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PUBLIC LAW 111–148—MAR. 23, 2010 124 STAT. 119
Public Law 111–
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]
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 I NSURANCE COMPETITION THROUGH HEALTH B ENEFIT 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.
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 I MPROVE 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.
PUBLIC LAW 111–148—MAR. 23, 2010 124 STAT. 123
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.
PUBLIC LAW 111–148—MAR. 23, 2010 124 STAT. 125
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.
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.
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.
PUBLIC LAW 111–148—MAR. 23, 2010 124 STAT. 129
Sec. 10212. Establishment of pregnancy assistance fund. Sec. 10213. Permissible uses of Fund. Sec. 10214. Appropriations.
PART III—INDIAN HEALTH CARE I MPROVEMENT
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.
PUBLIC LAW 111–148—MAR. 23, 2010 124 STAT. 131
‘‘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.
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.
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,
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.
PUBLIC LAW 111–148—MAR. 23, 2010 124 STAT. 135
‘‘(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.
PUBLIC LAW 111–148—MAR. 23, 2010 124 STAT. 137
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
groups established under section 1886(d)(4) of the Social Security
Act.
‘‘(d) DEFINITIONS.—The Secretary, in consultation with the
National Association of Insurance Commissions, shall establish uni-
form definitions for the activities reported under subsection (a).
‘‘SEC. 2719. APPEALS PROCESS.
‘‘A group health plan and a health insurance issuer offering
group or individual health insurance coverage shall implement an
effective appeals process for appeals of coverage determinations
and claims, under which the plan or issuer shall, at a minimum—
‘‘(1) have in effect an internal claims appeal process;
42 USC
300gg–19.
Public information. Web posting.
dkrause on GSDDPC29PROD with PUBLIC LAWS^ VerDate Nov 24 2008^ 16:48 Jun 11, 2010^ Jkt 089139^ PO 00000^ Frm 00019^ Fmt 6580^ Sfmt 6581^ E:\PUBLAW\PUBL148.111^ GPO1^ PsN: PUBL
124 STAT. 138 PUBLIC LAW 111–148—MAR. 23, 2010
‘‘(2) provide notice to enrollees, in a culturally and linguis-
tically appropriate manner, of available internal and external
appeals processes, and the availability of any applicable office
of health insurance consumer assistance or ombudsman estab-
lished under section 2793 to assist such enrollees with the
appeals processes;
‘‘(3) allow an enrollee to review their file, to present evi-
dence and testimony as part of the appeals process, and to
receive continued coverage pending the outcome of the appeals
process; and
‘‘(4) provide an external review process for such plans and
issuers that, at a minimum, includes the consumer protections
set forth in the Uniform External Review Model Act promul-
gated by the National Association of Insurance Commissioners
and is binding on such plans.’’.
SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION.
Part C of title XXVII of the Public Health Service Act (
U.S.C. 300gg–91 et seq.) is amended by adding at the end the
following:
‘‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.
‘‘(a) IN GENERAL.—The Secretary shall award grants to States
to enable such States (or the Exchanges operating in such States)
to establish, expand, or provide support for—
‘‘(1) offices of health insurance consumer assistance; or
‘‘(2) health insurance ombudsman programs.
‘‘(b) ELIGIBILITY.—
‘‘(1) IN GENERAL.—To be eligible to receive a grant, a State
shall designate an independent office of health insurance con-
sumer assistance, or an ombudsman, that, directly or in
coordination with State health insurance regulators and con-
sumer assistance organizations, receives and responds to
inquiries and complaints concerning health insurance coverage
with respect to Federal health insurance requirements and
under State law.
‘‘(2) CRITERIA.—A State that receives a grant under this
section shall comply with criteria established by the Secretary
for carrying out activities under such grant.
‘‘(c) DUTIES.—The office of health insurance consumer assist-
ance or health insurance ombudsman shall—
‘‘(1) assist with the filing of complaints and appeals,
including filing appeals with the internal appeal or grievance
process of the group health plan or health insurance issuer
involved and providing information about the external appeal
process;
‘‘(2) collect, track, and quantify problems and inquiries
encountered by consumers;
‘‘(3) educate consumers on their rights and responsibilities
with respect to group health plans and health insurance cov-
erage;
‘‘(4) assist consumers with enrollment in a group health
plan or health insurance coverage by providing information,
referral, and assistance; and
‘‘(5) resolve problems with obtaining premium tax credits
under section 36B of the Internal Revenue Code of 1986.
Grants.
42 USC
300gg–93.
Notification.
