• Establishes the World Trade Center Health Program, beginning July 1, 2011, to provide the following (Sec. 101):
• Medical monitoring and treatment benefits to certain emergency responders and cleanup workers who responded to the September 11, 2001, terrorist attacks; and
• Initial health evaluations, monitoring, and treatment benefits to New York City residents and workers who were directly impacted and adversely affected by the attacks.

• Defines a health condition related to the September 11, 2001, terrorist attacks as an illness or mental health condition for which exposure to adverse conditions resulting from the attacks is likely to be a significant factor in aggravating, contributing to, or causing the illness or condition (Sec. 101).

• Defines a World Trade Center responder as an individual who meets one of the following criteria (Sec. 101):
• Has been deemed eligible for monitoring, as of the bill's date of enactment, under arrangements between the National Institute for Occupational Safety and Health and either the New York City Fire Department or the consortium coordinated by Mt. Sinai Hospital;
• Performed rescue, recovery, demolition, cleanup, or other related services in the New York City disaster area in response to the attacks of September 11, 2001, and meets eligibility criteria determined by the World Trade Center Health Program Administrator;
• Was a member of the New York City Fire Department and participated in rescue and recovery efforts at any of the former World Trade Center sites, the Staten Island Landfill, or the New York City Chief Medical Examiner's Office, for at least one day between September 11, 2001, and July 31, 2002; 
• Is a surviving immediate family member of a member of the New York City Fire Department who was killed at the World Trade Center on September 11, 2001, and has received treatment for a health condition related to the attacks on or before September 8, 2008;
• Performed rescue, recovery, cleanup, or other related services in lower Manhattan, the Staten Island Landfill, or the barge loading piers for:
• At least 4 hours between September 11, 2001, and September 14, 2001; -At least 24 hours between September 11, 2001, and September 30, 2001; or
• At least 80 hours between September 11, 2001, and July 31, 2002;
• Was a member of the New York City Police Department or the Port Authority Police of the Port Authority of New York and New Jersey and:
• Participated in rescue and recovery efforts in lower Manhattan, the Staten Island Landfill, or the barge loading piers for at least 4 hours between September 11, 2001, and September 14, 2001;
• Participated in rescue and recovery efforts in lower Manhattan, the Staten Island Landfill, or the barge loading piers for at least 1 day between September 11, 2001, and July 31, 2002;
• Participated in rescue and recovery efforts in lower Manhattan for at least 24 hours between September 11, 2001, and September 30, 2001; or
• Participated in rescue and recovery efforts in lower Manhattan for at least 80 hours between September 11, 2001, and July 31, 2002;
• Was an employee of the New York City Chief Medical Examiner's Office, or was a morgue worker, who handled human remains from the World Trade Center attacks between September 11, 2001, and July 31, 2002;
• Was a worker in the Port Authority Trans-Hudson Corporation Tunnel for at least 24 hours between February 1, 2002, and July 1, 2002;
• Was a vehicle-maintenance worker exposed to debris from the World Trade Center while maintaining vehicles contaminated by toxins resulting from the September 11, 2001, terrorist attacks from September 11, 2001 until July 31, 2002; or
• Participated in the rescue and recovery efforts at the aircraft crash sites related to the September 11, 2001, terrorist attacks at the Pentagon or at Shanksville, Pennsylvania, from September 11, 2001 until the date cleanup concluded, and meets eligibility criteria determined by the World Trade Center Health Program Administrator.

• Defines a World Trade Center survivor as an individual that meets one of the following criteria (Sec. 101):
• Has been deemed eligible for medical treatment and monitoring by the World Trade Center Environmental Health Center as of the bill's date of enactment;
• Is not a World Trade Center responder, claims symptoms of a health condition related to the September 11, 2001, terrorist attacks, and meets eligibility criteria determined by the World Trade Center Health Program Administrator; or
• Is not a World Trade Center responder, claims symptoms of a health condition related to the September 11, 2001, terrorist attacks, and meets one of the following criteria:
• Was present in the New York City disaster area in the dust or dust cloud on September 11, 2001;
• Worked, resided, or attended school, childcare, or adult daycare in the New York City disaster area for at least 4 days between September 11, 2001, and January 10, 2002, or for at least 30 days between September 11, 2001, and July 31, 2002;
• Worked as a cleanup or maintenance worker in the New York City disaster area between September 11, 2001, and January 10, 2002, and had extensive exposure to dust related to the World Trade Center as a result of that work;
• Was deemed eligible for a grant from the Lower Manhattan Development Corporation Residential Grant Program, rented or owned a residence in the New York City disaster area, and resided in that residence between September 11, 2001, and May 31, 2003; or
• Was deemed eligible for any government incentive program designed to revitalize the lower Manhattan economy after the attacks of September 11, 2001, and whose place of employment was in the New York City disaster area at any time between September 11, 2001, and May 31, 2003.

• Prohibits individuals listed on the United States Department of Homeland Security's terrorist watch list from qualifying for the World Trade Center Health Program (Sec. 101).

• Limits the total number of eligible responders and survivors enrolled in the World Trade Center Health Program to no more than 25,000 at any giventime (Sec. 101).

• Requires the Inspector General of the United States Department of Health and Human Services to review the World Trade Center Health Program for fraudulent and unreasonable expenses (Sec. 101).

• Requires the World Trade Center Health Program Administrator to appoint and consult with an advisory committee consisting of the following members (Sec. 101):
• 4 occupational physicians, at least 2 of whom must have experience treating World Trade Center rescue and recovery workers;
• 1 each of a physician with expertise in pulmonary medicine, an industrial hygienist, a toxicologist, an epidemiologist, and a mental health professional;
• 2 environmental medicine specialists;
• 2 representatives of certified-eligible World Trade Center responders; and
• 2 representatives of World Trade Center survivors.

• Requires the World Trade Center Health Program Administrator to consult with steering committees representing World Trade Center responders and World Trade Center survivors (Sec. 101).

• Requires New York City to pay for 10 percent of the costs of the World Trade Center Health Program through fiscal year 2015, and to pay for 1/9 of the costs in fiscal year 2016 (Sec. 101).

• Establishes the World Trade Center Health Program Fund, and requires the Federal share of the fund to be the lesser of 90 percent of the costs of the World Trade Center Health Program or the following for each of fiscal years 2012 through 2016 (Sec. 101):
• $71 million for the last calendar quarter of fiscal year 2011;
• $318 million for fiscal year 2012;
• $354 million for fiscal year 2013;
• $382 million for fiscal year 2014;
• $431 million for fiscal year 2015; and
• An additional amount for fiscal year 2016 from unspent funds from previous fiscal years.

• Prohibits the total Federal share of the World Trade Center Health Program Fund from being greater than $1.56 billion (Sec. 101).

• Extends the deadline for claims under the September 11th Victim Compensation Fund from 2 years after the date regulations went into effect to 5 years after the date regulations went into effect (Sec. 202).

• Limits the total amount of compensation paid under the September 11th Victim Compensation Fund to $2.78 billion, of which no more than $875 million may be paid out during the 5-year extension (Sec. 205).

• Requires the September 11th Victim Compensation Fund to permanently close after all payments have been completed (Sec. 205).

• Authorizes the Secretary of Health and Human Services to award grants to state, county, city, territorial, or tribal health departments to create and implement infant mortality pilot programs (Sec. 2).

• Requires the Secretary, when awarding grants, to give preference to the 15 counties or groups of counties with the highest infant mortality rates in the United States in the last 3 years (Sec. 2).

• Authorizes infant mortality pilot programs do the following with grants awarded by this Act (Sec. 2):
• Develop a plan that identifies the needs of the community;
• Provide outreach to "at-risk mothers";
• Develop and implement systems for improved access, utilization, and quality of services to promote healthy pregnancies, full-term births, and healthy infancies;
• Establish a rural outreach program;
• Establish a regional public education campaign to prevent pre-term births and educate the public on infant mortality; and
• Provide for any other activities, programs, and strategies identified by the community plan.

• Requires each entity that receives a grant to submit a report to the Secretary of Health and Human Services within 1 year of receiving the grant detailing the infant mortality program, including the methodology of, and outcomes and statistics, from the program (Sec. 2).

• Appropriates $10 billion for the Education Jobs Fund to be allocated to states for the retention, rehiring, or hiring of elementary and secondary education employees (Sec. 101).

• Establishes the following Federal Medical Assistance Percentage (FMAP) increases for fiscal year 2010-2011 for states whose fiscal year 2010-2011 FMAPs would otherwise be less than their FMAPs for any single fiscal year from FY 2007-2008 to FY 2009-2010 (Sec. 201):
• An increase of 3.2 percent in the second quarter; and
• An increase of 1.2 percent in the third quarter.

• Extends the period during which a state can receive a further increase in its FMAP if it has as a specified level of increase in unemployment so that eligibility ends on January 1, 2011 rather than July 1, 2010 (Sec. 201).

• Repeals a provision in the Internal Revenue Code of 1986 that allows for "advanced payment of earned income credit" (Sec. 219).

• Rescinds funds that include, but are not limited to, the following amounts (Secs. 301-330):
• $2.2 billion from federal aid to the states for highways;
• $1.5 billion from the Department of Energy's Innovative Technology Loan Guarantee Program;
• $340 million from the Department of Defense's Army construction funds;
• $302 million from the Department of Commerce's Broadband Technology Opportunities Program;
• $122 million from the Department of Agriculture's rural development funds.

• Extends unemployment insurance provisions in the following Acts by approximately 2 months (Sec. 2):
• The "Supplemental Appropriations Act, 2008;"
• The "Assistance for Unemployed Workers and Struggling Families Act;" and
• The "Unemployment Compensation Extension Act of 2008."

• Extends the expiration date of the eligibility period for COBRA benefits from March 31, 2010 to May 31, 2010 (Sec. 3).

• Increases the Medicare physician payment update by extending the date through which the update to the single conversion factor shall be 0 percent from March 31, 2010 to May 31, 2010 (Sec. 4).

• Prohibits the Secretary of Health and Human Services from publishing updated poverty guidelines for 2010 before May 31, 2010, and specifies that the 2009 guidelines shall be in effect until updated guidelines are published (Sec. 6).

• Appropriates $80 million to the Business Loans Program Account of the Small Business Administration for fee reductions and eliminations and loan guarantees (Sec. 10).

• Designates this Act (with the exception of Section 4) an emergency with regard to the Statutory Pay-As-You-Go Act of 2010 (Sec. 12).

• Amends the penalty for individuals who fail to maintain "minimum essential health care coverage" as follows (Sec. 1002):
• Amends the income exemption from under 100 percent of the federal poverty line to below the income filing threshold;
• Reduces the applicable dollar amount that is used to determine the penalty (multiplied by the number of people for whom the individual is liable or 300 percent of such amount for the taxable year) from $495 to $325 for 2015, and from $750 to $695 for 2016 and each subsequent year thereafter; and 
• Increases the alternative penalty, assessed if it's greater than the penalty calculated by the applicable dollar amount, from 0.5 to 1 percent of income for 2014, 1 to 2 percent of income for 2015, and 2 to 2.5 for 2016 and each subsequent year thereafter.

• Amends the penalty for large employers (average of at least 50 full time employees, with exceptions for seasonal workers) that fail to offer minimum essential health care coverage to their employees as follows (Sec. 1003):
• Reduces the first 30 employees from the payment calculation; and
• Increases the applicable payment amount from $750 to $2,000.

• Repeals the $600 penalty for large employers that impose a waiting period for new employees to enroll in the company's health benefits plan (Sec. 1003).

• Appropriates $1 billion to the Health Insurance Reform Implementation Fund for the Secretary of Health and Human Services to cover administrative costs associated with implementing the Act (Sec. 1005).

• Repeals the $500 reduction in the coverage gap under Medicare Part D that separates the limit on initial coverage and the coverage for catastrophic care ("donut hole") in 2010, establishes a $250 rebate for individuals affected by the gap beginning in 2010, and phases out the gap by 2020 (Sec. 1101).

• Repeals amendments to Medicare Part C (Medicare Advantage Plan) rates of payments, and amends benchmarks beginning in 2012 based on Medicare costs, to be phased-in over 3, 5, or 7 years depending on the amount reduced, as follows (Sec. 1102):
• 95 percent of Medicare spending for areas ranked by the Secretary in the highest quartile;
• 100 percent of Medicare spending for areas ranked by the Secretary in the second highest quartile;
• 107.5 percent of Medicare spending for areas ranked by the Secretary in the third highest quartile; and
• 115 percent of Medicare spending for areas ranked by the Secretary in the highest quartile.

• Repeals the provision that exempts the state of Nebraska from the federal compensation guidelines for the expansion of Medicaid eligibility and guaranteed that the state will be compensated for 100 percent of the costs beginning in 2014 and each subsequent year thereafter (Sec. 1201).

• Specifies that states will be compensated for the expansion of Medicaid eligibility as follows (Sec. 1201):
• 100 percent for 2014, 2015, and 2016;
• 95 percent for 2017;
• 94 percent for 2018;
• 93 percent for 2019; and
• 90 percent for 2020 and each year thereafter.

• Requires Medicaid payment rates to physicians for primary care services be no less than 100 percent of the rates in 2013 and 2014 (Sec. 1202).

• Amends the effective date for the excise tax on "high cost employer-sponsored health care plans" from 2013 to 2018, and increases the cost threshold for imposing the tax as follows (Sec. 1401):
• For single coverage, the threshold is increased from $8,500 to $10,200, or from $9,850 to $11,850 for retirees and employees of high-risk professions; and
• For family coverage, the threshold is increased from $23,000 to $27,500, or from $26,000 to $30,950 for retirees and employees of high-risk professions.

• Repeals the non-deductible fee to be collected annually after 2010 totaling $2 billion on medical device manufacturers and importers making more than $5 million during a calendar year, and establishes a 2.3 percent excise tax on the first sale of medical devices beginning in 2013, with the following exemptions (Sec. 1405):
• Eyeglasses;
• Contact lenses;
• Hearing aids; and
• Any other medical device available to individuals for retail sale, as determined by the Secretary.

• Prohibits all existing health insurance plans ("grandfathered health plans") from imposing lifetime limits or rescinding coverage for reasons other than intentional misrepresentation of material fact, and requires such plans to provide coverage for non-dependent children up to 26 years of age who are ineligible to enroll in employer-sponsored coverage (Sec. 2301).

• Amends tax credits for the cost of health insurance premiums to be based on household income according to the following sliding scale (Sec. 1001):
• For household incomes up to 133 percent of the federal poverty line, the premium percentage is 2.0 percent;
• For household incomes between 133 percent and 150 percent of the federal poverty line, the initial premium percentage is 3 percent and the final premium percentage is 4 percent;
• For household incomes between 150 percent and 200 percent of the federal poverty line, the initial premium percentage is 4 percent and the final premium percentage is 6.3 percent;
• For household incomes between 200 percent and 250 percent of the federal poverty line, the initial premium percentage is 6.3 percent and the final premium percentage is 8.05 percent;
• For household incomes between 250 percent and 300 percent of the federal poverty line, the initial premium percentage is 8.05 percent and the final premium percentage is 9.5 percent; and
• For household incomes between 300 percent and 400 percent of the federal poverty line, the premium percentage is 9.5 percent.

• Appropriates $13.5 billion for the Federal Pell Grant program (Sec. 2101).

• Repeals the authority to issue loans through the Federal Family Education Loan program beginning July 1, 2010, and requires all loans be issued directly through a financial institution located or operating in the U.S. and designated by the Secretary of Education (Secs. 2201 & 2206).

Insurance Regulations

• Prohibits health insurers from excluding individuals who have preexisting conditions (Sec. 1201).

• Prohibits health insurers from establishing rules for eligibility (including continued eligibility) based on any of the following factors (Sec. 1201):
• Health status;
• Medical condition (including physical and mental illnesses);
• Claims experience;
• Receipt of health care;
• Medical history;
• Genetic information;
• Evidence of insurability (including conditions relating to domestic violence);
• Disability; and
• Any other health status-related factor determined appropriate by the Secretary.

• Requires health insurers to base premium rates for plans in the individual or small group markets on the following factors (Sec. 1201):
• Whether the plan covers an individual or family;
• Rating area;
• Age; and
• Tobacco use.

• Prohibits health insurers from establishing lifetime limits or annual limits on the dollar value of benefits for any participant or beneficiary (Secs. 1001 & 10101).

• Prohibits health insurers from rescinding coverage unless fraud or a violation of the terms of the health plan have occurred (Sec. 1001).

• Requires health insurers to provide coverage for certain services at no cost to the patient including, but not limited to, the following (Sec. 1001):
• Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and
• Preventive health care and screenings for women, infants, children and adolescents.

• Expands health insurance coverage for dependent children to cover any unmarried adult child until he or she turns 26 years old (Sec. 2714).

• Requires the Secretary to establish a temporary high risk health insurance pool program no later than 90 days after the date of enactment of this bill to provide coverage for the following individuals through 2013 (Sec. 1101):
• Citizens or nationals of the United States;
• Individuals who have not been covered during the 6 month period prior to the establishment of the high risk pool; and
• Individuals who have a preexisting condition.

• Limits the annual out-of-pocket maximum for plans in the high risk pool to $5,000 for self-only coverage and $10,000 for family coverage (Sec. 1101).

• Specifies that nothing in this bill requires an individual to terminate coverage under a group health plan or any other form of health insurance coverage in which the individual was enrolled on the date of enactment (Sec. 1251).

• Defines "qualified health plan" as a plan that meets certain criteria including, but not limited to, the following (Secs. 1301-1302):
• Provides the following levels of coverage, with some exceptions:
• "Bronze level," in which 60 percent of the costs are reimbursed;
• "Silver level," in which 70 percent of the costs are reimbursed;
• "Gold level," in which 80 percent of the costs are reimbursed; and
• "Platinum level," in which 90 percent of the costs are reimbursed;
• Covers the following services:
• Ambulatory patient Services
• Emergency services;
• Hospitalization;
• Maternity and newborn care;
• Mental health and substance use disorder services;
• Prescription drugs;
• Rehabilitative and habilitative services and devices;
• Laboratory services;
• Preventive and wellness services and chronic disease management; and
• Pediatric services, including oral and vision care.
• Limits deductibles to $2,000 for individual coverage beginning in 2014 and $4,000 for any other plan;
• Is offered by a health insurer that offers at least 1 "silver level" and "gold level" plan in each Exchange; and
• Is offered by a health insurer that agrees to charge the same premium rate for each plan regardless of whether the plan is offered through and Exchange or directly.

• Authorizes qualified health plans to refuse to provide coverage for abortion or abortion-related services (Sec. 1303).

Health Insurance Exchange

• Requires each state to establish a Health Benefit Exchange no later than January 1, 2014 (Sec. 1311).

• Defines "Health Benefit Exchange" as a governmental or non-profit agency that provides qualified health plans to qualified individuals (excluding undocumented immigrants and incarcerated individuals) and employers that meet certain requirements, including, but not limited to, the following (Secs. 1311 & 1312):
• Maintain a website through which prospective enrollees may compare health plans;
• Assign ratings for every qualified health plan offered; and
• Provide an electronic calculator for the purpose of determining the cost of coverage.

• Authorizes qualified individuals to refuse to participate in an Exchange (Sec. 1312).

• Requires the federal government to establish a Health Benefit Exchange within a state if that state fails to establish its own Exchange by January 1, 2014 (Sec. 1321).

• Authorizes states to enact laws prohibiting abortion coverage in qualified health plans offered through the state's Exchange (Sec. 10104).

• Establishes a program that allows states to enter into a competitive process to negotiate contracts, premiums, cost sharing, and benefits with standard health plans for the following individuals (Sec. 1331):
• Individuals who are ineligible to enroll in Medicaid;
• Individuals who are ineligible for minimum essential coverage or eligible for an employer-sponsored plan that is not "affordable";
• Individuals whose household income is above 133 percent but not more than 200 percent of the federal poverty line (according to the size of that individual's family); and
• Individuals who are under age 65 at the beginning of the plan year.

• Authorizes interstate health care compacts, under which qualified health plans offered in one state can be purchased in another state, beginning in 2016, provided that the insurers are licensed in each participating state and adhere to the consumer protection standards of the purchaser's state (Sec. 1333).

• Establishes tax credits to assist individuals with the cost of health insurance premiums, and specifies that such assistance shall be equal to the monthly premiums for one or more qualified Exchange health plans (Sec. 1401).

• Establishes the following discounts for individuals enrolled in a plan providing silver level coverage through an Exchange and whose household income is greater than 100 percent but less than 400 percent of the federal poverty line (Sec. 1402):
• 2/3 reduction if household income is between 100 and 200 percent of the federal poverty line;
• 1/2 reduction if household income is between 200 and 300 percent of the federal poverty line; and
• 1/3 reduction if household income is between 300 and 400 percent of the federal poverty line.

• Establishes a tax credit for small businesses that purchase health insurance for their employees of 50 percent (or 35 percent for a small employer eligible for tax exemption) of the lesser of (Sec. 1421):
• Total nonelective contributions the employer made on behalf of its employees for premiums for qualified health plans offered through an Exchange; or
• Total nonelective contributions the employer would have made if each employee had enrolled in a qualified health plan.

• Defines an "eligible small employer" as an employer with no more than 25 full-time employees whose average annual wages are less than $50,000 and who arrange to make nonelective contributions on behalf of each employee (Sec. 1421).

Employer and Individual Mandates

• Requires most individuals to maintain "minimum essential health care coverage" for themselves and any dependents beginning on January 1, 2014, defined as any of the following (Sec. 1501):
• Medicare and Medicaid;
• Children's Health Insurance Program;
• TRICARE;
• Veteran's health care program;
• Health care for Peace Corps volunteers;
• Employer-sponsored plans;
• Individual market plans;
• Grandfathered health care plans, meaning coverage that is offered and effective before the date of enactment; or
• Other health care plan recognized by the Secretary of Health and Human Services (including state high-risk pooling plans).

• Establishes a monthly penalty on individuals who can afford minimal health coverage but fail to provide it for themselves and any dependents, and specifies that the penalty shall be the greater of 1/12 of the following (Sec. 1501):
• A flat dollar amount, calculated by applying an "applicable dollar amount" multiplied by the number of people for whom the individual is liable, or 300 percent of such amount for the taxable year; or
• A percentage of the individual's income: 0.5 percent for taxable years beginning in 2014, 1.0 percent for taxable years beginning in 2015, or 2.0 percent for taxable years beginning after 2015

• Defines "applicable dollar amount" as $95 for 2014, $495 for 2015, and $750 thereafter for individuals over 18 years of age, and $47.50 for 2014, $247.50 for 2015, and $375 thereafter for individuals under 18 years of age (Sec. 1501).

• Exempts the following individuals from the penalty for failure to acquire coverage (Sec. 1501):
• Individuals with conflicts of "religious conscience";
• Individuals who are members of a health care sharing ministry;
• Undocumented immigrants;
• Incarcerated individuals;
• Individuals for whom the cost of minimal health care coverage would exceed 8 percent of his or her income for 2013;
• Individuals whose income is under 100 percent of the federal poverty line;
• Members of Native American tribes;
• Individual who has "suffered a hardship," as determined by the Secretary; and
• Any other applicable individual who was not covered on the last day of the month for 3 consecutive months.

• Specifies that taxpayers cannot be criminally prosecuted, nor can a lien be placed on a taxpayer's property, for failure to pay penalties for lack of health care coverage (Sec. 1501).

• Requires businesses that employ more than 200 full-time employees and offer more than 1 health benefits plan to automatically enroll employees into a plan, and requires the employer to notify employees that they may opt out of such plan (Secs. 1511 - 1512).

• Requires large employers that impose a waiting period of 60 days or more to enroll in the company's health benefits plan to pay $600 (adjusted for inflation beginning in 2015) for every full-time employee affected by the waiting period (Sec. 1513).

• Establishes an excise tax of 40 percent on coverage providers that provide "high cost employer-sponsored health care plans," to be applied to the amount of the premium in excess of the following thresholds (Sec. 9001):
• $8,500 for single coverage, or $9,850 for employees of high-risk professions and single retired persons 55 and older (cost of living adjustment applied beginning in 2014);
• $23,000 for family coverage, or $26,000 for employees of high-risk professions and retired persons 55 and older with family coverage (cost of living adjustment applied beginning in 2014); and
• If the plan is offered in 1 of the 17 states that the Secretary of Health and Human Services determines had the highest average cost of health care in 2012, the threshold will be increased from 2012 through 2015.

• Exempts the following types of coverage from the aforementioned excise tax (Sec. 9001):
• Long-term care;
• Accident or disability insurance;
• Coverage for a specific disease or illness; and
• Hospital or other fixed indemnity insurance.

• Defines "coverage provider" to include each of the following entities (Sec. 9001):
• Issuers of group health insurance plans;
• Employers who make contributions to employees Health Savings or Medical Savings Accounts;
• Self-employed individuals who are eligible to deduct the cost of their health insurance plan; and
• Administrators of other health care plans.

• Defines a "high risk profession" as any of the following (Secs. 9001 & 10901):
• Individuals who install or repair electrical and telecommunications lines;
• Law enforcement officers;
• Fire fighters;
• Emergency medical technicians, paramedics, first-responders, and others who provide out-of-hospital emergency medical care; or
• Construction workers, longshore workers, miners, most agricultural workers, foresters, and fishermen.

• Increases a tax on payment distributions from Health Savings Accounts to beneficiaries for non-qualified medical expenses from 10 percent to 20 percent, beginning in 2011 (Sec. 9004).

• Increases a tax on payment distributions from Archer Medical Savings Accounts to beneficiaries for non-qualified medical expenses from 15 percent to 20 percent, beginning in 2011 (Sec. 9004).

• Establishes a non-deductible flat fee to be collected annually after 2010 totaling $2 billion on medical device manufacturers and importers making more than $5 million during a calendar year (Sec. 9009).

• Increases the hospital insurance tax rate by 0.9 percent on individuals earning over $200,000 and on married couples filing jointly that earn over $250,000, beginning in 2013 (Secs. 9015 & 10906).

• Establishes a 10 percent excise tax on voluntary indoor tanning services, to be collected at the point of service beginning after July 1, 2010, and specifies that phototherapy services performed by a licensed professional are exempt from such tax (Secs. 9017 & 10907).

 Medicare and Medicaid

• Requires the Secretary of Health and Human Services to establish a modifier for Medicare rates of payments to physicians based on the quality of care compared to the cost during a performance period (Sec. 3007).

• Establishes a 1 percent Medicare payment reduction, beginning in fiscal year 2014-2015, for high cost, high volume hospitals (Sec. 3008):

• Requires the Secretary of Health and Human Services to reduce Medicare rates of payment to hospitals by specific amounts based upon their rates of "excess readmission" (Sec. 3025).

• Requires the Secretary to establish a Hospital Value-Based Purchasing Program in which incentive payments are made to hospitals, beginning with fiscal year 2012-2013, based on performance standards for the following conditions or procedures (Sec. 3001):
• Acute myocardia infarction (AMI);
• Heart failure;
• Pneumonia;
• Surgeries, as mentioned by the Surgical Care Improvement Project; and
• Healthcare-associated infections.

• Establishes the following quality performance bonuses for Medicare Part C plans beginning in 2014 based on their rating according to a 5 star rating system that measures clinical quality and enrollee satisfaction (Sec. 3201):
• For plans that achieve a 3 star rating, a monthly payment equal to 2 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program; and
• For plans that achieve a 4 or 5 star rating, a monthly payment equal to 4 percent of the national monthly per capita cost for expenditures for individuals enrolled under the original Medicare fee-for-service program.

• Reduces the coverage gap under Medicare Part D that separates the limit on initial coverage and the coverage for catastrophic care ("donut hole") by $500 beginning January 1, 2010 (Sec. 3315).

• Establishes a 50 percent discount for selected drugs for individuals who are subject to the Medicare Part D coverage gap, effective July 1, 2010 (Sec. 3301).

• Expands Medicaid eligibility to include individuals under 65 years of age with incomes that do not exceed 133 percent of the federal poverty level, including adults without children or a disability, beginning January 1, 2014 (Secs. 2001 & 10201).

• Specifies that the federal government will compensate the states for the costs of the aforementioned expansion in Medicaid eligibility (Sec. 2001).

• Defines "expansion state" as a state that on the date of enactment offers health coverage, including inpatient hospital services, to parents and nonpregnant, childless adults with incomes that are at least 100 percent of the federal poverty line and who do not have access to employer-based coverage (Secs. 2001 & 10201).

• Prohibits States from adopting eligibility standards, methodologies, or procedures for Medicaid that are a more restrictive than federal eligibility standards, methodologies, or procedures (Sec. 2001).

• Extends current funding for the Children's Health Insurance Program (CHIP) through September 31, 2015 (Secs. 2101 & 10203).

• Prohibits States from adopting eligibility standards, methodologies, or procedures for CHIP that are a more restrictive than than federal eligibility standards, methodologies, or procedures, but repeals this prohibition on September 30, 2019 (Sec. 2101).

Public Health and Workforce Development

• Establishes the National Prevention, Health Promotion and Public Health Council within the Department of Health and Human Services, and requires the Council to perform the following duties (Sec. 4001):

• Serve as a coordinating organization among all federal agencies with respect to prevention, wellness, and health promotion practices, the public health system, and integrative health care;
• Develop a national strategy to improve the health of Americans and reduce incidents of preventable illnesses;
• Provide the President and Congress with recommendations on the most pressing health issues, including any policy changes that may achieve national health and wellness goals;
• Propose innovative approaches and policies for prevention, integrative wellness and public health for individuals and on community-levels;
• Establish a process for continual public input at the regional, state, and local level;
• Develop and make public the Council's national health strategy and recommendations; and
• Perform other activities as required by the President.

• Establishes a Prevention and Public Health Fund to provide for the expansion and sustained investment in public health and preventative programs and to lessen growth in private and public sector health care costs, to which the following amounts are appropriated (Sec. 4002):
• $500 million for fiscal year 2009-2010;
• $750 million for fiscal year 2010-2011;
• $1 billion for fiscal year 2011-2012;
• $1.25 billion for fiscal year 2012-2013;
• $1.5 billion for fiscal year 2013-2014; and
• $2 billion for fiscal year 2014-2015 and each subsequent year thereafter.

• Appropriates $50 million for each fiscal year from 2009-2010 to 2012-2013 for the establishment of a grant program for school-based health centers, with preference given to health centers that serve a large child population eligible for assistance under the state Medicaid plan, and requires such health centers to provide the following core services (Sec. 4101):
• Health assessments, diagnosis, and treatment of minor, acute, and chronic medical conditions; and
• Mental health and substance use disorder assessments, crisis intervention, counseling, treatment, and referral to a continuum of services including emergency psychiatric care, community support programs, inpatient care, and outpatient programs.

• Requires chain restaurants with more than 20 locations to display calorie content information next to food items on menus, including drive-through menu boards and self-service food and beverage bars, and to have that calorie information reflect servings as usually prepared and offered for sale (Sec. 4205).

• Appropriates $25 million for the Childhood Obesity Demonstration Project for fiscal years 2009-2010 through 2013-2014 (Sec. 4306). 

• Increases the maximum amount available for nursing student loans from $2,500 to $3,300 for any student and $4,000 to $5,200 for students in their last 2 academic years (Sec. 5202).

• Establishes a pediatric specialty loan repayment program that covers the principal interest of undergraduate, graduate and medical degree loans up to $35,000 a year for not more then 3 years, provided that the recipient agrees to provide pediatric medical subspecialty, pediatric surgical specialty, or child and adolescent mental and behavioral health care in an area with a shortage (Sec. 5203).

• Authorizes the Secretary of Health and Human Services to award grants to higher education institutions that recruit and provide clinical experience to students in mental health and behavioral health education, and appropriates funds as follows for fiscal years 2009-2010 through 2012-2013 (Sec. 5306):
• $8 million for social work training;
• $12 million for graduate psychology training;
• $10 million for professional child and adolescent mental health training; and
• $5 million for paraprofessional child and adolescent work.

• Authorizes the establishment of a Unites States Public Health Sciences Track, which is authorized to award advanced degrees through existing accredited academic institutions and shall emphasize team-based service, public health, epidemiology, and emergency preparedness and response (Sec. 5315).

• Specifies that students admitted to the Track shall receive tuition (or tuition remission) and a stipend for each school year for up to 4 years, in exchange for the following (Sec. 5315):
• Maintain Track enrollment until the course of study is completed;
• Maintain "an acceptable level" of academic standing (as determined by the Surgeon General);
• Complete a residency or internship if pursuing a degree from a school of medicine or osteopathic medicine, dental, public health, or nursing school or a physician assistant, pharmacy, or behavioral and mental health professional program; and
• Serve in the Commissioned Corps for two years for each year of enrollment, unless serving in a capacity which qualifies for a reduction.

• Authorizes the Secretary of Health and Human Services to award grants to teaching health centers to establish new accredited or expanded primary care residency programs, and appropriates $125 million for such grants for fiscal years 2009-2010 through 2011-2012 (Sec. 5508).

• Establishes an approval pathway to license biological products that are biosimilar or interchangeable with products that are already licensed, and prohibits the licensing of biosimilar products until 12 years after the licensing of the already-licensed product (Sec. 7002).

• Amends the penalty for individuals who fail to maintain "minimum essential health care coverage" as follows (Sec. 1002):
• Amends the income exemption from under 100 percent of the federal poverty line to below the income filing threshold;
• Reduces the applicable dollar amount that is used to determine the penalty (multiplied by the number of people for whom the individual is liable or 300 percent of such amount for the taxable year) from $495 to $325 for 2015, and from $750 to $695 for 2016 and each subsequent year thereafter; and 
• Increases the alternative penalty, assessed if it's greater than the penalty calculated by the applicable dollar amount, from 0.5 to 1 percent of income for 2014, 1 to 2 percent of income for 2015, and 2 to 2.5 for 2016 and each subsequent year thereafter.

• Amends the penalty for large employers (average of at least 50 full time employees, with exceptions for seasonal workers) that fail to offer minimum essential health care coverage to their employees as follows (Sec. 1003):
• Reduces the first 30 employees from the payment calculation; and
• Increases the applicable payment amount from $750 to $2,000.

• Repeals the $600 penalty for large employers that impose a waiting period for new employees to enroll in the company's health benefits plan (Sec. 1003).

• Appropriates $1 billion to the Health Insurance Reform Implementation Fund for the Secretary of Health and Human Services to cover administrative costs associated with implementing the Act (Sec. 1005).

• Repeals the $500 reduction in the coverage gap under Medicare Part D that separates the limit on initial coverage and the coverage for catastrophic care ("donut hole") in 2010, establishes a $250 rebate for individuals affected by the gap beginning in 2010, and phases out the gap by 2020 (Sec. 1101).

• Repeals amendments to Medicare Part C (Medicare Advantage Plan) rates of payments, and amends benchmarks beginning in 2012 based on Medicare costs, to be phased-in over 3, 5, or 7 years depending on the amount reduced, as follows (Sec. 1102):
• 95 percent of Medicare spending for areas ranked by the Secretary in the highest quartile;
• 100 percent of Medicare spending for areas ranked by the Secretary in the second highest quartile;
• 107.5 percent of Medicare spending for areas ranked by the Secretary in the third highest quartile; and
• 115 percent of Medicare spending for areas ranked by the Secretary in the highest quartile.

• Repeals the provision that exempts the state of Nebraska from the federal compensation guidelines for the expansion of Medicaid eligibility and guaranteed that the state will be compensated for 100 percent of the costs beginning in 2014 and each subsequent year thereafter (Sec. 1201).

• Specifies that states will be compensated for the expansion of Medicaid eligibility as follows (Sec. 1201):
• 100 percent for 2014, 2015, and 2016;
• 95 percent for 2017;
• 94 percent for 2018;
• 93 percent for 2019; and
• 90 percent for 2020 and each year thereafter.

• Requires Medicaid payment rates to physicians for primary care services be no less than 100 percent of the rates in 2013 and 2014 (Sec. 1202).

• Amends the effective date for the excise tax on "high cost employer-sponsored health care plans" from 2013 to 2018, and increases the cost threshold for imposing the tax as follows (Sec. 1401):
• For single coverage, the threshold is increased from $8,500 to $10,200, or from $9,850 to $11,850 for retirees and employees of high-risk professions; and
• For family coverage, the threshold is increased from $23,000 to $27,500, or from $26,000 to $30,950 for retirees and employees of high-risk professions.

• Repeals the non-deductible fee to be collected annually after 2010 totaling $2 billion on medical device manufacturers and importers making more than $5 million during a calendar year, and establishes a 2.3 percent excise tax on the first sale of medical devices beginning in 2013, with the following exemptions (Sec. 1405):
• Eyeglasses;
• Contact lenses;
• Hearing aids; and
• Any other medical device available to individuals for retail sale, as determined by the Secretary.

• Prohibits all existing health insurance plans ("grandfathered health plans") from imposing lifetime limits or rescinding coverage for reasons other than intentional misrepresentation of material fact, and requires such plans to provide coverage for non-dependent children up to 26 years of age who are ineligible to enroll in employer-sponsored coverage (Sec. 2301).

• Amends tax credits for the cost of health insurance premiums to be based on household income according to the following sliding scale (Sec. 1001):
• For household incomes up to 133 percent of the federal poverty line, the premium percentage is 2.0 percent;
• For household incomes between 133 percent and 150 percent of the federal poverty line, the initial premium percentage is 3 percent and the final premium percentage is 4 percent;
• For household incomes between 150 percent and 200 percent of the federal poverty line, the initial premium percentage is 4 percent and the final premium percentage is 6.3 percent;
• For household incomes between 200 percent and 250 percent of the federal poverty line, the initial premium percentage is 6.3 percent and the final premium percentage is 8.05 percent;
• For household incomes between 250 percent and 300 percent of the federal poverty line, the initial premium percentage is 8.05 percent and the final premium percentage is 9.5 percent; and
• For household incomes between 300 percent and 400 percent of the federal poverty line, the premium percentage is 9.5 percent.

• Appropriates $13.5 billion for the Federal Pell Grant program (Sec. 2101).

• Repeals the authority to issue loans through the Federal Family Education Loan program beginning July 1, 2010, and requires all loans be issued directly through a financial institution located or operating in the U.S. and designated by the Secretary of Education (Secs. 2201 & 2206).