code of 1986 or under part I of 
     subtitle E for which they would otherwise be eligible, the 
     Secretary shall provide for an alternative means by which the 
     aggregate amount of such credits or reductions that would 
     have been paid on behalf of participants in the Exchanges 
     established under this title had the State not received such 
     waiver, shall be paid to the State for purposes of 
     implementing the State plan under the waiver. Such amount 
     shall be determined annually by the Secretary, taking into 
     consideration the experience of other States with respect to 
     participation in an Exchange and credits and reductions 
     provided under such provisions to residents of the other 
     States.
       (4) Waiver consideration and transparency.--
       (A) In general.--An application for a waiver under this 
     section shall be considered by the Secretary in accordance 
     with the regulations described in subparagraph (B).
       (B) Regulations.--Not later than 180 days after the date of 
     enactment of this Act, the Secretary shall promulgate 
     regulations relating to waivers under this section that 
     provide--
       (i) a process for public notice and comment at the State 
     level, including public hearings, sufficient to ensure a 
     meaningful level of public input;
       (ii) a process for the submission of an application that 
     ensures the disclosure of--

       (I) the provisions of law that the State involved seeks to 
     waive; and
       (II) the specific plans of the State to ensure that the 
     waiver will be in compliance with subsection (b);

       (iii) a process for providing public notice and comment 
     after the application is received by the Secretary, that is 
     sufficient to ensure a meaningful level of public input and 
     that does not impose requirements that are in addition to, or 
     duplicative of, requirements imposed under the Administrative 
     Procedures Act, or requirements that are unreasonable or 
     unnecessarily burdensome with respect to State compliance;
       (iv) a process for the submission to the Secretary of 
     periodic reports by the State concerning the implementation 
     of the program under the waiver; and
       (v) a process for the periodic evaluation by the Secretary 
     of the program under the waiver.
       (C) Report.--The Secretary shall annually report to 
     Congress concerning actions taken by the Secretary with 
     respect to applications for waivers under this section.
       (5) Coordinated waiver process.--The Secretary shall 
     develop a process for coordinating and consolidating the 
     State waiver processes applicable under the provisions of 
     this section, and the existing waiver processes applicable 
     under titles XVIII, XIX, and XXI of the Social Security Act, 
     and any other Federal law relating to the provision of health 
     care items or services. Such process shall permit a State to 
     submit a single application for a waiver under any or all of 
     such provisions.
       (6) Definition.--In this section, the term ``Secretary'' 
     means--

[[Page H1944]]

       (A) the Secretary of Health and Human Services with respect 
     to waivers relating to the provisions described in 
     subparagraph (A) through (C) of paragraph (2); and
       (B) the Secretary of the Treasury with respect to waivers 
     relating to the provisions described in paragraph (2)(D).
       (b) Granting of Waivers.--
       (1) In general.--The Secretary may grant a request for a 
     waiver under subsection (a)(1) only if the Secretary 
     determines that the State plan--
       (A) will provide coverage that is at least as comprehensive 
     as the coverage defined in section 1302(b) and offered 
     through Exchanges established under this title as certified 
     by Office of the Actuary of the Centers for Medicare & 
     Medicaid Services based on sufficient data from the State and 
     from comparable States about their experience with programs 
     created by this Act and the provisions of this Act that would 
     be waived;
       (B) will provide coverage and cost sharing protections 
     against excessive out-of-pocket spending that are at least as 
     affordable as the provisions of this title would provide;
       (C) will provide coverage to at least a comparable number 
     of its residents as the provisions of this title would 
     provide; and
       (D) will not increase the Federal deficit.
       (2) Requirement to enact a law.--
       (A) In general.--A law described in this paragraph is a 
     State law that provides for State actions under a waiver 
     under this section, including the implementation of the State 
     plan under subsection (a)(1)(B).
       (B) Termination of opt out.--A State may repeal a law 
     described in subparagraph (A) and terminate the authority 
     provided under the waiver with respect to the State.
       (c) Scope of Waiver.--
       (1) In general.--The Secretary shall determine the scope of 
     a waiver of a requirement described in subsection (a)(2) 
     granted to a State under subsection (a)(1).
       (2) Limitation.--The Secretary may not waive under this 
     section any Federal law or requirement that is not within the 
     authority of the Secretary.
       (d) Determinations by Secretary.--
       (1) Time for determination.--The Secretary shall make a 
     determination under subsection (a)(1) not later than 180 days 
     after the receipt of an application from a State under such 
     subsection.
       (2) Effect of determination.--
       (A) Granting of waivers.--If the Secretary determines to 
     grant a waiver under subsection (a)(1), the Secretary shall 
     notify the State involved of such determination and the terms 
     and effectiveness of such waiver.
       (B) Denial of waiver.--If the Secretary determines a waiver 
     should not be granted under subsection (a)(1), the Secretary 
     shall notify the State involved, and the appropriate 
     committees of Congress of such determination and the reasons 
     therefore.
       (e) Term of Waiver.--No waiver under this section may 
     extend over a period of longer than 5 years unless the State 
     requests continuation of such waiver, and such request shall 
     be deemed granted unless the Secretary, within 90 days after 
     the date of its submission to the Secretary, either denies 
     such request in writing or informs the State in writing with 
     respect to any additional information which is needed in 
     order to make a final determination with respect to the 
     request.

     SEC. 1333. PROVISIONS RELATING TO OFFERING OF PLANS IN MORE 
                   THAN ONE STATE.

       (a) Health Care Choice Compacts.--
       (1) In general.--Not later than July 1, 2013, the Secretary 
     shall, in consultation with the National Association of 
     Insurance Commissioners, issue regulations for the creation 
     of health care choice compacts under which 2 or more States 
     may enter into an agreement under which--
       (A) 1 or more qualified health plans could be offered in 
     the individual markets in all such States but, except as 
     provided in subparagraph (B), only be subject to the laws and 
     regulations of the State in which the plan was written or 
     issued;
       (B) the issuer of any qualified health plan to which the 
     compact applies--
       (i) would continue to be subject to market conduct, unfair 
     trade practices, network adequacy, and consumer protection 
     standards (including standards relating to rating), including 
     addressing disputes as to the performance of the contract, of 
     the State in which the purchaser resides;
       (ii) would be required to be licensed in each State in 
     which it offers the plan under the compact or to submit to 
     the jurisdiction of each such State with regard to the 
     standards described in clause (i) (including allowing access 
     to records as if the insurer were licensed in the State); and
       (iii) must clearly notify consumers that the policy may not 
     be subject to all the laws and regulations of the State in 
     which the purchaser resides.
       (2) State authority.--A State may not enter into an 
     agreement under this subsection unless the State enacts a law 
     after the date of the enactment of this title that 
     specifically authorizes the State to enter into such 
     agreements.
       (3) Approval of compacts.--The Secretary may approve 
     interstate health care choice compacts under paragraph (1) 
     only if the Secretary determines that such health care choice 
     compact--
       (A) will provide coverage that is at least as comprehensive 
     as the coverage defined in section 1302(b) and offered 
     through Exchanges established under this title;
       (B) will provide coverage and cost sharing protections 
     against excessive out-of-pocket spending that are at least as 
     affordable as the provisions of this title would provide;
       (C) will provide coverage to at least a comparable number 
     of its residents as the provisions of this title would 
     provide;
       (D) will not increase the Federal deficit; and
       (E) will not weaken enforcement of laws and regulations 
     described in paragraph (1)(B)(i) in any State that is 
     included in such compact.
       (4) Effective date.--A health care choice compact described 
     in paragraph (1) shall not take effect before January 1, 
     2016.
       (b) Authority for Nationwide Plans.--
       (1) In general.--Except as provided in paragraph (2), if an 
     issuer (including a group of health insurance issuers 
     affiliated either by common ownership and control or by the 
     common use of a nationally licensed service mark) of a 
     qualified health plan in the individual or small group market 
     meets the requirements of this subsection (in this subsection 
     a ``nationwide qualified health plan'')--
       (A) the issuer of the plan may offer the nationwide 
     qualified health plan in the individual or small group market 
     in more than 1 State; and
       (B) with respect to State laws mandating benefit coverage 
     by a health plan, only the State laws of the State in which 
     such plan is written or issued shall apply to the nationwide 
     qualified health plan.
       (2) State opt-out.--A State may, by specific reference in a 
     law enacted after the date of enactment of this title, 
     provide that this subsection shall not apply to that State. 
     Such opt-out shall be effective until such time as the State 
     by law revokes it.
       (3) Plan requirements.--An issuer meets the requirements of 
     this subsection with respect to a nationwide qualified health 
     plan if, in the determination of the Secretary--
       (A) the plan offers a benefits package that is uniform in 
     each State in which the plan is offered and meets the 
     requirements set forth in paragraphs (4) through (6);
       (B) the issuer is licensed in each State in which it offers 
     the plan and is subject to all requirements of State law not 
     inconsistent with this section, including but not limited to, 
     the standards and requirements that a State imposes that do 
     not prevent the application of a requirement of part A of 
     title XXVII of the Public Health Service Act or a requirement 
     of this title;
       (C) the issuer meets all requirements of this title with 
     respect to a qualified health plan, including the requirement 
     to offer the silver and gold levels of the plan in each 
     Exchange in the State for the market in which the plan is 
     offered;
       (D) the issuer determines the premiums for the plan in any 
     State on the basis of the rating rules in effect in that 
     State for the rating areas in which it is offered;
       (E) the issuer offers the nationwide qualified health plan 
     in at least 60 percent of the participating States in the 
     first year in which the plan is offered, 65 percent of such 
     States in the second year, 70 percent of such States in the 
     third year, 75 percent of such States in the fourth year, and 
     80 percent of such States in the fifth and subsequent years;
       (F) the issuer shall offer the plan in participating States 
     across the country, in all geographic regions, and in all 
     States that have adopted adjusted community rating before the 
     date of enactment of this Act; and
       (G) the issuer clearly notifies consumers that the policy 
     may not contain some benefits otherwise mandated for plans in 
     the State in which the purchaser resides and provides a 
     detailed statement of the benefits offered and the benefit 
     differences in that State, in accordance with rules 
     promulgated by the Secretary.
       (4) Form review for nationwide plans.--Notwithstanding any 
     contrary provision of State law, at least 3 months before any 
     nationwide qualified health plan is offered, the issuer shall 
     file all nationwide qualified health plan forms with the 
     regulator in each participating State in which the plan will 
     be offered. An issuer may appeal the disapproval of a 
     nationwide qualified health plan form to the Secretary.
       (5) Applicable rules.--The Secretary shall, in consultation 
     with the National Association of Insurance Commissioners, 
     issue rules for the offering of nationwide qualified health 
     plans under this subsection. Nationwide qualified health 
     plans may be offered only after such rules have taken effect.
       (6) Coverage.--The Secretary shall provide that the health 
     benefits coverage provided to an individual through a 
     nationwide qualified health plan under this subsection shall 
     include at least the essential benefits package described in 
     section 1302.
       (7) State law mandating benefit coverage by a health 
     benefits plan.--For the purposes of this subsection, a State 
     law mandating benefit coverage by a health plan is a law that 
     mandates health insurance coverage or the offer of health 
     insurance coverage for specific health services or specific 
     diseases. A law that mandates health insurance coverage or 
     reimbursement for services provided by certain classes of 
     providers of health care services, or a law that mandates 
     that certain classes of individuals must be covered as a 
     group or as dependents, is not a State law mandating benefit 
     coverage by a health benefits plan.

                PART V--REINSURANCE AND RISK ADJUSTMENT

     SEC. 1341. TRANSITIONAL REINSURANCE PROGRAM FOR INDIVIDUAL 
                   AND SMALL GROUP MARKETS IN EACH STATE.

       (a) In General.--Each State shall, not later than January 
     1, 2014--
       (1) include in the Federal standards or State law or 
     regulation the State adopts and has in effect under section 
     1321(b) the provisions described in subsection (b); and
       (2) establish (or enter into a contract with) 1 or more 
     applicable reinsurance entities to carry out the reinsurance 
     program under this section.
       (b) Model Regulation.--
       (1) In general.--In establishing the Federal standards 
     under section 1321(a), the Secretary,

[[Page H1945]]

     in consultation with the National Association of Insurance 
     Commissioners (the ``NAIC''), shall include provisions that 
     enable States to establish and maintain a program under 
     which--
       (A) health insurance issuers, and third party 
     administrators on behalf of group health plans, are required 
     to make payments to an applicable reinsurance entity for any 
     plan year beginning in the 3-year period beginning January 1, 
     2014 (as specified in paragraph (3); and
       (B) the applicable reinsurance entity collects payments 
     under subparagraph (A) and uses amounts so collected to make 
     reinsurance payments to health insurance issuers described in 
     subparagraph (A) that cover high risk individuals in the 
     individual market (excluding grandfathered health plans) for 
     any plan year beginning in such 3-year period.
       (2) High-risk individual; payment amounts.--The Secretary 
     shall include the following in the provisions under paragraph 
     (1):
       (A) Determination of high-risk individuals.--The method by 
     which individuals will be identified as high risk individuals 
     for purposes of the reinsurance program established under 
     this section. Such method shall provide for identification of 
     individuals as high-risk individuals on the basis of--
       (i) a list of at least 50 but not more than 100 medical 
     conditions that are identified as high-risk conditions and 
     that may be based on the identification of diagnostic and 
     procedure codes that are indicative of individuals with pre-
     existing, high-risk conditions; or
       (ii) any other comparable objective method of 
     identification recommended by the American Academy of 
     Actuaries.
       (B) Payment amount.--The formula for determining the amount 
     of payments that will be paid to health insurance issuers 
     described in paragraph (1)(A) that insure high-risk 
     individuals. Such formula shall provide for the equitable 
     allocation of available funds through reconciliation and may 
     be designed--
       (i) to provide a schedule of payments that specifies the 
     amount that will be paid for each of the conditions 
     identified under subparagraph (A); or
       (ii) to use any other comparable method for determining 
     payment amounts that is recommended by the American Academy 
     of Actuaries and that encourages the use of care coordination 
     and care management programs for high risk conditions.
       (3) Determination of required contributions.--
       (A) In general.--The Secretary shall include in the 
     provisions under paragraph (1) the method for determining the 
     amount each health insurance issuer and group health plan 
     described in paragraph (1)(A) contributing to the reinsurance 
     program under this section is required to contribute under 
     such paragraph for each plan year beginning in the 36-month 
     period beginning January 1, 2014. The contribution amount for 
     any plan year may be based on the percentage of revenue of 
     each issuer and the total costs of providing benefits to 
     enrollees in self-insured plans or on a specified amount per 
     enrollee and may be required to be paid in advance or 
     periodically throughout the plan year.
       (B) Specific requirements.--The method under this paragraph 
     shall be designed so that--
       (i) the contribution amount for each issuer proportionally 
     reflects each issuer's fully insured commercial book of 
     business for all major medical products and the total value 
     of all fees charged by the issuer and the costs of coverage 
     administered by the issuer as a third party administrator;
       (ii) the contribution amount can include an additional 
     amount to fund the administrative expenses of the applicable 
     reinsurance entity;
       (iii) the aggregate contribution amounts for all States 
     shall, based on the best estimates of the NAIC and without 
     regard to amounts described in clause (ii), equal 
     $10,000,000,000 for plan years beginning in 2014, 
     $6,000,000,000 for plan years beginning 2015, and 
     $4,000,000,000 for plan years beginning in 2016; and
       (iv) in addition to the aggregate contribution amounts 
     under clause (iii), each issuer's contribution amount for any 
     calendar year under clause (iii) reflects its proportionate 
     share of an additional $2,000,000,000 for 2014, an additional 
     $2,000,000,000 for 2015, and an additional $1,000,000,000 for 
     2016.

     Nothing in this subparagraph shall be construed to preclude a 
     State from collecting additional amounts from issuers on a 
     voluntary basis.
       (4) Expenditure of funds.--The provisions under paragraph 
     (1) shall provide that--
       (A) the contribution amounts collected for any calendar 
     year may be allocated and used in any of the three calendar 
     years for which amounts are collected based on the 
     reinsurance needs of a particular period or to reflect 
     experience in a prior period; and
       (B) amounts remaining unexpended as of December, 2016, may 
     be used to make payments under any reinsurance program of a 
     State in the individual market in effect in the 2-year period 
     beginning on January 1, 2017.

     Notwithstanding the preceding sentence, any contribution 
     amounts described in paragraph (3)(B)(iv) shall be deposited 
     into the general fund of the Treasury of the United States 
     and may not be used for the program established under this 
     section.
       (c) Applicable Reinsurance Entity.--For purposes of this 
     section--
       (1) In general.--The term ``applicable reinsurance entity'' 
     means a not-for-profit organization--
       (A) the purpose of which is to help stabilize premiums for 
     coverage in the individual and small group markets in a State 
     during the first 3 years of operation of an Exchange for such 
     markets within the State when the risk of adverse selection 
     related to new rating rules and market changes is greatest; 
     and
       (B) the duties of which shall be to carry out the 
     reinsurance program under this section by coordinating the 
     funding and operation of the risk-spreading mechanisms 
     designed to implement the reinsurance program.
       (2) State discretion.--A State may have more than 1 
     applicable reinsurance entity to carry out the reinsurance 
     program under this section within the State and 2 or more 
     States may enter into agreements to provide for an applicable 
     reinsurance entity to carry out such program in all such 
     States.
       (3) Entities are tax-exempt.--An applicable reinsurance 
     entity established under this section shall be exempt from 
     taxation under chapter 1 of the Internal Revenue Code of 
     1986. The preceding sentence shall not apply to the tax 
     imposed by section 511 such Code (relating to tax on 
     unrelated business taxable income of an exempt organization).
       (d) Coordination With State High-risk Pools.--The State 
     shall eliminate or modify any State high-risk pool to the 
     extent necessary to carry out the reinsurance program 
     established under this section. The State may coordinate the 
     State high-risk pool with such program to the extent not 
     inconsistent with the provisions of this section.

     SEC. 1342. ESTABLISHMENT OF RISK CORRIDORS FOR PLANS IN 
                   INDIVIDUAL AND SMALL GROUP MARKETS.

       (a) In General.--The Secretary shall establish and 
     administer a program of risk corridors for calendar years 
     2014, 2015, and 2016 under which a qualified health plan 
     offered in the individual or small group market shall 
     participate in a payment adjustment system based on the ratio 
     of the allowable costs of the plan to the plan's aggregate 
     premiums. Such program shall be based on the program for 
     regional participating provider organizations under part D of 
     title XVIII of the Social Security Act.
       (b) Payment Methodology.--
       (1) Payments out.--The Secretary shall provide under the 
     program established under subsection (a) that if--
       (A) a participating plan's allowable costs for any plan 
     year are more than 103 percent but not more than 108 percent 
     of the target amount, the Secretary shall pay to the plan an 
     amount equal to 50 percent of the target amount in excess of 
     103 percent of the target amount; and
       (B) a participating plan's allowable costs for any plan 
     year are more than 108 percent of the target amount, the 
     Secretary shall pay to the plan an amount equal to the sum of 
     2.5 percent of the target amount plus 80 percent of allowable 
     costs in excess of 108 percent of the target amount.
       (2) Payments in.--The Secretary shall provide under the 
     program established under subsection (a) that if--
       (A) a participating plan's allowable costs for any plan 
     year are less than 97 percent but not less than 92 percent of 
     the target amount, the plan shall pay to the Secretary an 
     amount equal to 50 percent of the excess of 97 percent of the 
     target amount over the allowable costs; and
       (B) a participating plan's allowable costs for any plan 
     year are less than 92 percent of the target amount, the plan 
     shall pay to the Secretary an amount equal to the sum of 2.5 
     percent of the target amount plus 80 percent of the excess of 
     92 percent of the target amount over the allowable costs.
       (c) Definitions.--In this section:
       (1) Allowable costs.--
       (A) In general.--The amount of allowable costs of a plan 
     for any year is an amount equal to the total costs (other 
     than administrative costs) of the plan in providing benefits 
     covered by the plan.
       (B) Reduction for risk adjustment and reinsurance 
     payments.--Allowable costs shall reduced by any risk 
     adjustment and reinsurance payments received under section 
     1341 and 1343.
       (2) Target amount.--The target amount of a plan for any 
     year is an amount equal to the total premiums (including any 
     premium subsidies under any governmental program), reduced by 
     the administrative costs of the plan.

     SEC. 1343. RISK ADJUSTMENT.

       (a) In General.--
       (1) Low actuarial risk plans.--Using the criteria and 
     methods developed under subsection (b), each State shall 
     assess a charge on health plans and health insurance issuers 
     (with respect to health insurance coverage) described in 
     subsection (c) if the actuarial risk of the enrollees of such 
     plans or coverage for a year is less than the average 
     actuarial risk of all enrollees in all plans or coverage in 
     such State for such year that are not self-insured group 
     health plans (which are subject to the provisions of the 
     Employee Retirement Income Security Act of 1974).
       (2) High actuarial risk plans.--Using the criteria and 
     methods developed under subsection (b), each State shall 
     provide a payment to health plans and health insurance 
     issuers (with respect to health insurance coverage) described 
     in subsection (c) if the actuarial risk of the enrollees of 
     such plans or coverage for a year is greater than the average 
     actuarial risk of all enrollees in all plans and coverage in 
     such State for such year that are not self-insured group 
     health plans (which are subject to the provisions of the 
     Employee Retirement Income Security Act of 1974).
       (b) Criteria and Methods.--The Secretary, in consultation 
     with States, shall establish criteria and methods to be used 
     in carrying out the risk adjustment activities under this 
     section. The Secretary may utilize criteria and methods 
     similar to the criteria and methods utilized under part C or 
     D of title XVIII of the Social Security Act. Such criteria 
     and methods shall be included in the standards and 
     requirements the Secretary prescribes under section 1321.
       (c) Scope.--A health plan or a health insurance issuer is 
     described in this subsection if such

[[Page H1946]]

     health plan or health insurance issuer provides coverage in 
     the individual or small group market within the State. This 
     subsection shall not apply to a grandfathered health plan or 
     the issuer of a grandfathered health plan with respect to 
     that plan.

       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.

       (a) In General.--Subpart C of part IV of subchapter A of 
     chapter 1 of the Internal Revenue Code of 1986 (relating to 
     refundable credits) is amended by inserting after section 36A 
     the following new section:

     ``SEC. 36B. REFUNDABLE CREDIT FOR COVERAGE UNDER A QUALIFIED 
                   HEALTH PLAN.

       ``(a) In General.--In the case of an applicable taxpayer, 
     there shall be allowed as a credit against the tax imposed by 
     this subtitle for any taxable year an amount equal to the 
     premium assistance credit amount of the taxpayer for the 
     taxable year.
       ``(b) Premium Assistance Credit Amount.--For purposes of 
     this section--
       ``(1) In general.--The term `premium assistance credit 
     amount' means, with respect to any taxable year, the sum of 
     the premium assistance amounts determined under paragraph (2) 
     with respect to all coverage months of the taxpayer occurring 
     during the taxable year.
       ``(2) Premium assistance amount.--The premium assistance 
     amount determined under this subsection with respect to any 
     coverage month is the amount equal to the lesser of--
       ``(A) the monthly premiums for such month for 1 or more 
     qualified health plans offered in the individual market 
     within a State which cover the taxpayer, the taxpayer's 
     spouse, or any dependent (as defined in section 152) of the 
     taxpayer and which were enrolled in through an Exchange 
     established by the State under 1311 of the Patient Protection 
     and Affordable Care Act, or
       ``(B) the excess (if any) of--
       ``(i) the adjusted monthly premium for such month for the 
     applicable second lowest cost silver plan with respect to the 
     taxpayer, over
       ``(ii) an amount equal to 1/12 of the product of the 
     applicable percentage and the taxpayer's household income for 
     the taxable year.
       ``(3) Other terms and rules relating to premium assistance 
     amounts.--For purposes of paragraph (2)--
       ``(A) Applicable percentage.--
       ``(i) In general.--Except as provided in clause (ii), the 
     applicable percentage with respect to any taxpayer for any 
     taxable year is equal to 2.8 percent, increased by the number 
     of percentage points (not greater than 7) which bears the 
     same ratio to 7 percentage points as--

       ``(I) the taxpayer's household income for the taxable year 
     in excess of 100 percent of the poverty line for a family of 
     the size involved, bears to
       ``(II) an amount equal to 200 percent of the poverty line 
     for a family of the size involved.

       ``(ii) Special rule for taxpayers under 133 percent of 
     poverty line.--If a taxpayer's household income for the 
     taxable year is in excess of 100 percent, but not more than 
     133 percent, of the poverty line for a family of the size 
     involved, the taxpayer's applicable percentage shall be 2 
     percent.
       ``(iii) Indexing.--In the case of taxable years beginning 
     in any calendar year after 2014, the Secretary shall adjust 
     the initial and final applicable percentages under clause 
     (i), and the 2 percent under clause (ii), for the calendar 
     year to reflect the excess of the rate of premium growth 
     between the preceding calendar year and 2013 over the rate of 
     income growth for such period.
       ``(B) Applicable second lowest cost silver plan.--The 
     applicable second lowest cost silver plan with respect to any 
     applicable taxpayer is the second lowest cost silver plan of 
     the individual market in the rating area in which the 
     taxpayer resides which--
       ``(i) is offered through the same Exchange through which 
     the qualified health plans taken into account under paragraph 
     (2)(A) were offered, and
       ``(ii) provides--

       ``(I) self-only coverage in the case of an applicable 
     taxpayer--

       ``(aa) whose tax for the taxable year is determined under 
     section 1(c) (relating to unmarried individuals other than 
     surviving spouses and heads of households) and who is not 
     allowed a deduction under section 151 for the taxable year 
     with respect to a dependent, or
       ``(bb) who is not described in item (aa) but who purchases 
     only self-only coverage, and

       ``(II) family coverage in the case of any other applicable 
     taxpayer.

     If a taxpayer files a joint return and no credit is allowed 
     under this section with respect to 1 of the spouses by reason 
     of subsection (e), the taxpayer shall be treated as described 
     in clause (ii)(I) unless a deduction is allowed under section 
     151 for the taxable year with respect to a dependent other 
     than either spouse and subsection (e) does not apply to the 
     dependent.
       ``(C) Adjusted monthly premium.--The adjusted monthly 
     premium for an applicable second lowest cost silver plan is 
     the monthly premium which would have been charged (for the 
     rating area with respect to which the premiums under 
     paragraph (2)(A) were determined) for the plan if each 
     individual covered under a qualified health plan taken into 
     account under paragraph (2)(A) were covered by such silver 
     plan and the premium was adjusted only for the age of each 
     such individual in the manner allowed under section 2701 of 
     the Public Health Service Act. In the case of a State 
     participating in the wellness discount demonstration project 
     under section 2705(d) of the Public Health Service Act, the 
     adjusted monthly premium shall be determined without regard 
     to any premium discount or rebate under such project.
       ``(D) Additional benefits.--If--
       ``(i) a qualified health plan under section 1302(b)(5) of 
     the Patient Protection and Affordable Care Act offers 
     benefits in addition to the essential health benefits 
     required to be provided by the plan, or
       ``(ii) a State requires a qualified health plan under 
     section 1311(d)(3)(B) of such Act to cover benefits in 
     addition to the essential health benefits required to be 
     provided by the plan,

     the portion of the premium for the plan properly allocable 
     (under rules prescribed by the Secretary of Health and Human 
     Services) to such additional benefits shall not be taken into 
     account in determining either the monthly premium or the 
     adjusted monthly premium under paragraph (2).
       ``(E) Special rule for pediatric dental coverage.--For 
     purposes of determining the amount of any monthly premium, if 
     an individual enrolls in both a qualified health plan and a 
     plan described in section 1311(d)(2)(B)(ii)(I) of the Patient 
     Protection and Affordable Care Act for any plan year, the 
     portion of the premium for the plan described in such section 
     that (under regulations prescribed by the Secretary) is 
     properly allocable to pediatric dental benefits which are 
     included in the essential health benefits required to be 
     provided by a qualified health plan under section 
     1302(b)(1)(J) of such Act shall be treated as a premium 
     payable for a qualified health plan.
       ``(c) Definition and Rules Relating to Applicable 
     Taxpayers, Coverage Months, and Qualified Health Plan.--For 
     purposes of this section--
       ``(1) Applicable taxpayer.--
       ``(A) In general.--The term `applicable taxpayer' means, 
     with respect to any taxable year, a taxpayer whose household 
     income for the taxable year exceeds 100 percent but does not 
     exceed 400 percent of an amount equal to the poverty line for 
     a family of the size involved.
       ``(B) Special rule for certain individuals lawfully present 
     in the united states.--If--
       ``(i) a taxpayer has a household income which is not 
     greater than 100 percent of an amount equal to the poverty 
     line for a family of the size involved, and
       ``(ii) the taxpayer is an alien lawfully present in the 
     United States, but is not eligible for the medicaid program 
     under title XIX of the Social Security Act by reason of such 
     alien status,

     the taxpayer shall, for purposes of the credit under this 
     section, be treated as an applicable taxpayer with a 
     household income which is equal to 100 percent of the poverty 
     line for a family of the size involved.
       ``(C) Married couples must file joint return.--If the 
     taxpayer is married (within the meaning of section 7703) at 
     the close of the taxable year, the taxpayer shall be treated 
     as an applicable taxpayer only if the taxpayer and the 
     taxpayer's spouse file a joint return for the taxable year.
       ``(D) Denial of credit to dependents.--No credit shall be 
     allowed under this section to any individual with respect to 
     whom a deduction under section 151 is allowable to another 
     taxpayer for a taxable year beginning in the calendar year in 
     which such individual's taxable year begins.
       ``(2) Coverage month.--For purposes of this subsection--
       ``(A) In general.--The term `coverage month' means, with 
     respect to an applicable taxpayer, any month if--
       ``(i) as of the first day of such month the taxpayer, the 
     taxpayer's spouse, or any dependent of the taxpayer is 
     covered by a qualified health plan described in subsection 
     (b)(2)(A) that was enrolled in through an Exchange 
     established by the State under section 1311 of the Patient 
     Protection and Affordable Care Act, and
       ``(ii) the premium for coverage under such plan for such 
     month is paid by the taxpayer (or through advance payment of 
     the credit under subsection (a) under section 1412 of the 
     Patient Protection and Affordable Care Act).
       ``(B) Exception for minimum essential coverage.--
       ``(i) In general.--The term `coverage month' shall not 
     include any month with respect to an individual if for such 
     month the individual is eligible for minimum essential 
     coverage other than eligibility for coverage described in 
     section 5000A(f)(1)(C) (relating to coverage in the 
     individual market).
       ``(ii) Minimum essential coverage.--The term `minimum 
     essential coverage' has the meaning given such term by 
     section 5000A(f).
       ``(C) Special rule for employer-sponsored minimum essential 
     coverage.--For purposes of subparagraph (B)--
       ``(i) Coverage must be affordable.--Except as provided in 
     clause (iii), an employee shall not be treated as eligible 
     for minimum essential coverage if such coverage--

       ``(I) consists of an eligible employer-sponsored plan (as 
     defined in section 5000A(f)(2)), and
       ``(II) the employee's required contribution (within the 
     meaning of section 5000A(e)(1)(B)) with respect to the plan 
     exceeds 9.8 percent of the applicable taxpayer's household 
     income.

     This clause shall also apply to an individual who is eligible 
     to enroll in the plan by reason of a relationship the 
     individual bears to the employee.
       ``(ii) Coverage must provide minimum value.--Except as 
     provided in clause (iii), an employee shall not be treated as 
     eligible for minimum essential coverage if such coverage 
     consists of an eligible employer-sponsored plan (as

[[Page H1947]]

     defined in section 5000A(f)(2)) and the plan's share of the 
     total allowed costs of benefits provided under the plan is 
     less than 60 percent of such costs.
       ``(iii) Employee or family must not be covered under 
     employer plan.--Clauses (i) and (ii) shall not apply if the 
     employee (or any individual described in the last sentence of 
     clause (i)) is covered under the eligible employer-sponsored 
     plan or the grandfathered health plan.
       ``(iv) Indexing.--In the case of plan years beginning in 
     any calendar year after 2014, the Secretary shall adjust the 
     9.8 percent under clause (i)(II) in the same manner as the 
     percentages are adjusted under subsection (b)(3)(A)(ii).
       ``(3) Definitions and other rules.--
       ``(A) Qualified health plan.--The term `qualified health 
     plan' has the meaning given such term by section 1301(a) of 
     the Patient Protection and Affordable Care Act, except that 
     such term shall not include a qualified health plan which is 
     a catastrophic plan described in section 1302(e) of such Act.
       ``(B) Grandfathered health plan.--The term `grandfathered 
     health plan' has the meaning given such term by section 1251 
     of the Patient Protection and Affordable Care Act.
       ``(d) Terms Relating to Income and Families.--For purposes 
     of this section--
       ``(1) Family size.--The family size involved with respect 
     to any taxpayer shall be equal to the number of individuals 
     for whom the taxpayer is allowed a deduction under section 
     151 (relating to allowance of deduction for personal 
     exemptions) for the taxable year.
       ``(2) Household income.--
       ``(A) Household income.--The term `household income' means, 
     with respect to any taxpayer, an amount equal to the sum of--
       ``(i) the modified gross income of the taxpayer, plus
       ``(ii) the aggregate modified gross incomes of all other 
     individuals who--

       ``(I) were taken into account in determining the taxpayer's 
     family size under paragraph (1), and
       ``(II) were required to file a return of tax imposed by 
     section 1 for the taxable year.

       ``(B) Modified gross income.--The term `modified gross 
     income' means gross income--
       ``(i) decreased by the amount of any deduction allowable 
     under paragraph (1), (3), (4), or (10) of section 62(a),
       ``(ii) increased by the amount of interest received or 
     accrued during the taxable year which is exempt from tax 
     imposed by this chapter, and
       ``(iii) determined without regard to sections 911, 931, and 
     933.
       ``(3) Poverty line.--
       ``(A) In general.--The term `poverty line' has the meaning 
     given that term in section 2110(c)(5) of the Social Security 
     Act (42 U.S.C. 1397jj(c)(5)).
       ``(B) Poverty line used.--In the case of any qualified 
     health plan offered through an Exchange for coverage during a 
     taxable year beginning in a calendar year, the poverty line 
     used shall be the most recently published poverty line as of 
     the 1st day of the regular enrollment period for coverage 
     during such calendar year.
       ``(e) Rules for Individuals Not Lawfully Present.--
       ``(1) In general.--If 1 or more individuals for whom a 
     taxpayer is allowed a deduction under section 151 (relating 
     to allowance of deduction for personal exemptions) for the 
     taxable year (including the taxpayer or his spouse) are 
     individuals who are not lawfully present--
       ``(A) the aggregate amount of premiums otherwise taken into 
     account under clauses (i) and (ii) of subsection (b)(2)(A) 
     shall be reduced by the portion (if any) of such premiums 
     which is attributable to such individuals, and
       ``(B) for purposes of applying this section, the 
     determination as to what percentage a taxpayer's household 
     income bears to the poverty level for a family of the size 
     involved shall be made under one of the following methods:
       ``(i) A method under which--

       ``(I) the taxpayer's family size is determined by not 
     taking such individuals into account, and
       ``(II) the taxpayer's household income is equal to the 
     product of the taxpayer's household income (determined 
     without regard to this subsection) and a fraction--

       ``(aa) the numerator of which is the poverty line for the 
     taxpayer's family size determined after application of 
     subclause (I), and
       ``(bb) the denominator of which is the poverty line for the 
     taxpayer's family size determined without regard to subclause 
     (I).
       ``(ii) A comparable method reaching the same result as the 
     method under clause (i).
       ``(2) Lawfully present.--For purposes of this section, an 
     individual shall be treated as lawfully present only if the 
     individual is, and is reasonably expected to be for the 
     entire period of enrollment for which the credit under this 
     section is being claimed, a citizen or national of the United 
     States or an alien lawfully present in the United States.
       ``(3) Secretarial authority.--The Secretary of Health and 
     Human Services, in consultation with the Secretary, shall 
     prescribe rules setting forth the methods by which 
     calculations of family size and household income are made for 
     purposes of this subsection. Such rules shall be designed to 
     ensure that the least burden is placed on individuals 
     enrolling in qualified health plans through an Exchange and 
     taxpayers eligible for the credit allowable under this 
     section.
       ``(f) Reconciliation of Credit and Advance Credit.--
       ``(1) In general.--The amount of the credit allowed under 
     this section for any taxable year shall be reduced (but not 
     below zero) by the amount of any advance payment of such 
     credit under section 1412 of the Patient Protection and 
     Affordable Care Act.
       ``(2) Excess advance payments.--
       ``(A) In general.--If the advance payments to a taxpayer 
     under section 1412 of the Patient Protection and Affordable 
     Care Act for a taxable year exceed the credit allowed by this 
     section (determined without regard to paragraph (1)), the tax 
     imposed by this chapter for the taxable year shall be 
     increased by the amount of such excess.
       ``(B) Limitation on increase where income less than 400 
     percent of poverty line.--
       ``(i) In general.--In the case of an applicable taxpayer 
     whose household income is less than 400 percent of the 
     poverty line for the size of the family involved for the 
     taxable year, the amount of the increase under subparagraph 
     (A) shall in no event exceed $400 ($250 in the case of a 
     taxpayer whose tax is determined under section 1(c) for the 
     taxable year).
       ``(ii) Indexing of amount.--In the case of any calendar 
     year beginning after 2014, each of the dollar amounts under 
     clause (i) shall be increased by an amount equal to--

       ``(I) such dollar amount, multiplied by
       ``(II) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year, determined by 
     substituting `calendar year 2013' for `calendar year 1992' in 
     subparagraph (B) thereof.

     If the amount of any increase under clause (i) is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.
       ``(g) Regulations.--The Secretary shall prescribe such 
     regulations as may be necessary to carry out the provisions 
     of this section, including regulations which provide for--
       ``(1) the coordination of the credit allowed under this 
     section with the program for advance payment of the credit 
     under section 1412 of the Patient Protection and Affordable 
     Care Act, and
       ``(2) the application of subsection (f) where the filing 
     status of the taxpayer for a taxable year is different from 
     such status used for determining the advance payment of the 
     credit.''.
       (b) Disallowance of Deduction.--Section 280C of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new subsection:
       ``(g) Credit for Health Insurance Premiums.--No deduction 
     shall be allowed for the portion of the premiums paid by the 
     taxpayer for coverage of 1 or more individuals under a 
     qualified health plan which is equal to the amount of the 
     credit determined for the taxable year under section 36B(a) 
     with respect to such premiums.''.
       (c) Study on Affordable Coverage.--
       (1) Study and report.--
       (A) In general.--Not later than 5 years after the date of 
     the enactment of this Act, the Comptroller General shall 
     conduct a study on the affordability of health insurance 
     coverage, including--
       (i) the impact of the tax credit for qualified health 
     insurance coverage of individuals under section 36B of the 
     Internal Revenue Code of 1986 and the tax credit for employee 
     health insurance expenses of small employers under section 
     45R of such Code on maintaining and expanding the health 
     insurance coverage of individuals;
       (ii) the availability of affordable health benefits plans, 
     including a study of whether the percentage of household 
     income used for purposes of section 36B(c)(2)(C) of the 
     Internal Revenue Code of 1986 (as added by this section) is 
     the appropriate level for determining whether employer-
     provided coverage is affordable for an employee and whether 
     such level may be lowered without significantly increasing 
     the costs to the Federal Government and reducing employer-
     provided coverage; and
       (iii) the ability of individuals to maintain essential 
     health benefits coverage (as defined in section 5000A(f) of 
     the Internal Revenue Code of 1986).
       (B) Report.--The Comptroller General shall submit to the 
     appropriate committees of Congress a report on the study 
     conducted under subparagraph (A), together with legislative 
     recommendations relating to the matters studied under such 
     subparagraph.
       (2) Appropriate committees of congress.--In this 
     subsection, the term ``appropriate committees of Congress'' 
     means the Committee on Ways and Means, the Committee on 
     Education and Labor, and the Committee on Energy and Commerce 
     of the House of Representatives and the Committee on Finance 
     and the Committee on Health, Education, Labor and Pensions of 
     the Senate.
       (d) Conforming Amendments.--
       (1) Paragraph (2) of section 1324(b) of title 31, United 
     States Code, is amended by inserting ``36B,'' after ``36A,''.
       (2) The table of sections for subpart C of part IV of 
     subchapter A of chapter 1 of the Internal Revenue Code of 
     1986 is amended by inserting after the item relating to 
     section 36A the following new item:

``Sec. 36B. Refundable credit for coverage under a qualified health 
              plan.''.
       (e) Effective Date.--The amendments made by this section 
     shall apply to taxable years ending after December 31, 2013.

     SEC. 1402. REDUCED COST-SHARING FOR INDIVIDUALS ENROLLING IN 
                   QUALIFIED HEALTH PLANS.

       (a) In General.--In the case of an eligible insured 
     enrolled in a qualified health plan--
       (1) the Secretary shall notify the issuer of the plan of 
     such eligibility; and
       (2) the issuer shall reduce the cost-sharing under the plan 
     at the level and in the manner specified in subsection (c).
       (b) Eligible Insured.--In this section, the term ``eligible 
     insured'' means an individual--
       (1) who enrolls in a qualified health plan in the silver 
     level of coverage in the individual market offered through an 
     Exchange; and
       (2) whose household income exceeds 100 percent but does not 
     exceed 400 percent of the poverty line for a family of the 
     size involved.

[[Page H1948]]

     In the case of an individual described in section 
     36B(c)(1)(B) of the Internal Revenue Code of 1986, the 
     individual shall be treated as having household income equal 
     to 100 percent for purposes of applying this section.
       (c) Determination of Reduction in Cost-sharing.--
       (1) Reduction in out-of-pocket limit.--
       (A) In general.--The reduction in cost-sharing under this 
     subsection shall first be achieved by reducing the applicable 
     out-of pocket limit under section 1302(c)(1) in the case of--
       (i) an eligible insured whose household income is more than 
     100 percent but not more than 200 percent of the poverty line 
     for a family of the size involved, by two-thirds;
       (ii) an eligible insured whose household income is more 
     than 200 percent but not more than 300 percent of the poverty 
     line for a family of the size involved, by one-half; and
       (iii) an eligible insured whose household income is more 
     than 300 percent but not more than 400 percent of the poverty 
     line for a family of the size involved, by one-third.
       (B) Coordination with actuarial value limits.--
       (i) In general.--The Secretary shall ensure the reduction 
     under this paragraph shall not result in an increase in the 
     plan's share of the total allowed costs of benefits provided 
     under the plan above--

       (I) 90 percent in the case of an eligible insured described 
     in paragraph (2)(A);
       (II) 80 percent in the case of an eligible insured 
     described in paragraph (2)(B); and
       (III) 70 percent in the case of an eligible insured 
     described in clause (ii) or (iii) of subparagraph (A).

       (ii) Adjustment.--The Secretary shall adjust the out-of 
     pocket limits under paragraph (1) if necessary to ensure that 
     such limits do not cause the respective actuarial values to 
     exceed the levels specified in clause (i).
       (2) Additional reduction for lower income insureds.--The 
     Secretary shall establish procedures under which the issuer 
     of a qualified health plan to which this section applies 
     shall further reduce cost-sharing under the plan in a manner 
     sufficient to--
       (A) in the case of an eligible insured whose household 
     income is not less than 100 percent but not more than 150 
     percent of the poverty line for a family of the size 
     involved, increase the plan's share of the total allowed 
     costs of benefits provided under the plan to 90 percent of 
     such costs; and
       (B) in the case of an eligible insured whose household 
     income is more than 150 percent but not more than 200 percent 
     of the poverty line for a family of the size involved, 
     increase the plan's share of the total allowed costs of 
     benefits provided under the plan to 80 percent of such costs.
       (3) Methods for reducing cost-sharing.--
       (A) In general.--An issuer of a qualified health plan 
     making reductions under this subsection shall notify the 
     Secretary of such reductions and the Secretary shall make 
     periodic and timely payments to the issuer equal to the value 
     of the reductions.
       (B) Capitated payments.--The Secretary may establish a 
     capitated payment system to carry out the payment of cost-
     sharing reductions under this section. Any such system shall 
     take into account the value of the reductions and make 
     appropriate risk adjustments to such payments.
       (4) Additional benefits.--If a qualified health plan under 
     section 1302(b)(5) offers benefits in addition to the 
     essential health benefits required to be provided by the 
     plan, or a State requires a qualified health plan under 
     section 1311(d)(3)(B) to cover benefits in addition to the 
     essential health benefits required to be provided by the 
     plan, the reductions in cost-sharing under this section shall 
     not apply to such additional benefits.
       (5) Special rule for pediatric dental plans.--If an 
     individual enrolls in both a qualified health plan and a plan 
     described in section 1311(d)(2)(B)(ii)(I) for any plan year, 
     subsection (a) shall not apply to that portion of any 
     reduction in cost-sharing under subsection (c) that (under 
     regulations prescribed by the Secretary) is properly 
     allocable to pediatric dental benefits which are included in 
     the essential health benefits required to be provided by a 
     qualified health plan under section 1302(b)(1)(J).
       (d) Special Rules for Indians.--
       (1) Indians under 300 percent of poverty.--If an individual 
     enrolled in any qualified health plan in the individual 
     market through an Exchange is an Indian (as defined in 
     section 4(d) of the Indian Self-Determination and Education 
     Assistance Act (25 U.S.C. 450b(d))) whose household income is 
     not more than 300 percent of the poverty line for a family of 
     the size involved, then, for purposes of this section--
       (A) such individual shall be treated as an eligible 
     insured; and
       (B) the issuer of the plan shall eliminate any cost-sharing 
     under the plan.
       (2) Items or services furnished through indian health 
     providers.--If an Indian (as so defined) enrolled in a 
     qualified health plan is furnished an item or service 
     directly by the Indian Health Service, an Indian Tribe, 
     Tribal Organization, or Urban Indian Organization or through 
     referral under contract health services--
       (A) no cost-sharing under the plan shall be imposed under 
     the plan for such item or service; and
       (B) the issuer of the plan shall not reduce the payment to 
     any such entity for such item or service by the amount of any 
     cost-sharing that would be due from the Indian but for 
     subparagraph (A).
       (3) Payment.--The Secretary shall pay to the issuer of a 
     qualified health plan the amount necessary to reflect the 
     increase in actuarial value of the plan required by reason of 
     this subsection.
       (e) Rules for Individuals Not Lawfully Present.--
       (1) In general.--If an individual who is an eligible 
     insured is not lawfully present--
       (A) no cost-sharing reduction under this section shall 
     apply with respect to the individual; and
       (B) for purposes of applying this section, the 
     determination as to what percentage a taxpayer's household 
     income bears to the poverty level for a family of the size 
     involved shall be made under one of the following methods:
       (i) A method under which--

       (I) the taxpayer's family size is determined by not taking 
     such individuals into account, and
       (II) the taxpayer's household income is equal to the 
     product of the taxpayer's household income (determined 
     without regard to this subsection) and a fraction--

       (aa) the numerator of which is the poverty line for the 
     taxpayer's family size determined after application of 
     subclause (I), and
       (bb) the denominator of which is the poverty line for the 
     taxpayer's family size determined without regard to subclause 
     (I).
       (ii) A comparable method reaching the same result as the 
     method under clause (i).
       (2) Lawfully present.--For purposes of this section, an 
     individual shall be treated as lawfully present only if the 
     individual is, and is reasonably expected to be for the 
     entire period of enrollment for which the cost-sharing 
     reduction under this section is being claimed, a citizen or 
     national of the United States or an alien lawfully present in 
     the United States.
       (3) Secretarial authority.--The Secretary, in consultation 
     with the Secretary of the Treasury, shall prescribe rules 
     setting forth the methods by which calculations of family 
     size and household income are made for purposes of this 
     subsection. Such rules shall be designed to ensure that the 
     least burden is placed on individuals enrolling in qualified 
     health plans through an Exchange and taxpayers eligible for 
     the credit allowable under this section.
       (f) Definitions and Special Rules.--In this section:
       (1) In general.--Any term used in this section which is 
     also used in section 36B of the Internal Revenue Code of 1986 
     shall have the meaning given such term by such section.
       (2) Limitations on reduction.--No cost-sharing reduction 
     shall be allowed under this section with respect to coverage 
     for any month unless the month is a coverage month with 
     respect to which a credit is allowed to the insured (or an 
     applicable taxpayer on behalf of the insured) under section 
     36B of such Code.
       (3) Data used for eligibility.--Any determination under 
     this section shall be made on the basis of the taxable year 
     for which the advance determination is made under section 
     1412 and not the taxable year for which the credit under 
     section 36B of such Code is allowed.

                 Subpart B--Eligibility Determinations

     SEC. 1411. PROCEDURES FOR DETERMINING ELIGIBILITY FOR 
                   EXCHANGE PARTICIPATION, PREMIUM TAX CREDITS AND 
                   REDUCED COST-SHARING, AND INDIVIDUAL 
                   RESPONSIBILITY EXEMPTIONS.

       (a) Establishment of Program.--The Secretary shall 
     establish a program meeting the requirements of this section 
     for determining--
       (1) whether an individual who is to be covered in the 
     individual market by a qualified health plan offered through 
     an Exchange, or who is claiming a premium tax credit or 
     reduced cost-sharing, meets the requirements of sections 
     1312(f)(3), 1402(e), and 1412(d) of this title and section 
     36B(e) of the Internal Revenue Code of 1986 that the 
     individual be a citizen or national of the United States or 
     an alien lawfully present in the United States;
       (2) in the case of an individual claiming a premium tax 
     credit or reduced cost-sharing under section 36B of such Code 
     or section 1402--
       (A) whether the individual meets the income and coverage 
     requirements of such sections; and
       (B) the amount of the tax credit or reduced cost-sharing;
       (3) whether an individual's coverage under an employer-
     sponsored health benefits plan is treated as unaffordable 
     under sections 36B(c)(2)(C) and 5000A(e)(2); and
       (4) whether to grant a certification under section 
     1311(d)(4)(H) attesting that, for purposes of the individual 
     responsibility requirement under section 5000A of the 
     Internal Revenue Code of 1986, an individual is entitled to 
     an exemption from either the individual responsibility 
     requirement or the penalty imposed by such section.
       (b) Information Required To Be Provided by Applicants.--
       (1) In general.--An applicant for enrollment in a qualified 
     health plan offered through an Exchange in the individual 
     market shall provide--
       (A) the name, address, and date of birth of each individual 
     who is to be covered by the plan (in this subsection referred 
     to as an ``enrollee''); and
       (B) the information required by any of the following 
     paragraphs that is applicable to an enrollee.
       (2) Citizenship or immigration status.--The following 
     information shall be provided with respect to every enrollee:
       (A) In the case of an enrollee whose eligibility is based 
     on an attestation of citizenship of the enrollee, the 
     enrollee's social security number.
       (B) In the case of an individual whose eligibility is based 
     on an attestation of the enrollee's immigration status, the 
     enrollee's social security number (if applicable) and such 
     identifying information with respect to the enrollee's 
     immigration status as the Secretary, after consultation with 
     the Secretary of Homeland Security, determines appropriate.
       (3) Eligibility and amount of tax credit or reduced cost-
     sharing.--In the case of an enrollee with respect to whom a 
     premium tax credit or reduced cost-sharing under section 36B

[[Page H1949]]

     of such Code or section 1402 is being claimed, the following 
     information:
       (A) Information regarding income and family size.--The 
     information described in section 6103(l)(21) for the taxable 
     year ending with or within the second calendar year preceding 
     the calendar year in which the plan year begins.
       (B) Changes in circumstances.--The information described in 
     section 1412(b)(2), including information with respect to 
     individuals who were not required to file an income tax 
     return for the taxable year described in subparagraph (A) or 
     individuals who experienced changes in marital status or 
     family size or significant reductions in income.
       (4) Employer-sponsored coverage.--In the case of an 
     enrollee with respect to whom eligibility for a premium tax 
     credit under section 36B of such Code or cost-sharing 
     reduction under section 1402 is being established on the 
     basis that the enrollee's (or related individual's) employer 
     is not treated under section 36B(c)(2)(C) of such Code as 
     providing minimum essential coverage or affordable minimum 
     essential coverage, the following information:
       (A) The name, address, and employer identification number 
     (if available) of the employer.
       (B) Whether the enrollee or individual is a full-time 
     employee and whether the employer provides such minimum 
     essential coverage.
       (C) If the employer provides such minimum essential 
     coverage, the lowest cost option for the enrollee's or 
     individual's enrollment status and the enrollee's or 
     individual's required contribution (within the meaning of 
     section 5000A(e)(1)(B) of such Code) under the employer-
     sponsored plan.
       (D) If an enrollee claims an employer's minimum essential 
     coverage is unaffordable, the information described in 
     paragraph (3).

     If an enrollee changes employment or obtains additional 
     employment while enrolled in a qualified health plan for 
     which such credit or reduction is allowed, the enrollee shall 
     notify the Exchange of such change or additional employment 
     and provide the information described in this paragraph with 
     respect to the new employer.
       (5) Exemptions from individual responsibility 
     requirements.--In the case of an individual who is seeking an 
     exemption certificate under section 1311(d)(4)(H) from any 
     requirement or penalty imposed by section 5000A, the 
     following information:
       (A) In the case of an individual seeking exemption based on 
     the individual's status as a member of an exempt religious 
     sect or division, as a member of a health care sharing 
     ministry, as an Indian, or as an individual eligible for a 
     hardship exemption, such information as the Secretary shall 
     prescribe.
       (B) In the case of an individual seeking exemption based on 
     the lack of affordable coverage or the individual's status as 
     a taxpayer with household income less than 100 percent of the 
     poverty line, the information described in paragraphs (3) and 
     (4), as applicable.
       (c) Verification of Information Contained in Records of 
     Specific Federal Officials.--
       (1) Information transferred to secretary.--An Exchange 
     shall submit the information provided by an applicant under 
     subsection (b) to the Secretary for verification in 
     accordance with the requirements of this subsection and 
     subsection (d).
       (2) Citizenship or immigration status.--
       (A) Commissioner of social security.--The Secretary shall 
     submit to the Commissioner of Social Security the following 
     information for a determination as to whether the information 
     provided is consistent with the information in the records of 
     the Commissioner:
       (i) The name, date of birth, and social security number of 
     each individual for whom such information was provided under 
     subsection (b)(2).
       (ii) The attestation of an individual that the individual 
     is a citizen.
       (B) Secretary of homeland security.--
       (i) In general.--In the case of an individual--

       (I) who attests that the individual is an alien lawfully 
     present in the United States; or
       (II) who attests that the individual is a citizen but with 
     respect to whom the Commissioner of Social Security has 
     notified the Secretary under subsection (e)(3) that the 
     attestation is inconsistent with information in the records 
     maintained by the Commissioner;

     the Secretary shall submit to the Secretary of Homeland 
     Security the information described in clause (ii) for a 
     determination as to whether the information provided is 
     consistent with the information in the records of the 
     Secretary of Homeland Security.
       (ii) Information.--The information described in clause (ii) 
     is the following:

       (I) The name, date of birth, and any identifying 
     information with respect to the individual's immigration 
     status provided under subsection (b)(2).
       (II) The attestation that the individual is an alien 
     lawfully present in the United States or in the case of an 
     individual described in clause (i)(II), the attestation that 
     the individual is a citizen.

       (3) Eligibility for tax credit and cost-sharing 
     reduction.--The Secretary shall submit the information 
     described in subsection (b)(3)(A) provided under paragraph 
     (3), (4), or (5) of subsection (b) to the Secretary of the 
     Treasury for verification of household income and family size 
     for purposes of eligibility.
       (4) Methods.--
       (A) In general.--The Secretary, in consultation with the 
     Secretary of the Treasury, the Secretary of Homeland 
     Security, and the Commissioner of Social Security, shall 
     provide that verifications and determinations under this 
     subsection shall be done--
       (i) through use of an on-line system or otherwise for the 
     electronic submission of, and response to, the information 
     submitted under this subsection with respect to an applicant; 
     or
       (ii) by determining the consistency of the information 
     submitted with the information maintained in the records of 
     the Secretary of the Treasury, the Secretary of Homeland 
     Security, or the Commissioner of Social Security through such 
     other method as is approved by the Secretary.
       (B) Flexibility.--The Secretary may modify the methods used 
     under the program established by this section for the 
     Exchange and verification of information if the Secretary 
     determines such modifications would reduce the administrative 
     costs and burdens on the applicant, including allowing an 
     applicant to request the Secretary of the Treasury to provide 
     the information described in paragraph (3) directly to the 
     Exchange or to the Secretary. The Secretary shall not make 
     any such modification unless the Secretary determines that 
     any applicable requirements under this section and section 
     6103 of the Internal Revenue Code of 1986 with respect to the 
     confidentiality, disclosure, maintenance, or use of 
     information will be met.
       (d) Verification by Secretary.--In the case of information 
     provided under subsection (b) that is not required under 
     subsection (c) to be submitted to another person for 
     verification, the Secretary shall verify the accuracy of such 
     information in such manner as the Secretary determines 
     appropriate, including delegating responsibility for 
     verification to the Exchange.
       (e) Actions Relating to Verification.--
       (1) In general.--Each person to whom the Secretary provided 
     information under subsection (c) shall report to the 
     Secretary under the method established under subsection 
     (c)(4) the results of its verification and the Secretary 
     shall notify the Exchange of such results. Each person to 
     whom the Secretary provided information under subsection (d) 
     shall report to the Secretary in such manner as the Secretary 
     determines appropriate.
       (2) Verification.--
       (A) Eligibility for enrollment and premium tax credits and 
     cost-sharing reductions.--If information provided by an 
     applicant under paragraphs (1), (2), (3), and (4) of 
     subsection (b) is verified under subsections (c) and (d)--
       (i) the individual's eligibility to enroll through the 
     Exchange and to apply for premium tax credits and cost-
     sharing reductions shall be satisfied; and
       (ii) the Secretary shall, if applicable, notify the 
     Secretary of the Treasury under section 1412(c) of the amount 
     of any advance payment to be made.
       (B) Exemption from individual responsibility.--If 
     information provided by an applicant under subsection (b)(5) 
     is verified under subsections (c) and (d), the Secretary 
     shall issue the certification of exemption described in 
     section 1311(d)(4)(H).
       (3) Inconsistencies involving attestation of citizenship or 
     lawful presence.--If the information provided by any 
     applicant under subsection (b)(2) is inconsistent with 
     information in the records maintained by the Commissioner of 
     Social Security or Secretary of Homeland Security, whichever 
     is applicable, the applicant's eligibility will be determined 
     in the same manner as an individual's eligibility under the 
     medicaid program is determined under section 1902(ee) of the 
     Social Security Act (as in effect on January 1, 2010).
       (4) Inconsistencies involving other information.--
       (A) In general.--If the information provided by an 
     applicant under subsection (b) (other than subsection (b)(2)) 
     is inconsistent with information in the records maintained by 
     persons under subsection (c) or is not verified under 
     subsection (d), the Secretary shall notify the Exchange and 
     the Exchange shall take the following actions:
       (i) Reasonable effort.--The Exchange shall make a 
     reasonable effort to identify and address the causes of such 
     inconsistency, including through typographical or other 
     clerical errors, by contacting the applicant to confirm the 
     accuracy of the information, and by taking such additional 
     actions as the Secretary, through regulation or other 
     guidance, may identify.
       (ii) Notice and opportunity to correct.--In the case the 
     inconsistency or inability to verify is not resolved under 
     subparagraph (A), the Exchange shall--

       (I) notify the applicant of such fact;
       (II) provide the applicant an opportunity to either present 
     satisfactory documentary evidence or resolve the 
     inconsistency with the person verifying the information under 
     subsection (c) or (d) during the 90-day period beginning the 
     date on which the notice required under subclause (I) is sent 
     to the applicant.

     The Secretary may extend the 90-day period under subclause 
     (II) for enrollments occurring during 2014.
       (B) Specific actions not involving citizenship or lawful 
     presence.--
       (i) In general.--Except as provided in paragraph (3), the 
     Exchange shall, during any period before the close of the 
     period under subparagraph (A)(ii)(II), make any determination 
     under paragraphs (2), (3), and (4) of subsection (a) on the 
     basis of the information contained on the application.
       (ii) Eligibility or amount of credit or reduction.--If an 
     inconsistency involving the eligibility for, or amount of, 
     any premium tax credit or cost-sharing reduction is 
     unresolved under this subsection as of the close of the 
     period under subparagraph (A)(ii)(II), the Exchange shall 
     notify the applicant of the amount (if any) of the credit or 
     reduction that is determined on the basis of the records 
     maintained by persons under subsection (c).
       (iii) Employer affordability.--If the Secretary notifies an 
     Exchange that an enrollee is

[[Page H1950]]

     eligible for a premium tax credit under section 36B of such 
     Code or cost-sharing reduction under section 1402 because the 
     enrollee's (or related individual's) employer does not 
     provide minimum essential coverage through an employer-
     sponsored plan or that the employer does provide that 
     coverage but it is not affordable coverage, the Exchange 
     shall notify the employer of such fact and that the employer 
     may be liable for the payment assessed under section 4980H of 
     such Code.
       (iv) Exemption.--In any case where the inconsistency 
     involving, or inability to verify, information provided under 
     subsection (b)(5) is not resolved as of the close of the 
     period under subparagraph (A)(ii)(II), the Exchange shall 
     notify an applicant that no certification of exemption from 
     any requirement or payment under section 5000A of such Code 
     will be issued.
       (C) Appeals process.--The Exchange shall also notify each 
     person receiving notice under this paragraph of the appeals 
     processes established under subsection (f).
       (f) Appeals and Redeterminations.--
       (1) In general.--The Secretary, in consultation with the 
     Secretary of the Treasury, the Secretary of Homeland 
     Security, and the Commissioner of Social Security, shall 
     establish procedures by which the Secretary or one of such 
     other Federal officers--
       (A) hears and makes decisions with respect to appeals of 
     any determination under subsection (e); and
       (B) redetermines eligibility on a periodic basis in 
     appropriate circumstances.
       (2) Employer liability.--
       (A) In general.--The Secretary shall establish a separate 
     appeals process for employers who are notified under 
     subsection (e)(4)(C) that the employer may be liable for a 
     tax imposed by section 4980H of the Internal Revenue Code of 
     1986 with respect to an employee because of a determination 
     that the employer does not provide minimum essential coverage 
     through an employer-sponsored plan or that the employer does 
     provide that coverage but it is not affordable coverage with 
     respect to an employee. Such process shall provide an 
     employer the opportunity to--
       (i) present information to the Exchange for review of the 
     determination either by the Exchange or the person making the 
     determination, including evidence of the employer-sponsored 
     plan and employer contributions to the plan; and
       (ii) have access to the data used to make the determination 
     to the extent allowable by law.
     Such process shall be in addition to any rights of appeal the 
     employer may have under subtitle F of such Code.
       (B) Confidentiality.--Notwithstanding any provision of this 
     title (or the amendments made by this title) or section 6103 
     of the Internal Revenue Code of 1986, an employer shall not 
     be entitled to any taxpayer return information with respect 
     to an employee for purposes of determining whether the 
     employer is subject to the penalty under section 4980H of 
     such Code with respect to the employee, except that--
       (i) the employer may be notified as to the name of an 
     employee and whether or not the employee's income is above or 
     below the threshold by which the affordability of an 
     employer's health insurance coverage is measured; and
       (ii) this subparagraph shall not apply to an employee who 
     provides a waiver (at such time and in such manner as the 
     Secretary may prescribe) authorizing an employer to have 
     access to the employee's taxpayer return information.
       (g) Confidentiality of Applicant Information.--
       (1) In general.--An applicant for insurance coverage or for 
     a premium tax credit or cost-sharing reduction shall be 
     required to provide only the information strictly necessary 
     to authenticate identity, determine eligibility, and 
     determine the amount of the credit or reduction.
       (2) Receipt of information.--Any person who receives 
     information provided by an applicant under subsection (b) 
     (whether directly or by another person at the request of the 
     applicant), or receives information from a Federal agency 
     under subsection (c), (d), or (e), shall--
       (A) use the information only for the purposes of, and to 
     the extent necessary in, ensuring the efficient operation of 
     the Exchange, including verifying the eligibility of an 
     individual to enroll through an Exchange or to claim a 
     premium tax credit or cost-sharing reduction or the amount of 
     the credit or reduction; and
       (B) not disclose the information to any other person except 
     as provided in this section.
       (h) Penalties.--
       (1) False or fraudulent information.--
       (A) Civil penalty.--
       (i) In general.--If--

       (I) any person fails to provides correct information under 
     subsection (b); and
       (II) such failure is attributable to negligence or 
     disregard of any rules or regulations of the Secretary,

     such person shall be subject, in addition to any other 
     penalties that may be prescribed by law, to a civil penalty 
     of not more than $25,000 with respect to any failures 
     involving an application for a plan year. For purposes of 
     this subparagraph, the terms ``negligence'' and ``disregard'' 
     shall have the same meanings as when used in section 6662 of 
     the Internal Revenue Code of 1986.
       (ii) Reasonable cause exception.--No penalty shall be 
     imposed under clause (i) if the Secretary determines that 
     there was a reasonable cause for the failure and that the 
     person acted in good faith.
       (B) Knowing and willful violations.--Any person who 
     knowingly and willfully provides false or fraudulent 
     information under subsection (b) shall be subject, in 
     addition to any other penalties that may be prescribed by 
     law, to a civil penalty of not more than $250,000.
       (2) Improper use or disclosure of information.--Any person 
     who knowingly and willfully uses or discloses information in 
     violation of subsection (g) shall be subject, in addition to 
     any other penalties that may be prescribed by law, to a civil 
     penalty of not more than $25,000.
       (3) Limitations on liens and levies.--The Secretary (or, if 
     applicable, the Attorney General of the United States) shall 
     not--
       (A) file notice of lien with respect to any property of a 
     person by reason of any failure to pay the penalty imposed by 
     this subsection; or
       (B) levy on any such property with respect to such failure.
       (i) Study of Administration of Employer Responsibility.--
       (1) In general.--The Secretary of Health and Human Services 
     shall, in consultation with the Secretary of the Treasury, 
     conduct a study of the procedures that are necessary to 
     ensure that in the administration of this title and section 
     4980H of the Internal Revenue Code of 1986 (as added by 
     section 1513) that the following rights are protected:
       (A) The rights of employees to preserve their right to 
     confidentiality of their taxpayer return information and 
     their right to enroll in a qualified health plan through an 
     Exchange if an employer does not provide affordable coverage.
       (B) The rights of employers to adequate due process and 
     access to information necessary to accurately determine any 
     payment assessed on employers.
       (2) Report.--Not later than January 1, 2013, the Secretary 
     of Health and Human Services shall report the results of the 
     study conducted under paragraph (1), including any 
     recommendations for legislative changes, to the Committees on 
     Finance and Health, Education, Labor and Pensions of the 
     Senate and the Committees of Education and Labor and Ways and 
     Means of the House of Representatives.

     SEC. 1412. ADVANCE DETERMINATION AND PAYMENT OF PREMIUM TAX 
                   CREDITS AND COST-SHARING REDUCTIONS.

       (a) In General.--The Secretary, in consultation with the 
     Secretary of the Treasury, shall establish a program under 
     which--
       (1) upon request of an Exchange, advance determinations are 
     made under section 1411 with respect to the income 
     eligibility of individuals enrolling in a qualified health 
     plan in the individual market through the Exchange for the 
     premium tax credit allowable under section 36B of the 
     Internal Revenue Code of 1986 and the cost-sharing reductions 
     under section 1402;
       (2) the Secretary notifies--
       (A) the Exchange and the Secretary of the Treasury of the 
     advance determinations; and
       (B) the Secretary of the Treasury of the name and employer 
     identification number of each employer with respect to whom 1 
     or more employee of the employer were determined to be 
     eligible for the premium tax credit under section 36B of the 
     Internal Revenue Code of 1986 and the cost-sharing reductions 
     under section 1402 because--
       (i) the employer did not provide minimum essential 
     coverage; or
       (ii) the employer provided such minimum essential coverage 
     but it was determined under section 36B(c)(2)(C) of such Code 
     to either be unaffordable to the employee or not provide the 
     required minimum actuarial value; and
       (3) the Secretary of the Treasury makes advance payments of 
     such credit or reductions to the issuers of the qualified 
     health plans in order to reduce the premiums payable by 
     individuals eligible for such credit.
       (b) Advance Determinations.--
       (1) In general.--The Secretary shall provide under the 
     program established under subsection (a) that advance 
     determination of eligibility with respect to any individual 
     shall be made--
       (A) during the annual open enrollment period applicable to 
     the individual (or such other enrollment period as may be 
     specified by the Secretary); and
       (B) on the basis of the individual's household income for 
     the most recent taxable year for which the Secretary, after 
     consultation with the Secretary of the Treasury, determines 
     information is available.
       (2) Changes in circumstances.--The Secretary shall provide 
     procedures for making advance determinations on the basis of 
     information other than that described in paragraph (1)(B) in 
     cases where information included with an application form 
     demonstrates substantial changes in income, changes in family 
     size or other household circumstances, change in filing 
     status, the filing of an application for unemployment 
     benefits, or other significant changes affecting eligibility, 
     including--
       (A) allowing an individual claiming a decrease of 20 
     percent or more in income, or filing an application for 
     unemployment benefits, to have eligibility for the credit 
     determined on the basis of household income for a later 
     period or on the basis of the individual's estimate of such 
     income for the taxable year; and
       (B) the determination of household income in cases where 
     the taxpayer was not required to file a return of tax imposed 
     by this chapter for the second preceding taxable year.
       (c) Payment of Premium Tax Credits and Cost-sharing 
     Reductions.--
       (1) In general.--The Secretary shall notify the Secretary 
     of the Treasury and the Exchange through which the individual 
     is enrolling of the advance determination under section 1411.
       (2) Premium tax credit.--
       (A) In general.--The Secretary of the Treasury shall make 
     the advance payment under this section of any premium tax 
     credit allowed under section 36B of the Internal Revenue Code 
     of 1986 to the issuer of a qualified health plan on a monthly 
     basis (or such other periodic basis as the Secretary may 
     provide).
       (B) Issuer responsibilities.--An issuer of a qualified 
     health plan receiving an advance payment with respect to an 
     individual enrolled in the plan shall--
       (i) reduce the premium charged the insured for any period 
     by the amount of the advance payment for the period;
       (ii) notify the Exchange and the Secretary of such 
     reduction;

[[Page H1951]]

       (iii) include with each billing statement the amount by 
     which the premium for the plan has been reduced by reason of 
     the advance payment; and
       (iv) in the case of any nonpayment of premiums by the 
     insured--

       (I) notify the Secretary of such nonpayment; and
       (II) allow a 3-month grace period for nonpayment of 
     premiums before discontinuing coverage.

       (3) Cost-sharing reductions.--The Secretary shall also 
     notify the Secretary of the Treasury and the Exchange under 
     paragraph (1) if an advance payment of the cost-sharing 
     reductions under section 1402 is to be made to the issuer of 
     any qualified health plan with respect to any individual 
     enrolled in the plan. The Secretary of the Treasury shall 
     make such advance payment at such time and in such amount as 
     the Secretary specifies in the notice.
       (d) No Federal Payments for Individuals Not Lawfully 
     Present.--Nothing in this subtitle or the amendments made by 
     this subtitle allows Federal payments, credits, or cost-
     sharing reductions for individuals who are not lawfully 
     present in the United States.
       (e) State Flexibility.--Nothing in this subtitle or the 
     amendments made by this subtitle shall be construed to 
     prohibit a State from making payments to or on behalf of an 
     individual for coverage under a qualified health plan offered 
     through an Exchange that are in addition to any credits or 
     cost-sharing reductions allowable to the individual under 
     this subtitle and such amendments.

     SEC. 1413. STREAMLINING OF PROCEDURES FOR ENROLLMENT THROUGH 
                   AN EXCHANGE AND STATE MEDICAID, CHIP, AND 
                   HEALTH SUBSIDY PROGRAMS.

       (a) In General.--The Secretary shall establish a system 
     meeting the requirements of this section under which 
     residents of each State may apply for enrollment in, receive 
     a determination of eligibility for participation in, and 
     continue participation in, applicable State health subsidy 
     programs. Such system shall ensure that if an individual 
     applying to an Exchange is found through screening to be 
     eligible for medical assistance under the State medicaid plan 
     under title XIX, or eligible for enrollment under a State 
     children's health insurance program (CHIP) under title XXI of 
     such Act, the individual is enrolled for assistance under 
     such plan or program.
       (b) Requirements Relating to Forms and Notice.--
       (1) Requirements relating to forms.--
       (A) In general.--The Secretary shall develop and provide to 
     each State a single, streamlined form that--
       (i) may be used to apply for all applicable State health 
     subsidy programs within the State;
       (ii) may be filed online, in person, by mail, or by 
     telephone;
       (iii) may be filed with an Exchange or with State officials 
     operating one of the other applicable State health subsidy 
     programs; and
       (iv) is structured to maximize an applicant's ability to 
     complete the form satisfactorily, taking into account the 
     characteristics of individuals who qualify for applicable 
     State health subsidy programs.
       (B) State authority to establish form.--A State may develop 
     and use its own single, streamlined form as an alternative to 
     the form developed under subparagraph (A) if the alternative 
     form is consistent with standards promulgated by the 
     Secretary under this section.
       (C) Supplemental eligibility forms.--The Secretary may 
     allow a State to use a supplemental or alternative form in 
     the case of individuals who apply for eligibility that is not 
     determined on the basis of the household income (as defined 
     in section 36B of the Internal Revenue Code of 1986).
       (2) Notice.--The Secretary shall provide that an applicant 
     filing a form under paragraph (1) shall receive notice of 
     eligibility for an applicable State health subsidy program 
     without any need to provide additional information or 
     paperwork unless such information or paperwork is 
     specifically required by law when information provided on the 
     form is inconsistent with data used for the electronic 
     verification under paragraph (3) or is otherwise insufficient 
     to determine eligibility.
       (c) Requirements Relating to Eligibility Based on Data 
     Exchanges.--
       (1) Development of secure interfaces.--Each State shall 
     develop for all applicable State health subsidy programs a 
     secure, electronic interface allowing an exchange of data 
     (including information contained in the application forms 
     described in subsection (b)) that allows a determination of 
     eligibility for all such programs based on a single 
     application. Such interface shall be compatible with the 
     method established for data verification under section 
     1411(c)(4).
       (2) Data matching program.--Each applicable State health 
     subsidy program shall participate in a data matching 
     arrangement for determining eligibility for participation in 
     the program under paragraph (3) that--
       (A) provides access to data described in paragraph (3);
       (B) applies only to individuals who--
       (i) receive assistance from an applicable State health 
     subsidy program; or
       (ii) apply for such assistance--

       (I) by filing a form described in subsection (b); or
       (II) by requesting a determination of eligibility and 
     authorizing disclosure of the information described in 
     paragraph (3) to applicable State health coverage subsidy 
     programs for purposes of determining and establishing 
     eligibility; and

       (C) consistent with standards promulgated by the Secretary, 
     including the privacy and data security safeguards described 
     in section 1942 of the Social Security Act or that are 
     otherwise applicable to such programs.
       (3) Determination of eligibility.--
       (A) In general.--Each applicable State health subsidy 
     program shall, to the maximum extent practicable--
       (i) establish, verify, and update eligibility for 
     participation in the program using the data matching 
     arrangement under paragraph (2); and
       (ii) determine such eligibility on the basis of reliable, 
     third party data, including information described in sections 
     1137, 453(i), and 1942(a) of the Social Security Act, 
     obtained through such arrangement.
       (B) Exception.--This paragraph shall not apply in 
     circumstances with respect to which the Secretary determines 
     that the administrative and other costs of use of the data 
     matching arrangement under paragraph (2) outweigh its 
     expected gains in accuracy, efficiency, and program 
     participation.
       (4) Secretarial standards.--The Secretary shall, after 
     consultation with persons in possession of the data to be 
     matched and representatives of applicable State health 
     subsidy programs, promulgate standards governing the timing, 
     contents, and procedures for data matching described in this 
     subsection. Such standards shall take into account 
     administrative and other costs and the value of data matching 
     to the establishment, verification, and updating of 
     eligibility for applicable State health subsidy programs.
       (d) Administrative Authority.--
       (1) Agreements.--Subject to section 1411 and section 
     6103(l)(21) of the Internal Revenue Code of 1986 and any 
     other requirement providing safeguards of privacy and data 
     integrity, the Secretary may establish model agreements, and 
     enter into agreements, for the sharing of data under this 
     section.
       (2) Authority of exchange to contract out.--Nothing in this 
     section shall be construed to--
       (A) prohibit contractual arrangements through which a State 
     medicaid agency determines eligibility for all applicable 
     State health subsidy programs, but only if such agency 
     complies with the Secretary's requirements ensuring reduced 
     administrative costs, eligibility errors, and disruptions in 
     coverage; or
       (B) change any requirement under title XIX that eligibility 
     for participation in a State's medicaid program must be 
     determined by a public agency.
       (e) Applicable State Health Subsidy Program.--In this 
     section, the term ``applicable State health subsidy program'' 
     means--
       (1) the program under this title for the enrollment in 
     qualified health plans offered through an Exchange, including 
     the premium tax credits under section 36B of the Internal 
     Revenue Code of 1986 and cost-sharing reductions under 
     section 1402;
       (2) a State medicaid program under title XIX of the Social 
     Security Act;
       (3) a State children's health insurance program (CHIP) 
     under title XXI of such Act; and
       (4) a State program under section 1331 establishing 
     qualified basic health plans.

     SEC. 1414. DISCLOSURES TO CARRY OUT ELIGIBILITY REQUIREMENTS 
                   FOR CERTAIN PROGRAMS.

       (a) Disclosure of Taxpayer Return Information and Social 
     Security Numbers.--
       (1) Taxpayer return information.--Subsection (l) of section 
     6103 of the Internal Revenue Code of 1986 is amended by 
     adding at the end the following new paragraph:
       ``(21) Disclosure of return information to carry out 
     eligibility requirements for certain programs.--
       ``(A) In general.--The Secretary, upon written request from 
     the Secretary of Health and Human Services, shall disclose to 
     officers, employees, and contractors of the Department of 
     Health and Human Services return information of any taxpayer 
     whose income is relevant in determining any premium tax 
     credit under section 36B or any cost-sharing reduction under 
     section 1402 of the Patient Protection and Affordable Care 
     Act or eligibility for participation in a State medicaid 
     program under title XIX of the Social Security Act, a State's 
     children's health insurance program under title XXI of the 
     Social Security Act, or a basic health program under section 
     1331 of Patient Protection and Affordable Care Act. Such 
     return information shall be limited to--
       ``(i) taxpayer identity information with respect to such 
     taxpayer,
       ``(ii) the filing status of such taxpayer,
       ``(iii) the number of individuals for whom a deduction is 
     allowed under section 151 with respect to the taxpayer 
     (including the taxpayer and the taxpayer's spouse),
       ``(iv) the modified gross income (as defined in section 
     36B) of such taxpayer and each of the other individuals 
     included under clause (iii) who are required to file a return 
     of tax imposed by chapter 1 for the taxable year,
       ``(v) such other information as is prescribed by the 
     Secretary by regulation as might indicate whether the 
     taxpayer is eligible for such credit or reduction (and the 
     amount thereof), and
       ``(vi) the taxable year with respect to which the preceding 
     information relates or, if applicable, the fact that such 
     information is not available.
       ``(B) Information to exchange and state agencies.--The 
     Secretary of Health and Human Services may disclose to an 
     Exchange established under the Patient Protection and 
     Affordable Care Act or its contractors, or to a State agency 
     administering a State program described in subparagraph (A) 
     or its contractors, any inconsistency between the information 
     provided by the Exchange or State agency to the Secretary and 
     the information provided to the Secretary under subparagraph 
     (A).
       ``(C) Restriction on use of disclosed information.--Return 
     information disclosed under subparagraph (A) or (B) may be 
     used by

[[Page H1952]]

     officers, employees, and contractors of the Department of 
     Health and Human Services, an Exchange, or a State agency 
     only for the purposes of, and to the extent necessary in--
       ``(i) establishing eligibility for participation in the 
     Exchange, and verifying the appropriate amount of, any credit 
     or reduction described in subparagraph (A),
       ``(ii) determining eligibility for participation in the 
     State programs described in subparagraph (A).''.
       (2) Social security numbers.--Section 205(c)(2)(C) of the 
     Social Security Act is amended by adding at the end the 
     following new clause:
       ``(x) The Secretary of Health and Human Services, and the 
     Exchanges established under section 1311 of the Patient 
     Protection and Affordable Care Act, are authorized to collect 
     and use the names and social security account numbers of 
     individuals as required to administer the provisions of, and 
     the amendments made by, the such Act.''.
       (b) Confidentiality and Disclosure.--Paragraph (3) of 
     section 6103(a) of such Code is amended by striking ``or 
     (20)'' and inserting ``(20), or (21)''.
       (c) Procedures and Recordkeeping Related to Disclosures.--
     Paragraph (4) of section 6103(p) of such Code is amended--
       (1) by inserting ``, or any entity described in subsection 
     (l)(21),'' after ``or (20)'' in the matter preceding 
     subparagraph (A),
       (2) by inserting ``or any entity described in subsection 
     (l)(21),'' after ``or (o)(1)(A)'' in subparagraph (F)(ii), 
     and
       (3) by inserting ``or any entity described in subsection 
     (l)(21),'' after ``or (20)'' both places it appears in the 
     matter after subparagraph (F).
       (d) Unauthorized Disclosure or Inspection.--Paragraph (2) 
     of section 7213(a) of such Code is amended by striking ``or 
     (20)'' and inserting ``(20), or (21)''.

     SEC. 1415. PREMIUM TAX CREDIT AND COST-SHARING REDUCTION 
                   PAYMENTS DISREGARDED FOR FEDERAL AND FEDERALLY-
                   ASSISTED PROGRAMS.

       For purposes of determining the eligibility of any 
     individual for benefits or assistance, or the amount or 
     extent of benefits or assistance, under any Federal program 
     or under any State or local program financed in whole or in 
     part with Federal funds--
       (1) any credit or refund allowed or made to any individual 
     by reason of section 36B of the Internal Revenue Code of 1986 
     (as added by section 1401) shall not be taken into account as 
     income and shall not be taken into account as resources for 
     the month of receipt and the following 2 months; and
       (2) any cost-sharing reduction payment or advance payment 
     of the credit allowed under such section 36B that is made 
     under section 1402 or 1412 shall be treated as made to the 
     qualified health plan in which an individual is enrolled and 
     not to that individual.

                   PART II--SMALL BUSINESS TAX CREDIT

     SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF 
                   SMALL BUSINESSES.

       (a) In General.--Subpart D of part IV of subchapter A of 
     chapter 1 of the Internal Revenue Code of 1986 (relating to 
     business-related credits) is amended by inserting after 
     section 45Q the following:

     ``SEC. 45R. EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL 
                   EMPLOYERS.

       ``(a) General Rule.--For purposes of section 38, in the 
     case of an eligible small employer, the small employer health 
     insurance credit determined under this section for any 
     taxable year in the credit period is the amount determined 
     under subsection (b).
       ``(b) Health Insurance Credit Amount.--Subject to 
     subsection (c), the amount determined under this subsection 
     with respect to any eligible small employer is equal to 50 
     percent (35 percent in the case of a tax-exempt eligible 
     small employer) of the lesser of--
       ``(1) the aggregate amount of nonelective contributions the 
     employer made on behalf of its employees during the taxable 
     year under the arrangement described in subsection (d)(4) for 
     premiums for qualified health plans offered by the employer 
     to its employees through an Exchange, or
       ``(2) the aggregate amount of nonelective contributions 
     which the employer would have made during the taxable year 
     under the arrangement if each employee taken into account 
     under paragraph (1) had enrolled in a qualified health plan 
     which had a premium equal to the average premium (as 
     determined by the Secretary of Health and Human Services) for 
     the small group market in the rating area in which the 
     employee enrolls for coverage.
       ``(c) Phaseout of Credit Amount Based on Number of 
     Employees and Average Wages.--The amount of the credit 
     determined under subsection (b) without regard to this 
     subsection shall be reduced (but not below zero) by the sum 
     of the following amounts:
       ``(1) Such amount multiplied by a fraction the numerator of 
     which is the total number of full-time equivalent employees 
     of the employer in excess of 10 and the denominator of which 
     is 15.
       ``(2) Such amount multiplied by a fraction the numerator of 
     which is the average annual wages of the employer in excess 
     of the dollar amount in effect under subsection (d)(3)(B) and 
     the denominator of which is such dollar amount.
       ``(d) Eligible Small Employer.--For purposes of this 
     section--
       ``(1) In general.--The term `eligible small employer' 
     means, with respect to any taxable year, an employer--
       ``(A) which has no more than 25 full-time equivalent 
     employees for the taxable year,
       ``(B) the average annual wages of which do not exceed an 
     amount equal to twice the dollar amount in effect under 
     paragraph (3)(B) for the taxable year, and
       ``(C) which has in effect an arrangement described in 
     paragraph (4).
       ``(2) Full-time equivalent employees.--
       ``(A) In general.--The term `full-time equivalent 
     employees' means a number of employees equal to the number 
     determined by dividing--
       ``(i) the total number of hours of service for which wages 
     were paid by the employer to employees during the taxable 
     year, by
       ``(ii) 2,080.

     Such number shall be rounded to the next lowest whole number 
     if not otherwise a whole number.
       ``(B) Excess hours not counted.--If an employee works in 
     excess of 2,080 hours of service during any taxable year, 
     such excess shall not be taken into account under 
     subparagraph (A).
       ``(C) Hours of service.--The Secretary, in consultation 
     with the Secretary of Labor, shall prescribe such 
     regulations, rules, and guidance as may be necessary to 
     determine the hours of service of an employee, including 
     rules for the application of this paragraph to employees who 
     are not compensated on an hourly basis.
       ``(3) Average annual wages.--
       ``(A) In general.--The average annual wages of an eligible 
     small employer for any taxable year is the amount determined 
     by dividing--
       ``(i) the aggregate amount of wages which were paid by the 
     employer to employees during the taxable year, by
       ``(ii) the number of full-time equivalent employees of the 
     employee determined under paragraph (2) for the taxable year.
     Such amount shall be rounded to the next lowest multiple of 
     $1,000 if not otherwise such a multiple.
       ``(B) Dollar amount.--For purposes of paragraph (1)(B)--
       ``(i) 2011, 2012, and 2013.--The dollar amount in effect 
     under this paragraph for taxable years beginning in 2011, 
     2012, or 2013 is $20,000.
       ``(ii) Subsequent years.--In the case of a taxable year 
     beginning in a calendar year after 2013, the dollar amount in 
     effect under this paragraph shall be equal to $20,000, 
     multiplied by the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year, determined by 
     substituting `calendar year 2012' for `calendar year 1992' in 
     subparagraph (B) thereof.
       ``(4) Contribution arrangement.--An arrangement is 
     described in this paragraph if it requires an eligible small 
     employer to make a nonelective contribution on behalf of each 
     employee who enrolls in a qualified health plan offered to 
     employees by the employer through an exchange in an amount 
     equal to a uniform percentage (not less than 50 percent) of 
     the premium cost of the qualified health plan.
       ``(5) Seasonal worker hours and wages not counted.--For 
     purposes of this subsection--
       ``(A) In general.--The number of hours of service worked 
     by, and wages paid to, a seasonal worker of an employer shall 
     not be taken into account in determining the full-time 
     equivalent employees and average annual wages of the employer 
     unless the worker works for the employer on more than 120 
     days during the taxable year.
       ``(B) Definition of seasonal worker.--The term `seasonal 
     worker' means a worker who performs labor or services on a 
     seasonal basis as defined by the Secretary of Labor, 
     including workers covered by section 500.20(s)(1) of title 
     29, Code of Federal Regulations and retail workers employed 
     exclusively during holiday seasons.
       ``(e) Other Rules and Definitions.--For purposes of this 
     section--
       ``(1) Employee.--
       ``(A) Certain employees excluded.--The term `employee' 
     shall not include--
       ``(i) an employee within the meaning of section 401(c)(1),
       ``(ii) any 2-percent shareholder (as defined in section 
     1372(b)) of an eligible small business which is an S 
     corporation,
       ``(iii) any 5-percent owner (as defined in section 
     416(i)(1)(B)(i)) of an eligible small business, or
       ``(iv) any individual who bears any of the relationships 
     described in subparagraphs (A) through (G) of section 
     152(d)(2) to, or is a dependent described in section 
     152(d)(2)(H) of, an individual described in clause (i), (ii), 
     or (iii).
       ``(B) Leased employees.--The term `employee' shall include 
     a leased employee within the meaning of section 414(n).
       ``(2) Credit period.--The term `credit period' means, with 
     respect to any eligible small employer, the 2-consecutive-
     taxable year period beginning with the 1st taxable year in 
     which the employer (or any predecessor) offers 1 or more 
     qualified health plans to its employees through an Exchange.
       ``(3) Nonelective contribution.--The term `nonelective 
     contribution' means an employer contribution other than an 
     employer contribution pursuant to a salary reduction 
     arrangement.
       ``(4) Wages.--The term `wages' has the meaning given such 
     term by section 3121(a) (determined without regard to any 
     dollar limitation contained in such section).
       ``(5) Aggregation and other rules made applicable.--
       ``(A) Aggregation rules.--All employers treated as a single 
     employer under subsection (b), (c), (m), or (o) of section 
     414 shall be treated as a single employer for purposes of 
     this section.
       ``(B) Other rules.--Rules similar to the rules of 
     subsections (c), (d), and (e) of section 52 shall apply.
       ``(f) Credit Made Available to Tax-exempt Eligible Small 
     Employers.--
       ``(1) In general.--In the case of a tax-exempt eligible 
     small employer, there shall be treated as a credit allowable 
     under subpart C (and not allowable under this subpart) the 
     lesser of--
       ``(A) the amount of the credit determined under this 
     section with respect to such employer, or

[[Page H1953]]

       ``(B) the amount of the payroll taxes of the employer 
     during the calendar year in which the taxable year begins.
       ``(2) Tax-exempt eligible small employer.--For purposes of 
     this section, the term `tax-exempt eligible small employer' 
     means an eligible small employer which is any organization 
     described in section 501(c) which is exempt from taxation 
     under section 501(a).
       ``(3) Payroll taxes.--For purposes of this subsection--
       ``(A) In general.--The term `payroll taxes' means--
       ``(i) amounts required to be withheld from the employees of 
     the tax-exempt eligible small employer under section 3401(a),
       ``(ii) amounts required to be withheld from such employees 
     under section 3101(b), and
       ``(iii) amounts of the taxes imposed on the tax-exempt 
     eligible small employer under section 3111(b).
       ``(B) Special rule.--A rule similar to the rule of section 
     24(d)(2)(C) shall apply for purposes of subparagraph (A).
       ``(g) Application of Section for Calendar Years 2011, 2012, 
     and 2013.--In the case of any taxable year beginning in 2011, 
     2012, or 2013, the following modifications to this section 
     shall apply in determining the amount of the credit under 
     subsection (a):
       ``(1) No credit period required.--The credit shall be 
     determined without regard to whether the taxable year is in a 
     credit period and for purposes of applying this section to 
     taxable years beginning after 2013, no credit period shall be 
     treated as beginning with a taxable year beginning before 
     2014.
       ``(2) Amount of credit.--The amount of the credit 
     determined under subsection (b) shall be determined--
       ``(A) by substituting `35 percent (25 percent in the case 
     of a tax-exempt eligible small employer)' for `50 percent (35 
     percent in the case of a tax-exempt eligible small 
     employer)',
       ``(B) by reference to an eligible small employer's 
     nonelective contributions for premiums paid for health 
     insurance coverage (within the meaning of section 9832(b)(1)) 
     of an employee, and
       ``(C) by substituting for the average premium determined 
     under subsection (b)(2) the amount the Secretary of Health 
     and Human Services determines is the average premium for the 
     small group market in the State in which the employer is 
     offering health insurance coverage (or for such area within 
     the State as is specified by the Secretary).
       ``(3) Contribution arrangement.--An arrangement shall not 
     fail to meet the requirements of subsection (d)(4) solely 
     because it provides for the offering of insurance outside of 
     an Exchange.
       ``(h) Insurance Definitions.--Any term used in this section 
     which is also used in the Public Health Service Act or 
     subtitle A of title I of the Patient Protection and 
     Affordable Care Act shall have the meaning given such term by 
     such Act or subtitle.
       ``(i) Regulations.--The Secretary shall prescribe such 
     regulations as may be necessary to carry out the provisions 
     of this section, including regulations to prevent the 
     avoidance of the 2-year limit on the credit period through 
     the use of successor entities and the avoidance of the 
     limitations under subsection (c) through the use of multiple 
     entities.''.
       (b) Credit To Be Part of General Business Credit.--Section 
     38(b) of the Internal Revenue Code of 1986 (relating to 
     current year business credit) is amended by striking ``plus'' 
     at the end of paragraph (34), by striking the period at the 
     end of paragraph (35) and inserting ``, plus'', and by 
     inserting after paragraph (35) the following:
       ``(36) the small employer health insurance credit 
     determined under section 45R.''.
       (c) Credit Allowed Against Alternative Minimum Tax.--
     Section 38(c)(4)(B) of the Internal Revenue Code of 1986 
     (defining specified credits) is amended by redesignating 
     clauses (vi), (vii), and (viii) as clauses (vii), (viii), and 
     (ix), respectively, and by inserting after clause (v) the 
     following new clause:
       ``(vi) the credit determined under section 45R,''.
       (d) Disallowance of Deduction for Certain Expenses for 
     Which Credit Allowed.--
       (1) In general.--Section 280C of the Internal Revenue Code 
     of 1986 (relating to disallowance of deduction for certain 
     expenses for which credit allowed), as amended by section 
     1401(b), is amended by adding at the end the following new 
     subsection:
       ``(h) Credit for Employee Health Insurance Expenses of 
     Small Employers.--No deduction shall be allowed for that 
     portion of the premiums for qualified health plans (as 
     defined in section 1301(a) of the Patient Protection and 
     Affordable Care Act), or for health insurance coverage in the 
     case of taxable years beginning in 2011, 2012, or 2013, paid 
     by an employer which is equal to the amount of the credit 
     determined under section 45R(a) with respect to the 
     premiums.''.
       (2) Deduction for expiring credits.--Section 196(c) of such 
     Code is amended by striking ``and'' at the end of paragraph 
     (12), by striking the period at the end of paragraph (13) and 
     inserting ``, and'', and by adding at the end the following 
     new paragraph:
       ``(14) the small employer health insurance credit 
     determined under section 45R(a).''.
       (e) Clerical Amendment.--The table of sections for subpart 
     D of part IV of subchapter A of chapter 1 of the Internal 
     Revenue Code of 1986 is amended by adding at the end the 
     following:

``Sec. 45R. Employee health insurance expenses of small employers.''.

       (f) Effective Dates.--
       (1) In general.--The amendments made by this section shall 
     apply to amounts paid or incurred in taxable years beginning 
     after December 31, 2010.
       (2) Minimum tax.--The amendments made by subsection (c) 
     shall apply to credits determined under section 45R of the 
     Internal Revenue Code of 1986 in taxable years beginning 
     after December 31, 2010, and to carrybacks of such credits.

           Subtitle F--Shared Responsibility for Health Care

                   PART I--INDIVIDUAL RESPONSIBILITY

     SEC. 1501. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL 
                   COVERAGE.

       (a) Findings.--Congress makes the following findings:
       (1) In general.--The individual responsibility requirement 
     provided for in this section (in this subsection referred to 
     as the ``requirement'') is commercial and economic in nature, 
     and substantially affects interstate commerce, as a result of 
     the effects described in paragraph (2).
       (2) Effects on the national economy and interstate 
     commerce.--The effects described in this paragraph are the 
     following:
       (A) The requirement regulates activity that is commercial 
     and economic in nature: economic and financial decisions 
     about how and when health care is paid for, and when health 
     insurance is purchased.
       (B) Health insurance and health care services are a 
     significant part of the national economy. National health 
     spending is projected to increase from $2,500,000,000,000, or 
     17.6 percent of the economy, in 2009 to $4,700,000,000,000 in 
     2019. Private health insurance spending is projected to be 
     $854,000,000,000 in 2009, and pays for medical supplies, 
     drugs, and equipment that are shipped in interstate commerce. 
     Since most health insurance is sold by national or regional 
     health insurance companies, health insurance is sold in 
     interstate commerce and claims payments flow through 
     interstate commerce.
       (C) The requirement, together with the other provisions of 
     this Act, will add millions of new consumers to the health 
     insurance market, increasing the supply of, and demand for, 
     health care services. According to the Congressional Budget 
     Office, the requirement will increase the number and share of 
     Americans who are insured.
       (D) The requirement achieves near-universal coverage by 
     building upon and strengthening the private employer-based 
     health insurance system, which covers 176,000,000 Americans 
     nationwide. In Massachusetts, a similar requirement has 
     strengthened private employer-based coverage: despite the 
     economic downturn, the number of workers offered employer-
     based coverage has actually increased.
       (E) Half of all personal bankruptcies are caused in part by 
     medical expenses. By significantly increasing health 
     insurance coverage, the requirement, together with the other 
     provisions of this Act, will improve financial security for 
     families.
       (F) Under the Employee Retirement Income Security Act of 
     1974 (29 U.S.C. 1001 et seq.), the Public Health Service Act 
     (42 U.S.C. 201 et seq.), and this Act, the Federal Government 
     has a significant role in regulating health insurance which 
     is in interstate commerce.
       (G) Under sections 2704 and 2705 of the Public Health 
     Service Act (as added by section 1201 of this Act), if there 
     were no requirement, many individuals would wait to purchase 
     health insurance until they needed care. By significantly 
     increasing health insurance coverage, the requirement, 
     together with the other provisions of this Act, will minimize 
     this adverse selection and broaden the health insurance risk 
     pool to include healthy individuals, which will lower health 
     insurance premiums. The requirement is essential to creating 
     effective health insurance markets in which improved health 
     insurance products that are guaranteed issue and do not 
     exclude coverage of pre-existing conditions can be sold.
       (H) Administrative costs for private health insurance, 
     which were $90,000,000,000 in 2006, are 26 to 30 percent of 
     premiums in the current individual and small group markets. 
     By significantly increasing health insurance coverage and the 
     size of purchasing pools, which will increase economies of 
     scale, the requirement, together with the other provisions of 
     this Act, will significantly reduce administrative costs and 
     lower health insurance premiums. The requirement is essential 
     to creating effective health insurance markets that do not 
     require underwriting and eliminate its associated 
     administrative costs.
       (3) Supreme court ruling.--In United States v. South-
     Eastern Underwriters Association (322 U.S. 533 (1944)), the 
     Supreme Court of the United States ruled that insurance is 
     interstate commerce subject to Federal regulation.
       (b) In General.--Subtitle D of the Internal Revenue Code of 
     1986 is amended by adding at the end the following new 
     chapter:

        ``CHAPTER 48--MAINTENANCE OF MINIMUM ESSENTIAL COVERAGE

``Sec. 5000A. Requirement to maintain minimum essential coverage.

     ``SEC. 5000A. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL 
                   COVERAGE.

       ``(a) Requirement To Maintain Minimum Essential Coverage.--
     An applicable individual shall for each month beginning after 
     2013 ensure that the individual, and any dependent of the 
     individual who is an applicable individual, is covered under 
     minimum essential coverage for such month.
       ``(b) Shared Responsibility Payment.--
       ``(1) In general.--If an applicable individual fails to 
     meet the requirement of subsection (a) for 1 or more months 
     during any calendar year beginning after 2013, then, except 
     as provided in subsection (d), there is hereby imposed a 
     penalty with respect to the individual in the amount 
     determined under subsection (c).
       ``(2) Inclusion with return.--Any penalty imposed by this 
     section with respect to any

[[Page H1954]]

     month shall be included with a taxpayer's return under 
     chapter 1 for the taxable year which includes such month.
       ``(3) Payment of penalty.--If an individual with respect to 
     whom a penalty is imposed by this section for any month--
       ``(A) is a dependent (as defined in section 152) of another 
     taxpayer for the other taxpayer's taxable year including such 
     month, such other taxpayer shall be liable for such penalty, 
     or
       ``(B) files a joint return for the taxable year including 
     such month, such individual and the spouse of such individual 
     shall be jointly liable for such penalty.
       ``(c) Amount of Penalty.--
       ``(1) In general.--The penalty determined under this 
     subsection for any month with respect to any individual is an 
     amount equal to \1/12\ of the applicable dollar amount for 
     the calendar year.
       ``(2) Dollar limitation.--The amount of the penalty imposed 
     by this section on any taxpayer for any taxable year with 
     respect to all individuals for whom the taxpayer is liable 
     under subsection (b)(3) shall not exceed an amount equal to 
     300 percent the applicable dollar amount (determined without 
     regard to paragraph (3)(C)) for the calendar year with or 
     within which the taxable year ends.
       ``(3) Applicable dollar amount.--For purposes of paragraph 
     (1)--
       ``(A) In general.--Except as provided in subparagraphs (B) 
     and (C), the applicable dollar amount is $750.
       ``(B) Phase in.--The applicable dollar amount is $95 for 
     2014 and $350 for 2015.
       ``(C) Special rule for individuals under age 18.--If an 
     applicable individual has not attained the age of 18 as of 
     the beginning of a month, the applicable dollar amount with 
     respect to such individual for the month shall be equal to 
     one-half of the applicable dollar amount for the calendar 
     year in which the month occurs.
       ``(D) Indexing of amount.--In the case of any calendar year 
     beginning after 2016, the applicable dollar amount shall be 
     equal to $750, increased by an amount equal to--
       ``(i) $750, multiplied by
       ``(ii) the cost-of-living adjustment determined under 
     section 1(f)(3) for the calendar year, determined by 
     substituting `calendar year 2015' for `calendar year 1992' in 
     subparagraph (B) thereof.

     If the amount of any increase under clause (i) is not a 
     multiple of $50, such increase shall be rounded to the next 
     lowest multiple of $50.
       ``(4) Terms relating to income and families.--For purposes 
     of this section--
       ``(A) Family size.--The family size involved with respect 
     to any taxpayer shall be equal to the number of individuals 
     for whom the taxpayer is allowed a deduction under section 
     151 (relating to allowance of deduction for personal 
     exemptions) for the taxable year.
       ``(B) Household income.--The term `household income' means, 
     with respect to any taxpayer for any taxable year, an amount 
     equal to the sum of--
       ``(i) the modified gross income of the taxpayer, plus
       ``(ii) the aggregate modified gross incomes of all other 
     individuals who--

       ``(I) were taken into account in determining the taxpayer's 
     family size under paragraph (1), and
       ``(II) were required to file a return of tax imposed by 
     section 1 for the taxable year.

       ``(C) Modified gross income.--The term `modified gross 
     income' means gross income--
       ``(i) decreased by the amount of any deduction allowable 
     under paragraph (1), (3), (4), or (10) of section 62(a),
       ``(ii) increased by the amount of interest received or 
     accrued during the taxable year which is exempt from tax 
     imposed by this chapter, and
       ``(iii) determined without regard to sections 911, 931, and 
     933.
       ``(D) Poverty line.--
       ``(i) In general.--The term `poverty line' has the meaning 
     given that term in section 2110(c)(5) of the Social Security 
     Act (42 U.S.C. 1397jj(c)(5)).
       ``(ii) Poverty line used.--In the case of any taxable year 
     ending with or within a calendar year, the poverty line used 
     shall be the most recently published poverty line as of the 
     1st day of such calendar year.
       ``(d) Applicable Individual.--For purposes of this 
     section--
       ``(1) In general.--The term `applicable individual' means, 
     with respect to any month, an individual other than an 
     individual described in paragraph (2), (3), or (4).
       ``(2) Religious exemptions.--
       ``(A) Religious conscience exemption.--Such term shall not 
     include any individual for any month if such individual has 
     in effect an exemption under section 1311(d)(4)(H) of the 
     Patient Protection and Affordable Care Act which certifies 
     that such individual is a member of a recognized religious 
     sect or division thereof described in section 1402(g)(1) and 
     an adherent of established tenets or teachings of such sect 
     or division as described in such section.
       ``(B) Health care sharing ministry.--
       ``(i) In general.--Such term shall not include any 
     individual for any month if such individual is a member of a 
     health care sharing ministry for the month.
       ``(ii) Health care sharing ministry.--The term `health care 
     sharing ministry' means an organization--

       ``(I) which is described in section 501(c)(3) and is exempt 
     from taxation under section 501(a),
       ``(II) members of which share a common set of ethical or 
     religious beliefs and share medical expenses among members in 
     accordance with those beliefs and without regard to the State 
     in which a member resides or is employed,
       ``(III) members of which retain membership even after they 
     develop a medical condition,
       ``(IV) which (or a predecessor of which) has been in 
     existence at all times since December 31, 1999, and medical 
     expenses of its members have been shared continuously and 
     without interruption since at least December 31, 1999, and
       ``(V) which conducts an annual audit which is performed by 
     an independent certified public accounting firm in accordance 
     with generally accepted accounting principles and which is 
     made available to the public upon request.

       ``(3) Individuals not lawfully present.--Such term shall 
     not include an individual for any month if for the month the 
     individual is not a citizen or national of the United States 
     or an alien lawfully present in the United States.
       ``(4) Incarcerated individuals.--Such term shall not 
     include an individual for any month if for the month the 
     individual is incarcerated, other than incarceration pending 
     the disposition of charges.
       ``(e) Exemptions.--No penalty shall be imposed under 
     subsection (a) with respect to--
       ``(1) Individuals who cannot afford coverage.--
       ``(A) In general.--Any applicable individual for any month 
     if the applicable individual's required contribution 
     (determined on an annual basis) for coverage for the month 
     exceeds 8 percent of such individual's household income for 
     the taxable year described in section 1412(b)(1)(B) of the 
     Patient Protection and Affordable Care Act. For purposes of 
     applying this subparagraph, the taxpayer's household income 
     shall be increased by any exclusion from gross income for any 
     portion of the required contribution made through a salary 
     reduction arrangement.
       ``(B) Required contribution.--For purposes of this 
     paragraph, the term `required contribution' means--
       ``(i) in the case of an individual eligible to purchase 
     minimum essential coverage consisting of coverage through an 
     eligible-employer-sponsored plan, the portion of the annual 
     premium which would be paid by the individual (without regard 
     to whether paid through salary reduction or otherwise) for 
     self-only coverage, or
       ``(ii) in the case of an individual eligible only to 
     purchase minimum essential coverage described in subsection 
     (f)(1)(C), the annual premium for the lowest cost bronze plan 
     available in the individual market through the Exchange in 
     the State in the rating area in which the individual resides 
     (without regard to whether the individual purchased a 
     qualified health plan through the Exchange), reduced by the 
     amount of the credit allowable under section 36B for the 
     taxable year (determined as if the individual was covered by 
     a qualified health plan offered through the Exchange for the 
     entire taxable year).
       ``(C) Special rules for individuals related to employees.--
     For purposes of subparagraph (B)(i), if an applicable 
     individual is eligible for minimum essential coverage through 
     an employer by reason of a relationship to an employee, the 
     determination shall be made by reference to the affordability 
     of the coverage to the employee.
       ``(D) Indexing.--In the case of plan years beginning in any 
     calendar year after 2014, subparagraph (A) shall be applied 
     by substituting for `8 percent' the percentage the Secretary 
     of Health and Human Services determines reflects the excess 
     of the rate of premium growth between the preceding calendar 
     year and 2013 over the rate of income growth for such period.
       ``(2) Taxpayers with income under 100 percent of poverty 
     line.--Any applicable individual for any month during a 
     calendar year if the individual's household income for the 
     taxable year described in section 1412(b)(1)(B) of the 
     Patient Protection and Affordable Care Act is less than 100 
     percent of the poverty line for the size of the family 
     involved (determined in the same manner as under subsection 
     (b)(4)).
       ``(3) Members of indian tribes.--Any applicable individual 
     for any month during which the individual is a member of an 
     Indian tribe (as defined in section 45A(c)(6)).
       ``(4) Months during short coverage gaps.--
       ``(A) In general.--Any month the last day of which occurred 
     during a period in which the applicable individual was not 
     covered by minimum essential coverage for a continuous period 
     of less than 3 months.
       ``(B) Special rules.--For purposes of applying this 
     paragraph--
       ``(i) the length of a continuous period shall be determined 
     without regard to the calendar years in which months in such 
     period occur,
       ``(ii) if a continuous period is greater than the period 
     allowed under subparagraph (A), no exception shall be 
     provided under this paragraph for any month in the period, 
     and
       ``(iii) if there is more than 1 continuous period described 
     in subparagraph (A) covering months in a calendar year, the 
     exception provided by this paragraph shall only apply to 
     months in the first of such periods.

     The Secretary shall prescribe rules for the collection of the 
     penalty imposed by this section in cases where continuous 
     periods include months in more than 1 taxable year.
       ``(5) Hardships.--Any applicable individual who for any 
     month is determined by the Secretary of Health and Human 
     Services under section 1311(d)(4)(H) to have suffered a 
     hardship with respect to the capability to obtain coverage 
     under a qualified health plan.
       ``(f) Minimum Essential Coverage.--For purposes of this 
     section--
       ``(1) In general.--The term `minimum essential coverage' 
     means any of the following:
       ``(A) Government sponsored programs.--Coverage under--
       ``(i) the Medicare program under part A of title XVIII of 
     the Social Security Act,
       ``(ii) the Medicaid program under title XIX of the Social 
     Security Act,
       ``(iii) the CHIP program under title XXI of the Social 
     Security Act,

[[Page H1955]]

       ``(iv) the TRICARE for Life program,
       ``(v) the veteran's health care program under chapter 17 of 
     title 38, United States Code, or
       ``(vi) a health plan under section 2504(e) of title 22, 
     United States Code (relating to Peace Corps volunteers).
       ``(B) Employer-sponsored plan.--Coverage under an eligible 
     employer-sponsored plan.
       ``(C) Plans in the individual market.--Coverage under a 
     health plan offered in the individual market within a State.
       ``(D) Grandfathered health plan.--Coverage under a 
     grandfathered health plan.
       ``(E) Other coverage.--Such other health benefits coverage, 
     such as a State health benefits risk pool, as the Secretary 
     of Health and Human Services, in coordination with the 
     Secretary, recognizes for purposes of this subsection.
       ``(2) Eligible employer-sponsored plan.--The term `eligible 
     employer-sponsored plan' means, with respect to any employee, 
     a group health plan or group health insurance coverage 
     offered by an employer to the employee which is--
       ``(A) a governmental plan (within the meaning of section 
     2791(d)(8) of the Public Health Service Act), or
       ``(B) any other plan or coverage offered in the small or 
     large group market within a State.
     Such term shall include a grandfathered health plan described 
     in paragraph (1)(D) offered in a group market.
       ``(3) Excepted benefits not treated as minimum essential 
     coverage.--The term `minimum essential coverage' shall not 
     include health insurance coverage which consists of coverage 
     of excepted benefits--
       ``(A) described in paragraph (1) of subsection (c) of 
     section 2791 of the Public Health Service Act; or
       ``(B) described in paragraph (2), (3), or (4) of such 
     subsection if the benefits are provided under a separate 
     policy, certificate, or contract of insurance.
       ``(4) Individuals residing outside united states or 
     residents of territories.--Any applicable individual shall be 
     treated as having minimum essential coverage for any month--
       ``(A) if such month occurs during any period described in 
     subparagraph (A) or (B) of section 911(d)(1) which is 
     applicable to the individual, or
       ``(B) if such individual is a bona fide resident of any 
     possession of the United States (as determined under section 
     937(a)) for such month.
       ``(5) Insurance-related terms.--Any term used in this 
     section which is also used in title I of the Patient 
     Protection and Affordable Care Act shall have the same 
     meaning as when used in such title.
       ``(g) Administration and Procedure.--
       ``(1) In general.--The penalty provided by this section 
     shall be paid upon notice and demand by the Secretary, and 
     except as provided in paragraph (2), shall be assessed and 
     collected in the same manner as an assessable penalty under 
     subchapter B of chapter 68.
       ``(2) Special rules.--Notwithstanding any other provision 
     of law--
       ``(A) Waiver of criminal penalties.--In the case of any 
     failure by a taxpayer to timely pay any penalty imposed by 
     this section, such taxpayer shall not be subject to any 
     criminal prosecution or penalty with respect to such failure.
       ``(B) Limitations on liens and levies.--The Secretary shall 
     not--
       ``(i) file notice of lien with respect to any property of a 
     taxpayer by reason of any failure to pay the penalty imposed 
     by this section, or
       ``(ii) levy on any such property with respect to such 
     failure.''.
       (c) Clerical Amendment.--The table of chapters for subtitle 
     D of the Internal Revenue Code of 1986 is amended by 
     inserting after the item relating to chapter 47 the following 
     new item:

      ``Chapter 48--Maintenance of Minimum Essential Coverage.''.

       (d) Effective Date.--The amendments made by this section 
     shall apply to taxable years ending after December 31, 2013.

     SEC. 1502. REPORTING OF HEALTH INSURANCE COVERAGE.

       (a) In General.--Part III of subchapter A of chapter 61 of 
     the Internal Revenue Code of 1986 is amended by inserting 
     after subpart C the following new subpart:

      ``Subpart D--Information Regarding Health Insurance Coverage

``Sec. 6055. Reporting of health insurance coverage.

     ``SEC. 6055. REPORTING OF HEALTH INSURANCE COVERAGE.

       ``(a) In General.--Every person who provides minimum 
     essential coverage to an individual during a calendar year 
     shall, at such time as the Secretary may prescribe, make a 
     return described in subsection (b).
       ``(b) Form and Manner of Return.--
       ``(1) In general.--A return is described in this subsection 
     if such return--
       ``(A) is in such form as the Secretary may prescribe, and
       ``(B) contains--
       ``(i) the name, address and TIN of the primary insured and 
     the name and TIN of each other individual obtaining coverage 
     under the policy,
       ``(ii) the dates during which such individual was covered 
     under minimum essential coverage during the calendar year,
       ``(iii) in the case of minimum essential coverage which 
     consists of health insurance coverage, information 
     concerning--

       ``(I) whether or not the coverage is a qualified health 
     plan offered through an Exchange established under section 
     1311 of the Patient Protection and Affordable Care Act, and
       ``(II) in the case of a qualified health plan, the amount 
     (if any) of any advance payment under section 1412 of the 
     Patient Protection and Affordable Care Act of any cost-
     sharing reduction under section 1402 of such Act or of any 
     premium tax credit under section 36B with respect to such 
     coverage, and

       ``(iv) such other information as the Secretary may require.
       ``(2) Information relating to employer-provided coverage.--
     If minimum essential coverage provided to an individual under 
     subsection (a) consists of health insurance coverage of a 
     health insurance issuer provided through a group health plan 
     of an employer, a return described in this subsection shall 
     include--
       ``(A) the name, address, and employer identification number 
     of the employer maintaining the plan,
       ``(B) the portion of the premium (if any) required to be 
     paid by the employer, and
       ``(C) if the health insurance coverage is a qualified 
     health plan in the small group market offered through an 
     Exchange, such other information as the Secretary may require 
     for administration of the credit under section 45R (relating 
     to credit for employee health insurance expenses of small 
     employers).
       ``(c) Statements To Be Furnished to Individuals With 
     Respect to Whom Information Is Reported.--
       ``(1) In general.--Every person required to make a return 
     under subsection (a) shall furnish to each individual whose 
     name is required to be set forth in such return a written 
     statement showing--
       ``(A) the name and address of the person required to make 
     such return and the phone number of the information contact 
     for such person, and
       ``(B) the information required to be shown on the return 
     with respect to such individual.
       ``(2) Time for furnishing statements.--The written 
     statement required under paragraph (1) shall be furnished on 
     or before January 31 of the year following the calendar year 
     for which the return under subsection (a) was required to be 
     made.
       ``(d) Coverage Provided by Governmental Units.--In the case 
     of coverage provided by any governmental unit or any agency 
     or instrumentality thereof, the officer or employee who 
     enters into the agreement to provide such coverage (or the 
     person appropriately designated for purposes of this section) 
     shall make the returns and statements required by this 
     section.
       ``(e) Minimum Essential Coverage.--For purposes of this 
     section, the term `minimum essential coverage' has the 
     meaning given such term by section 5000A(f).''.
       (b) Assessable Penalties.--
       (1) Subparagraph (B) of section 6724(d)(1) of the Internal 
     Revenue Code of 1986 (relating to definitions) is amended by 
     striking ``or'' at the end of clause (xxii), by striking 
     ``and'' at the end of clause (xxiii) and inserting ``or'', 
     and by inserting after clause (xxiii) the following new 
     clause:
       ``(xxiv) section 6055 (relating to returns relating to 
     information regarding health insurance coverage), and''.
       (2) Paragraph (2) of section 6724(d) of such Code is 
     amended by striking ``or'' at the end of subparagraph (EE), 
     by striking the period at the end of subparagraph (FF) and 
     inserting ``, or'' and by inserting after subparagraph (FF) 
     the following new subparagraph:
       ``(GG) section 6055(c) (relating to statements relating to 
     information regarding health insurance coverage).''.
       (c) Notification of Nonenrollment.--Not later than June 30 
     of each year, the Secretary of the Treasury, acting through 
     the Internal Revenue Service and in consultation with the 
     Secretary of Health and Human Services, shall send a 
     notification to each individual who files an individual 
     income tax return and who is not enrolled in minimum 
     essential coverage (as defined in section 5000A of the 
     Internal Revenue Code of 1986). Such notification shall 
     contain information on the services available through the 
     Exchange operating in the State in which such individual 
     resides.
       (d) Conforming Amendment.--The table of subparts for part 
     III of subchapter A of chapter 61 of such Code is amended by 
     inserting after the item relating to subpart C the following 
     new item:

    ``subpart d--information regarding health insurance coverage''.

       (e) Effective Date.--The amendments made by this section 
     shall apply to calendar years beginning after 2013.

                   PART II--EMPLOYER RESPONSIBILITIES

     SEC. 1511. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE 
                   EMPLOYERS.

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

     ``SEC. 18A. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE 
                   EMPLOYERS.

       ``In accordance with regulations promulgated by the 
     Secretary, an employer to which this Act applies that has 
     more than 200 full-time employees and that offers employees 
     enrollment in 1 or more health benefits plans shall 
     automatically enroll new full-time employees in one of the 
     plans offered (subject to any waiting period authorized by 
     law) and to continue the enrollment of current employees in a 
     health benefits plan offered through the employer. Any 
     automatic enrollment program shall include adequate notice 
     and the opportunity for an employee to opt out of any 
     coverage the individual or employee were automatically 
     enrolled in. Nothing in this section shall be construed to 
     supersede any State law which establishes, implements, or 
     continues in effect any standard or requirement relating to 
     employers in connection with payroll except to the extent 
     that such standard or requirement prevents an employer from 
     instituting

[[Page H1956]]

     the automatic enrollment program under this section.''.

     SEC. 1512. EMPLOYER REQUIREMENT TO INFORM EMPLOYEES OF 
                   COVERAGE OPTIONS.

       The Fair Labor Standards Act of 1938 is amended by 
     inserting after section 18A (as added by section 1513) the 
     following:

     ``SEC. 18B. NOTICE TO EMPLOYEES.

       ``(a) In General.--In accordance with regulations 
     promulgated by the Secretary, an employer to which this Act 
     applies, shall provide to each employee at the time of hiring 
     (or with respect to current employees, not later than March 
     1, 2013), written notice--
       ``(1) informing the employee of the existence of an 
     Exchange, including a description of the services provided by 
     such Exchange, and the manner in which the employee may 
     contact the Exchange to request assistance;
       ``(2) if the employer plan's share of the total allowed 
     costs of benefits provided under the plan is less than 60 
     percent of such costs, that the employee may be eligible for 
     a premium tax credit under section 36B of the Internal 
     Revenue Code of 1986 and a cost sharing reduction under 
     section 1402 of the Patient Protection and Affordable Care 
     Act if the employee purchases a qualified health plan through 
     the Exchange; and
       ``(3) if the employee purchases a qualified health plan 
     through the Exchange, the employee will lose the employer 
     contribution (if any) to any health benefits plan offered by 
     the employer and that all or a portion of such contribution 
     may be excludable from income for Federal income tax 
     purposes.
       ``(b) Effective Date.--Subsection (a) shall take effect 
     with respect to employers in a State beginning on March 1, 
     2013.''.

     SEC. 1513. SHARED RESPONSIBILITY FOR EMPLOYERS.

       (a) In General.--Chapter 43 of the Internal Revenue Code of 
     1986 is amended by adding at the end the following:

     ``SEC. 4980H. SHARED RESPONSIBILITY FOR EMPLOYERS REGARDING 
                   HEALTH COVERAGE.

       ``(a) Large Employers Not Offering Health Coverage.--If--
       ``(1) any applicable large employer fails to offer to its 
     full-time employees (and their dependents) the opportunity to 
     enroll in minimum essential coverage under an eligible 
     employer-sponsored plan (as defined in section 5000A(f)(2)) 
     for any month, and
       ``(2) at least one full-time employee of the applicable 
     large employer has been certified to the employer under 
     section 1411 of the Patient Protection and Affordable Care 
     Act as having enrolled for such month in a qualified health 
     plan with respect to which an applicable premium tax credit 
     or cost-sharing reduction is allowed or paid with respect to 
     the employee,

     then there is hereby imposed on the employer an assessable 
     payment equal to the product of the applicable payment amount 
     and the number of individuals employed by the employer as 
     full-time employees during such month.
       ``(b) Large Employers With Waiting Periods Exceeding 30 
     Days.--
       ``(1) In general.--In the case of any applicable large 
     employer which requires an extended waiting period to enroll 
     in any minimum essential coverage under an employer-sponsored 
     plan (as defined in section 5000A(f)(2)), there is hereby 
     imposed on the employer an assessable payment, in the amount 
     specified in paragraph (2), for each full-time employee of 
     the employer to whom the extended waiting period applies.
       ``(2) Amount.--For purposes of paragraph (1), the amount 
     specified in this paragraph for a full-time employee is--
       ``(A) in the case of an extended waiting period which 
     exceeds 30 days but does not exceed 60 days, $400, and
       ``(B) in the case of an extended waiting period which 
     exceeds 60 days, $600.
       ``(3) Extended waiting period.--The term `extended waiting 
     period' means any waiting period (as defined in section 
     2701(b)(4) of the Public Health Service Act) which exceeds 30 
     days.
       ``(c) Large Employers Offering Coverage With Employees Who 
     Qualify for Premium Tax Credits or Cost-sharing Reductions.--
       ``(1) In general.--If--
       ``(A) an applicable large employer offers to its full-time 
     employees (and their dependents) the opportunity to enroll in 
     minimum essential coverage under an eligible employer-
     sponsored plan (as defined in section 5000A(f)(2)) for any 
     month, and
       ``(B) 1 or more full-time employees of the applicable large 
     employer has been certified to the employer under section 
     1411 of the Patient Protection and Affordable Care Act as 
     having enrolled for such month in a qualified health plan 
     with respect to which an applicable premium tax credit or 
     cost-sharing reduction is allowed or paid with respect to the 
     employee,
     then there is hereby imposed on the employer an assessable 
     payment equal to the product of the number of full-time 
     employees of the applicable large employer described in 
     subparagraph (B) for such month and 400 percent of the 
     applicable payment amount.
       ``(2) Overall limitation.--The aggregate amount of tax 
     determined under paragraph (1) with respect to all employees 
     of an applicable large employer for any month shall not 
     exceed the product of the applicable payment amount and the 
     number of individuals employed by the employer as full-time 
     employees during such month.
       ``(d) Definitions and Special Rules.--For purposes of this 
     section--
       ``(1) Applicable payment amount.--The term `applicable 
     payment amount' means, with respect to any month, \1/12\ of 
     $750.
       ``(2) Applicable large employer.--
       ``(A) In general.--The term `applicable large employer' 
     means, with respect to a calendar year, an employer who 
     employed an average of at least 50 full-time employees on 
     business days during the preceding calendar year.
       ``(B) Exemption for certain employers.--
       ``(i) In general.--An employer shall not be considered to 
     employ more than 50 full-time employees if--

       ``(I) the employer's workforce exceeds 50 full-time 
     employees for 120 days or fewer during the calendar year, and
       ``(II) the employees in excess of 50 employed during such 
     120-day period were seasonal workers.

       ``(ii) Definition of seasonal workers.--The term `seasonal 
     worker' means a worker who performs labor or services on a 
     seasonal basis as defined by the Secretary of Labor, 
     including workers covered by section 500.20(s)(1) of title 
     29, Code of Federal Regulations and retail workers employed 
     exclusively during holiday seasons.
       ``(C) Rules for determining employer size.--For purposes of 
     this paragraph--
       ``(i) Application of aggregation rule for employers.--All 
     persons treated as a single employer under subsection (b), 
     (c), (m), or (o) of section 414 of the Internal Revenue Code 
     of 1986 shall be treated as 1 employer.
       ``(ii) Employers not in existence in preceding year.--In 
     the case of an employer which was not in existence throughout 
     the preceding calendar year, the determination of whether 
     such employer is an applicable large employer shall be based 
     on the average number of employees that it is reasonably 
     expected such employer will employ on business days in the 
     current calendar year.
       ``(iii) Predecessors.--Any reference in this subsection to 
     an employer shall include a reference to any predecessor of 
     such employer.
       ``(3) Applicable premium tax credit and cost-sharing 
     reduction.--The term `applicable premium tax credit and cost-
     sharing reduction' means--
       ``(A) any premium tax credit allowed under section 36B,
       ``(B) any cost-sharing reduction under section 1402 of the 
     Patient Protection and Affordable Care Act, and
       ``(C) any advance payment of such credit or reduction under 
     section 1412 of such Act.
       ``(4) Full-time employee.--
       ``(A) In general.--The term `full-time employee' means an 
     employee who is employed on average at least 30 hours of 
     service per week.
       ``(B) Hours of service.--The Secretary, in consultation 
     with the Secretary of Labor, shall prescribe such 
     regulations, rules, and guidance as may be necessary to 
     determine the hours of service of an employee, including 
     rules for the application of this paragraph to employees who 
     are not compensated on an hourly basis.
       ``(5) Inflation adjustment.--
       ``(A) In general.--In the case of any calendar year after 
     2014, each of the dollar amounts in subsection (b)(2) and 
     (d)(1) shall be increased by an amount equal to the product 
     of--
       ``(i) such dollar amount, and
       ``(ii) the premium adjustment percentage (as defined in 
     section 1302(c)(4) of the Patient Protection and Affordable 
     Care Act) for the calendar year.
       ``(B) Rounding.--If the amount of any increase under 
     subparagraph (A) is not a multiple of $10, such increase 
     shall be rounded to the next lowest multiple of $10.
       ``(6) Other definitions.--Any term used in this section 
     which is also used in the Patient Protection and Affordable 
     Care Act shall have the same meaning as when used in such 
     Act.
       ``(7) Tax nondeductible.--For denial of deduction for the 
     tax imposed by this section, see section 275(a)(6).
       ``(e) Administration and Procedure.--
       ``(1) In general.--Any assessable payment provided by this 
     section shall be paid upon notice and demand by the 
     Secretary, and shall be assessed and collected in the same 
     manner as an assessable penalty under subchapter B of chapter 
     68.
       ``(2) Time for payment.--The Secretary may provide for the 
     payment of any assessable payment provided by this section on 
     an annual, monthly, or other periodic basis as the Secretary 
     may prescribe.
       ``(3) Coordination with credits, etc..--The Secretary shall 
     prescribe rules, regulations, or guidance for the repayment 
     of any assessable payment (including interest) if such 
     payment is based on the allowance or payment of an applicable 
     premium tax credit or cost-sharing reduction with respect to 
     an employee, such allowance or payment is subsequently 
     disallowed, and the assessable payment would not have been 
     required to be made but for such allowance or payment.''.
       (b) Clerical Amendment.--The table of sections for chapter 
     43 of such Code is amended by adding at the end the following 
     new item:

``Sec. 4980H. Shared responsibility for employers regarding health 
              coverage.''.

       (c) Study and Report of Effect of Tax on Workers' Wages.--
       (1) In general.--The Secretary of Labor shall conduct a 
     study to determine whether employees' wages are reduced by 
     reason of the application of the assessable payments under 
     section 4980H of the Internal Revenue Code of 1986 (as added 
     by the amendments made by this section). The Secretary shall 
     make such determination on the basis of the National 
     Compensation Survey published by the Bureau of Labor 
     Statistics.
       (2) Report.--The Secretary shall report the results of the 
     study under paragraph (1) to the Committee on Ways and Means 
     of the House of Representatives and to the Committee on 
     Finance of the Senate.
       (d) Effective Date.--The amendments made by this section 
     shall apply to months beginning after December 31, 2013.

[[Page H1957]]

     SEC. 1514. REPORTING OF EMPLOYER HEALTH INSURANCE COVERAGE.

       (a) In General.--Subpart D of part III of subchapter A of 
     chapter 61 of the Internal Revenue Code of 1986, as added by 
     section 1502, is amended by inserting after section 6055 the 
     following new section:

     ``SEC. 6056. LARGE EMPLOYERS REQUIRED TO REPORT ON HEALTH 
                   INSURANCE COVERAGE.

       ``(a) In General.--Every applicable large employer required 
     to meet the requirements of section 4980H with respect to its 
     full-time employees during a calendar year shall, at such 
     time as the Secretary may prescribe, make a return described 
     in subsection (b).
       ``(b) Form and Manner of Return.--A return is described in 
     this subsection if such return--
       ``(1) is in such form as the Secretary may prescribe, and
       ``(2) contains--
       ``(A) the name, date, and employer identification number of 
     the employer,
       ``(B) a certification as to whether the employer offers to 
     its full-time employees (and their dependents) the 
     opportunity to enroll in minimum essential coverage under an 
     eligible employer-sponsored plan (as defined in section 
     5000A(f)(2)),
       ``(C) if the employer certifies that the employer did offer 
     to its full-time employees (and their dependents) the 
     opportunity to so enroll--
       ``(i) the length of any waiting period (as defined in 
     section 2701(b)(4) of the Public Health Service Act) with 
     respect to such coverage,
       ``(ii) the months during the calendar year for which 
     coverage under the plan was available,
       ``(iii) the monthly premium for the lowest cost option in 
     each of the enrollment categories under the plan, and
       ``(iv) the applicable large employer's share of the total 
     allowed costs of benefits provided under the plan,
       ``(D) the number of full-time employees for each month 
     during the calendar year,
       ``(E) the name, address, and TIN of each full-time employee 
     during the calendar year and the months (if any) during which 
     such employee (and any dependents) were covered under any 
     such health benefits plans, and
       ``(F) such other information as the Secretary may require.
       ``(c) Statements To Be Furnished to Individuals With 
     Respect to Whom Information Is Reported.--
       ``(1) In general.--Every person required to make a return 
     under subsection (a) shall furnish to each full-time employee 
     whose name is required to be set forth in such return under 
     subsection (b)(2)(E) a written statement showing--
       ``(A) the name and address of the person required to make 
     such return and the phone number of the information contact 
     for such person, and
       ``(B) the information required to be shown on the return 
     with respect to such individual.
       ``(2) Time for furnishing statements.--The written 
     statement required under paragraph (1) shall be furnished on 
     or before January 31 of the year following the calendar year 
     for which the return under subsection (a) was required to be 
     made.
       ``(d) Coordination With Other Requirements.--To the maximum 
     extent feasible, the Secretary may provide that--
       ``(1) any return or statement required to be provided under 
     this section may be provided as part of any return or 
     statement required under section 6051 or 6055, and
       ``(2) in the case of an applicable large employer offering 
     health insurance coverage of a health insurance issuer, the 
     employer may enter into an agreement with the issuer to 
     include information required under this section with the 
     return and statement required to be provided by the issuer 
     under section 6055.
       ``(e) Coverage Provided by Governmental Units.--In the case 
     of any applicable large employer which is a governmental unit 
     or any agency or instrumentality thereof, the person 
     appropriately designated for purposes of this section shall 
     make the returns and statements required by this section.
       ``(f) Definitions.--For purposes of this section, any term 
     used in this section which is also used in section 4980H 
     shall have the meaning given such term by section 4980H.''.
       (b) Assessable Penalties.--
       (1) Subparagraph (B) of section 6724(d)(1) of the Internal 
     Revenue Code of 1986 (relating to definitions), as amended by 
     section 1502, is amended by striking ``or'' at the end of 
     clause (xxiii), by striking ``and'' at the end of clause 
     (xxiv) and inserting ``or'', and by inserting after clause 
     (xxiv) the following new clause:
       ``(xxv) section 6056 (relating to returns relating to large 
     employers required to report on health insurance coverage), 
     and''.
       (2) Paragraph (2) of section 6724(d) of such Code, as so 
     amended, is amended by striking ``or'' at the end of 
     subparagraph (FF), by striking the period at the end of 
     subparagraph (GG) and inserting ``, or'' and by inserting 
     after subparagraph (GG) the following new subparagraph:
       ``(HH) section 6056(c) (relating to statements relating to 
     large employers required to report on health insurance 
     coverage).''.
       (c) Conforming Amendment.--The table of sections for 
     subpart D of part III of subchapter A of chapter 61 of such 
     Code, as added by section 1502, is amended by adding at the 
     end the following new item:

``Sec. 6056. Large employers required to report on health insurance 
              coverage.''.
       (d) Effective Date.--The amendments made by this section 
     shall apply to periods beginning after December 31, 2013.

     SEC. 1515. OFFERING OF EXCHANGE-PARTICIPATING QUALIFIED 
                   HEALTH PLANS THROUGH CAFETERIA PLANS.

       (a) In General.--Subsection (f) of section 125 of the 
     Internal Revenue Code of 1986 is amended by adding at the end 
     the following new paragraph:
       ``(3) Certain exchange-participating qualified health plans 
     not qualified.--
       ``(A) In general.--The term `qualified benefit' shall not 
     include any qualified health plan (as defined in section 
     1301(a) of the Patient Protection and Affordable Care Act) 
     offered through an Exchange established under section 1311 of 
     such Act.
       ``(B) Exception for exchange-eligible employers.--
     Subparagraph (A) shall not apply with respect to any employee 
     if such employee's employer is a qualified employer (as 
     defined in section 1312(f)(2) of the Patient Protection and 
     Affordable Care Act) offering the employee the opportunity to 
     enroll through such an Exchange in a qualified health plan in 
     a group market.''.
       (b) Conforming Amendments.--Subsection (f) of section 125 
     of such Code is amended--
       (1) by striking ``For purposes of this section, the term'' 
     and inserting ``For purposes of this section--
       ``(1) In General.--The term'', and
       (2) by striking ``Such term shall not include'' and 
     inserting the following:
       ``(2) Long-term care insurance not qualified.--The term 
     `qualified benefit' shall not include''.
       (c) Effective Date.--The amendments made by this section 
     shall apply to taxable years beginning after December 31, 
     2013.

                  Subtitle G--Miscellaneous Provisions

     SEC. 1551. DEFINITIONS.

       Unless specifically provided for otherwise, the definitions 
     contained in section 2791 of the Public Health Service Act 
     (42 U.S.C. 300gg-91) shall apply with respect to this title.

     SEC. 1552. TRANSPARENCY IN GOVERNMENT.

       Not later than 30 days after the date of enactment of this 
     Act, the Secretary of Health and Human Services shall publish 
     on the Internet website of the Department of Health and Human 
     Services, a list of all of the authorities provided to the 
     Secretary under this Act (and the amendments made by this 
     Act).

     SEC. 1553. PROHIBITION AGAINST DISCRIMINATION ON ASSISTED 
                   SUICIDE.

       (a) In General.--The Federal Government, and any State or 
     local government or health care provider that receives 
     Federal financial assistance under this Act (or under an 
     amendment made by this Act) or any health plan created under 
     this Act (or under an amendment made by this Act), may not 
     subject an individual or institutional health care entity to 
     discrimination on the basis that the entity does not provide 
     any health care item or service furnished for the purpose of 
     causing, or for the purpose of assisting in causing, the 
     death of any individual, such as by assisted suicide, 
     euthanasia, or mercy killing.
       (b) Definition.--In this section, the term ``health care 
     entity'' includes an individual physician or other health 
     care professional, a hospital, a provider-sponsored 
     organization, a health maintenance organization, a health 
     insurance plan, or any other kind of health care facility, 
     organization, or plan.
       (c) Construction and Treatment of Certain Services.--
     Nothing in subsection (a) shall be construed to apply to, or 
     to affect, any limitation relating to--
       (1) the withholding or withdrawing of medical treatment or 
     medical care;
       (2) the withholding or withdrawing of nutrition or 
     hydration;
       (3) abortion; or
       (4) the use of an item, good, benefit, or service furnished 
     for the purpose of alleviating pain or discomfort, even if 
     such use may increase the risk of death, so long as such 
     item, good, benefit, or service is not also furnished for the 
     purpose of causing, or the purpose of assisting in causing, 
     death, for any reason.
       (d) Administration.--The Office for Civil Rights of the 
     Department of Health and Human Services is designated to 
     receive complaints of discrimination based on this section.

     SEC. 1554. ACCESS TO THERAPIES.

       Notwithstanding any other provision of this Act, the 
     Secretary of Health and Human Services shall not promulgate 
     any regulation that--
       (1) creates any unreasonable barriers to the ability of 
     individuals to obtain appropriate medical care;
       (2) impedes timely access to health care services;
       (3) interferes with communications regarding a full range 
     of treatment options between the patient and the provider;
       (4) restricts the ability of health care providers to 
     provide full disclosure of all relevant information to 
     patients making health care decisions;
       (5) violates the principles of informed consent and the 
     ethical standards of health care professionals; or
       (6) limits the availability of health care treatment for 
     the full duration of a patient's medical needs.

     SEC. 1555. FREEDOM NOT TO PARTICIPATE IN FEDERAL HEALTH 
                   INSURANCE PROGRAMS.

       No individual, company, business, nonprofit entity, or 
     health insurance issuer offering group or individual health 
     insurance coverage shall be required to participate in any 
     Federal health insurance program created under this Act (or 
     any amendments made by this Act), or in any Federal health 
     insurance program expanded by this Act (or any such 
     amendments), and there shall be no penalty or fine imposed 
     upon any such issuer for choosing not to participate in such 
     programs.

     SEC. 1556. EQUITY FOR CERTAIN ELIGIBLE SURVIVORS.

       (a) Rebuttable Presumption.--Section 411(c)(4) of the Black 
     Lung Benefits Act (30

[[Page H1958]]

     U.S.C. 921(c)(4)) is amended by striking the last sentence.
       (b) Continuation of Benefits.--Section 422(l) of the Black 
     Lung Benefits Act (30 U.S.C. 932(l)) is amended by striking 
     ``, except with respect to a claim filed under this part on 
     or after the effective date of the Black Lung Benefits 
     Amendments of 1981''.
       (c) Effective Date.--The amendments made by this section 
     shall apply with respect to claims filed under part B or part 
     C of the Black Lung Benefits Act (30 U.S.C. 921 et seq., 931 
     et seq.) after January 1, 2005, that are pending on or after 
     the date of enactment of this Act.

     SEC. 1557. NONDISCRIMINATION.

       (a) In General.--Except as otherwise provided for in this 
     title (or an amendment made by this title), an individual 
     shall not, on the ground prohibited under title VI of the 
     Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title IX 
     of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), 
     the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.), 
     or section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 
     794), be excluded from participation in, be denied the 
     benefits of, or be subjected to discrimination under, any 
     health program or activity, any part of which is receiving 
     Federal financial assistance, including credits, subsidies, 
     or contracts of insurance, or under any program or activity 
     that is administered by an Executive Agency or any entity 
     established under this title (or amendments). The enforcement 
     mechanisms provided for and available under such title VI, 
     title IX, section 504, or such Age Discrimination Act shall 
     apply for purposes of violations of this subsection.
       (b) Continued Application of Laws.--Nothing in this title 
     (or an amendment made by this title) shall be construed to 
     invalidate or limit the rights, remedies, procedures, or 
     legal standards available to individuals aggrieved under 
     title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et 
     seq.), title VII of the Civil Rights Act of 1964 (42 U.S.C. 
     2000e et seq.), title IX of the Education Amendments of 1972 
     (20 U.S.C. 1681 et seq.), section 504 of the Rehabilitation 
     Act of 1973 (29 U.S.C. 794), or the Age Discrimination Act of 
     1975 (42 U.S.C. 611 et seq.), or to supersede State laws that 
     provide additional protections against discrimination on any 
     basis described in subsection (a).
       (c) Regulations.--The Secretary may promulgate regulations 
     to implement this section.

     SEC. 1558. PROTECTIONS FOR EMPLOYEES.

       The Fair Labor Standards Act of 1938 is amended by 
     inserting after section 18B (as added by section 1512) the 
     following:

     ``SEC. 18C. PROTECTIONS FOR EMPLOYEES.

       ``(a) Prohibition.--No employer shall discharge or in any 
     manner discriminate against any employee with respect to his 
     or her compensation, terms, conditions, or other privileges 
     of employment because the employee (or an individual acting 
     at the request of the employee) has--
       ``(1) received a credit under section 36B of the Internal 
     Revenue Code of 1986 or a subsidy under section 1402 of this 
     Act;
       ``(2) provided, caused to be provided, or is about to 
     provide or cause to be provided to the employer, the Federal 
     Government, or the attorney general of a State information 
     relating to any violation of, or any act or omission the 
     employee reasonably believes to be a violation of, any 
     provision of this title (or an amendment made by this title);
       ``(3) testified or is about to testify in a proceeding 
     concerning such violation;
       ``(4) assisted or participated, or is about to assist or 
     participate, in such a proceeding; or
       ``(5) objected to, or refused to participate in, any 
     activity, policy, practice, or assigned task that the 
     employee (or other such person) reasonably believed to be in 
     violation of any provision of this title (or amendment), or 
     any order, rule, regulation, standard, or ban under this 
     title (or amendment).
       ``(b) Complaint Procedure.--
       ``(1) In general.--An employee who believes that he or she 
     has been discharged or otherwise discriminated against by any 
     employer in violation of this section may seek relief in 
     accordance with the procedures, notifications, burdens of 
     proof, remedies, and statutes of limitation set forth in 
     section 2087(b) of title 15, United States Code.
       ``(2) No limitation on rights.--Nothing in this section 
     shall be deemed to diminish the rights, privileges, or 
     remedies of any employee under any Federal or State law or 
     under any collective bargaining agreement. The rights and 
     remedies in this section may not be waived by any agreement, 
     policy, form, or condition of employment.''.

     SEC. 1559. OVERSIGHT.

       The Inspector General of the Department of Health and Human 
     Services shall have oversight authority with respect to the 
     administration and implementation of this title as it relates 
     to such Department.

     SEC. 1560. RULES OF CONSTRUCTION.

       (a) No Effect on Antitrust Laws.--Nothing in this title (or 
     an amendment made by this title) shall be construed to 
     modify, impair, or supersede the operation of any of the 
     antitrust laws. For the purposes of this section, the term 
     ``antitrust laws'' has the meaning given such term in 
     subsection (a) of the first section of the Clayton Act, 
     except that such term includes section 5 of the Federal Trade 
     Commission Act to the extent that such section 5 applies to 
     unfair methods of competition.
       (b) Rule of Construction Regarding Hawaii's Prepaid Health 
     Care Act.--Nothing in this title (or an amendment made by 
     this title) shall be construed to modify or limit the 
     application of the exemption for Hawaii's Prepaid Health Care 
     Act (Haw. Rev. Stat. Sec. Sec.  393-1 et seq.) as provided 
     for under section 514(b)(5) of the Employee Retirement Income 
     Security Act of 1974 (29 U.S.C. 1144(b)(5)).
       (c) Student Health Insurance Plans.--Nothing in this title 
     (or an amendment made by this title) shall be construed to 
     prohibit an institution of higher education (as such term is 
     defined for purposes of the Higher Education Act of 1965) 
     from offering a student health insurance plan, to the extent 
     that such requirement is otherwise permitted under applicable 
     Federal, State or local law.
       (d) No Effect on Existing Requirements.--Nothing in this 
     title (or an amendment made by this title, unless specified 
     by direct statutory reference) shall be construed to modify 
     any existing Federal requirement concerning the State agency 
     responsible for determining eligibility for programs 
     identified in section 1413.

     SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STANDARDS 
                   AND PROTOCOLS.

       Title XXX of the Public Health Service Act (42 U.S.C. 300jj 
     et seq.) is amended by adding at the end the following:

                     ``Subtitle C--Other Provisions

     ``SEC. 3021. HEALTH INFORMATION TECHNOLOGY ENROLLMENT 
                   STANDARDS AND PROTOCOLS.

       ``(a) In General.--
       ``(1) Standards and protocols.--Not later than 180 days 
     after the date of enactment of this title, the Secretary, in 
     consultation with the HIT Policy Committee and the HIT 
     Standards Committee, shall develop interoperable and secure 
     standards and protocols that facilitate enrollment of 
     individuals in Federal and State health and human services 
     programs, as determined by the Secretary.
       ``(2) Methods.--The Secretary shall facilitate enrollment 
     in such programs through methods determined appropriate by 
     the Secretary, which shall include providing individuals and 
     third parties authorized by such individuals and their 
     designees notification of eligibility and verification of 
     eligibility required under such programs.
       ``(b) Content.--The standards and protocols for electronic 
     enrollment in the Federal and State programs described in 
     subsection (a) shall allow for the following:
       ``(1) Electronic matching against existing Federal and 
     State data, including vital records, employment history, 
     enrollment systems, tax records, and other data determined 
     appropriate by the Secretary to serve as evidence of 
     eligibility and in lieu of paper-based documentation.
       ``(2) Simplification and submission of electronic 
     documentation, digitization of documents, and systems 
     verification of eligibility.
       ``(3) Reuse of stored eligibility information (including 
     documentation) to assist with retention of eligible 
     individuals.
       ``(4) Capability for individuals to apply, recertify and 
     manage their eligibility information online, including at 
     home, at points of service, and other community-based 
     locations.
       ``(5) Ability to expand the enrollment system to integrate 
     new programs, rules, and functionalities, to operate at 
     increased volume, and to apply streamlined verification and 
     eligibility processes to other Federal and State programs, as 
     appropriate.
       ``(6) Notification of eligibility, recertification, and 
     other needed communication regarding eligibility, which may 
     include communication via email and cellular phones.
       ``(7) Other functionalities necessary to provide eligibles 
     with streamlined enrollment process.
       ``(c) Approval and Notification.--With respect to any 
     standard or protocol developed under subsection (a) that has 
     been approved by the HIT Policy Committee and the HIT 
     Standards Committee, the Secretary--
       ``(1) shall notify States of such standards or protocols; 
     and
       ``(2) may require, as a condition of receiving Federal 
     funds for the health information technology investments, that 
     States or other entities incorporate such standards and 
     protocols into such investments.
       ``(d) Grants for Implementation of Appropriate Enrollment 
     HIT.--
       ``(1) In general.--The Secretary shall award grant to 
     eligible entities to develop new, and adapt existing, 
     technology systems to implement the HIT enrollment standards 
     and protocols developed under subsection (a) (referred to in 
     this subsection as `appropriate HIT technology').
       ``(2) Eligible entities.--To be eligible for a grant under 
     this subsection, an entity shall--
       ``(A) be a State, political subdivision of a State, or a 
     local governmental entity; and
       ``(B) submit to the Secretary an application at such time, 
     in such manner, and containing--
       ``(i) a plan to adopt and implement appropriate enrollment 
     technology that includes--

       ``(I) proposed reduction in maintenance costs of technology 
     systems;
       ``(II) elimination or updating of legacy systems; and
       ``(III) demonstrated collaboration with other entities that 
     may receive a grant under this section that are located in 
     the same State, political subdivision, or locality;

       ``(ii) an assurance that the entity will share such 
     appropriate enrollment technology in accordance with 
     paragraph (4); and
       ``(iii) such other information as the Secretary may 
     require.
       ``(3) Sharing.--
       ``(A) In general.--The Secretary shall ensure that 
     appropriate enrollment HIT adopted under grants under this 
     subsection is made available to other qualified State, 
     qualified political subdivisions of a State, or other 
     appropriate qualified entities (as described in subparagraph 
     (B)) at no cost.
       ``(B) Qualified entities.--The Secretary shall determine 
     what entities are qualified to receive enrollment HIT under 
     subparagraph (A), taking into consideration the 
     recommendations of the HIT Policy Committee and the HIT 
     Standards Committee.''.

[[Page H1959]]

     SEC. 1562. CONFORMING AMENDMENTS.

       (a) Applicability.--Section 2735 of the Public Health 
     Service Act (42 U.S.C. 300gg-21), as so redesignated by 
     section 1001(4), is amended--
       (1) by striking subsection (a);
       (2) in subsection (b)--
       (A) in paragraph (1), by striking ``1 through 3'' and 
     inserting ``1 and 2''; and
       (B) in paragraph (2)--
       (i) in subparagraph (A), by striking ``subparagraph (D)'' 
     and inserting ``subparagraph (D) or (E)'';
       (ii) by striking ``1 through 3'' and inserting ``1 and 2''; 
     and
       (iii) by adding at the end the following:
       ``(E) Election not applicable.--The election described in 
     subparagraph (A) shall not be available with respect to the 
     provisions of subpart 1.'';
       (3) in subsection (c), by striking ``1 through 3 shall not 
     apply to any group'' and inserting ``1 and 2 shall not apply 
     to any individual coverage or any group''; and
       (4) in subsection (d)--
       (A) in paragraph (1), by striking ``1 through 3 shall not 
     apply to any group'' and inserting ``1 and 2 shall not apply 
     to any individual coverage or any group'';
       (B) in paragraph (2)--
       (i) in the matter preceding subparagraph (A), by striking 
     ``1 through 3 shall not apply to any group'' and inserting 
     ``1 and 2 shall not apply to any individual coverage or any 
     group''; and
       (ii) in subparagraph (C), by inserting ``or, with respect 
     to individual coverage, under any health insurance coverage 
     maintained by the same health insurance issuer''; and
       (C) in paragraph (3), by striking ``any group'' and 
     inserting ``any individual coverage or any group''.
       (b) Definitions.--Section 2791(d) of the Public Health 
     Service Act (42 U.S.C. 300gg-91(d)) is amended by adding at 
     the end the following:
       ``(20) Qualified health plan.--The term `qualified health 
     plan' has the meaning given such term in section 1301(a) of 
     the Patient Protection and Affordable Care Act.
       ``(21) Exchange.--The term `Exchange' means an American 
     Health Benefit Exchange established under section 1311 of the 
     Patient Protection and Affordable Care Act.''.
       (c) Technical and Conforming Amendments.--Title XXVII of 
     the Public Health Service Act (42 U.S.C. 300gg et seq.) is 
     amended--
       (1) in section 2704 (42 U.S.C. 300gg), as so redesignated 
     by section 1201(2)--
       (A) in subsection (c)--
       (i) in paragraph (2), by striking ``group health plan'' 
     each place that such term appears and inserting ``group or 
     individual health plan''; and
       (ii) in paragraph (3)--

       (I) by striking ``group health insurance'' each place that 
     such term appears and inserting ``group or individual health 
     insurance''; and
       (II) in subparagraph (D), by striking ``small or large'' 
     and inserting ``individual or group'';

       (B) in subsection (d), by striking ``group health 
     insurance'' each place that such term appears and inserting 
     ``group or individual health insurance''; and
       (C) in subsection (e)(1)(A), by striking ``group health 
     insurance'' and inserting ``group or individual health 
     insurance'';
       (2) by striking the second heading for subpart 2 of part A 
     (relating to other requirements);
       (3) in section 2725 (42 U.S.C. 300gg-4), as so redesignated 
     by section 1001(2)--
       (A) in subsection (a), by striking ``health insurance 
     issuer offering group health insurance coverage'' and 
     inserting ``health insurance issuer offering group or 
     individual health insurance coverage'';
       (B) in subsection (b)--
       (i) by striking ``health insurance issuer offering group 
     health insurance coverage in connection with a group health 
     plan'' in the matter preceding paragraph (1) and inserting 
     ``health insurance issuer offering group or individual health 
     insurance coverage''; and
       (ii) in paragraph (1), by striking ``plan'' and inserting 
     ``plan or coverage'';
       (C) in subsection (c)--
       (i) in paragraph (2), by striking ``group health insurance 
     coverage offered by a health insurance issuer'' and inserting 
     ``health insurance issuer offering group or individual health 
     insurance coverage''; and
       (ii) in paragraph (3), by striking ``issuer'' and inserting 
     ``health insurance issuer''; and
       (D) in subsection (e), by striking ``health insurance 
     issuer offering group health insurance coverage'' and 
     inserting ``health insurance issuer offering group or 
     individual health insurance coverage'';
       (4) in section 2726 (42 U.S.C. 300gg-5), as so redesignated 
     by section 1001(2)--
       (A) in subsection (a), by striking ``(or health insurance 
     coverage offered in connection with such a plan)'' each place 
     that such term appears and inserting ``or a health insurance 
     issuer offering group or individual health insurance 
     coverage'';
       (B) in subsection (b), by striking ``(or health insurance 
     coverage offered in connection with such a plan)'' each place 
     that such term appears and inserting ``or a health insurance 
     issuer offering group or individual health insurance 
     coverage''; and
       (C) in subsection (c)--
       (i) in paragraph (1), by striking ``(and group health 
     insurance coverage offered in connection with a group health 
     plan)'' and inserting ``and a health insurance issuer 
     offering group or individual health insurance coverage'';
       (ii) in paragraph (2), by striking ``(or health insurance 
     coverage offered in connection with such a plan)'' each place 
     that such term appears and inserting ``or a health insurance 
     issuer offering group or individual health insurance 
     coverage'';
       (5) in section 2727 (42 U.S.C. 300gg-6), as so redesignated 
     by section 1001(2), by striking ``health insurance issuers 
     providing health insurance coverage in connection with group 
     health plans'' and inserting ``and health insurance issuers 
     offering group or individual health insurance coverage'';
       (6) in section 2728 (42 U.S.C. 300gg-7), as so redesignated 
     by section 1001(2)--
       (A) in subsection (a), by striking ``health insurance 
     coverage offered in connection with such plan'' and inserting 
     ``individual health insurance coverage'';
       (B) in subsection (b)--
       (i) in paragraph (1), by striking ``or a health insurance 
     issuer that provides health insurance coverage in connection 
     with a group health plan'' and inserting ``or a health 
     insurance issuer that offers group or individual health 
     insurance coverage'';
       (ii) in paragraph (2), by striking ``health insurance 
     coverage offered in connection with the plan'' and inserting 
     ``individual health insurance coverage''; and
       (iii) in paragraph (3), by striking ``health insurance 
     coverage offered by an issuer in connection with such plan'' 
     and inserting ``individual health insurance coverage'';
       (C) in subsection (c), by striking ``health insurance 
     issuer providing health insurance coverage in connection with 
     a group health plan'' and inserting ``health insurance issuer 
     that offers group or individual health insurance coverage''; 
     and
       (D) in subsection (e)(1), by striking ``health insurance 
     coverage offered in connection with such a plan'' and 
     inserting ``individual health insurance coverage'';
       (7) by striking the heading for subpart 3;
       (8) in section 2731 (42 U.S.C. 300gg-11), as so 
     redesignated by section 1001(3)--
       (A) by striking the section heading and all that follows 
     through subsection (b);
       (B) in subsection (c)--
       (i) in paragraph (1)--

       (I) in the matter preceding subparagraph (A), by striking 
     ``small group'' and inserting ``group and individual''; and
       (II) in subparagraph (B)--

       (aa) in the matter preceding clause (i), by inserting ``and 
     individuals'' after ``employers'';
       (bb) in clause (i), by inserting ``or any additional 
     individuals'' after ``additional groups''; and
       (cc) in clause (ii), by striking ``without regard to the 
     claims experience of those employers and their employees (and 
     their dependents) or any health status-related factor 
     relating to such'' and inserting ``and individuals without 
     regard to the claims experience of those individuals, 
     employers and their employees (and their dependents) or any 
     health status-related factor relating to such individuals''; 
     and
       (ii) in paragraph (2), by striking ``small group'' and 
     inserting ``group or individual'';
       (C) in subsection (d)--
       (i) by striking ``small group'' each place that such 
     appears and inserting ``group or individual''; and
       (ii) in paragraph (1)(B)--

       (I) by striking ``all employers'' and inserting ``all 
     employers and individuals'';
       (II) by striking ``those employers'' and inserting ``those 
     individuals, employers''; and
       (III) by striking ``such employees'' and inserting ``such 
     individuals, employees'';

       (D) by striking subsection (e);
       (E) by striking subsection (f); and
       (F) by transferring such section (as amended by this 
     paragraph) to appear at the end of section 2702 (as added by 
     section 1001(4));
       (9) in section 2732 (42 U.S.C. 300gg-12), as so 
     redesignated by section 1001(3)--
       (A) by striking the section heading and all that follows 
     through subsection (a);
       (B) in subsection (b)--
       (i) in the matter preceding paragraph (1), by striking 
     ``group health plan in the small or large group market'' and 
     inserting ``health insurance coverage offered in the group or 
     individual market'';
       (ii) in paragraph (1), by inserting ``, or individual, as 
     applicable,'' after ``plan sponsor'';
       (iii) in paragraph (2), by inserting ``, or individual, as 
     applicable,'' after ``plan sponsor''; and
       (iv) by striking paragraph (3) and inserting the following:
       ``(3) Violation of participation or contribution rates.--In 
     the case of a group health plan, the plan sponsor has failed 
     to comply with a material plan provision relating to employer 
     contribution or group participation rules, pursuant to 
     applicable State law.'';
       (C) in subsection (c)--
       (i) in paragraph (1)--

       (I) in the matter preceding subparagraph (A), by striking 
     ``group health insurance coverage offered in the small or 
     large group market'' and inserting ``group or individual 
     health insurance coverage'';
       (II) in subparagraph (A), by inserting ``or individual, as 
     applicable,'' after ``plan sponsor'';
       (III) in subparagraph (B)--

       (aa) by inserting ``or individual, as applicable,'' after 
     ``plan sponsor''; and
       (bb) by inserting ``or individual health insurance 
     coverage''; and

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

       (ii) in paragraph (2)(A)--

       (I) in the matter preceding clause (i), by striking ``small 
     group market or the large group market, or both markets,'' 
     and inserting ``individual or group market, or all 
     markets,''; and
       (II) in clause (i), by inserting ``or individual, as 
     applicable,'' after ``plan sponsor''; and

       (D) by transferring such section (as amended by this 
     paragraph) to appear at the end of section 2703 (as added by 
     section 1001(4));
       (10) in section 2733 (42 U.S.C. 300gg-13), as so 
     redesignated by section 1001(4)--

[[Page H1960]]

       (A) in subsection (a)--
       (i) in the matter preceding paragraph (1), by striking 
     ``small employer'' and inserting ``small employer or an 
     individual'';
       (ii) in paragraph (1), by inserting ``, or individual, as 
     applicable,'' after ``employer'' each place that such 
     appears; and
       (iii) in paragraph (2), by striking ``small employer'' and 
     inserting ``employer, or individual, as applicable,'';
       (B) in subsection (b)--
       (i) in paragraph (1)--

       (I) in the matter preceding subparagraph (A), by striking 
     ``small employer'' and inserting ``employer, or individual, 
     as applicable,'';
       (II) in subparagraph (A), by adding ``and'' at the end;
       (III) by striking subparagraphs (B) and (C); and
       (IV) in subparagraph (D)--

       (aa) by inserting ``, or individual, as applicable,'' after 
     ``employer''; and
       (bb) by redesignating such subparagraph as subparagraph 
     (B);
       (ii) in paragraph (2)--

       (I) by striking ``small employers'' each place that such 
     term appears and inserting ``employers, or individuals, as 
     applicable,''; and
       (II) by striking ``small employer'' and inserting 
     ``employer, or individual, as applicable,''; and

       (C) by redesignating such section (as amended by this 
     paragraph) as section 2709 and transferring such section to 
     appear after section 2708 (as added by section 1001(5));
       (11) by redesignating subpart 4 as subpart 2;
       (12) in section 2735 (42 U.S.C. 300gg-21), as so 
     redesignated by section 1001(4)--
       (A) by striking subsection (a);
       (B) by striking ``subparts 1 through 3'' each place that 
     such appears and inserting ``subpart 1'';
       (C) by redesignating subsections (b) through (e) as 
     subsections (a) through (d), respectively; and
       (D) by redesignating such section (as amended by this 
     paragraph) as section 2722;
       (13) in section 2736 (42 U.S.C. 300gg-22), as so 
     redesignated by section 1001(4)--
       (A) in subsection (a)--
       (i) in paragraph (1), by striking ``small or large group 
     markets'' and inserting ``individual or group market''; and
       (ii) in paragraph (2), by inserting ``or individual health 
     insurance coverage'' after ``group health plans'';
       (B) in subsection (b)(1)(B), by inserting ``individual 
     health insurance coverage or'' after ``respect to''; and
       (C) by redesignating such section (as amended by this 
     paragraph) as section 2723;
       (14) in section 2737(a)(1) (42 U.S.C. 300gg-23), as so 
     redesignated by section 1001(4)--
       (A) by inserting ``individual or'' before ``group health 
     insurance''; and
       (B) by redesignating such section(as amended by this 
     paragraph) as section 2724;
       (15) in section 2762 (42 U.S.C. 300gg-62)--
       (A) in the section heading by inserting ``AND APPLICATION'' 
     before the period; and
       (B) by adding at the end the following:
       ``(c) Application of Part A Provisions.--
       ``(1) In general.--The provisions of part A shall apply to 
     health insurance issuers providing health insurance coverage 
     in the individual market in a State as provided for in such 
     part.
       ``(2) Clarification.--To the extent that any provision of 
     this part conflicts with a provision of part A with respect 
     to health insurance issuers providing health insurance 
     coverage in the individual market in a State, the provisions 
     of such part A shall apply.''; and
       (16) in section 2791(e) (42 U.S.C. 300gg-91(e))--
       (A) in paragraph (2), by striking ``51'' and inserting 
     ``101''; and
       (B) in paragraph (4)--
       (i) by striking ``at least 2'' each place that such appears 
     and inserting ``at least 1''; and
       (ii) by striking ``50'' and inserting ``100''.
       (d) Application.--Notwithstanding any other provision of 
     the Patient Protection and Affordable Care Act, nothing in 
     such Act (or an amendment made by such Act) shall be 
     construed to--
       (1) prohibit (or authorize the Secretary of Health and 
     Human Services to promulgate regulations that prohibit) a 
     group health plan or health insurance issuer from carrying 
     out utilization management techniques that are commonly used 
     as of the date of enactment of this Act; or
       (2) restrict the application of the amendments made by this 
     subtitle.
       (e) Technical Amendment to the Employee Retirement Income 
     Security Act of 1974.--Subpart B of part 7 of subtitle A of 
     title I of the Employee Retirement Income Security Act of 
     1974 (29 U.S.C. 1181 et. seq.) is amended, by adding at the 
     end the following:

     ``SEC. 715. ADDITIONAL MARKET REFORMS.

       ``(a) General Rule.--Except as provided in subsection (b)--
       ``(1) the provisions of part A of title XXVII of the Public 
     Health Service Act (as amended by the Patient Protection and 
     Affordable Care Act) shall apply to group health plans, and 
     health insurance issuers providing health insurance coverage 
     in connection with group health plans, as if included in this 
     subpart; and
       ``(2) to the extent that any provision of this part 
     conflicts with a provision of such part A with respect to 
     group health plans, or health insurance issuers providing 
     health insurance coverage in connection with group health 
     plans, the provisions of such part A shall apply.
       ``(b) Exception.--Notwithstanding subsection (a), the 
     provisions of sections 2716 and 2718 of title XXVII of the 
     Public Health Service Act (as amended by the Patient 
     Protection and Affordable Care Act) shall not apply with 
     respect to self-insured group health plans, and the 
     provisions of this part shall continue to apply to such plans 
     as if such sections of the Public Health Service Act (as so 
     amended) had not been enacted.''.
       (f) Technical Amendment to the Internal Revenue Code of 
     1986.--Subchapter B of chapter 100 of the Internal Revenue 
     Code of 1986 is amended by adding at the end the following:

     ``SEC. 9815. ADDITIONAL MARKET REFORMS.

       ``(a) General Rule.--Except as provided in subsection (b)--
       ``(1) the provisions of part A of title XXVII of the Public 
     Health Service Act (as amended by the Patient Protection and 
     Affordable Care Act) shall apply to group health plans, and 
     health insurance issuers providing health insurance coverage 
     in connection with group health plans, as if included in this 
     subchapter; and
       ``(2) to the extent that any provision of this subchapter 
     conflicts with a provision of such part A with respect to 
     group health plans, or health insurance issuers providing 
     health insurance coverage in connection with group health 
     plans, the provisions of such part A shall apply.
       ``(b) Exception.--Notwithstanding subsection (a), the 
     provisions of sections 2716 and 2718 of title XXVII of the 
     Public Health Service Act (as amended by the Patient 
     Protection and Affordable Care Act) shall not apply with 
     respect to self-insured group health plans, and the 
     provisions of this subchapter shall continue to apply to such 
     plans as if such sections of the Public Health Service Act 
     (as so amended) had not been enacted.''.

     SEC. 1563. SENSE OF THE SENATE PROMOTING FISCAL 
                   RESPONSIBILITY.

       (a) Findings.--The Senate makes the following findings:
       (1) Based on Congressional Budget Office (CBO) estimates, 
     this Act will reduce the Federal deficit between 2010 and 
     2019.
       (2) CBO projects this Act will continue to reduce budget 
     deficits after 2019.
       (3) Based on CBO estimates, this Act will extend the 
     solvency of the Medicare HI Trust Fund.
       (4) This Act will increase the surplus in the Social 
     Security Trust Fund, which should be reserved to strengthen 
     the finances of Social Security.
       (5) The initial net savings generated by the Community 
     Living Assistance Services and Supports (CLASS) program are 
     necessary to ensure the long-term solvency of that program.
       (b) Sense of the Senate.--It is the sense of the Senate 
     that--
       (1) the additional surplus in the Social Security Trust 
     Fund generated by this Act should be reserved for Social 
     Security and not spent in this Act for other purposes; and
       (2) the net savings generated by the CLASS program should 
     be reserved for the CLASS program and not spent in this Act 
     for other purposes.

                   TITLE II--ROLE OF PUBLIC PROGRAMS

                Subtitle A--Improved Access to Medicaid

     SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME 
                   POPULATIONS.

       (a) Coverage for Individuals With Income at or Below 133 
     Percent of the Poverty Line.--
       (1) Beginning 2014.--Section 1902(a)(10)(A)(i) of the 
     Social Security Act (42 U.S.C. 1396a) is amended--
       (A) by striking ``or'' at the end of subclause (VI);
       (B) by adding ``or'' at the end of subclause (VII); and
       (C) by inserting after subclause (VII) the following:

       ``(VIII) beginning January 1, 2014, who are under 65 years 
     of age, not pregnant, not entitled to, or enrolled for, 
     benefits under part A of title XVIII, or enrolled for 
     benefits under part B of title XVIII, and are not described 
     in a previous subclause of this clause, and whose income (as 
     determined under subsection (e)(14)) does not exceed 133 
     percent of the poverty line (as defined in section 
     2110(c)(5)) applicable to a family of the size involved, 
     subject to subsection (k);''.

       (2) Provision of at least minimum essential coverage.--
       (A) In general.--Section 1902 of such Act (42 U.S.C. 1396a) 
     is amended by inserting after subsection (j) the following:
       ``(k)(1) The medical assistance provided to an individual 
     described in subclause (VIII) of subsection (a)(10)(A)(i) 
     shall consist of benchmark coverage described in section 
     1937(b)(1) or benchmark equivalent coverage described in 
     section 1937(b)(2). Such medical assistance shall be provided 
     subject to the requirements of section 1937, without regard 
     to whether a State otherwise has elected the option to 
     provide medical assistance through coverage under that 
     section, unless an individual described in subclause (VIII) 
     of subsection (a)(10)(A)(i) is also an individual for whom, 
     under subparagraph (B) of section 1937(a)(2), the State may 
     not require enrollment in benchmark coverage described in 
     subsection (b)(1) of section 1937 or benchmark equivalent 
     coverage described in subsection (b)(2) of that section.''.
       (B) Conforming amendment.--Section 1903(i) of the Social 
     Security Act, as amended by section 6402(c), is amended--
       (i) in paragraph (24), by striking ``or'' at the end;
       (ii) in paragraph (25), by striking the period and 
     inserting ``; or''; and
       (iii) by adding at the end the following:
       ``(26) with respect to any amounts expended for medical 
     assistance for individuals described in subclause (VIII) of 
     subsection (a)(10)(A)(i) other than medical assistance 
     provided through benchmark coverage described in section 
     1937(b)(1) or benchmark equivalent coverage described in 
     section 1937(b)(2).''.
       (3) Federal funding for cost of covering newly eligible 
     individuals.--Section 1905 of the Social Security Act (42 
     U.S.C. 1396d), is amended--
       (A) in subsection (b), in the first sentence, by inserting 
     ``subsection (y) and'' before ``section 1933(d)''; and

[[Page H1961]]

       (B) by adding at the end the following new subsection:
       ``(y) Increased FMAP for Medical Assistance for Newly 
     Eligible Mandatory Individuals.--
       ``(1) Amount of increase.--
       ``(A) 100 percent fmap.--During the period that begins on 
     January 1, 2014, and ends on December 31, 2016, 
     notwithstanding subsection (b), the Federal medical 
     assistance percentage determined for a State that is one of 
     the 50 States or the District of Columbia for each fiscal 
     year occurring during that period with respect to amounts 
     expended for medical assistance for newly eligible 
     individuals described in subclause (VIII) of section 
     1902(a)(10)(A)(i) shall be equal to 100 percent.
       ``(B) 2017 and 2018.--
       ``(i) In general.--During the period that begins on January 
     1, 2017, and ends on December 31, 2018, notwithstanding 
     subsection (b) and subject to subparagraph (D), the Federal 
     medical assistance percentage determined for a State that is 
     one of the 50 States or the District of Columbia for each 
     fiscal year occurring during that period with respect to 
     amounts expended for medical assistance for newly eligible 
     individuals described in subclause (VIII) of section 
     1902(a)(10)(A)(i), shall be increased by the applicable 
     percentage point increase specified in clause (ii) for the 
     quarter and the State.
       ``(ii) Applicable percentage point increase.--

       ``(I) In general.--For purposes of clause (i), the 
     applicable percentage point increase for a quarter is the 
     following:


----------------------------------------------------------------------------------------------------------------
                                       If the State is an expansion State,    If the State is not an expansion
    ``For any fiscal year quarter        the applicable percentage point      State, the applicable percentage
   occurring in the calendar year:                increase is:                       point increase is:
----------------------------------------------------------------------------------------------------------------
2017                                  30.3                                  34.3
----------------------------------------------------------------------------------------------------------------
2018                                  31.3                                  33.3
----------------------------------------------------------------------------------------------------------------

       ``(II) Expansion state defined.--For purposes of the table 
     in subclause (I), a State is an expansion State if, on the 
     date of the enactment of the Patient Protection and 
     Affordable Care Act, the State offers health benefits 
     coverage statewide to parents and nonpregnant, childless 
     adults whose income is at least 100 percent of the poverty 
     line, that is not dependent on access to employer coverage, 
     employer contribution, or employment and is not limited to 
     premium assistance, hospital-only benefits, a high deductible 
     health plan, or alternative benefits under a demonstration 
     program authorized under section 1938. A State that offers 
     health benefits coverage to only parents or only nonpregnant 
     childless adults described in the preceding sentence shall 
     not be considered to be an expansion State.

       ``(C) 2019 and succeeding years.--Beginning January 1, 
     2019, notwithstanding subsection (b) but subject to 
     subparagraph (D), the Federal medical assistance percentage 
     determined for a State that is one of the 50 States or the 
     District of Columbia for each fiscal year quarter occurring 
     during that period with respect to amounts expended for 
     medical assistance for newly eligible individuals described 
     in subclause (VIII) of section 1902(a)(10)(A)(i), shall be 
     increased by 32.3 percentage points.
       ``(D) Limitation.--The Federal medical assistance 
     percentage determined for a State under subparagraph (B) or 
     (C) shall in no case be more than 95 percent.
       ``(2) Definitions.--In this subsection:
       ``(A) Newly eligible.--The term `newly eligible' means, 
     with respect to an individual described in subclause (VIII) 
     of section 1902(a)(10)(A)(i), an individual who is not under 
     19 years of age (or such higher age as the State may have 
     elected) and who, on the date of enactment of the Patient 
     Protection and Affordable Care Act, is not eligible under the 
     State plan or under a waiver of the plan for full benefits or 
     for benchmark coverage described in subparagraph (A), (B), or 
     (C) of section 1937(b)(1) or benchmark equivalent coverage 
     described in section 1937(b)(2) that has an aggregate 
     actuarial value that is at least actuarially equivalent to 
     benchmark coverage described in subparagraph (A), (B), or (C) 
     of section 1937(b)(1), or is eligible but not enrolled (or is 
     on a waiting list) for such benefits or coverage through a 
     waiver under the plan that has a capped or limited enrollment 
     that is full.
       ``(B) Full benefits.--The term `full benefits' means, with 
     respect to an individual, medical assistance for all services 
     covered under the State plan under this title that is not 
     less in amount, duration, or scope, or is determined by the 
     Secretary to be substantially equivalent, to the medical 
     assistance available for an individual described in section 
     1902(a)(10)(A)(i).''.
       (4) State options to offer coverage earlier and presumptive 
     eligibility; children required to have coverage for parents 
     to be eligible.--
       (A) In general.--Subsection (k) of section 1902 of the 
     Social Security Act (as added by paragraph (2)), is amended 
     by inserting after paragraph (1) the following:
       ``(2) Beginning with the first day of any fiscal year 
     quarter that begins on or after January 1, 2011, and before 
     January 1, 2014, a State may elect through a State plan 
     amendment to provide medical assistance to individuals who 
     would be described in subclause (VIII) of subsection 
     (a)(10)(A)(i) if that subclause were effective before January 
     1, 2014. A State may elect to phase-in the extension of 
     eligibility for medical assistance to such individuals based 
     on income, so long as the State does not extend such 
     eligibility to individuals described in such subclause with 
     higher income before making individuals described in such 
     subclause with lower income eligible for medical assistance.
       ``(3) If an individual described in subclause (VIII) of 
     subsection (a)(10)(A)(i) is the parent of a child who is 
     under 19 years of age (or such higher age as the State may 
     have elected) who is eligible for medical assistance under 
     the State plan or under a waiver of such plan (under that 
     subclause or under a State plan amendment under paragraph 
     (2), the individual may not be enrolled under the State plan 
     unless the individual's child is enrolled under the State 
     plan or under a waiver of the plan or is enrolled in other 
     health insurance coverage. For purposes of the preceding 
     sentence, the term `parent' includes an individual treated as 
     a caretaker relative for purposes of carrying out section 
     1931.''.
       (B) Presumptive eligibility.--Section 1920 of the Social 
     Security Act (42 U.S.C. 1396r-1) is amended by adding at the 
     end the following:
       ``(e) If the State has elected the option to provide a 
     presumptive eligibility period under this section or section 
     1920A, the State may elect to provide a presumptive 
     eligibility period (as defined in subsection (b)(1)) for 
     individuals who are eligible for medical assistance under 
     clause (i)(VIII) of subsection (a)(10)(A) or section 1931 in 
     the same manner as the State provides for such a period under 
     this section or section 1920A, subject to such guidance as 
     the Secretary shall establish.''.
       (5) Conforming amendments.--
       (A) Section 1902(a)(10) of such Act (42 U.S.C. 
     1396a(a)(10)) is amended in the matter following subparagraph 
     (G), by striking ``and (XIV)'' and inserting ``(XIV)'' and by 
     inserting ``and (XV) the medical assistance made available to 
     an individual described in subparagraph (A)(i)(VIII) shall be 
     limited to medical assistance described in subsection 
     (k)(1)'' before the semicolon.
       (B) Section 1902(l)(2)(C) of such Act (42 U.S.C. 
     1396a(l)(2)(C)) is amended by striking ``100'' and inserting 
     ``133''.
       (C) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is 
     amended in the matter preceding paragraph (1)--
       (i) by striking ``or'' at the end of clause (xii);
       (ii) by inserting ``or'' at the end of clause (xiii); and
       (iii) by inserting after clause (xiii) the following:
       ``(xiv) individuals described in section 
     1902(a)(10)(A)(i)(VIII),''.
       (D) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)) 
     is amended by inserting ``1902(a)(10)(A)(i)(VIII),'' after 
     ``1902(a)(10)(A)(i)(VII),''.
       (E) Section 1937(a)(1)(B) of such Act (42 U.S.C. 1396u-
     7(a)(1)(B)) is amended by inserting ``subclause (VIII) of 
     section 1902(a)(10)(A)(i) or under'' after ``eligible 
     under''.
       (b) Maintenance of Medicaid Income Eligibility.--Section 
     1902 of the Social Security Act (42 U.S.C. 1396a) is 
     amended--
       (1) in subsection (a)--
       (A) by striking ``and'' at the end of paragraph (72);
       (B) by striking the period at the end of paragraph (73) and 
     inserting ``; and''; and
       (C) by inserting after paragraph (73) the following new 
     paragraph:
       ``(74) provide for maintenance of effort under the State 
     plan or under any waiver of the plan in accordance with 
     subsection (gg).''; and
       (2) by adding at the end the following new subsection:
       ``(gg) Maintenance of Effort.--
       ``(1) General requirement to maintain eligibility standards 
     until state exchange is fully operational.--Subject to the 
     succeeding paragraphs of this subsection, during the period 
     that begins on the date of enactment of the Patient 
     Protection and Affordable Care Act and ends on the date on 
     which the Secretary determines that an Exchange established 
     by the State under section 1311 of the Patient Protection and 
     Affordable Care Act is fully operational, as a condition for 
     receiving any Federal payments under section 1903(a) for 
     calendar quarters occurring during such period, a State shall 
     not have in effect eligibility standards, methodologies, or 
     procedures under the State plan under this title or under any 
     waiver of such plan that is in effect during that period, 
     that are more restrictive than the eligibility standards, 
     methodologies, or procedures, respectively, under the plan or 
     waiver that are in effect on the date of enactment of the 
     Patient Protection and Affordable Care Act.
       ``(2) Continuation of eligibility standards for children 
     until october 1, 2019.--The requirement under paragraph (1) 
     shall continue to apply to a State through September 30, 
     2019, with respect to the eligibility standards, 
     methodologies, and procedures under the State plan under this 
     title or under any waiver of such plan that are applicable to 
     determining the eligibility for medical assistance of any 
     child who is under 19 years of age (or such higher age as the 
     State may have elected).
       ``(3) Nonapplication.--During the period that begins on 
     January 1, 2011, and ends on December 31, 2013, the 
     requirement under paragraph (1) shall not apply to a State 
     with respect to nonpregnant, nondisabled adults who are 
     eligible for medical assistance under the State plan or under 
     a waiver of the plan at the option of the State and whose 
     income exceeds 133 percent of the poverty line (as defined in 
     section 2110(c)(5)) applicable to a family of the size 
     involved if, on or after December 31, 2010, the

[[Page H1962]]

     State certifies to the Secretary that, with respect to the 
     State fiscal year during which the certification is made, the 
     State has a budget deficit, or with respect to the succeeding 
     State fiscal year, the State is projected to have a budget 
     deficit. Upon submission of such a certification to the 
     Secretary, the requirement under paragraph (1) shall not 
     apply to the State with respect to any remaining portion of 
     the period described in the preceding sentence.
       ``(4) Determination of compliance.--
       ``(A) States shall apply modified gross income.--A State's 
     determination of income in accordance with subsection (e)(14) 
     shall not be considered to be eligibility standards, 
     methodologies, or procedures that are more restrictive than 
     the standards, methodologies, or procedures in effect under 
     the State plan or under a waiver of the plan on the date of 
     enactment of the Patient Protection and Affordable Care Act 
     for purposes of determining compliance with the requirements 
     of paragraph (1), (2), or (3).
       ``(B) States may expand eligibility or move waivered 
     populations into coverage under the state plan.--With respect 
     to any period applicable under paragraph (1), (2), or (3), a 
     State that applies eligibility standards, methodologies, or 
     procedures under the State plan under this title or under any 
     waiver of the plan that are less restrictive than the 
     eligibility standards, methodologies, or procedures, applied 
     under the State plan or under a waiver of the plan on the 
     date of enactment of the Patient Protection and Affordable 
     Care Act, or that makes individuals who, on such date of 
     enactment, are eligible for medical assistance under a waiver 
     of the State plan, after such date of enactment eligible for 
     medical assistance through a State plan amendment with an 
     income eligibility level that is not less than the income 
     eligibility level that applied under the waiver, or as a 
     result of the application of subclause (VIII) of section 
     1902(a)(10)(A)(i), shall not be considered to have in effect 
     eligibility standards, methodologies, or procedures that are 
     more restrictive than the standards, methodologies, or 
     procedures in effect under the State plan or under a waiver 
     of the plan on the date of enactment of the Patient 
     Protection and Affordable Care Act for purposes of 
     determining compliance with the requirements of paragraph 
     (1), (2), or (3).''.
       (c) Medicaid Benchmark Benefits Must Consist of at Least 
     Minimum Essential Coverage.--Section 1937(b) of such Act (42 
     U.S.C. 1396u-7(b)) is amended--
       (1) in paragraph (1), in the matter preceding subparagraph 
     (A), by inserting ``subject to paragraphs (5) and (6),'' 
     before ``each'';
       (2) in paragraph (2)--
       (A) in the matter preceding subparagraph (A), by inserting 
     ``subject to paragraphs (5) and (6)'' after ``subsection 
     (a)(1),'';
       (B) in subparagraph (A)--
       (i) by redesignating clauses (iv) and (v) as clauses (vi) 
     and (vii), respectively; and
       (ii) by inserting after clause (iii), the following:
       ``(iv) Coverage of prescription drugs.
       ``(v) Mental health services.''; and
       (C) in subparagraph (C)--
       (i) by striking clauses (i) and (ii); and
       (ii) by redesignating clauses (iii) and (iv) as clauses (i) 
     and (ii), respectively; and
       (3) by adding at the end the following new paragraphs:
       ``(5) Minimum standards.--Effective January 1, 2014, any 
     benchmark benefit package under paragraph (1) or benchmark 
     equivalent coverage under paragraph (2) must provide at least 
     essential health benefits as described in section 1302(b) of 
     the Patient Protection and Affordable Care Act.
       ``(6) Mental health services parity.--
       ``(A) In general.--In the case of any benchmark benefit 
     package under paragraph (1) or benchmark equivalent coverage 
     under paragraph (2) that is offered by an entity that is not 
     a medicaid managed care organization and that provides both 
     medical and surgical benefits and mental health or substance 
     use disorder benefits, the entity shall ensure that the 
     financial requirements and treatment limitations applicable 
     to such mental health or substance use disorder benefits 
     comply with the requirements of section 2705(a) of the Public 
     Health Service Act in the same manner as such requirements 
     apply to a group health plan.
       ``(B) Deemed compliance.--Coverage provided with respect to 
     an individual described in section 1905(a)(4)(B) and covered 
     under the State plan under section 1902(a)(10)(A) of the 
     services described in section 1905(a)(4)(B) (relating to 
     early and periodic screening, diagnostic, and treatment 
     services defined in section 1905(r)) and provided in 
     accordance with section 1902(a)(43), shall be deemed to 
     satisfy the requirements of subparagraph (A).''.
       (d) Annual Reports on Medicaid Enrollment.--
       (1) State reports.--Section 1902(a) of the Social Security 
     Act (42 U.S.C. 1396a(a)), as amended by subsection (b), is 
     amended--
       (A) by striking ``and'' at the end of paragraph (73);
       (B) by striking the period at the end of paragraph (74) and 
     inserting ``; and''; and
       (C) by inserting after paragraph (74) the following new 
     paragraph:
       ``(75) provide that, beginning January 2015, and annually 
     thereafter, the State shall submit a report to the Secretary 
     that contains--
       ``(A) the total number of enrolled and newly enrolled 
     individuals in the State plan or under a waiver of the plan 
     for the fiscal year ending on September 30 of the preceding 
     calendar year, disaggregated by population, including 
     children, parents, nonpregnant childless adults, disabled 
     individuals, elderly individuals, and such other categories 
     or sub-categories of individuals eligible for medical 
     assistance under the State plan or under a waiver of the plan 
     as the Secretary may require;
       ``(B) a description, which may be specified by population, 
     of the outreach and enrollment processes used by the State 
     during such fiscal year; and
       ``(C) any other data reporting determined necessary by the 
     Secretary to monitor enrollment and retention of individuals 
     eligible for medical assistance under the State plan or under 
     a waiver of the plan.''.
       (2) Reports to congress.--Beginning April 2015, and 
     annually thereafter, the Secretary of Health and Human 
     Services shall submit a report to the appropriate committees 
     of Congress on the total enrollment and new enrollment in 
     Medicaid for the fiscal year ending on September 30 of the 
     preceding calendar year on a national and State-by-State 
     basis, and shall include in each such report such 
     recommendations for administrative or legislative changes to 
     improve enrollment in the Medicaid program as the Secretary 
     determines appropriate.
       (e) State Option for Coverage for Individuals With Income 
     That Exceeds 133 Percent of the Poverty Line.--
       (1) Coverage as optional categorically needy group.--
     Section 1902 of the Social Security Act (42 U.S.C. 1396a) is 
     amended--
       (A) in subsection (a)(10)(A)(ii)--
       (i) in subclause (XVIII), by striking ``or'' at the end;
       (ii) in subclause (XIX), by adding ``or'' at the end; and
       (iii) by adding at the end the following new subclause:

       ``(XX) beginning January 1, 2014, who are under 65 years of 
     age and are not described in or enrolled under a previous 
     subclause of this clause, and whose income (as determined 
     under subsection (e)(14)) exceeds 133 percent of the poverty 
     line (as defined in section 2110(c)(5)) applicable to a 
     family of the size involved but does not exceed the highest 
     income eligibility level established under the State plan or 
     under a waiver of the plan, subject to subsection (hh);'' and

       (B) by adding at the end the following new subsection:
       ``(hh)(1) A State may elect to phase-in the extension of 
     eligibility for medical assistance to individuals described 
     in subclause (XX) of subsection (a)(10)(A)(ii) based on the 
     categorical group (including nonpregnant childless adults) or 
     income, so long as the State does not extend such eligibility 
     to individuals described in such subclause with higher income 
     before making individuals described in such subclause with 
     lower income eligible for medical assistance.
       ``(2) If an individual described in subclause (XX) of 
     subsection (a)(10)(A)(ii) is the parent of a child who is 
     under 19 years of age (or such higher age as the State may 
     have elected) who is eligible for medical assistance under 
     the State plan or under a waiver of such plan, the individual 
     may not be enrolled under the State plan unless the 
     individual's child is enrolled under the State plan or under 
     a waiver of the plan or is enrolled in other health insurance 
     coverage. For purposes of the preceding sentence, the term 
     `parent' includes an individual treated as a caretaker 
     relative for purposes of carrying out section 1931.''.
       (2) Conforming amendments.--
       (A) Section 1905(a) of such Act (42 U.S.C. 1396d(a)), as 
     amended by subsection (a)(5)(C), is amended in the matter 
     preceding paragraph (1)--
       (i) by striking ``or'' at the end of clause (xiii);
       (ii) by inserting ``or'' at the end of clause (xiv); and
       (iii) by inserting after clause (xiv) the following:
       ``(xv) individuals described in section 
     1902(a)(10)(A)(ii)(XX),''.
       (B) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)) 
     is amended by inserting ``1902(a)(10)(A)(ii)(XX),'' after 
     ``1902(a)(10)(A)(ii)(XIX),''.
       (C) Section 1920(e) of such Act (42 U.S.C. 1396r-1(e)), as 
     added by subsection (a)(4)(B), is amended by inserting ``or 
     clause (ii)(XX)'' after ``clause (i)(VIII)''.

     SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETERMINED USING 
                   MODIFIED GROSS INCOME.

       (a) In General.--Section 1902(e) of the Social Security Act 
     (42 U.S.C. 1396a(e)) is amended by adding at the end the 
     following:
       ``(14) Income determined using modified gross income.--
       ``(A) In general.--Notwithstanding subsection (r) or any 
     other provision of this title, except as provided in 
     subparagraph (D), for purposes of determining income 
     eligibility for medical assistance under the State plan or 
     under any waiver of such plan and for any other purpose 
     applicable under the plan or waiver for which a determination 
     of income is required, including with respect to the 
     imposition of premiums and cost-sharing, a State shall use 
     the modified gross income of an individual and, in the case 
     of an individual in a family greater than 1, the household 
     income of such family. A State shall establish income 
     eligibility thresholds for populations to be eligible for 
     medical assistance under the State plan or a waiver of the 
     plan using modified gross income and household income that 
     are not less than the effective income eligibility levels 
     that applied under the State plan or waiver on the date of 
     enactment of the Patient Protection and Affordable Care Act. 
     For purposes of complying with the maintenance of effort 
     requirements under subsection (gg) during the transition to 
     modified gross income and household income, a State shall, 
     working with the Secretary, establish an equivalent income 
     test that ensures individuals eligible for medical assistance 
     under the State plan or under a waiver of the plan on the 
     date of enactment of the Patient Protection and Affordable 
     Care Act, do not lose coverage under the State plan or under 
     a waiver of the plan. The Secretary may waive such provisions 
     of this title and title XXI as are necessary to ensure

[[Page H1963]]

     that States establish income and eligibility determination 
     systems that protect beneficiaries.
       ``(B) No income or expense disregards.--No type of expense, 
     block, or other income disregard shall be applied by a State 
     to determine income eligibility for medical assistance under 
     the State plan or under any waiver of such plan or for any 
     other purpose applicable under the plan or waiver for which a 
     determination of income is required.
       ``(C) No assets test.--A State shall not apply any assets 
     or resources test for purposes of determining eligibility for 
     medical assistance under the State plan or under a waiver of 
     the plan.
       ``(D) Exceptions.--
       ``(i) Individuals eligible because of other aid or 
     assistance, elderly individuals, medically needy individuals, 
     and individuals eligible for medicare cost-sharing.--
     Subparagraphs (A), (B), and (C) shall not apply to the 
     determination of eligibility under the State plan or under a 
     waiver for medical assistance for the following:

       ``(I) Individuals who are eligible for medical assistance 
     under the State plan or under a waiver of the plan on a basis 
     that does not require a determination of income by the State 
     agency administering the State plan or waiver, including as a 
     result of eligibility for, or receipt of, other Federal or 
     State aid or assistance, individuals who are eligible on the 
     basis of receiving (or being treated as if receiving) 
     supplemental security income benefits under title XVI, and 
     individuals who are eligible as a result of being or being 
     deemed to be a child in foster care under the responsibility 
     of the State.
       ``(II) Individuals who have attained age 65.
       ``(III) Individuals who qualify for medical assistance 
     under the State plan or under any waiver of such plan on the 
     basis of being blind or disabled (or being treated as being 
     blind or disabled) without regard to whether the individual 
     is eligible for supplemental security income benefits under 
     title XVI on the basis of being blind or disabled and 
     including an individual who is eligible for medical 
     assistance on the basis of section 1902(e)(3).
       ``(IV) Individuals described in subsection (a)(10)(C).
       ``(V) Individuals described in any clause of subsection 
     (a)(10)(E).

       ``(ii) Express lane agency findings.--In the case of a 
     State that elects the Express Lane option under paragraph 
     (13), notwithstanding subparagraphs (A), (B), and (C), the 
     State may rely on a finding made by an Express Lane agency in 
     accordance with that paragraph relating to the income of an 
     individual for purposes of determining the individual's 
     eligibility for medical assistance under the State plan or 
     under a waiver of the plan.
       ``(iii) Medicare prescription drug subsidies 
     determinations.--Subparagraphs (A), (B), and (C) shall not 
     apply to any determinations of eligibility for premium and 
     cost-sharing subsidies under and in accordance with section 
     1860D-14 made by the State pursuant to section 1935(a)(2).
       ``(iv) Long-term care.--Subparagraphs (A), (B), and (C) 
     shall not apply to any determinations of eligibility of 
     individuals for purposes of medical assistance for nursing 
     facility services, a level of care in any institution 
     equivalent to that of nursing facility services, home or 
     community-based services furnished under a waiver or State 
     plan amendment under section 1915 or a waiver under section 
     1115, and services described in section 1917(c)(1)(C)(ii).
       ``(v) Grandfather of current enrollees until date of next 
     regular redetermination.--An individual who, on January 1, 
     2014, is enrolled in the State plan or under a waiver of the 
     plan and who would be determined ineligible for medical 
     assistance solely because of the application of the modified 
     gross income or household income standard described in 
     subparagraph (A), shall remain eligible for medical 
     assistance under the State plan or waiver (and subject to the 
     same premiums and cost-sharing as applied to the individual 
     on that date) through March 31, 2014, or the date on which 
     the individual's next regularly scheduled redetermination of 
     eligibility is to occur, whichever is later.
       ``(E) Transition planning and oversight.--Each State shall 
     submit to the Secretary for the Secretary's approval the 
     income eligibility thresholds proposed to be established 
     using modified gross income and household income, the 
     methodologies and procedures to be used to determine income 
     eligibility using modified gross income and household income 
     and, if applicable, a State plan amendment establishing an 
     optional eligibility category under subsection 
     (a)(10)(A)(ii)(XX). To the extent practicable, the State 
     shall use the same methodologies and procedures for purposes 
     of making such determinations as the State used on the date 
     of enactment of the Patient Protection and Affordable Care 
     Act. The Secretary shall ensure that the income eligibility 
     thresholds proposed to be established using modified gross 
     income and household income, including under the eligibility 
     category established under subsection (a)(10)(A)(ii)(XX), and 
     the methodologies and procedures proposed to be used to 
     determine income eligibility, will not result in children who 
     would have been eligible for medical assistance under the 
     State plan or under a waiver of the plan on the date of 
     enactment of the Patient Protection and Affordable Care Act 
     no longer being eligible for such assistance.
       ``(F) Limitation on secretarial authority.--The Secretary 
     shall not waive compliance with the requirements of this 
     paragraph except to the extent necessary to permit a State to 
     coordinate eligibility requirements for dual eligible 
     individuals (as defined in section 1915(h)(2)(B)) under the 
     State plan or under a waiver of the plan and under title 
     XVIII and individuals who require the level of care provided 
     in a hospital, a nursing facility, or an intermediate care 
     facility for the mentally retarded.
       ``(G) Definitions of modified gross income and household 
     income.--In this paragraph, the terms `modified gross income' 
     and `household income' have the meanings given such terms in 
     section 36B(d)(2) of the Internal Revenue Code of 1986.
       ``(H) Continued application of medicaid rules regarding 
     point-in-time income and sources of income.--The requirement 
     under this paragraph for States to use modified gross income 
     and household income to determine income eligibility for 
     medical assistance under the State plan or under any waiver 
     of such plan and for any other purpose applicable under the 
     plan or waiver for which a determination of income is 
     required shall not be construed as affecting or limiting the 
     application of--
       ``(i) the requirement under this title and under the State 
     plan or a waiver of the plan to determine an individual's 
     income as of the point in time at which an application for 
     medical assistance under the State plan or a waiver of the 
     plan is processed; or
       ``(ii) any rules established under this title or under the 
     State plan or a waiver of the plan regarding sources of 
     countable income.''.
       (b) Conforming Amendment.--Section 1902(a)(17) of such Act 
     (42 U.S.C. 1396a(a)(17)) is amended by inserting ``(e)(14),'' 
     before ``(l)(3)''.
       (c) Effective Date.--The amendments made by subsections (a) 
     and (b) take effect on January 1, 2014.

     SEC. 2003. REQUIREMENT TO OFFER PREMIUM ASSISTANCE FOR 
                   EMPLOYER-SPONSORED INSURANCE.

       (a) In General.--Section 1906A of such Act (42 U.S.C. 
     1396e-1) is amended--
       (1) in subsection (a)--
       (A) by striking ``may elect to'' and inserting ``shall'';
       (B) by striking ``under age 19''; and
       (C) by inserting ``, in the case of an individual under age 
     19,'' after ``(and'';
       (2) in subsection (c), in the first sentence, by striking 
     ``under age 19''; and
       (3) in subsection (d)--
       (A) in paragraph (2)--
       (i) in the first sentence, by striking ``under age 19''; 
     and
       (ii) by striking the third sentence and inserting ``A State 
     may not require, as a condition of an individual (or the 
     individual's parent) being or remaining eligible for medical 
     assistance under this title, that the individual (or the 
     individual's parent) apply for enrollment in qualified 
     employer-sponsored coverage under this section.''; and
       (B) in paragraph (3), by striking ``the parent of an 
     individual under age 19'' and inserting ``an individual (or 
     the parent of an individual)''; and
       (4) in subsection (e), by striking ``under age 19'' each 
     place it appears.
       (b) Conforming Amendment.--The heading for section 1906A of 
     such Act (42 U.S.C. 1396e-1) is amended by striking ``option 
     for children''.
       (c) Effective Date.--The amendments made by this section 
     take effect on January 1, 2014.

     SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER CARE CHILDREN.

       (a) In General.--Section 1902(a)(10)(A)(i) of the Social 
     Security Act (42 U.S.C. 1396a), as amended by section 
     2001(a)(1), is amended--
       (1) by striking ``or'' at the end of subclause (VII);
       (2) by adding ``or'' at the end of subclause (VIII); and
       (3) by inserting after subclause (VIII) the following:

       ``(IX) who were in foster care under the responsibility of 
     a State for more than 6 months (whether or not consecutive) 
     but are no longer in such care, who are not described in any 
     of subclauses (I) through (VII) of this clause, and who are 
     under 25 years of age;''.

       (b) Option To Provide Presumptive Eligibility.--Section 
     1920(e) of such Act (42 U.S.C. 1396r-1(e)), as added by 
     section 2001(a)(4)(B) and amended by section 2001(e)(2)(C), 
     is amended by inserting ``, clause (i)(IX),'' after ``clause 
     (i)(VIII)''.
       (c) Conforming Amendments.--
       (1) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)), 
     as amended by section 2001(a)(5)(D), is amended by inserting 
     ``1902(a)(10)(A)(i)(IX),'' after 
     ``1902(a)(10)(A)(i)(VIII),''.
       (2) Section 1937(a)(2)(B)(viii) of such Act (42 U.S.C. 
     1396u-7(a)(2)(B)(viii)) is amended by inserting ``, or the 
     individual qualifies for medical assistance on the basis of 
     section 1902(a)(10)(A)(i)(IX)'' before the period.
       (d) Effective Date.--The amendments made by this section 
     take effect on January 1, 2019.

     SEC. 2005. PAYMENTS TO TERRITORIES.

       (a) Increase in Limit on Payments.--Section 1108(g) of the 
     Social Security Act (42 U.S.C. 1308(g)) is amended--
       (1) in paragraph (2), in the matter preceding subparagraph 
     (A), by striking ``paragraph (3)'' and inserting ``paragraphs 
     (3) and (5)'';
       (2) in paragraph (4), by striking ``and (3)'' and inserting 
     ``(3), and (4)''; and
       (3) by adding at the end the following paragraph:
       ``(5) Fiscal year 2011 and thereafter.--The amounts 
     otherwise determined under this subsection for Puerto Rico, 
     the Virgin Islands, Guam, the Northern Mariana Islands, and 
     American Samoa for the second, third, and fourth quarters of 
     fiscal year 2011, and for each fiscal year after fiscal year 
     2011 (after the application of subsection (f) and the 
     preceding paragraphs of this subsection), shall be increased 
     by 30 percent.''.
       (b) Disregard of Payments for Mandatory Expanded 
     Enrollment.--Section 1108(g)(4) of such Act (42 U.S.C. 
     1308(g)(4)) is amended--
       (1) by striking ``to fiscal years beginning'' and inserting 
     ``to--

[[Page H1964]]

       ``(A) fiscal years beginning'';
       (2) by striking the period at the end and inserting ``; 
     and''; and
       (3) by adding at the end the following:
       ``(B) fiscal years beginning with fiscal year 2014, 
     payments made to Puerto Rico, the Virgin Islands, Guam, the 
     Northern Mariana Islands, or American Samoa with respect to 
     amounts expended for medical assistance for newly eligible 
     (as defined in section 1905(y)(2)) nonpregnant childless 
     adults who are eligible under subclause (VIII) of section 
     1902(a)(10)(A)(i) and whose income (as determined under 
     section 1902(e)(14)) does not exceed (in the case of each 
     such commonwealth and territory respectively) the income 
     eligibility level in effect for that population under title 
     XIX or under a waiver on the date of enactment of the Patient 
     Protection and Affordable Care Act, shall not be taken into 
     account in applying subsection (f) (as increased in 
     accordance with paragraphs (1), (2), (3), and (5) of this 
     subsection) to such commonwealth or territory for such fiscal 
     year.''.
       (c) Increased FMAP.--
       (1) In general.--The first sentence of section 1905(b) of 
     the Social Security Act (42 U.S.C. 1396d(b)) is amended by 
     striking ``shall be 50 per centum'' and inserting ``shall be 
     55 percent''.
       (2) Effective date.--The amendment made by paragraph (1) 
     takes effect on January 1, 2011.

     SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINATION FOR 
                   CERTAIN STATES RECOVERING FROM A MAJOR 
                   DISASTER.

       Section 1905 of the Social Security Act (42 U.S.C. 1396d), 
     as amended by sections 2001(a)(3) and 2001(b)(2), is 
     amended--
       (1) in subsection (b), in the first sentence, by striking 
     ``subsection (y)'' and inserting ``subsections (y) and 
     (aa)''; and
       (2) by adding at the end the following new subsection:
       ``(aa)(1) Notwithstanding subsection (b), beginning January 
     1, 2011, the Federal medical assistance percentage for a 
     fiscal year for a disaster-recovery FMAP adjustment State 
     shall be equal to the following:
       ``(A) In the case of the first fiscal year (or part of a 
     fiscal year) for which this subsection applies to the State, 
     the Federal medical assistance percentage determined for the 
     fiscal year without regard to this subsection and subsection 
     (y), increased by 50 percent of the number of percentage 
     points by which the Federal medical assistance percentage 
     determined for the State for the fiscal year without regard 
     to this subsection and subsection (y), is less than the 
     Federal medical assistance percentage determined for the 
     State for the preceding fiscal year after the application of 
     only subsection (a) of section 5001 of Public Law 111-5 (if 
     applicable to the preceding fiscal year) and without regard 
     to this subsection, subsection (y), and subsections (b) and 
     (c) of section 5001 of Public Law 111-5.
       ``(B) In the case of the second or any succeeding fiscal 
     year for which this subsection applies to the State, the 
     Federal medical assistance percentage determined for the 
     preceding fiscal year under this subsection for the State, 
     increased by 25 percent of the number of percentage points by 
     which the Federal medical assistance percentage determined 
     for the State for the fiscal year without regard to this 
     subsection and subsection (y), is less than the Federal 
     medical assistance percentage determined for the State for 
     the preceding fiscal year under this subsection.
       ``(2) In this subsection, the term `disaster-recovery FMAP 
     adjustment State' means a State that is one of the 50 States 
     or the District of Columbia, for which, at any time during 
     the preceding 7 fiscal years, the President has declared a 
     major disaster under section 401 of the Robert T. Stafford 
     Disaster Relief and Emergency Assistance Act and determined 
     as a result of such disaster that every county or parish in 
     the State warrant individual and public assistance or public 
     assistance from the Federal Government under such Act and for 
     which--
       ``(A) in the case of the first fiscal year (or part of a 
     fiscal year) for which this subsection applies to the State, 
     the Federal medical assistance percentage determined for the 
     State for the fiscal year without regard to this subsection 
     and subsection (y), is less than the Federal medical 
     assistance percentage determined for the State for the 
     preceding fiscal year after the application of only 
     subsection (a) of section 5001 of Public Law 111-5 (if 
     applicable to the preceding fiscal year) and without regard 
     to this subsection, subsection (y), and subsections (b) and 
     (c) of section 5001 of Public Law 111-5, by at least 3 
     percentage points; and
       ``(B) in the case of the second or any succeeding fiscal 
     year for which this subsection applies to the State, the 
     Federal medical assistance percentage determined for the 
     State for the fiscal year without regard to this subsection 
     and subsection (y), is less than the Federal medical 
     assistance percentage determined for the State for the 
     preceding fiscal year under this subsection by at least 3 
     percentage points.
       ``(3) The Federal medical assistance percentage determined 
     for a disaster-recovery FMAP adjustment State under paragraph 
     (1) shall apply for purposes of this title (other than with 
     respect to disproportionate share hospital payments described 
     in section 1923 and payments under this title that are based 
     on the enhanced FMAP described in 2105(b)) and shall not 
     apply with respect to payments under title IV (other than 
     under part E of title IV) or payments under title XXI.''.

     SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION.

       (a) Rescission.--Any amounts available to the Medicaid 
     Improvement Fund established under section 1941 of the Social 
     Security Act (42 U.S.C. 1396w-1) for any of fiscal years 2014 
     through 2018 that are available for expenditure from the Fund 
     and that are not so obligated as of the date of the enactment 
     of this Act are rescinded.
       (b) Conforming Amendments.--Section 1941(b)(1) of the 
     Social Security Act (42 U.S.C. 1396w-1(b)(1)) is amended--
       (1) in subparagraph (A), by striking ``$100,000,000'' and 
     inserting ``$0''; and
       (2) in subparagraph (B), by striking ``$150,000,000'' and 
     inserting ``$0''.

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

     SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR 
                   CHIP.

       (a) In General.--Section 2105(b) of the Social Security Act 
     (42 U.S.C. 1397ee(b)) is amended by adding at the end the 
     following: ``Notwithstanding the preceding sentence, during 
     the period that begins on October 1, 2013, and ends on 
     September 30, 2019, the enhanced FMAP determined for a State 
     for a fiscal year (or for any portion of a fiscal year 
     occurring during such period) shall be increased by 23 
     percentage points, but in no case shall exceed 100 percent. 
     The increase in the enhanced FMAP under the preceding 
     sentence shall not apply with respect to determining the 
     payment to a State under subsection (a)(1) for expenditures 
     described in subparagraph (D)(iv), paragraphs (8), (9), (11) 
     of subsection (c), or clause (4) of the first sentence of 
     section 1905(b).''.
       (b) Maintenance of Effort.--
       (1) In general.--Section 2105(d) of the Social Security Act 
     (42 U.S.C. 1397ee(d)) is amended by adding at the end the 
     following:
       ``(3) Continuation of eligibility standards for children 
     until october 1, 2019.--
       ``(A) In general.--During the period that begins on the 
     date of enactment of the Patient Protection and Affordable 
     Care Act and ends on September 30, 2019, a State shall not 
     have in effect eligibility standards, methodologies, or 
     procedures under its State child health plan (including any 
     waiver under such plan) for children (including children 
     provided medical assistance for which payment is made under 
     section 2105(a)(1)(A)) that are more restrictive than the 
     eligibility standards, methodologies, or procedures, 
     respectively, under such plan (or waiver) as in effect on the 
     date of enactment of that Act. The preceding sentence shall 
     not be construed as preventing a State during such period 
     from--
       ``(i) applying eligibility standards, methodologies, or 
     procedures for children under the State child health plan or 
     under any waiver of the plan that are less restrictive than 
     the eligibility standards, methodologies, or procedures, 
     respectively, for children under the plan or waiver that are 
     in effect on the date of enactment of such Act; or
       ``(ii) imposing a limitation described in section 
     2112(b)(7) for a fiscal year in order to limit expenditures 
     under the State child health plan to those for which Federal 
     financial participation is available under this section for 
     the fiscal year.
       ``(B) Assurance of exchange coverage for targeted low-
     income children unable to be provided child health assistance 
     as a result of funding shortfalls.--In the event that 
     allotments provided under section 2104 are insufficient to 
     provide coverage to all children who are eligible to be 
     targeted low-income children under the State child health 
     plan under this title, a State shall establish procedures to 
     ensure that such children are provided coverage through an 
     Exchange established by the State under section 1311 of the 
     Patient Protection and Affordable Care Act.''.
       (2) Conforming amendment to title xxi medicaid maintenance 
     of effort.--Section 2105(d)(1) of the Social Security Act (42 
     U.S.C. 1397ee(d)(1)) is amended by adding before the period 
     ``, except as required under section 1902(e)(14)''.
       (c) No Enrollment Bonus Payments for Children Enrolled 
     After Fiscal Year 2013.--Section 2105(a)(3)(F)(iii) of the 
     Social Security Act (42 U.S.C. 1397ee(a)(3)(F)(iii)) is 
     amended by inserting ``or any children enrolled on or after 
     October 1, 2013'' before the period.
       (d) Income Eligibility Determined Using Modified Gross 
     Income.--
       (1) State plan requirement.--Section 2102(b)(1)(B) of the 
     Social Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended--
       (A) in clause (iii), by striking ``and'' after the 
     semicolon;
       (B) in clause (iv), by striking the period and inserting 
     ``; and''; and
       (C) by adding at the end the following:
       ``(v) shall, beginning January 1, 2014, use modified gross 
     income and household income (as defined in section 36B(d)(2) 
     of the Internal Revenue Code of 1986) to determine 
     eligibility for child health assistance under the State child 
     health plan or under any waiver of such plan and for any 
     other purpose applicable under the plan or waiver for which a 
     determination of income is required, including with respect 
     to the imposition of premiums and cost-sharing, consistent 
     with section 1902(e)(14).''.
       (2) Conforming amendment.--Section 2107(e)(1) of the Social 
     Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
       (A) by redesignating subparagraphs (E) through (L) as 
     subparagraphs (F) through (M), respectively; and
       (B) by inserting after subparagraph (D), the following:
       ``(E) Section 1902(e)(14) (relating to income determined 
     using modified gross income and household income).''.
       (e) Application of Streamlined Enrollment System.--Section 
     2107(e)(1) of the Social Security Act (42 U.S.C. 
     1397gg(e)(1)), as amended by subsection (d)(2), is amended by 
     adding at the end the following:
       ``(N) Section 1943(b) (relating to coordination with State 
     Exchanges and the State Medicaid agency).''.

[[Page H1965]]

       (f) CHIP Eligibility for Children Ineligible for Medicaid 
     as a Result of Elimination of Disregards.--Notwithstanding 
     any other provision of law, a State shall treat any child who 
     is determined to be ineligible for medical assistance under 
     the State Medicaid plan or under a waiver of the plan as a 
     result of the elimination of the application of an income 
     disregard based on expense or type of income, as required 
     under section 1902(e)(14) of the Social Security Act (as 
     added by this Act), as a targeted low-income child under 
     section 2110(b) (unless the child is excluded under paragraph 
     (2) of that section) and shall provide child health 
     assistance to the child under the State child health plan 
     (whether implemented under title XIX or XXI, or both, of the 
     Social Security Act).

     SEC. 2102. TECHNICAL CORRECTIONS.

       (a) CHIPRA.--Effective as if included in the enactment of 
     the Children's Health Insurance Program Reauthorization Act 
     of 2009 (Public Law 111-3) (in this section referred to as 
     ``CHIPRA''):
       (1) Section 2104(m) of the Social Security Act, as added by 
     section 102 of CHIPRA, is amended--
       (A) by redesignating paragraph (7) as paragraph (8); and
       (B) by inserting after paragraph (6), the following:
       ``(7) Adjustment of fiscal year 2010 allotments to account 
     for changes in projected spending for certain previously 
     approved expansion programs.--For purposes of recalculating 
     the fiscal year 2010 allotment, in the case of one of the 50 
     States or the District of Columbia that has an approved State 
     plan amendment effective January 1, 2006, to provide child 
     health assistance through the provision of benefits under the 
     State plan under title XIX for children from birth through 
     age 5 whose family income does not exceed 200 percent of the 
     poverty line, the Secretary shall increase the allotment by 
     an amount that would be equal to the Federal share of 
     expenditures that would have been claimed at the enhanced 
     FMAP rate rather than the Federal medical assistance 
     percentage matching rate for such population.''.
       (2) Section 605 of CHIPRA is amended by striking ``legal 
     residents'' and insert ``lawfully residing in the United 
     States''.
       (3) Subclauses (I) and (II) of paragraph (3)(C)(i) of 
     section 2105(a) of the Social Security Act (42 U.S.C. 
     1397ee(a)(3)(ii)), as added by section 104 of CHIPRA, are 
     each amended by striking ``, respectively''.
       (4) Section 2105(a)(3)(E)(ii) of the Social Security Act 
     (42 U.S.C. 1397ee(a)(3)(E)(ii)), as added by section 104 of 
     CHIPRA, is amended by striking subclause (IV).
       (5) Section 2105(c)(9)(B) of the Social Security Act (42 
     U.S.C. 1397e(c)(9)(B)), as added by section 211(c)(1) of 
     CHIPRA, is amended by striking ``section 1903(a)(3)(F)'' and 
     inserting ``section 1903(a)(3)(G)''.
       (6) Section 2109(b)(2)(B) of the Social Security Act (42 
     U.S.C. 1397ii(b)(2)(B)), as added by section 602 of CHIPRA, 
     is amended by striking ``the child population growth factor 
     under section 2104(m)(5)(B)'' and inserting ``a high-
     performing State under section 2111(b)(3)(B)''.
       (7) Section 2110(c)(9)(B)(v) of the Social Security Act (42 
     U.S.C. 1397jj(c)(9)(B)(v)), as added by section 505(b) of 
     CHIPRA, is amended by striking ``school or school system'' 
     and inserting ``local educational agency (as defined under 
     section 9101 of the Elementary and Secondary Education Act of 
     1965''.
       (8) Section 211(a)(1)(B) of CHIPRA is amended--
       (A) by striking ``is amended'' and all that follows through 
     ``adding'' and inserting ``is amended by adding''; and
       (B) by redesignating the new subparagraph to be added by 
     such section to section 1903(a)(3) of the Social Security Act 
     as a new subparagraph (H).
       (b) ARRA.--Effective as if included in the enactment of 
     section 5006(a) of division B of the American Recovery and 
     Reinvestment Act of 2009 (Public Law 111-5), the second 
     sentence of section 1916A(a)(1) of the Social Security Act 
     (42 U.S.C. 1396o-1(a)(1)) is amended by striking ``or (i)'' 
     and inserting ``, (i), or (j)''.

        Subtitle C--Medicaid and CHIP Enrollment Simplification

     SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH 
                   STATE HEALTH INSURANCE EXCHANGES.

       Title XIX of the Social Security Act (42 U.S.C. 1397aa et 
     seq.) is amended by adding at the end the following:

     ``SEC. 1943. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH 
                   STATE HEALTH INSURANCE EXCHANGES.

       ``(a) Condition for Participation in Medicaid.--As a 
     condition of the State plan under this title and receipt of 
     any Federal financial assistance under section 1903(a) for 
     calendar quarters beginning after January 1, 2014, a State 
     shall ensure that the requirements of subsection (b) is met.
       ``(b) Enrollment Simplification and Coordination With State 
     Health Insurance Exchanges and Chip.--
       ``(1) In general.--A State shall establish procedures for--
       ``(A) enabling individuals, through an Internet website 
     that meets the requirements of paragraph (4), to apply for 
     medical assistance under the State plan or under a waiver of 
     the plan, to be enrolled in the State plan or waiver, to 
     renew their enrollment in the plan or waiver, and to consent 
     to enrollment or reenrollment in the State plan through 
     electronic signature;
       ``(B) enrolling, without any further determination by the 
     State and through such website, individuals who are 
     identified by an Exchange established by the State under 
     section 1311 of the Patient Protection and Affordable Care 
     Act as being eligible for--
       ``(i) medical assistance under the State plan or under a 
     waiver of the plan; or
       ``(ii) child health assistance under the State child health 
     plan under title XXI;
       ``(C) ensuring that individuals who apply for but are 
     determined to be ineligible for medical assistance under the 
     State plan or a waiver or ineligible for child health 
     assistance under the State child health plan under title XXI, 
     are screened for eligibility for enrollment in qualified 
     health plans offered through such an Exchange and, if 
     applicable, premium assistance for the purchase of a 
     qualified health plan under section 36B of the Internal 
     Revenue Code of 1986 (and, if applicable, advance payment of 
     such assistance under section 1412 of the Patient Protection 
     and Affordable Care Act), and, if eligible, enrolled in such 
     a plan without having to submit an additional or separate 
     application, and that such individuals receive information 
     regarding reduced cost-sharing for eligible individuals under 
     section 1402 of the Patient Protection and Affordable Care 
     Act, and any other assistance or subsidies available for 
     coverage obtained through the Exchange;
       ``(D) ensuring that the State agency responsible for 
     administering the State plan under this title (in this 
     section referred to as the `State Medicaid agency'), the 
     State agency responsible for administering the State child 
     health plan under title XXI (in this section referred to as 
     the `State CHIP agency') and an Exchange established by the 
     State under section 1311 of the Patient Protection and 
     Affordable Care Act utilize a secure electronic interface 
     sufficient to allow for a determination of an individual's 
     eligibility for such medical assistance, child health 
     assistance, or premium assistance, and enrollment in the 
     State plan under this title, title XXI, or a qualified health 
     plan, as appropriate;
       ``(E) coordinating, for individuals who are enrolled in the 
     State plan or under a waiver of the plan and who are also 
     enrolled in a qualified health plan offered through such an 
     Exchange, and for individuals who are enrolled in the State 
     child health plan under title XXI and who are also enrolled 
     in a qualified health plan, the provision of medical 
     assistance or child health assistance to such individuals 
     with the coverage provided under the qualified health plan in 
     which they are enrolled, including services described in 
     section 1905(a)(4)(B) (relating to early and periodic 
     screening, diagnostic, and treatment services defined in 
     section 1905(r)) and provided in accordance with the 
     requirements of section 1902(a)(43); and
       ``(F) conducting outreach to and enrolling vulnerable and 
     underserved populations eligible for medical assistance under 
     this title XIX or for child health assistance under title 
     XXI, including children, unaccompanied homeless youth, 
     children and youth with special health care needs, pregnant 
     women, racial and ethnic minorities, rural populations, 
     victims of abuse or trauma, individuals with mental health or 
     substance-related disorders, and individuals with HIV/AIDS.
       ``(2) Agreements with state health insurance exchanges.--
     The State Medicaid agency and the State CHIP agency may enter 
     into an agreement with an Exchange established by the State 
     under section 1311 of the Patient Protection and Affordable 
     Care Act under which the State Medicaid agency or State CHIP 
     agency may determine whether a State resident is eligible for 
     premium assistance for the purchase of a qualified health 
     plan under section 36B of the Internal Revenue Code of 1986 
     (and, if applicable, advance payment of such assistance under 
     section 1412 of the Patient Protection and Affordable Care 
     Act), so long as the agreement meets such conditions and 
     requirements as the Secretary of the Treasury may prescribe 
     to reduce administrative costs and the likelihood of 
     eligibility errors and disruptions in coverage.
       ``(3) Streamlined enrollment system.--The State Medicaid 
     agency and State CHIP agency shall participate in and comply 
     with the requirements for the system established under 
     section 1413 of the Patient Protection and Affordable Care 
     Act (relating to streamlined procedures for enrollment 
     through an Exchange, Medicaid, and CHIP).
       ``(4) Enrollment website requirements.--The procedures 
     established by State under paragraph (1) shall include 
     establishing and having in operation, not later than January 
     1, 2014, an Internet website that is linked to any website of 
     an Exchange established by the State under section 1311 of 
     the Patient Protection and Affordable Care Act and to the 
     State CHIP agency (if different from the State Medicaid 
     agency) and allows an individual who is eligible for medical 
     assistance under the State plan or under a waiver of the plan 
     and who is eligible to receive premium credit assistance for 
     the purchase of a qualified health plan under section 36B of 
     the Internal Revenue Code of 1986 to compare the benefits, 
     premiums, and cost-sharing applicable to the individual under 
     the State plan or waiver with the benefits, premiums, and 
     cost-sharing available to the individual under a qualified 
     health plan offered through such an Exchange, including, in 
     the case of a child, the coverage that would be provided for 
     the child through the State plan or waiver with the coverage 
     that would be provided to the child through enrollment in 
     family coverage under that plan and as supplemental coverage 
     by the State under the State plan or waiver.
       ``(5) Continued need for assessment for home and community-
     based services.--Nothing in paragraph (1) shall limit or 
     modify the requirement that the State assess an individual 
     for purposes of providing home and community-based services 
     under the State plan or under any waiver of such plan for 
     individuals described in subsection (a)(10)(A)(ii)(VI).''.

[[Page H1966]]

     SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMPTIVE 
                   ELIGIBILITY DETERMINATIONS FOR ALL MEDICAID 
                   ELIGIBLE POPULATIONS.

       (a) In General.--Section 1902(a)(47) of the Social Security 
     Act (42 U.S.C. 1396a(a)(47)) is amended--
       (1) by striking ``at the option of the State, provide'' and 
     inserting ``provide--
       ``(A) at the option of the State,'';
       (2) by inserting ``and'' after the semicolon; and
       (3) by adding at the end the following:
       ``(B) that any hospital that is a participating provider 
     under the State plan may elect to be a qualified entity for 
     purposes of determining, on the basis of preliminary 
     information, whether any individual is eligible for medical 
     assistance under the State plan or under a waiver of the plan 
     for purposes of providing the individual with medical 
     assistance during a presumptive eligibility period, in the 
     same manner, and subject to the same requirements, as apply 
     to the State options with respect to populations described in 
     section 1920, 1920A, or 1920B (but without regard to whether 
     the State has elected to provide for a presumptive 
     eligibility period under any such sections), subject to such 
     guidance as the Secretary shall establish;''.
       (b) Conforming Amendment.--Section 1903(u)(1)(D)(v) of such 
     Act (42 U.S.C. 1396b(u)(1)(D)v)) is amended--
       (1) by striking ``or for'' and inserting ``for''; and
       (2) by inserting before the period at the end the 
     following: ``, or for medical assistance provided to an 
     individual during a presumptive eligibility period resulting 
     from a determination of presumptive eligibility made by a 
     hospital that elects under section 1902(a)(47)(B) to be a 
     qualified entity for such purpose''.
       (c) Effective Date.--The amendments made by this section 
     take effect on January 1, 2014, and apply to services 
     furnished on or after that date.

             Subtitle D--Improvements to Medicaid Services

     SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES.

       (a) In General.--Section 1905 of the Social Security Act 
     (42 U.S.C. 1396d), is amended--
       (1) in subsection (a)--
       (A) in paragraph (27), by striking ``and'' at the end;
       (B) by redesignating paragraph (28) as paragraph (29); and
       (C) by inserting after paragraph (27) the following new 
     paragraph:
       ``(28) freestanding birth center services (as defined in 
     subsection (l)(3)(A)) and other ambulatory services that are 
     offered by a freestanding birth center (as defined in 
     subsection (l)(3)(B)) and that are otherwise included in the 
     plan; and''; and
       (2) in subsection (l), by adding at the end the following 
     new paragraph:
       ``(3)(A) The term `freestanding birth center services' 
     means services furnished to an individual at a freestanding 
     birth center (as defined in subparagraph (B)) at such center.
       ``(B) The term `freestanding birth center' means a health 
     facility--
       ``(i) that is not a hospital;
       ``(ii) where childbirth is planned to occur away from the 
     pregnant woman's residence;
       ``(iii) that is licensed or otherwise approved by the State 
     to provide prenatal labor and delivery or postpartum care and 
     other ambulatory services that are included in the plan; and
       ``(iv) that complies with such other requirements relating 
     to the health and safety of individuals furnished services by 
     the facility as the State shall establish.
       ``(C) A State shall provide separate payments to providers 
     administering prenatal labor and delivery or postpartum care 
     in a freestanding birth center (as defined in subparagraph 
     (B)), such as nurse midwives and other providers of services 
     such as birth attendants recognized under State law, as 
     determined appropriate by the Secretary. For purposes of the 
     preceding sentence, the term `birth attendant' means an 
     individual who is recognized or registered by the State 
     involved to provide health care at childbirth and who 
     provides such care within the scope of practice under which 
     the individual is legally authorized to perform such care 
     under State law (or the State regulatory mechanism provided 
     by State law), regardless of whether the individual is under 
     the supervision of, or associated with, a physician or other 
     health care provider. Nothing in this subparagraph shall be 
     construed as changing State law requirements applicable to a 
     birth attendant.''.
       (b) Conforming Amendment.--Section 1902(a)(10)(A) of the 
     Social Security Act (42 U.S.C. 1396a(a)(10)(A)), is amended 
     in the matter preceding clause (i) by striking ``and (21)'' 
     and inserting ``, (21), and (28)''.
       (c) Effective Date.--
       (1) In general.--Except as provided in paragraph (2), the 
     amendments made by this section shall take effect on the date 
     of the enactment of this Act and shall apply to services 
     furnished on or after such date.
       (2) Exception if state legislation required.--In the case 
     of a State plan for medical assistance under title XIX of the 
     Social Security Act which the Secretary of Health and Human 
     Services determines requires State legislation (other than 
     legislation appropriating funds) in order for the plan to 
     meet the additional requirement imposed by the amendments 
     made by this section, the State plan shall not be regarded as 
     failing to comply with the requirements of such title solely 
     on the basis of its failure to meet this additional 
     requirement before the first day of the first calendar 
     quarter beginning after the close of the first regular 
     session of the State legislature that begins after the date 
     of the enactment of this Act. For purposes of the previous 
     sentence, in the case of a State that has a 2-year 
     legislative session, each year of such session shall be 
     deemed to be a separate regular session of the State 
     legislature.

     SEC. 2302. CONCURRENT CARE FOR CHILDREN.

       (a) In General.--Section 1905(o)(1) of the Social Security 
     Act (42 U.S.C. 1396d(o)(1)) is amended--
       (1) in subparagraph (A), by striking ``subparagraph (B)'' 
     and inserting ``subparagraphs (B) and (C)''; and
       (2) by adding at the end the following new subparagraph:
       ``(C) A voluntary election to have payment made for hospice 
     care for a child (as defined by the State) shall not 
     constitute a waiver of any rights of the child to be provided 
     with, or to have payment made under this title for, services 
     that are related to the treatment of the child's condition 
     for which a diagnosis of terminal illness has been made.''.
       (b) Application to CHIP.--Section 2110(a)(23) of the Social 
     Security Act (42 U.S.C. 1397jj(a)(23)) is amended by 
     inserting ``(concurrent, in the case of an individual who is 
     a child, with care related to the treatment of the child's 
     condition with respect to which a diagnosis of terminal 
     illness has been made'' after ``hospice care''.

     SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING 
                   SERVICES.

       (a) Coverage as Optional Categorically Needy Group.--
       (1) In general.--Section 1902(a)(10)(A)(ii) of the Social 
     Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by 
     section 2001(e), is amended--
       (A) in subclause (XIX), by striking ``or'' at the end;
       (B) in subclause (XX), by adding ``or'' at the end; and
       (C) by adding at the end the following new subclause:

       ``(XXI) who are described in subsection (ii) (relating to 
     individuals who meet certain income standards);''.

       (2) Group described.--Section 1902 of such Act (42 U.S.C. 
     1396a), as amended by section 2001(d), is amended by adding 
     at the end the following new subsection:
       ``(ii)(1) Individuals described in this subsection are 
     individuals--
       ``(A) whose income does not exceed an income eligibility 
     level established by the State that does not exceed the 
     highest income eligibility level established under the State 
     plan under this title (or under its State child health plan 
     under title XXI) for pregnant women; and
       ``(B) who are not pregnant.
       ``(2) At the option of a State, individuals described in 
     this subsection may include individuals who, had individuals 
     applied on or before January 1, 2007, would have been made 
     eligible pursuant to the standards and processes imposed by 
     that State for benefits described in clause (XV) of the 
     matter following subparagraph (G) of section subsection 
     (a)(10) pursuant to a waiver granted under section 1115.
       ``(3) At the option of a State, for purposes of subsection 
     (a)(17)(B), in determining eligibility for services under 
     this subsection, the State may consider only the income of 
     the applicant or recipient.''.
       (3) Limitation on benefits.--Section 1902(a)(10) of the 
     Social Security Act (42 U.S.C. 1396a(a)(10)), as amended by 
     section 2001(a)(5)(A), is amended in the matter following 
     subparagraph (G)--
       (A) by striking ``and (XV)'' and inserting ``(XV)''; and
       (B) by inserting ``, and (XVI) the medical assistance made 
     available to an individual described in subsection (ii) shall 
     be limited to family planning services and supplies described 
     in section 1905(a)(4)(C) including medical diagnosis and 
     treatment services that are provided pursuant to a family 
     planning service in a family planning setting'' before the 
     semicolon.
       (4) Conforming amendments.--
       (A) Section 1905(a) of the Social Security Act (42 U.S.C. 
     1396d(a)), as amended by section 2001(e)(2)(A), is amended in 
     the matter preceding paragraph (1)--
       (i) in clause (xiv), by striking ``or'' at the end;
       (ii) in clause (xv), by adding ``or'' at the end; and
       (iii) by inserting after clause (xv) the following:
       ``(xvi) individuals described in section 1902(ii),''.
       (B) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)), 
     as amended by section 2001(e)(2)(B), is amended by inserting 
     ``1902(a)(10)(A)(ii)(XXI),'' after 
     ``1902(a)(10)(A)(ii)(XX),''.
       (b) Presumptive Eligibility.--
       (1) In general.--Title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.) is amended by inserting after section 
     1920B the following:


         ``presumptive eligibility for family planning services

       ``Sec. 1920C.  (a) State Option.--State plan approved under 
     section 1902 may provide for making medical assistance 
     available to an individual described in section 1902(ii) 
     (relating to individuals who meet certain income eligibility 
     standard) during a presumptive eligibility period. In the 
     case of an individual described in section 1902(ii), such 
     medical assistance shall be limited to family planning 
     services and supplies described in 1905(a)(4)(C) and, at the 
     State's option, medical diagnosis and treatment services that 
     are provided in conjunction with a family planning service in 
     a family planning setting.
       ``(b) Definitions.--For purposes of this section:
       ``(1) Presumptive eligibility period.--The term 
     `presumptive eligibility period' means, with respect to an 
     individual described in subsection (a), the period that--
       ``(A) begins with the date on which a qualified entity 
     determines, on the basis of preliminary information, that the 
     individual is described in section 1902(ii); and

[[Page H1967]]

       ``(B) ends with (and includes) the earlier of--
       ``(i) the day on which a determination is made with respect 
     to the eligibility of such individual for services under the 
     State plan; or
       ``(ii) in the case of such an individual who does not file 
     an application by the last day of the month following the 
     month during which the entity makes the determination 
     referred to in subparagraph (A), such last day.
       ``(2) Qualified entity.--
       ``(A) In general.--Subject to subparagraph (B), the term 
     `qualified entity' means any entity that--
       ``(i) is eligible for payments under a State plan approved 
     under this title; and
       ``(ii) is determined by the State agency to be capable of 
     making determinations of the type described in paragraph 
     (1)(A).
       ``(B) Rule of construction.--Nothing in this paragraph 
     shall be construed as preventing a State from limiting the 
     classes of entities that may become qualified entities in 
     order to prevent fraud and abuse.
       ``(c) Administration.--
       ``(1) In general.--The State agency shall provide qualified 
     entities with--
       ``(A) such forms as are necessary for an application to be 
     made by an individual described in subsection (a) for medical 
     assistance under the State plan; and
       ``(B) information on how to assist such individuals in 
     completing and filing such forms.
       ``(2) Notification requirements.--A qualified entity that 
     determines under subsection (b)(1)(A) that an individual 
     described in subsection (a) is presumptively eligible for 
     medical assistance under a State plan shall--
       ``(A) notify the State agency of the determination within 5 
     working days after the date on which determination is made; 
     and
       ``(B) inform such individual at the time the determination 
     is made that an application for medical assistance is 
     required to be made by not later than the last day of the 
     month following the month during which the determination is 
     made.
       ``(3) Application for medical assistance.--In the case of 
     an individual described in subsection (a) who is determined 
     by a qualified entity to be presumptively eligible for 
     medical assistance under a State plan, the individual shall 
     apply for medical assistance by not later than the last day 
     of the month following the month during which the 
     determination is made.
       ``(d) Payment.--Notwithstanding any other provision of law, 
     medical assistance that--
       ``(1) is furnished to an individual described in subsection 
     (a)--
       ``(A) during a presumptive eligibility period; and
       ``(B) by a entity that is eligible for payments under the 
     State plan; and
       ``(2) is included in the care and services covered by the 
     State plan,

     shall be treated as medical assistance provided by such plan 
     for purposes of clause (4) of the first sentence of section 
     1905(b).''.
       (2) Conforming amendments.--
       (A) Section 1902(a)(47) of the Social Security Act (42 
     U.S.C. 1396a(a)(47)), as amended by section 2202(a), is 
     amended--
       (i) in subparagraph (A), by inserting before the semicolon 
     at the end the following: ``and provide for making medical 
     assistance available to individuals described in subsection 
     (a) of section 1920C during a presumptive eligibility period 
     in accordance with such section''; and
       (ii) in subparagraph (B), by striking ``or 1920B'' and 
     inserting ``1920B, or 1920C''.
       (B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C. 
     1396b(u)(1)(D)(v)), as amended by section 2202(b), is amended 
     by inserting ``or for medical assistance provided to an 
     individual described in subsection (a) of section 1920C 
     during a presumptive eligibility period under such section,'' 
     after ``1920B during a presumptive eligibility period under 
     such section,''.
       (c) Clarification of Coverage of Family Planning Services 
     and Supplies.--Section 1937(b) of the Social Security Act (42 
     U.S.C. 1396u-7(b)), as amended by section 2001(c), is amended 
     by adding at the end the following:
       ``(7) Coverage of family planning services and supplies.--
     Notwithstanding the previous provisions of this section, a 
     State may not provide for medical assistance through 
     enrollment of an individual with benchmark coverage or 
     benchmark-equivalent coverage under this section unless such 
     coverage includes for any individual described in section 
     1905(a)(4)(C), medical assistance for family planning 
     services and supplies in accordance with such section.''.
       (d) Effective Date.--The amendments made by this section 
     take effect on the date of the enactment of this Act and 
     shall apply to items and services furnished on or after such 
     date.

     SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL ASSISTANCE.

       Section 1905(a) of the Social Security Act (42 U.S.C. 
     1396d(a)) is amended by inserting ``or the care and services 
     themselves, or both'' before ``(if provided in or after''.

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

     SEC. 2401. COMMUNITY FIRST CHOICE OPTION.

       Section 1915 of the Social Security Act (42 U.S.C. 1396n) 
     is amended by adding at the end the following:
       ``(k) State Plan Option To Provide Home and Community-based 
     Attendant Services and Supports.--
       ``(1) In general.--Subject to the succeeding provisions of 
     this subsection, beginning October 1, 2010, a State may 
     provide through a State plan amendment for the provision of 
     medical assistance for home and community-based attendant 
     services and supports for individuals who are eligible for 
     medical assistance under the State plan whose income does not 
     exceed 150 percent of the poverty line (as defined in section 
     2110(c)(5)) or, if greater, the income level applicable for 
     an individual who has been determined to require an 
     institutional level of care to be eligible for nursing 
     facility services under the State plan and with respect to 
     whom there has been a determination that, but for the 
     provision of such services, the individuals would require the 
     level of care provided in a hospital, a nursing facility, an 
     intermediate care facility for the mentally retarded, or an 
     institution for mental diseases, the cost of which could be 
     reimbursed under the State plan, but only if the individual 
     chooses to receive such home and community-based attendant 
     services and supports, and only if the State meets the 
     following requirements:
       ``(A) Availability.--The State shall make available home 
     and community-based attendant services and supports to 
     eligible individuals, as needed, to assist in accomplishing 
     activities of daily living, instrumental activities of daily 
     living, and health-related tasks through hands-on assistance, 
     supervision, or cueing--
       ``(i) under a person-centered plan of services and supports 
     that is based on an assessment of functional need and that is 
     agreed to in writing by the individual or, as appropriate, 
     the individual's representative;
       ``(ii) in a home or community setting, which does not 
     include a nursing facility, institution for mental diseases, 
     or an intermediate care facility for the mentally retarded;
       ``(iii) under an agency-provider model or other model (as 
     defined in paragraph (6)(C )); and
       ``(iv) the furnishing of which--

       ``(I) is selected, managed, and dismissed by the 
     individual, or, as appropriate, with assistance from the 
     individual's representative;
       ``(II) is controlled, to the maximum extent possible, by 
     the individual or where appropriate, the individual's 
     representative, regardless of who may act as the employer of 
     record; and
       ``(III) provided by an individual who is qualified to 
     provide such services, including family members (as defined 
     by the Secretary).

       ``(B) Included services and supports.--In addition to 
     assistance in accomplishing activities of daily living, 
     instrumental activities of daily living, and health related 
     tasks, the home and community-based attendant services and 
     supports made available include--
       ``(i) the acquisition, maintenance, and enhancement of 
     skills necessary for the individual to accomplish activities 
     of daily living, instrumental activities of daily living, and 
     health related tasks;
       ``(ii) back-up systems or mechanisms (such as the use of 
     beepers or other electronic devices) to ensure continuity of 
     services and supports; and
       ``(iii) voluntary training on how to select, manage, and 
     dismiss attendants.
       ``(C) Excluded services and supports.--Subject to 
     subparagraph (D), the home and community-based attendant 
     services and supports made available do not include--
       ``(i) room and board costs for the individual;
       ``(ii) special education and related services provided 
     under the Individuals with Disabilities Education Act and 
     vocational rehabilitation services provided under the 
     Rehabilitation Act of 1973;
       ``(iii) assistive technology devices and assistive 
     technology services other than those under (1)(B)(ii);
       ``(iv) medical supplies and equipment; or
       ``(v) home modifications.
       ``(D) Permissible services and supports.--The home and 
     community-based attendant services and supports may include--
       ``(i) expenditures for transition costs such as rent and 
     utility deposits, first month's rent and utilities, bedding, 
     basic kitchen supplies, and other necessities required for an 
     individual to make the transition from a nursing facility, 
     institution for mental diseases, or intermediate care 
     facility for the mentally retarded to a community-based home 
     setting where the individual resides; and
       ``(ii) expenditures relating to a need identified in an 
     individual's person-centered plan of services that increase 
     independence or substitute for human assistance, to the 
     extent that expenditures would otherwise be made for the 
     human assistance.
       ``(2) Increased federal financial participation.--For 
     purposes of payments to a State under section 1903(a)(1), 
     with respect to amounts expended by the State to provide 
     medical assistance under the State plan for home and 
     community-based attendant services and supports to eligible 
     individuals in accordance with this subsection during a 
     fiscal year quarter occurring during the period described in 
     paragraph (1), the Federal medical assistance percentage 
     applicable to the State (as determined under section 1905(b)) 
     shall be increased by 6 percentage points.
       ``(3) State requirements.--In order for a State plan 
     amendment to be approved under this subsection, the State 
     shall--
       ``(A) develop and implement such amendment in collaboration 
     with a Development and Implementation Council established by 
     the State that includes a majority of members with 
     disabilities, elderly individuals, and their representatives 
     and consults and collaborates with such individuals;
       ``(B) provide consumer controlled home and community-based 
     attendant services and supports to individuals on a statewide 
     basis, in a manner that provides such services and supports 
     in the most integrated setting appropriate to the 
     individual's needs, and without regard to the individual's 
     age, type or nature of disability, severity of disability, or 
     the form of home and community-based attendant services and 
     supports that the individual requires in order to lead an 
     independent life;
       ``(C) with respect to expenditures during the first full 
     fiscal year in which the State plan amendment is implemented, 
     maintain or exceed the level of State expenditures for 
     medical assistance that is provided under section 1905(a),

[[Page H1968]]

     section 1915, section 1115, or otherwise to individuals with 
     disabilities or elderly individuals attributable to the 
     preceding fiscal year;
       ``(D) establish and maintain a comprehensive, continuous 
     quality assurance system with respect to community- based 
     attendant services and supports that--
       ``(i) includes standards for agency-based and other 
     delivery models with respect to training, appeals for denials 
     and reconsideration procedures of an individual plan, and 
     other factors as determined by the Secretary;
       ``(ii) incorporates feedback from consumers and their 
     representatives, disability organizations, providers, 
     families of disabled or elderly individuals, members of the 
     community, and others and maximizes consumer independence and 
     consumer control;
       ``(iii) monitors the health and well-being of each 
     individual who receives home and community-based attendant 
     services and supports, including a process for the mandatory 
     reporting, investigation, and resolution of allegations of 
     neglect, abuse, or exploitation in connection with the 
     provision of such services and supports; and
       ``(iv) provides information about the provisions of the 
     quality assurance required under clauses (i) through (iii) to 
     each individual receiving such services; and
       ``(E) collect and report information, as determined 
     necessary by the Secretary, for the purposes of approving the 
     State plan amendment, providing Federal oversight, and 
     conducting an evaluation under paragraph (5)(A), including 
     data regarding how the State provides home and community-
     based attendant services and supports and other home and 
     community-based services, the cost of such services and 
     supports, and how the State provides individuals with 
     disabilities who otherwise qualify for institutional care 
     under the State plan or under a waiver the choice to instead 
     receive home and community-based services in lieu of 
     institutional care.
       ``(4) Compliance with certain laws.--A State shall ensure 
     that, regardless of whether the State uses an agency-provider 
     model or other models to provide home and community-based 
     attendant services and supports under a State plan amendment 
     under this subsection, such services and supports are 
     provided in accordance with the requirements of the Fair 
     Labor Standards Act of 1938 and applicable Federal and State 
     laws regarding--
       ``(A) withholding and payment of Federal and State income 
     and payroll taxes;
       ``(B) the provision of unemployment and workers 
     compensation insurance;
       ``(C) maintenance of general liability insurance; and
       ``(D) occupational health and safety.
       ``(5) Evaluation, data collection, and report to 
     congress.--
       ``(A) Evaluation.--The Secretary shall conduct an 
     evaluation of the provision of home and community-based 
     attendant services and supports under this subsection in 
     order to determine the effectiveness of the provision of such 
     services and supports in allowing the individuals receiving 
     such services and supports to lead an independent life to the 
     maximum extent possible; the impact on the physical and 
     emotional health of the individuals who receive such 
     services; and an comparative analysis of the costs of 
     services provided under the State plan amendment under this 
     subsection and those provided under institutional care in a 
     nursing facility, institution for mental diseases, or an 
     intermediate care facility for the mentally retarded.
       ``(B) Data collection.--The State shall provide the 
     Secretary with the following information regarding the 
     provision of home and community-based attendant services and 
     supports under this subsection for each fiscal year for which 
     such services and supports are provided:
       ``(i) The number of individuals who are estimated to 
     receive home and community-based attendant services and 
     supports under this subsection during the fiscal year.
       ``(ii) The number of individuals that received such 
     services and supports during the preceding fiscal year.
       ``(iii) The specific number of individuals served by type 
     of disability, age, gender, education level, and employment 
     status.
       ``(iv) Whether the specific individuals have been 
     previously served under any other home and community based 
     services program under the State plan or under a waiver.
       ``(C) Reports.--Not later than--
       ``(i) December 31, 2013, the Secretary shall submit to 
     Congress and make available to the public an interim report 
     on the findings of the evaluation under subparagraph (A); and
       ``(ii) December 31, 2015, the Secretary shall submit to 
     Congress and make available to the public a final report on 
     the findings of the evaluation under subparagraph (A).
       ``(6) Definitions.--In this subsection:
       ``(A) Activities of daily living.--The term `activities of 
     daily living' includes tasks such as eating, toileting, 
     grooming, dressing, bathing, and transferring.
       ``(B) Consumer controlled.--The term `consumer controlled' 
     means a method of selecting and providing services and 
     supports that allow the individual, or where appropriate, the 
     individual's representative, maximum control of the home and 
     community-based attendant services and supports, regardless 
     of who acts as the employer of record.
       ``(C) Delivery models.--
       ``(i) Agency-provider model.--The term `agency-provider 
     model' means, with respect to the provision of home and 
     community-based attendant services and supports for an 
     individual, subject to paragraph (4), a method of providing 
     consumer controlled services and supports under which 
     entities contract for the provision of such services and 
     supports.
       ``(ii) Other models.--The term `other models' means, 
     subject to paragraph (4), methods, other than an agency-
     provider model, for the provision of consumer controlled 
     services and supports. Such models may include the provision 
     of vouchers, direct cash payments, or use of a fiscal agent 
     to assist in obtaining services.
       ``(D) Health-related tasks.--The term `health-related 
     tasks' means specific tasks related to the needs of an 
     individual, which can be delegated or assigned by licensed 
     health-care professionals under State law to be performed by 
     an attendant.
       ``(E) Individual's representative.--The term `individual's 
     representative' means a parent, family member, guardian, 
     advocate, or other authorized representative of an 
     individual.
       ``(F) Instrumental activities of daily living.--The term 
     `instrumental activities of daily living' includes (but is 
     not limited to) meal planning and preparation, managing 
     finances, shopping for food, clothing, and other essential 
     items, performing essential household chores, communicating 
     by phone or other media, and traveling around and 
     participating in the community.''.

     SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME AND 
                   COMMUNITY-BASED SERVICES.

       (a) Oversight and Assessment of the Administration of Home 
     and Community-based Services.--The Secretary of Health and 
     Human Services shall promulgate regulations to ensure that 
     all States develop service systems that are designed to--
       (1) allocate resources for services in a manner that is 
     responsive to the changing needs and choices of beneficiaries 
     receiving non-institutionally-based long-term services and 
     supports (including such services and supports that are 
     provided under programs other the State Medicaid program), 
     and that provides strategies for beneficiaries receiving such 
     services to maximize their independence, including through 
     the use of client-employed providers;
       (2) provide the support and coordination needed for a 
     beneficiary in need of such services (and their family 
     caregivers or representative, if applicable) to design an 
     individualized, self-directed, community-supported life; and
       (3) improve coordination among, and the regulation of, all 
     providers of such services under federally and State-funded 
     programs in order to--
       (A) achieve a more consistent administration of policies 
     and procedures across programs in relation to the provision 
     of such services; and
       (B) oversee and monitor all service system functions to 
     assure--
       (i) coordination of, and effectiveness of, eligibility 
     determinations and individual assessments;
       (ii) development and service monitoring of a complaint 
     system, a management system, a system to qualify and monitor 
     providers, and systems for role-setting and individual budget 
     determinations; and
       (iii) an adequate number of qualified direct care workers 
     to provide self-directed personal assistance services.
       (b) Additional State Options.--Section 1915(i) of the 
     Social Security Act (42 U.S.C. 1396n(i)) is amended by adding 
     at the end the following new paragraphs:
       ``(6) State option to provide home and community-based 
     services to individuals eligible for services under a 
     waiver.--
       ``(A) In general.--A State that provides home and 
     community-based services in accordance with this subsection 
     to individuals who satisfy the needs-based criteria for the 
     receipt of such services established under paragraph (1)(A) 
     may, in addition to continuing to provide such services to 
     such individuals, elect to provide home and community-based 
     services in accordance with the requirements of this 
     paragraph to individuals who are eligible for home and 
     community-based services under a waiver approved for the 
     State under subsection (c), (d), or (e) or under section 1115 
     to provide such services, but only for those individuals 
     whose income does not exceed 300 percent of the supplemental 
     security income benefit rate established by section 
     1611(b)(1).
       ``(B) Application of same requirements for individuals 
     satisfying needs-based criteria.--Subject to subparagraph 
     (C), a State shall provide home and community-based services 
     to individuals under this paragraph in the same manner and 
     subject to the same requirements as apply under the other 
     paragraphs of this subsection to the provision of home and 
     community-based services to individuals who satisfy the 
     needs-based criteria established under paragraph (1)(A).
       ``(C) Authority to offer different type, amount, duration, 
     or scope of home and community-based services.--A State may 
     offer home and community-based services to individuals under 
     this paragraph that differ in type, amount, duration, or 
     scope from the home and community-based services offered for 
     individuals who satisfy the needs-based criteria established 
     under paragraph (1)(A), so long as such services are within 
     the scope of services described in paragraph (4)(B) of 
     subsection (c) for which the Secretary has the authority to 
     approve a waiver and do not include room or board.
       ``(7) State option to offer home and community-based 
     services to specific, targeted populations.--
       ``(A) In general.--A State may elect in a State plan 
     amendment under this subsection to target the provision of 
     home and community-based services under this subsection to 
     specific populations and to differ the type, amount, 
     duration, or scope of such services to such specific 
     populations.
       ``(B) 5-year term.--
       ``(i) In general.--An election by a State under this 
     paragraph shall be for a period of 5 years.
       ``(ii) Phase-in of services and eligibility permitted 
     during initial 5-year period.--A State making an election 
     under this paragraph

[[Page H1969]]

     may, during the first 5-year period for which the election is 
     made, phase-in the enrollment of eligible individuals, or the 
     provision of services to such individuals, or both, so long 
     as all eligible individuals in the State for such services 
     are enrolled, and all such services are provided, before the 
     end of the initial 5-year period.
       ``(C) Renewal.--An election by a State under this paragraph 
     may be renewed for additional 5-year terms if the Secretary 
     determines, prior to beginning of each such renewal period, 
     that the State has--
       ``(i) adhered to the requirements of this subsection and 
     paragraph in providing services under such an election; and
       ``(ii) met the State's objectives with respect to quality 
     improvement and beneficiary outcomes.''.
       (c) Removal of Limitation on Scope of Services.--Paragraph 
     (1) of section 1915(i) of the Social Security Act (42 U.S.C. 
     1396n(i)), as amended by subsection (a), is amended by 
     striking ``or such other services requested by the State as 
     the Secretary may approve''.
       (d) Optional Eligibility Category To Provide Full Medicaid 
     Benefits to Individuals Receiving Home and Community-based 
     Services Under a State Plan Amendment.--
       (1) In general.--Section 1902(a)(10)(A)(ii) of the Social 
     Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by 
     section 2304(a)(1), is amended--
       (A) in subclause (XX), by striking ``or'' at the end;
       (B) in subclause (XXI), by adding ``or'' at the end; and
       (C) by inserting after subclause (XXI), the following new 
     subclause:

       ``(XXII) who are eligible for home and community-based 
     services under needs-based criteria established under 
     paragraph (1)(A) of section 1915(i), or who are eligible for 
     home and community-based services under paragraph (6) of such 
     section, and who will receive home and community-based 
     services pursuant to a State plan amendment under such 
     subsection;''.

       (2) Conforming amendments.--
       (A) Section 1903(f)(4) of the Social Security Act (42 
     U.S.C. 1396b(f)(4)), as amended by section 2304(a)(4)(B), is 
     amended in the matter preceding subparagraph (A), by 
     inserting ``1902(a)(10)(A)(ii)(XXII),'' after 
     ``1902(a)(10)(A)(ii)(XXI),''.
       (B) Section 1905(a) of the Social Security Act (42 U.S.C. 
     1396d(a)), as so amended, is amended in the matter preceding 
     paragraph (1)--
       (i) in clause (xv), by striking ``or'' at the end;
       (ii) in clause (xvi), by adding ``or'' at the end; and
       (iii) by inserting after clause (xvi) the following new 
     clause:
       ``(xvii) individuals who are eligible for home and 
     community-based services under needs-based criteria 
     established under paragraph (1)(A) of section 1915(i), or who 
     are eligible for home and community-based services under 
     paragraph (6) of such section, and who will receive home and 
     community-based services pursuant to a State plan amendment 
     under such subsection,''.
       (e) Elimination of Option To Limit Number of Eligible 
     Individuals or Length of Period for Grandfathered Individuals 
     if Eligibility Criteria Is Modified.--Paragraph (1) of 
     section 1915(i) of such Act (42 U.S.C. 1396n(i)) is amended--
       (1) by striking subparagraph (C) and inserting the 
     following:
       ``(C) Projection of number of individuals to be provided 
     home and community-based services.--The State submits to the 
     Secretary, in such form and manner, and upon such frequency 
     as the Secretary shall specify, the projected number of 
     individuals to be provided home and community-based 
     services.''; and
       (2) in subclause (II) of subparagraph (D)(ii), by striking 
     ``to be eligible for such services for a period of at least 
     12 months beginning on the date the individual first received 
     medical assistance for such services'' and inserting ``to 
     continue to be eligible for such services after the effective 
     date of the modification and until such time as the 
     individual no longer meets the standard for receipt of such 
     services under such pre-modified criteria''.
       (f) Elimination of Option To Waive Statewideness; Addition 
     of Option To Waive Comparability.--Paragraph (3) of section 
     1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by 
     striking ``1902(a)(1) (relating to statewideness)'' and 
     inserting ``1902(a)(10)(B) (relating to comparability)''.
       (g) Effective Date.--The amendments made by subsections (b) 
     through (f) take effect on the first day of the first fiscal 
     year quarter that begins after the date of enactment of this 
     Act.

     SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING 
                   DEMONSTRATION.

       (a) Extension of Demonstration.--
       (1) In general.--Section 6071(h) of the Deficit Reduction 
     Act of 2005 (42 U.S.C. 1396a note) is amended--
       (A) in paragraph (1)(E), by striking ``fiscal year 2011'' 
     and inserting ``each of fiscal years 2011 through 2016''; and
       (B) in paragraph (2), by striking ``2011'' and inserting 
     ``2016''.
       (2) Evaluation.--Paragraphs (2) and (3) of section 6071(g) 
     of such Act is amended are each amended by striking ``2011'' 
     and inserting ``2016''.
       (b) Reduction of Institutional Residency Period.--
       (1) In general.--Section 6071(b)(2) of the Deficit 
     Reduction Act of 2005 (42 U.S.C. 1396a note) is amended--
       (A) in subparagraph (A)(i), by striking ``, for a period of 
     not less than 6 months or for such longer minimum period, not 
     to exceed 2 years, as may be specified by the State'' and 
     inserting ``for a period of not less than 90 consecutive 
     days''; and
       (B) by adding at the end the following:

     ``Any days that an individual resides in an institution on 
     the basis of having been admitted solely for purposes of 
     receiving short-term rehabilitative services for a period for 
     which payment for such services is limited under title XVIII 
     shall not be taken into account for purposes of determining 
     the 90-day period required under subparagraph (A)(i).''.
       (2) Effective date.--The amendments made by this subsection 
     take effect 30 days after the date of enactment of this Act.

     SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND COMMUNITY-
                   BASED SERVICES AGAINST SPOUSAL IMPOVERISHMENT.

       During the 5-year period that begins on January 1, 2014, 
     section 1924(h)(1)(A) of the Social Security Act (42 U.S.C. 
     1396r-5(h)(1)(A)) shall be applied as though ``is eligible 
     for medical assistance for home and community-based services 
     provided under subsection (c), (d), or (i) of section 1915, 
     under a waiver approved under section 1115, or who is 
     eligible for such medical assistance by reason of being 
     determined eligible under section 1902(a)(10)(C) or by reason 
     of section 1902(f) or otherwise on the basis of a reduction 
     of income based on costs incurred for medical or other 
     remedial care, or who is eligible for medical assistance for 
     home and community-based attendant services and supports 
     under section 1915(k)'' were substituted in such section for 
     ``(at the option of the State) is described in section 
     1902(a)(10)(A)(ii)(VI)''.

     SEC. 2405. FUNDING TO EXPAND STATE AGING AND DISABILITY 
                   RESOURCE CENTERS.

       Out of any funds in the Treasury not otherwise 
     appropriated, there is appropriated to the Secretary of 
     Health and Human Services, acting through the Assistant 
     Secretary for Aging, $10,000,000 for each of fiscal years 
     2010 through 2014, to carry out subsections (a)(20)(B)(iii) 
     and (b)(8) of section 202 of the Older Americans Act of 1965 
     (42 U.S.C. 3012).

     SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM CARE.

       (a) Findings.--The Senate makes the following findings:
       (1) Nearly 2 decades have passed since Congress seriously 
     considered long-term care reform. The United States 
     Bipartisan Commission on Comprehensive Health Care, also know 
     as the ``Pepper Commission'', released its ``Call for 
     Action'' blueprint for health reform in September 1990. In 
     the 20 years since those recommendations were made, Congress 
     has never acted on the report.
       (2) In 1999, under the United States Supreme Court's 
     decision in Olmstead v. L.C., 527 U.S. 581 (1999), 
     individuals with disabilities have the right to choose to 
     receive their long-term services and supports in the 
     community, rather than in an institutional setting.
       (3) Despite the Pepper Commission and Olmstead decision, 
     the long-term care provided to our Nation's elderly and 
     disabled has not improved. In fact, for many, it has gotten 
     far worse.
       (4) In 2007, 69 percent of Medicaid long-term care spending 
     for elderly individuals and adults with physical disabilities 
     paid for institutional services. Only 6 states spent 50 
     percent or more of their Medicaid long-term care dollars on 
     home and community-based services for elderly individuals and 
     adults with physical disabilities while \1/2\ of the States 
     spent less than 25 percent. This disparity continues even 
     though, on average, it is estimated that Medicaid dollars can 
     support nearly 3 elderly individuals and adults with physical 
     disabilities in home and community-based services for every 
     individual in a nursing home. Although every State has chosen 
     to provide certain services under home and community-based 
     waivers, these services are unevenly available within and 
     across States, and reach a small percentage of eligible 
     individuals.
       (b) Sense of the Senate.--It is the sense of the Senate 
     that--
       (1) during the 111th session of Congress, Congress should 
     address long-term services and supports in a comprehensive 
     way that guarantees elderly and disabled individuals the care 
     they need; and
       (2) long term services and supports should be made 
     available in the community in addition to in institutions.

            Subtitle F--Medicaid Prescription Drug Coverage

     SEC. 2501. PRESCRIPTION DRUG REBATES.

       (a) Increase in Minimum Rebate Percentage for Single Source 
     Drugs and Innovator Multiple Source Drugs.--
       (1) In general.--Section 1927(c)(1)(B) of the Social 
     Security Act (42 U.S.C. 1396r-8(c)(1)(B)) is amended--
       (A) in clause (i)--
       (i) in subclause (IV), by striking ``and'' at the end;
       (ii) in subclause (V)--

       (I) by inserting ``and before January 1, 2010'' after 
     ``December 31, 1995,''; and
       (II) by striking the period at the end and inserting ``; 
     and''; and

       (iii) by adding at the end the following new subclause:

       ``(VI) except as provided in clause (iii), after December 
     31, 2009, 23.1 percent.''; and

       (B) by adding at the end the following new clause:
       ``(iii) Minimum rebate percentage for certain drugs.--

       ``(I) In general.--In the case of a single source drug or 
     an innovator multiple source drug described in subclause 
     (II), the minimum rebate percentage for rebate periods 
     specified in clause (i)(VI) is 17.1 percent.
       ``(II) Drug described.--For purposes of subclause (I), a 
     single source drug or an innovator multiple source drug 
     described in this subclause is any of the following drugs:

[[Page H1970]]

       ``(aa) A clotting factor for which a separate furnishing 
     payment is made under section 1842(o)(5) and which is 
     included on a list of such factors specified and updated 
     regularly by the Secretary.
       ``(bb) A drug approved by the Food and Drug Administration 
     exclusively for pediatric indications.''.
       (2) Recapture of total savings due to increase.--Section 
     1927(b)(1) of such Act (42 U.S.C. 1396r-8(b)(1)) is amended 
     by adding at the end the following new subparagraph:
       ``(C) Special rule for increased minimum rebate 
     percentage.--
       ``(i) In general.--In addition to the amounts applied as a 
     reduction under subparagraph (B), for rebate periods 
     beginning on or after January 1, 2010, during a fiscal year, 
     the Secretary shall reduce payments to a State under section 
     1903(a) in the manner specified in clause (ii), in an amount 
     equal to the product of--

       ``(I) 100 percent minus the Federal medical assistance 
     percentage applicable to the rebate period for the State; and
       ``(II) the amounts received by the State under such 
     subparagraph that are attributable (as estimated by the 
     Secretary based on utilization and other data) to the 
     increase in the minimum rebate percentage effected by the 
     amendments made by subsections (a)(1), (b), and (d) of 
     section 2501 of the Patient Protection and Affordable Care 
     Act, taking into account the additional drugs included under 
     the amendments made by subsection (c) of section 2501 of such 
     Act.

     The Secretary shall adjust such payment reduction for a 
     calendar quarter to the extent the Secretary determines, 
     based upon subsequent utilization and other data, that the 
     reduction for such quarter was greater or less than the 
     amount of payment reduction that should have been made.
       ``(ii) Manner of payment reduction.--The amount of the 
     payment reduction under clause (i) for a State for a quarter 
     shall be deemed an overpayment to the State under this title 
     to be disallowed against the State's regular quarterly draw 
     for all Medicaid spending under section 1903(d)(2). Such a 
     disallowance is not subject to a reconsideration under 
     section 1116(d).''.
       (b) Increase in Rebate for Other Drugs.--Section 
     1927(c)(3)(B) of such Act (42 U.S.C. 1396r-8(c)(3)(B)) is 
     amended--
       (1) in clause (i), by striking ``and'' at the end;
       (2) in clause (ii)--
       (A) by inserting ``and before January 1, 2010,'' after 
     ``December 31, 1993,''; and
       (B) by striking the period and inserting ``; and''; and
       (3) by adding at the end the following new clause:
       ``(iii) after December 31, 2009, is 13 percent.''.
       (c) Extension of Prescription Drug Discounts to Enrollees 
     of Medicaid Managed Care Organizations.--
       (1) In general.--Section 1903(m)(2)(A) of such Act (42 
     U.S.C. 1396b(m)(2)(A)) is amended--
       (A) in clause (xi), by striking ``and'' at the end;
       (B) in clause (xii), by striking the period at the end and 
     inserting ``; and''; and
       (C) by adding at the end the following:
       ``(xiii) such contract provides that (I) covered outpatient 
     drugs dispensed to individuals eligible for medical 
     assistance who are enrolled with the entity shall be subject 
     to the same rebate required by the agreement entered into 
     under section 1927 as the State is subject to and that the 
     State shall collect such rebates from manufacturers, (II) 
     capitation rates paid to the entity shall be based on actual 
     cost experience related to rebates and subject to the Federal 
     regulations requiring actuarially sound rates, and (III) the 
     entity shall report to the State, on such timely and periodic 
     basis as specified by the Secretary in order to include in 
     the information submitted by the State to a manufacturer and 
     the Secretary under section 1927(b)(2)(A), information on the 
     total number of units of each dosage form and strength and 
     package size by National Drug Code of each covered outpatient 
     drug dispensed to individuals eligible for medical assistance 
     who are enrolled with the entity and for which the entity is 
     responsible for coverage of such drug under this subsection 
     (other than covered outpatient drugs that under subsection 
     (j)(1) of section 1927 are not subject to the requirements of 
     that section) and such other data as the Secretary determines 
     necessary to carry out this subsection.''.
       (2) Conforming amendments.--Section 1927 (42 U.S.C. 1396r-
     8) is amended--
       (A) in subsection (b)--
       (i) in paragraph (1)(A), in the first sentence, by 
     inserting ``, including such drugs dispensed to individuals 
     enrolled with a medicaid managed care organization if the 
     organization is responsible for coverage of such drugs'' 
     before the period; and
       (ii) in paragraph (2)(A), by inserting ``including such 
     information reported by each medicaid managed care 
     organization,'' after ``for which payment was made under the 
     plan during the period,''; and
       (B) in subsection (j), by striking paragraph (1) and 
     inserting the following:
       ``(1) Covered outpatient drugs are not subject to the 
     requirements of this section if such drugs are--
       ``(A) dispensed by health maintenance organizations, 
     including Medicaid managed care organizations that contract 
     under section 1903(m); and
       ``(B) subject to discounts under section 340B of the Public 
     Health Service Act.''.
       (d) Additional Rebate for New Formulations of Existing 
     Drugs.--
       (1) In general.--Section 1927(c)(2) of the Social Security 
     Act (42 U.S.C. 1396r-8(c)(2)) is amended by adding at the end 
     the following new subparagraph:
       ``(C) Treatment of new formulations.--
       ``(i) In general.--Except as provided in clause (ii), in 
     the case of a drug that is a new formulation, such as an 
     extended-release formulation, of a single source drug or an 
     innovator multiple source drug, the rebate obligation with 
     respect to the drug under this section shall be the amount 
     computed under this section for the new formulation of the 
     drug or, if greater, the product of--

       ``(I) the average manufacturer price for each dosage form 
     and strength of the new formulation of the single source drug 
     or innovator multiple source drug;
       ``(II) the highest additional rebate (calculated as a 
     percentage of average manufacturer price) under this section 
     for any strength of the original single source drug or 
     innovator multiple source drug; and
       ``(III) the total number of units of each dosage form and 
     strength of the new formulation paid for under the State plan 
     in the rebate period (as reported by the State).

       ``(ii) No application to new formulations of orphan 
     drugs.--Clause (i) shall not apply to a new formulation of a 
     covered outpatient drug that is or has been designated under 
     section 526 of the Federal Food, Drug, and Cosmetic Act (21 
     U.S.C. 360bb) for a rare disease or condition, without regard 
     to whether the period of market exclusivity for the drug 
     under section 527 of such Act has expired or the specific 
     indication for use of the drug.''.
       (2) Effective date.--The amendment made by paragraph (1) 
     shall apply to drugs that are paid for by a State after 
     December 31, 2009.
       (e) Maximum Rebate Amount.--Section 1927(c)(2) of such Act 
     (42 U.S.C. 1396r-8(c)(2)), as amended by subsection (d), is 
     amended by adding at the end the following new subparagraph:
       ``(D) Maximum rebate amount.--In no case shall the sum of 
     the amounts applied under paragraph (1)(A)(ii) and this 
     paragraph with respect to each dosage form and strength of a 
     single source drug or an innovator multiple source drug for a 
     rebate period beginning after December 31, 2009, exceed 100 
     percent of the average manufacturer price of the drug.''.
       (f) Conforming Amendments.--
       (1) In general.--Section 340B of the Public Health Service 
     Act (42 U.S.C. 256b) is amended--
       (A) in subsection (a)(2)(B)(i), by striking ``1927(c)(4)'' 
     and inserting ``1927(c)(3)''; and
       (B) by striking subsection (c); and
       (C) redesignating subsection (d) as subsection (c).
       (2) Effective date.--The amendments made by this subsection 
     take effect on January 1, 2010.

     SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF CERTAIN 
                   DRUGS.

       (a) In General.--Section 1927(d) of the Social Security Act 
     (42 U.S.C. 1397r-8(d)) is amended--
       (1) in paragraph (2)--
       (A) by striking subparagraphs (E), (I), and (J), 
     respectively; and
       (B) by redesignating subparagraphs (F), (G), (H), and (K) 
     as subparagraphs (E), (F), (G), and (H), respectively; and
       (2) by adding at the end the following new paragraph:
       ``(7) Non-excludable drugs.--The following drugs or classes 
     of drugs, or their medical uses, shall not be excluded from 
     coverage:
       ``(A) Agents when used to promote smoking cessation, 
     including agents approved by the Food and Drug Administration 
     under the over-the-counter monograph process for purposes of 
     promoting, and when used to promote, tobacco cessation.
       ``(B) Barbiturates.
       ``(C) Benzodiazepines.''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to services furnished on or after January 1, 
     2014.

     SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSEMENT.

       (a) Pharmacy Reimbursement Limits.--
       (1) In general.--Section 1927(e) of the Social Security Act 
     (42 U.S.C. 1396r-8(e)) is amended--
       (A) in paragraph (4), by striking ``(or, effective January 
     1, 2007, two or more)''; and
       (B) by striking paragraph (5) and inserting the following:
       ``(5) Use of amp in upper payment limits.--The Secretary 
     shall calculate the Federal upper reimbursement limit 
     established under paragraph (4) as no less than 175 percent 
     of the weighted average (determined on the basis of 
     utilization) of the most recently reported monthly average 
     manufacturer prices for pharmaceutically and therapeutically 
     equivalent multiple source drug products that are available 
     for purchase by retail community pharmacies on a nationwide 
     basis. The Secretary shall implement a smoothing process for 
     average manufacturer prices. Such process shall be similar to 
     the smoothing process used in determining the average sales 
     price of a drug or biological under section 1847A.''.
       (2) Definition of amp.--Section 1927(k)(1) of such Act (42 
     U.S.C. 1396r-8(k)(1)) is amended--
       (A) in subparagraph (A), by striking ``by'' and all that 
     follows through the period and inserting ``by--
       ``(i) wholesalers for drugs distributed to retail community 
     pharmacies; and
       ``(ii) retail community pharmacies that purchase drugs 
     directly from the manufacturer.''; and
       (B) by striking subparagraph (B) and inserting the 
     following:
       ``(B) Exclusion of customary prompt pay discounts and other 
     payments.--
       ``(i) In general.--The average manufacturer price for a 
     covered outpatient drug shall exclude--

       ``(I) customary prompt pay discounts extended to 
     wholesalers;
       ``(II) bona fide service fees paid by manufacturers to 
     wholesalers or retail community pharmacies, including (but 
     not limited to) distribution service fees, inventory 
     management fees,

[[Page H1971]]

     product stocking allowances, and fees associated with 
     administrative services agreements and patient care programs 
     (such as medication compliance programs and patient education 
     programs);
       ``(III) reimbursement by manufacturers for recalled, 
     damaged, expired, or otherwise unsalable returned goods, 
     including (but not limited to) reimbursement for the cost of 
     the goods and any reimbursement of costs associated with 
     return goods handling and processing, reverse logistics, and 
     drug destruction; and
       ``(IV) payments received from, and rebates or discounts 
     provided to, pharmacy benefit managers, managed care 
     organizations, health maintenance organizations, insurers, 
     hospitals, clinics, mail order pharmacies, long term care 
     providers, manufacturers, or any other entity that does not 
     conduct business as a wholesaler or a retail community 
     pharmacy.

       ``(ii) Inclusion of other discounts and payments.--
     Notwithstanding clause (i), any other discounts, rebates, 
     payments, or other financial transactions that are received 
     by, paid by, or passed through to, retail community 
     pharmacies shall be included in the average manufacturer 
     price for a covered outpatient drug.''; and
       (C) in subparagraph (C), by striking ``the retail pharmacy 
     class of trade'' and inserting ``retail community 
     pharmacies''.
       (3) Definition of multiple source drug.--Section 1927(k)(7) 
     of such Act (42 U.S.C. 1396r-8(k)(7)) is amended--
       (A) in subparagraph (A)(i)(III), by striking ``the State'' 
     and inserting ``the United States''; and
       (B) in subparagraph (C)--
       (i) in clause (i), by inserting ``and'' after the 
     semicolon;
       (ii) in clause (ii), by striking ``; and'' and inserting a 
     period; and
       (iii) by striking clause (iii).
       (4) Definitions of retail community pharmacy; wholesaler.--
     Section 1927(k) of such Act (42 U.S.C. 1396r-8(k)) is amended 
     by adding at the end the following new paragraphs:
       ``(10) Retail community pharmacy.--The term `retail 
     community pharmacy' means an independent pharmacy, a chain 
     pharmacy, a supermarket pharmacy, or a mass merchandiser 
     pharmacy that is licensed as a pharmacy by the State and that 
     dispenses medications to the general public at retail prices. 
     Such term does not include a pharmacy that dispenses 
     prescription medications to patients primarily through the 
     mail, nursing home pharmacies, long-term care facility 
     pharmacies, hospital pharmacies, clinics, charitable or not-
     for-profit pharmacies, government pharmacies, or pharmacy 
     benefit managers.
       ``(11) Wholesaler.--The term `wholesaler' means a drug 
     wholesaler that is engaged in wholesale distribution of 
     prescription drugs to retail community pharmacies, including 
     (but not limited to) manufacturers, repackers, distributors, 
     own-label distributors, private-label distributors, jobbers, 
     brokers, warehouses (including manufacturer's and 
     distributor's warehouses, chain drug warehouses, and 
     wholesale drug warehouses) independent wholesale drug 
     traders, and retail community pharmacies that conduct 
     wholesale distributions.''.
       (b) Disclosure of Price Information to the Public.--Section 
     1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended--
       (1) in subparagraph (A)--
       (A) in the first sentence, by inserting after clause (iii) 
     the following:
       ``(iv) not later than 30 days after the last day of each 
     month of a rebate period under the agreement, on the 
     manufacturer's total number of units that are used to 
     calculate the monthly average manufacturer price for each 
     covered outpatient drug;''; and
       (B) in the second sentence, by inserting ``(relating to the 
     weighted average of the most recently reported monthly 
     average manufacturer prices)'' after ``(D)(v)''; and
       (2) in subparagraph (D)(v), by striking ``average 
     manufacturer prices'' and inserting ``the weighted average of 
     the most recently reported monthly average manufacturer 
     prices and the average retail survey price determined for 
     each multiple source drug in accordance with subsection 
     (f)''.
       (c) Clarification of Application of Survey of Retail 
     Prices.--Section 1927(f)(1) of such Act (42 U.S.C. 1396r-
     8(b)(1)) is amended--
       (1) in subparagraph (A)(i), by inserting ``with respect to 
     a retail community pharmacy,'' before ``the determination''; 
     and
       (2) in subparagraph (C)(ii), by striking ``retail 
     pharmacies'' and inserting ``retail community pharmacies''.
       (d) Effective Date.--The amendments made by this section 
     shall take effect on the first day of the first calendar year 
     quarter that begins at least 180 days after the date of 
     enactment of this Act, without regard to whether or not final 
     regulations to carry out such amendments have been 
     promulgated by such date.

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

     SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS.

       (a) In General.--Section 1923(f) of the Social Security Act 
     (42 U.S.C. 1396r-4(f)) is amended--
       (1) in paragraph (1), by striking ``and (3)'' and inserting 
     ``, (3), and (7)'';
       (2) in paragraph (3)(A), by striking ``paragraph (6)'' and 
     inserting ``paragraphs (6) and (7)'';
       (3) by redesignating paragraph (7) as paragraph (8); and
       (4) by inserting after paragraph (6) the following new 
     paragraph:
       ``(7) Reduction of state dsh allotments once reduction in 
     uninsured threshold reached.--
       ``(A) In general.--Subject to subparagraph (E), the DSH 
     allotment for a State for fiscal years beginning with the 
     fiscal year described in subparagraph (C) (with respect to 
     the State), is equal to--
       ``(i) in the case of the first fiscal year described in 
     subparagraph (C) with respect to a State, the DSH allotment 
     that would be determined under this subsection for the State 
     for the fiscal year without application of this paragraph 
     (but after the application of subparagraph (D)), reduced by 
     the applicable percentage determined for the State for the 
     fiscal year under subparagraph (B)(i); and
       ``(ii) in the case of any subsequent fiscal year with 
     respect to the State, the DSH allotment determined under this 
     paragraph for the State for the preceding fiscal year, 
     reduced by the applicable percentage determined for the State 
     for the fiscal year under subparagraph (B)(ii).
       ``(B) Applicable percentage.--For purposes of subparagraph 
     (A), the applicable percentage for a State for a fiscal year 
     is the following:
       ``(i) Uninsured reduction threshold fiscal year.--In the 
     case of the first fiscal year described in subparagraph (C) 
     with respect to the State--

       ``(I) if the State is a low DSH State described in 
     paragraph (5)(B), the applicable percentage is equal to 25 
     percent; and
       ``(II) if the State is any other State, the applicable 
     percentage is 50 percent.

       ``(ii) Subsequent fiscal years in which the percentage of 
     uninsured decreases.--In the case of any fiscal year after 
     the first fiscal year described in subparagraph (C) with 
     respect to a State, if the Secretary determines on the basis 
     of the most recent American Community Survey of the Bureau of 
     the Census, that the percentage of uncovered individuals 
     residing in the State is less than the percentage of such 
     individuals determined for the State for the preceding fiscal 
     year--

       ``(I) if the State is a low DSH State described in 
     paragraph (5)(B), the applicable percentage is equal to the 
     product of the percentage reduction in uncovered individuals 
     for the fiscal year from the preceding fiscal year and 25 
     percent; and
       ``(II) if the State is any other State, the applicable 
     percentage is equal to the product of the percentage 
     reduction in uncovered individuals for the fiscal year from 
     the preceding fiscal year and 50 percent.

       ``(C) Fiscal year described.--For purposes of subparagraph 
     (A), the fiscal year described in this subparagraph with 
     respect to a State is the first fiscal year that occurs after 
     fiscal year 2012 for which the Secretary determines, on the 
     basis of the most recent American Community Survey of the 
     Bureau of the Census, that the percentage of uncovered 
     individuals residing in the State is at least 45 percent less 
     than the percentage of such individuals determined for the 
     State for fiscal year 2009.
       ``(D) Exclusion of portions diverted for coverage 
     expansions.--For purposes of applying the applicable 
     percentage reduction under subparagraph (A) to the DSH 
     allotment for a State for a fiscal year, the DSH allotment 
     for a State that would be determined under this subsection 
     for the State for the fiscal year without the application of 
     this paragraph (and prior to any such reduction) shall not 
     include any portion of the allotment for which the Secretary 
     has approved the State's diversion to the costs of providing 
     medical assistance or other health benefits coverage under a 
     waiver that is in effect on July 2009.
       ``(E) Minimum allotment.--In no event shall the DSH 
     allotment determined for a State in accordance with this 
     paragraph for fiscal year 2013 or any succeeding fiscal year 
     be less than the amount equal to 35 percent of the DSH 
     allotment determined for the State for fiscal year 2012 under 
     this subsection (and after the application of this paragraph, 
     if applicable), increased by the percentage change in the 
     consumer price index for all urban consumers (all items, U.S. 
     city average) for each previous fiscal year occurring before 
     the fiscal year.
       ``(F) Uncovered individuals.--In this paragraph, the term 
     `uncovered individuals' means individuals with no health 
     insurance coverage at any time during a year (as determined 
     by the Secretary based on the most recent data available).''.
       (b) Effective Date.--The amendments made by subsection (a) 
     take effect on October 1, 2011.

   Subtitle H--Improved Coordination for Dual Eligible Beneficiaries

     SEC. 2601. 5-YEAR PERIOD FOR DEMONSTRATION PROJECTS.

       (a) In General.--Section 1915(h) of the Social Security Act 
     (42 U.S.C. 1396n(h)) is amended--
       (1) by inserting ``(1)'' after ``(h)'';
       (2) by inserting ``, or a waiver described in paragraph 
     (2)'' after ``(e)''; and
       (3) by adding at the end the following new paragraph:
       ``(2)(A) Notwithstanding subsections (c)(3) and (d) (3), 
     any waiver under subsection (b), (c), or (d), or a waiver 
     under section 1115, that provides medical assistance for dual 
     eligible individuals (including any such waivers under which 
     non dual eligible individuals may be enrolled in addition to 
     dual eligible individuals) may be conducted for a period of 5 
     years and, upon the request of the State, may be extended for 
     additional 5-year periods unless the Secretary determines 
     that for the previous waiver period the conditions for the 
     waiver have not been met or it would no longer be cost-
     effective and efficient, or consistent with the purposes of 
     this title, to extend the waiver.
       ``(B) In this paragraph, the term `dual eligible 
     individual' means an individual who is entitled to, or 
     enrolled for, benefits under part A of title XVIII, or 
     enrolled for benefits under part B of title XVIII, and is 
     eligible for medical assistance under the State plan under 
     this title or under a waiver of such plan.''.
       (b) Conforming Amendments.--

[[Page H1972]]

       (1) Section 1915 of such Act (42 U.S.C. 1396n) is amended--
       (A) in subsection (b), by adding at the end the following 
     new sentence: ``Subsection (h)(2) shall apply to a waiver 
     under this subsection.'';
       (B) in subsection (c)(3), in the second sentence, by 
     inserting ``(other than a waiver described in subsection 
     (h)(2))'' after ``A waiver under this subsection'';
       (C) in subsection (d)(3), in the second sentence, by 
     inserting ``(other than a waiver described in subsection 
     (h)(2))'' after ``A waiver under this subsection''.
       (2) Section 1115 of such Act (42 U.S.C. 1315) is amended--
       (A) in subsection (e)(2), by inserting ``(5 years, in the 
     case of a waiver described in section 1915(h)(2))'' after ``3 
     years''; and
       (B) in subsection (f)(6), by inserting ``(5 years, in the 
     case of a waiver described in section 1915(h)(2))'' after ``3 
     years''.

     SEC. 2602. PROVIDING FEDERAL COVERAGE AND PAYMENT 
                   COORDINATION FOR DUAL ELIGIBLE BENEFICIARIES.

       (a) Establishment of Federal Coordinated Health Care 
     Office.--
       (1) In general.--Not later than March 1, 2010, the 
     Secretary of Health and Human Services (in this section 
     referred to as the ``Secretary'') shall establish a Federal 
     Coordinated Health Care Office.
       (2) Establishment and reporting to cms administrator.--The 
     Federal Coordinated Health Care Office--
       (A) shall be established within the Centers for Medicare & 
     Medicaid Services; and
       (B) have as the Office a Director who shall be appointed 
     by, and be in direct line of authority to, the Administrator 
     of the Centers for Medicare & Medicaid Services.
       (b) Purpose.--The purpose of the Federal Coordinated Health 
     Care Office is to bring together officers and employees of 
     the Medicare and Medicaid programs at the Centers for 
     Medicare & Medicaid Services in order to--
       (1) more effectively integrate benefits under the Medicare 
     program under title XVIII of the Social Security Act and the 
     Medicaid program under title XIX of such Act; and
       (2) improve the coordination between the Federal Government 
     and States for individuals eligible for benefits under both 
     such programs in order to ensure that such individuals get 
     full access to the items and services to which they are 
     entitled under titles XVIII and XIX of the Social Security 
     Act.
       (c) Goals.--The goals of the Federal Coordinated Health 
     Care Office are as follows:
       (1) Providing dual eligible individuals full access to the 
     benefits to which such individuals are entitled under the 
     Medicare and Medicaid programs.
       (2) Simplifying the processes for dual eligible individuals 
     to access the items and services they are entitled to under 
     the Medicare and Medicaid programs.
       (3) Improving the quality of health care and long-term 
     services for dual eligible individuals.
       (4) Increasing dual eligible individuals' understanding of 
     and satisfaction with coverage under the Medicare and 
     Medicaid programs.
       (5) Eliminating regulatory conflicts between rules under 
     the Medicare and Medicaid programs.
       (6) Improving care continuity and ensuring safe and 
     effective care transitions for dual eligible individuals.
       (7) Eliminating cost-shifting between the Medicare and 
     Medicaid program and among related health care providers.
       (8) Improving the quality of performance of providers of 
     services and suppliers under the Medicare and Medicaid 
     programs.
       (d) Specific Responsibilities.--The specific 
     responsibilities of the Federal Coordinated Health Care 
     Office are as follows:
       (1) Providing States, specialized MA plans for special 
     needs individuals (as defined in section 1859(b)(6) of the 
     Social Security Act (42 U.S.C. 1395w-28(b)(6))), physicians 
     and other relevant entities or individuals with the education 
     and tools necessary for developing programs that align 
     benefits under the Medicare and Medicaid programs for dual 
     eligible individuals.
       (2) Supporting State efforts to coordinate and align acute 
     care and long-term care services for dual eligible 
     individuals with other items and services furnished under the 
     Medicare program.
       (3) Providing support for coordination of contracting and 
     oversight by States and the Centers for Medicare & Medicaid 
     Services with respect to the integration of the Medicare and 
     Medicaid programs in a manner that is supportive of the goals 
     described in paragraph (3).
       (4) To consult and coordinate with the Medicare Payment 
     Advisory Commission established under section 1805 of the 
     Social Security Act (42 U.S.C. 1395b-6) and the Medicaid and 
     CHIP Payment and Access Commission established under section 
     1900 of such Act (42 U.S.C. 1396) with respect to policies 
     relating to the enrollment in, and provision of, benefits to 
     dual eligible individuals under the Medicare program under 
     title XVIII of the Social Security Act and the Medicaid 
     program under title XIX of such Act.
       (5) To study the provision of drug coverage for new full-
     benefit dual eligible individuals (as defined in section 
     1935(c)(6) of the Social Security Act (42 U.S.C. 1396u-
     5(c)(6)), as well as to monitor and report annual total 
     expenditures, health outcomes, and access to benefits for all 
     dual eligible individuals.
       (e) Report.--The Secretary shall, as part of the budget 
     transmitted under section 1105(a) of title 31, United States 
     Code, submit to Congress an annual report containing 
     recommendations for legislation that would improve care 
     coordination and benefits for dual eligible individuals.
       (f) Dual Eligible Defined.--In this section, the term 
     ``dual eligible individual'' means an individual who is 
     entitled to, or enrolled for, benefits under part A of title 
     XVIII of the Social Security Act, or enrolled for benefits 
     under part B of title XVIII of such Act, and is eligible for 
     medical assistance under a State plan under title XIX of such 
     Act or under a waiver of such plan.

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

     SEC. 2701. ADULT HEALTH QUALITY MEASURES.

       Title XI of the Social Security Act (42 U.S.C. 1301 et 
     seq.), as amended by section 401 of the Children's Health 
     Insurance Program Reauthorization Act of 2009 (Public Law 
     111-3), is amended by inserting after section 1139A the 
     following new section:

     ``SEC. 1139B. ADULT HEALTH QUALITY MEASURES.

       ``(a) Development of Core Set of Health Care Quality 
     Measures for Adults Eligible for Benefits Under Medicaid.--
     The Secretary shall identify and publish a recommended core 
     set of adult health quality measures for Medicaid eligible 
     adults in the same manner as the Secretary identifies and 
     publishes a core set of child health quality measures under 
     section 1139A, including with respect to identifying and 
     publishing existing adult health quality measures that are in 
     use under public and privately sponsored health care coverage 
     arrangements, or that are part of reporting systems that 
     measure both the presence and duration of health insurance 
     coverage over time, that may be applicable to Medicaid 
     eligible adults.
       ``(b) Deadlines.--
       ``(1) Recommended measures.--Not later than January 1, 
     2011, the Secretary shall identify and publish for comment a 
     recommended core set of adult health quality measures for 
     Medicaid eligible adults.
       ``(2) Dissemination.--Not later than January 1, 2012, the 
     Secretary shall publish an initial core set of adult health 
     quality measures that are applicable to Medicaid eligible 
     adults.
       ``(3) Standardized reporting.--Not later than January 1, 
     2013, the Secretary, in consultation with States, shall 
     develop a standardized format for reporting information based 
     on the initial core set of adult health quality measures and 
     create procedures to encourage States to use such measures to 
     voluntarily report information regarding the quality of 
     health care for Medicaid eligible adults.
       ``(4) Reports to congress.--Not later than January 1, 2014, 
     and every 3 years thereafter, the Secretary shall include in 
     the report to Congress required under section 1139A(a)(6) 
     information similar to the information required under that 
     section with respect to the measures established under this 
     section.
       ``(5) Establishment of medicaid quality measurement 
     program.--
       ``(A) In general.--Not later than 12 months after the 
     release of the recommended core set of adult health quality 
     measures under paragraph (1)), the Secretary shall establish 
     a Medicaid Quality Measurement Program in the same manner as 
     the Secretary establishes the pediatric quality measures 
     program under section 1139A(b). The aggregate amount awarded 
     by the Secretary for grants and contracts for the 
     development, testing, and validation of emerging and 
     innovative evidence-based measures under such program shall 
     equal the aggregate amount awarded by the Secretary for 
     grants under section 1139A(b)(4)(A)
       ``(B) Revising, strengthening, and improving initial core 
     measures.--Beginning not later than 24 months after the 
     establishment of the Medicaid Quality Measurement Program, 
     and annually thereafter, the Secretary shall publish 
     recommended changes to the initial core set of adult health 
     quality measures that shall reflect the results of the 
     testing, validation, and consensus process for the 
     development of adult health quality measures.
       ``(c) Construction.--Nothing in this section shall be 
     construed as supporting the restriction of coverage, under 
     title XIX or XXI or otherwise, to only those services that 
     are evidence-based, or in anyway limiting available services.
       ``(d) Annual State Reports Regarding State-Specific Quality 
     of Care Measures Applied Under Medicaid.--
       ``(1) Annual state reports.--Each State with a State plan 
     or waiver approved under title XIX shall annually report 
     (separately or as part of the annual report required under 
     section 1139A(c)), to the Secretary on the--
       ``(A) State-specific adult health quality measures applied 
     by the State under the such plan, including measures 
     described in subsection (a)(5); and
       ``(B) State-specific information on the quality of health 
     care furnished to Medicaid eligible adults under such plan, 
     including information collected through external quality 
     reviews of managed care organizations under section 1932 and 
     benchmark plans under section 1937.
       ``(2) Publication.--Not later than September 30, 2014, and 
     annually thereafter, the Secretary shall collect, analyze, 
     and make publicly available the information reported by 
     States under paragraph (1).
       ``(e) Appropriation.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated for each of 
     fiscal years 2010 through 2014, $60,000,000 for the purpose 
     of carrying out this section. Funds appropriated under this 
     subsection shall remain available until expended.''.

     SEC. 2702. PAYMENT ADJUSTMENT FOR HEALTH CARE-ACQUIRED 
                   CONDITIONS.

       (a) In General.--The Secretary of Health and Human Services 
     (in this subsection referred to as the ``Secretary'') shall 
     identify current State practices that prohibit payment for 
     health care-acquired conditions and shall incorporate the 
     practices identified, or elements of such practices, which 
     the Secretary determines appropriate for application to the 
     Medicaid program in regulations. Such regulations shall be 
     effective as of July 1, 2011, and shall prohibit payments to 
     States under section 1903 of the Social

[[Page H1973]]

     Security Act for any amounts expended for providing medical 
     assistance for health care-acquired conditions specified in 
     the regulations. The regulations shall ensure that the 
     prohibition on payment for health care-acquired conditions 
     shall not result in a loss of access to care or services for 
     Medicaid beneficiaries.
       (b) Health Care-Acquired Condition.--In this section. the 
     term ``health care-acquired condition'' means a medical 
     condition for which an individual was diagnosed that could be 
     identified by a secondary diagnostic code described in 
     section 1886(d)(4)(D)(iv) of the Social Security Act (42 
     U.S.C. 1395ww(d)(4)(D)(iv)).
       (c) Medicare Provisions.--In carrying out this section, the 
     Secretary shall apply to State plans (or waivers) under title 
     XIX of the Social Security Act the regulations promulgated 
     pursuant to section 1886(d)(4)(D) of such Act (42 U.S.C. 
     1395ww(d)(4)(D)) relating to the prohibition of payments 
     based on the presence of a secondary diagnosis code specified 
     by the Secretary in such regulations, as appropriate for the 
     Medicaid program. The Secretary may exclude certain 
     conditions identified under title XVIII of the Social 
     Security Act for non-payment under title XIX of such Act when 
     the Secretary finds the inclusion of such conditions to be 
     inapplicable to beneficiaries under title XIX.

     SEC. 2703. STATE OPTION TO PROVIDE HEALTH HOMES FOR ENROLLEES 
                   WITH CHRONIC CONDITIONS.

       (a) State Plan Amendment.--Title XIX of the Social Security 
     Act (42 U.S.C. 1396a et seq.), as amended by sections 2201 
     and 2305, is amended by adding at the end the following new 
     section:
       ``Sec. 1945. State Option To Provide Coordinated Care 
     Through a Health Home for Individuals With Chronic 
     Conditions.--
       ``(a) In General.--Notwithstanding section 1902(a)(1) 
     (relating to statewideness), section 1902(a)(10)(B) (relating 
     to comparability), and any other provision of this title for 
     which the Secretary determines it is necessary to waive in 
     order to implement this section, beginning January 1, 2011, a 
     State, at its option as a State plan amendment, may provide 
     for medical assistance under this title to eligible 
     individuals with chronic conditions who select a designated 
     provider (as described under subsection (h)(5)), a team of 
     health care professionals (as described under subsection 
     (h)(6)) operating with such a provider, or a health team (as 
     described under subsection (h)(7)) as the individual's health 
     home for purposes of providing the individual with health 
     home services.
       ``(b) Health Home Qualification Standards.--The Secretary 
     shall establish standards for qualification as a designated 
     provider for the purpose of being eligible to be a health 
     home for purposes of this section.
       ``(c) Payments.--
       ``(1) In general.--A State shall provide a designated 
     provider, a team of health care professionals operating with 
     such a provider, or a health team with payments for the 
     provision of health home services to each eligible individual 
     with chronic conditions that selects such provider, team of 
     health care professionals, or health team as the individual's 
     health home. Payments made to a designated provider, a team 
     of health care professionals operating with such a provider, 
     or a health team for such services shall be treated as 
     medical assistance for purposes of section 1903(a), except 
     that, during the first 8 fiscal year quarters that the State 
     plan amendment is in effect, the Federal medical assistance 
     percentage applicable to such payments shall be equal to 90 
     percent.
       ``(2) Methodology.--
       ``(A) In general.--The State shall specify in the State 
     plan amendment the methodology the State will use for 
     determining payment for the provision of health home 
     services. Such methodology for determining payment--
       ``(i) may be tiered to reflect, with respect to each 
     eligible individual with chronic conditions provided such 
     services by a designated provider, a team of health care 
     professionals operating with such a provider, or a health 
     team, as well as the severity or number of each such 
     individual's chronic conditions or the specific capabilities 
     of the provider, team of health care professionals, or health 
     team; and
       ``(ii) shall be established consistent with section 
     1902(a)(30)(A).
       ``(B) Alternate models of payment.--The methodology for 
     determining payment for provision of health home services 
     under this section shall not be limited to a per-member per-
     month basis and may provide (as proposed by the State and 
     subject to approval by the Secretary) for alternate models of 
     payment.
       ``(3) Planning grants.--
       ``(A) In general.--Beginning January 1, 2011, the Secretary 
     may award planning grants to States for purposes of 
     developing a State plan amendment under this section. A 
     planning grant awarded to a State under this paragraph shall 
     remain available until expended.
       ``(B) State contribution.--A State awarded a planning grant 
     shall contribute an amount equal to the State percentage 
     determined under section 1905(b) (without regard to section 
     5001 of Public Law 111-5) for each fiscal year for which the 
     grant is awarded.
       ``(C) Limitation.--The total amount of payments made to 
     States under this paragraph shall not exceed $25,000,000.
       ``(d) Hospital Referrals.--A State shall include in the 
     State plan amendment a requirement for hospitals that are 
     participating providers under the State plan or a waiver of 
     such plan to establish procedures for referring any eligible 
     individuals with chronic conditions who seek or need 
     treatment in a hospital emergency department to designated 
     providers.
       ``(e) Coordination.--A State shall consult and coordinate, 
     as appropriate, with the Substance Abuse and Mental Health 
     Services Administration in addressing issues regarding the 
     prevention and treatment of mental illness and substance 
     abuse among eligible individuals with chronic conditions.
       ``(f) Monitoring.--A State shall include in the State plan 
     amendment--
       ``(1) a methodology for tracking avoidable hospital 
     readmissions and calculating savings that result from 
     improved chronic care coordination and management under this 
     section; and
       ``(2) a proposal for use of health information technology 
     in providing health home services under this section and 
     improving service delivery and coordination across the care 
     continuum (including the use of wireless patient technology 
     to improve coordination and management of care and patient 
     adherence to recommendations made by their provider).
       ``(g) Report on Quality Measures.--As a condition for 
     receiving payment for health home services provided to an 
     eligible individual with chronic conditions, a designated 
     provider shall report to the State, in accordance with such 
     requirements as the Secretary shall specify, on all 
     applicable measures for determining the quality of such 
     services. When appropriate and feasible, a designated 
     provider shall use health information technology in providing 
     the State with such information.
       ``(h) Definitions.--In this section:
       ``(1) Eligible individual with chronic conditions.--
       ``(A) In general.--Subject to subparagraph (B), the term 
     `eligible individual with chronic conditions' means an 
     individual who--
       ``(i) is eligible for medical assistance under the State 
     plan or under a waiver of such plan; and
       ``(ii) has at least--

       ``(I) 2 chronic conditions;
       ``(II) 1 chronic condition and is at risk of having a 
     second chronic condition; or
       ``(III) 1 serious and persistent mental health condition.

       ``(B) Rule of construction.--Nothing in this paragraph 
     shall prevent the Secretary from establishing higher levels 
     as to the number or severity of chronic or mental health 
     conditions for purposes of determining eligibility for 
     receipt of health home services under this section.
       ``(2) Chronic condition.--The term `chronic condition' has 
     the meaning given that term by the Secretary and shall 
     include, but is not limited to, the following:
       ``(A) A mental health condition.
       ``(B) Substance use disorder.
       ``(C) Asthma.
       ``(D) Diabetes.
       ``(E) Heart disease.
       ``(F) Being overweight, as evidenced by having a Body Mass 
     Index (BMI) over 25.
       ``(3) Health home.--The term `health home' means a 
     designated provider (including a provider that operates in 
     coordination with a team of health care professionals) or a 
     health team selected by an eligible individual with chronic 
     conditions to provide health home services.
       ``(4) Health home services.--
       ``(A) In general.--The term `health home services' means 
     comprehensive and timely high-quality services described in 
     subparagraph (B) that are provided by a designated provider, 
     a team of health care professionals operating with such a 
     provider, or a health team.
       ``(B) Services described.--The services described in this 
     subparagraph are--
       ``(i) comprehensive care management;
       ``(ii) care coordination and health promotion;
       ``(iii) comprehensive transitional care, including 
     appropriate follow-up, from inpatient to other settings;
       ``(iv) patient and family support (including authorized 
     representatives);
       ``(v) referral to community and social support services, if 
     relevant; and
       ``(vi) use of health information technology to link 
     services, as feasible and appropriate.
       ``(5) Designated provider.--The term `designated provider' 
     means a physician, clinical practice or clinical group 
     practice, rural clinic, community health center, community 
     mental health center, home health agency, or any other entity 
     or provider (including pediatricians, gynecologists, and 
     obstetricians) that is determined by the State and approved 
     by the Secretary to be qualified to be a health home for 
     eligible individuals with chronic conditions on the basis of 
     documentation evidencing that the physician, practice, or 
     clinic--
       ``(A) has the systems and infrastructure in place to 
     provide health home services; and
       ``(B) satisfies the qualification standards established by 
     the Secretary under subsection (b).
       ``(6) Team of health care professionals.--The term `team of 
     health care professionals' means a team of health 
     professionals (as described in the State plan amendment) that 
     may--
       ``(A) include physicians and other professionals, such as a 
     nurse care coordinator, nutritionist, social worker, 
     behavioral health professional, or any professionals deemed 
     appropriate by the State; and
       ``(B) be free standing, virtual, or based at a hospital, 
     community health center, community mental health center, 
     rural clinic, clinical practice or clinical group practice, 
     academic health center, or any entity deemed appropriate by 
     the State and approved by the Secretary.
       ``(7) Health team.--The term `health team' has the meaning 
     given such term for purposes of section 3502 of the Patient 
     Protection and Affordable Care Act.''.
       (b) Evaluation.--
       (1) Independent evaluation.--
       (A) In general.--The Secretary shall enter into a contract 
     with an independent entity or organization to conduct an 
     evaluation and assessment of the States that have elected the 
     option to provide coordinated care through a health home for 
     Medicaid beneficiaries with chronic conditions under section 
     1945 of the Social Security Act (as added by subsection (a)) 
     for the purpose of determining the effect of such

[[Page H1974]]

     option on reducing hospital admissions, emergency room 
     visits, and admissions to skilled nursing facilities.
       (B) Evaluation report.--Not later than January 1, 2017, the 
     Secretary shall report to Congress on the evaluation and 
     assessment conducted under subparagraph (A).
       (2) Survey and interim report.--
       (A) In general.--Not later than January 1, 2014, the 
     Secretary of Health and Human Services shall survey States 
     that have elected the option under section 1945 of the Social 
     Security Act (as added by subsection (a)) and report to 
     Congress on the nature, extent, and use of such option, 
     particularly as it pertains to--
       (i) hospital admission rates;
       (ii) chronic disease management;
       (iii) coordination of care for individuals with chronic 
     conditions;
       (iv) assessment of program implementation;
       (v) processes and lessons learned (as described in 
     subparagraph (B));
       (vi) assessment of quality improvements and clinical 
     outcomes under such option; and
       (vii) estimates of cost savings.
       (B)  Implementation reporting.--A State that has elected 
     the option under section 1945 of the Social Security Act (as 
     added by subsection (a)) shall report to the Secretary, as 
     necessary, on processes that have been developed and lessons 
     learned regarding provision of coordinated care through a 
     health home for Medicaid beneficiaries with chronic 
     conditions under such option.

     SEC. 2704. DEMONSTRATION PROJECT TO EVALUATE INTEGRATED CARE 
                   AROUND A HOSPITALIZATION.

       (a) Authority To Conduct Project.--
       (1) In general.--The Secretary of Health and Human Services 
     (in this section referred to as the ``Secretary'') shall 
     establish a demonstration project under title XIX of the 
     Social Security Act to evaluate the use of bundled payments 
     for the provision of integrated care for a Medicaid 
     beneficiary--
       (A) with respect to an episode of care that includes a 
     hospitalization; and
       (B) for concurrent physicians services provided during a 
     hospitalization.
       (2) Duration.--The demonstration project shall begin on 
     January 1, 2012, and shall end on December 31, 2016.
       (b) Requirements.--The demonstration project shall be 
     conducted in accordance with the following:
       (1) The demonstration project shall be conducted in up to 8 
     States, determined by the Secretary based on consideration of 
     the potential to lower costs under the Medicaid program while 
     improving care for Medicaid beneficiaries. A State selected 
     to participate in the demonstration project may target the 
     demonstration project to particular categories of 
     beneficiaries, beneficiaries with particular diagnoses, or 
     particular geographic regions of the State, but the Secretary 
     shall insure that, as a whole, the demonstration project is, 
     to the greatest extent possible, representative of the 
     demographic and geographic composition of Medicaid 
     beneficiaries nationally.
       (2) The demonstration project shall focus on conditions 
     where there is evidence of an opportunity for providers of 
     services and suppliers to improve the quality of care 
     furnished to Medicaid beneficiaries while reducing total 
     expenditures under the State Medicaid programs selected to 
     participate, as determined by the Secretary.
       (3) A State selected to participate in the demonstration 
     project shall specify the 1 or more episodes of care the 
     State proposes to address in the project, the services to be 
     included in the bundled payments, and the rationale for the 
     selection of such episodes of care and services. The 
     Secretary may modify the episodes of care as well as the 
     services to be included in the bundled payments prior to or 
     after approving the project. The Secretary may also vary such 
     factors among the different States participating in the 
     demonstration project.
       (4) The Secretary shall ensure that payments made under the 
     demonstration project are adjusted for severity of illness 
     and other characteristics of Medicaid beneficiaries within a 
     category or having a diagnosis targeted as part of the 
     demonstration project. States shall ensure that Medicaid 
     beneficiaries are not liable for any additional cost sharing 
     than if their care had not been subject to payment under the 
     demonstration project.
       (5) Hospitals participating in the demonstration project 
     shall have or establish robust discharge planning programs to 
     ensure that Medicaid beneficiaries requiring post-acute care 
     are appropriately placed in, or have ready access to, post-
     acute care settings.
       (6) The Secretary and each State selected to participate in 
     the demonstration project shall ensure that the demonstration 
     project does not result in the Medicaid beneficiaries whose 
     care is subject to payment under the demonstration project 
     being provided with less items and services for which medical 
     assistance is provided under the State Medicaid program than 
     the items and services for which medical assistance would 
     have been provided to such beneficiaries under the State 
     Medicaid program in the absence of the demonstration project.
       (c) Waiver of Provisions.--Notwithstanding section 1115(a) 
     of the Social Security Act (42 U.S.C. 1315(a)), the Secretary 
     may waive such provisions of titles XIX, XVIII, and XI of 
     that Act as may be necessary to accomplish the goals of the 
     demonstration, ensure beneficiary access to acute and post-
     acute care, and maintain quality of care.
       (d) Evaluation and Report.--
       (1) Data.--Each State selected to participate in the 
     demonstration project under this section shall provide to the 
     Secretary, in such form and manner as the Secretary shall 
     specify, relevant data necessary to monitor outcomes, costs, 
     and quality, and evaluate the rationales for selection of the 
     episodes of care and services specified by States under 
     subsection (b)(3).
       (2) Report.--Not later than 1 year after the conclusion of 
     the demonstration project, the Secretary shall submit a 
     report to Congress on the results of the demonstration 
     project.

     SEC. 2705. MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION 
                   PROJECT.

       (a) In General.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary'') shall, in 
     coordination with the Center for Medicare and Medicaid 
     Innovation (as established under section 1115A of the Social 
     Security Act, as added by section 3021 of this Act), 
     establish the Medicaid Global Payment System Demonstration 
     Project under which a participating State shall adjust the 
     payments made to an eligible safety net hospital system or 
     network from a fee-for-service payment structure to a global 
     capitated payment model.
       (b) Duration and Scope.--The demonstration project 
     conducted under this section shall operate during a period of 
     fiscal years 2010 through 2012. The Secretary shall select 
     not more than 5 States to participate in the demonstration 
     project.
       (c) Eligible Safety Net Hospital System or Network.--For 
     purposes of this section, the term ``eligible safety net 
     hospital system or network'' means a large, safety net 
     hospital system or network (as defined by the Secretary) that 
     operates within a State selected by the Secretary under 
     subsection (b).
       (d) Evaluation.--
       (1) Testing.--The Innovation Center shall test and evaluate 
     the demonstration project conducted under this section to 
     examine any changes in health care quality outcomes and 
     spending by the eligible safety net hospital systems or 
     networks.
       (2) Budget neutrality.--During the testing period under 
     paragraph (1), any budget neutrality requirements under 
     section 1115A(b)(3) of the Social Security Act (as so added) 
     shall not be applicable.
       (3) Modification.--During the testing period under 
     paragraph (1), the Secretary may, in the Secretary's 
     discretion, modify or terminate the demonstration project 
     conducted under this section.
       (e) Report.--Not later than 12 months after the date of 
     completion of the demonstration project under this section, 
     the Secretary shall submit to Congress a report containing 
     the results of the evaluation and testing conducted under 
     subsection (d), together with recommendations for such 
     legislation and administrative action as the Secretary 
     determines appropriate.
       (f) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as are necessary to carry out 
     this section.

     SEC. 2706. PEDIATRIC ACCOUNTABLE CARE ORGANIZATION 
                   DEMONSTRATION PROJECT.

       (a) Authority To Conduct Demonstration.--
       (1) In general.--The Secretary of Health and Human Services 
     (referred to in this section as the ``Secretary'') shall 
     establish the Pediatric Accountable Care Organization 
     Demonstration Project to authorize a participating State to 
     allow pediatric medical providers that meet specified 
     requirements to be recognized as an accountable care 
     organization for purposes of receiving incentive payments (as 
     described under subsection (d)), in the same manner as an 
     accountable care organization is recognized and provided with 
     incentive payments under section 1899 of the Social Security 
     Act (as added by section 3022).
       (2) Duration.--The demonstration project shall begin on 
     January 1, 2012, and shall end on December 31, 2016.
       (b) Application.--A State that desires to participate in 
     the demonstration project under this section shall submit to 
     the Secretary an application at such time, in such manner, 
     and containing such information as the Secretary may require.
       (c) Requirements.--
       (1) Performance guidelines.--The Secretary, in consultation 
     with the States and pediatric providers, shall establish 
     guidelines to ensure that the quality of care delivered to 
     individuals by a provider recognized as an accountable care 
     organization under this section is not less than the quality 
     of care that would have otherwise been provided to such 
     individuals.
       (2) Savings requirement.--A participating State, in 
     consultation with the Secretary, shall establish an annual 
     minimal level of savings in expenditures for items and 
     services covered under the Medicaid program under title XIX 
     of the Social Security Act and the CHIP program under title 
     XXI of such Act that must be reached by an accountable care 
     organization in order for such organization to receive an 
     incentive payment under subsection (d).
       (3) Minimum participation period.--A provider desiring to 
     be recognized as an accountable care organization under the 
     demonstration project shall enter into an agreement with the 
     State to participate in the project for not less than a 3-
     year period.
       (d) Incentive Payment.--An accountable care organization 
     that meets the performance guidelines established by the 
     Secretary under subsection (c)(1) and achieves savings 
     greater than the annual minimal savings level established by 
     the State under subsection (c)(2) shall receive an incentive 
     payment for such year equal to a portion (as determined 
     appropriate by the Secretary) of the amount of such excess 
     savings. The Secretary may establish an annual cap on 
     incentive payments for an accountable care organization.
       (e) Authorization of Appropriations.--There are authorized 
     to be appropriated such sums as are necessary to carry out 
     this section.

[[Page H1975]]

     SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION 
                   PROJECT.

       (a) Authority To Conduct Demonstration Project.--The 
     Secretary of Health and Human Services (in this section 
     referred to as the ``Secretary'') shall establish a 
     demonstration project under which an eligible State (as 
     described in subsection (c)) shall provide payment under the 
     State Medicaid plan under title XIX of the Social Security 
     Act to an institution for mental diseases that is not 
     publicly owned or operated and that is subject to the 
     requirements of section 1867 of the Social Security Act (42 
     U.S.C. 1395dd) for the provision of medical assistance 
     available under such plan to individuals who--
       (1) have attained age 21, but have not attained age 65;
       (2) are eligible for medical assistance under such plan; 
     and
       (3) require such medical assistance to stabilize an 
     emergency medical condition.
       (b) Stabilization Review.--A State shall specify in its 
     application described in subsection (c)(1) establish a 
     mechanism for how it will ensure that institutions 
     participating in the demonstration will determine whether or 
     not such individuals have been stabilized (as defined in 
     subsection (h)(5)). This mechanism shall commence before the 
     third day of the inpatient stay. States participating in the 
     demonstration project may manage the provision of services 
     for the stabilization of medical emergency conditions through 
     utilization review, authorization, or management practices, 
     or the application of medical necessity and appropriateness 
     criteria applicable to behavioral health.
       (c) Eligible State Defined.--
       (1) In general.--An eligible State is a State that has made 
     an application and has been selected pursuant to paragraphs 
     (2) and (3).
       (2) Application.--A State seeking to participate in the 
     demonstration project under this section shall submit to the 
     Secretary, at such time and in such format as the Secretary 
     requires, an application that includes such information, 
     provisions, and assurances, as the Secretary may require.
       (3) Selection.--A State shall be determined eligible for 
     the demonstration by the Secretary on a competitive basis 
     among States with applications meeting the requirements of 
     paragraph (1). In selecting State applications for the 
     demonstration project, the Secretary shall seek to achieve an 
     appropriate national balance in the geographic distribution 
     of such projects.
       (d) Length of Demonstration Project.--The demonstration 
     project established under this section shall be conducted for 
     a period of 3 consecutive years.
       (e) Limitations on Federal Funding.--
       (1) Appropriation.--
       (A) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated to carry out 
     this section, $75,000,000 for fiscal year 2011.
       (B) Budget authority.--Subparagraph (A) constitutes budget 
     authority in advance of appropriations Act and represents the 
     obligation of the Federal Government to provide for the 
     payment of the amounts appropriated under that subparagraph.
       (2) 5-year availability.--Funds appropriated under 
     paragraph (1) shall remain available for obligation through 
     December 31, 2015.
       (3) Limitation on payments.--In no case may--
       (A) the aggregate amount of payments made by the Secretary 
     to eligible States under this section exceed $75,000,000; or
       (B) payments be provided by the Secretary under this 
     section after December 31, 2015.
       (4) Funds allocated to states.--Funds shall be allocated to 
     eligible States on the basis of criteria, including a State's 
     application and the availability of funds, as determined by 
     the Secretary.
       (5) Payments to states.--The Secretary shall pay to each 
     eligible State, from its allocation under paragraph (4), an 
     amount each quarter equal to the Federal medical assistance 
     percentage of expenditures in the quarter for medical 
     assistance described in subsection (a). As a condition of 
     receiving payment, a State shall collect and report 
     information, as determined necessary by the Secretary, for 
     the purposes of providing Federal oversight and conducting an 
     evaluation under subsection (f)(1).
       (f) Evaluation and Report to Congress.--
       (1) Evaluation.--The Secretary shall conduct an evaluation 
     of the demonstration project in order to determine the impact 
     on the functioning of the health and mental health service 
     system and on individuals enrolled in the Medicaid program 
     and shall include the following:
       (A) An assessment of access to inpatient mental health 
     services under the Medicaid program; average lengths of 
     inpatient stays; and emergency room visits.
       (B) An assessment of discharge planning by participating 
     hospitals.
       (C) An assessment of the impact of the demonstration 
     project on the costs of the full range of mental health 
     services (including inpatient, emergency and ambulatory 
     care).
       (D) An analysis of the percentage of consumers with 
     Medicaid coverage who are admitted to inpatient facilities as 
     a result of the demonstration project as compared to those 
     admitted to these same facilities through other means.
       (E) A recommendation regarding whether the demonstration 
     project should be continued after December 31, 2013, and 
     expanded on a national basis.
       (2) Report.--Not later than December 31, 2013, the 
     Secretary shall submit to Congress and make available to the 
     public a report on the findings of the evaluation under 
     paragraph (1).
       (g) Waiver Authority.--
       (1) In general.--The Secretary shall waive the limitation 
     of subdivision (B) following paragraph (28) of section 
     1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) 
     (relating to limitations on payments for care or services for 
     individuals under 65 years of age who are patients in an 
     institution for mental diseases) for purposes of carrying out 
     the demonstration project under this section.
       (2) Limited other waiver authority.--The Secretary may 
     waive other requirements of titles XI and XIX of the Social 
     Security Act (including the requirements of sections 
     1902(a)(1) (relating to statewideness) and 1902(1)(10)(B) 
     (relating to comparability)) only to extent necessary to 
     carry out the demonstration project under this section.
       (h) Definitions.--In this section:
       (1) Emergency medical condition.--The term ``emergency 
     medical condition'' means, with respect to an individual, an 
     individual who expresses suicidal or homicidal thoughts or 
     gestures, if determined dangerous to self or others.
       (2) Federal medical assistance percentage.--The term 
     ``Federal medical assistance percentage'' has the meaning 
     given that term with respect to a State under section 1905(b) 
     of the Social Security Act (42 U.S.C. 1396d(b)).
       (3) Institution for mental diseases.--The term 
     ``institution for mental diseases'' has the meaning given to 
     that term in section 1905(i) of the Social Security Act (42 
     U.S.C. 1396d(i)).
       (4) Medical assistance.--The term ``medical assistance'' 
     has the meaning given that term in section 1905(a) of the 
     Social Security Act (42 U.S.C. 1396d(a)).
       (5) Stabilized.--The term ``stabilized'' means, with 
     respect to an individual, that the emergency medical 
     condition no longer exists with respect to the individual and 
     the individual is no longer dangerous to self or others.
       (6) State.--The term ``State'' has the meaning given that 
     term for purposes of title XIX of the Social Security Act (42 
     U.S.C. 1396 et seq.).

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

     SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING ALL 
                   MEDICAID BENEFICIARIES.

       (a) In General.--Section 1900 of the Social Security Act 
     (42 U.S.C. 1396) is amended--
       (1) in subsection (b)--
       (A) in paragraph (1)--
       (i) in the paragraph heading, by inserting ``for all 
     states'' before ``and annual''; and
       (ii) in subparagraph (A), by striking ``children's'';
       (iii) in subparagraph (B), by inserting ``, the Secretary, 
     and States'' after ``Congress'';
       (iv) in subparagraph (C), by striking ``March 1'' and 
     inserting ``March 15''; and
       (v) in subparagraph (D), by striking ``June 1'' and 
     inserting ``June 15'';
       (B) in paragraph (2)--
       (i) in subparagraph (A)--

       (I) in clause (i)--

       (aa) by inserting ``the efficient provision of'' after 
     ``expenditures for''; and
       (bb) by striking ``hospital, skilled nursing facility, 
     physician, Federally-qualified health center, rural health 
     center, and other fees'' and inserting ``payments to medical, 
     dental, and health professionals, hospitals, residential and 
     long-term care providers, providers of home and community 
     based services, Federally-qualified health centers and rural 
     health clinics, managed care entities, and providers of other 
     covered items and services''; and

       (II) in clause (iii), by inserting ``(including how such 
     factors and methodologies enable such beneficiaries to obtain 
     the services for which they are eligible, affect provider 
     supply, and affect providers that serve a disproportionate 
     share of low-income and other vulnerable populations)'' after 
     ``beneficiaries'';

       (ii) by redesignating subparagraphs (B) and (C) as 
     subparagraphs (F) and (H), respectively;
       (iii) by inserting after subparagraph (A), the following:
       ``(B) Eligibility policies.--Medicaid and CHIP eligibility 
     policies, including a determination of the degree to which 
     Federal and State policies provide health care coverage to 
     needy populations.
       ``(C) Enrollment and retention processes.--Medicaid and 
     CHIP enrollment and retention processes, including a 
     determination of the degree to which Federal and State 
     policies encourage the enrollment of individuals who are 
     eligible for such programs and screen out individuals who are 
     ineligible, while minimizing the share of program expenses 
     devoted to such processes.
       ``(D) Coverage policies.--Medicaid and CHIP benefit and 
     coverage policies, including a determination of the degree to 
     which Federal and State policies provide access to the 
     services enrollees require to improve and maintain their 
     health and functional status.
       ``(E) Quality of care.--Medicaid and CHIP policies as they 
     relate to the quality of care provided under those programs, 
     including a determination of the degree to which Federal and 
     State policies achieve their stated goals and interact with 
     similar goals established by other purchasers of health care 
     services.'';
       (iv) by inserting after subparagraph (F) (as redesignated 
     by clause (ii) of this subparagraph), the following:
       ``(G) Interactions with medicare and medicaid.--Consistent 
     with paragraph (11), the interaction of policies under 
     Medicaid and the Medicare program under title XVIII, 
     including with respect to how such interactions affect access 
     to services, payments, and dual eligible individuals.'' and
       (v) in subparagraph (H) (as so redesignated), by inserting 
     ``and preventive, acute, and long-term services and 
     supports'' after ``barriers'';
       (C) by redesignating paragraphs (3) through (9) as 
     paragraphs (4) through (10), respectively;

[[Page H1976]]

       (D) by inserting after paragraph (2), the following new 
     paragraph:
       ``(3) Recommendations and reports of state-specific data.--
     MACPAC shall--
       ``(A) review national and State-specific Medicaid and CHIP 
     data; and
       ``(B) submit reports and recommendations to Congress, the 
     Secretary, and States based on such reviews.'';
       (E) in paragraph (4), as redesignated by subparagraph (C), 
     by striking ``or any other problems'' and all that follows 
     through the period and inserting ``, as well as other factors 
     that adversely affect, or have the potential to adversely 
     affect, access to care by, or the health care status of, 
     Medicaid and CHIP beneficiaries. MACPAC shall include in the 
     annual report required under paragraph (1)(D) a description 
     of all such areas or problems identified with respect to the 
     period addressed in the report.'';
       (F) in paragraph (5), as so redesignated,--
       (i) in the paragraph heading, by inserting ``and 
     regulations'' after ``reports''; and
       (ii) by striking ``If'' and inserting the following:
       ``(A) Certain secretarial reports.--If''; and
       (iii) in the second sentence, by inserting ``and the 
     Secretary'' after ``appropriate committees of Congress''; and
       (iv) by adding at the end the following:
       ``(B) Regulations.--MACPAC shall review Medicaid and CHIP 
     regulations and may comment through submission of a report to 
     the appropriate committees of Congress and the Secretary, on 
     any such regulations that affect access, quality, or 
     efficiency of health care.'';
       (G) in paragraph (10), as so redesignated, by inserting ``, 
     and shall submit with any recommendations, a report on the 
     Federal and State-specific budget consequences of the 
     recommendations'' before the period; and
       (H) by adding at the end the following:
       ``(11) Consultation and coordination with medpac.--
       ``(A) In general.--MACPAC shall consult with the Medicare 
     Payment Advisory Commission (in this paragraph referred to as 
     `MedPAC') established under section 1805 in carrying out its 
     duties under this section, as appropriate and particularly 
     with respect to the issues specified in paragraph (2) as they 
     relate to those Medicaid beneficiaries who are dually 
     eligible for Medicaid and the Medicare program under title 
     XVIII, adult Medicaid beneficiaries (who are not dually 
     eligible for Medicare), and beneficiaries under Medicare. 
     Responsibility for analysis of and recommendations to change 
     Medicare policy regarding Medicare beneficiaries, including 
     Medicare beneficiaries who are dually eligible for Medicare 
     and Medicaid, shall rest with MedPAC.
       ``(B) Information sharing.--MACPAC and MedPAC shall have 
     access to deliberations and records of the other such entity, 
     respectively, upon the request of the other such entity.
       ``(12) Consultation with states.--MACPAC shall regularly 
     consult with States in carrying out its duties under this 
     section, including with respect to developing processes for 
     carrying out such duties, and shall ensure that input from 
     States is taken into account and represented in MACPAC's 
     recommendations and reports.
       ``(13) Coordinate and consult with the federal coordinated 
     health care office.--MACPAC shall coordinate and consult with 
     the Federal Coordinated Health Care Office established under 
     section 2081 of the Patient Protection and Affordable Care 
     Act before making any recommendations regarding dual eligible 
     individuals.
       ``(14) Programmatic oversight vested in the secretary.--
     MACPAC's authority to make recommendations in accordance with 
     this section shall not affect, or be considered to duplicate, 
     the Secretary's authority to carry out Federal 
     responsibilities with respect to Medicaid and CHIP.'';
       (2) in subsection (c)(2)--
       (A) by striking subparagraphs (A) and (B) and inserting the 
     following:
       ``(A) In general.--The membership of MACPAC shall include 
     individuals who have had direct experience as enrollees or 
     parents or caregivers of enrollees in Medicaid or CHIP and 
     individuals with national recognition for their expertise in 
     Federal safety net health programs, health finance and 
     economics, actuarial science, health plans and integrated 
     delivery systems, reimbursement for health care, health 
     information technology, and other providers of health 
     services, public health, and other related fields, who 
     provide a mix of different professions, broad geographic 
     representation, and a balance between urban and rural 
     representation.
       ``(B) Inclusion.--The membership of MACPAC shall include 
     (but not be limited to) physicians, dentists, and other 
     health professionals, employers, third-party payers, and 
     individuals with expertise in the delivery of health 
     services. Such membership shall also include representatives 
     of children, pregnant women, the elderly, individuals with 
     disabilities, caregivers, and dual eligible individuals, 
     current or former representatives of State agencies 
     responsible for administering Medicaid, and current or former 
     representatives of State agencies responsible for 
     administering CHIP.''.
       (3) in subsection (d)(2), by inserting ``and State'' after 
     ``Federal'';
       (4) in subsection (e)(1), in the first sentence, by 
     inserting ``and, as a condition for receiving payments under 
     sections 1903(a) and 2105(a), from any State agency 
     responsible for administering Medicaid or CHIP,'' after 
     ``United States''; and
       (5) in subsection (f)--
       (A) in the subsection heading, by striking ``Authorization 
     of Appropriations'' and inserting ``Funding'';
       (B) in paragraph (1), by inserting ``(other than for fiscal 
     year 2010)'' before ``in the same manner''; and
       (C) by adding at the end the following:
       ``(3) Funding for fiscal year 2010.--
       ``(A) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there is appropriated to MACPAC to 
     carry out the provisions of this section for fiscal year 
     2010, $9,000,000.
       ``(B) Transfer of funds.--Notwithstanding section 
     2104(a)(13), from the amounts appropriated in such section 
     for fiscal year 2010, $2,000,000 is hereby transferred and 
     made available in such fiscal year to MACPAC to carry out the 
     provisions of this section.
       ``(4) Availability.--Amounts made available under 
     paragraphs (2) and (3) to MACPAC to carry out the provisions 
     of this section shall remain available until expended.''.
       (b) Conforming MedPAC Amendments.--Section 1805(b) of the 
     Social Security Act (42 U.S.C. 1395b-6(b)), is amended--
       (1) in paragraph (1)(C), by striking ``March 1 of each year 
     (beginning with 1998)'' and inserting ``March 15'';
       (2) in paragraph (1)(D), by inserting ``, and (beginning 
     with 2012) containing an examination of the topics described 
     in paragraph (9), to the extent feasible'' before the period; 
     and
       (3) by adding at the end the following:
       ``(9) Review and annual report on medicaid and commercial 
     trends.--The Commission shall review and report on aggregate 
     trends in spending, utilization, and financial performance 
     under the Medicaid program under title XIX and the private 
     market for health care services with respect to providers for 
     which, on an aggregate national basis, a significant portion 
     of revenue or services is associated with the Medicaid 
     program. Where appropriate, the Commission shall conduct such 
     review in consultation with the Medicaid and CHIP Payment and 
     Access Commission established under section 1900 (in this 
     section referred to as `MACPAC').
       ``(10) Coordinate and consult with the federal coordinated 
     health care office.--The Commission shall coordinate and 
     consult with the Federal Coordinated Health Care Office 
     established under section 2081 of the Patient Protection and 
     Affordable Care Act before making any recommendations 
     regarding dual eligible individuals.
       ``(11) Interaction of medicaid and medicare.--The 
     Commission shall consult with MACPAC in carrying out its 
     duties under this section, as appropriate. Responsibility for 
     analysis of and recommendations to change Medicare policy 
     regarding Medicare beneficiaries, including Medicare 
     beneficiaries who are dually eligible for Medicare and 
     Medicaid, shall rest with the Commission. Responsibility for 
     analysis of and recommendations to change Medicaid policy 
     regarding Medicaid beneficiaries, including Medicaid 
     beneficiaries who are dually eligible for Medicare and 
     Medicaid, shall rest with MACPAC.''.

    Subtitle K--Protections for American Indians and Alaska Natives

     SEC. 2901. SPECIAL RULES RELATING TO INDIANS.

       (a) No Cost-sharing for Indians With Income at or Below 300 
     Percent of Poverty Enrolled in Coverage Through a State 
     Exchange.--For provisions prohibiting cost sharing for 
     Indians enrolled in any qualified health plan in the 
     individual market through an Exchange, see section 1402(d) of 
     the Patient Protection and Affordable Care Act.
       (b) Payer of Last Resort.--Health programs operated by the 
     Indian Health Service, Indian tribes, tribal organizations, 
     and Urban Indian organizations (as those terms are defined in 
     section 4 of the Indian Health Care Improvement Act (25 
     U.S.C. 1603)) shall be the payer of last resort for services 
     provided by such Service, tribes, or organizations to 
     individuals eligible for services through such programs, 
     notwithstanding any Federal, State, or local law to the 
     contrary.
       (c) Facilitating Enrollment of Indians Under the Express 
     Lane Option.--Section 1902(e)(13)(F)(ii) of the Social 
     Security Act (42 U.S.C. 1396a(e)(13)(F)(ii)) is amended--
       (1) in the clause heading, by inserting ``and indian tribes 
     and tribal organizations'' after ``agencies''; and
       (2) by adding at the end the following:

       ``(IV) The Indian Health Service, an Indian Tribe, Tribal 
     Organization, or Urban Indian Organization (as defined in 
     section 1139(c)).''.

       (d) Technical Corrections.--Section 1139(c) of the Social 
     Security Act (42 U.S.C. 1320b-9(c)) is amended by striking 
     ``In this section'' and inserting ``For purposes of this 
     section, title XIX, and title XXI''.

     SEC. 2902. ELIMINATION OF SUNSET FOR REIMBURSEMENT FOR ALL 
                   MEDICARE PART B SERVICES FURNISHED BY CERTAIN 
                   INDIAN HOSPITALS AND CLINICS.

       (a) Reimbursement for All Medicare Part B Services 
     Furnished by Certain Indian Hospitals and Clinics.--Section 
     1880(e)(1)(A) of the Social Security Act (42 U.S.C. 
     1395qq(e)(1)(A)) is amended by striking ``during the 5-year 
     period beginning on'' and inserting ``on or after''.
       (b) Effective Date.--The amendments made by this section 
     shall apply to items or services furnished on or after 
     January 1, 2010.

             Subtitle L--Maternal and Child Health Services

     SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME 
                   VISITING PROGRAMS.

       Title V of the Social Security Act (42 U.S.C. 701 et seq.) 
     is amended by adding at the end the following new section:

     ``SEC. 511. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME 
                   VISITING PROGRAMS.

       ``(a) Purposes.--The purposes of this section are--

[[Page H1977]]

       ``(1) to strengthen and improve the programs and activities 
     carried out under this title;
       ``(2) to improve coordination of services for at risk 
     communities; and
       ``(3) to identify and provide comprehensive services to 
     improve outcomes for families who reside in at risk 
     communities.
       ``(b) Requirement for All States To Assess Statewide Needs 
     and Identify at Risk Communities.--
       ``(1) In general.--Not later than 6 months after the date 
     of enactment of this section, each State shall, as a 
     condition of receiving payments from an allotment for the 
     State under section 502 for fiscal year 2011, conduct a 
     statewide needs assessment (which shall be separate from the 
     statewide needs assessment required under section 505(a)) 
     that identifies--
       ``(A) communities with concentrations of--
       ``(i) premature birth, low-birth weight infants, and infant 
     mortality, including infant death due to neglect, or other 
     indicators of at-risk prenatal, maternal, newborn, or child 
     health;
       ``(ii) poverty;
       ``(iii) crime;
       ``(iv) domestic violence;
       ``(v) high rates of high-school drop-outs;
       ``(vi) substance abuse;
       ``(vii) unemployment; or
       ``(viii) child maltreatment;
       ``(B) the quality and capacity of existing programs or 
     initiatives for early childhood home visitation in the State 
     including--
       ``(i) the number and types of individuals and families who 
     are receiving services under such programs or initiatives;
       ``(ii) the gaps in early childhood home visitation in the 
     State; and
       ``(iii) the extent to which such programs or initiatives 
     are meeting the needs of eligible families described in 
     subsection (k)(2); and
       ``(C) the State's capacity for providing substance abuse 
     treatment and counseling services to individuals and families 
     in need of such treatment or services.
       ``(2) Coordination with other assessments.--In conducting 
     the statewide needs assessment required under paragraph (1), 
     the State shall coordinate with, and take into account, other 
     appropriate needs assessments conducted by the State, as 
     determined by the Secretary, including the needs assessment 
     required under section 505(a) (both the most recently 
     completed assessment and any such assessment in progress), 
     the communitywide strategic planning and needs assessments 
     conducted in accordance with section 640(g)(1)(C) of the Head 
     Start Act, and the inventory of current unmet needs and 
     current community-based and prevention-focused programs and 
     activities to prevent child abuse and neglect, and other 
     family resource services operating in the State required 
     under section 205(3) of the Child Abuse Prevention and 
     Treatment Act.
       ``(3) Submission to the secretary.--Each State shall submit 
     to the Secretary, in such form and manner as the Secretary 
     shall require--
       ``(A) the results of the statewide needs assessment 
     required under paragraph (1); and
       ``(B) a description of how the State intends to address 
     needs identified by the assessment, particularly with respect 
     to communities identified under paragraph (1)(A), which may 
     include applying for a grant to conduct an early childhood 
     home visitation program in accordance with the requirements 
     of this section.
       ``(c) Grants for Early Childhood Home Visitation 
     Programs.--
       ``(1) Authority to make grants.--In addition to any other 
     payments made under this title to a State, the Secretary 
     shall make grants to eligible entities to enable the entities 
     to deliver services under early childhood home visitation 
     programs that satisfy the requirements of subsection (d) to 
     eligible families in order to promote improvements in 
     maternal and prenatal health, infant health, child health and 
     development, parenting related to child development outcomes, 
     school readiness, and the socioeconomic status of such 
     families, and reductions in child abuse, neglect, and 
     injuries.
       ``(2) Authority to use initial grant funds for planning or 
     implementation.--An eligible entity that receives a grant 
     under paragraph (1) may use a portion of the funds made 
     available to the entity during the first 6 months of the 
     period for which the grant is made for planning or 
     implementation activities to assist with the establishment of 
     early childhood home visitation programs that satisfy the 
     requirements of subsection (d).
       ``(3) Grant duration.--The Secretary shall determine the 
     period of years for which a grant is made to an eligible 
     entity under paragraph (1).
       ``(4) Technical assistance.--The Secretary shall provide an 
     eligible entity that receives a grant under paragraph (1) 
     with technical assistance in administering programs or 
     activities conducted in whole or in part with grant funds.
       ``(d) Requirements.--The requirements of this subsection 
     for an early childhood home visitation program conducted with 
     a grant made under this section are as follows:
       ``(1) Quantifiable, measurable improvement in benchmark 
     areas.--
       ``(A) In general.--The eligible entity establishes, subject 
     to the approval of the Secretary, quantifiable, measurable 3- 
     and 5-year benchmarks for demonstrating that the program 
     results in improvements for the eligible families 
     participating in the program in each of the following areas:
       ``(i) Improved maternal and newborn health.
       ``(ii) Prevention of child injuries, child abuse, neglect, 
     or maltreatment, and reduction of emergency department 
     visits.
       ``(iii) Improvement in school readiness and achievement.
       ``(iv) Reduction in crime or domestic violence.
       ``(v) Improvements in family economic self-sufficiency.
       ``(vi) Improvements in the coordination and referrals for 
     other community resources and supports.
       ``(B) Demonstration of improvements after 3 years.--
       ``(i) Report to the secretary.--Not later than 30 days 
     after the end of the 3rd year in which the eligible entity 
     conducts the program, the entity submits to the Secretary a 
     report demonstrating improvement in at least 4 of the areas 
     specified in subparagraph (A).
       ``(ii) Corrective action plan.--If the report submitted by 
     the eligible entity under clause (i) fails to demonstrate 
     improvement in at least 4 of the areas specified in 
     subparagraph (A), the entity shall develop and implement a 
     plan to improve outcomes in each of the areas specified in 
     subparagraph (A), subject to approval by the Secretary. The 
     plan shall include provisions for the Secretary to monitor 
     implementation of the plan and conduct continued oversight of 
     the program, including through submission by the entity of 
     regular reports to the Secretary.
       ``(iii) Technical assistance.--

       ``(I) In general.--The Secretary shall provide an eligible 
     entity required to develop and implement an improvement plan 
     under clause (ii) with technical assistance to develop and 
     implement the plan. The Secretary may provide the technical 
     assistance directly or through grants, contracts, or 
     cooperative agreements.
       ``(II) Advisory panel.--The Secretary shall establish an 
     advisory panel for purposes of obtaining recommendations 
     regarding the technical assistance provided to entities in 
     accordance with subclause (I).

       ``(iv) No improvement or failure to submit report.--If the 
     Secretary determines after a period of time specified by the 
     Secretary that an eligible entity implementing an improvement 
     plan under clause (ii) has failed to demonstrate any 
     improvement in the areas specified in subparagraph (A), or if 
     the Secretary determines that an eligible entity has failed 
     to submit the report required under clause (i), the Secretary 
     shall terminate the entity's grant and may include any 
     unexpended grant funds in grants made to nonprofit 
     organizations under subsection (h)(2)(B).
       ``(C) Final report.--Not later than December 31, 2015, the 
     eligible entity shall submit a report to the Secretary 
     demonstrating improvements (if any) in each of the areas 
     specified in subparagraph (A).
       ``(2) Improvements in outcomes for individual families.--
       ``(A) In general.--The program is designed, with respect to 
     an eligible family participating in the program, to result in 
     the participant outcomes described in subparagraph (B) that 
     the eligible entity identifies on the basis of an 
     individualized assessment of the family, are relevant for 
     that family.
       ``(B) Participant outcomes.--The participant outcomes 
     described in this subparagraph are the following:
       ``(i) Improvements in prenatal, maternal, and newborn 
     health, including improved pregnancy outcomes
       ``(ii) Improvements in child health and development, 
     including the prevention of child injuries and maltreatment 
     and improvements in cognitive, language, social-emotional, 
     and physical developmental indicators.
       ``(iii) Improvements in parenting skills.
       ``(iv) Improvements in school readiness and child academic 
     achievement.
       ``(v) Reductions in crime or domestic violence.
       ``(vi) Improvements in family economic self-sufficiency.
       ``(vii) Improvements in the coordination of referrals for, 
     and the provision of, other community resources and supports 
     for eligible families, consistent with State child welfare 
     agency training.
       ``(3) Core components.--The program includes the following 
     core components:
       ``(A) Service delivery model or models.--
       ``(i) In general.--Subject to clause (ii), the program is 
     conducted using 1 or more of the service delivery models 
     described in item (aa) or (bb) of subclause (I) or in 
     subclause (II) selected by the eligible entity:

       ``(I) The model conforms to a clear consistent home 
     visitation model that has been in existence for at least 3 
     years and is research-based, grounded in relevant 
     empirically-based knowledge, linked to program determined 
     outcomes, associated with a national organization or 
     institution of higher education that has comprehensive home 
     visitation program standards that ensure high quality service 
     delivery and continuous program quality improvement, and has 
     demonstrated significant, (and in the case of the service 
     delivery model described in item (aa), sustained) positive 
     outcomes, as described in the benchmark areas specified in 
     paragraph (1)(A) and the participant outcomes described in 
     paragraph (2)(B), when evaluated using well-designed and 
     rigorous--

       ``(aa) randomized controlled research designs, and the 
     evaluation results have been published in a peer-reviewed 
     journal; or
       ``(bb) quasi-experimental research designs.

       ``(II) The model conforms to a promising and new approach 
     to achieving the benchmark areas specified in paragraph 
     (1)(A) and the participant outcomes described in paragraph 
     (2)(B), has been developed or identified by a national 
     organization or institution of higher education, and will be 
     evaluated through well-designed and rigorous process.

       ``(ii) Majority of grant funds used for evidence-based 
     models.--An eligible entity shall use not more than 25 
     percent of the amount of the grant paid to the entity for a 
     fiscal year for purposes of conducting a program using the 
     service delivery model described in clause (i)(II).
       ``(iii) Criteria for evidence of effectiveness of models.--
     The Secretary shall establish criteria for evidence of 
     effectiveness of the service delivery models and shall ensure 
     that the

[[Page H1978]]

     process for establishing the criteria is transparent and 
     provides the opportunity for public comment.
       ``(B) Additional requirements.--
       ``(i) The program adheres to a clear, consistent model that 
     satisfies the requirements of being grounded in empirically-
     based knowledge related to home visiting and linked to the 
     benchmark areas specified in paragraph (1)(A) and the 
     participant outcomes described in paragraph (2)(B) related to 
     the purposes of the program.
       ``(ii) The program employs well-trained and competent 
     staff, as demonstrated by education or training, such as 
     nurses, social workers, educators, child development 
     specialists, or other well-trained and competent staff, and 
     provides ongoing and specific training on the model being 
     delivered.
       ``(iii) The program maintains high quality supervision to 
     establish home visitor competencies.
       ``(iv) The program demonstrates strong organizational 
     capacity to implement the activities involved.
       ``(v) The program establishes appropriate linkages and 
     referral networks to other community resources and supports 
     for eligible families.
       ``(vi) The program monitors the fidelity of program 
     implementation to ensure that services are delivered pursuant 
     to the specified model.
       ``(4) Priority for serving high-risk populations.--The 
     eligible entity gives priority to providing services under 
     the program to the following:
       ``(A) Eligible families who reside in communities in need 
     of such services, as identified in the statewide needs 
     assessment required under subsection (b)(1)(A).
       ``(B) Low-income eligible families.
       ``(C) Eligible families who are pregnant women who have not 
     attained age 21.
       ``(D) Eligible families that have a history of child abuse 
     or neglect or have had interactions with child welfare 
     services.
       ``(E) Eligible families that have a history of substance 
     abuse or need substance abuse treatment.
       ``(F) Eligible families that have users of tobacco products 
     in the home.
       ``(G) Eligible families that are or have children with low 
     student achievement.
       ``(H) Eligible families with children with developmental 
     delays or disabilities.
       ``(I) Eligible families who, or that include individuals 
     who, are serving or formerly served in the Armed Forces, 
     including such families that have members of the Armed Forces 
     who have had multiple deployments outside of the United 
     States.
       ``(e) Application Requirements.--An eligible entity 
     desiring a grant under this section shall submit an 
     application to the Secretary for approval, in such manner as 
     the Secretary may require, that includes the following:
       ``(1) A description of the populations to be served by the 
     entity, including specific information regarding how the 
     entity will serve high risk populations described in 
     subsection (d)(4).
       ``(2) An assurance that the entity will give priority to 
     serving low-income eligible families and eligible families 
     who reside in at risk communities identified in the statewide 
     needs assessment required under subsection (b)(1)(A).
       ``(3) The service delivery model or models described in 
     subsection (d)(3)(A) that the entity will use under the 
     program and the basis for the selection of the model or 
     models.
       ``(4) A statement identifying how the selection of the 
     populations to be served and the service delivery model or 
     models that the entity will use under the program for such 
     populations is consistent with the results of the statewide 
     needs assessment conducted under subsection (b).
       ``(5) The quantifiable, measurable benchmarks established 
     by the State to demonstrate that the program contributes to 
     improvements in the areas specified in subsection (d)(1)(A).
       ``(6) An assurance that the entity will obtain and submit 
     documentation or other appropriate evidence from the 
     organization or entity that developed the service delivery 
     model or models used under the program to verify that the 
     program is implemented and services are delivered according 
     to the model specifications.
       ``(7) Assurances that the entity will establish procedures 
     to ensure that--
       ``(A) the participation of each eligible family in the 
     program is voluntary; and
       ``(B) services are provided to an eligible family in 
     accordance with the individual assessment for that family.
       ``(8) Assurances that the entity will--
       ``(A) submit annual reports to the Secretary regarding the 
     program and activities carried out under the program that 
     include such information and data as the Secretary shall 
     require; and
       ``(B) participate in, and cooperate with, data and 
     information collection necessary for the evaluation required 
     under subsection (g)(2) and other research and evaluation 
     activities carried out under subsection (h)(3).
       ``(9) A description of other State programs that include 
     home visitation services, including, if applicable to the 
     State, other programs carried out under this title with funds 
     made available from allotments under section 502(c), programs 
     funded under title IV, title II of the Child Abuse Prevention 
     and Treatment Act (relating to community-based grants for the 
     prevention of child abuse and neglect), and section 645A of 
     the Head Start Act (relating to Early Head Start programs).
       ``(10) Other information as required by the Secretary.
       ``(f) Maintenance of Effort.--Funds provided to an eligible 
     entity receiving a grant under this section shall supplement, 
     and not supplant, funds from other sources for early 
     childhood home visitation programs or initiatives.
       ``(g) Evaluation.--
       ``(1) Independent, expert advisory panel.--The Secretary, 
     in accordance with subsection (h)(1)(A), shall appoint an 
     independent advisory panel consisting of experts in program 
     evaluation and research, education, and early childhood 
     development--
       ``(A) to review, and make recommendations on, the design 
     and plan for the evaluation required under paragraph (2) 
     within 1 year after the date of enactment of this section;
       ``(B) to maintain and advise the Secretary regarding the 
     progress of the evaluation; and
       ``(C) to comment, if the panel so desires, on the report 
     submitted under paragraph (3).
       ``(2) Authority to conduct evaluation.--On the basis of the 
     recommendations of the advisory panel under paragraph (1), 
     the Secretary shall, by grant, contract, or interagency 
     agreement, conduct an evaluation of the statewide needs 
     assessments submitted under subsection (b) and the grants 
     made under subsections (c) and (h)(3)(B). The evaluation 
     shall include--
       ``(A) an analysis, on a State-by-State basis, of the 
     results of such assessments, including indicators of maternal 
     and prenatal health and infant health and mortality, and 
     State actions in response to the assessments; and
       ``(B) an assessment of--
       ``(i) the effect of early childhood home visitation 
     programs on child and parent outcomes, including with respect 
     to each of the benchmark areas specified in subsection 
     (d)(1)(A) and the participant outcomes described in 
     subsection (d)(2)(B);
       ``(ii) the effectiveness of such programs on different 
     populations, including the extent to which the ability of 
     programs to improve participant outcomes varies across 
     programs and populations; and
       ``(iii) the potential for the activities conducted under 
     such programs, if scaled broadly, to improve health care 
     practices, eliminate health disparities, and improve health 
     care system quality, efficiencies, and reduce costs.
       ``(3) Report.--Not later than March 31, 2015, the Secretary 
     shall submit a report to Congress on the results of the 
     evaluation conducted under paragraph (2) and shall make the 
     report publicly available.
       ``(h) Other Provisions.--
       ``(1) Intra-agency collaboration.--The Secretary shall 
     ensure that the Maternal and Child Health Bureau and the 
     Administration for Children and Families collaborate with 
     respect to carrying out this section, including with respect 
     to--
       ``(A) reviewing and analyzing the statewide needs 
     assessments required under subsection (b), the awarding and 
     oversight of grants awarded under this section, the 
     establishment of the advisory panels required under 
     subsections (d)(1)(B)(iii)(II) and (g)(1), and the evaluation 
     and report required under subsection (g); and
       ``(B) consulting with other Federal agencies with 
     responsibility for administering or evaluating programs that 
     serve eligible families to coordinate and collaborate with 
     respect to research related to such programs and families, 
     including the Office of the Assistant Secretary for Planning 
     and Evaluation of the Department of Health and Human 
     Services, the Centers for Disease Control and Prevention, the 
     National Institute of Child Health and Human Development of 
     the National Institutes of Health, the Office of Juvenile 
     Justice and Delinquency Prevention of the Department of 
     Justice, and the Institute of Education Sciences of the 
     Department of Education.
       ``(2) Grants to eligible entities that are not states.--
       ``(A) Indian tribes, tribal organizations, or urban indian 
     organizations.--The Secretary shall specify requirements for 
     eligible entities that are Indian Tribes (or a consortium of 
     Indian Tribes), Tribal Organizations, or Urban Indian 
     Organizations to apply for and conduct an early childhood 
     home visitation program with a grant under this section. Such 
     requirements shall, to the greatest extent practicable, be 
     consistent with the requirements applicable to eligible 
     entities that are States and shall require an Indian Tribe 
     (or consortium), Tribal Organization, or Urban Indian 
     Organization to--
       ``(i) conduct a needs assessment similar to the assessment 
     required for all States under subsection (b); and
       ``(ii) establish quantifiable, measurable 3- and 5-year 
     benchmarks consistent with subsection (d)(1)(A).
       ``(B) Nonprofit organizations.--If, as of the beginning of 
     fiscal year 2012, a State has not applied or been approved 
     for a grant under this section, the Secretary may use amounts 
     appropriated under paragraph (1) of subsection (j) that are 
     available for expenditure under paragraph (3) of that 
     subsection to make a grant to an eligible entity that is a 
     nonprofit organization described in subsection (k)(1)(B) to 
     conduct an early childhood home visitation program in the 
     State. The Secretary shall specify the requirements for such 
     an organization to apply for and conduct the program which 
     shall, to the greatest extent practicable, be consistent with 
     the requirements applicable to eligible entities that are 
     States and shall require the organization to--
       ``(i) carry out the program based on the needs assessment 
     conducted by the State under subsection (b); and
       ``(ii) establish quantifiable, measurable 3- and 5-year 
     benchmarks consistent with subsection (d)(1)(A).
       ``(3) Research and other evaluation activities.--
       ``(A) In general.--The Secretary shall carry out a 
     continuous program of research and evaluation activities in 
     order to increase knowledge about the implementation and 
     effectiveness of home visiting programs, using random 
     assignment designs to the maximum extent feasible. The 
     Secretary may carry out such activities directly, or through 
     grants, cooperative agreements, or contracts.

[[Page H1979]]

       ``(B) Requirements.--The Secretary shall ensure that--
       ``(i) evaluation of a specific program or project is 
     conducted by persons or individuals not directly involved in 
     the operation of such program or project; and
       ``(ii) the conduct of research and evaluation activities 
     includes consultation with independent researchers, State 
     officials, and developers and providers of home visiting 
     programs on topics including research design and 
     administrative data matching.
       ``(4) Report and recommendation.--Not later than December 
     31, 2015, the Secretary shall submit a report to Congress 
     regarding the programs conducted with grants under this 
     section. The report required under this paragraph shall 
     include--
       ``(A) information regarding the extent to which eligible 
     entities receiving grants under this section demonstrated 
     improvements in each of the areas specified in subsection 
     (d)(1)(A);
       ``(B) information regarding any technical assistance 
     provided under subsection (d)(1)(B)(iii)(I), including the 
     type of any such assistance provided; and
       ``(C) recommendations for such legislative or 
     administrative action as the Secretary determines 
     appropriate.
       ``(i) Application of Other Provisions of Title.--
       ``(1) In general.--Except as provided in paragraph (2), the 
     other provisions of this title shall not apply to a grant 
     made under this section.
       ``(2) Exceptions.--The following provisions of this title 
     shall apply to a grant made under this section to the same 
     extent and in the same manner as such provisions apply to 
     allotments made under section 502(c):
       ``(A) Section 504(b)(6) (relating to prohibition on 
     payments to excluded individuals and entities).
       ``(B) Section 504(c) (relating to the use of funds for the 
     purchase of technical assistance).
       ``(C) Section 504(d) (relating to a limitation on 
     administrative expenditures).
       ``(D) Section 506 (relating to reports and audits), but 
     only to the extent determined by the Secretary to be 
     appropriate for grants made under this section.
       ``(E) Section 507 (relating to penalties for false 
     statements).
       ``(F) Section 508 (relating to nondiscrimination).
       ``(G) Section 509(a) (relating to the administration of the 
     grant program).
       ``(j) Appropriations.--
       ``(1) In general.--Out of any funds in the Treasury not 
     otherwise appropriated, there are appropriated to the 
     Secretary to carry out this section--
       ``(A) $100,000,000 for fiscal year 2010;
       ``(B) $250,000,000 for fiscal year 2011;
       ``(C) $350,000,000 for fiscal year 2012;
       ``(D) $400,000,000 for fiscal year 2013; and
       ``(E) $400,000,000 for fiscal year 2014.
       ``(2) Reservations.--Of the amount appropriated under this 
     subsection for a fiscal year, the Secretary shall reserve--
       ``(A) 3 percent of such amount for purposes of making 
     grants to eligible entities that are Indian Tribes (or a 
     consortium of Indian Tribes), Tribal Organizations, or Urban 
     Indian Organizations; and
       ``(B) 3 percent of such amount for purposes of carrying out 
     subsections (d)(1)(B)(iii), (g), and (h)(3).
       ``(3) Availability.--Funds made available to an eligible 
     entity under this section for a fiscal year shall remain 
     available for expenditure by the eligible entity through the 
     end of the second succeeding fiscal year after award. Any 
     funds that are not expended by the eligible entity during the 
     period in which the funds are available under the preceding 
     sentence may be used for grants to nonprofit organizations 
     under subsection (h)(2)(B).
       ``(k) Definitions.--In this section:
       ``(1) Eligible entity.--
       ``(A) In general.--The term `eligible entity' means a 
     State, an Indian Tribe, Tribal Organization, or Urban Indian 
     Organization, Puerto Rico, Guam, the Virgin Islands, the 
     Northern Mariana Islands, and American Samoa.
       ``(B) Nonprofit organizations.--Only for purposes of 
     awarding grants under subsection (h)(2)(B), such term shall 
     include a nonprofit organization with an established record 
     of providing early childhood home visitation programs or 
     initiatives in a State or several States.
       ``(2) Eligible family.--The term `eligible family' means--
       ``(A) a woman who is pregnant, and the father of the child 
     if the father is available; or
       ``(B) a parent or primary caregiver of a child, including 
     grandparents or other relatives of the child, and foster 
     parents, who are serving as the child's primary caregiver 
     from birth to kindergarten entry, and including a 
     noncustodial parent who has an ongoing relationship with, and 
     at times provides physical care for, the child.
       ``(3) Indian tribe; tribal organization.--The terms `Indian 
     Tribe' and `Tribal Organization', and `Urban Indian 
     Organization' have the meanings given such terms in section 4 
     of the Indian Health Care Improvement Act.''.

     SEC. 2952. SUPPORT, EDUCATION, AND RESEARCH FOR POSTPARTUM 
                   DEPRESSION.

       (a) Research on Postpartum Conditions.--
       (1) Expansion and intensification of activities.--The 
     Secretary of Health and Human Services (in this subsection 
     and subsection (c) referred to as the ``Secretary'') is 
     encouraged to continue activities on postpartum depression or 
     postpartum psychosis (in this subsection and subsection (c) 
     referred to as ``postpartum conditions''), including research 
     to expand the understanding of the causes of, and treatments 
     for, postpartum conditions. Activities under this paragraph 
     shall include conducting and supporting the following:
       (A) Basic research concerning the etiology and causes of 
     the conditions.
       (B) Epidemiological studies to address the frequency and 
     natural history of the conditions and the differences among 
     racial and ethnic groups with respect to the conditions.
       (C) The development of improved screening and diagnostic 
     techniques.
       (D) Clinical research for the development and evaluation of 
     new treatments.
       (E) Information and education programs for health care 
     professionals and the public, which may include a coordinated 
     national campaign to increase the awareness and knowledge of 
     postpartum conditions. Activities under such a national 
     campaign may--
       (i) include public service announcements through 
     television, radio, and other means; and
       (ii) focus on--

       (I) raising awareness about screening;
       (II) educating new mothers and their families about 
     postpartum conditions to promote earlier diagnosis and 
     treatment; and
       (III) ensuring that such education includes complete 
     information concerning postpartum conditions, including its 
     symptoms, methods of coping with the illness, and treatment 
     resources.

       (2) Sense of congress regarding longitudinal study of 
     relative mental health consequences for women of resolving a 
     pregnancy.--
       (A) Sense of congress.--It is the sense of Congress that 
     the Director of the National Institute of Mental Health may 
     conduct a nationally representative longitudinal study 
     (during the period of fiscal years 2010 through 2019) of the 
     relative mental health consequences for women of resolving a 
     pregnancy (intended and unintended) in various ways, 
     including carrying the pregnancy to term and parenting the 
     child, carrying the pregnancy to term and placing the child 
     for adoption, miscarriage, and having an abortion. This study 
     may assess the incidence, timing, magnitude, and duration of 
     the immediate and long-term mental health consequences 
     (positive or negative) of these pregnancy outcomes.
       (B) Report.--Subject to the completion of the study under 
     subsection (a), beginning not later than 5 years after the 
     date of the enactment of this Act, and periodically 
     thereafter for the duration of the study, such Director may 
     prepare and submit to the Congress reports on the findings of 
     the study.
       (b) Grants To Provide Services to Individuals With a 
     Postpartum Condition and Their Families.--Title V of the 
     Social Security Act (42 U.S.C. 701 et seq.), as amended by 
     section 2951, is amended by adding at the end the following 
     new section:

     ``SEC. 512. SERVICES TO INDIVIDUALS WITH A POSTPARTUM 
                   CONDITION AND THEIR FAMILIES.

       ``(a) In General.--In addition to any other payments made 
     under this title to a State, the Secretary may make grants to 
     eligible entities for projects for the establishment, 
     operation, and coordination of effective and cost-efficient 
     systems for the delivery of essential services to individuals 
     with or at risk for postpartum conditions and their families.
       ``(b) Certain Activities.--To the extent practicable and 
     appropriate, the Secretary shall ensure that projects funded 
     under subsection (a) provide education and services with 
     respect to the diagnosis and management of postpartum 
     conditions for individuals with or at risk for postpartum 
     conditions and their families. The Secretary may allow such 
     projects to include the following:
       ``(1) Delivering or enhancing outpatient and home-based 
     health and support services, including case management and 
     comprehensive treatment services.
       ``(2) Delivering or enhancing inpatient care management 
     services that ensure the well-being of the mother and family 
     and the future development of the infant.
       ``(3) Improving the quality, availability, and organization 
     of health care and support services (including transportation 
     services, attendant care, homemaker services, day or respite 
     care, and providing counseling on financial assistance and 
     insurance).
       ``(4) Providing education about postpartum conditions to 
     promote earlier diagnosis and treatment. Such education may 
     include--
       ``(A) providing complete information on postpartum 
     conditions, symptoms, methods of coping with the illness, and 
     treatment resources; and
       ``(B) in the case of a grantee that is a State, hospital, 
     or birthing facility--
       ``(i) providing education to new mothers and fathers, and 
     other family members as appropriate, concerning postpartum 
     conditions before new mothers leave the health facility; and
       ``(ii) ensuring that training programs regarding such 
     education are carried out at the health facility.
       ``(c) Integration With Other Programs.--To the extent 
     practicable and appropriate, the Secretary may integrate the 
     grant program under this section with other grant programs 
     carried out by the Secretary, including the program under 
     section 330 of the Public Health Service Act.
       ``(d) Requirements.--The Secretary shall establish 
     requirements for grants made under this section that include 
     a limit on the amount of grants funds that may be used for 
     administration, accounting, reporting, or program oversight 
     functions and a requirement for each eligible entity that 
     receives a grant to submit, for each grant period, a report 
     to the Secretary that describes how grant funds were used 
     during such period.
       ``(e) Technical Assistance.--The Secretary may provide 
     technical assistance to entities seeking a grant under this 
     section in order to assist such entities in complying with 
     the requirements of this section.
       ``(f) Application of Other Provisions of Title.--

[[Page H1980]]

       ``(1) In general.--Except as provided in paragraph (2), the 
     other provisions of this title shall not apply to a grant 
     made under this section.
       ``(2) Exceptions.--The following provisions of this title 
     shall apply to a grant made under this section to the same 
     extent and in the same manner as such provisions apply to 
     allotments made under section 502(c):
       ``(A) Section 504(b)(6) (relating to prohibition on 
     payments to excluded individuals and entities).
       ``(B) Section 504(c) (relating to the use of funds for the 
     purchase of technical assistance).
       ``(C) Section 504(d) (relating to a limitation on 
     administrative expenditures).
       ``(D) Section 506 (relating to reports and audits), but 
     only to the extent determined by the Secretary to be 
     appropriate for grants made under this section.
       ``(E) Section 507 (relating to penalties for false 
     statements).
       ``(F) Section 508 (relating to nondiscrimination).
       ``(G) Section 509(a) (relating to the administration of the 
     grant program).
       ``(g) Definitions.--In this section:
       ``(1) The term `eligible entity'--
       ``(A) means a public or nonprofit private entity; and
       ``(B) includes a State or local government, public-private 
     partnership, recipient of a grant under section 330H of the 
     Public Health Service Act (relating to the Healthy Start 
     Initiative), public or nonprofit private hospital, community-
     based organization, hospice, ambulatory care facility, 
     community health center, migrant health center, public 
     housing primary care center, or homeless health center.
       ``(2) The term `postpartum condition' means postpartum 
     depression or postpartum psychosis.''.
       (c) General Provisions.--
       (1) Authorization of appropriations.--To carry out this 
     section and the amendment made by subsection (b), there are 
     authorized to be appropriated, in addition to such other sums 
     as may be available for such purpose--
       (A) $3,000,000 for fiscal year 2010; and
       (B) such sums as may be necessary for fiscal years 2011 and 
     2012.
       (2) Report by the secretary.--
       (A) Study.--The Secretary shall conduct a study on the 
     benefits of screening for postpartum conditions.
       (B) Report.--Not later than 2 years after the date of the 
     enactment of this Act, the Secretary shall complete the study 
     required by subparagraph (A) and submit a report to the 
     Congress on the results of such study.

     SEC. 2953. PERSONAL RESPONSIBILITY EDUCATION.

       Title V of the Social Security Act (42 U.S.C. 701 et seq.), 
     as amended by sections 2951 and 2952(c), is amended by adding 
     at the end the following:

     ``SEC. 513. PERSONAL RESPONSIBILITY EDUCATION.

       ``(a) Allotments to States.--
       ``(1) Amount.--
       ``(A) In general.--For the purpose described in subsection 
     (b), subject to the succeeding provisions of this section, 
     for each of fiscal years 2010 through 2014, the Secretary 
     shall allot to each State an amount equal to the product of--
       ``(i) the amount appropriated under subsection (f) for the 
     fiscal year and available for allotments to States after the 
     application of subsection (c); and
       ``(ii) the State youth population percentage determined 
     under paragraph (2).
       ``(B) Minimum allotment.--
       ``(i) In general.--Each State allotment under this 
     paragraph for a fiscal year shall be at least $250,000.
       ``(ii) Pro rata adjustments.--The Secretary shall adjust on 
     a pro rata basis the amount of the State allotments 
     determined under this paragraph for a fiscal year to the 
     extent necessary to comply with clause (i).
       ``(C) Application required to access allotments.--
       ``(i) In general.--A State shall not be paid from its 
     allotment for a fiscal year unless the State submits an 
     application to the Secretary for the fiscal year and the 
     Secretary approves the application (or requires changes to 
     the application that the State satisfies) and meets such 
     additional requirements as the Secretary may specify.
       ``(ii) Requirements.--The State application shall contain 
     an assurance that the State has complied with the 
     requirements of this section in preparing and submitting the 
     application and shall include the following as well as such 
     additional information as the Secretary may require:

       ``(I) Based on data from the Centers for Disease Control 
     and Prevention National Center for Health Statistics, the 
     most recent pregnancy rates for the State for youth ages 10 
     to 14 and youth ages 15 to 19 for which data are available, 
     the most recent birth rates for such youth populations in the 
     State for which data are available, and trends in those rates 
     for the most recently preceding 5-year period for which such 
     data are available.
       ``(II) State-established goals for reducing the pregnancy 
     rates and birth rates for such youth populations.
       ``(III) A description of the State's plan for using the 
     State allotments provided under this section to achieve such 
     goals, especially among youth populations that are the most 
     high-risk or vulnerable for pregnancies or otherwise have 
     special circumstances, including youth in foster care, 
     homeless youth, youth with HIV/AIDS, pregnant youth who are 
     under 21 years of age, mothers who are under 21 years of age, 
     and youth residing in areas with high birth rates for youth.

       ``(2) State youth population percentage.--
       ``(A) In general.--For purposes of paragraph (1)(A)(ii), 
     the State youth population percentage is, with respect to a 
     State, the proportion (expressed as a percentage) of--
       ``(i) the number of individuals who have attained age 10 
     but not attained age 20 in the State; to
       ``(ii) the number of such individuals in all States.
       ``(B) Determination of number of youth.--The number of 
     individuals described in clauses (i) and (ii) of subparagraph 
     (A) in a State shall be determined on the basis of the most 
     recent Bureau of the Census data.
       ``(3) Availability of state allotments.--Subject to 
     paragraph (4)(A), amounts allotted to a State pursuant to 
     this subsection for a fiscal year shall remain available for 
     expenditure by the State through the end of the second 
     succeeding fiscal year.
       ``(4) Authority to award grants from state allotments to 
     local organizations and entities in nonparticipating 
     states.--
       ``(A) Grants from unexpended allotments.--If a State does 
     not submit an application under this section for fiscal year 
     2010 or 2011, the State shall no longer be eligible to submit 
     an application to receive funds from the amounts allotted for 
     the State for each of fiscal years 2010 through 2014 and such 
     amounts shall be used by the Secretary to award grants under 
     this paragraph for each of fiscal years 2012 through 2014. 
     The Secretary also shall use any amounts from the allotments 
     of States that submit applications under this section for a 
     fiscal year that remain unexpended as of the end of the 
     period in which the allotments are available for expenditure 
     under paragraph (3) for awarding grants under this paragraph.
       ``(B) 3-year grants.--
       ``(i) In general.--The Secretary shall solicit applications 
     to award 3-year grants in each of fiscal years 2012, 2013, 
     and 2014 to local organizations and entities to conduct, 
     consistent with subsection (b), programs and activities in 
     States that do not submit an application for an allotment 
     under this section for fiscal year 2010 or 2011.
       ``(ii) Faith-based organizations or consortia.--The 
     Secretary may solicit and award grants under this paragraph 
     to faith-based organizations or consortia.
       ``(C) Evaluation.--An organization or entity awarded a 
     grant under this paragraph shall agree to participate in a 
     rigorous Federal evaluation.
       ``(5) Maintenance of effort.--No payment shall be made to a 
     State from the allotment determined for the State under this 
     subsection or to a local organization or entity awarded a 
     grant under paragraph (4), if the expenditure of non-federal 
     funds by the State, organization, or entity for activities, 
     programs, or initiatives for which amounts from allotments 
     and grants under this subsection may be expended is less than 
     the amount expended by the State, organization, or entity for 
     such programs or initiatives for fiscal year 2009.
       ``(6) Data collection and reporting.--A State or local 
     organization or entity receiving funds under this section 
     shall cooperate with such requirements relating to the 
     collection of data and information and reporting on outcomes 
     regarding the programs and activities carried out with such 
     funds, as the Secretary shall specify.
       ``(b) Purpose.--
       ``(1) In general.--The purpose of an allotment under 
     subsection (a)(1) to a State is to enable the State (or, in 
     the case of grants made under subsection (a)(4)(B), to enable 
     a local organization or entity) to carry out personal 
     responsibility education programs consistent with this 
     subsection.
       ``(2) Personal responsibility education programs.--
       ``(A) In general.--In this section, the term `personal 
     responsibility education program' means a program that is 
     designed to educate adolescents on--
       ``(i) both abstinence and contraception for the prevention 
     of pregnancy and sexually transmitted infections, including 
     HIV/AIDS, consistent with the requirements of subparagraph 
     (B); and
       ``(ii) at least 3 of the adulthood preparation subjects 
     described in subparagraph (C).
       ``(B) Requirements.--The requirements of this subparagraph 
     are the following:
       ``(i) The program replicates evidence-based effective 
     programs or substantially incorporates elements of effective 
     programs that have been proven on the basis of rigorous 
     scientific research to change behavior, which means delaying 
     sexual activity, increasing condom or contraceptive use for 
     sexually active youth, or reducing pregnancy among youth.
       ``(ii) The program is medically-accurate and complete.
       ``(iii) The program includes activities to educate youth 
     who are sexually active regarding responsible sexual behavior 
     with respect to both abstinence and the use of contraception.
       ``(iv) The program places substantial emphasis on both 
     abstinence and contraception for the prevention of pregnancy 
     among youth and sexually transmitted infections.
       ``(v) The program provides age-appropriate information and 
     activities.
       ``(vi) The information and activities carried out under the 
     program are provided in the cultural context that is most 
     appropriate for individuals in the particular population 
     group to which they are directed.
       ``(C) Adulthood preparation subjects.--The adulthood 
     preparation subjects described in this subparagraph are the 
     following:
       ``(i) Healthy relationships, such as positive self-esteem 
     and relationship dynamics, friendships, dating, romantic 
     involvement, marriage, and family interactions.
       ``(ii) Adolescent development, such as the development of 
     healthy attitudes and values about

[[Page H1981]]

     adolescent growth and development, body image, racial and 
     ethnic diversity, and other related subjects.
       ``(iii) Financial literacy.
       ``(iv) Parent-child communication.
       ``(v) Educational and career success, such as developing 
     skills for employment preparation, job seeking, independent 
     living, financial self-sufficiency, and workplace 
     productivity.
       ``(vi) Healthy life skills, such as goal-setting, decision 
     making, negotiation, communication and interpersonal skills, 
     and stress management.
       ``(c) Reservations of Funds.--
       ``(1) Grants to implement innovative strategies.--From the 
     amount appropriated under subsection (f) for the fiscal year, 
     the Secretary shall reserve $10,000,000 of such amount for 
     purposes of awarding grants to entities to implement 
     innovative youth pregnancy prevention strategies and target 
     services to high-risk, vulnerable, and culturally under-
     represented youth populations, including youth in foster 
     care, homeless youth, youth with HIV/AIDS, pregnant women who 
     are under 21 years of age and their partners, mothers who are 
     under 21 years of age and their partners, and youth residing 
     in areas with high birth rates for youth. An entity awarded a 
     grant under this paragraph shall agree to participate in a 
     rigorous Federal evaluation of the activities carried out 
     with grant funds.
       ``(2) Other reservations.--From the amount appropriated 
     under subsection (f) for the fiscal year that remains after 
     the application of paragraph (1), the Secretary shall reserve 
     the following amounts:
       ``(A) Grants for indian tribes or tribal organizations.--
     The Secretary shall reserve 5 percent of such remainder for 
     purposes of awarding grants to Indian tribes and tribal 
     organizations in such manner, and subject to such 
     requirements, as the Secretary, in consultation with Indian 
     tribes and tribal organizations, determines appropriate.
       ``(B) Secretarial responsibilities.--
       ``(i) Reservation of funds.--The Secretary shall reserve 10 
     percent of such remainder for expenditures by the Secretary 
     for the activities described in clauses (ii) and (iii).
       ``(ii) Program support.--The Secretary shall provide, 
     directly or through a competitive grant process, research, 
     training and technical assistance, including dissemination of 
     research and information regarding effective and promising 
     practices, providing consultation and resources on a broad 
     array of teen pregnancy prevention strategies, including 
     abstinence and contraception, and developing resources and 
     materials to support the activities of recipients of grants 
     and other State, tribal, and community organizations working 
     to reduce teen pregnancy. In carrying out such functions, the 
     Secretary shall collaborate with a variety of entities that 
     have expertise in the prevention of teen pregnancy, HIV and 
     sexually transmitted infections, healthy relationships, 
     financial literacy, and other topics addressed through the 
     personal responsibility education programs.
       ``(iii) Evaluation.--The Secretary shall evaluate the 
     programs and activities carried out with funds made available 
     through allotments or grants under this section.
       ``(d) Administration.--
       ``(1) In general.--The Secretary shall administer this 
     section through the Assistant Secretary for the 
     Administration for Children and Families within the 
     Department of Health and Human Services.
       ``(2) Application of other provisions of title.--
       ``(A) In general.--Except as provided in subparagraph (B), 
     the other provisions of this title shall not apply to 
     allotments or grants made under this section.
       ``(B) Exceptions.--The following provisions of this title 
     shall apply to allotments and grants made under this section 
     to the same extent and in the same manner as such provisions 
     apply to allotments made under section 502(c):
       ``(i) Section 504(b)(6) (relating to prohibition on 
     payments to excluded individuals and entities).
       ``(ii) Section 504(c) (relating to the use of funds for the 
     purchase of technical assistance).
       ``(iii) Section 504(d) (relating to a limitation on 
     administrative expenditures).
       ``(iv) Section 506 (relating to reports and audits), but 
     only to the extent determined by the Secretary to be 
     appropriate for grants made under this section.
       ``(v) Section 507 (relating to penalties for false 
     statements).
       ``(vi) Section 508 (relating to nondiscrimination).
       ``(e) Definitions.--In this section:
       ``(1) Age-appropriate.--The term `age-appropriate', with 
     respect to the information in pregnancy prevention, means 
     topics, messages, and teaching methods suitable to particular 
     ages or age groups of children and adolescents, based on 
     developing cognitive, emotional, and behavioral capacity 
     typical for the age or age group.
       ``(2) Medically accurate and complete.--The term `medically 
     accurate and complete' means verified or supported by the 
     weight of research conducted in compliance with accepted 
     scientific methods and--
       ``(A) published in peer-reviewed journals, where 
     applicable; or
       ``(B) comprising information that leading professional 
     organizations and agencies with relevant expertise in the 
     field recognize as accurate, objective, and complete.
       ``(3) Indian tribes; tribal organizations.--The terms 
     `Indian tribe' and `Tribal organization' have the meanings 
     given such terms in section 4 of the Indian Health Care 
     Improvement Act (25 U.S.C. 1603)).
       ``(4) Youth.--The term `youth' means an individual who has 
     attained age 10 but has not attained age 20.
       ``(f) Appropriation.--For the purpose of carrying out this 
     section, there is appropriated, out of any money in the 
     Treasury not otherwise appropriated, $75,000,000 for each of 
     fiscal years 2010 through 2014. Amounts appropriated under 
     this subsection shall remain available until expended.''.

     SEC. 2954. RESTORATION OF FUNDING FOR ABSTINENCE EDUCATION.

       Section 510 of the Social Security Act (42 U.S.C. 710) is 
     amended--
       (1) in subsection (a), by striking ``fiscal year 1998 and 
     each subsequent fiscal year'' and inserting ``each of fiscal 
     years 2010 through 2014''; and
       (2) in subsection (d)--
       (A) in the first sentence, by striking ``1998 through 
     2003'' and inserting ``2010 through 2014''; and
       (B) in the second sentence, by inserting ``(except that 
     such appropriation shall be made on the date of enactment of 
     the Patient Protection and Affordable Care Act in the case of 
     fiscal year 2010)'' before the period.

     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.

       (a) Transition Planning.--Section 475(5)(H) of the Social 
     Security Act (42 U.S.C. 675(5)(H)) is amended by inserting 
     ``includes information about the importance of designating 
     another individual to make health care treatment decisions on 
     behalf of the child if the child becomes unable to 
     participate in such decisions and the child does not have, or 
     does not want, a relative who would otherwise be authorized 
     under State law to make such decisions, and provides the 
     child with the option to execute a health care power of 
     attorney, health care proxy, or other similar document 
     recognized under State law,'' after ``employment services,''.
       (b) Independent Living Education.--Section 477(b)(3) of 
     such Act (42 U.S.C. 677(b)(3)) is amended by adding at the 
     end the following:
       ``(K) A certification by the chief executive officer of the 
     State that the State will ensure that an adolescent 
     participating in the program under this section are provided 
     with education about the importance of designating another 
     individual to make health care treatment decisions on behalf 
     of the adolescent if the adolescent becomes unable to 
     participate in such decisions and the adolescent does not 
     have, or does not want, a relative who would otherwise be 
     authorized under State law to make such decisions, whether a 
     health care power of attorney, health care proxy, or other 
     similar document is recognized under State law, and how to 
     execute such a document if the adolescent wants to do so.''.
       (c) Health Oversight and Coordination Plan.--Section 
     422(b)(15)(A) of such Act (42 U.S.C. 622(b)(15)(A)) is 
     amended--
       (1) in clause (v), by striking ``and'' at the end; and
       (2) by adding at the end the following:
       ``(vii) steps to ensure that the components of the 
     transition plan development process required under section 
     475(5)(H) that relate to the health care needs of children 
     aging out of foster care, including the requirements to 
     include options for health insurance, information about a 
     health care power of attorney, health care proxy, or other 
     similar document recognized under State law, and to provide 
     the child with the option to execute such a document, are 
     met; and''.
       (d) Effective Date.--The amendments made by this section 
     take effect on October 1, 2010.

     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.

       (a) Program.--
       (1) In general.--Section 1886 of the Social Security Act 
     (42 U.S.C. 1395ww), as amended by section 4102(a) of the 
     HITECH Act (Public Law 111-5), is amended by adding at the 
     end the following new subsection:
       ``(o) Hospital Value-Based Purchasing Program.--
       ``(1) Establishment.--
       ``(A) In general.--Subject to the succeeding provisions of 
     this subsection, the Secretary shall establish a hospital 
     value-based purchasing program (in this subsection referred 
     to as the `Program') under which value-based incentive 
     payments are made in a fiscal year to hospitals that meet the 
     performance standards under paragraph (3) for the performance 
     period for such fiscal year (as established under paragraph 
     (4)).
       ``(B) Program to begin in fiscal year 2013.--The Program 
     shall apply to payments for discharges occurring on or after 
     October 1, 2012.
       ``(C) Applicability of program to hospitals.--
       ``(i) In general.--For purposes of this subsection, subject 
     to clause (ii), the term `hospital' means a subsection (d) 
     hospital (as defined in subsection (d)(1)(B)).
       ``(ii) Exclusions.--The term `hospital' shall not include, 
     with respect to a fiscal year, a hospital--

       ``(I) that is subject to the payment reduction under 
     subsection (b)(3)(B)(viii)(I) for such fiscal year;
       ``(II) for which, during the performance period for such 
     fiscal year, the Secretary has cited deficiencies that pose 
     immediate jeopardy to the health or safety of patients;
       ``(III) for which there are not a minimum number (as 
     determined by the Secretary) of measures that apply to the 
     hospital for the performance period for such fiscal year; or

[[Page H1982]]

       ``(IV) for which there are not a minimum number (as 
     determined by the Secretary) of cases for the measures that 
     apply to the hospital for the performance period for such 
     fiscal year.

       ``(iii) Independent analysis.--For purposes of determining 
     the minimum numbers under subclauses (III) and (IV) of clause 
     (ii), the Secretary shall have conducted an independent 
     analysis of what numbers are appropriate.
       ``(iv) Exemption.--In the case of a hospital that is paid 
     under section 1814(b)(3), the Secretary may exempt such 
     hospital from the application of this subsection if the State 
     which is paid under such section submits an annual report to 
     the Secretary describing how a similar program in the State 
     for a participating hospital or hospitals achieves or 
     surpasses the measured results in terms of patient health 
     outcomes and cost savings established under this subsection.
       ``(2) Measures.--
       ``(A) In general.--The Secretary shall select measures for 
     purposes of the Program. Such measures shall be selected from 
     the measures specified under subsection (b)(3)(B)(viii).
       ``(B) Requirements.--
       ``(i) For fiscal year 2013.--For value-based incentive 
     payments made with respect to discharges occurring during 
     fiscal year 2013, the Secretary shall ensure the following:

       ``(I) Conditions or procedures.--Measures are selected 
     under subparagraph (A) that cover at least the following 5 
     specific conditions or procedures:

       ``(aa) Acute myocardial infarction (AMI).
       ``(bb) Heart failure.
       ``(cc) Pneumonia.
       ``(dd) Surgeries, as measured by the Surgical Care 
     Improvement Project (formerly referred to as `Surgical 
     Infection Prevention' for discharges occurring before July 
     2006).
       ``(ee) Healthcare-associated infections, as measured by the 
     prevention metrics and targets established in the HHS Action 
     Plan to Prevent Healthcare-Associated Infections (or any 
     successor plan) of the Department of Health and Human 
     Services.

       ``(II) HCAHPS.--Measures selected under subparagraph (A) 
     shall be related to the Hospital Consumer Assessment of 
     Healthcare Providers and Systems survey (HCAHPS).

       ``(ii) Inclusion of efficiency measures.--For value-based 
     incentive payments made with respect to discharges occurring 
     during fiscal year 2014 or a subsequent fiscal year, the 
     Secretary shall ensure that measures selected under 
     subparagraph (A) include efficiency measures, including 
     measures of `Medicare spending per beneficiary'. Such 
     measures shall be adjusted for factors such as age, sex, 
     race, severity of illness, and other factors that the 
     Secretary determines appropriate.
       ``(C) Limitations.--
       ``(i) Time requirement for prior reporting and notice.--The 
     Secretary may not select a measure under subparagraph (A) for 
     use under the Program with respect to a performance period 
     for a fiscal year (as established under paragraph (4)) unless 
     such measure has been specified under subsection 
     (b)(3)(B)(viii) and included on the Hospital Compare Internet 
     website for at least 1 year prior to the beginning of such 
     performance period.
       ``(ii) Measure not applicable unless hospital furnishes 
     services appropriate to the measure.--A measure selected 
     under subparagraph (A) shall not apply to a hospital if such 
     hospital does not furnish services appropriate to such 
     measure.
       ``(D) Replacing measures.--Subclause (VI) of subsection 
     (b)(3)(B)(viii) shall apply to measures selected under 
     subparagraph (A) in the same manner as such subclause applies 
     to measures selected under such subsection.
       ``(3) Performance standards.--
       ``(A) Establishment.--The Secretary shall establish 
     performance standards with respect to measures selected under 
     paragraph (2) for a performance period for a fiscal year (as 
     established under paragraph (4)).
       ``(B) Achievement and improvement.--The performance 
     standards established under subparagraph (A) shall include 
     levels of achievement and improvement.
       ``(C) Timing.--The Secretary shall establish and announce 
     the performance standards under subparagraph (A) not later 
     than 60 days prior to the beginning of the performance period 
     for the fiscal year involved.
       ``(D) Considerations in establishing standards.--In 
     establishing performance standards with respect to measures 
     under this paragraph, the Secretary shall take into account 
     appropriate factors, such as--
       ``(i) practical experience with the measures involved, 
     including whether a significant proportion of hospitals 
     failed to meet the performance standard during previous 
     performance periods;
       ``(ii) historical performance standards;
       ``(iii) improvement rates; and
       ``(iv) the opportunity for continued improvement.
       ``(4) Performance period.--For purposes of the Program, the 
     Secretary shall establish the performance period for a fiscal 
     year. Such performance period shall begin and end prior to 
     the beginning of such fiscal year.
       ``(5) Hospital performance score.--
       ``(A) In general.--Subject to subparagraph (B), the 
     Secretary shall develop a methodology for assessing the total 
     performance of each hospital based on performance standards 
     with respect to the measures selected under paragraph (2) for 
     a performance period (as established under paragraph (4)). 
     Using such methodology, the Secretary shall provide for an 
     assessment (in this subsection referred to as the `hospital 
     performance score') for each hospital for each performance 
     period.
       ``(B) Application.--
       ``(i) Appropriate distribution.--The Secretary shall ensure 
     that the application of the methodology developed under 
     subparagraph (A) results in an appropriate distribution of 
     value-based incentive payments under paragraph (6) among 
     hospitals achieving different levels of hospital performance 
     scores, with hospitals achieving the highest hospital 
     performance scores receiving the largest value-based 
     incentive payments.
       ``(ii) Higher of achievement or improvement.--The 
     methodology developed under subparagraph (A) shall provide 
     that the hospital performance score is determined using the 
     higher of its achievement or improvement score for each 
     measure.
       ``(iii) Weights.--The methodology developed under 
     subparagraph (A) shall provide for the assignment of weights 
     for categories of measures as the Secretary determines 
     appropriate.
       ``(iv) No minimum performance standard.--The Secretary 
     shall not set a minimum performance standard in determining 
     the hospital performance score for any hospital.
       ``(v) Reflection of measures applicable to the hospital.--
     The hospital performance score for a hospital shall reflect 
     the measures that apply to the hospital.
       ``(6) Calculation of value-based incentive payments.--
       ``(A) In general.--In the case of a hospital that the 
     Secretary determines meets (or exceeds) the performance 
     standards under paragraph (3) for the performance period for 
     a fiscal year (as established under paragraph (4)), the 
     Secretary shall increase the base operating DRG payment 
     amount (as defined in paragraph (7)(D)), as determined after 
     application of paragraph (7)(B)(i), for a hospital for each 
     discharge occurring in such fiscal year by the value-based 
     incentive payment amount.
       ``(B) Value-based incentive payment amount.--The value-
     based incentive payment amount for each discharge of a 
     hospital in a fiscal year shall be equal to the product of--
       ``(i) the base operating DRG payment amount (as defined in 
     paragraph (7)(D)) for the discharge for the hospital for such 
     fiscal year; and
       ``(ii) the value-based incentive payment percentage 
     specified under subparagraph (C) for the hospital for such 
     fiscal year.
       ``(C) Value-based incentive payment percentage.--
       ``(i) In general.--The Secretary shall specify a value-
     based incentive payment percentage for a hospital for a 
     fiscal year.
       ``(ii) Requirements.--In specifying the value-based 
     incentive payment percentage for each hospital for a fiscal 
     year under clause (i), the Secretary shall ensure that--

       ``(I) such percentage is based on the hospital performance 
     score of the hospital under paragraph (5); and
       ``(II) the total amount of value-based incentive payments 
     under this paragraph to all hospitals in such fiscal year is 
     equal to the total amount available for value-based incentive 
     payments for such fiscal year under paragraph (7)(A), as 
     estimated by the Secretary.

       ``(7) Funding for value-based incentive payments.--
       ``(A) Amount.--The total amount available for value-based 
     incentive payments under paragraph (6) for all hospitals for 
     a fiscal year shall be equal to the total amount of reduced 
     payments for all hospitals under subparagraph (B) for such 
     fiscal year, as estimated by the Secretary.
       ``(B) Adjustment to payments.--
       ``(i) In general.--The Secretary shall reduce the base 
     operating DRG payment amount (as defined in subparagraph (D)) 
     for a hospital for each discharge in a fiscal year (beginning 
     with fiscal year 2013) by an amount equal to the applicable 
     percent (as defined in subparagraph (C)) of the base 
     operating DRG payment amount for the discharge for the 
     hospital for such fiscal year. The Secretary shall make such 
     reductions for all hospitals in the fiscal year involved, 
     regardless of whether or not the hospital has been determined 
     by the Secretary to have earned a value-based incentive 
     payment under paragraph (6) for such fiscal year.
       ``(ii) No effect on other payments.--Payments described in 
     items (aa) and (bb) of subparagraph (D)(i)(II) for a hospital 
     shall be determined as if this subsection had not been 
     enacted.
       ``(C) Applicable percent defined.--For purposes of 
     subparagraph (B), the term `applicable percent' means--
       ``(i) with respect to fiscal year 2013, 1.0 percent;
       ``(ii) with respect to fiscal year 2014, 1.25 percent;
       ``(iii) with respect to fiscal year 2015, 1.5 percent;
       ``(iv) with respect to fiscal year 2016, 1.75 percent; and
       ``(v) with respect to fiscal year 2017 and succeeding 
     fiscal years, 2 percent.
       ``(D) Base operating drg payment amount defined.--
       ``(i) In general.--Except as provided in clause (ii), in 
     this subsection, the term `base operating DRG payment amount' 
     means, with respect to a hospital for a fiscal year--

       ``(I) the payment amount that would otherwise be made under 
     subsection (d) (determined without regard to subsection (q)) 
     for a discharge if this subsection did not apply; reduced by
       ``(II) any portion of such payment amount that is 
     attributable to--

       ``(aa) payments under paragraphs (5)(A), (5)(B), (5)(F), 
     and (12) of subsection (d); and
       ``(bb) such other payments under subsection (d) determined 
     appropriate by the Secretary.
       ``(ii) Special rules for certain hospitals.--

       ``(I) Sole community hospitals and medicare-dependent, 
     small rural hospitals.--In the case of a medicare-dependent, 
     small rural hospital (with respect to discharges occurring 
     during fiscal year 2012 and 2013) or a sole community 
     hospital, in applying subparagraph (A)(i), the payment amount 
     that would otherwise be made under subsection (d) shall be 
     determined without regard to subparagraphs (I)

[[Page H1983]]

     and (L) of subsection (b)(3) and subparagraphs (D) and (G) of 
     subsection (d)(5).
       ``(II) Hospitals paid under section 1814.--In the case of a 
     hospital that is paid under section 1814(b)(3), the term 
     `base operating DRG payment amount' means the payment amount 
     under such section.

       ``(8) Announcement of net result of adjustments.--Under the 
     Program, the Secretary shall, not later than 60 days prior to 
     the fiscal year involved, inform each hospital of the 
     adjustments to payments to the hospital for discharges 
     occurring in such fiscal year under paragraphs (6) and 
     (7)(B)(i).
       ``(9) No effect in subsequent fiscal years.--The value-
     based incentive payment under paragraph (6) and the payment 
     reduction under paragraph (7)(B)(i) shall each apply only 
     with respect to the fiscal year involved, and the Secretary 
     shall not take into account such value-based incentive 
     payment or payment reduction in making payments to a hospital 
     under this section in a subsequent fiscal year.
       ``(10) Public reporting.--
       ``(A) Hospital specific information.--
       ``(i) In general.--The Secretary shall make information 
     available to the public regarding the performance of 
     individual hospitals under the Program, including--

       ``(I) the performance of the hospital with respect to each 
     measure that applies to the hospital;
       ``(II) the performance of the hospital with respect to each 
     condition or procedure; and
       ``(III) the hospital performance score assessing the total 
     performance of the hospital.

       ``(ii) Opportunity to review and submit corrections.--The 
     Secretary shall ensure that a hospital has the opportunity to 
     review, and submit corrections for, the information to be 
     made public with respect to the hospital under clause (i) 
     prior to such information being made public.
       ``(iii) Website.--Such information shall be posted on the 
     Hospital Compare Internet website in an easily understandable 
     format.
       ``(B) Aggregate information.--The Secretary shall 
     periodically post on the Hospital Compare Internet website 
     aggregate information on the Program, including--
       ``(i) the number of hospitals receiving value-based 
     incentive payments under paragraph (6) and the range and 
     total amount of such value-based incentive payments; and
       ``(ii) the number of hospitals receiving less than the 
     maximum value-based incentive payment available to the 
     hospital for the fiscal year involved and the range and 
     amount of such payments.
       ``(11) Implementation.--
       ``(A) Appeals.--The Secretary shall establish a process by 
     which hospitals may appeal the calculation of a hospital's 
     performance assessment with respect to the performance 
     standards established under paragraph (3)(A) and the hospital 
     performance score under paragraph (5). The Secretary shall 
     ensure that such process provides for resolution of such 
     appeals in a timely manner.
       ``(B) Limitation on review.--Except as provided in 
     subparagraph (A), there shall be no administrative or 
     judicial review under section 1869, section 1878, or 
     otherwise of the following:
       ``(i) The methodology used to determine the amount of the 
     value-based incentive payment under paragraph (6) and the 
     determination of such amount.
       ``(ii) The determination of the amount of funding available 
     for such value-based incentive payments under paragraph 
     (7)(A) and the payment reduction under paragraph (7)(B)(i).
       ``(iii) The establishment of the performance standards 
     under paragraph (3) and the performance period under 
     paragraph (4).
       ``(iv) The measures specified under subsection 
     (b)(3)(B)(viii) and the measures selected under paragraph 
     (2).
       ``(v) The methodology developed under paragraph (5) that is 
     used to calculate hospital performance scores and the 
     calculation of such scores.
       ``(vi) The validation methodology specified in subsection 
     (b)(3)(B)(viii)(XI).
       ``(C) Consultation with small hospitals.--The Secretary 
     shall consult with small rural and urban hospitals on the 
     application of the Program to such hospitals.
       ``(12) Promulgation of regulations.--The Secretary shall 
     promulgate regulations to carry out the Program, including 
     the selection of measures under paragraph (2), the 
     methodology developed under paragraph (5) that is used to 
     calculate hospital performance scores, and the methodology 
     used to determine the amount of value-based incentive 
     payments under paragraph (6).''.
       (2) Amendments for reporting of hospital quality 
     information.--Section 1886(b)(3)(B)(viii) of the Social 
     Security Act (42 U.S.C. 1395ww(b)(3)(B)(viii)) is amended--
       (A) in subclause (II), by adding at the end the following 
     sentence: ``The Secretary may require hospitals to submit 
     data on measures that are not used for the determination of 
     value-based incentive payments under subsection (o).'';
       (B) in subclause (V), by striking ``beginning with fiscal 
     year 2008'' and inserting ``for fiscal years 2008 through 
     2012'';
       (C) in subclause (VII), in the first sentence, by striking 
     ``data submitted'' and inserting ``information regarding 
     measures submitted''; and
       (D) by adding at the end the following new subclauses:
       ``(VIII) Effective for payments beginning with fiscal year 
     2013, with respect to quality measures for outcomes of care, 
     the Secretary shall provide for such risk adjustment as the 
     Secretary determines to be appropriate to maintain incentives 
     for hospitals to treat patients with severe illnesses or 
     conditions.
       ``(IX)(aa) Subject to item (bb), effective for payments 
     beginning with fiscal year 2013, each measure specified by 
     the Secretary under this clause shall be endorsed by the 
     entity with a contract under section 1890(a).
       ``(bb) In the case of a specified area or medical topic 
     determined appropriate by the Secretary for which a feasible 
     and practical measure has not been endorsed by the entity 
     with a contract under section 1890(a), the Secretary may 
     specify a measure that is not so endorsed as long as due 
     consideration is given to measures that have been endorsed or 
     adopted by a consensus organization identified by the 
     Secretary.
       ``(X) To the extent practicable, the Secretary shall, with 
     input from consensus organizations and other stakeholders, 
     take steps to ensure that the measures specified by the 
     Secretary under this clause are coordinated and aligned with 
     quality measures applicable to--
       ``(aa) physicians under section 1848(k); and
       ``(bb) other providers of services and suppliers under this 
     title.
       ``(XI) The Secretary shall establish a process to validate 
     measures specified under this clause as appropriate. Such 
     process shall inclu