Appropriations and Fund Transfers in the Affordable Care Act (ACA)

Changes from March 6, 2015 to May 8, 2015

This page shows textual changes in the document between the two versions indicated in the dates above. Textual matter removed in the later version is indicated with ~~red strikethrough~~ and textual matter added in the later version is indicated with blue.
    Appropriations and Fund Transfers in the
Affordable Care Act (ACA)
C. Stephen Redhead
Specialist in Health Policy
March 6, 2015

Congressional Research Service
7-5700
www.crs.gov
R41301

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

Summary
Implementation of the Patient Protection and Affordable Care Act (Affordable Care Act, or ACA)
is having a significant impact on federal mandatory—also known as direct—spending. Most of
the projected spending under the law is for expanding health insurance coverage. This spending
includes premium tax credits and other subsidies for individuals and families that purchase
private insurance coverage through the health insurance exchanges established under the ACA, as
well as enhanced federal funding to expand state Medicaid programs and tax credits for small
employers.
In addition, the ACA included numerous appropriations that have provided billions of dollars in
mandatory funds to support new and existing grant programs and other activities. Other ACA
provisions require the Secretary of Health and Human Services (HHS) to transfer amounts from
the Medicare Part A and Part B trust funds for specified purposes. The law appropriated
significant amounts to support short-term health care programs for targeted groups prior to the
health insurance exchanges becoming operational in 2014. It also created a Center for Medicare
and Medicaid Innovation (CMMI) within the Centers for Medicare and Medicaid Services (CMS)
and appropriated $10 billion for the FY2011-FY2019 period—and $10 billion for each
subsequent 10-year period—for CMMI to test and implement innovative payment and service
delivery models.
The ACA established four special funds and appropriated substantial amounts to each one. First,
the Community Health Center Fund, to which the ACA appropriated a total of $11 billion in
annual appropriations over the five-year period FY2011-FY2015, has helped support the federal
health centers program and the National Health Service Corps. Second, the Prevention and Public
Health Fund, for which the ACA provided a permanent annual appropriation, is intended to
support prevention, wellness, and other public health-related programs authorized under the
Public Health Service Act. Third, the Patient-Centered Outcomes Research Trust Fund is
supporting comparative effectiveness research through FY2019 with a mix of annual
appropriations, fees assessed on private health insurance, and Medicare trust fund transfers.
Finally, the Health Insurance Reform Implementation Fund, to which the ACA appropriated $1
billion, has helped cover the administrative costs of implementing the law. Overall, the ACA
included more than $100 billion in appropriations over the 10-year period FY2010-FY2019,
including $40 billion to provide funding for the State Children’s Health Insurance Program
(CHIP) for FY2014 and FY2015.
Federal outlays on insurance expansion coverage under the ACA, which constitutes most of the
law’s mandatory spending, are almost entirely exempt from sequestration. However, the
mandatory appropriations in the ACA are, in general, fully sequestrable at the percentage rate
applicable to nonexempt nondefense mandatory spending.
Besides the mandatory appropriations discussed in this report, the ACA also is having an effect on
federal discretionary spending, which is controlled by the annual appropriations acts. A
 Affordable Care Act (ACA)
    May 8, 2015
            (R41301)
          Jump to Main Text of ReportContentsIntroduction
ACA Appropriations and Fund Transfers
Appropriations Vary by Duration and Amount
Numerous Programs Are Funded
Some Funding Has Been Extended or Rescinded
Impact of Sequestration
Key Takeaways

      Tables
      Table 1. Sequestration of Nonexempt Nondefense Mandatory Spending
Table 2. Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable Care Act
Table 3. ACA Appropriations and Fund Transfers by Fiscal Year in Which Funds Become Available for Obligation

    

      Appendixes
      Appendix A. Acronyms Used in the Report
Appendix B. Annual Spending Reductions Under the Budget Control Act

    
SummaryImplementation of the Patient Protection and Affordable Care Act (Affordable Care Act, or ACA) is having a significant impact on federal mandatory—also known as direct—spending. Most of the projected spending under the law is for expanding health insurance coverage. This spending includes premium tax credits and other subsidies for individuals and families that purchase private insurance coverage through the health insurance exchanges established under the ACA, as well as enhanced federal funding to expand state Medicaid programs and tax credits for small employers.
In addition, the ACA included numerous appropriations that have provided billions of dollars in mandatory funds to support new and existing grant programs and other activities. Other ACA provisions require the Secretary of Health and Human Services (HHS) to transfer amounts from the Medicare Part A and Part B trust funds for specified purposes. The law appropriated significant amounts to support short-term health care programs for targeted groups prior to the health insurance exchanges becoming operational in 2014. It also created a Center for Medicare and Medicaid Innovation (CMMI) within the Centers for Medicare and Medicaid Services (CMS) and appropriated $10 billion for the FY2011-FY2019 period—and $10 billion for each subsequent 10-year period—for CMMI to test and implement innovative payment and service delivery models.
The ACA established four special funds and appropriated substantial amounts to each one. First, the Community Health Center Fund, to which the ACA appropriated a total of $11 billion over the five-year period FY2011-FY2015, has helped support the federal health centers program and the National Health Service Corps. Second, the Prevention and Public Health Fund, for which the ACA provided a permanent annual appropriation, is supporting prevention, wellness, and other programs authorized under the Public Health Service Act. Third, the Patient-Centered Outcomes Research Trust Fund is supporting comparative effectiveness research through FY2019 with a mix of annual appropriations, fees assessed on private health insurance, and Medicare trust fund transfers. Finally, the Health Insurance Reform Implementation Fund, to which the ACA appropriated $1 billion, helped pay for implementing the law. Overall, the ACA included more than $100 billion in appropriations over the 10-year period FY2010-FY2019, including $40 billion to fund the State Children's Health Insurance Program (CHIP) for FY2014 and FY2015.
In subsequent legislative actions, Congress has extended funding through FY2017 for several programs whose ACA appropriations were about to expire.
Federal outlays on insurance expansion coverage under the ACA, which constitutes most of the law's mandatory spending, are almost entirely exempt from sequestration. However, the mandatory appropriations in the ACA are, in general, fully sequestrable at the percentage rate applicable to nonexempt nondefense mandatory spending.

    Besides the mandatory appropriations discussed in this report, the ACA also is having an effect on federal discretionary spending, which is controlled by the annual appropriations acts. A companion report, CRS Report R41390, Discretionary Spending Under the Affordable Care Act
 (ACA), discusses the law’s impact on discretionary spending.

Congressional Research Service

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

Contents
Introduction...................................................................................................................................... 1
ACA Appropriations and Fund Transfers ........................................................................................ 2
Appropriations Vary by Duration and Amount .......................................................................... 2
Numerous Programs Are Funded .............................................................................................. 3
Some Funding Has Been Extended or Rescinded ..................................................................... 5
Impact of Sequestration ............................................................................................................. 5
Key Takeaways ................................................................................................................................ 6

Tables
Table 1. Sequestration of Nonexempt Nondefense Mandatory Spending ....................................... 5
Table 2. Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable
Care Act ........................................................................................................................................ 8
Table 3. ACA Appropriations and Fund Transfers by Fiscal Year in Which Funds Become
Available for Obligation ............................................................................................................. 20

Appendixes
Appendix A. Acronyms Used in the Report................................................................................... 26
Appendix B. Annual Spending Reductions Under the Budget Control Act .................................. 28

Contacts
Author Contact Information........................................................................................................... 29
Acknowledgments ......................................................................................................................... 29

Congressional Research Service

 's impact on discretionary spending.
    
  Appropriations and Fund Transfers in the Affordable Care Act (ACA)

Introduction

  
    Introduction
    Implementation of the Patient Protection and Affordable Care Act (Affordable Care Act, or
 ACA)11 is having a significant impact on federal mandatory—also known as direct—spending.2
2 Most of the projected spending under the law is for expanding health insurance coverage. This
 spending includes premium tax credits and cost-sharing subsidies for individuals and families that
 purchase private insurance coverage through the health insurance exchanges established under the
 ACA, as well as enhanced federal funding to expand state Medicaid programs and tax credits for
 small employers.3
3
    The Congressional Budget Office (CBO) and the Joint Committee on Taxation (JCT) estimate
 that spending on insurance coverage expansion under the ACA will equal $81 billion in FY2015.
Overtotal $1.707 trillion over the 10-year period FY2016 through FY2025, they estimate that spending on coverage
expansion will total $1.993 trillion.4.4 CBO and the JCT project that these costs will be more than
offset by revenues from the ACA’'s taxes and fees, and by savings from the law’'s changes to the
 Medicare program that are designed to slow the rate of growth of Medicare payments to certain
 health care providers.

    The ACA also included numerous appropriations that are providing billions of dollars in
 mandatory funds to support new and existing grant programs and other activities. Several other
 provisions in the law require the Secretary of Health and Human Services (HHS) to transfer
 amounts from the Medicare Part A and Part B trust funds for specified purposes.
 
    This report summarizes all the mandatory appropriations and Medicare trust fund transfers in the
 ACA and provides details on the status of obligation of these funds. The information is presented
 in two tables. The report also includes a brief discussion of the impact that sequestration is having
 on ACA mandatory spending. This report is periodically revised and updated to reflect important
 legislative and other developments.
Besides its impact on mandatory spending, the ACA also is having an effect on federal

    A companion CRS report discusses the ACA's impact on discretionary spending, which is controlled by the annual appropriations acts.process.5 Discretionary
 spending under the ACA falls into two broad categories. First, there are the amounts provided in
 appropriations acts for specific grant and other programs pursuant to explicit authorizations of
appropriations in the ACA. Second, there are the costs incurred by the federal agencies that are
1

The ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). A week later, on March 30, 2010, the
President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029), which
amended numerous health care and revenue provisions in the ACA and added multiple new stand-alone provisions.
Congress and the President have since enacted several other bills that have made targeted changes to specific ACA
provisions. All references to the ACA in this report refer, collectively, to the law as amended and to other related
HCERA provisions.
2
Mandatory, or direct, spending generally refers to outlays from budget authority (i.e., the authority to incur financial
obligations that result in government expenditures such as paying salaries, purchasing services, or awarding grants) that
is provided in authorizing laws, as opposed to annual appropriations acts. It includes spending on entitlement programs
(e.g., Medicare, Social Security).
3
While a detailed examination of the ACA is beyond the scope of this report, numerous CRS products that provide
more in-depth information on the many new programs and activities authorized and funded by the law are available at
http://www.crs.loc.gov (see under “Issues Before Congress: Health”).
4
CBO, The Budget and Economic Outlook: 2015 to 2025, January 2015, https://www.cbo.gov/sites/default/files/
cbofiles/attachments/49892-Outlook2015.pdf. See Appendix B.

Congressional Research Service

1

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

 appropriations in the ACA. Second, there are the costs incurred by the federal agencies that are responsible for administering and enforcing the ACA’'s core provisions to expand insurance
coverage. A companion CRS report discusses the ACA’s impact on discretionary spending.5

 coverage. 
    ACA Appropriations and Fund Transfers

    Table 2 summarizes all the ACA provisions that include an appropriation of funds or a transfer of
 amounts from the Medicare trust funds. The provisions are grouped under the following headings:
 (1) Private Health Insurance; (2) Medicaid and the State Children’'s Health Insurance Program
 (CHIP); (3) Medicare; (4) Fraud and Abuse; (5) Health Centers; (6) Health Workforce and the
 National Health Service Corps; (7) Community-Based Prevention and Wellness; (8) Maternal and
 Child Health; (9) Long-Term Care; (10) Comparative Effectiveness Research; (11) Biomedical
 Research; and (12) ACA Implementation: Administrative Expenses.

    Each table row provides information on a specific ACA provision, organized across four columns.
 The first column shows the ACA section or subsection number. The second column indicates
 whether the provision is freestandingfreestanding (i.e., new statutory authority that is not amending an
 existing statute) or amendatoryamendatory (i.e., amends an existing statute, typically the Social Security
 Act). Amendatory provisions either add a new program to the statute or modify an existing one.
 The third column gives a brief description of the program or activity, including details of the
 appropriation or fund transfer. The entry also includes the name of the administering agency
 within HHS and, if applicable, the Catalog of Federal Domestic Assistance (CFDA) number for
 the grant program.66 The fourth column shows how much funding has been obligated to date. An
 agency incurs an obligation, for example, by placing an order, signing a contract, awarding a
 grant, purchasing a service, or taking other actions that require the government to make
 payments. The obligation amounts are based on information in the HHS Tracking Accountability
 in Government Grants System (TAGGS) unless specified otherwise. The TAGGS database is a
 central repository for grants awarded by all the HHS operating divisions (agencies) and several
 offices within the Office of the Secretary. It is updated daily with new data provided by these
 entities.7

7 
    Appropriations Vary by Duration and Amount

    In many instances the ACA provided annual appropriations of specified amounts for one or more
 fiscal years. Generally, these funds must be obligated during the fiscal year in which the funds
 become available for obligation. A few provisions are multiple-year appropriations, in which the
 amount appropriated is available for obligation for a period of time in excess of one fiscal year
 (e.g., for the period FY2011 through FY2014). Often the provision includes additional language
 stating that the funds are to remain available “"until expended”" or “without fiscal year limitation.”

5
CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by C. Stephen
Redhead.
6
CFDA is a government-wide compendium of federal grant and other assistance programs. Each program is assigned a
unique five-digit number, XX.XXX, where the first two digits represent the funding agency and the second three digits
represent the program. Programs funded by the Department of Health and Human Services begin with the number 93.
For more information, see https://www.cfda.gov.
7
To access and search the TAGGS database, go to http://www.taggs.hhs.gov/.

Congressional Research Service

2

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

"without fiscal year limitation." 
    Most ACA appropriations and fund transfers are temporary (i.e., time-limited). Often they end in
 FY2014 or FY2015, though in a handful of instances they extend until FY2019. The law included
 four provisions (i.e., Sections 3021(a), 3403, 10323(b), and 4002) that continue to provide annual
 or multiple-year appropriations in perpetuity.

    The ACA also included three indefiniteindefinite appropriations that provide an unspecified amount of
 funding as indicated by the phrase “"such sums as may be necessary,”" or SSAN. One such
 provision (i.e., Section 1311) appropriated SSAN and authorized the HHS Secretary to determine
 the specific amount necessary for the grant program.8
8 
    Table 3 provides additional details on each of the appropriations (and fund transfers) summarized
 in Table 2. It shows the amount available for obligation in each fiscal year (or multi-year period)
 over the 10-year period FY2010 through FY2019. Note that the provisions are organized and
 grouped under the same headings used in Table 2. The final column in Table 3 ("Total" (“Total”) shows
 for each provision the total amount of appropriations or fund transfers. Note that in several cases
 the total amount has yet to be determined (see table entries for Sections 1311, 3403, 6301(d) &
 (e), 9023(e), and 10323(a)). For three of the provisions that continue to provide funding beyond
 FY2019, the amount in the total column represents the cumulative amount appropriated through
 FY2019 (see table entries for Sections 3021(a), 4002, and 10323(b)). Unless otherwise stated,
 references to the Secretary in both tables refer to the HHS Secretary. A list of the federal laws,
 agencies, programs, and funds referred to in this report by their acronym is provided in Appendix
A.

Appendix A.
    Numerous Programs Are Funded
 
    As summarized in the tables, the ACA funded a broad range of new and existing programs. The
 law appropriated significant amounts to support the following short-term health care programs for
 targeted groups prior to the health insurance exchanges becoming operational in 2014: (1) $5
 billion for the Pre-Existing Condition Insurance Plan (PCIP), a temporary insurance program to
providethat provided health insurance coverage for uninsured individuals with a pre-existing condition; (2) $5
 billion for a temporary reinsurance program to reimburse employers for a portion of the costs of
 providing health benefits to early retirees aged 55-64; and (3) $6  billion for the Consumer
 Operated and Oriented Plan (CO-OP) program, to support temporary health insurance
 cooperatives. The ACA appropriated $2.4 billion for maternal and child health programs and
 provided an unspecified amount of funding for state grants to plan and establish health insurance
 exchanges.9
9
    The law established the Center for Medicare and Medicaid Innovation (CMMI) within the
 Centers for Medicare and Medicaid Services (CMS) and appropriated $10 billion for the FY2011FY2019FY2011-FY2019 period—and $10 billion for each subsequent 10-year period—for CMMI to test and
 implement innovative payment and service delivery models. It also established and funded an
 Independent Payment Advisory Board (IPAB) to make recommendations to Congress for
8

The two other indefinite appropriations (i.e., Sections 5508(c), and 9023(e)) provide SSAN to carry out a program,
but in each case there is an upper limit on the amount that may be appropriated. Note that a fourth provision (i.e.,
Section 10323(a)) requires the HHS Secretary to transfer SSAN from the Medicare trust funds to carry out a pilot
program.
9
For a state-by-state breakdown of ACA exchange planning and establishment grants, see CRS Report R43066,
Federal Funding for Health Insurance Exchanges, by Annie L. Mach and C. Stephen Redhead.

Congressional Research Service

3

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

 achieving specific Medicare spending reductions if costs exceed a target growth rate. IPAB’s
's recommendations are to take effect unless Congress overrides them, in which case Congress
 would be responsible for achieving the same level of savings.

    The ACA created four special funds and appropriated substantial amounts to each one:
•

The Community Health Center Fund (CHCF), to which the ACA appropriated
 a total of $11 billion in annual appropriations over the five-year period FY2011FY2015FY2011-FY2015, has helped support the federal health centers program and the National
 Health Service Corps (NHSC). (Note: A separate ACA appropriation provided
 $1.5 billion for health center construction and renovation.) While CHCF funding
 may have been intended to supplement annual discretionary appropriations for
 the health centers program and the NHSC, the funds have partially supplanted
 (i.e., replaced) discretionary health center funding and have become the sole
 source of funding for the NHSC program, which has not received an annual
 discretionary appropriation since FY2011.10

•

10 
    The Prevention and Public Health Fund (PPHF), for which the ACA provided
 a permanent annual appropriation, is intended to support prevention, wellness,
 and other public health-related programs and activities authorized under the
 Public Health Service Act (PHSA).1111 PPHF funds have been used to support
 several new discretionary grant programs authorized by the ACA. The funds are
 also supplementing, and in some cases supplanting, annual discretionary
 appropriations for a number of established programs, including ones that were
 reauthorized by the ACA. In FY2013, almost half of the PPHF funds were used
 to help pay for CMS’'s administrative costs associated with exchange
 operations.12

•

12
    The Patient-Centered Outcomes Research Trust Fund (PCORTF) is
 supporting comparative effectiveness research with a mix of annual
 appropriations—some of which are offset by revenues from a fee imposed on
 private health plans—and transfers from the Medicare Part A and Part B trust
 funds through FY2019.

•


    The Health Insurance Reform Implementation Fund (HIRIF), to which the
 ACA appropriated $1 billion, has helped cover the administrative costs of
implementing the law.

Overall, the law included more than $100 billion in direct appropriations over the 10-year period
FY2010-FY2019, including $40 billion to provide CHIP funding for FY2014 and FY2015 (Table
3).

10

For more information, see CRS Report R42433, Federal Health Centers, by Elayne J. Heisler; and CRS Report
R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by C. Stephen Redhead.
11
Section 3205 of the Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96, 126 Stat. 156) reduced the
ACA’s annual appropriations to the PPHF over the period FY2013-FY2021 by a total of $6.25 billion. See Table 2.
12
For more information, see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA),
coordinated by C. Stephen Redhead.

Congressional Research Service

4

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

 implementing the law.Some Funding Has Been Extended or Rescinded

    As already noted, most of the ACA appropriations are temporary. ThreeThe following laws enacted since 2012
 have extended funding for several programs whose ACA funding ended in FY2012 or FY2014.
Those laws are the funded by the ACA:American Taxpayer Relief Act of 2012 (ATRA),13 the ;13 
    Pathway for SGR
 Reform Act of 2013 (PSGRRA),14 and the ;14
    Protecting Access to Medicare Act of 2014 (PAMA).15
;15 and
    Medicare Access and CHIP Reauthorization Act of 2015.16
Lawmakers opposed to specific ACA provisions also have succeeded in getting some ACA
 funding rescinded. ATRA, the Middle Class Tax Relief and Job Creation Act of 2012, and enacted
 appropriations acts for each of the past five fiscal years (i.e., FY2011-FY2015) all included ACA
 funding rescissions.16
17
    The ACA funding extensions and rescissions are summarized in Table 2 and Table 3.

.
    Impact of Sequestration
 
    While the federal spending on insurance expansion coverage under the ACA is almost entirely
 exempt from annual sequestration, the ACA appropriations discussed in this report are, in general,
 fully sequestrable at the percentage rate applicable to nonexempt nondefense mandatory spending
 (see Table 1). Under the sequestration general rules,). For technical reasons, OMB concluded that cuts in CHCF funding for community
 health centers and migrant health centers are capped at 2%. See Appendix B for more
 background on the annual spending reductions triggered by the Budget Control Act of 2011.17
18
    
      
        Table 1. Sequestration of Nonexempt Nondefense Mandatory Spending
Fiscal Year

Percent Reduction

2013

5.1%a

2014

7.2%

2015

7.3%

2016

6.8%

Source: Office of Management and Budget annual reports to Congress on the
Joint Committee reductions (FY2013-FY2016).
a.

Fiscal Year
Percent Reduction
2013

          
          
            5.1%a2014
7.2%
2015
7.3%
2016
6.8%
Source: Office of Management and Budget annual reports to Congress on the Joint Committee reductions (FY2013-FY2016). 

        a.

    This percentage reflects adjustments made by ATRA; see Appendix B.

.
      
    
    Importantly, only new budget authority for nondefense programs is sequestrable in any given
 fiscal year. That includes advance appropriations that first become available for obligation in that
 year. Unobligated balances carried over from previous fiscal years are exempt from sequestration.

13

P.L. 112-240, 126 Stat. 2313.
P.L. 113-67, Division B, 127 Stat. 1195.
15
P.L. 113-93, 128 Stat. 1040.
16
For more information on all the legislative actions taken to amend the ACA since its enactment, including actions
taken through the annual appropriations process, see CRS Report R43289, Legislative Actions to Repeal, Defund, or
Delay the Affordable Care Act, by C. Stephen Redhead and Janet Kinzer.
17
P.L. 112-25, 125 Stat. 240.
14

Congressional Research Service

5

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

The exemption for unobligated balances carried over from prior fiscal years applies to a number
of ACA appropriations. As already mentioned, the appropriations provision often specifies that
the funds are to remain available “until expended” or “without fiscal year limitation.” One
example is the PCIP program, which was authorized and funded by ACA Section 1101 (see Table
2). It provided temporary health insurance coverage, prior to the establishment of the health
insurance exchanges, for eligible individuals who had been uninsured for six months and had a
pre-existing condition. The ACA appropriated $5 billion in FY2010, to remain available without
fiscal year limitation, to pay claims against the PCIP in excess of the premiums collected from
enrollees. Unobligated PCIP funds carried over to FY2013 or FY2014 were exempt from
sequestration. Another example is CMMI, which received a $10 billion multiple-year
appropriation in FY2011 to remain available for obligation through FY2019.

Key Takeaways
The following points should be kept in mind while examining Table 2 and Table 3:
•

The ACA appropriations through FY2019 total approximately $100 billion
(before sequestration). That amount includes $40 billion to fund CHIP in FY2014
and FY2015.Other significant amounts—rounded to the nearest billion dollars—
include:
•

$10 billion for PCIP and the Early Retiree Reinsurance program;

•

$5 billion for exchange planning and establishment grants;

•

$10 billion for CMMI for the first 10 years (FY2010-FY2019);

•

$11 billion for the CHCF;

•

$10 billion (after rescission) for the PPHF;

•

$4 billion (projected) for the PCORTF;

•

$2 billion for the maternal, infant, and early childhood visitation program
(includes extended funding); and

•

$2 billion for the Medicaid Money Follows the Person (MFP) demonstration.

•

Congress has partially rescinded funding for three programs (i.e., IPAB, PPHF,
and the CO-OP program).

•

Only four of the appropriations listed in the tables are permanent (i.e., CMMI,
IPAB, PPHF, and environmental health screening). All the other appropriations
are temporary, most of which have expired or are due to expire this year (i.e.,
FY2015).

•

Congress has extended funding for six programs whose ACA funding expired.
Three of the programs were established by the ACA and funded through FY2014:
(1) the personal responsibility education program (PREP); (2) the maternal,
infant, and early childhood home visiting program; and (3) the health workforce
demonstration program (actually, two separate demonstration projects).
Lawmakers last year funded each of these programs for an additional year (i.e.,
FY2015). The remaining programs were established and funded prior to the
ACA’s enactment: (1) abstinence education grants; (2) family-to-family health

Congressional Research Service

6

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

information centers; and (3) outreach and assistance for the low-income
programs (actually four separate programs; see Table 2). The ACA renewed
funding for each of these programs, providing annual appropriations for FY2010
through FY2012. Congress has since extended the funding through FY2015.
•

Congress is facing calls to extend ACA funding for a number of programs aimed
at expanding access to primary care services. FY2015 is the final year of funding
for the CHCF. As noted earlier, the CHCF has helped support the health centers
program and has been the sole source of funding for the NHSC program since
FY2012. ACA funding for Teaching Health Center Graduate Medical Education
(GME) payments also ends in FY2015.18 The FY2016 Budget proposes (1) $2.7
billion for FY2016 and a total of $8.1 billion over three years (FY2016-FY2018)
in new mandatory funding to support the federal health center program; (2) $810
million in FY2016 and $2.1 billion over the following four years (FY2017FY2020) for the NHSC; and (3) $400 million for FY2016 and a total of $5.25
billion over 10 years (FY2016-FY2025) for a new Targeted Support for Graduate
Medical Education program, which would replace the Teaching Health Center
GME program.19

•

One of the legislative priorities of the 114th Congress is CHIP reauthorization. As
already noted, ACA funded the program through FY2015.20

18
For more information, see CRS Insight IN10185, Congress Faces Calls to Address Expiring ACA Funds for Primary
Care, February 9, 2015, by Elayne J. Heisler and C. Stephen Redhead.
19
For more information, see CRS Insight IN10231, FY2016 Budget Request: Increasing Support for Medical Research,
Combatting Public Health Threats, and Expanding Access to Primary Health Care, February 12, 2015, by C. Stephen
Redhead.
20
For more information, see CRS Report R43627, State Children’s Health Insurance Program: An Overview, by
Evelyne P. Baumrucker and Alison Mitchell.

Congressional Research Service

7

 Table 2. Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable Care Act
ACA
Section

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

Private Health Insurance
1002

1003

1101

1102

CRS-8

New PHSA Sec.
2793


    Key Takeaways
    Overall, the ACA provided more than $100 billion in mandatory appropriations and Medicare fund transfers over the 10-year period FY2010-FY2019, including $40 billion to fund CHIP in FY2014 and FY2015. As enacted, the law also included the following amounts:
$15 billion for the PPHF through FY2019 (and $2 billion for each year thereafter);
$11 billion for the CHCF;
$10 billion for CMMI through FY2019 (and $10 billion for each 10-year period thereafter);
$6 billion for the CO-OP program;
$5 billion for PCIP;
$5 billion for the Early Retiree Reinsurance program
$4 billion (projected) for the PCORTF;
$2.25 billion for the Medicaid Money Follows the Person (MFP) demonstration; and
$1.5 billion for the maternal, infant, and early childhood visitation program.
Only four of the ACA appropriations are permanent (i.e., CMMI, IPAB, PPHF, and environmental health screening). All the other appropriations were temporary.

    In a series of legislative actions (described in more detail in Table 2 and Table 3), Congress extended funding for several programs whose ACA appropriations were about to expire. The following programs are now funded through FY2017:health centers (CHCF funding); 
National Health Service Corps (CHCF funding);
graduate medical education (GME) payments for teaching health centers;
maternal, infant, and early childhood home visiting program;
personal responsibility education program (PREP);
health workforce demonstration programs;
abstinence education grants;
family-to-family health information centers; and
outreach and assistance for low-income programs.
Congress has also provided two more years of funding (FY2016-FY2017) for CHIP.
Finally, Congress has partially rescinded ACA funding for IPAB, PPHF, and the CO-OP program.

    
    
    
      
        Table 2. Mandatory Appropriations and Medicare Trust Fund Transfers in the Affordable Care Act
      
      
        
          
            ACA Section
Statutory Authority
Summary of Provision
Obligations as of May 4, 2015, Based on TAGGS Unless Specified Otherwise
Private Health Insurance
1002
New PHSA Sec. 2793
Consumer Assistance Program (CAP). Appropriated $30 million, to
 remain available without fiscal year limitation, for CAP grants to states to
 enable them (or the exchanges operating in such states) to establish, expand,
 or provide support for offices of health insurance consumer assistance, and
 health insurance ombudsman programs. [CMS/CCIIO; CFDA 93.519]

$45 million

New PHSA Sec.
2794

$45 million

            Total includes original funding plus awards made using additional funds. See http://www.cms.gov/CCIIO/Programs-and-Initiatives/Consumer-Support-and-Information/Consumer-Assistance-Program-Grants.html.
          
        
        
          
            1003
New PHSA Sec. 2794
Review of health insurance premium rates. Appropriated $250 million
 for grants to states over the five-year period FY2010-FY2014 to support
 programs that review annual increases in health insurance premiums. No
 state may receive less than $1 million or more than $5 million in a grant
 year. Unobligated funds the end of FY2014 are to remain available for grants
 to states for planning and implementing ACA’'s individual and group market
 reforms. [CMS/CCIIO; CFDA 93.511]

$231 million

New
freestanding
authority

$231 million

            Four rounds of rate review grants have been awarded. See http://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Market-Reforms/Review-of-Insurance-Rates.html.1101
New freestanding authority
Pre-Existing Condition Insurance Plan (PCIP). Required the Secretary
 to establish a temporary program—PCIP—to provide health insurance
 coverage for eligible individuals who have been uninsured for six months and
 have a pre-existing condition. Appropriated $5 billion, to remain available
 without fiscal year limitation, to pay claims against (and administrative costs
 of) the PCIP program that are in excess of premiums collected from
 enrollees. Note: Until June 2013, 27 states administered their own PCIP
 programs; the remaining 23 states and DC elected to have their PCIP
 program federally administered. Seventeen state-run PCIP programs then
 transferred administration to the federal program. [CMS/CCIIO; CFDA
 93.529]


          
          
            According to the Budget Appendixes for FY2011-FY2016, net
 PCIP outlays through FY2014 = $4.579 billion; estimated net
outlays in FY2015 = $33 million.

Early Retiree Reinsurance Program (ERRP). Required the Secretary
to establish a temporary ERRP to provide reimbursement to participating
employer-based plans for a portion of the cost of providing health benefits
to early retirees age 55-64 and their families. Appropriated $5 billion, to
remain available without fiscal year limitation, to carry out the ERRP.
[CMS/CCIIO]

According to the Budget Appendixes for FY2011-FY2016, net
ERRP outlays through FY2014 = $4.973 billion.

New
freestanding
authority

Total includes original funding plus awards made using
additional funds. See http://www.cms.gov/CCIIO/Programsand-Initiatives/Consumer-Support-and-Information/
Consumer-Assistance-Program-Grants.html.
Four rounds of rate review grants have been awarded. See
http://www.cms.gov/CCIIO/Programs-and-Initiatives/HealthInsurance-Market-Reforms/Review-of-Insurance-Rates.html.

 outlays in FY2015 = $33 million.
            More than 134,000 individuals have received coverage under
 PCIP. Originally scheduled to end on January 1, 2014, the
 program was extended through April 30, 2014. However, the
 federally-run PCIP and the state-based PCIPs stopped
 accepting new enrollees on February 16, 2013, and March 2,
 2013, respectively, because of the limited amount of funding.
See  See http://www.cms.gov/CCIIO/Programs-and-Initiatives/
Insurance-Programs/Pre-Existing-Condition-InsurancePlan.html; and https://www.pcip.gov.

ERRP has provided payments to almost 2,900 employers and
other sponsors of retiree plans. The program ended on
January 1, 2014; however, HHS stopped accepting new ERRP
applications on May 5, 2011, because of limited funding. See
Insurance-Plan.html. 
          
        
        
          
            1102
New freestanding authority
Early Retiree Reinsurance Program (ERRP). Required the Secretary to establish a temporary ERRP to provide reimbursement to participating employer-based plans for a portion of the cost of providing health benefits to early retirees age 55-64 and their families. Appropriated $5 billion, to remain available without fiscal year limitation, to carry out the ERRP. [CMS/CCIIO]
According to the Budget Appendixes for FY2011-FY2016, net ERRP outlays through FY2014 = $4.973 billion.

            ERRP provided payments to almost 2,900 employers and other sponsors of retiree plans. The program ended on January 1, 2014; however, HHS stopped accepting new ERRP applications on May 5, 2011, because of limited funding. See http://www.cms.gov/CCIIO/Programs-and-Initiatives/
Insurance-Programs/Early-Retiree-Reinsurance-Program.html;
and http://www.errp.gov.

 ACA
Section
1311

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

New
freestanding
authority

.
          
        
        
          
            1311
New freestanding authority
Health insurance exchange grants. Appropriated to the Secretary an
 amount necessary to award exchange planning and establishment grants to
 states. Instructs the Secretary each fiscal year to determine the total amount
 to be made available. No grants may be awarded after January 1, 2015, by
 which time exchanges must be self-sustaining. [CMS/CCIIO; CFDA 93.525]

$5.190 billion

1322

New
freestanding
authority

$5.180 billion
For more information on federal funding for health insurance exchanges, see CRS Report R43066, Federal Funding for Health Insurance Exchanges.
1322
New freestanding authority
Consumer Operated and Oriented Plan (CO-OP). Required the
 Secretary to establish the CO-OP program to provide low-interest loans
 until July 1, 2013, for the creation of nonprofit member-run health insurance
 issuers that offer qualified health plans in the individual and small group
 markets. Appropriated $6 billion to carry out the CO-OP program. Note:
[CMS/CCIIO]
            The FY2011 and FY2012 Labor-HHS-Education appropriations acts (P.L.
 112-10 and P.L. 112-74, respectively) together rescinded a total of $2.6
 billion of the original appropriation. The American Taxpayer Relief Act of
2012 (ATRA; CO-OP appropriation. ATRA ( P.L. 112-240) then ) rescinded 90% of the program’'s unobligated
 balance as of January 2, 2013, and transferred the remaining unobligated
 funds to a new CO-OP contingency fund to provide assistance and oversight
 to existing to CO-OP loan recipients, ending CMS’and ended CMS's authority to make new loans.
 Overall, Congress rescinded a total of $4.879 billion, leaving $1.121 billion of
 the original $6 billion CO-OP program appropriation. [CMS/CCIIO]

As of September 26
          
          
            As of December 31, 2014, a total of $2.3575 billion in loans
 had been awarded to 23 nonprofits offering coverage in 26
states. See 25 states. Of that total, approximately $1.1 billion is from the ACA appropriation and the remaining $1.4 billion is from Treasury borrowing. See http://www.cms.gov/CCIIO/Programs-andInitiatives/and-Initiatives/Insurance-Programs/Consumer-Operated-andOrientedand-Oriented-Plan-Program.html.

1323

New
freestanding
authority

.
          
        
        
          
            1323
New freestanding authority
Funding for territories. Appropriated $1 billion, available for the period
 FY2014-FY2019, for U.S. territories that elect to establish a health insurance
 exchange. Funds must be used to provide premium and cost-sharing
 assistance to territory residents who obtain health insurance coverage
 through the exchange.


          
          
            No public information located on funding obligations.

For more information on federal funding for health insurance
exchanges, see CRS Report R43066, Federal Funding for Health
Insurance Exchanges, Federal Funding for Health Insurance
Exchanges.


          
        
        
          
            Medicaid and State Children’'s Health Insurance Program (CHIP)
2701

CRS-9

New SSA Sec.
1139B

2701
New SSA Sec. 1139B
Medicaid adult health quality measures. Required the Secretary to
 develop and, not later than January 1, 2012, publish an initial core set of
 quality measures for Medicaid-eligible adults. Appropriated $60 million for
 each of FY2010- through FY2014, to remain available until expended. Total amount =
$300 million. Note: The Protecting Access to Medicare Act of 2014 (PAMA;
 $300 million. [CMS; CFDA 93.609]
            PAMA (P.L. 113-93) required) requires $15 million of these funds to be used for the
development of quality measures for children enrolled in Medicaid and CHIP,
pursuant to SSA Sec. 1139A. [CMS; CFDA 93.609]

$49 million
See the ACA funds to be used for advancing and improving Medicaid/CHIP pediatric quality measures, pursuant to SSA Sec. 1139A(b).$49 million

            See http://www.medicaid.gov/Medicaid-CHIP-ProgramInformation/Program-Information/By-Topics/Quality-of-Care/Adult-Health-CareQuality-Measures.html.

 ACA
Section

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

2707

New
freestanding
authority

Care-Quality-Measures.html.
          
        
        
          
            2707
New freestanding authority
Medicaid emergency psychiatric demonstration program.
 Appropriated $75 million for FY2011, to remain available for obligation
 through December 2015, for a three-year demonstration in which eligible
 states are required to reimburse certain institutions for mental disease
 (IMDs) for services provided to Medicaid beneficiaries aged 21 through 64
 who are in need of medical assistance to stabilize an emergency psychiatric
 condition. [CMS/CMMI; CFDA 93.537]


          
          
            Eleven states plus DC are participating in the demonstration,
 which began in July 2012. Through June 2013, total federal
 and state outlays = $22 million. The federal share is
 approximately 57% of that total. See
 http://innovation.cms.gov/initiatives/Medicaid-Emergency-Psychiatric-Demo/.
          
        
        
          
            2801
Amends SSA Sec. 1900
Medicaid-EmergencyPsychiatric-Demo/.

2801

Amends SSA
Sec. 1900

Medicaid and CHIP Payment and Access Commission (MACPAC).
 Clarified and expanded MACPAC’'s duties; for example, to include a review
 and assessment of payment policies under Medicaid and CHIP and how
 factors affecting expenditures and payment methodologies enable
 beneficiaries to obtain services, affect provider supply, and affect providers
 that serve a disproportionate share of low-income and other vulnerable
 populations. Appropriated $9 million and transferred from CHIP funding an
 additional $2 million for FY2010. Total amount = $11 million, to remain
 available until expended.


          
          
            ACA funding was obligated in FY2011 and FY2012.

New
freestanding
authority

See http://www.macpac.gov/.
          
        
        
          
            4108
New freestanding authority
Medicaid Incentives for the Prevention of Chronic Diseases
 (MIPCD). Required the Secretary to award five-year grants to states,
 subject to annual renewal of funding, to provide incentives for Medicaid
 beneficiaries to participate in evidence-based healthy lifestyle programs to
 prevent or help manage chronic disease. Appropriated $100 million for the
 five-year period beginning January 1, 2011, to remain available until
 expended. [CMS/CMMI; CFDA 93.536]

$71 million

Amends SSA
Sec. 1139A(e)

$71 million

            MIPCD grants, administered by CMMI, have been awarded to 10 states. See http://www.innovations.cms.gov/initiatives/MIPCD/index.html.
          
        
        
          
            4306
Amends SSA Sec. 1139A(e)
CHIP childhood obesity demonstration program. Appropriated $25
 million for the period FY2010 through FY2014 for a program authorized by
 the Children’'s Health Insurance Program Reauthorization Act of 2009
 (CHIPRA; P.L. 111-3), which requires the Secretary to conduct a
 demonstration project to develop a model for reducing childhood obesity.
 [CDC; CFDA 93.535]

$24 million

Amends SSA
Secs. 2104 &
2113

CHIP annual appropriations, and outreach and enrollment grants.
Appropriated funding for the CHIP program for FY2014 ($19.147 billion)
and FY2015 ($21.061 billion); the program previously had been funded
through FY2013. Also, extended the time period for the Connecting Kids to
Coverage Outreach and Enrollment grants through FY2015 and increased
the existing appropriation for such grants from $100 million to $140 million.
[CMS; CFDA 93.767]

Since 2009, CMS has awarded three cycles of outreach and
enrollment grants totaling $122 million to states, local
governments, community organizations, and tribal
organizations.

4108

4306

10203(d)

CRS-10

See http://www.macpac.gov/.

MIPCD grants, administered by CMMI, have been awarded to
10 states. See http://www.innovations.cms.gov/initiatives/
MIPCD/index.html.

Funding has been awarded to three research facilities to
identify effective childhood obesity prevention strategies, and
to a fourth facility to evaluate the strategies and share
successes. See http://www.cdc.gov/obesity/childhood/
researchproject.html.

See MACRA (P.L. 114-10) appropriated additional funding for the childhood obesity demonstration program; $10 million for the two-year period FY2016 through FY2017.
$24 million

            Funding has been awarded to three research facilities to identify effective childhood obesity prevention strategies, and to a fourth facility to evaluate the strategies and share successes. See http://www.cdc.gov/obesity/childhood/researchproject.html.
          
        
        
          
            10203(d)
Amends SSA Secs. 2104 & 2113
CHIP annual appropriations; outreach and enrollment grants. Appropriated funding for the CHIP program for FY2014 ($19.147 billion) and FY2015 ($21.061 billion); the program previously had been funded through FY2013. 
MACRA (P.L. 114-10) appropriated two more years of funding for the CHIP program; $19.3 billion for FY2016 and $20.4 billion for FY2017.
Extended the time period for the Connecting Kids to Coverage Outreach and Enrollment grants through FY2015 and increased the existing appropriation for such grants from $100 million to $140 million. [CMS; CFDA 93.767]
MACRA (P.L. 114-10) appropriated $40 million for the two-year period FY2016 through FY2017 for outreach and enrollment grants.
Since 2009, CMS has awarded three cycles of outreach and enrollment grants totaling $126 million to states, local governments, community organizations, and tribal organizations.

            See http://www.insurekidsnow.gov/professionals/outreach/
grantees/index.html.
          
        
        
          
            Medicare
3014
Amends SSA Sec. 1890(b). New SSA Sec. 1890A
index.html.

 ACA
Section

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

Medicare
3014

Amends SSA
Sec. 1890(b).
New SSA Sec.
1890A

Medicare quality and efficiency measures. Expanded the duties of the
 consensus-based entity under contract with CMS pursuant to SSA Sec. 1890
 (currently the National Quality Forum). Required the entity to convene
 multi-stakeholder groups to provide input on the national priorities for
 health care quality improvement (developed under the ACA). In addition,
 the multi-stakeholder groups are required to provide input on the selection
 of quality measures for use in various specified Medicare payment systems
 for hospitals and other providers, as well as in other health care programs,
 and for use in reporting performance information to the public. Established a
 multi-step pre-rulemaking process and timeline for the adoption,
 dissemination, and review of measures by the Secretary. Required the
 Secretary to transfer from the Medicare Part A and Part B trust funds $20
 million for each of FY2010 through FY2014, to remain available until
 expended.aa Total amount = $100 million. [CMS]


          
          
            No public information located on funding obligations.

3021(a)

New SSA Sec.
1115A

3021(a)
New SSA Sec. 1115A
Center for Medicare and Medicaid Innovation (CMMI).CMMI). Required the
 Secretary, no later than January 1, 2011, to establish the CMMI within CMS.
 The purpose of CMMI is to test and evaluate innovative payment and service
 delivery models to reduce program expenditures under Medicare, Medicaid,
 and CHIP while preserving or enhancing the quality of care furnished under
 these programs. In selecting the models, the Secretary is also required to
 give preference to those that improve the coordination, quality, and
 efficiency of health care services. Appropriated (1) $5 million for FY2010 for
 the selection, testing, and evaluation of new payment and service delivery
 models; and (2) $10 billion for the period FY2011 through FY2019, plus $10
 billion for each subsequent 10-year period, to continue such activities and
 for the expansion and nationwide implementation of successful models.
 Amounts are to remain available until expended.bb [CMS]


          
          
            According to CMS’'s budget documents (FY2013-FY2016),
CMMI’ CMMI's obligations are as follows: FY2011 (actual) = $95
 million; FY2012 (actual) = $781 million; FY2013 (actual) =
 $953 million; FY2014 (actual) = $1.181 billion; FY2015
 (estimate) = $1.842 billion; FY2016 (estimate) = $1.646
 billion.


            For information on CMMI's programs, which include several of the initiatives summarized in this table, see http://www.innovations.cms.gov/.
          
        
        
          
            3024
New SSA Sec. 1866E
Medicare independence at home demonstration program. Required
 the Secretary to conduct a three-year Medicare demonstration program,
 beginning no later than January 1, 2012, to test a payment incentive and
 service delivery model that uses physician- and nurse practitioner-directed
 primary care teams to provide home-based services to chronically ill
 patients. The Secretary must submit a plan, no later than January 1, 2016, for
 expanding the program if it is determined that such expansion would
 improve the quality of care and reduce spending. Required the Secretary to
 transfer from the Medicare Part A and Part B trust funds $5 million for each
 of FY2010 through FY2015 for administering and carrying out the
 demonstration, to remain available until expended.a a Total amount = $30
 million. [CMS]


          
          
            Fourteen independent practices and one consortium are
 participating in the independence at home demonstration,
 administered by CMMI. No public information located on
funding obligations.

3024

CRS-11

New SSA Sec.
1866E

For information on CMMI’s programs, which include several
of the initiatives summarized in this table, see
http://www.innovations.cms.gov/.

See  funding obligations.
            See http://innovation.cms.gov/initiatives/Independence-at-Home/index.html.3026
New freestanding authority
Independence-atHome/index.html.

 ACA
Section
3026

3027(b)

3113

3306

CRS-12

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

Community-based Care Transitions Program (CCTP). Required the
 Secretary to establish a five-year program, beginning January 1, 2011, to
 provide funding to eligible hospitals and community-based organizations to
 test models for improving care transitions from the hospital to other
 settings for high-risk Medicare beneficiaries. Required the Secretary to
 transfer from the Medicare Part A and Part B trust funds $500 million for
 the period FY2011 through FY2015, to remain available until expended.a
Note: a [CMS]
            The FY2013 Labor-HHS-Education appropriations act (P.L. 113-6)
) rescinded $200 million of CCTP’'s transfer. [CMS]


          
          
            There are 72 organizations participating in the CCTP, which
 was launched in February 2012. The CCTP is administered by
 CMMI as part of the Partnership for Patients initiative. No
 public information located on funding obligations.


            See http://www.innovations.cms.gov/initiatives/CCTP/.
          
        
        
          
            3027(b)
Amends DRA Sec. 5007
Medicare hospital gainsharing demonstration program. CMS is
 supporting two projects that allow hospitals to provide gainsharing payments
 to physicians that represent a share of the savings incurred as a result of
 collaborative efforts to improve overall quality and efficiency. The ACA
 appropriated $1.6 million for FY2010, to remain available through FY2014 or
 until expended, for carrying out the demonstration. [CMS]


          
          
            There are two hospitals participating in the gainsharing
 demonstration, which is administered by CMMI. No public
 information located on funding obligations.

New
freestanding
authority


            See http://innovation.cms.gov/initiatives/Medicare-Hospital-Gainsharing/.
          
        
        
          
            3113
New freestanding authority
Diagnostic laboratory test demonstration program. Required the
 Secretary to conduct a two-year demonstration program beginning July 1,
 2011, with a subsequent report to Congress, to test the impact of direct
 payments for certain complex laboratory tests on Medicare costs and quality
 of care. Payments are to be made from the Part B trust fund and may not
 exceed $100 million. Transferred $5 million from the Medicare Part B trust
 fund, to remain available until expended, for carrying out the demonstration
 program and preparing the subsequent report. [CMS]


          
          
            Demonstration completed and evaluated, according to CMS.
 No other public information located.

Amends MIPPA
Sec. 119


            See http://www.cms.gov/Medicare/Demonstration-Projects/DemoProjectsEvalRpts/Downloads/TCCDLT_FactSheet.pdf. 
          
        
        
          
            3306
Amends MIPPA Sec. 119
Outreach and assistance for low-income programs. Transferred a
 total of $45 million from the Medicare Part A and Part B trust funds for the
 period FY2010 through FY2012 to extend funding for the following
 beneficiary outreach and education activities for low-income programs that
 were funded by the Medicare Improvements for Patients and Providers Act
 of 2008 (MIPPA; P.L. 110-275): (1) State Health Insurance Counseling and
 Assistance Programs (SHIPs), $15 million; (2) Area Agencies on Aging
 (AAAs), $15 million; (3) Aging and Disability Resource Centers (ADRCs),
 $10 million; and (4) the National Center for Benefits Outreach and
 Enrollment (NCBOE), $5 million. Note: Funds are to remain available until expended.c [ACL, CMS; CFDA 93.071]
            ATRA (P.L. 112-240) transferred
 $25 million for FY2013 for thesethe programs: (1) SHIPs, $7.5 million; (2)
 AAAs, $7.5 million; (3) ADRCs, $5 million; and (4) NCBOE, $5 million. The
Pathway for SGR Reform Act of 2013 (PSGRRA; PSGRRA (P.L. 113-67, Division B)
 transferred $12.5 million to provide prorated funding for the first half of
 FY2014. PAMA (P.L. 113-93) amended PSGRRA by transferring $25 million
 for FY2014 (same as FY2013) and by transferring $12.5 million for the first
half of FY2015. Funds are to remain available until expended.c [ACL, CMS;
CFDA 93.071]

$66 million (FY2009-FY2015)

New
freestanding
authority

Amends DRA
Sec. 5007

See http://www.innovations.cms.gov/initiatives/CCTP/.

See http://innovation.cms.gov/initiatives/Medicare-HospitalGainsharing/.

See http://www.cms.gov/Medicare/Demonstration-Projects/
DemoProjectsEvalRpts/Downloads/TCCDLT_FactSheet.pdf.

 ACA
Section

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

3403

New SSA Sec.
1899A

 half of FY2015. MACRA (P.L. 114-10) amended PAMA by transferring the following amounts for FY2015 through FY2017: (1) SHIPs, $7.5 million for FY2015 and $13 million for each of FY2016 and FY2017; (2) AAAs, $7.5 million for each of FY2015 through FY2017; (3) ADRCs, $5 million for each of FY2015 through FY2017; and (4) NCBOE, $5 million for FY2015 and $12 million for each of FY2016 and FY2017.$66 million (FY2009-FY2015)
3403
New SSA Sec. 1899A
Independent Payment Advisory Board (IPAB). Established an
 independent, 15-member advisory board tasked with presenting Congress
 with comprehensive proposals to reduce excess cost growth and improve
 quality of care for Medicare beneficiaries. Appropriated $15 million for
 FY2012 to support the board’'s activities. For each subsequent fiscal year,
 appropriates the amount from the previous fiscal year adjusted for inflation.
 Sixty percent of the appropriation is to be derived by transfer from the
 Medicare Part A trust fund, and 40% is to be derived by transfer from the
 Medicare Part B trust fund. Note: 
            The Labor-HHS-Education appropriations
 acts for FY2012, FY2013, FY2014, and FY2015 (P.L. 112-74, , P.L. 113-6, , P.L.
 113-76, and P.L. 113-235, respectively) each rescinded $10 million of IPAB’s
's appropriation for that fiscal year.


          
          
            The President has not appointed, nor has the Senate
 approved, any IPAB members.

4202(b)

New
freestanding
authority

4202(b)
New freestanding authority
Medicare prevention and wellness evaluation. Transferred $50 million
 from the Medicare Part A and Part B trust funds, to remain available until
 expended, to fund an evaluation of community-based prevention and
 wellness programs and, based on the findings, develop a plan to promote
 healthy lifestyles and chronic disease self-management among Medicare
 beneficiaries.aa [CMS]


          
          
            No public information located on funding obligations.

4204(e)

New
freestanding
authority

4204(e)
New freestanding authority
Medicare vaccine coverage. Appropriated $1 million for FY2010 for a
 GAO report on the impact of Medicare Part D vaccine coverage on access
 to those vaccines among beneficiaries.


          
          
            Report released in December 2011 (GAO-12-61;
 http://www.gao.gov/assets/590/587009.pdf).
          
        
        
          
            10323(a)
New SSA Sec. 1881A
).

10323(a)

New SSA Sec.
1881A

Environmental health hazards. Extended Medicare eligibility to
 individuals with specified health conditions linked to environmental
 exposures, who have resided for specified times in an area subject to a
 Superfund public health emergency declaration. Required the Secretary to
 establish a pilot program, with appropriate reimbursement methodologies,
 to provide comprehensive, coordinated, and cost-effective care to such
 individuals. Transferred such sums as may be necessary from the Medicare
 Part A and Part B trust funds to carry out the pilot program.aa [CMS]


          
          
            No public information located on funding obligations.

10323(b)

New SSA Sec.
2009

10323(b)
New SSA Sec. 2009
Environmental health hazards. Appropriated $23 million for the period
 FY2010 through FY2014, and $20 million for each five-year period
 thereafter, for grants to state and local government agencies, health care
 facilities, and other entities to (1) provide screening for specified lung
 diseases and other environmental health conditions to individuals who have
 resided for specified times in an area subject to a Superfund public health
 emergency declaration; and (2) disseminate public information about the
 availability of screening, the detection and treatment of environmental health
 conditions, and the availability of Medicare benefits to certain individuals
 diagnosed with such conditions, pursuant to new SSA Sec. 1881A (as added
 by ACA Sec. 10323(a)). [CMS; CFDA 93.534]

$10 million

CRS-13

$10 million
Funding provided for an asbestos health screening program in
Libby, Montana.

 ACA
Section

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

Fraud and Abuse
6402(i) &
HCERA
Sec.
1303(a)

Amends SSA
Sec. 1817(k)

 Libby, Montana.
          
        
        
          
            Fraud and Abuse
6402(i) & HCERA Sec. 1303(a)
Amends SSA Sec. 1817(k)
Health Care Fraud and Abuse Control (HCFAC) Account. Applied a
 permanent inflation adjustment to the annual appropriation (provided under
 SSA Sec. 1817(k)) for the HCFAC account. Appropriated from the Medicare
 Part A trust fund the following supplemental amounts for the HCFAC
 account: $10 million for each of FY2011 through FY2020; plus an additional
 $95 million for FY2011, $55 million for FY2012, $30 million for each of
 FY2013 and FY2014, and $20 million for each of FY2015 and FY2016. Total
 amount = $350 million. Funds are to remain available until expended. [CMS]


          
          
            No public information located on ACA funding obligations.

New
freestanding
authority

Health Centers
4101(a)
New freestanding authority
School-based health centers (SBHCs). Appropriated $50 million for
 each of FY2010 through FY2013, to remain available until expended, for a
 grant program to fund the construction and renovation of school-based
 health centers. Total amount = $200 million. [HRSA; CFDA 93.501]

$136 million

New
freestanding
authority

Community-based health centers. Transferred from the CHCF the
$135 million

            See http://bphc.hrsa.gov/about/healthcentersaca/acacapital/index.html.
          
        
        
          
            10503(b)(1)
New freestanding authority
Community-based health centers. Appropriated to the CHCF the following amounts for health center operations, to remain available until
 expended: FY2011 = $1 billion; FY2012 = $1.2 billion; FY2013 = $1.5 billion;
 FY2014 = $2.2 billion; and FY2015 = $3.6 billion. Total amount = $9.5
 billion. [HRSA; CFDA 93.527]

MACRA (P.L. 114-10) appropriated to the CHCF two years of additional funding for health center operations; $3.6 billion for each of FY2016 and FY2017. 
According to the Budget Appendixes for FY2013-FY2016, the
 obligations of ACA funds for health centers are as follows:
 FY2011 (actual) = $998 million; FY2012 (actual) = $1.171
 billion; FY2013 (actual) = $1.491 billion; FY2014 (actual) =
 $2.152 billion; FY2015 (estimate) = $2.968 billion; FY2016
 (estimate) = $178 million.

Health Centers
4101(a)

10503(b)(1)


            See http://bphc.hrsa.gov/.10503(c)
New freestanding authority
http://bphc.hrsa.gov/about/schoolbased/index.html.

See http://bphc.hrsa.gov/index.html.
10503(c)

New
freestanding
authority

Health center construction and renovation. Appropriated $1.5 billion,
 to be available for the period FY2011 through FY2015, and to remain
 available until expended, for health center construction and renovation.
[HRSA; CFDA 93.526]

$1.520 billion

Health Workforce and the National Health Service Corps
10503(b)(2)

New
freestanding
authority

 [HRSA; CFDA 93.526]
          
          
            $1.520 billion

            See http://bphc.hrsa.gov/about/healthcentersaca/acacapital/index.html. 
          
        
        
          
            Health Workforce and the National Health Service Corps
10503(b)(2)
New freestanding authority
National Health Service Corps (NHSC). Transfers from the CHCF the
 following amounts for NHSC operations, scholarships, and loan repayments,
 to remain available until expended: FY2011 = $290 million; FY2012 = $295
 million; FY2013 = $300 million; FY2014 = $305 million; and FY2015 = $310
 million. Total amount = $1.5 billion. [HRSA; CFDA 93.547]

MACRA (P.L. 114-10) appropriated to the CHCF two years of additional funding for NHSC operations, scholarships, and loan repayments; $310 million for each of FY2016 and FY2017.
According to the Budget Appendixes for FY2013-FY2016, the
 obligations of ACA funds for the NHSC are as follows:
 FY2011 (actual) = $289 million; FY2012 (actual) = $297
 million; FY2013 (actual) = $286 million; FY2014 (actual) =
 $281 million; FY2015 (estimate) = $287 million.

            See http://nhsc.hrsa.gov/.
          
        
        
          
            5507(a)
New SSA Sec. 2008
http://nhsc.hrsa.gov/.

CRS-14

 ACA
Section
5507(a)

5507(b)

5508(c)

5509

10502

CRS-15

Statutory
Authority
New SSA Sec.
2008

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

Health workforce demonstration programs. Required the Secretary
 to establish two demonstration projects. The first is to award health
 profession opportunity grants to states, Indian tribes, institutions of higher
 education, and local workforce investment boards to help low-income
 individuals obtain education and training in health care jobs that pay well and
 are in high demand. Funds may be used to provide financial aid and other
 supportive services. The second project is to provide states with grants to
 develop core training competencies and certification programs for personal
 and home care aides. Appropriated $85 million for each of FY2010 through
 FY2014, of which $5 million in each of FY2010 through FY2012 is to be used
 for the second project. Total amount = $425 million. Note: [ACF, HRSA; CFDA 93.093, 93.512]
            PAMA (P.L. 113-93) appropriated $85 million for FY2015. MACRA (P.L. 114-10) appropriated $85 million for each of FY2016 and FY2017. $330 million: Health Profession Opportunity Grant (HPOG)
$13 million: Personal and Home Care Aide State Training (PHCAST) program

            See http://www.acf.hhs.gov/programs/ofa/programs/hpog; and http://bhpr.hrsa.gov/nursing/grants/phcast.html.
          
        
        
          
            5507(b)
Amends SSA Sec. 501(c)
P.L. 11393) provided an additional year of funding (i.e., $85 million for FY2015).
[ACF, HRSA; CFDA 93.093, 93.512]

$330 million: Health Profession Opportunity Grant (HPOG)

Amends SSA
Sec. 501(c)

Family-to-family health information centers. Renewed funding for the
 family-to-family information centers, which assist families of children with
 disabilities or special health care needs and the professionals who serve
 them, by appropriating $5 million for each of FY2010 through FY2012, to
 remain available until expended. Total amount = $15 million. Note: ATRA
([HRSA; CFDA 93.504]
            ATRA (P.L. 112-240) appropriated $5 million for FY2013;. PSGRRA (P.L. 113-67,
, Division B) appropriated $2.5 million for the first half of FY2014; and PAMA
(. PAMA (P.L. 113-93) appropriated $2.5 million for the second half of FY2014 and
 $2.5 million for the first half of FY2015. [HRSA; CFDA 93.504]

$11 million (FY2012-FY2015)

New PHSA Sec.
340H

 MACRA (P.L. 114-10) amended PAMA by appropriating $5 million for each of FY2015 through FY2017.$11 million (FY2012-FY2015)

            See http://mchb.hrsa.gov/programs/familytofamily/index.html.
          
        
        
          
            5508(c)
New PHSA Sec. 340H
Teaching health centers. Appropriated such sums as may be necessary,
 not to exceed $230 million, for the period FY2011 through FY2015 to make
 payments for direct and indirect graduate medical education (GME) costs to
 qualified teaching health centers (THCs). [HRSA; CFDA 93.530]

$160 million

New
freestanding
authority

Medicare graduate nurse education demonstration program.
MACRA (P.L. 114-10) appropriated two years of additional funding for GME payments to THCs; $60 million for each of FY2016 and FY2017.
$160 million

            See http://bhpr.hrsa.gov/grants/teachinghealthcenters/.
          
        
        
          
            5509
New freestanding authority
Medicare graduate nurse education demonstration program.Appropriated $50 million for each of FY2012 through FY2015, to remain
 available until expended, for a Medicare demonstration program under
 which up to five eligible hospitals will receive reimbursement for providing
 advanced practice nurses with clinical training in primary care, preventive
 care, transitional care, and chronic care management. Total amount = $200
 million. [CMS/CMMI]


          
          
            CMMI, which is administering this program, selected five
 participating hospitals and has begun making reimbursement
 payments. No public information located on funding
 obligations.


            See http://innovations.cms.gov/initiatives/GNE/index.html.
          
        
        
          
            10502
New freestanding authority
Health care facility construction. Appropriated $100 million for
 FY2010, to remain available for obligation until Sept. 30, 2011, for debt
 service on, or construction or renovation of, a hospital affiliated with a
state’s sole public medical and dental school. [HRSA; CFDA 93.502]

$100 million

New
freestanding
authority

$13 million: Personal and Home Care Aide State Training
(PHCAST) program
See http://www.acf.hhs.gov/programs/ofa/programs/hpog; and
http://bhpr.hrsa.gov/nursing/grants/phcast.html.

See http://mchb.hrsa.gov/programs/familytofamily/index.html.

See http://bhpr.hrsa.gov/grants/teachinghealthcenters/.

See http://innovations.cms.gov/initiatives/GNE/index.html.

Funding awarded to Ohio State University.

 ACA
Section

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

Community-Based Prevention and Wellness
4002

New
freestanding
authority

 state's sole public medical and dental school. [HRSA; CFDA 93.502]
          
          
            $100 million
Funding awarded to Ohio State University.
Community-Based Prevention and Wellness
4002
New freestanding authority
Prevention and Public Health Fund (PPHF). Established a PPHF and
 originally provided a permanent annual appropriation to the fund, as follows:
 FY2010 = $500 million; FY2011 = $750 million; FY2012 = $1 billion; FY2013
 = $1.25 billion; FY2014 = $1.5 billion; FY2015 and each year thereafter = $2
 billion. Required the Secretary to transfer amounts from the fund to HHS
 accounts to increase funding, over the FY2008 level, for PHSA-authorized
 prevention, wellness, and public health activities, including prevention
 research and health screenings. Provided House and Senate appropriators
 with the authority to transfer monies from the PPHF to eligible activities.
 Note: The Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 11296112-96) reduced the annual appropriations to the PPHF over the period FY2013FY2021FY2013-FY2021 as follows: FY2013 through FY2017 = $1 billion; FY2018 and FY2019
 = $1.25 billion; FY2020 and FY2021 = $1.5 billion; FY2022 and each year
 thereafter = $2 billion. [OS, CDC, HRSA, SAMHSA, ACL; CFDA 93.507,
, 93.521, 93.522, 93.523, 93.524, 93.531, 93.533, 93.538, 93.539, 93.540,
 93.542.]


          
          
            PPHF funds are annual appropriations that must be obligated
 during the fiscal year in which they are made available. For an
 analysis and complete list of all PPHF awards for FY2010 and
 FY2011, see the GAO report, Prevention and Public Health
 Fund: Activities Funded in Fiscal Years 2010 and 2011 (GAO-1278812-788), at http://www.gao.gov/assets/650/648310.pdf.

Maternal, infant, and early childhood home visiting program.
. 
            For a summary of the allocation of PPHF funds for FY2012, FY2013, FY2014, and FY2015, by agency and program, see http://www.hhs.gov/open/recordsandreports/prevention/index.html.
            The listed CFDA programs do not capture all the uses of PPHF funding. PPHF funds have also been integrated into existing programs that do not mention PPHF.
Maternal and Child Health
2951
New SSA Sec. 511
Maternal, infant, and early childhood home visiting program.Appropriated the following amounts for grants to states, U.S. territories, and
 Indian tribes to develop and implement early childhood home visiting
 programs that adhere to evidence-based models of service delivery: FY2010
 = $100 million; FY2011 = $250 million, FY2012 = $350 million; FY2013 =
 $400 million; FY2014 = $400 million. Total amount = $1.5 billion. Programs
 must establish benchmarks to measure improvements for the participating
 families in maternal and newborn health; prevention of child abuse or neglect
 or child injuries; school readiness and achievement; reductions in crime or
 domestic violence; family economic self-sufficiency; and coordination and
 referrals for other community resources and supports. Note: [HRSA, ACF; CFDA 93.505, 93.508]
            PAMA (P.L.
 113-93) appropriated $400 million for the first half of FY2015. MACRA (P.L. 114-10) amended PAMA by appropriating $400 million for each of FY2015 through FY2017.$1.717 billion

            See ) appropriated $400 million for the first half of FY2015. [HRSA, ACF;
CFDA 93.505, 93.508]

$1.677 billion

For a summary of the allocation of PPHF funds for FY2012,
FY2013, FY2014, and FY2015, by agency and program, see
http://www.hhs.gov/open/recordsandreports/prevention/
index.html.
The listed CFDA programs do not capture all the uses of
PPHF funding. PPHF funds have also been integrated into
existing programs that do not mention PPHF.

Maternal and Child Health
2951

CRS-16

New SSA Sec.
511

See http://mchb.hrsa.gov/programs/homevisiting/.
          
        
        
          
            2953
New SSA Sec. 513
homevisiting/.

 ACA
Section
2953

2954

1021110214

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

New SSA Sec.
513

Personal Responsibility Education Program (PREP). Established a
 state formula grant program to support evidence-based PREPs designed to
 educate adolescents about abstinence, contraception, and adulthood. Also,
 required the Secretary to award grants to implement innovative youth
 pregnancy prevention strategies and to target services at high-risk
 populations. Appropriated $75 million for each of FY2010 through FY2014,
 of which $10 million each year is to be reserved for the youth pregnancy
 prevention grants. Total amount = $375 million. Funds are to remain
 available until expended. Note: [ACF; CFDA 93.092]
            PAMA (P.L. 113-93) appropriated $75 million
for FY2015. [ACF; CFDA 93.092]

$360 million

Amends SSA
Sec. 510

 for FY2015. MACRA (P.L. 114-10) appropriated two more years of funding; $75 million for each of FY2016 and FY2017.$360 million

            See http://www.acf.hhs.gov/programs/fysb/programs/adolescent-pregnancy-prevention/programs/prep-competitive. 
          
        
        
          
            2954
Amends SSA Sec. 510
Abstinence education grants. Renewed funding for the state formula
 grant program to support abstinence education programs by appropriating
 $50 million for each of FY2010 through FY2014. Total amount = $250
 million. Funds are awarded to states based on the proportion of low-income
 children in each state compared to the national total, and may only be used
 for teaching abstinence. Note: [ACF, CDC; CFDA 93.235]
            PAMA (P.L. 113-93) appropriated $50 million
for FY2015. [ACF, CDC; CFDA 93.235]

$195 million (FY2010-FY2015)

New
freestanding
authority

 for FY2015. MACRA (P.L. 114-10) appropriated two more years of funding; $75 million for each of FY2016 and FY2017.$195 million (FY2010-FY2015)

            See http://www.acf.hhs.gov/programs/fysb/resource/aegp-fact-sheet.
          
        
        
          
            10211-10214
New freestanding authority
Pregnancy assistance grants. Appropriated $25 million for each of
 FY2010 through FY2019 (total amount = $250 million) to establish a
 Pregnancy Assistance Fund for the purpose of awarding grants to states to
 assist pregnant and parenting teens and women. State grantees have the
 flexibility to make funds available to institutions of higher education, high
 schools and community service centers, and to the state attorneys general
 to improve services for pregnant women who are victims of domestic
 violence, sexual assault, or stalking. [OS; CFDA 93.500]

$108 million

$108 million

            See http://www.hhs.gov/ash/oah/oah-initiatives/paf/home.html. 
          
        
        
          
            Long-Term Care
2403
Amends DRA Sec. 6071(h)
Medicaid Money Follows the Person (MFP) demonstration
 program. Extended funding for the MFP demonstration through FY2016.
 The program authorizes the Secretary to award competitive grants to states
 to reduce their reliance on institutional care for people needing long-term
 care, and expand options for elderly people and individuals with disabilities
 to receive home and community-based long-term care services.
 Appropriated $450 million for each of FY2012 through FY2016, to remain
 available through FY2016. Total amount = $2.25 billion. [CMS; CFDA
 93.791]

$1.591 billion (FY2010-FY2015)

See http://www.acf.hhs.gov/programs/fysb/programs/
adolescent-pregnancy-prevention/programs/prep-competitive.

See http://www.acf.hhs.gov/programs/fysb/resource/aegp-factsheet.

See http://www.hhs.gov/ash/oah/oah-initiatives/paf/home.html.

Long-Term Care
2403

CRS-17

Amends DRA
Sec. 6071(h)

See $1.654 billion (FY2010-FY2015)

            See http://www.medicaid.gov/Medicaid-CHIP-ProgramInformation/Program-Information/By-Topics/Long-Term-Services-and-Supports/
Balancing/Money-Follows-the-Person.html.
          
        
        
          
            2405
New freestanding authority
Money-Follows-the-Person.html.

 ACA
Section
2405

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

New
freestanding
authority

State Aging and Disability Resource Centers (ADRCs). Appropriated
 $10 million for each of FY2010 through FY2014 (total amount = $50 million)
 for ADRCs, authorized under OAA Sec. 202. ADRCs serve as a single,
 coordinated resource for consumer information on the range of long-term
 care options in community and institutional settings. Some ADRCs also
 serve as the entry point to publicly administered long-term care programs
 (e.g., Medicaid, OAA services, state assistance programs). Over 500 ADRC
 sites have been established across 50 states, DC, and two territories. See
 also the entry for ACA Sec. 3306, above. [ACL; CFDA 93.517]

]
          
          
            $28 million (FY2010-FY2015; includes ACA mandatory +
 discretionary funds)

6201

New
freestanding
authority


            See http://www.acl.gov/Programs/CDAP/OIP/ADRC/index.aspx.
          
        
        
          
            6201
New freestanding authority
Background checks of long-term care providers. Required the
 Secretary to establish a nationwide program for background checks on
 direct patient access employees of long-term care facilities or providers, and
 to provide federal matching funds to states to conduct these activities.
 Required the Treasury Secretary to transfer to HHS an amount, not to
 exceed $160 million, specified by the HHS Secretary as necessary to carry
 out the program for the period FY2010 through FY2012. Funds are to
 remain available until expended. [CMS; CFDA 93.506]

$56 million

8002(d)

Amends DRA
Sec. 6021(d)

$58 million
8002(d)
Amends DRA Sec. 6021(d)
National Clearinghouse for Long-Term Care Information.
 Appropriated $3 million for each of FY2011 through FY2015 for the
 National Clearinghouse for Long-Term Care Information, and required the
 Clearinghouse to include information on the Community Living Assistance
 Services and Supports (CLASS) program, established under ACA Sec.
 8002(a). Total amount = $15 million. Note: [ACL]
            ATRA (P.L. 112-240) repealed
 the appropriations for the National Clearinghouse and rescinded all
 unobligated FY2013 funds (as of January 3, 2013), and . It also repealed the CLASS
 program. [ACL]

$6 million (FY2011-FY2013)

See http://www.acl.gov/Programs/CDAP/OIP/ADRC/
index.aspx.

See http://longtermcare.gov/.

Comparative Effectiveness Research
6301(d)-(e)

CRS-18

New IRC Secs.
9511, 4375, &
4376. New SSA
Sec. 1183

Patient-Centered Outcomes Research Trust Fund (PCORTF).
$6 million (FY2011-FY2013)

            See http://longtermcare.gov/.
          
        
        
          
            Comparative Effectiveness Research
6301(d)-(e)
New IRC Secs. 9511, 4375, & 4376. New SSA Sec. 1183
Patient-Centered Outcomes Research Trust Fund (PCORTF).Established the PCORTF to fund the new Patient-Centered Outcomes
 Research Institute (PCORI) and its comparative effectiveness research
 activities. Appropriated to the PCORTF $10 million for FY2010, $50 million
 for FY2011, and $150 million for each of FY2012 through FY2019, for a total
 of $1.26 billion over that 10-year period. For each of FY2013 through
 FY2019, the PCORTF is to receive additional appropriations equal to the net
 revenues from a new fee on health insurance policies and self-insured plans,d
d as well as Medicare trust fund transfers.ee Each fiscal year, 20% of the funds in
 the PCORTF are to be transferred to the Secretary, to remain available until
 expended. Of those transferred funds, 80% are to be provided to AHRQ.
 [OS, AHRQ]

As of March
          
          
            As of May 2015, PCORI has awarded a total of $735855 million
 for research and other initiatives. For complete details on all
 the research awards, see http://www.pcori.org/.
.
            Based on the actual (FY2010-FY2014) and estimated (FY2015FY2016FY2015-FY2016) PCORTF receipts shown in the FY2016 Budget, and
 the projected receipts over the remaining three years
 (FY2017-FY2019), the PCORTF will receive a total of more
than $4 billion through FY2019.

 ACA
Section

Statutory
Authority

Summary of Provision

Obligations as of Mar. 4, 2015, Based on TAGGS
Unless Specified Otherwise

Biomedical Research
9023

New IRC Sec.
48D

 than $4 billion through FY2019.
          
        
        
          
            Biomedical Research
9023
New IRC Sec. 48D
Therapeutic research and development tax credits and grants.
 Created a two-year tax credit program, subject to an overall cap of $1
 billion, for small companies (250 or fewer employees) that invest in new
 therapies to prevent, diagnose, and treat cancer and other diseases.
 Companies could apply for one or more tax credits, each covering up to
 50% of the cost of qualifying research investments made in 2009 and 2010.
 However, the total amount of tax credits any one company receives for the
 two years could not exceed $5 million. Companies could elect to receive
 one or more grants in lieu of tax credits, subject to the same restrictions
 (i.e., grants could cover up to 50% of the cost of qualifying investments made
 in 2009 and 2010; the total amount of grants any one company receives for
 the two years could not exceed $5 million). Appropriated such sums as may
 be necessary to carry out the grant program. [IRS]


          
          
            According to the IRS: total grant awards = $970 million; total
 tax credits = $17 million.

            See http://www.irs.gov/Businesses/Small-Businesses-&-SelfEmployed/-Self-Employed/Qualifying-Therapeutic-Discovery-Project-Creditsand-Grants.

ACA Implementation: Administrative Expenses
HCERA
Sec. 1005

New
freestanding
authority

Credits-and-Grants.
          
        
        
          
            ACA Implementation: Administrative Expenses
HCERA Sec. 1005
New freestanding authority
Health Insurance Reform Implementation Fund (HIRIF).
 Appropriated $1 billion to the HIRIF for federal administrative expenses to
 carry out the ACA. [OS]


          
          
            According to the FY2016 Budget, there was an unobligated
 balance of $26 million at the beginning of FY2015.

Source:
          
        
      
      
        Sources: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), as amended.
a.

ACA (P.L. 111-148), HCERA (P.L. 111-152), ATRA (P.L. 112-240), PSGRRA (P.L. 113-67, Division B), PAMA (P.L. 113-93), and MACRA (P.L. 114-10). 
        a.

    Transfers from the two trust funds are in such proportion as the Secretary determines appropriate.

b.

to be appropriate.
        b.

    Of the amounts appropriated for the period FY2011-FY2019, and for each subsequent 10-year period, at least $25 million must be made available each fiscal year for
 the selection, testing, and evaluation of new payment and service delivery models.

c.


        c.

    Transfers from the two trust funds are in the same proportion as the Secretary determines under SSA Sec. 1853(f).

d.


        d.

    The health insurance fee is to equal $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of a policy/plan year ending during
 FY2013), updated annually by the rate of medical inflation beginning in FY2015.

e.


        e.

    The trust fund transfers are to equal $2 ($1 in FY2013) multiplied by the average number of individuals entitled to benefits under Part A or enrolled under Part B in a
 given fiscal year, updated annually by the rate of medical inflation beginning in FY2015.

CRS-19

 
      
    
    
      
        Table 3. ACA Appropriations and Fund Transfers by Fiscal Year in Which Funds Become Available for Obligation

        Dollars in Millions, Includes Funding Extensions and Rescissions
Fiscal Year
ACA
Section

Program

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

Totala

(Note: This section also authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter.)

30

Private Health Insurance
1002

Health insurance consumer
information

30b

1003

Review of health insurance
premium rates

250

—

—

—

—

—

—

—

—

—

250

1101

Temporary high-risk health
insurance pools

5,000b

—

—

—

—

—

—

—

—

—

5,000

1102

Early retiree reinsurance
program

5,000b

—

—

—

—

—

—

—

—

—

5,000

1311

Health insurance exchange
planning and establishment

Indefinite appropriation; annual amounts determined by the Secretary.
No awards after Jan. 1, 2015. Obligations as of Mar. 4 = $5.2 billion.

—

—

—

—

TBDc

1322

Consumer operated and
oriented plans (CO-OPs)

—

—

—

—

1,121d

1323

Health insurance exchange
subsides (U.S. territories)

1,121d

—

—

—

—

—

—

—

—

—

$1 billion total for CY2014 through CY2109e

1,000

Medicaid and Children’s Health Insurance Program (CHIP)
2701

Medicaid adult health quality
measures

60

60

60

60

60

—

—

—

—

—

300f

2707

Medicaid emergency
psychiatric demonstration

—

75g

—

—

—

—

—

—

—

—

75

2801

Medicaid and CHIP Payment
and Access Commission

4108

Medicaid prevention and
wellness incentives

—

4306

CHIP childhood obesity
demonstration

$25 million total for FY2010 through FY2014

10203(d)

CHIP annual appropriationi

—

10203(d)

CHIP outreach and
enrollment grants

CRS-20

11h

(Note: This section also authorizes to be appropriated SSAN for FY2011 and each fiscal year thereafter.)
$100 million total for CY2011 through CY2015f

11

—

—

—

—

100

—

—

—

—

—

25

21,061

—

—

—

—

40,208

Increases total funding from $100 million to $140 million and extends
funding period through FY2015.

—

—

—

—

40

—

—

—

19,147

 Fiscal Year
ACA
Section

Program

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

Totala

Medicare
3014

Medicare quality and
efficiency measures

3021(a)

Center for Medicare and
Medicaid Innovation

5

3024

Medicare independence at
home demonstration

5j

3026

Community-based care
transition services

3027(b)

Medicare gainsharing
demonstration

2

—

—

—

—

3113

Diagnostic laboratory test
demonstration

5l

—

—

—

3306

Outreach and assistance for
low-income programs

25m

3403

Independent Payment
Advisory Board

—

—

5n

4202(b)

Prevention and wellness
evaluation

50j

—

—

—

—

—

—

—

—

—

50

4204(e)

GAO study of Medicare
vaccine coverage

1

—

—

—

—

—

—

—

—

—

1

10323(a)

Environmental health pilot
program

10323(b)

Environmental health
screening and education

20j

—

20

20

20

20

—

—

—

—

—

$10 billion total for FY2011 through FY2019, and $10 billion for each subsequent 10-year period.
5

5

5

5

5

10,005f

—

—

—

—

30

—

—

—

—

300k

—

—

—

—

—

2f

—

—

—

—

—

—

5

25m

12.5m

—

—

—

—

107.5

$300 million total for FY2011 through FY2015k

$45 million total for FY2010
through FY2012m

100

For FY2013 and each subsequent fiscal year, appropriates previous year’s
amount adjusted for inflation; funds derived from the Medicare trust funds.n

TBDc

SSANj

TBDc
$20 million total for FY2015 though FY2019, and for
each 5-year period thereafter

$23 million total for FY2010 through FY2014

43f

Fraud and Abuse
6402(i) &
HCERA
1303(a)

Health Care Fraud and
Abuse Control (HCFAC)
Account

—

105

65

40

40

30

30

10

10

10

350o

50

50

50

50

—

—

—

—

—

—

200f

Health Centers
4101(a)

CRS-21

School-based health center
establishment grants

 Fiscal Year
ACA
Section

Program

2010

2011

10503(b)(1)

Community-based health
center operations (CHCF)

—

10503(c)

Health center construction
and renovation

—

2012

1,000

2013

1,200

1,500

2014

2015

2,200

3,600

$1.5 billion total for FY2011 through FY2015

2016

2017

2018

2019

Totala

—

—

—

—

9,500f

—

—

—

—

1,500f

Health Workforce and the National Health Service Corps
10503(b)(2)

National Health Service
Corps (CHCF)

—

290

295

300

305

310

—

—

—

—

1,500f

5507(a)

Health workforce
demonstration grants

85

85

85

85

85

85p

—

—

—

—

510

5507(b)

Family-to-family health
information centers

5

5

5

5q

5q

2.5q

—

—

—

—

27.5f

5508(c)

Teaching health centers,
GME payments

—

SSAN for FY2011 through FY2015, not to exceed $230
million

—

—

—

—

≤230

5509

Medicare graduate nurse
education demonstration

—

—

50

50

50

50

—

—

—

—

200f

10502

Health care facility
construction

100

—

—

—

—

—

—

—

—

—

100r

500

750

1,000

1,000

1,000

1,000

1,000

1,000

1,250

1,250

9,750s

Community-Based Prevention and Wellness
4002

Prevention and Public Health
Fund

Maternal and Child Health
2951

Maternal, infant, and early
childhood home visitation

100

250

350

400

400

400t

—

—

—

—

1,900

2953

Personal responsibility
education program grants

75

75

75

75

75

75u

—

—

—

—

450f

2954

Abstinence education state
grants

50

50

50

50

50

50v

—

—

—

—

300

10214

Pregnancy assistance grants

25

25

25

25

25

25

25

25

25

25

250

—

450

450

450

450

450

450

—

—

—

2,700

Long-Term Care
2403

CRS-22

Medicaid money follows the
person demonstration

 Fiscal Year
ACA
Section

Program

2405

State Aging and Disability
Resource Centers

6201

Background checks of longterm care providers

8002(d)

National Clearinghouse for
Long-Term Care Information

2010
10

2011

2012

10

2013

10

Up to $160 million total for
FY2010 through FY2012
—

3

3

2014

2015

2016

2017

2018

2019

Totala

10

10

—

—

—

—

—

50

—

—

—

—

—

—

—

≤160w

0x

0x

0x

—

—

—

—

6

Comparative Effectiveness Research
6301(d)

Medicare trust fund transfers
(PCORTF)

—

—

—

For each of FY2013-FY2019, transfers amounts from the Medicare trust funds as
determined by a formula.y

TBDc

6301(e)

Appropriations and fees
(PCORTF)

10

50

150

For each of FY2013-FY2019, appropriates $150 million plus an amount equal to
the net revenue from a fee levied on health insurance and self-insured plans.z

TBDc

SSAN

—

—

—

—

—

—

—

—

—

≤1aa

—

—

—

—

—

—

—

—

—

1,000

Biomedical Research
9023(e)

Grants for investment in
new therapeutics

ACA Implementation: Administrative Expenses
HCERA
1005

Health Insurance Reform
Implementation Fund

1,000

Source: Prepared by the Congressional Research Service based on the text of the Patient Protection and Affordable Care Act (ACA; P.L. 111-148), as amended.
Notes: Funds are provided from the Treasury unless otherwise noted. A dash means that ACA does not appropriate or transfer funds for the fiscal year(s) noted.
a.

Total represents the cumulative amount of appropriations or fund transfers over the 10-year period FY2010-FY2019. Note that in several instances the 10-year total is
yet to be determined (TBD); see table entries for ACA Secs. 1311, 3403, 6301(d) & (e), 9023(e), and 10323(a). In addition, four provisions provide annual or multipleyear appropriations beyond FY2019. The total shown in the table for three of these provisions represents the cumulative amount appropriated through FY2019; see
table entries for ACA Secs. 3021(a), 4002 (discussed in table note “s” below), and 10323(b). Finally, the total for ACA Sec. 6402(i) includes an amount appropriated in
FY2020 (see table note “o” below).

b.

Funds are to remain available without fiscal year limitation.

c.

To be determined.

d.

ACA Sec. 1322 appropriated $6 billion for the CO-OP program. P.L. 112-10 rescinded $2.2 billion of that amount, and then P.L. 112-74 rescinded an additional $400
million. Finally, P.L. 112-240 rescinded 90% of the program’s unobligated balance as of January 2, 2013, and transferred the remaining unobligated funds to a new COOP contingency fund to provide assistance and oversight to CO-OP loan recipients. This effectively terminated CMS’s authority to make new loan awards. Overall,
Congress rescinded a total of $4.879 billion, leaving $1.121 billion of the original $6 billion CO-OP program appropriation.

e.

Of this total amount, $925 million is for Puerto Rico, and the remaining $75 million is for the other U.S. territories in amounts as specified by the Secretary.

f.

Funds are to remain available until expended.

CRS-23

 g.

Funds are to remain available for obligation through December 31, 2015.

h.

Of this total amount, $9 million is appropriated, and the remaining $2 million is a transfer from CHIP funding for FY2010. Funds are to remain available until expended.

i.

Prior to enactment of ACA, the CHIP program was funded through FY2013.

j.

The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds each fiscal year in such proportion as the Secretary determines
appropriate. Funds are to remain available until expended.

k.

The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds each fiscal year in such proportion as the Secretary determines
appropriate. Funds are to remain available until expended. P.L. 113-6 rescinded $200 million of the ACA’s original transfer of $500 million for CCTP.

l.

The Secretary is required to transfer the $5 million from the Medicare Part B trust fund, to remain available until expended.

m.

The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds in the same proportion as the Secretary determines under SSA Sec.
1853(f). P.L. 112-240 extended funding for an additional year by transferring $25 million for FY2013 for the four outreach and assistance programs funded by ACA
through FY2012. P.L. 113-93 further extended funding for the programs by transferring $25 million for FY2014 and $12.5 million for the first half of FY2015. Funds are
to remain available until expended. See Table 2.

n.

P.L. 112-74 rescinded $10 million of IPAB’ (Subsequent Funding Extensions Shown in Italics)
      
      
        
          
            ACA Section
Program
Fiscal Year

          
          
            Totala2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Private Health Insurance
1002
Health insurance consumer information

          
          
            30b(Note: This section also authorized to be appropriated SSAN for FY2011 and each fiscal year thereafter.)
30
1003
Review of health insurance premium rates
250
—
—
—
—
—
—
—
—
—
250
1101
Temporary high-risk health insurance pools 

          
          
            5,000b—
—
—
—
—
—
—
—
—
5,000
1102
Early retiree reinsurance program

          
          
            5,000b—
—
—
—
—
—
—
—
—
5,000
1311
Health insurance exchange planning and establishment
Indefinite appropriation; annual amounts determined by the Secretary. No grant awards after Jan. 1, 2015.
—
—
—
—

          
          
            5,180c1322
Consumer operated and oriented plans (CO-OPs)

          
          
            1,121d—
—
—
—
—
—
—
—
—

          
          
            1,121d1323
Health insurance exchange subsides (U.S. territories)
—
—
—
—

          
          
            $1 billion total for CY2014 through CY2109e1,000
Medicaid and Children's Health Insurance Program (CHIP)
2701
Medicaid adult health quality measures
60
60
60
60
60
—
—
—
—
—

          
          
            300f2707
Medicaid emergency psychiatric demonstration
—

          
          
            75g—
—
—
—
—
—
—
—
75
2801
Medicaid and CHIP Payment and Access Commission

          
          
            11h(Note: This section also authorized to be appropriated SSAN for FY2011 and each fiscal year thereafter.)
11
4108
Medicaid prevention and wellness incentives
—

          
          
            $100 million total for CY2011 through CY2015f—
—
—
—
100
4306
CHIP childhood obesity demonstration
$25 million total for FY2010 through FY2014
—
$10 million total for FY2016-FY2017i—
—
35
10203(d)

          
          
            CHIP annual appropriationj—
—
—
—
19,147
21,061
19,300
20,400
—
—
79,908
10203(d)
CHIP outreach and enrollment grants
Increased total funding from $100 million to $140 million and extended the funding period through FY2015.
$40 million total for FY2016-FY2017k—
—
80
Medicare
3014
Medicare quality and efficiency measures

          
          
            20l20
20
20
20
—
—
—
—
—
100
3021(a)
Center for Medicare and Medicaid Innovation
5
$10 billion total for FY2011 through FY2019, and $10 billion for each subsequent 10-year period.

          
          
            10,005f3024
Medicare independence at home demonstration

          
          
            5l5
5
5
5
5
—
—
—
—
30
3026
Community-based care transition services
—

          
          
            $300 million total for FY2011 through FY2015m—
—
—
—

          
          
            300m3027(b)
Medicare gainsharing demonstration
2
—
—
—
—
—
—
—
—
—

          
          
            2f3113
Diagnostic laboratory test demonstration

          
          
            5n—
—
—
—
—
—
—
—
—
5
3306

          
          
            Outreach and assistance for low-income programso$45 million total for FY2010 through FY2012
25
25
25
37.5
37.5
—
—
195
3403

          
          
            Independent Payment Advisory Boardp—
—
5
For FY2013 and each subsequent fiscal year, appropriates previous year's amount adjusted for inflation; funds derived from the Medicare trust funds. 

          
          
            TBDq4202(b)
Prevention and wellness evaluation

          
          
            50l—
—
—
—
—
—
—
—
—
50
4204(e)
GAO study of Medicare vaccine coverage
1
—
—
—
—
—
—
—
—
—
1
10323(a)
Environmental health pilot program

          
          
            SSANl
          
           
          
           
          
           
          
           
          
           
          
           
          
           
          
           
          
           
          
          
            TBDq10323(b)
Environmental health screening and education
$23 million total for FY2010 through FY2014
$20 million total for FY2015 though FY2019, and for each 5-year period thereafter

          
          
            43fFraud and Abuse
6402(i) & HCERA 1303(a)
Health Care Fraud and Abuse Control (HCFAC) Account
—
105
65
40
40
30
30
10
10
10

          
          
            350rHealth Centers
4101(a)
School-based health center establishment grants
50
50
50
50
—
—
—
—
—
—

          
          
            200f10503(b)(1)
Community-based health center operations (CHCF)
—
1,000
1,200
1,500
2,200
3,600
3,600s3,600s—
—

          
          
            16,700f10503(c)
Health center construction and renovation
—
$1.5 billion total for FY2011 through FY2015
—
—
—
—

          
          
            1,500fHealth Workforce and the National Health Service Corps
10503(b)(2)
National Health Service Corps (CHCF)
—
290
295
300
305
310
310t310t—
—

          
          
            2,120f5507(a)
Health workforce demonstration grants
85
85
85
85
85
85u85u85u—
—
680
5507(b)
Family-to-family health information centers 
5
5
5
5v5v5v5v5v—
—

          
          
            40f5508(c)
Teaching health centers, GME payments
—
  SSAN for FY2011 through FY2015, not to exceed $230 million
60w60w—
—
≤350
5509
Medicare graduate nurse education demonstration
—
—
50
50
50
50
—
—
—
—

          
          
            200f10502
Health care facility construction
100
—
—
—
—
—
—
—
—
—

          
          
            100xCommunity-Based Prevention and Wellness
4002
Prevention and Public Health Fund
500
750
1,000
1,000
1,000
1,000
1,000
1,000
1,250
1,250

          
          
            9,750yMaternal and Child Health
2951
Maternal, infant, and early childhood home visitation
100
250
350
400
400
400z400z400z—
—
2,700
2953
Personal responsibility education program grants
75
75
75
75
75
75aa75aa75aa—
—

          
          
            600f2954
Abstinence education state grants
50
50
50
50
50
50bb75bb75bb—
—
450
10214
Pregnancy assistance grants
25
25
25
25
25
25
25
25
25
25
250
Long-Term Care
2403
Medicaid money follows the person demonstration
—
450
450
450
450
450
450
—
—
—
2,700
2405
State Aging and Disability Resource Centers
10
10
10
10
10
—
—
—
—
—
50
6201
Background checks of long-term care providers

          
          
            Up to $160 million total for FY2010 through FY2012
          
          
            —
—
—
—
—
—
—

          
          
            ≤160cc8002(d)
National Clearinghouse for Long-Term Care Information
—
3
3

          
          
            0dd
          
          
            0dd
          
          
            0dd—
—
—
—
6
Comparative Effectiveness Research
6301(d)
Medicare trust fund transfers (PCORTF)
—
—
—

          
          
            For each of FY2013-FY2019, transfers amounts from the Medicare trust funds as determined by a formula.ee
          
          
            TBDq6301(e)
Appropriations and fees (PCORTF)
10
50
150

          
          
            For each of FY2013-FY2019, appropriates $150 million plus an amount equal to the net revenue from a fee levied on health insurance and self-insured plans.ff
          
          
            TBDqBiomedical Research
9023(e)
Grants for investment in new therapeutics
SSAN
—
—
—
—
—
—
—
—
—

          
          
            ≤1ggACA Implementation: Administrative Expenses
HCERA 1005
Health Insurance Reform Implementation Fund
1,000
—
—
—
—
—
—
—
—
—
1,000
Sources: Prepared by the Congressional Research Service based on the text of the ACA (P.L. 111-148), HCERA (P.L. 111-152), ATRA (P.L. 112-240), PSGRRA (P.L. 113-67, Division B), PAMA (P.L. 113-93), and MACRA (P.L. 114-10).
Notes: Funds are provided from the Treasury unless otherwise noted. A dash means that ACA did not appropriate or transfer funds for the fiscal year(s) noted.

        a.

    Total represents the cumulative amount of ACA appropriations or fund transfers over the 10-year period FY2010-FY2019, including any subsequent funding extensions (as summarized in Table 2 and highlighted in the table notes below). Note that in several instances the 10-year total is yet to be determined (TBD); see table entries for ACA Secs. 1311, 3403, 6301(d) & (e), 9023(e), and 10323(a). In addition, four provisions provide annual or multiple-year appropriations beyond FY2019. The total shown in the table for three of these provisions represents the cumulative amount appropriated through FY2019; see table entries for ACA Secs. 3021(a), 4002 (discussed in table note "s" below), and 10323(b). Finally, the total for ACA Sec. 6402(i) includes an amount appropriated in FY2020 (see table note "o" below).
        b.

    Funds are to remain available without fiscal year limitation.
        c.

    Total obligated funding as of May 4, 2015. 
        d.

    The ACA appropriated $6 billion for the CO-OP program. The FY2011 and FY2012 Labor-HHS-Education appropriations acts (P.L. 112-10 and P.L. 112-74, respectively) rescinded a total of $2.6 billion of that amount. ATRA (P.L. 112-240) then rescinded 90% of the program's unobligated balance as of January 2, 2013, and transferred the remaining unobligated funds to a new CO-OP contingency fund to provide assistance and oversight to existing CO-OP loan recipients. This terminated CMS's authority to make new loan awards. Overall, Congress rescinded a total of $4.879 billion, leaving $1.121 billion of the original $6 billion CO-OP program appropriation.
        e.

    Of this total amount, $925 million is for Puerto Rico, and the remaining $75 million is for the other U.S. territories in amounts as specified by the Secretary.
        f.

    Funds are to remain available until expended.
        g.

    Funds are to remain available for obligation through December 31, 2015.
        h.

    Of this total amount, $9 million was appropriated, and the remaining $2 million was a transfer from CHIP funding for FY2010.
        i.

    MACRA (P.L. 114-10) appropriated additional funding—$10 million for the two-year period FY2016 through FY2017—for the childhood obesity demonstration. 
        j.

    The ACA funded the CHIP program for FY2014 and FY2015. MACRA (P.L. 114-10) provided two extra years of funding (i.e., FY2016 and FY2017).
        k.

    MACRA (P.L. 114-10) appropriated additional funding—$40 million for the two-year period FY2016 through FY2017—for CHIP outreach and enrollment grants. 
        l.

    The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds each fiscal year in such proportion as the Secretary determines to be appropriate. Funds are to remain available until expended.
        m.

    The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds each fiscal year in such proportion as the Secretary determines to be appropriate. Funds are to remain available until expended. The FY2013 Labor-HHS-Education appropriations act (P.L. 113-6) rescinded $200 million of the ACA's original transfer of $500 million for CCTP.
        n.

    The Secretary is required to transfer the $5 million from the Medicare Part B trust fund, to remain available until expended.
        o.

    The ACA funded these programs through FY2012. In subsequent legislative actions, Congress extended funding through FY2017; see Table 2. The Secretary is required to transfer amounts from the Medicare Part A and Part B trust funds in the same proportion as the Secretary determines under SSA Sec. 1853(f). Funds are to remain available until expended.
        p.

    The following Labor-HHS-Education appropriations acts rescinded IPAB funding: P.L. 112-74 rescinded $10 million of IPAB's $15 million appropriation for FY2012; P.L. 113-6 rescinded $10 million of IPAB’'s appropriation for FY2013; and P.L. 113-76
 rescinded $10 million of IPAB’'s appropriation for FY2014; and P.L. 113-235 rescinded $10 million of IPAB’'s appropriation for FY2015.

o.


        q.

    To be determined.
        r.

    Funds are to be appropriated from the Medicare Part A trust fund. Note: The total amount appropriated (i.e., $350 million) includes a final appropriation of $10 million
for FY2020.

p.

P.L. 113-93 provided an additional year of funding for health workforce demonstration grants.

q.

P.L. 112-240 appropriated $5 million for FY2013 for family-to-family health information centers. P.L. 113-67 and P.L. 113-93 provided an additional $5 million for
FY2014 and a prorated amount for the first half of FY2015. See Table 2.

r.

Funds are to remain available for obligation until September 30, 2011.

s.

 for FY2020.
        s.

    MACRA (P.L. 114-10) appropriated two years of additional funding (i.e., FY2016 and FY2017) for health center operations. 
        t.

    MACRA (P.L. 114-10) appropriated two years of additional funding (i.e., FY2016 and FY2017) for the NHSC. 
        u.

    In two separate legislative actions, Congress has extended funding for health workforce demonstration grants through FY2017; see Table 2.
        v.

    The ACA funded family-to-family health information centers through FY2012. In several subsequent legislative actions, Congress has extended funding through FY2017; see Table 2.
        w.

    MACRA (P.L. 114-10) appropriated two years of additional funding (i.e., FY2016 and FY2017) for teaching health centers. 
        x.

    Funds were to remain available for obligation until September 30, 2011.
        y.

    ACA Sec. 4002 originally provided a permanent annual appropriation to the Prevention and Public Health Fund, as follows: FY2010 = $500 million; FY2011 = $750
 million; FY2012 = $1 billion; FY2013 = $1.25 billion; FY2014 = $1.5 billion; FY2015 and each year thereafter = $2 billion. The Middle Class Tax Relief and Job Creation Act (P.L. 112-96)P.L. 112-96 reduced the annual appropriations
 to the PPHF over the period FY2013-FY2021, as follows: FY2013 through FY2017 = $1 billion; FY2018 and FY2019 = $1.25 billion; FY2020 and FY2021 = $1.5 billion;
 FY2022 and each year thereafter = $2 billion. Thus, appropriations to the fund now total $9.750 billion over the period FY2010-FY2019.

t.

P.L. 113-93 appropriated $400 million for the first half of FY2015.

u.

P.L. 113-93 provided an additional year of funding for PREP grants.

v.

P.L. 113-93 provided an additional year of funding for abstinence education grants.

w.


        z.

    In two separate legislative actions, Congress has extended funding for the maternal, infant, and early childhood home visiting program through FY2017; see Table 2.
        .

    In two separate legislative actions, Congress has extended funding for PREP grants through FY2017; see Table 2.
        .

    In two separate legislative actions, Congress has extended funding for abstinence education grants through FY2017; see Table 2.
        .

    The HHS Secretary is required to notify the Treasury Secretary of the amount necessary to carry out activities under this section for the period of FY2010 through
 FY2012, but not to exceed $160 million. The Treasury Secretary must then transfer the amount specified from the Treasury to the HHS Secretary. Funds are to
 remain available until expended.

x.


        .

    ATRA (P.L. 112-240) repealed the appropriations for the National Clearinghouse and rescinded all unobligated FY2013 funds (as of January 3, 2013).

y.


        .

    ACA Sec. 6301(d) provided the following formula for the transfer of funds from the Medicare Part A and Part B trust funds to the PCORTF: (1) for FY2013, an
 amount from each respective Medicare trust fund equal to $1 multiplied by the average number of individuals entitled to Part A benefits, or enrolled in Part B during
 that period; and (2) for each of FY2014-FY2019, an amount from each respective Medicare trust fund equal to $2 multiplied by the average number of individuals
 entitled to Part A benefits, or enrolled in Part B during that fiscal year. Beginning in FY2015, amounts are subject to adjustment for increases in health care spending.

CRS-24

 The FY2015 Budget includes The FY2016 Budget included the following transfer amounts from the Medicare trust funds to the PCORTF: FY2013FY2014 actual = $52107 million; FY2014FY2015 estimate = $107
117 million; FY2015FY2016 estimate = $117124 million.
z.


        .

    The fee is equal to $2 multiplied by the average number of covered lives in a policy/plan year ($1 in the case of policy/plan years ending during FY2013). Beginning in
 FY2015, amounts are subject to adjustment for increases in health care spending. The FY2015FY2016 Budget includesincluded the following fee revenue: FY2013FY2014 actual = $277135 million;
FY2014 FY2015 estimate = $347373 million; FY2015FY2016 estimate = $392401 million.

aa. 
        .

    To be determined. ACA Sec. 9023(e) created a two-year tax credit program, subject to an overall cap of $1 billion, for small companies that invest in new therapies to
 prevent, diagnose and treat cancer and other diseases. The total amount of tax credits any one company can receive for the two years may not exceed $5 million.
 Companies may elect to receive one or more grants—for which SSAN are appropriated—in lieu of tax credits. Grant applications musthad to be received before January 1,
2013.

CRS-25

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

Appendix A.  2013.
      
    
    
    
    Acronyms Used in the Report

    The following laws, agencies, programs, and funds are referred to in this report by their acronym:
ACA

ACA
Patient Protection and Affordable Care Act (P.L. 111-148) 
          
        
        
          
            ACF
Administration for Children and Families
ACL
Administration for Community Living
ADRC
Aging and Disability Resource Center
AHRQ
Agency for Healthcare Research and Quality
ATRA
P.L. 111-148)

ACF

Administration for Children and Families

ACL

Administration for Community Living

ADRC

Aging and Disability Resource Center

AHRQ

Agency for Healthcare Research and Quality

ATRA

American Taxpayer Relief Act of 2012 (P.L. 112-240)

BBA

)
          
        
        
          
            BBA
Bipartisan Budget Act of 2013 (P.L. 113-67, Division A)

BBEDCA

BBEDCA
Balanced Budget and Emergency Deficit Control Act of 1985 (P.L. 99-177)

BCA

)
          
        
        
          
            BCA
Budget Control Act of 2011 (P.L. 112-25)
          
        
        
          
            CBO
Congressional Budget Office
CCIIO
Center for Consumer Information and Insurance Oversight
CCTP
Community-Based Care Transition Program
CDC
Centers for Disease Control and Prevention
CFDA
Catalog of Federal Domestic Assistance
CHCF
Community Health Center Fund
CHIP
State Children's Health Insurance Program
CMMI
Center for Medicare & Medicaid Innovation
CMS
Centers for Medicare & Medicaid Services
CO-OP
Consumer Operated and Oriented Plan
DRA
P.L. 112-25)

CBO

Congressional Budget Office

CCIIO

Center for Consumer Information and Insurance Oversight

CCTP

Community-Based Care Transition Program

CDC

Centers for Disease Control and Prevention

CFDA

Catalog of Federal Domestic Assistance

CHCF

Community Health Center Fund

CHIP

State Children’s Health Insurance Program

CMMI

Center for Medicare & Medicaid Innovation

CMS

Centers for Medicare & Medicaid Services

CO-OP

Consumer Operated and Oriented Plan

DRA

Deficit Reduction Act of 2005 (P.L. 109-171)
          
        
        
          
            ERRP
Early Retiree Reinsurance Program
HCERA
P.L. 109-171)

ERRP

Early Retiree Reinsurance Program

HCERA

Health Care and Education Reconciliation Act of 2010 (P.L. 111-152)
          
        
        
          
            HCFAC
Health Care Fraud and Abuse Control
HHS
Department of Health and Human Services
HIRIF
Health Insurance Reform Implementation Fund
HRSA
Health Resources and Services Administration
OS
Office of the Secretary (HHS)
IPAB
Independent Payment Advisory Board
IRC
Internal Revenue Code
IRS
Internal Revenue Service
MACPAC
Medicaid and CHIP Payment and Access Commission
MIPCD
Medicaid Incentives for the Prevention of Chronic Diseases
MIPPA
P.L. 111-152)

HCFAC

Health Care Fraud and Abuse Control

HHS

Department of Health and Human Services

HIRIF

Health Insurance Reform Implementation Fund

HRSA

Health Resources and Services Administration

OS

Office of the Secretary (HHS)

IPAB

Independent Payment Advisory Board

IRC

Internal Revenue Code

IRS

Internal Revenue Service

MACPAC

Medicaid and CHIP Payment and Access Commission

MIPCD

Medicaid Incentives for the Prevention of Chronic Diseases

MIPPA

Medicare Improvements for Patients and Providers Act of 2008 (P.L. 110-275)
          
        
        
          
            MFP
Medicaid Money Follows the Person Demonstration
NHSC
National Health Service Corps
OAA
Older Americans Act
OMB
Office of Management and Budget
PAMA
P.L. 110-275)

MFP

Medicaid Money Follows the Person Demonstration

NHSC

National Health Service Corps

Congressional Research Service

26

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

OAA

Older Americans Act

OMB

Office of Management and Budget

PAMA

Protecting Access to Medicare Act of 2014 (P.L. 113-93)
          
        
        
          
            PCIP
Pre-Existing Condition Insurance Plan
PCORTF
Patient-Centered Outcomes Research Trust Fund
PHSA
Public Health Service Act
PPHF
Prevention and Public Health Fund
PREP
Personal Responsibility Education Program
PSGRRA
P.L. 113-93)

PCIP

Pre-Existing Condition Insurance Plan

PCORTF

Patient-Centered Outcomes Research Trust Fund

PHSA

Public Health Service Act

PPHF

Prevention and Public Health Fund

PREP

Personal Responsibility Education Program

PSGRRA

Pathway for SGR Reform Act of 2013 (P.L. 113-67, Division B)
          
        
        
          
            SBHC
School-Based Health Center
SSA
Social Security Act
TAGGS
Tracking Accountability in Government Grants System

          
        
      
    
    
    Annual Spending Reductions Under the Budget Control Act
    The Budget Control Act of 2011 (BCA)19 amended the Balanced Budget and Emergency Deficit , Division B)

SBHC

School-Based Health Center

SSA

Social Security Act

TAGGS

Tracking Accountability in Government Grants System

Congressional Research Service

27

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

Appendix B. Annual Spending Reductions Under
the Budget Control Act
The Budget Control Act of 2011 (BCA)21 amended the Balanced Budget and Emergency Deficit
Control Act of 1985 (BBEDCA) by establishing two budget enforcement mechanisms to reduce
 federal spending by at least $2.1 trillion over the 10-year period FY2012 through FY2021. First,
 the BCA established enforceable limits, or caps, on discretionary spending for each of those
 years. Second, the BCA created a Joint Committee on Deficit Reduction to develop legislation to
 further limit federal spending. The failure of the Joint Committee to agree on deficit-reduction
 legislation triggered automatic annual spending reductions for each of FY2013 through FY2021.

     The BCA specified that a total of $109 billion must be cut each year from nonexempt budget
 accounts. That amount is equally divided between defense and nondefense spending. Within each
 category—defense and nondefense—the spending cuts are divided proportionately between
 discretionary spending and nonexempt mandatory (i.e., direct) spending. Under the BCA, the
 spending reductions are achieved through a combination of sequestration (i.e., an across-theboardthe-board cancellation of budgetary resources) and lowering the BCA-imposed discretionary
 spending caps.

    The BCA requires that the mandatory spending reductions in each category—defense and
 nondefense—must be executed each year by a sequestration of all nonexempt accounts, subject to
 the BBEDCA sequestration rules. Discretionary spending in each category is also subject to
 sequestration, but only in FY2013. For each of the remaining fiscal years (i.e., FY2014 through
 FY2021), discretionary spending reductions are to be achieved by lowering the discretionary
 spending caps for defense and nondefense spending by the total dollar amount of the reduction.
 Thus, congressional appropriators get to decide how to apportion the cuts within the lowered
 spending caps rather than having the cuts applied across-the-board to all nonexempt discretionary
 spending accounts through sequestration. The Office of Management and Budget (OMB) is
 responsible for calculating the percentages and amounts by which mandatory and discretionary
 spending are required to be reduced each year, and for applying the BBEDCA’'s sequestration
 exemptions and rules.

    The American Taxpayer Relief of 2012 (ATRA)2220 revised the discretionary spending caps for
 FY2013 and FY2014 and reduced the overall dollar amount that needed to be sequestered from
 FY2013 defense and nondefense spending. The Bipartisan Budget Act of 201323201321 further revised
 the spending caps for FY2014 and FY2015 and eliminated the requirements that these caps be
 lowered pursuant to the BCA’'s annual spending reductions.24

21

P.L. 112-25, 125 Stat. 240.
P.L. 112-240, 126 Stat. 2313.
23
P.L. 113-67, Division A, 127 Stat. 1165.
24
For a more complete analysis of the Budget Control Act of 2011 and the amendments that were made to it by the
American Taxpayer Relief Act of 2012, see CRS Report R41965, The Budget Control Act of 2011, by Bill Heniff Jr.,
Elizabeth Rybicki, and Shannon M. Mahan; and CRS Report R42949, The American Taxpayer Relief Act of 2012:
Modifications to the Budget Enforcement Procedures in the Budget Control Act, by Bill Heniff Jr.
22

Congressional Research Service

28

 Appropriations and Fund Transfers in the Affordable Care Act (ACA)

Author Contact Information
C. Stephen Redhead
Specialist in Health Policy
credhead@crs.loc.gov, 7-2261

Acknowledgments
The following CRS analysts contributed to earlier versions of this report: Kirsten Colello, Patricia Davis,
Gary Guenther, Elayne Heisler, Lisa Herz, Janet Kinzer, Sarah Lister, Alison Mitchell, Bernice Reyes,
Amanda Sarata, Carmen Solomon-Fears, Emilie Stoltzfus, and Susan Thaul.

Congressional Research Service

29

 22
  
  
    Author Contact Information
[author name scrubbed], Specialist in Health Policy
        ([email address scrubbed], [phone number scrubbed])
      
Acknowledgments
The following CRS analysts contributed to earlier versions of this report: Kirsten Colello, Patricia Davis, [author name scrubbed], Elayne Heisler, Lisa Herz, [author name scrubbed], Sarah Lister, [author name scrubbed], Bernice Reyes, Amanda Sarata, [author name scrubbed], [author name scrubbed], and [author name scrubbed].
Footnotes1.
            
        
           The ACA was signed into law on March 23, 2010 (P.L. 111-148, 124 Stat. 119). A week later, on March 30, 2010, the President signed the Health Care and Education Reconciliation Act (HCERA; P.L. 111-152, 124 Stat. 1029), which amended numerous health care and revenue provisions in the ACA and added multiple new stand-alone provisions. Congress and the President have since enacted several other bills that have made targeted changes to specific ACA provisions. All references to the ACA in this report refer, collectively, to the law as amended and to other related HCERA provisions.
2.
            
        
           Mandatory, or direct, spending generally refers to outlays from budget authority (i.e., the authority to incur financial obligations that result in government expenditures such as paying salaries, purchasing services, or awarding grants) that is provided in authorizing laws, as opposed to annual appropriations acts. It includes spending on entitlement programs (e.g., Medicare, Social Security).
3.
            
        
           While a detailed examination of the ACA is beyond the scope of this report, numerous CRS products that provide more in-depth information on the many new programs and activities authorized and funded by the law are available at http://www.crs.loc.gov (see under "Issues Before Congress: Health").
4.
            
        
           CBO, Updated Budget Projections: 2015 to 2025, March 2015, https://www.cbo.gov/sites/default/files/cbofiles/attachments/49973-UpdatedBudgetProjections.pdf. 
5.
            
        
           CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by [author name scrubbed].
6.
            
        
           CFDA is a government-wide compendium of federal grant and other assistance programs. Each program is assigned a unique five-digit number, XX.XXX, where the first two digits represent the funding agency and the second three digits represent the program. Programs funded by the Department of Health and Human Services begin with the number 93. For more information, see https://www.cfda.gov.
7.
            
        
           To access and search the TAGGS database, go to http://www.taggs.hhs.gov/.
        
      
      
        8.
            
        
           The two other indefinite appropriations (i.e., Sections 5508(c), and 9023(e)) provide SSAN to carry out a program, but in each case there is an upper limit on the amount that may be appropriated. Note that a fourth provision (i.e., Section 10323(a)) requires the HHS Secretary to transfer SSAN from the Medicare trust funds to carry out a pilot program.
9.
            
        
           For a state-by-state breakdown of ACA exchange planning and establishment grants, see CRS Report R43066, Federal Funding for Health Insurance Exchanges, by [author name scrubbed] and [author name scrubbed].
10.
            
        
           For more information, see CRS Report R42433, Federal Health Centers, by [author name scrubbed]; and CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by [author name scrubbed].
11.
            
        
           Section 3205 of the Middle Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96, 126 Stat. 156) reduced the ACA's annual appropriations to the PPHF over the period FY2013-FY2021 by a total of $6.25 billion. See Table 2.
        
      
      
        12.
            
        
           For more information, see CRS Report R41390, Discretionary Spending Under the Affordable Care Act (ACA), coordinated by [author name scrubbed].
13.
            
        
           P.L. 112-240, 126 Stat. 2313.
14.
            
        
           P.L. 113-67, Division B, 127 Stat. 1195.
15.
            
        
           P.L. 113-93, 128 Stat. 1040.
16.
            
        
           P.L. 114-10, 129 Stat. 87.
17.
            
        
           For more information on all the legislative actions taken to amend the ACA since its enactment, including actions taken through the annual appropriations process, see CRS Report R43289, Legislative Actions to Repeal, Defund, or Delay the Affordable Care Act, by [author name scrubbed] and [author name scrubbed].
18.
            
        
           P.L. 112-25, 125 Stat. 240.
19.
            
        
           P.L. 112-25, 125 Stat. 240.
20.
            
        
           P.L. 112-240, 126 Stat. 2313.
21.
            
        
           P.L. 113-67, Division A, 127 Stat. 1165.
22.
            
        
           For a more complete analysis of the Budget Control Act of 2011 and the amendments that were made to it by the American Taxpayer Relief Act of 2012, see CRS Report R41965, The Budget Control Act of 2011, by [author name scrubbed], [author name scrubbed], and [author name scrubbed]; and CRS Report R42949, The American Taxpayer Relief Act of 2012: Modifications to the Budget Enforcement Procedures in the Budget Control Act, by [author name scrubbed]