Health Hippo: The Patient Protection and Affordable Care Act (Obamacare)
Entitled The Patient Protection and Affordable Care Act. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled
(a) SHORT TITLE. This Act may be cited as the Patient Protection and Affordable Care Act.
TITLE I–QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
- Sec. 1001. Amendments to the Public Health Service Act.
- No Lifetime or Annual Limits
- Prohibition on Recessions
- Coverage of Preventative Health Services
- Extension of Dependant Coverage
- Uniform Coverage Explanations
- Prohibition of Discrimination Based on Salary
- Ensuring Quality Care
- Bringing Down the Cost of Care
- 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
- Sec. 1201. Amendment to the Public Health Service Act.
- Prohibition of Preexisting Condition Exclusions
- Fair Health Insurance Premiums
- Guaranteed Availability of Coverage
- Guaranteed Renewability of Coverage
- Prohibiting Discrimination Based on Health Status
- Non-Discrimination in Health Care
- Comprehensive Covereage
- Prohibition on Excessive Waiting Periods
- 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
- Sec. 1301. Qualified health plan defined.
- Sec. 1302. Essential health benefits requirements
- Sec. 1303. Special rules.
- Sec. 1304. Related definitions.
- Sec. 1311. Affordable choices of health benefit plans.
- Sec. 1312. Consumer choice.
- Sec. 1313. Financial integrity.
- 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.
- 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.
- Sec. 1341. Transitional reinsurance program for individual and small group markets in each State.
- Sec. 1342. Establishment of risk corridors for plans in individual and small group markets.
- Sec. 1343. Risk adjustment.
Subtitle E–Affordable Coverage Choices for All Americans
- 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.
- 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.
- Sec. 1421. Credit for employee health insurance expenses of small businesses.
Subtitle F–Shared Responsibility for Health Care
- Sec. 1501. Requirement to maintain minimum essential coverage.
- Sec. 1502. Reporting of health insurance coverage.
- 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.
Subtitle A–Immediate Improvements in Health Care Coverage for All Americans
TITLE II–ROLE OF PUBLIC PROGRAMS
- 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.
Subtitle A–Improved Access to Medicaid
TITLE III–IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE
- 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.
- 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.
- 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
- Sec. 3101. Increase in the physician payment update.
- Sec. 3102. Extension of the work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee schedule.
- Sec. 3103. Extension of exceptions process for Medicare therapy caps.
- Sec. 3104. Extension of payment for technical component of certain physician pathology services.
- Sec. 3105. Extension of ambulance add-ons.
- Sec. 3106. Extension of certain payment rules for long-term care hospital services and of moratorium on the establishment of certain hospitals and facilities.
- Sec. 3107. Extension of physician fee schedule mental health add-on.
- Sec. 3108. Permitting physician assistants to order post-Hospital extended care services.
- Sec. 3109. Exemption of certain pharmacies from accreditation requirements.
- Sec. 3110. Part B special enrollment period for disabled TRICARE beneficiaries.
- Sec. 3111. Payment for bone density tests.
- Sec. 3112. Revision to the Medicare Improvement Fund.
- Sec. 3113. Treatment of certain complex diagnostic laboratory tests.
- Sec. 3114. Improved access for certified nurse-midwife services.
- 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.
- 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 Related 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 MAPD 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 womens health.
- Sec. 3510. Patient navigator program.
- Sec. 3511. Authorization of appropriations.
- Sec. 3602. No cuts in guaranteed benefits.
Subtitle A—Transforming the Health Care Delivery System
TITLE IV–PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH
- 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.
Subtitle A – Modernizing Disease Prevention and Public Health Systems
TITLE V–HEALTH CARE WORKFORCE
- Sec. 5001. Purpose.
- Sec. 5002. Definitions.
Subtitle B–Innovations in the Health Care Workforce
- Sec. 5101. National health care workforce commission.
- Sec. 5102. State health care workforce development grants.
- Sec. 5103. Health care workforce assessment.
Subtitle C–Increasing the Supply of the Health Care Workforce
- Sec. 5201. Federally supported student loan funds.
- Sec. 5202. Nursing student loan program.
- Sec. 5203. Health care workforce loan repayment programs.
- Sec. 5204. Public health workforce recruitment and retention programs.
- Sec. 5205. Allied health workforce recruitment and retention programs.
- Sec. 5206. Grants for State and local programs.
- Sec. 5207. Funding for National Health Service Corps.
- Sec. 5208. Nurse-managed health clinics.
- Sec. 5209. Elimination of cap on commissioned corps.
- Sec. 5210. Establishing a Ready Reserve Corps.
Subtitle D–Enhancing Health Care Workforce Education and Training
- Sec. 5301. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship.
- Sec. 5302. Training opportunities for direct care workers.
- Sec. 5303. Training in general, pediatric, and public health dentistry.
- Sec. 5304. Alternative dental health care providers demonstration project.
- Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric education.
- Sec. 5306. Mental and behavioral health education and training grants.
- Sec. 5307. Cultural competency, prevention, and public health and individuals with disabilities training.
- Sec. 5308. Advanced nursing education grants.
- Sec. 5309. Nurse education, practice, and retention grants.
- Sec. 5310. Loan repayment and scholarship program.
- Sec. 5311. Nurse faculty loan program.
- Sec. 5312. Authorization of appropriations for parts B through D of title VIII.
- Sec. 5313. Grants to promote the community health workforce.
- Sec. 5314. Fellowship training in public health.
- Sec. 5315. United States Public Health Sciences Track.
Subtitle E–Supporting the Existing Health Care Workforce
- Sec. 5401. Centers of excellence.
- Sec. 5402. Health care professionals training for diversity.
- Sec. 5403. Interdisciplinary, community-based linkages.
- Sec. 5404. Workforce diversity
- 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.
- Sec. 5701. Reports.
TITLE VI–TRANSPARENCY AND PROGRAM INTEGRITY
- 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
- 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.
- 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.
- 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.
Subtitle A – Physician Ownership
TITLE VII–IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES
- Sec. 7001. Short Title.
- Sec. 7002. Approval pathway for biosimilar biological products.
- Sec. 7003. Savings.
- Sec. 7101. Expanded participation in 340B program.
- Sec. 7102. Improvements to 340B program integrity.
- Sec. 7103. GAO study to make recommendations on improving the 340B program.
TITLE VIII–CLASS ACT [Repealed]
- Sec. 8001. Short title.
- Sec. 8002. Establishment of national voluntary insurance program for purchasing community living assistance services and support.
TITLE IX–REVENUE 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.
Subtitle A – Revenue Offset Provisions
TITLE X–STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
- Sec. 10101. Amendments to subtitle A.
- No Lifetime Or Annual Limits
- Provision Of Additional Information
- Prohibition On Discrimination In Favor Of Highly Compensated Individuals
- Bringing Down The Cost Of Health Care Coverage
- Appeals Process
- Patient Protections
- Sec. 10102. Amendments to subtitle B.
- Connecting To Affordable Coverage
- Sec. 10103. Amendments to subtitle C.
- Coverage For Individuals Participating In Approved Clinical Trials
- Annual Report On Self-Insured Plans
- Study Of Large Group Market
- Sec. 10104. Amendments to subtitle D.
- State Opt-out of Abortion Coverage
- Multi-State Plans
- Sec. 10105. Amendments to subtitle E.
- Study Of Geographic Variation In Application Of FPL
- Sec. 10106. Amendments to subtitle F.
- Effects On The National Economy And Interstate Commerce
- Tax Penalties
- Sec. 10107. Amendments to subtitle G.
- GAO Study Regarding The Rate Of Denial Of Coverage And Enrollment
- Small Business Procurement
- Sec. 10108. Free choice vouchers.
- Sec. 10109. Development of standards for financial and administrative transactions.
Subtitle B — Provisions Relating to Title II
- 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.
- Sec. 10211. Definitions.
- Sec. 10212. Establishment of pregnancy assistance fund.
- Sec. 10213. Permissible uses of Fund.
- Sec. 10214. Appropriations.
- 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.
- Research, health screenings, and initiatives
- Sec. 10402. Amendments to subtitle B.
- Preventive physical examination
- Sec. 10403. Amendments to subtitle C.
- Urban, rural and frontier grants
- Sec. 10404. Amendments to subtitle D.
- Urban, rural and frontier grants
- Sec. 10405. Amendments to subtitle E.
- Striking section 4401
- 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.
- Interagency Task Force To Assess And Improve Access To Health Care In The State Of Alaska
- Demonstration Grants For Family Nurse Practitioner Training Programs
- National Diabetes Prevention Program
- Grants To Providers Of Medically Underserved Populations Or Other Special Populations
- Rural Physician Training Grants
- Preventive Medicine And Public Health Training Grant Program
- 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. CLASS program.
Subtitle H — Provisions Relating to Title IX
- Sec. 10901. Modifications to excise tax on high cost employer-sponsored health coverage.
- Sec. 10902. Inflation adjustment of limitation on health flexible spending arrangements under cafeteria plans.
- Sec. 10903. Modification of limitation on charges by charitable hospitals.
- Sec. 10904. Modification of annual fee on medical device manufacturers and importers.
- Sec. 10905. Modification of annual fee on health insurance providers.
- Sec. 10906. Modifications to additional hospital insurance tax on high-income taxpayers.
- Sec. 10907. Excise tax on indoor tanning services in lieu of elective cosmetic medical procedures.
- Sec. 10908. Exclusion for assistance provided to participants in State student loan repayment programs for certain health professionals.
- Sec. 10909. Expansion of adoption credit and adoption assistance programs.
Subtitle A — Provisions Relating to Title I
- An Overview of 60 Contracts That Contributed to the Development and Operation of the Federal Marketplace (OIG 2014) CMS relied, and continues to rely extensively, on contractors to operate the Federal Marketplace. The troubled launch of the Federal Marketplace on October 1, 2013, raised serious concerns about the Department’s management and oversight of the project.
- Challenges for Those Claiming Social Security Benefits Early and New Health Coverage Options (GAO 2014) GAO estimates that nearly a million early claimers did not have government or employer-sponsored health insurance before 2014. Of these, 14 percent may be newly eligible for Medicaid in 2014 due to expansion in 25 states and the District of Columbia and 58 percent could be eligible for tax credits that reduce the premiums for coverage purchased through the new health insurance exchanges. However, GAO estimates that 10 percent of these early claimers had incomes below the federal poverty level but lived in states that did not expand Medicaid and had incomes too low for federal exchange tax credits.
- Health Insurance: Seven States’ Actions to Establish Exchanges under the Patient Protection and Affordable Care Act (GAO 2013) Despite some challenges, the seven selected states in GAO’s review reported they have taken actions to create exchanges, which they expect will be ready for enrollment by the deadline of October 1, 2013.
- Medicaid Expansion:States’ Implementation of the Patient Protection and Affordable Care Act (GAO 2012) In terms of states’ views on the fiscal implications of the Medicaid expansion on states’ budget planning, our survey found that across fiscal years 2012 to 2020, the majority of state budget directors believe that three aspects of Medicaid expansion will contribute to costs: (1) the administration for managing Medicaid enrollment, (2) the acquisition or modification of information technology systems to support Medicaid, and (3) enrolling previously eligible but not enrolled individuals in Medicaid.
- Patient Protection and Affordable Care Act: IRS Managing Implementation Risks, but Its Approach Could Be Refined (GAO 2012) GAO did not find evidence that a risk plan was used to track and mitigate risks when coordinating with partner agencies, such as the Department of Health and Human Services. Without a system for tracking shared risks, IRS is more likely to overlook risks or duplicate efforts.
- Causes of Action under the Patient Protection and Affordable Care Act (GAO 2013) We do not believe that the implementation of the provisions identified in section 3512 of PPACA, including the development, recognition, or implementation of related guidelines and standards, is likely to give rise to new causes of action or claims. Ultimately, the courts will determine, in the context of specific litigation, whether the PPACA provisions identified in section 3512 give rise to new causes of action or claims.
- Patient Protection and Affordable Care Act: HHS’s Process for Awarding and Overseeing Exchange and Rate Review Grants to States (GAO 2013) The grant award process consists of a series of steps during which the agency solicits, screens, and evaluates grant applications, and then makes funding awards. Once HHS deems that applications meet program eligibility criteria, applications go through various reviews, including a review by independent experts and HHS officials. On the basis of these reviews, HHS determines whether states’ proposed activities are allowable, and if so, whether the associated requests for grant funding are reasonable.
- Patient Protection and Affordable Care Act: Status of CMS Efforts to Establish Federally Facilitated Health Insurance Exchanges (GAO 2013) CMS recently completed risk assessments and plans for mitigating risks associated with the data hub, and is also working on strategies to address state preparedness contingencies. Whether these efforts will assure the timely and smooth implementation of the exchanges by October 2013 cannot yet be determined.
- Patient Protection and Affordable Care Act: Status of Federal and State Efforts to Establish Health Insurance Exchanges for Small Businesses (GAO 2013) Of the 33 states with FF-SHOPs and 34 states with FFEs, 15 states are expected to assist CMS to carry out certain functions of the exchange. However, the activities that CMS plans to complete in these 15 exchanges have evolved, and CMS activities in these and other exchanges may continue to change.
- Patient Protection and Affordable Care Act: IRS Should Expand Its Strategic Approach to Implementation (GAO 2011) The report (1) describes IRS’s PPACA responsibilities and effective dates and (2) assesses the extent to which IRS, in planning PPACA implementation, is following leading practices in four areas–developing an overall management structure (including goals and performance measures), estimating and tracking costs, assuring compliance with the new law while minimizing burden, and managing risk.
- Patient Protection and Affordable Care Act: Effect on Long-Term Federal Budget Outlook Largely Depends on Whether Cost Containment Sustained (GAO 2013) Federal health care spending is expected to continue growing faster than the economy. In the near term, this is driven by increasing enrollment in federal health care programs due to the aging of the population and expanded eligibility.
- Office of Personnel Management; Patient Protection and Affordable Care Act; Establishment of the Multi-State Plan Program for the Affordable Insurance Exchanges (GAO 2013) Through contracts with OPM, health insurance issuers will offer at least two multi-state plans (MSPs) on each of the Affordable Insurance Exchanges. One of the issuers must be non-profit.
- Patient Protection and Affordable Care Act: Estimates of the Effect on the Prevalence of Employer-Sponsored Health Coverage (GAO 2012) The five studies GAO reviewed that used microsimulation models to estimate the effects of the Patient Protection and Affordable Care Act (PPACA) on employer-sponsored coverage generally predicted little change in prevalence in the near term, while results of employer surveys varied more widely.
- Health Care: Survey on States’ Implementation of the Patient Protection and Affordable Care Act (GAO 2012) This e-supplement presents the questions and aggregate results from a Web survey of state budget directors on the fiscal implications of Medicaid expansion implementation on state budget planning.
- Health Care Coverage: Job Lock and the Potential Impact of the Patient Protection and Affordable Care Act (GAO 2011) Empirical research generally indicates that certain types of workers are more likely to remain in jobs they would otherwise leave in order to keep their employer-sponsored health care coverage.
- Patient Protection and Affordable Care Act: Status of CMS Efforts to Establish Federally Facilitated Health Care Exchanges and the Federal Data Services Hub (GAO 2013) n brief, GAO’s work found that CMS will operate a health insurance exchange in the 34 states that will not operate a state-based exchange for 2014. While CMS will retain full authority over each of these 34 FFEs, it planned to allow 15 of these states to assist it in carrying out certain FFE functions. To support consumer-eligibility determinations, CMS is developing a data hub that will provide electronic, near real-time access to federal data, as well as provide access to state and third-party data sources needed to verify consumer-eligibility information.
- HHS Research Awards: Use of Recovery Act and Patient Protection and Affordable Care Act Funds for Comparative Effectiveness Research (GAO 2011) Comparative effectiveness research (CER) is research comparing different interventions and strategies to prevent, diagnose, treat, and monitor health conditions.
- Patient Protection and Affordable Care Act: Enrollment and Spending in the Early Retiree Reinsurance and Pre-existing Condition Insurance Plan Programs (GAO 2013) The Center for Consumer Information and Insurance Oversight (CCIIO) discontinued enrollment in the Early Retiree Reinsurance Program (ERRP) in early 2011 and stopped most program reimbursements the following year to keep spending within the $5 billion ERRP appropriation. Enrollment and spending for the Pre-existing Condition Insurance Plan (PCIP) program have grown substantially.
- Patient Protection and Affordable Care Act: Establishment of Consumer Operated and Oriented Plan (CO-OP) Program (GAO 2011) The CO-OP program, which provides loans to foster the creation of consumer governed, private, nonprofit health insurance issuers to offer qualified health plans in the Affordable Insurance Exchanges (Exchanges). Starting in 2014, individuals and small businesses will be able to purchase private health insurance through state-based competitive marketplaces called Exchanges. Insurance companies will compete for new business on the basis of price and value and consumers will have a choice of health plans to fit their needs.
- Health Insurance Issuers Implementing Medical Loss Ratio (MLR) Requirements Under the Patient Protection and Affordable Care Act (GAO 2010) HHS complied with applicable requirements in promulgating the rule, which requires health insurance issuers in the group or individual market, including grandfathered health plans, to provide an annual rebate to enrollees, if the issuer’s
MLR fails to meet minimum requirements–generally, 85 percent in the large group market and 80 percent in the small group or individual market.
- Patient Protection and Affordable Care Act: Contracts Awarded and Consultants Retained by Federal Departments and Agencies to Assist in Implementing the Act (GAO 2011) This report provides information on contracts awarded by the Department of Health and Human Services (HHS) and other federal departments and agencies related to authority provided by PPACA, including information on firms retained to facilitate contracting and consultants retained by HHS and other federal departments and agencies to assist in PPACA implementation.
- Medicaid Outpatient Prescription Drugs: Estimated Changes to Federal Upper Limits Using the Formula under the Patient Protection and Affordable Care Act (GAO 2010) Spending on prescription drugs in Medicaid–the joint federal-state program that finances medical services for certain low-income adults and children–totaled $15.2 billion in fiscal year 2008. State Medicaid programs do not directly purchase prescription drugs; instead, they reimburse retail pharmacies for covered prescription drugs dispensed to Medicaid beneficiaries.
- Health Care Advisory Committees (GAO 2010) The Comptroller General of the United States is mandated in law to make appointments to certain health care-related commissions, advisory boards and governing boards. The requirements for these entities vary with regard to purpose, size, composition, reporting relationship and terms of appointment.
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