Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Obamacare: Examination and Response
An appraisal of the Affordable Care Act and-- with some guesswork-- its tricky politics. Then, a way to capture major new revenue, even paying down existing Medicare debt, without raising premiums or harming quality care. Then, an offering of reforms even more basic, but more incremental. Finally, the briefest of statements about the basic premise.

Text of AFFORDABLE CARE ACT, PL 111-148, March 23, 2010, Renamed HR 3590

Introductory Note. In an effort to make it easier to find specific passages in the Affordable Care Act, this chapter displays its bare-bones Table of Contents. There are over four hundred sections, fairly well labelled and organized. It is comparatively easy to find a relevant section in these printed Contents, but usually much harder to find it in several thousand pages of text. It is suggested the section number should be found here, first . On most search engines it is unnecessary to enter this page, or the table of contents, just enter the section number, and the number of the Act. In case the Act's full URL is needed, it can be found at the top of this page. We suggest the use of cut-and-paste in the URL box of any large-screen computer.

Alternatively, search for the section or subsection number within the text of the entire document on a computer monitor. The entire text can also be found on any search engine by entering "Text Obamacare" , or "H.R. 3590 (111th)" in the search box of the search engine. Most search engines can find what you are looking for if you give them accurate information

Then, with the text of the entire act on your screen, hold down both the control key and the F key,(or on an Apple, the command key and the F key). Enter the section number in the find box which pops up in the upper right corner of the screen. This maneuver should bring up the text of the section. Remember, sometimes the table of contents is repreated in the text of the act, so be sure to go to all of the iterations of the section number. For practice, sections 1251 and 1501 make a good place to begin your exploration.

One Hundred Eleventh Congress of the United States of America


Begun and held at the City of Washington on Tuesday, the fifth day of January, two thousand and ten

An Act Entitled The Patient Protection and Affordable Care Act.

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


(a) SHORT TITLE.—This Act may be cited as the ''Patient Protection and Affordable Care Act''.

(b) TABLE OF CONTENTS.—The table of contents of this Act is as follows:

Sec. 1. Short title; table of contents.


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

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



Sec. 2711. No lifetime or annual limits. Sec. 2712. Prohibition on rescissions. Sec. 2713. Coverage of preventive health services. Sec. 2714. Extension of dependent coverage. Sec. 2715. Development and utilization of uniform explanation of coverage documents and standardized definitions. Sec. 2716. Prohibition of discrimination based on salary. Sec. 2717. Ensuring the quality of care. Sec. 2718.Bringing down the cost of health care coverage. Sec. 2719. Appeals process. Sec. 1002. Health insurance consumer information. Sec. 1003. Ensuring that consumers get value for their dollars. Sec. 1004. Effective dates.

Subtitle B—Immediate Actions to Preserve and Expand Coverage

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

Subtitle C—Quality Health Insurance Coverage for All Americans


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


Sec. 2704. Prohibition of preexisting condition exclusions or other discrimination based on health status. Sec. 2701. Fair health insurance premiums. Sec. 2702. Guaranteed availability of coverage. H. R. 3590—2 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.


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. H. R. 3590—3 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—Improved Access to Medicaid

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

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

Subtitle C—Medicaid and CHIP Enrollment Simplification

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

Subtitle D—Improvements to Medicaid Services

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

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

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

Subtitle F—Medicaid Prescription Drug Coverage

Sec. 2501. Prescription drug rebates. H. R. 3590—4 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—Transforming the Health Care Delivery System


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. H. R. 3590—5 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 Relating to Part C

Sec. 3201. Medicare Advantage payment. Sec. 3202. Benefit protection and simplification. Sec. 3203. Application of coding intensity adjustment during MA payment transition. Sec. 3204. Simplification of annual beneficiary election periods. Sec. 3205. Extension for specialized MA plans for special needs individuals. Sec. 3206. Extension of reasonable cost contracts. Sec. 3207. Technical correction to MA private fee-for-service plans. Sec. 3208. Making senior housing facility demonstration permanent. H. R. 3590—6 Sec. 3209. Authority to deny plan bids. Sec. 3210. Development of new standards for certain Medigap plans.

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

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

Subtitle E—Ensuring Medicare Sustainability

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

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

Subtitle G—Protecting and Improving Guaranteed Medicare Benefits

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


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. H. R. 3590—7 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—Purpose and Definitions

Sec. 5001. Purpose. Sec. 5002. Definitions.
Subtitle B—Innovations in the Health Care Workforce

Sec. 5101. National health care workforce commission. Sec. 5102. State health care workforce development grants. Sec. 5103. Health care workforce assessment. Subtitle C—Increasing the Supply of the Health Care Workforce

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

Sec. 5301. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship. Sec. 5302. Training opportunities for direct care workers. Sec. 5303. Training in general, pediatric, and public health dentistry. Sec. 5304. Alternative dental health care providers demonstration project. Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric education. Sec. 5306. Mental and behavioral health education and training grants. Sec. 5307. Cultural competency, prevention, and public health and individuals with disabilities training. Sec. 5308. Advanced nursing education grants. Sec. 5309. Nurse education, practice, and retention grants. Sec. 5310. Loan repayment and scholarship program. Sec. 5311. Nurse faculty loan program. H. R. 3590—8 Sec. 5312. Authorization of appropriations for parts B through D of title VIII. Sec. 5313. Grants to promote the community health workforce. Sec. 5314. Fellowship training in public health. Sec. 5315. United States Public Health Sciences Track.
Subtitle E—Supporting the Existing Health Care Workforce

Sec. 5401. Centers of excellence. Sec. 5402. Health care professionals training for diversity. Sec. 5403. Interdisciplinary, community-based linkages. Sec. 5404. Workforce diversity grants. Sec. 5405. Primary care extension program.
Subtitle F—Strengthening Primary Care and Other Workforce Improvements

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

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

Subtitle H—General Provisions

Sec. 5701. Reports.

Subtitle A—Physician Ownership and Other Transparency

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

Subtitle B—Nursing Home Transparency and Improvement


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. H. R. 3590—9


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—Biologics Price Competition and Innovation

Sec. 7001. Short title. H. R. 3590—10 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.


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

Subtitle A—Revenue Offset Provisions

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

Subtitle B—Other Provisions

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


Subtitle A—Provisions Relating to Title I

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

Subtitle B—Provisions Relating to Title II


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. H. R. 3590—11 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. Secxxxxxxx. 10310. Repeal of physician payment update. Sec. 10311. Revisions to extension of ambulance add-ons. Sec. 10312. Certain payment rules for long-term care hospital services and moratorium on the establishment of certain hospitals and facilities. Sec. 10313. Revisions to the extension for the rural community hospital demonstration program. Sec. 10314. Adjustment to low-volume hospital provision. Sec. 10315. Revisions to home health care provisions. Sec. 10316. Medicare DSH. Sec. 10317. Revisions to extension of section 508 hospital provisions. Sec. 10318. Revisions to transitional extra benefits under Medicare Advantage. Sec. 10319. Revisions to market basket adjustments. Sec. 10320. Expansion of the scope of, and additional improvements to, the Independent Medicare Advisory Board. Sec. 10321. Revision to community health teams. Sec. 10322. Quality reporting for psychiatric hospitals. Sec. 10323. Medicare coverage for individuals exposed to environmental health hazards. Sec. 10324. Protections for frontier States. Sec. 10325. Revision to skilled nursing facility prospective payment system. Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare providers. Sec. 10327. Improvements to the physician quality reporting system. Sec. 10328. Improvement in part D medication therapy management (MTM) programs. Sec. 10329. Developing methodology to assess health plan value. Sec. 10330. Modernizing computer and data systems of the Centers for Medicare & Medicaid services to support improvements in care delivery. Sec. 10331. Public reporting of performance information. Sec. 10332. Availability of medicare data for performance measurement. Sec. 10333. Community-based collaborative care networks. Sec. 10334. Minority health. Sec. 10335. Technical correction to the hospital value-based purchasing program. Sec. 10336. GAO study and report on Medicare beneficiary access to high-quality dialysis services.
Subtitle D—Provisions Relating to Title IV

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

Subtitle E—Provisions Relating to Title V

Sec. 10501. Amendments to the Public Health Service Act, the Social Security Act, and title V of this Act. H. R. 3590—12 Sec. 10502. Infrastructure to Expand Access to Care. Sec. 10503. Community Health Centers and the National Health Service Corps Fund. Sec. 10504. Demonstration project to provide access to affordable care.

Subtitle F—Provisions Relating to Title VI

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

Subtitle G—Provisions Relating to Title VIII

Sec. 10801. Provisions relating to title VIII.

Subtitle H—Provisions Relating to Title IX

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


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