Appendix E. Section Review - Maryland State Archivesmsa.maryland.gov/megafile/msa/speccol/sc5300/sc5339/000113/013000/...U“Sec. 2712. ” U UProhibition ... Draft working document

Appendix E. Section Review

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Introduction The Section Review Appendix provides an initial summary of the over 2,000-page federal health reform law, section by section. This appendix is a working document that provides preliminary identification of implementation decisions to be considered by Maryland. The document will change as it is shared more widely and as new decisions are identified through the continued work of reform implementation. In addition, much of the guidance needed from the federal government has yet to be released. The federal government is disseminating new information on a daily basis. Additional decisions for Maryland are likely to arise as federal guidance is issued. The appendix is a living document; this version captures only the most recently available information at a point in time. In addition to identifying decisions, the appendix provides a framework for when decisions are to be made, and federal implementation deadlines where available. The appendix also identifies affected Maryland law and regulation where applicable. The value of the appendix is as an initial tool to help focus the HCRCC’s efforts on coordination of the key implementation priorities for Maryland. The “Decisions” column highlights major questions Maryland must consider in implementing reform. The answers to these questions could significantly affect health care across the public and private sectors. This appendix attempts to identify instances in which the state may want to consider amending or adding to existing law and regulations in order to take the fullest advantage of the opportunities offered by the federal health care reform statutes. It may not be exhaustive, and further analysis in light of proposed projects or actions may identify additional areas in which changes may be needed or desirable or establish that no change is necessary. The appendix helps to manage the breadth of the health reform law. The Department of Legislative Services provided invaluable support by analyzing all provisions of the law to identify the Maryland statutes potentially affected by reform. Relevant section summaries were shared with many Executive branch agencies and commissions under aggressive timeframes to gain initial input on the decisions, statutes and regulations affected, and timeframes for decisions and implementation. The document will evolve as these agencies and commissions have additional opportunity to assess the law. Continued input from the public as well as private sectors is essential. This comprehensive review also helps to clarify which provisions do not require the HCRCC’s focus. Many provisions will be implemented at the federal level, noted as “Federal” in the “Decisions” column of the appendix. The appendix also notes some provisions as “Conforming” in the decisions column. These may require significant effort to implement, but do not present transformative decisions.


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The “Date Decision Needed” column backs out when decisions must be made or activities taken to meet federal implementation deadlines. In many cases, the column indicates “awaiting federal guidance” because more information is needed to ensure that state decisions comply with new federal policies being developed. The column highlights two main categories of decisions where work needs to begin quickly: “immediate—required,” and “immediate—essential.” “Immediate” is defined as the remainder of calendar year 2010 through the end of calendar year 2011, to prepare for Maryland’s 2012 legislative session. In some cases it may be desirable to introduce legislation earlier, during the 2011 legislative session. “Required” decisions are those that are needed to meet required provisions of the federal law. “Essential” decisions are not required by federal law, but the state needs to act in these areas in order to comply with other required provisions. For example, Maryland is not required to address health care workforce capacity, but in order to expand coverage in a meaningful way in 2014, it is essential to address workforce capacity. The last column, “Implementation Date,” lists available federal deadlines included in the law, as well as the most recent federal updates as of July 14, 2010. For many sections, the “Decision” column notes “refer to grants process.” This is a reference to a new multi-agency process for assessing the many health reform grant opportunities available to states, coordinated by the office of the Governor. As a next step, the HCRCC may provide relevant portions of the evolving Section Review Appendix to workgroups to help frame the topics they are to address.


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Draft working document as of July 21, 2010, subject to change. See description in Appendix E: Section Review Introduction.

UP.L. 111‐148 & P.L. 111‐152 (PPACA & HCERA) Section Review

Section DescriptionP0F

1P and Required State Action Decisions Maryland Statute

Affected Maryland Regulations

Affected Date Decision

Needed Implementation

Date The Patient Protection and Affordable Care Act

TITLE I—QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS Subtitle A—Immediate Improvements in Health Care Coverage for All Americans

USection 1001

U“Sec. 2711.”U ULifetime and annual limit prohibitions apply only to “dollar” limits and only to “essential benefitsU.” UAs amended by SectionU U10101U prohibits plans from establishing lifetime limits, and annual limits beginning in 2014, on the dollar value of benefits. Prior to 2014, plans may only establish restricted annual limits as defined by the Secretary of Health and Human Services (HHS), ensuring access to needed services with minimal impact on premiums. UFederal Action Required: Secretary of HHS will need to establish by regulation and define “restrictive annual limit” and the permissible annual limits. Regulations published June 28, 2010. UState Action Required: Carriers will need to revise contracts; MIA will need to approve amendments.

Conforming.

Will need to revise Insurance Article to restrict annual and lifetime limits.

Immediate—required.

Lifetime limit prohibition—Begins for plan years (for individual contracts policy years) that begin 6 months or later from enactment. Annual limit restrictions‐‐ Begins for plan years (for individual contracts policy years) that begin 6 months or later from enactment.

USection 1001

U“Sec. 2712.”U UProhibition on rescissionsU. Prohibits all plans from rescinding coverage

Conforming. Revise §15‐1106, Insurance Article to


Begins for plan years (for individual

1 Description summaries based on Democratic Policy Committee (2010). "Section-by-Section Analysis With Changes Made by Title X and Reconciliation Included Within I - IX." Washington, D.C.: United States Senate. Retrieved from http://dpc.senate.gov/healthreformbill/healthbill96.pdf.


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Date except in instances of fraud or intentional

misrepresentation.

comply with federal requirements.

contracts policy years) that begin 6 months or later from enactment.

USection 1001

U“Sec. 2713.”U UCoverage of preventive health servicesU. Requires all new plans to cover preventive services and immunizations recommended by the U.S. Preventive Services Task Force and the CDC, certain child preventive services recommended by the Health Resources and Services Administration (HRSA), and women’s preventive care and screening recommended by HRSA, without any cost‐sharing. UFederal Action Required: Secretary of HHS will adopt by regulations the rules for implementing changes to the preventive services guidelines

UState Action Required: Carriers will need to revise contracts; MIA will need to review/approve contract changes.

Conforming. Determine if the following Maryland mandates dealing with preventive services need revision:

Insurance Article

§15‐814 Mammography Screening

§15‐817 Child Wellness

§15‐823 Osteoporosis Screening

§15‐825 Prostate Cancer Screening

§15‐829 Chlamydia and Human Papillomavirus Screening

§15‐837 Colorectal Cancer Screening

§15‐841 Smoking Cessation Treatment

MIA will work with MHCC to revise small group regulations to provide the required preventive services—COMAR 31.11.06.03A(9), (9‐1), (9‐2),(10) and (33) and cost sharing found in COMAR 31.11.06.05


Begins for plan years (for individual contracts policy years) that begin 6 months or later from enactment.

USection 1001

U“Sec. 2714.”U UExtension of dependent coverageU. Requires all plans offering dependent coverage to allow individuals

Conforming. Insurance Article, §15‐418 and §15‐403.2 to

MIA will work with MHCC to revise small


Begins for plan years (for individual contracts policy


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Date under age 26 to remain on their parents’ health insurance. Section 2301 of the Reconciliation Act eliminates the requirement that adult children be unmarried. Grandfathered plans can exclude adult children who are eligible for their own group coverage (see Section 1251). UFederal Action Required: The Secretary of HHS published regulations May 13, 2010. UState Action Required: Carriers will need to revise contracts; MIA will need to review/approve contract changes. MIA issued bulletin notifying carriers on June 3rd.

change the limiting ages from 25 to 26 and possible other changes to these laws, depending on the new definition of “dependent” developed by the Secretary of HHS

group regulations to comply—COMAR 31.11.06.02B(12)

years) that begin 6 months or later from enactment.

USection 1001

U“Sec. 2715.”U UDevelopment and utilization of uniform explanation of coverage documents and standardized definitionsU. Requires the Secretary to develop standards for use by health insurers in compiling and providing an accurate summary of benefits and explanation of coverage for applicants, policyholders or certificate holders, and enrollees. The standards must be in a uniform format, using language that is easily understood by the average enrollee, and must include uniform definitions of standard insurance and medical terms. The explanation must also describe any cost‐sharing, exceptions, reductions, and limitations on coverage, and examples to

Conforming. Will need to revise Insurance Article to require carriers to provide these documents

Will need to revise COMAR 31.10.37 to provide for the time period to provide these documents to consumers.

Awaiting federal guidance.

Standards must be developed not later than 12 months after enactment; Carriers must begin providing the documents in compliance with requirements within 24 months of enactment


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Date illustrate common benefits scenarios. UFederal Action Required: Secretary of HHS works with NAIC to develop standards for summary of benefits and coverage explanation.

USection 1001

U“Sec. 2715A.”U UProvision of additional informationU. UAs added by sectionU U10101U requires all plans to disclose the information required in section 1311(e), such as claims payment policies and rating practices. Plans that are not offered through the Exchange must submit this information to the Secretary of HHS and the State insurance commissioner and make such information available to the public. UFederal Action Required: Secretary of HHS will accept filings made by the group health plans and health insurers

Secretary of HHS will determine what information the Exchange shall require health plans to provide and how to make this information “transparent” UState Action Required: MIA will accept filings made by the group health plans and health insurers regarding transparency issues—see §1311(e)(3) of the PPACA

Identify process issues on how to collect.

May need to revise the Insurance Article and Health‐General Article to require carriers participating in the Exchange to file the required information

Exchangetimeframes apply.

Not before 2014.


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Date USection 1001

U“Sec. 2716.”U Prohibition of discrimination in favor of highly compensated individuals.

USection 1001

U“Sec. 2717.”U UEnsuring quality of careU. Requires the Secretary to develop guidelines for use by health insurers to report information on initiatives and programs that improve health outcomes through the use of care coordination and chronic disease management, prevent hospital readmissions and improve patient safety, and promote wellness and health. UAs added by sectionU U10101U protects Second Amendment gun rights by precluding the collection and disclosure of information related to gun ownership or use for purposes of determining premium rates. UFederal Action Required: Secretary of HHS to develop reporting requirements

How will this affect current Maryland reporting efforts? Determine whether and how it should be coordinated with Report Cards.

Revise Insurance Article to require carriers to provide enrollees with the report.

Revise §§27‐501 and 15‐509 of the Insurance Article to prohibit carriers from disclosing or collecting information about firearms or using lawful ownership or possession of a firearm or ammunition or lawful use or possession of a firearm to discriminate in rating, underwriting for health coverage or to refuse to provide a discount, rebate or reward under a wellness program.


Not later than 2 years after enactment, Secretary of HHS to have developed reporting requirements.

USection 1001

U“Sec. 2718.”U UBringing down the cost of health care coverageU. UAs amended by SectionU U10101U, requires plans offering coverage in the group and individual markets (including grandfathered plans but excluding self‐insured plans) to report to the Secretary the amount of premium revenues

Revise loss ratio requirements found in Insurance Article, §15‐605


Rebates begin for plan years beginning 1‐1‐2011 for group plans and individual health insurance


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Date spent on clinical services, activities to improve quality, and all other non‐claims costs as defined by the National Association of Insurance Commissioners and certified by the Secretary of HHS. Beginning in 2011, large group plans that spend less than 85 percent of premium revenue and small group and individual market plans that spend less than 80 percent of premium revenue on clinical services and quality must provide a rebate to enrollees. In addition, each hospital operating within the United States shall publish a list of standard charges for items and services provided by the hospital. UFederal Action Required: Secretary of HHS will consult with NAIC on defining how the loss ratios will be determined

Secretary will receive annual reports from health insurance issuers offering group or individual health insurance coverage

Secretary will promulgate regulations for enforcing this section

NAIC will consult with Secretary of HHS to establish how the loss ratios will be determined

UState Action Required:

The NAIC is required to develop the loss ratio determinations by 12‐31‐2010.


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Date MIA will work with NAIC to help develop needed definitions.

MIA will also enforce the annual rebating requirements.

USection 1001

U“Sec. 2719.”U UAppeals processU. UAs amended by SectionU U10101U requires new plans to implement an effective internal appeals process of coverage determinations and claims and comply with any applicable State external review process. If the State has not established an external review process or the plan is self‐insured, the plan shall implement an external review process that meets minimum standards established by the Secretary. The Secretary may deem the external review process of a plan in operation as of enactment to be in compliance with this section. UFederal Action Required: Internal appeal process—Secretary will establish standards that will apply to individual health coverage and any other issuer not subject to federal regulations

Self‐insured plans not subject to state insurance regulation must establish an external review process.

Conforming May need to revise Title 15, Subtitles 10A and 10D, regarding internal review, depending on the standards that the Secretary establishes (initial plans complying with State law are grandfathered until the Secretary establishes new standards)

May need to include more requirements in Title 15, Subtitles 10A and 10B to deal with notice being “culturally and linguistically appropriate”


No firm deadline to change Maryland law—will depend on standards established by Secretary.

USection 1001

U“Sec. 2719A.”U UPatient protectionsU. UAs added by section 10101U requires that a plan

Conforming, with options regarding

According to recently CSHBP regulations. Immediate—required.

Begins for plan years (for individual


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Date enrollee be allowed to select their primary

care provider, or pediatrician in the case of a child, from any available participating primary care provider. Precludes the need for prior authorization or increased cost‐sharing for emergency services, whether provided by in‐network or out‐of‐network providers. Plans are precluded from requiring authorization or referral by the plan for a patient who seeks coverage for obstetrical or gynecological care by a specialist in these areas. Certain provisions, including those related to emergency services and OB/GYN, do not apply to grandfathered plans.

grandfathering. One option: For those benefit changes that apply only to non‐grandfathered plans, have a two‐fold set of statutory or regulatory provisions, the first applying to “new” plans, and the second (currently existing in law or regulation) applying to grandfathered plans. Other option: Take state action to adopt the new ACA benefit into required coverage for all State‐regulated plans, whether new or renewal, grandfathered or not. This would not jeopardize the grandfathered status of the plan for other purposes, since it occurs because of State action to increase the benefit.

published federal regulations, Insurance Article, §15‐816 is not as generous as the federal requirements. Maryland law limits the protection of not needing a primary care physician referral for “routine care” received from an OB/GYN. Federal law prohibitions go behond Maryland law in permitting a woman to receive any type of OB/GYN care from a participating OB/GYN without needing a referral from the primary care physician.

Need to pass a law that provides for access to any participating primary care provider and for ability for child to choose participating pediatrician as primary care physician

contracts policy years) that begin 6 months or later from enactment.


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Date Need to pass a law that includes the required provisions regarding emergency care. The definition in federal law is very similar to the definition applicable to HMOs in Health‐General Article, §19‐701(e)

Also, law will need to specify the prohibition on pre‐authorization, same coverage for in‐network and out‐of‐network providers (e.g., copays, coinsurance)

USection 1002

UHealth insurance consumer information.U The Secretary shall award grants to States to enable them (or the Exchange) to establish, expand, or provide support for offices of health insurance consumer assistance or health insurance ombudsman programs. These independent offices will assist consumers with filing complaints and appeals, educate consumers on their rights and responsibilities, and collect, track, and quantify consumer problems and inquiries. Provides $30 million in funding and is effective upon the date of enactment of the

Refer to grants process.

Effective upon enactment, except Secretary of HHS must establish criteria for grant


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Date bill. UFederal Action Required: Secretary of HHS must establish criteria for grant UState Action Required: MIA/OAG can apply for the grant. Appears current MIA Life/Health Complaint Unit and Appeals and Grievance units perform all functions required, except for “resolving problems with obtaining premium tax credit under section 36B of the Internal Revenue Code of 1986”

USection 1003

U Ensuring that consumers get value for their dollars. UFor plan years beginning in 2010, the Secretary and States will establish a process for the annual review of increases in premiums for health insurance coverage. Requires States to make recommendations to their Exchanges about whether health insurance issuers should be excluded from participation in the Exchanges based on unjustified premium increases. Provides $250 million in funding to States from 2010 until 2014 to assist States in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage and in providing information and recommendations to the Secretary. UAs added by sectionU U10101U, allows for the establishment of medical reimbursement data centers to develop fee schedules and other database tools that reflect market rates for medical services.


Once final process developed by HHS, may need to revise rate review requirements specified in the Insurance Article and the Health‐General Article.

Premium increase review begins with 2010 plan years

Grant approval for rate review will apply beginning with fiscal year 2010


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Date UFederal Action Required: Secretary of HHS, in conjunction with the States will establish a process for annual review of “unreasonable increases” in premiums UState Action Required: MIA will work with HHS to establish the annual review process for premium increases

MIA will receive filings from issuers before any implementation of “unreasonable increases,” which current Maryland law already requires

MIA applied for grant from HHS to review/approve premium increases.

USection 1004

UEffective dates.U Except for sections 1002 and 1003 (effective upon the date of enactment of this Act), this subtitle shall become effective for plan years beginning on or after the date that is 6 months after the date of enactment of this Act.

Subtitle B – Immediate Action to Make Coverage More Affordable and More AvailableUSection 1101

UImmediate access to insurance for people with a preexisting condition.U Enacts a temporary insurance program with financial assistance for those who have been uninsured for several months and have a pre‐existing condition. Ensures premium

How will federal high risk pool be coordinated with State for MHIP Plus? Whether to buy‐down Pre X in federal high risk

Chapter 173 (HB 1564) of 2010 altered the provisions of Insurance Article Title 14 Subtitle 5 to authorize the MHIP Board to

Immediate—essential.


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Date rate limits for the newly insured population. Provides up to $5 billion for this program, which terminates when the American Health Benefit Exchanges are operational in 2014. Also establishes a transition to the Exchanges for eligible individuals.

pool consistent with existing MHIP? Single application for federal and state? How to address transition issues in 2014 (logistical flow of enrollment, minimizing selection issues) How to maximize federal funding? How to address potential federal cap on enrollment?

administer the temporary high risk pool in the State. No additional changes would appear to be needed.

USection 1102

UReinsurance for early retirees. UEstablishes a temporary reinsurance program to provide reimbursement to participating employment‐based plans, including (as clarified by Section 10102) plans sponsored by State and local governments, for part of the cost of providing health benefits to retirees (age 55‐64) and their families. The program reimburses participating employment‐based plans for 80 percent of the cost of benefits provided per enrollee in excess of $15,000 and below $90,000. The plans are required to use the funds to lower costs borne directly by participants and beneficiaries, and the program incentivizes plans to implement programs and procedures to better manage chronic conditions. The Act appropriates $5 billion for this fund and funds are available until expended.

State Employee participation has already applied.

State Personnel and Pensions Article Title 2 Subtitle 5 establishes the State Employee and Retiree Health and Welfare Benefits Program and gives the Secretary broad authority to administer the Program.

Approval pending. Program Effective June 1, 2010, will end no later than January 1, 2014.


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Date USection 1103

UImmediate information that allows consumers to identify affordable coverage options. UEstablishes an Internet portal for beneficiaries to easily access affordable and comprehensive coverage options. This information will include eligibility, availability, premium rates, cost sharing, and the percentage of total premium revenues spent on health care, rather than administrative expenses, by the issuer. Section 10102 clarifies that the internet portal shall be available to small businesses and shall contain information on coverage options available to small businesses. UFederal Action Required: Secretary, in consultation with States, shall establish a mechanism, including an Internet website through which residents and small businesses may identity affordable health coverage options

Determine how state should coordinate w/federal efforts – both current state efforts such as Virtual Compare or long term efforts to coordinate outreach and enrollment activities.

Health‐General Article § 19‐108.1 requires MHCC to maintain on its website an application that a small business may use to compare premiums of small group market plans. Federal Internet portal should have similar information by October 2010, making the MHCC application unnecessary.


July 1, initial information

October 2010 pricing information

Not later than July 1, 2010, the Secretary of HHS shall establish the mechanism

Not later than 60 days after enactment the Secretary of HHS shall develop a standardized format for presentation of information

USection 1104

UAdministrative simplification. U Accelerates HHS adoption of uniform standards and operating rules for the electronic transactions that occur between providers and health plans that are governed under the Health Insurance Portability and Accountability Act (such as benefit eligibility verification, prior authorization and electronic funds transfer payments). Establishes a process to regularly update the standards and operating rules for electronic transactions and requires health plans to certify compliance or face financial penalties

Should not affect State law.



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Date collected by the Treasury Secretary. The goal of this section is to make the health system more efficient by reducing the clerical burden on providers, patients, and health plans.

USection 1105

UEffective dates. UProvides that this subtitle is effective upon enactment.

Subtitle C – Quality Health Insurance Coverage for All Americans ‐ Part I – Health Insurance Market Reforms

USection 1201

U“Sec. 2701.”U UFair health insurance premiumsU. Establishes that premiums in the individual and small group markets may vary only by family structure, geography, the actuarial value of the benefit, age (limited to a ratio of 3 to 1), and tobacco use (limited to a ratio of 1.5 to 1). Section 10103 clarifies that this provision applies to insured plans in the large group market, not self‐insured plans. UFederal Action Required: NAIC will work with Secretary of HHS to define permissible age bands. UState Action Required: State/MIA shall establish one or more ratings areas within the State.

Make revisions to ratings areas? Reduce the maximum premium variation based on age and the 1.5:1 variation based on smoking? Consider strategies to minimize “rate shock” of collapsing bands in the individual market

Revise portions of small group reform legislation dealing with rating bands—Insurance Article, §15‐1205

Need to add laws for insurers, nonprofit health service plans and HMOs regarding rate bands and rating issues for other than small employer health benefit plan market.


Applies to plan years beginning on or after 1‐1‐2014

USection 1201

U“Sec. 2702.”U UGuaranteed availability of coverageU. Each health insurance issuer must accept every employer and individual in the State that applies for coverage, permitting annual and special open enrollment periods for those with qualifying lifetime events.

How to minimize selection issues?

Need new law regarding guarantee issuance in the large group market, Insurance Article, Title




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Date UFederal Action Required: Secretary of HHS shall promulgate regulations regarding special enrollment periods

15, Subtitle 14

Need to add new law requiring guarantee issuance in the individual market, Insurance Article, Title 15, Subtitle 13

May need to revise Title 15 Subtitle 12 for small employers depending on the final regulations.

USection 1201

U“Sec. 2703.”U UGuaranteed renewability of coverageU. Requires guaranteed renewability of coverage regardless of health status, utilization of health services or any other related factor.


May need to revise the guaranteed renewability provisions applicable to small group, individual and large group health coverage found in Insurance Article, §§15‐1212, 15‐1309 and 15‐1408

Work on small group market laws



USection 1201

U“Sec. 2704.”U UProhibition of preexisting condition exclusions or other discrimination based on health status.U No group health plan or insurer offering group or individual


Revise the following laws dealing with pre‐existing condition

CSHBP regs being revised for the child preexisting condition exclusion.


Prohibition against pre‐existing condition


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Date coverage may impose any pre‐existing condition exclusion or discriminate against those who have been sick in the past. UState Action Required: MIA will need to review and approve:

amendments to large group and individual health insurance contracts for children on or before 6 months from enactment

amendments to large group and individual health insurance contracts for all other entities before 1‐1‐2014

limitations:

Insurance Article, §§15‐508, 15‐508.1

limitations for enrollees under age 19 begins for plan years (for individual contracts policy years) that begin 6 months or later from enactment.

Prohibition against pre‐existing condition limitations for all other entities applies to plan years (for individual contracts policy years) beginning on or after 1‐1‐2014.

USection 1201

U“Sec. 2705.”U UProhibiting discrimination against individual participants and beneficiaries based on health statusU. No group health plan or insurer offering group or individual coverage may set eligibility rules based on health status, medical condition, and claims experience, receipt of health care, medical history, genetic information, and evidence of insurability – including acts of domestic violence or disability. Permits employers to vary insurance premiums by as much as 30 percent for employee participation in certain health promotion and disease

Assess federal guidance and changes needed. Determine whether to apply for 10‐State demo?

Need to add laws to prohibit discrimination in issuing coverage bases on health status—may be combined with the guaranteed issuance requirements of Title I, Subtitle C, §1201, Subsection 2702

May need to revise the



Demonstration project for individual market by 7‐1‐2014

May expand demonstration project to additional states beginning 7‐


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Date prevention programs. Wellness requirement‐‐ Secretary of HHS in consultation with Secretary of Treasury and Secretary of Labor shall establish a 10‐State demonstration.

UFederal Action Required: Secretary of HHS will define “health status’related factor” Secretaries of Labor, HHS, and Treasury may change the permissible award from 30% to as high as 50%

Secretary of HHS, in consultation with Secretary of Treasury and Secretary of Labor shall establish a 10‐State demonstration project for wellness benefits in the individual market.

definition of “health factor” in Insurance Article, §15‐509, if the Secretary of HHS adds any other item to the definition

Insurance Article, §15‐509 appears to be more generous than PPACA

1‐2017

USection 1201

U“Sec. 2706.”U UNon‐discrimination in health care. UProhibits discrimination against health care providers acting within the scope of their professional license and applicable State laws.

Conforming

Insurance Article, §15‐701 provides protection for insurance

Insurance Article, §15‐112 may need revision to provide protection for providers contracting with



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Date insurers, nonprofit health service plans, HMOs

USection 1201

U“Sec. 2707.”U UComprehensive health insurance coverageU. Requires health insurance issuers in the small group and individual markets to include coverage which incorporates defined essential benefits, provides a specified actuarial value, and requires all health plans to comply with limitations on allowable cost‐sharing.

Will need to add law requiring carriers to provide essential coverage in the individual market. Insurance Article, Title 15, Subtitle 12 already requires minimum coverage in small group market

COMAR 31.11.06 already requires minimum coverage in small group market



USection 1201

U“Sec. 2708.”U UProhibition on excessive waiting periodsU. Prohibits any waiting periods for group coverage that exceeds 90 days. Section 10103 clarifies that waiting periods do not apply to the individual market.

Conforming Need to add law prohibiting waiting periods in excess of 90‐days for group contracts



USection 1201

U“Sec. 2709.”U UCoverage for individuals participating in approved clinical trialsU. UAs added by sectionU 10103, prohibits insurers from dropping coverage because an individual chooses to participate in a clinical trial and from denying coverage for routine care that they would otherwise provide just because an individual is enrolled in a clinical trial. Applies to all clinical trials that treat cancer or other life‐threatening diseases.

Conforming Will need to revise Insurance Article, §15‐827(e)(2) with regard to include all the agencies that could approve or fund the trial listed in the federal law




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Date UFederal Action Required: Secretary of HHS will need to determine if the studies or investigations conducted by a “Department” as listed in §2709(d)(1)(A)(vii), are comparable to the system of peer review of studies and investigations used by NIH and assures unbiased review of the highest scientific standards

Part II – Other Provisions

USection 1251

UPreservation of right to maintain existing coverage.U Allows any individual enrolled in any form of health insurance to maintain their coverage as it existed on the date of enactment. Section 10103 applies the requirements for medical loss ratios and uniform coverage documents to grandfathered plans. Section 2301 of the Reconciliation Act applies the requirements for excessive waiting periods, lifetime limits, rescissions, and extension of young adult coverage to grandfathered plans. Also, applies requirements relating to pre‐existing coverage exclusions to group health plans, applies requirements regarding adult child coverage to group health plans only if the adult child is not eligible to enroll in an employer‐sponsored plan.

Applicable text added to Senate Bill 57, Acts of 2010, sunsets June 30, 2011. If protection is needed in statute, additional legislation is needed to provide the portections of SB 57 beyond June 30, 2011.

Effective upon enactment

USection 1252

URating reforms must apply uniformly to all health insurance issuers and group health plans.U Standards and requirements adopted by States must be applied uniformly to all plans in each relevant insurance market in a



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Date State. UState Action Required: In drafting laws or regulations to implement, must be consistent in each insurance market

USection 1253

UAnnual report on self‐insured plans.U UAs added by sectionU U10103U, requires the Secretary of Labor to prepare an annual report on various aspects of self‐insured group health plans. UFederal Action Required: Secretary of Labor creates report and submits to Congress

Federal First report due not later than 1 year after enactment

USection 1254

UStudy of large group market. U UAs added by sectionU U10103U, requires the Secretary of HHS to conduct a study of the fully‐insured and self‐insured group health plan markets to compare characteristics and determine the extent to which new insurance market reforms are likely to cause adverse selection in the large group market. UFederal Action Required: Secretary of HHS will conduct study of fully‐insured and self‐insured market and submit report to Congress

Federal Report due not later than 1 year after enactment

USection 1255

UEffective dates.U USection 10103 re‐designates this sectionU, previously 1253, as 1255. All provisions in this subtitle take effect on January 1, 2014. Section 10103 clarifies that the grandfathering takes effect on the date of enactment and applies the


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Date prohibition on pre‐existing condition exclusions with respect to children effective six months after enactment.

Subtitle D – Available Coverage for All Americans ‐ Part I—Establishment of Qualified Health Plans

USection 1301

UQualified health plan defined.U Requires qualified health plans to be certified by Exchanges, provide the essential health benefits package, and be offered by licensed insurers that offer at least one qualified health plan at the silver and gold levels. USection 10104U strikes the community health insurance option from this section, adds multi‐state plans, and allows qualified health plans to provide coverage through a qualified direct primary care medical home plan that meets requirements established by the Secretary of HHS.

To what extent will Maryland allow or encourage variation in products offered?

Awaiting federal guidance. Decision needed before 2012 legislative session.

USection 1302

UEssential health benefits requirements.U Defines an essential health benefits package as one that covers essential health benefits, limits cost‐sharing, and has a specified actuarial value (pays for a specified percentage of costs), as follows: 1. For the individual and small group

markets, requires the Secretary to define essential health benefits, which must be equal in scope to the benefits of a typical employer plan.

2. For all plans in all markets, prohibits out‐

of‐pocket limits that are greater than the limits for Health Savings Accounts. For

Assess scope of changes to CSHBP. Assess what to do about state mandates that exceed plan. Whether to maintain certain mandates that go beyond the essential benefits defined at the federal level? To what extent will Maryland allow or encourage variation in products offered?

The mandated benefits in Insurance Article, Title 15, Subtitle 8 and Health General Article Title 19, Subtitle 7 will need to be revised

A requirement for the essential health benefits package to be offered to individuals may need to be added to the Insurance Article as a condition of

Will need to revise the small group regulations (COMAR 31.11.06) to change maximum deductible amounts and benefits.


Plan years beginning on or after January 1, 2014.


E-24








Date the small group market, prohibits deductibles that are greater than $2,000 for individuals and $4,000 for families. Indexes the limits and deductible amounts by the percentage increase in average per capita premiums.

3. For the individual and small group

markets, requires one of the following levels of coverage, under which the plan pays for the specified percentage of costs:

Bronze: 60 percent Silver: 70 percent Gold: 80 percent Platinum: 90 percent

In the individual market, a catastrophic‐only plan may be offered to individuals who are under the age of 30 or who are exempt from the individual responsibility requirement because coverage is unaffordable to them or because of a hardship. A catastrophic plan must cover essential health benefits and at least three primary care visits, but must require cost‐sharing up to the HSA out‐of‐pocket limits. Also, if an insurer offers a qualified health plan, it must offer a child‐only plan at the same level of coverage. Finally, USection 10104U requires payments by qualified health plans to Federally Qualified Health Centers (FQHCs) to be at least as high as payments to FQHCs under Medicaid.

offering insurance to individuals.


E-25








Date UFederal Action Required: Secretary of HHS shall define the essential health benefits.

Secretary of HHS will determine the scope of benefits covered under a “typical employer plan.”

Secretary will periodically update the essential health benefits and provide notice to public and Congress.

Secretary shall issue regulations regarding employer contributions to HSAs.

Secretary shall determine guidelines for de minimus variations from actuarial values of various plans.

USection 1303

USpecial rules.U UAs amended by SectionU U10104U, this section: Affirms that States may prohibit abortion coverage in qualified health plans offered through an Exchange in such State if such State enacts a law to provide for such prohibition.

Ensures that plans may elect whether or not to cover abortion. Requires a segregation of funds for subsidy‐eligible individuals in plans that cover abortions for which the expenditure of Federal funds appropriated for the Department of

Decide whether to permit or prohibit abortion coverage.

No provision in State insurance law that addresses abortion.

Small group regulations COMAR 31.11.06.03A(25) currently cover abortion.

Plan years beginning on or after January 1, 2014


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Date Health and Human Services is not permitted. Subsidy‐eligible individuals would pay one premium with two distinct payment transactions, with one going to an allocation account to be used exclusively for payment of such services. Requires State insurance commissioners to ensure compliance with the requirement to segregate federal funds in accordance with generally accepted accounting requirements and guidance from the Office of Management and Budget (OMB) and Government Accountability Office (GAO). Plans would be required to include in their benefit descriptions whether or not they cover abortion, as they will do for all other benefits. The allocation of the premium into its components would not be advertised or used in enrollment material. All applicants would see the same premium when they are choosing a plan.

Includes conscience language that prohibits qualified health plans from discriminating against any individual health care provider or health care facility because of its unwillingness to provide, pay for, provide coverage of, or refer for abortions.

Ensures that federal and State laws regarding abortion are not preempted.

UState Action Required: Insurance Commissioner is required to


E-27








Date ensure that health plans comply with segregation rules regarding premiums for abortion coverage.

USection 1304

URelated definitionsU. Defines the small group market as the market in which a plan is offered by a small employer that employs 1‐100 employees. Defines the large group market as the market in which a plan is offered by a large employer that employs more than 100 employees. Before 2016, a State may limit the small group market to 50 employees. UAs amended by SectionU U10104U, defines an “educated health care consumer,” and requires Exchanges to consult with enrollees who are educated health care consumers.

Decide to whether to delay the expansion of the small group market from 2‐50 to 2‐100 employees.

Need to amend definition of small employer in Insurance Article, §15‐1203.

Before 2013 legislative session.

Plan years beginning on or after January 1, 2014 for new definition.

Part II—Consumer Choices and Insurance Competition through Health Benefit Exchanges

USection 1311

UAffordable choices of health benefit plans.U

Requires the Secretary to award grants, available until 2015, to States for planning and establishment of American Health Benefit Exchanges. By 2014, requires States to establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans and includes a SHOP Exchange for small businesses. Requires the Secretary to: Establish certification criteria for

qualified health plans, requiring such plans to meet marketing requirements, ensure a sufficient choice of providers, include essential community providers in

Refer to grants process. Structure and governance of exchange? Functions of exchange? Encourage participation in exchange? Assess market rules to avoid selection issues. Merge individual and SHOP exchange?

Legislation will be necessary to establish an Exchange. Key decisions affecting legislation include: Establish separate Exchages for individuals and small businesses or merge them in one?

Designate a government agency or establish a nonprofit entity to run the Exchange?

Require health plans

Awaiting federal guidance. Exchange timeframes apply. Immediate—required (before 2012 legislative session).

2014


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Date their networks, be accredited on quality, implement a quality improvement strategy, use a uniform enrollment form, present plan information in a standard format, and provide data on quality measures.

Develop a rating system for qualified

health plans, including information on enrollee satisfaction, and a model template for an Exchange’s Internet portal.

Determine an initial and annual open

enrollment period, as well as special enrollment periods for certain circumstances.

Allows States to require benefits in addition to essential health benefits, but States must defray the cost of such additional benefits. USection 10104U clarifies that States must make payments to cover the cost of additional benefits directly to individuals or plans, and not to Exchanges. Requires Exchanges to certify qualified health plans, operate a toll‐free hotline and Internet website, rate qualified health plans, present plan options in a standard format, inform individuals of eligibility for Medicaid and CHIP, provide an electronic calculator to calculate plan costs, and grant certifications of exemption from the individual responsibility requirement. Beginning in

One statewide exchange or multiple regional? Multi‐state exchange? Whether to establish Exchange prior to 2014 requirement? How to coordinate enrollment from MHIP to Exchange or other coverage to minimize disruptions in coverage? How seamless should Exchange be with Medicaid or other coverage? (eligibility, plans, benefits, network, plan certification) Determine financing of Exchange so that it is self sustaining (2015) Determine how best to coordinate outreach and enrollment and role for Navigators.

to offer benefits in addition to the federal essential benefits?

Provide a financing source.

Join a Regional or Interstate Exchange?

Establish subsidiary Exchanges?

Authorize the Exchange to contract with an “eligible entity” to carry out any of its responsibilities?


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Date 2015, requires Exchanges to be self‐sustaining and allows them to charge assessments or user fees. Allows Exchanges to certify qualified health plans if they meet certification criteria and offering them is in the interests of individuals and employers, and, UAs amended by SectionU U10104U, requires Exchanges to consider the reasonableness of premium rate increases when determining whether to certify and offer plans. Allows regional or interstate Exchanges if the States agree to, and the Secretary approves, such Exchanges. Requires Exchanges to award grants to Navigators, which may include resource partners of the Small Business Administration, to educate the public about qualified health plans, distribute information on enrollment and tax credits, facilitate enrollment, and provide referrals on grievances, complaints, or questions. UAs added by sectionU U10104U, requires plans seeking certification by Exchanges to publicly disclose, in plain language, information on claims payment policies, enrollment, denials, rating practices, out‐of‐network cost‐sharing, and enrollee rights. Requires such plans to provide information to enrollees on the amount of cost‐sharing for a specific item or service. Requires the Secretary of Labor to update disclosure rules for group health plans to conform to these


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Date standards. Requires qualified health plans to implement activities to reduce health disparities, including the use of language services, community outreach, and cultural competency trainings. Allows for merger of individual and SHOP exchanges (1311(b)(2). UFederal Action Required: Federal guidance on certification criteria; rating system; enrollment periods. UState Action Required: Establish exchange. Develop enrollment process. Develop website and toll free hotline and other resources for consumers. Certify plans. Award grants to Navigators

USection 1312

UConsumer choice.U Allows qualified individuals, defined as individuals who are not incarcerated and who are lawfully residing in a State, to enroll in qualified health plans through that State’s Exchange. Allows qualified employers to offer a choice of qualified health plans at one level of coverage; small employers qualify to do so, and States may allow large employers to qualify beginning in 2017. State may require

Merge individual and small group market (2014)? Allow large employers to qualify through exchange (2017)? The extent to which state wants to

Legislation will be needed to allow a qualified individual to enroll in any qualified health plan, allow employers to specify the level of coverage to offer employees, and allow employees to choose a plan within


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Date the individual and small group market to be merged. Requires insurers to pool the risk of all enrollees in all plans (except grandfathered plans) in each market, regardless of whether plans are offered through Exchanges. Requires the offering of only qualified health plans though Exchanges to Members of Congress and their staff. UAs amended by SectionU U10104U, requires the Secretary to establish procedures to allow agents or brokers to enroll individuals and employers in qualified health plans and assist them in applying for tax credits and cost‐sharing reductions.

encourage or discourage parallel market outside the exchange?

that level. Legislation will also be needed to require insurers to pool risk in each market. Legislation will be needed if the State wants to: Merge the individual and small group markets

Allow agents and brokers to enroll individuals and employers in health plans and assist them in applying for subsidies

Allow large employers to participate in the Exchange

USection 1313

UFinancial integrity.U Requires Exchanges to keep an accurate accounting of all expenditures and submit annual accounting reports to the Secretary. Requires Exchanges to cooperate with Secretarial investigations and allows for Secretarial audits of Exchanges. If the Secretary finds serious misconduct in a State, allows the Secretary to rescind up to 1 percent of Federal payments to the State. UAs amended by SectionU U10104U, narrows the application of the False Claims Act’s public disclosure bar

Determine financial reporting requirements.

Legislation will be needed to make payments made through the Exchange subject to the (federal) False Claims Act. The State will need to decide if it wants to also make payments through the Exchange subject to the State False Claims Act.



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Date to ensure that whistleblowers who play a significant role in exposing fraud can be included in otherwise meritorious litigation. Also, requires GAO to study the cost and affordability of qualified health plans offered through Exchanges. UState Action Required: Accounting of all expenditures

Part III—State Flexibility Relating to Exchanges

USection 1321

UState flexibility in operation and enforcement of Exchanges and related requirements.U Requires the Secretary, in consultation with NAIC, to set standards for Exchanges, qualified health plans, reinsurance, and risk adjustment. Requires States to implement these standards by 2014. If the Secretary determines before 2013 that a State will not have an Exchange operational by 2014, or will not implement the standards, requires the Secretary to establish and operate an Exchange in the State and to implement the standards. Presumes that a State operating an Exchange before 2010 meets the standards, and establishes a process for the State to come into compliance with the standards.

Whether the state will meet the 2014 deadline for establishment of Exchange

Legislation will be needed to implement the federal standards for the Exchange. Alternatively, the State could decide to let the federal government establish and operate the Exchange.


2013

USection 1322

UFederal program to assist establishment and operation of nonprofit, member‐run health insurance issuers.U Requires the Secretary to award loans for start‐up costs and grants to meet solvency requirements,

Legislation will be needed if the State wants to authorize licensure of nonprofit health insurance


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Date until July 1, 2013, to member‐run nonprofits that will offer qualified health plans. UAs amended by SectionU U10104U, such loans must be repaid within 15 years. Establishes an Advisory Board with members appointed by the Comptroller General, to terminate by 2016. Prohibits health insurance issuers that existed on July 16, 2009 or governmental organizations from qualifying for the program. Allows participants to form a private purchasing council to enter into collective purchasing arrangements for items and services, but which may not set provider payment rates. Prohibits government representatives from serving on the board of directors of participants or the council. Appropriates $6 billion for the CO‐OP program, and exempts participants from taxation.

issuers for the purpose of offering qualified health plans in the State.

USection 1323

(UDeletedU by Amendment in Sec. 10104) UFunding for the territories.U As re‐designated and added by Section 1204 of the Reconciliation Act, increases federal funding in the Senate bill for Puerto Rico, Virgin Islands, Guam, American Samoa, and the Northern Marianas Islands by $2 billion. Effective July 1, 2011, raises the caps on federal Medicaid funding for each of the territories. Allows each territory to elect to operate a Health Benefits Exchange, by October 1, 2013.

N/A

USection 1324

ULevel playing field.U Requires qualified health plans offered under the CO‐OP

Legislation will be needed to specify the


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Date program, or as multi‐state plans, to be subject to all Federal and State laws that apply to private health insurers.

State laws that apply to CO‐OP plans

Part IV—State Flexibility to Establish Alternative Programs

USection 1331

UState flexibility to establish basic health programs for low‐income individuals not eligible for Medicaid.U Allows States to contract, through a competitive process that includes negotiation of premiums, cost‐sharing, and benefits, with standard health plans for individuals who are not eligible for Medicaid or other affordable coverage and have income below 200 percent of the Federal Poverty Level (FPL). Requires the Secretary to certify that participating individuals do not have to pay more in premiums and cost‐sharing than they would have paid under qualified health plans, and that the plans cover essential health benefits. Requires the Secretary to transfer to participating States 95 percent of the tax credits and cost‐sharing reductions that would have been provided to individuals enrolled in standard health plans if they were enrolled in qualified health plans. Section 10104 clarifies that legal immigrants whose income is less than 133 percent of the Federal Poverty Level (FPL), and who are not eligible for Medicaid by virtue of the five year waiting period, are eligible for the basic health program.

Determine whether to establish alternative programs.

Legislation will be needed if the State wants to establish an alternative basic health program.



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Date

USection 1332

UWaiver for State innovation.U Beginning in 2017, allows States to apply for a waiver for up to 5 years of requirements relating to qualified health plans, Exchanges, cost‐sharing reductions, tax credits, the individual responsibility requirement, and shared responsibility for employers. Requires States to enact a law and to comply with regulations that ensure transparency. Requires the Secretary to provide to a State the aggregate amount of tax credits and cost‐sharing reductions that would have been paid to residents of the State in the absence of a waiver. Requires the Secretary to determine that the State plan for a waiver will provide coverage that is at least as comprehensive and affordable, to at least a comparable number of residents, as this title would provide; and that it will not increase the Federal deficit. UFederal Action Required: HHS to develop regulations 180 days after enactment

Depending on federal guidance or benefit design, and related implementation requirements, consider whether waiver is needed.

Legislation will be needed if the State wants to apply for a State innovation waiver

2017

USection 1333

UProvisions relating to offering of plans in more than one State.U By July 1, 2013, requires the Secretary, in consultation with NAIC, to issue regulations for interstate health care choice compacts, which can be entered into beginning in 2016. Under such compacts, qualified health plans could be

Determine interest and determine what, if any, comments to provide through NAIC. Determine whether to

Legislation will be needed if the State wants to participate in an interstate health care compact

Beginning plan year 2016


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Date offered in all participating States, but insurers would still be subject to the consumer protection laws of the purchaser’s State. Insurers would be required to be licensed in all participating States (or comply as if they were licensed), and to clearly notify consumers that a policy may not be subject to all the laws and regulations of the purchaser’s State. Requires States to enact a law to enter into compacts and Secretarial approval, but only if the Secretary determines that the compact will provide coverage that is at least as comprehensive and affordable, to at least a comparable number of residents, as this title would provide; and that it will not increase the Federal deficit or weaken enforcement of State consumer protection laws.

enter into multi‐state Compact.

USection 1334

UMulti‐State Plans.U UAs added by sectionU U10104U, requires the Office of Personnel Management (OPM) to contract with health insurers to offer at least two multi‐state qualified health plans (at least one non‐profit) through Exchanges in each State. Requires OPM to negotiate contracts in a manner similar to the manner in which it negotiates contracts for Federal Employees Health Benefits Program (FEHBP), and allows OPM to prohibit multi‐state plans that do not meet standards for medical loss ratios, profit margins, and premiums. Requires multi‐state plans to cover essential health benefits and meet all of the requirements of

Legislation will be needed to require multi‐state health plans selected by OPM to be licensed in the State and meet State requirements that are not inconsistent with federal law. The State will need to decide whether to require multi‐state plans to offer benefits in addition to the federal essential benefits.


E-37








Date a qualified health plan; States may require multi‐state plans to offer additional benefits, but must pay for the additional cost. Multi‐state plans must comply with 3:1 age rating, except States may require more protective age rating. Multi‐state plans must comply with the minimum standards and requirements of FEHBP, unless they conflict with the PPACA. Guarantees that FEHBP will maintain a separate risk pool and remain a separate program.

Part V—Reinsurance and Risk Adjustment

USection 1341

UTransitional reinsurance program for individual and small group markets in each State.U For 2014, 2015, and 2016, requires States to establish a nonprofit reinsurance entity that collects payments from insurers market and makes payments to insurers in the individual market that cover high‐risk individuals. Requires the Secretary to establish Federal standards for the determination of high‐risk individuals, a formula for payment amounts, and the contributions required of insurers, which must total $25 billion over the three years. UFederal Action Required: Federal Standards UState Action Required: To establish a nonprofit reinsurance entity

Evaluate federal guidance to clarify decisions for states

Legislation will be needed to establish a reinsurance entity and incorporate the federal standards. The legislation will also need to eliminate or modify the State high‐risk pool to carry out the reinsurance program.


Plan years 2014‐2016

USection UEstablishment of risk corridors for plans in The reinsurance Awaiting federal


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Date 1342 individual and small group markets.U

Requires the Secretary to establish risk corridors for qualified health plans in 2014, 2015, and 2016. If a plan’s costs (other than administrative costs) exceed 103 percent of total premiums, the Secretary makes payments to the plan to defray the excess. If a plan’s costs (other than administrative costs) are less than 97 percent of total premiums, the plan makes payments to the Secretary. UState Action Required: Establish a risk‐adjustment process

legislation will need to include the risk corridors established by the Secretary.

guidance.

USection 1343

URisk adjustment.U Requires States to assess charges on health plans with enrollees of lower‐than‐average risk, and to provide payments to health plans with enrollees of higher‐than‐average risk. Risk adjustment applies to plans in the individual and small group markets, but not to grandfathered health plans. UState Action Required: Implement risk adjustment methodology.

The reinsurance legislation will need to include the federal risk adjustment requirements. Risk adjustment is an ongoing issue, requiring adjustment based on a priori risk and/or past claims history.


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

USection 1401

URefundable tax credit providing premium assistance for coverage under a qualified health plan.U Amends the Internal Revenue Code to provide tax credits to assist with the

Require health plans in the Exchange to offer additional benefits for which the tax credits are

Legislation establishing the Exchange should require the Exchange and the health plans



E-39








Date cost of health insurance premiums. U“Sec. 36B.”U URefundable credit for coverage under a qualified health plan. U UAs amended by SectionU U1001U of the Reconciliation Act, the premium assistance credit amount is two percent for those up to 133 percent of poverty, and calculated on sliding scale starting at three percent of income for those at or above 133 percent of poverty and phasing out to 9.5 percent of income for those at 300‐400 percent of poverty. The reference premium is the second lowest cost silver plan available in the individual market in the rating area in which the taxpayer resides. The premium assistance credits do not take into account benefits mandated by States. Employees offered coverage by an employer under which the plan’s share of the total allowed costs of benefits provided under the plan is less than 60 percent of such costs or the premium exceeds 9.5 percent of the employee’s income are eligible for the premium assistance credit. This section also provides for reconciliation of the premium assistance credit amount at the end of the taxable year and for a study on the affordability of health insurance coverage by the Comptroller General. The Reconciliation Act requires each Exchange to report to the Secretary and to the taxpayer information regarding health insurance coverage and any tax credits received.

not available? offered through the Exchange to support the tax credits available to individuals purchasing coverage through the Exchange. If the State decides to require health plans in the Exchange to offer additional benefits for which the tax credits are not available, the legislation should so specify.


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Date USection 1402

UReduced cost‐sharing for individuals enrolling in qualified health plans.U The standard out‐of‐pocket maximum limits ($5,950 for individuals and $11,900 for families) would be reduced to one‐third for those between 100‐200 percent of poverty, one‐half for those between 200‐300 percent of poverty, and to two‐thirds for those between 300‐400 percent of poverty. UAs amended by SectionU 1001 of the Reconciliation Act, the plan’s share of total allowed costs of benefits would be increased to 94 percent for those between 100‐150 percent of poverty (i.e., the individual’s liability is limited to 10 percent on average); 87 percent for those between 150‐200 percent of poverty; 73 percent for those between 200‐250 percent of poverty; and 70 percent for those between 250‐400 percent of poverty. The cost‐sharing assistance does not take into account benefits mandated by States.

Require health plans in the Exchange to offer additional benefits for which the tax credits are not available?

As indicated above for Section 1401, legislation establishing the Exchange should require the Exchange to meet federal standards for individuals to benefit from reduced cost‐sharing provisions. If the State decides to require health plans in the Exchange to offer additional benefits for which the reduced cost‐sharing is not available, the legislation should so specify.


Subpart B – Eligibility Determinations

USection 1411

UProcedures for determining eligibility for Exchange participation, premium tax credits and reduced cost‐sharing, and individual responsibility exemptions.U The Secretary shall establish a program for determining whether an individual applying for coverage in the individual market by a

How to simplify documentation processes?

Legislation establishing the Exchange should require applicants to comply with the eligibility requirements established by the Secretary.



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Date qualified health plan offered through an Exchange, or who is claiming a premium tax credit or reduced cost‐sharing, is a citizen or national of the United States or an alien lawfully present in the United States and meets the income and coverage requirements; whether an individual’s coverage under an employer‐sponsored health benefits plan is treated as unaffordable; and whether to grant a certification attesting that, for purposes of the individual responsibility requirement, an individual is entitled to an exemption from either the individual responsibility requirement or the penalty imposed by such section.

USection 1412

UAdvance determination and payment of premium tax credits and cost‐sharing reductions.U Allows for the advanced payment of premium assistance tax credits and cost‐sharing reductions for eligible individuals. Prohibits any Federal payments to individuals who are not lawfully present in the United States.

Federal Legislation is not needed as this is a federal function.

USection 1413

UStreamlining of procedures for enrollment through an Exchange and State Medicaid, CHIP, and health subsidy programs.U Requires the Secretary to establish a system for the residents of each State to apply for

How to ensure no one loses eligibility without determining eligibility twice— the old way and using

Legislation may be needed to allow individuals to apply for State health subsidy programs through the

COMAR 10.09.24. Medical Assistance Eligibility COMAR 10.09.11

Awaiting federal guidance. Immediate—required.


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Date enrollment in, receive a determination of eligibility for participation in, and continue participation in, applicable State health subsidy programs. The system will ensure that if any individual applying to an Exchange is found to be eligible for Medicaid or a State children’s health insurance program (CHIP), the individual is enrolled for assistance under such plan or program. UFederal Action Required: Need clarification from HHS regarding plans to move to “all health program” application versus “all program—health, cash assistance, food, etc” application. Need clarification from HHS regarding necessity of calculating eligibility the old way as well as using MAGI method. HHS anticipates timeframe for decisions by end of CY 2010. Single application form. Promulgate standards for electronic data interface. UState Action Required: Ability to apply online, in person, by mail, or by phone. Apply for MA/ CHIP through Exchange—electronic data interface for all “applicable

MAGI? What are Maryland’s income levels when taking disregards into consideration? Decouple health insurance from other programs? Interface with 1‐e‐app, CARES, SAIL, exchange? What improvements are needed for CARES for this to work? How will MA/ CHIP eligibles applying to Exchange be handled? And the reverse? How does this fit with express lane eligibility? State or federal application form? How will this track to MMIS?

system established by the Secretary. Legislation may also be needed to require the development of an electronic interface for State health subsidy programs and to require those subsidy programs to participate in data matching. The State will also need to decide whether to use the single form developed by the Secretary or develop its own form or a supplemental form.

Maryland Children’s Health Program COMAR 10.09.43 Maryland Children’s Health Program Premium


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Date State health subsidy programs”—plans offered through Exchange, MA, CHIP, State basic health plan. MA eligibility still determined by public agency.

USection 1414

UDisclosures to carry out eligibility requirements for certain programs.U Allows for limited disclosure of tax return information to carry out eligibility requirements for certain programs listed in the Act. UFederal Action Required: IRS can give taxpayer info to HHS; HHS can disclose to Exchange or state “inconsistency” between HHS and state’s info

Need to change law to bring Kids First Act into conformity? Information to be used for mandate?

Legislation establishing the Exchange should require the Exchange to restrict the use of shared tax information to the purpose specified in the federal law.


USection 1415

UPremium tax credit and cost‐sharing reduction payments disregarded for Federal and Federally‐assisted programs.U Precludes the premium assistance tax credits and cost‐sharing reductions from being counted as income for purposes of determining eligibility for any Federal program or under any State or local program financed in whole or in part with Federal funds.

The federal treatment of this credit or refund not as income will flow thorugh to the state of Maryland; no state income tax impact.

COMAR 10.09.24 Medical Assistance Eligibility

USection 1416

UStudy of geographic variation in application of FPL.U UAs added by sectionU 10105, directs the Secretary of HHS to study adjusting the definition of “federal poverty level” to

Federal N/A – federal study.


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Date reflect cost of living variations among different geographic areas within the United States.

Part II – Small Business Tax Credit

USection 1421

UCredit for employee health insurance expenses of small businesses.U Amends the Internal Revenue Code to provide tax credits to small employers.

U“Sec. 45R.”U UEmployee health insurance expenses of small employers. As amended by SectionU U10105U, provides a sliding scale tax credit to small employers with fewer than 25 employees and average annual wages of less than $50,000 that purchase health insurance for their employees. The full credit will be available to employers with 10 or fewer employees and average annual wages of less than $25,000. To be eligible for a tax credit, the employer must contribute at least 50 percent of the total premium cost or 50 percent of a benchmark premium. In 2010 through 2013, eligible employers can receive a small business tax credit for up to 35 percent of their contribution toward the employee’s health insurance premium. Tax‐exempt small businesses meeting the above requirements are eligible for tax credits of up to 25 percent of their contribution. In

Determine how federal tax credit and current Maryland Partnership will interact. Consider potential changes to Partnership. How to facilitate outreach and information on federal tax credit and Partnership for small businesses in Maryland.

Insurance Article Title 15 Subtitle 12A provides a premium subsidy for employers with 2 – 9 employees that have not previously offered insurance. The new federal small business tax credit provides a less generous subsidy but more businesses are eligible. Legislation to alter the current State subsidy is not necessary, unless the State wants to alter or eliminate it.



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Date 2014 and beyond, eligible employers who purchase coverage through the State Exchange can receive a tax credit for two years of up to 50 percent of their contribution. Tax‐exempt small businesses meeting the above requirements are eligible for tax credits of up to 35 percent of their contribution.

Subtitle F—Shared Responsibility for Health Care ‐ Part I – Individual Responsibility

USection 1501

URequirement to maintain minimum essential coverage. U Contains findings of Congress related to the individual responsibility requirement, which are Uamended by Section 10106U. U“Sec. 5000A.”U URequirement to maintain minimum essential coverage. U Requires individuals to maintain minimum essential coverage beginning in 2014. UAs amended by SectionU 1002 of the Reconciliation Act, failure to maintain coverage will result in a penalty of the greater of $95 or one percent of income in 2014, $325 or two percent of income in 2015 and $695 or 2.5 percent of income in 2016, up to a cap of the national average bronze plan premium. Families will pay half the amount for children up to a cap of $2,250 for the entire family. After 2016, dollar amounts will increase by the annual cost of living adjustment. Exceptions to the

Whether to strengthen the individual mandate? Whether to consider strategies to mitigate adverse selection?. Change Kids First law? Is the Kids First Express Act of 2010 necessary in light of Sec. 5000A requiring that an individual and any dependent of the individual be covered under minimum essential coverage, even though the federal health care coverage requirement does not go into actual effect until

No effect on State law – federal tax code



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Date individual responsibility requirement to maintain minimum essential coverage are made for religious objectors, individuals not lawfully present, and incarcerated individuals. Exemptions from the penalty will be made for those who cannot afford coverage, taxpayers with income below the filing threshold, members of Indian tribes, those who have received a hardship waiver and those who were not covered for a period of less than three months during the year.

2014?

USection 1502

UReporting of health insurance coverage. UAmends the Internal Revenue Code to require the reporting of health insurance coverage. U“Sec. 6055.”U UReporting of health insurance coverage.U Requires every person that provides coverage to report certain information about the coverage to the IRS.

Tax‐General Article § 10‐211.1 requires taxpayers to report health insurance for dependent children, but there is no penalty for not reporting. The provision terminates 6/30/14 and should no longer be needed at that point. TG § 10‐211.1 requires the insured to report his or her dependents’ health care coverage. Sec. 6055 required the insurers to report information on the insured. The federal provision and the Maryland provision


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Date impose reporting requirements on different parties.

Part II – Employer Responsibilities

USection 1511

UAutomatic enrollment for employees of large employers.U Requires employers with more than 200 employees to automatically enroll new full‐time employees in coverage (subject to any waiting period authorized by law) with adequate notice and the opportunity for an employee to opt out of any coverage the individual or employee was automatically enrolled in.

State Personnel and Pensions Article Title 2 Subtitle 5 establishes the State Employee and Retiree Health and Welfare Benefits Program. § 2‐507 allows a State employee to enroll and participate in any of the health insurance or other benefit options established under the Program. Legislation may be desirable to provide that a new full‐time employee is automatically enrolled unless the employee opts out.

USection 1512

UEmployer requirement to inform employees of coverage options.U Requires that an employer provide notice to their employees informing them of the existence of an Exchange. Also, if the employer plan’s share of the total allowed costs of benefits provided under the plan is less than 60 percent of such costs, that the employee may be eligible for a premium assistance tax

No effect on State law – Fair Labor Standards Act.


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Date credit and cost sharing reduction. Finally, if the employee purchases a qualified health plan through the Exchange, the employee will lose the employer contribution (if any) to any health benefits plan offered by the employer and that all or a portion of such contribution may be excludable from income for Federal income tax purposes.

USection 1513

UShared responsibility for employers.U As amended by the Reconciliation Act, requires an employer with at least 50 full‐time employees that does not offer coverage and has at least one full‐time employee receiving a premium assistance tax credit to make a payment of $2,000 per full‐time employee. Includes the number of full‐time equivalent employees for purposes of determining whether an employer has at least 50 employees. Exempts the first 30 full‐time employees for the purposes of calculating the amount of the payment. Section 10106 clarifies that the calculation of full‐time workers is made on a monthly basis. The Reconciliation Act eliminates the penalty for waiting periods before an employee may enroll in coverage. An employer with at least 50 employees that does offer coverage but has at least one full‐time employee receiving the premium assistance tax credit will pay the lesser of $3,000 for each of those employees receiving a tax credit or $2,000 for each of their full‐time employees total, not including the first 30 workers. The Secretary of Labor shall conduct a study to

No effect on State law – Internal Revenue Code.


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Date determine whether employees’ wages are reduced by reason of the application of the assessable payments.

USection 1514

UReporting of employer health insurance coverage.U Requires large employers to report to the Secretary whether it offers to its full‐time employees (and their dependents) the opportunity to enroll in minimum essential coverage under an eligible employer‐sponsored plan, the length of any applicable waiting period, the lowest cost option in each of the enrollment categories under the plan, and the employer’s share of the total allowed costs of benefits provided under the plan. The employer must also report the number and names of full‐time employees receiving coverage.

No effect on State law – Internal Revenue Code.

USection 1515

UOffering of exchange‐participating qualified health plans through cafeteria plans.U Amends the Internal Revenue Code related to cafeteria plans. U“Sec. 125(f)(3).”U UCertain exchange‐participating health plans not qualified.U Plans provided through the exchange will not be an eligible benefit under an employer‐sponsored cafeteria plan, except in the case of qualified employers (i.e., small employers, and, after 2017, large employers in electing states) offering a choice of plans to their employees through the exchange.

No effect on State law – Internal Revenue Code

Subtitle G—Miscellaneous Provisions

USection UDefinitions.U Applies the definitions N/A ‐ definitions


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Date 1551 contained in section 2791 of the Public

Health Service Act to this title.

USection 1552

UTransparency in government.U Not later than 30 days after the date of enactment of this Act, the HHS Secretary shall publish on the HHS website a list of all of the authorities provided to the Secretary under this Act.

Federal N/A – applies only to HHS

USection 1553

UProhibition against discrimination on assisted suicide. UPrevents the Federal government, and any State or local government or health care provider that receives Federal financial assistance from subjecting any individual or institutional health care entity to discrimination on the basis that the entity does not provide assisted suicide, euthanasia, or mercy killing.

Criminal Law Article § 3‐102 prohibits an individual from assisting another individual to commit suicide. (No changes needed.) See also the Health Care Decisions Act, HG 5‐601, et seq.

USection 1554

UAccess to therapies.U Prevents the HHS Secretary from promulgating certain regulations limiting access to health care services.

Federal N/A – HHS only

USection 1555

UFreedom not to participate in Federal health insurance programs.U Provides that no individual, company, business, nonprofit entity, or health insurance issuer shall be required to participate in any Federal health insurance program created under this Act.

Federal N/A COMAR 10.09.36State has option of issuing clarifying language to show that participation in the Medicaid program is not required.

USection 1556

UEquity for certain eligible survivors.U Provides for improvements to the Black Lung Benefits Act.

Federal N/A


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Date

USection 1557

UNondiscrimination.U Protects individuals against discrimination under the Civil Rights Act, the Education Amendments Act, the Age Discrimination Act, and the Rehabilitation Act, through exclusion from participation in or denial of benefits under any health program or activity.

Federal Legislation will be needed to amend Insurance Article § 27‐501, which prohibits discrimination in underwriting but allows discrimination based on gender, if actuarially justified. IN § 27‐910 prohibiting a health network from denying health care services on the basis of gender, race, age, religion, national origin, or an ADA protected category need not be changed. IN § 27‐913 prohibiting benefits for treatment of specified diseases or diagnoses from being subject to different copays, coinsurance, deductibles, annual maximum limits, or lifetime maximum limits will need to be amended to strike lifetime maximum limits.

COMAR 10.09.36The general fee‐for‐srvice MA conditions of participation do not specifically reference the federal statutory provisions although they reference their tenants (race, gender, handicap, etc.). DHMH may seek to revise this section to bring fee‐for‐service and capitated standards into alignment. See: COMAR 10.09.76.07A(2) prohibits an MCO from discriminating against an enrollee on any basis, including, but not limited to, age, sex, race, creed, color, marital status, national origin, physical or mental handicap, health status, or need for health services. COMAR 10.09.03.03G, 10.09.04.03C(9),


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Date 10.09.10.03J, 10.09.14.03E, 10.09.16.05E, 10.09.18.03E, 10.09.27.03B(1)(vi), 10.09.29.03I, 10.09.30.03A(8), 10.09.36.03A(7), 10.09.38.03A(8), 10.09.44.03G, 10.09.44.05C, 10.09.59.03G, also requires a provider to provide services without regard to race, color, age, sex, national origin, marital status, or physical or mental handicap.

USection 1558

UProtection for employees. UAmends the Fair Labor Standards Act to ensure that no employer shall discharge or in any manner discriminate against any employee with respect to his or her compensation, terms, conditions, or other privileges of employment because the employee has received a premium tax credit or for other reasons.

Federal N/A – federal labor law.

USection 1559

UOversight.U The Inspector General of the Department of HHS shall have oversight authority with respect to the administration and implementation of this title as it relates to such Department.

N/A – HHS oversight.


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Date

USection 1560

URules of construction.U Nothing in this title shall be construed to modify, impair, or supersede the operation of any antitrust laws. Nothing in this title shall modify or limit the application of the exemption for Hawaii’s Prepaid Health Care Act under ERISA. Nothing in this title shall be construed to prohibit an institution of higher education from offering a student health insurance plan, to the extent that such requirement is otherwise permitted under applicable Federal, State, or local law.

Commercial Law Article Title 11 Subtitle 2 is the Maryland Antitrust Act. CL § 11‐203 exempts from antitrust the activities of insurers regulated under the Insurance Article, with some exceptions, and hospitals’ joint ventures and mergers, to the extent the hospital activity is approved by the MD Health Care Commission. Student health insurance plans are considered blanket health insurance, regulated under Insurance Article §§ 15‐305 through 15‐310. Such plans often provide very limited benefits.

USection 1561

UHealth information technology enrollment standards and protocols.U Requires the development of standards and protocols to promote the interoperability of systems for enrollment of individuals in Federal and

Tax‐General Article § 10‐211.1 requires the Comptroller and DHMH to enter into an interagency agreement


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Date State health and human services programs. These standards shall allow for electronic data matching, and electronic documentation. The Secretary may require State or other entities to incorporate such standards as a condition of receiving Federal health information technology funds.

that allows sharing of tax data for the purpose of identifying and enrolling kids into Medicaid and CHIP (law sunsets 6/30/14). State Medical Record Act confidentiality requirements could be amended to clarify provisions dealing with interagency data sharing. See Health General Article, Title 4.

USection 1562

UGAO study regarding the rate of denial of coverage and enrollment by health insurance issuers and group health plans.U UAs added by sectionU 10107, Directs the GAO to study the rate of denial of coverage and enrollment by health insurance issuers and group health plans.

Federal N/A – study.

USection 1563

UConforming amendments.U Provides for technical and conforming amendments. USmall business procurement.U USection 10107 moved this sectionU, previously Section 1562, to Section 1563. Disallows any waiver of small business contracts under the Federal Acquisition Regulation of the Small Business Act.

N/A


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Date

TITLE II – ROLE OF PUBLIC PROGRAMS Subtitle A – Improved Access to Medicaid

USection 2001

UMedicaid coverage for the lowest income populations. Eligibility. Creates a new State option to provide Medicaid coverage through a State plan amendment beginning on April 1, 2010, UAs amended by SectionU U10201U. Eligible individuals include: all non‐elderly, non‐pregnant individuals who are not entitled to Medicare (e.g., childless adults and certain parents). Creates a new mandatory Medicaid eligibility category for all such “newly‐eligible” individuals with income at or below 133 percent of the Federal Poverty Level (FPL) beginning January 1, 2014. Also, as of January 1, 2014, the mandatory Medicaid income eligibility level for children ages six to 19 changes from 100 percent FPL to 133 percent FPL. Effective April 1, 2010, states have the option to provide Medicaid coverage to all non‐elderly individuals above 133 percent of FPL through a State plan amendment. Benefits. Newly‐eligible, non‐elderly, non‐pregnant individuals would receive benchmark or benchmark‐equivalent coverage consistent with the requirements of section 1937 of the Social Security Act. Benchmark and benchmark‐equivalent

How seamless is delivery system for MA, CHIP, Exchange (procurement, monitoring, etc)? Consideration for seamlessness: state will need to continue special MA monitoring required under BBA. SPA to expand MA pre‐2014? SPA to expand above 133% FPL? Move waiver populations under state plan? Need waiver authority to mandatorily enroll disabled and foster care populations in managed care. Move Family Planning under State Plan. What benefit package? Benchmark, or benchmark equivalent?

Health‐General Article § 15‐103 authorizes Medicaid eligibility for parents and childless adults with income up to 116% FPL. Limits may be placed on childless adults. Children ages 6 – 18 with income below 100% FPL are eligible (higher income kids are eligible under MCHP). Legislation will be needed to comply with the new federal income eligibility standards.

COMAR 10.09.24 Medical Assistance Eligibility COMAR 10.09.60 Primary Adult Care Program


January 1, 2014


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Date coverage would be required to provide at least essential benefits (as defined for the Exchange) and prescription drugs and mental health services would be added to the list of services that must be covered at actuarial equivalence. Increased Federal assistance. UAs amended by SectionU U1201U of the Reconciliation Act, strikes the provision for a permanent 100 percent federal matching rate for Nebraska for the Medicaid costs of newly eligible individuals. Provides federal Medicaid matching payments for the costs of services to newly eligible individuals at the following rates: 100 percent in 2014, 2015, and 2016; 95 percent in 2017; 94 percent in 2018; 93 percent in 2019; and 90 percent thereafter. In the case of expansion states, additional federal support for covering nonpregnant childless adults is phased‐in so that in 2019 and thereafter, expansion states would receive the same FMAP as other states for newly‐eligible and previously‐eligible nonpregnant childless adults. Maintenance of income eligibility. States would be required to maintain the same income eligibility levels through December 31, 2013 for all adults. This “maintenance of effort” (MOE) requirement would be extended through September 30, 2019 for all children currently covered in Medicaid or CHIP. Between January 1, 2011 and January 1, 2014, a State would be exempt from the

Implications of benefit package for MMIS/ rate‐setting? Per HHS, full Medicaid will be allowed. How to ensure adequate provider capacity? MCO rate‐setting for new populations? Effect on budgets/ special programs to shift uninsured to MA. How will Exchange enrollment/ timing operate?


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Date MOE requirement for optional, non‐pregnant, non‐disabled, adult populations whose family income is above 133 percent of FPL if the State certifies to the Secretary that the State is currently experiencing a budget deficit or projects to have a budget deficit in the following State fiscal year. UFederal Action Required: Guidance on presumptive eligibility Higher FMAP UState Action Required: Expand MA to 133% FPL, including for childless adults. Ensure children are covered for parents to be eligible. Annual enrollment reports to feds by January 2015. Track newly eligible for higher FMAP MOE income eligibility—December 31, 2012 for adults, September 30, 2019 for children. MOE—eligibility standards, methods, procedures not more restrictive until Exchange fully operational. Clarification on presumptive eligibility note—if state has opted to provide


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Date presumptive eligibility period, may do some in same manner for new population.

USection 2002

UIncome eligibility for nonelderly determined using modified adjusted gross income.U Beginning January 1, 2014, States would be required to use modified adjusted gross income to determine Medicaid eligibility, the same measure used in the State Exchanges. Income disregards and asset tests would generally no longer apply in Medicaid, except for individuals eligible for long‐term services and supports and individuals that are eligible for Medicaid through another program. UAs amended by SectionU U1004U of the Reconciliation Act, applies a five percent income disregard for all Medicaid applicantsU. UFederal Action Required: Information needed from HHS. UState Action Required: Use MAGI. No adults lose coverage as result through March 31, 2014; no children lose coverage as result. During transition to MAGI, use equivalent test to prevent loss of coverage. No assets test, no disregards. N/A for Medicare cost sharing. Submit to HHS eligibility thresholds and methods.

Transitional test? How to use new method while ensuring no loss of coverage without determining eligibility two ways? Express lane eligibility?

Health‐General Article § 15‐103(a) uses both “family income” and “household income”. Legislation should change these terms to “modified adjusted gross income.” Income disregards and asset tests are not in statute, except in the Maryland Pharmacy Assistance Program (HG § 15‐124).



January 1, 2014


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Date

USection 2003

UPremium assistance for employer‐sponsored insurance.U States to offer premium assistance and wrap‐around benefits to all Medicaid beneficiaries who are offered employer‐sponsored insurance (ESI) if it is cost‐effective to do so, based on current law requirements. UState Action Required: Voluntary for states.

Offer premium assistance for ESI?

Current law does not address premium assistance and wrap‐around benefits. Although DHMH has broad authority under the Health‐General Article to run the Medical Assistance program, legislation may be desirable to require DHMH to offer premium assistance and wrap‐around benefits.

Promulgate new chapter of regulations if state offers as cost‐effective

January 1, 2014

USection 2004

UMedicaid coverage for former foster care children.U UAs amended by SectionU 10201, Makes the State option to cover former foster children in Medicaid mandatory, moves the effective date up to 2014, and limits it to only those children who have aged out of the foster care system as of the date of enactment. Children who qualify for Medicaid through this eligibility pathway would receive all benefits under Medicaid, including EPSDT. UState Action Required: Clarification—EPSDT covered up to 21, not 26. Currently covered up to 25. Change to 26.

Conforming. Health‐General Article §§ 15‐101 (definition) and 15‐103(a)(2)(xi) authorize eligibility for independent foster care adolescents. Legislation is needed to raise the eligible age up to 26.




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Date USection 2005

Payments to territories. USection 1204 of the Reconciliation Act U, redesignates funding for the territories as Section 1323, above.

N/A

USection 2006

USpecial adjustment to FMAP determination for certain States recovering from a major disaster.U Reduces projected decreases in Medicaid funding for States that have experienced major, statewide disasters.

N/A

USection 2007

UMedicaid Improvement Fund rescission.U Rescinds funds available in the Medicaid Improvement Fund (MIF) for fiscal years 2014 through 2018.

N/A

Subtitle B – Enhanced Support for the Children’s Health Insurance Program

USection 2101

UAdditional Federal financial participation for CHIP.U Upon enactment, States would be required to maintain income eligibility levels for CHIP through September 30, 2019. From fiscal year 2014 to 2019, States would receive a 23 percentage point increase in the CHIP match rate, subject to a cap of 100 percent. CHIP‐eligible children who cannot enroll in CHIP due to Federal allotment caps would be eligible for tax credits in the State Exchange. UAs amended by SectionU U10203U, extends the current reauthorization period of CHIP for two years, through September 30, 2015. States will receive a 23 percentage point increase in their federal match rates beginning fiscal year 2016 through fiscal year 2019. This provision also increases outreach and enrollment grants by $40 million, makes some children of public employees eligible for CHIP, and precludes

Expand coverage of public employees? Continue current policy of covering public employees with required 6‐month crowd out provision?

Health‐General Article Title 15 Subtitle 3 establishes the Maryland Children’s Health Program. Legislation may be desirable to require that (1) children unable to enroll in MCHP due to funding shortfalls be screened for Medicaid and, if not eligible, enrolled in a plan through the Exchange: and (2) children found ineligible for Medicaid as a result of eliminating income disregards be enrolled in MCHP.

COMAR 10.09.11 Maryland Children’s Health Program COMAR 10.09.43 Maryland Children’s Health Program Premium


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Date transitioning coverage from CHIP to the Exchange without Secretarial certification. It also requires insurers in the Exchange to report to the Secretary on pediatric quality measures. UFederal Action Required: By April 1, 2015 certify Exchange plans are comparable to State child health plans. UState Action Required: Eligibility MOE through Sep 30, 2019. Use MAGI for eligibility. Children who are not MA eligible because of elimination of disregards get CHIP. Allotment issue—If CHIP allotment runs out, screen for MA or cover children through Exchange. No enhanced match available if there is insufficient allotment.

USection 2102

UTechnical corrections. U Makes technical corrections to selected provisions in the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA) and the American Recovery and Reinvestment Act of 2009 (ARRA).

N/A

Subtitle C – Medicaid and CHIP Enrollment Simplification

USection 2201

UEnrollment Simplification and coordination with State Health Insurance Exchanges.U

Where is website housed/ maintained?

Although DHMH has broad authority to run

COMAR 10.09.24 Medical Assistance


Website effective January 1, 2014.


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Date Allows individuals to apply for and enroll in Medicaid, CHIP or the Exchange through a State‐run website. Requires State Medicaid and CHIP programs and the Exchange to coordinate enrollment procedures to provide seamless enrollment for all programs. UFederal Action Required: Need clarification from HHS—see Section 1413. UState Action Required: Single website for MA, CHIP, Exchange eligibility/ enrollment. People applying for Exchange/ premium assistance & subsidies can be determined for MA/ CHIP (and the reverse). Accept electronic signature for enrollment & reenrollment. Website links MA, CHIP, Exchange. Website compares benefits, premiums, cost‐sharing between public programs and Exchange. Secure electronic interface among MA, CHIP, Exchange to determine eligiblity. For people with MA or CHIP AND Exchange plan coverage, State coordinates services. State conducts MA/ CHIP outreach/

Where do electronic applications go? (Public agency needs to determine eligibility) Who manages electronic interface? What data are needed for eligibility determination? Is MMIS able to handle this/ will it be? How is balance of statewide versus localized infrastructure changed? State has to guarantee out‐stationed workers. Different forces will change capacity needed in different ways—expanded population, electronic submissions, etc. Data elements for plan comparisons? Outreach needed? How to handle MA/ CHIP applicants eligible for

the Medicaid and MCHP programs, legislation may be desirable to require DHMH to allow individuals to enroll in the programs through a State‐run website and to require DHMH and the Exchange to coordinate enrollment procedures.

Eligibility COMAR 10.09.11 Maryland Children’s Health Program COMAR 10.09.43 Maryland Children’s Health Program Premium


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Date enrollment of vulnerable pops defined as homeless, SHCN, pregnant, minorities, rural, victims of abuse/ trauma, MI or SA, HIV/AIDS. MA or CHIP agencies may determine premium assistance eligibility for Exchange.

subsidies?

USection 2202

UPermitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations. UAllows any hospital the option, based off preliminary information, to provide Medicaid services during a period of presumptive eligibility to members of all Medicaid eligibility categories. UState Action Required: At option of state.

Increase hospital presumptive eligibility activities?

Current law does not address permitting hospitals to make presumptive eligibility determinations. Legislation may be desirable to do so.

COMAR 10.09.24 Medical Assistance Eligibility (if state decides to exercise option)

January 1, 2014

Subtitle D – Improvements to Medicaid Services

USection 2301

UCoverage for freestanding birth center services.U Requires coverage of services provided by free‐standing birth centers. UState Action Required: Ask CMS if current policy meets requirement.

Will current coverage (higher physician or midwife fee in birth center) meet requirement?

Current law does not address Medicaid coverage for freestanding birth center services, but this should be able to be accomplished administratively.


Date of enactment unless change in state law required—then Q1 after 2011 session.

USection 2302

UConcurrent care for children. U Allows children who are enrolled in either Medicaid or CHIP to receive hospice services without foregoing curative treatment related to a terminal illness.

Add new services? Potentially expensive.

Health‐General Article § 15‐128 authorizes reimbursement for hospice.

COMAR 10.09.35 Hospice Care


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Date UState Action Required: Hospice defined by the State.

USection 2303

UState eligibility option for family planning services.U Adds a new optional categorically‐needy eligibility group to Medicaid comprised of (1) non‐pregnant individuals with income up to the highest level applicable to pregnant women covered under Medicaid or CHIP, and (2) individuals eligible under the standards and processes of existing section 1115 waivers that provide family planning services and supplies. Benefits would be limited to family planning services and supplies, including related medical diagnostic and treatment services.

SPA to move family planning program from 1115 waiver to State Plan? Expand presumptive eligibility?

Health‐General Article § 15‐103(a)(2)(iv) requires coverage of family planning services for women eligible under the pregnant woman category of Medicaid and income up to 250% FPL for 5 years after delivery. Legislation will be needed if the State wants to also provide family planning services to non‐pregnant women with income up to 250% FPL.

COMAR 10.09.58 (if state exercises option) COMAR 10.09.67.19 (if state exercises option)

USection 2304

UClarification of definition of medical assistance.U Clarifies that “medical assistance” encompasses both payment for services provided and the services themselves.

N/A – clarification.

Subtitle E – New Options for States to Provide Long‐Term Services and Supports

USection 2401

UCommunity First Choice Option.U Establishes an optional Medicaid benefit through which States could offer community‐based attendant services and supports to Medicaid beneficiaries with disabilities who would otherwise require the level of care offered in a hospital, nursing facility, or intermediate

Apply for SPA? Health‐General Article Title 15 Subtitle 8 establishes the Living at Home Waiver Program of community attendant services and supports for individuals

Promulgate new chapter of regulations (if state exercises option)

Begins October 1, 2011.


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Date care facility for the mentally retarded. UAs amended by SectionU U1205U of the Reconciliation Act, October 1, 2011 is the effective date for this policy. UFederal Action Required: FMAP increased by 6%. Define family members. Reporting. UState Action Required: Need a consumer council. Cannot reduce expenditures in first year. Report to HHS. LTC reform group will consider.

ages 18 – 64. Legislation will be needed if the State wants to make this benefit available more broadly. Note: The PPACA requires compliance with the Fair Labor Standards Act for the attendant services.

USection 2402

URemoval of barriers to providing home and community‐based services.U Removes barriers to providing HCBS by giving States the option to provide more types of HCBS through a State plan amendment to individuals with higher levels of need, rather than through a waiver, and to extend full Medicaid benefits to individuals receiving HCBS under a State plan amendment. UFederal Action Required: HHS promulgate regulations

Take up new 1915i options? May target by amount, duration, scope. How to integrate with LTC reform initiative?

Home and community‐based services are now provided through waivers established as a result of Health‐General Article §§ 15‐130 (residential treatment center), 15‐132 (older adults), and 15‐137 (prohibition on denial of access to waiver services). Legislation will be needed if the State wants to make these benefits available more broadly.

Promulgate new chapter of regulations (if state exercises option)


Begins FYQ1 after enactment.


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Date USection 2403

UMoney Follows the Person Rebalancing Demonstration.U Extends the Money Follows the Person Rebalancing Demonstration through September 30, 2016 and changes the eligibility rules for individuals to participate in the demonstration project by requiring that individuals reside in an inpatient facility for not less than 90 consecutive days. UState Action Required: LTC reform group will consider.

Apply for extension? Expand current project given change in eligibility?

Health‐General Article § 15‐144 requires an annual report on the status of the Money Follows the Person grant (sunsets in 2013).

Currently effective.

USection 2404

UProtection for recipients of home and community‐based services against spousal impoverishment.U Requires States to apply spousal impoverishment rules to beneficiaries who receive HCBS. This provision would apply for a five‐year period beginning on January 1, 2014. UState Action Required: Apply spousal impoverishment rules to HCBS pop. Already doing this.

Health‐General Article § 15‐132(d)(4)(iii) requires the financial eligibility criteria for the older adults waiver to include protection from spousal impoverishment.

COMAR 10.09.26 Community Based Services for Developmentally Disabled Individuals Pursuant to a 1915(c) Waiver COMAR 10.09.46 Home and Community‐Based Services Waiver for Adults with Traumatic Brain Injury COMAR 10.09.54 Home/Community Based Services Waiver for Older Adults COMAR 10.09.55 Living at Home Waiver Program

January 1, 2014.


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Date USection 2405

UFunding to expand State Aging and Disability Resource Centers.U Appropriates, to the Secretary of HHS, $10 million for each of FYs 2010 through 2014 to carry out Aging and Disability Resource Center (ADRC) initiatives. Three different funding opportunities (ADRC Options Counseling, ADRC Nursing Home Transition and Diversion Programs, and ADRC Evicence‐Based Care Transition Programs). UFederal Action Required: Asst Sec Aging award funds. Need to issue RFP? UState Action Required: LTC reform group will consider.

Expand ADRCs? The Centers are not in statute.

Proposals due July 30, 2010. FFYs 2010 through 2014

USection 2406

USense of the Senate regarding long‐term care. U Expresses the Sense of the Senate that during the 111th Congress, Congress should address long‐term services and supports in a comprehensive way that guarantees elderly and disabled individuals the care they need, in the community as well as in institutions.

N/A – sense of the Senate.

Subtitle F – Medicaid Prescription Drug Coverage

USection 2501

UPrescription drug rebates.U The flat rebate for single source and innovator multiple source outpatient prescription drugs would increase from 15.1 percent to 23.1 percent,

Rebates are not in statute, but State legislation is not needed.

Promulgate new chapter of regulations

Effective


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Date except the rebate for clotting factors and outpatient drugs approved by the Food and Drug Administration exclusively for pediatric indications would increase to 17.1 percent. The basic rebate percentage for multi‐source, non‐innovator drugs would increase from 11 percent to 13 percent. Drug manufacturers would also be required to pay rebates for drugs dispensed to Medicaid beneficiaries who receive care from a Medicaid managed care organization (MCO). Total rebate liability would be limited to 100 percent of the average manufacturer price (AMP). Additional revenue generated by these increases will be remitted to the federal government. UAs amended by SectionU U1206U of the Reconciliation Act, for purposes of applying the additional rebate, narrows the definition of a new formulation of a drug to a line extension of a single source or innovator multiple source drug that is an oral solid dosage form of the drug. UFederal Action Required: UReduce payments to states beginning Jan 1, 2010. Specify reporting requirements for MCOs—units, dosage form, strength, package size UState Action required: Administrative changes. Collect rebates for MCO enrollees by


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Date adjusting capitation. MCO reporting requirements Drugs not subject—MCO contracts under 1903(m)? and 340B

USection 2502

UElimination of exclusion of coverage of certain drugs. UBeginning with drugs dispensed on January 1, 2014, smoking cessation drugs, barbiturates, and benzodiazepines would be removed from Medicaid’s excludable drug list. UState Action Required: Administrative changes. Add coverage for smoking cessation—including OTC‐‐s (already covered), barbiturates, benzodiazepines.

Medicaid coverage of specific drugs is not in statute, but State legislation is not needed.

January 1, 2014

USection 2503

UProviding adequate pharmacy reimbursement.U Requires the Secretary to calculate the Federal upper limit (FUL) as no less than 175 percent of the weighted average (determined on the basis of utilization) of the most recently reported monthly average manufacturer prices for pharmaceutically and therapeutically equivalent multiple source drugs available nationally through commercial pharmacies. UFederal Action Required: New UPL method

Change to state calculation methods/ definitions?

Amount of Medicaid reimbursement for pharmacy services is not in statute, but State legislation is not needed.

First CY quarter at least 6 months after enactment, even if regs not promulgated


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Date UState Action Required: Requires any state action?

Subtitle G – Medicaid Disproportionate Share Hospital (DSH) Payments

USection 2551

UDisproportionate share hospital payments. As amended by SectionU 1203 of the Reconciliation Act, lowers the reduction in federal Medicaid DSH payments from $18.1 billion to $14.1 billion and advances the reductions to begin in fiscal year 2014. Directs the Secretary to develop a methodology for reducing DSH allotments to all states in order to achieve the mandated reductions. Extends through FY 2013 the federal DSH allotment for a state that has a $0 allotment after FY 2011. UFederal Action Required:U Develop method to reduce DSH. Reduction processed as disallowance on State’s quarterly draw. UState Action Required: MD is a low‐DSH state.

Where are funds reduced in MD?

DSH is not in statute, but State legislation is not needed.


FFY 2014 through FFY 2020, phased in

Subtitle H – Improved Coordination for Dual Eligible Beneficiaries

USection 2601

U5‐year period for demonstration projects.U Clarifies that Medicaid waivers for coordinating care for dual eligible beneficiaries could be authorized for as long as five years.

Waivers for coordinating care for dual eligibles are not in statute, but this provision relates only to the length of the


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Date UState Action Required: Affects 1115s (per NCSL summary)

waiver period.

USection 2602

UProviding Federal coverage and payment coordination for dual eligible beneficiaries. U Requires the Secretary to establish a Federal Coordinated Health Care Office (CHCO) within CMS by March 1, 2010. The purpose of the CHCO would be to bring together officials of the Medicare and Medicaid programs to (1) more effectively integrate benefits under those programs, and (2) improve the coordination between the Federal and State governments for individuals eligible for benefits under both Medicare and Medicaid (dual eligibles) to ensure that dual eligibles have full access to the items and services to which they are entitled. UFederal Action Required: New CMS office. Annual report to Congress with legislative recs. UState Action Required: Nothing as of yet.

Federal N/A – federal office. Effective

Subtitle I – Improving the Quality of Medicaid for Patients and Providers

USection 2701

UAdult health quality measures.U Directs the Secretary of HHS to develop a set of quality measures for Medicaid eligible adults that is similar to the quality measurement program for children enacted in the Children’s Health

Health‐General Article § 15‐103(b)(9) requires each MCO to have a quality assurance program that complies

Regulations may need to be added or amended depending on HHS requirements.


States required to report prior to Sep 30, 2014. HHS publish measures for


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Date Insurance Program Reauthorization Act of 2009. The Secretary and the States will report on the development of and improvements to the quality measurement program on a regular basis. UFederal Action Required: ID, publish measures. Create Medicaid Quality Measurement Program. Create reporting format with input from states. Annually publish changes to measures. Report to Congress. $60 M FFY 2010‐14—any for states? UState Action Required: Voluntarily report beginning Jan 1, 2013. Required annual reporting to HHS prior to Sep 30, 2014.

with any health care quality improvement system developed by CMS and the quality requirements of State licensure laws and regulations. HG § 15‐103.3 establishes the Health Choice Performance Incentive Fund designed to improve MCO quality of care. HG § 15‐106 requires the Secretary to establish a system of review for all health care, including a study of quality of care.

comment by Jan 1, 2011. HHS create “Program” and publish measures by Jan 1, 2012. Format for reporting/ publication of changes to measures by Jan 1, 2013. HHS makes aggregate info available by Sep 30, 2014. HHS report to Congress by Jan 1, 2014, and every 3 yrs after.

USection 2702

UPayment adjustment for health care‐acquired conditions.U Prohibits Medicaid payment for services related to a health care‐acquired condition. The Secretary will develop a list of health care‐acquired conditions for Medicaid based on those defined under Medicare as well as current State practices. UFederal Action Required: ID current state practices. New regulations effective July 1, 2011 prohibiting payment.

How to coordinate with HSCRC?

Payment for health care‐acquired conditions is not in statute. Health‐General Article § 15‐110 requires Medicaid to pay hospitals in accordance with rates approved by the Health Services Cost Review Commission under HG Title 19 Subtitle 2.

Regulations will need to amended depending on CMS guidance. Hospital Services Chapter, COMAR 10.09.06, will likely need to be amended.


July 1, 2011


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Date UState Action Required: Depends on HHS regulations

USection 2703

UState option to provide health homes for enrollees with chronic conditions.U Provide States the option of enrolling Medicaid beneficiaries with chronic conditions into a health home. Health homes would be composed of a team of health professionals and would provide a comprehensive set of medical services, including care coordination. UFederal Action Required: 90% FFP for first 8 FY quarters. Independent evaluation. Issue planning grant RFP. UState Action Required: Integration with MCOs? Hospital referral system from ED to health homes. MI/SA coordination. Provisions on avoidable hosp tracking, HIT.

Refer to grants process. Apply for SPA? Apply for planning grant (50‐50 FMAP)? Integrate with REM or Quality Council initiatives?

Health‐General Article § 19‐1A‐02(b) authorizes DHMH to require MCOs and Medicaid enrollees to participate in the Maryland Patient Centered Medical Home Program.

Promulgate new chapter of regulations if state exercises option

SPA app Jan 1, 2011. Planning grant awards Jan 1, 2011 (total $25M). HHS repor Jan 1, 2014. HHS evaluation Jan 1, 2017.

USection 2704

UDemonstration project to evaluate integrated care around a hospitalization.U Establishes a demonstration project, in up to eight States, to study the use of bundled payments for hospital and physicians services under Medicaid. UFederal Action Required: Select 8 states based on potential to lower


Health‐General Article § 19‐219 authorizes HSCRC to promote and approve alternative methods of rate determination and payment for hospitals.

Promulgate new chapter of regulations if state applies and receives demonstration project approval

Jan 1, 2012—Dec 31, 2016. HHS report to Congress one year after end of demo.


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Date costs/ improve care. Flexibility to waive provisions. Issue RFP. UState Action Required: Reporting requirements.

USection 2705

UMedicaid global payment system demonstration project.U Establishes a demonstration project, in coordination with the CMS Innovation Center, in up to five States that would allow participating States to adjust their current payment structure for safety net hospitals from a fee‐for‐service model to a global capitated payment structure. UFederal Action Required: Select 5 states. Evaluate. Issue RFP. UState Action Required: Affects FFS payments to safety net hospital system or network. Budget neutrality requirements N/A.

Refer to grants process. How to integrate with MCO model?

Same cite as for Section 2704 above.


Operates FFY 2010—12. HHS report to Congress one year after end of demo.

USection 2706

UPediatric Accountable Care Organization demonstration project.U Establishes a demonstration project that allows qualified pediatric providers to be recognized and receive payments as Accountable Care

Refer to grants process. Pediatric ACOs are not mentioned in statute.


Jan 1, 2012—Dec 31, 2016.


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Date Organizations (ACO) under Medicaid. The pediatric ACO would be required to meet certain performance guidelines. Pediatric ACOs that met these guidelines and provided services at a lower cost would share in those savings. UFederal Action Required: Establish quality guidelines. Determine proportion of shared savings. Issue RFP. Need clarity on difference from medical home demo. UState Action Required: Establish savings level. Providers sign on for 3‐year minimum.

USection 2707

UMedicaid emergency psychiatric demonstration project.U Requires the Secretary of HHS to establish a three‐year Medicaid demonstration project in up to eight States. Participating States would be required to reimburse certain institutions for mental disease (IMDs) for services provided to Medicaid beneficiaries between the ages of 21 and 65 who are in need of medical assistance to stabilize an emergency psychiatric condition.

Refer to grants process. Health‐General Article § 15‐103(b)(21) requires DHMH to establish a delivery system for specialty mental health services for MCO enrollees.


FFY 2011—Dec 31, 2015. Three‐year projects. HHS report to Congress Dec 31, 2013.


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Date UFederal Action Required: Select states based on geographic distribution. $75M for FFY 2011. Evaluate. Waiver authority. Issue RFP. UState Action Required: Method to determine “stabilization.” Coordination with MHA.

Subtitle J – Improvements to the Medicaid and CHIP Payment and Access

Commission

USection 2801

UMACPAC assessment of policies affecting all Medicaid beneficiaries.U Clarifies the topics to be reviewed by the Medicaid and CHIP Payment and Access Commission (MACPAC) including Federal Medicaid and CHIP regulations, additional reports of State‐specific data, and an assessment of adult services in Medicaid. The provision would also authorize $11 million to fund MACPAC for FY2010. UFederal Action Required: Includes review of state‐specific data.

Federal N/A ‐MACPAC Effective Jan 1, 2013.

Subtitle K – Protections for American Indians and Alaska Natives


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Date USection 2901

USpecial rules relating to Indians.U Prohibits cost‐sharing for Indians enrolled in a qualified health benefit plan in the individual market through a State Exchange. Also, facilities operated by the Indian Health Service (IHS) and Indian, Tribal, and Urban Indian facilities (I/T/Us) would be added to the list of agencies that could serve as an “Express Lane” agency able to determine Medicaid and CHIP eligibility.

State Exchange will need to comply.

USection 2902

UElimination of sunset for reimbursement for all Medicare Part B services furnished by certain Indian hospitals and clinics.U Removes the sunset provision, allowing IHS and I/T/U services to continue to be reimbursed by Medicare Part B.

N/A Effective January, 1, 2010.

Subtitle L – Maternal and Child Health Services

USection 2951

UMaternal, infant, and early childhood home visiting programs.U Provides funding to States, tribes, and territories to develop and implement one or more evidence‐based Maternal, Infant, and Early Childhood Visitation model(s). Model options would be targeted at reducing infant and maternal mortality and its related causes by producing improvements in prenatal, maternal, and newborn health, child health and development, parenting skills, school readiness, juvenile delinquency, and family economic self‐sufficiency.

Refer to grants process. Health‐General Article § 18‐107 establishes the Morbidity, Mortality and Quality Review Committee in DHMH to improve the system of care for pregnancy, childbirth, infancy and early childhood. Education Article § 5‐217 establishes the Judith Hoyer Early Child Care and Education



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Date Enhancement program to promote school readiness through early child care and family support services.

USection 2952

USupport, education, and research for postpartum depression.U Provides support services to women suffering from postpartum depression and psychosis and also helps educate mothers and their families about these conditions. Provides support for research into the causes, diagnoses, and treatments for postpartum depression and psychosis.

Federal N/A ‐ HHS

USection 2953

UPersonal responsibility education.U Provides $75 million per year through FY2014 for Personal Responsibility Education grants to States for programs to educate adolescents on both abstinence and contraception for prevention of teenage pregnancy and sexually transmitted infections, including HIV/AIDS. Funding is also available for 1) innovative teen pregnancy prevention strategies and services to high‐risk, vulnerable, and culturally under‐represented populations, 2) allotments to Indian tribes and tribal organizations, and 3) research and evaluation, training, and technical assistance.

Refer to grants process. Nothing in statute on personal responsibility education.


USection 2954

URestoration of funding for abstinence education.U Appropriates $50 million per year through FY 2014 for abstinence

N/A


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Date education.

USection 2955

UInclusion 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. U Enables children aging out of the foster care system to have the opportunity to designate a medical power of attorney prior to emancipation from foster care. States must supply information and an opportunity for the child to designate another individual to make medical decisions on their behalf should they be unable to participate in such decision making process as part of the transition process for children expected to age out of the foster care system.

Nothing in statute addresses transition planning for children aging out of foster care and independent living. Legislation may be needed to implement this new federal requirement.

Effective October 1, 2010.

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

USection 3001

UHospital value‐based purchasing program.U

The proposal would establish a value‐based purchasing program for hospitals starting in FY2013. Under this program, a percentage of hospital payment would be tied to hospital performance on quality measures related to common and high‐cost conditions, such as cardiac, surgical and pneumonia care. Quality measures included in the program

Changes to State law likely not needed. Authorizes a special exception for HSCRC, so long as the State gives an annual report to the Secretary of HHS regarding the State’s program. HSCRC’s rate

Starting for Discharges on October 1, 2012, hospitals will receive value‐based incentive payments from Medicare. Beginning in FFY 2013, hospital


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Date (and in all other quality programs in this title) will be developed and chosen with input from external stakeholders. Section 10335 clarifies that the hospital VBP program shall not include measures of hospital readmissions.

setting authority is under Title 19, Subtitle 2 of the Health‐General Article. HSCRC’s authority is likely broad enough that even if program is applicable, statutory changes would most likely not be needed, though regulatory changes could be needed.

payments will be adjusted based on performance under the VBP program.

USection 3002

UImprovements to the physician quality reporting initiative.U Extends through 2014 payments under the PQRI program, which provide incentives to physicians who report quality data to Medicare. Creates appeals and feedback processes for participating professionals in PQRI. Establishes a participation pathway for physicians completing a qualified Maintenance of Certification program with their specialty board of medicine. Beginning in 2014, physicians who do not submit measures to PQRI will have their Medicare payments reduced. Section 10327 provides an additional 0.5 percent Medicare payment bonus to physicians who successfully report quality measures to CMS via the new Maintenance of Certification program and eliminates the MA Regional Plan Stabilization Fund.

Federal Implications for Maryland reporting?

N/A – applies to physician payments through Medicare.


Extends PQRI incentive payments through 2014 and implements a penalty for providers who do not report quality measures beginning in 2015.

USection 3003

UImprovements to the physician feedback program.U Expands Medicare’s physician

Federal N/A – applies to treatment of physicians


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Date resource use feedback program to provide for development of individualized reports by 2012. Reports will compare the per capita utilization of physicians (or groups of physicians) to other physicians who see similar patients. Reports will be risk‐adjusted and standardized to take into account local health care costs.

through Medicare.

USection 3004

UQuality reporting for long‐term care hospitals, inpatient rehabilitation hospitals, inpatient psychiatric hospitals and hospice programs.U Establishes a path toward value‐based purchasing for long‐term care hospitals, inpatient rehabilitation facilities, and hospice providers by requiring the Secretary to implement quality measure reporting programs for these providers in FY2014. Providers under this section who do not successfully participate in the program would be subject to a reduction in their annual market basket update. Section 10322 also establishes a quality measure reporting program for inpatient psychiatric hospitals beginning FY2014. Maryland State owned and operated psychiatric hospitals have already implemented quality measure data collection for reporting to the Mental Hygiene Administration. They are reported and reviewed monthly. A subset of these indicators are also reported to the National Association of State Mental Health Program Directors (NASMHPD) through their National


N/A – federal reporting requirements.

The quality indicators collected are not required by statute nor are they in regulation.



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Date Research Institute (NRI) and to The Joint Commission. Indicators collected are: ‐rate of seclusion hours ‐rate of restraint hours ‐rate of elopements ‐rate of patient to patient assaults ‐rate of patient to staff assaults ‐ rate of medication errors ‐ rate of patient injuries.

USection 3005

UQuality reporting for PPS‐exempt cancer hospitalsU. Establishes a quality measure reporting program for PPS‐exempt cancer hospitals beginning in FY2014. Providers under this section who do not successfully participate in the program would be subject to a reduction in their annual market basket update.

Federal N/A – federal reporting requirements.

USection 3006

UPlans for a value‐based purchasing program for skilled nursing facilities and home health agencies.U Directs the Secretary to submit a plan to Congress by FY2012 outlining how to effectively move these providers into a value‐based purchasing payment system. UAs amended by SectionU U10301U, requires the Secretary of HHS to develop a plan to reimburse Ambulatory Surgery Centers (ASCs) based on the quality and efficiency of care delivered in ASCs.


N/A – applies to Secretary of HHS.


USection 3007

UValue‐based payment modifier under the physician fee schedule.U Directs the Secretary of HHS to develop and implement a budget‐neutral payment system that will adjust Medicare physician payments based on the quality and cost of the care they

Federal N/A – applies to Secretary of HHS and physician payments through Medicare.


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Date deliver. Quality and cost measures will be risk‐adjusted and geographically standardized. The Secretary will phase‐in the new payment system over a two‐year period beginning in 2015.

USection 3008

UPayment adjustment for conditions acquired in hospitals.U Starting in FY2015, hospitals in the top 25th percentile of rates of hospital acquired conditions for certain high‐cost and common conditions would be subject to a payment penalty under Medicare. This provision also requires the Secretary to submit a report to Congress by January 1, 2012 on the appropriateness of establishing a healthcare acquired condition policy related to other providers participating in Medicare, including nursing homes, inpatient rehabilitation facilities, long‐term care hospitals, outpatient hospital departments, ambulatory surgical centers, and health clinics.


Changes to State law likely not needed. Authorizes a special exception for HSCRC, so long as the State gives an annual report to the Secretary of HHS regarding the State’s program. HSCRC’s rate setting authority is under Title 19, Subtitle 2 of the Health‐General Article. HSCRC’s authority is likely broad enough that even if program is applicable, statutory changes would most likely not be needed, though regulatory changes could be needed.


Part II – National Strategy to Improve Health Care Quality

USection 3011

UNational strategy.U Requires the Secretary to establish and update annually a national strategy to improve the delivery of health care services, patient health outcomes, and population health. Establishes, not later

Federal N/A – requirements for HHS. (note – does require HHS to collaborate and consult with State agencies


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Date than January 1, 2011, a Federal health care quality internet website. USection 10302U clarifies that the limitations on use of comparative effectiveness data apply to the development of the National Strategy for Quality Improvement.

administering Medicaid and CHIP in developing the national strategy).

USection 3012

UInteragency Working Group on Health Care Quality.U Requires the President to convene an Interagency Working Group on Health Care Quality comprised of Federal agencies to collaborate on the development and dissemination of quality initiatives consistent with the national strategy. (CMS). Quality measures developed under this section will be consistent with the national strategy. UAs amended by SectionU U10303U, requires the Secretary of HHS to develop and publicly report on patient outcomes measures.

Federal N/A –requirements of federal agencies.

USection 3013

UQuality measure development.U Authorizes $75 million over 5 years for the development of quality measures at AHRQ and the Centers for Medicare and Medicaid Services

Federal N/A – authorization for federal spending on development of quality measures. However, may result in new quality measures for Medicaid program.

USection 3014

UQuality measurement. U Provides $20 million to support the endorsement and use of endorsed quality and efficiency measures by the HHS Secretary for use in Medicare, reporting performance information to the public, and in health care programs.

Federal N/A – authorization and duties for HHS Secretary. However, may result in new quality measures for Medicaid program.


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Date

USection 3015

UData Collection; Public ReportingU. Requires the Secretary to collect and aggregate consistent data on quality and resource use measures from information systems used to support health care delivery to implement the public reporting of performance information. UAs amended by SectionU U10305U, requires the Secretary of HHS to develop a plan for the collection and public reporting of quality measures.

Implications for Maryland reporting?

N/A – requirements for HHS Secretary. However, may result in new quality measures for Medicaid program.


Part III – Encouraging Development of New Patient Care Models

USection 3021

UEstablishment of Center for Medicare and Medicaid Innovation within CMS.U Establishes within the Centers for Medicare and Medicaid Services (CMS) a Center for Medicare & Medicaid Innovation. The purpose of the Center will be to research, develop, test, and expand innovative payment and delivery arrangements to improve the quality and reduce the cost of care provided to patients in each program. Dedicated funding is provided to allow for testing of models that require benefits not currently covered by Medicare. Successful models can be expanded nationally. Section 10306 adds payment reform models to the list of projects for the Center to consider, including rural telehealth expansions and the development of a rapid learning network. Ensures that quality measures used by the Center are consistent with the

Federal N/A. Note – there may be opportunities for the State to implement experimental payment models under this section.


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Date quality framework within the underlying bill, and requires the Secretary to focus on models that both improve quality and reduce costs.

USection 3022

UMedicare shared savings program. U Rewards Accountable Care Organizations (ACOs) that take responsibility for the costs and quality of care received by their patient panel over time. ACOs can include groups of health care providers (including physician groups, hospitals, nurse practitioners and physician assistants, and others). ACOs that meet quality‐of‐care targets and reduce the costs of their patients relative to a spending benchmark are rewarded with a share of the savings they achieve for the Medicare program. USection 10307U provides additional flexibility to the Secretary of HHS to implement innovative payment models for participating Accountable Care Organizations, including models currently used in the private sector.

Refer to grants process. N/A. Note – hospitals may be part of ACOs under this section, which could impact payment under the State’s all‐payor system. Note – Chapters 598 and 599 of 2010 promote the establishment of ACOs by exempting certain types of ACOs from statutory prohibitions on certain bonuses and sharing of personal health information.

USection 3023

UNational pilot program on payment bundling.U Directs the Secretary to develop a national, voluntary pilot program encouraging hospitals, doctors, and post‐acute care providers to improve patient care and achieve savings for the Medicare program through bundled payment models. Requires the Secretary to establish this program by January 1, 2013 for a period of five years. Before January 1, 2016, the Secretary is also required to submit a plan to Congress to expand the pilot program if

Funding not targeted directly to states.

N/A; creates a voluntary program. However, the State will need to decide whether to participate in the pilot program.


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Date doing so will improve patient care and reduce spending. USection 10308U provides the Secretary of HHS authority to expand the payment bundling pilot if it is found to improve quality and reduce costs. Also, directs the Secretary to test bundled payment arrangements involving continuing care hospitals within the bundling pilot program.

USection 3024

UIndependence at home demonstration program.U Creates a new demonstration program for chronically ill Medicare beneficiaries to test a payment incentive and service delivery system that utilizes physician and nurse practitioner directed home‐based primary care teams aimed at reducing expenditures and improving health outcomes.

Federal N/A – program for home‐based care for Medicare beneficiaries.

USection 3025

UHospital readmissions reduction program. U

Beginning in FY2012, this provision would adjust payments for hospitals paid under the inpatient prospective payment system based on the dollar value of each hospital’s percentage of potentially preventable Medicare readmissions for the three conditions with risk adjusted readmission measures that are currently endorsed by the National Quality Forum. Also, provides the Secretary authority to expand the policy to additional conditions in future years and directs the Secretary to calculate and make publicly available information on all patient

Changes to State law likely not needed. Authorizes a special exception for HSCRC, so long as the State gives an annual report to the Secretary of HHS regarding the State’s program. HSCRC’s rate setting authority is under Title 19, Subtitle 2 of the Health‐General Article. HSCRC’s authority is likely broad

Starting for discharges on October 1, 2012, the Secretary establishes a hospital readmissions program for certain potentially preventable Medicaire Inpatient hospital readmissions covering 3


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Date hospital readmission rates for certain conditions. USection 10309U makes a technical correction to the hospital readmissions payment policy establishing in the underlying section.

enough that even if program is applicable, statutory changes would most likely not be needed, though regulatory changes could be needed.

conditions with high volume or high rate (or both).

USection 3026

UCommunity‐based care transitions program.U Provides funding to hospitals and community‐based entities that furnish evidence‐based care transition services to Medicare beneficiaries at high risk for readmission.


N/A – federal program between hospitals and HHS.

USection 3027

UExtension of gain‐sharing demonstration.U The Deficit Reduction Act of 2005 authorized a demonstration to evaluate arrangements between hospitals and physicians designed to improve the quality and efficiency of care provided to beneficiaries. This provision would extend the demonstration through September 30, 2011 and extend the date for the final report to Congress on the demonstration to September 30, 2012. It would also authorize an additional $1.6 million in FY2010 for carrying out the demonstration.


N/A – federal program between hospitals and HHS.

Subtitle B – Improving Medicare for Patients and Providers

USection 3101

(UDeletedU by Section 10310)

N/A.

USection 3102

UExtension of the work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee schedule.U Extends a floor on

Federal No effect on State law ‐ Medicare physician payments. Note: various


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Date geographic adjustments to the work portion of the fee schedule through the end of 2010, with the effect of increasing practitioner fees in rural areas. Also provides immediate relief to areas negatively impacted by the geographic adjustment for practice expenses, and requires the Secretary of HHS to improve the methodology for calculating practice expense adjustments beginning in 2012. UAs amended by SectionU 1108 of the Reconciliation Act, accelerates phase‐in of Medicare physician practice expense adjustment for areas with below average practice expense payment rates. In 2010, the national blend would be increased from ¼ to ½.

provisions in the Health‐General and Insurance Articles link insurance reimbursement to Medicare payment, so a change in Medicare reimbursement could have an impact on insurance reimbursement.

USection 3103

UExtension of exceptions process for Medicare therapy caps. UExtends the process allowing exceptions to limitations on medically necessary therapy until December 31, 2010.

Federal N/A – limitation on Medicare payment.

USection 3104

UExtension of payment for technical component of certain physician pathology services.U Extends a provision that directly reimburses qualified rural hospitals for certain clinical laboratory services through the end of 2010.

Federal N/A – federal direct payments to hospitals.

USection 3105

UExtension of ambulance add‐ons.U Extends bonus payments made by Medicare for ground and air ambulance services in rural and other areas through the end of 2010.

Federal N/A – Medicare bonus payments for ambulances.


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Date Section 10311 requires the Secretary of HHS to implement the extension of the ambulance payment bonuses on January 1, 2010.

USection 3106

UExtension of certain payment rules for long‐term care hospital services and of moratorium on the establishment of certain hospitals and facilitiesU. Extends Sections 114 (c) and (d) of the Medicare, Medicaid and SCHIP Extension Act of 2007 by two years, UAs amended by SectionU U10312U.

Federal N/A.

USection 3107

UExtension of physician fee schedule mental health add‐on.U Increases the payment rate for psychiatric services by 5 percent for two years, through the end of 2010.

Federal N/A – Medicare physician payments.

USection 3108

UPermitting physician assistants to order post‐hospital extended care services.U Authorizes physician assistants to order skilled nursing care services in the Medicare program beginning in 2011.

Federal N/A – Medicare authorization.

USection 3109

UExemption of certain pharmacies from accreditation requirements.U Allows pharmacies with less than 5 percent of revenues from Medicare DMEPOS billings to be exempt from accreditation requirements until the Secretary of HHS develops pharmacy‐specific standards.

Federal N/A – Medicare requirements for pharmacy accreditation.


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Date USection 3110

UPart B special enrollment period for disabled TRICARE beneficiaries.U Creates a twelve‐month special enrollment period for military retirees, their spouses (including widows/widowers) and dependent children, who are otherwise eligible for TRICARE and entitled to Medicare Part A based on disability or ESRD, but who have declined Part B.

Federal N/A – Medicare enrollment.

USection 3111

UPayment for bone density tests.U Restores payment for dual‐energy x‐ray absorptiometry (DXA) services furnished during 2010 and 2011 to 70 percent of the Medicare rate paid in 2006.

Federal N/A – Medicare payment for DXA services.

USection 3112

URevision to the Medicare Improvement Fund.U Eliminates the remaining funds in the Medicare Improvement Fund.

Federal N/A.

USection 3113

UTreatment of certain complex diagnostic laboratory tests.U Creates a demonstration program to test the impact of direct payments for certain complex laboratory tests on Medicare quality and costs.

Federal N/A – demonstration project.

USection 3114

UImproved access for certified nurse‐midwife services.U Increases the payment rate for certified nurse midwives for covered services from 65 percent of the rate that would be paid were a physician performing a service to the full rate.

Federal N/A.


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Date PART II – Rural Protections

USection 3121

UExtension of outpatient hold harmless provision.U Extends the existing outpatient hold harmless provision through the end of FY2010 and would allow Sole Community Hospitals with more than 100 beds to also be eligible to receive this adjustment through the end of FY2010.

Federal N/A.

USection 3122

UExtension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas.U Reinstates the policy included in the Medicare Modernization Act of 2003 (P.L. 108‐173) that provides reasonable cost reimbursement for laboratory services provided by certain small rural hospitals from July 1, 2010 to July 1, 2011.

Federal N/A.

USection 3123

UExtension of the Rural Community Hospital Demonstration Program.U Extends the program for five years, UAs amended by SectionU U10313U, expands eligible sites to additional States and additional rural hospitals, and makes adjustments to payment levels provided within the demonstration program.

Federal N/A.

USection 3124

UExtension of the Medicare‐dependent hospital (MDH) program.U Extends the Medicare‐dependent hospital program by one year through October 1, 2012. It would

Federal N/A.


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Date also require HHS to study whether certain urban hospitals should qualify for the MDH program.

USection 3125

UTemporary improvements to the Medicare inpatient hospital payment adjustment for low‐volume hospitals.U Expands the program providing a temporary adjustment to inpatient hospital payments for certain low‐volume hospitals through FY2012 and would modify eligibility requirements regarding distance from another facility. Also, in USection 10314U, modifies requirements regarding the number of eligible discharges.

Federal N/A.

USection 3126

UImprovements to the demonstration project on community health integration models in certain rural counties.U The Medicare Improvements for Patients and Providers Act (MIPPA, P.L. 110‐275) authorized a demonstration project that will allow eligible rural entities to test new models for the delivery of health care services in rural areas. This provision will expand the demonstration to allow additional counties to participate and will also allow physicians to participate in the demonstration project.

Federal N/A – demonstration project through Medicare.

USection 3127

UMedPAC study on adequacy of Medicare payments for health care providers serving in rural areas.U This provision would require MedPAC to review payment adequacy for rural health care providers serving the

Federal N/A – required MedPAC study.


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Date Medicare program, including an analysis of the rural payment adjustments included in this legislation and beneficiaries’ access to care in rural communities.

USection 3128

UTechnical correction related to critical access hospital services.U This provision clarifies that CAHs can continue to be eligible to receive 101 percent of reasonable costs for providing outpatient care regardless of eligible billing method the facility uses and for providing qualifying ambulance services.

Federal N/A.

USection 3129

UExtension of and revisions to Medicare rural hospital flexibility program.U This provision extends the Flex Grant program through 2012 and will allow Flex grant funding to be used to support rural hospitals’ efforts to implement delivery system reform programs, such as value‐based purchasing programs, bundling, and other quality programs.

Federal N/A.

Part III – Improving Payment Accuracy

USection 3131

UPayment adjustments for home health care. U This provision would direct the Secretary to improve payment accuracy through rebasing home health payments starting in 2014, UAs amended by SectionU U10315U, based on an analysis of the current mix of services and intensity of care provided to home health patients. The

Federal N/A – home health care payments by Medicare.


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Date provision would also establish a 10 percent cap on the amount of reimbursement a home health provider can receive from outlier payments and would reinstate an add‐on payment for rural home health providers from April 1, 2010 through 2015. In addition, it would require the Secretary to submit a report to Congress by March 1, 2011 on recommended payment reforms related to serving patients with varying severity of illness or to improve beneficiary access to care. UAs amended by SectionU U10315U, directs the Secretary to study improving access to home health care for certain patients, including those with high‐severity levels of illness, low‐income and living in underserved areas, and provides the Secretary authority to conduct a demonstration program based on the results of the study.

USection 3132

UHospice reform.U This provision would require the Secretary to update Medicare hospice claims forms and cost reports by 2011. Based on this information, the Secretary would be required to implement changes to the hospice payment system to improve payment accuracy in FY2013. The Secretary would also impose certain requirements on hospice providers designed to increase accountability in the Medicare hospice program.

Federal N/A – hospice payments by Medicare.


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Date USection 3133

UImprovement to Medicare disproportionate share hospital (DSH) payments.U This provision would require the Secretary to update hospital payments to better account for hospitals’ uncompensated care costs. Starting in FY2014, hospitals’ Medicare Disproportionate Share Hospital (DSH) payments would be reduced to reflect lower uncompensated care costs relative to increases in the number of insured. UAs amended by SectionU U1104U of the Reconciliation Act, reduces the 10‐year reduction in Medicare DSH payments by $3 billion.

N/A, though could affect DSH payments for hospitals that do receive DSH payments in the State.

USection 3134

UMisvalued codes under the physician fee schedule.U Directs the Secretary to regularly review fee schedule rates for physician services paid for by Medicare, including services that have experienced high growth rates. Strengthens the Secretary’s authority to adjust fees schedule rates that are found to be misvalued or inaccurate.

Federal N/A – Medicare physician fees.

USection 3135

UModification of equipment utilization factor for advanced imaging services.U UAs amended by SectionU U1107U of the Reconciliation Act, effective January 1, 2011, takes into account the CMS imaging rule that went into effect on January 1, 2010, but sets the assumed utilization rate at 75 percent for the practice expense portion of advanced diagnostic imaging services. Excludes low‐tech imaging such as

Federal N/A.


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Date ultrasound, x‐rays and EKGs from this adjustment. Also adjusts the technical component discount on single session imaging studies on contiguous body parts from 25 percent to 50 percent.

USection 3136

URevision of payment for power‐driven wheelchairs.U Eliminates the option for Medicare to purchase power‐driven wheelchairs with a lump‐sum payment at the time the chair is supplied. Medicare would continue to make the same payments for power‐driven chairs over a 13‐month period. Purchase option for complex rehabilitative power wheelchairs would be maintained.

Federal N/A.

USection 3137

UHospital wage index improvement.U Extends reclassifications under section 508 of the Medicare Modernization Act (P.L 108‐173) through the end of FY2010. In addition, requires the Secretary to provide recommendations to Congress on ways to comprehensively reform the Medicare wage index system by December 31, 2011. Also directs the Secretary to restore the reclassification thresholds used to determine hospital reclassifications to the percentages used in FY2009, starting in FY2011 until the first fiscal year that is on or after the date the Secretary submits the report to Congress on reforming the wage index system. Section 10317 clarifies the Secretary may only use wage data of certain eligible hospitals in carrying out this

Federal N/A.


E-98








Date provision if doing so does not result in lower wage index adjustments for affected facilities.

USection 3138

UTreatment of certain cancer hospitals.U Directs the Secretary to study whether existing cancer hospitals that are exempt from the inpatient prospective payment system have costs under the outpatient prospective payment system (OPPS) that exceed costs of other hospitals, and to make an appropriate payment adjustment under OPPS based on that analysis.

Federal N/A.

USection 3139

UPayment for biosimilar biological products.U

Sets the add‐on payment rate for biosimilar products reimbursement under Medicare Part B at 6 percent of the average sales price of the brand biological product.

Federal N/A.

USection 3140

UMedicare hospice concurrent care demonstration program.U Directs the Secretary to establish a three‐year demonstration program that would allow patients who are eligible for hospice care to also receive all other Medicare covered services during the same period of time. The demonstration would be conducted in up to 15 hospice programs in both rural and urban areas and would evaluate the impacts of the demonstration on patient care, quality of life and spending in the Medicare program.

Federal N/A – Medicare hospice demonstration project.


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Date USection 3141

UApplication of budget neutrality on a national basis in the calculation of the Medicare hospital wage index floor.U Starting on October 1, 2010, the provision would require application of budget neutrality associated with the effect of the imputed rural and rural floor to be applied on a national, rather than State‐specific basis through a uniform, national adjustment to the area wage index.

Federal N/A.

USection 3142

UHHS study on urban Medicare‐dependent hospitals.U Requires the Secretary to conduct a study on the need for additional Medicare payments for certain urban Medicare‐dependent hospitals paid under the inpatient prospective payment system.

Federal N/A – HHS study.

USection 3143

UProtecting home health benefits.U Ensures that guaranteed Medicare home health benefits will not be reduced.

Federal N/A ‐Medicare home health benefits.

Subtitle C – Provisions Related to Part C

USection 3201

UMedicare Advantage payment.U This section was UrepealedU by Section 1102 of the Reconciliation Act.

N/A.

USection 3202

UBenefit protection and simplification.U Prohibits Medicare Advantage plans from charging beneficiaries cost sharing for covered services that is greater than what is charged under the traditional fee‐for‐service program. Requires plans that provide extra benefits to give priority to cost sharing

Federal N/A.


E-100








Date reductions, wellness and preventive care, and then benefits not covered under Medicare.

USection 3203

UApplication of coding intensity adjustment during MA payment transition.U This section was UrepealedU by Section 1102 of the Reconciliation Act.

Federal N/A.

USection 3204

USimplification of annual beneficiary election periods.U Provides extra time for CMS, Medicare Advantage plans and prescription drug plans to process enrollment paperwork during annual enrollment periods and eliminates a duplicative open enrollment period for Medicare Advantage plans. Allows beneficiaries to disenroll from a Medicare Advantage plan and return to the traditional fee‐for‐service program from January 1 to March 15 of each year.

Federal N/A.

USection 3205

UExtension for specialized MA plans for special needs individuals.U Extends the SNP program through 2013 and requires SNPs to be NCQA approved. Allows HHS to apply a frailty payment adjustment to fully‐integrated, dual‐eligible SNPs that enroll frail populations. Requires HHS to transition beneficiaries enrolled in SNPs that do not meet statutory target definitions and requires dual‐eligible SNPs to contract with State Medicaid programs beginning 2013. Also requires an evaluation of Medicare Advantage risk adjustment for chronically ill

N/A, but may have impact on State Medicaid program.


E-101








Date populations.

USection 3206

UExtension of reasonable cost contracts.U Extends the period of time for which cost plans may operate in areas that have other health plan options.

Federal N/A.

USection 3207

UTechnical correction to MA private fee‐for‐service plans.U Allows employer‐sponsored private fee‐for‐service plans authorized under 1857(i)(2) with current enrollment to use, beginning 2011, a CMS service area waiver available to employer and union group health plans that are coordinated care plans.

Federal N/A.

USection 3208

UMaking senior housing facility demonstration permanent.U Allows demonstration plans that serve residents in continuing care retirement communities to operate under the Medicare Advantage program.

Federal N/A.

USection 3209

UAuthority to deny plan bids.U Authorizes the HHS Secretary to deny bids submitted by Medicare Advantage and prescription plans, beginning in 2011, that propose to significantly increase beneficiary cost sharing or decrease benefits offered under the plan.

Federal N/A.

USection 3210

UDevelopment of new standards for certain Medigap plans. U Requires HHS to request NAIC revisions to the standards for benefit

N/A, but will change standards for benefit packages that effective

COMAR 31.10.06


E-102








Date packages classified as “C” and “F” so that these packages include nominal cost sharing that encourages the use of appropriate Part B physician services.

2015 may require changes in State insurance regulations. Maryland statute for regulating Medicare supplement plans is under Title 15, Subtitle 9 of the Insurance Article; § 15‐915 requires the Commissioner to adopt regulations to conform Medicare supplement policies to the requirements of federal law.

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

Plans

USection 3301

UMedicare coverage gap discount program.U

Requires drug manufacturers to provide a 50 percent discount to Part D beneficiaries for brand‐name drugs and biologics purchased during the coverage gap beginning January 1, 2011.

Federal N/A, but will reduce impact of coverage gap.

USection 3302

UImprovement in determination of Medicare part D low‐income benchmark premium.U Removes Medicare Advantage rebates and quality bonus payments from the calculation of the low‐income subsidy benchmark.

Federal N/A.

USection 3303

UVoluntary de minimis policy for subsidy‐eligible individuals under prescription drug plans and MA–PD plans.U Allows Part D plans

Federal N/A.


E-103








Date that bid a nominal amount above the regional low‐income subsidy (LIS) benchmark to absorb the cost of the difference between their bid and the LIS benchmark in order to remain a $0 premium LIS plan.

USection 3304

USpecial rule for widows and widowers regarding eligibility for low‐income assistance.U Allows the surviving spouse of an LIS‐eligible couple to delay LIS redetermination for one year after the death of a spouse.

Federal N/A.

USection 3305

UImproved information for subsidy‐eligible individuals reassigned to prescription drug plans and MA–PD plans.U Requires HHS, beginning in 2011, to transmit formulary and coverage determination information to subsidy‐eligible beneficiaries who have been automatically reassigned to a new Part D low‐income subsidy plan.

Federal N/A.

USection 3306

UFunding outreach and assistance for low‐income programs.U Provides $45 million for outreach and education activities to State Health Insurance Programs, Administration on Aging, Aging Disability Resource Centers and the National Benefits Outreach and Enrollment.

Refer to grants process N/A, but new funding available for State programs.

Application deadline July 30, 2010. Awards announced September 29, 2010. Implementation Secptember 30, 2010.

USection 3307

UImproving formulary requirements for prescription drug plans and MA–PD plans with respect to certain categories or classes

Federal N/A.


E-104








Date of drugs.U Codifies the current six classes of clinical concern, removes the criteria specified in section 176 of MIPPA that would have been used by HHS to identify protected classes of drugs and gives the Secretary authority to identify classes of clinical concern through rulemaking.

USection 3308

UReducing part D premium subsidy for high‐income beneficiaries. UReduces the Part D premium subsidy for beneficiaries with incomes above the Part B income thresholds.

Federal N/A.

USection 3309

UElimination of cost sharing for certain dual‐eligible individuals.U Eliminates cost sharing for beneficiaries receiving care under a home and community‐based waiver program who would otherwise require institutional care.

Not clear whether this would impact the State’s payments for dual eligibles – if it does, likely does not impact a statute.

Effective on date specified by Secretary, but no later than January 1, 2012.

USection 3310

UReducing wasteful dispensing of outpatient prescription drugs in long‐term care facilities under prescription drug plans and MA‐PD plans.U Requires Part D plans to develop drug dispensing techniques to reduce prescription drug waste in long‐term care facilities.

Federal N/A.

USection 3311

UImproved Medicare prescription drug plan and MA–PD plan complaint system.U Requires the Secretary to develop and maintain a plan complaint system to handle

Federal N/A.


E-105








Date complaints regarding Medicare Advantage and Part D plans or their sponsors.

USection 3312

UUniform exceptions and appeals process for prescription drug plans and MA–PD plans.U Requires Part D plans to use a single, uniform exceptions and appeals process.

Federal N/A.

USection 3313

UOffice of the Inspector General studies and reports.U Requires the OIG to conduct a study comparing prescription drug prices paid under the Medicare Part D program to those paid under State Medicaid programs.

Federal N/A.

USection 3314

UIncluding costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the annual out‐of‐pocket threshold under part D.U Allows drugs provided to beneficiaries by AIDS Drug Assistance Programs or the Indian Health Service to count toward the annual out‐of‐pocket threshold.

Federal N/A.

USection 3315

UImmediate reduction in coverage gap for 2010.U This section was UrepealedU by Section 1101 of the Reconciliation Act..

Federal N/A.

Subtitle E – Ensuring Medicare Sustainability

USection 3401

URevision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not already incorporate such improvements. U Incorporates a productivity

Federal N/A. The reduction of the market basket will affect IPPS rates for discharges occurring on or after April 1,


E-106








Date adjustment into the market basket update for inpatient hospitals, home health providers, nursing homes, hospice providers, inpatient psychiatric facilities, long‐term care hospitals and inpatient rehabilitation facilities beginning in various years and implements additional market basket reductions for certain providers. It would also incorporate a productivity adjustment into payment updates for Part B providers who do not already have such an adjustment. USection 10319U modifies market adjustments for inpatient hospitals, inpatient rehabilitation facilities, inpatient psychiatric hospitals and outpatient hospitals in 2012 and 2013 and for long‐term care hospitals in 2011, 2012 and 2013. Also, modifies market basket adjustments for home health providers in 2013 and hospice providers in 2013 through 2019. USection 1105U of the Reconciliation Act revises the hospital market basket reduction that is in addition to the productivity adjustment as follows: ‐0.3 in FY14 and ‐0.75 in FY17, FY18 and FY19. Removes Senate provision that eliminates the additional market basket for hospitals based on coverage levels. Providers affected are inpatient hospitals, long‐term care hospitals, inpatient rehabilitation facilities, psychiatric hospitals and outpatient hospitals.

2010 through September 30, 2010.

USection 3402

UTemporary adjustment to the calculation of part B premiumsU. For higher‐income

Federal N/A.


E-107








Date beneficiaries who pay a higher Part B premium rate, freezes the income thresholds at 2010 levels through 2019.

USection 3403

UIndependent Payment Advisory Board.U Creates an independent, 15‐member Payment Advisory Board tasked with presenting Congress with comprehensive proposals to reduce excess cost growth and improve quality of care for Medicare beneficiaries. In years when Medicare costs are projected to be unsustainable, the Board’s proposals will take effect unless Congress passes an alternative measure that achieves the same level of savings. Congress would be allowed to consider an alternative provision on a fast‐track basis. The Board would be prohibited from making proposals that ration care, raise taxes or Part B premiums, or change Medicare benefit, eligibility, or cost‐sharing standards. UAs amended by SectionU U10320U, requires the Board to make annual recommendations to the President, Congress, and private entities on actions they can take to improve quality and constrain the rate of cost growth in the private sector. Requires the Board to make non‐binding Medicare recommendations to Congress in years in which Medicare growth is below the targeted growth rate. Clarifies that the Board is prohibited from making recommendations that would reduce premium supports for low‐income Medicare beneficiaries. Beginning in 2020, limits the

Federal N/A.


E-108








Date Board’s binding recommendations to Congress to only every‐other‐year if the growth in overall health spending exceeds growth in Medicare spending; such recommendations would focus on slowing overall health spending while maintaining or enhancing beneficiary access to quality care under Medicare. Changes the name of the Board to the “Independent Payment Advisory Board.”

Subtitle F—Health Care Quality Improvements

USection 3501

UHealth care delivery system research; Quality improvement technical assistance.U Builds on the Center for Quality Improvement and Patient Safety of the Agency for Healthcare Research and Quality (AHRQ) to support research, technical assistance and process implementation grants. Grants funded under this section will identify, develop, evaluate, disseminate, and provide training in innovative methodologies and strategies for quality improvement practices in the delivery of health care services.

Funds not targeted directly to states.

N/A.

USection 3502

UGrants or contracts to establish community health teams to support the patient‐centered medical home.U Creates a program to establish and fund the development of community health teams to support the development of medical homes by increasing access to comprehensive,

Refer to grants process. Makes grants available to States or State‐designated agencies. Likely no impact on statute; State’s patient‐centered medical home was established in


E-109








Date community based, coordinated care. Section 10321 clarifies that nurse practitioners and other primary care providers can participate in community care teams.

Chapters 5 and 6 of 2010 (Title 19, Subtitle 1A of the Health‐General Article.)

USection 3503

UGrants to implement medication management services in treatment of chronic disease.U Creates a program to support medication management services by local health providers. Medication management services will help manage chronic disease, reduce medical errors, and improve patient adherence to therapies while reducing acute care costs and reducing hospital readmissions.


Makes grants available to provide medication management, as allowed under State law. Maryland allows pharmacists to enter therapy management contracts under Title 12, Subtitle 6A of the Health Occupations Article. However, likely no direct impact on statute.

USection 3504

UDesign and implementation of regionalized systems for emergency care. U Provides funding to the Assistant Secretary for Preparedness and Response to support pilot projects that design, implement, and evaluate innovative models of regionalized, comprehensive, and accountable emergency care and trauma systems. Requires the HHS Secretary to support emergency medicine research, including pediatric emergency medical research.

Refer to grants process. Makes grants available to States for pilot projects that design, implement, and evaluate innovative models of regionalized trauma care. Likely no impact on statute. Maryland’s EMS and Trauma system is regulated under Title 13, Subtitle 5 of the Education Article. Also addressed in the State EMS plan.

COMAR Title 30


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Date USection 3505

UTrauma care centers and service availability.U Reauthorizes and improves the trauma care program, providing grants administered by the HHS Secretary to States for two specific areas 1) trauma centers to strengthen the nation’s trauma system. Grants are targeted to assist trauma care centers in underserved areas, and 2) for physician workforce, compensation.

Refer to grants process. Authorizes States to apply for federal money and distribute funds to trauma centers, subject to certain restrictions. Physician workforce funding seems to be similar to Maryland’s Trauma Physician Services Fund administered by MHCC (§ 19‐130 of the Health‐General Article), except that funding is also available for the establishment of new trauma services. MIEMSS has the authority in statue to regulate trauma centers and the Trauma system under Title 13, Subtitle 5 of the Education Article.

COMAR 30.05

USection 3506

UProgram to facilitate shared decision‐makingU. Establishes a program at HHS for the development, testing, and disseminating of educational tools to help patients, caregivers, and authorized representatives understand their treatment options.

Federal N/A – establishes duties for federal agency.

USection 3507

UPresentation of prescription drug benefit and risk informationU. Requires the Food and

Federal N/A – study required by FDA.


E-111








Date Drug Administration (FDA) to evaluate and determine if the use of drug fact boxes which would clearly communicate drug risks and benefits and support clinician and patient decision making in advertising and other forms of communication for prescription medications is warranted.

USection 3508

UDemonstration program to integrate quality improvement and patient safety training into clinical education of health professionals.U Establishes a program at AHRQ to give grants to academic institutions to develop and implement academic curricula that integrate quality improvement and patient safety into health professionals’ clinical education.

Federal N/A – federal grants to academic institutions.

USection 3509

UOffice of women’s health. UProvides for women's health offices at various Federal agencies to improve prevention, treatment, and research for women in health programs.

Federal N/A.

USection 3510

UPatient navigator program.U Reauthorizes demonstration programs to provide patient navigator services within communities to assist patients overcome barriers to health services. Program facilitates care by assisting individuals coordinate health services and provider referrals, assist community organizations in helping individuals receive better access to care, information on clinical trials, and conduct outreach to health disparity populations.


N/A – federal patient navigator program.


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Date USection 3511

UAuthorization of appropriations.

N/A.

USection 3512

UGAO study and report on causes of action.U

UAs added by sectionU U10201U, directs the Comptroller General to conduct a study, within two years of enactment, as to whether implementation of provisions in the legislation would result in the establishment of a new cause of action or claim.

Federal N/A.

Subtitle G – Protecting and Improving Guaranteed Medicare Benefits

USection 3601

UProtecting and improving guaranteed Medicare benefits.U Reaffirms that Medicare guaranteed benefits will not be reduced and that any savings generated for the Medicare program will extend the solvency of the Medicare trust funds, reduce Medicare premiums and cost‐sharing, and improve or expand guaranteed Medicare benefits or protect access to providers.

Federal N/A.

USection 3602

UNo cuts in guaranteed benefits.U Reaffirms that benefits guaranteed to Medicare Advantage plan participants will not be reduced or eliminated.

Federal N/A.

TITLE IV—PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH

Subtitle A – Modernizing Disease Prevention and Public Health Systems

USection 4001

UNational Prevention, Health Promotion and Public Health Council.U Creates an

Federal N/A


E-113








Date interagency council dedicated to promoting healthy policies at the Federal level. The Council shall consist of representatives of Federal agencies that interact with Federal health and safety policy, including the departments of HHS, Agriculture, Education, Labor, Transportation, and others. The Council will establish a national prevention and health promotion strategy and develop interagency working relationships to implement the strategy. The Council will report annually to Congress on the health promotion activities of the Council and progress in meeting goals of the national strategy.

USection 4002

UPrevention and Public Health Fund.U Establishes a Prevention and Public Health Investment Fund. The goal of the Investment Fund is to provide an expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs. This will involve a dedicated, stable funding stream for prevention, wellness and public health activities authorized by the Public Health Service Act.

Federal New public health fund – could be funding opportunity, but no legislation appears to be needed.

USection 4003

UClinical and community preventive services. U

Expands the efforts of, and improves the coordination between, two task forces which provide recommendations for

Federal N/A – coordination of two federal task forces.


E-114








Date preventive interventions. The U.S. Preventive Services Task Force is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness of clinical preventive services such as colorectal cancer screening or aspirin to prevent heart disease, and develops recommendations for their use. The Community Preventive Services Task Force uses a public health perspective to review the evidence of effectiveness of population‐based preventive services such as tobacco cessation, increasing physical activity and preventing skin cancer, and develops recommendations for their use.

USection 4004

UEducation and outreach campaign regarding preventive benefits.U Directs the Secretary to convene a national public/private partnership for the purposes of conducting a national prevention and health promotion outreach and education campaign. The goal of the campaign is to raise awareness of activities to promote health and prevent disease across the lifespan. The Secretary will conduct a national media campaign on health promotion and disease prevention focusing on nutrition, physical activity, and smoking cessation using science‐based social

Federal Health‐General Article Title 13 Subtitle 2 establishes a State Advisory Council on Heart Disease and Stroke for the purpose of developing and promoting education programs in prevention, early detection, and treatment of heart disease and stroke.


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Date research. The Secretary shall also maintain a web‐based portal that provides informational guidelines on health promotion and disease prevention to health care providers and the public as well as a personalized prevention plan tool for individuals to determine their disease risks and obtain tailored guidance on health promotion and disease prevention. In addition, the Secretary will provide guidance and relevant information to States and health care providers regarding preventive and obesity‐related services that are available to Medicaid enrollees, including obesity screening and counseling for children and adults. Each State would be required to design a public awareness campaign to educate Medicaid enrollees regarding availability and coverage of such services.

Subtitle B – Increasing Access to Clinical Preventive Services

USection 4101

USchool‐based health centers. U Authorizes a grant program for the operation and development of School‐Based Health Clinics, which will provide comprehensive and accessible preventive and primary health care services to medically underserved children and families. Appropriates $50 million each year for fiscal years 2010 through 2013 for expenditures for facilities and equipment. Section 10402 adds vision services to the list of health services for which a School Based Health Center should

Funds targeted to school‐based health center or sponsoring facility.

Nothing in statute appears to limit the services provided by School‐Based Health Centers. Health‐General Article § 15‐103(b)(19) requires SBHCs and MCOs to collaborate to provide continuity of care to Medicaid enrollees.



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Date provide referrals.

USection 4102

UOral healthcare prevention activities.U Establishes an oral healthcare prevention education campaign at CDC focusing on preventive measures and targeted towards key populations including children and pregnant women. Creates demonstration programs on oral health delivery and strengthens surveillance capacity.

Refer to grants process. Health‐General Article Title 13 Subtitle 25 establishes an Oral Health Safety Net Program to expand oral health capacity for underserved low income and disabled individuals. HG Title 18 Subtitle 8 requires the Secretary of DHMH to establish an Oral Health Program to prevent and detect oral cancer.

USection 4103

UMedicare coverage of annual wellness visit providing a personalized prevention plan.U Provides coverage under Medicare, with no co‐payment or deductible, for an annual wellness visit and personalized prevention plan services. Such services would include a comprehensive health risk assessment. The personalized prevention plan would take into account the findings of the health risk assessment and include elements such as: a five‐ to ten‐year screening schedule; a list of identified risk factors and conditions and a strategy to address them; health advice and referral to education and preventive counseling or community‐based interventions to address modifiable risk factors such as physical activity, smoking,

Federal N/A – Medicare coverage.


E-117








Date and nutrition. USection 10402U clarifies that Medicare beneficiaries are eligible for the initial preventive physical exam in their first year of Medicare coverage and for personalized prevention services annually thereafter.

USection 4104

URemoval of barriers to preventive services in Medicare.U This section would waive beneficiary coinsurance requirements for most preventive services, requiring Medicare to cover 100 percent of the costs. Services for which no coinsurance or deductible would be required are the personalized prevention plan services and any covered preventive service if it is recommended with a grade of A or B by the U.S. Preventive Services Task Force. USection 10406U clarifies that Medicare beneficiaries do not have to pay coinsurance (including co‐pays and deductibles) for preventive services delivered in all settings.


USection 4105

UEvidence‐based coverage of preventive services in Medicare.U This section would authorize the Secretary to modify the coverage of any currently covered preventive service in the Medicare program to the extent that the modification is consistent with U.S. Preventive Services Task Force recommendations and the services are not used for diagnosis or treatment. The Secretary will also conduct a provider and beneficiary outreach program regarding



E-118








Date covered preventive services. This section also authorizes a Government Accountability Office (GAO) study of the utilization of and payment for Medicare covered preventive services, the use of health information technology in coordinating such services, and whether there are barriers to the utilization of such services.

USection 4106

UImproving access to preventive services for eligible adults in Medicaid.U The current Medicaid State option to provide other diagnostic, screening, preventive, and rehabilitation services would be expanded to include: (1) any clinical preventive service recommended with a grade of A or B by the U.S. Preventive Services Task Force and (2) with respect to adults, immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) and their administration. States that elect to cover these additional services and vaccines, and also prohibit cost‐sharing for such services and vaccines, would receive an increased Federal medical assistance percentage (FMAP) of one percentage point for these services. UFederal Action Required: Increased 1% FFP. Need more information on how defined. UState Action Required: Services are already covered.

How to track to take advantage of FFP increase?

Health‐General Article § 15‐103(b)(12) requires MCOs to notify enrollees about when they should get an immunization, exam, or other wellness service. Penalties are assessed for non‐compliance. No specific preventive services are named in statute.

COMAR 10.09.02 Physicians’ Services



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Date USection 4107

UCoverage of comprehensive tobacco cessation services for pregnant women in Medicaid.U States would be required to provide Medicaid coverage for counseling and pharmacotherapy to pregnant women for cessation of tobacco use. Such services would include diagnostic, therapy and counseling services, and prescription and nonprescription tobacco cessation agents approved by the Food and Drug Administration for cessation of tobacco use by pregnant women. This section would also prohibit cost‐sharing for these services. UState Action Required: Already covered.

Nothing in statute addresses tobacco cessation services in Medicaid, but this benefit is already being offered.

Effective Oct 1, 2010.

USection 4108

UIncentives for prevention of chronic diseases in Medicaid.U The Secretary would award grants to States to provide incentives for Medicaid beneficiaries to participate in programs providing incentives for healthy lifestyles. These programs must be comprehensive and uniquely suited to address the needs of Medicaid eligible beneficiaries and must have demonstrated success in helping individuals lower or control cholesterol and/or blood pressure, lose weight, quit smoking and/or manage or prevent diabetes, and may address co‐morbidities, such as depression, associated with these conditions. UFederal Action Required:

Refer to grants process. Chap. 693 (HB 1395) of 2008 required DHMH and the MD Health Quality and Cost Council to develop a chronic care management plan to improve quality and cost effectiveness of at‐risk individuals.

Promulgate new chapter of regulations depending on whether the Department applies for and is awarded a grant

Grant awards begin Jan 1, 2011 or earlier, for five year period. State grants of at least 3 years. States submit semi‐annual reports to HHS. HHS report to Congress by Jan 1, 2014. HHS final report to Congress by Jan 1,2 016.


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Date Make grants. $100M appropriated. Waive statewideness. State awareness campaign. Independent evaluation. UState Action Required: Based on participation, completion, demonstration of change. Range of collaborators/ partners. Provider/ beneficiary outreach campaign. Evaluate effectiveness. Reporting.

Subtitle C – Creating Healthier Communities

USection 4201

UCommunity transformation grants.U This section authorizes the Secretary to award competitive grants to eligible entities for programs that promote individual and community health and prevent the incidence of chronic disease. Communities can carry out programs to prevent and reduce the incidence of chronic diseases associated with overweight and obesity, tobacco use, or mental illness; or other activities that are consistent with the goals of promoting healthy communities. USection 10403U ensures that 20 percent of the Community Transformation Grants are awarded to rural and frontier areas.

Refer to grants process. Nothing in statute addresses community transformation.


USection 4202

UHealthy aging, living well; evaluation of community‐based prevention and wellness

Refer to grants process. Nothing in statute addresses health status



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Date programs for Medicare beneficiaries.U The goal of this program is to improve the health status of the pre‐Medicare‐eligible population to help control chronic disease and reduce Medicare costs. The CDC would provide grants to States or large local health departments to conduct pilot programs in the 55‐to‐64 year old population. Pilot programs would evaluate chronic disease risk factors, conduct evidence‐based public health interventions, and ensure that individuals identified with chronic disease or at‐risk for chronic disease receive clinical treatment to reduce risk. Pilot programs would be evaluated for success in controlling Medicare costs in the community. Additionally, the Centers for Medicare & Medicaid Services (CMS) would conduct a comprehensive assessment of community‐based disease self‐management programs that help control chronic diseases. The Secretary would then develop a plan for improving access to such services for Medicare beneficiaries.

of the pre‐Medicare‐eligible population.

USection 4203

URemoving barriers and improving access to wellness for individuals with disabilities.U Requires the Access Board to establish standards for accessibility of medical diagnostic equipment to individuals with disabilities.

Federal N/A ‐ standards for access to medical equipment.

USection 4204

UImmunizations. UAuthorizes States to purchase adult vaccines under CDC contracts. Currently, 23 States purchase vaccines under CDC contracts. These

Health‐General Article § 18‐214 establishes the Statewide Advisory Commission on



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Date contracts for adult vaccines provide savings that range from 23‐69 percent compared to the private sector cost. Authorizes a demonstration program to improve immunization coverage. Under this program, CDC will provide grants to States to improve immunization coverage of children, adolescents, and adults through the use of evidence‐based interventions. States may use funds to implement interventions that are recommended by the Community Preventive Services Task Force, such as reminders or recalls for patients or providers, or home visits. Reauthorizes the Immunization Program in Section 317 of the Public Health Service Act. This section would also require a GAO study and report to Congress on coverage of vaccines under Medicare Part D and the impact on access to those vaccines.

Immunization. One of its duties is to study and make recommendations on options for purchase of vaccines, including development of a Universal Vaccine Purchasing System.

USection 4205

UNutrition labeling of standard menu items at chain restaurants.U This initiative represents a compromise between the Menu Education and Labeling (MEAL) Act, sponsored by Senator Harkin, and the Labeling Education and Nutrition (LEAN) Act, sponsored by Senators Carper and Murkowski. Under the terms of the compromise, a restaurant that is part of a chain with 20 or more locations doing business under the same name (other restaurants are exempt) would be required to disclose calories on the menu board and in a written form, available to customers

Federal Nothing in statute addresses nutrition labeling


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Date upon request, additional nutrition information pertaining to total calories and calories from fat, as well as amounts of fat, saturated fat, cholesterol, sodium, total carbohydrates, complex carbohydrates, sugars, dietary fiber, and protein.

USection 4206

UDemonstration project concerning individualized wellness plan. UThis pilot program provides at‐risk populations who utilize community health centers with a comprehensive risk‐factor assessment and an individualized wellness plan designed to reduce risk factors for preventable conditions.

Not targeted to states. N/A – pilot program for community health centers.

USection 4207

UReasonable break time for nursing mothers.U This initiative would amend the Fair Labor Standard Act to require employers to provide break time and a place for breastfeeding mothers to express milk. This would not apply to an employer with fewer than 50 employees, and there are no monetary damages.

N/A – federal labor law.

Subtitle D – Support for Prevention and Public Health Innovation

USection 4301

UResearch on optimizing the delivery of public health services.U The Secretary, acting through the Director of CDC, shall provide funding for research in the area of public health services and systems. This research shall include examining best practices relating to prevention, analyzing the translation of interventions from academic institutions to clinics and communities, and

Not targeted directly to states.

N/A – new CDC research.


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Date identifying effective strategies for delivering public health services in real world settings. CDC shall annually report research findings to Congress.

USection 4302

UUnderstanding health disparities; data collection and analysis.U Ensures that any ongoing or new Federal health program achieve the collection and reporting of data by race, ethnicity, primary language and any other indicator of disparity. The Secretary shall analyze data collected to detect and monitor trends in health disparities and disseminate this information to the relevant Federal agencies.

Health‐General Article Title 20 Subtitle 10 establishes the Office of Minority Health and Health Disparities. One of its duties is to collect, classify, and analyze data.

USection 4303

UCDC and employer‐based wellness programs.U Requires the CDC to study and evaluate best employer‐based wellness practices and provide an educational campaign and technical assistance to promote the benefits of worksite health promotion to employers.

Federal N/A – CDC study.

USection 4304

UEpidemiology‐Laboratory Capacity Grants.U

Establishes a program at the CDC that awards grants to assist State, local, and tribal public health agencies in improving surveillance for and responses to infectious diseases and other conditions of public health importance. Amounts received under the grants shall be used to strengthen epidemiologic capacity, enhance laboratory practices, improve information systems, and

Refer to grants process. Health‐General Article § 18‐102 requires the Secretary of DHMH to adopt rules and regulations necessary to prevent infection or contagious disease as well as investigate and act to prevent the spread of disease. HG



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Date develop outbreak control strategies. Requires the Director of the CDC to issue national standards on information Exchange systems to public health entities for the reporting of infectious diseases and other conditions of public health importance in consultation with the National Coordinator for Health Information Technology.

Article Title 18 Subtitle 2 requires reporting of infectious or contagious disease.

USection 4305

UAdvancing research and treatment for pain care management.U Authorizes an Institute of Medicine Conference on Pain Care to evaluate the adequacy of pain assessment, treatment, and management; identify and address barriers to appropriate pain care; increase awareness; and report to Congress on findings and recommendations. Also authorizes the Pain Consortium at the National Institutes of Health to enhance and coordinate clinical research on pain causes and treatments. Establishes a grant program to improve health professionals’ understanding and ability to assess and appropriately treat pain.

Federal N/A – federal pain initiatives. However, there are references in the Health‐General Article to pain management for arthritis and as part of the hospital and nursing home bill of rights.

USection 4306

UFunding for childhood obesity demonstration project.U The Children's Health Insurance Program Reauthorization Act of 2009 included several provisions designed to improve the quality of care under Medicaid and CHIP. This law directed the Secretary to initiate a demonstration project to develop a comprehensive and systematic model for reducing childhood obesity. This section appropriates $25

Refer to grants process. Health – General Article § 13‐2A establishes a Committee on Childhood Obesity (provision terminated 6/30/10).



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Date million for the childhood obesity demonstration project and adjusts the demonstration time period to fiscal years 2010 through 2014.

Subtitle E – Miscellaneous Provisions

USection 4401

USense of the Senate concerning CBO scoring.U This section is struck by Section 10405.

N/A

USection 4402

UEffectiveness of Federal health and wellness initiatives.U The Secretary of Health and Human Services will evaluate the effectiveness of existing Federal health and wellness initiatives. The Secretary will consider whether such programs are effective in achieving their stated goals and evaluate their effect on the health and productivity of the Federal workforce.

Federal N/A – federal activities.

TITLE V—HEALTH CARE WORKFORCE Subtitle A‐‐Purpose and Definitions

USection 5001

Declares that the purpose of this title is to improve access to and the delivery of health care services for all individuals, particularly low‐income, underserved, uninsured, minority, health disparity, and rural populations.

N/A

USection 5002

Definitions used for this section. N/A

Subtitle B‐‐Innovations in the Health Care Workforce

USection 5101

UNational health care workforce commission.U Establishes a national

Federal N/A – national commission.


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Date commission tasked with reviewing health care workforce and projected workforce needs. The overall goal of the Commission is to provide comprehensive, unbiased information to Congress and the Administration about how to align Federal health care workforce resources with national needs. Congress will use this information when providing appropriations to discretionary programs or in restructuring other Federal funding sources. UAs amended by SectionU U10501U, adds representation from small businesses to the Commission membership; adds an examination of the barriers of entering and remaining in primary care careers as a high‐priority area for the Commission; and includes optometrists and ophthalmologists as members of the health care workforce.

USection 5102

UState health care workforce development grants.U Competitive grants are created for the purpose of enabling State partnerships to complete comprehensive planning and to carry out activities leading to coherent and comprehensive health care workforce development strategies at the State and local levels. Grants will support innovative approaches to increase the number of skilled health care workers such as health care career pathways for young people and adults.

Refer to grants process. Various provisions in statute relate to workforce generally or to a specific sector of the health care workforce. The Governor’s Workforce Investment Board (GWIB) is the Governor’s chief policymaking body for workforce development and is authorized under the


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Date Labor and Employment Article Title 11 Subtitle 5, the Maryland Workforce Investment Act. Health Occupations Article § 1‐601 established the Statewide Commission on the Shortage in the Health Workforce (terminated in 2008).

USection 5103

UHealth care workforce assessment.U Codifies the existing national center and establishes several regional centers for health workforce analysis to collect, analyze, and report data related to Title VII (of the Public Health Service Act) primary care workforce programs. The centers will coordinate with State and local agencies collecting labor and workforce statistical information and coordinate and provide analyses and reports on Title VII to the Commission.

Federal As indicated above, GWIB is authorized under LE Article Title 11 Subtitle 5. The health care reform law authorizes a GWIB to be a regional center.

USection 5104

UInteragency task force to assess and improve access to health care in the State of Alaska.U UAs added by sectionU U10501U, establishes a temporary Task Force to assess health care access and develop a strategy to improve health care delivery in Alaska.

Federal N/A

Subtitle C‐‐Increasing the Supply of the Health Care Workforce

Education Article Title 18 authorizes a variety of higher education grant, loan assistance,


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Date and scholarship programs. ED Article §18‐708 provides for the consolidation of several scholarship programs under the Workforce Shortage Student Assistance grants.

USection 5201

UFederally supported student loan funds.U Eases current criteria for schools and students to qualify for loans, shorten payback periods, and decreases the non‐compliance provision to make the primary care student loan program more attractive to medical students.


Federally supported student loan funds are not addressed in statute.

USection 5202

UNursing student loan program.U Increases loan amounts and updates the years for nursing schools to establish and maintain student loan funds.


No nursing student loan program in statute.

USection 5203

UHealth care workforce loan repayment programs.U Establishes a loan repayment program for pediatric subspecialists and providers of mental and behavioral health services to children and adolescents who are or will be working in a Health Professional Shortage Area, Medically Underserved Area, or with a Medically Underserved Population.


Two loan assistance repayment programs relate to the health care workforce: The Maryland Loan Assistance Repayment Program for Physicians, established in Education Article Title 18 Subtitle 28, and the Janet L. Hoffman Loan Assistance Repayment Program, established in ED Article Title 18


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Date Subtitle 15.

USection 5204

UPublic health workforce recruitment and retention program. U Offers loan repayment to public health students and workers in exchange for working at least 3 years at a federal, state, local, or tribal public health agency.


Public health workers could be eligible for Workforce Shortage Student Assistance grants or the JL Hoffman Loan Assistance Repayment Program.

USection 5205

UAllied health workforce recruitment and retention program. U Offers loan repayment to allied health professionals employed at public health agencies or in settings providing health care to patients, including acute care facilities, ambulatory care facilities, residences, and other settings located in Health Professional Shortage Areas, Medically Underserved Areas, or serving Medically Underserved Populations.


Allied health workers could be eligible for Workforce Shortage Student Assistance grants or the JL Hoffman Loan Assistance Repayment Program.

USection 5206

UGrants for States and local programs.U Awards scholarships to mid‐career public and allied health professionals employed in public and allied health positions at the Federal, State, tribal, or local level to receive additional training in public or allied health fields.


No specific mid‐career health professional programs in statute.

USection 5207

UFunding for National Health Service CorpsU. Increases and extends the authorization of appropriations for the National Health Service Corps scholarship and loan repayment program for FY10‐15.

Federal N/A – federal program.


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Date USection 5208

UNurse‐managed health clinics.U Strengthens the health care safety‐net by creating a $50 million grant program administered by HRSA to support nurse‐managed health clinics.


No nurse‐managed health clinic program in statute.

USection 5209

UElimination of cap on the Commissioned Corps.U Eliminates the artificial cap on the number of Commissioned Corps members, allowing the Corps to expand to meet national public health needs.

Federal N/A

USection 5210

UEstablishing a Ready Reserve Corps.U Establishes a Ready Reserve Corps within the Commissioned Corps for service in times of national emergency. Ready Reserve Corps members may be called to active duty to respond to national emergencies and public health crises and to fill critical public health positions left vacant by members of the Regular Corps who have been called to duty elsewhere.

Federal N/A

Subtitle D‐‐Enhancing Health Care Workforce Education and Training

COMAR 09.33.03, DLLR’s Job Service Program for Hospital Employees Re‐Training may be affected.

USection 5301

UTraining in family medicine, general internal medicine, general pediatrics, and physician assistantship.U Provides grants to develop and operate training programs, provide financial assistance to trainees and faculty, enhance faculty development in primary care and physician assistant programs, and to establish, maintain, and

Refer to grants process. ED Article § 18‐802 provides grants to higher ed institutions that train PAs or nurse practitioners. ED Article § 18‐803 establishes the Health Personnel Shortage


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Date improve academic units in primary care. Priority is given to programs that educate students in team‐based approaches to care, including the patient‐centered medical home.

Incentive Grant Program of grants to higher ed institutions.

USection 5302

UTraining opportunities for direct care workers.U Authorizes funding over three years to establish new training opportunities for direct care workers providing long‐term care services and supports.

Federal A comparable program was folded into the Workforce Shortage Student Assistance Grants program.

USection 5303

UTraining in general, pediatric, and public health dentistry. U Reinstates a separate line of dental funding in Title VII of the Public Health Service Act. Allows dental schools and education programs to use grants for pre‐doctoral training, faculty development, dental faculty loan repayment, and academic administrative units.

Federal Education Article Title 18 Subtitle 24 establishes the Maryland Dent‐Care Program of higher education loan assistance grants to dentists who serve Medicaid patients.

USection 5304

UAlternative dental health care provider demonstration project.U Authorizes the Secretary to award grants to establish training programs for alternative dental health care providers to increase access to dental health care services in rural, tribal, and underserved communities.

Refer to grants process. No alternative dental health care provider programs in statute.

USection 5305

UGeriatric education and training; career awards; comprehensive geriatric education.U Authorizes funding to geriatric education centers to support training in geriatrics, chronic care management, and long‐term care for faculty in health professions schools and family caregivers; develop curricula and best practices in geriatrics; expand the

Federal No geriatric education programs in statute.


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Date geriatric career awards to advanced practice nurses, clinical social workers, pharmacists, and psychologists; and establish traineeships for individuals who are preparing for advanced education nursing degrees in geriatric nursing.

USection 5306

UMental and behavioral health education and training grants.U Awards grants to schools for the development, expansion, or enhancement of training programs in social work, graduate psychology, professional training in child and adolescent mental health, and pre‐service or in‐service training to paraprofessionals in child and adolescent mental health.


No mental and behavioral health education and training grants in statute.

USection 5307

UCultural competency, prevention, and public health and individuals with disabilities training.U Reauthorizes and expands programs to support the development, evaluation, and dissemination of model curricula for cultural competency, prevention, and public health proficiency and aptitude for working with individuals with disabilities training for use in health professions schools and continuing education programs.

Federal Health‐General Article Title 20 Subtitle 9 encourages courses that identify and eliminate health care disparities.

USection 5308

UAdvanced nursing education grants.U Strengthens language for accredited Nurse Midwifery programs to receive advanced nurse education grants in Title VIII of the Public Health Service Act.


No advanced nursing education grants in statute.

USection 5309

UNurse education, practice, and retention grants.U Awards grants to nursing schools to strengthen nurse education and training


Education Article § 11‐405 establishes the Nurse Support Program


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Date programs and to improve nurse retention.

Assistance Fund to support grants to increase the number of hospital nurses.

USection 5310

ULoan repayment and scholarship program.U

Adds faculty at nursing schools as eligible individuals for loan repayment and scholarship programs.


Nursing faculty could be eligible for Workforce Shortage Student Assistance grants or the JL Hoffman Loan Assistance Repayment Program.

USection 5311

UNurse faculty loan program.U Establishes a Federally‐funded student loan repayment program for nurses with outstanding debt who pursue careers in nurse education. Nurses agree to teach at an accredited school of nursing for at least 4 years within a 6‐year period.

Federal No loan programs in statute for nursing faculty.

USection 5312

UAuthorization of appropriations for parts B through D of title VIIIU. Authorizes $338 million to fund Title VIII of the Public Health Service Act nursing programs.

Federal N/A

USection 5313

UGrants to promote the community health workforce.U Authorizes the Secretary to award grants to States, public health departments, clinics, hospitals, Federally qualified health centers, and other nonprofits to promote positive health behaviors and outcomes in medically underserved areas through the use of community health workers. Community health workers offer interpretation and translation services, provide culturally

Refer to grants process. No programs in statute for community health workforce.


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Date appropriate health education and information, offer informal counseling and guidance on health behaviors, advocate for individual and community health needs, and can provide some direct primary care services and screenings. Section 10501 clarifies the definition and activities of community health workers.

USection 5314

UFellowship training in public healthU. Authorizes the Secretary to address workforce shortages in State and local health departments in applied public health epidemiology and public health laboratory science and informatics.


No public health training programs in statute.


USection 5315

UUnited States Public Health Sciences Track. U

Directs the Surgeon General to establish a U.S. Public Health Sciences Track to train physicians, dentists, nurses, physician assistants, mental and behavior health specialists, and public health professionals emphasizing team‐based service, public health, epidemiology, and emergency preparedness and response in affiliated institutions. Students receive tuition remission and a stipend and are accepted as Commission Corps officers in the U.S. Public Health Service with a 2‐year service commitment for each year of school covered.

Federal N/A

USection 5316

URural physician training grantsU. UAs added by sectionU U10501U, establishes a grant program


No rural physician training grants in


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Date for medical schools to recruit and train medical students to practice medicine in underserved rural communities.

statute.

USection 5317

UDemonstration grants for family nurse practitioner training programs.U UAs added by sectionU U10501U, establishes a training demonstration program that supports recent Family Nurse Practitioner graduates in primary care for a twelve month period in Federally Qualified Health Centers (FQHCs) and nurse‐managed health clinics. The demonstration is authorized from 2011 through 2014.

Funding does not appear to be targeted directly to states.

No family nurse practitioner training programs in statute.

Subtitle E‐‐Supporting the Existing Health Care Workforce

USection 5401

UCenters of excellenceU. The Centers of Excellence program, which develops a minority applicant pool to enhance recruitment, training, academic performance and other supports for minorities interested in careers in health, is reauthorized at 150 percent of 2005 appropriations, $50 million.

Federal Centers of Excellence program is not in statute.

USection 5402

UHealth professions training for diversity.U Provides scholarships for disadvantaged students who commit to work in medically underserved areas as primary care providers, and expands loan repayments for individuals who will serve as faculty in eligible institutions. Funding is increased from $37 to $51 million for 2009 through 2013.

Federal Nothing comparable in statute pertaining to training for diversity.


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Date USection 5403

UInterdisciplinary, community‐based linkagesU. Authorizes funding to establish community‐based training and education grants for Area Health Education Centers (AHECs) and Programs. Two programs are supported ‐ Infrastructure Development Awards and Points of Service Enhancement and Maintenance Awards ‐ targeting individuals seeking careers in the health professions from urban and rural medically underserved communities.


Health‐General Article § 19‐2109 requires the Community Health Resources Commission to work in cooperation with AHECs and others to enhance access to care.


USection 5404

UWorkforce diversity grants.U Expands the allowable uses of nursing diversity grants to include completion of associate degrees, bridge or degree completion program, or advanced degrees in nursing, as well as pre‐entry preparation, advanced education preparation, and retention activities.

Federal No workforce diversity grants in statute.

USection 5405

UPrimary care extension program. UCreates a Primary Care Extension Program to educate and provide technical assistance to primary care providers about evidence‐based therapies, preventive medicine, health promotion, chronic disease management, and mental health. The Agency for Healthcare Research and Quality (AHRQ) will award planning and program grants to State hubs including, at a minimum, the State health department, State‐level entities administering Medicare and Medicaid, and at least one health professions school. These State hubs may also include Quality

Refer to grants process No primary care extension program in statute. Legislation to create a State Hub for this purpose may be desirable.


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Date Improvement Organizations, AHECs, and other quality and training organizations.

Subtitle F – Strengthening Primary Care and Other Workforce Improvements

USection 5501

UExpanding access to primary care services and general surgery services.U Beginning in 2011, provides primary care practitioners, as well as general surgeons practicing in health professional shortage areas, with a 10 percent Medicare payment bonus for five years. Section 10501 removes the budget‐neutrality adjustment that would have offset half of the cost of the primary care and general surgery bonuses.

Federal Potential impact on Medicaid, as Section 2 of Chapter 329 of 2008 declares the intent of the General Assembly that, until Medicaid provider rates are at the Medicare level, funds from the Rate Stabilization Fund should be used only to increase provider rates and not generally support the operation of the Medicaid program.

USection 5502

(UDeletedU by Sec. 10501) UMedicare Federally qualified health center improvements. U Directs the Secretary of Health and Human Services to develop and implement a prospective payment system (PPS) for Medicare‐covered services furnished by Federally Qualified Health Centers (FQHCs). Additionally, adds remaining Medicare‐covered preventive services to the list of services eligible for reimbursement when furnished by an FQHC. Section 10501 clarifies that the Secretary of HHS shall vary payments to FQHCs based on

Federal N/A – repealed.


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Date the type, duration, and intensity of services they deliver and establishes an annual FQHC market basket update.

USection 5503

UDistribution of additional residency positions.U Beginning July 1, 2011, directs the Secretary to redistribute residency positions that have been unfilled for the prior three cost reports and directs those slots for training of primary care physicians. In distributing the residency slots under this section, special preference will be given to programs located in States with a low physician resident to general population ratio and to programs located in States with the highest ratio of population living in a health professional shortage area (HPSA) relative to the general population.

Federal Nothing in statute addresses residency positions.

USection 5504

UCounting resident time in outpatient settings and allowing flexibility for jointly operated residency training programs.U Modifies rules governing when hospitals can receive indirect medical education (IME) and direct graduate medical education (DGME) funding for residents who train in a non‐provider setting so that any time spent by the resident in a non‐provider setting shall be counted toward DGME and IME if the hospital incurs the costs of the stipends and fringe benefits.

Federal Nothing in statute addresses resident time.

USection 5505

URules for counting resident time for didactic and scholarly activities and other activities.U Modifies current law to allow hospitals to count resident time spent in didactic conferences toward IME costs in the

Federal Nothing in statute addresses resident time.


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Date provider (i.e., hospital) setting and toward DGME in the non‐provider (i.e., non‐hospital) setting. Section 10501 clarifies that the Secretary is not required to reopen certain settled cost reports in applying changes to Medicare graduate medical education payment rules related to didactic training.

USection 5506

UPreservation of resident cap positions from closed hospitals.U Directs the Secretary to redistribute medical residency slots from a hospital that closes on or after the date that is two years before enactment of the this legislation based on certain criteria.

Federal Nothing in statute addresses resident caps.

USection 5507

UDemonstration project to address health professions workforce needs; extension of family‐to‐family health information centers. UEstablishes a demonstration grant program through competitive grants to provide aid and supportive services to low‐income individuals with the opportunity to obtain education and training for occupations in the health care field that pay well and are expected to experience labor shortages or be in high demand. The demonstration grant is to serve low‐income persons including recipients of assistance under State Temporary Assistance for Needy Families (TANF) programs.

Also establishes a demonstration program to

Refer to grants process. Nothing in statute addresses health information centers.


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Date competitively award grants for up to six States for three years to develop core training competencies and certification programs for personal and home care aides. Extends funding for family‐to‐family health information centers at $5 million for FY2010 through FY2012.

USection 5508

UIncreasing teaching capacity.U Directs the Secretary to establish a grant program to support new or expanded primary care residency programs at teaching health centers and authorizes $25 million for FY2010, $50 million for FY2011 and FY2012 and such sums as may be necessary for each fiscal year thereafter to carry out such program. Also provides $230 million in funding under the Public Health Service Act to cover the indirect and direct expenses of qualifying teaching health centers related to training primary care residents in certain expanded or new programs.


Nothing in statute addresses primary care residency grants.

USection 5509

UGraduate nurse education demonstration program.U This provision directs the Secretary to establish a demonstration program to increase graduate nurse education training under Medicare and authorizes $50 million to be appropriated from the Medicare Hospital Insurance Trust Fund for each of the fiscal years 2012 through 2015 for such purpose.

Federal Nurse Support Program is partly funded by Medicare (through hospital rates).

Subtitle G‐‐Improving Access to Health Care Services


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Date USection 5601

USpending for Federally Qualified Health Centers (FQHCs).U Authorizes the following appropriations: FY2010 ‐ $2.98B; FY2011 ‐ $3.86B; FY2012 ‐ $4.99B; FY 2013 ‐ $6.44B; FY2014 ‐ $7.33B; FY2015 ‐ $8.33B.

How to leverage and foster capacity of historic safety net providers?

Health‐General Article Title 24 Subtitle 13 establishes the FQHC Grant Program for the purpose of capital grants.


USection 5602

UNegotiated rulemaking for development of methodology and criteria for designating medically underserved populations and health professions shortage areas U. Directs the Secretary, in consultation with stakeholders, to establish a comprehensive methodology and criteria for designating medically underserved populations and Health Professional Shortage Areas.

Federal Nothing in statute addresses the designation of medically underserved populations and health professions shortage areas.

USection 5603

UReauthorization of Wakefield Emergency Medical Services for Children Program.U Reauthorizes program to award grants to States and medical schools to support the improvement and expansion of emergency medical services for children needing trauma or critical care treatment.

Refer to grants process. Maryland’s EMS system is regulated under Title 13, Subtitle 5 of the Education Article, which encompasses EMS for Children and is currently funded by the Wakefield Emergency Medical Services for Children Program grant.

USection 5604

UCo‐locating primary and specialty care in community‐based mental health settings.U Authorizes $50 million in grants for coordinated and integrated services through the co‐location of primary and specialty care in community‐based mental and behavioral health settings.


Nothing in statute addresses co‐location of primary and specialty care in mental health settings.


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Date

USection 5605

UKey national indicators.U Establishes a Commission on Key National Indicators to conduct a comprehensive oversight of a newly established key national indicators system, with a required annual report to Congress.

Federal N/A – federal commission

USection 5606

UState grants to health care providers who provide services to a high percentage of medically underserved populations or other special populations.U UAs added by sectionU U10501U, creates a grant program to support health care providers who treat a high percentage of medically underserved populations.

Refer to grants process. Maryland Loan Assistance Repayment program for Physicians prioritizes loan repayment for physicians who practice in underserved areas.

Subtitle H – General Provisions

USection 5701

UReports. URequires the Secretary to submit to the appropriate congressional committees a report on activities carried out under this title and the effectiveness of such activities.

Federal N/A – federal reports.

TITLE VI—TRANSPARENCY AND PROGRAM INTEGRITY

Subtitle A – Physician Ownership and Other Transparency

USection 6001

ULimitation on Medicare exception to the prohibition on certain physician referrals

Federal N/A ‐ Applies to hospital participation in


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Date for hospitals.U Prohibits physician‐owned hospitals that do not have a provider agreement prior to December 31, 2010, (UAs amended by SectionU U1106U of the Reconciliation Act) to participate in Medicare. Such hospitals that have a provider agreement prior to December 31, 2010, could continue to participate in Medicare under certain requirements addressing conflict of interest, bona fide investments, and patient safety issues, and expansion limitations. UAs amended by SectionU U1106U of the Reconciliation Act, provides a limited exception to the growth restrictions for grandfathered physician owned hospitals that treat the highest percentage of Medicaid patients in their county (and are not the sole hospital in a county).

Medicare.

USection 6002

UTransparency reports and reporting of physician ownership or investment interests.U Requires drug, device, biological and medical supply manufacturers to report transfers of value made to a physician, physician medical practice, a physician group practice, and/or a teaching hospital. Duplicative State or local laws would be preempted by Federal law, however, Federal preemption would not occur for State or local laws that are beyond the scope of this section

Preemption provision. May want legislation to include provision in State law. No reporting requirements currently in State law.


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Date USection 6003

UDisclosure requirements for in‐office ancillary services exception to the prohibition on physician self‐referral for certain imaging servicesU. Adds an additional requirement to the Medicare in‐office ancillary exception that requires the referring physician to inform the patient in writing that the individual may obtain the specified service from a person other than the referring physician, a physician who is a member of the same group practice as the referring physician, or an individual who is directly supervised by the physician or by another physician in the group practice.

Federal N/A ‐ Applies to disclosure requirements under physician self‐referral for Medicare.

USection 6004

UPrescription drug sample transparency.U Requires prescription drug manufacturers and distributors to report to the Secretary information pertaining to drug samples currently being collected internally, as required under the Federal Food, Drug and Cosmetic Act.

Federal N/A – Report to Secretary of HHS by drug manufacturers and distributors.

USection 6005

UPharmacy benefit managers transparency requirements.U Requires a pharmacy benefit manager (PBM) or a health benefits plan that provides pharmacy benefits management services that contract with health plans under Medicare or the Exchange to report to the Secretary information regarding the generic dispensing rate: the rebates, discounts, or price concessions negotiated by the PBM and the payment difference between health

Federal N/A – Report to Secretary of HHS by PBMs. Note: The Secretary may disclose information to States to carry out the Exchange. Under IN § 15‐10B‐20,


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Date plans and PBMs and the PBMs and pharmacies. All disclosed information would be confidential, except for certain specific purposes.

PBMs are required to undergo an examination by the Insurance Commissioner. A report of the examination is required.

Subtitle B – Nursing Home Transparency and Improvement ‐ Part I – Improving

Transparency of Information

USection 6101

URequired disclosure of ownership and additional disclosable parties information.U Requires that skilled nursing facilities (SNFs) under Medicare and nursing facilities (NFs) under Medicaid make available on request by the Secretary, the Inspector General of the Department of Health and Human Services, the States, and the State long‐term care ombudsman, information on ownership, including a description of the governing body and organizational structure of the facility and information regarding additional disclosable parties.


See HG § 19‐1401.1 for reporting requirements for nursing homes. Federal provision requires submission of ownership disclosure information to the State in which the facility is located and the State long‐term care ombudsman in the case where the State or LTC ombudsman requests such information. This provision also requires the Secretary to provide guidance and technical assistance to states on how to adopt the standardized format under this


E-147








Date section. This provision does not preempt any reporting requirement for a facility that is in effect as of the date of enactment. Assure HG can be read consistently with federal requirements.

USection 6102

UAccountability requirements for skilled nursing facilities and nursing facilities.U Requires SNFs and NFs to implement a compliance and ethics program to be followed by the facility’s employees and its agents within 36 months of enactment, and requires the Secretary to evaluate this program and report the results to Congress.

Federal requirements.

USection 6103

UNursing home compare Medicare website.U

Requires the Secretary to publish the following information on the Nursing Home Compare Medicare website: standardized staffing data, links to State internet websites regarding State survey and certification programs, the model standardized complaint form, a summary of substantiated complaints, and the number of adjudicated instances of criminal violations by a facility or its employee.


States are required to submit information on surveys or certification made with respect to a skilled nursing facility under Medicare and Medicaid to the Secretary of HHS. This provision requires the Secretary of HHS to provide guidance to States on how States can establish electronic links to Form 2567 State inspection reports or other


E-148








Date reports on the Internet website of the State that provides information on skilled nursing facilities and nursing facilities. OHCQ

USection 6104

UReporting of expendituresU. Requires the Secretary to modify cost reports for SNFs to require reporting of expenditures on wages and benefits for direct care staff, breaking out registered nurses, licensed professional nurses, certified nurse assistants, and other medical and therapy staff.

Federal requirements – reporting requirements for skilled nursing facilities. Requires the Secretary of HHS to redesign cost reports into certain functional accounts and make the information available upon request. Assure HG can be read consistently with federal requirements.


USection 6105

UStandardized complaint form. U Requires the Secretary to develop a standardized complaint form for use by residents (or a person acting on a resident’s behalf) in filing complaints with a State survey and certification agency and a State long‐term care ombudsman program. States would also be required to establish complaint resolution processes.

Secretary of HHS is required to develop a standardized complaint form for use by a resident in filing a complaint with a State survey and certification agency and a State long‐term care ombudsman program with respect to a facility. The State is required to make the standardized complaint


E-149








Date form available upon request to a resident or a person acting on behalf of a resident. HG § 19‐1409 Oversight Committee on Quality of Care HS § 10‐213 Long Term Care Ombudsman Program Federal requirements, assess consistency with State requirements.

USection 6106

UEnsuring staffing accountability.U Requires the Secretary to develop a program for facilities to report staffing information in a uniform format based on payroll data, and to also take into account services provided by any agency or contract staff.

N/A ‐ Federal requirements. Assure HG can be read consistently with federal requirements. HG § 19‐1409 Oversight Committee on Quality of Care HS § 10‐213 Long Term Care Ombudsman Program


USection 6107

UGAO study and report on Five‐Star Quality Rating System. U Requires the Government Accountability Office to conduct a study on the Five‐Star Quality Rating System which would include an analysis of the systems implementation and any potential

Federal N/A


E-150








Date improvements to the system.

Part II – Targeting Enforcement

USection 6111

UCivil money penalties.U Provides the Secretary with authority to reduce civil monetary penalties (CMPs) from the level that they would otherwise be by 50 percent for certain facilities that self‐report and promptly correct deficiencies within ten calendar days of imposition. For CMPs that are cited at the level of actual harm and immediate jeopardy, the Secretary would be provided with the authority to place CMPs in an escrow account following completion of the informal dispute resolution process, or the date that is 90 days after the date of the imposition of the CMP, whichever is earlier. If the facility’s appeal is successful, the CMP, with interest, would be returned to the facility. If the appeal is unsuccessful, some portion of the proceeds may be used to fund activities that benefit facility residents.

N/A – Federal CMPs. See HG, § 19‐1402 through § 19‐1406

USection 6112

UNational independent monitor demonstration project.U Directs the Secretary to establish a demonstration project within one year of enactment for developing, testing and implementing a national independent monitor program to conduct oversight of interstate and large

N/A – Requires Secretary to establish demonstration project. (See HG, § 19‐1405 Independent State Monitor)


E-151








Date intrastate chains. The HHS OIG would evaluate the demonstration project after two years.

USection 6113

UNotification of facility closure.U Requires the administrator of a facility that is preparing to close to provide written notification to residents, legal representatives of residents or other responsible parties, the State, the Secretary and the long‐term ombudsman program in advance of the closure by at least 60 days. Facilities would be required to prepare a plan for closing the facility by a specified date that is provided to the State, which must approve it and ensure the safe transfer of residents to another facility or alternative setting that the State finds appropriate in terms of quality, services and location, taking into consideration the needs and best interests of each resident.

Federal requirements. Administrator is required to submit written notification of an impending closure to the State long‐term care ombudsman. Federal requirement. A State is required to ensure that, before a facility closes, all residents of the facility have been successfully relocated. Evaluate to assure consistency with HG, § 19‐1413 Notice Regarding Closure

USection 6114

UNational demonstration projects on culture change and use of information technology in nursing homesU. Requires the Secretary to conduct two facility‐based demonstration projects that would develop best practice models in two areas. The first would be designed to identify best practices in


N/A – Requires Secretary to establish demonstration project.


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Date facilities that are involved in the “culture change” movement, including the development of resources where facilities may be able to access information in order to implement culture change. The second demonstration would focus on development of best practices in information technology that facilities are using to improve resident care.

Part III – Improving staff training

USection 6121

UDementia and abuse prevention trainingU. Requires facilities to include dementia management and abuse prevention training as part of pre‐employment initial training for permanent and contract or agency staff, and if the Secretary determines appropriate, as part of ongoing in‐service training.

Federal requirement. Assure HG can be read consistently with federal requirements. See HG, § 19‐319.1 In –service education program HS § 10‐209 Congregate Housing Services

Subtitle C – Nationwide Program for National and State Background Checks on Direct Patient Access Employees of Long

Term Care Facilities and Providers

USection 6201

UNationwide program for National and State background checks on direct patient access employees of long‐term care facilities and

Require the Secretary of HHS to establish nationwide program.



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Date providers.U Requires the Secretary to establish a nationwide program for national and State background checks on direct patient access employees of certain long‐term supports and services facilities or providers. This program is based on the background check pilot program in the Medicare Modernization Act.

Federal requirements for States. Revise State law to require background checks on direct patient access employees of certain long‐term supports and services facilties or providers. **Newly participating states vs. certain previously participating states (governs application procedure and federal match) See HG, § 19‐1902 Criminal history record checks and background checks HG, § 19‐2002 Office of Health Care Quality CJP, § 5‐619 Criminal history records checks and background checks for employees of adult dependent care programs

Subtitle D – Patient‐Centered Outcomes Research

USection 6301

UPatient‐Centered Outcomes Research.U Establishes a private, nonprofit entity (the

Federal N/A


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Date Patient‐Centered Outcomes Research Institute) governed by a public‐private sector board appointed by the Comptroller General to identify priorities for and provide for the conduct of comparative outcomes research. Requires the Institute to ensure that subpopulations are appropriately accounted for in research designs. Prohibits any findings to be construed as mandates on practice guidelines or coverage decisions and contains patient safeguards to protect against discriminatory coverage decisions by HHS based on age, disability, terminal illness, or an individual’s quality of life preference. Provides funding for the Institute and authorizes and provides funding for the Agency for Health Research and Quality to disseminate research findings of the Institute, as well as other government‐funded research, to train researchers in comparative research methods and to build data capacity for comparative effectiveness research. USection 10602U clarifies publication rights of researchers with respect to peer‐reviewed journals and clarifies that findings published by the Institute do not include practice guidelines, coverage, payment, or policy recommendations. The provision also increases the number of physicians on the Board of Governors from three to four.

USection 6302

UFederal coordinating council for comparative effectiveness research.U Upon

Federal N/A


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Date date of enactment, this provision would sunset the Federal Coordinating Council created in the American Recovery and Reinvestment Act of 2010 (P.L. 111‐5).

Subtitle E – Medicare, Medicaid, and CHIP Program Integrity Provisions

USection 6401

Provider screening and other enrollment requirements under Medicare, Medicaid, and CHIP. UProvider ScreeningU. Requires that the Secretary, in consultation with the HHS Office of Inspector General (HHS OIG), establish procedures for screening providers and suppliers participating in Medicare, Medicaid, and CHIP. The Secretary would be required to determine the level of screening according to the risk of fraud, waste, and abuse with respect to each category of provider or supplier. At a minimum, all providers and suppliers would be subject to licensure checks. The Secretary would have the authority to impose additional screening measures based on risk, including fingerprinting, criminal background checks, multi‐State data base inquiries, and random or unannounced site visits. An application fee of $200 for individual practitioners and $500 for institutional providers and suppliers would be imposed to cover the costs of screening each time they re‐verify their enrollment (every five years). USection 10603U removes the enrollment fee for

Take up option re moratorium on high risk providers in Maryland?

Federal requirements. Revise Health – General Article to require screening of providers and suppliers participating in Medicaid and CHIP. Licensure checks – Screening measures – Federal requirements. Add to Health‐General Article.

COMAR 10.09.36 General Medical Assistance Provider Participation Criteria


Implementation date of September 23, 2010. HHS establish screening procedures 6 months after enactment. Screening applies to new providers one year after enactment. Screening applies to current providers two years after enactment. Screening applies to revalidation of enrollment 6 months after enactment. Three years after


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Date physicians. UDisclosure RequirementsU. Providers and suppliers enrolling or re‐enrolling in Medicare, Medicaid, or CHIP would be subject to new disclosure requirements. Applicants would be required to disclose current or previous affiliations with any provider or supplier that has uncollected debt, has had their payments suspended, has been excluded from participating in a Federal health care program, or has had their billing privileges revoked. The Secretary would be authorized to deny enrollment in these programs if these affiliations pose an undue risk to a program. UCompliance ProgramsU. By a date determined by the Secretary, certain providers and suppliers would be required to establish a compliance program. The requirements for the compliance program would be developed by the Secretary and the HHS OIG. UFederal Action Required: Establish procedures for screening. Establish procedures for provisional period of enhanced oversight for first year of providers’ participation. HHS can waive fees.

Once compliance program is developed by the Secretary, add to Health – General Article.

enactment: Cannot enroll providers without going through this screening process. Disclosure requirements: one year after enactment.


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Date Can withhold payments for high‐risk DME providers for 3 month provisional period. Define compliance programs. Notify states of terminated providers. UState Action Required: Clarification on fees—HHS can waive fees for MA providers if State demonstrates that fee would impede access. HHS can also waive fee for hardship on case‐by‐case basis. Comply with procedures to be established by HHS—screening, provisional period, disclosure, temporary moratorium on enrollment imposed by HHS (unless it impacts access) or at option of State (unless it impacts access), compliance programs, reporting, NPI.

USection 6402

UEnhanced Medicare and Medicaid program integrity provisions. UIntegrated Data RepositoryU. Requires CMS to include in the integrated data repository (IDR) claims and payment data from the following programs: Medicare (Parts A, B, C, and D), Medicaid, CHIP, health‐related programs administered by the Departments of Veterans Affairs (VA) and Defense (DOD), the Social Security Administration, and the Indian Health Service (IHS).

Federal requirement – integrated data repository. N/A


HHS promulgates NPI regs by Jan 1, 2011.


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Date UAccess to DataU. The Secretary would be required to enter into data‐sharing agreements with the Commissioner of Social Security, the Secretaries of the VA and DOD, and the Director of the IHS to help identity fraud, waste, and abuse. The Committee Bill would grant the HHS OIG and the Department of Justice (DOJ) access to the IDR for the purposes of conducting law enforcement and oversight activities consistent with applicable privacy, security, and disclosure laws. UOverpayments.U Requires that overpayments be reported and returned within 60 days from the date the overpayment was identified or by the date a corresponding cost report was due, whichever is later. UNational Provider IdentifierU. Requires the Secretary to issue a regulation mandating that all Medicare, Medicaid, and CHIP providers include their NPI on enrollment applications. UMedicaid Management Information SystemU. Authorizes the Secretary to withhold the Federal matching payment to States for medical assistance expenditures when the State does not report enrollee encounter data in a timely manner to the State’s Medicaid Management Information System (MMIS).

Add to Human Services Article (HS, § 5‐607) Federal requirement. Add to Health‐General Article. May need to revise Human Services Article (HS, § 5‐607). Requires States to report enrollee encounter data in a timely manner to the State’s MMIS. Add to Health‐General Article. Federal requirement. Add to Health‐General Article. Federal requirements.


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Date UPermissive ExclusionsU. Subjects providers and suppliers to exclusion for providing false information on any application to enroll or participate in a Federal health care program. UCivil Monetary PenaltiesU. Expands the use of Civil Monetary Penalties (CMPs) to excluded individuals who order or prescribe an item or service, make false statements on applications or contracts to participate in a Federal health care program, or who know of an overpayment and do not return the overpayment. Each violation would be subject to CMPs of up to $50,000. UTestimonial Subpoena Authority U. The Secretary would be able to issue subpoenas and require the attendance and testimony of witnesses and the production of any other evidence that relates to matters under investigation or in question by the Secretary. USurety Bonds.U Requires that the Secretary take into account the volume of billing for a DME supplier or home health agency when determining the size of the surety bond. The Secretary would have the authority to impose this requirement on other providers and suppliers considered to be at risk by the Secretary. UPayment SuspensionsU. Authorizes the Secretary to suspend payments to a provider or supplier pending a fraud investigation. UAs

See False Claims, Health‐General §§ 2‐601 through 2‐611. HG, § 2‐602 CMP is no more than $10,000. Federal requirements. See False Claims, Health‐General §§ 2‐601 through 2‐611. Federal requirement. Federal requirement. Add to Health‐General Article. N/A. Any funding for States?


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Date amended by SectionU U1304U of the Reconciliation Act, allows a 90‐day period of enhanced oversight and withholding of payment in cases where the HHS Secretary identifies a significant risk of fraud among DME suppliers. UHealth Care Fraud and Abuse Control AccountU. UAs amended by SectionU U1301U of the Reconciliation Act, increases Health Care Fraud and Abuse Control (HCFAC) funding by $350 million over the next decade. The provision would also permanently apply the CPI‐U adjustment to HCFAC and Medicare Integrity Program (MIP) funding. UMedicare and Medicaid Integrity Programs.U Requires Medicare and Medicaid Integrity Program contractors to provide the Secretary and the HHS OIG with performance statistics, including the number and amount of overpayments recovered, the number of fraud referrals, and the return on investment for such activities. UFederal Action Required: UNPIU ‐ Issue regulations. UMedicaid Management Information SystemU ‐ Define enrollee encounter data. UPermissive ExclusionsU ‐ Applies to MA MCOs

Federal requirement ‐ Requires information to be provided to Secretary of HHS on overpayments, fraud referrals, and return on investment. Add collection of data to Health‐General Article.


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Date and MCO providers. UCivil Monetary PenaltiesU ‐ Applies to MA MCOs and MCO providers. UPayment SuspensionsU ‐ HHS to promulgate payment suspension regulations. UState Action Required: UOverpaymentsU ‐ Overpayment returns applies to States. Does not apply to beneficiaries. UNPIU ‐ Depends on HHS NPI regulations. UMedicaid Management Information SystemU ‐ Depends on HHS definition. UPayment SuspensionsU ‐ State can determine (in accordance with HHS regulations) to cause to suspend payments.

USection 6403

UElimination of duplication between the Healthcare Integrity and Protection Data Bank and the National Practitioner Data BankU. Requires the Secretary to maintain a national health care fraud and abuse data collection program for reporting certain adverse actions taken against health care providers, suppliers, and practitioners, and submit information on the actions to the National Practitioner Data Bank (NPDB). The Secretary would also be required to establish a process to terminate the

Federal Federal requirement. Effective on enactment, with transition period, the later of one year after enactment or the effective date of regs.


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Date Healthcare Integrity and Protection Databank (HIPDB) and ensure that the information formerly collected in the HIPDB is transferred to the NPDB. UFederal Action Required: HHS regulations on reporting, transition process. UState Action Required: State has reporting system in compliance with HHS regulations

USection 6404

UMaximum period for submission of Medicare claims reduced to not more than 12 months.U Beginning January 2010, the maximum period for submission of Medicare claims would be reduced to not more than 12 months.

Federal N/A – Applies to submission of Medicare claims.

Claims furnished before January 1, 2010, must be filed no later than December 31, 2010.

USection 6405

UPhysicians who order items or services required to be Medicare enrolled physicians or eligible professionals.U Requires durable medical equipment (DME) or home health services to be ordered by a Medicare eligible professional or physician enrolled in the Medicare program. The Secretary would have the authority to extend these requirements to other Medicare items and services to reduce fraud, waste, and abuse. USection 10604U clarifies that only physicians enrolled in the Medicare program may order home health

Federal N/A – Applies to DME or home health services ordered by a Medicare provider.


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Date services under Medicare Part A and Part B.

USection 6406

URequirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse. UBeginning January 1, 2010, the Secretary would have the authority to disenroll, for no more than one year, a Medicare enrolled physician or supplier that fails to maintain and provide access to written orders or requests for payment for DME, certification for home health services, or referrals for other items and services. The provision would also extend the HHS OIG’s permissive exclusion authority to include individuals or entities that order, refer, or certify the need for health care services that fail to provide adequate documentation to verify payment.

Federal N/A – Applies to disenrolling a Medicare provider for up to one year for failing to provide certain documentation.

USection 6407

UFace‐to‐face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment under Medicare.U Requires physicians to have a face‐to‐face encounter with the individual prior to issuing a certification for home health services or DME. The Secretary would be authorized to apply the face‐to‐face encounter requirement to other items and services based upon a finding that doing so would reduce the risk of fraud, waste, and abuse. Section 10605 clarifies that the face‐to‐face encounter required prior to certification for home health services may

Federal N/A – Applies to certifying eligibility for home health services or DME under Medicare.


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Date be performed by a physician, nurse practitioner, clinical nurse specialist, certified nurse‐midwife, or physician assistant.

USection 6408

UEnhanced penalties.U Subjects persons who fail to grant HHS OIG timely access to documents, for the purpose of audits, investigations, evaluations, or other statutory functions, to CMPs of $15,000 for each day of failure. Also, persons who knowingly make, use, or cause to be made or used any false statement to a Federal health care program would be subject to a CMP of $50,000 for each violation. The violations that could be subject to the imposition of sanctions and CMPs by the Secretary would include Medicare Advantage (MA) or Part D plans that: (1) enroll individuals in a MA or Part D plan without their consent, (2) transfer an individual from one plan to another for the purpose of earning a commission, (3) fail to comply with marketing requirements and CMS guidance, or (4) employ or contract with an individual or entity that commits a violation. Penalties for MA and Part D plans that misrepresent or falsify information would be increased to up to three times the amount claimed by a plan or plan sponsor based on the misrepresentation or falsified information.

Federal Federal requirements. Allies to false statement to a Federal health care program (include Medicaid?) See False Claims, Health‐General §§ 2‐601 through 2‐611. HG, § 2‐602 CMP is no more than $10,000. N/A – This provision applies to Medicare Advantage or Medicare Part D


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Date USection 6409

UMedicare self‐referral disclosure protocol.U

Within six months of enactment, the Secretary, in cooperation with the HHS OIG, would be required to establish a self‐referral disclosure protocol to enable health care providers and suppliers to disclose actual or potential violations of the physician self‐referral law.

Federal N/A – Applies to Medicare self‐referral disclosure protocol.

USection 6410

UAdjustments to the Medicare durable medical equipment, prosthetics, orthotics, and supplies competitive acquisition program.U Requires the Secretary to expand the number of areas to be included in round two of the competitive bidding program from 79 of the largest metropolitan statistical areas (MSAs) to 100 of the largest MSAs, and to use competitively bid prices in all areas by 2016.

Federal N/A – Applies to Medicare program.

USection 6411

UExpansion of the Recovery Audit Contractor (RAC) program. U Requires States to establish contracts with one or more Recovery Audit Contractors (RACs). These State RAC contracts would be established to identify underpayments and overpayments and to recoup overpayments made for services provided under State Medicaid plans as well as State plan waivers. The Secretary would also be required to expand the RAC program to Medicare Parts C and D. UFederal Action Required: Coordinate with states and promulgate

Add to Health –General Article.


States establish program by Dec 31, 2010.


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Date regulations. Annual report to Congress on effectiveness. UState Action Required: RACS already exist for hospitals. Establish or amend contracts. Contingency payment to contractors. Adequate appeals process. Coordinate with other efforts

Subtitle F – Additional Medicaid Program Integrity Provisions

USection 6501

UTermination of provider participation under Medicaid if terminated under Medicare or other State plan.U Requires States to terminate individuals or entities from their Medicaid programs if the individuals or entities were terminated from Medicare or another State’s Medicaid program.

Add to Health –General Article


See Sec. 6508.

USection 6502

UMedicaid exclusion from participation relating to certain ownership, control, and management affiliations.U Requires Medicaid agencies to exclude individuals or entities from participating in Medicaid for a specified period of time if the entity or individual owns, controls, or manages an entity that: (1) has failed to repay overpayments during the period as determined by the Secretary; (2) is

Add to Health‐General Article.

COMAR 10.09.36 General Medical Assistance Provider Participation Criteria


See Sec. 6508.


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Date suspended, excluded, or terminated from participation in any Medicaid program; or (3) is affiliated with an individual or entity that has been suspended, excluded, or terminated from Medicaid participation.

USection 6503

UBilling agents, clearinghouses, or other alternate payees required to register under Medicaid.U Requires any agents, clearinghouses, or other alternate payees that submit claims on behalf of health care providers to register with the State and the Secretary in a form and manner specified by the Secretary.

Add to Health –General Article (after form and manner of data elements from MMIS are determined by the Secretary of HHS).


See Sec. 6508.

USection 6504

URequirement to report expanded set of data elements under MMIS to detect fraud and abuse.U Requires States and Medicaid managed care entities to submit data elements from MMIS as determined necessary by the Secretary for program integrity, program oversight, and administration. UFederal Action Required: Define data elements.

Add to Health –General Article.


Submissions on or after Jan 1, 2010.

USection 6505

UProhibition on payments to institutions or entities located outside of the United StatesU. Prohibits States from making any payments for items or services provided

Conforming. Add to Health –General Article.

See Sec. 6508.


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Date under a Medicaid State plan or waiver to any financial institution or entity located outside of the United States.

USection 6506

UOverpaymentsU. Extends the period for States to repay overpayments to one year when a final determination of the amount of the overpayment has not been determined due to an ongoing judicial or administrative process. When overpayments due to fraud are pending, State repayments of the Federal portion would not be due until 30 days after the date of the final judgment. UFederal Action Required: HHS promulgates regulations.

Conforming. Federal requirement for States to repay federal portion of overpayments.

Upon enactment. Applies to overpayments discovered on or after date of enactment.

USection 6507

UMandatory State use of national correct coding initiativeU. Requires States to make their MMIS methodologies compatible with Medicare’s national correct coding initiative (NCCI) that promotes correct coding and controls improper coding. UFederal Action Required: By Sep 1, 2010, notify states of methodologies and how States are to incorporate them. Report to Congress.

Conforming. Federal requirement – States required to make MMIS methodologies compatible with Medicare. Administrative.

Effective for claims filed on or after Oct 1, 2010. Report to Congress due March 1, 2011.

USection 6508

UGeneral effective date.U Requires States to implement fraud, waste, and abuse

See False Claims, Health‐General §§ 2‐

General effective date: Jan 1, 2011,


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Date programs before January 1, 2011.

601 through 2‐611‐effective October 1, 2010. States will need to implement any additional changes before January 1, 2011. Administrative?

or if state legislation required: first day of first calendar quarter after end or regular session after enactment (July 1, 2011).

Subtitle G—Additional Program Integrity Provisions

USection 6601

UProhibition on false statements and representationsU. Employees and agents of multiple employer welfare arrangements (MEWAs) will be subject to criminal penalties if they provide false statements in marketing materials regarding a plan’s financial solvency, benefits, or regulatory status.

Federal N/A ‐ Amendment to ERISA.

USection 6602

U Clarifying definition. N/A ‐ERISA

USection 6603

UDevelopment of model uniform report form.U To facilitate consistent reporting by private health plans of suspected cases of fraud and abuse, a model uniform reporting form will be developed by the National Association of Insurance Commissioners, under the direction of the HHS Secretary.

Requires NAIC, under the direction of the Secretary of HHS, to develop a model uniform reporting form for fraud and abuse by private health plans.

USection 6604

UApplicability of State law to combat fraud and abuseU. The Department of Labor will adopt regulatory standards and/or issue orders to prevent fraudulent MEWAs from escaping liability for their actions under State law by claiming that State law

N/A – DOL issue regulations to allow State law enforcement of MEWAs.


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Date enforcement is preempted by Federal law.

USection 6605

UEnabling the Department of Labor to issue administrative summary cease and desist orders and summary seizures orders against plans in financially hazardous condition.U The Department of Labor is authorized to issue “cease and desist” orders to temporarily shut down operations of plans conducting fraudulent activities or posing a serious threat to the public, until hearings can be completed. If it appears that a plan is in a financially hazardous condition, the agency may seize the plan’s assets.

Federal N/A – DOL authority.

USection 6606

UMEWA plan registration with the Department of LaborU. MEWAs will be required to file their Federal registration forms, and thereby be subject to government verification of their legitimacy, before enrolling anyone.

Federal N/A – federal registration of MEWAs.

USection 6607

UPermitting evidentiary privilege and confidential communications.U Permits the Department of Labor to allow confidential communication among public officials relating to investigation of fraud and abuse.

Federal N/A – Amendment to ERISA. Allows Secretary of DOL to communicate confidential information with State authority.

Subtitle H – Elder Justice Act

USection 6701

UShort title of subtitle.U The “Elder Justice Act of 2009.”

N/A


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Date USection 6702

UDefinitionsU. Defines the terms used in this subtitle using the same definitions in section 2011 of the Social Security Act.

N/A

USection 6703

UElder Justice. U Requires the Secretary of HHS, in consultation with the Departments of Justice and Labor, to award grants and carry out activities that provide greater protection to those individuals seeking care in facilities that provide long‐term services and supports and provide greater incentives for individuals to train and seek employment at such facilities. Owners, operators, and certain employees of these facilities would be required to report suspected crimes committed at a facility. Owners or operators of such facilities would also be required to submit to the Secretary and to the State written notification of an impending closure of a facility within 60 days prior to the closure. In the notice, the owner or operator would be required to include a plan for transfer and adequate relocation of all residents.

Refer to grants process. N/A – Grant opportunities for a long‐term care facility or a community‐based long‐term care entity.

Subtitle I – Sense of the Senate Regarding Medical Malpractice

USection 6801

USense of the Senate regarding medical malpractice.U Expresses the sense of the Senate that health reform presents an opportunity to address issues related to medical malpractice and medical liability insurance, states should be encouraged to develop and test alternative models to the

Statement encouraging States to develop and test alternatives to existing civil litigation system. Directs Congress to consider State demonstration


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Date existing civil litigation system, and Congress should consider state demonstration projects to evaluate such alternatives.

program.

Title VII – IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES

Subtitle A—Biologics Price Competition and Innovation

USection 7001

UShort Title.U The “Biologics Price Competition and Innovation Act of 2009.”

Federal N/A

USection 7002

UApproval pathway for biosimilar biological products.U Establishes a process under which the Secretary is required to license a biological product that is shown to be biosimilar to or interchangeable with a licensed biological product, commonly referred to as a reference product.Prohibits the approval of an application as either biosimilar or interchangeable until 12 years from the date on which the reference product is first approved. If FDA approves a biological product on the grounds that it is interchangeable to a reference product, HHS is prohibited from making a determination that a second or subsequent biological product is interchangeable to that same reference product until 1 year after the first commercial marketing of the first interchangeable product. Authorizes HHS to issue guidance with respect to the licensure of biological

Federal N/A ‐ Requirement for Secretary of HHS. N/A – Authorizes HHS to issue guidance and recommendations for Congress.


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Date products under this new pathway, and it includes provisions governing patent infringement concerns such as the exchange of information, good faith negotiations, and initiation infringement actions. Applies certain provisions of the Food, Drug, and Cosmetic Act to this subtitle with respect to pediatric studies of biological products. Requires HHS to develop recommendations for Congress with respect to the goals for the process for the review of biosimilar biological product applications for the first five fiscal years after FY 2012.

USection 7003

Savings. The Secretary of the Treasury, in consultation with the HHS Secretary, shall for each fiscal year determine the amount of savings to the Federal Government as a result of the enactment of this subtitle. Notwithstanding any other provision of this subtitle, the savings to the Federal Government generated as a result of the enactment of this subtitle shall be used for deficit reduction.

Federal N/A – Requirement for the Secretary of the Treasury.

Subtitle B—More Affordable Medicines for Children and Underserved Communities

USection 7101

UExpanded participation in 340B programU. UAs amended by SectionU U2302U of the Reconciliation Act, extends participation in the 340B program to certain children’s hospitals, cancer hospitals, critical access and sole community hospitals, and rural referral centers, and exempts orphan drugs

N/A – Applies to eligibility for certain facilities in the 340B program (340B program limits the cost of covered outpatient drugs to certain federal



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Date from required discounts for new 340B entities.

grantees, federally‐qualified health center look‐alikes and qualified disproportionate share hospitals).

USection 7102

UImprovements to 340B program integrity.U Establishes new auditing, reporting, and other compliance requirements for the Secretary, and for pharmaceutical manufacturers and 340B covered entities.

N/A – applies to auditing and reporting under the 340B program.


USection 7103

UGAO study to make recommendations on improving the 340B program.U Requires the GAO to make recommendations to Congress within 18 months on improvements to the 340B program.

Federal N/A – GAO study.

Title VIII – COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS

USection 8001

U Title.U ‘‘Community Living Assistance Services and Supports Act’’ or the ‘‘CLASS Act

N/A

USection 8002

UEstablishment of national voluntary insurance program for purchasing community living assistance services and support (CLASS program).U Establishes a new, voluntary, self‐funded public long‐term care insurance program, to be known as the CLASS Independence Benefit Plan, for the purchase of community living assistance services and supports by individuals with functional limitations. Requires the Secretary to develop an actuarially sound

Federal N/A – Secretary of HHS is required to establish and administer a new, voluntary, self‐funded public long‐term care insurance program. Includes primary payor rules for beneficiaries enrolled in Medicaid. These benefits will supplement, not supplant other health


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Date benefit plan that ensures solvency for 75 years; allows for a five‐year vesting period for eligibility of benefits; creates benefit triggers that allow for the determination of functional limitation; and provides cash benefit that is not less than an average of $50 per day. No taxpayer funds will be used to pay benefits under this provision. USection 10801U made technical corrections to Title VIII

care benefits. No effect on eligibility for other benefits.

TITLE IX – REVENUE PROVISIONS Subtitle A – Revenue Offset Provisions

USection 9001

UExcise tax on high cost employer‐sponsored health coverage U. UAs amended by SectionU U1401U of the Reconciliation Act, levies an excise tax of 40 percent on insurance companies and plan administrators for any health coverage plan that is above the threshold of $10,200 for single coverage and $27,500 for family coverage. The tax applies to self‐insured plans and plans sold in the group market, but not to plans sold in the individual market (except for coverage eligible for the deduction for self‐employed individuals). The tax does not apply to stand‐alone dental and vision coverage. The tax applies to the amount of the premium in excess of the threshold. The threshold is indexed at CPI‐U plus one percentage point in year 2019 and CPI‐U in years thereafter. An increase in the threshold amount of

N/A – federal excise tax.


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Date $1,650 for singles and $3,450 for families is available for retired individuals age 55 and older and for plans that cover employees engaged in high risk professions. This provision also includes an adjustment for firms whose health costs are higher due to the age or gender of their workers and adjusts the initial threshold if there is unexpected high growth in premiums before 2018.

USection 9002

UInclusion of cost of employer‐sponsored health coverage on W‐2.U Requires employers to disclose the value of the benefit provided by the employer for each employee’s health insurance coverage on the employee’s annual Form W‐2.

N/A – reporting on W2 form.

USection 9003

UDistributions for medicine qualified only if for prescribed drug or insulinU. Conforms the definition of qualified medical expenses for HSAs, FSAs, and HRAs to the definition used for the medical expense itemized deduction. Over‐the‐counter medicine obtained with a prescription continues to qualify as a qualified medical expense.

N/A – federal regulation of HSAs, FSAs, and HRAs. Flow through to States.

USection 9004

UIncrease in additional tax on distributions from HSAs and Archer MSAs not used for qualified medical expenses.U Increases the additional tax for HSA withdrawals prior to age 65 that are used for purposes other than qualified medical expenses from 10 percent to 20 percent. The additional tax for Archer

N/A – federal regulation of HSAs and Archer MSAs. Flow through to States.


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Date MSA withdrawals not used for qualified medical expenses would increase from 15 percent to 20 percent.

USection 9005

ULimitation on health flexible spending arrangements under cafeteria plansU. Limits the amount of contributions to health FSAs to $2,500 per year beginning in 2013. The cap is indexed at CPI‐U in subsequent years.

N/A – federal regulation of FSAs. Flow through to States.

USection 9006

UExpansion of information reporting requirementsU. Requires businesses that pay any amount greater than $600 during the year to corporate and non‐corporate providers of property and services to file an information report with each provider and with the IRS. Information reporting is already required on payments for services to non‐corporate providers.

Federal reporting requirement.

USection 9007

UAdditional requirements for charitable hospitals.U Establishes new requirements applicable to nonprofit hospitals. The requirements would include a periodic community needs assessment.

Federal requirements to qualify as 501(c)(3) charitable hospital organization. Federal excise tax for failure to meet certain requirements. Health‐General Article § 19‐303 requires nonprofit hospitals to submit an annual community benefit report to HSCRC. The report must consider any community needs


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Date assessment by DHMH or a local health department. Legislation may be desirable to incorporate the new federal requirements in statute.

USection 9008

UImposition of annual fee on branded prescription pharmaceutical manufacturers and importers. U UAs amended by SectionU U1404U of the Reconciliation Act, imposes an annual fee on the pharmaceutical manufacturing sector. The amount of the fee is $2.5 billion in 2011, $2.8 billion in years 2012‐2013, $3.0 billion in 2014‐2016, $4.0 billion in 2017, $4.1 billion in 2018 and $2.8 billion in 2019 and years thereafter. This non‐deductible fee is allocated across the industry according to market share with a reduction in share for companies with annual sales of branded pharmaceuticals of less than $400 million.

Federal requirement – fee imposed on certain pharmaceutical manufacturers and importers.

USection 9009

UExcise Tax on Medical DevicesU. UAs amended by SectionU U1405U of the Reconciliation Act, imposes an excise tax on the sale of medical devices by the manufacturer or importer equal to 2.3 percent of the sales price. The tax is deductible for federal income tax purposes. The excise tax does not apply to any sale of eyeglasses, contact lenses, hearing aids, or any medical device of a type

Federal excise tax on sale of certain medical devices. Some possibly negligible state revenue reduction as a result of the federal treatment that the excise tax be deductible for federal


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Date generally purchased by the public at retail. In addition, sales for export and sales of devices for use in further manufacturing are exempt from the excise tax.

income tax purposes, which will flow through to the State.

USection 9010

UImposition of annual fee on health insurance providers.U Imposes an annual fee of on the health insurance sector. UAs amended by SectionU U1406U of the Reconciliation Act, the amount of the fee is $8.0 billion in 2014, $11.3 billion in years 2015‐2016, $13.9 billion in 2017, and $14.3 billion in 2018. For years after 2018, the amount of the annual fee is the amount for the preceding year increased by the rate of premium growth for the preceding calendar year. This non‐deductible fee is allocated across the industry according to market share and does not apply to companies whose net premiums written are $50 million or less. The fee also does not apply to any employer or governmental entity. Cooperatives and the national plan would be subject to the insurance provider fee. This provision exempts from the fee non‐profits which receive more than 80 percent of their gross revenues from government programs that target low‐income, elderly, or disabled populations. In addition, only 50 percent of net premiums written by entities who are tax exempt under Internal Revenue Code sections 501(c)(3), (4), (26), and (29) are included for purposes of determining an entity’s market share.

Federal requirement – fee imposed on certain health insurance providers.


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Date

USection 9011

UStudy and report of effect on veterans health care U. The Secretary of the U.S. Department of Veterans Affairs will review and report to Congress on the effect that the fees assessed on pharmaceutical and medical device manufacturers and health insurance providers have on the cost of medical care provided to veterans and veterans’ access to medical devices and branded drugs.

Requires the Secretary of Veterans Affairs to conduct a study.

USection 9012

UEliminate deduction for expenses allocable to Medicare Part D. U Eliminates the deduction for the subsidy paid by the federal government to employers who maintain prescription drug plans for their Medicare Part D eligible retirees, effective for taxable years beginning after December 31, 2012 ( UAs amended by SectionU U1407U of the Reconciliation Act).

Federal requirement – eliminate deduction for the subsidy paid by the federal government to employers for maintaining prescription drug plans for Medicare Part D eligible retirees. Takes effect in tax year 2013. May result in some revenue increase due to the fact that the Maryland taxable income calculation begins with federal adjusted gross income for individuals and federal taxable income for corporations.


E-181








Date USection 9013

UModification of itemized deduction for medical expenses.U Increases the adjusted gross income threshold for claiming the itemized deduction for medical expenses from 7.5 percent to 10 percent. Individuals age 65 and older would be able to claim the itemized deduction for medical expenses at 7.5 percent of adjusted gross income through 2016.

Federal tax –Implication for State ‐ if itemized for federal purposes, the deduction will flow through to the State. This increase in federal adjusted gross income floor reduces both the number of taxpayers who can claim the deduction and the amount of medical expenses that can be deducted by any given taxpayer. The resulting increase to federal adjusted gross income will flow through to the State individual income tax return. See Tax General Article §§ 10‐217 and 10‐218.

USection 9014

ULimitation on excessive remuneration paid by certain health insurance providers. ULimits the deductibility of executive compensation under Section 162(m) for insurance providers if at least 25 percent of the insurance provider’s gross premium income from health business is derived from health insurance plans that meet the minimum essential coverage requirements

Federal requirement – limit deduction of executive compensation for certain health insurance providers. Federal tax deductions for health insurance


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Date in the bill (“covered health insurance provider”). The deduction is limited to $500,000 per taxable year and applies to all officers, employees, directors, and other workers or service providers performing services for or on behalf of a covered health insurance provider.

providers would flow through to States.

USection 9015

UAdditional hospital insurance tax on high‐income taxpayers U. Increases the hospital insurance tax rate by 0.9 percentage points on an individual taxpayer earning more than $200,000 ($250,000 for married couples filing jointly). The revenues from this tax will be credited to the HI trust fund. UAs amended by SectionU U1402U of the Reconciliation Act, expands the hospital insurance tax to include a 3.8 percent tax on income from interest, dividends, annuities, royalties and rents which are not derived in the ordinary course of trade or business, excluding active S corporation or partnership income, on taxpayers with income above $200,000 for singles ($250,000 for married filing jointly).

Federal requirement – increase federal tax rate for high‐income taxpayers.

USection 9016

USpecial deduction for Blue Cross Blue Shield (BCBS)U. Requires that non‐profit BCBS organizations have a medical loss ratio of 85 percent or higher in order to take advantage of the special tax benefits provided to them under IRC Section 833, including the deduction for 25 percent of claims and expenses and the 100 percent deduction for

Federal requirement – Non‐profit BCBS must meet certain medical loss ratio to take advantage of special tax benefits. State law exempts nonprofit health


E-183








Date unearned premium reserves.

service plans, including nonprofit BCBS organizations, from both State income tax (Tax‐General Article § 10‐104) and the insurance premium tax (Insurance Article § 6‐101). Instead, nonprofit health service plans are subject to the public interest requirements under Insurance Article § 14‐106.

USection 9017

UExcise tax on indoor tanning services.U UAs added by sectionU U10907U, imposes a ten percent tax on amounts paid for indoor tanning services. Indoor tanning services are services that use an electronic product with one of more ultraviolet lamps to induce skin tanning. The tax would be effective for services on or after July 1, 2010.

Federal excise tax on indoor tanning services. Note: See Section 10907

Subtitle B – Other Provisions

USection 9021

UExclusion of health benefits provided by Indian tribal governmentsU. Provides an exclusion from gross income for the value of specified Indian tribal health benefits.

Federal requirement – exclusion from gross income for value of Indian tribal health benefits. Federal tax exclusion


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Date from gross income would flow‐through to States. Likely to be negligible impact.

USection 9022

UEstablishment of simple cafeteria plans for small businessesU. Establishes Simple Cafeteria Plans that ease participation restrictions so that small businesses can provide tax‐free benefits to their employees. Under this provision, self‐employed individuals are included as qualified employees. The provision also exempts employers who make contributions for employees under a simple cafeteria plan from pension plan nondiscrimination requirements applicable to highly compensated and key employees.

Federal regulation of cafeteria plans. Flow through to States.

USection 9023

UQualifying therapeutic discovery project creditU. Creates a two year temporary tax credit subject to an overall cap of $1 billion to encourage investments in new therapies to prevent, diagnose, and treat acute and chronic diseases. The credit would be available for two years.

Federal tax credit. No direct impact on State income tax. Note that a credit under this federal provision shall not be allowed for any investment for which bonus depreciation is allowed under Sections 168(k), 1400L(b)(1), or 1400N(d)(1) of the Internal Revenue Code.


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Date In addition, basis of any depreciable assets, for which expenditure a credit is sought, shall be reduced by the amount of the credit.

USection 9024

UHealth professionals State loan repayment tax relief. U UAs added by sectionU U10908U, excludes from gross income payments made under any State loan repayment or loan forgiveness program that is intended to provide for the increased availability of health care services in underserved or health professional shortage areas. This provision is effective for amounts received by an individual in taxable years beginning after December 31, 2008.

Federal requirement – exclusion from gross income for payments made under any State loan repayment or loan forgiveness program. See Education Article, §§ 18‐2801 through 18‐2806. Flow through to States. Note: See Section 10908.

USection 9025

UExpansion of adoption tax credit and adoption assistance programsU. UAs added by sectionU U10909U, increases the adoption tax credit and adoption assistance exclusion ($12,170 for 2009) by $1,000, and makes the credit refundable. The credit is extended through 2011.

Federal tax credit. Adoption exclusion flow through to states. Note: See Section 10909.

TITLE X— STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE

FOR ALL AMERICANS Subtitle A – Provisions Relating to Title I


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Date USection 10101

**Only those sections that Udo notU revise previous sections are listed below. Section that do revise are already incorporated into the respective section.

N/A

USection 10102

Revisions incorporated into respective sections.

N/A

USection 10103


N/A

USection 10104


N/A

USection 10105


N/A

USection 10106


N/A

USection 10107


N/A

USection 10108

UFree choice vouchers.U Requires employers that offer coverage and make a contribution to provide free choice vouchers to qualified employees for the purchase of qualified health plans through Exchanges. The free choice voucher must be equal to the contribution that the employer would have made to its own plan. Employees qualify if their required contribution under the employer’s plan would be between 8 and 9.8 percent of their income. Excludes free choice vouchers from taxation and voucher recipients are not eligible for tax credits.

Federal requirements – applies to employers that offer free choice vouchers. Exclusion of free choice vouchers from taxation – flow‐through to States?

USection 10109

UDevelopment of standards for financial and administrative transactionsU. Requires the Secretary to consult stakeholders and the National Committee on Vital and Health

Federal


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Date Statistics and the Health Information Technology Standards and Policy Committees to identify opportunities to create uniform standards for financial and administrative health care transactions, not already named under HIPAA, that would improve the operation of the health system and reduce costs.

Subtitle B—Provisions Relating to Title II –Part I – Medicaid and CHIP

USection 10201


N/A

USection 10202

UIncentives for States to offer home and community based services as a long‐term care alternative to nursing homes. UAdds a new policy that creates financial incentives for States to shift Medicaid beneficiaries out of nursing homes and into home and community based services (HCBS). The provision provides Federal Medical Assistance Percentage (FMAP) increases to States to rebalance their spending between nursing homes and HCBS. UFederal Action Required: Establish rebalancing program with incentives for selected states. $3B Thresholds for states <25% spending on HCBS (5% extra FMAP) and <50% spending on HCBS (2% extra FMAP). UState Action Required:

Apply for rebalancing program? Apply for SPA through 1915(i)? Increased FMAP for States for shifting Medicaid beneficiaries out of nursing homes and into communities. State is already working on shifting beneficiaries into community – will need to determine how to qualify for increased FMAP.

Oct 1, 2011—Sep 30, 2015. Targets are for Oct 1, 2015. State implement changes by 6 months after submitting app.


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Date Use new funds for HCBS. Required state changes: single entry point, conflict‐free case management, core standardized assessments. Data collection requirements.

USection 10203

Revisions incorporated into respective sections. UState Action Required: CHIP reauthorization—rebasing in FFY 2013. Growth factor update FFY 2014.

N/A

Part II – Support for Pregnant and Parenting Teens and Women

USection 10211

UDefinitions.U Defines “eligible institution of higher learning” as having the same meaning as in section 101 of the Higher Education Act of 1965 (20 U.S.C. 1001). The terms “accompaniment”, “community service center”, “high school”, “intervention service”, “Secretary”, “State”, “supportive social service”, and “violence” are also defined.

Federal definitions.

USection 10212

UFundU. Establishes a Pregnancy Assistance Fund for the purpose of awarding competitive grants to States to assist pregnant and parenting teens and women. The fund will be established by the Secretary of Health and Human Services in coordination and collaboration with the Secretary of Education.

Refer to grants process. Awaiting federal guidance.

USection 10213

UPermissible use of fundsU. Requires States to use the funds provided by these grants to provide support to pregnant and parenting




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Date teens and young women. States may use the funds provided to make funding available to eligible institutions of higher learning. UMatching requirementU. An eligible institution of higher learning that receives funding under this provision shall contribute non‐federal funds equal to 25 percent. Permissible uses of funds include for programs such as those that help pregnant or parenting teens stay in or complete high school, assistance to states in providing intervention services, and outreach so that pregnant and parenting teens and women are aware of services available to them. UState Actions Required If a State receives funding through a grant under this part, must use funds for specified purposes. Includes reporting requirements.

USection 10214

UAppropriations.U Appropriates $25 million for each of the fiscal years 2010 through 2019.

Part III – Indian Health Care Improvement

USection 10221

UIndian health care improvement.U Authorizes appropriations for the Indian Health Care Improvement Act, including programs to increase the Indian health care workforce, new programs for innovative care delivery models, behavioral health care services, new services for health promotion and disease prevention, efforts to improve access to

Federal – amendments to Indian Health Care Improvement Act.


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Date health care services, construction of Indian health facilities, and an Indian youth suicide prevention grant program.

Subtitle C – Provisions Related to Title III

USection 10301


N/A

USection 10302


N/A

USection 10303


N/A

USection 10304


N/A

USection 10305


N/A

USection 10306


N/A

USection 10307


N/A

USection 10308


N/A

USection 10309


N/A

USection 10310


N/A

USection 10311


N/A

USection 10312


N/A

USection 10313


N/A

USection 10314


N/A


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Date USection 10315


N/A

USection 10316


N/A

USection 10317


N/A

USection 10318


N/A

USection 10319


N/A

USection 10320


N/A

USection 10321


N/A

USection 10322


N/A

USection 10323

UMedicare coverage for individuals exposed to environment health hazards.U Provides Medicare coverage and medical screening services to individuals exposed to environmental health hazards as a result of a public health determination under the Comprehensive Environmental Response, Compensation, and Liability Act of 1980. Requires Secretary of HHS to establish a Pilot Program for Care of Certain Individuals Residing in Emergency Declaration Areas. Requires the Secretary of HHS to establish a grant program for early detection of certain medical conditions relating to environmental health hazards.

Refer to grants process. N/A – Applies to expanded Medicare coverage


E-192








Date An agency of any State or local government may apply for a grant under this section. Appropriations for grant program $23 million for fiscal 2010 through 2014 and $20 million for each 5‐fiscal year period thereafter.

USection 10324

UProtections for frontier statesU. Starting in fiscal year 2011, establishes hospital wage index and geographic practice expense floors for hospitals and physicians located in states in which at least 50 percent of the counties in the state are frontier.

Need to determine if State meets definition of “Frontier State” to qualify for protection.

USection 10325

URevision to skilled nursing facility prospective payment systemU. Delays implementation of certain skilled nursing facility “RUGs‐IV” payment system changes by one year to October 1, 2011. Applies to State payment system for Medicaid nursing facilities.

USection 10326

UPilot testing pay‐for‐performance programs for certain Medicare providers U. Provides the Secretary of HHS the authority to test value‐based purchasing programs for inpatient rehabilitation facilities, inpatient psychiatric hospitals, long‐term care hospitals, certain cancer hospitals and hospice providers by no later than January 1, 2016.


N/A – applies to pilot testing pay‐for‐performance for certain Medicare providers.

USection 10327


N/A –revisions/improvements to physician quality


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Date reporting system.

USection 10328

UImprovement in Part D medication therapy management (MTM) programsU. Requires Part D prescription drug plans to include a comprehensive review of medications (either in person or through telehealth technology) and a written summary of the review as part of their medication therapy management programs. Plans must also enroll beneficiaries who qualify on a quarterly basis and allow for opt out.

Federal N/A – Applies to Medicare Part D medication therapy management programs.

USection 10329

UDeveloping methodology to assess health plan value.U Requires the Secretary of HHS to develop a methodology to measure health plan value.

Federal N/A – Requires Secretary of HHS to develop methodology to measure health plan value.

USection 10330

UModernizing computer and data systems of the Centers for Medicare & Medicaid Services to support improvements in care delivery.U Requires the Secretary of HHS to develop a plan (and a detailed budget for the resources needed to implement such plan) to modernize the computer and data systems of the Centers for Medicare & Medicaid Services to support improvements in care delivery.

Federal N/A – Require Secretary of HHS to develop a plan to modernize CMS IT system.

USection 10331

UPublic reporting of performance informationU. Requires the Secretary of HHS to develop a “Physician Compare” website where Medicare beneficiaries can compare scientifically‐sound measures of physician


N/A – Require Secreatry of HHS to develop “Physician Compare” website with information on



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Date quality and patient experience measures, provided that such information provides an accurate portrayal of physician performance.

physicians enrolled in Medicare and other eligible professionals.

USection 10332

UAvailability of Medicare data for performance measurementU. Authorizes the release and use of standardized extracts of Medicare claims data to measure the performance of providers and suppliers in ways that protect patient privacy and in accordance with other requirements.

Federal Requires the Secretary of HHS to make available to certain qualified entities certain data for the evaluation of the performance of providers of services and suppliers under Medicare. Note: A “qualified entity” can be a public or private entity that meets certain requirements.

USection 10333

UCommunity‐based collaborative care networks.U Provides grants to develop networks of providers to deliver coordinated care to low‐income populations. Authorizes the Secretary of HHS to award grants to eligible entities to support community‐based collaborative care networks that meet certain requirements. Note: eligible entity is not defined. Includes requirements for a “network”.



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Date In awarding grants, the Secretary is required to give priority to networks that include certain entities.

USection 10334

UMinority healthU. Codifies the Office of Minority Health at the Department of Health and Human Services (HHS) and a network of minority health offices located within HHS. Elevates the National Center on Minority Health and Health Disparities at the National Institutes of Health from a Center to an Institute. The Offices of Minority Health will monitor health, health care trends, and quality of care among minority patients and evaluate the success of minority health programs and initiatives.

Federal N/A – applies to HHS Office of Minority Health.

USection 10335

U Technical correction to hospital value‐based purchasing (VBP) program U. Clarifies that the hospital VBP program shall not include measures of hospital readmissions.

Note: repealed in consolidated bill.

USection 10336

UGAO study and report on Medicare beneficiary access to high‐quality dialysis services.U Directs the Comptroller General to submit to Congress, within one year of enactment, a study on the impact on Medicare beneficiary access to high‐quality dialysis services of the end stage renal disease prospective payment system.

Federal N/A – GAO study.

Subtitle D—Provisions Relating to Title IV

USection Revisions incorporated into respective N/A


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Date 10401 sections.

USection 10402


N/A

USection 10403


N/A

USection 10404


N/A

USection 10405


N/A

USection 10406


N/A

USection 10407

UBetter diabetes careU. Directs the Secretary of HHS to develop a national report card on diabetes to be updated every two years and to the extent possible, for each State. The Secretary, in collaboration with States, shall meet certain requirements. Directs the Secretary to work with health professionals and States to improve data collection related to diabetes and other chronic diseases. Provides for an Institute of Medicine study on the impact of diabetes on medical care.


N/A – IOM Study on diabetes.


USection 10408

UGrants for small businesses to provide comprehensive workplace wellness programs.U Authorizes an appropriation of $200 million to give employees of small businesses access to comprehensive workplace wellness programs. Federal 5‐year grant program for small businesses that provide their employees

Funds not targeted directly to states. Conform state definition(s) of comprehensive wellness program to federal definition?

Insurance Article §15‐1201 (Health Insurance Partnership) defines “wellness benefit” and “wellness program.” Insurance Article §15‐509 defines “bona fide wellness program.”


Funding available FY 2011‐FY 2015.


E-197








Date access to comprehensive workplace wellness programs. Definition of “comprehensive wellness program” to be developed by HHS.

USection 10409

UCures Acceleration NetworkU. Authorizes the Cures Acceleration Network, within the National Institutes of Health (NIH), to award grants and contracts to develop cures and treatments of diseases. Grants will be awarded to accelerate the development of medical products and behavioral therapies. The network shall work with the Food and Drug Administration (FDA) to streamline protocols assuring compliance with regulations and standards that meet regulatory requirements at all stages of manufacturing, review, approval, and safety surveillance. Requires Director of NIH to establish a Cures Acceleration Network. The Cures Acceleration Network Program is required to award grants and contracts to eligible entities to accelerate the development of high need cures. “Eligible Entity” is defined and includes public or private entities. Appropriation $500 million for fiscal year 2010.



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Date USection 10410

UCenters of excellence for depressionU. Directs the Administrator of the Substance Abuse and Mental Health Services Administration to award grants to centers of excellence in the treatment of depressive disorders. The Secretary of HHS, acting through the Administrator, is required to award grants to eligible entities to establish national centers of excellence for depression. “Eligible Entity” is an institution of higher education or a public or private nonprofit research institution. Appropriations $100 million for each of fiscal years 2011 through 2015 and $150 million for each of the fiscal years 2016 through 2020.


USection 10411

UPrograms relating to congenital heart diseaseU. Allows the Secretary of HHS to enhance and expand existing infrastructure to track the epidemiology of congenital heart disease and to organize such information into a National Congenital Heart Disease Surveillance System. Expands, intensifies, and coordinates research at the NIH on congenital heart disease. Authorizes the Secretary to establish the National Congenital Heart Disease Surveillance System or award a grant to one eligible entity.



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Date “Eligible Entity” is a public or private nonprofit entity with specialized experience in congenital heart disease.

USection 10412

UAutomated Defibrillation in Adam’s Memory ActU. Amends and reauthorizes through 2014 public access defibrillation programs in Sec. 312 of the Public Health Service Act.

Federal See Education Article, § 13‐517. Does State currently qualify for public access defibrillation program?

USection 10413

UYoung women’s breast health awareness and support of young women diagnosed with breast cancer.U Directs the Secretary of HHS to develop a national education campaign for young women and health care professionals about breast health and risk factors for breast cancer. Supports prevention research activities at the Centers for Disease Control and Prevention (CDC) on breast cancer in younger women. Requires the Secretary of HHS to conduct a national evidence‐based education campaign to increase awareness of young women’s knowledge. Grant program to organizations and institutions to provide health information. Appropriation $9 million for each of the fiscal years 2010 through 2014.

Grants not targeted directly to states.

Subtitle E – Provisions Relating to Title V

USection UAmendments to Title V. Refer to grants process. (d) See Education


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Date 10501

U(d) Loan repayment for faculty at schools that train physician assistantsU. Includes faculty at schools for physician assistants as eligible or faculty loan repayment within the workforce diversity program. U(g) National diabetes prevention programU. Establishes a national diabetes prevention program at the CDC. State, local, and tribal public health departments and non‐profit entities can use funds for community‐based prevention activities, training and outreach, and evaluation. U(l) Rural physician training grantsU. Authorizes grants for medical schools to establish programs that recruit students from underserved rural areas who have a desire to practice in their hometowns. Programs would provide students with specialized training in rural health issues, and assist them in finding residencies that specialize in training doctors for practice in underserved rural communities. U(m)(1) Preventive medicine and public health training grant programU. Amends and reauthorizes section 768 of the Public Health Service Act, the preventive medicine and public health residency program. U(n)(1) National Health Service Corps improvements.U Improves the National

Some funding not targeted directly to states.

Article, § 18‐802. (g) Grant program. “Eligible Entities” is a State or local health department, a tribal organization, a national network of community‐based non‐profits focused on health and wellbeing, an academic institution. (l) Grant program for grants to a school of allopathic or osteopathic medicine. (m)(1) The Secretary of HHS is required to award grants and contracts to eligible entities to provide training to graduate medical residents in preventive medicine specialties. “Eligible Entity” includes an accredited school of public health or school of medicine or osteopathic medicine, a public or


E-201








Date Health Service Corps program by increasing the loan repayment amount, allowing for half‐time service, and allowing for teaching to count for up to 20% of the Corps service commitment.

private nonprofit hospital, or a State, local or tribal health department (or a consortium of the above). Appropriation $43 million for fiscal year 2011. (n)(1) N/A – Federal program.

USection 10502

UInfrastructure to expand access to care U. Provides funding to HHS for construction or debt service on hospital construction costs for a new health facility meeting certain criteria.

Appropriation $100 million for fiscal year 2010. To qualify, a facility shall be affiliated with an academic health center at a public research university in the US that contains a State’s sole public academic medical and dental school.

USection 10503

UCommunity Health Centers and National Health Service Corps FundU. Establishes a Community Health Centers and National Health Service Corps Fund. The fund will create an expanded and sustained national investment in community health centers under section 330 of the Public Health Service Act and the National Health Service

Increased funding for community health centers.


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Date Corps. UAs amended by SectionU U2303U of the Reconciliation Act, increases mandatory funding for community health centers to $11 billion over five years (FY 2011 – FY 2015).

USection 10504

UDemonstration project to provide access to affordable care.U Directs the Secretary of HHS to establish a 3‐year demonstration project in States to provide comprehensive health care services to the uninsured at reduced fees. Within 6 months of Act, The Secretary of HHS is required to establish a demonstration project in up to 10 states.


Subtitle F—Provisions Relating to Title VI

USection 10601


N/A

USection 10602


N/A

USection 10603


N/A

USection 10604


N/A

USection 10605


N/A

USection 10606

UHealth care fraud enforcement.U Enhances the fraud sentencing guidelines, changes the intent requirement for fraud under the anti‐kickback statute, and increases subpoena authority relating to health care fraud.

Federal Federal requirements.

USection UState demonstration programs to evaluate Refer to grants process.


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Date 10607 alternatives to current medical tort

litigation.U Authorizes grants to States to test alternatives to civil tort litigation. These models would be required to emphasize patient safety, the disclosure of health care errors, and the early resolution of disputes. Patients would be able to opt‐out of these alternatives at any time. The Secretary of HHS would be required to conduct an evaluation to determine the effectiveness of the alternatives. The Secretary of HHS is authorized to award demonstration grants to States to develop, implement, and evaluate alternatives to current tort litigation for resolving disputes over injuries allegedly caused by health care providers or health care organizations. Appropriation: $50 million for the 5‐fiscal year period beginning fiscal 2011.

USection 10608

UExtension of medical malpractice coverage to free clinicsU. Extends the protections from liability contained in the Federal Tort Claims Act to free clinics.

N/A – Federal Tort Claims Act

USection 10609

ULabeling changes.U Modifies requirements applicable to the labeling of generic drugs.

Federal requirement. Revise State law: See Health Occupations Article, § 12‐505 Labeling requirements for prescription medications


E-204








Date

USection 10801


N/A

USection 10901


N/A

USection 10902


N/A

USection 10903


N/A

USection 10904


N/A

USection 10905


N/A

USection 10906


N/A

USection 10907

Amends the Internal Revenue Code to impose a 10% excise tax on any amount paid for indoor tanning services on or after July 1, 2010. Exempts phototherapy services performed by a licensed medical professional from the definition of "indoor tanning services."

Federal excise tax.

USection 10908

Excludes from gross income any payments under the National Health Service Corps Loan Repayment Program and any other state loan repayment or forgiveness programs intended to increase the availability of health care services in underserved or health professional shortage area.

Federal requirement – exclusion from gross income for payments made under any State loan repayment or loan forgiveness program. Maryland’s Loan


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Date Assistance Repayment Program for physicians already provides for the tax exclusion.

USection 10909

Increases from $10,000 to $13,170 the dollar limitation on: (1) the tax credit for adoption expenses; and (2) the tax exclusion for employer‐provided adoption assistance. Allows an inflation adjustment to such limitation after 2010. Makes such credit refundable. Extends through 2011 the general terminating date of the Economic Growth and Tax Relief Reconciliation Act of 2001 with respect to such credit and exclusion.

Federal tax credit. Adoption exclusion will flow through to the State.

The Health Care and Education Reconciliation Act

Only those provisions of the Reconciliation Act that do not make changes to the Patient Protection and Affordable Care Act are described below. The provisions which make changes are already incorporated in the respective section. TITLE I – COVERAGE, MEDICARE, MEDICAID

AND REVENUES Subtitle A – Coverage

USection 1004

UIncome definitionsU. Adds new definition for “modified adjusted gross income,” and replaces all references of “modified gross income” with “modified adjusted gross income” in all sections created under or amended by PPACA, as amended by HCERA. The provision also extends the exclusion from gross income for employer provided health coverage for adult children up to the end of the calendar year in which the child turns age 26.

N/A – federal definitions. Extension of exclusion from gross income for employer provided health coverage for adult children up to 26 will flow through to the State.


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Date USection 1005

UImplementation funding.U Provides $1 billion to the Secretary of Health and Human Services to finance the administrative costs of implementing health insurance reform. Federal funding for health reform.

Subtitle B ‐ Medicare

USection 1101

UClosing the Medicare prescription drug ―”donut hole.”U Provides a $250 rebate for all Medicare Part D enrollees who enter the donut hole in 2010. Builds on pharmaceutical manufacturers’ 50 percent discount on brand‐name drugs beginning in 2011 to provide 75 percent coverage for brand‐name and generic drugs by 2020 to fill the donut hole.

Federal Revise State law. See Insurance Article, §§ 14‐512 and 14‐513

USection 1102

UMedicare Advantage payments.U Freezes Medicare Advantage payments in 2011. Beginning in 2012, the provision reduces Medicare Advantage benchmarks relative to current levels. Benchmarks will vary from 95 percent of Medicare spending in high‐cost areas to 115 percent of Medicare spending in low‐cost areas, with benchmarks increased by five percentage points in all areas for high‐quality plans. Changes will be phased‐in over three, five or seven years, depending on the level of payment reductions. Extends CMS authority to adjust risk scores in Medicare Advantage for observed differences in coding patterns

Federal N/A – Applies to Medicare Advantage payments.


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Date relative to fee‐for‐service and phases up the adjustment beginning in 2014.

USection 1103

USavings from limits on MA plan administrative costs.U Ensures Medicare Advantage plans spend at least 85% of revenue on medical costs or activities that improve quality of care, rather than profit and overhead.

Federal N/A – Applies to Medicare Advantage plans.

USection 1109

UPayment for qualifying hospitals.U Provides an additional payment under the Medicare inpatient prospective payment system to hospitals located in counties in the bottom quartile of counties as ranked by risk adjusted spending per Medicare enrollee. Applies to hospitals located in counties in bottom quartile of counties as ranked by risk adjusted spending per Medicare enrollee.

Federal N/A – applies Medicare inpatient prospective payment system to certain hospitals.

Subtitle C – Medicaid

USection 1202

UPayments to primary care physicians.U Requires that Medicaid payment rates to primary care physicians for furnishing primary care services be no less than 100% of Medicare payment rates in 2013 and 2014. Provides 100% federal funding for the additional costs to States of meeting this requirement.

Subtitle D – Reducing Fraud, Waste, and Abuse

USection UCommunity mental health centers.U Federal Federal requirements –


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Date 1301 Establishes new requirements for

community mental health centers that provide Medicare partial hospitalization services in order to prevent fraud and abuse.

applies to community mental health centers that provide Medicare partial hospitalization services.

USection 1302

UMedicare prepayment medical review limitationsU. Streamlines procedures to conduct Medicare prepayment reviews to facilitate additional reviews designed to reduce fraud and abuse.

Federal N/A – applies to Medicare prepayment reviews.

Subtitle E – Revenues

USection 1408

UElimination of unintended application of cellulosic biofuel producer creditU. Adds an additional revenue provision. Modifies the $1.01 per gallon cellulosic biofuel producer credit to exclude fuels with significant water, sediment, or ash content, such as black liquor. The provision would exclude from the definition of cellulosic biofuel any fuels that (1) are more than four percent (according to weight) water and sediment in any combination, or (2) have an ash content of more than one percent (according to weight). The provision would be effective for fuel sold or used after January 1, 2010.

Federal N/A ‐Modify federal credit to exclude certain fuels. See Tax ‐ General, § 10‐726 Cellulosic Ethanol Technology (State credit).

USection 1409

UCodification of economic substance doctrine and penaltiesU. Adds an additional revenue provision. Clarifies the application of the economic substance doctrine which has been used by courts to deny tax benefits

Federal tax. Any State or local income tax effect which is related to a Federal


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Date for transactions lacking economic substance. The provision would also impose a 40 percent strict liability penalty on underpayments attributable to a transaction lacking economic substance (unless the transaction was disclosed, in which case the penalty is 20 percent). This provision is effective for transactions entered into after the date of enactment.

income tax effect shall be treated in the same manner as a Federal income tax effect.

USection 1410

UTime for payment of corporate estimated taxesU. Provides for a one‐time adjustment to corporate estimated taxes for payments made during calendar year 2014.

Federal Federal adjustment. Flow‐through to State.

Subtitle F – Other Provisions

USection 1501

UTAA for communities.U Appropriates $500 Million a year for fiscal years 2010 through 2014 in the Community College and Career Training Grant program for community colleges to develop and improve educational or career training programs. Ensures that each state receives at least 0.5 percent of the total funds appropriated.

Federal funding for community colleges. See Education Article, § 16‐301 Budget for community colleges.

Documents

Appendix E. Section Review - Maryland State Archivesmsa.maryland.gov/megafile/msa/speccol/sc5300/sc5339/000113/013000/...U“Sec. 2712. ” U UProhibition ... Draft working document