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H. R. Ll

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H.L.C.
.....................................................................
(Original Signature of Member)
111TH CONGRESS
1ST SESSION
H. R. ll
To provide affordable, quality health care for all Americans and reduce
the growth in health care spending, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
Mr. DINGELL (for himself, Mr. RANGEL, Mr. WAXMAN, Mr. GEORGE MILLER
of California, Mr. STARK, Mr. PALLONE, and Mr. ANDREWS) introduced
the following bill; which was referred to the Committee on
lllllllllllllll
A BILL
To provide affordable, quality health care for all Americans
and reduce the growth in health care spending, and
for other purposes.
1
Be it enacted by the Senate and House of Representa-
2 tives of the United States of America in Congress assembled,
3 SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES,
4
AND SUBTITLES.
5
(a) SHORT TITLE.—This Act may be cited as the
6 ‘‘America’s Affordable Health Choices Act of 2009’’.
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1
(b) TABLE
OF
DIVISIONS, TITLES, AND
SUB-
2 TITLES.—This Act is divided into divisions, titles, and
3 subtitles as follows:
DIVISION A—AFFORDABLE HEALTH CARE CHOICES
TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED
HEALTH BENEFITS PLANS
Subtitle A—General Standards
Subtitle B—Standards Guaranteeing Access to Affordable Coverage
Subtitle C—Standards Guaranteeing Access to Essential Benefits
Subtitle D—Additional Consumer Protections
Subtitle E—Governance
Subtitle F—Relation to Other Requirements; Miscellaneous
Subtitle G—Early Investments
TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED
PROVISIONS
Subtitle A—Health Insurance Exchange
Subtitle B—Public Health Insurance Option
Subtitle C—Individual Affordability Credits
TITLE III—SHARED RESPONSIBILITY
Subtitle A—Individual Responsibility
Subtitle B—Employer Responsibility
TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
Subtitle A—Shared Responsibility
Subtitle B—Credit for Small Business Employee Health Coverage Expenses
Subtitle C—Disclosures to Carry Out Health Insurance Exchange Subsidies
Subtitle D—Other Revenue Provisions
DIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS
TITLE I—IMPROVING HEALTH CARE VALUE
Subtitle A—Provisions Related to Medicare Part A
Subtitle B—Provisions Related to Part B
Subtitle C—Provisions Related to Medicare Parts A and B
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3
Subtitle D—Medicare Advantage Reforms
Subtitle E—Improvements to Medicare Part D
Subtitle F—Medicare Rural Access Protections
TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A—Improving and Simplifying Financial Assistance for Low Income
Medicare Beneficiaries
Subtitle B—Reducing Health Disparities
Subtitle C—Miscellaneous Improvements
TITLE III—PROMOTING PRIMARY CARE, MENTAL HEALTH
SERVICES, AND COORDINATED CARE
TITLE IV—QUALITY
Subtitle A—Comparative Effectiveness Research
Subtitle B—Nursing Home Transparency
Subtitle C—Quality Measurements
Subtitle D—Physician Payments Sunshine Provision
Subtitle E—Public Reporting on Health Care-Associated Infections
TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION
TITLE VI—PROGRAM INTEGRITY
Subtitle A—Increased Funding to Fight Waste, Fraud, and Abuse
Subtitle B—Enhanced Penalties for Fraud and Abuse
Subtitle C—Enhanced Program and Provider Protections
Subtitle D—Access to Information Needed to Prevent Fraud, Waste, and
Abuse
TITLE VII—MEDICAID AND CHIP
Subtitle A—Medicaid and Health Reform
Subtitle B—Prevention
Subtitle C—Access
Subtitle D—Coverage
Subtitle E—Financing
Subtitle F—Waste, Fraud, and Abuse
Subtitle G—Puerto Rico and the Territories
Subtitle H—Miscellaneous
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TITLE VIII—REVENUE-RELATED PROVISIONS
TITLE IX—MISCELLANEOUS PROVISIONS
DIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT
TITLE I—COMMUNITY HEALTH CENTERS
TITLE II—WORKFORCE
Subtitle A—Primary Care Workforce
Subtitle B—Nursing Workforce
Subtitle C—Public Health Workforce
Subtitle D—Adapting Workforce to Evolving Health System Needs
TITLE III—PREVENTION AND WELLNESS
TITLE IV—QUALITY AND SURVEILLANCE
TITLE V—OTHER PROVISIONS
Subtitle A—Drug Discount for Rural and Other Hospitals
Subtitle B—School-Based Health Clinics
Subtitle C—National Medical Device Registry
Subtitle D—Grants for Comprehensive Programs to Provide Education to
Nurses and Create a Pipeline to Nursing
Subtitle E—States Failing to Adhere to Certain Employment Obligations
1
DIVISION A—AFFORDABLE
2
HEALTH CARE CHOICES
3 SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION;
4
GENERAL DEFINITIONS.
5
(a) PURPOSE.—
6
(1) IN GENERAL.—The purpose of this division
7
is to provide affordable, quality health care for all
8
Americans and reduce the growth in health care
9
spending.
10
(2) BUILDING ON CURRENT SYSTEM.—This di-
11
vision achieves this purpose by building on what
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1
works in today’s health care system, while repairing
2
the aspects that are broken.
3
(3) INSURANCE REFORMS.—This division—
4
(A) enacts strong insurance market re-
5
forms;
6
(B) creates a new Health Insurance Ex-
7
change, with a public health insurance option
8
alongside private plans;
9
(C) includes sliding scale affordability
10
credits; and
11
(D) initiates shared responsibility among
12
workers, employers, and the government;
13
so that all Americans have coverage of essential
14
health benefits.
15
(4) HEALTH DELIVERY REFORM.—This division
16
institutes health delivery system reforms both to in-
17
crease quality and to reduce growth in health spend-
18
ing so that health care becomes more affordable for
19
businesses, families, and government.
20
(b) TABLE OF CONTENTS OF DIVISION.—The table
21 of contents of this division is as follows:
Sec. 100. Purpose; table of contents of division; general definitions.
TITLE I—PROTECTIONS AND STANDARDS FOR QUALIFIED
HEALTH BENEFITS PLANS
Subtitle A—General Standards
Sec. 101. Requirements reforming health insurance marketplace.
Sec. 102. Protecting the choice to keep current coverage.
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Subtitle B—Standards Guaranteeing Access to Affordable Coverage
Sec. 111. Prohibiting pre-existing condition exclusions.
Sec. 112. Guaranteed issue and renewal for insured plans.
Sec. 113. Insurance rating rules.
Sec. 114. Nondiscrimination in benefits; parity in mental health and substance
abuse disorder benefits.
Sec. 115. Ensuring adequacy of provider networks.
Sec. 116. Ensuring value and lower premiums.
Subtitle C—Standards Guaranteeing Access to Essential Benefits
Sec. 121. Coverage of essential benefits package.
Sec. 122. Essential benefits package defined.
Sec. 123. Health Benefits Advisory Committee.
Sec. 124. Process for adoption of recommendations; adoption of benefit stand-
ards.
Subtitle D—Additional Consumer Protections
Sec. 131. Requiring fair marketing practices by health insurers.
Sec. 132. Requiring fair grievance and appeals mechanisms.
Sec. 133. Requiring information transparency and plan disclosure.
Sec. 134. Application to qualified health benefits plans not offered through the
Health Insurance Exchange.
Sec. 135. Timely payment of claims.
Sec. 136. Standardized rules for coordination and subrogation of benefits.
Sec. 137. Application of administrative simplification.
Subtitle E—Governance
Sec. 141. Health Choices Administration; Health Choices Commissioner.
Sec. 142. Duties and authority of Commissioner.
Sec. 143. Consultation and coordination.
Sec. 144. Health Insurance Ombudsman.
Subtitle F—Relation to Other Requirements; Miscellaneous
Sec. 151. Relation to other requirements.
Sec. 152. Prohibiting discrimination in health care.
Sec. 153. Whistleblower protection.
Sec. 154. Construction regarding collective bargaining.
Sec. 155. Severability.
Subtitle G—Early Investments
Sec. 161. Ensuring value and lower premiums.
Sec. 162. Ending health insurance rescission abuse.
Sec. 163. Administrative simplification.
Sec. 164. Reinsurance program for retirees.
TITLE II—HEALTH INSURANCE EXCHANGE AND RELATED
PROVISIONS
Subtitle A—Health Insurance Exchange
Sec. 201. Establishment of Health Insurance Exchange; outline of duties; defi-
nitions.
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Sec. 202. Exchange-eligible individuals and employers.
Sec. 203. Benefits package levels.
Sec. 204. Contracts for the offering of Exchange-participating health benefits
plans.
Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employ-
ers in Exchange-participating health benefits plan.
Sec. 206. Other functions.
Sec. 207. Health Insurance Exchange Trust Fund.
Sec. 208. Optional operation of State-based health insurance exchanges.
Subtitle B—Public Health Insurance Option
Sec. 221. Establishment and administration of a public health insurance option
as an Exchange-qualified health benefits plan.
Sec. 222. Premiums and financing.
Sec. 223. Payment rates for items and services.
Sec. 224. Modernized payment initiatives and delivery system reform.
Sec. 225. Provider participation.
Sec. 226. Application of fraud and abuse provisions.
Subtitle C—Individual Affordability Credits
Sec. 241. Availability through Health Insurance Exchange.
Sec. 242. Affordable credit eligible individual.
Sec. 243. Affordable premium credit.
Sec. 244. Affordability cost-sharing credit.
Sec. 245. Income determinations.
Sec. 246. No Federal payment for undocumented aliens.
TITLE III—SHARED RESPONSIBILITY
Subtitle A—Individual Responsibility
Sec. 301. Individual responsibility.
Subtitle B—Employer Responsibility
PART 1—HEALTH COVERAGE PARTICIPATION REQUIREMENTS
Sec. 311. Health coverage participation requirements.
Sec. 312. Employer responsibility to contribute towards employee and depend-
ent coverage.
Sec. 313. Employer contributions in lieu of coverage.
Sec. 314. Authority related to improper steering.
PART 2—SATISFACTION OF HEALTH COVERAGE PARTICIPATION
REQUIREMENTS
Sec. 321. Satisfaction of health coverage participation requirements under the
Employee Retirement Income Security Act of 1974.
Sec. 322. Satisfaction of health coverage participation requirements under the
Internal Revenue Code of 1986.
Sec. 323. Satisfaction of health coverage participation requirements under the
Public Health Service Act.
Sec. 324. Additional rules relating to health coverage participation require-
ments.
TITLE IV—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986
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Subtitle A—Shared Responsibility
PART 1—INDIVIDUAL RESPONSIBILITY
Sec. 401. Tax on individuals without acceptable health care coverage.
PART 2—EMPLOYER RESPONSIBILITY
Sec. 411. Election to satisfy health coverage participation requirements.
Sec. 412. Responsibilities of nonelecting employers.
Subtitle B—Credit for Small Business Employee Health Coverage Expenses
Sec. 421. Credit for small business employee health coverage expenses.
Subtitle C—Disclosures to Carry Out Health Insurance Exchange Subsidies
Sec. 431. Disclosures to carry out health insurance exchange subsidies.
Subtitle D—Other Revenue Provisions
PART 1—GENERAL PROVISIONS
Sec. 441. Surcharge on high income individuals.
Sec. 442. Delay in application of worldwide allocation of interest.
PART 2—PREVENTION OF TAX AVOIDANCE
Sec. 451. Limitation on treaty benefits for certain deductible payments.
Sec. 452. Codification of economic substance doctrine.
Sec. 453. Penalties for underpayments.
1
(c) GENERAL DEFINITIONS.—Except as otherwise
2 provided, in this division:
3
(1) ACCEPTABLE COVERAGE.—The term ‘‘ac-
4
ceptable coverage’’ has the meaning given such term
5
in section 202(d)(2).
6
(2) BASIC PLAN.—The term ‘‘basic plan’’ has
7
the meaning given such term in section 203(c).
8
(3) COMMISSIONER.—The term ‘‘Commis-
9
sioner’’ means the Health Choices Commissioner es-
10
tablished under section 141.
11
(4) COST-SHARING.—The term ‘‘cost-sharing’’
12
includes deductibles, coinsurance, copayments, and
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1
similar charges but does not include premiums or
2
any network payment differential for covered serv-
3
ices or spending for non-covered services.
4
(5) DEPENDENT.—The term ‘‘dependent’’ has
5
the meaning given such term by the Commissioner
6
and includes a spouse.
7
(6) EMPLOYMENT-BASED HEALTH PLAN.—The
8
term ‘‘employment-based health plan’’—
9
(A) means a group health plan (as defined
10
in section 733(a)(1) of the Employee Retire-
11
ment Income Security Act of 1974); and
12
(B) includes such a plan that is the fol-
13
lowing:
14
(i) FEDERAL, STATE, AND TRIBAL
15
GOVERNMENTAL PLANS.—A governmental
16
plan (as defined in section 3(32) of the
17
Employee Retirement Income Security Act
18
of 1974), including a health benefits plan
19
offered under chapter 89 of title 5, United
20
States Code.
21
(ii) CHURCH PLANS.—A church plan
22
(as defined in section 3(33) of the Em-
23
ployee Retirement Income Security Act of
24
1974).
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1
(7) ENHANCED PLAN.—The term ‘‘enhanced
2
plan’’ has the meaning given such term in section
3
203(c).
4
(8) ESSENTIAL BENEFITS PACKAGE.—The term
5
‘‘essential benefits package’’ is defined in section
6
122(a).
7
(9) FAMILY.—The term ‘‘family’’ means an in-
8
dividual and includes the individual’s dependents.
9
(10) FEDERAL POVERTY LEVEL; FPL.—The
10
terms ‘‘Federal poverty level’’ and ‘‘FPL’’ have the
11
meaning given the term ‘‘poverty line’’ in section
12
673(2) of the Community Services Block Grant Act
13
(42 U.S.C. 9902(2)), including any revision required
14
by such section.
15
(11) HEALTH BENEFITS PLAN.—The terms
16
‘‘health benefits plan’’ means health insurance cov-
17
erage and an employment-based health plan and in-
18
cludes the public health insurance option.
19
(12) HEALTH INSURANCE COVERAGE; HEALTH
20
INSURANCE ISSUER.—The terms ‘‘health insurance
21
coverage’’ and ‘‘health insurance issuer’’ have the
22
meanings given such terms in section 2791 of the
23
Public Health Service Act.
24
(13) HEALTH INSURANCE EXCHANGE.—The
25
term ‘‘Health Insurance Exchange’’ means the
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1
Health Insurance Exchange established under sec-
2
tion 201.
3
(14) MEDICAID.—The term ‘‘Medicaid’’ means
4
a State plan under title XIX of the Social Security
5
Act (whether or not the plan is operating under a
6
waiver under section 1115 of such Act).
7
(15) MEDICARE.—The term ‘‘Medicare’’ means
8
the health insurance programs under title XVIII of
9
the Social Security Act.
10
(16) PLAN SPONSOR.—The term ‘‘plan spon-
11
sor’’ has the meaning given such term in section
12
3(16)(B) of the Employee Retirement Income Secu-
13
rity Act of 1974.
14
(17) PLAN
YEAR.—The term ‘‘plan year’’
15
means—
16
(A) with respect to an employment-based
17
health plan, a plan year as specified under such
18
plan; or
19
(B) with respect to a health benefits plan
20
other than an employment-based health plan, a
21
12-month period as specified by the Commis-
22
sioner.
23
(18) PREMIUM PLAN; PREMIUM-PLUS PLAN.—
24
The terms ‘‘premium plan’’ and ‘‘premium-plus
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1
plan’’ have the meanings given such terms in section
2
203(c).
3
(19) QHBP OFFERING ENTITY.—The terms
4
‘‘QHBP offering entity’’ means, with respect to a
5
health benefits plan that is—
6
(A) a group health plan (as defined, sub-
7
ject to subsection (d), in section 733(a)(1) of
8
the Employee Retirement Income Security Act
9
of 1974), the plan sponsor in relation to such
10
group health plan, except that, in the case of a
11
plan maintained jointly by 1 or more employers
12
and 1 or more employee organizations and with
13
respect to which an employer is the primary
14
source of financing, such term means such em-
15
ployer;
16
(B) health insurance coverage, the health
17
insurance issuer offering the coverage;
18
(C) the public health insurance option, the
19
Secretary of Health and Human Services;
20
(D) a non-Federal governmental plan (as
21
defined in section 2791(d) of the Public Health
22
Service Act), the State or political subdivision
23
of a State (or agency or instrumentality of such
24
State or subdivision) which establishes or main-
25
tains such plan; or
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1
(E) a Federal governmental plan (as de-
2
fined in section 2791(d) of the Public Health
3
Service Act), the appropriate Federal official.
4
(20) QUALIFIED HEALTH BENEFITS PLAN.—
5
The term ‘‘qualified health benefits plan’’ means a
6
health benefits plan that meets the requirements for
7
such a plan under title I and includes the public
8
health insurance option.
9
(21) PUBLIC HEALTH INSURANCE OPTION.—
10
The term ‘‘public health insurance option’’ means
11
the public health insurance option as provided under
12
subtitle B of title II.
13
(22) SERVICE AREA; PREMIUM RATING AREA.—
14
The terms ‘‘service area’’ and ‘‘premium rating
15
area’’ mean with respect to health insurance cov-
16
erage—
17
(A) offered other than through the Health
18
Insurance Exchange, such an area as estab-
19
lished by the QHBP offering entity of such cov-
20
erage in accordance with applicable State law;
21
and
22
(B) offered through the Health Insurance
23
Exchange, such an area as established by such
24
entity in accordance with applicable State law
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1
and applicable rules of the Commissioner for
2
Exchange-participating health benefits plans.
3
(23) STATE.—The term ‘‘State’’ means the 50
4
States and the District of Columbia.
5
(24) STATE MEDICAID AGENCY.—The term
6
‘‘State Medicaid agency’’ means, with respect to a
7
Medicaid plan, the single State agency responsible
8
for administering such plan under title XIX of the
9
Social Security Act.
10
(25) Y1, Y2, ETC..—The terms ‘‘Y1’’ , ‘‘Y2’’,
11
‘‘Y3’’, ‘‘Y4’’, ‘‘Y5’’, and similar subsequently num-
12
bered terms, mean 2013 and subsequent years, re-
13
spectively.
14 TITLE I—PROTECTIONS AND
15
STANDARDS FOR QUALIFIED
16
HEALTH BENEFITS PLANS
17
Subtitle A—General Standards
18 SEC. 101. REQUIREMENTS REFORMING HEALTH INSUR-
19
ANCE MARKETPLACE.
20
(a) PURPOSE.—The purpose of this title is to estab-
21 lish standards to ensure that new health insurance cov-
22 erage and employment-based health plans that are offered
23 meet standards guaranteeing access to affordable cov-
24 erage, essential benefits, and other consumer protections.
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1
(b) REQUIREMENTS FOR QUALIFIED HEALTH BENE-
2 FITS PLANS.—On or after the first day of Y1, a health
3 benefits plan shall not be a qualified health benefits plan
4 under this division unless the plan meets the applicable
5 requirements of the following subtitles for the type of plan
6 and plan year involved:
7
(1) Subtitle B (relating to affordable coverage).
8
(2) Subtitle C (relating to essential benefits).
9
(3) Subtitle D (relating to consumer protec-
10
tion).
11
(c) TERMINOLOGY.—In this division:
12
(1) ENROLLMENT
IN
EMPLOYMENT-BASED
13
HEALTH PLANS.—An individual shall be treated as
14
being ‘‘enrolled’’ in an employment-based health
15
plan if the individual is a participant or beneficiary
16
(as such terms are defined in section 3(7) and 3(8),
17
respectively, of the Employee Retirement Income Se-
18
curity Act of 1974) in such plan.
19
(2) INDIVIDUAL AND GROUP HEALTH INSUR-
20
ANCE COVERAGE.—The terms ‘‘individual health in-
21
surance coverage’’ and ‘‘group health insurance cov-
22
erage’’ mean health insurance coverage offered in
23
the individual market or large or small group mar-
24
ket, respectively, as defined in section 2791 of the
25
Public Health Service Act.
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1 SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT
2
COVERAGE.
3
(a) GRANDFATHERED HEALTH INSURANCE COV-
4 ERAGE DEFINED.—Subject to the succeeding provisions of
5 this section, for purposes of establishing acceptable cov-
6 erage under this division, the term ‘‘grandfathered health
7 insurance coverage’’ means individual health insurance
8 coverage that is offered and in force and effect before the
9 first day of Y1 if the following conditions are met:
10
(1) LIMITATION ON NEW ENROLLMENT.—
11
(A) IN GENERAL.—Except as provided in
12
this paragraph, the individual health insurance
13
issuer offering such coverage does not enroll
14
any individual in such coverage if the first ef-
15
fective date of coverage is on or after the first
16
day of Y1.
17
(B) DEPENDENT
COVERAGE
PER-
18
MITTED.—Subparagraph (A) shall not affect
19
the subsequent enrollment of a dependent of an
20
individual who is covered as of such first day.
21
(2) LIMITATION ON CHANGES IN TERMS OR
22
CONDITIONS.—Subject to paragraph (3) and except
23
as required by law, the issuer does not change any
24
of its terms or conditions, including benefits and
25
cost-sharing, from those in effect as of the day be-
26
fore the first day of Y1.
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17
1
(3) RESTRICTIONS ON PREMIUM INCREASES.—
2
The issuer cannot vary the percentage increase in
3
the premium for a risk group of enrollees in specific
4
grandfathered health insurance coverage without
5
changing the premium for all enrollees in the same
6
risk group at the same rate, as specified by the
7
Commissioner.
8
(b) GRACE PERIOD FOR CURRENT EMPLOYMENT-
9 BASED HEALTH PLANS.—
10
(1) GRACE PERIOD.—
11
(A) IN
GENERAL.—The Commissioner
12
shall establish a grace period whereby, for plan
13
years beginning after the end of the 5-year pe-
14
riod beginning with Y1, an employment-based
15
health plan in operation as of the day before
16
the first day of Y1 must meet the same require-
17
ments as apply to a qualified health benefits
18
plan under section 101, including the essential
19
benefit package requirement under section 121.
20
(B) EXCEPTION FOR LIMITED BENEFITS
21
PLANS.—Subparagraph (A) shall not apply to
22
an employment-based health plan in which the
23
coverage consists only of one or more of the fol-
24
lowing:
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18
1
(i) Any coverage described in section
2
3001(a)(1)(B)(ii)(IV) of division B of the
3
American Recovery and Reinvestment Act
4
of 2009 (PL 111–5).
5
(ii) Excepted benefits (as defined in
6
section 733(c) of the Employee Retirement
7
Income Security Act of 1974), including
8
coverage under a specified disease or ill-
9
ness policy described in paragraph (3)(A)
10
of such section.
11
(iii) Such other limited benefits as the
12
Commissioner may specify.
13
In no case shall an employment-based health
14
plan in which the coverage consists only of one
15
or more of the coverage or benefits described in
16
clauses (i) through (iii) be treated as acceptable
17
coverage under this division
18
(2) TRANSITIONAL TREATMENT AS ACCEPT-
19
ABLE COVERAGE.—During the grace period specified
20
in paragraph (1)(A), an employment-based health
21
plan that is described in such paragraph shall be
22
treated as acceptable coverage under this division.
23
(c) LIMITATION ON INDIVIDUAL HEALTH INSURANCE
24 COVERAGE.—
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19
1
(1) IN GENERAL.—Individual health insurance
2
coverage that is not grandfathered health insurance
3
coverage under subsection (a) may only be offered
4
on or after the first day of Y1 as an Exchange-par-
5
ticipating health benefits plan.
6
(2) SEPARATE, EXCEPTED
COVERAGE
PER-
7
MITTED.—Excepted benefits (as defined in section
8
2791(c) of the Public Health Service Act) are not
9
included within the definition of health insurance
10
coverage. Nothing in paragraph (1) shall prevent the
11
offering, other than through the Health Insurance
12
Exchange, of excepted benefits so long as it is of-
13
fered and priced separately from health insurance
14
coverage.
15 Subtitle B—Standards Guaran-
16
teeing Access to Affordable Cov-
17
erage
18 SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLU-
19
SIONS.
20
A qualified health benefits plan may not impose any
21 pre-existing condition exclusion (as defined in section
22 2701(b)(1)(A) of the Public Health Service Act) or other-
23 wise impose any limit or condition on the coverage under
24 the plan with respect to an individual or dependent based
25 on any health status-related factors (as defined in section
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20
1 2791(d)(9) of the Public Health Service Act) in relation
2 to the individual or dependent.
3 SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR IN-
4
SURED PLANS.
5
The requirements of sections 2711 (other than sub-
6 sections (c) and (e)) and 2712 (other than paragraphs (3),
7 and (6) of subsection (b) and subsection (e)) of the Public
8 Health Service Act, relating to guaranteed availability and
9 renewability of health insurance coverage, shall apply to
10 individuals and employers in all individual and group
11 health insurance coverage, whether offered to individuals
12 or employers through the Health Insurance Exchange,
13 through any employment-based health plan, or otherwise,
14 in the same manner as such sections apply to employers
15 and health insurance coverage offered in the small group
16 market, except that such section 2712(b)(1) shall apply
17 only if, before nonrenewal or discontinuation of coverage,
18 the issuer has provided the enrollee with notice of non-
19 payment of premiums and there is a grace period during
20 which the enrollees has an opportunity to correct such
21 nonpayment. Rescissions of such coverage shall be prohib-
22 ited except in cases of fraud as defined in sections
23 2712(b)(2) of such Act.
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21
1 SEC. 113. INSURANCE RATING RULES.
2
(a) IN GENERAL.—The premium rate charged for an
3 insured qualified health benefits plan may not vary except
4 as follows:
5
(1) LIMITED AGE VARIATION PERMITTED.—By
6
age (within such age categories as the Commissioner
7
shall specify) so long as the ratio of the highest such
8
premium to the lowest such premium does not ex-
9
ceed the ratio of 2 to 1.
10
(2) BY AREA.—By premium rating area (as
11
permitted by State insurance regulators or, in the
12
case of Exchange-participating health benefits plans,
13
as specified by the Commissioner in consultation
14
with such regulators).
15
(3) BY FAMILY ENROLLMENT.—By family en-
16
rollment (such as variations within categories and
17
compositions of families) so long as the ratio of the
18
premium for family enrollment (or enrollments) to
19
the premium for individual enrollment is uniform, as
20
specified under State law and consistent with rules
21
of the Commissioner.
22
(b) STUDY AND REPORTS.—
23
(1) STUDY.—The Commissioner, in coordina-
24
tion with the Secretary of Health and Human Serv-
25
ices and the Secretary of Labor, shall conduct a
26
study of the large group insured and self-insured
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22
1
employer health care markets. Such study shall ex-
2
amine the following:
3
(A) The types of employers by key charac-
4
teristics, including size, that purchase insured
5
products versus those that self-insure.
6
(B) The similarities and differences be-
7
tween typical insured and self-insured health
8
plans.
9
(C) The financial solvency and capital re-
10
serve levels of employers that self-insure by em-
11
ployer size.
12
(D) The risk of self-insured employers not
13
being able to pay obligations or otherwise be-
14
coming financially insolvent.
15
(E) The extent to which rating rules are
16
likely to cause adverse selection in the large
17
group market or to encourage small and mid
18
size employers to self-insure
19
(2) REPORTS.—Not later than 18 months after
20
the date of the enactment of this Act, the Commis-
21
sioner shall submit to Congress and the applicable
22
agencies a report on the study conducted under
23
paragraph (1). Such report shall include any rec-
24
ommendations the Commissioner deems appropriate
25
to ensure that the law does not provide incentives
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23
1
for small and mid-size employers to self-insure or
2
create adverse selection in the risk pools of large
3
group insurers and self-insured employers. Not later
4
than 18 months after the first day of Y1, the Com-
5
missioner shall submit to Congress and the applica-
6
ble agencies an updated report on such study, in-
7
cluding updates on such recommendations.
8 SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN
9
MENTAL HEALTH AND SUBSTANCE ABUSE
10
DISORDER BENEFITS.
11
(a) NONDISCRIMINATION IN BENEFITS.—A qualified
12 health benefits plan shall comply with standards estab-
13 lished by the Commissioner to prohibit discrimination in
14 health benefits or benefit structures for qualifying health
15 benefits plans, building from sections 702 of Employee
16 Retirement Income Security Act of 1974, 2702 of the
17 Public Health Service Act, and section 9802 of the Inter-
18 nal Revenue Code of 1986.
19
(b) PARITY IN MENTAL HEALTH AND SUBSTANCE
20 ABUSE DISORDER BENEFITS.—To the extent such provi-
21 sions are not superceded by or inconsistent with subtitle
22 C, the provisions of section 2705 (other than subsections
23 (a)(1), (a)(2), and (c)) of section 2705 of the Public
24 Health Service Act shall apply to a qualified health bene-
25 fits plan, regardless of whether it is offered in the indi-
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24
1 vidual or group market, in the same manner as such provi-
2 sions apply to health insurance coverage offered in the
3 large group market.
4 SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS.
5
(a) IN GENERAL.—A qualified health benefits plan
6 that uses a provider network for items and services shall
7 meet such standards respecting provider networks as the
8 Commissioner may establish to assure the adequacy of
9 such networks in ensuring enrollee access to such items
10 and services and transparency in the cost-sharing differen-
11 tials between in-network coverage and out-of-network cov-
12 erage.
13
(b) PROVIDER NETWORK DEFINED.—In this divi-
14 sion, the term ‘‘provider network’’ means the providers
15 with respect to which covered benefits, treatments, and
16 services are available under a health benefits plan.
17 SEC. 116. ENSURING VALUE AND LOWER PREMIUMS.
18
(a) IN GENERAL.—A qualified health benefits plan
19 shall meet a medical loss ratio as defined by the Commis-
20 sioner. For any plan year in which the qualified health
21 benefits plan does not meet such medical loss ratio, QHBP
22 offering entity shall provide in a manner specified by the
23 Commissioner for rebates to enrollees of payment suffi-
24 cient to meet such loss ratio.
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25
1
(b) BUILDING ON INTERIM RULES.—In imple-
2 menting subsection (a), the Commissioner shall build on
3 the definition and methodology developed by the Secretary
4 of Health and Human Services under the amendments
5 made by section 161 for determining how to calculate the
6 medical loss ratio. Such methodology shall be set at the
7 highest level medical loss ratio possible that is designed
8 to ensure adequate participation by QHBP offering enti-
9 ties, competition in the health insurance market in and
10 out of the Health Insurance Exchange, and value for con-
11 sumers so that their premiums are used for services.
12 Subtitle C—Standards Guaran-
13
teeing Access to Essential Bene-
14
fits
15 SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.
16
(a) IN GENERAL.—A qualified health benefits plan
17 shall provide coverage that at least meets the benefit
18 standards adopted under section 124 for the essential ben-
19 efits package described in section 122 for the plan year
20 involved.
21
(b) CHOICE OF COVERAGE.—
22
(1) NON-EXCHANGE-PARTICIPATING
HEALTH
23
BENEFITS PLANS.—In the case of a qualified health
24
benefits plan that is not an Exchange-participating
25
health benefits plan, such plan may offer such cov-
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26
1
erage in addition to the essential benefits package as
2
the QHBP offering entity may specify.
3
(2) EXCHANGE-PARTICIPATING HEALTH BENE-
4
FITS PLANS.—In the case of an Exchange-partici-
5
pating health benefits plan, such plan is required
6
under section 203 to provide specified levels of bene-
7
fits and, in the case of a plan offering a premium-
8
plus level of benefits, provide additional benefits.
9
(3) CONTINUATION OF OFFERING OF SEPARATE
10
EXCEPTED BENEFITS COVERAGE.—Nothing in this
11
division shall be construed as affecting the offering
12
of health benefits in the form of excepted benefits
13
(described in section 102(b)(1)(B)(ii)) if such bene-
14
fits are offered under a separate policy, contract, or
15
certificate of insurance.
16
(c) NO RESTRICTIONS ON COVERAGE UNRELATED
17 TO CLINICAL APPROPRIATENESS.—A qualified health ben-
18 efits plan may not impose any restriction (other than cost-
19 sharing) unrelated to clinical appropriateness on the cov-
20 erage of the health care items and services.
21 SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED.
22
(a) IN GENERAL.—In this division, the term ‘‘essen-
23 tial benefits package’’ means health benefits coverage,
24 consistent with standards adopted under section 124 to
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27
1 ensure the provision of quality health care and financial
2 security, that—
3
(1) provides payment for the items and services
4
described in subsection (b) in accordance with gen-
5
erally accepted standards of medical or other appro-
6
priate clinical or professional practice;
7
(2) limits cost-sharing for such covered health
8
care items and services in accordance with such ben-
9
efit standards, consistent with subsection (c);
10
(3) does not impose any annual or lifetime limit
11
on the coverage of covered health care items and
12
services;
13
(4) complies with section 115(a) (relating to
14
network adequacy); and
15
(5) is equivalent, as certified by Office of the
16
Actuary of the Centers for Medicare & Medicaid
17
Services, to the average prevailing employer-spon-
18
sored coverage.
19
(b) MINIMUM SERVICES TO BE COVERED.—The
20 items and services described in this subsection are the fol-
21 lowing:
22
(1) Hospitalization.
23
(2) Outpatient hospital and outpatient clinic
24
services, including emergency department services.
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28
1
(3) Professional services of physicians and other
2
health professionals.
3
(4) Such services, equipment, and supplies inci-
4
dent to the services of a physician’s or a health pro-
5
fessional’s delivery of care in institutional settings,
6
physician offices, patients’ homes or place of resi-
7
dence, or other settings, as appropriate.
8
(5) Prescription drugs.
9
(6) Rehabilitative and habilitative services.
10
(7) Mental health and substance use disorder
11
services.
12
(8) Preventive services, including those services
13
recommended with a grade of A or B by the Task
14
Force on Clinical Preventive Services and those vac-
15
cines recommended for use by the Director of the
16
Centers for Disease Control and Prevention.
17
(9) Maternity care.
18
(10) Well baby and well child care and oral
19
health, vision, and hearing services, equipment, and
20
supplies at least for children under 21 years of age.
21
(c) REQUIREMENTS RELATING TO COST-SHARING
22 AND MINIMUM ACTUARIAL VALUE.—
23
(1) NO COST-SHARING FOR PREVENTIVE SERV-
24
ICES.—There shall be no cost-sharing under the es-
25
sential benefits package for preventive items and
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29
1
services (as specified under the benefit standards),
2
including well baby and well child care.
3
(2) ANNUAL LIMITATION.—
4
(A) ANNUAL LIMITATION.—The cost-shar-
5
ing incurred under the essential benefits pack-
6
age with respect to an individual (or family) for
7
a year does not exceed the applicable level spec-
8
ified in subparagraph (B).
9
(B) APPLICABLE LEVEL.—The applicable
10
level specified in this subparagraph for Y1 is
11
$5,000 for an individual and $10,000 for a
12
family. Such levels shall be increased (rounded
13
to the nearest $100) for each subsequent year
14
by the annual percentage increase in the Con-
15
sumer Price Index (United States city average)
16
applicable to such year.
17
(C) USE OF COPAYMENTS.—In establishing
18
cost-sharing levels for basic, enhanced, and pre-
19
mium plans under this subsection, the Sec-
20
retary shall, to the maximum extent possible,
21
use only copayments and not coinsurance.
22
(3) MINIMUM ACTUARIAL VALUE.—
23
(A) IN GENERAL.—The cost-sharing under
24
the essential benefits package shall be designed
25
to provide a level of coverage that is designed
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30
1
to provide benefits that are actuarially equiva-
2
lent to approximately 70 percent of the full ac-
3
tuarial value of the benefits provided under the
4
reference benefits package described in sub-
5
paragraph (B).
6
(B) REFERENCE BENEFITS PACKAGE DE-
7
SCRIBED.—The reference benefits package de-
8
scribed in this subparagraph is the essential
9
benefits package if there were no cost-sharing
10
imposed.
11 SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE.
12
(a) ESTABLISHMENT.—
13
(1) IN GENERAL.—There is established a pri-
14
vate-public advisory committee which shall be a
15
panel of medical and other experts to be known as
16
the Health Benefits Advisory Committee to rec-
17
ommend covered benefits and essential, enhanced,
18
and premium plans.
19
(2) CHAIR.—The Surgeon General shall be a
20
member and the chair of the Health Benefits Advi-
21
sory Committee.
22
(3) MEMBERSHIP.—The Health Benefits Advi-
23
sory Committee shall be composed of the following
24
members, in addition to the Surgeon General:
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31
1
(A) 9 members who are not Federal em-
2
ployees or officers and who are appointed by
3
the President.
4
(B) 9 members who are not Federal em-
5
ployees or officers and who are appointed by
6
the Comptroller General of the United States in
7
a manner similar to the manner in which the
8
Comptroller General appoints members to the
9
Medicare Payment Advisory Commission under
10
section 1805(c) of the Social Security Act.
11
(C) Such even number of members (not to
12
exceed 8) who are Federal employees and offi-
13
cers, as the President may appoint.
14
Such initial appointments shall be made not later
15
than 60 days after the date of the enactment of this
16
Act.
17
(4) TERMS.—Each member of the Health Bene-
18
fits Advisory Committee shall serve a 3-year term on
19
the Committee, except that the terms of the initial
20
members shall be adjusted in order to provide for a
21
staggered term of appointment for all such mem-
22
bers.
23
(5) PARTICIPATION.—The membership of the
24
Health Benefits Advisory Committee shall at least
25
reflect providers, consumer representatives, employ-
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32
1
ers, labor, health insurance issuers, experts in health
2
care financing and delivery, experts in racial and
3
ethnic disparities, experts in care for those with dis-
4
abilities, representatives of relevant governmental
5
agencies. and at least one practicing physician or
6
other health professional and an expert on children’s
7
health and shall represent a balance among various
8
sectors of the health care system so that no single
9
sector unduly influences the recommendations of
10
such Committee.
11
(b) DUTIES.—
12
(1) RECOMMENDATIONS ON BENEFIT STAND-
13
ARDS.—The Health Benefits Advisory Committee
14
shall recommend to the Secretary of Health and
15
Human Services (in this subtitle referred to as the
16
‘‘Secretary’’) benefit standards (as defined in para-
17
graph (4)), and periodic updates to such standards.
18
In developing such recommendations, the Committee
19
shall take into account innovation in health care and
20
consider how such standards could reduce health dis-
21
parities.
22
(2) DEADLINE.—The Health Benefits Advisory
23
Committee shall recommend initial benefit standards
24
to the Secretary not later than 1 year after the date
25
of the enactment of this Act.
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1
(3) PUBLIC INPUT.—The Health Benefits Advi-
2
sory Committee shall allow for public input as a part
3
of developing recommendations under this sub-
4
section.
5
(4) BENEFIT STANDARDS DEFINED.—In this
6
subtitle, the term ‘‘benefit standards’’ means stand-
7
ards respecting—
8
(A) the essential benefits package de-
9
scribed in section 122, including categories of
10
covered treatments, items and services within
11
benefit classes, and cost-sharing; and
12
(B) the cost-sharing levels for enhanced
13
plans and premium plans (as provided under
14
section 203(c)) consistent with paragraph (5).
15
(5) LEVELS OF COST-SHARING FOR ENHANCED
16
AND PREMIUM PLANS.—
17
(A) ENHANCED PLAN.—The level of cost-
18
sharing for enhanced plans shall be designed so
19
that such plans have benefits that are actuari-
20
ally equivalent to approximately 85 percent of
21
the actuarial value of the benefits provided
22
under the reference benefits package described
23
in section 122(c)(3)(B).
24
(B) PREMIUM PLAN.—The level of cost-
25
sharing for premium plans shall be designed so
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34
1
that such plans have benefits that are actuari-
2
ally equivalent to approximately 95 percent of
3
the actuarial value of the benefits provided
4
under the reference benefits package described
5
in section 122(c)(3)(B).
6
(c) OPERATIONS.—
7
(1) PER DIEM PAY.—Each member of the
8
Health Benefits Advisory Committee shall receive
9
travel expenses, including per diem in accordance
10
with applicable provisions under subchapter I of
11
chapter 57 of title 5, United States Code, and shall
12
otherwise serve without additional pay.
13
(2) MEMBERS NOT TREATED AS FEDERAL EM-
14
PLOYEES.—Members of the Health Benefits Advi-
15
sory Committee shall not be considered employees of
16
the Federal government solely by reason of any serv-
17
ice on the Committee.
18
(3) APPLICATION OF FACA.—The Federal Advi-
19
sory Committee Act (5 U.S.C. App.), other than sec-
20
tion 14, shall apply to the Health Benefits Advisory
21
Committee.
22
(d) PUBLICATION.—The Secretary shall provide for
23 publication in the Federal Register and the posting on the
24 Internet website of the Department of Health and Human
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35
1 Services of all recommendations made by the Health Ben-
2 efits Advisory Committee under this section.
3 SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDA-
4
TIONS; ADOPTION OF BENEFIT STANDARDS.
5
(a) PROCESS FOR ADOPTION OF RECOMMENDA-
6 TIONS.—
7
(1) REVIEW OF RECOMMENDED STANDARDS.—
8
Not later than 45 days after the date of receipt of
9
benefit standards recommended under section 123
10
(including such standards as modified under para-
11
graph (2)(B)), the Secretary shall review such
12
standards and shall determine whether to propose
13
adoption of such standards as a package.
14
(2) DETERMINATION TO ADOPT STANDARDS.—
15
If the Secretary determines—
16
(A) to propose adoption of benefit stand-
17
ards so recommended as a package, the Sec-
18
retary shall, by regulation under section 553 of
19
title 5, United States Code, propose adoption
20
such standards; or
21
(B) not to propose adoption of such stand-
22
ards as a package, the Secretary shall notify
23
the Health Benefits Advisory Committee in
24
writing of such determination and the reasons
25
for not proposing the adoption of such rec-
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36
1
ommendation and provide the Committee with a
2
further opportunity to modify its previous rec-
3
ommendations and submit new recommenda-
4
tions to the Secretary on a timely basis.
5
(3) CONTINGENCY.—If, because of the applica-
6
tion of paragraph (2)(B), the Secretary would other-
7
wise be unable to propose initial adoption of such
8
recommended standards by the deadline specified in
9
subsection (b)(1), the Secretary shall, by regulation
10
under section 553 of title 5, United States Code,
11
propose adoption of initial benefit standards by such
12
deadline.
13
(4) PUBLICATION.—The Secretary shall provide
14
for publication in the Federal Register of all deter-
15
minations made by the Secretary under this sub-
16
section.
17
(b) ADOPTION OF STANDARDS.—
18
(1) INITIAL STANDARDS.—Not later than 18
19
months after the date of the enactment of this Act,
20
the Secretary shall, through the rulemaking process
21
consistent with subsection (a), adopt an initial set of
22
benefit standards.
23
(2) PERIODIC UPDATING STANDARDS.—Under
24
subsection (a), the Secretary shall provide for the
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37
1
periodic updating of the benefit standards previously
2
adopted under this section.
3
(3) REQUIREMENT.—The Secretary may not
4
adopt any benefit standards for an essential benefits
5
package or for level of cost-sharing that are incon-
6
sistent with the requirements for such a package or
7
level under sections 122 and 123(b)(5).
8
Subtitle D—Additional Consumer
9
Protections
10 SEC. 131. REQUIRING FAIR MARKETING PRACTICES BY
11
HEALTH INSURERS.
12
The Commissioner shall establish uniform marketing
13 standards that all insured QHBP offering entities shall
14 meet.
15 SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS
16
MECHANISMS.
17
(a) IN GENERAL.—A QHBP offering entity shall pro-
18 vide for timely grievance and appeals mechanisms that the
19 Commissioner shall establish.
20
(b) INTERNAL CLAIMS AND APPEALS PROCESS.—
21 Under a qualified health benefits plan the QHBP offering
22 entity shall provide an internal claims and appeals process
23 that initially incorporates the claims and appeals proce-
24 dures (including urgent claims) set forth at section
25 2560.503–1 of title 29, Code of Federal Regulations, as
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38
1 published on November 21, 2000 (65 Fed. Reg. 70246)
2 and shall update such process in accordance with any
3 standards that the Commissioner may establish.
4
(c) EXTERNAL REVIEW PROCESS.—
5
(1) IN GENERAL.—The Commissioner shall es-
6
tablish an external review process (including proce-
7
dures for expedited reviews of urgent claims) that
8
provides for an impartial, independent, and de novo
9
review of denied claims under this division.
10
(2) REQUIRING FAIR GRIEVANCE AND APPEALS
11
MECHANISMS.—A determination made, with respect
12
to a qualified health benefits plan offered by a
13
QHBP offering entity, under the external review
14
process established under this subsection shall be
15
binding on the plan and the entity.
16
(d) CONSTRUCTION.—Nothing in this section shall be
17 construed as affecting the availability of judicial review
18 under State law for adverse decisions under subsection (b)
19 or (c), subject to section 151.
20 SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND
21
PLAN DISCLOSURE.
22
(a) ACCURATE AND TIMELY DISCLOSURE.—
23
(1) IN GENERAL.—A qualified health benefits
24
plan shall comply with standards established by the
25
Commissioner for the accurate and timely disclosure
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39
1
of plan documents, plan terms and conditions,
2
claims payment policies and practices, periodic fi-
3
nancial disclosure, data on enrollment, data on
4
disenrollment, data on the number of claims denials,
5
data on rating practices, information on cost-sharing
6
and payments with respect to any out-of-network
7
coverage, and other information as determined ap-
8
propriate by the Commissioner. The Commissioner
9
shall require that such disclosure be provided in
10
plain language.
11
(2) PLAIN LANGUAGE.—In this subsection, the
12
term ‘‘plain language’’ means language that the in-
13
tended audience, including individuals with limited
14
English proficiency, can readily understand and use
15
because that language is clean, concise, well-orga-
16
nized, and follows other best practices of plain lan-
17
guage writing.
18
(3) GUIDANCE.—The Commissioner shall de-
19
velop and issue guidance on best practices of plain
20
language writing.
21
(b) CONTRACTING REIMBURSEMENT.—A qualified
22 health benefits plan shall comply with standards estab-
23 lished by the Commissioner to ensure transparency to each
24 health care provider relating to reimbursement arrange-
25 ments between such plan and such provider.
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1
(c) ADVANCE
NOTICE
OF
PLAN
CHANGES.—A
2 change in a qualified health benefits plan shall not be
3 made without such reasonable and timely advance notice
4 to enrollees of such change.
5 SEC. 134. APPLICATION TO QUALIFIED HEALTH BENEFITS
6
PLANS NOT OFFERED THROUGH THE
7
HEALTH INSURANCE EXCHANGE.
8
The requirements of the previous provisions of this
9 subtitle shall apply to qualified health benefits plans that
10 are not being offered through the Health Insurance Ex-
11 change only to the extent specified by the Commissioner.
12 SEC. 135. TIMELY PAYMENT OF CLAIMS.
13
A QHBP offering entity shall comply with the re-
14 quirements of section 1857(f) of the Social Security Act
15 with respect to a qualified health benefits plan it offers
16 in the same manner an Medicare Advantage organization
17 is required to comply with such requirements with respect
18 to a Medicare Advantage plan it offers under part C of
19 Medicare.
20 SEC. 136. STANDARDIZED RULES FOR COORDINATION AND
21
SUBROGATION OF BENEFITS.
22
The Commissioner shall establish standards for the
23 coordination and subrogation of benefits and reimburse-
24 ment of payments in cases involving individuals and mul-
25 tiple plan coverage.
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41
1 SEC. 137. APPLICATION OF ADMINISTRATIVE SIMPLIFICA-
2
TION.
3
A QHBP offering entity is required to comply with
4 standards for electronic financial and administrative
5 transactions under section 1173A of the Social Security
6 Act, added by section 163(a).
7
Subtitle E—Governance
8 SEC. 141. HEALTH CHOICES ADMINISTRATION; HEALTH
9
CHOICES COMMISSIONER.
10
(a) IN GENERAL.—There is hereby established, as an
11 independent agency in the executive branch of the Govern-
12 ment, a Health Choices Administration (in this division
13 referred to as the ‘‘Administration’’).
14
(b) COMMISSIONER.—
15
(1) IN GENERAL.—The Administration shall be
16
headed by a Health Choices Commissioner (in this
17
division referred to as the ‘‘Commissioner’’) who
18
shall be appointed by the President, by and with the
19
advice and consent of the Senate.
20
(2) COMPENSATION; ETC.—The provisions of
21
paragraphs (2), (5) and (7) of subsection (a) (relat-
22
ing to compensation, terms, general powers, rule-
23
making, and delegation) of section 702 of the Social
24
Security Act (42 U.S.C. 902) shall apply to the
25
Commissioner and the Administration in the same
26
manner as such provisions apply to the Commis-
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42
1
sioner of Social Security and the Social Security Ad-
2
ministration.
3 SEC. 142. DUTIES AND AUTHORITY OF COMMISSIONER.
4
(a) DUTIES.—The Commissioner is responsible for
5 carrying out the following functions under this division:
6
(1) QUALIFIED PLAN STANDARDS.—The estab-
7
lishment of qualified health benefits plan standards
8
under this title, including the enforcement of such
9
standards in coordination with State insurance regu-
10
lators and the Secretaries of Labor and the Treas-
11
ury.
12
(2) HEALTH INSURANCE EXCHANGE.—The es-
13
tablishment and operation of a Health Insurance
14
Exchange under subtitle A of title II.
15
(3) INDIVIDUAL AFFORDABILITY CREDITS.—
16
The administration of individual affordability credits
17
under subtitle C of title II, including determination
18
of eligibility for such credits.
19
(4) ADDITIONAL FUNCTIONS.—Such additional
20
functions as may be specified in this division.
21
(b) PROMOTING ACCOUNTABILITY.—
22
(1) IN GENERAL.—The Commissioner shall un-
23
dertake activities in accordance with this subtitle to
24
promote accountability of QHBP offering entities in
25
meeting Federal health insurance requirements, re-
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43
1
gardless of whether such accountability is with re-
2
spect to qualified health benefits plans offered
3
through the Health Insurance Exchange or outside
4
of such Exchange.
5
(2) COMPLIANCE EXAMINATION AND AUDITS.—
6
(A) IN
GENERAL.—The commissioner
7
shall, in coordination with States, conduct au-
8
dits of qualified health benefits plan compliance
9
with Federal requirements.
Such audits may
10
include random compliance audits and targeted
11
audits in response to complaints or other sus-
12
pected non-compliance.
13
(B) RECOUPMENT OF COSTS IN CONNEC-
14
TION WITH EXAMINATION AND AUDITS.—The
15
Commissioner is authorized to recoup from
16
qualified health benefits plans reimbursement
17
for the costs of such examinations and audit of
18
such QHBP offering entities.
19
(c) DATA COLLECTION.—The Commissioner shall
20 collect data for purposes of carrying out the Commis-
21 sioner’s duties, including for purposes of promoting qual-
22 ity and value, protecting consumers, and addressing dis-
23 parities in health and health care and may share such data
24 with the Secretary of Health and Human Services.
25
(d) SANCTIONS AUTHORITY.—
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44
1
(1) IN GENERAL.—In the case that the Com-
2
missioner determines that a QHBP offering entity
3
violates a requirement of this title, the Commis-
4
sioner may, in coordination with State insurance
5
regulators and the Secretary of Labor, provide, in
6
addition to any other remedies authorized by law,
7
for any of the remedies described in paragraph (2).
8
(2) REMEDIES.—The remedies described in this
9
paragraph, with respect to a qualified health benefits
10
plan offered by a QHBP offering entity, are—
11
(A) civil money penalties of not more than
12
the amount that would be applicable under
13
similar circumstances for similar violations
14
under section 1857(g) of the Social Security
15
Act;
16
(B) suspension of enrollment of individuals
17
under such plan after the date the Commis-
18
sioner notifies the entity of a determination
19
under paragraph (1) and until the Commis-
20
sioner is satisfied that the basis for such deter-
21
mination has been corrected and is not likely to
22
recur;
23
(C) in the case of an Exchange-partici-
24
pating health benefits plan, suspension of pay-
25
ment to the entity under the Health Insurance
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45
1
Exchange for individuals enrolled in such plan
2
after the date the Commissioner notifies the en-
3
tity of a determination under paragraph (1)
4
and until the Secretary is satisfied that the
5
basis for such determination has been corrected
6
and is not likely to recur; or
7
(D) working with State insurance regu-
8
lators to terminate plans for repeated failure by
9
the offering entity to meet the requirements of
10
this title.
11
(e) STANDARD DEFINITIONS OF INSURANCE AND
12 MEDICAL TERMS.—The Commissioner shall provide for
13 the development of standards for the definitions of terms
14 used in health insurance coverage, including insurance-re-
15 lated terms.
16
(f) EFFICIENCY IN ADMINISTRATION.—The Commis-
17 sioner shall issue regulations for the effective and efficient
18 administration of the Health Insurance Exchange and af-
19 fordability credits under subtitle C, including, with respect
20 to the determination of eligibility for affordability credits,
21 the use of personnel who are employed in accordance with
22 the requirements of title 5, United States Code, to carry
23 out the duties of the Commissioner or, in the case of sec-
24 tions 208 and 241(b)(2), the use of State personnel who
25 are employed in accordance with standards prescribed by
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46
1 the Office of Personnel Management pursuant to section
2 208 of the Intergovernmental Personnel Act of 1970 (42
3 U.S.C. 4728).
4 SEC. 143. CONSULTATION AND COORDINATION.
5
(a) CONSULTATION.—In carrying out the Commis-
6 sioner’s duties under this division, the Commissioner, as
7 appropriate, shall consult with at least with the following:
8
(1) The National Association of Insurance
9
Commissioners, State attorneys general, and State
10
insurance regulators, including concerning the
11
standards for insured qualified health benefits plans
12
under this title and enforcement of such standards.
13
(2) Appropriate State agencies, specifically con-
14
cerning the administration of individual affordability
15
credits under subtitle C of title II and the offering
16
of Exchange-participating health benefits plans, to
17
Medicaid eligible individuals under subtitle A of such
18
title.
19
(3) Other appropriate Federal agencies.
20
(4) Indian tribes and tribal organizations.
21
(5) The National Association of Insurance
22
Commissioners for purposes of using model guide-
23
lines established by such association for purposes of
24
subtitles B and D.
25
(b) COORDINATION.—
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1
(1) IN GENERAL.—In carrying out the func-
2
tions of the Commissioner, including with respect to
3
the enforcement of the provisions of this division,
4
the Commissioner shall work in coordination with
5
existing Federal and State entities to the maximum
6
extent feasible consistent with this division and in a
7
manner that prevents conflicts of interest in duties
8
and ensures effective enforcement.
9
(2) UNIFORM STANDARDS.—The Commissioner,
10
in coordination with such entities, shall seek to
11
achieve uniform standards that adequately protect
12
consumers in a manner that does not unreasonably
13
affect employers and insurers.
14 SEC. 144. HEALTH INSURANCE OMBUDSMAN.
15
(a) IN GENERAL.—The Commissioner shall appoint
16 within the Health Choices Administration a Qualified
17 Health Benefits Plan Ombudsman who shall have exper-
18 tise and experience in the fields of health care and edu-
19 cation of (and assistance to) individuals.
20
(b) DUTIES.—The Qualified Health Benefits Plan
21 Ombudsman shall, in a linguistically appropriate man-
22 ner—
23
(1) receive complaints, grievances, and requests
24
for information submitted by individuals;
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48
1
(2) provide assistance with respect to com-
2
plaints, grievances, and requests referred to in para-
3
graph (1), including—
4
(A) helping individuals determine the rel-
5
evant information needed to seek an appeal of
6
a decision or determination;
7
(B) assistance to such individuals with any
8
problems arising from disenrollment from such
9
a plan;
10
(C) assistance to such individuals in choos-
11
ing a qualified health benefits plan in which to
12
enroll; and
13
(D) assistance to such individuals in pre-
14
senting information under subtitle C (relating
15
to affordability credits); and
16
(3) submit annual reports to Congress and the
17
Commissioner that describe the activities of the Om-
18
budsman and that include such recommendations for
19
improvement in the administration of this division as
20
the Ombudsman determines appropriate. The Om-
21
budsman shall not serve as an advocate for any in-
22
creases in payments or new coverage of services, but
23
may identify issues and problems in payment or cov-
24
erage policies.
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49
1
Subtitle F—Relation to Other
2
Requirements; Miscellaneous
3 SEC. 151. RELATION TO OTHER REQUIREMENTS.
4
(a) COVERAGE
NOT
OFFERED
THROUGH
EX-
5 CHANGE.—
6
(1) IN GENERAL.—In the case of health insur-
7
ance coverage not offered through the Health Insur-
8
ance Exchange (whether or not offered in connection
9
with an employment-based health plan), and in the
10
case of employment-based health plans, the require-
11
ments of this title do not supercede any require-
12
ments applicable under titles XXII and XXVII of
13
the Public Health Service Act, parts 6 and 7 of sub-
14
title B of title I of the Employee Retirement Income
15
Security Act of 1974, or State law, except insofar as
16
such requirements prevent the application of a re-
17
quirement of this division, as determined by the
18
Commissioner.
19
(2) CONSTRUCTION.—Nothing in paragraph (1)
20
shall be construed as affecting the application of sec-
21
tion 514 of the Employee Retirement Income Secu-
22
rity Act of 1974.
23
(b) COVERAGE OFFERED THROUGH EXCHANGE.—
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1
(1) IN GENERAL.—In the case of health insur-
2
ance coverage offered through the Health Insurance
3
Exchange—
4
(A) the requirements of this title do not
5
supercede any requirements (including require-
6
ments relating to genetic information non-
7
discrimination and mental health) applicable
8
under title XXVII of the Public Health Service
9
Act or under State law, except insofar as such
10
requirements prevent the application of a re-
11
quirement of this division, as determined by the
12
Commissioner; and
13
(B) individual rights and remedies under
14
State laws shall apply.
15
(2) CONSTRUCTION.—In the case of coverage
16
described in paragraph (1), nothing in such para-
17
graph shall be construed as preventing the applica-
18
tion of rights and remedies under State laws with
19
respect to any requirement referred to in paragraph
20
(1)(A).
21 SEC. 152. PROHIBITING DISCRIMINATION IN HEALTH CARE.
22
(a) IN GENERAL.—Except as otherwise explicitly per-
23 mitted by this Act and by subsequent regulations con-
24 sistent with this Act, all health care and related services
25 (including insurance coverage and public health activities)
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51
1 covered by this Act shall be provided without regard to
2 personal characteristics extraneous to the provision of
3 high quality health care or related services.
4
(b) IMPLEMENTATION.—To implement the require-
5 ment set forth in subsection (a), the Secretary of Health
6 and Human Services shall, not later than 18 months after
7 the date of the enactment of this Act, promulgate such
8 regulations as are necessary or appropriate to insure that
9 all health care and related services (including insurance
10 coverage and public health activities) covered by this Act
11 are provided (whether directly or through contractual, li-
12 censing, or other arrangements) without regard to per-
13 sonal characteristics extraneous to the provision of high
14 quality health care or related services.
15 SEC. 153. WHISTLEBLOWER PROTECTION.
16
(a) RETALIATION PROHIBITED.—No employer may
17 discharge any employee or otherwise discriminate against
18 any employee with respect to his compensation, terms,
19 conditions, or other privileges of employment because the
20 employee (or any person acting pursuant to a request of
21 the employee)—
22
(1) provided, caused to be provided, or is about
23
to provide or cause to be provided to the employer,
24
the Federal Government, or the attorney general of
25
a State information relating to any violation of, or
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52
1
any act or omission the employee reasonably believes
2
to be a violation of any provision of this Act or any
3
order, rule, or regulation promulgated under this
4
Act;
5
(2) testified or is about to testify in a pro-
6
ceeding concerning such violation;
7
(3) assisted or participated or is about to assist
8
or participate in such a proceeding; or
9
(4) objected to, or refused to participate in, any
10
activity, policy, practice, or assigned task that the
11
employee (or other such person) reasonably believed
12
to be in violation of any provision of this Act or any
13
order, rule, or regulation promulgated under this
14
Act.
15
(b) ENFORCEMENT ACTION.—An employee covered
16 by this section who alleges discrimination by an employer
17 in violation of subsection (a) may bring an action governed
18 by the rules, procedures, legal burdens of proof, and rem-
19 edies set forth in section 40(b) of the Consumer Product
20 Safety Act (15 U.S.C. 2087(b)).
21
(c) EMPLOYER DEFINED.—As used in this section,
22 the term ‘‘employer’’ means any person (including one or
23 more individuals, partnerships, associations, corporations,
24 trusts, professional membership organization including a
25 certification, disciplinary, or other professional body, unin-
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53
1 corporated organizations, nongovernmental organizations,
2 or trustees) engaged in profit or nonprofit business or in-
3 dustry whose activities are governed by this Act, and any
4 agent, contractor, subcontractor, grantee, or consultant of
5 such person.
6
(d) RULE OF CONSTRUCTION.—The rule of construc-
7 tion set forth in section 20109(h) of title 49, United
8 States Code, shall also apply to this section.
9 SEC. 154. CONSTRUCTION REGARDING COLLECTIVE BAR-
10
GAINING.
11
Nothing in this division shall be construed to alter
12 of supercede any statutory or other obligation to engage
13 in collective bargaining over the terms and conditions of
14 employment related to health care.
15 SEC. 155. SEVERABILITY.
16
If any provision of this Act, or any application of such
17 provision to any person or circumstance, is held to be un-
18 constitutional, the remainder of the provisions of this Act
19 and the application of the provision to any other person
20 or circumstance shall not be affected.
21
Subtitle G—Early Investments
22 SEC. 161. ENSURING VALUE AND LOWER PREMIUMS.
23
(a) GROUP HEALTH INSURANCE COVERAGE.—Title
24 XXVII of the Public Health Service Act is amended by
25 inserting after section 2713 the following new section:
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54
1 ‘‘SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.
2
‘‘(a) IN GENERAL.—Each health insurance issuer
3 that offers health insurance coverage in the small or large
4 group market shall provide that for any plan year in which
5 the coverage has a medical loss ratio below a level specified
6 by the Secretary, the issuer shall provide in a manner
7 specified by the Secretary for rebates to enrollees of pay-
8 ment sufficient to meet such loss ratio. Such methodology
9 shall be set at the highest level medical loss ratio possible
10 that is designed to ensure adequate participation by
11 issuers, competition in the health insurance market, and
12 value for consumers so that their premiums are used for
13 services.
14
‘‘(b) UNIFORM DEFINITIONS.—The Secretary shall
15 establish a uniform definition of medical loss ratio and
16 methodology for determining how to calculate the medical
17 loss ratio. Such methodology shall be designed to take into
18 account the special circumstances of smaller plans, dif-
19 ferent types of plans, and newer plans.’’.
20
(b) INDIVIDUAL HEALTH INSURANCE COVERAGE.—
21 Such title is further amended by inserting after section
22 2753 the following new section:
23 ‘‘SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.
24
‘‘The provisions of section 2714 shall apply to health
25 insurance coverage offered in the individual market in the
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55
1 same manner as such provisions apply to health insurance
2 coverage offered in the small or large group market.’’.
3
(c) IMMEDIATE
IMPLEMENTATION.—The amend-
4 ments made by this section shall apply in the group and
5 individual market for plan years beginning on or after
6 January 1, 2011.
7 SEC. 162. ENDING HEALTH INSURANCE RESCISSION ABUSE.
8
(a) CLARIFICATION REGARDING APPLICATION OF
9 GUARANTEED RENEWABILITY OF INDIVIDUAL HEALTH
10 INSURANCE COVERAGE.—Section 2742 of the Public
11 Health Service Act (42 U.S.C. 300gg–42) is amended—
12
(1) in its heading, by inserting ‘‘AND CON-
13
TINUATION
IN
FORCE, INCLUDING PROHIBI-
14
TION OF RESCISSION,’’ after ‘‘GUARANTEED RE-
15
NEWABILITY’’; and
16
(2) in subsection (a), by inserting ‘‘, including
17
without rescission,’’ after ‘‘continue in force’’.
18
(b) SECRETARIAL GUIDANCE REGARDING RESCIS-
19 SIONS.—Section 2742 of such Act (42 U.S.C. 300gg–42)
20 is amended by adding at the end the following:
21
‘‘(f) RESCISSION.—A health insurance issuer may re-
22 scind health insurance coverage only upon clear and con-
23 vincing evidence of fraud described in subsection (b)(2).
24 The Secretary, no later than July 1, 2010, shall issue
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56
1 guidance implementing this requirement, including proce-
2 dures for independent, external third party review.’’.
3
(c) OPPORTUNITY FOR INDEPENDENT, EXTERNAL
4 THIRD PARTY REVIEW IN CERTAIN CASES.—Subpart 1
5 of part B of title XXVII of such Act (42 U.S.C. 300gg–
6 41 et seq.) is amended by adding at the end the following:
7 ‘‘SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL
8
THIRD PARTY REVIEW IN CASES OF RESCIS-
9
SION.
10
‘‘(a) NOTICE AND REVIEW RIGHT.—If a health in-
11 surance issuer determines to rescind health insurance cov-
12 erage for an individual in the individual market, before
13 such rescission may take effect the issuer shall provide the
14 individual with notice of such proposed rescission and an
15 opportunity for a review of such determination by an inde-
16 pendent, external third party under procedures specified
17 by the Secretary under section 2742(f).
18
‘‘(b) INDEPENDENT DETERMINATION.—If the indi-
19 vidual requests such review by an independent, external
20 third party of a rescission of health insurance coverage,
21 the coverage shall remain in effect until such third party
22 determines that the coverage may be rescinded under the
23 guidance issued by the Secretary under section 2742(f).’’.
24
(d) EFFECTIVE DATE.—The amendments made by
25 this section shall apply on and after October 1, 2010, with
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57
1 respect to health insurance coverage issued before, on, or
2 after such date.
3 SEC. 163. ADMINISTRATIVE SIMPLIFICATION.
4
(a) STANDARDIZING ELECTRONIC ADMINISTRATIVE
5 TRANSACTIONS.—
6
(1) IN GENERAL.—Part C of title XI of the So-
7
cial Security Act (42 U.S.C. 1320d et seq.) is
8
amended by inserting after section 1173 the fol-
9
lowing new section:
10 ‘‘SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE
11
TRANSACTIONS.
12
‘‘(a) STANDARDS FOR FINANCIAL AND ADMINISTRA-
13 TIVE TRANSACTIONS.—
14
‘‘(1) IN GENERAL.—The Secretary shall adopt
15
and regularly update standards consistent with the
16
goals described in paragraph (2).
17
‘‘(2) GOALS FOR FINANCIAL AND ADMINISTRA-
18
TIVE
TRANSACTIONS.—The goals for standards
19
under paragraph (1) are that such standards shall—
20
‘‘(A) be unique with no conflicting or re-
21
dundant standards;
22
‘‘(B) be authoritative, permitting no addi-
23
tions or constraints for electronic transactions,
24
including companion guides;
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58
1
‘‘(C) be comprehensive, efficient and ro-
2
bust, requiring minimal augmentation by paper
3
transactions or clarification by further commu-
4
nications;
5
‘‘(D) enable the real-time (or near real-
6
time) determination of an individual’s financial
7
responsibility at the point of service and, to the
8
extent possible, prior to service, including
9
whether the individual is eligible for a specific
10
service with a specific physician at a specific fa-
11
cility, which may include utilization of a ma-
12
chine-readable health plan beneficiary identi-
13
fication card;
14
‘‘(E) enable, where feasible, near real-time
15
adjudication of claims;
16
‘‘(F) provide for timely acknowledgment,
17
response, and status reporting applicable to any
18
electronic transaction deemed appropriate by
19
the Secretary;
20
‘‘(G) describe all data elements (such as
21
reason and remark codes) in unambiguous
22
terms, not permit optional fields, require that
23
data elements be either required or conditioned
24
upon set values in other fields, and prohibit ad-
25
ditional conditions; and
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1
‘‘(H) harmonize all common data elements
2
across administrative and clinical transaction
3
standards.
4
‘‘(3) TIME FOR ADOPTION.—Not later than 2
5
years after the date of implementation of the X12
6
Version 5010 transaction standards implemented
7
under this part, the Secretary shall adopt standards
8
under this section.
9
‘‘(4) REQUIREMENTS FOR SPECIFIC STAND-
10
ARDS.—The standards under this section shall be
11
developed, adopted and enforced so as to—
12
‘‘(A) clarify, refine, complete, and expand,
13
as needed, the standards required under section
14
1173;
15
‘‘(B) require paper versions of standard-
16
ized transactions to comply with the same
17
standards as to data content such that a fully
18
compliant, equivalent electronic transaction can
19
be populated from the data from a paper
20
version;
21
‘‘(C) enable electronic funds transfers, in
22
order to allow automated reconciliation with the
23
related health care payment and remittance ad-
24
vice;
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60
1
‘‘(D) require timely and transparent claim
2
and denial management processes, including
3
tracking, adjudication, and appeal processing ;
4
‘‘(E) require the use of a standard elec-
5
tronic transaction with which health care pro-
6
viders may quickly and efficiently enroll with a
7
health plan to conduct the other electronic
8
transactions provided for in this part; and
9
‘‘(F) provide for other requirements relat-
10
ing to administrative simplification as identified
11
by the Secretary, in consultation with stake-
12
holders.
13
‘‘(5) BUILDING ON EXISTING STANDARDS.—In
14
developing the standards under this section, the Sec-
15
retary shall build upon existing and planned stand-
16
ards.
17
‘‘(6) IMPLEMENTATION AND ENFORCEMENT.—
18
Not later than 6 months after the date of the enact-
19
ment of this section, the Secretary shall submit to
20
the appropriate committees of Congress a plan for
21
the implementation and enforcement, by not later
22
than 5 years after such date of enactment, of the
23
standards under this section. Such plan shall in-
24
clude—
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61
1
‘‘(A) a process and timeframe with mile-
2
stones for developing the complete set of stand-
3
ards;
4
‘‘(B) an expedited upgrade program for
5
continually developing and approving additions
6
and modifications to the standards as often as
7
annually to improve their quality and extend
8
their functionality to meet evolving require-
9
ments in health care;
10
‘‘(C) programs to provide incentives for,
11
and ease the burden of, implementation for cer-
12
tain health care providers, with special consid-
13
eration given to such providers serving rural or
14
underserved areas and ensure coordination with
15
standards, implementation specifications, and
16
certification criteria being adopted under the
17
HITECH Act;
18
‘‘(D) programs to provide incentives for,
19
and ease the burden of, health care providers
20
who volunteer to participate in the process of
21
setting standards for electronic transactions;
22
‘‘(E) an estimate of total funds needed to
23
ensure timely completion of the implementation
24
plan; and
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62
1
‘‘(F) an enforcement process that includes
2
timely investigation of complaints, random au-
3
dits to ensure compliance, civil monetary and
4
programmatic penalties for non-compliance con-
5
sistent with existing laws and regulations, and
6
a fair and reasonable appeals process building
7
off of enforcement provisions under this part.
8
‘‘(b) LIMITATIONS ON USE OF DATA.—Nothing in
9 this section shall be construed to permit the use of infor-
10 mation collected under this section in a manner that would
11 adversely affect any individual.
12
‘‘(c) PROTECTION OF DATA.—The Secretary shall en-
13 sure (through the promulgation of regulations or other-
14 wise) that all data collected pursuant to subsection (a)
15 are—
16
‘‘(1) used and disclosed in a manner that meets
17
the HIPAA privacy and security law (as defined in
18
section 3009(a)(2) of the Public Health Service
19
Act), including any privacy or security standard
20
adopted under section 3004 of such Act; and
21
‘‘(2) protected from all inappropriate internal
22
use by any entity that collects, stores, or receives the
23
data, including use of such data in determinations of
24
eligibility (or continued eligibility) in health plans,
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1
and from other inappropriate uses, as defined by the
2
Secretary.’’.
3
(2) DEFINITIONS.—Section 1171 of such Act
4
(42 U.S.C. 1320d) is amended—
5
(A) in paragraph (7), by striking ‘‘with
6
reference to’’ and all that follows and inserting
7
‘‘with reference to a transaction or data ele-
8
ment of health information in section 1173
9
means implementation specifications, certifi-
10
cation criteria, operating rules, messaging for-
11
mats, codes, and code sets adopted or estab-
12
lished by the Secretary for the electronic ex-
13
change and use of information’’; and
14
(B) by adding at the end the following new
15
paragraph:
16
‘‘(9) OPERATING RULES.—The term ‘operating
17
rules’ means business rules for using and processing
18
transactions. Operating rules should address the fol-
19
lowing:
20
‘‘(A) Requirements for data content using
21
available and established national standards.
22
‘‘(B) Infrastructure requirements that es-
23
tablish best practices for streamlining data flow
24
to yield timely execution of transactions.
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64
1
‘‘(C) Policies defining the transaction re-
2
lated rights and responsibilities for entities that
3
are transmitting or receiving data.’’.
4
(3) CONFORMING
AMENDMENT.—Section
5
1179(a) of such Act (42 U.S.C. 1320d–8(a)) is
6
amended, in the matter before paragraph (1)—
7
(A) by inserting ‘‘on behalf of an indi-
8
vidual’’ after ‘‘1978)’’; and
9
(B) by inserting ‘‘on behalf of an indi-
10
vidual’’ after ‘‘for a financial institution’’ and
11
(b) STANDARDS FOR CLAIMS ATTACHMENTS AND
12 COORDINATION OF BENEFITS .—
13
(1) STANDARD FOR HEALTH CLAIMS ATTACH-
14
MENTS.—Not later than 1 year after the date of the
15
enactment of this Act, the Secretary of Health and
16
Human Services shall promulgate a final rule to es-
17
tablish a standard for health claims attachment
18
transaction described in section 1173(a)(2)(B) of the
19
Social Security Act (42 U.S.C. 1320d-2(a)(2)(B))
20
and coordination of benefits.
21
(2) REVISION IN PROCESSING PAYMENT TRANS-
22
ACTIONS BY FINANCIAL INSTITUTIONS.—
23
(A) IN GENERAL.—Section 1179 of the So-
24
cial Security Act (42 U.S.C. 1320d–8) is
25
amended, in the matter before paragraph (1)—
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65
1
(i) by striking ‘‘or is engaged’’ and in-
2
serting ‘‘and is engaged’’; and
3
(ii) by inserting ‘‘(other than as a
4
business associate for a covered entity)’’
5
after ‘‘for a financial institution’’.
6
(B) EFFECTIVE DATE.—The amendments
7
made by paragraph (1) shall apply to trans-
8
actions occurring on or after such date (not
9
later than 6 months after the date of the enact-
10
ment of this Act) as the Secretary of Health
11
and Human Services shall specify.
12 SEC. 164. REINSURANCE PROGRAM FOR RETIREES.
13
(a) ESTABLISHMENT.—
14
(1) IN GENERAL.—Not later than 90 days after
15
the date of the enactment of this Act, the Secretary
16
of Health and Human Services shall establish a tem-
17
porary reinsurance program (in this section referred
18
to as the ‘‘reinsurance program’’) to provide reim-
19
bursement to assist participating employment-based
20
plans with the cost of providing health benefits to
21
retirees and to eligible spouses, surviving spouses
22
and dependents of such retirees.
23
(2) DEFINITIONS.—For purposes of this sec-
24
tion:
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66
1
(A) The term ‘‘eligible employment-based
2
plan’’ means a group health benefits plan
3
that—
4
(i) is maintained by one or more em-
5
ployers, former employers or employee as-
6
sociations, or a voluntary employees’ bene-
7
ficiary association, or a committee or board
8
of individuals appointed to administer such
9
plan, and
10
(ii) provides health benefits to retir-
11
ees.
12
(B) The term ‘‘health benefits’’ means
13
medical, surgical, hospital, prescription drug,
14
and such other benefits as shall be determined
15
by the Secretary, whether self-funded or deliv-
16
ered through the purchase of insurance or oth-
17
erwise.
18
(C) The term ‘‘participating employment-
19
based plan’’ means an eligible employment-
20
based plan that is participating in the reinsur-
21
ance program.
22
(D) The term ‘‘retiree’’ means, with re-
23
spect to a participating employment-benefit
24
plan, an individual who—
25
(i) is 55 years of age or older;
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67
1
(ii) is not eligible for coverage under
2
title XVIII of the Social Security Act; and
3
(iii) is not an active employee of an
4
employer maintaining the plan or of any
5
employer that makes or has made substan-
6
tial contributions to fund such plan.
7
(E) The term ‘‘Secretary’’ means Sec-
8
retary of Health and Human Services.
9
(b) PARTICIPATION.—To be eligible to participate in
10 the reinsurance program, an eligible employment-based
11 plan shall submit to the Secretary an application for par-
12 ticipation in the program, at such time, in such manner,
13 and containing such information as the Secretary shall re-
14 quire.
15
(c) PAYMENT.—
16
(1) SUBMISSION OF CLAIMS.—
17
(A) IN GENERAL.—Under the reinsurance
18
program, a participating employment-based
19
plan shall submit claims for reimbursement to
20
the Secretary which shall contain documenta-
21
tion of the actual costs of the items and serv-
22
ices for which each claim is being submitted.
23
(B) BASIS FOR CLAIMS.—Each claim sub-
24
mitted under subparagraph (A) shall be based
25
on the actual amount expended by the partici-
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68
1
pating employment-based plan involved within
2
the plan year for the appropriate employment
3
based health benefits provided to a retiree or to
4
the spouse, surviving spouse, or dependent of a
5
retiree. In determining the amount of any claim
6
for purposes of this subsection, the partici-
7
pating employment-based plan shall take into
8
account any negotiated price concessions (such
9
as discounts, direct or indirect subsidies, re-
10
bates, and direct or indirect remunerations) ob-
11
tained by such plan with respect to such health
12
benefits. For purposes of calculating the
13
amount of any claim, the costs paid by the re-
14
tiree or by the spouse, surviving spouse, or de-
15
pendent of the retiree in the form of
16
deductibles, co-payments, and co-insurance shall
17
be included along with the amounts paid by the
18
participating employment-based plan.
19
(2) PROGRAM PAYMENTS AND LIMIT.—If the
20
Secretary determines that a participating employ-
21
ment-based plan has submitted a valid claim under
22
paragraph (1), the Secretary shall reimburse such
23
plan for 80 percent of that portion of the costs at-
24
tributable to such claim that exceeds $15,000, but is
25
less than $90,000. Such amounts shall be adjusted
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69
1
each year based on the percentage increase in the
2
medical care component of the Consumer Price
3
Index (rounded to the nearest multiple of $1,000)
4
for the year involved.
5
(3) USE OF PAYMENTS.—Amounts paid to a
6
participating employment-based plan under this sub-
7
section shall be used to lower the costs borne di-
8
rectly by the participants and beneficiaries for health
9
benefits provided under such plan in the form of
10
premiums, co-payments, deductibles, co-insurance, or
11
other out-of-pocket costs. Such payments shall not
12
be used to reduce the costs of an employer maintain-
13
ing the participating employment-based plan. The
14
Secretary shall develop a mechanism to monitor the
15
appropriate use of such payments by such plans.
16
(4) APPEALS AND PROGRAM PROTECTIONS.—
17
The Secretary shall establish—
18
(A) an appeals process to permit partici-
19
pating employment-based plans to appeal a de-
20
termination of the Secretary with respect to
21
claims submitted under this section; and
22
(B) procedures to protect against fraud,
23
waste, and abuse under the program.
24
(5) AUDITS.—The Secretary shall conduct an-
25
nual audits of claims data submitted by partici-
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70
1
pating employment-based plans under this section to
2
ensure that they are in compliance with the require-
3
ments of this section.
4
(d) RETIREE RESERVE TRUST FUND.—
5
(1) ESTABLISHMENT.—
6
(A) IN GENERAL.—There is established in
7
the Treasury of the United States a trust fund
8
to be known as the ‘‘Retiree Reserve Trust
9
Fund’’ (referred to in this section as the ‘‘Trust
10
Fund’’), that shall consist of such amounts as
11
may be appropriated or credited to the Trust
12
Fund as provided for in this subsection to en-
13
able the Secretary to carry out the reinsurance
14
program. Such amounts shall remain available
15
until expended.
16
(B) FUNDING.—There are hereby appro-
17
priated to the Trust Fund, out of any moneys
18
in the Treasury not otherwise appropriated, an
19
amount requested by the Secretary as necessary
20
to carry out this section, except that the total
21
of all such amounts requested shall not exceed
22
$10,000,000,000.
23
(C) APPROPRIATIONS FROM THE TRUST
24
FUND.—
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71
1
(i) IN GENERAL.—Amounts in the
2
Trust Fund are appropriated to provide
3
funding to carry out the reinsurance pro-
4
gram and shall be used to carry out such
5
program.
6
(ii) BUDGETARY
IMPLICATIONS.—
7
Amounts appropriated under clause (i),
8
and outlays flowing from such appropria-
9
tions, shall not be taken into account for
10
purposes of any budget enforcement proce-
11
dures including allocations under section
12
302(a) and (b) of the Balanced Budget
13
and Emergency Deficit Control Act and
14
budget resolutions for fiscal years during
15
which appropriations are made from the
16
Trust Fund.
17
(iii) LIMITATION
TO
AVAILABLE
18
FUNDS.—The Secretary has the authority
19
to stop taking applications for participa-
20
tion in the program or take such other
21
steps in reducing expenditures under the
22
reinsurance program in order to ensure
23
that expenditures under the reinsurance
24
program do not exceed the funds available
25
under this subsection.
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72
1 TITLE II—HEALTH INSURANCE
2
EXCHANGE AND RELATED
3
PROVISIONS
4
Subtitle A—Health Insurance
5
Exchange
6 SEC. 201. ESTABLISHMENT OF HEALTH INSURANCE EX-
7
CHANGE; OUTLINE OF DUTIES; DEFINITIONS.
8
(a) ESTABLISHMENT.—There is established within
9 the Health Choices Administration and under the direc-
10 tion of the Commissioner a Health Insurance Exchange
11 in order to facilitate access of individuals and employers,
12 through a transparent process, to a variety of choices of
13 affordable, quality health insurance coverage, including a
14 public health insurance option.
15
(b) OUTLINE OF DUTIES OF COMMISSIONER.—In ac-
16 cordance with this subtitle and in coordination with appro-
17 priate Federal and State officials as provided under sec-
18 tion 143(b), the Commissioner shall—
19
(1) under section 204 establish standards for,
20
accept bids from, and negotiate and enter into con-
21
tracts with, QHBP offering entities for the offering
22
of health benefits plans through the Health Insur-
23
ance Exchange, with different levels of benefits re-
24
quired under section 203, and including with respect
25
to oversight and enforcement;
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73
1
(2) under section 205 facilitate outreach and
2
enrollment in such plans of Exchange-eligible indi-
3
viduals and employers described in section 202; and
4
(3) conduct such activities related to the Health
5
Insurance Exchange as required, including establish-
6
ment of a risk pooling mechanism under section 206
7
and consumer protections under subtitle D of title I.
8
(c) EXCHANGE-PARTICIPATING HEALTH BENEFITS
9 PLAN DEFINED.—In this division, the term ‘‘Exchange-
10 participating health benefits plan’’ means a qualified
11 health benefits plan that is offered through the Health In-
12 surance Exchange.
13 SEC. 202. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOY-
14
ERS.
15
(a) ACCESS TO COVERAGE.—In accordance with this
16 section, all individuals are eligible to obtain coverage
17 through enrollment in an Exchange-participating health
18 benefits plan offered through the Health Insurance Ex-
19 change unless such individuals are enrolled in another
20 qualified health benefits plan or other acceptable coverage.
21
(b) DEFINITIONS.—In this division:
22
(1) EXCHANGE-ELIGIBLE
INDIVIDUAL.—The
23
term ‘‘Exchange-eligible individual’’ means an indi-
24
vidual who is eligible under this section to be en-
25
rolled through the Health Insurance Exchange in an
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74
1
Exchange-participating health benefits plan and,
2
with respect to family coverage, includes dependents
3
of such individual.
4
(2) EXCHANGE-ELIGIBLE
EMPLOYER.—The
5
term ‘‘Exchange-eligible employer’’ means an em-
6
ployer that is eligible under this section to enroll
7
through the Health Insurance Exchange employees
8
of the employer (and their dependents) in Exchange-
9
eligible health benefits plans.
10
(3) EMPLOYMENT-RELATED
DEFINITIONS.—
11
The terms ‘‘employer’’, ‘‘employee’’, ‘‘full-time em-
12
ployee’’, and ‘‘part-time employee’’ have the mean-
13
ings given such terms by the Commissioner for pur-
14
poses of this division.
15
(c) TRANSITION.—Individuals and employers shall
16 only be eligible to enroll or participate in the Health Insur-
17 ance Exchange in accordance with the following transition
18 schedule:
19
(1) FIRST YEAR.—In Y1 (as defined in section
20
100(c))—
21
(A) individuals described in subsection
22
(d)(1), including individuals described in para-
23
graphs (3) and (4) of subsection (d); and
24
(B) smallest employers described in sub-
25
section (e)(1).
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75
1
(2) SECOND YEAR.—In Y2—
2
(A) individuals and employers described in
3
paragraph (1); and
4
(B) smaller employers described in sub-
5
section (e)(2).
6
(3) THIRD AND SUBSEQUENT YEARS.—In Y3
7
and subsequent years—
8
(A) individuals and employers described in
9
paragraph (2); and
10
(B) larger employers as permitted by the
11
Commissioner under subsection (e)(3).
12
(d) INDIVIDUALS.—
13
(1) INDIVIDUAL DESCRIBED.—Subject to the
14
succeeding provisions of this subsection, an indi-
15
vidual described in this paragraph is an individual
16
who—
17
(A) is not enrolled in coverage described in
18
subparagraphs (C) through (F) of paragraph
19
(2); and
20
(B) is not enrolled in coverage as a full-
21
time employee (or as a dependent of such an
22
employee) under a group health plan if the cov-
23
erage and an employer contribution under the
24
plan meet the requirements of section 312.
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76
1
For purposes of subparagraph (B), in the case of an
2
individual who is self-employed, who has at least 1
3
employee, and who meets the requirements of section
4
312, such individual shall be deemed a full-time em-
5
ployee described in such subparagraph.
6
(2) ACCEPTABLE COVERAGE.—For purposes of
7
this division, the term ‘‘acceptable coverage’’ means
8
any of the following:
9
(A) QUALIFIED HEALTH BENEFITS PLAN
10
COVERAGE.—Coverage under a qualified health
11
benefits plan.
12
(B) GRANDFATHERED HEALTH INSURANCE
13
COVERAGE; COVERAGE UNDER CURRENT GROUP
14
HEALTH
PLAN.—Coverage under a grand-
15
fathered health insurance coverage (as defined
16
in subsection (a) of section 102) or under a
17
current group health plan (described in sub-
18
section (b) of such section).
19
(C) MEDICARE.—Coverage under part A of
20
title XVIII of the Social Security Act.
21
(D) MEDICAID.—Coverage for medical as-
22
sistance under title XIX of the Social Security
23
Act, excluding such coverage that is only avail-
24
able because of the application of subsection
25
(u), (z), or (aa) of section 1902 of such Act
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77
1
(E) MEMBERS OF THE ARMED FORCES
2
AND
DEPENDENTS
(INCLUDING
TRICARE).—
3
Coverage under chapter 55 of title 10, United
4
States Code, including similar coverage fur-
5
nished under section 1781 of title 38 of such
6
Code.
7
(F) VA.—Coverage under the veteran’s
8
health care program under chapter 17 of title
9
38, United States Code, but only if the cov-
10
erage for the individual involved is determined
11
by the Commissioner in coordination with the
12
Secretary of Treasury to be not less than a level
13
specified by the Commissioner and Secretary of
14
Veteran’s Affairs, in coordination with the Sec-
15
retary of Treasury, based on the individual’s
16
priority for services as provided under section
17
1705(a) of such title.
18
(G) OTHER COVERAGE.—Such other health
19
benefits coverage, such as a State health bene-
20
fits risk pool, as the Commissioner, in coordina-
21
tion with the Secretary of the Treasury, recog-
22
nizes for purposes of this paragraph.
23
The Commissioner shall make determinations under
24
this paragraph in coordination with the Secretary of
25
the Treasury.
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78
1
(3) TREATMENT
OF
CERTAIN
NON-TRADI-
2
TIONAL MEDICAID ELIGIBLE INDIVIDUALS.—An indi-
3
vidual who is a non-traditional Medicaid eligible in-
4
dividual (as defined in section 205(e)(4)(C)) in a
5
State may be an Exchange-eligible individual if the
6
individual was enrolled in a qualified health benefits
7
plan, grandfathered health insurance coverage, or
8
current group health plan during the 6 months be-
9
fore the individual became a non-traditional Med-
10
icaid eligible individual. During the period in which
11
such an individual has chosen to enroll in an Ex-
12
change-participating health benefits plan, the indi-
13
vidual is not also eligible for medical assistance
14
under Medicaid.
15
(4) CONTINUING ELIGIBILITY PERMITTED.—
16
(A) IN GENERAL.—Except as provided in
17
subparagraph (B), once an individual qualifies
18
as an Exchange-eligible individual under this
19
subsection (including as an employee or depend-
20
ent of an employee of an Exchange-eligible em-
21
ployer) and enrolls under an Exchange-partici-
22
pating health benefits plan through the Health
23
Insurance Exchange, the individual shall con-
24
tinue to be treated as an Exchange-eligible indi-
25
vidual until the individual is no longer enrolled
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79
1
with an Exchange-participating health benefits
2
plan.
3
(B) EXCEPTIONS.—
4
(i) IN GENERAL.—Subparagraph (A)
5
shall not apply to an individual once the
6
individual becomes eligible for coverage—
7
(I) under part A of the Medicare
8
program;
9
(II) under the Medicaid program
10
as a Medicaid eligible individual, ex-
11
cept as permitted under paragraph
12
(3) or clause (ii); or
13
(III) in such other circumstances
14
as the Commissioner may provide.
15
(ii) TRANSITION PERIOD.—In the case
16
described in clause (i)(II), the Commis-
17
sioner shall permit the individual to con-
18
tinue treatment under subparagraph (A)
19
until such limited time as the Commis-
20
sioner determines it is administratively fea-
21
sible, consistent with minimizing disruption
22
in the individual’s access to health care.
23
(e) EMPLOYERS.—
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80
1
(1) SMALLEST EMPLOYER.—Subject to para-
2
graph (4), smallest employers described in this para-
3
graph are employers with 10 or fewer employees.
4
(2) SMALLER EMPLOYERS.—Subject to para-
5
graph (4), smaller employers described in this para-
6
graph are employers that are not smallest employers
7
described in paragraph (1) and have 20 or fewer em-
8
ployees.
9
(3) LARGER EMPLOYERS.—
10
(A) IN GENERAL.—Beginning with Y3, the
11
Commissioner may permit employers not de-
12
scribed in paragraph (1) or (2) to be Exchange-
13
eligible employers.
14
(B) PHASE-IN.—In applying subparagraph
15
(A), the Commissioner may phase-in the appli-
16
cation of such subparagraph based on the num-
17
ber of full-time employees of an employer and
18
such other considerations as the Commissioner
19
deems appropriate.
20
(4) CONTINUING ELIGIBILITY.—Once an em-
21
ployer is permitted to be an Exchange-eligible em-
22
ployer under this subsection and enrolls employees
23
through the Health Insurance Exchange, the em-
24
ployer shall continue to be treated as an Exchange-
25
eligible employer for each subsequent plan year re-
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81
1
gardless of the number of employees involved unless
2
and until the employer meets the requirement of sec-
3
tion 311(a) through paragraph (1) of such section
4
by offering a group health plan and not through of-
5
fering Exchange-participating health benefits plan.
6
(5) EMPLOYER PARTICIPATION AND CONTRIBU-
7
TIONS.—
8
(A) SATISFACTION OF EMPLOYER RESPON-
9
SIBILITY.—For any year in which an employer
10
is an Exchange-eligible employer, such employer
11
may meet the requirements of section 312 with
12
respect to employees of such employer by offer-
13
ing such employees the option of enrolling with
14
Exchange-participating health benefits plans
15
through the Health Insurance Exchange con-
16
sistent with the provisions of subtitle B of title
17
III.
18
(B) EMPLOYEE CHOICE.—Any employee
19
offered Exchange-participating health benefits
20
plans by the employer of such employee under
21
subparagraph (A) may choose coverage under
22
any such plan. That choice includes, with re-
23
spect to family coverage, coverage of the de-
24
pendents of such employee.
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82
1
(6) AFFILIATED GROUPS.—Any employer which
2
is part of a group of employers who are treated as
3
a single employer under subsection (b), (c), (m), or
4
(o) of section 414 of the Internal Revenue Code of
5
1986 shall be treated, for purposes of this subtitle,
6
as a single employer.
7
(7) OTHER COUNTING RULES.—The Commis-
8
sioner shall establish rules relating to how employees
9
are counted for purposes of carrying out this sub-
10
section.
11
(f) SPECIAL SITUATION AUTHORITY.—The Commis-
12 sioner shall have the authority to establish such rules as
13 may be necessary to deal with special situations with re-
14 gard to uninsured individuals and employers participating
15 as Exchange-eligible individuals and employers, such as
16 transition periods for individuals and employers who gain,
17 or lose, Exchange-eligible participation status, and to es-
18 tablish grace periods for premium payment.
19
(g) SURVEYS OF INDIVIDUALS AND EMPLOYERS.—
20 The Commissioner shall provide for periodic surveys of
21 Exchange-eligible individuals and employers concerning
22 satisfaction of such individuals and employers with the
23 Health Insurance Exchange and Exchange-participating
24 health benefits plans.
25
(h) EXCHANGE ACCESS STUDY.—
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1
(1) IN GENERAL.—The Commissioner shall con-
2
duct a study of access to the Health Insurance Ex-
3
change for individuals and for employers, including
4
individuals and employers who are not eligible and
5
enrolled in Exchange-participating health benefits
6
plans. The goal of the study is to determine if there
7
are significant groups and types of individuals and
8
employers who are not Exchange eligible individuals
9
or employers, but who would have improved benefits
10
and affordability if made eligible for coverage in the
11
Exchange.
12
(2) ITEMS INCLUDED IN STUDY.—Such study
13
also shall examine—
14
(A) the terms, conditions, and affordability
15
of group health coverage offered by employers
16
and QHBP offering entities outside of the Ex-
17
change compared to Exchange-participating
18
health benefits plans; and
19
(B) the affordability-test standard for ac-
20
cess of certain employed individuals to coverage
21
in the Health Insurance Exchange.
22
(3) REPORT.—Not later than January 1 of Y3,
23
in Y6, and thereafter, the Commissioner shall sub-
24
mit to Congress on the study conducted under this
25
subsection and shall include in such report rec-
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84
1
ommendations regarding changes in standards for
2
Exchange eligibility for for individuals and employ-
3
ers.
4 SEC. 203. BENEFITS PACKAGE LEVELS.
5
(a) IN GENERAL.—The Commissioner shall specify
6 the benefits to be made available under Exchange-partici-
7 pating health benefits plans during each plan year, con-
8 sistent with subtitle C of title I and this section.
9
(b) LIMITATION ON HEALTH BENEFITS PLANS OF-
10 FERED BY OFFERING ENTITIES.—The Commissioner may
11 not enter into a contract with a QHBP offering entity
12 under section 204(c) for the offering of an Exchange-par-
13 ticipating health benefits plan in a service area unless the
14 following requirements are met:
15
(1) REQUIRED OFFERING OF BASIC PLAN.—The
16
entity offers only one basic plan for such service
17
area.
18
(2) OPTIONAL
OFFERING
OF
ENHANCED
19
PLAN.—If and only if the entity offers a basic plan
20
for such service area, the entity may offer one en-
21
hanced plan for such area.
22
(3) OPTIONAL OFFERING OF PREMIUM PLAN.—
23
If and only if the entity offers an enhanced plan for
24
such service area, the entity may offer one premium
25
plan for such area.
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85
1
(4) OPTIONAL OFFERING OF PREMIUM-PLUS
2
PLANS.—If and only if the entity offers a premium
3
plan for such service area, the entity may offer one
4
or more premium-plus plans for such area.
5 All such plans may be offered under a single contract with
6 the Commissioner.
7
(c) SPECIFICATION
OF
BENEFIT
LEVELS
FOR
8 PLANS.—
9
(1) IN GENERAL.—The Commissioner shall es-
10
tablish the following standards consistent with this
11
subsection and title I:
12
(A) BASIC, ENHANCED, AND PREMIUM
13
PLANS.—Standards for 3 levels of Exchange-
14
participating health benefits plans: basic, en-
15
hanced, and premium (in this division referred
16
to as a ‘‘basic plan’’, ‘‘enhanced plan’’, and
17
‘‘premium plan’’, respectively).
18
(B) PREMIUM-PLUS
PLAN
BENEFITS.—
19
Standards for additional benefits that may be
20
offered, consistent with this subsection and sub-
21
title C of title I, under a premium plan (such
22
a plan with additional benefits referred to in
23
this division as a ‘‘premium-plus plan’’) .
24
(2) BASIC PLAN.—
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86
1
(A) IN GENERAL.—A basic plan shall offer
2
the essential benefits package required under
3
title I for a qualified health benefits plan.
4
(B) TIERED COST-SHARING FOR AFFORD-
5
ABLE CREDIT ELIGIBLE INDIVIDUALS.—In the
6
case of an affordable credit eligible individual
7
(as defined in section 242(a)(1)) enrolled in an
8
Exchange-participating health benefits plan, the
9
benefits under a basic plan are modified to pro-
10
vide for the reduced cost-sharing for the income
11
tier applicable to the individual under section
12
244(c).
13
(3) ENHANCED PLAN.—A enhanced plan shall
14
offer, in addition to the level of benefits under the
15
basic plan, a lower level of cost-sharing as provided
16
under title I consistent with section 123(b)(5)(A).
17
(4) PREMIUM PLAN.—A premium plan shall
18
offer, in addition to the level of benefits under the
19
basic plan, a lower level of cost-sharing as provided
20
under title I consistent with section 123(b)(5)(B).
21
(5) PREMIUM-PLUS
PLAN.—A premium-plus
22
plan is a premium plan that also provides additional
23
benefits, such as adult oral health and vision care,
24
approved by the Commissioner. The portion of the
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87
1
premium that is attributable to such additional ben-
2
efits shall be separately specified.
3
(6) RANGE OF PERMISSIBLE VARIATION IN
4
COST-SHARING.—The Commissioner shall establish a
5
permissible range of variation of cost-sharing for
6
each basic, enhanced, and premium plan, except with
7
respect to any benefit for which there is no cost-
8
sharing permitted under the essential benefits pack-
9
age. Such variation shall permit a variation of not
10
more than plus (or minus) 10 percent in cost-shar-
11
ing with respect to each benefit category specified
12
under section 122.
13
(d) TREATMENT OF STATE BENEFIT MANDATES.—
14 Insofar as a State requires a health insurance issuer offer-
15 ing health insurance coverage to include benefits beyond
16 the essential benefits package, such requirement shall con-
17 tinue to apply to an Exchange-participating health bene-
18 fits plan, if the State has entered into an arrangement
19 satisfactory to the Commissioner to reimburse the Com-
20 missioner for the amount of any net increase in afford-
21 ability premium credits under subtitle C as a result of an
22 increase in premium in basic plans as a result of applica-
23 tion of such requirement.
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88
1 SEC. 204. CONTRACTS FOR THE OFFERING OF EXCHANGE-
2
PARTICIPATING HEALTH BENEFITS PLANS.
3
(a) CONTRACTING DUTIES.—In carrying out section
4 201(b)(1) and consistent with this subtitle:
5
(1) OFFERING
ENTITY
AND
PLAN
STAND-
6
ARDS.—The Commissioner shall—
7
(A) establish standards necessary to imple-
8
ment the requirements of this title and title I
9
for—
10
(i) QHBP offering entities for the of-
11
fering of an Exchange-participating health
12
benefits plan; and
13
(ii) for Exchange-participating health
14
benefits plans; and
15
(B) certify QHBP offering entities and
16
qualified health benefits plans as meeting such
17
standards and requirements of this title and
18
title I for purposes of this subtitle.
19
(2) SOLICITING AND NEGOTIATING BIDS; CON-
20
TRACTS.—The Commissioner shall—
21
(A) solicit bids from QHBP offering enti-
22
ties for the offering of Exchange-participating
23
health benefits plans;
24
(B) based upon a review of such bids, ne-
25
gotiate with such entities for the offering of
26
such plans; and
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89
1
(C) enter into contracts with such entities
2
for the offering of such plans through the
3
Health Insurance Exchange under terms (con-
4
sistent with this title) negotiated between the
5
Commissioner and such entities.
6
(3) FAR NOT APPLICABLE.—The provisions of
7
the Federal Acquisition Regulation shall not apply to
8
contracts between the Commissioner and QHBP of-
9
fering entities for the offering of Exchange-partici-
10
pating health benefits plans under this title.
11
(b) STANDARDS FOR QHBP OFFERING ENTITIES TO
12 OFFER EXCHANGE-PARTICIPATING HEALTH BENEFITS
13 PLANS.—The standards established under subsection
14 (a)(1)(A) shall require that, in order for a QHBP offering
15 entity to offer an Exchange-participating health benefits
16 plan, the entity must meet the following requirements:
17
(1) LICENSED.—The entity shall be licensed to
18
offer health insurance coverage under State law for
19
each State in which it is offering such coverage.
20
(2) DATA REPORTING.—The entity shall pro-
21
vide for the reporting of such information as the
22
Commissioner may specify, including information
23
necessary to administer the risk pooling mechanism
24
described in section 206(b) and information to ad-
25
dress disparities in health and health care.
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1
(3) IMPLEMENTING
AFFORDABILITY
CRED-
2
ITS.—The entity shall provide for implementation of
3
the affordability credits provided for enrollees under
4
subtitle C, including the reduction in cost-sharing
5
under section 244(c).
6
(4) ENROLLMENT.—The entity shall accept all
7
enrollments under this subtitle, subject to such ex-
8
ceptions (such as capacity limitations) in accordance
9
with the requirements under title I for a qualified
10
health benefits plan. The entity shall notify the
11
Commissioner if the entity projects or anticipates
12
reaching such a capacity limitation that would result
13
in a limitation in enrollment.
14
(5) RISK POOLING PARTICIPATION.—The entity
15
shall participate in such risk pooling mechanism as
16
the Commissioner establishes under section 206(b).
17
(6) ESSENTIAL COMMUNITY PROVIDERS.—With
18
respect to the basic plan offered by the entity, the
19
entity shall contract for outpatient services with cov-
20
ered entities (as defined in section 340B(a)(4) of the
21
Public Health Service Act, as in effect as of July 1,
22
2009). The Commissioner shall specify the extent to
23
which and manner in which the previous sentence
24
shall apply in the case of a basic plan with respect
25
to which the Commissioner determines provides sub-
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91
1
stantially all benefits through a health maintenance
2
organization, as defined in section 2791(b)(3) of the
3
Public Health Service Act.
4
(7) CULTURALLY AND LINGUISTICALLY APPRO-
5
PRIATE SERVICES AND COMMUNICATIONS.—The en-
6
tity shall provide for culturally and linguistically ap-
7
propriate communication and health services.
8
(8) ADDITIONAL REQUIREMENTS.—The entity
9
shall comply with other applicable requirements of
10
this title, as specified by the Commissioner, which
11
shall include standards regarding billing and collec-
12
tion practices for premiums and related grace peri-
13
ods and which may include standards to ensure that
14
the entity does not use coercive practices to force
15
providers not to contract with other entities offering
16
coverage through the Health Insurance Exchange.
17
(c) CONTRACTS.—
18
(1) BID APPLICATION.—To be eligible to enter
19
into a contract under this section, a QHBP offering
20
entity shall submit to the Commissioner a bid at
21
such time, in such manner, and containing such in-
22
formation as the Commissioner may require.
23
(2) TERM.—Each contract with a QHBP offer-
24
ing entity under this section shall be for a term of
25
not less than one year, but may be made automati-
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92
1
cally renewable from term to term in the absence of
2
notice of termination by either party.
3
(3) ENFORCEMENT OF NETWORK ADEQUACY.—
4
In the case of a health benefits plan of a QHBP of-
5
fering entity that uses a provider network, the con-
6
tract under this section with the entity shall provide
7
that if—
8
(A) the Commissioner determines that
9
such provider network does not meet such
10
standards as the Commissioner shall establish
11
under section 115; and
12
(B) an individual enrolled in such plan re-
13
ceives an item or service from a provider that
14
is not within such network;
15
then any cost-sharing for such item or service shall
16
be equal to the amount of such cost-sharing that
17
would be imposed if such item or service was fur-
18
nished by a provider within such network.
19
(4) OVERSIGHT AND ENFORCEMENT RESPON-
20
SIBILITIES.—The Commissioner shall establish proc-
21
esses, in coordination with State insurance regu-
22
lators, to oversee, monitor, and enforce applicable re-
23
quirements of this title with respect to QHBP offer-
24
ing entities offering Exchange-participating health
25
benefits plans and such plans, including the mar-
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93
1
keting of such plans. Such processes shall include
2
the following:
3
(A) GRIEVANCE AND COMPLAINT MECHA-
4
NISMS.—The Commissioner shall establish, in
5
coordination with State insurance regulators, a
6
process under which Exchange-eligible individ-
7
uals and employers may file complaints con-
8
cerning violations of such standards.
9
(B) ENFORCEMENT.—In carrying out au-
10
thorities under this division relating to the
11
Health Insurance Exchange, the Commissioner
12
may impose one or more of the intermediate
13
sanctions described in section 142(c).
14
(C) TERMINATION.—
15
(i) IN GENERAL.—The Commissioner
16
may terminate a contract with a QHBP of-
17
fering entity under this section for the of-
18
fering of an Exchange-participating health
19
benefits plan if such entity fails to comply
20
with the applicable requirements of this
21
title. Any determination by the Commis-
22
sioner to terminate a contract shall be
23
made in accordance with formal investiga-
24
tion and compliance procedures established
25
by the Commissioner under which—
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94
1
(I) the Commissioner provides
2
the entity with the reasonable oppor-
3
tunity to develop and implement a
4
corrective action plan to correct the
5
deficiencies that were the basis of the
6
Commissioner’s determination; and
7
(II) the Commissioner provides
8
the entity with reasonable notice and
9
opportunity for hearing (including the
10
right to appeal an initial decision) be-
11
fore terminating the contract.
12
(ii) EXCEPTION FOR IMMINENT AND
13
SERIOUS
RISK
TO
HEALTH.—Clause (i)
14
shall not apply if the Commissioner deter-
15
mines that a delay in termination, result-
16
ing from compliance with the procedures
17
specified in such clause prior to termi-
18
nation, would pose an imminent and seri-
19
ous risk to the health of individuals en-
20
rolled under the qualified health benefits
21
plan of the QHBP offering entity.
22
(D) CONSTRUCTION.—Nothing in this sub-
23
section shall be construed as preventing the ap-
24
plication of other sanctions under subtitle E of
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95
1
title I with respect to an entity for a violation
2
of such a requirement.
3 SEC. 205. OUTREACH AND ENROLLMENT OF EXCHANGE-EL-
4
IGIBLE INDIVIDUALS AND EMPLOYERS IN EX-
5
CHANGE-PARTICIPATING HEALTH BENEFITS
6
PLAN.
7
(a) IN GENERAL.—
8
(1) OUTREACH.—The Commissioner shall con-
9
duct outreach activities consistent with subsection
10
(c), including through use of appropriate entities as
11
described in paragraph (4) of such subsection, to in-
12
form and educate individuals and employers about
13
the Health Insurance Exchange and Exchange-par-
14
ticipating health benefits plan options. Such out-
15
reach shall include outreach specific to vulnerable
16
populations, such as children, individuals with dis-
17
abilities, individuals with mental illness, and individ-
18
uals with other cognitive impairments.
19
(2) ELIGIBILITY.—The Commissioner shall
20
make timely determinations of whether individuals
21
and employers are Exchange-eligible individuals and
22
employers (as defined in section 202).
23
(3) ENROLLMENT.—The Commissioner shall es-
24
tablish and carry out an enrollment process for Ex-
25
change-eligible individuals and employers, including
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96
1
at community locations, in accordance with sub-
2
section (b).
3
(b) ENROLLMENT PROCESS.—
4
(1) IN GENERAL.—The Commissioner shall es-
5
tablish a process consistent with this title for enroll-
6
ments in Exchange-participating health benefits
7
plans. Such process shall provide for enrollment
8
through means such as the mail, by telephone, elec-
9
tronically, and in person.
10
(2) ENROLLMENT PERIODS.—
11
(A) OPEN
ENROLLMENT
PERIOD.—The
12
Commissioner shall establish an annual open
13
enrollment period during which an Exchange-el-
14
igible individual or employer may elect to enroll
15
in an Exchange-participating health benefits
16
plan for the following plan year and an enroll-
17
ment period for affordability credits under sub-
18
title C. Such periods shall be during September
19
through November of each year, or such other
20
time that would maximize timeliness of income
21
verification for purposes of such subtitle. The
22
open enrollment period shall not be less than 30
23
days.
24
(B) SPECIAL ENROLLMENT.—The Com-
25
missioner shall also provide for special enroll-
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97
1
ment periods to take into account special cir-
2
cumstances of individuals and employers, such
3
as an individual who—
4
(i) loses acceptable coverage;
5
(ii) experiences a change in marital or
6
other dependent status;
7
(iii) moves outside the service area of
8
the Exchange-participating health benefits
9
plan in which the individual is enrolled; or
10
(iv) experiences a significant change
11
in income.
12
(C) ENROLLMENT
INFORMATION.—The
13
Commissioner shall provide for the broad dis-
14
semination of information to prospective enroll-
15
ees on the enrollment process, including before
16
each open enrollment period. In carrying out
17
the previous sentence, the Commissioner may
18
work with other appropriate entities to facilitate
19
such provision of information.
20
(3) AUTOMATIC ENROLLMENT FOR NON-MED-
21
ICAID ELIGIBLE INDIVIDUALS.—
22
(A) IN
GENERAL.—The Commissioner
23
shall provide for a process under which individ-
24
uals who are Exchange-eligible individuals de-
25
scribed in subparagraph (B) are automatically
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98
1
enrolled under an appropriate Exchange-partici-
2
pating health benefits plan. Such process may
3
involve a random assignment or some other
4
form of assignment that takes into account the
5
health care providers used by the individual in-
6
volved or such other relevant factors as the
7
Commissioner may specify.
8
(B) SUBSIDIZED
INDIVIDUALS
DE-
9
SCRIBED.—An individual described in this sub-
10
paragraph is an Exchange-eligible individual
11
who is either of the following:
12
(i) AFFORDABILITY CREDIT ELIGIBLE
13
INDIVIDUALS.—The individual—
14
(I) has applied for, and been de-
15
termined eligible for, affordability
16
credits under subtitle C;
17
(II) has not opted out from re-
18
ceiving such affordability credit; and
19
(III) does not otherwise enroll in
20
another Exchange-participating health
21
benefits plan.
22
(ii) INDIVIDUALS ENROLLED IN A
23
TERMINATED PLAN.—The individual is en-
24
rolled in an Exchange-participating health
25
benefits plan that is terminated (during or
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99
1
at the end of a plan year) and who does
2
not otherwise enroll in another Exchange-
3
participating health benefits plan.
4
(4) DIRECT
PAYMENT
OF
PREMIUMS
TO
5
PLANS.—Under the enrollment process, individuals
6
enrolled in an Exchange-partcipating health benefits
7
plan shall pay such plans directly, and not through
8
the Commissioner or the Health Insurance Ex-
9
change.
10
(c) COVERAGE INFORMATION AND ASSISTANCE.—
11
(1) COVERAGE INFORMATION.—The Commis-
12
sioner shall provide for the broad dissemination of
13
information on Exchange-participating health bene-
14
fits plans offered under this title. Such information
15
shall be provided in a comparative manner, and shall
16
include information on benefits, premiums, cost-
17
sharing, quality, provider networks, and consumer
18
satisfaction.
19
(2) CONSUMER ASSISTANCE WITH CHOICE.—To
20
provide assistance to Exchange-eligible individuals
21
and employers, the Commissioner shall—
22
(A) provide for the operation of a toll-free
23
telephone hotline to respond to requests for as-
24
sistance and maintain an Internet website
25
through which individuals may obtain informa-
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100
1
tion on coverage under Exchange-participating
2
health benefits plans and file complaints;
3
(B) develop and disseminate information to
4
Exchange-eligible enrollees on their rights and
5
responsibilities;
6
(C) assist Exchange-eligible individuals in
7
selecting Exchange-participating health benefits
8
plans and obtaining benefits through such
9
plans; and
10
(D) ensure that the Internet website de-
11
scribed in subparagraph (A) and the informa-
12
tion described in subparagraph (B) is developed
13
using plain language (as defined in section
14
133(a)(2)).
15
(3) USE OF OTHER ENTITIES.—In carrying out
16
this subsection, the Commissioner may work with
17
other appropriate entities to facilitate the dissemina-
18
tion of information under this subsection and to pro-
19
vide assistance as described in paragraph (2).
20
(d) SPECIAL DUTIES RELATED TO MEDICAID AND
21 CHIP.—
22
(1) COVERAGE FOR CERTAIN NEWBORNS.—
23
(A) IN GENERAL.—In the case of a child
24
born in the United States who at the time of
25
birth is not otherwise covered under acceptable
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101
1
coverage, for the period of time beginning on
2
the date of birth and ending on the date the
3
child otherwise is covered under acceptable cov-
4
erage (or, if earlier, the end of the month in
5
which the 60-day period, beginning on the date
6
of birth, ends), the child shall be deemed—
7
(i) to be a non-traditional Medicaid el-
8
igible individual (as defined in subsection
9
(e)(5)) for purposes of this division and
10
Medicaid; and
11
(ii) to have elected to enroll in Med-
12
icaid through the application of paragraph
13
(3).
14
(B) EXTENDED TREATMENT AS TRADI-
15
TIONAL MEDICAID ELIGIBLE INDIVIDUAL.—In
16
the case of a child described in subparagraph
17
(A) who at the end of the period referred to in
18
such subparagraph is not otherwise covered
19
under acceptable coverage, the child shall be
20
deemed (until such time as the child obtains
21
such coverage or the State otherwise makes a
22
determination of the child’s eligibility for med-
23
ical assistance under its Medicaid plan pursuant
24
to section 1943(c)(1) of the Social Security
25
Act) to be a traditional Medicaid eligible indi-
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102
1
vidual described in section 1902(l)(1)(B) of
2
such Act.
3
(2) CHIP TRANSITION.—A child who, as of the
4
day before the first day of Y1, is eligible for child
5
health assistance under title XXI of the Social Secu-
6
rity Act (including a child receiving coverage under
7
an arrangement described in section 2101(a)(2) of
8
such Act) is deemed as of such first day to be an
9
Exchange-eligible individual unless the individual is
10
a traditional Medicaid eligible individual as of such
11
day.
12
(3) AUTOMATIC ENROLLMENT OF MEDICAID EL-
13
IGIBLE
INDIVIDUALS
INTO
MEDICAID.—The Com-
14
missioner shall provide for a process under which an
15
individual who is described in section 202(d)(3) and
16
has not elected to enroll in an Exchange-partici-
17
pating health benefits plan is automatically enrolled
18
under Medicaid.
19
(4) NOTIFICATIONS.—The Commissioner shall
20
notify each State in Y1 and for purposes of section
21
1902(gg)(1) of the Social Security Act (as added by
22
section 1703(a)) whether the Health Insurance Ex-
23
change can support enrollment of children described
24
in paragraph (2) in such State in such year.
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103
1
(e) MEDICAID COVERAGE FOR MEDICAID ELIGIBLE
2 INDIVIDUALS.—
3
(1) IN GENERAL.—
4
(A) CHOICE FOR LIMITED EXCHANGE-ELI-
5
GIBLE INDIVIDUALS.—As part of the enrollment
6
process under subsection (b), the Commissioner
7
shall provide the option, in the case of an Ex-
8
change-eligible individual described in section
9
202(d)(3), for the individual to elect to enroll
10
under Medicaid instead of under an Exchange-
11
participating health benefits plan. Such an indi-
12
vidual may change such election during an en-
13
rollment period under subsection (b)(2).
14
(B) MEDICAID
ENROLLMENT
OBLIGA-
15
TION.—An Exchange eligible individual may
16
apply, in the manner described in section
17
241(b)(1), for a determination of whether the
18
individual is a Medicaid-eligible individual. If
19
the individual is determined to be so eligible,
20
the Commissioner, through the Medicaid memo-
21
randum of understanding, shall provide for the
22
enrollment of the individual under the State
23
Medicaid plan in accordance with the Medicaid
24
memorandum of understanding under para-
25
graph (4). In the case of such an enrollment,
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104
1
the State shall provide for the same periodic re-
2
determination of eligibility under Medicaid as
3
would otherwise apply if the individual had di-
4
rectly applied for medical assistance to the
5
State Medicaid agency.
6
(2) NON-TRADITIONAL MEDICAID ELIGIBLE IN-
7
DIVIDUALS.—In the case of a non-traditional Med-
8
icaid eligible individual described in section
9
202(d)(3) who elects to enroll under Medicaid under
10
paragraph (1)(A), the Commissioner shall provide
11
for the enrollment of the individual under the State
12
Medicaid plan in accordance with the Medicaid
13
memorandum of understanding under paragraph
14
(4).
15
(3) COORDINATED ENROLLMENT WITH STATE
16
THROUGH
MEMORANDUM
OF
UNDERSTANDING.—
17
The Commissioner, in consultation with the Sec-
18
retary of Health and Human Services, shall enter
19
into a memorandum of understanding with each
20
State (each in this division referred to as a ‘‘Med-
21
icaid memorandum of understanding’’) with respect
22
to coordinating enrollment of individuals in Ex-
23
change-participating health benefits plans and under
24
the State’s Medicaid program consistent with this
25
section and to otherwise coordinate the implementa-
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105
1
tion of the provisions of this division with respect to
2
the Medicaid program. Such memorandum shall per-
3
mit the exchange of information consistent with the
4
limitations described in section 1902(a)(7) of the So-
5
cial Security Act. Nothing in this section shall be
6
construed as permitting such memorandum to mod-
7
ify or vitiate any requirement of a State Medicaid
8
plan.
9
(4) MEDICAID ELIGIBLE INDIVIDUALS.—For
10
purposes of this division:
11
(A) MEDICAID ELIGIBLE INDIVIDUAL.—
12
The term ‘‘Medicaid eligible individual’’ means
13
an individual who is eligible for medical assist-
14
ance under Medicaid.
15
(B) TRADITIONAL MEDICAID ELIGIBLE IN-
16
DIVIDUAL.—The term ‘‘traditional Medicaid eli-
17
gible individual’’ means a Medicaid eligible indi-
18
vidual other than an individual who is—
19
(i) a Medicaid eligible individual by
20
reason of the application of subclause
21
(VIII) of section 1902(a)(10)(A)(i) of the
22
Social Security Act; or
23
(ii) a childless adult not described in
24
section 1902(a)(10)(A) or (C) of such Act
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106
1
(as in effect as of the day before the date
2
of the enactment of this Act).
3
(C) NON-TRADITIONAL MEDICAID ELIGI-
4
BLE
INDIVIDUAL.—The term ‘‘non-traditional
5
Medicaid eligible individual’’ means a Medicaid
6
eligible individual who is not a traditional Med-
7
icaid eligible individual.
8
(f) EFFECTIVE CULTURALLY AND LINGUISTICALLY
9 APPROPRIATE COMMUNICATION.—In carrying out this
10 section, the Commissioner shall establish effective methods
11 for communicating in plain language and a culturally and
12 linguistically appropriate manner.
13 SEC. 206. OTHER FUNCTIONS.
14
(a) COORDINATION OF AFFORDABILITY CREDITS.—
15 The Commissioner shall coordinate the distribution of af-
16 fordability premium and cost-sharing credits under sub-
17 title C to QHBP offering entities offering Exchange-par-
18 ticipating health benefits plans.
19
(b) COORDINATION OF RISK POOLING.—The Com-
20 missioner shall establish a mechanism whereby there is an
21 adjustment made of the premium amounts payable among
22 QHBP offering entities offering Exchange-participating
23 health benefits plans of premiums collected for such plans
24 that takes into account (in a manner specified by the Com-
25 missioner) the differences in the risk characteristics of in-
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107
1 dividuals and employers enrolled under the different Ex-
2 change-participating health benefits plans offered by such
3 entities so as to minimize the impact of adverse selection
4 of enrollees among the plans offered by such entities.
5
(c) SPECIAL INSPECTOR GENERAL FOR THE HEALTH
6 INSURANCE EXCHANGE.—
7
(1) ESTABLISHMENT; APPOINTMENT.—There is
8
hereby established the Office of the Special Inspec-
9
tor General for the Health Insurance Exchange, to
10
be headed by a Special Inspector General for the
11
Health Insurance Exchange (in this subsection re-
12
ferred to as the ‘‘Special Inspector General’’) to be
13
appointed by the President, by and with the advice
14
and consent of the Senate. The nomination of an in-
15
dividual as Special Inspector General shall be made
16
as soon as practicable after the establishment of the
17
program under this subtitle.
18
(2) DUTIES.—The Special Inspector General
19
shall—
20
(A) conduct, supervise, and coordinate au-
21
dits, evaluations and investigations of the
22
Health Insurance Exchange to protect the in-
23
tegrity of the Health Insurance Exchange, as
24
well as the health and welfare of participants in
25
the Exchange;
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108
1
(B) report both to the Commissioner and
2
to the Congress regarding program and man-
3
agement problems and recommendations to cor-
4
rect them;
5
(C) have other duties (described in para-
6
graphs (2) and (3) of section 121 of division A
7
of Public Law 110–343) in relation to the du-
8
ties described in the previous subparagraphs;
9
and
10
(D) have the authorities provided in sec-
11
tion 6 of the Inspector General Act of 1978 in
12
carrying out duties under this paragraph.
13
(3) APPLICATION OF OTHER SPECIAL INSPEC-
14
TOR GENERAL PROVISIONS.—The provisions of sub-
15
sections (b) (other than paragraphs (1) and (3)), (d)
16
(other than paragraph (1)), and (e) of section 121
17
of division A of the Emergency Economic Stabiliza-
18
tion Act of 2009 (Public Law 110–343) shall apply
19
to the Special Inspector General under this sub-
20
section in the same manner as such provisions apply
21
to the Special Inspector General under such section.
22
(4) REPORTS.—Not later than one year after
23
the confirmation of the Special Inspector General,
24
and annually thereafter, the Special Inspector Gen-
25
eral shall submit to the appropriate committees of
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109
1
Congress a report summarizing the activities of the
2
Special Inspector General during the one year period
3
ending on the date such report is submitted.
4
(5) TERMINATION.—The Office of the Special
5
Inspector General shall terminate five years after
6
the date of the enactment of this Act.
7 SEC. 207. HEALTH INSURANCE EXCHANGE TRUST FUND.
8
(a) ESTABLISHMENT OF HEALTH INSURANCE EX-
9 CHANGE TRUST FUND.—There is created within the
10 Treasury of the United States a trust fund to be known
11 as the ‘‘Health Insurance Exchange Trust Fund’’ (in this
12 section referred to as the ‘‘Trust Fund’’), consisting of
13 such amounts as may be appropriated or credited to the
14 Trust Fund under this section or any other provision of
15 law.
16
(b) PAYMENTS FROM TRUST FUND.—The Commis-
17 sioner shall pay from time to time from the Trust Fund
18 such amounts as the Commissioner determines are nec-
19 essary to make payments to operate the Health Insurance
20 Exchange, including payments under subtitle C (relating
21 to affordability credits).
22
(c) TRANSFERS TO TRUST FUND.—
23
(1) DEDICATED PAYMENTS.—There is hereby
24
appropriated to the Trust Fund amounts equivalent
25
to the following:
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110
1
(A) TAXES ON INDIVIDUALS NOT OBTAIN-
2
ING ACCEPTABLE COVERAGE.—The amounts re-
3
ceived in the Treasury under section 59B of the
4
Internal Revenue Code of 1986 (relating to re-
5
quirement of health insurance coverage for indi-
6
viduals).
7
(B) EMPLOYMENT TAXES ON EMPLOYERS
8
NOT PROVIDING ACCEPTABLE COVERAGE.—The
9
amounts received in the Treasury under section
10
3111(c) of the Internal Revenue Code of 1986
11
(relating to employers electing to not provide
12
health benefits).
13
(C) EXCISE TAX ON FAILURES TO MEET
14
CERTAIN
HEALTH
COVERAGE
REQUIRE-
15
MENTS.—The amounts received in the Treasury
16
under section 4980H(b) (relating to excise tax
17
with respect to failure to meet health coverage
18
participation requirements).
19
(2) APPROPRIATIONS TO COVER GOVERNMENT
20
CONTRIBUTIONS.—There are hereby appropriated,
21
out of any moneys in the Treasury not otherwise ap-
22
propriated, to the Trust Fund, an amount equivalent
23
to the amount of payments made from the Trust
24
Fund under subsection (b) plus such amounts as are
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111
1
necessary reduced by the amounts deposited under
2
paragraph (1).
3
(d) APPLICATION OF CERTAIN RULES.—Rules simi-
4 lar to the rules of subchapter B of chapter 98 of the Inter-
5 nal Revenue Code of 1986 shall apply with respect to the
6 Trust Fund.
7 SEC. 208. OPTIONAL OPERATION OF STATE-BASED HEALTH
8
INSURANCE EXCHANGES.
9
(a) IN GENERAL.—If—
10
(1) a State (or group of States, subject to the
11
approval of the Commissioner) applies to the Com-
12
missioner for approval of a State-based Health In-
13
surance Exchange to operate in the State (or group
14
of States); and
15
(2) the Commissioner approves such State-
16
based Health Insurance Exchange,
17 then, subject to subsections (c) and (d), the State-based
18 Health Insurance Exchange shall operate, instead of the
19 Health Insurance Exchange, with respect to such State
20 (or group of States). The Commissioner shall approve a
21 State-based Health Insurance Exchange if it meets the re-
22 quirements for approval under subsection (b).
23
(b) REQUIREMENTS FOR APPROVAL.—The Commis-
24 sioner may not approve a State-based Health Insurance
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112
1 Exchange under this section unless the following require-
2 ments are met:
3
(1) The State-based Health Insurance Ex-
4
change must demonstrate the capacity to and pro-
5
vide assurances satisfactory to the Commissioner
6
that the State-based Health Insurance Exchange will
7
carry out the functions specified for the Health In-
8
surance Exchange in the State (or States) involved,
9
including—
10
(A) negotiating and contracting with
11
QHBP offering entities for the offering of Ex-
12
change-participating health benefits plan, which
13
satisfy the standards and requirements of this
14
title and title I;
15
(B) enrolling Exchange-eligible individuals
16
and employers in such State in such plans;
17
(C) the establishment of sufficient local of-
18
fices to meet the needs of Exchange-eligible in-
19
dividuals and employers;
20
(D) administering affordability credits
21
under subtitle B using the same methodologies
22
(and at least the same income verification
23
methods) as would otherwise apply under such
24
subtitle and at a cost to the Federal Govern-
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113
1
ment which does exceed the cost to the Federal
2
Government if this section did not apply; and
3
(E) enforcement activities consistent with
4
federal requirements.
5
(2) There is no more than one Health Insur-
6
ance Exchange operating with respect to any one
7
State.
8
(3) The State provides assurances satisfactory
9
to the Commissioner that approval of such an Ex-
10
change will not result in any net increase in expendi-
11
tures to the Federal Government.
12
(4) The State provides for reporting of such in-
13
formation as the Commissioner determines and as-
14
surances satisfactory to the Commissioner that it
15
will vigorously enforce violations of applicable re-
16
quirements.
17
(5) Such other requirements as the Commis-
18
sioner may specify.
19
(c) CEASING OPERATION.—
20
(1) IN GENERAL.—A State-based Health Insur-
21
ance Exchange may, at the option of each State in-
22
volved, and only after providing timely and reason-
23
able notice to the Commissioner, cease operation as
24
such an Exchange, in which case the Health Insur-
25
ance Exchange shall operate, instead of such State-
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114
1
based Health Insurance Exchange, with respect to
2
such State (or States).
3
(2) TERMINATION; HEALTH INSURANCE EX-
4
CHANGE RESUMPTION OF FUNCTIONS.—The Com-
5
missioner may terminate the approval (for some or
6
all functions) of a State-based Health Insurance Ex-
7
change under this section if the Commissioner deter-
8
mines that such Exchange no longer meets the re-
9
quirements of subsection (b) or is no longer capable
10
of carrying out such functions in accordance with
11
the requirements of this subtitle. In lieu of termi-
12
nating such approval, the Commissioner may tempo-
13
rarily assume some or all functions of the State-
14
based Health Insurance Exchange until such time as
15
the Commissioner determines the State-based
16
Health Insurance Exchange meets such require-
17
ments of subsection (b) and is capable of carrying
18
out such functions in accordance with the require-
19
ments of this subtitle.
20
(3) EFFECTIVENESS.—The ceasing or termi-
21
nation of a State-based Health Insurance Exchange
22
under this subsection shall be effective in such time
23
and manner as the Commissioner shall specify.
24
(d) RETENTION OF AUTHORITY.—
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115
1
(1) AUTHORITY RETAINED.—Enforcement au-
2
thorities of the Commissioner shall be retained by
3
the Commissioner.
4
(2) DISCRETION TO RETAIN ADDITIONAL AU-
5
THORITY.—The Commissioner may specify functions
6
of the Health Insurance Exchange that—
7
(A) may not be performed by a State-
8
based Health Insurance Exchange under this
9
section; or
10
(B) may be performed by the Commis-
11
sioner and by such a State-based Health Insur-
12
ance Exchange.
13
(e) REFERENCES.—In the case of a State-based
14 Health Insurance Exchange, except as the Commissioner
15 may otherwise specify under subsection (d), any references
16 in this subtitle to the Health Insurance Exchange or to
17 the Commissioner in the area in which the State-based
18 Health Insurance Exchange operates shall be deemed a
19 reference to the State-based Health Insurance Exchange
20 and the head of such Exchange, respectively.
21
(f) FUNDING.—In the case of a State-based Health
22 Insurance Exchange, there shall be assistance provided for
23 the operation of such Exchange in the form of a matching
24 grant with a State share of expenditures required.
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116
1
Subtitle B—Public Health
2
Insurance Option
3 SEC. 221. ESTABLISHMENT AND ADMINISTRATION OF A
4
PUBLIC HEALTH INSURANCE OPTION AS AN
5
EXCHANGE-QUALIFIED HEALTH BENEFITS
6
PLAN.
7
(a) ESTABLISHMENT.—For years beginning with Y1,
8 the Secretary of Health and Human Services (in this sub-
9 title referred to as the ‘‘Secretary’’) shall provide for the
10 offering of an Exchange-participating health benefits plan
11 (in this division referred to as the ‘‘public health insurance
12 option’’) that ensures choice, competition, and stability of
13 affordable, high quality coverage throughout the United
14 States in accordance with this subtitle. In designing the
15 option, the Secretary’s primary responsibility is to create
16 a low-cost plan without comprimising quality or access to
17 care.
18
(b) OFFERING AS AN EXCHANGE-PARTICIPATING
19 HEALTH BENEFITS PLAN.—
20
(1) EXCLUSIVE TO THE EXCHANGE.—The pub-
21
lic health insurance option shall only be made avail-
22
able through the Health Insurance Exchange.
23
(2) ENSURING A LEVEL PLAYING FIELD.—Con-
24
sistent with this subtitle, the public health insurance
25
option shall comply with requirements that are ap-
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117
1
plicable under this title to an Exchange-participating
2
health benefits plan, including requirements related
3
to benefits, benefit levels, provider networks, notices,
4
consumer protections, and cost sharing.
5
(3) PROVISION OF BENEFIT LEVELS.—The pub-
6
lic health insurance option—
7
(A) shall offer basic, enhanced, and pre-
8
mium plans; and
9
(B) may offer premium-plus plans.
10
(c) ADMINISTRATIVE CONTRACTING.—The Secretary
11 may enter into contracts for the purpose of performing
12 administrative functions (including functions described in
13 subsection (a)(4) of section 1874A of the Social Security
14 Act) with respect to the public health insurance option in
15 the same manner as the Secretary may enter into con-
16 tracts under subsection (a)(1) of such section. The Sec-
17 retary has the same authority with respect to the public
18 health insurance option as the Secretary has under sub-
19 sections (a)(1) and (b) of section 1874A of the Social Se-
20 curity Act with respect to title XVIII of such Act. Con-
21 tracts under this subsection shall not involve the transfer
22 of insurance risk to such entity.
23
(d) OMBUDSMAN.—The Secretary shall establish an
24 office of the ombudsman for the public health insurance
25 option which shall have duties with respect to the public
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118
1 health insurance option similar to the duties of the Medi-
2 care Beneficiary Ombudsman under section 1808(c)(2) of
3 the Social Security Act.
4
(e) DATA COLLECTION.—The Secretary shall collect
5 such data as may be required to establish premiums and
6 payment rates for the public health insurance option and
7 for other purposes under this subtitle, including to im-
8 prove quality and to reduce racial, ethnic, and other dis-
9 parities in health and health care.
10
(f) TREATMENT OF PUBLIC HEALTH INSURANCE OP-
11 TION.—With respect to the public health insurance option,
12 the Secretary shall be treated as a QHBP offering entity
13 offering an Exchange-participating health benefits plan.
14
(g) ACCESS TO FEDERAL COURTS.—The provisions
15 of Medicare (and related provisions of title II of the Social
16 Security Act) relating to access of Medicare beneficiaries
17 to Federal courts for the enforcement of rights under
18 Medicare, including with respect to amounts in con-
19 troversy, shall apply to the public health insurance option
20 and individuals enrolled under such option under this title
21 in the same manner as such provisions apply to Medicare
22 and Medicare beneficiaries.
23 SEC. 222. PREMIUMS AND FINANCING.
24
(a) ESTABLISHMENT OF PREMIUMS.—
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119
1
(1) IN GENERAL.—The Secretary shall establish
2
geographically-adjusted premium rates for the public
3
health insurance option in a manner—
4
(A) that complies with the premium rules
5
established by the Commissioner under section
6
113 for Exchange-participating health benefit
7
plans; and
8
(B) at a level sufficient to fully finance the
9
costs of—
10
(i) health benefits provided by the
11
public health insurance option; and
12
(ii) administrative costs related to op-
13
erating the public health insurance option.
14
(2) CONTINGENCY MARGIN.—In establishing
15
premium rates under paragraph (1), the Secretary
16
shall include an appropriate amount for a contin-
17
gency margin.
18
(b) ACCOUNT.—
19
(1) ESTABLISHMENT.—There is established in
20
the Treasury of the United States an Account for
21
the receipts and disbursements attributable to the
22
operation of the public health insurance option, in-
23
cluding the start-up funding under paragraph (2).
24
Section 1854(g) of the Social Security Act shall
25
apply to receipts described in the previous sentence
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120
1
in the same manner as such section applies to pay-
2
ments or premiums described in such section.
3
(2) START-UP FUNDING.—
4
(A) IN GENERAL.—In order to provide for
5
the establishment of the public health insurance
6
option there is hereby appropriated to the Sec-
7
retary, out of any funds in the Treasury not
8
otherwise appropriated, $2,000,000,000. In
9
order to provide for initial claims reserves be-
10
fore the collection of premiums, there is hereby
11
appropriated to the Secretary, out of any funds
12
in the Treasury not otherwise appropriated,
13
such sums as necessary to cover 90 days worth
14
of claims reserves based on projected enroll-
15
ment.
16
(B) AMORTIZATION OF START-UP FUND-
17
ING.—The Secretary shall provide for the re-
18
payment of the startup funding provided under
19
subparagraph (A) to the Treasury in an amor-
20
tized manner over the 10-year period beginning
21
with Y1.
22
(C) LIMITATION ON FUNDING.—Nothing in
23
this section shall be construed as authorizing
24
any additional appropriations to the Account,
25
other than such amounts as are otherwise pro-
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121
1
vided with respect to other Exchange-partici-
2
pating health benefits plans.
3 SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES.
4
(a) RATES ESTABLISHED BY SECRETARY.—
5
(1) IN GENERAL.—The Secretary shall establish
6
payment rates for the public health insurance option
7
for services and health care providers consistent with
8
this section and may change such payment rates in
9
accordance with section 224.
10
(2) INITIAL PAYMENT RULES.—
11
(A) IN GENERAL.—Except as provided in
12
subparagraph (B) and subsection (b)(1), during
13
Y1, Y2, and Y3, the Secretary shall base the
14
payment rates under this section for services
15
and providers described in paragraph (1) on the
16
payment rates for similar services and providers
17
under parts A and B of Medicare.
18
(B) EXCEPTIONS.—
19
(i) PRACTITIONERS’ SERVICES.—Pay-
20
ment rates for practitioners’ services other-
21
wise established under the fee schedule
22
under section 1848 of the Social Security
23
Act shall be applied without regard to the
24
provisions under subsection (f) of such sec-
25
tion and the update under subsection
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122
1
(d)(4) under such section for a year as ap-
2
plied under this paragraph shall be not less
3
than 1 percent.
4
(ii) ADJUSTMENTS.—The Secretary
5
may determine the extent to which Medi-
6
care adjustments applicable to base pay-
7
ment rates under parts A and B of Medi-
8
care shall apply under this subtitle.
9
(3) FOR NEW SERVICES.—The Secretary shall
10
modify payment rates described in paragraph (2) in
11
order to accommodate payments for services, such as
12
well-child visits, that are not otherwise covered
13
under Medicare.
14
(4) PRESCRIPTION
DRUGS.—Payment rates
15
under this section for prescription drugs that are not
16
paid for under part A or part B of Medicare shall
17
be at rates negotiated by the Secretary.
18
(b) INCENTIVES FOR PARTICIPATING PROVIDERS.—
19
(1) INITIAL INCENTIVE PERIOD.—
20
(A) IN GENERAL.—The Secretary shall
21
provide, in the case of services described in sub-
22
paragraph (B) furnished during Y1, Y2, and
23
Y3, for payment rates that are 5 percent great-
24
er than the rates established under subsection
25
(a).
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123
1
(B) SERVICES DESCRIBED.—The services
2
described in this subparagraph are items and
3
professional services, under the public health in-
4
surance option by a physician or other health
5
care practitioner who participates in both Medi-
6
care and the public health insurance option.
7
(C) SPECIAL RULES.—A pediatrician and
8
any other health care practitioner who is a type
9
of practitioner that does not typically partici-
10
pate in Medicare (as determined by the Sec-
11
retary) shall also be eligible for the increased
12
payment rates under subparagraph (A).
13
(2) SUBSEQUENT PERIODS.— Beginning with
14
Y4 and for subsequent years, the Secretary shall
15
continue to use an administrative process to set such
16
rates in order to promote payment accuracy, to en-
17
sure adequate beneficiary access to providers, and to
18
promote affordablility and the efficient delivery of
19
medical care consistent with section 221(a). Such
20
rates shall not be set at levels expected to increase
21
overall medical costs under the option beyond what
22
would be expected if the process under subsection
23
(a)(2) and paragraph (1) of this subsection were
24
continued.
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124
1
(3) ESTABLISHMENT OF A PROVIDER NET-
2
WORK.—Health care providers participating under
3
Medicare are participating providers in the public
4
health insurance option unless they opt out in a
5
process established by the Secretary.
6
(c) ADMINISTRATIVE
PROCESS
FOR
SETTING
7 RATES.—Chapter 5 of title 5, United States Code shall
8 apply to the process for the initial establishment of pay-
9 ment rates under this section but not to the specific meth-
10 odology for establishing such rates or the calculation of
11 such rates.
12
(d) CONSTRUCTION.—Nothing in this subtitle shall
13 be construed as limiting the Secretary’s authority to cor-
14 rect for payments that are excessive or deficient, taking
15 into account the provisions of section 221(a) and the
16 amounts paid for similar health care providers and serv-
17 ices under other Exchange-participating health benefits
18 plans.
19
(e) CONSTRUCTION.—Nothing in this subtitle shall be
20 construed as affecting the authority of the Secretary to
21 establish payment rates, including payments to provide for
22 the more efficient delivery of services, such as the initia-
23 tives provided for under section 224.
24
(f) LIMITATIONS ON REVIEW.—There shall be no ad-
25 ministrative or judicial review of a payment rate or meth-
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125
1 odology established under this section or under section
2 224.
3 SEC. 224. MODERNIZED PAYMENT INITIATIVES AND DELIV-
4
ERY SYSTEM REFORM.
5
(a) IN GENERAL.—For plan years beginning with Y1,
6 the Secretary may utilize innovative payment mechanisms
7 and policies to determine payments for items and services
8 under the public health insurance option. The payment
9 mechanisms and policies under this section may include
10 patient-centered medical home and other care manage-
11 ment payments, accountable care organizations, value-
12 based purchasing, bundling of services, differential pay-
13 ment rates, performance or utilization based payments,
14 partial capitation, and direct contracting with providers.
15
(b) REQUIREMENTS FOR INNOVATIVE PAYMENTS.—
16 The Secretary shall design and implement the payment
17 mechanisms and policies under this section in a manner
18 that—
19
(1) seeks to—
20
(A) improve health outcomes;
21
(B) reduce health disparities (including ra-
22
cial, ethnic, and other disparities);
23
(C) provide efficent and affordable care;
24
(D) address geographic variation in the
25
provision of health services; or
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126
1
(E) prevent or manage chronic illness; and
2
(2) promotes care that is integrated, patient-
3
centered, quality, and efficient.
4
(c) ENCOURAGING THE USE OF HIGH VALUE SERV-
5 ICES.—To the extent allowed by the benefit standards ap-
6 plied to all Exchange-participating health benefits plans,
7 the public health insurance option may modify cost shar-
8 ing and payment rates to encourage the use of services
9 that promote health and value.
10
(d) NON-UNIFORMITY PERMITTED.—Nothing in this
11 subtitle shall prevent the Secretary from varying payments
12 based on different payment structure models (such as ac-
13 countable care organizations and medical homes) under
14 the public health insurance option for different geographic
15 areas.
16 SEC. 225. PROVIDER PARTICIPATION.
17
(a) IN GENERAL.—The Secretary shall establish con-
18 ditions of participation for health care providers under the
19 public health insurance option.
20
(b) LICENSURE OR CERTIFICATION.—The Secretary
21 shall not allow a health care provider to participate in the
22 public health insurance option unless such provider is ap-
23 propriately licensed or certified under State law.
24
(c) PAYMENT TERMS FOR PROVIDERS.—
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127
1
(1) PHYSICIANS.—The Secretary shall provide
2
for the annual participation of physicians under the
3
public health insurance option, for which payment
4
may be made for services furnished during the year,
5
in one of 2 classes:
6
(A) PREFERRED PHYSICIANS.—Those phy-
7
sicians who agree to accept the payment rate
8
established under section 223 (without regard
9
to cost-sharing) as the payment in full.
10
(B) PARTICIPATING,
NON-PREFERRED
11
PHYSICIANS.—Those physicians who agree not
12
to impose charges (in relation to the payment
13
rate described in section 223 for such physi-
14
cians) that exceed the ratio permitted under
15
section 1848(g)(2)(C) of the Social Security
16
Act.
17
(2) OTHER PROVIDERS.—The Secretary shall
18
provide for the participation (on an annual or other
19
basis specified by the Secretary) of health care pro-
20
viders (other than physicians) under the public
21
health insurance option under which payment shall
22
only be available if the provider agrees to accept the
23
payment rate established under section 223 (without
24
regard to cost-sharing) as the payment in full.
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128
1
(d) EXCLUSION OF CERTAIN PROVIDERS.—The Sec-
2 retary shall exclude from participation under the public
3 health insurance option a health care provider that is ex-
4 cluded from participation in a Federal health care pro-
5 gram (as defined in section 1128B(f) of the Social Secu-
6 rity Act).
7 SEC. 226. APPLICATION OF FRAUD AND ABUSE PROVI-
8
SIONS.
9
Provisions of law (other than criminal law provisions)
10 identified by the Secretary by regulation, in consultation
11 with the Inspector General of the Department of Health
12 and Human Services, that impose sanctions with respect
13 to waste, fraud, and abuse under Medicare, such as the
14 False Claims Act (31 U.S.C. 3729 et seq.), shall also
15 apply to the public health insurance option.
16
Subtitle C—Individual
17
Affordability Credits
18 SEC. 241. AVAILABILITY THROUGH HEALTH INSURANCE EX-
19
CHANGE.
20
(a) IN GENERAL.—Subject to the succeeding provi-
21 sions of this subtitle, in the case of an affordable credit
22 eligible individual enrolled in an Exchange-participating
23 health benefits plan—
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129
1
(1) the individual shall be eligible for, in accord-
2
ance with this subtitle, affordability credits con-
3
sisting of—
4
(A) an affordability premium credit under
5
section 243 to be applied against the premium
6
for the Exchange-participating health benefits
7
plan in which the individual is enrolled; and
8
(B) an affordability cost-sharing credit
9
under section 244 to be applied as a reduction
10
of the cost-sharing otherwise applicable to such
11
plan; and
12
(2) the Commissioner shall pay the QHBP of-
13
fering entity that offers such plan from the Health
14
Insurance Exchange Trust Fund the aggregate
15
amount of affordability credits for all affordable
16
credit eligible individuals enrolled in such plan.
17
(b) APPLICATION.—
18
(1) IN GENERAL.—An Exchange eligible indi-
19
vidual may apply to the Commissioner through the
20
Health Insurance Exchange or through another enti-
21
ty under an arrangement made with the Commis-
22
sioner, in a form and manner specified by the Com-
23
missioner. The Commissioner through the Health
24
Insurance Exchange or through another public enti-
25
ty under an arrangement made with the Commis-
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130
1
sioner shall make a determination as to eligibility of
2
an individual for affordability credits under this sub-
3
title.The Commissioner shall establish a process
4
whereby, on the basis of information otherwise avail-
5
able, individuals may be deemed to be affordable
6
credit eligible individuals. In carrying this subtitle,
7
the Commissioner shall establish effective methods
8
that ensure that individuals with limited English
9
proficiency are able to apply for affordability credits.
10
(2) USE OF STATE MEDICAID AGENCIES.—If
11
the Commissioner determines that a State Medicaid
12
agency has the capacity to make a determination of
13
eligibility for affordability credits under this subtitle
14
and under the same standards as used by the Com-
15
missioner, under the Medicaid memorandum of un-
16
derstanding (as defined in section 205(c)(4))—
17
(A) the State Medicaid agency is author-
18
ized to conduct such determinations for any Ex-
19
change-eligible individual who requests such a
20
determination; and
21
(B) the Commissioner shall reimburse the
22
State Medicaid agency for the costs of con-
23
ducting such determinations.
24
(3) MEDICAID SCREEN AND ENROLL OBLIGA-
25
TION.—In the case of an application made under
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131
1
paragraph (1), there shall be a determination of
2
whether the individual is a Medicaid-eligible indi-
3
vidual. If the individual is determined to be so eligi-
4
ble, the Commissioner, through the Medicaid memo-
5
randum of understanding, shall provide for the en-
6
rollment of the individual under the State Medicaid
7
plan in accordance with the Medicaid memorandum
8
of understanding. In the case of such an enrollment,
9
the State shall provide for the same periodic redeter-
10
mination of eligibility under Medicaid as would oth-
11
erwise apply if the individual had directly applied for
12
medical assistance to the State Medicaid agency.
13
(c) USE OF AFFORDABILITY CREDITS.—
14
(1) IN GENERAL.—In Y1 and Y2 an affordable
15
credit eligible individual may use an affordability
16
credit only with respect to a basic plan.
17
(2) FLEXIBILITY IN PLAN ENROLLMENT AU-
18
THORIZED.—Beginning with Y3, the Commissioner
19
shall establish a process to allow an affordability
20
credit to be used for enrollees in enhanced or pre-
21
mium plans. In the case of an affordable credit eligi-
22
ble individual who enrolls in an enhanced or pre-
23
mium plan, the individual shall be responsible for
24
any difference between the premium for such plan
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132
1
and the affordable credit amount otherwise applica-
2
ble if the individual had enrolled in a basic plan.
3
(d) ACCESS TO DATA.—In carrying out this subtitle,
4 the Commissioner shall request from the Secretary of the
5 Treasury consistent with section 6103 of the Internal Rev-
6 enue Code of 1986 such information as may be required
7 to carry out this subtitle.
8
(e) NO CASH REBATES.—In no case shall an afford-
9 able credit eligible individual receive any cash payment as
10 a result of the application of this subtitle.
11 SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.
12
(a) DEFINITION.—
13
(1) IN GENERAL.—For purposes of this divi-
14
sion, the term ‘‘affordable credit eligible individual’’
15
means, subject to subsection (b), an individual who
16
is lawfully present in a State in the United States
17
(other than as a nonimmigrant described in a sub-
18
paragraph (excluding subparagraphs (K), (T), (U),
19
and (V)) of section 101(a)(15) of the Immigration
20
and Nationality Act)—
21
(A) who is enrolled under an Exchange-
22
participating health benefits plan and is not en-
23
rolled under such plan as an employee (or de-
24
pendent of an employee) through an employer
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133
1
qualified health benefits plan that meets the re-
2
quirements of section 312;
3
(B) with family income below 400 percent
4
of the Federal poverty level for a family of the
5
size involved; and
6
(C) who is not a Medicaid eligible indi-
7
vidual, other than an individual described in
8
section 202(d)(3) or an individual during a
9
transition period under section 202(d)(4)(B)(ii).
10
(2) TREATMENT OF FAMILY.—Except as the
11
Commissioner may otherwise provide, members of
12
the same family who are affordable credit eligible in-
13
dividuals shall be treated as a single affordable cred-
14
it individual eligible for the applicable credit for such
15
a family under this subtitle.
16
(b) LIMITATIONS ON EMPLOYEE AND DEPENDENT
17 DISQUALIFICATION.—
18
(1) IN GENERAL.—Subject to paragraph (2),
19
the term ‘‘affordable credit eligible individual’’ does
20
not include a full-time employee of an employer if
21
the employer offers the employee coverage (for the
22
employee and dependents) as a full-time employee
23
under a group health plan if the coverage and em-
24
ployer contribution under the plan meet the require-
25
ments of section 312.
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134
1
(2) EXCEPTIONS.—
2
(A) FOR
CERTAIN
FAMILY
CIR-
3
CUMSTANCES.—The Commissioner shall estab-
4
lish such exceptions and special rules in the
5
case described in paragraph (1) as may be ap-
6
propriate in the case of a divorced or separated
7
individual or such a dependent of an employee
8
who would otherwise be an affordable credit eli-
9
gible individual.
10
(B) FOR UNAFFORDABLE EMPLOYER COV-
11
ERAGE.—Beginning in Y2, in the case of full-
12
time employees for which the cost of the em-
13
ployee premium for coverage under a group
14
health plan would exceed 11 percent of current
15
family income (determined by the Commissioner
16
on the basis of verifiable documentation and
17
without regard to section 245), paragraph (1)
18
shall not apply.
19
(c) INCOME DEFINED.—
20
(1) IN GENERAL.—In this title, the term ‘‘in-
21
come’’ means modified adjusted gross income (as de-
22
fined in section 59B of the Internal Revenue Code
23
of 1986).
24
(2) STUDY
OF
INCOME
DISREGARDS.—The
25
Commissioner shall conduct a study that examines
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135
1
the application of income disregards for purposes of
2
this subtitle. Not later than the first day of Y2, the
3
Commissioner shall submit to Congress a report on
4
such study and shall include such recommendations
5
as the Commissioner determines appropriate.
6
(d) CLARIFICATION OF TREATMENT OF AFFORD-
7 ABILITY CREDITS.—Affordabilty credits under this sub-
8 title shall not be treated, for purposes of title IV of the
9 Personal Responsibility and Work Opportunity Reconcili-
10 ation Act of 1996, to be a benefit provided under section
11 403 of such title.
12 SEC. 243. AFFORDABLE PREMIUM CREDIT.
13
(a) IN GENERAL.—The affordability premium credit
14 under this section for an affordable credit eligible indi-
15 vidual enrolled in an Exchange-participating health bene-
16 fits plan is in an amount equal to the amount (if any)
17 by which the premium for the plan (or, if less, the ref-
18 erence premium amount specified in subsection (c)), ex-
19 ceeds the affordable premium amount specified in sub-
20 section (b) for the individual.
21
(b) AFFORDABLE PREMIUM AMOUNT.—
22
(1) IN GENERAL.—The affordable premium
23
amount specified in this subsection for an individual
24
for monthly premium in a plan year shall be equal
25
to 1⁄12 of the product of—
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136
1
(A) the premium percentage limit specified
2
in paragraph (2) for the individual based upon
3
the individual’s family income for the plan year;
4
and
5
(B) the individual’s family income for such
6
plan year.
7
(2) PREMIUM PERCENTAGE LIMITS BASED ON
8
TABLE.—The Commissioner shall establish premium
9
percentage limits so that for individuals whose fam-
10
ily income is within an income tier specified in the
11
table in subsection (d) such percentage limits shall
12
increase, on a sliding scale in a linear manner, from
13
the initial premium percentage to the final premium
14
percentage specified in such table for such income
15
tier.
16
(c) REFERENCE PREMIUM AMOUNT.—The reference
17 premium amount specified in this subsection for a plan
18 year for an individual in a premium rating area is equal
19 to the average premium for the 3 basic plans in the area
20 for the plan year with the lowest premium levels. In com-
21 puting such amount the Commissioner may exclude plans
22 with extremely limited enrollments.
23
(d) TABLE OF PREMIUM PERCENTAGE LIMITS AND
24 ACTUARIAL VALUE PERCENTAGES BASED ON INCOME
25 TIER.—
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137
1
(1) IN GENERAL.—For purposes of this sub-
2
title, the table specified in this subsection is as fol-
3
lows:
In the case of family in-
come (expressed as a
The initial pre-
The final pre-
The actuarial
percent of FPL) within
mium percent-
mium percent-
value percent-
the following income
age is—
age is—
age is—
tier:
133% through 150%
1.5%
3%
97%
150% through 200%
3%
5%
93%
200% through 250%
5%
7%
85%
250% through 300%
7%
9%
78%
300% through 350%
9%
10%
72%
350% through 400%
10%
11%
70%
4
(2) SPECIAL RULES.—For purposes of applying
5
the table under paragraph (1)—
6
(A) FOR LOWEST LEVEL OF INCOME.—In
7
the case of an individual with income that does
8
not exceed 133 percent of FPL, the individual
9
shall be considered to have income that is 133%
10
of FPL.
11
(B) APPLICATION OF HIGHER ACTUARIAL
12
VALUE
PERCENTAGE
AT
TIER
TRANSITION
13
POINTS.—If two actuarial value percentages
14
may be determined with respect to an indi-
15
vidual, the actuarial value percentage shall be
16
the higher of such percentages.
17 SEC. 244. AFFORDABILITY COST-SHARING CREDIT.
18
(a) IN GENERAL.—The affordability cost-sharing
19 credit under this section for an affordable credit eligible
20 individual enrolled in an Exchange-participating health
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138
1 benefits plan is in the form of the cost-sharing reduction
2 described in subsection (b) provided under this section for
3 the income tier in which the individual is classified based
4 on the individual’s family income.
5
(b) COST-SHARING
REDUCTIONS.—The Commis-
6 sioner shall specify a reduction in cost-sharing amounts
7 and the annual limitation on cost-sharing specified in sec-
8 tion 122(c)(2)(B) under a basic plan for each income tier
9 specified in the table under section 243(d), with respect
10 to a year, in a manner so that, as estimated by the Com-
11 missioner, the actuarial value of the coverage with such
12 reduced cost-sharing amounts (and the reduced annual
13 cost-sharing limit) is equal to the actuarial value percent-
14 age (specified in the table under section 243(d) for the
15 income tier involved) of the full actuarial value if there
16 were no cost-sharing imposed under the plan.
17
(c) DETERMINATION AND PAYMENT OF COST-SHAR-
18 ING AFFORDABILITY CREDIT.—In the case of an afford-
19 able credit eligible individual in a tier enrolled in an Ex-
20 change-participating health benefits plan offered by a
21 QHBP offering entity, the Commissioner shall provide for
22 payment to the offering entity of an amount equivalent
23 to the increased actuarial value of the benefits under the
24 plan provided under section 203(c)(2)(B) resulting from
25 the reduction in cost-sharing described in subsection (b).
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139
1 SEC. 245. INCOME DETERMINATIONS.
2
(a) IN GENERAL.—In applying this subtitle for an
3 affordability credit for an individual for a plan year, the
4 individual’s income shall be the income (as defined in sec-
5 tion 242(c)) for the individual for the most recent taxable
6 year (as determined in accordance with rules of the Com-
7 missioner). The Federal poverty level applied shall be such
8 level in effect as of the date of the application.
9
(b) PROGRAM INTEGRITY; INCOME VERIFICATION
10 PROCEDURES.—
11
(1) PROGRAM INTEGRITY.—The Commissioner
12
shall take such steps as may be appropriate to en-
13
sure the accuracy of determinations and redeter-
14
minations under this subtitle.
15
(2) INCOME VERIFICATION.—
16
(A) IN GENERAL.—Upon an initial applica-
17
tion of an individual for an affordability credit
18
under this subtitle (or in applying section
19
242(b)) or upon an application for a change in
20
the affordability credit based upon a significant
21
change in family income described in subpara-
22
graph (A)—
23
(i) the Commissioner shall request
24
from the Secretary of the Treasury the dis-
25
closure to the Commissioner of such infor-
26
mation as may be permitted to verify the
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140
1
information contained in such application;
2
and
3
(ii) the Commissioner shall use the in-
4
formation so disclosed to verify such infor-
5
mation.
6
(B) ALTERNATIVE
PROCEDURES.—The
7
Commissioner shall establish procedures for the
8
verification of income for purposes of this sub-
9
title if no income tax return is available for the
10
most recent completed tax year.
11
(c) SPECIAL RULES.—
12
(1) CHANGES IN INCOME AS A PERCENT OF
13
FPL.—In the case that an individual’s income (ex-
14
pressed as a percentage of the Federal poverty level
15
for a family of the size involved) for a plan year is
16
expected (in a manner specified by the Commis-
17
sioner) to be significantly different from the income
18
(as so expressed) used under subsection (a), the
19
Commissioner shall establish rules requiring an indi-
20
vidual to report, consistent with the mechanism es-
21
tablished under paragraph (2), significant changes
22
in such income (including a significant change in
23
family composition) to the Commissioner and requir-
24
ing the substitution of such income for the income
25
otherwise applicable.
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141
1
(2) REPORTING OF SIGNIFICANT CHANGES IN
2
INCOME.—The Commissioner shall establish rules
3
under which an individual determined to be an af-
4
fordable credit eligible individual would be required
5
to inform the Commissioner when there is a signifi-
6
cant change in the family income of the individual
7
(expressed as a percentage of the FPL for a family
8
of the size involved) and of the information regard-
9
ing such change. Such mechanism shall provide for
10
guidelines that specify the circumstances that qual-
11
ify as a significant change, the verifiable information
12
required to document such a change, and the process
13
for submission of such information. If the Commis-
14
sioner receives new information from an individual
15
regarding the family income of the individual,the
16
Commissioner shall provide for a redetermination of
17
the individual’s eligibility to be an affordable credit
18
eligible individual.
19
(3) TRANSITION FOR CHIP.—In the case of a
20
child described in section 202(d)(2), the Commis-
21
sioner shall establish rules under which the family
22
income of the child is deemed to be no greater than
23
the family income of the child as most recently de-
24
termined before Y1 by the State under title XXI of
25
the Social Security Act.
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142
1
(4) STUDY OF GEOGRAPHIC VARIATION IN AP-
2
PLICATION OF FPL.—The Commissioner shall exam-
3
ine the feasibility and implication of adjusting the
4
application of the Federal poverty level under this
5
subtitle for different geographic areas so as to re-
6
flect the variations in cost-of-living among different
7
areas within the United States. If the Commissioner
8
determines that an adjustment is feasible, the study
9
should include a methodology to make such an ad-
10
justment. Not later than the first day of Y2, the
11
Commissioner shall submit to Congress a report on
12
such study and shall include such recommendations
13
as the Commissioner determines appropriate.
14
(d) PENALTIES FOR MISREPRESENTATION.—In the
15 case of an individual intentionally misrepresents family in-
16 come or the individual fails (without regard to intent) to
17 disclose to the Commissioner a significant change in fam-
18 ily income under subsection (c) in a manner that results
19 in the individual becoming an affordable credit eligible in-
20 dividual when the individual is not or in the amount of
21 the affordability credit exceeding the correct amount—
22
(1) the individual is liable for repayment of the
23
amount of the improper affordability credit; ;and
24
(2) in the case of such an intentional misrepre-
25
sentation or other egregious circumstances specified
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143
1
by the Commissioner, the Commissioner may impose
2
an additional penalty.
3 SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED
4
ALIENS.
5
Nothing in this subtitle shall allow Federal payments
6 for affordability credits on behalf of individuals who are
7 not lawfully present in the United States.
8
TITLE III—SHARED
9
RESPONSIBILITY
10
Subtitle A—Individual
11
Responsibility
12 SEC. 301. INDIVIDUAL RESPONSIBILITY.
13
For an individual’s responsibility to obtain acceptable
14 coverage, see section 59B of the Internal Revenue Code
15 of 1986 (as added by section 401 of this Act).
16
Subtitle B—Employer
17
Responsibility
18
PART 1—HEALTH COVERAGE PARTICIPATION
19
REQUIREMENTS
20 SEC. 311. HEALTH COVERAGE PARTICIPATION REQUIRE-
21
MENTS.
22
An employer meets the requirements of this section
23 if such employer does all of the following:
24
(1) OFFER OF COVERAGE.—The employer of-
25
fers each employee individual and family coverage
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144
1
under a qualified health benefits plan (or under a
2
current employment-based health plan (within the
3
meaning of section 102(b))) in accordance with sec-
4
tion 312.
5
(2) CONTRIBUTION TOWARDS COVERAGE.—If
6
an employee accepts such offer of coverage, the em-
7
ployer makes timely contributions towards such cov-
8
erage in accordance with section 312.
9
(3) CONTRIBUTION IN LIEU OF COVERAGE.—
10
Beginning with Y2, if an employee declines such
11
offer but otherwise obtains coverage in an Exchange-
12
participating health benefits plan (other than by rea-
13
son of being covered by family coverage as a spouse
14
or dependent of the primary insured), the employer
15
shall make a timely contribution to the Health In-
16
surance Exchange with respect to each such em-
17
ployee in accordance with section 313.
18 SEC. 312. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TO-
19
WARDS EMPLOYEE AND DEPENDENT COV-
20
ERAGE.
21
(a) IN GENERAL.—An employer meets the require-
22 ments of this section with respect to an employee if the
23 following requirements are met:
24
(1) OFFERING OF COVERAGE.—The employer
25
offers the coverage described in section 311(1) either
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145
1
through an Exchange-participating health benefits
2
plan or other than through such a plan.
3
(2) EMPLOYER REQUIRED CONTRIBUTION.—
4
The employer timely pays to the issuer of such cov-
5
erage an amount not less than the employer required
6
contribution specified in subsection (b) for such cov-
7
erage.
8
(3) PROVISION OF INFORMATION.—The em-
9
ployer provides the Health Choices Commissioner,
10
the Secretary of Labor, the Secretary of Health and
11
Human Services, and the Secretary of the Treasury,
12
as applicable, with such information as the Commis-
13
sioner may require to ascertain compliance with the
14
requirements of this section.
15
(4) AUTOENROLLMENT OF EMPLOYEES.—The
16
employer provides for autoenrollment of the em-
17
ployee in accordance with subsection (c).
18
(b) REDUCTION OF EMPLOYEE PREMIUMS THROUGH
19 MINIMUM EMPLOYER CONTRIBUTION.—
20
(1) FULL-TIME EMPLOYEES.—The minimum
21
employer contribution described in this subsection
22
for coverage of a full-time employee (and, if any, the
23
employee’s spouse and qualifying children (as de-
24
fined in section 152(c) of the Internal Revenue Code
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146
1
of 1986) under a qualified health benefits plan (or
2
current employment-based health plan) is equal to—
3
(A) in case of individual coverage, not less
4
than 72.5 percent of the applicable premium
5
(as defined in section 4980B(f)(4) of such
6
Code, subject to paragraph (2)) of the lowest
7
cost plan offered by the employer that is a
8
qualified health benefits plan (or is such cur-
9
rent employment-based health plan); and
10
(B) in the case of family coverage which
11
includes coverage of such spouse and children,
12
not less 65 percent of such applicable premium
13
of such lowest cost plan.
14
(2) APPLICABLE PREMIUM FOR EXCHANGE COV-
15
ERAGE.—In this subtitle, the amount of the applica-
16
ble premium of the lowest cost plan with respect to
17
coverage of an employee under an Exchange-partici-
18
pating health benefits plan is the reference premium
19
amount under section 243(c) for individual coverage
20
(or, if elected, family coverage) for the premium rat-
21
ing area in which the individual or family resides.
22
(3) MINIMUM EMPLOYER CONTRIBUTION FOR
23
EMPLOYEES
OTHER
THAN
FULL-TIME
EMPLOY-
24
EES.—In the case of coverage for an employee who
25
is not a full-time employee, the amount of the min-
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147
1
imum employer contribution under this subsection
2
shall be a proportion (as determined in accordance
3
with rules of the Health Choices Commissioner, the
4
Secretary of Labor, the Secretary of Health and
5
Human Services, and the Secretary of the Treasury,
6
as applicable) of the minimum employer contribution
7
under this subsection with respect to a full-time em-
8
ployee that reflects the proportion of—
9
(A) the average weekly hours of employ-
10
ment of the employee by the employer, to
11
(B) the minimum weekly hours specified
12
by the Commissioner for an employee to be a
13
full-time employee.
14
(4) SALARY REDUCTIONS NOT TREATED AS EM-
15
PLOYER CONTRIBUTIONS.—For purposes of this sec-
16
tion, any contribution on behalf of an employee with
17
respect to which there is a corresponding reduction
18
in the compensation of the employee shall not be
19
treated as an amount paid by the employer.
20
(c) AUTOMATIC ENROLLMENT FOR EMPLOYER SPON-
21 SORED HEALTH BENEFITS.—
22
(1) IN GENERAL.—The requirement of this sub-
23
section with respect to an employer and an employee
24
is that the employer automatically enroll suchs em-
25
ployee into the employment-based health benefits
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148
1
plan for individual coverage under the plan option
2
with the lowest applicable employee premium.
3
(2) OPT-OUT.—In no case may an employer
4
automatically enroll an employee in a plan under
5
paragraph (1) if such employee makes an affirmative
6
election to opt out of such plan or to elect coverage
7
under an employment-based health benefits plan of-
8
fered by such employer. An employer shall provide
9
an employee with a 30-day period to make such an
10
affirmative election before the employer may auto-
11
matically enroll the employee in such a plan.
12
(3) NOTICE REQUIREMENTS.—
13
(A) IN
GENERAL.—Each employer de-
14
scribed in paragraph (1) who automatically en-
15
rolls an employee into a plan as described in
16
such paragraph shall provide the employees,
17
within a reasonable period before the beginning
18
of each plan year (or, in the case of new em-
19
ployees, within a reasonable period before the
20
end of the enrollment period for such a new em-
21
ployee), written notice of the employees’ rights
22
and obligations relating to the automatic enroll-
23
ment requirement under such paragraph. Such
24
notice must be comprehensive and understood
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149
1
by the average employee to whom the automatic
2
enrollment requirement applies.
3
(B) INCLUSION OF SPECIFIC INFORMA-
4
TION.—The written notice under subparagraph
5
(A) must explain an employee’s right to opt out
6
of being automatically enrolled in a plan and in
7
the case that more than one level of benefits or
8
employee premium level is offered by the em-
9
ployer involved, the notice must explain which
10
level of benefits and employee premium level the
11
employee will be automatically enrolled in the
12
absence of an affirmative election by the em-
13
ployee.
14 SEC. 313. EMPLOYER CONTRIBUTIONS IN LIEU OF COV-
15
ERAGE.
16
(a) IN GENERAK.—A contribution is made in accord-
17 ance with this section with respect to an employee if such
18 contribution is equal to an amount equal to 8 percent of
19 the average wages paid by the employer during the period
20 of enrollment (determined by taking into account all em-
21 ployees of the employer and in such manner as the Com-
22 missioner provides, including rules providing for the ap-
23 propriate aggregation of related employers). Any such con-
24 tribution—
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150
1
(1) shall be paid to the Health Choices Com-
2
missioner for deposit into the Health Insurance Ex-
3
change Trust Fund, and
4
(2) shall not be applied against the premium of
5
the employee under the Exchange-participating
6
health benefits plan in which the employee is en-
7
rolled.
8
(b) SPECIAL RULES FOR SMALL EMPLOYERS.—
9
(1) IN GENERAL.—In the case of any employer
10
who is a small employer for any calendar year, sub-
11
section (a) shall be applied by substituting the appli-
12
cable percentage determined in accordance with the
13
following table for ‘‘8 percent’’:
If the annual payroll of such employer for The applicable
the preceding calendar year:
percentage is:
Does not exceed $250,000 .....................................
0 percent
Exceeds $250,000, but does not exceed $300,000
2 percent
Exceeds $300,000, but does not exceed $350,000
4 percent
Exceeds $350,000, but does not exceed $400,000
6 percent
14
(2) SMALL EMPLOYER.—For purposes of this
15
subsection, the term ‘‘small employer’’ means any
16
employer for any calendar year if the annual payroll
17
of such employer for the preceding calendar year
18
does not exceed $400,000.
19
(3) ANNUAL PAYROLL.—For purposes of this
20
paragraph, the term ‘‘annual payroll’’ means, with
21
respect to any employer for any calendar year, the
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151
1
aggregate wages paid by the employer during such
2
calendar year.
3
(4) AGGREGATION RULES.—Related employers
4
and predecessors shall be treated as a single em-
5
ployer for purposes of this subsection.
6 SEC. 314. AUTHORITY RELATED TO IMPROPER STEERING.
7
The Health Choices Commissioner (in coordination
8 with the Secretary of Labor, the Secretary of Health and
9 Human Services, and the Secretary of the Treasury) shall
10 have authority to set standards for determining whether
11 employers or insurers are undertaking any actions to af-
12 fect the risk pool within the Health Insurance Exchange
13 by inducing individuals to decline coverage under a quali-
14 fied health benefits plan (or current employment-based
15 health plan (within the meaning of section 102(b)) offered
16 by the employer and instead to enroll in an Exchange-par-
17 ticipating health benefits plan. An employer violating such
18 standards shall be treated as not meeting the require-
19 ments of this section.
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152
1
PART 2—SATISFACTION OF HEALTH COVERAGE
2
PARTICIPATION REQUIREMENTS
3 SEC. 321. SATISFACTION OF HEALTH COVERAGE PARTICI-
4
PATION REQUIREMENTS UNDER THE EM-
5
PLOYEE RETIREMENT INCOME SECURITY
6
ACT OF 1974.
7
(a) IN GENERAL.—Subtitle B of title I of the Em-
8 ployee Retirement Income Security Act of 1974 is amend-
9 ed by adding at the end the following new part:
10
‘‘PART 8—NATIONAL HEALTH COVERAGE
11
PARTICIPATION REQUIREMENTS
12 ‘‘SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NA-
13
TIONAL HEALTH COVERAGE PARTICIPATION
14
REQUIREMENTS.
15
‘‘(a) IN GENERAL.—An employer may make an elec-
16 tion with the Secretary to be subject to the health coverage
17 participation requirements.
18
‘‘(b) TIME AND MANNER.—An election under sub-
19 section (a) may be made at such time and in such form
20 and manner as the Secretary may prescribe.
21 ‘‘SEC. 802. TREATMENT OF COVERAGE RESULTING FROM
22
ELECTION.
23
‘‘(a) IN GENERAL.—If an employer makes an election
24 to the Secretary under section 801—
25
‘‘(1) such election shall be treated as the estab-
26
lishment and maintenance of a group health plan (as
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153
1
defined in section 733(a)) for purposes of this title,
2
subject to section 151 of the America’s Affordable
3
Health Choices Act of 2009, and
4
‘‘(2) the health coverage participation require-
5
ments shall be deemed to be included as terms and
6
conditions of such plan.
7
‘‘(b) PERIODIC INVESTIGATIONS TO DISCOVER NON-
8 COMPLIANCE.—The Secretary shall regularly audit a rep-
9 resentative sampling of employers and group health plans
10 and conduct investigations and other activities under sec-
11 tion 504 with respect to such sampling of plans so as to
12 discover noncompliance with the health coverage participa-
13 tion requirements in connection with such plans. The Sec-
14 retary shall communicate findings of noncompliance made
15 by the Secretary under this subsection to the Secretary
16 of the Treasury and the Health Choices Commissioner.
17 The Secretary shall take such timely enforcement action
18 as appropriate to achieve compliance.
19 ‘‘SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIRE-
20
MENTS.
21
‘‘For purposes of this part, the term ‘health coverage
22 participation requirements’ means the requirements of
23 part 1 of subtitle B of title III of division A of America’s
24 Affordable Health Choices Act of 2009 (as in effect on
25 the date of the enactment of such Act).
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154
1 ‘‘SEC. 804. RULES FOR APPLYING REQUIREMENTS.
2
‘‘(a) AFFILIATED GROUPS.—In the case of any em-
3 ployer which is part of a group of employers who are treat-
4 ed as a single employer under subsection (b), (c), (m), or
5 (o) of section 414 of the Internal Revenue Code of 1986,
6 the election under section 801 shall be made by such em-
7 ployer as the Secretary may provide. Any such election,
8 once made, shall apply to all members of such group.
9
‘‘(b) SEPARATE ELECTIONS.—Under regulations pre-
10 scribed by the Secretary, separate elections may be made
11 under section 801 with respect to—
12
‘‘(1) separate lines of business, and
13
‘‘(2) full-time employees and employees who are
14
not full-time employees.
15 ‘‘SEC. 805. TERMINATION OF ELECTION IN CASES OF SUB-
16
STANTIAL NONCOMPLIANCE.
17
‘‘The Secretary may terminate the election of any em-
18 ployer under section 801 if the Secretary (in coordination
19 with the Health Choices Commissioner) determines that
20 such employer is in substantial noncompliance with the
21 health coverage participation requirements and shall refer
22 any such determination to the Secretary of the Treasury
23 as appropriate.
24 ‘‘SEC. 806. REGULATIONS.
25
‘‘The Secretary may promulgate such regulations as
26 may be necessary or appropriate to carry out the provi-
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155
1 sions of this part, in accordance with section 324(a) of
2 the America’s Affordable Health Choices Act of 2009. The
3 Secretary may promulgate any interim final rules as the
4 Secretary determines are appropriate to carry out this
5 part.’’.
6
(b) ENFORCEMENT OF HEALTH COVERAGE PARTICI-
7 PATION REQUIREMENTS.—Section 502 of such Act (29
8 U.S.C. 1132) is amended—
9
(1) in subsection (a)(6), by striking ‘‘para-
10
graph’’ and all that follows through ‘‘subsection (c)’’
11
and inserting ‘‘paragraph (2), (4), (5), (6), (7), (8),
12
(9), (10), or (11) of subsection (c)’’; and
13
(2) in subsection (c), by redesignating the sec-
14
ond paragraph (10) as paragraph (12) and by in-
15
serting after the first paragraph (10) the following
16
new paragraph:
17
‘‘(11) HEALTH COVERAGE PARTICIPATION RE-
18
QUIREMENTS.—
19
‘‘(A) CIVIL PENALTIES.—In the case of
20
any employer who fails (during any period with
21
respect to which an election under section
22
801(a) is in effect) to satisfy the health cov-
23
erage participation requirements with respect to
24
any employee, the Secretary may assess a civil
25
penalty against the employer of $100 for each
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156
1
day in the period beginning on the date such
2
failure first occurs and ending on the date such
3
failure is corrected.
4
‘‘(B) HEALTH COVERAGE PARTICIPATION
5
REQUIREMENTS.—For purposes of this para-
6
graph, the term ‘health coverage participation
7
requirements’ has the meaning provided in sec-
8
tion 803.
9
‘‘(C) LIMITATIONS ON AMOUNT OF PEN-
10
ALTY.—
11
‘‘(i) PENALTY NOT TO APPLY WHERE
12
FAILURE
NOT
DISCOVERED
EXERCISING
13
REASONABLE
DILIGENCE.—No penalty
14
shall be assessed under subparagraph (A)
15
with respect to any failure during any pe-
16
riod for which it is established to the satis-
17
faction of the Secretary that the employer
18
did not know, or exercising reasonable dili-
19
gence would not have known, that such
20
failure existed.
21
‘‘(ii) PENALTY NOT TO APPLY TO
22
FAILURES CORRECTED WITHIN 30 DAYS.—
23
No penalty shall be assessed under sub-
24
paragraph (A) with respect to any failure
25
if—
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157
1
‘‘(I) such failure was due to rea-
2
sonable cause and not to willful ne-
3
glect, and
4
‘‘(II) such failure is corrected
5
during the 30-day period beginning on
6
the 1st date that the employer knew,
7
or exercising reasonable diligence
8
would have known, that such failure
9
existed.
10
‘‘(iii) OVERALL LIMITATION FOR UN-
11
INTENTIONAL FAILURES.—In the case of
12
failures which are due to reasonable cause
13
and not to willful neglect, the penalty as-
14
sessed under subparagraph (A) for failures
15
during any 1-year period shall not exceed
16
the amount equal to the lesser of—
17
‘‘(I) 10 percent of the aggregate
18
amount paid or incurred by the em-
19
ployer (or predecessor employer) dur-
20
ing the preceding 1-year period for
21
group health plans, or
22
‘‘(II) $500,000.
23
‘‘(D) ADVANCE NOTIFICATION OF FAILURE
24
PRIOR TO ASSESSMENT.—Before a reasonable
25
time prior to the assessment of any penalty
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158
1
under this paragraph with respect to any failure
2
by an employer, the Secretary shall inform the
3
employer in writing of such failure and shall
4
provide the employer information regarding ef-
5
forts and procedures which may be undertaken
6
by the employer to correct such failure.
7
‘‘(E) COORDINATION WITH EXCISE TAX.—
8
Under regulations prescribed in accordance
9
with section 324 of the America’s Affordable
10
Health Choices Act of 2009, the Secretary and
11
the Secretary of the Treasury shall coordinate
12
the assessment of penalties under this section
13
in connection with failures to satisfy health cov-
14
erage participation requirements with the impo-
15
sition of excise taxes on such failures under sec-
16
tion 4980H(b) of the Internal Revenue Code of
17
1986 so as to avoid duplication of penalties
18
with respect to such failures.
19
‘‘(F) DEPOSIT OF PENALTY COLLECTED.—
20
Any amount of penalty collected under this
21
paragraph shall be deposited as miscellaneous
22
receipts in the Treasury of the United States.’’.
23
(c) CLERICAL AMENDMENTS.—The table of contents
24 in section 1 of such Act is amended by inserting after the
25 item relating to section 734 the following new items:
‘‘PART 8—NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS
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159
‘‘Sec. 801. Election of employer to be subject to national health coverage par-
ticipation requirements.
‘‘Sec. 802. Treatment of coverage resulting from election.
‘‘Sec. 803. Health coverage participation requirements.
‘‘Sec. 804. Rules for applying requirements.
‘‘Sec. 805. Termination of election in cases of substantial noncompliance.
‘‘Sec. 806. Regulations.’’.
1
(d) EFFECTIVE DATE.—The amendments made by
2 this section shall apply to periods beginning after Decem-
3 ber 31, 2012.
4 SEC. 322. SATISFACTION OF HEALTH COVERAGE PARTICI-
5
PATION REQUIREMENTS UNDER THE INTER-
6
NAL REVENUE CODE OF 1986.
7
(a) FAILURE TO ELECT, OR SUBSTANTIALLY COM-
8 PLY WITH, HEALTH COVERAGE PARTICIPATION RE-
9 QUIREMENTS.—For employment tax on employers who fail
10 to elect, or substantially comply with, the health coverage
11 participation requirements described in part 1, see section
12 3111(c) of the Internal Revenue Code of 1986 (as added
13 by section 412 of this Act).
14
(b) OTHER FAILURES.—For excise tax on other fail-
15 ures of electing employers to comply with such require-
16 ments, see section 4980H of the Internal Revenue Code
17 of 1986 (as added by section 411 of this Act).
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160
1 SEC. 323. SATISFACTION OF HEALTH COVERAGE PARTICI-
2
PATION REQUIREMENTS UNDER THE PUBLIC
3
HEALTH SERVICE ACT.
4
(a) IN GENERAL.—Part C of title XXVII of the Pub-
5 lic Health Service Act is amended by adding at the end
6 the following new section:
7 ‘‘SEC. 2793. NATIONAL HEALTH COVERAGE PARTICIPATION
8
REQUIREMENTS.
9
‘‘(a) ELECTION OF EMPLOYER TO BE SUBJECT TO
10 NATIONAL HEALTH COVERAGE PARTICIPATION REQUIRE-
11 MENTS.—
12
‘‘(1) IN GENERAL.—An employer may make an
13
election with the Secretary to be subject to the
14
health coverage participation requirements.
15
‘‘(2) TIME AND MANNER.—An election under
16
paragraph (1) may be made at such time and in
17
such form and manner as the Secretary may pre-
18
scribe.
19
‘‘(b) TREATMENT OF COVERAGE RESULTING FROM
20 ELECTION.—
21
‘‘(1) IN GENERAL.—If an employer makes an
22
election to the Secretary under subsection (a)—
23
‘‘(A) such election shall be treated as the
24
establishment and maintenance of a group
25
health plan for purposes of this title, subject to
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161
1
section 151 of the America’s Affordable Health
2
Choices Act of 2009, and
3
‘‘(B) the health coverage participation re-
4
quirements shall be deemed to be included as
5
terms and conditions of such plan.
6
‘‘(2) PERIODIC INVESTIGATIONS TO DETERMINE
7
COMPLIANCE WITH HEALTH COVERAGE PARTICIPA-
8
TION
REQUIREMENTS.—The Secretary shall regu-
9
larly audit a representative sampling of employers
10
and conduct investigations and other activities with
11
respect to such sampling of employers so as to dis-
12
cover noncompliance with the health coverage par-
13
ticipation requirements in connection with such em-
14
ployers (during any period with respect to which an
15
election under subsection (a) is in effect). The Sec-
16
retary shall communicate findings of noncompliance
17
made by the Secretary under this subsection to the
18
Secretary of the Treasury and the Health Choices
19
Commissioner. The Secretary shall take such timely
20
enforcement action as appropriate to achieve compli-
21
ance.
22
‘‘(c) HEALTH COVERAGE PARTICIPATION REQUIRE-
23 MENTS.—For purposes of this section, the term ‘health
24 coverage participation requirements’ means the require-
25 ments of part 1 of subtitle B of title III of division A
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162
1 of the America’s Affordable Health Choices Act of 2009
2 (as in effect on the date of the enactment of this section).
3
‘‘(d) SEPARATE ELECTIONS.—Under regulations pre-
4 scribed by the Secretary, separate elections may be made
5 under subsection (a) with respect to full-time employees
6 and employees who are not full-time employees.
7
‘‘(e) TERMINATION OF ELECTION IN CASES OF SUB-
8 STANTIAL NONCOMPLIANCE.—The Secretary may termi-
9 nate the election of any employer under subsection (a) if
10 the Secretary (in coordination with the Health Choices
11 Commissioner) determines that such employer is in sub-
12 stantial noncompliance with the health coverage participa-
13 tion requirements and shall refer any such determination
14 to the Secretary of the Treasury as appropriate.
15
‘‘(f) ENFORCEMENT OF HEALTH COVERAGE PAR-
16 TICIPATION REQUIREMENTS.—
17
‘‘(1) CIVIL PENALTIES.—In the case of any em-
18
ployer who fails (during any period with respect to
19
which the election under subsection (a) is in effect)
20
to satisfy the health coverage participation require-
21
ments with respect to any employee, the Secretary
22
may assess a civil penalty against the employer of
23
$100 for each day in the period beginning on the
24
date such failure first occurs and ending on the date
25
such failure is corrected.
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163
1
‘‘(2) LIMITATIONS ON AMOUNT OF PENALTY.—
2
‘‘(A) PENALTY NOT TO APPLY WHERE
3
FAILURE NOT DISCOVERED EXERCISING REA-
4
SONABLE DILIGENCE.—No penalty shall be as-
5
sessed under paragraph (1) with respect to any
6
failure during any period for which it is estab-
7
lished to the satisfaction of the Secretary that
8
the employer did not know, or exercising rea-
9
sonable diligence would not have known, that
10
such failure existed.
11
‘‘(B) PENALTY NOT TO APPLY TO FAIL-
12
URES CORRECTED WITHIN 30 DAYS.—No pen-
13
alty shall be assessed under paragraph (1) with
14
respect to any failure if—
15
‘‘(i) such failure was due to reason-
16
able cause and not to willful neglect, and
17
‘‘(ii) such failure is corrected during
18
the 30-day period beginning on the 1st
19
date that the employer knew, or exercising
20
reasonable diligence would have known,
21
that such failure existed.
22
‘‘(C) OVERALL LIMITATION FOR UNINTEN-
23
TIONAL
FAILURES.—In the case of failures
24
which are due to reasonable cause and not to
25
willful neglect, the penalty assessed under para-
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164
1
graph (1) for failures during any 1-year period
2
shall not exceed the amount equal to the lesser
3
of—
4
‘‘(i) 10 percent of the aggregate
5
amount paid or incurred by the employer
6
(or predecessor employer) during the pre-
7
ceding taxable year for group health plans,
8
or
9
‘‘(ii) $500,000.
10
‘‘(3) ADVANCE
NOTIFICATION
OF
FAILURE
11
PRIOR TO ASSESSMENT.—Before a reasonable time
12
prior to the assessment of any penalty under para-
13
graph (1) with respect to any failure by an em-
14
ployer, the Secretary shall inform the employer in
15
writing of such failure and shall provide the em-
16
ployer information regarding efforts and procedures
17
which may be undertaken by the employer to correct
18
such failure.
19
‘‘(4) ACTIONS TO ENFORCE ASSESSMENTS.—
20
The Secretary may bring a civil action in any Dis-
21
trict Court of the United States to collect any civil
22
penalty under this subsection.
23
‘‘(5) COORDINATION
WITH
EXCISE
TAX.—
24
Under regulations prescribed in accordance with sec-
25
tion 324 of the America’s Affordable Health Choices
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165
1
Act of 2009, the Secretary and the Secretary of the
2
Treasury shall coordinate the assessment of pen-
3
alties under paragraph (1) in connection with fail-
4
ures to satisfy health coverage participation require-
5
ments with the imposition of excise taxes on such
6
failures under section 4980H(b) of the Internal Rev-
7
enue Code of 1986 so as to avoid duplication of pen-
8
alties with respect to such failures.
9
‘‘(6) DEPOSIT OF PENALTY COLLECTED.—Any
10
amount of penalty collected under this subsection
11
shall be deposited as miscellaneous receipts in the
12
Treasury of the United States.
13
‘‘(g) REGULATIONS.—The Secretary may promulgate
14 such regulations as may be necessary or appropriate to
15 carry out the provisions of this section, in accordance with
16 section 324(a) of the America’s Affordable Health Choices
17 Act of 2009. The Secretary may promulgate any interim
18 final rules as the Secretary determines are appropriate to
19 carry out this section.’’.
20
(b) EFFECTIVE DATE.—The amendments made by
21 subsection (a) shall apply to periods beginning after De-
22 cember 31, 2012.
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166
1 SEC. 324. ADDITIONAL RULES RELATING TO HEALTH COV-
2
ERAGE PARTICIPATION REQUIREMENTS.
3
(a) ASSURING COORDINATION.—The officers con-
4 sisting of the Secretary of Labor, the Secretary of the
5 Treasury, the Secretary of Health and Human Services,
6 and the Health Choices Commissioner shall ensure,
7 through the execution of an interagency memorandum of
8 understanding among such officers, that—
9
(1) regulations, rulings, and interpretations
10
issued by such officers relating to the same matter
11
over which two or more of such officers have respon-
12
sibility under subpart B of part 6 of subtitle B of
13
title I of the Employee Retirement Income Security
14
Act of 1974, section 4980H of the Internal Revenue
15
Code of 1986, and section 2793 of the Public Health
16
Service Act are administered so as to have the same
17
effect at all times; and
18
(2) coordination of policies relating to enforcing
19
the same requirements through such officers in
20
order to have a coordinated enforcement strategy
21
that avoids duplication of enforcement efforts and
22
assigns priorities in enforcement.
23
(b) MULTIEMPLOYER PLANS.—In the case of a group
24 health plan that is a multiemployer plan (as defined in
25 section 3(37) of the Employee Retirement Income Secu-
26 rity Act of 1974), the regulations prescribed in accordance
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167
1 with subsection (a) by the officers referred to in subsection
2 (a) shall provide for the application of the health coverage
3 participation requirements to the plan sponsor and con-
4 tributing sponsors of such plan.
5 TITLE IV—AMENDMENTS TO IN-
6
TERNAL REVENUE CODE OF
7
1986
8
Subtitle A—Shared Responsibility
9
PART 1—INDIVIDUAL RESPONSIBILITY
10 SEC. 401. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE
11
HEALTH CARE COVERAGE.
12
(a) IN GENERAL.—Subchapter A of chapter 1 of the
13 Internal Revenue Code of 1986 is amended by adding at
14 the end the following new part:
15
‘‘PART VIII—HEALTH CARE RELATED TAXES
‘‘SUBPART A. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE
COVERAGE.
16
‘‘Subpart A—Tax on Individuals Without Acceptable
17
Health Care Coverage
‘‘Sec. 59B. Tax on individuals without acceptable health care coverage.
18 ‘‘SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE
19
HEALTH CARE COVERAGE.
20
‘‘(a) TAX IMPOSED.—In the case of any individual
21 who does not meet the requirements of subsection (d) at
22 any time during the taxable year, there is hereby imposed
23 a tax equal to 2.5 percent of the excess of—
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168
1
‘‘(1) the taxpayer’s modified adjusted gross in-
2
come for the taxable year, over
3
‘‘(2) the amount of gross income specified in
4
section 6012(a)(1) with respect to the taxpayer.
5
‘‘(b) LIMITATIONS.—
6
‘‘(1) TAX LIMITED TO AVERAGE PREMIUM.—
7
‘‘(A) IN
GENERAL.—The tax imposed
8
under subsection (a) with respect to any tax-
9
payer for any taxable year shall not exceed the
10
applicable national average premium for such
11
taxable year.
12
‘‘(B) APPLICABLE
NATIONAL
AVERAGE
13
PREMIUM.—
14
‘‘(i) IN GENERAL.—For purposes of
15
subparagraph (A), the ‘applicable national
16
average premium’ means, with respect to
17
any taxable year, the average premium (as
18
determined by the Secretary, in coordina-
19
tion with the Health Choices Commis-
20
sioner) for self-only coverage under a basic
21
plan which is offered in a Health Insur-
22
ance Exchange for the calendar year in
23
which such taxable year begins.
24
‘‘(ii) FAILURE TO PROVIDE COVERAGE
25
FOR MORE THAN ONE INDIVIDUAL.—In the
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169
1
case of any taxpayer who fails to meet the
2
requirements of subsection (e) with respect
3
to more than one individual during the tax-
4
able year, clause (i) shall be applied by
5
substituting ‘family coverage’ for ‘self-only
6
coverage’.
7
‘‘(2) PRORATION FOR PART YEAR FAILURES.—
8
The tax imposed under subsection (a) with respect
9
to any taxpayer for any taxable year shall not exceed
10
the amount which bears the same ratio to the
11
amount of tax so imposed (determined without re-
12
gard to this paragraph and after application of para-
13
graph (1)) as—
14
‘‘(A) the aggregate periods during such
15
taxable year for which such individual failed to
16
meet the requirements of subsection (d), bears
17
to
18
‘‘(B) the entire taxable year.
19
‘‘(c) EXCEPTIONS.—
20
‘‘(1) DEPENDENTS.—Subsection (a) shall not
21
apply to any individual for any taxable year if a de-
22
duction is allowable under section 151 with respect
23
to such individual to another taxpayer for any tax-
24
able year beginning in the same calendar year as
25
such taxable year.
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170
1
‘‘(2) NONRESIDENT ALIENS.—Subsection (a)
2
shall not apply to any individual who is a non-
3
resident alien.
4
‘‘(3) INDIVIDUALS RESIDING OUTSIDE UNITED
5
STATES.—Any qualified individual (as defined in
6
section 911(d)) (and any qualifying child residing
7
with such individual) shall be treated for purposes of
8
this section as covered by acceptable coverage during
9
the period described in subparagraph (A) or (B) of
10
section 911(d)(1), whichever is applicable.
11
‘‘(4) INDIVIDUALS RESIDING IN POSSESSIONS
12
OF THE UNITED STATES.—Any individual who is a
13
bona fide resident of any possession of the United
14
States (as determined under section 937(a)) for any
15
taxable year (and any qualifying child residing with
16
such individual) shall be treated for purposes of this
17
section as covered by acceptable coverage during
18
such taxable year.
19
‘‘(5) RELIGIOUS CONSCIENCE EXEMPTION.—
20
‘‘(A) IN GENERAL.—Subsection (a) shall
21
not apply to any individual (and any qualifying
22
child residing with such individual) for any pe-
23
riod if such individual has in effect an exemp-
24
tion which certifies that such individual is a
25
member of a recognized religious sect or divi-
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171
1
sion thereof described in section 1402(g)(1) and
2
an adherent of established tenets or teachings
3
of such sect or division as described in such sec-
4
tion.
5
‘‘(B) EXEMPTION.—An application for the
6
exemption described in subparagraph (A) shall
7
be filed with the Secretary at such time and in
8
such form and manner as the Secretary may
9
prescribe. Any such exemption granted by the
10
Secretary shall be effective for such period as
11
the Secretary determines appropriate.
12
‘‘(d) ACCEPTABLE COVERAGE REQUIREMENT.—
13
‘‘(1) IN GENERAL.—The requirements of this
14
subsection are met with respect to any individual for
15
any period if such individual (and each qualifying
16
child of such individual) is covered by acceptable
17
coverage at all times during such period.
18
‘‘(2) ACCEPTABLE COVERAGE.—For purposes
19
of this section, the term ‘acceptable coverage’ means
20
any of the following:
21
‘‘(A) QUALIFIED HEALTH BENEFITS PLAN
22
COVERAGE.—Coverage under a qualified health
23
benefits plan (as defined in section 100(c) of
24
the America’s Affordable Health Choices Act of
25
2009).
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172
1
‘‘(B) GRANDFATHERED HEALTH INSUR-
2
ANCE
COVERAGE; COVERAGE
UNDER
GRAND-
3
FATHERED
EMPLOYMENT-BASED
HEALTH
4
PLAN.—Coverage under a grandfathered health
5
insurance coverage (as defined in subsection (a)
6
of section 102 of the America’s Affordable
7
Health Choices Act of 2009) or under a current
8
employment-based health plan (within the
9
meaning of subsection (b) of such section).
10
‘‘(C) MEDICARE.—Coverage under part A
11
of title XVIII of the Social Security Act.
12
‘‘(D) MEDICAID.—Coverage for medical as-
13
sistance under title XIX of the Social Security
14
Act.
15
‘‘(E) MEMBERS OF THE ARMED FORCES
16
AND
DEPENDENTS
(INCLUDING
TRICARE).—
17
Coverage under chapter 55 of title 10, United
18
States Code, including similar coverage fur-
19
nished under section 1781 of title 38 of such
20
Code.
21
‘‘(F) VA.—Coverage under the veteran’s
22
health care program under chapter 17 of title
23
38, United States Code, but only if the cov-
24
erage for the individual involved is determined
25
by the Secretary in coordination with the
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173
1
Health Choices Commissioner to be not less
2
than the level specified by the Secretary of the
3
Treasury, in coordination with the Secretary of
4
Veteran’s Affairs and the Health Choices Com-
5
missioner, based on the individual’s priority for
6
services as provided under section 1705(a) of
7
such title.
8
‘‘(G) OTHER
COVERAGE.—Such other
9
health benefits coverage as the Secretary, in co-
10
ordination with the Health Choices Commis-
11
sioner, recognizes for purposes of this sub-
12
section.
13
‘‘(e) OTHER DEFINITIONS AND SPECIAL RULES.—
14
‘‘(1) QUALIFYING CHILD.—For purposes of this
15
section, the term ‘qualifying child’ has the meaning
16
given such term by section 152(c).
17
‘‘(2) BASIC PLAN.—For purposes of this sec-
18
tion, the term ‘basic plan’ has the meaning given
19
such term under section 100(c) of the America’s Af-
20
fordable Health Choices Act of 2009.
21
‘‘(3) HEALTH
INSURANCE
EXCHANGE.—For
22
purposes of this section, the term ‘Health Insurance
23
Exchange’ has the meaning given such term under
24
section 100(c) of the America’s Affordable Health
25
Choices Act of 2009, including any State-based
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174
1
health insurance exchange approved for operation
2
under section 208 of such Act.
3
‘‘(4) FAMILY COVERAGE.—For purposes of this
4
section, the term ‘family coverage’ means any cov-
5
erage other than self-only coverage.
6
‘‘(5) MODIFIED ADJUSTED GROSS INCOME.—
7
For purposes of this section, the term ‘modified ad-
8
justed gross income’ means adjusted gross income—
9
‘‘(A) determined without regard to section
10
911, and
11
‘‘(B) increased by the amount of interest
12
received or accrued by the taxpayer during the
13
taxable year which is exempt from tax.
14
‘‘(6) NOT TREATED AS TAX IMPOSED BY THIS
15
CHAPTER FOR CERTAIN PURPOSES.—The tax im-
16
posed under this section shall not be treated as tax
17
imposed by this chapter for purposes of determining
18
the amount of any credit under this chapter or for
19
purposes of section 55.
20
‘‘(f) REGULATIONS.—The Secretary shall prescribe
21 such regulations or other guidance as may be necessary
22 or appropriate to carry out the purposes of this section,
23 including regulations or other guidance (developed in co-
24 ordination with the Health Choices Commissioner) which
25 provide—
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175
1
‘‘(1) exemption from the tax imposed under
2
subsection (a) in cases of de minimis lapses of ac-
3
ceptable coverage, and
4
‘‘(2) a process for applying for a waiver of the
5
application of subsection (a) in cases of hardship.’’.
6
(b) INFORMATION REPORTING.—
7
(1) IN GENERAL.—Subpart B of part III of
8
subchapter A of chapter 61 of such Code is amended
9
by inserting after section 6050W the following new
10
section:
11 ‘‘SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE
12
COVERAGE.
13
‘‘(a) REQUIREMENT OF REPORTING.—Every person
14 who provides acceptable coverage (as defined in section
15 59B(d)) to any individual during any calendar year shall,
16 at such time as the Secretary may prescribe, make the
17 return described in subsection (b) with respect to such in-
18 dividual.
19
‘‘(b) FORM AND MANNER OF RETURNS.—A return
20 is described in this subsection if such return—
21
‘‘(1) is in such form as the Secretary may pre-
22
scribe, and
23
‘‘(2) contains—
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176
1
‘‘(A) the name, address, and TIN of the
2
primary insured and the name of each other in-
3
dividual obtaining coverage under the policy,
4
‘‘(B) the period for which each such indi-
5
vidual was provided with the coverage referred
6
to in subsection (a), and
7
‘‘(C) such other information as the Sec-
8
retary may require.
9
‘‘(c) STATEMENTS TO BE FURNISHED TO INDIVID-
10 UALS WITH RESPECT TO WHOM INFORMATION IS RE-
11 QUIRED.—Every person required to make a return under
12 subsection (a) shall furnish to each primary insured whose
13 name is required to be set forth in such return a written
14 statement showing—
15
‘‘(1) the name and address of the person re-
16
quired to make such return and the phone number
17
of the information contact for such person, and
18
‘‘(2) the information required to be shown on
19
the return with respect to such individual.
20 The written statement required under the preceding sen-
21 tence shall be furnished on or before January 31 of the
22 year following the calendar year for which the return
23 under subsection (a) is required to be made.
24
‘‘(d) COVERAGE
PROVIDED
BY
GOVERNMENTAL
25 UNITS.—In the case of coverage provided by any govern-
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177
1 mental unit or any agency or instrumentality thereof, the
2 officer or employee who enters into the agreement to pro-
3 vide such coverage (or the person appropriately designated
4 for purposes of this section) shall make the returns and
5 statements required by this section.’’.
6
(2) PENALTY FOR FAILURE TO FILE.—
7
(A) RETURN.—Subparagraph (B) of sec-
8
tion 6724(d)(1) of such Code is amended by
9
striking ‘‘or’’ at the end of clause (xxii), by
10
striking ‘‘and’’ at the end of clause (xxiii) and
11
inserting ‘‘or’’, and by adding at the end the
12
following new clause:
13
‘‘(xxiv) section 6050X (relating to re-
14
turns relating to health insurance cov-
15
erage), and’’.
16
(B) STATEMENT.—Paragraph (2) of sec-
17
tion 6724(d) of such Code is amended by strik-
18
ing ‘‘or’’ at the end of subparagraph (EE), by
19
striking the period at the end of subparagraph
20
(FF) and inserting ‘‘, or’’, and by inserting
21
after subparagraph (FF) the following new sub-
22
paragraph:
23
‘‘(GG) section 6050X (relating to returns
24
relating to health insurance coverage).’’.
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178
1
(c) RETURN REQUIREMENT.—Subsection (a) of sec-
2 tion 6012 of such Code is amended by inserting after
3 paragraph (9) the following new paragraph:
4
‘‘(10) Every individual to whom section 59B(a)
5
applies and who fails to meet the requirements of
6
section 59B(d) with respect to such individual or
7
any qualifying child (as defined in section 152(c)) of
8
such individual.’’.
9
(d) CLERICAL AMENDMENTS.—
10
(1) The table of parts for subchapter A of chap-
11
ter 1 of the Internal Revenue Code of 1986 is
12
amended by adding at the end the following new
13
item:
‘‘PART VIII. HEALTH CARE RELATED TAXES.’’.
14
(2) The table of sections for subpart B of part
15
III of subchapter A of chapter 61 is amended by
16
adding at the end the following new item:
‘‘Sec. 6050X. Returns relating to health insurance coverage.’’.
17
(e) SECTION 15 NOT TO APPLY.—The amendment
18 made by subsection (a) shall not be treated as a change
19 in a rate of tax for purposes of section 15 of the Internal
20 Revenue Code of 1986.
21
(f) EFFECTIVE DATE.—
22
(1) IN GENERAL.—The amendments made by
23
this section shall apply to taxable years beginning
24
after December 31, 2012.
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179
1
(2) RETURNS.—The amendments made by sub-
2
section (b) shall apply to calendar years beginning
3
after December 31, 2012.
4
PART 2—EMPLOYER RESPONSIBILITY
5 SEC. 411. ELECTION TO SATISFY HEALTH COVERAGE PAR-
6
TICIPATION REQUIREMENTS.
7
(a) IN GENERAL.—Chapter 43 of the Internal Rev-
8 enue Code of 1986 is amended by adding at the end the
9 following new section:
10 ‘‘SEC. 4980H. ELECTION WITH RESPECT TO HEALTH COV-
11
ERAGE PARTICIPATION REQUIREMENTS.
12
‘‘(a) ELECTION OF EMPLOYER RESPONSIBILITY TO
13 PROVIDE HEALTH COVERAGE.—
14
‘‘(1) IN GENERAL.—Subsection (b) shall apply
15
to any employer with respect to whom an election
16
under paragraph (2) is in effect.
17
‘‘(2) TIME AND MANNER.—An employer may
18
make an election under this paragraph at such time
19
and in such form and manner as the Secretary may
20
prescribe.
21
‘‘(3) AFFILIATED GROUPS.—In the case of any
22
employer which is part of a group of employers who
23
are treated as a single employer under subsection
24
(b), (c), (m), or (o) of section 414, the election
25
under paragraph (2) shall be made by such person
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180
1
as the Secretary may provide. Any such election,
2
once made, shall apply to all members of such
3
group.
4
‘‘(4) SEPARATE ELECTIONS.—Under regula-
5
tions prescribed by the Secretary, separate elections
6
may be made under paragraph (2) with respect to—
7
‘‘(A) separate lines of business, and
8
‘‘(B) full-time employees and employees
9
who are not full-time employees.
10
‘‘(5) TERMINATION OF ELECTION IN CASES OF
11
SUBSTANTIAL
NONCOMPLIANCE.—The Secretary
12
may terminate the election of any employer under
13
paragraph (2) if the Secretary (in coordination with
14
the Health Choices Commissioner) determines that
15
such employer is in substantial noncompliance with
16
the health coverage participation requirements.
17
‘‘(b) EXCISE TAX WITH RESPECT TO FAILURE TO
18 MEET HEALTH COVERAGE PARTICIPATION REQUIRE-
19 MENTS.—
20
‘‘(1) IN GENERAL.—In the case of any employer
21
who fails (during any period with respect to which
22
the election under subsection (a) is in effect) to sat-
23
isfy the health coverage participation requirements
24
with respect to any employee to whom such election
25
applies, there is hereby imposed on each such failure
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181
1
with respect to each such employee a tax of $100 for
2
each day in the period beginning on the date such
3
failure first occurs and ending on the date such fail-
4
ure is corrected.
5
‘‘(2) LIMITATIONS ON AMOUNT OF TAX.—
6
‘‘(A) TAX NOT TO APPLY WHERE FAILURE
7
NOT
DISCOVERED
EXERCISING
REASONABLE
8
DILIGENCE.—No tax shall be imposed by para-
9
graph (1) on any failure during any period for
10
which it is established to the satisfaction of the
11
Secretary that the employer neither knew, nor
12
exercising reasonable diligence would have
13
known, that such failure existed.
14
‘‘(B) TAX NOT TO APPLY TO FAILURES
15
CORRECTED WITHIN 30 DAYS.—No tax shall be
16
imposed by paragraph (1) on any failure if—
17
‘‘(i) such failure was due to reason-
18
able cause and not to willful neglect, and
19
‘‘(ii) such failure is corrected during
20
the 30-day period beginning on the 1st
21
date that the employer knew, or exercising
22
reasonable diligence would have known,
23
that such failure existed.
24
‘‘(C) OVERALL LIMITATION FOR UNINTEN-
25
TIONAL
FAILURES.—In the case of failures
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182
1
which are due to reasonable cause and not to
2
willful neglect, the tax imposed by subsection
3
(a) for failures during the taxable year of the
4
employer shall not exceed the amount equal to
5
the lesser of—
6
‘‘(i) 10 percent of the aggregate
7
amount paid or incurred by the employer
8
(or predecessor employer) during the pre-
9
ceding taxable year for employment-based
10
health plans, or
11
‘‘(ii) $500,000.
12
‘‘(D) COORDINATION WITH OTHER EN-
13
FORCEMENT
PROVISIONS.—The tax imposed
14
under paragraph (1) with respect to any failure
15
shall be reduced (but not below zero) by the
16
amount of any civil penalty collected under sec-
17
tion 502(c)(11) of the Employee Retirement In-
18
come Security Act of 1974 or section 2793(g)
19
of the Public Health Service Act with respect to
20
such failure.
21
‘‘(c) HEALTH COVERAGE PARTICIPATION REQUIRE-
22 MENTS.—For purposes of this section, the term ‘health
23 coverage participation requirements’ means the require-
24 ments of part I of subtitle B of title III of the America’s
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183
1 Affordable Health Choices Act of 2009 (as in effect on
2 the date of the enactment of this section).’’.
3
(b) CLERICAL AMENDMENT.—The table of sections
4 for chapter 43 of such Code is amended by adding at the
5 end the following new item:
‘‘Sec. 4980H. Election to satisfy health coverage participation requirements.’’.
6
(c) EFFECTIVE DATE.—The amendments made by
7 this section shall apply to periods beginning after Decem-
8 ber 31, 2012.
9 SEC. 412. RESPONSIBILITIES OF NONELECTING EMPLOY-
10
ERS.
11
(a) IN GENERAL.—Section 3111 of the Internal Rev-
12 enue Code of 1986 is amended by redesignating subsection
13 (c) as subsection (d) and by inserting after subsection (b)
14 the following new subsection:
15
‘‘(c) EMPLOYERS
ELECTING
TO
NOT
PROVIDE
16 HEALTH BENEFITS.—
17
‘‘(1) IN GENERAL.—In addition to other taxes,
18
there is hereby imposed on every nonelecting em-
19
ployer an excise tax, with respect to having individ-
20
uals in his employ, equal to 8 percent of the wages
21
(as defined in section 3121(a)) paid by him with re-
22
spect to employment (as defined in section 3121(b)).
23
‘‘(2) SPECIAL RULES FOR SMALL EMPLOY-
24
ERS.—
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184
1
‘‘(A) IN GENERAL.—In the case of any em-
2
ployer who is small employer for any calendar
3
year, paragraph (1) shall be applied by sub-
4
stituting the applicable percentage determined
5
in accordance with the following table for ‘8
6
percent’:
‘‘If the annual payroll of such employer for The applicable
the preceding calendar year:
percentage is:
Does not exceed $250,000 .....................................
0 percent
Exceeds $250,000, but does not exceed $300,000
2 percent
Exceeds $300,000, but does not exceed $350,000
4 percent
Exceeds $350,000, but does not exceed $400,000
6 percent
7
‘‘(B) SMALL EMPLOYER.—For purposes of
8
this paragraph, the term ‘small employer’
9
means any employer for any calendar year if
10
the annual payroll of such employer for the pre-
11
ceding calendar year does not exceed $400,000.
12
‘‘(C) ANNUAL PAYROLL.—For purposes of
13
this paragraph, the term ‘annual payroll’
14
means, with respect to any employer for any
15
calendar year, the aggregate wages (as defined
16
in section 3121(a)) paid by him with respect to
17
employment (as defined in section 3121(b))
18
during such calendar year.
19
‘‘(3) NONELECTING EMPLOYER.—For purposes
20
of paragraph (1), the term ‘nonelecting employer’
21
means any employer for any period with respect to
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185
1
which such employer does not have an election under
2
section 4980H(a) in effect.
3
‘‘(4) SPECIAL RULE FOR SEPARATE ELEC-
4
TIONS.—In the case of an employer who makes a
5
separate election described in section 4980H(a)(4)
6
for any period, paragraph (1) shall be applied for
7
such period by taking into account only the wages
8
paid to employees who are not subject to such elec-
9
tion.
10
‘‘(5) AGGREGATION; PREDECESSORS.—For pur-
11
poses of this subsection—
12
‘‘(A) all persons treated as a single em-
13
ployer under subsection (b), (c), (m), or (o) of
14
section 414 shall be treated as 1 employer, and
15
‘‘(B) any reference to any person shall be
16
treated as including a reference to any prede-
17
cessor of such person.’’.
18
(b) DEFINITIONS.—Section 3121 of such Code is
19 amended by adding at the end the following new sub-
20 section:
21
‘‘(aa) SPECIAL RULES FOR TAX ON EMPLOYERS
22 ELECTING NOT TO PROVIDE HEALTH BENEFITS.—For
23 purposes of section 3111(c)—
24
‘‘(1) Paragraphs (1), (5), and (19) of sub-
25
section (b) shall not apply.
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186
1
‘‘(2) Paragraph (7) of subsection (b) shall apply
2
by treating all services as not covered by the retire-
3
ment systems referred to in subparagraphs (C) and
4
(F) thereof.
5
‘‘(3) Subsection (e) shall not apply and the
6
term ‘State’ shall include the District of Columbia.’’.
7
(c) CONFORMING AMENDMENT.—Subsection (d) of
8 section 3111 of such Code, as redesignated by this section,
9 is amended by striking ‘‘this section’’ and inserting ‘‘sub-
10 sections (a) and (b)’’.
11
(d) APPLICATION TO RAILROADS.—
12
(1) IN GENERAL.—Section 3221 of such Code
13
is amended by redesignating subsection (c) as sub-
14
section (d) and by inserting after subsection (b) the
15
following new subsection:
16
‘‘(c) EMPLOYERS
ELECTING
TO
NOT
PROVIDE
17 HEALTH BENEFITS.—
18
‘‘(1) IN GENERAL.—In addition to other taxes,
19
there is hereby imposed on every nonelecting em-
20
ployer an excise tax, with respect to having individ-
21
uals in his employ, equal to 8 percent of the com-
22
pensation paid during any calendar year by such em-
23
ployer for services rendered to such employer.
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187
1
‘‘(2) EXCEPTION FOR SMALL EMPLOYERS.—
2
Rules similar to the rules of section 3111(c)(2) shall
3
apply for purposes of this subsection.
4
‘‘(3) NONELECTING EMPLOYER.—For purposes
5
of paragraph (1), the term ‘nonelecting employer’
6
means any employer for any period with respect to
7
which such employer does not have an election under
8
section 4980H(a) in effect.
9
‘‘(4) SPECIAL RULE FOR SEPARATE ELEC-
10
TIONS.—In the case of an employer who makes a
11
separate election described in section 4980H(a)(4)
12
for any period, subsection (a) shall be applied for
13
such period by taking into account only the wages
14
paid to employees who are not subject to such elec-
15
tion.’’.
16
(2) DEFINITIONS.—Subsection (e) of section
17
3231 of such Code is amended by adding at the end
18
the following new paragraph:
19
‘‘(13) SPECIAL RULES FOR TAX ON EMPLOYERS
20
ELECTING NOT TO PROVIDE HEALTH BENEFITS.—
21
For purposes of section 3221(c)—
22
‘‘(A) Paragraph (1) shall be applied with-
23
out regard to the third sentence thereof.
24
‘‘(B) Paragraph (2) shall not apply.’’.
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188
1
(3) CONFORMING AMENDMENT.—Subsection (d)
2
of section 3221 of such Code, as redesignated by
3
this section, is amended by striking ‘‘subsections (a)
4
and (b), see section 3231(e)(2)’’ and inserting ‘‘this
5
section, see paragraphs (2) and (13)(B) of section
6
3231(e)’’.
7
(e) EFFECTIVE DATE.—The amendments made by
8 this section shall apply to periods beginning after Decem-
9 ber 31, 2012.
10 Subtitle B—Credit for Small Busi-
11
ness Employee Health Coverage
12
Expenses
13 SEC. 421. CREDIT FOR SMALL BUSINESS EMPLOYEE
14
HEALTH COVERAGE EXPENSES.
15
(a) IN GENERAL.—Subpart D of part IV of sub-
16 chapter A of chapter 1 of the Internal Revenue Code of
17 1986 (relating to business-related credits) is amended by
18 adding at the end the following new section:
19 ‘‘SEC. 45R. SMALL BUSINESS EMPLOYEE HEALTH COV-
20
ERAGE CREDIT.
21
‘‘(a) IN GENERAL.—For purposes of section 38, in
22 the case of a qualified small employer, the small business
23 employee health coverage credit determined under this sec-
24 tion for the taxable year is an amount equal to the applica-
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189
1 ble percentage of the qualified employee health coverage
2 expenses of such employer for such taxable year.
3
‘‘(b) APPLICABLE PERCENTAGE.—
4
‘‘(1) IN GENERAL.—For purposes of this sec-
5
tion, the applicable percentage is 50 percent.
6
‘‘(2) PHASEOUT BASED ON AVERAGE COM-
7
PENSATION OF EMPLOYEES.—In the case of an em-
8
ployer whose average annual employee compensation
9
for the taxable year exceeds $20,000, the percentage
10
specified in paragraph (1) shall be reduced by a
11
number of percentage points which bears the same
12
ratio to 50 as such excess bears to $20,000.
13
‘‘(c) LIMITATIONS.—
14
‘‘(1) PHASEOUT BASED ON EMPLOYER SIZE.—
15
In the case of an employer who employs more than
16
10 qualified employees during the taxable year, the
17
credit determined under subsection (a) shall be re-
18
duced by an amount which bears the same ratio to
19
the amount of such credit (determined without re-
20
gard to this paragraph and after the application of
21
the other provisions of this section) as—
22
‘‘(A) the excess of—
23
‘‘(i) the number of qualified employees
24
employed by the employer during the tax-
25
able year, over
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190
1
‘‘(ii) 10, bears to
2
‘‘(B) 15.
3
‘‘(2) CREDIT NOT ALLOWED WITH RESPECT TO
4
CERTAIN HIGHLY COMPENSATED EMPLOYEES.—No
5
credit shall be allowed under subsection (a) with re-
6
spect to qualified employee health coverage expenses
7
paid or incurred with respect to any employee for
8
any taxable year if the aggregate compensation paid
9
by the employer to such employee during such tax-
10
able year exceeds $80,000.
11
‘‘(d) QUALIFIED EMPLOYEE HEALTH COVERAGE EX-
12 PENSES.—For purposes of this section—
13
‘‘(1) IN GENERAL.—The term ‘qualified em-
14
ployee health coverage expenses’ means, with respect
15
to any employer for any taxable year, the aggregate
16
amount paid or incurred by such employer during
17
such taxable year for coverage of any qualified em-
18
ployee of the employer (including any family cov-
19
erage which covers such employee) under qualified
20
health coverage.
21
‘‘(2) QUALIFIED
HEALTH
COVERAGE.—The
22
term ‘qualified health coverage’ means acceptable
23
coverage (as defined in section 59B(d)) which—
24
‘‘(A) is provided pursuant to an election
25
under section 4980H(a), and
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191
1
‘‘(B) satisfies the requirements referred to
2
in section 4980H(c).
3
‘‘(e) OTHER DEFINITIONS.—For purposes of this
4 section—
5
‘‘(1) QUALIFIED SMALL EMPLOYER.—For pur-
6
poses of this section, the term ‘qualified small em-
7
ployer’ means any employer for any taxable year
8
if—
9
‘‘(A) the number of qualified employees
10
employed by such employer during the taxable
11
year does not exceed 25, and
12
‘‘(B) the average annual employee com-
13
pensation of such employer for such taxable
14
year does not exceed the sum of the dollar
15
amounts in effect under subsection (b)(2).
16
‘‘(2) QUALIFIED EMPLOYEE.—The term ‘quali-
17
fied employee’ means any employee of an employer
18
for any taxable year of the employer if such em-
19
ployee received at least $5,000 of compensation from
20
such employer during such taxable year.
21
‘‘(3) AVERAGE ANNUAL EMPLOYEE COMPENSA-
22
TION.—The term ‘average annual employee com-
23
pensation’ means, with respect to any employer for
24
any taxable year, the average amount of compensa-
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192
1
tion paid by such employer to qualified employees of
2
such employer during such taxable year.
3
‘‘(4) COMPENSATION.—The term ‘compensa-
4
tion’ has the meaning given such term in section
5
408(p)(6)(A).
6
‘‘(5) FAMILY COVERAGE.—The term ‘family
7
coverage’ means any coverage other than self-only
8
coverage.
9
‘‘(f) SPECIAL RULES.—For purposes of this sec-
10 tion—
11
‘‘(1) SPECIAL RULE FOR PARTNERSHIPS AND
12
SELF-EMPLOYED.—In the case of a partnership (or
13
a trade or business carried on by an individual)
14
which has one or more qualified employees (deter-
15
mined without regard to this paragraph) with re-
16
spect to whom the election under 4980H(a) applies,
17
each partner (or, in the case of a trade or business
18
carried on by an individual, such individual) shall be
19
treated as an employee.
20
‘‘(2) AGGREGATION RULE.—All persons treated
21
as a single employer under subsection (b), (c), (m),
22
or (o) of section 414 shall be treated as 1 employer.
23
‘‘(3) DENIAL OF DOUBLE BENEFIT.—Any de-
24
duction otherwise allowable with respect to amounts
25
paid or incurred for health insurance coverage to
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193
1
which subsection (a) applies shall be reduced by the
2
amount of the credit determined under this section.
3
‘‘(4) INFLATION ADJUSTMENT.—In the case of
4
any taxable year beginning after 2013, each of the
5
dollar amounts in subsections (b)(2), (c)(2), and
6
(e)(2) shall be increased by an amount equal to—
7
‘‘(A) such dollar amount, multiplied by
8
‘‘(B) the cost of living adjustment deter-
9
mined under section 1(f)(3) for the calendar
10
year in which the taxable year begins deter-
11
mined by substituting ‘calendar year 2012’ for
12
‘calendar year 1992’ in subparagraph (B)
13
thereof.
14
If any increase determined under this paragraph is
15
not a multiple of $50, such increase shall be rounded
16
to the next lowest multiple of $50.’’.
17
(b) CREDIT TO BE PART OF GENERAL BUSINESS
18 CREDIT.—Subsection (b) of section 38 of such Code (re-
19 lating to general business credit) is amended by striking
20 ‘‘plus’’ at the end of paragraph (34), by striking the period
21 at the end of paragraph (35) and inserting ‘‘, plus’’ , and
22 by adding at the end the following new paragraph:
23
‘‘(36) in the case of a qualified small employer
24
(as defined in section 45R(e)), the small business
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194
1
employee health coverage credit determined under
2
section 45R(a).’’.
3
(c) CLERICAL AMENDMENT.—The table of sections
4 for subpart D of part IV of subchapter A of chapter 1
5 of such Code is amended by inserting after the item relat-
6 ing to section 45Q the following new item:
‘‘Sec. 45R. Small business employee health coverage credit.’’.
7
(d) EFFECTIVE DATE.—The amendments made by
8 this section shall apply to taxable years beginning after
9 December 31, 2012.
10 Subtitle C—Disclosures to Carry
11
Out Health Insurance Exchange
12
Subsidies
13 SEC. 431. DISCLOSURES TO CARRY OUT HEALTH INSUR-
14
ANCE EXCHANGE SUBSIDIES.
15
(a) IN GENERAL.—Subsection (l) of section 6103 of
16 the Internal Revenue Code of 1986 is amended by adding
17 at the end the following new paragraph:
18
‘‘(21) DISCLOSURE OF RETURN INFORMATION
19
TO CARRY OUT HEALTH INSURANCE EXCHANGE SUB-
20
SIDIES.—
21
‘‘(A) IN GENERAL.—The Secretary, upon
22
written request from the Health Choices Com-
23
missioner or the head of a State-based health
24
insurance exchange approved for operation
25
under section 208 of the America’s Affordable
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195
1
Health Choices Act of 2009, shall disclose to of-
2
ficers and employees of the Health Choices Ad-
3
ministration or such State-based health insur-
4
ance exchange, as the case may be, return in-
5
formation of any taxpayer whose income is rel-
6
evant in determining any affordability credit de-
7
scribed in subtitle C of title II of the America’s
8
Affordable Health Choices Act of 2009. Such
9
return information shall be limited to—
10
‘‘(i) taxpayer identity information
11
with respect to such taxpayer,
12
‘‘(ii) the filing status of such tax-
13
payer,
14
‘‘(iii) the modified adjusted gross in-
15
come of such taxpayer (as defined in sec-
16
tion 59B(e)(5)),
17
‘‘(iv) the number of dependents of the
18
taxpayer,
19
‘‘(v) such other information as is pre-
20
scribed by the Secretary by regulation as
21
might indicate whether the taxpayer is eli-
22
gible for such affordability credits (and the
23
amount thereof), and
24
‘‘(vi) the taxable year with respect to
25
which the preceding information relates or,
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196
1
if applicable, the fact that such informa-
2
tion is not available.
3
‘‘(B) RESTRICTION ON USE OF DISCLOSED
4
INFORMATION.—Return information disclosed
5
under subparagraph (A) may be used by offi-
6
cers and employees of the Health Choices Ad-
7
ministration or such State-based health insur-
8
ance exchange, as the case may be, only for the
9
purposes of, and to the extent necessary in, es-
10
tablishing and verifying the appropriate amount
11
of any affordability credit described in subtitle
12
C of title II of the America’s Affordable Health
13
Choices Act of 2009 and providing for the re-
14
payment of any such credit which was in excess
15
of such appropriate amount.’’.
16
(b) PROCEDURES AND RECORDKEEPING RELATED
17 TO DISCLOSURES.—Paragraph (4) of section 6103(p) of
18 such Code is amended—
19
(1) by inserting ‘‘, or any entity described in
20
subsection (l)(21),’’ after ‘‘or (20)’’ in the matter
21
preceding subparagraph (A),
22
(2) by inserting ‘‘or any entity described in sub-
23
section (l)(21),’’ after ‘‘or (o)(1)(A)’’ in subpara-
24
graph (F)(ii), and
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197
1
(3) by inserting ‘‘or any entity described in sub-
2
section (l)(21),’’ after ‘‘or (20)’’ both places it ap-
3
pears in the matter after subparagraph (F).
4
(c) UNAUTHORIZED DISCLOSURE OR INSPECTION.—
5 Paragraph (2) of section 7213(a) of such Code is amended
6 by striking ‘‘or (20)’’ and inserting ‘‘(20), or (21)’’.
7
Subtitle D—Other Revenue
8
Provisions
9
PART 1—GENERAL PROVISIONS
10 SEC. 441. SURCHARGE ON HIGH INCOME INDIVIDUALS.
11
(a) IN GENERAL.—Part VIII of subchapter A of
12 chapter 1 of the Internal Revenue Code of 1986, as added
13 by this title, is amended by adding at the end the following
14 new subpart:
15
‘‘Subpart B—Surcharge on High Income Individuals
‘‘Sec. 59C. Surcharge on high income individuals.
16 ‘‘SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.
17
‘‘(a) GENERAL RULE.—In the case of a taxpayer
18 other than a corporation, there is hereby imposed (in addi-
19 tion to any other tax imposed by this subtitle) a tax equal
20 to—
21
‘‘(1) 1 percent of so much of the modified ad-
22
justed gross income of the taxpayer as exceeds
23
$350,000 but does not exceed $500,000,
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198
1
‘‘(2) 1.5 percent of so much of the modified ad-
2
justed gross income of the taxpayer as exceeds
3
$500,000 but does not exceed $1,000,000, and
4
‘‘(3) 5.4 percent of so much of the modified ad-
5
justed gross income of the taxpayer as exceeds
6
$1,000,000.
7
‘‘(b) TAXPAYERS NOT MAKING A JOINT RETURN.—
8 In the case of any taxpayer other than a taxpayer making
9 a joint return under section 6013 or a surviving spouse
10 (as defined in section 2(a)), subsection (a) shall be applied
11 by substituting for each of the dollar amounts therein
12 (after any increase determined under subsection (e)) a dol-
13 lar amount equal to—
14
‘‘(1) 50 percent of the dollar amount so in ef-
15
fect in the case of a married individual filing a sepa-
16
rate return, and
17
‘‘(2) 80 percent of the dollar amount so in ef-
18
fect in any other case.
19
‘‘(c) ADJUSTMENTS BASED ON FEDERAL HEALTH
20 REFORM SAVINGS.—
21
‘‘(1) IN GENERAL.—Except as provided in para-
22
graph (2), in the case of any taxable year beginning
23
after December 31, 2012, subsection (a) shall be ap-
24
plied—
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199
1
‘‘(A) by substituting ‘2 percent’ for ‘1 per-
2
cent’, and
3
‘‘(B) by substituting ‘3 percent’ for ‘1.5
4
percent’.
5
‘‘(2) ADJUSTMENTS BASED ON EXCESS FED-
6
ERAL HEALTH REFORM SAVINGS.—
7
‘‘(A) EXCEPTION IF FEDERAL HEALTH RE-
8
FORM SAVINGS SIGNIFICANTLY EXCEEDS BASE
9
AMOUNT.—If the excess Federal health reform
10
savings is more than $150,000,000,000 but not
11
more than $175,000,000,000, paragraph (1)
12
shall not apply.
13
‘‘(B) FURTHER ADJUSTMENT FOR ADDI-
14
TIONAL FEDERAL HEALTH REFORM SAVINGS.—
15
If the excess Federal health reform savings is
16
more than $175,000,000,000, paragraphs (1)
17
and (2) of subsection (a) (and paragraph (1) of
18
this subsection) shall not apply to any taxable
19
year beginning after December 31, 2012.
20
‘‘(C) EXCESS FEDERAL HEALTH REFORM
21
SAVINGS.—For purposes of this subsection, the
22
term ‘excess Federal health reform savings’
23
means the excess of—
24
‘‘(i) the Federal health reform sav-
25
ings, over
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1
‘‘(ii) $525,000,000,000.
2
‘‘(D) FEDERAL HEALTH REFORM SAV-
3
INGS.—The term ‘Federal health reform sav-
4
ings’ means the sum of the amounts described
5
in subparagraphs (A) and (B) of paragraph (3).
6
‘‘(3) DETERMINATION OF FEDERAL HEALTH
7
REFORM
SAVINGS.—Not later than December 1,
8
2012, the Director of the Office of Management and
9
Budget shall—
10
‘‘(A) determine, on the basis of the study
11
conducted under paragraph (4), the aggregate
12
reductions in Federal expenditures which have
13
been achieved as a result of the provisions of,
14
and amendments made by, division B of the
15
America’s Affordable Health Choices Act of
16
2009 during the period beginning on October 1,
17
2009, and ending with the latest date with re-
18
spect to which the Director has sufficient data
19
to make such determination, and
20
‘‘(B) estimate, on the basis of such study
21
and the determination under subparagraph (A),
22
the aggregate reductions in Federal expendi-
23
tures which will be achieved as a result of such
24
provisions and amendments during so much of
25
the period beginning with fiscal year 2010 and
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1
ending with fiscal year 2019 as is not taken
2
into account under subparagraph (A).
3
‘‘(4) STUDY OF FEDERAL HEALTH REFORM
4
SAVINGS.—The Director of the Office of Manage-
5
ment and Budget shall conduct a study of the reduc-
6
tions in Federal expenditures during fiscal years
7
2010 through 2019 which are attributable to the
8
provisions of, and amendments made by, division B
9
of the America’s Affordable Health Choices Act of
10
2009. The Director shall complete such study not
11
later than December 1, 2012.
12
‘‘(5) REDUCTIONS IN FEDERAL EXPENDITURES
13
DETERMINED WITHOUT REGARD TO PROGRAM IN-
14
VESTMENTS.—For purposes of paragraphs (3) and
15
(4), reductions in Federal expenditures shall be de-
16
termined without regard to section 1121 of the
17
America’s Affordable Health Choices Act of 2009
18
and other program investments under division B
19
thereof.
20
‘‘(d) MODIFIED ADJUSTED GROSS INCOME.—For
21 purposes of this section, the term ‘modified adjusted gross
22 income’ means adjusted gross income reduced by any de-
23 duction allowed for investment interest (as defined in sec-
24 tion 163(d)). In the case of an estate or trust, adjusted
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202
1 gross income shall be determined as provided in section
2 67(e).
3
‘‘(e) INFLATION ADJUSTMENTS.—
4
‘‘(1) IN GENERAL.—In the case of taxable years
5
beginning after 2011, the dollar amounts in sub-
6
section (a) shall be increased by an amount equal
7
to—
8
‘‘(A) such dollar amount, multiplied by
9
‘‘(B) the cost-of-living adjustment deter-
10
mined under section 1(f)(3) for the calendar
11
year in which the taxable year begins, by sub-
12
stituting ‘calendar year 2010’ for ‘calendar year
13
1992’ in subparagraph (B) thereof.
14
‘‘(2) ROUNDING.—If any amount as adjusted
15
under paragraph (1) is not a multiple of $5,000,
16
such amount shall be rounded to the next lowest
17
multiple of $5,000.
18
‘‘(f) SPECIAL RULES.—
19
‘‘(1) NONRESIDENT ALIEN.—In the case of a
20
nonresident alien individual, only amounts taken
21
into account in connection with the tax imposed
22
under section 871(b) shall be taken into account
23
under this section.
24
‘‘(2) CITIZENS
AND
RESIDENTS
LIVING
25
ABROAD.—The dollar amounts in effect under sub-
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203
1
section (a) (after the application of subsections (b)
2
and (e)) shall be decreased by the excess of—
3
‘‘(A) the amounts excluded from the tax-
4
payer’s gross income under section 911, over
5
‘‘(B) the amounts of any deductions or ex-
6
clusions disallowed under section 911(d)(6)
7
with respect to the amounts described in sub-
8
paragraph (A).
9
‘‘(3) CHARITABLE
TRUSTS.—Subsection (a)
10
shall not apply to a trust all the unexpired interests
11
in which are devoted to one or more of the purposes
12
described in section 170(c)(2)(B).
13
‘‘(4) NOT TREATED AS TAX IMPOSED BY THIS
14
CHAPTER FOR CERTAIN PURPOSES.—The tax im-
15
posed under this section shall not be treated as tax
16
imposed by this chapter for purposes of determining
17
the amount of any credit under this chapter or for
18
purposes of section 55.’’.
19
(b) CLERICAL AMENDMENT.—The table of subparts
20 for part VIII of subchapter A of chapter 1 of such Code,
21 as added by this title, is amended by inserting after the
22 item relating to subpart A the following new item:
‘‘SUBPART B. SURCHARGE ON HIGH INCOME INDIVIDUALS.’’.
23
(c) SECTION 15 NOT TO APPLY.—The amendment
24 made by subsection (a) shall not be treated as a change
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204
1 in a rate of tax for purposes of section 15 of the Internal
2 Revenue Code of 1986.
3
(d) EFFECTIVE DATE.—The amendments made by
4 this section shall apply to taxable years beginning after
5 December 31, 2010.
6 SEC. 442. DELAY IN APPLICATION OF WORLDWIDE ALLOCA-
7
TION OF INTEREST.
8
(a) IN GENERAL.—Paragraphs (5)(D) and (6) of sec-
9 tion 864(f) of the Internal Revenue Code of 1986 are each
10 amended by striking ‘‘December 31, 2010’’ and inserting
11 ‘‘December 31, 2019’’.
12
(b) TRANSITION.—Subsection (f) of section 864 of
13 such Code is amended by striking paragraph (7).
14
PART 2—PREVENTION OF TAX AVOIDANCE
15 SEC. 451. LIMITATION ON TREATY BENEFITS FOR CERTAIN
16
DEDUCTIBLE PAYMENTS.
17
(a) IN GENERAL.—Section 894 of the Internal Rev-
18 enue Code of 1986 (relating to income affected by treaty)
19 is amended by adding at the end the following new sub-
20 section:
21
‘‘(d) LIMITATION ON TREATY BENEFITS FOR CER-
22 TAIN DEDUCTIBLE PAYMENTS.—
23
‘‘(1) IN GENERAL.—In the case of any deduct-
24
ible related-party payment, any withholding tax im-
25
posed under chapter 3 (and any tax imposed under
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205
1
subpart A or B of this part) with respect to such
2
payment may not be reduced under any treaty of the
3
United States unless any such withholding tax would
4
be reduced under a treaty of the United States if
5
such payment were made directly to the foreign par-
6
ent corporation.
7
‘‘(2) DEDUCTIBLE
RELATED-PARTY
PAY-
8
MENT.—For purposes of this subsection, the term
9
‘deductible related-party payment’ means any pay-
10
ment made, directly or indirectly, by any person to
11
any other person if the payment is allowable as a de-
12
duction under this chapter and both persons are
13
members of the same foreign controlled group of en-
14
tities.
15
‘‘(3) FOREIGN CONTROLLED GROUP OF ENTI-
16
TIES.—For purposes of this subsection—
17
‘‘(A) IN GENERAL.—The term ‘foreign
18
controlled group of entities’ means a controlled
19
group of entities the common parent of which
20
is a foreign corporation.
21
‘‘(B) CONTROLLED GROUP OF ENTITIES.—
22
The term ‘controlled group of entities’ means a
23
controlled group of corporations as defined in
24
section 1563(a)(1), except that—
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206
1
‘‘(i) ‘more than 50 percent’ shall be
2
substituted for ‘at least 80 percent’ each
3
place it appears therein, and
4
‘‘(ii) the determination shall be made
5
without regard to subsections (a)(4) and
6
(b)(2) of section 1563.
7
A partnership or any other entity (other than a
8
corporation) shall be treated as a member of a
9
controlled group of entities if such entity is con-
10
trolled (within the meaning of section
11
954(d)(3)) by members of such group (includ-
12
ing any entity treated as a member of such
13
group by reason of this sentence).
14
‘‘(4) FOREIGN
PARENT
CORPORATION.—For
15
purposes of this subsection, the term ‘foreign parent
16
corporation’ means, with respect to any deductible
17
related-party payment, the common parent of the
18
foreign controlled group of entities referred to in
19
paragraph (3)(A).
20
‘‘(5) REGULATIONS.—The Secretary may pre-
21
scribe such regulations or other guidance as are nec-
22
essary or appropriate to carry out the purposes of
23
this subsection, including regulations or other guid-
24
ance which provide for—
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207
1
‘‘(A) the treatment of two or more persons
2
as members of a foreign controlled group of en-
3
tities if such persons would be the common par-
4
ent of such group if treated as one corporation,
5
and
6
‘‘(B) the treatment of any member of a
7
foreign controlled group of entities as the com-
8
mon parent of such group if such treatment is
9
appropriate taking into account the economic
10
relationships among such entities.’’.
11
(b) EFFECTIVE DATE.—The amendment made by
12 this section shall apply to payments made after the date
13 of the enactment of this Act.
14 SEC. 452. CODIFICATION OF ECONOMIC SUBSTANCE DOC-
15
TRINE.
16
(a) IN GENERAL.—Section 7701 of the Internal Rev-
17 enue Code of 1986 is amended by redesignating subsection
18 (o) as subsection (p) and by inserting after subsection (n)
19 the following new subsection:
20
‘‘(o) CLARIFICATION OF ECONOMIC SUBSTANCE
21 DOCTRINE.—
22
‘‘(1) APPLICATION OF DOCTRINE.—In the case
23
of any transaction to which the economic substance
24
doctrine is relevant, such transaction shall be treated
25
as having economic substance only if—
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208
1
‘‘(A) the transaction changes in a mean-
2
ingful way (apart from Federal income tax ef-
3
fects) the taxpayer’s economic position, and
4
‘‘(B) the taxpayer has a substantial pur-
5
pose (apart from Federal income tax effects)
6
for entering into such transaction.
7
‘‘(2) SPECIAL RULE WHERE TAXPAYER RELIES
8
ON PROFIT POTENTIAL.—
9
‘‘(A) IN
GENERAL.—The potential for
10
profit of a transaction shall be taken into ac-
11
count in determining whether the requirements
12
of subparagraphs (A) and (B) of paragraph (1)
13
are met with respect to the transaction only if
14
the present value of the reasonably expected
15
pre-tax profit from the transaction is substan-
16
tial in relation to the present value of the ex-
17
pected net tax benefits that would be allowed if
18
the transaction were respected.
19
‘‘(B) TREATMENT OF FEES AND FOREIGN
20
TAXES.—Fees and other transaction expenses
21
and foreign taxes shall be taken into account as
22
expenses in determining pre-tax profit under
23
subparagraph (A).
24
‘‘(3) STATE AND LOCAL TAX BENEFITS.—For
25
purposes of paragraph (1), any State or local income
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209
1
tax effect which is related to a Federal income tax
2
effect shall be treated in the same manner as a Fed-
3
eral income tax effect.
4
‘‘(4) FINANCIAL ACCOUNTING BENEFITS.—For
5
purposes of paragraph (1)(B), achieving a financial
6
accounting benefit shall not be taken into account as
7
a purpose for entering into a transaction if the ori-
8
gin of such financial accounting benefit is a reduc-
9
tion of Federal income tax.
10
‘‘(5) DEFINITIONS AND SPECIAL RULES.—For
11
purposes of this subsection—
12
‘‘(A) ECONOMIC SUBSTANCE DOCTRINE.—
13
The term ‘economic substance doctrine’ means
14
the common law doctrine under which tax bene-
15
fits under subtitle A with respect to a trans-
16
action are not allowable if the transaction does
17
not have economic substance or lacks a business
18
purpose.
19
‘‘(B) EXCEPTION FOR PERSONAL TRANS-
20
ACTIONS OF INDIVIDUALS.—In the case of an
21
individual, paragraph (1) shall apply only to
22
transactions entered into in connection with a
23
trade or business or an activity engaged in for
24
the production of income.
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210
1
‘‘(C) OTHER COMMON LAW DOCTRINES
2
NOT
AFFECTED.—Except as specifically pro-
3
vided in this subsection, the provisions of this
4
subsection shall not be construed as altering or
5
supplanting any other rule of law, and the re-
6
quirements of this subsection shall be construed
7
as being in addition to any such other rule of
8
law.
9
‘‘(D) DETERMINATION OF APPLICATION OF
10
DOCTRINE NOT AFFECTED.—The determination
11
of whether the economic substance doctrine is
12
relevant to a transaction (or series of trans-
13
actions) shall be made in the same manner as
14
if this subsection had never been enacted.
15
‘‘(6) REGULATIONS.—The Secretary shall pre-
16
scribe such regulations as may be necessary or ap-
17
propriate to carry out the purposes of this sub-
18
section.’’.
19
(b) EFFECTIVE DATE.—The amendments made by
20 this section shall apply to transactions entered into after
21 the date of the enactment of this Act.
22 SEC. 453. PENALTIES FOR UNDERPAYMENTS.
23
(a) PENALTY FOR UNDERPAYMENTS ATTRIBUTABLE
24 TO TRANSACTIONS LACKING ECONOMIC SUBSTANCE.—
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211
1
(1) IN GENERAL.—Subsection (b) of section
2
6662 of the Internal Revenue Code of 1986 is
3
amended by inserting after paragraph (5) the fol-
4
lowing new paragraph:
5
‘‘(6) Any disallowance of claimed tax benefits
6
by reason of a transaction lacking economic sub-
7
stance (within the meaning of section 7701(o)) or
8
failing to meet the requirements of any similar rule
9
of law.’’.
10
(2) INCREASED PENALTY FOR NONDISCLOSED
11
TRANSACTIONS.—Section 6662 of such Code is
12
amended by adding at the end the following new
13
subsection:
14
‘‘(i) INCREASE IN PENALTY IN CASE OF NONDIS-
15 CLOSED NONECONOMIC SUBSTANCE TRANSACTIONS.—
16
‘‘(1) IN GENERAL.—In the case of any portion
17
of an underpayment which is attributable to one or
18
more nondisclosed noneconomic substance trans-
19
actions, subsection (a) shall be applied with respect
20
to such portion by substituting ‘40 percent’ for ‘20
21
percent’.
22
‘‘(2) NONDISCLOSED
NONECONOMIC
SUB-
23
STANCE TRANSACTIONS.—For purposes of this sub-
24
section, the term ‘nondisclosed noneconomic sub-
25
stance transaction’ means any portion of a trans-
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212
1
action described in subsection (b)(6) with respect to
2
which the relevant facts affecting the tax treatment
3
are not adequately disclosed in the return nor in a
4
statement attached to the return.
5
‘‘(3) SPECIAL
RULE
FOR
AMENDED
RE-
6
TURNS.—Except as provided in regulations, in no
7
event shall any amendment or supplement to a re-
8
turn of tax be taken into account for purposes of
9
this subsection if the amendment or supplement is
10
filed after the earlier of the date the taxpayer is first
11
contacted by the Secretary regarding the examina-
12
tion of the return or such other date as is specified
13
by the Secretary.’’.
14
(3) CONFORMING AMENDMENT.—Subparagraph
15
(B) of section 6662A(e)(2) of such Code is amend-
16
ed—
17
(A) by striking ‘‘section 6662(h)’’ and in-
18
serting ‘‘subsections (h) or (i) of section 6662’’,
19
and
20
(B) by striking ‘‘GROSS
VALUATION
21
MISSTATEMENT PENALTY’’ in the heading and
22
inserting ‘‘CERTAIN
INCREASED
UNDER-
23
PAYMENT PENALTIES’’.
24
(b) REASONABLE CAUSE EXCEPTION NOT APPLICA-
25 BLE TO NONECONOMIC SUBSTANCE TRANSACTIONS, TAX
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213
1 SHELTERS, AND CERTAIN LARGE OR PUBLICLY TRADED
2 PERSONS.—Subsection (c) of section 6664 of such Code
3 is amended—
4
(1) by redesignating paragraphs (2) and (3) as
5
paragraphs (3) and (4), respectively,
6
(2) by striking ‘‘paragraph (2)’’ in paragraph
7
(4), as so redesignated, and inserting ‘‘paragraph
8
(3)’’, and
9
(3) by inserting after paragraph (1) the fol-
10
lowing new paragraph:
11
‘‘(2) EXCEPTION.—Paragraph (1) shall not
12
apply to—
13
‘‘(A) to any portion of an underpayment
14
which is attributable to one or more tax shelters
15
(as defined in section 6662(d)(2)(C)) or trans-
16
actions described in section 6662(b)(6), and
17
‘‘(B) to any taxpayer if such taxpayer is a
18
specified person (as defined in section
19
6662(d)(2)(D)(ii)).’’.
20
(c) APPLICATION OF PENALTY FOR ERRONEOUS
21 CLAIM FOR REFUND OR CREDIT TO NONECONOMIC SUB-
22 STANCE TRANSACTIONS.—Section 6676 of such Code is
23 amended by redesignating subsection (c) as subsection (d)
24 and inserting after subsection (b) the following new sub-
25 section:
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214
1
‘‘(c) NONECONOMIC
SUBSTANCE
TRANSACTIONS
2 TREATED AS LACKING REASONABLE BASIS.—For pur-
3 poses of this section, any excessive amount which is attrib-
4 utable to any transaction described in section 6662(b)(6)
5 shall not be treated as having a reasonable basis.’’.
6
(d) SPECIAL UNDERSTATEMENT REDUCTION RULE
7 FOR CERTAIN LARGE OR PUBLICLY TRADED PERSONS.—
8
(1) IN GENERAL.—Paragraph (2) of section
9
6662(d) of such Code is amended by adding at the
10
end the following new subparagraph:
11
‘‘(D) SPECIAL REDUCTION RULE FOR CER-
12
TAIN LARGE OR PUBLICLY TRADED PERSONS.—
13
‘‘(i) IN GENERAL.—In the case of any
14
specified person—
15
‘‘(I) subparagraph (B) shall not
16
apply, and
17
‘‘(II) the amount of the under-
18
statement under subparagraph (A)
19
shall be reduced by that portion of the
20
understatement which is attributable
21
to any item with respect to which the
22
taxpayer has a reasonable belief that
23
the tax treatment of such item by the
24
taxpayer is more likely than not the
25
proper tax treatment of such item.
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215
1
‘‘(ii) SPECIFIED PERSON.—For pur-
2
poses of this subparagraph, the term ‘spec-
3
ified person’ means—
4
‘‘(I) any person required to file
5
periodic or other reports under section
6
13 of the Securities Exchange Act of
7
1934, and
8
‘‘(II) any corporation with gross
9
receipts in excess of $100,000,000 for
10
the taxable year involved.
11
All persons treated as a single employer
12
under section 52(a) shall be treated as one
13
person for purposes of subclause (II).’’.
14
(2) CONFORMING AMENDMENT.—Subparagraph
15
(C) of section 6662(d)(2) of such Code is amended
16
by striking ‘‘Subparagraph (B)’’ and inserting ‘‘Sub-
17
paragraphs (B) and (D)(i)(II)’’.
18
(e) EFFECTIVE DATE.—The amendments made by
19 this section shall apply to transactions entered into after
20 the date of the enactment of this Act.
21
DIVISION B—MEDICARE AND
22
MEDICAID IMPROVEMENTS
23 SEC. 1001. TABLE OF CONTENTS OF DIVISION.
24
The table of contents for this division is as follows:
DIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS
Sec. 1001. Table of contents of division.
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216
TITLE I—IMPROVING HEALTH CARE VALUE
Subtitle A—Provisions Related to Medicare Part A
PART 1—MARKET BASKET UPDATES
Sec. 1101. Skilled nursing facility payment update.
Sec. 1102. Inpatient rehabilitation facility payment update.
Sec. 1103. Incorporating productivity improvements into market basket updates
that do not already incorporate such improvements.
PART 2—OTHER MEDICARE PART A PROVISIONS
Sec. 1111. Payments to skilled nursing facilities.
Sec. 1112. Medicare DSH report and payment adjustments in response to cov-
erage expansion.
Subtitle B—Provisions Related to Part B
PART 1—PHYSICIANS’ SERVICES
Sec. 1121. Sustainable growth rate reform.
Sec. 1122. Misvalued codes under the physician fee schedule.
Sec. 1123. Payments for efficient areas.
Sec. 1124. Modifications to the Physician Quality Reporting Initiative (PQRI).
Sec. 1125. Adjustment to Medicare payment localities.
PART 2—MARKET BASKET UPDATES
Sec. 1131. Incorporating productivity improvements into market basket updates
that do not already incorporate such improvements.
PART 3—OTHER PROVISIONS
Sec. 1141. Rental and purchase of power-driven wheelchairs.
Sec. 1142. Extension of payment rule for brachytherapy.
Sec. 1143. Home infusion therapy report to congress.
Sec. 1144. Require ambulatory surgical centers (ASCs) to submit cost data and
other data.
Sec. 1145. Treatment of certain cancer hospitals.
Sec. 1146. Medicare Improvement Fund.
Sec. 1147. Payment for imaging services.
Sec. 1148. Durable medical equipment program improvements.
Sec. 1149. MedPAC study and report on bone mass measurement.
Subtitle C—Provisions Related to Medicare Parts A and B
Sec. 1151. Reducing potentially preventable hospital readmissions.
Sec. 1152. Post acute care services payment reform plan and bundling pilot
program.
Sec. 1153. Home health payment update for 2010.
Sec. 1154. Payment adjustments for home health care.
Sec. 1155. Incorporating productivity improvements into market basket update
for home health services.
Sec. 1156. Limitation on Medicare exceptions to the prohibition on certain phy-
sician referrals made to hospitals.
Sec. 1157. Institute of Medicine study of geographic adjustment factors under
Medicare.
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217
Sec. 1158. Revision of Medicare payment systems to address geographic inequi-
ties.
Subtitle D—Medicare Advantage Reforms
PART 1—PAYMENT AND ADMINISTRATION
Sec. 1161. Phase-in of payment based on fee-for-service costs.
Sec. 1162. Quality bonus payments.
Sec. 1163. Extension of Secretarial coding intensity adjustment authority.
Sec. 1164. Simplification of annual beneficiary election periods.
Sec. 1165. Extension of reasonable cost contracts.
Sec. 1166. Limitation of waiver authority for employer group plans.
Sec. 1167. Improving risk adjustment for payments.
Sec. 1168. Elimination of MA Regional Plan Stabilization Fund.
PART 2—BENEFICIARY PROTECTIONS AND ANTI-FRAUD
Sec. 1171. Limitation on cost-sharing for individual health services.
Sec. 1172. Continuous open enrollment for enrollees in plans with enrollment
suspension.
Sec. 1173. Information for beneficiaries on MA plan administrative costs.
Sec. 1174. Strengthening audit authority.
Sec. 1175. Authority to deny plan bids.
PART 3—TREATMENT OF SPECIAL NEEDS PLANS
Sec. 1176. Limitation on enrollment outside open enrollment period of individ-
uals into chronic care specialized MA plans for special needs
individuals.
Sec. 1177. Extension of authority of special needs plans to restrict enrollment.
Subtitle E—Improvements to Medicare Part D
Sec. 1181. Elimination of coverage gap.
Sec. 1182. Discounts for certain part D drugs in original coverage gap.
Sec. 1183. Repeal of provision relating to submission of claims by pharmacies
located in or contracting with long-term care facilities.
Sec. 1184. Including costs incurred by AIDS drug assistance programs and In-
dian Health Service in providing prescription drugs toward the
annual out-of-pocket threshold under part D.
Sec. 1185. Permitting mid-year changes in enrollment for formulary changes
that adversely impact an enrollee.
Subtitle F—Medicare Rural Access Protections
Sec. 1191. Telehealth expansion and enhancements.
Sec. 1192. Extension of outpatient hold harmless provision.
Sec. 1193. Extension of section 508 hospital reclassifications.
Sec. 1194. Extension of geographic floor for work.
Sec. 1195. Extension of payment for technical component of certain physician
pathology services.
Sec. 1196. Extension of ambulance add-ons.
TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS
Subtitle A—Improving and Simplifying Financial Assistance for Low Income
Medicare Beneficiaries
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218
Sec. 1201. Improving assets tests for Medicare Savings Program and low-in-
come subsidy program.
Sec. 1202. Elimination of part D cost-sharing for certain non-institutionalized
full-benefit dual eligible individuals.
Sec. 1203. Eliminating barriers to enrollment.
Sec. 1204. Enhanced oversight relating to reimbursements for retroactive low
income subsidy enrollment.
Sec. 1205. Intelligent assignment in enrollment.
Sec. 1206. Special enrollment period and automatic enrollment process for cer-
tain subsidy eligible individuals.
Sec. 1207. Application of MA premiums prior to rebate in calculation of low
income subsidy benchmark.
Subtitle B—Reducing Health Disparities
Sec. 1221. Ensuring effective communication in Medicare.
Sec. 1222. Demonstration to promote access for Medicare beneficiaries with
limited English proficiency by providing reimbursement for cul-
turally and linguistically appropriate services.
Sec. 1223. IOM report on impact of language access services.
Sec. 1224. Definitions.
Subtitle C—Miscellaneous Improvements
Sec. 1231. Extension of therapy caps exceptions process.
Sec. 1232. Extended months of coverage of immunosuppressive drugs for kid-
ney transplant patients and other renal dialysis provisions.
Sec. 1233. Advance care planning consultation.
Sec. 1234. Part B special enrollment period and waiver of limited enrollment
penalty for TRICARE beneficiaries.
Sec. 1235. Exception for use of more recent tax year in case of gains from sale
of primary residence in computing part B income-related pre-
mium.
Sec. 1236. Demonstration program on use of patient decisions aids.
TITLE III—PROMOTING PRIMARY CARE, MENTAL HEALTH
SERVICES, AND COORDINATED CARE
Sec. 1301. Accountable Care Organization pilot program.
Sec. 1302. Medical home pilot program.
Sec. 1303. Payment incentive for selected primary care services.
Sec. 1304. Increased reimbursement rate for certified nurse-midwives.
Sec. 1305. Coverage and waiver of cost-sharing for preventive services.
Sec. 1306. Waiver of deductible for colorectal cancer screening tests regardless
of coding, subsequent diagnosis, or ancillary tissue removal.
Sec. 1307. Excluding clinical social worker services from coverage under the
medicare skilled nursing facility prospective payment system
and consolidated payment.
Sec. 1308. Coverage of marriage and family therapist services and mental
health counselor services.
Sec. 1309. Extension of physician fee schedule mental health add-on.
Sec. 1310. Expanding access to vaccines.
TITLE IV—QUALITY
Subtitle A—Comparative Effectiveness Research
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219
Sec. 1401. Comparative effectiveness research.
Subtitle B—Nursing Home Transparency
PART 1—IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED
NURSING FACILITIES AND NURSING FACILITIES
Sec. 1411. Required disclosure of ownership and additional disclosable parties
information.
Sec. 1412. Accountability requirements.
Sec. 1413. Nursing home compare Medicare website.
Sec. 1414. Reporting of expenditures.
Sec. 1415. Standardized complaint form.
Sec. 1416. Ensuring staffing accountability.
PART 2—TARGETING ENFORCEMENT
Sec. 1421. Civil money penalties.
Sec. 1422. National independent monitor pilot program.
Sec. 1423. Notification of facility closure.
PART 3—IMPROVING STAFF TRAINING
Sec. 1431. Dementia and abuse prevention training.
Sec. 1432. Study and report on training required for certified nurse aides and
supervisory staff.
Subtitle C—Quality Measurements
Sec. 1441. Establishment of national priorities for quality improvement.
Sec. 1442. Development of new quality measures; GAO evaluation of data col-
lection process for quality measurement.
Sec. 1443. Multi-stakeholder pre-rulemaking input into selection of quality
measures.
Sec. 1444. Application of quality measures.
Sec. 1445. Consensus-based entity funding.
Subtitle D—Physician Payments Sunshine Provision
Sec. 1451. Reports on financial relationships between manufacturers and dis-
tributors of covered drugs, devices, biologicals, or medical sup-
plies under Medicare, Medicaid, or CHIP and physicians and
other health care entities and between physicians and other
health care entities.
Subtitle E—Public Reporting on Health Care-Associated Infections
Sec. 1461. Requirement for public reporting by hospitals and ambulatory sur-
gical centers on health care-associated infections.
TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION
Sec. 1501. Distribution of unused residency positions.
Sec. 1502. Increasing training in nonprovider settings.
Sec. 1503. Rules for counting resident time for didactic and scholarly activities
and other activities.
Sec. 1504. Preservation of resident cap positions from closed hospitals.
Sec. 1505. Improving accountability for approved medical residency training.
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220
TITLE VI—PROGRAM INTEGRITY
Subtitle A—Increased Funding to Fight Waste, Fraud, and Abuse
Sec. 1601. Increased funding and flexibility to fight fraud and abuse.
Subtitle B—Enhanced Penalties for Fraud and Abuse
Sec. 1611. Enhanced penalties for false statements on provider or supplier en-
rollment applications.
Sec. 1612. Enhanced penalties for submission of false statements material to
a false claim.
Sec. 1613. Enhanced penalties for delaying inspections.
Sec. 1614. Enhanced hospice program safeguards.
Sec. 1615. Enhanced penalties for individuals excluded from program participa-
tion.
Sec. 1616. Enhanced penalties for provision of false information by Medicare
Advantage and part D plans.
Sec. 1617. Enhanced penalties for Medicare Advantage and part D marketing
violations.
Sec. 1618. Enhanced penalties for obstruction of program audits.
Sec. 1619. Exclusion of certain individuals and entities from participation in
Medicare and State health care programs.
Subtitle C—Enhanced Program and Provider Protections
Sec. 1631. Enhanced CMS program protection authority.
Sec. 1632. Enhanced Medicare, Medicaid, and CHIP program disclosure re-
quirements relating to previous affiliations.
Sec. 1633. Required inclusion of payment modifier for certain evaluation and
management services.
Sec. 1634. Evaluations and reports required under Medicare Integrity Pro-
gram.
Sec. 1635. Require providers and suppliers to adopt programs to reduce waste,
fraud, and abuse.
Sec. 1636. Maximum period for submission of Medicare claims reduced to not
more than 12 months.
Sec. 1637. Physicians who order durable medical equipment or home health
services required to be Medicare enrolled physicians or eligible
professionals.
Sec. 1638. Requirement for physicians to provide documentation on referrals to
programs at high risk of waste and abuse.
Sec. 1639. Face to face encounter with patient required before physicians may
certify eligibility for home health services or durable medical
equipment under Medicare.
Sec. 1640. Extension of testimonial subpoena authority to program exclusion
investigations.
Sec. 1641. Required repayments of Medicare and Medicaid overpayments.
Sec. 1642. Expanded application of hardship waivers for OIG exclusions to
beneficiaries of any Federal health care program.
Sec. 1643. Access to certain information on renal dialysis facilities.
Sec. 1644. Billing agents, clearinghouses, or other alternate payees required to
register under Medicare.
Sec. 1645. Conforming civil monetary penalties to False Claims Act amend-
ments.
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221
Subtitle D—Access to Information Needed to Prevent Fraud, Waste, and
Abuse
Sec. 1651. Access to Information Necessary to Identify Fraud, Waste, and
Abuse.
Sec. 1652. Elimination of duplication between the Healthcare Integrity and
Protection Data Bank and the National Practitioner Data
Bank.
Sec. 1653. Compliance with HIPAA privacy and security standards.
TITLE VII—MEDICAID AND CHIP
Subtitle A—Medicaid and Health Reform
Sec. 1701. Eligibility for individuals with income below 133-1⁄3 percent of the
Federal poverty level.
Sec. 1702. Requirements and special rules for certain Medicaid eligible individ-
uals.
Sec. 1703. CHIP and Medicaid maintenance of effort.
Sec. 1704. Reduction in Medicaid DSH.
Sec. 1705. Expanded outstationing.
Subtitle B—Prevention
Sec. 1711. Required coverage of preventive services.
Sec. 1712. Tobacco cessation.
Sec. 1713. Optional coverage of nurse home visitation services.
Sec. 1714. State eligibility option for family planning services.
Subtitle C—Access
Sec. 1721. Payments to primary care practitioners.
Sec. 1722. Medical home pilot program.
Sec. 1723. Translation or interpretation services.
Sec. 1724. Optional coverage for freestanding birth center services.
Sec. 1725. Inclusion of public health clinics under the vaccines for children pro-
gram.
Subtitle D—Coverage
Sec. 1731. Optional medicaid coverage of low-income HIV-infected individuals.
Sec. 1732. Extending transitional Medicaid Assistance (TMA).
Sec. 1733. Requirement of 12-month continuous coverage under certain CHIP
programs.
Subtitle E—Financing
Sec. 1741. Payments to pharmacists.
Sec. 1742. Prescription drug rebates.
Sec. 1743. Extension of prescription drug discounts to enrollees of medicaid
managed care organizations.
Sec. 1744. Payments for graduate medical education.
Subtitle F—Waste, Fraud, and Abuse
Sec. 1751. Health-care acquired conditions.
Sec. 1752. Evaluations and reports required under Medicaid Integrity Program.
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222
Sec. 1753. Require providers and suppliers to adopt programs to reduce waste,
fraud, and abuse.
Sec. 1754. Overpayments.
Sec. 1755. Managed Care Organizations.
Sec. 1756. Termination of provider participation under Medicaid and CHIP if
terminated under Medicare or other State plan or child health
plan.
Sec. 1757.
Medicaid and CHIP exclusion from participation relating to certain
ownership, control, and management affiliations.
Sec. 1758.
Requirement to report expanded set of data elements under MMIS
to detect fraud and abuse.
Sec. 1759. Billing agents, clearinghouses, or other alternate payees required to
register under Medicaid.
Sec. 1760. Denial of payments for litigation-related misconduct.
Subtitle G—Puerto Rico and the Territories
Sec. 1771. Puerto Rico and territories.
Subtitle H—Miscellaneous
Sec. 1781. Technical corrections.
Sec. 1782. Extension of QI program.
TITLE VIII—REVENUE-RELATED PROVISIONS
Sec. 1801. Disclosures to facilitate identification of individuals likely to be ineli-
gible for the low-income assistance under the Medicare pre-
scription drug program to assist Social Security Administra-
tion’s outreach to eligible individuals.
Sec. 1802. Comparative Effectiveness Research Trust Fund; financing for
Trust Fund.
TITLE IX—MISCELLANEOUS PROVISIONS
Sec. 1901. Repeal of trigger provision.
Sec. 1902. Repeal of comparative cost adjustment (CCA) program.
Sec. 1903. Extension of gainsharing demonstration.
Sec. 1904. Grants to States for quality home visitation programs for families
with young children and families expecting children.
Sec. 1905. Improved coordination and protection for dual eligibles.
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1
TITLE I—IMPROVING HEALTH
2
CARE VALUE
3
Subtitle A—Provisions Related to
4
Medicare Part A
5
PART 1—MARKET BASKET UPDATES
6 SEC. 1101. SKILLED NURSING FACILITY PAYMENT UPDATE.
7
(a) IN GENERAL.—Section 1888(e)(4)(E)(ii) of the
8 Social Security Act (42 U.S.C. 1395yy(e)(4)(E)(ii)) is
9 amended—
10
(1) in subclause (III), by striking ‘‘and’’ at the
11
end;
12
(2) by redesignating subclause (IV) as sub-
13
clause (VI); and
14
(3) by inserting after subclause (III) the fol-
15
lowing new subclauses:
16
‘‘(IV) for each of fiscal years
17
2004 through 2009, the rate com-
18
puted for the previous fiscal year in-
19
creased by the skilled nursing facility
20
market basket percentage change for
21
the fiscal year involved;
22
‘‘(V) for fiscal year 2010, the
23
rate computed for the previous fiscal
24
year; and’’.
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224
1
(b) DELAYED
EFFECTIVE
DATE.—Section
2 1888(e)(4)(E)(ii)(V) of the Social Security Act, as in-
3 serted by subsection (a)(3), shall not apply to payment
4 for days before January 1, 2010.
5 SEC. 1102. INPATIENT REHABILITATION FACILITY PAY-
6
MENT UPDATE.
7
(a) IN GENERAL.—Section 1886(j)(3)(C) of the So-
8 cial Security Act (42 U.S.C. 1395ww(j)(3)(C)) is amended
9 by striking ‘‘and 2009’’ and inserting ‘‘through 2010’’.
10
(b) DELAYED EFFECTIVE DATE.—The amendment
11 made by subsection (a) shall not apply to payment units
12 occurring before January 1, 2010.
13 SEC. 1103. INCORPORATING PRODUCTIVITY IMPROVE-
14
MENTS INTO MARKET BASKET UPDATES
15
THAT DO NOT ALREADY INCORPORATE SUCH
16
IMPROVEMENTS.
17
(a) INPATIENT
ACUTE
HOSPITALS.—Section
18 1886(b)(3)(B) of the Social Security Act (42 U.S.C.
19 1395ww(b)(3)(B)) is amended—
20
(1) in clause (iii)—
21
(A) by striking ‘‘(iii) For purposes of this
22
subparagraph,’’ and inserting ‘‘(iii)(I) For pur-
23
poses of this subparagraph, subject to the pro-
24
ductivity adjustment described in subclause
25
(II),’’; and
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225
1
(B) by adding at the end the following new
2
subclause:
3
‘‘(II) The productivity adjustment described in this
4 subclause, with respect to an increase or change for a fis-
5 cal year or year or cost reporting period, or other annual
6 period, is a productivity offset equal to the percentage
7 change in the 10-year moving average of annual economy-
8 wide private nonfarm business multi-factor productivity
9 (as recently published before the promulgation of such in-
10 crease for the year or period involved). Except as other-
11 wise provided, any reference to the increase described in
12 this clause shall be a reference to the percentage increase
13 described in subclause (I) minus the percentage change
14 under this subclause.’’;
15
(2) in the first sentence of clause (viii)(I), by
16
inserting ‘‘(but not below zero)’’ after ‘‘shall be re-
17
duced’’; and
18
(3) in the first sentence of clause (ix)(I)—
19
(A) by inserting ‘‘(determined without re-
20
gard to clause (iii)(II)’’ after ‘‘clause (i)’’ the
21
second time it appears; and
22
(B) by inserting ‘‘(but not below zero)’’
23
after ‘‘reduced’’.
24
(b) SKILLED
NURSING
FACILITIES.—Section
25 1888(e)(5)(B) of such Act (42 U.S.C. 1395yy(e)(5))(B)
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226
1 is amended by inserting ‘‘subject to the productivity ad-
2 justment described in section 1886(b)(3)(B)(iii)(II)’’ after
3 ‘‘as calculated by the Secretary’’.
4
(c) LONG
TERM
CARE
HOSPITALS.—Section
5 1886(m) of the Social Security Act (42 U.S.C.
6 1395ww(m)) is amended by adding at the end the fol-
7 lowing new paragraph:
8
‘‘(3) PRODUCTIVITY ADJUSTMENT.—In imple-
9
menting the system described in paragraph (1) for
10
discharges occurring during the rate year ending in
11
2010 or any subsequent rate year for a hospital, to
12
the extent that an annual percentage increase factor
13
applies to a base rate for such discharges for the
14
hospital, such factor shall be subject to the produc-
15
tivity adjustment described in section
16
1886(b)(3)(B)(iii)(II).’’.
17
(d) INPATIENT REHABILITATION FACILITIES.—The
18 second sentence of section 1886(j)(3)(C) of the Social Se-
19 curity Act (42 U.S.C. 1395ww(j)(3)(C)) is amended by in-
20 serting ‘‘(subject to the productivity adjustment described
21 in section 1886(b)(3)(B)(iii)(II))’’ after ‘‘appropriate per-
22 centage increase’’.
23
(e) PSYCHIATRIC HOSPITALS.—Section 1886 of the
24 Social Security Act (42 U.S.C. 1395ww) is amended by
25 adding at the end the following new subsection:
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227
1
‘‘(o) PROSPECTIVE PAYMENT FOR PSYCHIATRIC
2 HOSPITALS.—
3
‘‘(1) REFERENCE TO ESTABLISHMENT AND IM-
4
PLEMENTATION OF SYSTEM.—For provisions related
5
to the establishment and implementation of a pro-
6
spective payment system for payments under this
7
title for inpatient hospital services furnished by psy-
8
chiatric hospitals (as described in clause (i) of sub-
9
section (d)(1)(B) and psychiatric units (as described
10
in the matter following clause (v) of such sub-
11
section), see section 124 of the Medicare, Medicaid,
12
and SCHIP Balanced Budget Refinement Act of
13
1999.
14
‘‘(2) PRODUCTIVITY ADJUSTMENT.—In imple-
15
menting the system described in paragraph (1) for
16
discharges occurring during the rate year ending in
17
2011 or any subsequent rate year for a psychiatric
18
hospital or unit described in such paragraph, to the
19
extent that an annual percentage increase factor ap-
20
plies to a base rate for such discharges for the hos-
21
pital or unit, respectively, such factor shall be sub-
22
ject to the productivity adjustment described in sec-
23
tion 1886(b)(3)(B)(iii)(II).’’.
24
(f) HOSPICE CARE.—Subclause (VII) of section
25 1814(i)(1)(C)(ii) of the Social Security Act (42 U.S.C.
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228
1 1395f(i)(1)(C)(ii)) is amended by inserting after ‘‘the
2 market basket percentage increase’’ the following: ‘‘(which
3 is subject to the productivity adjustment described in sec-
4 tion 1886(b)(3)(B)(iii)(II))’’.
5
(g) EFFECTIVE DATE.—The amendments made by
6 subsections (a), (b), (d), and (f) shall apply to annual in-
7 creases effected for fiscal years beginning with fiscal year
8 2010.
9
PART 2—OTHER MEDICARE PART A PROVISIONS
10 SEC. 1111. PAYMENTS TO SKILLED NURSING FACILITIES.
11
(a) CHANGE IN RECALIBRATION FACTOR.—
12
(1) ANALYSIS.—The Secretary of Health and
13
Human Services shall conduct, using calendar year
14
2006 claims data, an initial analysis comparing total
15
payments under title XVIII of the Social Security
16
Act for skilled nursing facility services under the
17
RUG–53 and under the RUG–44 classification sys-
18
tems.
19
(2) ADJUSTMENT
IN
RECALIBRATION
FAC-
20
TOR.—Based on the initial analysis under paragraph
21
(1), the Secretary shall adjust the case mix indexes
22
under section 1888(e)(4)(G)(i) of the Social Security
23
Act (42 U.S.C. 1395yy(e)(4)(G)(i)) for fiscal year
24
2010 by the appropriate recalibration factor as pro-
25
posed in the proposed rule for Medicare skilled nurs-
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229
1
ing facilities issued by such Secretary on May 12,
2
2009 (74 Federal Register 22214 et seq.).
3
(b) CHANGE IN PAYMENT FOR NONTHERAPY ANCIL-
4 LARY (NTA) SERVICES AND THERAPY SERVICES.—
5
(1) CHANGES UNDER CURRENT SNF CLASSI-
6
FICATION SYSTEM.—
7
(A) IN GENERAL.—Subject to subpara-
8
graph (B), the Secretary of Health and Human
9
Services shall, under the system for payment of
10
skilled nursing facility services under section
11
1888(e) of the Social Security Act (42 U.S.C.
12
1395yy(e)), increase payment by 10 percent for
13
non-therapy ancillary services (as specified by
14
the Secretary in the notice issued on November
15
27, 1998 (63 Federal Register 65561 et seq.))
16
and shall decrease payment for the therapy case
17
mix component of such rates by 5.5 percent.
18
(B) EFFECTIVE DATE.—The changes in
19
payment described in subparagraph (A) shall
20
apply for days on or after January 1, 2010,
21
and until the Secretary implements an alter-
22
native case mix classification system for pay-
23
ment of skilled nursing facility services under
24
section 1888(e) of the Social Security Act (42
25
U.S.C. 1395yy(e)).
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230
1
(C) IMPLEMENTATION.—Notwithstanding
2
any other provision of law, the Secretary may
3
implement by program instruction or otherwise
4
the provisions of this paragraph.
5
(2) CHANGES UNDER A FUTURE SNF CASE MIX
6
CLASSIFICATION SYSTEM.—
7
(A) ANALYSIS.—
8
(i) IN GENERAL.—The Secretary of
9
Health and Human Services shall analyze
10
payments for non-therapy ancillary services
11
under a future skilled nursing facility clas-
12
sification system to ensure the accuracy of
13
payment for non-therapy ancillary services.
14
Such analysis shall consider use of appro-
15
priate indicators which may include age,
16
physical and mental status, ability to per-
17
form activities of daily living, prior nursing
18
home stay, broad RUG category, and a
19
proxy for length of stay.
20
(ii) APPLICATION.—Such analysis
21
shall be conducted in a manner such that
22
the future skilled nursing facility classifica-
23
tion system is implemented to apply to
24
services furnished during a fiscal year be-
25
ginning with fiscal year 2011.
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231
1
(B) CONSULTATION.—In conducting the
2
analysis under subparagraph (A), the Secretary
3
shall consult with interested parties, including
4
the Medicare Payment Advisory Commission
5
and other interested stakeholders, to identify
6
appropriate predictors of nontherapy ancillary
7
costs.
8
(C) RULEMAKING.—The Secretary shall
9
include the result of the analysis under sub-
10
paragraph (A) in the fiscal year 2011 rule-
11
making cycle for purposes of implementation
12
beginning for such fiscal year.
13
(D) IMPLEMENTATION.—Subject to sub-
14
paragraph (E) and consistent with subpara-
15
graph (A)(ii), the Secretary shall implement
16
changes to payments for non-therapy ancillary
17
services (which may include a separate rate
18
component for non-therapy ancillary services
19
and may include use of a model that predicts
20
payment amounts applicable for non-therapy
21
ancillary services) under such future skilled
22
nursing facility services classification system as
23
the Secretary determines appropriate based on
24
the analysis conducted pursuant to subpara-
25
graph (A).
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232
1
(E) BUDGET NEUTRALITY.—The Secretary
2
shall implement changes described in subpara-
3
graph (D) in a manner such that the estimated
4
expenditures under such future skilled nursing
5
facility services classification system for a fiscal
6
year beginning with fiscal year 2011 with such
7
changes would be equal to the estimated ex-
8
penditures that would otherwise occur under
9
title XVIII of the Social Security Act under
10
such future skilled nursing facility services clas-
11
sification system for such year without such
12
changes.
13
(c) OUTLIER POLICY FOR NTA AND THERAPY.—Sec-
14 tion 1888(e) of the Social Security Act (42 U.S.C.
15 1395yy(e)) is amended by adding at the end the following
16 new paragraph:
17
‘‘(13) OUTLIERS FOR NTA AND THERAPY.—
18
‘‘(A) IN
GENERAL.—With respect to
19
outliers because of unusual variations in the
20
type or amount of medically necessary care, be-
21
ginning with October 1, 2010, the Secretary—
22
‘‘(i) shall provide for an addition or
23
adjustment to the payment amount other-
24
wise made under this section with respect
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233
1
to non-therapy ancillary services in the
2
case of such outliers; and
3
‘‘(ii) may provide for such an addition
4
or adjustment to the payment amount oth-
5
erwise made under this section with re-
6
spect to therapy services in the case of
7
such outliers.
8
‘‘(B) OUTLIERS BASED ON AGGREGATE
9
COSTS.—Outlier adjustments or additional pay-
10
ments described in subparagraph (A) shall be
11
based on aggregate costs during a stay in a
12
skilled nursing facility and not on the number
13
of days in such stay.
14
‘‘(C) BUDGET NEUTRALITY.— The Sec-
15
retary shall reduce estimated payments that
16
would otherwise be made under the prospective
17
payment system under this subsection with re-
18
spect to a fiscal year by 2 percent. The total
19
amount of the additional payments or payment
20
adjustments for outliers made under this para-
21
graph with respect to a fiscal year may not ex-
22
ceed 2 percent of the total payments projected
23
or estimated to be made based on the prospec-
24
tive payment system under this subsection for
25
the fiscal year.’’.
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234
1
(d) CONFORMING
AMENDMENTS.—Section
2 1888(e)(8) of such Act (42 U.S.C. 1395yy(e)(8)) is
3 amended—
4
(1) in subparagraph (A), by inserting ‘‘and ad-
5
justment under section 1111(b) of the America’s Af-
6
fordable Health Choices Act of 2009;
7
(2) in subparagraph (B), by striking ‘‘and’’;
8
(3) in subparagraph (C), by striking the period
9
and inserting ‘‘; and’’; and
10
(4) by adding at the end the following new sub-
11
paragraph:
12
‘‘(D) the establishment of outliers under
13
paragraph (13).’’.
14 SEC. 1112. MEDICARE DSH REPORT AND PAYMENT ADJUST-
15
MENTS IN RESPONSE TO COVERAGE EXPAN-
16
SION.
17
(a) DSH REPORT.—
18
(1) IN GENERAL.—Not later than January 1,
19
2016, the Secretary of Health and Human Services
20
shall submit to Congress a report on Medicare DSH
21
taking into account the impact of the health care re-
22
forms carried out under division A in reducing the
23
number of uninsured individuals. The report shall
24
include recommendations relating to the following:
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235
1
(A) The appropriate amount, targeting,
2
and distribution of Medicare DSH to com-
3
pensate for higher Medicare costs associated
4
with serving low-income beneficiaries (taking
5
into account variations in the empirical jus-
6
tification for Medicare DSH attributable to hos-
7
pital characteristics, including bed size), con-
8
sistent with the original intent of Medicare
9
DSH.
10
(B) The appropriate amount, targeting,
11
and distribution of Medicare DSH to hospitals
12
given their continued uncompensated care costs,
13
to the extent such costs remain.
14
(2) COORDINATION WITH MEDICAID DSH RE-
15
PORT.—The Secretary shall coordinate the report
16
under this subsection with the report on Medicaid
17
DSH under section 1704(a).
18
(b) PAYMENT ADJUSTMENTS IN RESPONSE TO COV-
19 ERAGE EXPANSION.—
20
(1) IN GENERAL.—If there is a significant de-
21
crease in the national rate of uninsurance as a result
22
of this Act (as determined under paragraph (2)(A)),
23
then the Secretary of Health and Human Services
24
shall, beginning in fiscal year 2017, implement the
25
following adjustments to Medicare DSH:
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236
1
(A) The amount of Medicare DSH shall be
2
adjusted based on the recommendations of the
3
report under subsection (a)(1)(A) and shall
4
take into account variations in the empirical
5
justification for Medicare DSH attributable to
6
hospital characteristics, including bed size.
7
(B) Subject to paragraph (3), increase
8
Medicare DSH for a hospital by an additional
9
amount that is based on the amount of uncom-
10
pensated care provided by the hospital based on
11
criteria for uncompensated care as determined
12
by the Secretary, which shall exclude bad debt.
13
(2) SIGNIFICANT DECREASE IN NATIONAL RATE
14
OF UNINSURANCE AS A RESULT OF THIS ACT.—For
15
purposes of this subsection—
16
(A) IN GENERAL.—There is a ‘‘significant
17
decrease in the national rate of uninsurance as
18
a result of this Act’’ if there is a decrease in
19
the national rate of uninsurance (as defined in
20
subparagraph (B)) from 2012 to 2014 that ex-
21
ceeds 8 percentage points.
22
(B) NATIONAL RATE OF UNINSURANCE
23
DEFINED.—The term ‘‘national rate of
24
uninsurance’’ means, for a year, such rate for
25
the under-65 population for the year as deter-
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237
1
mined and published by the Bureau of the Cen-
2
sus in its Current Population Survey in or
3
about September of the succeeding year.
4
(3) UNCOMPENSATED CARE INCREASE.—
5
(A) COMPUTATION OF DSH SAVINGS.—For
6
each fiscal year (beginning with fiscal year
7
2017), the Secretary shall estimate the aggre-
8
gate reduction in Medicare DSH that will result
9
from the adjustment under paragraph (1)(A).
10
(B) STRUCTURE
OF
PAYMENT
IN-
11
CREASE.—The Secretary shall compute the in-
12
crease in Medicare DSH under paragraph
13
(1)(B) for a fiscal year in accordance with a
14
formula established by the Secretary that pro-
15
vides that—
16
(i) the aggregate amount of such in-
17
crease for the fiscal year does not exceed
18
50 percent of the aggregate reduction in
19
Medicare DSH estimated by the Secretary
20
for such fiscal year; and
21
(ii) hospitals with higher levels of un-
22
compensated care receive a greater in-
23
crease.
24
(c) MEDICARE DSH.—In this section, the term
25 ‘‘Medicare DSH’’ means adjustments in payments under
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238
1 section 1886(d)(5)(F) of the Social Security Act (42
2 U.S.C. 1395ww(d)(5)(F)) for inpatient hospital services
3 furnished by disproportionate share hospitals.
4
Subtitle B—Provisions Related to
5
Part B
6
PART 1—PHYSICIANS’ SERVICES
7 SEC. 1121. SUSTAINABLE GROWTH RATE REFORM.
8
(a) TRANSITIONAL UPDATE FOR 2010.—Section
9 1848(d) of the Social Security Act (42 U.S.C. 1395w–
10 4(d)) is amended by adding at the end the following new
11 paragraph:
12
‘‘(10) UPDATE FOR 2010.—The update to the
13
single conversion factor established in paragraph
14
(1)(C) for 2010 shall be the percentage increase in
15
the MEI (as defined in section 1842(i)(3)) for that
16
year.’’.
17
(b) REBASING SGR USING 2009; LIMITATION ON
18 CUMULATIVE ADJUSTMENT PERIOD.—Section 1848(d)(4)
19 of such Act (42 U.S.C. 1395w–4(d)(4)) is amended—
20
(1) in subparagraph (B), by striking ‘‘subpara-
21
graph (D)’’ and inserting ‘‘subparagraphs (D) and
22
(G)’’; and
23
(2) by adding at the end the following new sub-
24
paragraph:
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1
‘‘(G) REBASING USING 2009 FOR FUTURE
2
UPDATE
ADJUSTMENTS.—In determining the
3
update adjustment factor under subparagraph
4
(B) for 2011 and subsequent years—
5
‘‘(i) the allowed expenditures for 2009
6
shall be equal to the amount of the actual
7
expenditures for physicians’ services during
8
2009; and
9
‘‘(ii) the reference in subparagraph
10
(B)(ii)(I) to ‘April 1, 1996’ shall be treat-
11
ed as a reference to ‘January 1, 2009 (or,
12
if later, the first day of the fifth year be-
13
fore the year involved)’.’’.
14
(c) LIMITATION ON PHYSICIANS’ SERVICES IN-
15 CLUDED IN TARGET GROWTH RATE COMPUTATION TO
16 SERVICES COVERED UNDER PHYSICIAN FEE SCHED-
17 ULE.—Effective for services furnished on or after January
18 1, 2009, section 1848(f)(4)(A) of such Act is amended
19 striking ‘‘(such as clinical’’ and all that follows through
20 ‘‘in a physician’s office’’ and inserting ‘‘for which payment
21 under this part is made under the fee schedule under this
22 section, for services for practitioners described in section
23 1842(b)(18)(C) on a basis related to such fee schedule,
24 or for services described in section 1861(p) (other than
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240
1 such services when furnished in the facility of a provider
2 of services)’’.
3
(d) ESTABLISHMENT
OF
SEPARATE
TARGET
4 GROWTH RATES FOR CATEGORIES OF SERVICES.—
5
(1) ESTABLISHMENT
OF
SERVICE
CAT-
6
EGORIES.—Subsection (j) of section 1848 of the So-
7
cial Security Act (42 U.S.C. 1395w–4) is amended
8
by adding at the end the following new paragraph:
9
‘‘(5) SERVICE CATEGORIES.—For services fur-
10
nished on or after January 1, 2009, each of the fol-
11
lowing categories of physicians’ services (as defined
12
in paragraph (3)) shall be treated as a separate
13
‘service category’:
14
‘‘(A) Evaluation and management services
15
that are procedure codes (for services covered
16
under this title) for—
17
‘‘(i) services in the category des-
18
ignated Evaluation and Management in the
19
Health Care Common Procedure Coding
20
System (established by the Secretary under
21
subsection (c)(5) as of December 31, 2009,
22
and as subsequently modified by the Sec-
23
retary); and
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241
1
‘‘(ii) preventive services (as defined in
2
section 1861(iii)) for which payment is
3
made under this section.
4
‘‘(B) All other services not described in
5
subparagraph (A).
6
Service categories established under this paragraph
7
shall apply without regard to the specialty of the
8
physician furnishing the service.’’.
9
(2) ESTABLISHMENT OF SEPARATE CONVER-
10
SION
FACTORS
FOR
EACH
SERVICE
CATEGORY.—
11
Subsection (d)(1) of section 1848 of the Social Secu-
12
rity Act (42 U.S.C. 1395w–4) is amended—
13
(A) in subparagraph (A)—
14
(i) by designating the sentence begin-
15
ning ‘‘The conversion factor’’ as clause (i)
16
with the heading ‘‘APPLICATION OF SIN-
17
GLE
CONVERSION
FACTOR.—’’ and with
18
appropriate indentation;
19
(ii) by striking ‘‘The conversion fac-
20
tor’’ and inserting ‘‘Subject to clause (ii),
21
the conversion factor’’; and
22
(iii) by adding at the end the fol-
23
lowing new clause:
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242
1
‘‘(ii) APPLICATION OF MULTIPLE CON-
2
VERSION
FACTORS
BEGINNING
WITH
3
2011.—
4
‘‘(I) IN GENERAL.—In applying
5
clause (i) for years beginning with
6
2011, separate conversion factors
7
shall be established for each service
8
category of physicians’ services (as de-
9
fined in subsection (j)(5)) and any
10
reference in this section to a conver-
11
sion factor for such years shall be
12
deemed to be a reference to the con-
13
version factor for each of such cat-
14
egories.
15
‘‘(II) INITIAL CONVERSION FAC-
16
TORS.—Such factors for 2011 shall be
17
based upon the single conversion fac-
18
tor for the previous year multiplied by
19
the update established under para-
20
graph (11) for such category for
21
2011.
22
‘‘(III) UPDATING OF CONVER-
23
SION
FACTORS.—Such factor for a
24
service category for a subsequent year
25
shall be based upon the conversion
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243
1
factor for such category for the pre-
2
vious year and adjusted by the update
3
established for such category under
4
paragraph (11) for the year in-
5
volved.’’; and
6
(B) in subparagraph (D), by striking
7
‘‘other physicians’ services’’ and inserting ‘‘for
8
physicians’ services described in the service cat-
9
egory described in subsection (j)(5)(B)’’.
10
(3) ESTABLISHING UPDATES FOR CONVERSION
11
FACTORS
FOR
SERVICE
CATEGORIES.—Section
12
1848(d) of the Social Security Act (42 U.S.C.
13
1395w–4(d)), as amended by subsection (a), is
14
amended—
15
(A) in paragraph (4)(C)(iii), by striking
16
‘‘The allowed’’ and inserting ‘‘Subject to para-
17
graph (11)(B), the allowed’’; and
18
(B) by adding at the end the following new
19
paragraph:
20
‘‘(11) UPDATES FOR SERVICE CATEGORIES BE-
21
GINNING WITH 2011.—
22
‘‘(A) IN GENERAL.—In applying paragraph
23
(4) for a year beginning with 2011, the fol-
24
lowing rules apply:
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244
1
‘‘(i) APPLICATION OF SEPARATE UP-
2
DATE ADJUSTMENTS FOR EACH SERVICE
3
CATEGORY.—Pursuant to paragraph
4
(1)(A)(ii)(I), the update shall be made to
5
the conversion factor for each service cat-
6
egory (as defined in subsection (j)(5))
7
based upon an update adjustment factor
8
for the respective category and year and
9
the update adjustment factor shall be com-
10
puted, for a year, separately for each serv-
11
ice category.
12
‘‘(ii) COMPUTATION OF ALLOWED AND
13
ACTUAL EXPENDITURES BASED ON SERV-
14
ICE CATEGORIES.—In computing the prior
15
year adjustment component and the cumu-
16
lative adjustment component under clauses
17
(i) and (ii) of paragraph (4)(B), the fol-
18
lowing rules apply:
19
‘‘(I) APPLICATION
BASED
ON
20
SERVICE
CATEGORIES.—The allowed
21
expenditures and actual expenditures
22
shall be the allowed and actual ex-
23
penditures for the service category, as
24
determined under subparagraph (B).
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245
1
‘‘(II) APPLICATION OF CATEGORY
2
SPECIFIC
TARGET
GROWTH
RATE.—
3
The growth rate applied under clause
4
(ii)(II) of such paragraph shall be the
5
target growth rate for the service cat-
6
egory involved under subsection (f)(5).
7
‘‘(B) DETERMINATION OF ALLOWED EX-
8
PENDITURES.—In applying paragraph (4) for a
9
year beginning with 2010, notwithstanding sub-
10
paragraph (C)(iii) of such paragraph, the al-
11
lowed expenditures for a service category for a
12
year is an amount computed by the Secretary
13
as follows:
14
‘‘(i) FOR 2010.—For 2010:
15
‘‘(I) TOTAL 2009 ACTUAL EX-
16
PENDITURES FOR ALL SERVICES IN-
17
CLUDED IN SGR COMPUTATION FOR
18
EACH SERVICE CATEGORY.—Compute
19
total actual expenditures for physi-
20
cians’ services (as defined in sub-
21
section (f)(4)(A)) for 2009 for each
22
service category.
23
‘‘(II) INCREASE
BY
GROWTH
24
RATE TO OBTAIN 2010 ALLOWED EX-
25
PENDITURES
FOR
SERVICE
CAT-
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246
1
EGORY.—Compute allowed expendi-
2
tures for the service category for 2010
3
by increasing the allowed expenditures
4
for the service category for 2009 com-
5
puted under subclause (I) by the tar-
6
get growth rate for such service cat-
7
egory under subsection (f) for 2010.
8
‘‘(ii) FOR SUBSEQUENT YEARS.—For
9
a subsequent year, take the amount of al-
10
lowed expenditures for such category for
11
the preceding year (under clause (i) or this
12
clause) and increase it by the target
13
growth rate determined under subsection
14
(f) for such category and year.’’.
15
(4) APPLICATION
OF
SEPARATE
TARGET
16
GROWTH RATES FOR EACH CATEGORY.—
17
(A) IN GENERAL.—Section 1848(f) of the
18
Social Security Act (42 U.S.C. 1395w–4(f)) is
19
amended by adding at the end the following
20
new paragraph:
21
‘‘(5) APPLICATION
OF
SEPARATE
TARGET
22
GROWTH RATES FOR EACH SERVICE CATEGORY BE-
23
GINNING WITH 2010.—The target growth rate for a
24
year beginning with 2010 shall be computed and ap-
25
plied separately under this subsection for each serv-
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247
1
ice category (as defined in subsection (j)(5)) and
2
shall be computed using the same method for com-
3
puting the target growth rate except that the factor
4
described in paragraph (2)(C) for—
5
‘‘(A) the service category described in sub-
6
section (j)(5)(A) shall be increased by 0.02; and
7
‘‘(B) the service category described in sub-
8
section (j)(5)(B) shall be increased by 0.01.’’.
9
(B) USE OF TARGET GROWTH RATES.—
10
Section 1848 of such Act is further amended—
11
(i) in subsection (d)—
12
(I) in paragraph (1)(E)(ii), by in-
13
serting ‘‘or target’’ after ‘‘sustain-
14
able’’; and
15
(II) in paragraph (4)(B)(ii)(II),
16
by inserting ‘‘or target’’ after ‘‘sus-
17
tainable’’; and
18
(ii) in the heading of subsection (f),
19
by inserting ‘‘AND
TARGET
GROWTH
20
RATE’’ after ‘‘SUSTAINABLE
GROWTH
21
RATE’’;
22
(iii) in subsection (f)(1)—
23
(I) by striking ‘‘and’’ at the end
24
of subparagraph (A);
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248
1
(II) in subparagraph (B), by in-
2
serting ‘‘before 2010’’ after ‘‘each
3
succeeding year’’ and by striking the
4
period at the end and inserting ‘‘;
5
and’’; and
6
(III) by adding at the end the
7
following new subparagraph:
8
‘‘(C) November 1 of each succeeding year
9
the target growth rate for such succeeding year
10
and each of the 2 preceding years.’’; and
11
(iv) in subsection (f)(2), in the matter
12
before subparagraph (A), by inserting after
13
‘‘beginning with 2000’’ the following: ‘‘and
14
ending with 2009’’.
15
(e) APPLICATION TO ACCOUNTABLE CARE ORGANI-
16 ZATION PILOT PROGRAM.—In applying the target growth
17 rate under subsections (d) and (f) of section 1848 of the
18 Social Security Act to services furnished by a practitioner
19 to beneficiaries who are attributable to an accountable
20 care organization under the pilot program provided under
21 section 1866D of such Act, the Secretary of Health and
22 Human Services shall develop, not later than January 1,
23 2012, for application beginning with 2012, a method
24 that—
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249
1
(1) allows each such organization to have its
2
own expenditure targets and updates for such practi-
3
tioners, with respect to beneficiaries who are attrib-
4
utable to that organization, that are consistent with
5
the methodologies described in such subsection (f);
6
and
7
(2) provides that the target growth rate appli-
8
cable to other physicians shall not apply to such
9
physicians to the extent that the physicians’ services
10
are furnished through the accountable care organiza-
11
tion.
12 In applying paragraph (1), the Secretary of Health and
13 Human Services may apply the difference in the update
14 under such paragraph on a claim-by-claim or lump sum
15 basis and such a payment shall be taken into account
16 under the pilot program.
17 SEC. 1122. MISVALUED CODES UNDER THE PHYSICIAN FEE
18
SCHEDULE.
19
(a) IN GENERAL.—Section 1848(c)(2) of the Social
20 Security Act (42 U.S.C. 1395w-4(c)(2)) is amended by
21 adding at the end the following new subparagraphs:
22
‘‘(K) POTENTIALLY MISVALUED CODES.—
23
‘‘(i) IN
GENERAL.—The Secretary
24
shall—
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250
1
‘‘(I) periodically identify services
2
as being potentially misvalued using
3
criteria specified in clause (ii); and
4
‘‘(II) review and make appro-
5
priate adjustments to the relative val-
6
ues established under this paragraph
7
for services identified as being poten-
8
tially misvalued under subclause (I).
9
‘‘(ii) IDENTIFICATION
OF
POTEN-
10
TIALLY MISVALUED CODES.—For purposes
11
of identifying potentially misvalued services
12
pursuant to clause (i)(I), the Secretary
13
shall examine (as the Secretary determines
14
to be appropriate) codes (and families of
15
codes as appropriate) for which there has
16
been the fastest growth; codes (and fami-
17
lies of codes as appropriate) that have ex-
18
perienced substantial changes in practice
19
expenses; codes for new technologies or
20
services within an appropriate period (such
21
as three years) after the relative values are
22
initially established for such codes; mul-
23
tiple codes that are frequently billed in
24
conjunction with furnishing a single serv-
25
ice; codes with low relative values, particu-
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251
1
larly those that are often billed multiple
2
times for a single treatment; codes which
3
have not been subject to review since the
4
implementation of the RBRVS (the so-
5
called ‘Harvard-valued codes’); and such
6
other codes determined to be appropriate
7
by the Secretary.
8
‘‘(iii) REVIEW AND ADJUSTMENTS.—
9
‘‘(I) The Secretary may use ex-
10
isting processes to receive rec-
11
ommendations on the review and ap-
12
propriate adjustment of potentially
13
misvalued services described clause
14
(i)(II).
15
‘‘(II) The Secretary may conduct
16
surveys, other data collection activi-
17
ties, studies, or other analyses as the
18
Secretary determines to be appro-
19
priate to facilitate the review and ap-
20
propriate adjustment described in
21
clause (i)(II).
22
‘‘(III) The Secretary may use
23
analytic contractors to identify and
24
analyze services identified under
25
clause (i)(I), conduct surveys or col-
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252
1
lect data, and make recommendations
2
on the review and appropriate adjust-
3
ment of services described in clause
4
(i)(II).
5
‘‘(IV) The Secretary may coordi-
6
nate the review and appropriate ad-
7
justment described in clause (i)(II)
8
with the periodic review described in
9
subparagraph (B).
10
‘‘(V) As part of the review and
11
adjustment described in clause (i)(II),
12
including with respect to codes with
13
low relative values described in clause
14
(ii), the Secretary may make appro-
15
priate coding revisions (including
16
using existing processes for consider-
17
ation of coding changes) which may
18
include consolidation of individual
19
services into bundled codes for pay-
20
ment under the fee schedule under
21
subsection (b).
22
‘‘(VI) The provisions of subpara-
23
graph (B)(ii)(II) shall apply to adjust-
24
ments to relative value units made
25
pursuant to this subparagraph in the
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253
1
same manner as such provisions apply
2
to adjustments under subparagraph
3
(B)(ii)(II).
4
‘‘(L) VALIDATING
RELATIVE
VALUE
5
UNITS.—
6
‘‘(i) IN
GENERAL.—The Secretary
7
shall establish a process to validate relative
8
value units under the fee schedule under
9
subsection (b).
10
‘‘(ii) COMPONENTS AND ELEMENTS
11
OF
WORK.—The process described in
12
clause (i) may include validation of work
13
elements (such as time, mental effort and
14
professional judgment, technical skill and
15
physical effort, and stress due to risk) in-
16
volved with furnishing a service and may
17
include validation of the pre, post, and
18
intra-service components of work.
19
‘‘(iii) SCOPE OF CODES.—The valida-
20
tion of work relative value units shall in-
21
clude a sampling of codes for services that
22
is the same as the codes listed under sub-
23
paragraph (K)(ii)
24
‘‘(iv) METHODS.—The Secretary may
25
conduct the validation under this subpara-
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254
1
graph using methods described in sub-
2
clauses (I) through (V) of subparagraph
3
(K)(iii) as the Secretary determines to be
4
appropriate.
5
‘‘(v) ADJUSTMENTS.—The Secretary
6
shall make appropriate adjustments to the
7
work relative value units under the fee
8
schedule under subsection (b). The provi-
9
sions of subparagraph (B)(ii)(II) shall
10
apply to adjustments to relative value units
11
made pursuant to this subparagraph in the
12
same manner as such provisions apply to
13
adjustments under subparagraph
14
(B)(ii)(II).’’.
15
(b) IMPLEMENTATION.—
16
(1) FUNDING.—For purposes of carrying out
17
the provisions of subparagraphs (K) and (L) of
18
1848(c)(2) of the Social Security Act, as added by
19
subsection (a), in addition to funds otherwise avail-
20
able, out of any funds in the Treasury not otherwise
21
appropriated, there are appropriated to the Sec-
22
retary of Health and Human Services for the Center
23
for Medicare & Medicaid Services Program Manage-
24
ment Account $20,000,000 for fiscal year 2010 and
25
each subsequent fiscal year. Amounts appropriated
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255
1
under this paragraph for a fiscal year shall be avail-
2
able until expended.
3
(2) ADMINISTRATION.—
4
(A) Chapter 35 of title 44, United States
5
Code and the provisions of the Federal Advisory
6
Committee Act (5 U.S.C. App.) shall not apply
7
to this section or the amendment made by this
8
section.
9
(B) Notwithstanding any other provision of
10
law, the Secretary may implement subpara-
11
graphs (K) and (L) of 1848(c)(2) of the Social
12
Security Act, as added by subsection (a), by
13
program instruction or otherwise.
14
(C) Section 4505(d) of the Balanced
15
Budget Act of 1997 is repealed.
16
(D) Except for provisions related to con-
17
fidentiality of information, the provisions of the
18
Federal Acquisition Regulation shall not apply
19
to this section or the amendment made by this
20
section.
21
(3) FOCUSING CMS RESOURCES ON POTEN-
22
TIALLY OVERVALUED CODES.—Section 1868(a) of
23
the Social Security Act (42 1395ee(a)) is repealed.
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256
1 SEC. 1123. PAYMENTS FOR EFFICIENT AREAS.
2
Section 1833 of the Social Security Act (42 U.S.C.
3 1395l) is amended by adding at the end the following new
4 subsection:
5
‘‘(x) INCENTIVE
PAYMENTS
FOR
EFFICIENT
6 AREAS.—
7
‘‘(1) IN GENERAL.—In the case of services fur-
8
nished under the physician fee schedule under sec-
9
tion 1848 on or after January 1, 2011, and before
10
January 1, 2013, by a supplier that is paid under
11
such fee schedule in an efficient area (as identified
12
under paragraph (2)), in addition to the amount of
13
payment that would otherwise be made for such
14
services under this part, there also shall be paid (on
15
a monthly or quarterly basis) an amount equal to 5
16
percent of the payment amount for the services
17
under this part.
18
‘‘(2) IDENTIFICATION OF EFFICIENT AREAS.—
19
‘‘(A) IN GENERAL.—Based upon available
20
data, the Secretary shall identify those counties
21
or equivalent areas in the United States in the
22
lowest fifth percentile of utilization based on
23
per capita spending under this part and part A
24
for services provided in the most recent year for
25
which data are available as of the date of the
26
enactment of this subsection, as standardized to
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257
1
eliminate the effect of geographic adjustments
2
in payment rates.
3
‘‘(B) IDENTIFICATION
OF
COUNTIES
4
WHERE
SERVICE
IS
FURNISHED..—For pur-
5
poses of paying the additional amount specified
6
in paragraph (1), if the Secretary uses the 5-
7
digit postal ZIP Code where the service is fur-
8
nished, the dominant county of the postal ZIP
9
Code (as determined by the United States Post-
10
al Service, or otherwise) shall be used to deter-
11
mine whether the postal ZIP Code is in a coun-
12
ty described in subparagraph (A).
13
‘‘(C) LIMITATION
ON
REVIEW.—There
14
shall be no administrative or judicial review
15
under section 1869, 1878, or otherwise, respect-
16
ing—
17
‘‘(i) the identification of a county or
18
other area under subparagraph (A); or
19
‘‘(ii) the assignment of a postal ZIP
20
Code to a county or other area under sub-
21
paragraph (B).
22
‘‘(D) PUBLICATION OF LIST OF COUNTIES;
23
POSTING ON WEBSITE.—With respect to a year
24
for which a county or area is identified under
25
this paragraph, the Secretary shall identify
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1
such counties or areas as part of the proposed
2
and final rule to implement the physician fee
3
schedule under section 1848 for the applicable
4
year. The Secretary shall post the list of coun-
5
ties identified under this paragraph on the
6
Internet website of the Centers for Medicare &
7
Medicaid Services.’’.
8 SEC. 1124. MODIFICATIONS TO THE PHYSICIAN QUALITY
9
REPORTING INITIATIVE (PQRI).
10
(a) FEEDBACK.—Section 1848(m)(5) of the Social
11 Security Act (42 U.S.C. 1395w–4(m)(5)) is amended by
12 adding at the end the following new subparagraph:
13
‘‘(H) FEEDBACK.—The Secretary shall
14
provide timely feedback to eligible professionals
15
on the performance of the eligible professional
16
with respect to satisfactorily submitting data on
17
quality measures under this subsection.’’.
18
(b) APPEALS.—Such section is further amended—
19
(1) in subparagraph (E), by striking ‘‘There
20
shall be’’ and inserting ‘‘Subject to subparagraph
21
(I), there shall be’’; and
22
(2) by adding at the end the following new sub-
23
paragraph:
24
‘‘(I) INFORMAL APPEALS PROCESS.—Not-
25
withstanding subparagraph (E), by not later
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259
1
than January 1, 2011, the Secretary shall es-
2
tablish and have in place an informal process
3
for eligible professionals to appeal the deter-
4
mination that an eligible professional did not
5
satisfactorily submit data on quality measures
6
under this subsection.’’.
7
(c) INTEGRATION OF PHYSICIAN QUALITY REPORT-
8 ING AND EHR REPORTING.—Section 1848(m) of such
9 Act is amended by adding at the end the following new
10 paragraph:
11
‘‘(7) INTEGRATION OF PHYSICIAN QUALITY RE-
12
PORTING
AND
EHR
REPORTING.—Not later than
13
January 1, 2012, the Secretary shall develop a plan
14
to integrate clinical reporting on quality measures
15
under this subsection with reporting requirements
16
under subsection (o) relating to the meaningful use
17
of electronic health records. Such integration shall
18
consist of the following:
19
‘‘(A) The development of measures, the re-
20
porting of which would both demonstrate—
21
‘‘(i) meaningful use of an electronic
22
health record for purposes of subsection
23
(o); and
24
‘‘(ii) clinical quality of care furnished
25
to an individual.
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260
1
‘‘(B) The collection of health data to iden-
2
tify deficiencies in the quality and coordination
3
of care for individuals eligible for benefits under
4
this part.
5
‘‘(C) Such other activities as specified by
6
the Secretary.’’.
7
(d) EXTENSION OF INCENTIVE PAYMENTS.—Section
8 1848(m)(1) of such Act (42 U.S.C. 1395w–4(m)(1)) is
9 amended—
10
(1) in subparagraph (A), by striking ‘‘2010’’
11
and inserting ‘‘2012’’; and
12
(2) in subparagraph (B)(ii), by striking ‘‘2009
13
and 2010’’ and inserting ‘‘for each of the years 2009
14
through 2012’’.
15 SEC. 1125. ADJUSTMENT TO MEDICARE PAYMENT LOCAL-
16
ITIES.
17
(a) IN GENERAL.—Section 1848(e) of the Social Se-
18 curity Act (42 U.S.C.1395w–4(e)) is amended by adding
19 at the end the following new paragraph:
20
‘‘(6) TRANSITION TO USE OF MSAS AS FEE
21
SCHEDULE AREAS IN CALIFORNIA.—
22
‘‘(A) IN GENERAL.—
23
‘‘(i) REVISION.—Subject to clause (ii)
24
and notwithstanding the previous provi-
25
sions of this subsection, for services fur-
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261
1
nished on or after January 1, 2011, the
2
Secretary shall revise the fee schedule
3
areas used for payment under this section
4
applicable to the State of California using
5
the Metropolitan Statistical Area (MSA)
6
iterative Geographic Adjustment Factor
7
methodology as follows:
8
‘‘(I) The Secretary shall con-
9
figure the physician fee schedule areas
10
using the Core-Based Statistical
11
Areas-Metropolitan Statistical Areas
12
(each in this paragraph referred to as
13
an ‘MSA’), as defined by the Director
14
of the Office of Management and
15
Budget, as the basis for the fee sched-
16
ule areas. The Secretary shall employ
17
an iterative process to transition fee
18
schedule areas. First, the Secretary
19
shall list all MSAs within the State by
20
Geographic Adjustment Factor de-
21
scribed in paragraph (2) (in this para-
22
graph referred to as a ‘GAF’) in de-
23
scending order. In the first iteration,
24
the Secretary shall compare the GAF
25
of the highest cost MSA in the State
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262
1
to the weighted-average GAF of the
2
group of remaining MSAs in the
3
State. If the ratio of the GAF of the
4
highest cost MSA to the weighted-av-
5
erage GAF of the rest of State is 1.05
6
or greater then the highest cost MSA
7
becomes a separate fee schedule area.
8
‘‘(II) In the next iteration, the
9
Secretary shall compare the MSA of
10
the second-highest GAF to the weight-
11
ed-average GAF of the group of re-
12
maining MSAs. If the ratio of the sec-
13
ond-highest MSA’s GAF to the
14
weighted-average of the remaining
15
lower cost MSAs is 1.05 or greater,
16
the second-highest MSA becomes a
17
separate fee schedule area. The
18
iterative process continues until the
19
ratio of the GAF of the highest-cost
20
remaining MSA to the weighted-aver-
21
age of the remaining lower-cost MSAs
22
is less than 1.05, and the remaining
23
group of lower cost MSAs form a sin-
24
gle fee schedule area, If two MSAs
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263
1
have identical GAFs, they shall be
2
combined in the iterative comparison.
3
‘‘(ii) TRANSITION.—For services fur-
4
nished on or after January 1, 2011, and
5
before January 1, 2016, in the State of
6
California, after calculating the work, prac-
7
tice expense, and malpractice geographic
8
indices described in clauses (i), (ii), and
9
(iii) of paragraph (1)(A) that would other-
10
wise apply through application of this
11
paragraph, the Secretary shall increase any
12
such index to the county-based fee sched-
13
ule area value on December 31, 2009, if
14
such index would otherwise be less than
15
the value on January 1, 2010.
16
‘‘(B) SUBSEQUENT REVISIONS.—
17
‘‘(i) PERIODIC REVIEW AND ADJUST-
18
MENTS IN FEE SCHEDULE AREAS.—Subse-
19
quent to the process outlined in paragraph
20
(1)(C), not less often than every three
21
years, the Secretary shall review and up-
22
date the California Rest-of-State fee sched-
23
ule area using MSAs as defined by the Di-
24
rector of the Office of Management and
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264
1
Budget and the iterative methodology de-
2
scribed in subparagraph (A)(i).
3
‘‘(ii) LINK WITH GEOGRAPHIC INDEX
4
DATA REVISION.—The revision described in
5
clause (i) shall be made effective concur-
6
rently with the application of the periodic
7
review of the adjustment factors required
8
under paragraph (1)(C) for California for
9
2012 and subsequent periods. Upon re-
10
quest, the Secretary shall make available
11
to the public any county-level or MSA de-
12
rived data used to calculate the geographic
13
practice cost index.
14
‘‘(C) REFERENCES TO FEE SCHEDULE
15
AREAS.—Effective for services furnished on or
16
after January 1, 2010, for the State of Cali-
17
fornia, any reference in this section to a fee
18
schedule area shall be deemed a reference to an
19
MSA in the State.’’.
20
(b) CONFORMING AMENDMENT TO DEFINITION OF
21 FEE SCHEDULE AREA.—Section 1848(j)(2) of the Social
22 Security Act (42 U.S.C. 1395w(j)(2)) is amended by strik-
23 ing ‘‘The term’’ and inserting ‘‘Except as provided in sub-
24 section (e)(6)(C), the term’’.
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1
PART 2—MARKET BASKET UPDATES
2 SEC. 1131. INCORPORATING PRODUCTIVITY IMPROVE-
3
MENTS INTO MARKET BASKET UPDATES
4
THAT DO NOT ALREADY INCORPORATE SUCH
5
IMPROVEMENTS.
6
(a) OUTPATIENT HOSPITALS.—
7
(1) IN GENERAL.—The first sentence of section
8
1833(t)(3)(C)(iv) of the Social Security Act (42
9
U.S.C. 1395l(t)(3)(C)(iv)) is amended—
10
(A) by inserting ‘‘(which is subject to the
11
productivity adjustment described in subclause
12
(II) of such section)’’ after
13
‘‘1886(b)(3)(B)(iii)’’; and
14
(B) by inserting ‘‘(but not below 0)’’ after
15
‘‘reduced’’.
16
(2) EFFECTIVE DATE.—The amendments made
17
by paragraph (1) shall apply to increase factors for
18
services furnished in years beginning with 2010.
19
(b) AMBULANCE SERVICES.—Section 1834(l)(3)(B)
20 of such Act (42 U.S.C. 1395m(l)(3)(B))) is amended by
21 inserting before the period at the end the following: ‘‘and,
22 in the case of years beginning with 2010, subject to the
23 productivity adjustment described in section
24 1886(b)(3)(B)(iii)(II)’’.
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266
1
(c) AMBULATORY SURGICAL CENTER SERVICES.—
2 Section 1833(i)(2)(D) of such Act (42 U.S.C.
3 1395l(i)(2)(D)) is amended—
4
(1) by redesignating clause (v) as clause (vi);
5
and
6
(2) by inserting after clause (iv) the following
7
new clause:
8
‘‘(v) In implementing the system described in clause
9 (i), for services furnished during 2010 or any subsequent
10 year, to the extent that an annual percentage change fac-
11 tor applies, such factor shall be subject to the productivity
12 adjustment described in section 1886(b)(3)(B)(iii)(II).’’.
13
(d) LABORATORY
SERVICES.—Section
14 1833(h)(2)(A)) of such Act (42 U.S.C. 1395l(h)(2)(A)) is
15 amended—
16
(1) in clause (i), by striking ‘‘for each of years
17
2009 through 2013’’ and inserting ‘‘for 2009’’; and
18
(2) clause (ii)—
19
(A) by striking ‘‘and’’ at the end of sub-
20
clause (III);
21
(B) by striking the period at the end of
22
subclause (IV) and inserting ‘‘; and’’; and
23
(C) by adding at the end the following new
24
subclause:
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267
1
‘‘(V) the annual adjustment in the fee schedules
2
determined under clause (i) for years beginning with
3
2010 shall be subject to the productivity adjustment
4
described in section 1886(b)(3)(B)(iii)(II).’’.
5
(e) CERTAIN DURABLE MEDICAL EQUIPMENT.—Sec-
6 tion 1834(a)(14) of such Act (42 U.S.C. 1395m(a)(14))
7 is amended—
8
(1) in subparagraph (K), by inserting before
9
the semicolon at the end the following: ‘‘, subject to
10
the productivity adjustment described in section
11
1886(b)(3)(B)(iii)(II)’’;
12
(2) in subparagraph (L)(i), by inserting after
13
‘‘June 2013,’’ the following: ‘‘subject to the produc-
14
tivity adjustment described in section
15
1886(b)(3)(B)(iii)(II),’’;
16
(3) in subparagraph (L)(ii), by inserting after
17
‘‘June 2013’’ the following: ‘‘, subject to the produc-
18
tivity adjustment described in section
19
1886(b)(3)(B)(iii)(II)’’; and
20
(4) in subparagraph (M), by inserting before
21
the period at the end the following: ‘‘, subject to the
22
productivity adjustment described in section
23
1886(b)(3)(B)(iii)(II)’’.
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268
1
PART 3—OTHER PROVISIONS
2 SEC. 1141. RENTAL AND PURCHASE OF POWER-DRIVEN
3
WHEELCHAIRS.
4
(a) IN GENERAL.—Section 1834(a)(7)(A)(iii) of the
5 Social Security Act (42 U.S.C. 1395m(a)(7)(A)(iii)) is
6 amended—
7
(1) in the heading, by inserting ‘‘CERTAIN COM-
8
PLEX REHABILITATIVE’’ after ‘‘OPTION FOR’’; and
9
(2) by striking ‘‘power-driven wheelchair’’ and
10
inserting ‘‘complex rehabilitative power-driven wheel-
11
chair recognized by the Secretary as classified within
12
group 3 or higher’’.
13
(b) EFFECTIVE DATE.—The amendments made by
14 subsection (a) shall take effect on January 1, 2011, and
15 shall apply to power-driven wheelchairs furnished on or
16 after such date. Such amendments shall not apply to con-
17 tracts entered into under section 1847 of the Social Secu-
18 rity Act (42 U.S.C. 1395w–3) pursuant to a bid submitted
19 under such section before October 1, 2010, under sub-
20 section (a)(1)(B)(i)(I) of such section.
21 SEC. 1142. EXTENSION OF PAYMENT RULE FOR
22
BRACHYTHERAPY.
23
Section 1833(t)(16)(C) of the Social Security Act (42
24 U.S.C. 1395l(t)(16)(C)), as amended by section 142 of the
25 Medicare Improvements for Patients and Providers Act of
26 2008 (Public Law 110–275), is amended by striking, the
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269
1 first place it appears, ‘‘January 1, 2010’’ and inserting
2 ‘‘January 1, 2012’’.
3 SEC. 1143. HOME INFUSION THERAPY REPORT TO CON-
4
GRESS.
5
Not later than 12 months after the date of enactment
6 of this Act, the Medicare Payment Advisory Commission
7 shall submit to Congress a report on the following:
8
(1) The scope of coverage for home infusion
9
therapy in the fee-for-service Medicare program
10
under title XVIII of the Social Security Act, Medi-
11
care Advantage under part C of such title, the vet-
12
eran’s health care program under chapter 17 of title
13
38, United States Code, and among private payers,
14
including an analysis of the scope of services pro-
15
vided by home infusion therapy providers to their
16
patients in such programs.
17
(2) The benefits and costs of providing such
18
coverage under the Medicare program, including a
19
calculation of the potential savings achieved through
20
avoided or shortened hospital and nursing home
21
stays as a result of Medicare coverage of home infu-
22
sion therapy.
23
(3) An assessment of sources of data on the
24
costs of home infusion therapy that might be used
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1
to construct payment mechanisms in the Medicare
2
program.
3
(4) Recommendations, if any, on the structure
4
of a payment system under the Medicare program
5
for home infusion therapy, including an analysis of
6
the payment methodologies used under Medicare Ad-
7
vantage plans and private health plans for the provi-
8
sion of home infusion therapy and their applicability
9
to the Medicare program.
10 SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS
11
(ASCS) TO SUBMIT COST DATA AND OTHER
12
DATA.
13
(a) COST REPORTING.—
14
(1) IN GENERAL.—Section 1833(i) of the Social
15
Security Act (42 U.S.C. 1395l(i)) is amended by
16
adding at the end the following new paragraph:
17
‘‘(8) The Secretary shall require, as a condition of
18 the agreement described in section 1832(a)(2)(F)(i), the
19 submission of such cost report as the Secretary may speci-
20 fy, taking into account the requirements for such reports
21 under section 1815 in the case of a hospital.’’.
22
(2) DEVELOPMENT OF COST REPORT.—Not
23
later than 3 years after the date of the enactment
24
of this Act, the Secretary of Health and Human
25
Services shall develop a cost report form for use
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1
under section 1833(i)(8) of the Social Security Act,
2
as added by paragraph (1).
3
(3) AUDIT REQUIREMENT.—The Secretary shall
4
provide for periodic auditing of cost reports sub-
5
mitted under section 1833(i)(8) of the Social Secu-
6
rity Act, as added by paragraph (1).
7
(4) EFFECTIVE DATE.—The amendment made
8
by paragraph (1) shall apply to agreements applica-
9
ble to cost reporting periods beginning 18 months
10
after the date the Secretary develops the cost report
11
form under paragraph (2).
12
(b) ADDITIONAL DATA ON QUALITY.—
13
(1) IN GENERAL.—Section 1833(i)(7) of such
14
Act (42 U.S.C. 1395l(i)(7)) is amended—
15
(A) in subparagraph (B), by inserting
16
‘‘subject to subparagraph (C),’’ after ‘‘may oth-
17
erwise provide,’’; and
18
(B) by adding at the end the following new
19
subparagraph:
20
‘‘(C) Under subparagraph (B) the Secretary shall re-
21 quire the reporting of such additional data relating to
22 quality of services furnished in an ambulatory surgical fa-
23 cility, including data on health care associated infections,
24 as the Secretary may specify.’’.
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1
(2) EFFECTIVE DATE.—The amendment made
2
by paragraph (1) shall to reporting for years begin-
3
ning with 2012.
4 SEC. 1145. TREATMENT OF CERTAIN CANCER HOSPITALS.
5
Section 1833(t) of the Social Security Act (42 U.S.C.
6 1395l(t)) is amended by adding at the end the following
7 new paragraph:
8
‘‘(18) AUTHORIZATION OF ADJUSTMENT FOR
9
CANCER HOSPITALS.—
10
‘‘(A) STUDY.—The Secretary shall conduct
11
a study to determine if, under the system under
12
this subsection, costs incurred by hospitals de-
13
scribed in section 1886(d)(1)(B)(v) with respect
14
to ambulatory payment classification groups ex-
15
ceed those costs incurred by other hospitals fur-
16
nishing services under this subsection (as deter-
17
mined appropriate by the Secretary).
18
‘‘(B) AUTHORIZATION OF ADJUSTMENT.—
19
Insofar as the Secretary determines under sub-
20
paragraph (A) that costs incurred by hospitals
21
described in section 1886(d)(1)(B)(v) exceed
22
those costs incurred by other hospitals fur-
23
nishing services under this subsection, the Sec-
24
retary shall provide for an appropriate adjust-
25
ment under paragraph (2)(E) to reflect those
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273
1
higher costs effective for services furnished on
2
or after January 1, 2011.’’.
3 SEC. 1146. MEDICARE IMPROVEMENT FUND.
4
Section 1898(b)(1)(A) of the Social Security Act (42
5 U.S.C. 1395iii(b)(1)(A)) is amended to read as follows:
6
‘‘(A) the period beginning with fiscal year
7
2011 and ending with fiscal year 2019,
8
$8,000,000,000; and’’.
9 SEC. 1147. PAYMENT FOR IMAGING SERVICES.
10
(a) ADJUSTMENT IN PRACTICE EXPENSE TO RE-
11 FLECT HIGHER PRESUMED UTILIZATION.—Section 1848
12 of the Social Security Act (42 U.S.C. 1395w) is amend-
13 ed—
14
(1) in subsection (b)(4)—
15
(A) in subparagraph (B), by striking ‘‘sub-
16
paragraph (A)’’ and inserting ‘‘this paragraph’’;
17
and
18
(B) by adding at the end the following new
19
subparagraph:
20
‘‘(C) ADJUSTMENT IN PRACTICE EXPENSE
21
TO
REFLECT
HIGHER
PRESUMED
UTILIZA-
22
TION.—In computing the number of practice
23
expense relative value units under subsection
24
(c)(2)(C)(ii) with respect to advanced diagnostic
25
imaging services (as defined in section
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1
1834(e)(1)(B)) , the Secretary shall adjust such
2
number of units so it reflects a 75 percent
3
(rather than 50 percent) presumed rate of utili-
4
zation of imaging equipment.’’; and
5
(2) in subsection (c)(2)(B)(v)(II), by inserting
6
‘‘AND OTHER PROVISIONS’’ after ‘‘OPD PAYMENT
7
CAP’’.
8
(b) ADJUSTMENT IN TECHNICAL COMPONENT ‘‘DIS-
9 COUNT’’ ON SINGLE-SESSION IMAGING TO CONSECUTIVE
10 BODY PARTS.—Section 1848(b)(4) of such Act is further
11 amended by adding at the end the following new subpara-
12 graph:
13
‘‘(D) ADJUSTMENT IN TECHNICAL COMPO-
14
NENT DISCOUNT ON SINGLE-SESSION IMAGING
15
INVOLVING
CONSECUTIVE
BODY
PARTS.—The
16
Secretary shall increase the reduction in ex-
17
penditures attributable to the multiple proce-
18
dure payment reduction applicable to the tech-
19
nical component for imaging under the final
20
rule published by the Secretary in the Federal
21
Register on November 21, 2005 (part 405 of
22
title 42, Code of Federal Regulations) from 25
23
percent to 50 percent.’’.
24
(c) EFFECTIVE DATE.—Except as otherwise pro-
25 vided, this section, and the amendments made by this sec-
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1 tion, shall apply to services furnished on or after January
2 1, 2011.
3 SEC. 1148. DURABLE MEDICAL EQUIPMENT PROGRAM IM-
4
PROVEMENTS.
5
(a) WAIVER OF SURETY BOND REQUIREMENT.—Sec-
6 tion 1834(a)(16) of the Social Security Act (42 U.S.C.
7 1395m(a)(16)) is amended by adding at the end the fol-
8 lowing: ‘‘The requirement for a surety bond described in
9 subparagraph (B) shall not apply in the case of a phar-
10 macy (i) that has been enrolled under section 1866(j) as
11 a supplier of durable medical equipment, prosthetics,
12 orthotics, and supplies and has been issued (which may
13 include renewal of) a provider number (as described in the
14 first sentence of this paragraph) for at least 5 years, and
15 (ii) for which a final adverse action (as defined in section
16 424.57(a) of title 42, Code of Federal Regulations) has
17 never been imposed.’’.
18
(b) ENSURING SUPPLY OF OXYGEN EQUIPMENT .—
19
(1) IN GENERAL.—Section 1834(a)(5)(F) of the
20
Social Security Act (42 U.S.C. 1395m(a)(5)(F)) is
21
amended—
22
(A) in clause (ii), by striking ‘‘After the’’
23
and inserting ‘‘Except as provided in clause
24
(iii), after the’’; and
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276
1
(B) by adding at the end the following new
2
clause:
3
‘‘(iii) CONTINUATION OF SUPPLY.—In
4
the case of a supplier furnishing such
5
equipment to an individual under this sub-
6
section as of the 27th month of the 36
7
months described in clause (i), the supplier
8
furnishing such equipment as of such
9
month shall continue to furnish such
10
equipment to such individual (either di-
11
rectly or though arrangements with other
12
suppliers of such equipment) during any
13
subsequent period of medical need for the
14
remainder of the reasonable useful lifetime
15
of the equipment, as determined by the
16
Secretary, regardless of the location of the
17
individual, unless another supplier has ac-
18
cepted responsibility for continuing to fur-
19
nish such equipment during the remainder
20
of such period.’’.
21
(2) EFFECTIVE DATE.—The amendments made
22
by paragraph (1) shall take effect as of the date of
23
the enactment of this Act and shall apply to the fur-
24
nishing of equipment to individuals for whom the
25
27th month of a continuous period of use of oxygen
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1
equipment described in section 1834(a)(5)(F) of the
2
Social Security Act occurs on or after July 1, 2010.
3
(c) TREATMENT OF CURRENT ACCREDITATION AP-
4 PLICATIONS.—Section 1834(a)(20)(F) of such Act (42
5 U.S.C. 1395m(a)(20)(F)) is amended—
6
(1) in clause (i)—
7
(A) by striking ‘‘clause (ii)’’ and inserting
8
‘‘clauses (ii) and (iii)’’; and
9
(B) by striking ‘‘and’’ at the end;
10
(2) by striking the period at the end of clause
11
(ii)(II) and by inserting ‘‘; and’’; and
12
(3) by adding at the end the following:
13
‘‘(iii) the requirement for accredita-
14
tion described in clause (i) shall not apply
15
for purposes of supplying diabetic testing
16
supplies, canes, and crutches in the case of
17
a pharmacy that is enrolled under section
18
1866(j) as a supplier of durable medical
19
equipment, prosthetics, orthotics, and sup-
20
plies.
21
Any supplier that has submitted an application
22
for accreditation before August 1, 2009, shall
23
be deemed as meeting applicable standards and
24
accreditation requirement under this subpara-
25
graph until such time as the independent ac-
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278
1
creditation organization takes action on the
2
supplier’s application.’’.
3
(d) RESTORING 36-MONTH OXYGEN RENTAL PE-
4 RIOD IN CASE OF SUPPLIER BANKRUPTCY FOR CERTAIN
5 INDIVIDUALS.—Section 1834(a)(5)(F) of such Act (42
6 U.S.C. 1395m(a)(5)(F)) is amended by adding at the end
7 the following new clause:
8
‘‘(iii) EXCEPTION
FOR
BANK-
9
RUPTCY.—If a supplier of oxygen to an in-
10
dividual is declared bankrupt and its assets
11
are liquidated and at the time of such dec-
12
laration and liquidation more than 24
13
months of rental payments have been
14
made, the individual may begin under this
15
subparagraph a new 36-month rental pe-
16
riod with another supplier of oxygen.’’.
17 SEC. 1149. MEDPAC STUDY AND REPORT ON BONE MASS
18
MEASUREMENT.
19
(a) IN GENERAL.—The Medicare Payment Advisory
20 Commission shall conduct a study regarding bone mass
21 measurement, including computed tomography, duel-en-
22 ergy x-ray absorptriometry, and vertebral fracture assess-
23 ment. The study shall focus on the following:
24
(1) An assessment of the adequacy of Medicare
25
payment rates for such services, taking into account
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279
1
costs of acquiring the necessary equipment, profes-
2
sional work time, and practice expense costs.
3
(2) The impact of Medicare payment changes
4
since 2006 on beneficiary access to bone mass meas-
5
urement benefits in general and in rural and minor-
6
ity communities specifically.
7
(3) A review of the clinically appropriate and
8
recommended use among Medicare beneficiaries and
9
how usage rates among such beneficiaries compares
10
to such recommendations.
11
(4) In conjunction with the findings under (3),
12
recommendations, if necessary, regarding methods
13
for reaching appropriate use of bone mass measure-
14
ment studies among Medicare beneficiaries.
15
(b) REPORT.—The Commission shall submit a report
16 to the Congress, not later than 9 months after the date
17 of the enactment of this Act, containing a description of
18 the results of the study conducted under subsection (a)
19 and the conclusions and recommendations, if any, regard-
20 ing each of the issues described in paragraphs (1), (2) (3)
21 and (4) of such subsection.
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280
1
Subtitle C—Provisions Related to
2
Medicare Parts A and B
3 SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOS-
4
PITAL READMISSIONS.
5
(a) HOSPITALS.—
6
(1) IN GENERAL.—Section 1886 of the Social
7
Security Act (42 U.S.C. 1395ww), as amended by
8
section 1103(a), is amended by adding at the end
9
the following new subsection:
10
‘‘(p) ADJUSTMENT TO HOSPITAL PAYMENTS FOR
11 EXCESS READMISSIONS.—
12
‘‘(1) IN GENERAL.—With respect to payment
13
for discharges from an applicable hospital (as de-
14
fined in paragraph (5)(C)) occurring during a fiscal
15
year beginning on or after October 1, 2011, in order
16
to account for excess readmissions in the hospital,
17
the Secretary shall reduce the payments that would
18
otherwise be made to such hospital under subsection
19
(d) (or section 1814(b)(3), as the case may be) for
20
such a discharge by an amount equal to the product
21
of—
22
‘‘(A) the base operating DRG payment
23
amount (as defined in paragraph (2)) for the
24
discharge; and
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281
1
‘‘(B) the adjustment factor (described in
2
paragraph (3)(A)) for the hospital for the fiscal
3
year.
4
‘‘(2) BASE
OPERATING
DRG
PAYMENT
5
AMOUNT.—
6
‘‘(A) IN GENERAL.—Except as provided in
7
subparagraph (B), for purposes of this sub-
8
section, the term ‘base operating DRG payment
9
amount’ means, with respect to a hospital for a
10
fiscal year, the payment amount that would
11
otherwise be made under subsection (d) for a
12
discharge if this subsection did not apply, re-
13
duced by any portion of such amount that is at-
14
tributable to payments under subparagraphs
15
(B) and (F) of paragraph (5).
16
‘‘(B) ADJUSTMENTS.—For purposes of
17
subparagraph (A), in the case of a hospital that
18
is paid under section 1814(b)(3), the term ‘base
19
operating DRG payment amount’ means the
20
payment amount under such section.
21
‘‘(3) ADJUSTMENT FACTOR.—
22
‘‘(A) IN GENERAL.—For purposes of para-
23
graph (1), the adjustment factor under this
24
paragraph for an applicable hospital for a fiscal
25
year is equal to the greater of—
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282
1
‘‘(i) the ratio described in subpara-
2
graph (B) for the hospital for the applica-
3
ble period (as defined in paragraph (5)(D))
4
for such fiscal year; or
5
‘‘(ii) the floor adjustment factor speci-
6
fied in subparagraph (C).
7
‘‘(B) RATIO.—The ratio described in this
8
subparagraph for a hospital for an applicable
9
period is equal to 1 minus the ratio of—
10
‘‘(i) the aggregate payments for ex-
11
cess readmissions (as defined in paragraph
12
(4)(A)) with respect to an applicable hos-
13
pital for the applicable period; and
14
‘‘(ii) the aggregate payments for all
15
discharges (as defined in paragraph
16
(4)(B)) with respect to such applicable
17
hospital for such applicable period.
18
‘‘(C) FLOOR ADJUSTMENT FACTOR.—For
19
purposes of subparagraph (A), the floor adjust-
20
ment factor specified in this subparagraph
21
for—
22
‘‘(i) fiscal year 2012 is 0.99;
23
‘‘(ii) fiscal year 2013 is 0.98;
24
‘‘(iii) fiscal year 2014 is 0.97; or
25
‘‘(iv) a subsequent fiscal year is 0.95.
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1
‘‘(4) AGGREGATE PAYMENTS, EXCESS READMIS-
2
SION RATIO DEFINED.—For purposes of this sub-
3
section:
4
‘‘(A) AGGREGATE PAYMENTS FOR EXCESS
5
READMISSIONS.—The term ‘aggregate payments
6
for excess readmissions’ means, for a hospital
7
for a fiscal year, the sum, for applicable condi-
8
tions (as defined in paragraph (5)(A)), of the
9
product, for each applicable condition, of—
10
‘‘(i) the base operating DRG payment
11
amount for such hospital for such fiscal
12
year for such condition;
13
‘‘(ii) the number of admissions for
14
such condition for such hospital for such
15
fiscal year; and
16
‘‘(iii) the excess readmissions ratio (as
17
defined in subparagraph (C)) for such hos-
18
pital for the applicable period for such fis-
19
cal year minus 1.
20
‘‘(B) AGGREGATE PAYMENTS FOR ALL DIS-
21
CHARGES.—The term ‘aggregate payments for
22
all discharges’ means, for a hospital for a fiscal
23
year, the sum of the base operating DRG pay-
24
ment amounts for all discharges for all condi-
25
tions from such hospital for such fiscal year.
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1
‘‘(C) EXCESS READMISSION RATIO.—
2
‘‘(i) IN GENERAL.—Subject to clauses
3
(ii) and (iii), the term ‘excess readmissions
4
ratio’ means, with respect to an applicable
5
condition for a hospital for an applicable
6
period, the ratio (but not less than 1.0)
7
of—
8
‘‘(I) the risk adjusted readmis-
9
sions based on actual readmissions, as
10
determined consistent with a readmis-
11
sion measure methodology that has
12
been endorsed under paragraph
13
(5)(A)(ii)(I), for an applicable hospital
14
for such condition with respect to the
15
applicable period; to
16
‘‘(II) the risk adjusted expected
17
readmissions (as determined con-
18
sistent with such a methodology) for
19
such hospital for such condition with
20
respect to such applicable period.
21
‘‘(ii) EXCLUSION OF CERTAIN RE-
22
ADMISSIONS.—For purposes of clause (i),
23
with respect to a hospital, excess readmis-
24
sions shall not include readmissions for an
25
applicable condition for which there are
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285
1
fewer than a minimum number (as deter-
2
mined by the Secretary) of discharges for
3
such applicable condition for the applicable
4
period and such hospital.
5
‘‘(iii) ADJUSTMENT.—In order to pro-
6
mote a reduction over time in the overall
7
rate of readmissions for applicable condi-
8
tions, the Secretary may provide, beginning
9
with discharges for fiscal year 2014, for
10
the determination of the excess readmis-
11
sions ratio under subparagraph (C) to be
12
based on a ranking of hospitals by read-
13
mission ratios (from lower to higher read-
14
mission ratios) normalized to a benchmark
15
that is lower than the 50th percentile.
16
‘‘(5) DEFINITIONS.—For purposes of this sub-
17
section:
18
‘‘(A) APPLICABLE CONDITION.—The term
19
‘applicable condition’ means, subject to sub-
20
paragraph (B), a condition or procedure se-
21
lected by the Secretary among conditions and
22
procedures for which—
23
‘‘(i) readmissions (as defined in sub-
24
paragraph (E)) that represent conditions
25
or procedures that are high volume or high
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286
1
expenditures under this title (or other cri-
2
teria specified by the Secretary); and
3
‘‘(ii) measures of such readmissions—
4
‘‘(I) have been endorsed by the
5
entity with a contract under section
6
1890(a); and
7
‘‘(II) such endorsed measures
8
have appropriate exclusions for re-
9
admissions that are unrelated to the
10
prior discharge (such as a planned re-
11
admission or transfer to another ap-
12
plicable hospital).
13
‘‘(B) EXPANSION OF APPLICABLE CONDI-
14
TIONS.—Beginning with fiscal year 2013, the
15
Secretary shall expand the applicable conditions
16
beyond the 3 conditions for which measures
17
have been endorsed as described in subpara-
18
graph (A)(ii)(I) as of the date of the enactment
19
of this subsection to the additional 4 conditions
20
that have been so identified by the Medicare
21
Payment Advisory Commission in its report to
22
Congress in June 2007 and to other conditions
23
and procedures which may include an all-condi-
24
tion measure of readmissions, as determined
25
appropriate by the Secretary. In expanding
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1
such applicable conditions, the Secretary shall
2
seek the endorsement described in subpara-
3
graph (A)(ii)(I) but may apply such measures
4
without such an endorsement.
5
‘‘(C) APPLICABLE HOSPITAL.—The term
6
‘applicable hospital’ means a subsection (d) hos-
7
pital or a hospital that is paid under section
8
1814(b)(3).
9
‘‘(D) APPLICABLE PERIOD.—The term ‘ap-
10
plicable period’ means, with respect to a fiscal
11
year, such period as the Secretary shall specify
12
for purposes of determining excess readmis-
13
sions.
14
‘‘(E) READMISSION.—The term ‘readmis-
15
sion’ means, in the case of an individual who is
16
discharged from an applicable hospital, the ad-
17
mission of the individual to the same or another
18
applicable hospital within a time period speci-
19
fied by the Secretary from the date of such dis-
20
charge. Insofar as the discharge relates to an
21
applicable condition for which there is an en-
22
dorsed measure described in subparagraph
23
(A)(ii)(I), such time period (such as 30 days)
24
shall be consistent with the time period speci-
25
fied for such measure.
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1
‘‘(6) LIMITATIONS ON REVIEW.—There shall be
2
no administrative or judicial review under section
3
1869, section 1878, or otherwise of—
4
‘‘(A) the determination of base operating
5
DRG payment amounts;
6
‘‘(B) the methodology for determining the
7
adjustment factor under paragraph (3), includ-
8
ing excess readmissions ratio under paragraph
9
(4)(C), aggregate payments for excess readmis-
10
sions under paragraph (4)(A), and aggregate
11
payments for all discharges under paragraph
12
(4)(B), and applicable periods and applicable
13
conditions under paragraph (5);
14
‘‘(C) the measures of readmissions as de-
15
scribed in paragraph (5)(A)(ii); and
16
‘‘(D) the determination of a targeted hos-
17
pital under paragraph (8)(B)(i), the increase in
18
payment under paragraph (8)(B)(ii), the aggre-
19
gate cap under paragraph (8)(C)(i), the hos-
20
pital-specific limit under paragraph (8)(C)(ii),
21
and the form of payment made by the Secretary
22
under paragraph (8)(D).
23
‘‘(7) MONITORING INAPPROPRIATE CHANGES IN
24
ADMISSIONS PRACTICES.—The Secretary shall mon-
25
itor the activities of applicable hospitals to determine
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1
if such hospitals have taken steps to avoid patients
2
at risk in order to reduce the likelihood of increasing
3
readmissions for applicable conditions. If the Sec-
4
retary determines that such a hospital has taken
5
such a step, after notice to the hospital and oppor-
6
tunity for the hospital to undertake action to allevi-
7
ate such steps, the Secretary may impose an appro-
8
priate sanction.
9
‘‘(8) ASSISTANCE TO CERTAIN HOSPITALS.—
10
‘‘(A) IN GENERAL.—For purposes of pro-
11
viding funds to applicable hospitals to take
12
steps described in subparagraph (E) to address
13
factors that may impact readmissions of indi-
14
viduals who are discharged from such a hos-
15
pital, for fiscal years beginning on or after Oc-
16
tober 1, 2011, the Secretary shall make a pay-
17
ment adjustment for a hospital described in
18
subparagraph (B), with respect to each such
19
fiscal year, by a percent estimated by the Sec-
20
retary to be consistent with subparagraph (C).
21
‘‘(B) TARGETED
HOSPITALS.—Subpara-
22
graph (A) shall apply to an applicable hospital
23
that—
24
‘‘(i) received (or, in the case of an
25
1814(b)(3) hospital, otherwise would have
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290
1
been eligible to receive) $10,000,000 or
2
more in disproportionate share payments
3
using the latest available data as estimated
4
by the Secretary; and
5
‘‘(ii) provides assurances satisfactory
6
to the Secretary that the increase in pay-
7
ment under this paragraph shall be used
8
for purposes described in subparagraph
9
(E).
10
‘‘(C) CAPS.—
11
‘‘(i) AGGREGATE CAP.—The aggregate
12
amount of the payment adjustment under
13
this paragraph for a fiscal year shall not
14
exceed 5 percent of the estimated dif-
15
ference in the spending that would occur
16
for such fiscal year with and without appli-
17
cation of the adjustment factor described
18
in paragraph (3) and applied pursuant to
19
paragraph (1).
20
‘‘(ii) HOSPITAL-SPECIFIC LIMIT.—The
21
aggregate amount of the payment adjust-
22
ment for a hospital under this paragraph
23
shall not exceed the estimated difference in
24
spending that would occur for such fiscal
25
year for such hospital with and without ap-
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291
1
plication of the adjustment factor de-
2
scribed in paragraph (3) and applied pur-
3
suant to paragraph (1).
4
‘‘(D) FORM OF PAYMENT.—The Secretary
5
may make the additional payments under this
6
paragraph on a lump sum basis, a periodic
7
basis, a claim by claim basis, or otherwise.
8
‘‘(E) USE OF ADDITIONAL PAYMENT.—
9
Funding under this paragraph shall be used by
10
targeted hospitals for transitional care activities
11
designed to address the patient noncompliance
12
issues that result in higher than normal read-
13
mission rates, such as one or more of the fol-
14
lowing:
15
‘‘(i) Providing care coordination serv-
16
ices to assist in transitions from the tar-
17
geted hospital to other settings.
18
‘‘(ii) Hiring translators and inter-
19
preters.
20
‘‘(iii) Increasing services offered by
21
discharge planners.
22
‘‘(iv) Ensuring that individuals receive
23
a summary of care and medication orders
24
upon discharge.
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292
1
‘‘(v) Developing a quality improve-
2
ment plan to assess and remedy prevent-
3
able readmission rates.
4
‘‘(vi) Assigning discharged individuals
5
to a medical home.
6
‘‘(vii) Doing other activities as deter-
7
mined appropriate by the Secretary.
8
‘‘(F) GAO REPORT ON USE OF FUNDS.—
9
Not later than 3 years after the date on which
10
funds are first made available under this para-
11
graph, the Comptroller General of the United
12
States shall submit to Congress a report on the
13
use of such funds.
14
‘‘(G) DISPROPORTIONATE
SHARE
HOS-
15
PITAL PAYMENT.—In this paragraph, the term
16
‘disproportionate share hospital payment’
17
means an additional payment amount under
18
subsection (d)(5)(F).’’.
19
(b) APPLICATION
TO
CRITICAL
ACCESS
HOS-
20 PITALS.—Section 1814(l) of the Social Security Act (42
21 U.S.C. 1395f(l)) is amended—
22
(1) in paragraph (5)—
23
(A) by striking ‘‘and’’ at the end of sub-
24
paragraph (C);
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293
1
(B) by striking the period at the end of
2
subparagraph (D) and inserting ‘‘; and’’;
3
(C) by inserting at the end the following
4
new subparagraph:
5
‘‘(E) The methodology for determining the ad-
6
justment factor under paragraph (5), including the
7
determination of aggregate payments for actual and
8
expected readmissions, applicable periods, applicable
9
conditions and measures of readmissions.’’; and
10
(D) by redesignating such paragraph as
11
paragraph (6); and
12
(2) by inserting after paragraph (4) the fol-
13
lowing new paragraph:
14
‘‘(5) The adjustment factor described in section
15 1886(p)(3) shall apply to payments with respect to a crit-
16 ical access hospital with respect to a cost reporting period
17 beginning in fiscal year 2012 and each subsequent fiscal
18 year (after application of paragraph (4) of this subsection)
19 in a manner similar to the manner in which such section
20 applies with respect to a fiscal year to an applicable hos-
21 pital as described in section 1886(p)(2).’’.
22
(c) POST ACUTE CARE PROVIDERS.—
23
(1) INTERIM POLICY.—
24
(A) IN GENERAL.—With respect to a read-
25
mission to an applicable hospital or a critical
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294
1
access hospital (as described in section 1814(l)
2
of the Social Security Act) from a post acute
3
care provider (as defined in paragraph (3)) and
4
such a readmission is not governed by section
5
412.531 of title 42, Code of Federal Regula-
6
tions, if the claim submitted by such a post-
7
acute care provider under title XVIII of the So-
8
cial Security Act indicates that the individual
9
was readmitted to a hospital from such a post-
10
acute care provider or admitted from home and
11
under the care of a home health agency within
12
30 days of an initial discharge from an applica-
13
ble hospital or critical access hospital, the pay-
14
ment under such title on such claim shall be the
15
applicable percent specified in subparagraph
16
(B) of the payment that would otherwise be
17
made under the respective payment system
18
under such title for such post-acute care pro-
19
vider if this subsection did not apply.
20
(B) APPLICABLE PERCENT DEFINED.—For
21
purposes of subparagraph (A), the applicable
22
percent is—
23
(i) for fiscal or rate year 2012 is
24
0.996;
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295
1
(ii) for fiscal or rate year 2013 is
2
0.993; and
3
(iii) for fiscal or rate year 2014 is
4
0.99.
5
(C) EFFECTIVE DATE.—Subparagraph (1)
6
shall apply to discharges or services furnished
7
(as the case may be with respect to the applica-
8
ble post acute care provider) on or after the
9
first day of the fiscal year or rate year, begin-
10
ning on or after October 1, 2011, with respect
11
to the applicable post acute care provider.
12
(2) DEVELOPMENT AND APPLICATION OF PER-
13
FORMANCE MEASURES.—
14
(A) IN
GENERAL.—The Secretary of
15
Health and Human Services shall develop ap-
16
propriate measures of readmission rates for
17
post acute care providers. The Secretary shall
18
seek endorsement of such measures by the enti-
19
ty with a contract under section 1890(a) of the
20
Social Security Act but may adopt and apply
21
such measures under this paragraph without
22
such an endorsement. The Secretary shall ex-
23
pand such measures in a manner similar to the
24
manner in which applicable conditions are ex-
25
panded under paragraph (5)(B) of section
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296
1
1886(p) of the Social Security Act, as added by
2
subsection (a).
3
(B) IMPLEMENTATION.—The Secretary
4
shall apply, on or after October 1, 2014, with
5
respect to post acute care providers, policies
6
similar to the policies applied with respect to
7
applicable hospitals and critical access hospitals
8
under the amendments made by subsection (a).
9
The provisions of paragraph (1) shall apply
10
with respect to any period on or after October
11
1, 2014, and before such application date de-
12
scribed in the previous sentence in the same
13
manner as such provisions apply with respect to
14
fiscal or rate year 2014.
15
(C) MONITORING AND PENALTIES.—The
16
provisions of paragraph (7) of such section
17
1886(p) shall apply to providers under this
18
paragraph in the same manner as they apply to
19
hospitals under such section.
20
(3) DEFINITIONS.—For purposes of this sub-
21
section:
22
(A) POST ACUTE CARE PROVIDER.—The
23
term ‘‘post acute care provider’’ means—
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297
1
(i) a skilled nursing facility (as de-
2
fined in section 1819(a) of the Social Secu-
3
rity Act);
4
(ii) an inpatient rehabilitation facility
5
(described in section 1886(h)(1)(A) of such
6
Act);
7
(iii) a home health agency (as defined
8
in section 1861(o) of such Act); and
9
(iv) a long term care hospital (as de-
10
fined in section 1861(ccc) of such Act).
11
(B) OTHER TERMS .—The terms ‘‘applica-
12
ble condition’’, ‘‘applicable hospital’’, and ‘‘re-
13
admission’’ have the meanings given such terms
14
in section 1886(p)(5) of the Social Security
15
Act, as added by subsection (a)(1).
16
(d) PHYSICIANS.—
17
(1) STUDY.—The Secretary of Health and
18
Human Services shall conduct a study to determine
19
how the readmissions policy described in the pre-
20
vious subsections could be applied to physicians.
21
(2) CONSIDERATIONS.—In conducting the
22
study, the Secretary shall consider approaches such
23
as—
24
(A) creating a new code (or codes) and
25
payment amount (or amounts) under the fee
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298
1
schedule in section 1848 of the Social Security
2
Act (in a budget neutral manner) for services
3
furnished by an appropriate physician who sees
4
an individual within the first week after dis-
5
charge from a hospital or critical access hos-
6
pital;
7
(B) developing measures of rates of read-
8
mission for individuals treated by physicians;
9
(C) applying a payment reduction for phy-
10
sicians who treat the patient during the initial
11
admission that results in a readmission; and
12
(D) methods for attributing payments or
13
payment reductions to the appropriate physi-
14
cian or physicians.
15
(3) REPORT.—The Secretary shall issue a pub-
16
lic report on such study not later than the date that
17
is one year after the date of the enactment of this
18
Act.
19
(e) FUNDING.—For purposes of carrying out the pro-
20 visions of this section, in addition to funds otherwise avail-
21 able, out of any funds in the Treasury not otherwise ap-
22 propriated, there are appropriated to the Secretary of
23 Health and Human Services for the Center for Medicare
24 & Medicaid Services Program Management Account
25 $25,000,000 for each fiscal year beginning with 2010.
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299
1 Amounts appropriated under this subsection for a fiscal
2 year shall be available until expended.
3 SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM
4
PLAN AND BUNDLING PILOT PROGRAM.
5
(a) PLAN.—
6
(1) IN GENERAL.—The Secretary of Health and
7
Human Services (in this section referred to as the
8
‘‘Secretary’’) shall develop a detailed plan to reform
9
payment for post acute care (PAC) services under
10
the Medicare program under title XVIII of the So-
11
cial Security Act (in this section referred to as the
12
‘‘Medicare program)’’. The goals of such payment
13
reform are to—
14
(A) improve the coordination, quality, and
15
efficiency of such services; and
16
(B) improve outcomes for individuals such
17
as reducing the need for readmission to hos-
18
pitals from providers of such services.
19
(2) BUNDLING POST ACUTE SERVICES.—The
20
plan described in paragraph (1) shall include de-
21
tailed specifications for a bundled payment for post
22
acute services (in this section referred to as the
23
‘‘post acute care bundle’’), and may include other
24
approaches determined appropriate by the Secretary.
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300
1
(3) POST ACUTE SERVICES.—For purposes of
2
this section, the term ‘‘post acute services’’ means
3
services for which payment may be made under the
4
Medicare program that are furnished by skilled
5
nursing facilities, inpatient rehabilitation facilities,
6
long term care hospitals, hospital based outpatient
7
rehabilitation facilities and home health agencies to
8
an individual after discharge of such individual from
9
a hospital, and such other services determined ap-
10
propriate by the Secretary.
11
(b) DETAILS.—The plan described in subsection
12 (a)(1) shall include consideration of the following issues:
13
(1) The nature of payments under a post acute
14
care bundle, including the type of provider or entity
15
to whom payment should be made, the scope of ac-
16
tivities and services included in the bundle, whether
17
payment for physicians’ services should be included
18
in the bundle, and the period covered by the bundle.
19
(2) Whether the payment should be consoli-
20
dated with the payment under the inpatient prospec-
21
tive system under section 1886 of the Social Secu-
22
rity Act (in this section referred to as MS–DRGs)
23
or a separate payment should be established for such
24
bundle, and if a separate payment is established,
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301
1
whether it should be made only upon use of post
2
acute care services or for every discharge.
3
(3) Whether the bundle should be applied
4
across all categories of providers of inpatient serv-
5
ices (including critical access hospitals) and post
6
acute care services or whether it should be limited
7
to certain categories of providers, services, or dis-
8
charges, such as high volume or high cost MS–
9
DRGs.
10
(4) The extent to which payment rates could be
11
established to achieve offsets for efficiencies that
12
could be expected to be achieved with a bundle pay-
13
ment, whether such rates should be established on a
14
national basis or for different geographic areas,
15
should vary according to discharge, case mix,
16
outliers, and geographic differences in wages or
17
other appropriate adjustments, and how to update
18
such rates.
19
(5) The nature of protections needed for indi-
20
viduals under a system of bundled payments to en-
21
sure that individuals receive quality care, are fur-
22
nished the level and amount of services needed as
23
determined by an appropriate assessment instru-
24
ment, are offered choice of provider, and the extent
25
to which transitional care services would improve
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302
1
quality of care for individuals and the functioning of
2
a bundled post-acute system.
3
(6) The nature of relationships that may be re-
4
quired between hospitals and providers of post acute
5
care services to facilitate bundled payments, includ-
6
ing the application of gainsharing, anti-referral,
7
anti-kickback, and anti-trust laws.
8
(7) Quality measures that would be appropriate
9
for reporting by hospitals and post acute providers
10
(such as measures that assess changes in functional
11
status and quality measures appropriate for each
12
type of post acute services provider including how
13
the reporting of such quality measures could be co-
14
ordinated with other reporting of such quality meas-
15
ures by such providers otherwise required).
16
(8) How cost-sharing for a post acute care bun-
17
dle should be treated relative to current rules for
18
cost-sharing for inpatient hospital, home health,
19
skilled nursing facility, and other services.
20
(9) How other programmatic issues should be
21
treated in a post acute care bundle, including rules
22
specific to various types of post-acute providers such
23
as the post-acute transfer policy, three-day hospital
24
stay to qualify for services furnished by skilled nurs-
25
ing facilities, and the coordination of payments and
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303
1
care under the Medicare program and the Medicaid
2
program.
3
(10) Such other issues as the Secretary deems
4
appropriate.
5
(c) CONSULTATIONS AND ANALYSIS.—
6
(1) CONSULTATION WITH STAKEHOLDERS.—In
7
developing the plan under subsection (a)(1), the Sec-
8
retary shall consult with relevant stakeholders and
9
shall consider experience with such research studies
10
and demonstrations that the Secretary determines
11
appropriate.
12
(2) ANALYSIS AND DATA COLLECTION.—In de-
13
veloping such plan, the Secretary shall—
14
(A) analyze the issues described in sub-
15
section (b) and other issues that the Secretary
16
determines appropriate;
17
(B) analyze the impacts (including geo-
18
graphic impacts) of post acute service reform
19
approaches, including bundling of such services
20
on individuals, hospitals, post acute care pro-
21
viders, and physicians;
22
(C) use existing data (such as data sub-
23
mitted on claims) and collect such data as the
24
Secretary determines are appropriate to develop
25
such plan required in this section; and
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304
1
(D) if patient functional status measures
2
are appropriate for the analysis, to the extent
3
practical, build upon the CARE tool being de-
4
veloped pursuant to section 5008 of the Deficit
5
Reduction Act of 2005.
6
(d) ADMINISTRATION.—
7
(1) FUNDING.—For purposes of carrying out
8
the provisions of this section, in addition to funds
9
otherwise available, out of any funds in the Treasury
10
not otherwise appropriated, there are appropriated
11
to the Secretary for the Center for Medicare & Med-
12
icaid Services Program Management Account
13
$15,000,000 for each of the fiscal years 2010
14
through 2012. Amounts appropriated under this
15
paragraph for a fiscal year shall be available until
16
expended.
17
(2) EXPEDITED DATA COLLECTION.—Chapter
18
35 of title 44, United States Code shall not apply to
19
this section.
20
(e) PUBLIC REPORTS.—
21
(1) INTERIM REPORTS.—The Secretary shall
22
issue interim public reports on a periodic basis on
23
the plan described in subsection (a)(1), the issues
24
described in subsection (b), and impact analyses as
25
the Secretary determines appropriate.
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305
1
(2) FINAL REPORT.—Not later than the date
2
that is 3 years after the date of the enactment of
3
this Act, the Secretary shall issue a final public re-
4
port on such plan, including analysis of issues de-
5
scribed in subsection (b) and impact analyses.
6
(f) CONVERSION OF ACUTE CARE EPISODE DEM-
7 ONSTRATION TO PILOT PROGRAM AND EXPANSION TO IN-
8 CLUDE POST ACUTE SERVICES.—
9
(1) IN GENERAL.—Part E of title XVIII of the
10
Social Security Act is amended by inserting after
11
section 1866C the following new section:
12 ‘‘SEC. 1866D. CONVERSION OF ACUTE CARE EPISODE DEM-
13
ONSTRATION TO PILOT PROGRAM AND EX-
14
PANSION TO INCLUDE POST ACUTE SERV-
15
ICES.
16
‘‘(a) IN GENERAL.—By not later than January 1,
17 2011, the Secretary shall, for the purpose of promoting
18 the use of bundled payments to promote efficient and high
19 quality delivery of care—
20
‘‘(1) convert the acute care episode demonstra-
21
tion program conducted under section 1866C to a
22
pilot program; and
23
‘‘(2) subject to subsection (c), expand such pro-
24
gram as so converted to include post acute services
25
and such other services the Secretary determines to
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306
1
be appropriate, which may include transitional serv-
2
ices.
3
‘‘(b) SCOPE.—The pilot program under subsection
4 (a) may include additional geographic areas and additional
5 conditions which account for significant program spend-
6 ing, as defined by the Secretary. Nothing in this sub-
7 section shall be construed as limiting the number of hos-
8 pital and physician groups or the number of hospital and
9 post-acute provider groups that may participate in the
10 pilot program.
11
‘‘(c) LIMITATION.—The Secretary shall only expand
12 the pilot program under subsection (a)(2) if the Secretary
13 finds that—
14
‘‘(1) the demonstration program under section
15
1866C and pilot program under this section main-
16
tain or increase the quality of care received by indi-
17
viduals enrolled under this title; and
18
‘‘(2) such demonstration program and pilot pro-
19
gram reduce program expenditures and, based on
20
the certification under subsection (d), that the ex-
21
pansion of such pilot program would result in esti-
22
mated spending that would be less than what spend-
23
ing would otherwise be in the absence of this section.
24
‘‘(d) CERTIFICATION.—For purposes of subsection
25 (c), the Chief Actuary of the Centers for Medicare & Med-
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307
1 icaid Services shall certify whether expansion of the pilot
2 program under this section would result in estimated
3 spending that would be less than what spending would
4 otherwise be in the absence of this section.
5
‘‘(e) VOLUNTARY PARTICIPATION.—Nothing in this
6 paragraph shall be construed as requiring the participa-
7 tion of an entity in the pilot program under this section.’’.
8
(2) CONFORMING
AMENDMENT.—Section
9
1866C(b) of the Social Security Act (42 U.S.C.
10
1395cc–3(b)) is amended by striking ‘‘The Sec-
11
retary’’ and inserting ‘‘Subject to section 1866D, the
12
Secretary’’.
13 SEC. 1153. HOME HEALTH PAYMENT UPDATE FOR 2010.
14
Section 1895(b)(3)(B)(ii) of the Social Security Act
15 (42 U.S.C. 1395fff(b)(3)(B)(ii)) is amended—
16
(1) in subclause (IV), by striking ‘‘and’’;
17
(2) by redesignating subclause (V) as subclause
18
(VII); and
19
(3) by inserting after subclause (IV) the fol-
20
lowing new subclauses:
21
‘‘(V) 2007, 2008, and 2009, sub-
22
ject to clause (v), the home health
23
market basket percentage increase;
24
‘‘(VI) 2010, subject to clause (v),
25
0 percent; and’’.
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308
1 SEC. 1154. PAYMENT ADJUSTMENTS FOR HOME HEALTH
2
CARE.
3
(a) ACCELERATION OF ADJUSTMENT FOR CASE MIX
4 CHANGES.—Section 1895(b)(3)(B) of the Social Security
5 Act (42 U.S.C. 1395fff(b)(3)(B)) is amended—
6
(1) in clause (iv), by striking ‘‘Insofar as’’ and
7
inserting ‘‘Subject to clause (vi), insofar as’’; and
8
(2) by adding at the end the following new
9
clause:
10
‘‘(vi) SPECIAL RULE FOR CASE MIX
11
CHANGES FOR 2011.—
12
‘‘(I) IN GENERAL.—With respect
13
to the case mix adjustments estab-
14
lished in section 484.220(a) of title
15
42, Code of Federal Regulations, the
16
Secretary shall apply, in 2010, the ad-
17
justment established in paragraph (3)
18
of such section for 2011, in addition
19
to applying the adjustment established
20
in paragraph (2) for 2010.
21
‘‘(II) CONSTRUCTION.—Nothing
22
in this clause shall be construed as
23
limiting the amount of adjustment for
24
case mix for 2010 or 2011 if more re-
25
cent data indicate an appropriate ad-
26
justment that is greater than the
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309
1
amount established in the section de-
2
scribed in subclause (I).’’.
3
(b) REBASING HOME HEALTH PROSPECTIVE PAY-
4 MENT AMOUNT.—Section 1895(b)(3)(A) of the Social Se-
5 curity Act (42 U.S.C. 1395fff(b)(3)(A)) is amended—
6
(1) in clause (i)—
7
(A) in subclause (III), by inserting ‘‘and
8
before 2011’’ after ‘‘after the period described
9
in subclause (II)’’; and
10
(B) by inserting after subclause (III) the
11
following new subclauses:
12
‘‘(IV) Subject to clause (iii)(I),
13
for 2011, such amount (or amounts)
14
shall be adjusted by a uniform per-
15
centage determined to be appropriate
16
by the Secretary based on analysis of
17
factors such as changes in the average
18
number and types of visits in an epi-
19
sode, the change in intensity of visits
20
in an episode, growth in cost per epi-
21
sode, and other factors that the Sec-
22
retary considers to be relevant.
23
‘‘(V) Subject to clause (iii)(II),
24
for a year after 2011, such a amount
25
(or amounts) shall be equal to the
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310
1
amount (or amounts) determined
2
under this clause for the previous
3
year, updated under subparagraph
4
(B).’’; and
5
(2) by adding at the end the following new
6
clause:
7
‘‘(iii) SPECIAL RULE IN CASE OF IN-
8
ABILITY TO EFFECT TIMELY REBASING.—
9
‘‘(I) APPLICATION
OF
PROXY
10
AMOUNT FOR 2011.—If the Secretary
11
is not able to compute the amount (or
12
amounts) under clause (i)(IV) so as to
13
permit, on a timely basis, the applica-
14
tion of such clause for 2011, the Sec-
15
retary shall substitute for such
16
amount (or amounts) 95 percent of
17
the amount (or amounts) that would
18
otherwise be specified under clause
19
(i)(III) if it applied for 2011.
20
‘‘(II) ADJUSTMENT FOR SUBSE-
21
QUENT YEARS BASED ON DATA.—If
22
the Secretary applies subclause (I),
23
the Secretary before July 1, 2011,
24
shall compare the amount (or
25
amounts) applied under such sub-
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