Text: H.R.2068 — 111th Congress (2009-2010)All Bill Information (Except Text)

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Introduced in House (04/23/2009)


111th CONGRESS
1st Session
H. R. 2068

To improve the provision of telehealth services under the Medicare Program, to provide grants for the development of telehealth networks, and for other purposes.


IN THE HOUSE OF REPRESENTATIVES
April 23, 2009

Mr. Thompson of California (for himself, Mr. Stupak, Mr. Terry, and Mr. Sam Johnson of Texas) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned


A BILL

To improve the provision of telehealth services under the Medicare Program, to provide grants for the development of telehealth networks, and for other purposes.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. Short title; table of contents.

(a) Short title.—This Act may be cited as the “Medicare Telehealth Enhancement Act of 2009”.

(b) Table of contents.—The table of contents of this Act is as follows:


Sec. 1. Short title; table of contents.

Sec. 101. Expansion and improvement of telehealth services.

Sec. 102. Increase in number of types of originating sites; clarification.

Sec. 103. Expansion of eligible telehealth providers and credentialing of telemedicine practitioners.

Sec. 104. Access to telehealth services in the home.

Sec. 105. Coverage of home health remote patient management services for chronic health conditions.

Sec. 106. Sense of Congress on the use of remote patient management services.

Sec. 107. Telehealth Advisory Committee.

Sec. 201. Grant program for the development of telehealth networks.

Sec. 202. Reauthorization of telehealth network and telehealth resource centers grant programs.

SEC. 101. Expansion and improvement of telehealth services.

(a) Expanding access to telehealth services to all areas.—Section 1834(m)(4)(C)(i) of the Social Security Act (42 U.S.C. 1395m(m)(4)(C)(i)) is amended in paragraph (4)(C)(i) by striking “and only if such site is located” and all that follows and inserting “without regard to the geographic area within the United States where the site is located.”.

(b) Expansion of use of store-and-forward technology.—The second sentence of section 1834(m)(1) of such Act (42 U.S.C. 1395m(m)(1)) is amended by inserting “and any telehealth program that has been the recipient of any Federal support from the Centers for Medicare & Medicaid Services, the Indian Health Service, or the Health Services and Resources Administration” after “Alaska or Hawaii”.

(c) Effective date.—The amendments made by this section shall apply to services furnished on or after January 1, 2010.

SEC. 102. Increase in number of types of originating sites; clarification.

(a) Increase.—Paragraph (4)(C)(ii) of section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) is amended by adding at the end the following new subclause:

“(IX) A renal dialysis facility.”

(b) Clarification of Intent of the Term Originating Site.—Such section is further amended by adding at the end the following new paragraph:

“(5) CONSTRUCTION.—In applying the term ‘originating site’ under this subsection, the Secretary shall apply the term only for the purpose of determining whether a site is eligible to receive a facility fee. Nothing in the application of such term under this subsection shall be construed as affecting the ability of an eligible practitioner to submit claims for telehealth services that are provided to other sites that have telehealth systems and capabilities.”.

(c) Effective date.—The amendments made by this section shall apply to services furnished on or after January 1, 2010.

SEC. 103. Expansion of eligible telehealth providers and credentialing of telemedicine practitioners.

(a) Expansion of eligible telehealth providers.—Section 1834(m)(1) of the Social Security Act (42 U.S.C. 1395m(m)(1)) is amended—

(1) in paragraph (1)—

(A) by striking “or a practitioner” and inserting “, a practitioner”;

(B) by inserting “, or other telehealth provider” after “1842(b)(18)(C))”; and

(C) by striking “or practitioner” and inserting “, practitioner, or provider”;

(2) in paragraphs (2), (3)(A), and (4), by striking “or practitioner” and inserting “, practitioner, or other telehealth provider” each place it appears;

(3) in paragraph (4), by adding at the end the following new subparagraph:

“(G) TELEHEALTH PROVIDER.—The term ‘telehealth provider’ means any supplier or provider of services (other than a physician or practitioner) that is eligible to provide other health services under this title.”.

(b) Credentialing Telemedicine Practitioners.—Section 1834(m) of such Act is amended by adding at the end the following new paragraph:

“(5) HOSPITAL CREDENTIALING OF TELEMEDICINE PRACTITIONERS.—A telemedicine practitioner that is credentialed by a hospital in compliance with the Joint Commission Standards for Telemedicine shall be considered in compliance with Medicare condition of participation and reimbursement credentialing requirements for telemedicine services.

SEC. 104. Access to telehealth services in the home.

(a) In general.—Section 1895 of the Social Security Act (42 U.S.C. 1395fff(e)) is amended by adding at the end the following new subsection:

“(f) Coverage of Telehealth Services.—

“(1) IN GENERAL.—The Secretary shall include telehealth services that are furnished via a telecommunication system by a home health agency to an individual receiving home health services under section 1814(a)(2)(C) or 1835(a)(2)(A) as a home health visit for purposes of eligibility and payment under this title if the telehealth services—

“(A) are ordered as part of a plan of care certified by a physician pursuant to section 1814(a)(2)(C) or 1835(a)(2)(A);

“(B) do not substitute for in-person home health services ordered as part of a plan of care certified by a physician pursuant to such respective section; and

“(C) are considered the equivalent of a visit under criteria developed by the Secretary under paragraph (3).

“(2) PHYSICIAN CERTIFICATION.—Nothing in this section shall be construed as waiving the requirement for a physician certification under section 1814(a)(2)(C) or 1835(a)(2)(A) for the payment for home health services, whether or not furnished via a telecommunication system.

“(3) CRITERIA FOR VISIT EQUIVALENCY.—

“(A) STANDARDS.—The Secretary shall establish standards and qualifications for categorizing and coding under HCPCS codes telehealth services under this subsection as equivalent to an in-person visit for purposes of eligibility and payment for home health services under this title. In establishing the standards and qualifications, the Secretary may distinguish between varying modes and modalities of telehealth services and shall consider—

“(i) the nature and amount of service time involved; and

“(ii) the functions of the telecommunications.

“(B) LIMITATION.—A telecommunication that consists solely of a telephone audio conversation, facsimile, electronic text mail, or consultation between two health care practitioners is not considered a visit under this subsection.

“(4) TELEHEALTH SERVICE.—

“(A) DEFINITION.—For purposes of this subsection, the term ‘telehealth service’ means technology-based professional consultations, patient monitoring, patient training services, clinical observation, assessment, or treatment, and any additional services that utilize technologies specified by the Secretary as HCPCS codes developed under paragraph (3).

“(B) UPDATE OF HCPCS CODES.—The Secretary shall establish a process for the updating, not less frequently than annually, of HCPCS codes for telehealth services.

“(5) CONDITIONS FOR PAYMENT AND COVERAGE.—Nothing in this subsection shall be construed as waiving any condition of payment under sections 1814(a)(2)(C) or 1835(a)(2)(A) or exclusion of coverage under section 1862(a)(1).

“(6) COST REPORTING.—Notwithstanding any provision to the contrary, the Secretary shall provide that the costs of telehealth services under this subsection shall be reported as a reimbursable cost center on any cost report submitted by a home health agency to the Secretary.”.

(b) Effective date.—

(1) The amendment made by subsection (a) shall apply to telehealth services furnished on or after October 1, 2010. The Secretary of Health and Human Services shall develop and implement criteria and standards under section 1895(f)(3) of the Social Security Act, as amended by subsection (a), by no later than July 1, 2010.

(2) In the event that the Secretary has not complied with these deadlines, beginning October 1, 2010, a home health visit for purpose of eligibility and payment under title XVIII of the Social Security Act shall include telehealth services under section 1895(f) of such Act with the aggregate of telecommunication encounters in a 24-hour period considered the equivalent of one in-person visit.

SEC. 105. Coverage of home health remote patient management services for chronic health conditions.

(a) Medicare coverage.—

(1) IN GENERAL.—Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended—

(A) in subparagraph (DD), by striking “and” at the end;

(B) in subparagraph (EE), by adding “and” at the end; and

(C) by inserting after subparagraph (EE) the following new subparagraph:

“(FF) home health remote patient management services (as defined in subsection (hhh));”.

(2) SERVICES DESCRIBED.—Section 1861 of such Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection:

“(hhh) Home health remote patient management services for chronic health conditions.—(1) The term ‘remote patient management services’ means the remote monitoring, evaluation, and management of an individual with a covered chronic health condition (as defined in paragraph (2)) through the utilization of a system of technology that allows a remote interface to collect and transmit clinical data between the individual and a home health agency, in accordance with a plan of care established by a physician, for the purposes of clinical review or response by the home health agency. Such term, with respect to an individual, does not include any remote monitoring, evaluation, or management of the individual if such remote monitoring, evaluation, or management, respectively, is included as a home health visit under section 1895(f) for purposes of payment under this title.

“(2) For purposes of paragraph (1), the term ‘covered chronic health condition’ means any chronic health condition specified by the Secretary.”.

(b) Payment.—

(1) IN GENERAL.—Section 1834 of such Act (42 U.S.C. 1395l) is amended by adding at the end the following new subsection:

“(n) Home Health Remote Patient Management Services.—

“(1) IN GENERAL.—The Secretary shall establish a fee schedule for home health remote patient management services (as defined in section 1861(hhh)) for which payment is made under this part. The fee schedule shall be designed in a manner so that, on an annual basis, the aggregate payment amounts under this title for such services approximates 50 percent of the savings amount described in paragraph (2) for such year.

“(2) SAVINGS DESCRIBED.—

“(A) IN GENERAL.—For purposes of paragraph (1), the savings amount described in this paragraph for a year is the amount (if any), as estimated by the Secretary before the beginning of the year, by which—

“(i) the product described in subparagraph (B) for the year, exceeds

“(ii) the total payments under this part and part A for items and services furnished to individuals receiving home health remote patient management services at any time during the year.

“(B) PRODUCT DESCRIBED.—The product described in this subparagraph for a year is the product of—

“(i) the average per capita total payments under this part and part A for items and services furnished during the year to individuals not described in subparagraph (A)(ii), adjusted to remove case mix differences between such individuals not described in such subparagraph and the individuals described in such subparagraph; and

“(ii) the number of individuals under subparagraph (A)(ii) for the year.

“(3) LIMITATION.—In no case may payments under this subsection result in the aggregate expenditures under this title (including payments under this subsection) exceeding the amount that the Secretary estimates would have been expended if coverage under this title for home health patient management services was not provided.

“(4) CLARIFICATION.—Payments under the fee schedule under this subsection, with respect to an individual, shall be in addition to any other payments that a home health agency would otherwise receive under this title for items and services furnished to such individual and shall have no effect on the amount of such other payments.

“(5) PAYMENT TRANSFER.—There shall be transferred from the Federal Hospital Insurance Trust Fund under section 1817 to the Federal Supplementary Medical Insurance Trust Fund under section 1841 each year an amount equivalent to the product of—

“(A) expenditures under this subsection for the year, and

“(B) the ratio of the portion of the savings described in paragraph (2) for the year that are attributable to part A, to the total savings described in such paragraph for the year.”.

(2) CONFORMING AMENDMENT.—Section 1833(a)(1) of such Act (42 U.S.C. 1395l(1)) is amended—

(A) by striking “and (W)” and inserting “(W)”; and

(B) by inserting before the semicolon at the end the following: “, (X) with respect to home health remote patient management services (as defined in section 1861(hhh)), the amounts paid shall be the amount determined under the fee schedule established under section 1834(n)”.

(c) Expansion of Home Health Remote Patient Management Services Coverage to Additional Chronic Health Conditions.—The Secretary of Health and Human Services is authorized to carry out pilot projects for purposes of determining the extent to which the coverage under title XVIII of the Social Security Act of home health remote patient management services (as defined in paragraph (1) of section 1861(hhh) of such Act, as added by subsection (a)) should be extended to individuals with chronic health conditions other than those initially specified by the Secretary under paragraph (2) of such section.

(d) Effective date.—The amendments made by subsections (a), (b), and (c) shall apply to services furnished on or after January 1, 2010.

SEC. 106. Sense of Congress on the use of remote patient management services.

(a) Findings.—Congress finds as follows:

(1) Remote patient management services can make chronic disease management more effective and efficient for patients and for the health care system.

(2) By collecting, analyzing, and transmitting clinical health information to a health care provider, remote patient management services allow patients and providers to manage the medical condition of patients in a consistent and real time fashion.

(3) Utilization of remote patient management services not only improves the quality of care given to patients, it also reduces the need for frequent office appointments, costly emergency room visits, and unnecessary hospitalizations.

(4) Management the medical condition or disease of a patient from the patient's home reduces the need for face to face provider interactions. Use of remote patient management services minimizes unnecessary travel and missed work and provides particular value to patients residing in rural or underserved communities who would otherwise face potentially significant access barriers to receiving needed care.

(5) Among the areas in which remote patient management services are emerging in health care are the treatment of congestive heart failure, diabetes, cardiac arrhythmia, epilepsy, and sleep apnea. Prompt transmission of clinical data on each of these conditions, to the health care provider or the patient as appropriate, is essential to providing timely and appropriate therapeutic interventions which can then reduce expensive hospitalizations.

(6) Despite these benefits, remote patient management services have failed to diffuse rapidly. A significant barrier to wider adoption is the relative lack of payment mechanisms in fee for service Medicare to reimburse for remote, non face to face patient management.

(7) Elimination of this barrier to new remote patient management services should be encouraged by requiring reimbursement under the Medicare program for providers’ time spent analyzing and responding to patient data transmitted by remote technologies.

(8) Reimbursement under the Medicare program for health care providers’ time spent analyzing and responding to data transmitted to providers by remote technologies should be made on a separate basis and should not be combined with payments for others services (also referred to as “bundled payments”).

(9) Payment codes used for reporting and billing for payment for providers’ remote patient management services should be revised or adjusted, as appropriate, to encourage the application of such services for other medical conditions.

(b) Sense of congress.—It is the sense of the Congress that—

(1) remote patient management services are integral to improvement in the delivery, care, and efficiency of health care services furnished in the United States; and

(2) the Administrator of the Centers for Medicare & Medicaid Services should be encouraged to—

(A) expand the types of medical conditions for which the use of remote patient management services are reimbursed under the Medicare program;

(B) provide for separate, non-bundled payment under the Medicare program for remote patient management services; and

(C) create, revise and adjust, as appropriate, codes for the accurate reporting and billing for payment for remote patient management services.

SEC. 107. Telehealth Advisory Committee.

(a) In general.—Section 1834(m)(4)(F)(ii) of the Social Security Act (42 U.S.C. 1395m(m)(4)(F)(ii)) is amended by adding at the end the following sentences: “Such process shall require the Secretary to take into account the recommendations of the Telehealth Advisory Committee (as established under section 107(b) of the Medicare Telehealth Enhancement Act of 2009) when adding or deleting services (and HCPCS codes) and in establishing policies of the Centers for Medicare & Medicaid Services regarding the delivery of telehealth services. If the Secretary does not implement a recommendation of the Telehealth Advisory Committee, the Secretary shall publish in the Federal Register a statement regarding the reason such recommendation was not implemented.”.

(b) Telehealth Advisory Committee.—

(1) ESTABLISHMENT.—On and after the date that is 6 months after the date of enactment of this Act, the Secretary of Health and Human Services (in this subsection referred to as the “Secretary”) shall have in place a Telehealth Advisory Committee (in this subsection referred to as the “Advisory Committee”) to make recommendations to the Secretary on—

(A) policies of the Centers for Medicare & Medicaid Services regarding the delivery of telehealth services; and

(B) the appropriate addition or deletion of services (and HCPCS codes) to those specified in paragraph (4)(F)(i) of section 1834(m) of the Social Security Act (42 U.S.C. 1395m(m)) for authorized payment under paragraph (1) of such section.

(2) MEMBERSHIP; TERMS.—

(A) MEMBERSHIP.—

(i) IN GENERAL.—The Advisory Committee shall be composed of 9 members, to be appointed by the Secretary, of whom—

(I) five shall be practicing physicians;

(II) two shall be practicing non-physician health care providers; and

(III) two shall be administrators of telehealth programs.

(ii) REQUIREMENTS FOR APPOINTING MEMBERS.—In appointing members of the Advisory Committee, the Secretary shall—

(I) ensure that each member has prior experience with the practice of telemedicine or telehealth;

(II) give preference to individuals who are currently providing telemedicine or telehealth services or who are involved in telemedicine or telehealth programs;

(III) ensure that the membership of the Advisory Committee represents a balance of specialties and geographic regions; and

(IV) take into account the recommendations of stakeholders.

(B) TERMS.—The members of the Advisory Committee shall serve for such term as the Secretary may specify.

(C) CONFLICTS OF INTEREST.—An advisory committee member may not participate with respect to a particular matter considered in an advisory committee meeting if such member (or an immediate family member of such member) has a financial interest that could be affected by the advice given to the Secretary with respect to such matter.

(3) MEETINGS.—The Advisory Committee shall meet twice per year and at such other times as the Advisory Committee may provide.

(4) PERMANENT COMMITTEE.—Section 14 of the Federal Advisory Committee Act (5 U.S.C. App.) shall not apply to the Advisory Committee.

(5) WAIVER OF ADMINISTRATIVE LIMITATION.—The Secretary shall establish the Advisory Committee notwithstanding any limitation that may apply to the number of advisory committees that may be established (within the Department of Health and Human Services or otherwise).

SEC. 201. Grant program for the development of telehealth networks.

(a) In general.—The Secretary of Health and Human Services (in this section referred to as the “Secretary”), acting through the Director of the Office for the Advancement of Telehealth (of the Health Resources and Services Administration), shall make grants to eligible entities (as described in subsection (b)(2)) for the purpose of expanding access to health care services for individuals in rural areas, frontier areas, and urban medically underserved areas through the use of telehealth.

(b) Eligible entities.—

(1) APPLICATION.—To be eligible to receive a grant under this section, an eligible entity described in paragraph (2) shall, in consultation with the State office of rural health or other appropriate State entity, prepare and submit to the Secretary an application, at such time, in such manner, and containing such information as the Secretary may require, including the following:

(A) A description of the anticipated need for the grant.

(B) A description of the activities which the entity intends to carry out using amounts provided under the grant.

(C) A plan for continuing the project after Federal support under this section is ended.

(D) A description of the manner in which the activities funded under the grant will meet health care needs of underserved rural populations within the State.

(E) A description of how the local community or region to be served by the network or proposed network will be involved in the development and ongoing operations of the network.

(F) The source and amount of non-Federal funds the entity would pledge for the project.

(G) A showing of the long-term viability of the project and evidence of health care provider commitment to the network.

The application should demonstrate the manner in which the project will promote the integration of telehealth in the community so as to avoid redundancy of technology and achieve economies of scale.

(2) ELIGIBLE ENTITIES.—

(A) IN GENERAL.—An eligible entity described in this paragraph is a hospital or other health care provider in a health care network of community-based health care providers that includes at least—

(i) two of the organizations described in subparagraph (B); and

(ii) one of the institutions and entities described in subparagraph (C),

if the institution or entity is able to demonstrate use of the network for purposes of education or economic development (as required by the Secretary).

(B) ORGANIZATIONS DESCRIBED.—The organizations described in this subparagraph are the following:

(i) Community or migrant health centers.

(ii) Local health departments.

(iii) Nonprofit hospitals.

(iv) Private practice health professionals, including community and rural health clinics.

(v) Other publicly funded health or social services agencies.

(vi) Skilled nursing facilities.

(vii) County mental health and other publicly funded mental health facilities.

(viii) Providers of home health services.

(ix) Renal dialysis facilities.

(C) INSTITUTIONS AND ENTITIES DESCRIBED.—The institutions and entities described in this subparagraph are the following:

(i) A public school.

(ii) A public library.

(iii) A university or college.

(iv) A local government entity.

(v) A local health entity.

(vi) A health-related nonprofit foundation.

(vii) An academic health center.

An eligible entity may include for-profit entities so long as the recipient of the grant is a not-for-profit entity.

(c) Preference.—The Secretary shall establish procedures to prioritize financial assistance under this section based upon the following considerations:

(1) The applicant is a health care provider in a health care network or a health care provider that proposes to form such a network that furnishes or proposes to furnish services in a medically underserved area, health professional shortage area, or mental health professional shortage area.

(2) The applicant is able to demonstrate broad geographic coverage in the rural or medically underserved areas of the State, or States in which the applicant is located.

(3) The applicant proposes to use Federal funds to develop plans for, or to establish, telehealth systems that will link rural hospitals and rural health care providers to other hospitals, health care providers, and patients.

(4) The applicant will use the amounts provided for a range of health care applications and to promote greater efficiency in the use of health care resources.

(5) The applicant is able to demonstrate the long-term viability of projects through cost participation (cash or in-kind).

(6) The applicant is able to demonstrate financial, institutional, and community support for the long-term viability of the network.

(7) The applicant is able to provide a detailed plan for coordinating system use by eligible entities so that health care services are given a priority over non-clinical uses.

(d) Maximum amount of assistance to individual recipients.—The Secretary shall establish, by regulation, the terms and conditions of the grant and the maximum amount of a grant award to be made available to an individual recipient for each fiscal year under this section. The Secretary shall cause to have published in the Federal Register or the “HRSA Preview” notice of the terms and conditions of a grant under this section and the maximum amount of such a grant for a fiscal year.

(e) Use of amounts.—The recipient of a grant under this section may use sums received under such grant for the acquisition of telehealth equipment and modifications or improvements of telecommunications facilities including the following:

(1) The development and acquisition through lease or purchase of computer hardware and software, audio and video equipment, computer network equipment, interactive equipment, data terminal equipment, and other facilities and equipment that would further the purposes of this section.

(2) The provision of technical assistance and instruction for the development and use of such programming equipment or facilities.

(3) The development and acquisition of instructional programming.

(4) Demonstration projects for teaching or training medical students, residents, and other health profession students in rural or medically underserved training sites about the application of telehealth.

(5) The provision of telenursing services designed to enhance care coordination and promote patient self-management skills.

(6) The provision of services designed to promote patient understanding and adherence to national guidelines for common chronic diseases, such as congestive heart failure or diabetes.

(7) Transmission costs, maintenance of equipment, and compensation of specialists and referring health care providers, when no other form of reimbursement is available.

(8) Development of projects to use telehealth to facilitate collaboration between health care providers.

(9) Electronic archival of patient records.

(10) Collection and analysis of usage statistics and data that can be used to document the cost-effectiveness of the telehealth services.

(11) Such other uses that are consistent with achieving the purposes of this section as approved by the Secretary.

(f) Prohibited uses.—Sums received under a grant under this section may not be used for any of the following:

(1) To acquire real property.

(2) Expenditures to purchase or lease equipment to the extent the expenditures would exceed more than 40 percent of the total grant funds.

(3) To purchase or install transmission equipment off the premises of the telehealth site and any transmission costs not directly related to the grant.

(4) For construction, except that such funds may be expended for minor renovations relating to the installation of equipment.

(5) Expenditures for indirect costs (as determined by the Secretary) to the extent the expenditures would exceed more than 15 percent of the total grant.

(g) Administration.—

(1) NONDUPLICATION.—The Secretary shall ensure that facilities constructed using grants provided under this section do not duplicate adequately established telehealth networks.

(2) COORDINATION WITH OTHER AGENCIES.—The Secretary shall coordinate, to the extent practicable, with other Federal and State agencies and not-for-profit organizations, operating similar grant programs to pool resources for funding meritorious proposals.

(3) INFORMATIONAL EFFORTS.—The Secretary shall establish and implement procedures to carry out outreach activities to advise potential end users located in rural and medically underserved areas of each State about the program authorized by this section.

(h) Prompt implementation.—The Secretary shall take such actions as are necessary to carry out the grant program as expeditiously as possible.

(i) Authorization of appropriations.—There are authorized to be appropriated to carry out this section $10,000,000 for fiscal year 2010, and such sums as may be necessary for each of the fiscal years 2011 through 2014.

SEC. 202. Reauthorization of telehealth network and telehealth resource centers grant programs.

Subsection (s) of section 330I of the Public Health Service Act (42 U.S.C. 254c–14) is amended—

(1) in paragraph (1)—

(A) by striking “and” before “such sums”; and

(B) by inserting “$10,000,000 for fiscal year 2010, and such sums as may be necessary for each of fiscal years 2011 through 2014” before the semicolon; and

(2) in paragraph (2)—

(A) by striking “and” before “such sums”; and

(B) by inserting “$10,000,000 for fiscal year 2010, and such sums as may be necessary for each of fiscal years 2011 through 2014” before the semicolon.