<p>124 STAT. 119 PUBLIC LAW 111–148—MAR. 23, 2010 Public Law 111–148 111th Congress An Act Entitled The Patient Protection and Affordable Care Act. Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, SECTION 1. SHORT TITLE; TABLE OF CONTENTS. (a) SHORT TITLE.—This Act may be cited as the ‘‘Patient Protec- tion 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 pre- existing condition. Sec. 1102. Reinsurance for early retirees. Sec. 1103. Immediate information that allows consumers to identify affordable cov- erage 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 discrimina- tion based on health status. ‘‘Sec. 2701. Fair health insurance premiums. ‘‘Sec. 2702. Guaranteed availability of coverage. 42 USC 18001 note. Patient Protection and Affordable Care Act. Mar. 23, 2010 [H.R. 3590] VerDate Nov 24 2008 10:54 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00001 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 120 PUBLIC LAW 111–148—MAR. 23, 2010 ‘‘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 indi- viduals 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 mar- kets in each State. Sec. 1342. Establishment of risk corridors for plans in individual and small group markets. Sec. 1343. Risk adjustment. Subtitle E—Affordable Coverage Choices for All Americans PART I—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS SUBPART A—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS Sec. 1401. Refundable tax credit providing premium assistance for coverage under a qualified health plan. Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans. SUBPART B—ELIGIBILITY DETERMINATIONS Sec. 1411. Procedures for determining eligibility for Exchange participation, pre- mium 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. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00002 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 121 PUBLIC LAW 111–148—MAR. 23, 2010 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 cafe- teria 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 in- come. Sec. 2003. Requirement to offer premium assistance for employer-sponsored insur- ance. 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. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00003 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 122 PUBLIC LAW 111–148—MAR. 23, 2010 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 condi- tions. Sec. 2704. Demonstration project to evaluate integrated care around a hospitaliza- tion. 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. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00004 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 123 PUBLIC LAW 111–148—MAR. 23, 2010 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 prac- tice 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 pa- thology 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 facili- ties. 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 di- agnostic 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 inte- gration models in certain rural counties. Sec. 3127. MedPAC study on adequacy of Medicare payments for health care pro- viders 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) pay- ments. Sec. 3134. Misvalued codes under the physician fee schedule. Sec. 3135. Modification of equipment utilization factor for advanced imaging serv- ices. 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 transi- tion. 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. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00005 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 124 PUBLIC LAW 111–148—MAR. 23, 2010 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 bench- mark premium. Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals under pre- scription drug plans and MA–PD plans. Sec. 3304. Special rule for widows and widowers regarding eligibility for low-in- come assistance. Sec. 3305. Improved information for subsidy eligible individuals reassigned to pre- scription 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 produc- tivity improvements into market basket updates that do not already in- corporate 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 as- sistance. 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. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00006 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 125 PUBLIC LAW 111–148—MAR. 23, 2010 Sec. 4103. Medicare coverage of annual wellness visit providing a personalized pre- vention plan. Sec. 4104. Removal of barriers to preventive services in Medicare. Sec. 4105. Evidence-based coverage of preventive services in Medicare. Sec. 4106. Improving access to preventive services for eligible adults in Medicaid. Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant women in Medicaid. Sec. 4108. Incentives for prevention of chronic diseases in medicaid. Subtitle C—Creating Healthier Communities Sec. 4201. Community transformation grants. Sec. 4202. Healthy aging, living well; evaluation of community-based prevention and wellness programs for Medicare beneficiaries. Sec. 4203. Removing barriers and improving access to wellness for individuals with disabilities. Sec. 4204. Immunizations. Sec. 4205. Nutrition labeling of standard menu items at chain restaurants. Sec. 4206. Demonstration project concerning individualized wellness plan. Sec. 4207. Reasonable break time for nursing mothers. Subtitle D—Support for Prevention and Public Health Innovation Sec. 4301. Research on optimizing the delivery of public health services. Sec. 4302. Understanding health disparities: data collection and analysis. Sec. 4303. CDC and employer-based wellness programs. Sec. 4304. Epidemiology-Laboratory Capacity Grants. Sec. 4305. Advancing research and treatment for pain care management. Sec. 4306. Funding for Childhood Obesity Demonstration Project. Subtitle E—Miscellaneous Provisions Sec. 4401. Sense of the Senate concerning CBO scoring. Sec. 4402. Effectiveness of Federal health and wellness initiatives. TITLE V—HEALTH CARE WORKFORCE Subtitle A—Purpose and Definitions Sec. 5001. Purpose. Sec. 5002. Definitions. Subtitle B—Innovations in the Health Care Workforce Sec. 5101. National health care workforce commission. Sec. 5102. State health care workforce development grants. Sec. 5103. Health care workforce assessment. Subtitle C—Increasing the Supply of the Health Care Workforce Sec. 5201. Federally supported student loan funds. Sec. 5202. Nursing student loan program. Sec. 5203. Health care workforce loan repayment programs. Sec. 5204. Public health workforce recruitment and retention programs. Sec. 5205. Allied health workforce recruitment and retention programs. Sec. 5206. Grants for State and local programs. Sec. 5207. Funding for National Health Service Corps. Sec. 5208. Nurse-managed health clinics. Sec. 5209. Elimination of cap on commissioned corps. Sec. 5210. Establishing a Ready Reserve Corps. Subtitle D—Enhancing Health Care Workforce Education and Training Sec. 5301. Training in family medicine, general internal medicine, general pediat- rics, 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. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00007 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 126 PUBLIC LAW 111–148—MAR. 23, 2010 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 Chil- dren 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 invest- ment 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 in- formation. Sec. 6102. Accountability requirements for skilled nursing facilities and nursing fa- cilities. 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 informa- tion technology in nursing homes. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00008 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 127 PUBLIC LAW 111–148—MAR. 23, 2010 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 Protec- tion 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 pro- grams at high risk of waste and abuse. Sec. 6407. Face to face encounter with patient required before physicians may cer- tify 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, con- trol, and management affiliations. Sec. 6503. Billing agents, clearinghouses, or other alternate payees required to reg- ister under Medicaid. Sec. 6504. Requirement to report expanded set of data elements under MMIS to de- tect 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. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00009 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 128 PUBLIC LAW 111–148—MAR. 23, 2010 Sec. 7002. Approval pathway for biosimilar biological products. Sec. 7003. Savings. Subtitle B—More Affordable Medicines for Children and Underserved Communities Sec. 7101. Expanded participation in 340B program. Sec. 7102. Improvements to 340B program integrity. Sec. 7103. GAO study to make recommendations on improving the 340B program. TITLE VIII—CLASS ACT Sec. 8001. Short title of title. Sec. 8002. Establishment of national voluntary insurance program for purchasing community living assistance services and support. TITLE IX—REVENUE PROVISIONS Subtitle A—Revenue Offset Provisions Sec. 9001. Excise tax on high cost employer-sponsored health coverage. Sec. 9002. Inclusion of cost of employer-sponsored health coverage on W–2. Sec. 9003. Distributions for medicine qualified only if for prescribed drug or insulin. Sec. 9004. Increase in additional tax on distributions from HSAs and Archer MSAs not used for qualified medical expenses. Sec. 9005. Limitation on health flexible spending arrangements under cafeteria plans. Sec. 9006. Expansion of information reporting requirements. Sec. 9007. Additional requirements for charitable hospitals. Sec. 9008. Imposition of annual fee on branded prescription pharmaceutical manu- facturers and importers. Sec. 9009. Imposition of annual fee on medical device manufacturers and import- ers. 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 sub- sidy. 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 trans- actions. 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. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00010 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 129 PUBLIC LAW 111–148—MAR. 23, 2010 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 morato- rium on the establishment of certain hospitals and facilities. Sec. 10313. Revisions to the extension for the rural community hospital demonstra- tion 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 Inde- pendent 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 haz- ards. 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 pro- viders. Sec. 10327. Improvements to the physician quality reporting system. Sec. 10328. Improvement in part D medication therapy management (MTM) pro- grams. 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. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00011 Fmt 6580 Sfmt 6582 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 130 PUBLIC LAW 111–148—MAR. 23, 2010 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 cer- tain 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 med- ical 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 cov- erage. Sec. 10902. Inflation adjustment of limitation on health flexible spending arrange- ments under cafeteria plans. Sec. 10903. Modification of limitation on charges by charitable hospitals. Sec. 10904. Modification of annual fee on medical device manufacturers and im- porters. Sec. 10905. Modification of annual fee on health insurance providers. Sec. 10906. Modifications to additional hospital insurance tax on high-income tax- payers. Sec. 10907. Excise tax on indoor tanning services in lieu of elective cosmetic med- ical procedures. Sec. 10908. Exclusion for assistance provided to participants in State student loan repayment programs for certain health professionals. Sec. 10909. Expansion of adoption credit and adoption assistance programs. TITLE I—QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS Subtitle A—Immediate Improvements in Health Care Coverage for All Americans SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT. Part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended— (1) by striking the part heading and inserting the following: ‘‘PART A—INDIVIDUAL AND GROUP MARKET REFORMS’’; (2) by redesignating sections 2704 through 2707 as sections 2725 through 2728, respectively; (3) by redesignating sections 2711 through 2713 as sections 2731 through 2733, respectively; (4) by redesignating sections 2721 through 2723 as sections 2735 through 2737, respectively; and (5) by inserting after section 2702, the following: 42 USC 300gg–21— 300gg–23. 42 USC 300gg–11— 300gg–13, 300gg–9. 42 USC 300gg–4— 300gg–7, 300gg–25— 300gg–28. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00012 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 131 PUBLIC LAW 111–148—MAR. 23, 2010 ‘‘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 con- strued 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 per- mitted under Federal or State law. ‘‘SEC. 2712. PROHIBITION ON RESCISSIONS. ‘‘A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage involved, except that this section shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 2702(c) or 2742(b). ‘‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES. ‘‘(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for— ‘‘(1) evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force; ‘‘(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and ‘‘(3) with respect to infants, children, and adolescents, evi- dence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. ‘‘(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph. ‘‘(5) for the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall 42 USC 300gg–13. 42 USC 300gg–12. 42 USC 300gg–11. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00013 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 132 PUBLIC LAW 111–148—MAR. 23, 2010 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 cov- erage 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 EXPLA- NATION 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 lim- ited English proficiency, and other qualified individuals. ‘‘(b) REQUIREMENTS.—The standards for the summary of bene- fits and coverage developed under subsection (a) shall provide for the following: Deadline. 42 USC 300gg–15. 42 USC 300gg–14. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00014 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 133 PUBLIC LAW 111–148—MAR. 23, 2010 ‘‘(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 sum- mary 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 sum- mary 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 cov- erage; ‘‘(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 devel- oped 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 Deadline. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00015 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 134 PUBLIC LAW 111–148—MAR. 23, 2010 to any enrollment restriction, a summary of benefits and cov- erage 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 insur- ance coverage within the United States; or ‘‘(B) in the case of a self-insured group health plan, the plan sponsor or designated administrator of the plan (as such terms are defined in section 3(16) of the Employee Retirement Income Security Act of 1974). ‘‘(4) NOTICE OF MODIFICATIONS.—If a group health plan or health insurance issuer makes any material modification in any of the terms of the plan or coverage involved (as defined for purposes of section 102 of the Employee Retirement Income Security Act of 1974) that is not reflected in the most recently provided summary of benefits and coverage, the plan or issuer shall provide notice of such modification to enrollees not later than 60 days prior to the date on which such modification will become effective. ‘‘(e) PREEMPTION.—The standards developed under subsection (a) shall preempt any related State standards that require a sum- mary 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, pro- vide for the development of standards for the definitions of terms used in health insurance coverage, including the insur- ance-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 pro- vider, non-preferred provider, out-of-network co-payments, UCR (usual, customary and reasonable) fees, excluded services, griev- ance and appeals, and such other terms as the Secretary deter- mines are important to define so that consumers may compare health insurance coverage and understand the terms of their coverage. Regulations. Fine. Deadline. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00016 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 135 PUBLIC LAW 111–148—MAR. 23, 2010 ‘‘(3) MEDICAL TERMS.—The medical terms described in this paragraph are hospitalization, hospital outpatient care, emer- gency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency med- ical 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 pro- hibit 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 com- pensation. ‘‘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 implementa- tion of activities such as quality reporting, effective case management, care coordination, chronic disease manage- ment, 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 serv- ices under the plan or coverage; ‘‘(B) implement activities to prevent hospital readmis- sions through a comprehensive program for hospital dis- charge that includes patient-centered education and coun- seling, comprehensive discharge planning, and post dis- charge reinforcement by an appropriate health care profes- sional; ‘‘(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 activi- ties. ‘‘(2) REPORTING REQUIREMENTS.— 42 USC 300gg–17. 42 USC 300gg–16. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00017 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 136 PUBLIC LAW 111–148—MAR. 23, 2010 ‘‘(A) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insur- ance 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 subpara- graph (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 require- ments under paragraph (1), the Secretary may develop and impose appropriate penalties for non-compliance with such requirements. ‘‘(E) EXCEPTIONS.—In developing the reporting require- ments 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 assess- ments or offers ongoing face-to-face, telephonic or web-based inter- vention 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 Reports. 42 USC 300gg–18. Deadline. VerDate Nov 24 2008 06:35 Apr 30, 2010 Jkt 089139 PO 00148 Frm 00018 Fmt 6580 Sfmt 6581 E:\PUBLAW\PUBL148.111 APPS06 PsN: PUBL148 dk ra us e on G SD DP C2 9P RO D wi th P UB LI C LA W S 124 STAT. 137 PUBLIC LAW 111–148—MAR. 23, 2010 respect to each plan year, submit to the Secretary a report con- cerning 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 avail- able 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 PAY- MENTS.—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 indi- vidual market in such State. ‘‘(2) CONSIDERATION IN SETTING PERCENTAGES.—In deter- mining 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 gro</p>