U.S. Congress - Text of H.R.3590 as Amendment in Senate (OC Prepared) Patient Protection and Affordable Care Act
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Donate NowH.R.3590 - Patient Protection and Affordable Care Act
To amend the Internal Revenue Code of 1986 to modify the first-time homebuyers credit in the case of members of the Armed Forces and certain other Federal employees, and for other purposes.
| Version | Word Count | Changes From Previous Version | Percent Change |
|---|---|---|---|
| Introduced in House | 989 | n/a | n/a |
| Engrossed in House | 899 | 3 | 20% |
| Placed on Calendar Senate | 970 | 8 | 5% |
| Amendment in Senate (OC Prepared) | 327,911 | n/a | n/a |
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IN THE SENATE OF THE UNITED STATES 111th Cong., 1st Sess.
H. R. 3590
To amend the Internal Revenue Code of 1986 to modify the first-time homebuyers credit in the case of members of the Armed Forces and certain other Federal employees, and for other purposes.CommentsClose CommentsPermalink
Referred to the Committee on _____________and ordered to be printed Ordered to lie on the table and to be printedCommentsClose CommentsPermalink
AMENDMENT IN THE NATURE OF A SUBSTITUTE intended to be proposed by Mr. REIDCommentsClose CommentsPermalink
(for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN)CommentsClose CommentsPermalink
Viz:CommentsClose CommentsPermalink
Strike all after the enacting clause and insert the following:CommentsClose CommentsPermalink
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE. This Act may be cited as the Patient Protection and Affordable Care Act.(B) tABLE OF CONTENTS. The table of contents of this Act is as follows:CommentsClose CommentsPermalink
Sec. 1. Short title; table of contents.CommentsClose CommentsPermalink
TITLE I QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
Subtitle A Immediate Improvements in Health Care Coverage for All AmericansCommentsClose CommentsPermalink
Sec. 1001. Amendments to the Public Health Service Act.CommentsClose CommentsPermalink
Sec. 2711. No lifetime or annual limits.CommentsClose CommentsPermalink
Sec. 2712. Prohibition on rescissions.CommentsClose CommentsPermalink
Sec. 2713. Coverage of preventive health services.CommentsClose CommentsPermalink
Sec. 2714. Extension of dependent coverage.CommentsClose CommentsPermalink
Sec. 2715. Development and utilization of uniform explanation of cov erage documents and standardized definitions.CommentsClose CommentsPermalink
Sec. 2716. Prohibition of discrimination based on salary.CommentsClose CommentsPermalink
Sec. 2717. Ensuring the quality of care.CommentsClose CommentsPermalink
Sec. 2718. Bringing down the cost of health care coverage.CommentsClose CommentsPermalink
Sec. 2719. Appeals process.CommentsClose CommentsPermalink
Sec. 1002. Health insurance consumer information.CommentsClose CommentsPermalink
Sec. 1003. Ensuring that consumers get value for their dollars.CommentsClose CommentsPermalink
Sec. 1004. Effective dates.CommentsClose CommentsPermalink
Subtitle B Immediate Actions to Preserve and Expand CoverageCommentsClose CommentsPermalink
Sec. 1101. Immediate access to insurance for uninsured individuals with a pre existing condition.CommentsClose CommentsPermalink
Sec. 1102. Reinsurance for early retirees.CommentsClose CommentsPermalink
Sec. 1103. Immediate information that allows consumers to identify affordable coverage options.CommentsClose CommentsPermalink
Sec. 1104. Administrative simplification.CommentsClose CommentsPermalink
Sec. 1105. Effective date.CommentsClose CommentsPermalink
Subtitle C Quality Health Insurance Coverage for All AmericansCommentsClose CommentsPermalink
Sec. 1201. Amendment to the Public Health Service Act.CommentsClose CommentsPermalink
Sec. 2701. Fair health insurance premiums.CommentsClose CommentsPermalink
Sec. 2702. Guaranteed availability of coverage.CommentsClose CommentsPermalink
Sec. 2703. Guaranteed renewability of coverage.CommentsClose CommentsPermalink
Sec. 2704. Prohibition of preexisting condition exclusions or other dis crimination based on health status.CommentsClose CommentsPermalink
Sec. 2705. Prohibiting discrimination against individual participants and beneficiaries based on health status.CommentsClose CommentsPermalink
Sec. 2706. Non-discrimination in health care.CommentsClose CommentsPermalink
Sec. 2707. Comprehensive health insurance coverage.CommentsClose CommentsPermalink
Sec. 2708. Prohibition on excessive waiting periods.CommentsClose CommentsPermalink
Sec. 1251. Preservation of right to maintain existing coverage.CommentsClose CommentsPermalink
Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers and group health plans.CommentsClose CommentsPermalink
Sec. 1253. Effective dates.CommentsClose CommentsPermalink
Subtitle D Available Coverage Choices for All AmericansCommentsClose CommentsPermalink
Sec. 1301. Qualified health plan defined.CommentsClose CommentsPermalink
Sec. 1302. Essential health benefits requirements.CommentsClose CommentsPermalink
Sec. 1303. Special rules.CommentsClose CommentsPermalink
Sec. 1304. Related definitions.CommentsClose CommentsPermalink
Sec. 1311. Affordable choices of health benefit plans.CommentsClose CommentsPermalink
Sec. 1312. Consumer choice.CommentsClose CommentsPermalink
Sec. 1313. Financial integrity.CommentsClose CommentsPermalink
Sec. 1321. State flexibility in operation and enforcement of Exchanges and related requirements.CommentsClose CommentsPermalink
Sec. 1322. Federal program to assist establishment and operation of nonprofit, member-run health insurance issuers.CommentsClose CommentsPermalink
Sec. 1323. Community health insurance option.CommentsClose CommentsPermalink
Sec. 1324. Level playing field.CommentsClose CommentsPermalink
Sec. 1331. State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid.CommentsClose CommentsPermalink
Sec. 1332. Waiver for State innovation.CommentsClose CommentsPermalink
Sec. 1333. Provisions relating to offering of plans in more than one State.CommentsClose CommentsPermalink
Sec. 1341. Transitional reinsurance program for individual and small group markets in each State.CommentsClose CommentsPermalink
Sec. 1342. Establishment of risk corridors for plans in individual and small group markets.CommentsClose CommentsPermalink
Sec. 1343. Risk adjustment.CommentsClose CommentsPermalink
Subtitle E Affordable Coverage Choices for All AmericansCommentsClose CommentsPermalink
Sec. 1401. Refundable tax credit providing premium assistance for coverage under a qualified health plan.CommentsClose CommentsPermalink
Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans.CommentsClose CommentsPermalink
Sec. 1411. Procedures for determining eligibility for Exchange participation, premium tax credits and reduced cost-sharing , and individual responsibility exemptions.CommentsClose CommentsPermalink
Sec. 1412. Advance determination and payment of premium tax credits and cost-sharing reductions.CommentsClose CommentsPermalink
Sec. 1413. Streamlining of procedures for enrollment through an exchange and State Medicaid, CHIP, and health subsidy programs.CommentsClose CommentsPermalink
Sec. 1414. Disclosures to carry out eligibility requirements for certain programs.CommentsClose CommentsPermalink
Sec. 1415. Premium tax credit and cost-sharing reduction payments disregarded for Federal and Federally-assisted programs.CommentsClose CommentsPermalink
Sec. 1421. Credit for employee health insurance expenses of small businesses.CommentsClose CommentsPermalink
Subtitle F Shared Responsibility for Health CareCommentsClose CommentsPermalink
Sec. 1501. Requirement to maintain minimum essential coverage.CommentsClose CommentsPermalink
Sec. 1502. Reporting of health insurance coverage.CommentsClose CommentsPermalink
Sec. 1511. Automatic enrollment for employees of large employers.CommentsClose CommentsPermalink
Sec. 1512. Employer requirement to inform employees of coverage options.CommentsClose CommentsPermalink
Sec. 1513. Shared responsibility for employers.CommentsClose CommentsPermalink
Sec. 1514. Reporting of employer health insurance coverage.CommentsClose CommentsPermalink
Sec. 1515. Offering of Exchange-participating qualified health plans through cafeteria plans.CommentsClose CommentsPermalink
Subtitle G Miscellaneous ProvisionsCommentsClose CommentsPermalink
Sec. 1551. Definitions.CommentsClose CommentsPermalink
Sec. 1552. Transparency in government.CommentsClose CommentsPermalink
Sec. 1553. Prohibition against discrimination on assisted suicide.CommentsClose CommentsPermalink
Sec. 1554. Access to therapies.CommentsClose CommentsPermalink
Sec. 1555. Freedom not to participate in Federal health insurance programs.CommentsClose CommentsPermalink
Sec. 1556. Equity for certain eligible survivors.CommentsClose CommentsPermalink
Sec. 1557. Nondiscrimination.CommentsClose CommentsPermalink
Sec. 1558. Protections for employees.CommentsClose CommentsPermalink
Sec. 1559. Oversight.CommentsClose CommentsPermalink
Sec. 1560. Rules of construction.CommentsClose CommentsPermalink
Sec. 1561. Health information technology enrollment standards and protocols.CommentsClose CommentsPermalink
Sec. 1562. Conforming amendments.CommentsClose CommentsPermalink
Subtitle A Improved Access to MedicaidCommentsClose CommentsPermalink
Sec. 2001. Medicaid coverage for the lowest income populations.CommentsClose CommentsPermalink
Sec. 2002. Income eligibility for nonelderly determined using modified gross income.CommentsClose CommentsPermalink
Sec. 2003. Requirement to offer premium assistance for employer-sponsored insurance.CommentsClose CommentsPermalink
Sec. 2004. Medicaid coverage for former foster care children.CommentsClose CommentsPermalink
Sec. 2005. Payments to territories.CommentsClose CommentsPermalink
Sec. 2006. Special adjustment to FMAP determination for certain States recovering from a major disaster.CommentsClose CommentsPermalink
Sec. 2007. Medicaid Improvement Fund rescission.CommentsClose CommentsPermalink
Subtitle B Enhanced Support for the Childrens Health Insurance ProgramCommentsClose CommentsPermalink
Sec. 2101. Additional federal financial participation for CHIP.CommentsClose CommentsPermalink
Sec. 2102. Technical corrections.CommentsClose CommentsPermalink
Subtitle C Medicaid and CHIP Enrollment SimplificationCommentsClose CommentsPermalink
Sec. 2201. Enrollment Simplification and coordination with State Health Insurance Exchanges.CommentsClose CommentsPermalink
Sec. 2202. Permitting hospitals to make presumptive eligibility determinations for all Medicaid eligible populations.CommentsClose CommentsPermalink
Subtitle D Improvements to Medicaid ServicesCommentsClose CommentsPermalink
Sec. 2301. Coverage for freestanding birth center services.CommentsClose CommentsPermalink
Sec. 2302. Concurrent care for children.CommentsClose CommentsPermalink
Sec. 2303. State eligibility option for family planning services.CommentsClose CommentsPermalink
Sec. 2304. Clarification of definition of medical assistance.CommentsClose CommentsPermalink
Subtitle E New Options for States to Provide Long-Term Services and SupportsCommentsClose CommentsPermalink
Sec. 2401. Community First Choice Option.CommentsClose CommentsPermalink
Sec. 2402. Removal of barriers to providing home and community-based services.CommentsClose CommentsPermalink
Sec. 2403. Money Follows the Person Rebalancing Demonstration.CommentsClose CommentsPermalink
Sec. 2404. Protection for recipients of home and community-based services against spousal impoverishment.CommentsClose CommentsPermalink
Sec. 2405. Funding to expand State Aging and Disability Resource Centers.CommentsClose CommentsPermalink
Sec. 2406. Sense of the Senate regarding long-term care.CommentsClose CommentsPermalink
Subtitle F Medicaid Prescription Drug CoverageCommentsClose CommentsPermalink
Sec. 2501. Prescription drug rebates.CommentsClose CommentsPermalink
Sec. 2502. Elimination of exclusion of coverage of certain drugs.CommentsClose CommentsPermalink
Sec. 2503. Providing adequate pharmacy reimbursement.CommentsClose CommentsPermalink
Subtitle G Medicaid Disproportionate Share HospitalCommentsClose CommentsPermalink
(DSH) PaymentsCommentsClose CommentsPermalink
Sec. 2551. Disproportionate share hospital payments.CommentsClose CommentsPermalink
Subtitle H Improved Coordination for Dual Eligible BeneficiariesCommentsClose CommentsPermalink
Sec. 2601. 5-year period for demonstration projects.CommentsClose CommentsPermalink
Sec. 2602. Providing Federal coverage and payment coordination for dual eligible beneficiaries.CommentsClose CommentsPermalink
Subtitle I Improving the Quality of Medicaid for Patients and ProvidersCommentsClose CommentsPermalink
Sec. 2701. Adult health quality measures.CommentsClose CommentsPermalink
Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions.CommentsClose CommentsPermalink
Sec. 2703. State option to provide health homes for enrollees with chronic conditions.CommentsClose CommentsPermalink
Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization.CommentsClose CommentsPermalink
Sec. 2705. Medicaid Global Payment System Demonstration Project.CommentsClose CommentsPermalink
Sec. 2706. Pediatric Accountable Care Organization Demonstration Project.CommentsClose CommentsPermalink
Sec. 2707. Medicaid emergency psychiatric demonstration project.CommentsClose CommentsPermalink
Subtitle J Improvements to the Medicaid and CHIP Payment and Access CommissionCommentsClose CommentsPermalink
(MACPAC)CommentsClose CommentsPermalink
Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries.CommentsClose CommentsPermalink
Subtitle K Protections for American Indians and Alaska NativesCommentsClose CommentsPermalink
Sec. 2901. Special rules relating to Indians.CommentsClose CommentsPermalink
Sec. 2902. Elimination of sunset for reimbursement for all medicare part B services furnished by certain indian hospitals and clinics.CommentsClose CommentsPermalink
Subtitle L Maternal and Child Health ServicesCommentsClose CommentsPermalink
Sec. 2951. Maternal, infant, and early childhood home visiting programs.CommentsClose CommentsPermalink
Sec. 2952. Support, education, and research for postpartum depression.CommentsClose CommentsPermalink
Sec. 2953. Personal responsibility education.CommentsClose CommentsPermalink
Sec. 2954. Restoration of funding for abstinence education.CommentsClose CommentsPermalink
Sec. 2955. Inclusion of information about the importance of having a health care power of attorney in transition planning for children aging out of foster care and independent living programs.CommentsClose CommentsPermalink
Subtitle A Transforming the Health Care Delivery SystemCommentsClose CommentsPermalink
Sec. 3001. Hospital Value-Based purchasing program.CommentsClose CommentsPermalink
Sec. 3002. Improvements to the physician quality reporting system.CommentsClose CommentsPermalink
Sec. 3003. Improvements to the physician feedback program.CommentsClose CommentsPermalink
Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation hospitals, and hospice programs.CommentsClose CommentsPermalink
Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.CommentsClose CommentsPermalink
Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities and home health agencies.CommentsClose CommentsPermalink
Sec. 3007. Value-based payment modifier under the physician fee schedule.CommentsClose CommentsPermalink
Sec. 3008. Payment adjustment for conditions acquired in hospitals.CommentsClose CommentsPermalink
Sec. 3011. National strategy.CommentsClose CommentsPermalink
Sec. 3012. Interagency Working Group on Health Care Quality.CommentsClose CommentsPermalink
Sec. 3013. Quality measure development.CommentsClose CommentsPermalink
Sec. 3014. Quality measurement.CommentsClose CommentsPermalink
Sec. 3015. Data collection; public reporting.CommentsClose CommentsPermalink
Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation within CMS.CommentsClose CommentsPermalink
Sec. 3022. Medicare shared savings program.CommentsClose CommentsPermalink
Sec. 3023. National pilot program on payment bundling.CommentsClose CommentsPermalink
Sec. 3024. Independence at home demonstration program.CommentsClose CommentsPermalink
Sec. 3025. Hospital readmissions reduction program.CommentsClose CommentsPermalink
Sec. 3026. Community-Based Care Transitions Program.CommentsClose CommentsPermalink
Sec. 3027. Extension of gainsharing demonstration.CommentsClose CommentsPermalink
Subtitle B Improving Medicare for Patients and ProvidersCommentsClose CommentsPermalink
Sec. 3101. Increase in the physician payment update.CommentsClose CommentsPermalink
Sec. 3102. Extension of the work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee schedule.CommentsClose CommentsPermalink
Sec. 3103. Extension of exceptions process for Medicare therapy caps.CommentsClose CommentsPermalink
Sec. 3104. Extension of payment for technical component of certain physician pathology services.CommentsClose CommentsPermalink
Sec. 3105. Extension of ambulance add-ons.CommentsClose CommentsPermalink
Sec. 3106. Extension of certain payment rules for long-term care hospital services and of moratorium on the establishment of certain hospitals and facilities.CommentsClose CommentsPermalink
Sec. 3107. Extension of physician fee schedule mental health add-on.CommentsClose CommentsPermalink
Sec. 3108. Permitting physician assistants to order post-Hospital extended care services.CommentsClose CommentsPermalink
Sec. 3109. Exemption of certain pharmacies from accreditation requirements.CommentsClose CommentsPermalink
Sec. 3110. Part B special enrollment period for disabled TRICARE beneficiaries.CommentsClose CommentsPermalink
Sec. 3111. Payment for bone density tests.CommentsClose CommentsPermalink
Sec. 3112. Revision to the Medicare Improvement Fund.CommentsClose CommentsPermalink
Sec. 3113. Treatment of certain complex diagnostic laboratory tests.CommentsClose CommentsPermalink
Sec. 3114. Improved access for certified nurse-midwife services.CommentsClose CommentsPermalink
Sec. 3121. Extension of outpatient hold harmless provision.CommentsClose CommentsPermalink
Sec. 3122. Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural areas.CommentsClose CommentsPermalink
Sec. 3123. Extension of the Rural Community Hospital Demonstration Program.CommentsClose CommentsPermalink
Sec. 3124. Extension of the Medicare-dependent hospitalCommentsClose CommentsPermalink
(MDH) program.CommentsClose CommentsPermalink
Sec. 3125. Temporary improvements to the Medicare inpatient hospital payment adjustment for low-volume hospitals.CommentsClose CommentsPermalink
Sec. 3126. Improvements to the demonstration project on community health integration models in certain rural counties.CommentsClose CommentsPermalink
Sec. 3127. MedPAC study on adequacy of Medicare payments for health care providers serving in rural areas.CommentsClose CommentsPermalink
Sec. 3128. Technical correction related to critical access hospital services.CommentsClose CommentsPermalink
Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility program.CommentsClose CommentsPermalink
Sec. 3131. Payment adjustments for home health care.CommentsClose CommentsPermalink
Sec. 3132. Hospice reform.CommentsClose CommentsPermalink
Sec. 3133. Improvement to medicare disproportionate share hospitalCommentsClose CommentsPermalink
(DSH) payments.CommentsClose CommentsPermalink
Sec. 3134. Misvalued codes under the physician fee schedule.CommentsClose CommentsPermalink
Sec. 3135. Modification of equipment utilization factor for advanced imaging services.CommentsClose CommentsPermalink
Sec. 3136. Revision of payment for power-driven wheelchairs.CommentsClose CommentsPermalink
Sec. 3137. Hospital wage index improvement.CommentsClose CommentsPermalink
Sec. 3138. Treatment of certain cancer hospitals.CommentsClose CommentsPermalink
Sec. 3139. Payment for biosimilar biological products.CommentsClose CommentsPermalink
Sec. 3140. Medicare hospice concurrent care demonstration program.CommentsClose CommentsPermalink
Sec. 3141. Application of budget neutrality on a national basis in the calculation of the Medicare hospital wage index floor.CommentsClose CommentsPermalink
Sec. 3142. HHS study on urban Medicare-dependent hospitals.CommentsClose CommentsPermalink
Subtitle C Provisions Relating to Part CCommentsClose CommentsPermalink
Sec. 3201. Medicare Advantage payment.CommentsClose CommentsPermalink
Sec. 3202. Benefit protection and simplification.CommentsClose CommentsPermalink
Sec. 3203. Application of coding intensity adjustment during MA payment transition.CommentsClose CommentsPermalink
Sec. 3204. Simplification of annual beneficiary election periods.CommentsClose CommentsPermalink
Sec. 3205. Extension for specialized MA plans for special needs individuals.CommentsClose CommentsPermalink
Sec. 3206. Extension of reasonable cost contracts.CommentsClose CommentsPermalink
Sec. 3207. Technical correction to MA private fee-for-service plans.CommentsClose CommentsPermalink
Sec. 3208. Making senior housing facility demonstration permanent.CommentsClose CommentsPermalink
Sec. 3209. Authority to deny plan bids.CommentsClose CommentsPermalink
Sec. 3210. Development of new standards for certain Medigap plans.CommentsClose CommentsPermalink
Subtitle D Medicare Part D Improvements for Prescription Drug Plans and MAPD PlansCommentsClose CommentsPermalink
Sec. 3301. Medicare coverage gap discount program.CommentsClose CommentsPermalink
Sec. 3302. Improvement in determination of Medicare part D low-income benchmark premium.CommentsClose CommentsPermalink
Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals under prescription drug plans and MAPD plans.CommentsClose CommentsPermalink
Sec. 3304. Special rule for widows and widowers regarding eligibility for low- income assistance.CommentsClose CommentsPermalink
Sec. 3305. Improved information for subsidy eligible individuals reassigned to prescription drug plans and MAPD plans.CommentsClose CommentsPermalink
Sec. 3306. Funding outreach and assistance for low-income programs.CommentsClose CommentsPermalink
Sec. 3307. Improving formulary requirements for prescription drug plans and MAPD plans with respect to certain categories or classes of drugs.CommentsClose CommentsPermalink
Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries.CommentsClose CommentsPermalink
Sec. 3309. Elimination of cost sharing for certain dual eligible individuals.CommentsClose CommentsPermalink
Sec. 3310. Reducing wasteful dispensing of outpatient prescription drugs in long-term care facilities under prescription drug plans and MAPD plans.CommentsClose CommentsPermalink
Sec. 3311. Improved Medicare prescription drug plan and MAPD plan complaint system.CommentsClose CommentsPermalink
Sec. 3312. Uniform exceptions and appeals process for prescription drug plans and MAPD plans.CommentsClose CommentsPermalink
Sec. 3313. Office of the Inspector General studies and reports.CommentsClose CommentsPermalink
Sec. 3314. Including costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the annual out-of-pocket threshold under part D.CommentsClose CommentsPermalink
Sec. 3315. Immediate reduction in coverage gap in 2010.CommentsClose CommentsPermalink
Subtitle E Ensuring Medicare SustainabilityCommentsClose CommentsPermalink
Sec. 3401. Revision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not already incorporate such improvements.CommentsClose CommentsPermalink
Sec. 3402. Temporary adjustment to the calculation of part B premiums.CommentsClose CommentsPermalink
Sec. 3403. Independent Medicare Advisory Board.CommentsClose CommentsPermalink
Subtitle F Health Care Quality ImprovementsCommentsClose CommentsPermalink
Sec. 3501. Health care delivery system research; Quality improvement technical assistance.CommentsClose CommentsPermalink
Sec. 3502. Establishing community health teams to support the patient-centered medical home.CommentsClose CommentsPermalink
Sec. 3503. Medication management services in treatment of chronic disease.CommentsClose CommentsPermalink
Sec. 3504. Design and implementation of regionalized systems for emergency care.CommentsClose CommentsPermalink
Sec. 3505. Trauma care centers and service availability.CommentsClose CommentsPermalink
Sec. 3506. Program to facilitate shared decisionmaking.CommentsClose CommentsPermalink
Sec. 3507. Presentation of prescription drug benefit and risk information.CommentsClose CommentsPermalink
Sec. 3508. Demonstration program to integrate quality improvement and patient safety training into clinical education of health professionals.CommentsClose CommentsPermalink
Sec. 3509. Improving womens health.CommentsClose CommentsPermalink
Sec. 3510. Patient navigator program.CommentsClose CommentsPermalink
Sec. 3511. Authorization of appropriations.CommentsClose CommentsPermalink
Subtitle A Modernizing Disease Prevention and Public Health SystemsCommentsClose CommentsPermalink
Sec. 4001. National Prevention, Health Promotion and Public Health Council.CommentsClose CommentsPermalink
Sec. 4002. Prevention and Public Health Fund.CommentsClose CommentsPermalink
Sec. 4003. Clinical and community preventive services.CommentsClose CommentsPermalink
Sec. 4004. Education and outreach campaign regarding preventive benefits.CommentsClose CommentsPermalink
Subtitle B Increasing Access to Clinical Preventive ServicesCommentsClose CommentsPermalink
Sec. 4101. School-based health centers.CommentsClose CommentsPermalink
Sec. 4102. Oral healthcare prevention activities.CommentsClose CommentsPermalink
Sec. 4103. Medicare coverage of annual wellness visit providing a personalized prevention plan.CommentsClose CommentsPermalink
Sec. 4104. Removal of barriers to preventive services in Medicare.CommentsClose CommentsPermalink
Sec. 4105. Evidence-based coverage of preventive services in Medicare.CommentsClose CommentsPermalink
Sec. 4106. Improving access to preventive services for eligible adults in Medicaid.CommentsClose CommentsPermalink
Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant women in Medicaid.CommentsClose CommentsPermalink
Sec. 4108. Incentives for prevention of chronic diseases in medicaid.CommentsClose CommentsPermalink
Subtitle C Creating Healthier CommunitiesCommentsClose CommentsPermalink
Sec. 4201. Community transformation grants.CommentsClose CommentsPermalink
Sec. 4202. Healthy aging, living well; evaluation of community-based prevention and wellness programs for Medicare beneficiaries.CommentsClose CommentsPermalink
Sec. 4203. Removing barriers and improving access to wellness for individuals with disabilities.CommentsClose CommentsPermalink
Sec. 4204. Immunizations.CommentsClose CommentsPermalink
Sec. 4205. Nutrition labeling of standard menu items at chain restaurants.CommentsClose CommentsPermalink
Sec. 4206. Demonstration project concerning individualized wellness plan.CommentsClose CommentsPermalink
Sec. 4207. Reasonable break time for nursing mothers.CommentsClose CommentsPermalink
Subtitle D Support for Prevention and Public Health InnovationCommentsClose CommentsPermalink
Sec. 4301. Research on optimizing the delivery of public health services.CommentsClose CommentsPermalink
Sec. 4302. Understanding health disparities: data collection and analysis.CommentsClose CommentsPermalink
Sec. 4303. CDC and employer-based wellness programs.CommentsClose CommentsPermalink
Sec. 4304. Epidemiology-Laboratory Capacity Grants.CommentsClose CommentsPermalink
Sec. 4305. Advancing research and treatment for pain care management.CommentsClose CommentsPermalink
Sec. 4306. Funding for Childhood Obesity Demonstration Project.CommentsClose CommentsPermalink
Subtitle E Miscellaneous ProvisionsCommentsClose CommentsPermalink
Sec. 4401. Sense of the Senate concerning CBO scoring.CommentsClose CommentsPermalink
Sec. 4402. Effectiveness of Federal health and wellness initiatives.CommentsClose CommentsPermalink
Subtitle A Purpose and DefinitionsCommentsClose CommentsPermalink
Sec. 5001. Purpose.CommentsClose CommentsPermalink
Sec. 5002. Definitions.CommentsClose CommentsPermalink
Subtitle B Innovations in the Health Care WorkforceCommentsClose CommentsPermalink
Sec. 5101. National health care workforce commission.CommentsClose CommentsPermalink
Sec. 5102. State health care workforce development grants.CommentsClose CommentsPermalink
Sec. 5103. Health care workforce assessment.CommentsClose CommentsPermalink
Subtitle C Increasing the Supply of the Health Care WorkforceCommentsClose CommentsPermalink
Sec. 5201. Federally supported student loan funds.CommentsClose CommentsPermalink
Sec. 5202. Nursing student loan program.CommentsClose CommentsPermalink
Sec. 5203. Health care workforce loan repayment programs.CommentsClose CommentsPermalink
Sec. 5204. Public health workforce recruitment and retention programs.CommentsClose CommentsPermalink
Sec. 5205. Allied health workforce recruitment and retention programs.CommentsClose CommentsPermalink
Sec. 5206. Grants for State and local programs.CommentsClose CommentsPermalink
Sec. 5207. Funding for National Health Service Corps.CommentsClose CommentsPermalink
Sec. 5208. Nurse-managed health clinics.CommentsClose CommentsPermalink
Sec. 5209. Elimination of cap on commissioned corps.CommentsClose CommentsPermalink
Sec. 5210. Establishing a Ready Reserve Corps.CommentsClose CommentsPermalink
Subtitle D Enhancing Health Care Workforce Education and TrainingCommentsClose CommentsPermalink
Sec. 5301. Training in family medicine, general internal medicine, general pedi atrics, and physician assistantship.CommentsClose CommentsPermalink
Sec. 5302. Training opportunities for direct care workers.CommentsClose CommentsPermalink
Sec. 5303. Training in general, pediatric, and public health dentistry.CommentsClose CommentsPermalink
Sec. 5304. Alternative dental health care providers demonstration project.CommentsClose CommentsPermalink
Sec. 5305. Geriatric education and training; career awards; comprehensive geri atric education.CommentsClose CommentsPermalink
Sec. 5306. Mental and behavioral health education and training grants.CommentsClose CommentsPermalink
Sec. 5307. Cultural competency, prevention, and public health and individuals with disabilities training.CommentsClose CommentsPermalink
Sec. 5308. Advanced nursing education grants.CommentsClose CommentsPermalink
Sec. 5309. Nurse education, practice, and retention grants.CommentsClose CommentsPermalink
Sec. 5310. Loan repayment and scholarship program.CommentsClose CommentsPermalink
Sec. 5311. Nurse faculty loan program.CommentsClose CommentsPermalink
Sec. 5312. Authorization of appropriations for parts B through D of title VIII.CommentsClose CommentsPermalink
Sec. 5313. Grants to promote the community health workforce.CommentsClose CommentsPermalink
Sec. 5314. Fellowship training in public health.CommentsClose CommentsPermalink
Sec. 5315. United States Public Health Sciences Track.CommentsClose CommentsPermalink
Subtitle E Supporting the Existing Health Care WorkforceCommentsClose CommentsPermalink
Sec. 5401. Centers of excellence.CommentsClose CommentsPermalink
Sec. 5402. Health care professionals training for diversity.CommentsClose CommentsPermalink
Sec. 5403. Interdisciplinary, community-based linkages.CommentsClose CommentsPermalink
Sec. 5404. Workforce diversity grants.CommentsClose CommentsPermalink
Sec. 5405. Primary care extension program.CommentsClose CommentsPermalink
Subtitle F Strengthening Primary Care and Other Workforce ImprovementsCommentsClose CommentsPermalink
Sec. 5501. Expanding access to primary care services and general surgery services.CommentsClose CommentsPermalink
Sec. 5502. Medicare Federally qualified health center improvements.CommentsClose CommentsPermalink
Sec. 5503. Distribution of additional residency positions.CommentsClose CommentsPermalink
Sec. 5504. Counting resident time in outpatient settings and allowing flexibility for jointly operated residency training programs.CommentsClose CommentsPermalink
Sec. 5505. Rules for counting resident time for didactic and scholarly activities and other activities.CommentsClose CommentsPermalink
Sec. 5506. Preservation of resident cap positions from closed hospitals.CommentsClose CommentsPermalink
Sec. 5507. Demonstration projects To address health professions workforce needs; extension of family-to-family health information centers.CommentsClose CommentsPermalink
Sec. 5508. Increasing teaching capacity.CommentsClose CommentsPermalink
Sec. 5509. Graduate nurse education demonstration.CommentsClose CommentsPermalink
Subtitle G Improving Access to Health Care ServicesCommentsClose CommentsPermalink
Sec. 5601. Spending for Federally Qualified Health CentersCommentsClose CommentsPermalink
(FQHCs).CommentsClose CommentsPermalink
Sec. 5602. Negotiated rulemaking for development of methodology and criteria for designating medically underserved populations and health professions shortage areas.CommentsClose CommentsPermalink
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services for Children Program.CommentsClose CommentsPermalink
Sec. 5604. Co-locating primary and specialty care in community-based mental health settings.CommentsClose CommentsPermalink
Sec. 5605. Key National indicators.CommentsClose CommentsPermalink
Subtitle H General ProvisionsCommentsClose CommentsPermalink
Sec. 5701. Reports.CommentsClose CommentsPermalink
Subtitle A Physician Ownership and Other TransparencyCommentsClose CommentsPermalink
Sec. 6001. Limitation on Medicare exception to the prohibition on certain physician referrals for hospitals.CommentsClose CommentsPermalink
Sec. 6002. Transparency reports and reporting of physician ownership or investment interests.CommentsClose CommentsPermalink
Sec. 6003. Disclosure requirements for in-office ancillary services exception to the prohibition on physician self-referral for certain imaging services.CommentsClose CommentsPermalink
Sec. 6004. Prescription drug sample transparency.CommentsClose CommentsPermalink
Sec. 6005. Pharmacy benefit managers transparency requirements.CommentsClose CommentsPermalink
Subtitle B Nursing Home Transparency and ImprovementCommentsClose CommentsPermalink
Sec. 6101. Required disclosure of ownership and additional disclosable parties information.CommentsClose CommentsPermalink
Sec. 6102. Accountability requirements for skilled nursing facilities and nursing facilities.CommentsClose CommentsPermalink
Sec. 6103. Nursing home compare Medicare website.CommentsClose CommentsPermalink
Sec. 6104. Reporting of expenditures.CommentsClose CommentsPermalink
Sec. 6105. Standardized complaint form.CommentsClose CommentsPermalink
Sec. 6106. Ensuring staffing accountability.CommentsClose CommentsPermalink
Sec. 6107. GAO study and report on Five-Star Quality Rating System.CommentsClose CommentsPermalink
Sec. 6111. Civil money penalties.CommentsClose CommentsPermalink
Sec. 6112. National independent monitor demonstration project.CommentsClose CommentsPermalink
Sec. 6113. Notification of facility closure.CommentsClose CommentsPermalink
Sec. 6114. National demonstration projects on culture change and use of information technology in nursing homes.CommentsClose CommentsPermalink
Sec. 6121. Dementia and abuse prevention training.CommentsClose CommentsPermalink
Subtitle C Nationwide Program for National and State Background Checks on Direct Patient Access Employees of Long-term Care Facilities and ProvidersCommentsClose CommentsPermalink
Sec. 6201. Nationwide program for National and State background checks on direct patient access employees of long-term care facilities and providers.CommentsClose CommentsPermalink
Subtitle D Patient-Centered Outcomes ResearchCommentsClose CommentsPermalink
Sec. 6301. Patient-Centered Outcomes Research.CommentsClose CommentsPermalink
Sec. 6302. Federal coordinating council for comparative effectiveness research.CommentsClose CommentsPermalink
Sec. 6401. Provider screening and other enrollment requirements under Medicare, Medicaid, and CHIP.CommentsClose CommentsPermalink
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions.CommentsClose CommentsPermalink
Sec. 6403. Elimination of duplication between the Healthcare Integrity and Protection Data Bank and the National Practitioner Data Bank.CommentsClose CommentsPermalink
Sec. 6404. Maximum period for submission of Medicare claims reduced to not more than 12 months.CommentsClose CommentsPermalink
Sec. 6405. Physicians who order items or services required to be Medicare enrolled physicians or eligible professionals.CommentsClose CommentsPermalink
Sec. 6406. Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse.CommentsClose CommentsPermalink
Sec. 6407. Face to face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment under Medicare.CommentsClose CommentsPermalink
Sec. 6408. Enhanced penalties.CommentsClose CommentsPermalink
Sec. 6409. Medicare self-referral disclosure protocol.CommentsClose CommentsPermalink
Sec. 6410. Adjustments to the Medicare durable medical equipment, prosthetics, orthotics, and supplies competitive acquisition program.CommentsClose CommentsPermalink
Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program.CommentsClose CommentsPermalink
Subtitle F Additional Medicaid Program Integrity ProvisionsCommentsClose CommentsPermalink
Sec. 6501. Termination of provider participation under Medicaid if terminated under Medicare or other State plan.CommentsClose CommentsPermalink
Sec. 6502. Medicaid exclusion from participation relating to certain ownership, control, and management affiliations.CommentsClose CommentsPermalink
Sec. 6503. Billing agents, clearinghouses, or other alternate payees required to register under Medicaid.CommentsClose CommentsPermalink
Sec. 6504. Requirement to report expanded set of data elements under MMIS to detect fraud and abuse.CommentsClose CommentsPermalink
Sec. 6505. Prohibition on payments to institutions or entities located outside of the United States.CommentsClose CommentsPermalink
Sec. 6506. Overpayments.CommentsClose CommentsPermalink
Sec. 6507. Mandatory State use of national correct coding initiative.CommentsClose CommentsPermalink
Sec. 6508. General effective date.CommentsClose CommentsPermalink
Subtitle G Additional Program Integrity ProvisionsCommentsClose CommentsPermalink
Sec. 6601. Prohibition on false statements and representations.CommentsClose CommentsPermalink
Sec. 6602. Clarifying definition.CommentsClose CommentsPermalink
Sec. 6603. Development of model uniform report form.CommentsClose CommentsPermalink
Sec. 6604. Applicability of State law to combat fraud and abuse.CommentsClose CommentsPermalink
Sec. 6605. Enabling the Department of Labor to issue administrative summary cease and desist orders and summary seizures orders against plans that are in financially hazardous condition.CommentsClose CommentsPermalink
Sec. 6606. MEWA plan registration with Department of Labor.CommentsClose CommentsPermalink
Sec. 6607. Permitting evidentiary privilege and confidential communications.CommentsClose CommentsPermalink
Subtitle H Elder Justice ActCommentsClose CommentsPermalink
Sec. 6701. Short title of subtitle.CommentsClose CommentsPermalink
Sec. 6702. Definitions.CommentsClose CommentsPermalink
Sec. 6703. Elder Justice.CommentsClose CommentsPermalink
Subtitle I Sense of the Senate Regarding Medical MalpracticeCommentsClose CommentsPermalink
Sec. 6801. Sense of the Senate regarding medical malpractice.CommentsClose CommentsPermalink
Subtitle A Biologics Price Competition and InnovationCommentsClose CommentsPermalink
Sec. 7001. Short title.CommentsClose CommentsPermalink
Sec. 7002. Approval pathway for biosimilar biological products.CommentsClose CommentsPermalink
Sec. 7003. Savings.CommentsClose CommentsPermalink
Subtitle B More Affordable Medicines for Children and Underserved CommunitiesCommentsClose CommentsPermalink
Sec. 7101. Expanded participation in 340B program.CommentsClose CommentsPermalink
Sec. 7102. Improvements to 340B program integrity.CommentsClose CommentsPermalink
Sec. 7103. GAO study to make recommendations on improving the 340B program.CommentsClose CommentsPermalink
Sec. 8001. Short title of title.CommentsClose CommentsPermalink
Sec. 8002. Establishment of national voluntary insurance program for purchasing community living assistance services and support.CommentsClose CommentsPermalink
Subtitle A Revenue Offset ProvisionsCommentsClose CommentsPermalink
Sec. 9001. Excise tax on high cost employer-sponsored health coverage.CommentsClose CommentsPermalink
Sec. 9002. Inclusion of cost of employer-sponsored health coverage on W2.CommentsClose CommentsPermalink
Sec. 9003. Distributions for medicine qualified only if for prescribed drug or insulin.CommentsClose CommentsPermalink
Sec. 9004. Increase in additional tax on distributions from HSAs and Archer MSAs not used for qualified medical expenses.CommentsClose CommentsPermalink
Sec. 9005. Limitation on health flexible spending arrangements under cafeteria plans.CommentsClose CommentsPermalink
Sec. 9006. Expansion of information reporting requirements.CommentsClose CommentsPermalink
Sec. 9007. Additional requirements for charitable hospitals.CommentsClose CommentsPermalink
Sec. 9008. Imposition of annual fee on branded prescription pharmaceutical manufacturers and importers.CommentsClose CommentsPermalink
Sec. 9009. Imposition of annual fee on medical device manufacturers and importers.CommentsClose CommentsPermalink
Sec. 9010. Imposition of annual fee on health insurance providers.CommentsClose CommentsPermalink
Sec. 9011. Study and report of effect on veterans health care.CommentsClose CommentsPermalink
Sec. 9012. Elimination of deduction for expenses allocable to Medicare Part D subsidy.CommentsClose CommentsPermalink
Sec. 9013. Modification of itemized deduction for medical expenses.CommentsClose CommentsPermalink
Sec. 9014. Limitation on excessive remuneration paid by certain health insurance providers.CommentsClose CommentsPermalink
Sec. 9015. Additional hospital insurance tax on high-income taxpayers.CommentsClose CommentsPermalink
Sec. 9016. Modification of section 833 treatment of certain health organizations.CommentsClose CommentsPermalink
Sec. 9017. Excise tax on elective cosmetic medical procedures.CommentsClose CommentsPermalink
Subtitle B Other ProvisionsCommentsClose CommentsPermalink
Sec. 9021. Exclusion of health benefits provided by Indian tribal governments.CommentsClose CommentsPermalink
Sec. 9022. Establishment of simple cafeteria plans for small businesses.CommentsClose CommentsPermalink
Sec. 9023. Qualifying therapeutic discovery project credit.CommentsClose CommentsPermalink
Subtitle A Immediate Improvements in Health Care Coverage for All AmericansCommentsClose CommentsPermalink
Part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended (1) by striking the part heading and inserting the following: PART A INDIVIDUAL AND GROUP MARKET REFORMS;CommentsClose CommentsPermalink
(2) by redesignating sections 2704 through 2707 as sections 2725 through 2728, respectively;CommentsClose CommentsPermalink
(3) by redesignating sections 2711 through 2713 as sections 2731 through 2733, respectively;CommentsClose CommentsPermalink
(4) by redesignating sections 2721 through 2723 as sections 2735 through 2737, respectively; and (5) by inserting after section 2702, the following:CommentsClose CommentsPermalink
(A) IN GENERAL. A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establishCommentsClose CommentsPermalink
(1) lifetime limits on the dollar value of bene fits for any participant or beneficiary; or (2) unreasonable annual limits (within the meaning of section 223 of the Internal Revenue Code of 1986) on the dollar value of benefits for any participant or beneficiary. (B) PER BENEFICIARY LIMITS. Subsection (a) shall not be construed to prevent a group health plan or health insurance coverage that is not required to provide essential health benefits under section 1302(b) of the Patient Protection and Affordable Care Act from placing annual or lifetime per beneficiary limits on specific covered benefits to the extent that such limits are otherwise permitted under Federal or State law.CommentsClose CommentsPermalink
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not rescind such plan or coverage with respect to an enrollee once the enrollee is covered under such plan or coverage involved, except that this section shall not apply to a covered individual who has performed an act or practice that constitutes fraud or makes an intentional misrepresentation of material fact as prohibited by the terms of the plan or coverage. Such plan or coverage may not be cancelled except with prior notice to the enrollee, and only as permitted under section 2702(c) or 2742(b).CommentsClose CommentsPermalink
(a) IN GENERAL. A group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost sharing requirements for (1) evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force;CommentsClose CommentsPermalink
(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved; and (3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. (B) INTERVAL.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary shall establish a minimum interval between the date on which a recommendation described in subsection (a) (1) or (a) (2) or a guideline under subsection (a) (3) is issued and the plan year with respect to which the requirement described in subsection (a) is effective with respect to the service described in such recommendation or guideline.CommentsClose CommentsPermalink
(2) MINIMUM. The interval described in paragraph (1) shall not be less than 1 year. (C) VALUE-BASED INSURANCE DESIGN. The Sec retary may develop guidelines to permit a group health plan and a health insurance issuer offering group or individual health insurance coverage to utilize value-based insurance designs.CommentsClose CommentsPermalink
(a) IN GENERAL. A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult childCommentsClose CommentsPermalink
(who is not married) until the child turns 26 years of age. Nothing in this section shall require a health plan or a health insurance issuer described in the preceding sentence to make coverage available for a child of a child receiving dependent coverage. (B) REGULATIONS. The Secretary shall promulgate regulations to define the dependents to which coverage shall be made available under subsection (a). (C) RULE OF CONSTRUCTION. Nothing in this section shall be construed to modify the definition of dependent as used in the Internal Revenue Code of 1986 with respect to the tax treatment of the cost of coverage. CommentsClose CommentsPermalink
(A) IN GENERAL. Not later than 12 months after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary shall develop standards for use by a group health plan and a health insurance issuer offering group or individual health insurance coverage, in compiling and providing to enrollees a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the applicable plan or coverage. In developing such standards, the Secretary shall consult with the National Association of Insurance Commissioners (referred to in this section as the NAIC), a working group composed of representatives of health in- surance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advo cates including those representing individuals with limited English proficiency, and other qualified individuals. (B) REQUIREMENTS. The standards for the sum mary of benefits and coverage developed under subsection (a) shall provide for the following:CommentsClose CommentsPermalink
(1) APPEARANCE. The standards shall ensure that the summary of benefits and coverage is presented in a uniform format that does not exceed 4 pages in length and does not include print smaller than 12-point font.CommentsClose CommentsPermalink
(2) LANGUAGE. The standards shall ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee.CommentsClose CommentsPermalink
(3) CONTENTS. The standards shall ensure that the summary of benefits and coverage includes (A) uniform definitions of standard insurance terms and medical terms (consistent with subsection (g)) so that consumers may compare health insurance coverage and understand the terms of coverage (or exception to such coverage); (B) a description of the coverage, including cost sharing for (i) each of the categories of the essential health benefits described in subparagraphs (A) through (J) of section 1302(b)(1) of the Patient Protection and Affordable Care Act; and (ii) other benefits, as identified by the Secretary; (C) the exceptions, reductions, and limitations on coverage; (d) the cost-sharing provisions, including deductible, coinsurance, and co-payment obligations;(e)the renewability and continuation of coverage provisions;(f) a coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing, such scenarios to be based on recognized clinical practice guidelines; (g) a statement of whether the plan or coverage (i) provides minimum essential coverage (as defined under section 5000A (f) of the Internal Revenue Code 1986); and (ii) ensures that the plan or coverage share of the total allowed costs of benefits provided under the plan or coverage is not less than 60 percent of such costs; (h) a statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and (I) a contact number for the consumer to call with additional questions and an Internet web address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained. (C) PERIODIC REVIEW AND UPDATING. The Sec retary shall periodically review and update, as appropriate, the standards developed under this section. (d) REQUIREMENT TO PROVIDE.CommentsClose CommentsPermalink
(1) IN GENERAL. Not later than 24 months after the date of enactment of the Patient Protection and Affordable Care Act, each entity described in paragraph (3) shall provide, prior to any enrollment restriction, a summary of benefits and coverage explanation pursuant to the standards developed by the Secretary under subsection (a) to (A) an applicant at the time of application; (B) an enrollee prior to the time of enrollment or reenrollment, as applicable; and (C) a policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate.CommentsClose CommentsPermalink
(2) COMPLIANCE. An entity described in paragraph (3) is deemed to be in compliance with this section if the summary of benefits and coverage described in subsection (a) is provided in paper or electronic form.CommentsClose CommentsPermalink
(3) ENTITIES IN GENERAL. An entity described in this paragraph is (A) a health insurance issuer (including a group health plan that is not a self-insured plan) offering health insurance coverage within the United States; or (B) in the case of a self-insured group health plan, the plan sponsor or designated administrator of the plan (as such terms are defined in section 3 (16) of the Employee Retirement Income Security Act of 1974).CommentsClose CommentsPermalink
(4) NOTICE OF MODIFICATIONS. If a group health plan or health insurance issuer makes any material modification in any of the terms of the plan or coverage involved (as defined for purposes of section 102 of the Employee Retirement Income Security Act of 1974) that is not reflected in the most recently provided summary of benefits and coverage, the plan or issuer shall provide notice of such modification to enrollees not later than 60 days prior to the date on which such modification will become effective.(e)PREEMPTION. The standards developed under subsection (a) shall preempt any related State standards that require a summary of benefits and coverage that provides less information to consumers than that required to be provided under this section, as determined by the Secretary.(f) FAILURE TO PROVIDE. An entity described in subsection (d) (3) that willfully fails to provide the information required under this section shall be subject to a fine of not more than $1,000 for each such failure. Such failure with respect to each enrollee shall constitute a separate offense for purposes of this subsection. (g) DEVELOPMENT OF STANDARD DEFINITIONS.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary shall, by regulation, provide for the development of standards for the definitions of terms used in health insurance coverage, including the insurance-related terms described in paragraph (2) and the medical terms described in paragraph (3).CommentsClose CommentsPermalink
(2) INSURANCE-RELATED TERMS. The insurance- related terms described in this paragraph are premium, deductible, co-insurance, co-payment, out- of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, UCRCommentsClose CommentsPermalink
(usual, customary and reasonable) fees, excluded services, grievance and appeals, and such other terms as the Secretary determines are important to define so that consumers may compare health insurance coverage and understand the terms of their coverage.CommentsClose CommentsPermalink
(3) MEDICAL TERMS. The medical terms described in this paragraph are hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as the Secretary determines are important to define so that consumers may compare the medical benefits offered by health insurance and understand the extent of those medical benefits (or exceptions to those benefits). CommentsClose CommentsPermalink
(A) IN GENERAL. The plan sponsor of a group health plan (other than a self-insured plan) may not establish rules relating to the health insurance coverage eligibility (including continued eligibility) of any full-time employee under the terms of the plan that are based on the total hourly or annual salary of the employee or otherwise establish eligibility rules that have the effect of discriminating in favor of higher wage employees. (B) LIMITATION. Subsection (a) shall not be construed to prohibit a plan sponsor from establishing contribution requirements for enrollment in the plan or coverage that provide for the payment by employees with lower hourly or annual compensation of a lower dollar or percentage contribution than the payment required of similarly situated employees with a higher hourly or annual compensation. CommentsClose CommentsPermalink
(A) QUALITY REPORTING.CommentsClose CommentsPermalink
(1) IN GENERAL. Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary, in consultation with experts in health care quality and stakeholders, shall develop reporting requirements for use by a group health plan, and a health insurance issuer offering group or individual health insurance coverage, with respect to plan or coverage benefits and health care provider reimbursement structures that (A) improve health outcomes through the implementation of activities such as quality reporting, effective case management, care coordination, chronic disease management, and medication and care compliance initiatives, including through the use of the medical homes model as defined for purposes of section 3602 of the Patient Protection and Affordable Care Act, for treatment or services under the plan or coverage; (B) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient- centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; (C) implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; and (D) implement wellness and health promotion activities.CommentsClose CommentsPermalink
(2) REPORTING REQUIREMENTS. (A) IN GENERAL. A group health plan and a health insurance issuer offering group or individual health insurance coverage shall annually submit to the Secretary, and to enrollees under the plan or coverage, a report on whether the benefits under the plan or coverage satisfy the elements described in subparagraphs (A) through (d) of paragraph (1). (B) tIMING OF REPORTS. A report under subparagraph (A) shall be made available to an enrollee under the plan or coverage during each open enrollment period. (C) AVAILABILITY OF REPORTS. The Secretary shall make reports submitted under subparagraph (A) available to the public through an Internet website (d) PENALTIES. In developing the reporting requirements under paragraph (1), the Secretary may develop and impose appropriate penalties for non-compliance with such requirements.(e)EXCEPTIONS. In developing the reporting requirements under paragraph (1), the Secretary may provide for exceptions to such requirements for group health plans and health insurance issuers that substantially meet the goals of this section. (B) WELLNESS AND PREVENTION PROGRAMS. For purposes of subsection (a) (1) (D), wellness and health promotion activities may include personalized wellness and prevention services, which are coordinated, maintained or delivered by a health care provider, a wellness and prevention plan manager, or a health, wellness or prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic or web- based intervention efforts for each of the programs participants, and which may include the following wellness and prevention efforts:CommentsClose CommentsPermalink
(1) Smoking cessation.CommentsClose CommentsPermalink
(2) Weight management.CommentsClose CommentsPermalink
(3) Stress management.CommentsClose CommentsPermalink
(4) Physical fitness.CommentsClose CommentsPermalink
(5) Nutrition.CommentsClose CommentsPermalink
(6) Heart disease prevention.CommentsClose CommentsPermalink
(7) Healthy lifestyle support.CommentsClose CommentsPermalink
(8) Diabetes prevention. (C) REGULATIONS. Not later than 2 years after the date of enactment of the Patient Protection and Afford able Care Act, the Secretary shall promulgate regulations that provide criteria for determining whether a reimbursement structure is described in subsection (a). (d) STUDY AND REPORT. Not later than 180 days after the date on which regulations are promulgated under subsection (c), the Government Accountability Office shall review such regulations and conduct a study and submit to the Committee on Health, Education, Labor, and Pensions of the Senate and the Committee on Energy and Commerce of the House of Representatives a report regarding the impact the activities under this section have had on the quality and cost of health care. CommentsClose CommentsPermalink
(A) CLEAR ACCOUNTING FOR COSTS. A health insurance issuer offering group or individual health insurance coverage shall, with respect to each plan year, submit to the Secretary a report concerning the percentage of total premium revenue that such coverage expendsCommentsClose CommentsPermalink
(1) on reimbursement for clinical services pro vided to enrollees under such coverage;CommentsClose CommentsPermalink
(2) for activities that improve health care quality; and (3) on all other non-claims costs, including an explanation of the nature of such costs, and excluding State taxes and licensing or regulatory fees. The Secretary shall make reports received under this sec tion available to the public on the Internet website of the Department of Health and Human Services. (B) ENSURING THAT CONSUMERS RECEIVE VALUE FOR THEIR PREMIUM PAYMENTS.CommentsClose CommentsPermalink
(1) REQUIREMENT TO PROVIDE VALUE FOR PREMIUM PAYMENTS. A health insurance issuer offering group or individual health insurance coverage shall, with respect to each plan year, provide an annual rebate to each enrollee under such coverage, on a pro rata basis, in an amount that is equal to the amount by which premium revenue expended by the issuer on activities described in subsection (a) (3) exceeds (A) with respect to a health insurance issuer offering coverage in the group market, 20 percent, or such lower percentage as a State may by regulation determine; or (B) with respect to a health insurance issuer offering coverage in the individual mar ket, 25 percent, or such lower percentage as a State may by regulation determine, except that such percentage shall be adjusted to the extent the Secretary determines that the application of such percentage with a State may destabilize the existing individual market in such State.CommentsClose CommentsPermalink
(2) CONSIDERATION IN SETTING PERCENT- AGES. In determining the percentages under paragraph (1), a State shall seek to ensure adequate participation by health insurance issuers, competition in the health insurance market in the State, and value for consumers so that premiums are used for clinical services and quality improvements.CommentsClose CommentsPermalink
(3) TERMINATION. The provisions of this subsection shall have no force or effect after December 31, 2013. (C) STANDARD HOSPITAL CHARGES. Each hospital operating within the United States shall for each year establish (and update) and make public (in accordance with guidelines developed by the Secretary) a list of the hospitals standard charges for items and services provided by the hospital, including for diagnosis-related groups established under section 1886 (d) (4) of the Social Security Act. (d) DEFINITIONS. The Secretary, in consultation with the National Association of Insurance Commissions, shall establish uniform definitions for the activities reported under subsection (a). CommentsClose CommentsPermalink
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall implement an effective appeals process for appeals of coverage determinations and claims, under which the plan or issuer shall, at a minimumCommentsClose CommentsPermalink
(1) have in effect an internal claims appeal process;CommentsClose CommentsPermalink
(2) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external appeals processes, and the availability of any applicable office of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the appeals processes;CommentsClose CommentsPermalink
(3) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process; and (4) provide an external review process for such plans and issuers that, at a minimum, includes the consumer protections set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners and is binding on such plans.. CommentsClose CommentsPermalink
Part C of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-91 et seq.) is amended by adding at the end the following: CommentsClose CommentsPermalink
(A) IN GENERAL. The Secretary shall award grants to States to enable such States (or the Exchanges operating in such States) to establish, expand, or provide support for (1) offices of health insurance consumer assistance; or (2) health insurance ombudsman programs. (B) ELIGIBILITY.CommentsClose CommentsPermalink
(1) IN GENERAL. To be eligible to receive a grant, a State shall designate an independent office of health insurance consumer assistance, or an ombudsman, that, directly or in coordination with State health insurance regulators and consumer assistance organizations, receives and responds to inquiries and complaints concerning health insurance coverage with respect to Federal health insurance requirements and under State law.CommentsClose CommentsPermalink
(2) CRITERIA. A State that receives a grant under this section shall comply with criteria established by the Secretary for carrying out activities under such grant. (C) DUTIES. The office of health insurance con sumer assistance or health insurance ombudsman shallCommentsClose CommentsPermalink
(1) assist with the filing of complaints and appeals, including filing appeals with the internal appeal or grievance process of the group health plan or health insurance issuer involved and providing information about the external appeal process;CommentsClose CommentsPermalink
(2) collect, track, and quantify problems and inquiries encountered by consumers;CommentsClose CommentsPermalink
(3) educate consumers on their rights and responsibilities with respect to group health plans and health insurance coverage;CommentsClose CommentsPermalink
(4) assist consumers with enrollment in a group health plan or health insurance coverage by providing information, referral, and assistance; and (5) resolve problems with obtaining premium tax credits under section 36B of the Internal Revenue Code of 1986. (d) DATA COLLECTION. As a condition of receiving a grant under subsection (a), an office of health insurance consumer assistance or ombudsman program shall be required to collect and report data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to identify areas where more enforcement action is necessary and shall share such information with State insurance regulators, the Secretary of Labor, and the Secretary of the Treasury for use in the enforcement activities of such agencies.(e)FUNDING.CommentsClose CommentsPermalink
(1) INITIAL FUNDING. There is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $30,000,000 for the first fiscal year for which this section applies to carry out this section. Such amount shall remain available without fiscal year limitation.CommentsClose CommentsPermalink
(2) AUTHORIZATION FOR SUBSEQUENT YEARS. There is authorized to be appropriated to the Secretary for each fiscal year following the fiscal year described in paragraph (1), such sums as may be necessary to carry out this section..CommentsClose CommentsPermalink
Part C of title XXVII of the Public Health Service Act (42 U.S.C. 300gg-91 et seq.), as amended by section 1002, is further amended by adding at the end the following:CommentsClose CommentsPermalink
(a) INITIAL PREMIUM REVIEW PROCESS.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary, in conjunction with States, shall establish a process for the annual review, beginning with the 2010 plan year and subject to subsection (b)(2)(A), of unreasonable increases in premiums for health insurance coverage.CommentsClose CommentsPermalink
(2) JUSTIFICATION AND DISCLOSURE. The process established under paragraph (1) shall require health insurance issuers to submit to the Secretary and the relevant State a justification for an unreasonable premium increase prior to the implementation of the increase. Such issuers shall prominently post such information on their Internet websites. The Secretary shall ensure the public disclosure of information on such increases and justifications for all health insurance issuers. (B) CONTINUING PREMIUM REVIEW PROCESS.CommentsClose CommentsPermalink
(1) INFORMING SECRETARY OF PREMIUM IN CREASE PATTERNS. As a condition of receiving a grant under subsection (c) (1), a State, through its Commissioner of Insurance, shall (A) provide the Secretary with information about trends in premium increases in health insurance coverage in premium rating areas in the State; and (B) make recommendations, as appropriate, to the State Exchange about whether particular health insurance issuers should be excluded from participation in the Exchange based on a pattern or practice of excessive or unjustified premium increases.CommentsClose CommentsPermalink
(2) MONITORING BY SECRETARY OF PREMIUM INCREASES. (A) IN GENERAL. Beginning with plan years beginning in 2014, the Secretary, in conjunction with the States and consistent with the provisions of subsection (a) (2), shall monitor premium increases of health insurance coverage offered through an Exchange and outside of an Exchange. (B) CONSIDERATION IN OPENING EX- CHANGE. In determining under section 1312 (f) (2) (b) of the Patient Protection and Affordable Care Act whether to offer qualified health plans in the large group market through an Exchange, the State shall take into account any excess of premium growth outside of the Exchange as compared to the rate of such growth inside the Exchange. (C) GRANTS IN SUPPORT OF PROCESS.CommentsClose CommentsPermalink
(1) PREMIUM REVIEW GRANTS DURING 2010 THROUGH 2014. The Secretary shall carry out a program to award grants to States during the 5-year period beginning with fiscal year 2010 to assist such States in carrying out subsection (a), including (A) in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage; and (B) in providing information and recommendations to the Secretary under subsection (b)(1).CommentsClose CommentsPermalink
(2) FUNDING. (A) IN GENERAL. Out of all funds in the Treasury not otherwise appropriated, there are appropriated to the Secretary $250,000,000, to be available for expenditure for grants under paragraph (1) and subparagraph (B). (B) FURTHER AVAILABILITY FOR INSURANCE REFORM AND CONSUMER PROTECTION. If the amounts appropriated under subparagraph (A) are not fully obligated under grants under paragraph (1) by the end of fiscal year 2014, any remaining funds shall remain available to the Secretary for grants to States for planning and implementing the insurance reforms and consumer protections under part A. (C) ALLOCATION. The Secretary shall establish a formula for determining the amount of any grant to a State under this subsection. Under such formula (i) the Secretary shall consider the number of plans of health insurance coverage offered in each State and the population of the State; and (ii) no State qualifying for a grant under paragraph (1) shall receive less than $1,000,000, or more than $5,000,000 for a grant year.. CommentsClose CommentsPermalink
(A) IN GENERAL. Except as provided for in subsection (b), this subtitle (and the amendments made by this subtitle) shall become effective for plan years begin ning on or after the date that is 6 months after the date of enactment of this Act, except that the amendments made by sections 1002 and 1003 shall become effective for fiscal years beginning with fiscal year 2010. (B) SPECIAL RULE. The amendments made by sections 1002 and 1003 shall take effect on the date of enactment of this Act. Subtitle B Immediate Actions to Preserve and Expand Coverage CommentsClose CommentsPermalink
(A) IN GENERAL. Not later than 90 days after the date of enactment of this Act, the Secretary shall establish a temporary high risk health insurance pool program to provide health insurance coverage for eligible individuals during the period beginning on the date on which such program is established and ending on January 1, 2014. (B) ADMINISTRATION.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary may carry out the program under this section directly or through contracts to eligible entities.CommentsClose CommentsPermalink
(2) ELIGIBLE ENTITIES. To be eligible for a contract under paragraph (1), an entity shall (A) be a State or nonprofit private entity; (B) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require; and (C) agree to utilize contract funding to establish and administer a qualified high risk pool for eligible individuals.CommentsClose CommentsPermalink
(3) MAINTENANCE OF EFFORT. To be eligible to enter into a contract with the Secretary under this subsection, a State shall agree not to reduce the annual amount the State expended for the operation of one or more State high risk pools during the year preceding the year in which such contract is entered into. (C) QUALIFIED HIGH RISK POOL.CommentsClose CommentsPermalink
(1) IN GENERAL. Amounts made available under this section shall be used to establish a qualified high risk pool that meets the requirements of paragraph (2).CommentsClose CommentsPermalink
(2) REQUIREMENTS. A qualified high risk pool meets the requirements of this paragraph if such pool (A) provides to all eligible individuals health insurance coverage that does not impose any preexisting condition exclusion with respect to such coverage; (B) provides health insurance coverage (i) in which the issuers share of the total allowed costs of benefits provided under such coverage is not less than 65 percent of such costs; and (ii) that has an out of pocket limit not greater than the applicable amount described in section 223 (c) (2) of the Internal Revenue Code of 1986 for the year involved, except that the Secretary may modify such limit if necessary to ensure the pool meets the actuarial value limit under clause (i); (C) ensures that with respect to the premium rate charged for health insurance coverage offered to eligible individuals through the high risk pool, such rate shall (i) except as provided in clause (ii), vary only as provided for under section 2701 of the Public Health Service Act (as amended by this Act and notwithstanding the date on which such amendments take effect); (ii) vary on the basis of age by a factor of not greater than 4 to 1; and (iii) be established at a standard rate for a standard population; and (D) meets any other requirements determined appropriate by the Secretary. (d) ELIGIBLE INDIVIDUAL. An individual shall be deemed to be an eligible individual for purposes of this section if such individual (1) is a citizen or national of the United States or is lawfully present in the United States (as determined in accordance with section 1411);CommentsClose CommentsPermalink
(2) has not been covered under creditable coverage (as defined in section 2701 (c) (1) of the Public Health Service Act as in effect on the date of enactment of this Act) during the 6-month period prior to the date on which such individual is applying for coverage through the high risk pool; and (3) has a pre-existing condition, as determined in a manner consistent with guidance issued by the Secretary.(e)PROTECTION AGAINST DUMPING RISK BY INSURERS.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary shall establish criteria for determining whether health insurance issuers and employment-based health plans have discouraged an individual from remaining enrolled in prior coverage based on that individuals health status.CommentsClose CommentsPermalink
(2) SANCTIONS. An issuer or employment- based health plan shall be responsible for reimbursing the program under this section for the medical expenses incurred by the program for an individual who, based on criteria established by the Secretary, the Secretary finds was encouraged by the issuer to disenroll from health benefits coverage prior to enrolling in coverage through the program. The criteria shall include at least the following circumstances: (A) In the case of prior coverage obtained through an employer, the provision by the employer, group health plan, or the issuer of money or other financial consideration for disenrolling from the coverage. (B) In the case of prior coverage obtained directly from an issuer or under an employment- based health plan (i) the provision by the issuer or plan of money or other financial consideration for disenrolling from the coverage; or (ii) in the case of an individual whose premium for the prior coverage exceeded the premium required by the programCommentsClose CommentsPermalink
(adjusted based on the age factors applied to the prior coverage) (i) the prior coverage is a policy that is no longer being actively marketed (as defined by the Secretary) by the issuer; or (II) the prior coverage is a policy for which duration of coverage form issue or health status are factors that can be considered in determining premiums at renewal.CommentsClose CommentsPermalink
(3) CONSTRUCTION. Nothing in this subsection shall be construed as constituting exclusive remedies for violations of criteria established under paragraph (1) or as preventing States from applying or enforcing such paragraph or other provisions under law with respect to health insurance issuers.(f) OVERSIGHT. The Secretary shall establishCommentsClose CommentsPermalink
(1) an appeals process to enable individuals to appeal a determination under this section; and (2) procedures to protect against waste, fraud, and abuse. (g) FUNDING; TERMINATION OF AUTHORITY.CommentsClose CommentsPermalink
(1) IN GENERAL. There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to pay claims against (and the administrative costs of) the high risk pool under this section that are in excess of the amount of premiums collected from eligible individuals enrolled in the high risk pool. Such funds shall be available without fiscal year limitation.CommentsClose CommentsPermalink
(2) INSUFFICIENT FUNDS. If the Secretary estimates for any fiscal year that the aggregate amounts available for the payment of the expenses of the high risk pool will be less than the actual amount of such expenses, the Secretary shall make such adjustments as are necessary to eliminate such deficit.CommentsClose CommentsPermalink
(3) TERMINATION OF AUTHORITY. (A) IN GENERAL. Except as provided in subparagraph (B), coverage of eligible individuals under a high risk pool in a State shall terminate on January 1, 2014. (B) tRANSITION TO EXCHANGE. The Secretary shall develop procedures to provide for the transition of eligible individuals enrolled in health insurance coverage offered through a high risk pool established under this section into qualified health plans offered through an Exchange. Such procedures shall ensure that there is no lapse in coverage with respect to the individual and may extend coverage after the termination of the risk pool involved, if the Secretary determines necessary to avoid such a lapse.CommentsClose CommentsPermalink
(4) LIMITATIONS. The Secretary has the authority to stop taking applications for participation in the program under this section to comply with the funding limitation provided for in paragraph (1).CommentsClose CommentsPermalink
(5) RELATION TO STATE LAWS. The standards established under this section shall supersede any State law or regulation (other than State licensing laws or State laws relating to plan solvency) with respect to qualified high risk pools which are established in accordance with this section. CommentsClose CommentsPermalink
(A) ADMINISTRATION.CommentsClose CommentsPermalink
(1) IN GENERAL. Not later than 90 days after the date of enactment of this Act, the Secretary shall establish a temporary reinsurance program to provide reimbursement to participating employment- based plans for a portion of the cost of providing health insurance coverage to early retirees (and to the eligible spouses, surviving spouses, and dependents of such retirees) during the period beginning on the date on which such program is established and ending on January 1, 2014.CommentsClose CommentsPermalink
(2) REFERENCE. In this section: (A) HEALTH BENEFITS. The term health benefits means medical, surgical, hospital, prescription drug, and such other benefits as shall be determined by the Secretary, whether self-funded, or delivered through the purchase of insurance or otherwise. (B) EMPLOYMENT-BASED PLAN. The term employment-based plan means a group health benefits plan that (i) is (i) maintained by one or more current or former employers (including without limitation any State or local government or political subdivision thereof), employee organization, a voluntary employees beneficiary association, or a committee or board of individuals appointed to administer such plan; or (II) a multiemployer plan (as defined in section 3CommentsClose CommentsPermalink
(37) of the Employee Retirement Income Security Act of 1974); and (ii) provides health benefits to early retirees. (C) EARLY RETIREES. The term early retirees means individuals who are age 55 and older but are not eligible for coverage under title XVIII of the Social Security Act, and who are not active employees of an employer maintaining, or currently contributing to, the employment- based plan or of any employer that has made substantial contributions to fund such plan. (B) PARTICIPATION.CommentsClose CommentsPermalink
(1) EMPLOYMENT-BASED PLAN ELIGIBILITY. A participating employment-based plan is an employment- based plan that (A) meets the requirements of paragraph (2) with respect to health benefits provided under the plan; and (B) submits to the Secretary an application for participation in the program, at such time, in such manner, and containing such information as the Secretary shall require.CommentsClose CommentsPermalink
(2) EMPLOYMENT-BASED HEALTH BENEFITS. An employment-based plan meets the requirements of this paragraph if the plan (A) implements programs and procedures to generate cost-savings with respect to participants with chronic and high-cost conditions; (B) provides documentation of the actual cost of medical claims involved; and (C) is certified by the Secretary. (C) PAYMENTS.CommentsClose CommentsPermalink
(1) SUBMISSION OF CLAIMS. (A) IN GENERAL. A participating employment- based plan shall submit claims for reimbursement to the Secretary which shall contain documentation of the actual costs of the items and services for which each claim is being submitted. (B) BASIS FOR CLAIMS. Claims submitted under subparagraph (A) shall be based on the actual amount expended by the participating employment-based plan involved within the plan year for the health benefits provided to an early retiree or the spouse, surviving spouse, or de pendent of such retiree. In determining the amount of a claim for purposes of this subsection, the participating employment-based plan shall take into account any negotiated price concessions (such as discounts, direct or indirect subsidies, rebates, and direct or indirect remunerations) obtained by such plan with respect to such health benefit. For purposes of determining the amount of any such claim, the costs paid by the early retiree or the retirees spouse, surviving spouse, or dependent in the form of deductibles, co-payments, or co-insurance shall be included in the amounts paid by the participating employment-based plan.CommentsClose CommentsPermalink
(2) PROGRAM PAYMENTS. If the Secretary determines that a participating employment-based plan has submitted a valid claim under paragraph (1), the Secretary shall reimburse such plan for 80 percent of that portion of the costs attributable to such claim that exceed $15,000, subject to the limits contained in paragraph (3).CommentsClose CommentsPermalink
(3) LIMIT. To be eligible for reimbursement under the program, a claim submitted by a participating employment-based plan shall not be less than $15,000 nor greater than $90,000. Such amounts shall be adjusted each fiscal year based on the percentage increase in the Medical Care Component of the Consumer Price Index for all urban consumersCommentsClose CommentsPermalink
(rounded to the nearest multiple of $1,000) for the year involved.CommentsClose CommentsPermalink
(4) USE OF PAYMENTS. Amounts paid to a participating employment-based plan under this subsection shall be used to lower costs for the plan. Such payments may be used to reduce premium costs for an entity described in subsection (a) (2) (B) (i) or to reduce premium contributions, co- payments, deductibles, co-insurance, or other out-of- pocket costs for plan participants. Such payments shall not be used as general revenues for an entity described in subsection (a) (2) (B) (i). The Secretary shall develop a mechanism to monitor the appropriate use of such payments by such entities.CommentsClose CommentsPermalink
(5) PAYMENTS NOT TREATED AS INCOME. Payments received under this subsection shall not be included in determining the gross income of an entity described in subsection (a) (2) (B) (i) that is maintaining or currently contributing to a participating employment-based plan.CommentsClose CommentsPermalink
(6) APPEALS. The Secretary shall establish (A) an appeals process to permit participating employment-based plans to appeal a determination of the Secretary with respect to claims submitted under this section; and (B) procedures to protect against fraud, waste, and abuse under the program. (d) AUDITS. The Secretary shall conduct annual audits of claims data submitted by participating employment- based plans under this section to ensure that such plans are in compliance with the requirements of this section.(e)FUNDING. There is appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, $5,000,000,000 to carry out the program under this section. Such funds shall be available without fiscal year limitation.(f) LIMITATION. The Secretary has the authority to stop taking applications for participation in the program based on the availability of funding under subsection (e). CommentsClose CommentsPermalink
(A) INTERNET PORTAL TO AFFORDABLE COVERAGE OPTIONS.CommentsClose CommentsPermalink
(1) IMMEDIATE ESTABLISHMENT. Not later than July 1, 2010, the Secretary, in consultation with the States, shall establish a mechanism, including an Internet website, through which a resident of any State may identify affordable health insurance coverage options in that State.CommentsClose CommentsPermalink
(2) CONNECTING TO AFFORDABLE COV- ERAGE. An Internet website established under paragraph (1) shall, to the extent practicable, provide ways for residents of any State to receive information on at least the following coverage options: (A) Health insurance coverage offered by health insurance issuers, other than coverage that provides reimbursement only for the treatment or mitigation of (i) a single disease or condition; or (ii) an unreasonably limited set of diseases or conditions (as determined by the Secretary); (B) Medicaid coverage under title XIX of the Social Security Act. (C) Coverage under title XXI of the Social Security Act. (d) A State health benefits high risk pool, to the extent that such high risk pool is offered in such State; and (E) Coverage under a high risk pool under section 1101. (B) ENHANCING COMPARATIVE PURCHASING OPTIONS.CommentsClose CommentsPermalink
(1) IN GENERAL. Not later than 60 days after the date of enactment of this Act, the Secretary shall develop a standardized format to be used for the presentation of information relating to the coverage options described in subsection (a) (2). Such format shall, at a minimum, require the inclusion of information on the percentage of total premium revenue expended on nonclinical costs (as reported under section 2718 (a) of the Public Health Service Act), eligibility, availability, premium rates, and cost sharing with respect to such coverage options and be consistent with the standards adopted for the uniform explanation of coverage as provided for in section 2715 of the Public Health Service Act.CommentsClose CommentsPermalink
(2) USE OF FORMAT. The Secretary shall utilize the format developed under paragraph (1) in compiling information concerning coverage options on the Internet website established under subsection (a). (C) AUTHORITY TO CONTRACT. The Secretary may carry out this section through contracts entered into with qualified entities. CommentsClose CommentsPermalink
(A) PURPOSE OF ADMINISTRATIVE SIMPLIFICATION. Section 261 of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d note) is amended (1) by inserting uniform before standards; and (2) by inserting and to reduce the clerical burden on patients, health care providers, and health plans before the period at the end. (B) OPERATING RULES FOR HEALTH INFORMATION TRANSACTIONS.CommentsClose CommentsPermalink
(1) DEFINITION OF OPERATING RULES. Section 1171 of the Social Security Act (42 U.S.C. 1320d) is amended by adding at the end the following:CommentsClose CommentsPermalink
(9) OPERATING RULES. The term operating rules means the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications as adopted for purposes of this part..CommentsClose CommentsPermalink
(2) TRANSACTION STANDARDS; OPERATING RULES AND COMPLIANCE. Section 1173 of the Social Security Act (42 U.S.C. 1320d2) is amended (A) in subsection (a) (2), by adding at the end the following new subparagraph: (j) Electronic funds transfers.; (B) in subsection (a), by adding at the end the following new paragraph:CommentsClose CommentsPermalink
(4) REQUIREMENTS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS. (A) IN GENERAL. The standards and associated operating rules adopted by the Secretary shall (i) to the extent feasible and appropriate, enable determination of an individuals eligibility and financial responsibility for specific services prior to or at the point of care; (ii) be comprehensive, requiring minimal augmentation by paper or other communications; (iii) provide for timely acknowledgment, response, and status reporting that supports a transparent claims and denial management process (including adjudication and appeals); and (iv) describe all data elements (including reason and remark codes) in unambiguous terms, require that such data elements be required or conditioned upon set values in other fields, and prohibit additional conditions (except where necessary to implement State or Federal law, or to protect against fraud and abuse). (B) REDUCTION OF CLERICAL BUR- DEN. In adopting standards and operating rules for the transactions referred to under paragraph (1), the Secretary shall seek to reduce the number and complexity of forms (including paper and electronic forms) and data entry required by patients and providers.; and (C) by adding at the end the following new subsections: (g) OPERATING RULES.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary shall adopt a single set of operating rules for each transaction referred to under subsection (a) (1) with the goal of creating as much uniformity in the implementation of the electronic standards as possible. Such operating rules shall be consensus-based and reflect the necessary business rules affecting health plans and health care providers and the manner in which they operate pursuant to standards issued under Health Insurance Portability and Accountability Act of 1996.CommentsClose CommentsPermalink
(2) OPERATING RULES DEVELOPMENT. In adopting operating rules under this subsection, the Secretary shall consider recommendations for operating rules developed by a qualified nonprofit entity that meets the following requirements: (A) The entity focuses its mission on administrative simplification. (B) the entity demonstrates a multi- stakeholder and consensus-based process for development of operating rules, including representation by or participation from health plans, health care providers, vendors, relevant Federal agencies, and other standard development organizations. (C) The entity has a public set of guiding principles that ensure the operating rules and process are open and transparent, and supports nondiscrimination and conflict of interest poli cies that demonstrate a commitment to open, fair, and nondiscriminatory practices. (d) The entity builds on the transaction standards issued under Health Insurance Portability and Accountability Act of 1996.(e)The entity allows for public review and updates of the operating rules.CommentsClose CommentsPermalink
(3) REVIEW AND RECOMMENDATIONS. The National Committee on Vital and Health Statistics shall (A) advise the Secretary as to whether a nonprofit entity meets the requirements under paragraph (2); (B) review the operating rules developed and recommended by such nonprofit entity; (C) determine whether such operating rules represent a consensus view of the health care stakeholders and are consistent with and do not conflict with other existing standards; (d) evaluate whether such operating rules are consistent with electronic standards adopted for health information technology; and (E) submit to the Secretary a recommendation as to whether the Secretary should adopt such operating rules.CommentsClose CommentsPermalink
(4) IMPLEMENTATION. (A) IN GENERAL. The Secretary shall adopt operating rules under this subsection, by regulation in accordance with subparagraph (C), following consideration of the operating rules developed by the non-profit entity described in paragraph (2) and the recommendation submitted by the National Committee on Vital and Health Statistics under paragraph (3)(e)and having ensured consultation with providers. (B) ADOPTION REQUIREMENTS; EFFECTIVE DATES. (i) ELIGIBILITY FOR A HEALTH PLAN AND HEALTH CLAIM STATUS. The set of operating rules for eligibility for a health plan and health claim status transactions shall be adopted not later than July 1, 2011, in a manner ensuring that such operating rules are effective not later than January 1, 2013, and may allow for the use of a machine readable identification card. (ii) ELECTRONIC FUNDS TRANSFERS AND HEALTH CARE PAYMENT AND REMIT TANCE ADVICE. The set of operating rules for electronic funds transfers and health care payment and remittance advice transactions shall (i) allow for automated reconciliation of the electronic payment with the remittance advice; and (II) be adopted not later than July 1, 2012, in a manner ensuring that such operating rules are effective not later than January 1, 2014. (iii) HEALTH CLAIMS OR EQUIVA LENT ENCOUNTER INFORMATION, ENROLLMENT AND DISENROLLMENT IN A HEALTH PLAN, HEALTH PLAN PREMIUM PAYMENTS, REFERRAL CERTIFICATION AND AUTHOR- IZATION. The set of operating rules for health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, and referral certification and authorization transactions shall be adopted not later than July 1, 2014, in a manner ensuring that such operating rules are effective not later than January 1, 2016. (C) EXPEDITED RULEMAKING. The Secretary shall promulgate an interim final rule applying any standard or operating rule recommended by the National Committee on Vital and Health Statistics pursuant to paragraph (3). The Secretary shall accept and consider public comments on any interim final rule published under this subparagraph for 60 days after the date of such publication. (h) COMPLIANCE.CommentsClose CommentsPermalink
(1) HEALTH PLAN CERTIFICATION. (A) ELIGIBILITY FOR A HEALTH PLAN, HEALTH CLAIM STATUS, ELECTRONIC FUNDS TRANSFERS, HEALTH CARE PAYMENT AND REMITTANCE ADVICE. Not later than December 31, 2013, a health plan shall file a statement with the Secretary, in such form as the Secretary may require, certifying that the data and information systems for such plan are in compliance with any applicable standards (as described under paragraph (7) of section 1171) and associated operating rules (as described under paragraph (9) of such section) for electronic funds transfers, eligibility for a health plan, health claim status, and health care payment and remittance advice, respectively. (B) HEALTH CLAIMS OR EQUIVALENT ENCOUNTER INFORMATION, ENROLLMENT AND DISENROLLMENT IN A HEALTH PLAN, HEALTH PLAN PREMIUM PAYMENTS, HEALTH CLAIMS ATTACHMENTS, REFERRAL CERTIFICATION AND AUTHORIZATION. Not later than December 31, 2015, a health plan shall file a statement with the Secretary, in such form as the Secretary may require, certifying that the data and information systems for such plan are in compliance with any applicable standards and associated operating rules for health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, health claims attachments, and referral certification and authorization, respectively. A health plan shall provide the same level of documentation to certify compliance with such transactions as is required to certify compliance with the transactions specified in subparagraph (A).CommentsClose CommentsPermalink
(2) DOCUMENTATION OF COMPLIANCE. A health plan shall provide the Secretary, in such form as the Secretary may require, with adequate documentation of compliance with the standards and operating rules described under paragraph (1). A health plan shall not be considered to have provided adequate documentation and shall not be certified as being in compliance with such standards, unless the health plan (A) demonstrates to the Secretary that the plan conducts the electronic transactions specified in paragraph (1) in a manner that fully complies with the regulations of the Secretary; and (B) provides documentation showing that the plan has completed end-to-end testing for such transactions with their partners, such as hospitals and physicians.CommentsClose CommentsPermalink
(3) SERVICE CONTRACTS. A health plan shall be required to ensure that any entities that provide services pursuant to a contract with such health plan shall comply with any applicable certification and compliance requirements (and provide the Secretary with adequate documentation of such compliance) under this subsection.CommentsClose CommentsPermalink
(4) CERTIFICATION BY OUTSIDE ENTITY. The Secretary may designate independent, outside entities to certify that a health plan has complied with the requirements under this subsection, provided that the certification standards employed by such entities are in accordance with any standards or operating rules issued by the Secretary.CommentsClose CommentsPermalink
(5) COMPLIANCE WITH REVISED STANDARDS AND OPERATING RULES. (A) IN GENERAL. A health plan (including entities described under paragraph (3)) shall file a statement with the Secretary, in such form as the Secretary may require, certifying that the data and information systems for such plan are in compliance with any applicable revised standards and associated operating rules under this subsection for any interim final rule promulgated by the Secretary under subsection (i) that (i) amends any standard or operating rule described under paragraph (1) of this subsection; or (ii) establishes a standard (as described under subsection (a) (1) (B)) or associated operating rules (as described under subsection (i)CommentsClose CommentsPermalink
(5)) for any other financial and administrative transactions. (B) DATE OF COMPLIANCE. A health plan shall comply with such requirements not later than the effective date of the applicable standard or operating rule.CommentsClose CommentsPermalink
(6) AUDITS OF HEALTH PLANS. The Sec retary shall conduct periodic audits to ensure that health plans (including entities described under paragraph (3)) are in compliance with any standards and operating rules that are described under paragraph (1) or subsection (i)CommentsClose CommentsPermalink
(5). (i) REVIEW AND AMENDMENT OF STANDARDS AND OPERATING RULES.CommentsClose CommentsPermalink
(1) ESTABLISHMENT. Not later than January 1, 2014, the Secretary shall establish a review committee (as described under paragraph (4)).CommentsClose CommentsPermalink
(2) EVALUATIONS AND REPORTS. (A) HEARINGS. Not later than April 1, 2014, and not less than biennially thereafter, the Secretary, acting through the review committee, shall conduct hearings to evaluate and review the adopted standards and operating rules established under this section. (B) REPORT. Not later than July 1, 2014, and not less than biennially thereafter, the review committee shall provide rec ommendations for updating and improving such standards and operating rules. The review committee shall recommend a single set of operating rules per transaction standard and maintain the goal of creating as much uniformity as possible in the implementation of the electronic standards.CommentsClose CommentsPermalink
(3) INTERIM FINAL RULEMAKING. (A) IN GENERAL. Any recommendations to amend adopted standards and operating rules that have been approved by the review committee and reported to the Secretary under paragraph (2) (B) shall be adopted by the Secretary through promulgation of an interim final rule not later than 90 days after receipt of the committees report. (B) PUBLIC COMMENT. (i) PUBLIC COMMENT PERIOD. The Secretary shall accept and consider public comments on any interim final rule published under this paragraph for 60 days after the date of such publication. (ii) EFFECTIVE DATE. The effective date of any amendment to existing standards or operating rules that is adopted through an interim final rule published under this paragraph shall be 25 months following the close of such public comment period.CommentsClose CommentsPermalink
(4) REVIEW COMMITTEE. (A) DEFINITION. For the purposes of this subsection, the term review committee means a committee chartered by or within the Department of Health and Human services that has been designated by the Secretary to carry out this subsection, including (i) the National Committee on Vital and Health Statistics; or (ii) any appropriate committee as determined by the Secretary. (B) COORDINATION OF HIT STAND- ARDS. In developing recommendations under this subsection, the review committee shall ensure coordination, as appropriate, with the standards that support the certified electronic health record technology approved by the Office of the National Coordinator for Health Information Technology.CommentsClose CommentsPermalink
(5) OPERATING RULES FOR OTHER STAND ARDS ADOPTED BY THE SECRETARY. The Secretary shall adopt a single set of operating rulesCommentsClose CommentsPermalink
(pursuant to the process described under subsection (g)) for any transaction for which a standard had been adopted pursuant to subsection (a) (1) (B). (j) PENALTIES.CommentsClose CommentsPermalink
(1) PENALTY FEE. (A) IN GENERAL. Not later than April 1, 2014, and annually thereafter, the Secretary shall assess a penalty fee (as determined under subparagraph (B)) against a health plan that has failed to meet the requirements under subsection (h) with respect to certification and documentation of compliance with (i) the standards and associated operating rules described under paragraph (1) of such subsection; and (ii) a standard (as described under subsection (a) (1) (B)) and associated operating rules (as described under subsection (i)CommentsClose CommentsPermalink
(5)) for any other financial and administrative transactions. (B) FEE AMOUNT. Subject to subpara graphs (C), (D), and (E), the Secretary shall assess a penalty fee against a health plan in the amount of $1 per covered life until certification is complete. The penalty shall be assessed per person covered by the plan for which its data systems for major medical policies are not in compliance and shall be imposed against the health plan for each day that the plan is not in compliance with the requirements under subsection (h). (C) ADDITIONAL PENALTY FOR MISREPRESENTATION. A health plan that knowingly provides inaccurate or incomplete information in a statement of certification or documentation of compliance under subsection (h) shall be subject to a penalty fee that is double the amount that would otherwise be imposed under this subsection. (d) ANNUAL FEE INCREASE. The amount of the penalty fee imposed under this subsection shall be increased on an annual basis by the annual percentage increase in total national health care expenditures, as determined by the Secretary.(e)PENALTY LIMIT. A penalty fee assessed against a health plan under this subsection shall not exceed, on an annual basis (i) an amount equal to $20 per covered life under such plan; or (ii) an amount equal to $40 per covered life under the plan if such plan has knowingly provided inaccurate or incomplete information (as described under subparagraph (C)).(f) DETERMINATION OF COVERED INDI- VIDUALS. The Secretary shall determine the number of covered lives under a health plan based upon the most recent statements and filings that have been submitted by such plan to the Securities and Exchange Commission.CommentsClose CommentsPermalink
(2) NOTICE AND DISPUTE PROCEDURE. The Secretary shall establish a procedure for assessment of penalty fees under this subsection that provides a health plan with reasonable notice and a dispute resolution procedure prior to provision of a notice of assessment by the Secretary of the Treasury (as described under paragraph (4)(b)).CommentsClose CommentsPermalink
(3) PENALTY FEE REPORT. Not later than May 1, 2014, and annually thereafter, the Secretary shall provide the Secretary of the Treasury with a report identifying those health plans that have been assessed a penalty fee under this subsection.CommentsClose CommentsPermalink
(4) COLLECTION OF PENALTY FEE. (A) IN GENERAL. The Secretary of the Treasury, acting through the Financial Management Service, shall administer the collection of penalty fees from health plans that have been identified by the Secretary in the penalty fee report provided under paragraph (3). (B) NOTICE. Not later than August 1, 2014, and annually thereafter, the Secretary of the Treasury shall provide notice to each health plan that has been assessed a penalty fee by the Secretary under this subsection. Such notice shall include the amount of the penalty fee assessed by the Secretary and the due date for payment of such fee to the Secretary of the Treasury (as described in subparagraph (C)). (C) PAYMENT DUE DATE. Payment by a health plan for a penalty fee assessed under this subsection shall be made to the Secretary of the Treasury not later than November 1, 2014, and annually thereafter. (d) UNPAID PENALTY FEES. Any amount of a penalty fee assessed against a health plan under this subsection for which pay ment has not been made by the due date provided under subparagraph (C) shall be (i) increased by the interest accrued on such amount, as determined pursuant to the underpayment rate established under section 6621 of the Internal Revenue Code of 1986; and (ii) treated as a past-due, legally enforceable debt owed to a Federal agency for purposes of section 6402 (d) of the Internal Revenue Code of 1986.(e)ADMINISTRATIVE FEES. Any fee charged or allocated for collection activities conducted by the Financial Management Service will be passed on to a health plan on a pro-rata basis and added to any penalty fee collected from the plan.. (C) PROMULGATION OF RULES.CommentsClose CommentsPermalink
(1) UNIQUE HEALTH PLAN IDENTIFIER. The Secretary shall promulgate a final rule to establish a unique health plan identifier (as described in section 1173(b) of the Social Security Act (42 U.S.C. 1320d-2(b))) based on the input of the National Committee on Vital and Health Statistics. The Secretary may do so on an interim final basis and such rule shall be effective not later than October 1, 2012.CommentsClose CommentsPermalink
(2) ELECTRONIC FUNDS TRANSFER. The Secretary shall promulgate a final rule to establish a standard for electronic funds transfers (as described in section 1173 (A) (2)(J) of the Social Security Act, as added by subsection (b)(2) (A) ). The Secretary may do so on an interim final basis and shall adopt such standard not later than January 1, 2012, in a manner ensuring that such standard is effective not later than January 1, 2014.CommentsClose CommentsPermalink
(3) HEALTH CLAIMS ATTACHMENTS. The Secretary shall promulgate a final rule to establish a transaction standard and a single set of associated operating rules for health claims attachments (as described in section 1173 (A) (2)(b) of the Social Security Act (42 U.S.C. 1320d-2 (A) (2)(b))) that is consistent with the X12 Version 5010 transaction standards. The Secretary may do so on an interim final basis and shall adopt a transaction standard and a single set of associated operating rules not later than January 1, 2014, in a manner ensuring that such standard is effective not later than January 1, 2016. (d) EXPANSION OF ELECTRONIC TRANSACTIONS IN MEDICARE. Section 1862 (a) of the Social Security Act (42 U.S.C. 1395y (A) ) is amended (1) in paragraph (23), by striking the or at the end;CommentsClose CommentsPermalink
(2) in paragraph (24), by striking the period and inserting ; or; and (3) by inserting after paragraph (24) the following new paragraph:CommentsClose CommentsPermalink
(25) not later than January 1, 2014, for which the payment is other than by electronic funds transferCommentsClose CommentsPermalink
(EFT) or an electronic remittance in a form as specified in ASC X12 835 Health Care Payment and Remittance Advice or subsequent standard.. CommentsClose CommentsPermalink
This subtitle shall take effect on the date of enactment of this Act. CommentsClose CommentsPermalink
Part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.), as amended by section 1001, is further amended (1) by striking the heading for subpart 1 and inserting the following: Subpart I General Reform;CommentsClose CommentsPermalink
(2) (A) in section 2701 (42 U.S.C. 300gg), by striking the section heading and subsection (a) and inserting the following: CommentsClose CommentsPermalink
(A) IN GENERAL. A group health plan and a health insurance issuer offering group or individual health insurance coverage may not impose any preexisting condition exclusion with respect to such plan or coverage.; and (B) by transferring such section (as amended by subparagraph (A)) so as to appear after the section 2703 added by paragraph (4);79CommentsClose CommentsPermalink
(3) (A) in section 2702 (42 U.S.C. 300gg-1) (i) by striking the section heading and all that follows through subsection (a); (ii) in subsection (b)(I) by striking health insurance issuer offering health insurance coverage in connection with a group health plan each place that such appears and inserting health insurance issuer offering group or individual health insurance coverage; and (II) in paragraph (2) (A) (aa) by inserting or individual after employer; and (bb) by inserting or individual health coverage, as the case may be before the semicolon; and (iii) in subsection (e)(I) by striking (a) (1) (F) and inserting (a) (6); (ii) by striking 2701 and inserting 2704; and (III) by striking 2721 (A) and inserting 2735 (A) ; and80 (B) by transferring such section (as amended by subparagraph (A)) to appear after section 2705 (A) as added by paragraph (4); and (4) by inserting after the subpart heading (as added by paragraph (1)) the following: CommentsClose CommentsPermalink
(A) PROHIBITING DISCRIMINATORY PREMIUM RATES.CommentsClose CommentsPermalink
(1) IN GENERAL. With respect to the premium rate charged by a health insurance issuer for health insurance coverage offered in the individual or small group market (A) such rate shall vary with respect to the particular plan or coverage involved only by (i) whether such plan or coverage covers an individual or family; (ii) rating area, as established in accordance with paragraph (2); (iii) age, except that such rate shall not vary by more than 3 to 1 for adults (consistent with section 2707 (C) ); and (iv) tobacco use, except that such rate shall not vary by more than 1.5 to 1; and81 (B) such rate shall not vary with respect to the particular plan or coverage involved by any other factor not described in subparagraph (A).CommentsClose CommentsPermalink
(2) RATING AREA. (A) IN GENERAL. Each State shall establish 1 or more rating areas within that State for purposes of applying the requirements of this title. (B) SECRETARIAL REVIEW. The Secretary shall review the rating areas established by each State under subparagraph (A) to ensure the adequacy of such areas for purposes of carrying out the requirements of this title. If the Secretary determines a States rating areas are not adequate, or that a State does not establish such areas, the Secretary may establish rating areas for that State.CommentsClose CommentsPermalink
(3) PERMISSIBLE AGE BANDS. The Sec retary, in consultation with the National Association of Insurance Commissioners, shall define the permissible age bands for rating purposes under paragraph (1) (A) (iii).CommentsClose CommentsPermalink
(4) APPLICATION OF VARIATIONS BASED ON AGE OR TOBACCO USE. With respect to family cov82 erage under a group health plan or health insurance coverage, the rating variations permitted under clauses (iii) and (iv) of paragraph (1) (A) shall be applied based on the portion of the premium that is attributable to each family member covered under the plan or coverage.CommentsClose CommentsPermalink
(5) SPECIAL RULE FOR LARGE GROUP MAR- KET. If a State permits health insurance issuers that offer coverage in the large group market in the State to offer such coverage through the State Exchange (as provided for under section 1312(f) (2) (B) of the Patient Protection and Affordable Care Act), the provisions of this subsection shall apply to all coverage offered in such market in the State. CommentsClose CommentsPermalink
(A) GUARANTEED ISSUANCE OF COVERAGE IN THE INDIVIDUAL AND GROUP MARKET. Subject to subsections (B) through(e), each health insurance issuer that offers health insurance coverage in the individual or group market in a State must accept every employer and individual in the State that applies for such coverage. (B) ENROLLMENT.CommentsClose CommentsPermalink
(1) RESTRICTION. A health insurance issuer described in subsection (a) may restrict enrollment83 in coverage described in such subsection to open or special enrollment periods.CommentsClose CommentsPermalink
(2) ESTABLISHMENT. A health insurance issuer described in subsection (a) shall, in accordance with the regulations promulgated under paragraph (3), establish special enrollment periods for qualifying events (under section 603 of the Employee Retirement Income Security Act of 1974).CommentsClose CommentsPermalink
(3) REGULATIONS. The Secretary shall promulgate regulations with respect to enrollment periods under paragraphs (1) and (2). CommentsClose CommentsPermalink
(A) IN GENERAL. Except as provided in this section, if a health insurance issuer offers health insurance coverage in the individual or group market, the issuer must renew or continue in force such coverage at the option of the plan sponsor or the individual, as applicable. CommentsClose CommentsPermalink
(A) IN GENERAL. A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan or coverage based on any of84 the following health status-related factors in relation to the individual or a dependent of the individual:CommentsClose CommentsPermalink
(1) Health status.CommentsClose CommentsPermalink
(2) Medical condition (including both physical and mental illnesses).CommentsClose CommentsPermalink
(3) Claims experience.CommentsClose CommentsPermalink
(4) Receipt of health care.CommentsClose CommentsPermalink
(5) Medical history.CommentsClose CommentsPermalink
(6) Genetic information.CommentsClose CommentsPermalink
(7) Evidence of insurability (including condi tions arising out of acts of domestic violence).CommentsClose CommentsPermalink
(8) Disability.CommentsClose CommentsPermalink
(9) Any other health status-related factor de termined appropriate by the Secretary. (j) PROGRAMS OF HEALTH PROMOTION OR DISEASE PREVENTION.CommentsClose CommentsPermalink
(1) GENERAL PROVISIONS. (A) GENERAL RULE. For purposes of subsection (b)(2)(b), a program of health promotion or disease prevention (referred to in this subsection as a wellness program) shall be a program offered by an employer that is designed to promote health or prevent disease that meets the applicable requirements of this subsection.85 (B) NO CONDITIONS BASED ON HEALTH STATUS FACTOR. If none of the conditions for obtaining a premium discount or rebate or other reward for participation in a wellness program is based on an individual satisfying a standard that is related to a health status factor, such wellness program shall not violate this section if participation in the program is made available to all similarly situated individuals and the requirements of paragraph (2) are complied with. (C) CONDITIONS BASED ON HEALTH STATUS FACTOR. If any of the conditions for obtaining a premium discount or rebate or other reward for participation in a wellness program is based on an individual satisfying a standard that is related to a health status factor, such wellness program shall not violate this section if the requirements of paragraph (3) are complied with.CommentsClose CommentsPermalink
(2) WELLNESS PROGRAMS NOT SUBJECT TO REQUIREMENTS. If none of the conditions for ob taining a premium discount or rebate or other re ward under a wellness program as described in para (1) (B) are based on an individual satisfying86 a standard that is related to a health status factor (or if such a wellness program does not provide such a reward), the wellness program shall not violate this section if participation in the program is made available to all similarly situated individuals. The following programs shall not have to comply with the requirements of paragraph (3) if participation in the program is made available to all similarly situated individuals: (A) A program that reimburses all or part of the cost for memberships in a fitness center. (B) A diagnostic testing program that provides a reward for participation and does not base any part of the reward on outcomes. (C) A program that encourages preventive care related to a health condition through the waiver of the copayment or deductible requirement under group health plan for the costs of certain items or services related to a health condition (such as prenatal care or well-baby visits). (d) A program that reimburses individuals for the costs of smoking cessation pro87 grams without regard to whether the individual quits smoking.(e)A program that provides a reward to individuals for attending a periodic health education seminar.CommentsClose CommentsPermalink
(3) WELLNESS PROGRAMS SUBJECT TO RE- QUIREMENTS. If any of the conditions for obtaining a premium discount, rebate, or reward under a wellness program as described in paragraph (1) (C) is based on an individual satisfying a standard that is related to a health status factor, the wellness program shall not violate this section if the following requirements are complied with: (A) The reward for the wellness program, together with the reward for other wellness programs with respect to the plan that requires satisfaction of a standard related to a health status factor, shall not exceed 30 percent of the cost of employee-only coverage under the plan. If, in addition to employees or individuals, any class of dependents (such as spouses or spouses and dependent children) may participate fully in the wellness program, such reward shall not exceed 30 percent of the cost of the coverage in which an employee or individual and any de88 pendents are enrolled. For purposes of this paragraph, the cost of coverage shall be determined based on the total amount of employer and employee contributions for the benefit package under which the employee is (or the employee and any dependents are) receiving coverage. A reward may be in the form of a discount or rebate of a premium or contribution, a waiver of all or part of a cost-sharing mechanism (such as deductibles, copayments, or coinsurance), the absence of a surcharge, or the value of a benefit that would otherwise not be provided under the plan. The Secretaries of Labor, Health and Human Services, and the Treasury may increase the reward available under this subparagraph to up to 50 percent of the cost of coverage if the Secretaries determine that such an increase is appropriate. (B) the wellness program shall be reasonably designed to promote health or prevent disease. A program complies with the preceding sentence if the program has a reasonable chance of improving the health of, or preventing disease in, participating individuals and it is not overly burdensome, is not a subterfuge for89 discriminating based on a health status factor, and is not highly suspect in the method chosen to promote health or prevent disease. (C) The plan shall give individuals eligible for the program the opportunity to qualify for the reward under the program at least once each year. (d) The full reward under the wellness program shall be made available to all similarly situated individuals. For such purpose, among other things: (i) The reward is not available to all similarly situated individuals for a period unless the wellness program allows (i) for a reasonable alternative standard (or waiver of the otherwise applicable standard) for obtaining the reward for any individual for whom, for that period, it is unreasonably difficult due to a medical condition to satisfy the otherwise applicable standard; and (II) for a reasonable alternative standard (or waiver of the otherwise applicable standard) for obtaining the90 reward for any individual for whom, for that period, it is medically inadvisable to attempt to satisfy the otherwise applicable standard. (ii) If reasonable under the cir cumstances, the plan or issuer may seek verification, such as a statement from an individuals physician, that a health status factor makes it unreasonably difficult or medically inadvisable for the individual to satisfy or attempt to satisfy the otherwise applicable standard.(e)The plan or issuer involved shall dis close in all plan materials describing the terms of the wellness program the availability of a reasonable alternative standard (or the possibility of waiver of the otherwise applicable standard) required under subparagraph (D). If plan materials disclose that such a program is available, without describing its terms, the disclosure under this subparagraph shall not be required. (k) EXISTING PROGRAMS. Nothing in this section shall prohibit a program of health promotion or disease prevention that was established prior to the date of enact91 ment of this section and applied with all applicable regulations, and that is operating on such date, from continuing to be carried out for as long as such regulations remain in effect. (l) WELLNESS PROGRAM DEMONSTRATION PROJECT.CommentsClose CommentsPermalink
(1) IN GENERAL. Not later than July 1, 2014, the Secretary, in consultation with the Secretary of the Treasury and the Secretary of Labor, shall establish a 10-State demonstration project under which participating States shall apply the provisions of subsection (j) to programs of health promotion offered by a health insurance issuer that offers health insurance coverage in the individual market in such State.CommentsClose CommentsPermalink
(2) EXPANSION OF DEMONSTRATION PROJECT. If the Secretary, in consultation with the Secretary of the Treasury and the Secretary of Labor, determines that the demonstration project described in paragraph (1) is effective, such Secretaries may, beginning on July 1, 2017 expand such demonstration project to include additional participating States.CommentsClose CommentsPermalink
(3) REQUIREMENTS.92 (A) MAINTENANCE OF COVERAGE. The Secretary, in consultation with the Secretary of the Treasury and the Secretary of Labor, shall not approve the participation of a State in the demonstration project under this section unless the Secretaries determine that the States project is designed in a manner that (i) will not result in any decrease in coverage; and (ii) will not increase the cost to the Federal Government in providing credits under section 36B of the Internal Revenue Code of 1986 or cost-sharing assistance under section 1402 of the Patient Protection and Affordable Care Act. (B) OTHER REQUIREMENTS. States that participate in the demonstration project under this subsection (i) may permit premium discounts or rebates or the modification of otherwise applicable copayments or deductibles for adherence to, or participation in, a reasonably designed program of health promotion and disease prevention;93 (ii) shall ensure that requirements of consumer protection are met in programs of health promotion in the individual market; (iii) shall require verification from health insurance issuers that offer health insurance coverage in the individual market of such State that premium discounts (i) do not create undue burdens for individuals insured in the indi vidual market; (ii) do not lead to cost shifting; and (III) are not a subterfuge for discrimination; (iv) shall ensure that consumer data is protected in accordance with the requirements of section 264 (c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d-2 note); and (v) shall ensure and demonstrate to the satisfaction of the Secretary that the discounts or other rewards provided under the project reflect the expected level of par94 ticipation in the wellness program involved and the anticipated effect the program will have on utilization or medical claim costs. (m) REPORT.CommentsClose CommentsPermalink
(1) IN GENERAL. Not later than 3 years after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary, in consultation with the Secretary of the Treasury and the Secretary of Labor, shall submit a report to the appropriate committees of Congress concerning (A) the effectiveness of wellness programs (as defined in subsection (j)) in promoting health and preventing disease; (B) the impact of such wellness programs on the access to care and affordability of coverage for participants and non-participants of such programs; (C) the impact of premium-based and cost-sharing incentives on participant behavior and the role of such programs in changing behavior; and (D) the effectiveness of different types of rewards.CommentsClose CommentsPermalink
(2) DATA COLLECTION. In preparing the re port described in paragraph (1), the Secretaries95 shall gather relevant information from employers who provide employees with access to wellness pro grams, including State and Federal agencies. (n) REGULATIONS. Nothing in this section shall be construed as prohibiting the Secretaries of Labor, Health and Human Services, or the Treasury from promulgating regulations in connection with this section.CommentsClose CommentsPermalink
(a) PROVIDERS. A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against any health care provider who is acting within the scope of that providers license or certification under applicable State law. This section shall not require that a group health plan or health insurance issuer contract with any health care provider willing to abide by the terms and conditions for participation established by the plan or issuer. Nothing in this section shall be construed as preventing a group health plan, a health insurance issuer, or the Secretary from establishing varying reimbursement rates based on quality or performance measures. (B) INDIVIDUALS. The provisions of section 1558 of the Patient Protection and Affordable Care Act (relating to non-discrimination) shall apply with respect to a96 group health plan or health insurance issuer offering group or individual health insurance coverage. CommentsClose CommentsPermalink
(A) COVERAGE FOR ESSENTIAL HEALTH BENEFITS PACKAGE. A health insurance issuer that offers health insurance coverage in the individual or small group market shall ensure that such coverage includes the essential health benefits package required under section 1302 (a) of the Patient Protection and Affordable Care Act. (B) COST-SHARING UNDER GROUP HEALTH PLANS. A group health plan shall ensure that any annual cost-sharing imposed under the plan does not exceed the limitations provided for under paragraphs (1) and (2) of section 1302 (c). (c) CHILD-ONLY PLANS. If a health insurance issuer offers health insurance coverage in any level of coverage specified under section 1302 (d) of the Patient Protection and Affordable Care Act, the issuer shall also offer such coverage in that level as a plan in which the only enrollees are individuals who, as of the beginning of a plan year, have not attained the age of 21. (d) DENTAL ONLY. This section shall not apply to a plan described in section 1302(d) (2) (b)(ii) (i) .97 CommentsClose CommentsPermalink
A group health plan and a health insurance issuer offering group or individual health insurance coverage shall not apply any waiting period (as defined in section 2704 (B) (4)) that exceeds 90 days.. PART II OTHER PROVISIONS SEC. 1251. PRESERVATION OF RIGHT TO MAINTAIN EXIST ING COVERAGE.
(A) NO CHANGES TO EXISTING COVERAGE.CommentsClose CommentsPermalink
(1) IN GENERAL. Nothing in this Act (or an amendment made by this Act) shall be construed to require that an individual terminate coverage under a group health plan or health insurance coverage in which such individual was enrolled on the date of enactment of this Act.CommentsClose CommentsPermalink
(2) CONTINUATION OF COVERAGE. With respect to a group health plan or health insurance coverage in which an individual was enrolled on the date of enactment of this Act, this subtitle and subtitle A (and the amendments made by such subtitles) shall not apply to such plan or coverage, regardless of whether the individual renews such coverage after such date of enactment. (B) ALLOWANCE FOR FAMILY MEMBERS TO JOIN CURRENT COVERAGE. With respect to a group health98 plan or health insurance coverage in which an individual was enrolled on the date of enactment of this Act and which is renewed after such date, family members of such individual shall be permitted to enroll in such plan or coverage if such enrollment is permitted under the terms of the plan in effect as of such date of enactment. (C) ALLOWANCE FOR NEW EMPLOYEES TO JOIN CURRENT PLAN. A group health plan that provides coverage on the date of enactment of this Act may provide for the enrolling of new employees (and their families) in such plan, and this subtitle and subtitle A (and the amendments made by such subtitles) shall not apply with respect to such plan and such new employees (and their families). (d) EFFECT ON COLLECTIVE BARGAINING AGREE- MENTS. In the case of health insurance coverage maintained pursuant to one or more collective bargaining agreements between employee representatives and one or more employers that was ratified before the date of enactment of this Act, the provisions of this subtitle and subtitle A (and the amendments made by such subtitles) shall not apply until the date on which the last of the collective bargaining agreements relating to the coverage terminates. Any coverage amendment made pursuant to a collective bargaining agreement relating to the coverage99 which amends the coverage solely to conform to any requirement added by this subtitle or subtitle A (or amendments) shall not be treated as a termination of such collective bargaining agreement.(e)DEFINITION. In this title, the term grandfathered health plan means any group health plan or health insurance coverage to which this section applies.CommentsClose CommentsPermalink
Any standard or requirement adopted by a State pursuant to this title, or any amendment made by this title, shall be applied uniformly to all health plans in each insurance market to which the standard and requirements apply. The preceding sentence shall also apply to a State standard or requirement relating to the standard or requirement required by this title (or any such amendment) that is not the same as the standard or requirement but that is not preempted under section 1321 (d).CommentsClose CommentsPermalink
This subtitle (and the amendments made by this subtitle) shall become effective for plan years beginning on or after January 1, 2014.100CommentsClose CommentsPermalink
Subtitle D Available Coverage Choices for All AmericansCommentsClose CommentsPermalink
(a) QUALIFIED HEALTH PLAN. In this title:CommentsClose CommentsPermalink
(1) IN GENERAL. The term qualified health plan means a health plan that (A) has in effect a certification (which may include a seal or other indication of approval) that such plan meets the criteria for certification described in section 1311 (C) issued or recognized by each Exchange through which such plan is offered; (B) provides the essential health benefits package described in section 1302 (A) ; and (C) is offered by a health insurance issuer that (i) is licensed and in good standing to offer health insurance coverage in each State in which such issuer offers health insurance coverage under this title; (ii) agrees to offer at least one qualified health plan in the silver level and at101 least one plan in the gold level in each such Exchange; (iii) agrees to charge the same premium rate for each qualified health plan of the issuer without regard to whether the plan is offered through an Exchange or whether the plan is offered directly from the issuer or through an agent; and (iv) complies with the regulations developed by the Secretary under section 1311 (d) and such other requirements as an applicable Exchange may establish.CommentsClose CommentsPermalink
(2) INCLUSION OF CO-OP PLANS AND COMMUNITY HEALTH INSURANCE OPTION. Any reference in this title to a qualified health plan shall be deemed to include a qualified health plan offered through the CO-OP program under section 1322 or a community health insurance option under section 1323, unless specifically provided for otherwise. (B) tERMS RELATING TO HEALTH PLANS. In this title:CommentsClose CommentsPermalink
(1) HEALTH PLAN. (A) IN GENERAL. The term health plan means health insurance coverage and a group health plan.102 (B) EXCEPTION FOR SELF-INSURED PLANS AND MEWAS. Except to the extent specifically provided by this title, the term health plan shall not include a group health plan or multiple employer welfare arrangement to the extent the plan or arrangement is not subject to State insurance regulation under section 514 of the Employee Retirement Income Security Act of 1974.CommentsClose CommentsPermalink
(2) HEALTH INSURANCE COVERAGE AND ISSUER. The terms health insurance coverage and health insurance issuer have the meanings given such terms by section 2791(b) of the Public Health Service Act.CommentsClose CommentsPermalink
(3) GROUP HEALTH PLAN. The term group health plan has the meaning given such term by section 2791 (a) of the Public Health Service Act. CommentsClose CommentsPermalink
(A) ESSENTIAL HEALTH BENEFITS PACKAGE. In this title, the term essential health benefits package means, with respect to any health plan, coverage that (1) provides for the essential health benefits defined by the Secretary under subsection (b);CommentsClose CommentsPermalink
(2) limits cost-sharing for such coverage in accordance with subsection (c); and 103CommentsClose CommentsPermalink
(3) subject to subsection (e), provides either the bronze, silver, gold, or platinum level of coverage described in subsection (d). (b) ESSENTIAL HEALTH BENEFITS.CommentsClose CommentsPermalink
(1) IN GENERAL. Subject to paragraph (2), the Secretary shall define the essential health benefits, except that such benefits shall include at least the following general categories and the items and services covered within the categories: (A) Ambulatory patient services. (B) Emergency services. (C) Hospitalization. (d) Maternity and newborn care.(e)Mental health and substance use disorder services, including behavioral health treatment.(f) Prescription drugs. (g) Rehabilitative and habilitative services and devices. (h) Laboratory services. (i) Preventive and wellness services and chronic disease management. (j) Pediatric services, including oral and vision care.CommentsClose CommentsPermalink
(2) LIMITATION.104 (A) IN GENERAL. The Secretary shall ensure that the scope of the essential health benefits under paragraph (1) is equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary. To inform this determination, the Secretary of Labor shall conduct a survey of employer-sponsored coverage to determine the benefits typically covered by employers, including multiemployer plans, and provide a report on such survey to the Secretary. (B) CERTIFICATION. In defining the essential health benefits described in paragraph (1), and in revising the benefits under paragraph (4) (h), the Secretary shall submit a report to the appropriate committees of Congress containing a certification from the Chief Actuary of the Centers for Medicare & Medicaid Services that such essential health benefits meet the limitation described in paragraph (2).CommentsClose CommentsPermalink
(3) NOTICE AND HEARING. In defining the essential health benefits described in paragraph (1), and in revising the benefits under paragraph (4) (h), the Secretary shall provide notice and an opportunity for public comment.105CommentsClose CommentsPermalink
(4) REQUIRED ELEMENTS FOR CONSIDER- ATION. In defining the essential health benefits under paragraph (1), the Secretary shall (A) ensure that such essential health benefits reflect an appropriate balance among the categories described in such subsection, so that benefits are not unduly weighted toward any category; (B) not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life; (C) take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups; (d) ensure that health benefits established as essential not be subject to denial to individuals against their wishes on the basis of the individuals age or expected length of life or of the individuals present or predicted disability, degree of medical dependency, or quality of life;(e)provide that a qualified health plan shall not be treated as providing coverage for106 the essential health benefits described in paragraph (1) unless the plan provides that (i) coverage for emergency department services will be provided without imposing any requirement under the plan for prior authorization of services or any limitation on coverage where the provider of services does not have a contractual relationship with the plan for the providing of services that is more restrictive than the requirements or limitations that apply to emergency department services received from providers who do have such a contractual relationship with the plan; and (ii) if such services are provided out- of-network, the cost-sharing requirementCommentsClose CommentsPermalink
(expressed as a copayment amount or coinsurance rate) is the same requirement that would apply if such services were provided in-network;(f) provide that if a plan described in section 1311 (B) (2) (B) (ii) (relating to stand-alone dental benefits plans) is offered through an Exchange, another health plan offered through such Exchange shall not fail to be treated as a107 qualified health plan solely because the plan does not offer coverage of benefits offered through the stand-alone plan that are otherwise required under paragraph (1) (J); and (G) periodically review the essential health benefits under paragraph (1), and provide a report to Congress and the public that contains (i) an assessment of whether enrollees are facing any difficulty accessing needed services for reasons of coverage or cost; (ii) an assessment of whether the essential health benefits needs to be modified or updated to account for changes in medical evidence or scientific advancement; (iii) information on how the essential health benefits will be modified to address any such gaps in access or changes in the evidence base; (iv) an assessment of the potential of additional or expanded benefits to increase costs and the interactions between the addition or expansion of benefits and reductions in existing benefits to meet actuarial limitations described in paragraph (2); and108 (h) periodically update the essential health benefits under paragraph (1) to address any gaps in access to coverage or changes in the evidence base the Secretary identifies in the review conducted under subparagraph (G).CommentsClose CommentsPermalink
(5) RULE OF CONSTRUCTION. Nothing in this title shall be construed to prohibit a health plan from providing benefits in excess of the essential health benefits described in this subsection. (C) REQUIREMENTS RELATING TO COST-SHARING.CommentsClose CommentsPermalink
(1) ANNUAL LIMITATION ON COST-SHARING. (A) 2014. The cost-sharing incurred under a health plan with respect to self-only coverage or coverage other than self-only coverage for a plan year beginning in 2014 shall not exceed the dollar amounts in effect under section 223 (C) (2) (A) (ii) of the Internal Revenue Code of 1986 for self-only and family coverage, respectively, for taxable years beginning in 2014. (B) 2015 AND LATER. In the case of any plan year beginning in a calendar year after 2014, the limitation under this paragraph shall109 (i) in the case of self-only coverage, be equal to the dollar amount under subparagraph (A) for self-only coverage for plan years beginning in 2014, increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph (4) for the calendar year; and (ii) in the case of other coverage, twice the amount in effect under clause (i). If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50.CommentsClose CommentsPermalink
(2) ANNUAL LIMITATION ON DEDUCTIBLES FOR EMPLOYER-SPONSORED PLANS. (A) IN GENERAL. In the case of a health plan offered in the small group market, the deductible under the plan shall not exceed (i) $2,000 in the case of a plan covering a single individual; and (ii) $4,000 in the case of any other plan. The amounts under clauses (i) and (ii) may be increased by the maximum amount of reimbursement which is reasonably available to a110 participant under a flexible spending arrangement described in section 106 (C) (2) of the Internal Revenue Code of 1986 (determined without regard to any salary reduction arrangement). (B) INDEXING OF LIMITS. In the case of any plan year beginning in a calendar year after 2014 (i) the dollar amount under subparagraph (a) (i) shall be increased by an amount equal to the product of that amount and the premium adjustment percentage under paragraph (4) for the calendar year; and (ii) the dollar amount under subparagraph (a) (ii) shall be increased to an amount equal to twice the amount in effect under subparagraph (a) (i) for plan years beginning in the calendar year, determined after application of clause (i). If the amount of any increase under clause (i) is not a multiple of $50, such increase shall be rounded to the next lowest multiple of $50. (C) ACTUARIAL VALUE. The limitation under this paragraph shall be applied in such a111 manner so as to not affect the actuarial value of any health plan, including a plan in the bronze level. (d) COORDINATION WITH PREVENTIVE LIMITS. Nothing in this paragraph shall be construed to allow a plan to have a deductible under the plan apply to benefits described in section 2713 of the Public Health Service Act.CommentsClose CommentsPermalink
(3) COST-SHARING. In this title (A) IN GENERAL. The term cost-sharing includes (i) deductibles, coinsurance, copayments, or similar charges; and (ii) any other expenditure required of an insured individual which is a qualified medical expense (within the meaning of section 223(d) (2) of the Internal Revenue Code of 1986) with respect to essential health benefits covered under the plan. (B) EXCEPTIONS. Such term does not include premiums, balance billing amounts for non-network providers, or spending for non-covered services.CommentsClose CommentsPermalink
(4) PREMIUM ADJUSTMENT PERCENTAGE. For purposes of paragraphs (1) (B) (i) and (2) (B) (i), the112 premium adjustment percentage for any calendar year is the percentageCommentsClose CommentsPermalink
(if any) by which the average per capita premium for health insurance coverage in the United States for the preceding calendar year (as estimated by the Secretary no later than October 1 of such preceding calendar year) exceeds such average per capita premium for 2013 (as determined by the Secretary). (d) LEVELS OF COVERAGE.CommentsClose CommentsPermalink
(1) LEVELS OF COVERAGE DEFINED. The levels of coverage described in this subsection are as follows: (A) BRONZE LEVEL. A plan in the bronze level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 60 percent of the full actuarial value of the benefits provided under the plan. (B) SILVER LEVEL. A plan in the silver level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 70 percent of the full actuarial value of the benefits provided under the plan. (C) GOLD LEVEL. A plan in the gold level shall provide a level of coverage that is designed to provide benefits that are actuarially equiva113 lent to 80 percent of the full actuarial value of the benefits provided under the plan. (d) PLATINUM LEVEL. A plan in the platinum level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 90 percent of the full actuarial value of the benefits provided under the plan.CommentsClose CommentsPermalink
(2) ACTUARIAL VALUE. (A) IN GENERAL. Under regulations issued by the Secretary, the level of coverage of a plan shall be determined on the basis that the essential health benefits described in subsection (b) shall be provided to a standard population (and without regard to the population the plan may actually provide benefits to). (B) EMPLOYER CONTRIBUTIONS. The Secretary may issue regulations under which employer contributions to a health savings account (within the meaning of section 223 of the Internal Revenue Code of 1986) may be taken into account in determining the level of coverage for a plan of the employer. (C) APPLICATION. In determining under this title, the Public Health Service Act, or the114 Internal Revenue Code of 1986 the percentage of the total allowed costs of benefits provided under a group health plan or health insurance coverage that are provided by such plan or coverage, the rules contained in the regulations under this paragraph shall apply.CommentsClose CommentsPermalink
(3) ALLOWABLE VARIANCE. The Secretary shall develop guidelines to provide for a de minimis variation in the actuarial valuations used in determining the level of coverage of a plan to account for differences in actuarial estimates.CommentsClose CommentsPermalink
(4) PLAN REFERENCE. In this title, any reference to a bronze, silver, gold, or platinum plan shall be treated as a reference to a qualified health plan providing a bronze, silver, gold, or platinum level of coverage, as the case may be.(e)CATASTROPHIC PLAN.CommentsClose CommentsPermalink
(1) IN GENERAL. A health plan not providing a bronze, silver, gold, or platinum level of coverage shall be treated as meeting the requirements of subsection (d) with respect to any plan year if (A) the only individuals who are eligible to enroll in the plan are individuals described in paragraph (2); and (B) the plan provides115 (i) except as provided in clause (ii), the essential health benefits determined under subsection (b), except that the plan provides no benefits for any plan year until the individual has incurred cost-sharing expenses in an amount equal to the annual limitation in effect under subsection (c) (1) for the plan year (except as provided for in section 2713); and (ii) coverage for at least three primary care visits.CommentsClose CommentsPermalink
(2) INDIVIDUALS ELIGIBLE FOR ENROLL- MENT. An individual is described in this paragraph for any plan year if the individual (A) has not attained the age of 30 before the beginning of the plan year; or (B) has a certification in effect for any plan year under this title that the individual is exempt from the requirement under section 5000A of the Internal Revenue Code of 1986 by reason of (i) section 5000A (e)(1) of such Code (relating to individuals without affordable coverage); or116 (ii) section 5000A(e)(5) of such Code (relating to individuals with hardships).CommentsClose CommentsPermalink
(3) RESTRICTION TO INDIVIDUAL MARKET. If a health insurance issuer offers a health plan described in this subsection, the issuer may only offer the plan in the individual market.(f) CHILD-ONLY PLANS. If a qualified health plan is offered through the Exchange in any level of coverage specified under subsection (d), the issuer shall also offer that plan through the Exchange in that level as a plan in which the only enrollees are individuals who, as of the beginning of a plan year, have not attained the age of 21, and such plan shall be treated as a qualified health plan. CommentsClose CommentsPermalink
(A) SPECIAL RULES RELATING TO COVERAGE OF ABORTION SERVICES.CommentsClose CommentsPermalink
(1) VOLUNTARY CHOICE OF COVERAGE OF ABORTION SERVICES. (A) IN GENERAL. Notwithstanding any other provision of this title (or any amendment made by this title), and subject to subparagraphs (C) and (d) (i) nothing in this title (or any amendment made by this title), shall be construed to require a qualified health plan117 to provide coverage of services described in subparagraph (b)(i) or (b)(ii) as part of its essential health benefits for any plan year; and (ii) the issuer of a qualified health plan shall determine whether or not the plan provides coverage of services described in subparagraph (b)(i) or (b)(ii) as part of such benefits for the plan year. (B) ABORTION SERVICES. (i) ABORTIONS FOR WHICH PUBLIC FUNDING IS PROHIBITED. The services described in this clause are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is not permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. (ii) ABORTIONS FOR WHICH PUBLIC FUNDING IS ALLOWED. The services described in this clause are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted, based118 on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. (C) PROHIBITION ON FEDERAL FUNDS FOR ABORTION SERVICES IN COMMUNITY HEALTH INSURANCE OPTION. (i) DETERMINATION BY SEC- RETARY. The Secretary may not determine, in accordance with subparagraph (a) (ii), that the community health insurance option established under section 1323 shall provide coverage of services described in subparagraph (b)(i) as part of benefits for the plan year unless the Secretary (i) assures compliance with the requirements of paragraph (2); (ii) assures, in accordance with applicable provisions of generally accepted accounting requirements, circulars on funds management of the Office of Management and Budget, and guidance on accounting of the Government Accountability Office, that no Federal funds are used for such coverage; and119 (iii) notwithstanding section 1323 (e)(1) (C) or any other provision of this title, takes all necessary steps to assure that the United States does not bear the insurance risk for a community health insurance options coverage of services described in subparagraph (b)(i). (ii) STATE REQUIREMENT. If a State requires, in addition to the essential health benefits required under section 1323(b)(3) (a), coverage of services described in subparagraph (b)(i) for enrollees of a community health insurance option offered in such State, the State shall assure that no funds flowing through or from the community health insurance option, and no other Federal funds, pay or defray the cost of providing coverage of services described in subparagraph (b)(i). The United States shall not bear the insurance risk for a States required coverage of services described in subparagraph (b)(i). (iii) EXCEPTIONS. Nothing in this subparagraph shall apply to coverage of120 services described in subparagraph (b)(ii) by the community health insurance option. Services described in subparagraph (b)(ii) shall be covered to the same extent as such services are covered under title XIX of the Social Security Act. (d) ASSURED AVAILABILITY OF VARIED COVERAGE THROUGH EXCHANGES. (i) IN GENERAL. The Secretary shall assure that with respect to qualified health plans offered in any Exchange established pursuant to this title (i) there is at least one such plan that provides coverage of services described in clauses (i) and (ii) of subparagraph (B); and (II) there is at least one such plan that does not provide coverage of services described in subparagraph (b)(i). (ii) SPECIAL RULES. For purposes of clause (i) (i) a plan shall be treated as described in clause (i) (ii) if the plan does not provide coverage of services121 described in either subparagraph (b)(i) or (b)(ii); and (II) if a State has one Exchange covering more than 1 insurance market, the Secretary shall meet the requirements of clause (i) separately with respect to each such market.CommentsClose CommentsPermalink
(2) PROHIBITION ON THE USE OF FEDERAL FUNDS. (A) IN GENERAL. If a qualified health plan provides coverage of services described in paragraph (1) (B) (i) , the issuer of the plan shall not use any amount attributable to any of the following for purposes of paying for such services: (i) The credit under section 36B of the Internal Revenue Code of 1986 (and the amountCommentsClose CommentsPermalink
(if any) of the advance payment of the credit under section 1412 of the Patient Protection and Affordable Care Act). (ii) Any cost-sharing reduction under section 1402 of thePatient Protection and Affordable Care Act (and the amountCommentsClose CommentsPermalink
(if any) of the advance payment of the reduc122 tion under section 1412 of the Patient Protection and Affordable Care Act). (B) SEGREGATION OF FUNDS. In the case of a plan to which subparagraph (A) applies, the issuer of the plan shall, out of amounts not described in subparagraph (A), segregate an amount equal to the actuarial amounts determined under subparagraph (C) for all enrollees from the amounts described in subparagraph (A). (C) ACTUARIAL VALUE OF OPTIONAL SERVICE COVERAGE. (i) IN GENERAL. The Secretary shall estimate the basic per enrollee, per month cost, determined on an average actuarial basis, for including coverage under a qualified health plan of the services described in paragraph (1) (B) (i) . (ii) CONSIDERATIONS. In making such estimate, the Secretary (i) may take into account the impact on overall costs of the inclusion of such coverage, but may not take into account any cost reduction estimated to result from such services, in123 cluding prenatal care, delivery, or postnatal care; (ii) shall estimate such costs as if such coverage were included for the entire population covered; and (III) may not estimate such a cost at less than $1 per enrollee, per month.CommentsClose CommentsPermalink
(3) PROVIDER CONSCIENCE PROTECTIONS. No individual health care provider or health care facility may be discriminated against because of a willingness or an unwillingness, if doing so is contrary to the religious or moral beliefs of the provider or facility, to provide, pay for, provide coverage of, or refer for abortions. (B) APPLICATION OF STATE AND FEDERAL LAWS REGARDING ABORTION.CommentsClose CommentsPermalink
(1) NO PREEMPTION OF STATE LAWS REGARDING ABORTION. Nothing in this Act shall be construed to preempt or otherwise have any effect on State laws regarding the prohibition of (or requirement of) coverage, funding, or procedural requirements on abortions, including parental notification or consent for the performance of an abortion on a minor.124CommentsClose CommentsPermalink
(2) NO EFFECT ON FEDERAL LAWS REGARDING ABORTION. (A) IN GENERAL. Nothing in this Act shall be construed to have any effect on Federal laws regarding (i) conscience protection; (ii) willingness or refusal to provide abortion; and (iii) discrimination on the basis of the willingness or refusal to provide, pay for, cover, or refer for abortion or to provide or participate in training to provide abortion.CommentsClose CommentsPermalink
(3) NO EFFECT ON FEDERAL CIVIL RIGHTS LAW. Nothing in this subsection shall alter the rights and obligations of employees and employers under title VII of the Civil Rights Act of 1964. (C) APPLICATION OF EMERGENCY SERVICES LAWS. Nothing in this Act shall be construed to relieve any health care provider from providing emergency services as required by State or Federal law, including section 1867 of the Social Security Act (popularly known as EMTALA). CommentsClose CommentsPermalink
(A) DEFINITIONS RELATING TO MARKETS. In this title:125CommentsClose CommentsPermalink
(1) GROUP MARKET. The term group market means the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by an employer.CommentsClose CommentsPermalink
(2) INDIVIDUAL MARKET. The term individual market means the market for health insurance coverage offered to individuals other than in connection with a group health plan.CommentsClose CommentsPermalink
(3) LARGE AND SMALL GROUP MARKETS. The terms large group market and small group market mean the health insurance market under which individuals obtain health insurance coverage (directly or through any arrangement) on behalf of themselves (and their dependents) through a group health plan maintained by a large employer (as defined in subsection (b)(1)) or by a small employer (as defined in subsection (b)(2)), respectively. (B) EMPLOYERS. In this title:CommentsClose CommentsPermalink
(1) LARGE EMPLOYER. The term large employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 101 employees on business days during the pre126 ceding calendar year and who employs at least 1 employee on the first day of the plan year.CommentsClose CommentsPermalink
(2) SMALL EMPLOYER. The term small employer means, in connection with a group health plan with respect to a calendar year and a plan year, an employer who employed an average of at least 1 but not more than 100 employees on business days during the preceding calendar year and who employs at least 1 employee on the first day of the plan year.CommentsClose CommentsPermalink
(3) STATE OPTION TO TREAT 50 EMPLOYEES AS SMALL. In the case of plan years beginning before January 1, 2016, a State may elect to apply this subsection by substituting 51 employees for 101 employees in paragraph (1) and by substituting 50 employees for 100 employees in paragraph (2).CommentsClose CommentsPermalink
(4) RULES FOR DETERMINING EMPLOYER SIZE. For purposes of this subsection (A) APPLICATION OF AGGREGATION RULE FOR EMPLOYERS. All persons treated as a single employer under subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue Code of 1986 shall be treated as 1 employer. (B) EMPLOYERS NOT IN EXISTENCE IN PRECEDING YEAR. In the case of an employer127 which was not in existence throughout the preceding calendar year, the determination of whether such employer is a small or large employer shall be based on the average number of employees that it is reasonably expected such employer will employ on business days in the current calendar year. (C) PREDECESSORS. Any reference in this subsection to an employer shall include a reference to any predecessor of such employer. (d) CONTINUATION OF PARTICIPATION FOR GROWING SMALL EMPLOYERS. If (i) a qualified employer that is a small employer makes enrollment in qualified health plans offered in the small group market available to its employees through an Exchange; and (ii) the employer ceases to be a small employer by reason of an increase in the number of employees of such employer; the employer shall continue to be treated as a small employer for purposes of this subtitle for the period beginning with the increase and ending with the first day on which the employer128 does not make such enrollment available to its employees. (C) SECRETARY. In this title, the term Secretary means the Secretary of Health and Human Services. (d) STATE. In this title, the term State means each of the 50 States and the District of Columbia. CommentsClose CommentsPermalink
(A) ASSISTANCE TO STATES TO ESTABLISH AMERICAN HEALTH BENEFIT EXCHANGES.CommentsClose CommentsPermalink
(1) PLANNING AND ESTABLISHMENT GRANTS. There shall be appropriated to the Secretary, out of any moneys in the Treasury not otherwise appropriated, an amount necessary to enable the Secretary to make awards, not later than 1 year after the date of enactment of this Act, to States in the amount specified in paragraph (2) for the uses described in paragraph (3).CommentsClose CommentsPermalink
(2) AMOUNT SPECIFIED. For each fiscal year, the Secretary shall determine the total amount that the Secretary will make available to each State for grants under this subsection.129CommentsClose CommentsPermalink
(3) USE OF FUNDS. A State shall use amounts awarded under this subsection for activities (including planning activities) related to establishing an American Health Benefit Exchange, as described in subsection (b).CommentsClose CommentsPermalink
(4) RENEWABILITY OF GRANT. (A) IN GENERAL. Subject to subsection (d) (4), the Secretary may renew a grant awarded under paragraph (1) if the State recipient of such grant (i) is making progress, as determined by the Secretary, toward (i) establishing an Exchange; and (II) implementing the reforms described in subtitles A and C (and the amendments made by such subtitles); and (ii) is meeting such other benchmarks as the Secretary may establish. (B) LIMITATION. No grant shall be awarded under this subsection after January 1, 2015.CommentsClose CommentsPermalink
(5) TECHNICAL ASSISTANCE TO FACILITATE PARTICIPATION IN SHOP EXCHANGES. The Sec130 retary shall provide technical assistance to States to facilitate the participation of qualified small businesses in such States in SHOP Exchanges. (B) AMERICAN HEALTH BENEFIT EXCHANGES.CommentsClose CommentsPermalink
(1) IN GENERAL. Each State shall, not later than January 1, 2014, establish an American Health Benefit Exchange (referred to in this title as an Exchange) for the State that (A) facilitates the purchase of qualified health plans; (B) provides for the establishment of a Small Business Health Options Program (in this title referred to as a SHOP Exchange) that is designed to assist qualified employers in the State who are small employers in facilitating the enrollment of their employees in qualified health plans offered in the small group market in the State; and (C) meets the requirements of subsection (d). (2) MERGER OF INDIVIDUAL AND SHOP EXCHANGES. A State may elect to provide only one Exchange in the State for providing both Exchange and SHOP Exchange services to both qualified individuals and qualified small employers, but only if the131 Exchange has adequate resources to assist such individuals and employers. (C) RESPONSIBILITIES OF THE SECRETARY.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary shall, by regulation, establish criteria for the certification of health plans as qualified health plans. Such criteria shall require that, to be certified, a plan shall, at a minimum (A) meet marketing requirements, and not employ marketing practices or benefit designs that have the effect of discouraging the enrollment in such plan by individuals with significant health needs; (B) ensure a sufficient choice of providers (in a manner consistent with applicable network adequacy provisions under section 2702 (c) of the Public Health Service Act), and provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers; (C) include within health insurance plan networks those essential community providers, where available, that serve predominately low- income, medically-underserved individuals, such as health care providers defined in section132 340B (A) (4) of the Public Health Service Act and providers described in section 1927 (C) (1) (D)(i) (iv) of the Social Security Act as set forth by section 221 of Public Law 111- 8, except that nothing in this subparagraph shall be construed to require any health plan to provide coverage for any specific medical procedure; (d) (i) be accredited with respect to local performance on clinical quality measures such as the Healthcare Effectiveness Data and Information Set, patient experience ratings on a standardized Consumer Assessment of Healthcare Providers and Systems survey, as well as consumer access, utilization management, quality assurance, provider credentialing, complaints and appeals, network adequacy and access, and patient information programs by any entity recognized by the Secretary for the accreditation of health insurance issuers or plansCommentsClose CommentsPermalink
(so long as any such entity has transparent and rigorous methodological and scoring criteria); or (ii) receive such accreditation within a period established by an Exchange for such ac133 creditation that is applicable to all qualified health plans;(e)implement a quality improvement strategy described in subsection (g)CommentsClose CommentsPermalink
(1);(f) utilize a uniform enrollment form that qualified individuals and qualified employers may useCommentsClose CommentsPermalink
(either electronically or on paper) in enrolling in qualified health plans offered through such Exchange, and that takes into account criteria that the National Association of Insurance Commissioners develops and submits to the Secretary; (g) utilize the standard format established for presenting health benefits plan options; and (H) provide information to enrollees and prospective enrollees, and to each Exchange in which the plan is offered, on any quality measures for health plan performance endorsed under section 399JJ of the Public Health Service Act, as applicable.CommentsClose CommentsPermalink
(2) RULE OF CONSTRUCTION. Nothing in paragraph (1) (C) shall be construed to require a qualified health plan to contract with a provider described in such paragraph if such provider refuses to134 accept the generally applicable payment rates of such plan.CommentsClose CommentsPermalink
(3) RATING SYSTEM. The Secretary shall develop a rating system that would rate qualified health plans offered through an Exchange in each benefits level on the basis of the relative quality and price. The Exchange shall include the quality rating in the information provided to individuals and employers through the Internet portal established under paragraph (4).CommentsClose CommentsPermalink
(4) INTERNET PORTALS. The Secretary shall (A) continue to operate, maintain, and update the Internet portal developed under section 1103 (A) and to assist States in developing and maintaining their own such portal; and (B) make available for use by Exchanges a model template for an Internet portal that may be used to direct qualified individuals and qualified employers to qualified health plans, to assist such individuals and employers in determining whether they are eligible to participate in an Exchange or eligible for a premium tax credit or cost-sharing reduction, and to present standardized information (including quality rat135 ings) regarding qualified health plans offered through an Exchange to assist consumers in making easy health insurance choices. Such template shall include, with respect to each qualified health plan offered through the Exchange in each rating area, access to the uniform outline of coverage the plan is required to provide under section 2716 of the Public Health Service Act and to a copy of the plans written policy.CommentsClose CommentsPermalink
(5) ENROLLMENT PERIODS. The Secretary shall require an Exchange to provide for (A) an initial open enrollment, as determined by the Secretary (such determination to be made not later than July 1, 2012); (B) annual open enrollment periods, as determined by the Secretary for calendar years after the initial enrollment period; (C) special enrollment periods specified in section 9801 of the Internal Revenue Code of 1986 and other special enrollment periods under circumstances similar to such periods under part D of title XVIII of the Social Security Act; and136 (d) special monthly enrollment periods for Indians (as defined in section 4 of the Indian Health Care Improvement Act). (d) REQUIREMENTS.CommentsClose CommentsPermalink
(1) IN GENERAL. An Exchange shall be a governmental agency or nonprofit entity that is established by a State.CommentsClose CommentsPermalink
(2) OFFERING OF COVERAGE. (A) IN GENERAL. An Exchange shall make available qualified health plans to qualified individuals and qualified employers. (B) LIMITATION. (i) IN GENERAL. An Exchange may not make available any health plan that is not a qualified health plan. (ii) OFFERING OF STAND-ALONE DENTAL BENEFITS. Each Exchange within a State shall allow an issuer of a plan that only provides limited scope dental benefits meeting the requirements of section 9832 (C) (2) (a) of the Internal Revenue Code of 1986 to offer the plan through the ExchangeCommentsClose CommentsPermalink
(either separately or in conjunction with a qualified health plan) if the plan provides pediatric dental benefits137 meeting the requirements of section 1302(b)(1) (J)).CommentsClose CommentsPermalink
(3) RULES RELATING TO ADDITIONAL REQUIRED BENEFITS. (A) IN GENERAL. Except as provided in subparagraph (B), an Exchange may make available a qualified health plan notwithstanding any provision of law that may require benefits other than the essential health benefits specified under section 1302 (b). (B) STATES MAY REQUIRE ADDITIONAL BENEFITS. (i) IN GENERAL. Subject to the requirements of clause (ii), a State may require that a qualified health plan offered in such State offer benefits in addition to the essential health benefits specified under section 1302 (b). (ii) STATE MUST ASSUME COST. A State shall make payments to or on behalf of an individual eligible for the premium tax credit under section 36B of the Internal Revenue Code of 1986 and any cost- sharing reduction under section 1402 to defray the cost to the individual of any ad138 ditional benefits described in clause (i) which are not eligible for such credit or reduction under section 36B(b)(3) (d) of such Code and section 1402 (C) (4).CommentsClose CommentsPermalink
(4) FUNCTIONS. An Exchange shall, at a minimum (A) implement procedures for the certification, recertification, and decertification, consistent with guidelines developed by the Secretary under subsection (c), of health plans as qualified health plans; (B) provide for the operation of a toll-free telephone hotline to respond to requests for assistance; (C) maintain an Internet website through which enrollees and prospective enrollees of qualified health plans may obtain standardized comparative information on such plans; (d) assign a rating to each qualified health plan offered through such Exchange in accordance with the criteria developed by the Secretary under subsection (c) (3);(e)utilize a standardized format for presenting health benefits plan options in the Exchange, including the use of the uniform outline139 of coverage established under section 2715 of the Public Health Service Act;(f) in accordance with section 1413, inform individuals of eligibility requirements for the medicaid program under title XIX of the Social Security Act, the CHIP program under title XXI of such Act, or any applicable State or local public program and if through screening of the application by the Exchange, the Exchange determines that such individuals are eligible for any such program, enroll such individuals in such program; (g) establish and make available by electronic means a calculator to determine the actual cost of coverage after the application of any premium tax credit under section 36B of the Internal Revenue Code of 1986 and any cost-sharing reduction under section 1402; (h) subject to section 1411, grant a certification attesting that, for purposes of the individual responsibility penalty under section 5000A of the Internal Revenue Code of 1986, an individual is exempt from the individual requirement or from the penalty imposed by such section because140 (i) there is no affordable qualified health plan available through the Exchange, or the individuals employer, covering the individual; or (ii) the individual meets the requirements for any other such exemption from the individual responsibility requirement or penalty; (i) transfer to the Secretary of the Treasury (i) a list of the individuals who are issued a certification under subparagraph (H), including the name and taxpayer identification number of each individual; (ii) the name and taxpayer identification number of each individual who was an employee of an employer but who was determined to be eligible for the premium tax credit under section 36B of the Internal Revenue Code of 1986 because (i) the employer did not provide minimum essential coverage; or (II) the employer provided such minimum essential coverage but it was determined under section141 36B (C) (2) (c) of such Code to either be unaffordable to the employee or not provide the required minimum actuarial value; and (iii) the name and taxpayer identification number of each individual who notifies the Exchange under section 1411 (B) (4) that they have changed employers and of each individual who ceases coverage under a qualified health plan during a plan year (and the effective date of such cessation); (j) provide to each employer the name of each employee of the employer described in subparagraph (I) (ii) who ceases coverage under a qualified health plan during a plan year (and the effective date of such cessation); and (K) establish the Navigator program described in subsection (i).CommentsClose CommentsPermalink
(5) FUNDING LIMITATIONS. (A) NO FEDERAL FUNDS FOR CONTINUED OPERATIONS. In establishing an Exchange under this section, the State shall ensure that such Exchange is self-sustaining beginning on January 1, 2015, including allowing the Exchange to charge assessments or user fees to142 participating health insurance issuers, or to otherwise generate funding, to support its operations. (B) PROHIBITING WASTEFUL USE OF FUNDS. In carrying out activities under this subsection, an Exchange shall not utilize any funds intended for the administrative and operational expenses of the Exchange for staff retreats, promotional giveaways, excessive executive compensation, or promotion of Federal or State legislative and regulatory modifications.CommentsClose CommentsPermalink
(6) CONSULTATION. An Exchange shall consult with stakeholders relevant to carrying out the activities under this section, including (A) health care consumers who are enrollees in qualified health plans; (B) individuals and entities with experience in facilitating enrollment in qualified health plans; (C) representatives of small businesses and self-employed individuals; (d) State Medicaid offices; and (E) advocates for enrolling hard to reach populations.143CommentsClose CommentsPermalink
(7) PUBLICATION OF COSTS. An Exchange shall publish the average costs of licensing, regulatory fees, and any other payments required by the Exchange, and the administrative costs of such Exchange, on an Internet website to educate consumers on such costs. Such information shall also include monies lost to waste, fraud, and abuse.(e)CERTIFICATION.CommentsClose CommentsPermalink
(1) IN GENERAL. An Exchange may certify a health plan as a qualified health plan if (A) such health plan meets the requirements for certification as promulgated by the Secretary under subsection (c) (1); and (B) the Exchange determines that making available such health plan through such Exchange is in the interests of qualified individuals and qualified employers in the State or States in which such Exchange operates, except that the Exchange may not exclude a health plan (i) on the basis that such plan is a fee-for-service plan; (ii) through the imposition of premium price controls; or144 (iii) on the basis that the plan provides treatments necessary to prevent patients deaths in circumstances the Exchange determines are inappropriate or too costly.CommentsClose CommentsPermalink
(2) PREMIUM CONSIDERATIONS. The Exchange shall require health plans seeking certification as qualified health plans to submit a justification for any premium increase prior to implementation of the increase. Such plans shall prominently post such information on their websites. The Exchange may take this information, and the information and the recommendations provided to the Exchange by the State under section 2794(b)(1) of the Public Health Service Act (relating to patterns or practices of excessive or unjustified premium increases), into consideration when determining whether to make such health plan available through the Exchange. The Exchange shall take into account any excess of premium growth outside the Exchange as compared to the rate of such growth inside the Exchange, including information reported by the States.(f) FLEXIBILITY.145CommentsClose CommentsPermalink
(1) REGIONAL OR OTHER INTERSTATE EX- CHANGES. An Exchange may operate in more than one State if (A) each State in which such Exchange operates permits such operation; and (B) the Secretary approves such regional or interstate Exchange.CommentsClose CommentsPermalink
(2) SUBSIDIARY EXCHANGES. A State may establish one or more subsidiary Exchanges if (A) each such Exchange serves a geographically distinct area; and (B) the area served by each such Exchange is at least as large as a rating area described in section 2701 (a) of the Public Health Service Act.CommentsClose CommentsPermalink
(3) AUTHORITY TO CONTRACT. (A) IN GENERAL. A State may elect to authorize an Exchange established by the State under this section to enter into an agreement with an eligible entity to carry out 1 or more responsibilities of the Exchange. (B) ELIGIBLE ENTITY. In this paragraph, the term eligible entity means (i) a person (I) incorporated under, and subject to the laws of, 1 or more States; (ii) that has demonstrated experience on a State or regional basis in the individual and small group health insurance markets and in benefits coverage; and (III) that is not a health insurance issuer or that is treated under subsection (a) or (b) of section 52 of the Internal Revenue Code of 1986 as a member of the same controlled group of corporations (or under common control with) as a health insurance issuer; or (ii) the State medicaid agency under title XIX of the Social Security Act. (g) REWARDING QUALITY THROUGH MARKET- BASED INCENTIVES.CommentsClose CommentsPermalink
(1) STRATEGY DESCRIBED. A strategy described in this paragraph is a payment structure that provides increased reimbursement or other incentives for (A) improving health outcomes through the implementation of activities that shall include quality reporting, effective case management, care coordination, chronic disease management, medication and care compliance initiatives, including through the use of the medical home model, for treatment or services under the plan or coverage; (B) the implementation of activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; (C) the implementation of activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology under the plan or coverage; and (D) the implementation of wellness and health promotion activities.CommentsClose CommentsPermalink
(2) GUIDELINES. The Secretary, in consultation with experts in health care quality and stakeholders, shall develop guidelines concerning the matters described in paragraph (1).CommentsClose CommentsPermalink
(3) REQUIREMENTS. The guidelines developed under paragraph (2) shall require the periodic reporting to the applicable Exchange of the activities that a qualified health plan has conducted to implement a strategy described in paragraph (1). (h) QUALITY IMPROVEMENT.CommentsClose CommentsPermalink
(1) ENHANCING PATIENT SAFETY. Beginning on January 1, 2015, a qualified health plan may contract with (A) a hospital with greater than 50 beds only if such hospital (i) utilizes a patient safety evaluation system as described in part C of title IX of the Public Health Service Act; and (ii) implements a mechanism to ensure that each patient receives a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional; or (B) a health care provider only if such provider implements such mechanisms to improve health care quality as the Secretary may by regulation require.CommentsClose CommentsPermalink
(2) EXCEPTIONS. The Secretary may establish reasonable exceptions to the requirements described in paragraph (1).CommentsClose CommentsPermalink
(3) ADJUSTMENT. The Secretary may by regulation adjust the number of beds described in paragraph (1) (A). (i) NAVIGATORS.CommentsClose CommentsPermalink
(1) IN GENERAL. An Exchange shall establish a program under which it awards grants to entities described in paragraph (2) to carry out the duties described in paragraph (3).CommentsClose CommentsPermalink
(2) ELIGIBILITY. (A) IN GENERAL. To be eligible to receive a grant under paragraph (1), an entity shall demonstrate to the Exchange involved that the entity has existing relationships, or could readily establish relationships, with employers and employees, consumers (including uninsured and underinsured consumers), or self-employed individuals likely to be qualified to enroll in a qualified health plan. (B) tYPES. Entities described in subparagraph (A) may include trade, industry, and150 professional associations, commercial fishing industry organizations, ranching and farming organizations, community and consumer-focused nonprofit groups, chambers of commerce, unions, small business development centers, other licensed insurance agents and brokers, and other entities that (i) are capable of carrying out the duties described in paragraph (3); (ii) meet the standards described in paragraph (4); and (iii) provide information consistent with the standards developed under paragraph (5). (3) DUTIES. An entity that serves as a navigator under a grant under this subsection shall (A) conduct public education activities to raise awareness of the availability of qualified health plans; (B) distribute fair and impartial information concerning enrollment in qualified health plans, and the availability of premium tax credits under section 36B of the Internal Revenue Code of 1986 and cost-sharing reductions under section 1402;151 and (C) facilitate enrollment in qualified health plans; (d) provide referrals to any applicable office of health insurance consumer assistance or health insurance ombudsman established under section 2793 of the Public Health Service Act, or any other appropriate State agency or agencies, for any enrollee with a grievance, complaint, or question regarding their health plan, coverage, or a determination under such plan or coverage; and (E) provide information in a manner that is culturally and linguistically appropriate to the needs of the population being served by the Exchange or Exchanges.CommentsClose CommentsPermalink
(4) STANDARDS. (A) IN GENERAL. The Secretary shall establish standards for navigators under this subsection, including provisions to ensure that any private or public entity that is selected as a navigator is qualified, and licensed if appropriate, to engage in the navigator activities described in this subsection and to avoid conflicts of interest. Under such standards, a navigator shall not152 (i) be a health insurance issuer; or (ii) receive any consideration directly or indirectly from any health insurance issuer in connection with the enrollment of any qualified individuals or employees of a qualified employer in a qualified health plan.CommentsClose CommentsPermalink
(5) FAIR AND IMPARTIAL INFORMATION AND SERVICES. The Secretary, in collaboration with States, shall develop standards to ensure that information made available by navigators is fair, accurate, and impartial.CommentsClose CommentsPermalink
(6) FUNDING. Grants under this subsection shall be made from the operational funds of the Exchange and not Federal funds received by the State to establish the Exchange. (j) APPLICABILITY OF MENTAL HEALTH PARITY. Section 2726 of the Public Health Service Act shall apply to qualified health plans in the same manner and to the same extent as such section applies to health insurance issuers and group health plans. (k) CONFLICT. An Exchange may not establish rules that conflict with or prevent the application of regulations promulgated by the Secretary under this subtitle.153 CommentsClose CommentsPermalink
(A) CHOICE.CommentsClose CommentsPermalink
(1) QUALIFIED INDIVIDUALS. A qualified individual may enroll in any qualified health plan available to such individual.CommentsClose CommentsPermalink
(2) QUALIFIED EMPLOYERS. (A) EMPLOYER MAY SPECIFY LEVEL. A qualified employer may provide support for coverage of employees under a qualified health plan by selecting any level of coverage under section 1302 (d) to be made available to employees through an Exchange. (B) EMPLOYEE MAY CHOOSE PLANS WITHIN A LEVEL. Each employee of a qualified employer that elects a level of coverage under subparagraph (A) may choose to enroll in a qualified health plan that offers coverage at that level. (B) PAYMENT OF PREMIUMS BY QUALIFIED INDIVIDUALS. A qualified individual enrolled in any qualified health plan may pay any applicable premium owed by such individual to the health insurance issuer issuing such qualified health plan. (C) SINGLE RISK POOL.CommentsClose CommentsPermalink
(1) INDIVIDUAL MARKET. A health insurance issuer shall consider all enrollees in all health plans154 (other than grandfathered health plans) offered by such issuer in the individual market, including those enrollees who do not enroll in such plans through the Exchange, to be members of a single risk pool.CommentsClose CommentsPermalink
(2) SMALL GROUP MARKET. A health insurance issuer shall consider all enrollees in all health plans (other than grandfathered health plans) offered by such issuer in the small group market, including those enrollees who do not enroll in such plans through the Exchange, to be members of a single risk pool.CommentsClose CommentsPermalink
(3) MERGER OF MARKETS. A State may require the individual and small group insurance markets within a State to be merged if the State determines appropriate.CommentsClose CommentsPermalink
(4) STATE LAW. A State law requiring grand- fathered health plans to be included in a pool described in paragraph (1) or (2) shall not apply. (d) EMPOWERING CONSUMER CHOICE.CommentsClose CommentsPermalink
(1) CONTINUED OPERATION OF MARKET OUTSIDE EXCHANGES. Nothing in this title shall be construed to prohibit (A) a health insurance issuer from offering outside of an Exchange a health plan to a qualified individual or qualified employer; and155 (B) a qualified individual from enrolling in, or a qualified employer from selecting for its employees, a health plan offered outside of an Exchange.CommentsClose CommentsPermalink
(2) CONTINUED OPERATION OF STATE BENEFIT REQUIREMENTS. Nothing in this title shall be construed to terminate, abridge, or limit the operation of any requirement under State law with respect to any policy or plan that is offered outside of an Exchange to offer benefits.CommentsClose CommentsPermalink
(3) VOLUNTARY NATURE OF AN EXCHANGE. (A) CHOICE TO ENROLL OR NOT TO ENROLL. Nothing in this title shall be construed to restrict the choice of a qualified individual to enroll or not to enroll in a qualified health plan or to participate in an Exchange. (B) PROHIBITION AGAINST COMPELLED ENROLLMENT. Nothing in this title shall be construed to compel an individual to enroll in a qualified health plan or to participate in an Exchange. (C) INDIVIDUALS ALLOWED TO ENROLL IN ANY PLAN. A qualified individual may enroll in any qualified health plan, except that in the case of a catastrophic plan described in section156 1302(e), a qualified individual may enroll in the plan only if the individual is eligible to enroll in the plan under section 1302 (e)(2). (d) MEMBERS OF CONGRESS IN THE EXCHANGE. (i) REQUIREMENT. Notwithstanding any other provision of law, after the effective date of this subtitle, the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are (i) created under this Act (or an amendment made by this Act); or (II) offered through an Exchange established under this Act (or an amendment made by this Act). (ii) DEFINITIONS. In this section: (i) MEMBER OF CONGRESS. The term Member of Congress means any member of the House of Representatives or the Senate.157 (ii) CONGRESSIONAL STAFF. The term congressional staff means all full-time and part-time employees employed by the official office of a Member of Congress, whether in Washington, DC or outside of Washington, DC.CommentsClose CommentsPermalink
(4) NO PENALTY FOR TRANSFERRING TO MINIMUM ESSENTIAL COVERAGE OUTSIDE EXCHANGE. An Exchange, or a qualified health plan offered through an Exchange, shall not impose any penalty or other fee on an individual who cancels enrollment in a plan because the individual becomes eligible for minimum essential coverage (as defined in section 5000A(f) of the Internal Revenue Code of 1986 without regard to paragraph (1) (C) or (D) thereof) or such coverage becomes affordable (within the meaning of section 36B (C) (2) (c) of such Code).(e)ENROLLMENT THROUGH AGENTS OR BRO- KERS. The Secretary shall establish procedures under which a State may allow agents or brokersCommentsClose CommentsPermalink
(1) to enroll individuals in any qualified health plans in the individual or small group market as soon as the plan is offered through an Exchange in the State; and158CommentsClose CommentsPermalink
(2) to assist individuals in applying for premium tax credits and cost-sharing reductions for plans sold through an Exchange. Such procedures may include the establishment of rate schedules for broker commissions paid by health benefits plans offered through an exchange.(f) QUALIFIED INDIVIDUALS AND EMPLOYERS; ACCESS LIMITED TO CITIZENS AND LAWFUL RESIDENTS.CommentsClose CommentsPermalink
(1) QUALIFIED INDIVIDUALS. In this title: (A) IN GENERAL. The term qualified individual means, with respect to an Exchange, an individual who (i) is seeking to enroll in a qualified health plan in the individual market offered through the Exchange; and (ii) resides in the State that established the Exchange (except with respect to territorial agreements under section 1312(f)). (B) INCARCERATED INDIVIDUALS EX- CLUDED. An individual shall not be treated as a qualified individual if, at the time of enrollment, the individual is incarcerated, other than incarceration pending the disposition of charges.159CommentsClose CommentsPermalink
(2) QUALIFIED EMPLOYER. In this title: (A) IN GENERAL. The term qualified employer means a small employer that elects to make all full-time employees of such employer eligible for 1 or more qualified health plans offered in the small group market through an Exchange that offers qualified health plans. (B) EXTENSION TO LARGE GROUPS. (i) IN GENERAL. Beginning in 2017, each State may allow issuers of health insurance coverage in the large group market in the State to offer qualified health plans in such market through an Exchange. Nothing in this subparagraph shall be construed as requiring the issuer to offer such plans through an Exchange. (ii) LARGE EMPLOYERS ELIGIBLE. If a State under clause (i) allows issuers to offer qualified health plans in the large group market through an Exchange, the term qualified employer shall include a large employer that elects to make all full- time employees of such employer eligible for 1 or more qualified health plans offered160 in the large group market through the Exchange.CommentsClose CommentsPermalink
(3) ACCESS LIMITED TO LAWFUL RESIDENTS. If an individual is not, or is not reasonably expected to be for the entire period for which enrollment is sought, a citizen or national of the United States or an alien lawfully present in the United States, the individual shall not be treated as a qualified individual and may not be covered under a qualified health plan in the individual market that is offered through an Exchange. CommentsClose CommentsPermalink
(A) ACCOUNTING FOR EXPENDITURES.CommentsClose CommentsPermalink
(1) IN GENERAL. An Exchange shall keep an accurate accounting of all activities, receipts, and expenditures and shall annually submit to the Secretary a report concerning such accountings.CommentsClose CommentsPermalink
(2) INVESTIGATIONS. The Secretary, in coordination with the Inspector General of the Department of Health and Human Services, may investigate the affairs of an Exchange, may examine the properties and records of an Exchange, and may require periodic reports in relation to activities undertaken by an Exchange. An Exchange shall fully co161 operate in any investigation conducted under this paragraph.CommentsClose CommentsPermalink
(3) AUDITS. An Exchange shall be subject to annual audits by the Secretary.CommentsClose CommentsPermalink
(4) PATTERN OF ABUSE. If the Secretary determines that an Exchange or a State has engaged in serious misconduct with respect to compliance with the requirements of, or carrying out of activities required under, this title, the Secretary may rescind from payments otherwise due to such State involved under this or any other Act administered by the Secretary an amount not to exceed 1 percent of such payments per year until corrective actions are taken by the State that are determined to be adequate by the Secretary.CommentsClose CommentsPermalink
(5) PROTECTIONS AGAINST FRAUD AND ABUSE. With respect to activities carried out under this title, the Secretary shall provide for the efficient and non-discriminatory administration of Exchange activities and implement any measure or procedure that (A) the Secretary determines is appropriate to reduce fraud and abuse in the administration of this title; and162 (B) the Secretary has authority to implement under this title or any other Act.CommentsClose CommentsPermalink
(6) APPLICATION OF THE FALSE CLAIMS ACT. (A) IN GENERAL. Payments made by, through, or in connection with an Exchange are subject to the False Claims ActCommentsClose CommentsPermalink
(31 U.S.C. 3729 et seq.) if those payments include any Federal funds. Compliance with the requirements of this Act concerning eligibility for a health insurance issuer to participate in the Exchange shall be a material condition of an issuers entitlement to receive payments, including payments of premium tax credits and cost- sharing reductions, through the Exchange. (B) DAMAGES. Notwithstanding paragraph (1) of section 3729 (a) of title 31, United States Code, and subject to paragraph (2) of such section, the civil penalty assessed under the False Claims Act on any person found liable under such Act as described in subparagraph (A) shall be increased by not less than 3 times and not more than 6 times the amount of damages which the Government sustains because of the act of that person.163 (B) GAO OVERSIGHT. Not later than 5 years after the first date on which Exchanges are required to be operational under this title, the Comptroller General shall conduct an ongoing study of Exchange activities and the enrollees in qualified health plans offered through Exchanges. Such study shall reviewCommentsClose CommentsPermalink
(1) the operations and administration of Exchanges, including surveys and reports of qualified health plans offered through Exchanges and on the experience of such plans (including data on enrollees in Exchanges and individuals purchasing health insurance coverage outside of Exchanges), the expenses of Exchanges, claims statistics relating to qualified health plans, complaints data relating to such plans, and the manner in which Exchanges meet their goals;CommentsClose CommentsPermalink
(2) any significant observations regarding the utilization and adoption of Exchanges;CommentsClose CommentsPermalink
(3) where appropriate, recommendations for improvements in the operations or policies of Exchanges; and (4) how many physicians, by area and specialty, are not taking or accepting new patients enrolled in Federal Government health care programs, and the164 adequacy of provider networks of Federal Government health care programs. CommentsClose CommentsPermalink
(A) ESTABLISHMENT OF STANDARDS.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary shall, as soon as practicable after the date of enactment of this Act, issue regulations setting standards for meeting the requirements under this title, and the amendments made by this title, with respect to (A) the establishment and operation of Exchanges (including SHOP Exchanges); (B) the offering of qualified health plans through such Exchanges; (C) the establishment of the reinsurance and risk adjustment programs under part V; and (D) such other requirements as the Secretary determines appropriate. The preceding sentence shall not apply to standards for requirements under subtitles A and C (and the amendments made by such subtitles) for which the165 Secretary issues regulations under the Public Health Service Act.CommentsClose CommentsPermalink
(2) CONSULTATION. In issuing the regulations under paragraph (1), the Secretary shall consult with the National Association of Insurance Commissioners and its members and with health insurance issuers, consumer organizations, and such other individuals as the Secretary selects in a manner designed to ensure balanced representation among interested parties. (B) STATE ACTION. Each State that elects, at such time and in such manner as the Secretary may prescribe, to apply the requirements described in subsection (a) shall, not later than January 1, 2014, adopt and have in effectCommentsClose CommentsPermalink
(1) the Federal standards established under subsection (a); or (2) a State law or regulation that the Secretary determines implements the standards within the State. (C) FAILURE TO ESTABLISH EXCHANGE OR IMPLEMENT REQUIREMENTS.CommentsClose CommentsPermalink
(1) IN GENERAL. If (A) a State is not an electing State under subsection (b); or166 (B) the Secretary determines, on or before January 1, 2013, that an electing State (i) will not have any required Exchange operational by January 1, 2014; or (ii) has not taken the actions the Secretary determines necessary to implement (i) the other requirements set forth in the standards under subsection (a); or (II) the requirements set forth in subtitles A and C and the amendments made by such subtitles; the Secretary shall (directly or through agreement with a not-for-profit entity) establish and operate such Exchange within the State and the Secretary shall take such actions as are necessary to implement such other requirements.CommentsClose CommentsPermalink
(2) ENFORCEMENT AUTHORITY. The provisions of section 2736(b) of the Public Health Services Act shall apply to the enforcement under paragraph (1) of requirements of subsection (a) (1) (without regard to any limitation on the application of those provisions to group health plans).167 (d) NO INTERFERENCE WITH STATE REGULATORY AUTHORITY. Nothing in this title shall be construed to preempt any State law that does not prevent the application of the provisions of this title.(e)PRESUMPTION FOR CERTAIN STATE-OPERATED EXCHANGES.CommentsClose CommentsPermalink
(1) IN GENERAL. In the case of a State operating an Exchange before January 1, 2010, and which has insured a percentage of its population not less than the percentage of the population projected to be covered nationally after the implementation of this Act, that seeks to operate an Exchange under this section, the Secretary shall presume that such Exchange meets the standards under this section unless the Secretary determines, after completion of the process established under paragraph (2), that the Exchange does not comply with such standards.CommentsClose CommentsPermalink
(2) PROCESS. The Secretary shall establish a process to work with a State described in paragraph (1) to provide assistance necessary to assist the States Exchange in coming into compliance with the standards for approval under this section.168 CommentsClose CommentsPermalink
(A) ESTABLISHMENT OF PROGRAM.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary shall establish a program to carry out the purposes of this section to be known as the Consumer Operated and Oriented Plan (co-OP) program.CommentsClose CommentsPermalink
(2) PURPOSE. It is the purpose of the CO-OP program to foster the creation of qualified nonprofit health insurance issuers to offer qualified health plans in the individual and small group markets in the States in which the issuers are licensed to offer such plans. (B) LOANS AND GRANTS UNDER THE CO-OP PROGRAM.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary shall provide through the CO-OP program for the awarding to persons applying to become qualified nonprofit health insurance issuers of (A) loans to provide assistance to such person in meeting its start-up costs; and (B) grants to provide assistance to such person in meeting any solvency requirements of States in which the person seeks to be licensed to issue qualified health plans.169CommentsClose CommentsPermalink
(2) REQUIREMENTS FOR AWARDING LOANS AND GRANTS. (A) IN GENERAL. In awarding loans and grants under the CO-OP program, the Secretary shall (i) take into account the recommendations of the advisory board established under paragraph (3); (ii) give priority to applicants that will offer qualified health plans on a Statewide basis, will utilize integrated care models, and have significant private support; and (iii) ensure that there is sufficient funding to establish at least 1 qualified nonprofit health insurance issuer in each State, except that nothing in this clause shall prohibit the Secretary from funding the establishment of multiple qualified nonprofit health insurance issuers in any State if the funding is sufficient to do so. (B) STATES WITHOUT ISSUERS IN PRO- GRAM. If no health insurance issuer applies to be a qualified nonprofit health insurance issuer within a State, the Secretary may use amounts appropriated under this section for the award170 ing of grants to encourage the establishment of a qualified nonprofit health insurance issuer within the State or the expansion of a qualified nonprofit health insurance issuer from another State to the State. (C) AGREEMENT. (i) IN GENERAL. The Secretary shall require any person receiving a loan or grant under the CO-OP program to enter into an agreement with the Secretary which requires such person to meet (and to continue to meet) (i) any requirement under this section for such person to be treated as a qualified nonprofit health insurance issuer; and (II) any requirements contained in the agreement for such person to receive such loan or grant. (ii) RESTRICTIONS ON USE OF FEDERAL FUNDS. The agreement shall include a requirement that no portion of the funds made available by any loan or grant under this section may be used171 (i) for carrying on propaganda, or otherwise attempting, to influence legislation; or (II) for marketing. Nothing in this clause shall be construed to allow a person to take any action prohibited by section 501 (C) (29) of the Internal Revenue Code of 1986. (iii) FAILURE TO MEET REQUIRE- MENTS. If the Secretary determines that a person has failed to meet any requirement described in clause (i) or (ii) and has failed to correct such failure within a reasonable period of time of when the person first knows (or reasonably should have known) of such failure, such person shall repay to the Secretary an amount equal to the sum of (I) 110 percent of the aggregate amount of loans and grants received under this section; plus (ii) interest on the aggregate amount of loans and grants received under this section for the period the loans or grants were outstanding.172 The Secretary shall notify the Secretary of the Treasury of any determination under this section of a failure that results in the termination of an issuers tax-exempt status under section 501 (C) (29) of such Code. (d) TIME FOR AWARDING LOANS AND GRANTS. The Secretary shall not later than July 1, 2013, award the loans and grants under the CO-OP program and begin the distribution of amounts awarded under such loans and grants.CommentsClose CommentsPermalink
(3) ADVISORY BOARD. (A) IN GENERAL. The advisory board under this paragraph shall consist of 15 members appointed by the Comptroller General of the United States from among individuals with qualifications described in section 1805 (C) (2) of the Social Security Act. (B) RULES RELATING TO APPOINTMENTS. (i) STANDARDS. Any individual appointed under subparagraph (A) shall meet ethics and conflict of interest standards protecting against insurance industry involvement and interference.173 (ii) ORIGINAL APPOINTMENTS. The original appointment of board members under subparagraph (a) (ii) shall be made no later than 3 months after the date of enactment of this Act. (C) VACANCY. Any vacancy on the advisory board shall be filled in the same manner as the original appointment. (d) PAY AND REIMBURSEMENT. (i) NO COMPENSATION FOR MEMBERS OF ADVISORY BOARD. Except as provided in clause (ii), a member of the advisory board may not receive pay, allowances, or benefits by reason of their service on the board. (ii) TRAVEL EXPENSES. Each member shall receive travel expenses, including per diem in lieu of subsistence under sub- chapter I of chapter 57 of title 5, United States Code.(e)APPLICATION OF FACA. The Federal Advisory Committee ActCommentsClose CommentsPermalink
(5 U.S.C. App.) shall apply to the advisory board, except that section 14 of such Act shall not apply.174(f) TERMINATION. The advisory board shall terminate on the earlier of the date that it completes its duties under this section or December 31, 2015. (C) QUALIFIED NONPROFIT HEALTH INSURANCE ISSUER. For purposes of this sectionCommentsClose CommentsPermalink
(1) IN GENERAL. The term qualified nonprofit health insurance issuer means a health insurance issuer that is an organization (A) that is organized under State law as a nonprofit, member corporation; (B) substantially all of the activities of which consist of the issuance of qualified health plans in the individual and small group markets in each State in which it is licensed to issue such plans; and (C) that meets the other requirements of this subsection.CommentsClose CommentsPermalink
(2) CERTAIN ORGANIZATIONS PROHIBITED. An organization shall not be treated as a qualified nonprofit health insurance issuer if (A) the organization or a related entity (or any predecessor of either) was a health insurance issuer on July 16, 2009; or175 (B) the organization is sponsored by a State or local government, any political subdivision thereof, or any instrumentality of such government or political subdivision.CommentsClose CommentsPermalink
(3) GOVERNANCE REQUIREMENTS. An organization shall not be treated as a qualified nonprofit health insurance issuer unless (A) the governance of the organization is subject to a majority vote of its members; (B) its governing documents incorporate ethics and conflict of interest standards protecting against insurance industry involvement and interference; and (C) as provided in regulations promulgated by the Secretary, the organization is required to operate with a strong consumer focus, including timeliness, responsiveness, and accountability to members.CommentsClose CommentsPermalink
(4) PROFITS INURE TO BENEFIT OF MEM- BERS. An organization shall not be treated as a qualified nonprofit health insurance issuer unless any profits made by the organization are required to be used to lower premiums, to improve benefits, or for other programs intended to improve the quality of health care delivered to its members.176CommentsClose CommentsPermalink
(5) COMPLIANCE WITH STATE INSURANCE LAWS. An organization shall not be treated as a qualified nonprofit health insurance issuer unless the organization meets all the requirements that other issuers of qualified health plans are required to meet in any State where the issuer offers a qualified health plan, including solvency and licensure requirements, rules on payments to providers, and compliance with network adequacy rules, rate and form filing rules, any applicable State premium assessments and any other State law described in section 1324(b).CommentsClose CommentsPermalink
(6) COORDINATION WITH STATE INSURANCE REFORMS. An organization shall not be treated as a qualified nonprofit health insurance issuer unless the organization does not offer a health plan in a State until that State has in effect (or the Secretary has implemented for the State) the market reforms required by part A of title XXVII of the Public Health Service Act (as amended by subtitles A and C of this Act). (d) ESTABLISHMENT OF PRIVATE PURCHASING COUNCIL.CommentsClose CommentsPermalink
(1) IN GENERAL. Qualified nonprofit health insurance issuers participating in the CO-OP pro177 gram under this section may establish a private purchasing council to enter into collective purchasing arrangements for items and services that increase administrative and other cost efficiencies, including claims administration, administrative services, health information technology, and actuarial services.CommentsClose CommentsPermalink
(2) COUNCIL MAY NOT SET PAYMENT RATES. The private purchasing council established under paragraph (1) shall not set payment rates for health care facilities or providers participating in health insurance coverage provided by qualified nonprofit health insurance issuers.CommentsClose CommentsPermalink
(3) CONTINUED APPLICATION OF ANTITRUST LAWS. (A) IN GENERAL. Nothing in this section shall be construed to limit the application of the antitrust laws to any private purchasing council (whether or not established under this subsection) or to any qualified nonprofit health insurance issuer participating in such a council. (B) ANTITRUST LAWS. For purposes of this subparagraph, the term antitrust laws has the meaning given the term in subsection (a) of the first section of the Clayton Act (15 U.S.C. 12 (a)). Such term also includes section 1785 of the Federal Trade Commission Act (15 U.S.C. 45) to the extent that such section 5 applies to unfair methods of competition.(e)LIMITATION ON PARTICIPATION. No representative of any Federal, State, or local government (or of any political subdivision or instrumentality thereof), and no representative of a person described in subsection (c) (2)(a), may serve on the board of directors of a qualified nonprofit health insurance issuer or with a private purchasing council established under subsection (d). (f) LIMITATIONS ON SECRETARY.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary shall not (A) participate in any negotiations between 1 or more qualified nonprofit health insurance issuers (or a private purchasing council established under subsection (d)) and any health care facilities or providers, including any drug manufacturer, pharmacy, or hospital; and (B) establish or maintain a price structure for reimbursement of any health benefits covered by such issuers.CommentsClose CommentsPermalink
(2) COMPETITION. Nothing in this section shall be construed as authorizing the Secretary to interfere with the competitive nature of providing179 health benefits through qualified nonprofit health insurance issuers. (g) APPROPRIATIONS. There are hereby appropriated, out of any funds in the Treasury not otherwise appropriated, $6,000,000,000 to carry out this section. (h) TAX EXEMPTION FOR QUALIFIED NONPROFIT HEALTH INSURANCE ISSUER.CommentsClose CommentsPermalink
(1) IN GENERAL. Section 501 (c) of the Internal Revenue Code of 1986 (relating to list of exempt organizations) is amended by adding at the end the following: (29) CO-OP HEALTH INSURANCE ISSUERS. (A) IN GENERAL. A qualified nonprofit health insurance issuer (within the meaning of section 1322 of the Patient Protection and Affordable Care Act) which has received a loan or grant under the CO-OP program under such section, but only with respect to periods for which the issuer is in compliance with the requirements of such section and any agreement with respect to the loan or grant. (B) CONDITIONS FOR EXEMPTION. Subparagraph (A) shall apply to an organization only if180 (i) the organization has given notice to the Secretary, in such manner as the Secretary may by regulations prescribe, that it is applying for recognition of its status under this paragraph, (ii) except as provided in section 1322 (C) (4) of the Patient Protection and Affordable Care Act, no part of the net earnings of which inures to the benefit of any private shareholder or individual, (iii) no substantial part of the activities of which is carrying on propaganda, or otherwise attempting, to influence legislation, and (iv) the organization does not participate in, or intervene in (including the publishing or distributing of statements), any political campaign on behalf of(or in opposition to) any candidate for public office..CommentsClose CommentsPermalink
(2) ADDITIONAL REPORTING REQUIREMENT. Section 6033 of such Code (relating to returns by exempt organizations) is amended by redesignating subsection (m) as subsection (n) and by inserting after subsection (l) the following:181 (m) ADDITIONAL INFORMATION REQUIRED FROM CO-OP INSURERS. An organization described in section 501 (c) (29) shall include on the return required under subsection (a) the following information:CommentsClose CommentsPermalink
(1) The amount of the reserves required by each State in which the organization is licensed to issue qualified health plans.CommentsClose CommentsPermalink
(2) The amount of reserves on hand..CommentsClose CommentsPermalink
(3) APPLICATION OF TAX ON EXCESS BENEFIT TRANSACTIONS. Section 4958 (e)(1) of such Code (defining applicable tax-exempt organization) is amended by striking paragraph (3) or (4) and inserting paragraph (3), (4), or (29). (i) GAO STUDY AND REPORT.CommentsClose CommentsPermalink
(1) STUDY. The Comptroller General of the General Accountability Office shall conduct an ongoing study on competition and market concentration in the health insurance market in the United States after the implementation of the reforms in such market under the provisions of, and the amendments made by, this Act. Such study shall include an analysis of new issuers of health insurance in such market.CommentsClose CommentsPermalink
(2) REPORT. The Comptroller General shall, not later than December 31 of each even-numbered182 year (beginning with 2014), report to the appropriate committees of the Congress the results of the study conducted under paragraph (1), including any recommendations for administrative or legislative changes the Comptroller General determines necessary or appropriate to increase competition in the health insurance market. CommentsClose CommentsPermalink
(A) VOLUNTARY NATURE.CommentsClose CommentsPermalink
(1) NO REQUIREMENT FOR HEALTH CARE PROVIDERS TO PARTICIPATE. Nothing in this section shall be construed to require a health care provider to participate in a community health insurance option, or to impose any penalty for non-participation.CommentsClose CommentsPermalink
(2) NO REQUIREMENT FOR INDIVIDUALS TO JOIN. Nothing in this section shall be construed to require an individual to participate in a community health insurance option, or to impose any penalty for non-participation.CommentsClose CommentsPermalink
(3) STATE OPT OUT. (A) IN GENERAL. A State may elect to prohibit Exchanges in such State from offering a community health insurance option if such State enacts a law to provide for such prohibition. 183 (B) TERMINATION OF OPT OUT. A State may repeal a law described in subparagraph (A) and provide for the offering of such an option through the Exchange. (B) ESTABLISHMENT OF COMMUNITY HEALTH INSURANCE OPTION.CommentsClose CommentsPermalink
(1) ESTABLISHMENT. The Secretary shall establish a community health insurance option to offer, through the Exchanges established under this title (other than Exchanges in States that elect to opt out as provided for in subsection (a) (3)), health care coverage that provides value, choice, competition, and stability of affordable, high quality coverage throughout the United States.CommentsClose CommentsPermalink
(2) COMMUNITY HEALTH INSURANCE OP- TION. In this section, the term community health insurance option means health insurance coverage that (A) except as specifically provided for in this section, complies with the requirements for being a qualified health plan; (B) provides high value for the premium charged;184 (C) reduces administrative costs and promotes administrative simplification for beneficiaries; (d) promotes high quality clinical care;(e)provides high quality customer service to beneficiaries; (f) offers a sufficient choice of providers; and (G) complies with State lawsCommentsClose CommentsPermalink
(if any), except as otherwise provided for in this title, relating to the laws described in section 1324(b).CommentsClose CommentsPermalink
(3) ESSENTIAL HEALTH BENEFITS. (A) GENERAL RULE. Except as provided in subparagraph (B), a community health insurance option offered under this section shall provide coverage only for the essential health benefits described in section 1302(b). (B) STATES MAY OFFER ADDITIONAL BEN- EFITS. Nothing in this section shall preclude a State from requiring that benefits in addition to the essential health benefits required under subparagraph (A) be provided to enrollees of a community health insurance option offered in such State. (C) CREDITS.185 (i) IN GENERAL. An individual enrolled in a community health insurance option under this section shall be eligible for credits under section 36B of the Internal Revenue Code of 1986 in the same manner as an individual who is enrolled in a qualified health plan. (ii) NO ADDITIONAL FEDERAL COST. A requirement by a State under subparagraph (B) that benefits in addition to the essential health benefits required under subparagraph (A) be provided to enrollees of a community health insurance option shall not affect the amount of a premium tax credit provided under section 36B of the Internal Revenue Code of 1986 with respect to such plan. (d) STATE MUST ASSUME COST. A State shall make payments to or on behalf of an eligible individual to defray the cost of any additional benefits described in subparagraph (B).(e)ENSURING ACCESS TO ALL SERVICES. Nothing in this Act shall prohibit an individual enrolled in a community health insurance option from paying out-of-pocket the full 186 cost of any item or service not included as an essential health benefit or otherwise covered as a benefit by a health plan. Nothing in subparagraph (B) shall prohibit any type of medical provider from accepting an out-of-pocket payment from an individual enrolled in a community health insurance option for a service otherwise not included as an essential health benefit.(f) PROTECTING ACCESS TO END OF LIFE CARE. A community health insurance option offered under this section shall be prohibited from limiting access to end of life care.CommentsClose CommentsPermalink
(4) COST SHARING. A community health insurance option shall offer coverage at each of the levels of coverage described in section 1302 (d) . (5) PREMIUMS. (A) PREMIUMS SUFFICIENT TO COVER COSTS. The Secretary shall establish geographically adjusted premium rates in an amount sufficient to cover expected costs (including claims and administrative costs) using methods in general use by qualified health plans. (B) APPLICABLE RULES. The provisions of title XXVII of the Public Health Service Act187 relating to premiums shall apply to community health insurance options under this section, including modified community rating provisions under section 2701 of such Act. (C) COLLECTION OF DATA. The Secretary shall collect data as necessary to set premium rates under subparagraph (A). (d) NATIONAL POOLING. Notwithstanding any other provision of law, the Secretary may treat all enrollees in community health insurance options as members of a single pool.(e)CONTINGENCY MARGIN. In establishing premium rates under subparagraph (A), the Secretary shall include an appropriate amount for a contingency margin.CommentsClose CommentsPermalink
(6) REIMBURSEMENT RATES. (A) NEGOTIATED RATES. The Secretary shall negotiate rates for the reimbursement of health care providers for benefits covered under a community health insurance option. (B) LIMITATION. The rates described in subparagraph (A) shall not be higher, in aggregate, than the average reimbursement rates188 paid by health insurance issuers offering qualified health plans through the Exchange. (C) INNOVATION. Subject to the limits contained in subparagraph (A), a State Advisory Council established or designated under subsection (d) may develop or encourage the use of innovative payment policies that promote quality, efficiency and savings to consumers.CommentsClose CommentsPermalink
(7) SOLVENCY AND CONSUMER PROTECTION. (A) SOLVENCY. The Secretary shall establish a Federal solvency standard to be applied with respect to a community health insurance option. A community health insurance option shall also be subject to the solvency standard of each State in which such community health insurance option is offered. (B) MINIMUM REQUIRED. In establishing the standard described under subparagraph (A), the Secretary shall require a reserve fund that shall be equal to at least the dollar value of the incurred but not reported claims of a community health insurance option. (C) CONSUMER PROTECTIONS. The consumer protection laws of a State shall apply to a community health insurance option.189CommentsClose CommentsPermalink
(8) REQUIREMENTS ESTABLISHED IN PARTNERSHIP WITH INSURANCE COMMISSIONERS. (A) IN GENERAL. The Secretary, in collaboration with the National Association of Insurance Commissioners (in this paragraph referred to as the NAIC), may promulgate regulations to establish additional requirements for a community health insurance option. (B) APPLICABILITY. Any requirement promulgated under subparagraph (A) shall be applicable to such option beginning 90 days after the date on which the regulation involved becomes final. (C) START-UP FUND.CommentsClose CommentsPermalink
(1) ESTABLISHMENT OF FUND. (A) IN GENERAL. There is established in the Treasury of the United States a trust fund to be known as the Health Benefit Plan Start- Up Fund (referred to in this section as the Start-Up Fund), that shall consist of such amounts as may be appropriated or credited to the Start-Up Fund as provided for in this subsection to provide loans for the initial operations of a community health insurance option.190 Such amounts shall remain available until expended. (B) FUNDING. There is hereby appropriated to the Start-Up Fund, out of any moneys in the Treasury not otherwise appropriated an amount requested by the Secretary of Health and Human Services as necessary to (i) pay the start-up costs associated with the initial operations of a community health insurance option; and (ii) pay the costs of making payments on claims submitted during the period that is not more than 90 days from the date on which such option is offered.CommentsClose CommentsPermalink
(2) USE OF START-UP FUND. The Secretary shall use amounts contained in the Start-Up Fund to make payments (subject to the repayment requirements in paragraph (4)) for the purposes described in paragraph (1) (B). (3) PASS THROUGH OF REBATES. The Secretary may establish procedures for reducing the amount of payments to a contracting administrator to take into account any rebates or price concessions. (4) REPAYMENT.191 (A) IN GENERAL. A community health insurance option shall be required to repay the Secretary of the Treasury (on such terms as the Secretary may require) for any payments made under paragraph (1) (B) by the date that is not later than 9 years after the date on which the payment is made. The Secretary may require the payment of interest with respect to such repayments at rates that do not exceed the market interest rate (as determined by the Secretary). (B) SANCTIONS IN CASE OF FOR-PROFIT CONVERSION. In any case in which the Secretary enters into a contract with a qualified entity for the offering of a community health insurance option and such entity is determined to be a for-profit entity by the Secretary, such entity shall be (i) immediately liable to the Secretary for any payments received by such entity from the Start-Up Fund; and (ii) permanently ineligible to offer a qualified health plan. (d) STATE ADVISORY COUNCIL.192CommentsClose CommentsPermalink
(1) ESTABLISHMENT. A State (other than a State that elects to opt out as provided for in subsection (a) (3)) shall establish or designate a public or non-profit private entity to serve as the State Advisory Council to provide recommendations to the Secretary on the operations and policies of a community health insurance option in the State. Such Council shall provide recommendations on at least the following: (A) policies and procedures to integrate quality improvement and cost containment mechanisms into the health care delivery system; (B) mechanisms to facilitate public awareness of the availability of a community health insurance option; and (C) alternative payment structures under a community health insurance option for health care providers that encourage quality improvement and cost control.CommentsClose CommentsPermalink
(2) MEMBERS. The members of the State Advisory Council shall be representatives of the public and shall include health care consumers and providers.193CommentsClose CommentsPermalink
(3) APPLICABILITY OF RECOMMENDATIONS. The Secretary may apply the recommendations of a State Advisory Council to a community health insurance option in that State, in any other State, or in all States.(e)AUTHORITY TO CONTRACT; TERMS OF CONTRACT.CommentsClose CommentsPermalink
(1) AUTHORITY. (A) IN GENERAL. The Secretary may enter into a contract or contracts with one or more qualified entities for the purpose of performing administrative functions (including functions described in subsection (a) (4) of section 1874A of the Social Security Act) with respect to a community health insurance option in the same manner as the Secretary may enter into contracts under subsection (a) (1) of such section. The Secretary shall have the same authority with respect to a community health insurance option under this section as the Secretary has under subsections a) (1) and (b) of section 1874A of the Social Security Act with respect to title XVIII of such Act. (B) REQUIREMENTS APPLY. If the Secretary enters into a contract with a qualified 194 entity to offer a community health insurance option, under such contract such entity (i) shall meet the criteria established under paragraph (2); and (ii) shall receive an administrative fee under paragraph (7). (C) LIMITATION. Contracts under this subsection shall not involve the transfer of insurance risk to the contracting administrator. (d) REFERENCE. An entity with which the Secretary has entered into a contract under this paragraph shall be referred to as a contracting administrator.CommentsClose CommentsPermalink
(2) QUALIFIED ENTITY. To be qualified to be selected by the Secretary to offer a community health insurance option, an entity shall (A) meet the criteria established under section 1874A (A) (2) of the Social Security Act; (B) be a nonprofit entity for purposes of offering such option; (C) meet the solvency standards applicable under subsection (b)(7); (d) be eligible to offer health insurance or health benefits coverage;195(e)meet quality standards specified by the Secretary;(f) have in place effective procedures to control fraud, abuse, and waste; and (G) meet such other requirements as the Secretary may impose. Procedures described under subparagraph (F) shall include the implementation of procedures to use beneficiary identifiers to identify individuals entitled to benefits so that such an individuals social security account number is not used, and shall also include procedures for the use of technology (including front-end, prepayment intelligent data-matching technology similar to that used by hedge funds, investment funds, and banks) to provide real-time data analysis of claims for payment under this title to identify and investigate unusual billing or order practices under this title that could indicate fraud or abuse.CommentsClose CommentsPermalink
(3) TERM. A contract provided for under paragraph (1) shall be for a term of at least 5 years but not more than 10 years, as determined by the Secretary. At the end of each such term, the Secretary shall conduct a competitive bidding process for the purposes of renewing existing contracts or196 selecting new qualified entities with which to enter into contracts under such paragraph.CommentsClose CommentsPermalink
(4) LIMITATION. A contract may not be renewed under this subsection unless the Secretary determines that the contracting administrator has met performance requirements established by the Secretary in the areas described in paragraph (7)(B).CommentsClose CommentsPermalink
(5) AUDITS. The Inspector General shall conduct periodic audits with respect to contracting administrators under this subsection to ensure that the administrator involved is in compliance with this section.CommentsClose CommentsPermalink
(6) REVOCATION. A contract awarded under this subsection shall be revoked by the Secretary, upon the recommendation of the Inspector General, only after notice to the contracting administrator involved and an opportunity for a hearing. The Secretary may revoke such contract if the Secretary determines that such administrator has engaged in fraud, deception, waste, abuse of power, negligence, mismanagement of taxpayer dollars, or gross mismanagement. An entity that has had a contract revoked under this paragraph shall not be qualified to enter into a subsequent contract under this subsection.197CommentsClose CommentsPermalink
(7) FEE FOR ADMINISTRATION. (A) IN GENERAL. The Secretary shall pay the contracting administrator a fee for the management, administration, and delivery of the benefits under this section. (B) REQUIREMENT FOR HIGH QUALITY ADMINISTRATION. The Secretary may increase the fee described in subparagraph (A) by not more than 10 percent, or reduce the fee described in subparagraph (A) by not more than 50 percent, based on the extent to which the contracting administrator, in the determination of the Secretary, meets performance requirements established by the Secretary, in at least the following areas: (i) Maintaining low premium costs and low cost sharing requirements, provided that such requirements are consistent with section 1302. (ii) Reducing administrative costs and promoting administrative simplification for beneficiaries. (iii) Promoting high quality clinical care.198 (iv) Providing high quality customer service to beneficiaries. (C) NON-RENEWAL. The Secretary may not renew a contract to offer a community health insurance option under this section with any contracting entity that has been assessed more than one reduction under subparagraph (B) during the contract period.CommentsClose CommentsPermalink
(8) LIMITATION. Notwithstanding the terms of a contract under this subsection, the Secretary shall negotiate the reimbursement rates for purposes of subsection (b)(6).(f) REPORT BY HHS AND INSOLVENCY WARNINGS.CommentsClose CommentsPermalink
(1) IN GENERAL. On an annual basis, the Secretary shall conduct a study on the solvency of a community health insurance option and submit to Congress a report describing the results of such study.CommentsClose CommentsPermalink
(2) RESULT. If, in any year, the result of the study under paragraph (1) is that a community health insurance option is insolvent, such result shall be treated as a community health insurance option solvency warning.CommentsClose CommentsPermalink
(3) SUBMISSION OF PLAN AND PROCEDURE.199 (A) IN GENERAL. If there is a community health insurance option solvency warning under paragraph (2) made in a year, the President shall submit to Congress, within the 15-day period beginning on the date of the budget submission to Congress under section 1105 (a) of title 31, United States Code, for the succeeding year, proposed legislation to respond to such warning. (B) PROCEDURE. In the case of a legislative proposal submitted by the President pursuant to subparagraph (A), such proposal shall be considered by Congress using the same procedures described under sections 803 and 804 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 that shall be used for a medicare funding warning. (g) MARKETING PARITY. In a facility controlled by the Federal Government, or by a State, where marketing or promotional materials related to a community health insurance option are made available to the public, making available marketing or promotional materials relating to private health insurance plans shall not be prohibited. Such materials include informational pamphlets, guide200 books, enrollment forms, or other materials determined reasonable for display. (h) AUTHORIZATION OF APPROPRIATIONS. There is authorized to be appropriated such sums as may be necessary to carry out this section. CommentsClose CommentsPermalink
(A) IN GENERAL. Notwithstanding any other provision of law, any health insurance coverage offered by a private health insurance issuer shall not be subject to any Federal or State law described in subsection (b) if a qualified health plan offered under the Consumer Operated and Oriented Plan program under section 1322, a community health insurance option under section 1323, or a nationwide qualified health plan under section 1333 (b), is not subject to such law. (B) LAWS DESCRIBED. The Federal and State laws described in this subsection are those Federal and State laws relating toCommentsClose CommentsPermalink
(1) guaranteed renewal;CommentsClose CommentsPermalink
(2) rating;CommentsClose CommentsPermalink
(3) preexisting conditions;CommentsClose CommentsPermalink
(4) non-discrimination;CommentsClose CommentsPermalink
(5) quality improvement and reporting;CommentsClose CommentsPermalink
(6) fraud and abuse;CommentsClose CommentsPermalink
(7) solvency and financial requirements;201CommentsClose CommentsPermalink
(8) market conduct;CommentsClose CommentsPermalink
(9) prompt payment;CommentsClose CommentsPermalink
(10) appeals and grievances;CommentsClose CommentsPermalink
(11) privacy and confidentiality;CommentsClose CommentsPermalink
(12) licensure; and (13) benefit plan material or information. PART IV STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS SEC. 1331. STATE FLEXIBILITY TO ESTABLISH BASIC HEALTH PROGRAMS FOR LOW-INCOME INDI VIDUALS NOT ELIGIBLE FOR MEDICAID.
(A) ESTABLISHMENT OF PROGRAM.CommentsClose CommentsPermalink
(1) IN GENERAL. The Secretary shall establish a basic health program meeting the requirements of this section under which a State may enter into contracts to offer 1 or more standard health plans providing at least the essential health benefits described in section 1302 (b) to eligible individuals in lieu of offering such individuals coverage through an Exchange. (2) CERTIFICATIONS AS TO BENEFIT COVERAGE AND COSTS. Such program shall provide that a State may not establish a basic health program under this section unless the State establishes to the202 satisfaction of the Secretary, and the Secretary certifies, that (A) in the case of an eligible individual enrolled in a standard health plan offered through the program, the State provides (i) that the amount of the monthly premium an eligible individual is required to pay for coverage under the standard health plan for the individual and the individuals dependents does not exceed the amount of the monthly premium that the eligible individual would have been required to pay (in the rating area in which the individual resides) if the individual had enrolled in the applicable second lowest cost silver plan (as defined in section 36B (b)(3) (B) of the Internal Revenue Code of 1986) offered to the individual through an Exchange; and (ii) that the cost-sharing an eligible individual is required to pay under the standard health plan does not exceed (i) the cost-sharing required under a platinum plan in the case of an eligible individual with household203 income not in excess of 150 percent of the poverty line for the size of the family involved; and (II) the cost-sharing required under a gold plan in the case of an eligible individual not described in sub- clause (I); and (B) the benefits provided under the standard health plans offered through the program cover at least the essential health benefits described in section 1302(b). For purposes of subparagraph (a) (i), the amount of the monthly premium an individual is required to pay under either the standard health plan or the applicable second lowest cost silver plan shall be determined after reduction for any premium tax credits and cost-sharing reductions allowable with respect to either plan. (B) STANDARD HEALTH PLAN. In this section, the term standard heath plan means a health benefits plan that the State contracts with under this sectionCommentsClose CommentsPermalink
(1) under which the only individuals eligible to enroll are eligible individuals;CommentsClose CommentsPermalink
(2) that provides at least the essential health benefits described in section 1302 (b); and 204 (3) in the case of a plan that provides health insurance coverage offered by a health insurance issuer, that has a medical loss ratio of at least 85 percent. (C) CONTRACTING PROCESS.CommentsClose CommentsPermalink
(1) IN GENERAL. A State basic health program shall establish a competitive process for entering into contracts with standard health plans under subsection (a), including negotiation of premiums and cost-sharing and negotiation of benefits in addition to the essential health benefits described in section 1302(b).CommentsClose CommentsPermalink
(2) SPECIFIC ITEMS TO BE CONSIDERED. A State shall, as part of its competitive process under paragraph (1), include at least the following: (A) INNOVATION. Negotiation with offerors of a standard health plan for the inclusion of innovative features in the plan, including (i) care coordination and care management for enrollees, especially for those with chronic health conditions; (ii) incentives for use of preventive services; and205 (iii) the establishment of relationships between providers and patients that maximize patient involvement in health care de- cision-making, including providing incentives for appropriate utilization under the plan. (B) HEALTH AND RESOURCE DIFFERENCES. Consideration of, and the making of suitable allowances for, differences in health care needs of enrollees and differences in local availability of, and access to, health care providers. Nothing in this subparagraph shall be construed as allowing discrimination on the basis of pre-existing conditions or other health status-related factors. (C) MANAGED CARE. Contracting with managed care systems, or with systems that offer as many of the attributes of managed care as are feasible in the local health care market. (d) PERFORMANCE MEASURES. Establishing specific performance measures and standards for issuers of standard health plans that focus on quality of care and improved health outcomes, requiring such plans to report to the State with respect to the measures and206 standards, and making the performance and quality information available to enrollees in a useful form.CommentsClose CommentsPermalink
(3) ENHANCED AVAILABILITY. (A) MULTIPLE PLANS. A State shall, to the maximum extent feasible, seek to make multiple standard health plans available to eligible individuals within a State to ensure individuals have a choice of such plans. (B) REGIONAL COMPACTS. A State may negotiate a regional compact with other States to include coverage of eligible individuals in all such States in agreements with issuers of standard health plans.CommentsClose CommentsPermalink
(4) COORDINATION WITH OTHER STATE PROGRAMS. A State shall seek to coordinate the administration of, and provision of benefits under, its program under this section with the State medicaid program under title XIX of the Social Security Act, the State child health plan under title XXI of such Act, and other State-administered health programs to maximize the efficiency of such programs and to improve the continuity of care. (d) TRANSFER OF FUNDS TO STATES.207CommentsClose CommentsPermalink
(1) IN GENERAL. If the Secretary determines that a State electing the application of this section meets the requirements of the program established under subsection (a), the Secretary shall transfer to the State for each fiscal year for which 1 or more standard health plans are operating within the State the amount determined under paragraph (3).CommentsClose CommentsPermalink
(2) USE OF FUNDS. A State shall establish a trust for the deposit of the amounts received under paragraph (1) and amounts in the trust fund shall only be used to reduce the premiums and cost-sharing of, or to provide additional benefits for, eligible individuals enrolled in standard health plans within the State. Amounts in the trust fund, and expenditures of such amounts, shall not be included in determining the amount of any non-Federal funds for purposes of meeting any matching or expenditure requirement of any federally-funded program.CommentsClose CommentsPermalink
(3) AMOUNT OF PAYMENT. (A) SECRETARIAL DETERMINATION. (i) IN GENERAL. The amount determined under this paragraph for any fiscal year is the amount the Secretary determines is equal to 85 percent of the premium tax credits under section 36B of the208 Internal Revenue Code of 1986, and the cost-sharing reductions under section 1402, that would have been provided for the fiscal year to eligible individuals enrolled in standard health plans in the State if such eligible individuals were allowed to enroll in qualified health plans through an Exchange established under this subtitle. (ii) SPECIFIC REQUIREMENTS. The Secretary shall make the determination under clause (i) on a per enrollee basis and shall take into account all relevant factors necessary to determine the value of the premium tax credits and cost-sharing reductions that would have been provided to eligible individuals described in clause (i), including the age and income of the enrollee, whether the enrollment is for self- only or family coverage, geographic differences in average spending for health care across rating areas, the health status of the enrollee for purposes of determining risk adjustment payments and reinsurance payments that would have been made if the enrollee had enrolled in a qualified 209 health plan through an Exchange, and whether any reconciliation of the credit or cost-sharing reductions would have occurred if the enrollee had been so enrolled. This determination shall take into consideration the experience of other States with respect to participation in an Exchange and such credits and reductions provided to residents of the other States, with a special focus on enrollees with income below 200 percent of poverty. (iii) CERTIFICATION. The Chief Actuary of the Centers for Medicare & Medicaid Services, in consultation with the Office of Tax Analysis of the Department of the Treasury, shall certify whether the methodology used to make determinations under this subparagraph, and such determinations, meet the requirements of clause (ii). Such certifications shall be based on sufficient data from the State and from comparable States about their experience with programs created by this Act. (B) CORRECTIONS. The Secretary shall adjust the payment for any fiscal year to reflect210 any error in the determinations under subparagraph (A) for any preceding fiscal year.CommentsClose CommentsPermalink
(4) APPLICATION OF SPECIAL RULES. The provisions of section 1303 shall apply to a State basic health program, and to standard health plans offered through such program, in the same manner as such rules apply to qualified health plans.(e)ELIGIBLE INDIVIDUAL.CommentsClose CommentsPermalink
(1) IN GENERAL. In this section, the term eligible individual means, with respect to any State, an individual (A) who a resident of the State who is not eligible to enroll in the States medicaid program under title XIX of the Social Security Act for benefits that at a minimum consist of the essential health benefits described in section 1302 (b); (B) whose household income exceeds 133 percent but does not exceed 200 percent of the poverty line for the size of the family involved; (C) who is not eligible for minimum essential coverage (as defined in section 5000A(f) of the Internal Revenue Code of 1986) or is eligible for an employer-sponsored plan that is not211 affordable coverage (as determined under section 5000A (e)(2) of such Code); and (D) who has not attained age 65 as of the beginning of the plan year. Such term shall not include any individual who is not a qualified individual under section 1312 who is eligible to be covered by a qualified health plan offered through an Exchange.CommentsClose CommentsPermalink
(2) ELIGIBLE INDIVIDUALS MAY NOT USE EX- CHANGE. An eligible individual shall not be treated as a qualified individual under section 1312 eligible for enrollment in a qualified health plan offered through an Exchange established under section 1311.(f) SECRETARIAL OVERSIGHT. The Secretary shall each year conduct a review of each State program to ensure compliance with the requirements of this section, including ensuring that the State program meets