Display Version Introduced in House

HR 2520 IHCommentsClose CommentsPermalink

111th CONGRESSCommentsClose CommentsPermalink

1st SessionCommentsClose CommentsPermalink

H. R. 2520CommentsClose CommentsPermalink

To provide comprehensive solutions for the health care system of the United States, and for other purposes.CommentsClose CommentsPermalink

IN THE HOUSE OF REPRESENTATIVESCommentsClose CommentsPermalink

May 20, 2009CommentsClose CommentsPermalink

Mr. RYAN of Wisconsin (for himself and Mr. NUNES) 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 concernedCommentsClose CommentsPermalink

---

A BILLCommentsClose CommentsPermalink

To provide comprehensive solutions for the health care system of the United States, and for other purposes.CommentsClose CommentsPermalink

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

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

(a) Short Title- This Act may be cited as the ‘Patients’ Choice Act’.CommentsClose CommentsPermalink





(b) Table of Contents- The table of contents for this Act is as follows:CommentsClose CommentsPermalink





Sec. 1. Short title; table of contents.CommentsClose CommentsPermalink

TITLE I--INVESTING IN PREVENTION

Sec. 101. Strategic approach to outcome-based prevention.CommentsClose CommentsPermalink





Sec. 102. State grants for outcome-based prevention effort.CommentsClose CommentsPermalink





Sec. 103. Focusing the food stamp program on nutrition.CommentsClose CommentsPermalink





Sec. 104. Immunizations.CommentsClose CommentsPermalink

TITLE II--STATE-BASED HEALTH CARE EXCHANGES

Sec. 201. State-based health care exchanges.CommentsClose CommentsPermalink





Sec. 202. Requirements.CommentsClose CommentsPermalink





Sec. 203. State Exchange incentives.CommentsClose CommentsPermalink

TITLE III--FAIR TAX TREATMENT FOR ALL AMERICANS TO AFFORD HEALTH CARE

Sec. 300. Reference.CommentsClose CommentsPermalink

Subtitle A--Refundable and Advanceable Credit for Certain Health Insurance Coverage

Sec. 301. Refundable and advanceable credit for certain health insurance coverage.CommentsClose CommentsPermalink





Sec. 302. Requiring employer transparency about employee benefits.CommentsClose CommentsPermalink





Sec. 303. Changes to existing tax preferences for medical coverage, etc., for individuals eligible for qualified health insurance credit.CommentsClose CommentsPermalink

Subtitle B--Health Savings Accounts

Sec. 311. Improvements to health savings accounts.CommentsClose CommentsPermalink





Sec. 312. Exception to requirement for employers to make comparable health savings account contributions.CommentsClose CommentsPermalink

TITLE IV--FAIRNESS FOR EVERY AMERICAN PATIENT

Subtitle A--Medicaid Modernization

Sec. 401. Medicaid modernization.CommentsClose CommentsPermalink





Sec. 402. Outreach.CommentsClose CommentsPermalink





Sec. 403. Transition rules; miscellaneous provisions.CommentsClose CommentsPermalink

Subtitle B--Supplemental Health Care Assistance for Low-Income Families

Sec. 411. Supplemental Health Care Assistance for Low-Income Families.CommentsClose CommentsPermalink

TITLE V--FIXING MEDICARE FOR AMERICAN SENIORS

Subtitle A--Increasing Programmatic Efficiency, Economy, and Accountability

Sec. 501. Eliminating inefficiencies and increasing choice in Medicare Advantage.CommentsClose CommentsPermalink





Sec. 502. Medicare Accountable Care Organization demonstration program.CommentsClose CommentsPermalink





Sec. 503. Reducing government handouts to wealthier seniors.CommentsClose CommentsPermalink





Sec. 504. Rewarding prevention.CommentsClose CommentsPermalink





Sec. 505. Promoting healthcare provider transparency.CommentsClose CommentsPermalink





Sec. 506. Availability of Medicare and Medicaid claims and patient encounter data.CommentsClose CommentsPermalink

Subtitle B--Reducing Fraud and Abuse

Sec. 511. Requiring the Secretary of Health and Human Services to change the Medicare beneficiary identifier used to identify Medicare beneficiaries under the Medicare program.CommentsClose CommentsPermalink





Sec. 512. Use of technology for real-time data review.CommentsClose CommentsPermalink





Sec. 513. Detection of medicare fraud and abuse.CommentsClose CommentsPermalink





Sec. 514. Edits on 855S Medicare enrollment application and exemption of pharmacists from surety bond requirement.CommentsClose CommentsPermalink





Sec. 515. GAO study and report on effectiveness of surety bond requirements for suppliers of durable medical equipment in combating fraud.CommentsClose CommentsPermalink

TITLE VI--ENDING LAWSUIT ABUSE

Sec. 601. State grants to create health court solutions.CommentsClose CommentsPermalink

TITLE VII--PROMOTING HEALTH INFORMATION TECHNOLOGY

Subtitle A--Assisting the Development of Health Information Technology

Sec. 701. Purpose.CommentsClose CommentsPermalink





Sec. 702. Health record banking.CommentsClose CommentsPermalink





Sec. 703. Application of Federal and State security and confidentiality standards.CommentsClose CommentsPermalink

Subtitle B--Removing Barriers to the Use of Health Information Technology to Better Coordinate Health Care

Sec. 711. Safe harbors to antikickback civil penalties and criminal penalties for provision of health information technology and training services.CommentsClose CommentsPermalink





Sec. 712. Exception to limitation on certain physician referrals (under Stark) for provision of health information technology and training services to health care professionals.CommentsClose CommentsPermalink





Sec. 713. Rules of construction regarding use of consortia.CommentsClose CommentsPermalink

TITLE VIII--HEALTH CARE SERVICES COMMISSION

Subtitle A--Establishment and General Duties

Sec. 801. Establishment.CommentsClose CommentsPermalink





Sec. 802. General authorities and duties.CommentsClose CommentsPermalink





Sec. 803. Dissemination.CommentsClose CommentsPermalink

Subtitle B--Forum for Quality and Effectiveness in Health Care

Sec. 811. Establishment of office.CommentsClose CommentsPermalink





Sec. 812. Membership.CommentsClose CommentsPermalink





Sec. 813. Duties.CommentsClose CommentsPermalink





Sec. 814. Adoption and enforcement of guidelines and standards.CommentsClose CommentsPermalink





Sec. 815. Additional requirements.CommentsClose CommentsPermalink

Subtitle C--General Provisions

Sec. 821. Certain administrative authorities.CommentsClose CommentsPermalink





Sec. 822. Funding.CommentsClose CommentsPermalink





Sec. 823. Definitions.CommentsClose CommentsPermalink

Subtitle D--Terminations and Transition

Sec. 831. Termination of Agency for Healthcare Research and Quality.CommentsClose CommentsPermalink





Sec. 832. Transition.CommentsClose CommentsPermalink

Subtitle E--Independent Health Record Trust

Sec. 841. Short title.CommentsClose CommentsPermalink





Sec. 842. Purpose.CommentsClose CommentsPermalink





Sec. 843. Definitions.CommentsClose CommentsPermalink





Sec. 844. Establishment, certification, and membership of Independent Health Record Trusts.CommentsClose CommentsPermalink





Sec. 845. Duties of IHRT to IHRT participants.CommentsClose CommentsPermalink





Sec. 846. Availability and use of information from records in IHRT consistent with privacy protections and agreements.CommentsClose CommentsPermalink





Sec. 847. Voluntary nature of trust participation and information sharing.CommentsClose CommentsPermalink





Sec. 848. Financing of activities.CommentsClose CommentsPermalink





Sec. 849. Regulatory oversight.CommentsClose CommentsPermalink

TITLE IX--MISCELLANEOUS

Sec. 901. Health care choice for veterans.CommentsClose CommentsPermalink





Sec. 902. Health care choice for Indians.CommentsClose CommentsPermalink





Sec. 903. Termination of Federal Coordinating Council for Comparative Effectiveness Research.CommentsClose CommentsPermalink





Sec. 904. HHS and GAO joint study and report on costs of the 5 medical conditions that have the greatest impact.CommentsClose CommentsPermalink

TITLE I--INVESTING IN PREVENTIONCommentsClose CommentsPermalink

SEC. 101. STRATEGIC APPROACH TO OUTCOME-BASED PREVENTION.

(a) Interagency Coordinating Committee-CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary of Health and Human Services (referred to in this title as the ‘Secretary’) shall convene an interagency coordinating committee to develop a national strategic plan for prevention. The Secretary shall serve as the chairperson of the committee.CommentsClose CommentsPermalink





(2) COMPOSITION- In carrying out paragraph (1), the Secretary shall include the participation of--CommentsClose CommentsPermalink





(A) the Director of the National Institutes of Health;CommentsClose CommentsPermalink





(B) the Director of the Centers for Disease Control and Prevention;CommentsClose CommentsPermalink





(C) the Administrator of the Agency for Healthcare Research and Quality;CommentsClose CommentsPermalink





(D) the Administrator of the Substance Abuse and Mental Health Services Administration;CommentsClose CommentsPermalink





(E) the Administrator of the Health Resources and Services Administration;CommentsClose CommentsPermalink





(F) the Secretary of Agriculture;CommentsClose CommentsPermalink





(G) the Director of the Centers for Medicare & Medicaid Services;CommentsClose CommentsPermalink





(H) the Administrator of the Environmental Protection Agency;CommentsClose CommentsPermalink





(I) the Director of the Indian Health Service;CommentsClose CommentsPermalink





(J) the Administrator of the Administration on Aging;CommentsClose CommentsPermalink





(K) the Secretary of Veterans Affairs;CommentsClose CommentsPermalink





(L) the Secretary of Defense;CommentsClose CommentsPermalink





(M) the Secretary of Education; andCommentsClose CommentsPermalink





(N) the Secretary of Labor.CommentsClose CommentsPermalink





(3) REPORT AND PLAN- Not later than 1 year after the date of enactment of this Act, the Secretary, acting through the coordinating committee convened under paragraph (1), shall submit to Congress a report concerning the recommendation of the committee for health promotion and disease prevention activities. Such report shall include a specific strategic plan that shall include--CommentsClose CommentsPermalink





(A) a list of national priorities on health promotion and disease prevention to address lifestyle behavior modification (smoking cessation, proper nutrition, and appropriate exercise) and the prevention measures for the 5 leading disease killers in the United States;CommentsClose CommentsPermalink





(B) specific science-based initiatives to achieve the measurable goals of Healthy People 2010 regarding nutrition, exercise, and smoking cessation, and targeting the 5 leading disease killers in the United States;CommentsClose CommentsPermalink





(C) specific plans for consolidating Federal health programs and Centers that exist to promote healthy behavior and reduce disease risk (including eliminating programs and offices determined to be ineffective in meeting the priority goals of Healthy People 2010), that include transferring the nutrition guideline development responsibility from the Secretary of Agriculture to the Director of the Centers for Disease Control and Prevention;CommentsClose CommentsPermalink





(D) specific plans to ensure that all Federal health care programs are fully coordinated with science-based prevention recommendations promulgated by the Director of the Centers for Disease Control and Prevention;CommentsClose CommentsPermalink





(E) specific plans to ensure that all non-Department of Health and Human Services prevention programs are based on the science-based guidelines developed by the Centers for Disease Control and Prevention under subparagraph (D); andCommentsClose CommentsPermalink





(F) a list of new non-Federal and non-government partners identified by the committee to build Federal capacity in health promotion and disease prevention efforts.CommentsClose CommentsPermalink





(4) ANNUAL REQUEST TO GIVE TESTIMONY- The Secretary shall annually request an opportunity to testify before Congress concerning the progress made by the United States in meeting the outcome-based standards of Healthy People 2010 with respect to disease prevention and measurable outcomes and effectiveness of Federal programs related to this goal.CommentsClose CommentsPermalink





(5) PERIODIC REVIEWS- The Secretary shall conduct periodic reviews, not less than every 5 years, and grading of every Federal disease prevention and health promotion initiatives, programs, and agencies. Such reviews shall be evaluated based on effectiveness in meeting metrics-based goals with an analysis posted on such agencies’ public Internet websites.CommentsClose CommentsPermalink





(b) Federal Messaging on Health Promotion and Disease Prevention-CommentsClose CommentsPermalink





(1) MEDIA CAMPAIGNS-CommentsClose CommentsPermalink





(A) IN GENERAL- Not later than 1 year after the date of enactment of this Act, the Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall establish and implement a national science-based media campaign on health promotion and disease prevention.CommentsClose CommentsPermalink





(B) REQUIREMENTS OF CAMPAIGN- The campaign implemented under subparagraph (A)--CommentsClose CommentsPermalink





(i) shall be designed to address proper nutrition, regular exercise, smoking cessation, obesity reduction, the 5 leading disease killers in the United States, and secondary prevention through disease screening promotion;CommentsClose CommentsPermalink





(ii) shall be carried out through competitively bid contracts awarded to entities providing for the professional production and design of such campaign;CommentsClose CommentsPermalink





(iii) may include the use of television, radio, Internet, and other commercial marketing venues and may be targeted to specific age groups based on peer-reviewed social research;CommentsClose CommentsPermalink





(iv) shall not be duplicative of any other Federal efforts relating to health promotion and disease prevention; andCommentsClose CommentsPermalink





(v) may include the use of humor and nationally recognized positive role models.CommentsClose CommentsPermalink





(C) EVALUATION- The Secretary shall ensure that the campaign implemented under subparagraph (A) is subject to an independent evaluation every 2 years and shall report every 2 years to Congress on the effectiveness of such campaigns towards meeting science-based metrics.CommentsClose CommentsPermalink





(2) WEBSITE- The Secretary, in consultation with private-sector experts, shall maintain or enter into a contract to maintain an Internet website to provide science-based information on guidelines for nutrition, regular exercise, obesity reduction, smoking cessation, and specific chronic disease prevention. Such website shall be designed to provide information to health care providers and consumers.CommentsClose CommentsPermalink





(3) DISSEMINATION OF INFORMATION THROUGH PROVIDERS- The Secretary, acting through the Centers for Disease Control and Prevention, shall develop and implement a plan for the dissemination of health promotion and disease prevention information consistent with national priorities described in the strategic and implementing plan under subsection (a)(3)(A), to health care providers who participate in Federal programs, including programs administered by the Indian Health Service, the Department of Veterans Affairs, the Department of Defense, and the Health Resources and Services Administration, and the Medicare and Medicaid Programs.CommentsClose CommentsPermalink





(4) PERSONALIZED PREVENTION PLANS-CommentsClose CommentsPermalink





(A) CONTRACT- The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall enter into a contract with a qualified entity for the development and operation of a Federal Internet website personalized prevention plan tool.CommentsClose CommentsPermalink





(B) USE- The website developed under subparagraph (A) shall be designed to be used as a source of the most up-to-date scientific evidence relating to disease prevention for use by individuals. Such website shall contain a component that enables an individual to determine their disease risk (based on personal health and family history, BMI, and other relevant information) relating to the 5 leading diseases in the United States, and obtain personalized suggestions for preventing such diseases.CommentsClose CommentsPermalink





(5) INTERNET PORTAL- The Secretary shall establish an Internet portal for accessing risk-assessment tools developed and maintained by private and academic entities.CommentsClose CommentsPermalink





(6) PRIORITY FUNDING- Funding for the activities authorized under this section shall take priority over funding from the Centers for Disease Control and Prevention provided for grants to States and other entities for similar purposes and goals as provided for in this section. Not to exceed $500,000,000 shall be expended on the campaigns and activities required under this Act.CommentsClose CommentsPermalink

SEC. 102. STATE GRANTS FOR OUTCOME-BASED PREVENTION EFFORT.

(a) In General- If the Secretary determines that it is essential to meeting the national priorities described in the plan required under section 101(a)(3)(A), the Secretary may award grants to States for the conduct of specific health promotion and disease prevention activities.CommentsClose CommentsPermalink





(b) Eligibility- To be eligible to receive a grant under subsection (a), a State shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require, including a strategic plan that shall--CommentsClose CommentsPermalink





(1) describe the specific health promotion and disease prevention activities to be carried out under this grant;CommentsClose CommentsPermalink





(2) include a list of the barriers that exist within the State to meeting specific goals of Healthy People 2010;CommentsClose CommentsPermalink





(3) include targeted demographic indicators and measurable objectives with respect to health promotion and disease prevention;CommentsClose CommentsPermalink





(4) contain a set of process outcomes and milestones, based on the process outcomes and milestones developed by the Secretary, for measuring the effectiveness of activities carried out under the grant in the State; andCommentsClose CommentsPermalink





(5) outline the manner in which interventions to be carried out under this grant will reduce morbidity and mortality within the State over a 5-year period (or over a 10-year period, if the Secretary determines such period appropriate for adequately measuring progress).CommentsClose CommentsPermalink





(c) Process Outcomes and Milestones-CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary shall develop process outcomes and milestones to be used to measure the effectiveness of activities carried out under a grant under this section by a State.CommentsClose CommentsPermalink





(2) DETERMINATIONS- If, beginning 2 years after the date on which a grant is awarded to a State under this section, the Secretary determines that the State is failing to make adequate progress in meeting the outcomes and milestones contained in the State plan under subsection (b)(4), the Secretary shall provide the State with technical assistance on how to make such progress. Such technical assistance shall continue for a period of 2 years.CommentsClose CommentsPermalink





(3) CONTINUED FAILURE TO MEET OBJECTIVES- If after the expiration of the 2-year period described in paragraph (2), the Secretary determines that the State is failing to make adequate progress in meeting the outcomes and milestones contained in the State plan under subsection (b)(4) over a 5-year period, the Secretary shall terminate all funding to the State under a grant under this section.CommentsClose CommentsPermalink





(d) Regional Activities- A State may use an amount, not to exceed 15 percent of the total grant amount to such State, to carry out regional activities in conjunction with other States.CommentsClose CommentsPermalink





(e) Targeted Activities- A State may use grant funds to target specific populations within the State to achieve specific outcomes described in Healthy People 2010.CommentsClose CommentsPermalink





(f) Innovative Incentive Structures- The Secretary may award grants to States for the purposes of developing innovative incentive structures to encourage individuals to adopt specific prevention behaviors such as reducing their body mass index or for smoking cessation.CommentsClose CommentsPermalink





(g) Wellness Bonuses-CommentsClose CommentsPermalink





(1) IN GENERAL- The Secretary shall award wellness bonus payments to at least 5, but not more than 10, States that demonstrate the greatest progress in reducing disease rates and risk factors and increasing heathy behaviors.CommentsClose CommentsPermalink





(2) REQUIREMENT- To be eligible to receive a bonus payment under paragraph (1), a State shall demonstrate--CommentsClose CommentsPermalink





(A) the progress described in paragraph (1); andCommentsClose CommentsPermalink





(B) that the State has met a specific floor for progress outlined in the science-based metrics of Healthy People 2010.CommentsClose CommentsPermalink





(3) USE OF PAYMENTS- Bonus payments under this subsection may only be used by a State for the purposes of health promotion and disease prevention.CommentsClose CommentsPermalink





(4) FUNDING- Out of funds appropriated to the Director of the Centers for Disease Control and Prevention for each fiscal year beginning with fiscal year 2010, the Director shall give priority to using $50,000,000 of such funds to make bonus payments under this subsection.CommentsClose CommentsPermalink





(h) Administrative Expenses- A State may use not more than 5 percent of the amount of a grant under this section to carry out administrative activities.CommentsClose CommentsPermalink





(i) State- In this section, the term ‘State’ means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, Samoa, the United States Virgin Islands, and the Commonwealth of the Northern Mariana Islands.CommentsClose CommentsPermalink





(j) Authorization of Appropriations- Funding for the activities authorized under this section shall take priority over funding from the Centers for Disease Control and Prevention provided for grants to States and other entities for similar purposes and goals as provided for in this section, not to exceed $300,000,000 for each fiscal year.CommentsClose CommentsPermalink

SEC. 103. FOCUSING THE FOOD STAMP PROGRAM ON NUTRITION.

(a) Counseling Brochure- The Director of the Centers for Disease Control and Prevention shall develop, and the Secretary of Agriculture shall distribute to each individual and family enrolled in the Food Stamp Program under the Food Stamp Act of 1977 (7 U.S.C. 2011 et seq.), a science-based nutrition counseling brochure.CommentsClose CommentsPermalink





(b) Limitations on Food Stamp Purchases-CommentsClose CommentsPermalink





(1) IN GENERAL- Not later than 6 months after the date of enactment of this Act, the Secretary of Agriculture shall, based on scientific, peer-reviewed recommendations provided by a Commission that includes public health, medical, and nutrition experts and the Director of the Centers for Disease Control and Prevention, develop lists of foods that do not meet science-based standards for proper nutrition and that may not be purchased under the food stamp program. Such list shall be updated on an annual basis to ensure the most current science-based recommendations are applied to the food stamp program.CommentsClose CommentsPermalink





(2) AUTOMATED ENFORCEMENT- The Secretary of Agriculture shall, through regulations, ensure that the limitations on food purchases under paragraph (1) is enforced through the food stamp program’s automated system.CommentsClose CommentsPermalink





(3) IMPLEMENTATION- The Secretary of Agriculture shall promulgate the regulations described in paragraph (2) by the date that is not later than 1 year after the date of enactment of this section.CommentsClose CommentsPermalink

SEC. 104. IMMUNIZATIONS.

(a) Purchase of Vaccines- Notwithstanding any other provision of law, a State may use amounts provided under section 317 of the Public Health Service Act (42 U.S.C. 247b) for immunization programs to purchase vaccines for use in health care provider offices and schools.CommentsClose CommentsPermalink





(b) Technical Assistance and Reduction in Funding- If a State does not achieve a benchmark of 80 percent coverage within the State for Centers for Disease Control and Prevention-recommended vaccines, the Director of the Centers shall provide technical assistance to the State for a period of 2 years. If after the expiration of such 2-year period the State continues to fail to achieve such benchmark, the Secretary shall reduce funding provided under section 317 of the Public Health Service Act to such State by 5 percent.CommentsClose CommentsPermalink





(c) Bonus Grant- A State achieving a benchmark of 90 percent or greater coverage within the State for Centers for Disease Control and Prevention-recommended vaccines shall be eligible for a bonus grant from amounts appropriated under subsection (d).CommentsClose CommentsPermalink





(d) Authorization of Appropriations- Out of funds appropriated to the Director of the Centers for Disease Control and Prevention for each fiscal year beginning with fiscal year 2010, there shall be made available to carry out this section, $50,000,000 for each fiscal year.CommentsClose CommentsPermalink





(e) Funding for Section 317- Section 317(j)(1) of the Public Health Service Act (42 U.S.C. 247b(j)(1)) is amended by striking ‘2005’ and inserting ‘2012’.CommentsClose CommentsPermalink

TITLE II--STATE-BASED HEALTH CARE EXCHANGESCommentsClose CommentsPermalink

SEC. 201. STATE-BASED HEALTH CARE EXCHANGES.

(a) In General- The Secretary of Health and Human Services (referred to in this title as the ‘Secretary’) shall establish a process for the review of applications submitted by States for the establishment and implementation of State-based health care Exchanges (referred to in this title as a ‘State Exchange’) and for the certification of such Exchanges. The Secretary shall certify a State Exchange if the Secretary determines that such Exchange meets the requirements of this title.CommentsClose CommentsPermalink





(b) Continued Certification- The certification of a State Exchange under subsection (a) shall remain in effect until the Secretary determines that the Exchange has failed to meet any of the requirements under this title.CommentsClose CommentsPermalink

SEC. 202. REQUIREMENTS.

(a) General Requirements for Certification- An application for certification under section 201(a) shall demonstrate compliance with the following:CommentsClose CommentsPermalink





(1) PURPOSE- The primary purpose of a State Exchange shall be the facilitation of the individual purchase of innovative private health insurance and the creation of a market where private health plans compete for enrollees based on price and quality.CommentsClose CommentsPermalink





(2) ADMINISTRATION- A State shall ensure the operation of the State Exchange through direct contracts with the health insurance plans that are participating in the State Exchange or through a contract with a third party administrator for the operation of the Exchange.CommentsClose CommentsPermalink





(3) PLAN PARTICIPATION- A State shall not restrict or otherwise limit the ability of a health insurance plan to participate in, and offer health insurance coverage through, the State Exchange, so long as the health insurance issuers involved are duly licensed under State insurance laws applicable to all health insurance issuers in the State and otherwise comply with the requirements of this title.CommentsClose CommentsPermalink





(4) PREMIUMS-CommentsClose CommentsPermalink





(A) AMOUNT- A State shall not determine premium or cost sharing amounts for health insurance coverage offered through the State Exchange.CommentsClose CommentsPermalink





(B) COLLECTION METHOD- A State shall ensure the existence of an effective and efficient method for the collection of premiums for health insurance coverage offered through the State Exchange.CommentsClose CommentsPermalink





(b) Benefit Parity With Members of Congress- With respect to health insurance issuers offering health insurance coverage through the State Exchange, the State shall not impose any requirement that such issuers provide coverage that includes benefits different than requirements on plans offered to Members of Congress under chapter 89 of title 5, United States Code.CommentsClose CommentsPermalink





(c) Facilitating Universal Coverage for Americans-CommentsClose CommentsPermalink





(1) AUTOMATIC ENROLLMENT- The State Exchange shall ensure that health insurance coverage offered through the Exchange provides for the application of uniform mechanisms that are designed to encourage and facilitate the enrollment of all eligible individuals in Exchange-based health insurance coverage. Such mechanisms shall include automatic enrollment through various venues, which may include emergency rooms, the submission of State tax forms, places of employment in the State, and State departments of motor vehicles.CommentsClose CommentsPermalink





(2) OTHER ENROLLMENT OPPORTUNITIES-CommentsClose CommentsPermalink





(A) IN GENERAL- The State Exchange shall ensure that health insurance coverage offered through the Exchange permits enrollment, and changes in enrollment, of individuals at the time such individuals become eligible individuals in the State.CommentsClose CommentsPermalink





(B) ANNUAL OPEN ENROLLMENT PERIODS- The State Exchange shall ensure that health insurance coverage offered through the Exchange permits eligible individuals to annually change enrollment among the coverage offered through the Exchange, subject to subparagraph (A).CommentsClose CommentsPermalink





(C) INCENTIVES FOR CONTINUOUS ANNUAL COVERAGE- The State Exchange shall include an incentive for eligible individuals to remain insured from plan year to plan year, and may include incentives such as State tax incentives or premium-based incentives.CommentsClose CommentsPermalink





(3) GUARANTEED ACCESS FOR INDIVIDUALS- The State Exchange shall ensure that, with respect to health insurance coverage offered through the Exchange, all eligible individuals are able to enroll in the coverage of their choice provided that such individuals agree to make applicable premium and cost sharing payments.CommentsClose CommentsPermalink





(4) LIMITATION ON PRE-EXISTING CONDITION EXCLUSIONS- The State Exchange shall ensure that health insurance coverage offered through the Exchange meets the requirements of section 9801 of the Internal Revenue Code of 1986 in the same manner as if such coverage was a group health plan.CommentsClose CommentsPermalink





(5) OPT-OUT- Nothing in this title shall be construed to require that an individual be enrolled in health insurance coverage.CommentsClose CommentsPermalink





(d) Limitation on Exorbitant Premiums-CommentsClose CommentsPermalink





(1) ESTABLISHMENT OF MECHANISM- With respect to health insurance coverage offered through the State Exchange, the Exchange shall establish a mechanisms to protect enrollees from the imposition of excessive premiums, to reduce adverse selection, and to share risk.CommentsClose CommentsPermalink





(2) MECHANISM OPTIONS- The mechanisms referred to in paragraph (1) may include the following:CommentsClose CommentsPermalink





(A) INDEPENDENT RISK ADJUSTMENT- The implementation of risk-adjustment among health insurance coverage offered through the State Exchange through a contract entered into with a private, independent board. Such board shall include representation of health insurance issuers and State officials but shall be independently controlled. The State Exchange shall ensure that risk-adjustment implemented under this subparagraph shall be based on a blend of patient diagnoses and estimated costs.CommentsClose CommentsPermalink





(B) HEALTH SECURITY POOLS- The establishment (or continued operation under section 2745 of the Public Health Service Act) of a health security pool to guarantee high-risk individuals access to affordable, quality health care.CommentsClose CommentsPermalink





(C) REINSURANCE- The implementation of a successful reinsurance mechanisms to guarantee high-risk individuals access to affordable, quality health care.CommentsClose CommentsPermalink





(e) Medicaid and SCHIP Beneficiaries- The State Exchange shall include procedures to permit eligible individuals who are receiving (or who are eligible to receive) health care under title XIX or XXI of the Social Security Act to enroll in health insurance coverage offered through the Exchange.CommentsClose CommentsPermalink





(f) Dissemination of Coverage Information- The State Exchange shall ensure that each health insurance issuer that provides health insurance coverage through the Exchange disseminate to eligible individuals and employers within the State information concerning health insurance coverage options, including the plans offered and premiums and benefits for such plans.CommentsClose CommentsPermalink





(g) Regional Options-CommentsClose CommentsPermalink





(1) INTERSTATE COMPACTS- Two or more States that establish a State Exchange may enter into interstate compacts providing for the regulations of health insurance coverage offered within such States.CommentsClose CommentsPermalink





(2) MODEL LEGISLATION- States adopting model legislation as developed by the National Association of Insurance Commissioners shall be eligible to enter into an interstate compact as provided for in this section.CommentsClose CommentsPermalink





(3) MULTI-STATE POOLING ARRANGEMENTS- State Exchanges may implement a multi-state health care coverage pooling arrangement under this title.CommentsClose CommentsPermalink





(h) Eligible Individual- In this title, the term ‘eligible individual’ means an individual who is--CommentsClose CommentsPermalink





(1) a citizen or national of the United States or an alien lawfully admitted to the United States for permanent residence or otherwise residing in the United States under color of law;CommentsClose CommentsPermalink





(2) a resident of the State involved;CommentsClose CommentsPermalink





(3) not incarcerated; andCommentsClose CommentsPermalink





(4) not eligible for coverage under parts A and B (or C) of the Medicare program under title XVIII of the Social Security Act.CommentsClose CommentsPermalink

SEC. 203. STATE EXCHANGE INCENTIVES.

(a) Grants- The Secretary may award grants, pursuant to subsection (b), to States for the development, implementation, and evaluation of certified State Exchanges and to provide more options and choice for individuals purchasing health insurance coverage.CommentsClose CommentsPermalink





(b) One-Time Increase in Medicaid Payment- In the case of a State awarded a grant to carry out this section, the total amount of the Federal payment determined for the State under section 1913 of the Social Security Act (as amended by section 401) for fiscal year 2011 shall be increased by an amount equal to 1 percent of the total amount of payments made to the State for fiscal year 2010 under section 1903(a) of the Social Security Act (42 U.S.C. 1396b(a)) for purposes of carrying out a grant awarded under this section. Amounts paid to a State pursuant to this subsection shall remain available until expended.CommentsClose CommentsPermalink

TITLE III--FAIR TAX TREATMENT FOR ALL AMERICANS TO AFFORD HEALTH CARECommentsClose CommentsPermalink

SEC. 300. REFERENCE.

Except as otherwise expressly provided, whenever in this title an amendment or repeal is expressed in terms of an amendment to, or repeal of, a section or other provision, the reference shall be considered to be made to a section or other provision of the Internal Revenue Code of 1986.CommentsClose CommentsPermalink

Subtitle A--Refundable and Advanceable Credit for Certain Health Insurance CoverageCommentsClose CommentsPermalink

SEC. 301. REFUNDABLE AND ADVANCEABLE CREDIT FOR CERTAIN HEALTH INSURANCE COVERAGE.

(a) Advanceable Credit- Subpart A of part IV of subchapter A of chapter 1 (relating to nonrefundable personal credits) is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘SEC. 25E. QUALIFIED HEALTH INSURANCE CREDIT.

‘(a) Allowance of Credit- In the case of an individual, there shall be allowed as a credit against the tax imposed by this chapter for the taxable year the sum of the monthly limitations determined under subsection (b) for the taxpayer and the taxpayer’s spouse and dependents.CommentsClose CommentsPermalink





‘(b) Monthly Limitation-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The monthly limitation for each month during the taxable year for an eligible individual is 1/12 th of--CommentsClose CommentsPermalink





‘(A) the applicable adult amount, in the case that the eligible individual is the taxpayer or the taxpayer’s spouse,CommentsClose CommentsPermalink





‘(B) the applicable adult amount, in the case that the eligible individual is an adult dependent, andCommentsClose CommentsPermalink





‘(C) the applicable child amount, in the case that the eligible individual is a child dependent.CommentsClose CommentsPermalink





‘(2) LIMITATION ON AGGREGATE AMOUNT- Notwithstanding paragraph (1), the aggregate monthly limitations for the taxpayer and the taxpayer’s spouse and dependents for any month shall not exceed 1/12 th of the applicable aggregate amount.CommentsClose CommentsPermalink





‘(3) NO CREDIT FOR INELIGIBLE MONTHS- With respect to any individual, the monthly limitation shall be zero for any month for which such individual is not an eligible individual.CommentsClose CommentsPermalink





‘(4) APPLICABLE AMOUNT-CommentsClose CommentsPermalink





‘(A) IN GENERAL- For purposes of this section--CommentsClose CommentsPermalink





‘(i) APPLICABLE ADULT AMOUNT- The applicable adult amount is $2,290.CommentsClose CommentsPermalink





‘(ii) APPLICABLE CHILD AMOUNT- The applicable child amount is $1,710.CommentsClose CommentsPermalink





‘(iii) APPLICABLE AGGREGATE AMOUNT- The applicable aggregate amount is $5,710.CommentsClose CommentsPermalink





‘(B) COST-OF-LIVING ADJUSTMENTS-CommentsClose CommentsPermalink





‘(i) IN GENERAL- In the case of any taxable year beginning in a calendar year after 2011, each dollar amount contained in subparagraph (A) shall be increased by an amount equal to such dollar amount multiplied by the blended cost-of-living adjustment.CommentsClose CommentsPermalink





‘(ii) BLENDED COST-OF-LIVING ADJUSTMENT- For purposes of clause (i), the blended cost-of-living adjustment means one-half of the sum of--CommentsClose CommentsPermalink





‘(I) the cost-of-living adjustment determined under section 1(f)(3) for the calendar year in which the taxable year begins by substituting ‘calendar year 2010’ for ‘calendar year 1992’ in subparagraph (B) thereof, plusCommentsClose CommentsPermalink





‘(II) the cost-of-living adjustment determined under section 213(d)(10)(B)(ii) for the calendar year in which the taxable year begins by substituting ‘2010’ for ‘1996’ in subclause (II) thereof.CommentsClose CommentsPermalink





‘(iii) ROUNDING- Any increase determined under clause (i) shall be rounded to the nearest multiple of $10.CommentsClose CommentsPermalink





‘(C) REVENUE NEUTRALITY ADJUSTMENTS-CommentsClose CommentsPermalink





‘(i) IN GENERAL- In the case of any taxable year beginning in a calendar year after 2011, each dollar amount contained in subparagraph (A), as adjusted under subparagraph (B), shall be further adjusted (if necessary) such that the aggregate of such dollar amounts allowed as credits under this section for such taxable year equals but does not exceed the total increase in revenues in the Treasury resulting from the amendments made by sections 303 and 401 of the Patients’ Choice Act for such taxable year as estimated by the Secretary.CommentsClose CommentsPermalink





‘(ii) DATE OF ADJUSTMENT- The Secretary shall announce the adjustments for any taxable year under this subparagraph not later than the preceding October 1.CommentsClose CommentsPermalink





‘(c) Limitation Based on Amount of Tax- In the case of a taxable year to which section 26(a)(2) does not apply, the credit allowed under subsection (a) for the taxable year shall not exceed the excess of--CommentsClose CommentsPermalink





‘(1) the sum of the regular tax liability (as defined in section 26(b)) plus the tax imposed by section 55, overCommentsClose CommentsPermalink





‘(2) the sum of the credits allowable under this subpart (other than this section) and section 27 for the taxable year.CommentsClose CommentsPermalink





‘(d) Excess Credit Refundable to Certain Tax-Favored Accounts- If--CommentsClose CommentsPermalink





‘(1) the credit which would be allowable under subsection (a) if only qualified refund eligible health insurance were taken into account under this section, exceedsCommentsClose CommentsPermalink





‘(2) the limitation imposed by section 26 or subsection (c) for the taxable year,CommentsClose CommentsPermalink





such excess shall be paid by the Secretary into the designated account of the taxpayer.CommentsClose CommentsPermalink





‘(e) Eligible Individual- For purposes of this section--CommentsClose CommentsPermalink





‘(1) IN GENERAL- The term ‘eligible individual’ means, with respect to any month, an individual who--CommentsClose CommentsPermalink





‘(A) is the taxpayer, the taxpayer’s spouse, or the taxpayer’s dependent, andCommentsClose CommentsPermalink





‘(B) is covered under qualified health insurance as of the 1st day of such month.CommentsClose CommentsPermalink





‘(2) MEDICARE COVERAGE, MEDICAID DISABILITY COVERAGE, AND MILITARY COVERAGE- The term ‘eligible individual’ shall not include any individual who for any month is--CommentsClose CommentsPermalink





‘(A) entitled to benefits under part A of title XVIII of the Social Security Act or enrolled under part B of such title, and the individual is not a participant or beneficiary in a group health plan or large group health plan that is a primary plan (as defined in section 1862(b)(2)(A) of such Act),CommentsClose CommentsPermalink





‘(B) enrolled by reason of disability in the program under title XIX of such Act, orCommentsClose CommentsPermalink





‘(C) entitled to benefits under chapter 55 of title 10, United States Code, including under the TRICARE program (as defined in section 1072(7) of such title).CommentsClose CommentsPermalink





‘(3) IDENTIFICATION REQUIREMENTS- The term ‘eligible individual’ shall not include any individual for any month unless the policy number associated with the qualified health insurance and the TIN of each eligible individual covered under such health insurance for such month are included on the return of tax for the taxable year in which such month occurs.CommentsClose CommentsPermalink





‘(4) PRISONERS- The term ‘eligible individual’ shall not include any individual for a month if, as of the first day of such month, such individual is imprisoned under Federal, State, or local authority.CommentsClose CommentsPermalink





‘(5) ALIENS- The term ‘eligible individual’ shall not include any alien individual who is not a lawful permanent resident of the United States.CommentsClose CommentsPermalink





‘(f) Health Insurance- For purposes of this section--CommentsClose CommentsPermalink





‘(1) QUALIFIED HEALTH INSURANCE- The term ‘qualified health insurance’ means any insurance constituting medical care which (as determined under regulations prescribed by the Secretary)--CommentsClose CommentsPermalink





‘(A) has a reasonable annual and lifetime benefit maximum, andCommentsClose CommentsPermalink





‘(B) provides coverage for inpatient and outpatient care, emergency benefits, and physician care.CommentsClose CommentsPermalink





Such term does not include any insurance substantially all of the coverage of which is coverage described in section 223(c)(1)(B).CommentsClose CommentsPermalink





‘(2) QUALIFIED REFUND ELIGIBLE HEALTH INSURANCE- The term ‘qualified refund eligible health insurance’ means any qualified health insurance which is coverage under a group health plan (as defined in section 5000(b)(1)).CommentsClose CommentsPermalink





‘(g) Designated Accounts-CommentsClose CommentsPermalink





‘(1) DESIGNATED ACCOUNT- For purposes of this section, the term ‘designated account’ means any specified account established and maintained by the provider of the taxpayer’s qualified refund eligible health insurance--CommentsClose CommentsPermalink





‘(A) which is designated by the taxpayer (in such form and manner as the Secretary may provide) on the return of tax for the taxable year,CommentsClose CommentsPermalink





‘(B) which, under the terms of the account, accepts the payment described in subsection (d) on behalf of the taxpayer, andCommentsClose CommentsPermalink





‘(C) which, under such terms, provides for the payment of expenses by the taxpayer or on behalf of such taxpayer by the trustee or custodian of such account, including payment to such provider.CommentsClose CommentsPermalink





‘(2) SPECIFIED ACCOUNT- For purposes of this paragraph, the term ‘specified account’ means--CommentsClose CommentsPermalink





‘(A) any health savings account under section 223 or Archer MSA under section 220, orCommentsClose CommentsPermalink





‘(B) any health insurance reserve account.CommentsClose CommentsPermalink





‘(3) HEALTH INSURANCE RESERVE ACCOUNT- For purposes of this subsection, the term ‘health insurance reserve account’ means a trust created or organized in the United States as a health insurance reserve account exclusively for the purpose of paying the qualified medical expenses (within the meaning of section 223(d)(2)) of the account beneficiary (as defined in section 223(d)(3)), but only if the written governing instrument creating the trust meets the requirements described in subparagraphs (B), (C), (D), and (E) of section 223(d)(1). Rules similar to the rules under subsections (g) and (h) of section 408 shall apply for purposes of this subparagraph.CommentsClose CommentsPermalink





‘(4) TREATMENT OF PAYMENT- Any payment under subsection (d) to a designated account shall not be taken into account with respect to any dollar limitation which applies with respect to contributions to such account (or to tax benefits with respect to such contributions).CommentsClose CommentsPermalink





‘(h) Other Definitions- For purposes of this section--CommentsClose CommentsPermalink





‘(1) DEPENDENT- The term ‘dependent’ has the meaning given such term by section 152 (determined without regard to subsections (b)(1), (b)(2), and (d)(1)(B) thereof). An individual who is a child to whom section 152(e) applies shall be treated as a dependent of the custodial parent for a coverage month unless the custodial and noncustodial parent provide otherwise.CommentsClose CommentsPermalink





‘(2) ADULT- The term ‘adult’ means an individual who is not a child.CommentsClose CommentsPermalink





‘(3) CHILD- The term ‘child’ means a qualifying child (as defined in section 152(c)).CommentsClose CommentsPermalink





‘(i) Special Rules-CommentsClose CommentsPermalink





‘(1) COORDINATION WITH MEDICAL DEDUCTION- Any amount paid by a taxpayer for insurance which is taken into account for purposes of determining the credit allowable to the taxpayer under subsection (a) shall not be taken into account in computing the amount allowable to the taxpayer as a deduction under section 213(a) or 162(l).CommentsClose CommentsPermalink





‘(2) COORDINATION WITH HEALTH CARE TAX CREDIT- No credit shall be allowed under subsection (a) for any taxable year to any taxpayer and qualifying family members with respect to whom a credit under section 35 is allowed for such taxable year.CommentsClose CommentsPermalink





‘(3) DENIAL OF CREDIT TO DEPENDENTS- No credit shall be allowed under this section to any individual with respect to whom a deduction under section 151 is allowable to another taxpayer for a taxable year beginning in the calendar year in which such individual’s taxable year begins.CommentsClose CommentsPermalink





‘(4) MARRIED COUPLES MUST FILE JOINT RETURN-CommentsClose CommentsPermalink





‘(A) IN GENERAL- If the taxpayer is married at the close of the taxable year, the credit shall be allowed under subsection (a) only if the taxpayer and his spouse file a joint return for the taxable year.CommentsClose CommentsPermalink





‘(B) MARITAL STATUS; CERTAIN MARRIED INDIVIDUALS LIVING APART- Rules similar to the rules of paragraphs (3) and (4) of section 21(e) shall apply for purposes of this paragraph.CommentsClose CommentsPermalink





‘(5) VERIFICATION OF COVERAGE, ETC- No credit shall be allowed under this section with respect to any individual unless such individual’s coverage (and such related information as the Secretary may require) is verified in such manner as the Secretary may prescribe.CommentsClose CommentsPermalink





‘(6) INSURANCE WHICH COVERS OTHER INDIVIDUALS; TREATMENT OF PAYMENTS- Rules similar to the rules of paragraphs (7) and (8) of section 35(g) shall apply for purposes of this section.CommentsClose CommentsPermalink





‘(j) Coordination With Advance Payments-CommentsClose CommentsPermalink





‘(1) REDUCTION IN CREDIT FOR ADVANCE PAYMENTS- With respect to any taxable year, the amount which would (but for this subsection) be allowed as a credit to the taxpayer under subsection (a) shall be reduced (but not below zero) by the aggregate amount paid on behalf of such taxpayer under section 7527A for months beginning in such taxable year.CommentsClose CommentsPermalink





‘(2) RECAPTURE OF EXCESS ADVANCE PAYMENTS- If the aggregate amount paid on behalf of the taxpayer under section 7527A for months beginning in the taxable year exceeds the sum of the monthly limitations determined under subsection (b) for the taxpayer and the taxpayer’s spouse and dependents for such months, then the tax imposed by this chapter for such taxable year shall be increased by the sum of--CommentsClose CommentsPermalink





‘(A) such excess, plusCommentsClose CommentsPermalink





‘(B) interest on such excess determined at the underpayment rate established under section 6621 for the period from the date of the payment under section 7527A to the date such excess is paid.CommentsClose CommentsPermalink





For purposes of subparagraph (B), an equal part of the aggregate amount of the excess shall be deemed to be attributable to payments made under section 7527A on the first day of each month beginning in such taxable year, unless the taxpayer establishes the date on which each such payment giving rise to such excess occurred, in which case subparagraph (B) shall be applied with respect to each date so established. The Secretary may rescind or waive all or any portion of any amount imposed by reason of subparagraph (B) if such excess was not the result of the actions of the taxpayer.’.CommentsClose CommentsPermalink





(b) Advance Payment of Credit- Chapter 77 (relating to miscellaneous provisions) is amended by inserting after section 7527 the following new section:CommentsClose CommentsPermalink

‘SEC. 7527A. ADVANCE PAYMENT OF CREDIT FOR QUALIFIED REFUND ELIGIBLE HEALTH INSURANCE.

‘(a) In General- The Secretary shall establish a program for making payments on behalf of individuals to providers of qualified refund eligible health insurance (as defined in section 25E(f)(2)) for such individuals.CommentsClose CommentsPermalink





‘(b) Limitation- The Secretary may make payments under subsection (a) only to the extent that the Secretary determines that the amount of such payments made on behalf of any taxpayer for any month does not exceed the sum of the monthly limitations determined under section 25E(b) for the taxpayer and taxpayer’s spouse and dependents for such month.’.CommentsClose CommentsPermalink





(c) Information Reporting-CommentsClose CommentsPermalink





(1) IN GENERAL- Subpart B of part III of subchapter A of chapter 61 (relating to information concerning transactions with other persons) is amended by inserting after section 6050W the following new section:CommentsClose CommentsPermalink

‘SEC. 6050X. RETURNS RELATING TO CREDIT FOR QUALIFIED REFUND ELIGIBLE HEALTH INSURANCE.

‘(a) Requirement of Reporting- Every person who is entitled to receive payments for any month of any calendar year under section 7527A (relating to advance payment of credit for qualified refund eligible health insurance) with respect to any individual shall, at such time as the Secretary may prescribe, make the return described in subsection (b) with respect to each such individual.CommentsClose CommentsPermalink





‘(b) Form and Manner of Returns- A return is described in this subsection if such return--CommentsClose CommentsPermalink





‘(1) is in such form as the Secretary may prescribe, andCommentsClose CommentsPermalink





‘(2) contains, with respect to each individual referred to in subsection (a)--CommentsClose CommentsPermalink





‘(A) the name, address, and TIN of each such individual,CommentsClose CommentsPermalink





‘(B) the months for which amounts payments under section 7527A were received,CommentsClose CommentsPermalink





‘(C) the amount of each such payment,CommentsClose CommentsPermalink





‘(D) the type of insurance coverage provided by such person with respect to such individual and the policy number associated with such coverage,CommentsClose CommentsPermalink





‘(E) the name, address, and TIN of the spouse and each dependent covered under such coverage, andCommentsClose CommentsPermalink





‘(F) such other information as the Secretary may prescribe.CommentsClose CommentsPermalink





‘(c) Statements To Be Furnished to Individuals With Respect to Whom Information Is Required- Every person required to make a return under subsection (a) shall furnish to each individual whose name is required to be set forth in such return a written statement showing--CommentsClose CommentsPermalink





‘(1) the contact information of the person required to make such return, andCommentsClose CommentsPermalink





‘(2) the information required to be shown on the return with respect to such individual.CommentsClose CommentsPermalink





The written statement required under the preceding sentence shall be furnished on or before January 31 of the year following the calendar year for which the return under subsection (a) is required to be made.CommentsClose CommentsPermalink





‘(d) Returns Which Would Be Required To Be Made by 2 or More Persons- Except to the extent provided in regulations prescribed by the Secretary, in the case of any amount received by any person on behalf of another person, only the person first receiving such amount shall be required to make the return under subsection (a).’.CommentsClose CommentsPermalink





(2) ASSESSABLE PENALTIES-CommentsClose CommentsPermalink





(A) Subparagraph (B) of section 6724(d)(1) (relating to definitions) is amended by striking ‘or’ at the end of clause (xxii), by striking ‘and’ at the end of clause (xxiii) and inserting ‘or’, and by inserting after clause (xxiii) the following new clause:CommentsClose CommentsPermalink





‘(xxiv) section 6050X (relating to returns relating to credit for qualified refund eligible health insurance), and’.CommentsClose CommentsPermalink





(B) Paragraph (2) of section 6724(d) is amended by striking ‘or’ at the end of subparagraph (EE), by striking the period at the end of subparagraph (FF) and inserting ‘, or’ and by inserting after subparagraph (FF) the following new subparagraph:CommentsClose CommentsPermalink





‘(GG) section 6050X (relating to returns relating to credit for qualified refund eligible health insurance).’.CommentsClose CommentsPermalink





(d) Conforming Amendments-CommentsClose CommentsPermalink





(1) Paragraph (2) of section 1324(b) of title 31, United States Code, is amended by inserting ‘25E,’ before ‘35,’.CommentsClose CommentsPermalink





(2)(A) Section 24(b)(3)(B) is amended by inserting ‘, 25E,’ after ‘25D’.CommentsClose CommentsPermalink





(B) Section 25(e)(1)(C)(ii) is amended by inserting ‘25E,’ after ‘25D,’.CommentsClose CommentsPermalink





(C) Section 25B(g)(2) is amended by inserting ‘25E,’ after ‘25D,’.CommentsClose CommentsPermalink





(D) Section 26(a)(1) is amended by inserting ‘25E,’ after ‘25D,’.CommentsClose CommentsPermalink





(E) Section 30(c)(2)(B)(ii) is amended by inserting ‘25E,’ after ‘25D,’.CommentsClose CommentsPermalink





(F) Section 30D(c)(2)(B)(ii) is amended by striking ‘and 25D’ and inserting ‘, 25D, and 25E’.CommentsClose CommentsPermalink





(G) Section 904(i) is amended by inserting ‘25E,’ after ‘25B,’.CommentsClose CommentsPermalink





(H) Section 1400C(d)(2) is amended by inserting ‘25E,’ after ‘25D,’.CommentsClose CommentsPermalink





(3) The table of sections for subpart A of part IV of subchapter A of chapter 1 is amended by inserting after the item relating to section 25D the following new item:CommentsClose CommentsPermalink





‘Sec. 25E. Qualified health insurance credit.’.CommentsClose CommentsPermalink





(4) The table of sections for chapter 77 is amended by inserting after the item relating to section 7527 the following new item:CommentsClose CommentsPermalink





‘Sec. 7527A. Advance payment of credit for qualified refund eligible health insurance.’.CommentsClose CommentsPermalink





(5) The table of sections for subpart B of part III of subchapter A of chapter 61 is amended by adding at the end the following new item:CommentsClose CommentsPermalink





‘Sec. 6050X. Returns relating to credit for qualified refund eligible health insurance.’.CommentsClose CommentsPermalink





(e) Effective Date- The amendments made by this section shall apply to taxable years beginning after December 31, 2010.CommentsClose CommentsPermalink

SEC. 302. REQUIRING EMPLOYER TRANSPARENCY ABOUT EMPLOYEE BENEFITS.

(a) In General- Section 6051(a) (relating to W-2 requirement) is amended by striking ‘and’ at the end of paragraph (12), by striking the period at the end of paragraph (13) and inserting ‘, and’ and by inserting after paragraph (13) the following new paragraph:CommentsClose CommentsPermalink





‘(14) the aggregate cost (within the meaning of section 4980B(f)(4)) for coverage of the employee under an accident or health plan which is excludable from the gross income of the employee under section 106(a) (other than coverage under a health flexible spending arrangement).’.CommentsClose CommentsPermalink





(b) Effective Date- The amendments made by this section shall apply to statements for calendar years beginning after 2009.CommentsClose CommentsPermalink

SEC. 303. CHANGES TO EXISTING TAX PREFERENCES FOR MEDICAL COVERAGE, ETC., FOR INDIVIDUALS ELIGIBLE FOR QUALIFIED HEALTH INSURANCE CREDIT.

(a) Exclusion for Contributions by Employer to Accident and Health Plans-CommentsClose CommentsPermalink





(1) IN GENERAL- Section 106 (relating to contributions by employer to accident and health plans) is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(f) No Exclusion for Individuals Eligible for Qualified Health Insurance Credit- Subsection (a) shall not apply with respect to any employer-provided coverage under an accident or health plan for any individual for any month unless such individual is described in paragraph (2) or (5) of section 25E(e) for such month. The amount includible in gross income by reason of this subsection shall be determined under rules similar to the rules of section 4980B(f)(4).’.CommentsClose CommentsPermalink





(2) CONFORMING AMENDMENTS-CommentsClose CommentsPermalink





(A) Section 106(b)(1) is amended--CommentsClose CommentsPermalink





(i) by inserting ‘gross income does not include’ before ‘amounts contributed’, andCommentsClose CommentsPermalink





(ii) by striking ‘shall be treated as employer-provided coverage for medical expenses under an accident or health plan’.CommentsClose CommentsPermalink





(B) Section 106(d)(1) is amended--CommentsClose CommentsPermalink





(i) by inserting ‘gross income does not include’ before ‘amounts contributed’, andCommentsClose CommentsPermalink





(ii) by striking ‘shall be treated as employer-provided coverage for medical expenses under an accident or health plan’.CommentsClose CommentsPermalink





(b) Amounts Received Under Accident and Health Plans- Section 105 (relating to amounts received under accident and health plans) is amended by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(f) No Exclusion for Individuals Eligible for Qualified Health Insurance Credit- Subsection (b) shall not apply with respect to any employer-provided coverage under an accident or health plan for any individual for any month unless such individual is described in paragraph (2) or (5) of section 25E(e) for such month.’.CommentsClose CommentsPermalink





(c) Special Rules for Health Insurance Costs of Self-Employed Individuals- Subsection (l) of section 162 (relating to special rules for health insurance costs of self-employed individuals) is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink





‘(6) NO DEDUCTION TO INDIVIDUALS ELIGIBLE FOR QUALIFIED HEALTH INSURANCE- Paragraph (1) shall not apply for any individual for any month unless such individual is described in paragraph (2) or (5) of section 25E(e) for such month.’.CommentsClose CommentsPermalink





(d) Earned Income Credit Unaffected by Repealed Exclusions- Subparagraph (B) of section 32(c)(2) is amended by redesignating clauses (v) and (vi) as clauses (vi) and (vii), respectively, and by inserting after clause (iv) the following new clause:CommentsClose CommentsPermalink





‘(v) the earned income of an individual shall be computed without regard to sections 105(f) and 106(f),’.CommentsClose CommentsPermalink





(e) Modification of Deduction for Medical Expenses- Subsection (d) of section 213 is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink





‘(12) PREMIUMS FOR QUALIFIED HEALTH INSURANCE- The term ‘medical care’ does not include any amount paid as a premium for coverage of an eligible individual (as defined in section 25E(e)) under qualified health insurance (as defined in section 25E(f)) for any month.’.CommentsClose CommentsPermalink





(f) Reporting Requirement- Subsection (a) of section 6051 is amended by striking ‘and’ at the end of paragraph (12), by striking the period at the end of paragraph (13) and inserting ‘and’, and by inserting after paragraph (13) the following new paragraph:CommentsClose CommentsPermalink





‘(14) the total amount of employer-provided coverage under an accident or health plan which is includible in gross income by reason of sections 105(f) and 106(f).’.CommentsClose CommentsPermalink





(g) Retired Public Safety Officers- Section 402(l)(4)(D) is amended by adding at the end the following: ‘Such term shall not include any premium for coverage by an accident or health insurance plan for any month unless such individual is described in paragraph (2) or (5) of section 25E(e) for such month.’.CommentsClose CommentsPermalink





(h) Effective Date- The amendments made by this section shall apply to taxable years beginning after December 31, 2010.CommentsClose CommentsPermalink





(i) No Intent To Encourage State Taxation of Health Benefits- No intent to encourage any State to treat health benefits as taxable income for the purpose of increasing State income taxes may be inferred from the provisions of, and amendments made by, this section.CommentsClose CommentsPermalink

Subtitle B--Health Savings AccountsCommentsClose CommentsPermalink

SEC. 311. IMPROVEMENTS TO HEALTH SAVINGS ACCOUNTS.

(a) Increase in Monthly Contribution Limit-CommentsClose CommentsPermalink





(1) IN GENERAL- Paragraph (2) of section 223(b) (relating to limitations) is amended to read as follows:CommentsClose CommentsPermalink





‘(2) MONTHLY LIMITATION-CommentsClose CommentsPermalink





‘(A) IN GENERAL- In the case of an eligible individual who has coverage under a high deductible health plan, the monthly limitation for any month of such coverage is 1/12 of the sum of--CommentsClose CommentsPermalink





‘(i) the greater of--CommentsClose CommentsPermalink





‘(I) the sum of the annual deductible and the other annual out-of-pocket expenses (other than for premiums) required to be paid under the plan by the eligible individual for covered benefits, orCommentsClose CommentsPermalink





‘(II) in the case of an eligible individual who has--CommentsClose CommentsPermalink

‘(aa) self-only coverage under a high deductible health plan as of the first day of such month, $3,000, orCommentsClose CommentsPermalink

‘(bb) family coverage under a high deductible health plan as of the first day of such month, $5,950, andCommentsClose CommentsPermalink

‘(ii) in the case of an eligible individual who has coverage under a qualified long-term care insurance contract (as defined in section 7702B(b)), the lesser of--CommentsClose CommentsPermalink





‘(I) the annual premium for such coverage, orCommentsClose CommentsPermalink





‘(II) $1,000.CommentsClose CommentsPermalink





‘(B) SPECIAL RULES RELATING TO OUT-OF-POCKET EXPENSES-CommentsClose CommentsPermalink





‘(i) REDUCTION FOR SEPARATE PLAN- The annual out-of-pocket expenses taken into account under subparagraph (A)(i)(I) with respect to any eligible individual shall be reduced by any out-of-pocket expense payable under a separate plan covering the individual.CommentsClose CommentsPermalink





‘(ii) SECRETARIAL AUTHORITY- The Secretary may by regulations provide that annual out-of-pocket expenses will not be taken into account under subparagraph (A)(i)(I) to the extent that there is only a remote likelihood that such amounts will be required to be paid.’.CommentsClose CommentsPermalink





(2) APPLICATION OF SPECIAL RULES FOR MARRIED INDIVIDUALS- Paragraph (5) of section 223(b) (relating to limitations) is amended to read as follows:CommentsClose CommentsPermalink





‘(5) SPECIAL RULES FOR MARRIED INDIVIDUALS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- In the case of individuals who are married to each other and who are both eligible individuals, the limitation under paragraph (1) for each spouse shall be equal to the spouse’s applicable share of the combined marital limit.CommentsClose CommentsPermalink





‘(B) COMBINED MARITAL LIMIT- For purposes of subparagraph (A), the combined marital limit is the excess (if any) of--CommentsClose CommentsPermalink





‘(i) the lesser of--CommentsClose CommentsPermalink





‘(I) subject to subparagraph (C), the sum of the limitations computed separately under paragraph (1) for each spouse (including any additional contribution amount under paragraph (3)), orCommentsClose CommentsPermalink





‘(II) the dollar amount in effect under subsection (c)(2)(A)(ii)(II), overCommentsClose CommentsPermalink





‘(ii) the aggregate amount paid to Archer MSAs of such spouses for the taxable year.CommentsClose CommentsPermalink





‘(C) SPECIAL RULE WHERE BOTH SPOUSES HAVE FAMILY COVERAGE- For purposes of subparagraph (B)(i)(I), if either spouse has family coverage which covers both spouses, both spouses shall be treated as having only such coverage (and if both spouses each have such coverage under different plans, shall be treated as having only family coverage with the plan with respect to which the lowest amount is determined under paragraph (2)(A)(i)(I)).CommentsClose CommentsPermalink





‘(D) APPLICABLE SHARE- For purposes of subparagraph (A), a spouse’s applicable share is 1/2 of the combined marital limit unless both spouses agree on a different division.CommentsClose CommentsPermalink





‘(E) COUPLES NOT MARRIED ENTIRE YEAR- The Secretary shall prescribe rules for the application of this paragraph in the case of any taxable year for which the individuals were not married to each other during all months included in the taxable year, including rules which allow individuals in appropriate cases to take into account coverage prior to marriage in computing the combined marital limit for purposes of this paragraph.’.CommentsClose CommentsPermalink





(3) SELF-ONLY COVERAGE- Paragraph (4) of section 223(c) (relating to definitions and special rules) is amended to read as follows:CommentsClose CommentsPermalink





‘(4) COVERAGE-CommentsClose CommentsPermalink





‘(A) FAMILY COVERAGE- The term ‘family coverage’ means any coverage other than self-only coverage.CommentsClose CommentsPermalink





‘(B) SELF-ONLY COVERAGE- If more than 1 individual is covered by a high deductible health plan but only 1 of the individuals is an eligible individual, the coverage shall be treated as self-only coverage.’.CommentsClose CommentsPermalink





(4) CONFORMING AMENDMENTS-CommentsClose CommentsPermalink





(A) Section 223(b)(3)(A) is amended by striking ‘subparagraphs (A) and (B) of’.CommentsClose CommentsPermalink





(B) Section 223(c)(2)(A) is amended--CommentsClose CommentsPermalink





(i) by striking ‘$1,000’ in clause (i)(I) and inserting ‘$1,150’, andCommentsClose CommentsPermalink





(ii) by striking ‘$5,000’ in clause (ii)(I) and inserting ‘$5,800’.CommentsClose CommentsPermalink





(C) Section 223(d)(1)(A)(ii)(I) is amended by striking ‘subsection (b)(2)(B)(ii)’ and inserting ‘subsection (c)(2)(A)(ii)(II)’.CommentsClose CommentsPermalink





(D) Clause (ii) of section 223(c)(2)(D) is amended to read as follows:CommentsClose CommentsPermalink





‘(ii) CERTAIN ITEMS DISREGARDED IN COMPUTING MONTHLY LIMITATION- Such plan’s annual deductible, and such plan’s annual out-of-pocket limitation, for services provided outside of such network shall not be taken into account for purposes of subsection (b)(2).’CommentsClose CommentsPermalink





(E) Subsection (g) of section 223 is amended to read as follows:CommentsClose CommentsPermalink





‘(g) Cost-of-Living Adjustments-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In the case of any taxable year beginning in a calendar year after 2009, each dollar amount contained in subsections (b)(2)(A) and (c)(2)(A) shall be increased by an amount equal to such dollar amount multiplied by the blended cost-of-living adjustment.CommentsClose CommentsPermalink





‘(2) BLENDED COST-OF-LIVING ADJUSTMENT- For purposes of paragraph (1), the blended cost-of-living adjustment means one-half of the sum of--CommentsClose CommentsPermalink





‘(A) the cost-of-living adjustment determined under section 1(f)(3) for the calendar year in which the taxable year begins by substituting ‘calendar year 2008’ for ‘calendar year 1992’ in subparagraph (B) thereof, plusCommentsClose CommentsPermalink





‘(B) the cost-of-living adjustment determined under section 213(d)(10)(B)(ii) for the calendar year in which the taxable year begins by substituting ‘2008’ for ‘1996’ in subclause (II) thereof.CommentsClose CommentsPermalink





‘(3) ROUNDING- Any increase determined under paragraph (2) shall be rounded to the nearest multiple of $50.’.CommentsClose CommentsPermalink





(b) Use of Account for Individual High Deductible Health Plan Premiums- Section 223(d)(2)(C) (relating to exceptions) is amended by striking ‘or’ at the end of clause (iii), by striking the period at the end of clause (iv) and inserting ‘, or’, and by adding at the end the following new clause:CommentsClose CommentsPermalink





‘(v) a high deductible health plan, but only if--CommentsClose CommentsPermalink





‘(I) the plan is not a group health plan (as defined in section 5000(b)(1) without regard to section 5000(d)), andCommentsClose CommentsPermalink





‘(II) the expenses are for coverage for a month with respect to which the account beneficiary is an eligible individual by reason of the coverage under the plan.CommentsClose CommentsPermalink





For purposes of clause (v), an arrangement which constitutes individual health insurance shall not be treated as a group health plan, notwithstanding that an employer or employee organization negotiates the cost of benefits of such arrangement.’.CommentsClose CommentsPermalink





(c) Safe Harbor for Absence of Maintenance of Chronic Disease- Section 223(c)(2)(C) (safe harbor for absence of preventive care deductible) is amended--CommentsClose CommentsPermalink





(1) by inserting ‘or maintenance of chronic disease, or both’ after ‘the Secretary)’, andCommentsClose CommentsPermalink





(2) by inserting ‘OR MAINTENANCE OF CHRONIC DISEASE’ in the heading after ‘PREVENTIVE CARE’.CommentsClose CommentsPermalink





(d) Clarification of Treatment of Capitated Primary Care Payments as Amounts Paid for Medical Care- Section 213(d) (relating to definitions) is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink





‘(12) TREATMENT OF CAPITATED PRIMARY CARE PAYMENTS- Capitated primary care payments shall be treated as amounts paid for medical care.’.CommentsClose CommentsPermalink





(e) Special Rule for Individuals Eligible for Veterans or Indian Health Benefits- Section 223(c)(1) (defining eligible individual) is amended by adding at the end the following new subparagraph:CommentsClose CommentsPermalink





‘(C) SPECIAL RULE FOR INDIVIDUALS ELIGIBLE FOR VETERANS OR INDIAN HEALTH BENEFITS- For purposes of subparagraph (A)(ii), an individual shall not be treated as covered under a health plan described in such subparagraph merely because the individual receives periodic hospital care or medical services under any law administered by the Secretary of Veterans Affairs or the Bureau of Indian Affairs.’.CommentsClose CommentsPermalink





(f) Certain Physician Fees To Be Treated as Medical Care-CommentsClose CommentsPermalink





(1) IN GENERAL- Section 213(d), is amended by adding at the end the following new paragraph:CommentsClose CommentsPermalink





‘(12) PRE-PAID PHYSICIAN FEES- The term ‘medical care’ shall include amounts paid by patients to their primary physician in advance for the right to receive medical services on an as-needed basis.’.CommentsClose CommentsPermalink





(2) EFFECTIVE DATE- The amendment made by this section shall apply to taxable years beginning after the date of the enactment of this Act.CommentsClose CommentsPermalink





(g) Effective Dates-CommentsClose CommentsPermalink





(1) IN GENERAL- Except as provided in paragraph (2), the amendments made by this section shall apply to taxable years beginning after December 31, 2009.CommentsClose CommentsPermalink





(2) CAPITATED PRIMARY CARE PAYMENTS- The amendment made by subsection (d) shall apply to amounts paid before, on, or after the date of the enactment of this Act.CommentsClose CommentsPermalink

SEC. 312. EXCEPTION TO REQUIREMENT FOR EMPLOYERS TO MAKE COMPARABLE HEALTH SAVINGS ACCOUNT CONTRIBUTIONS.

(a) Greater Employer-Provided Contributions to HSAs for Chronically Ill Employees Treated as Meeting Comparability Requirements- Subsection (b) of section 4980G (relating to failure of employer to make comparable health savings account contributions) is amended to read as follows:CommentsClose CommentsPermalink





‘(b) Rules and Requirements-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Except as provided in paragraph (2), rules and requirements similar to the rules and requirements of section 4980E shall apply for purposes of this section.CommentsClose CommentsPermalink





‘(2) TREATMENT OF EMPLOYER-PROVIDED CONTRIBUTIONS TO HSAS FOR CHRONICALLY ILL EMPLOYEES- For purposes of this section--CommentsClose CommentsPermalink





‘(A) IN GENERAL- Any contribution by an employer to a health savings account of an employee who is (or the spouse or any dependent of the employee who is) a chronically ill individual in an amount which is greater than a contribution to a health savings account of a comparable participating employee who is not a chronically ill individual shall not fail to be considered a comparable contribution.CommentsClose CommentsPermalink





‘(B) NONDISCRIMINATION REQUIREMENT- Subparagraph (A) shall not apply unless the excess employer contributions described in subparagraph (A) are the same for all chronically ill individuals who are similarly situated.CommentsClose CommentsPermalink





‘(C) CHRONICALLY ILL INDIVIDUAL- For purposes of this paragraph, the term ‘chronically ill individual’ means any individual whose qualified medical expenses for any taxable year are more than 50 percent greater than the average qualified medical expenses of all employees of the employer for such year.’.CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by this section shall apply to taxable years beginning after December 31, 2009.CommentsClose CommentsPermalink

TITLE IV--FAIRNESS FOR EVERY AMERICAN PATIENTCommentsClose CommentsPermalink

Subtitle A--Medicaid ModernizationCommentsClose CommentsPermalink

SEC. 401. MEDICAID MODERNIZATION.

(a) In General- Effective January 1, 2011, title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is amended to read as follows:CommentsClose CommentsPermalink

‘TITLE XIX--GRANTS TO STATES FOR MEDICAL ASSISTANCE PROGRAMSCommentsClose CommentsPermalink

‘TABLE OF CONTENTS OF TITLE

‘Sec. 1900. References to pre-modernized Medicaid provisions; continuity for commonwealths and territories.CommentsClose CommentsPermalink

‘Part A--Grants to States for Acute Care for Individuals With Disabilities and Certain Low-Income Individuals

‘Sec. 1901. Purpose; Appropriation.CommentsClose CommentsPermalink





‘Sec. 1902. Payments to States for acute care medical assistance.CommentsClose CommentsPermalink





‘Sec. 1903. Definitions of eligible individuals and acute care medical assistance.CommentsClose CommentsPermalink





‘Sec. 1904. State plan requirements for acute care medical assistance.CommentsClose CommentsPermalink





‘Sec. 1905. Definitions.CommentsClose CommentsPermalink





‘Sec. 1906. Enrollment of individuals under group health plans and other arrangements.CommentsClose CommentsPermalink





‘Sec. 1907. Drug rebates.CommentsClose CommentsPermalink





‘Sec. 1908. Managed care.CommentsClose CommentsPermalink





‘Sec. 1909. Annual reports.CommentsClose CommentsPermalink

‘Part B--Grants to States for Long-Term Care Services and Supports

‘Sec. 1911. Purpose.CommentsClose CommentsPermalink





‘Sec. 1912. State plan.CommentsClose CommentsPermalink





‘Sec. 1913. State allotments.CommentsClose CommentsPermalink





‘Sec. 1914. Use of grants.CommentsClose CommentsPermalink





‘Sec. 1915. Administrative provisions.CommentsClose CommentsPermalink





‘Sec. 1916. Definition of long-term care services and supports.CommentsClose CommentsPermalink





‘Sec. 1917. Provision requirements for long-term care services and supports, including option for self-directed services and supports.CommentsClose CommentsPermalink





‘Sec. 1918. Treatment of income and resources for certain institutionalized spouses.CommentsClose CommentsPermalink





‘Sec. 1919. Annual reports.CommentsClose CommentsPermalink

‘Part C--Grants to States for Survey and Certification of Medical Facilities and Other Requirements

‘Sec. 1931. Authorization of appropriations.CommentsClose CommentsPermalink





‘Sec. 1932. Application of certain requirements under pre-modernized Medicaid.CommentsClose CommentsPermalink

‘Part D--Grants to States for Program Integrity

‘Sec. 1941. Authorization of appropriations.CommentsClose CommentsPermalink





‘Sec. 1942. Application of certain requirements under pre-modernized Medicaid.CommentsClose CommentsPermalink

‘Part E--Grants to States for Administration

‘Sec. 1951. Authorization of appropriations; payments to states.CommentsClose CommentsPermalink





‘Sec. 1952. Cost-sharing protections.CommentsClose CommentsPermalink





‘Sec. 1953. Application of certain requirements under pre-modernized Medicaid.CommentsClose CommentsPermalink

‘Part F--Other Provisions

‘Sec. 1961. Application of certain requirements under pre-modernized Medicaid.CommentsClose CommentsPermalink

‘SEC. 1900. REFERENCES TO PRE-MODERNIZED MEDICAID PROVISIONS; CONTINUITY FOR COMMONWEALTHS AND TERRITORIES.

‘(a) In General- In this title, if a reference to this title or to a provision of this title is prefaced by the term ‘old’, such reference is to this title or a provision of this title as in effect on December 31, 2010.CommentsClose CommentsPermalink





‘(b) Regulations- The Secretary shall promulgate regulations to bring requirements imposed under an old provision of this title that applies under this title after December 31, 2010, into conformity with the policies embodied in this title as in effect on and after January 1, 2011.CommentsClose CommentsPermalink





‘(c) Continuity for Commonwealths and Territories- In the case of Puerto Rico, the United States Virgin Islands, Guam, the Northen Mariana Islands, and American Samoa, this title as in effect on and after January 1, 2011, shall not apply to such commonwealths and territories, and old title XIX shall apply to a Medicaid program operated by such commonwealths or territories on and after that date.CommentsClose CommentsPermalink

‘PART A--GRANTS TO STATES FOR ACUTE CARE FOR INDIVIDUALS WITH DISABILITIES AND CERTAIN LOW-INCOME INDIVIDUALS

‘SEC. 1901. PURPOSE; APPROPRIATION.

‘(a) Purpose- It is the purpose of this part to enable each State, as far as practicable under the conditions in the State, to provide acute care medical assistance to eligible individuals described in section 1903 whose income and resources are insufficient to meet the costs of necessary medical services, and (2) rehabilitation and other services to help such individuals attain or retain capability for independence or self-care.CommentsClose CommentsPermalink





‘(b) Appropriation- For the purpose of making payments to States under this part, there is appropriated out of any money in the Treasury not otherwise appropriated, such sums as are necessary for fiscal year 2011 and each fiscal year thereafter.CommentsClose CommentsPermalink

‘SEC. 1902. PAYMENTS TO STATES FOR ACUTE CARE MEDICAL ASSISTANCE.

‘(a) In General- From the amounts appropriated under section 1901 for a fiscal year, the Secretary shall pay to each State which has a plan approved under this part, for each quarter, beginning with the quarter commencing January 1, 2011, an amount equal to the Federal medical assistance percentage (as defined in section 1905(b)) of the total amount expended during such quarter as acute care medical assistance under the State plan under this part.CommentsClose CommentsPermalink





‘(b) Administrative Expenses- Each State with a plan approved under this part shall receive a payment determined in accordance with part E for administrative expenses incurred in carrying out the plan under this part and part B (if the State has a plan approved under that part).CommentsClose CommentsPermalink

‘SEC. 1903. DEFINITIONS OF ELIGIBLE INDIVIDUALS AND ACUTE CARE MEDICAL ASSISTANCE.

‘(a) Eligible Individuals-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In this part, the term ‘eligible individual’ means an individual--CommentsClose CommentsPermalink





‘(A) who is--CommentsClose CommentsPermalink





‘(i) a blind or disabled individual; orCommentsClose CommentsPermalink





‘(ii) an individual described in paragraph (2); andCommentsClose CommentsPermalink





‘(B) who the State determines satisfies--CommentsClose CommentsPermalink





‘(i) the income and resources eligibility requirements established by the State under the State plan under this part; andCommentsClose CommentsPermalink





‘(ii) such other requirements for assistance as are imposed under this title, including documentation of citizenship or status as a qualified alien under title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996.CommentsClose CommentsPermalink





‘(2) INDIVIDUALS DESCRIBED- For purposes of paragraph (1)(A)(ii), the following individuals are described in this paragraph:CommentsClose CommentsPermalink





‘(A) A child in foster care under the responsibility of the State.CommentsClose CommentsPermalink





‘(B) A low-income woman with breast or cervical cancer described in old section 1902(aa).CommentsClose CommentsPermalink





‘(C) Certain TB-infected individuals described in old section 1902(z)(1).CommentsClose CommentsPermalink





‘(3) GRANDFATHERED INDIVIDUALS- An individual shall be an eligible individual under the State plan under this part if--CommentsClose CommentsPermalink





‘(A) the individual is described in paragraph (1)(A);CommentsClose CommentsPermalink





‘(B) the individual satisfies the documentation requirements referred to in paragraph (1)(B)(ii); andCommentsClose CommentsPermalink





‘(C) the State would have provided medical assistance under the State plan under old title XIX to the individual, but only so long as the individual continues to satisfy such old eligibility requirements.CommentsClose CommentsPermalink





‘(4) CONCURRENT ELIGIBILITY FOR PART B- An eligible individual under this part may be eligible under part B, but only if the individual satisfies the eligibility requirements of part B in addition to satisfying the requirements for eligibility under this part.CommentsClose CommentsPermalink





‘(5) PRESUMPTIVE ELIGIBILITY FOR CERTAIN BREAST OR CERVICAL CANCER PATIENTS- Old section 1920B (relating to presumptive eligibility for certain breast or cervical cancer patients) shall apply under this part.CommentsClose CommentsPermalink





‘(b) Benefits- Subject to paragraph (3), in this part, the term ‘acute care medical assistance’ means the following:CommentsClose CommentsPermalink





‘(1) MANDATORY BENEFITS- The care and services listed in paragraphs (1) through (5), (17), and (21) of old section 1905(a) (but, in the case of paragraph (4)(A) of such section, without regard to any limitation based on age or services in an institution for mental diseases).CommentsClose CommentsPermalink





‘(2) OPTIONAL BENEFITS- Any care or services listed in a paragraph of old section 1905(a) (other than paragraph (16)).CommentsClose CommentsPermalink





‘(3) EXCEPTIONS-CommentsClose CommentsPermalink





‘(A) CERTAIN SERVICES LIMITED TO PART B- Services described in paragraphs (15), (22), (23), (24), and (26) of old section 1905(a) shall only be provided under the State plan under part B.CommentsClose CommentsPermalink





‘(B) LIMIT ON PROVISION OF LONG-TERM CARE SERVICES AND SUPPORTS- A care or service that the Secretary determines is a long-term care service and support (including nursing facility services described in old section 1905(a)(4)(A)) shall not be provided to an individual under the State plan under this part for more than 30 days within any 12-month period.CommentsClose CommentsPermalink





‘(C) EXCLUSIONS- Such term shall not include any payments with respect to care or services for any individual who is an inmate of a public institution or a patient in an institution for mental diseases (regardless of age).CommentsClose CommentsPermalink

‘SEC. 1904. STATE PLAN REQUIREMENTS FOR ACUTE CARE MEDICAL ASSISTANCE.

‘(a) In General- In order to receive payments under this part, a State shall have an approved State plan for acute care medical assistance. For purposes of this part, such assistance includes payments for preventive care, primary care, diagnosis and treatment of acute and chronic health conditions, emergency care, diagnosis and treatment of mental illnesses and related conditions, and rehabilitation and other services to help eligible individuals attain or retain capability for independence or self-care. A State medical assistance plan shall include a description, consistent with the requirements of this part of--CommentsClose CommentsPermalink





‘(1) eligibility standards, including income and asset standards;CommentsClose CommentsPermalink





‘(2) benefits, including the amount, duration, and scope of covered items and services;CommentsClose CommentsPermalink





‘(3) strategies for improving access and quality of care; andCommentsClose CommentsPermalink





‘(4) methods of service delivery.CommentsClose CommentsPermalink





‘(b) Public Availability of State Plan- The State shall make available to the public the State plan under this part and any amendments submitted by the State to the plan.CommentsClose CommentsPermalink





‘(c) Amount, Duration, and Scope- The State plan shall provide that the acute care medical assistance made available to any eligible individual shall not be less in amount, duration, or scope than the acute care medical assistance made available to any other eligible individual.CommentsClose CommentsPermalink





‘(d) Application of Certain Pre-Modernized Medicaid Requirements-CommentsClose CommentsPermalink





‘(1) OLD STATE PLAN REQUIREMENTS- The following provisions of old section 1902 shall apply to the State plans under this part:CommentsClose CommentsPermalink





‘(A) Old section 1902(a)(10)(C) (relating to certain eligibility and other requirements).CommentsClose CommentsPermalink





‘(B) Old section 1902(a)(10)(D) (relating to home health services).CommentsClose CommentsPermalink





‘(C) Old section 1902(a)(10)(G) (relating to nonapplication of certain supplemental security income eligibility criteria).CommentsClose CommentsPermalink





‘(D) The subclauses in the flush matter following old section 1902(a)(10)(G) (relating to the provision of certain services) other than subclauses (V), (VII), (VIII), and (IX).CommentsClose CommentsPermalink





‘(E) Old section 1902(a)(17) (relating to reasonable standards for determining eligibility).CommentsClose CommentsPermalink





‘(F) Old section 1902(a)(19) (relating to eligibility safeguards).CommentsClose CommentsPermalink





‘(G) Old section 1902(a)(34) (relating to eligibility beginning with the third month prior to the month of application).CommentsClose CommentsPermalink





‘(H) Subparagraphs (A), (B), and (C) of old section 1902(a)(43) (relating to early and periodic screening, diagnostic, and treatment services).CommentsClose CommentsPermalink





‘(I) Old section 1902(a)(46)(A) (relating to compliance with section 1137 requirements).CommentsClose CommentsPermalink





‘(J) The fourth and sixth sentences of old section 1902(a) (relating to eligibility for certain individuals).CommentsClose CommentsPermalink





‘(2) OTHER OLD TITLE XIX REQUIREMENTS-CommentsClose CommentsPermalink





‘(A) Old section 1902(e)(3) (relating to optional eligibility for certain disabled individuals).CommentsClose CommentsPermalink





‘(B) Old section 1902(e)(9) (relating to optional respiratory care services).CommentsClose CommentsPermalink





‘(C) Old section 1902(f) (relating to eligibility of certain aged, blind, or disabled individuals).CommentsClose CommentsPermalink





‘(D) Old section 1902(m) (relating to eligibility of certain aged or disabled individuals), other than paragraph (4).CommentsClose CommentsPermalink





‘(E) Old section 1902(o) (relating to disregard of certain supplemental security income benefits).CommentsClose CommentsPermalink





‘(F) Old section 1902(v) (relating to eligibility determinations of blind or disabled individuals).CommentsClose CommentsPermalink





‘(e) Other Requirements- The State plan under this part shall--CommentsClose CommentsPermalink





‘(1) comply with the requirements of the other parts of this title; andCommentsClose CommentsPermalink





‘(2) provide that the State will make the contributions specified under section 340A-1(e) of the Public Health Service Act .CommentsClose CommentsPermalink

‘SEC. 1905. DEFINITIONS.

‘(a) In General- The definitions specified in this section shall apply for purposes of this part and, to the extent applicable and consistent with the policy embodied in such part, parts B, C, D, E, and F.CommentsClose CommentsPermalink





‘(b) Federal Medical Assistance Percentage- The term ‘Federal medical assistance percentage’ for any State shall be 100 percent less the State percentage; and the State percentage shall be that percentage which bears the same ratio to 45 percent as the square of the per capita income of such State bears to the square of the per capita income of the continental United States (including Alaska) and Hawaii, except that the Federal medical assistance percentage shall in no case be less than 50 percent or more than 83 percent. The Federal medical assistance percentage for any State shall be determined and promulgated in accordance with the provisions of section 1101(a)(8)(B).CommentsClose CommentsPermalink





‘(c) Application of Certain Pre-Modernized Medicaid Provisions- The following old provisions shall apply under this part:CommentsClose CommentsPermalink





‘(1) OLD SECTION 1905 PROVISIONS- The following provisions of old section 1905:CommentsClose CommentsPermalink





‘(A) Old section 1905(d) (relating to the definition of an intermediate care facility for the mentally retarded).CommentsClose CommentsPermalink





‘(B) Old section 1905(e) (relating to the definition of physicians services).CommentsClose CommentsPermalink





‘(C) Old section 1905(f) (relating to the definition of nursing facility services).CommentsClose CommentsPermalink





‘(D) Old section 1905(g) (relating to the provision of chiropractors’ services).CommentsClose CommentsPermalink





‘(E) Old section 1905(j) (relating to State supplementary payments).CommentsClose CommentsPermalink





‘(F) Old section 1905(k) (relating to supplemental security income benefits payable pursuant to section 211 of Public Law 93-66).CommentsClose CommentsPermalink





‘(G) Old section 1905(l)(1) (relating to rural health clinic services).CommentsClose CommentsPermalink





‘(H) Old section 1905(o) (relating to hospice care).CommentsClose CommentsPermalink





‘(I) Old section 1905(q) (relating to the definition of a qualified severely impaired individual).CommentsClose CommentsPermalink





‘(J) Old section 1905(r) (relating to the definition of early and periodic screening, diagnostic, and treatment services).CommentsClose CommentsPermalink





‘(K) Old section 1905(s) (relating to the definition of a qualified disabled and working individual).CommentsClose CommentsPermalink





‘(L) Old section 1905(t) (relating to the definition of primary care case management services).CommentsClose CommentsPermalink





‘(M) Old section 1905(v) (relating to the definition of an employed individual with a medically improved disability).CommentsClose CommentsPermalink





‘(N) Paragraphs (1) and (3) of old section 1905(w) (relating to the definition of an independent foster care adolescent).CommentsClose CommentsPermalink





‘(O) Old section 1905(x) (relating to strategies, treatment, and services for individuals with Sickle Cell Disease).CommentsClose CommentsPermalink





‘(2) OTHER OLD PROVISIONS-CommentsClose CommentsPermalink





‘(A) Old section 1903(m) (relating to the definition of a medicaid managed care organization).CommentsClose CommentsPermalink

‘SEC. 1906. ENROLLMENT OF INDIVIDUALS UNDER GROUP HEALTH PLANS AND OTHER ARRANGEMENTS.

‘The following old provisions shall apply under this part:CommentsClose CommentsPermalink





‘(1) Old section 1906 (relating to enrollment of individuals under group health plans).CommentsClose CommentsPermalink





‘(2) Old section 1902(a)(70) (relating to State option to establish a non-emergency medical transportation brokerage program).CommentsClose CommentsPermalink





‘(3) Paragraphs (2) and (11) of old section 1902(e) (relating to eligibility for individuals enrolled with a group health plan or under a managed care arrangement during a minimum enrollment period).CommentsClose CommentsPermalink

‘SEC. 1907. DRUG REBATES.

‘Old sections 1902(a)(54) and 1927 (relating to payment for covered outpatient drugs and rebates) shall apply under this part.CommentsClose CommentsPermalink

‘SEC. 1908. MANAGED CARE.

‘The following old provisions shall apply under this part:CommentsClose CommentsPermalink





‘(1) Old section 1932 (relating to managed care), other than subsection (a)(2) of such section.CommentsClose CommentsPermalink





‘(2) Old section 1903(k) (relating to technical and actuarial assistance for States).CommentsClose CommentsPermalink

‘SEC. 1909. ANNUAL REPORTS.

‘(a) In General- Each State that receives payments under this part shall submit an annual report to the Secretary, in such form and manner as the Secretary shall specify.CommentsClose CommentsPermalink





‘(b) Application of Old EPSDT Reporting Requirements- Each annual report shall include the information required to be reported under old section 1902(a)(43)(D)(iv).CommentsClose CommentsPermalink

‘PART B--GRANTS TO STATES FOR LONG-TERM CARE SERVICES AND SUPPORTS

‘SEC. 1911. PURPOSE.

‘(a) In General- The purpose of this part is to increase the flexibility of States in operating a system of long-term care services and supports designed to--CommentsClose CommentsPermalink





‘(1) provide assistance to needy families so that individuals with disabilities and low-income senior citizens may be served and supported in their own homes and communities;CommentsClose CommentsPermalink





‘(2) emphasize the independence and dignity of the person served by public programs;CommentsClose CommentsPermalink





‘(3) end the institutional bias that existed under the Medicaid program prior to January 1, 2011;CommentsClose CommentsPermalink





‘(4) provide stable and predictable funding for States as they rebalance their long-term care systems from institutions to communities;CommentsClose CommentsPermalink





‘(5) provide flexibility to States to adopt new and innovative service delivery methods; andCommentsClose CommentsPermalink





‘(6) promote independence and support activities that will enable individuals to return or maintain ties to the community, including through employment.CommentsClose CommentsPermalink





‘(b) No Individual Entitlement- No individual determined eligible for long-term care services and supports under this part shall be entitled to a specific service or type of delivery of service.CommentsClose CommentsPermalink

‘SEC. 1912. STATE PLAN.

‘(a) In General- In order to receive payments under this part, a State must have an approved State plan for long-term care services and supports. A State long term care services and supports plan shall include a description, consistent with the requirements of this part, of--CommentsClose CommentsPermalink





‘(1) income and assets eligibility standards and spousal impoverishment protections consistent with subsection (b);CommentsClose CommentsPermalink





‘(2) the standardized assessments tools used to determine eligibility for specific long-term care services and supports;CommentsClose CommentsPermalink





‘(3) the person-centered plans used to provide such services and supports;CommentsClose CommentsPermalink





‘(4) the proposed uses of funding, if applicable, to provide targeted methods to meet individual level of support needs including tiering (preventive, emergency, low, medium, high); andCommentsClose CommentsPermalink





‘(5) the long-term care services and supports to be available under the plan based on individual assessment of need in accordance with sections 1916 and 1917.CommentsClose CommentsPermalink





‘(b) Minimum Eligibility Standards-CommentsClose CommentsPermalink





‘(1) POPULATIONS COVERED- The State plan shall specify the disabled and elderly populations who are eligible for long-term care services and supports.CommentsClose CommentsPermalink





‘(2) NEEDS-BASED CRITERIA- The plan shall include a description of the needs-based criteria the State will use to assess an individual’s need for specific services and supports available under the State plan.CommentsClose CommentsPermalink





‘(3) OTHER ELIGIBILITY REQUIREMENTS-CommentsClose CommentsPermalink





‘(A) INCOME AND ASSETS- A State may use different income and asset standards and methodologies for determining eligibility than those used for determining eligibility for acute care medical assistance under part A. A State may not make eligibility standards related to income, asset, and spousal impoverishment protection more restrictive than the Federal minimum requirements of December 31, 2008.CommentsClose CommentsPermalink





‘(B) APPLICATION OF SPOUSAL IMPOVERISHMENT PROTECTIONS- The State plan shall provide that the State shall comply with the requirements of section 1918 (relating to spousal impoverishment protections).CommentsClose CommentsPermalink





‘(C) STATEWIDENESS- The State plan shall provide that, except with respect to methods used for determining homestead exemptions, the income and asset standards and methodologies shall be in effect in all political subdivisions of the State.CommentsClose CommentsPermalink





‘(4) TRANSITION ASSISTANCE- The State plan shall specify how the State will provide transition assistance for individuals who, on December 31, 2010, are enrolled under the State plan under old title XIX (or under a waiver of that plan) and receiving long-term care services or supports on that date. The State shall provide such assistance to individuals who are and are not likely to be determined eligible for long-term care services and supports under the State plan under this part, as in effect on January 1, 2011 (or the first day on which the State plan is in effect under this part).CommentsClose CommentsPermalink





‘(c) Payment Methodologies to Providers-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The State plan shall describe the methodologies used to determine payments to providers. Such methodologies--CommentsClose CommentsPermalink





‘(A) may be varied to assist in transitioning from facilities-based to community-based care; andCommentsClose CommentsPermalink





‘(B) shall not be subject to Secretarial approval.CommentsClose CommentsPermalink





‘(2) TRANSPARENCY- The State plan shall provide that the State shall make publicly available--CommentsClose CommentsPermalink





‘(A) the payment methodologies applicable under the plan; andCommentsClose CommentsPermalink





‘(B) the name of any provider that receives $1,000,000 or more in any 12-month period and the actual amount paid to the provider during that period.CommentsClose CommentsPermalink





‘(d) Coordination of Effort With Other Related Public and Private Programs- The plan shall include a description of the State’s efforts to coordinate the delivery of services and supports under the plan with other related public and private programs that serve individuals with disabilities or aged populations that need or may be at risk of needing long term care.CommentsClose CommentsPermalink





‘(e) Public Availability of State Plan- The State shall make available to the public the State plan under this part and any amendments submitted by the State to the plan.CommentsClose CommentsPermalink





‘(f) Application of Old Title XIX Requirements- The following old title XIX provisions shall apply to a State plan under this part:CommentsClose CommentsPermalink





‘(1) Subsections (a)(50) and (q) of old section 1902 (relating to a monthly personal needs allowance for certain institutionalized individuals and couples).CommentsClose CommentsPermalink





‘(2) Old section 1902(a)(67) (relating to payment for certain services furnished to a PACE program eligible individual).CommentsClose CommentsPermalink





‘(3) Paragraph (1) of old section 1902(r) (relating to the post-eligibility treatment of income for certain individuals) and paragraph (2) of such section (relating to methodologies for determining income and resource eligibility for individuals, but only with respect to individuals who are eligible under this part on or after January 1, 2011).CommentsClose CommentsPermalink





‘(4) Old section 1905(i) (relating to the definition of an institution for mental diseases).CommentsClose CommentsPermalink





‘(g) Other Requirements of Other Parts- The State plan under this part shall--CommentsClose CommentsPermalink





‘(1) comply with the requirements of the other parts of this title; andCommentsClose CommentsPermalink





‘(2) provide that the State will make the contributions specified under section 340A-1(e) of the Public Health Service Act.CommentsClose CommentsPermalink

‘SEC. 1913. STATE ALLOTMENTS.

‘(a) Appropriation- For the purpose of providing allotments to States under this section, there is appropriated out of any money in the Treasury not otherwise appropriated--CommentsClose CommentsPermalink





‘(1) for fiscal year 2011, $65,274,560,000;CommentsClose CommentsPermalink





‘(2) for fiscal year 2012, $67,885,540,000;CommentsClose CommentsPermalink





‘(3) for fiscal year 2013, $70,600,964,100;CommentsClose CommentsPermalink





‘(4) for fiscal year 2014, $73,425,000,000;CommentsClose CommentsPermalink





‘(5) for fiscal year 2015, $76,362,000,000;CommentsClose CommentsPermalink





‘(6) for fiscal year 2016, $79,416,480,000;CommentsClose CommentsPermalink





‘(7) for fiscal year 2017, $82,593,140,000;CommentsClose CommentsPermalink





‘(8) for fiscal year 2018, $85,896,870,000; andCommentsClose CommentsPermalink





‘(9) for fiscal year 2019, $89,332,743,000.CommentsClose CommentsPermalink





‘(b) Allotments to 50 States and the District of Columbia-CommentsClose CommentsPermalink





‘(1) FISCAL YEAR 2011 ALLOTMENTS- Subject to subsection (e), the Secretary shall allot to each State with a long term care plan approved under this title an amount in fiscal year 2011 equal to the Federal expenditures made by the State for long-term care as defined in section 1916 in fiscal year 2008, increased by 8 percent.CommentsClose CommentsPermalink





‘(2) SUBSEQUENT FISCAL YEAR ALLOTMENTS- For fiscal year 2012 and each subsequent fiscal year through fiscal year 2019, the allotment for a State under this section is equal to the allotment for the State determined for the preceding fiscal year, increased by 4 percent.CommentsClose CommentsPermalink





‘(c) Limitation-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Except as provided in paragraph (2), no other Federal funds are available under this title for expenditures incurred for long-term care services and supports after December 31, 2010, except as provided under a State plan approved under this part.CommentsClose CommentsPermalink





‘(2) EXCEPTION-CommentsClose CommentsPermalink





‘(A) IN GENERAL- If a State does not have an approved State plan by October 1, 2010, the Secretary may make payments equal to 85 percent of the State’s estimated quarterly allotment until June 30, 2011.CommentsClose CommentsPermalink





‘(B) FULL FUNDING- A State shall receive 100 percent of its allotment for fiscal year 2011 if the State has a plan approved under this part by June 30, 2011.CommentsClose CommentsPermalink





‘(d) Maintenance of Effort- In order to qualify for the grant payable under this section, the State must demonstrate in each fiscal year that it made long-term care service and supports expenditures (including funding from local government sources) equal to the amount of not less than 95 percent of the nonfederal share amount spent in fiscal year 2009 under the State plan under old title XIX on long term care services and supports (as defined in section 1916). Expenditures not made under this part shall not be recognized by the Secretary for purposes of this requirement.CommentsClose CommentsPermalink





‘(e) Grants Reduced if Insufficient Appropriations-CommentsClose CommentsPermalink





‘(1) IN GENERAL- If the amount appropriated for fiscal year 2011 under subsection (a)(1) is less than the amount necessary to fund each State’s allotment for that fiscal year, the Secretary shall reduce the allotment for each State for that fiscal year based on the applicable percentage determined for the State under paragraph (2) provide a reduced percentage basis as follows: Each state shall receive a percentage of its allotment based on the ratio of non-institutional spending to total long term care spending in FY 2009.CommentsClose CommentsPermalink





‘(2) APPLICABLE PERCENTAGE- For purposes of paragraph (1), the applicable percentage determined with respect to a State is as follows:CommentsClose CommentsPermalink

-------------------------------------------------------------------------------- CommentsClose CommentsPermalink

-------------------------------------------------------------------------------- CommentsClose CommentsPermalink

‘If the ratio of the State’s non-institutional spending to total long-term care spending for fiscal year 2009 is: The applicable percentage is: CommentsClose CommentsPermalink

                                                                                                   50 percent or greater                                  100 CommentsClose CommentsPermalink

                                                                                   at least 46, but less than 50 percent                                   99 CommentsClose CommentsPermalink

                                                                                   at least 40, but less than 46 percent                                   98 CommentsClose CommentsPermalink

                                                                                           at least 36, but less than 40                                   97 CommentsClose CommentsPermalink

                                                                                           at least 30, but less than 36                                   96 CommentsClose CommentsPermalink

                                                                                                    less than 30 percent                                  95. CommentsClose CommentsPermalink

-------------------------------------------------------------------------------- CommentsClose CommentsPermalink

‘(f) Administrative Expenses-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Each State with a plan approved under this part shall receive a payment determined in accordance with amounts appropriated for part E for administrative expenses incurred in carrying out the plan under this part and part A.CommentsClose CommentsPermalink





‘(2) ASSESSMENT-RELATED COSTS- Costs attributable to providing an individualized needs-based assessment for purposes of identifying the long-term care services and supports to be provided under the State plan to an individual shall be considered a long-term care service and support and shall not be treated as an administrative expense.CommentsClose CommentsPermalink

‘SEC. 1914. USE OF GRANTS.

‘(a) In General- A State shall use funds for long-term care services and supports as defined in section 1916.CommentsClose CommentsPermalink





‘(b) Self-Direction- A State shall offer individuals the opportunity to self-direct their long-term care services and supports.CommentsClose CommentsPermalink

‘SEC. 1915. ADMINISTRATIVE PROVISIONS.

‘(a) Funding on a Quarterly Basis- The Secretary shall make payments to States in equal amounts of a State’s annual allotment on a quarterly basis. Each quarterly payment shall remain available for use by the State for twelve succeeding fiscal year quarters.CommentsClose CommentsPermalink





‘(b) Publication- The Secretary shall publish each State’s allotment--CommentsClose CommentsPermalink





‘(1) for fiscal year 2011 not later than December 15, 2009; andCommentsClose CommentsPermalink





‘(2) for each subsequent fiscal year, not later than December 15 of the calendar year preceding the calendar year in which the fiscal year begins.CommentsClose CommentsPermalink

‘SEC. 1916. DEFINITION OF LONG-TERM CARE SERVICES AND SUPPORTS.

‘(a) Definition-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Subject to subsection (e), in this part, the term ‘long-term care services and supports’ means any of the services or supports specified in paragraphs (2) or (3) that may be provided in a nursing facility, an institution, a home, or other setting.CommentsClose CommentsPermalink





‘(2) SERVICES AND SUPPORTS DESCRIBED- For purposes of paragraph (1), the services and supports described in this paragraph include assistive technology, adaptive equipment, remote monitoring equipment, case management for the aged, case management for individuals with disabilities, nursing home services, long-term rehabilitative services necessary to restore functional abilities, services provided in intermediate care facilities for people with disabilities, habilitation services (including adult day care programs), community treatment teams for individuals with mental illness, home health services, services provided in an institution for mental disease, a Program of All-Inclusive Care for the Elderly (PACE), personal care (including personal assistance services), recovery support including peer counseling, supportive employment, training skills necessary to assist the individual in achieving or maintaining independence, training of family members including foster parents in supportive and behavioral modification skills, ongoing and periodic training to maintain life skills, transitional care including room and board not to exceed 60 days within a 12-month period.CommentsClose CommentsPermalink





‘(3) INCLUSION OF CERTAIN BENEFITS UNDER OLD TITLE XIX- Such services and supports may include any of the following services:CommentsClose CommentsPermalink





‘(A) Old section 1905(a)(15) (relating to services in an intermediate care facility for the mentally retarded).CommentsClose CommentsPermalink





‘(B) Services described in subsections (a)(16) and (h) of old section 1905, but without regard to any restriction on such services on the basis of age (relating to inpatient psychiatric hospital services).CommentsClose CommentsPermalink





‘(C) Old section 1905(a)(22) (relating to home and community care (to the extent allowed and as defined in old section 1929) for functionally disabled elderly individuals).CommentsClose CommentsPermalink





‘(D) Old section 1905(a)(23) (relating to community supported living arrangements services (to the extent allowed and as defined in old section 1930)).CommentsClose CommentsPermalink





‘(E) Subject to subsection (e), old section 1905(a)(24) but without regard to any restriction on furnishing services to patients or residents of facilities or institutions (relating to personal care services).CommentsClose CommentsPermalink





‘(F) Old sections 1905(a)(26) and 1934 (relating to services furnished under a PACE program under old section 1934 to PACE program eligible individuals enrolled under the program under such old section).CommentsClose CommentsPermalink





‘(G) Old section 1915(c)(5) (relating to the definition of habilitation services).CommentsClose CommentsPermalink





‘(4) LIMITATION- Long-term care services and supports cannot be used for services and administrative costs provided through the foster care (with the exception of training of foster care parents), child welfare, adult protective services, juvenile justice, public guardianship, or correctional systems.CommentsClose CommentsPermalink





‘(b) Rehabilitative Care- For purposes of rehabilitation due to acute care medical needs, a State may claim rehabilitative services provided in an institutional setting, nursing home, or as part of home health expenditures as acute care benefits under the State plan under part A rather than under the State plan under this part for a cumulative period of 30 days within a 12-month period if such care is directly related to the onset of an acute care need. A State shall demonstrate the services were provided as a direct result of an acute care need.CommentsClose CommentsPermalink





‘(c) Managed Care- If a State provides long-term care services and supports through managed care, the State shall submit a methodology for determining the level of expenditures attributed to long term care for approval by the Secretary.CommentsClose CommentsPermalink





‘(d) Application of Part A Definitions- A definition specified in section 1905 shall apply to the same term used in this part, unless the Secretary determines that the application of such definition would be inconsistent with the purpose of this part.CommentsClose CommentsPermalink





‘(e) Exclusion- No payments shall be made under the State plan under this part with respect to long-term care supports and services provided for any individual who is an inmate of a public institution. Nothing in the preceding sentence shall be construed as precluding the provision of long-term care services and supports under the State plan under this part to an individual who is a patient in an institution for mental diseases.CommentsClose CommentsPermalink

‘SEC. 1917. PROVISION REQUIREMENTS FOR LONG-TERM CARE SERVICES AND SUPPORT, INCLUDING OPTION FOR SELF-DIRECTED SERVICES AND SUPPORTS.

‘(a) Requirements for the Provision of Long-Term Care Services and Supports-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Subject to the succeeding provisions of this subsection, a State may provide through a State plan amendment for the provision of long-term care services and supports for individuals eligible under the State plan under this part, subject to the following requirements:CommentsClose CommentsPermalink





‘(A) NEEDS-BASED CRITERIA FOR ELIGIBILITY FOR, AND RECEIPT OF, LONG-TERM CARE SERVICES AND SUPPORTS- The State establishes needs-based criteria for determining an individual’s eligibility under the State plan for medical assistance for such long-term care services and supports, and if the individual is eligible for such services and supports, the specific services and supports that will be available under the State plan to the individual.CommentsClose CommentsPermalink





‘(B) CRITERIA FOR INSTITUTIONALIZED VERSUS NON-INSTITUTIONALIZED SERVICES- In establishing needs-based criteria, the State may establish criteria for determining eligibility for, and receipt of, services and supports provided in a facility or institution that are more stringent that the criteria established for eligibility and receipt of services and supports in a non-facility or non-institutionalized setting.CommentsClose CommentsPermalink





‘(C) AUTHORITY TO LIMIT NUMBER OF ELIGIBLE INDIVIDUALS- A State may limit the number of individuals who are eligible for such services and supports and may establish waiting lists for the receipt of such services and supports.CommentsClose CommentsPermalink





‘(D) CRITERIA BASED ON INDIVIDUAL ASSESSMENT-CommentsClose CommentsPermalink





‘(i) IN GENERAL- The criteria established by the State shall require an assessment of an individual’s support needs and capabilities, and may take into account the inability of the individual to perform 2 or more activities of daily living (as defined in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986) or the need for significant assistance to perform such activities, and such other risk factors as the State determines to be appropriate.CommentsClose CommentsPermalink





‘(ii) ADJUSTMENT AUTHORITY- The State plan amendment provides the State with the option to modify the criteria established under subparagraph (A) (without having to obtain prior approval from the Secretary) in the event that the enrollment of individuals eligible for services exceeds the projected enrollment, but only if--CommentsClose CommentsPermalink





‘(I) the State provides at least 60 days notice to the Secretary and the public of the proposed modification;CommentsClose CommentsPermalink





‘(II) the State deems an individual receiving long-term care services and supports on the basis of the most recent version of the criteria in effect prior to the effective date of the modification to be eligible for such services and supports for a period of at least 12 months beginning on the date the individual first received medical assistance for such services and supports; andCommentsClose CommentsPermalink





‘(III) after the effective date of such modification, the State, at a minimum, applies the criteria for determining whether an individual requires the level of care provided in a facility or institutionalized setting which applied under the State plan immediately prior to the application of the modified criteria.CommentsClose CommentsPermalink





‘(E) INDEPENDENT EVALUATION AND ASSESSMENT-CommentsClose CommentsPermalink





‘(i) ELIGIBILITY DETERMINATION- The State uses an independent evaluation for making the determinations described in subparagraph (A).CommentsClose CommentsPermalink





‘(ii) ASSESSMENT- In the case of an individual who is determined to be eligible for long-term care services and supports, the State uses an independent assessment, based on the needs of the individual to--CommentsClose CommentsPermalink





‘(I) determine a necessary level of services and supports to be provided, consistent with an individual’s physical and mental capacity;CommentsClose CommentsPermalink





‘(II) prevent the provision of unnecessary or inappropriate care; andCommentsClose CommentsPermalink





‘(III) establish an individualized care plan for the individual in accordance with subparagraph (G).CommentsClose CommentsPermalink





‘(F) ASSESSMENT- The independent assessment required under subparagraph (E)(ii) shall include the following:CommentsClose CommentsPermalink





‘(i) An objective evaluation of an individual’s inability to perform 2 or more activities of daily living (as defined in section 7702B(c)(2)(B) of the Internal Revenue Code of 1986) or the need for significant assistance to perform such activities.CommentsClose CommentsPermalink





‘(ii) A face-to-face evaluation of the individual by an individual trained in the assessment and evaluation of individuals whose physical or mental conditions trigger a potential need for long-term care services and supports.CommentsClose CommentsPermalink





‘(iii) Where appropriate, consultation with the individual’s family, spouse, guardian, or other responsible individual.CommentsClose CommentsPermalink





‘(iv) Consultation with appropriate treating and consulting health and support professionals caring for the individual.CommentsClose CommentsPermalink





‘(v) An examination of the individual’s relevant history, medical records, and care and support needs, guided by best practices and research on effective strategies that result in improved health and quality of life outcomes.CommentsClose CommentsPermalink





‘(vi) An evaluation of the ability of the individual or the individual’s representative to self-direct the purchase of, or control the receipt of, such services and supports if the individual so elects.CommentsClose CommentsPermalink





‘(G) INDIVIDUALIZED CARE PLAN-CommentsClose CommentsPermalink





‘(i) IN GENERAL- In the case of an individual who is determined to be eligible for long-term care services and supports, the State uses the independent assessment required under subparagraph (E)(ii) to establish a written individualized care plan for the individual.CommentsClose CommentsPermalink





‘(ii) PLAN REQUIREMENTS- The State ensures that the individualized care plan for an individual--CommentsClose CommentsPermalink





‘(I) is developed--CommentsClose CommentsPermalink

‘(aa) in consultation with the individual, the individual’s treating physician, health care or support professional, or other appropriate individuals, as defined by the State, and, where appropriate the individual’s family, caregiver, or representative; andCommentsClose CommentsPermalink

‘(bb) taking into account the extent of, and need for, any family or other supports for the individual;CommentsClose CommentsPermalink

‘(II) identifies the long-term care services and supports to be furnished to the individual (or, if the individual elects to self-direct the purchase of, or control the receipt of, such services and supports, funded for the individual); andCommentsClose CommentsPermalink





‘(III) is reviewed at least annually and as needed when there is a significant change in the individual’s circumstances.CommentsClose CommentsPermalink





‘(iii) STATE REQUIREMENT TO OFFER ELECTION FOR SELF-DIRECTED SERVICES AND SUPPORTS-CommentsClose CommentsPermalink





‘(I) INDIVIDUAL CHOICE- The State shall allow an individual or the individual’s representative the opportunity to elect to receive self-directed long-term care services and supports in a manner which gives them the most control over such services and supports consistent with the individual’s abilities and the requirements of subclauses (II) and (III).CommentsClose CommentsPermalink





‘(II) SELF-DIRECTED- The term ‘self-directed’ means, with respect to the long-term care services and supports offered under the State plan amendment, such services and supports for the individual which are planned and purchased under the direction and control of such individual or the individual’s authorized representative, including the amount, duration, scope, provider, and location of such services and supports, under the State plan consistent with the following requirements:CommentsClose CommentsPermalink

‘(aa) ASSESSMENT- There is an assessment of the needs, capabilities, and preferences of the individual with respect to such services and supports.CommentsClose CommentsPermalink

‘(bb) SERVICE PLAN- Based on such assessment, there is developed jointly with such individual or the individual’s authorized representative a plan for such services and supports for such individual that is approved by the State and that satisfies the requirements of subclause (III).CommentsClose CommentsPermalink

‘(III) PLAN REQUIREMENTS- For purposes of subclause (II)(bb), the requirements of this subclause are that the plan--CommentsClose CommentsPermalink

‘(aa) specifies those services and supports which the individual or the individual’s authorized representative would be responsible for directing;CommentsClose CommentsPermalink

‘(bb) identifies the methods by which the individual or the individual’s authorized representative will select, manage, and dismiss providers of such services and supports;CommentsClose CommentsPermalink

‘(cc) specifies the role of family members and others whose participation is sought by the individual or the individual’s authorized representative with respect to such services and supports;CommentsClose CommentsPermalink

‘(dd) is developed through a person-centered process that is directed by the individual or the individual’s authorized representative, builds upon the individual’s capacity to engage in activities that promote community life and that respects the individual’s preferences, choices, and abilities, and involves families, friends, and professionals as desired or required by the individual or the individual’s authorized representative;CommentsClose CommentsPermalink

‘(ee) includes appropriate risk management techniques that recognize the roles and sharing of responsibilities in obtaining services and supports in a self-directed manner and assure the appropriateness of such plan based upon the resources and capabilities of the individual or the individual’s authorized representative; andCommentsClose CommentsPermalink

‘(ff) may include an individualized budget which identifies the dollar value of the services and supports under the control and direction of the individual or the individual’s authorized representative.CommentsClose CommentsPermalink

‘(IV) BUDGET PROCESS- With respect to individualized budgets described in subclause (III)(ff), the State plan amendment--CommentsClose CommentsPermalink

‘(aa) describes the method for calculating the dollar values in such budgets based on reliable costs and service utilization;CommentsClose CommentsPermalink

‘(bb) defines a process for making adjustments in such dollar values to reflect changes in individual assessments and service plans; andCommentsClose CommentsPermalink

‘(cc) provides a procedure to evaluate expenditures under such budgets.CommentsClose CommentsPermalink

‘(H) QUALITY ASSURANCE; CONFLICT OF INTEREST STANDARDS-CommentsClose CommentsPermalink





‘(i) QUALITY ASSURANCE- The State ensures that the provision of long-term care services and supports meets Federal and State guidelines for quality assurance.CommentsClose CommentsPermalink





‘(ii) CONFLICT OF INTEREST STANDARDS- The State establishes standards for the conduct of the independent evaluation and the independent assessment to safeguard against conflicts of interest.CommentsClose CommentsPermalink





‘(I) REDETERMINATIONS AND APPEALS- The State allows for at least annual redeterminations of eligibility, and appeals in accordance with the frequency of, and manner in which, redeterminations and appeals of eligibility are made under the State plan.CommentsClose CommentsPermalink





‘(J) PRESUMPTIVE ELIGIBILITY FOR ASSESSMENT- The State, at its option, elects to provide for a period of presumptive eligibility (not to exceed a period of 60 days) only for those individuals that the State has reason to believe may be eligible for long-term care services and supports. Such presumptive eligibility shall be limited to medical assistance for carrying out the independent evaluation and assessment under subparagraph (E) to determine an individual’s eligibility for such services and if the individual is so eligible, the specific long-term care services and supports that the individual will receive.CommentsClose CommentsPermalink





‘(2) DEFINITION OF INDIVIDUAL’S REPRESENTATIVE- In this section, the term ‘individual’s representative’ means, with respect to an individual, a parent, a family member, or a guardian of the individual, an advocate for the individual, or any other individual who is authorized to represent the individual.CommentsClose CommentsPermalink





‘(b) Self-Directed Personal Assistance Services- If a State includes personal care or personal assistance services in the long-term care services and supports available under the State plan, the State shall comply with the requirements of old section 1915(j) in the case of an individual who elects to self-direct the receipt of such care or services.CommentsClose CommentsPermalink

‘SEC. 1918. TREATMENT OF INCOME AND RESOURCES FOR CERTAIN INSTITUTIONALIZED SPOUSES.

‘Old section 1924 (relating to treatment of income and resources for certain institutionalized spouses), other than paragraphs (2) and (4)(A) of subsection (a) of such section, shall apply under this part.CommentsClose CommentsPermalink

‘SEC. 1919. ANNUAL REPORTS.

‘(a) In General- Each State that receives payments under this part shall submit an annual report to the Secretary, in such form and manner as the Secretary shall specify.CommentsClose CommentsPermalink





‘(b) Requirements- The report shall include the following with respect to the most recent fiscal year ended:CommentsClose CommentsPermalink





‘(1) The number of individuals served under the plan.CommentsClose CommentsPermalink





‘(2) The number of individuals served by tier (preventive, emergency, low, medium, and high needs).CommentsClose CommentsPermalink





‘(3) The number of individuals known to the State on waiting list for services (if any) and type of disability (physical, developmental, mental health) or aged.CommentsClose CommentsPermalink





‘(4) Expenditures by service category.CommentsClose CommentsPermalink

‘PART C--GRANTS TO STATES FOR SURVEY AND CERTIFICATION OF MEDICAL FACILITIES AND OTHER REQUIREMENTS

‘SEC. 1931. AUTHORIZATION OF APPROPRIATIONS.

‘For the purpose of carrying our Federal activities and providing grants to States for expenses necessary to carry out this part, there is authorized to be appropriated--CommentsClose CommentsPermalink





‘(1) for fiscal year 2011, $300,000,000; andCommentsClose CommentsPermalink





‘(2) for each succeeding fiscal year, the amount authorized under this section for the preceding fiscal year, increased by 5 percent.CommentsClose CommentsPermalink

‘SEC. 1932. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-MODERNIZED MEDICAID.

‘The following old provisions shall apply under this part:CommentsClose CommentsPermalink





‘(1) Old section 1902(a)(9) (relating to health standards and applicable requirements for laboratory services).CommentsClose CommentsPermalink





‘(2) Old section 1902(a)(28) (relating to nursing facilities and nursing facility services).CommentsClose CommentsPermalink





‘(3) Old sections 1902(a)(29) and 1908 (relating to a State program for the licensing of administrators of nursing homes).CommentsClose CommentsPermalink





‘(4) Old section 1902(a)(33)(B) (relating to licensing health institutions).CommentsClose CommentsPermalink





‘(5) Old section 1902(d) (relating to medical or utilization review functions).CommentsClose CommentsPermalink





‘(6) Old section 1902(i) (relating to intermediate care facilities for the mentally retarded).CommentsClose CommentsPermalink





‘(7) Old section 1902(y) (relating to psychiatric hospitals).CommentsClose CommentsPermalink





‘(8) Paragraphs (2) and (6) of old section 1903(g) (relating to the Secretarial requirement to conduct sample onsite surveys of private and public institutions and recertifications for the need for certain services).CommentsClose CommentsPermalink





‘(9) Old section 1903(q)(4)(B) (relating to the definition of a board and care facility).CommentsClose CommentsPermalink





‘(10) Old section 1910 (relating to certification and approval of rural health clinics and intermediate care facilities for the mentally retarded).CommentsClose CommentsPermalink





‘(11) Old section 1911 (relating to Indian Health Service facilities).CommentsClose CommentsPermalink





‘(12) Old section 1913 (relating to hospital providers of nursing facility services).CommentsClose CommentsPermalink





‘(13) Old section 1919 (relating to requirements for nursing facilities).CommentsClose CommentsPermalink

‘PART D--GRANTS TO STATES FOR PROGRAM INTEGRITY

‘SEC. 1941. AUTHORIZATION OF APPROPRIATIONS.

‘(a) In General- For the purpose of carrying out Federal activities under this part and providing grants to States for expenses necessary to carry out this part, there is authorized to be appropriated--CommentsClose CommentsPermalink





‘(1) for fiscal year 2011, $100,000,000; andCommentsClose CommentsPermalink





‘(2) for each succeeding fiscal year, the amount authorized under this section for the preceding fiscal year, increased by 5 percent.CommentsClose CommentsPermalink





‘(b) Availability; Authority for Use of Funds-CommentsClose CommentsPermalink





‘(1) AVAILABILITY- Amounts appropriated pursuant to subsection (a) shall remain available until expended.CommentsClose CommentsPermalink





‘(2) AUTHORITY FOR USE OF FUNDS FOR TRANSPORTATION AND TRAVEL EXPENSES FOR ATTENDEES AT EDUCATION, TRAINING, OR CONSULTATIVE ACTIVITIES-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary may use amounts appropriated pursuant to subsection (a) to pay for transportation and the travel expenses, including per diem in lieu of subsistence, at rates authorized for employees of agencies under subchapter I of chapter 57 of title 5, United States Code, while away from their homes or regular places of business, of individuals described in subsection (b)(4) who attend education, training, or consultative activities conducted under the authority of that subsection.CommentsClose CommentsPermalink





‘(B) PUBLIC DISCLOSURE- The Secretary shall make available on a website of the Centers for Medicare & Medicaid Services that is accessible to the public--CommentsClose CommentsPermalink





‘(i) the total amount of funds expended for each conference conducted under the authority of subsection (b)(4); andCommentsClose CommentsPermalink





‘(ii) the amount of funds expended for each such conference that were for transportation and for travel expenses.CommentsClose CommentsPermalink





‘(c) Annual Report- Not later than 180 days after the end of each fiscal year, the Secretary shall submit a report to Congress which identifies--CommentsClose CommentsPermalink





‘(1) the use of funds appropriated pursuant to subsection (a); andCommentsClose CommentsPermalink





‘(2) the effectiveness of the use of such funds.CommentsClose CommentsPermalink

‘SEC. 1942. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-MODERNIZED MEDICAID.

‘The following old provisions shall apply under this part:CommentsClose CommentsPermalink





‘(1) Old subsections (a)(25) (other than subparagraph (E)) and (g) of section 1902 and section 1903(o) (relating to third party liability).CommentsClose CommentsPermalink





‘(2) Old section 1902(a)(30)(B) (relating to hospital, intermediate care facility for the mentally retarded, or hospital for mental diseases admission screening and review requirements).CommentsClose CommentsPermalink





‘(3) Old section 1902(a)(32) (relating to certain payment requirements).CommentsClose CommentsPermalink





‘(4) Old section 1902(a)(35) (relating to disclosing entities under section 1124).CommentsClose CommentsPermalink





‘(5) Old section 1902(a)(37) and the fifth sentence (relating to claims payment procedures).CommentsClose CommentsPermalink





‘(6) Old section 1902(a)(44) (relating to payment for inpatient hospital services, services in an intermediate care facility for the mentally retarded, or inpatient mental hospital services).CommentsClose CommentsPermalink





‘(7) Old sections 1902(a)(45) and 1912 (relating to assignment of rights of payment).CommentsClose CommentsPermalink





‘(8) Old sections 1902(a)(49) and 1921 (relating to information and access to information concerning sanctions taken by State licensing authorities against health care practitioners and providers).CommentsClose CommentsPermalink





‘(9) Old sections 1902(a)(61) and 1903(q) (relating to requirements for a medicaid fraud and abuse control unit).CommentsClose CommentsPermalink





‘(10) Old section 1902(a)(64) (relating to reports from beneficiaries and others and data compilation requirements concerning alleged instances of waste, fraud, and abuse).CommentsClose CommentsPermalink





‘(11) Old section 1902(a)(65) (relating to provider number and surety bond requirement for suppliers of durable medical equipment).CommentsClose CommentsPermalink





‘(12) Old section 1902(a)(68) (relating to requirements for certain entities).CommentsClose CommentsPermalink





‘(13) Old sections 1902(a)(69) and 1936 (relating to the Medicaid Integrity Program) other than paragraphs (1), (2)(A), and (3) of old section 1936(e).CommentsClose CommentsPermalink





‘(14) Old section 1902(a)(70)(B)(iv) (relating to prohibitions on referrals and conflict of interest for certain brokers of non-emergency medical transportation).CommentsClose CommentsPermalink





‘(15) Old sections 1902(a)(71) and 1940 (relating to a required asset verification program).CommentsClose CommentsPermalink





‘(16) Old section 1902(p) (relating to exclusion of certain individuals or entities).CommentsClose CommentsPermalink





‘(17) Old section 1902(x) (relating to unique identifiers for physicians).CommentsClose CommentsPermalink





‘(18) Old section 1903(p) (relating to interstate collection of rights of support).CommentsClose CommentsPermalink





‘(19) Old section 1903(r)(2) (relating to requirements for mechanized claims processing and information retrieval systems).CommentsClose CommentsPermalink





‘(20) Old section 1903(u) (relating to erroneous excess payments), other than clause (v) of paragraph (1)(D).CommentsClose CommentsPermalink





‘(21) Old section 1903(v) and the seventh sentence of old section 1902(a) (relating to limitations on payments for services furnished to aliens), other than subparagraphs (A) and (B) of paragraph (4).CommentsClose CommentsPermalink





‘(22) Old section 1903(x) (relating to citizenship documentation).CommentsClose CommentsPermalink





‘(23) Old section 1909 (relating to State false claims act requirements for increased State share of recoveries).CommentsClose CommentsPermalink





‘(24) Old section 1914 (relating to withholding of Federal share of payments for certain Medicare providers).CommentsClose CommentsPermalink





‘(25) Old section 1917 (relating to liens, adjustments and recoveries, and transfers of assets).CommentsClose CommentsPermalink





‘(26) Old section 1922 (relating to correction and reduction plans for intermediate care facilities for the mentally retarded).CommentsClose CommentsPermalink

‘PART E--GRANTS TO STATES FOR ADMINISTRATION

‘SEC. 1951. AUTHORIZATION OF APPROPRIATIONS; PAYMENTS TO STATES.

‘(a) In General- For the purpose of providing grants to States for administrative expenses necessary to carry out parts A and B, there is authorized to be appropriated--CommentsClose CommentsPermalink





‘(1) for fiscal year 2011, $7,000,000,000; andCommentsClose CommentsPermalink





‘(2) for each succeeding fiscal year, the amount authorized under this subsection for the preceding fiscal year, increased by 3 percent.CommentsClose CommentsPermalink





‘(b) Payments to States-CommentsClose CommentsPermalink





‘(1) IN GENERAL- From the amount appropriated pursuant to subsection (a) for a fiscal year, the Secretary shall pay each State with approved plans under parts A and B for the fiscal year an amount equal to the product of the amount appropriated for the fiscal year and the ratio of the total amount of payments made to the State under paragraphs (2) through (7) of section 1903(a) for fiscal year 2008 (as such section was in effect for that fiscal year) to the total amount of such payments made to all States for such fiscal year.CommentsClose CommentsPermalink





‘(2) PRO RATA ADJUSTMENT- The Secretary shall make pro rata adjustments to the amounts determined under paragraph (1) for a fiscal year as necessary so as to not exceed the amount appropriated pursuant to subsection (a) for the fiscal year.CommentsClose CommentsPermalink

‘SEC. 1952. COST-SHARING PROTECTIONS.

‘(a) In General- A State may impose cost-sharing for individuals provided acute care medical assistance under a State plan under part A or long-term care services and supports under a State plan under part B consistent with the following:CommentsClose CommentsPermalink





‘(1) The State may (in a uniform manner) require payment of monthly premiums or other cost-sharing set on a sliding scale based on family income.CommentsClose CommentsPermalink





‘(2) A premium or other cost-sharing requirement imposed under paragraph (1) may only apply to the extent that, in the case of an individual whose family income--CommentsClose CommentsPermalink





‘(A) exceeds 150 percent of the poverty line, the aggregate annual amount of such premium and other cost-sharing charges imposed under the plan does not exceed 5 percent of the individual’s annual income; andCommentsClose CommentsPermalink





‘(B) exceeds 250 percent of the poverty line, the aggregate annual amount of such premium and other cost-sharing charges do not exceed 7.5 percent of the individual’s annual income.CommentsClose CommentsPermalink





‘(3) A State shall not require prepayment of any premium or cost-sharing imposed pursuant to paragraph (1) and shall not terminate eligibility of an individual under the State plan on the basis of failure to pay any such premium or cost-sharing until such failure continues for a period of at least 60 days from the date on which the premium or cost-sharing became past due. The State may waive payment of any such premium or cost-sharing in any case where the State determines that requiring such payment would create an undue hardship.CommentsClose CommentsPermalink





‘(b) Application to Institutionalized Individuals- A State may impose cost-sharing consistent with subsection (a) to individuals who are patients in, or residents of, a medical institution or nursing facility except that rules relating to the post-eligibility treatment of income (including a minium monthly personal needs allowance) applicable to institutionalized individuals under old title XIX shall apply in the same manner to individuals eligible for long-term care services and supports under a State plan under part B.CommentsClose CommentsPermalink





‘(c) Poverty Line Defined- In this section, the term ‘poverty line’ has the meaning given such term in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section.CommentsClose CommentsPermalink

‘SEC. 1953. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-MODERNIZED MEDICAID.

‘The following old provisions shall apply to the State plans under this title:CommentsClose CommentsPermalink





‘(1) OLD STATE PLAN REQUIREMENTS-CommentsClose CommentsPermalink





‘(A) Old section 1902(a)(1) (relating to the requirement for plans to be in effect in all political subdivisions of the State).CommentsClose CommentsPermalink





‘(B) Old section 1902(a)(2) (relating to State financial participation).CommentsClose CommentsPermalink





‘(C) Old section 1902(a)(3) (relating to opportunity for a fair hearing).CommentsClose CommentsPermalink





‘(D) Old section 1902(a)(4) (relating to administration).CommentsClose CommentsPermalink





‘(E) Old section 1902(a)(5) (relating to designation of a single State agency).CommentsClose CommentsPermalink





‘(F) Old section 1902(a)(6) (relating to reporting requirements).CommentsClose CommentsPermalink





‘(G) Old section 1902(a)(7) (relating to restrictions on the use or disclosure of information).CommentsClose CommentsPermalink





‘(H) Old section 1902(a)(8) (relating to applications for assistance).CommentsClose CommentsPermalink





‘(I) Old section 1902(a)(11) (relating to cooperative agreements with other State agencies).CommentsClose CommentsPermalink





‘(J) Old section 1902(a)(12) (relating to determinations of blindness).CommentsClose CommentsPermalink





‘(K) Old section 1902(a)(13) (relating to determination of rates of payment for certain services), other than clause (iv) of subparagraph (A).CommentsClose CommentsPermalink





‘(L) Subsections (a)(15) and (bb) of old section 1902(a) (relating to payment for services provided by rural health clinics and federally qualified health centers).CommentsClose CommentsPermalink





‘(M) Old section 1902(a)(16) (relating to furnishing services to individuals when absent from the State).CommentsClose CommentsPermalink





‘(N) Old section 1902(a)(22) (relating to certain administrative provisions).CommentsClose CommentsPermalink





‘(O) Paragraphs (23) and (25)(D) of old section 1902(a) (relating to any willing provider requirements).CommentsClose CommentsPermalink





‘(P) Old section 1902(a)(24) (relating to consultative services by other agencies).CommentsClose CommentsPermalink





‘(Q) Old section 1902(a)(26) (relating to review of need for inpatient mental hospital services and written plan of care requirements).CommentsClose CommentsPermalink





‘(R) Old section 1902(a)(27) (relating to provider record keeping requirements).CommentsClose CommentsPermalink





‘(S) Old section 1902(a)(30)(A) (relating to utilization review).CommentsClose CommentsPermalink





‘(T) Old section 1902(a)(31) (relating to written plan of care for services and review for intermediate care facility for the mentally retarded services).CommentsClose CommentsPermalink





‘(U) Old section 1902(a)(33)(A) (relating to quality review requirements).CommentsClose CommentsPermalink





‘(V) Old section 1902(a)(36) (relating to public availability of facility surveys).CommentsClose CommentsPermalink





‘(W) Old section 1902(a)(38) (relating to the provision of information described in section 1128(b)(9) by certain entities).CommentsClose CommentsPermalink





‘(X) Old section 1902(a)(39) (relating to the exclusion of certain entities).CommentsClose CommentsPermalink





‘(Y) Old section 1902(a)(40) (relating to requirement for uniform reporting systems).CommentsClose CommentsPermalink





‘(Z) Old section 1902(a)(41) (relating to notice to State medical licensing boards).CommentsClose CommentsPermalink





‘(AA) Old section 1902(a)(42) (relating to certain audit requirements).CommentsClose CommentsPermalink





‘(BB) Old section 1902(a)(48) (relating to eligibility cards).CommentsClose CommentsPermalink





‘(CC) Old section 1902(a)(55) (relating to the receipt and initial processing of applications, but only to the extent such section is consistent with the policy embodied in the State plans under parts A and B).CommentsClose CommentsPermalink





‘(DD) Subsections (a)(56) and (s) of old section 1902 (relating to adjusted payments for certain inpatient hospital services).CommentsClose CommentsPermalink





‘(EE) Old section 1902(a)(59) (relating to maintenance of list of participating physicians).CommentsClose CommentsPermalink





‘(FF) The second sentence of old section 1902 (relating to designation of certain State agencies).CommentsClose CommentsPermalink





‘(GG) Old section 1902(b) (relating to limitations on approval of plans).CommentsClose CommentsPermalink





‘(HH) Old section 1902(j) (relating to application of requirements to American Samoa and the Northern Mariana Islands).CommentsClose CommentsPermalink





‘(2) OTHER OLD TITLE XIX REQUIREMENTS-CommentsClose CommentsPermalink





‘(A) Old section 1903(b)(4) (relating to limitations on payments to enrollment brokers).CommentsClose CommentsPermalink





‘(B) Old section 1903(c) (relating to furnishing of services included in a program or plan under part B or C of the Individuals with Disabilities Education Act).CommentsClose CommentsPermalink





‘(C) Old section 1903(d) (relating to payments).CommentsClose CommentsPermalink





‘(D) Old section 1903(e) (relating to costs with respect to certain hospital services).CommentsClose CommentsPermalink





‘(E) Old section 1903(i) (relating to limitations on payments).CommentsClose CommentsPermalink





‘(F) Old section 1903(r) (relating to requirements for mechanized claims processing and information retrieval systems).CommentsClose CommentsPermalink





‘(G) Subsections (b)(5) and (w) of old section 1903 (relating to limitations on payments related to provider taxes).CommentsClose CommentsPermalink





‘(H) Old section 1904 (relating to operation of State plans).CommentsClose CommentsPermalink





‘(I) Old sections 1902(a)(60) and 1908A (relating to medical child support).CommentsClose CommentsPermalink





‘(J) Paragraphs (32)(D) and (62) of old section 1902(a) and section 1928 (relating to program for distribution of pediatric vaccines).CommentsClose CommentsPermalink

‘PART F--OTHER PROVISIONS

‘SEC. 1961. APPLICATION OF CERTAIN REQUIREMENTS UNDER PRE-MODERNIZED MEDICAID.

‘The following old provisions shall apply under this part:CommentsClose CommentsPermalink





‘(1) The third sentence of old section 1902 (relating to nonapplication of certain old provisions to a religious nonmedical health care institution).CommentsClose CommentsPermalink





‘(2) Old section 1918 (relating to application of provisions of title II relating to subpoenas).CommentsClose CommentsPermalink





‘(3) Old section 1939 (relating to references to laws directly affecting the Medicaid program.’.CommentsClose CommentsPermalink





(b) Repeal of Title XXI- Effective January 1, 2011, title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.) is repealed.CommentsClose CommentsPermalink

SEC. 402. OUTREACH.

(a) Authorization of Appropriations- The following amounts are authorized to be appropriated to the Secretary of Health and Human Services:CommentsClose CommentsPermalink





(1) For fiscal year 2009, $100,000,000 for the design and implementation of a public outreach campaign to inform the public about the changes to the programs under such titles that take effect on January 1, 2011, as a result of the amendment made by section 401.CommentsClose CommentsPermalink





(2) For each of fiscal years 2010 and 2011, $200,000,000 to carry out such public outreach campaign.CommentsClose CommentsPermalink





(3) For fiscal year 2012, $50,000,000 to carry out such public outreach campaign.CommentsClose CommentsPermalink





(b) Availability- Funds appropriated under subsection (a) shall remain available for expenditure through September 30, 2012.CommentsClose CommentsPermalink





(c) Authority for Use of Funds- The Secretary may use funds made available under paragraphs (2) and (3) of subsection (a) to award grants to, or enter into contracts with, public or private entities, including States, local governments, schools, churches, and community groups.CommentsClose CommentsPermalink

SEC. 403. TRANSITION RULES; MISCELLANEOUS PROVISIONS.

(a) In General-CommentsClose CommentsPermalink





(1) Not later than June 30, 2010, a State that is one of the 50 States or the District of Columbia shall inform all individuals enrolled in a State plan under title XIX or XXI of the Social Security Act on such date (and any new enrollees after such date) of the changes to the programs under such titles that take effect on January 1, 2011, as a result of the amendment made by section 401.CommentsClose CommentsPermalink





(2) No State that is one of the 50 States or the District of Columbia shall approve any applications for medical assistance or child health assistance under a State plan under title XIX or XXI (as in effect for fiscal year 2010) after December 31, 2010.CommentsClose CommentsPermalink





(b) Submission of Legislative Proposal for Technical and Conforming Amendments- Not later than 6 months after the date of enactment of this Act, the Secretary of Health and Human Services shall submit to Congress a legislative proposal for such technical and conforming amendments as are necessary to carry out the amendments made by this Act.CommentsClose CommentsPermalink

Subtitle B--Supplemental Health Care Assistance for Low-Income FamiliesCommentsClose CommentsPermalink

SEC. 411. SUPPLEMENTAL HEALTH CARE ASSISTANCE FOR LOW-INCOME FAMILIES.

Part D of title III of the Public Health Service Act (42 U.S.C. 254b et seq.) is amended by adding at the end the following:CommentsClose CommentsPermalink

‘Subpart XI--Health Care Assistance to Low-Income Families

‘SEC. 340A-1. FINANCIAL ASSISTANCE TO LOW-INCOME FAMILIES.

‘(a) In General- The Secretary shall supplement the costs of private health insurance for eligible low-income families through the distribution of supplemental debit cards to eligible families, which may be used to pay for costs associated with health care for the members of such eligible families and provide direct support to such families in accessing health care.CommentsClose CommentsPermalink





‘(b) Eligibility-CommentsClose CommentsPermalink





‘(1) ELIGIBLE FAMILIES- To be eligible for financial assistance under this section--CommentsClose CommentsPermalink





‘(A) a family shall--CommentsClose CommentsPermalink





‘(i) consist of 2 or more individuals living together who are related by marriage, birth, adoption, or guardianship;CommentsClose CommentsPermalink





‘(ii) have a gross income that does not exceed 200 percent of the poverty line, as applicable to a family of the size involved; andCommentsClose CommentsPermalink





‘(iii) include at least 1 individual who is a dependent under the age of 19; andCommentsClose CommentsPermalink





‘(B) no member of the family shall be covered by private health insurance.CommentsClose CommentsPermalink





‘(2) DETERMINATION OF GROSS INCOME- The gross income of a family shall be determined by taking the sum of the income of each family member who is at least age 21 but not older than age 65, except that the income of any member of the family who qualifies for coverage under Medicaid Part A or B shall not be counted.CommentsClose CommentsPermalink





‘(3) LIMITATION ON INDIVIDUAL ELIGIBILITY; ASSISTANCE-CommentsClose CommentsPermalink





‘(A) IN GENERAL- No individual who is a member of an eligible family under paragraph (1) is eligible to qualify separately for financial assistance under this section.CommentsClose CommentsPermalink





‘(B) ALIENS- The Secretary shall ensure that financial assistance under this section is not provided for costs associated with health care for any member of an eligible family who is an alien individual who is not a lawful permanent resident of the United States.CommentsClose CommentsPermalink





‘(c) Supplemental Debit Card for Health Care Expenditures-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall issue to each eligible family that enrolls in the program in accordance with subsection (f) a supplemental debit card with a dollar-amount value, in accordance with subsection (d), that may be used to pay for qualifying health care expenses.CommentsClose CommentsPermalink





‘(2) USE OF THE DEBIT CARD-CommentsClose CommentsPermalink





‘(A) QUALIFYING HEALTH CARE EXPENSES- A supplemental debit card issued under this section may be used by members of the eligible family to pay for--CommentsClose CommentsPermalink





‘(i) the purchase of health care insurance for any member of the family;CommentsClose CommentsPermalink





‘(ii) cost sharing expenses related to health care, including deductibles, copayments, and coinsurance, for any member of the family; andCommentsClose CommentsPermalink





‘(iii) the direct purchase of health care services and supplies for any member of the family.CommentsClose CommentsPermalink





‘(B) GEOGRAPHIC RANGE- Each supplemental debit card may be used to pay for qualifying health care expenses incurred anywhere in the 50 States or the District of Columbia.CommentsClose CommentsPermalink





‘(C) LIMITATIONS- No supplemental debit card shall be used to make a payment for any cost--CommentsClose CommentsPermalink





‘(i) incurred prior to the determination of the family’s eligibility for assistance under this section; orCommentsClose CommentsPermalink





‘(ii) that is not a health-related expense.CommentsClose CommentsPermalink





‘(3) ROLLOVER OF UNUSED AMOUNTS- Not more than one-quarter of the annual dollar amount of a supplemental debit card that is unexpended at the end of each 12-month period may rollover--CommentsClose CommentsPermalink





‘(A) to the family’s supplemental debit card for expenditure during the subsequent 12-month period, provided that the family to which the supplemental debit card was issued in the previous 12-month period is eligible to receive a supplemental debit card in the subsequent 12-month period; orCommentsClose CommentsPermalink





‘(B) to the family’s health savings account (as defined in section 223(g)(2) of the Internal Revenue Code of 1986).CommentsClose CommentsPermalink





‘(4) MONTHLY STATEMENTS- The Secretary shall issue a monthly statement to each family to which a supplemental debit card has been issued under this section, which shall state each payment made with the family’s supplemental debit card during the month covered by the statement, the dollar amount of each such payment, and the provider to which each such payment was made.CommentsClose CommentsPermalink





‘(d) Amount of Financial Assistance-CommentsClose CommentsPermalink





‘(1) AMOUNTS FOR CALENDAR YEAR 2011- Subject to paragraph (5), the amount of financial assistance available to each eligible family during the calendar year 2011 shall be determined as follows:CommentsClose CommentsPermalink





‘(A) Each family whose annual income does not exceed 100 percent of the poverty level, as applicable to a family of the size involved, shall receive $5,000.CommentsClose CommentsPermalink





‘(B) Each family whose annual income exceeds 100 percent, but does not exceed 200 percent, of the poverty level, as applicable to a family of the size involved, shall receive an amount as follows:CommentsClose CommentsPermalink





‘(i) For families whose annual income exceeds 100 percent but does not exceed 120 percent, of the poverty level, $4,000.CommentsClose CommentsPermalink





‘(ii) For families whose annual income exceeds 120 percent but does not exceed 140 percent, of the poverty level, $3,500.CommentsClose CommentsPermalink





‘(iii) For families whose annual income exceeds 140 percent but does not exceed 160 percent, of the poverty level, $3,000.CommentsClose CommentsPermalink





‘(iv) For families whose annual income exceeds 160 percent but does not exceed 180 percent, of the poverty level, $2,500.CommentsClose CommentsPermalink





‘(v) For families whose annual income exceeds 180 percent but does not exceed 200 percent, of the poverty level, $2,000.CommentsClose CommentsPermalink





‘(2) ADDITIONAL AMOUNTS- In addition to the amounts under paragraph (1), subject to paragraph (5), the following amounts shall be added to the supplemental debit cards of qualifying families:CommentsClose CommentsPermalink





‘(A) For each pregnancy during which a pregnant woman’s family is eligible for assistance under this section, an additional amount of $1,000 shall be added to the family’s supplemental debit card, except that no family shall receive such additional $1,000 for any pregnancy for which the family received such amount in the previous 12-month period.CommentsClose CommentsPermalink





‘(B) For each member of an eligible family who is less than 1 year old on any day within the calendar year in which the family is eligible for assistance, an additional amount of $500 shall be added to the family’s supplemental debit card.CommentsClose CommentsPermalink





‘(3) COST OF LIVING ADJUSTMENTS- In the case of any taxable year beginning in a calendar year after 2011, each dollar amount contained in paragraphs (1) and (2) shall be increased in the same manner as the dollar amounts specified in section 25E(b)(3) of the Internal Revenue Code of 1986 are increased by the blended cost-of-living adjustment determined under subsection (k)(2) of section 25E of the Internal Revenue Code for the taxable year involved.CommentsClose CommentsPermalink





‘(4) STATE OPTION TO INCREASE AMOUNTS- At the option of each State, amounts in excess of the annual dollar amounts under paragraphs (1) and (2) may be provided through the supplemental debit card to eligible families in that State, but no Federal funds shall be paid to any State for any amount provided in excess of such annual dollar amount.CommentsClose CommentsPermalink





‘(5) RISK ADJUSTMENT- The Secretary may adjust the amount of financial assistance available to an eligible family for a calendar year under this section based on age, health indicators, and other factors that represent distinct patterns of health care services utilization and costs.CommentsClose CommentsPermalink





‘(e) Contributions of States-CommentsClose CommentsPermalink





‘(1) IN GENERAL- As a condition for receiving Federal funds under Part A or Part B of Medicaid, each State shall contribute 50 percent of the total amount expended under the supplemental debit card program by the participating families that reside within the State during the time that the family resides in that State. For purposes of this section, the residency of a family is determined by the residency the legally responsible head of the household.CommentsClose CommentsPermalink





‘(2) PAYMENTS FROM STATES-CommentsClose CommentsPermalink





‘(A) BILLING NOTIFICATION-CommentsClose CommentsPermalink





‘(i) TIMING- On June 30th and December 31st of each year, the Secretary shall send written notification to each State of that State’s 50 percent share of expenses, as described in paragraph (1), for the 6-month period ending on the last day of the month previous to such notification.CommentsClose CommentsPermalink





‘(ii) CONTENTS- Each such notification to a State shall clearly state--CommentsClose CommentsPermalink





‘(I) the payment amount due from the State;CommentsClose CommentsPermalink





‘(II) the name of each individual for whom payment was made through the supplemental debit card program;CommentsClose CommentsPermalink





‘(III) the health care provider to whom each payment was made;CommentsClose CommentsPermalink





‘(IV) the amount of each payment; andCommentsClose CommentsPermalink





‘(V) any other information, as the Secretary requires.CommentsClose CommentsPermalink





‘(B) PAYMENTS- Each State shall make a payment to the Secretary, in the amount billed, not later than 30 days after the billing notification date, in accordance with subparagraph (A)(i).CommentsClose CommentsPermalink





‘(C) PENALTIES- If a State fails to pay to the Secretary an amount required under subparagraph (B), interest shall accrue on such amount at the rate provided under old section 1903(d)(5) of the Social Security Act. The amount so owed and applicable interest shall be immediately offset against amounts otherwise payable to the State under this section, in accordance with the Federal Claims Collection Act of 1996 and applicable regulations.CommentsClose CommentsPermalink





‘(f) Enrollment-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall establish procedures and times for enrollment in the supplemental debit card program. Open enrollment shall be available not less than 4 times per calendar year.CommentsClose CommentsPermalink





‘(2) TRANSITION OF INDIVIDUALS ENROLLED IN MEDICAID OR THE STATE CHILDREN’S HEALTH INSURANCE PROGRAM-CommentsClose CommentsPermalink





‘(A) INFORMATION FROM THE STATES- Each State shall--CommentsClose CommentsPermalink





‘(i) not later than June 30, 2010, inform all individuals then enrolled in Medicaid or the State Children’s Health Insurance Program (SCHIP), of the changes in effect beginning on January 1, 2011; andCommentsClose CommentsPermalink





‘(ii) not later than October 31, 2010, redetermine the eligibility of each individual enrolled in Medicaid or SCHIP, other than those individuals who qualify for Medicaid or SCHIP as disabled, elderly, or a special population, for the supplemental debit card program, according to the eligibility criteria under subsection (b).CommentsClose CommentsPermalink





‘(B) AUTOMATIC ENROLLMENT- The Secretary shall provide for the automatic enrollment in the supplemental debit card program of all individuals who are enrolled in Medicaid or SCHIP and who have been redetermined by a State under subparagraph (A) to be eligible for Medicaid or SCHIP. Any individual who is determined by a State not to qualify for the supplemental debit card program may retain coverage under Medicaid or SCHIP until June 30, 2011.CommentsClose CommentsPermalink





‘(3) ASSISTANCE WITH QUALIFIED HEALTH INSURANCE CREDIT- Each State shall, to the extent practicable, provide individuals residing within the State with information regarding the qualified health insurance credit described in section 25E of the Internal Revenue Code of 1986, including information regarding eligibility for, and how to claim, such credit.CommentsClose CommentsPermalink





‘(g) Administration-CommentsClose CommentsPermalink





‘(1) NATIONAL SYSTEM- The Secretary may enter into contracts or agreements with a State, a consortium of States, or a private entity, including a bank, enrollment broker, or similar entity, to establish and maintain a unified national system to support the processes and transactions necessary to administer this section.CommentsClose CommentsPermalink





‘(2) AUTOMATED SYSTEM- The Secretary shall establish an automated means, such as an electronic benefit transfer system, by which the benefits under this section shall be transferred to eligible families.CommentsClose CommentsPermalink





‘(3) VERIFICATION OF APPLICANT INFORMATION- The Secretary may verify information provided by applicants with the appropriate Federal, State, and local agencies, including the Internal Revenue Service, the Social Security Administration, the Department of Labor, and child support enforcement agencies.CommentsClose CommentsPermalink





‘(4) CHOICE COUNSELING- The Secretary may enter into contracts or agreements with a State, a consortium of a State, or a private entity, including an enrollment broker or community organization or other organization, to educate eligible families about their options and to assist in their enrollment in the supplemental debit card plan.CommentsClose CommentsPermalink





‘(5) APPEALS- The Secretary shall establish an independent appeals process, to be administered by an entity separate from the entity that makes initial eligibility determinations, which shall be available to individuals who are denied benefits under the supplemental debit card program.CommentsClose CommentsPermalink





‘(6) RESOLUTION OF ERRORS- The Secretary shall provide for a reconciliation process with the States to resolve any errors and adjudicate disputes due to incomplete or false information in a family’s application or in the billing process described in subsection (e).CommentsClose CommentsPermalink





‘(7) PENALTIES FOR FALSE INFORMATION- Any person who provides false information to qualify for the supplemental debit card program shall pay a penalty in the amount of 110 percent of the amount of assistance paid on behalf of such person and all members of such person’s family.CommentsClose CommentsPermalink





‘(h) Implementation Plan- Not later than 6 months after the date of enactment of this section, the Secretary shall submit to Congress a plan for implementing this program during fiscal years 2009-2012.CommentsClose CommentsPermalink





‘(i) Authorization of Appropriations-CommentsClose CommentsPermalink





‘(1) ADMINISTRATION OF THE SUPPLEMENTAL DEBIT CARD PROGRAM- To administer the program under this section, there are authorized to be appropriated--CommentsClose CommentsPermalink





‘(A) for fiscal year 2009, $300,000,000, for the design of a unified, national system of conducting the supplemental debit card program;CommentsClose CommentsPermalink





‘(B) for fiscal year 2010, $1,000,000,000 for start-up costs, including, contracting, hiring and training employees, and testing the program; andCommentsClose CommentsPermalink





‘(C) for fiscal year 2011 and each subsequent fiscal year, $3,000,000,000.CommentsClose CommentsPermalink





‘(2) AUTHORIZATION OF BENEFITS UNDER THE SUPPLEMENTAL DEBIT CARD PROGRAM- To provide the supplemental debit card benefits described in this section, there are authorized to be appropriated--CommentsClose CommentsPermalink





‘(A) for fiscal year 2011, $24,020,000,000;CommentsClose CommentsPermalink





‘(B) for fiscal year 2012, $25,220,000,000;CommentsClose CommentsPermalink





‘(C) for fiscal year 2013, $26,480,000,000;CommentsClose CommentsPermalink





‘(D) for fiscal year 2014, $27,810,000,000; andCommentsClose CommentsPermalink





‘(E) for fiscal year 2015, $29,200,000,000.’.CommentsClose CommentsPermalink

TITLE V--FIXING MEDICARE FOR AMERICAN SENIORSCommentsClose CommentsPermalink

Subtitle A--Increasing Programmatic Efficiency, Economy, and AccountabilityCommentsClose CommentsPermalink

SEC. 501. ELIMINATING INEFFICIENCIES AND INCREASING CHOICE IN MEDICARE ADVANTAGE.

Part C of title XVIII of the Social Security Act is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘MEDICARE ADVANTAGE COMPETITIVE BIDDING

‘Sec. 1860C-2. (a) Competitive Bidding-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In order to promote competition among Medicare Advantage plans and to increase the quality of care furnished under such plans, the Secretary shall establish and implement a competitive bidding mechanism under this part.CommentsClose CommentsPermalink





‘(2) MECHANISM TO BEGIN IN 2011- The mechanism established under paragraph (1) shall apply to all MA organizations and plans beginning in 2011.CommentsClose CommentsPermalink





‘(3) NO EFFECT ON PART D BENEFITS- The mechanism established under paragraph (1) shall not affect the provisions of this part relating to benefits under part D, including the bidding mechanism used for benefits under such part.CommentsClose CommentsPermalink





‘(b) Rules for Competitive Bidding Mechanism- Notwithstanding any other provision of this part, the following rules shall apply under the competitive bidding mechanism established under subsection (a).CommentsClose CommentsPermalink





‘(1) BENCHMARK- Benchmark amounts for an area for a year shall be established solely through the competitive bids of MA plans. The benchmark amount for each area for a year shall be the average bid of the plans in that area for that year. In establishing the benchmark for an area for a year under the preceding sentence, the Secretary shall exclude the highest and lowest bid for that area and year. The benchmark amount for an area for a year may not exceed the benchmark amount for that area and year that would have applied if this section had not been enacted.CommentsClose CommentsPermalink





‘(2) BIDS- The MA plan bid shall reflect the per capita payments that the MA plan will accept for providing a benefit package that is actuarially equivalent to 106 percent of the value of the original Medicare fee-for-service program option. MA plan bid submissions shall include data on plan average provider network contract rates compared to the rates under the original Medicare fee-for-service program option for the top 5 most common claim submissions per provider type.CommentsClose CommentsPermalink





‘(3) RISK ADJUSTMENT- The benchmark under paragraph (1) and the MA plan bid shall be risk adjusted using the risk adjustment requirements under this part.CommentsClose CommentsPermalink





‘(4) BENEFICIARY PREMIUMS- The MA monthly basic beneficiary premium for a beneficiary who enrolls in an MA plan whose plan bid is at or below the benchmark shall be zero and the beneficiary shall receive the full difference (if any) between the bid and the benchmark in the form of additional benefits or as a rebate on their premiums under this title. The MA monthly basic beneficiary premium for a beneficiary who enrolls in an MA plan whose plan bid is above the benchmark shall be equal to the amount by which the bid exceeds the benchmark.CommentsClose CommentsPermalink





‘(5) BENCHMARK AMOUNTS FOR RURAL COUNTIES- The Secretary may adjust the benchmark amount established under paragraph (1) for any rural county (as identified by the Secretary after consultation with the Secretary of Commerce) to encourage plan participation in such county.CommentsClose CommentsPermalink





‘(6) EXISTING REQUIREMENTS- Requirements relating to licensure, quality, and beneficiary protections that would otherwise apply under this part shall apply under the competitive bidding mechanism established under subsection (a).CommentsClose CommentsPermalink





‘(c) Waiver- In order to implement the competitive bidding mechanism under established subsection (a), the Secretary may waive or modify requirements under this part.’.CommentsClose CommentsPermalink

SEC. 502. MEDICARE ACCOUNTABLE CARE ORGANIZATION DEMONSTRATION PROGRAM.

(a) Establishment-CommentsClose CommentsPermalink





(1) IN GENERAL- In order to promote innovative care coordination and delivery that is cost-effective, the Secretary of Health and Human Services (in this section referred to as the ‘Secretary’) shall conduct a demonstration program under the Medicare program under which--CommentsClose CommentsPermalink





(A) groups of providers meeting certain criteria may work together to manage and coordinate care for Medicare fee-for-service beneficiaries through an Accountable Care Organization (in this section referred to as an ‘ACO’); andCommentsClose CommentsPermalink





(B) providers in participating ACOs are eligible for bonuses based on performance.CommentsClose CommentsPermalink





(2) MEDICARE FEE-FOR-SERVICE BENEFICIARY DEFINED- In this section, the term ‘Medicare fee-for-service beneficiary’ means an individual who is enrolled in the original medicare fee-for-service program under parts A and B of title XVIII of the Social Security Act and not enrolled in an MA plan under part C of such title.CommentsClose CommentsPermalink





(b) Eligible ACOs-CommentsClose CommentsPermalink





(1) IN GENERAL- Subject to paragraph (2), the following provider groups are eligible to participate as ACOs under the demonstration program under this section:CommentsClose CommentsPermalink





(A) Physicians in group practice arrangements.CommentsClose CommentsPermalink





(B) Networks of individual physician practices.CommentsClose CommentsPermalink





(C) Partnerships or joint venture arrangements between hospitals and physicians.CommentsClose CommentsPermalink





(D) Partnerships or joint ventures, which may include pharmacists providing medication therapy management.CommentsClose CommentsPermalink





(E) Hospitals employing physicians.CommentsClose CommentsPermalink





(F) Integrated delivery systems.CommentsClose CommentsPermalink





(G) Community-based coalitions of providers.