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	353,330	753	99%
Engrossed Amendment Senate	425,157	112 Show Changes Hide Changes	22%

Display Version Introduced in House Engrossed in House Placed on Calendar Senate Amendment in Senate Engrossed Amendment Senate

AMENDMENT NO. 2786Purpose: In the nature of a substitute.

IN THE SENATE OF THE UNITED STATES--111th Cong., 1st Sess.H. HR 3590 EAS/PP CommentsClose CommentsPermalink

Resolved,That the bill from the House of Representatives (H.R. 3590T) entitled ‘An 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.

November 19, 2009Ordered to lie on the table and to be printedAmendment in the nature of a substitute intended to be proposed by Mr. REID (for himself, Mr. BAUCUS, Mr. DODD, and Mr. HARKIN)Viz’, do pass with the followingCommentsClose CommentsPermalink

AMENDMENTS: 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’. CommentsClose CommentsPermalink





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





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

TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

Subtitle A--Immediate Improvements in Health Care Coverage for All Americans

Sec. 1001. Amendments to the Public Health Service Act. CommentsClose CommentsPermalink

‘PART A--Individual and Group Market Reforms

‘subpart ii--improving coverage

‘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 coverage 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 Coverage

Sec. 1101. Immediate access to insurance for uninsured individuals with a preexisting 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 Americans

PART I--Health Insurance Market Reforms

Sec. 1201. Amendment to the Public Health Service Act. CommentsClose CommentsPermalink

‘subpart i--general reform

‘Sec. 2704. Prohibition of preexisting condition exclusions or other discrimination based on health status. 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 discrimination based on health status.‘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

PART II--Other Provisions

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 Americans

PART I--Establishment of Qualified Health Plans

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

PART II--Consumer Choices and Insurance Competition Through Health Benefit Exchanges

Sec. 1311. Affordable choices of health benefit plans. CommentsClose CommentsPermalink





Sec. 1312. Consumer choice. CommentsClose CommentsPermalink





Sec. 1313. Financial integrity. CommentsClose CommentsPermalink

PART III--State Flexibility Relating to Exchanges

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

PART IV--State Flexibility to Establish Alternative Programs

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

PART V--Reinsurance and Risk Adjustment

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 Americans

PART I--Premium Tax Credits and Cost-sharing Reductions

subpart a--premium tax credits and cost-sharing reductions

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

subpart b--eligibility determinations

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

PART II--Small Business Tax Credit

Sec. 1421. Credit for employee health insurance expenses of small businesses. CommentsClose CommentsPermalink

Subtitle F--Shared Responsibility for Health Care

PART I--Individual Responsibility

Sec. 1501. Requirement to maintain minimum essential coverage. CommentsClose CommentsPermalink





Sec. 1502. Reporting of health insurance coverage. CommentsClose CommentsPermalink

PART II--Employer Responsibilities

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 Provisions

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





Sec. 1563. Sense of the Senate promoting fiscal responsibility. CommentsClose CommentsPermalink

TITLE II--ROLE OF PUBLIC PROGRAMS

Subtitle A--Improved Access to Medicaid

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 Children’s Health Insurance Program

Sec. 2101. Additional federal financial participation for CHIP. CommentsClose CommentsPermalink





Sec. 2102. Technical corrections. CommentsClose CommentsPermalink

Subtitle C--Medicaid and CHIP Enrollment Simplification

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 Services

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 Supports

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 Coverage

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 Hospital (DSH) Payments

Sec. 2551. Disproportionate share hospital payments. CommentsClose CommentsPermalink

Subtitle H--Improved Coordination for Dual Eligible Beneficiaries

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 Providers

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 Commission (MACPAC)

Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries. CommentsClose CommentsPermalink

Subtitle K--Protections for American Indians and Alaska Natives

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 Services

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

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

Subtitle A--Transforming the Health Care Delivery System

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

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





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





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





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





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





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





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





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

PART II--National Strategy to Improve Health Care Quality

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

PART III--Encouraging Development of New Patient Care Models

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





Sec. 3022. Medicare shared savings program. CommentsClose CommentsPermalink





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





Sec. 3024. Independence at home 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 Providers

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

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





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





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





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





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





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





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





Sec. 3108. Permitting physician assistants to order post-Hospital extended care services. 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

PART II--Rural Protections

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





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





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





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





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





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





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





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





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

PART III--Improving Payment Accuracy

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





Sec. 3132. Hospice reform. CommentsClose CommentsPermalink





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





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





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





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





Sec. 3137. Hospital wage index improvement. CommentsClose CommentsPermalink





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





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





Sec. 3140. 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





Sec. 3143. Protecting home health benefits. CommentsClose CommentsPermalink

Subtitle C--Provisions Relating to Part C

Sec. 3201. Medicare Advantage payment. CommentsClose CommentsPermalink





Sec. 3202. Benefit protection and simplification. CommentsClose CommentsPermalink





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





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





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





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





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





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





Sec. 3209. 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 MA-PD Plans

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 MA-PD plans. CommentsClose CommentsPermalink





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





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





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





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





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





Sec. 3309. 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 MA-PD plans. CommentsClose CommentsPermalink





Sec. 3311. Improved Medicare prescription drug plan and MA-PD plan complaint system. CommentsClose CommentsPermalink





Sec. 3312. Uniform exceptions and appeals process for prescription drug plans and MA-PD 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 Sustainability

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





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





Sec. 3403. Independent Medicare Advisory Board. CommentsClose CommentsPermalink

Subtitle F--Health Care Quality Improvements

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 women’s health. CommentsClose CommentsPermalink





Sec. 3510. Patient navigator program. CommentsClose CommentsPermalink





Sec. 3511. Authorization of appropriations. CommentsClose CommentsPermalink

TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH

Subtitle A--Modernizing Disease Prevention and Public Health Systems

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 Services

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 Communities

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 Innovation

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 Provisions

Sec. 4401. Sense of the Senate concerning CBO scoring. CommentsClose CommentsPermalink





Sec. 4402. Effectiveness of Federal health and wellness initiatives. CommentsClose CommentsPermalink

TITLE V--HEALTH CARE WORKFORCE

Subtitle A--Purpose and Definitions

Sec. 5001. Purpose. CommentsClose CommentsPermalink





Sec. 5002. Definitions. CommentsClose CommentsPermalink

Subtitle B--Innovations in the Health Care Workforce

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 Workforce

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 Training

Sec. 5301. Training in family medicine, general internal medicine, general pediatrics, 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 geriatric 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 Workforce

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 Improvements

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 programnonprovider settings. 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 Services

Sec. 5601. Spending for Federally Qualified Health Centers (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 Provisions

Sec. 5701. Reports. CommentsClose CommentsPermalink

TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY

Subtitle A--Physician Ownership and Other Transparency

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 Improvement

PART I--Improving Transparency of Information

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

PART II--Targeting Enforcement

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

PART III--Improving Staff Training

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 Providers

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 Research

Sec. 6301. Patient-Centered Outcomes Research. CommentsClose CommentsPermalink





Sec. 6302. Federal coordinating council for comparative effectiveness research. CommentsClose CommentsPermalink

Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions

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 Provisions

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 Provisions

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. 6607. Permitting evidentiary privilege and confidential cSec. 6606. MEWA plan registration with Department of Labor. CommentsClose CommentsPermalink





Sec. 6607. Permitting evidentiary privilege and confidential communications. CommentsClose CommentsPermalink

Subtitle H--Elder Justice Act

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 Malpractice

Sec. 6801. Sense of the Senate regarding medical malpractice. CommentsClose CommentsPermalink

TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES

Subtitle A--Biologics Price Competition and Innovation

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 Communities

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

TITLE VIII--CLASS ACT

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

TITLE IX--REVENUE PROVISIONS

Subtitle A--Revenue Offset Provisions

Sec. 9001. Excise tax on high cost employer-sponsored health coverage. CommentsClose CommentsPermalink





Sec. 9002. Inclusion of cost of employer-sponsored health coverage on W-2. 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 Provisions

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

TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS

TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS CommentsClose CommentsPermalink

Subtitle A--Immediate Improvements in Health Care Coverage for All Americans CommentsClose CommentsPermalink

SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.

Part A of title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended-- CommentsClose CommentsPermalink





(1) by striking the part heading and inserting the following: CommentsClose CommentsPermalink

‘PART A--INDIVIDUAL AND GROUP MARKET REFORMS’;

(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 CommentsClose CommentsPermalink





(5) by inserting after section 2702, the following: CommentsClose CommentsPermalink

‘Subpart II--Improving Coverage

‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.

‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish-- CommentsClose CommentsPermalink





‘(1) lifetime limits on the dollar value of benefits for any participant or beneficiary; or CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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

‘SEC. 2712. PROHIBITION ON RESCISSIONS.

‘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

‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.

‘(a) In General- A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for-- CommentsClose CommentsPermalink





‘(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 CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.‘(b) for purposes of this paragraph. CommentsClose CommentsPermalink





‘(5) for the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009. CommentsClose CommentsPermalink





Nothing in this subsection shall be construed to prohibit a plan or issuer from providing coverage for services in addition to those recommended by United States Preventive Services Task Force or to deny coverage for services that are not recommended by such Task Force. CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(c) Value-based Insurance Design- The Secretary 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

‘SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.

‘(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 child (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. CommentsClose CommentsPermalink





‘(b) Regulations- The Secretary shall promulgate regulations to define the dependents to which coverage shall be made available under subsection (a). CommentsClose CommentsPermalink





‘(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

‘SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM EXPLANATION OF COVERAGE DOCUMENTS AND STANDARDIZED DEFINITIONS.

‘(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 insurance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals. CommentsClose CommentsPermalink





‘(b) Requirements- The standards for the summary 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-- CommentsClose CommentsPermalink





‘(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); CommentsClose CommentsPermalink





‘(B) a description of the coverage, including cost sharing for-- CommentsClose CommentsPermalink





‘(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 CommentsClose CommentsPermalink





‘(ii) other benefits, as identified by the Secretary; CommentsClose CommentsPermalink





‘(C) the exceptions, reductions, and limitations on coverage; CommentsClose CommentsPermalink





‘(D) the cost-sharing provisions, including deductible, coinsurance, and co-payment obligations; CommentsClose CommentsPermalink





‘(E) the renewability and continuation of coverage provisions; CommentsClose CommentsPermalink





‘(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; CommentsClose CommentsPermalink





‘(G) a statement of whether the plan or coverage-- CommentsClose CommentsPermalink





‘(i) provides minimum essential coverage (as defined under section 5000A(f) of the Internal Revenue Code 1986); and CommentsClose CommentsPermalink





‘(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; CommentsClose CommentsPermalink





‘(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 CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(c) Periodic Review and Updating- The Secretary shall periodically review and update, as appropriate, the standards developed under this section. CommentsClose CommentsPermalink





‘(d) Requirement tTo 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-- CommentsClose CommentsPermalink





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





‘(B) an enrollee prior to the time of enrollment or reenrollment, as applicable; and CommentsClose CommentsPermalink





‘(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-- CommentsClose CommentsPermalink





‘(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 CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(f) Failure tTo 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. CommentsClose CommentsPermalink





‘(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, UCR (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

‘SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON SALARY.

‘(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. CommentsClose CommentsPermalink





‘(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

‘SEC. 2717. ENSURING THE QUALITY OF CARE.

‘(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-- CommentsClose CommentsPermalink





‘(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; CommentsClose CommentsPermalink





‘(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; CommentsClose CommentsPermalink





‘(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 CommentsClose CommentsPermalink





‘(D) implement wellness and health promotion activities. CommentsClose CommentsPermalink





‘(2) REPORTING REQUIREMENTS- CommentsClose CommentsPermalink





‘(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). CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(C) AVAILABILITY OF REPORTS- The Secretary shall make reports submitted under subparagraph (A) available to the public through an Internet website‘(D) . CommentsClose CommentsPermalink





‘(D) PENALTIES- In developing the reporting requirements under paragraph (1), the Secretary may develop and impose appropriate penalties for non-compliance with such requirements. CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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 program’s 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. CommentsClose CommentsPermalink





‘(c) Regulations- Not later than 2 years after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary shall promulgate regulations that provide criteria for determining whether a reimbursement structure is described in subsection (a). CommentsClose CommentsPermalink





‘(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

‘SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE.

‘(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 expends-- CommentsClose CommentsPermalink





‘(1) on reimbursement for clinical services provided to enrollees under such coverage; CommentsClose CommentsPermalink





‘(2) for activities that improve health care quality; and CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





The Secretary shall make reports received under this section available to the public on the Internet website of the Department of Health and Human Services. CommentsClose CommentsPermalink





‘(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-- CommentsClose CommentsPermalink





‘(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 CommentsClose CommentsPermalink





‘(B) with respect to a health insurance issuer offering coverage in the individual market, 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 PERCENTAGES- 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. CommentsClose CommentsPermalink





‘(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 hospital’s 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. CommentsClose CommentsPermalink





‘(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

‘SEC. 2719. APPEALS PROCESS.

‘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 minimum-- CommentsClose 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 CommentsClose CommentsPermalink





‘(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

SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION.

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

‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.

‘(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-- CommentsClose CommentsPermalink





‘(1) offices of health insurance consumer assistance; or CommentsClose CommentsPermalink





‘(2) health insurance ombudsman programs. CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(c) Duties- The office of health insurance consumer assistance or health insurance ombudsman shall-- CommentsClose 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 CommentsClose CommentsPermalink





‘(5) resolve problems with obtaining premium tax credits under section 36B of the Internal Revenue Code of 1986. CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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

SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS.

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

‘SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS.

‘(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. CommentsClose CommentsPermalink





‘(b) Continuing Premium Review Process- CommentsClose CommentsPermalink





‘(1) INFORMING SECRETARY OF PREMIUM INCREASE PATTERNS- As a condition of receiving a grant under subsection (c)(1), a State, through its Commissioner of Insurance, shall-- CommentsClose CommentsPermalink





‘(A) provide the Secretary with information about trends in premium increases in health insurance coverage in premium rating areas in the State; and CommentsClose CommentsPermalink





‘(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- CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(B) CONSIDERATION IN OPENING EXCHANGE- 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. CommentsClose CommentsPermalink





‘(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-- CommentsClose CommentsPermalink





‘(A) in reviewing and, if appropriate under State law, approving premium increases for health insurance coverage; and CommentsClose CommentsPermalink





‘(B) in providing information and recommendations to the Secretary under subsection (b)(1). CommentsClose CommentsPermalink





‘(2) FUNDING- CommentsClose CommentsPermalink





‘(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). CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(C) ALLOCATION- The Secretary shall establish a formula for determining the amount of any grant to a State under this subsection. Under such formula-- CommentsClose CommentsPermalink





‘(i) the Secretary shall consider the number of plans of health insurance coverage offered in each State and the population of the State; and CommentsClose CommentsPermalink





‘(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

SEC. 1004. EFFECTIVE DATES.

(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 beginning 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. CommentsClose CommentsPermalink





(b) Special Rule- The amendments made by sections 1002 and 1003 shall take effect on the date of enactment of this Act. CommentsClose CommentsPermalink

Subtitle B--Immediate Actions to Preserve and Expand Coverage CommentsClose CommentsPermalink

SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED INDIVIDUALS WITH A PREEXISTING CONDITION.

(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. CommentsClose CommentsPermalink





(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-- CommentsClose CommentsPermalink





(A) be a State or nonprofit private entity; CommentsClose CommentsPermalink





(B) submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require; and CommentsClose CommentsPermalink





(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. CommentsClose CommentsPermalink





(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-- CommentsClose CommentsPermalink





(A) provides to all eligible individuals health insurance coverage that does not impose any preexisting condition exclusion with respect to such coverage; CommentsClose CommentsPermalink





(B) provides health insurance coverage-- CommentsClose CommentsPermalink





(i) in which the issuer’s share of the total allowed costs of benefits provided under such coverage is not less than 65 percent of such costs; and CommentsClose CommentsPermalink





(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); CommentsClose CommentsPermalink





(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-- CommentsClose CommentsPermalink





(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); CommentsClose CommentsPermalink





(ii) vary on the basis of age by a factor of not greater than 4 to 1; and CommentsClose CommentsPermalink





(iii) be established at a standard rate for a standard population; and CommentsClose CommentsPermalink





(D) meets any other requirements determined appropriate by the Secretary. CommentsClose CommentsPermalink





(d) Eligible Individual- An individual shall be deemed to be an eligible individual for purposes of this section if such individual-- CommentsClose CommentsPermalink





(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 CommentsClose CommentsPermalink





(3) has a pre-existing condition, as determined in a manner consistent with guidance issued by the Secretary. CommentsClose CommentsPermalink





(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 individual’s 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: CommentsClose CommentsPermalink





(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. CommentsClose CommentsPermalink





(B) In the case of prior coverage obtained directly from an issuer or under an employment-based health plan-- CommentsClose CommentsPermalink





(i) the provision by the issuer or plan of money or other financial consideration for disenrolling from the coverage; or CommentsClose CommentsPermalink





(ii) in the case of an individual whose premium for the prior coverage exceeded the premium required by the program (adjusted based on the age factors applied to the prior coverage)-- CommentsClose CommentsPermalink





(I) the prior coverage is a policy that is no longer being actively marketed (as defined by the Secretary) by the issuer; or CommentsClose CommentsPermalink





(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. CommentsClose CommentsPermalink





(f) Oversight- The Secretary shall establish-- CommentsClose CommentsPermalink





(1) an appeals process to enable individuals to appeal a determination under this section; and CommentsClose CommentsPermalink





(2) procedures to protect against waste, fraud, and abuse. CommentsClose CommentsPermalink





(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- CommentsClose CommentsPermalink





(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. CommentsClose CommentsPermalink





(B) TRANSITION TO EXCHANGE- The Secretary shall develop procedures to provide for the transition of eligible individuals enrolled in health insurance coverage offered through a high risk pool established under this section into qualified health 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

SEC. 1102. REINSURANCE FOR EARLY RETIREES.

(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: CommentsClose CommentsPermalink





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





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





(i) is-- CommentsClose CommentsPermalink





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





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





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





(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. CommentsClose CommentsPermalink





(b) Participation- CommentsClose CommentsPermalink





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





(A) meets the requirements of paragraph (2) with respect to health benefits provided under the plan; and CommentsClose CommentsPermalink





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





(2) EMPLOYMENT-BASED HEALTH BENEFITS- An employment-based plan meets the requirements of this paragraph if the plan-- CommentsClose CommentsPermalink





(A) implements programs and procedures to generate cost-savings with respect to participants with chronic and high-cost conditions; CommentsClose CommentsPermalink





(B) provides documentation of the actual cost of medical claims involved; and CommentsClose CommentsPermalink





(C) is certified by the Secretary. CommentsClose CommentsPermalink





(c) Payments- CommentsClose CommentsPermalink





(1) SUBMISSION OF CLAIMS- CommentsClose CommentsPermalink





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





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





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





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





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





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





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





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





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





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





(e) 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. CommentsClose CommentsPermalink





(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

SEC. 1103. IMMEDIATE INFORMATION THAT ALLOWS CONSUMERS TO IDENTIFY AFFORDABLE COVERAGE OPTIONS.

(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 COVERAGE- 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: CommentsClose CommentsPermalink





(A) Health insurance coverage offered by health insurance issuers, other than coverage that provides reimbursement only for the treatment or mitigation of-- CommentsClose CommentsPermalink





(i) a single disease or condition; or CommentsClose CommentsPermalink





(ii) an unreasonably limited set of diseases or conditions (as determined by the Secretary); CommentsClose CommentsPermalink





(B) Medicaid coverage under title XIX of the Social Security Act. CommentsClose CommentsPermalink





(C) Coverage under title XXI of the Social Security Act. CommentsClose CommentsPermalink





(D) A State health benefits high risk pool, to the extent that such high risk pool is offered in such State; and CommentsClose CommentsPermalink





(E) Coverage under a high risk pool under section 1101. CommentsClose CommentsPermalink





(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). CommentsClose CommentsPermalink





(c) Authority tTo Contract- The Secretary may carry out this section through contracts entered into with qualified entities. CommentsClose CommentsPermalink

SEC. 1104. ADMINISTRATIVE SIMPLIFICATION.

(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-- CommentsClose CommentsPermalink





(1) by inserting ‘uniform’ before ‘standards’; and CommentsClose CommentsPermalink





(2) by inserting ‘and to reduce the clerical burden on patients, health care providers, and health plans’ before the period at the end. CommentsClose CommentsPermalink





(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. 1320d-2) is amended-- CommentsClose CommentsPermalink





(A) in subsection (a)(2), by adding at the end the following new subparagraph: CommentsClose CommentsPermalink





‘(J) Electronic funds transfers.’; CommentsClose CommentsPermalink





(B) in subsection (a), by adding at the end the following new paragraph: CommentsClose CommentsPermalink





‘(4) REQUIREMENTS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS- CommentsClose CommentsPermalink





‘(A) IN GENERAL- The standards and associated operating rules adopted by the Secretary shall-- CommentsClose CommentsPermalink





‘(i) to the extent feasible and appropriate, enable determination of an individual’s eligibility and financial responsibility for specific services prior to or at the point of care; CommentsClose CommentsPermalink





‘(ii) be comprehensive, requiring minimal augmentation by paper or other communications; CommentsClose CommentsPermalink





‘(iii) provide for timely acknowledgment, response, and status reporting that supports a transparent claims and denial management process (including adjudication and appeals); and CommentsClose CommentsPermalink





‘(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). CommentsClose CommentsPermalink





‘(B) REDUCTION OF CLERICAL BURDEN- 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 CommentsClose CommentsPermalink





(C) by adding at the end the following new subsections: CommentsClose CommentsPermalink





‘(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: CommentsClose CommentsPermalink





‘(A) The entity focuses its mission on administrative simplification. CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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 policies that demonstrate a commitment to open, fair, and nondiscriminatory practices. CommentsClose CommentsPermalink





‘(D) The entity builds on the transaction standards issued under Health Insurance Portability and Accountability Act of 1996. CommentsClose CommentsPermalink





‘(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-- CommentsClose CommentsPermalink





‘(A) advise the Secretary as to whether a nonprofit entity meets the requirements under paragraph (2); CommentsClose CommentsPermalink





‘(B) review the operating rules developed and recommended by such nonprofit entity; CommentsClose CommentsPermalink





‘(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; CommentsClose CommentsPermalink





‘(D) evaluate whether such operating rules are consistent with electronic standards adopted for health information technology; and CommentsClose CommentsPermalink





‘(E) submit to the Secretary a recommendation as to whether the Secretary should adopt such operating rules. CommentsClose CommentsPermalink





‘(4) IMPLEMENTATION- CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(B) ADOPTION REQUIREMENTS; EFFECTIVE DATES- CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(ii) ELECTRONIC FUNDS TRANSFERS AND HEALTH CARE PAYMENT AND REMITTANCE ADVICE- The set of operating rules for electronic funds transfers and health care payment and remittance advice transactions shall-- CommentsClose CommentsPermalink





‘(I) allow for automated reconciliation of the electronic payment with the remittance advice; and CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(iii) HEALTH CLAIMS OR EQUIVALENT ENCOUNTER INFORMATION, ENROLLMENT AND DISENROLLMENT IN A HEALTH PLAN, HEALTH PLAN PREMIUM PAYMENTS, REFERRAL CERTIFICATION AND AUTHORIZATION- 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. CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(h) Compliance- CommentsClose CommentsPermalink





‘(1) HEALTH PLAN CERTIFICATION- CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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-- CommentsClose CommentsPermalink





‘(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 CommentsClose CommentsPermalink





‘(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- CommentsClose CommentsPermalink





‘(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-- CommentsClose CommentsPermalink





‘(i) amends any standard or operating rule described under paragraph (1) of this subsection; or CommentsClose CommentsPermalink





‘(ii) establishes a standard (as described under subsection (a)(1)(B)) or associated operating rules (as described under subsection (i)(5)) for any other financial and administrative transactions. CommentsClose CommentsPermalink





‘(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 Secretary 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)(5). CommentsClose CommentsPermalink





‘(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- CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(B) REPORT- Not later than July 1, 2014, and not less than biennially thereafter, the review committee shall provide recommendations 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- CommentsClose CommentsPermalink





‘(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 committee’s report. CommentsClose CommentsPermalink





‘(B) PUBLIC COMMENT- CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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- CommentsClose CommentsPermalink





‘(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-- CommentsClose CommentsPermalink





‘(i) the National Committee on Vital and Health Statistics; or CommentsClose CommentsPermalink





‘(ii) any appropriate committee as determined by the Secretary. CommentsClose CommentsPermalink





‘(B) COORDINATION OF HIT STANDARDS- 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 STANDARDS ADOPTED BY THE SECRETARY- The Secretary shall adopt a single set of operating rules (pursuant to the process described under subsection (g)) for any transaction for which a standard had been adopted pursuant to subsection (a)(1)(B). CommentsClose CommentsPermalink





‘(j) Penalties- CommentsClose CommentsPermalink





‘(1) PENALTY FEE- CommentsClose CommentsPermalink





‘(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-- CommentsClose CommentsPermalink





‘(i) the standards and associated operating rules described under paragraph (1) of such subsection; and CommentsClose CommentsPermalink





‘(ii) a standard (as described under subsection (a)(1)(B)) and associated operating rules (as described under subsection (i)(5)) for any other financial and administrative transactions. CommentsClose CommentsPermalink





‘(B) FEE AMOUNT- Subject to subparagraphs (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). CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(E) PENALTY LIMIT- A penalty fee assessed against a health plan under this subsection shall not exceed, on an annual basis-- CommentsClose CommentsPermalink





‘(i) an amount equal to $20 per covered life under such plan; or CommentsClose CommentsPermalink





‘(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)). CommentsClose CommentsPermalink





‘(F) DETERMINATION OF COVERED INDIVIDUALS- 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- CommentsClose CommentsPermalink





‘(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). CommentsClose CommentsPermalink





‘(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)). CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(D) UNPAID PENALTY FEES- Any amount of a penalty fee assessed against a health plan under this subsection for which payment has not been made by the due date provided under subparagraph (C) shall be-- CommentsClose CommentsPermalink





‘(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 CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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.’. CommentsClose CommentsPermalink





(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. CommentsClose CommentsPermalink





(d) Expansion of Electronic Transactions in Medicare- Section 1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended-- CommentsClose CommentsPermalink





(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 CommentsClose CommentsPermalink





(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 transfer (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

SEC. 1105. EFFECTIVE DATE.

This subtitle shall take effect on the date of enactment of this Act. CommentsClose CommentsPermalink

Subtitle C--Quality Health Insurance Coverage for All Americans CommentsClose CommentsPermalink

PART I--HEALTH INSURANCE MARKET REFORMS

SEC. 1201. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT.

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-- CommentsClose CommentsPermalink





(1) by striking the heading for subpart 1 and inserting the following: CommentsClose CommentsPermalink

‘Subpart I--General Reform’;

(2)(A) in section 2701 (42 U.S.C. 300gg), by striking the section heading and subsection (a) and inserting the following: CommentsClose CommentsPermalink

‘SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS OR OTHER DISCRIMINATION BASED ON HEALTH STATUS.

‘(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 CommentsClose CommentsPermalink





(B) by transferring such section (as amended by subparagraph (A)) so as to appear after the section 2703 added by paragraph (4); CommentsClose CommentsPermalink





(3)(A) in section 2702 (42 U.S.C. 300gg-1)-- CommentsClose CommentsPermalink





(i) by striking the section heading and all that follows through subsection (a); CommentsClose CommentsPermalink





(ii) in subsection (b)-- CommentsClose CommentsPermalink





(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 CommentsClose CommentsPermalink





(II) in paragraph (2)(A)-- CommentsClose CommentsPermalink





(aa) by inserting ‘or individual’ after ‘employer’; and CommentsClose CommentsPermalink





(bb) by inserting ‘or individual health coverage, as the case may be’ before the semicolon; and CommentsClose CommentsPermalink





(iii) in subsection (e)-- CommentsClose CommentsPermalink





(I) by striking ‘(a)(1)(F)’ and inserting ‘(a)(6)’; CommentsClose CommentsPermalink





(II) by striking ‘2701’ and inserting ‘2704’; and CommentsClose CommentsPermalink





(III) by striking ‘2721(a)’ and inserting ‘2735(a)’; and CommentsClose CommentsPermalink





(B) by transferring such section (as amended by subparagraph (A)) to appear after section 2705(a) as added by paragraph (4); and CommentsClose CommentsPermalink





(4) by inserting after the subpart heading (as added by paragraph (1)) the following: CommentsClose CommentsPermalink

‘SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS.

‘(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-- CommentsClose CommentsPermalink





‘(A) such rate shall vary with respect to the particular plan or coverage involved only by-- CommentsClose CommentsPermalink





‘(i) whether such plan or coverage covers an individual or family; CommentsClose CommentsPermalink





‘(ii) rating area, as established in accordance with paragraph (2); CommentsClose CommentsPermalink





‘(iii) age, except that such rate shall not vary by more than 3 to 1 for adults (consistent with section 2707(c)); and CommentsClose CommentsPermalink





‘(iv) tobacco use, except that such rate shall not vary by more than 1.5 to 1; and CommentsClose CommentsPermalink





‘(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- CommentsClose CommentsPermalink





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





‘(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 State’s 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 Secretary, 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 coverage 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 MARKET- 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

‘SEC. 2702. GUARANTEED AVAILABILITY OF COVERAGE.

‘(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. CommentsClose CommentsPermalink





‘(b) Enrollment- CommentsClose CommentsPermalink





‘(1) RESTRICTION- A health insurance issuer described in subsection (a) may restrict enrollment 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

‘SEC. 2703. GUARANTEED RENEWABILITY OF COVERAGE.

‘(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

‘SEC. 2705. PROHIBITING DISCRIMINATION AGAINST INDIVIDUAL PARTICIPANTS AND BENEFICIARIES BASED ON HEALTH STATUS.

‘(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 of 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 conditions arising out of acts of domestic violence). CommentsClose CommentsPermalink





‘(8) Disability. CommentsClose CommentsPermalink





‘(9) Any other health status-related factor determined appropriate by the Secretary. CommentsClose CommentsPermalink





‘(j) Programs of Health Promotion or Disease Prevention- CommentsClose CommentsPermalink





‘(1) GENERAL PROVISIONS- CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(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 obtaining a premium discount or rebate or other reward under a wellness program as described in paragraph (1)(B) are based on an individual satisfying 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: CommentsClose CommentsPermalink





‘(A) A program that reimburses all or part of the cost for memberships in a fitness center. CommentsClose CommentsPermalink





‘(B) A diagnostic testing program that provides a reward for participation and does not base any part of the reward on outcomes. CommentsClose CommentsPermalink





‘(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). CommentsClose CommentsPermalink





‘(D) A program that reimburses individuals for the costs of smoking cessation programs without regard to whether the individual quits smoking. CommentsClose CommentsPermalink





‘(E) A program that provides a reward to individuals for attending a periodic health education seminar. CommentsClose CommentsPermalink





‘(3) WELLNESS PROGRAMS SUBJECT TO REQUIREMENTS- 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: CommentsClose CommentsPermalink





‘(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 dependents 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. CommentsClose CommentsPermalink





‘(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 for discriminating based on a health status factor, and is not highly suspect in the method chosen to promote health or prevent disease. CommentsClose CommentsPermalink





‘(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. CommentsClose CommentsPermalink





‘(D) The full reward under the wellness program shall be made available to all similarly situated individuals. For such purpose, among other things: CommentsClose CommentsPermalink





‘(i) The reward is not available to all similarly situated individuals for a period unless the wellness program allows-- CommentsClose CommentsPermalink





‘(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 CommentsClose CommentsPermalink





‘(II) 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 medically inadvisable to attempt to satisfy the otherwise applicable standard. CommentsClose CommentsPermalink





‘(ii) If reasonable under the circumstances, the plan or issuer may seek verification, such as a statement from an individual’s 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. CommentsClose CommentsPermalink





‘(E) The plan or issuer involved shall disclose 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. CommentsClose CommentsPermalink





‘(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 enactment 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. CommentsClose CommentsPermalink





‘(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- CommentsClose CommentsPermalink





‘(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 State’s project is designed in a manner that-- CommentsClose CommentsPermalink





‘(i) will not result in any decrease in coverage; and CommentsClose CommentsPermalink





‘(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 Prote