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S 1796 PCSCommentsClose CommentsPermalink

To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.CommentsClose CommentsPermalink

October 19, 2009CommentsClose CommentsPermalink

Mr. BAUCUS, from the Committee on Finance reported the following original bill; which was read twice and placed on the calendarCommentsClose CommentsPermalink

To provide affordable, quality health care for all Americans and reduce the growth in health care spending, 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 ‘America’s Healthy Future Act of 2009’.CommentsClose CommentsPermalink





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





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

TITLE I--HEALTH CARE COVERAGE

Subtitle A--Insurance Market Reforms

Sec. 1001. Insurance market reforms in the individual and small group markets.CommentsClose CommentsPermalink

‘TITLE XXII--HEALTH INSURANCE COVERAGE

‘Sec. 2200. Ensuring essential and affordable health benefits coverage for all Americans.CommentsClose CommentsPermalink

‘PART A--Insurance Reforms

‘subpart 1--requirements in individual and small group markets

‘Sec. 2201. General requirements and definitions.CommentsClose CommentsPermalink

‘Sec. 2202. Prohibition on preexisting condition exclusions.CommentsClose CommentsPermalink

‘Sec. 2203. Guaranteed issue and renewal for insured plans.CommentsClose CommentsPermalink

‘Sec. 2204. Premium rating rules.CommentsClose CommentsPermalink

‘Sec. 2205. Use of uniform outline of coverage documents.CommentsClose CommentsPermalink

‘subpart 2--reforms relating to allocation of risks

‘Sec. 2211. Rating areas; pooling of risks; phase in of rating rules in small group markets.CommentsClose CommentsPermalink

‘Sec. 2212. Risk adjustment.CommentsClose CommentsPermalink

‘Sec. 2213. Establishment of transitional reinsurance program for individual markets in each State.CommentsClose CommentsPermalink

‘Sec. 2214. Establishment of risk corridors for plans in individual and small group markets.CommentsClose CommentsPermalink

‘Sec. 2215. Temporary high risk pools for individuals with preexisting conditions.CommentsClose CommentsPermalink

‘Sec. 2216. Reinsurance for retirees covered by employer-based plans.CommentsClose CommentsPermalink

‘subpart 3--preservation of right to maintain existing coverage

‘Sec. 2221. Grandfathered health benefits plans.CommentsClose CommentsPermalink

‘subpart 4--continued role of states

‘Sec. 2225. Continued State enforcement of insurance regulations.CommentsClose CommentsPermalink

‘Sec. 2226. Waiver of health insurance reform requirements.CommentsClose CommentsPermalink

‘Sec. 2227. Provisions relating to offering of plans in more than one State.CommentsClose CommentsPermalink

‘Sec. 2228. State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid.CommentsClose CommentsPermalink

‘subpart 5--other definitions and rules

‘Sec. 2230. Other definitions and rules.CommentsClose CommentsPermalink

Subtitle B--Exchanges and Consumer Assistance

Sec. 1101. Establishment of qualified health benefits plan exchanges.CommentsClose CommentsPermalink

‘PART B--Exchange and Consumer Assistance

‘subpart 1--individuals and small employers offered affordable choices

‘Sec. 2231. Rights and responsibilities regarding choice of coverage through exchange.CommentsClose CommentsPermalink

‘Sec. 2232. Qualified individuals and small employers; access limited to citizens and lawful residents.CommentsClose CommentsPermalink

‘subpart 2--establishment of exchanges

‘Sec. 2235. Establishment of exchanges by States.CommentsClose CommentsPermalink

‘Sec. 2236. Functions performed by Secretary, States, and exchanges.CommentsClose CommentsPermalink

‘Sec. 2237. Duties of the Secretary to facilitate exchanges.CommentsClose CommentsPermalink

‘Sec. 2238. Procedures for determining eligibility for exchange participation, premium credits and cost-sharing subsidies, and individual responsibility exemptions.CommentsClose CommentsPermalink

‘Sec. 2239. Streamlining of procedures for enrollment through an exchange and State Medicaid, CHIP, and health subsidy programs.CommentsClose CommentsPermalink

Sec. 1102. Encouraging meaningful use of electronic health records.CommentsClose CommentsPermalink

Subtitle C--Making Coverage Affordable

PART I--Essential Benefits Coverage

Sec. 1201. Provisions to ensure coverage of essential benefits.CommentsClose CommentsPermalink

‘PART C--Making Coverage Affordable

‘subpart 1--essential benefits coverage

‘Sec. 2241. Requirements for qualified health benefits plan.CommentsClose CommentsPermalink

‘Sec. 2242. Essential benefits package defined.CommentsClose CommentsPermalink

‘Sec. 2243. Levels of coverage.CommentsClose CommentsPermalink

‘Sec. 2244. Application of certain rules to plans in group markets.CommentsClose CommentsPermalink

‘Sec. 2245. Special rules relating to coverage of abortion services.CommentsClose CommentsPermalink

Sec. 1202. Application of State and Federal laws regarding abortion.CommentsClose CommentsPermalink





Sec. 1203. Application of emergency services laws.CommentsClose CommentsPermalink

PART II--Premium Credits, Cost-sharing Subsidies, and Small Business Credits

subpart a--premium credits and cost-sharing subsidies

Sec. 1205. Refundable credit providing premium assistance for coverage under a qualified health benefits plan.CommentsClose CommentsPermalink

‘Sec. 36B. Refundable credit for coverage under a qualified health benefits plan.CommentsClose CommentsPermalink

Sec. 1206. Cost-sharing subsidies and advance payments of premium credits and cost-sharing subsidies.CommentsClose CommentsPermalink

‘subpart 2--premium credits and cost-sharing subsidies

‘Sec. 2246. Premium credits.CommentsClose CommentsPermalink

‘Sec. 2247. Cost-sharing subsidies for individuals enrolling in qualified health benefit plans.CommentsClose CommentsPermalink

‘Sec. 2248. Advance determination and payment of premium credits and cost-sharing subsidies.CommentsClose CommentsPermalink

Sec. 1207. Disclosures to carry out eligibility requirements for certain programs.CommentsClose CommentsPermalink





Sec. 1208. Premium credit and subsidy refunds and payments disregarded for Federal and Federally-assisted programs.CommentsClose CommentsPermalink





Sec. 1209. Fail-safe mechanism to prevent increase in Federal budget deficit.CommentsClose CommentsPermalink

subpart b--credit for small employers

Sec. 1221. Credit for employee health insurance expenses of small businesses.CommentsClose CommentsPermalink

‘Sec. 45R. Employee health insurance expenses of small employers.CommentsClose CommentsPermalink

Subtitle D--Shared Responsibility

PART I--Individual Responsibility

Sec. 1301. Excise tax on individuals without essential health benefits coverage.CommentsClose CommentsPermalink

‘Chapter 48--Maintenance of Essential Health Benefits Coverage

‘Sec. 5000A. Failure to maintain essential health benefits coverage.CommentsClose CommentsPermalink

Sec. 1302. Reporting of health insurance coverage.CommentsClose CommentsPermalink

‘subpart d--information regarding health insurance coverage

‘Sec. 6055. Reporting of health insurance coverage.CommentsClose CommentsPermalink

PART II--Employer Responsibility

Sec. 1306. Employer shared responsibility requirement.CommentsClose CommentsPermalink

‘Sec. 4980H. Employer responsibility to provide health coverage.CommentsClose CommentsPermalink

Sec. 1307. Reporting of employer health insurance coverage.CommentsClose CommentsPermalink

‘Sec. 6056. Large employers required to report on health insurance coverage.CommentsClose CommentsPermalink

Subtitle E--Federal Program for Health Care Cooperatives

Sec. 1401. Establishment of Federal program for health care cooperatives.CommentsClose CommentsPermalink

‘PART D--Federal Program for Health Care Cooperatives

‘Sec. 2251. Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers.CommentsClose CommentsPermalink

Subtitle F--Transparency and Accountability

Sec. 1501. Provisions ensuring transparency and accountability.CommentsClose CommentsPermalink

‘Sec. 2229. Requirements relating to transparency and accountability.CommentsClose CommentsPermalink

Sec. 1502. Reporting on utilization of premium dollars and standard hospital charges.CommentsClose CommentsPermalink





Sec. 1503. Development and utilization of uniform outline of coverage documents.CommentsClose CommentsPermalink





Sec. 1504. Development of standard definitions, personal scenarios, and annual personalized statements.CommentsClose CommentsPermalink

Subtitle G--Role of Public Programs

PART I--Medicaid Coverage for the Lowest Income Populations

Sec. 1601. Medicaid coverage for the lowest income populations.CommentsClose CommentsPermalink





Sec. 1602. Income eligibility for nonelderly determined using modified gross income.CommentsClose CommentsPermalink





Sec. 1603. Requirement to offer premium assistance for employer-sponsored insurance.CommentsClose CommentsPermalink





Sec. 1604. Payments to territories.CommentsClose CommentsPermalink





Sec. 1605. Medicaid Improvement Fund rescission.CommentsClose CommentsPermalink

PART II--Children’s Health Insurance Program

Sec. 1611. Additional federal financial participation for CHIP.CommentsClose CommentsPermalink





Sec. 1612. Technical corrections.CommentsClose CommentsPermalink

PART III--Enrollment Simplification

Sec. 1621. Enrollment Simplification and coordination with State health insurance exchanges.CommentsClose CommentsPermalink





Sec. 1622. Permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations.CommentsClose CommentsPermalink





Sec. 1623. Promoting transparency in the development, implementation, and evaluation of Medicaid and CHIP waivers and section 1937 State plan amendments.CommentsClose CommentsPermalink





Sec. 1624. Standards and best practices to improve enrollment of vulnerable and underserved populations.CommentsClose CommentsPermalink

PART IV--Medicaid Services

Sec. 1631. Coverage for freestanding birth center services.CommentsClose CommentsPermalink





Sec. 1632. Concurrent care for children.CommentsClose CommentsPermalink





Sec. 1633. Funding to expand State Aging and Disability Resource Centers.CommentsClose CommentsPermalink





Sec. 1634. Community First Choice Option.CommentsClose CommentsPermalink





Sec. 1635. Protection for recipients of home and community-based services against spousal impoverishment.CommentsClose CommentsPermalink





Sec. 1636. Incentives for States to offer home and community-based services as a long-term care alternative to nursing homes.CommentsClose CommentsPermalink





Sec. 1636A. Removal of barriers to providing home and community-based services.CommentsClose CommentsPermalink





Sec. 1637. Money Follows the Person Rebalancing Demonstration.CommentsClose CommentsPermalink





Sec. 1638. Clarification of definition of medical assistance.CommentsClose CommentsPermalink





Sec. 1639. State eligibility option for family planning services.CommentsClose CommentsPermalink





Sec. 1640. Grants for school-based health centers.CommentsClose CommentsPermalink





Sec. 1641. Therapeutic foster care.CommentsClose CommentsPermalink





Sec. 1642. Sense of the Senate regarding long-term care.CommentsClose CommentsPermalink

PART V--Medicaid Prescription Drug Coverage

Sec. 1651. Prescription drug rebates.CommentsClose CommentsPermalink





Sec. 1652. Elimination of exclusion of coverage of certain drugs.CommentsClose CommentsPermalink





Sec. 1653. Providing adequate pharmacy reimbursement.CommentsClose CommentsPermalink





Sec. 1654. Study of barriers to appropriate utilization of generic medicine in federal health care programs.CommentsClose CommentsPermalink

PART VI--Medicaid Disproportionate Share Hospital (DSH) Payments

Sec. 1655. Disproportionate share hospital payments.CommentsClose CommentsPermalink

PART VII--Dual Eligibles

Sec. 1661. 5-year period for demonstration projects.CommentsClose CommentsPermalink





Sec. 1662. Providing Federal coverage and payment coordination for low-income Medicare beneficiaries.CommentsClose CommentsPermalink

PART VIII--Medicaid Quality

Sec. 1671. Adult health quality measures.CommentsClose CommentsPermalink





Sec. 1672. Payment Adjustment for Health Care-Acquired Conditions.CommentsClose CommentsPermalink





Sec. 1673. Demonstration project to evaluate integrated care around a hospitalization.CommentsClose CommentsPermalink





Sec. 1674. Medicaid Global Payment System Demonstration Project.CommentsClose CommentsPermalink





Sec. 1675. Pediatric Accountable Care Organization Demonstration Project.CommentsClose CommentsPermalink





Sec. 1676. Medicaid emergency psychiatric demonstration project.CommentsClose CommentsPermalink

PART IX--Improvements to the Medicaid and CHIP Payment and Access Commission (MACPAC)

Sec. 1681. MACPAC assessment of policies affecting all Medicaid beneficiaries.CommentsClose CommentsPermalink

PART X--American Indians and Alaska Natives

Sec. 1691. Special rules relating to Indians.CommentsClose CommentsPermalink





Sec. 1692. Elimination of sunset for reimbursement for all medicare part B services furnished by certain indian hospitals and clinics.CommentsClose CommentsPermalink

Subtitle H--Addressing Health Disparities

Sec. 1701. Standardized collection of data.CommentsClose CommentsPermalink





Sec. 1702. Required collection of data.CommentsClose CommentsPermalink





Sec. 1703. Data sharing and protection.CommentsClose CommentsPermalink





Sec. 1704. Inclusion of information about the importance of having a health care power of attorney in transition planning for children aging out of foster care and independent living programs.CommentsClose CommentsPermalink

Subtitle I--Maternal and Child Health Services

Sec. 1801. Maternal, infant, and early childhood home visiting programs.CommentsClose CommentsPermalink





Sec. 1802. Support, education, and research for postpartum depression.CommentsClose CommentsPermalink





Sec. 1803. Personal responsibility education for adulthood training.CommentsClose CommentsPermalink





Sec. 1804. Restoration of funding for abstinence education.CommentsClose CommentsPermalink

Subtitle J--Programs of Health Promotion and Disease Prevention

Sec. 1901. Programs of health promotion and disease prevention.CommentsClose CommentsPermalink

Subtitle K--Elder Justice Act

Sec. 1911. Short title of subtitle.CommentsClose CommentsPermalink





Sec. 1912. Definitions.CommentsClose CommentsPermalink





Sec. 1913. Elder Justice.CommentsClose CommentsPermalink

Subtitle L--Provisions of General Application

Sec. 1921. Protecting Americans and ensuring taxpayer funds in government health care plans do not support or fund physician-assisted suicide; prohibition against discrimination on assisted suicide.CommentsClose CommentsPermalink





Sec. 1922. Protection of access to quality health care through the Department of Veterans Affairs and the Department of Defense.CommentsClose CommentsPermalink





Sec. 1923. Continued application of antitrust laws.CommentsClose CommentsPermalink

TITLE II--PROMOTING DISEASE PREVENTION AND WELLNESS

Subtitle A--Medicare

Sec. 2001. Coverage of annual wellness visit providing a personalized prevention plan.CommentsClose CommentsPermalink





Sec. 2002. Removal of barriers to preventive services.CommentsClose CommentsPermalink





Sec. 2003. Evidence-based coverage of preventive services.CommentsClose CommentsPermalink





Sec. 2004. GAO study and report on medicare beneficiary access to vaccines.CommentsClose CommentsPermalink





Sec. 2005. Incentives for healthy lifestyles.CommentsClose CommentsPermalink

Subtitle B--Medicaid

Sec. 2101. Improving access to preventive services for eligible adults.CommentsClose CommentsPermalink





Sec. 2102. Coverage of comprehensive tobacco cessation services for pregnant women.CommentsClose CommentsPermalink





Sec. 2103. Incentives for healthy lifestyles.CommentsClose CommentsPermalink





Sec. 2104. State option to provide health homes for enrollees with chronic conditions.CommentsClose CommentsPermalink





Sec. 2105. Funding for Childhood Obesity Demonstration Project.CommentsClose CommentsPermalink





Sec. 2106. Public awareness of preventive and obesity-related services.CommentsClose CommentsPermalink

TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE

Subtitle A--Transforming the Health Care Delivery System

PART I--Linking Payment to Quality Outcomes Under the Medicare Program

Sec. 3001. Hospital Value-Based purchasing program.CommentsClose CommentsPermalink





Sec. 3002. Improvements to the physician quality reporting system.CommentsClose CommentsPermalink





Sec. 3003. Improvements to the physician feedback program.CommentsClose CommentsPermalink





Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs.CommentsClose CommentsPermalink





Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.CommentsClose CommentsPermalink





Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities and home health agencies.CommentsClose CommentsPermalink





Sec. 3007. Value-based payment modifier under the physician fee schedule.CommentsClose CommentsPermalink





Sec. 3008. Payment adjustment for conditions acquired in hospitals.CommentsClose CommentsPermalink

PART II--Strengthening the Quality Infrastructure

Sec. 3011. National strategy.CommentsClose CommentsPermalink





Sec. 3012. Interagency Working Group on Health Care Quality.CommentsClose CommentsPermalink





Sec. 3013. Quality measure development.CommentsClose CommentsPermalink





Sec. 3014. Quality measure endorsement.CommentsClose CommentsPermalink

PART III--Encouraging Development of New Patient Care Models

Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation within CMS.CommentsClose CommentsPermalink





Sec. 3022. Medicare shared savings program.CommentsClose CommentsPermalink





Sec. 3023. National pilot program on payment bundling.CommentsClose CommentsPermalink





Sec. 3024. Independence at home pilot program.CommentsClose CommentsPermalink





Sec. 3025. Hospital readmissions reduction program.CommentsClose CommentsPermalink





Sec. 3026. Community-Based Care Transitions Program.CommentsClose CommentsPermalink





Sec. 3027. Extension of gainsharing demonstration.CommentsClose CommentsPermalink

PART IV--Strengthening Primary Care and Other Workforce Improvements

Sec. 3031. Expanding access to primary care services and general surgery services.CommentsClose CommentsPermalink





Sec. 3031A. Medicare Federally qualified health center improvements.CommentsClose CommentsPermalink





Sec. 3032. Distribution of additional residency positions.CommentsClose CommentsPermalink





Sec. 3033. Counting resident time in outpatient settings and allowing flexibility for jointly operated residency training programs.CommentsClose CommentsPermalink





Sec. 3034. Rules for counting resident time for didactic and scholarly activities and other activities.CommentsClose CommentsPermalink





Sec. 3035. Preservation of resident cap positions from closed and acquired hospitals.CommentsClose CommentsPermalink





Sec. 3036. Workforce Advisory Committee.CommentsClose CommentsPermalink





Sec. 3037. Demonstration projects To address health professions workforce needs; extension of family-to-family health information centers.CommentsClose CommentsPermalink





Sec. 3038. Increasing teaching capacity.CommentsClose CommentsPermalink





Sec. 3039. Graduate nurse education demonstration program.CommentsClose CommentsPermalink

PART V--Health Information Technology

Sec. 3041. Free clinics and certified EHR technology.CommentsClose CommentsPermalink

Subtitle B--Improving Medicare for Patients and Providers

PART I--Ensuring Beneficiary Access to Physician Care and Other Services

Sec. 3101. Increase in the physician payment update.CommentsClose CommentsPermalink





Sec. 3102. Extension of the work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee schedule.CommentsClose CommentsPermalink





Sec. 3103. Extension of exceptions process for Medicare therapy caps.CommentsClose CommentsPermalink





Sec. 3104. Extension of payment for technical component of certain physician pathology services.CommentsClose CommentsPermalink





Sec. 3105. Extension of ambulance add-ons.CommentsClose CommentsPermalink





Sec. 3106. Extension of certain payment rules for long-term care hospital services and of moratorium on the establishment of certain hospitals and facilities.CommentsClose CommentsPermalink





Sec. 3107. Extension of physician fee schedule mental health add-on.CommentsClose CommentsPermalink





Sec. 3108. Permitting physician assistants to order post-Hospital extended care services and to provide for recognition of attending physician assistants as attending physicians to serve hospice patients.CommentsClose CommentsPermalink





Sec. 3109. Recognition of certified diabetes educators as certified providers for purposes of Medicare diabetes outpatient self-management training services.CommentsClose CommentsPermalink





Sec. 3110. Exemption of certain pharmacies from accreditation requirements.CommentsClose CommentsPermalink





Sec. 3111. Part B special enrollment period for disabled TRICARE beneficiaries.CommentsClose CommentsPermalink





Sec. 3112. Payment for bone density tests.CommentsClose CommentsPermalink





Sec. 3113. Revision to the Medicare Improvement Fund.CommentsClose CommentsPermalink





Sec. 3114. Treatment of certain complex diagnostic laboratory tests.CommentsClose CommentsPermalink





Sec. 3115. Improved access for certified-midwife services.CommentsClose CommentsPermalink





Sec. 3116. Working Group on Access to Emergency Medical Care.CommentsClose CommentsPermalink

PART II--Rural Protections

Sec. 3121. Extension of outpatient hold harmless provision.CommentsClose CommentsPermalink





Sec. 3122. Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas.CommentsClose CommentsPermalink





Sec. 3123. Extension of the Rural Community Hospital Demonstration Program.CommentsClose CommentsPermalink





Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program.CommentsClose CommentsPermalink





Sec. 3125. Temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals.CommentsClose CommentsPermalink





Sec. 3126. Improvements to the demonstration project on community health integration models in certain rural counties.CommentsClose CommentsPermalink





Sec. 3127. MedPAC study on adequacy of Medicare payments for health care providers serving in rural areas.CommentsClose CommentsPermalink





Sec. 3128. Technical correction related to critical access hospital services.CommentsClose CommentsPermalink





Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility program.CommentsClose CommentsPermalink

PART III--Improving Payment Accuracy

Sec. 3131. Payment adjustments for home health care.CommentsClose CommentsPermalink





Sec. 3132. Hospice reform.CommentsClose CommentsPermalink





Sec. 3133. Improvement to medicare disproportionate share hospital (DSH) payments.CommentsClose CommentsPermalink





Sec. 3134. Misvalued codes under the physician fee schedule.CommentsClose CommentsPermalink





Sec. 3135. Modification of equipment utilization factor for advanced imaging services.CommentsClose CommentsPermalink





Sec. 3136. Revision of payment for power-driven wheelchairs.CommentsClose CommentsPermalink





Sec. 3137. Hospital wage index improvement.CommentsClose CommentsPermalink





Sec. 3138. Treatment of certain cancer hospitals.CommentsClose CommentsPermalink





Sec. 3139. Payment for biosimilar biological products.CommentsClose CommentsPermalink





Sec. 3140. Public meeting and report on payment systems for new clinical laboratory diagnostic tests.CommentsClose CommentsPermalink





Sec. 3141. Medicare hospice concurrent care demonstration program.CommentsClose CommentsPermalink





Sec. 3142. Application of budget neutrality on a national basis in the calculation of the Medicare hospital wage index floor for each all-urban and rural state.CommentsClose CommentsPermalink





Sec. 3143. HHS study on urban Medicare-dependent hospitals.CommentsClose CommentsPermalink

Subtitle C--Provisions Relating to Part C

Sec. 3201. Medicare Advantage payment.CommentsClose CommentsPermalink





Sec. 3202. Benefit protection and simplification.CommentsClose CommentsPermalink





Sec. 3203. Application of coding intensity adjustment during MA payment transition.CommentsClose CommentsPermalink





Sec. 3204. Simplification of annual beneficiary election periods.CommentsClose CommentsPermalink





Sec. 3205. Extension for specialized MA plans for special needs individuals.CommentsClose CommentsPermalink





Sec. 3206. Extension of reasonable cost contracts.CommentsClose CommentsPermalink





Sec. 3207. Technical correction to MA private fee-for-service plans.CommentsClose CommentsPermalink





Sec. 3208. Making senior housing facility demonstration permanent.CommentsClose CommentsPermalink





Sec. 3209. Development of new standards for certain Medigap plans.CommentsClose CommentsPermalink

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

Sec. 3301. Medicare prescription drug discount program for brand-Name drugs.CommentsClose CommentsPermalink





Sec. 3302. Improvement in determination of Medicare part D low-income benchmark premium.CommentsClose CommentsPermalink





Sec. 3303. Voluntary de minimus policy for subsidy eligible individuals under prescription drug plans and MA-PD plans.CommentsClose CommentsPermalink





Sec. 3304. Special rule for widows and widowers regarding eligibility for low-income assistance.CommentsClose CommentsPermalink





Sec. 3305. Improved information for subsidy eligible individuals reassigned to prescription drug plans and MA-PD plans.CommentsClose CommentsPermalink





Sec. 3306. Funding outreach and assistance for low-income programs.CommentsClose CommentsPermalink





Sec. 3307. Improving formulary requirements for prescription drug plans and MA-PD plans with respect to certain categories or classes of drugs.CommentsClose CommentsPermalink





Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries.CommentsClose CommentsPermalink





Sec. 3309. Simplification of plan information.CommentsClose CommentsPermalink





Sec. 3310. Limitation on removal or change of coverage of covered part D drugs under a formulary under a prescription drug plan or an MA-PD plan.CommentsClose CommentsPermalink





Sec. 3311. Elimination of cost sharing for certain dual eligible individuals.CommentsClose CommentsPermalink





Sec. 3312. Reducing wasteful dispensing of outpatient prescription drugs in long-term care facilities under prescription drug plans and MA-PD plans.CommentsClose CommentsPermalink





Sec. 3313. Improved Medicare prescription drug plan and MA-PD plan complaint system.CommentsClose CommentsPermalink





Sec. 3314. Uniform exceptions and appeals process for prescription drug plans and MA-PD plans.CommentsClose CommentsPermalink





Sec. 3315. Office of the Inspector General studies and reports.CommentsClose CommentsPermalink





Sec. 3316. HHS study and annual reports on coverage for dual eligibles.CommentsClose CommentsPermalink





Sec. 3317. Including costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the annual out-of-pocket threshold under part D.CommentsClose CommentsPermalink

Subtitle E--Ensuring Medicare Sustainability

Sec. 3401. Revision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not already incorporate such improvements.CommentsClose CommentsPermalink





Sec. 3402. Temporary adjustment to the calculation of part B premiums.CommentsClose CommentsPermalink





Sec. 3403. Medicare Commission.CommentsClose CommentsPermalink





Sec. 3404. Ensuring medicare savings are kept in the medicare program.CommentsClose CommentsPermalink

Subtitle F--Comparative Effectiveness Research

Sec. 3501. Comparative effectiveness research.CommentsClose CommentsPermalink





Sec. 3502. Coordination with Federal coordinating council for comparative effectiveness research.CommentsClose CommentsPermalink





Sec. 3503. GAO report on national coverage determinations process.CommentsClose CommentsPermalink

Subtitle G--Administrative Simplification

Sec. 3601. Administrative Simplification.CommentsClose CommentsPermalink

Subtitle H--Sense of the Senate Regarding Medical Malpractice

Sec. 3701. Sense of the Senate regarding medical malpractice.CommentsClose CommentsPermalink

TITLE IV--TRANSPARENCY AND PROGRAM INTEGRITY

Subtitle A--Limitation on Medicare Exception to the Prohibition on Certain Physician Referrals for Hospitals

Sec. 4001. Limitation on Medicare exception to the prohibition on certain physician referrals for hospitals.CommentsClose CommentsPermalink

Subtitle B--Physician Ownership and Other Transparency

Sec. 4101. Transparency reports and reporting of physician ownership or investment interests.CommentsClose CommentsPermalink





Sec. 4102. Disclosure requirements for in-office ancillary services exception to the prohibition on physician self-referral for certain imaging services.CommentsClose CommentsPermalink





Sec. 4103. Prescription drug sample transparency.CommentsClose CommentsPermalink

Subtitle C--Nursing Home Transparency and Improvement

PART I--Improving Transparency of Information

Sec. 4201. Required disclosure of ownership and additional disclosable parties information.CommentsClose CommentsPermalink





Sec. 4202. Accountability requirements for skilled nursing facilities and nursing facilities.CommentsClose CommentsPermalink





Sec. 4203. Nursing home compare Medicare website.CommentsClose CommentsPermalink





Sec. 4204. Reporting of expenditures.CommentsClose CommentsPermalink





Sec. 4205. Standardized complaint form.CommentsClose CommentsPermalink





Sec. 4206. Ensuring staffing accountability.CommentsClose CommentsPermalink





Sec. 4207. GAO study and report on Five-Star Quality Rating System.CommentsClose CommentsPermalink

PART II--Targeting Enforcement

Sec. 4211. Civil money penalties.CommentsClose CommentsPermalink





Sec. 4212. National independent monitor pilot program.CommentsClose CommentsPermalink





Sec. 4213. Notification of facility closure.CommentsClose CommentsPermalink





Sec. 4214. National demonstration projects on culture change and use of information technology in nursing homes.CommentsClose CommentsPermalink

PART III--Improving Staff Training

Sec. 4221. Dementia and abuse prevention training.CommentsClose CommentsPermalink

Subtitle D--Nationwide Program for National and State Background Checks on Direct Patient Access Employees of Long-term Care Facilities and Providers

Sec. 4301. Nationwide program for National and State background checks on direct patient access employees of long-term care facilities and providers.CommentsClose CommentsPermalink

Subtitle E--Pharmacy Benefit Managers

Sec. 4401. Pharmacy benefit managers transparency requirements.CommentsClose CommentsPermalink

TITLE V--FRAUD, WASTE, AND ABUSE

Subtitle A--Medicare and Medicaid

Sec. 5001. Provider screening and other enrollment requirements under Medicare and Medicaid.CommentsClose CommentsPermalink





Sec. 5002. Enhanced Medicare and Medicaid program integrity provisions.CommentsClose CommentsPermalink





Sec. 5003. Elimination of duplication between the Healthcare Integrity and Protection Data Bank and the National Practitioner Data Bank.CommentsClose CommentsPermalink





Sec. 5004. Maximum period for submission of Medicare claims reduced to not more than 12 months.CommentsClose CommentsPermalink





Sec. 5005. Physicians who order items or services required to be Medicare enrolled physicians or eligible professionals.CommentsClose CommentsPermalink





Sec. 5006. Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse.CommentsClose CommentsPermalink





Sec. 5007. Face to face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment under Medicare.CommentsClose CommentsPermalink





Sec. 5008. Enhanced penalties.CommentsClose CommentsPermalink





Sec. 5009. Medicare self-referral disclosure protocol.CommentsClose CommentsPermalink





Sec. 5010. Adjustments to the Medicare durable medical equipment, prosthetics, orthotics, and supplies competitive acquisition program.CommentsClose CommentsPermalink





Sec. 5011. Expansion of the Recovery Audit Contractor (RAC) program.CommentsClose CommentsPermalink

Subtitle B--Additional Medicaid Provisions

Sec. 5101. Termination of provider participation under Medicaid if terminated under Medicare or other State plan.CommentsClose CommentsPermalink





Sec. 5102. Medicaid exclusion from participation relating to certain ownership, control, and management affiliations.CommentsClose CommentsPermalink





Sec. 5103. Billing agents, clearinghouses, or other alternate payees required to register under Medicaid.CommentsClose CommentsPermalink





Sec. 5104. Requirement to report expanded set of data elements under MMIS to detect fraud and abuse.CommentsClose CommentsPermalink





Sec. 5105. Prohibition on payments to institutions or entities located outside of the United States.CommentsClose CommentsPermalink





Sec. 5106. Overpayments.CommentsClose CommentsPermalink





Sec. 5107. Enhanced funding for program integrity activities.CommentsClose CommentsPermalink





Sec. 5108. Mandatory State use of national correct coding initiative.CommentsClose CommentsPermalink





Sec. 5109. General effective date.CommentsClose CommentsPermalink

TITLE VI--REVENUE PROVISIONS

Subtitle A--Revenue Offset Provisions

Sec. 6001. Excise tax on high cost employer-sponsored health coverage.CommentsClose CommentsPermalink





Sec. 6002. Inclusion of cost of employer-sponsored health coverage on W-2.CommentsClose CommentsPermalink





Sec. 6003. Distributions for medicine qualified only if for prescribed drug or insulin.CommentsClose CommentsPermalink





Sec. 6004. Increase in additional tax on distributions from HSAs not used for qualified medical expenses.CommentsClose CommentsPermalink





Sec. 6005. Limitation on health flexible spending arrangements under cafeteria plans.CommentsClose CommentsPermalink





Sec. 6006. Expansion of information reporting requirements.CommentsClose CommentsPermalink





Sec. 6007. Additional requirements for charitable hospitals.CommentsClose CommentsPermalink





Sec. 6008. Imposition of annual fee on branded prescription pharmaceutical manufacturers and importers.CommentsClose CommentsPermalink





Sec. 6009. Imposition of annual fee on medical device manufacturers and importers.CommentsClose CommentsPermalink





Sec. 6010. Imposition of annual fee on health insurance providers.CommentsClose CommentsPermalink





Sec. 6011. Study and report of effect on veterans health care.CommentsClose CommentsPermalink





Sec. 6012. Elimination of deduction for expenses allocable to Medicare Part D subsidy.CommentsClose CommentsPermalink





Sec. 6013. Modification of itemized deduction for medical expenses.CommentsClose CommentsPermalink





Sec. 6014. Limitation on excessive remuneration paid by certain health insurance providers.CommentsClose CommentsPermalink

Subtitle B--Other Provisions

Sec. 6021. Exclusion of health benefits provided by Indian tribal governments.CommentsClose CommentsPermalink





Sec. 6022. Establishment of simple cafeteria plans for small businesses.CommentsClose CommentsPermalink





Sec. 6023. Qualifying therapeutic discovery project credit.CommentsClose CommentsPermalink

TITLE I--HEALTH CARE COVERAGECommentsClose CommentsPermalink

Subtitle A--Insurance Market ReformsCommentsClose CommentsPermalink

SEC. 1001. INSURANCE MARKET REFORMS IN THE INDIVIDUAL AND SMALL GROUP MARKETS.

The Social Security Act (42 U.S.C. 301 et seq.) is amended by adding at the end the following:CommentsClose CommentsPermalink

‘TITLE XXII--HEALTH INSURANCE COVERAGECommentsClose CommentsPermalink

‘SEC. 2200. ENSURING ESSENTIAL AND AFFORDABLE HEALTH BENEFITS COVERAGE FOR ALL AMERICANS.

‘It is the purpose of this title to ensure that all Americans have access to affordable and essential health benefits coverage--CommentsClose CommentsPermalink





‘(1) by requiring that all new health benefits plans offered to individuals and employees in the individual and small group markets be qualified health benefits plans that meet the insurance rating reforms and essential health benefits coverage requirements established under parts A and C;CommentsClose CommentsPermalink





‘(2) by establishing State exchanges under part B that provide individuals and employees in the individual and small group markets greater access to qualified health benefits plans and to information concerning these health plans;CommentsClose CommentsPermalink





‘(3) by making health benefits coverage more affordable by establishing premium credits and cost-sharing subsidies under part C for individuals enrolling in a health benefits plan through an exchange; andCommentsClose CommentsPermalink





‘(4) by establishing the CO-OP program under part D to encourage the establishment of nonprofit health care cooperatives.CommentsClose CommentsPermalink

‘PART A--INSURANCE REFORMS

‘Subpart 1--Requirements in Individual and Small Group Markets

‘SEC. 2201. GENERAL REQUIREMENTS AND DEFINITIONS.

‘(a) New Plans Must Be Qualified Health Benefits Plans- Except as provided in subpart 3 (relating to preservation of existing coverage), each State shall provide that each health benefits plan which is offered in the individual or small group market within the State shall be a qualified health benefits plan.CommentsClose CommentsPermalink





‘(b) Qualified Health Benefits Plan- For purposes of this title, a health benefits plan which is offered in the individual or small group market shall be a qualified health benefits plan with respect to a State if--CommentsClose CommentsPermalink





‘(1) the plan has in effect a certification (which may include a seal or other indication of approval) issued or recognized by the State that such plan meets the applicable requirements of--CommentsClose CommentsPermalink





‘(A) this part (relating to requirements for insurance market reforms); andCommentsClose CommentsPermalink





‘(B) part C (relating to requirements to make health insurance affordable); andCommentsClose CommentsPermalink





‘(2) the offeror of the plan--CommentsClose CommentsPermalink





‘(A) is licensed by the State (and in good standing with the State) to offer a health benefits plan in the State; andCommentsClose CommentsPermalink





‘(B) complies with such other requirements as the Secretary or the State may establish pursuant to this title for qualified health benefits plans.CommentsClose CommentsPermalink





‘(c) Terms Relating to Health Benefits Plans- In this title:CommentsClose CommentsPermalink





‘(1) HEALTH BENEFITS PLAN-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The term ‘health benefits plan’ means health insurance coverage and a group health plan.CommentsClose CommentsPermalink





‘(B) EXCEPTION FOR SELF-INSURED PLANS AND MEWAS- Except to the extent specifically provided by this title, the term ‘health benefits plan’ shall not include a group health plan or multiple employer welfare arrangement to the extent the plan is not subject to State insurance regulation under section 514 of the Employee Retirement Income Security Act of 1974.CommentsClose CommentsPermalink





‘(2) HEALTH INSURANCE COVERAGE AND ISSUER- The terms ‘health insurance coverage’ and ‘health insurance issuer’ have the meanings given such terms by section 9832(b) of the Internal Revenue Code of 1986.CommentsClose CommentsPermalink





‘(3) GROUP HEALTH PLAN- The term ‘group health plan’ has the meaning given such term by section 5000(b) of such Code.CommentsClose CommentsPermalink





‘(4) HEALTH BENEFITS PLAN OFFEROR- The terms ‘health benefits plan offeror’ and ‘offeror’ mean in the case of--CommentsClose CommentsPermalink





‘(A) health insurance coverage, the health insurance issuer offering the coverage; andCommentsClose CommentsPermalink





‘(B) a group health plan--CommentsClose CommentsPermalink





‘(i) the plan sponsor; orCommentsClose CommentsPermalink





‘(ii) in the case of a plan maintained jointly by 1 or more employers and 1 or more employee organizations and with respect to which an employer is the primary source of financing, such employer.CommentsClose CommentsPermalink





‘(d) Definitions Relating to Markets- In this title:CommentsClose CommentsPermalink





‘(1) GROUP MARKET- The term ‘group market’ means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by an employer.CommentsClose CommentsPermalink





‘(2) INDIVIDUAL MARKET- The term ‘individual market’ means the market for health insurance coverage offered to individuals other than in connection with a group health plan.CommentsClose CommentsPermalink





‘(3) LARGE AND SMALL GROUP MARKETS- The terms ‘large group market’ and ‘small group market’ mean the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a large employer (as defined in section 2230(a)(1)) or by a small employer (as defined in section 2230(a)(2)), respectively.CommentsClose CommentsPermalink

‘SEC. 2202. PROHIBITION ON PREEXISTING CONDITION EXCLUSIONS.

‘(a) Prohibition- A health benefits plan shall be treated as a qualified health benefits plan only if the plan does not--CommentsClose CommentsPermalink





‘(1) impose any preexisting condition exclusion with respect to the plan; orCommentsClose CommentsPermalink





‘(2) otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent of an individual based on any health status-related factors in relation to the individual or dependent.CommentsClose CommentsPermalink





‘(b) Preexisting Condition Exclusion- For purposes of this section, the term ‘preexisting condition exclusion’ means, with respect to coverage, a limitation or exclusion of benefits relating to a condition based on the fact that the condition was present before the date of enrollment for such coverage, whether or not any medical advice, diagnosis, care, or treatment was recommended or received before such date.CommentsClose CommentsPermalink





‘(c) Health Status-related Factors- For purposes of this section, the term ‘health status-related factors’ means health status, medical condition (including both physical and mental illnesses), claims experience, receipt of health care, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), and disability.CommentsClose CommentsPermalink

‘SEC. 2203. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS.

‘(a) In General- Except as provided in this section, a health benefits plan shall be treated as a qualified health benefits plan only if the offeror of the plan--CommentsClose CommentsPermalink





‘(1) in the case of a plan offered--CommentsClose CommentsPermalink





‘(A) in the individual market in a State, must accept every individual that applies for enrollment in the plan;CommentsClose CommentsPermalink





‘(B) in the small group market in a State, must accept--CommentsClose CommentsPermalink





‘(i) every small employer in the State that applies for enrollment of its employees under the plan; andCommentsClose CommentsPermalink





‘(ii) every individual who is eligible to enroll in the plan by reason of a relationship to the employer as is determined--CommentsClose CommentsPermalink





‘(I) in accordance with the terms of such plan;CommentsClose CommentsPermalink





‘(II) as provided by the offeror under rules of the offeror that are uniformly applicable to small employers in the small group market within a State; andCommentsClose CommentsPermalink





‘(III) in accordance with all applicable State laws governing the offeror and the small group market; andCommentsClose CommentsPermalink





‘(2) must renew or continue in force coverage under the plan at the option of the individual or small employer, as applicable.CommentsClose CommentsPermalink





An offeror of a plan shall not be treated as meeting the requirements of this subsection unless the plan also accepts, renews, or continues in force coverage of an individual who is eligible for enrollment in the plan by reason of their relationship to the named insured under the plan.CommentsClose CommentsPermalink





‘(b) Special Rules for Guaranteed Issue-CommentsClose CommentsPermalink





‘(1) ENROLLMENT- Each offeror of a health benefits plan shall establish annual and special enrollment periods meeting the requirements of section 2236(d)(2) and may restrict enrollment described in subsection (a)(1) to such enrollment periods.CommentsClose CommentsPermalink





‘(2) CAPACITY LIMITS- For purposes of applying subsection (a)(1), if, as determined under regulations prescribed by the Secretary, a plan has a capacity limit, the plan may limit enrollment to that capacity limit but only if the plan selects individuals for enrollment on the basis of the order in which the individuals applied for enrollment and in a manner that does not discriminate in any manner prohibited under section 2202.CommentsClose CommentsPermalink





‘(c) Guaranteed Renewability- For purposes of applying subsection (a)(2)--CommentsClose CommentsPermalink





‘(1) rescissions of coverage shall be treated in the same manner as non-renewals of coverage; andCommentsClose CommentsPermalink





‘(2) the premium rate at the time of renewal shall be determined using only the same categories of rate adjustment factors that were used at issue.CommentsClose CommentsPermalink





The Secretary may prescribe rules for the application of paragraph (2) during any period during which the reforms under this subpart are being phased in by a State.CommentsClose CommentsPermalink

‘SEC. 2204. PREMIUM RATING RULES.

‘(a) In General- A health benefits plan shall be treated as a qualified health benefits plan only if the premium rate charged for any benefit level of the plan may not vary except as provided in this section.CommentsClose CommentsPermalink





‘(b) Limits Based on Specific Ratios-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In the case of a health benefits plan offered in a rating area, the premium rate charged under the plan may vary only as provided in paragraphs (2) and (3).CommentsClose CommentsPermalink





‘(2) BY FAMILY ENROLLMENT- The premium rate may vary by family enrollment (such as variations within categories and compositions of families) so long as the ratio of the premium for the following types of enrollment to the premium for individual enrollment does not exceed the following ratios:CommentsClose CommentsPermalink





‘(A) Individual, 1 to 1.CommentsClose CommentsPermalink





‘(B) Adult with child, 1.8 to 1.CommentsClose CommentsPermalink





‘(C) Two adults, 2 to 1.CommentsClose CommentsPermalink





‘(D) Family, 3 to 1.CommentsClose CommentsPermalink





‘(3) AGE AND TOBACCO USE- Within any family enrollment category, the portion of the premium attributable to each individual covered by the health benefits plan in that category may vary as follows:CommentsClose CommentsPermalink





‘(A) LIMITED AGE VARIATION PERMITTED- By age (within the standard age bands established under subsection (c)) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 4 to 1.CommentsClose CommentsPermalink





‘(B) TOBACCO USE- By tobacco use so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 1.5 to 1.CommentsClose CommentsPermalink





‘(c) Standard Age Categories- The Secretary shall establish standard age bands between which premium rates may vary as provided in subsection (b)(3)(A).CommentsClose CommentsPermalink





‘(d) Rule of Construction- Nothing in this section shall be construed to allow a health benefits plan to vary a premium rate on the basis of health status-related factors, gender, class of business, claims experience, or any other factor not described in subsection (b).CommentsClose CommentsPermalink

‘SEC. 2205. USE OF UNIFORM OUTLINE OF COVERAGE DOCUMENTS.

‘A health benefits plan shall provide an outline of the plan’s health insurance coverage meeting the standards of uniformity adopted by the Secretary under section 1503 of the America’s Healthy Future Act of 2009 to--CommentsClose CommentsPermalink





‘(1) an applicant at the time of application;CommentsClose CommentsPermalink





‘(2) an enrollee at the time of enrollment; andCommentsClose CommentsPermalink





‘(3) a policyholder or certificate holder of the plan at the time the policy is issued or the certificate is delivered.CommentsClose CommentsPermalink

‘Subpart 2--Reforms Relating to Allocation of Risks

‘SEC. 2211. RATING AREAS; POOLING OF RISKS; PHASE IN OF RATING RULES IN SMALL GROUP MARKETS.

‘(a) Rating Areas-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Each State shall establish 1 or more rating areas within that State for purposes of applying the requirements of this title.CommentsClose CommentsPermalink





‘(2) SECRETARIAL REVIEW- The Secretary shall review the rating areas established by each State under subsection (a) to ensure the adequacy of such areas for purposes of carrying out the requirements of this title. If the Secretary determines a State’s rating areas are not so adequate, the Secretary may establish rating areas for that State.CommentsClose CommentsPermalink





‘(b) Single Risk Pool-CommentsClose CommentsPermalink





‘(1) IN GENERAL- For purposes of applying the insurance reform requirements under subpart 1--CommentsClose CommentsPermalink





‘(A) INDIVIDUAL MARKET- The offeror of an insured qualified health benefits plan offered in the individual market in an area covered by an exchange shall consider all enrollees in the plan, including individuals who do not purchase such a plan through an exchange, to be members of a single risk pool.CommentsClose CommentsPermalink





‘(B) SMALL GROUP MARKET- The offeror of a qualified health benefits plan offered in the small group market in an area covered by an exchange shall consider all enrollees in the plan, including individuals who do not purchase such a plan through an exchange, to be members of a single risk pool.CommentsClose CommentsPermalink





‘(2) STATE ELECTION- A State may elect to combine the individual and small group markets within the State for purposes of applying this subsection.CommentsClose CommentsPermalink





‘(c) Phase in of Insurance Reform Rules in Small Group Market- Upon request to, and approval by, the Secretary, each State shall phase in the application to the small group market of the insurance reform requirements under subpart 1 over a consecutive period of years (not greater than 5) beginning July 1, 2013.CommentsClose CommentsPermalink

‘SEC. 2212. RISK ADJUSTMENT.

‘(a) In General- Each State shall adopt a risk adjustment model described in subsection (b) to implement procedures for the application of risk adjustment among qualified health benefit plans and grandfathered health benefits plans offered in both the individual and small group market. Such procedures shall apply to such qualified health benefit plans whether or not purchased through an exchange.CommentsClose CommentsPermalink





‘(b) Risk Adjustment Models-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall establish 1 or more risk adjustment models for proper adjustments of premium amounts payable among offerors of qualified health benefits plans that take into account (in a manner specified by the Secretary) the differences in the risk characteristics of individuals and employers enrolled under the different plans so as to minimize the impact of adverse selection of enrollees among the plans.CommentsClose CommentsPermalink





‘(2) STATE OPTION- A State may--CommentsClose CommentsPermalink





‘(A) adopt a risk adjustment model established under paragraph (1); orCommentsClose CommentsPermalink





‘(B) establish its own risk adjustment model for purposes of subsection (a), but only if the State establishes to the satisfaction of the Secretary that such model will produce results substantially similar to the results of risk adjustment models established under paragraph (1) and will not increase costs to the Federal government.CommentsClose CommentsPermalink





‘(3) OPERATION OF RISK ADJUSTMENT SYSTEM- A State may select an entity certified under subsection (c) to implement and operate its risk adjustment model under this section.CommentsClose CommentsPermalink





‘(c) Certification of Entities Conducting Risk Adjustment- The Secretary shall certify entities which the Secretary determines have the required expertise to implement the risk adjustment models adopted or established under subsection (b). The Secretary may not certify any entity which is a health benefits plan offeror or any entity owned or operated by such an offeror.CommentsClose CommentsPermalink

‘SEC. 2213. ESTABLISHMENT OF TRANSITIONAL REINSURANCE PROGRAM FOR INDIVIDUAL MARKETS IN EACH STATE.

‘(a) In General- Each State shall, not later than July 1, 2013--CommentsClose CommentsPermalink





‘(1) include in the Model Regulation, Federal standard, or State law or regulation the State adopts and has in effect under section 2225(a)(2) the provisions described in subsection (b); andCommentsClose CommentsPermalink





‘(2) establish (or enter into a contract with) 1 or more applicable reinsurance entities to carry out the reinsurance program under this section.CommentsClose CommentsPermalink





‘(b) Model Regulation-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In establishing the Model Regulation under section 2225 to carry out this part, the Secretary shall request the National Association of Insurance Commissioners (the ‘NAIC’) to include provisions that enable States to establish and maintain a program under which--CommentsClose CommentsPermalink





‘(A) the offerors of health benefits plans that are offered in the individual market are required to make payments to an applicable reinsurance entity for any plan year beginning in the 36-month period beginning July 1, 2013; andCommentsClose CommentsPermalink





‘(B) the applicable reinsurance entity collects payments under subparagraph (A) and uses amounts so collected to make reinsurance payments to offerors of health benefits plans described in subparagraph (A) that cover high risk individuals for any plan year beginning in such 36-month period.CommentsClose CommentsPermalink





If the NAIC does not include such provisions as part of the Model Regulation , the Secretary shall include such provisions in a Federal standard under section 2225(a)(1)(B).CommentsClose CommentsPermalink





‘(2) HIGH-RISK INDIVIDUAL; PAYMENT AMOUNTS- The following shall be included in the provisions under paragraph (1):CommentsClose CommentsPermalink





‘(A) DETERMINATION OF HIGH-RISK INDIVIDUALS- The method by which individuals will be identified as high risk individuals for purposes of the reinsurance program established under this section. Such method shall provide for identification of individuals as high-risk individuals on the basis of--CommentsClose CommentsPermalink





‘(i) a list of at least 50 but not more than 100 medical conditions that are identified as high-risk conditions and that may be based on the identification of diagnostic and procedure codes that are indicative of individuals with pre-existing, high-risk conditions; orCommentsClose CommentsPermalink





‘(ii) any other comparable objective method of identification recommended by the American Academy of Actuaries.CommentsClose CommentsPermalink





‘(B) PAYMENT AMOUNT-CommentsClose CommentsPermalink





‘(i) IN GENERAL- The formula for determining the amount of payments that will be paid to the offerors of health benefits plans that insure high-risk individuals. Such formula shall provide for the equitable allocation of available funds through reconciliation and may be designed--CommentsClose CommentsPermalink





‘(I) to provide a schedule of payments that specifies the amount that will be paid for each of the conditions identified under subparagraph (A); orCommentsClose CommentsPermalink





‘(II) to use any other comparable method for determining payment amounts that is recommended by the American Academy of Actuaries and that encourages the use of care coordination and care management programs for high risk conditions.CommentsClose CommentsPermalink





‘(ii) COORDINATION WITH COST-SHARING AND RISK ADJUSTMENT PAYMENTS- Such provisions shall provide methods to coordinate the payment system under this section with any cost-sharing requirements of a plan and the risk-adjustment program under section 2212.CommentsClose CommentsPermalink





‘(3) DETERMINATION OF REQUIRED CONTRIBUTIONS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The provisions under paragraph (1) shall include the method for determining the amount each offeror of a health benefits plan participating in the reinsurance program under this section is required to contribute under paragraph (1)(A) for each plan year beginning in the 36-month period beginning July 1, 2013. The contribution amount for any plan year may be based on the percentage of revenue of each offeror or on a specified amount per enrollee and may be required to be paid in advance or periodically throughout the plan year.CommentsClose CommentsPermalink





‘(B) SPECIFIC REQUIREMENTS- The method under this paragraph shall be designed so that--CommentsClose CommentsPermalink





‘(i) the contribution amount for each offeror proportionally reflects each offeror’s fully insured commercial book of business for all major medical products and third party administration fees;CommentsClose CommentsPermalink





‘(ii) the contribution amount can include an additional amount to fund the administrative expenses of the applicable reinsurance entity;CommentsClose CommentsPermalink





‘(iii) subject to clause (iv), the aggregate contribution amounts for all States shall, based on the best estimates of the NAIC or the Secretary, whichever is applicable, and without regard to amounts described in clause (ii), equal $10,000,000,000 for plan years beginning in the 12-month period beginning July 1, 2013, $6,000,000,000 for plan years beginning in the 12-month period beginning July 1, 2014, and $4,000,000,000 for plan years beginning in the 12-month period beginning July 1, 2015; andCommentsClose CommentsPermalink





‘(iv) in addition to the aggregate contribution amounts under clause (iii), each offeror’s contribution amount reflects its proportionate share of the $5,000,000,000 amount used to fund the retiree reinsurance program under section 2216.CommentsClose CommentsPermalink





Nothing in this subparagraph shall be construed to preclude a State from collecting additional amounts from offerors on a voluntary basis.CommentsClose CommentsPermalink





‘(4) EXPENDITURE OF FUNDS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Except as provided in subparagraph (B), the provisions under paragraph (1) shall provide that--CommentsClose CommentsPermalink





‘(i) the contribution amounts collected for any 12-month period may be allocated and used in any of the three 12-month periods for which amounts are collected based on the reinsurance needs of a particular period or to reflect experience in a prior period; andCommentsClose CommentsPermalink





‘(ii) amounts remaining unexpended as of June 30, 2016, may be used to make payments under any reinsurance program of a State in the individual market in effect in the 24-month period beginning on July 1, 2016.CommentsClose CommentsPermalink





‘(B) TRANSFERS TO SECRETARY FOR RETIREE REINSURANCE- The provisions under paragraph (1) shall provide that each applicable reinsurance entity shall transfer to the Secretary amounts collected that are allocable to amounts required to be collected under paragraph (3)(B)(iv).CommentsClose CommentsPermalink





‘(c) Applicable Reinsurance Entity- For purposes of this section--CommentsClose CommentsPermalink





‘(1) IN GENERAL- The term ‘applicable reinsurance entity’ means a not-for-profit organization--CommentsClose CommentsPermalink





‘(A) the purpose of which is to help stabilize premiums for coverage in the individual market in a State during the first 3 years of operation of an exchange for that market within the State when the risk of adverse selection related to new rating rules and market changes is greatest; andCommentsClose CommentsPermalink





‘(B) the duties of which shall be to carry out the reinsurance program under this section by coordinating the funding and operation of the risk-spreading mechanisms designed to implement the reinsurance program.CommentsClose CommentsPermalink





‘(2) STATE DISCRETION- A State may have more than 1 applicable reinsurance entity to carry out the reinsurance program under this section within the State and 2 or more States may enter into agreements to provide for an applicable reinsurance entity to carry out such program in all such States.CommentsClose CommentsPermalink





‘(3) ENTITIES ARE TAX-EXEMPT- An applicable reinsurance entity established under this section shall be treated as an organization exempt from taxation under section 501(a) of the Internal Revenue Code of 1986. The preceding sentence shall not apply to the tax imposed by section 511 such Code (relating to tax on unrelated business taxable income of an exempt organization).CommentsClose CommentsPermalink





‘(d) Coordination With State High-risk Pools- The State shall eliminate or modify any State high-risk pool to the extent necessary to carry out the reinsurance program established under this section. The State may coordinate the State high-risk pool with such program to the extent not inconsistent with the provisions of this section.CommentsClose CommentsPermalink

‘SEC. 2214. ESTABLISHMENT OF RISK CORRIDORS FOR PLANS IN INDIVIDUAL AND SMALL GROUP MARKETS.

‘(a) In General- The Secretary shall establish and administer a program of risk corridors for plan years beginning during the 36-month period beginning on July 1, 2013, under which a qualified health benefits plan offered in the individual or small group market may elect (before the beginning of such 36-month period) to participate in a payment adjustment system based on the ratio of the allowable costs of the plan to the plan’s aggregate premiums. Such program shall be based on the program for regional participating provider organizations under part D of title XVIII.CommentsClose CommentsPermalink





‘(b) Payment Methodology-CommentsClose CommentsPermalink





‘(1) PAYMENTS OUT- The Secretary shall provide under the program established under subsection (a) that if--CommentsClose CommentsPermalink





‘(A) a participating plan’s allowable costs for any plan year are more than 103 percent but not more than 108 percent of the target amount, the Secretary shall pay to the plan an amount equal to 50 percent of the target amount in excess of 103 percent of the target amount; andCommentsClose CommentsPermalink





‘(B) a participating plan’s allowable costs for any plan year are more than 108 percent of the target amount, the Secretary shall pay to the plan an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of allowable costs in excess of 108 percent of the target amount.CommentsClose CommentsPermalink





‘(2) PAYMENTS IN- The Secretary shall provide under the program established under subsection (a) that if--CommentsClose CommentsPermalink





‘(A) a participating plan’s allowable costs for any plan year are less than 97 percent but not less than 92 percent of the target amount, the plan shall pay to the Secretary an amount equal to 50 percent of the excess of 97 percent of the target amount over the allowable costs; andCommentsClose CommentsPermalink





‘(B) a participating plan’s allowable costs for any plan year are less than 92 percent of the target amount, the plan shall pay to the Secretary an amount equal to the sum of 2.5 percent of the target amount plus 80 percent of the excess of 92 percent of the target amount over the allowable costs.CommentsClose CommentsPermalink





‘(c) Definitions- In this section:CommentsClose CommentsPermalink





‘(1) ALLOWABLE COSTS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The amount of allowable costs of a plan for any year is an amount equal to the total costs (other than administrative costs) of the plan in providing benefits covered by the plan.CommentsClose CommentsPermalink





‘(B) REDUCTION FOR RISK ADJUSTMENT AND REINSURANCE PAYMENTS- Allowable costs shall be reduced by any risk adjustment and reinsurance payments received under section 2212 and 2213.CommentsClose CommentsPermalink





‘(2) TARGET AMOUNT- The target amount of a plan for any year is an amount equal to the total premiums (including any premium credits or subsidies under any governmental program) reduced by the administrative costs of the plan.CommentsClose CommentsPermalink

‘SEC. 2215. TEMPORARY HIGH RISK POOLS FOR INDIVIDUALS WITH PREEXISTING CONDITIONS.

‘(a) Establishment of High Risk Pools-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Not later than 1 year after the date of enactment of this title, the Secretary shall establish 1 or more high risk pools that--CommentsClose CommentsPermalink





‘(A) provide to all eligible individuals health insurance coverage (or comparable coverage) that does not impose any preexisting condition exclusion with respect to such coverage for all eligible individuals; andCommentsClose CommentsPermalink





‘(B) provide for health benefits coverage and premium rates described under subsection (b).CommentsClose CommentsPermalink





‘(2) ADMINISTRATION- The Secretary may carry out this section--CommentsClose CommentsPermalink





‘(A) directly; orCommentsClose CommentsPermalink





‘(B) through agreements, grants, or contracts with States or other persons the Secretary determines appropriate.CommentsClose CommentsPermalink





‘(b) Coverage and Premium Rates- Except as provided in subsection (c)(2)--CommentsClose CommentsPermalink





‘(1) COVERAGE- The Secretary shall provide that the health benefits coverage provided to an eligible individual through a high risk pool under this section shall--CommentsClose CommentsPermalink





‘(A) consist of the essential benefits package described in section 2242; andCommentsClose CommentsPermalink





‘(B) provide the bronze level of coverage described in section 2243(b)(1).CommentsClose CommentsPermalink





‘(2) PREMIUM RATES-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Except as provided in subparagraph (B), the premium rate charged to an eligible individual enrolled in a high risk pool shall be equal to the standard premium rate for a health benefits plan providing the essential benefits package and bronze level of coverage described in paragraph (1).CommentsClose CommentsPermalink





‘(B) VARIATION OF PREMIUMS- The Secretary may vary the premium under subparagraph (A) to the same extent, and in the same manner, as the offeror of a qualified health benefits plan may vary the premium for the plan under section 2204.CommentsClose CommentsPermalink





‘(c) Funding; Termination of Authority-CommentsClose CommentsPermalink





‘(1) IN GENERAL- There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to pay claims against (and administrative costs of) the high risk pool in excess of the premiums collected from eligible individuals enrolled in the high risk pool. Such funds shall be available without fiscal year limitation.CommentsClose CommentsPermalink





‘(2) INSUFFICIENT FUNDS- If the Secretary estimates for any fiscal year that the aggregate amounts available for payment of expenses of the high risk pool will be less than the amount of the expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficit, including reducing benefits, increasing premiums, or establishing waiting lists.CommentsClose CommentsPermalink





‘(3) TERMINATION OF AUTHORITY-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Except as provided in subparagraph (B), coverage of eligible individuals under a high risk pool shall terminate as of the end of June 30, 2013.CommentsClose CommentsPermalink





‘(B) TRANSITION TO EXCHANGE- The Secretary shall develop procedures to provide for the transition of eligible individuals enrolled in health insurance coverage offered through a high risk pool established under this section into qualified health benefits plans offered through an exchange. Such procedures shall ensure that there is no lapse in coverage with respect to the individual and may extend coverage after June 30, 2013, if the Secretary determines necessary to avoid such a lapse.CommentsClose CommentsPermalink





‘(d) Eligible Individual- In this section, the term ‘eligible individual’ means an individual who demonstrates to the satisfaction of the Secretary that the individual--CommentsClose CommentsPermalink





‘(1) has been denied health insurance coverage by reason of a preexisting condition (as defined in section 2202(b));CommentsClose CommentsPermalink





‘(2) has been uninsured for a continuous period of at least 6 months before the date of application for enrollment in a high risk pool;CommentsClose CommentsPermalink





‘(3) is not eligible for essential health benefits coverage (as defined in section 5000A(f)); andCommentsClose CommentsPermalink





‘(4) is an individual who is, and who is reasonably expected to be for the entire period of coverage, a citizen or national of the United States, an alien lawfully admitted to the United States for permanent residence, or an alien lawfully present in the United States.CommentsClose CommentsPermalink

‘SEC. 2216. REINSURANCE FOR RETIREES COVERED BY EMPLOYER-BASED PLANS.

‘(a) Administration-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Not later than 90 days after the date of enactment of this section, the Secretary shall establish a temporary reinsurance program to provide reimbursement to participating employment-based plans for a portion of the cost of providing health benefits to retirees during the period beginning on the date on which such program is established and ending on the date on which the Secretary estimates that applications for payments under this section will have been made that equal the funds made available under this section (reduced by any administrative costs of the program).CommentsClose CommentsPermalink





‘(2) REFERENCE- In this section:CommentsClose CommentsPermalink





‘(A) HEALTH BENEFITS- The term ‘health benefits’ means medical, surgical, hospital, prescription drug, and such other benefits as shall be determined by the Secretary, whether self-funded, or delivered through the purchase of insurance or otherwise.CommentsClose CommentsPermalink





‘(B) EMPLOYMENT-BASED PLAN- The term ‘employment-based plan’ means a group health benefits plan that--CommentsClose CommentsPermalink





‘(i) is--CommentsClose CommentsPermalink





‘(I) maintained by one or more current or former employers (including without limitation any State or local government or political subdivision thereof), an employee organization, a voluntary employees’ beneficiary association, or a committee or board of individuals appointed to administer such plan; orCommentsClose CommentsPermalink





‘(II) a multiemployer plan (as defined in section 3(37) of the Employee Retirement Income Security Act of 1974); andCommentsClose CommentsPermalink





‘(ii) provides health benefits to retirees.CommentsClose CommentsPermalink





‘(C) RETIREES- The term ‘retirees’ means individuals who are age 55 and older but are not eligible for coverage under title XVIII of the Social Security Act, and who are not active employees of an employer maintaining, or currently contributing to, the employment-based plan or of any employer that has made substantial contributions to fund such plan.CommentsClose CommentsPermalink





‘(b) Participation-CommentsClose CommentsPermalink





‘(1) EMPLOYMENT-BASED PLAN ELIGIBILITY- A participating employment-based plan is an employment-based plan that--CommentsClose CommentsPermalink





‘(A) meets the requirements of paragraph (2) with respect to benefits provided under the plan; andCommentsClose CommentsPermalink





‘(B) submits to the Secretary an application for participation in the program, at such time, in such manner, and containing such information as the Secretary shall require.CommentsClose CommentsPermalink





‘(2) PLAN REQUIREMENTS- An employment-based plan meets the requirements of this paragraph if the plan--CommentsClose CommentsPermalink





‘(A) provides benefits appropriate for individuals between the ages described in subsection (a)(2)(C) and that are certified as so appropriate by the Secretary;CommentsClose CommentsPermalink





‘(B) implements programs and procedures to generate cost-savings with respect to participants with chronic and high-cost conditions; andCommentsClose CommentsPermalink





‘(C) provides documentation of the actual cost of medical claims involved and for which reimbursement is sought under this section.CommentsClose CommentsPermalink





‘(c) Payments-CommentsClose CommentsPermalink





‘(1) SUBMISSION OF CLAIMS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- A participating employment-based plan shall submit claims for reimbursement to the Secretary which shall contain documentation of the actual costs of the items and services for which each claim is being submitted.CommentsClose CommentsPermalink





‘(B) BASIS FOR CLAIMS- Claims submitted under paragraph (1) shall be based on the actual amount expended by the participating employment-based plan involved within the plan year for the appropriate employment-based health benefits provided to a retiree or the spouse, surviving spouse, or dependent of such retiree. In determining the amount of a claim for purposes of this subsection, the participating employment-based plan shall take into account any negotiated price concessions (such as discounts, direct or indirect subsidies, rebates, and direct or indirect remunerations) obtained by such plan with respect to such health benefit. For purposes of determining the amount of any such claim, the costs paid by the retiree or the retiree’s spouse, surviving spouse, or dependent in the form of deductibles, co-payments, or co-insurance shall be included in the amounts paid by the participating employment-based plan.CommentsClose CommentsPermalink





‘(2) PROGRAM PAYMENTS- If the Secretary determines that a participating employment-based plan has submitted a valid claim under paragraph (1), the Secretary shall reimburse such plan for 80 percent of that portion of the costs attributable to such claim that exceed $15,000, subject to the limits contained in paragraph (3).CommentsClose CommentsPermalink





‘(3) LIMIT- To be eligible for reimbursement under the program, a claim submitted by a participating employment-based plan under paragraph (1) with respect to any individual shall not be less than $15,000 nor greater than $90,000. Such amounts shall be adjusted each fiscal year based on the percentage increase in the Medical Care Component of the Consumer Price Index for all urban consumers (rounded to the nearest multiple of $1,000) for the year involved.CommentsClose CommentsPermalink





‘(4) USE OF PAYMENTS- Amounts paid to a participating employment-based plan under this subsection shall be used to lower costs for the plan. Such payments may be used to reduce premium costs for an entity described in subsection (a)(2)(B)(i) or to reduce premium contributions, co-payments, deductibles, co-insurance, or other out-of-pocket costs for plan participants. Such payments shall not be used as general revenues for an entity described in subsection (a)(2)(B)(i). The Secretary shall develop a mechanism to monitor the appropriate use of such payments by such entities.CommentsClose CommentsPermalink





‘(5) PAYMENTS NOT TREATED AS INCOME- Payments received under this subsection shall not be included in determining the gross income of an entity described in subsection (a)(2)(B)(i) that is maintaining or currently contributing to a participating employment-based plan.CommentsClose CommentsPermalink





‘(6) APPEALS- The Secretary shall establish--CommentsClose CommentsPermalink





‘(A) an appeals process to permit participating employment-based plans to appeal a determination of the Secretary with respect to claims submitted under this section; andCommentsClose CommentsPermalink





‘(B) procedures to protect against fraud, waste, and abuse under the program.CommentsClose CommentsPermalink





‘(d) Audits- The Secretary shall conduct annual audits of claims data submitted by participating employment-based plans under this section to ensure that such plans are in compliance with the requirements of this section.CommentsClose CommentsPermalink





‘(e) Available Funds-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary of the Treasury shall establish a separate account within the Treasury of the United States for deposit of amounts transferred to the Secretary of Health and Human Services under section 2213(b)(4)(B).CommentsClose CommentsPermalink





‘(2) APPROPRIATIONS- Amounts in the account are hereby appropriated for use by the Secretary in carrying out the program under this section.CommentsClose CommentsPermalink





‘(3) LIMITATIONS- The Secretary has the authority to stop taking applications for participation in the program if applications will exceed amounts in the account.CommentsClose CommentsPermalink

‘Subpart 3--Preservation of Right to Maintain Existing Coverage

‘SEC. 2221. GRANDFATHERED HEALTH BENEFITS PLANS.

‘(a) In General- In the case of a grandfathered health benefits plan--CommentsClose CommentsPermalink





‘(1) nothing in this title shall be construed to require that an individual terminate coverage under the plan if such individual was enrolled in the plan as of the day before the effective date of this title;CommentsClose CommentsPermalink





‘(2) except as provided in subsection (b), the requirements of this part shall not apply to the plan; andCommentsClose CommentsPermalink





‘(3) the plan shall not be treated as a qualified health benefits plan for purposes of this title.CommentsClose CommentsPermalink





‘(b) Application of Rating Rules in Small Group Market- Each State shall phase in the application of the insurance reform requirements under subpart 1 to grandfathered health benefits plans offered in the small group market within the State over a consecutive period of years (not greater than 5) beginning July 1, 2013.CommentsClose CommentsPermalink





‘(c) Grandfathered Health Benefits Plan- In this title:CommentsClose CommentsPermalink





‘(1) IN GENERAL- The term ‘grandfathered health benefits plan’ means any of the following that was offered and was in force and effect on the effective date of this title:CommentsClose CommentsPermalink





‘(A) Health insurance coverage in the individual market.CommentsClose CommentsPermalink





‘(B) A group health plan.CommentsClose CommentsPermalink





‘(2) LIMITED NEW ENROLLMENT-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Except as provided in subparagraphs (B) and (C), a health benefits plan shall cease to be a grandfathered health benefits plan if it enrolls individuals who were not enrolled in the plan as of the day before the date described in paragraph (1).CommentsClose CommentsPermalink





‘(B) ALLOWANCE FOR FAMILY MEMBERS TO JOIN CURRENT COVERAGE- Family members of an individual enrolled in a health benefits plan as of the day before the date described in paragraph (1) may enroll in the plan on or after such date.CommentsClose CommentsPermalink





‘(C) ALLOWANCE FOR NEW EMPLOYEES TO JOIN CURRENT PLAN- A group health plan of an employer that provides coverage as of the day before the date described in paragraph (1) may provide for the enrolling of new employees (and their families) in such plan.CommentsClose CommentsPermalink





‘(3) SPECIAL RULE FOR CATASTROPHIC PLANS- If health insurance coverage offered and in force in the individual market as of the day before the effective of this title is actuarially equivalent to a catastrophic plan described in section 2243(c), such coverage shall be treated as a grandfathered health benefits plan for purposes of this section.CommentsClose CommentsPermalink

‘Subpart 4--Continued Role of States

‘SEC. 2225. CONTINUED STATE ENFORCEMENT OF INSURANCE REGULATIONS.

‘(a) In General-CommentsClose CommentsPermalink





‘(1) MODEL REGULATION-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall request the National Association of Insurance Commissioners (in this section referred to as the ‘NAIC’) to, not later than 12 months after the date of enactment of this title, develop and promulgate a Model Regulation that implements the requirements set forth in this title for health benefit plans offered within a State. In developing and promulgating the Model Regulation, the NAIC shall consult with its members, health insurance issuers, consumer organizations, and such other individuals as the NAIC selects in a manner designed to ensure balanced representation among interested parties.CommentsClose CommentsPermalink





‘(B) SECRETARIAL ACTION- The Secretary shall include the Model Regulation established under paragraph (1) in the regulations prescribed by the Secretary to implement the requirements described in subparagraph (A). If the NAIC does not promulgate the Model Regulation within the 12-month period under subparagraph (A), the Secretary shall establish a Federal standard implementing such requirements.CommentsClose CommentsPermalink





‘(2) STATE ACTION- Each State that elects to apply the requirements set forth in this title to health benefit plans offered within the State shall, not later than July 1, 2013, adopt and have in effect--CommentsClose CommentsPermalink





‘(A) the Model Regulation or Federal standard established under paragraph (1), whichever is applicable; orCommentsClose CommentsPermalink





‘(B) a State law or regulation that the Secretary determines implements the requirements for health benefit plans offered within the State.CommentsClose CommentsPermalink





‘(3) FAILURE TO IMPLEMENT PROVISIONS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- If--CommentsClose CommentsPermalink





‘(i) a State does not elect to apply the requirements set forth in this title to health benefit plans offered within the State; orCommentsClose CommentsPermalink





‘(ii) the Secretary determines that an electing State has failed to adopt or substantially enforce the Model Regulation, Federal standard, or State law or regulations described in paragraph (2), whichever is applicable, with respect to health benefits plan offerors in the State,CommentsClose CommentsPermalink





the Secretary shall implement and enforce such requirements insofar as they relate to the issuance, sale, renewal, and offering of health benefits plans in such State until such time as the Secretary determines the State has adopted and is substantially enforcing the requirements.CommentsClose CommentsPermalink





‘(B) ENFORCEMENT AUTHORITY- The provisions of section 2722(b) of the Public Health Services Act shall apply to the enforcement under subparagraph (A) of the provisions of this part (without regard to any limitation on the application of those provisions to group health plans).CommentsClose CommentsPermalink





‘(4) RATINGS REFORMS MUST APPLY UNIFORMLY TO ALL OFFERORS- The Model Regulation, Federal standard, or State law and regulation implemented by a State under this subsection shall require that any standard or requirement adopted pursuant to this title (including any standard or requirement described in subsection (c) that offers more protection to consumers than the protection offered by any standard or requirement set forth in this title) shall be applied uniformly to all offerors of all health benefits plans in the individual or small group market, whichever is applicable.CommentsClose CommentsPermalink





‘(b) State Exchanges-CommentsClose CommentsPermalink





‘(1) EXCHANGES FOR QUALIFIED PLANS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to paragraph (2), not later than July 1, 2013, an electing State under subsection (a)(2) shall establish and have in operation 1 or more exchanges (including SHOP exchanges) meeting the requirements of part B with respect to the offering of qualified health benefits plans through the exchange.CommentsClose CommentsPermalink





‘(B) FAILURE TO ESTABLISH- If--CommentsClose CommentsPermalink





‘(i) a State is not an electing State under subsection (a)(2); orCommentsClose CommentsPermalink





‘(ii) an electing State does not establish the exchanges described in subparagraph (A) within 24 months after the date of enactment of this title (or the Secretary determines at the end of the 24-month period that the exchanges will not be operational by July 1, 2013),CommentsClose CommentsPermalink





the Secretary shall enter into a contract with a nongovernmental entity to establish and operate the exchanges within the State.CommentsClose CommentsPermalink





‘(2) INTERIM EXCHANGES- Each electing State under subsection (a)(2) shall as soon as practicable establish the exchanges described in section 2235(e) for use by residents of the State during the period beginning January 1, 2010, and ending June 30, 2013. In the case of a State that is not an electing State under subsection (a)(2), or if the Secretary determines that the exchanges in an electing State will not be operational within a reasonable period of time after the date of enactment of this title, the Secretary shall enter into a contract with a nongovernmental entity to establish and operate the exchanges within the State during such period.CommentsClose CommentsPermalink





‘(c) Continued Applicability of State Law With Respect to Health Benefits Plans-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Subject to paragraphs (2) and (3), this title shall not be construed to supersede any provision of State law which establishes, implements, or continues in effect any standard or requirement relating to health benefits plan offerors in connection with a health benefits plan that offers more protection to consumers than the protection offered by any standard or requirement set forth in this title. The standards or requirements referred to in the preceding sentence shall include standards or requirements relating to--CommentsClose CommentsPermalink





‘(A) consumer protections, including claims grievance procedures, external review of claims determinations, oversight of insurance agent practices and training, and insurance market conduct;CommentsClose CommentsPermalink





‘(B) premium rating reviews;CommentsClose CommentsPermalink





‘(C) solvency and reserve requirements relating to the licensure of health insurance issuers operating in the State; andCommentsClose CommentsPermalink





‘(D) the assessment of State-based premium taxes on health insurance issuers.CommentsClose CommentsPermalink





‘(2) SPECIAL RULE FOR RATING REQUIREMENTS- For purposes of paragraph (1), in the case of the ratings requirements under section 2204, a State law shall not be treated as offering more protection to consumers than the protection offered by such requirements if the State law imposes ratios that are greater than the ratios specified in section 2204(b).CommentsClose CommentsPermalink





‘(3) CONTINUED PREEMPTION WITH RESPECT TO GROUP HEALTH PLANS- Nothing in this part shall be construed to affect or modify the provisions of section 514 of the Employee Retirement Income Security Act of 1974 with respect to group health plans.CommentsClose CommentsPermalink





‘(d) Automatic Enrollment- A State may institute a program to provide that offerors of qualified health benefit plans, small employers, and exchanges offering qualified health benefits plans in the individual and small group market within the State may automatically enroll individuals and employees in, or continue enrollment of individuals in, qualified health benefit plans where appropriate to ensure coverage of the individuals. Any automatic enrollment program shall include adequate notice and the opportunity for an individual or employee to opt out of any coverage the individual or employee were automatically enrolled in.CommentsClose CommentsPermalink





‘(e) Claims Review Process- Each State shall--CommentsClose CommentsPermalink





‘(1) require each offeror of a qualified health benefits plans offered through an exchange--CommentsClose CommentsPermalink





‘(A) to provide an internal claims appeal process;CommentsClose CommentsPermalink





‘(B) to provide notice in clear language and in the enrollee’s primary language of available internal and external appeals processes and the availability of the ombudsman established under section 2229(a) to assist them with the appeals processes; andCommentsClose CommentsPermalink





‘(C) to allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process;CommentsClose CommentsPermalink





‘(2) provide an external review process for such plans that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans; andCommentsClose CommentsPermalink





‘(3) ensure enrollees can seek judicial review through available Federal or State procedures.CommentsClose CommentsPermalink





‘(f) Applicable State Authority- In this title, the term ‘applicable State authority’ means the State insurance commissioner or official or officials designated by the State to enforce the requirements of this title for the State involved.CommentsClose CommentsPermalink

‘SEC. 2226. WAIVER OF HEALTH INSURANCE REFORM REQUIREMENTS.

‘(a) Application- A State may apply to the Secretary for the waiver of all or any requirements under this title and section 5000A of the Internal Revenue Code of 1986 with respect to health insurance coverage within that State for plan years beginning on or after July 1, 2015. Such application shall--CommentsClose CommentsPermalink





‘(1) be filed at such time and in such manner as the Secretary may require; andCommentsClose CommentsPermalink





‘(2) contain such information as the Secretary may require, including--CommentsClose CommentsPermalink





‘(A) a comprehensive description of the State legislation or program for implementing a plan meeting the requirements for a waiver under this section; andCommentsClose CommentsPermalink





‘(B) a 10-year budget plan for such plan that is budget neutral for the Federal government.CommentsClose CommentsPermalink





‘(b) Granting of Waivers- The Secretary may grant a request for a waiver under this section if the Secretary determines that--CommentsClose CommentsPermalink





‘(1) the State plan to provide health care coverage to its residents provides coverage that is at least as comprehensive as the coverage required under a qualified health benefits plan offered through exchanges established under this title; andCommentsClose CommentsPermalink





‘(2) the State plan to provide health care coverage to its residents will lower the growth in health care spending, will improve delivery system performance, will provide affordable choices for its citizens, will expand protection against excessive out-of-pocket spending, will provide coverage to the same number of uninsured as the provisions of this title will provide, and will not increase the Federal deficit.CommentsClose CommentsPermalink





‘(c) Scope of Waiver-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall determine the scope of a waiver granted to a State under this section, including which Federal laws and requirements will not apply to the State under the waiver.CommentsClose CommentsPermalink





‘(2) LIMITATION- The Secretary may not waive under this section any Federal law or requirement that is not within the authority of the Secretary.CommentsClose CommentsPermalink





‘(d) Determinations by Secretary-CommentsClose CommentsPermalink





‘(1) TIME FOR DETERMINATION- The Secretary shall make a determination under this section not later than 180 days after the receipt of an application from a State under subsection (a).CommentsClose CommentsPermalink





‘(2) EFFECT OF DETERMINATION-CommentsClose CommentsPermalink





‘(A) GRANTING OF WAIVERS- If the Secretary determines to grant a waiver under this section, the Secretary shall notify the State involved of such determination and the terms and effectiveness of such waiver.CommentsClose CommentsPermalink





‘(B) DENIAL OF WAIVER- If the Secretary determines a waiver should not be granted under this section, the Secretary shall notify the State involved, and the appropriate committees of Congress of such determination and the reasons therefor.CommentsClose CommentsPermalink

‘SEC. 2227. PROVISIONS RELATING TO OFFERING OF PLANS IN MORE THAN ONE STATE.

‘(a) Health Care Choice Compacts-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall request the National Association of Insurance Commissioners to, no later than July 1, 2012, develop model rules for the creation of health care choice compacts under which 2 or more States may enter into an agreement under which--CommentsClose CommentsPermalink





‘(A) 1 or more qualified health benefits plans could be offered in the individual markets in all such States but, except as provided in subparagraph (B), only be subject to the laws and regulations of the State in which the plan was written or issued;CommentsClose CommentsPermalink





‘(B) the offeror of any qualified health benefits plan to which the compact applies--CommentsClose CommentsPermalink





‘(i) would continue to be subject to market conduct, unfair trade practices, network adequacy, and consumer protection standards, including addressing disputes as to the performance of the contract, of the State in which the purchaser resides;CommentsClose CommentsPermalink





‘(ii) would be required to be licensed in each State in which it offers the plan under the compact or to submit to the jurisdiction of each such State with regard to the standards described in clause (i) (including allowing access to records as if the insurer were licensed in the State); andCommentsClose CommentsPermalink





‘(iii) must clearly notify consumers that the policy may not be subject to all the laws and regulations of the State in which the purchaser resides.CommentsClose CommentsPermalink





If the NAIC does not promulgate the model rules by July 1, 2012, the Secretary shall, not later than July 1, 2013, establish a Federal standard implementing such rules.CommentsClose CommentsPermalink





‘(2) STATE AUTHORITY- A State may not enter into an agreement under this subsection unless the State enacts a law after the date of the enactment of this title that specifically authorizes the State to enter into such agreements.CommentsClose CommentsPermalink





‘(3) EFFECTIVE DATE- A health care choice compact described in paragraph (1) shall not take effect before January 1, 2015.CommentsClose CommentsPermalink





‘(b) Authority for Nationwide Plans-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Notwithstanding section 2225(c)(1), and except as provided in paragraph (2), if an offeror of a qualified health benefits plan in the individual or small group market meets the requirements of this subsection--CommentsClose CommentsPermalink





‘(A) the offeror of the plan may offer the qualified health benefits plan in more than 1 State; andCommentsClose CommentsPermalink





‘(B) any State law mandating benefit coverage by a health benefits plan shall not apply to the qualified health benefits plan.CommentsClose CommentsPermalink





‘(2) STATE OPT-OUT- A State may, by specific reference in a law enacted after the date of enactment of this title, provide that this subsection shall not apply to that State. Such opt-out shall be effective until such time as the State by law revokes it.CommentsClose CommentsPermalink





‘(3) PLAN REQUIREMENTS- An offeror meets the requirements of this subsection with respect to a qualified health benefits plan if--CommentsClose CommentsPermalink





‘(A) the plan offers a benefits package that is uniform in each State in which the plan is offered and meets the requirements set forth in paragraph (3);CommentsClose CommentsPermalink





‘(B) the offeror is licensed in each State in which it offers the plan and is subject in such State to the standards and requirements described in the last sentence of section 2225(c)(1);CommentsClose CommentsPermalink





‘(C) the offeror meets all requirements of this title with respect to a qualified health benefits plan, including the requirement to offer the silver and gold levels of the plan in each exchange in the State for the market in which the plan is offered; andCommentsClose CommentsPermalink





‘(D) the offeror determines the premiums for the plan in any State on the basis of the ratings rules in effect in that State for the ratings areas in which it is offered.CommentsClose CommentsPermalink





‘(4) APPLICABLE REGULATIONS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall request the National Association of Insurance Commissioners to, no later than 2012, develop model rules for the offering of a qualified health benefits plans on a national basis. Such rules shall establish standards for--CommentsClose CommentsPermalink





‘(i) the implementation of benefit categories, taking into account how each benefit is offered in a majority of States; andCommentsClose CommentsPermalink





‘(ii) harmonization between applicable State authorities of State insurance regulations relating to filing of forms and the filing of premium rates.CommentsClose CommentsPermalink





If the NAIC does not promulgate the model rules by December 31, 2012, the Secretary shall, not later than December 31, 2013, establish a Federal standard implementing such rules.CommentsClose CommentsPermalink





‘(B) STATE ACTION- Each State (other than a State described in paragraph (2)) shall include the provisions described in subparagraph (A) in the Model Regulation, Federal standard, or State law or regulation the State adopts and has in effect under section 2225(a)(2).CommentsClose CommentsPermalink

‘SEC. 2228. STATE FLEXIBILITY TO ESTABLISH BASIC HEALTH PROGRAMS FOR LOW-INCOME INDIVIDUALS NOT ELIGIBLE FOR MEDICAID.

‘(a) Establishment of Program-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall establish a basic health program meeting the requirements of this section under which a State may enter into contracts to offer 1 or more standard health plans providing at least an essential benefits package described in section 2242 to eligible individuals in lieu of offering such individuals coverage through an exchange established under part B.CommentsClose CommentsPermalink





‘(2) CERTIFICATIONS AS TO BENEFIT COVERAGE AND COSTS- Such program shall provide that a State may not establish a basic health program under this section unless the State establishes to the satisfaction of the Secretary, and the Secretary certifies, that--CommentsClose CommentsPermalink





‘(A) in the case of an eligible individual enrolled in a standard health plan offered through the program, the State provides--CommentsClose CommentsPermalink





‘(i) that the amount of the monthly premium an eligible individual is required to pay for coverage under the standard health plan for the individual and the individual’s dependents does not exceed the amount of the monthly premium that the eligible individual would have been required to pay if the individual had enrolled in the applicable second lowest cost silver plan (as defined in section 36B(b)(3)(B) of the Internal Revenue Code of 1986) offered to the individual through an exchange; andCommentsClose CommentsPermalink





‘(ii) that the cost-sharing an eligible individual is required to pay under the standard health plan does not exceed--CommentsClose CommentsPermalink





‘(I) the cost-sharing required under a platinum plan in the case of an eligible individual with household income not in excess of 150 percent of the poverty line for the size of the family involved; andCommentsClose CommentsPermalink





‘(II) the cost-sharing required under a gold plan in the case of an eligible individual; andCommentsClose CommentsPermalink





‘(B) the benefits provided under the standard health plans offered through the program cover at least benefits required under an essential benefits package described in section 2242.CommentsClose CommentsPermalink





For purposes of subparagraph (A)(i), the amount of the monthly premium an individual is required to pay under either the standard health plan or the applicable second lowest cost silver plan shall be determined after reduction for any premium credits and premium subsidies allowable with respect to either plan.CommentsClose CommentsPermalink





‘(b) Standard Health Plan- In this section, the term ‘standard heath plan’ means a health benefits plan that the State contracts with under this section--CommentsClose CommentsPermalink





‘(1) under which the only individuals eligible to enroll are eligible individuals;CommentsClose CommentsPermalink





‘(2) that provides at least an essential benefits package described in section 2242; andCommentsClose CommentsPermalink





‘(3) in the case of a plan that provides health insurance coverage offered by a health insurance issuer, that has a medical loss ratio of at least 85 percent.CommentsClose CommentsPermalink





‘(c) Contracting Process-CommentsClose CommentsPermalink





‘(1) IN GENERAL- A State basic health program shall establish a competitive process for entering into contracts with standard health plans under subsection (a), including negotiation of premiums and cost-sharing and negotiation of benefits in addition to those required by an essential benefits package described in section 2242.CommentsClose CommentsPermalink





‘(2) SPECIFIC ITEMS TO BE CONSIDERED- A State shall, as part of its competitive process under paragraph (1), include at least the following:CommentsClose CommentsPermalink





‘(A) INNOVATION- Negotiation with offerors of a standard health plan for the inclusion of innovative features in the plan, including--CommentsClose CommentsPermalink





‘(i) care coordination and care management for enrollees, especially for those with chronic health conditions;CommentsClose CommentsPermalink





‘(ii) incentives for use of preventive services; andCommentsClose CommentsPermalink





‘(iii) the establishment of relationships between providers and patients that maximize patient involvement in health care decision-making, including providing incentives for appropriate utilization under the plan.CommentsClose CommentsPermalink





‘(B) HEALTH AND RESOURCE DIFFERENCES- Consideration of, and the making of suitable allowances for, differences in health care needs of enrollees and differences in local availability of, and access to, health care providers. Nothing in this subparagraph shall be construed as allowing discrimination on the basis of pre-existing condition or other health status-related factors.CommentsClose CommentsPermalink





‘(C) MANAGED CARE- Contracting with managed care systems, or with systems that offer as many of the attributes of managed care as are feasible in the local health care market.CommentsClose CommentsPermalink





‘(D) PERFORMANCE MEASURES- Establishing specific performance measures and standards for offerors of standard health plans that focus on quality of care and improved health outcomes, requiring such plan to report to the State with respect to the measures and standards, and making the performance and quality information available to enrollees in a useful form.CommentsClose CommentsPermalink





‘(3) ENHANCED AVAILABILITY-CommentsClose CommentsPermalink





‘(A) MULTIPLE PLANS- A State shall, to the maximum extent feasible, seek to make multiple standard health plans available to eligible individuals within a State to ensure individuals have a choice of such plans.CommentsClose CommentsPermalink





‘(B) REGIONAL COMPACTS- A State may negotiate a regional compact with other States to include coverage of eligible individuals in all such States in agreements with offerors of standard health plans.CommentsClose CommentsPermalink





‘(4) COORDINATION WITH OTHER STATE PROGRAMS- A State shall, to the maximum extent feasible, seek to coordinate the administration of, and provision of benefits under, its program under this section with the State medicaid program under title XIX, the State child health plan under title XXI, and other State-administered health programs to maximize the efficiency of such programs and to improve the continuity of care.CommentsClose CommentsPermalink





‘(d) Transfer of Funds to States-CommentsClose CommentsPermalink





‘(1) IN GENERAL- If the Secretary determines that a State electing the application of this section meets the requirements of the program established under subsection (a), the Secretary shall transfer to the State for each fiscal year for which 1 or more standard health plans are operating within the State the amount determined under paragraph (3).CommentsClose CommentsPermalink





‘(2) USE OF FUNDS- A State shall establish a trust for the deposit of the amounts received under paragraph (1) and amounts in the trust fund shall only be used to reduce the premiums and cost-sharing of, or to provide additional benefits for, eligible individuals enrolled in standard health plans within the State. Amounts in the trust fund, and expenditures of such amounts, shall not be included in determining the amount of any non-Federal funds for purposes of meeting any matching or expenditure requirement of any federally-funded program.CommentsClose CommentsPermalink





‘(3) AMOUNT OF PAYMENT-CommentsClose CommentsPermalink





‘(A) SECRETARIAL DETERMINATION-CommentsClose CommentsPermalink





‘(i) IN GENERAL- The amount determined under this paragraph for any fiscal year is the amount the Secretary determines is equal to 85 percent of the credits under section 36B of the Internal Revenue Code of 1986, and the cost-sharing subsidies under section 2247, that would have been provided for the fiscal year to eligible individuals enrolled in standard health plans in the State if such eligible individuals were allowed to enroll in qualified health benefits plans through an exchange established under part B.CommentsClose CommentsPermalink





‘(ii) SPECIFIC REQUIREMENTS- The Secretary shall make the determination under clause (i) on a per enrollee basis and shall take into account all relevant factors necessary to determine the value of the credits and subsidies that would have been provided to eligible individuals described in clause (i).CommentsClose CommentsPermalink





‘(B) CORRECTIONS- The Secretary shall adjust the payment for any fiscal year to reflect any error in the determinations under subparagraph (A) for any preceding fiscal year.CommentsClose CommentsPermalink





‘(4) APPLICATION OF ABORTION COVERAGE REQUIREMENTS- The rules of section 2245 shall apply to a State basic health program, and to standard health plans offered through such program, in the same manner as such rules apply to qualified basic health benefits plans.CommentsClose CommentsPermalink





‘(e) Eligible Individual-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In this section, the term ‘eligible individual’ means, with respect to any State, an individual--CommentsClose CommentsPermalink





‘(A) who a resident of the State who is not eligible to enroll in the State’s medicaid program under title XIX for benefits that at a minimum consist of the essential benefits package described in section 2242;CommentsClose CommentsPermalink





‘(B) whose household income exceeds 133 percent but does not exceed 200 percent of the poverty line for the size of the family involved;CommentsClose CommentsPermalink





‘(C) who is not eligible for essential health benefits coverage (as defined in section 5000A(f)) or is eligible for an employer-sponsored plan that is not affordable coverage (as determined under section 5000A(e)(2)); andCommentsClose CommentsPermalink





‘(D) who has not attained age 65 as of the beginning of the plan year.CommentsClose CommentsPermalink





Such term shall not include any individual who is not eligible under section 2232(c) to be covered by a qualified health benefits plan offered through an exchange.CommentsClose CommentsPermalink





‘(2) ELIGIBLE INDIVIDUALS MAY NOT USE EXCHANGE- An eligible individual shall not be treated as a qualified individual under section 2223 eligible for enrollment in a qualified health benefits plan offered through an exchange established under part B.CommentsClose CommentsPermalink





‘(f) Secretarial Oversight- The Secretary shall each year conduct a review of each State program to ensure compliance with the requirements of this section, including ensuring that the State program meets--CommentsClose CommentsPermalink





‘(1) eligibility verification requirements for participation in the program;CommentsClose CommentsPermalink





‘(2) the requirements for use of Federal funds received by the program; andCommentsClose CommentsPermalink





‘(3) the quality and performance standards under this section.CommentsClose CommentsPermalink





‘(g) Standard Health Plan Offerors- A State may provide that persons eligible to offer standard health plans under a basic health program established under this section may include a licensed health maintenance organization, a licensed health insurance insurer, or a network of health care providers established to offer services under the program.CommentsClose CommentsPermalink





‘(h) Definitions- Any term used in this section which is also used in section 36B of the Internal Revenue Code of 1986 shall have the meaning given such term by such section.CommentsClose CommentsPermalink