[Congressional Record Volume 156, Number 43 (Sunday, March 21, 2010)]
[House]
[Pages H1891-H2169]
From the Congressional Record Online through the Government Printing Office [www.gpo.gov]
[[Page H1891]]
Senate
The Senate was not in session today. Its next meeting will be held on
Monday, March 22, 2010, at 2 p.m.
House of Representatives
Sunday, March 21, 2010
SENATE AMENDMENTS TO H.R. 3590, SERVICE MEMBERS HOME OWNERSHIP TAX ACT
OF 2009, AND H.R. 4872, HEALTH CARE AND EDUCATION RECONCILIATION ACT OF
2010--Continued
{time} 2145
Mr. CAMP. Mr. Speaker, for the purposes of a unanimous consent
request, I yield to the gentleman from Texas (Mr. Hall).
(Mr. HALL of Texas asked and was given permission to revise and
extend his remarks.)
Mr. HALL of Texas. Mr. Speaker, I rise in opposition to this flawed
health care bill.
Mr. CAMP. Mr. Speaker, for the purpose of a unanimous consent
request, I yield to the gentlewoman from North Carolina (Ms. Foxx).
(Ms. FOXX asked and was given permission to revise and extend her
remarks.)
Ms. FOXX. Mr. Speaker, I rise in opposition to this flawed health
bill.
Mr. CAMP. For the purpose of a unanimous consent request, I yield to
the gentleman from New York (Mr. King).
(Mr. KING of New York asked and was given permission to revise and
extend his remarks.)
Mr. KING of New York. Mr. Speaker, I rise in opposition to this
flawed health care bill.
Mr. CAMP. Mr. Speaker, I yield 4 minutes to the distinguished
gentleman from Virginia (Mr. Cantor), the Republican whip.
Mr. CANTOR. Mr. Speaker, all of us in this body, Republicans and
Democrats alike, care about Americans' health care, but many of us from
both sides of the aisle don't care for this trillion dollar overhaul.
And the fact is, the majority of Americans don't care for it either.
Sadly, Mr. Speaker, the only bipartisanship we've seen surrounding
this overhaul has been in opposition to it, and there's a reason for
that. Health care is a very personal issue, and this overhaul will
impact every man, woman, and child in this country. It will even affect
future generations that have not yet been born.
Mr. Speaker, this overhaul will have a huge impact on our parents,
our spouses, and our kids. This is something that they'll be paying for
for the rest of their lives. And for too long, Mr. Speaker, the
majority in this body and the President of the United States have
refused to listen to the American people.
So, Mr. Speaker, I have a message for those Americans. We hear you.
We hear you loud and clear, because we believe this government must
stop spending money that it doesn't have, and this trillion dollar
overhaul will do the opposite.
We believe that this government must stop piling debt upon our
children and grandchildren, and this trillion dollar overhaul will do
the opposite.
We believe that this government must stop raising taxes on small
businesses and families, and, Mr. Speaker, this trillion dollar
overhaul will do the opposite.
We believe that America is the land of innovation and that government
must stop crippling job creators and entrepreneurs with oppressive
mandates and taxes, and this trillion dollar overhaul will do the
opposite.
Mr. Speaker, we believe that in America our government must not force
those who fundamentally object to abortion to have to pay for it, and
this trillion dollar overhaul does the opposite.
And we believe in building upon what works in our current health
care, Mr. Speaker, so that doctors in America can continue to provide
the best care in the world, and this trillion dollar overhaul does the
opposite.
And, Mr. Speaker, we believe that families and patients should have
the freedom and the right to choose the doctors they want, and this
trillion dollar overhaul will begin to take that freedom away.
Mr. Speaker, if there's one thing that the American people have
learned over the past year, it's that we are truly at a critical time
in this country. We are at a crossroads.
This trillion dollar health care overhaul before us today has caused
a lot of fear and uncertainty. It's the latest part of an agenda that
is being forced upon the American people that attempts to seize more
control over the economy and our lives.
The choices we make on deficit spending, higher taxes, energy
security, and health care, they're all important. They're important
because they will all determine what kind of country we want to be.
[[Page H1892]]
The SPEAKER pro tempore (Mr. Obey). The time of the gentleman has
expired.
Mr. CAMP. I yield the gentleman 30 additional seconds.
Mr. CANTOR. Mr. Speaker, the choice before us is very clear. The
choice is whether we want to become a country that is unrecognizable,
or one that will fulfill the American Dream so that we remain the most
secure and most prosperous, freest country in the history of the world.
Mr. Speaker, I urge my colleagues today to listen to the people and
vote ``no'' against this legislation.
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to Mr. Ackerman of New York.
(Mr. ACKERMAN asked and was given permission to revise and extend his
remarks.)
Mr. ACKERMAN. I rise in enthusiastic support of this historic,
important bill.
The SPEAKER pro tempore. The gentleman will be charged.
Mr. SPRATT. For purposes of another unanimous consent request, I
yield to the gentlelady from California (Ms. Waters).
(Ms. WATERS asked and was given permission to revise and extend her
remarks.)
Ms. WATERS. Mr. Speaker, I rise in support of this bill.
Our health care system is broken; no one can deny it.
Every day, millions of Americans go without needed health care
because they have no insurance. Some of these people work for small
businesses and other employers that do not provide insurance. Some of
them lost their insurance when they lost their jobs. Some of them were
denied coverage by insurance companies because of a pre-existing
condition. And some of them simply could not afford the escalating
premiums. Even for people with health insurance, a devastating accident
or illness can be very expensive. The cost of health care is the number
one reason for bankruptcies in America.
So we cannot afford inaction. Today, we have a clear choice--to start
to fix the broken health care system--or to do nothing.
However, this bill is not perfect. I would like to have seen included
measures such as a public health insurance option like Medicare that
would compete with the private insurance plans and a single national
insurance exchange where people could purchase the health plan of their
choice instead of separate state-based exchanges with different
standards. I believe these measures would be more effective at
containing costs and creating competition for the insurance industry.
I am also concerned that this bill should not be used to limit the
right of women to reproductive choice. Despite the President's
Executive Order, attempting to codify existing law under the so-called
Hyde Amendment, it is not clear that the Senate bill does not go beyond
the Hyde amendment.
Nevertheless, I have decided to support H.R. 3590, together with the
improvements included in H.R. 4872, because it will make health care
more affordable and more accessible for thousands of my constituents
and millions of Americans. By passing this legislation today we are
taking a critically important step in the right direction.
According to an analysis by the House Energy and Commerce Committee,
this health care reform bill will benefit California's 35th District in
the following ways:
Improve coverage for 281,000 residents with health insurance.
Extend coverage to 125,500 residents who lack insurance.
Guarantee that 21,200 residents with pre-existing conditions can
obtain coverage.
Allow 58,000 young adults to obtain coverage on their parents'
insurance plans.
Give tax credits and other assistance to up to 157,000 families and
15,100 small businesses to help them afford coverage.
Improve Medicare for 62,000 beneficiaries, including reducing the
costs of prescription drugs and closing the donut hole.
Protect 1,100 families from bankruptcy due to unaffordable health
care costs.
Provide millions of dollars in new funding for 10 community health
centers.
Reduce the cost of uncompensated care for hospitals and other health
care providers by $15 million annually.
Many provisions of the bill will kick in immediately. Insurance
companies will no longer be able to take away a person's insurance
because the person gets sick, an unfair practice known as rescission.
It will immediately prevent insurance companies from denying coverage
to children with pre-existing conditions, and eventually end
discrimination against anyone with a pre-existing condition. It will
immediately allow young people the ability to remain on their parents'
insurance until age 26. It will immediately help seniors pay for
prescription drugs and eventually eliminate the donut hole completely.
And it will extend tax credits to small businesses so that they can
provide health insurance to their employees.
Over the next few years, the bill will extend coverage to 32 million
Americans, or 95 percent of the population, providing affordability
credits for individuals who cannot afford to purchase health insurance
on their own.
Improving our health care system is essential to setting us on the
right path to healthier lives, renewed American innovation, and a
stronger, more stable American economy. I urge my colleagues to support
this bill and expand access to health care for families and small
businesses throughout the United States of America.
Mr. SPRATT. For purposes of a unanimous consent request, I yield to
Mr. Driehaus from Ohio.
(Mr. DRIEHAUS asked and was given permission to revise and extend his
remarks.)
Mr. DRIEHAUS. Mr. Speaker, I rise in support of this health care
legislation.
Mr. SPRATT. Mr. Speaker, I now yield 1 minute to the gentlelady from
Minnesota (Ms. McCollum).
Ms. McCOLLUM. Mr. Speaker, beyond the walls of this Capitol, there
are millions of Americans who can't afford health insurance and they
live in fear of getting sick. Millions more are discriminated against
by insurance companies because they have preexisting medical
conditions.
In my own life, as a child and as an adult, I've lived without health
insurance. A dear, dear niece of mine has a preexisting condition that
makes her uninsurable.
Passing health insurance reform is not a political game. It's
personal. It's about real people's lives. When we pass this bill, we
will save lives. Families will be protected. Millions of Americans will
no longer live in fear.
Today I will vote to end discrimination against people with
preexisting conditions. Today I will vote to extend health care to 32
million Americans. And when this bill becomes law, health care security
will finally become a reality for the American people.
Mr. CAMP. Mr. Speaker, at this time I will yield to the gentleman
from California for the purpose of a unanimous consent request.
Mr. DANIEL E. LUNGREN of California. Mr. Speaker, because of
confusion over its legal effect, I ask unanimous consent that the text
of President Obama's Executive order referring to abortion funding,
that it be considered as a freestanding amendment to the text of H.R.
3590 and we be allowed to vote on it separately.
The SPEAKER pro tempore. The Chair cannot entertain such a request
unless it has been cleared.
Parliamentary Inquiries
Mr. DANIEL E. LUNGREN of California. Mr. Speaker, parliamentary
inquiry.
The SPEAKER pro tempore. The gentleman will state his parliamentary
inquiry.
Mr. DANIEL E. LUNGREN of California. Mr. Speaker, is such unanimous
consent request, is it, in fact, in order under the rules of the House?
The SPEAKER pro tempore. The Chair has indicated that requests for
these matters must be cleared.
The Chair is not obligated to instruct Members on the rules of the
House.
Mr. DANIEL E. LUNGREN of California. Mr. Speaker, with respect, may I
make a further inquiry, Mr. Speaker?
The SPEAKER pro tempore. The gentleman may inquire.
Mr. DANIEL E. LUNGREN of California. Would that request, if it were
cleared, be considered germane to the bill under consideration?
The SPEAKER pro tempore. The Chair will not respond to hypotheticals.
Mr. DANIEL E. LUNGREN of California. Mr. Speaker, additional
parliamentary inquiry.
The SPEAKER pro tempore. The gentleman may proceed.
Mr. DANIEL E. LUNGREN of California. When I am informed that it must
be cleared, do I understand that to mean it must be cleared by the
Speaker or the majority leader?
The SPEAKER pro tempore. Leadership on both sides must clear these
matters. I'm sure the gentleman knows that.
Mr. DANIEL E. LUNGREN of California. I thank the Speaker.
Mr. CAMP. Mr. Speaker, I reserve my time.
[[Page H1893]]
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to the gentlewoman from Ohio (Ms. Kaptur).
(Ms. KAPTUR asked and was given permission to revise and extend her
remarks.)
Ms. KAPTUR. Mr. Speaker, I rise in support of affordable health
insurance for all Americans.
I rise in support of this historic legislation because affordable
health care is really about life--about a healthier and more secure
life for all Americans.
This is about life--the life of a senior who can't afford
prescription drugs, or a mother carrying a new life waiting to be born.
This legislation says every American has the right to the dignity of
a healthy life. Nothing more, nothing less. Its promise is true for all
citizens, of all ages, from all walks of life. In that respect, it is
profoundly American.
It is most certainly about the millions of citizens in our nation who
run small businesses and about their employees--who after all these
years comprise over half the uninsured in our nation. These businesses
embody the hopes and dreams of life in America. They are the engines of
job growth, but after all these decades, they are treated like second
class citizens.
This bill is about women and children--the millions of women who have
no health care and the millions of children who are born frail and weak
because their mothers have no access to prenatal care and their fathers
have no insurance. The March of Dimes tells us that every year, more
than half a million American children are born underweight, one out of
every eight children born premature, malnourished, and so many with
disability. That should not happen in America. Our nation's insurance
programs aren't meeting the market nor the promise of America.
This legislation will help millions of women obtain health coverage
and thus reduce abortion by enhancing broad coverage options for
women's and children's health. It will vastly improve preventive care,
more than double funds available to community health centers (including
obstetric and gynecological care), and move America fully into this
21st century. No woman, no woman--including poor women, pregnant women,
working women, single women, and nursing women--will be denied health
insurance coverage.
Mr. Speaker, the best anti-abortion bill we can pass is one that
gives women and children a real chance through health insurance
coverage that allows fragile life to come to term. This bill does that.
It gives hope, to every family, to every woman to every child yet to be
born. It says you have a right to be born. It provides for prenatal
care during a woman's pregnancy, preventive care for newborns, funding
to help pregnant and parenting teens and college students with
assistance for basic necessities, as well as adoption tax credits. No
family, no mother, no father will ever have to question again whether
they can afford to bring a conceived child to term
This bill is about a better life for seniors, too. By closing the
doughnut hole, it makes sure they can afford the medicine they need to
live healthy, independent lives.
As the costs of insurance have risen, emptying the wallets of our
neighbors, almost one in three Americans (87 million of our fellow
citizens) went without health insurance for some period last year. We
can do better in America.
There is so much shifting in the marketplace, it is becoming less
stable and reliable. Thousands more of our citizens are losing their
insurance because they have lost their jobs as the unemployment
epidemic rages throughout our nation.
Even those with insurance, no matter how expensive or robust it might
be, learn their coverage is not guaranteed nor continuous nor quality.
Millions of hardworking Americans are denied coverage; charged an
impossibly higher rate, or discriminated against because of a pre-
existing condition. Family employer-sponsored health insurance
increased 119 percent over the last decade. Small business premiums
alone have risen 129 percent. Without reform, rates are projected to
increase to $23,842 on average by 2020. This simply cannot continue;
the system is broken.
I can identify with the tens of millions of our fellow citizens who
have no health insurance, over half of whom are either small business
owners or their employees. When my brother, Steve, and I were growing
up, our beloved, hardworking father, ``Kappy,'' had three heart
attacks. He made the gut-wrenching decision to sell our small family
market to go to work in an auto plant for one reason: to get health
insurance for his wife, Anastasia, and their two children. He didn't
even care about himself. I shall never forget that piercing experience:
it is the story of millions upon millions of our fellow citizens
excluded, priced out or eliminated from the insurance market place. In
our parents' memory, the best jobs bill I can vote is one that takes
the health insurance anxiety off the backs of small businesspeople
across our nation. I do so today in our parents' memory.
I have listened closely to the concerns of citizens in Ohio's Ninth
Congressional District. There is passion on both sides. Some claim this
legislation is unconstitutional. I respectfully disagree. To accept
that argument is to say that Social Security is unconstitutional, or
Medicare is unconstitutional, or veterans' benefits are
unconstitutional, or the interstate highway system is unconstitutional.
I believe that argument would tear apart the fabric of our Republic.
Affordable health insurance reform is necessary to provide greater
competition among available plans to cut the costs of doing business,
reduce the share of government expenditures spent on health care, help
our companies to be more competitive in the world market, unleash the
entrepreneurial talents of the American people, and give peace of mind
to the middle class, our seniors and others that everything they have
worked for will not be taken away if they get sick.
I have been touched by stories from constituents and I rise today in
support of this historic bill for them:
David owns a small business. In 1999, he offered health insurance to
his 15 employees. Over the course of the next decade, his insurance
premiums skyrocketed and he had to let some employees go. By 2007 he
was down to three employees and could no longer provide insurance for
them--or himself. Now uninsured, he recently suffered a heart attack.
Health care expenses forced him to file for bankruptcy. Sad to say, his
case is not all that unusual--health care costs are the leading cause
of bankruptcy in America.
Jeff changed jobs and was required to obtain different health
insurance while his wife was mid-term in a pregnancy. The pregnancy was
high risk, the birth was problematic, and the insurer, a ``health
maintenance organization,'' an HMO, denied coverage not only for the
mother's labor and delivery, but also their baby's conditions at birth.
Lillian will reach her allowable Part D private drug plan coverage in
March. She cannot afford to pay for her medicines, so she never climbs
out of the ``doughnut hole'' to obtain coverage again. As a result, she
will quit taking her prescription drugs for nine months, until the new
year starts. As a result, she has been hospitalized.
Mary has suffered from bipolar disorder since her twenties. She is
now in her fifties. She is married, with a family. She has experienced
many exacerbations of her illness and resulting hospitalizations. She
reached the insurer's lifetime maximum when in her early forties. Since
then, her family has had to pay her expenses.
Susan is the director of a nonprofit organization that serves
homeless families. The organization offers health insurance to
employees, but the premium increase this year was 49%. Now the agency
must choose between dropping insurance as an employee benefit or
reducing services to the vulnerable families it serves. Meanwhile, the
insurer posted record profits last year.
Bob and Catherine were married for 53 years and raised six children.
Catherine developed a chronic debilitating illness which worsened over
time. Bob took care of her at home for nine years, using all of their
savings and having to sell their house.
Cassandra is a12-year-old girl with juvenile diabetes. Since her
diagnosis as a toddler, her parents have been unable to obtain health
care coverage even though they could afford to pay for it. They must
pay all her health expenses out of pocket. They live in a small
apartment.
Aaron is 14. He has a failing liver and has needed a liver transplant
for five years. His mom could not work because she had to care for him.
The family has no health care coverage. Though the hospital absorbed
much of the cost for his care and treatment, the family held
fundraisers through the years to pay for his transplant and the health
care which has subsequently followed. All of us are familiar with the
spaghetti dinners, and benefit dances, and silent auctions to help
families in similar circumstances. Heroic compassionate people rise to
the occasion in communities across our nation, but often it simply is
not enough.
For too long, the health of our nation has dwindled--indeed the U.S.
ranks behind over a dozen major nations in health outcomes--while the
pockets of the insurance giants have thickened. Insurance companies
raise rates and deny coverage to pay their CEOs excessive salaries and
bonuses. WellCare and Aetna's executives, for example, received between
$18 and $23 million dollars alone in 2008. Despite wanting to increase
premiums recently for individuals by 39 percent, WellPoint's
executives, which is an insurance provider in the state of Ohio where I
represent, received over $8.6 million.
Our seniors have compromised prescription drugs for necessary
groceries, while the insurance and pharmaceutical industries have made
record profits. Hard working families
[[Page H1894]]
have watched their savings plummet and their homes foreclosed after
unexpected illnesses. Women with breast cancer, men with heart disease
and children with leukemia or childhood diabetes have been flat-out
denied health insurance coverage for pre-existing conditions or
reaching insurance policy caps.
With the mounting economic strain on American families and the rising
costs of health insurance to workers, businesses and the federal
budget, the status quo has proven itself unsustainable, fiscally
irresponsible and morally unacceptable. The time has come for this
historical change. The bill before us pays for itself and actually
brings revenues back to the health system as a result of the
combination of added competition and better use of the health dollar. I
stand in support of its promise to the American people--the promise of
a better and healthier life for all in this blessed land.
Mr. SPRATT. Also for purposes of a unanimous consent request, I yield
to Mrs. Dahlkemper from Pennsylvania.
(Mrs. DAHLKEMPER asked and was given permission to revise and extend
her remarks.)
Mrs. DAHLKEMPER. Mr. Speaker, I rise in support of this health care
legislation.
Mr. SPRATT. I now yield 1\1/2\ minutes to the gentlewoman from
Connecticut (Ms. DeLauro).
Ms. DeLAURO. Mr. Speaker, I rise in support of this historic
legislation, arguably the most important vote we here today will ever
take in this Chamber.
Today fulfills a promise made 100 years ago by Theodore Roosevelt
when he first called for comprehensive health insurance reform. It
fulfills a promise made by Franklin Roosevelt to our parents, our
grandparents, our great grandparents in 1944. President Richard Nixon
also labored and lost on this national mission. And President Bill
Clinton, too, tried to climb this mountain.
Today's legislation builds on the great achievements of Social
Security and Medicare, those big changes that we all take for granted,
regardless of party. And yes, they, too, were characterized as
socialist government takeovers.
And today we have a chance to make health insurance affordable for
people and for small businesses that ends the power of the insurance
companies to deny them coverage, increase their rates and, yes, drop
them when they get sick. Enough.
This reform law allows 32 million of our citizens to get insurance, a
moral imperative. It closes the doughnut hole in prescription drugs for
seniors, and women will no longer have to pay more for their insurance,
a long overdue reckoning.
I am humbled by the opportunity to cast a vote for this historic
change.
Mr. CAMP. Mr. Speaker, I yield myself 2 minutes.
We've heard a lot of discussion tonight about this bill and how it's
been characterized. Let me just read a few quotes from my friends on
the Democratic side who've characterized this bill.
A Democrat from North Carolina says: There is no question that our
current health care system is broken and that we need to make
significant reforms to improve it in an equitable, fiscally
responsible, and sustainable manner. In my opinion, the bill as written
does not meet those criteria.
A Democrat from Tennessee says: After thorough and careful review of
the legislation, I am unconvinced that the long-term trend of rising
health care costs is adequately addressed and am, therefore, unable to
support the legislation.
A Democrat from New Mexico said: I do not believe that the bill does
enough to contain costs.
A Democrat from North Carolina says: Health care reform is needed,
but the bill before us is too expensive, does not adequately address
rising medical costs and skyrocketing insurance premiums, and tries to
do too much too soon. We simply cannot afford to create a new Federal
bureaucracy that costs nearly $1 trillion when our national debt is $12
trillion and there is no plan in place to address it. I will not vote
for it.
Another Democrat from Virginia says: I have spoken with countless
small business owners, families, medical professionals, and average
citizens across Virginia, and it becomes very clear that this bill is
not the right solution for Virginia's health care challenges.
On and on and on again. This is not the right bill for America. This
costs $1 trillion, raises a half a trillion in taxes, and cuts Medicare
by half a trillion dollars. Vote ``no'' on this bill.
{time} 2200
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to the gentlelady from New York (Mrs. Lowey).
(Mrs. LOWEY asked and was given permission to revise and extend her
remarks.)
Mrs. LOWEY. I rise in strong support of this bill.
Mr. Speaker, I rise in support of enacting historic health care
reform.
Over the past fifteen months, I have held countless meetings with
community organizations, small business owners, senior citizens,
doctors, nurses, and patients, joined public forums and community
meetings, and held telephone town halls. It is clear to me the status
quo is unsustainable. Without action, individuals would continue to be
denied coverage and care, more families would go into bankruptcy due to
the costs of care, and businesses would continue to struggle to cover
their employees.
Some benefits will be evident almost immediately after this bill is
signed. The most egregious practices of insurance companies, like
denying coverage for children due to pre-existing conditions and
dropping coverage when patients become sick, will be illegal. Small
businesses will gain tax credits to provide affordable insurance to
their employees. Senior citizens will benefit from immediate steps to
close the Medicare prescription drug ``donut hole.''
I have heard hundreds of personal stories. A social worker in Ardsley
earning $53,000 per year whose out-of-pocket insurance premium just
increased by $110 to $831 per month. Or the man from White Plains who
was denied life saving cancer medication by his insurance company until
my intervention. The small business owner from Ossining whose premium
costs increased 40 percent this year.
I want to assure you that:
Medicare benefits will be strengthened by closing the prescription
drug ``donut hole,'' eliminating charges for preventive care, and
extending the solvency of the Medicare Trust Fund.
The vast majority of families in Westchester and Rockland Counties
will see absolutely no change in their income taxes due to this bill. I
fought to protect our region, and I continue my work to index federal
taxes to cost of living, which would help residents in our expensive
area.
Small businesses with fewer than 50 employees are exempt from
employer requirements and some will immediately be offered tax credits
to provide coverage for their employees.
This legislation will not provide taxpayer funding for abortion, and
in fact I am not pleased with new obstacles to reproductive health
care.
And finally, this bill will reduce the federal deficit by more than
$143 billion in the first ten years and more than $1.2 trillion in the
second ten years after passage.
Instead of passing the House bill, the Senate adopted a flawed bill
that I will support for the sole purpose of immediately making
improvements through reconciliation to help American families and
businesses.
Although the legislation we passed this week is not perfect, it will
rein in skyrocketing insurance premiums for families, prevent the worst
practices of the insurance industry, help 30 million uninsured
Americans gain access to care, allow insured Americans to keep their
coverage if they like it, help small businesses afford coverage for
their employees, allow children up to 26 years old to stay on their
parents' plans and protect Medicare for senior citizens.
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to the gentleman from New Jersey (Mr. Payne).
(Mr. PAYNE asked and was given permission to revise and extend his
remarks.)
Mr. PAYNE. Mr. Speaker, I rise in support of this great health care
reform bill.
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to the gentleman from Florida (Mr. Grayson).
(Mr. GRAYSON asked and was given permission to revise and extend his
remarks.)
Mr. GRAYSON. I rise in support of this bill.
Mr. SPRATT. Mr. Speaker, for purposes of a unanimous consent request,
I yield to the gentleman from Georgia (Mr. Bishop).
[[Page H1895]]
(Mr. BISHOP of Georgia asked and was given permission to revise and
extend his remarks.)
Mr. BISHOP of Georgia. I rise in support of this historic health care
reform bill.
Mr. SPRATT. Mr. Speaker, can you tell me how much time is remaining
on my side?
The SPEAKER pro tempore. There are 2\1/4\ minutes remaining for the
gentleman from South Carolina.
Mr. SPRATT. Mr. Speaker, I yield 1\1/4\ minutes to the gentleman from
New Jersey (Mr. Andrews).
(Mr. ANDREWS asked and was given permission to revise and extend his
remarks.)
Mr. ANDREWS. Mr. Speaker, our friends on the other side of the aisle
have asked frequently tonight what kind of country are we. They've
asked exactly the right question. Tomorrow when a person is denied a
job because she has breast cancer or is charged higher premiums because
he has asthma, what kind of country will we be? Tomorrow when a senior
citizen has enough money in her checking account to pay the utility
bill or her prescription bill but not both, what kind of country will
we be? When a person who tonight is scrubbing floors or pumping gas or
waiting on tables tomorrow tries to go to buy a health insurance policy
for herself or her children, what kind of country will we be?
For Social Security, we gave decency for seniors. In Medicare, we
gave compassion for seniors. In the Civil Rights Act, we gave equality
for all Americans. Tonight, we will give justice and decency. That's
the kind of country that we will be.
Mr. CAMP. Mr. Speaker, at this time I yield 1 minute to the
distinguished minority leader, the gentleman from Ohio (Mr. Boehner).
Mr. BOEHNER. Mr. Speaker and my colleagues, I rise tonight with a sad
and heavy heart. Today we should be standing together reflecting on a
year of bipartisanship and working to answer our country's call and
their challenge to address the rising costs of health insurance in our
country.
Today, this body, this institution, enshrined in the first article of
the Constitution by our Founding Fathers as a sign of the importance
they placed on this House, should be looking with pride on this
legislation and our work.
But it is not so.
No, today we're standing here looking at a health care bill that no
one in this body believes is satisfactory. Today we stand here amidst
the wreckage of what was once the respect and honor that this House was
held in by our fellow citizens. And we all know why it is so. We have
failed to listen to America. And we have failed to reflect the will of
our constituents. And when we fail to reflect that will, we fail
ourselves, and we fail our country.
Look at this bill. Ask yourself, do you really believe that if you
like the health plan that you have that you can keep it? No, you can't.
You can't say that.
In this economy, with this unemployment, with our desperate need for
jobs and economic growth, is this really the time to raise taxes, to
create bureaucracies, and burden every job creator in our land? The
answer is no.
Can you go home and tell your senior citizens that these cuts in
Medicare will not limit their access to doctors or further weaken the
program instead of strengthening it? No, you cannot.
Can you go home and tell your constituents with confidence that this
bill respects the sanctity of all human life and that it won't allow
for taxpayer funding of abortions for the first time in 30 years? No,
you cannot.
And look at how this bill was written. Can you say it was done
openly, with transparency and accountability? Without backroom deals
and struck behind closed doors hidden from the people? Hell, no, you
can't.
Have you read the bill? Have you read the reconciliation bill? Have
you read the manager' s amendment? Hell, no, you haven't.
Announcement by the Speaker Pro Tempore
The SPEAKER pro tempore. Both sides would do well to remember the
dignity of the House.
Mr. BOEHNER. Mr. Speaker, in a few minutes we will cast some of the
most consequential votes that any of us will ever cast in this Chamber.
The decision we make will affect every man, woman, and child in this
Nation for generations to come. If we're going to vote to defy the will
of the American people, then we ought to have the courage to stand
before them and announce our votes, one at a time.
I sent a letter to the Speaker this week asking that the ``call of
the roll'' be ordered for this vote. Madam Speaker, I ask you, will
you, in the interest of this institution, grant my request?
Will you, Mr. Speaker, grant my request that we have a call of the
roll?
The SPEAKER pro tempore. Is the gentleman asking a rhetorical
question?
Mr. BOEHNER. Mr. Speaker, will you grant my request that we have a
call of the roll?
The SPEAKER pro tempore. Under clause 2(a) of rule XX, a record vote
is conducted by electronic device unless the Speaker directs otherwise.
MR. BOEHNER. And you, Mr. Speaker, will you grant that request?
The SPEAKER pro tempore. The Chair will decide at the time the
question is ripe. This is not it.
Mr. BOEHNER. My colleagues, this is the People's House.
When we came here, we each swore an oath to uphold and abide by the
Constitution as representatives of the people. But the process here is
broken. The institution is broken. And as a result, this bill is not
what the American people need nor what our constituents want.
Americans are out there making sacrifices and struggling to make a
better future for their kids, and over the last year as the damn-the-
torpedoes outline of this legislation became more clear, millions of
Americans lifted their voices and many, for the first time, asking us
to slow down, not to try to cram through more than this system could
handle, not to spend money that we didn't have. In this time of
recession, they wanted us to focus on jobs, not more spending, not more
government, and certainly not more taxes.
But what they see today frightens them. They're frightened because
they don't know what comes next. They're disgusted because what they
see is one political party closing out the other from what should be a
national solution. And they're angry. They're angry that no matter how
they engage in this debate, this body moves forward against their will.
Shame on us. Shame on this body. Shame on each and every one of you
who substitutes your will and your desires above those of your fellow
countrymen.
Around this Chamber, looking upon us are the lawgivers from Moses, to
Gaius, to Blackstone, to Thomas Jefferson. By our actions today, we
disgrace their values. We break the ties of history in this Chamber. We
break our trust with America.
When I handed the Speaker the gavel in 2007, I said this: ``This is
the People's House. And the moment a majority forgets it, it starts
writing itself a ticket to minority status.''
If we pass this bill, there will be no turning back. It will be the
last straw for the American people. In a democracy, you can only ignore
the will of the people for so long and get away with it. And if we defy
the will of our fellow citizens and pass this bill, we're going to be
held to account by those who have placed us in their trust. We will
have shattered those bonds of trust.
I beg you, I beg each and every one of you on both sides of the
aisle: Do not further strike at the heart of this country and this
institution with arrogance, for surely you will not strike with
impunity.
I ask each of you to vow to never let this happen again--this
process, this defiance of our citizens. It's not too late to begin to
restore the bonds of trust with our Nation and return comity to this
institution.
And so join me. Join me in voting against this bill so that we can
come together, together anew and addressing the challenge of health
care in a manner that brings credit to this body and brings credit to
the ideals of this Nation, and most importantly, that reflects the will
of the American people.
{time} 2215
Mr. SPRATT. Mr. Speaker, I yield 1 minute to the gentlewoman from
California, who has led the way in this quest for health care reform
and tirelessly, persistently, she has brought us to this moment of the
decision, the
[[Page H1896]]
gentlewoman from California, the Speaker of the House, Ms. Pelosi.
Ms. PELOSI. Thank you, my colleagues. I thank the gentleman for
yielding. I thank all of you for bringing us to this moment.
Mr. Speaker, it is with great humility and with great pride that
tonight we will make history for our country and progress for the
American people. Just think, we will be joining those who established
Social Security, Medicare, and now tonight health care for all
Americans.
In doing so, we will honor the vows of our Founders, who, in the
Declaration of Independence, said that we are endowed by our Creator
with certain inalienable rights and among these are life, liberty, and
the pursuit of happiness.
This legislation will lead to healthier lives, more liberty to pursue
hopes and dreams and happiness for the American people. This is an
American proposal that honors the traditions of our country.
We would not be here tonight for sure without the extraordinary
leadership and vision of President Barack Obama. We thank him for his
unwavering commitment to health care for all Americans. This began over
a year ago under his leadership in the American Recovery and
Reinvestment Act where we had very significant investments in science,
technology, and innovation for health care reform.
It continued in the President's budget a few months later, a budget
which was a statement of our national values, which allocated resources
that were part of our value system and in a way that stabilized our
economy, created jobs, lowered taxes for the middle class and did so
and reduced the deficit and did so in a way that had pillars of
investment, including education and health care reform.
Health care reform and education equal opportunity for the American
people. This legislation tonight, if I had one word to describe it,
would be opportunity with its investments in education and health care
as a continuation of the President's budget.
We all know, and it's been said over and over again, that our economy
needs something new, a jolt, and I believe that this legislation will
unleash tremendous entrepreneurial power into our economy. Imagine a
society and an economy where a person could change jobs without losing
health insurance, where they could be self-employed or start a small
business.
Imagine an economy where people could follow their passions and their
talent without having to worry that their children would not have
health insurance, that if they had a child with diabetes who was
bipolar or preexisting medical condition in their family, that they
would be job locked. Under this bill, their entrepreneurial spirit will
be unleashed.
We all know that the present health care system and health insurance
system in our country is unsustainable. We simply cannot afford it. It
doesn't work for enough people in terms of delivery of service, and it
is bankrupting the country with the upward spiral of increasing medical
cost. The best action that we can take on behalf of America's family
budgets and on behalf of the Federal budget is to pass health care
reform.
The best action we can take to strengthen Medicare and improve care
and benefits for our seniors is to pass this legislation tonight, pass
health care reform. The best action we can do to create jobs and
strengthen our economic security is pass health care reform.
The best action we can take to keep America competitive, ignite
innovation, again, unleash entrepreneurial spirit is to pass health
care reform.
With this action tonight, with this health care reform, 32 million
more Americans will have health care insurance and those who have
insurance now will be spared of being at the mercy of the health
insurance industry with their obscene increases in premiums, their
rescinding of policies at the time of illness, their cutting off of
policies even if you have been fully paying but become sick. The list
goes on and on about the health care reforms that are in this
legislation: insure 32 million more people, make it more affordable for
the middle class, end insurance company discrimination on preexisting
conditions, improve care and benefits under Medicare and extending
Medicare solvency for almost a decade, creating a healthier America
through prevention, through wellness and innovation, create 4 million
jobs in the life of the bill and doing all of that by saving the
taxpayer $1.3 trillion.
Another Speaker, Tip O'Neill, once said, All politics is local. I say
tonight that when it comes to health care for all Americans, all
politics is personal. It's personal for the family that wrote to me,
who had to choose between buying groceries and seeing a doctor. It's
personal to the family that was refused coverage because their child
had a preexisting condition, no coverage, the child got worse, sicker.
It's personal for women. After we pass this bill, being a woman will
no longer be a preexisting medical condition.
It's personal for the senior gentleman whom I met in Michigan who
told me about his wife who had been bedridden for 16 years. He told me
he didn't know how he was going to be able to pay his medical bills. As
I said to you before, I saw a grown man cry. He was worried that he
might lose his home, that they might lose their home because of his
medical bills and he didn't know how he was going to pay them and, most
of all, he was too embarrassed to tell his children and ask them for
help. How many times have you heard a story like that?
It's personal for millions of families who have gone into bankruptcy
under the weight of rising health care costs, and so many, many, many--
a high percentage of the bankruptcy in our country--are caused by
medical bills that people cannot pay. It's personal for 45,000
Americans and families who have lost a loved one each year because they
didn't and couldn't get health insurance.
That is why we are proud and also humble today to act with the
support of millions of Americans who recognize the urgency of passing
health care reform and more than 350 organizations representing
Americans of every age, every background, every part of the country who
have endorsed this legislation. Our coalition ranges from AARP who said
that our legislation ``improves efforts to crack down on fraud and
waste in Medicare, strengthening the program for today's seniors and
future generations.'' I repeat: ``improves efforts to crack down on
fraud and waste in Medicare, strengthening the program for today's
seniors and future generations.''
To the American Medical Association, the Catholic Health Association,
the United Methodist Church and Voices for America's Children, from A
to Z, they are sending a clear message to Members of Congress, say
``yes'' to health care reform.
We have also reached this historic moment because of the
extraordinary leadership and hard work and dedication of all of the
Members of Congress, but I want to especially recognize our esteemed
Chairs, Mr. Waxman, Mr. Rangel, Mr. Levin, Mr. Miller, Mr. Spratt, Ms.
Slaughter, for bringing this bill to the floor today. Let us
acknowledge them.
I want to acknowledge the staff of the committees and of the
leadership. They have done a remarkable job, dazzling us with their
knowledge and their know-how.
I would like to thank on my own staff Amy Rosenbaum, Wendell Primus
and Arshi Siddiqui.
Now I will close by saying it wouldn't be possible to talk about
health care without acknowledging the great leadership of Senator
Edward Kennedy, who made health care his life's work. In a letter to
President Obama before he passed away--he left a letter to be read
after he died--Senator Kennedy wrote that access to health care was
``the great unfinished business of our society.'' That is, until today.
After more than a year of debate and, by the way, the legislation
that will go forth from here has over 200 Republican amendments, and
while it may not get Republican votes and be bipartisan in that
respect, it is bipartisan in having over 200 Republican amendments.
After a year of debate and hearing the calls of millions of
Americans, we have come to this historic moment. Today we have the
opportunity to complete the great unfinished business of our society
and pass health insurance reform for all Americans. That is a right and
not a privilege.
[[Page H1897]]
In that same letter to the President, Senator Kennedy wrote, What is
at stake? He said at stake are not just the details of policy, but the
character of our country. Americans will look back on this day as one
in which we honored the character of our country and honored our
commitment to our Nation's Founders for a commitment to life, liberty
and the pursuit of happiness.
As our colleague, John Lewis, has said, we may not have chosen the
time, but the time has chosen us. We have been given this country, an
opportunity to stay right up there with, again, Social Security,
Medicare, health care for all Americans.
I urge my colleagues to join together in passing health insurance
reform, making history and restoring the American Dream. I urge an
``aye'' vote.
{time} 2230
Announcement By the Speaker Pro Tempore
The SPEAKER pro tempore. The Chair will again remind all persons in
the gallery that they are here as guests of the House, and that any
manifestation of approval or disapproval of proceedings or other
audible conversation is in violation of the rules of the House.
Mr. AL GREEN of Texas. Mr. Speaker, I am proud to support H.R. 4872,
the Reconciliation Act of 2010 and the healthcare reform package that
its passage will complete.
Today, the House of Representatives has been given the opportunity to
take a concrete and powerful step toward completing the work of
reforming our healthcare system that began decades ago. For much of the
last year, my colleagues and I have debated many ways in which we could
work to lower costs, improve the quality of care and expand coverage.
What we pass today will begin to achieve all three.
In the wake of the financial crisis that has devastated our economy,
concerns of our nation's deficit are well-placed and wholly
appropriate. Despite what many of its opponents would argue, the
passage of this healthcare reform package will reduce the national
deficit by an estimated $1.3 trillion over the next 20 years according
to the Congressional Budget Office.
Through the course of this debate, we have seen misinformation about
healthcare reform instill fear into the hearts of the American people.
We have seen the distortion of truth breed uncertainty about whether
healthcare reform will be to the benefit of our country. Despite all of
the debate, and at times confusion, there remains one incontrovertible
truth: the cost of inaction, when our country spends nearly $2.5
trillion a year on healthcare, over 45 million Americans are without
health insurance, and 45,000 people die every year due to lack of
health insurance, is simply too great.
The time for debate has ended. The question we are faced with is
quite simple: do we act to shift the course of this country towards
affordable, quality healthcare, or do we continue down the path of
unsustainable costs and squander this historic opportunity to bring
about meaningful change in the lives of the American people?
I am proud to vote in favor of this giant step toward putting
Americans in control of their health care and I look forward to this
legislation being signed into law so that we may move forward with this
much needed reform.
Mr. SMITH of Texas. Mr. Speaker, Republicans and Democrats agree on
the need for health insurance to cover those who cannot afford it. But
this legislation is the wrong way.
The health care bill is built on the shifting sands of higher
premiums, increased taxes and reduced benefits. Such a foundation
cannot last and will be washed away by the American people in the
November election.
A majority of the American people want to choose their own health
care plan, not have the government do it for them. Under this bill,
many health care decisions will be made by federal employees, not
patients and their doctors. The result will be less care at higher
cost.
Mr. PUTNAM. Mr. Speaker, at the end of this term, I will have served
in Congress for 10 years. I have had the privilege of participating in
countless debates--from war resolutions and trade policies to the
aftermath of the 9/11 attacks--and working with Members of Congress on
both sides of the aisle on some of America's greatest challenges.
We now stand on the floor of the House of Representatives to address
one of today's greatest challenges in America--healthcare reform. While
this may be one of the more complicated issues we are faced with, the
goals--in my mind--are simple. We need to lower the cost of healthcare,
while expanding healthcare coverage to more individuals. To accomplish
this, I have advocated for policies like allowing small businesses to
pool together and form association health plans, providing incentives
for wellness programs and healthy life decisions, making reforms to our
medical malpractice laws, and allowing individuals to purchase
insurance across state lines. These policies are far-reaching, free-
market based, and--most of all--don't require new government
bureaucracies. Unfortunately, they all lost out to a partisan process
of backroom deals that have tainted this proposal and further
undermined the already low esteem in which the people we serve hold in
this institution.
Ever since the first 2,000 page healthcare bill was dropped on my
desk just prior to the vote in November, I have listened to
Floridians--from parents and patients to doctors and seniors--who
understand that healthcare is just too dynamic to be taken over by a
stale, cold federal government. They understand that we don't need to
model our healthcare system on those systems across the globe who envy
our quality of care, technology, and research investment. We don't need
some agency to make decisions about our family's healthcare that has
the efficiency of FEMA and the compassion of the drivers license
office. While we do have some aspects of our system that need to be
improved, Floridians understand we should address them in a manner that
actually solves the problem--not having government destroy the
innovation that comes from competition. Madam Speaker, they understand
this, but Congress clearly doesn't.
The misguided policies we are voting on today are sadly coupled with
the broken process they followed to get here. The measure we will vote
on hasn't seen a single legislative committee, bi-partisan negotiation,
or open process. Like anything with such an impact to the American
people, this legislation deserves the scrutiny of the legislative
process and the challenges that may come with amendments and committee
debate. In short, this measure deserves a public vetting to arrive at
the best possible outcome.
Had our founders seen the process this healthcare debate has taken,
they simply would not have recognized it as the House of
Representatives they envisioned. Would they have supported a process
that didn't even include the committees responsible for healthcare?
Would they have appreciated gimmicks that only budget analysts would
understand in order to ensure a certain overall cost? Could they
explain why a student loan bill was mysteriously attached to a massive
healthcare reform proposal or why Congress decided to give one state a
better deal than the rest of the country? Could they have ever imagined
a Congress that is only willing to dedicate two hours of debate to a
measure that spends $1 trillion?
Our schoolchildren are taught the way an idea becomes law and that as
an elected Representative, I have the ability to amend this legislation
on their behalf and spend days debating every provision that may have
been included. They know they deserve a process that allows their
representative to have a seat at the drafting table, not one where the
bill is dropped on his desk just prior to a vote. Even the most casual
observer of this process and this bill's journey would find it
unrecognizable from our most basic understanding of civics and
representative democracy.
When the outcome of this vote became more important than the product
itself, taxpayers lost. When the legislative process became an
afterthought to salvaging a presidency, taxpayers lost. When debate was
sacrificed for special deals, taxpayers lost.
Madam Speaker, this process is a disservice and has birthed a flawed
product that restrains patient freedom and choice, burdens future
generations with debt, undermines a competitive business model for
medicine and, most tragically, will reduce the most innovative
diagnostics and treatment on Earth to the lowest common bureaucratic
denominator.
Time and again, the government proves inefficient and obsolete in
changing times with rapidly emerging technologies. In medicine, that is
a recipe for obsolescence, archaic approaches, and delayed treatments
that costs lives and weakens the human condition.
While I do not hold up the current health care model as perfect--I do
observe the quality of the treatment options, the daily miracles made
possible by world-class technology guided by well-trained health care
professionals, and the range of options in large and small towns alike
as evidence that the American model is far superior to the cumbersome,
one-size-fits-all models that are found in nations like Canada and the
UK whose citizens frequently flee to our nation to find the quality
care they believe is not available in their own countries.
Tonight's vote against this bill is cast on behalf of patients and
doctors, taxpayers and citizens who value innovation, competition, and
the spirit of the individual that has created the American experience
and built this great nation into the envy of the world.
While we can and must do more to improve access and affordability, we
shouldn't sacrifice all we are as a nation for the security of mediocre
medicine, bureaucratically administered.
[[Page H1898]]
Mr. PAULSEN. Mr. Speaker, this body is nearing what will be a
defining vote for the future of our nation.
While Majority Leadership continued the arm twisting until enough
members would vote for the bill, the voice of the American people got
louder.
They have made it clear they do not want this bill. My constituents,
by a margin of over 3 to 1, have told me they don't like this plan--and
with good reason.
This bill will cost nearly 1 trillion dollars in the next decade
alone--and the true cost of this bill will surely go higher as
entitlement spending soars and other provisions are fully phased in.
The bill is loaded with job-killing tax increases--and an Associated
Press analysis said health care premiums will actually go up under this
plan.
The bill will also allow the IRS to verify if you have ``acceptable''
health care coverage and fine you if you don't!
This bill will cut $500 billion from Medicare and in turn use that
money for new entitlement spending. And history has shown entitlement
spending goes up, not down, over time. With our current entitlement
programs already headed for insolvency, why on earth would you
exacerbate the problem?
I would be remiss if I didn't mention that this legislation also
negatively impacts our Nation's veterans. It betrays the promise that
this county made to honor their sacrifice by failing to cover millions
of beneficiaries including dependents, widows, survivors and orphans.
The VFW has expressed their opposition to this bill and this body
should not pass any bill that negatively impacts our veterans. Those
families who have proudly served this country deserve better.
Finally, the legislation contains a $20-billion tax on American
medical manufacturers. This tax--which will hit manufacturers of
technologies now common in modern medicine such as pacemakers, stents
and MRI scanners--will be levied against many medical device
manufacturers in my home state of Minnesota. In the end, this will harm
jobs and cause patients to pay more for fewer medical technologies--the
exact opposite of what we need.
I believe this Nation needs real, bipartisan health care reform the
American people can support. This bill should be set aside and replaced
with common sense measures that will actually lower costs for everyone.
Ms. LINDA T. SANCHEZ of California. Mr. Speaker, whether all
Americans should have access to quality health care at a reasonable
price is a question a century old. First raised by Teddy Roosevelt in
1912, then repeated by FDR, Harry Truman, and later presidents, the
question almost answers itself. No nation can be strong whose citizens
are sick and poor. To improve our economy, to care for our people, to
fix our expensive and broken healthcare system, the time is now.
Truman argued that the principal reason why people could not receive
the care they needed in 1946 was that they could not afford to pay for
it. At the time, the cost of health care accounted for 4 percent of the
nation's income. Today, the reason people don't receive care most
likely remains its unaffordability, but the aggregate cost of health
care has since risen to 16 percent of the nation's income.
Having grown up in a working family of seven kids, I know how
important health insurance is. My parents couldn't predict which of us
might break a leg, need our tonsils out, or worse, but they could
predict that without insurance, they couldn't pay to get us the care we
needed. There is no reason that hard working Americans should be priced
out of needed healthcare.
Without doubt, this is not a perfect bill. It does not contain strong
employer responsibility provisions or a public plan to provide real
competition to private insurers. It cuts DSH payments for hospitals too
much. It benefits states that have left some of their poorest citizens
out of Medicaid without rewarding states like California that have been
doing the right thing all along.
It contains an Independent Payment Advisory Board, which would
severely limit Congressional oversight of the Medicare program and
place authority within the executive branch, without Congressional
oversight, judicial review, or state or community input. It also does
something no bill has ever done before--prohibits undocumented
immigrants from spending their own money to buy private health
insurance within an insurance exchange or marketplace.
But the bill's strength--that it makes health insurance accessible
and affordable for more than 30 million Americans who currently lack
insurance--is so much more important than its weaknesses.
After fifteen months of hearings, meetings, debates, and ideas, the
time has come for Congress to act to make healthcare better for all
Americans.
I take this vote after much thought and consideration, not for any
politician, but for my constituents who are anxious about whether they
will be able to afford care for themselves and their children when they
need it. For a nation as wealthy as America to have tens of millions of
people without health insurance is shameful.
Even those who have insurance fear losing their jobs, and with it
their insurance. Some are concerned that they will reach their annual
or lifetime caps on coverage. Others are anxious that their insurance
companies will simply drop them as soon as they get sick.
This bill, which my constituents have told me this Nation desperately
needs, will address a number of shortcomings in our current system.
In our current system, those who have insurance pay more to subsidize
care for those who don't have insurance. This bill changes that by
requiring everyone to have basic health coverage. Everyone has a stake
in improving public health. Currently, the uninsured don't get
preventive care, and once they're sick, they wind up in the most
expensive place to get treatment--the emergency room. The large number
of uninsured distorts our system, acting as a hidden tax on the
insured. This bill repeals that hidden tax.
In our current system, those with pre-existing conditions are
discriminated against. No child asks to be born with muscular
dystrophy, juvenile diabetes, asthma, or Down Syndrome. Yet current law
allows insurance companies to deny or limit their coverage. This bill
fixes that injustice, protecting our children, and ensuring they can
access coverage for life.
In our current system, some women pay twice as much as men for
insurance simply because they are women. This bill will change that so
insurance companies will treat all people equally.
In our current system, Americans who work just as long and just as
hard as their fellow citizens often lack insurance simply because they
work for a small company instead of a large one. This bill addresses
that too, by creating generous tax credits to small businesses to make
insurance more affordable, and by creating affordability credits to
help self-employed folks buy insurance at an affordable price in an
insurance marketplace.
In our current system, healthcare costs are skyrocketing out of
control. This bill will help rein in costs by paying doctors for
quality, not quantity, and actually reduces the budget deficit, making
our Nation more fiscally stable.
Oh, and one more thing, in our current system, millions of Americans
like their doctors and insurance companies. This bill allows you to
keep them. Millions of Americans will see no change in this bill except
for the added peace of mind that occurs when you are no longer at the
mercy of an insurance company that can drop or deny coverage at the
drop of a hat.
And I haven't even mentioned the improvements to Medicare: closing
the donut hole, eliminating co-payments on preventive tests, and
reducing fraud and waste to extend the life of the Medicare Trust Fund.
Yes, anyone who looks at this bill can find something wrong with it.
But I can't remember the last time I voted on a perfect bill here in
Congress. Just about every bill can be improved in one way or another.
On balance, this bill does what I came to Washington to do: to give a
voice to average working people, whose voices are too often drowned out
by the voices of moneyed interests.
Because I believe this bill would make America a stronger, more
stable, healthier, fairer, and more just Nation, I vote yes.
Mr. CONYERS. Mr. Speaker, I rise today in strong support of the
American people's call to pass health reform, and I urge this body to
pass this historic bill.
We are here at this moment, principally, because of one number: 45
million. These are the uninsured Americans, many of whom have lost
their job and their health insurance in the worst economic downturn
since the Great Depression. Today's vote on this imperfect legislation
is necessary because our fellow citizens desperately need access to
affordable comprehensive health care services. This legislation will
give them that foot in the door and pave the way for greater future
reforms.
America remains the only nation in the industrialized world where
health care is a for-profit corporate enterprise, where approximately
45,000 uninsured people die each year from lack of coverage, and over 1
million people go bankrupt each year.
Let me be clear. This is not a perfect bill. I would have preferred a
different approach that covered more people. But let me address those
who oppose this bill. Tomorrow, they are going to wake up and our
democracy will still stand. We will continue to live in the greatest
country with the hardest working, most patriotic, freedom-loving
citizens on the planet.
The real impact of the bill will be felt tomorrow when:
Insurance companies can no longer drop a person's coverage once they
become sick;
[[Page H1899]]
The average senior citizen will gain an additional $1,727 in
prescription drug coverage; and
Our children cannot be denied coverage based on pre-existing
conditions and will be covered under our policies until they are 26.
When health reform is fully enacted, approximately 31 million
additional Americans will have access to health insurance, with 15
million of them receiving care via an improved Medicaid.
Don't let anyone fool you--Medicare will be strengthened by this
bill. The only Medicare cuts in this bill are the billions in corporate
welfare subsidies to health insurance companies that provide minimal
benefit to seniors. The bill takes this wasteful spending and applies
these funds to benefit consumers, not insurance companies. Medicare
will become more affordable, offer more comprehensive benefits, and
continue to provide peace of mind to America's seniors for years to
come.
We will not end our efforts to improve our health system with the
passage of this bill. Just as we have improved Medicare and Social
Security, so too will we strengthen this initial package of reforms.
Members of the Senate Leadership have made it clear they will revisit
the idea of a public health insurance plan this year. I call on my
fellow progressives to hold firm in our insistence on such a vote. The
health insurance monopolies fear the competition an efficient not-for-
profit public health insurance plan would provide and that is exactly
why we must have an up or down vote on this proposal.
I support a public health option because I fundamentally believe in
the value of public health insurance. For this reason, I remain an
ardent supporter of universal single-payer health care. This system has
successfully provided quality, affordable, and cost-effective health
care wherever implemented, whether with Medicare, the U.S. military,
Europe, Taiwan, or Japan.
Adoption of a single-payer system is the only long-term means to
eliminate the
corporate-medical-industrial-complex which threatens to undermine our
health system with continued rising costs and an insatiable desire to
pass costs onto already burdened citizens. For-profit investor-owned
hospitals, prescription drug companies, and medical device
manufacturers are just as culpable as the health insurance industry and
future reforms must seek to address the profits-first mindset that
prevails in these industries.
If this bill passes, we should celebrate it. Tomorrow we will begin
the work to make it better--to truly secure health care as a human
right.
Mr. HOEKSTRA. Mr. Speaker, I rise today to vehemently object to the
government takeover of health care.
It is bad social policy, bad public policy and bad fiscal policy for
the United States.
The health care bills we will vote on today are estimated to cost
more than $1 trillion, will expand government bureaucracy, permit
taxpayer-funded abortions, increase taxes and cut Medicare.
Additionally, it includes egregious sweetheart deals such as the
``Cornhusker Kickback'' for Nebraska, ``Gator Aid'' for Florida and the
``Louisiana Purchase.''
My home state of Michigan alone will be forced to pay $710 million
annually for new Medicaid enrollees, money the state does not have to
spare. It is verging on denying the state's ability to regulate health
care programs and insurance and encroach on its sovereignty in doing
so.
Every American is personally impacted by health care. As such over
the last year Michigan residents and all Americans have voiced their
opposition with the health care proposals in Congress. It is
disheartening to see that Congress is blatantly ignoring the voice of
the public.
The U.S. health care system remains the best in the world, but still
needs reform. Reform can be achieved by targeted measures such as
allowing insurance competition across state lines and creating high-
risk pools of money for states to support those with pre-existing
conditions.
I had hoped that we could work in a bipartisan manner to achieve
reform of health care, but Republicans were not allowed a seat at the
table.
We do not need the federal government to take over one-sixth of the
American economy, and saddle states like Michigan with mandates, tax
increases and debt.
Mr. Speaker, in Michigan a situation has developed in which home
health car providers have been forced to pay union dues to state
because they accept federal dollars.
How can we be sure that the same will not happen to medical
practitioners who will be forced into a government-run system?
Additionally, I am concerned that the reconciliation bill that we
will vote upon today will completely federalize student lending,
leading to lost jobs, tax increases and the elimination of choice.
Mr. Speaker, I will be voting against the bills, and I respectfully
submit my remarks for the Record.
Mr. COBLE. Mr. Speaker, I rise in opposition to the proposed
government takeover of our health care system.
I have not come at this decision lightly. Although a small portion of
my constituents support this proposal, the vast majority want nothing
to do with it. Clearly there are areas of our health care system that
need to be improved. That being said, this bill is a complete overhaul
of the system.
Make no mistake about it. This bill will put the government in
control of our health care. It is a train wreck waiting to occur and
considering our current economic morass, we need no train wrecks.
It is with the best interests of all of my constituents, their
children and future generations that I will oppose this legislation.
Mr. POSEY. Mr. Speaker, I rise to express my strong objections to the
health care legislation, H.R. 3950, and the unprecedented, process
through which it is being considered. The overwhelming majority of
Americans are telling Washington through their letters, calls and every
poll that they don't want this bill. Nearly eight in ten of my
constituents who have contacted me on this issue have asked that I vote
against the bill.
Social Security is already unsustainable. Medicare is unsustainable.
Medicaid is unsustainable and reimbursements are already so low that
few doctors will even see Medicaid patients. These programs have tens
of trillions of dollars in unfunded liabilities. Rather than fix these
problems, the bill before us makes them worse. This bill takes over
$500 billion out of Medicare and spends it on this new health care
plan. It adds millions of new enrollees to Medicaid--already one of the
fastest growing federal and state budget line items. H.R. 3950 takes
over $53 billion out of the Social Security Trust Fund and spends it on
this new health care plan. And, they say that this bill will save the
taxpayers money.
The American people have figured it out and that is why they want
this particular piece of legislation stopped. It's not that they don't
want health care reform; it's just that they don't want this particular
bill. No one is suggesting that the status quo is acceptable. In fact,
I have cosponsored more than a dozen health care bills aimed at fixing
the problems with our current system. I suggested in a meeting with the
Secretary of Health and Human Services Kathleen Sebelius, that we move
forward with those things upon which we can reach agreement--like
addressing preexisting conditions and ending the practice of insurance
companies dropping coverage for someone when they get sick.
Unfortunately, she rejected that offer.
I want to talk just briefly about the cost of this bill. On Thursday,
a preliminary Congressional Budget Office, CBO, cost estimate of the
bill was released. But that budget included a number of gimmicks that
hide the real costs of health care reform legislation. I believe the
American people want and deserve honest budgeting because once the
smoke and mirrors are removed, they will have to pay the costs of this
bill.
Let's look at why we have the differences. It is important to
remember that the CBO can only estimate the costs of the specific
language that is presented to them. An analysis of the costs of the
bill that was released by the Senate Budget Committee found that after
you remove the budget gimmicks, this bill increases the budget deficit
by nearly $600 billion in the first 10 years and $1.6 trillion over the
second 10 years. This is a far cry from the preliminary budget estimate
from the CBO, which put the net effect of the bill at reducing the
deficit by $118 billion over 10 years. So, what causes this
discrepancy?
What are some of the reasons for the differences? CBO does not
include in its calculation the $53 billion that is borrowed from Social
Security to pay for H.R. 3950. CBO assumes these monies will not have
to be repaid to the Social Security Trust Fund.
Likewise, the bill includes over $500 billion in cuts to Medicare
program and assumes that future Congresses will allow these cuts to be
fully implemented. Anyone remotely familiar with Congress knows that
time and again Congress has stepped in to stop such Medicare cuts and
may well do so again in the future. Thus to assume that Medicare will
be cut by nearly $500 billion is simply not realistic. Furthermore,
rather than take these Medicare savings and spend them elsewhere, these
funds could have been used to help secure the long-term solvency of
Medicare.
This bill creates a new long-term care entitlement benefit, known as
the CLASS Act. This bill collects $70 billion more in premiums than it
will pay out in benefits over the first 10 years of the program. Rather
than keep this $70 billion in the Trust Fund to pay future benefits,
H.R. 3950 takes the money out of this trust fund and uses it to pay the
costs of H.R. 3950.
[[Page H1900]]
H.R. 3950 creates dozens of new programs; however, the CB0 cost
estimate does not include any costs associated with these programs. The
Senate Budget Committee estimates the 10-year costs of these programs
at $114 billion.
Medicare also faces more than a $200 billion shortfall in the amount
of funding needed to pay physicians. It would have been appropriate to
use the Medicare savings in H.R. 3950 to fix this problem. However,
H.R. 3950 leaves in place the 21 percent cut in payments to doctors.
Speaker Pelosi has said that we can expect another bill to come to the
House floor in a few weeks that fixes this shortfall. The cost of that
bill will simply be added to the deficit and no one will have to pay
for it.
So, rather than saving $118 billion over 10 years as CBO estimates,
the real costs will be hundreds of billions of dollars in deficit
spending in just the first 10 years. Between 2020 and 2029 the debt
rises even more.
Our nation has lost millions of jobs since January of 2008. To
restore these jobs, our nation would have to create 250,000 jobs per
month for each of the next 5 years. Hundreds of billions of dollars in
new taxes on small business and new costly mandates included in H.R.
3950 will only result in the loss of additional jobs and it will make
it harder for businesses to hire new employees. In fact, it is
estimated that this bill may result in the loss of more than 2 million
additional jobs.
Not only does this bill have a costly impact on businesses, but it
imposes tens of billions of dollars in unfunded mandates on the states.
Our state budgets are already stretched thin and governors and state
legislatures are cutting tens of billions of dollars just to balance
their budgets--something many states are required to do, but not
Washington. This bill makes that task harder for the states and will
ultimately result in higher taxes on individuals and businesses.
H.R. 3950 lacks sufficient protections to ensure that American
taxpayers are not forced to pay for the health care of millions of
illegal immigrants.
I am further concerned that this bill fails to include protections,
passed earlier this year in the House, that would ensure that taxpayer
money is not used to pay for elective abortions. This bill also lacks
sufficient conscience protections to ensure that health care providers,
doctors, nurses, hospitals, and health plans are not required to
participate or in any way support elective abortions.
Never before has Congress considered a bill that so fundamentally
changes the relationship between the people and the government.
This bill gives the federal government unprecedented powers. H.R.
3950 empowers government panels to make coverage determinations. It
also creates the Independent Medicare Advisory Board, IMAB, which is
given broad authority to make cuts in Medicare.
Over 4,000 times in this bill, the word ``shall'' appears, and
``shall'' indicates a federal mandate. In more than a dozen places, the
bill provides that there will be ``no administrative or judicial
review'' of a federal bureaucrat's decision.
It has been said that: ``A democracy cannot exist as a permanent form
of government . . . It can only exist until the voters discover they
can vote themselves largess from the public treasury. From that moment
on, the majority usually votes for the candidates promising them the
most benefits. Therefore the average age of the world's greatest
civilizations has been about 200 years. These nations have progressed
through this sequence: From bondage to spiritual faith; from spiritual
faith to great courage; from courage to liberty; from liberty to
abundance; from abundance to selfishness; from selfishness to apathy;
from apathy to dependence; from dependency back again into bondage.''
This bill vastly expands the powers of the Internal Revenue Service,
IRS. If this bill becomes law, the IRS may have to hire up to 16,500
additional employees just to enforce all the new taxes and penalties.
The bill empowers the IRS to: (1) verify that Americans have
government-approved health care coverage; (2) fine Americans up to
$2,085 or 2 percent of income (whichever 'is greater) for the failure
to purchase a government-approved plan; (3) confiscate tax refunds; and
(4) increase audits.
Finally, I would be remiss if I did not express my deep
disappointment with the process that has characterized this debate and
the manner in which this legislation has been written. I come from the
sunshine state, where we have very strict laws about transparency and
openness in government--a process that is seriously lacking in
Washington.
The House considered a bill in three committees last summer. A
handful of Republican amendments were adopted in those committees.
Unfortunately, when the bill was rewritten behind closed doors before
coming to the House floor in November; those amendments were removed
from the bill. When the House considered this bill in November 2009,
over 200 amendments were filed to be offered, but the leaders in the
majority allowed only one amendment to be voted on.
Likewise the Senate bill was written behind closed doors and no
amendments were allowed to be offered when it was considered in the
Senate in December 2009. It includes special earmarks meant to secure
the votes of particular Senators. Now we are debating that bill today,
and once again no amendments are allowed to be offered.
We are also debating a new bill drafted by the majority in the House
that purports to make changes to the Senate bill. Again, this bill was
drafted behind closed doors over the last few days and includes yet
again more special provisions intended to secure particular votes.
Yesterday, at the House Rules Committee, Republicans presented over 80
amendments that they wanted to offer to this bill, but not a single one
allowed an up or down vote.
Mr. Speaker, is it any wonder that the American people have so much
disdain for Washington and this body? This is a sad day characterized
by a lack of openness and transparency. The American people deserve
better.
Mr. KANJORSKI. Mr. Speaker, today I voted for legislation designed to
improve the affordability and accessibility of health care. Americans
already spend more on health care than the people of any other nation.
If we take no action, health care costs are expected to double over the
next 10 years, just as they have over the last 10 years. It is not the
bill I would have written if it were up to me alone, but it is the best
we can do at this time.
This was one of the most difficult votes I have ever cast, primarily
because there is a great deal of confusion about what this bill will
do. Over the last year, many people throughout Northeastern
Pennsylvania have taken the time to voice their thoughts on this health
care reform bill, and I have taken each voice into consideration. I
have heard the desperate pleas from people who have been sick and can
no longer obtain any insurance. I have heard from small business owners
who struggle to pay the premiums for their employees. I have also heard
from a sizable number of my constituents who fear they will lose
fundamental freedoms if this bill becomes law. From my careful review
of the legislation, I have come to the conclusion that this fear is
unfounded.
Democracy requires the consent of the governed, but that consent
needs to be informed with facts, not the widespread misinformation
which has permeated the national conversation about this legislation. I
had hoped that the House and Senate would conduct a conference
committee to iron out the differences between the House and Senate
bills televised by C-SPAN so that the American people would have an
opportunity to understand the provisions included in this very complex
bill. It is important to set the record straight between facts and
myths.
This bill does not empower the federal government to take over health
care. In fact, this bill preserves the employment-based private
insurance delivery system upon which a majority of working Americans
relies for insurance coverage. It allows participants to choose the
health insurance plan that best fits individual and family needs by
creating a marketplace of insurance plans, resembling the Federal
Employees Health Program used by all federal workers, including Members
of Congress. The bill attempts to rein in those private insurers by
prohibiting their most egregious abuses: denying coverage for
individuals with pre-existing medical conditions, imposing a lifetime
cap on medical care, and limiting the ability of individuals to change
jobs without the fear of losing insurance coverage. It will also enable
young adults to stay on their parents' insurance until age 26.
If people currently have health insurance, whether it is through an
employer or another means, their coverage will not change. If anything,
their premiums are expected to decrease because there will be more
people in the insurance pool. But, if people are unsatisfied with their
insurance, they will have the capabilities to switch to a plan that
best fits their needs.
Senior citizens have expressed a great deal of worry that they will
be denied services if this bill becomes law. In fact, seniors will
experience better coverage for their prescription drug costs and will
have no out of pocket costs for preventive care. In addition, this
legislation reduces excessive payments to private insurance companies
that administer Medicare Advantage Plans and applies those savings to
the bill. It also works to reduce waste, fraud, and abuse in the
Medicare program, which will help strengthen the program. As a result
of this legislation, the non-partisan Congressional Budget Office (CBO)
estimates that the solvency of the Medicare program will be extended by
more than 9 years.
This bill will help save American families money and prevent health
care costs from bankrupting our country. The U.S. spent 16 percent of
its gross domestic product, GDP,
[[Page H1901]]
on health care in 2008, more than any other industrialized country. CBO
estimates that number will rise to 25 percent without changes to
federal law. CBO also estimates that this bill will reduce the deficit
by $138 billion over the 2010-2019 period.
Many of my friends who oppose abortion have expressed concern that
their tax dollars could be used to pay for abortions. I have been
assured that this is not the case, and I am pleased that President
Obama intends to issue an executive order to clarify that no funds in
the bill will be used for abortion. Moreover, I will continue to remain
vigilant to ensure that the Hyde Amendment, which prevents federal
funding of abortion, remains the law of the land.
I was greatly disturbed when the student loan legislation was hastily
attached to the health care reform bill at the last minute because of
the impact it would have on the 1,100 Sallie Mae workers in my
district. Yesterday, Education Secretary Arne Duncan assured me that he
will use all of the tools at his disposal to help ensure that these
workers will remain employed.
I thank the many Northeastern Pennsylvanians who have shared their
thoughts with me on this important legislation over the past few
months. When you are sick, the last thing you should have to worry
about is how to pay the bills. Insurance is supposed to relieve this
worry, but instead the current system has made that worry worse. Today,
we are working to reverse this course.
Mr. GALLEGLY. Mr. Speaker, if Congress wants to remove fraud and
abuse from the healthcare system, it can start by overturning this
bill.
The Congressional Budget Office released an updated analysis of H.R.
4872. According to the Congressional Budget Office, this bill will cost
taxpayers $1 trillion. The analysis also confirmed that this bill will
raise healthcare premiums $2,100 more a year for millions of families
than if Speaker Pelosi had left healthcare alone.
It also reaffirmed that as many as 9 million people now enrolled in
employer-based plans will lose their coverage.
At a time when our military men and women are fighting terrorists
around the world, the national commander of the Veterans of Foreign
Wars urged Congress to vote the bill down because it does not protect
veteran healthcare plans.
At a time when unemployment has hit a record 11.6 percent in Ventura
County and 10.4 percent in Santa Barbara County, Speaker Pelosi's bill
adds $569.2 billion of additional taxes onto the backs of American
families and $52 billion on struggling employers.
It hurts seniors with $200 billion in cuts to Medicare Advantage and
raids Medicare and Social Security to fund the new mandate and hide the
true cost of the bill.
This bill must be overturned before the bulk of its provisions take
effect in 2014. I support real reform that reduces premiums, reduces
government spending and protects the doctor-patient relationship.
I cosponsored a bill that would provide real reform, but Speaker
Pelosi will not allow a vote on it. It includes:
Allowing small businesses to band together to purchase health
insurance for employees and use their combined bargaining power to
negotiate better health benefits at lower prices.
Reforming medical liability laws to discourage unnecessary and
frivolous lawsuits, which only drive up prices for everyone and force
doctors to practice defensive medicine.
Removing unnecessary regulations that prevent health insurance
companies from operating across state lines--which will provide the
competition without government-run health care.
Establishing high-risk pools to help people with pre-existing
conditions find affordable insurance.
I and many of my colleagues believe issues of portability, increasing
costs and rescinding coverage must be addressed. However, in doing so,
we must also protect a patient's right to choose the best coverage for
him or herself in a vibrant, competitive marketplace, not force
Americans into a one-size-fits-all government-run program designed by
Speaker Pelosi.
Mr. YOUNG of Florida. Mr. Speaker, four and a half months ago when
the House first considered health care reform legislation I voted
against it saying that it did not represent good public policy.
Nothing in the package of legislation we will consider today and
tonight changes my mind. It is still not good public policy, it was not
considered under an open process envisioned by the drafters of our
Constitution, and it will drive up--not down--the cost of health
insurance and medical care for individuals.
This bill cuts Medicare by $523.5 billion. This cannot do anything
but compromise the quality and availability of care for older Americans
who depend upon the program for their medical care. The Chief Actuary
for the Centers for Medicare and Medicaid Services confirmed that in
December when he advised Congress that ``providers for whom Medicare
constitutes a substantive portion of their business could find it
difficult to remain profitable and, absent legislative intervention,
might end their participation in the program (possibly jeopardizing
access to care for beneficiaries).''
A large percentage of my constituents in the 10th Congressional
District rely on Medicare for their health care coverage and a large
number of medical providers in my area care for a high percentage of
Medicare patients. In a survey I sent to every registered voter last
fall in my Congressional District, and to which more than 31,500
responded, 83 percent of the respondents said they were opposed to
paying for health care reform by cutting billions from the Medicare
program. They are concerned about the cuts in this legislation for
inpatient and outpatient hospital services, inpatient rehabilitation
services, long term care facilities, skilled nursing programs, hospice
services, kidney dialysis facilities, and medical laboratory services.
If this is not of concern enough to our nation's seniors, the
legislation we consider today cuts $200 billion from the Medicare
Advantage program, through which an estimated 47,000 residents of the
10th Congressional District receive their medical care. The Chief
Actuary for Medicare has said that cuts of this magnitude would force
more than 60 percent of these Medicare Advantage beneficiaries from the
program. Nationally, that totals 4.8 million Americans who would lose
their current coverage.
Despite the fact that this legislation makes draconian cuts in
Medicare, it will increase, not decrease, overall federal spending on
health care. The non-partisan Congressional Budget Office (CBO)
estimates that overall federal spending on health care will increase by
$390 billion over 10 years. This is at a time when proponents of this
legislation say it will save money.
Supporters of this legislation also tout the expansion in health
insurance coverage they claim it will bring about. However, this
expansion is due in large part to increasing the Medicaid rolls. In
fact, the CBO estimates that of the 32 million newly insured Americans
under this legislation, half, or 16 million, will receive their
insurance through the federally and state sponsored Medicaid program.
At the same time, millions of people will be enrolled in subsidized
plans on the government run health insurance exchanges and millions
will lose their employer sponsored health insurance.
Mr. Speaker, the majority of people I represent like the health care
coverage they currently have and do not believe this legislation will
improve the quality of their coverage. In my Town Hall by mail survey
last fall, 73 percent of those who responded said they are satisfied
with their current coverage and 70 percent say this legislation would
not improve the quality of their coverage. Furthermore, 75 percent say
Congress should not raise taxes to pay for this legislation and 74
percent say individuals should not be required to purchase health
insurance.
Many constituents have also expressed their grave concerns about the
insertion of the federal government into the precious patient-doctor
relationship. A perfect example of this is the creation of 159 new
boards, bureaucracies, and programs created in the 2,733 page health
care bill.
For example, in an effort to keep Medicare spending below targeted
levels the legislation creates the Independent Medicare Advisory Board.
This new entity will be required to submit recommendations to Congress
to keep Medicare spending below targeted levels. This could result in
additional coverage decisions being made by unelected bureaucrats
largely or exclusively on cost grounds.
Few issues have divided the American people as much as this health
care debate and given the interest and passion they have shown on this
matter demands that we give it serious consideration with a lot less
politics. Many of us have suggested that we start with legislation in
areas that we all agree we can fix now. That includes lowering health
insurance costs by allowing small businesses and individuals to pool
together in lower priced plans, requiring the coverage of individuals
with serious pre-existing medical conditions, prohibiting insurance
companies from canceling policies for those who become sick,
prohibiting insurance companies from imposing arbitrary spending caps
for policyholders, allowing families to purchase health insurance
policies across state lines, closing the Medicare Part D doughnut hole,
and providing for medical liability tort reform which the Congressional
Budget Office says would save $54 billion over 10 years in large part
due to lower medical malpractice premiums and the reduction of
defensive medicine practices.
In addition to Medicare cuts, the authors of this legislation pay for
new big government programs by raising federal taxes by $569 billion
over a ten year period. Many of those taxes will impact middle class
families. These are families who will pay a penalty if they choose not
to carry health insurance, the owners of small businesses who will pay
a penalty
[[Page H1902]]
if they do not provide health insurance for their employees, a sales
tax on medical devices, a tax on prescription drugs, and a tax on
health insurance premiums.
This bill also violates the President's promise that if you like your
insurance you can keep it. In addition to the 4.8 million seniors who
will lose their coverage under the Medicare Advantage program, the CBO
estimates that another 8 to 9 million people would lose their employer
based coverage when their employers choose to drop their coverage or
shift their coverage to the new subsidized policies on the health care
exchange.
This legislation would also contradict the President's promise that
the cost of health care coverage would go down. Instead, the CBO
estimates that the enactment of this legislation will raise private
health insurance premiums from 10 to 13 percent.
Mr. Speaker, most Presidents make it a practice of trying to bring
the country together in the face of difficult issues. We did this in
bipartisan fashion when it came to ensuring the financial solvency of
the Social Security system, reforming our nation's welfare programs,
and in engaging in an international war on terrorism. Yet this
administration has sought to do it their way whether the country agreed
or not.
Tonight we are faced with legislation that affects every American,
every American family, and every American business. The decision we
make tonight could be irreversible and the changes to the Senate passed
bill that are promised tonight may never take place. This is no way to
conduct our nation's business. It engenders no level of confidence in
the people who elected us to serve them.
Mrs. CAPPS. Mr. Speaker, I rise in strong support of passing
comprehensive health care reform legislation.
This moment has been a long time coming. I've worked on health care
since coming to Congress and passing comprehensive reform has always
been a major goal of mine.
I've met with and listened to my constituents, along with countless
doctors, nurses, hospital administrators, researchers, and other health
care experts. They know that America's health care system has many
wonderful aspects: it can provide the most cutting edge care, cure
diseases thought fatal only a few years ago, and devise new and
exciting drugs, devices and treatments with mind numbing speed.
But we also know our health care system's problems are legion.
Coverage is erratic, incomplete and can evaporate without notice; costs
are out of control for consumers, businesses and taxpayers; and health
outcomes are actually better in dozens of countries that spend far less
per capita than we do.
The legislation before us addresses these problems and will help
ensure that affordable, quality health care is always available to all
Americans.
The most trumpeted aspect of the bill is the coverage it would
provide to some 32 million Americans who are currently uninsured,
including an estimated 92,000 citizens in my own district. Passing this
legislation is a matter of life or death for them as an estimated
45,000 Americans die every year because they lack health care
insurance. In addition, the uninsured are much more likely to forego
primary care and delay other health care services leading to the
development of otherwise preventable disease, requiring much more
invasive and costly treatments.
The bill expands Medicaid to provide coverage for more very low
income individuals, and sets up state exchanges that will serve as
marketplaces for individuals and small businesses to buy affordable
health plans. The bill provides assistance to some individuals to
purchase coverage and tax credits to small businesses so that they can
provide health insurance to their employees. And it lets young adults
stay on their parents' plans until age 26. These new mechanisms and
support systems should provide coverage to the vast majority of today's
uninsured, improving both the physical and financial health of millions
of our fellow citizens.
But, perhaps just as important, the bill offers critical protection
for those already with health insurance. Today, insurance companies
often drop consumers if they get sick, refuse coverage for so-called
pre-existing conditions, and put annual and lifetime limits on a
consumer's coverage. This bill puts an end to those unfair practices. A
wife's diagnosis of cancer or a child's serious accident shouldn't be
the cause for a family losing health insurance just when it is needed
most.
Those currently with coverage will also benefit through lowered
insurance premiums. The Congressional Budget Office says premiums will
be 14 to 20 percent lower per policy holder. Furthermore, the
nonpartisan Robert Wood Johnson Foundation estimates that without
health care reform individuals and families would see their health
insurance premiums rise by as much as 79 percent over the next decade.
That is unaffordable, unsustainable and just one of the many reasons we
must enact this legislation.
The bill also makes significant investments to train our next
generation of doctors, nurses and allied-health professionals. This is
critical because today's current shortages of nurses and doctors would
only be exacerbated as we bring millions of new regular patients into
the system without the appropriate investment in our health care
workforce.
The legislation will also make it much easier to access preventive
health care services by eliminating co-pays for important recommended
screenings such as those for heart disease or cervical cancer.
Mr. Speaker, I've been hearing a lot from senior citizens concerned
about what our health care reform proposal would mean for them.
The bill will close Medicare's prescription drug ``donut hole,''
which in my Congressional district affects nearly 9,000 beneficiaries.
It is unfair that policyholders should have to pay insurance premiums
while receiving no coverage. The legislation before us today will give
seniors who fall into the donut hole a $250 rebate this year, 50
percent discounts on brand name drugs when they fall into the donut
hole beginning next year, and completely close the donut hole by 2020.
In addition to closing the donut hole, we take steps to crack down on
fraud, waste and abuse which will extend the solvency of the Medicare
Trust Fund by 9 years, according to CBO.
Finally, this bill is the largest deficit reduction measure in a
generation. According to CBO enactment of this legislation is projected
to reduce the federal deficit by $130 billion by 2020 and by over $1.2
trillion during the following decade. Earlier this year, the
Democratic-led Congress reinstated tough ``pay-go'' budget rules the
Republican-led Congress had allowed to lapse in 2003 and this health
care bill is a reflection of our determination to bring our federal
books back into balance as they were prior to the Bush Administration.
Mr. Speaker, I will not argue this is a perfect bill because it is
not. Most problematically, it lacks a public option, which would make
the insurance market more competitive, ensure the greatest possible
choice for consumers and bring down health care costs even more than
the bill does already. I am also deeply disappointed the bill contains
inappropriate language that may restrict a woman's access to
reproductive health services.
But I'm also not one to let the perfect be the enemy of the good and
in this case, we have legislation that is very good and deserves our
favorable consideration.
I urge my colleagues to do the same.
Mr. HOLT. Mr. Speaker, I rise today to support the health reform
package we are debating today. It is an important, very beneficial step
in America's history.
I see the need for this legislation when I meet with my constituents,
read their letters, and talk with them on the phone. A woman from
Pennington, New Jersey called me yesterday. She was concerned that she
would lose her job due to state budget cuts in New Jersey, which would
mean that she would lose her health coverage as well. She told me her
worries about finding affordable coverage while she looks for a new job
and tries to keep food on her table. To complicate her situation, she
has a pre-existing condition. This means that even if she could afford
health care, it is possible she could be denied due to her pre-existing
condition.
This woman's story is not unique. At a roundtable in Trenton, a
spouse of a cancer patient told me that when she and her husband came
home from the hospital after one extensive treatment, they returned to
foot-high stacks of insurance paperwork and $150,000 of out-of-pocket
charges for her husband's needed care. A self-employed woman from East
Brunswick wrote to me to let me know she pays $2,000 a month for her
family's coverage and still sometimes has to pay out-of-pocket to see
physicians.
I vote for health reform to help middle-class women and men just like
these hardworking New Jerseyans, who play by the rules and still find
health coverage out of reach.
Once reform goes into effect, families and small businesses will have
more control over their own health care.
Families with health insurance through their employers would benefit
from caps on yearly out-of-pocket costs. Seniors would find that
Medicare not only remains intact, but is improved--recipients would
receive free preventive care and better primary care. Small businesses
would have more health insurance options and additional support for
their health insurance expenses. Patients with diseases such as
diabetes or cancer would be able to obtain insurance without being
turned away because of their pre-existing condition.
The benefits of this health reform would be felt immediately upon
enactment of the health insurance reform package. For example, small
business owners who provide insurance for their employees would receive
tax credits, families would no longer face annual or lifetime caps on
their insurance benefits, and
[[Page H1903]]
seniors with high prescription drug costs would receive $250 of
additional assistance in their Medicare prescription drug plan.
The health reform package would do all these things while reducing
the deficit by $138 billion for the first ten years and by $1.2
trillion in the next ten years.
Today's vote is the culmination of over a century of debate about
health reform. Since Teddy Roosevelt ran for President in 1912, our
nation has been debating how to ensure that sick Americans can access
the care they need. This Congress has been debating this health reform
legislation in one of the most thorough processes in recent memory.
During the past few years, the House of Representatives has held 79
bipartisan hearings on health insurance reform, debated 239 amendments,
and heard from 181 witnesses.
The vote today brings this extensive process to a close at least here
in the house, finally passing health reform legislation that will
provide secure coverage to all Americans, ensure families have stable
costs, and improve Medicare for our seniors.
I urge my colleagues to vote in favor of this health reform package
to provide health security to our nation's families and small
businesses.
Mr. McCLINTOCK. Mr. Speaker, I rise in opposition to this flawed
health care bill. Under the provisions of this bill, Americans will be
required by federal law to purchase health insurance policies that
include every mandate imposed by the new federal health czar and will
face federal fines and even imprisonment if they refuse. And they will
pay for them through a combination of higher taxes, higher premiums or
lower wages.
The proposition that Congress has the power to order Americans to
purchase insurance--or any other product--is contrary to the
fundamental concept of individual liberty and antithetical to the
takings clause of the Fifth Amendment. If this precedent were to be
upheld, the federal government will have assumed authority over every
aspect of individual choice in the care of ourselves and our families
and can logically be extended to what foods we choose or to what
physical activities we engage in. Nor is this brave new doctrine
limited to health care. Once the precedent is established that
government may usurp individual decisions in the marketplace, what
limitation remains on its power to order any other of our decisions as
consumers?
Fortunately, the Constitution still protects our freedom from such
usurpations. It will fall to the Supreme Court to hold this act
accountable to the Constitution and it will fall to ``We the People''
to hold those responsible for it accountable at the polls.
Mr. HERGER. Mr. Speaker, the ``Reconciliation Act of 2010,'' written
behind closed doors and published just a few days ago, does nothing to
improve the Senate health care bill. It is simply more of the same:
higher taxes on investment and job creation, more cuts to Medicare to
pay for the new government health care program, and more special
backroom deals reflecting the Majority's determination to pass this
bill by any means necessary.
The reconciliation bill raises the Medicare payroll tax and, for the
first time in history, applies it to unearned income. This tax hike is
aimed squarely at small businesses and is sure to result in the loss of
even more jobs. Even worse, Congress is once again raiding the Medicare
and Social Security Trust Funds to pay for other programs.
The reconciliation bill also contains higher cuts to Medicare
Advantage--over $200 billion in all. If this passes, it is the end of
Medicare Advantage as we know it. Senior citizens in many parts of the
country will no longer be able to choose their Medicare plan. Once
again, these cuts have nothing to do with solving Medicare's long-term
budget problems. They are greasing the skids for the new government
health care program.
Not only does the reconciliation bill leave in place many of the
backroom deals included in the Senate bill, it adds several new ones,
including a special tax exemption for union multiemployer health plans
and extra Medicare money for hospitals and physicians in certain parts
of the country. The American people have repeatedly expressed outrage
at the special deals that are being made behind closed doors, yet the
Democratic Majority still refuses to listen.
One of the most serious concerns I have heard from my constituents is
that the Senate government health care bill will lead to rationing.
Unfortunately, the Rules Committee refused to make in order my
amendment to ensure that the new comparative effectiveness research
board established by the Senate bill cannot be used as a basis for
cost-based coverage denials. The Majority has repeatedly refused to
include an ironclad guarantee that Medicare will not start rationing
access to life-saving treatments because of their cost. The
reconciliation bill also leaves intact a new Independent Payment
Advisory Board of unelected bureaucrats that will have the power to
change Medicare payment policies without congressional approval, and
that cannot be repealed without a supermajority vote of the House and
Senate. This board is charged not only with issuing recommendations,
but also implementing Medicare policy. It is the ultimate embodiment of
government-run health care where decisions about access to innovative
new drugs, treatments and therapies are decided not by patients and
doctors and a functioning marketplace, but by unresponsive and
unaccountable bureaucrats working to contain costs.
In a final touch of irony for a Majority that has repeatedly insisted
that they are not aiming for a government takeover of health care, this
reconciliation bill incorporates a complete government takeover of the
private student loan industry. The Majority's rationale for this policy
is that the current policy of government subsidies for private
businesses is not controlling costs and has become too expensive. The
Congressional Budget Office has already told us that the Senate health
care bill will cause individual private insurance premiums to rise
faster than they would under current law. It is difficult to imagine
that a government-industry cartel will be any more efficient for health
insurance than it was for student loans. After a few years of this
policy, will Democrats again conclude that costs are out of control and
the government must take over?
The House should reject both the Senate government health care bill
and this reconciliation bill that only makes things worse.
Mr. FRANKS of Arizona. Mr. Speaker, today I resolutely intend to vote
against H.R. 3590 and H.R. 4872, the imposition of government-run
health care on the American people.
It appears that Democrats in this majority are determined to shove
this bill down the throats of the American people with not even a
single Republican vote. Never has such sweeping legislation--taking
over fully one-sixth of our economy--been done with a purely partisan
vote. Therefore, whatever ill comes from this bill, history should
record that Democrats alone chose the path of socialism over the
highway of freedom. Let future generations hold them accountable.
My first reason for voting against this bill will be the conviction
in my heart that I will be voting to protect my children, their
contemporaries, and generations to come from being forced to live under
the socialist ideal of a bill that will dim the light of freedom and
suppress many of the hopes they might have otherwise had.
I vote against this bill because it is my deepest conviction that its
cost will grow to threaten the entire economy of the United States in
the years to come. In every corner of the planet, in every corridor of
history, socialized medicine has always cost more, not less. Every
government health care program the United States has ever implemented
has cost many times the amount that was first predicted.
I am fundamentally convinced that the costs of this bill will so
overwhelmingly outpace present predictions that Congress will have no
choice but to drastically alter its provisions in the future.
I also intend to vote against this bill because of the provisions in
it that will increase the killing of unborn children in the name of
health care. Nothing so completely destroys the notion that this bill
is about compassion than the arrogant and cruel disenfranchisement of
those helpless unborn children who have no voice in this twisted and
corrupt process.
It is also my conviction that this bill will reduce the quality of
the greatest health care system in the world, and that many of those
who support it today will be its victims tomorrow.
Ultimately, this bill is about robbing America of one of its greatest
distinctives: freedom of the individual. It's about robbing the
American citizen of power, and putting it in the hands of left-wing
bureaucrats and elitists who think they know more about running
people's lives than the people themselves do.
Finally, I vote against this bill because I believe one day America
will look back and see what a tragic mistake that it was. It is my hope
that when that occurs, my children and my children's children will know
that it was my deepest desire to protect their freedom as faithfully as
my father protected mine.
Mrs. SCHMIDT. Mr. Speaker, I rise in opposition to both the Patient
Protection and Affordable Care and the Health Care and Education
Reconciliation Acts. Most likely, this package of bills will pass
tonight without a single Republican vote. It did not have to be this
way.
There is bipartisan consensus that our health care system is in need
of real reform. President Obama is correct when he says that the costs
associated with our current health care system are unsustainable. Too
many of my constituents are struggling to provide coverage for their
families and employees. The ever-rising costs of medical coverage have
left too many Americans without the means to purchase the health
insurance that many of us take for granted. Individuals with pre-
existing medical conditions are often unable to purchase insurance at
all. And, people should not
[[Page H1904]]
be forced to remain in a job they hate just for the health insurance
benefits.
We can begin to right these wrongs and others, as well. But, we do
not need to destroy a system that has given us the best doctors and
hospitals in the world and put us on the cutting edge of life-saving
technology and pharmaceuticals. Unfortunately, the package of bills we
are considering today, will actually increase premiums and ration care.
People will be forced out of their current coverage--whether they like
it or not. The bills will stifle economic growth and cost jobs. They
actually manage to cut Medicare by a half-trillion dollars, yet make
our entitlement crisis even more urgent. And, perhaps worst of all, it
allows federal funding for abortions for the first time in 34 years.
The President is fond of saying that Americans have been fighting for
this type of healthcare reform for a hundred years. That might be true
for some Americans. However, over the last nine months, we have all had
the opportunity to hear from the vast majority of Americans. We have
heard from them in a number of different ways--rallies at the Capitol,
letters, phone calls, and, yes, town hall meetings throughout all of
our districts. Their message is clear. If you were listening this
weekend, you would have heard it summed up at rallies at the Capitol--
``Kill the Bill.'' They fear government involvement in their medical
decisions. They fear a future of higher taxes and debt heaped on their
children and grandchildren. They fear a bill that rations care. And,
they are tired of the backroom deals and politics as usual. Worse than
all of these, they are afraid of a government too arrogant to listen to
what they have to say.
The House of Representatives is the people's house. We have a duty to
listen to what the American people are telling us. There is still time
to listen and defeat this flawed and dangerous bill.
Mr. MANZULLO. Mr. Speaker, the President's $1 trillion health care
bill is a job-killing disaster that will slap Americans with massive
tax increases and Medicare cuts immediately while delaying the bulk of
the health care benefits until 2014. This is not health care reform;
this is an unprecedented and unnecessary government takeover employing
some of the highest and cruelest tax increases and perhaps the broadest
expansion of the power of the federal government in history. It didn't
have to be this way. I do support health care reform. Bipartisan
alternatives exist that would make health care more affordable and
accessible for the uninsured without having to wait four years for
benefits.
Here are just a few of the most egregious policies within the
President's massive government takeover of health care. H.R. 3590 would
increase taxes on Americans by $569 billion, including a new $210
billion 2.9 percent ``Medicare'' tax on investment income; cut Medicare
benefits for seniors by $530 billion; increase Americans' health
insurance premiums $2,100 by 2014, according to the non-partisan
Congressional Budget Office; put another 3 to 5 million Americans on
the unemployment lines due to the heavy mandates that require employers
to provide health care coverage to their employees and families whether
they can afford it or not; require the Internal Revenue Service (IRS)
to hire up to 16,500 additional workers to enforce all the new tax
penalties on Americans who can not afford to purchase health insurance;
and puts another 16 million Americans on Medicaid, a struggling program
that pays such low reimbursement rates that 121 Walgreens stores in
Washington announced last week they would no longer accept Medicaid for
prescriptions. This bill will burden states with additional Medicaid
share costs. The State of Illinois, already facing a $12 billion budget
deficit with plans to cut $1.3 billion from local school funding, would
have to pay at least $1.8 billion in additional Medicaid sharing costs
to cover the additional enrollments. To add insult to injury, this bill
makes Americans wait until 2014 to receive the bulk of the benefits. In
fact, the ban on preexisting conditions does not kick in until 2014 for
adults.
This bill implements tax increases and Medicare cuts immediately, but
delays most of the benefit provisions for four years. However, when you
look at the first 10 years of benefits, the estimated true cost will be
$2.6 trillion. And that does not even include the nearly $1 trillion of
additional spending that was either pulled out of the bill to be dealt
with later or the result of correcting double counting cuts in
unrelated programs.
Plus, H.R. 3590 would not have a true firewall of protection to
prevent federal tax dollars from paying for abortions. According to a
Quinnipiac University survey released on December 22, 2009, 72 percent
of Americans said they oppose allowing abortions to be paid for with
public funds under any new health care system created by the
government. Thus, because a ``reconciliation'' bill cannot solve this
particular issue due to the fact that it is not directly a budget
issue, the President has promised to issue an executive order to ban
federal funding of abortion. However, an Executive Order cannot trump
the language in this bill that would become law, if passed. In 1952,
the Supreme Court struck down President Truman's executive order during
the Korean War that assumed federal control of certain domestic steel
mills due to labor unrest because it was an unconstitutional exercise
of lawmaking authority reserved to Congress. In 1996, the District of
Columbia Court of Appeals struck down an executive order issued by
President Clinton which authorized sanctions on federal contractors
that permanently replaced workers who went on strike because it
superseded existing law guaranteeing the right of employers the right
to hire permanent replacement workers. Finally, the Supreme Court
struck down an executive order issued by President G.W. Bush because
Congress, in enacting a statutory military commissions system, had
impliedly prohibited the President's invocation of military commission
jurisdiction over a terrorist detainee.
I also want to expand upon what I believe to be one of the cruelest
elements of this bill. As if raising taxes on struggling families and
their employers, cutting benefits for seniors, growing the IRS
enforcement police by thousands, and further jeopardizing the budgets
of all states in the union was not cruel enough, this bill creates a
new 2.9 percent tax on life-saving medical devices like the titanium
brace that was inserted into the spine of my wife after a cancerous
tumor shattered one of her vertebrae. That medical device saved my wife
from the wheelchair. The authors of this bill believe that life-saving
medical devices should be nearly three percent more expensive. I fail
to understand how we make health care more affordable by pursuing
policies that intentionally make health care more expensive.
As the former Chairman of the House Small Business Committee, I have
long supported legislation that would help small employers purchase
health insurance for their employees and their families. Of the 47
million uninsured Americans, 57 percent work for small employers who
cannot afford to offer them health insurance. I support two bipartisan
solutions that would go a long way to reduce the number of uninsured in
America. First, Congress should pass H.R. 2360, the Small Business
Health Options Program Act of 2009 (SHOP Act) as a stand-alone bill.
H.R. 2360 would allow small employers to purchase health insurance at
reduced group rates through national associations while still following
state rules. I am one of 60 bipartisan cosponsors of H.R. 2360, which
also enjoys support from the liberal Service Employees International
Union (SEIU), the AARP, and the conservative National Federation of
Independent Business (NFIB). A companion bill in the Senate was
authored by my fellow Illinoisan, Senator Dick Durbin, and enjoys
similar bipartisan support.
Second, Congress should also pass H.R. 1470, the Equity for Our
Nation's Self-Employed Act of 2009. This bill would let small employers
pay for their health insurance before they pay their Social Security
and Medicare tax liabilities, giving them the same deduction as large
employers. The self-employed pay on average $12,106 annually for family
health care coverage, and H.R. 1470 would save them $1,852 a year,
according to the Kaiser Foundation. I am one of 48 bipartisan co-
sponsors of H.R. 1470.
These bills would dramatically reduce the costs of health insurance
for small employers so they can better afford to provide coverage for
their employees and their families. And they will reduce the rolls of
the uninsured without increasing taxes, killing jobs, forcing Americans
into a government-run program, and burdening our children and
grandchildren with even more debt.
Mr. Speaker, I also support making the following four changes to
America's health care system. First, we need to reform our out-of-
control medical liability system. Medical malpractice insurance
continues to surge, skyrocketing health care costs and forcing doctors
and other medical professionals to practice ``defensive medicine,''
which entails ordering costly and often unnecessary tests to cover all
the bases from lawsuits. I am a cosponsor of the HEALTH Act (H.R. 1086)
that would fully compensate victims for medical injuries but place
reasonable caps on punitive and non-economic damages that often inflate
the awards and contribute to out-of-control liability and health care
costs.
Second, we need to expand tax-free availability to Health Savings
Accounts (HSAs). HSAs allow small business owners to offer more
affordable high-deductible health insurance plans to their employees
and make tax-deductible contributions to employee savings accounts to
allow their employees to build equity and assume personal control of
their health care needs. Congress should increase the tax deductibility
for these insurance plans.
Third, we need to preserve high-quality health care through America's
community health centers. I am a strong supporter of continued funding
of our community health center system, which provides high-quality
health
[[Page H1905]]
care to America's low-income families. The district I am privileged to
represent has one of the model community health centers in America, the
Crusader Clinic in Rockford, which serves more than 40,000 needy
patients in northern Illinois each year.
Finally, we need to create refundable tax credits to help low-income
Americans purchase health insurance. Low-income children are already
covered through the federal State Children's Health Insurance Program
(SCHIP), and I support refundable tax credits to help low-income adults
purchase health insurance.
Mr. Speaker, this bill today will increase taxes, cut Medicare, raise
health care premiums, and put millions more Americans on the
unemployment lines. And amazingly, most of the benefits--including the
ban on pre-existing conditions for adults--will not be available for
another four years. We should instead be pursuing the bipartisan
reforms that would make health care more affordable and accessible to
Americans now, and not make them wait four years for assistance. This
bill is certainly not the type of health care reform Americans deserve.
Ms. KILPATRICK of Michigan. Mr. Speaker, I rise today in support of
H.R. 4872, the Health Care and Education Affordability Reconciliation
Act. I urge all my colleagues to support this bill because it will
improve the accessibility and affordability of health care for millions
of Americans.
Today, there are more than 44 million Americans who lack health care
insurance. We must ensure that the needs of these Americans are met.
This bill will help us begin to do just that.
While we in Congress have deliberated and debated the costs,
challenges, and consequences of health care reform, millions of
Americans continue to sacrifice, struggle, and suffer. Hundreds of
people have sent me letters and e-mails, called and visited my office,
and participated in town hall meetings to express their opinions. The
majority of my constituents want and need health care reform. Many are
unemployed and struggling to maintain their health care insurance while
trying to make sure that there is food on the table, that they have
shelter, and that their lights, gas, and water are on. Others are
dealing with increases in health care premiums that continue to rise at
the will of insurance companies. Still others are trying to get
adequate treatment for serious illnesses and to pay for the medicines
that can help them.
I am a strong supporter of the single payer health care plan. I also
support a strong public option. I support this bill because it begins
the process of universal health care coverage for all Americans.
This measure expands coverage to 32 million more people, or more than
95% of Americans, while lowering health care costs over the long term.
It prevents insurance companies from discriminating based on pre-
existing conditions, health status, and gender. It creates health
insurance exchanges--competitive marketplaces where individuals and
small businesses can buy affordable health care coverage--and offers
premium tax credits and cost-sharing to low and middle income
Americans, providing families and small businesses with the largest tax
cut for health care in history. It also invests in Community Health
Centers to expand access to health care in communities where it is
needed most. The bill also empowers the Department of Health and Human
Services (HHS) and state insurance commissioners to conduct annual
reviews of new plans demanding unjustified, egregious premium
increases.
This bill puts patients and doctors in charge of their health care--
not health insurance companies. Children can no longer be discriminated
against because of preexisting conditions. Seniors will no longer have
to pay deductibles and co-pays. There will be free mandatory preventive
health care provided for all under all health care plans. Plus, there
will be a ban on lifetime coverage limits under this bill.
The bill cuts taxes to small businesses to help small employers pay
for health care coverage for their employees. Small businesses will
have tax credits and vouchers so as to be able to afford health care
coverage for their employees.
The bill makes key investments in Medicaid and children's health. It
expands eligibility for Medicaid to include all non-elderly Americans
with income below 133% of the Federal Poverty Level and provides fair
assistance to states to help cover the costs of these new Medicaid
populations. The measure also maintains current funding levels for the
Children's Health Insurance Program (CHIP) through fiscal year 2015 and
increases payments to primary care doctors in Medicaid.
The Health Care and Education Affordability Reconciliation Act
strengthens Medicare. It adds at least nine years to the solvency of
the Medicare Hospital Insurance Fund, fills the Medicare prescription
drug donut hole, improves Medicare payments for primary care, and
reduces overpayments to private Medicare Advantage plans. It
also provides new, free annual wellness visits; eliminates out-of-
pocket copayments for preventive benefits under Medicare, such as
cancer and diabetes screenings; and provides better chronic care, with
doctors collaborating to provide patient-centered care for the 80% of
older Americans who have at least one chronic medical condition, such
as high blood pressure or diabetes. The bill also encourages
reimbursing health care providers on the basis of volume instead of
value by including a number of proposals aimed at moving away from the
``a la carte'' Medicare fee-for-service system toward paying for
quality and value, while reducing costs for America's seniors.
This legislation reins in the abuse by health insurance companies of
arbitrarily increasing premiums and stops insurance companies from
dropping individuals from policies when people get sick and need health
care insurance. If you change or lose your job, you will still have
health care coverage. When you enter a hospital, you and your family
can rest assured, knowing that your policy will cover the costs
associated with your health care.
Last, this legislation demonstrates fiscal sensibility and
responsibility. It will reduce the deficit by $138 billion over the
next decade, with an additional $1.2 trillion in additional deficit
reduction in the following decade. The bill tightens current health tax
incentives, collects industry fees, institutes modest excise taxes, and
slightly increases the Medicare Hospital Insurance tax for individuals
who earn more than $200,000 and couples who earn more than $250,000. It
includes a fee on insurance companies that sell high cost health
insurance plans to promote smarter, more cost-effective health coverage
choices and changes health care tax incentives by increasing penalties
on nonqualified distributions from health savings accounts, capping
federal saving account contributions, and standardizing the definition
of qualified medical expenses. The cost of health care reform under
this legislation is fully paid for, in large part, by eliminating
waste, fraud, abuse, and excessive profits for private insurers.
As Democrats promised the American people, this bill is fully paid
for. This legislation is the single largest deficit reduction tool in
the history of our country. It is not balanced on the backs of our
children and our grandchildren.
My family and my faith provide the foundation for my commitment to
service. I am honored and humbled to represent the people of the 13th
Congressional District. As Members of Congress, we serve others.
Through this service, we often provide people with the tools and
resources they want and need. Our service not only changes us for the
better by giving our lives meaning and fulfillment, but it also creates
positive change in the lives of others. Like a raindrop in a river, our
service creates ripples that leave an indelible impact on all those it
touches.
Today, we will make history by finishing what many Congresses before
us started. The debate has gone on long enough. The American people
want action. We must reject the status quo. We must stand up and do
what is right. We must be a voice for the voiceless, give hope to the
hopeless, and provide help to the helpless by supporting health care
reform now.
Let us be the light in the darkness by voting in support of the
Health Care and Education Affordability Reconciliation Act. It will
give much needed assistance to millions of Americans by making health
care affordable for the middle class, providing security for our
seniors, and guaranteeing access to health insurance for the uninsured.
It is common sense for the common good, and I urge all my colleagues to
vote yes on this historic measure.
Mr. LARSON of Connecticut. Mr. Speaker, I rise on this momentous day
in support of this historic legislation. Just as our predecessors stood
up for the American people to pass Social Security and Medicare, today
we affirm our commitment to families across this country by passing
comprehensive health care reform. Today, Democrats are once again
showing whose side they are on, the side of the American people.
While my colleagues on the other side of the aisle like to focus on
those who are against this effort, I've heard from too many of my own
constituents whose stories exemplify why we need health reform and
encouraged me to support this bill.
Constituents like Jody from Bristol. Jody and her family had to
downgrade their health insurance after their premiums jumped 30% in one
year. Just a few months later Jody was diagnosed with Crohn's disease.
After 12 months her medical debt was more than $30,000. Now, even after
she has insurance, she is struggling to pay off the $35,000 in credit
card bills her family amassed to pay her health care.
It's in stories like these, of people facing severe financial
difficulty because of medical debt, being denied coverage because of a
pre-existing condition, or losing their coverage when they get sick
that creates the moral imperative to right these wrongs. In this bill
we
[[Page H1906]]
will cap out of pocket costs, end discrimination based on pre-existing
health conditions, and end the practice of insurance rescissions.
The American people may not like the complicated legal language of
the bill or the messy process it takes in Washington to get historic
acts accomplished. But after this bill is signed the parent whose
children have been denied coverage because of a pre-existing condition
will be able to get health insurance for them; young adults will no
longer have to fear being without coverage because they will be able to
stay on their parent's insurance; seniors will get relief from
skyrocketing prescription drug prices; and small businesses will get
tax breaks for offering their employees health.
Once this bill is signed, this country will be stronger, the economy
will be stronger and the American people will be stronger than ever
before. I thank the Speaker and my Democratic colleagues for their
efforts on behalf of the American people and urge my colleagues to
support this legislation.
Mr. GARAMENDI. Mr. Speaker, today, Democrats in the House of
Representatives voted to form a more perfect union. By expanding health
care coverage to 32 million Americans, we are continuing the proud
American tradition of promoting justice, ensuring the general welfare,
and broadening access to life, liberty, and the pursuit of happiness.
Republican leaders in the 1930s said Social Security would lead to
``the lash of the dictator'' and in the 1960s said Medicare would lead
to grandparents telling stories of ``what it once was like in America
when men were free.'' Yet with time, Social Security and Medicare
became incredibly popular services cherished by most Americans. A
broader consensus emerged, and a more perfect union was formed. I am
confident that the same will soon be said about today's health care
reform bill.
When the people get past the slogans, the fear tactics, and the gross
distortions, what they find in this legislation is a series of ideas
widely popular and aligned with the best of American values. This is
the second largest deficit reduction bill in 20 years. In my district,
9,000 people with preexisting conditions will finally be able to have
access to insurance. 96,000 seniors will see their Medicare improved
with significant prescription drug discounts and free preventative
screenings. 106,000 families will receive tax credits to make their
coverage more affordable. 52,000 young adults will be able to attain
coverage through their parents' insurance. 13,100 small business owners
will receive significant tax rebates. 1,400 families will avoid
bankruptcy. A similar story exists in every corner of this great
country.
In the fight to extend health coverage to every man, woman, and
child, this bill is an incredibly important beginning. But it's still
just a beginning. ``A more perfect union'' implies that the progress of
the American experience is never complete. Each subsequent generation
is expected to pick up the torch and continue on our long road toward
positive change. Today the House of Representatives bestowed upon this
great nation the most historic health reform since Medicare. I am proud
to have voted ``yes'' for health care reform. I won't live to see a
perfect union, but it is a tremendous honor to see a more perfect union
formed before my eyes.
Mr. OBERSTAR. Mr. Speaker, today the House of Representatives crosses
a historic threshold in the evolution of social justice, quality of
life, equity of health service delivery, and a worthy legacy for our
children, with passage of comprehensive health care reform legislation.
Our Nation enjoys the best, but the most expensive health care in the
world. The comprehensive health care legislation under consideration
will preserve what works best in our health care system and make that
system more efficient and affordable.
In Minnesota and throughout the Nation, citizens will quickly see the
benefits of this legislation that includes important consumer
protections to reduce the power of health insurance companies. You will
have greater control of your health care decisions. This bill will
assure that no one's current health care can be dropped. No one will be
forced out of the health care they now hold. No one will be denied
coverage because of a previously existing condition. No one's health
insurance will be dropped because of lifetime caps; no one can be
denied when they need their health insurance the most. People will be
able to retain their health insurance if they change jobs.
For seniors, the legislation closes the doughnut hole that has
existed for five years, which will save seniors thousands of dollars in
prescription drug costs. Young adults will be able to stay on their
parents' policy until age 26.
If we fail to provide health care for all of our citizens, we all
will pay higher taxes and higher health insurance premiums because we
eventually pay for ``sick care'' rather than make the wise investments
in the promotion of preventive health care.
This health care legislation, which assures that all Americans will
be able to have and to keep health insurance, is central to our
economic recovery and to balancing our federal budget.
To be sure, this health care reform legislation will not cure every
shortcoming in our health care system, but unquestionably the status
quo is unacceptable and unaffordable. For far too long, too many
citizens have been denied essential health care, and our commitment to
fundamental justice demands that we make affordable access available to
every American.
This health care legislation will provide numerous benefits for
Minnesota and the Nation. Importantly, this legislation expands access
to health care to more than 32 million Americans. This expansion of
health care will be achieved without increasing the federal deficit.
The nonpartisan Congressional Budget Office has objectively analyzed
the legislation and has determined that its enactment will reduce the
deficit by $143 billion over the first decade and more than $1.2
trillion over the second decade. The health care legislation is fully
financed by ending the excessive subsides in the Medicare Advantage
program and by additional changes in Medicare reimbursement that will
make Medicare more efficient without reducing essential Medicare
benefits; it will expand the solvency of the Medicare Trust Fund by an
additional seven years.
This health care legislation also includes important improvements in
rural health care for Minnesota and the Nation. I was concerned that
the original House health care bill did not incorporate a number of
necessary reforms to expand access in rural America. I am pleased to
report that the health care legislation under consideration not only
expands health insurance coverage in rural America, but it also
promotes the training and placement of health care professionals in
rural areas. I am also very pleased that this legislation addresses the
longstanding geographic disparity in Medicare reimbursement. Northland
health care providers have been greatly disadvantaged by unfair
Medicare reimbursement, and this legislation closes that gap and moves
us inexorably toward payment parity with the rest of the country.
Just as the Hippocratic oath requires that medical providers adhere
to the admonition of ``First, do no harm,'' the same is true for
legislators, and this legislation, while not perfect, will implement
significant and positive changes in the delivery of health care.
This is especially true with regard to vulnerable women and unborn
children. I am confident that abortion will not be funded in this
legislation. Current law dating back to October 12, 1979 (Public Law
96-86), has contained a federal prohibition on the use of federal funds
for abortion in community health centers. Conscience clause protections
that have existed in the past, that are in effect today, will remain in
effect in the future. The legislation also prohibits the use of federal
tax credits and cost-sharing assistance to pay for abortion. I am very
pleased that President Obama has prepared and will issue an Executive
Order upon enactment to reaffirm the enforcement of current law that
prevents the use of federal funds for abortion.
Today, we keep faith with the American people. Today we ensure that
quality, affordable health care is available to everyone to this
generation and generations to come.
Support this bill.
Mr. TOWNS. Mr. Speaker, I would like to clarify several points in
Section 1334 of H.R. 3590, regarding the Office of Personnel
Management's authority to provide oversight and set premiums of multi-
State plans.
OPM, of course, has administered the Federal Employees Health
Benefits Program for over 50 years, and that program has served as a
model for the Exchanges envisioned under this legislation. In
administering the FEHB Program, OPM has been able to address the
problem of uniformity of benefits and requirements across State lines
using its authority under 8902(m) of Title 5. Section 1334(a)(4) of the
Senate-passed bill states that ``the Director shall implement this
subsection in a manner similar to the manner in which the Director
implements the . . . Federal employees health benefit program under
chapter 89 of title 5, United States Code''. The intent of this
provision is that OPM oversee multi-State health plans in the same
manner in which oversight is provided under the FEHB Program for the
purposes of uniformity of health insurance plans. OPM should exercise
this authority, as it does in the FEHBP, to ensure that multi-State
plans offer uniform benefits, negotiate premiums with multi-State
plans, and require these plans to set aside a certain amount of reserve
funds. Moreover, it is imperative that OPM issue rules and guidelines
as necessary to effectively and efficiently administer the multi-State
plans, including for uniform adjudication procedures for disputes
involving the multi-state plans.
Another issue that requires clarification is the interaction between
the Secretary of Health and Human Services and the Director
[[Page H1907]]
of OPM. The legislation gives the Secretary broad authority to issue
regulations governing the operation of State Exchanges. Any rule or
regulation governing plans offered on State Exchanges would affect
OPM's administration of the multi-State plans, which will also be
offered on the Exchanges. There are overlapping responsibilities
between HHS and OPM with regard to the multi-State plans offered on
State Exchanges. The legislation envisions that the Secretary of HHS
will coordinate and consult with the Director of OPM on any policy
decisions that would affect the administration of multi-State plans.
This joint effort is essential to ensuring the proper operation of the
multi-State program as envisioned by Section 1334.
Under section 1334, OPM is directed to ensure that sufficient
resources are allocated to the ongoing administration of the FEHBP. The
intent of this provision is to ensure that essential resources are not
pulled away from FEHBP in order to start up the new program created by
this bill. However, where greater efficiencies can be found from the
administration of both programs jointly, we would expect OPM to adopt
that approach.
Lastly, section 2714 of H.R. 3590 would allow unmarried adult
children to remain on their parent's plan up to the age of 26. Congress
intends that this mandate apply to individual FEHB plans in their
capacity as private health insurers and to the FEHBP as a group health
plan. This Congressional Budget Office incorporated this interpretation
of section 2714 in preparing its cost estimate of the legislation.
Given the economic conditions in country, this is an important reform
that will help families across the country, including the families of
federal employees and retirees. I am pleased to support this provision
as one of many reforms that will improve health care coverage for low
and middle income Americans.
Mr. BOUCHER. Mr. Speaker, health care reform is needed. More than 36
million American citizens do not have health insurance, and millions
more are underinsured and cannot afford to pay for the medical care
they need. Those who have health insurance are finding that health care
costs and health insurance premiums are rapidly rising. In fact, health
insurance premiums are increasing 3.5 times faster than the rate of
increase in family incomes.
This status quo is unsustainable, and finding a way for everyone to
afford health insurance is necessary to benefit both the uninsured and
those who have insurance. It is also essential that health insurance
reform control health care costs and prevent rapid increases in health
insurance premiums. But reform legislation must also ensure that the
residents of my district in Southwest Virginia continue to have access
to the high quality health care services that are now delivered
locally.
After reading and carefully reviewing the legislation, I oppose
passage of the health care measure before the House today. My concern
largely centers on the dramatic reductions in Medicare funding required
by the legislation. Over the next 10 years, the bill requires that
Medicare funding be reduced by $450 billion. In fact, in April of this
year, doctors in our region and across the nation will have their
Medicare payments reduced by 21 percent. Over the next several years,
additional reductions in payments to doctors will occur. Other health
care providers will also experience substantial reductions in their
Medicare reimbursements. These Medicare payment reductions are fully
accommodated by and expected to occur in order to achieve the $450
billion Medicare payment reduction required by the reform legislation.
The population of the Ninth Congressional District is more elderly
than in the typical congressional district. Most senior citizens in our
region depend upon Medicare to pay their medical bills. Therefore,
these Medicare funding cuts will be far more harmful to the population
of our region than to the population of the typical congressional
district. The dramatic cuts in Medicare funding that would be required
by the health reform bill would adversely affect the quality of health
care for senior citizens and other Medicare recipients.
Because Medicare is paying less, doctors, hospitals and other health
care providers would increase charges to patients who have health
insurance to make up for what they are not receiving from Medicare.
This cost shifting of some substantial portion of the Medicare cuts
would raise health insurance premiums for those who have insurance.
While it is important that means be found to enable everyone,
including those who are currently uninsured, to be able to afford
health insurance, achieving that goal cannot occur at the expense of
people who are currently insured. Having concluded that these dramatic
Medicare cuts would both decrease the quality of health care that is
delivered to our region's senior citizens and result in increases in
health insurance premiums for the currently insured, I simply cannot
lend my support to passage of the bill.
I am also concerned about the unsavory deal-making that occurred in
the United States Senate when the health care bill was considered in
December. Some states received special benefits at the expense of other
states. While the measure before the House today removes several of the
special benefits, others remain and were not removed by the
legislation. For example, the states of Louisiana, Tennessee,
Connecticut and Montana have each received special benefits in the
health care reform legislation not made available to other states. I
simply cannot countenance this kind of deal-making which goes well
beyond the bounds of normal legislative negotiations.
In my view, the legislation does not do enough to eliminate the
historical disparity in Medicare funding between urban areas and rural
areas under which rural areas receive less than the urban regions of
the country. There is no justification for Medicare paying less for
medical procedures performed in our region than in the cities.
The bill also fails to achieve the tort reform which is necessary to
control health care costs. Virginia's tort reform law, which was
adopted when I was a member of the Virginia General Assembly, has
worked well, and I have urged that it be a model for national
application. Unfortunately, the reform bill fails to include this
needed provision.
I deeply regret that the legislation does not have a bipartisan
foundation. On a matter of this scope, affecting every American
citizen, the best ideas of both political parties should be drawn upon
in crafting balanced legislation that well serves the public interest.
That did not happen as the reform bill was constructed.
Reform is needed, but the measure being debated in the House today
falls short. Because of massive funding reductions for Medicare, it
would adversely affect the quality of care received by Southwest
Virginia senior citizens. It would result in health insurance premium
increases for those who have insurance. It contains unacceptable
special benefits for some states at the expense of the others. It does
not correct the unwarranted disparities in Medicare reimbursements that
penalize rural areas. It does not contain meaningful tort reform, and
it lacks the necessary bipartisan foundation.
The reform legislation contains many helpful provisions; however, in
my view its shortcomings outweigh its merits. I will cast my vote
accordingly.
Mr. PRICE of North Carolina. Mr. Speaker, ``once to every man and
nation,'' wrote the great abolitionist poet James Russell Lowell,
``comes the moment to decide.''
Mr. Speaker, there are moments in history when it becomes clear that
we simply cannot wait any longer to do what is right. When we have the
opportunity to take a significant step to make our country better, the
sort of opportunity that comes only a few times in a lifetime. We face
such a moment tonight.
Our health insurance system is falling far short of the American
peoples' basic needs. It isn't working for families, who have seen
their insurance premiums increase 75 percent over the past decade,
while their earnings have risen only 14 percent. It isn't working for
young adults, whose parents' policies stop covering them in their early
twenties in most states, as if people that age don't need health
insurance. It isn't working for people who have pre-existing conditions
and can't find affordable coverage. It isn't working for the countless
Americans whose coverage has been revoked when they get sick and need
it most. And it isn't working for small business owners who want to
provide coverage for their employees but can't access the low group
rates that insurance companies willingly negotiate with large
employers.
Over the past year, I have attended numerous town hall meetings and
roundtable discussions. I have met personally with doctors and
patients, parents and children, seniors and students, business owners
and employees. I have read thousands of letters and emails from
constituents about this critical issue.
In the course of these conversations, I have heard a rich and diverse
range of views on the current state of our nation's health care system,
but one conclusion has been shared by almost everyone: The status quo
is unacceptable.
Our current system penalizes the sick. It sells young people short.
It puts small businesses--the primary engine of job creation in our
country--at a competitive disadvantage. And instead of medicine, it
offers seniors the Medicare doughnut hole.
Why, then, would we continue to accept it? Particularly when we have
before us a carefully crafted bill that directly addresses the system's
flaws, preserves its strengths, and sets us on the path to meeting
longer-term challenges.
The time for reform is now.
In an effort to defeat this bill, some of my colleagues have
fabricated claims about ``death panels'' and damage to Medicare. They
have raised the specter of ``socialism'' and ``government takeovers''
when they know quite well that this bill leaves the provision of
[[Page H1908]]
care, and most insurance, in the private sector. They urge us to
``start over,'' but when challenged to come up with an alternative,
they produced a plan that leaves insurance discrimination in place as
well as tens of millions of uninsured.
Reform will save money for employees, business owners, and taxpayers.
It will end insurance company abuses. It will let young people stay on
their parents' policies until age 27. It will extend coverage to 95
percent of Americans. It expands community health centers and increases
the number of primary care doctors and nurses. And it will end the
hidden tax that the insured pay every month in the form of higher
premiums.
If my colleagues don't want to take my word for it, ask some of the
people--right in their own backyards--who have lived through it
firsthand. Ask David Swanson, whose insurance company raised the
premium for his daughter's coverage 54 percent when she turned 17. Ask
Blake Anderson, a small business owner who cannot afford coverage for
his four employees. Ask Libbie Hough, who fears her 18-year-old
daughter won't be able to find insurance when she finishes college
because of a genetic disorder. Or ask the thousands of Americans who
think they have good coverage until they get sick and hit annual or
lifetime benefit caps, or lose their jobs.
Mr. Speaker, the American people have waited long enough. We face an
historic decision tonight, one that will resonate throughout our
country, as have Social Security and Medicare, for decades to come. Let
us seize the moment for the people we were elected to serve, and for
future generations.
Mr. RAHALL. Mr. Speaker, throughout my career of public service,
there have been a few critical challenges that have remained at the top
of my priority list; protecting our coal miners and our coal jobs and
the need to provide our people with access to affordable, quality
health care.
Across southern West Virginia, especially in rural areas where senior
populations are high, that challenge has been particularly daunting,
because so many health insurance companies have been increasingly
putting high profit margins above all else, even the compassionate
treatment of the sick and the elderly.
I have consistently spoken out against the abuses of and mistreatment
by huge, for-profit health insurance companies. And I have advocated
for competition, recognizing that it is good for consumers and drives
down prices for all buyers, while driving up quality of service.
At the same time, I have consistently stood against the use of
federal funds to pay for abortions--a stand I took again when I worked
to have anti-abortion language included in the original House-passed
health care bill. That was, in fact, one of many issues that I heard a
lot about from West Virginians in recent months and that I successfully
pressed to have addressed in the House bill.
With the Executive Order strengthening the life protections in this
bill, we have achieved a firm anchor for the protection of life in this
country, reflecting the principles of the Hyde Amendment, no federal
funding for abortions. Administrative chipping away and mischief will
be held at bay with this order throughout this administration. Future
administrations should be held to this standard.
Health care is a deeply personal issue for all Americans. But it is
also true that there are no people in the world more personally
generous than Americans when it comes to helping the ill and the
injured.
I understand people's frustrations and concerns over coal, jobs, our
economy. The rhetoric about health care this year has been emotional,
at times angry, and, ultimately divisive. Much of the legitimate debate
has been undermined by millions of dollars in advertising, underwritten
by massive health insurance companies interested only in protecting
their record profits and lucrative salaries. The result has been a
polarized public and a polarized Congress.
But underlying the most contentious, most calculatingly advertised
issues, there can be found common ground. Certainly the status quo--
where honest, hardworking parents are forced into bankruptcy to afford
lifesaving treatments for their child and where longtime, loyal workers
lose their health care coverage along with their jobs during tough
economic times--does not comport with American values.
One of my constituents, Fred Long, is a Vietnam veteran and a proud
West Virginian who has long had private health insurance. Fred, blessed
with good health, needed his insurance little until he was 63 years old
when he had to have cataracts removed from both eyes.
Fred's brother was born with cerebral palsy. His problems were
covered by SSI and Medicaid. He, too, had cataracts removed, but
because of Medicaid, it did not cost his family a dime.
The two brothers had the same procedure, used the same hospital, and
same doctor, yet Fred's surgery cost him $3,099.36 despite Fred's $480
a month health insurance premiums.
Mr. Long closed his letter to me with this:
``. . . how many thousands of dollars have been paid in insurance
premiums over the years . . . I don't know if this will be of any help
in changing the thinking of those that can't see where national health
care would benefit the working man.
``The insurance companies could have done this, collected from those
that weren't sick and paid the heath care cost for those that were
sick, just like the government helped my brother when he needed it. He
is on Medicare now and I just hope I can get by the next few years when
I can sign up for Medicare. (Sincerely, Fred Long)''
Mr. Long's personal story echoes so many others I have heard from all
across southern West Virginia--this is just one of the reasons I
believe health care reform is necessary.
We must end the polarization of America and find that common ground
for the common good. The health care system as it currently exists is
not sustainable for the long-term and this Nation has a host of serious
challenges that cry out for attention--jobs for our people, renewed
transportation funding for our highways, expansion of our technology,
and diversification of our economy.
Unfortunately, as long as the needs of the people can be subverted by
special interests, financed by donors who operate in secrecy without
any accountability to the American public, I worry that we will see
little more than the same polarization that has dominated this Nation
for months.
Free speech is a wonderful American right that must be protected. But
much of the speech we have been witnessing of late has been anything
but free. It has been well-financed by special interests whose hands
are in the pockets of political operatives, and their motivation is not
the preservation of health care for our citizens, but, instead, the
preservation of power for themselves. Worse still, to the degree that
these operatives are able to bend government to suit their own
purposes, you can be sure that others will line up to use the same
tactics for their own good.
This is bad for West Virginia. And it is bad for our Nation.
Throughout my years of hard work for the people of West Virginia, I
have worked with Republicans, Democrats, and Independents alike, always
focused on the needs of southern West Virginia and the Nation. In all
that time, I have used my experience, honesty, and integrity to sustain
jobs for our coal miners, to ensure their health and safety and that of
their homes and their families. I have fought to expand our job base
and to build improved infrastructure, to advance technology, ensure
veterans care, improve education, and protect our God-given natural
resources, including the unborn.
Today, I call for an end to the polarization. We must put away our
personal interests, set aside our differences, and do the People's
work. We must come together for the common good, using common sense.
Ms. SUTTON. Mr. Speaker, every year 45,000 people in this country die
because they do not have insurance coverage, and in this great nation
it should not be that way. And, on this day, in this moment, we have
been called to stand up and vote to put an end to that sad reality.
This is the moment when we will finally take the long-overdue step of
ending the unconscionable practices of the insurance companies, who
through their greed and disregard have enjoyed record profits even as
American families have suffered, sometimes fatally because of their
actions.
I support this legislation because it will put a stop to the
discriminatory practices by insurance companies that deny care based on
pre-existing conditions and impose outrageous premium increases on
American families.
I support this legislation because it will cap out-of-pocket expenses
that insurance companies impose on our constituents forcing many into
bankruptcy when they or their children are stricken by illness or
injury.
I support this legislation because it is a vote to stop insurance
companies from inflicting lifetime caps on people who have paid for
insurance, only to find that it was not there for them when they needed
it most.
I support this legislation, because it will strengthen the solvency
of Medicare, lower drug costs and close the donut hole for our seniors,
and has the support of the AARP.
This legislation will make health insurance more affordable and
accessible for small businesses and individuals.
This legislation will finally curb the perpetual, skyrocketing costs
of health care that have been drowning far too many American families
for far too long.
This measure will reduce our deficit by more than $1.3 trillion in
the next two decades.
I support this legislation because within the 13th District of Ohio,
which I am so honored to serve, it will improve coverage for 420,000 of
my constituents with health insurance.
[[Page H1909]]
It will give tax credits and other assistance to up to 154,000
families and 13,200 small businesses to help them afford coverage.
It will improve Medicare for 107,000 beneficiaries, including closing
the donut hole. ``It will extend coverage to 33,500 uninsured residents
of the 13th District.
It will guarantee that 9,000 residents with pre-existing conditions
can obtain coverage.
It will protect 1,700 families from bankruptcy due to unaffordable
health care costs. ``It will allow 45,000 young adults to obtain
coverage on their parents'' insurance plans.
It will help support 3 community health centers in the 13th District
and reduce the cost of uncompensated care for hospitals and other
health care providers by $34 million annually.
For all of these reasons, this is the day, this is the moment, and I
am honored to support this health care measure.
Ms. VELAZQUEZ. Mr. Speaker, for too long, working families have lived
in fear that they are just one illness away from financial ruin. For
too long, the men and women in my home state of New York have watched
their premiums skyrocket, with family rates up 97 percent in the last
decade. For too long, Latinos have been left behind, suffering the
highest uninsured rate of any other community. Tonight, it is time to
say enough.
It is time to say enough to the discriminatory policies that charge
women and minorities more money for the same services. It is time to
say enough to a system that has pushed more than 2.5 million New
Yorkers over the brink and into the ranks of the uninsured. And it is
time to say enough to a status quo that robs Americans of the peace of
mind that can only come from knowing this--they, and they alone, are in
charge of their own well-being.
Mr. Speaker, this bill gives every American that autonomy. For the
Latino community, it delivers coverage to 8.8 million people. In my
home district, it improves options for 324,000 residents, and expands
care to 86,000 more. For 16,000 people with preexisting conditions, it
allows them to buy affordable health plans right away, promising them:
Never again. Never again can you be denied coverage. And for 4,300 of
my district's seniors paying full price for prescription drugs, it
closes the Medicare donut hole.
Meanwhile, this bill invests in New York's network of community
health centers. In my district alone, 33 clinics will see critical
improvements, meaning more options for the men and women of Brooklyn,
Queens and the Lower East Side. And at the end of the day, Mr. Speaker,
isn't that what this legislation is all about--options?
The Patient Protection and Affordable Care Act will deliver better
choices--not just for New Yorkers, but for all Americans. With the
passage of health care reform, we are finally answering a decades-long
cry for help. We are finally empowering the American people with
quality, affordable options that put them in the driver's seat, and I
urge support of this landmark legislation.
Mr. BISHOP of Georgia. Mr. Speaker, I have decided to support the
health reform legislation because it represents an historic opportunity
to make health care more accessible and affordable now and into the
future. I base this decision not on what is popular, but on what I
believe is in the best interest for Georgia's Second Congressional
District both in the short- and long-term.
Throughout this process, I have solicited the views of people both
supporting and opposing health care reform. I have heard from doctors
and patients, small business owners and the CEOs of large corporations,
as well as residents of rural and urban areas. I also have heard from
the healthy and the sick, the young and the old, and the rich and the
poor. I thank each of you who shared your views with me, and I have
listened to your opinions.
In my district there are more than 83,000 uninsured residents who
will receive health insurance coverage under this bill. There are
14,500 uninsured individuals who have a pre-existing medical condition
such as cancer, heart disease, and diabetes and who will now no longer
be denied affordable health insurance coverage. In addition, there are
12,100 small business owners in my district who will qualify for tax
credits to help employees afford health care.
My district is also home to 96,000 senior citizens who will benefit
from a stronger Medicare program whose solvency is extended to 2026.
There are 6,600 Medicare beneficiaries who will now be able to afford
their prescription drugs with the closure of the Part D 'donut hole.'
And, through the health care reform bill, 181,000 households in
Southwest Georgia could qualify for tax credits to purchase health
insurance through Medicaid, employer sponsored insurance, or other
acceptable coverage. For these people and for millions of Americans
like them, I have decided to support the health care reform bill.
Some people have asked how I could be a fiscally conservative Blue
Dog Democrat and still support the health reform bill. I do not know
how I could be a Blue Dog Democrat and not support this bill. According
to the nonpartisan Congressional Budget Office, the bill will reduce
the deficit by $138 billion over the next 10 years and $1.2 trillion in
the decade after that. It includes tough provisions attacking waste and
fraud in the Medicare and Medicaid programs, including some proposed by
Republicans. It will slow the growth in health care costs that are
becoming an increasing burden on families, businesses, and governments.
And the legislation will benefit rural America by boosting mandatory
funding for community health centers by $11 billion over five years and
making significant investments in the training of primary care doctors.
This bill is not perfect. We cannot, however, let the perfect be the
enemy of the good. Nor can we allow fear, misinformation, political
motivation and partisanship to prevent us from taking the necessary
steps to improve our health care system. I believe that we have a moral
obligation to ensure that all Americans, regardless of race, ethnicity,
geography, or income, receive the health care they need to lead healthy
and productive lives.
As a man of faith, I know that Jesus taught us to provide and care
for others, especially the `least of these' who often have few
advocates. In addition, when I ask myself, `What would Jesus do if he
represented the Second Congressional district, and had the opportunity
to vote to enable more than 32 million uninsured Americans to receive
health insurance?' I believe He would take care of this immediate need
of the people--not let them fend for themselves while we start over or
do nothing. This legislation goes a long way toward living up to this
moral principle, and I am proud to support it.
Ms. EDDIE BERNICE JOHNSON of Texas. Mr. Speaker, I rise to claim time
in support of the Reconciliation Bill and the Senate amendments to the
Patient Protection and Affordable Care Act.
Health care in the United States has degraded in accessibility and
quality to the extent that we are a nation in crisis. Change is needed
to truly make progress toward a healthier America, and the time for
change is now.
We are the closest in 60 years of legislative efforts to provide
access to health care for all Americans. We must pass this legislation
for the people.
It is time to place compassion and dignity over corporate greed.
My experiences as a legislator--and as a nurse--have provided a
unique vantage point from which to discuss this issue. I have seen
first-hand the state of affairs of our health care system.
We cannot sustain the current system as premiums rise, prescription
prices soar, and medical bankruptcies increase as services decline.
Texas leads the Nation in uninsured, including the highest rate of
uninsured children, and I am here today to stand up for my constituents
who desperately seek access to care.
Thousands of families are crushed by the growing cost of health care.
This legislation reins in health care costs for families and businesses
and reduces the deficit.
We have come to a point where we must choose consumers over insurance
companies. Insurance companies have held the public hostage for many
years, controlling and rationing care. It is time to give citizens the
right to control their own health care.
I stand in strong support of the legislation and urge my colleagues
to do the same.
Mr. HALL of Texas. Mr. Speaker, as we enter the most important and
eventful week of the thirty years I've been up here--I think of the
consequences of the votes we will cast--both Republican and Democrat.
When we passed the health bill on this very floor--the Democrats--
with a 40 vote advantage on the House Floor--passed H.R. 3962 with a 5
vote advantage--which showed that the outrageous health bill had been
lessened in severity in the Commerce Committee--and was softened up
enough for the Senate to kill it. Then, a series of Senators negotiated
gifts they were not entitled to--each receiving a different
consideration--into being the coveted 60th vote. If we take the Floor
back--I would favor subpoenaing those who may have made the overtures
to compare it to the law of bribery or corrupt deals. I would send the
results to the Federal and State Prosecutors. The bribery penalty as
set out in 18 U.S. Code Section 203 ``is imprisonment for not more than
a year and a civil fine of not more than $50,000 for each violation.''
I consider offering a bribe--for a personal benefit--as worse than
accepting one; let's clean up the United States Congress--and listen to
our people whose only request is to take back our country.
Webster's Dictionary defines ``bribe'' as money or favor given or
promised to a person in a position of trust to influence their judgment
or conduct.
Mr. MARIO DIAZ-BALART of Florida. Mr. Speaker, I rise today to
express my strong opposition to the eventual government takeover of
health care that took place on the floor of the House today.
[[Page H1910]]
Though I strongly believe that America needs health care reform, I
cannot in good conscience cast a vote for a bill that will take our
country down the path of bankruptcy.
This deeply flawed legislation raids Medicare, which faces insolvency
in 2017, by over half a trillion dollars in order to create a massive
new entitlement program. It raises taxes on our families and small
businesses by over half a trillion dollars. It will lead to increases
in insurance premiums, increase overall spending on health care by over
$200 billion and will result in job losses. This bill will also
increase the national debt and deficit, leaving our children and
grandchildren to pay the price.
Today Democrat leadership abused and manipulated the legislative
process for political gain, in an effort to force an eventual
government takeover of health care that the American people do not
want. This legislation was drafted in secret and is loaded with
backroom deals for certain Members of Congress and special interests.
The American people need, demand and deserve health care reform that
will increase access, improve quality and lower costs. What the
American people do not want is this ill-conceived legislation that will
bankrupt our country and leave a lasting negative impact on generations
to come.
Nothing is more sacred in this country then our freedom and
democracy. These are the fundamental principles that make America the
greatest country in the world, and I cannot and will not vote for
legislation that jeopardizes the freedom, democracy, prosperity and
opportunity of future generations of Americans.
Mr. COSTELLO. Mr. Speaker, we meet today for what will truly be a
historic debate and vote on national health care reform. Like the
passage of Social Security in 1935 and Medicare in 1965, it is sure to
be one of a handful of votes that will stand the test of time as of
great national significance. Also like those votes, the public debate
surrounding national health care reform has engendered great passion on
both sides, often generating more heat than light, but instructive all
the same, as we must listen to all viewpoints as we contemplate major
changes that will affect the entire country.
Today's vote is a major milestone in what has been a decades-long
effort to ensure access to quality health care for all Americans. In my
district, 34,000 people are uninsured and use the hospital emergency
room for treatment. Nine thousand people have a pre-existing condition
that precludes them from getting insurance. Meanwhile, health insurance
premiums have increased 131 percent over the last decade while wages
have gone up only 38 percent. While the process over the last 14 months
to develop health care reform legislation has been far from perfect, it
is undeniable that our current health care system is broken, and we
must take action to fix it. Toward this goal, I will vote in support of
H.R. 3590 and H.R. 4872.
This has been the hardest decision regarding a vote I have had to
make during my service in the House of Representatives. During that
time, I have strived to serve the people I represent with diligence and
integrity, while remaining true to my core individual beliefs.
One of those core beliefs is my support of protecting the unborn. I
along with Congressman Bart Stupak (D-MI) and other pro-life Democrats
have worked hard through the passage of the House bill and since the
passage of the Senate bill to ensure that current law Hyde amendment
abortion restrictions are applied to the final legislation. However, we
were successful in convincing President Obama--a pro-choice President--
to issue an executive order that clearly states that the Hyde amendment
will apply to the bill. This is a highly significant act. In addition,
a colloquy on the House floor clearly stated that this is the intent of
Congress. With these changes, I believe we have accomplished our goal.
This belief is shared by the Catholic Health Association, NETWORK--a
national Catholic social justice lobby, the Catholic Sisters--60
Catholic women religious leaders representing 59,000 Catholic Nuns, and
Democrats for Life.
I stated that I would not vote for the Senate-passed bill in its
current form. With the presidential executive order approving the Hyde
abortion language and the fact that H.R. 4872 eliminates the
``Cornhusker Kickback'' and other state-specific promises, combined
with assurances from the Senate that H.R. 4872 will pass that body, I
feel I can now support the Senate bill as amended.
The fact is that this may be our last best chance to address a health
care system that is unsustainable, that is spending $1 billion annually
on medical costs for the uninsured while insurance premiums rise
uncontrollably. Our current system is grossly inefficient and
jeopardizes our future economic health. This legislation will insure 32
million additional Americans, eliminate pre-existing condition
restrictions, allow for the interstate sale of health insurance,
eliminate lifetime caps on insurance benefits, allow dependent children
to stay on their parents' insurance until age 26, and improve health
care for seniors, all while reducing our budget deficit by $138 billion
over the next 10 years, and by $1.2 trillion over the next 10.
While the legislation will allow those that have health insurance to
keep it, it will also end the fear that so many uninsured Americans
have of becoming sick--of having to use their life savings or declare
bankruptcy to pay for a medical emergency. It can be the difference
that allows the disabled to live with dignity, and provides workers the
confidence to reach their maximum professional potential.
Mr. Speaker, after much deliberation, it is clear to me that we must
take this opportunity to improve the provision of health care in our
country. While it is a difficult thing to do, it is unquestionably the
right thing to do, and I am confident that history will reflect this
fact.
Mr. GOODLATTE. Mr. Speaker, nearly two months ago President Obama
stood here before the Members of the House of Representatives, the
Senate, the Supreme Court Justices, his own Cabinet Members and
millions of Americans who were watching on television to deliver his
first State of the Union address. In that speech he declared that as
economic uncertainty continues to plague our Nation the government must
focus on policies that promote economic growth and job creation. My how
things have changed in just two short months.
Congress should be working to reduce the tax and regulatory burdens
that hinder small businesses and ultimately overall economic growth and
job creation. Instead, over the loud objections of a majority of
Americans, the Majority continues to advance their health care reform
proposal which sets the tone for a Washington takeover of the health
care system. This legislation which contains a multitude of new federal
regulations, mandates, new big government programs, and a significant
increase in federal spending and debt, will be extremely detrimental to
American businesses and particularly our small businesses, which will
make job losses even worse.
The legislation includes over $569 billion in tax increases and over
$523 billion in Medicare cuts. This includes $52 billion in new taxes
on employers, including small businesses, that cannot afford to provide
health coverage or that don't offer coverage. The effect of this type
of tax, similar to a payroll tax increase, would ultimately fall
squarely on workers in the form of lower wages or reduced employment.
Additionally, the legislation includes $17 billion in new taxes on
Americans who do not comply with the individual insurance mandate which
is sure to further stifle economic growth.
In fact, 130 economists from all across the country sent President
Obama a letter explaining how this legislation is a job-killer. In
their letter, the economists stated that the insurance mandate and the
tax increases, among other things, will ``constrict economic growth and
reduce employment'' while ``increasing spending on health care and
increasing the cost of health coverage''.
That is why I strongly support an alternative proposal which allows
for the purchase of health insurance across state lines, allows
individuals and small businesses to join large pools to get more
competitive rates, provides tort reform to cut down the high cost of
defensive medicine, allows full tax deductibility of health insurance
premiums, portability of health insurance and protection against pre-
existing condition exclusions. In addition, I support health insurance
tax credits for individuals and families who don't have access to
employer-based health insurance, increasing the number of community
health centers, and encouraging the use of health information
technology to achieve greater efficiencies.
Congress should not be pushing this government takeover of health
care that will inflict even more harm on our Nation's economy, making
job losses even worse. Instead Congress must focus on strategies that
help Americans obtain the best quality health care at the least cost,
and ensure that the government fosters increased access to quality care
based on individual choice, not by taking away choices from people on
the grounds that government knows best.
Mr. SMITH of New Jersey. Mr. Speaker, for those of us who recognize
abortion as lethal violence against children and the exploitation of
women, nothing less than a comprehensive prohibition on public funding,
promotion and facilitation of elective abortion in any federal health
program, including the bill under consideration today, satisfies the
demands of social justice.
The Stupak-Pitts Amendment which passed 240-194-1 ensures that not
some, but all the elements of the Hyde amendment applies to the
programs that are both authorized and appropriated in this bill.
By now, I trust that all members fully understand that because
programs in Obamacare are both authorized and appropriated in this
legislation, the actual Hyde Amendment has no legal affect. It only
affects Labor HHS not this massive expansion of government funded
health care.
[[Page H1911]]
Regrettably the language that emerged from the Senate is weak,
duplicitous and ineffective, not by accident, but by design. It will
open up the floodgates of public funding for abortion in a myriad of
programs resulting in more dead babies and wounded moms than would
otherwise have been the case.
Because abortion methods dismember, decapitate, crush, poison, starve
to death and induce premature labor, pro-life Members of Congress, and
according to every reputable poll, significant majorities of Americans
want no complicity whatsoever in this evil. Obamacare forces us to be
complicit.
Abortion hurts women's health and puts future children subsequently
born to women who aborted at significant risk. At least 102 studies
show significant psychological harm, major depression and elevated
suicide risk in women who abort.
Recently, the Times of London reported that, ``[S]enior . . .
psychiatrists say that new evidence has uncovered a clear link between
abortion and mental illness in women with no previous history of
psychological problems.'' They found, ``that women who have had
abortions have twice the level of psychological problems and three
times the level of depression as women who have given birth or who have
never been pregnant . . .''
In 2006, a comprehensive New Zealand study found that 78.6 percent of
the 15-18 year olds who had abortions displayed symptoms of major
depression as compared to 31 percent of their peers. The study also
found that 27 percent of the 21-25 year old women who had abortions had
suicidal idealizations compared to 8 percent of those who did not have
an abortion.
At least 28 studies--including three in 2009--show that abortion
increases the risk of breast cancer by some 30-40 percent or more yet
the abortion industry has largely succeeded in suppressing these facts.
Abortion isn't safe for subsequent children born to women who have had
an abortion. At least 113 studies show a significant association
between abortion and subsequent premature births. For example a study
by researchers Shah and Zoe showed a 36 percent increased risk for
preterm birth after one abortion and a staggering 93 percent increased
risk after two.
Similarly, the risk of subsequent children being born with low birth
weight increases by 35 percent after one and 72 percent after two or
more abortions. Another study shows the risk increases 9 times after a
woman has had three abortions.
What does this mean for her children? Preterm birth is the leading
cause of infant mortality in the industrialized world after congenital
anomalies. Preterm infants have a greater risk of suffering from
chronic lung disease, sensory deficits, cerebral palsy, cognitive
impairments and behavior problems. Low birth weight is similarly
associated with neonatal mortality and morbidity.
Unlike both the Hyde Amendment and what would be the effect of the
Stupak-Pitts amendment, the Senate passed bill permits health care
plans and policies funded with tax credits to pay for abortion, so long
as the issuer of the federally subsided plan collects a new,
congressionally mandated fee from every enrollee in that plan to pay
for other peoples abortions. Requiring the segregation of funds into
allocation accounts--a mere bookkeeping exercise touted by some as an
improvement to the new pro-abortion funding scheme--does absolutely
nothing to protect any victims--baby or mother--from publically funded
abortion.
The Senate passed bill creates a new Community Health Center fund and
appropriates at least $7 billion for Community Health Centers (CHC).
Again recognizing that the Hyde Amendment does not apply to this bill
and absent enactment of the Stupak-Pitts amendment, it is clear that
the 1,250 CHC clinics (among the most effective means of reaching the
poor and underserved with basic health care) will likely be compelled
either by the Obama Administration or the courts or both to fund
abortion on demand at CHC sites. There is no statutory protection
against this abuse in the Senate-passed bill.
Additionally, under the federal employee health benefits plan, which
includes Members of Congress, since 1984, no funds may be used for
abortion or the administrative expenses in connection with any health
plans that provide any benefit or coverage for abortions or even the
administrative expense, except in the case of rape, incest or to
protect the life of the mother.
The Office of Personnel Management (OPM) administers the program.
The Senate-passed bill on the other hand creates a huge new program
administered by OPM that would manage two or more new multi-state or
national health plans. The bill stipulates that at least one plan not
pay for abortion. Which only begs to question: what about the other new
multi-state plans administered by OPM? Why can those federally
administered plans include funding abortion on demand? This represents
a radical departure from current policy.
Additionally, other appropriated funds in the bill have no Hyde/
Stupak-Pitts type protections either including $5 billion for a
temporary high risk health insurance fund and $6 billion in grants and
loans for health cover co-ops. Pro-life members who vote for this bill
will roll the dice on this one.
When the bill left the House, it contained the Hyde-Weldon language
protecting health care providers who refuse to participate in abortion
against discrimination by government entities. The Senate passed bill
instead only includes more narrow text that prevents discrimination by
a ``qualified health plan'' on the Exchange. This narrow language was
included in the House bill, but without the additional protections
against discrimination by federal and state governmental entities, pro-
life health care providers are not fully protected.
Then there's the Mikulski Amendment, Sec. 2713, which empowers the
HHS Secretary with broad new authority to compel private health care
plans in America to cover ``preventable'' services. When Senator Ben
Nelson suggested that abortion not be included in the so-called
preventative services mandate, Ms. Mikulski said no--raising a serious
red flag that abortion is being postured as ``preventable abortion
service in the future''--after all, abortion prevents a live birth.
Abortion as preventative health care isn't new.
And as far back as 1976, Dr. Willard Cates, Jr. and Dr. David Grimes,
then with CDC, presented a paper to a Planned Parenthood meeting,
entitled: Abortion as a Treatment for Unintended Pregnancy: The Number
Two Sexually Transmitted ``Disease''. To call pregnancy sexually
transmitted disease; to call abortion a treatment or a means of
prevention for this ``disease'' is barbaric.
Abortion isn't health care--preventative or otherwise.
Mr. Speaker, we live in an age of ultrasound imaging--the ultimate
window to the womb and its occupant. We are in the midst of a fetal
health care revolution, an explosion of benign innovative interventions
designed to diagnose, treat and cure disease or illness any unborn
child may be suffering.
Unborn children are society's youngest and most vulnerable patients.
Obamacare should do them no harm. Tragically, it does the worst harm of
all. It kills them.
Mr. FILNER. Mr. Speaker, I rise in support of this bill and I would
like to take the opportunity to remind America's veterans that the plan
will not affect the VA health care system. I continue to work in
concert with leaders in the House of Representatives to ensure that
veterans receive the world-class health care services they have so
bravely earned.
Let me be clear: enrolled veterans meet the individual responsibility
requirements under the bill to maintain quality health coverage.
I firmly believe all of our citizens should have access to health
care. I am proud that Congress has crafted a plan to bring stability
and security to Americans who have insurance today, and affordable
coverage to those who do not. This plan, however, will not jeopardize
the current health care services and benefits provided by VA. We will
keep our promise to our Nation's heroes of the past, present, and
future.
I was pleased to sign a letter with House Armed Services Chairman Ike
Shelton, House Ways & Means Chairman Sander Levin, House Education &
Labor Chairman George Miller, and House Energy and Commerce Chairman
Henry Waxman affirming that current health care reform legislation does
not undermine or change the Department of Veterans Affairs mandate to
provide comprehensive health care to veterans. I would like to submit
this letter, along with statements from the Vietnam Veterans of America
and AMVETS and a statement from General Eric Shinseki, Secretary of the
VA, affirming this fact for the Record.
Congress of the United States,
Washington, DC, March 21, 2010.
Hon. Louise Slaughter,
Committee on Rules, The Capitol,
Washington, DC.
Dear Chairwoman Slaughter: The House Democratic leadership
asked our committees to review HR 3590 and HR 4872 to assess
the impact of the bills on the health care provided by the
Department of Defense and the Department of Veterans Affairs.
Our reviews of HR 3590 and HR 4872 lead us to believe that
the intent of the bills was never to undermine or change the
Department of Defense and Department of Veterans Affairs
operation of their health care programs or interfere with the
care that our service members receive under TRICARE. However,
we commit to look into this issue further to ensure that no
unintended consequences may arise and to take any legislative
action that may be necessary.
HR 3590, as drafted, does not specifically mention that
TRICARE coverage meets the individual responsibility
requirement. but such coverage would satisfy the requirements
of this bill. To affirm that this is the case, the U.S. House
of Representatives unanimously passed HR 4887, the TRICARE
[[Page H1912]]
Affirmation Act, which provides assurances to the American
people that care provided to those in the military and their
families, as well as military retirees under age 65 and their
families, would indeed meet the requirement for coverage.
The members of our nation's military sacrifice much to
defend us all. We commit to these dedicated service members
and their families as well as our veterans that we will
protect the quality healthcare they receive,
Sincerely,
Bob Filner,
Chairman, Committee on Veterans' Affairs.
George Miller,
Chairman, Committee on Education and Labor.
Henry Waxman,
Chairman, Committee on Energy and Commerce.
Ike Skelton,
Chairman, Committee on Armed Services.
Sander Levin,
Chairman, Committee on Ways and Means.
____
March 21, 2010.
Vietnam Veterans of America Applauds Passage of Skelton Bill Ensuring
Protection of TRICARE, VA Health Care, and CHAMPUS; Decries ``Scare
Tactics''
Washington, DC.--`` We thank and applaud passage of H.R.
4887 yesterday in the House of Representatives, by a vote of
403-0. Passage of this bill ensures that health care programs
for veterans, active duty military, retired military, and
their families/survivors will not be affected negatively by
the pending health care reform legislation.'' said John
Rowan, National President of Vietnam Veterans of America
(VVA).
``It is unfortunate that some continue to raise what is now
is even more clearly a false alarm that is apparently meant
to frighten veterans and their families in order to prompt
them to oppose the pending legislation. While there is
legitimate debate as to whether or not the pending health
care measures should become law, VVA does not appreciate
spreading rumors that are not accurate by any political
partisan from any point of the political spectrum,''
continued Rowan.
``Last summer there was a similar incident, also involving
partisans in the health care reform debate, that VVA soundly
condemned. We said then: ``It is our hope that sane minds
reject fear-mongering, and that veterans recognize these
scare tactics for what they are,'' Rowan said. Rowan
concluded by saying: ``VVA has always worked hard for justice
for veterans of all generations, and their families. We have
always, and will continue to, work with public officials
representing all political parties and points of view. Issues
affecting veterans and their families are not, should not,
and must not become partisan footballs to bat around. VVA
decries any effort, by anyone, that would do just that.''
____
Department of Veterans Affairs,
March 21, 2010.
Statement from VA Secretary Eric K. Shinseki
As Secretary of Veterans Affairs, I accepted the solemn
responsibility to uphold our sacred trust with our nation's
Veterans. Fears that Veterans health care and TRICARE will be
undermined by the health reform legislation are unfounded. I
am confident that the legislation being voted on today will
provide the protections afforded our nation's Veterans and
the health care they have earned through their service. The
President and I stand firm in our commitment to those who
serve and have served in our armed forces. We pledge to
continue to provide the men and women in uniform and our
Veterans the high quality health care they have earned.
President Obama has strongly supported Veterans and their
needs, specifically health care needs, on every major issue
for these past 14 months--advance appropriations, new GI Bill
implementation, new Agent Orange presumptions for three
additional diseases, new Gulf War Illness presumptions for
nine additional diseases, and a 16% budget increase in 2010
for the Department of Veterans Affairs, that is the largest
in over 30 years, and which has been followed by a 2011 VA
budget request that increases that record budget by an
additional 7.6%.
To give our Veterans further assurance that health reform
legislation will not affect their health care systems, the
Chairmen of five House committees, including Veterans Affairs
Chairman Bob Filner and Armed Services Chairman Ike Skelton,
have just issued a joint letter reaffirming that the health
reform legislation as written would protect those receiving
care through all TRICARE and Department of Veterans Affairs
programs.
____
AMVETS Applauds Skelton Bill To Protect Military Health Care
Lanham, Md. March 21, 2010--AMVETS leaders applauded the
passing of H.R. 4887, introduced by Rep. Ike Skelton, D-Mo.,
that will protect specific health care benefits of military
veterans, members of the Armed Forces and their families.
AMVETS National Legislative Director Raymond Kelly said
Sunday that AMVETS leaders have always understood the intent
of H.R. 3590: The Patient Protection and Affordable Care Act,
and believed it would not compromise the health care benefits
of American Veterans.
``AMVETS continues to share the opinion of Department of
Veterans Affairs Secretary Eric Shinseki and other VA and
Department of Defense leaders that health care reform
legislation does not threaten the veterans' community,'' said
Kelley. ``The successful passing of Rep. Skelton's
legislation only solidifies our belief and erases any and all
doubt of potential harm.''
Kelly said AMVETS will continue to monitor the debate to
ensure the Senate version of H.R. 4887 also passes.
Ms. HIRONO. Mr. Speaker, today we take a stand for hard-working
middle class families who deserve a better value for their health care
dollar. We take a stand for better health care for America's seniors.
We take a stand for those who have been denied insurance coverage
because of a preexisting condition or whose insurance is rescinded when
they need it most.
This has been a difficult debate. There are strong, personal feelings
about the issue of health care, because it affects all of us. This
makes it even more important that we focus on the substance of health
care reform, rather than engage in demagoguery, name calling, and
worse. Republicans and Democrats alike know that our health care system
is broken and not sustainable. Our country spends more on health care
than any other developed country and we fall far below these other
countries in the health of our people.
H.R. 4872 and the Senate health care reform bill, H.R. 3590, are not
perfect, but they are a step in the right direction. The health
insurance reform measure achieves the three key goals of affordability
for the middle class, accessibility for all Americans, and
accountability for the insurance industry.
More than 350 organizations support the health insurance reform
legislation that we are voting on today. They include: the American
Medical Association, AARP, Catholic Health Association, Main Street
Alliance, Federation of American Hospitals, National Association of
Public Hospitals and Health Systems, American College of Physicians,
Paralyzed Veterans of America, American Heart Association, American
Cancer Society Cancer Action Network, American Diabetes Association,
American Nurses Association, Families USA, National Committee to
Preserve Social Security and Medicare, National Women's Law Center,
Consumer Federation of America, and the Consumers Union.
Once this bill is passed, Americans will see immediate benefits:
seniors will start to see immediate relief from high prescription
prices with a $250 rebate for Medicare beneficiaries who hit the donut
hole; preventative services and immunizations will be free under
Medicare right away--eliminating co-payments for preventative services
and exempting preventative services from deductibles; and small
businesses that provide coverage to their employees will be eligible
for a tax credit of up to 35% of premiums. The bill will also ban
insurers from denying coverage to children with pre-existing conditions
and eliminates lifetime limits and restrictive annual limits on
coverage.
These are real reforms yielding real benefits to people who are not
getting their money's worth from the current system. It will soon be
much harder to mischaracterize what this effort to change the health
care system has been about once reform is enacted and the benefits
accrue.
I was appalled at the news that my colleagues John Lewis, Andre
Carson, Emanuel Cleaver, and Barney Frank were verbally insulted and in
one instance spat on by anti-health care reform protestors yesterday.
The ugliness that this behavior exemplified reminded me of why ``Live
Aloha'' is more than a motto to us in Hawaii. The Hawaiian word aloha,
has deep meaning in my state; it is far more than hello or goodbye. To
``Live Aloha'' is to also have respect for yourself and respect for
others, especially those with whom we disagree. To treat each other
with decency--not hatred, or racism, or bigotry--is to ``Live Aloha.''
I'm proud to represent a state where we strive toward that ideal.
My office has taken many calls and received many emails and letters
on health care reform. A call that my office received on Friday was
particularly heartfelt. It was from a woman on the island of Kauai who
called to tell me that she and her 93 year-old friend both wanted me to
stay strong and to vote in support of health care reform. I mention
this particular call because it reminded me of the people and places I
represent, who I fight for every day, and what this health care debate
is all about.
In his recent address to the Democratic Caucus, President Barack
Obama quoted President Abraham Lincoln who said, ``I am not bound to
win, but I'm bound to be true. I'm not bound to succeed, but I'm bound
to live up to what light I have.'' This bill calls us to be true to the
millions of Americans who want and need enlightened health care reform.
It is a privilege to vote for H.R. 4872.
[[Page H1913]]
Mr. ISRAEL. Mr. Speaker, I rise in support of this bill for one
fundamental reason. It is-simply the right thing to do. Not for my
Party, not for the President, not for the Speaker, not for me. But for
the people I represent. The middle class and working families; the
backbones of our economy--small businesses--challenged by rising health
costs.
Few debates have been as long and as passionate as this one. Since
last August I have heard the strong voices on both sides of this issue.
I have listened to the angry chants of opponents of the bill at Town
Hall meetings. I have read the mail from people who insist this is a
march towards socialism, that it is a dangerous experiment, that it
involves government death panels who will deny senior citizens the
life-saving health care they need. I have watched protesters march
outside my district office on Long Island. I have seen the repugnant
signs here in Washington comparing health care to the Holocaust.
I have seen and heard it all. But I have also heard others. They are
the average Long Islanders--not rich, not poor, but usually somewhere
in between--who live in quiet desperation and concern.
The small business owner on Long Island who told me he just received
a 22 percent increase in health insurance premiums and agonizes at the
prospect of either scaling back the care he provides his workers or
scaling back the workers he pays. Under this bill, his business will
receive a tax credit to help him provide insurance to his workers. And
he will be able to shop for competitive rates and services in a new
market-driven ``Health Insurance Exchange.''
The woman who thought health care worked pretty well for her, until
her daughter was diagnosed with breast cancer. She's been forced to
deal with high medical costs to care for her daughter. But, under this
bill, she will not have to worry about an insurance company that
refuses to pay for her chemotherapy.
The middle class family with two kids just out of college who are
having trouble finding a job that provides health insurance. Under this
bill, those young adults can get coverage on their parents' plans until
they turn 26.
The retired plumber on the block where I live. One day he came to my
house. I thought he wanted to debate this bill with me. Instead, he
said: ``I wish you would pass this now. Don't these people know that if
they lose their jobs they lose their health care?''
And just yesterday, Mr. Speaker, a small business owner called me
with concerns and plentiful questions about the legislation we will
vote on today. After I explained it, he said: ``There's been too much
confusion about this bill. I wish it had been explained.''
He is right. This bill has changed in over a year of debate.
Sometimes in an effort to accept bipartisan recommendations. Sometimes
to reduce its cost. While one side has had the responsibility to
improve the bill, the other side has taken the opportunity to brand it
with mischaracterizations. But now the ink is dry, Mr. Speaker. And the
dry ink of this bill represents the best hope to protect the middle
class and working families I represent. The small business owner in
East Northport who now has a level playing field when shopping for
insurance. The family in Sayville who can now keep a child insured
until the age of twenty-six. The senior in Deer Park whose drug costs
will be covered. The accountant in Huntington who lost his job but will
be able to shop for affordable health care.
This bill will improve coverage for 485,000 of my constituents with
coverage through their employer, give tax credits to as many as 81,000
families and 21,000 small businesses to make health care affordable in
my district, and extend coverage to 29,000 uninsured residents of the
towns I represent.
This bill will reduce our debt. Yesterday, the Congressional Budget
Office certified that the bill is fully funded and will actually reduce
federal deficits by $143 billion in the first ten years and over a
trillion dollars in the next ten.
This bill is an urgent reversal from eight years of ignoring the
crisis. Between 2000 and 2008, health insurance premiums doubled,
insurance company profits quadrupled, and an additional 6 million
Americans became uninsured. As a result, the leading cause of personal
bankruptcy today is unpaid medical bills. Without action, these trends
will grow worse.
These are the middle class families and businesses that have always
expanded our economy. But rising health costs and insecurity have
undermined the middle class. This bill will provide them with the basic
security they need to do what they've always done: build our economy.
This vote is no different than the 1965 vote for Medicare. Back then,
when one-quarter of American seniors were living in poverty and wracked
with un-payable medical bills, there were loud voices that said, ``do
nothing'' and ``start over'' and ``vote no.'' Public opinion was
skeptical then. Had I been in Congress in 1965, and the choice was
voting for Medicare and risking my seat, or voting against Medicare and
saving my seat, I would have voted for Medicare. It became the back
bone of economic security for our senior citizens and helped build a
middle class with economic security. This is no different. No less
necessary. No less historic.
Mr. STARK. Mr. Speaker, This is a historic day. We have worked to
enact health reform in America for decades. President Johnson took a
major step when he signed Medicare into law in 1965 and guaranteed
every American age sixty-five and over quality, affordable health care.
Forty-five years later, we are about to extend that guarantee to all
Americans.
It isn't the bill I would have written. However when it comes to
legislating health insurance reform in America, we will not get
everything each of us want. This bill is a compromise that bridges the
differences among us.
I am proud to support this legislation and urge my colleagues to do
the same.
This bill builds a solid foundation. It will:
Extend coverage to 95 percent of all Americans.
Assure affordability of health insurance by providing tax credits and
cost-sharing assistance to families up to 400 percent of poverty.
Halt abuses of the health insurance industry--forcing them to compete
on quality, not just their ability to avoid covering needed health
services.
Guarantee a standard benefit package for all Americans with an annual
cap on out-of-pocket spending. No family should go bankrupt because of
medical expenses.
Create a new marketplace, called an Exchange, where people will be
able to comparison shop among health insurance plans.
Require that insurance plans spend at least a certain percentage of
their premium dollars on benefits and end discrimination by health
status, gender, occupation.
Help senior citizens by filling the Republican Medicare prescription
drug donut hole--ensuring that Medicare beneficiaries will be able to
afford their medications year-round.
We are joined in support of this legislation by a coalition of
patients, doctors, nurses, hospitals, businesses, labor unions,
children's advocates and senior citizens.
President Obama has worked tirelessly to achieve this goal and he
deserves much of the credit.
There are components I wish had turned out differently and I pledge
to continue working to improve them. In particular, I have some
concerns about Medicare.
I oppose the inclusion the Independent Payment Advisory Commission,
called IPAB. Some of my colleagues support this Commission because it
shields them from having to take tough votes when it comes to cutting
Medicare provider payments. It's my experience that Congress always
does what is needed to protect and strengthen the Medicare program.
IPAB is a dangerous provision. By statute, this Commission would be
required to hold Medicare spending to an arbitrary and unrealistic
growth rate. It is a mindless-rate cutting machine that sets the
program up for unsustainable cuts. That will endanger the health of
America's seniors and people with disabilities. It is an unprecedented
abrogation of Congressional authority to an unelected, unaccountable
body of so-called experts. I intend to work tirelessly to mitigate the
damage that will be caused by IPAB.
I am pleased that this legislation reduces government overpayments to
private health insurance plans in Medicare and that our reconciliation
negotiations improved on those savings. It still should eliminate the
overpayments. I support the choice of private plans in Medicare, but I
don't support wasting taxpayer dollars on corporate subsidies to
achieve that goal. Plans that can meet or beat Medicare should be
allowed to participate. Those that can't should be excluded. We've got
more work to be done here.
We also lost a provision in the House bill that ensured Medicare
beneficiaries in private plans would never pay higher cost-sharing for
Medicare services than if they were enrolled in traditional Medicare.
I'll be working with the Administration to see that they move forward
with steps in their authority to resolve that disparity.
I am disappointed in the lack of a public health insurance option.
This provision fell victim to the strength of the insurance industry
lobby. It would have saved taxpayers money, enhanced competition, and
increased efficiencies. That it isn't in this bill does not mean it
can't be added in the future.
These flaws are what one must expect when bringing a bill through the
US Congress that touches more than one-sixth of our economy. In the
past, we've allowed health reform to fail because of similar
imperfections. We, can't let that happen now.
Our vote today will determine whether we finally provide affordable,
quality health care to all Americans. I am proud to rise in support of
this legislation, and I urge my colleagues to join me in voting yes.
Mr. PIERLUISI. Mr. Speaker, I rise so that the record will reflect
the following point about the Medicare Advantage program and its
application in Puerto Rico. For a variety of reasons, relatively few
Medicare beneficiaries in
[[Page H1914]]
Puerto Rico are enrolled in Part B. The Medicare Payment Advisory
Commission (MedPac) has determined that, as a result, fee-for-service
reimbursement rates for providers on the Island are artifically low and
unstable. Over the past year, I have worked with the House Committee on
Ways and Means to examine ways to address this problem. In the report
accompanying the health care reform bill it approved, the Committee
candidly acknowledged the problem and urged CMS to use its existing
authority to adjust the reimbursement rates in Puerto Rico. I strongly
supported this language and believe it is still operative. Working with
Committee leadership and my colleagues, I will do everything within my
power to ensure that CMS uses its current authority to make certain
that reimbursement rates to MA providers in Puerto Rico are fair.
The language included in the House Ways and Means Committee report
is:
The phase-down of MA payments to FFS costs applies equally to all 50
states and the territories, however, Puerto Rico is a unique situation
that the Committee expects that the Secretary will use authority under
current law to examine. Specifically, very few Medicare beneficiaries
in Puerto Rico choose to enroll in Part B; instead, MA plans buy down
the Part B premium for enrollees and therefore many Medicare
beneficiaries enroll in MA to receive all of their Medicare services.
With only a small population enrolled in Part B through traditional
Medicare, the county FFS expenditures calculated by the Secretary are
artificially low and unstable from year-to-year. Therefore, the
Committee expects that when calculating county FFS rates in Puerto
Rico, the Secretary will use utilization and expenditure data from MA
plans under current authority and adjust these rates and risk scores
appropriately.
Mr. SMITH of Texas. Mr. Speaker, by a 12-point margin, Americans say
the Administration's health care plan is a ``bad idea,'' according to a
new NBC News/Wall Street Journal survey.
And the number of people who call the health plan a ``bad idea'' has
reached a new high.
But you won't hear about this from the national media--not even NBC,
who conducted the poll. During a report about the survey on NBC's
Nightly News, anchor Brian Williams failed to mention this finding.
Other polls show even greater opposition to the Administration's
plan. According to Investor's Business Daily, Americans want Congress
to ``start fresh'' by 61 percent to 32 percent.
NBC and the national media should give the American people the facts
about health care, not hide them.
Mr. POE of Texas. Mr. Speaker, in a new survey of doctors published
by The New England Journal of Medicine--nearly half of all primary care
physicians said they may leave the medical profession if Obama-care
passes.
Doctors are getting railroaded out of practice now. Medicare doesn't
pay the cost to keep their doors open. The new healthcare scheme makes
it worse. Some doctors who can stay in business won't see Medicare
patients anymore. They can't afford it.
More patients and fewer physicians will cause long lines and
rationing for our senior citizens.
Government-run Medicare already denies claims twice as much as
private insurance. But when Medicare denies coverage for a procedure--
you can't pay for it with your own money. The procedure--not the
coverage--but the procedure is denied under Medicare. That's government
rationing.
Passing the healthcare bill would only make those problems worse.
Government-run healthcare has the competence of FEMA, the efficiency
of the Post Office, and the compassion of the IRS. It is not fit for a
free people.
And that's just the way it is.
Mr. PETRI. Mr. Speaker, I rise in opposition to H.R. 3590 and H.R.
4872. I certainly agree that it is time to fix the health care system
in the United States so that all Americans have access to quality,
affordable health care. However, the path we are considering takes us
in the entirely wrong direction. And this reconciliation bill only
makes worse the Senate amendment considered by the House today.
Overall, it will break the bank because it is filled with budget
gimmicks to hide its true cost. It imposes over $500 billion in new
taxes as our fragile economy struggles towards recovery. It makes
significant cuts to Medicare, including to Medicare Advantage Plans
which will surely eliminate or reduce benefits to the 216,000
beneficiaries in Wisconsin. It gives the government unprecedented
authority over the regulation of health insurance, which will lead to
increased costs for those who currently have health insurance.
We need the right reforms to eliminate waste throughout the system
and reward high quality low-cost care. We should be choosing approaches
which give consumers incentives to use their health care dollars
wisely. Instead, we are going in the opposite direction by turning
decisions over to government bureaucrats.
Instead of getting everybody into the old, dysfunctional system and
then figuring out how to pay for it, we should emphasize advances in
efficiency so that more people will be able to afford their health
care, and the government will be better able to take care of the rest.
Unfortunately, the majority in Congress has committed us to a path
which will make the right reforms much harder to achieve.
Despite the fact that I will vote against both bills, I do want to
express my support for provisions in H.R. 4872 that make changes to the
federal student loan program. This bill eliminates the Federal Family
Education Loan (FFEL) Program and moves the origination of all federal
student loans to the Direct Loan Program. For over two decades I have
championed the Direct Loan Program as the most efficient, stable, and
cost effective federal student loan program. The change to 100 percent
direct lending marks an important step forward for students, parents,
and taxpayers.
Currently we have two federal student loan programs that provide the
exact same student loans to borrowers, and schools choose to
participate in either one or the other. The FFEL Program uses private
capital to fund student loans but receives a federal subsidy to ensure
a guaranteed rate of return. The federal government also provides a
guarantee on these loans. Thus, if a student defaults, taxpayers are on
the hook, not the private lender. The Direct Loan Program uses the
proceeds from the wholesale auction of Treasury securities to the
private sector to fund loans to students, and all servicing and bill
collection is handled by private companies operating through
performance-based contracts. The loans are delivered to students
through the same system that universities use to disburse Pell Grants.
I first became interested in student loan reform in the early 1980s
when the head of the Wisconsin higher education agency convinced me
that the FFEL program was wildly costly to the government. I introduced
the first direct loan proposal in 1983 and almost ten years later won
approval of a pilot program to test the direct loan program at hundreds
of schools nationwide, including Marquette University in my state of
Wisconsin. A year later, I successfully worked with President Clinton
to authorize the Direct Loan Program.
Over the years, there has been unanimous agreement about the
excessive costs of the FFEL program compared to the Direct Loan Program
when studied by the Congressional Budget Office (CBO), the U.S.
Government Accountability Office (GAO), and the Office of Management
and Budget (OMB) and the Treasury Department under both Presidents
Clinton and Bush. Most recently, the Congressional Budget Office
reported that a switch to all direct lending would save taxpayers $61
billion over ten years.
Besides being more expensive for the taxpayers, the FFEL program has
also been plagued by fraud and abuse which further illustrates the
drawbacks of this program for students and taxpayers. For instance,
last Congress it was found that from 2001 to 2006 nonprofit lenders
illegally claimed, according to one estimate, over $1 billion in
improper taxpayers subsidies by knowingly manipulating a loophole in
the law. And then there was the ``pay for play'' scandal in which it
was revealed that colleges and administrators received special favors,
benefits and kickbacks from lenders in exchange for steering students
to their loans.
The FFEL program has also been proven to be unreliable. In 2008,
because of the turmoil in the credit markets, Congress passed emergency
legislation to temporarily allow lenders access to Treasury funds so
they could continue to make loans. Between the Direct Loan Program and
an emergency program, the federal government now funds $8.80 of every
$10 in federal student lending activity. Over the past year, hundreds
of schools have switched to the Direct Loan Program. They report smooth
and easy transitions to the program and satisfaction with the service.
In fact, according to Student Lending Analytics, only two percent of
schools surveyed indicated they had not taken the steps necessary to
originate direct loans.
By moving to 100 percent direct lending we are not favoring
government over the private markets, there is no ``takeover'' here.
Eliminating guaranteed loans in favor of direct loans means replacing a
wasteful program with one that is more cost effective and in the
interests of students and taxpayers. So, while I must vote against this
bill due to the ill-conceived health care provisions, I strongly
support the switch to 100 percent direct lending.
Mr. HASTINGS of Florida. Mr. Speaker, we are on the brink of passing
a bill that will lay the foundation for comprehensive health care
reform. We have discussed and debated various aspects of this bill for
over a year. Now, it is time to act.
Developing and executing major reform efforts has never been easy or
pretty. Violent
[[Page H1915]]
and divisive debates waged when Congress was considering legislation
that instituted Medicare.
And yet, few would dispute that this program is essential to
delivering quality health care to some of our Nation's most vulnerable
communities--the elderly and disabled.
Like reform efforts of the past, the health care reform bill has been
met with blind criticisms and incessant fear mongering. Amazingly, some
of my colleagues talk about horrific scenarios that will result from
passing the bill and ignore the horrific conditions that people are
enduring right now. They don't speak for me. They don't speak for the
161,000 uninsured Floridians in my district, and they don't speak for
people who know that this bill is fiscally responsible and takes a
multifaceted approach to improving our health care system.
Every single day, people are forced to choose between paying their
mortgage or financing costly life-saving treatments. Every single day,
seniors are forced to choose between buying food or buying their
medication. Every single day, people are dying prematurely because they
don't have regular access to health care services. You can't tell me
that these people don't want or need health care reform.
Mr. Speaker, health care reform boils down to whether you believe
that 47 million uninsured Americans is an unfortunate but acceptable
fact, or an injustice that must be addressed.
Achieving comprehensive health care reform requires a uniquely
American approach that preserves what works and introduces new elements
that will allow us to meet 21st century needs and goals. This reform
bill does just that. I urge my colleagues to vote in support of this
historic bill and ensure that our fellow Americans have access to
affordable and high quality health care.
Mr. BACA. Mr. Speaker, I stand today in strong support of the health
care reform the American people so desperately need.
American families and small businesses--not insurance companies--
deserve control over their health care decisions.
The bill we are debating today will:
Lower insurance costs--and hold insurance companies accountable.
End denial of coverage for pre-existing conditions.
Provide coverage to 32 million uninsured Americans.
Close the Medicare Doughnut Hole--so seniors will be able to afford
the coverage they need.
Eliminate waste in our current system--and lower the deficit by $138
billion over 10 years; and $1.2 trillion over the next 20 years.
And allow young adults to stay on their parents' insurance coverage
until the age of 26.
Health care reform is an issue that affects every single American--
but is especially important to our Hispanic American community.
Forty-one percent of Hispanics over the age of 18 lack health
coverage. We must do better--and with this bill--we will.
Twenty-one percent of older Hispanics suffer from diabetes--compared
to only 14 percent of non-Hispanic whites.
The preventive care this bill provides will lower this disparity.
This truly is a historic time.
In 1935 we passed Social Security. In 1965, we passed Medicare.
Today--we pass a health care reform that will save millions of
lives--shrink our deficit, and put our nation on a path to prosperity.
We must move past the hate, the fear, and the lies that have
dominated this debate, and get the job done for the American people.
I urge my colleagues to vote for this bill and pass health care
reform that we need now and for generations to come.
Ms. BERKLEY. Mr. Speaker, I rise today in support of health care
reform.
While not perfect, this bill addresses key obstacles that continue to
plague the system. The cost of health care premiums is skyrocketing out
of control, creating an atmosphere where only insurance companies can
and will prosper and prevail. Without this reform, our individual
citizens and businesses will continue to be devastated by unsustainable
costs or barriers to coverage.
This bill would increase access for those who have been denied
insurance in the past, either because they can't afford it, have a pre-
existing condition, or have been dropped from coverage after getting
sick. It would provide financial assistance to working families to make
their health care costs affordable and it would provide businesses with
tax credits for providing health care for their employees.
In my district, this bill would extend coverage to 155,500 uninsured
residents, guarantee that 26,200 residents with pre-existing conditions
can obtain coverage, reduce the cost of uncompensated care for
hospitals and other health care providers by $74 million annually, and
allow 63,000 young adults to obtain coverage on their parents'
insurance plans.
I believe it is my duty to fight for the health, well-being and
protection of the citizens I represent. While this package does not
contain all the reforms needed, it provides a framework of very
positive first steps that will achieve a great deal for Nevada
families. There is no doubt that more must be done, but I believe this
is a step in the right direction. I urge my colleagues to vote yes on
this legislation.
Mr. PLATTS. Mr. Speaker, all members of Congress agree that the
status quo in health care is unacceptable and that we must act to make
affordable, quality health care accessible for all Americans. The
legislation before us today, however, is the wrong solution. Simply
put, it is bad public policy.
Throughout the debate on health care reform, I have emphasized that
Congress must be certain to adhere to the physician's principle of
``First, do no harm.'' Unfortunately, the Senate-passed health care
bill (H.R. 3590) and reconciliation legislation (H.R. 4278) that we are
considering today will do significant harm.
A primary focus of health care reform must be on bringing down the
rapidly rising cost of health care and health insurance. Instead, the
legislation before us today costs over $1 trillion in the first 10
years. When fully implemented, the proposed plan's costs will total
more than $200 billion per year. That's $2 trillion in additional
health care-related costs over the course of the plan's first full
decade of implementation. Once the budgetary gimmicks are stripped
away, the legislation before us will increase the overall budget
deficit dramatically.
According to the Congressional Budget Office (CBO), the proposed
legislation will do significant additional harm as well. CBO analysis
concludes that health insurance premiums in the individual market will
increase by 10-13%, Medicare will be cut by more than $500 billion,
taxes will increase by $579 billion, and millions of Americans will
ultimately be forced off private health insurance plans into
government-run plans.
Countless new taxes are included in the proposed health care
legislation. For example, new taxes would be imposed on: individuals
without health insurance; employers, whether they provide health
insurance for their employees or not; certain employer-provided health
insurance plans, more and more of them over time; medical devices, like
wheelchairs and walkers; investment income; Flexible Spending Accounts;
and health insurers and pharmaceutical companies, taxes that are likely
to be passed along to their customers.
The proposed legislation's cuts to Medicare will detrimentally impact
millions of senior citizens. For example, CBO estimates that, as
drafted, the cuts to Medicare Advantage funding will result in
approximately 4.8 million seniors losing access to such plans. Plans in
which they chose to enroll.
Mr. Speaker, the process by which we are considering these bills is
also wrong. Ordinarily, the reconciliation process is used to pass
legislation making changes in existing federal programs or taxes. The
reconciliation legislation under consideration today will make changes
to a health care bill that has yet to even be enacted. Importantly,
there is no guarantee that the reconciliation bill will be passed in
the Senate. This means that the House would be effectively trusting
that the Senate health care bill will be ``fixed'' by the
reconciliation process, even as the Senate health care bill is approved
by the House and becomes law.
The entire health care reform legislative process has been tainted by
proposals offered along the way to gain votes--like the infamous
``Cornhusker Kickback,'' as well as special provisions for other states
that have undermined confidence in the final product. Similarly, the
House leadership's initial plan of using a ``deem-and-pass''
legislative tactic--enacting the Senate bill into law without a
straight up-or-down vote--greatly diminished the American people's
trust in this legislation's provisions.
Rather than enacting the legislation before us today, Congress should
restart the process and enact common sense health care reforms that
have bipartisan support. Reforms such as small business health
insurance pools, medical malpractice liability reform, tax credits and
deductions for health care expenses, and insurance reforms addressing
the issues of pre-existing conditions and wrongful coverage termination
will better ensure access to affordable, quality health care for all
Americans, while also adhering to the physician's principle of ``First,
do no harm.''
Mr. COOPER. Mr. Speaker. I woke up this Sunday morning, said my
prayers, and finally decided that I will vote ``yes'' on health care
reform.
Having heard from tens of thousands of Middle Tennesseans on all
sides of the issue (including the flood of messages in the last few
days and hours), and having spent months studying the various bills, I
know that America must improve its health care system because it is
unsustainable. This legislation will make it better.
[[Page H1916]]
Any decision of this magnitude must be made very carefully, after
weighing every concern. We Nashvillians are proud of our outstanding
health care community that makes us ``the nation's health care industry
capital.'' Given our community's expertise, it is interesting to note
that:
Every Nashville hospital strongly supports the legislation, whether
it's St. Thomas, Vanderbilt (both University and Hospital), Centennial,
Meharry Medical School, Nashville General, Summit, Skyline, or Southern
Hills.
A majority of physicians who contacted me support the legislation
and, although the Tennessee Medical Association opposes it, the TMA's
national organization, the conservative American Medical Association,
supports it.
A majority of local nurses support the legislation, along with the
American Nurses Association.
Despite media controversy regarding abortion, the Catholic Health
Association, Catholics United, and groups representing 59,000 Catholic
Sisters support the legislation.
The largest Nashville and national senior organization, AARP,
supports the legislation.
It means a lot to me that so many local people who know so much about
health care agree with my decision.
Of course, there are plenty of people who disagree who are also very
knowledgeable about health care, and I have great respect for their
opinions. I've learned a lot from their views. Several of their
suggested improvements are already in the legislation. You may be
surprised that many of these critics want the legislation to do more,
not less. Having taught health policy at Vanderbilt's business school
for many years, I can easily point out many flaws in the legislation
myself, both substantive and procedural. I have been working hard in
Congress to eliminate those flaws. For example, yesterday we were able
to force a clear, up-or-down vote on today's legislation instead of
using the parliamentary maneuver that was favored by some in my own
party.
Let me make clear that I respect the advocacy of those who are
opposed to the legislation. They actually help me make sure that more
people in Congress do their homework and pay attention to America's
financial problems. They are strengthening our democracy with their
voices.
The bottom line is that this legislation offers the only realistic
hope that most Americans have for getting a fair deal in today's
private health insurance markets. This is not a government takeover of
those markets, but a way to encourage better private-market
competition. In the future, private insurance companies should compete
to keep us healthy, not drop us from coverage. Tens of millions of
Americans will benefit immediately from reform of these insurance
markets. Thousands of lives will literally be saved due to the greater
affordability of health insurance. This is as major a public health
accomplishment as reducing car wrecks or finding a cure for a dread
disease. One of the lives saved could be yours.
My health insurance is Tennessee Blue Cross/Blue Shield (just like I
had when I was a small businessman in Nashville) but, as a Congressman,
I am able to purchase it as part of a large pool, an exchange. I want
every American to have the same purchasing power. No matter what your
insurance company is, most Tennesseans are only one illness away, one
pink slip away, or one premium hike away from being mistreated by
current insurance practices: discrimination against pre-existing
conditions, arbitrary premium pricing, and last-minute rescission of
coverage when you need it most. This legislation will cover 32 million
hardworking, middle-class Americans who are left out in the cold by
today's insurance practices. Rival legislation only attempts to cover 3
million uninsured people, or less than 10% of the problem. America can,
and must, do better.
The financial issues involved are just as important as the coverage
issues, as I pointed out in my remarks at the President's bipartisan
summit on health care at Blair House in February. Will improved
coverage increase the deficit, either short-term or long-term? And will
this legislation start containing the explosion in health costs that
threaten our economy but do not improve our health?
Although CBO claims that the legislation will reduce deficits in the
first ten years by over $100 billion, and by over $1 trillion after
that, you don't have to believe CBO to realize that, even if you assume
zero deficit reduction, this is a huge improvement in the policymaking
of recent years. In plain English, this bill is paid for, and may even
save big money. Should these projections prove faulty, there are fail-
safe mechanisms within the legislation that, with public support,
should correct any budget problems. I proudly voted against the 2003
Medicare drug bill because it did not even attempt to pay for itself.
That one bill (which very few constituents complained about) added $600
billion to the short-term deficit and as much as $7.8 trillion in the
out years. Fiscal conservatives have much more reason to protest that
legislation than this.
There is a legitimate concern about whether the so-called ``doc fix''
should have been included in this legislation. It is not. That issue is
the result of the 1997 Balanced Budget Act formula that limits the
growth of physician reimbursement under Medicare. Since 1997, some
doctors have been able to increase their reimbursement more than
others, but all are now threatened with a 21 percent cut. This is a
$320 billion problem over the next 10 years, and a $4.2 trillion
problem in the out years. Unless this issue is resolved, it could have
more deficit impact than all of health reform. I think that we must
figure out a way to pay for the ``doc fix'' now, not add it to the
deficit. If you really care about the deficit, watch how your elected
officials vote on this key issue.
This legislation does not do enough to contain medical inflation, but
it makes a good start because it contains the largest proposed savings
in health costs in history, $600 billion over ten years. To make these
savings stick, we will all have to be vigilant because every health
care provider will immediately be asking for Congress to reduce or even
reverse those savings. For those who sincerely want Congress to have
more backbone on these issues, the answer is to support more savings
now by asking for tougher follow-on legislation. You won't achieve more
savings by encouraging Congress to slouch away from its
responsibilities today.
There are many talking heads on television who claim to want more
cuts, but their immediate plan is to do nothing. Today the official
Republican Party position is to scare seniors about Medicare and,
despite a blizzard of words, do nothing. They are behaving as badly as
the Democratic Party used to behave when scaring Social Security
recipients. If history is any guide, America only has the political
will to face up to these issues every 15 years, and, when we did
address them, Congress did not make much progress. Neither political
party will tell you that the real cost of delaying reform is roughly
$16 billion a day. That's my estimate, based on accrual accounting, of
the financial harm being done to America by a failure to resolve these
problems on a timely basis. Waiting too long to pass reform could be as
terrible a fiscal tragedy as waiting too long to treat cancer. Of
course, the pundits have no way of paying for the delay, and the fiscal
harm, that they foster. The opportunity cost of endless arguments may
even be greater than the cost of solving the problems themselves!
Opponents of today's reform also claim to have a better plan. I'd
love to see it. I am thoroughly familiar with their legislative ideas
because I have been working in a bipartisan way on these issues for
many years. They simply do not have a better plan today that could
garner more than a handful of votes, and, given their track record, are
not likely to ever present one. There is no magic wand. For example,
I've tried for many years to promote the bipartisan Healthy Americans
Act, H.R. 1321. We ended up with only a handful of cosponsors. Another
example is my friend Rep. Paul Ryan's (R-WI) interesting plan that has
made him the darling of The Wall Street Journal. His bill, H.R. 4529,
has exactly 13 cosponsors. You need at least 216 votes to get anything
accomplished. As intriguing as some of these ideas are, they are not a
solution, especially when the meter is ticking at about $16 billion a
day.
There is a lot of rhetoric about which political party is more
sincere about deficit reduction. The facts are that the last Democratic
president to have a balanced budget was Bill Clinton, just ten years
ago. The last Republican president to have a balanced budget was
Herbert Hoover, almost eighty years ago. Today's Congress has finally
passed into law important ``pay-as-you-go'' legislation that will force
Washington to start living within its means. Budget experts think that
this is the single most important step toward getting our fiscal house
in order. Blue Dog Democrats, of which I am a member, forced this
improvement in budgeting.
The President has created a bipartisan Fiscal Responsibility
Commission that will help Washington face up to its deficit problems.
The President is doing his best to implement my bipartisan legislation
on this issue, legislation that the Senate failed to pass because seven
Republican senators (who are original cosponsors) voted against their
own bill! None of these important steps toward fiscal sanity was
allowed under the previous Administration. In fact, the previous Vice
President, Dick Cheney, was famous for saying, ``Deficits don't
matter.'' He could not have been more mistaken.
Regardless of what happens to this legislation today, America cannot
afford to ignore the growing crisis in financing today's medical
system. In the future, we need to focus on these issues every year, not
every 15 years. Passage of this legislation is absolutely certain to do
that. Flaws will need to be corrected, adjustments made, new ideas
explored. I have a list ready. Just as continual advances in medicine
must be made, continual advancements
[[Page H1917]]
in delivery of medical care must be made. Both types of advancements
save lives. It is better when the private sector makes these
improvements but, when the private sector fails, then government should
help the private-sector, not run their businesses for them.
I am well aware of the fact that this is a big vote, and perhaps a
career-limiting decision. But I think most folks back home want me to
do what is right, not just what's temporarily popular. That's what my
90-year-old mother taught me. I've made tough votes before and been
proven right. Against united Republican opposition, I voted for the
1993 Clinton budget that put America on the path to the longest
economic recovery in history. Against united Republican leadership, I
voted against the 2003 Medicare drug bill that was the largest unfunded
expansion of entitlement programs in history. And against united
Republican opposition, I voted for the House health reform bill in
November of 2009 that enabled us to vote on the much better Senate
measure today.
I have the honor of representing the Hermitage District. Our greatest
hero, Andrew Jackson, said ``One man with courage is a majority.'' I
sure hope he was right.
Mr. TOWNS. Mr. Speaker, today the House of Representatives is
preparing to vote on historic health insurance reform legislation, H.R.
4872, the Health Care and Education Affordability Reconciliation Act.
We have spent more than a year debating this important bill that will
provide 32 million Americans health insurance. In my home district, New
York's 10th Congressional District, access to affordable health
insurance will make a tremendous difference in the lives of men and
women who have been burdened by the escalating costs of health care.
We can no longer wait to stem the rising tide of the uninsured and
underinsured, implement important reforms to prevent insurers from
discriminating against persons with pre-existing conditions and enact
important measures to rein in costs.
When this bill is signed into law, millions of Americans who do not
have health care today will finally walk the pathway to coverage.
American families will no longer face bankruptcy when a loved one gets
ill and seniors will finally get relief from the high cost of
prescription drugs due to our expanded coverage under Medicare Part D.
Importantly, we are doing all of this without adding one penny to the
federal deficit. In fact, this bill will reduce our federal debt by
$143 billion over the next ten years, and hundreds of billions more in
the years thereafter.
Health insurance reform is an issue I have been committed to
throughout my long congressional career. We have been close to this day
before, but this time, at long last, I am confident we will see this
legislation signed into law.
Mr. Speaker, I thank my colleagues who supported this bill.
Mr. ACKERMAN. Mr. Speaker, I rise on this historic day in strong
support of the Health Care and Education Affordability Reconciliation
Act of 2010, H.R. 4872.
Let me be perfectly clear: all Americans should have access to
affordable and quality health-care coverage. For too long, drastically
needed health-insurance reform has been delayed. I'm proud that the
overdue reform of our health-care insurance system has finally begun.
Many of us, including Members of Congress, enjoy excellent health-care
coverage. But far too many people have inadequate coverage, including
over 70,000 of my constituents who are completely uninsured. And for
those of us with coverage, the status quo is unsustainable and costly:
Without health insurance reform, the insurance premium for an average
family is expected to rise from $13,000 today to $24,000 in less than a
decade. Mr. Speaker, my constituents want reduced costs, more choices
and expanded coverage.
I support this landmark legislation because it changes the way that
insurance companies currently ration medical care: The legislation we
are about to pass would require all plans to eliminate coverage denials
because of pre-existing conditions, eliminate dropping coverage when
individuals become sick, eliminate annual and lifetime caps on how much
can be spent on care, and eliminate exorbitant out-of-pocket expenses.
Opponents of this bill would rather have the big health-insurance
companies dictate the rules. But I think all Americans deserve these
basic protections from their health-insurance plans, and these
important guarantees will improve the coverage for nearly all those who
already have insurance--even those Americans who are extremely
satisfied with their current plans.
The Act starts with what works well in today's health care system and
fixes the parts that are broken. No one has to give up the health care
they enjoy today--everyone can keep their current health plan, doctors
and hospitals. New state marketplaces called exchanges will allow
uninsured individuals to shop among a large number of private plans
with a core set of benefits. For the first time ever, American
families--even those who keep their current health insurance--will
benefit from no longer having to worry about losing health coverage
because of a new or lost job. The bill finally brings the type of
health insurance reform that Americans need and deserve.
Many opposed to comprehensive health insurance claim there are no
immediate benefits to these bills; that somehow nothing happens until
the exchanges are set up. Mr. Speaker, here are just some of the
immediate benefits that take effect this very year: small businesses
will receive tax credits for offering health insurance to their
employees; seniors who fall within the infamous Medicare prescription-
drug donut hole will receive a $250 rebate; people who have been denied
health-care coverage because of a pre-existing condition will be able
to get affordable coverage through temporary high-risk pools; children
will no longer be callously denied coverage because of a pre-existing
condition; annual limits and lifetime limits on the cost of care will
start to be prohibited; and also this year, insurance companies will no
longer be able to take away an individual's coverage because they get
sick.
Mr. Speaker, unfortunately, the previous Administration and the
former leadership of the House of Representatives never acknowledged
the moral or economic costs we pay every day for our failure to make
health coverage affordable and accessible for everyone. Today, that
ends. Today we recognize that more people with good coverage saves
lives and saves costs. Today we unequivocally state that people should
not have to go bankrupt to pay their medical bills. And today we
finally realize that no one should have to go to an emergency room just
to receive routine medical care. I am proud to be voting today to make
sure that health-care insurance reform is putting these essential
principles into action.
So, Mr. Speaker, I urge all my colleagues to support the Health Care
and Education Affordability Reconciliation Act of 2010, H.R. 4872 so
that all Americans will have access to health care.
Mr. ANDREWS. Mr. Speaker, I rise today in support of millions of
individuals throughout our country who are working for small businesses
which are in PEO arrangements. The clear objective of this legislation
is to create incentives for health care coverage and not to provide
disincentives. I would like to clarify that for purposes of the
application of section 2716 of the Public Health Service Act
(Prohibition on Discrimination in Favor of Highly Compensated
Individuals) and Internal Revenue Code section 45R (Credit for Employee
Health Insurance Expenses of Small Businesses), to any health plans
sponsored by a professional employer organization (PEO) or a PEO client
organization, the rules would be applied to each client organization
separately and eligibility for the small business tax credits would
also apply to each client organization separately, and not at the PEO
level.
Mr. KIRK. Mr. Speaker, I rise today in opposition to H.R. 3590, the
Senate Health Care bill. I strongly support reforms to lower the cost
of health insurance and cover Americans with pre-existing conditions.
That is why I authored the Medical Rights and Reform Act, H.R. 3790.
Under our centrist Reform Act, we cover Americans with pre-existing
conditions and advance three major reforms:
(1) The Medical Rights Act: Under our bill, Congress shall make no
law interfering with the personal decisions that you make with your
doctor,
(2) Lawsuit Reform: By applying the lawsuit reforms (recently
eliminated in Illinois) similar to successful California reforms, we
could reduce defensive medicine, saving over $200 billion annually, and
(3) Granting Americans Interstate Rights: Our bill grants the right
to all Americans to buy health coverage from any state in the union,
especially if you find a plan that is less expensive or more flexible
for your family or small business. This improves choice and competition
for each American.
Unfortunately, the Congressional leadership will not permit a debate
on our bill. Instead, the House will only allow one vote on the health
care bill adopted by the Senate.
Under the Senate bill, the Congress will increase spending by $1.2
trillion, including $940 billion for new subsidies, $144 billion for
new mandates, $70 billion to administer the bill and $41 billion in
unrelated spending. To attempt to pay for the bill, Congress will raise
taxes, cut Medicare and borrow a historic amount of money. To pass the
Senate, the bill also included the ``Louisiana Purchase'', ``Cornhusker
Kickback'' and ``Gatoraide'' that advantaged Louisiana, Nebraska and
Florida over the people of Illinois.
The bill imposes 12 new federal taxes, imposing over $500 billion in
new payments to the government, including over $23 billion in taxes on
the people of Illinois. Among the new taxes is a new ``Individual
Mandate Tax'' (IMT) of $2,250 per household or 2 percent of
[[Page H1918]]
household income. The bill increases the Medicare payroll tax and does
not adjust this for inflation. Therefore, like the infamous Alternative
Minimum Tax (AMT), the new Medicare tax will soon reach most middle
class families as inflation pushes more Americans into its bracket.
The bill also increases the capital gains tax. Most economists worry
that too many businesses plan for the short-term, hurting long-term
economic growth. That is why investments which are held for longer
periods of time pay a lower capital gains tax. The Senate bill reverses
this wise policy by imposing a new 3.8 percent tax on capital gains,
raising the rate from 15 percent to 23.8 percent by 2013.
Both Americans for Tax Reform and the Heritage Foundation estimated
that the new taxes and Medicare cuts in the bill would cost over
600,000 job opportunities per year or an estimated 26,042 fewer
Illinois jobs. The bill also has a number of budget gimmicks to hide
spending. Once the Social Security Trust Fund, long-term health care
and student loan gimmicks are removed, the bill adds $755 billion to
the federal deficit or $2,460 in new debt for each man, woman, and
child.
Here is a look at the estimated national job losses under the bill:
------------------------------------------------------------------------
Sector Jobs
------------------------------------------------------------------------
Agriculture, forestry, fishing and hunting.................. -5,441
Mining...................................................... -5,478
Construction................................................ -43,316
Manufacturing............................................... -105,229
Wholesale trade............................................. -47,663
Retail trade................................................ -84,339
Transportation and warehousing.............................. -36,806
Utilities................................................... -5,271
Information................................................. -26,342
Financial Activities........................................ -77,269
Professional and business services.......................... -132,596
Educational services........................................ -32,102
Leisure and hospitality..................................... -49,682
Other services.............................................. -46,564
------------------------------------------------------------------------
Total................................................... -698,098
------------------------------------------------------------------------
Half of all people employed in Illinois work in a small business and
over 80 percent of job losses during this Great Recession have been
from small business employers. Nevertheless, this legislation requires
the federal government to levy a new $52 billion tax on small
businesses, even though unemployment now tops 12 percent in Illinois.
The bill begins a new $2,000 tax on small business with over 50
employees. Over 21,600 small businesses in Illinois could be subject to
this new tax. This tax applies to part-time as well as full-time
workers. The follow-up Reconciliation Bill also includes an
unprecedented extension of the Medicare tax to all non-wage income.
The legislation stands for the principle that we should cut senior
health care under Medicare to fund a new entitlement spending program.
Over 40 million seniors depend on Medicare for their health care. Under
the Senate bill, the federal government would cut over $500 billion
from Medicare. This includes cutting over $200 billion from Medicare
Advantage, cancelling the Medicare choice of over 120,000 Illinois
seniors.
Here is a summary of the Medicare cuts:
------------------------------------------------------------------------
------------------------------------------------------------------------
Medicare Advantage........................ $202 billion.
Home Health............................... 39 billion.
Medicare Part B........................... 25 billion.
Hospital DSH Payments..................... 25 billion.
Medicare Part D........................... 10 billion.
Medical Imaging........................... 1 billion.
Preventative Services..................... 700 million.
Durable Medical Equipment................. 1 billion.
Power-Driven Wheelchairs.................. 800 million.
Hospice................................... 100 million.
Medicare Improvement Fund................. 20 billion.
Medigap................................... 100 million.
------------------------------------------------------------------------
Total................................. $523 billion.
------------------------------------------------------------------------
While the American people overwhelmingly want to lower health
insurance costs, the bill increases costs because it requires Americans
to buy health insurance that include new mandates for coverage.
According to the Administration, individual insurance premiums will
increase by 10 percent for over 600,000 people in Illinois. On average,
Illinois individuals currently pay $2,499 annually for insurance. Under
the bill, costs will go up at least $150 a month to a level of $4,299
annually.
On March 4, the Chicago Tribune reported that for ``more than half-
million consumers in individual health plans, base rates will go up
from 8.5 percent to more than 60 percent.'' The non-partisan
Congressional Budget Office reported that the bill's provisions that
double the tax on health insurers, drug makers and medical devices will
all be passed on to patients in the form of higher health costs and
rising insurance premiums.
Under the federal Medicaid program for the poor, states must pay half
of all costs. As you know, the State of Illinois has one of the highest
deficits of any state, totaling over $12 billion. Spending on the
Illinois Medicaid program rose 65 percent from $8 billion in 2001 to
$13 billion in 2008 to now cover 2.4 million people. Under the Senate
Health Care bill, Illinois would have to cover an additional 400,000
people, adding an additional $1 billion to the state's deficit over
five years.
Health care under Medicaid is already deteriorating. Over 9,000
doctors in Illinois refuse to accept Medicaid patients (28 percent
nationwide), in part because it takes Illinois over 100 days to pay for
services.
About the only jobs created by the legislation would be at the IRS.
According to the nonpartisan Congressional Budget Office, the IRS would
need to hire over 16,000 people--over 700 just in Illinois--to audit
the American people and impose the new taxes and mandates of the bill.
New IRS agents would verify if you have acceptable authority, fine you
up to 2 percent of your income for failure to prove that you have
purchased ``minimum essential coverage,'' confiscate your tax refund
and conduct audits. Under the bill, nearly half of the new individual
mandate taxes will be paid by Americans earning less than $66,150 for a
family of four.
I will vote against this legislation because it costs Illinois jobs,
raises taxes and deepens the debt our children must one day pay. I wish
that we could adopt a more modest set of reforms that do not have such
harsh consequences for our economy.
In the coming days, I will outline policies and legislation that will
reduce spending, lower the debt and prevent new taxes on the American
people. While we did not prevail in this contest, I will continue to
work and ensure a strong economy and bright future for every Illinois
citizen.
Mr. GRIJALVA. Mr. Speaker, after a long battle for this Nation's
health care reform, my decision to vote in favor of this bill was
ultimately made, not by myself, but by the people I represent.
This bill is a beginning to the end of an abusive system:
It is a beginning to provide the people of our great Nation access
the most basic health care services;
It is a beginning to stop insurance companies from reaping benefits
at the cost of the sick, injured, poor and dying people in our Nation;
It is a beginning to making our health care system one that we can be
proud of--
One that includes everyone regardless of their social status;
One that treats people equal regardless of their age, race or gender;
One that makes sure our children are treated properly and that our
parents will be provided for in the future; and
It finally provides reauthorization of Indian Health Care.
Every day I am flooded by groups, businesses and individuals that can
no longer bear the abuses from our current health care system. I want
to share of few of their reasons for supporting this bill:
The National Committee to Preserve Social Security and Medicare
states:
The bill preserves and improves Medicare for current and
future beneficiaries. Because of our strong commitment to
Medicare, we support the health reform currently before
Congress. Indeed, we consider it to be vital for preserving
and protecting Medicare. On behalf of the seniors you
represent, we ask that you commit to supporting health reform
as well.
Catholic Sisters for Healthcare Reform states:
We have witnessed firsthand the impact of our national
health care crisis, particularly its impact on women,
children and people who are poor. We see the toll on families
who have delayed seeking care due to a lack of health
insurance coverage or lack of funds with which to pay high
deductibles and co-pays. We have counseled and prayed with
men, women and children who have been denied health care
coverage by insurance companies. We have witnessed early and
avoidable deaths because of delayed medical treatment.
American Nurses Association states:
We understand the cost of inaction--our patients can no
longer afford to wait. The uninsured and underinsured
continue to delay or forgo much-needed care; they continue to
arrive in the emergency rooms across the country for
conditions that could have been easily prevented with access
to primary care--we are all paying a high price for inaction.
My dear friend, Karen, from the National Breast Cancer Coalition came
to me and poured her heart out on behalf of the millions of women
battling cancer, this vote is for you. The National Breast Cancer
Coalition states:
For women who are battling breast cancer, health care
reform will mean accessing potentially life-saving treatment
and not losing their health insurance coverage if they lose
their job. For their families, it means not being driven into
bankruptcy when the person they love has been diagnosed with
breast cancer, must contend with a recurrence of the disease,
or struggle with equally life threatening complications. For
the tens of thousands of women who will be diagnosed with
breast cancer today and in the future, enacting health care
reform will mean being able to focus their energy on battling
the disease, not fighting with their insurance company. We
cannot delay any longer.
United States Hispanic Chamber of Commerce states:
[[Page H1919]]
As business owners, we know well the concept of opportunity
cost. The rate of premium growth has become such a burden to
our businesses that we are required to support this
compromise rather than see premiums double, or triple, once
again as they have done this decade. As organizations that
believe in free market solutions, this decision was not taken
lightly. But, the fact remains that the small business
components in this compromise bill will provide real relief--
a small business exchange that pools risk while respecting
the free market and tax credits to incentivize those
businesses that are just within reach of providing health
care to their workers.
While these groups and the American people understand this bill is
the beginning of reforming our system, I can assure you it is not the
end.
I will continue to fight for a public entity to be part of our
system.
I will continue to fight for immigrants to be treated fairly in our
Nation, and I will argue the grave economic impacts of leaving these
people out of our system.
I will continue to fight for stricter control of the pharmaceutical
companies to force them to negotiate prices instead of dictating them.
And above all I will not stop, I will continue to push to make our
system more efficient and more equitable--this is only the beginning.
I would like to end with a quote from my dear friend that we lost
during the mist of this battle, who I feel has been our guiding light.
Ted Kennedy said:
The battle to achieve Medicare for All will not be easy.
Powerful interests will strongly oppose it, because they
profit immensely from the status quo. Right wing forces will
unleash false attack ads ranting against socialized medicine
and government-run health care.
Ted--we will not give up--this is the beginning.
Mr. FRELINGHUYSEN. Mr. Speaker, at the outset, let me be very clear:
I support health care reform. I just do not support Speaker Nancy
Pelosi's version of health care reform.
With respect to controlling costs for New Jersey's families, changing
insurance company practices and making coverage more available to more
Americans, the status quo is simply unacceptable. We can, and we must,
do better, but not at the expense of millions of American families who
are worried about a government takeover of their health care decisions!
With that said, the health care package before the House today is
wrong on both process and policy.
On process, the American people know instinctively that a change as
historic as this will only be successful with full engagement of the
American people and bipartisan support in Congress. However, from the
beginning, Speaker Nancy Pelosi and Senate Majority Leader Harry Reid
adopted a `go-it-alone' strategy and refused to consider Republican
ideas in any significant way. Indeed, the Majority today is even
refusing to listen to the very valid concerns of the American people.
In addition, this legislation, and all the versions that preceded it,
were drafted behind closed doors at the White House or in Capitol
backrooms, with no transparency whatsoever as to which organizations
were participating and benefitting! In fact, the Majority had to be
`shamed' into releasing the contents of the bill 72 hours before a vote
to allow Republicans and the American people to review its contents.
To add insult to injury, the President and Speaker Pelosi decided to
use the budget 'reconciliation' process solely to deny the Senate
Minority the ability to use its traditional practice of the filibuster
to block passage of harmful legislation such as this.
Madame Speaker, the process the Majority has used is shameful, but
the policy they seek to impose is downright harmful.
Once again, I state without hesitation that I support health reform.
However, I cannot support this proposal.
First, this package contains over $523 billion in job-killing, higher
taxes. I cannot think of a worse time to tax families and small
businessmen and women than in the middle of a serious recession.
The American people need to understand the destructive nature of this
bill: $17 billion in new taxes on Americans who do not obey the bill's
requirement that individuals must buy health insurance whether they
want to or not, and $52 billion in new taxes on employers that do not
provide health coverage deemed ``acceptable'' or ``affordable'' by
Washington-based government bureaucrats. This provision alone may force
the IRS to hire another 16,000 agents and auditors to enforce
compliance with the new law.
In addition, the bill contains new taxes on capital gains, dividends
and interest that will further stifle economic growth and job creation.
The Medicare tax on capital gains, dividends, and other investment
income gets bigger, magnifying the destructive power of the tax. The
bill increases the tax from 2.9 percent to 3.8 percent and for the
first time, this tax will be extended beyond wages to include interest,
dividends, capital gains, annuities, royalties, home sales and rents.
This new tax will be particularly damaging to New Jersey's seniors,
many of whom depend on such income to survive.
Second, this package contains over $569 billion in total cuts to
Medicare.
These reductions include $202.3 billion from seniors' Medicare health
plans, including massive cuts targeting the extra benefits and reduced
cost-sharing seniors receive through Medicare Advantage. 148,000
seniors in New Jersey, including over 35,000 in my Congressional
District enjoy the benefits of this innovative program. The
Congressional Budget Office predicts that three million seniors
nationwide currently receiving health benefits through these Medicare
plans will be dropped.
But the Medicare cuts go deeper. The bill slashes $156 billion from
hospitals, including long-term care hospitals, skilled nursing
facilities, Ambulatory Surgical Centers, hospice, ambulances, dialysis
facilities, labs and durable medical equipment (DME) suppliers.
The package also contains $40 billion in cuts to home health
reimbursements and $22 billion in additional cuts to hospitals by
slashing reimbursements designed to assist hospitals that serve low-
income patients. In addition, $65.7 billion in money will be taken from
seniors in the form of higher premiums.
My colleagues, I am also shocked that the Majority has not protected
our men and women in uniform, military retirees and veterans who could
be affected by the new law. The Senate-passed health care bill omitted
protections for military health plans that were included in the House
bill.
Specifically, the Senate language does not appear to give the
Department of Veterans' Affairs (VA) health care system specific
protection from interference by other government agencies administering
the various authorities contained in the massive bill, as it pertains
to ``minimum essential coverage.''
Further, the final bills would leave it up to bureaucrats at the
Department of the Treasury to determine whether TRICARE meets the
minimum standards under the bill's individual health insurance mandate.
If that bureaucrat decides against TRICARE, service members and their
families would have to buy some other health coverage or pay a penalty.
Our men and women in uniform, and our veterans, have earned the best
health care available. They need to know that they will continue to
receive this same level of care. It is truly regrettable that, in a
bill stuffed with `backroom' deals and special `arrangements', this
group of American heroes is denied the consideration they earn on the
battlefield each and every day.
Mr. Speaker, this bill is also notable for what it does not contain.
There is no medical lawsuit reform. It fails to promote portability of
coverage. It does not allow insurance companies to sell their policies
across state lines. It fails to recognize the value of Association
Health Plans, which permit small businesses to pool their risk in order
to secure lower insurance rates. The bill does not expand Health
Savings Accounts which millions of families use to provide protection
against catastrophic illness or injury. The package also does very
little to enhance medical training for doctors, nurses and technicians.
If we are going to expand coverage for tens of millions of Americans,
we need to increase graduation rates in these critical medical
professions.
I would also add that this bill completely ignores the ongoing crisis
in Medicare reimbursement rates for doctors. My colleagues, the
question is not whether you can choose your doctor under the Pelosi
health care proposal, but whether your doctor will choose you! Many
doctors in New Jersey are already questioning their participation in
the Medicare program, putting in greater jeopardy our seniors' access
to care. Does the Majority actually believe that the pending 22-percent
reimbursement reduction will not cause more doctors to `opt out' of
Medicare?
Mr. Speaker, I end this statement where I started: I support health
care reform. The status quo is unacceptable and I would welcome the
opportunity to work with anyone who will work with me to draft and pass
single, individual bills that promote portability of coverage, allow
individuals to buy health care across state lines, cover people with
preexisting conditions, improve access to Health Savings Accounts, and
enact `junk lawsuit' reform, among other actions to bring down the cost
of coverage for New Jersey families and businesses.
We can do better than this process and this package. America's future
economic and security freedoms depend on it.
Mr. TAYLOR. Mr. Speaker, I voted against H.R. 3962, the Affordable
Health Care for America Act, on November 7, 2009 and I will continue to
oppose this legislation in the House. The House passed the bill by a
vote of 220-215. During House consideration, I voted for the Stupak
amendment, which prohibits federal funds from paying for abortions
[[Page H1920]]
or from subsidizing health insurance plans that would cover abortions.
The House passed the Stupak amendment by a vote of 240-194.
Taxpayers cannot afford a new federal health insurance program. The
government already provides Medicare, Medicaid, and other programs to
provide medical care for senior citizens, people with disabilities, and
others who have substantial medical needs. Our nation also has an
obligation to provide medical coverage for veterans, active-duty
military and their dependents, National Guard and Reserve personnel,
and military retirees. With the national debt in excess of $12 trillion
and projected to grow far into the future, I believe that Congress
should focus on fulfilling the promises that have already been made
rather than make new promises that we cannot afford.
There are several ways to make health care more efficient without
increasing costs and without creating a whole new government program.
I strongly support efforts to allow the government to use their
purchasing power to negotiate directly with drug manufacturers when
buying prescription drugs for beneficiaries enrolled in the Medicare
Part D Program. Negotiating prices with insurance companies would help
to ensure that taxpayers are paying the best available price and that
tax dollars are spent wisely without reducing coverage or affecting the
individuals enrolled in Medicare Part D. In 2008, the government spent
about $49 billion on Medicare Part D drugs. If the government could
save even 10% by negotiating directly with drug companies, taxpayers
would save nearly $4.9 billion.
The government should purchase generic drugs instead of more
expensive alternatives, unless the prescribing physician says that a
name brand drug is medically necessary. On average, generic drugs cost
1/10th of the cost of their name brand equivalent.
I am a cosponsor of H.R. 1583, legislation to repeal the insurance
industry's antitrust exemption. The health care bill that passed the
House included a repeal of antitrust laws only for the health care
industry. While this is important, I firmly believe that repealing
antitrust laws from the entire insurance industry would force insurers
to compete with one another in a competitive market on the basis of
price, service, and value. I strongly supported the bill that passed in
the House which repealed the exemption of antitrust laws for the health
care insurance industry.
I am also in favor of proposals that would allow individuals to
continue to be covered under their parents' insurance plan until they
reach the age of 27.
I would like to remind you that I do not support creating a whole new
health care program, but I do support smaller reforms to make the
current system more effective for taxpayers and consumers. Again, I
voted against the health care bill that passed the House, and I will
oppose this bill.
Mr. MORAN of Virginia. Mr. Speaker, today we will define who we are--
as Americans, and as Democrats or Republicans.
No Republican will vote for this bill because they say they want a
smaller government, lower taxes, and less spending.
Democrats, on the other hand, believe that America's government can
be fiscally responsible and also play an essential role in helping
America achieve its true greatness.
We know that America is a lesser Nation when we have to pay twice
what other countries citizens' pay for health care, while we live
shorter and less healthy lives; We are a lesser nation when millions of
America's families lose their homes and life savings because a loved
one gets seriously sick.
We know that we can reduce the suffering of our people, while
lengthening and bettering their lives. And because we know this, we
have a responsibility to change it.
As with Social Security and Medicare and Civil Rights legislation, it
is now time for another step in our historic progress toward greatness.
That's why we chose public service and why we, as Democrats, will pass
this bill today.
The SPEAKER pro tempore. Under the rule, all time for debate has
expired.
Mr. SPRATT. Mr. Speaker, pursuant to House Resolution 1203, I call up
the bill (H.R. 3590) to amend the Internal Revenue Code of 1986 to
modify the first-time homebuyers credit in the case of members of the
Armed Forces and certain other Federal employees, and for other
purposes, with the Senate amendments thereto, and I have a motion at
the desk.
The Clerk read the title of the bill.
The SPEAKER pro tempore. The Clerk will designate the Senate
amendments.
The text of the Senate amendments is as follows:
Senate amendments:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Patient
Protection and Affordable Care Act''.
(b) Table of Contents.--The table of contents of this Act
is as follows:
Sec. 1. Short title; table of contents.
TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
Subtitle A--Immediate Improvements in Health Care Coverage for All
Americans
Sec. 1001. Amendments to the Public Health Service Act.
``PART A--Individual and Group Market Reforms
``subpart ii--improving coverage
``Sec. 2711. No lifetime or annual limits.
``Sec. 2712. Prohibition on rescissions.
``Sec. 2713. Coverage of preventive health services.
``Sec. 2714. Extension of dependent coverage.
``Sec. 2715. Development and utilization of uniform explanation of
coverage documents and standardized definitions.
``Sec. 2716. Prohibition of discrimination based on salary.
``Sec. 2717. Ensuring the quality of care.
``Sec. 2718. Bringing down the cost of health care coverage.
``Sec. 2719. Appeals process.
Sec. 1002. Health insurance consumer information.
Sec. 1003. Ensuring that consumers get value for their dollars.
Sec. 1004. Effective dates.
Subtitle B--Immediate Actions to Preserve and Expand Coverage
Sec. 1101. Immediate access to insurance for uninsured individuals with
a preexisting condition.
Sec. 1102. Reinsurance for early retirees.
Sec. 1103. Immediate information that allows consumers to identify
affordable coverage options.
Sec. 1104. Administrative simplification.
Sec. 1105. Effective date.
Subtitle C--Quality Health Insurance Coverage for All Americans
PART I--Health Insurance Market Reforms
Sec. 1201. Amendment to the Public Health Service Act.
``subpart i--general reform
``Sec. 2704. Prohibition of preexisting condition exclusions or other
discrimination based on health status.
``Sec. 2701. Fair health insurance premiums.
``Sec. 2702. Guaranteed availability of coverage.
``Sec. 2703. Guaranteed renewability of coverage.
``Sec. 2705. Prohibiting discrimination against individual participants
and beneficiaries based on health status.
``Sec. 2706. Non-discrimination in health care.
``Sec. 2707. Comprehensive health insurance coverage.
``Sec. 2708. Prohibition on excessive waiting periods.
PART II--Other Provisions
Sec. 1251. Preservation of right to maintain existing coverage.
Sec. 1252. Rating reforms must apply uniformly to all health insurance
issuers and group health plans.
Sec. 1253. Effective dates.
Subtitle D--Available Coverage Choices for All Americans
PART I--Establishment of Qualified Health Plans
Sec. 1301. Qualified health plan defined.
Sec. 1302. Essential health benefits requirements.
Sec. 1303. Special rules.
Sec. 1304. Related definitions.
PART II--Consumer Choices and Insurance Competition Through Health
Benefit Exchanges
Sec. 1311. Affordable choices of health benefit plans.
Sec. 1312. Consumer choice.
Sec. 1313. Financial integrity.
PART III--State Flexibility Relating to Exchanges
Sec. 1321. State flexibility in operation and enforcement of Exchanges
and related requirements.
Sec. 1322. Federal program to assist establishment and operation of
nonprofit, member-run health insurance issuers.
Sec. 1323. Community health insurance option.
Sec. 1324. Level playing field.
PART IV--State Flexibility to Establish Alternative Programs
Sec. 1331. State flexibility to establish basic health programs for
low-income individuals not eligible for Medicaid.
Sec. 1332. Waiver for State innovation.
Sec. 1333. Provisions relating to offering of plans in more than one
State.
PART V--Reinsurance and Risk Adjustment
Sec. 1341. Transitional reinsurance program for individual and small
group markets in each State.
Sec. 1342. Establishment of risk corridors for plans in individual and
small group markets.
Sec. 1343. Risk adjustment.
[[Page H1921]]
Subtitle E--Affordable Coverage Choices for All Americans
PART I--Premium Tax Credits and Cost-sharing Reductions
subpart a--premium tax credits and cost-sharing reductions
Sec. 1401. Refundable tax credit providing premium assistance for
coverage under a qualified health plan.
Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified
health plans.
subpart b--eligibility determinations
Sec. 1411. Procedures for determining eligibility for Exchange
participation, premium tax credits and reduced cost-
sharing, and individual responsibility exemptions.
Sec. 1412. Advance determination and payment of premium tax credits and
cost-sharing reductions.
Sec. 1413. Streamlining of procedures for enrollment through an
exchange and State Medicaid, CHIP, and health subsidy
programs.
Sec. 1414. Disclosures to carry out eligibility requirements for
certain programs.
Sec. 1415. Premium tax credit and cost-sharing reduction payments
disregarded for Federal and Federally-assisted programs.
PART II--Small Business Tax Credit
Sec. 1421. Credit for employee health insurance expenses of small
businesses.
Subtitle F--Shared Responsibility for Health Care
PART I--Individual Responsibility
Sec. 1501. Requirement to maintain minimum essential coverage.
Sec. 1502. Reporting of health insurance coverage.
PART II--Employer Responsibilities
Sec. 1511. Automatic enrollment for employees of large employers.
Sec. 1512. Employer requirement to inform employees of coverage
options.
Sec. 1513. Shared responsibility for employers.
Sec. 1514. Reporting of employer health insurance coverage.
Sec. 1515. Offering of Exchange-participating qualified health plans
through cafeteria plans.
Subtitle G--Miscellaneous Provisions
Sec. 1551. Definitions.
Sec. 1552. Transparency in government.
Sec. 1553. Prohibition against discrimination on assisted suicide.
Sec. 1554. Access to therapies.
Sec. 1555. Freedom not to participate in Federal health insurance
programs.
Sec. 1556. Equity for certain eligible survivors.
Sec. 1557. Nondiscrimination.
Sec. 1558. Protections for employees.
Sec. 1559. Oversight.
Sec. 1560. Rules of construction.
Sec. 1561. Health information technology enrollment standards and
protocols.
Sec. 1562. Conforming amendments.
Sec. 1563. Sense of the Senate promoting fiscal responsibility.
TITLE II--ROLE OF PUBLIC PROGRAMS
Subtitle A--Improved Access to Medicaid
Sec. 2001. Medicaid coverage for the lowest income populations.
Sec. 2002. Income eligibility for nonelderly determined using modified
gross income.
Sec. 2003. Requirement to offer premium assistance for employer-
sponsored insurance.
Sec. 2004. Medicaid coverage for former foster care children.
Sec. 2005. Payments to territories.
Sec. 2006. Special adjustment to FMAP determination for certain States
recovering from a major disaster.
Sec. 2007. Medicaid Improvement Fund rescission.
Subtitle B--Enhanced Support for the Children's Health Insurance
Program
Sec. 2101. Additional federal financial participation for CHIP.
Sec. 2102. Technical corrections.
Subtitle C--Medicaid and CHIP Enrollment Simplification
Sec. 2201. Enrollment Simplification and coordination with State Health
Insurance Exchanges.
Sec. 2202. Permitting hospitals to make presumptive eligibility
determinations for all Medicaid eligible populations.
Subtitle D--Improvements to Medicaid Services
Sec. 2301. Coverage for freestanding birth center services.
Sec. 2302. Concurrent care for children.
Sec. 2303. State eligibility option for family planning services.
Sec. 2304. Clarification of definition of medical assistance.
Subtitle E--New Options for States to Provide Long-Term Services and
Supports
Sec. 2401. Community First Choice Option.
Sec. 2402. Removal of barriers to providing home and community-based
services.
Sec. 2403. Money Follows the Person Rebalancing Demonstration.
Sec. 2404. Protection for recipients of home and community-based
services against spousal impoverishment.
Sec. 2405. Funding to expand State Aging and Disability Resource
Centers.
Sec. 2406. Sense of the Senate regarding long-term care.
Subtitle F--Medicaid Prescription Drug Coverage
Sec. 2501. Prescription drug rebates.
Sec. 2502. Elimination of exclusion of coverage of certain drugs.
Sec. 2503. Providing adequate pharmacy reimbursement.
Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments
Sec. 2551. Disproportionate share hospital payments.
Subtitle H--Improved Coordination for Dual Eligible Beneficiaries
Sec. 2601. 5-year period for demonstration projects.
Sec. 2602. Providing Federal coverage and payment coordination for dual
eligible beneficiaries.
Subtitle I--Improving the Quality of Medicaid for Patients and
Providers
Sec. 2701. Adult health quality measures.
Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions.
Sec. 2703. State option to provide health homes for enrollees with
chronic conditions.
Sec. 2704. Demonstration project to evaluate integrated care around a
hospitalization.
Sec. 2705. Medicaid Global Payment System Demonstration Project.
Sec. 2706. Pediatric Accountable Care Organization Demonstration
Project.
Sec. 2707. Medicaid emergency psychiatric demonstration project.
Subtitle J--Improvements to the Medicaid and CHIP Payment and Access
Commission (MACPAC)
Sec. 2801. MACPAC assessment of policies affecting all Medicaid
beneficiaries.
Subtitle K--Protections for American Indians and Alaska Natives
Sec. 2901. Special rules relating to Indians.
Sec. 2902. Elimination of sunset for reimbursement for all medicare
part B services furnished by certain indian hospitals and
clinics.
Subtitle L--Maternal and Child Health Services
Sec. 2951. Maternal, infant, and early childhood home visiting
programs.
Sec. 2952. Support, education, and research for postpartum depression.
Sec. 2953. Personal responsibility education.
Sec. 2954. Restoration of funding for abstinence education.
Sec. 2955. Inclusion of information about the importance of having a
health care power of attorney in transition planning for
children aging out of foster care and independent living
programs.
TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE
Subtitle A--Transforming the Health Care Delivery System
PART I--Linking Payment to Quality Outcomes Under the Medicare Program
Sec. 3001. Hospital Value-Based purchasing program.
Sec. 3002. Improvements to the physician quality reporting system.
Sec. 3003. Improvements to the physician feedback program.
Sec. 3004. Quality reporting for long-term care hospitals, inpatient
rehabilitation hospitals, and hospice programs.
Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.
Sec. 3006. Plans for a Value-Based purchasing program for skilled
nursing facilities and home health agencies.
Sec. 3007. Value-based payment modifier under the physician fee
schedule.
Sec. 3008. Payment adjustment for conditions acquired in hospitals.
PART II--National Strategy to Improve Health Care Quality
Sec. 3011. National strategy.
Sec. 3012. Interagency Working Group on Health Care Quality.
Sec. 3013. Quality measure development.
Sec. 3014. Quality measurement.
Sec. 3015. Data collection; public reporting.
PART III--Encouraging Development of New Patient Care Models
Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation
within CMS.
Sec. 3022. Medicare shared savings program.
Sec. 3023. National pilot program on payment bundling.
Sec. 3024. Independence at home demonstration program.
Sec. 3025. Hospital readmissions reduction program.
Sec. 3026. Community-Based Care Transitions Program.
Sec. 3027. Extension of gainsharing demonstration.
Subtitle B--Improving Medicare for Patients and Providers
PART I--Ensuring Beneficiary Access to Physician Care and Other
Services
Sec. 3101. Increase in the physician payment update.
Sec. 3102. Extension of the work geographic index floor and revisions
to the practice expense geographic adjustment under the
Medicare physician fee schedule.
Sec. 3103. Extension of exceptions process for Medicare therapy caps.
Sec. 3104. Extension of payment for technical component of certain
physician pathology services.
Sec. 3105. Extension of ambulance add-ons.
[[Page H1922]]
Sec. 3106. Extension of certain payment rules for long-term care
hospital services and of moratorium on the establishment
of certain hospitals and facilities.
Sec. 3107. Extension of physician fee schedule mental health add-on.
Sec. 3108. Permitting physician assistants to order post-Hospital
extended care services.
Sec. 3109. Exemption of certain pharmacies from accreditation
requirements.
Sec. 3110. Part B special enrollment period for disabled TRICARE
beneficiaries.
Sec. 3111. Payment for bone density tests.
Sec. 3112. Revision to the Medicare Improvement Fund.
Sec. 3113. Treatment of certain complex diagnostic laboratory tests.
Sec. 3114. Improved access for certified nurse-midwife services.
PART II--Rural Protections
Sec. 3121. Extension of outpatient hold harmless provision.
Sec. 3122. Extension of Medicare reasonable costs payments for certain
clinical diagnostic laboratory tests furnished to
hospital patients in certain rural areas.
Sec. 3123. Extension of the Rural Community Hospital Demonstration
Program.
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 3125. Temporary improvements to the Medicare inpatient hospital
payment adjustment for low-volume hospitals.
Sec. 3126. Improvements to the demonstration project on community
health integration models in certain rural counties.
Sec. 3127. MedPAC study on adequacy of Medicare payments for health
care providers serving in rural areas.
Sec. 3128. Technical correction related to critical access hospital
services.
Sec. 3129. Extension of and revisions to Medicare rural hospital
flexibility program.
PART III--Improving Payment Accuracy
Sec. 3131. Payment adjustments for home health care.
Sec. 3132. Hospice reform.
Sec. 3133. Improvement to medicare disproportionate share hospital
(DSH) payments.
Sec. 3134. Misvalued codes under the physician fee schedule.
Sec. 3135. Modification of equipment utilization factor for advanced
imaging services.
Sec. 3136. Revision of payment for power-driven wheelchairs.
Sec. 3137. Hospital wage index improvement.
Sec. 3138. Treatment of certain cancer hospitals.
Sec. 3139. Payment for biosimilar biological products.
Sec. 3140. Medicare hospice concurrent care demonstration program.
Sec. 3141. Application of budget neutrality on a national basis in the
calculation of the Medicare hospital wage index floor.
Sec. 3142. HHS study on urban Medicare-dependent hospitals.
Sec. 3143. Protecting home health benefits.
Subtitle C--Provisions Relating to Part C
Sec. 3201. Medicare Advantage payment.
Sec. 3202. Benefit protection and simplification.
Sec. 3203. Application of coding intensity adjustment during MA payment
transition.
Sec. 3204. Simplification of annual beneficiary election periods.
Sec. 3205. Extension for specialized MA plans for special needs
individuals.
Sec. 3206. Extension of reasonable cost contracts.
Sec. 3207. Technical correction to MA private fee-for-service plans.
Sec. 3208. Making senior housing facility demonstration permanent.
Sec. 3209. Authority to deny plan bids.
Sec. 3210. Development of new standards for certain Medigap plans.
Subtitle D--Medicare Part D Improvements for Prescription Drug Plans
and MA-PD Plans
Sec. 3301. Medicare coverage gap discount program.
Sec. 3302. Improvement in determination of Medicare part D low-income
benchmark premium.
Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals
under prescription drug plans and MA-PD plans.
Sec. 3304. Special rule for widows and widowers regarding eligibility
for low-income assistance.
Sec. 3305. Improved information for subsidy eligible individuals
reassigned to prescription drug plans and MA-PD plans.
Sec. 3306. Funding outreach and assistance for low-income programs.
Sec. 3307. Improving formulary requirements for prescription drug plans
and MA-PD plans with respect to certain categories or
classes of drugs.
Sec. 3308. Reducing part D premium subsidy for high-income
beneficiaries.
Sec. 3309. Elimination of cost sharing for certain dual eligible
individuals.
Sec. 3310. Reducing wasteful dispensing of outpatient prescription
drugs in long-term care facilities under prescription
drug plans and MA-PD plans.
Sec. 3311. Improved Medicare prescription drug plan and MA-PD plan
complaint system.
Sec. 3312. Uniform exceptions and appeals process for prescription drug
plans and MA-PD plans.
Sec. 3313. Office of the Inspector General studies and reports.
Sec. 3314. Including costs incurred by AIDS drug assistance programs
and Indian Health Service in providing prescription drugs
toward the annual out-of-pocket threshold under part D.
Sec. 3315. Immediate reduction in coverage gap in 2010.
Subtitle E--Ensuring Medicare Sustainability
Sec. 3401. Revision of certain market basket updates and incorporation
of productivity improvements into market basket updates
that do not already incorporate such improvements.
Sec. 3402. Temporary adjustment to the calculation of part B premiums.
Sec. 3403. Independent Medicare Advisory Board.
Subtitle F--Health Care Quality Improvements
Sec. 3501. Health care delivery system research; Quality improvement
technical assistance.
Sec. 3502. Establishing community health teams to support the patient-
centered medical home.
Sec. 3503. Medication management services in treatment of chronic
disease.
Sec. 3504. Design and implementation of regionalized systems for
emergency care.
Sec. 3505. Trauma care centers and service availability.
Sec. 3506. Program to facilitate shared decisionmaking.
Sec. 3507. Presentation of prescription drug benefit and risk
information.
Sec. 3508. Demonstration program to integrate quality improvement and
patient safety training into clinical education of health
professionals.
Sec. 3509. Improving women's health.
Sec. 3510. Patient navigator program.
Sec. 3511. Authorization of appropriations.
Subtitle G--Protecting and Improving Guaranteed Medicare Benefits
Sec. 3601. Protecting and improving guaranteed Medicare benefits.
Sec. 3602. No cuts in guaranteed benefits.
TITLE IV--PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH
Subtitle A--Modernizing Disease Prevention and Public Health Systems
Sec. 4001. National Prevention, Health Promotion and Public Health
Council.
Sec. 4002. Prevention and Public Health Fund.
Sec. 4003. Clinical and community preventive services.
Sec. 4004. Education and outreach campaign regarding preventive
benefits.
Subtitle B--Increasing Access to Clinical Preventive Services
Sec. 4101. School-based health centers.
Sec. 4102. Oral healthcare prevention activities.
Sec. 4103. Medicare coverage of annual wellness visit providing a
personalized prevention plan.
Sec. 4104. Removal of barriers to preventive services in Medicare.
Sec. 4105. Evidence-based coverage of preventive services in Medicare.
Sec. 4106. Improving access to preventive services for eligible adults
in Medicaid.
Sec. 4107. Coverage of comprehensive tobacco cessation services for
pregnant women in Medicaid.
Sec. 4108. Incentives for prevention of chronic diseases in medicaid.
Subtitle C--Creating Healthier Communities
Sec. 4201. Community transformation grants.
Sec. 4202. Healthy aging, living well; evaluation of community-based
prevention and wellness programs for Medicare
beneficiaries.
Sec. 4203. Removing barriers and improving access to wellness for
individuals with disabilities.
Sec. 4204. Immunizations.
Sec. 4205. Nutrition labeling of standard menu items at chain
restaurants.
Sec. 4206. Demonstration project concerning individualized wellness
plan.
Sec. 4207. Reasonable break time for nursing mothers.
Subtitle D--Support for Prevention and Public Health Innovation
Sec. 4301. Research on optimizing the delivery of public health
services.
Sec. 4302. Understanding health disparities: data collection and
analysis.
Sec. 4303. CDC and employer-based wellness programs.
Sec. 4304. Epidemiology-Laboratory Capacity Grants.
Sec. 4305. Advancing research and treatment for pain care management.
Sec. 4306. Funding for Childhood Obesity Demonstration Project.
Subtitle E--Miscellaneous Provisions
Sec. 4401. Sense of the Senate concerning CBO scoring.
Sec. 4402. Effectiveness of Federal health and wellness initiatives.
TITLE V--HEALTH CARE WORKFORCE
Subtitle A--Purpose and Definitions
Sec. 5001. Purpose.
Sec. 5002. Definitions.
Subtitle B--Innovations in the Health Care Workforce
Sec. 5101. National health care workforce commission.
[[Page H1923]]
Sec. 5102. State health care workforce development grants.
Sec. 5103. Health care workforce assessment.
Subtitle C--Increasing the Supply of the Health Care Workforce
Sec. 5201. Federally supported student loan funds.
Sec. 5202. Nursing student loan program.
Sec. 5203. Health care workforce loan repayment programs.
Sec. 5204. Public health workforce recruitment and retention programs.
Sec. 5205. Allied health workforce recruitment and retention programs.
Sec. 5206. Grants for State and local programs.
Sec. 5207. Funding for National Health Service Corps.
Sec. 5208. Nurse-managed health clinics.
Sec. 5209. Elimination of cap on commissioned corps.
Sec. 5210. Establishing a Ready Reserve Corps.
Subtitle D--Enhancing Health Care Workforce Education and Training
Sec. 5301. Training in family medicine, general internal medicine,
general pediatrics, and physician assistantship.
Sec. 5302. Training opportunities for direct care workers.
Sec. 5303. Training in general, pediatric, and public health dentistry.
Sec. 5304. Alternative dental health care providers demonstration
project.
Sec. 5305. Geriatric education and training; career awards;
comprehensive geriatric education.
Sec. 5306. Mental and behavioral health education and training grants.
Sec. 5307. Cultural competency, prevention, and public health and
individuals with disabilities training.
Sec. 5308. Advanced nursing education grants.
Sec. 5309. Nurse education, practice, and retention grants.
Sec. 5310. Loan repayment and scholarship program.
Sec. 5311. Nurse faculty loan program.
Sec. 5312. Authorization of appropriations for parts B through D of
title VIII.
Sec. 5313. Grants to promote the community health workforce.
Sec. 5314. Fellowship training in public health.
Sec. 5315. United States Public Health Sciences Track.
Subtitle E--Supporting the Existing Health Care Workforce
Sec. 5401. Centers of excellence.
Sec. 5402. Health care professionals training for diversity.
Sec. 5403. Interdisciplinary, community-based linkages.
Sec. 5404. Workforce diversity grants.
Sec. 5405. Primary care extension program.
Subtitle F--Strengthening Primary Care and Other Workforce Improvements
Sec. 5501. Expanding access to primary care services and general
surgery services.
Sec. 5502. Medicare Federally qualified health center improvements.
Sec. 5503. Distribution of additional residency positions.
Sec. 5504. Counting resident time in nonprovider settings.
Sec. 5505. Rules for counting resident time for didactic and scholarly
activities and other activities.
Sec. 5506. Preservation of resident cap positions from closed
hospitals.
Sec. 5507. Demonstration projects To address health professions
workforce needs; extension of family-to-family health
information centers.
Sec. 5508. Increasing teaching capacity.
Sec. 5509. Graduate nurse education demonstration.
Subtitle G--Improving Access to Health Care Services
Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs).
Sec. 5602. Negotiated rulemaking for development of methodology and
criteria for designating medically underserved
populations and health professions shortage areas.
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services
for Children Program.
Sec. 5604. Co-locating primary and specialty care in community-based
mental health settings.
Sec. 5605. Key National indicators.
Subtitle H--General Provisions
Sec. 5701. Reports.
TITLE VI--TRANSPARENCY AND PROGRAM INTEGRITY
Subtitle A--Physician Ownership and Other Transparency
Sec. 6001. Limitation on Medicare exception to the prohibition on
certain physician referrals for hospitals.
Sec. 6002. Transparency reports and reporting of physician ownership or
investment interests.
Sec. 6003. Disclosure requirements for in-office ancillary services
exception to the prohibition on physician self-referral
for certain imaging services.
Sec. 6004. Prescription drug sample transparency.
Sec. 6005. Pharmacy benefit managers transparency requirements.
Subtitle B--Nursing Home Transparency and Improvement
PART I--Improving Transparency of Information
Sec. 6101. Required disclosure of ownership and additional disclosable
parties information.
Sec. 6102. Accountability requirements for skilled nursing facilities
and nursing facilities.
Sec. 6103. Nursing home compare Medicare website.
Sec. 6104. Reporting of expenditures.
Sec. 6105. Standardized complaint form.
Sec. 6106. Ensuring staffing accountability.
Sec. 6107. GAO study and report on Five-Star Quality Rating System.
PART II--Targeting Enforcement
Sec. 6111. Civil money penalties.
Sec. 6112. National independent monitor demonstration project.
Sec. 6113. Notification of facility closure.
Sec. 6114. National demonstration projects on culture change and use of
information technology in nursing homes.
PART III--Improving Staff Training
Sec. 6121. Dementia and abuse prevention training.
Subtitle C--Nationwide Program for National and State Background Checks
on Direct Patient Access Employees of Long-term Care Facilities and
Providers
Sec. 6201. Nationwide program for National and State background checks
on direct patient access employees of long-term care
facilities and providers.
Subtitle D--Patient-Centered Outcomes Research
Sec. 6301. Patient-Centered Outcomes Research.
Sec. 6302. Federal coordinating council for comparative effectiveness
research.
Subtitle E--Medicare, Medicaid, and CHIP Program Integrity Provisions
Sec. 6401. Provider screening and other enrollment requirements under
Medicare, Medicaid, and CHIP.
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions.
Sec. 6403. Elimination of duplication between the Healthcare Integrity
and Protection Data Bank and the National Practitioner
Data Bank.
Sec. 6404. Maximum period for submission of Medicare claims reduced to
not more than 12 months.
Sec. 6405. Physicians who order items or services required to be
Medicare enrolled physicians or eligible professionals.
Sec. 6406. Requirement for physicians to provide documentation on
referrals to programs at high risk of waste and abuse.
Sec. 6407. Face to face encounter with patient required before
physicians may certify eligibility for home health
services or durable medical equipment under Medicare.
Sec. 6408. Enhanced penalties.
Sec. 6409. Medicare self-referral disclosure protocol.
Sec. 6410. Adjustments to the Medicare durable medical equipment,
prosthetics, orthotics, and supplies competitive
acquisition program.
Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program.
Subtitle F--Additional Medicaid Program Integrity Provisions
Sec. 6501. Termination of provider participation under Medicaid if
terminated under Medicare or other State plan.
Sec. 6502. Medicaid exclusion from participation relating to certain
ownership, control, and management affiliations.
Sec. 6503. Billing agents, clearinghouses, or other alternate payees
required to register under Medicaid.
Sec. 6504. Requirement to report expanded set of data elements under
MMIS to detect fraud and abuse.
Sec. 6505. Prohibition on payments to institutions or entities located
outside of the United States.
Sec. 6506. Overpayments.
Sec. 6507. Mandatory State use of national correct coding initiative.
Sec. 6508. General effective date.
Subtitle G--Additional Program Integrity Provisions
Sec. 6601. Prohibition on false statements and representations.
Sec. 6602. Clarifying definition.
Sec. 6603. Development of model uniform report form.
Sec. 6604. Applicability of State law to combat fraud and abuse.
Sec. 6605. Enabling the Department of Labor to issue administrative
summary cease and desist orders and summary seizures
orders against plans that are in financially hazardous
condition.
Sec. 6606. MEWA plan registration with Department of Labor.
Sec. 6607. Permitting evidentiary privilege and confidential
communications.
Subtitle H--Elder Justice Act
Sec. 6701. Short title of subtitle.
Sec. 6702. Definitions.
Sec. 6703. Elder Justice.
Subtitle I--Sense of the Senate Regarding Medical Malpractice
Sec. 6801. Sense of the Senate regarding medical malpractice.
TITLE VII--IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES
Subtitle A--Biologics Price Competition and Innovation
Sec. 7001. Short title.
Sec. 7002. Approval pathway for biosimilar biological products.
Sec. 7003. Savings.
Subtitle B--More Affordable Medicines for Children and Underserved
Communities
Sec. 7101. Expanded participation in 340B program.
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Sec. 7102. Improvements to 340B program integrity.
Sec. 7103. GAO study to make recommendations on improving the 340B
program.
TITLE VIII--CLASS ACT
Sec. 8001. Short title of title.
Sec. 8002. Establishment of national voluntary insurance program for
purchasing community living assistance services and
support.
TITLE IX--REVENUE PROVISIONS
Subtitle A--Revenue Offset Provisions
Sec. 9001. Excise tax on high cost employer-sponsored health coverage.
Sec. 9002. Inclusion of cost of employer-sponsored health coverage on
W-2.
Sec. 9003. Distributions for medicine qualified only if for prescribed
drug or insulin.
Sec. 9004. Increase in additional tax on distributions from HSAs and
Archer MSAs not used for qualified medical expenses.
Sec. 9005. Limitation on health flexible spending arrangements under
cafeteria plans.
Sec. 9006. Expansion of information reporting requirements.
Sec. 9007. Additional requirements for charitable hospitals.
Sec. 9008. Imposition of annual fee on branded prescription
pharmaceutical manufacturers and importers.
Sec. 9009. Imposition of annual fee on medical device manufacturers and
importers.
Sec. 9010. Imposition of annual fee on health insurance providers.
Sec. 9011. Study and report of effect on veterans health care.
Sec. 9012. Elimination of deduction for expenses allocable to Medicare
Part D subsidy.
Sec. 9013. Modification of itemized deduction for medical expenses.
Sec. 9014. Limitation on excessive remuneration paid by certain health
insurance providers.
Sec. 9015. Additional hospital insurance tax on high-income taxpayers.
Sec. 9016. Modification of section 833 treatment of certain health
organizations.
Sec. 9017. Excise tax on elective cosmetic medical procedures.
Subtitle B--Other Provisions
Sec. 9021. Exclusion of health benefits provided by Indian tribal
governments.
Sec. 9022. Establishment of simple cafeteria plans for small
businesses.
Sec. 9023. Qualifying therapeutic discovery project credit.
TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL
AMERICANS
Subtitle A--Provisions Relating to Title I
Sec. 10101. Amendments to subtitle A.
Sec. 10102. Amendments to subtitle B.
Sec. 10103. Amendments to subtitle C.
Sec. 10104. Amendments to subtitle D.
Sec. 10105. Amendments to subtitle E.
Sec. 10106. Amendments to subtitle F.
Sec. 10107. Amendments to subtitle G.
Sec. 10108. Free choice vouchers.
Sec. 10109. Development of standards for financial and administrative
transactions.
Subtitle B--Provisions Relating to Title II
PART I--Medicaid and CHIP
Sec. 10201. Amendments to the Social Security Act and title II of this
Act.
Sec. 10202. Incentives for States to offer home and community-based
services as a long-term care alternative to nursing
homes.
Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and
other CHIP-related provisions.
PART II--Support for Pregnant and Parenting Teens and Women
Sec. 10211. Definitions.
Sec. 10212. Establishment of pregnancy assistance fund.
Sec. 10213. Permissible uses of Fund.
Sec. 10214. Appropriations.
PART III--Indian Health Care Improvement
Sec. 10221. Indian health care improvement.
Subtitle C--Provisions Relating to Title III
Sec. 10301. Plans for a Value-Based purchasing program for ambulatory
surgical centers.
Sec. 10302. Revision to national strategy for quality improvement in
health care.
Sec. 10303. Development of outcome measures.
Sec. 10304. Selection of efficiency measures.
Sec. 10305. Data collection; public reporting.
Sec. 10306. Improvements under the Center for Medicare and Medicaid
Innovation.
Sec. 10307. Improvements to the Medicare shared savings program.
Sec. 10308. Revisions to national pilot program on payment bundling.
Sec. 10309. Revisions to hospital readmissions reduction program.
Sec. 10310. Repeal of physician payment update.
Sec. 10311. Revisions to extension of ambulance add-ons.
Sec. 10312. Certain payment rules for long-term care hospital services
and moratorium on the establishment of certain hospitals
and facilities.
Sec. 10313. Revisions to the extension for the rural community hospital
demonstration program.
Sec. 10314. Adjustment to low-volume hospital provision.
Sec. 10315. Revisions to home health care provisions.
Sec. 10316. Medicare DSH.
Sec. 10317. Revisions to extension of section 508 hospital provisions.
Sec. 10318. Revisions to transitional extra benefits under Medicare
Advantage.
Sec. 10319. Revisions to market basket adjustments.
Sec. 10320. Expansion of the scope of, and additional improvements to,
the Independent Medicare Advisory Board.
Sec. 10321. Revision to community health teams.
Sec. 10322. Quality reporting for psychiatric hospitals.
Sec. 10323. Medicare coverage for individuals exposed to environmental
health hazards.
Sec. 10324. Protections for frontier States.
Sec. 10325. Revision to skilled nursing facility prospective payment
system.
Sec. 10326. Pilot testing pay-for-performance programs for certain
Medicare providers.
Sec. 10327. Improvements to the physician quality reporting system.
Sec. 10328. Improvement in part D medication therapy management (MTM)
programs.
Sec. 10329. Developing methodology to assess health plan value.
Sec. 10330. Modernizing computer and data systems of the Centers for
Medicare & Medicaid services to support improvements in
care delivery.
Sec. 10331. Public reporting of performance information.
Sec. 10332. Availability of medicare data for performance measurement.
Sec. 10333. Community-based collaborative care networks.
Sec. 10334. Minority health.
Sec. 10335. Technical correction to the hospital value-based purchasing
program.
Sec. 10336. GAO study and report on Medicare beneficiary access to
high-quality dialysis services.
Subtitle D--Provisions Relating to Title IV
Sec. 10401. Amendments to subtitle A.
Sec. 10402. Amendments to subtitle B.
Sec. 10403. Amendments to subtitle C.
Sec. 10404. Amendments to subtitle D.
Sec. 10405. Amendments to subtitle E.
Sec. 10406. Amendment relating to waiving coinsurance for preventive
services.
Sec. 10407. Better diabetes care.
Sec. 10408. Grants for small businesses to provide comprehensive
workplace wellness programs.
Sec. 10409. Cures Acceleration Network.
Sec. 10410. Centers of Excellence for Depression.
Sec. 10411. Programs relating to congenital heart disease.
Sec. 10412. Automated Defibrillation in Adam's Memory Act.
Sec. 10413. Young women's breast health awareness and support of young
women diagnosed with breast cancer.
Subtitle E--Provisions Relating to Title V
Sec. 10501. Amendments to the Public Health Service Act, the Social
Security Act, and title V of this Act.
Sec. 10502. Infrastructure to Expand Access to Care.
Sec. 10503. Community Health Centers and the National Health Service
Corps Fund.
Sec. 10504. Demonstration project to provide access to affordable care.
Subtitle F--Provisions Relating to Title VI
Sec. 10601. Revisions to limitation on medicare exception to the
prohibition on certain physician referrals for hospitals.
Sec. 10602. Clarifications to patient-centered outcomes research.
Sec. 10603. Striking provisions relating to individual provider
application fees.
Sec. 10604. Technical correction to section 6405.
Sec. 10605. Certain other providers permitted to conduct face to face
encounter for home health services.
Sec. 10606. Health care fraud enforcement.
Sec. 10607. State demonstration programs to evaluate alternatives to
current medical tort litigation.
Sec. 10608. Extension of medical malpractice coverage to free clinics.
Sec. 10609. Labeling changes.
Subtitle G--Provisions Relating to Title VIII
Sec. 10801. Provisions relating to title VIII.
Subtitle H--Provisions Relating to Title IX
Sec. 10901. Modifications to excise tax on high cost employer-sponsored
health coverage.
Sec. 10902. Inflation adjustment of limitation on health flexible
spending arrangements under cafeteria plans.
Sec. 10903. Modification of limitation on charges by charitable
hospitals.
Sec. 10904. Modification of annual fee on medical device manufacturers
and importers.
Sec. 10905. Modification of annual fee on health insurance providers.
Sec. 10906. Modifications to additional hospital insurance tax on high-
income taxpayers.
Sec. 10907. Excise tax on indoor tanning services in lieu of elective
cosmetic medical procedures.
Sec. 10908. Exclusion for assistance provided to participants in State
student loan repayment programs for certain health
professionals.
[[Page H1925]]
Sec. 10909. Expansion of adoption credit and adoption assistance
programs.
TITLE I--QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
Subtitle A--Immediate Improvements in Health Care Coverage for All
Americans
SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
Part A of title XXVII of the Public Health Service Act (42
U.S.C. 300gg et seq.) is amended--
(1) by striking the part heading and inserting the
following:
``PART A--INDIVIDUAL AND GROUP MARKET REFORMS'';
(2) by redesignating sections 2704 through 2707 as sections
2725 through 2728, respectively;
(3) by redesignating sections 2711 through 2713 as sections
2731 through 2733, respectively;
(4) by redesignating sections 2721 through 2723 as sections
2735 through 2737, respectively; and
(5) by inserting after section 2702, the following:
``Subpart II--Improving Coverage
``SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.
``(a) In General.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage may not establish--
``(1) lifetime limits on the dollar value of benefits for
any participant or beneficiary; or
``(2) unreasonable annual limits (within the meaning of
section 223 of the Internal Revenue Code of 1986) on the
dollar value of benefits for any participant or beneficiary.
``(b) Per Beneficiary Limits.--Subsection (a) shall not be
construed to prevent a group health plan or health insurance
coverage that is not required to provide essential health
benefits under section 1302(b) of the Patient Protection and
Affordable Care Act from placing annual or lifetime per
beneficiary limits on specific covered benefits to the extent
that such limits are otherwise permitted under Federal or
State law.
``SEC. 2712. PROHIBITION ON RESCISSIONS.
``A group health plan and a health insurance issuer
offering group or individual health insurance coverage shall
not rescind such plan or coverage with respect to an enrollee
once the enrollee is covered under such plan or coverage
involved, except that this section shall not apply to a
covered individual who has performed an act or practice that
constitutes fraud or makes an intentional misrepresentation
of material fact as prohibited by the terms of the plan or
coverage. Such plan or coverage may not be cancelled except
with prior notice to the enrollee, and only as permitted
under section 2702(c) or 2742(b).
``SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.
``(a) In General.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage shall, at a minimum provide coverage for
and shall not impose any cost sharing requirements for--
``(1) evidence-based items or services that have in effect
a rating of `A' or `B' in the current recommendations of the
United States Preventive Services Task Force;
``(2) immunizations that have in effect a recommendation
from the Advisory Committee on Immunization Practices of the
Centers for Disease Control and Prevention with respect to
the individual involved;
``(3) with respect to infants, children, and adolescents,
evidence-informed preventive care and screenings provided for
in the comprehensive guidelines supported by the Health
Resources and Services Administration;
``(4) with respect to women, such additional preventive
care and screenings not described in paragraph (1) as
provided for in comprehensive guidelines supported by the
Health Resources and Services Administration for purposes of
this paragraph; and
``(5) for the purposes of this Act, and for the purposes of
any other provision of law, the current recommendations of
the United States Preventive Service Task Force regarding
breast cancer screening, mammography, and prevention shall be
considered the most current other than those issued in or
around November 2009.
Nothing in this subsection shall be construed to prohibit a
plan or issuer from providing coverage for services in
addition to those recommended by United States Preventive
Services Task Force or to deny coverage for services that are
not recommended by such Task Force.
``(b) Interval.--
``(1) In general.--The Secretary shall establish a minimum
interval between the date on which a recommendation described
in subsection (a)(1) or (a)(2) or a guideline under
subsection (a)(3) is issued and the plan year with respect to
which the requirement described in subsection (a) is
effective with respect to the service described in such
recommendation or guideline.
``(2) Minimum.--The interval described in paragraph (1)
shall not be less than 1 year.
``(c) Value-Based Insurance Design.--The Secretary may
develop guidelines to permit a group health plan and a health
insurance issuer offering group or individual health
insurance coverage to utilize value-based insurance designs.
``SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.
``(a) In General.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage that provides dependent coverage of
children shall continue to make such coverage available for
an adult child (who is not married) until the child turns 26
years of age. Nothing in this section shall require a health
plan or a health insurance issuer described in the preceding
sentence to make coverage available for a child of a child
receiving dependent coverage.
``(b) Regulations.--The Secretary shall promulgate
regulations to define the dependents to which coverage shall
be made available under subsection (a).
``(c) Rule of Construction.--Nothing in this section shall
be construed to modify the definition of `dependent' as used
in the Internal Revenue Code of 1986 with respect to the tax
treatment of the cost of coverage.
``SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM
EXPLANATION OF COVERAGE DOCUMENTS AND
STANDARDIZED DEFINITIONS.
``(a) In General.--Not later than 12 months after the date
of enactment of the Patient Protection and Affordable Care
Act, the Secretary shall develop standards for use by a group
health plan and a health insurance issuer offering group or
individual health insurance coverage, in compiling and
providing to enrollees a summary of benefits and coverage
explanation that accurately describes the benefits and
coverage under the applicable plan or coverage. In developing
such standards, the Secretary shall consult with the National
Association of Insurance Commissioners (referred to in this
section as the `NAIC'), a working group composed of
representatives of health insurance-related consumer advocacy
organizations, health insurance issuers, health care
professionals, patient advocates including those representing
individuals with limited English proficiency, and other
qualified individuals.
``(b) Requirements.--The standards for the summary of
benefits and coverage developed under subsection (a) shall
provide for the following:
``(1) Appearance.--The standards shall ensure that the
summary of benefits and coverage is presented in a uniform
format that does not exceed 4 pages in length and does not
include print smaller than 12-point font.
``(2) Language.--The standards shall ensure that the
summary is presented in a culturally and linguistically
appropriate manner and utilizes terminology understandable by
the average plan enrollee.
``(3) Contents.--The standards shall ensure that the
summary of benefits and coverage includes--
``(A) uniform definitions of standard insurance terms and
medical terms (consistent with subsection (g)) so that
consumers may compare health insurance coverage and
understand the terms of coverage (or exception to such
coverage);
``(B) a description of the coverage, including cost sharing
for--
``(i) each of the categories of the essential health
benefits described in subparagraphs (A) through (J) of
section 1302(b)(1) of the Patient Protection and Affordable
Care Act; and
``(ii) other benefits, as identified by the Secretary;
``(C) the exceptions, reductions, and limitations on
coverage;
``(D) the cost-sharing provisions, including deductible,
coinsurance, and co-payment obligations;
``(E) the renewability and continuation of coverage
provisions;
``(F) a coverage facts label that includes examples to
illustrate common benefits scenarios, including pregnancy and
serious or chronic medical conditions and related cost
sharing, such scenarios to be based on recognized clinical
practice guidelines;
``(G) a statement of whether the plan or coverage--
``(i) provides minimum essential coverage (as defined under
section 5000A(f) of the Internal Revenue Code 1986); and
``(ii) ensures that the plan or coverage share of the total
allowed costs of benefits provided under the plan or coverage
is not less than 60 percent of such costs;
``(H) a statement that the outline is a summary of the
policy or certificate and that the coverage document itself
should be consulted to determine the governing contractual
provisions; and
``(I) a contact number for the consumer to call with
additional questions and an Internet web address where a copy
of the actual individual coverage policy or group certificate
of coverage can be reviewed and obtained.
``(c) Periodic Review and Updating.--The Secretary shall
periodically review and update, as appropriate, the standards
developed under this section.
``(d) Requirement To Provide.--
``(1) In general.--Not later than 24 months after the date
of enactment of the Patient Protection and Affordable Care
Act, each entity described in paragraph (3) shall provide,
prior to any enrollment restriction, a summary of benefits
and coverage explanation pursuant to the standards
developed by the Secretary under subsection (a) to--
``(A) an applicant at the time of application;
``(B) an enrollee prior to the time of enrollment or
reenrollment, as applicable; and
``(C) a policyholder or certificate holder at the time of
issuance of the policy or delivery of the certificate.
``(2) Compliance.--An entity described in paragraph (3) is
deemed to be in compliance with this section if the summary
of benefits and coverage described in subsection (a) is
provided in paper or electronic form.
``(3) Entities in general.--An entity described in this
paragraph is--
``(A) a health insurance issuer (including a group health
plan that is not a self-insured plan) offering health
insurance coverage within the United States; or
``(B) in the case of a self-insured group health plan, the
plan sponsor or designated administrator of the plan (as such
terms are defined in section 3(16) of the Employee Retirement
Income Security Act of 1974).
``(4) Notice of modifications.--If a group health plan or
health insurance issuer makes
[[Page H1926]]
any material modification in any of the terms of the plan or
coverage involved (as defined for purposes of section 102 of
the Employee Retirement Income Security Act of 1974) that is
not reflected in the most recently provided summary of
benefits and coverage, the plan or issuer shall provide
notice of such modification to enrollees not later than 60
days prior to the date on which such modification will become
effective.
``(e) Preemption.--The standards developed under subsection
(a) shall preempt any related State standards that require a
summary of benefits and coverage that provides less
information to consumers than that required to be provided
under this section, as determined by the Secretary.
``(f) Failure To Provide.--An entity described in
subsection (d)(3) that willfully fails to provide the
information required under this section shall be subject to a
fine of not more than $1,000 for each such failure. Such
failure with respect to each enrollee shall constitute a
separate offense for purposes of this subsection.
``(g) Development of Standard Definitions.--
``(1) In general.--The Secretary shall, by regulation,
provide for the development of standards for the definitions
of terms used in health insurance coverage, including the
insurance-related terms described in paragraph (2) and the
medical terms described in paragraph (3).
``(2) Insurance-related terms.--The insurance-related terms
described in this paragraph are premium, deductible, co-
insurance, co-payment, out-of-pocket limit, preferred
provider, non-preferred provider, out-of-network co-payments,
UCR (usual, customary and reasonable) fees, excluded
services, grievance and appeals, and such other terms as the
Secretary determines are important to define so that
consumers may compare health insurance coverage and
understand the terms of their coverage.
``(3) Medical terms.--The medical terms described in this
paragraph are hospitalization, hospital outpatient care,
emergency room care, physician services, prescription drug
coverage, durable medical equipment, home health care,
skilled nursing care, rehabilitation services, hospice
services, emergency medical transportation, and such other
terms as the Secretary determines are important to define so
that consumers may compare the medical benefits offered by
health insurance and understand the extent of those medical
benefits (or exceptions to those benefits).
``SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON SALARY.
``(a) In General.--The plan sponsor of a group health plan
(other than a self-insured plan) may not establish rules
relating to the health insurance coverage eligibility
(including continued eligibility) of any full-time employee
under the terms of the plan that are based on the total
hourly or annual salary of the employee or otherwise
establish eligibility rules that have the effect of
discriminating in favor of higher wage employees.
``(b) Limitation.--Subsection (a) shall not be construed to
prohibit a plan sponsor from establishing contribution
requirements for enrollment in the plan or coverage that
provide for the payment by employees with lower hourly or
annual compensation of a lower dollar or percentage
contribution than the payment required of similarly situated
employees with a higher hourly or annual compensation.
``SEC. 2717. ENSURING THE QUALITY OF CARE.
``(a) Quality Reporting.--
``(1) In general.--Not later than 2 years after the date of
enactment of the Patient Protection and Affordable Care Act,
the Secretary, in consultation with experts in health care
quality and stakeholders, shall develop reporting
requirements for use by a group health plan, and a health
insurance issuer offering group or individual health
insurance coverage, with respect to plan or coverage benefits
and health care provider reimbursement structures that--
``(A) improve health outcomes through the implementation of
activities such as quality reporting, effective case
management, care coordination, chronic disease management,
and medication and care compliance initiatives, including
through the use of the medical homes model as defined for
purposes of section 3602 of the Patient Protection and
Affordable Care Act, for treatment or services under the plan
or coverage;
``(B) implement activities to prevent hospital readmissions
through a comprehensive program for hospital discharge that
includes patient-centered education and counseling,
comprehensive discharge planning, and post discharge
reinforcement by an appropriate health care professional;
``(C) implement activities to improve patient safety and
reduce medical errors through the appropriate use of best
clinical practices, evidence based medicine, and health
information technology under the plan or coverage; and
``(D) implement wellness and health promotion activities.
``(2) Reporting requirements.--
``(A) In general.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage shall annually submit to the Secretary,
and to enrollees under the plan or coverage, a report on
whether the benefits under the plan or coverage satisfy the
elements described in subparagraphs (A) through (D) of
paragraph (1).
``(B) Timing of reports.--A report under subparagraph (A)
shall be made available to an enrollee under the plan or
coverage during each open enrollment period.
``(C) Availability of reports.--The Secretary shall make
reports submitted under subparagraph (A) available to the
public through an Internet website.
``(D) Penalties.--In developing the reporting requirements
under paragraph (1), the Secretary may develop and impose
appropriate penalties for non-compliance with such
requirements.
``(E) Exceptions.--In developing the reporting requirements
under paragraph (1), the Secretary may provide for exceptions
to such requirements for group health plans and health
insurance issuers that substantially meet the goals of this
section.
``(b) Wellness and Prevention Programs.--For purposes of
subsection (a)(1)(D), wellness and health promotion
activities may include personalized wellness and prevention
services, which are coordinated, maintained or delivered by a
health care provider, a wellness and prevention plan manager,
or a health, wellness or prevention services organization
that conducts health risk assessments or offers ongoing face-
to-face, telephonic or web-based intervention efforts for
each of the program's participants, and which may include the
following wellness and prevention efforts:
``(1) Smoking cessation.
``(2) Weight management.
``(3) Stress management.
``(4) Physical fitness.
``(5) Nutrition.
``(6) Heart disease prevention.
``(7) Healthy lifestyle support.
``(8) Diabetes prevention.
``(c) Regulations.--Not later than 2 years after the date
of enactment of the Patient Protection and Affordable Care
Act, the Secretary shall promulgate regulations that provide
criteria for determining whether a reimbursement structure is
described in subsection (a).
``(d) Study and Report.--Not later than 180 days after the
date on which regulations are promulgated under subsection
(c), the Government Accountability Office shall review such
regulations and conduct a study and submit to the Committee
on Health, Education, Labor, and Pensions of the Senate and
the Committee on Energy and Commerce of the House of
Representatives a report regarding the impact the activities
under this section have had on the quality and cost of health
care.
``SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE.
``(a) Clear Accounting for Costs.--A health insurance
issuer offering group or individual health insurance coverage
shall, with respect to each plan year, submit to the
Secretary a report concerning the percentage of total premium
revenue that such coverage expends--
``(1) on reimbursement for clinical services provided to
enrollees under such coverage;
``(2) for activities that improve health care quality; and
``(3) on all other non-claims costs, including an
explanation of the nature of such costs, and excluding State
taxes and licensing or regulatory fees.
The Secretary shall make reports received under this section
available to the public on the Internet website of the
Department of Health and Human Services.
``(b) Ensuring That Consumers Receive Value for Their
Premium Payments.--
``(1) Requirement to provide value for premium payments.--A
health insurance issuer offering group or individual health
insurance coverage shall, with respect to each plan year,
provide an annual rebate to each enrollee under such
coverage, on a pro rata basis, in an amount that is equal to
the amount by which premium revenue expended by the issuer on
activities described in subsection (a)(3) exceeds--
``(A) with respect to a health insurance issuer offering
coverage in the group market, 20 percent, or such lower
percentage as a State may by regulation determine; or
``(B) with respect to a health insurance issuer offering
coverage in the individual market, 25 percent, or such lower
percentage as a State may by regulation determine, except
that such percentage shall be adjusted to the extent the
Secretary determines that the application of such percentage
with a State may destabilize the existing individual market
in such State.
``(2) Consideration in setting percentages.--In determining
the percentages under paragraph (1), a State shall seek to
ensure adequate participation by health insurance issuers,
competition in the health insurance market in the State, and
value for consumers so that premiums are used for clinical
services and quality improvements.
``(3) Termination.--The provisions of this subsection shall
have no force or effect after December 31, 2013.
``(c) Standard Hospital Charges.--Each hospital operating
within the United States shall for each year establish (and
update) and make public (in accordance with guidelines
developed by the Secretary) a list of the hospital's standard
charges for items and services provided by the hospital,
including for diagnosis-related groups established under
section 1886(d)(4) of the Social Security Act.
``(d) Definitions.--The Secretary, in consultation with the
National Association of Insurance Commissions, shall
establish uniform definitions for the activities reported
under subsection (a).
``SEC. 2719. APPEALS PROCESS.
``A group health plan and a health insurance issuer
offering group or individual health insurance coverage shall
implement an effective appeals process for appeals of
coverage determinations and claims, under which the plan or
issuer shall, at a minimum--
``(1) have in effect an internal claims appeal process;
``(2) provide notice to enrollees, in a culturally and
linguistically appropriate manner, of available internal and
external appeals processes, and the availability of any
applicable office of health insurance consumer assistance or
ombudsman established under section 2793 to assist such
enrollees with the appeals processes;
``(3) allow an enrollee to review their file, to present
evidence and testimony as part of the appeals process, and to
receive continued coverage pending the outcome of the appeals
process; and
[[Page H1927]]
``(4) provide an external review process for such plans and
issuers that, at a minimum, includes the consumer protections
set forth in the Uniform External Review Model Act
promulgated by the National Association of Insurance
Commissioners and is binding on such plans.''.
SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION.
Part C of title XXVII of the Public Health Service Act (42
U.S.C. 300gg-91 et seq.) is amended by adding at the end the
following:
``SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.
``(a) In General.--The Secretary shall award grants to
States to enable such States (or the Exchanges operating in
such States) to establish, expand, or provide support for--
``(1) offices of health insurance consumer assistance; or
``(2) health insurance ombudsman programs.
``(b) Eligibility.--
``(1) In general.--To be eligible to receive a grant, a
State shall designate an independent office of health
insurance consumer assistance, or an ombudsman, that,
directly or in coordination with State health insurance
regulators and consumer assistance organizations, receives
and responds to inquiries and complaints concerning health
insurance coverage with respect to Federal health insurance
requirements and under State law.
``(2) Criteria.--A State that receives a grant under this
section shall comply with criteria established by the
Secretary for carrying out activities under such grant.
``(c) Duties.--The office of health insurance consumer
assistance or health insurance ombudsman shall--
``(1) assist with the filing of complaints and appeals,
including filing appeals with the internal appeal or
grievance process of the group health plan or health
insurance issuer involved and providing information about the
external appeal process;
``(2) collect, track, and quantify problems and inquiries
encountered by consumers;
``(3) educate consumers on their rights and
responsibilities with respect to group health plans and
health insurance coverage;
``(4) assist consumers with enrollment in a group health
plan or health insurance coverage by providing information,
referral, and assistance; and
``(5) resolve problems with obtaining premium tax credits
under section 36B of the Internal Revenue Code of 1986.
``(d) Data Collection.--As a condition of receiving a grant
under subsection (a), an office of health insurance consumer
assistance or ombudsman program shall be required to collect
and report data to the Secretary on the types of problems and
inquiries encountered by consumers. The Secretary shall
utilize such data to identify areas where more enforcement
action is necessary and shall share such information with
State insurance regulators, the Secretary of Labor, and the
Secretary of the Treasury for use in the enforcement
activities of such agencies.
``(e) Funding.--
``(1) Initial funding.--There is hereby appropriated to the
Secretary, out of any funds in the Treasury not otherwise
appropriated, $30,000,000 for the first fiscal year for which
this section applies to carry out this section. Such amount
shall remain available without fiscal year limitation.
``(2) Authorization for subsequent years.--There is
authorized to be appropriated to the Secretary for each
fiscal year following the fiscal year described in paragraph
(1), such sums as may be necessary to carry out this
section.''.
SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR
DOLLARS.
Part C of title XXVII of the Public Health Service Act (42
U.S.C. 300gg-91 et seq.), as amended by section 1002, is
further amended by adding at the end the following:
``SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR THEIR
DOLLARS.
``(a) Initial Premium Review Process.--
``(1) In general.--The Secretary, in conjunction with
States, shall establish a process for the annual review,
beginning with the 2010 plan year and subject to subsection
(b)(2)(A), of unreasonable increases in premiums for health
insurance coverage.
``(2) Justification and disclosure.--The process
established under paragraph (1) shall require health
insurance issuers to submit to the Secretary and the relevant
State a justification for an unreasonable premium increase
prior to the implementation of the increase. Such issuers
shall prominently post such information on their Internet
websites. The Secretary shall ensure the public disclosure of
information on such increases and justifications for all
health insurance issuers.
``(b) Continuing Premium Review Process.--
``(1) Informing secretary of premium increase patterns.--As
a condition of receiving a grant under subsection (c)(1), a
State, through its Commissioner of Insurance, shall--
``(A) provide the Secretary with information about trends
in premium increases in health insurance coverage in premium
rating areas in the State; and
``(B) make recommendations, as appropriate, to the State
Exchange about whether particular health insurance issuers
should be excluded from participation in the Exchange based
on a pattern or practice of excessive or unjustified premium
increases.
``(2) Monitoring by secretary of premium increases.--
``(A) In general.--Beginning with plan years beginning in
2014, the Secretary, in conjunction with the States and
consistent with the provisions of subsection (a)(2), shall
monitor premium increases of health insurance coverage
offered through an Exchange and outside of an Exchange.
``(B) Consideration in opening exchange.--In determining
under section 1312(f)(2)(B) of the Patient Protection and
Affordable Care Act whether to offer qualified health plans
in the large group market through an Exchange, the State
shall take into account any excess of premium growth outside
of the Exchange as compared to the rate of such growth inside
the Exchange.
``(c) Grants in Support of Process.--
``(1) Premium review grants during 2010 through 2014.--The
Secretary shall carry out a program to award grants to States
during the 5-year period beginning with fiscal year 2010 to
assist such States in carrying out subsection (a),
including--
``(A) in reviewing and, if appropriate under State law,
approving premium increases for health insurance coverage;
and
``(B) in providing information and recommendations to the
Secretary under subsection (b)(1).
``(2) Funding.--
``(A) In general.--Out of all funds in the Treasury not
otherwise appropriated, there are appropriated to the
Secretary $250,000,000, to be available for expenditure for
grants under paragraph (1) and subparagraph (B).
``(B) Further availability for insurance reform and
consumer protection.--If the amounts appropriated under
subparagraph (A) are not fully obligated under grants under
paragraph (1) by the end of fiscal year 2014, any remaining
funds shall remain available to the Secretary for grants to
States for planning and implementing the insurance reforms
and consumer protections under part A.
``(C) Allocation.--The Secretary shall establish a formula
for determining the amount of any grant to a State under this
subsection. Under such formula--
``(i) the Secretary shall consider the number of plans of
health insurance coverage offered in each State and the
population of the State; and
``(ii) no State qualifying for a grant under paragraph (1)
shall receive less than $1,000,000, or more than $5,000,000
for a grant year.''.
SEC. 1004. EFFECTIVE DATES.
(a) In General.--Except as provided for in subsection (b),
this subtitle (and the amendments made by this subtitle)
shall become effective for plan years beginning on or after
the date that is 6 months after the date of enactment of this
Act, except that the amendments made by sections 1002 and
1003 shall become effective for fiscal years beginning with
fiscal year 2010.
(b) Special Rule.--The amendments made by sections 1002 and
1003 shall take effect on the date of enactment of this Act.
Subtitle B--Immediate Actions to Preserve and Expand Coverage
SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED
INDIVIDUALS WITH A PREEXISTING CONDITION.
(a) In General.--Not later than 90 days after the date of
enactment of this Act, the Secretary shall establish a
temporary high risk health insurance pool program to provide
health insurance coverage for eligible individuals during the
period beginning on the date on which such program is
established and ending on January 1, 2014.
(b) Administration.--
(1) In general.--The Secretary may carry out the program
under this section directly or through contracts to eligible
entities.
(2) Eligible entities.--To be eligible for a contract under
paragraph (1), an entity shall--
(A) be a State or nonprofit private entity;
(B) submit to the Secretary an application at such time, in
such manner, and containing such information as the Secretary
may require; and
(C) agree to utilize contract funding to establish and
administer a qualified high risk pool for eligible
individuals.
(3) Maintenance of effort.--To be eligible to enter into a
contract with the Secretary under this subsection, a State
shall agree not to reduce the annual amount the State
expended for the operation of one or more State high risk
pools during the year preceding the year in which such
contract is entered into.
(c) Qualified High Risk Pool.--
(1) In general.--Amounts made available under this section
shall be used to establish a qualified high risk pool that
meets the requirements of paragraph (2).
(2) Requirements.--A qualified high risk pool meets the
requirements of this paragraph if such pool--
(A) provides to all eligible individuals health insurance
coverage that does not impose any preexisting condition
exclusion with respect to such coverage;
(B) provides health insurance coverage--
(i) in which the issuer's share of the total allowed costs
of benefits provided under such coverage is not less than 65
percent of such costs; and
(ii) that has an out of pocket limit not greater than the
applicable amount described in section 223(c)(2) of the
Internal Revenue Code of 1986 for the year involved, except
that the Secretary may modify such limit if necessary to
ensure the pool meets the actuarial value limit under clause
(i);
(C) ensures that with respect to the premium rate charged
for health insurance coverage offered to eligible individuals
through the high risk pool, such rate shall--
(i) except as provided in clause (ii), vary only as
provided for under section 2701 of the Public Health Service
Act (as amended by this Act and notwithstanding the date on
which such amendments take effect);
(ii) vary on the basis of age by a factor of not greater
than 4 to 1; and
(iii) be established at a standard rate for a standard
population; and
(D) meets any other requirements determined appropriate by
the Secretary.
[[Page H1928]]
(d) Eligible Individual.--An individual shall be deemed to
be an eligible individual for purposes of this section if
such individual--
(1) is a citizen or national of the United States or is
lawfully present in the United States (as determined in
accordance with section 1411);
(2) has not been covered under creditable coverage (as
defined in section 2701(c)(1) of the Public Health Service
Act as in effect on the date of enactment of this Act) during
the 6-month period prior to the date on which such individual
is applying for coverage through the high risk pool; and
(3) has a pre-existing condition, as determined in a manner
consistent with guidance issued by the Secretary.
(e) Protection Against Dumping Risk by Insurers.--
(1) In general.--The Secretary shall establish criteria for
determining whether health insurance issuers and employment-
based health plans have discouraged an individual from
remaining enrolled in prior coverage based on that
individual's health status.
(2) Sanctions.--An issuer or employment-based health plan
shall be responsible for reimbursing the program under this
section for the medical expenses incurred by the program for
an individual who, based on criteria established by the
Secretary, the Secretary finds was encouraged by the issuer
to disenroll from health benefits coverage prior to enrolling
in coverage through the program. The criteria shall include
at least the following circumstances:
(A) In the case of prior coverage obtained through an
employer, the provision by the employer, group health plan,
or the issuer of money or other financial consideration for
disenrolling from the coverage.
(B) In the case of prior coverage obtained directly from an
issuer or under an employment-based health plan--
(i) the provision by the issuer or plan of money or other
financial consideration for disenrolling from the coverage;
or
(ii) in the case of an individual whose premium for the
prior coverage exceeded the premium required by the program
(adjusted based on the age factors applied to the prior
coverage)--
(I) the prior coverage is a policy that is no longer being
actively marketed (as defined by the Secretary) by the
issuer; or
(II) the prior coverage is a policy for which duration of
coverage form issue or health status are factors that can be
considered in determining premiums at renewal.
(3) Construction.--Nothing in this subsection shall be
construed as constituting exclusive remedies for violations
of criteria established under paragraph (1) or as preventing
States from applying or enforcing such paragraph or other
provisions under law with respect to health insurance
issuers.
(f) Oversight.--The Secretary shall establish--
(1) an appeals process to enable individuals to appeal a
determination under this section; and
(2) procedures to protect against waste, fraud, and abuse.
(g) Funding; Termination of Authority.--
(1) In general.--There is appropriated to the Secretary,
out of any moneys in the Treasury not otherwise appropriated,
$5,000,000,000 to pay claims against (and the administrative
costs of) the high risk pool under this section that are in
excess of the amount of premiums collected from eligible
individuals enrolled in the high risk pool. Such funds shall
be available without fiscal year limitation.
(2) Insufficient funds.--If the Secretary estimates for any
fiscal year that the aggregate amounts available for the
payment of the expenses of the high risk pool will be less
than the actual amount of such expenses, the Secretary shall
make such adjustments as are necessary to eliminate such
deficit.
(3) Termination of authority.--
(A) In general.--Except as provided in subparagraph (B),
coverage of eligible individuals under a high risk pool in a
State shall terminate on January 1, 2014.
(B) Transition to exchange.--The Secretary shall develop
procedures to provide for the transition of eligible
individuals enrolled in health insurance coverage offered
through a high risk pool established under this section into
qualified health plans offered through an Exchange. Such
procedures shall ensure that there is no lapse in coverage
with respect to the individual and may extend coverage after
the termination of the risk pool involved, if the Secretary
determines necessary to avoid such a lapse.
(4) Limitations.--The Secretary has the authority to stop
taking applications for participation in the program under
this section to comply with the funding limitation provided
for in paragraph (1).
(5) Relation to state laws.--The standards established
under this section shall supersede any State law or
regulation (other than State licensing laws or State laws
relating to plan solvency) with respect to qualified high
risk pools which are established in accordance with this
section.
SEC. 1102. REINSURANCE FOR EARLY RETIREES.
(a) Administration.--
(1) In general.--Not later than 90 days after the date of
enactment of this Act, the Secretary shall establish a
temporary reinsurance program to provide reimbursement to
participating employment-based plans for a portion of the
cost of providing health insurance coverage to early retirees
(and to the eligible spouses, surviving spouses, and
dependents of such retirees) during the period beginning on
the date on which such program is established and ending on
January 1, 2014.
(2) Reference.--In this section:
(A) Health benefits.--The term ``health benefits'' means
medical, surgical, hospital, prescription drug, and such
other benefits as shall be determined by the Secretary,
whether self-funded, or delivered through the purchase of
insurance or otherwise.
(B) Employment-based plan.--The term ``employment-based
plan'' means a group health benefits plan that--
(i) is--
(I) maintained by one or more current or former employers
(including without limitation any State or local government
or political subdivision thereof), employee organization, a
voluntary employees' beneficiary association, or a committee
or board of individuals appointed to administer such plan; or
(II) a multiemployer plan (as defined in section 3(37) of
the Employee Retirement Income Security Act of 1974); and
(ii) provides health benefits to early retirees.
(C) Early retirees.--The term ``early retirees'' means
individuals who are age 55 and older but are not eligible for
coverage under title XVIII of the Social Security Act, and
who are not active employees of an employer maintaining, or
currently contributing to, the employment-based plan or of
any employer that has made substantial contributions to fund
such plan.
(b) Participation.--
(1) Employment-based plan eligibility.--A participating
employment-based plan is an employment-based plan that--
(A) meets the requirements of paragraph (2) with respect to
health benefits provided under the plan; and
(B) submits to the Secretary an application for
participation in the program, at such time, in such manner,
and containing such information as the Secretary shall
require.
(2) Employment-based health benefits.--An employment-based
plan meets the requirements of this paragraph if the plan--
(A) implements programs and procedures to generate cost-
savings with respect to participants with chronic and high-
cost conditions;
(B) provides documentation of the actual cost of medical
claims involved; and
(C) is certified by the Secretary.
(c) Payments.--
(1) Submission of claims.--
(A) In general.--A participating employment-based plan
shall submit claims for reimbursement to the Secretary which
shall contain documentation of the actual costs of the items
and services for which each claim is being submitted.
(B) Basis for claims.--Claims submitted under subparagraph
(A) shall be based on the actual amount expended by the
participating employment-based plan involved within the plan
year for the health benefits provided to an early retiree or
the spouse, surviving spouse, or dependent of such retiree.
In determining the amount of a claim for purposes of this
subsection, the participating employment-based plan shall
take into account any negotiated price concessions (such as
discounts, direct or indirect subsidies, rebates, and direct
or indirect remunerations) obtained by such plan with respect
to such health benefit. For purposes of determining the
amount of any such claim, the costs paid by the early retiree
or the retiree's spouse, surviving spouse, or dependent in
the form of deductibles, co-payments, or co-insurance shall
be included in the amounts paid by the participating
employment-based plan.
(2) Program payments.--If the Secretary determines that a
participating employment-based plan has submitted a valid
claim under paragraph (1), the Secretary shall reimburse such
plan for 80 percent of that portion of the costs attributable
to such claim that exceed $15,000, subject to the limits
contained in paragraph (3).
(3) Limit.--To be eligible for reimbursement under the
program, a claim submitted by a participating employment-
based plan shall not be less than $15,000 nor greater than
$90,000. Such amounts shall be adjusted each fiscal year
based on the percentage increase in the Medical Care
Component of the Consumer Price Index for all urban consumers
(rounded to the nearest multiple of $1,000) for the year
involved.
(4) Use of payments.--Amounts paid to a participating
employment-based plan under this subsection shall be used to
lower costs for the plan. Such payments may be used to reduce
premium costs for an entity described in subsection
(a)(2)(B)(i) or to reduce premium contributions, co-payments,
deductibles, co-insurance, or other out-of-pocket costs for
plan participants. Such payments shall not be used as general
revenues for an entity described in subsection (a)(2)(B)(i).
The Secretary shall develop a mechanism to monitor the
appropriate use of such payments by such entities.
(5) Payments not treated as income.--Payments received
under this subsection shall not be included in determining
the gross income of an entity described in subsection
(a)(2)(B)(i) that is maintaining or currently contributing to
a participating employment-based plan.
(6) Appeals.--The Secretary shall establish--
(A) an appeals process to permit participating employment-
based plans to appeal a determination of the Secretary with
respect to claims submitted under this section; and
(B) procedures to protect against fraud, waste, and abuse
under the program.
(d) Audits.--The Secretary shall conduct annual audits of
claims data submitted by participating employment-based plans
under this section to ensure that such plans are in
compliance with the requirements of this section.
(e) Funding.--There is appropriated to the Secretary, out
of any moneys in the Treasury not otherwise appropriated,
$5,000,000,000 to carry out the program under this section.
Such funds shall be available without fiscal year limitation.
(f) Limitation.--The Secretary has the authority to stop
taking applications for participation in the program based on
the availability of funding under subsection (e).
[[Page H1929]]
SEC. 1103. IMMEDIATE INFORMATION THAT ALLOWS CONSUMERS TO
IDENTIFY AFFORDABLE COVERAGE OPTIONS.
(a) Internet Portal to Affordable Coverage Options.--
(1) Immediate establishment.--Not later than July 1, 2010,
the Secretary, in consultation with the States, shall
establish a mechanism, including an Internet website, through
which a resident of any State may identify affordable health
insurance coverage options in that State.
(2) Connecting to affordable coverage.--An Internet website
established under paragraph (1) shall, to the extent
practicable, provide ways for residents of any State to
receive information on at least the following coverage
options:
(A) Health insurance coverage offered by health insurance
issuers, other than coverage that provides reimbursement only
for the treatment or mitigation of--
(i) a single disease or condition; or
(ii) an unreasonably limited set of diseases or conditions
(as determined by the Secretary);
(B) Medicaid coverage under title XIX of the Social
Security Act.
(C) Coverage under title XXI of the Social Security Act.
(D) A State health benefits high risk pool, to the extent
that such high risk pool is offered in such State; and
(E) Coverage under a high risk pool under section 1101.
(b) Enhancing Comparative Purchasing Options.--
(1) In general.--Not later than 60 days after the date of
enactment of this Act, the Secretary shall develop a
standardized format to be used for the presentation of
information relating to the coverage options described in
subsection (a)(2). Such format shall, at a minimum, require
the inclusion of information on the percentage of total
premium revenue expended on nonclinical costs (as reported
under section 2718(a) of the Public Health Service Act),
eligibility, availability, premium rates, and cost sharing
with respect to such coverage options and be consistent with
the standards adopted for the uniform explanation of coverage
as provided for in section 2715 of the Public Health Service
Act.
(2) Use of format.--The Secretary shall utilize the format
developed under paragraph (1) in compiling information
concerning coverage options on the Internet website
established under subsection (a).
(c) Authority To Contract.--The Secretary may carry out
this section through contracts entered into with qualified
entities.
SEC. 1104. ADMINISTRATIVE SIMPLIFICATION.
(a) Purpose of Administrative Simplification.--Section 261
of the Health Insurance Portability and Accountability Act of
1996 (42 U.S.C. 1320d note) is amended--
(1) by inserting ``uniform'' before ``standards''; and
(2) by inserting ``and to reduce the clerical burden on
patients, health care providers, and health plans'' before
the period at the end.
(b) Operating Rules for Health Information Transactions.--
(1) Definition of operating rules.--Section 1171 of the
Social Security Act (42 U.S.C. 1320d) is amended by adding at
the end the following:
``(9) Operating rules.--The term `operating rules' means
the necessary business rules and guidelines for the
electronic exchange of information that are not defined by a
standard or its implementation specifications as adopted for
purposes of this part.''.
(2) Transaction standards; operating rules and
compliance.--Section 1173 of the Social Security Act (42
U.S.C. 1320d-2) is amended--
(A) in subsection (a)(2), by adding at the end the
following new subparagraph:
``(J) Electronic funds transfers.'';
(B) in subsection (a), by adding at the end the following
new paragraph:
``(4) Requirements for financial and administrative
transactions.--
``(A) In general.--The standards and associated operating
rules adopted by the Secretary shall--
``(i) to the extent feasible and appropriate, enable
determination of an individual's eligibility and financial
responsibility for specific services prior to or at the point
of care;
``(ii) be comprehensive, requiring minimal augmentation by
paper or other communications;
``(iii) provide for timely acknowledgment, response, and
status reporting that supports a transparent claims and
denial management process (including adjudication and
appeals); and
``(iv) describe all data elements (including reason and
remark codes) in unambiguous terms, require that such data
elements be required or conditioned upon set values in other
fields, and prohibit additional conditions (except where
necessary to implement State or Federal law, or to protect
against fraud and abuse).
``(B) Reduction of clerical burden.--In adopting standards
and operating rules for the transactions referred to under
paragraph (1), the Secretary shall seek to reduce the number
and complexity of forms (including paper and electronic
forms) and data entry required by patients and providers.'';
and
(C) by adding at the end the following new subsections:
``(g) Operating Rules.--
``(1) In general.--The Secretary shall adopt a single set
of operating rules for each transaction referred to under
subsection (a)(1) with the goal of creating as much
uniformity in the implementation of the electronic standards
as possible. Such operating rules shall be consensus-based
and reflect the necessary business rules affecting health
plans and health care providers and the manner in which they
operate pursuant to standards issued under Health Insurance
Portability and Accountability Act of 1996.
``(2) Operating rules development.--In adopting operating
rules under this subsection, the Secretary shall consider
recommendations for operating rules developed by a qualified
nonprofit entity that meets the following requirements:
``(A) The entity focuses its mission on administrative
simplification.
``(B) The entity demonstrates a multi-stakeholder and
consensus-based process for development of operating rules,
including representation by or participation from health
plans, health care providers, vendors, relevant Federal
agencies, and other standard development organizations.
``(C) The entity has a public set of guiding principles
that ensure the operating rules and process are open and
transparent, and supports nondiscrimination and conflict of
interest policies that demonstrate a commitment to open,
fair, and nondiscriminatory practices.
``(D) The entity builds on the transaction standards issued
under Health Insurance Portability and Accountability Act of
1996.
``(E) The entity allows for public review and updates of
the operating rules.
``(3) Review and recommendations.--The National Committee
on Vital and Health Statistics shall--
``(A) advise the Secretary as to whether a nonprofit entity
meets the requirements under paragraph (2);
``(B) review the operating rules developed and recommended
by such nonprofit entity;
``(C) determine whether such operating rules represent a
consensus view of the health care stakeholders and are
consistent with and do not conflict with other existing
standards;
``(D) evaluate whether such operating rules are consistent
with electronic standards adopted for health information
technology; and
``(E) submit to the Secretary a recommendation as to
whether the Secretary should adopt such operating rules.
``(4) Implementation.--
``(A) In general.--The Secretary shall adopt operating
rules under this subsection, by regulation in accordance with
subparagraph (C), following consideration of the operating
rules developed by the non-profit entity described in
paragraph (2) and the recommendation submitted by the
National Committee on Vital and Health Statistics under
paragraph (3)(E) and having ensured consultation with
providers.
``(B) Adoption requirements; effective dates.--
``(i) Eligibility for a health plan and health claim
status.--The set of operating rules for eligibility for a
health plan and health claim status transactions shall be
adopted not later than July 1, 2011, in a manner ensuring
that such operating rules are effective not later than
January 1, 2013, and may allow for the use of a machine
readable identification card.
``(ii) Electronic funds transfers and health care payment
and remittance advice.--The set of operating rules for
electronic funds transfers and health care payment and
remittance advice transactions shall--
``(I) allow for automated reconciliation of the electronic
payment with the remittance advice; and
``(II) be adopted not later than July 1, 2012, in a manner
ensuring that such operating rules are effective not later
than January 1, 2014.
``(iii) Health claims or equivalent encounter information,
enrollment and disenrollment in a health plan, health plan
premium payments, referral certification and authorization.--
The set of operating rules for health claims or equivalent
encounter information, enrollment and disenrollment in a
health plan, health plan premium payments, and referral
certification and authorization transactions shall be adopted
not later than July 1, 2014, in a manner ensuring that such
operating rules are effective not later than January 1, 2016.
``(C) Expedited rulemaking.--The Secretary shall promulgate
an interim final rule applying any standard or operating rule
recommended by the National Committee on Vital and Health
Statistics pursuant to paragraph (3). The Secretary shall
accept and consider public comments on any interim final rule
published under this subparagraph for 60 days after the date
of such publication.
``(h) Compliance.--
``(1) Health plan certification.--
``(A) Eligibility for a health plan, health claim status,
electronic funds transfers, health care payment and
remittance advice.--Not later than December 31, 2013, a
health plan shall file a statement with the Secretary, in
such form as the Secretary may require, certifying that the
data and information systems for such plan are in compliance
with any applicable standards (as described under paragraph
(7) of section 1171) and associated operating rules (as
described under paragraph (9) of such section) for electronic
funds transfers, eligibility for a health plan, health claim
status, and health care payment and remittance advice,
respectively.
``(B) Health claims or equivalent encounter information,
enrollment and disenrollment in a health plan, health plan
premium payments, health claims attachments, referral
certification and authorization.--Not later than December 31,
2015, a health plan shall file a statement with the
Secretary, in such form as the Secretary may require,
certifying that the data and information systems for such
plan are in compliance with any applicable standards and
associated operating rules for health claims or equivalent
encounter information, enrollment and disenrollment in a
health plan, health plan premium payments, health claims
attachments, and referral certification and authorization,
respectively. A health plan shall provide the same level of
documentation to certify compliance
[[Page H1930]]
with such transactions as is required to certify compliance
with the transactions specified in subparagraph (A).
``(2) Documentation of compliance.--A health plan shall
provide the Secretary, in such form as the Secretary may
require, with adequate documentation of compliance with the
standards and operating rules described under paragraph (1).
A health plan shall not be considered to have provided
adequate documentation and shall not be certified as being in
compliance with such standards, unless the health plan--
``(A) demonstrates to the Secretary that the plan conducts
the electronic transactions specified in paragraph (1) in a
manner that fully complies with the regulations of the
Secretary; and
``(B) provides documentation showing that the plan has
completed end-to-end testing for such transactions with their
partners, such as hospitals and physicians.
``(3) Service contracts.--A health plan shall be required
to ensure that any entities that provide services pursuant to
a contract with such health plan shall comply with any
applicable certification and compliance requirements (and
provide the Secretary with adequate documentation of such
compliance) under this subsection.
``(4) Certification by outside entity.--The Secretary may
designate independent, outside entities to certify that a
health plan has complied with the requirements under this
subsection, provided that the certification standards
employed by such entities are in accordance with any
standards or operating rules issued by the Secretary.
``(5) Compliance with revised standards and operating
rules.--
``(A) In general.--A health plan (including entities
described under paragraph (3)) shall file a statement with
the Secretary, in such form as the Secretary may require,
certifying that the data and information systems for such
plan are in compliance with any applicable revised standards
and associated operating rules under this subsection for any
interim final rule promulgated by the Secretary under
subsection (i) that--
``(i) amends any standard or operating rule described under
paragraph (1) of this subsection; or
``(ii) establishes a standard (as described under
subsection (a)(1)(B)) or associated operating rules (as
described under subsection (i)(5)) for any other financial
and administrative transactions.
``(B) Date of compliance.--A health plan shall comply with
such requirements not later than the effective date of the
applicable standard or operating rule.
``(6) Audits of health plans.--The Secretary shall conduct
periodic audits to ensure that health plans (including
entities described under paragraph (3)) are in compliance
with any standards and operating rules that are described
under paragraph (1) or subsection (i)(5).
``(i) Review and Amendment of Standards and Operating
Rules.--
``(1) Establishment.--Not later than January 1, 2014, the
Secretary shall establish a review committee (as described
under paragraph (4)).
``(2) Evaluations and reports.--
``(A) Hearings.--Not later than April 1, 2014, and not less
than biennially thereafter, the Secretary, acting through the
review committee, shall conduct hearings to evaluate and
review the adopted standards and operating rules established
under this section.
``(B) Report.--Not later than July 1, 2014, and not less
than biennially thereafter, the review committee shall
provide recommendations for updating and improving such
standards and operating rules. The review committee shall
recommend a single set of operating rules per transaction
standard and maintain the goal of creating as much uniformity
as possible in the implementation of the electronic
standards.
``(3) Interim final rulemaking.--
``(A) In general.--Any recommendations to amend adopted
standards and operating rules that have been approved by the
review committee and reported to the Secretary under
paragraph (2)(B) shall be adopted by the Secretary through
promulgation of an interim final rule not later than 90 days
after receipt of the committee's report.
``(B) Public comment.--
``(i) Public comment period.--The Secretary shall accept
and consider public comments on any interim final rule
published under this paragraph for 60 days after the date of
such publication.
``(ii) Effective date.--The effective date of any amendment
to existing standards or operating rules that is adopted
through an interim final rule published under this paragraph
shall be 25 months following the close of such public comment
period.
``(4) Review committee.--
``(A) Definition.--For the purposes of this subsection, the
term `review committee' means a committee chartered by or
within the Department of Health and Human services that has
been designated by the Secretary to carry out this
subsection, including--
``(i) the National Committee on Vital and Health
Statistics; or
``(ii) any appropriate committee as determined by the
Secretary.
``(B) Coordination of hit standards.--In developing
recommendations under this subsection, the review committee
shall ensure coordination, as appropriate, with the standards
that support the certified electronic health record
technology approved by the Office of the National Coordinator
for Health Information Technology.
``(5) Operating rules for other standards adopted by the
secretary.--The Secretary shall adopt a single set of
operating rules (pursuant to the process described under
subsection (g)) for any transaction for which a standard had
been adopted pursuant to subsection (a)(1)(B).
``(j) Penalties.--
``(1) Penalty fee.--
``(A) In general.--Not later than April 1, 2014, and
annually thereafter, the Secretary shall assess a penalty fee
(as determined under subparagraph (B)) against a health plan
that has failed to meet the requirements under subsection (h)
with respect to certification and documentation of compliance
with--
``(i) the standards and associated operating rules
described under paragraph (1) of such subsection; and
``(ii) a standard (as described under subsection (a)(1)(B))
and associated operating rules (as described under subsection
(i)(5)) for any other financial and administrative
transactions.
``(B) Fee amount.--Subject to subparagraphs (C), (D), and
(E), the Secretary shall assess a penalty fee against a
health plan in the amount of $1 per covered life until
certification is complete. The penalty shall be assessed per
person covered by the plan for which its data systems for
major medical policies are not in compliance and shall be
imposed against the health plan for each day that the plan is
not in compliance with the requirements under subsection (h).
``(C) Additional penalty for misrepresentation.--A health
plan that knowingly provides inaccurate or incomplete
information in a statement of certification or documentation
of compliance under subsection (h) shall be subject to a
penalty fee that is double the amount that would otherwise be
imposed under this subsection.
``(D) Annual fee increase.--The amount of the penalty fee
imposed under this subsection shall be increased on an annual
basis by the annual percentage increase in total national
health care expenditures, as determined by the Secretary.
``(E) Penalty limit.--A penalty fee assessed against a
health plan under this subsection shall not exceed, on an
annual basis--
``(i) an amount equal to $20 per covered life under such
plan; or
``(ii) an amount equal to $40 per covered life under the
plan if such plan has knowingly provided inaccurate or
incomplete information (as described under subparagraph (C)).
``(F) Determination of covered individuals.--The Secretary
shall determine the number of covered lives under a health
plan based upon the most recent statements and filings that
have been submitted by such plan to the Securities and
Exchange Commission.
``(2) Notice and dispute procedure.--The Secretary shall
establish a procedure for assessment of penalty fees under
this subsection that provides a health plan with reasonable
notice and a dispute resolution procedure prior to provision
of a notice of assessment by the Secretary of the Treasury
(as described under paragraph (4)(B)).
``(3) Penalty fee report.--Not later than May 1, 2014, and
annually thereafter, the Secretary shall provide the
Secretary of the Treasury with a report identifying those
health plans that have been assessed a penalty fee under this
subsection.
``(4) Collection of penalty fee.--
``(A) In general.--The Secretary of the Treasury, acting
through the Financial Management Service, shall administer
the collection of penalty fees from health plans that have
been identified by the Secretary in the penalty fee report
provided under paragraph (3).
``(B) Notice.--Not later than August 1, 2014, and annually
thereafter, the Secretary of the Treasury shall provide
notice to each health plan that has been assessed a penalty
fee by the Secretary under this subsection. Such notice shall
include the amount of the penalty fee assessed by the
Secretary and the due date for payment of such fee to the
Secretary of the Treasury (as described in subparagraph (C)).
``(C) Payment due date.--Payment by a health plan for a
penalty fee assessed under this subsection shall be made to
the Secretary of the Treasury not later than November 1,
2014, and annually thereafter.
``(D) Unpaid penalty fees.--Any amount of a penalty fee
assessed against a health plan under this subsection for
which payment has not been made by the due date provided
under subparagraph (C) shall be--
``(i) increased by the interest accrued on such amount, as
determined pursuant to the underpayment rate established
under section 6621 of the Internal Revenue Code of 1986; and
``(ii) treated as a past-due, legally enforceable debt owed
to a Federal agency for purposes of section 6402(d) of the
Internal Revenue Code of 1986.
``(E) Administrative fees.--Any fee charged or allocated
for collection activities conducted by the Financial
Management Service will be passed on to a health plan on a
pro-rata basis and added to any penalty fee collected from
the plan.''.
(c) Promulgation of Rules.--
(1) Unique health plan identifier.--The Secretary shall
promulgate a final rule to establish a unique health plan
identifier (as described in section 1173(b) of the Social
Security Act (42 U.S.C. 1320d-2(b))) based on the input of
the National Committee on Vital and Health Statistics. The
Secretary may do so on an interim final basis and such rule
shall be effective not later than October 1, 2012.
(2) Electronic funds transfer.--The Secretary shall
promulgate a final rule to establish a standard for
electronic funds transfers (as described in section
1173(a)(2)(J) of the Social Security Act, as added by
subsection (b)(2)(A)). The Secretary may do so on an interim
final basis and shall adopt such standard not later than
January 1, 2012, in a manner ensuring that such standard is
effective not later than January 1, 2014.
(3) Health claims attachments.--The Secretary shall
promulgate a final rule to establish
[[Page H1931]]
a transaction standard and a single set of associated
operating rules for health claims attachments (as described
in section 1173(a)(2)(B) of the Social Security Act (42
U.S.C. 1320d-2(a)(2)(B))) that is consistent with the X12
Version 5010 transaction standards. The Secretary may do so
on an interim final basis and shall adopt a transaction
standard and a single set of associated operating rules not
later than January 1, 2014, in a manner ensuring that such
standard is effective not later than January 1, 2016.
(d) Expansion of Electronic Transactions in Medicare.--
Section 1862(a) of the Social Security Act (42 U.S.C.
1395y(a)) is amended--
(1) in paragraph (23), by striking the ``or'' at the end;
(2) in paragraph (24), by striking the period and inserting
``; or''; and
(3) by inserting after paragraph (24) the following new
paragraph:
``(25) not later than January 1, 2014, for which the
payment is other than by electronic funds transfer (EFT) or
an electronic remittance in a form as specified in ASC X12
835 Health Care Payment and Remittance Advice or subsequent
standard.''.
SEC. 1105. EFFECTIVE DATE.
This subtitle shall take effect on the date of enactment of
this Act.
Subtitle C--Quality Health Insurance Coverage for All Americans
PART I--HEALTH INSURANCE MARKET REFORMS
SEC. 1201. AMENDMENT TO THE PUBLIC HEALTH SERVICE ACT.
Part A of title XXVII of the Public Health Service Act (42
U.S.C. 300gg et seq.), as amended by section 1001, is further
amended--
(1) by striking the heading for subpart 1 and inserting the
following:
``Subpart I--General Reform'';
(2)(A) in section 2701 (42 U.S.C. 300gg), by striking the
section heading and subsection (a) and inserting the
following:
``SEC. 2704. PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS
OR OTHER DISCRIMINATION BASED ON HEALTH STATUS.
``(a) In General.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage may not impose any preexisting condition
exclusion with respect to such plan or coverage.''; and
(B) by transferring such section (as amended by
subparagraph (A)) so as to appear after the section 2703
added by paragraph (4);
(3)(A) in section 2702 (42 U.S.C. 300gg-1)--
(i) by striking the section heading and all that follows
through subsection (a);
(ii) in subsection (b)--
(I) by striking ``health insurance issuer offering health
insurance coverage in connection with a group health plan''
each place that such appears and inserting ``health insurance
issuer offering group or individual health insurance
coverage''; and
(II) in paragraph (2)(A)--
(aa) by inserting ``or individual'' after ``employer''; and
(bb) by inserting ``or individual health coverage, as the
case may be'' before the semicolon; and
(iii) in subsection (e)--
(I) by striking ``(a)(1)(F)'' and inserting ``(a)(6)'';
(II) by striking ``2701'' and inserting ``2704''; and
(III) by striking ``2721(a)'' and inserting ``2735(a)'';
and
(B) by transferring such section (as amended by
subparagraph (A)) to appear after section 2705(a) as added by
paragraph (4); and
(4) by inserting after the subpart heading (as added by
paragraph (1)) the following:
``SEC. 2701. FAIR HEALTH INSURANCE PREMIUMS.
``(a) Prohibiting Discriminatory Premium Rates.--
``(1) In general.--With respect to the premium rate charged
by a health insurance issuer for health insurance coverage
offered in the individual or small group market--
``(A) such rate shall vary with respect to the particular
plan or coverage involved only by--
``(i) whether such plan or coverage covers an individual or
family;
``(ii) rating area, as established in accordance with
paragraph (2);
``(iii) age, except that such rate shall not vary by more
than 3 to 1 for adults (consistent with section 2707(c)); and
``(iv) tobacco use, except that such rate shall not vary by
more than 1.5 to 1; and
``(B) such rate shall not vary with respect to the
particular plan or coverage involved by any other factor not
described in subparagraph (A).
``(2) Rating area.--
``(A) In general.--Each State shall establish 1 or more
rating areas within that State for purposes of applying the
requirements of this title.
``(B) Secretarial review.--The Secretary shall review the
rating areas established by each State under subparagraph (A)
to ensure the adequacy of such areas for purposes of carrying
out the requirements of this title. If the Secretary
determines a State's rating areas are not adequate, or that a
State does not establish such areas, the Secretary may
establish rating areas for that State.
``(3) Permissible age bands.--The Secretary, in
consultation with the National Association of Insurance
Commissioners, shall define the permissible age bands for
rating purposes under paragraph (1)(A)(iii).
``(4) Application of variations based on age or tobacco
use.--With respect to family coverage under a group health
plan or health insurance coverage, the rating variations
permitted under clauses (iii) and (iv) of paragraph (1)(A)
shall be applied based on the portion of the premium that is
attributable to each family member covered under the plan or
coverage.
``(5) Special rule for large group market.--If a State
permits health insurance issuers that offer coverage in the
large group market in the State to offer such coverage
through the State Exchange (as provided for under section
1312(f)(2)(B) of the Patient Protection and Affordable Care
Act), the provisions of this subsection shall apply to all
coverage offered in such market in the State.
``SEC. 2702. GUARANTEED AVAILABILITY OF COVERAGE.
``(a) Guaranteed Issuance of Coverage in the Individual and
Group Market.--Subject to subsections (b) through (e), each
health insurance issuer that offers health insurance coverage
in the individual or group market in a State must accept
every employer and individual in the State that applies for
such coverage.
``(b) Enrollment.--
``(1) Restriction.--A health insurance issuer described in
subsection (a) may restrict enrollment in coverage described
in such subsection to open or special enrollment periods.
``(2) Establishment.--A health insurance issuer described
in subsection (a) shall, in accordance with the regulations
promulgated under paragraph (3), establish special enrollment
periods for qualifying events (under section 603 of the
Employee Retirement Income Security Act of 1974).
``(3) Regulations.--The Secretary shall promulgate
regulations with respect to enrollment periods under
paragraphs (1) and (2).
``SEC. 2703. GUARANTEED RENEWABILITY OF COVERAGE.
``(a) In General.--Except as provided in this section, if a
health insurance issuer offers health insurance coverage in
the individual or group market, the issuer must renew or
continue in force such coverage at the option of the plan
sponsor or the individual, as applicable.
``SEC. 2705. PROHIBITING DISCRIMINATION AGAINST INDIVIDUAL
PARTICIPANTS AND BENEFICIARIES BASED ON HEALTH
STATUS.
``(a) In General.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage may not establish rules for eligibility
(including continued eligibility) of any individual to enroll
under the terms of the plan or coverage based on any of the
following health status-related factors in relation to the
individual or a dependent of the individual:
``(1) Health status.
``(2) Medical condition (including both physical and mental
illnesses).
``(3) Claims experience.
``(4) Receipt of health care.
``(5) Medical history.
``(6) Genetic information.
``(7) Evidence of insurability (including conditions
arising out of acts of domestic violence).
``(8) Disability.
``(9) Any other health status-related factor determined
appropriate by the Secretary.
``(j) Programs of Health Promotion or Disease Prevention.--
``(1) General provisions.--
``(A) General rule.--For purposes of subsection (b)(2)(B),
a program of health promotion or disease prevention (referred
to in this subsection as a `wellness program') shall be a
program offered by an employer that is designed to promote
health or prevent disease that meets the applicable
requirements of this subsection.
``(B) No conditions based on health status factor.--If none
of the conditions for obtaining a premium discount or rebate
or other reward for participation in a wellness program is
based on an individual satisfying a standard that is related
to a health status factor, such wellness program shall not
violate this section if participation in the program is made
available to all similarly situated individuals and the
requirements of paragraph (2) are complied with.
``(C) Conditions based on health status factor.--If any of
the conditions for obtaining a premium discount or rebate or
other reward for participation in a wellness program is based
on an individual satisfying a standard that is related to a
health status factor, such wellness program shall not violate
this section if the requirements of paragraph (3) are
complied with.
``(2) Wellness programs not subject to requirements.--If
none of the conditions for obtaining a premium discount or
rebate or other reward under a wellness program as described
in paragraph (1)(B) are based on an individual satisfying a
standard that is related to a health status factor (or if
such a wellness program does not provide such a reward), the
wellness program shall not violate this section if
participation in the program is made available to all
similarly situated individuals. The following programs shall
not have to comply with the requirements of paragraph (3) if
participation in the program is made available to all
similarly situated individuals:
``(A) A program that reimburses all or part of the cost for
memberships in a fitness center.
``(B) A diagnostic testing program that provides a reward
for participation and does not base any part of the reward on
outcomes.
``(C) A program that encourages preventive care related to
a health condition through the waiver of the copayment or
deductible requirement under group health plan for the costs
of certain items or services related to a health condition
(such as prenatal care or well-baby visits).
``(D) A program that reimburses individuals for the costs
of smoking cessation programs without regard to whether the
individual quits smoking.
``(E) A program that provides a reward to individuals for
attending a periodic health education seminar.
``(3) Wellness programs subject to requirements.--If any of
the conditions for obtaining a premium discount, rebate, or
reward
[[Page H1932]]
under a wellness program as described in paragraph (1)(C) is
based on an individual satisfying a standard that is related
to a health status factor, the wellness program shall not
violate this section if the following requirements are
complied with:
``(A) The reward for the wellness program, together with
the reward for other wellness programs with respect to the
plan that requires satisfaction of a standard related to a
health status factor, shall not exceed 30 percent of the cost
of employee-only coverage under the plan. If, in addition to
employees or individuals, any class of dependents (such as
spouses or spouses and dependent children) may participate
fully in the wellness program, such reward shall not exceed
30 percent of the cost of the coverage in which an employee
or individual and any dependents are enrolled. For purposes
of this paragraph, the cost of coverage shall be determined
based on the total amount of employer and employee
contributions for the benefit package under which the
employee is (or the employee and any dependents are)
receiving coverage. A reward may be in the form of a discount
or rebate of a premium or contribution, a waiver of all or
part of a cost-sharing mechanism (such as deductibles,
copayments, or coinsurance), the absence of a surcharge, or
the value of a benefit that would otherwise not be provided
under the plan. The Secretaries of Labor, Health and Human
Services, and the Treasury may increase the reward available
under this subparagraph to up to 50 percent of the cost of
coverage if the Secretaries determine that such an increase
is appropriate.
``(B) The wellness program shall be reasonably designed to
promote health or prevent disease. A program complies with
the preceding sentence if the program has a reasonable chance
of improving the health of, or preventing disease in,
participating individuals and it is not overly burdensome, is
not a subterfuge for discriminating based on a health status
factor, and is not highly suspect in the method chosen to
promote health or prevent disease.
``(C) The plan shall give individuals eligible for the
program the opportunity to qualify for the reward under the
program at least once each year.
``(D) The full reward under the wellness program shall be
made available to all similarly situated individuals. For
such purpose, among other things:
``(i) The reward is not available to all similarly situated
individuals for a period unless the wellness program allows--
``(I) for a reasonable alternative standard (or waiver of
the otherwise applicable standard) for obtaining the reward
for any individual for whom, for that period, it is
unreasonably difficult due to a medical condition to satisfy
the otherwise applicable standard; and
``(II) for a reasonable alternative standard (or waiver of
the otherwise applicable standard) for obtaining the reward
for any individual for whom, for that period, it is medically
inadvisable to attempt to satisfy the otherwise applicable
standard.
``(ii) If reasonable under the circumstances, the plan or
issuer may seek verification, such as a statement from an
individual's physician, that a health status factor makes it
unreasonably difficult or medically inadvisable for the
individual to satisfy or attempt to satisfy the otherwise
applicable standard.
``(E) The plan or issuer involved shall disclose in all
plan materials describing the terms of the wellness program
the availability of a reasonable alternative standard (or the
possibility of waiver of the otherwise applicable standard)
required under subparagraph (D). If plan materials disclose
that such a program is available, without describing its
terms, the disclosure under this subparagraph shall not be
required.
``(k) Existing Programs.--Nothing in this section shall
prohibit a program of health promotion or disease prevention
that was established prior to the date of enactment of this
section and applied with all applicable regulations, and that
is operating on such date, from continuing to be carried out
for as long as such regulations remain in effect.
``(l) Wellness Program Demonstration Project.--
``(1) In general.--Not later than July 1, 2014, the
Secretary, in consultation with the Secretary of the Treasury
and the Secretary of Labor, shall establish a 10-State
demonstration project under which participating States shall
apply the provisions of subsection (j) to programs of health
promotion offered by a health insurance issuer that offers
health insurance coverage in the individual market in such
State.
``(2) Expansion of demonstration project.--If the
Secretary, in consultation with the Secretary of the Treasury
and the Secretary of Labor, determines that the demonstration
project described in paragraph (1) is effective, such
Secretaries may, beginning on July 1, 2017 expand such
demonstration project to include additional participating
States.
``(3) Requirements.--
``(A) Maintenance of coverage.--The Secretary, in
consultation with the Secretary of the Treasury and the
Secretary of Labor, shall not approve the participation of a
State in the demonstration project under this section unless
the Secretaries determine that the State's project is
designed in a manner that--
``(i) will not result in any decrease in coverage; and
``(ii) will not increase the cost to the Federal Government
in providing credits under section 36B of the Internal
Revenue Code of 1986 or cost-sharing assistance under section
1402 of the Patient Protection and Affordable Care Act.
``(B) Other requirements.--States that participate in the
demonstration project under this subsection--
``(i) may permit premium discounts or rebates or the
modification of otherwise applicable copayments or
deductibles for adherence to, or participation in, a
reasonably designed program of health promotion and disease
prevention;
``(ii) shall ensure that requirements of consumer
protection are met in programs of health promotion in the
individual market;
``(iii) shall require verification from health insurance
issuers that offer health insurance coverage in the
individual market of such State that premium discounts--
``(I) do not create undue burdens for individuals insured
in the individual market;
``(II) do not lead to cost shifting; and
``(III) are not a subterfuge for discrimination;
``(iv) shall ensure that consumer data is protected in
accordance with the requirements of section 264(c) of the
Health Insurance Portability and Accountability Act of 1996
(42 U.S.C. 1320d-2 note); and
``(v) shall ensure and demonstrate to the satisfaction of
the Secretary that the discounts or other rewards provided
under the project reflect the expected level of participation
in the wellness program involved and the anticipated effect
the program will have on utilization or medical claim costs.
``(m) Report.--
``(1) In general.--Not later than 3 years after the date of
enactment of the Patient Protection and Affordable Care Act,
the Secretary, in consultation with the Secretary of the
Treasury and the Secretary of Labor, shall submit a report to
the appropriate committees of Congress concerning--
``(A) the effectiveness of wellness programs (as defined in
subsection (j)) in promoting health and preventing disease;
``(B) the impact of such wellness programs on the access to
care and affordability of coverage for participants and non-
participants of such programs;
``(C) the impact of premium-based and cost-sharing
incentives on participant behavior and the role of such
programs in changing behavior; and
``(D) the effectiveness of different types of rewards.
``(2) Data collection.--In preparing the report described
in paragraph (1), the Secretaries shall gather relevant
information from employers who provide employees with access
to wellness programs, including State and Federal agencies.
``(n) Regulations.--Nothing in this section shall be
construed as prohibiting the Secretaries of Labor, Health and
Human Services, or the Treasury from promulgating regulations
in connection with this section.
``SEC. 2706. NON-DISCRIMINATION IN HEALTH CARE.
``(a) Providers.--A group health plan and a health
insurance issuer offering group or individual health
insurance coverage shall not discriminate with respect to
participation under the plan or coverage against any health
care provider who is acting within the scope of that
provider's license or certification under applicable State
law. This section shall not require that a group health plan
or health insurance issuer contract with any health care
provider willing to abide by the terms and conditions for
participation established by the plan or issuer. Nothing in
this section shall be construed as preventing a group health
plan, a health insurance issuer, or the Secretary from
establishing varying reimbursement rates based on quality or
performance measures.
``(b) Individuals.--The provisions of section 1558 of the
Patient Protection and Affordable Care Act (relating to non-
discrimination) shall apply with respect to a group health
plan or health insurance issuer offering group or individual
health insurance coverage.
``SEC. 2707. COMPREHENSIVE HEALTH INSURANCE COVERAGE.
``(a) Coverage for Essential Health Benefits Package.--A
health insurance issuer that offers health insurance coverage
in the individual or small group market shall ensure that
such coverage includes the essential health benefits package
required under section 1302(a) of the Patient Protection and
Affordable Care Act.
``(b) Cost-sharing Under Group Health Plans.--A group
health plan shall ensure that any annual cost-sharing imposed
under the plan does not exceed the limitations provided for
under paragraphs (1) and (2) of section 1302(c).
``(c) Child-only Plans.--If a health insurance issuer
offers health insurance coverage in any level of coverage
specified under section 1302(d) of the Patient Protection and
Affordable Care Act, the issuer shall also offer such
coverage in that level as a plan in which the only enrollees
are individuals who, as of the beginning of a plan year, have
not attained the age of 21.
``(d) Dental Only.--This section shall not apply to a plan
described in section 1302(d)(2)(B)(ii)(I).
``SEC. 2708. PROHIBITION ON EXCESSIVE WAITING PERIODS.
``A group health plan and a health insurance issuer
offering group or individual health insurance coverage shall
not apply any waiting period (as defined in section
2704(b)(4)) that exceeds 90 days.''.
PART II--OTHER PROVISIONS
SEC. 1251. PRESERVATION OF RIGHT TO MAINTAIN EXISTING
COVERAGE.
(a) No Changes to Existing Coverage.--
(1) In general.--Nothing in this Act (or an amendment made
by this Act) shall be construed to require that an individual
terminate coverage under a group health plan or health
insurance coverage in which such individual was enrolled on
the date of enactment of this Act.
(2) Continuation of coverage.--With respect to a group
health plan or health insurance coverage in which an
individual was enrolled on the date of enactment of this Act,
this subtitle and subtitle A (and the amendments made by such
subtitles) shall not apply to such plan or
[[Page H1933]]
coverage, regardless of whether the individual renews such
coverage after such date of enactment.
(b) Allowance for Family Members To Join Current
Coverage.--With respect to a group health plan or health
insurance coverage in which an individual was enrolled on the
date of enactment of this Act and which is renewed after such
date, family members of such individual shall be permitted to
enroll in such plan or coverage if such enrollment is
permitted under the terms of the plan in effect as of such
date of enactment.
(c) Allowance for New Employees To Join Current Plan.--A
group health plan that provides coverage on the date of
enactment of this Act may provide for the enrolling of new
employees (and their families) in such plan, and this
subtitle and subtitle A (and the amendments made by such
subtitles) shall not apply with respect to such plan and such
new employees (and their families).
(d) Effect on Collective Bargaining Agreements.--In the
case of health insurance coverage maintained pursuant to one
or more collective bargaining agreements between employee
representatives and one or more employers that was ratified
before the date of enactment of this Act, the provisions of
this subtitle and subtitle A (and the amendments made by such
subtitles) shall not apply until the date on which the last
of the collective bargaining agreements relating to the
coverage terminates. Any coverage amendment made pursuant to
a collective bargaining agreement relating to the coverage
which amends the coverage solely to conform to any
requirement added by this subtitle or subtitle A (or
amendments) shall not be treated as a termination of such
collective bargaining agreement.
(e) Definition.--In this title, the term ``grandfathered
health plan'' means any group health plan or health insurance
coverage to which this section applies.
SEC. 1252. RATING REFORMS MUST APPLY UNIFORMLY TO ALL HEALTH
INSURANCE ISSUERS AND GROUP HEALTH PLANS.
Any standard or requirement adopted by a State pursuant to
this title, or any amendment made by this title, shall be
applied uniformly to all health plans in each insurance
market to which the standard and requirements apply. The
preceding sentence shall also apply to a State standard or
requirement relating to the standard or requirement required
by this title (or any such amendment) that is not the same as
the standard or requirement but that is not preempted under
section 1321(d).
SEC. 1253. EFFECTIVE DATES.
This subtitle (and the amendments made by this subtitle)
shall become effective for plan years beginning on or after
January 1, 2014.
Subtitle D--Available Coverage Choices for All Americans
PART I--ESTABLISHMENT OF QUALIFIED HEALTH PLANS
SEC. 1301. QUALIFIED HEALTH PLAN DEFINED.
(a) Qualified Health Plan.--In this title:
(1) In general.--The term ``qualified health plan'' means a
health plan that--
(A) has in effect a certification (which may include a seal
or other indication of approval) that such plan meets the
criteria for certification described in section 1311(c)
issued or recognized by each Exchange through which such plan
is offered;
(B) provides the essential health benefits package
described in section 1302(a); and
(C) is offered by a health insurance issuer that--
(i) is licensed and in good standing to offer health
insurance coverage in each State in which such issuer offers
health insurance coverage under this title;
(ii) agrees to offer at least one qualified health plan in
the silver level and at least one plan in the gold level in
each such Exchange;
(iii) agrees to charge the same premium rate for each
qualified health plan of the issuer without regard to whether
the plan is offered through an Exchange or whether the plan
is offered directly from the issuer or through an agent; and
(iv) complies with the regulations developed by the
Secretary under section 1311(d) and such other requirements
as an applicable Exchange may establish.
(2) Inclusion of co-op plans and community health insurance
option.--Any reference in this title to a qualified health
plan shall be deemed to include a qualified health plan
offered through the CO-OP program under section 1322 or a
community health insurance option under section 1323, unless
specifically provided for otherwise.
(b) Terms Relating to Health Plans.--In this title:
(1) Health plan.--
(A) In general.--The term ``health plan'' means health
insurance coverage and a group health plan.
(B) Exception for self-insured plans and mewas.--Except to
the extent specifically provided by this title, the term
``health plan'' shall not include a group health plan or
multiple employer welfare arrangement to the extent the plan
or arrangement is not subject to State insurance regulation
under section 514 of the Employee Retirement Income Security
Act of 1974.
(2) Health insurance coverage and issuer.--The terms
``health insurance coverage'' and ``health insurance issuer''
have the meanings given such terms by section 2791(b) of the
Public Health Service Act.
(3) Group health plan.--The term ``group health plan'' has
the meaning given such term by section 2791(a) of the Public
Health Service Act.
SEC. 1302. ESSENTIAL HEALTH BENEFITS REQUIREMENTS.
(a) Essential Health Benefits Package.--In this title, the
term ``essential health benefits package'' means, with
respect to any health plan, coverage that--
(1) provides for the essential health benefits defined by
the Secretary under subsection (b);
(2) limits cost-sharing for such coverage in accordance
with subsection (c); and
(3) subject to subsection (e), provides either the bronze,
silver, gold, or platinum level of coverage described in
subsection (d).
(b) Essential Health Benefits.--
(1) In general.--Subject to paragraph (2), the Secretary
shall define the essential health benefits, except that such
benefits shall include at least the following general
categories and the items and services covered within the
categories:
(A) Ambulatory patient services.
(B) Emergency services.
(C) Hospitalization.
(D) Maternity and newborn care.
(E) Mental health and substance use disorder services,
including behavioral health treatment.
(F) Prescription drugs.
(G) Rehabilitative and habilitative services and devices.
(H) Laboratory services.
(I) Preventive and wellness services and chronic disease
management.
(J) Pediatric services, including oral and vision care.
(2) Limitation.--
(A) In general.--The Secretary shall ensure that the scope
of the essential health benefits under paragraph (1) is equal
to the scope of benefits provided under a typical employer
plan, as determined by the Secretary. To inform this
determination, the Secretary of Labor shall conduct a survey
of employer-sponsored coverage to determine the benefits
typically covered by employers, including multiemployer
plans, and provide a report on such survey to the Secretary.
(B) Certification.--In defining the essential health
benefits described in paragraph (1), and in revising the
benefits under paragraph (4)(H), the Secretary shall submit a
report to the appropriate committees of Congress containing a
certification from the Chief Actuary of the Centers for
Medicare & Medicaid Services that such essential health
benefits meet the limitation described in paragraph (2).
(3) Notice and hearing.--In defining the essential health
benefits described in paragraph (1), and in revising the
benefits under paragraph (4)(H), the Secretary shall provide
notice and an opportunity for public comment.
(4) Required elements for consideration.--In defining the
essential health benefits under paragraph (1), the Secretary
shall--
(A) ensure that such essential health benefits reflect an
appropriate balance among the categories described in such
subsection, so that benefits are not unduly weighted toward
any category;
(B) not make coverage decisions, determine reimbursement
rates, establish incentive programs, or design benefits in
ways that discriminate against individuals because of their
age, disability, or expected length of life;
(C) take into account the health care needs of diverse
segments of the population, including women, children,
persons with disabilities, and other groups;
(D) ensure that health benefits established as essential
not be subject to denial to individuals against their wishes
on the basis of the individuals' age or expected length of
life or of the individuals' present or predicted disability,
degree of medical dependency, or quality of life;
(E) provide that a qualified health plan shall not be
treated as providing coverage for the essential health
benefits described in paragraph (1) unless the plan provides
that--
(i) coverage for emergency department services will be
provided without imposing any requirement under the plan for
prior authorization of services or any limitation on coverage
where the provider of services does not have a contractual
relationship with the plan for the providing of services that
is more restrictive than the requirements or limitations that
apply to emergency department services received from
providers who do have such a contractual relationship with
the plan; and
(ii) if such services are provided out-of-network, the
cost-sharing requirement (expressed as a copayment amount or
coinsurance rate) is the same requirement that would apply if
such services were provided in-network;
(F) provide that if a plan described in section
1311(b)(2)(B)(ii) (relating to stand-alone dental benefits
plans) is offered through an Exchange, another health plan
offered through such Exchange shall not fail to be treated as
a qualified health plan solely because the plan does not
offer coverage of benefits offered through the stand-alone
plan that are otherwise required under paragraph (1)(J); and
(G) periodically review the essential health benefits under
paragraph (1), and provide a report to Congress and the
public that contains--
(i) an assessment of whether enrollees are facing any
difficulty accessing needed services for reasons of coverage
or cost;
(ii) an assessment of whether the essential health benefits
needs to be modified or updated to account for changes in
medical evidence or scientific advancement;
(iii) information on how the essential health benefits will
be modified to address any such gaps in access or changes in
the evidence base;
(iv) an assessment of the potential of additional or
expanded benefits to increase costs and the interactions
between the addition or expansion of benefits and reductions
in existing benefits to meet actuarial limitations described
in paragraph (2); and
(H) periodically update the essential health benefits under
paragraph (1) to address any gaps in access to coverage or
changes in the evidence base the Secretary identifies in the
review conducted under subparagraph (G).
[[Page H1934]]
(5) Rule of construction.--Nothing in this title shall be
construed to prohibit a health plan from providing benefits
in excess of the essential health benefits described in this
subsection.
(c) Requirements Relating to Cost-Sharing.--
(1) Annual limitation on cost-sharing.--
(A) 2014.--The cost-sharing incurred under a health plan
with respect to self-only coverage or coverage other than
self-only coverage for a plan year beginning in 2014 shall
not exceed the dollar amounts in effect under section
223(c)(2)(A)(ii) of the Internal Revenue Code of 1986 for
self-only and family coverage, respectively, for taxable
years beginning in 2014.
(B) 2015 and later.--In the case of any plan year beginning
in a calendar year after 2014, the limitation under this
paragraph shall--
(i) in the case of self-only coverage, be equal to the
dollar amount under subparagraph (A) for self-only coverage
for plan years beginning in 2014, increased by an amount
equal to the product of that amount and the premium
adjustment percentage under paragraph (4) for the calendar
year; and
(ii) in the case of other coverage, twice the amount in
effect under clause (i).
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.
(2) Annual limitation on deductibles for employer-sponsored
plans.--
(A) In general.--In the case of a health plan offered in
the small group market, the deductible under the plan shall
not exceed--
(i) $2,000 in the case of a plan covering a single
individual; and
(ii) $4,000 in the case of any other plan.
The amounts under clauses (i) and (ii) may be increased by
the maximum amount of reimbursement which is reasonably
available to a participant under a flexible spending
arrangement described in section 106(c)(2) of the Internal
Revenue Code of 1986 (determined without regard to any salary
reduction arrangement).
(B) Indexing of limits.--In the case of any plan year
beginning in a calendar year after 2014--
(i) the dollar amount under subparagraph (A)(i) shall be
increased by an amount equal to the product of that amount
and the premium adjustment percentage under paragraph (4) for
the calendar year; and
(ii) the dollar amount under subparagraph (A)(ii) shall be
increased to an amount equal to twice the amount in effect
under subparagraph (A)(i) for plan years beginning in the
calendar year, determined after application of clause (i).
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.
(C) Actuarial value.--The limitation under this paragraph
shall be applied in such a manner so as to not affect the
actuarial value of any health plan, including a plan in the
bronze level.
(D) Coordination with preventive limits.--Nothing in this
paragraph shall be construed to allow a plan to have a
deductible under the plan apply to benefits described in
section 2713 of the Public Health Service Act.
(3) Cost-sharing.--In this title--
(A) In general.--The term ``cost-sharing'' includes--
(i) deductibles, coinsurance, copayments, or similar
charges; and
(ii) any other expenditure required of an insured
individual which is a qualified medical expense (within the
meaning of section 223(d)(2) of the Internal Revenue Code of
1986) with respect to essential health benefits covered under
the plan.
(B) Exceptions.--Such term does not include premiums,
balance billing amounts for non-network providers, or
spending for non-covered services.
(4) Premium adjustment percentage.--For purposes of
paragraphs (1)(B)(i) and (2)(B)(i), the premium adjustment
percentage for any calendar year is the percentage (if any)
by which the average per capita premium for health insurance
coverage in the United States for the preceding calendar year
(as estimated by the Secretary no later than October 1 of
such preceding calendar year) exceeds such average per capita
premium for 2013 (as determined by the Secretary).
(d) Levels of Coverage.--
(1) Levels of coverage defined.--The levels of coverage
described in this subsection are as follows:
(A) Bronze level.--A plan in the bronze level shall provide
a level of coverage that is designed to provide benefits that
are actuarially equivalent to 60 percent of the full
actuarial value of the benefits provided under the plan.
(B) Silver level.--A plan in the silver level shall provide
a level of coverage that is designed to provide benefits that
are actuarially equivalent to 70 percent of the full
actuarial value of the benefits provided under the plan.
(C) Gold level.--A plan in the gold level shall provide a
level of coverage that is designed to provide benefits that
are actuarially equivalent to 80 percent of the full
actuarial value of the benefits provided under the plan.
(D) Platinum level.--A plan in the platinum level shall
provide a level of coverage that is designed to provide
benefits that are actuarially equivalent to 90 percent of the
full actuarial value of the benefits provided under the plan.
(2) Actuarial value.--
(A) In general.--Under regulations issued by the Secretary,
the level of coverage of a plan shall be determined on the
basis that the essential health benefits described in
subsection (b) shall be provided to a standard population
(and without regard to the population the plan may actually
provide benefits to).
(B) Employer contributions.--The Secretary may issue
regulations under which employer contributions to a health
savings account (within the meaning of section 223 of the
Internal Revenue Code of 1986) may be taken into account in
determining the level of coverage for a plan of the employer.
(C) Application.--In determining under this title, the
Public Health Service Act, or the Internal Revenue Code of
1986 the percentage of the total allowed costs of benefits
provided under a group health plan or health insurance
coverage that are provided by such plan or coverage, the
rules contained in the regulations under this paragraph shall
apply.
(3) Allowable variance.--The Secretary shall develop
guidelines to provide for a de minimis variation in the
actuarial valuations used in determining the level of
coverage of a plan to account for differences in actuarial
estimates.
(4) Plan reference.--In this title, any reference to a
bronze, silver, gold, or platinum plan shall be treated as a
reference to a qualified health plan providing a bronze,
silver, gold, or platinum level of coverage, as the case may
be.
(e) Catastrophic Plan.--
(1) In general.--A health plan not providing a bronze,
silver, gold, or platinum level of coverage shall be treated
as meeting the requirements of subsection (d) with respect to
any plan year if--
(A) the only individuals who are eligible to enroll in the
plan are individuals described in paragraph (2); and
(B) the plan provides--
(i) except as provided in clause (ii), the essential health
benefits determined under subsection (b), except that the
plan provides no benefits for any plan year until the
individual has incurred cost-sharing expenses in an amount
equal to the annual limitation in effect under subsection
(c)(1) for the plan year (except as provided for in section
2713); and
(ii) coverage for at least three primary care visits.
(2) Individuals eligible for enrollment.--An individual is
described in this paragraph for any plan year if the
individual--
(A) has not attained the age of 30 before the beginning of
the plan year; or
(B) has a certification in effect for any plan year under
this title that the individual is exempt from the requirement
under section 5000A of the Internal Revenue Code of 1986 by
reason of--
(i) section 5000A(e)(1) of such Code (relating to
individuals without affordable coverage); or
(ii) section 5000A(e)(5) of such Code (relating to
individuals with hardships).
(3) Restriction to individual market.--If a health
insurance issuer offers a health plan described in this
subsection, the issuer may only offer the plan in the
individual market.
(f) Child-only Plans.--If a qualified health plan is
offered through the Exchange in any level of coverage
specified under subsection (d), the issuer shall also offer
that plan through the Exchange in that level as a plan in
which the only enrollees are individuals who, as of the
beginning of a plan year, have not attained the age of 21,
and such plan shall be treated as a qualified health plan.
SEC. 1303. SPECIAL RULES.
(a) Special Rules Relating to Coverage of Abortion
Services.--
(1) Voluntary choice of coverage of abortion services.--
(A) In general.--Notwithstanding any other provision of
this title (or any amendment made by this title), and subject
to subparagraphs (C) and (D)--
(i) nothing in this title (or any amendment made by this
title), shall be construed to require a qualified health plan
to provide coverage of services described in subparagraph
(B)(i) or (B)(ii) as part of its essential health benefits
for any plan year; and
(ii) the issuer of a qualified health plan shall determine
whether or not the plan provides coverage of services
described in subparagraph (B)(i) or (B)(ii) as part of such
benefits for the plan year.
(B) Abortion services.--
(i) Abortions for which public funding is prohibited.--The
services described in this clause are abortions for which the
expenditure of Federal funds appropriated for the Department
of Health and Human Services is not permitted, based on the
law as in effect as of the date that is 6 months before the
beginning of the plan year involved.
(ii) Abortions for which public funding is allowed.--The
services described in this clause are abortions for which the
expenditure of Federal funds appropriated for the Department
of Health and Human Services is permitted, based on the law
as in effect as of the date that is 6 months before the
beginning of the plan year involved.
(C) Prohibition on federal funds for abortion services in
community health insurance option.--
(i) Determination by secretary.--The Secretary may not
determine, in accordance with subparagraph (A)(ii), that the
community health insurance option established under section
1323 shall provide coverage of services described in
subparagraph (B)(i) as part of benefits for the plan year
unless the Secretary--
(I) assures compliance with the requirements of paragraph
(2);
(II) assures, in accordance with applicable provisions of
generally accepted accounting requirements, circulars on
funds management of the Office of Management and Budget, and
guidance on accounting of the Government Accountability
Office, that no Federal funds are used for such coverage; and
(III) notwithstanding section 1323(e)(1)(C) or any other
provision of this title, takes all necessary steps to assure
that the United States does not bear the insurance risk for a
community health insurance option's coverage of services
described in subparagraph (B)(i).
(ii) State requirement.--If a State requires, in addition
to the essential health benefits required under section
1323(b)(3) (A), coverage of
[[Page H1935]]
services described in subparagraph (B)(i) for enrollees of a
community health insurance option offered in such State, the
State shall assure that no funds flowing through or from the
community health insurance option, and no other Federal
funds, pay or defray the cost of providing coverage of
services described in subparagraph (B)(i). The United States
shall not bear the insurance risk for a State's required
coverage of services described in subparagraph (B)(i).
(iii) Exceptions.--Nothing in this subparagraph shall apply
to coverage of services described in subparagraph (B)(ii) by
the community health insurance option. Services described in
subparagraph (B)(ii) shall be covered to the same extent as
such services are covered under title XIX of the Social
Security Act.
(D) Assured availability of varied coverage through
exchanges.--
(i) In general.--The Secretary shall assure that with
respect to qualified health plans offered in any Exchange
established pursuant to this title--
(I) there is at least one such plan that provides coverage
of services described in clauses (i) and (ii) of subparagraph
(B); and
(II) there is at least one such plan that does not provide
coverage of services described in subparagraph (B)(i).
(ii) Special rules.--For purposes of clause (i)--
(I) a plan shall be treated as described in clause (i)(II)
if the plan does not provide coverage of services described
in either subparagraph (B)(i) or (B)(ii); and
(II) if a State has one Exchange covering more than 1
insurance market, the Secretary shall meet the requirements
of clause (i) separately with respect to each such market.
(2) Prohibition on the use of federal funds.--
(A) In general.--If a qualified health plan provides
coverage of services described in paragraph (1)(B)(i), the
issuer of the plan shall not use any amount attributable to
any of the following for purposes of paying for such
services:
(i) The credit under section 36B of the Internal Revenue
Code of 1986 (and the amount (if any) of the advance payment
of the credit under section 1412 of the Patient Protection
and Affordable Care Act).
(ii) Any cost-sharing reduction under section 1402 of
thePatient Protection and Affordable Care Act (and the amount
(if any) of the advance payment of the reduction under
section 1412 of the Patient Protection and Affordable Care
Act).
(B) Segregation of funds.--In the case of a plan to which
subparagraph (A) applies, the issuer of the plan shall, out
of amounts not described in subparagraph (A), segregate an
amount equal to the actuarial amounts determined under
subparagraph (C) for all enrollees from the amounts described
in subparagraph (A).
(C) Actuarial value of optional service coverage.--
(i) In general.--The Secretary shall estimate the basic per
enrollee, per month cost, determined on an average actuarial
basis, for including coverage under a qualified health plan
of the services described in paragraph (1)(B)(i).
(ii) Considerations.--In making such estimate, the
Secretary--
(I) may take into account the impact on overall costs of
the inclusion of such coverage, but may not take into account
any cost reduction estimated to result from such services,
including prenatal care, delivery, or postnatal care;
(II) shall estimate such costs as if such coverage were
included for the entire population covered; and
(III) may not estimate such a cost at less than $1 per
enrollee, per month.
(3) Provider conscience protections.--No individual health
care provider or health care facility may be discriminated
against because of a willingness or an unwillingness, if
doing so is contrary to the religious or moral beliefs of the
provider or facility, to provide, pay for, provide coverage
of, or refer for abortions.
(b) Application of State and Federal Laws Regarding
Abortion.--
(1) No preemption of state laws regarding abortion.--
Nothing in this Act shall be construed to preempt or
otherwise have any effect on State laws regarding the
prohibition of (or requirement of) coverage, funding, or
procedural requirements on abortions, including parental
notification or consent for the performance of an abortion on
a minor.
(2) No effect on federal laws regarding abortion.--
(A) In general.--Nothing in this Act shall be construed to
have any effect on Federal laws regarding--
(i) conscience protection;
(ii) willingness or refusal to provide abortion; and
(iii) discrimination on the basis of the willingness or
refusal to provide, pay for, cover, or refer for abortion or
to provide or participate in training to provide abortion.
(3) No effect on federal civil rights law.--Nothing in this
subsection shall alter the rights and obligations of
employees and employers under title VII of the Civil Rights
Act of 1964.
(c) Application of Emergency Services Laws.--Nothing in
this Act shall be construed to relieve any health care
provider from providing emergency services as required by
State or Federal law, including section 1867 of the Social
Security Act (popularly known as ``EMTALA'').
SEC. 1304. RELATED DEFINITIONS.
(a) Definitions Relating to Markets.--In this title:
(1) Group market.--The term ``group market'' means the
health insurance market under which individuals obtain health
insurance coverage (directly or through any arrangement) on
behalf of themselves (and their dependents) through a group
health plan maintained by an employer.
(2) Individual market.--The term ``individual market''
means the market for health insurance coverage offered to
individuals other than in connection with a group health
plan.
(3) Large and small group markets.--The terms ``large group
market'' and ``small group market'' mean the health insurance
market under which individuals obtain health insurance
coverage (directly or through any arrangement) on behalf of
themselves (and their dependents) through a group health plan
maintained by a large employer (as defined in subsection
(b)(1)) or by a small employer (as defined in subsection
(b)(2)), respectively.
(b) Employers.--In this title:
(1) Large employer.--The term ``large employer'' means, in
connection with a group health plan with respect to a
calendar year and a plan year, an employer who employed an
average of at least 101 employees on business days during the
preceding calendar year and who employs at least 1 employee
on the first day of the plan year.
(2) Small employer.--The term ``small employer'' means, in
connection with a group health plan with respect to a
calendar year and a plan year, an employer who employed an
average of at least 1 but not more than 100 employees on
business days during the preceding calendar year and who
employs at least 1 employee on the first day of the plan
year.
(3) State option to treat 50 employees as small.--In the
case of plan years beginning before January 1, 2016, a State
may elect to apply this subsection by substituting ``51
employees'' for ``101 employees'' in paragraph (1) and by
substituting ``50 employees'' for ``100 employees'' in
paragraph (2).
(4) Rules for determining employer size.--For purposes of
this subsection--
(A) Application of aggregation rule for employers.--All
persons treated as a single employer under subsection (b),
(c), (m), or (o) of section 414 of the Internal Revenue Code
of 1986 shall be treated as 1 employer.
(B) Employers not in existence in preceding year.--In the
case of an employer which was not in existence throughout the
preceding calendar year, the determination of whether such
employer is a small or large employer shall be based on the
average number of employees that it is reasonably expected
such employer will employ on business days in the current
calendar year.
(C) Predecessors.--Any reference in this subsection to an
employer shall include a reference to any predecessor of such
employer.
(D) Continuation of participation for growing small
employers.--If--
(i) a qualified employer that is a small employer makes
enrollment in qualified health plans offered in the small
group market available to its employees through an Exchange;
and
(ii) the employer ceases to be a small employer by reason
of an increase in the number of employees of such employer;
the employer shall continue to be treated as a small employer
for purposes of this subtitle for the period beginning with
the increase and ending with the first day on which the
employer does not make such enrollment available to its
employees.
(c) Secretary.--In this title, the term ``Secretary'' means
the Secretary of Health and Human Services.
(d) State.--In this title, the term ``State'' means each of
the 50 States and the District of Columbia.
PART II--CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH
BENEFIT EXCHANGES
SEC. 1311. AFFORDABLE CHOICES OF HEALTH BENEFIT PLANS.
(a) Assistance to States to Establish American Health
Benefit Exchanges.--
(1) Planning and establishment grants.--There shall be
appropriated to the Secretary, out of any moneys in the
Treasury not otherwise appropriated, an amount necessary to
enable the Secretary to make awards, not later than 1 year
after the date of enactment of this Act, to States in the
amount specified in paragraph (2) for the uses described in
paragraph (3).
(2) Amount specified.--For each fiscal year, the Secretary
shall determine the total amount that the Secretary will make
available to each State for grants under this subsection.
(3) Use of funds.--A State shall use amounts awarded under
this subsection for activities (including planning
activities) related to establishing an American Health
Benefit Exchange, as described in subsection (b).
(4) Renewability of grant.--
(A) In general.--Subject to subsection (d)(4), the
Secretary may renew a grant awarded under paragraph (1) if
the State recipient of such grant--
(i) is making progress, as determined by the Secretary,
toward--
(I) establishing an Exchange; and
(II) implementing the reforms described in subtitles A and
C (and the amendments made by such subtitles); and
(ii) is meeting such other benchmarks as the Secretary may
establish.
(B) Limitation.--No grant shall be awarded under this
subsection after January 1, 2015.
(5) Technical assistance to facilitate participation in
shop exchanges.--The Secretary shall provide technical
assistance to States to facilitate the participation of
qualified small businesses in such States in SHOP Exchanges.
(b) American Health Benefit Exchanges.--
(1) In general.--Each State shall, not later than January
1, 2014, establish an American Health Benefit Exchange
(referred to in this title as an ``Exchange'') for the State
that--
(A) facilitates the purchase of qualified health plans;
[[Page H1936]]
(B) provides for the establishment of a Small Business
Health Options Program (in this title referred to as a ``SHOP
Exchange'') that is designed to assist qualified employers in
the State who are small employers in facilitating the
enrollment of their employees in qualified health plans
offered in the small group market in the State; and
(C) meets the requirements of subsection (d).
(2) Merger of individual and shop exchanges.--A State may
elect to provide only one Exchange in the State for providing
both Exchange and SHOP Exchange services to both qualified
individuals and qualified small employers, but only if the
Exchange has adequate resources to assist such individuals
and employers.
(c) Responsibilities of the Secretary.--
(1) In general.--The Secretary shall, by regulation,
establish criteria for the certification of health plans as
qualified health plans. Such criteria shall require that, to
be certified, a plan shall, at a minimum--
(A) meet marketing requirements, and not employ marketing
practices or benefit designs that have the effect of
discouraging the enrollment in such plan by individuals with
significant health needs;
(B) ensure a sufficient choice of providers (in a manner
consistent with applicable network adequacy provisions under
section 2702(c) of the Public Health Service Act), and
provide information to enrollees and prospective enrollees on
the availability of in-network and out-of-network providers;
(C) include within health insurance plan networks those
essential community providers, where available, that serve
predominately low-income, medically-underserved individuals,
such as health care providers defined in section 340B(a)(4)
of the Public Health Service Act and providers described in
section 1927(c)(1)(D)(i)(IV) of the Social Security Act as
set forth by section 221 of Public Law 111-8, except that
nothing in this subparagraph shall be construed to require
any health plan to provide coverage for any specific medical
procedure;
(D)(i) be accredited with respect to local performance on
clinical quality measures such as the Healthcare
Effectiveness Data and Information Set, patient experience
ratings on a standardized Consumer Assessment of Healthcare
Providers and Systems survey, as well as consumer access,
utilization management, quality assurance, provider
credentialing, complaints and appeals, network adequacy and
access, and patient information programs by any entity
recognized by the Secretary for the accreditation of health
insurance issuers or plans (so long as any such entity has
transparent and rigorous methodological and scoring
criteria); or
(ii) receive such accreditation within a period established
by an Exchange for such accreditation that is applicable to
all qualified health plans;
(E) implement a quality improvement strategy described in
subsection (g)(1);
(F) utilize a uniform enrollment form that qualified
individuals and qualified employers may use (either
electronically or on paper) in enrolling in qualified health
plans offered through such Exchange, and that takes into
account criteria that the National Association of Insurance
Commissioners develops and submits to the Secretary;
(G) utilize the standard format established for presenting
health benefits plan options; and
(H) provide information to enrollees and prospective
enrollees, and to each Exchange in which the plan is offered,
on any quality measures for health plan performance endorsed
under section 399JJ of the Public Health Service Act, as
applicable.
(2) Rule of construction.--Nothing in paragraph (1)(C)
shall be construed to require a qualified health plan to
contract with a provider described in such paragraph if such
provider refuses to accept the generally applicable payment
rates of such plan.
(3) Rating system.--The Secretary shall develop a rating
system that would rate qualified health plans offered through
an Exchange in each benefits level on the basis of the
relative quality and price. The Exchange shall include the
quality rating in the information provided to individuals and
employers through the Internet portal established under
paragraph (4).
(4) Enrollee satisfaction system.--The Secretary shall
develop an enrollee satisfaction survey system that would
evaluate the level of enrollee satisfaction with qualified
health plans offered through an Exchange, for each such
qualified health plan that had more than 500 enrollees in the
previous year. The Exchange shall include enrollee
satisfaction information in the information provided to
individuals and employers through the Internet portal
established under paragraph (5) in a manner that allows
individuals to easily compare enrollee satisfaction levels
between comparable plans.
(5) Internet portals.--The Secretary shall--
(A) continue to operate, maintain, and update the Internet
portal developed under section 1103(a) and to assist States
in developing and maintaining their own such portal; and
(B) make available for use by Exchanges a model template
for an Internet portal that may be used to direct qualified
individuals and qualified employers to qualified health
plans, to assist such individuals and employers in
determining whether they are eligible to participate in an
Exchange or eligible for a premium tax credit or cost-sharing
reduction, and to present standardized information (including
quality ratings) regarding qualified health plans offered
through an Exchange to assist consumers in making easy health
insurance choices.
Such template shall include, with respect to each qualified
health plan offered through the Exchange in each rating area,
access to the uniform outline of coverage the plan is
required to provide under section 2716 of the Public Health
Service Act and to a copy of the plan's written policy.
(6) Enrollment periods.--The Secretary shall require an
Exchange to provide for--
(A) an initial open enrollment, as determined by the
Secretary (such determination to be made not later than July
1, 2012);
(B) annual open enrollment periods, as determined by the
Secretary for calendar years after the initial enrollment
period;
(C) special enrollment periods specified in section 9801 of
the Internal Revenue Code of 1986 and other special
enrollment periods under circumstances similar to such
periods under part D of title XVIII of the Social Security
Act; and
(D) special monthly enrollment periods for Indians (as
defined in section 4 of the Indian Health Care Improvement
Act).
(d) Requirements.--
(1) In general.--An Exchange shall be a governmental agency
or nonprofit entity that is established by a State.
(2) Offering of coverage.--
(A) In general.--An Exchange shall make available qualified
health plans to qualified individuals and qualified
employers.
(B) Limitation.--
(i) In general.--An Exchange may not make available any
health plan that is not a qualified health plan.
(ii) Offering of stand-alone dental benefits.--Each
Exchange within a State shall allow an issuer of a plan that
only provides limited scope dental benefits meeting the
requirements of section 9832(c)(2)(A) of the Internal Revenue
Code of 1986 to offer the plan through the Exchange (either
separately or in conjunction with a qualified health plan) if
the plan provides pediatric dental benefits meeting the
requirements of section 1302(b)(1)(J)).
(3) Rules relating to additional required benefits.--
(A) In general.--Except as provided in subparagraph (B), an
Exchange may make available a qualified health plan
notwithstanding any provision of law that may require
benefits other than the essential health benefits specified
under section 1302(b).
(B) States may require additional benefits.--
(i) In general.--Subject to the requirements of clause
(ii), a State may require that a qualified health plan
offered in such State offer benefits in addition to the
essential health benefits specified under section 1302(b).
(ii) State must assume cost.--A State shall make payments
to or on behalf of an individual eligible for the premium tax
credit under section 36B of the Internal Revenue Code of 1986
and any cost-sharing reduction under section 1402 to defray
the cost to the individual of any additional benefits
described in clause (i) which are not eligible for such
credit or reduction under section 36B(b)(3)(D) of such Code
and section 1402(c)(4).
(4) Functions.--An Exchange shall, at a minimum--
(A) implement procedures for the certification,
recertification, and decertification, consistent with
guidelines developed by the Secretary under subsection (c),
of health plans as qualified health plans;
(B) provide for the operation of a toll-free telephone
hotline to respond to requests for assistance;
(C) maintain an Internet website through which enrollees
and prospective enrollees of qualified health plans may
obtain standardized comparative information on such plans;
(D) assign a rating to each qualified health plan offered
through such Exchange in accordance with the criteria
developed by the Secretary under subsection (c)(3);
(E) utilize a standardized format for presenting health
benefits plan options in the Exchange, including the use of
the uniform outline of coverage established under section
2715 of the Public Health Service Act;
(F) in accordance with section 1413, inform individuals of
eligibility requirements for the medicaid program under title
XIX of the Social Security Act, the CHIP program under title
XXI of such Act, or any applicable State or local public
program and if through screening of the application by the
Exchange, the Exchange determines that such individuals are
eligible for any such program, enroll such individuals in
such program;
(G) establish and make available by electronic means a
calculator to determine the actual cost of coverage after the
application of any premium tax credit under section 36B of
the Internal Revenue Code of 1986 and any cost-sharing
reduction under section 1402;
(H) subject to section 1411, grant a certification
attesting that, for purposes of the individual responsibility
penalty under section 5000A of the Internal Revenue Code of
1986, an individual is exempt from the individual requirement
or from the penalty imposed by such section because--
(i) there is no affordable qualified health plan available
through the Exchange, or the individual's employer, covering
the individual; or
(ii) the individual meets the requirements for any other
such exemption from the individual responsibility requirement
or penalty;
(I) transfer to the Secretary of the Treasury--
(i) a list of the individuals who are issued a
certification under subparagraph (H), including the name and
taxpayer identification number of each individual;
(ii) the name and taxpayer identification number of each
individual who was an employee of an employer but who was
determined to be eligible for the premium tax credit under
section 36B of the Internal Revenue Code of 1986 because--
(I) the employer did not provide minimum essential
coverage; or
(II) the employer provided such minimum essential coverage
but it was determined under
[[Page H1937]]
section 36B(c)(2)(C) of such Code to either be unaffordable
to the employee or not provide the required minimum actuarial
value; and
(iii) the name and taxpayer identification number of each
individual who notifies the Exchange under section 1411(b)(4)
that they have changed employers and of each individual who
ceases coverage under a qualified health plan during a plan
year (and the effective date of such cessation);
(J) provide to each employer the name of each employee of
the employer described in subparagraph (I)(ii) who ceases
coverage under a qualified health plan during a plan year
(and the effective date of such cessation); and
(K) establish the Navigator program described in subsection
(i).
(5) Funding limitations.--
(A) No federal funds for continued operations.--In
establishing an Exchange under this section, the State shall
ensure that such Exchange is self-sustaining beginning on
January 1, 2015, including allowing the Exchange to charge
assessments or user fees to participating health insurance
issuers, or to otherwise generate funding, to support its
operations.
(B) Prohibiting wasteful use of funds.--In carrying out
activities under this subsection, an Exchange shall not
utilize any funds intended for the administrative and
operational expenses of the Exchange for staff retreats,
promotional giveaways, excessive executive compensation, or
promotion of Federal or State legislative and regulatory
modifications.
(6) Consultation.--An Exchange shall consult with
stakeholders relevant to carrying out the activities under
this section, including--
(A) health care consumers who are enrollees in qualified
health plans;
(B) individuals and entities with experience in
facilitating enrollment in qualified health plans;
(C) representatives of small businesses and self-employed
individuals;
(D) State Medicaid offices; and
(E) advocates for enrolling hard to reach populations.
(7) Publication of costs.--An Exchange shall publish the
average costs of licensing, regulatory fees, and any other
payments required by the Exchange, and the administrative
costs of such Exchange, on an Internet website to educate
consumers on such costs. Such information shall also include
monies lost to waste, fraud, and abuse.
(e) Certification.--
(1) In general.--An Exchange may certify a health plan as a
qualified health plan if--
(A) such health plan meets the requirements for
certification as promulgated by the Secretary under
subsection (c)(1); and
(B) the Exchange determines that making available such
health plan through such Exchange is in the interests of
qualified individuals and qualified employers in the State or
States in which such Exchange operates, except that the
Exchange may not exclude a health plan--
(i) on the basis that such plan is a fee-for-service plan;
(ii) through the imposition of premium price controls; or
(iii) on the basis that the plan provides treatments
necessary to prevent patients' deaths in circumstances the
Exchange determines are inappropriate or too costly.
(2) Premium considerations.--The Exchange shall require
health plans seeking certification as qualified health plans
to submit a justification for any premium increase prior to
implementation of the increase. Such plans shall prominently
post such information on their websites. The Exchange may
take this information, and the information and the
recommendations provided to the Exchange by the State under
section 2794(b)(1) of the Public Health Service Act (relating
to patterns or practices of excessive or unjustified premium
increases), into consideration when determining whether to
make such health plan available through the Exchange. The
Exchange shall take into account any excess of premium growth
outside the Exchange as compared to the rate of such growth
inside the Exchange, including information reported by the
States.
(f) Flexibility.--
(1) Regional or other interstate exchanges.--An Exchange
may operate in more than one State if--
(A) each State in which such Exchange operates permits such
operation; and
(B) the Secretary approves such regional or interstate
Exchange.
(2) Subsidiary exchanges.--A State may establish one or
more subsidiary Exchanges if--
(A) each such Exchange serves a geographically distinct
area; and
(B) the area served by each such Exchange is at least as
large as a rating area described in section 2701(a) of the
Public Health Service Act.
(3) Authority to contract.--
(A) In general.--A State may elect to authorize an Exchange
established by the State under this section to enter into an
agreement with an eligible entity to carry out 1 or more
responsibilities of the Exchange.
(B) Eligible entity.--In this paragraph, the term
``eligible entity'' means--
(i) a person--
(I) incorporated under, and subject to the laws of, 1 or
more States;
(II) that has demonstrated experience on a State or
regional basis in the individual and small group health
insurance markets and in benefits coverage; and
(III) that is not a health insurance issuer or that is
treated under subsection (a) or (b) of section 52 of the
Internal Revenue Code of 1986 as a member of the same
controlled group of corporations (or under common control
with) as a health insurance issuer; or
(ii) the State medicaid agency under title XIX of the
Social Security Act.
(g) Rewarding Quality Through Market-Based Incentives.--
(1) Strategy described.--A strategy described in this
paragraph is a payment structure that provides increased
reimbursement or other incentives for--
(A) improving health outcomes through the implementation of
activities that shall include quality reporting, effective
case management, care coordination, chronic disease
management, medication and care compliance initiatives,
including through the use of the medical home model, for
treatment or services under the plan or coverage;
(B) the implementation of activities to prevent hospital
readmissions through a comprehensive program for hospital
discharge that includes patient-centered education and
counseling, comprehensive discharge planning, and post
discharge reinforcement by an appropriate health care
professional;
(C) the implementation of activities to improve patient
safety and reduce medical errors through the appropriate use
of best clinical practices, evidence based medicine, and
health information technology under the plan or coverage; and
(D) the implementation of wellness and health promotion
activities.
(2) Guidelines.--The Secretary, in consultation with
experts in health care quality and stakeholders, shall
develop guidelines concerning the matters described in
paragraph (1).
(3) Requirements.--The guidelines developed under paragraph
(2) shall require the periodic reporting to the applicable
Exchange of the activities that a qualified health plan has
conducted to implement a strategy described in paragraph (1).
(h) Quality Improvement.--
(1) Enhancing patient safety.--Beginning on January 1,
2015, a qualified health plan may contract with--
(A) a hospital with greater than 50 beds only if such
hospital--
(i) utilizes a patient safety evaluation system as
described in part C of title IX of the Public Health Service
Act; and
(ii) implements a mechanism to ensure that each patient
receives a comprehensive program for hospital discharge that
includes patient-centered education and counseling,
comprehensive discharge planning, and post discharge
reinforcement by an appropriate health care professional; or
(B) a health care provider only if such provider implements
such mechanisms to improve health care quality as the
Secretary may by regulation require.
(2) Exceptions.--The Secretary may establish reasonable
exceptions to the requirements described in paragraph (1).
(3) Adjustment.--The Secretary may by regulation adjust the
number of beds described in paragraph (1)(A).
(i) Navigators.--
(1) In general.--An Exchange shall establish a program
under which it awards grants to entities described in
paragraph (2) to carry out the duties described in paragraph
(3).
(2) Eligibility.--
(A) In general.--To be eligible to receive a grant under
paragraph (1), an entity shall demonstrate to the Exchange
involved that the entity has existing relationships, or could
readily establish relationships, with employers and
employees, consumers (including uninsured and underinsured
consumers), or self-employed individuals likely to be
qualified to enroll in a qualified health plan.
(B) Types.--Entities described in subparagraph (A) may
include trade, industry, and professional associations,
commercial fishing industry organizations, ranching and
farming organizations, community and consumer-focused
nonprofit groups, chambers of commerce, unions, small
business development centers, other licensed insurance agents
and brokers, and other entities that--
(i) are capable of carrying out the duties described in
paragraph (3);
(ii) meet the standards described in paragraph (4); and
(iii) provide information consistent with the standards
developed under paragraph (5).
(3) Duties.--An entity that serves as a navigator under a
grant under this subsection shall--
(A) conduct public education activities to raise awareness
of the availability of qualified health plans;
(B) distribute fair and impartial information concerning
enrollment in qualified health plans, and the availability of
premium tax credits under section 36B of the Internal Revenue
Code of 1986 and cost-sharing reductions under section 1402;
(C) facilitate enrollment in qualified health plans;
(D) provide referrals to any applicable office of health
insurance consumer assistance or health insurance ombudsman
established under section 2793 of the Public Health Service
Act, or any other appropriate State agency or agencies, for
any enrollee with a grievance, complaint, or question
regarding their health plan, coverage, or a determination
under such plan or coverage; and
(E) provide information in a manner that is culturally and
linguistically appropriate to the needs of the population
being served by the Exchange or Exchanges.
(4) Standards.--
(A) In general.--The Secretary shall establish standards
for navigators under this subsection, including provisions to
ensure that any private or public entity that is selected as
a navigator is qualified, and licensed if appropriate, to
engage in the navigator activities described in this
subsection and to avoid conflicts of interest. Under such
standards, a navigator shall not--
(i) be a health insurance issuer; or
[[Page H1938]]
(ii) receive any consideration directly or indirectly from
any health insurance issuer in connection with the enrollment
of any qualified individuals or employees of a qualified
employer in a qualified health plan.
(5) Fair and impartial information and services.--The
Secretary, in collaboration with States, shall develop
standards to ensure that information made available by
navigators is fair, accurate, and impartial.
(6) Funding.--Grants under this subsection shall be made
from the operational funds of the Exchange and not Federal
funds received by the State to establish the Exchange.
(j) Applicability of Mental Health Parity.--Section 2726 of
the Public Health Service Act shall apply to qualified health
plans in the same manner and to the same extent as such
section applies to health insurance issuers and group health
plans.
(k) Conflict.--An Exchange may not establish rules that
conflict with or prevent the application of regulations
promulgated by the Secretary under this subtitle.
SEC. 1312. CONSUMER CHOICE.
(a) Choice.--
(1) Qualified individuals.--A qualified individual may
enroll in any qualified health plan available to such
individual.
(2) Qualified employers.--
(A) Employer may specify level.--A qualified employer may
provide support for coverage of employees under a qualified
health plan by selecting any level of coverage under section
1302(d) to be made available to employees through an
Exchange.
(B) Employee may choose plans within a level.--Each
employee of a qualified employer that elects a level of
coverage under subparagraph (A) may choose to enroll in a
qualified health plan that offers coverage at that level.
(b) Payment of Premiums by Qualified Individuals.--A
qualified individual enrolled in any qualified health plan
may pay any applicable premium owed by such individual to the
health insurance issuer issuing such qualified health plan.
(c) Single Risk Pool.--
(1) Individual market.--A health insurance issuer shall
consider all enrollees in all health plans (other than
grandfathered health plans) offered by such issuer in the
individual market, including those enrollees who do not
enroll in such plans through the Exchange, to be members of a
single risk pool.
(2) Small group market.--A health insurance issuer shall
consider all enrollees in all health plans (other than
grandfathered health plans) offered by such issuer in the
small group market, including those enrollees who do not
enroll in such plans through the Exchange, to be members of a
single risk pool.
(3) Merger of markets.--A State may require the individual
and small group insurance markets within a State to be merged
if the State determines appropriate.
(4) State law.--A State law requiring grandfathered health
plans to be included in a pool described in paragraph (1) or
(2) shall not apply.
(d) Empowering Consumer Choice.--
(1) Continued operation of market outside exchanges.--
Nothing in this title shall be construed to prohibit--
(A) a health insurance issuer from offering outside of an
Exchange a health plan to a qualified individual or qualified
employer; and
(B) a qualified individual from enrolling in, or a
qualified employer from selecting for its employees, a health
plan offered outside of an Exchange.
(2) Continued operation of state benefit requirements.--
Nothing in this title shall be construed to terminate,
abridge, or limit the operation of any requirement under
State law with respect to any policy or plan that is offered
outside of an Exchange to offer benefits.
(3) Voluntary nature of an exchange.--
(A) Choice to enroll or not to enroll.--Nothing in this
title shall be construed to restrict the choice of a
qualified individual to enroll or not to enroll in a
qualified health plan or to participate in an Exchange.
(B) Prohibition against compelled enrollment.--Nothing in
this title shall be construed to compel an individual to
enroll in a qualified health plan or to participate in an
Exchange.
(C) Individuals allowed to enroll in any plan.--A qualified
individual may enroll in any qualified health plan, except
that in the case of a catastrophic plan described in section
1302(e), a qualified individual may enroll in the plan only
if the individual is eligible to enroll in the plan under
section 1302(e)(2).
(D) Members of congress in the exchange.--
(i) Requirement.--Notwithstanding any other provision of
law, after the effective date of this subtitle, the only
health plans that the Federal Government may make available
to Members of Congress and congressional staff with respect
to their service as a Member of Congress or congressional
staff shall be health plans that are--
(I) created under this Act (or an amendment made by this
Act); or
(II) offered through an Exchange established under this Act
(or an amendment made by this Act).
(ii) Definitions.--In this section:
(I) Member of congress.--The term ``Member of Congress''
means any member of the House of Representatives or the
Senate.
(II) Congressional staff.--The term ``congressional staff''
means all full-time and part-time employees employed by the
official office of a Member of Congress, whether in
Washington, DC or outside of Washington, DC.
(4) No penalty for transferring to minimum essential
coverage outside exchange.--An Exchange, or a qualified
health plan offered through an Exchange, shall not impose any
penalty or other fee on an individual who cancels enrollment
in a plan because the individual becomes eligible for minimum
essential coverage (as defined in section 5000A(f) of the
Internal Revenue Code of 1986 without regard to paragraph
(1)(C) or (D) thereof) or such coverage becomes affordable
(within the meaning of section 36B(c)(2)(C) of such Code).
(e) Enrollment Through Agents or Brokers.--The Secretary
shall establish procedures under which a State may allow
agents or brokers--
(1) to enroll individuals in any qualified health plans in
the individual or small group market as soon as the plan is
offered through an Exchange in the State; and
(2) to assist individuals in applying for premium tax
credits and cost-sharing reductions for plans sold through an
Exchange.
Such procedures may include the establishment of rate
schedules for broker commissions paid by health benefits
plans offered through an exchange.
(f) Qualified Individuals and Employers; Access Limited to
Citizens and Lawful Residents.--
(1) Qualified individuals.--In this title:
(A) In general.--The term ``qualified individual'' means,
with respect to an Exchange, an individual who--
(i) is seeking to enroll in a qualified health plan in the
individual market offered through the Exchange; and
(ii) resides in the State that established the Exchange
(except with respect to territorial agreements under section
1312(f)).
(B) Incarcerated individuals excluded.--An individual shall
not be treated as a qualified individual if, at the time of
enrollment, the individual is incarcerated, other than
incarceration pending the disposition of charges.
(2) Qualified employer.--In this title:
(A) In general.--The term ``qualified employer'' means a
small employer that elects to make all full-time employees of
such employer eligible for 1 or more qualified health plans
offered in the small group market through an Exchange that
offers qualified health plans.
(B) Extension to large groups.--
(i) In general.--Beginning in 2017, each State may allow
issuers of health insurance coverage in the large group
market in the State to offer qualified health plans in such
market through an Exchange. Nothing in this subparagraph
shall be construed as requiring the issuer to offer such
plans through an Exchange.
(ii) Large employers eligible.--If a State under clause (i)
allows issuers to offer qualified health plans in the large
group market through an Exchange, the term ``qualified
employer'' shall include a large employer that elects to make
all full-time employees of such employer eligible for 1 or
more qualified health plans offered in the large group market
through the Exchange.
(3) Access limited to lawful residents.--If an individual
is not, or is not reasonably expected to be for the entire
period for which enrollment is sought, a citizen or national
of the United States or an alien lawfully present in the
United States, the individual shall not be treated as a
qualified individual and may not be covered under a qualified
health plan in the individual market that is offered through
an Exchange.
SEC. 1313. FINANCIAL INTEGRITY.
(a) Accounting for Expenditures.--
(1) In general.--An Exchange shall keep an accurate
accounting of all activities, receipts, and expenditures and
shall annually submit to the Secretary a report concerning
such accountings.
(2) Investigations.--The Secretary, in coordination with
the Inspector General of the Department of Health and Human
Services, may investigate the affairs of an Exchange, may
examine the properties and records of an Exchange, and may
require periodic reports in relation to activities undertaken
by an Exchange. An Exchange shall fully cooperate in any
investigation conducted under this paragraph.
(3) Audits.--An Exchange shall be subject to annual audits
by the Secretary.
(4) Pattern of abuse.--If the Secretary determines that an
Exchange or a State has engaged in serious misconduct with
respect to compliance with the requirements of, or carrying
out of activities required under, this title, the Secretary
may rescind from payments otherwise due to such State
involved under this or any other Act administered by the
Secretary an amount not to exceed 1 percent of such payments
per year until corrective actions are taken by the State that
are determined to be adequate by the Secretary.
(5) Protections against fraud and abuse.--With respect to
activities carried out under this title, the Secretary shall
provide for the efficient and non-discriminatory
administration of Exchange activities and implement any
measure or procedure that--
(A) the Secretary determines is appropriate to reduce fraud
and abuse in the administration of this title; and
(B) the Secretary has authority to implement under this
title or any other Act.
(6) Application of the false claims act.--
(A) In general.--Payments made by, through, or in
connection with an Exchange are subject to the False Claims
Act (31 U.S.C. 3729 et seq.) if those payments include any
Federal funds. Compliance with the requirements of this Act
concerning eligibility for a health insurance issuer to
participate in the Exchange shall be a material condition of
an issuer's entitlement to receive payments, including
payments of premium tax credits and cost-sharing reductions,
through the Exchange.
(B) Damages.--Notwithstanding paragraph (1) of section
3729(a) of title 31, United States
[[Page H1939]]
Code, and subject to paragraph (2) of such section, the civil
penalty assessed under the False Claims Act on any person
found liable under such Act as described in subparagraph (A)
shall be increased by not less than 3 times and not more than
6 times the amount of damages which the Government sustains
because of the act of that person.
(b) GAO Oversight.--Not later than 5 years after the first
date on which Exchanges are required to be operational under
this title, the Comptroller General shall conduct an ongoing
study of Exchange activities and the enrollees in qualified
health plans offered through Exchanges. Such study shall
review--
(1) the operations and administration of Exchanges,
including surveys and reports of qualified health plans
offered through Exchanges and on the experience of such plans
(including data on enrollees in Exchanges and individuals
purchasing health insurance coverage outside of Exchanges),
the expenses of Exchanges, claims statistics relating to
qualified health plans, complaints data relating to such
plans, and the manner in which Exchanges meet their goals;
(2) any significant observations regarding the utilization
and adoption of Exchanges;
(3) where appropriate, recommendations for improvements in
the operations or policies of Exchanges; and
(4) how many physicians, by area and specialty, are not
taking or accepting new patients enrolled in Federal
Government health care programs, and the adequacy of provider
networks of Federal Government health care programs.
PART III--STATE FLEXIBILITY RELATING TO EXCHANGES
SEC. 1321. STATE FLEXIBILITY IN OPERATION AND ENFORCEMENT OF
EXCHANGES AND RELATED REQUIREMENTS.
(a) Establishment of Standards.--
(1) In general.--The Secretary shall, as soon as
practicable after the date of enactment of this Act, issue
regulations setting standards for meeting the requirements
under this title, and the amendments made by this title, with
respect to--
(A) the establishment and operation of Exchanges (including
SHOP Exchanges);
(B) the offering of qualified health plans through such
Exchanges;
(C) the establishment of the reinsurance and risk
adjustment programs under part V; and
(D) such other requirements as the Secretary determines
appropriate.
The preceding sentence shall not apply to standards for
requirements under subtitles A and C (and the amendments made
by such subtitles) for which the Secretary issues regulations
under the Public Health Service Act.
(2) Consultation.--In issuing the regulations under
paragraph (1), the Secretary shall consult with the National
Association of Insurance Commissioners and its members and
with health insurance issuers, consumer organizations, and
such other individuals as the Secretary selects in a manner
designed to ensure balanced representation among interested
parties.
(b) State Action.--Each State that elects, at such time and
in such manner as the Secretary may prescribe, to apply the
requirements described in subsection (a) shall, not later
than January 1, 2014, adopt and have in effect--
(1) the Federal standards established under subsection (a);
or
(2) a State law or regulation that the Secretary determines
implements the standards within the State.
(c) Failure To Establish Exchange or Implement
Requirements.--
(1) In general.--If--
(A) a State is not an electing State under subsection (b);
or
(B) the Secretary determines, on or before January 1, 2013,
that an electing State--
(i) will not have any required Exchange operational by
January 1, 2014; or
(ii) has not taken the actions the Secretary determines
necessary to implement--
(I) the other requirements set forth in the standards under
subsection (a); or
(II) the requirements set forth in subtitles A and C and
the amendments made by such subtitles;
the Secretary shall (directly or through agreement with a
not-for-profit entity) establish and operate such Exchange
within the State and the Secretary shall take such actions as
are necessary to implement such other requirements.
(2) Enforcement authority.--The provisions of section
2736(b) of the Public Health Services Act shall apply to the
enforcement under paragraph (1) of requirements of subsection
(a)(1) (without regard to any limitation on the application
of those provisions to group health plans).
(d) No Interference With State Regulatory Authority.--
Nothing in this title shall be construed to preempt any State
law that does not prevent the application of the provisions
of this title.
(e) Presumption for Certain State-Operated Exchanges.--
(1) In general.--In the case of a State operating an
Exchange before January 1, 2010, and which has insured a
percentage of its population not less than the percentage of
the population projected to be covered nationally after the
implementation of this Act, that seeks to operate an Exchange
under this section, the Secretary shall presume that such
Exchange meets the standards under this section unless the
Secretary determines, after completion of the process
established under paragraph (2), that the Exchange does not
comply with such standards.
(2) Process.--The Secretary shall establish a process to
work with a State described in paragraph (1) to provide
assistance necessary to assist the State's Exchange in coming
into compliance with the standards for approval under this
section.
SEC. 1322. FEDERAL PROGRAM TO ASSIST ESTABLISHMENT AND
OPERATION OF NONPROFIT, MEMBER-RUN HEALTH
INSURANCE ISSUERS.
(a) Establishment of Program.--
(1) In general.--The Secretary shall establish a program to
carry out the purposes of this section to be known as the
Consumer Operated and Oriented Plan (CO-OP) program.
(2) Purpose.--It is the purpose of the CO-OP program to
foster the creation of qualified nonprofit health insurance
issuers to offer qualified health plans in the individual and
small group markets in the States in which the issuers are
licensed to offer such plans.
(b) Loans and Grants Under the CO-OP Program.--
(1) In general.--The Secretary shall provide through the
CO-OP program for the awarding to persons applying to become
qualified nonprofit health insurance issuers of--
(A) loans to provide assistance to such person in meeting
its start-up costs; and
(B) grants to provide assistance to such person in meeting
any solvency requirements of States in which the person seeks
to be licensed to issue qualified health plans.
(2) Requirements for awarding loans and grants.--
(A) In general.--In awarding loans and grants under the CO-
OP program, the Secretary shall--
(i) take into account the recommendations of the advisory
board established under paragraph (3);
(ii) give priority to applicants that will offer qualified
health plans on a Statewide basis, will utilize integrated
care models, and have significant private support; and
(iii) ensure that there is sufficient funding to establish
at least 1 qualified nonprofit health insurance issuer in
each State, except that nothing in this clause shall prohibit
the Secretary from funding the establishment of multiple
qualified nonprofit health insurance issuers in any State if
the funding is sufficient to do so.
(B) States without issuers in program.--If no health
insurance issuer applies to be a qualified nonprofit health
insurance issuer within a State, the Secretary may use
amounts appropriated under this section for the awarding of
grants to encourage the establishment of a qualified
nonprofit health insurance issuer within the State or the
expansion of a qualified nonprofit health insurance issuer
from another State to the State.
(C) Agreement.--
(i) In general.--The Secretary shall require any person
receiving a loan or grant under the CO-OP program to enter
into an agreement with the Secretary which requires such
person to meet (and to continue to meet)--
(I) any requirement under this section for such person to
be treated as a qualified nonprofit health insurance issuer;
and
(II) any requirements contained in the agreement for such
person to receive such loan or grant.
(ii) Restrictions on use of federal funds.--The agreement
shall include a requirement that no portion of the funds made
available by any loan or grant under this section may be
used--
(I) for carrying on propaganda, or otherwise attempting, to
influence legislation; or
(II) for marketing.
Nothing in this clause shall be construed to allow a person
to take any action prohibited by section 501(c)(29) of the
Internal Revenue Code of 1986.
(iii) Failure to meet requirements.--If the Secretary
determines that a person has failed to meet any requirement
described in clause (i) or (ii) and has failed to correct
such failure within a reasonable period of time of when the
person first knows (or reasonably should have known) of such
failure, such person shall repay to the Secretary an amount
equal to the sum of--
(I) 110 percent of the aggregate amount of loans and grants
received under this section; plus
(II) interest on the aggregate amount of loans and grants
received under this section for the period the loans or
grants were outstanding.
The Secretary shall notify the Secretary of the Treasury of
any determination under this section of a failure that
results in the termination of an issuer's tax-exempt status
under section 501(c)(29) of such Code.
(D) Time for awarding loans and grants.--The Secretary
shall not later than July 1, 2013, award the loans and grants
under the CO-OP program and begin the distribution of amounts
awarded under such loans and grants.
(3) Advisory board.--
(A) In general.--The advisory board under this paragraph
shall consist of 15 members appointed by the Comptroller
General of the United States from among individuals with
qualifications described in section 1805(c)(2) of the Social
Security Act.
(B) Rules relating to appointments.--
(i) Standards.--Any individual appointed under subparagraph
(A) shall meet ethics and conflict of interest standards
protecting against insurance industry involvement and
interference.
(ii) Original appointments.--The original appointment of
board members under subparagraph (A)(ii) shall be made no
later than 3 months after the date of enactment of this Act.
(C) Vacancy.--Any vacancy on the advisory board shall be
filled in the same manner as the original appointment.
(D) Pay and reimbursement.--
(i) No compensation for members of advisory board.--Except
as provided in clause (ii), a member of the advisory board
may not receive pay, allowances, or benefits by reason of
their service on the board.
(ii) Travel expenses.--Each member shall receive travel
expenses, including per diem in lieu
[[Page H1940]]
of subsistence under subchapter I of chapter 57 of title 5,
United States Code.
(E) Application of faca.--The Federal Advisory Committee
Act (5 U.S.C. App.) shall apply to the advisory board, except
that section 14 of such Act shall not apply.
(F) Termination.--The advisory board shall terminate on the
earlier of the date that it completes its duties under this
section or December 31, 2015.
(c) Qualified Nonprofit Health Insurance Issuer.--For
purposes of this section--
(1) In general.--The term ``qualified nonprofit health
insurance issuer'' means a health insurance issuer that is an
organization--
(A) that is organized under State law as a nonprofit,
member corporation;
(B) substantially all of the activities of which consist of
the issuance of qualified health plans in the individual and
small group markets in each State in which it is licensed to
issue such plans; and
(C) that meets the other requirements of this subsection.
(2) Certain organizations prohibited.--An organization
shall not be treated as a qualified nonprofit health
insurance issuer if--
(A) the organization or a related entity (or any
predecessor of either) was a health insurance issuer on July
16, 2009; or
(B) the organization is sponsored by a State or local
government, any political subdivision thereof, or any
instrumentality of such government or political subdivision.
(3) Governance requirements.--An organization shall not be
treated as a qualified nonprofit health insurance issuer
unless--
(A) the governance of the organization is subject to a
majority vote of its members;
(B) its governing documents incorporate ethics and conflict
of interest standards protecting against insurance industry
involvement and interference; and
(C) as provided in regulations promulgated by the
Secretary, the organization is required to operate with a
strong consumer focus, including timeliness, responsiveness,
and accountability to members.
(4) Profits inure to benefit of members.--An organization
shall not be treated as a qualified nonprofit health
insurance issuer unless any profits made by the organization
are required to be used to lower premiums, to improve
benefits, or for other programs intended to improve the
quality of health care delivered to its members.
(5) Compliance with state insurance laws.--An organization
shall not be treated as a qualified nonprofit health
insurance issuer unless the organization meets all the
requirements that other issuers of qualified health plans are
required to meet in any State where the issuer offers a
qualified health plan, including solvency and licensure
requirements, rules on payments to providers, and compliance
with network adequacy rules, rate and form filing rules, any
applicable State premium assessments and any other State law
described in section 1324(b).
(6) Coordination with state insurance reforms.--An
organization shall not be treated as a qualified nonprofit
health insurance issuer unless the organization does not
offer a health plan in a State until that State has in effect
(or the Secretary has implemented for the State) the market
reforms required by part A of title XXVII of the Public
Health Service Act (as amended by subtitles A and C of this
Act).
(d) Establishment of Private Purchasing Council.--
(1) In general.--Qualified nonprofit health insurance
issuers participating in the CO-OP program under this section
may establish a private purchasing council to enter into
collective purchasing arrangements for items and services
that increase administrative and other cost efficiencies,
including claims administration, administrative services,
health information technology, and actuarial services.
(2) Council may not set payment rates.--The private
purchasing council established under paragraph (1) shall not
set payment rates for health care facilities or providers
participating in health insurance coverage provided by
qualified nonprofit health insurance issuers.
(3) Continued application of antitrust laws.--
(A) In general.--Nothing in this section shall be construed
to limit the application of the antitrust laws to any private
purchasing council (whether or not established under this
subsection) or to any qualified nonprofit health insurance
issuer participating in such a council.
(B) Antitrust laws.--For purposes of this subparagraph, the
term ``antitrust laws'' has the meaning given the term in
subsection (a) of the first section of the Clayton Act (15
U.S.C. 12(a)). Such term also includes section 5 of the
Federal Trade Commission Act (15 U.S.C. 45) to the extent
that such section 5 applies to unfair methods of competition.
(e) Limitation on Participation.--No representative of any
Federal, State, or local government (or of any political
subdivision or instrumentality thereof), and no
representative of a person described in subsection (c)(2)(A),
may serve on the board of directors of a qualified nonprofit
health insurance issuer or with a private purchasing council
established under subsection (d).
(f) Limitations on Secretary.--
(1) In general.--The Secretary shall not--
(A) participate in any negotiations between 1 or more
qualified nonprofit health insurance issuers (or a private
purchasing council established under subsection (d)) and any
health care facilities or providers, including any drug
manufacturer, pharmacy, or hospital; and
(B) establish or maintain a price structure for
reimbursement of any health benefits covered by such issuers.
(2) Competition.--Nothing in this section shall be
construed as authorizing the Secretary to interfere with the
competitive nature of providing health benefits through
qualified nonprofit health insurance issuers.
(g) Appropriations.--There are hereby appropriated, out of
any funds in the Treasury not otherwise appropriated,
$6,000,000,000 to carry out this section.
(h) Tax Exemption for Qualified Nonprofit Health Insurance
Issuer.--
(1) In general.--Section 501(c) of the Internal Revenue
Code of 1986 (relating to list of exempt organizations) is
amended by adding at the end the following:
``(29) CO-OP health insurance issuers.--
``(A) In general.--A qualified nonprofit health insurance
issuer (within the meaning of section 1322 of the Patient
Protection and Affordable Care Act) which has received a loan
or grant under the CO-OP program under such section, but only
with respect to periods for which the issuer is in compliance
with the requirements of such section and any agreement with
respect to the loan or grant.
``(B) Conditions for exemption.--Subparagraph (A) shall
apply to an organization only if--
``(i) the organization has given notice to the Secretary,
in such manner as the Secretary may by regulations prescribe,
that it is applying for recognition of its status under this
paragraph,
``(ii) except as provided in section 1322(c)(4) of the
Patient Protection and Affordable Care Act, no part of the
net earnings of which inures to the benefit of any private
shareholder or individual,
``(iii) no substantial part of the activities of which is
carrying on propaganda, or otherwise attempting, to influence
legislation, and
``(iv) the organization does not participate in, or
intervene in (including the publishing or distributing of
statements), any political campaign on behalf of (or in
opposition to) any candidate for public office.''.
(2) Additional reporting requirement.--Section 6033 of such
Code (relating to returns by exempt organizations) is amended
by redesignating subsection (m) as subsection (n) and by
inserting after subsection (l) the following:
``(m) Additional Information Required From CO-OP
Insurers.--An organization described in section 501(c)(29)
shall include on the return required under subsection (a) the
following information:
``(1) The amount of the reserves required by each State in
which the organization is licensed to issue qualified health
plans.
``(2) The amount of reserves on hand.''.
(3) Application of tax on excess benefit transactions.--
Section 4958(e)(1) of such Code (defining applicable tax-
exempt organization) is amended by striking ``paragraph (3)
or (4)'' and inserting ``paragraph (3), (4), or (29)''.
(i) GAO Study and Report.--
(1) Study.--The Comptroller General of the General
Accountability Office shall conduct an ongoing study on
competition and market concentration in the health insurance
market in the United States after the implementation of the
reforms in such market under the provisions of, and the
amendments made by, this Act. Such study shall include an
analysis of new issuers of health insurance in such market.
(2) Report.--The Comptroller General shall, not later than
December 31 of each even-numbered year (beginning with 2014),
report to the appropriate committees of the Congress the
results of the study conducted under paragraph (1), including
any recommendations for administrative or legislative changes
the Comptroller General determines necessary or appropriate
to increase competition in the health insurance market.
SEC. 1323. COMMUNITY HEALTH INSURANCE OPTION.
(a) Voluntary Nature.--
(1) No requirement for health care providers to
participate.--Nothing in this section shall be construed to
require a health care provider to participate in a community
health insurance option, or to impose any penalty for non-
participation.
(2) No requirement for individuals to join.--Nothing in
this section shall be construed to require an individual to
participate in a community health insurance option, or to
impose any penalty for non-participation.
(3) State opt out.--
(A) In general.--A State may elect to prohibit Exchanges in
such State from offering a community health insurance option
if such State enacts a law to provide for such prohibition.
(B) Termination of opt out.--A State may repeal a law
described in subparagraph (A) and provide for the offering of
such an option through the Exchange.
(b) Establishment of Community Health Insurance Option.--
(1) Establishment.--The Secretary shall establish a
community health insurance option to offer, through the
Exchanges established under this title (other than Exchanges
in States that elect to opt out as provided for in subsection
(a)(3)), health care coverage that provides value, choice,
competition, and stability of affordable, high quality
coverage throughout the United States.
(2) Community health insurance option.--In this section,
the term ``community health insurance option'' means health
insurance coverage that--
(A) except as specifically provided for in this section,
complies with the requirements for being a qualified health
plan;
(B) provides high value for the premium charged;
(C) reduces administrative costs and promotes
administrative simplification for beneficiaries;
(D) promotes high quality clinical care;
(E) provides high quality customer service to
beneficiaries;
(F) offers a sufficient choice of providers; and
(G) complies with State laws (if any), except as otherwise
provided for in this title, relating to the laws described in
section 1324(b).
[[Page H1941]]
(3) Essential health benefits.--
(A) General rule.--Except as provided in subparagraph (B),
a community health insurance option offered under this
section shall provide coverage only for the essential health
benefits described in section 1302(b).
(B) States may offer additional benefits.--Nothing in this
section shall preclude a State from requiring that benefits
in addition to the essential health benefits required under
subparagraph (A) be provided to enrollees of a community
health insurance option offered in such State.
(C) Credits.--
(i) In general.--An individual enrolled in a community
health insurance option under this section shall be eligible
for credits under section 36B of the Internal Revenue Code of
1986 in the same manner as an individual who is enrolled in a
qualified health plan.
(ii) No additional federal cost.--A requirement by a State
under subparagraph (B) that benefits in addition to the
essential health benefits required under subparagraph (A) be
provided to enrollees of a community health insurance option
shall not affect the amount of a premium tax credit provided
under section 36B of the Internal Revenue Code of 1986 with
respect to such plan.
(D) State must assume cost.--A State shall make payments to
or on behalf of an eligible individual to defray the cost of
any additional benefits described in subparagraph (B).
(E) Ensuring access to all services.--Nothing in this Act
shall prohibit an individual enrolled in a community health
insurance option from paying out-of-pocket the full cost of
any item or service not included as an essential health
benefit or otherwise covered as a benefit by a health plan.
Nothing in subparagraph (B) shall prohibit any type of
medical provider from accepting an out-of-pocket payment from
an individual enrolled in a community health insurance option
for a service otherwise not included as an essential health
benefit.
(F) Protecting access to end of life care.--A community
health insurance option offered under this section shall be
prohibited from limiting access to end of life care.
(4) Cost sharing.--A community health insurance option
shall offer coverage at each of the levels of coverage
described in section 1302(d).
(5) Premiums.--
(A) Premiums sufficient to cover costs.--The Secretary
shall establish geographically adjusted premium rates in an
amount sufficient to cover expected costs (including claims
and administrative costs) using methods in general use by
qualified health plans.
(B) Applicable rules.--The provisions of title XXVII of the
Public Health Service Act relating to premiums shall apply to
community health insurance options under this section,
including modified community rating provisions under section
2701 of such Act.
(C) Collection of data.--The Secretary shall collect data
as necessary to set premium rates under subparagraph (A).
(D) National pooling.--Notwithstanding any other provision
of law, the Secretary may treat all enrollees in community
health insurance options as members of a single pool.
(E) Contingency margin.--In establishing premium rates
under subparagraph (A), the Secretary shall include an
appropriate amount for a contingency margin.
(6) Reimbursement rates.--
(A) Negotiated rates.--The Secretary shall negotiate rates
for the reimbursement of health care providers for benefits
covered under a community health insurance option.
(B) Limitation.--The rates described in subparagraph (A)
shall not be higher, in aggregate, than the average
reimbursement rates paid by health insurance issuers offering
qualified health plans through the Exchange.
(C) Innovation.--Subject to the limits contained in
subparagraph (A), a State Advisory Council established or
designated under subsection (d) may develop or encourage the
use of innovative payment policies that promote quality,
efficiency and savings to consumers.
(7) Solvency and consumer protection.--
(A) Solvency.--The Secretary shall establish a Federal
solvency standard to be applied with respect to a community
health insurance option. A community health insurance option
shall also be subject to the solvency standard of each State
in which such community health insurance option is offered.
(B) Minimum required.--In establishing the standard
described under subparagraph (A), the Secretary shall require
a reserve fund that shall be equal to at least the dollar
value of the incurred but not reported claims of a community
health insurance option.
(C) Consumer protections.--The consumer protection laws of
a State shall apply to a community health insurance option.
(8) Requirements established in partnership with insurance
commissioners.--
(A) In general.--The Secretary, in collaboration with the
National Association of Insurance Commissioners (in this
paragraph referred to as the ``NAIC''), may promulgate
regulations to establish additional requirements for a
community health insurance option.
(B) Applicability.--Any requirement promulgated under
subparagraph (A) shall be applicable to such option beginning
90 days after the date on which the regulation involved
becomes final.
(c) Start-up Fund.--
(1) Establishment of fund.--
(A) In general.--There is established in the Treasury of
the United States a trust fund to be known as the ``Health
Benefit Plan Start-Up Fund'' (referred to in this section as
the ``Start-Up Fund''), that shall consist of such amounts as
may be appropriated or credited to the Start-Up Fund as
provided for in this subsection to provide loans for the
initial operations of a community health insurance option.
Such amounts shall remain available until expended.
(B) Funding.--There is hereby appropriated to the Start-Up
Fund, out of any moneys in the Treasury not otherwise
appropriated an amount requested by the Secretary of Health
and Human Services as necessary to--
(i) pay the start-up costs associated with the initial
operations of a community health insurance option; and
(ii) pay the costs of making payments on claims submitted
during the period that is not more than 90 days from the date
on which such option is offered.
(2) Use of start-up fund.--The Secretary shall use amounts
contained in the Start-Up Fund to make payments (subject to
the repayment requirements in paragraph (4)) for the purposes
described in paragraph (1)(B).
(3) Pass through of rebates.--The Secretary may establish
procedures for reducing the amount of payments to a
contracting administrator to take into account any rebates or
price concessions.
(4) Repayment.--
(A) In general.--A community health insurance option shall
be required to repay the Secretary of the Treasury (on such
terms as the Secretary may require) for any payments made
under paragraph (1)(B) by the date that is not later than 9
years after the date on which the payment is made. The
Secretary may require the payment of interest with respect to
such repayments at rates that do not exceed the market
interest rate (as determined by the Secretary).
(B) Sanctions in case of for-profit conversion.--In any
case in which the Secretary enters into a contract with a
qualified entity for the offering of a community health
insurance option and such entity is determined to be a for-
profit entity by the Secretary, such entity shall be--
(i) immediately liable to the Secretary for any payments
received by such entity from the Start-Up Fund; and
(ii) permanently ineligible to offer a qualified health
plan.
(d) State Advisory Council.--
(1) Establishment.--A State (other than a State that elects
to opt out as provided for in subsection (a)(3)) shall
establish or designate a public or non-profit private entity
to serve as the State Advisory Council to provide
recommendations to the Secretary on the operations and
policies of a community health insurance option in the State.
Such Council shall provide recommendations on at least the
following:
(A) policies and procedures to integrate quality
improvement and cost containment mechanisms into the health
care delivery system;
(B) mechanisms to facilitate public awareness of the
availability of a community health insurance option; and
(C) alternative payment structures under a community health
insurance option for health care providers that encourage
quality improvement and cost control.
(2) Members.--The members of the State Advisory Council
shall be representatives of the public and shall include
health care consumers and providers.
(3) Applicability of recommendations.--The Secretary may
apply the recommendations of a State Advisory Council to a
community health insurance option in that State, in any other
State, or in all States.
(e) Authority To Contract; Terms of Contract.--
(1) Authority.--
(A) In general.--The Secretary may enter into a contract or
contracts with one or more qualified entities for the purpose
of performing administrative functions (including functions
described in subsection (a)(4) of section 1874A of the Social
Security Act) with respect to a community health insurance
option in the same manner as the Secretary may enter into
contracts under subsection (a)(1) of such section. The
Secretary shall have the same authority with respect to a
community health insurance option under this section as the
Secretary has under subsections (a)(1) and (b) of section
1874A of the Social Security Act with respect to title XVIII
of such Act.
(B) Requirements apply.--If the Secretary enters into a
contract with a qualified entity to offer a community health
insurance option, under such contract such entity--
(i) shall meet the criteria established under paragraph
(2); and
(ii) shall receive an administrative fee under paragraph
(7).
(C) Limitation.--Contracts under this subsection shall not
involve the transfer of insurance risk to the contracting
administrator.
(D) Reference.--An entity with which the Secretary has
entered into a contract under this paragraph shall be
referred to as a ``contracting administrator''.
(2) Qualified entity.--To be qualified to be selected by
the Secretary to offer a community health insurance option,
an entity shall--
(A) meet the criteria established under section 1874A(a)(2)
of the Social Security Act;
(B) be a nonprofit entity for purposes of offering such
option;
(C) meet the solvency standards applicable under subsection
(b)(7);
(D) be eligible to offer health insurance or health
benefits coverage;
(E) meet quality standards specified by the Secretary;
(F) have in place effective procedures to control fraud,
abuse, and waste; and
(G) meet such other requirements as the Secretary may
impose.
Procedures described under subparagraph (F) shall include the
implementation of procedures to use beneficiary identifiers
to identify individuals entitled to benefits so that such an
individual's social security account number is not used,
[[Page H1942]]
and shall also include procedures for the use of technology
(including front-end, prepayment intelligent data-matching
technology similar to that used by hedge funds, investment
funds, and banks) to provide real-time data analysis of
claims for payment under this title to identify and
investigate unusual billing or order practices under this
title that could indicate fraud or abuse.
(3) Term.--A contract provided for under paragraph (1)
shall be for a term of at least 5 years but not more than 10
years, as determined by the Secretary. At the end of each
such term, the Secretary shall conduct a competitive bidding
process for the purposes of renewing existing contracts or
selecting new qualified entities with which to enter into
contracts under such paragraph.
(4) Limitation.--A contract may not be renewed under this
subsection unless the Secretary determines that the
contracting administrator has met performance requirements
established by the Secretary in the areas described in
paragraph (7)(B).
(5) Audits.--The Inspector General shall conduct periodic
audits with respect to contracting administrators under this
subsection to ensure that the administrator involved is in
compliance with this section.
(6) Revocation.--A contract awarded under this subsection
shall be revoked by the Secretary, upon the recommendation of
the Inspector General, only after notice to the contracting
administrator involved and an opportunity for a hearing. The
Secretary may revoke such contract if the Secretary
determines that such administrator has engaged in fraud,
deception, waste, abuse of power, negligence, mismanagement
of taxpayer dollars, or gross mismanagement. An entity that
has had a contract revoked under this paragraph shall not be
qualified to enter into a subsequent contract under this
subsection.
(7) Fee for administration.--
(A) In general.--The Secretary shall pay the contracting
administrator a fee for the management, administration, and
delivery of the benefits under this section.
(B) Requirement for high quality administration.--The
Secretary may increase the fee described in subparagraph (A)
by not more than 10 percent, or reduce the fee described in
subparagraph (A) by not more than 50 percent, based on the
extent to which the contracting administrator, in the
determination of the Secretary, meets performance
requirements established by the Secretary, in at least the
following areas:
(i) Maintaining low premium costs and low cost sharing
requirements, provided that such requirements are consistent
with section 1302.
(ii) Reducing administrative costs and promoting
administrative simplification for beneficiaries.
(iii) Promoting high quality clinical care.
(iv) Providing high quality customer service to
beneficiaries.
(C) Non-renewal.--The Secretary may not renew a contract to
offer a community health insurance option under this section
with any contracting entity that has been assessed more than
one reduction under subparagraph (B) during the contract
period.
(8) Limitation.--Notwithstanding the terms of a contract
under this subsection, the Secretary shall negotiate the
reimbursement rates for purposes of subsection (b)(6).
(f) Report by HHS and Insolvency Warnings.--
(1) In general.--On an annual basis, the Secretary shall
conduct a study on the solvency of a community health
insurance option and submit to Congress a report describing
the results of such study.
(2) Result.--If, in any year, the result of the study under
paragraph (1) is that a community health insurance option is
insolvent, such result shall be treated as a community health
insurance option solvency warning.
(3) Submission of plan and procedure.--
(A) In general.--If there is a community health insurance
option solvency warning under paragraph (2) made in a year,
the President shall submit to Congress, within the 15-day
period beginning on the date of the budget submission to
Congress under section 1105(a) of title 31, United States
Code, for the succeeding year, proposed legislation to
respond to such warning.
(B) Procedure.--In the case of a legislative proposal
submitted by the President pursuant to subparagraph (A), such
proposal shall be considered by Congress using the same
procedures described under sections 803 and 804 of the
Medicare Prescription Drug, Improvement, and Modernization
Act of 2003 that shall be used for a medicare funding
warning.
(g) Marketing Parity.--In a facility controlled by the
Federal Government, or by a State, where marketing or
promotional materials related to a community health insurance
option are made available to the public, making available
marketing or promotional materials relating to private health
insurance plans shall not be prohibited. Such materials
include informational pamphlets, guidebooks, enrollment
forms, or other materials determined reasonable for display.
(h) Authorization of Appropriations.--There is authorized
to be appropriated such sums as may be necessary to carry out
this section.
SEC. 1324. LEVEL PLAYING FIELD.
(a) In General.--Notwithstanding any other provision of
law, any health insurance coverage offered by a private
health insurance issuer shall not be subject to any Federal
or State law described in subsection (b) if a qualified
health plan offered under the Consumer Operated and Oriented
Plan program under section 1322, a community health insurance
option under section 1323, or a nationwide qualified health
plan under section 1333(b), is not subject to such law.
(b) Laws Described.--The Federal and State laws described
in this subsection are those Federal and State laws relating
to--
(1) guaranteed renewal;
(2) rating;
(3) preexisting conditions;
(4) non-discrimination;
(5) quality improvement and reporting;
(6) fraud and abuse;
(7) solvency and financial requirements;
(8) market conduct;
(9) prompt payment;
(10) appeals and grievances;
(11) privacy and confidentiality;
(12) licensure; and
(13) benefit plan material or information.
PART IV--STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS
SEC. 1331. STATE FLEXIBILITY TO ESTABLISH BASIC HEALTH
PROGRAMS FOR LOW-INCOME INDIVIDUALS NOT
ELIGIBLE FOR MEDICAID.
(a) Establishment of Program.--
(1) In general.--The Secretary shall establish a basic
health program meeting the requirements of this section under
which a State may enter into contracts to offer 1 or more
standard health plans providing at least the essential health
benefits described in section 1302(b) to eligible individuals
in lieu of offering such individuals coverage through an
Exchange.
(2) Certifications as to benefit coverage and costs.--Such
program shall provide that a State may not establish a basic
health program under this section unless the State
establishes to the satisfaction of the Secretary, and the
Secretary certifies, that--
(A) in the case of an eligible individual enrolled in a
standard health plan offered through the program, the State
provides--
(i) that the amount of the monthly premium an eligible
individual is required to pay for coverage under the standard
health plan for the individual and the individual's
dependents does not exceed the amount of the monthly premium
that the eligible individual would have been required to pay
(in the rating area in which the individual resides) if the
individual had enrolled in the applicable second lowest cost
silver plan (as defined in section 36B(b)(3)(B) of the
Internal Revenue Code of 1986) offered to the individual
through an Exchange; and
(ii) that the cost-sharing an eligible individual is
required to pay under the standard health plan does not
exceed--
(I) the cost-sharing required under a platinum plan in the
case of an eligible individual with household income not in
excess of 150 percent of the poverty line for the size of the
family involved; and
(II) the cost-sharing required under a gold plan in the
case of an eligible individual not described in subclause
(I); and
(B) the benefits provided under the standard health plans
offered through the program cover at least the essential
health benefits described in section 1302(b).
For purposes of subparagraph (A)(i), the amount of the
monthly premium an individual is required to pay under either
the standard health plan or the applicable second lowest cost
silver plan shall be determined after reduction for any
premium tax credits and cost-sharing reductions allowable
with respect to either plan.
(b) Standard Health Plan.--In this section, the term
``standard heath plan'' means a health benefits plan that the
State contracts with under this section--
(1) under which the only individuals eligible to enroll are
eligible individuals;
(2) that provides at least the essential health benefits
described in section 1302(b); and
(3) in the case of a plan that provides health insurance
coverage offered by a health insurance issuer, that has a
medical loss ratio of at least 85 percent.
(c) Contracting Process.--
(1) In general.--A State basic health program shall
establish a competitive process for entering into contracts
with standard health plans under subsection (a), including
negotiation of premiums and cost-sharing and negotiation of
benefits in addition to the essential health benefits
described in section 1302(b).
(2) Specific items to be considered.--A State shall, as
part of its competitive process under paragraph (1), include
at least the following:
(A) Innovation.--Negotiation with offerors of a standard
health plan for the inclusion of innovative features in the
plan, including--
(i) care coordination and care management for enrollees,
especially for those with chronic health conditions;
(ii) incentives for use of preventive services; and
(iii) the establishment of relationships between providers
and patients that maximize patient involvement in health care
decision-making, including providing incentives for
appropriate utilization under the plan.
(B) Health and resource differences.--Consideration of, and
the making of suitable allowances for, differences in health
care needs of enrollees and differences in local availability
of, and access to, health care providers. Nothing in this
subparagraph shall be construed as allowing discrimination on
the basis of pre-existing conditions or other health status-
related factors.
(C) Managed care.--Contracting with managed care systems,
or with systems that offer as many of the attributes of
managed care as are feasible in the local health care market.
(D) Performance measures.--Establishing specific
performance measures and standards for issuers of standard
health plans that focus on quality of care and improved
health outcomes, requiring such plans to report to the State
with respect to the measures and standards, and making the
performance and quality information available to enrollees in
a useful form.
[[Page H1943]]
(3) Enhanced availability.--
(A) Multiple plans.--A State shall, to the maximum extent
feasible, seek to make multiple standard health plans
available to eligible individuals within a State to ensure
individuals have a choice of such plans.
(B) Regional compacts.--A State may negotiate a regional
compact with other States to include coverage of eligible
individuals in all such States in agreements with issuers of
standard health plans.
(4) Coordination with other state programs.--A State shall
seek to coordinate the administration of, and provision of
benefits under, its program under this section with the State
medicaid program under title XIX of the Social Security Act,
the State child health plan under title XXI of such Act, and
other State-administered health programs to maximize the
efficiency of such programs and to improve the continuity of
care.
(d) Transfer of Funds to States.--
(1) In general.--If the Secretary determines that a State
electing the application of this section meets the
requirements of the program established under subsection (a),
the Secretary shall transfer to the State for each fiscal
year for which 1 or more standard health plans are operating
within the State the amount determined under paragraph (3).
(2) Use of funds.--A State shall establish a trust for the
deposit of the amounts received under paragraph (1) and
amounts in the trust fund shall only be used to reduce the
premiums and cost-sharing of, or to provide additional
benefits for, eligible individuals enrolled in standard
health plans within the State. Amounts in the trust fund, and
expenditures of such amounts, shall not be included in
determining the amount of any non-Federal funds for purposes
of meeting any matching or expenditure requirement of any
federally-funded program.
(3) Amount of payment.--
(A) Secretarial determination.--
(i) In general.--The amount determined under this paragraph
for any fiscal year is the amount the Secretary determines is
equal to 85 percent of the premium tax credits under section
36B of the Internal Revenue Code of 1986, and the cost-
sharing reductions under section 1402, that would have been
provided for the fiscal year to eligible individuals enrolled
in standard health plans in the State if such eligible
individuals were allowed to enroll in qualified health plans
through an Exchange established under this subtitle.
(ii) Specific requirements.--The Secretary shall make the
determination under clause (i) on a per enrollee basis and
shall take into account all relevant factors necessary to
determine the value of the premium tax credits and cost-
sharing reductions that would have been provided to eligible
individuals described in clause (i), including the age and
income of the enrollee, whether the enrollment is for self-
only or family coverage, geographic differences in average
spending for health care across rating areas, the health
status of the enrollee for purposes of determining risk
adjustment payments and reinsurance payments that would have
been made if the enrollee had enrolled in a qualified health
plan through an Exchange, and whether any reconciliation of
the credit or cost-sharing reductions would have occurred if
the enrollee had been so enrolled. This determination shall
take into consideration the experience of other States with
respect to participation in an Exchange and such credits and
reductions provided to residents of the other States, with a
special focus on enrollees with income below 200 percent of
poverty.
(iii) Certification.--The Chief Actuary of the Centers for
Medicare & Medicaid Services, in consultation with the Office
of Tax Analysis of the Department of the Treasury, shall
certify whether the methodology used to make determinations
under this subparagraph, and such determinations, meet the
requirements of clause (ii). Such certifications shall be
based on sufficient data from the State and from comparable
States about their experience with programs created by this
Act.
(B) Corrections.--The Secretary shall adjust the payment
for any fiscal year to reflect any error in the
determinations under subparagraph (A) for any preceding
fiscal year.
(4) Application of special rules.--The provisions of
section 1303 shall apply to a State basic health program, and
to standard health plans offered through such program, in the
same manner as such rules apply to qualified health plans.
(e) Eligible Individual.--
(1) In general.--In this section, the term ``eligible
individual'' means, with respect to any State, an
individual--
(A) who a resident of the State who is not eligible to
enroll in the State's medicaid program under title XIX of the
Social Security Act for benefits that at a minimum consist of
the essential health benefits described in section 1302(b);
(B) whose household income exceeds 133 percent but does not
exceed 200 percent of the poverty line for the size of the
family involved;
(C) who is not eligible for minimum essential coverage (as
defined in section 5000A(f) of the Internal Revenue Code of
1986) or is eligible for an employer-sponsored plan that is
not affordable coverage (as determined under section
5000A(e)(2) of such Code); and
(D) who has not attained age 65 as of the beginning of the
plan year.
Such term shall not include any individual who is not a
qualified individual under section 1312 who is eligible to be
covered by a qualified health plan offered through an
Exchange.
(2) Eligible individuals may not use exchange.--An eligible
individual shall not be treated as a qualified individual
under section 1312 eligible for enrollment in a qualified
health plan offered through an Exchange established under
section 1311.
(f) Secretarial Oversight.--The Secretary shall each year
conduct a review of each State program to ensure compliance
with the requirements of this section, including ensuring
that the State program meets--
(1) eligibility verification requirements for participation
in the program;
(2) the requirements for use of Federal funds received by
the program; and
(3) the quality and performance standards under this
section.
(g) Standard Health Plan Offerors.--A State may provide
that persons eligible to offer standard health plans under a
basic health program established under this section may
include a licensed health maintenance organization, a
licensed health insurance insurer, or a network of health
care providers established to offer services under the
program.
(h) Definitions.--Any term used in this section which is
also used in section 36B of the Internal Revenue Code of 1986
shall have the meaning given such term by such section.
SEC. 1332. WAIVER FOR STATE INNOVATION.
(a) Application.--
(1) In general.--A State may apply to the Secretary for the
waiver of all or any requirements described in paragraph (2)
with respect to health insurance coverage within that State
for plan years beginning on or after January 1, 2017. Such
application shall--
(A) be filed at such time and in such manner as the
Secretary may require;
(B) contain such information as the Secretary may require,
including--
(i) a comprehensive description of the State legislation
and program to implement a plan meeting the requirements for
a waiver under this section; and
(ii) a 10-year budget plan for such plan that is budget
neutral for the Federal Government; and
(C) provide an assurance that the State has enacted the law
described in subsection (b)(2).
(2) Requirements.--The requirements described in this
paragraph with respect to health insurance coverage within
the State for plan years beginning on or after January 1,
2014, are as follows:
(A) Part I of subtitle D.
(B) Part II of subtitle D.
(C) Section 1402.
(D) Sections 36B, 4980H, and 5000A of the Internal Revenue
Code of 1986.
(3) Pass through of funding.--With respect to a State
waiver under paragraph (1), under which, due to the structure
of the State plan, individuals and small employers in the
State would not qualify for the premium tax credits, cost-
sharing reductions, or small business credits under sections
36B of the Internal Revenue Code of 1986 or under part I of
subtitle E for which they would otherwise be eligible, the
Secretary shall provide for an alternative means by which the
aggregate amount of such credits or reductions that would
have been paid on behalf of participants in the Exchanges
established under this title had the State not received such
waiver, shall be paid to the State for purposes of
implementing the State plan under the waiver. Such amount
shall be determined annually by the Secretary, taking into
consideration the experience of other States with respect to
participation in an Exchange and credits and reductions
provided under such provisions to residents of the other
States.
(4) Waiver consideration and transparency.--
(A) In general.--An application for a waiver under this
section shall be considered by the Secretary in accordance
with the regulations described in subparagraph (B).
(B) Regulations.--Not later than 180 days after the date of
enactment of this Act, the Secretary shall promulgate
regulations relating to waivers under this section that
provide--
(i) a process for public notice and comment at the State
level, including public hearings, sufficient to ensure a
meaningful level of public input;
(ii) a process for the submission of an application that
ensures the disclosure of--
(I) the provisions of law that the State involved seeks to
waive; and
(II) the specific plans of the State to ensure that the
waiver will be in compliance with subsection (b);
(iii) a process for providing public notice and comment
after the application is received by the Secretary, that is
sufficient to ensure a meaningful level of public input and
that does not impose requirements that are in addition to, or
duplicative of, requirements imposed under the Administrative
Procedures Act, or requirements that are unreasonable or
unnecessarily burdensome with respect to State compliance;
(iv) a process for the submission to the Secretary of
periodic reports by the State concerning the implementation
of the program under the waiver; and
(v) a process for the periodic evaluation by the Secretary
of the program under the waiver.
(C) Report.--The Secretary shall annually report to
Congress concerning actions taken by the Secretary with
respect to applications for waivers under this section.
(5) Coordinated waiver process.--The Secretary shall
develop a process for coordinating and consolidating the
State waiver processes applicable under the provisions of
this section, and the existing waiver processes applicable
under titles XVIII, XIX, and XXI of the Social Security Act,
and any other Federal law relating to the provision of health
care items or services. Such process shall permit a State to
submit a single application for a waiver under any or all of
such provisions.
(6) Definition.--In this section, the term ``Secretary''
means--
[[Page H1944]]
(A) the Secretary of Health and Human Services with respect
to waivers relating to the provisions described in
subparagraph (A) through (C) of paragraph (2); and
(B) the Secretary of the Treasury with respect to waivers
relating to the provisions described in paragraph (2)(D).
(b) Granting of Waivers.--
(1) In general.--The Secretary may grant a request for a
waiver under subsection (a)(1) only if the Secretary
determines that the State plan--
(A) will provide coverage that is at least as comprehensive
as the coverage defined in section 1302(b) and offered
through Exchanges established under this title as certified
by Office of the Actuary of the Centers for Medicare &
Medicaid Services based on sufficient data from the State and
from comparable States about their experience with programs
created by this Act and the provisions of this Act that would
be waived;
(B) will provide coverage and cost sharing protections
against excessive out-of-pocket spending that are at least as
affordable as the provisions of this title would provide;
(C) will provide coverage to at least a comparable number
of its residents as the provisions of this title would
provide; and
(D) will not increase the Federal deficit.
(2) Requirement to enact a law.--
(A) In general.--A law described in this paragraph is a
State law that provides for State actions under a waiver
under this section, including the implementation of the State
plan under subsection (a)(1)(B).
(B) Termination of opt out.--A State may repeal a law
described in subparagraph (A) and terminate the authority
provided under the waiver with respect to the State.
(c) Scope of Waiver.--
(1) In general.--The Secretary shall determine the scope of
a waiver of a requirement described in subsection (a)(2)
granted to a State under subsection (a)(1).
(2) Limitation.--The Secretary may not waive under this
section any Federal law or requirement that is not within the
authority of the Secretary.
(d) Determinations by Secretary.--
(1) Time for determination.--The Secretary shall make a
determination under subsection (a)(1) not later than 180 days
after the receipt of an application from a State under such
subsection.
(2) Effect of determination.--
(A) Granting of waivers.--If the Secretary determines to
grant a waiver under subsection (a)(1), the Secretary shall
notify the State involved of such determination and the terms
and effectiveness of such waiver.
(B) Denial of waiver.--If the Secretary determines a waiver
should not be granted under subsection (a)(1), the Secretary
shall notify the State involved, and the appropriate
committees of Congress of such determination and the reasons
therefore.
(e) Term of Waiver.--No waiver under this section may
extend over a period of longer than 5 years unless the State
requests continuation of such waiver, and such request shall
be deemed granted unless the Secretary, within 90 days after
the date of its submission to the Secretary, either denies
such request in writing or informs the State in writing with
respect to any additional information which is needed in
order to make a final determination with respect to the
request.
SEC. 1333. PROVISIONS RELATING TO OFFERING OF PLANS IN MORE
THAN ONE STATE.
(a) Health Care Choice Compacts.--
(1) In general.--Not later than July 1, 2013, the Secretary
shall, in consultation with the National Association of
Insurance Commissioners, issue regulations for the creation
of health care choice compacts under which 2 or more States
may enter into an agreement under which--
(A) 1 or more qualified health plans could be offered in
the individual markets in all such States but, except as
provided in subparagraph (B), only be subject to the laws and
regulations of the State in which the plan was written or
issued;
(B) the issuer of any qualified health plan to which the
compact applies--
(i) would continue to be subject to market conduct, unfair
trade practices, network adequacy, and consumer protection
standards (including standards relating to rating), including
addressing disputes as to the performance of the contract, of
the State in which the purchaser resides;
(ii) would be required to be licensed in each State in
which it offers the plan under the compact or to submit to
the jurisdiction of each such State with regard to the
standards described in clause (i) (including allowing access
to records as if the insurer were licensed in the State); and
(iii) must clearly notify consumers that the policy may not
be subject to all the laws and regulations of the State in
which the purchaser resides.
(2) State authority.--A State may not enter into an
agreement under this subsection unless the State enacts a law
after the date of the enactment of this title that
specifically authorizes the State to enter into such
agreements.
(3) Approval of compacts.--The Secretary may approve
interstate health care choice compacts under paragraph (1)
only if the Secretary determines that such health care choice
compact--
(A) will provide coverage that is at least as comprehensive
as the coverage defined in section 1302(b) and offered
through Exchanges established under this title;
(B) will provide coverage and cost sharing protections
against excessive out-of-pocket spending that are at least as
affordable as the provisions of this title would provide;
(C) will provide coverage to at least a comparable number
of its residents as the provisions of this title would
provide;
(D) will not increase the Federal deficit; and
(E) will not weaken enforcement of laws and regulations
described in paragraph (1)(B)(i) in any State that is
included in such compact.
(4) Effective date.--A health care choice compact described
in paragraph (1) shall not take effect before January 1,
2016.
(b) Authority for Nationwide Plans.--
(1) In general.--Except as provided in paragraph (2), if an
issuer (including a group of health insurance issuers
affiliated either by common ownership and control or by the
common use of a nationally licensed service mark) of a
qualified health plan in the individual or small group market
meets the requirements of this subsection (in this subsection
a ``nationwide qualified health plan'')--
(A) the issuer of the plan may offer the nationwide
qualified health plan in the individual or small group market
in more than 1 State; and
(B) with respect to State laws mandating benefit coverage
by a health plan, only the State laws of the State in which
such plan is written or issued shall apply to the nationwide
qualified health plan.
(2) State opt-out.--A State may, by specific reference in a
law enacted after the date of enactment of this title,
provide that this subsection shall not apply to that State.
Such opt-out shall be effective until such time as the State
by law revokes it.
(3) Plan requirements.--An issuer meets the requirements of
this subsection with respect to a nationwide qualified health
plan if, in the determination of the Secretary--
(A) the plan offers a benefits package that is uniform in
each State in which the plan is offered and meets the
requirements set forth in paragraphs (4) through (6);
(B) the issuer is licensed in each State in which it offers
the plan and is subject to all requirements of State law not
inconsistent with this section, including but not limited to,
the standards and requirements that a State imposes that do
not prevent the application of a requirement of part A of
title XXVII of the Public Health Service Act or a requirement
of this title;
(C) the issuer meets all requirements of this title with
respect to a qualified health plan, including the requirement
to offer the silver and gold levels of the plan in each
Exchange in the State for the market in which the plan is
offered;
(D) the issuer determines the premiums for the plan in any
State on the basis of the rating rules in effect in that
State for the rating areas in which it is offered;
(E) the issuer offers the nationwide qualified health plan
in at least 60 percent of the participating States in the
first year in which the plan is offered, 65 percent of such
States in the second year, 70 percent of such States in the
third year, 75 percent of such States in the fourth year, and
80 percent of such States in the fifth and subsequent years;
(F) the issuer shall offer the plan in participating States
across the country, in all geographic regions, and in all
States that have adopted adjusted community rating before the
date of enactment of this Act; and
(G) the issuer clearly notifies consumers that the policy
may not contain some benefits otherwise mandated for plans in
the State in which the purchaser resides and provides a
detailed statement of the benefits offered and the benefit
differences in that State, in accordance with rules
promulgated by the Secretary.
(4) Form review for nationwide plans.--Notwithstanding any
contrary provision of State law, at least 3 months before any
nationwide qualified health plan is offered, the issuer shall
file all nationwide qualified health plan forms with the
regulator in each participating State in which the plan will
be offered. An issuer may appeal the disapproval of a
nationwide qualified health plan form to the Secretary.
(5) Applicable rules.--The Secretary shall, in consultation
with the National Association of Insurance Commissioners,
issue rules for the offering of nationwide qualified health
plans under this subsection. Nationwide qualified health
plans may be offered only after such rules have taken effect.
(6) Coverage.--The Secretary shall provide that the health
benefits coverage provided to an individual through a
nationwide qualified health plan under this subsection shall
include at least the essential benefits package described in
section 1302.
(7) State law mandating benefit coverage by a health
benefits plan.--For the purposes of this subsection, a State
law mandating benefit coverage by a health plan is a law that
mandates health insurance coverage or the offer of health
insurance coverage for specific health services or specific
diseases. A law that mandates health insurance coverage or
reimbursement for services provided by certain classes of
providers of health care services, or a law that mandates
that certain classes of individuals must be covered as a
group or as dependents, is not a State law mandating benefit
coverage by a health benefits plan.
PART V--REINSURANCE AND RISK ADJUSTMENT
SEC. 1341. TRANSITIONAL REINSURANCE PROGRAM FOR INDIVIDUAL
AND SMALL GROUP MARKETS IN EACH STATE.
(a) In General.--Each State shall, not later than January
1, 2014--
(1) include in the Federal standards or State law or
regulation the State adopts and has in effect under section
1321(b) the provisions described in subsection (b); and
(2) establish (or enter into a contract with) 1 or more
applicable reinsurance entities to carry out the reinsurance
program under this section.
(b) Model Regulation.--
(1) In general.--In establishing the Federal standards
under section 1321(a), the Secretary,
[[Page H1945]]
in consultation with the National Association of Insurance
Commissioners (the ``NAIC''), shall include provisions that
enable States to establish and maintain a program under
which--
(A) health insurance issuers, and third party
administrators on behalf of group health plans, are required
to make payments to an applicable reinsurance entity for any
plan year beginning in the 3-year period beginning January 1,
2014 (as specified in paragraph (3); and
(B) the applicable reinsurance entity collects payments
under subparagraph (A) and uses amounts so collected to make
reinsurance payments to health insurance issuers described in
subparagraph (A) that cover high risk individuals in the
individual market (excluding grandfathered health plans) for
any plan year beginning in such 3-year period.
(2) High-risk individual; payment amounts.--The Secretary
shall include the following in the provisions under paragraph
(1):
(A) Determination of high-risk individuals.--The method by
which individuals will be identified as high risk individuals
for purposes of the reinsurance program established under
this section. Such method shall provide for identification of
individuals as high-risk individuals on the basis of--
(i) a list of at least 50 but not more than 100 medical
conditions that are identified as high-risk conditions and
that may be based on the identification of diagnostic and
procedure codes that are indicative of individuals with pre-
existing, high-risk conditions; or
(ii) any other comparable objective method of
identification recommended by the American Academy of
Actuaries.
(B) Payment amount.--The formula for determining the amount
of payments that will be paid to health insurance issuers
described in paragraph (1)(A) that insure high-risk
individuals. Such formula shall provide for the equitable
allocation of available funds through reconciliation and may
be designed--
(i) to provide a schedule of payments that specifies the
amount that will be paid for each of the conditions
identified under subparagraph (A); or
(ii) to use any other comparable method for determining
payment amounts that is recommended by the American Academy
of Actuaries and that encourages the use of care coordination
and care management programs for high risk conditions.
(3) Determination of required contributions.--
(A) In general.--The Secretary shall include in the
provisions under paragraph (1) the method for determining the
amount each health insurance issuer and group health plan
described in paragraph (1)(A) contributing to the reinsurance
program under this section is required to contribute under
such paragraph for each plan year beginning in the 36-month
period beginning January 1, 2014. The contribution amount for
any plan year may be based on the percentage of revenue of
each issuer and the total costs of providing benefits to
enrollees in self-insured plans or on a specified amount per
enrollee and may be required to be paid in advance or
periodically throughout the plan year.
(B) Specific requirements.--The method under this paragraph
shall be designed so that--
(i) the contribution amount for each issuer proportionally
reflects each issuer's fully insured commercial book of
business for all major medical products and the total value
of all fees charged by the issuer and the costs of coverage
administered by the issuer as a third party administrator;
(ii) the contribution amount can include an additional
amount to fund the administrative expenses of the applicable
reinsurance entity;
(iii) the aggregate contribution amounts for all States
shall, based on the best estimates of the NAIC and without
regard to amounts described in clause (ii), equal
$10,000,000,000 for plan years beginning in 2014,
$6,000,000,000 for plan years beginning 2015, and
$4,000,000,000 for plan years beginning in 2016; and
(iv) in addition to the aggregate contribution amounts
under clause (iii), each issuer's contribution amount for any
calendar year under clause (iii) reflects its proportionate
share of an additional $2,000,000,000 for 2014, an additional
$2,000,000,000 for 2015, and an additional $1,000,000,000 for
2016.
Nothing in this subparagraph shall be construed to preclude a
State from collecting additional amounts from issuers on a
voluntary basis.
(4) Expenditure of funds.--The provisions under paragraph
(1) shall provide that--
(A) the contribution amounts collected for any calendar
year may be allocated and used in any of the three calendar
years for which amounts are collected based on the
reinsurance needs of a particular period or to reflect
experience in a prior period; and
(B) amounts remaining unexpended as of December, 2016, may
be used to make payments under any reinsurance program of a
State in the individual market in effect in the 2-year period
beginning on January 1, 2017.
Notwithstanding the preceding sentence, any contribution
amounts described in paragraph (3)(B)(iv) shall be deposited
into the general fund of the Treasury of the United States
and may not be used for the program established under this
section.
(c) Applicable Reinsurance Entity.--For purposes of this
section--
(1) In general.--The term ``applicable reinsurance entity''
means a not-for-profit organization--
(A) the purpose of which is to help stabilize premiums for
coverage in the individual and small group markets in a State
during the first 3 years of operation of an Exchange for such
markets within the State when the risk of adverse selection
related to new rating rules and market changes is greatest;
and
(B) the duties of which shall be to carry out the
reinsurance program under this section by coordinating the
funding and operation of the risk-spreading mechanisms
designed to implement the reinsurance program.
(2) State discretion.--A State may have more than 1
applicable reinsurance entity to carry out the reinsurance
program under this section within the State and 2 or more
States may enter into agreements to provide for an applicable
reinsurance entity to carry out such program in all such
States.
(3) Entities are tax-exempt.--An applicable reinsurance
entity established under this section shall be exempt from
taxation under chapter 1 of the Internal Revenue Code of
1986. The preceding sentence shall not apply to the tax
imposed by section 511 such Code (relating to tax on
unrelated business taxable income of an exempt organization).
(d) Coordination With State High-risk Pools.--The State
shall eliminate or modify any State high-risk pool to the
extent necessary to carry out the reinsurance program
established under this section. The State may coordinate the
State high-risk pool with such program to the extent not
inconsistent with the provisions of this section.
SEC. 1342. ESTABLISHMENT OF RISK CORRIDORS FOR PLANS IN
INDIVIDUAL AND SMALL GROUP MARKETS.
(a) In General.--The Secretary shall establish and
administer a program of risk corridors for calendar years
2014, 2015, and 2016 under which a qualified health plan
offered in the individual or small group market shall
participate in a payment adjustment system based on the ratio
of the allowable costs of the plan to the plan's aggregate
premiums. Such program shall be based on the program for
regional participating provider organizations under part D of
title XVIII of the Social Security Act.
(b) Payment Methodology.--
(1) Payments out.--The Secretary shall provide under the
program established under subsection (a) that if--
(A) a participating plan's allowable costs for any plan
year are more than 103 percent but not more than 108 percent
of the target amount, the Secretary shall pay to the plan an
amount equal to 50 percent of the target amount in excess of
103 percent of the target amount; and
(B) a participating plan's allowable costs for any plan
year are more than 108 percent of the target amount, the
Secretary shall pay to the plan an amount equal to the sum of
2.5 percent of the target amount plus 80 percent of allowable
costs in excess of 108 percent of the target amount.
(2) Payments in.--The Secretary shall provide under the
program established under subsection (a) that if--
(A) a participating plan's allowable costs for any plan
year are less than 97 percent but not less than 92 percent of
the target amount, the plan shall pay to the Secretary an
amount equal to 50 percent of the excess of 97 percent of the
target amount over the allowable costs; and
(B) a participating plan's allowable costs for any plan
year are less than 92 percent of the target amount, the plan
shall pay to the Secretary an amount equal to the sum of 2.5
percent of the target amount plus 80 percent of the excess of
92 percent of the target amount over the allowable costs.
(c) Definitions.--In this section:
(1) Allowable costs.--
(A) In general.--The amount of allowable costs of a plan
for any year is an amount equal to the total costs (other
than administrative costs) of the plan in providing benefits
covered by the plan.
(B) Reduction for risk adjustment and reinsurance
payments.--Allowable costs shall reduced by any risk
adjustment and reinsurance payments received under section
1341 and 1343.
(2) Target amount.--The target amount of a plan for any
year is an amount equal to the total premiums (including any
premium subsidies under any governmental program), reduced by
the administrative costs of the plan.
SEC. 1343. RISK ADJUSTMENT.
(a) In General.--
(1) Low actuarial risk plans.--Using the criteria and
methods developed under subsection (b), each State shall
assess a charge on health plans and health insurance issuers
(with respect to health insurance coverage) described in
subsection (c) if the actuarial risk of the enrollees of such
plans or coverage for a year is less than the average
actuarial risk of all enrollees in all plans or coverage in
such State for such year that are not self-insured group
health plans (which are subject to the provisions of the
Employee Retirement Income Security Act of 1974).
(2) High actuarial risk plans.--Using the criteria and
methods developed under subsection (b), each State shall
provide a payment to health plans and health insurance
issuers (with respect to health insurance coverage) described
in subsection (c) if the actuarial risk of the enrollees of
such plans or coverage for a year is greater than the average
actuarial risk of all enrollees in all plans and coverage in
such State for such year that are not self-insured group
health plans (which are subject to the provisions of the
Employee Retirement Income Security Act of 1974).
(b) Criteria and Methods.--The Secretary, in consultation
with States, shall establish criteria and methods to be used
in carrying out the risk adjustment activities under this
section. The Secretary may utilize criteria and methods
similar to the criteria and methods utilized under part C or
D of title XVIII of the Social Security Act. Such criteria
and methods shall be included in the standards and
requirements the Secretary prescribes under section 1321.
(c) Scope.--A health plan or a health insurance issuer is
described in this subsection if such
[[Page H1946]]
health plan or health insurance issuer provides coverage in
the individual or small group market within the State. This
subsection shall not apply to a grandfathered health plan or
the issuer of a grandfathered health plan with respect to
that plan.
Subtitle E--Affordable Coverage Choices for All Americans
PART I--PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS
Subpart A--Premium Tax Credits and Cost-sharing Reductions
SEC. 1401. REFUNDABLE TAX CREDIT PROVIDING PREMIUM ASSISTANCE
FOR COVERAGE UNDER A QUALIFIED HEALTH PLAN.
(a) In General.--Subpart C of part IV of subchapter A of
chapter 1 of the Internal Revenue Code of 1986 (relating to
refundable credits) is amended by inserting after section 36A
the following new section:
``SEC. 36B. REFUNDABLE CREDIT FOR COVERAGE UNDER A QUALIFIED
HEALTH PLAN.
``(a) In General.--In the case of an applicable taxpayer,
there shall be allowed as a credit against the tax imposed by
this subtitle for any taxable year an amount equal to the
premium assistance credit amount of the taxpayer for the
taxable year.
``(b) Premium Assistance Credit Amount.--For purposes of
this section--
``(1) In general.--The term `premium assistance credit
amount' means, with respect to any taxable year, the sum of
the premium assistance amounts determined under paragraph (2)
with respect to all coverage months of the taxpayer occurring
during the taxable year.
``(2) Premium assistance amount.--The premium assistance
amount determined under this subsection with respect to any
coverage month is the amount equal to the lesser of--
``(A) the monthly premiums for such month for 1 or more
qualified health plans offered in the individual market
within a State which cover the taxpayer, the taxpayer's
spouse, or any dependent (as defined in section 152) of the
taxpayer and which were enrolled in through an Exchange
established by the State under 1311 of the Patient Protection
and Affordable Care Act, or
``(B) the excess (if any) of--
``(i) the adjusted monthly premium for such month for the
applicable second lowest cost silver plan with respect to the
taxpayer, over
``(ii) an amount equal to 1/12 of the product of the
applicable percentage and the taxpayer's household income for
the taxable year.
``(3) Other terms and rules relating to premium assistance
amounts.--For purposes of paragraph (2)--
``(A) Applicable percentage.--
``(i) In general.--Except as provided in clause (ii), the
applicable percentage with respect to any taxpayer for any
taxable year is equal to 2.8 percent, increased by the number
of percentage points (not greater than 7) which bears the
same ratio to 7 percentage points as--
``(I) the taxpayer's household income for the taxable year
in excess of 100 percent of the poverty line for a family of
the size involved, bears to
``(II) an amount equal to 200 percent of the poverty line
for a family of the size involved.
``(ii) Special rule for taxpayers under 133 percent of
poverty line.--If a taxpayer's household income for the
taxable year is in excess of 100 percent, but not more than
133 percent, of the poverty line for a family of the size
involved, the taxpayer's applicable percentage shall be 2
percent.
``(iii) Indexing.--In the case of taxable years beginning
in any calendar year after 2014, the Secretary shall adjust
the initial and final applicable percentages under clause
(i), and the 2 percent under clause (ii), for the calendar
year to reflect the excess of the rate of premium growth
between the preceding calendar year and 2013 over the rate of
income growth for such period.
``(B) Applicable second lowest cost silver plan.--The
applicable second lowest cost silver plan with respect to any
applicable taxpayer is the second lowest cost silver plan of
the individual market in the rating area in which the
taxpayer resides which--
``(i) is offered through the same Exchange through which
the qualified health plans taken into account under paragraph
(2)(A) were offered, and
``(ii) provides--
``(I) self-only coverage in the case of an applicable
taxpayer--
``(aa) whose tax for the taxable year is determined under
section 1(c) (relating to unmarried individuals other than
surviving spouses and heads of households) and who is not
allowed a deduction under section 151 for the taxable year
with respect to a dependent, or
``(bb) who is not described in item (aa) but who purchases
only self-only coverage, and
``(II) family coverage in the case of any other applicable
taxpayer.
If a taxpayer files a joint return and no credit is allowed
under this section with respect to 1 of the spouses by reason
of subsection (e), the taxpayer shall be treated as described
in clause (ii)(I) unless a deduction is allowed under section
151 for the taxable year with respect to a dependent other
than either spouse and subsection (e) does not apply to the
dependent.
``(C) Adjusted monthly premium.--The adjusted monthly
premium for an applicable second lowest cost silver plan is
the monthly premium which would have been charged (for the
rating area with respect to which the premiums under
paragraph (2)(A) were determined) for the plan if each
individual covered under a qualified health plan taken into
account under paragraph (2)(A) were covered by such silver
plan and the premium was adjusted only for the age of each
such individual in the manner allowed under section 2701 of
the Public Health Service Act. In the case of a State
participating in the wellness discount demonstration project
under section 2705(d) of the Public Health Service Act, the
adjusted monthly premium shall be determined without regard
to any premium discount or rebate under such project.
``(D) Additional benefits.--If--
``(i) a qualified health plan under section 1302(b)(5) of
the Patient Protection and Affordable Care Act offers
benefits in addition to the essential health benefits
required to be provided by the plan, or
``(ii) a State requires a qualified health plan under
section 1311(d)(3)(B) of such Act to cover benefits in
addition to the essential health benefits required to be
provided by the plan,
the portion of the premium for the plan properly allocable
(under rules prescribed by the Secretary of Health and Human
Services) to such additional benefits shall not be taken into
account in determining either the monthly premium or the
adjusted monthly premium under paragraph (2).
``(E) Special rule for pediatric dental coverage.--For
purposes of determining the amount of any monthly premium, if
an individual enrolls in both a qualified health plan and a
plan described in section 1311(d)(2)(B)(ii)(I) of the Patient
Protection and Affordable Care Act for any plan year, the
portion of the premium for the plan described in such section
that (under regulations prescribed by the Secretary) is
properly allocable to pediatric dental benefits which are
included in the essential health benefits required to be
provided by a qualified health plan under section
1302(b)(1)(J) of such Act shall be treated as a premium
payable for a qualified health plan.
``(c) Definition and Rules Relating to Applicable
Taxpayers, Coverage Months, and Qualified Health Plan.--For
purposes of this section--
``(1) Applicable taxpayer.--
``(A) In general.--The term `applicable taxpayer' means,
with respect to any taxable year, a taxpayer whose household
income for the taxable year exceeds 100 percent but does not
exceed 400 percent of an amount equal to the poverty line for
a family of the size involved.
``(B) Special rule for certain individuals lawfully present
in the united states.--If--
``(i) a taxpayer has a household income which is not
greater than 100 percent of an amount equal to the poverty
line for a family of the size involved, and
``(ii) the taxpayer is an alien lawfully present in the
United States, but is not eligible for the medicaid program
under title XIX of the Social Security Act by reason of such
alien status,
the taxpayer shall, for purposes of the credit under this
section, be treated as an applicable taxpayer with a
household income which is equal to 100 percent of the poverty
line for a family of the size involved.
``(C) Married couples must file joint return.--If the
taxpayer is married (within the meaning of section 7703) at
the close of the taxable year, the taxpayer shall be treated
as an applicable taxpayer only if the taxpayer and the
taxpayer's spouse file a joint return for the taxable year.
``(D) Denial of credit to dependents.--No credit shall be
allowed under this section to any individual with respect to
whom a deduction under section 151 is allowable to another
taxpayer for a taxable year beginning in the calendar year in
which such individual's taxable year begins.
``(2) Coverage month.--For purposes of this subsection--
``(A) In general.--The term `coverage month' means, with
respect to an applicable taxpayer, any month if--
``(i) as of the first day of such month the taxpayer, the
taxpayer's spouse, or any dependent of the taxpayer is
covered by a qualified health plan described in subsection
(b)(2)(A) that was enrolled in through an Exchange
established by the State under section 1311 of the Patient
Protection and Affordable Care Act, and
``(ii) the premium for coverage under such plan for such
month is paid by the taxpayer (or through advance payment of
the credit under subsection (a) under section 1412 of the
Patient Protection and Affordable Care Act).
``(B) Exception for minimum essential coverage.--
``(i) In general.--The term `coverage month' shall not
include any month with respect to an individual if for such
month the individual is eligible for minimum essential
coverage other than eligibility for coverage described in
section 5000A(f)(1)(C) (relating to coverage in the
individual market).
``(ii) Minimum essential coverage.--The term `minimum
essential coverage' has the meaning given such term by
section 5000A(f).
``(C) Special rule for employer-sponsored minimum essential
coverage.--For purposes of subparagraph (B)--
``(i) Coverage must be affordable.--Except as provided in
clause (iii), an employee shall not be treated as eligible
for minimum essential coverage if such coverage--
``(I) consists of an eligible employer-sponsored plan (as
defined in section 5000A(f)(2)), and
``(II) the employee's required contribution (within the
meaning of section 5000A(e)(1)(B)) with respect to the plan
exceeds 9.8 percent of the applicable taxpayer's household
income.
This clause shall also apply to an individual who is eligible
to enroll in the plan by reason of a relationship the
individual bears to the employee.
``(ii) Coverage must provide minimum value.--Except as
provided in clause (iii), an employee shall not be treated as
eligible for minimum essential coverage if such coverage
consists of an eligible employer-sponsored plan (as
[[Page H1947]]
defined in section 5000A(f)(2)) and the plan's share of the
total allowed costs of benefits provided under the plan is
less than 60 percent of such costs.
``(iii) Employee or family must not be covered under
employer plan.--Clauses (i) and (ii) shall not apply if the
employee (or any individual described in the last sentence of
clause (i)) is covered under the eligible employer-sponsored
plan or the grandfathered health plan.
``(iv) Indexing.--In the case of plan years beginning in
any calendar year after 2014, the Secretary shall adjust the
9.8 percent under clause (i)(II) in the same manner as the
percentages are adjusted under subsection (b)(3)(A)(ii).
``(3) Definitions and other rules.--
``(A) Qualified health plan.--The term `qualified health
plan' has the meaning given such term by section 1301(a) of
the Patient Protection and Affordable Care Act, except that
such term shall not include a qualified health plan which is
a catastrophic plan described in section 1302(e) of such Act.
``(B) Grandfathered health plan.--The term `grandfathered
health plan' has the meaning given such term by section 1251
of the Patient Protection and Affordable Care Act.
``(d) Terms Relating to Income and Families.--For purposes
of this section--
``(1) Family size.--The family size involved with respect
to any taxpayer shall be equal to the number of individuals
for whom the taxpayer is allowed a deduction under section
151 (relating to allowance of deduction for personal
exemptions) for the taxable year.
``(2) Household income.--
``(A) Household income.--The term `household income' means,
with respect to any taxpayer, an amount equal to the sum of--
``(i) the modified gross income of the taxpayer, plus
``(ii) the aggregate modified gross incomes of all other
individuals who--
``(I) were taken into account in determining the taxpayer's
family size under paragraph (1), and
``(II) were required to file a return of tax imposed by
section 1 for the taxable year.
``(B) Modified gross income.--The term `modified gross
income' means gross income--
``(i) decreased by the amount of any deduction allowable
under paragraph (1), (3), (4), or (10) of section 62(a),
``(ii) increased by the amount of interest received or
accrued during the taxable year which is exempt from tax
imposed by this chapter, and
``(iii) determined without regard to sections 911, 931, and
933.
``(3) Poverty line.--
``(A) In general.--The term `poverty line' has the meaning
given that term in section 2110(c)(5) of the Social Security
Act (42 U.S.C. 1397jj(c)(5)).
``(B) Poverty line used.--In the case of any qualified
health plan offered through an Exchange for coverage during a
taxable year beginning in a calendar year, the poverty line
used shall be the most recently published poverty line as of
the 1st day of the regular enrollment period for coverage
during such calendar year.
``(e) Rules for Individuals Not Lawfully Present.--
``(1) In general.--If 1 or more individuals for whom a
taxpayer is allowed a deduction under section 151 (relating
to allowance of deduction for personal exemptions) for the
taxable year (including the taxpayer or his spouse) are
individuals who are not lawfully present--
``(A) the aggregate amount of premiums otherwise taken into
account under clauses (i) and (ii) of subsection (b)(2)(A)
shall be reduced by the portion (if any) of such premiums
which is attributable to such individuals, and
``(B) for purposes of applying this section, the
determination as to what percentage a taxpayer's household
income bears to the poverty level for a family of the size
involved shall be made under one of the following methods:
``(i) A method under which--
``(I) the taxpayer's family size is determined by not
taking such individuals into account, and
``(II) the taxpayer's household income is equal to the
product of the taxpayer's household income (determined
without regard to this subsection) and a fraction--
``(aa) the numerator of which is the poverty line for the
taxpayer's family size determined after application of
subclause (I), and
``(bb) the denominator of which is the poverty line for the
taxpayer's family size determined without regard to subclause
(I).
``(ii) A comparable method reaching the same result as the
method under clause (i).
``(2) Lawfully present.--For purposes of this section, an
individual shall be treated as lawfully present only if the
individual is, and is reasonably expected to be for the
entire period of enrollment for which the credit under this
section is being claimed, a citizen or national of the United
States or an alien lawfully present in the United States.
``(3) Secretarial authority.--The Secretary of Health and
Human Services, in consultation with the Secretary, shall
prescribe rules setting forth the methods by which
calculations of family size and household income are made for
purposes of this subsection. Such rules shall be designed to
ensure that the least burden is placed on individuals
enrolling in qualified health plans through an Exchange and
taxpayers eligible for the credit allowable under this
section.
``(f) Reconciliation of Credit and Advance Credit.--
``(1) In general.--The amount of the credit allowed under
this section for any taxable year shall be reduced (but not
below zero) by the amount of any advance payment of such
credit under section 1412 of the Patient Protection and
Affordable Care Act.
``(2) Excess advance payments.--
``(A) In general.--If the advance payments to a taxpayer
under section 1412 of the Patient Protection and Affordable
Care Act for a taxable year exceed the credit allowed by this
section (determined without regard to paragraph (1)), the tax
imposed by this chapter for the taxable year shall be
increased by the amount of such excess.
``(B) Limitation on increase where income less than 400
percent of poverty line.--
``(i) In general.--In the case of an applicable taxpayer
whose household income is less than 400 percent of the
poverty line for the size of the family involved for the
taxable year, the amount of the increase under subparagraph
(A) shall in no event exceed $400 ($250 in the case of a
taxpayer whose tax is determined under section 1(c) for the
taxable year).
``(ii) Indexing of amount.--In the case of any calendar
year beginning after 2014, each of the dollar amounts under
clause (i) shall be increased by an amount equal to--
``(I) such dollar amount, multiplied by
``(II) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year, determined by
substituting `calendar year 2013' for `calendar year 1992' in
subparagraph (B) thereof.
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.
``(g) Regulations.--The Secretary shall prescribe such
regulations as may be necessary to carry out the provisions
of this section, including regulations which provide for--
``(1) the coordination of the credit allowed under this
section with the program for advance payment of the credit
under section 1412 of the Patient Protection and Affordable
Care Act, and
``(2) the application of subsection (f) where the filing
status of the taxpayer for a taxable year is different from
such status used for determining the advance payment of the
credit.''.
(b) Disallowance of Deduction.--Section 280C of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new subsection:
``(g) Credit for Health Insurance Premiums.--No deduction
shall be allowed for the portion of the premiums paid by the
taxpayer for coverage of 1 or more individuals under a
qualified health plan which is equal to the amount of the
credit determined for the taxable year under section 36B(a)
with respect to such premiums.''.
(c) Study on Affordable Coverage.--
(1) Study and report.--
(A) In general.--Not later than 5 years after the date of
the enactment of this Act, the Comptroller General shall
conduct a study on the affordability of health insurance
coverage, including--
(i) the impact of the tax credit for qualified health
insurance coverage of individuals under section 36B of the
Internal Revenue Code of 1986 and the tax credit for employee
health insurance expenses of small employers under section
45R of such Code on maintaining and expanding the health
insurance coverage of individuals;
(ii) the availability of affordable health benefits plans,
including a study of whether the percentage of household
income used for purposes of section 36B(c)(2)(C) of the
Internal Revenue Code of 1986 (as added by this section) is
the appropriate level for determining whether employer-
provided coverage is affordable for an employee and whether
such level may be lowered without significantly increasing
the costs to the Federal Government and reducing employer-
provided coverage; and
(iii) the ability of individuals to maintain essential
health benefits coverage (as defined in section 5000A(f) of
the Internal Revenue Code of 1986).
(B) Report.--The Comptroller General shall submit to the
appropriate committees of Congress a report on the study
conducted under subparagraph (A), together with legislative
recommendations relating to the matters studied under such
subparagraph.
(2) Appropriate committees of congress.--In this
subsection, the term ``appropriate committees of Congress''
means the Committee on Ways and Means, the Committee on
Education and Labor, and the Committee on Energy and Commerce
of the House of Representatives and the Committee on Finance
and the Committee on Health, Education, Labor and Pensions of
the Senate.
(d) Conforming Amendments.--
(1) Paragraph (2) of section 1324(b) of title 31, United
States Code, is amended by inserting ``36B,'' after ``36A,''.
(2) The table of sections for subpart C of part IV of
subchapter A of chapter 1 of the Internal Revenue Code of
1986 is amended by inserting after the item relating to
section 36A the following new item:
``Sec. 36B. Refundable credit for coverage under a qualified health
plan.''.
(e) Effective Date.--The amendments made by this section
shall apply to taxable years ending after December 31, 2013.
SEC. 1402. REDUCED COST-SHARING FOR INDIVIDUALS ENROLLING IN
QUALIFIED HEALTH PLANS.
(a) In General.--In the case of an eligible insured
enrolled in a qualified health plan--
(1) the Secretary shall notify the issuer of the plan of
such eligibility; and
(2) the issuer shall reduce the cost-sharing under the plan
at the level and in the manner specified in subsection (c).
(b) Eligible Insured.--In this section, the term ``eligible
insured'' means an individual--
(1) who enrolls in a qualified health plan in the silver
level of coverage in the individual market offered through an
Exchange; and
(2) whose household income exceeds 100 percent but does not
exceed 400 percent of the poverty line for a family of the
size involved.
[[Page H1948]]
In the case of an individual described in section
36B(c)(1)(B) of the Internal Revenue Code of 1986, the
individual shall be treated as having household income equal
to 100 percent for purposes of applying this section.
(c) Determination of Reduction in Cost-sharing.--
(1) Reduction in out-of-pocket limit.--
(A) In general.--The reduction in cost-sharing under this
subsection shall first be achieved by reducing the applicable
out-of pocket limit under section 1302(c)(1) in the case of--
(i) an eligible insured whose household income is more than
100 percent but not more than 200 percent of the poverty line
for a family of the size involved, by two-thirds;
(ii) an eligible insured whose household income is more
than 200 percent but not more than 300 percent of the poverty
line for a family of the size involved, by one-half; and
(iii) an eligible insured whose household income is more
than 300 percent but not more than 400 percent of the poverty
line for a family of the size involved, by one-third.
(B) Coordination with actuarial value limits.--
(i) In general.--The Secretary shall ensure the reduction
under this paragraph shall not result in an increase in the
plan's share of the total allowed costs of benefits provided
under the plan above--
(I) 90 percent in the case of an eligible insured described
in paragraph (2)(A);
(II) 80 percent in the case of an eligible insured
described in paragraph (2)(B); and
(III) 70 percent in the case of an eligible insured
described in clause (ii) or (iii) of subparagraph (A).
(ii) Adjustment.--The Secretary shall adjust the out-of
pocket limits under paragraph (1) if necessary to ensure that
such limits do not cause the respective actuarial values to
exceed the levels specified in clause (i).
(2) Additional reduction for lower income insureds.--The
Secretary shall establish procedures under which the issuer
of a qualified health plan to which this section applies
shall further reduce cost-sharing under the plan in a manner
sufficient to--
(A) in the case of an eligible insured whose household
income is not less than 100 percent but not more than 150
percent of the poverty line for a family of the size
involved, increase the plan's share of the total allowed
costs of benefits provided under the plan to 90 percent of
such costs; and
(B) in the case of an eligible insured whose household
income is more than 150 percent but not more than 200 percent
of the poverty line for a family of the size involved,
increase the plan's share of the total allowed costs of
benefits provided under the plan to 80 percent of such costs.
(3) Methods for reducing cost-sharing.--
(A) In general.--An issuer of a qualified health plan
making reductions under this subsection shall notify the
Secretary of such reductions and the Secretary shall make
periodic and timely payments to the issuer equal to the value
of the reductions.
(B) Capitated payments.--The Secretary may establish a
capitated payment system to carry out the payment of cost-
sharing reductions under this section. Any such system shall
take into account the value of the reductions and make
appropriate risk adjustments to such payments.
(4) Additional benefits.--If a qualified health plan under
section 1302(b)(5) offers benefits in addition to the
essential health benefits required to be provided by the
plan, or a State requires a qualified health plan under
section 1311(d)(3)(B) to cover benefits in addition to the
essential health benefits required to be provided by the
plan, the reductions in cost-sharing under this section shall
not apply to such additional benefits.
(5) Special rule for pediatric dental plans.--If an
individual enrolls in both a qualified health plan and a plan
described in section 1311(d)(2)(B)(ii)(I) for any plan year,
subsection (a) shall not apply to that portion of any
reduction in cost-sharing under subsection (c) that (under
regulations prescribed by the Secretary) is properly
allocable to pediatric dental benefits which are included in
the essential health benefits required to be provided by a
qualified health plan under section 1302(b)(1)(J).
(d) Special Rules for Indians.--
(1) Indians under 300 percent of poverty.--If an individual
enrolled in any qualified health plan in the individual
market through an Exchange is an Indian (as defined in
section 4(d) of the Indian Self-Determination and Education
Assistance Act (25 U.S.C. 450b(d))) whose household income is
not more than 300 percent of the poverty line for a family of
the size involved, then, for purposes of this section--
(A) such individual shall be treated as an eligible
insured; and
(B) the issuer of the plan shall eliminate any cost-sharing
under the plan.
(2) Items or services furnished through indian health
providers.--If an Indian (as so defined) enrolled in a
qualified health plan is furnished an item or service
directly by the Indian Health Service, an Indian Tribe,
Tribal Organization, or Urban Indian Organization or through
referral under contract health services--
(A) no cost-sharing under the plan shall be imposed under
the plan for such item or service; and
(B) the issuer of the plan shall not reduce the payment to
any such entity for such item or service by the amount of any
cost-sharing that would be due from the Indian but for
subparagraph (A).
(3) Payment.--The Secretary shall pay to the issuer of a
qualified health plan the amount necessary to reflect the
increase in actuarial value of the plan required by reason of
this subsection.
(e) Rules for Individuals Not Lawfully Present.--
(1) In general.--If an individual who is an eligible
insured is not lawfully present--
(A) no cost-sharing reduction under this section shall
apply with respect to the individual; and
(B) for purposes of applying this section, the
determination as to what percentage a taxpayer's household
income bears to the poverty level for a family of the size
involved shall be made under one of the following methods:
(i) A method under which--
(I) the taxpayer's family size is determined by not taking
such individuals into account, and
(II) the taxpayer's household income is equal to the
product of the taxpayer's household income (determined
without regard to this subsection) and a fraction--
(aa) the numerator of which is the poverty line for the
taxpayer's family size determined after application of
subclause (I), and
(bb) the denominator of which is the poverty line for the
taxpayer's family size determined without regard to subclause
(I).
(ii) A comparable method reaching the same result as the
method under clause (i).
(2) Lawfully present.--For purposes of this section, an
individual shall be treated as lawfully present only if the
individual is, and is reasonably expected to be for the
entire period of enrollment for which the cost-sharing
reduction under this section is being claimed, a citizen or
national of the United States or an alien lawfully present in
the United States.
(3) Secretarial authority.--The Secretary, in consultation
with the Secretary of the Treasury, shall prescribe rules
setting forth the methods by which calculations of family
size and household income are made for purposes of this
subsection. Such rules shall be designed to ensure that the
least burden is placed on individuals enrolling in qualified
health plans through an Exchange and taxpayers eligible for
the credit allowable under this section.
(f) Definitions and Special Rules.--In this section:
(1) In general.--Any term used in this section which is
also used in section 36B of the Internal Revenue Code of 1986
shall have the meaning given such term by such section.
(2) Limitations on reduction.--No cost-sharing reduction
shall be allowed under this section with respect to coverage
for any month unless the month is a coverage month with
respect to which a credit is allowed to the insured (or an
applicable taxpayer on behalf of the insured) under section
36B of such Code.
(3) Data used for eligibility.--Any determination under
this section shall be made on the basis of the taxable year
for which the advance determination is made under section
1412 and not the taxable year for which the credit under
section 36B of such Code is allowed.
Subpart B--Eligibility Determinations
SEC. 1411. PROCEDURES FOR DETERMINING ELIGIBILITY FOR
EXCHANGE PARTICIPATION, PREMIUM TAX CREDITS AND
REDUCED COST-SHARING, AND INDIVIDUAL
RESPONSIBILITY EXEMPTIONS.
(a) Establishment of Program.--The Secretary shall
establish a program meeting the requirements of this section
for determining--
(1) whether an individual who is to be covered in the
individual market by a qualified health plan offered through
an Exchange, or who is claiming a premium tax credit or
reduced cost-sharing, meets the requirements of sections
1312(f)(3), 1402(e), and 1412(d) of this title and section
36B(e) of the Internal Revenue Code of 1986 that the
individual be a citizen or national of the United States or
an alien lawfully present in the United States;
(2) in the case of an individual claiming a premium tax
credit or reduced cost-sharing under section 36B of such Code
or section 1402--
(A) whether the individual meets the income and coverage
requirements of such sections; and
(B) the amount of the tax credit or reduced cost-sharing;
(3) whether an individual's coverage under an employer-
sponsored health benefits plan is treated as unaffordable
under sections 36B(c)(2)(C) and 5000A(e)(2); and
(4) whether to grant a certification under section
1311(d)(4)(H) attesting that, for purposes of the individual
responsibility requirement under section 5000A of the
Internal Revenue Code of 1986, an individual is entitled to
an exemption from either the individual responsibility
requirement or the penalty imposed by such section.
(b) Information Required To Be Provided by Applicants.--
(1) In general.--An applicant for enrollment in a qualified
health plan offered through an Exchange in the individual
market shall provide--
(A) the name, address, and date of birth of each individual
who is to be covered by the plan (in this subsection referred
to as an ``enrollee''); and
(B) the information required by any of the following
paragraphs that is applicable to an enrollee.
(2) Citizenship or immigration status.--The following
information shall be provided with respect to every enrollee:
(A) In the case of an enrollee whose eligibility is based
on an attestation of citizenship of the enrollee, the
enrollee's social security number.
(B) In the case of an individual whose eligibility is based
on an attestation of the enrollee's immigration status, the
enrollee's social security number (if applicable) and such
identifying information with respect to the enrollee's
immigration status as the Secretary, after consultation with
the Secretary of Homeland Security, determines appropriate.
(3) Eligibility and amount of tax credit or reduced cost-
sharing.--In the case of an enrollee with respect to whom a
premium tax credit or reduced cost-sharing under section 36B
[[Page H1949]]
of such Code or section 1402 is being claimed, the following
information:
(A) Information regarding income and family size.--The
information described in section 6103(l)(21) for the taxable
year ending with or within the second calendar year preceding
the calendar year in which the plan year begins.
(B) Changes in circumstances.--The information described in
section 1412(b)(2), including information with respect to
individuals who were not required to file an income tax
return for the taxable year described in subparagraph (A) or
individuals who experienced changes in marital status or
family size or significant reductions in income.
(4) Employer-sponsored coverage.--In the case of an
enrollee with respect to whom eligibility for a premium tax
credit under section 36B of such Code or cost-sharing
reduction under section 1402 is being established on the
basis that the enrollee's (or related individual's) employer
is not treated under section 36B(c)(2)(C) of such Code as
providing minimum essential coverage or affordable minimum
essential coverage, the following information:
(A) The name, address, and employer identification number
(if available) of the employer.
(B) Whether the enrollee or individual is a full-time
employee and whether the employer provides such minimum
essential coverage.
(C) If the employer provides such minimum essential
coverage, the lowest cost option for the enrollee's or
individual's enrollment status and the enrollee's or
individual's required contribution (within the meaning of
section 5000A(e)(1)(B) of such Code) under the employer-
sponsored plan.
(D) If an enrollee claims an employer's minimum essential
coverage is unaffordable, the information described in
paragraph (3).
If an enrollee changes employment or obtains additional
employment while enrolled in a qualified health plan for
which such credit or reduction is allowed, the enrollee shall
notify the Exchange of such change or additional employment
and provide the information described in this paragraph with
respect to the new employer.
(5) Exemptions from individual responsibility
requirements.--In the case of an individual who is seeking an
exemption certificate under section 1311(d)(4)(H) from any
requirement or penalty imposed by section 5000A, the
following information:
(A) In the case of an individual seeking exemption based on
the individual's status as a member of an exempt religious
sect or division, as a member of a health care sharing
ministry, as an Indian, or as an individual eligible for a
hardship exemption, such information as the Secretary shall
prescribe.
(B) In the case of an individual seeking exemption based on
the lack of affordable coverage or the individual's status as
a taxpayer with household income less than 100 percent of the
poverty line, the information described in paragraphs (3) and
(4), as applicable.
(c) Verification of Information Contained in Records of
Specific Federal Officials.--
(1) Information transferred to secretary.--An Exchange
shall submit the information provided by an applicant under
subsection (b) to the Secretary for verification in
accordance with the requirements of this subsection and
subsection (d).
(2) Citizenship or immigration status.--
(A) Commissioner of social security.--The Secretary shall
submit to the Commissioner of Social Security the following
information for a determination as to whether the information
provided is consistent with the information in the records of
the Commissioner:
(i) The name, date of birth, and social security number of
each individual for whom such information was provided under
subsection (b)(2).
(ii) The attestation of an individual that the individual
is a citizen.
(B) Secretary of homeland security.--
(i) In general.--In the case of an individual--
(I) who attests that the individual is an alien lawfully
present in the United States; or
(II) who attests that the individual is a citizen but with
respect to whom the Commissioner of Social Security has
notified the Secretary under subsection (e)(3) that the
attestation is inconsistent with information in the records
maintained by the Commissioner;
the Secretary shall submit to the Secretary of Homeland
Security the information described in clause (ii) for a
determination as to whether the information provided is
consistent with the information in the records of the
Secretary of Homeland Security.
(ii) Information.--The information described in clause (ii)
is the following:
(I) The name, date of birth, and any identifying
information with respect to the individual's immigration
status provided under subsection (b)(2).
(II) The attestation that the individual is an alien
lawfully present in the United States or in the case of an
individual described in clause (i)(II), the attestation that
the individual is a citizen.
(3) Eligibility for tax credit and cost-sharing
reduction.--The Secretary shall submit the information
described in subsection (b)(3)(A) provided under paragraph
(3), (4), or (5) of subsection (b) to the Secretary of the
Treasury for verification of household income and family size
for purposes of eligibility.
(4) Methods.--
(A) In general.--The Secretary, in consultation with the
Secretary of the Treasury, the Secretary of Homeland
Security, and the Commissioner of Social Security, shall
provide that verifications and determinations under this
subsection shall be done--
(i) through use of an on-line system or otherwise for the
electronic submission of, and response to, the information
submitted under this subsection with respect to an applicant;
or
(ii) by determining the consistency of the information
submitted with the information maintained in the records of
the Secretary of the Treasury, the Secretary of Homeland
Security, or the Commissioner of Social Security through such
other method as is approved by the Secretary.
(B) Flexibility.--The Secretary may modify the methods used
under the program established by this section for the
Exchange and verification of information if the Secretary
determines such modifications would reduce the administrative
costs and burdens on the applicant, including allowing an
applicant to request the Secretary of the Treasury to provide
the information described in paragraph (3) directly to the
Exchange or to the Secretary. The Secretary shall not make
any such modification unless the Secretary determines that
any applicable requirements under this section and section
6103 of the Internal Revenue Code of 1986 with respect to the
confidentiality, disclosure, maintenance, or use of
information will be met.
(d) Verification by Secretary.--In the case of information
provided under subsection (b) that is not required under
subsection (c) to be submitted to another person for
verification, the Secretary shall verify the accuracy of such
information in such manner as the Secretary determines
appropriate, including delegating responsibility for
verification to the Exchange.
(e) Actions Relating to Verification.--
(1) In general.--Each person to whom the Secretary provided
information under subsection (c) shall report to the
Secretary under the method established under subsection
(c)(4) the results of its verification and the Secretary
shall notify the Exchange of such results. Each person to
whom the Secretary provided information under subsection (d)
shall report to the Secretary in such manner as the Secretary
determines appropriate.
(2) Verification.--
(A) Eligibility for enrollment and premium tax credits and
cost-sharing reductions.--If information provided by an
applicant under paragraphs (1), (2), (3), and (4) of
subsection (b) is verified under subsections (c) and (d)--
(i) the individual's eligibility to enroll through the
Exchange and to apply for premium tax credits and cost-
sharing reductions shall be satisfied; and
(ii) the Secretary shall, if applicable, notify the
Secretary of the Treasury under section 1412(c) of the amount
of any advance payment to be made.
(B) Exemption from individual responsibility.--If
information provided by an applicant under subsection (b)(5)
is verified under subsections (c) and (d), the Secretary
shall issue the certification of exemption described in
section 1311(d)(4)(H).
(3) Inconsistencies involving attestation of citizenship or
lawful presence.--If the information provided by any
applicant under subsection (b)(2) is inconsistent with
information in the records maintained by the Commissioner of
Social Security or Secretary of Homeland Security, whichever
is applicable, the applicant's eligibility will be determined
in the same manner as an individual's eligibility under the
medicaid program is determined under section 1902(ee) of the
Social Security Act (as in effect on January 1, 2010).
(4) Inconsistencies involving other information.--
(A) In general.--If the information provided by an
applicant under subsection (b) (other than subsection (b)(2))
is inconsistent with information in the records maintained by
persons under subsection (c) or is not verified under
subsection (d), the Secretary shall notify the Exchange and
the Exchange shall take the following actions:
(i) Reasonable effort.--The Exchange shall make a
reasonable effort to identify and address the causes of such
inconsistency, including through typographical or other
clerical errors, by contacting the applicant to confirm the
accuracy of the information, and by taking such additional
actions as the Secretary, through regulation or other
guidance, may identify.
(ii) Notice and opportunity to correct.--In the case the
inconsistency or inability to verify is not resolved under
subparagraph (A), the Exchange shall--
(I) notify the applicant of such fact;
(II) provide the applicant an opportunity to either present
satisfactory documentary evidence or resolve the
inconsistency with the person verifying the information under
subsection (c) or (d) during the 90-day period beginning the
date on which the notice required under subclause (I) is sent
to the applicant.
The Secretary may extend the 90-day period under subclause
(II) for enrollments occurring during 2014.
(B) Specific actions not involving citizenship or lawful
presence.--
(i) In general.--Except as provided in paragraph (3), the
Exchange shall, during any period before the close of the
period under subparagraph (A)(ii)(II), make any determination
under paragraphs (2), (3), and (4) of subsection (a) on the
basis of the information contained on the application.
(ii) Eligibility or amount of credit or reduction.--If an
inconsistency involving the eligibility for, or amount of,
any premium tax credit or cost-sharing reduction is
unresolved under this subsection as of the close of the
period under subparagraph (A)(ii)(II), the Exchange shall
notify the applicant of the amount (if any) of the credit or
reduction that is determined on the basis of the records
maintained by persons under subsection (c).
(iii) Employer affordability.--If the Secretary notifies an
Exchange that an enrollee is
[[Page H1950]]
eligible for a premium tax credit under section 36B of such
Code or cost-sharing reduction under section 1402 because the
enrollee's (or related individual's) employer does not
provide minimum essential coverage through an employer-
sponsored plan or that the employer does provide that
coverage but it is not affordable coverage, the Exchange
shall notify the employer of such fact and that the employer
may be liable for the payment assessed under section 4980H of
such Code.
(iv) Exemption.--In any case where the inconsistency
involving, or inability to verify, information provided under
subsection (b)(5) is not resolved as of the close of the
period under subparagraph (A)(ii)(II), the Exchange shall
notify an applicant that no certification of exemption from
any requirement or payment under section 5000A of such Code
will be issued.
(C) Appeals process.--The Exchange shall also notify each
person receiving notice under this paragraph of the appeals
processes established under subsection (f).
(f) Appeals and Redeterminations.--
(1) In general.--The Secretary, in consultation with the
Secretary of the Treasury, the Secretary of Homeland
Security, and the Commissioner of Social Security, shall
establish procedures by which the Secretary or one of such
other Federal officers--
(A) hears and makes decisions with respect to appeals of
any determination under subsection (e); and
(B) redetermines eligibility on a periodic basis in
appropriate circumstances.
(2) Employer liability.--
(A) In general.--The Secretary shall establish a separate
appeals process for employers who are notified under
subsection (e)(4)(C) that the employer may be liable for a
tax imposed by section 4980H of the Internal Revenue Code of
1986 with respect to an employee because of a determination
that the employer does not provide minimum essential coverage
through an employer-sponsored plan or that the employer does
provide that coverage but it is not affordable coverage with
respect to an employee. Such process shall provide an
employer the opportunity to--
(i) present information to the Exchange for review of the
determination either by the Exchange or the person making the
determination, including evidence of the employer-sponsored
plan and employer contributions to the plan; and
(ii) have access to the data used to make the determination
to the extent allowable by law.
Such process shall be in addition to any rights of appeal the
employer may have under subtitle F of such Code.
(B) Confidentiality.--Notwithstanding any provision of this
title (or the amendments made by this title) or section 6103
of the Internal Revenue Code of 1986, an employer shall not
be entitled to any taxpayer return information with respect
to an employee for purposes of determining whether the
employer is subject to the penalty under section 4980H of
such Code with respect to the employee, except that--
(i) the employer may be notified as to the name of an
employee and whether or not the employee's income is above or
below the threshold by which the affordability of an
employer's health insurance coverage is measured; and
(ii) this subparagraph shall not apply to an employee who
provides a waiver (at such time and in such manner as the
Secretary may prescribe) authorizing an employer to have
access to the employee's taxpayer return information.
(g) Confidentiality of Applicant Information.--
(1) In general.--An applicant for insurance coverage or for
a premium tax credit or cost-sharing reduction shall be
required to provide only the information strictly necessary
to authenticate identity, determine eligibility, and
determine the amount of the credit or reduction.
(2) Receipt of information.--Any person who receives
information provided by an applicant under subsection (b)
(whether directly or by another person at the request of the
applicant), or receives information from a Federal agency
under subsection (c), (d), or (e), shall--
(A) use the information only for the purposes of, and to
the extent necessary in, ensuring the efficient operation of
the Exchange, including verifying the eligibility of an
individual to enroll through an Exchange or to claim a
premium tax credit or cost-sharing reduction or the amount of
the credit or reduction; and
(B) not disclose the information to any other person except
as provided in this section.
(h) Penalties.--
(1) False or fraudulent information.--
(A) Civil penalty.--
(i) In general.--If--
(I) any person fails to provides correct information under
subsection (b); and
(II) such failure is attributable to negligence or
disregard of any rules or regulations of the Secretary,
such person shall be subject, in addition to any other
penalties that may be prescribed by law, to a civil penalty
of not more than $25,000 with respect to any failures
involving an application for a plan year. For purposes of
this subparagraph, the terms ``negligence'' and ``disregard''
shall have the same meanings as when used in section 6662 of
the Internal Revenue Code of 1986.
(ii) Reasonable cause exception.--No penalty shall be
imposed under clause (i) if the Secretary determines that
there was a reasonable cause for the failure and that the
person acted in good faith.
(B) Knowing and willful violations.--Any person who
knowingly and willfully provides false or fraudulent
information under subsection (b) shall be subject, in
addition to any other penalties that may be prescribed by
law, to a civil penalty of not more than $250,000.
(2) Improper use or disclosure of information.--Any person
who knowingly and willfully uses or discloses information in
violation of subsection (g) shall be subject, in addition to
any other penalties that may be prescribed by law, to a civil
penalty of not more than $25,000.
(3) Limitations on liens and levies.--The Secretary (or, if
applicable, the Attorney General of the United States) shall
not--
(A) file notice of lien with respect to any property of a
person by reason of any failure to pay the penalty imposed by
this subsection; or
(B) levy on any such property with respect to such failure.
(i) Study of Administration of Employer Responsibility.--
(1) In general.--The Secretary of Health and Human Services
shall, in consultation with the Secretary of the Treasury,
conduct a study of the procedures that are necessary to
ensure that in the administration of this title and section
4980H of the Internal Revenue Code of 1986 (as added by
section 1513) that the following rights are protected:
(A) The rights of employees to preserve their right to
confidentiality of their taxpayer return information and
their right to enroll in a qualified health plan through an
Exchange if an employer does not provide affordable coverage.
(B) The rights of employers to adequate due process and
access to information necessary to accurately determine any
payment assessed on employers.
(2) Report.--Not later than January 1, 2013, the Secretary
of Health and Human Services shall report the results of the
study conducted under paragraph (1), including any
recommendations for legislative changes, to the Committees on
Finance and Health, Education, Labor and Pensions of the
Senate and the Committees of Education and Labor and Ways and
Means of the House of Representatives.
SEC. 1412. ADVANCE DETERMINATION AND PAYMENT OF PREMIUM TAX
CREDITS AND COST-SHARING REDUCTIONS.
(a) In General.--The Secretary, in consultation with the
Secretary of the Treasury, shall establish a program under
which--
(1) upon request of an Exchange, advance determinations are
made under section 1411 with respect to the income
eligibility of individuals enrolling in a qualified health
plan in the individual market through the Exchange for the
premium tax credit allowable under section 36B of the
Internal Revenue Code of 1986 and the cost-sharing reductions
under section 1402;
(2) the Secretary notifies--
(A) the Exchange and the Secretary of the Treasury of the
advance determinations; and
(B) the Secretary of the Treasury of the name and employer
identification number of each employer with respect to whom 1
or more employee of the employer were determined to be
eligible for the premium tax credit under section 36B of the
Internal Revenue Code of 1986 and the cost-sharing reductions
under section 1402 because--
(i) the employer did not provide minimum essential
coverage; or
(ii) the employer provided such minimum essential coverage
but it was determined under section 36B(c)(2)(C) of such Code
to either be unaffordable to the employee or not provide the
required minimum actuarial value; and
(3) the Secretary of the Treasury makes advance payments of
such credit or reductions to the issuers of the qualified
health plans in order to reduce the premiums payable by
individuals eligible for such credit.
(b) Advance Determinations.--
(1) In general.--The Secretary shall provide under the
program established under subsection (a) that advance
determination of eligibility with respect to any individual
shall be made--
(A) during the annual open enrollment period applicable to
the individual (or such other enrollment period as may be
specified by the Secretary); and
(B) on the basis of the individual's household income for
the most recent taxable year for which the Secretary, after
consultation with the Secretary of the Treasury, determines
information is available.
(2) Changes in circumstances.--The Secretary shall provide
procedures for making advance determinations on the basis of
information other than that described in paragraph (1)(B) in
cases where information included with an application form
demonstrates substantial changes in income, changes in family
size or other household circumstances, change in filing
status, the filing of an application for unemployment
benefits, or other significant changes affecting eligibility,
including--
(A) allowing an individual claiming a decrease of 20
percent or more in income, or filing an application for
unemployment benefits, to have eligibility for the credit
determined on the basis of household income for a later
period or on the basis of the individual's estimate of such
income for the taxable year; and
(B) the determination of household income in cases where
the taxpayer was not required to file a return of tax imposed
by this chapter for the second preceding taxable year.
(c) Payment of Premium Tax Credits and Cost-sharing
Reductions.--
(1) In general.--The Secretary shall notify the Secretary
of the Treasury and the Exchange through which the individual
is enrolling of the advance determination under section 1411.
(2) Premium tax credit.--
(A) In general.--The Secretary of the Treasury shall make
the advance payment under this section of any premium tax
credit allowed under section 36B of the Internal Revenue Code
of 1986 to the issuer of a qualified health plan on a monthly
basis (or such other periodic basis as the Secretary may
provide).
(B) Issuer responsibilities.--An issuer of a qualified
health plan receiving an advance payment with respect to an
individual enrolled in the plan shall--
(i) reduce the premium charged the insured for any period
by the amount of the advance payment for the period;
(ii) notify the Exchange and the Secretary of such
reduction;
[[Page H1951]]
(iii) include with each billing statement the amount by
which the premium for the plan has been reduced by reason of
the advance payment; and
(iv) in the case of any nonpayment of premiums by the
insured--
(I) notify the Secretary of such nonpayment; and
(II) allow a 3-month grace period for nonpayment of
premiums before discontinuing coverage.
(3) Cost-sharing reductions.--The Secretary shall also
notify the Secretary of the Treasury and the Exchange under
paragraph (1) if an advance payment of the cost-sharing
reductions under section 1402 is to be made to the issuer of
any qualified health plan with respect to any individual
enrolled in the plan. The Secretary of the Treasury shall
make such advance payment at such time and in such amount as
the Secretary specifies in the notice.
(d) No Federal Payments for Individuals Not Lawfully
Present.--Nothing in this subtitle or the amendments made by
this subtitle allows Federal payments, credits, or cost-
sharing reductions for individuals who are not lawfully
present in the United States.
(e) State Flexibility.--Nothing in this subtitle or the
amendments made by this subtitle shall be construed to
prohibit a State from making payments to or on behalf of an
individual for coverage under a qualified health plan offered
through an Exchange that are in addition to any credits or
cost-sharing reductions allowable to the individual under
this subtitle and such amendments.
SEC. 1413. STREAMLINING OF PROCEDURES FOR ENROLLMENT THROUGH
AN EXCHANGE AND STATE MEDICAID, CHIP, AND
HEALTH SUBSIDY PROGRAMS.
(a) In General.--The Secretary shall establish a system
meeting the requirements of this section under which
residents of each State may apply for enrollment in, receive
a determination of eligibility for participation in, and
continue participation in, applicable State health subsidy
programs. Such system shall ensure that if an individual
applying to an Exchange is found through screening to be
eligible for medical assistance under the State medicaid plan
under title XIX, or eligible for enrollment under a State
children's health insurance program (CHIP) under title XXI of
such Act, the individual is enrolled for assistance under
such plan or program.
(b) Requirements Relating to Forms and Notice.--
(1) Requirements relating to forms.--
(A) In general.--The Secretary shall develop and provide to
each State a single, streamlined form that--
(i) may be used to apply for all applicable State health
subsidy programs within the State;
(ii) may be filed online, in person, by mail, or by
telephone;
(iii) may be filed with an Exchange or with State officials
operating one of the other applicable State health subsidy
programs; and
(iv) is structured to maximize an applicant's ability to
complete the form satisfactorily, taking into account the
characteristics of individuals who qualify for applicable
State health subsidy programs.
(B) State authority to establish form.--A State may develop
and use its own single, streamlined form as an alternative to
the form developed under subparagraph (A) if the alternative
form is consistent with standards promulgated by the
Secretary under this section.
(C) Supplemental eligibility forms.--The Secretary may
allow a State to use a supplemental or alternative form in
the case of individuals who apply for eligibility that is not
determined on the basis of the household income (as defined
in section 36B of the Internal Revenue Code of 1986).
(2) Notice.--The Secretary shall provide that an applicant
filing a form under paragraph (1) shall receive notice of
eligibility for an applicable State health subsidy program
without any need to provide additional information or
paperwork unless such information or paperwork is
specifically required by law when information provided on the
form is inconsistent with data used for the electronic
verification under paragraph (3) or is otherwise insufficient
to determine eligibility.
(c) Requirements Relating to Eligibility Based on Data
Exchanges.--
(1) Development of secure interfaces.--Each State shall
develop for all applicable State health subsidy programs a
secure, electronic interface allowing an exchange of data
(including information contained in the application forms
described in subsection (b)) that allows a determination of
eligibility for all such programs based on a single
application. Such interface shall be compatible with the
method established for data verification under section
1411(c)(4).
(2) Data matching program.--Each applicable State health
subsidy program shall participate in a data matching
arrangement for determining eligibility for participation in
the program under paragraph (3) that--
(A) provides access to data described in paragraph (3);
(B) applies only to individuals who--
(i) receive assistance from an applicable State health
subsidy program; or
(ii) apply for such assistance--
(I) by filing a form described in subsection (b); or
(II) by requesting a determination of eligibility and
authorizing disclosure of the information described in
paragraph (3) to applicable State health coverage subsidy
programs for purposes of determining and establishing
eligibility; and
(C) consistent with standards promulgated by the Secretary,
including the privacy and data security safeguards described
in section 1942 of the Social Security Act or that are
otherwise applicable to such programs.
(3) Determination of eligibility.--
(A) In general.--Each applicable State health subsidy
program shall, to the maximum extent practicable--
(i) establish, verify, and update eligibility for
participation in the program using the data matching
arrangement under paragraph (2); and
(ii) determine such eligibility on the basis of reliable,
third party data, including information described in sections
1137, 453(i), and 1942(a) of the Social Security Act,
obtained through such arrangement.
(B) Exception.--This paragraph shall not apply in
circumstances with respect to which the Secretary determines
that the administrative and other costs of use of the data
matching arrangement under paragraph (2) outweigh its
expected gains in accuracy, efficiency, and program
participation.
(4) Secretarial standards.--The Secretary shall, after
consultation with persons in possession of the data to be
matched and representatives of applicable State health
subsidy programs, promulgate standards governing the timing,
contents, and procedures for data matching described in this
subsection. Such standards shall take into account
administrative and other costs and the value of data matching
to the establishment, verification, and updating of
eligibility for applicable State health subsidy programs.
(d) Administrative Authority.--
(1) Agreements.--Subject to section 1411 and section
6103(l)(21) of the Internal Revenue Code of 1986 and any
other requirement providing safeguards of privacy and data
integrity, the Secretary may establish model agreements, and
enter into agreements, for the sharing of data under this
section.
(2) Authority of exchange to contract out.--Nothing in this
section shall be construed to--
(A) prohibit contractual arrangements through which a State
medicaid agency determines eligibility for all applicable
State health subsidy programs, but only if such agency
complies with the Secretary's requirements ensuring reduced
administrative costs, eligibility errors, and disruptions in
coverage; or
(B) change any requirement under title XIX that eligibility
for participation in a State's medicaid program must be
determined by a public agency.
(e) Applicable State Health Subsidy Program.--In this
section, the term ``applicable State health subsidy program''
means--
(1) the program under this title for the enrollment in
qualified health plans offered through an Exchange, including
the premium tax credits under section 36B of the Internal
Revenue Code of 1986 and cost-sharing reductions under
section 1402;
(2) a State medicaid program under title XIX of the Social
Security Act;
(3) a State children's health insurance program (CHIP)
under title XXI of such Act; and
(4) a State program under section 1331 establishing
qualified basic health plans.
SEC. 1414. DISCLOSURES TO CARRY OUT ELIGIBILITY REQUIREMENTS
FOR CERTAIN PROGRAMS.
(a) Disclosure of Taxpayer Return Information and Social
Security Numbers.--
(1) Taxpayer return information.--Subsection (l) of section
6103 of the Internal Revenue Code of 1986 is amended by
adding at the end the following new paragraph:
``(21) Disclosure of return information to carry out
eligibility requirements for certain programs.--
``(A) In general.--The Secretary, upon written request from
the Secretary of Health and Human Services, shall disclose to
officers, employees, and contractors of the Department of
Health and Human Services return information of any taxpayer
whose income is relevant in determining any premium tax
credit under section 36B or any cost-sharing reduction under
section 1402 of the Patient Protection and Affordable Care
Act or eligibility for participation in a State medicaid
program under title XIX of the Social Security Act, a State's
children's health insurance program under title XXI of the
Social Security Act, or a basic health program under section
1331 of Patient Protection and Affordable Care Act. Such
return information shall be limited to--
``(i) taxpayer identity information with respect to such
taxpayer,
``(ii) the filing status of such taxpayer,
``(iii) the number of individuals for whom a deduction is
allowed under section 151 with respect to the taxpayer
(including the taxpayer and the taxpayer's spouse),
``(iv) the modified gross income (as defined in section
36B) of such taxpayer and each of the other individuals
included under clause (iii) who are required to file a return
of tax imposed by chapter 1 for the taxable year,
``(v) such other information as is prescribed by the
Secretary by regulation as might indicate whether the
taxpayer is eligible for such credit or reduction (and the
amount thereof), and
``(vi) the taxable year with respect to which the preceding
information relates or, if applicable, the fact that such
information is not available.
``(B) Information to exchange and state agencies.--The
Secretary of Health and Human Services may disclose to an
Exchange established under the Patient Protection and
Affordable Care Act or its contractors, or to a State agency
administering a State program described in subparagraph (A)
or its contractors, any inconsistency between the information
provided by the Exchange or State agency to the Secretary and
the information provided to the Secretary under subparagraph
(A).
``(C) Restriction on use of disclosed information.--Return
information disclosed under subparagraph (A) or (B) may be
used by
[[Page H1952]]
officers, employees, and contractors of the Department of
Health and Human Services, an Exchange, or a State agency
only for the purposes of, and to the extent necessary in--
``(i) establishing eligibility for participation in the
Exchange, and verifying the appropriate amount of, any credit
or reduction described in subparagraph (A),
``(ii) determining eligibility for participation in the
State programs described in subparagraph (A).''.
(2) Social security numbers.--Section 205(c)(2)(C) of the
Social Security Act is amended by adding at the end the
following new clause:
``(x) The Secretary of Health and Human Services, and the
Exchanges established under section 1311 of the Patient
Protection and Affordable Care Act, are authorized to collect
and use the names and social security account numbers of
individuals as required to administer the provisions of, and
the amendments made by, the such Act.''.
(b) Confidentiality and Disclosure.--Paragraph (3) of
section 6103(a) of such Code is amended by striking ``or
(20)'' and inserting ``(20), or (21)''.
(c) Procedures and Recordkeeping Related to Disclosures.--
Paragraph (4) of section 6103(p) of such Code is amended--
(1) by inserting ``, or any entity described in subsection
(l)(21),'' after ``or (20)'' in the matter preceding
subparagraph (A),
(2) by inserting ``or any entity described in subsection
(l)(21),'' after ``or (o)(1)(A)'' in subparagraph (F)(ii),
and
(3) by inserting ``or any entity described in subsection
(l)(21),'' after ``or (20)'' both places it appears in the
matter after subparagraph (F).
(d) Unauthorized Disclosure or Inspection.--Paragraph (2)
of section 7213(a) of such Code is amended by striking ``or
(20)'' and inserting ``(20), or (21)''.
SEC. 1415. PREMIUM TAX CREDIT AND COST-SHARING REDUCTION
PAYMENTS DISREGARDED FOR FEDERAL AND FEDERALLY-
ASSISTED PROGRAMS.
For purposes of determining the eligibility of any
individual for benefits or assistance, or the amount or
extent of benefits or assistance, under any Federal program
or under any State or local program financed in whole or in
part with Federal funds--
(1) any credit or refund allowed or made to any individual
by reason of section 36B of the Internal Revenue Code of 1986
(as added by section 1401) shall not be taken into account as
income and shall not be taken into account as resources for
the month of receipt and the following 2 months; and
(2) any cost-sharing reduction payment or advance payment
of the credit allowed under such section 36B that is made
under section 1402 or 1412 shall be treated as made to the
qualified health plan in which an individual is enrolled and
not to that individual.
PART II--SMALL BUSINESS TAX CREDIT
SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF
SMALL BUSINESSES.
(a) In General.--Subpart D of part IV of subchapter A of
chapter 1 of the Internal Revenue Code of 1986 (relating to
business-related credits) is amended by inserting after
section 45Q the following:
``SEC. 45R. EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL
EMPLOYERS.
``(a) General Rule.--For purposes of section 38, in the
case of an eligible small employer, the small employer health
insurance credit determined under this section for any
taxable year in the credit period is the amount determined
under subsection (b).
``(b) Health Insurance Credit Amount.--Subject to
subsection (c), the amount determined under this subsection
with respect to any eligible small employer is equal to 50
percent (35 percent in the case of a tax-exempt eligible
small employer) of the lesser of--
``(1) the aggregate amount of nonelective contributions the
employer made on behalf of its employees during the taxable
year under the arrangement described in subsection (d)(4) for
premiums for qualified health plans offered by the employer
to its employees through an Exchange, or
``(2) the aggregate amount of nonelective contributions
which the employer would have made during the taxable year
under the arrangement if each employee taken into account
under paragraph (1) had enrolled in a qualified health plan
which had a premium equal to the average premium (as
determined by the Secretary of Health and Human Services) for
the small group market in the rating area in which the
employee enrolls for coverage.
``(c) Phaseout of Credit Amount Based on Number of
Employees and Average Wages.--The amount of the credit
determined under subsection (b) without regard to this
subsection shall be reduced (but not below zero) by the sum
of the following amounts:
``(1) Such amount multiplied by a fraction the numerator of
which is the total number of full-time equivalent employees
of the employer in excess of 10 and the denominator of which
is 15.
``(2) Such amount multiplied by a fraction the numerator of
which is the average annual wages of the employer in excess
of the dollar amount in effect under subsection (d)(3)(B) and
the denominator of which is such dollar amount.
``(d) Eligible Small Employer.--For purposes of this
section--
``(1) In general.--The term `eligible small employer'
means, with respect to any taxable year, an employer--
``(A) which has no more than 25 full-time equivalent
employees for the taxable year,
``(B) the average annual wages of which do not exceed an
amount equal to twice the dollar amount in effect under
paragraph (3)(B) for the taxable year, and
``(C) which has in effect an arrangement described in
paragraph (4).
``(2) Full-time equivalent employees.--
``(A) In general.--The term `full-time equivalent
employees' means a number of employees equal to the number
determined by dividing--
``(i) the total number of hours of service for which wages
were paid by the employer to employees during the taxable
year, by
``(ii) 2,080.
Such number shall be rounded to the next lowest whole number
if not otherwise a whole number.
``(B) Excess hours not counted.--If an employee works in
excess of 2,080 hours of service during any taxable year,
such excess shall not be taken into account under
subparagraph (A).
``(C) Hours of service.--The Secretary, in consultation
with the Secretary of Labor, shall prescribe such
regulations, rules, and guidance as may be necessary to
determine the hours of service of an employee, including
rules for the application of this paragraph to employees who
are not compensated on an hourly basis.
``(3) Average annual wages.--
``(A) In general.--The average annual wages of an eligible
small employer for any taxable year is the amount determined
by dividing--
``(i) the aggregate amount of wages which were paid by the
employer to employees during the taxable year, by
``(ii) the number of full-time equivalent employees of the
employee determined under paragraph (2) for the taxable year.
Such amount shall be rounded to the next lowest multiple of
$1,000 if not otherwise such a multiple.
``(B) Dollar amount.--For purposes of paragraph (1)(B)--
``(i) 2011, 2012, and 2013.--The dollar amount in effect
under this paragraph for taxable years beginning in 2011,
2012, or 2013 is $20,000.
``(ii) Subsequent years.--In the case of a taxable year
beginning in a calendar year after 2013, the dollar amount in
effect under this paragraph shall be equal to $20,000,
multiplied by the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year, determined by
substituting `calendar year 2012' for `calendar year 1992' in
subparagraph (B) thereof.
``(4) Contribution arrangement.--An arrangement is
described in this paragraph if it requires an eligible small
employer to make a nonelective contribution on behalf of each
employee who enrolls in a qualified health plan offered to
employees by the employer through an exchange in an amount
equal to a uniform percentage (not less than 50 percent) of
the premium cost of the qualified health plan.
``(5) Seasonal worker hours and wages not counted.--For
purposes of this subsection--
``(A) In general.--The number of hours of service worked
by, and wages paid to, a seasonal worker of an employer shall
not be taken into account in determining the full-time
equivalent employees and average annual wages of the employer
unless the worker works for the employer on more than 120
days during the taxable year.
``(B) Definition of seasonal worker.--The term `seasonal
worker' means a worker who performs labor or services on a
seasonal basis as defined by the Secretary of Labor,
including workers covered by section 500.20(s)(1) of title
29, Code of Federal Regulations and retail workers employed
exclusively during holiday seasons.
``(e) Other Rules and Definitions.--For purposes of this
section--
``(1) Employee.--
``(A) Certain employees excluded.--The term `employee'
shall not include--
``(i) an employee within the meaning of section 401(c)(1),
``(ii) any 2-percent shareholder (as defined in section
1372(b)) of an eligible small business which is an S
corporation,
``(iii) any 5-percent owner (as defined in section
416(i)(1)(B)(i)) of an eligible small business, or
``(iv) any individual who bears any of the relationships
described in subparagraphs (A) through (G) of section
152(d)(2) to, or is a dependent described in section
152(d)(2)(H) of, an individual described in clause (i), (ii),
or (iii).
``(B) Leased employees.--The term `employee' shall include
a leased employee within the meaning of section 414(n).
``(2) Credit period.--The term `credit period' means, with
respect to any eligible small employer, the 2-consecutive-
taxable year period beginning with the 1st taxable year in
which the employer (or any predecessor) offers 1 or more
qualified health plans to its employees through an Exchange.
``(3) Nonelective contribution.--The term `nonelective
contribution' means an employer contribution other than an
employer contribution pursuant to a salary reduction
arrangement.
``(4) Wages.--The term `wages' has the meaning given such
term by section 3121(a) (determined without regard to any
dollar limitation contained in such section).
``(5) Aggregation and other rules made applicable.--
``(A) Aggregation rules.--All employers treated as a single
employer under subsection (b), (c), (m), or (o) of section
414 shall be treated as a single employer for purposes of
this section.
``(B) Other rules.--Rules similar to the rules of
subsections (c), (d), and (e) of section 52 shall apply.
``(f) Credit Made Available to Tax-exempt Eligible Small
Employers.--
``(1) In general.--In the case of a tax-exempt eligible
small employer, there shall be treated as a credit allowable
under subpart C (and not allowable under this subpart) the
lesser of--
``(A) the amount of the credit determined under this
section with respect to such employer, or
[[Page H1953]]
``(B) the amount of the payroll taxes of the employer
during the calendar year in which the taxable year begins.
``(2) Tax-exempt eligible small employer.--For purposes of
this section, the term `tax-exempt eligible small employer'
means an eligible small employer which is any organization
described in section 501(c) which is exempt from taxation
under section 501(a).
``(3) Payroll taxes.--For purposes of this subsection--
``(A) In general.--The term `payroll taxes' means--
``(i) amounts required to be withheld from the employees of
the tax-exempt eligible small employer under section 3401(a),
``(ii) amounts required to be withheld from such employees
under section 3101(b), and
``(iii) amounts of the taxes imposed on the tax-exempt
eligible small employer under section 3111(b).
``(B) Special rule.--A rule similar to the rule of section
24(d)(2)(C) shall apply for purposes of subparagraph (A).
``(g) Application of Section for Calendar Years 2011, 2012,
and 2013.--In the case of any taxable year beginning in 2011,
2012, or 2013, the following modifications to this section
shall apply in determining the amount of the credit under
subsection (a):
``(1) No credit period required.--The credit shall be
determined without regard to whether the taxable year is in a
credit period and for purposes of applying this section to
taxable years beginning after 2013, no credit period shall be
treated as beginning with a taxable year beginning before
2014.
``(2) Amount of credit.--The amount of the credit
determined under subsection (b) shall be determined--
``(A) by substituting `35 percent (25 percent in the case
of a tax-exempt eligible small employer)' for `50 percent (35
percent in the case of a tax-exempt eligible small
employer)',
``(B) by reference to an eligible small employer's
nonelective contributions for premiums paid for health
insurance coverage (within the meaning of section 9832(b)(1))
of an employee, and
``(C) by substituting for the average premium determined
under subsection (b)(2) the amount the Secretary of Health
and Human Services determines is the average premium for the
small group market in the State in which the employer is
offering health insurance coverage (or for such area within
the State as is specified by the Secretary).
``(3) Contribution arrangement.--An arrangement shall not
fail to meet the requirements of subsection (d)(4) solely
because it provides for the offering of insurance outside of
an Exchange.
``(h) Insurance Definitions.--Any term used in this section
which is also used in the Public Health Service Act or
subtitle A of title I of the Patient Protection and
Affordable Care Act shall have the meaning given such term by
such Act or subtitle.
``(i) Regulations.--The Secretary shall prescribe such
regulations as may be necessary to carry out the provisions
of this section, including regulations to prevent the
avoidance of the 2-year limit on the credit period through
the use of successor entities and the avoidance of the
limitations under subsection (c) through the use of multiple
entities.''.
(b) Credit To Be Part of General Business Credit.--Section
38(b) of the Internal Revenue Code of 1986 (relating to
current year business credit) is amended by striking ``plus''
at the end of paragraph (34), by striking the period at the
end of paragraph (35) and inserting ``, plus'', and by
inserting after paragraph (35) the following:
``(36) the small employer health insurance credit
determined under section 45R.''.
(c) Credit Allowed Against Alternative Minimum Tax.--
Section 38(c)(4)(B) of the Internal Revenue Code of 1986
(defining specified credits) is amended by redesignating
clauses (vi), (vii), and (viii) as clauses (vii), (viii), and
(ix), respectively, and by inserting after clause (v) the
following new clause:
``(vi) the credit determined under section 45R,''.
(d) Disallowance of Deduction for Certain Expenses for
Which Credit Allowed.--
(1) In general.--Section 280C of the Internal Revenue Code
of 1986 (relating to disallowance of deduction for certain
expenses for which credit allowed), as amended by section
1401(b), is amended by adding at the end the following new
subsection:
``(h) Credit for Employee Health Insurance Expenses of
Small Employers.--No deduction shall be allowed for that
portion of the premiums for qualified health plans (as
defined in section 1301(a) of the Patient Protection and
Affordable Care Act), or for health insurance coverage in the
case of taxable years beginning in 2011, 2012, or 2013, paid
by an employer which is equal to the amount of the credit
determined under section 45R(a) with respect to the
premiums.''.
(2) Deduction for expiring credits.--Section 196(c) of such
Code is amended by striking ``and'' at the end of paragraph
(12), by striking the period at the end of paragraph (13) and
inserting ``, and'', and by adding at the end the following
new paragraph:
``(14) the small employer health insurance credit
determined under section 45R(a).''.
(e) Clerical Amendment.--The table of sections for subpart
D of part IV of subchapter A of chapter 1 of the Internal
Revenue Code of 1986 is amended by adding at the end the
following:
``Sec. 45R. Employee health insurance expenses of small employers.''.
(f) Effective Dates.--
(1) In general.--The amendments made by this section shall
apply to amounts paid or incurred in taxable years beginning
after December 31, 2010.
(2) Minimum tax.--The amendments made by subsection (c)
shall apply to credits determined under section 45R of the
Internal Revenue Code of 1986 in taxable years beginning
after December 31, 2010, and to carrybacks of such credits.
Subtitle F--Shared Responsibility for Health Care
PART I--INDIVIDUAL RESPONSIBILITY
SEC. 1501. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL
COVERAGE.
(a) Findings.--Congress makes the following findings:
(1) In general.--The individual responsibility requirement
provided for in this section (in this subsection referred to
as the ``requirement'') is commercial and economic in nature,
and substantially affects interstate commerce, as a result of
the effects described in paragraph (2).
(2) Effects on the national economy and interstate
commerce.--The effects described in this paragraph are the
following:
(A) The requirement regulates activity that is commercial
and economic in nature: economic and financial decisions
about how and when health care is paid for, and when health
insurance is purchased.
(B) Health insurance and health care services are a
significant part of the national economy. National health
spending is projected to increase from $2,500,000,000,000, or
17.6 percent of the economy, in 2009 to $4,700,000,000,000 in
2019. Private health insurance spending is projected to be
$854,000,000,000 in 2009, and pays for medical supplies,
drugs, and equipment that are shipped in interstate commerce.
Since most health insurance is sold by national or regional
health insurance companies, health insurance is sold in
interstate commerce and claims payments flow through
interstate commerce.
(C) The requirement, together with the other provisions of
this Act, will add millions of new consumers to the health
insurance market, increasing the supply of, and demand for,
health care services. According to the Congressional Budget
Office, the requirement will increase the number and share of
Americans who are insured.
(D) The requirement achieves near-universal coverage by
building upon and strengthening the private employer-based
health insurance system, which covers 176,000,000 Americans
nationwide. In Massachusetts, a similar requirement has
strengthened private employer-based coverage: despite the
economic downturn, the number of workers offered employer-
based coverage has actually increased.
(E) Half of all personal bankruptcies are caused in part by
medical expenses. By significantly increasing health
insurance coverage, the requirement, together with the other
provisions of this Act, will improve financial security for
families.
(F) Under the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1001 et seq.), the Public Health Service Act
(42 U.S.C. 201 et seq.), and this Act, the Federal Government
has a significant role in regulating health insurance which
is in interstate commerce.
(G) Under sections 2704 and 2705 of the Public Health
Service Act (as added by section 1201 of this Act), if there
were no requirement, many individuals would wait to purchase
health insurance until they needed care. By significantly
increasing health insurance coverage, the requirement,
together with the other provisions of this Act, will minimize
this adverse selection and broaden the health insurance risk
pool to include healthy individuals, which will lower health
insurance premiums. The requirement is essential to creating
effective health insurance markets in which improved health
insurance products that are guaranteed issue and do not
exclude coverage of pre-existing conditions can be sold.
(H) Administrative costs for private health insurance,
which were $90,000,000,000 in 2006, are 26 to 30 percent of
premiums in the current individual and small group markets.
By significantly increasing health insurance coverage and the
size of purchasing pools, which will increase economies of
scale, the requirement, together with the other provisions of
this Act, will significantly reduce administrative costs and
lower health insurance premiums. The requirement is essential
to creating effective health insurance markets that do not
require underwriting and eliminate its associated
administrative costs.
(3) Supreme court ruling.--In United States v. South-
Eastern Underwriters Association (322 U.S. 533 (1944)), the
Supreme Court of the United States ruled that insurance is
interstate commerce subject to Federal regulation.
(b) In General.--Subtitle D of the Internal Revenue Code of
1986 is amended by adding at the end the following new
chapter:
``CHAPTER 48--MAINTENANCE OF MINIMUM ESSENTIAL COVERAGE
``Sec. 5000A. Requirement to maintain minimum essential coverage.
``SEC. 5000A. REQUIREMENT TO MAINTAIN MINIMUM ESSENTIAL
COVERAGE.
``(a) Requirement To Maintain Minimum Essential Coverage.--
An applicable individual shall for each month beginning after
2013 ensure that the individual, and any dependent of the
individual who is an applicable individual, is covered under
minimum essential coverage for such month.
``(b) Shared Responsibility Payment.--
``(1) In general.--If an applicable individual fails to
meet the requirement of subsection (a) for 1 or more months
during any calendar year beginning after 2013, then, except
as provided in subsection (d), there is hereby imposed a
penalty with respect to the individual in the amount
determined under subsection (c).
``(2) Inclusion with return.--Any penalty imposed by this
section with respect to any
[[Page H1954]]
month shall be included with a taxpayer's return under
chapter 1 for the taxable year which includes such month.
``(3) Payment of penalty.--If an individual with respect to
whom a penalty is imposed by this section for any month--
``(A) is a dependent (as defined in section 152) of another
taxpayer for the other taxpayer's taxable year including such
month, such other taxpayer shall be liable for such penalty,
or
``(B) files a joint return for the taxable year including
such month, such individual and the spouse of such individual
shall be jointly liable for such penalty.
``(c) Amount of Penalty.--
``(1) In general.--The penalty determined under this
subsection for any month with respect to any individual is an
amount equal to \1/12\ of the applicable dollar amount for
the calendar year.
``(2) Dollar limitation.--The amount of the penalty imposed
by this section on any taxpayer for any taxable year with
respect to all individuals for whom the taxpayer is liable
under subsection (b)(3) shall not exceed an amount equal to
300 percent the applicable dollar amount (determined without
regard to paragraph (3)(C)) for the calendar year with or
within which the taxable year ends.
``(3) Applicable dollar amount.--For purposes of paragraph
(1)--
``(A) In general.--Except as provided in subparagraphs (B)
and (C), the applicable dollar amount is $750.
``(B) Phase in.--The applicable dollar amount is $95 for
2014 and $350 for 2015.
``(C) Special rule for individuals under age 18.--If an
applicable individual has not attained the age of 18 as of
the beginning of a month, the applicable dollar amount with
respect to such individual for the month shall be equal to
one-half of the applicable dollar amount for the calendar
year in which the month occurs.
``(D) Indexing of amount.--In the case of any calendar year
beginning after 2016, the applicable dollar amount shall be
equal to $750, increased by an amount equal to--
``(i) $750, multiplied by
``(ii) the cost-of-living adjustment determined under
section 1(f)(3) for the calendar year, determined by
substituting `calendar year 2015' for `calendar year 1992' in
subparagraph (B) thereof.
If the amount of any increase under clause (i) is not a
multiple of $50, such increase shall be rounded to the next
lowest multiple of $50.
``(4) Terms relating to income and families.--For purposes
of this section--
``(A) Family size.--The family size involved with respect
to any taxpayer shall be equal to the number of individuals
for whom the taxpayer is allowed a deduction under section
151 (relating to allowance of deduction for personal
exemptions) for the taxable year.
``(B) Household income.--The term `household income' means,
with respect to any taxpayer for any taxable year, an amount
equal to the sum of--
``(i) the modified gross income of the taxpayer, plus
``(ii) the aggregate modified gross incomes of all other
individuals who--
``(I) were taken into account in determining the taxpayer's
family size under paragraph (1), and
``(II) were required to file a return of tax imposed by
section 1 for the taxable year.
``(C) Modified gross income.--The term `modified gross
income' means gross income--
``(i) decreased by the amount of any deduction allowable
under paragraph (1), (3), (4), or (10) of section 62(a),
``(ii) increased by the amount of interest received or
accrued during the taxable year which is exempt from tax
imposed by this chapter, and
``(iii) determined without regard to sections 911, 931, and
933.
``(D) Poverty line.--
``(i) In general.--The term `poverty line' has the meaning
given that term in section 2110(c)(5) of the Social Security
Act (42 U.S.C. 1397jj(c)(5)).
``(ii) Poverty line used.--In the case of any taxable year
ending with or within a calendar year, the poverty line used
shall be the most recently published poverty line as of the
1st day of such calendar year.
``(d) Applicable Individual.--For purposes of this
section--
``(1) In general.--The term `applicable individual' means,
with respect to any month, an individual other than an
individual described in paragraph (2), (3), or (4).
``(2) Religious exemptions.--
``(A) Religious conscience exemption.--Such term shall not
include any individual for any month if such individual has
in effect an exemption under section 1311(d)(4)(H) of the
Patient Protection and Affordable Care Act which certifies
that such individual is a member of a recognized religious
sect or division thereof described in section 1402(g)(1) and
an adherent of established tenets or teachings of such sect
or division as described in such section.
``(B) Health care sharing ministry.--
``(i) In general.--Such term shall not include any
individual for any month if such individual is a member of a
health care sharing ministry for the month.
``(ii) Health care sharing ministry.--The term `health care
sharing ministry' means an organization--
``(I) which is described in section 501(c)(3) and is exempt
from taxation under section 501(a),
``(II) members of which share a common set of ethical or
religious beliefs and share medical expenses among members in
accordance with those beliefs and without regard to the State
in which a member resides or is employed,
``(III) members of which retain membership even after they
develop a medical condition,
``(IV) which (or a predecessor of which) has been in
existence at all times since December 31, 1999, and medical
expenses of its members have been shared continuously and
without interruption since at least December 31, 1999, and
``(V) which conducts an annual audit which is performed by
an independent certified public accounting firm in accordance
with generally accepted accounting principles and which is
made available to the public upon request.
``(3) Individuals not lawfully present.--Such term shall
not include an individual for any month if for the month the
individual is not a citizen or national of the United States
or an alien lawfully present in the United States.
``(4) Incarcerated individuals.--Such term shall not
include an individual for any month if for the month the
individual is incarcerated, other than incarceration pending
the disposition of charges.
``(e) Exemptions.--No penalty shall be imposed under
subsection (a) with respect to--
``(1) Individuals who cannot afford coverage.--
``(A) In general.--Any applicable individual for any month
if the applicable individual's required contribution
(determined on an annual basis) for coverage for the month
exceeds 8 percent of such individual's household income for
the taxable year described in section 1412(b)(1)(B) of the
Patient Protection and Affordable Care Act. For purposes of
applying this subparagraph, the taxpayer's household income
shall be increased by any exclusion from gross income for any
portion of the required contribution made through a salary
reduction arrangement.
``(B) Required contribution.--For purposes of this
paragraph, the term `required contribution' means--
``(i) in the case of an individual eligible to purchase
minimum essential coverage consisting of coverage through an
eligible-employer-sponsored plan, the portion of the annual
premium which would be paid by the individual (without regard
to whether paid through salary reduction or otherwise) for
self-only coverage, or
``(ii) in the case of an individual eligible only to
purchase minimum essential coverage described in subsection
(f)(1)(C), the annual premium for the lowest cost bronze plan
available in the individual market through the Exchange in
the State in the rating area in which the individual resides
(without regard to whether the individual purchased a
qualified health plan through the Exchange), reduced by the
amount of the credit allowable under section 36B for the
taxable year (determined as if the individual was covered by
a qualified health plan offered through the Exchange for the
entire taxable year).
``(C) Special rules for individuals related to employees.--
For purposes of subparagraph (B)(i), if an applicable
individual is eligible for minimum essential coverage through
an employer by reason of a relationship to an employee, the
determination shall be made by reference to the affordability
of the coverage to the employee.
``(D) Indexing.--In the case of plan years beginning in any
calendar year after 2014, subparagraph (A) shall be applied
by substituting for `8 percent' the percentage the Secretary
of Health and Human Services determines reflects the excess
of the rate of premium growth between the preceding calendar
year and 2013 over the rate of income growth for such period.
``(2) Taxpayers with income under 100 percent of poverty
line.--Any applicable individual for any month during a
calendar year if the individual's household income for the
taxable year described in section 1412(b)(1)(B) of the
Patient Protection and Affordable Care Act is less than 100
percent of the poverty line for the size of the family
involved (determined in the same manner as under subsection
(b)(4)).
``(3) Members of indian tribes.--Any applicable individual
for any month during which the individual is a member of an
Indian tribe (as defined in section 45A(c)(6)).
``(4) Months during short coverage gaps.--
``(A) In general.--Any month the last day of which occurred
during a period in which the applicable individual was not
covered by minimum essential coverage for a continuous period
of less than 3 months.
``(B) Special rules.--For purposes of applying this
paragraph--
``(i) the length of a continuous period shall be determined
without regard to the calendar years in which months in such
period occur,
``(ii) if a continuous period is greater than the period
allowed under subparagraph (A), no exception shall be
provided under this paragraph for any month in the period,
and
``(iii) if there is more than 1 continuous period described
in subparagraph (A) covering months in a calendar year, the
exception provided by this paragraph shall only apply to
months in the first of such periods.
The Secretary shall prescribe rules for the collection of the
penalty imposed by this section in cases where continuous
periods include months in more than 1 taxable year.
``(5) Hardships.--Any applicable individual who for any
month is determined by the Secretary of Health and Human
Services under section 1311(d)(4)(H) to have suffered a
hardship with respect to the capability to obtain coverage
under a qualified health plan.
``(f) Minimum Essential Coverage.--For purposes of this
section--
``(1) In general.--The term `minimum essential coverage'
means any of the following:
``(A) Government sponsored programs.--Coverage under--
``(i) the Medicare program under part A of title XVIII of
the Social Security Act,
``(ii) the Medicaid program under title XIX of the Social
Security Act,
``(iii) the CHIP program under title XXI of the Social
Security Act,
[[Page H1955]]
``(iv) the TRICARE for Life program,
``(v) the veteran's health care program under chapter 17 of
title 38, United States Code, or
``(vi) a health plan under section 2504(e) of title 22,
United States Code (relating to Peace Corps volunteers).
``(B) Employer-sponsored plan.--Coverage under an eligible
employer-sponsored plan.
``(C) Plans in the individual market.--Coverage under a
health plan offered in the individual market within a State.
``(D) Grandfathered health plan.--Coverage under a
grandfathered health plan.
``(E) Other coverage.--Such other health benefits coverage,
such as a State health benefits risk pool, as the Secretary
of Health and Human Services, in coordination with the
Secretary, recognizes for purposes of this subsection.
``(2) Eligible employer-sponsored plan.--The term `eligible
employer-sponsored plan' means, with respect to any employee,
a group health plan or group health insurance coverage
offered by an employer to the employee which is--
``(A) a governmental plan (within the meaning of section
2791(d)(8) of the Public Health Service Act), or
``(B) any other plan or coverage offered in the small or
large group market within a State.
Such term shall include a grandfathered health plan described
in paragraph (1)(D) offered in a group market.
``(3) Excepted benefits not treated as minimum essential
coverage.--The term `minimum essential coverage' shall not
include health insurance coverage which consists of coverage
of excepted benefits--
``(A) described in paragraph (1) of subsection (c) of
section 2791 of the Public Health Service Act; or
``(B) described in paragraph (2), (3), or (4) of such
subsection if the benefits are provided under a separate
policy, certificate, or contract of insurance.
``(4) Individuals residing outside united states or
residents of territories.--Any applicable individual shall be
treated as having minimum essential coverage for any month--
``(A) if such month occurs during any period described in
subparagraph (A) or (B) of section 911(d)(1) which is
applicable to the individual, or
``(B) if such individual is a bona fide resident of any
possession of the United States (as determined under section
937(a)) for such month.
``(5) Insurance-related terms.--Any term used in this
section which is also used in title I of the Patient
Protection and Affordable Care Act shall have the same
meaning as when used in such title.
``(g) Administration and Procedure.--
``(1) In general.--The penalty provided by this section
shall be paid upon notice and demand by the Secretary, and
except as provided in paragraph (2), shall be assessed and
collected in the same manner as an assessable penalty under
subchapter B of chapter 68.
``(2) Special rules.--Notwithstanding any other provision
of law--
``(A) Waiver of criminal penalties.--In the case of any
failure by a taxpayer to timely pay any penalty imposed by
this section, such taxpayer shall not be subject to any
criminal prosecution or penalty with respect to such failure.
``(B) Limitations on liens and levies.--The Secretary shall
not--
``(i) file notice of lien with respect to any property of a
taxpayer by reason of any failure to pay the penalty imposed
by this section, or
``(ii) levy on any such property with respect to such
failure.''.
(c) Clerical Amendment.--The table of chapters for subtitle
D of the Internal Revenue Code of 1986 is amended by
inserting after the item relating to chapter 47 the following
new item:
``Chapter 48--Maintenance of Minimum Essential Coverage.''.
(d) Effective Date.--The amendments made by this section
shall apply to taxable years ending after December 31, 2013.
SEC. 1502. REPORTING OF HEALTH INSURANCE COVERAGE.
(a) In General.--Part III of subchapter A of chapter 61 of
the Internal Revenue Code of 1986 is amended by inserting
after subpart C the following new subpart:
``Subpart D--Information Regarding Health Insurance Coverage
``Sec. 6055. Reporting of health insurance coverage.
``SEC. 6055. REPORTING OF HEALTH INSURANCE COVERAGE.
``(a) In General.--Every person who provides minimum
essential coverage to an individual during a calendar year
shall, at such time as the Secretary may prescribe, make a
return described in subsection (b).
``(b) Form and Manner of Return.--
``(1) In general.--A return is described in this subsection
if such return--
``(A) is in such form as the Secretary may prescribe, and
``(B) contains--
``(i) the name, address and TIN of the primary insured and
the name and TIN of each other individual obtaining coverage
under the policy,
``(ii) the dates during which such individual was covered
under minimum essential coverage during the calendar year,
``(iii) in the case of minimum essential coverage which
consists of health insurance coverage, information
concerning--
``(I) whether or not the coverage is a qualified health
plan offered through an Exchange established under section
1311 of the Patient Protection and Affordable Care Act, and
``(II) in the case of a qualified health plan, the amount
(if any) of any advance payment under section 1412 of the
Patient Protection and Affordable Care Act of any cost-
sharing reduction under section 1402 of such Act or of any
premium tax credit under section 36B with respect to such
coverage, and
``(iv) such other information as the Secretary may require.
``(2) Information relating to employer-provided coverage.--
If minimum essential coverage provided to an individual under
subsection (a) consists of health insurance coverage of a
health insurance issuer provided through a group health plan
of an employer, a return described in this subsection shall
include--
``(A) the name, address, and employer identification number
of the employer maintaining the plan,
``(B) the portion of the premium (if any) required to be
paid by the employer, and
``(C) if the health insurance coverage is a qualified
health plan in the small group market offered through an
Exchange, such other information as the Secretary may require
for administration of the credit under section 45R (relating
to credit for employee health insurance expenses of small
employers).
``(c) Statements To Be Furnished to Individuals With
Respect to Whom Information Is Reported.--
``(1) In general.--Every person required to make a return
under subsection (a) shall furnish to each individual whose
name is required to be set forth in such return a written
statement showing--
``(A) the name and address of the person required to make
such return and the phone number of the information contact
for such person, and
``(B) the information required to be shown on the return
with respect to such individual.
``(2) Time for furnishing statements.--The written
statement required under paragraph (1) shall be furnished on
or before January 31 of the year following the calendar year
for which the return under subsection (a) was required to be
made.
``(d) Coverage Provided by Governmental Units.--In the case
of coverage provided by any governmental unit or any agency
or instrumentality thereof, the officer or employee who
enters into the agreement to provide such coverage (or the
person appropriately designated for purposes of this section)
shall make the returns and statements required by this
section.
``(e) Minimum Essential Coverage.--For purposes of this
section, the term `minimum essential coverage' has the
meaning given such term by section 5000A(f).''.
(b) Assessable Penalties.--
(1) Subparagraph (B) of section 6724(d)(1) of the Internal
Revenue Code of 1986 (relating to definitions) is amended by
striking ``or'' at the end of clause (xxii), by striking
``and'' at the end of clause (xxiii) and inserting ``or'',
and by inserting after clause (xxiii) the following new
clause:
``(xxiv) section 6055 (relating to returns relating to
information regarding health insurance coverage), and''.
(2) Paragraph (2) of section 6724(d) of such Code is
amended by striking ``or'' at the end of subparagraph (EE),
by striking the period at the end of subparagraph (FF) and
inserting ``, or'' and by inserting after subparagraph (FF)
the following new subparagraph:
``(GG) section 6055(c) (relating to statements relating to
information regarding health insurance coverage).''.
(c) Notification of Nonenrollment.--Not later than June 30
of each year, the Secretary of the Treasury, acting through
the Internal Revenue Service and in consultation with the
Secretary of Health and Human Services, shall send a
notification to each individual who files an individual
income tax return and who is not enrolled in minimum
essential coverage (as defined in section 5000A of the
Internal Revenue Code of 1986). Such notification shall
contain information on the services available through the
Exchange operating in the State in which such individual
resides.
(d) Conforming Amendment.--The table of subparts for part
III of subchapter A of chapter 61 of such Code is amended by
inserting after the item relating to subpart C the following
new item:
``subpart d--information regarding health insurance coverage''.
(e) Effective Date.--The amendments made by this section
shall apply to calendar years beginning after 2013.
PART II--EMPLOYER RESPONSIBILITIES
SEC. 1511. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE
EMPLOYERS.
The Fair Labor Standards Act of 1938 is amended by
inserting after section 18 (29 U.S.C. 218) the following:
``SEC. 18A. AUTOMATIC ENROLLMENT FOR EMPLOYEES OF LARGE
EMPLOYERS.
``In accordance with regulations promulgated by the
Secretary, an employer to which this Act applies that has
more than 200 full-time employees and that offers employees
enrollment in 1 or more health benefits plans shall
automatically enroll new full-time employees in one of the
plans offered (subject to any waiting period authorized by
law) and to continue the enrollment of current employees in a
health benefits plan offered through the employer. Any
automatic enrollment program shall include adequate notice
and the opportunity for an employee to opt out of any
coverage the individual or employee were automatically
enrolled in. Nothing in this section shall be construed to
supersede any State law which establishes, implements, or
continues in effect any standard or requirement relating to
employers in connection with payroll except to the extent
that such standard or requirement prevents an employer from
instituting
[[Page H1956]]
the automatic enrollment program under this section.''.
SEC. 1512. EMPLOYER REQUIREMENT TO INFORM EMPLOYEES OF
COVERAGE OPTIONS.
The Fair Labor Standards Act of 1938 is amended by
inserting after section 18A (as added by section 1513) the
following:
``SEC. 18B. NOTICE TO EMPLOYEES.
``(a) In General.--In accordance with regulations
promulgated by the Secretary, an employer to which this Act
applies, shall provide to each employee at the time of hiring
(or with respect to current employees, not later than March
1, 2013), written notice--
``(1) informing the employee of the existence of an
Exchange, including a description of the services provided by
such Exchange, and the manner in which the employee may
contact the Exchange to request assistance;
``(2) if the employer plan's share of the total allowed
costs of benefits provided under the plan is less than 60
percent of such costs, that the employee may be eligible for
a premium tax credit under section 36B of the Internal
Revenue Code of 1986 and a cost sharing reduction under
section 1402 of the Patient Protection and Affordable Care
Act if the employee purchases a qualified health plan through
the Exchange; and
``(3) if the employee purchases a qualified health plan
through the Exchange, the employee will lose the employer
contribution (if any) to any health benefits plan offered by
the employer and that all or a portion of such contribution
may be excludable from income for Federal income tax
purposes.
``(b) Effective Date.--Subsection (a) shall take effect
with respect to employers in a State beginning on March 1,
2013.''.
SEC. 1513. SHARED RESPONSIBILITY FOR EMPLOYERS.
(a) In General.--Chapter 43 of the Internal Revenue Code of
1986 is amended by adding at the end the following:
``SEC. 4980H. SHARED RESPONSIBILITY FOR EMPLOYERS REGARDING
HEALTH COVERAGE.
``(a) Large Employers Not Offering Health Coverage.--If--
``(1) any applicable large employer fails to offer to its
full-time employees (and their dependents) the opportunity to
enroll in minimum essential coverage under an eligible
employer-sponsored plan (as defined in section 5000A(f)(2))
for any month, and
``(2) at least one full-time employee of the applicable
large employer has been certified to the employer under
section 1411 of the Patient Protection and Affordable Care
Act as having enrolled for such month in a qualified health
plan with respect to which an applicable premium tax credit
or cost-sharing reduction is allowed or paid with respect to
the employee,
then there is hereby imposed on the employer an assessable
payment equal to the product of the applicable payment amount
and the number of individuals employed by the employer as
full-time employees during such month.
``(b) Large Employers With Waiting Periods Exceeding 30
Days.--
``(1) In general.--In the case of any applicable large
employer which requires an extended waiting period to enroll
in any minimum essential coverage under an employer-sponsored
plan (as defined in section 5000A(f)(2)), there is hereby
imposed on the employer an assessable payment, in the amount
specified in paragraph (2), for each full-time employee of
the employer to whom the extended waiting period applies.
``(2) Amount.--For purposes of paragraph (1), the amount
specified in this paragraph for a full-time employee is--
``(A) in the case of an extended waiting period which
exceeds 30 days but does not exceed 60 days, $400, and
``(B) in the case of an extended waiting period which
exceeds 60 days, $600.
``(3) Extended waiting period.--The term `extended waiting
period' means any waiting period (as defined in section
2701(b)(4) of the Public Health Service Act) which exceeds 30
days.
``(c) Large Employers Offering Coverage With Employees Who
Qualify for Premium Tax Credits or Cost-sharing Reductions.--
``(1) In general.--If--
``(A) an applicable large employer offers to its full-time
employees (and their dependents) the opportunity to enroll in
minimum essential coverage under an eligible employer-
sponsored plan (as defined in section 5000A(f)(2)) for any
month, and
``(B) 1 or more full-time employees of the applicable large
employer has been certified to the employer under section
1411 of the Patient Protection and Affordable Care Act as
having enrolled for such month in a qualified health plan
with respect to which an applicable premium tax credit or
cost-sharing reduction is allowed or paid with respect to the
employee,
then there is hereby imposed on the employer an assessable
payment equal to the product of the number of full-time
employees of the applicable large employer described in
subparagraph (B) for such month and 400 percent of the
applicable payment amount.
``(2) Overall limitation.--The aggregate amount of tax
determined under paragraph (1) with respect to all employees
of an applicable large employer for any month shall not
exceed the product of the applicable payment amount and the
number of individuals employed by the employer as full-time
employees during such month.
``(d) Definitions and Special Rules.--For purposes of this
section--
``(1) Applicable payment amount.--The term `applicable
payment amount' means, with respect to any month, \1/12\ of
$750.
``(2) Applicable large employer.--
``(A) In general.--The term `applicable large employer'
means, with respect to a calendar year, an employer who
employed an average of at least 50 full-time employees on
business days during the preceding calendar year.
``(B) Exemption for certain employers.--
``(i) In general.--An employer shall not be considered to
employ more than 50 full-time employees if--
``(I) the employer's workforce exceeds 50 full-time
employees for 120 days or fewer during the calendar year, and
``(II) the employees in excess of 50 employed during such
120-day period were seasonal workers.
``(ii) Definition of seasonal workers.--The term `seasonal
worker' means a worker who performs labor or services on a
seasonal basis as defined by the Secretary of Labor,
including workers covered by section 500.20(s)(1) of title
29, Code of Federal Regulations and retail workers employed
exclusively during holiday seasons.
``(C) Rules for determining employer size.--For purposes of
this paragraph--
``(i) Application of aggregation rule for employers.--All
persons treated as a single employer under subsection (b),
(c), (m), or (o) of section 414 of the Internal Revenue Code
of 1986 shall be treated as 1 employer.
``(ii) Employers not in existence in preceding year.--In
the case of an employer which was not in existence throughout
the preceding calendar year, the determination of whether
such employer is an applicable large employer shall be based
on the average number of employees that it is reasonably
expected such employer will employ on business days in the
current calendar year.
``(iii) Predecessors.--Any reference in this subsection to
an employer shall include a reference to any predecessor of
such employer.
``(3) Applicable premium tax credit and cost-sharing
reduction.--The term `applicable premium tax credit and cost-
sharing reduction' means--
``(A) any premium tax credit allowed under section 36B,
``(B) any cost-sharing reduction under section 1402 of the
Patient Protection and Affordable Care Act, and
``(C) any advance payment of such credit or reduction under
section 1412 of such Act.
``(4) Full-time employee.--
``(A) In general.--The term `full-time employee' means an
employee who is employed on average at least 30 hours of
service per week.
``(B) Hours of service.--The Secretary, in consultation
with the Secretary of Labor, shall prescribe such
regulations, rules, and guidance as may be necessary to
determine the hours of service of an employee, including
rules for the application of this paragraph to employees who
are not compensated on an hourly basis.
``(5) Inflation adjustment.--
``(A) In general.--In the case of any calendar year after
2014, each of the dollar amounts in subsection (b)(2) and
(d)(1) shall be increased by an amount equal to the product
of--
``(i) such dollar amount, and
``(ii) the premium adjustment percentage (as defined in
section 1302(c)(4) of the Patient Protection and Affordable
Care Act) for the calendar year.
``(B) Rounding.--If the amount of any increase under
subparagraph (A) is not a multiple of $10, such increase
shall be rounded to the next lowest multiple of $10.
``(6) Other definitions.--Any term used in this section
which is also used in the Patient Protection and Affordable
Care Act shall have the same meaning as when used in such
Act.
``(7) Tax nondeductible.--For denial of deduction for the
tax imposed by this section, see section 275(a)(6).
``(e) Administration and Procedure.--
``(1) In general.--Any assessable payment provided by this
section shall be paid upon notice and demand by the
Secretary, and shall be assessed and collected in the same
manner as an assessable penalty under subchapter B of chapter
68.
``(2) Time for payment.--The Secretary may provide for the
payment of any assessable payment provided by this section on
an annual, monthly, or other periodic basis as the Secretary
may prescribe.
``(3) Coordination with credits, etc..--The Secretary shall
prescribe rules, regulations, or guidance for the repayment
of any assessable payment (including interest) if such
payment is based on the allowance or payment of an applicable
premium tax credit or cost-sharing reduction with respect to
an employee, such allowance or payment is subsequently
disallowed, and the assessable payment would not have been
required to be made but for such allowance or payment.''.
(b) Clerical Amendment.--The table of sections for chapter
43 of such Code is amended by adding at the end the following
new item:
``Sec. 4980H. Shared responsibility for employers regarding health
coverage.''.
(c) Study and Report of Effect of Tax on Workers' Wages.--
(1) In general.--The Secretary of Labor shall conduct a
study to determine whether employees' wages are reduced by
reason of the application of the assessable payments under
section 4980H of the Internal Revenue Code of 1986 (as added
by the amendments made by this section). The Secretary shall
make such determination on the basis of the National
Compensation Survey published by the Bureau of Labor
Statistics.
(2) Report.--The Secretary shall report the results of the
study under paragraph (1) to the Committee on Ways and Means
of the House of Representatives and to the Committee on
Finance of the Senate.
(d) Effective Date.--The amendments made by this section
shall apply to months beginning after December 31, 2013.
[[Page H1957]]
SEC. 1514. REPORTING OF EMPLOYER HEALTH INSURANCE COVERAGE.
(a) In General.--Subpart D of part III of subchapter A of
chapter 61 of the Internal Revenue Code of 1986, as added by
section 1502, is amended by inserting after section 6055 the
following new section:
``SEC. 6056. LARGE EMPLOYERS REQUIRED TO REPORT ON HEALTH
INSURANCE COVERAGE.
``(a) In General.--Every applicable large employer required
to meet the requirements of section 4980H with respect to its
full-time employees during a calendar year shall, at such
time as the Secretary may prescribe, make a return described
in subsection (b).
``(b) Form and Manner of Return.--A return is described in
this subsection if such return--
``(1) is in such form as the Secretary may prescribe, and
``(2) contains--
``(A) the name, date, and employer identification number of
the employer,
``(B) a certification as to whether the employer offers to
its full-time employees (and their dependents) the
opportunity to enroll in minimum essential coverage under an
eligible employer-sponsored plan (as defined in section
5000A(f)(2)),
``(C) if the employer certifies that the employer did offer
to its full-time employees (and their dependents) the
opportunity to so enroll--
``(i) the length of any waiting period (as defined in
section 2701(b)(4) of the Public Health Service Act) with
respect to such coverage,
``(ii) the months during the calendar year for which
coverage under the plan was available,
``(iii) the monthly premium for the lowest cost option in
each of the enrollment categories under the plan, and
``(iv) the applicable large employer's share of the total
allowed costs of benefits provided under the plan,
``(D) the number of full-time employees for each month
during the calendar year,
``(E) the name, address, and TIN of each full-time employee
during the calendar year and the months (if any) during which
such employee (and any dependents) were covered under any
such health benefits plans, and
``(F) such other information as the Secretary may require.
``(c) Statements To Be Furnished to Individuals With
Respect to Whom Information Is Reported.--
``(1) In general.--Every person required to make a return
under subsection (a) shall furnish to each full-time employee
whose name is required to be set forth in such return under
subsection (b)(2)(E) a written statement showing--
``(A) the name and address of the person required to make
such return and the phone number of the information contact
for such person, and
``(B) the information required to be shown on the return
with respect to such individual.
``(2) Time for furnishing statements.--The written
statement required under paragraph (1) shall be furnished on
or before January 31 of the year following the calendar year
for which the return under subsection (a) was required to be
made.
``(d) Coordination With Other Requirements.--To the maximum
extent feasible, the Secretary may provide that--
``(1) any return or statement required to be provided under
this section may be provided as part of any return or
statement required under section 6051 or 6055, and
``(2) in the case of an applicable large employer offering
health insurance coverage of a health insurance issuer, the
employer may enter into an agreement with the issuer to
include information required under this section with the
return and statement required to be provided by the issuer
under section 6055.
``(e) Coverage Provided by Governmental Units.--In the case
of any applicable large employer which is a governmental unit
or any agency or instrumentality thereof, the person
appropriately designated for purposes of this section shall
make the returns and statements required by this section.
``(f) Definitions.--For purposes of this section, any term
used in this section which is also used in section 4980H
shall have the meaning given such term by section 4980H.''.
(b) Assessable Penalties.--
(1) Subparagraph (B) of section 6724(d)(1) of the Internal
Revenue Code of 1986 (relating to definitions), as amended by
section 1502, is amended by striking ``or'' at the end of
clause (xxiii), by striking ``and'' at the end of clause
(xxiv) and inserting ``or'', and by inserting after clause
(xxiv) the following new clause:
``(xxv) section 6056 (relating to returns relating to large
employers required to report on health insurance coverage),
and''.
(2) Paragraph (2) of section 6724(d) of such Code, as so
amended, is amended by striking ``or'' at the end of
subparagraph (FF), by striking the period at the end of
subparagraph (GG) and inserting ``, or'' and by inserting
after subparagraph (GG) the following new subparagraph:
``(HH) section 6056(c) (relating to statements relating to
large employers required to report on health insurance
coverage).''.
(c) Conforming Amendment.--The table of sections for
subpart D of part III of subchapter A of chapter 61 of such
Code, as added by section 1502, is amended by adding at the
end the following new item:
``Sec. 6056. Large employers required to report on health insurance
coverage.''.
(d) Effective Date.--The amendments made by this section
shall apply to periods beginning after December 31, 2013.
SEC. 1515. OFFERING OF EXCHANGE-PARTICIPATING QUALIFIED
HEALTH PLANS THROUGH CAFETERIA PLANS.
(a) In General.--Subsection (f) of section 125 of the
Internal Revenue Code of 1986 is amended by adding at the end
the following new paragraph:
``(3) Certain exchange-participating qualified health plans
not qualified.--
``(A) In general.--The term `qualified benefit' shall not
include any qualified health plan (as defined in section
1301(a) of the Patient Protection and Affordable Care Act)
offered through an Exchange established under section 1311 of
such Act.
``(B) Exception for exchange-eligible employers.--
Subparagraph (A) shall not apply with respect to any employee
if such employee's employer is a qualified employer (as
defined in section 1312(f)(2) of the Patient Protection and
Affordable Care Act) offering the employee the opportunity to
enroll through such an Exchange in a qualified health plan in
a group market.''.
(b) Conforming Amendments.--Subsection (f) of section 125
of such Code is amended--
(1) by striking ``For purposes of this section, the term''
and inserting ``For purposes of this section--
``(1) In General.--The term'', and
(2) by striking ``Such term shall not include'' and
inserting the following:
``(2) Long-term care insurance not qualified.--The term
`qualified benefit' shall not include''.
(c) Effective Date.--The amendments made by this section
shall apply to taxable years beginning after December 31,
2013.
Subtitle G--Miscellaneous Provisions
SEC. 1551. DEFINITIONS.
Unless specifically provided for otherwise, the definitions
contained in section 2791 of the Public Health Service Act
(42 U.S.C. 300gg-91) shall apply with respect to this title.
SEC. 1552. TRANSPARENCY IN GOVERNMENT.
Not later than 30 days after the date of enactment of this
Act, the Secretary of Health and Human Services shall publish
on the Internet website of the Department of Health and Human
Services, a list of all of the authorities provided to the
Secretary under this Act (and the amendments made by this
Act).
SEC. 1553. PROHIBITION AGAINST DISCRIMINATION ON ASSISTED
SUICIDE.
(a) In General.--The Federal Government, and any State or
local government or health care provider that receives
Federal financial assistance under this Act (or under an
amendment made by this Act) or any health plan created under
this Act (or under an amendment made by this Act), may not
subject an individual or institutional health care entity to
discrimination on the basis that the entity does not provide
any health care item or service furnished for the purpose of
causing, or for the purpose of assisting in causing, the
death of any individual, such as by assisted suicide,
euthanasia, or mercy killing.
(b) Definition.--In this section, the term ``health care
entity'' includes an individual physician or other health
care professional, a hospital, a provider-sponsored
organization, a health maintenance organization, a health
insurance plan, or any other kind of health care facility,
organization, or plan.
(c) Construction and Treatment of Certain Services.--
Nothing in subsection (a) shall be construed to apply to, or
to affect, any limitation relating to--
(1) the withholding or withdrawing of medical treatment or
medical care;
(2) the withholding or withdrawing of nutrition or
hydration;
(3) abortion; or
(4) the use of an item, good, benefit, or service furnished
for the purpose of alleviating pain or discomfort, even if
such use may increase the risk of death, so long as such
item, good, benefit, or service is not also furnished for the
purpose of causing, or the purpose of assisting in causing,
death, for any reason.
(d) Administration.--The Office for Civil Rights of the
Department of Health and Human Services is designated to
receive complaints of discrimination based on this section.
SEC. 1554. ACCESS TO THERAPIES.
Notwithstanding any other provision of this Act, the
Secretary of Health and Human Services shall not promulgate
any regulation that--
(1) creates any unreasonable barriers to the ability of
individuals to obtain appropriate medical care;
(2) impedes timely access to health care services;
(3) interferes with communications regarding a full range
of treatment options between the patient and the provider;
(4) restricts the ability of health care providers to
provide full disclosure of all relevant information to
patients making health care decisions;
(5) violates the principles of informed consent and the
ethical standards of health care professionals; or
(6) limits the availability of health care treatment for
the full duration of a patient's medical needs.
SEC. 1555. FREEDOM NOT TO PARTICIPATE IN FEDERAL HEALTH
INSURANCE PROGRAMS.
No individual, company, business, nonprofit entity, or
health insurance issuer offering group or individual health
insurance coverage shall be required to participate in any
Federal health insurance program created under this Act (or
any amendments made by this Act), or in any Federal health
insurance program expanded by this Act (or any such
amendments), and there shall be no penalty or fine imposed
upon any such issuer for choosing not to participate in such
programs.
SEC. 1556. EQUITY FOR CERTAIN ELIGIBLE SURVIVORS.
(a) Rebuttable Presumption.--Section 411(c)(4) of the Black
Lung Benefits Act (30
[[Page H1958]]
U.S.C. 921(c)(4)) is amended by striking the last sentence.
(b) Continuation of Benefits.--Section 422(l) of the Black
Lung Benefits Act (30 U.S.C. 932(l)) is amended by striking
``, except with respect to a claim filed under this part on
or after the effective date of the Black Lung Benefits
Amendments of 1981''.
(c) Effective Date.--The amendments made by this section
shall apply with respect to claims filed under part B or part
C of the Black Lung Benefits Act (30 U.S.C. 921 et seq., 931
et seq.) after January 1, 2005, that are pending on or after
the date of enactment of this Act.
SEC. 1557. NONDISCRIMINATION.
(a) In General.--Except as otherwise provided for in this
title (or an amendment made by this title), an individual
shall not, on the ground prohibited under title VI of the
Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), title IX
of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.),
the Age Discrimination Act of 1975 (42 U.S.C. 6101 et seq.),
or section 504 of the Rehabilitation Act of 1973 (29 U.S.C.
794), be excluded from participation in, be denied the
benefits of, or be subjected to discrimination under, any
health program or activity, any part of which is receiving
Federal financial assistance, including credits, subsidies,
or contracts of insurance, or under any program or activity
that is administered by an Executive Agency or any entity
established under this title (or amendments). The enforcement
mechanisms provided for and available under such title VI,
title IX, section 504, or such Age Discrimination Act shall
apply for purposes of violations of this subsection.
(b) Continued Application of Laws.--Nothing in this title
(or an amendment made by this title) shall be construed to
invalidate or limit the rights, remedies, procedures, or
legal standards available to individuals aggrieved under
title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et
seq.), title VII of the Civil Rights Act of 1964 (42 U.S.C.
2000e et seq.), title IX of the Education Amendments of 1972
(20 U.S.C. 1681 et seq.), section 504 of the Rehabilitation
Act of 1973 (29 U.S.C. 794), or the Age Discrimination Act of
1975 (42 U.S.C. 611 et seq.), or to supersede State laws that
provide additional protections against discrimination on any
basis described in subsection (a).
(c) Regulations.--The Secretary may promulgate regulations
to implement this section.
SEC. 1558. PROTECTIONS FOR EMPLOYEES.
The Fair Labor Standards Act of 1938 is amended by
inserting after section 18B (as added by section 1512) the
following:
``SEC. 18C. PROTECTIONS FOR EMPLOYEES.
``(a) Prohibition.--No employer shall discharge or in any
manner discriminate against any employee with respect to his
or her compensation, terms, conditions, or other privileges
of employment because the employee (or an individual acting
at the request of the employee) has--
``(1) received a credit under section 36B of the Internal
Revenue Code of 1986 or a subsidy under section 1402 of this
Act;
``(2) 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 title (or an amendment made by this title);
``(3) testified or is about to testify in a proceeding
concerning such violation;
``(4) assisted or participated, or is about to assist or
participate, in such a proceeding; or
``(5) 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 title (or amendment), or
any order, rule, regulation, standard, or ban under this
title (or amendment).
``(b) Complaint Procedure.--
``(1) In general.--An employee who believes that he or she
has been discharged or otherwise discriminated against by any
employer in violation of this section may seek relief in
accordance with the procedures, notifications, burdens of
proof, remedies, and statutes of limitation set forth in
section 2087(b) of title 15, United States Code.
``(2) No limitation on rights.--Nothing in this section
shall be deemed to diminish the rights, privileges, or
remedies of any employee under any Federal or State law or
under any collective bargaining agreement. The rights and
remedies in this section may not be waived by any agreement,
policy, form, or condition of employment.''.
SEC. 1559. OVERSIGHT.
The Inspector General of the Department of Health and Human
Services shall have oversight authority with respect to the
administration and implementation of this title as it relates
to such Department.
SEC. 1560. RULES OF CONSTRUCTION.
(a) No Effect on Antitrust Laws.--Nothing in this title (or
an amendment made by this title) shall be construed to
modify, impair, or supersede the operation of any of the
antitrust laws. For the purposes of this section, the term
``antitrust laws'' has the meaning given such term in
subsection (a) of the first section of the Clayton Act,
except that such term includes section 5 of the Federal Trade
Commission Act to the extent that such section 5 applies to
unfair methods of competition.
(b) Rule of Construction Regarding Hawaii's Prepaid Health
Care Act.--Nothing in this title (or an amendment made by
this title) shall be construed to modify or limit the
application of the exemption for Hawaii's Prepaid Health Care
Act (Haw. Rev. Stat. Sec. Sec. 393-1 et seq.) as provided
for under section 514(b)(5) of the Employee Retirement Income
Security Act of 1974 (29 U.S.C. 1144(b)(5)).
(c) Student Health Insurance Plans.--Nothing in this title
(or an amendment made by this title) shall be construed to
prohibit an institution of higher education (as such term is
defined for purposes of the Higher Education Act of 1965)
from offering a student health insurance plan, to the extent
that such requirement is otherwise permitted under applicable
Federal, State or local law.
(d) No Effect on Existing Requirements.--Nothing in this
title (or an amendment made by this title, unless specified
by direct statutory reference) shall be construed to modify
any existing Federal requirement concerning the State agency
responsible for determining eligibility for programs
identified in section 1413.
SEC. 1561. HEALTH INFORMATION TECHNOLOGY ENROLLMENT STANDARDS
AND PROTOCOLS.
Title XXX of the Public Health Service Act (42 U.S.C. 300jj
et seq.) is amended by adding at the end the following:
``Subtitle C--Other Provisions
``SEC. 3021. HEALTH INFORMATION TECHNOLOGY ENROLLMENT
STANDARDS AND PROTOCOLS.
``(a) In General.--
``(1) Standards and protocols.--Not later than 180 days
after the date of enactment of this title, the Secretary, in
consultation with the HIT Policy Committee and the HIT
Standards Committee, shall develop interoperable and secure
standards and protocols that facilitate enrollment of
individuals in Federal and State health and human services
programs, as determined by the Secretary.
``(2) Methods.--The Secretary shall facilitate enrollment
in such programs through methods determined appropriate by
the Secretary, which shall include providing individuals and
third parties authorized by such individuals and their
designees notification of eligibility and verification of
eligibility required under such programs.
``(b) Content.--The standards and protocols for electronic
enrollment in the Federal and State programs described in
subsection (a) shall allow for the following:
``(1) Electronic matching against existing Federal and
State data, including vital records, employment history,
enrollment systems, tax records, and other data determined
appropriate by the Secretary to serve as evidence of
eligibility and in lieu of paper-based documentation.
``(2) Simplification and submission of electronic
documentation, digitization of documents, and systems
verification of eligibility.
``(3) Reuse of stored eligibility information (including
documentation) to assist with retention of eligible
individuals.
``(4) Capability for individuals to apply, recertify and
manage their eligibility information online, including at
home, at points of service, and other community-based
locations.
``(5) Ability to expand the enrollment system to integrate
new programs, rules, and functionalities, to operate at
increased volume, and to apply streamlined verification and
eligibility processes to other Federal and State programs, as
appropriate.
``(6) Notification of eligibility, recertification, and
other needed communication regarding eligibility, which may
include communication via email and cellular phones.
``(7) Other functionalities necessary to provide eligibles
with streamlined enrollment process.
``(c) Approval and Notification.--With respect to any
standard or protocol developed under subsection (a) that has
been approved by the HIT Policy Committee and the HIT
Standards Committee, the Secretary--
``(1) shall notify States of such standards or protocols;
and
``(2) may require, as a condition of receiving Federal
funds for the health information technology investments, that
States or other entities incorporate such standards and
protocols into such investments.
``(d) Grants for Implementation of Appropriate Enrollment
HIT.--
``(1) In general.--The Secretary shall award grant to
eligible entities to develop new, and adapt existing,
technology systems to implement the HIT enrollment standards
and protocols developed under subsection (a) (referred to in
this subsection as `appropriate HIT technology').
``(2) Eligible entities.--To be eligible for a grant under
this subsection, an entity shall--
``(A) be a State, political subdivision of a State, or a
local governmental entity; and
``(B) submit to the Secretary an application at such time,
in such manner, and containing--
``(i) a plan to adopt and implement appropriate enrollment
technology that includes--
``(I) proposed reduction in maintenance costs of technology
systems;
``(II) elimination or updating of legacy systems; and
``(III) demonstrated collaboration with other entities that
may receive a grant under this section that are located in
the same State, political subdivision, or locality;
``(ii) an assurance that the entity will share such
appropriate enrollment technology in accordance with
paragraph (4); and
``(iii) such other information as the Secretary may
require.
``(3) Sharing.--
``(A) In general.--The Secretary shall ensure that
appropriate enrollment HIT adopted under grants under this
subsection is made available to other qualified State,
qualified political subdivisions of a State, or other
appropriate qualified entities (as described in subparagraph
(B)) at no cost.
``(B) Qualified entities.--The Secretary shall determine
what entities are qualified to receive enrollment HIT under
subparagraph (A), taking into consideration the
recommendations of the HIT Policy Committee and the HIT
Standards Committee.''.
[[Page H1959]]
SEC. 1562. CONFORMING AMENDMENTS.
(a) Applicability.--Section 2735 of the Public Health
Service Act (42 U.S.C. 300gg-21), as so redesignated by
section 1001(4), is amended--
(1) by striking subsection (a);
(2) in subsection (b)--
(A) in paragraph (1), by striking ``1 through 3'' and
inserting ``1 and 2''; and
(B) in paragraph (2)--
(i) in subparagraph (A), by striking ``subparagraph (D)''
and inserting ``subparagraph (D) or (E)'';
(ii) by striking ``1 through 3'' and inserting ``1 and 2'';
and
(iii) by adding at the end the following:
``(E) Election not applicable.--The election described in
subparagraph (A) shall not be available with respect to the
provisions of subpart 1.'';
(3) in subsection (c), by striking ``1 through 3 shall not
apply to any group'' and inserting ``1 and 2 shall not apply
to any individual coverage or any group''; and
(4) in subsection (d)--
(A) in paragraph (1), by striking ``1 through 3 shall not
apply to any group'' and inserting ``1 and 2 shall not apply
to any individual coverage or any group'';
(B) in paragraph (2)--
(i) in the matter preceding subparagraph (A), by striking
``1 through 3 shall not apply to any group'' and inserting
``1 and 2 shall not apply to any individual coverage or any
group''; and
(ii) in subparagraph (C), by inserting ``or, with respect
to individual coverage, under any health insurance coverage
maintained by the same health insurance issuer''; and
(C) in paragraph (3), by striking ``any group'' and
inserting ``any individual coverage or any group''.
(b) Definitions.--Section 2791(d) of the Public Health
Service Act (42 U.S.C. 300gg-91(d)) is amended by adding at
the end the following:
``(20) Qualified health plan.--The term `qualified health
plan' has the meaning given such term in section 1301(a) of
the Patient Protection and Affordable Care Act.
``(21) Exchange.--The term `Exchange' means an American
Health Benefit Exchange established under section 1311 of the
Patient Protection and Affordable Care Act.''.
(c) Technical and Conforming Amendments.--Title XXVII of
the Public Health Service Act (42 U.S.C. 300gg et seq.) is
amended--
(1) in section 2704 (42 U.S.C. 300gg), as so redesignated
by section 1201(2)--
(A) in subsection (c)--
(i) in paragraph (2), by striking ``group health plan''
each place that such term appears and inserting ``group or
individual health plan''; and
(ii) in paragraph (3)--
(I) by striking ``group health insurance'' each place that
such term appears and inserting ``group or individual health
insurance''; and
(II) in subparagraph (D), by striking ``small or large''
and inserting ``individual or group'';
(B) in subsection (d), by striking ``group health
insurance'' each place that such term appears and inserting
``group or individual health insurance''; and
(C) in subsection (e)(1)(A), by striking ``group health
insurance'' and inserting ``group or individual health
insurance'';
(2) by striking the second heading for subpart 2 of part A
(relating to other requirements);
(3) in section 2725 (42 U.S.C. 300gg-4), as so redesignated
by section 1001(2)--
(A) in subsection (a), by striking ``health insurance
issuer offering group health insurance coverage'' and
inserting ``health insurance issuer offering group or
individual health insurance coverage'';
(B) in subsection (b)--
(i) by striking ``health insurance issuer offering group
health insurance coverage in connection with a group health
plan'' in the matter preceding paragraph (1) and inserting
``health insurance issuer offering group or individual health
insurance coverage''; and
(ii) in paragraph (1), by striking ``plan'' and inserting
``plan or coverage'';
(C) in subsection (c)--
(i) in paragraph (2), by striking ``group health insurance
coverage offered by a health insurance issuer'' and inserting
``health insurance issuer offering group or individual health
insurance coverage''; and
(ii) in paragraph (3), by striking ``issuer'' and inserting
``health insurance issuer''; and
(D) in subsection (e), by striking ``health insurance
issuer offering group health insurance coverage'' and
inserting ``health insurance issuer offering group or
individual health insurance coverage'';
(4) in section 2726 (42 U.S.C. 300gg-5), as so redesignated
by section 1001(2)--
(A) in subsection (a), by striking ``(or health insurance
coverage offered in connection with such a plan)'' each place
that such term appears and inserting ``or a health insurance
issuer offering group or individual health insurance
coverage'';
(B) in subsection (b), by striking ``(or health insurance
coverage offered in connection with such a plan)'' each place
that such term appears and inserting ``or a health insurance
issuer offering group or individual health insurance
coverage''; and
(C) in subsection (c)--
(i) in paragraph (1), by striking ``(and group health
insurance coverage offered in connection with a group health
plan)'' and inserting ``and a health insurance issuer
offering group or individual health insurance coverage'';
(ii) in paragraph (2), by striking ``(or health insurance
coverage offered in connection with such a plan)'' each place
that such term appears and inserting ``or a health insurance
issuer offering group or individual health insurance
coverage'';
(5) in section 2727 (42 U.S.C. 300gg-6), as so redesignated
by section 1001(2), by striking ``health insurance issuers
providing health insurance coverage in connection with group
health plans'' and inserting ``and health insurance issuers
offering group or individual health insurance coverage'';
(6) in section 2728 (42 U.S.C. 300gg-7), as so redesignated
by section 1001(2)--
(A) in subsection (a), by striking ``health insurance
coverage offered in connection with such plan'' and inserting
``individual health insurance coverage'';
(B) in subsection (b)--
(i) in paragraph (1), by striking ``or a health insurance
issuer that provides health insurance coverage in connection
with a group health plan'' and inserting ``or a health
insurance issuer that offers group or individual health
insurance coverage'';
(ii) in paragraph (2), by striking ``health insurance
coverage offered in connection with the plan'' and inserting
``individual health insurance coverage''; and
(iii) in paragraph (3), by striking ``health insurance
coverage offered by an issuer in connection with such plan''
and inserting ``individual health insurance coverage'';
(C) in subsection (c), by striking ``health insurance
issuer providing health insurance coverage in connection with
a group health plan'' and inserting ``health insurance issuer
that offers group or individual health insurance coverage'';
and
(D) in subsection (e)(1), by striking ``health insurance
coverage offered in connection with such a plan'' and
inserting ``individual health insurance coverage'';
(7) by striking the heading for subpart 3;
(8) in section 2731 (42 U.S.C. 300gg-11), as so
redesignated by section 1001(3)--
(A) by striking the section heading and all that follows
through subsection (b);
(B) in subsection (c)--
(i) in paragraph (1)--
(I) in the matter preceding subparagraph (A), by striking
``small group'' and inserting ``group and individual''; and
(II) in subparagraph (B)--
(aa) in the matter preceding clause (i), by inserting ``and
individuals'' after ``employers'';
(bb) in clause (i), by inserting ``or any additional
individuals'' after ``additional groups''; and
(cc) in clause (ii), by striking ``without regard to the
claims experience of those employers and their employees (and
their dependents) or any health status-related factor
relating to such'' and inserting ``and individuals without
regard to the claims experience of those individuals,
employers and their employees (and their dependents) or any
health status-related factor relating to such individuals'';
and
(ii) in paragraph (2), by striking ``small group'' and
inserting ``group or individual'';
(C) in subsection (d)--
(i) by striking ``small group'' each place that such
appears and inserting ``group or individual''; and
(ii) in paragraph (1)(B)--
(I) by striking ``all employers'' and inserting ``all
employers and individuals'';
(II) by striking ``those employers'' and inserting ``those
individuals, employers''; and
(III) by striking ``such employees'' and inserting ``such
individuals, employees'';
(D) by striking subsection (e);
(E) by striking subsection (f); and
(F) by transferring such section (as amended by this
paragraph) to appear at the end of section 2702 (as added by
section 1001(4));
(9) in section 2732 (42 U.S.C. 300gg-12), as so
redesignated by section 1001(3)--
(A) by striking the section heading and all that follows
through subsection (a);
(B) in subsection (b)--
(i) in the matter preceding paragraph (1), by striking
``group health plan in the small or large group market'' and
inserting ``health insurance coverage offered in the group or
individual market'';
(ii) in paragraph (1), by inserting ``, or individual, as
applicable,'' after ``plan sponsor'';
(iii) in paragraph (2), by inserting ``, or individual, as
applicable,'' after ``plan sponsor''; and
(iv) by striking paragraph (3) and inserting the following:
``(3) Violation of participation or contribution rates.--In
the case of a group health plan, the plan sponsor has failed
to comply with a material plan provision relating to employer
contribution or group participation rules, pursuant to
applicable State law.'';
(C) in subsection (c)--
(i) in paragraph (1)--
(I) in the matter preceding subparagraph (A), by striking
``group health insurance coverage offered in the small or
large group market'' and inserting ``group or individual
health insurance coverage'';
(II) in subparagraph (A), by inserting ``or individual, as
applicable,'' after ``plan sponsor'';
(III) in subparagraph (B)--
(aa) by inserting ``or individual, as applicable,'' after
``plan sponsor''; and
(bb) by inserting ``or individual health insurance
coverage''; and
(IV) in subparagraph (C), by inserting ``or individuals, as
applicable,'' after ``those sponsors''; and
(ii) in paragraph (2)(A)--
(I) in the matter preceding clause (i), by striking ``small
group market or the large group market, or both markets,''
and inserting ``individual or group market, or all
markets,''; and
(II) in clause (i), by inserting ``or individual, as
applicable,'' after ``plan sponsor''; and
(D) by transferring such section (as amended by this
paragraph) to appear at the end of section 2703 (as added by
section 1001(4));
(10) in section 2733 (42 U.S.C. 300gg-13), as so
redesignated by section 1001(4)--
[[Page H1960]]
(A) in subsection (a)--
(i) in the matter preceding paragraph (1), by striking
``small employer'' and inserting ``small employer or an
individual'';
(ii) in paragraph (1), by inserting ``, or individual, as
applicable,'' after ``employer'' each place that such
appears; and
(iii) in paragraph (2), by striking ``small employer'' and
inserting ``employer, or individual, as applicable,'';
(B) in subsection (b)--
(i) in paragraph (1)--
(I) in the matter preceding subparagraph (A), by striking
``small employer'' and inserting ``employer, or individual,
as applicable,'';
(II) in subparagraph (A), by adding ``and'' at the end;
(III) by striking subparagraphs (B) and (C); and
(IV) in subparagraph (D)--
(aa) by inserting ``, or individual, as applicable,'' after
``employer''; and
(bb) by redesignating such subparagraph as subparagraph
(B);
(ii) in paragraph (2)--
(I) by striking ``small employers'' each place that such
term appears and inserting ``employers, or individuals, as
applicable,''; and
(II) by striking ``small employer'' and inserting
``employer, or individual, as applicable,''; and
(C) by redesignating such section (as amended by this
paragraph) as section 2709 and transferring such section to
appear after section 2708 (as added by section 1001(5));
(11) by redesignating subpart 4 as subpart 2;
(12) in section 2735 (42 U.S.C. 300gg-21), as so
redesignated by section 1001(4)--
(A) by striking subsection (a);
(B) by striking ``subparts 1 through 3'' each place that
such appears and inserting ``subpart 1'';
(C) by redesignating subsections (b) through (e) as
subsections (a) through (d), respectively; and
(D) by redesignating such section (as amended by this
paragraph) as section 2722;
(13) in section 2736 (42 U.S.C. 300gg-22), as so
redesignated by section 1001(4)--
(A) in subsection (a)--
(i) in paragraph (1), by striking ``small or large group
markets'' and inserting ``individual or group market''; and
(ii) in paragraph (2), by inserting ``or individual health
insurance coverage'' after ``group health plans'';
(B) in subsection (b)(1)(B), by inserting ``individual
health insurance coverage or'' after ``respect to''; and
(C) by redesignating such section (as amended by this
paragraph) as section 2723;
(14) in section 2737(a)(1) (42 U.S.C. 300gg-23), as so
redesignated by section 1001(4)--
(A) by inserting ``individual or'' before ``group health
insurance''; and
(B) by redesignating such section(as amended by this
paragraph) as section 2724;
(15) in section 2762 (42 U.S.C. 300gg-62)--
(A) in the section heading by inserting ``AND APPLICATION''
before the period; and
(B) by adding at the end the following:
``(c) Application of Part A Provisions.--
``(1) In general.--The provisions of part A shall apply to
health insurance issuers providing health insurance coverage
in the individual market in a State as provided for in such
part.
``(2) Clarification.--To the extent that any provision of
this part conflicts with a provision of part A with respect
to health insurance issuers providing health insurance
coverage in the individual market in a State, the provisions
of such part A shall apply.''; and
(16) in section 2791(e) (42 U.S.C. 300gg-91(e))--
(A) in paragraph (2), by striking ``51'' and inserting
``101''; and
(B) in paragraph (4)--
(i) by striking ``at least 2'' each place that such appears
and inserting ``at least 1''; and
(ii) by striking ``50'' and inserting ``100''.
(d) Application.--Notwithstanding any other provision of
the Patient Protection and Affordable Care Act, nothing in
such Act (or an amendment made by such Act) shall be
construed to--
(1) prohibit (or authorize the Secretary of Health and
Human Services to promulgate regulations that prohibit) a
group health plan or health insurance issuer from carrying
out utilization management techniques that are commonly used
as of the date of enactment of this Act; or
(2) restrict the application of the amendments made by this
subtitle.
(e) Technical Amendment to the Employee Retirement Income
Security Act of 1974.--Subpart B of part 7 of subtitle A of
title I of the Employee Retirement Income Security Act of
1974 (29 U.S.C. 1181 et. seq.) is amended, by adding at the
end the following:
``SEC. 715. ADDITIONAL MARKET REFORMS.
``(a) General Rule.--Except as provided in subsection (b)--
``(1) the provisions of part A of title XXVII of the Public
Health Service Act (as amended by the Patient Protection and
Affordable Care Act) shall apply to group health plans, and
health insurance issuers providing health insurance coverage
in connection with group health plans, as if included in this
subpart; and
``(2) to the extent that any provision of this part
conflicts with a provision of such part A with respect to
group health plans, or health insurance issuers providing
health insurance coverage in connection with group health
plans, the provisions of such part A shall apply.
``(b) Exception.--Notwithstanding subsection (a), the
provisions of sections 2716 and 2718 of title XXVII of the
Public Health Service Act (as amended by the Patient
Protection and Affordable Care Act) shall not apply with
respect to self-insured group health plans, and the
provisions of this part shall continue to apply to such plans
as if such sections of the Public Health Service Act (as so
amended) had not been enacted.''.
(f) Technical Amendment to the Internal Revenue Code of
1986.--Subchapter B of chapter 100 of the Internal Revenue
Code of 1986 is amended by adding at the end the following:
``SEC. 9815. ADDITIONAL MARKET REFORMS.
``(a) General Rule.--Except as provided in subsection (b)--
``(1) the provisions of part A of title XXVII of the Public
Health Service Act (as amended by the Patient Protection and
Affordable Care Act) shall apply to group health plans, and
health insurance issuers providing health insurance coverage
in connection with group health plans, as if included in this
subchapter; and
``(2) to the extent that any provision of this subchapter
conflicts with a provision of such part A with respect to
group health plans, or health insurance issuers providing
health insurance coverage in connection with group health
plans, the provisions of such part A shall apply.
``(b) Exception.--Notwithstanding subsection (a), the
provisions of sections 2716 and 2718 of title XXVII of the
Public Health Service Act (as amended by the Patient
Protection and Affordable Care Act) shall not apply with
respect to self-insured group health plans, and the
provisions of this subchapter shall continue to apply to such
plans as if such sections of the Public Health Service Act
(as so amended) had not been enacted.''.
SEC. 1563. SENSE OF THE SENATE PROMOTING FISCAL
RESPONSIBILITY.
(a) Findings.--The Senate makes the following findings:
(1) Based on Congressional Budget Office (CBO) estimates,
this Act will reduce the Federal deficit between 2010 and
2019.
(2) CBO projects this Act will continue to reduce budget
deficits after 2019.
(3) Based on CBO estimates, this Act will extend the
solvency of the Medicare HI Trust Fund.
(4) This Act will increase the surplus in the Social
Security Trust Fund, which should be reserved to strengthen
the finances of Social Security.
(5) The initial net savings generated by the Community
Living Assistance Services and Supports (CLASS) program are
necessary to ensure the long-term solvency of that program.
(b) Sense of the Senate.--It is the sense of the Senate
that--
(1) the additional surplus in the Social Security Trust
Fund generated by this Act should be reserved for Social
Security and not spent in this Act for other purposes; and
(2) the net savings generated by the CLASS program should
be reserved for the CLASS program and not spent in this Act
for other purposes.
TITLE II--ROLE OF PUBLIC PROGRAMS
Subtitle A--Improved Access to Medicaid
SEC. 2001. MEDICAID COVERAGE FOR THE LOWEST INCOME
POPULATIONS.
(a) Coverage for Individuals With Income at or Below 133
Percent of the Poverty Line.--
(1) Beginning 2014.--Section 1902(a)(10)(A)(i) of the
Social Security Act (42 U.S.C. 1396a) is amended--
(A) by striking ``or'' at the end of subclause (VI);
(B) by adding ``or'' at the end of subclause (VII); and
(C) by inserting after subclause (VII) the following:
``(VIII) beginning January 1, 2014, who are under 65 years
of age, not pregnant, not entitled to, or enrolled for,
benefits under part A of title XVIII, or enrolled for
benefits under part B of title XVIII, and are not described
in a previous subclause of this clause, and whose income (as
determined under subsection (e)(14)) does not exceed 133
percent of the poverty line (as defined in section
2110(c)(5)) applicable to a family of the size involved,
subject to subsection (k);''.
(2) Provision of at least minimum essential coverage.--
(A) In general.--Section 1902 of such Act (42 U.S.C. 1396a)
is amended by inserting after subsection (j) the following:
``(k)(1) The medical assistance provided to an individual
described in subclause (VIII) of subsection (a)(10)(A)(i)
shall consist of benchmark coverage described in section
1937(b)(1) or benchmark equivalent coverage described in
section 1937(b)(2). Such medical assistance shall be provided
subject to the requirements of section 1937, without regard
to whether a State otherwise has elected the option to
provide medical assistance through coverage under that
section, unless an individual described in subclause (VIII)
of subsection (a)(10)(A)(i) is also an individual for whom,
under subparagraph (B) of section 1937(a)(2), the State may
not require enrollment in benchmark coverage described in
subsection (b)(1) of section 1937 or benchmark equivalent
coverage described in subsection (b)(2) of that section.''.
(B) Conforming amendment.--Section 1903(i) of the Social
Security Act, as amended by section 6402(c), is amended--
(i) in paragraph (24), by striking ``or'' at the end;
(ii) in paragraph (25), by striking the period and
inserting ``; or''; and
(iii) by adding at the end the following:
``(26) with respect to any amounts expended for medical
assistance for individuals described in subclause (VIII) of
subsection (a)(10)(A)(i) other than medical assistance
provided through benchmark coverage described in section
1937(b)(1) or benchmark equivalent coverage described in
section 1937(b)(2).''.
(3) Federal funding for cost of covering newly eligible
individuals.--Section 1905 of the Social Security Act (42
U.S.C. 1396d), is amended--
(A) in subsection (b), in the first sentence, by inserting
``subsection (y) and'' before ``section 1933(d)''; and
[[Page H1961]]
(B) by adding at the end the following new subsection:
``(y) Increased FMAP for Medical Assistance for Newly
Eligible Mandatory Individuals.--
``(1) Amount of increase.--
``(A) 100 percent fmap.--During the period that begins on
January 1, 2014, and ends on December 31, 2016,
notwithstanding subsection (b), the Federal medical
assistance percentage determined for a State that is one of
the 50 States or the District of Columbia for each fiscal
year occurring during that period with respect to amounts
expended for medical assistance for newly eligible
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i) shall be equal to 100 percent.
``(B) 2017 and 2018.--
``(i) In general.--During the period that begins on January
1, 2017, and ends on December 31, 2018, notwithstanding
subsection (b) and subject to subparagraph (D), the Federal
medical assistance percentage determined for a State that is
one of the 50 States or the District of Columbia for each
fiscal year occurring during that period with respect to
amounts expended for medical assistance for newly eligible
individuals described in subclause (VIII) of section
1902(a)(10)(A)(i), shall be increased by the applicable
percentage point increase specified in clause (ii) for the
quarter and the State.
``(ii) Applicable percentage point increase.--
``(I) In general.--For purposes of clause (i), the
applicable percentage point increase for a quarter is the
following:
----------------------------------------------------------------------------------------------------------------
If the State is an expansion State, If the State is not an expansion
``For any fiscal year quarter the applicable percentage point State, the applicable percentage
occurring in the calendar year: increase is: point increase is:
----------------------------------------------------------------------------------------------------------------
2017 30.3 34.3
----------------------------------------------------------------------------------------------------------------
2018 31.3 33.3
----------------------------------------------------------------------------------------------------------------
``(II) Expansion state defined.--For purposes of the table
in subclause (I), a State is an expansion State if, on the
date of the enactment of the Patient Protection and
Affordable Care Act, the State offers health benefits
coverage statewide to parents and nonpregnant, childless
adults whose income is at least 100 percent of the poverty
line, that is not dependent on access to employer coverage,
employer contribution, or employment and is not limited to
premium assistance, hospital-only benefits, a high deductible
health plan, or alternative benefits under a demonstration
program authorized under section 1938. A State that offers
health benefits coverage to only parents or only nonpregnant
childless adults described in the preceding sentence shall
not be considered to be an expansion State.
``(C) 2019 and succeeding years.--Beginning January 1,
2019, notwithstanding subsection (b) but subject to
subparagraph (D), the Federal medical assistance percentage
determined for a State that is one of the 50 States or the
District of Columbia for each fiscal year quarter occurring
during that period with respect to amounts expended for
medical assistance for newly eligible individuals described
in subclause (VIII) of section 1902(a)(10)(A)(i), shall be
increased by 32.3 percentage points.
``(D) Limitation.--The Federal medical assistance
percentage determined for a State under subparagraph (B) or
(C) shall in no case be more than 95 percent.
``(2) Definitions.--In this subsection:
``(A) Newly eligible.--The term `newly eligible' means,
with respect to an individual described in subclause (VIII)
of section 1902(a)(10)(A)(i), an individual who is not under
19 years of age (or such higher age as the State may have
elected) and who, on the date of enactment of the Patient
Protection and Affordable Care Act, is not eligible under the
State plan or under a waiver of the plan for full benefits or
for benchmark coverage described in subparagraph (A), (B), or
(C) of section 1937(b)(1) or benchmark equivalent coverage
described in section 1937(b)(2) that has an aggregate
actuarial value that is at least actuarially equivalent to
benchmark coverage described in subparagraph (A), (B), or (C)
of section 1937(b)(1), or is eligible but not enrolled (or is
on a waiting list) for such benefits or coverage through a
waiver under the plan that has a capped or limited enrollment
that is full.
``(B) Full benefits.--The term `full benefits' means, with
respect to an individual, medical assistance for all services
covered under the State plan under this title that is not
less in amount, duration, or scope, or is determined by the
Secretary to be substantially equivalent, to the medical
assistance available for an individual described in section
1902(a)(10)(A)(i).''.
(4) State options to offer coverage earlier and presumptive
eligibility; children required to have coverage for parents
to be eligible.--
(A) In general.--Subsection (k) of section 1902 of the
Social Security Act (as added by paragraph (2)), is amended
by inserting after paragraph (1) the following:
``(2) Beginning with the first day of any fiscal year
quarter that begins on or after January 1, 2011, and before
January 1, 2014, a State may elect through a State plan
amendment to provide medical assistance to individuals who
would be described in subclause (VIII) of subsection
(a)(10)(A)(i) if that subclause were effective before January
1, 2014. A State may elect to phase-in the extension of
eligibility for medical assistance to such individuals based
on income, so long as the State does not extend such
eligibility to individuals described in such subclause with
higher income before making individuals described in such
subclause with lower income eligible for medical assistance.
``(3) If an individual described in subclause (VIII) of
subsection (a)(10)(A)(i) is the parent of a child who is
under 19 years of age (or such higher age as the State may
have elected) who is eligible for medical assistance under
the State plan or under a waiver of such plan (under that
subclause or under a State plan amendment under paragraph
(2), the individual may not be enrolled under the State plan
unless the individual's child is enrolled under the State
plan or under a waiver of the plan or is enrolled in other
health insurance coverage. For purposes of the preceding
sentence, the term `parent' includes an individual treated as
a caretaker relative for purposes of carrying out section
1931.''.
(B) Presumptive eligibility.--Section 1920 of the Social
Security Act (42 U.S.C. 1396r-1) is amended by adding at the
end the following:
``(e) If the State has elected the option to provide a
presumptive eligibility period under this section or section
1920A, the State may elect to provide a presumptive
eligibility period (as defined in subsection (b)(1)) for
individuals who are eligible for medical assistance under
clause (i)(VIII) of subsection (a)(10)(A) or section 1931 in
the same manner as the State provides for such a period under
this section or section 1920A, subject to such guidance as
the Secretary shall establish.''.
(5) Conforming amendments.--
(A) Section 1902(a)(10) of such Act (42 U.S.C.
1396a(a)(10)) is amended in the matter following subparagraph
(G), by striking ``and (XIV)'' and inserting ``(XIV)'' and by
inserting ``and (XV) the medical assistance made available to
an individual described in subparagraph (A)(i)(VIII) shall be
limited to medical assistance described in subsection
(k)(1)'' before the semicolon.
(B) Section 1902(l)(2)(C) of such Act (42 U.S.C.
1396a(l)(2)(C)) is amended by striking ``100'' and inserting
``133''.
(C) Section 1905(a) of such Act (42 U.S.C. 1396d(a)) is
amended in the matter preceding paragraph (1)--
(i) by striking ``or'' at the end of clause (xii);
(ii) by inserting ``or'' at the end of clause (xiii); and
(iii) by inserting after clause (xiii) the following:
``(xiv) individuals described in section
1902(a)(10)(A)(i)(VIII),''.
(D) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4))
is amended by inserting ``1902(a)(10)(A)(i)(VIII),'' after
``1902(a)(10)(A)(i)(VII),''.
(E) Section 1937(a)(1)(B) of such Act (42 U.S.C. 1396u-
7(a)(1)(B)) is amended by inserting ``subclause (VIII) of
section 1902(a)(10)(A)(i) or under'' after ``eligible
under''.
(b) Maintenance of Medicaid Income Eligibility.--Section
1902 of the Social Security Act (42 U.S.C. 1396a) is
amended--
(1) in subsection (a)--
(A) by striking ``and'' at the end of paragraph (72);
(B) by striking the period at the end of paragraph (73) and
inserting ``; and''; and
(C) by inserting after paragraph (73) the following new
paragraph:
``(74) provide for maintenance of effort under the State
plan or under any waiver of the plan in accordance with
subsection (gg).''; and
(2) by adding at the end the following new subsection:
``(gg) Maintenance of Effort.--
``(1) General requirement to maintain eligibility standards
until state exchange is fully operational.--Subject to the
succeeding paragraphs of this subsection, during the period
that begins on the date of enactment of the Patient
Protection and Affordable Care Act and ends on the date on
which the Secretary determines that an Exchange established
by the State under section 1311 of the Patient Protection and
Affordable Care Act is fully operational, as a condition for
receiving any Federal payments under section 1903(a) for
calendar quarters occurring during such period, a State shall
not have in effect eligibility standards, methodologies, or
procedures under the State plan under this title or under any
waiver of such plan that is in effect during that period,
that are more restrictive than the eligibility standards,
methodologies, or procedures, respectively, under the plan or
waiver that are in effect on the date of enactment of the
Patient Protection and Affordable Care Act.
``(2) Continuation of eligibility standards for children
until october 1, 2019.--The requirement under paragraph (1)
shall continue to apply to a State through September 30,
2019, with respect to the eligibility standards,
methodologies, and procedures under the State plan under this
title or under any waiver of such plan that are applicable to
determining the eligibility for medical assistance of any
child who is under 19 years of age (or such higher age as the
State may have elected).
``(3) Nonapplication.--During the period that begins on
January 1, 2011, and ends on December 31, 2013, the
requirement under paragraph (1) shall not apply to a State
with respect to nonpregnant, nondisabled adults who are
eligible for medical assistance under the State plan or under
a waiver of the plan at the option of the State and whose
income exceeds 133 percent of the poverty line (as defined in
section 2110(c)(5)) applicable to a family of the size
involved if, on or after December 31, 2010, the
[[Page H1962]]
State certifies to the Secretary that, with respect to the
State fiscal year during which the certification is made, the
State has a budget deficit, or with respect to the succeeding
State fiscal year, the State is projected to have a budget
deficit. Upon submission of such a certification to the
Secretary, the requirement under paragraph (1) shall not
apply to the State with respect to any remaining portion of
the period described in the preceding sentence.
``(4) Determination of compliance.--
``(A) States shall apply modified gross income.--A State's
determination of income in accordance with subsection (e)(14)
shall not be considered to be eligibility standards,
methodologies, or procedures that are more restrictive than
the standards, methodologies, or procedures in effect under
the State plan or under a waiver of the plan on the date of
enactment of the Patient Protection and Affordable Care Act
for purposes of determining compliance with the requirements
of paragraph (1), (2), or (3).
``(B) States may expand eligibility or move waivered
populations into coverage under the state plan.--With respect
to any period applicable under paragraph (1), (2), or (3), a
State that applies eligibility standards, methodologies, or
procedures under the State plan under this title or under any
waiver of the plan that are less restrictive than the
eligibility standards, methodologies, or procedures, applied
under the State plan or under a waiver of the plan on the
date of enactment of the Patient Protection and Affordable
Care Act, or that makes individuals who, on such date of
enactment, are eligible for medical assistance under a waiver
of the State plan, after such date of enactment eligible for
medical assistance through a State plan amendment with an
income eligibility level that is not less than the income
eligibility level that applied under the waiver, or as a
result of the application of subclause (VIII) of section
1902(a)(10)(A)(i), shall not be considered to have in effect
eligibility standards, methodologies, or procedures that are
more restrictive than the standards, methodologies, or
procedures in effect under the State plan or under a waiver
of the plan on the date of enactment of the Patient
Protection and Affordable Care Act for purposes of
determining compliance with the requirements of paragraph
(1), (2), or (3).''.
(c) Medicaid Benchmark Benefits Must Consist of at Least
Minimum Essential Coverage.--Section 1937(b) of such Act (42
U.S.C. 1396u-7(b)) is amended--
(1) in paragraph (1), in the matter preceding subparagraph
(A), by inserting ``subject to paragraphs (5) and (6),''
before ``each'';
(2) in paragraph (2)--
(A) in the matter preceding subparagraph (A), by inserting
``subject to paragraphs (5) and (6)'' after ``subsection
(a)(1),'';
(B) in subparagraph (A)--
(i) by redesignating clauses (iv) and (v) as clauses (vi)
and (vii), respectively; and
(ii) by inserting after clause (iii), the following:
``(iv) Coverage of prescription drugs.
``(v) Mental health services.''; and
(C) in subparagraph (C)--
(i) by striking clauses (i) and (ii); and
(ii) by redesignating clauses (iii) and (iv) as clauses (i)
and (ii), respectively; and
(3) by adding at the end the following new paragraphs:
``(5) Minimum standards.--Effective January 1, 2014, any
benchmark benefit package under paragraph (1) or benchmark
equivalent coverage under paragraph (2) must provide at least
essential health benefits as described in section 1302(b) of
the Patient Protection and Affordable Care Act.
``(6) Mental health services parity.--
``(A) In general.--In the case of any benchmark benefit
package under paragraph (1) or benchmark equivalent coverage
under paragraph (2) that is offered by an entity that is not
a medicaid managed care organization and that provides both
medical and surgical benefits and mental health or substance
use disorder benefits, the entity shall ensure that the
financial requirements and treatment limitations applicable
to such mental health or substance use disorder benefits
comply with the requirements of section 2705(a) of the Public
Health Service Act in the same manner as such requirements
apply to a group health plan.
``(B) Deemed compliance.--Coverage provided with respect to
an individual described in section 1905(a)(4)(B) and covered
under the State plan under section 1902(a)(10)(A) of the
services described in section 1905(a)(4)(B) (relating to
early and periodic screening, diagnostic, and treatment
services defined in section 1905(r)) and provided in
accordance with section 1902(a)(43), shall be deemed to
satisfy the requirements of subparagraph (A).''.
(d) Annual Reports on Medicaid Enrollment.--
(1) State reports.--Section 1902(a) of the Social Security
Act (42 U.S.C. 1396a(a)), as amended by subsection (b), is
amended--
(A) by striking ``and'' at the end of paragraph (73);
(B) by striking the period at the end of paragraph (74) and
inserting ``; and''; and
(C) by inserting after paragraph (74) the following new
paragraph:
``(75) provide that, beginning January 2015, and annually
thereafter, the State shall submit a report to the Secretary
that contains--
``(A) the total number of enrolled and newly enrolled
individuals in the State plan or under a waiver of the plan
for the fiscal year ending on September 30 of the preceding
calendar year, disaggregated by population, including
children, parents, nonpregnant childless adults, disabled
individuals, elderly individuals, and such other categories
or sub-categories of individuals eligible for medical
assistance under the State plan or under a waiver of the plan
as the Secretary may require;
``(B) a description, which may be specified by population,
of the outreach and enrollment processes used by the State
during such fiscal year; and
``(C) any other data reporting determined necessary by the
Secretary to monitor enrollment and retention of individuals
eligible for medical assistance under the State plan or under
a waiver of the plan.''.
(2) Reports to congress.--Beginning April 2015, and
annually thereafter, the Secretary of Health and Human
Services shall submit a report to the appropriate committees
of Congress on the total enrollment and new enrollment in
Medicaid for the fiscal year ending on September 30 of the
preceding calendar year on a national and State-by-State
basis, and shall include in each such report such
recommendations for administrative or legislative changes to
improve enrollment in the Medicaid program as the Secretary
determines appropriate.
(e) State Option for Coverage for Individuals With Income
That Exceeds 133 Percent of the Poverty Line.--
(1) Coverage as optional categorically needy group.--
Section 1902 of the Social Security Act (42 U.S.C. 1396a) is
amended--
(A) in subsection (a)(10)(A)(ii)--
(i) in subclause (XVIII), by striking ``or'' at the end;
(ii) in subclause (XIX), by adding ``or'' at the end; and
(iii) by adding at the end the following new subclause:
``(XX) beginning January 1, 2014, who are under 65 years of
age and are not described in or enrolled under a previous
subclause of this clause, and whose income (as determined
under subsection (e)(14)) exceeds 133 percent of the poverty
line (as defined in section 2110(c)(5)) applicable to a
family of the size involved but does not exceed the highest
income eligibility level established under the State plan or
under a waiver of the plan, subject to subsection (hh);'' and
(B) by adding at the end the following new subsection:
``(hh)(1) A State may elect to phase-in the extension of
eligibility for medical assistance to individuals described
in subclause (XX) of subsection (a)(10)(A)(ii) based on the
categorical group (including nonpregnant childless adults) or
income, so long as the State does not extend such eligibility
to individuals described in such subclause with higher income
before making individuals described in such subclause with
lower income eligible for medical assistance.
``(2) If an individual described in subclause (XX) of
subsection (a)(10)(A)(ii) is the parent of a child who is
under 19 years of age (or such higher age as the State may
have elected) who is eligible for medical assistance under
the State plan or under a waiver of such plan, the individual
may not be enrolled under the State plan unless the
individual's child is enrolled under the State plan or under
a waiver of the plan or is enrolled in other health insurance
coverage. For purposes of the preceding sentence, the term
`parent' includes an individual treated as a caretaker
relative for purposes of carrying out section 1931.''.
(2) Conforming amendments.--
(A) Section 1905(a) of such Act (42 U.S.C. 1396d(a)), as
amended by subsection (a)(5)(C), is amended in the matter
preceding paragraph (1)--
(i) by striking ``or'' at the end of clause (xiii);
(ii) by inserting ``or'' at the end of clause (xiv); and
(iii) by inserting after clause (xiv) the following:
``(xv) individuals described in section
1902(a)(10)(A)(ii)(XX),''.
(B) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4))
is amended by inserting ``1902(a)(10)(A)(ii)(XX),'' after
``1902(a)(10)(A)(ii)(XIX),''.
(C) Section 1920(e) of such Act (42 U.S.C. 1396r-1(e)), as
added by subsection (a)(4)(B), is amended by inserting ``or
clause (ii)(XX)'' after ``clause (i)(VIII)''.
SEC. 2002. INCOME ELIGIBILITY FOR NONELDERLY DETERMINED USING
MODIFIED GROSS INCOME.
(a) In General.--Section 1902(e) of the Social Security Act
(42 U.S.C. 1396a(e)) is amended by adding at the end the
following:
``(14) Income determined using modified gross income.--
``(A) In general.--Notwithstanding subsection (r) or any
other provision of this title, except as provided in
subparagraph (D), for purposes of determining income
eligibility for medical assistance under the State plan or
under any waiver of such plan and for any other purpose
applicable under the plan or waiver for which a determination
of income is required, including with respect to the
imposition of premiums and cost-sharing, a State shall use
the modified gross income of an individual and, in the case
of an individual in a family greater than 1, the household
income of such family. A State shall establish income
eligibility thresholds for populations to be eligible for
medical assistance under the State plan or a waiver of the
plan using modified gross income and household income that
are not less than the effective income eligibility levels
that applied under the State plan or waiver on the date of
enactment of the Patient Protection and Affordable Care Act.
For purposes of complying with the maintenance of effort
requirements under subsection (gg) during the transition to
modified gross income and household income, a State shall,
working with the Secretary, establish an equivalent income
test that ensures individuals eligible for medical assistance
under the State plan or under a waiver of the plan on the
date of enactment of the Patient Protection and Affordable
Care Act, do not lose coverage under the State plan or under
a waiver of the plan. The Secretary may waive such provisions
of this title and title XXI as are necessary to ensure
[[Page H1963]]
that States establish income and eligibility determination
systems that protect beneficiaries.
``(B) No income or expense disregards.--No type of expense,
block, or other income disregard shall be applied by a State
to determine income eligibility for medical assistance under
the State plan or under any waiver of such plan or for any
other purpose applicable under the plan or waiver for which a
determination of income is required.
``(C) No assets test.--A State shall not apply any assets
or resources test for purposes of determining eligibility for
medical assistance under the State plan or under a waiver of
the plan.
``(D) Exceptions.--
``(i) Individuals eligible because of other aid or
assistance, elderly individuals, medically needy individuals,
and individuals eligible for medicare cost-sharing.--
Subparagraphs (A), (B), and (C) shall not apply to the
determination of eligibility under the State plan or under a
waiver for medical assistance for the following:
``(I) Individuals who are eligible for medical assistance
under the State plan or under a waiver of the plan on a basis
that does not require a determination of income by the State
agency administering the State plan or waiver, including as a
result of eligibility for, or receipt of, other Federal or
State aid or assistance, individuals who are eligible on the
basis of receiving (or being treated as if receiving)
supplemental security income benefits under title XVI, and
individuals who are eligible as a result of being or being
deemed to be a child in foster care under the responsibility
of the State.
``(II) Individuals who have attained age 65.
``(III) Individuals who qualify for medical assistance
under the State plan or under any waiver of such plan on the
basis of being blind or disabled (or being treated as being
blind or disabled) without regard to whether the individual
is eligible for supplemental security income benefits under
title XVI on the basis of being blind or disabled and
including an individual who is eligible for medical
assistance on the basis of section 1902(e)(3).
``(IV) Individuals described in subsection (a)(10)(C).
``(V) Individuals described in any clause of subsection
(a)(10)(E).
``(ii) Express lane agency findings.--In the case of a
State that elects the Express Lane option under paragraph
(13), notwithstanding subparagraphs (A), (B), and (C), the
State may rely on a finding made by an Express Lane agency in
accordance with that paragraph relating to the income of an
individual for purposes of determining the individual's
eligibility for medical assistance under the State plan or
under a waiver of the plan.
``(iii) Medicare prescription drug subsidies
determinations.--Subparagraphs (A), (B), and (C) shall not
apply to any determinations of eligibility for premium and
cost-sharing subsidies under and in accordance with section
1860D-14 made by the State pursuant to section 1935(a)(2).
``(iv) Long-term care.--Subparagraphs (A), (B), and (C)
shall not apply to any determinations of eligibility of
individuals for purposes of medical assistance for nursing
facility services, a level of care in any institution
equivalent to that of nursing facility services, home or
community-based services furnished under a waiver or State
plan amendment under section 1915 or a waiver under section
1115, and services described in section 1917(c)(1)(C)(ii).
``(v) Grandfather of current enrollees until date of next
regular redetermination.--An individual who, on January 1,
2014, is enrolled in the State plan or under a waiver of the
plan and who would be determined ineligible for medical
assistance solely because of the application of the modified
gross income or household income standard described in
subparagraph (A), shall remain eligible for medical
assistance under the State plan or waiver (and subject to the
same premiums and cost-sharing as applied to the individual
on that date) through March 31, 2014, or the date on which
the individual's next regularly scheduled redetermination of
eligibility is to occur, whichever is later.
``(E) Transition planning and oversight.--Each State shall
submit to the Secretary for the Secretary's approval the
income eligibility thresholds proposed to be established
using modified gross income and household income, the
methodologies and procedures to be used to determine income
eligibility using modified gross income and household income
and, if applicable, a State plan amendment establishing an
optional eligibility category under subsection
(a)(10)(A)(ii)(XX). To the extent practicable, the State
shall use the same methodologies and procedures for purposes
of making such determinations as the State used on the date
of enactment of the Patient Protection and Affordable Care
Act. The Secretary shall ensure that the income eligibility
thresholds proposed to be established using modified gross
income and household income, including under the eligibility
category established under subsection (a)(10)(A)(ii)(XX), and
the methodologies and procedures proposed to be used to
determine income eligibility, will not result in children who
would have been eligible for medical assistance under the
State plan or under a waiver of the plan on the date of
enactment of the Patient Protection and Affordable Care Act
no longer being eligible for such assistance.
``(F) Limitation on secretarial authority.--The Secretary
shall not waive compliance with the requirements of this
paragraph except to the extent necessary to permit a State to
coordinate eligibility requirements for dual eligible
individuals (as defined in section 1915(h)(2)(B)) under the
State plan or under a waiver of the plan and under title
XVIII and individuals who require the level of care provided
in a hospital, a nursing facility, or an intermediate care
facility for the mentally retarded.
``(G) Definitions of modified gross income and household
income.--In this paragraph, the terms `modified gross income'
and `household income' have the meanings given such terms in
section 36B(d)(2) of the Internal Revenue Code of 1986.
``(H) Continued application of medicaid rules regarding
point-in-time income and sources of income.--The requirement
under this paragraph for States to use modified gross income
and household income to determine income eligibility for
medical assistance under the State plan or under any waiver
of such plan and for any other purpose applicable under the
plan or waiver for which a determination of income is
required shall not be construed as affecting or limiting the
application of--
``(i) the requirement under this title and under the State
plan or a waiver of the plan to determine an individual's
income as of the point in time at which an application for
medical assistance under the State plan or a waiver of the
plan is processed; or
``(ii) any rules established under this title or under the
State plan or a waiver of the plan regarding sources of
countable income.''.
(b) Conforming Amendment.--Section 1902(a)(17) of such Act
(42 U.S.C. 1396a(a)(17)) is amended by inserting ``(e)(14),''
before ``(l)(3)''.
(c) Effective Date.--The amendments made by subsections (a)
and (b) take effect on January 1, 2014.
SEC. 2003. REQUIREMENT TO OFFER PREMIUM ASSISTANCE FOR
EMPLOYER-SPONSORED INSURANCE.
(a) In General.--Section 1906A of such Act (42 U.S.C.
1396e-1) is amended--
(1) in subsection (a)--
(A) by striking ``may elect to'' and inserting ``shall'';
(B) by striking ``under age 19''; and
(C) by inserting ``, in the case of an individual under age
19,'' after ``(and'';
(2) in subsection (c), in the first sentence, by striking
``under age 19''; and
(3) in subsection (d)--
(A) in paragraph (2)--
(i) in the first sentence, by striking ``under age 19'';
and
(ii) by striking the third sentence and inserting ``A State
may not require, as a condition of an individual (or the
individual's parent) being or remaining eligible for medical
assistance under this title, that the individual (or the
individual's parent) apply for enrollment in qualified
employer-sponsored coverage under this section.''; and
(B) in paragraph (3), by striking ``the parent of an
individual under age 19'' and inserting ``an individual (or
the parent of an individual)''; and
(4) in subsection (e), by striking ``under age 19'' each
place it appears.
(b) Conforming Amendment.--The heading for section 1906A of
such Act (42 U.S.C. 1396e-1) is amended by striking ``option
for children''.
(c) Effective Date.--The amendments made by this section
take effect on January 1, 2014.
SEC. 2004. MEDICAID COVERAGE FOR FORMER FOSTER CARE CHILDREN.
(a) In General.--Section 1902(a)(10)(A)(i) of the Social
Security Act (42 U.S.C. 1396a), as amended by section
2001(a)(1), is amended--
(1) by striking ``or'' at the end of subclause (VII);
(2) by adding ``or'' at the end of subclause (VIII); and
(3) by inserting after subclause (VIII) the following:
``(IX) who were in foster care under the responsibility of
a State for more than 6 months (whether or not consecutive)
but are no longer in such care, who are not described in any
of subclauses (I) through (VII) of this clause, and who are
under 25 years of age;''.
(b) Option To Provide Presumptive Eligibility.--Section
1920(e) of such Act (42 U.S.C. 1396r-1(e)), as added by
section 2001(a)(4)(B) and amended by section 2001(e)(2)(C),
is amended by inserting ``, clause (i)(IX),'' after ``clause
(i)(VIII)''.
(c) Conforming Amendments.--
(1) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)),
as amended by section 2001(a)(5)(D), is amended by inserting
``1902(a)(10)(A)(i)(IX),'' after
``1902(a)(10)(A)(i)(VIII),''.
(2) Section 1937(a)(2)(B)(viii) of such Act (42 U.S.C.
1396u-7(a)(2)(B)(viii)) is amended by inserting ``, or the
individual qualifies for medical assistance on the basis of
section 1902(a)(10)(A)(i)(IX)'' before the period.
(d) Effective Date.--The amendments made by this section
take effect on January 1, 2019.
SEC. 2005. PAYMENTS TO TERRITORIES.
(a) Increase in Limit on Payments.--Section 1108(g) of the
Social Security Act (42 U.S.C. 1308(g)) is amended--
(1) in paragraph (2), in the matter preceding subparagraph
(A), by striking ``paragraph (3)'' and inserting ``paragraphs
(3) and (5)'';
(2) in paragraph (4), by striking ``and (3)'' and inserting
``(3), and (4)''; and
(3) by adding at the end the following paragraph:
``(5) Fiscal year 2011 and thereafter.--The amounts
otherwise determined under this subsection for Puerto Rico,
the Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa for the second, third, and fourth quarters of
fiscal year 2011, and for each fiscal year after fiscal year
2011 (after the application of subsection (f) and the
preceding paragraphs of this subsection), shall be increased
by 30 percent.''.
(b) Disregard of Payments for Mandatory Expanded
Enrollment.--Section 1108(g)(4) of such Act (42 U.S.C.
1308(g)(4)) is amended--
(1) by striking ``to fiscal years beginning'' and inserting
``to--
[[Page H1964]]
``(A) fiscal years beginning'';
(2) by striking the period at the end and inserting ``;
and''; and
(3) by adding at the end the following:
``(B) fiscal years beginning with fiscal year 2014,
payments made to Puerto Rico, the Virgin Islands, Guam, the
Northern Mariana Islands, or American Samoa with respect to
amounts expended for medical assistance for newly eligible
(as defined in section 1905(y)(2)) nonpregnant childless
adults who are eligible under subclause (VIII) of section
1902(a)(10)(A)(i) and whose income (as determined under
section 1902(e)(14)) does not exceed (in the case of each
such commonwealth and territory respectively) the income
eligibility level in effect for that population under title
XIX or under a waiver on the date of enactment of the Patient
Protection and Affordable Care Act, shall not be taken into
account in applying subsection (f) (as increased in
accordance with paragraphs (1), (2), (3), and (5) of this
subsection) to such commonwealth or territory for such fiscal
year.''.
(c) Increased FMAP.--
(1) In general.--The first sentence of section 1905(b) of
the Social Security Act (42 U.S.C. 1396d(b)) is amended by
striking ``shall be 50 per centum'' and inserting ``shall be
55 percent''.
(2) Effective date.--The amendment made by paragraph (1)
takes effect on January 1, 2011.
SEC. 2006. SPECIAL ADJUSTMENT TO FMAP DETERMINATION FOR
CERTAIN STATES RECOVERING FROM A MAJOR
DISASTER.
Section 1905 of the Social Security Act (42 U.S.C. 1396d),
as amended by sections 2001(a)(3) and 2001(b)(2), is
amended--
(1) in subsection (b), in the first sentence, by striking
``subsection (y)'' and inserting ``subsections (y) and
(aa)''; and
(2) by adding at the end the following new subsection:
``(aa)(1) Notwithstanding subsection (b), beginning January
1, 2011, the Federal medical assistance percentage for a
fiscal year for a disaster-recovery FMAP adjustment State
shall be equal to the following:
``(A) In the case of the first fiscal year (or part of a
fiscal year) for which this subsection applies to the State,
the Federal medical assistance percentage determined for the
fiscal year without regard to this subsection and subsection
(y), increased by 50 percent of the number of percentage
points by which the Federal medical assistance percentage
determined for the State for the fiscal year without regard
to this subsection and subsection (y), is less than the
Federal medical assistance percentage determined for the
State for the preceding fiscal year after the application of
only subsection (a) of section 5001 of Public Law 111-5 (if
applicable to the preceding fiscal year) and without regard
to this subsection, subsection (y), and subsections (b) and
(c) of section 5001 of Public Law 111-5.
``(B) In the case of the second or any succeeding fiscal
year for which this subsection applies to the State, the
Federal medical assistance percentage determined for the
preceding fiscal year under this subsection for the State,
increased by 25 percent of the number of percentage points by
which the Federal medical assistance percentage determined
for the State for the fiscal year without regard to this
subsection and subsection (y), is less than the Federal
medical assistance percentage determined for the State for
the preceding fiscal year under this subsection.
``(2) In this subsection, the term `disaster-recovery FMAP
adjustment State' means a State that is one of the 50 States
or the District of Columbia, for which, at any time during
the preceding 7 fiscal years, the President has declared a
major disaster under section 401 of the Robert T. Stafford
Disaster Relief and Emergency Assistance Act and determined
as a result of such disaster that every county or parish in
the State warrant individual and public assistance or public
assistance from the Federal Government under such Act and for
which--
``(A) in the case of the first fiscal year (or part of a
fiscal year) for which this subsection applies to the State,
the Federal medical assistance percentage determined for the
State for the fiscal year without regard to this subsection
and subsection (y), is less than the Federal medical
assistance percentage determined for the State for the
preceding fiscal year after the application of only
subsection (a) of section 5001 of Public Law 111-5 (if
applicable to the preceding fiscal year) and without regard
to this subsection, subsection (y), and subsections (b) and
(c) of section 5001 of Public Law 111-5, by at least 3
percentage points; and
``(B) in the case of the second or any succeeding fiscal
year for which this subsection applies to the State, the
Federal medical assistance percentage determined for the
State for the fiscal year without regard to this subsection
and subsection (y), is less than the Federal medical
assistance percentage determined for the State for the
preceding fiscal year under this subsection by at least 3
percentage points.
``(3) The Federal medical assistance percentage determined
for a disaster-recovery FMAP adjustment State under paragraph
(1) shall apply for purposes of this title (other than with
respect to disproportionate share hospital payments described
in section 1923 and payments under this title that are based
on the enhanced FMAP described in 2105(b)) and shall not
apply with respect to payments under title IV (other than
under part E of title IV) or payments under title XXI.''.
SEC. 2007. MEDICAID IMPROVEMENT FUND RESCISSION.
(a) Rescission.--Any amounts available to the Medicaid
Improvement Fund established under section 1941 of the Social
Security Act (42 U.S.C. 1396w-1) for any of fiscal years 2014
through 2018 that are available for expenditure from the Fund
and that are not so obligated as of the date of the enactment
of this Act are rescinded.
(b) Conforming Amendments.--Section 1941(b)(1) of the
Social Security Act (42 U.S.C. 1396w-1(b)(1)) is amended--
(1) in subparagraph (A), by striking ``$100,000,000'' and
inserting ``$0''; and
(2) in subparagraph (B), by striking ``$150,000,000'' and
inserting ``$0''.
Subtitle B--Enhanced Support for the Children's Health Insurance
Program
SEC. 2101. ADDITIONAL FEDERAL FINANCIAL PARTICIPATION FOR
CHIP.
(a) In General.--Section 2105(b) of the Social Security Act
(42 U.S.C. 1397ee(b)) is amended by adding at the end the
following: ``Notwithstanding the preceding sentence, during
the period that begins on October 1, 2013, and ends on
September 30, 2019, the enhanced FMAP determined for a State
for a fiscal year (or for any portion of a fiscal year
occurring during such period) shall be increased by 23
percentage points, but in no case shall exceed 100 percent.
The increase in the enhanced FMAP under the preceding
sentence shall not apply with respect to determining the
payment to a State under subsection (a)(1) for expenditures
described in subparagraph (D)(iv), paragraphs (8), (9), (11)
of subsection (c), or clause (4) of the first sentence of
section 1905(b).''.
(b) Maintenance of Effort.--
(1) In general.--Section 2105(d) of the Social Security Act
(42 U.S.C. 1397ee(d)) is amended by adding at the end the
following:
``(3) Continuation of eligibility standards for children
until october 1, 2019.--
``(A) In general.--During the period that begins on the
date of enactment of the Patient Protection and Affordable
Care Act and ends on September 30, 2019, a State shall not
have in effect eligibility standards, methodologies, or
procedures under its State child health plan (including any
waiver under such plan) for children (including children
provided medical assistance for which payment is made under
section 2105(a)(1)(A)) that are more restrictive than the
eligibility standards, methodologies, or procedures,
respectively, under such plan (or waiver) as in effect on the
date of enactment of that Act. The preceding sentence shall
not be construed as preventing a State during such period
from--
``(i) applying eligibility standards, methodologies, or
procedures for children under the State child health plan or
under any waiver of the plan that are less restrictive than
the eligibility standards, methodologies, or procedures,
respectively, for children under the plan or waiver that are
in effect on the date of enactment of such Act; or
``(ii) imposing a limitation described in section
2112(b)(7) for a fiscal year in order to limit expenditures
under the State child health plan to those for which Federal
financial participation is available under this section for
the fiscal year.
``(B) Assurance of exchange coverage for targeted low-
income children unable to be provided child health assistance
as a result of funding shortfalls.--In the event that
allotments provided under section 2104 are insufficient to
provide coverage to all children who are eligible to be
targeted low-income children under the State child health
plan under this title, a State shall establish procedures to
ensure that such children are provided coverage through an
Exchange established by the State under section 1311 of the
Patient Protection and Affordable Care Act.''.
(2) Conforming amendment to title xxi medicaid maintenance
of effort.--Section 2105(d)(1) of the Social Security Act (42
U.S.C. 1397ee(d)(1)) is amended by adding before the period
``, except as required under section 1902(e)(14)''.
(c) No Enrollment Bonus Payments for Children Enrolled
After Fiscal Year 2013.--Section 2105(a)(3)(F)(iii) of the
Social Security Act (42 U.S.C. 1397ee(a)(3)(F)(iii)) is
amended by inserting ``or any children enrolled on or after
October 1, 2013'' before the period.
(d) Income Eligibility Determined Using Modified Gross
Income.--
(1) State plan requirement.--Section 2102(b)(1)(B) of the
Social Security Act (42 U.S.C. 1397bb(b)(1)(B)) is amended--
(A) in clause (iii), by striking ``and'' after the
semicolon;
(B) in clause (iv), by striking the period and inserting
``; and''; and
(C) by adding at the end the following:
``(v) shall, beginning January 1, 2014, use modified gross
income and household income (as defined in section 36B(d)(2)
of the Internal Revenue Code of 1986) to determine
eligibility for child health assistance under the State child
health plan or under any waiver of such plan and for any
other purpose applicable under the plan or waiver for which a
determination of income is required, including with respect
to the imposition of premiums and cost-sharing, consistent
with section 1902(e)(14).''.
(2) Conforming amendment.--Section 2107(e)(1) of the Social
Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
(A) by redesignating subparagraphs (E) through (L) as
subparagraphs (F) through (M), respectively; and
(B) by inserting after subparagraph (D), the following:
``(E) Section 1902(e)(14) (relating to income determined
using modified gross income and household income).''.
(e) Application of Streamlined Enrollment System.--Section
2107(e)(1) of the Social Security Act (42 U.S.C.
1397gg(e)(1)), as amended by subsection (d)(2), is amended by
adding at the end the following:
``(N) Section 1943(b) (relating to coordination with State
Exchanges and the State Medicaid agency).''.
[[Page H1965]]
(f) CHIP Eligibility for Children Ineligible for Medicaid
as a Result of Elimination of Disregards.--Notwithstanding
any other provision of law, a State shall treat any child who
is determined to be ineligible for medical assistance under
the State Medicaid plan or under a waiver of the plan as a
result of the elimination of the application of an income
disregard based on expense or type of income, as required
under section 1902(e)(14) of the Social Security Act (as
added by this Act), as a targeted low-income child under
section 2110(b) (unless the child is excluded under paragraph
(2) of that section) and shall provide child health
assistance to the child under the State child health plan
(whether implemented under title XIX or XXI, or both, of the
Social Security Act).
SEC. 2102. TECHNICAL CORRECTIONS.
(a) CHIPRA.--Effective as if included in the enactment of
the Children's Health Insurance Program Reauthorization Act
of 2009 (Public Law 111-3) (in this section referred to as
``CHIPRA''):
(1) Section 2104(m) of the Social Security Act, as added by
section 102 of CHIPRA, is amended--
(A) by redesignating paragraph (7) as paragraph (8); and
(B) by inserting after paragraph (6), the following:
``(7) Adjustment of fiscal year 2010 allotments to account
for changes in projected spending for certain previously
approved expansion programs.--For purposes of recalculating
the fiscal year 2010 allotment, in the case of one of the 50
States or the District of Columbia that has an approved State
plan amendment effective January 1, 2006, to provide child
health assistance through the provision of benefits under the
State plan under title XIX for children from birth through
age 5 whose family income does not exceed 200 percent of the
poverty line, the Secretary shall increase the allotment by
an amount that would be equal to the Federal share of
expenditures that would have been claimed at the enhanced
FMAP rate rather than the Federal medical assistance
percentage matching rate for such population.''.
(2) Section 605 of CHIPRA is amended by striking ``legal
residents'' and insert ``lawfully residing in the United
States''.
(3) Subclauses (I) and (II) of paragraph (3)(C)(i) of
section 2105(a) of the Social Security Act (42 U.S.C.
1397ee(a)(3)(ii)), as added by section 104 of CHIPRA, are
each amended by striking ``, respectively''.
(4) Section 2105(a)(3)(E)(ii) of the Social Security Act
(42 U.S.C. 1397ee(a)(3)(E)(ii)), as added by section 104 of
CHIPRA, is amended by striking subclause (IV).
(5) Section 2105(c)(9)(B) of the Social Security Act (42
U.S.C. 1397e(c)(9)(B)), as added by section 211(c)(1) of
CHIPRA, is amended by striking ``section 1903(a)(3)(F)'' and
inserting ``section 1903(a)(3)(G)''.
(6) Section 2109(b)(2)(B) of the Social Security Act (42
U.S.C. 1397ii(b)(2)(B)), as added by section 602 of CHIPRA,
is amended by striking ``the child population growth factor
under section 2104(m)(5)(B)'' and inserting ``a high-
performing State under section 2111(b)(3)(B)''.
(7) Section 2110(c)(9)(B)(v) of the Social Security Act (42
U.S.C. 1397jj(c)(9)(B)(v)), as added by section 505(b) of
CHIPRA, is amended by striking ``school or school system''
and inserting ``local educational agency (as defined under
section 9101 of the Elementary and Secondary Education Act of
1965''.
(8) Section 211(a)(1)(B) of CHIPRA is amended--
(A) by striking ``is amended'' and all that follows through
``adding'' and inserting ``is amended by adding''; and
(B) by redesignating the new subparagraph to be added by
such section to section 1903(a)(3) of the Social Security Act
as a new subparagraph (H).
(b) ARRA.--Effective as if included in the enactment of
section 5006(a) of division B of the American Recovery and
Reinvestment Act of 2009 (Public Law 111-5), the second
sentence of section 1916A(a)(1) of the Social Security Act
(42 U.S.C. 1396o-1(a)(1)) is amended by striking ``or (i)''
and inserting ``, (i), or (j)''.
Subtitle C--Medicaid and CHIP Enrollment Simplification
SEC. 2201. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH
STATE HEALTH INSURANCE EXCHANGES.
Title XIX of the Social Security Act (42 U.S.C. 1397aa et
seq.) is amended by adding at the end the following:
``SEC. 1943. ENROLLMENT SIMPLIFICATION AND COORDINATION WITH
STATE HEALTH INSURANCE EXCHANGES.
``(a) Condition for Participation in Medicaid.--As a
condition of the State plan under this title and receipt of
any Federal financial assistance under section 1903(a) for
calendar quarters beginning after January 1, 2014, a State
shall ensure that the requirements of subsection (b) is met.
``(b) Enrollment Simplification and Coordination With State
Health Insurance Exchanges and Chip.--
``(1) In general.--A State shall establish procedures for--
``(A) enabling individuals, through an Internet website
that meets the requirements of paragraph (4), to apply for
medical assistance under the State plan or under a waiver of
the plan, to be enrolled in the State plan or waiver, to
renew their enrollment in the plan or waiver, and to consent
to enrollment or reenrollment in the State plan through
electronic signature;
``(B) enrolling, without any further determination by the
State and through such website, individuals who are
identified by an Exchange established by the State under
section 1311 of the Patient Protection and Affordable Care
Act as being eligible for--
``(i) medical assistance under the State plan or under a
waiver of the plan; or
``(ii) child health assistance under the State child health
plan under title XXI;
``(C) ensuring that individuals who apply for but are
determined to be ineligible for medical assistance under the
State plan or a waiver or ineligible for child health
assistance under the State child health plan under title XXI,
are screened for eligibility for enrollment in qualified
health plans offered through such an Exchange and, if
applicable, premium assistance for the purchase of a
qualified health plan under section 36B of the Internal
Revenue Code of 1986 (and, if applicable, advance payment of
such assistance under section 1412 of the Patient Protection
and Affordable Care Act), and, if eligible, enrolled in such
a plan without having to submit an additional or separate
application, and that such individuals receive information
regarding reduced cost-sharing for eligible individuals under
section 1402 of the Patient Protection and Affordable Care
Act, and any other assistance or subsidies available for
coverage obtained through the Exchange;
``(D) ensuring that the State agency responsible for
administering the State plan under this title (in this
section referred to as the `State Medicaid agency'), the
State agency responsible for administering the State child
health plan under title XXI (in this section referred to as
the `State CHIP agency') and an Exchange established by the
State under section 1311 of the Patient Protection and
Affordable Care Act utilize a secure electronic interface
sufficient to allow for a determination of an individual's
eligibility for such medical assistance, child health
assistance, or premium assistance, and enrollment in the
State plan under this title, title XXI, or a qualified health
plan, as appropriate;
``(E) coordinating, for individuals who are enrolled in the
State plan or under a waiver of the plan and who are also
enrolled in a qualified health plan offered through such an
Exchange, and for individuals who are enrolled in the State
child health plan under title XXI and who are also enrolled
in a qualified health plan, the provision of medical
assistance or child health assistance to such individuals
with the coverage provided under the qualified health plan in
which they are enrolled, including services described in
section 1905(a)(4)(B) (relating to early and periodic
screening, diagnostic, and treatment services defined in
section 1905(r)) and provided in accordance with the
requirements of section 1902(a)(43); and
``(F) conducting outreach to and enrolling vulnerable and
underserved populations eligible for medical assistance under
this title XIX or for child health assistance under title
XXI, including children, unaccompanied homeless youth,
children and youth with special health care needs, pregnant
women, racial and ethnic minorities, rural populations,
victims of abuse or trauma, individuals with mental health or
substance-related disorders, and individuals with HIV/AIDS.
``(2) Agreements with state health insurance exchanges.--
The State Medicaid agency and the State CHIP agency may enter
into an agreement with an Exchange established by the State
under section 1311 of the Patient Protection and Affordable
Care Act under which the State Medicaid agency or State CHIP
agency may determine whether a State resident is eligible for
premium assistance for the purchase of a qualified health
plan under section 36B of the Internal Revenue Code of 1986
(and, if applicable, advance payment of such assistance under
section 1412 of the Patient Protection and Affordable Care
Act), so long as the agreement meets such conditions and
requirements as the Secretary of the Treasury may prescribe
to reduce administrative costs and the likelihood of
eligibility errors and disruptions in coverage.
``(3) Streamlined enrollment system.--The State Medicaid
agency and State CHIP agency shall participate in and comply
with the requirements for the system established under
section 1413 of the Patient Protection and Affordable Care
Act (relating to streamlined procedures for enrollment
through an Exchange, Medicaid, and CHIP).
``(4) Enrollment website requirements.--The procedures
established by State under paragraph (1) shall include
establishing and having in operation, not later than January
1, 2014, an Internet website that is linked to any website of
an Exchange established by the State under section 1311 of
the Patient Protection and Affordable Care Act and to the
State CHIP agency (if different from the State Medicaid
agency) and allows an individual who is eligible for medical
assistance under the State plan or under a waiver of the plan
and who is eligible to receive premium credit assistance for
the purchase of a qualified health plan under section 36B of
the Internal Revenue Code of 1986 to compare the benefits,
premiums, and cost-sharing applicable to the individual under
the State plan or waiver with the benefits, premiums, and
cost-sharing available to the individual under a qualified
health plan offered through such an Exchange, including, in
the case of a child, the coverage that would be provided for
the child through the State plan or waiver with the coverage
that would be provided to the child through enrollment in
family coverage under that plan and as supplemental coverage
by the State under the State plan or waiver.
``(5) Continued need for assessment for home and community-
based services.--Nothing in paragraph (1) shall limit or
modify the requirement that the State assess an individual
for purposes of providing home and community-based services
under the State plan or under any waiver of such plan for
individuals described in subsection (a)(10)(A)(ii)(VI).''.
[[Page H1966]]
SEC. 2202. PERMITTING HOSPITALS TO MAKE PRESUMPTIVE
ELIGIBILITY DETERMINATIONS FOR ALL MEDICAID
ELIGIBLE POPULATIONS.
(a) In General.--Section 1902(a)(47) of the Social Security
Act (42 U.S.C. 1396a(a)(47)) is amended--
(1) by striking ``at the option of the State, provide'' and
inserting ``provide--
``(A) at the option of the State,'';
(2) by inserting ``and'' after the semicolon; and
(3) by adding at the end the following:
``(B) that any hospital that is a participating provider
under the State plan may elect to be a qualified entity for
purposes of determining, on the basis of preliminary
information, whether any individual is eligible for medical
assistance under the State plan or under a waiver of the plan
for purposes of providing the individual with medical
assistance during a presumptive eligibility period, in the
same manner, and subject to the same requirements, as apply
to the State options with respect to populations described in
section 1920, 1920A, or 1920B (but without regard to whether
the State has elected to provide for a presumptive
eligibility period under any such sections), subject to such
guidance as the Secretary shall establish;''.
(b) Conforming Amendment.--Section 1903(u)(1)(D)(v) of such
Act (42 U.S.C. 1396b(u)(1)(D)v)) is amended--
(1) by striking ``or for'' and inserting ``for''; and
(2) by inserting before the period at the end the
following: ``, or for medical assistance provided to an
individual during a presumptive eligibility period resulting
from a determination of presumptive eligibility made by a
hospital that elects under section 1902(a)(47)(B) to be a
qualified entity for such purpose''.
(c) Effective Date.--The amendments made by this section
take effect on January 1, 2014, and apply to services
furnished on or after that date.
Subtitle D--Improvements to Medicaid Services
SEC. 2301. COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES.
(a) In General.--Section 1905 of the Social Security Act
(42 U.S.C. 1396d), is amended--
(1) in subsection (a)--
(A) in paragraph (27), by striking ``and'' at the end;
(B) by redesignating paragraph (28) as paragraph (29); and
(C) by inserting after paragraph (27) the following new
paragraph:
``(28) freestanding birth center services (as defined in
subsection (l)(3)(A)) and other ambulatory services that are
offered by a freestanding birth center (as defined in
subsection (l)(3)(B)) and that are otherwise included in the
plan; and''; and
(2) in subsection (l), by adding at the end the following
new paragraph:
``(3)(A) The term `freestanding birth center services'
means services furnished to an individual at a freestanding
birth center (as defined in subparagraph (B)) at such center.
``(B) The term `freestanding birth center' means a health
facility--
``(i) that is not a hospital;
``(ii) where childbirth is planned to occur away from the
pregnant woman's residence;
``(iii) that is licensed or otherwise approved by the State
to provide prenatal labor and delivery or postpartum care and
other ambulatory services that are included in the plan; and
``(iv) that complies with such other requirements relating
to the health and safety of individuals furnished services by
the facility as the State shall establish.
``(C) A State shall provide separate payments to providers
administering prenatal labor and delivery or postpartum care
in a freestanding birth center (as defined in subparagraph
(B)), such as nurse midwives and other providers of services
such as birth attendants recognized under State law, as
determined appropriate by the Secretary. For purposes of the
preceding sentence, the term `birth attendant' means an
individual who is recognized or registered by the State
involved to provide health care at childbirth and who
provides such care within the scope of practice under which
the individual is legally authorized to perform such care
under State law (or the State regulatory mechanism provided
by State law), regardless of whether the individual is under
the supervision of, or associated with, a physician or other
health care provider. Nothing in this subparagraph shall be
construed as changing State law requirements applicable to a
birth attendant.''.
(b) Conforming Amendment.--Section 1902(a)(10)(A) of the
Social Security Act (42 U.S.C. 1396a(a)(10)(A)), is amended
in the matter preceding clause (i) by striking ``and (21)''
and inserting ``, (21), and (28)''.
(c) Effective Date.--
(1) In general.--Except as provided in paragraph (2), the
amendments made by this section shall take effect on the date
of the enactment of this Act and shall apply to services
furnished on or after such date.
(2) Exception if state legislation required.--In the case
of a State plan for medical assistance under title XIX of the
Social Security Act which the Secretary of Health and Human
Services determines requires State legislation (other than
legislation appropriating funds) in order for the plan to
meet the additional requirement imposed by the amendments
made by this section, the State plan shall not be regarded as
failing to comply with the requirements of such title solely
on the basis of its failure to meet this additional
requirement before the first day of the first calendar
quarter beginning after the close of the first regular
session of the State legislature that begins after the date
of the enactment of this Act. For purposes of the previous
sentence, in the case of a State that has a 2-year
legislative session, each year of such session shall be
deemed to be a separate regular session of the State
legislature.
SEC. 2302. CONCURRENT CARE FOR CHILDREN.
(a) In General.--Section 1905(o)(1) of the Social Security
Act (42 U.S.C. 1396d(o)(1)) is amended--
(1) in subparagraph (A), by striking ``subparagraph (B)''
and inserting ``subparagraphs (B) and (C)''; and
(2) by adding at the end the following new subparagraph:
``(C) A voluntary election to have payment made for hospice
care for a child (as defined by the State) shall not
constitute a waiver of any rights of the child to be provided
with, or to have payment made under this title for, services
that are related to the treatment of the child's condition
for which a diagnosis of terminal illness has been made.''.
(b) Application to CHIP.--Section 2110(a)(23) of the Social
Security Act (42 U.S.C. 1397jj(a)(23)) is amended by
inserting ``(concurrent, in the case of an individual who is
a child, with care related to the treatment of the child's
condition with respect to which a diagnosis of terminal
illness has been made'' after ``hospice care''.
SEC. 2303. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING
SERVICES.
(a) Coverage as Optional Categorically Needy Group.--
(1) In general.--Section 1902(a)(10)(A)(ii) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by
section 2001(e), is amended--
(A) in subclause (XIX), by striking ``or'' at the end;
(B) in subclause (XX), by adding ``or'' at the end; and
(C) by adding at the end the following new subclause:
``(XXI) who are described in subsection (ii) (relating to
individuals who meet certain income standards);''.
(2) Group described.--Section 1902 of such Act (42 U.S.C.
1396a), as amended by section 2001(d), is amended by adding
at the end the following new subsection:
``(ii)(1) Individuals described in this subsection are
individuals--
``(A) whose income does not exceed an income eligibility
level established by the State that does not exceed the
highest income eligibility level established under the State
plan under this title (or under its State child health plan
under title XXI) for pregnant women; and
``(B) who are not pregnant.
``(2) At the option of a State, individuals described in
this subsection may include individuals who, had individuals
applied on or before January 1, 2007, would have been made
eligible pursuant to the standards and processes imposed by
that State for benefits described in clause (XV) of the
matter following subparagraph (G) of section subsection
(a)(10) pursuant to a waiver granted under section 1115.
``(3) At the option of a State, for purposes of subsection
(a)(17)(B), in determining eligibility for services under
this subsection, the State may consider only the income of
the applicant or recipient.''.
(3) Limitation on benefits.--Section 1902(a)(10) of the
Social Security Act (42 U.S.C. 1396a(a)(10)), as amended by
section 2001(a)(5)(A), is amended in the matter following
subparagraph (G)--
(A) by striking ``and (XV)'' and inserting ``(XV)''; and
(B) by inserting ``, and (XVI) the medical assistance made
available to an individual described in subsection (ii) shall
be limited to family planning services and supplies described
in section 1905(a)(4)(C) including medical diagnosis and
treatment services that are provided pursuant to a family
planning service in a family planning setting'' before the
semicolon.
(4) Conforming amendments.--
(A) Section 1905(a) of the Social Security Act (42 U.S.C.
1396d(a)), as amended by section 2001(e)(2)(A), is amended in
the matter preceding paragraph (1)--
(i) in clause (xiv), by striking ``or'' at the end;
(ii) in clause (xv), by adding ``or'' at the end; and
(iii) by inserting after clause (xv) the following:
``(xvi) individuals described in section 1902(ii),''.
(B) Section 1903(f)(4) of such Act (42 U.S.C. 1396b(f)(4)),
as amended by section 2001(e)(2)(B), is amended by inserting
``1902(a)(10)(A)(ii)(XXI),'' after
``1902(a)(10)(A)(ii)(XX),''.
(b) Presumptive Eligibility.--
(1) In general.--Title XIX of the Social Security Act (42
U.S.C. 1396 et seq.) is amended by inserting after section
1920B the following:
``presumptive eligibility for family planning services
``Sec. 1920C. (a) State Option.--State plan approved under
section 1902 may provide for making medical assistance
available to an individual described in section 1902(ii)
(relating to individuals who meet certain income eligibility
standard) during a presumptive eligibility period. In the
case of an individual described in section 1902(ii), such
medical assistance shall be limited to family planning
services and supplies described in 1905(a)(4)(C) and, at the
State's option, medical diagnosis and treatment services that
are provided in conjunction with a family planning service in
a family planning setting.
``(b) Definitions.--For purposes of this section:
``(1) Presumptive eligibility period.--The term
`presumptive eligibility period' means, with respect to an
individual described in subsection (a), the period that--
``(A) begins with the date on which a qualified entity
determines, on the basis of preliminary information, that the
individual is described in section 1902(ii); and
[[Page H1967]]
``(B) ends with (and includes) the earlier of--
``(i) the day on which a determination is made with respect
to the eligibility of such individual for services under the
State plan; or
``(ii) in the case of such an individual who does not file
an application by the last day of the month following the
month during which the entity makes the determination
referred to in subparagraph (A), such last day.
``(2) Qualified entity.--
``(A) In general.--Subject to subparagraph (B), the term
`qualified entity' means any entity that--
``(i) is eligible for payments under a State plan approved
under this title; and
``(ii) is determined by the State agency to be capable of
making determinations of the type described in paragraph
(1)(A).
``(B) Rule of construction.--Nothing in this paragraph
shall be construed as preventing a State from limiting the
classes of entities that may become qualified entities in
order to prevent fraud and abuse.
``(c) Administration.--
``(1) In general.--The State agency shall provide qualified
entities with--
``(A) such forms as are necessary for an application to be
made by an individual described in subsection (a) for medical
assistance under the State plan; and
``(B) information on how to assist such individuals in
completing and filing such forms.
``(2) Notification requirements.--A qualified entity that
determines under subsection (b)(1)(A) that an individual
described in subsection (a) is presumptively eligible for
medical assistance under a State plan shall--
``(A) notify the State agency of the determination within 5
working days after the date on which determination is made;
and
``(B) inform such individual at the time the determination
is made that an application for medical assistance is
required to be made by not later than the last day of the
month following the month during which the determination is
made.
``(3) Application for medical assistance.--In the case of
an individual described in subsection (a) who is determined
by a qualified entity to be presumptively eligible for
medical assistance under a State plan, the individual shall
apply for medical assistance by not later than the last day
of the month following the month during which the
determination is made.
``(d) Payment.--Notwithstanding any other provision of law,
medical assistance that--
``(1) is furnished to an individual described in subsection
(a)--
``(A) during a presumptive eligibility period; and
``(B) by a entity that is eligible for payments under the
State plan; and
``(2) is included in the care and services covered by the
State plan,
shall be treated as medical assistance provided by such plan
for purposes of clause (4) of the first sentence of section
1905(b).''.
(2) Conforming amendments.--
(A) Section 1902(a)(47) of the Social Security Act (42
U.S.C. 1396a(a)(47)), as amended by section 2202(a), is
amended--
(i) in subparagraph (A), by inserting before the semicolon
at the end the following: ``and provide for making medical
assistance available to individuals described in subsection
(a) of section 1920C during a presumptive eligibility period
in accordance with such section''; and
(ii) in subparagraph (B), by striking ``or 1920B'' and
inserting ``1920B, or 1920C''.
(B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C.
1396b(u)(1)(D)(v)), as amended by section 2202(b), is amended
by inserting ``or for medical assistance provided to an
individual described in subsection (a) of section 1920C
during a presumptive eligibility period under such section,''
after ``1920B during a presumptive eligibility period under
such section,''.
(c) Clarification of Coverage of Family Planning Services
and Supplies.--Section 1937(b) of the Social Security Act (42
U.S.C. 1396u-7(b)), as amended by section 2001(c), is amended
by adding at the end the following:
``(7) Coverage of family planning services and supplies.--
Notwithstanding the previous provisions of this section, a
State may not provide for medical assistance through
enrollment of an individual with benchmark coverage or
benchmark-equivalent coverage under this section unless such
coverage includes for any individual described in section
1905(a)(4)(C), medical assistance for family planning
services and supplies in accordance with such section.''.
(d) Effective Date.--The amendments made by this section
take effect on the date of the enactment of this Act and
shall apply to items and services furnished on or after such
date.
SEC. 2304. CLARIFICATION OF DEFINITION OF MEDICAL ASSISTANCE.
Section 1905(a) of the Social Security Act (42 U.S.C.
1396d(a)) is amended by inserting ``or the care and services
themselves, or both'' before ``(if provided in or after''.
Subtitle E--New Options for States to Provide Long-Term Services and
Supports
SEC. 2401. COMMUNITY FIRST CHOICE OPTION.
Section 1915 of the Social Security Act (42 U.S.C. 1396n)
is amended by adding at the end the following:
``(k) State Plan Option To Provide Home and Community-based
Attendant Services and Supports.--
``(1) In general.--Subject to the succeeding provisions of
this subsection, beginning October 1, 2010, a State may
provide through a State plan amendment for the provision of
medical assistance for home and community-based attendant
services and supports for individuals who are eligible for
medical assistance under the State plan whose income does not
exceed 150 percent of the poverty line (as defined in section
2110(c)(5)) or, if greater, the income level applicable for
an individual who has been determined to require an
institutional level of care to be eligible for nursing
facility services under the State plan and with respect to
whom there has been a determination that, but for the
provision of such services, the individuals would require the
level of care provided in a hospital, a nursing facility, an
intermediate care facility for the mentally retarded, or an
institution for mental diseases, the cost of which could be
reimbursed under the State plan, but only if the individual
chooses to receive such home and community-based attendant
services and supports, and only if the State meets the
following requirements:
``(A) Availability.--The State shall make available home
and community-based attendant services and supports to
eligible individuals, as needed, to assist in accomplishing
activities of daily living, instrumental activities of daily
living, and health-related tasks through hands-on assistance,
supervision, or cueing--
``(i) under a person-centered plan of services and supports
that is based on an assessment of functional need and that is
agreed to in writing by the individual or, as appropriate,
the individual's representative;
``(ii) in a home or community setting, which does not
include a nursing facility, institution for mental diseases,
or an intermediate care facility for the mentally retarded;
``(iii) under an agency-provider model or other model (as
defined in paragraph (6)(C )); and
``(iv) the furnishing of which--
``(I) is selected, managed, and dismissed by the
individual, or, as appropriate, with assistance from the
individual's representative;
``(II) is controlled, to the maximum extent possible, by
the individual or where appropriate, the individual's
representative, regardless of who may act as the employer of
record; and
``(III) provided by an individual who is qualified to
provide such services, including family members (as defined
by the Secretary).
``(B) Included services and supports.--In addition to
assistance in accomplishing activities of daily living,
instrumental activities of daily living, and health related
tasks, the home and community-based attendant services and
supports made available include--
``(i) the acquisition, maintenance, and enhancement of
skills necessary for the individual to accomplish activities
of daily living, instrumental activities of daily living, and
health related tasks;
``(ii) back-up systems or mechanisms (such as the use of
beepers or other electronic devices) to ensure continuity of
services and supports; and
``(iii) voluntary training on how to select, manage, and
dismiss attendants.
``(C) Excluded services and supports.--Subject to
subparagraph (D), the home and community-based attendant
services and supports made available do not include--
``(i) room and board costs for the individual;
``(ii) special education and related services provided
under the Individuals with Disabilities Education Act and
vocational rehabilitation services provided under the
Rehabilitation Act of 1973;
``(iii) assistive technology devices and assistive
technology services other than those under (1)(B)(ii);
``(iv) medical supplies and equipment; or
``(v) home modifications.
``(D) Permissible services and supports.--The home and
community-based attendant services and supports may include--
``(i) expenditures for transition costs such as rent and
utility deposits, first month's rent and utilities, bedding,
basic kitchen supplies, and other necessities required for an
individual to make the transition from a nursing facility,
institution for mental diseases, or intermediate care
facility for the mentally retarded to a community-based home
setting where the individual resides; and
``(ii) expenditures relating to a need identified in an
individual's person-centered plan of services that increase
independence or substitute for human assistance, to the
extent that expenditures would otherwise be made for the
human assistance.
``(2) Increased federal financial participation.--For
purposes of payments to a State under section 1903(a)(1),
with respect to amounts expended by the State to provide
medical assistance under the State plan for home and
community-based attendant services and supports to eligible
individuals in accordance with this subsection during a
fiscal year quarter occurring during the period described in
paragraph (1), the Federal medical assistance percentage
applicable to the State (as determined under section 1905(b))
shall be increased by 6 percentage points.
``(3) State requirements.--In order for a State plan
amendment to be approved under this subsection, the State
shall--
``(A) develop and implement such amendment in collaboration
with a Development and Implementation Council established by
the State that includes a majority of members with
disabilities, elderly individuals, and their representatives
and consults and collaborates with such individuals;
``(B) provide consumer controlled home and community-based
attendant services and supports to individuals on a statewide
basis, in a manner that provides such services and supports
in the most integrated setting appropriate to the
individual's needs, and without regard to the individual's
age, type or nature of disability, severity of disability, or
the form of home and community-based attendant services and
supports that the individual requires in order to lead an
independent life;
``(C) with respect to expenditures during the first full
fiscal year in which the State plan amendment is implemented,
maintain or exceed the level of State expenditures for
medical assistance that is provided under section 1905(a),
[[Page H1968]]
section 1915, section 1115, or otherwise to individuals with
disabilities or elderly individuals attributable to the
preceding fiscal year;
``(D) establish and maintain a comprehensive, continuous
quality assurance system with respect to community- based
attendant services and supports that--
``(i) includes standards for agency-based and other
delivery models with respect to training, appeals for denials
and reconsideration procedures of an individual plan, and
other factors as determined by the Secretary;
``(ii) incorporates feedback from consumers and their
representatives, disability organizations, providers,
families of disabled or elderly individuals, members of the
community, and others and maximizes consumer independence and
consumer control;
``(iii) monitors the health and well-being of each
individual who receives home and community-based attendant
services and supports, including a process for the mandatory
reporting, investigation, and resolution of allegations of
neglect, abuse, or exploitation in connection with the
provision of such services and supports; and
``(iv) provides information about the provisions of the
quality assurance required under clauses (i) through (iii) to
each individual receiving such services; and
``(E) collect and report information, as determined
necessary by the Secretary, for the purposes of approving the
State plan amendment, providing Federal oversight, and
conducting an evaluation under paragraph (5)(A), including
data regarding how the State provides home and community-
based attendant services and supports and other home and
community-based services, the cost of such services and
supports, and how the State provides individuals with
disabilities who otherwise qualify for institutional care
under the State plan or under a waiver the choice to instead
receive home and community-based services in lieu of
institutional care.
``(4) Compliance with certain laws.--A State shall ensure
that, regardless of whether the State uses an agency-provider
model or other models to provide home and community-based
attendant services and supports under a State plan amendment
under this subsection, such services and supports are
provided in accordance with the requirements of the Fair
Labor Standards Act of 1938 and applicable Federal and State
laws regarding--
``(A) withholding and payment of Federal and State income
and payroll taxes;
``(B) the provision of unemployment and workers
compensation insurance;
``(C) maintenance of general liability insurance; and
``(D) occupational health and safety.
``(5) Evaluation, data collection, and report to
congress.--
``(A) Evaluation.--The Secretary shall conduct an
evaluation of the provision of home and community-based
attendant services and supports under this subsection in
order to determine the effectiveness of the provision of such
services and supports in allowing the individuals receiving
such services and supports to lead an independent life to the
maximum extent possible; the impact on the physical and
emotional health of the individuals who receive such
services; and an comparative analysis of the costs of
services provided under the State plan amendment under this
subsection and those provided under institutional care in a
nursing facility, institution for mental diseases, or an
intermediate care facility for the mentally retarded.
``(B) Data collection.--The State shall provide the
Secretary with the following information regarding the
provision of home and community-based attendant services and
supports under this subsection for each fiscal year for which
such services and supports are provided:
``(i) The number of individuals who are estimated to
receive home and community-based attendant services and
supports under this subsection during the fiscal year.
``(ii) The number of individuals that received such
services and supports during the preceding fiscal year.
``(iii) The specific number of individuals served by type
of disability, age, gender, education level, and employment
status.
``(iv) Whether the specific individuals have been
previously served under any other home and community based
services program under the State plan or under a waiver.
``(C) Reports.--Not later than--
``(i) December 31, 2013, the Secretary shall submit to
Congress and make available to the public an interim report
on the findings of the evaluation under subparagraph (A); and
``(ii) December 31, 2015, the Secretary shall submit to
Congress and make available to the public a final report on
the findings of the evaluation under subparagraph (A).
``(6) Definitions.--In this subsection:
``(A) Activities of daily living.--The term `activities of
daily living' includes tasks such as eating, toileting,
grooming, dressing, bathing, and transferring.
``(B) Consumer controlled.--The term `consumer controlled'
means a method of selecting and providing services and
supports that allow the individual, or where appropriate, the
individual's representative, maximum control of the home and
community-based attendant services and supports, regardless
of who acts as the employer of record.
``(C) Delivery models.--
``(i) Agency-provider model.--The term `agency-provider
model' means, with respect to the provision of home and
community-based attendant services and supports for an
individual, subject to paragraph (4), a method of providing
consumer controlled services and supports under which
entities contract for the provision of such services and
supports.
``(ii) Other models.--The term `other models' means,
subject to paragraph (4), methods, other than an agency-
provider model, for the provision of consumer controlled
services and supports. Such models may include the provision
of vouchers, direct cash payments, or use of a fiscal agent
to assist in obtaining services.
``(D) Health-related tasks.--The term `health-related
tasks' means specific tasks related to the needs of an
individual, which can be delegated or assigned by licensed
health-care professionals under State law to be performed by
an attendant.
``(E) Individual's representative.--The term `individual's
representative' means a parent, family member, guardian,
advocate, or other authorized representative of an
individual.
``(F) Instrumental activities of daily living.--The term
`instrumental activities of daily living' includes (but is
not limited to) meal planning and preparation, managing
finances, shopping for food, clothing, and other essential
items, performing essential household chores, communicating
by phone or other media, and traveling around and
participating in the community.''.
SEC. 2402. REMOVAL OF BARRIERS TO PROVIDING HOME AND
COMMUNITY-BASED SERVICES.
(a) Oversight and Assessment of the Administration of Home
and Community-based Services.--The Secretary of Health and
Human Services shall promulgate regulations to ensure that
all States develop service systems that are designed to--
(1) allocate resources for services in a manner that is
responsive to the changing needs and choices of beneficiaries
receiving non-institutionally-based long-term services and
supports (including such services and supports that are
provided under programs other the State Medicaid program),
and that provides strategies for beneficiaries receiving such
services to maximize their independence, including through
the use of client-employed providers;
(2) provide the support and coordination needed for a
beneficiary in need of such services (and their family
caregivers or representative, if applicable) to design an
individualized, self-directed, community-supported life; and
(3) improve coordination among, and the regulation of, all
providers of such services under federally and State-funded
programs in order to--
(A) achieve a more consistent administration of policies
and procedures across programs in relation to the provision
of such services; and
(B) oversee and monitor all service system functions to
assure--
(i) coordination of, and effectiveness of, eligibility
determinations and individual assessments;
(ii) development and service monitoring of a complaint
system, a management system, a system to qualify and monitor
providers, and systems for role-setting and individual budget
determinations; and
(iii) an adequate number of qualified direct care workers
to provide self-directed personal assistance services.
(b) Additional State Options.--Section 1915(i) of the
Social Security Act (42 U.S.C. 1396n(i)) is amended by adding
at the end the following new paragraphs:
``(6) State option to provide home and community-based
services to individuals eligible for services under a
waiver.--
``(A) In general.--A State that provides home and
community-based services in accordance with this subsection
to individuals who satisfy the needs-based criteria for the
receipt of such services established under paragraph (1)(A)
may, in addition to continuing to provide such services to
such individuals, elect to provide home and community-based
services in accordance with the requirements of this
paragraph to individuals who are eligible for home and
community-based services under a waiver approved for the
State under subsection (c), (d), or (e) or under section 1115
to provide such services, but only for those individuals
whose income does not exceed 300 percent of the supplemental
security income benefit rate established by section
1611(b)(1).
``(B) Application of same requirements for individuals
satisfying needs-based criteria.--Subject to subparagraph
(C), a State shall provide home and community-based services
to individuals under this paragraph in the same manner and
subject to the same requirements as apply under the other
paragraphs of this subsection to the provision of home and
community-based services to individuals who satisfy the
needs-based criteria established under paragraph (1)(A).
``(C) Authority to offer different type, amount, duration,
or scope of home and community-based services.--A State may
offer home and community-based services to individuals under
this paragraph that differ in type, amount, duration, or
scope from the home and community-based services offered for
individuals who satisfy the needs-based criteria established
under paragraph (1)(A), so long as such services are within
the scope of services described in paragraph (4)(B) of
subsection (c) for which the Secretary has the authority to
approve a waiver and do not include room or board.
``(7) State option to offer home and community-based
services to specific, targeted populations.--
``(A) In general.--A State may elect in a State plan
amendment under this subsection to target the provision of
home and community-based services under this subsection to
specific populations and to differ the type, amount,
duration, or scope of such services to such specific
populations.
``(B) 5-year term.--
``(i) In general.--An election by a State under this
paragraph shall be for a period of 5 years.
``(ii) Phase-in of services and eligibility permitted
during initial 5-year period.--A State making an election
under this paragraph
[[Page H1969]]
may, during the first 5-year period for which the election is
made, phase-in the enrollment of eligible individuals, or the
provision of services to such individuals, or both, so long
as all eligible individuals in the State for such services
are enrolled, and all such services are provided, before the
end of the initial 5-year period.
``(C) Renewal.--An election by a State under this paragraph
may be renewed for additional 5-year terms if the Secretary
determines, prior to beginning of each such renewal period,
that the State has--
``(i) adhered to the requirements of this subsection and
paragraph in providing services under such an election; and
``(ii) met the State's objectives with respect to quality
improvement and beneficiary outcomes.''.
(c) Removal of Limitation on Scope of Services.--Paragraph
(1) of section 1915(i) of the Social Security Act (42 U.S.C.
1396n(i)), as amended by subsection (a), is amended by
striking ``or such other services requested by the State as
the Secretary may approve''.
(d) Optional Eligibility Category To Provide Full Medicaid
Benefits to Individuals Receiving Home and Community-based
Services Under a State Plan Amendment.--
(1) In general.--Section 1902(a)(10)(A)(ii) of the Social
Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)), as amended by
section 2304(a)(1), is amended--
(A) in subclause (XX), by striking ``or'' at the end;
(B) in subclause (XXI), by adding ``or'' at the end; and
(C) by inserting after subclause (XXI), the following new
subclause:
``(XXII) who are eligible for home and community-based
services under needs-based criteria established under
paragraph (1)(A) of section 1915(i), or who are eligible for
home and community-based services under paragraph (6) of such
section, and who will receive home and community-based
services pursuant to a State plan amendment under such
subsection;''.
(2) Conforming amendments.--
(A) Section 1903(f)(4) of the Social Security Act (42
U.S.C. 1396b(f)(4)), as amended by section 2304(a)(4)(B), is
amended in the matter preceding subparagraph (A), by
inserting ``1902(a)(10)(A)(ii)(XXII),'' after
``1902(a)(10)(A)(ii)(XXI),''.
(B) Section 1905(a) of the Social Security Act (42 U.S.C.
1396d(a)), as so amended, is amended in the matter preceding
paragraph (1)--
(i) in clause (xv), by striking ``or'' at the end;
(ii) in clause (xvi), by adding ``or'' at the end; and
(iii) by inserting after clause (xvi) the following new
clause:
``(xvii) individuals who are eligible for home and
community-based services under needs-based criteria
established under paragraph (1)(A) of section 1915(i), or who
are eligible for home and community-based services under
paragraph (6) of such section, and who will receive home and
community-based services pursuant to a State plan amendment
under such subsection,''.
(e) Elimination of Option To Limit Number of Eligible
Individuals or Length of Period for Grandfathered Individuals
if Eligibility Criteria Is Modified.--Paragraph (1) of
section 1915(i) of such Act (42 U.S.C. 1396n(i)) is amended--
(1) by striking subparagraph (C) and inserting the
following:
``(C) Projection of number of individuals to be provided
home and community-based services.--The State submits to the
Secretary, in such form and manner, and upon such frequency
as the Secretary shall specify, the projected number of
individuals to be provided home and community-based
services.''; and
(2) in subclause (II) of subparagraph (D)(ii), by striking
``to be eligible for such services for a period of at least
12 months beginning on the date the individual first received
medical assistance for such services'' and inserting ``to
continue to be eligible for such services after the effective
date of the modification and until such time as the
individual no longer meets the standard for receipt of such
services under such pre-modified criteria''.
(f) Elimination of Option To Waive Statewideness; Addition
of Option To Waive Comparability.--Paragraph (3) of section
1915(i) of such Act (42 U.S.C. 1396n(3)) is amended by
striking ``1902(a)(1) (relating to statewideness)'' and
inserting ``1902(a)(10)(B) (relating to comparability)''.
(g) Effective Date.--The amendments made by subsections (b)
through (f) take effect on the first day of the first fiscal
year quarter that begins after the date of enactment of this
Act.
SEC. 2403. MONEY FOLLOWS THE PERSON REBALANCING
DEMONSTRATION.
(a) Extension of Demonstration.--
(1) In general.--Section 6071(h) of the Deficit Reduction
Act of 2005 (42 U.S.C. 1396a note) is amended--
(A) in paragraph (1)(E), by striking ``fiscal year 2011''
and inserting ``each of fiscal years 2011 through 2016''; and
(B) in paragraph (2), by striking ``2011'' and inserting
``2016''.
(2) Evaluation.--Paragraphs (2) and (3) of section 6071(g)
of such Act is amended are each amended by striking ``2011''
and inserting ``2016''.
(b) Reduction of Institutional Residency Period.--
(1) In general.--Section 6071(b)(2) of the Deficit
Reduction Act of 2005 (42 U.S.C. 1396a note) is amended--
(A) in subparagraph (A)(i), by striking ``, for a period of
not less than 6 months or for such longer minimum period, not
to exceed 2 years, as may be specified by the State'' and
inserting ``for a period of not less than 90 consecutive
days''; and
(B) by adding at the end the following:
``Any days that an individual resides in an institution on
the basis of having been admitted solely for purposes of
receiving short-term rehabilitative services for a period for
which payment for such services is limited under title XVIII
shall not be taken into account for purposes of determining
the 90-day period required under subparagraph (A)(i).''.
(2) Effective date.--The amendments made by this subsection
take effect 30 days after the date of enactment of this Act.
SEC. 2404. PROTECTION FOR RECIPIENTS OF HOME AND COMMUNITY-
BASED SERVICES AGAINST SPOUSAL IMPOVERISHMENT.
During the 5-year period that begins on January 1, 2014,
section 1924(h)(1)(A) of the Social Security Act (42 U.S.C.
1396r-5(h)(1)(A)) shall be applied as though ``is eligible
for medical assistance for home and community-based services
provided under subsection (c), (d), or (i) of section 1915,
under a waiver approved under section 1115, or who is
eligible for such medical assistance by reason of being
determined eligible under section 1902(a)(10)(C) or by reason
of section 1902(f) or otherwise on the basis of a reduction
of income based on costs incurred for medical or other
remedial care, or who is eligible for medical assistance for
home and community-based attendant services and supports
under section 1915(k)'' were substituted in such section for
``(at the option of the State) is described in section
1902(a)(10)(A)(ii)(VI)''.
SEC. 2405. FUNDING TO EXPAND STATE AGING AND DISABILITY
RESOURCE CENTERS.
Out of any funds in the Treasury not otherwise
appropriated, there is appropriated to the Secretary of
Health and Human Services, acting through the Assistant
Secretary for Aging, $10,000,000 for each of fiscal years
2010 through 2014, to carry out subsections (a)(20)(B)(iii)
and (b)(8) of section 202 of the Older Americans Act of 1965
(42 U.S.C. 3012).
SEC. 2406. SENSE OF THE SENATE REGARDING LONG-TERM CARE.
(a) Findings.--The Senate makes the following findings:
(1) Nearly 2 decades have passed since Congress seriously
considered long-term care reform. The United States
Bipartisan Commission on Comprehensive Health Care, also know
as the ``Pepper Commission'', released its ``Call for
Action'' blueprint for health reform in September 1990. In
the 20 years since those recommendations were made, Congress
has never acted on the report.
(2) In 1999, under the United States Supreme Court's
decision in Olmstead v. L.C., 527 U.S. 581 (1999),
individuals with disabilities have the right to choose to
receive their long-term services and supports in the
community, rather than in an institutional setting.
(3) Despite the Pepper Commission and Olmstead decision,
the long-term care provided to our Nation's elderly and
disabled has not improved. In fact, for many, it has gotten
far worse.
(4) In 2007, 69 percent of Medicaid long-term care spending
for elderly individuals and adults with physical disabilities
paid for institutional services. Only 6 states spent 50
percent or more of their Medicaid long-term care dollars on
home and community-based services for elderly individuals and
adults with physical disabilities while \1/2\ of the States
spent less than 25 percent. This disparity continues even
though, on average, it is estimated that Medicaid dollars can
support nearly 3 elderly individuals and adults with physical
disabilities in home and community-based services for every
individual in a nursing home. Although every State has chosen
to provide certain services under home and community-based
waivers, these services are unevenly available within and
across States, and reach a small percentage of eligible
individuals.
(b) Sense of the Senate.--It is the sense of the Senate
that--
(1) during the 111th session of Congress, Congress should
address long-term services and supports in a comprehensive
way that guarantees elderly and disabled individuals the care
they need; and
(2) long term services and supports should be made
available in the community in addition to in institutions.
Subtitle F--Medicaid Prescription Drug Coverage
SEC. 2501. PRESCRIPTION DRUG REBATES.
(a) Increase in Minimum Rebate Percentage for Single Source
Drugs and Innovator Multiple Source Drugs.--
(1) In general.--Section 1927(c)(1)(B) of the Social
Security Act (42 U.S.C. 1396r-8(c)(1)(B)) is amended--
(A) in clause (i)--
(i) in subclause (IV), by striking ``and'' at the end;
(ii) in subclause (V)--
(I) by inserting ``and before January 1, 2010'' after
``December 31, 1995,''; and
(II) by striking the period at the end and inserting ``;
and''; and
(iii) by adding at the end the following new subclause:
``(VI) except as provided in clause (iii), after December
31, 2009, 23.1 percent.''; and
(B) by adding at the end the following new clause:
``(iii) Minimum rebate percentage for certain drugs.--
``(I) In general.--In the case of a single source drug or
an innovator multiple source drug described in subclause
(II), the minimum rebate percentage for rebate periods
specified in clause (i)(VI) is 17.1 percent.
``(II) Drug described.--For purposes of subclause (I), a
single source drug or an innovator multiple source drug
described in this subclause is any of the following drugs:
[[Page H1970]]
``(aa) A clotting factor for which a separate furnishing
payment is made under section 1842(o)(5) and which is
included on a list of such factors specified and updated
regularly by the Secretary.
``(bb) A drug approved by the Food and Drug Administration
exclusively for pediatric indications.''.
(2) Recapture of total savings due to increase.--Section
1927(b)(1) of such Act (42 U.S.C. 1396r-8(b)(1)) is amended
by adding at the end the following new subparagraph:
``(C) Special rule for increased minimum rebate
percentage.--
``(i) In general.--In addition to the amounts applied as a
reduction under subparagraph (B), for rebate periods
beginning on or after January 1, 2010, during a fiscal year,
the Secretary shall reduce payments to a State under section
1903(a) in the manner specified in clause (ii), in an amount
equal to the product of--
``(I) 100 percent minus the Federal medical assistance
percentage applicable to the rebate period for the State; and
``(II) the amounts received by the State under such
subparagraph that are attributable (as estimated by the
Secretary based on utilization and other data) to the
increase in the minimum rebate percentage effected by the
amendments made by subsections (a)(1), (b), and (d) of
section 2501 of the Patient Protection and Affordable Care
Act, taking into account the additional drugs included under
the amendments made by subsection (c) of section 2501 of such
Act.
The Secretary shall adjust such payment reduction for a
calendar quarter to the extent the Secretary determines,
based upon subsequent utilization and other data, that the
reduction for such quarter was greater or less than the
amount of payment reduction that should have been made.
``(ii) Manner of payment reduction.--The amount of the
payment reduction under clause (i) for a State for a quarter
shall be deemed an overpayment to the State under this title
to be disallowed against the State's regular quarterly draw
for all Medicaid spending under section 1903(d)(2). Such a
disallowance is not subject to a reconsideration under
section 1116(d).''.
(b) Increase in Rebate for Other Drugs.--Section
1927(c)(3)(B) of such Act (42 U.S.C. 1396r-8(c)(3)(B)) is
amended--
(1) in clause (i), by striking ``and'' at the end;
(2) in clause (ii)--
(A) by inserting ``and before January 1, 2010,'' after
``December 31, 1993,''; and
(B) by striking the period and inserting ``; and''; and
(3) by adding at the end the following new clause:
``(iii) after December 31, 2009, is 13 percent.''.
(c) Extension of Prescription Drug Discounts to Enrollees
of Medicaid Managed Care Organizations.--
(1) In general.--Section 1903(m)(2)(A) of such Act (42
U.S.C. 1396b(m)(2)(A)) is amended--
(A) in clause (xi), by striking ``and'' at the end;
(B) in clause (xii), by striking the period at the end and
inserting ``; and''; and
(C) by adding at the end the following:
``(xiii) such contract provides that (I) covered outpatient
drugs dispensed to individuals eligible for medical
assistance who are enrolled with the entity shall be subject
to the same rebate required by the agreement entered into
under section 1927 as the State is subject to and that the
State shall collect such rebates from manufacturers, (II)
capitation rates paid to the entity shall be based on actual
cost experience related to rebates and subject to the Federal
regulations requiring actuarially sound rates, and (III) the
entity shall report to the State, on such timely and periodic
basis as specified by the Secretary in order to include in
the information submitted by the State to a manufacturer and
the Secretary under section 1927(b)(2)(A), information on the
total number of units of each dosage form and strength and
package size by National Drug Code of each covered outpatient
drug dispensed to individuals eligible for medical assistance
who are enrolled with the entity and for which the entity is
responsible for coverage of such drug under this subsection
(other than covered outpatient drugs that under subsection
(j)(1) of section 1927 are not subject to the requirements of
that section) and such other data as the Secretary determines
necessary to carry out this subsection.''.
(2) Conforming amendments.--Section 1927 (42 U.S.C. 1396r-
8) is amended--
(A) in subsection (b)--
(i) in paragraph (1)(A), in the first sentence, by
inserting ``, including such drugs dispensed to individuals
enrolled with a medicaid managed care organization if the
organization is responsible for coverage of such drugs''
before the period; and
(ii) in paragraph (2)(A), by inserting ``including such
information reported by each medicaid managed care
organization,'' after ``for which payment was made under the
plan during the period,''; and
(B) in subsection (j), by striking paragraph (1) and
inserting the following:
``(1) Covered outpatient drugs are not subject to the
requirements of this section if such drugs are--
``(A) dispensed by health maintenance organizations,
including Medicaid managed care organizations that contract
under section 1903(m); and
``(B) subject to discounts under section 340B of the Public
Health Service Act.''.
(d) Additional Rebate for New Formulations of Existing
Drugs.--
(1) In general.--Section 1927(c)(2) of the Social Security
Act (42 U.S.C. 1396r-8(c)(2)) is amended by adding at the end
the following new subparagraph:
``(C) Treatment of new formulations.--
``(i) In general.--Except as provided in clause (ii), in
the case of a drug that is a new formulation, such as an
extended-release formulation, of a single source drug or an
innovator multiple source drug, the rebate obligation with
respect to the drug under this section shall be the amount
computed under this section for the new formulation of the
drug or, if greater, the product of--
``(I) the average manufacturer price for each dosage form
and strength of the new formulation of the single source drug
or innovator multiple source drug;
``(II) the highest additional rebate (calculated as a
percentage of average manufacturer price) under this section
for any strength of the original single source drug or
innovator multiple source drug; and
``(III) the total number of units of each dosage form and
strength of the new formulation paid for under the State plan
in the rebate period (as reported by the State).
``(ii) No application to new formulations of orphan
drugs.--Clause (i) shall not apply to a new formulation of a
covered outpatient drug that is or has been designated under
section 526 of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 360bb) for a rare disease or condition, without regard
to whether the period of market exclusivity for the drug
under section 527 of such Act has expired or the specific
indication for use of the drug.''.
(2) Effective date.--The amendment made by paragraph (1)
shall apply to drugs that are paid for by a State after
December 31, 2009.
(e) Maximum Rebate Amount.--Section 1927(c)(2) of such Act
(42 U.S.C. 1396r-8(c)(2)), as amended by subsection (d), is
amended by adding at the end the following new subparagraph:
``(D) Maximum rebate amount.--In no case shall the sum of
the amounts applied under paragraph (1)(A)(ii) and this
paragraph with respect to each dosage form and strength of a
single source drug or an innovator multiple source drug for a
rebate period beginning after December 31, 2009, exceed 100
percent of the average manufacturer price of the drug.''.
(f) Conforming Amendments.--
(1) In general.--Section 340B of the Public Health Service
Act (42 U.S.C. 256b) is amended--
(A) in subsection (a)(2)(B)(i), by striking ``1927(c)(4)''
and inserting ``1927(c)(3)''; and
(B) by striking subsection (c); and
(C) redesignating subsection (d) as subsection (c).
(2) Effective date.--The amendments made by this subsection
take effect on January 1, 2010.
SEC. 2502. ELIMINATION OF EXCLUSION OF COVERAGE OF CERTAIN
DRUGS.
(a) In General.--Section 1927(d) of the Social Security Act
(42 U.S.C. 1397r-8(d)) is amended--
(1) in paragraph (2)--
(A) by striking subparagraphs (E), (I), and (J),
respectively; and
(B) by redesignating subparagraphs (F), (G), (H), and (K)
as subparagraphs (E), (F), (G), and (H), respectively; and
(2) by adding at the end the following new paragraph:
``(7) Non-excludable drugs.--The following drugs or classes
of drugs, or their medical uses, shall not be excluded from
coverage:
``(A) Agents when used to promote smoking cessation,
including agents approved by the Food and Drug Administration
under the over-the-counter monograph process for purposes of
promoting, and when used to promote, tobacco cessation.
``(B) Barbiturates.
``(C) Benzodiazepines.''.
(b) Effective Date.--The amendments made by this section
shall apply to services furnished on or after January 1,
2014.
SEC. 2503. PROVIDING ADEQUATE PHARMACY REIMBURSEMENT.
(a) Pharmacy Reimbursement Limits.--
(1) In general.--Section 1927(e) of the Social Security Act
(42 U.S.C. 1396r-8(e)) is amended--
(A) in paragraph (4), by striking ``(or, effective January
1, 2007, two or more)''; and
(B) by striking paragraph (5) and inserting the following:
``(5) Use of amp in upper payment limits.--The Secretary
shall calculate the Federal upper reimbursement limit
established under paragraph (4) as no less than 175 percent
of the weighted average (determined on the basis of
utilization) of the most recently reported monthly average
manufacturer prices for pharmaceutically and therapeutically
equivalent multiple source drug products that are available
for purchase by retail community pharmacies on a nationwide
basis. The Secretary shall implement a smoothing process for
average manufacturer prices. Such process shall be similar to
the smoothing process used in determining the average sales
price of a drug or biological under section 1847A.''.
(2) Definition of amp.--Section 1927(k)(1) of such Act (42
U.S.C. 1396r-8(k)(1)) is amended--
(A) in subparagraph (A), by striking ``by'' and all that
follows through the period and inserting ``by--
``(i) wholesalers for drugs distributed to retail community
pharmacies; and
``(ii) retail community pharmacies that purchase drugs
directly from the manufacturer.''; and
(B) by striking subparagraph (B) and inserting the
following:
``(B) Exclusion of customary prompt pay discounts and other
payments.--
``(i) In general.--The average manufacturer price for a
covered outpatient drug shall exclude--
``(I) customary prompt pay discounts extended to
wholesalers;
``(II) bona fide service fees paid by manufacturers to
wholesalers or retail community pharmacies, including (but
not limited to) distribution service fees, inventory
management fees,
[[Page H1971]]
product stocking allowances, and fees associated with
administrative services agreements and patient care programs
(such as medication compliance programs and patient education
programs);
``(III) reimbursement by manufacturers for recalled,
damaged, expired, or otherwise unsalable returned goods,
including (but not limited to) reimbursement for the cost of
the goods and any reimbursement of costs associated with
return goods handling and processing, reverse logistics, and
drug destruction; and
``(IV) payments received from, and rebates or discounts
provided to, pharmacy benefit managers, managed care
organizations, health maintenance organizations, insurers,
hospitals, clinics, mail order pharmacies, long term care
providers, manufacturers, or any other entity that does not
conduct business as a wholesaler or a retail community
pharmacy.
``(ii) Inclusion of other discounts and payments.--
Notwithstanding clause (i), any other discounts, rebates,
payments, or other financial transactions that are received
by, paid by, or passed through to, retail community
pharmacies shall be included in the average manufacturer
price for a covered outpatient drug.''; and
(C) in subparagraph (C), by striking ``the retail pharmacy
class of trade'' and inserting ``retail community
pharmacies''.
(3) Definition of multiple source drug.--Section 1927(k)(7)
of such Act (42 U.S.C. 1396r-8(k)(7)) is amended--
(A) in subparagraph (A)(i)(III), by striking ``the State''
and inserting ``the United States''; and
(B) in subparagraph (C)--
(i) in clause (i), by inserting ``and'' after the
semicolon;
(ii) in clause (ii), by striking ``; and'' and inserting a
period; and
(iii) by striking clause (iii).
(4) Definitions of retail community pharmacy; wholesaler.--
Section 1927(k) of such Act (42 U.S.C. 1396r-8(k)) is amended
by adding at the end the following new paragraphs:
``(10) Retail community pharmacy.--The term `retail
community pharmacy' means an independent pharmacy, a chain
pharmacy, a supermarket pharmacy, or a mass merchandiser
pharmacy that is licensed as a pharmacy by the State and that
dispenses medications to the general public at retail prices.
Such term does not include a pharmacy that dispenses
prescription medications to patients primarily through the
mail, nursing home pharmacies, long-term care facility
pharmacies, hospital pharmacies, clinics, charitable or not-
for-profit pharmacies, government pharmacies, or pharmacy
benefit managers.
``(11) Wholesaler.--The term `wholesaler' means a drug
wholesaler that is engaged in wholesale distribution of
prescription drugs to retail community pharmacies, including
(but not limited to) manufacturers, repackers, distributors,
own-label distributors, private-label distributors, jobbers,
brokers, warehouses (including manufacturer's and
distributor's warehouses, chain drug warehouses, and
wholesale drug warehouses) independent wholesale drug
traders, and retail community pharmacies that conduct
wholesale distributions.''.
(b) Disclosure of Price Information to the Public.--Section
1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended--
(1) in subparagraph (A)--
(A) in the first sentence, by inserting after clause (iii)
the following:
``(iv) not later than 30 days after the last day of each
month of a rebate period under the agreement, on the
manufacturer's total number of units that are used to
calculate the monthly average manufacturer price for each
covered outpatient drug;''; and
(B) in the second sentence, by inserting ``(relating to the
weighted average of the most recently reported monthly
average manufacturer prices)'' after ``(D)(v)''; and
(2) in subparagraph (D)(v), by striking ``average
manufacturer prices'' and inserting ``the weighted average of
the most recently reported monthly average manufacturer
prices and the average retail survey price determined for
each multiple source drug in accordance with subsection
(f)''.
(c) Clarification of Application of Survey of Retail
Prices.--Section 1927(f)(1) of such Act (42 U.S.C. 1396r-
8(b)(1)) is amended--
(1) in subparagraph (A)(i), by inserting ``with respect to
a retail community pharmacy,'' before ``the determination'';
and
(2) in subparagraph (C)(ii), by striking ``retail
pharmacies'' and inserting ``retail community pharmacies''.
(d) Effective Date.--The amendments made by this section
shall take effect on the first day of the first calendar year
quarter that begins at least 180 days after the date of
enactment of this Act, without regard to whether or not final
regulations to carry out such amendments have been
promulgated by such date.
Subtitle G--Medicaid Disproportionate Share Hospital (DSH) Payments
SEC. 2551. DISPROPORTIONATE SHARE HOSPITAL PAYMENTS.
(a) In General.--Section 1923(f) of the Social Security Act
(42 U.S.C. 1396r-4(f)) is amended--
(1) in paragraph (1), by striking ``and (3)'' and inserting
``, (3), and (7)'';
(2) in paragraph (3)(A), by striking ``paragraph (6)'' and
inserting ``paragraphs (6) and (7)'';
(3) by redesignating paragraph (7) as paragraph (8); and
(4) by inserting after paragraph (6) the following new
paragraph:
``(7) Reduction of state dsh allotments once reduction in
uninsured threshold reached.--
``(A) In general.--Subject to subparagraph (E), the DSH
allotment for a State for fiscal years beginning with the
fiscal year described in subparagraph (C) (with respect to
the State), is equal to--
``(i) in the case of the first fiscal year described in
subparagraph (C) with respect to a State, the DSH allotment
that would be determined under this subsection for the State
for the fiscal year without application of this paragraph
(but after the application of subparagraph (D)), reduced by
the applicable percentage determined for the State for the
fiscal year under subparagraph (B)(i); and
``(ii) in the case of any subsequent fiscal year with
respect to the State, the DSH allotment determined under this
paragraph for the State for the preceding fiscal year,
reduced by the applicable percentage determined for the State
for the fiscal year under subparagraph (B)(ii).
``(B) Applicable percentage.--For purposes of subparagraph
(A), the applicable percentage for a State for a fiscal year
is the following:
``(i) Uninsured reduction threshold fiscal year.--In the
case of the first fiscal year described in subparagraph (C)
with respect to the State--
``(I) if the State is a low DSH State described in
paragraph (5)(B), the applicable percentage is equal to 25
percent; and
``(II) if the State is any other State, the applicable
percentage is 50 percent.
``(ii) Subsequent fiscal years in which the percentage of
uninsured decreases.--In the case of any fiscal year after
the first fiscal year described in subparagraph (C) with
respect to a State, if the Secretary determines on the basis
of the most recent American Community Survey of the Bureau of
the Census, that the percentage of uncovered individuals
residing in the State is less than the percentage of such
individuals determined for the State for the preceding fiscal
year--
``(I) if the State is a low DSH State described in
paragraph (5)(B), the applicable percentage is equal to the
product of the percentage reduction in uncovered individuals
for the fiscal year from the preceding fiscal year and 25
percent; and
``(II) if the State is any other State, the applicable
percentage is equal to the product of the percentage
reduction in uncovered individuals for the fiscal year from
the preceding fiscal year and 50 percent.
``(C) Fiscal year described.--For purposes of subparagraph
(A), the fiscal year described in this subparagraph with
respect to a State is the first fiscal year that occurs after
fiscal year 2012 for which the Secretary determines, on the
basis of the most recent American Community Survey of the
Bureau of the Census, that the percentage of uncovered
individuals residing in the State is at least 45 percent less
than the percentage of such individuals determined for the
State for fiscal year 2009.
``(D) Exclusion of portions diverted for coverage
expansions.--For purposes of applying the applicable
percentage reduction under subparagraph (A) to the DSH
allotment for a State for a fiscal year, the DSH allotment
for a State that would be determined under this subsection
for the State for the fiscal year without the application of
this paragraph (and prior to any such reduction) shall not
include any portion of the allotment for which the Secretary
has approved the State's diversion to the costs of providing
medical assistance or other health benefits coverage under a
waiver that is in effect on July 2009.
``(E) Minimum allotment.--In no event shall the DSH
allotment determined for a State in accordance with this
paragraph for fiscal year 2013 or any succeeding fiscal year
be less than the amount equal to 35 percent of the DSH
allotment determined for the State for fiscal year 2012 under
this subsection (and after the application of this paragraph,
if applicable), increased by the percentage change in the
consumer price index for all urban consumers (all items, U.S.
city average) for each previous fiscal year occurring before
the fiscal year.
``(F) Uncovered individuals.--In this paragraph, the term
`uncovered individuals' means individuals with no health
insurance coverage at any time during a year (as determined
by the Secretary based on the most recent data available).''.
(b) Effective Date.--The amendments made by subsection (a)
take effect on October 1, 2011.
Subtitle H--Improved Coordination for Dual Eligible Beneficiaries
SEC. 2601. 5-YEAR PERIOD FOR DEMONSTRATION PROJECTS.
(a) In General.--Section 1915(h) of the Social Security Act
(42 U.S.C. 1396n(h)) is amended--
(1) by inserting ``(1)'' after ``(h)'';
(2) by inserting ``, or a waiver described in paragraph
(2)'' after ``(e)''; and
(3) by adding at the end the following new paragraph:
``(2)(A) Notwithstanding subsections (c)(3) and (d) (3),
any waiver under subsection (b), (c), or (d), or a waiver
under section 1115, that provides medical assistance for dual
eligible individuals (including any such waivers under which
non dual eligible individuals may be enrolled in addition to
dual eligible individuals) may be conducted for a period of 5
years and, upon the request of the State, may be extended for
additional 5-year periods unless the Secretary determines
that for the previous waiver period the conditions for the
waiver have not been met or it would no longer be cost-
effective and efficient, or consistent with the purposes of
this title, to extend the waiver.
``(B) In this paragraph, the term `dual eligible
individual' means an individual who is entitled to, or
enrolled for, benefits under part A of title XVIII, or
enrolled for benefits under part B of title XVIII, and is
eligible for medical assistance under the State plan under
this title or under a waiver of such plan.''.
(b) Conforming Amendments.--
[[Page H1972]]
(1) Section 1915 of such Act (42 U.S.C. 1396n) is amended--
(A) in subsection (b), by adding at the end the following
new sentence: ``Subsection (h)(2) shall apply to a waiver
under this subsection.'';
(B) in subsection (c)(3), in the second sentence, by
inserting ``(other than a waiver described in subsection
(h)(2))'' after ``A waiver under this subsection'';
(C) in subsection (d)(3), in the second sentence, by
inserting ``(other than a waiver described in subsection
(h)(2))'' after ``A waiver under this subsection''.
(2) Section 1115 of such Act (42 U.S.C. 1315) is amended--
(A) in subsection (e)(2), by inserting ``(5 years, in the
case of a waiver described in section 1915(h)(2))'' after ``3
years''; and
(B) in subsection (f)(6), by inserting ``(5 years, in the
case of a waiver described in section 1915(h)(2))'' after ``3
years''.
SEC. 2602. PROVIDING FEDERAL COVERAGE AND PAYMENT
COORDINATION FOR DUAL ELIGIBLE BENEFICIARIES.
(a) Establishment of Federal Coordinated Health Care
Office.--
(1) In general.--Not later than March 1, 2010, the
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall establish a Federal
Coordinated Health Care Office.
(2) Establishment and reporting to cms administrator.--The
Federal Coordinated Health Care Office--
(A) shall be established within the Centers for Medicare &
Medicaid Services; and
(B) have as the Office a Director who shall be appointed
by, and be in direct line of authority to, the Administrator
of the Centers for Medicare & Medicaid Services.
(b) Purpose.--The purpose of the Federal Coordinated Health
Care Office is to bring together officers and employees of
the Medicare and Medicaid programs at the Centers for
Medicare & Medicaid Services in order to--
(1) more effectively integrate benefits under the Medicare
program under title XVIII of the Social Security Act and the
Medicaid program under title XIX of such Act; and
(2) improve the coordination between the Federal Government
and States for individuals eligible for benefits under both
such programs in order to ensure that such individuals get
full access to the items and services to which they are
entitled under titles XVIII and XIX of the Social Security
Act.
(c) Goals.--The goals of the Federal Coordinated Health
Care Office are as follows:
(1) Providing dual eligible individuals full access to the
benefits to which such individuals are entitled under the
Medicare and Medicaid programs.
(2) Simplifying the processes for dual eligible individuals
to access the items and services they are entitled to under
the Medicare and Medicaid programs.
(3) Improving the quality of health care and long-term
services for dual eligible individuals.
(4) Increasing dual eligible individuals' understanding of
and satisfaction with coverage under the Medicare and
Medicaid programs.
(5) Eliminating regulatory conflicts between rules under
the Medicare and Medicaid programs.
(6) Improving care continuity and ensuring safe and
effective care transitions for dual eligible individuals.
(7) Eliminating cost-shifting between the Medicare and
Medicaid program and among related health care providers.
(8) Improving the quality of performance of providers of
services and suppliers under the Medicare and Medicaid
programs.
(d) Specific Responsibilities.--The specific
responsibilities of the Federal Coordinated Health Care
Office are as follows:
(1) Providing States, specialized MA plans for special
needs individuals (as defined in section 1859(b)(6) of the
Social Security Act (42 U.S.C. 1395w-28(b)(6))), physicians
and other relevant entities or individuals with the education
and tools necessary for developing programs that align
benefits under the Medicare and Medicaid programs for dual
eligible individuals.
(2) Supporting State efforts to coordinate and align acute
care and long-term care services for dual eligible
individuals with other items and services furnished under the
Medicare program.
(3) Providing support for coordination of contracting and
oversight by States and the Centers for Medicare & Medicaid
Services with respect to the integration of the Medicare and
Medicaid programs in a manner that is supportive of the goals
described in paragraph (3).
(4) To consult and coordinate with the Medicare Payment
Advisory Commission established under section 1805 of the
Social Security Act (42 U.S.C. 1395b-6) and the Medicaid and
CHIP Payment and Access Commission established under section
1900 of such Act (42 U.S.C. 1396) with respect to policies
relating to the enrollment in, and provision of, benefits to
dual eligible individuals under the Medicare program under
title XVIII of the Social Security Act and the Medicaid
program under title XIX of such Act.
(5) To study the provision of drug coverage for new full-
benefit dual eligible individuals (as defined in section
1935(c)(6) of the Social Security Act (42 U.S.C. 1396u-
5(c)(6)), as well as to monitor and report annual total
expenditures, health outcomes, and access to benefits for all
dual eligible individuals.
(e) Report.--The Secretary shall, as part of the budget
transmitted under section 1105(a) of title 31, United States
Code, submit to Congress an annual report containing
recommendations for legislation that would improve care
coordination and benefits for dual eligible individuals.
(f) Dual Eligible Defined.--In this section, the term
``dual eligible individual'' means an individual who is
entitled to, or enrolled for, benefits under part A of title
XVIII of the Social Security Act, or enrolled for benefits
under part B of title XVIII of such Act, and is eligible for
medical assistance under a State plan under title XIX of such
Act or under a waiver of such plan.
Subtitle I--Improving the Quality of Medicaid for Patients and
Providers
SEC. 2701. ADULT HEALTH QUALITY MEASURES.
Title XI of the Social Security Act (42 U.S.C. 1301 et
seq.), as amended by section 401 of the Children's Health
Insurance Program Reauthorization Act of 2009 (Public Law
111-3), is amended by inserting after section 1139A the
following new section:
``SEC. 1139B. ADULT HEALTH QUALITY MEASURES.
``(a) Development of Core Set of Health Care Quality
Measures for Adults Eligible for Benefits Under Medicaid.--
The Secretary shall identify and publish a recommended core
set of adult health quality measures for Medicaid eligible
adults in the same manner as the Secretary identifies and
publishes a core set of child health quality measures under
section 1139A, including with respect to identifying and
publishing existing adult health quality measures that are in
use under public and privately sponsored health care coverage
arrangements, or that are part of reporting systems that
measure both the presence and duration of health insurance
coverage over time, that may be applicable to Medicaid
eligible adults.
``(b) Deadlines.--
``(1) Recommended measures.--Not later than January 1,
2011, the Secretary shall identify and publish for comment a
recommended core set of adult health quality measures for
Medicaid eligible adults.
``(2) Dissemination.--Not later than January 1, 2012, the
Secretary shall publish an initial core set of adult health
quality measures that are applicable to Medicaid eligible
adults.
``(3) Standardized reporting.--Not later than January 1,
2013, the Secretary, in consultation with States, shall
develop a standardized format for reporting information based
on the initial core set of adult health quality measures and
create procedures to encourage States to use such measures to
voluntarily report information regarding the quality of
health care for Medicaid eligible adults.
``(4) Reports to congress.--Not later than January 1, 2014,
and every 3 years thereafter, the Secretary shall include in
the report to Congress required under section 1139A(a)(6)
information similar to the information required under that
section with respect to the measures established under this
section.
``(5) Establishment of medicaid quality measurement
program.--
``(A) In general.--Not later than 12 months after the
release of the recommended core set of adult health quality
measures under paragraph (1)), the Secretary shall establish
a Medicaid Quality Measurement Program in the same manner as
the Secretary establishes the pediatric quality measures
program under section 1139A(b). The aggregate amount awarded
by the Secretary for grants and contracts for the
development, testing, and validation of emerging and
innovative evidence-based measures under such program shall
equal the aggregate amount awarded by the Secretary for
grants under section 1139A(b)(4)(A)
``(B) Revising, strengthening, and improving initial core
measures.--Beginning not later than 24 months after the
establishment of the Medicaid Quality Measurement Program,
and annually thereafter, the Secretary shall publish
recommended changes to the initial core set of adult health
quality measures that shall reflect the results of the
testing, validation, and consensus process for the
development of adult health quality measures.
``(c) Construction.--Nothing in this section shall be
construed as supporting the restriction of coverage, under
title XIX or XXI or otherwise, to only those services that
are evidence-based, or in anyway limiting available services.
``(d) Annual State Reports Regarding State-Specific Quality
of Care Measures Applied Under Medicaid.--
``(1) Annual state reports.--Each State with a State plan
or waiver approved under title XIX shall annually report
(separately or as part of the annual report required under
section 1139A(c)), to the Secretary on the--
``(A) State-specific adult health quality measures applied
by the State under the such plan, including measures
described in subsection (a)(5); and
``(B) State-specific information on the quality of health
care furnished to Medicaid eligible adults under such plan,
including information collected through external quality
reviews of managed care organizations under section 1932 and
benchmark plans under section 1937.
``(2) Publication.--Not later than September 30, 2014, and
annually thereafter, the Secretary shall collect, analyze,
and make publicly available the information reported by
States under paragraph (1).
``(e) Appropriation.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated for each of
fiscal years 2010 through 2014, $60,000,000 for the purpose
of carrying out this section. Funds appropriated under this
subsection shall remain available until expended.''.
SEC. 2702. PAYMENT ADJUSTMENT FOR HEALTH CARE-ACQUIRED
CONDITIONS.
(a) In General.--The Secretary of Health and Human Services
(in this subsection referred to as the ``Secretary'') shall
identify current State practices that prohibit payment for
health care-acquired conditions and shall incorporate the
practices identified, or elements of such practices, which
the Secretary determines appropriate for application to the
Medicaid program in regulations. Such regulations shall be
effective as of July 1, 2011, and shall prohibit payments to
States under section 1903 of the Social
[[Page H1973]]
Security Act for any amounts expended for providing medical
assistance for health care-acquired conditions specified in
the regulations. The regulations shall ensure that the
prohibition on payment for health care-acquired conditions
shall not result in a loss of access to care or services for
Medicaid beneficiaries.
(b) Health Care-Acquired Condition.--In this section. the
term ``health care-acquired condition'' means a medical
condition for which an individual was diagnosed that could be
identified by a secondary diagnostic code described in
section 1886(d)(4)(D)(iv) of the Social Security Act (42
U.S.C. 1395ww(d)(4)(D)(iv)).
(c) Medicare Provisions.--In carrying out this section, the
Secretary shall apply to State plans (or waivers) under title
XIX of the Social Security Act the regulations promulgated
pursuant to section 1886(d)(4)(D) of such Act (42 U.S.C.
1395ww(d)(4)(D)) relating to the prohibition of payments
based on the presence of a secondary diagnosis code specified
by the Secretary in such regulations, as appropriate for the
Medicaid program. The Secretary may exclude certain
conditions identified under title XVIII of the Social
Security Act for non-payment under title XIX of such Act when
the Secretary finds the inclusion of such conditions to be
inapplicable to beneficiaries under title XIX.
SEC. 2703. STATE OPTION TO PROVIDE HEALTH HOMES FOR ENROLLEES
WITH CHRONIC CONDITIONS.
(a) State Plan Amendment.--Title XIX of the Social Security
Act (42 U.S.C. 1396a et seq.), as amended by sections 2201
and 2305, is amended by adding at the end the following new
section:
``Sec. 1945. State Option To Provide Coordinated Care
Through a Health Home for Individuals With Chronic
Conditions.--
``(a) In General.--Notwithstanding section 1902(a)(1)
(relating to statewideness), section 1902(a)(10)(B) (relating
to comparability), and any other provision of this title for
which the Secretary determines it is necessary to waive in
order to implement this section, beginning January 1, 2011, a
State, at its option as a State plan amendment, may provide
for medical assistance under this title to eligible
individuals with chronic conditions who select a designated
provider (as described under subsection (h)(5)), a team of
health care professionals (as described under subsection
(h)(6)) operating with such a provider, or a health team (as
described under subsection (h)(7)) as the individual's health
home for purposes of providing the individual with health
home services.
``(b) Health Home Qualification Standards.--The Secretary
shall establish standards for qualification as a designated
provider for the purpose of being eligible to be a health
home for purposes of this section.
``(c) Payments.--
``(1) In general.--A State shall provide a designated
provider, a team of health care professionals operating with
such a provider, or a health team with payments for the
provision of health home services to each eligible individual
with chronic conditions that selects such provider, team of
health care professionals, or health team as the individual's
health home. Payments made to a designated provider, a team
of health care professionals operating with such a provider,
or a health team for such services shall be treated as
medical assistance for purposes of section 1903(a), except
that, during the first 8 fiscal year quarters that the State
plan amendment is in effect, the Federal medical assistance
percentage applicable to such payments shall be equal to 90
percent.
``(2) Methodology.--
``(A) In general.--The State shall specify in the State
plan amendment the methodology the State will use for
determining payment for the provision of health home
services. Such methodology for determining payment--
``(i) may be tiered to reflect, with respect to each
eligible individual with chronic conditions provided such
services by a designated provider, a team of health care
professionals operating with such a provider, or a health
team, as well as the severity or number of each such
individual's chronic conditions or the specific capabilities
of the provider, team of health care professionals, or health
team; and
``(ii) shall be established consistent with section
1902(a)(30)(A).
``(B) Alternate models of payment.--The methodology for
determining payment for provision of health home services
under this section shall not be limited to a per-member per-
month basis and may provide (as proposed by the State and
subject to approval by the Secretary) for alternate models of
payment.
``(3) Planning grants.--
``(A) In general.--Beginning January 1, 2011, the Secretary
may award planning grants to States for purposes of
developing a State plan amendment under this section. A
planning grant awarded to a State under this paragraph shall
remain available until expended.
``(B) State contribution.--A State awarded a planning grant
shall contribute an amount equal to the State percentage
determined under section 1905(b) (without regard to section
5001 of Public Law 111-5) for each fiscal year for which the
grant is awarded.
``(C) Limitation.--The total amount of payments made to
States under this paragraph shall not exceed $25,000,000.
``(d) Hospital Referrals.--A State shall include in the
State plan amendment a requirement for hospitals that are
participating providers under the State plan or a waiver of
such plan to establish procedures for referring any eligible
individuals with chronic conditions who seek or need
treatment in a hospital emergency department to designated
providers.
``(e) Coordination.--A State shall consult and coordinate,
as appropriate, with the Substance Abuse and Mental Health
Services Administration in addressing issues regarding the
prevention and treatment of mental illness and substance
abuse among eligible individuals with chronic conditions.
``(f) Monitoring.--A State shall include in the State plan
amendment--
``(1) a methodology for tracking avoidable hospital
readmissions and calculating savings that result from
improved chronic care coordination and management under this
section; and
``(2) a proposal for use of health information technology
in providing health home services under this section and
improving service delivery and coordination across the care
continuum (including the use of wireless patient technology
to improve coordination and management of care and patient
adherence to recommendations made by their provider).
``(g) Report on Quality Measures.--As a condition for
receiving payment for health home services provided to an
eligible individual with chronic conditions, a designated
provider shall report to the State, in accordance with such
requirements as the Secretary shall specify, on all
applicable measures for determining the quality of such
services. When appropriate and feasible, a designated
provider shall use health information technology in providing
the State with such information.
``(h) Definitions.--In this section:
``(1) Eligible individual with chronic conditions.--
``(A) In general.--Subject to subparagraph (B), the term
`eligible individual with chronic conditions' means an
individual who--
``(i) is eligible for medical assistance under the State
plan or under a waiver of such plan; and
``(ii) has at least--
``(I) 2 chronic conditions;
``(II) 1 chronic condition and is at risk of having a
second chronic condition; or
``(III) 1 serious and persistent mental health condition.
``(B) Rule of construction.--Nothing in this paragraph
shall prevent the Secretary from establishing higher levels
as to the number or severity of chronic or mental health
conditions for purposes of determining eligibility for
receipt of health home services under this section.
``(2) Chronic condition.--The term `chronic condition' has
the meaning given that term by the Secretary and shall
include, but is not limited to, the following:
``(A) A mental health condition.
``(B) Substance use disorder.
``(C) Asthma.
``(D) Diabetes.
``(E) Heart disease.
``(F) Being overweight, as evidenced by having a Body Mass
Index (BMI) over 25.
``(3) Health home.--The term `health home' means a
designated provider (including a provider that operates in
coordination with a team of health care professionals) or a
health team selected by an eligible individual with chronic
conditions to provide health home services.
``(4) Health home services.--
``(A) In general.--The term `health home services' means
comprehensive and timely high-quality services described in
subparagraph (B) that are provided by a designated provider,
a team of health care professionals operating with such a
provider, or a health team.
``(B) Services described.--The services described in this
subparagraph are--
``(i) comprehensive care management;
``(ii) care coordination and health promotion;
``(iii) comprehensive transitional care, including
appropriate follow-up, from inpatient to other settings;
``(iv) patient and family support (including authorized
representatives);
``(v) referral to community and social support services, if
relevant; and
``(vi) use of health information technology to link
services, as feasible and appropriate.
``(5) Designated provider.--The term `designated provider'
means a physician, clinical practice or clinical group
practice, rural clinic, community health center, community
mental health center, home health agency, or any other entity
or provider (including pediatricians, gynecologists, and
obstetricians) that is determined by the State and approved
by the Secretary to be qualified to be a health home for
eligible individuals with chronic conditions on the basis of
documentation evidencing that the physician, practice, or
clinic--
``(A) has the systems and infrastructure in place to
provide health home services; and
``(B) satisfies the qualification standards established by
the Secretary under subsection (b).
``(6) Team of health care professionals.--The term `team of
health care professionals' means a team of health
professionals (as described in the State plan amendment) that
may--
``(A) include physicians and other professionals, such as a
nurse care coordinator, nutritionist, social worker,
behavioral health professional, or any professionals deemed
appropriate by the State; and
``(B) be free standing, virtual, or based at a hospital,
community health center, community mental health center,
rural clinic, clinical practice or clinical group practice,
academic health center, or any entity deemed appropriate by
the State and approved by the Secretary.
``(7) Health team.--The term `health team' has the meaning
given such term for purposes of section 3502 of the Patient
Protection and Affordable Care Act.''.
(b) Evaluation.--
(1) Independent evaluation.--
(A) In general.--The Secretary shall enter into a contract
with an independent entity or organization to conduct an
evaluation and assessment of the States that have elected the
option to provide coordinated care through a health home for
Medicaid beneficiaries with chronic conditions under section
1945 of the Social Security Act (as added by subsection (a))
for the purpose of determining the effect of such
[[Page H1974]]
option on reducing hospital admissions, emergency room
visits, and admissions to skilled nursing facilities.
(B) Evaluation report.--Not later than January 1, 2017, the
Secretary shall report to Congress on the evaluation and
assessment conducted under subparagraph (A).
(2) Survey and interim report.--
(A) In general.--Not later than January 1, 2014, the
Secretary of Health and Human Services shall survey States
that have elected the option under section 1945 of the Social
Security Act (as added by subsection (a)) and report to
Congress on the nature, extent, and use of such option,
particularly as it pertains to--
(i) hospital admission rates;
(ii) chronic disease management;
(iii) coordination of care for individuals with chronic
conditions;
(iv) assessment of program implementation;
(v) processes and lessons learned (as described in
subparagraph (B));
(vi) assessment of quality improvements and clinical
outcomes under such option; and
(vii) estimates of cost savings.
(B) Implementation reporting.--A State that has elected
the option under section 1945 of the Social Security Act (as
added by subsection (a)) shall report to the Secretary, as
necessary, on processes that have been developed and lessons
learned regarding provision of coordinated care through a
health home for Medicaid beneficiaries with chronic
conditions under such option.
SEC. 2704. DEMONSTRATION PROJECT TO EVALUATE INTEGRATED CARE
AROUND A HOSPITALIZATION.
(a) Authority To Conduct Project.--
(1) In general.--The Secretary of Health and Human Services
(in this section referred to as the ``Secretary'') shall
establish a demonstration project under title XIX of the
Social Security Act to evaluate the use of bundled payments
for the provision of integrated care for a Medicaid
beneficiary--
(A) with respect to an episode of care that includes a
hospitalization; and
(B) for concurrent physicians services provided during a
hospitalization.
(2) Duration.--The demonstration project shall begin on
January 1, 2012, and shall end on December 31, 2016.
(b) Requirements.--The demonstration project shall be
conducted in accordance with the following:
(1) The demonstration project shall be conducted in up to 8
States, determined by the Secretary based on consideration of
the potential to lower costs under the Medicaid program while
improving care for Medicaid beneficiaries. A State selected
to participate in the demonstration project may target the
demonstration project to particular categories of
beneficiaries, beneficiaries with particular diagnoses, or
particular geographic regions of the State, but the Secretary
shall insure that, as a whole, the demonstration project is,
to the greatest extent possible, representative of the
demographic and geographic composition of Medicaid
beneficiaries nationally.
(2) The demonstration project shall focus on conditions
where there is evidence of an opportunity for providers of
services and suppliers to improve the quality of care
furnished to Medicaid beneficiaries while reducing total
expenditures under the State Medicaid programs selected to
participate, as determined by the Secretary.
(3) A State selected to participate in the demonstration
project shall specify the 1 or more episodes of care the
State proposes to address in the project, the services to be
included in the bundled payments, and the rationale for the
selection of such episodes of care and services. The
Secretary may modify the episodes of care as well as the
services to be included in the bundled payments prior to or
after approving the project. The Secretary may also vary such
factors among the different States participating in the
demonstration project.
(4) The Secretary shall ensure that payments made under the
demonstration project are adjusted for severity of illness
and other characteristics of Medicaid beneficiaries within a
category or having a diagnosis targeted as part of the
demonstration project. States shall ensure that Medicaid
beneficiaries are not liable for any additional cost sharing
than if their care had not been subject to payment under the
demonstration project.
(5) Hospitals participating in the demonstration project
shall have or establish robust discharge planning programs to
ensure that Medicaid beneficiaries requiring post-acute care
are appropriately placed in, or have ready access to, post-
acute care settings.
(6) The Secretary and each State selected to participate in
the demonstration project shall ensure that the demonstration
project does not result in the Medicaid beneficiaries whose
care is subject to payment under the demonstration project
being provided with less items and services for which medical
assistance is provided under the State Medicaid program than
the items and services for which medical assistance would
have been provided to such beneficiaries under the State
Medicaid program in the absence of the demonstration project.
(c) Waiver of Provisions.--Notwithstanding section 1115(a)
of the Social Security Act (42 U.S.C. 1315(a)), the Secretary
may waive such provisions of titles XIX, XVIII, and XI of
that Act as may be necessary to accomplish the goals of the
demonstration, ensure beneficiary access to acute and post-
acute care, and maintain quality of care.
(d) Evaluation and Report.--
(1) Data.--Each State selected to participate in the
demonstration project under this section shall provide to the
Secretary, in such form and manner as the Secretary shall
specify, relevant data necessary to monitor outcomes, costs,
and quality, and evaluate the rationales for selection of the
episodes of care and services specified by States under
subsection (b)(3).
(2) Report.--Not later than 1 year after the conclusion of
the demonstration project, the Secretary shall submit a
report to Congress on the results of the demonstration
project.
SEC. 2705. MEDICAID GLOBAL PAYMENT SYSTEM DEMONSTRATION
PROJECT.
(a) In General.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall, in
coordination with the Center for Medicare and Medicaid
Innovation (as established under section 1115A of the Social
Security Act, as added by section 3021 of this Act),
establish the Medicaid Global Payment System Demonstration
Project under which a participating State shall adjust the
payments made to an eligible safety net hospital system or
network from a fee-for-service payment structure to a global
capitated payment model.
(b) Duration and Scope.--The demonstration project
conducted under this section shall operate during a period of
fiscal years 2010 through 2012. The Secretary shall select
not more than 5 States to participate in the demonstration
project.
(c) Eligible Safety Net Hospital System or Network.--For
purposes of this section, the term ``eligible safety net
hospital system or network'' means a large, safety net
hospital system or network (as defined by the Secretary) that
operates within a State selected by the Secretary under
subsection (b).
(d) Evaluation.--
(1) Testing.--The Innovation Center shall test and evaluate
the demonstration project conducted under this section to
examine any changes in health care quality outcomes and
spending by the eligible safety net hospital systems or
networks.
(2) Budget neutrality.--During the testing period under
paragraph (1), any budget neutrality requirements under
section 1115A(b)(3) of the Social Security Act (as so added)
shall not be applicable.
(3) Modification.--During the testing period under
paragraph (1), the Secretary may, in the Secretary's
discretion, modify or terminate the demonstration project
conducted under this section.
(e) Report.--Not later than 12 months after the date of
completion of the demonstration project under this section,
the Secretary shall submit to Congress a report containing
the results of the evaluation and testing conducted under
subsection (d), together with recommendations for such
legislation and administrative action as the Secretary
determines appropriate.
(f) Authorization of Appropriations.--There are authorized
to be appropriated such sums as are necessary to carry out
this section.
SEC. 2706. PEDIATRIC ACCOUNTABLE CARE ORGANIZATION
DEMONSTRATION PROJECT.
(a) Authority To Conduct Demonstration.--
(1) In general.--The Secretary of Health and Human Services
(referred to in this section as the ``Secretary'') shall
establish the Pediatric Accountable Care Organization
Demonstration Project to authorize a participating State to
allow pediatric medical providers that meet specified
requirements to be recognized as an accountable care
organization for purposes of receiving incentive payments (as
described under subsection (d)), in the same manner as an
accountable care organization is recognized and provided with
incentive payments under section 1899 of the Social Security
Act (as added by section 3022).
(2) Duration.--The demonstration project shall begin on
January 1, 2012, and shall end on December 31, 2016.
(b) Application.--A State that desires to participate in
the demonstration project under this section shall submit to
the Secretary an application at such time, in such manner,
and containing such information as the Secretary may require.
(c) Requirements.--
(1) Performance guidelines.--The Secretary, in consultation
with the States and pediatric providers, shall establish
guidelines to ensure that the quality of care delivered to
individuals by a provider recognized as an accountable care
organization under this section is not less than the quality
of care that would have otherwise been provided to such
individuals.
(2) Savings requirement.--A participating State, in
consultation with the Secretary, shall establish an annual
minimal level of savings in expenditures for items and
services covered under the Medicaid program under title XIX
of the Social Security Act and the CHIP program under title
XXI of such Act that must be reached by an accountable care
organization in order for such organization to receive an
incentive payment under subsection (d).
(3) Minimum participation period.--A provider desiring to
be recognized as an accountable care organization under the
demonstration project shall enter into an agreement with the
State to participate in the project for not less than a 3-
year period.
(d) Incentive Payment.--An accountable care organization
that meets the performance guidelines established by the
Secretary under subsection (c)(1) and achieves savings
greater than the annual minimal savings level established by
the State under subsection (c)(2) shall receive an incentive
payment for such year equal to a portion (as determined
appropriate by the Secretary) of the amount of such excess
savings. The Secretary may establish an annual cap on
incentive payments for an accountable care organization.
(e) Authorization of Appropriations.--There are authorized
to be appropriated such sums as are necessary to carry out
this section.
[[Page H1975]]
SEC. 2707. MEDICAID EMERGENCY PSYCHIATRIC DEMONSTRATION
PROJECT.
(a) Authority To Conduct Demonstration Project.--The
Secretary of Health and Human Services (in this section
referred to as the ``Secretary'') shall establish a
demonstration project under which an eligible State (as
described in subsection (c)) shall provide payment under the
State Medicaid plan under title XIX of the Social Security
Act to an institution for mental diseases that is not
publicly owned or operated and that is subject to the
requirements of section 1867 of the Social Security Act (42
U.S.C. 1395dd) for the provision of medical assistance
available under such plan to individuals who--
(1) have attained age 21, but have not attained age 65;
(2) are eligible for medical assistance under such plan;
and
(3) require such medical assistance to stabilize an
emergency medical condition.
(b) Stabilization Review.--A State shall specify in its
application described in subsection (c)(1) establish a
mechanism for how it will ensure that institutions
participating in the demonstration will determine whether or
not such individuals have been stabilized (as defined in
subsection (h)(5)). This mechanism shall commence before the
third day of the inpatient stay. States participating in the
demonstration project may manage the provision of services
for the stabilization of medical emergency conditions through
utilization review, authorization, or management practices,
or the application of medical necessity and appropriateness
criteria applicable to behavioral health.
(c) Eligible State Defined.--
(1) In general.--An eligible State is a State that has made
an application and has been selected pursuant to paragraphs
(2) and (3).
(2) Application.--A State seeking to participate in the
demonstration project under this section shall submit to the
Secretary, at such time and in such format as the Secretary
requires, an application that includes such information,
provisions, and assurances, as the Secretary may require.
(3) Selection.--A State shall be determined eligible for
the demonstration by the Secretary on a competitive basis
among States with applications meeting the requirements of
paragraph (1). In selecting State applications for the
demonstration project, the Secretary shall seek to achieve an
appropriate national balance in the geographic distribution
of such projects.
(d) Length of Demonstration Project.--The demonstration
project established under this section shall be conducted for
a period of 3 consecutive years.
(e) Limitations on Federal Funding.--
(1) Appropriation.--
(A) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to carry out
this section, $75,000,000 for fiscal year 2011.
(B) Budget authority.--Subparagraph (A) constitutes budget
authority in advance of appropriations Act and represents the
obligation of the Federal Government to provide for the
payment of the amounts appropriated under that subparagraph.
(2) 5-year availability.--Funds appropriated under
paragraph (1) shall remain available for obligation through
December 31, 2015.
(3) Limitation on payments.--In no case may--
(A) the aggregate amount of payments made by the Secretary
to eligible States under this section exceed $75,000,000; or
(B) payments be provided by the Secretary under this
section after December 31, 2015.
(4) Funds allocated to states.--Funds shall be allocated to
eligible States on the basis of criteria, including a State's
application and the availability of funds, as determined by
the Secretary.
(5) Payments to states.--The Secretary shall pay to each
eligible State, from its allocation under paragraph (4), an
amount each quarter equal to the Federal medical assistance
percentage of expenditures in the quarter for medical
assistance described in subsection (a). As a condition of
receiving payment, a State shall collect and report
information, as determined necessary by the Secretary, for
the purposes of providing Federal oversight and conducting an
evaluation under subsection (f)(1).
(f) Evaluation and Report to Congress.--
(1) Evaluation.--The Secretary shall conduct an evaluation
of the demonstration project in order to determine the impact
on the functioning of the health and mental health service
system and on individuals enrolled in the Medicaid program
and shall include the following:
(A) An assessment of access to inpatient mental health
services under the Medicaid program; average lengths of
inpatient stays; and emergency room visits.
(B) An assessment of discharge planning by participating
hospitals.
(C) An assessment of the impact of the demonstration
project on the costs of the full range of mental health
services (including inpatient, emergency and ambulatory
care).
(D) An analysis of the percentage of consumers with
Medicaid coverage who are admitted to inpatient facilities as
a result of the demonstration project as compared to those
admitted to these same facilities through other means.
(E) A recommendation regarding whether the demonstration
project should be continued after December 31, 2013, and
expanded on a national basis.
(2) Report.--Not later than December 31, 2013, the
Secretary shall submit to Congress and make available to the
public a report on the findings of the evaluation under
paragraph (1).
(g) Waiver Authority.--
(1) In general.--The Secretary shall waive the limitation
of subdivision (B) following paragraph (28) of section
1905(a) of the Social Security Act (42 U.S.C. 1396d(a))
(relating to limitations on payments for care or services for
individuals under 65 years of age who are patients in an
institution for mental diseases) for purposes of carrying out
the demonstration project under this section.
(2) Limited other waiver authority.--The Secretary may
waive other requirements of titles XI and XIX of the Social
Security Act (including the requirements of sections
1902(a)(1) (relating to statewideness) and 1902(1)(10)(B)
(relating to comparability)) only to extent necessary to
carry out the demonstration project under this section.
(h) Definitions.--In this section:
(1) Emergency medical condition.--The term ``emergency
medical condition'' means, with respect to an individual, an
individual who expresses suicidal or homicidal thoughts or
gestures, if determined dangerous to self or others.
(2) Federal medical assistance percentage.--The term
``Federal medical assistance percentage'' has the meaning
given that term with respect to a State under section 1905(b)
of the Social Security Act (42 U.S.C. 1396d(b)).
(3) Institution for mental diseases.--The term
``institution for mental diseases'' has the meaning given to
that term in section 1905(i) of the Social Security Act (42
U.S.C. 1396d(i)).
(4) Medical assistance.--The term ``medical assistance''
has the meaning given that term in section 1905(a) of the
Social Security Act (42 U.S.C. 1396d(a)).
(5) Stabilized.--The term ``stabilized'' means, with
respect to an individual, that the emergency medical
condition no longer exists with respect to the individual and
the individual is no longer dangerous to self or others.
(6) State.--The term ``State'' has the meaning given that
term for purposes of title XIX of the Social Security Act (42
U.S.C. 1396 et seq.).
Subtitle J--Improvements to the Medicaid and CHIP Payment and Access
Commission (MACPAC)
SEC. 2801. MACPAC ASSESSMENT OF POLICIES AFFECTING ALL
MEDICAID BENEFICIARIES.
(a) In General.--Section 1900 of the Social Security Act
(42 U.S.C. 1396) is amended--
(1) in subsection (b)--
(A) in paragraph (1)--
(i) in the paragraph heading, by inserting ``for all
states'' before ``and annual''; and
(ii) in subparagraph (A), by striking ``children's'';
(iii) in subparagraph (B), by inserting ``, the Secretary,
and States'' after ``Congress'';
(iv) in subparagraph (C), by striking ``March 1'' and
inserting ``March 15''; and
(v) in subparagraph (D), by striking ``June 1'' and
inserting ``June 15'';
(B) in paragraph (2)--
(i) in subparagraph (A)--
(I) in clause (i)--
(aa) by inserting ``the efficient provision of'' after
``expenditures for''; and
(bb) by striking ``hospital, skilled nursing facility,
physician, Federally-qualified health center, rural health
center, and other fees'' and inserting ``payments to medical,
dental, and health professionals, hospitals, residential and
long-term care providers, providers of home and community
based services, Federally-qualified health centers and rural
health clinics, managed care entities, and providers of other
covered items and services''; and
(II) in clause (iii), by inserting ``(including how such
factors and methodologies enable such beneficiaries to obtain
the services for which they are eligible, affect provider
supply, and affect providers that serve a disproportionate
share of low-income and other vulnerable populations)'' after
``beneficiaries'';
(ii) by redesignating subparagraphs (B) and (C) as
subparagraphs (F) and (H), respectively;
(iii) by inserting after subparagraph (A), the following:
``(B) Eligibility policies.--Medicaid and CHIP eligibility
policies, including a determination of the degree to which
Federal and State policies provide health care coverage to
needy populations.
``(C) Enrollment and retention processes.--Medicaid and
CHIP enrollment and retention processes, including a
determination of the degree to which Federal and State
policies encourage the enrollment of individuals who are
eligible for such programs and screen out individuals who are
ineligible, while minimizing the share of program expenses
devoted to such processes.
``(D) Coverage policies.--Medicaid and CHIP benefit and
coverage policies, including a determination of the degree to
which Federal and State policies provide access to the
services enrollees require to improve and maintain their
health and functional status.
``(E) Quality of care.--Medicaid and CHIP policies as they
relate to the quality of care provided under those programs,
including a determination of the degree to which Federal and
State policies achieve their stated goals and interact with
similar goals established by other purchasers of health care
services.'';
(iv) by inserting after subparagraph (F) (as redesignated
by clause (ii) of this subparagraph), the following:
``(G) Interactions with medicare and medicaid.--Consistent
with paragraph (11), the interaction of policies under
Medicaid and the Medicare program under title XVIII,
including with respect to how such interactions affect access
to services, payments, and dual eligible individuals.'' and
(v) in subparagraph (H) (as so redesignated), by inserting
``and preventive, acute, and long-term services and
supports'' after ``barriers'';
(C) by redesignating paragraphs (3) through (9) as
paragraphs (4) through (10), respectively;
[[Page H1976]]
(D) by inserting after paragraph (2), the following new
paragraph:
``(3) Recommendations and reports of state-specific data.--
MACPAC shall--
``(A) review national and State-specific Medicaid and CHIP
data; and
``(B) submit reports and recommendations to Congress, the
Secretary, and States based on such reviews.'';
(E) in paragraph (4), as redesignated by subparagraph (C),
by striking ``or any other problems'' and all that follows
through the period and inserting ``, as well as other factors
that adversely affect, or have the potential to adversely
affect, access to care by, or the health care status of,
Medicaid and CHIP beneficiaries. MACPAC shall include in the
annual report required under paragraph (1)(D) a description
of all such areas or problems identified with respect to the
period addressed in the report.'';
(F) in paragraph (5), as so redesignated,--
(i) in the paragraph heading, by inserting ``and
regulations'' after ``reports''; and
(ii) by striking ``If'' and inserting the following:
``(A) Certain secretarial reports.--If''; and
(iii) in the second sentence, by inserting ``and the
Secretary'' after ``appropriate committees of Congress''; and
(iv) by adding at the end the following:
``(B) Regulations.--MACPAC shall review Medicaid and CHIP
regulations and may comment through submission of a report to
the appropriate committees of Congress and the Secretary, on
any such regulations that affect access, quality, or
efficiency of health care.'';
(G) in paragraph (10), as so redesignated, by inserting ``,
and shall submit with any recommendations, a report on the
Federal and State-specific budget consequences of the
recommendations'' before the period; and
(H) by adding at the end the following:
``(11) Consultation and coordination with medpac.--
``(A) In general.--MACPAC shall consult with the Medicare
Payment Advisory Commission (in this paragraph referred to as
`MedPAC') established under section 1805 in carrying out its
duties under this section, as appropriate and particularly
with respect to the issues specified in paragraph (2) as they
relate to those Medicaid beneficiaries who are dually
eligible for Medicaid and the Medicare program under title
XVIII, adult Medicaid beneficiaries (who are not dually
eligible for Medicare), and beneficiaries under Medicare.
Responsibility for analysis of and recommendations to change
Medicare policy regarding Medicare beneficiaries, including
Medicare beneficiaries who are dually eligible for Medicare
and Medicaid, shall rest with MedPAC.
``(B) Information sharing.--MACPAC and MedPAC shall have
access to deliberations and records of the other such entity,
respectively, upon the request of the other such entity.
``(12) Consultation with states.--MACPAC shall regularly
consult with States in carrying out its duties under this
section, including with respect to developing processes for
carrying out such duties, and shall ensure that input from
States is taken into account and represented in MACPAC's
recommendations and reports.
``(13) Coordinate and consult with the federal coordinated
health care office.--MACPAC shall coordinate and consult with
the Federal Coordinated Health Care Office established under
section 2081 of the Patient Protection and Affordable Care
Act before making any recommendations regarding dual eligible
individuals.
``(14) Programmatic oversight vested in the secretary.--
MACPAC's authority to make recommendations in accordance with
this section shall not affect, or be considered to duplicate,
the Secretary's authority to carry out Federal
responsibilities with respect to Medicaid and CHIP.'';
(2) in subsection (c)(2)--
(A) by striking subparagraphs (A) and (B) and inserting the
following:
``(A) In general.--The membership of MACPAC shall include
individuals who have had direct experience as enrollees or
parents or caregivers of enrollees in Medicaid or CHIP and
individuals with national recognition for their expertise in
Federal safety net health programs, health finance and
economics, actuarial science, health plans and integrated
delivery systems, reimbursement for health care, health
information technology, and other providers of health
services, public health, and other related fields, who
provide a mix of different professions, broad geographic
representation, and a balance between urban and rural
representation.
``(B) Inclusion.--The membership of MACPAC shall include
(but not be limited to) physicians, dentists, and other
health professionals, employers, third-party payers, and
individuals with expertise in the delivery of health
services. Such membership shall also include representatives
of children, pregnant women, the elderly, individuals with
disabilities, caregivers, and dual eligible individuals,
current or former representatives of State agencies
responsible for administering Medicaid, and current or former
representatives of State agencies responsible for
administering CHIP.''.
(3) in subsection (d)(2), by inserting ``and State'' after
``Federal'';
(4) in subsection (e)(1), in the first sentence, by
inserting ``and, as a condition for receiving payments under
sections 1903(a) and 2105(a), from any State agency
responsible for administering Medicaid or CHIP,'' after
``United States''; and
(5) in subsection (f)--
(A) in the subsection heading, by striking ``Authorization
of Appropriations'' and inserting ``Funding'';
(B) in paragraph (1), by inserting ``(other than for fiscal
year 2010)'' before ``in the same manner''; and
(C) by adding at the end the following:
``(3) Funding for fiscal year 2010.--
``(A) In general.--Out of any funds in the Treasury not
otherwise appropriated, there is appropriated to MACPAC to
carry out the provisions of this section for fiscal year
2010, $9,000,000.
``(B) Transfer of funds.--Notwithstanding section
2104(a)(13), from the amounts appropriated in such section
for fiscal year 2010, $2,000,000 is hereby transferred and
made available in such fiscal year to MACPAC to carry out the
provisions of this section.
``(4) Availability.--Amounts made available under
paragraphs (2) and (3) to MACPAC to carry out the provisions
of this section shall remain available until expended.''.
(b) Conforming MedPAC Amendments.--Section 1805(b) of the
Social Security Act (42 U.S.C. 1395b-6(b)), is amended--
(1) in paragraph (1)(C), by striking ``March 1 of each year
(beginning with 1998)'' and inserting ``March 15'';
(2) in paragraph (1)(D), by inserting ``, and (beginning
with 2012) containing an examination of the topics described
in paragraph (9), to the extent feasible'' before the period;
and
(3) by adding at the end the following:
``(9) Review and annual report on medicaid and commercial
trends.--The Commission shall review and report on aggregate
trends in spending, utilization, and financial performance
under the Medicaid program under title XIX and the private
market for health care services with respect to providers for
which, on an aggregate national basis, a significant portion
of revenue or services is associated with the Medicaid
program. Where appropriate, the Commission shall conduct such
review in consultation with the Medicaid and CHIP Payment and
Access Commission established under section 1900 (in this
section referred to as `MACPAC').
``(10) Coordinate and consult with the federal coordinated
health care office.--The Commission shall coordinate and
consult with the Federal Coordinated Health Care Office
established under section 2081 of the Patient Protection and
Affordable Care Act before making any recommendations
regarding dual eligible individuals.
``(11) Interaction of medicaid and medicare.--The
Commission shall consult with MACPAC in carrying out its
duties under this section, as appropriate. Responsibility for
analysis of and recommendations to change Medicare policy
regarding Medicare beneficiaries, including Medicare
beneficiaries who are dually eligible for Medicare and
Medicaid, shall rest with the Commission. Responsibility for
analysis of and recommendations to change Medicaid policy
regarding Medicaid beneficiaries, including Medicaid
beneficiaries who are dually eligible for Medicare and
Medicaid, shall rest with MACPAC.''.
Subtitle K--Protections for American Indians and Alaska Natives
SEC. 2901. SPECIAL RULES RELATING TO INDIANS.
(a) No Cost-sharing for Indians With Income at or Below 300
Percent of Poverty Enrolled in Coverage Through a State
Exchange.--For provisions prohibiting cost sharing for
Indians enrolled in any qualified health plan in the
individual market through an Exchange, see section 1402(d) of
the Patient Protection and Affordable Care Act.
(b) Payer of Last Resort.--Health programs operated by the
Indian Health Service, Indian tribes, tribal organizations,
and Urban Indian organizations (as those terms are defined in
section 4 of the Indian Health Care Improvement Act (25
U.S.C. 1603)) shall be the payer of last resort for services
provided by such Service, tribes, or organizations to
individuals eligible for services through such programs,
notwithstanding any Federal, State, or local law to the
contrary.
(c) Facilitating Enrollment of Indians Under the Express
Lane Option.--Section 1902(e)(13)(F)(ii) of the Social
Security Act (42 U.S.C. 1396a(e)(13)(F)(ii)) is amended--
(1) in the clause heading, by inserting ``and indian tribes
and tribal organizations'' after ``agencies''; and
(2) by adding at the end the following:
``(IV) The Indian Health Service, an Indian Tribe, Tribal
Organization, or Urban Indian Organization (as defined in
section 1139(c)).''.
(d) Technical Corrections.--Section 1139(c) of the Social
Security Act (42 U.S.C. 1320b-9(c)) is amended by striking
``In this section'' and inserting ``For purposes of this
section, title XIX, and title XXI''.
SEC. 2902. ELIMINATION OF SUNSET FOR REIMBURSEMENT FOR ALL
MEDICARE PART B SERVICES FURNISHED BY CERTAIN
INDIAN HOSPITALS AND CLINICS.
(a) Reimbursement for All Medicare Part B Services
Furnished by Certain Indian Hospitals and Clinics.--Section
1880(e)(1)(A) of the Social Security Act (42 U.S.C.
1395qq(e)(1)(A)) is amended by striking ``during the 5-year
period beginning on'' and inserting ``on or after''.
(b) Effective Date.--The amendments made by this section
shall apply to items or services furnished on or after
January 1, 2010.
Subtitle L--Maternal and Child Health Services
SEC. 2951. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME
VISITING PROGRAMS.
Title V of the Social Security Act (42 U.S.C. 701 et seq.)
is amended by adding at the end the following new section:
``SEC. 511. MATERNAL, INFANT, AND EARLY CHILDHOOD HOME
VISITING PROGRAMS.
``(a) Purposes.--The purposes of this section are--
[[Page H1977]]
``(1) to strengthen and improve the programs and activities
carried out under this title;
``(2) to improve coordination of services for at risk
communities; and
``(3) to identify and provide comprehensive services to
improve outcomes for families who reside in at risk
communities.
``(b) Requirement for All States To Assess Statewide Needs
and Identify at Risk Communities.--
``(1) In general.--Not later than 6 months after the date
of enactment of this section, each State shall, as a
condition of receiving payments from an allotment for the
State under section 502 for fiscal year 2011, conduct a
statewide needs assessment (which shall be separate from the
statewide needs assessment required under section 505(a))
that identifies--
``(A) communities with concentrations of--
``(i) premature birth, low-birth weight infants, and infant
mortality, including infant death due to neglect, or other
indicators of at-risk prenatal, maternal, newborn, or child
health;
``(ii) poverty;
``(iii) crime;
``(iv) domestic violence;
``(v) high rates of high-school drop-outs;
``(vi) substance abuse;
``(vii) unemployment; or
``(viii) child maltreatment;
``(B) the quality and capacity of existing programs or
initiatives for early childhood home visitation in the State
including--
``(i) the number and types of individuals and families who
are receiving services under such programs or initiatives;
``(ii) the gaps in early childhood home visitation in the
State; and
``(iii) the extent to which such programs or initiatives
are meeting the needs of eligible families described in
subsection (k)(2); and
``(C) the State's capacity for providing substance abuse
treatment and counseling services to individuals and families
in need of such treatment or services.
``(2) Coordination with other assessments.--In conducting
the statewide needs assessment required under paragraph (1),
the State shall coordinate with, and take into account, other
appropriate needs assessments conducted by the State, as
determined by the Secretary, including the needs assessment
required under section 505(a) (both the most recently
completed assessment and any such assessment in progress),
the communitywide strategic planning and needs assessments
conducted in accordance with section 640(g)(1)(C) of the Head
Start Act, and the inventory of current unmet needs and
current community-based and prevention-focused programs and
activities to prevent child abuse and neglect, and other
family resource services operating in the State required
under section 205(3) of the Child Abuse Prevention and
Treatment Act.
``(3) Submission to the secretary.--Each State shall submit
to the Secretary, in such form and manner as the Secretary
shall require--
``(A) the results of the statewide needs assessment
required under paragraph (1); and
``(B) a description of how the State intends to address
needs identified by the assessment, particularly with respect
to communities identified under paragraph (1)(A), which may
include applying for a grant to conduct an early childhood
home visitation program in accordance with the requirements
of this section.
``(c) Grants for Early Childhood Home Visitation
Programs.--
``(1) Authority to make grants.--In addition to any other
payments made under this title to a State, the Secretary
shall make grants to eligible entities to enable the entities
to deliver services under early childhood home visitation
programs that satisfy the requirements of subsection (d) to
eligible families in order to promote improvements in
maternal and prenatal health, infant health, child health and
development, parenting related to child development outcomes,
school readiness, and the socioeconomic status of such
families, and reductions in child abuse, neglect, and
injuries.
``(2) Authority to use initial grant funds for planning or
implementation.--An eligible entity that receives a grant
under paragraph (1) may use a portion of the funds made
available to the entity during the first 6 months of the
period for which the grant is made for planning or
implementation activities to assist with the establishment of
early childhood home visitation programs that satisfy the
requirements of subsection (d).
``(3) Grant duration.--The Secretary shall determine the
period of years for which a grant is made to an eligible
entity under paragraph (1).
``(4) Technical assistance.--The Secretary shall provide an
eligible entity that receives a grant under paragraph (1)
with technical assistance in administering programs or
activities conducted in whole or in part with grant funds.
``(d) Requirements.--The requirements of this subsection
for an early childhood home visitation program conducted with
a grant made under this section are as follows:
``(1) Quantifiable, measurable improvement in benchmark
areas.--
``(A) In general.--The eligible entity establishes, subject
to the approval of the Secretary, quantifiable, measurable 3-
and 5-year benchmarks for demonstrating that the program
results in improvements for the eligible families
participating in the program in each of the following areas:
``(i) Improved maternal and newborn health.
``(ii) Prevention of child injuries, child abuse, neglect,
or maltreatment, and reduction of emergency department
visits.
``(iii) Improvement in school readiness and achievement.
``(iv) Reduction in crime or domestic violence.
``(v) Improvements in family economic self-sufficiency.
``(vi) Improvements in the coordination and referrals for
other community resources and supports.
``(B) Demonstration of improvements after 3 years.--
``(i) Report to the secretary.--Not later than 30 days
after the end of the 3rd year in which the eligible entity
conducts the program, the entity submits to the Secretary a
report demonstrating improvement in at least 4 of the areas
specified in subparagraph (A).
``(ii) Corrective action plan.--If the report submitted by
the eligible entity under clause (i) fails to demonstrate
improvement in at least 4 of the areas specified in
subparagraph (A), the entity shall develop and implement a
plan to improve outcomes in each of the areas specified in
subparagraph (A), subject to approval by the Secretary. The
plan shall include provisions for the Secretary to monitor
implementation of the plan and conduct continued oversight of
the program, including through submission by the entity of
regular reports to the Secretary.
``(iii) Technical assistance.--
``(I) In general.--The Secretary shall provide an eligible
entity required to develop and implement an improvement plan
under clause (ii) with technical assistance to develop and
implement the plan. The Secretary may provide the technical
assistance directly or through grants, contracts, or
cooperative agreements.
``(II) Advisory panel.--The Secretary shall establish an
advisory panel for purposes of obtaining recommendations
regarding the technical assistance provided to entities in
accordance with subclause (I).
``(iv) No improvement or failure to submit report.--If the
Secretary determines after a period of time specified by the
Secretary that an eligible entity implementing an improvement
plan under clause (ii) has failed to demonstrate any
improvement in the areas specified in subparagraph (A), or if
the Secretary determines that an eligible entity has failed
to submit the report required under clause (i), the Secretary
shall terminate the entity's grant and may include any
unexpended grant funds in grants made to nonprofit
organizations under subsection (h)(2)(B).
``(C) Final report.--Not later than December 31, 2015, the
eligible entity shall submit a report to the Secretary
demonstrating improvements (if any) in each of the areas
specified in subparagraph (A).
``(2) Improvements in outcomes for individual families.--
``(A) In general.--The program is designed, with respect to
an eligible family participating in the program, to result in
the participant outcomes described in subparagraph (B) that
the eligible entity identifies on the basis of an
individualized assessment of the family, are relevant for
that family.
``(B) Participant outcomes.--The participant outcomes
described in this subparagraph are the following:
``(i) Improvements in prenatal, maternal, and newborn
health, including improved pregnancy outcomes
``(ii) Improvements in child health and development,
including the prevention of child injuries and maltreatment
and improvements in cognitive, language, social-emotional,
and physical developmental indicators.
``(iii) Improvements in parenting skills.
``(iv) Improvements in school readiness and child academic
achievement.
``(v) Reductions in crime or domestic violence.
``(vi) Improvements in family economic self-sufficiency.
``(vii) Improvements in the coordination of referrals for,
and the provision of, other community resources and supports
for eligible families, consistent with State child welfare
agency training.
``(3) Core components.--The program includes the following
core components:
``(A) Service delivery model or models.--
``(i) In general.--Subject to clause (ii), the program is
conducted using 1 or more of the service delivery models
described in item (aa) or (bb) of subclause (I) or in
subclause (II) selected by the eligible entity:
``(I) The model conforms to a clear consistent home
visitation model that has been in existence for at least 3
years and is research-based, grounded in relevant
empirically-based knowledge, linked to program determined
outcomes, associated with a national organization or
institution of higher education that has comprehensive home
visitation program standards that ensure high quality service
delivery and continuous program quality improvement, and has
demonstrated significant, (and in the case of the service
delivery model described in item (aa), sustained) positive
outcomes, as described in the benchmark areas specified in
paragraph (1)(A) and the participant outcomes described in
paragraph (2)(B), when evaluated using well-designed and
rigorous--
``(aa) randomized controlled research designs, and the
evaluation results have been published in a peer-reviewed
journal; or
``(bb) quasi-experimental research designs.
``(II) The model conforms to a promising and new approach
to achieving the benchmark areas specified in paragraph
(1)(A) and the participant outcomes described in paragraph
(2)(B), has been developed or identified by a national
organization or institution of higher education, and will be
evaluated through well-designed and rigorous process.
``(ii) Majority of grant funds used for evidence-based
models.--An eligible entity shall use not more than 25
percent of the amount of the grant paid to the entity for a
fiscal year for purposes of conducting a program using the
service delivery model described in clause (i)(II).
``(iii) Criteria for evidence of effectiveness of models.--
The Secretary shall establish criteria for evidence of
effectiveness of the service delivery models and shall ensure
that the
[[Page H1978]]
process for establishing the criteria is transparent and
provides the opportunity for public comment.
``(B) Additional requirements.--
``(i) The program adheres to a clear, consistent model that
satisfies the requirements of being grounded in empirically-
based knowledge related to home visiting and linked to the
benchmark areas specified in paragraph (1)(A) and the
participant outcomes described in paragraph (2)(B) related to
the purposes of the program.
``(ii) The program employs well-trained and competent
staff, as demonstrated by education or training, such as
nurses, social workers, educators, child development
specialists, or other well-trained and competent staff, and
provides ongoing and specific training on the model being
delivered.
``(iii) The program maintains high quality supervision to
establish home visitor competencies.
``(iv) The program demonstrates strong organizational
capacity to implement the activities involved.
``(v) The program establishes appropriate linkages and
referral networks to other community resources and supports
for eligible families.
``(vi) The program monitors the fidelity of program
implementation to ensure that services are delivered pursuant
to the specified model.
``(4) Priority for serving high-risk populations.--The
eligible entity gives priority to providing services under
the program to the following:
``(A) Eligible families who reside in communities in need
of such services, as identified in the statewide needs
assessment required under subsection (b)(1)(A).
``(B) Low-income eligible families.
``(C) Eligible families who are pregnant women who have not
attained age 21.
``(D) Eligible families that have a history of child abuse
or neglect or have had interactions with child welfare
services.
``(E) Eligible families that have a history of substance
abuse or need substance abuse treatment.
``(F) Eligible families that have users of tobacco products
in the home.
``(G) Eligible families that are or have children with low
student achievement.
``(H) Eligible families with children with developmental
delays or disabilities.
``(I) Eligible families who, or that include individuals
who, are serving or formerly served in the Armed Forces,
including such families that have members of the Armed Forces
who have had multiple deployments outside of the United
States.
``(e) Application Requirements.--An eligible entity
desiring a grant under this section shall submit an
application to the Secretary for approval, in such manner as
the Secretary may require, that includes the following:
``(1) A description of the populations to be served by the
entity, including specific information regarding how the
entity will serve high risk populations described in
subsection (d)(4).
``(2) An assurance that the entity will give priority to
serving low-income eligible families and eligible families
who reside in at risk communities identified in the statewide
needs assessment required under subsection (b)(1)(A).
``(3) The service delivery model or models described in
subsection (d)(3)(A) that the entity will use under the
program and the basis for the selection of the model or
models.
``(4) A statement identifying how the selection of the
populations to be served and the service delivery model or
models that the entity will use under the program for such
populations is consistent with the results of the statewide
needs assessment conducted under subsection (b).
``(5) The quantifiable, measurable benchmarks established
by the State to demonstrate that the program contributes to
improvements in the areas specified in subsection (d)(1)(A).
``(6) An assurance that the entity will obtain and submit
documentation or other appropriate evidence from the
organization or entity that developed the service delivery
model or models used under the program to verify that the
program is implemented and services are delivered according
to the model specifications.
``(7) Assurances that the entity will establish procedures
to ensure that--
``(A) the participation of each eligible family in the
program is voluntary; and
``(B) services are provided to an eligible family in
accordance with the individual assessment for that family.
``(8) Assurances that the entity will--
``(A) submit annual reports to the Secretary regarding the
program and activities carried out under the program that
include such information and data as the Secretary shall
require; and
``(B) participate in, and cooperate with, data and
information collection necessary for the evaluation required
under subsection (g)(2) and other research and evaluation
activities carried out under subsection (h)(3).
``(9) A description of other State programs that include
home visitation services, including, if applicable to the
State, other programs carried out under this title with funds
made available from allotments under section 502(c), programs
funded under title IV, title II of the Child Abuse Prevention
and Treatment Act (relating to community-based grants for the
prevention of child abuse and neglect), and section 645A of
the Head Start Act (relating to Early Head Start programs).
``(10) Other information as required by the Secretary.
``(f) Maintenance of Effort.--Funds provided to an eligible
entity receiving a grant under this section shall supplement,
and not supplant, funds from other sources for early
childhood home visitation programs or initiatives.
``(g) Evaluation.--
``(1) Independent, expert advisory panel.--The Secretary,
in accordance with subsection (h)(1)(A), shall appoint an
independent advisory panel consisting of experts in program
evaluation and research, education, and early childhood
development--
``(A) to review, and make recommendations on, the design
and plan for the evaluation required under paragraph (2)
within 1 year after the date of enactment of this section;
``(B) to maintain and advise the Secretary regarding the
progress of the evaluation; and
``(C) to comment, if the panel so desires, on the report
submitted under paragraph (3).
``(2) Authority to conduct evaluation.--On the basis of the
recommendations of the advisory panel under paragraph (1),
the Secretary shall, by grant, contract, or interagency
agreement, conduct an evaluation of the statewide needs
assessments submitted under subsection (b) and the grants
made under subsections (c) and (h)(3)(B). The evaluation
shall include--
``(A) an analysis, on a State-by-State basis, of the
results of such assessments, including indicators of maternal
and prenatal health and infant health and mortality, and
State actions in response to the assessments; and
``(B) an assessment of--
``(i) the effect of early childhood home visitation
programs on child and parent outcomes, including with respect
to each of the benchmark areas specified in subsection
(d)(1)(A) and the participant outcomes described in
subsection (d)(2)(B);
``(ii) the effectiveness of such programs on different
populations, including the extent to which the ability of
programs to improve participant outcomes varies across
programs and populations; and
``(iii) the potential for the activities conducted under
such programs, if scaled broadly, to improve health care
practices, eliminate health disparities, and improve health
care system quality, efficiencies, and reduce costs.
``(3) Report.--Not later than March 31, 2015, the Secretary
shall submit a report to Congress on the results of the
evaluation conducted under paragraph (2) and shall make the
report publicly available.
``(h) Other Provisions.--
``(1) Intra-agency collaboration.--The Secretary shall
ensure that the Maternal and Child Health Bureau and the
Administration for Children and Families collaborate with
respect to carrying out this section, including with respect
to--
``(A) reviewing and analyzing the statewide needs
assessments required under subsection (b), the awarding and
oversight of grants awarded under this section, the
establishment of the advisory panels required under
subsections (d)(1)(B)(iii)(II) and (g)(1), and the evaluation
and report required under subsection (g); and
``(B) consulting with other Federal agencies with
responsibility for administering or evaluating programs that
serve eligible families to coordinate and collaborate with
respect to research related to such programs and families,
including the Office of the Assistant Secretary for Planning
and Evaluation of the Department of Health and Human
Services, the Centers for Disease Control and Prevention, the
National Institute of Child Health and Human Development of
the National Institutes of Health, the Office of Juvenile
Justice and Delinquency Prevention of the Department of
Justice, and the Institute of Education Sciences of the
Department of Education.
``(2) Grants to eligible entities that are not states.--
``(A) Indian tribes, tribal organizations, or urban indian
organizations.--The Secretary shall specify requirements for
eligible entities that are Indian Tribes (or a consortium of
Indian Tribes), Tribal Organizations, or Urban Indian
Organizations to apply for and conduct an early childhood
home visitation program with a grant under this section. Such
requirements shall, to the greatest extent practicable, be
consistent with the requirements applicable to eligible
entities that are States and shall require an Indian Tribe
(or consortium), Tribal Organization, or Urban Indian
Organization to--
``(i) conduct a needs assessment similar to the assessment
required for all States under subsection (b); and
``(ii) establish quantifiable, measurable 3- and 5-year
benchmarks consistent with subsection (d)(1)(A).
``(B) Nonprofit organizations.--If, as of the beginning of
fiscal year 2012, a State has not applied or been approved
for a grant under this section, the Secretary may use amounts
appropriated under paragraph (1) of subsection (j) that are
available for expenditure under paragraph (3) of that
subsection to make a grant to an eligible entity that is a
nonprofit organization described in subsection (k)(1)(B) to
conduct an early childhood home visitation program in the
State. The Secretary shall specify the requirements for such
an organization to apply for and conduct the program which
shall, to the greatest extent practicable, be consistent with
the requirements applicable to eligible entities that are
States and shall require the organization to--
``(i) carry out the program based on the needs assessment
conducted by the State under subsection (b); and
``(ii) establish quantifiable, measurable 3- and 5-year
benchmarks consistent with subsection (d)(1)(A).
``(3) Research and other evaluation activities.--
``(A) In general.--The Secretary shall carry out a
continuous program of research and evaluation activities in
order to increase knowledge about the implementation and
effectiveness of home visiting programs, using random
assignment designs to the maximum extent feasible. The
Secretary may carry out such activities directly, or through
grants, cooperative agreements, or contracts.
[[Page H1979]]
``(B) Requirements.--The Secretary shall ensure that--
``(i) evaluation of a specific program or project is
conducted by persons or individuals not directly involved in
the operation of such program or project; and
``(ii) the conduct of research and evaluation activities
includes consultation with independent researchers, State
officials, and developers and providers of home visiting
programs on topics including research design and
administrative data matching.
``(4) Report and recommendation.--Not later than December
31, 2015, the Secretary shall submit a report to Congress
regarding the programs conducted with grants under this
section. The report required under this paragraph shall
include--
``(A) information regarding the extent to which eligible
entities receiving grants under this section demonstrated
improvements in each of the areas specified in subsection
(d)(1)(A);
``(B) information regarding any technical assistance
provided under subsection (d)(1)(B)(iii)(I), including the
type of any such assistance provided; and
``(C) recommendations for such legislative or
administrative action as the Secretary determines
appropriate.
``(i) Application of Other Provisions of Title.--
``(1) In general.--Except as provided in paragraph (2), the
other provisions of this title shall not apply to a grant
made under this section.
``(2) Exceptions.--The following provisions of this title
shall apply to a grant made under this section to the same
extent and in the same manner as such provisions apply to
allotments made under section 502(c):
``(A) Section 504(b)(6) (relating to prohibition on
payments to excluded individuals and entities).
``(B) Section 504(c) (relating to the use of funds for the
purchase of technical assistance).
``(C) Section 504(d) (relating to a limitation on
administrative expenditures).
``(D) Section 506 (relating to reports and audits), but
only to the extent determined by the Secretary to be
appropriate for grants made under this section.
``(E) Section 507 (relating to penalties for false
statements).
``(F) Section 508 (relating to nondiscrimination).
``(G) Section 509(a) (relating to the administration of the
grant program).
``(j) Appropriations.--
``(1) In general.--Out of any funds in the Treasury not
otherwise appropriated, there are appropriated to the
Secretary to carry out this section--
``(A) $100,000,000 for fiscal year 2010;
``(B) $250,000,000 for fiscal year 2011;
``(C) $350,000,000 for fiscal year 2012;
``(D) $400,000,000 for fiscal year 2013; and
``(E) $400,000,000 for fiscal year 2014.
``(2) Reservations.--Of the amount appropriated under this
subsection for a fiscal year, the Secretary shall reserve--
``(A) 3 percent of such amount for purposes of making
grants to eligible entities that are Indian Tribes (or a
consortium of Indian Tribes), Tribal Organizations, or Urban
Indian Organizations; and
``(B) 3 percent of such amount for purposes of carrying out
subsections (d)(1)(B)(iii), (g), and (h)(3).
``(3) Availability.--Funds made available to an eligible
entity under this section for a fiscal year shall remain
available for expenditure by the eligible entity through the
end of the second succeeding fiscal year after award. Any
funds that are not expended by the eligible entity during the
period in which the funds are available under the preceding
sentence may be used for grants to nonprofit organizations
under subsection (h)(2)(B).
``(k) Definitions.--In this section:
``(1) Eligible entity.--
``(A) In general.--The term `eligible entity' means a
State, an Indian Tribe, Tribal Organization, or Urban Indian
Organization, Puerto Rico, Guam, the Virgin Islands, the
Northern Mariana Islands, and American Samoa.
``(B) Nonprofit organizations.--Only for purposes of
awarding grants under subsection (h)(2)(B), such term shall
include a nonprofit organization with an established record
of providing early childhood home visitation programs or
initiatives in a State or several States.
``(2) Eligible family.--The term `eligible family' means--
``(A) a woman who is pregnant, and the father of the child
if the father is available; or
``(B) a parent or primary caregiver of a child, including
grandparents or other relatives of the child, and foster
parents, who are serving as the child's primary caregiver
from birth to kindergarten entry, and including a
noncustodial parent who has an ongoing relationship with, and
at times provides physical care for, the child.
``(3) Indian tribe; tribal organization.--The terms `Indian
Tribe' and `Tribal Organization', and `Urban Indian
Organization' have the meanings given such terms in section 4
of the Indian Health Care Improvement Act.''.
SEC. 2952. SUPPORT, EDUCATION, AND RESEARCH FOR POSTPARTUM
DEPRESSION.
(a) Research on Postpartum Conditions.--
(1) Expansion and intensification of activities.--The
Secretary of Health and Human Services (in this subsection
and subsection (c) referred to as the ``Secretary'') is
encouraged to continue activities on postpartum depression or
postpartum psychosis (in this subsection and subsection (c)
referred to as ``postpartum conditions''), including research
to expand the understanding of the causes of, and treatments
for, postpartum conditions. Activities under this paragraph
shall include conducting and supporting the following:
(A) Basic research concerning the etiology and causes of
the conditions.
(B) Epidemiological studies to address the frequency and
natural history of the conditions and the differences among
racial and ethnic groups with respect to the conditions.
(C) The development of improved screening and diagnostic
techniques.
(D) Clinical research for the development and evaluation of
new treatments.
(E) Information and education programs for health care
professionals and the public, which may include a coordinated
national campaign to increase the awareness and knowledge of
postpartum conditions. Activities under such a national
campaign may--
(i) include public service announcements through
television, radio, and other means; and
(ii) focus on--
(I) raising awareness about screening;
(II) educating new mothers and their families about
postpartum conditions to promote earlier diagnosis and
treatment; and
(III) ensuring that such education includes complete
information concerning postpartum conditions, including its
symptoms, methods of coping with the illness, and treatment
resources.
(2) Sense of congress regarding longitudinal study of
relative mental health consequences for women of resolving a
pregnancy.--
(A) Sense of congress.--It is the sense of Congress that
the Director of the National Institute of Mental Health may
conduct a nationally representative longitudinal study
(during the period of fiscal years 2010 through 2019) of the
relative mental health consequences for women of resolving a
pregnancy (intended and unintended) in various ways,
including carrying the pregnancy to term and parenting the
child, carrying the pregnancy to term and placing the child
for adoption, miscarriage, and having an abortion. This study
may assess the incidence, timing, magnitude, and duration of
the immediate and long-term mental health consequences
(positive or negative) of these pregnancy outcomes.
(B) Report.--Subject to the completion of the study under
subsection (a), beginning not later than 5 years after the
date of the enactment of this Act, and periodically
thereafter for the duration of the study, such Director may
prepare and submit to the Congress reports on the findings of
the study.
(b) Grants To Provide Services to Individuals With a
Postpartum Condition and Their Families.--Title V of the
Social Security Act (42 U.S.C. 701 et seq.), as amended by
section 2951, is amended by adding at the end the following
new section:
``SEC. 512. SERVICES TO INDIVIDUALS WITH A POSTPARTUM
CONDITION AND THEIR FAMILIES.
``(a) In General.--In addition to any other payments made
under this title to a State, the Secretary may make grants to
eligible entities for projects for the establishment,
operation, and coordination of effective and cost-efficient
systems for the delivery of essential services to individuals
with or at risk for postpartum conditions and their families.
``(b) Certain Activities.--To the extent practicable and
appropriate, the Secretary shall ensure that projects funded
under subsection (a) provide education and services with
respect to the diagnosis and management of postpartum
conditions for individuals with or at risk for postpartum
conditions and their families. The Secretary may allow such
projects to include the following:
``(1) Delivering or enhancing outpatient and home-based
health and support services, including case management and
comprehensive treatment services.
``(2) Delivering or enhancing inpatient care management
services that ensure the well-being of the mother and family
and the future development of the infant.
``(3) Improving the quality, availability, and organization
of health care and support services (including transportation
services, attendant care, homemaker services, day or respite
care, and providing counseling on financial assistance and
insurance).
``(4) Providing education about postpartum conditions to
promote earlier diagnosis and treatment. Such education may
include--
``(A) providing complete information on postpartum
conditions, symptoms, methods of coping with the illness, and
treatment resources; and
``(B) in the case of a grantee that is a State, hospital,
or birthing facility--
``(i) providing education to new mothers and fathers, and
other family members as appropriate, concerning postpartum
conditions before new mothers leave the health facility; and
``(ii) ensuring that training programs regarding such
education are carried out at the health facility.
``(c) Integration With Other Programs.--To the extent
practicable and appropriate, the Secretary may integrate the
grant program under this section with other grant programs
carried out by the Secretary, including the program under
section 330 of the Public Health Service Act.
``(d) Requirements.--The Secretary shall establish
requirements for grants made under this section that include
a limit on the amount of grants funds that may be used for
administration, accounting, reporting, or program oversight
functions and a requirement for each eligible entity that
receives a grant to submit, for each grant period, a report
to the Secretary that describes how grant funds were used
during such period.
``(e) Technical Assistance.--The Secretary may provide
technical assistance to entities seeking a grant under this
section in order to assist such entities in complying with
the requirements of this section.
``(f) Application of Other Provisions of Title.--
[[Page H1980]]
``(1) In general.--Except as provided in paragraph (2), the
other provisions of this title shall not apply to a grant
made under this section.
``(2) Exceptions.--The following provisions of this title
shall apply to a grant made under this section to the same
extent and in the same manner as such provisions apply to
allotments made under section 502(c):
``(A) Section 504(b)(6) (relating to prohibition on
payments to excluded individuals and entities).
``(B) Section 504(c) (relating to the use of funds for the
purchase of technical assistance).
``(C) Section 504(d) (relating to a limitation on
administrative expenditures).
``(D) Section 506 (relating to reports and audits), but
only to the extent determined by the Secretary to be
appropriate for grants made under this section.
``(E) Section 507 (relating to penalties for false
statements).
``(F) Section 508 (relating to nondiscrimination).
``(G) Section 509(a) (relating to the administration of the
grant program).
``(g) Definitions.--In this section:
``(1) The term `eligible entity'--
``(A) means a public or nonprofit private entity; and
``(B) includes a State or local government, public-private
partnership, recipient of a grant under section 330H of the
Public Health Service Act (relating to the Healthy Start
Initiative), public or nonprofit private hospital, community-
based organization, hospice, ambulatory care facility,
community health center, migrant health center, public
housing primary care center, or homeless health center.
``(2) The term `postpartum condition' means postpartum
depression or postpartum psychosis.''.
(c) General Provisions.--
(1) Authorization of appropriations.--To carry out this
section and the amendment made by subsection (b), there are
authorized to be appropriated, in addition to such other sums
as may be available for such purpose--
(A) $3,000,000 for fiscal year 2010; and
(B) such sums as may be necessary for fiscal years 2011 and
2012.
(2) Report by the secretary.--
(A) Study.--The Secretary shall conduct a study on the
benefits of screening for postpartum conditions.
(B) Report.--Not later than 2 years after the date of the
enactment of this Act, the Secretary shall complete the study
required by subparagraph (A) and submit a report to the
Congress on the results of such study.
SEC. 2953. PERSONAL RESPONSIBILITY EDUCATION.
Title V of the Social Security Act (42 U.S.C. 701 et seq.),
as amended by sections 2951 and 2952(c), is amended by adding
at the end the following:
``SEC. 513. PERSONAL RESPONSIBILITY EDUCATION.
``(a) Allotments to States.--
``(1) Amount.--
``(A) In general.--For the purpose described in subsection
(b), subject to the succeeding provisions of this section,
for each of fiscal years 2010 through 2014, the Secretary
shall allot to each State an amount equal to the product of--
``(i) the amount appropriated under subsection (f) for the
fiscal year and available for allotments to States after the
application of subsection (c); and
``(ii) the State youth population percentage determined
under paragraph (2).
``(B) Minimum allotment.--
``(i) In general.--Each State allotment under this
paragraph for a fiscal year shall be at least $250,000.
``(ii) Pro rata adjustments.--The Secretary shall adjust on
a pro rata basis the amount of the State allotments
determined under this paragraph for a fiscal year to the
extent necessary to comply with clause (i).
``(C) Application required to access allotments.--
``(i) In general.--A State shall not be paid from its
allotment for a fiscal year unless the State submits an
application to the Secretary for the fiscal year and the
Secretary approves the application (or requires changes to
the application that the State satisfies) and meets such
additional requirements as the Secretary may specify.
``(ii) Requirements.--The State application shall contain
an assurance that the State has complied with the
requirements of this section in preparing and submitting the
application and shall include the following as well as such
additional information as the Secretary may require:
``(I) Based on data from the Centers for Disease Control
and Prevention National Center for Health Statistics, the
most recent pregnancy rates for the State for youth ages 10
to 14 and youth ages 15 to 19 for which data are available,
the most recent birth rates for such youth populations in the
State for which data are available, and trends in those rates
for the most recently preceding 5-year period for which such
data are available.
``(II) State-established goals for reducing the pregnancy
rates and birth rates for such youth populations.
``(III) A description of the State's plan for using the
State allotments provided under this section to achieve such
goals, especially among youth populations that are the most
high-risk or vulnerable for pregnancies or otherwise have
special circumstances, including youth in foster care,
homeless youth, youth with HIV/AIDS, pregnant youth who are
under 21 years of age, mothers who are under 21 years of age,
and youth residing in areas with high birth rates for youth.
``(2) State youth population percentage.--
``(A) In general.--For purposes of paragraph (1)(A)(ii),
the State youth population percentage is, with respect to a
State, the proportion (expressed as a percentage) of--
``(i) the number of individuals who have attained age 10
but not attained age 20 in the State; to
``(ii) the number of such individuals in all States.
``(B) Determination of number of youth.--The number of
individuals described in clauses (i) and (ii) of subparagraph
(A) in a State shall be determined on the basis of the most
recent Bureau of the Census data.
``(3) Availability of state allotments.--Subject to
paragraph (4)(A), amounts allotted to a State pursuant to
this subsection for a fiscal year shall remain available for
expenditure by the State through the end of the second
succeeding fiscal year.
``(4) Authority to award grants from state allotments to
local organizations and entities in nonparticipating
states.--
``(A) Grants from unexpended allotments.--If a State does
not submit an application under this section for fiscal year
2010 or 2011, the State shall no longer be eligible to submit
an application to receive funds from the amounts allotted for
the State for each of fiscal years 2010 through 2014 and such
amounts shall be used by the Secretary to award grants under
this paragraph for each of fiscal years 2012 through 2014.
The Secretary also shall use any amounts from the allotments
of States that submit applications under this section for a
fiscal year that remain unexpended as of the end of the
period in which the allotments are available for expenditure
under paragraph (3) for awarding grants under this paragraph.
``(B) 3-year grants.--
``(i) In general.--The Secretary shall solicit applications
to award 3-year grants in each of fiscal years 2012, 2013,
and 2014 to local organizations and entities to conduct,
consistent with subsection (b), programs and activities in
States that do not submit an application for an allotment
under this section for fiscal year 2010 or 2011.
``(ii) Faith-based organizations or consortia.--The
Secretary may solicit and award grants under this paragraph
to faith-based organizations or consortia.
``(C) Evaluation.--An organization or entity awarded a
grant under this paragraph shall agree to participate in a
rigorous Federal evaluation.
``(5) Maintenance of effort.--No payment shall be made to a
State from the allotment determined for the State under this
subsection or to a local organization or entity awarded a
grant under paragraph (4), if the expenditure of non-federal
funds by the State, organization, or entity for activities,
programs, or initiatives for which amounts from allotments
and grants under this subsection may be expended is less than
the amount expended by the State, organization, or entity for
such programs or initiatives for fiscal year 2009.
``(6) Data collection and reporting.--A State or local
organization or entity receiving funds under this section
shall cooperate with such requirements relating to the
collection of data and information and reporting on outcomes
regarding the programs and activities carried out with such
funds, as the Secretary shall specify.
``(b) Purpose.--
``(1) In general.--The purpose of an allotment under
subsection (a)(1) to a State is to enable the State (or, in
the case of grants made under subsection (a)(4)(B), to enable
a local organization or entity) to carry out personal
responsibility education programs consistent with this
subsection.
``(2) Personal responsibility education programs.--
``(A) In general.--In this section, the term `personal
responsibility education program' means a program that is
designed to educate adolescents on--
``(i) both abstinence and contraception for the prevention
of pregnancy and sexually transmitted infections, including
HIV/AIDS, consistent with the requirements of subparagraph
(B); and
``(ii) at least 3 of the adulthood preparation subjects
described in subparagraph (C).
``(B) Requirements.--The requirements of this subparagraph
are the following:
``(i) The program replicates evidence-based effective
programs or substantially incorporates elements of effective
programs that have been proven on the basis of rigorous
scientific research to change behavior, which means delaying
sexual activity, increasing condom or contraceptive use for
sexually active youth, or reducing pregnancy among youth.
``(ii) The program is medically-accurate and complete.
``(iii) The program includes activities to educate youth
who are sexually active regarding responsible sexual behavior
with respect to both abstinence and the use of contraception.
``(iv) The program places substantial emphasis on both
abstinence and contraception for the prevention of pregnancy
among youth and sexually transmitted infections.
``(v) The program provides age-appropriate information and
activities.
``(vi) The information and activities carried out under the
program are provided in the cultural context that is most
appropriate for individuals in the particular population
group to which they are directed.
``(C) Adulthood preparation subjects.--The adulthood
preparation subjects described in this subparagraph are the
following:
``(i) Healthy relationships, such as positive self-esteem
and relationship dynamics, friendships, dating, romantic
involvement, marriage, and family interactions.
``(ii) Adolescent development, such as the development of
healthy attitudes and values about
[[Page H1981]]
adolescent growth and development, body image, racial and
ethnic diversity, and other related subjects.
``(iii) Financial literacy.
``(iv) Parent-child communication.
``(v) Educational and career success, such as developing
skills for employment preparation, job seeking, independent
living, financial self-sufficiency, and workplace
productivity.
``(vi) Healthy life skills, such as goal-setting, decision
making, negotiation, communication and interpersonal skills,
and stress management.
``(c) Reservations of Funds.--
``(1) Grants to implement innovative strategies.--From the
amount appropriated under subsection (f) for the fiscal year,
the Secretary shall reserve $10,000,000 of such amount for
purposes of awarding grants to entities to implement
innovative youth pregnancy prevention strategies and target
services to high-risk, vulnerable, and culturally under-
represented youth populations, including youth in foster
care, homeless youth, youth with HIV/AIDS, pregnant women who
are under 21 years of age and their partners, mothers who are
under 21 years of age and their partners, and youth residing
in areas with high birth rates for youth. An entity awarded a
grant under this paragraph shall agree to participate in a
rigorous Federal evaluation of the activities carried out
with grant funds.
``(2) Other reservations.--From the amount appropriated
under subsection (f) for the fiscal year that remains after
the application of paragraph (1), the Secretary shall reserve
the following amounts:
``(A) Grants for indian tribes or tribal organizations.--
The Secretary shall reserve 5 percent of such remainder for
purposes of awarding grants to Indian tribes and tribal
organizations in such manner, and subject to such
requirements, as the Secretary, in consultation with Indian
tribes and tribal organizations, determines appropriate.
``(B) Secretarial responsibilities.--
``(i) Reservation of funds.--The Secretary shall reserve 10
percent of such remainder for expenditures by the Secretary
for the activities described in clauses (ii) and (iii).
``(ii) Program support.--The Secretary shall provide,
directly or through a competitive grant process, research,
training and technical assistance, including dissemination of
research and information regarding effective and promising
practices, providing consultation and resources on a broad
array of teen pregnancy prevention strategies, including
abstinence and contraception, and developing resources and
materials to support the activities of recipients of grants
and other State, tribal, and community organizations working
to reduce teen pregnancy. In carrying out such functions, the
Secretary shall collaborate with a variety of entities that
have expertise in the prevention of teen pregnancy, HIV and
sexually transmitted infections, healthy relationships,
financial literacy, and other topics addressed through the
personal responsibility education programs.
``(iii) Evaluation.--The Secretary shall evaluate the
programs and activities carried out with funds made available
through allotments or grants under this section.
``(d) Administration.--
``(1) In general.--The Secretary shall administer this
section through the Assistant Secretary for the
Administration for Children and Families within the
Department of Health and Human Services.
``(2) Application of other provisions of title.--
``(A) In general.--Except as provided in subparagraph (B),
the other provisions of this title shall not apply to
allotments or grants made under this section.
``(B) Exceptions.--The following provisions of this title
shall apply to allotments and grants made under this section
to the same extent and in the same manner as such provisions
apply to allotments made under section 502(c):
``(i) Section 504(b)(6) (relating to prohibition on
payments to excluded individuals and entities).
``(ii) Section 504(c) (relating to the use of funds for the
purchase of technical assistance).
``(iii) Section 504(d) (relating to a limitation on
administrative expenditures).
``(iv) Section 506 (relating to reports and audits), but
only to the extent determined by the Secretary to be
appropriate for grants made under this section.
``(v) Section 507 (relating to penalties for false
statements).
``(vi) Section 508 (relating to nondiscrimination).
``(e) Definitions.--In this section:
``(1) Age-appropriate.--The term `age-appropriate', with
respect to the information in pregnancy prevention, means
topics, messages, and teaching methods suitable to particular
ages or age groups of children and adolescents, based on
developing cognitive, emotional, and behavioral capacity
typical for the age or age group.
``(2) Medically accurate and complete.--The term `medically
accurate and complete' means verified or supported by the
weight of research conducted in compliance with accepted
scientific methods and--
``(A) published in peer-reviewed journals, where
applicable; or
``(B) comprising information that leading professional
organizations and agencies with relevant expertise in the
field recognize as accurate, objective, and complete.
``(3) Indian tribes; tribal organizations.--The terms
`Indian tribe' and `Tribal organization' have the meanings
given such terms in section 4 of the Indian Health Care
Improvement Act (25 U.S.C. 1603)).
``(4) Youth.--The term `youth' means an individual who has
attained age 10 but has not attained age 20.
``(f) Appropriation.--For the purpose of carrying out this
section, there is appropriated, out of any money in the
Treasury not otherwise appropriated, $75,000,000 for each of
fiscal years 2010 through 2014. Amounts appropriated under
this subsection shall remain available until expended.''.
SEC. 2954. RESTORATION OF FUNDING FOR ABSTINENCE EDUCATION.
Section 510 of the Social Security Act (42 U.S.C. 710) is
amended--
(1) in subsection (a), by striking ``fiscal year 1998 and
each subsequent fiscal year'' and inserting ``each of fiscal
years 2010 through 2014''; and
(2) in subsection (d)--
(A) in the first sentence, by striking ``1998 through
2003'' and inserting ``2010 through 2014''; and
(B) in the second sentence, by inserting ``(except that
such appropriation shall be made on the date of enactment of
the Patient Protection and Affordable Care Act in the case of
fiscal year 2010)'' before the period.
SEC. 2955. INCLUSION OF INFORMATION ABOUT THE IMPORTANCE OF
HAVING A HEALTH CARE POWER OF ATTORNEY IN
TRANSITION PLANNING FOR CHILDREN AGING OUT OF
FOSTER CARE AND INDEPENDENT LIVING PROGRAMS.
(a) Transition Planning.--Section 475(5)(H) of the Social
Security Act (42 U.S.C. 675(5)(H)) is amended by inserting
``includes information about the importance of designating
another individual to make health care treatment decisions on
behalf of the child if the child becomes unable to
participate in such decisions and the child does not have, or
does not want, a relative who would otherwise be authorized
under State law to make such decisions, and provides the
child with the option to execute a health care power of
attorney, health care proxy, or other similar document
recognized under State law,'' after ``employment services,''.
(b) Independent Living Education.--Section 477(b)(3) of
such Act (42 U.S.C. 677(b)(3)) is amended by adding at the
end the following:
``(K) A certification by the chief executive officer of the
State that the State will ensure that an adolescent
participating in the program under this section are provided
with education about the importance of designating another
individual to make health care treatment decisions on behalf
of the adolescent if the adolescent becomes unable to
participate in such decisions and the adolescent does not
have, or does not want, a relative who would otherwise be
authorized under State law to make such decisions, whether a
health care power of attorney, health care proxy, or other
similar document is recognized under State law, and how to
execute such a document if the adolescent wants to do so.''.
(c) Health Oversight and Coordination Plan.--Section
422(b)(15)(A) of such Act (42 U.S.C. 622(b)(15)(A)) is
amended--
(1) in clause (v), by striking ``and'' at the end; and
(2) by adding at the end the following:
``(vii) steps to ensure that the components of the
transition plan development process required under section
475(5)(H) that relate to the health care needs of children
aging out of foster care, including the requirements to
include options for health insurance, information about a
health care power of attorney, health care proxy, or other
similar document recognized under State law, and to provide
the child with the option to execute such a document, are
met; and''.
(d) Effective Date.--The amendments made by this section
take effect on October 1, 2010.
TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE
Subtitle A--Transforming the Health Care Delivery System
PART I--LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM
SEC. 3001. HOSPITAL VALUE-BASED PURCHASING PROGRAM.
(a) Program.--
(1) In general.--Section 1886 of the Social Security Act
(42 U.S.C. 1395ww), as amended by section 4102(a) of the
HITECH Act (Public Law 111-5), is amended by adding at the
end the following new subsection:
``(o) Hospital Value-Based Purchasing Program.--
``(1) Establishment.--
``(A) In general.--Subject to the succeeding provisions of
this subsection, the Secretary shall establish a hospital
value-based purchasing program (in this subsection referred
to as the `Program') under which value-based incentive
payments are made in a fiscal year to hospitals that meet the
performance standards under paragraph (3) for the performance
period for such fiscal year (as established under paragraph
(4)).
``(B) Program to begin in fiscal year 2013.--The Program
shall apply to payments for discharges occurring on or after
October 1, 2012.
``(C) Applicability of program to hospitals.--
``(i) In general.--For purposes of this subsection, subject
to clause (ii), the term `hospital' means a subsection (d)
hospital (as defined in subsection (d)(1)(B)).
``(ii) Exclusions.--The term `hospital' shall not include,
with respect to a fiscal year, a hospital--
``(I) that is subject to the payment reduction under
subsection (b)(3)(B)(viii)(I) for such fiscal year;
``(II) for which, during the performance period for such
fiscal year, the Secretary has cited deficiencies that pose
immediate jeopardy to the health or safety of patients;
``(III) for which there are not a minimum number (as
determined by the Secretary) of measures that apply to the
hospital for the performance period for such fiscal year; or
[[Page H1982]]
``(IV) for which there are not a minimum number (as
determined by the Secretary) of cases for the measures that
apply to the hospital for the performance period for such
fiscal year.
``(iii) Independent analysis.--For purposes of determining
the minimum numbers under subclauses (III) and (IV) of clause
(ii), the Secretary shall have conducted an independent
analysis of what numbers are appropriate.
``(iv) Exemption.--In the case of a hospital that is paid
under section 1814(b)(3), the Secretary may exempt such
hospital from the application of this subsection if the State
which is paid under such section submits an annual report to
the Secretary describing how a similar program in the State
for a participating hospital or hospitals achieves or
surpasses the measured results in terms of patient health
outcomes and cost savings established under this subsection.
``(2) Measures.--
``(A) In general.--The Secretary shall select measures for
purposes of the Program. Such measures shall be selected from
the measures specified under subsection (b)(3)(B)(viii).
``(B) Requirements.--
``(i) For fiscal year 2013.--For value-based incentive
payments made with respect to discharges occurring during
fiscal year 2013, the Secretary shall ensure the following:
``(I) Conditions or procedures.--Measures are selected
under subparagraph (A) that cover at least the following 5
specific conditions or procedures:
``(aa) Acute myocardial infarction (AMI).
``(bb) Heart failure.
``(cc) Pneumonia.
``(dd) Surgeries, as measured by the Surgical Care
Improvement Project (formerly referred to as `Surgical
Infection Prevention' for discharges occurring before July
2006).
``(ee) Healthcare-associated infections, as measured by the
prevention metrics and targets established in the HHS Action
Plan to Prevent Healthcare-Associated Infections (or any
successor plan) of the Department of Health and Human
Services.
``(II) HCAHPS.--Measures selected under subparagraph (A)
shall be related to the Hospital Consumer Assessment of
Healthcare Providers and Systems survey (HCAHPS).
``(ii) Inclusion of efficiency measures.--For value-based
incentive payments made with respect to discharges occurring
during fiscal year 2014 or a subsequent fiscal year, the
Secretary shall ensure that measures selected under
subparagraph (A) include efficiency measures, including
measures of `Medicare spending per beneficiary'. Such
measures shall be adjusted for factors such as age, sex,
race, severity of illness, and other factors that the
Secretary determines appropriate.
``(C) Limitations.--
``(i) Time requirement for prior reporting and notice.--The
Secretary may not select a measure under subparagraph (A) for
use under the Program with respect to a performance period
for a fiscal year (as established under paragraph (4)) unless
such measure has been specified under subsection
(b)(3)(B)(viii) and included on the Hospital Compare Internet
website for at least 1 year prior to the beginning of such
performance period.
``(ii) Measure not applicable unless hospital furnishes
services appropriate to the measure.--A measure selected
under subparagraph (A) shall not apply to a hospital if such
hospital does not furnish services appropriate to such
measure.
``(D) Replacing measures.--Subclause (VI) of subsection
(b)(3)(B)(viii) shall apply to measures selected under
subparagraph (A) in the same manner as such subclause applies
to measures selected under such subsection.
``(3) Performance standards.--
``(A) Establishment.--The Secretary shall establish
performance standards with respect to measures selected under
paragraph (2) for a performance period for a fiscal year (as
established under paragraph (4)).
``(B) Achievement and improvement.--The performance
standards established under subparagraph (A) shall include
levels of achievement and improvement.
``(C) Timing.--The Secretary shall establish and announce
the performance standards under subparagraph (A) not later
than 60 days prior to the beginning of the performance period
for the fiscal year involved.
``(D) Considerations in establishing standards.--In
establishing performance standards with respect to measures
under this paragraph, the Secretary shall take into account
appropriate factors, such as--
``(i) practical experience with the measures involved,
including whether a significant proportion of hospitals
failed to meet the performance standard during previous
performance periods;
``(ii) historical performance standards;
``(iii) improvement rates; and
``(iv) the opportunity for continued improvement.
``(4) Performance period.--For purposes of the Program, the
Secretary shall establish the performance period for a fiscal
year. Such performance period shall begin and end prior to
the beginning of such fiscal year.
``(5) Hospital performance score.--
``(A) In general.--Subject to subparagraph (B), the
Secretary shall develop a methodology for assessing the total
performance of each hospital based on performance standards
with respect to the measures selected under paragraph (2) for
a performance period (as established under paragraph (4)).
Using such methodology, the Secretary shall provide for an
assessment (in this subsection referred to as the `hospital
performance score') for each hospital for each performance
period.
``(B) Application.--
``(i) Appropriate distribution.--The Secretary shall ensure
that the application of the methodology developed under
subparagraph (A) results in an appropriate distribution of
value-based incentive payments under paragraph (6) among
hospitals achieving different levels of hospital performance
scores, with hospitals achieving the highest hospital
performance scores receiving the largest value-based
incentive payments.
``(ii) Higher of achievement or improvement.--The
methodology developed under subparagraph (A) shall provide
that the hospital performance score is determined using the
higher of its achievement or improvement score for each
measure.
``(iii) Weights.--The methodology developed under
subparagraph (A) shall provide for the assignment of weights
for categories of measures as the Secretary determines
appropriate.
``(iv) No minimum performance standard.--The Secretary
shall not set a minimum performance standard in determining
the hospital performance score for any hospital.
``(v) Reflection of measures applicable to the hospital.--
The hospital performance score for a hospital shall reflect
the measures that apply to the hospital.
``(6) Calculation of value-based incentive payments.--
``(A) In general.--In the case of a hospital that the
Secretary determines meets (or exceeds) the performance
standards under paragraph (3) for the performance period for
a fiscal year (as established under paragraph (4)), the
Secretary shall increase the base operating DRG payment
amount (as defined in paragraph (7)(D)), as determined after
application of paragraph (7)(B)(i), for a hospital for each
discharge occurring in such fiscal year by the value-based
incentive payment amount.
``(B) Value-based incentive payment amount.--The value-
based incentive payment amount for each discharge of a
hospital in a fiscal year shall be equal to the product of--
``(i) the base operating DRG payment amount (as defined in
paragraph (7)(D)) for the discharge for the hospital for such
fiscal year; and
``(ii) the value-based incentive payment percentage
specified under subparagraph (C) for the hospital for such
fiscal year.
``(C) Value-based incentive payment percentage.--
``(i) In general.--The Secretary shall specify a value-
based incentive payment percentage for a hospital for a
fiscal year.
``(ii) Requirements.--In specifying the value-based
incentive payment percentage for each hospital for a fiscal
year under clause (i), the Secretary shall ensure that--
``(I) such percentage is based on the hospital performance
score of the hospital under paragraph (5); and
``(II) the total amount of value-based incentive payments
under this paragraph to all hospitals in such fiscal year is
equal to the total amount available for value-based incentive
payments for such fiscal year under paragraph (7)(A), as
estimated by the Secretary.
``(7) Funding for value-based incentive payments.--
``(A) Amount.--The total amount available for value-based
incentive payments under paragraph (6) for all hospitals for
a fiscal year shall be equal to the total amount of reduced
payments for all hospitals under subparagraph (B) for such
fiscal year, as estimated by the Secretary.
``(B) Adjustment to payments.--
``(i) In general.--The Secretary shall reduce the base
operating DRG payment amount (as defined in subparagraph (D))
for a hospital for each discharge in a fiscal year (beginning
with fiscal year 2013) by an amount equal to the applicable
percent (as defined in subparagraph (C)) of the base
operating DRG payment amount for the discharge for the
hospital for such fiscal year. The Secretary shall make such
reductions for all hospitals in the fiscal year involved,
regardless of whether or not the hospital has been determined
by the Secretary to have earned a value-based incentive
payment under paragraph (6) for such fiscal year.
``(ii) No effect on other payments.--Payments described in
items (aa) and (bb) of subparagraph (D)(i)(II) for a hospital
shall be determined as if this subsection had not been
enacted.
``(C) Applicable percent defined.--For purposes of
subparagraph (B), the term `applicable percent' means--
``(i) with respect to fiscal year 2013, 1.0 percent;
``(ii) with respect to fiscal year 2014, 1.25 percent;
``(iii) with respect to fiscal year 2015, 1.5 percent;
``(iv) with respect to fiscal year 2016, 1.75 percent; and
``(v) with respect to fiscal year 2017 and succeeding
fiscal years, 2 percent.
``(D) Base operating drg payment amount defined.--
``(i) In general.--Except as provided in clause (ii), in
this subsection, the term `base operating DRG payment amount'
means, with respect to a hospital for a fiscal year--
``(I) the payment amount that would otherwise be made under
subsection (d) (determined without regard to subsection (q))
for a discharge if this subsection did not apply; reduced by
``(II) any portion of such payment amount that is
attributable to--
``(aa) payments under paragraphs (5)(A), (5)(B), (5)(F),
and (12) of subsection (d); and
``(bb) such other payments under subsection (d) determined
appropriate by the Secretary.
``(ii) Special rules for certain hospitals.--
``(I) Sole community hospitals and medicare-dependent,
small rural hospitals.--In the case of a medicare-dependent,
small rural hospital (with respect to discharges occurring
during fiscal year 2012 and 2013) or a sole community
hospital, in applying subparagraph (A)(i), the payment amount
that would otherwise be made under subsection (d) shall be
determined without regard to subparagraphs (I)
[[Page H1983]]
and (L) of subsection (b)(3) and subparagraphs (D) and (G) of
subsection (d)(5).
``(II) Hospitals paid under section 1814.--In the case of a
hospital that is paid under section 1814(b)(3), the term
`base operating DRG payment amount' means the payment amount
under such section.
``(8) Announcement of net result of adjustments.--Under the
Program, the Secretary shall, not later than 60 days prior to
the fiscal year involved, inform each hospital of the
adjustments to payments to the hospital for discharges
occurring in such fiscal year under paragraphs (6) and
(7)(B)(i).
``(9) No effect in subsequent fiscal years.--The value-
based incentive payment under paragraph (6) and the payment
reduction under paragraph (7)(B)(i) shall each apply only
with respect to the fiscal year involved, and the Secretary
shall not take into account such value-based incentive
payment or payment reduction in making payments to a hospital
under this section in a subsequent fiscal year.
``(10) Public reporting.--
``(A) Hospital specific information.--
``(i) In general.--The Secretary shall make information
available to the public regarding the performance of
individual hospitals under the Program, including--
``(I) the performance of the hospital with respect to each
measure that applies to the hospital;
``(II) the performance of the hospital with respect to each
condition or procedure; and
``(III) the hospital performance score assessing the total
performance of the hospital.
``(ii) Opportunity to review and submit corrections.--The
Secretary shall ensure that a hospital has the opportunity to
review, and submit corrections for, the information to be
made public with respect to the hospital under clause (i)
prior to such information being made public.
``(iii) Website.--Such information shall be posted on the
Hospital Compare Internet website in an easily understandable
format.
``(B) Aggregate information.--The Secretary shall
periodically post on the Hospital Compare Internet website
aggregate information on the Program, including--
``(i) the number of hospitals receiving value-based
incentive payments under paragraph (6) and the range and
total amount of such value-based incentive payments; and
``(ii) the number of hospitals receiving less than the
maximum value-based incentive payment available to the
hospital for the fiscal year involved and the range and
amount of such payments.
``(11) Implementation.--
``(A) Appeals.--The Secretary shall establish a process by
which hospitals may appeal the calculation of a hospital's
performance assessment with respect to the performance
standards established under paragraph (3)(A) and the hospital
performance score under paragraph (5). The Secretary shall
ensure that such process provides for resolution of such
appeals in a timely manner.
``(B) Limitation on review.--Except as provided in
subparagraph (A), there shall be no administrative or
judicial review under section 1869, section 1878, or
otherwise of the following:
``(i) The methodology used to determine the amount of the
value-based incentive payment under paragraph (6) and the
determination of such amount.
``(ii) The determination of the amount of funding available
for such value-based incentive payments under paragraph
(7)(A) and the payment reduction under paragraph (7)(B)(i).
``(iii) The establishment of the performance standards
under paragraph (3) and the performance period under
paragraph (4).
``(iv) The measures specified under subsection
(b)(3