S 3673 ISCommentsClose CommentsPermalink

112th CONGRESSCommentsClose CommentsPermalink

2d SessionCommentsClose CommentsPermalink

S. 3673CommentsClose CommentsPermalink

To provide a comprehensive deficit reduction plan, and for other purposes.CommentsClose CommentsPermalink

IN THE SENATE OF THE UNITED STATESCommentsClose CommentsPermalink

December 12, 2012CommentsClose CommentsPermalink

Mr. CORKER introduced the following bill; which was read twice and referred to the Committee on FinanceCommentsClose CommentsPermalink

A BILLCommentsClose CommentsPermalink

To provide a comprehensive deficit reduction plan, 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 ‘The Dollar for Dollar Act of 2012’.CommentsClose CommentsPermalink





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





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

TITLE I--MEDICAID

Sec. 1101. Comprehensive Medicaid Waivers.CommentsClose CommentsPermalink





Sec. 1102. Phased-in elimination of allowable provider taxes under Medicaid.CommentsClose CommentsPermalink

TITLE II--MEDICARE

Subtitle A--Medicare Total Health Program; Medicare Fee-for-Service Program Reforms; Reports

Sec. 2000. Short title; purpose.CommentsClose CommentsPermalink

PART I--Medicare Total Health Program

Sec. 2001. Establishment of Medicare Total Health program.CommentsClose CommentsPermalink





Sec. 2002. Replacement of part B premium with Medicare Total Health program plan premium; other technical and conforming amendments.CommentsClose CommentsPermalink

PART II--Medicare Fee-for-Service Reforms

Sec. 2011. Medicare protection against high out-of-pocket expenditures for fee-for-service benefits.CommentsClose CommentsPermalink





Sec. 2012. Unified Medicare deductible.CommentsClose CommentsPermalink





Sec. 2013. Uniform Medicare coinsurance rate.CommentsClose CommentsPermalink





Sec. 2014. Prohibition on first-dollar coverage under Medigap policies and development of new standards for Medigap policies.CommentsClose CommentsPermalink

PART III--Annual Report to Congress

Sec. 2021. Annual report to Congress.CommentsClose CommentsPermalink

Subtitle B--Elimination of Exemption of Medicare Payments to Physicians Under Statutory PAYGO

Sec. 2101. Elimination of exemption of Medicare payments to physicians under statutory PAYGO.CommentsClose CommentsPermalink

Subtitle C--Adjustments to Medicare Part B and D Premiums for High-Income Beneficiaries

Sec. 2201. Adjustments to Medicare part B and D premiums for high-income beneficiaries.CommentsClose CommentsPermalink

Subtitle D--Increase in the Medicare Eligibility Age

Sec. 2301. Increase in the Medicare eligibility age.CommentsClose CommentsPermalink

Subtitle E--Other Provisions

Sec. 2401. Limitation on Medicare payments for direct graduate medical education (DGME).CommentsClose CommentsPermalink





Sec. 2402. Reduction in Medicare indirect graduate medical education (IME) payments.CommentsClose CommentsPermalink





Sec. 2403. Acceleration of application of productivity adjustment to Medicare home health prospective payment amounts.CommentsClose CommentsPermalink





Sec. 2404. Acceleration of rebasing of Medicare home health prospective payment amounts.CommentsClose CommentsPermalink





Sec. 2405. Reduction of bad debt treated as an allowable cost.CommentsClose CommentsPermalink

TITLE III--SOCIAL SECURITY

Sec. 3101. Adjustments to bend points in determining primary insurance amount.CommentsClose CommentsPermalink





Sec. 3102. Adjustment to calculation of benefit computation years.CommentsClose CommentsPermalink





Sec. 3103. Minimum social security benefit.CommentsClose CommentsPermalink





Sec. 3104. Increase in benefits starting 20 years after initial eligibility.CommentsClose CommentsPermalink





Sec. 3105. Adjustment to normal and early retirement ages.CommentsClose CommentsPermalink





Sec. 3106. Application of actuarial reduction for disabled beneficiaries who attain early retirement age.CommentsClose CommentsPermalink





Sec. 3107. Option to collect up to one-half of old-age insurance benefit at age 62.CommentsClose CommentsPermalink





Sec. 3108. Coverage of newly hired state and local employees.CommentsClose CommentsPermalink





Sec. 3109. Inclusion in annual social security account statement of estimated present value of taxes and benefits for Social Security and Medicare and projected deficit as a percent of lifetime earnings.CommentsClose CommentsPermalink





Sec. 3110. Retirement information campaign.CommentsClose CommentsPermalink

TITLE IV--CONVERSION TO CHAINED CPI

Sec. 4101. Conversion to chained CPI.CommentsClose CommentsPermalink

TITLE V--PUBLIC DEBT LIMIT

Sec. 5101. Increase in public debt limit.CommentsClose CommentsPermalink

TITLE I--MEDICAIDCommentsClose CommentsPermalink

SEC. 1101. COMPREHENSIVE MEDICAID WAIVERS.

Section 1115 of the Social Security Act (42 U.S.C. 1315) is amended by adding at the end the following:CommentsClose CommentsPermalink





‘(g) Comprehensive Medicaid Waivers-CommentsClose CommentsPermalink





‘(1) AUTHORITY-CommentsClose CommentsPermalink





‘(A) IN GENERAL- A State may elect to provide medical assistance under title XIX, directly or by contract, to eligible individuals pursuant to a comprehensive Medicaid waiver under this subsection in lieu of providing such assistance under a State plan approved under title XIX or a waiver approved under subsection (d) or extended under subsection (e). A State shall make such an election by submitting a waiver application to the Secretary for certification that the application satisfies the requirements of paragraph (2).CommentsClose CommentsPermalink





‘(B) WAIVER OF STATE MEDICAID PROGRAM REQUIREMENTS- Any requirements applicable under this title or title XIX that would prevent a State from carrying out a comprehensive Medicaid waiver in accordance with the State’s certified application and the requirements of this subsection are deemed waived.CommentsClose CommentsPermalink





‘(C) SHARED SAVINGS BONUS- A State conducting a comprehensive Medicaid waiver under this subsection shall be eligible for a shared savings bonus in accordance with paragraph (4).CommentsClose CommentsPermalink





‘(D) OPTION TO INCLUDE CHIP-ELIGIBLE INDIVIDUALS- A State may elect to treat individuals eligible for child health assistance under the State child health plan under title XXI as eligible individuals under a comprehensive Medicaid waiver. The waiver application and determination of the aggregate spending cap for the State for the waiver period shall take into account the inclusion of such individuals in the comprehensive Medicaid waiver. Any requirements applicable under this title, title XIX, or title XXI that would prevent a State from including such individuals in the comprehensive Medicaid waiver in accordance with the State’s certified application and the requirements of this subsection are deemed waived.CommentsClose CommentsPermalink





‘(2) COMPREHENSIVE MEDICAID WAIVER APPLICATION- An application for a comprehensive Medicaid waiver under this subsection shall contain the following:CommentsClose CommentsPermalink





‘(A) GENERAL DESCRIPTION OF PROPOSED BENEFIT DELIVERY MODELS, ELIGIBILITY CRITERIA, AND BENEFITS- A brief description, which may be in outline form, of the eligibility criteria and medical assistance to be provided that includes the methods for delivery of such assistance, the criteria for the determination of eligibility for such assistance, and the amount, duration, and scope of such assistance, including a description of the amount (if any) of premiums, deductibles, coinsurance, or other cost-sharing.CommentsClose CommentsPermalink





‘(B) HEDIS MEASURES TO EVALUATE PERFORMANCE-CommentsClose CommentsPermalink





‘(i) IN GENERAL- A description of not less than 20 of the standard Medicaid Healthcare Effectiveness Data and Information Set (HEDIS) measures established by the National Committee for Quality Assurance selected by the State to annually evaluate the quality and cost-effectiveness of the medical assistance provided under the waiver, and for each such measure (and, if applicable, the distinct rates associated with the measure), the baseline data and the target performance goal applicable for each such measure or rate. The State shall select HEDIS measures that are closely aligned with the health care items and services that are provided to eligible individuals as medical assistance under the waiver.CommentsClose CommentsPermalink





‘(ii) EVALUATION- The description under this subparagraph shall specify the independent entity that the State will use to evaluate the waiver. The State shall provide an assurance that the State will submit a copy of the annual evaluation to the Secretary.CommentsClose CommentsPermalink





‘(C) PROGRAM INTEGRITY- A brief description of the State’s program to prevent waste, fraud, and abuse under the waiver.CommentsClose CommentsPermalink





‘(D) AGGREGATE SPENDING CAP- An assurance that the State agrees--CommentsClose CommentsPermalink





‘(i) to establish categories that accurately account for each of the distinct population groups that will qualify as eligible individuals under the waiver (such as children, parents, pregnant women, and the blind or disabled) based on such criteria as are determined appropriate by the State (referred to in this subsection as a ‘population category’);CommentsClose CommentsPermalink





‘(ii) to provide the Secretary with all data relevant to the determination of the aggregate spending cap for the State for the waiver period, as determined by the Secretary under paragraph (3)(B); andCommentsClose CommentsPermalink





‘(iii) with respect to each period for which the waiver is approved, to not receive any Federal payments from the Secretary for amounts expended during such period that exceed the aggregate spending cap.CommentsClose CommentsPermalink





‘(3) DETERMINATION OF AGGREGATE SPENDING CAP-CommentsClose CommentsPermalink





‘(A) ESTABLISHMENT OF SPENDING TEMPLATE-CommentsClose CommentsPermalink





‘(i) IN GENERAL- The Secretary, in coordination with the Director of the Office of Management and Budget (referred to in this subsection as the ‘Director’), shall establish a template for determining, with respect to each State, the aggregate spending cap for each period for which the State conducts a comprehensive Medicaid waiver under this subsection. The Secretary shall--CommentsClose CommentsPermalink





‘(I) publish a proposed template not later than 60 days after the date of enactment of this subsection;CommentsClose CommentsPermalink





‘(II) provide for a period for public comment on the proposed template; andCommentsClose CommentsPermalink





‘(III) promulgate a final template not later than 120 days after such date of enactment.CommentsClose CommentsPermalink





‘(ii) REVISIONS-CommentsClose CommentsPermalink





‘(I) IN GENERAL- Subject to subclause (II), the Secretary, in coordination with the Director, shall revise the template, as appropriate, not less than every 5 years pursuant to a process that allows for public comment prior to publication of the revised template.CommentsClose CommentsPermalink





‘(II) TECHNICAL CHANGES- The Secretary or the Director may make any necessary technical or conforming changes to the template at such times and in such manner as is determined appropriate.CommentsClose CommentsPermalink





‘(B) DETERMINATION OF AGGREGATE SPENDING CAP FOR EACH STATE-CommentsClose CommentsPermalink





‘(i) IN GENERAL- Subject to subparagraph (C), the aggregate spending cap applicable to a State for a waiver period shall be equal to 99 percent of the amount determined under clause (ii).CommentsClose CommentsPermalink





‘(ii) TOTAL AMOUNT OF PROJECTED FEDERAL PAYMENTS- The amount described in this clause is equal to the sum of--CommentsClose CommentsPermalink





‘(I) the total amount of Federal payments that would otherwise be made to the State during the waiver period with respect to any disproportionate share payment adjustment made under section 1923; andCommentsClose CommentsPermalink





‘(II) the sum of the amounts determined under clause (iii) for each population category.CommentsClose CommentsPermalink





‘(iii) PROJECTED FEDERAL PAYMENTS FOR MEDICAL ASSISTANCE PROVIDED TO POPULATION CATEGORIES- For purposes of clause (ii)(II), the Secretary and the Director shall calculate the amount of projected expenditures for the provision of medical assistance to eligible individuals in each population category during the waiver period (as determined based upon the population categories established and the data provided by the State pursuant to paragraph (2)(D), as well as the annual baseline estimates supplied by the Director and such other data as is determined appropriate by the Secretary), which shall be equal to the product of--CommentsClose CommentsPermalink





‘(I) subject to clause (iv), the monthly per capita amount of Federal payments that were made to the State under the State plan under title XIX (or under a waiver approved under subsection (d) or extended under subsection (e)) for an individual in such population category during the fiscal year prior to the State application for the waiver (referred to in this paragraph as the ‘population category per capita baseline’);CommentsClose CommentsPermalink





‘(II) the number of individuals within such population category that are projected to be eligible to receive medical assistance during the waiver period; andCommentsClose CommentsPermalink





‘(III) the number of months in the waiver period.CommentsClose CommentsPermalink





‘(iv) POPULATION CATEGORIES WITH NO BASELINE DATA- For purposes of any determination under clause (iii)(I) for a population category that lacks sufficient data to calculate the population category per capita baseline and that consists of individuals for which the State would otherwise be required to provide medical assistance to pursuant to section 1902(a)(10)(A)(i)(VIII), the population category per capita baseline shall be equal to the monthly per capita amount of Federal payments that would otherwise have been made to the State under the State plan under title XIX (or under a waiver approved under subsection (d) or extended under subsection (e)) during the preceding fiscal year for an individual who is under 65 years of age, not pregnant, not entitled to, or enrolled for, benefits under part A of title XVIII, or enrolled for benefits under part B of title XVIII.CommentsClose CommentsPermalink





‘(v) BUDGET NEUTRALITY- In no event shall the aggregate spending cap established for a State for a waiver period allow for Federal payments to the State during the waiver period that exceed the amount of Federal payments to the State that would have been made during that period if the State had not elected to conduct a comprehensive Medicaid waiver under this subsection during the period.CommentsClose CommentsPermalink





‘(C) ADJUSTMENT OF AGGREGATE SPENDING CAP FOR HIGH UNEMPLOYMENT- For purposes of subparagraph (B)(i), if the average monthly unemployment rate (as defined in paragraph (8)(A)) for a State exceeds 10 percent for any consecutive period of at least 6 months occurring during the waiver period, the aggregate spending cap applicable to the State for such waiver period shall be equal to 100 percent of the amount determined under subparagraph (B)(ii).CommentsClose CommentsPermalink





‘(4) SHARED SAVINGS BONUSES-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall annually pay each State conducting a comprehensive Medicaid waiver under this subsection an amount equal to 25 percent of the waiver savings determined with respect to a State and a waiver period under subparagraph (C).CommentsClose CommentsPermalink





‘(B) DEDICATED TO HEALTH CARE- A State that receives a payment under this paragraph shall spend not less than 80 percent of the payment on health care services or health-related activities for eligible individuals.CommentsClose CommentsPermalink





‘(C) DETERMINATION OF WAIVER SAVINGS- The Secretary and the Director shall establish a process for determining with respect to a State and a waiver period the amount of savings achieved by a State for the period. The process shall take into account the difference between the aggregate spending cap applicable to the State for the waiver period and the total amount expended by the State under the waiver for the period.CommentsClose CommentsPermalink





‘(D) PAYMENT; RETROSPECTIVE ADJUSTMENT- The Secretary shall make annual payments under this paragraph on the basis of claims submitted by the State for expenses paid by the State for medical assistance provided under the waiver, and such other investigation as the Secretary or the Director may find necessary, and may reduce or increase the payments as necessary to adjust for prior overpayments or under payments under this paragraph.CommentsClose CommentsPermalink





‘(5) DURATION-CommentsClose CommentsPermalink





‘(A) IN GENERAL- A State shall conduct a comprehensive Medicaid waiver under this subsection for a 5-year period. Subject to subparagraph (B), a comprehensive Medicaid waiver may be renewed for additional 3-year periods upon the request of the State, unless within 90 days after receipt of a State request for a renewal of a waiver, the Secretary and the Director determine, based on the State evaluations required under paragraph (2)(B), that the waiver should not be renewed.CommentsClose CommentsPermalink





‘(B) STATE EVALUATIONS AND TARGET PERFORMANCE GOALS- For purposes of subparagraph (A), the Secretary and the Director may not renew a waiver unless each of the measures or rates selected by the State pursuant to paragraph (2)(B) has improved or remained constant during the waiver period.CommentsClose CommentsPermalink





‘(6) LIMITED SECRETARIAL AUTHORITY; ADMINISTRATIVE AND JUDICIAL REVIEW-CommentsClose CommentsPermalink





‘(A) CERTIFICATION OF WAIVER APPLICATIONS-CommentsClose CommentsPermalink





‘(i) IN GENERAL- Except as provided under clause (ii), the Secretary and the Director shall have 90 days from receipt of an application by a State for a comprehensive Medicaid waiver to certify the application as satisfying the requirements of paragraph (2).CommentsClose CommentsPermalink





‘(ii) INQUIRIES- The Secretary and the Director may submit a single set of inquiries for additional information to the State during the initial 90-day period described under clause (i). If a State receives a set of inquires, the State shall have up to 60 days to respond. The Secretary and the Director shall have an additional 30-day period, starting on the date the Secretary receives a State response to a set of inquiries, to make a final determination as to whether the State’s waiver application may be certified as complying with the requirements of paragraph (2).CommentsClose CommentsPermalink





‘(iii) FAILURE TO RESPOND BY THE SECRETARY- An application by a State for a comprehensive Medicaid waiver shall be deemed certified by the Secretary if the Secretary does not submit any inquiries during the initial 90-day review period.CommentsClose CommentsPermalink





‘(iv) EFFECTIVE DATE- A waiver that has been certified by the Secretary (or deemed to be certified) may be effective, at the discretion of the State, as of the first day of the calendar quarter in which the application for the waiver was submitted by the State.CommentsClose CommentsPermalink





‘(B) DENIAL OF WAIVER APPLICATIONS OR RENEWAL REQUESTS-CommentsClose CommentsPermalink





‘(i) IN GENERAL- If the Secretary and the Director determine that an application for a comprehensive Medicaid waiver, or a request for extension of an existing comprehensive Medicaid waiver, does not satisfy the requirements of paragraph (2), the Secretary shall notify the State of the disapproval by written notification, not later than 10 days following the issuance of such determination and shall provide a detailed description of the reasons for the denial of the waiver to--CommentsClose CommentsPermalink





‘(I) the State that submitted the waiver application or extension request;CommentsClose CommentsPermalink





‘(II) the members of Congress representing such State; andCommentsClose CommentsPermalink





‘(III) the Committee on Finance of the Senate and the Committee on Energy and Commerce of the House of Representatives.CommentsClose CommentsPermalink





‘(ii) ADMINISTRATIVE AND JUDICIAL REVIEW-CommentsClose CommentsPermalink





‘(I) ADMINISTRATIVE REVIEW- Within 60 days after the date that a State receives notice of the denial of a waiver application or extension request, the State may appeal the determination to the Departmental Appeals Board established in the Department of Health and Human Services. The Departmental Appeals Board shall make a final determination with respect to an appeal filed under this subparagraph not less than 60 days after the date on which the appeal is filed.CommentsClose CommentsPermalink





‘(II) JUDICIAL REVIEW- Within 60 days after the date of a final decision by the Board under subclause (I) that is adverse to a State, the State may obtain judicial review of the final decision by filing an action in the district court of the United States for the judicial district in which the principal or headquarters office of the State agency responsible for administering the State Medicaid program is located or the United States District Court for the District of Columbia.CommentsClose CommentsPermalink





‘(C) REPORTS-CommentsClose CommentsPermalink





‘(i) IN GENERAL- Not later than 2 years after the date on which the Secretary and the Director first approve an application for a comprehensive Medicaid waiver under this subsection and every 3 years thereafter, the Comptroller General of the United States (referred to in this subparagraph as the ‘Comptroller’) shall submit to the Committee on Finance of the Senate and the Committee on Energy and Commerce of the House of Representatives a report on the waivers certified as of the date of such report. Each report shall include an evaluation of the quality and cost-effectiveness of the comprehensive Medicaid waivers in effect during the reporting period in providing medical assistance to eligible individuals, as well as the financial effort of the waiver on State and Federal budgets.CommentsClose CommentsPermalink





‘(ii) REPORTING OF INFORMATION- A State with a comprehensive Medicaid waiver under this subsection shall provide the Comptroller, in such form and manner as the Comptroller may require, with any relevant information regarding the waiver, including total expenditures by the State under the waiver, the number of individuals provided medical assistance under the waiver, and such other information as the Comptroller may require for purposes of preparing the reports required under this subparagraph.CommentsClose CommentsPermalink





‘(7) NON-APPLICATIONS- A comprehensive Medicaid waiver shall not apply to--CommentsClose CommentsPermalink





‘(A) the pediatric vaccine program under section 1928; andCommentsClose CommentsPermalink





‘(B) limitations on total payments to territories under section 1108.CommentsClose CommentsPermalink





‘(8) OUTREACH AND EDUCATION-CommentsClose CommentsPermalink





‘(A) STATE AWARENESS- Not later than 30 days after the date of enactment of this subsection, the Secretary shall conduct an outreach and education campaign to States regarding the availability of comprehensive Medicaid waivers under this subsection.CommentsClose CommentsPermalink





‘(B) PUBLIC NOTICE AND COMMENT- Before submitting an application for a comprehensive Medicaid waiver, a State shall make the proposed application available to the public through such means as the State determines appropriate and allow for a reasonable public comment period of not greater than 30 days.CommentsClose CommentsPermalink





‘(C) PUBLIC AWARENESS OF APPROVED WAIVER- A State that has been certified for a comprehensive Medicaid waiver shall conduct an outreach and education campaign to ensure that health care providers and eligible individuals within the State are provided with adequate notice regarding the methods and criteria through which the State intends to provide medical assistance under the waiver.CommentsClose CommentsPermalink





‘(9) DEFINITIONS- In this subsection:CommentsClose CommentsPermalink





‘(A) AVERAGE MONTHLY UNEMPLOYMENT RATE- The term ‘average monthly unemployment rate’ means the average of the monthly number unemployed in the State, divided by the average of the monthly civilian labor force in the State, seasonally adjusted, as determined based on the most recent monthly publications of the Bureau of Labor Statistics of the Department of Labor.CommentsClose CommentsPermalink





‘(B) ELIGIBLE INDIVIDUAL- The term ‘eligible individual’ means, for each year during the waiver period--CommentsClose CommentsPermalink





‘(i) any individual who, for such year, the State would otherwise be required to provide medical assistance to pursuant to--CommentsClose CommentsPermalink





‘(I) section 1902(a)(10)(A)(i);CommentsClose CommentsPermalink





‘(II) paragraphs (1) or (4) of section 1902(e);CommentsClose CommentsPermalink





‘(III) section 1925; orCommentsClose CommentsPermalink





‘(IV) section 1931;CommentsClose CommentsPermalink





‘(ii) at the option of the State, any individual who, for such year, the State would otherwise provide child health assistance to under the State child health plan under title XXI; andCommentsClose CommentsPermalink





‘(iii) at the option of the State, any individual who is not described in clause (i) or (ii) and who satisfies such income, resources, health status, or other criteria as the State may establish.CommentsClose CommentsPermalink





‘(C) MEDICAL ASSISTANCE- The term ‘medical assistance’ means--CommentsClose CommentsPermalink





‘(i) health care coverage (as determined by the State); andCommentsClose CommentsPermalink





‘(ii) rehabilitation and other services to help eligible individuals attain or retain capability for independence or self-care, such as home and community-based services.CommentsClose CommentsPermalink





‘(D) STATE MEDICAID PROGRAM- The term ‘State Medicaid program’ means the State program for medical assistance provided under a State plan under title XIX, including any waiver that has been approved with respect to a State plan prior to an application by the State for a comprehensive Medicaid waiver under this subsection.’.CommentsClose CommentsPermalink

SEC. 1102. PHASED-IN ELIMINATION OF ALLOWABLE PROVIDER TAXES UNDER MEDICAID.

(a) In General- Clause (ii) of section 1903(w)(4)(C) of the Social Security Act (42 U.S.C. 1396b(w)(4)(C)) is amended to read as follows:CommentsClose CommentsPermalink





‘(ii) For purposes of clause (i), a determination of the existence of an indirect guarantee shall be made under paragraph (3)(i) of section 433.68(f) of title 42, Code of Federal Regulations, as in effect on November 1, 2006, except that--CommentsClose CommentsPermalink





‘(I) for portions of fiscal years beginning on or after January 1, 2008, and before October 1, 2011, ‘5.5 percent’ shall be substituted for ‘6 percent’ each place it appears;CommentsClose CommentsPermalink





‘(II) for fiscal years 2012 and 2013, the percentage specified under such paragraph shall apply;CommentsClose CommentsPermalink





‘(III) for fiscal years 2014 through 2022, the percentage determined under clause (iii) for the fiscal year shall be substituted for ‘6 percent’ each place it appears; andCommentsClose CommentsPermalink





‘(IV) for fiscal year 2023 and each fiscal year thereafter, ‘0 percent’ shall be substituted for ‘6 percent’ each place it appears.CommentsClose CommentsPermalink





‘(iii) For purposes of clause (ii)(III), the percentage determined under this clause shall be equal to the percentage applicable under subclause (II) or (III) of clause (ii) for the preceding fiscal year, reduced by 0.6 percentage points.’.CommentsClose CommentsPermalink





(b) Effective Date- The amendment made by subsection (a) shall take effect on October 1, 2013.CommentsClose CommentsPermalink

TITLE II--MEDICARECommentsClose CommentsPermalink

Subtitle A--Medicare Total Health Program; Medicare Fee-for-Service Program Reforms; ReportsCommentsClose CommentsPermalink

SEC. 2000. SHORT TITLE; PURPOSE.

(a) Short Title- This subtitle may be cited as the ‘Medicare Total Health Act of 2012’.CommentsClose CommentsPermalink





(b) Purpose- The purpose of this subtitle is to amend title XVIII of the Social Security Act to improve the sustainability of the Medicare program by establishing a Total Health system, reforming the Medicare fee-for-service program, and for other purposes.CommentsClose CommentsPermalink

PART I--MEDICARE TOTAL HEALTH PROGRAM

SEC. 2001. ESTABLISHMENT OF MEDICARE TOTAL HEALTH PROGRAM.

(a) Sunset of Medicare Advantage Plans- Section 1851(a)(1) of the Social Security Act (42 U.S.C. 1395w-21(a)(1)), in the matter preceding subparagraph (A), is amended by striking ‘Subject to’ and inserting ‘For plan years beginning prior to January 1, 2017, and subject to’.CommentsClose CommentsPermalink





(b) Establishment- Part C of title XVIII of the Social Security Act (42 U.S.C. 1395w-21 et seq.) is amended--CommentsClose CommentsPermalink





(1) in the part heading, by striking ‘medicare+choice program’ and inserting ‘medicare advantage program; medicare total health program’;CommentsClose CommentsPermalink





(2) by inserting before section 1851 the following:CommentsClose CommentsPermalink

‘Subpart 1--Medicare Advantage Program’; and

(3) by adding at the end the following new subpart:CommentsClose CommentsPermalink

‘Subpart 2--Medicare Total Health Program

‘ELIGIBILITY, ENROLLMENT, AND INFORMATION

‘Sec. 1860C-1. (a) Eligibility-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Notwithstanding section 1851(a)(1) and subject to the succeeding provisions of this subpart, each Total Health eligible individual (as defined in paragraph (3)) may elect to receive benefits under this title--CommentsClose CommentsPermalink





‘(A) through the original medicare fee-for-service program under parts A and B, including the option to elect qualified prescription drug coverage in accordance with section 1860D-1; orCommentsClose CommentsPermalink





‘(B) through enrollment in a Total Health plan under this subpart.CommentsClose CommentsPermalink





‘(2) COVERAGE FIRST EFFECTIVE JANUARY 1, 2017- Coverage under the Medicare Total Health program shall first be effective on January 1, 2017.CommentsClose CommentsPermalink





‘(3) TOTAL HEALTH ELIGIBLE INDIVIDUAL- For purposes of this subpart, the term ‘Total Health eligible individual’ means an individual who is entitled to benefits under part A and enrolled under part B who resides in a Total Health region.CommentsClose CommentsPermalink





‘(4) TYPES OF TOTAL HEALTH PLANS THAT MAY BE AVAILABLE- A Total Health plan may be any of the types of plans of health insurance described in section 1851(a)(2)(A), including a plan for special needs individuals described in clause (ii) of such section.CommentsClose CommentsPermalink





‘(b) Enrollment Process for Total Health Plans-CommentsClose CommentsPermalink





‘(1) ESTABLISHMENT OF PROCESS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall establish a process for the enrollment, disenrollment, termination, and change of enrollment of Total Health eligible individuals in Total Health plans in a manner similar to (and coordinated with) the process established under section 1860D-1(b)(1).CommentsClose CommentsPermalink





‘(B) REQUIREMENTS- Except as otherwise provided in this subsection, the process established under subparagraph (A) shall include a residency requirement similar to the residency requirement described in section 1851(b)(1) and shall take into account the process for exercising choice described in section 1851(c).CommentsClose CommentsPermalink





‘(2) INITIAL ENROLLMENT PERIOD-CommentsClose CommentsPermalink





‘(A) PROGRAM INITIATION- In the case of an individual who is a Total Health eligible individual as of November 15, 2016, there shall be an initial enrollment period beginning on October 15, 2016, and ending on December 7, 2016.CommentsClose CommentsPermalink





‘(B) CONTINUING PERIODS- In the case of an individual who first becomes a Total Health eligible individual after November 15, 2016, there shall be an initial enrollment period which is the same as the period under section 1851(e)(1).CommentsClose CommentsPermalink





‘(3) ANNUAL, COORDINATED ELECTION PERIOD-CommentsClose CommentsPermalink





‘(A) IN GENERAL- As part of the process established under paragraph (1), each individual who is eligible to make an election under this section may change such election during an annual, coordinated election period.CommentsClose CommentsPermalink





‘(B) ANNUAL, COORDINATED ELECTION PERIOD- For purposes of this section, the term ‘annual, coordinated election period’ means, with respect to 2017 and succeeding years, the period beginning on October 15 and ending on December 7 of the year before such year.CommentsClose CommentsPermalink





‘(4) SPECIAL ENROLLMENT PERIODS- The Secretary shall establish special enrollment periods that are similar to the special enrollment periods established under section 1851(e)(4).CommentsClose CommentsPermalink





‘(5) SPECIAL RULE-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Notwithstanding any other provision of law, the process established under paragraph (1) shall include, in the case of a Total Health eligible individual who has failed to enroll in either the original medicare fee-for-service program option or a Total Health plan prior to the beginning of a plan year (including a full-benefit dual eligible individual (as defined in section 1935(c)(6))), for the enrollment in a Total Health plan with a monthly beneficiary premium under section 1860C-7(a) (taking into account any adjustment under subparagraph (B) or (C) of section 1860C-7(a)(2) and without regard to any adjustment under subparagraph (D) or (E) of such section) that does not exceed the base beneficiary premium computed under section 1860C-7(a)(1).CommentsClose CommentsPermalink





‘(B) SELECTION OF PLAN BY THE SECRETARY- In selecting a plan for the enrollment of a Total Health eligible individual under subparagraph (A), the Secretary shall first attempt to identify the Total Health plan in which the cost-sharing and health benefits are most similar to the coverage the individual had in the preceding plan year. If there is more than one such plan available, the Secretary shall enroll such an individual on a random basis among all such plans in the Total Health region. Nothing in the previous sentence shall prevent such an individual from declining or changing such enrollment.CommentsClose CommentsPermalink





‘(C) INDIVIDUALS WHO ARE NOT TOTAL HEALTH ELIGIBLE INDIVIDUALS- The Secretary shall establish procedures under which individuals who are entitled to, or enrolled for, coverage under part A or enrolled for coverage under part B (but not both), may continue to receive benefits with deductible and coinsurance amounts comparable to the benefits, deductible, and coinsurance amounts they would have received if this subpart had not been enacted.CommentsClose CommentsPermalink





‘(c) Providing Information to Beneficiaries-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall conduct activities that are designed to broadly disseminate information to Total Health eligible individuals (and prospective Total Health eligible individuals) regarding the coverage provided under this subpart. Such activities shall ensure that such information is first made available at least 30 days prior to the initial enrollment period described in subsection (b)(2)(A).CommentsClose CommentsPermalink





‘(2) ACTIVITIES- The activities conducted under paragraph (1) shall be similar to the activities described in paragraph (2) of section 1860D-1(c) and contain comparative information similar to the information described in paragraph (3) of such section.CommentsClose CommentsPermalink

‘TOTAL HEALTH PLAN BENEFITS

‘Sec. 1860C-2. (a) Requirements-CommentsClose CommentsPermalink





‘(1) QUALIFIED TOTAL HEALTH BENEFITS- Each Total Health plan shall provide to individuals enrolled under this subpart, through providers and other persons that meet the applicable requirements of this title and part A of title XI, a qualified Total Health benefits package and qualified prescription drug coverage (described in section 1860D-2(a)).CommentsClose CommentsPermalink





‘(2) DEFINITION OF QUALIFIED TOTAL HEALTH BENEFITS PACKAGE- For purposes of this subpart, the term ‘qualified Total Health benefits package’ means either of the following:CommentsClose CommentsPermalink





‘(A) STANDARD HEALTH BENEFITS COVERAGE WITH ACCESS TO NEGOTIATED PRICES- Standard health benefits coverage (as defined in subsection (b)) and access to negotiated prices under subsection (d).CommentsClose CommentsPermalink





‘(B) ALTERNATIVE TOTAL HEALTH BENEFITS COVERAGE WITH AT LEAST ACTUARIALLY EQUIVALENT BENEFITS AND ACCESS TO NEGOTIATED PRICES- Coverage of health benefits which meets the alternative health benefits coverage requirements under subsection (c) and access to negotiated prices under subsection (d), but only if the benefit design of such coverage is approved by the Secretary, as provided under subsection (c).CommentsClose CommentsPermalink





‘(3) PERMITTING SUPPLEMENTAL HEALTH BENEFITS COVERAGE-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to subparagraph (B), a qualified Total Health benefits package may include supplemental health benefits coverage consisting of either or both of the following:CommentsClose CommentsPermalink





‘(i) CERTAIN REDUCTIONS IN COST-SHARING-CommentsClose CommentsPermalink





‘(I) IN GENERAL- A reduction in the annual deductible or a reduction in the coinsurance percentage, or any combination thereof, insofar as such a reduction or increase increases the actuarial value of benefits above the actuarial value of a basic Total Health benefits package.CommentsClose CommentsPermalink





‘(II) CONSTRUCTION- Nothing in this clause shall be construed as affecting the application of subsection (c)(3).CommentsClose CommentsPermalink





‘(ii) ADDITIONAL BENEFITS- Coverage of any health care item or service that is not covered under the original medicare fee-for-service program option or that is eligible for coverage under part D, subject to the approval of the Secretary.CommentsClose CommentsPermalink





‘(B) REQUIREMENT FOR AT LEAST ONE BASIC BENEFITS PLAN- A Total Health sponsor may not offer a Total Health plan that provides supplemental health benefits coverage pursuant to subparagraph (A) in an area unless the sponsor also offers a Total Health plan in the area that only provides a basic Total Health benefits package.CommentsClose CommentsPermalink





‘(4) BASIC TOTAL HEALTH BENEFITS PACKAGE- For purposes of this subpart, the term ‘basic Total Health benefits package’ means either of the following:CommentsClose CommentsPermalink





‘(A) Coverage that meets the requirements of paragraph (2)(A).CommentsClose CommentsPermalink





‘(B) Coverage that meets the requirements of paragraph (2)(B) but does not have any supplemental health benefits coverage described in paragraph (3)(A).CommentsClose CommentsPermalink





‘(5) APPLICATION OF SECONDARY PAYER PROVISIONS- The provisions of section 1852(a)(4) shall apply under this subpart in the same manner as such provisions applied to a Medicare Advantage plan.CommentsClose CommentsPermalink





‘(6) CONSTRUCTION- Nothing in this subsection shall be construed as changing the computation of incurred costs under subsection (b)(3).CommentsClose CommentsPermalink





‘(b) Standard Health Benefits Coverage- For purposes of this subpart, the term ‘standard health benefits coverage’ means coverage of benefits under the original medicare fee-for-service program option (as defined in section 1852(a)(1)(B)), including the following requirements:CommentsClose CommentsPermalink





‘(1) DEDUCTIBLE- The coverage has an annual deductible that is equal to the amount of the unified deductible for the year under section 1899C.CommentsClose CommentsPermalink





‘(2) 20 PERCENT COINSURANCE- The coverage has coinsurance (for costs above the annual deductible specified in paragraph (1) and up to the first threshold annual out-of-pocket limit specified in paragraph (3)(B)(i)) that is--CommentsClose CommentsPermalink





‘(A) equal to 20 percent; orCommentsClose CommentsPermalink





‘(B) actuarially equivalent (using processes and methods established by the Secretary) to an average expected payment of 20 percent of such costs.CommentsClose CommentsPermalink





‘(3) PROTECTION AGAINST HIGH OUT-OF-POCKET EXPENDITURES-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The coverage provides benefits, after the Total Health eligible individual has incurred costs (as described in subparagraph (C)) for health benefits in a year equal to--CommentsClose CommentsPermalink





‘(i) the first threshold annual out-of-pocket limit specified in subparagraph (B)(i) for that year but less than the second threshold annual out-of-pocket limit specified in subparagraph (B)(ii) for that year, with coinsurance that is equal to 5 percent; andCommentsClose CommentsPermalink





‘(ii) the second threshold annual out-of-pocket limit specified in subparagraph (B)(ii) for that year, without coinsurance.CommentsClose CommentsPermalink





‘(B) ANNUAL OUT-OF-POCKET LIMITS SPECIFIED- For purposes of this subpart:CommentsClose CommentsPermalink





‘(i) FIRST THRESHOLD ANNUAL OUT-OF-POCKET LIMIT SPECIFIED- The ‘first threshold annual out-of-pocket limit’ specified in this clause is equal to the first threshold annual out-of-pocket limit for the year specified in section 1899B(b)(1).CommentsClose CommentsPermalink





‘(ii) SECOND THRESHOLD ANNUAL OUT-OF-POCKET LIMIT SPECIFIED- The ‘second threshold annual out-of-pocket limit’ specified in this clause is equal to the second threshold annual out-of-pocket limit for the year specified in section 1899B(b)(2).CommentsClose CommentsPermalink





‘(C) APPLICATION- In applying subparagraph (A), incurred costs shall only include costs incurred with respect to health benefits for the annual deductible described in paragraph (1) and for cost-sharing described in paragraph (2) or paragraph (3)(A)(i), or for benefits that would have otherwise been covered under the plan but for the exhaustion of those benefits. Incurred costs do not include any costs incurred for health benefits which are not included (or treated as being included) under the plan.CommentsClose CommentsPermalink





‘(c) Alternative Total Health Benefits Coverage Requirements- A Total Health plan may provide a different benefit design from standard health benefits coverage so long as the Secretary determines that the following requirements are met and the plan applies for, and receives, the approval of the Secretary for such benefit design:CommentsClose CommentsPermalink





‘(1) ASSURING AT LEAST ACTUARIALLY EQUIVALENT COVERAGE-CommentsClose CommentsPermalink





‘(A) ASSURING EQUIVALENT VALUE OF TOTAL COVERAGE- The actuarial value of the total coverage is at least equal to the actuarial value of standard health benefits coverage.CommentsClose CommentsPermalink





‘(B) ASSURING EQUIVALENT UNSUBSIDIZED VALUE OF COVERAGE- The unsubsidized value of the coverage is at least equal to the unsubsidized value of standard health benefits coverage. For purposes of this subparagraph, the unsubsidized value of coverage is the amount by which the actuarial value of the coverage exceeds the subsidy payments with respect to such coverage.CommentsClose CommentsPermalink





‘(C) ASSURING STANDARD PAYMENT FOR COSTS BELOW FIRST THRESHOLD ANNUAL OUT-OF-POCKET LIMIT- The coverage is designed, based upon an actuarially representative pattern of utilization, to provide for the payment, with respect to costs incurred up to the first threshold annual out-of-pocket limit specified in subsection (b)(3)(B)(i), of an amount equal to at least the product of--CommentsClose CommentsPermalink





‘(i) the amount by which the costs incurred exceed the deductible described in subsection (b)(1) for the year; andCommentsClose CommentsPermalink





‘(ii) 100 percent minus the coinsurance percentage specified in subsection (b)(2).CommentsClose CommentsPermalink





‘(2) APPROVAL OF BENEFIT PACKAGE- The benefit package is approved by the Secretary as containing a comparable range of benefits to standard health benefits coverage and meets such other requirements of this subpart as the Secretary may specify.CommentsClose CommentsPermalink





‘(3) MAXIMUM REQUIRED DEDUCTIBLE- The deductible under the coverage shall not exceed the deductible amount specified under subsection (b)(1) for the year.CommentsClose CommentsPermalink





‘(4) SAME PROTECTION AGAINST HIGH OUT-OF-POCKET EXPENDITURES- The coverage provides the coverage required under subsection (b)(3).CommentsClose CommentsPermalink





‘(d) Access to Negotiated Prices-CommentsClose CommentsPermalink





‘(1) ACCESS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Under a qualified Total Health benefits package offered by a Total Health sponsor offering a Total Health plan, the sponsor shall provide enrollees with access to negotiated prices used for payment for covered health benefits, regardless of the fact that no benefits may be payable under the coverage with respect to such benefits because of the application of a deductible or other cost-sharing.CommentsClose CommentsPermalink





‘(B) NEGOTIATED PRICES- For purposes of this subpart, negotiated prices shall take into account negotiated price concessions, such as discounts, direct or indirect subsidies, rebates, and direct or indirect remunerations, for covered health benefits.CommentsClose CommentsPermalink





‘(2) AUDITS- To protect against fraud and abuse and to ensure proper disclosures and accounting under this part and in accordance with section 1857(d)(2)(B), the Secretary may conduct periodic audits, directly or through contracts, of the financial statements and records of Total Health sponsors with respect to Total Health Plans.CommentsClose CommentsPermalink





‘(3) APPLICATION OF GENERAL EXCLUSION PROVISIONS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- A Total Health plan may exclude from a qualified Total Health benefits package any health care item or service--CommentsClose CommentsPermalink





‘(i) for which payment would not be made if section 1862(a) applied to this subpart; orCommentsClose CommentsPermalink





‘(ii) which is not prescribed in accordance with the Total Health plan or this subpart.CommentsClose CommentsPermalink





‘(B) RECONSIDERATION AND APPEAL- Any exclusion under subparagraph (A) is a determination subject to reconsideration and appeal under this subpart.CommentsClose CommentsPermalink





‘(e) Satisfaction of Requirements- A Total Health plan satisfies the requirements of subsection (a) in the same way a Medicare Advantage plan satisfied the requirements of section 1852(a)(2).CommentsClose CommentsPermalink

‘ACCESS TO A CHOICE OF QUALIFIED TOTAL HEALTH BENEFITS PLANS

‘Sec. 1860C-3. (a) Assuring Access to a Choice of Plans-CommentsClose CommentsPermalink





‘(1) CHOICE OF AT LEAST TWO PLANS IN EACH AREA- The Secretary shall ensure that each Total Health eligible individual has available, consistent with paragraph (2), a choice of enrollment in at least 2 Total Health plans in the area in which the individual resides.CommentsClose CommentsPermalink





‘(2) REQUIREMENT FOR DIFFERENT PLAN SPONSORS- The requirement in paragraph (1) is not satisfied with respect to an area if only one entity offers all of the qualifying plans in the area.CommentsClose CommentsPermalink





‘(b) Flexibility in Risk Assumed- In order to ensure access pursuant to subsection (a) in an area the Secretary may approve limited risk plans under section 1860C-5(g) for the area.CommentsClose CommentsPermalink

‘BENEFICIARY PROTECTIONS FOR TOTAL HEALTH PLAN ENROLLEES

‘Sec. 1860C-4. (a) Dissemination of Information-CommentsClose CommentsPermalink





‘(1) GENERAL INFORMATION- A Total Health sponsor shall disclose, in a clear, accurate, and standardized form to each enrollee with a Total Health plan offered by the sponsor under this subpart at the time of enrollment and at least annually thereafter, the information described in section 1852(c)(1) relating to such plan, insofar as the Secretary determines appropriate with respect to benefits provided under this subpart, and including the information described in section 1860D-4 relating to qualified prescription drug coverage under the plan.CommentsClose CommentsPermalink





‘(2) DISCLOSURE UPON REQUEST OF GENERAL COVERAGE, UTILIZATION, AND GRIEVANCE INFORMATION- Upon request of a Total Health eligible individual who is eligible to enroll in a Total Health plan, the Total Health sponsor offering such plan shall provide information similar (as determined by the Secretary) to the information described in section 1852(c)(2) to such individual.CommentsClose CommentsPermalink





‘(3) PROVISION OF SPECIFIC INFORMATION- Each Total Health sponsor offering a Total Health plan shall have a mechanism for providing specific information on a timely basis to enrollees upon request. Such mechanism shall include access to information through the use of a toll-free telephone number and, upon request, the provision of such information in writing.CommentsClose CommentsPermalink





‘(4) CLAIMS INFORMATION-CommentsClose CommentsPermalink





‘(A) IN GENERAL- A Total Health sponsor offering a Total Health plan must furnish to each enrollee in a form easily understandable to such enrollees--CommentsClose CommentsPermalink





‘(i) an explanation of benefits (in accordance with section 1806(a) or in a comparable manner); andCommentsClose CommentsPermalink





‘(ii) when Total Health benefits are provided under this subpart, a notice of the benefits in relation to--CommentsClose CommentsPermalink





‘(I) the deductible described in paragraph (1) of section 1860C-2(b) for the current year; andCommentsClose CommentsPermalink





‘(II) the annual out-of-pocket limits under paragraph (3) of such section for the current year.CommentsClose CommentsPermalink





‘(B) TIMING OF NOTICES- Notices under subparagraph (A)(ii) need not be provided more often than as specified by the Secretary.CommentsClose CommentsPermalink





‘(b) Access to Health Care Providers-CommentsClose CommentsPermalink





‘(1) ASSURING PROVIDER ACCESS-CommentsClose CommentsPermalink





‘(A) DISCOUNTS ALLOWED FOR NETWORK PROVIDERS- For health benefits furnished through in-network providers, a Total Health plan may reduce coinsurance or copayments for Total Health eligible individuals enrolled in the plan below the level otherwise required. In no case shall such a reduction result in an increase in payments made by the Secretary under section 1860C-8 to the Total Health sponsor of the plan.CommentsClose CommentsPermalink





‘(B) CONVENIENT ACCESS FOR NETWORK PROVIDERS-CommentsClose CommentsPermalink





‘(i) IN GENERAL- The Total Health sponsor of the Total Health plan shall secure the participation in its network of a sufficient number of health care providers that furnish health care items and services under the plan directly to patients to ensure convenient access (consistent with rules established by the Secretary).CommentsClose CommentsPermalink





‘(ii) ADEQUATE EMERGENCY ACCESS- Such rules shall include adequate emergency access for enrollees.CommentsClose CommentsPermalink





‘(C) LEVEL PLAYING FIELD- Such a sponsor shall permit enrollees to receive benefits through any health care provider participating in the program under this title with any differential in charge paid by such enrollees.CommentsClose CommentsPermalink





‘(2) USE OF STANDARDIZED TECHNOLOGY-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Total Health sponsor of a Total Health plan shall issue (and reissue, as appropriate) such a card (or other technology) that may be used by an enrollee to assure access to health benefits under this subpart.CommentsClose CommentsPermalink





‘(B) STANDARDS-CommentsClose CommentsPermalink





‘(i) IN GENERAL- The Secretary shall provide for the development, adoption, or recognition of standards relating to a standardized format for the card or other technology required under subparagraph (A). Such standards shall be compatible with part C of title XI and may be based on standards developed by an appropriate standard setting organization.CommentsClose CommentsPermalink





‘(ii) CONSULTATION- In developing the standards under clause (i), the Secretary shall consult with standard setting organizations determined appropriate by the Secretary.CommentsClose CommentsPermalink





‘(iii) IMPLEMENTATION- The Secretary shall develop, adopt, or recognize the standards under clause (i) by such date as the Secretary determines shall be sufficient to ensure that Total Health sponsors utilize such standards beginning January 1, 2017.CommentsClose CommentsPermalink





‘(c) Cost and Utilization Management; Quality Assurance; Wellness Program-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Total Health sponsor shall have in place, directly or through appropriate arrangements, the following:CommentsClose CommentsPermalink





‘(A) A cost-effective health benefits management program, including incentives to reduce costs when medically appropriate.CommentsClose CommentsPermalink





‘(B) Quality assurance measures and systems to reduce errors and improve the use of health benefits.CommentsClose CommentsPermalink





‘(C) A wellness program described in paragraph (2).CommentsClose CommentsPermalink





‘(D) A program to control fraud, abuse, and waste.CommentsClose CommentsPermalink





Nothing in this section shall be construed as impairing a Total Health sponsor from utilizing cost management tools (including differential payments) under all methods of operation.CommentsClose CommentsPermalink





‘(2) WELLNESS PROGRAM-CommentsClose CommentsPermalink





‘(A) DESCRIPTION- A wellness program described in this paragraph is a program focused on health improvement, disease prevention, and management of chronic conditions for Total Health eligible individuals enrolled in a plan under this part to optimize health outcomes through improved use of health care items and services and to reduce the risk of adverse events.CommentsClose CommentsPermalink





‘(B) ELEMENTS- Such program may include elements that promote--CommentsClose CommentsPermalink





‘(i) enhanced enrollee understanding to promote the appropriate use of health care items and services by enrollees and to reduce the risk of potential adverse events and to improve health outcomes through beneficiary education, counseling, and other appropriate means;CommentsClose CommentsPermalink





‘(ii) increased enrollee adherence with recommended regimens through compliance programs and other appropriate means; andCommentsClose CommentsPermalink





‘(iii) detection of adverse events and patterns of overuse and underuse of health care items and services.CommentsClose CommentsPermalink





‘(C) ASSESSMENT- The Total Health sponsor shall have in place a process to assess, at least on a quarterly basis, the health benefits use of individuals who are not enrolled in the wellness program.CommentsClose CommentsPermalink





‘(D) WELLNESS PROGRAM ENROLLMENT- The Total Health sponsor shall have in place a process to--CommentsClose CommentsPermalink





‘(i) subject to clause (ii), automatically enroll plan enrollees in the wellness program required under this subsection; andCommentsClose CommentsPermalink





‘(ii) permit plan enrolles to opt-out of enrollment in the wellness program.CommentsClose CommentsPermalink





‘(E) DEVELOPMENT OF PROGRAM IN COOPERATION WITH PHYSICIANS- Such program shall be developed in cooperation with physicians.CommentsClose CommentsPermalink





‘(F) COORDINATION WITH CARE MANAGEMENT PLANS- The Secretary shall establish guidelines for the coordination of any wellness program under this paragraph with respect to a targeted beneficiary described in section 1860D-4(c)(2)(A)(i) (applied by substituting ‘Total Health eligible individual’ for ‘part D eligible individual’) with any care management plan established with respect to such beneficiary under a chronic care improvement program under section 1807.CommentsClose CommentsPermalink





‘(G) CONSIDERATIONS IN PROVIDER FEES- The Total Health sponsor of a Total Health plan shall take into account, in establishing fees for entities providing services under such plan, the resources used, and time required to, implement the wellness program under this paragraph. Each such sponsor shall disclose to the Secretary upon request the amount of any such fees.CommentsClose CommentsPermalink





‘(d) Consumer Satisfaction Surveys- In order to provide for comparative information under section 1860C-1(c), the Secretary shall conduct consumer satisfaction surveys with respect to Total Health sponsors and Total Health plans in a manner similar to the manner such surveys were conducted for MA organizations and MA plans under subpart 1.CommentsClose CommentsPermalink





‘(e) Grievance Mechanism- Each Total Health sponsor shall provide meaningful procedures for hearing and resolving grievances between the sponsor (including any entity or individual through which the sponsor provides covered benefits) and enrollees with Total Health plans of the sponsor under this part in accordance with section 1852(f).CommentsClose CommentsPermalink





‘(f) Coverage Determinations and Reconsiderations- A Total Health sponsor shall meet the requirements of paragraphs (1) through (3) of section 1852(g) with respect to covered benefits under the Total Health plan offered by the sponsor under this subpart in the same manner as such requirements applied to an MA organization with respect to covered benefits under an MA plan offered by the organization under subpart 1.CommentsClose CommentsPermalink





‘(g) Appeals- A Total Health sponsor shall meet the requirements of paragraphs (4) and (5) of section 1852(g) with respect to benefits in a manner similar (as determined by the Secretary) to the manner such requirements applied to an MA organization with respect to benefits under the original medicare fee-for-service program option under an MA plan. In applying this subsection, only the Total Health eligible individual shall be entitled to bring such an appeal.CommentsClose CommentsPermalink





‘(h) Privacy, Confidentiality, and Accuracy of Enrollee Records- The provisions of section 1852(h) shall apply to a Total Health sponsor and Total Health plan in the same manner as such provisions applied to an MA organization and an MA plan.CommentsClose CommentsPermalink





‘(i) Treatment of Accreditation- Subparagraph (A) of section 1852(e)(4) (relating to treatment of accreditation) shall apply to a Total Health sponsor under this part in the same manner as such subparagraph applied to an MA organization.CommentsClose CommentsPermalink





‘(j) Requirements With Respect to Sales and Marketing Activities- The following provisions shall apply to a Total Health sponsor (and the agents, brokers, and other third parties representing such sponsor) in the same manner as such provisions applied to a Medicare Advantage organization (and the agents, brokers, and other third parties representing such organization):CommentsClose CommentsPermalink





‘(1) The prohibition under section 1851(h)(4)(C) on conducting activities described in section 1851(j)(1).CommentsClose CommentsPermalink





‘(2) The requirement under section 1851(h)(4)(D) to conduct activities described in paragraph (2) of section 1851(j) in accordance with the limitations established under such section.CommentsClose CommentsPermalink





‘(3) The inclusion of the plan type in the plan name under section 1851(h)(6).CommentsClose CommentsPermalink





‘(4) The requirements regarding the appointment of agents and brokers and compliance with State information requests under subparagraphs (A) and (B), respectively, of section 1851(h)(7).CommentsClose CommentsPermalink

‘TOTAL HEALTH REGIONS; SUBMISSION OF BIDS; TOTAL HEALTH PLAN APPROVAL

‘Sec. 1860C-5. (a) Establishment of Total Health Regions; Service Areas-CommentsClose CommentsPermalink





‘(1) COVERAGE OF ENTIRE TOTAL HEALTH REGION-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The service area for a Total Health plan shall consist of an entire Total Health region established under paragraph (2).CommentsClose CommentsPermalink





‘(B) NO USE OF SEGMENTS OF SERVICE AREAS- In no case may a Total Health plan serve only segments of the service area.CommentsClose CommentsPermalink





‘(2) ESTABLISHMENT OF TOTAL HEALTH REGIONS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The Secretary shall establish, and may revise, Total Health regions in accordance with the requirements of this paragraph.CommentsClose CommentsPermalink





‘(B) REGIONS TO BE LARGER THAN A SINGLE COUNTY- Total Health regions shall include more than one county.CommentsClose CommentsPermalink





‘(C) REGIONS WITHIN MSAS- Among counties in a metropolitan statistical area, a Total Health region shall include all of the counties located in the same State in that metropolitan statistical area.CommentsClose CommentsPermalink





‘(D) REGIONS OUTSIDE MSAS- Among counties outside a metropolitan statistical area, a Total Health region shall include all of the counties in the same State that the Secretary determines are accurate reflections of health care market areas, such as health service areas.CommentsClose CommentsPermalink





‘(E) AUTHORITY FOR TERRITORIES- The Secretary shall establish, and may revise, Total Health regions for areas in States that are not within the 50 States or the District of Columbia.CommentsClose CommentsPermalink





‘(3) NATIONAL PLAN- Nothing in this subsection shall be construed as preventing a Total Health plan from being offered in more than one Total Health region (including all Total Health regions).CommentsClose CommentsPermalink





‘(b) Submission of Bids, Premiums, and Related Information-CommentsClose CommentsPermalink





‘(1) IN GENERAL- A Total Health sponsor shall submit to the Secretary information described in paragraph (2) with respect to each Total Health plan it offers. Such information shall be submitted at the same time and in a similar manner to the manner in which information described in paragraph (6) of section 1854(a) was submitted by an MA organization under paragraph (1) of such section.CommentsClose CommentsPermalink





‘(2) INFORMATION DESCRIBED- The information described in this paragraph is information on the following:CommentsClose CommentsPermalink





‘(A) BENEFITS PACKAGE PROVIDED- The qualified Total Health benefits package provided under the plan, including the deductible and other cost-sharing.CommentsClose CommentsPermalink





‘(B) ACTUARIAL VALUE- The actuarial value of the qualified Total Health benefits package in the Total Health region for a Total Health eligible individual with a national average risk profile for the factors described in section 1860C-8(b)(1)(A) (as specified by the Secretary).CommentsClose CommentsPermalink





‘(C) BID- Information on the bid, including an actuarial certification of--CommentsClose CommentsPermalink





‘(i) the basis for the actuarial value described in subparagraph (B) assumed in such bid;CommentsClose CommentsPermalink





‘(ii) the portion of such bid attributable to a basic Total Health benefits package and, if applicable, the portion of such bid attributable to supplemental benefits; andCommentsClose CommentsPermalink





‘(iii) administrative expenses assumed in the bid.CommentsClose CommentsPermalink





‘(D) SERVICE AREA- The service area for the plan (as described in subsection (a)(1)).CommentsClose CommentsPermalink





‘(E) LEVEL OF RISK ASSUMED- Whether the Total Health sponsor requires a modification of risk level and, if so, the extent of such modification. Any such modification shall apply with respect to all Total Health plans offered by a Total Health sponsor in a Total Health region.CommentsClose CommentsPermalink





‘(F) ADDITIONAL INFORMATION- Such other information as the Secretary may require to carry out this subpart.CommentsClose CommentsPermalink





‘(3) PAPERWORK REDUCTION FOR OFFERING OF TOTAL HEALTH PLANS NATIONALLY OR IN MULTI-REGION AREAS- The Secretary shall establish requirements for the submission of information under this subsection in a manner that promotes the offering of such plans in more than one Total Health region (including all regions) through the filing of consolidated information.CommentsClose CommentsPermalink





‘(c) Medicare Fee-for-Service Bid- For purposes of this subpart, the bid for benefits under the original medicare fee-for-service program option (as defined in section 1852(a)(1)(B)) is the dollar amount of the actuarial valuation of the benefits under that option for each Total Health region (as determined and submitted by the Chief Actuary of the Centers for Medicare & Medicaid Services using the same processes used to value Total Health plans under subsection (d)).CommentsClose CommentsPermalink





‘(d) Actuarial Valuation-CommentsClose CommentsPermalink





‘(1) PROCESSES- For purposes of this subpart, the Secretary shall establish processes and methods for determining the actuarial valuation of a Total Health benefits package, including--CommentsClose CommentsPermalink





‘(A) an actuarial valuation of the benefits under the original medicare fee-for-service program option (as defined in section 1852(a)(1)(B)) in each service area;CommentsClose CommentsPermalink





‘(B) actuarial valuations relating to the qualified Total Health benefits package under section 1860C-2(a)(1);CommentsClose CommentsPermalink





‘(C) the use of generally accepted actuarial principles and methodologies; andCommentsClose CommentsPermalink





‘(D) applying the same methodology for determinations of actuarial valuations under subparagraphs (A) and (B).CommentsClose CommentsPermalink





‘(2) ACCOUNTING FOR UTILIZATION- Such processes and methods for determining actuarial valuation shall take into account the effect that providing a qualified Total Health benefits package (rather than benefits under the original medicare fee-for-service program option) has on the utilization of health care items and services.CommentsClose CommentsPermalink





‘(3) RESPONSIBILITIES-CommentsClose CommentsPermalink





‘(A) PLAN RESPONSIBILITIES- Total Health sponsors are responsible for the preparation and submission of actuarial valuations required under this subpart for the Total Health plans offered by the sponsor.CommentsClose CommentsPermalink





‘(B) USE OF OUTSIDE ACTUARIES- Under the processes and methods established under paragraph (1), Total Health sponsors offering a Total Health benefits package may use actuarial opinions certified by independent, qualified actuaries to establish actuarial values.CommentsClose CommentsPermalink





‘(e) Review of Information and Negotiation-CommentsClose CommentsPermalink





‘(1) REVIEW OF INFORMATION- The Secretary shall review the information submitted under subsection (b) for the purpose of conducting negotiations under paragraph (2).CommentsClose CommentsPermalink





‘(2) NEGOTIATION REGARDING TERMS AND CONDITIONS- Subject to subsection (i), in exercising the authority under paragraph (1), the Secretary--CommentsClose CommentsPermalink





‘(A) has the authority to negotiate the terms and conditions of the proposed bid submitted and other terms and conditions of a proposed plan; andCommentsClose CommentsPermalink





‘(B) has authority similar to the authority of the Director of the Office of Personnel Management with respect to health benefits plans under chapter 89 of title 5, United States Code.CommentsClose CommentsPermalink





‘(3) REJECTION OF BIDS- Paragraph (5)(C) of section 1854(a) shall apply with respect to bids submitted by a Total Health sponsor under subsection (b) in the same manner as such paragraph applied to bids submitted by an MA organization under such section 1854(a).CommentsClose CommentsPermalink





‘(f) Approval of Proposed Plans-CommentsClose CommentsPermalink





‘(1) IN GENERAL- After review and negotiation under subsection (e), the Secretary shall approve or disapprove the Total Health plan.CommentsClose CommentsPermalink





‘(2) REQUIREMENTS FOR APPROVAL- The Secretary may approve a Total Health plan only if the Secretary determines the following requirements are met:CommentsClose CommentsPermalink





‘(A) COMPLIANCE WITH REQUIREMENTS- The plan and the Total Health sponsor offering the plan comply with the requirements under this subpart, including the provision of a qualified Total Health benefits package.CommentsClose CommentsPermalink





‘(B) ACTUARIAL DETERMINATIONS- The plan and Total Health sponsor offering the plan meet the requirements under this subpart relating to actuarial determinations, including such requirements under section 1860C-2(c).CommentsClose CommentsPermalink





‘(C) APPLICATION OF FEHBP STANDARD-CommentsClose CommentsPermalink





‘(i) IN GENERAL- The portion of the bid submitted under subsection (b) that is attributable to basic health benefits coverage is supported by the actuarial bases provided under such subsection and reasonably and equitably reflects the revenue requirements (as used for purposes of section 1302(8)(C) of the Public Health Service Act) for benefits provided under that plan.CommentsClose CommentsPermalink





‘(ii) SUPPLEMENTAL COVERAGE- The portion of the bid submitted under subsection (b) that is attributable to supplemental health benefits coverage pursuant to section 1860C-2(a)(3) is supported by the actuarial bases provided under such subsection and reasonably and equitably reflects the revenue requirements (as used for purposes of section 1302(8)(C) of the Public Health Service Act) for such coverage under the plan.CommentsClose CommentsPermalink





‘(D) PLAN DESIGN- The design of the plan and covered benefits under the plan are not likely to substantially discourage enrollment by certain Total Health eligible individuals in the plan.CommentsClose CommentsPermalink





‘(g) Application of Limited Risk Plans-CommentsClose CommentsPermalink





‘(1) CONDITIONS FOR APPROVAL OF LIMITED RISK PLANS- The Secretary may only approve a limited risk plan (as defined in paragraph (4)(A)) for a Total Health region if the access requirements under section 1860C-3(a) would not be met for the region but for the approval of such a plan.CommentsClose CommentsPermalink





‘(2) RULES- The following rules shall apply with respect to the approval of a limited risk plan in a Total Health region:CommentsClose CommentsPermalink





‘(A) LIMITED EXERCISE OF AUTHORITY- Only the minimum number of such plans may be approved in order to meet the access requirements under section 1860C-3(a).CommentsClose CommentsPermalink





‘(B) MAXIMIZING ASSUMPTION OF RISK- The Secretary shall provide priority in approval for those plans bearing the highest level of risk (as computed by the Secretary), but the Secretary may take into account the level of the bids submitted by such plans.CommentsClose CommentsPermalink





‘(C) NO FULL UNDERWRITING FOR LIMITED RISK PLANS- In no case may the Secretary approve a limited risk plan under which the modification of risk level provides for no (or a de minimis) level of financial risk.CommentsClose CommentsPermalink





‘(3) ACCEPTANCE OF ALL FULL RISK CONTRACTS- There shall be no limit on the number of full risk plans that are approved under subsection (e).CommentsClose CommentsPermalink





‘(4) RISK-PLANS DEFINED- For purposes of this subsection:CommentsClose CommentsPermalink





‘(A) LIMITED RISK PLAN- The term ‘limited risk plan’ means a Total Health plan that provides a basic Total Health benefits package and for which the Total Health sponsor includes a modification of risk level described in subparagraph (E) of subsection (b)(2) in the bid submitted for the plan under such subsection.CommentsClose CommentsPermalink





‘(B) FULL RISK PLAN- The term ‘full risk plan’ means a Total Health plan that is not a limited risk plan.CommentsClose CommentsPermalink





‘(h) Annual Report on Use of Limited Risk Plans- The Secretary shall submit to Congress an annual report that describes instances in which limited risk plans were approved under this section. The Secretary shall include in such report such recommendations as may be appropriate to limit the need for the provision of such plans and to maximize the assumption of financial risk under such subsection.CommentsClose CommentsPermalink





‘(i) Noninterference- In order to promote competition under this part and in carrying out this part, the Secretary--CommentsClose CommentsPermalink





‘(1) may not interfere with the negotiations between physicians or other health professionals, providers, suppliers, drug manufacturers, pharmacies, and Total Health sponsors; andCommentsClose CommentsPermalink





‘(2) may not require a particular benefit design or formulary, or institute a price structure for the reimbursement of covered items and services.CommentsClose CommentsPermalink

‘REQUIREMENTS FOR AND CONTRACTS WITH TOTAL HEALTH SPONSORS

‘Sec. 1860C-6. (a) General Requirements- Each sponsor of a Total Health plan shall meet the following requirements:CommentsClose CommentsPermalink





‘(1) LICENSURE- Subject to subsection (c), the sponsor is organized and licensed under State law as a risk-bearing entity eligible to offer health insurance or health benefits coverage in each State in which it offers a Total Health plan.CommentsClose CommentsPermalink





‘(2) ASSUMPTION OF FINANCIAL RISK FOR UNSUBSIDIZED COVERAGE-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to subparagraph (B), to the extent that the entity is at risk the entity assumes financial risk on a prospective basis for benefits that it offers under a Total Health plan.CommentsClose CommentsPermalink





‘(B) REINSURANCE PERMITTED- The plan sponsor may obtain insurance or make other arrangements for the cost of coverage provided to any enrollee to the extent that the sponsor is at risk for providing such coverage.CommentsClose CommentsPermalink





‘(3) SOLVENCY FOR UNLICENSED SPONSORS- In the case of a Total Health sponsor that is not described in paragraph (1) and for which a waiver has been approved under subsection (c), such sponsor shall meet solvency standards established by the Secretary under subsection (d).CommentsClose CommentsPermalink





‘(b) Contract Requirements-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall not permit the enrollment under section 1860C-1 in a Total Health plan offered by a Total Health sponsor under this subpart, and the sponsor shall not be eligible for payments under section 1860C-8, unless the Secretary has entered into a contract under this subsection with the sponsor with respect to the offering of such plan. Such a contract with a sponsor may cover more than one Total Health plan. Such contract shall provide that the sponsor agrees to comply with the applicable requirements and standards of this subpart and the terms and conditions of payment as provided for in this subpart.CommentsClose CommentsPermalink





‘(2) INCORPORATION OF CERTAIN MEDICARE ADVANTAGE CONTRACT REQUIREMENTS- Except as otherwise provided, the following provisions of section 1857 shall apply to contracts under this section in the same manner as such provisions applied to contracts under section 1857(a):CommentsClose CommentsPermalink





‘(A) MINIMUM ENROLLMENT- Paragraphs (1) and (3) of section 1857(b), except that--CommentsClose CommentsPermalink





‘(i) the Secretary may increase the minimum number of enrollees required under such paragraph (1) as the Secretary determines appropriate; andCommentsClose CommentsPermalink





‘(ii) the requirement of such paragraph (1) shall be waived during the first contract year with respect to an organization in a region.CommentsClose CommentsPermalink





‘(B) CONTRACT PERIOD AND EFFECTIVENESS- Section 1857(c), except that in applying paragraph (4)(B) of such section any reference to payment amounts under section 1853 is deemed a reference to payment amounts under section 1860C-8.CommentsClose CommentsPermalink





‘(C) PROTECTIONS AGAINST FRAUD AND BENEFICIARY PROTECTIONS- Section 1857(d).CommentsClose CommentsPermalink





‘(D) ADDITIONAL CONTRACT TERMS- Section 1857(e); except that section 1857(e)(2) shall apply as specified to Total Health sponsors and payments to a Total Health plan under this subpart shall be treated as expenditures made under this subpart. Notwithstanding any other provision of law, information provided to the Secretary under the application of section 1857(e)(1) to contracts under this section under the preceding sentence--CommentsClose CommentsPermalink





‘(i) may be used for the purposes of carrying out this subpart, improving public health through research on the utilization, safety, effectiveness, quality, and efficiency of health care services (as the Secretary determines appropriate); andCommentsClose CommentsPermalink





‘(ii) shall be made available to Congressional support agencies (in accordance with their obligations to support Congress as set out in their authorizing statutes) for the purposes of conducting Congressional oversight, monitoring, making recommendations, and analysis of the program under this title.CommentsClose CommentsPermalink





‘(E) INTERMEDIATE SANCTIONS- Section 1857(g) (other than paragraph (1)(F) of such section), except that in applying such section the reference in section 1857(g)(1)(B) to section 1854 is deemed a reference to this subpart.CommentsClose CommentsPermalink





‘(F) PROCEDURES FOR TERMINATION- Section 1857(h).CommentsClose CommentsPermalink





‘(c) Waiver of Certain Requirements To Expand Choice-CommentsClose CommentsPermalink





‘(1) AUTHORIZING WAIVER-CommentsClose CommentsPermalink





‘(A) IN GENERAL- In the case of an entity that seeks to offer a Total Health plan in a State, the Secretary shall waive the requirement of subsection (a)(1) that the entity be licensed in that State if the Secretary determines, based on the application and other evidence presented to the Secretary, that any of the grounds for approval of the application described in paragraph (2) have been met.CommentsClose CommentsPermalink





‘(B) APPLICATION OF REGIONAL PLAN WAIVER RULE- In addition to the waiver available under subparagraph (A), the provisions of section 1858(d) shall apply to Total Health sponsors under this part in a manner similar to the manner in which such provisions applied to MA organizations.CommentsClose CommentsPermalink





‘(2) GROUNDS FOR APPROVAL-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The grounds for approval under this paragraph are--CommentsClose CommentsPermalink





‘(i) subject to subparagraph (B), the grounds for approval described in subparagraphs (B), (C), and (D) of section 1855(a)(2); andCommentsClose CommentsPermalink





‘(ii) the application by a State of any grounds other than those required under Federal law.CommentsClose CommentsPermalink





‘(B) SPECIAL RULES- In applying subparagraph (A)(i)--CommentsClose CommentsPermalink





‘(i) the ground of approval described in section 1855(a)(2)(B) is deemed to have been met if the State does not have a licensing process in effect with respect to the Total Health sponsor; andCommentsClose CommentsPermalink





‘(ii) for plan years beginning before January 1, 2019, if the State does have such a licensing process in effect, such ground for approval described in such section is deemed to have been met upon submission of an application described in such section.CommentsClose CommentsPermalink





‘(3) APPLICATION OF WAIVER PROCEDURES- With respect to an application for a waiver (or a waiver granted) under paragraph (1)(A) of this subsection, the provisions of subparagraphs (E), (F), and (G) of section 1855(a)(2) shall apply, except that clauses (i) and (ii) of such subparagraph (E) shall not apply in the case of a State that does not have a licensing process described in paragraph (2)(B)(i) in effect.CommentsClose CommentsPermalink





‘(4) REFERENCES TO CERTAIN PROVISIONS- In applying provisions of section 1855(a)(2) under paragraphs (2) and (3) of this subsection to Total Health plans and Total Health sponsors--CommentsClose CommentsPermalink





‘(A) any reference to a waiver application under section 1855 shall be treated as a reference to a waiver application under paragraph (1)(A) of this subsection; andCommentsClose CommentsPermalink





‘(B) any reference to solvency standards shall be treated as a reference to solvency standards established under subsection (d) of this section.CommentsClose CommentsPermalink





‘(d) Solvency Standards for Non-Licensed Entities-CommentsClose CommentsPermalink





‘(1) ESTABLISHMENT AND PUBLICATION- The Secretary, in consultation with the National Association of Insurance Commissioners, shall establish and publish, by not later than January 1, 2016, financial solvency and capital adequacy standards for entities described in paragraph (2).CommentsClose CommentsPermalink





‘(2) COMPLIANCE WITH STANDARDS- A Total Health sponsor that is not licensed by a State under subsection (a)(1) and for which a waiver application has been approved under subsection (c) shall meet solvency and capital adequacy standards established under paragraph (1). The Secretary shall establish certification procedures for such sponsors with respect to such solvency standards in the manner described in section 1855(c)(2).CommentsClose CommentsPermalink





‘(e) Licensure Does Not Substitute for or Constitute Certification- The fact that a Total Health sponsor is licensed in accordance with subsection (a)(1) or has a waiver application approved under subsection (c) does not deem the sponsor to meet other requirements imposed under this subpart for a sponsor.CommentsClose CommentsPermalink





‘(f) Periodic Review and Revision of Standards-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Subject to paragraph (2), the Secretary may periodically review the standards established under this section and, based on such review, may revise such standards if the Secretary determines such revision to be appropriate.CommentsClose CommentsPermalink





‘(2) PROHIBITION OF MIDYEAR IMPLEMENTATION OF SIGNIFICANT NEW REGULATORY REQUIREMENTS- The Secretary may not implement, other than at the beginning of a calendar year, regulations under this section that impose new, significant regulatory requirements on a Total Health sponsor or a Total Health plan.CommentsClose CommentsPermalink





‘(g) Prohibition of State Imposition of Premium Taxes; Relation to State Laws- The provisions of sections 1854(g) and 1856(b)(3) shall apply with respect to Total Health sponsors and Total Health plans under this part in the same manner as such provisions applied to MA organizations and MA plans.CommentsClose CommentsPermalink

‘TOTAL HEALTH PREMIUMS

‘Sec. 1860C-7. (a) Monthly Beneficiary Premium-CommentsClose CommentsPermalink





‘(1) BASE BENEFICIARY PREMIUM- The base beneficiary premium under this paragraph for a Total Health plan for a month is equal to the product of--CommentsClose CommentsPermalink





‘(A) 15 percent; andCommentsClose CommentsPermalink





‘(B) an amount determined by the Secretary to be equal to the 40th percentile of the monthly standardized bid amounts (as defined in subsection (c), weighted under subsection (b), and adjusted under section 1860C-8(b)(2)) for the service area in which the plan is offered.CommentsClose CommentsPermalink





‘(2) COMPUTATION OF MONTHLY BENEFICIARY PREMIUM-CommentsClose CommentsPermalink





‘(A) IN GENERAL- The monthly beneficiary premium for a Total Health plan is the base beneficiary premium computed under paragraph (1) as adjusted under this paragraph.CommentsClose CommentsPermalink





‘(B) ADJUSTMENT TO REFLECT DIFFERENCE BETWEEN BID AND 40TH PERCENTILE OF THE MONTHLY STANDARDIZED BID AMOUNT-CommentsClose CommentsPermalink





‘(i) ABOVE 40TH PERCENTILE- If the beneficiary enrolls in a plan with a monthly standardized bid amount that exceeds the 40th percentile (as determined under paragraph (1)(B)), the base beneficiary premium for the month shall be increased by the amount of such excess.CommentsClose CommentsPermalink





‘(ii) BELOW 40TH PERCENTILE- If the beneficiary enrolls in a plan with a monthly standardized bid amount that is less than the 40th percentile (as determined under paragraph (1)(B)), the base beneficiary premium for the month shall be decreased by the amount of such difference. Any reduction under the preceding sentence shall not result in a monthly beneficiary premium that is less than $0.CommentsClose CommentsPermalink





‘(C) INCREASE FOR SUPPLEMENTAL BENEFITS- The base beneficiary premium shall be increased by the portion of the Total Health approved bid that is attributable to supplemental benefits.CommentsClose CommentsPermalink





‘(D) INCREASE FOR LATE ENROLLMENT PENALTY- The base beneficiary premium shall be increased by the amount of any late enrollment penalty under subsection (e).CommentsClose CommentsPermalink





‘(E) INCREASE BASED ON INCOME- The monthly beneficiary premium shall be increased pursuant to subsection (f).CommentsClose CommentsPermalink





‘(F) UNIFORM PREMIUM- Except as provided in subparagraphs (D) and (E), the monthly beneficiary premium for a Total Health plan in a Total Health region is the same for all Total Health eligible individuals enrolled in the plan.CommentsClose CommentsPermalink





‘(b) Weighting of Bid Amounts Based on Enrollment-CommentsClose CommentsPermalink





‘(1) IN GENERAL- For purposes of subsection (a)(1)(B), the weight for each plan in the service area shall be equal to the average number of Total Health eligible individuals enrolled in such plan in the reference month (as defined in section 1858(f)(4)).CommentsClose CommentsPermalink





‘(2) SPECIAL RULE FOR 2017- For purposes of applying this paragraph for 2017, the Secretary shall establish procedures for determining the weighted average under paragraph (1) for 2016.CommentsClose CommentsPermalink





‘(c) Standardized Bid Amount Defined- For purposes of this subsection, the term ‘standardized bid amount’ means the following:CommentsClose CommentsPermalink





‘(1) BASIC COVERAGE ONLY- In the case of a Total Health plan that provides basic health benefits coverage, the Total Health approved bid (as defined in subsection (d)).CommentsClose CommentsPermalink





‘(2) PLANS OFFERING SUPPLEMENTAL COVERAGE- In the case of a Total Health plan that provides supplemental health benefits coverage, only the portion of the Total Health approved bid that is attributable to basic health benefits coverage.CommentsClose CommentsPermalink





‘(d) Total Health Approved Bid Defined- For purposes of this subpart, the term ‘Total Health approved bid’ means--CommentsClose CommentsPermalink





‘(1) with respect to a Total Health plan, the bid amount approved for the plan under section 1860C-5; andCommentsClose CommentsPermalink





‘(2) with respect to the original medicare fee-for-service program option, the bid described in section 1860C-5(c).CommentsClose CommentsPermalink





‘(e) Late Enrollment Penalty- The monthly beneficiary premium established under subsection (a) shall be subject to adjustment in the same manner as the part B monthly beneficiary premium computed under section 1839 is subject to adjustment under subsection (b) of such section, except that, in applying the late enrollment penalty under such subsection, the initial enrollment period of the individual shall be the enrollment period under 1860C-1(b)(2) instead of the initial enrollment period described in such section 1839(b).CommentsClose CommentsPermalink





‘(f) Increase in Base Beneficiary Premium Based on Income-CommentsClose CommentsPermalink





‘(1) IN GENERAL- In the case of an individual whose modified adjusted gross income (as defined in paragraph (2)) exceeds the threshold amount applicable under paragraph (2) of section 1839(i) (including application of paragraph (5) of such section), the Secretary shall substitute the applicable percentage determined under paragraph (3)(C) of section 1839(i) for the individual for the calendar year for the percentage described in subsection (a)(1)(A).CommentsClose CommentsPermalink





‘(2) MODIFIED ADJUSTED GROSS INCOME- For purposes of this subsection, the term ‘modified adjusted gross income’ has the meaning given such term in subparagraph (A) of section 1839(i)(4), determined for the taxable year applicable under subparagraphs (B) and (C) of such section.CommentsClose CommentsPermalink





‘(3) DETERMINATION BY COMMISSIONER OF SOCIAL SECURITY- The Commissioner of Social Security shall make any determination necessary to carry out the income-related increase in the base beneficiary premium under this subsection.CommentsClose CommentsPermalink





‘(4) PROCEDURES TO ASSURE CORRECT INCOME-RELATED INCREASE IN BASE BENEFICIARY PREMIUM-CommentsClose CommentsPermalink





‘(A) DISCLOSURE OF BASE BENEFICIARY PREMIUM- Not later than September 15 of each year beginning with 2016, the Secretary shall disclose to the Commissioner of Social Security the amount of the base beneficiary premium (as computed under subsection (a)(1)) for the purpose of carrying out the income-related increase in the base beneficiary premium under this subsection with respect to the following year.CommentsClose CommentsPermalink





‘(B) ADDITIONAL DISCLOSURE- Not later than October 15 of each year beginning with 2016, the Secretary shall disclose to the Commissioner of Social Security the following information for the purpose of carrying out the income-related increase in the base beneficiary premium under this subsection with respect to the following year:CommentsClose CommentsPermalink





‘(i) The modified adjusted gross income threshold applicable under paragraph (2) of section 1839(i) (including application of paragraph (5) of such section).CommentsClose CommentsPermalink





‘(ii) The applicable percentage determined under paragraph (3)(C) of section 1839(i) (including application of paragraph (5) of such section).CommentsClose CommentsPermalink





‘(iii) Any other information the Commissioner of Social Security determines necessary to carry out the income-related increase in the base beneficiary premium under this subsection.CommentsClose CommentsPermalink

‘PREMIUM AND COST-SHARING SUPPORT FOR TOTAL HEALTH ELIGIBLE INDIVIDUALS

‘Sec. 1860C-8. (a) Direct Subsidy Payment- The Secretary shall provide for payment to a Total Health sponsor that offers a Total Health plan a direct subsidy for each Total Health eligible individual enrolled in a Total Health plan for a month equal to--CommentsClose CommentsPermalink





‘(1) the amount of the plan’s standardized bid amount (as defined in section 1860C-7(c)), adjusted under subsection (b)(1), reduced byCommentsClose CommentsPermalink





‘(2) the base beneficiary premium (as computed under paragraph (1) of section 1860C-7(a) and as adjusted under paragraph (2)(B) of such section).CommentsClose CommentsPermalink





‘(b) Adjustments Relating to Bids-CommentsClose CommentsPermalink





‘(1) HEALTH STATUS RISK ADJUSTMENT-CommentsClose CommentsPermalink





‘(A) ESTABLISHMENT OF RISK ADJUSTORS- The Secretary shall establish an appropriate methodology for adjusting the standardized bid amount under subsection (a)(1) to take into account variation in costs for health benefits coverage among Total Health plans based on the differences in actuarial risk of different enrollees being served. Any such risk adjustment shall be designed in a manner so as not to result in a change in the aggregate amounts payable to such plans under subsection (a) and through that portion of the monthly beneficiary Total Health premiums described in subsection (a)(2).CommentsClose CommentsPermalink





‘(B) CONSIDERATIONS- In establishing the methodology under subparagraph (A), the Secretary may take into account the similar methodologies used under section 1853(a)(3) to adjust payments to MA organizations for benefits under the original medicare fee-for-service program option.CommentsClose CommentsPermalink





‘(C) DATA COLLECTION- In order to carry out this paragraph, the Secretary shall require Total Health sponsors to submit data regarding claims that can be linked at the individual level to data under this title and such other information as the Secretary determines necessary.CommentsClose CommentsPermalink





‘(D) PUBLICATION- At the time of publication of risk adjustment factors under section 1860D-15(c)(1)(D), the Secretary shall publish the risk adjusters established under this paragraph for the succeeding year.CommentsClose CommentsPermalink





‘(2) GEOGRAPHIC ADJUSTMENT-CommentsClose CommentsPermalink





‘(A) IN GENERAL- Subject to subparagraph (B), for purposes of section 1860C-7(a)(1)(B), the Secretary shall establish an appropriate methodology for adjusting the amount determined under such section to take into account differences in prices for covered health benefits among Total Health regions.CommentsClose CommentsPermalink





‘(B) DE MINIMIS RULE- If the Secretary determines that the price variations described in subparagraph (A) among Total Health regions are de minimis, the Secretary shall not provide for adjustment under this paragraph.CommentsClose CommentsPermalink





‘(C) BUDGET NEUTRAL ADJUSTMENT- Any adjustment under this paragraph shall be applied in a manner so as to not result in a change in the aggregate payments made under this subpart that would have been made if the Secretary had not applied such adjustment.CommentsClose CommentsPermalink





‘(c) Payment Methods-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Payments under this section shall be based on such a method as the Secretary determines. The Secretary may establish a payment method by which interim payments of amounts under this section are made during a year based on the Secretary’s best estimate of amounts that will be payable after obtaining all of the information.CommentsClose CommentsPermalink





‘(2) REQUIREMENT FOR PROVISION OF INFORMATION-CommentsClose CommentsPermalink





‘(A) REQUIREMENT- Payments under this section to a Total Health sponsor are conditioned upon the furnishing to the Secretary, in a form and manner specified by the Secretary, of such information as may be required to carry out this section.CommentsClose CommentsPermalink





‘(B) RESTRICTION ON USE OF INFORMATION- Information disclosed or obtained pursuant to subparagraph (A) may be used by officers, employees, and contractors of the Department of Health and Human Services only for the purposes of, and to the extent necessary in, carrying out this section.CommentsClose CommentsPermalink





‘(3) SOURCE OF PAYMENTS- Payments under this section shall be made from the Federal Hospital Insurance Trust Fund under section 1817 and the Federal Supplementary Medical Insurance Trust Fund under section 1841, in such proportion as the Secretary determines appropriate.CommentsClose CommentsPermalink





‘(4) APPLICATION OF ENROLLEE ADJUSTMENT- The provisions of section 1853(a)(2) shall apply to payments to Total Health sponsors under this section in the same manner as they applied to payments to MA organizations under section 1853(a).CommentsClose CommentsPermalink





‘(d) Plans at Risk for Entire Amount of Benefits- A Total Health sponsor that offers a plan under this subpart shall be at full financial risk for the provision of benefits under such plan.CommentsClose CommentsPermalink





‘(e) Disclosure of Information-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Each contract under this subpart shall provide that--CommentsClose CommentsPermalink





‘(A) the Total Health sponsor offering a Total Health plan shall provide the Secretary with such information as the Secretary determines is necessary to carry out this section; andCommentsClose CommentsPermalink





‘(B) the Secretary shall have the right in accordance with section 1857(d)(2)(B) (as applied under section 1860C-6(b)(2)(C)) to inspect and audit any books and records of a Total Health sponsor that pertain to the information regarding costs provided to the Secretary under subparagraph (A).CommentsClose CommentsPermalink





‘(2) RESTRICTION ON USE OF INFORMATION- Information disclosed or obtained pursuant to the provisions of this section may be used--CommentsClose CommentsPermalink





‘(A) by officers, employees, and contractors of the Department of Health and Human Services for the purposes of, and to the extent necessary in--CommentsClose CommentsPermalink





‘(i) carrying out this section; andCommentsClose CommentsPermalink





‘(ii) conducting oversight, evaluation, and enforcement under this title; andCommentsClose CommentsPermalink





‘(B) by the Attorney General and the Comptroller General of the United States for the purposes of, and to the extent necessary in, carrying out health oversight activities.CommentsClose CommentsPermalink

‘EXEMPTION FOR MSA PLANS

‘Sec. 1860C-9. (a) In General- None of the provisions in this subpart shall apply to an MSA plan (as defined in section 1859(b)(3)) and an MSA plan may not be a Total Health plan.CommentsClose CommentsPermalink





‘(b) Continuing Availability- Notwithstanding any other provision of law, the Secretary shall establish procedures under which--CommentsClose CommentsPermalink





‘(1) MSA plans may continue to operate on and after January 1, 2017; andCommentsClose CommentsPermalink





‘(2) individuals who would have been eligible to enroll in those plans prior to such date continue to be eligible to enroll in such a plan.CommentsClose CommentsPermalink

‘SPECIAL RULES FOR EMPLOYER-SPONSORED PROGRAMS

‘Sec. 1860C-10. (a) Subsidy Payment-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary shall provide in accordance with this subsection for payment to the sponsor of a qualified retiree health benefits plan (as defined in paragraph (2)) of a special subsidy payment equal to the amount specified in paragraph (3) for each qualified covered retiree under the plan (as defined in paragraph (4)). This subsection constitutes budget authority in advance of appropriations Acts and represents the obligation of the Secretary to provide for the payment of amounts provided under this section.CommentsClose CommentsPermalink





‘(2) QUALIFIED RETIREE HEALTH BENEFITS PLAN DEFINED- For purposes of this subsection, the term ‘qualified retiree health benefits plan’ means employment-based retiree health coverage (as defined in subsection (c)(1)) if, with respect to a Total Health eligible individual who is a participant or beneficiary under such coverage, the following requirements are met:CommentsClose CommentsPermalink





‘(A) ATTESTATION OF ACTUARIAL EQUIVALENCE TO STANDARD COVERAGE- The sponsor of the plan provides the Secretary, annually or at such other time as the Secretary may require, with an attestation that the actuarial value of health benefits coverage under the plan (as determined using the processes and methods described in section 1860C-5(d)) is at least equal to the actuarial value of standard health benefits coverage.CommentsClose CommentsPermalink





‘(B) AUDITS- The sponsor of the plan, or an administrator of the plan designated by the sponsor, shall maintain (and afford the Secretary access to) such records as the Secretary may require for purposes of audits and other oversight activities necessary to ensure the adequacy of health benefits coverage and the accuracy of payments made under this section. The provisions of section 1860C-2(d)(2) shall apply to such information under this section (including such actuarial value and attestation) in a manner similar to the manner in which they apply to financial records of Total Health sponsors.CommentsClose CommentsPermalink





‘(C) PROVISION OF DISCLOSURE REGARDING HEALTH BENEFITS COVERAGE-CommentsClose CommentsPermalink





‘(i) IN GENERAL- Each entity that offers employment-based retiree health coverage shall provide for disclosure, in a form, manner, and time consistent with standards established by the Secretary, to the Secretary and Total Health eligible individuals of whether the coverage meets the requirement of subparagraph (A) or whether such coverage is changed so it no longer meets such requirement.CommentsClose CommentsPermalink





‘(ii) DISCLOSURE OF NON-QUALIFIED COVERAGE- In the case of such coverage that does not meet such requirement, the disclosure to Total Health eligible individuals under this subparagraph shall include information regarding the fact that because such coverage does not meet such requirement there are limitations on the periods in a year in which the individuals may enroll under a Total Health plan.CommentsClose CommentsPermalink





‘(iii) WAIVER OF REQUIREMENT- In the case of a Total Health eligible individual who was enrolled in employment-based retiree health coverage which does not meet the requirement of subparagraph (A), the individual may apply to the Secretary to have such coverage treated as a qualified retiree health benefits plan if the individual establishes that the individual was not adequately informed that such coverage did not meet such requirement.CommentsClose CommentsPermalink





‘(3) EMPLOYER AND UNION SPECIAL SUBSIDY AMOUNTS-CommentsClose CommentsPermalink





‘(A) IN GENERAL- For purposes of this subsection, the special subsidy payment amount under this paragraph for a qualifying covered retiree for a coverage year enrolled with the sponsor of a qualified retiree health benefits plan is, for the portion of the retiree’s gross covered retiree plan-related health benefits costs (as defined in subparagraph (C)(ii)) for such year that exceeds the cost threshold amount specified in subparagraph (B) and does not exceed the cost limit under such subparagraph, an amount equal to 28 percent of the allowable retiree costs (as defined in subparagraph (C)(i)) attributable to such gross covered retiree plan-related health benefits costs.CommentsClose CommentsPermalink





‘(B) COST THRESHOLD AND COST LIMIT APPLICABLE-CommentsClose CommentsPermalink





‘(i) IN GENERAL- Subject to clause (ii)--CommentsClose CommentsPermalink





‘(I) the cost threshold under this subparagraph is equal to $250 for plan years that end in 2017; andCommentsClose CommentsPermalink





‘(II) the cost limit under this subparagraph is equal to $5,000 for plan years that end in 2017.CommentsClose CommentsPermalink





‘(ii) INDEXING- The cost threshold and cost limit amounts specified in subclauses (I) and (II) of clause (i) for a plan year that ends after 2017 shall be adjusted in the same manner as the unified deductible and the annual out-of-pocket limits, respectively, are annually adjusted under sections 1899B and 1899C.CommentsClose CommentsPermalink





‘(C) DEFINITIONS- For purposes of this paragraph:CommentsClose CommentsPermalink





‘(i) ALLOWABLE RETIREE COSTS- The term ‘allowable retiree costs’ means, with respect to gross covered health benefits costs under a qualified retiree health benefits plan by a plan sponsor, the part of such costs that are actually paid (net of discounts, chargebacks, and average percentage rebates) by the sponsor or by or on behalf of a qualifying covered retiree under the plan.CommentsClose CommentsPermalink





‘(ii) GROSS COVERED RETIREE PLAN-RELATED HEALTH BENEFITS COSTS- The term ‘gross covered retiree plan-related health benefits costs’ means, with respect to a qualifying covered retiree enrolled in a qualified retiree health benefits plan during a coverage year, the costs incurred under the plan, not including administrative costs, but including costs directly related to the furnishing of health benefits items and services during the year. Such costs shall be determined whether they are paid by the retiree or under the plan.CommentsClose CommentsPermalink





‘(iii) COVERAGE YEAR- The term ‘coverage year’ has the meaning given such term in section 1860D-15(b)(4) (as applied by substituting ‘covered health benefits’ for ‘covered part D drugs’).CommentsClose CommentsPermalink





‘(4) QUALIFYING COVERED RETIREE DEFINED- For purposes of this subsection, the term ‘qualifying covered retiree’ means a Total Health eligible individual who is not enrolled in a Total Health plan but is covered under a qualified retiree health benefits plan.CommentsClose CommentsPermalink





‘(5) PAYMENT METHODS, INCLUDING PROVISION OF NECESSARY INFORMATION- The provisions of section 1860C-8(c) (including paragraph (2) of such section, relating to requirement for provision of information) shall apply to payments under this subsection in a manner similar to the manner in which they apply to payments under section 1860C-8.CommentsClose CommentsPermalink





‘(6) CONSTRUCTION- Nothing in this subsection shall be construed as--CommentsClose CommentsPermalink





‘(A) precluding a Total Health eligible individual who is covered under employment-based retiree health coverage from enrolling in a Total Health plan;CommentsClose CommentsPermalink





‘(B) precluding such employment-based retiree health coverage or an employer or other person from paying all or any portion of any premium required for coverage under a Total Health plan on behalf of such an individual;CommentsClose CommentsPermalink





‘(C) preventing such employment-based retiree health coverage from providing coverage--CommentsClose CommentsPermalink





‘(i) that is better than standard health benefits coverage to retirees who are covered under a qualified retiree health benefits plan; orCommentsClose CommentsPermalink





‘(ii) that is supplemental to the benefits provided under a Total Health plan, including benefits to retirees who are not covered under a qualified retiree health benefits plan but who are enrolled in such a Total Health plan; orCommentsClose CommentsPermalink





‘(D) preventing employers from providing for flexibility in benefit design and provider access provisions, without regard to the requirements for basic health benefits coverage, so long as the actuarial equivalence requirement of paragraph (2)(A) is met.CommentsClose CommentsPermalink





‘(b) Application of Medicare Advantage Waiver Authority- The provisions of section 1857(i) shall apply with respect to Total Health plans in relation to employment-based retiree health coverage in a manner similar to the manner in which they applied to an MA plan in relation to employers, including authorizing the establishment of separate premium amounts for enrollees in a Total Health plan by reason of such coverage and limitations on enrollment to Total Health eligible individuals enrolled under such coverage.CommentsClose CommentsPermalink





‘(c) Definitions- For purposes of this section:CommentsClose CommentsPermalink





‘(1) EMPLOYMENT-BASED RETIREE HEALTH COVERAGE- The term ‘employment-based retiree health coverage’ means health insurance or other coverage of health care costs (whether provided by voluntary insurance coverage or pursuant to statutory or contractual obligation) for Total Health eligible individuals (or for such individuals and their spouses and dependents) under a group health plan based on their status as retired participants in such plan.CommentsClose CommentsPermalink





‘(2) SPONSOR- The term ‘sponsor’ means a plan sponsor, as defined in section (16)(B) of the Employee Retirement Income Security Act of 1974, in relation to a group health plan, except that, in the case of a plan maintained jointly by one employer and an employee organization and with respect to which the employer is the primary source of financing, such term means such employer.CommentsClose CommentsPermalink





‘(3) GROUP HEALTH PLAN- The term ‘group health plan’ includes such a plan as defined in section 607(1) of the Employee Retirement Income Security Act of 1974 and also includes the following:CommentsClose CommentsPermalink





‘(A) FEDERAL AND STATE GOVERNMENTAL PLANS- Such a plan established or maintained for its employees by the Government of the United States, by the government of any State or political subdivision thereof, or by any agency or instrumentality of any of the foregoing, including a health benefits plan offered under chapter 89 of title 5, United States Code.CommentsClose CommentsPermalink





‘(B) COLLECTIVELY BARGAINED PLANS- Such a plan established or maintained under or pursuant to one or more collective bargaining agreements.CommentsClose CommentsPermalink





‘(C) CHURCH PLANS- Such a plan established and maintained for its employees (or their beneficiaries) by a church or by a convention or association of churches which is exempt from tax under section 501 of the Internal Revenue Code of 1986.CommentsClose CommentsPermalink

‘COORDINATION WITH STATE MEDICAID PROGRAMS

‘Sec. 1860C-11. (a) Application-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Subject to subsection (c)(2), a State may apply to the Secretary for the waiver of any or all requirements described in this subpart for plan years beginning on or after January 1, 2017, with respect to a Total Health plan offered within the State for the purpose of coordinating that plan with its State plan under title XIX to ensure--CommentsClose CommentsPermalink





‘(A) dually eligible individuals have full access to the services to which they are entitled;CommentsClose CommentsPermalink





‘(B) the development of innovative care coordination and integration models; andCommentsClose CommentsPermalink





‘(C) the elimination of financial misalignments that lead to poor quality and cost-shifting.CommentsClose CommentsPermalink





‘(2) REQUIREMENTS- Such application shall--CommentsClose CommentsPermalink





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





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





‘(i) a comprehensive description of the proposal and program to implement a plan meeting the requirements for a waiver under this section; andCommentsClose CommentsPermalink





‘(ii) an analysis of the proposal demonstrating that the plan will not increase Federal Government expenditures; andCommentsClose CommentsPermalink





‘(C) provide an assurance that, if approved, the Total Health sponsor will offer the plan that is the subject of the proposal.CommentsClose CommentsPermalink





‘(3) WAIVER CONSIDERATION AND TRANSPARENCY-CommentsClose CommentsPermalink





‘(A) IN GENERAL- An application for a waiver under this section shall be considered by the Secretary in accordance with the regulations described in subparagraph (B).CommentsClose CommentsPermalink





‘(B) REGULATIONS- Not later than 180 days after the date of enactment of this subpart, the Secretary shall promulgate regulations relating to waivers under this section that provide--CommentsClose CommentsPermalink





‘(i) a process for public notice and comment sufficient to ensure a meaningful level of public input;CommentsClose CommentsPermalink





‘(ii) a process for the submission of an application for the waiver;CommentsClose CommentsPermalink





‘(iii) a process for the submission to the Secretary of periodic reports by the State concerning the implementation of the program under the waiver; andCommentsClose CommentsPermalink





‘(iv) a process for the periodic evaluation by the Secretary of the program under the waiver.CommentsClose CommentsPermalink





‘(C) REPORT- The Secretary shall annually report to Congress concerning actions taken by the Secretary with respect to applications for waivers under this section.CommentsClose CommentsPermalink





‘(4) STATE OPTION TO BE A TOTAL HEALTH SPONSOR- For purposes of this section, a State may elect to be the sponsor of a Total Health plan for residents of the State who are eligible for benefits under this title and title XIX or to apply on behalf of a Total Health sponsor offering a Total Health plan in the State.CommentsClose CommentsPermalink





‘(5) COORDINATED WAIVER PROCESS- The Secretary shall develop a process for coordinating and consolidating the waiver processes applicable under the provisions of this section to ensure that individuals eligible to enroll in a plan offered under the waiver are initially able to do so during an annual, coordinated election period.CommentsClose CommentsPermalink





‘(b) Granting of Waivers-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The Secretary may grant a request for a waiver under subsection (a)(1) only if the Secretary determines that the proposed Total Health plan--CommentsClose CommentsPermalink





‘(A) will provide coverage that is at least as comprehensive as the coverage described in section 1860C-2(a)(1) as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services;CommentsClose CommentsPermalink





‘(B) will provide coverage and cost-sharing protections against excessive out-of-pocket spending that are at least as affordable as the provisions of this subtitle would provide; andCommentsClose CommentsPermalink





‘(C) will not increase the Federal deficit.CommentsClose CommentsPermalink





‘(c) Scope of Waiver-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Subject to paragraph (2), the Secretary shall determine the scope of a waiver granted with respect to a Total Health plan under subsection (a)(1).CommentsClose CommentsPermalink





‘(2) LIMITATION- The Secretary may only waive provisions under this title and titles II, XI, XIX, and XXI under a waiver under this section.CommentsClose CommentsPermalink





‘(d) Determinations by the Secretary-CommentsClose CommentsPermalink





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





‘(2) EFFECT OF DETERMINATION-CommentsClose CommentsPermalink





‘(A) GRANTING OF WAIVERS- If the Secretary determines to grant a waiver under subsection (a)(1), the Secretary shall notify the Total Health sponsor 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 subsection (a)(1), the Secretary shall notify the Total Health sponsor involved, including the reasons therefor.CommentsClose CommentsPermalink





‘(e) Term of Waiver- No waiver under this section may extend over a period of longer than 5 years unless the Total Health sponsor requests continuation of such waiver, and such request shall be deemed granted unless the Secretary, within 90 days after the date of the submission of the request to the Secretary, either denies such request in writing or informs the State in writing with respect to any additional information that is needed in order to make a final determination with respect to the request.CommentsClose CommentsPermalink

‘DEFINITIONS AND MISCELLANEOUS PROVISIONS

‘Sec. 1860C-12. (a) Definitions- For purposes of this subpart:CommentsClose CommentsPermalink





‘(1) BASIC HEALTH BENEFITS COVERAGE- The term ‘basic health benefits coverage’ means coverage of the health care items and services for which payment may be made under the original medicare fee-for-service program option.CommentsClose CommentsPermalink





‘(2) INSURANCE RISK- The term ‘insurance risk’ means, with respect to a participating health care provider, risk of the type commonly assumed only by insurers licensed by a State and does not include payment variations designed to reflect performance-based measures of activities within the control of the health care provider.CommentsClose CommentsPermalink





‘(3) MA PLAN; MEDICARE ADVANTAGE PLAN- The terms ‘MA plan’ and ‘Medicare Advantage plan’ have the meaning given such terms in section 1859(b)(1).CommentsClose CommentsPermalink





‘(4) ORIGINAL MEDICARE FEE-FOR-SERVICE PROGRAM OPTION- The term ‘original medicare fee-for-service program option’ means the original medicare fee-for-service program under parts A and B, as modified by this subpart.CommentsClose CommentsPermalink





‘(5) STANDARD HEALTH BENEFITS COVERAGE- The term ‘standard health benefits coverage’ has the meaning given such term in section 1860C-2(b).CommentsClose CommentsPermalink





‘(6) TOTAL HEALTH ELIGIBLE INDIVIDUAL- The term ‘Total Health eligible individual’ has the meaning given such term in section 1860C-1(a)(3).CommentsClose CommentsPermalink





‘(7) TOTAL HEALTH PLAN- The term ‘Total Health plan’ means health benefits coverage that is offered--CommentsClose CommentsPermalink





‘(A) under a policy, contract, or plan that has been approved under section 1860C-5(f); andCommentsClose CommentsPermalink





‘(B) by a Total Health sponsor pursuant to, and in accordance with, a contract between the Secretary and the sponsor under section 1860C-6(b).CommentsClose CommentsPermalink





‘(8) TOTAL HEALTH SPONSOR- The term ‘Total Health sponsor’ means a nongovernmental entity that is certified under this subpart as meeting the requirements and standards of this subpart for such a sponsor.CommentsClose CommentsPermalink





‘(b) Application of Subpart 1 Provisions and Regulations Under This Subpart- For purposes of applying provisions of subpart 1 under this subpart (and regulations implementing such provisions) with respect to a Total Health plan and a Total Health sponsor, unless otherwise provided in this subpart, and to the extent consistent with this subpart, such provisions (and regulations implementing such provisions) shall be applied as the provisions (and regulations) applied for plan years beginning prior to January 1, 2017, and as if--CommentsClose CommentsPermalink





‘(1) any reference to a Medicare Advantage plan or an MA plan included a reference to a Total Health plan;CommentsClose CommentsPermalink





‘(2) any reference to an MA organization or a provider-sponsored organization included a reference to a Total Health sponsor;CommentsClose CommentsPermalink





‘(3) any reference to a contract under section 1857 included a reference to a contract under section 1860C-6(b);CommentsClose CommentsPermalink





‘(4) any reference to subpart 1 included a reference to this subpart; andCommentsClose CommentsPermalink





‘(5) any reference to an election period under section 1851 were a reference to an enrollment period under section 1860C-1.’.CommentsClose CommentsPermalink

SEC. 2002. REPLACEMENT OF PART B PREMIUM WITH MEDICARE TOTAL HEALTH PROGRAM PLAN PREMIUM; OTHER TECHNICAL AND CONFORMING AMENDMENTS.

(a) Replacement of Part B Premium With Medicare Total Health Program Plan Premium- Section 1839 of the Social Security Act (42 U.S.C. 1395r) is amended--CommentsClose CommentsPermalink





(1) in subsection (a)(2), by striking ‘The monthly premium’ and inserting ‘Subject to subsection (j),’; andCommentsClose CommentsPermalink





(2) by adding at the end the following new subsection:CommentsClose CommentsPermalink





‘(j) Replacement of Part B Premium With Medicare Total Health Program Plan Premium-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Notwithstanding the preceding provisions of this section, except as provided in paragraph (2), on and after January 1, 2017, in lieu of the premium otherwise applicable under this section, the monthly premium of each Total Health eligible individual (as defined in section 1860C-1(a)(3)) shall be the monthly beneficiary premium determined under section 1860C-7 for the Total Health plan or the original medicare fee-for-service program option and the plan year involved.CommentsClose CommentsPermalink





‘(2) INDIVIDUALS ENROLLED FOR COVERAGE UNDER PART B ONLY- Individuals enrolled under this part only (and not entitled to, or enrolled for, benefits under part A) shall pay the premium that would have been calculated under this section but for the enactment of this subsection.CommentsClose CommentsPermalink





‘(3) CREDITING OF PREMIUMS- Premiums paid by each Total Health eligible individual enrolled in the original medicare fee-for-service program option (as defined in section 1860E-13(a)(4)), shall be deposited in the Treasury to the credit of the Federal Supplementary Medical Insurance Trust Fund under section 1841.’.CommentsClose CommentsPermalink





(b) Other Technical and Conforming Amendments- Not later than 6 months after the date of the enactment of this Act, the Secretary of Health and Human Services shall submit to the appropriate committees of Congress a legislative proposal providing for such technical and conforming amendments in the law as are required by the provisions of this part and part II.CommentsClose CommentsPermalink

PART II--MEDICARE FEE-FOR-SERVICE REFORMS

SEC. 2011. MEDICARE PROTECTION AGAINST HIGH OUT-OF-POCKET EXPENDITURES FOR FEE-FOR-SERVICE BENEFITS.

Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘PROTECTION AGAINST HIGH OUT-OF-POCKET EXPENDITURES

‘Sec. 1899B. (a) In General- Notwithstanding any other provision of this title, in the case of an individual entitled to, or enrolled for, benefits under part A or enrolled in part B, if the amount of the out-of-pocket cost-sharing of such individual for a year (beginning with 2015) equals or exceeds--CommentsClose CommentsPermalink





‘(1) the first threshold annual out-of-pocket limit under subsection (b)(1) but is less than the second threshold annual out-of-pocket limit under subsection (b)(2) for that year, section 1899D(a) shall be applied by substituting ‘5 percent’ for ‘20 percent’; andCommentsClose CommentsPermalink





‘(2) the second threshold annual out-of-pocket limit under subsection (b)(2) for that year, there shall not be any additional reduction under section 1899D for the remainder of the year (and the individual shall not be responsible for additional out-of-pocket cost-sharing incurred during that year).CommentsClose CommentsPermalink





‘(b) Amount of Annual Out-of-Pocket Limits-CommentsClose CommentsPermalink





‘(1) FIRST THRESHOLD ANNUAL OUT-OF-POCKET LIMIT- The amount of the first threshold annual out-of-pocket limit under this subsection shall be--CommentsClose CommentsPermalink





‘(A) for 2015, $5,500; orCommentsClose CommentsPermalink





‘(B) for a subsequent year, the amount specified in this subsection for the preceding year increased or decreased by the percentage change in the Chained Consumer Price Index for All Urban Consumers for the 12-month period ending with June of such preceding year (as published in its initial form by the Bureau of Labor Statistics of the Department of Labor as of the end of such period).CommentsClose CommentsPermalink





‘(2) SECOND THRESHOLD ANNUAL OUT-OF-POCKET LIMIT- The amount of the second threshold annual out-of-pocket limit under this subsection shall be--CommentsClose CommentsPermalink





‘(A) for 2015, $7,500; orCommentsClose CommentsPermalink





‘(B) for a subsequent year, the amount specified in this subsection for the preceding year increased or decreased by the percentage change in the Chained Consumer Price Index for All Urban Consumers for the 12-month period ending with June of such preceding year (as published in its initial form by the Bureau of Labor Statistics of the Department of Labor as of the end of such period).CommentsClose CommentsPermalink





‘(3) ROUNDING- If any amount determined under subparagraph (A) or (B) is not a multiple of $5, such amount shall be rounded to the nearest multiple of $5.CommentsClose CommentsPermalink





‘(c) Out-of-Pocket Cost-Sharing Defined-CommentsClose CommentsPermalink





‘(1) IN GENERAL- Subject to paragraphs (2) and (3), in this section, the term ‘out-of-pocket cost-sharing’ means, with respect to an individual, the amount of the expenses incurred by the individual that are attributable to--CommentsClose CommentsPermalink





‘(A) deductibles, coinsurance and copayments applicable under part A or B; orCommentsClose CommentsPermalink





‘(B) for items and services that would have otherwise been covered under part A or B but for the exhaustion of those benefits.CommentsClose CommentsPermalink





‘(2) CERTAIN COSTS NOT INCLUDED-CommentsClose CommentsPermalink





‘(A) NON-COVERED ITEMS AND SERVICES- Expenses incurred for items and services which are not included (or treated as being included) under part A or B shall not be considered incurred expenses for purposes of determining out-of-pocket cost-sharing under paragraph (1).CommentsClose CommentsPermalink





‘(B) ITEMS AND SERVICES NOT FURNISHED ON AN ASSIGNMENT-RELATED BASIS- If an item or service is furnished to an individual under this title and is not furnished on an assignment-related basis, any additional expenses the individual incurs above the amount the individual would have incurred if the item or service was furnished on an assignment-related basis shall not be considered incurred expenses for purposes of determining out-of-pocket cost-sharing under paragraph (1).CommentsClose CommentsPermalink





‘(3) SOURCE OF PAYMENT- For purposes of paragraph (1), the Secretary shall consider expenses to be incurred by the individual without regard to whether the individual or another person, including a State program or other third-party coverage, has paid for such expenses.CommentsClose CommentsPermalink





‘(d) Announcement of Annual Out-of-Pocket Limit and Unified Deductible- The Secretary shall (beginning in 2014) announce (in a manner intended to provide notice to all interested parties) the annual out-of-pocket limit under this section and the unified deductible under section 1899C that will be applicable for the succeeding year.’.CommentsClose CommentsPermalink

SEC. 2012. UNIFIED MEDICARE DEDUCTIBLE.

(a) In General- Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), as amended by section 2011, is amended by adding at the end the following new section:CommentsClose CommentsPermalink

‘UNIFIED PART A AND B DEDUCTIBLE

‘Sec. 1899C. (a) In General- Notwithstanding any other provision of this title, subject to subsection (d), for a year (beginning with 2015), in the case of an individual entitled to, or enrolled for, benefits under part A or enrolled in part B--CommentsClose CommentsPermalink





‘(1) the amount otherwise payable under part A and the total amount of expenses incurred by the individual during a year which would (except for this section) constitute incurred expenses for which benefits payable under section 1833(a) are determinable, shall be reduced by the amount of the unified deductible under subsection (b); andCommentsClose CommentsPermalink





‘(2) the individual shall be responsible for payment of such amount.CommentsClose CommentsPermalink





‘(b) Amount of Unified Deductible-CommentsClose CommentsPermalink





‘(1) IN GENERAL- The amount of the unified deductible under this section shall be--CommentsClose CommentsPermalink





‘(A) for 2015, $550; orCommentsClose CommentsPermalink





‘(B) for a subsequent year, the amount specified in this subsection for the preceding year increased or decreased by the percentage change in the Chained Consumer Price Index for All Urban Consumers for the 12-month period ending with June of such preceding year (as published in its initial form by the Bureau of Labor Statistics of the Department of Labor as of the end of such period).CommentsClose CommentsPermalink





‘(2) ROUNDING- If any amount determined under paragraph (1) is not a multiple of $5, such amount shall be rounded to the nearest multiple of $5.CommentsClose CommentsPermalink





‘(c) Application to All Items and Services- The unified deductible under this section for a year shall be applied as follows:CommentsClose CommentsPermalink





‘(1) With respect to items and services covered under part A, such unified deductible shall be applied on the basis of the amount that is payable for such items and services without regard to any copayments or coinsurance and before the application of any such copayments or coinsurance.CommentsClose CommentsPermalink





‘(2) With respect to items and services covered under part B, such unified deductible shall be applied on the basis of the total amount of the expenses incurred by the individual during a year which would, except for the application of the unified deductible, constitute incurred expenses for which items and services are payable under part B, without regard to any copayments or coinsurance and before the application of any such copayments or coinsurance.CommentsClose CommentsPermalink





‘(3)(A) Except as provided in subparagraph (B), such unified deductible shall be applied with respect to all items and services covered under parts A and B and in lieu of the deductibles described in sections 1813(b) and 1833(b) or otherwise.CommentsClose CommentsPermalink





‘(B) The deductible applicable to blood under sections 1813 and 1833 shall apply to blood instead of such unified deductible.CommentsClose CommentsPermalink





‘(d) Treatment of Individuals Not Enrolled in Both Parts A and B- The Secretary shall establish procedures under which an individual who entitled to, or enrolled for, benefits under part A or enrolled in part B (but not both) will continue to be subject to a deductible under this title that is comparable to the deductible the individual would have been subject to if this section had not been enacted.’.CommentsClose CommentsPermalink





(b) Clarification Regarding Application Under Medicare Advantage- Section 1852(a)(1)(B)(iii) of the Social Security Act (42 U.S.C. 1395w-22(a)(1)(B)(iii)) is amended by adding at the end the following new sentence: ‘For plan years 2015 and 2016, the preceding sentence shall be applied to take into account the application of sections 1899B, 1899C, and 1899D.’.CommentsClose CommentsPermalink