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Latest Healthcare Bill Review working short title as shown in the bill

“Affordable Health Care for America Act” as of 10/29/09 1,990 pages Submitted by Mr. DINGELL, Mr. RANGEL, Mr. WAXMAN, Mr. GEORGE MILLER of California, Mr. STARK, Mr. PALLONE, and Mr. ANDREWS

The following is from my personal review of the document. It includes specific page numbers for reference and generally follows the sequence of the bill. I have included a table of timelines at the end and a list of acts, bills, and laws that are changed as a result of this legislation. Much is based on the IRS code and thus, penalties have the full weight of the IRS for prosecution. Some parts of the legislation are set to take affect immediately upon signature and it uses January 1, 2010 as that date. The Act/bill is much more onerous and pervasive than we hear on TV. It invades every part of our lives and will be vastly more complex, all-encompassing, and costly that most can imagine. This bill leaves out many of the dollar figures that other bills showed and a CBO review has yet to be made available to review the actual costs. The previous 1200 page bill was projected to cost at least a trillion dollars by the CBO and it concluded that it could not assess a large percentage of the costs due to lack of data. This bill is far more complex, so it would be reasonable to assume a conservative figure of at least two trillion dollars. Ongoing costs cannot be easily projected, but are likely to be enormous. Annual healthcare costs are currently about $2 trillion dollars. Although the term is not specifically used in this Act, many of the new leaders are really Czars, chosen by the President, with supreme authority, and accountable only to the President. This ultimate power, without recourse, is probably the scariest part of the Act. In fact, some have said this whole Act is not constitutional because it confers powers to the government that it does not have by virtue of the constitution. Throughout the bill are various carrots (money to change behaviors) and sticks (severe monetary penalties, including jail in some instances, and $10,000 a day fines for failure to provide some reports on time). Reporting of detail transactions to various agencies and committees will be extremely burdensome for providers and insurers. The largest immediate effect is the increase in Medicaid coverages. Much of the first year and into the second year will consist of various agencies, committees, and consultants pouring over information in great detail to come up with reports and recommendations to be acted on during the third year and beyond. It is obvious that the purpose of this Act is to solve a problem that is yet to be defined. The following summary and detail observations are taken straight from the Act without political bias. Samples I couldn’t resist adding. The following is a definition on page 12 – “100 C (16) INDIAN.—The term ‘‘Indian’’ has the meaning given such term in section 4 of the Indian Health Care Improvement Act (24 U.S.C. 1603).” Also, “power-driven wheelchair’’ is now called ‘‘complex rehabilitative power-driven wheelchair.” TFS

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Summary Many provisions and enactment dates in the Act are set to January 1, 2010 to prevent changes being by the marketplace in anticipation of the new rules. Even though many dates will have to be revised, the marketplace is ‘on hold’ for changes as of that date. All insurance plans, and coverages, and costs will be determined by the Czars, including exclusions and exceptions. Reviews will be made annually and appropriate changes promulgated to the affected parties. Premiums are geography based and credits for low income are also ‘modified adjusted gross income’ based. The greatest changes in increased coverage beginning Jan 1, 2010 are for Medicaid. Medicaid changes effective Jan 1, 2010 include coverage for - family planning (States may opt out) (for people who applied as far back as Jan 1, 2007), smoking cessation drugs, in-home nursing services, translation and interpretation services, medical home pilot (equipment), coverage for free-standing birthing centers (states may opt out), free vaccines for children, cover podiatrist services, therapeutic foster care, Optometrists, optional coverage for low-income HIV individuals, nonemergency transportation to medically necessary services. States can opt out of disregarding income for individuals with extremely high prescription drug costs.  Eliminate funding limits for territories (Like Guam, Samoa, Puerto Rico, Mariana islands). Another category of covered individuals under Medicaid is called the “non-traditional individual” “an individual determined by the Commissioner to be a non-traditional Medicaid eligible individual.” There is no further explanation of what that means.  Medicaid coverage is now increased to include, under the “Compacts of Free Association between the Government of the United States and the Governments of the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau.”  CHIP will be repealed in 2014.  Under “financing” Medicaid will define upper limits paid to physicians based on June 2009 rates and to pharmacists based on Dec 31, 2006 rates. Also drug manufacturers will be required to give discounts and make rebates for existing drugs based on a formula.  Medicaid and CHIP will not cover ‘undocumented aliens’.  States are required to change their legislation to conform to the Act by the “first day of the first calendar quarter beginning after the close of the first regular session of the State legislature that begins after the date of the enactment of this Act.” Individuals that do not have coverage for any part of a year will be taxed according to a formula, based on ‘modified adjusted gross income’ (gross income increased by ‘any amount excluded from gross income under section 911, and any amount of interest received or accrued by the taxpayer during the taxable year which is exempt from tax). This is not to exceed the national average premium (even though premiums are geography based). There are exemptions for religious reasons and non-resident aliens, and military. Health savings accounts are amended (in the IRS tax code) to include only prescription drugs or insulin. Since individual income information is required by agencies and employers, insurers and exchanges must submit and/or receive the information it will be difficult to hide anything and unless security is a hundred times better than today, one can anticipate leakage of personal income information. All insurers and employers must submit bids to be qualified to be acceptable as a ‘QBHP’ Qualified Health Benefit Plan acceptable. A monumental increase in the amount of reporting will be immediately TFS

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imposed on all insurers, employers, individuals, hospitals, clinics, community centers, and care givers. New codes for providers, medical devices, clinical codes, and administrative codes, will all be developed to specifically identify individuals, providers, devices and any other level of detail as deemed ‘necessary’ for reporting purposes. All insurers are required to annually submit the name, address, and tax id of each enrollee. Employers are required to report to the Health Choices Commissioner, the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable, the name, address, and tax id of each full time employee, along with other employer information, each year. Employers will pay an excise tax of 8% if they do not provide health insurance coverage, with smaller percentages for small employers (less than $750,000 wages paid). Providers (hospitals, doctors, etc.) can be excluded from any plan, or all plans for reasons determined by a committee. Penalties and sanctions to any party, for any infractions, including reporting, can include monetary damages and incarceration. Enforcement is mostly left up to States and Insurance Exchanges. Hospital expansion will be limited and no beds, operation rooms, or procedure rooms can be added after Jan 1, 2010. All facilities must apply for any increases in beds, operating rooms, or procedure rooms. Increases will be reviewed for 150% population increases. It does not address the current ‘Certificate of Need’ process. Health Insurance Exchanges will be the primary tool for determining eligibility, premiums, etc. Exchanges are intended to be regional and states must bid to create an exchange. States can work together for multi-state exchanges for economic reasons. Public Option - There is a Public Health Insurance Option available on the day of signing, but contrary to the current TV talk it means little, as the whole Act is government controlled health care. Members of Congress are allowed to use the Public Option, but are not required to do so. Current insurance coverage in effect as of signing date is called “grandfathered.” Individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of year one. Also, insurer cannot change coverage, benefits from day before this act is signed. All new coverage as of the date of signing the bill must be purchased through an exchange participating plan. Self insured employer’s coverages will be studied and a report is to be sent back with recommendations within 18 months of signing. The vast majority of agencies, commissions, panels, and committees are appointed directly by the president or the president’s direct appointees. Some appointees are to be reviewed by senate committees, but most are not. Many are limited to serving two consecutive terms. Some committees are not paid a salary, but paid with per diem and expenses. A few are specifically excluded from being designated as government employees. The Ombusdman is directed to ‘in a linguistically appropriate manner’ receive complaints and provide assistance. The Commissioner is required to conduct vast outreach to educate employers, providers, and individuals as to the benefits of Health Exchanges.


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Racial, ethnic, women’s, poor, underprivileged, and language challenged are all specifically and generously represented and benefits abound for these groups. The Act comes up with new words for discrimination, “Without regard for personal characteristics” to describe all of the groups above. It will immediately (January 1, 2010) set up a $15 billion dollar temporary high-risk pool and temporary reinsurance program for retirees and their families. Claims will be submitted directly to HHS. Even though this is immediate, there is no mechanism in place to actually produce claims and the beneficiaries have not been specifically defined. Preventative services are to be added to new plans. Lifetime benefit limits and pre-existing conditions are to be eliminated from insurance plan coverage. Cost sharing co-pays and out-of-pocket cost sharing are not to exceed $5,000 per individual and $10,000 per family. Abortion coverage is not required, nor is it specifically excluded. If it is paid for now under federal programs, it will continue to be paid for. Dental (oral) coverage will not be immediately part of the plan, but will be studied with a report and recommendations to be completed within one year. Other parts of the Act call for including dental provisions as part of the process, so it is likely that the final recommendation will include dental coverage. Medical devices will now be taxed and deductions for money paid to foreign persons or companies that is now deductable due to treaties with the US are no longer allowed. Foreign taxes will still be deductible. Medicare and Medicaid changes are numerous and too many to summarize here. Basically, most payments to facilities, including home health, skilled nursing facilities, etc. and physicians will be reviewed and lowered or eliminated. Most take affect beginning in 2011. in addition, hospitals with physician ownership (physician owner or investor means a physician (or an immediate family member of such physician) with a direct or an indirect ownership or investment interest in the hospital) will have to report annually the amount of ownership and the referrals by each physician owner/investor. Fines of $10,000 per day are levied for failure to report on time. Hospitals will have to hire translators and interpreters. No reduction in costs is planned - costs for ten years are not to exceed costs that were expected under the current system. Drug manufacturers will be required to provide rebates and/or discounts (up to 50% of agreed to price) to the “secretary” for purchased drugs (by dosage and strength) by Medicare and Medicaid enrollees sold after Dec 31, 2009. Terms and conditions are TBD. Penalties of $10,000 a day are imposed for untimely reporting. The government is now allowed to negotiate drug prices with manufacturers. Secretary of Health and Human Services shall enter into a contract with the Institute of Medicine of the National Academy of Science to conduct a comprehensive empirical study, and provide recommendations as appropriate, on the accuracy of the geographic adjustment factors, including level and distribution of workers, recruitment and retention, patient access and more. Recommendations are due to Congress within one year. Congress will recommend Medicare payment adjustments for facilities and physicians, based on the recommendations. Insidious provisions regarding the IOM recommendations above include, “Debate in the Senate on a joint resolution, and all debatable motions and appeals in connection therewith, shall be limited to not more than 20 hours.”  House Committees are limited to “50 legislative days” from receipt for resolution or it will be “discharged from further consideration”. Within that 50 days, If a committee fails to TFS

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   

report such joint resolution at the close of the 15th legislative day after its receipt by the Senate, such committee shall be automatically discharged from further consideration.” “A vote on final passage of such joint resolution shall be taken in the Senate on or before the close of the second legislative day after such joint resolution is reported by the committee or committees.” “Points of Order” against a resolution “shall not be in order.” “A motion in the Senate to proceed to the consideration of a joint resolution shall be privileged and not debatable.” If “the Senate then receives the companion measure from the House of Representatives, the companion measure shall not be debatable.” “BUDGETARY TREATMENT - For the purposes of consideration of a joint resolution, the Chairmen of the House of Representatives and Senate Committees on the Budget shall exclude from the evaluation of the budgetary effects of the measure, any such effects that are directly attributable to disapproving a Medicare final implementation plan of the Secretary submitted under subsection (a).”

Advanced directives (includes a living will, comfort care order, or a durable power of attorney for health care) must be offered by all qualifying insurance plans, including “information related to other planning tools” These plans cannot specifically promote suicide or euthanasia. Although funding is not specifically written to be paid by state funds, States will be greatly affected by; state insurance exchanges, community coverage programs, reinsurance plan programs, ‘transparent marketplace programs (for selling insurance), statewide automated enrollments for public assistance, strategies to insure low-income childless adults, purchasing collaboratives. More people will be eligible for Medicaid and Medicaid increased overages effective Jan 1, 2010. Community mental health and elderly programs will be set up within states. Thousands of jobs will be added to the local government payrolls. Transaction codes, clinical descriptions, and harmonizing data and descriptions are all due by 2014, three years after the EHR (electronic Health Record) is supposed to be in use. New regulations for nutrition labeling for chain restaurants (more than 20 locations) and vending machines will be put in place on January 1, 2011. Specific programs will be set up for healthy living, with obesity programs, shots for children, and other ‘lifestyle’ wellness programs. The last 350 pages of the 1990 pages are devoted to Indian healthcare. It almost reads like a cut and paste of the rest of the Act, except it is for the Indian population. The interesting part of this section is that it also calls for physical construction projects.


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Detail Observations 

Secretary of health and human services shall establish a temporary national high-risk pool program to provide health benefits to eligible individuals during the period beginning on January 1, 2010, and ending on the date on which the Health Insurance Exchange is established. P16-26 

Appropriate $5,000,000,000 (billion) on top of premiums to pay claims against, and administrative costs of the high-risk pool under this section in excess of the premiums collected with respect to eligible individuals enrolled in the high-risk pool. Such funds shall be available without fiscal year limitation, and more will be set aside if it runs out of funds.

This program can reduce benefits, increase premiums, or establish waiting lists.

HHS and States will conduct annual reviews of premiums of insurers, who must submit justifications before increases are put into effect. P31

Eliminate lifetime limits for payouts by insurers. P50-53

Appropriate $10 billion to set up, within 90 days after the date of the enactment of this Act. Health and Human Services shall establish a temporary reinsurance program to provide reimbursement to assist participating employment-based plans with the cost of providing health benefits to retirees and to eligible spouses, surviving spouses and dependents of such retirees. All claims are submitted to HHS. P56-62

Funding is undefined, but it sets up state insurance exchanges, community coverage programs, Reinsurance plan programs, ‘transparent marketplace programs (for selling insurance), statewide automated enrollments are required for public assistance, strategies to insure low-income childless adults, purchasing collaboratives. P7276

Real-time standard administrative and financial transactions to be defined, developed, adopted, and enforced, with all data elements harmonized among all standards and to be completed within 2 years of signing this Act. Six months after those 2 years, it has another 5 years to complete and must comply with the Hitech Act. P77-89 

Companion guides for eligibility adopted not later than October 1, 2011 and effective beginning January 1, 2013. The companion guide, for the remainder of the transactions adopted October 1, 2012, effective beginning not later than January 1, 2014.

Current insurance coverage in effect as of signing is called “grandfathered”. Individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1. Also, insurer cannot change coverage, benefits from day before this act is signed. P91 

All new insurance as of day of signing must be purchased by “Exchange participating health plan” P94

HHS to study self insured employers and report back within 18 months with recommendations. P100

Current employer plans can continue medical management for clinical appropriateness.

No cost sharing for preventative care P107

Cost sharing not to exceed $5,000 individual and $10,000 family. P107

Abortion coverage is not required (but not prohibited either) Also, abortions, currently paid for will continue to be paid for with public funds p109-111

Dental coverage will be studied and may be added to basic coverage within one year. P111

No insurance plans can have exclusions for “pre-existing conditions”. P97

Set up non-elected “Health Benefits Advisory Committee” (Including members with “racial and ethnic disparities expertise” and at least 1 physician) 28 people chaired by Surgeon General - 9 non federal employees appointed by the president, 9 appointed by the Comptroller of US, 8 federal employees appointed by


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the president – all to serve 3 year terms. The purpose is to develop benefit standards, including each state standards. P112 - 115 

Advanced directives (includes a living will, comfort care order, or a durable power of attorney for health care) must be offered by all qualifying insurance plans, including “information related to other planning tools” These plans cannot promote suicide or euthanasia. P129

Established, as an independent agency in the executive branch of the Government, a Health Choices Administration, headed by a commissioner appointed by the president. P131-139 

Duties are to set standards, audit insurance plans, set and collect penalties, create standard definitions of insurance and medical terms, achieve uniform standards

The Commissioner (appointed by the president) will appoint a Health Choices Administration Ombudsman, who “shall in a linguistically appropriate manner” receive complaints and provide assistance.

Whistleblowers, who are treated badly by employers, can take the employer to court under the Consumer Product Safety Act. P144

Collective bargaining is not changed P144

Hawaii prepaid health plan is treated as qualified as long as it meets the same conditions as all other qualified plans. P145-146

Anti-Trust laws are re-applied to insurance companies. They had been exempt since 1945. P151-153

Health Insurance Exchanges start on day 1, but some employers and employees will be phased in over three years. All insurance plans and coverages will be dictated by the Act. The fifty plus pages are devoted in detail to the setting up and running of the exchanges. P155-211

Establishment and administration of a public health insurance option as an exchange-qualified health benefits plan effective day 1. P211-225 

Physicians can be designated as preferred, those who accept government payment as pay-in-full, and participating non-preferred, those who accept payment plus a formula not to exceed an additional 15% over government payment.

Credits toward premiums are available to low income and other individuals as deemed eligible by the exchanges. Illegals are not allowed to receive credits. All determinations use the IRS and Social Security system and social security numbers will be used for verification and other accounting. Credits are also available for territories, including Puerto Rico. P225-267

Commissioner shall conduct a study that examines the application of income disregards for purposes of this subtitle. Not later than the first day of Y2, the Commissioner shall submit to Congress a report on such study and shall include such recommendations. P249-250

Shared Responsibility for individuals is based on the IRS code. P268-296 

Employer responsibilities include providing the Health Choices Commissioner, the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable, with such information as the Commissioner may require to ascertain compliance with the requirements, including the name, address, and tax id of each full time employee.

Individual tax for not having insurance - at any time during the taxable year, there is hereby imposed a tax equal to 2.5 percent of the excess of ‘‘the taxpayer’s modified adjusted gross income (income increased by any amount excluded from gross income under section 911, and any amount of interest received or accrued by the taxpayer during the taxable year which is exempt from tax) for the taxable year, over ‘‘the amount of gross income specified in section 6012(a)(1) P296-336

Surcharge on high income individuals, modified adjusted gross income 1 million dollars, is 5.4% on top of all other fees and taxes. P336-339


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Excise tax on medical devices is 2.5% of the first taxable sale price sold. Leases are treated as sales. P339366 

No deductions are allowed for payments to foreign persons or companies based on treaties with the United States.

Medicare P366-1010 

Payments to skilled nursing facilities will be adjusted based on studying 2006 RUG data and adjusting for inclusion in 2010 payments.

Other payments for therapies and other services will be adjusted for 2011 payments.

Physician assistants can now order post-hospital extended services as physicians do.

Physician payments will change based on yet-to-be determined reports. It should occur after Jan 1, 2011, but before Jan 1, 2013

Certain locations, such as California MSA (Metropolitan Statistical Area) will have fee schedules changed.

“power-driven wheelchair’’ are now called ‘‘complex rehabilitative power-driven wheelchair” recognized by the Secretary as classified within group 3 or higher. After 13 months of rent, supplier must turn title over to renter as owner.

Costs for imaging services are to be adjusted to reflect 75% usage and reduced for single images of multiple body parts.

After 27 months continuous rent of oxygen equipment, supplier must supply for free the equipment for the useful life of the equipment.

Increased reporting for physician owned or invested in hospitals and clinics.

Hospitals may not add beds, operating rooms, or procedure rooms as of the date of enactment of the bill and must file for an exception to add any of these.

“Over the initial 10-year period in which the plan is implemented, the aggregate level of net expenditures under the Medicare program under title XVIII of the Social Security Act will not exceed the aggregate level of such expenditures that would have occurred if the plan were not implemented.” P509-510

Physician pay for quality performance will be based on HEDIS effectiveness of carequality measures; CAHPS quality measures; and such other measures of clinical quality as the Secretary may specify. P524

Senior housing may not be increased in a select area before jan 1, 2013 and selected areas may not be increased. P548-549

Medicare part D coverage is increased by $500. Beginning in 2011 the gap is decreased annually until 2019, when benefits should be totally covered. P551-559

Drug manufacturers required to provide rebates to “the secretary’ beginning Jan 1, 2010. If a manufacturer does not agree to rebates, its drugs will not be eligible for payment under Medicare Part D.

No mid-year formulary changes are permitted.

Provides accreditation or training for providers of interpretation, translation, or language services in medicare.

Extended 36 months of coverage of immuno-suppressive drugs for kidney transplant patients. P637

Advanced care planning is voluntary, but with specific details of what is to be discussed. P641-644

Pilot programs for mental health, primary care, and home healthcare. P653-702

Increase nursing home and skilled nursing home reporting requirements. P762-873


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Establish national priorities for quality improvement. Funded with $2 million for years 2010 through 2014. P873-888

Create reports on financial relationships between manufacturers and distributors of covered drugs, devices, biologicals, or medical supplies under Medicare, Medicaid, or CHIP and physicians and other health care entities and between physicians and other health care entities, including payments and other transfers of value, investments, stocks, etc. P889-912

Public reporting of healthcare associated infections P913-918

Redistribution of unused residency positions. P918-945

Increase funding to fight waste, fraud, and abuse. $100 million per year, beginning 2011. Increase penalties for waste, fraud, and abuse, includes $50,000 for each false statement. P945

Medicare claims submission reduced to 1 year from 3 years. P980

Require Medicare payments to be electronic. P999

Establish Office of Inspector General for Health Choices Administration, appointed by the president. Has authority to authority to conduct, supervise, and coordinate audits, evaluations, and investigations of the programs and operations of the Health Choices Administration. P1000-1003

Medicaid and Chip P1010-1158 

Under exchanged referred individuals - Non-traditional individuals - Pursuant to such memorandum the State shall accept without further determination the enrollment under this title of an individual determined by the Commissioner to be a non-traditional Medicaid eligible individual. The State shall not do any redeterminations of eligibility for such individuals. (not sure of this, could it be illegal aliens?) P1022

Repeal of CHIP Section 2104(a) of the Social Security Act is amended by inserting at the end the following: ‘‘No funds shall be appropriated or authorized to be appropriated under this section for fiscal year 2014 and subsequent years.’’

Reduce DSH (Disproportionate Share Hospitals) Allotments by 25% to states each year 2017 through 2019.

Medicaid cover smoking cessation drugs, family planning services, in-home nursing services as of Jan 1, 2010

Adjust primary care physician rates based on rates as of June 16, 2009 rates

Adjust upper limits of amounts paid to pharmacists, based on rates as of December 31, 2006. P1092-1095

Preserves Medicaid coverage for youths upon release from public institutions. P1067

Extension of delay in managed care organization provider tax elimination. P1117

Medicaid will not pay for healthcare acquired conditions. P1118-1119

Providers required to establish a compliance program to reduce waste, fraud, and abuse. P1120

Overpayments discovered after Jan 1, 2010 can be recovered and the 60 day rule is eliminated. P1121-1122

Billing agents, clearinghouses, or other alternate payees required to register under Medicaid. P1126

Social Security Act is amended to “eliminate funding limitations.” P1139

Medicaid and CHIP - Nothing in this title shall change current prohibitions against Federal Medicaid and CHIP payments under titles XIX and XXI of the Social Security Act on behalf of individuals who are not lawfully present in the United States.

Medicaid will continue to use ‘Medicaid brokers’.

Public Health and workforce development P1209-

Nursing p1246-


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Quality and Surveillance P1322

 

Prevention and Wellness

Establish a Task Force on Clinical Preventive Services whose purpose is to review the scientific evidence related to the benefits, effectiveness, appropriateness, and costs of clinical preventive services. P1291-1297

Composed of 30 members appointed by the Secretary and will determine whether subsidies and rewards meet the Task Force’s standards. Terms are 6 years, but limit to two terms.

Members may delegate authority for conducting reviews and making recommendations to sub-groups.

It will convene a clinical prevention stakeholders board composed of representatives of appropriate public and private entities with an interest in clinical preventive services to advise the Task Force on developing, updating, publishing, and disseminating evidence-based recommendations.

Establish a Task Force on Community Preventive Services to review the scientific evidence related to the benefits, effectiveness, appropriateness, and costs of community preventive services for the purpose of developing, updating, publishing, and disseminating evidence-based recommendations on the use of such services P1298-1308 

Composed of 30 members appointed by the secretary with term of 6 years limit to two terms. It includes state and local health officers

It will convene a community prevention stakeholders board composed of representatives of appropriate public and private entities with an interest in community preventive services to advise the Task Force. This board will include the Office of Minority Health, the National Center on Minority Health, and Health Disparities, and the Office on Women’s Health.

Establish Comparative Effectiveness Research Commission. P738-761 

Membership is the Director of the Agency for Healthcare Research and Quality or their designee; the Chief Medical Officer of the Centers for Medicare & Medicaid Services or their designee; the Director of the National Institutes of Health or their designee; and 16 additional members who shall represent broad constituencies of stakeholders including clinicians, patients, researchers, third-party payers, and consumers of Federal and State beneficiary programs.

Comptroller General will appoint members. Eight will serve for 4 years and eight will serve for 3 years. Pay will be per diem and expenses, except the committee can determine compensation for the director.

The Chairman shall serve as an ex officio member of the National Advisory Council of the Agency for Health Care Research and Quality.

Will be funded by a Comparative Effectiveness Research Trust Fund (CERTF).

Quality and surveillance implementation of best practices in the delivery of health care P1322

Establish the Center for Quality Improvement role is to identify existing best practices, develop new best practices, evaluate best practices, and implement best practices

Includes use of electronic health records

Establish, within the Department an Assistant Secretary for Health Information to be appointed by the Secretary. 

Role is to ensure the collection, collation, reporting, and publishing of information (including full and complete statistics) on key health indicators regarding the Nation’s health and the performance of the Nation’s health care.

Ensure, with respect to data on race and ethnicity, consistency with the 1997 Office of Management and Budget Standards for Maintaining, Collecting and Presenting Federal Data on Race and Ethnicity (or any


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successor standards); and in consultation with the Director of the Office of Minority Health, and the Director of the Office of Civil Rights of the Department, develop standards for the collection of data on health and health care with respect to primary language.  

Initially funded by $300,000,000 for each of fiscal years 2011 through 2015.

Prohibits Group Purchasing Arrangements - A (rural, substance abuse, receiving title IX funds, title V funds, children’s hospital not eligible for Medicare, free standing cancer hospital, or critical access) hospital shall not obtain covered outpatient drugs through a group purchasing organization or other group purchasing arrangement. P1340-1346 

Secretary shall provide for improvements in compliance by manufacturers with the requirements of this section in order to prevent overcharges and other violations of the discounted pricing. It will establish and publish, through regulation or policy “appropriate ceiling prices” that can be charged. And implement civil monetary penalties up to $100,000 per occurrence.

Develop and implement procedures for billing Medicaid and to impose penalties.

Implement a single standard identification system for all covered entities for purchasing drugs and sales prices, up to Secretary published ceilings, with penalties up to $5,000 for each violation and exclusion from participating.

Administrator of the Health Resources and Services Administration, shall establish a nurse-managed health centers consisting of awarding grants to establish nurse-managed comprehensive primary care and wellness services. P1361-1367 

Eliminate Community based mental health services and provide federally qualified behavioral health centers. Regulations to include what services can be performed. P1367-1369 

Includes grants to provide education and a ‘pipeline’ to nursing. P1372 - 1381

Includes grants for mental health practioner training. p1382-1385

Grants, grants, and more grants – pages 1385 to 1501 

Grants for increased tele-health. P589, 1385-1391

Grants for studying use of interpreters for Medicare patients. P617-619

Grants for “no child left unimmunized.” P1391-1397

Extension of the “Wise Woman” program with grants of $400,000. P1397-1398

Grants for “Healthy Teens” to prevent teen pregnancy. P1398-1402

More grants for Autism, chronic illness, postpartum depression, promote positive health behaviors, infant mortality, secondary school health sciences training, community based collaborative care, community based overweight and obesity prevention, reducing student to nurse ratios, medical/legal relationships, Emergency care programs, assisting veterans to become EMTs, Dental emergency responders, pain care management and many others costing Billions of dollars. P1402-1501

Set up a national medical device registry to analyze postmarket safety. Develop a unique identifier for each device to be used in electronic health records and for reporting purposes. P1501-1510

Set up standard nutrition labeling for standard menu items at chain restaurants (more than 20 locations) and food vending machines P1510-1519

Protect consumer access to generic drugs (and biosimilars) – eliminate drug makers deals with generic manufactures and make generic drugs available sooner. Penalties filed under the Federal Trade Commission Act will make these deals illegal. P1519-1562

Create an Advisory Committee to be known as the ‘CLASS Independence Advisory Council’. The Chair and fifteen people, all appointed by the President. Terms are three years with two terms max. P1562-1606


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Also appointed a Board of Trustees of the CLASS Independence Fund. Four people nominated by the president for a term of four years, whose job is to Hold the CLASS Independence Fund and make sure it is solvent.

Beneficiaries enrolled in programs of all-inclusive care for the elderly programs of all-inclusive care for the elderly “PACE” and Community Living Assistance Services and Supports “CLASS”. ‘Basically senior centers for assisted living or nursing homes. CLASS is a national voluntary insurance program.

The Commissioner of Social Security has entered into an agreement, with respect to any State, to make disability determinations for purposes of title II or XVI of the Social Security Act to serve as an Eligibility Assessment System by providing for eligibility assessments of active enrollees who apply for receipt of benefits.

Establish within the Office of the Secretary, an Office on Women’s Health. The Office shall be headed by a Deputy Assistant Secretary for Women’s Health who may report to the Secretary. P1609-1623 

Purpose is to establish short-range and long-range goals and objectives within the Department of Health and Human Services and, as relevant and appropriate, coordinate with other appropriate offices on activities within the Department that relate to disease prevention, health promotion, service delivery, research, and public and health care professional education, for issues of particular concern to women throughout their lifespan.

Establish within the Office of the Commissioner, an office to be known as another Office of Women’s Health. The Office shall be headed by a director who shall be appointed by the Commissioner of Food and Drugs and will also serve as a member of the Department of Health and Human Services Coordinating Committee on Women’s Health. On levels of activity regarding women’s participation in clinical trials and the analysis of data by sex in the testing of drugs, medical devices, and biological products across, where appropriate, age, biological, and sociocultural contexts and establish short-range and long-range goals.

Indian Healthcare Improvement Act Amendments of 2009. Mostly the same as the rest of the bill, except these billions of dollars are specifically set up for Indian agencies, commissions, cooperatives, etc. A huge chunk is also set aside for actual construction of facilities. P1635- 1990 

Expansion of payments from Medicare, Medicaid, Social Security, SCHIP for Indians.

Other items and costs 

Non-State recipients P266, 1130-1133 

Puerto Rico gets $3 billion, seven hundred million, plus up to another $1 billion, Guam, Virgin Islands, Mariana Islands, and Samoa, each get a few hundred million The Social Security Act had to be changed by striking “American Samoa and the Northern Mariana Islands” and inserting “Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.”

Small Employers

If the annual payroll of such employer for the preceding calendar year: The applicable percentage 

Does not exceed $500,000 ..................................... 0 percent

Exceeds $500,000, but does not exceed $585,000 2 percent

Exceeds $585,000, but does not exceed $670,000 4 percent

Exceeds $670,000, but does not exceed $750,000 6 percent


Page 12 of 19


Those over $750,000 are not considered small employers

Taxing the Rich

GENERAL RULE.—In the case of a taxpayer other than a corporation, there is hereby imposed in addition to any other tax imposed by this subtitle) a tax equal to 5.4 percent of so much of the modified adjusted gross income of the taxpayer as exceeds $1,000,000. P337

Medical Devices

There is hereby imposed on the first taxable sale (to an individual) of any medical device a tax equal to 2.5 percent of the price for which so sold.

Revising Medicare payment systems funded by $8 billion through 2014 for improvements. P500


Reduce disproportionate share by $1.5 billion for fiscal year 2017; $2.5 billion for fiscal year 2018; and $6 billion for fiscal year 2019. Government will redistribute the monies as it sees fit.

Promotion of Public Health and Dentistry P1245 

(1) $240,000,000 for fiscal year 2011.

(2) $253,000,000 for fiscal year 2012.

(3) $265,000,000 for fiscal year 2013.

(4) $278,000,000 for fiscal year 2014.

(5) $292,000,000 for fiscal year 2015.

Special Fund

‘‘Public Health Investment Fund’’ There shall be deposited into the Fund “funds to remain available until expended” Total $33.9 billion 

for fiscal year 2011, $4,600,000,000;

for fiscal year 2012, $5,600,000,000;

for fiscal year 2013, $6,900,000,000;

for fiscal year 2014, $7,800,000,000; and

for fiscal year 2015, $9,000,000,000.

“Fund are authorized to be appropriated for carrying out activities under designated public health provisions.”

Community Health Centers Total $11 billion 

(1) For fiscal year 2011, $1,000,000,000.

(2) For fiscal year 2012, $1,500,000,000.


Page 13 of 19


(3) For fiscal year 2013, $2,500,000,000.

(4) For fiscal year 2014, $3,000,000,000.

(5) For fiscal year 2015, $4,000,000,000.

National Health Service Corps 

Obligated to clinical practice through half-time service for those under the Scholarship Program or the Loan Repayment Program.

Service would be minimum of two years (45 weeks per year) and double current period or half-time for 50% payback amount.


Page 14 of 19


Timeline Date


Jan 1, 2010

High risk insurance pool

Jan 1, 2010

No new employer coverage enrollments

Jan 1, 2010

Any amount contained in the MA Regional Plan Stabilization Fund as of the date of the enactment of this Act shall be transferred to the Federal Supplementary Medical Insurance Trust Fund.

Comments $5 billion


Jan 1, 2010

All new insurance must be purchased by “Exchange participating health plan�

Jan 1, 2010

Submission of claims for pharmacies located in or contracting with long-term care facilities is repealed


Jan 1, 2010

Drop tobacco cessation exclusion from covered drugs Medicaid


Jan 1, 2010

Pay for interpretation and translation services. Podiatrist, optometrist, Medicaid


Jan 1, 2010

Allow optional in-home nursing service Medicaid


Jan 1, 2010

States can option to allow family planning services for individuals who applied beginning back to Jan 1, 2007 Medicaid


Jan 1, 2010

Adjust primary care physician rates based on Jun 16, 2009 rates Medicaid


Jan 1, 2010

Penalties enacted for waste, fraud, and abuse. Also for marketing violations, obstruction of audits.

Minimum $50,000 for each false statement up to triple damages and expulsion for any federal programs P946-966

Jan 1, 2010

Price controls for manufacturing charges and covered entity charges for drugs sold after that date

Jan 1, 2010

Jan 1, 2010


Medicare includes payment for services performed by a marriage and family therapist for the diagnosis and treatment of mental illnesses. Also pays for mental health counselor services. Medicare excludes marriage and family therapist services from skilled nursing facility prospective payment system. Page 15 of 19

P705, 710 Must have Masters or better, licensed or certified, and two years clinical experience



Date April 1, 2010 April 1, 2010

What Temporary re-insurance program

Secretary shall initiate procedures under subchapter III of chapter 5 of title 5, United States Code, to negotiate and promulgate such regulations as needed to set up Indian programs

Comments $10 billion Indian services

Jul 1, 2010

Oxygen use provision (see details above)


Jul 1, 2010

Medicaid preventative services paid for, including immunizations


Sep 1, 2010

Recommendations due to determine whether Medicare will no longer pay for bone mass measurements


1 year after signing

Interim final rule for claims attachments

Oct 1, 2010

ARRA Hospice moratorium is extended to this date

Oct 1, 2010

Jan 1, 2011

Jan 1, 2011


Excludes clinical social worker services P704 from coverage under the Medicare skilled nursing facility prospective payment system and consolidated payment. First report of benefit standards must be submitted

Results and recommendations from study to P532-533 determine the potential effects of calculating Medicare Advantage payment rates on a more aggregated geographic basis (such as metropolitan statistical areas or other regional delineations) rather than using county boundaries.

Jan 1, 2011

Results from Dental study will determine whether dental should be part of basic coverage

Jan 1, 2011

Propose a national strategy that is designed to improve the Nation’s health through evidencebased clinical and community prevention and wellness activities

Jan 1, 2011

Change California MSA fee schedules


Jan 1, 2011

Report and recommendations of adjusted gross income for determining premiums


Jan 1, 2011

Wheel chairs redesignated



Page 16 of 19





Jan 1, 2011

Medicare post acute care services will be paid as a bundle


Jan 1, 2011

Home health services payments adjusted


Jan 1, 2011

Develop regulations for nutrition labeling for chain restaurants and vending machines


Jan 1, 2011

Waiver of deductible for colorectal cancer screening tests regardless of coding, subsequent diagnosis, or ancillary tissue removal


Jan 1, 2011

Study results and recommendations due regarding bids for durable medical equipment


Jan 1, 2011

Institute of Medicine report and recommendations on workforce and other geographical issues

P497-499 Medicare payments will be adjusted based on the recommendations

Jan 1, 2011

Cost adjustments for free standing Cancer Hospitals

Jan 1, 2011

Report and recommendations for Medicare payment of translators


Jan 1, 2011

Reduced payment of imaging multiple body parts in single image


July 1, 2011

Adopt initial set of basic benefit standards

As recommended by Health benefits advisory Committee

July 1, 2011

Study results for self-insured employers, with recommendations


July 1, 2011

Report due on impact of nurse-to-patient ratios, including recommendations


Jul 1, 2011

Jul 1, 2011

July 1, 2011

Oct 1, 2011


Distribute new rules to provide “without regard to personal characteristics extraneous to the provision of high quality health care or related services” Medicare Payment Advisory Commission shall submit to Congress a report on the scope of coverage for home infusion therapy Final regulations due to certify federally qualified behavioral health centers. Medicare reduce hospital payments for certain, excess readmissions.

Page 17 of 19

Prohibits discrimination in healthcare

Also eliminates community mental health centers P441 Certain hospital with excesses will be ‘target hospitals’




Comments with other provisions

Jan 1, 2012

Begin eligibility for senior “CLASS” benefits

Jan 1. 2012

Feedback report for physician services due

Jan 1, 2012

Jan 1, 2012

P395 concerns changing practices for physicians and reevaluating RVUs

Report to congress on the current state of parasitic diseases that have been overlooked among the poorest Americans. Recommendation regarding the need or P279 lack of need for a partial or complete employer hardship waiver.

Jan 1, 2013

Eligibility claims defined and implemented

Jan 1, 2013

Ambulatory surgery centers to begin submitting cost and quality reports for Medicare audit

Jan 1, 2013

Another name for assisted living or nursing homes

Report and recommendation by IOM on the impact of language access services on the health and health care of limited English proficient populations.



Jan 1, 2013

Minimum standards for basic benefit insurance coverage package for states due (Medicaid)


Dec 31, 2013

Report and recommendations due for getting small practitioners to use electronic EHRs


Dec 31, 2013

Report of results and costs of committee on comparative effectiveness research commission


Jan 1, 2014

All other claims electronic

Jan 1, 2014

Interim final rule for ‘first report of injury transaction’

FY 2014

CHIP Program is repealed

Jan 1, 2015

All payments EFT (electronic funds transfer)

Jan 1, 2015

End of employer paid insurance “grace period”

Jan 1, 2016 Dec 31, 2019


Recommendation whether to eliminate Medicaid DSH program Delay in application of worldwide allocation of interest

Page 18 of 19


P1034 P345


Current Acts that are affected or changed by this one

I may have missed a few, but you can get the idea from these I found

Act of November 2, 1921 (commonly known as the ‘Snyder Act’) (for Indian Services) American Recovery and Reinvestment Act of 2009 (ARRA) Balanced Budget and Emergency Deficit Control Act of 1985 Consumer Product Safety Act ERISA Act 1974 Federal Advisory Committee Act Federal Trade Commission Act Health Insurance Portability and Accountability Act of 1996 Hitech Act Inspector General Act of 1978 IRS Tax Act 1986 McCarran-Ferguson Act of 1945 Medicare Prescription Drug, Improvement, and Modernization Act of 2003 Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 Older Americans Act of 1965 Omnibus Appropriations Act, 2009 - Public Law 111–8 Personal Responsibility and Work Opportunity Reconciliation Act of 1996 Public Health Service Act Social Security Act


Page 19 of 19


Healthcare bill Summary  

Summary from the 1990 page healthcare bill

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