TITLE I--
PROTECTIONS AND STANDARDS
FOR QUALIFIED HEALTH BENEFITS PLANS
Fast-forward to
Title II
Subtitle A--General
Standards
SEC. 101. REQUIREMENTS REFORMING HEALTH
INSURANCE MARKETPLACE.
- (a) Purpose- The
purpose of this title is to establish standards to ensure that new
health insurance coverage and employment-based health plans that are
offered meet standards guaranteeing access to affordable coverage,
essential benefits, and other consumer protections.
(b)
Requirements for Qualified Health Benefits Plans- On or after the
first day of Y1, a health benefits plan shall not be a qualified
health benefits plan under this division unless the plan meets the
applicable requirements of the following subtitles for the type of
plan and plan year involved:
- (1) Subtitle
B (relating to affordable coverage).
(2) Subtitle C (relating
to essential benefits).
(3) Subtitle D (relating to consumer
protection).
- (c) Terminology-
In this division:
- (1)
ENROLLMENT IN EMPLOYMENT-BASED HEALTH PLANS- An individual shall
be treated as being ‘enrolled’ in an employment-based health
plan if the individual is a participant or beneficiary (as such
terms are defined in section 3(7) and 3(8), respectively, of the
Employee Retirement Income Security Act of 1974) in such
plan.
(2) INDIVIDUAL AND GROUP HEALTH INSURANCE COVERAGE- The
terms ‘individual health insurance coverage’ and ‘group health
insurance coverage’ mean health insurance coverage offered in
the individual market or large or small group market,
respectively, as defined in section 2791 of the Public Health
Service Act.
SEC. 102. PROTECTING THE CHOICE TO
KEEP CURRENT COVERAGE.
- (a)
Grandfathered Health Insurance Coverage Defined- Subject to the
succeeding provisions of this section, for purposes of establishing
acceptable coverage under this division, the term ‘grandfathered
health insurance coverage’ means individual health insurance
coverage that is offered and in force and effect before the first
day of Y1 if the following conditions are met:
- (1)
LIMITATION ON NEW ENROLLMENT-
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(A)
IN GENERAL- Except as provided in this paragraph, the
individual health insurance issuer offering such coverage
does not enroll any individual in such coverage if the first
effective date of coverage is on or after the first day of
Y1.
(B) DEPENDENT COVERAGE PERMITTED- Subparagraph (A)
shall not affect the subsequent enrollment of a dependent of
an individual who is covered as of such first day.
- (2)
LIMITATION ON CHANGES IN TERMS OR CONDITIONS- Subject to
paragraph (3) and except as required by law, the issuer does not
change any of its terms or conditions, including benefits and
cost-sharing, from those in effect as of the day before the
first day of Y1.
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(3)
RESTRICTIONS ON PREMIUM INCREASES- The issuer cannot vary the
percentage increase in the premium for a risk group of enrollees
in specific grandfathered health insurance coverage without
changing the premium for all enrollees in the same risk group at
the same rate, as specified by the Commissioner.
- (b) Grace Period
for Current Employment-based Health Plans-
- (1) GRACE
PERIOD-
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(A)
IN GENERAL- The Commissioner shall establish a grace period
whereby, for plan years beginning after the end of the
5-year period beginning with Y1, an employment-based health
plan in operation as of the day before the first day of Y1
must meet the same requirements as apply to a qualified
health benefits plan under section 101, including the
essential benefit package requirement under section
121.
(B) EXCEPTION FOR LIMITED BENEFITS PLANS- Subparagraph
(A) shall not apply to an employment-based health plan in
which the coverage consists only of one or more of the
following:
- (i)
Any coverage described in section 3001(a)(1)(B)(ii)(IV)
of division B of the American Recovery and Reinvestment
Act of 2009 (Public Law 111-5).
(ii) Excepted benefits
(as defined in section 733(c) of the Employee Retirement
Income Security Act of 1974), including coverage under a
specified disease or illness policy described in
paragraph (3)(A) of such section.
(iii) Such other
limited benefits as the Commissioner may specify.
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In
no case shall an employment-based health plan in which the
coverage consists only of one or more of the coverage or
benefits described in clauses (i) through (iii) be treated
as acceptable coverage under this division
- (2)
TRANSITIONAL TREATMENT AS ACCEPTABLE COVERAGE- During the grace
period specified in paragraph (1)(A), an employment-based health
plan that is described in such paragraph shall be treated as
acceptable coverage under this division.
- (c) Limitation
on Individual Health Insurance Coverage-
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(1)
IN GENERAL- Individual health insurance coverage that is not
grandfathered health insurance coverage under subsection (a) may
only be offered on or after the first day of Y1 as an
Exchange-participating health benefits plan.
(2) SEPARATE,
EXCEPTED COVERAGE PERMITTED- Excepted benefits (as defined in
section 2791(c) of the Public Health Service Act) are not
included within the definition of health insurance coverage.
Nothing in paragraph (1) shall prevent the offering, other than
through the Health Insurance Exchange, of excepted benefits so
long as it is offered and priced separately from health
insurance coverage.
Subtitle B--Standards
Guaranteeing Access to Affordable Coverage
SEC. 111. PROHIBITING PRE-EXISTING
CONDITION EXCLUSIONS.
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A
qualified health benefits plan may not impose any pre-existing
condition exclusion (as defined in section 2701(b)(1)(A) of the
Public Health Service Act) or otherwise impose any limit or
condition on the coverage under the plan with respect to an
individual or dependent based on any health status-related factors
(as defined in section 2791(d)(9) of the Public Health Service Act)
in relation to the individual or dependent.
SEC. 112. GUARANTEED ISSUE AND
RENEWAL FOR INSURED PLANS.
- The requirements
of sections 2711 (other than subsections (c) and (e)) and 2712
(other than paragraphs (3), and (6) of subsection (b) and subsection
(e)) of the Public Health Service Act, relating to
guaranteed
availability and re-newability of health insurance coverage, shall
apply to individuals and employers in all individual and group
health insurance coverage, whether offered to individuals or
employers through the Health Insurance Exchange,
through any employment-based health plan, or otherwise, in the same
manner as such sections apply to employers and health insurance
coverage offered in the small group market, except that such section
2712(b)(1) shall apply only if, before non-renewal or
discontinuation of coverage, the issuer has provided the enrollee
with notice of non-payment of premiums and there is a grace period
during which the enrollees has an opportunity to correct such
nonpayment.
Rescissions of such coverage shall be prohibited except in cases of
fraud as defined in sections 2712(b)(2) of such Act.
SEC. 113. INSURANCE RATING RULES.
- (a) In General-
The premium
rate charged for an insured qualified health benefits plan may not
vary except as follows:
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(1)
LIMITED AGE VARIATION PERMITTED- By age (within such age
categories as the Commissioner shall specify) so long as the
ratio of
the highest such premium to the lowest such premium does not
exceed the ratio of 2 to 1.
(2)
BY AREA- By premium rating area (as permitted by State insurance
regulators or, in the case of Exchange-participating health
benefits plans, as specified by the Commissioner in consultation
with such regulators).
(3) BY FAMILY ENROLLMENT- By family
enrollment (such as variations within categories and
compositions of families) so long as the ratio of the premium
for family enrollment (or enrollments) to the premium for
individual enrollment is uniform, as specified under State law
and consistent with rules of the Commissioner.
- (b) Study and
Reports-
- (1) STUDY-
The Commissioner, in coordination with the Secretary of Health
and Human Services and the Secretary of Labor, shall conduct a
study of the large group insured and self-insured employer
health care markets. Such study shall examine the following:
- (A) The
types of employers by key characteristics, including size,
that purchase insured products versus those that
self-insure.
(B) The similarities and differences between
typical insured and self-insured health plans.
(C) The
financial solvency and capital reserve levels of employers
that self-insure by employer size.
(D) The risk of
self-insured employers not being able to pay obligations or
otherwise becoming financially insolvent.
(E) The extent to
which rating rules are likely to cause adverse selection in
the large group market or to encourage small and mid size
employers to self-insure
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(2)
REPORTS- Not later than 18 months after the date of the
enactment of this Act, the Commissioner shall submit to Congress
and the applicable agencies a report on the study conducted
under paragraph (1). Such report shall include any
recommendations the Commissioner deems appropriate to ensure
that the law does not provide incentives for small and mid-size
employers to self-insure or create adverse selection in the risk
pools of large group insurers and self-insured employers. Not
later than 18 months after the first day of Y1, the Commissioner
shall submit to Congress and the applicable agencies an updated
report on such study, including updates on such
recommendations.
SEC. 114. NONDISCRIMINATION IN
BENEFITS; PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS.
- (a)
Nondiscrimination in
Benefits- A qualified health benefits plan shall comply with
standards established by the Commissioner to prohibit discrimination
in health
benefits or benefit structures for qualifying health benefits plans,
building from sections 702 of Employee Retirement Income Security
Act of 1974, 2702 of the Public Health Service Act, and section 9802
of the Internal Revenue Code of 1986.
(b)
Parity in Mental
Health and Substance Abuse Disorder Benefits-
To the extent such provisions are not superceded by or inconsistent
with subtitle C, the provisions of section 2705 (other than
subsections (a)(1), (a)(2), and (c)) of section 2705 of the Public
Health Service Act shall apply to a qualified health benefits plan,
regardless of whether it is offered in the individual or group
market, in the same manner as such provisions apply to health
insurance coverage offered in the large group market.
SEC. 115. ENSURING ADEQUACY OF
PROVIDER NETWORKS.
- (a) In General-
A qualified health benefits plan that uses a provider network for
items and services shall meet such standards respecting provider
networks as the Commissioner may establish to assure the adequacy of
such networks in ensuring enrollee access to such items and services
and transparency in the cost-sharing differentials between
in-network coverage and out-of-network coverage.
(b) Provider
Network Defined- In this division, the term ‘provider network’ means
the providers with respect to which covered benefits, treatments,
and services are available under a health benefits plan.
SEC. 116. ENSURING VALUE AND LOWER
PREMIUMS.
- (a) In General-
A qualified health benefits plan shall meet a medical loss ratio as
defined by the Commissioner. For any plan year in which the
qualified health benefits plan does not meet such medical loss
ratio, QHBP offering entity shall provide in
a manner specified by
the Commissioner for rebates to enrollees of payment sufficient to
meet such loss ratio.
- (b) Building on
Interim Rules- In implementing subsection (a), the Commissioner
shall build on the definition and methodology developed by the
Secretary of Health and Human Services under the amendments made by
section 161 for determining how to calculate the medical loss ratio.
Such methodology shall be set at the highest level medical loss
ratio possible that is designed to ensure adequate participation by
QHBP offering entities, competition in the health insurance market
in and out of the Health Insurance Exchange, and value for consumers
so that their premiums are used for services.
Subtitle C--Standards
Guaranteeing Access to Essential Benefits
SEC. 121. COVERAGE OF ESSENTIAL
BENEFITS PACKAGE.
- (a) In General-
A qualified health benefits plan shall provide coverage that at
least meets the benefit standards adopted under section 124 for the
essential benefits package described in section 122 for the plan
year involved.
(b)
Choice of Coverage-
- (1)
NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of
a qualified health benefits plan that is not an
Exchange-participating health benefits plan, such plan may offer
such coverage in addition to the essential benefits package as
the QHBP offering entity may specify.
(2)
EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of an
Exchange-participating health benefits plan, such plan is
required under section 203 to provide specified levels of
benefits and, in the case of a plan offering a premium-plus
level of benefits, provide additional benefits.
(3)
CONTINUATION OF OFFERING OF SEPARATE EXCEPTED BENEFITS COVERAGE-
Nothing in this division shall be construed as affecting the
offering of health benefits in the form of excepted benefits
(described in section 102(b)(1)(B)(ii)) if such benefits are
offered under a separate policy, contract, or certificate of
insurance.
- (c) No
Restrictions on Coverage Unrelated to Clinical Appropriateness- A
qualified health benefits plan may not impose any restriction (other
than cost-sharing) unrelated to clinical appropriateness on the
coverage of the health care items and services.
SEC. 122. ESSENTIAL BENEFITS PACKAGE
DEFINED.
- (a) In General-
In this division, the term ‘essential benefits package’ means health
benefits coverage, consistent with standards adopted under section
124 to ensure the provision of quality health care and financial
security, that--
- (1) provides
payment for the items and services described in subsection (b)
in accordance with generally accepted standards of medical or
other appropriate clinical or professional practice;
(2) limits
cost-sharing for such covered health care items and services in
accordance with such benefit standards, consistent with
subsection (c);
(3) does not impose any annual or lifetime
limit on the coverage of covered health care items and
services;
(4) complies with section 115(a) (relating to network
adequacy); and
(5) is equivalent, as certified by Office of the
Actuary of the Centers for Medicare & Medicaid Services, to the
average prevailing employer-sponsored coverage.
- (b) Minimum
Services To Be Covered- The items and services described in this
subsection are the following:
- (1)
Hospitalization.
(2) Outpatient hospital and outpatient clinic
services, including emergency department services.
(3)
Professional services of physicians and other health
professionals.
(4) Such services, equipment, and supplies
incident to the services of a physician’s or a health
professional’s delivery of care in institutional settings,
physician offices, patients’ homes or place of residence, or
other settings, as appropriate.
(5) Prescription drugs.
(6)
Rehabilitative and habilitative services.
(7) Mental health and
substance use disorder services.
(8) Preventive services,
including those services recommended with a grade of A or B by
the Task Force on Clinical Preventive Services and those
vaccines recommended for use by the Director of the Centers for
Disease Control and Prevention.
(9) Maternity care.
(10) Well
baby and well child care and oral health, vision, and hearing
services, equipment, and supplies at least for children under 21
years of age.
- (c) Requirements
Relating to Cost-sharing and Minimum Actuarial Value-
- (1) NO
COST-SHARING FOR PREVENTIVE SERVICES- There shall be no
cost-sharing under the essential benefits package for preventive
items and services (as specified under the benefit standards),
including well baby and well child care.
(2) ANNUAL
LIMITATION-
- (A)
ANNUAL LIMITATION- The cost-sharing incurred under the
essential benefits package with respect to an individual (or
family) for a year does not exceed the applicable level
specified in subparagraph (B).
(B) APPLICABLE LEVEL- The
applicable level specified in this subparagraph for Y1 is
$5,000 for an individual and $10,000 for a family. Such
levels shall be increased (rounded to the nearest $100) for
each subsequent year by the annual percentage increase in
the Consumer Price Index (United States city average)
applicable to such year.
(C) USE OF COPAYMENTS- In
establishing cost-sharing levels for basic, enhanced, and
premium plans under this subsection, the Secretary shall, to
the maximum extent possible, use only copayments and not
coinsurance.
- (3) MINIMUM
ACTUARIAL VALUE-
- (A) IN
GENERAL- The cost-sharing under the essential benefits
package shall be designed to provide a level of coverage
that is designed to provide benefits that are actuarially
equivalent to approximately 70 percent of the full actuarial
value of the benefits provided under the reference benefits
package described in subparagraph (B).
(B) REFERENCE
BENEFITS PACKAGE DESCRIBED- The reference benefits package
described in this subparagraph is the essential benefits
package if there were no cost-sharing imposed.
SEC. 123. HEALTH BENEFITS ADVISORY
COMMITTEE.
- (a)
Establishment-
- (1) IN
GENERAL- There is established a private-public advisory
committee which shall be a panel of medical and other experts to
be known as the Health Benefits Advisory Committee to recommend
covered benefits and essential, enhanced, and premium
plans.
(2) CHAIR- The Surgeon General shall be a member and the
chair of the Health Benefits Advisory Committee.
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(3)
MEMBERSHIP- The Health Benefits Advisory Committee shall be
composed of the following members, in addition to the Surgeon
General:
- (A) 9
members who are not Federal employees or officers and who
are appointed by the President.
(B) 9 members who are not
Federal employees or officers and who are appointed by the
Comptroller General of the United States in a manner similar
to the manner in which the Comptroller General appoints
members to the Medicare Payment Advisory Commission under
section 1805(c) of the Social Security Act.
(C) Such even
number of members (not to exceed 8) who are Federal
employees and officers, as the President may appoint.
- Such initial
appointments shall be made not later than 60 days after the date
of the enactment of this Act.
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(4)
TERMS- Each member of the Health Benefits Advisory Committee
shall serve a 3-year term on the Committee, except that the
terms of the initial members shall be adjusted in order to
provide for a staggered term of appointment for all such
members.
(5) PARTICIPATION- The membership of the Health
Benefits Advisory Committee shall at least reflect providers,
consumer representatives, employers, labor, health insurance
issuers, experts in health care financing and delivery, experts
in racial and ethnic disparities, experts in care for those with
disabilities, representatives of relevant governmental agencies.
and at least one practicing physician or other health
professional and an expert on children’s health and shall
represent a balance among various sectors of the health care
system so that no single sector unduly influences the
recommendations of such Committee.
- (b) Duties-
- (1)
RECOMMENDATIONS ON BENEFIT STANDARDS- The Health Benefits
Advisory Committee shall recommend to the Secretary of Health
and Human Services (in this subtitle referred to as the
‘Secretary’) benefit standards (as defined in paragraph (4)),
and periodic updates to such standards. In developing such
recommendations, the Committee shall take into account
innovation in health care and consider how such standards could
reduce health disparities.
(2) DEADLINE- The Health Benefits
Advisory Committee shall recommend initial benefit standards to
the Secretary not later than 1 year after the date of the
enactment of this Act.
(3) PUBLIC INPUT- The Health Benefits
Advisory Committee shall allow for public input as a part of
developing recommendations under this subsection.
(4) BENEFIT
STANDARDS DEFINED- In this subtitle, the term ‘benefit
standards’ means standards respecting--
- (A) the
essential benefits package described in section 122,
including categories of covered treatments, items and
services within benefit classes, and cost-sharing; and
(B)
the cost-sharing levels for enhanced plans and premium plans
(as provided under section 203(c)) consistent with paragraph
(5).
- (5) LEVELS
OF COST-SHARING FOR ENHANCED AND PREMIUM PLANS-
- (A)
ENHANCED PLAN- The level of cost-sharing for enhanced plans
shall be designed so that such plans have benefits that are
actuarially equivalent to approximately 85 percent of the
actuarial value of the benefits provided under the reference
benefits package described in section 122(c)(3)(B).
(B)
PREMIUM PLAN- The level of cost-sharing for premium plans
shall be designed so that such plans have benefits that are
actuarially equivalent to approximately 95 percent of the
actuarial value of the benefits provided under the reference
benefits package described in section 122(c)(3)(B).
- (c) Operations-
- (1) PER DIEM
PAY- Each member of the Health Benefits Advisory Committee shall
receive travel expenses, including per diem in accordance with
applicable provisions under subchapter I of chapter 57 of title
5, United States Code, and shall otherwise serve without
additional pay.
(2) MEMBERS NOT TREATED AS FEDERAL EMPLOYEES-
Members of the Health Benefits Advisory Committee shall not be
considered employees of the Federal government solely by reason
of any service on the Committee.
(3) APPLICATION OF FACA- The
Federal Advisory Committee Act (5 U.S.C. App.), other than
section 14, shall apply to the Health Benefits Advisory
Committee.
- (d) Publication-
The Secretary shall provide for publication in the Federal Register
and the posting on the Internet website of the Department of Health
and Human Services of all recommendations made by the Health
Benefits Advisory Committee under this section.
SEC. 124. PROCESS FOR ADOPTION OF
RECOMMENDATIONS; ADOPTION OF BENEFIT STANDARDS.
- (a) Process for
Adoption of Recommendations-
- (1) REVIEW
OF RECOMMENDED STANDARDS- Not later than 45 days after the date
of receipt of benefit standards recommended under section 123
(including such standards as modified under paragraph (2)(B)),
the Secretary shall review such standards and shall determine
whether to propose adoption of such standards as a package.
(2)
DETERMINATION TO ADOPT STANDARDS- If the Secretary determines--
- (A) to
propose adoption of benefit standards so recommended as a
package, the Secretary shall, by regulation under section
553 of title 5, United States Code, propose adoption such
standards; or
(B) not to propose adoption of such standards
as a package, the Secretary shall notify the Health Benefits
Advisory Committee in writing of such determination and the
reasons for not proposing the adoption of such
recommendation and provide the Committee with a further
opportunity to modify its previous recommendations and
submit new recommendations to the Secretary on a timely
basis.
- (3)
CONTINGENCY- If, because of the application of paragraph (2)(B),
the Secretary would otherwise be unable to propose initial
adoption of such recommended standards by the deadline specified
in subsection (b)(1), the Secretary shall, by regulation under
section 553 of title 5, United States Code, propose adoption of
initial benefit standards by such deadline.
(4) PUBLICATION-
The Secretary shall provide for publication in the Federal
Register of all determinations made by the Secretary under this
subsection.
- (b) Adoption of
Standards-
- (1) INITIAL
STANDARDS- Not later than 18 months after the date of the
enactment of this Act, the Secretary shall, through the
rulemaking process consistent with subsection (a), adopt an
initial set of benefit standards.
(2) PERIODIC UPDATING
STANDARDS- Under subsection (a), the Secretary shall provide for
the periodic updating of the benefit standards previously
adopted under this section.
(3) REQUIREMENT- The Secretary may
not adopt any benefit standards for an essential benefits
package or for level of cost-sharing that are inconsistent with
the requirements for such a package or level under sections 122
and 123(b)(5).
Subtitle
D--Additional Consumer Protections
SEC. 131. REQUIRING FAIR MARKETING
PRACTICES BY HEALTH INSURERS.
- The Commissioner
shall establish uniform marketing standards that all insured QHBP
offering entities shall meet.
SEC. 132. REQUIRING FAIR GRIEVANCE
AND APPEALS MECHANISMS.
- (a) In General-
A QHBP offering entity shall provide for timely grievance and
appeals mechanisms that the Commissioner shall establish.
(b)
Internal Claims and Appeals Process- Under a qualified health
benefits plan the QHBP offering entity shall provide an internal
claims and appeals process that initially incorporates the claims
and appeals procedures (including urgent claims) set forth at
section 2560.503-1 of title 29, Code of Federal Regulations, as
published on November 21, 2000 (65 Fed. Reg. 70246) and shall update
such process in accordance with any standards that the Commissioner
may establish.
(c) External Review Process-
- (1) IN
GENERAL- The Commissioner shall establish an external review
process (including procedures for expedited reviews of urgent
claims) that provides for an impartial, independent, and de novo
review of denied claims under this division.
(2) REQUIRING FAIR
GRIEVANCE AND APPEALS MECHANISMS- A determination made, with
respect to a qualified health benefits plan offered by a QHBP
offering entity, under the external review process established
under this subsection shall be binding on the plan and the
entity.
- (d)
Construction- Nothing in this section shall be construed as
affecting the availability of judicial review under State law for
adverse decisions under subsection (b) or (c), subject to section
151.
SEC. 133. REQUIRING INFORMATION
TRANSPARENCY AND PLAN DISCLOSURE.
- (a) Accurate and
Timely Disclosure-
- (1) IN
GENERAL- A qualified health benefits plan shall comply with
standards established by the Commissioner for the accurate and
timely disclosure of plan documents, plan terms and conditions,
claims payment policies and practices, periodic financial
disclosure, data on enrollment, data on disenrollment, data on
the number of claims denials, data on rating practices,
information on cost-sharing and payments with respect to any
out-of-network coverage, and other information as determined
appropriate by the Commissioner. The Commissioner shall require
that such disclosure be provided in plain language.
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(2)
PLAIN LANGUAGE- In this subsection, the term ‘plain language’
means language that the intended audience, including individuals
with limited English proficiency, can readily understand and use
because that language is clean, concise, well-organized, and
follows other best practices of plain language writing.
(3)
GUIDANCE- The Commissioner shall develop and issue guidance on
best practices of plain language writing.
- (b) Contracting
Reimbursement- A qualified health benefits plan shall comply with
standards established by the Commissioner to ensure transparency to
each health care provider relating to reimbursement arrangements
between such plan and such provider.
(c) Advance Notice of Plan
Changes- A change in a qualified health benefits plan shall not be
made without such reasonable and timely advance notice to enrollees
of such change.
SEC. 134. APPLICATION TO QUALIFIED
HEALTH BENEFITS PLANS NOT OFFERED THROUGH THE HEALTH INSURANCE EXCHANGE.
- The requirements
of the previous provisions of this subtitle shall apply to qualified
health benefits plans that are not being offered through the Health
Insurance Exchange only to the extent specified by the Commissioner.
SEC. 135. TIMELY PAYMENT OF CLAIMS.
- A QHBP offering
entity shall comply with the requirements of section 1857(f) of the
Social Security Act with respect to a qualified health benefits plan
it offers in the same manner an Medicare Advantage organization is
required to comply with such requirements with respect to a Medicare
Advantage plan it offers under part C of Medicare.
SEC. 136. STANDARDIZED RULES FOR
COORDINATION AND SUBROGATION OF BENEFITS.
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The
Commissioner shall establish standards for the coordination and
subrogation of benefits and reimbursement of payments in cases
involving individuals and multiple plan coverage.
SEC. 137. APPLICATION OF
ADMINISTRATIVE SIMPLIFICATION.
- A QHBP offering
entity is required to comply with standards for electronic financial
and administrative transactions under section 1173A of the Social
Security Act, added by section 163(a).
Subtitle
E--Governance
SEC. 141. HEALTH CHOICES
ADMINISTRATION; HEALTH CHOICES COMMISSIONER.
- (a) In General-
There is hereby established, as an independent agency in the
executive branch of the Government, a Health Choices Administration
(in this division referred to as the ‘Administration’).
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(b)
Commissioner-
- (1) IN
GENERAL- The Administration shall be headed by a Health Choices
Commissioner (in this division referred to as the
‘Commissioner’) who shall be appointed by the President, by and
with the advice and consent of the Senate.
(2) COMPENSATION;
ETC- The provisions of paragraphs (2), (5), and (7) of
subsection (a) (relating to compensation, terms, general powers,
rulemaking, and delegation) of section 702 of the Social
Security Act (42 U.S.C. 902) shall apply to the Commissioner and
the Administration in the same manner as such provisions apply
to the Commissioner of Social Security and the Social Security
Administration.
SEC. 142. DUTIES AND AUTHORITY OF
COMMISSIONER.
- (a) Duties- The
Commissioner is responsible for carrying out the following functions
under this division:
- (1)
QUALIFIED PLAN STANDARDS- The establishment of qualified health
benefits plan standards under this title, including the
enforcement of such standards in coordination with State
insurance regulators and the Secretaries of Labor and the
Treasury.
(2) HEALTH INSURANCE EXCHANGE- The establishment and
operation of a Health Insurance Exchange under subtitle A of
title II.
(3) INDIVIDUAL AFFORDABILITY CREDITS- The
administration of individual affordability credits under
subtitle C of title II, including determination of eligibility
for such credits.
(4) ADDITIONAL FUNCTIONS- Such additional
functions as may be specified in this division.
- (b) Promoting
Accountability-
- (1) IN
GENERAL- The Commissioner shall undertake activities in
accordance with this subtitle to promote accountability of QHBP
offering entities in meeting Federal health insurance
requirements, regardless of whether such accountability is with
respect to qualified health benefits plans offered through the
Health Insurance Exchange or outside of such Exchange.
(2)
COMPLIANCE EXAMINATION AND AUDITS-
- (A) IN
GENERAL- The commissioner shall, in coordination with
States, conduct audits of qualified health benefits plan
compliance with Federal requirements. Such audits may
include random compliance audits and targeted audits in
response to complaints or other suspected non-compliance.
1
(B)
RECOUPMENT OF COSTS IN CONNECTION WITH EXAMINATION AND
AUDITS- The Commissioner is authorized to recoup from
qualified health benefits plans reimbursement for the costs
of such examinations and audit of such QHBP offering
entities.
- (c) Data
Collection- The Commissioner shall collect data for purposes of
carrying out the Commissioner’s duties, including for purposes of
promoting quality and value, protecting consumers, and addressing
disparities in health and health care and may share such data with
the Secretary of Health and Human Services.
(d) Sanctions
Authority-
- (1) IN
GENERAL- In the case that the Commissioner determines that a
QHBP offering entity violates a requirement of this title, the
Commissioner may, in coordination with State insurance
regulators and the Secretary of Labor, provide, in addition to
any other remedies authorized by law, for any of the remedies
described in paragraph (2).
(2) REMEDIES- The remedies
described in this paragraph, with respect to a qualified health
benefits plan offered by a QHBP offering entity, are--
- (A)
civil money penalties of not more than the amount that would
be applicable under similar circumstances for similar
violations under section 1857(g) of the Social Security
Act;
(B) suspension of enrollment of individuals under such
plan after the date the Commissioner notifies the entity of
a determination under paragraph (1) and until the
Commissioner is satisfied that the basis for such
determination has been corrected and is not likely to
recur;
(C) in the case of an Exchange-participating health
benefits plan, suspension of payment to the entity under the
Health Insurance Exchange for individuals enrolled in such
plan after the date the Commissioner notifies the entity of
a determination under paragraph (1) and until the Secretary
is satisfied that the basis for such determination has been
corrected and is not likely to recur; or
(D) working with
State insurance regulators to terminate plans for repeated
failure by the offering entity to meet the requirements of
this title.
- (e) Standard
Definitions of Insurance and Medical Terms- The Commissioner shall
provide for the development of standards for the definitions of
terms used in health insurance coverage, including insurance-related
terms.
(f) Efficiency in Administration- The Commissioner shall
issue regulations for the effective and efficient administration of
the Health Insurance Exchange and affordability credits under
subtitle C, including, with respect to the determination of
eligibility for affordability credits, the use of personnel who are
employed in accordance with the requirements of title 5, United
States Code, to carry out the duties of the Commissioner or, in the
case of sections 208 and 241(b)(2), the use of State personnel who
are employed in accordance with standards prescribed by the Office
of Personnel Management pursuant to section 208 of the
Intergovernmental Personnel Act of 1970 (42 U.S.C. 4728).
SEC. 143. CONSULTATION AND
COORDINATION.
- (a)
Consultation- In carrying out the Commissioner’s duties under this
division, the Commissioner, as appropriate, shall consult with at
least with the following:
- (1) The
National Association of Insurance Commissioners, State attorneys
general, and State insurance regulators, including concerning
the standards for insured qualified health benefits plans under
this title and enforcement of such standards.
(2) Appropriate
State agencies, specifically concerning the administration of
individual affordability credits under subtitle C of title II
and the offering of Exchange-participating health benefits
plans, to Medicaid eligible individuals under subtitle A of such
title.
(3) Other appropriate Federal agencies.
(4) Indian
tribes and tribal organizations.
(5) The National Association
of Insurance Commissioners for purposes of using model
guidelines established by such association for purposes of
subtitles B and D.
- (b)
Coordination-
- (1) IN
GENERAL- In carrying out the functions of the Commissioner,
including with respect to the enforcement of the provisions of
this division, the Commissioner shall work in coordination with
existing Federal and State entities to the maximum extent
feasible consistent with this division and in a manner that
prevents conflicts of interest in duties and ensures effective
enforcement.
(2) UNIFORM STANDARDS- The Commissioner, in
coordination with such entities, shall seek to achieve uniform
standards that adequately protect consumers in a manner that
does not unreasonably affect employers and insurers.
SEC. 144. HEALTH INSURANCE
OMBUDSMAN.
- (a) In General-
The Commissioner shall appoint within the Health Choices
Administration a Qualified Health Benefits Plan Ombudsman who shall
have expertise and experience in the fields of health care and
education of (and assistance to) individuals.
(b) Duties- The
Qualified Health Benefits Plan Ombudsman shall, in a linguistically
appropriate manner--
- (1) receive
complaints, grievances, and requests for information submitted
by individuals;
(2) provide assistance with respect to
complaints, grievances, and requests referred to in paragraph
(1), including--
- (A)
helping individuals determine the relevant information
needed to seek an appeal of a decision or
determination;
(B) assistance to such individuals with any
problems arising from disenrollment from such a plan;
(C)
assistance to such individuals in choosing a qualified
health benefits plan in which to enroll; and
(D) assistance
to such individuals in presenting information under subtitle
C (relating to affordability credits); and
- (3) submit
annual reports to Congress and the Commissioner that describe
the activities of the Ombudsman and that include such
recommendations for improvement in the administration of this
division as the Ombudsman determines appropriate. The Ombudsman
shall not serve as an advocate for any increases in payments or
new coverage of services, but may identify issues and problems
in payment or coverage policies.
Subtitle F--Relation
to Other Requirements; Miscellaneous
SEC. 151. RELATION TO OTHER
REQUIREMENTS.
- (a) Coverage Not
Offered Through Exchange-
- (1) IN
GENERAL- In the case of health insurance coverage not offered
through the Health Insurance Exchange (whether or not offered in
connection with an employment-based health plan), and in the
case of employment-based health plans, the requirements of this
title do not supercede any requirements applicable under titles
XXII and XXVII of the Public Health Service Act, parts 6 and 7
of subtitle B of title I of the Employee Retirement Income
Security Act of 1974, or State law, except insofar as such
requirements prevent the application of a requirement of this
division, as determined by the Commissioner.
(2) CONSTRUCTION-
Nothing in paragraph (1) shall be construed as affecting the
application of section 514 of the Employee Retirement Income
Security Act of 1974.
- (b) Coverage
Offered Through Exchange-
- (1) IN
GENERAL- In the case of health insurance coverage offered
through the Health Insurance Exchange--
- (A) the
requirements of this title do not supercede any requirements
(including requirements relating to genetic information
nondiscrimination and mental health) applicable under title
XXVII of the Public Health Service Act or under State law,
except insofar as such requirements prevent the application
of a requirement of this division, as determined by the
Commissioner; and
(B) individual rights and remedies under
State laws shall apply.
- (2)
CONSTRUCTION- In the case of coverage described in paragraph
(1), nothing in such paragraph shall be construed as preventing
the application of rights and remedies under State laws with
respect to any requirement referred to in paragraph (1)(A).
SEC. 152. PROHIBITING DISCRIMINATION
IN HEALTH CARE.
- (a) In General-
Except as otherwise explicitly permitted by this Act and by
subsequent regulations consistent with this Act, all health care and
related services (including insurance coverage and public health
activities) covered by this Act shall be provided without regard to
personal characteristics extraneous to the provision of high quality
health care or related services.
(b) Implementation- To implement
the requirement set forth in subsection (a), the Secretary of Health
and Human Services shall, not later than 18 months after the date of
the enactment of this Act, promulgate such regulations as are
necessary or appropriate to insure that all health care and related
services (including insurance coverage and public health activities)
covered by this Act are provided (whether directly or through
contractual, licensing, or other arrangements) without regard to
personal characteristics extraneous to the provision of high quality
health care or related services.
SEC. 153. WHISTLEBLOWER PROTECTION.
- (a) Retaliation
Prohibited- No employer may discharge any employee or otherwise
discriminate against any employee with respect to his compensation,
terms, conditions, or other privileges of employment because the
employee (or any person acting pursuant to a request of the
employee)--
- (1)
provided, caused to be provided, or is about to provide or cause
to be provided to the employer, the Federal Government, or the
attorney general of a State information relating to any
violation of, or any act or omission the employee reasonably
believes to be a violation of any provision of this Act or any
order, rule, or regulation promulgated under this Act;
(2)
testified or is about to testify in a proceeding concerning such
violation;
(3) assisted or participated or is about to assist
or participate in such a proceeding; or
(4) objected to, or
refused to participate in, any activity, policy, practice, or
assigned task that the employee (or other such person)
reasonably believed to be in violation of any provision of this
Act or any order, rule, or regulation promulgated under this
Act.
- (b) Enforcement
Action- An employee covered by this section who alleges
discrimination by an employer in violation of subsection (a) may
bring an action governed by the rules, procedures, legal burdens of
proof, and remedies set forth in section 40(b) of the Consumer
Product Safety Act (15 U.S.C. 2087(b)).
(c) Employer Defined- As
used in this section, the term ‘employer’ means any person
(including one or more individuals, partnerships, associations,
corporations, trusts, professional membership organization including
a certification, disciplinary, or other professional body,
unincorporated organizations, nongovernmental organizations, or
trustees) engaged in profit or nonprofit business or industry whose
activities are governed by this Act, and any agent, contractor,
subcontractor, grantee, or consultant of such person.
(d) Rule of
Construction- The rule of construction set forth in section 20109(h)
of title 49, United States Code, shall also apply to this section.
SEC. 154. CONSTRUCTION REGARDING
COLLECTIVE BARGAINING.
- Nothing in this
division shall be construed to alter of supercede any statutory or
other obligation to engage in collective bargaining over the terms
and conditions of employment related to health care.
SEC. 155. SEVERABILITY.
- If any provision
of this Act, or any application of such provision to any person or
circumstance, is held to be unconstitutional, the remainder of the
provisions of this Act and the application of the provision to any
other person or circumstance shall not be affected.
Subtitle G--Early Investments
SEC. 161. ENSURING VALUE AND LOWER
PREMIUMS.
- (a) Group Health
Insurance Coverage- Title XXVII of the Public Health Service Act is
amended by inserting after section 2713 the following new section:
‘SEC. 2714. ENSURING VALUE AND LOWER
PREMIUMS.
- 1
‘(a)
In General- Each health insurance issuer that offers health
insurance coverage in the small or large group market shall provide
that for any plan year in which the coverage has a medical loss
ratio below a level specified by the Secretary, the issuer shall
provide in a manner specified by the Secretary for rebates to
enrollees of payment sufficient to meet such loss ratio. Such
methodology shall be set at the highest level medical loss ratio
possible that is designed to ensure adequate participation by
issuers, competition in the health insurance market, and value for
consumers so that their premiums are used for services.
‘(b)
Uniform Definitions- The Secretary shall establish a uniform
definition of medical loss ratio and methodology for determining how
to calculate the medical loss ratio. Such methodology shall be
designed to take into account the special circumstances of smaller
plans, different types of plans, and newer plans.’.
(b) Individual
Health Insurance Coverage- Such title is further amended by
inserting after section 2753 the following new section:
‘SEC. 2754. ENSURING VALUE AND LOWER
PREMIUMS.
- ‘The provisions
of section 2714 shall apply to health insurance coverage offered in
the individual market in the same manner as such provisions apply to
health insurance coverage offered in the small or large group
market.’.
(c) Immediate Implementation- The amendments made by this
section shall apply in the group and individual market for plan
years beginning on or after January 1, 2011.
SEC. 162. ENDING HEALTH INSURANCE
RESCISSION ABUSE.
- (a)
Clarification Regarding Application of Guaranteed Renewability of
Individual Health Insurance Coverage- Section 2742 of the Public
Health Service Act (42 U.S.C. 300gg-42) is amended--
- (1) in its
heading, by inserting ‘and continuation in force, including
prohibition of rescission,’ after ‘guaranteed renewability’;
and
(2) in subsection (a), by inserting ‘, including without
rescission,’ after ‘continue in force’.
- (b) Secretarial
Guidance Regarding Rescissions- Section 2742 of such Act (42 U.S.C.
300gg-42) is amended by adding at the end the following:
‘(f)
Rescission- A health insurance issuer may rescind health insurance
coverage only upon clear and convincing evidence of fraud described
in subsection (b)(2). The Secretary, no later than July 1, 2010,
shall issue guidance implementing this requirement, including
procedures for independent, external third party review.’.
(c)
Opportunity for Independent, External Third Party Review in Certain
Cases- Subpart 1 of part B of title XXVII of such Act (42 U.S.C.
300gg-41 et seq.) is amended by adding at the end the following:
‘SEC. 2746. OPPORTUNITY FOR
INDEPENDENT, EXTERNAL THIRD PARTY REVIEW IN CASES OF RESCISSION.
- ‘(a) Notice and
Review Right- If a health insurance issuer determines to rescind
health insurance coverage for an individual in the individual
market, before such rescission may take effect the issuer shall
provide the individual with notice of such proposed rescission and
an opportunity for a review of such determination by an independent,
external third party under procedures specified by the Secretary
under section 2742(f).
‘(b) Independent Determination- If the
individual requests such review by an independent, external third
party of a rescission of health insurance coverage, the coverage
shall remain in effect until such third party determines that the
coverage may be rescinded under the guidance issued by the Secretary
under section 2742(f).’.
(d) Effective Date- The amendments made by
this section shall apply on and after October 1, 2010, with respect
to health insurance coverage issued before, on, or after such date.
SEC. 163. ADMINISTRATIVE
SIMPLIFICATION.
- (a)
Standardizing Electronic Administrative Transactions-
- (1) IN
GENERAL- Part C of title XI of the Social Security Act (42 U.S.C.
1320d et seq.) is amended by inserting after section 1173 the
following new section:
‘SEC. 1173A. STANDARDIZE ELECTRONIC
ADMINISTRATIVE TRANSACTIONS.
- ‘(a) Standards
for Financial and Administrative Transactions-
- ‘(1) IN
GENERAL- The Secretary shall adopt and regularly update
standards consistent with the goals described in paragraph
(2).
‘(2) GOALS FOR FINANCIAL AND ADMINISTRATIVE TRANSACTIONS-
The goals for standards under paragraph (1) are that such
standards shall--
- ‘(A) be
unique with no conflicting or redundant standards;
‘(B) be
authoritative, permitting no additions or constraints for
electronic transactions, including companion guides;
‘(C)
be comprehensive, efficient and robust, requiring minimal
augmentation by paper transactions or clarification by
further communications;
‘(D) enable the real-time (or near
real-time) determination of an individual’s financial
responsibility at the point of service and, to the extent
possible, prior to service, including whether the individual
is eligible for a specific service with a specific physician
at a specific facility, which may include utilization of a
machine-readable health plan beneficiary identification
card;
‘(E) enable, where feasible, near real-time
adjudication of claims;
‘(F) provide for timely
acknowledgment, response, and status reporting applicable to
any electronic transaction deemed appropriate by the
Secretary;
‘(G) describe all data elements (such as reason
and remark codes) in unambiguous terms, not permit optional
fields, require that data elements be either required or
conditioned upon set values in other fields, and prohibit
additional conditions; and
‘(H) harmonize all common data
elements across administrative and clinical transaction
standards.
- ‘(3) TIME
FOR ADOPTION- Not later than 2 years after the date of
implementation of the X12 Version 5010 transaction standards
implemented under this part, the Secretary shall adopt standards
under this section.
‘(4) REQUIREMENTS FOR SPECIFIC STANDARDS-
The standards under this section shall be developed, adopted and
enforced so as to--
- ‘(A)
clarify, refine, complete, and expand, as needed, the
standards required under section 1173;
‘(B) require paper
versions of standardized transactions to comply with the
same standards as to data content such that a fully
compliant, equivalent electronic transaction can be
populated from the data from a paper version;
‘(C) enable
electronic funds transfers, in order to allow automated
reconciliation with the related health care payment and
remittance advice;
‘(D) require timely and transparent
claim and denial management processes, including tracking,
adjudication, and appeal processing;
‘(E) require the use
of a standard electronic transaction with which health care
providers may quickly and efficiently enroll with a health
plan to conduct the other electronic transactions provided
for in this part; and
‘(F) provide for other requirements
relating to administrative simplification as identified by
the Secretary, in consultation with stakeholders.
- ‘(5)
BUILDING ON EXISTING STANDARDS- In developing the standards
under this section, the Secretary shall build upon existing and
planned standards.
‘(6) IMPLEMENTATION AND ENFORCEMENT- Not
later than 6 months after the date of the enactment of this
section, the Secretary shall submit to the appropriate
committees of Congress a plan for the implementation and
enforcement, by not later than 5 years after such date of
enactment, of the standards under this section. Such plan shall
include--
- ‘(A) a
process and timeframe with milestones for developing the
complete set of standards;
‘(B) an expedited upgrade
program for continually developing and approving additions
and modifications to the standards as often as annually to
improve their quality and extend their functionality to meet
evolving requirements in health care;
‘(C) programs to
provide incentives for, and ease the burden of,
implementation for certain health care providers, with
special consideration given to such providers serving rural
or underserved areas and ensure coordination with standards,
implementation specifications, and certification criteria
being adopted under the HITECH Act;
‘(D) programs to
provide incentives for, and ease the burden of, health care
providers who volunteer to participate in the process of
setting standards for electronic transactions;
‘(E) an
estimate of total funds needed to ensure timely completion
of the implementation plan; and
‘(F) an enforcement process
that includes timely investigation of complaints, random
audits to ensure compliance, civil monetary and programmatic
penalties for non-compliance consistent with existing laws
and regulations, and a fair and reasonable appeals process
building off of enforcement provisions under this part.
- ‘(b) Limitations
on Use of Data- Nothing in this section shall be construed to permit
the use of information collected under this section in a manner that
would adversely affect any individual.
‘(c) Protection of Data- The
Secretary shall ensure (through the promulgation of regulations or
otherwise) that all data collected pursuant to subsection (a) are--
- ‘(1) used
and disclosed in a manner that meets the HIPAA privacy and
security law (as defined in section 3009(a)(2) of the Public
Health Service Act), including any privacy or security standard
adopted under section 3004 of such Act; and
‘(2) protected from
all inappropriate internal use by any entity that collects,
stores, or receives the data, including use of such data in
determinations of eligibility (or continued eligibility) in
health plans, and from other inappropriate uses, as defined by
the Secretary.’.
(2) DEFINITIONS- Section 1171 of such Act (42
U.S.C. 1320d) is amended--
- (A) in
paragraph (7), by striking ‘with reference to’ and all that
follows and inserting ‘with reference to a transaction or
data element of health information in section 1173 means
implementation specifications, certification criteria,
operating rules, messaging formats, codes, and code sets
adopted or established by the Secretary for the electronic
exchange and use of information’; and
(B) by adding at the
end the following new paragraph:
- ‘(9)
OPERATING RULES- The term ‘operating rules’ means business rules
for using and processing transactions. Operating rules should
address the following:
- ‘(A)
Requirements for data content using available and
established national standards.
‘(B) Infrastructure
requirements that establish best practices for streamlining
data flow to yield timely execution of transactions.
‘(C)
Policies defining the transaction related rights and
responsibilities for entities that are transmitting or
receiving data.’.
- (3)
CONFORMING AMENDMENT- Section 1179(a) of such Act (42 U.S.C.
1320d-8(a)) is amended, in the matter before paragraph (1)--
- (A) by
inserting ‘on behalf of an individual’ after ‘1978)’;
and
(B) by inserting ‘on behalf of an individual’ after
‘for a financial institution.’
- (b) Standards
for Claims Attachments and Coordination of Benefits -
- (1) STANDARD
FOR HEALTH CLAIMS ATTACHMENTS- Not later than 1 year after the
date of the enactment of this Act, the Secretary of Health and
Human Services shall promulgate a final rule to establish a
standard for health claims attachment transaction described in
section 1173(a)(2)(B) of the Social Security Act (42 U.S.C.
1320d-2(a)(2)(B)) and coordination of benefits.
(2) REVISION IN
PROCESSING PAYMENT TRANSACTIONS BY FINANCIAL INSTITUTIONS-
- (A) IN
GENERAL- Section 1179 of the Social Security Act (42 U.S.C.
1320d-8) is amended, in the matter before paragraph (1)--
- (i)
by striking ‘or is engaged’ and inserting ‘and is
engaged’; and
(ii) by inserting ‘(other than as a
business associate for a covered entity)’ after ‘for a
financial institution’.
- (B)
EFFECTIVE DATE- The amendments made by paragraph (1) shall
apply to transactions occurring on or after such date (not
later than 6 months after the date of the enactment of this
Act) as the Secretary of Health and Human Services shall
specify.
SEC. 164. REINSURANCE PROGRAM FOR
RETIREES.
- (a)
Establishment-
- (1) IN
GENERAL- Not later than 90 days after the date of the enactment
of this Act, the Secretary of Health and Human Services shall
establish a temporary reinsurance program (in this section
referred to as the ‘reinsurance program’) to provide
reimbursement to assist participating employment-based plans
with the cost of providing health benefits to retirees and to
eligible spouses, surviving spouses and dependents of such
retirees.
(2) DEFINITIONS- For purposes of this section:
- (A)
The term ‘eligible employment-based plan’ means a group
health benefits plan that--
-
(i)
is maintained by one or more employers, former
employers or employee associations, or a
voluntary employees’ beneficiary association, or
a committee or board of individuals appointed to
administer such plan, and
(ii) provides health
benefits to retirees.
- (B)
The term ‘health benefits’ means medical, surgical,
hospital, prescription drug, and such other benefits as
shall be determined by the Secretary, whether
self-funded or delivered through the purchase of
insurance or otherwise.
(C) The term ‘participating
employment-based plan’ means an eligible
employment-based plan that is participating in the
reinsurance program.
(D) The term ‘retiree’ means, with
respect to a participating employment-benefit plan, an
individual who--
-
(i)
is 55 years of age or older;
(ii) is not
eligible for coverage under title XVIII of the
Social Security Act; and
(iii) is not an active
employee of an employer maintaining the plan or
of any employer that makes or has made
substantial contributions to fund such plan.
- (E)
The term ‘Secretary’ means Secretary of Health and Human
Services.
- (b)
Participation- To be eligible to participate in the reinsurance
program, an eligible employment-based plan shall submit to the
Secretary an application for participation in the program, at
such time, in such manner, and containing such information as
the Secretary shall require.
(c) Payment-
- (1)
SUBMISSION OF CLAIMS-
-
(A) IN GENERAL- Under the reinsurance program, a
participating employment-based plan shall submit
claims for reimbursement to the Secretary which
shall contain documentation of the actual costs of
the items and services for which each claim is being
submitted.
(B) BASIS FOR CLAIMS- Each claim
submitted under subparagraph (A) shall be based on
the actual amount expended by the participating
employment-based plan involved within the plan year
for the appropriate employment based health benefits
provided to a retiree or to the spouse, surviving
spouse, or dependent of a retiree. In determining
the amount of any claim for purposes of this
subsection, the participating employment-based plan
shall take into account any negotiated price
concessions (such as discounts, direct or indirect
subsidies, rebates, and direct or indirect
remunerations) obtained by such plan with respect to
such health benefits. For purposes of calculating
the amount of any claim, the costs paid by the
retiree or by the spouse, surviving spouse, or
dependent of the retiree in the form of deductibles,
co-payments, and co-insurance shall be included
along with the amounts paid by the participating
employment-based plan.
- (2)
PROGRAM PAYMENTS AND LIMIT- If the Secretary determines
that a participating employment-based plan has submitted
a valid claim under paragraph (1), the Secretary shall
reimburse such plan for 80 percent of that portion of
the costs attributable to such claim that exceeds
$15,000, but is less than $90,000. Such amounts shall be
adjusted each year based on the percentage increase in
the medical care component of the Consumer Price Index
(rounded to the nearest multiple of $1,000) for the year
involved.
(3) USE OF PAYMENTS- Amounts paid to a
participating employment-based plan under this
subsection shall be used to lower the costs borne
directly by the participants and beneficiaries for
health benefits provided under such plan in the form of
premiums, co-payments, deductibles, co-insurance, or
other out-of-pocket costs. Such payments shall not be
used to reduce the costs of an employer maintaining the
participating employment-based plan. The Secretary shall
develop a mechanism to monitor the appropriate use of
such payments by such plans.
(4) APPEALS AND PROGRAM
PROTECTIONS- The Secretary shall establish--
-
(A) an appeals process to permit participating
employment-based plans to appeal a determination of
the Secretary with respect to claims submitted under
this section; and
(B) procedures to protect against
fraud, waste, and abuse under the program.
- (5)
AUDITS- The Secretary shall conduct annual audits of
claims data submitted by participating employment-based
plans under this section to ensure that they are in
compliance with the requirements of this section.
- (d)
Retiree Reserve Trust Fund-
-
(A) IN GENERAL- There is established in the
Treasury of the United States a trust fund to be
known as the ‘Retiree Reserve Trust
Fund’ (referred to in this section as the ‘Trust
Fund’), that shall consist of such amounts as
may be appropriated or credited to the Trust
Fund as provided for in this subsection to
enable the Secretary to carry out the
reinsurance program. Such amounts shall remain
available until expended.
(B) FUNDING- There
are hereby appropriated to the Trust Fund, out
of any moneys in the Treasury not otherwise
appropriated, an amount requested by the
Secretary as necessary to carry out this
section, except that the total of all such
amounts requested shall not exceed
$10,000,000,000.
(C) APPROPRIATIONS FROM THE
TRUST FUND-
-
(i) IN GENERAL- Amounts in the Trust
Fund are appropriated to provide funding
to carry out the reinsurance program and
shall be used to carry out such
program.
(ii) BUDGETARY IMPLICATIONS-
Amounts appropriated under clause (i),
and outlays flowing from such
appropriations, shall not be taken into
account for purposes of any budget
enforcement procedures including
allocations under section 302(a) and (b)
of the Balanced Budget and Emergency
Deficit Control Act and budget
resolutions for fiscal years during
which appropriations are made from the
Trust Fund.
(iii) LIMITATION TO
AVAILABLE FUNDS- The Secretary has the
authority to stop taking applications
for participation in the program or take
such other steps in reducing
expenditures under the reinsurance
program in order to ensure that
expenditures under the reinsurance
program do not exceed the funds
available under this subsection.
TITLE II--
HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS
Subtitle
A--Health Insurance Exchange
SEC. 201. ESTABLISHMENT OF
HEALTH INSURANCE EXCHANGE; OUTLINE OF DUTIES; DEFINITIONS.
- (a)
Establishment- There is established within the Health Choices
Administration and under the direction of the Commissioner a
Health Insurance Exchange in order to facilitate access of
individuals and employers, through a transparent process, to a
variety of choices of affordable, quality health insurance
coverage, including a public health insurance option.
(b)
Outline of Duties of Commissioner- In accordance with this
subtitle and in coordination with appropriate Federal and State
officials as provided under section 143(b), the Commissioner
shall--
- 1
(1)
under section 204 establish standards for, accept bids from,
and negotiate and enter into contracts with, QHBP offering
entities for the offering of health benefits plans through
the Health Insurance Exchange, with different levels of
benefits required under section 203, and including with
respect to oversight and enforcement;
(2) under section 205
facilitate outreach and enrollment in such plans of
Exchange-eligible individuals and employers described in
section 202; and
(3) conduct such activities related to the
Health Insurance Exchange as required, including
establishment of a risk pooling mechanism under section 206
and consumer protections under subtitle D of title I.
- (c)
Exchange-participating Health Benefits Plan Defined- In this
division, the term ‘Exchange-participating health benefits plan’
means a qualified health benefits plan that is offered through
the Health Insurance Exchange.
SEC. 204. CONTRACTS FOR THE OFFERING
OF EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS.
-
(a) Contracting Duties- In carrying out section
201(b)(1) and consistent with this subtitle:
-
(1) OFFERING ENTITY AND PLAN STANDARDS- The
Commissioner shall--
-
(A) establish standards necessary to
implement the requirements of this title and
title I for--
-
(i) QHBP offering entities for the
offering of an
Exchange-participating health
benefits plan; and
(ii) for
Exchange-participating health
benefits plans; and
-
(B) certify QHBP offering entities and
qualified health benefits plans as
meeting such standards and requirements
of this title and title I for purposes
of this subtitle.
-
(2) SOLICITING AND NEGOTIATING BIDS;
CONTRACTS- The Commissioner shall--
-
(A) solicit bids from QHBP offering
entities for the offering of
Exchange-participating health benefits
plans;
(B) based upon a review of such
bids, negotiate with such entities for
the offering of such plans; and
(C)
enter into contracts with such entities
for the offering of such plans through
the Health Insurance Exchange under
terms (consistent with this title)
negotiated between the Commissioner and
such entities.
-
(3) FAR NOT APPLICABLE- The provisions of
the Federal Acquisition Regulation shall not
apply to contracts between the Commissioner
and QHBP offering entities for the offering
of Exchange-participating health benefits
plans under this title.
-
(b) Standards for QHBP Offering Entities To
Offer Exchange-Participating Health Benefits
Plans- The standards established under
subsection (a)(1)(A) shall require that, in
order for a QHBP offering entity to offer an
Exchange-participating health benefits plan, the
entity must meet the following requirements:
-
(1) LICENSED- The entity shall be licensed
to offer health insurance coverage under
State law for each State in which it is
offering such coverage.
(2) DATA REPORTING-
The entity shall provide for the reporting
of such information as the Commissioner may
specify, including information necessary to
administer the risk pooling mechanism
described in section 206(b) and information
to address disparities in health and health
care.
(3) IMPLEMENTING AFFORDABILITY
CREDITS- The entity shall provide for
implementation of the affordability credits
provided for enrollees under subtitle C,
including the reduction in cost-sharing
under section 244(c).
(4) ENROLLMENT- The
entity shall accept all enrollments under
this subtitle, subject to such exceptions
(such as capacity limitations) in accordance
with the requirements under title I for a
qualified health benefits plan. The entity
shall notify the Commissioner if the entity
projects or anticipates reaching such a
capacity limitation that would result in a
limitation in enrollment.
1
(5)
RISK POOLING PARTICIPATION- The entity shall
participate in such risk pooling mechanism
as the Commissioner establishes under
section 206(b).
(6) ESSENTIAL COMMUNITY
PROVIDERS- With respect to the basic plan
offered by the entity, the entity shall
contract for outpatient services with
covered entities (as defined in section
340B(a)(4) of the Public Health Service Act,
as in effect as of July 1, 2009). The
Commissioner shall specify the extent to
which and manner in which the previous
sentence shall apply in the case of a basic
plan with respect to which the Commissioner
determines provides substantially all
benefits through a health maintenance
organization, as defined in section
2791(b)(3) of the Public Health Service
Act.
(7) CULTURALLY AND LINGUISTICALLY
APPROPRIATE SERVICES AND COMMUNICATIONS- The
entity shall provide for culturally and
linguistically appropriate communication and
health services.
(8) ADDITIONAL
REQUIREMENTS- The entity shall comply with
other applicable requirements of this title,
as specified by the Commissioner, which
shall include standards regarding billing
and collection practices for premiums and
related grace periods and which may include
standards to ensure that the entity does not
use coercive practices to force providers
not to contract with other entities offering
coverage through the Health Insurance
Exchange.
-
(c) Contracts-
-
(1) BID APPLICATION- To be eligible to
enter into a contract under this section, a
QHBP offering entity shall submit to the
Commissioner a bid at such time, in such
manner, and containing such information as
the Commissioner may require.
(2) TERM-
Each contract with a QHBP offering entity
under this section shall be for a term of
not less than one year, but may be made
automatically renewable from term to term in
the absence of notice of termination by
either party.
(3) ENFORCEMENT OF NETWORK
ADEQUACY- In the case of a health benefits
plan of a QHBP offering entity that uses a
provider network, the contract under this
section with the entity shall provide that
if--
-
(A) the Commissioner determines that
such provider network does not meet such
standards as the Commissioner shall
establish under section 115; and
(B) an
individual enrolled in such plan
receives an item or service from a
provider that is not within such
network;
-
then any cost-sharing for such item or
service shall be equal to the amount of such
cost-sharing that would be imposed if such
item or service was furnished by a provider
within such network.
(4) OVERSIGHT AND
ENFORCEMENT RESPONSIBILITIES- The
Commissioner shall establish processes, in
coordination with State insurance
regulators, to oversee, monitor, and enforce
applicable requirements of this title with
respect to QHBP offering entities offering
Exchange-participating health benefits plans
and such plans, including the marketing of
such plans. Such processes shall include the
following:
-
(A) GRIEVANCE AND COMPLAINT
MECHANISMS- The Commissioner shall
establish, in coordination with State
insurance regulators, a process under
which Exchange-eligible individuals and
employers may file complaints concerning
violations of such standards.
(B)
ENFORCEMENT- In carrying out authorities
under this division relating to the
Health Insurance Exchange, the
Commissioner may impose one or more of
the intermediate sanctions described in
section 142(c).
(C) TERMINATION-
-
(i) IN GENERAL- The Commissioner
may terminate a contract with a
QHBP offering entity under this
section for the offering of an
Exchange-participating health
benefits plan if such entity
fails to comply with the
applicable requirements of this
title. Any determination by the
Commissioner to terminate a
contract shall be made in
accordance with formal
investigation and compliance
procedures established by the
Commissioner under which--
-
(I) the Commissioner
provides the entity with the
reasonable opportunity to
develop and implement a
corrective action plan to
correct the deficiencies
that were the basis of the
Commissioner’s
determination; and
(II) the
Commissioner provides the
entity with reasonable
notice and opportunity for
hearing (including the right
to appeal an initial
decision) before terminating
the contract.
-
(ii) EXCEPTION FOR IMMINENT AND
SERIOUS RISK TO HEALTH- Clause (i)
shall not apply if the
Commissioner determines that a
delay in termination, resulting
from compliance with the
procedures specified in such
clause prior to termination,
would pose an imminent and
serious risk to the health of
individuals enrolled under the
qualified health benefits plan
of the QHBP offering entity.
-
(D) CONSTRUCTION- Nothing in this
subsection shall be construed as
preventing the application of other
sanctions under subtitle E of title
I with respect to an entity for a
violation of such a requirement.
SEC. 205. OUTREACH AND ENROLLMENT OF
EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS IN EXCHANGE-PARTICIPATING
HEALTH BENEFITS PLAN.
- (1) OUTREACH-
The Commissioner shall conduct outreach activities consistent
with subsection (c), including through use of appropriate
entities as described in paragraph (4) of such subsection, to
inform and educate individuals and employers about the Health
Insurance Exchange and Exchange-participating health benefits
plan options. Such outreach shall include outreach specific to
vulnerable populations, such as children, individuals with
disabilities, individuals with mental illness, and individuals
with other cognitive impairments.
(2) ELIGIBILITY- The
Commissioner shall make timely determinations of whether
individuals and employers are Exchange-eligible individuals and
employers (as defined in section 202).
(3) ENROLLMENT- The
Commissioner shall establish and carry out an enrollment process
for Exchange-eligible individuals and employers, including at
community locations, in accordance with subsection (b).
- (1) IN
GENERAL- The Commissioner shall establish a process consistent
with this title for enrollments in Exchange-participating health
benefits plans. Such process shall provide for enrollment
through means such as the mail, by telephone, electronically,
and in person.
(2) ENROLLMENT PERIODS-
- (A)
OPEN ENROLLMENT PERIOD- The Commissioner shall establish
an annual open enrollment period during which an
Exchange-eligible individual or employer may elect to
enroll in an Exchange-participating health benefits plan
for the following plan year and an enrollment period for
affordability credits under subtitle C. Such periods
shall be during September through November of each year,
or such other time that would maximize timeliness of
income verification for purposes of such subtitle. The
open enrollment period shall not be less than 30
days.
(B) SPECIAL ENROLLMENT- The Commissioner shall
also provide for special enrollment periods to take into
account special circumstances of individuals and
employers, such as an individual who--
-
(i)
loses acceptable coverage;
(ii) experiences a
change in marital or other dependent
status;
(iii) moves outside the service area of
the Exchange-participating health benefits plan
in which the individual is enrolled; or
(iv)
experiences a significant change in income.
- (C)
ENROLLMENT INFORMATION- The Commissioner shall provide
for the broad dissemination of information to
prospective enrollees on the enrollment process,
including before each open enrollment period. In
carrying out the previous sentence, the Commissioner may
work with other appropriate entities to facilitate such
provision of information.
- (3) AUTOMATIC
ENROLLMENT FOR NON-MEDICAID ELIGIBLE INDIVIDUALS-
- (A) IN
GENERAL- The Commissioner shall provide for a process
under which individuals who are Exchange-eligible
individuals described in subparagraph (B) are
automatically enrolled under an appropriate
Exchange-participating health benefits plan. Such
process may involve a random assignment or some other
form of assignment that takes into account the health
care providers used by the individual involved or such
other relevant factors as the Commissioner may
specify.
(B) SUBSIDIZED INDIVIDUALS DESCRIBED- An
individual described in this subparagraph is an
Exchange-eligible individual who is either of the
following:
-
(i)
AFFORDABILITY CREDIT ELIGIBLE INDIVIDUALS- The
individual--
-
(I) has applied for, and been determined
eligible for, affordability credits
under subtitle C;
(II) has not opted
out from receiving such affordability
credit; and
(III) does not otherwise
enroll in another Exchange-participating
health benefits plan.
-
(ii) INDIVIDUALS ENROLLED IN A TERMINATED PLAN-
The individual is enrolled in an
Exchange-participating health benefits plan that
is terminated (during or at the end of a plan
year) and who does not otherwise enroll in
another Exchange-participating health benefits
plan.
- (4) DIRECT
PAYMENT OF PREMIUMS TO PLANS- Under the enrollment process,
individuals enrolled in an Exchange-partcipating health benefits
plan shall pay such plans directly, and not through the
Commissioner or the Health Insurance Exchange.
- (c) Coverage
Information and Assistance-
- (1) COVERAGE
INFORMATION- The Commissioner shall provide for the broad
dissemination of information on Exchange-participating health
benefits plans offered under this title. Such information shall
be provided in a comparative manner, and shall include
information on benefits, premiums, cost-sharing, quality,
provider networks, and consumer satisfaction.
(2) CONSUMER
ASSISTANCE WITH CHOICE- To provide assistance to
Exchange-eligible individuals and employers, the Commissioner
shall--
- (A)
provide for the operation of a toll-free telephone
hotline to respond to requests for assistance and
maintain an Internet website through which individuals
may obtain information on coverage under
Exchange-participating health benefits plans and file
complaints;
(B) develop and disseminate information to
Exchange-eligible enrollees on their rights and
responsibilities;
(C) assist Exchange-eligible
individuals in selecting Exchange-participating health
benefits plans and obtaining benefits through such
plans; and
(D) ensure that the Internet website
described in subparagraph (A) and the information
described in subparagraph (B) is developed using plain
language (as defined in section 133(a)(2)).
- (3) USE OF
OTHER ENTITIES- In carrying out this subsection, the
Commissioner may work with other appropriate entities to
facilitate the dissemination of information under this
subsection and to provide assistance as described in paragraph
(2).
- (d) Special
Duties Related to Medicaid and CHIP-
- (1) COVERAGE
FOR CERTAIN NEWBORNS-
- (A) IN
GENERAL- In the case of a child born in the United
States who at the time of birth is not otherwise covered
under acceptable coverage, for the period of time
beginning on the date of birth and ending on the date
the child otherwise is covered under acceptable coverage
(or, if earlier, the end of the month in which the
60-day period, beginning on the date of birth, ends),
the child shall be deemed--
-
(i)
to be a non-traditional Medicaid eligible
individual (as defined in subsection (e)(5)) for
purposes of this division and Medicaid;
and
(ii) to have elected to enroll in Medicaid
through the application of paragraph (3).
- (B)
EXTENDED TREATMENT AS TRADITIONAL MEDICAID ELIGIBLE
INDIVIDUAL- In the case of a child described in
subparagraph (A) who at the end of the period referred
to in such subparagraph is not otherwise covered under
acceptable coverage, the child shall be deemed (until
such time as the child obtains such coverage or the
State otherwise makes a determination of the child’s
eligibility for medical assistance under its Medicaid
plan pursuant to section 1943(c)(1) of the Social
Security Act) to be a traditional Medicaid eligible
individual described in section 1902(l)(1)(B) of such
Act.
- (2) CHIP
TRANSITION- A child who, as of the day before the first day of
Y1, is eligible for child health assistance under title XXI of
the Social Security Act (including a child receiving coverage
under an arrangement described in section 2101(a)(2) of such
Act) is deemed as of such first day to be an Exchange-eligible
individual unless the individual is a traditional Medicaid
eligible individual as of such day.
(3) AUTOMATIC ENROLLMENT OF
MEDICAID ELIGIBLE INDIVIDUALS INTO MEDICAID- The Commissioner
shall provide for a process under which an individual who is
described in section 202(d)(3) and has not elected to enroll in
an Exchange-participating health benefits plan is automatically
enrolled under Medicaid.
(4) NOTIFICATIONS- The Commissioner
shall notify each State in Y1 and for purposes of section
1902(gg)(1) of the Social Security Act (as added by section
1703(a)) whether the Health Insurance Exchange can support
enrollment of children described in paragraph (2) in such State
in such year.
- (e) Medicaid
Coverage for Medicaid Eligible Individuals-
- (A)
CHOICE FOR LIMITED EXCHANGE-ELIGIBLE INDIVIDUALS- As
part of the enrollment process under subsection (b), the
Commissioner shall provide the option, in the case of an
Exchange-eligible individual described in section
202(d)(3), for the individual to elect to enroll under
Medicaid instead of under an Exchange-participating
health benefits plan. Such an individual may change such
election during an enrollment period under subsection
(b)(2).
(B) MEDICAID ENROLLMENT OBLIGATION- An Exchange
eligible individual may apply, in the manner described
in section 241(b)(1), for a determination of whether the
individual is a Medicaid-eligible individual. If the
individual is determined to be so eligible, the
Commissioner, through the Medicaid memorandum of
understanding, shall provide for the enrollment of the
individual under the State Medicaid plan in accordance
with the Medicaid memorandum of understanding under
paragraph (4). In the case of such an enrollment, the
State shall provide for the same periodic
redetermination of eligibility under Medicaid as would
otherwise apply if the individual had directly applied
for medical assistance to the State Medicaid agency.
- (2)
NON-TRADITIONAL MEDICAID ELIGIBLE INDIVIDUALS- In the case of a
non-traditional Medicaid eligible individual described in
section 202(d)(3) who elects to enroll under Medicaid under
paragraph (1)(A), the Commissioner shall provide for the
enrollment of the individual under the State Medicaid plan in
accordance with the Medicaid memorandum of understanding under
paragraph (4).
(3) COORDINATED ENROLLMENT WITH STATE THROUGH
MEMORANDUM OF UNDERSTANDING- The Commissioner, in consultation
with the Secretary of Health and Human Services, shall enter
into a memorandum of understanding with each State (each in this
division referred to as a ‘Medicaid memorandum of
understanding’) with respect to coordinating enrollment of
individuals in Exchange-participating health benefits plans and
under the State’s Medicaid program consistent with this section
and to otherwise coordinate the implementation of the provisions
of this division with respect to the Medicaid program. Such
memorandum shall permit the exchange of information consistent
with the limitations described in section 1902(a)(7) of the
Social Security Act. Nothing in this section shall be construed
as permitting such memorandum to modify or vitiate any
requirement of a State Medicaid plan.
(4) MEDICAID ELIGIBLE
INDIVIDUALS- For purposes of this division:
- (A)
MEDICAID ELIGIBLE INDIVIDUAL- The term ‘Medicaid
eligible individual’ means an individual who is
eligible for medical assistance under Medicaid.
(B)
TRADITIONAL MEDICAID ELIGIBLE INDIVIDUAL- The term
‘traditional Medicaid eligible individual’ means a
Medicaid eligible individual other than an individual
who is--
-
(i)
a Medicaid eligible individual by reason of the
application of subclause (VIII) of section
1902(a)(10)(A)(i) of the Social Security Act;
or
(ii) a childless adult not described in
section 1902(a)(10) (A) or (C) of such Act (as
in effect as of the day before the date of the
enactment of this Act).
- (C)
NON-TRADITIONAL MEDICAID ELIGIBLE INDIVIDUAL- The term
‘non-traditional Medicaid eligible individual’ means a
Medicaid eligible individual who is not a traditional
Medicaid eligible individual.
- (f)
Effective Culturally and Linguistically Appropriate
Communication- In carrying out this section, the Commissioner
shall establish effective methods for communicating in plain
language and a culturally and linguistically appropriate
manner.
SEC. 206. OTHER FUNCTIONS.
- (a)
Coordination of Affordability Credits- The Commissioner shall
coordinate the distribution of affordability premium and
cost-sharing credits under subtitle C to QHBP offering entities
offering Exchange-participating health benefits plans.
(b)
Coordination of Risk Pooling- The Commissioner shall establish a
mechanism whereby there is an adjustment made of the premium
amounts payable among QHBP offering entities offering
Exchange-participating health benefits plans of premiums
collected for such plans that takes into account (in a manner
specified by the Commissioner) the differences in the risk
characteristics of individuals and employers enrolled under the
different Exchange-participating health benefits plans offered
by such entities so as to minimize the impact of adverse
selection of enrollees among the plans offered by such
entities.
(c) Special Inspector General for the Health
Insurance Exchange-
- (1)
ESTABLISHMENT; APPOINTMENT- There is hereby established the
Office of the Special Inspector General for the Health
Insurance Exchange, to be headed by a Special Inspector
General for the Health Insurance Exchange (in this
subsection referred to as the ‘Special Inspector General’)
to be appointed by the President, by and with the advice and
consent of the Senate. The nomination of an individual as
Special Inspector General shall be made as soon as
practicable after the establishment of the program under
this subtitle.
(2) DUTIES- The Special Inspector General
shall--
-
(A) conduct, supervise, and coordinate audits,
evaluations and investigations of the Health
Insurance Exchange to protect the integrity of the
Health Insurance Exchange, as well as the health and
welfare of participants in the Exchange;
(B) report
both to the Commissioner and to the Congress
regarding program and management problems and
recommendations to correct them;
(C) have other
duties (described in paragraphs (2) and (3) of
section 121 of division A of Public Law 110-343) in
relation to the duties described in the previous
subparagraphs; and
(D) have the authorities
provided in section 6 of the Inspector General Act
of 1978 in carrying out duties under this
paragraph.
- (3)
APPLICATION OF OTHER SPECIAL INSPECTOR GENERAL PROVISIONS-
The provisions of subsections (b) (other than paragraphs (1)
and (3)), (d) (other than paragraph (1)), and (e) of section
121 of division A of the Emergency Economic Stabilization
Act of 2009 (Public Law 110-343) shall apply to the Special
Inspector General under this subsection in the same manner
as such provisions apply to the Special Inspector General
under such section.
(4) REPORTS- Not later than one year
after the confirmation of the Special Inspector General, and
annually thereafter, the Special Inspector General shall
submit to the appropriate committees of Congress a report
summarizing the activities of the Special Inspector General
during the one year period ending on the date such report is
submitted.
(5) TERMINATION- The Office of the Special
Inspector General shall terminate five years after the date
of the enactment of this Act.
SEC. 207. HEALTH INSURANCE EXCHANGE
TRUST FUND.
- (a)
Establishment of Health Insurance Exchange Trust Fund- There is
created within the Treasury of the United States a trust fund to
be known as the ‘Health Insurance Exchange Trust Fund’ (in this
section referred to as the ‘Trust Fund’), consisting of such
amounts as may be appropriated or credited to the Trust Fund
under this section or any other provision of law.
(b) Payments
From Trust Fund- The Commissioner shall pay from time to time
from the Trust Fund such amounts as the Commissioner determines
are necessary to make payments to operate the Health Insurance
Exchange, including payments under subtitle C (relating to
affordability credits).
(c) Transfers to Trust Fund-
- (1)
DEDICATED PAYMENTS- There is hereby appropriated to the
Trust Fund amounts equivalent to the following:
-
(A) TAXES ON INDIVIDUALS NOT OBTAINING ACCEPTABLE
COVERAGE- The amounts received in the Treasury under
section 59B of the Internal Revenue Code of 1986
(relating to requirement of health insurance
coverage for individuals).
(B) EMPLOYMENT TAXES ON
EMPLOYERS NOT PROVIDING ACCEPTABLE COVERAGE- The
amounts received in the Treasury under section
3111(c) of the Internal Revenue Code of 1986
(relating to employers electing to not provide
health benefits).
(C) EXCISE TAX ON FAILURES TO
MEET CERTAIN HEALTH COVERAGE REQUIREMENTS- The
amounts received in the Treasury under section
4980H(b) (relating to excise tax with respect to
failure to meet health coverage participation
requirements).
- (2)
APPROPRIATIONS TO COVER GOVERNMENT CONTRIBUTIONS- There are
hereby appropriated, out of any moneys in the Treasury not
otherwise appropriated, to the Trust Fund, an amount
equivalent to the amount of payments made from the Trust
Fund under subsection (b) plus such amounts as are necessary
reduced by the amounts deposited under paragraph (1).
- (d)
Application of Certain Rules- Rules similar to the rules of
subchapter B of chapter 98 of the Internal Revenue Code of 1986
shall apply with respect to the Trust Fund.
SEC. 208. OPTIONAL OPERATION OF
STATE-BASED HEALTH INSURANCE EXCHANGES.
- (a) In
General- If--
- 1
(1)
a State (or group of States, subject to the approval of the
Commissioner) applies to the Commissioner for approval of a
State-based Health Insurance Exchange to operate in the
State (or group of States); and
(2) the Commissioner
approves such State-based Health Insurance Exchange,
- then,
subject to subsections (c) and (d), the State-based Health
Insurance Exchange shall operate, instead of the Health
Insurance Exchange, with respect to such State (or group of
States). The Commissioner shall approve a State-based Health
Insurance Exchange if it meets the requirements for approval
under subsection (b).
(b) Requirements for Approval- The
Commissioner may not approve a State-based Health Insurance
Exchange under this section unless the following requirements
are met:
- (1) The
State-based Health Insurance Exchange must demonstrate the
capacity to and provide assurances satisfactory to the
Commissioner that the State-based Health Insurance Exchange
will carry out the functions specified for the Health
Insurance Exchange in the State (or States) involved,
including--
-
(A) negotiating and contracting with QHBP offering
entities for the offering of Exchange-participating
health benefits plan, which satisfy the standards
and requirements of this title and title I;
(B)
enrolling Exchange-eligible individuals and
employers in such State in such plans;
(C) the
establishment of sufficient local offices to meet
the needs of Exchange-eligible individuals and
employers;
(D) administering affordability credits
under subtitle B using the same methodologies (and
at least the same income verification methods) as
would otherwise apply under such subtitle and at a
cost to the Federal Government which does exceed the
cost to the Federal Government if this section did
not apply; and
(E) enforcement activities
consistent with federal requirements.
- (2)
There is no more than one Health Insurance Exchange
operating with respect to any one State.
(3) The State
provides assurances satisfactory to the Commissioner
that approval of such an Exchange will not result in any
net increase in expenditures to the Federal
Government.
(4) The State provides for reporting of
such information as the Commissioner determines and
assurances satisfactory to the Commissioner that it will
vigorously enforce violations of applicable
requirements.
(5) Such other requirements as the
Commissioner may specify.
- (c)
Ceasing Operation-
- (1)
IN GENERAL- A State-based Health Insurance Exchange may,
at the option of each State involved, and only after
providing timely and reasonable notice to the
Commissioner, cease operation as such an Exchange, in
which case the Health Insurance Exchange shall operate,
instead of such State-based Health Insurance Exchange,
with respect to such State (or States).
(2)
TERMINATION; HEALTH INSURANCE EXCHANGE RESUMPTION OF
FUNCTIONS- The Commissioner may terminate the approval
(for some or all functions) of a State-based Health
Insurance Exchange under this section if the
Commissioner determines that such Exchange no longer
meets the requirements of subsection (b) or is no longer
capable of carrying out such functions in accordance
with the requirements of this subtitle. In lieu of
terminating such approval, the Commissioner may
temporarily assume some or all functions of the
State-based Health Insurance Exchange until such time as
the Commissioner determines the State-based Health
Insurance Exchange meets such requirements of subsection
(b) and is capable of carrying out such functions in
accordance with the requirements of this subtitle.
(3)
EFFECTIVENESS- The ceasing or termination of a
State-based Health Insurance Exchange under this
subsection shall be effective in such time and manner as
the Commissioner shall specify.
- (d)
Retention of Authority-
- (1)
AUTHORITY RETAINED- Enforcement authorities of the
Commissioner shall be retained by the Commissioner.
(2)
DISCRETION TO RETAIN ADDITIONAL AUTHORITY- The
Commissioner may specify functions of the Health
Insurance Exchange that--
-
(A) may not be performed by a State-based Health
Insurance Exchange under this section; or
(B)
may be performed by the Commissioner and by such
a State-based Health Insurance Exchange.
(e)
References- In the case of a State-based Health Insurance
Exchange, except as the Commissioner may otherwise specify
under subsection (d), any references in this subtitle to the
Health Insurance Exchange or to the Commissioner in the area
in which the State-based Health Insurance Exchange operates
shall be deemed a reference to the State-based Health
Insurance Exchange and the head of such Exchange,
respectively.
(f) Funding- In the case of a State-based
Health Insurance Exchange, there shall be assistance
provided for the operation of such Exchange in the form of a
matching grant with a State share of expenditures required.
Subtitle B--Public
Health Insurance Option
SEC. 221. ESTABLISHMENT AND
ADMINISTRATION OF A PUBLIC HEALTH INSURANCE OPTION AS AN
EXCHANGE-QUALIFIED HEALTH BENEFITS PLAN.
- 1
(a)
Establishment- For years beginning with Y1, the Secretary of Health
and Human Services (in this subtitle referred to as the ‘Secretary’)
shall provide for the offering of an Exchange-participating health
benefits plan (in this division referred to as the ‘public health
insurance option’) that ensures choice, competition, and stability
of affordable, high quality coverage throughout the United States in
accordance with this subtitle. In designing the option, the
Secretary’s primary responsibility is to create a low-cost plan
without comprimising quality or access to care.
(b) Offering as an
Exchange-participating Health Benefits Plan-
- (1)
EXCLUSIVE TO THE EXCHANGE- The public health insurance option
shall only be made available through the Health Insurance
Exchange.
(2) ENSURING A LEVEL PLAYING FIELD- Consistent with
this subtitle, the public health insurance option shall comply
with requirements that are applicable under this title to an
Exchange-participating health benefits plan, including
requirements related to benefits, benefit levels, provider
networks, notices, consumer protections, and cost sharing.
(3)
PROVISION OF BENEFIT LEVELS- The public health insurance
option--
- (A)
shall offer basic, enhanced, and premium plans; and
(B) may
offer premium-plus plans.
- (c)
Administrative Contracting- The Secretary may enter into contracts
for the purpose of performing administrative functions (including
functions described in subsection (a)(4) of section 1874A of the
Social Security Act) with respect to the public health insurance
option in the same manner as the Secretary may enter into contracts
under subsection (a)(1) of such section. The Secretary has the same
authority with respect to the public health insurance option as the
Secretary has under subsections (a)(1) and (b) of section 1874A of
the Social Security Act with respect to title XVIII of such Act.
Contracts under this subsection shall not involve the transfer of
insurance risk to such entity.
(d) Ombudsman- The Secretary shall
establish an office of the ombudsman for the public health insurance
option which shall have duties with respect to the public health
insurance option similar to the duties of the Medicare Beneficiary
Ombudsman under section 1808(c)(2) of the Social Security Act.
(e)
Data Collection- The Secretary shall collect such data as may be
required to establish premiums and payment rates for the public
health insurance option and for other purposes under this subtitle,
including to improve quality and to reduce racial, ethnic, and other
disparities in health and health care.
(f) Treatment of Public
Health Insurance Option- With respect to the public health insurance
option, the Secretary shall be treated as a QHBP offering entity
offering an Exchange-participating health benefits plan.
(g) Access
to Federal Courts- The provisions of Medicare (and related
provisions of title II of the Social Security Act) relating to
access of Medicare beneficiaries to Federal courts for the
enforcement of rights under Medicare, including with respect to
amounts in controversy, shall apply to the public health insurance
option and individuals enrolled under such option under this title
in the same manner as such provisions apply to Medicare and Medicare
beneficiaries.
SEC. 222. PREMIUMS AND FINANCING.
- (a)
Establishment of Premiums-
- (1) IN
GENERAL- The Secretary shall establish geographically-adjusted
premium rates for the public health insurance option in a
manner--
- (A) that
complies with the premium rules established by the
Commissioner under section 113 for Exchange-participating
health benefit plans; and
(B) at a level sufficient to
fully finance the costs of--
- (i)
health benefits provided by the public health insurance
option; and
(ii) administrative costs related to
operating the public health insurance option.
- (2)
CONTINGENCY MARGIN- In establishing premium rates under
paragraph (1), the Secretary shall include an appropriate amount
for a contingency margin.
- (b) Account-
- (1)
ESTABLISHMENT- There is established in the Treasury of the
United States an Account for the receipts and disbursements
attributable to the operation of the public health insurance
option, including the start-up funding under paragraph (2).
Section 1854(g) of the Social Security Act shall apply to
receipts described in the previous sentence in the same manner
as such section applies to payments or premiums described in
such section.
(2) START-UP FUNDING-
- (A) IN
GENERAL- In order to provide for the establishment of the
public health insurance option there is hereby appropriated
to the Secretary, out of any funds in the Treasury not
otherwise appropriated, $2,000,000,000. In order to provide
for initial claims reserves before the collection of
premiums, there is hereby appropriated to the Secretary, out
of any funds in the Treasury not otherwise appropriated,
such sums as necessary to cover 90 days worth of claims
reserves based on projected enrollment.
(B) AMORTIZATION OF
START-UP FUNDING- The Secretary shall provide for the
repayment of the startup funding provided under subparagraph
(A) to the Treasury in an amortized manner over the 10-year
period beginning with Y1.
(C) LIMITATION ON FUNDING-
Nothing in this section shall be construed as authorizing
any additional appropriations to the Account, other than
such amounts as are otherwise provided with respect to other
Exchange-participating health benefits plans.
SEC. 223. PAYMENT RATES FOR ITEMS
AND SERVICES.
- (a) Rates
Established by Secretary-
- (1) IN
GENERAL- The Secretary shall establish payment rates for the
public health insurance option for services and health care
providers consistent with this section and may change such
payment rates in accordance with section 224.
(2) INITIAL
PAYMENT RULES-
- (A) IN
GENERAL- Except as provided in subparagraph (B) and
subsection (b)(1), during Y1, Y2, and Y3, the Secretary
shall base the payment rates under this section for services
and providers described in paragraph (1) on the payment
rates for similar services and providers under parts A and B
of Medicare.
(B) EXCEPTIONS-
- (i)
Practitioners’ SERVICES- Payment rates for
practitioners’ services otherwise established under the
fee schedule under section 1848 of the Social Security
Act shall be applied without regard to the provisions
under subsection (f) of such section and the update
under subsection (d)(4) under such section for a year as
applied under this paragraph shall be not less than 1
percent.
(ii) ADJUSTMENTS- The Secretary may determine
the extent to which Medicare adjustments applicable to
base payment rates under parts A and B of Medicare shall
apply under this subtitle.
- (3) FOR NEW
SERVICES- The Secretary shall modify payment rates described in
paragraph (2) in order to accommodate payments for services,
such as well-child visits, that are not otherwise covered under
Medicare.
(4) PRESCRIPTION DRUGS- Payment rates under this
section for prescription drugs that are not paid for under part
A or part B of Medicare shall be at rates negotiated by the
Secretary.
- (b) Incentives
for Participating Providers-
- (1) INITIAL
INCENTIVE PERIOD-
- (A) IN
GENERAL- The Secretary shall provide, in the case of
services described in subparagraph (B) furnished during Y1,
Y2, and Y3, for payment rates that are 5 percent greater
than the rates established under subsection (a).
(B)
SERVICES DESCRIBED- The services described in this
subparagraph are items and professional services, under the
public health insurance option by a physician or other
health care practitioner who participates in both Medicare
and the public health insurance option.
(C) SPECIAL RULES-
A pediatrician and any other health care practitioner who is
a type of practitioner that does not typically participate
in Medicare (as determined by the Secretary) shall also be
eligible for the increased payment rates under subparagraph
(A).
- (2)
SUBSEQUENT PERIODS- Beginning with Y4 and for subsequent years,
the Secretary shall continue to use an administrative process to
set such rates in order to promote payment accuracy, to ensure
adequate beneficiary access to providers, and to promote
affordablility and the efficient delivery of medical care
consistent with section 221(a). Such rates shall not be set at
levels expected to increase overall medical costs under the
option beyond what would be expected if the process under
subsection (a)(2) and paragraph (1) of this subsection were
continued.
(3) ESTABLISHMENT OF A PROVIDER NETWORK- Health care
providers participating under Medicare are participating
providers in the public health insurance option unless they opt
out in a process established by the Secretary.
- (c)
Administrative Process for Setting Rates- Chapter 5 of title 5,
United States Code shall apply to the process for the initial
establishment of payment rates under this section but not to the
specific methodology for establishing such rates or the calculation
of such rates.
(d) Construction- Nothing in this subtitle shall be
construed as limiting the Secretary’s authority to correct for
payments that are excessive or deficient, taking into account the
provisions of section 221(a) and the amounts paid for similar health
care providers and services under other Exchange-participating
health benefits plans.
(e) Construction- Nothing in this subtitle
shall be construed as affecting the authority of the Secretary to
establish payment rates, including payments to provide for the more
efficient delivery of services, such as the initiatives provided for
under section 224.
(f) Limitations on Review- There shall be no
administrative or judicial review of a payment rate or methodology
established under this section or under section 224.
SEC. 224. MODERNIZED PAYMENT
INITIATIVES AND DELIVERY SYSTEM REFORM.
- (a) In General-
For plan years beginning with Y1, the Secretary may utilize
innovative payment mechanisms and policies to determine payments for
items and services under the public health insurance option. The
payment mechanisms and policies under this section may include
patient-centered medical home and other care management payments,
accountable care organizations, value-based purchasing, bundling of
services, differential payment rates, performance or utilization
based payments, partial capitation, and direct contracting with
providers.
(b) Requirements for Innovative Payments- The Secretary
shall design and implement the payment mechanisms and policies under
this section in a manner that--
- (1) seeks
to--
- (A)
improve health outcomes;
(B) reduce health disparities
(including racial, ethnic, and other disparities);
(C)
provide efficent and affordable care;
(D) address
geographic variation in the provision of health services;
or
(E) prevent or manage chronic illness; and
- (2) promotes
care that is integrated, patient-centered, quality, and
efficient.
- (c) Encouraging
the Use of High Value Services- To the extent allowed by the benefit
standards applied to all Exchange-participating health benefits
plans, the public health insurance option may modify cost sharing
and payment rates to encourage the use of services that promote
health and value.
(d) Non-uniformity Permitted- Nothing in this
subtitle shall prevent the Secretary from varying payments based on
different payment structure models (such as accountable care
organizations and medical homes) under the public health insurance
option for different geographic areas.
SEC. 225. PROVIDER PARTICIPATION.
- (a) In General-
The Secretary shall establish conditions of participation for health
care providers under the public health insurance option.
(b)
Licensure or Certification- The Secretary shall not allow a health
care provider to participate in the public health insurance option
unless such provider is appropriately licensed or certified under
State law.
(c) Payment Terms for Providers-
- (1)
PHYSICIANS- The Secretary shall provide for the annual
participation of physicians under the public health insurance
option, for which payment may be made for services furnished
during the year, in one of 2 classes:
- (A)
PREFERRED PHYSICIANS- Those physicians who agree to accept
the payment rate established under section 223 (without
regard to cost-sharing) as the payment in full.
(B)
PARTICIPATING, NON-PREFERRED PHYSICIANS- Those physicians
who agree not to impose charges (in relation to the payment
rate described in section 223 for such physicians) that
exceed the ratio permitted under section 1848(g)(2)(C) of
the Social Security Act.
- (2) OTHER
PROVIDERS- The Secretary shall provide for the participation (on
an annual or other basis specified by the Secretary) of health
care providers (other than physicians) under the public health
insurance option under which payment shall only be available if
the provider agrees to accept the payment rate established under
section 223 (without regard to cost-sharing) as the payment in
full.
- (d) Exclusion of
Certain Providers- The Secretary shall exclude from participation
under the public health insurance option a health care provider that
is excluded from participation in a Federal health care program (as
defined in section 1128B(f) of the Social Security Act).
SEC. 226. APPLICATION OF FRAUD AND
ABUSE PROVISIONS.
- Provisions of
law (other than criminal law provisions) identified by the Secretary
by regulation, in consultation with the Inspector General of the
Department of Health and Human Services, that impose sanctions with
respect to waste, fraud, and abuse under Medicare, such as the False
Claims Act (31 U.S.C. 3729 et seq.), shall also apply to the public
health insurance option.
Subtitle
C--Individual Affordability Credits
SEC. 241. AVAILABILITY THROUGH
HEALTH INSURANCE EXCHANGE.
- (a) In General-
Subject to the succeeding provisions of this subtitle, in the case
of an affordable credit eligible individual enrolled in an
Exchange-participating health benefits plan--
- (1) the
individual shall be eligible for, in accordance with this
subtitle, affordability credits consisting of--
- (A) an
affordability premium credit under section 243 to be applied
against the premium for the Exchange-participating health
benefits plan in which the individual is enrolled; and
(B)
an affordability cost-sharing credit under section 244 to be
applied as a reduction of the cost-sharing otherwise
applicable to such plan; and
- (2) the
Commissioner shall pay the QHBP offering entity that offers such
plan from the Health Insurance Exchange Trust Fund the aggregate
amount of affordability credits for all affordable credit
eligible individuals enrolled in such plan.
- (b)
Application-
- (1) IN
GENERAL- An Exchange eligible individual may apply to the
Commissioner through the Health Insurance Exchange or through
another entity under an arrangement made with the Commissioner,
in a form and manner specified by the Commissioner. The
Commissioner through the Health Insurance Exchange or through
another public entity under an arrangement made with the
Commissioner shall make a determination as to eligibility of an
individual for affordability credits under this subtitle. The
Commissioner shall establish a process whereby, on the basis of
information otherwise available, individuals may be deemed to be
affordable credit eligible individuals. In carrying this
subtitle, the Commissioner shall establish effective methods
that ensure that individuals with limited English proficiency
are able to apply for affordability credits.
(2) USE OF STATE
MEDICAID AGENCIES- If the Commissioner determines that a State
Medicaid agency has the capacity to make a determination of
eligibility for affordability credits under this subtitle and
under the same standards as used by the Commissioner, under the
Medicaid memorandum of understanding (as defined in section
205(c)(4))--
- (A) the
State Medicaid agency is authorized to conduct such
determinations for any Exchange-eligible individual who
requests such a determination; and
(B) the Commissioner
shall reimburse the State Medicaid agency for the costs of
conducting such determinations.
- (3) MEDICAID
SCREEN AND ENROLL OBLIGATION- In the case of an application made
under paragraph (1), there shall be a determination of whether
the individual is a Medicaid-eligible individual. If the
individual is determined to be so eligible, the Commissioner,
through the Medicaid memorandum of understanding, shall provide
for the enrollment of the individual under the State Medicaid
plan in accordance with the Medicaid memorandum of
understanding. In the case of such an enrollment, the State
shall provide for the same periodic redetermination of
eligibility under Medicaid as would otherwise apply if the
individual had directly applied for medical assistance to the
State Medicaid agency.
- (c) Use of
Affordability Credits-
- (1) IN
GENERAL- In Y1 and Y2 an affordable credit eligible individual
may use an affordability credit only with respect to a basic
plan.
(2) FLEXIBILITY IN PLAN ENROLLMENT AUTHORIZED- Beginning
with Y3, the Commissioner shall establish a process to allow an
affordability credit to be used for enrollees in enhanced or
premium plans. In the case of an affordable credit eligible
individual who enrolls in an enhanced or premium plan, the
individual shall be responsible for any difference between the
premium for such plan and the affordable credit amount otherwise
applicable if the individual had enrolled in a basic plan.
- (d) Access to
Data- In carrying out this subtitle, the Commissioner shall request
from the Secretary of the Treasury consistent with section 6103 of
the Internal Revenue Code of 1986 such information as may be
required to carry out this subtitle.
(e) No Cash Rebates- In no
case shall an affordable credit eligible individual receive any cash
payment as a result of the application of this subtitle.
SEC. 242. AFFORDABLE CREDIT ELIGIBLE
INDIVIDUAL.
- (a) Definition-
- (1) IN
GENERAL- For purposes of this division, the term ‘affordable
credit eligible individual’ means, subject to subsection (b), an
individual who is lawfully present in a State in the United
States (other than as a nonimmigrant described in a subparagraph
(excluding subparagraphs (K), (T), (U), and (V)) of section
101(a)(15) of the Immigration and Nationality Act)--
- (A) who
is enrolled under an Exchange-participating health benefits
plan and is not enrolled under such plan as an employee (or
dependent of an employee) through an employer qualified
health benefits plan that meets the requirements of section
312;
1
(B)
with family income below 400 percent of the Federal poverty
level for a family of the size involved; and
(C) who is not
a Medicaid eligible individual, other than an individual
described in section 202(d)(3) or an individual during a
transition period under section 202(d)(4)(B)(ii).
- (2)
TREATMENT OF FAMILY- Except as the Commissioner may otherwise
provide, members of the same family who are affordable credit
eligible individuals shall be treated as a single affordable
credit individual eligible for the applicable credit for such a
family under this subtitle.
- (b) Limitations
on Employee and Dependent Disqualification-
- (1) IN
GENERAL- Subject to paragraph (2), the term ‘affordable credit
eligible individual’ does not include a full-time employee of an
employer if the employer offers the employee coverage (for the
employee and dependents) as a full-time employee under a group
health plan if the coverage and employer contribution under the
plan meet the requirements of section 312.
(2) EXCEPTIONS-
- (A) FOR
CERTAIN FAMILY CIRCUMSTANCES- The Commissioner shall
establish such exceptions and special rules in the case
described in paragraph (1) as may be appropriate in the case
of a divorced or separated individual or such a dependent of
an employee who would otherwise be an affordable credit
eligible individual.
(B) FOR UNAFFORDABLE EMPLOYER
COVERAGE- Beginning in Y2, in the case of full-time
employees for which the cost of the employee premium for
coverage under a group health plan would exceed 11 percent
of current family income (determined by the Commissioner on
the basis of verifiable documentation and without regard to
section 245), paragraph (1) shall not apply.
- (c) Income
Defined-
- (1) IN
GENERAL- In this title, the term ‘income’ means modified
adjusted gross income (as defined in section 59B of the Internal
Revenue Code of 1986).
(2) STUDY OF INCOME DISREGARDS- The
Commissioner shall conduct a study that examines the application
of income disregards for purposes of this subtitle. Not later
than the first day of Y2, the Commissioner shall submit to
Congress a report on such study and shall include such
recommendations as the Commissioner determines appropriate.
- (d)
Clarification of Treatment of Affordability Credits- Affordabilty
credits under this subtitle shall not be treated, for purposes of
title IV of the Personal Responsibility and Work Opportunity
Reconciliation Act of 1996, to be a benefit provided under section
403 of such title.
SEC. 243. AFFORDABLE PREMIUM CREDIT.
- (a) In General-
The affordability premium credit under this section for an
affordable credit eligible individual enrolled in an
Exchange-participating health benefits plan is in an amount equal to
the amount (if any) by which the premium for the plan (or, if less,
the reference premium amount specified in subsection (c)), exceeds
the affordable premium amount specified in subsection (b) for the
individual.
(b) Affordable Premium Amount-
- (1) IN
GENERAL- The affordable premium amount specified in this
subsection for an individual for monthly premium in a plan year
shall be equal to 1/12 of the product of--
- (A) the
premium percentage limit specified in paragraph (2) for the
individual based upon the individual’s family income for the
plan year; and
(B) the individual’s family income for such
plan year.
- (2) PREMIUM
PERCENTAGE LIMITS BASED ON TABLE- The Commissioner shall
establish premium percentage limits so that for individuals
whose family income is within an income tier specified in the
table in subsection (d) such percentage limits shall increase,
on a sliding scale in a linear manner, from the initial premium
percentage to the final premium percentage specified in such
table for such income tier.
- (c) Reference
Premium Amount- The reference premium amount specified in this
subsection for a plan year for an individual in a premium rating
area is equal to the average premium for the 3 basic plans in the
area for the plan year with the lowest premium levels. In computing
such amount the Commissioner may exclude plans with extremely
limited enrollments.
(d) Table of Premium Percentage Limits and
Actuarial Value Percentages Based on Income Tier-
- (1) IN
GENERAL- For purposes of this subtitle, the table specified in
this subsection is as follows:
--------------------------------------------------------------------------------
The
initial premium percentage is-- The final premium percentage is-- The
actuarial value percentage is--
--------------------------------------------------------------------------------
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%
--------------------------------------------------------------------------------
-
- (2) SPECIAL
RULES- For purposes of applying the table under paragraph (1)--
- (A) FOR
LOWEST LEVEL OF INCOME- In the case of an individual with
income that does not exceed 133 percent of FPL, the
individual shall be considered to have income that is 133
percent of FPL.
(B) APPLICATION OF HIGHER ACTUARIAL VALUE
PERCENTAGE AT TIER TRANSITION POINTS- If two actuarial value
percentages may be determined with respect to an individual,
the actuarial value percentage shall be the higher of such
percentages.
SEC. 244. AFFORDABILITY COST-SHARING
CREDIT.
- (a) In General-
The affordability cost-sharing credit under this section for an
affordable credit eligible individual enrolled in an
Exchange-participating health benefits plan is in the form of the
cost-sharing reduction described in subsection (b) provided under
this section for the income tier in which the individual is
classified based on the individual’s family income.
(b)
Cost-sharing Reductions- The Commissioner shall specify a reduction
in cost-sharing amounts and the annual limitation on cost-sharing
specified in section 122(c)(2)(B) under a basic plan for each income
tier specified in the table under section 243(d), with respect to a
year, in a manner so that, as estimated by the Commissioner, the
actuarial value of the coverage with such reduced cost-sharing
amounts (and the reduced annual cost-sharing limit) is equal to the
actuarial value percentage (specified in the table under section
243(d) for the income tier involved) of the full actuarial value if
there were no cost-sharing imposed under the plan.
(c)
Determination and Payment of Cost-sharing Affordability Credit- In
the case of an affordable credit eligible individual in a tier
enrolled in an Exchange-participating health benefits plan offered
by a QHBP offering entity, the Commissioner shall provide for
payment to the offering entity of an amount equivalent to the
increased actuarial value of the benefits under the plan provided
under section 203(c)(2)(B) resulting from the reduction in
cost-sharing described in subsection (b).
SEC. 245. INCOME DETERMINATIONS.
- (a) In General-
In applying this subtitle for an affordability credit for an
individual for a plan year, the individual’s income shall be the
income (as defined in section 242(c)) for the individual for the
most recent taxable year (as determined in accordance with rules of
the Commissioner). The Federal poverty level applied shall be such
level in effect as of the date of the application.
(b) Program
Integrity; Income Verification Procedures-
- (1) PROGRAM
INTEGRITY- The Commissioner shall take such steps as may be
appropriate to ensure the accuracy of determinations and
redeterminations under this subtitle.
(2) INCOME VERIFICATION-
- (A) IN
GENERAL- Upon an initial application of an individual for an
affordability credit under this subtitle (or in applying
section 242(b)) or upon an application for a change in the
affordability credit based upon a significant change in
family income described in subparagraph (A)--
- (i)
the Commissioner shall request from the Secretary of the
Treasury the disclosure to the Commissioner of such
information as may be permitted to verify the
information contained in such application; and
(ii) the
Commissioner shall use the information so disclosed to
verify such information.
- (B)
ALTERNATIVE PROCEDURES- The Commissioner shall establish
procedures for the verification of income for purposes of
this subtitle if no income tax return is available for the
most recent completed tax year.
- (c) Special
Rules-
- (1) CHANGES
IN INCOME AS A PERCENT OF FPL- In the case that an individual’s
income (expressed as a percentage of the Federal poverty level
for a family of the size involved) for a plan year is expected
(in a manner specified by the Commissioner) to be significantly
different from the income (as so expressed) used under
subsection (a), the Commissioner shall establish rules requiring
an individual to report, consistent with the mechanism
established under paragraph (2), significant changes in such
income (including a significant change in family composition) to
the Commissioner and requiring the substitution of such income
for the income otherwise applicable.
(2) REPORTING OF
SIGNIFICANT CHANGES IN INCOME- The Commissioner shall establish
rules under which an individual determined to be an affordable
credit eligible individual would be required to inform the
Commissioner when there is a significant change in the family
income of the individual (expressed as a percentage of the FPL
for a family of the size involved) and of the information
regarding such change. Such mechanism shall provide for
guidelines that specify the circumstances that qualify as a
significant change, the verifiable information required to
document such a change, and the process for submission of such
information. If the Commissioner receives new information from
an individual regarding the family income of the individual, the
Commissioner shall provide for a redetermination of the
individual’s eligibility to be an affordable credit eligible
individual.
(3) TRANSITION FOR CHIP- In the case of a child
described in section 202(d)(2), the Commissioner shall establish
rules under which the family income of the child is deemed to be
no greater than the family income of the child as most recently
determined before Y1 by the State under title XXI of the Social
Security Act.
(4) STUDY OF GEOGRAPHIC VARIATION IN APPLICATION
OF FPL- The Commissioner shall examine the feasibility and
implication of adjusting the application of the Federal poverty
level under this subtitle for different geographic areas so as
to reflect the variations in cost-of-living among different
areas within the United States. If the Commissioner determines
that an adjustment is feasible, the study should include a
methodology to make such an adjustment. Not later than the first
day of Y2, the Commissioner shall submit to Congress a report on
such study and shall include such recommendations as the
Commissioner determines appropriate.
- (d) Penalties
for Misrepresentation- In the case of an individual intentionally
misrepresents family income or the individual fails (without regard
to intent) to disclose to the Commissioner a significant change in
family income under subsection (c) in a manner that results in the
individual becoming an affordable credit eligible individual when
the individual is not or in the amount of the affordability credit
exceeding the correct amount--
- (1) the
individual is liable for repayment of the amount of the improper
affordability credit; and
(2) in the case of such an
intentional misrepresentation or other egregious circumstances
specified by the Commissioner, the Commissioner may impose an
additional penalty.
SEC. 246. NO FEDERAL PAYMENT FOR
UNDOCUMENTED ALIENS.
1
Nothing
in this subtitle shall allow Federal payments for affordability credits
on behalf of individuals who are not lawfully present in the United
States.
