110th CONGRESS
1st Session
H. R. 1841
To amend the Social Security Act and the Internal Revenue Code
of 1986 to provide for an AmeriCare that assures the provision of health
insurance coverage to all residents, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
March 29, 2007
Mr. STARK (for himself, Ms. SCHAKOWSKY, Mr. BECERRA, Ms. CORRINE BROWN
of Florida, Ms. CARSON, Mrs. CHRISTENSEN, Mr. COHEN, Mr. CONYERS, Mr. FILNER,
Mr. GRIJALVA, Mr. HINCHEY, Ms. NORTON, Mr. JACKSON of Illinois, Ms. KILPATRICK,
Ms. LEE, Mr. LEWIS of Georgia, Mr. MCNULTY, Mr. GEORGE MILLER of California,
Mr. NADLER, Mr. PASTOR, Mr. RANGEL, Mr. THOMPSON of Mississippi, Mr. TOWNS,
Mr. WAXMAN, and Ms. WOOLSEY) introduced the following bill; which was referred
to the Committee on Energy and Commerce, and in addition to the Committees
on Ways and Means and Education and Labor, for a period to be subsequently
determined by the Speaker, in each case for consideration of such provisions
as fall within the jurisdiction of the committee concerned
A BILL
To amend the Social Security Act and the Internal Revenue Code
of 1986 to provide for an AmeriCare that assures the provision of health
insurance coverage to all residents, and for other purposes.
Be it enacted by the Senate and House of Representatives of the United
States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) SHORT TITLE- This Act may be cited as the `AmeriCare Health Care Act
of 2007'.
(b) TABLE OF CONTENTS- The table of contents of this Act is as follows:
Sec. 1. Short title; table of contents.
TITLE I--HEALTH CARE ELIGIBILITY AND BENEFITS
Sec. 101. Eligibility and benefits.
`TITLE XXII--AMERICARE HEALTH BENEFITS
`Part A--Eligibility
`Sec. 2201. Eligibility.
`Sec. 2202. Enrollment and AmeriCare cards.
`Part B--Benefits
`Sec. 2221. Scope of benefits.
`Sec. 2222. Exclusions.
`Part C--Payment for Benefits and Financing
`Sec. 2241. Payments for benefits.
`Sec. 2242. AmeriCare Trust Fund.
`Part D--Administrative Simplification
`Sec. 2251. Requirement for entitlement verification system.
`Sec. 2252. Requirements for uniform claims and electronic claims data
set.
`Sec. 2253. Electronic medical records and reporting.
`Sec. 2254. Uniform hospital cost reporting.
`Sec. 2255. Health service provider defined.
`Part E--General Provisions
`Sec. 2261. Definitions relating to beneficiaries and income.
`Sec. 2262. Incorporation of certain medicare provisions and other provisions.
`Sec. 2263. State maintenance of effort payments.
`Sec. 2264. Modification of medicaid and other programs to avoid duplication
of benefits.
`Sec. 2265. Construction regarding continuation of obligations under current
group health plan contracts and provision of additional benefits.
`Sec. 2266. Standards and requirements for AmeriCare supplemental policies.
TITLE II--FINANCING PROVISIONS
Subtitle A--Individual Contributions
Sec. 201. General obligation for individuals.
Sec. 202. Additional premium subsidies.
Sec. 203. Effective date.
Subtitle B--Employer Contributions
Sec. 211. General obligation for employers.
Sec. 212. Effective date.
TITLE I--HEALTH CARE ELIGIBILITY AND BENEFITS
SEC. 101. ELIGIBILITY AND BENEFITS.
(a) IN GENERAL- The Social Security Act is amended by adding at the end
the following new title:
`TITLE XXII--AMERICARE HEALTH BENEFITS
`Part A--Eligibility
`SEC. 2201. ELIGIBILITY.
`(a) UNIVERSAL ELIGIBILITY FOR RESIDENTS-
`(1) IN GENERAL- Except as provided in section 2263(a), each individual
who is a resident of the United States is entitled to health insurance
benefits under this title.
`(2) EFFECTIVE DATE FOR BENEFITS- This title shall apply to items and
services furnished on or after January 1, 2010.
`(b) SPECIAL ELIGIBILITY GROUPS- For purposes of this title, an individual
described in subsection (a) may obtain special benefits under this title
on the basis of one or more of the following special eligibility groups:
`(1) Children (as defined in section 2261(a)(1)).
`(2) Low-income individuals (as defined in section 2261(a)(2)).
`(3) Pregnant women (as defined in section 2261(a)(3)).
`(c) RECIPROCAL COVERAGE OF NONRESIDENTS- An individual who--
`(1) is not a resident of the United States,
`(2) is in the United States, and
`(3) is a national of a foreign state which provides health benefits to
nationals of the United States who are nonresidents in that state,
is entitled to such health insurance benefits under this title, but only
to the extent the Secretary determines that such benefits would be available
to nationals of the United States similarly situated as a nonresident in
the foreign state.
`SEC. 2202. ENROLLMENT AND AMERICARE CARDS.
`(a) ENROLLMENT- The Secretary shall provide a mechanism for the enrollment
of individuals entitled to benefits under this title and, in conjunction
with such enrollment, the issuance of an AmeriCare card which may be used
for purposes of identification and processing of claims for benefits under
this title. AmeriCare cards shall identify (as appropriate) the date of
birth (for purposes of identifying children) and provide a coded means for
identifying whether the individual is a low-income individual for the year
involved.
`(b) CLASSES OF ENROLLMENT- The mechanism under subsection (a) shall provide
for individuals to be enrolled on the basis of the following classes of
enrollment:
`(1) Coverage only of an individual.
`(2) Coverage of a married couple without children.
`(3) Coverage of an unmarried individual and one or more children.
`(4) Coverage of a married couple and one or more children.
`(c) ENROLLMENT AT BIRTH- The mechanism under subsection (a) shall include
a process for the automatic enrollment of individuals at the time of birth
in the United States.
`(d) OPT OUT FOR THOSE COVERED UNDER GROUP HEALTH PLAN- Notwithstanding
any other provision of this title, an individual may elect not to be enrolled
for benefits under this title if the individual demonstrates to the satisfaction
of the Secretary that the individual has health benefits coverage under
a group health plan (as defined in section 5000(b)(1) of the Internal Revenue
Code of 1986) that is at least equivalent to the coverage otherwise provided
under this title, as certified by the Secretary.
`Part B--Benefits
`SEC. 2221. SCOPE OF BENEFITS.
`(a) IN GENERAL- Except as provided in the succeeding provisions of this
part, the benefits provided to an individual described in section 2201(a)
by the program established by this title shall consist of entitlement to
the same benefits as are provided under parts A and B of title XVIII to
individuals entitled to benefits under part A, and enrolled under part B,
of title XVIII.
`(b) CHANGE IN THE COST-SHARING-
`(1) DEDUCTIBLE- Except as provided in the succeeding provisions of this
part, the amount of expenses (other than expenses for benefits described
in subsection (c)) with respect to which an individual is entitled to
have payment made under this title for any year shall first be reduced
by a deductible of $350, except that in no case shall the amount of the
deductible for all the members of a family exceed $500. Such deductible
shall be instead of the deductible for inpatient hospital services under
the first sentence of section 1813(a)(1) and the deductible under section
1833(b).
`(2) COINSURANCE- After the application of the deductible under paragraph
(1), the expenses referred to in such paragraph shall be subject to a
coinsurance of 20 percent until the limit on out-of-pocket expenses under
paragraph (3) is met.
`(3) LIMIT ON OUT-OF-POCKET EXPENSES AND TOTAL EXPENSES-
`(A) LIMITATION ON COST-SHARING- Subject to subparagraph (B), whenever
in a calendar year an individual's expenses for the deductible and coinsurance
with respect to services covered under this title (including expenses
for benefits described in subsection (c)) and furnished during the year
equals $2,500, or $4,000 for all the members of a family, payment of
benefits under this title for the individual (or for the members of
such family, respectively) for services furnished during the remainder
of the year shall be paid without the application of any coinsurance.
`(B) LIMITATION ON PREMIUMS AND COST-SHARING FOR CERTAIN INDIVIDUALS
BASED ON INCOME-
`(i) INCOME BETWEEN 200 AND 300 PERCENT OF POVERTY LINE- In the case
of a family whose applicable modified gross income (expressed as a
percentage of the poverty level, as defined in section 2261(b)(2))
is equal to or exceeds 200 percent, but does not exceed 300 percent,
of the poverty level applicable to a family of the size involved,
whenever in a calendar year an individual's expenses in the family
for premiums under this title and for the deductible and coinsurance
with respect to services covered under this title (including expenses
for benefits described in subsection (c)) and furnished during the
year equals 5 percent of the amount of such applicable modified gross
income for the family--
`(I) no additional premiums shall be imposed for remaining months
in the year; and
`(II) payment of benefits under this title for members of such family
for services furnished during the remainder of the year shall be
paid without the application of any deductible or coinsurance.
`(ii) INCOME BETWEEN 300 AND 500 PERCENT OF POVERTY LINE- In the case
of a family whose applicable modified gross income (expressed as a
percentage of the poverty level, as defined in section 2261(b)(2))
exceeds 300 percent, but does not exceed 500 percent, of such poverty
level applicable to a family of the size involved, whenever in a calendar
year an individual's expenses in the family for premiums under this
title and for the deductible and coinsurance with respect to services
covered under this title (including expenses for benefits described
in subsection (c)) and furnished during the year equals 7.5 percent
of the amount of such applicable modified gross income for the family--
`(I) no additional premiums shall be imposed for remaining months
in the year; and
`(II) payment of benefits under this title for members of such family
for services furnished during the remainder of the year shall be
paid without the application of any deductible or coinsurance.
`(C) COUNTING ALL EXPENSES FOR PREMIUMS, DEDUCTIBLES AND COINSURANCE
WITHOUT REGARD TO TRUE OUT-OF-POCKET COSTS- In applying subparagraphs
(A) and (B), expenses for an individual's premiums, deductible, and
coinsurance shall be counted without regard to whether such expenses
are paid, payable, reimbursed, or reimbursable by another person, including
through a group health plan, insurance or otherwise, or other third
party payment arrangement.
`(4) INDEXING DOLLAR AMOUNTS BY CPI- Each dollar amount specified in paragraphs
(1) and (3)(A) shall be increased to the year involved by the compounded
sum of the increase in the consumer price index for all urban consumers
(U.S. City average, as published by the Bureau of Labor Statistics of
the Department of Labor) for each year after 2007 and up to the year involved.
Any increase under this paragraph for a year shall be rounded, with respect
to paragraph (1), to the nearest multiple of $5 and, with respect to paragraph
(2), to the nearest multiple of $100.
`(c) PRESCRIPTION DRUGS- Benefits shall also be made available under this
title (as specified by the Secretary) for prescription drugs and biologicals
which are not less than the benefits for such drugs and biologicals under
the standard option for the service benefit plan described in section 8903(1)
of title 5, United States Code, offered during 2006.
`(1) NO DEDUCTIBLES OR COINSURANCE- In the case of children (as defined
in section 2261(a)(1)), there shall be no deductible or coinsurance applicable
to covered benefits (including benefits described in paragraphs (2) and
(3)).
`(2) ADDITIONAL PREVENTIVE BENEFITS-
`(A) IN GENERAL- Subject to the periodicity schedule established with
respect to the services under subparagraph (B), for children benefits
shall be available under this title for the following items and services:
`(i) Newborn and well-baby care, including normal newborn care and
pediatrician services for high-risk deliveries.
`(ii) Well-child care, including routine office visits, routine immunizations
(including the vaccine itself), routine laboratory tests, and preventive
dental care.
`(B) PERIODICITY SCHEDULE- The Secretary, in consultation with the American
Academy of Pediatrics and the American Dental Association, shall establish
a schedule of periodicity which reflects the general, appropriate frequency
with which services listed in subparagraph (A) should be provided to
healthy children.
`(3) COVERAGE OF EPSDT- For children, benefits also shall be available
under this title for early and periodic screening, diagnostic, and treatment
services (as defined in section 1905(r)) not otherwise covered under paragraph
(2).
`(4) OTHER ADDITIONAL SERVICES FOR CHILDREN- For children, benefits also
shall be available under this title for the following:
`(A) Inpatient hospital services (without regard to the restrictions
described in subsections (a)(1) and (b)(1) of section 1812 and the coinsurance
described in section 1813(a)(1)).
`(B) Eyeglasses and hearing aids, and examinations therefor.
`(e) PREGNANCY-RELATED SERVICES- In the case of a pregnant woman (as defined
in section 2261(a)(3)), benefits under this title shall include entitlement
to have payment made for the following, without the application of a deductible
or coinsurance:
`(1) Prenatal care, including care for all complications of pregnancy.
`(2) Inpatient labor and delivery services.
`(f) LOWER-INCOME INDIVIDUALS-
`(1) LIMITATIONS ON DEDUCTIBLES AND COINSURANCE-
`(A) NONE FOR LOW-INCOME INDIVIDUALS- In the case of a low-income individual,
there shall be no deductible or coinsurance under this title.
`(B) PHASE-IN FOR OTHER LOWER-INCOME INDIVIDUALS- In the case of an
individual whose applicable modified gross income (as defined in section
2261(b)(1)) exceeds twice the poverty level (as defined in section 2261(b)(2))
but does not exceed three times the poverty level, the deductible and
coinsurance applicable under this title shall bear the same ratio to
the deductible or coinsurance otherwise applicable as--
`(i) the excess of the applicable modified gross income over the poverty
level, bears to
If the ratio determined under the preceding sentence is not a multiple
of 25 percentage points, such ratio shall be rounded to the nearest
25 percentage points.
`(2) ADDITIONAL BENEFITS FOR LOW-INCOME INDIVIDUALS- In the case of low-income
individuals (as defined in section 2261(a)(2)), benefits under this title
shall also include entitlement to have payment made for the following,
without the application of a deductible or coinsurance:
`(A) Inpatient hospital services (without regard to the restrictions
described in subsections (a)(1) and (b)(1) of section 1812 and the coinsurance
described in section 1813(a)(1)).
`(B) Eyeglasses and hearing aids and examinations therefor.
`(g) PREVENTIVE BENEFITS- Benefits shall also be made available under this
title, without the application of any deductible or coinsurance for preventive
services that are recommended by the United States Preventive Services Task
Force.
`(h) MENTAL HEALTH PARITY AND SUBSTANCE ABUSE BENEFITS- Benefits shall be
made available under this title for mental health services and for substance
abuse treatment in the same manner as such benefits are made available for
medical and surgical services.
`(i) FAMILY PLANNING SERVICES- Benefits shall be made available under this
title for family planning services.
`(j) CONFORMING MEDICARE BENEFITS- Notwithstanding any other provision of
law, benefits under title XVIII shall be expanded and conformed to the benefits
made available under this title (including the application of a single deductible
and uniform coinsurance amounts, a limitation on the coinsurance, and additional
benefits for low-income individuals under subsection (f)), but nothing in
this subsection shall be construed as providing for any such additional
benefits under this title rather than under such title.
`(k) Enrollment in Health Plans- The Secretary shall provide for the offering
of benefits under this title through enrollment in a health benefit plan
that meets the same (or similar) requirements as the requirements that apply
to Medicare Advantage plans under part C of title XVIII (other than any
such requirements that relate to part D of such title). In the case of individuals
enrolled under this title in such a plan, the payment rate to the plan under
this title shall be based on adjusted average per capita cost (AAPCC) payment
rate methodology described in section 1853(c)(1)(D) for benefits under this
title and for individuals entitled to benefits under this title who are
not enrolled in such a plan.
`SEC. 2222. EXCLUSIONS.
`(a) IN GENERAL- Except as provided in this section, section 1862 shall
apply to expenses incurred for items and services provided under this title
the same manner as such section applies to items and services provided under
title XVIII.
`(1) CHILDREN'S SERVICES- In applying section 1862(a) with respect to
services described in section 2221(d)(2)(A) (relating to well-child services),
payment shall not be denied under paragraph (1), (7), or (12) of such
section 1862(a) if the services are provided in accordance with the periodicity
schedule described in section 2221(d)(2)(B).
`(2) TREATMENT OF EYEGLASSES AND HEARING AIDS FOR CHILDREN AND LOW-INCOME
INDIVIDUALS- Payment shall not be denied under this title under section
1862(a)(7) with respect to eyeglasses and hearing aids and examinations
therefor in the case of children and low-income individuals.
`(c) COORDINATION OF PAYMENTS-
`(1) PRIMARY TO GROUP HEALTH PLANS- Section 1862(b)(1) (relating to requirements
of group health plans) shall not apply under this title.
`(2) SECONDARY TO MEDICARE- Payment shall not be made under this title
with respect to benefits to the extent that payment for such benefits
may be made under title XVIII.
`Part C--Payment for Benefits and Financing
`SEC. 2241. PAYMENTS FOR BENEFITS.
`(a) IN GENERAL- Except as otherwise provided in this section and in section
2221--
`(1) payment of benefits under this title with respect to benefits shall
be made on the same basis as payment is made with respect to such benefits
under title XVIII, and
`(2) the provisions of sections 1814, 1833, 1834, 1842, 1848, and 1886
shall apply to payment of benefits under this title in the same manner
as they apply to benefits under title XVIII.
`(b) NO EXTRA BILLING PERMITTED- Payment under this title may only be made
on an assignment-related basis (as defined in section 1842(i)(1)). If an
entity knowingly and willfully presents or causes to be presented a claim
or bills an individual enrolled under this title for charges for services
other than on an assignment-related basis, the Secretary may apply sanctions
against such entity in accordance with section 1842(j)(2).
`(c) ADJUSTMENT OF PAYMENTS-
`(1) ESTABLISHMENT OF NEW DRGS AND WEIGHTS- In making payment under this
title with respect to inpatient hospital services, the Secretary shall
establish such additional diagnosis-related groups (and weighting factors
with respect to discharges within such groups) and make such adjustments
in the diagnosis-related groups and weighting factors with respect to
discharges within such groups otherwise established under section 1886(d)(4)
as may be necessary to reflect the types of discharges occurring under
this title which are not occurring under title XVIII.
`(2) PAYMENT FOR OBSTETRICAL SERVICES-
`(A) GLOBAL FEE- In making payment under this title with respect to
the group of obstetrical services typical of treatment throughout a
course of pregnancy, the Secretary shall establish, as a schedule under
section 1848, a global fee with respect to such group of services.
`(B) BONUS FOR EARLY PRESENTATION- The fee schedule amount with respect
to obstetrical services under this title shall be increased by 5 percent
in the case of services furnished to women who have presented for prenatal
care during the first trimester.
`(d) CONDITIONS OF AND LIMITATIONS ON PAYMENTS- The provisions of sections
1814 and 1835 shall apply to payment for services under this title in the
same manner as they apply to payment for services under parts A and B, respectively,
of title XVIII.
`(e) USE OF TRUST FUND- In carrying out this section, any reference in title
XVIII to a trust fund shall be treated as a reference to the AmeriCare Trust
Fund established under section 2242.
`(f) PAYMENT FOR OUTPATIENT PRESCRIPTION DRUGS AND BIOLOGICALS- The Secretary
shall establish a fee schedule for the payment for outpatient prescription
drugs and biologicals under this title and, notwithstanding section 1860D-11(i)(1),
under title XVIII. The Secretary shall negotiate with pharmaceutical manufacturers
with respect to the purchase price of such drugs and biologicals and shall
encourage the use of more affordable therapeutic equivalents to the extent
such practices do not override medical necessity, as determined by the prescribing
physician. To the extent practicable and consistent with the previous sentence,
the Secretary shall implement strategies similar to those used by other
Federal purchasers of prescription drugs, and other strategies, to reduce
the purchase cost of outpatient prescription drugs and biologicals.
`SEC. 2242. AMERICARE TRUST FUND.
`(a) ESTABLISHMENT- (1) There is hereby created on the books of the Treasury
of the United States a trust fund to be known as the `AmeriCare Trust Fund'
(in this section referred to as the `Trust Fund'). The Trust Fund shall
consist of such gifts and bequests as may be made as provided in section
201(i)(1) and amounts appropriated under paragraph (2).
`(2) There are hereby appropriated to the Trust Fund amounts equivalent
to 100 percent of the increase in revenues to the Treasury by reason of
the provisions of and amendments made by title II of the AmeriCare Health
Care Act of 2007. The amounts appropriated by the preceding sentence shall
be transferred from time to time from the general fund in the Treasury to
the Trust Fund, such amounts to be determined on the basis of estimates
by the Secretary of the Treasury of the increase in revenues which are paid
to or deposited into the Treasury; and proper adjustments shall be made
in amounts subsequently transferred to the extent prior estimates were in
excess of or were less than such increase.
`(b) INCORPORATION OF PROVISIONS-
`(1) IN GENERAL- Subject to paragraph (2), the provisions of subsections
(b) through (e) and (g) through (i) of section 1817 shall apply to the
Trust Fund in the same manner as they apply to the Federal Hospital Insurance
Trust Fund.
`(2) EXCEPTIONS- In applying paragraph (1)--
`(A) the Board of Trustees and Managing Trustee of the Trust Fund shall
be composed of the members of the Board of Trustees and the Managing
Trustee, respectively, of the Federal Hospital Insurance Trust Fund;
and
`(B) any reference in section 1817 to the Federal Hospital Insurance
Trust Fund or to title XVIII (or part A thereof) is deemed a reference
to the Trust Fund under this section and this title, respectively.
`Part D--Administrative Simplification
`SEC. 2251. REQUIREMENT FOR ENTITLEMENT VERIFICATION SYSTEM.
`(1) REQUIREMENT- The Secretary with respect to the plan provided under
this title, and each AmeriCare supplemental plan (as defined in section
2279(3)), shall provide for an electronic system, that is certified by
the Secretary as meeting the standards established under subsection (b),
for the verification of an individual's entitlement to benefits under
such plan.
`(2) DEADLINE FOR APPLICATION OF REQUIREMENT- The deadline specified under
this paragraph for the requirement under paragraph (1) is 6 months after
the date the standards are established under subsection (b).
`(b) STANDARDS FOR ENTITLEMENT VERIFICATION SYSTEMS-
`(1) IN GENERAL- The Secretary shall establish standards consistent with
this subsection respecting the requirements for certification of entitlement
verification systems.
`(2) INFORMATION AVAILABLE- Such standards shall require a system to provide
information, with respect to individuals, concerning the following:
`(A) The specific benefits to which the individual is entitled under
the plan.
`(B) Current status of the individual with respect to fulfillment of
deductibles, coinsurance, and out-of-pocket limits on cost-sharing.
`(C) Restrictions on providers who may provide covered services, including
utilization controls (such as preadmission certification).
`(3) FORM OF INQUIRY- Each verification system shall be capable of accepting
inquiries under this subsection from health care providers in a variety
of electronic forms. The system shall also provide, for an additional
fee, for the acceptance of inquiries in a nonelectronic form.
`(4) FORM OF RESPONSE- Each such system shall be capable of responding
to such inquiries under this subsection in a variety of electronic and
other forms, including--
`(A) through modem transmission of information,
`(B) through computer synthesized voice communication, and
`(C) through transmission of information to a facsimile (fax) machine.
The system shall also provide, for an additional fee, for the response
to inquiries in a nonelectronic form.
`(5) LIMITATION ON FEES- Neither the Secretary nor an AmeriCare supplemental
plan may impose a fee for the acceptance or response to an inquiry under
this subsection except where the acceptance or response is in a nonelectronic
form.
`(6) WEBSITE AVAILABILITY TO PROVIDERS- The Secretary shall establish
and maintain a website through which--
`(A) health service providers may make inquiries, and receive responses,
with respect to the eligibility and benefits of an individual under
plans; and
`(B) AmeriCare supplemental plans may make inquiries, and receive responses,
to determine the liability of other plans for the provision or payment
of benefits.
`(7) DEADLINE- The Secretary shall first establish the standards under
this subsection (and shall establish the website under paragraph (6))
by not later than 12 months after the date of the enactment of this title.
`SEC. 2252. REQUIREMENTS FOR UNIFORM CLAIMS AND ELECTRONIC CLAIMS DATA
SET.
`(1) SUBMISSION OF CLAIMS- Each health service provider that furnishes
services in the United States for which payment may be made under this
title or under an AmeriCare supplemental plan shall submit any claim for
payment for such services only in a form and manner consistent with standards
established under subsection (c).
`(2) ACCEPTANCE OF CLAIMS- The Secretary and an AmeriCare supplemental
plan may not reject a claim for payment under this title or the plan on
the basis of the form or manner in which the claim is submitted if the
claim is submitted in accordance with the standards established under
subsection (c).
`(3) EFFECTIVE DATE- This subsection shall apply to claims for services
furnished on or after the date that is 6 months after the date standards
are established under subsection (c).
`(b) ENFORCEMENT THROUGH CIVIL MONEY PENALTIES-
`(A) PROVIDERS- In the case of a health service provider that submits
a claim in violation of subsection (a)(1), the provider is subject to
a civil money penalty of not to exceed $100 (or, if greater, the amount
of the claim) for each such violation.
`(B) PLANS- In the case of an AmeriCare supplemental plan that rejects
a claim in violation of subsection (a)(2), the plan is subject to a
civil money penalty of not to exceed $100 (or, if greater, the amount
of the claim) for each such violation.
`(2) PROCESS- The provisions of section 1128A of the Social Security Act
(other than subsections (a) and (b)) shall apply to a civil money penalty
under paragraph (1) in the same manner as such provisions apply to a penalty
or proceeding under section 1128A(a) of such Act.
`(c) STANDARDS RELATING TO UNIFORM CLAIMS AND ELECTRONIC CLAIMS DATA SET-
`(1) ESTABLISHMENT OF STANDARDS- The Secretary shall establish standards
that--
`(A) relate to the form and manner of submission of claims for benefits
under this title and under an AmeriCare supplemental plan, and
`(B) define the data elements to be contained in a uniform electronic
claims data set to be used with respect to such claims.
`(2) SCOPE OF INFORMATION-
`(A) ENSURING ACCOUNTABILITY FOR CLAIMS SUBMITTED ELECTRONICALLY- In
establishing standards under this section, the Secretary, in consultation
with appropriate agencies, shall include such methods of ensuring provider
responsibility and accountability for claims submitted electronically
that are designed to control fraud and abuse in the submission of such
claims.
`(B) COMPONENTS- In establishing such standards the Secretary shall--
`(i) with respect to data elements, define data fields, formats, and
medical nomenclature, and plan benefit and insurance information;
`(ii) develop a single, uniform coding system for diagnostic and procedure
codes; and
`(iii) provide for standards for the uniform electronic transmission
of such elements.
`(3) COORDINATION WITH STANDARDS FOR ELECTRONIC MEDICAL RECORDS- In establishing
standards under this subsection, the Secretary shall assure that--
`(A) the development of such standards is coordinated with the development
of the standards for electronic medical records under section 2253,
and
`(B) the coding of data elements under the uniform electronic claims
data set and the coding of the same elements in the uniform hospital
clinical data set are consistent.
`(4) USE OF TASK FORCES- In adopting standards under this subsection--
`(A) the Secretary shall take into account the recommendations of current
task forces; and
`(B) the Secretary shall provide that the electronic transmission standards
are consistent, to the extent practicable, with the applicable standards
established by the Accredited Standards Committee X-12 of the American
National Standards Institute.
`(5) UNIFORM, UNIQUE PROVIDER IDENTIFICATION CODES- In establishing standards
under this subsection--
`(A) the Secretary shall provide for a unique identifier code for each
health service provider that furnishes services for which a claim may
be submitted under this title or under an AmeriCare supplemental plan,
and
`(B) in the case of a provider that has a unique identifier issued for
purposes of title XVIII, the code provided under subparagraph (A) shall
be the same as such unique identifier.
`(6) WEBSITE AVAILABILITY TO PROVIDERS- The Secretary shall establish
and maintain a website that will enable health service providers, without
charge, to submit claims and to receive verification of claims status
electronically.
`(7) STANDARDS FOR PAPER CLAIMS- The standards shall provide for a uniform
paper claims form which is consistent with data elements required for
the submission of claims electronically.
`(8) STANDARDS FOR CLAIMS FOR CLINICAL LABORATORY TESTS- The standards
shall provide that claims for clinical laboratory tests for which benefits
are provided under this title or under an AmeriCare supplemental plan
shall be submitted directly by the person or entity that performed (or
supervised the performance of) the tests to the plan in a manner consistent
with (and subject to such exceptions as are provided under) the requirement
for direct submission of such claims under title XVIII.
`(9) DEADLINE- The Secretary shall first provide for the standards for
the uniform claims under this subsection (and shall develop and make available
the software under paragraph (6)) by not later than 1 year after the date
of the enactment of this title.
`(d) USE UNDER THIS TITLE AND MEDICARE AND MEDICAID PROGRAMS-
`(1) REQUIREMENT FOR PROVIDERS- In the case of a health service provider
that submits a claim for services furnished under this title in violation
of subsection (a)(1), no payment shall be made under this title for such
services.
`(2) REQUIREMENTS OF MEDICARE ADMINISTRATIVE CONTRACTORS UNDER MEDICARE
PROGRAM- The Secretary shall provide, in regulations promulgated to carry
out this title, that the claims process provided under this title conforms
to the standards established under subsection (c).
`(3) REQUIREMENTS OF STATE MEDICAID PLANS- As a condition for the approval
of State plans under the medicaid program, effective as of the effective
date specified in subsection (a)(3), each such plan shall provide, in
accordance with regulations of the Secretary, that the claims process
provided under the plan is modified to the extent required to conform
to the standards established under subsection (c).
`SEC. 2253. ELECTRONIC MEDICAL RECORDS AND REPORTING.
`(a) STANDARDS FOR ELECTRONIC MEDICAL RECORDS-
`(1) Promulgation of standards-
`(A) IN GENERAL- Not later than January 1, 2009, the Secretary shall
promulgate standards described in paragraph (2) for hospitals and other
health care providers concerning electronic medical records. Such standards
shall include the standards established under part C of title XI.
`(B) REVISION- The Secretary may from time to time revise the standards
promulgated under this paragraph.
`(2) CONTENTS OF STANDARDS- The standards promulgated under paragraph
(1) shall include at least the following:
`(A) A definition of a uniform provider clinical data set, including
a definition of the set of comprehensive data elements, for use by utilization
and quality control peer review organizations.
`(B) Standards for an electronic patient care information system with
data obtained at the point of care.
`(C) A specification of, and manner of presentation of, the individual
data elements of the set and system under this paragraph.
`(D) Standards concerning the transmission of electronic medical data.
`(E) Standards relating to confidentiality of patient-specific information,
which include the physical security of electronic data and the use of
keys, passwords, encryption, and other means to ensure the protection
of the confidentiality and privacy of electronic data.
`(3) COORDINATION WITH STANDARDS FOR UNIFORM ELECTRONIC CLAIMS DATA SET-
In establishing standards under this subsection, the Secretary shall assure
that--
`(A) the development of such standards is coordinated with the development
of the standards for the uniform electronic claims data set under subsection
(b), and
`(B) the coding of data elements under the uniform provider clinical
data set and the coding of the same elements under the uniform electronic
claims data set are consistent.
`(4) CONSULTATION- In establishing standards under this subsection, the
Secretary shall--
`(A) consult with the American National Standards Institute, hospitals
and other health care providers, health benefit plans, and other interested
parties, and
`(B) take into consideration, in developing standards under paragraph
(2)(A), the data set used by the utilization and quality control peer
review program under part B of title XI.
`(b) REQUIREMENT FOR APPLICATION OF ELECTRONIC RECORDS STANDARDS-
`(1) AS CONDITION OF MEDICARE, MEDICAID, SCHIP, AND AMERICARE PARTICIPATION-
Effective January 1, 2010, each hospital or other institutional or noninstitutional
health care provider, as a requirement of each participation agreement
under this title, title XVIII, title XIX, and title XXI, shall, in accordance
with the standards promulgated under subsection (a)(1)--
`(A) maintain clinical data included in the uniform provider clinical
data set under subsection (a)(2)(A) in electronic form on all patients,
`(B) upon request of the Secretary or of a utilization and quality control
peer review organization (with which the Secretary has entered into
a contract under part B of title XI), transmit electronically data requested
from such data set, and
`(C) upon request of the Secretary, or of a fiscal intermediary or carrier,
transmit electronically any data (with respect to a claim) from such
data set.
`(2) APPLICATION OF PRESENTATION AND TRANSMISSION STANDARDS TO ELECTRONIC
TRANSMISSION TO FEDERAL AGENCIES- Effective January 1, 2009, if a hospital
or other health care provider is required under a Federal program to transmit
a data element that is subject to a standard, promulgated under subsection
(a)(1), described in subparagraph (C) or (D) of subsection (a)(2), the
head of the Federal agency responsible for such program (if not otherwise
authorized) is authorized to require the provider to present and transmit
the data element electronically in accordance with such a standard.
`(c) Limitation on Data Requirements Where Standards in Effect-
`(1) IN GENERAL- On or after January 1, 2009, the Secretary under this
title or under title XVIII (including any carrier or fiscal intermediary
or any utilization and quality control peer review organization) and an
AmeriCare supplemental plan may not require, for the purpose of utilization
review or as a condition of providing benefits or making payments under
this title, title XVIII, or the plan, that a hospital or other health
care provider--
`(A) provide any data element not in the uniform provider clinical data
set specified under the standards promulgated under subsection (a),
or
`(B) transmit or present any such data element in a manner inconsistent
with such standards applicable to such transmission or presentation.
`(2) COMPLIANCE- The Secretary may impose a civil money penalty on any
AmeriCare supplemental plan that fails to comply with paragraph (1) in
an amount not to exceed $100 for each such failure. The provisions of
section 1128A of the Social Security Act (other than the first sentence
of subsection (a) and other than subsection (b)) shall apply to a civil
money penalty under this paragraph in the same manner as such provisions
apply to a penalty or proceeding under section 1128A(a) of such Act.
`(3) APPLICATION TO MEDICAID PROGRAM- As a condition for the approval
of State plans under the medicaid program and in accordance with regulations
of the Secretary, effective as of January 1, 2009, each such plan may
not require that a hospital or other health care provider, for the purpose
of utilization review or as a condition of providing benefits or making
payments under the plan--
`(A) provide any data element not in the uniform provider clinical data
set specified under the standards promulgated under subsection (a),
or
`(B) transmit or present any such data element in a manner inconsistent
with such standards applicable to such transmission or presentation.
`(d) PREEMPTION OF STATE QUILL PEN LAWS-
`(1) IN GENERAL- Any provision of State law that requires medical or health
insurance records (including billing information) to be maintained in
written, rather than electronic, form shall deemed to be satisfied if
the records are maintained in an electronic form that meets standards
established by the Secretary under paragraph (2).
`(2) SECRETARIAL AUTHORITY- Not later than 1 year after the date of the
enactment of this title, the Secretary shall issue regulations to carry
out paragraph (1). The regulations shall provide for an electronic substitute
that is in the form of a unique identifier (assigned to each authorized
individual) that serves the functional equivalent of a signature. The
regulations may provide for such exceptions to paragraph (1) as the Secretary
determines to be necessary to prevent fraud and abuse, to prevent the
illegal distribution of controlled substances, and in such other cases
as the Secretary deems appropriate.
`(3) EFFECTIVE DATE- Paragraph (1) shall take effect on the first day
of the first month that begins more than 30 days after the date the Secretary
issues the regulations referred to in paragraph (2).
`SEC. 2254. UNIFORM HOSPITAL COST REPORTING.
`Each hospital, as a requirement under a participation agreement under this
title for each cost reporting period beginning during or after fiscal year
2008, shall provide for the reporting of information to the Secretary with
respect to any hospital care provided in a uniform manner consistent with
standards established by the Secretary to carry out section 4007(c) of the
Omnibus Budget Reconciliation Act of 1987 and in an electronic form consistent
with standards established by the Secretary.
`SEC. 2255. HEALTH SERVICE PROVIDER DEFINED.
`In this part, the term `health service provider' includes a provider of
services (as defined in section 1861(u)), physician, supplier, and other
entity furnishing health care services.
`Part E--General Provisions
`SEC. 2261. DEFINITIONS RELATING TO BENEFICIARIES AND INCOME.
`(a) TERMS RELATING TO BENEFICIARIES- In this title:
`(1) CHILD- The term `child' means an individual who throughout a month
has not attained 24 years of age.
`(2) LOW-INCOME INDIVIDUAL- The term `low-income individual' means an
individual whose applicable modified gross income (as defined in subsection
(b)(1)) is less than 200 percent of the poverty level (as defined in subsection
(b)(2)). The determination that an individual is a low-income individual
shall be effective for a period of one year and shall be redetermined
on an annual basis.
`(3) PREGNANT WOMAN- The term `pregnant woman' means a woman (regardless
of age) who has been certified by a physician (in a manner specified by
the Secretary) as being pregnant, until the last day of the month in which
the 60-day period (beginning on the date of termination of the pregnancy)
ends.
`(b) TERMS RELATING TO INCOME- In this title:
`(1) APPLICABLE MODIFIED GROSS INCOME-
`(A) IN GENERAL- Except as provided in this paragraph, the term `applicable
modified gross income' means, for a calendar year for an individual,
the modified gross income (as defined in section 202(a)(3)(B) of the
Americare Health Care Act of 2007) of the taxpayer (or the taxpayer
for whom the individual may be claimed as a dependent) for the taxable
year ending in the second previous calendar year.
`(B) APPLICATION OF CURRENT YEAR MODIFIED GROSS INCOME-
`(i) IN GENERAL- Subject to clause (ii), the Secretary shall establish
a procedure under which an individual may file a declaration of estimated
modified gross income for a taxable year ending in a calendar year,
which modified gross income will apply under this subsection as the
applicable modified gross income for the calendar year. Subject to
clause (ii), such procedure shall be applicable regardless of whether
or not the individual filed a tax return for the taxable year ending
in the second previous calendar year.
`(ii) LIMITATION ON APPLICATION- The Secretary may limit the application
of clause (i), in the case of individuals who have filed tax returns
for the taxable year ending in the second previous calendar year,
to individuals with respect to whom the applicable modified gross
income will be reduced by at least 20 percent as a result of the application
of such clause.
`(iii) REQUIREMENT FOR RETURN- Any individual who has filed a declaration
under clause (i) for a calendar year is required to file an income
tax return for the taxable year in the calendar year, regardless of
whether any income tax is actually owed for the year. The failure
of the individual to file such a return makes the individual liable
for overpayments under this title under clause (iv) in the same manner
as if this paragraph had not applied.
`(iv) COLLECTION FOR OVERPAYMENTS- If a declaration of estimated modified
gross income is made applicable to a calendar year under clause (i)
and the actual modified gross income for that taxable year exceeds
such estimated modified gross income, the individual shall be liable
to the United States for 110 percent of the amount of additional payments
made under this title as a result of the use of such estimated modified
gross income instead of the actual modified gross income for that
taxable year.
`(C) TRANSMITTAL OF INFORMATION- By not later than October 1 of each
year, the Secretary of the Treasury shall transmit to the Secretary
such information relating to the applicable modified gross income of
individuals for the taxable year ending in the previous year as may
be necessary to apply this title in the succeeding calendar year.
`(2) POVERTY LEVEL- The term `poverty level' means, for an individual
in a family, the official poverty line (as defined by the Office of Management
and Budget, and revised annually in accordance with section 673(2) of
the Omnibus Budget Reconciliation Act of 1981) applicable to a family
of the size involved.
`SEC. 2262. INCORPORATION OF CERTAIN MEDICARE PROVISIONS AND OTHER
PROVISIONS.
`(a) USE OF MEDICARE ADMINISTRATIVE CONTRACTORS- The Secretary shall provide
for the administration of this title through the use of medicare administrative
contractors in the same manner as title XVIII is carried out through the
use of such contractors, except that no payment shall be made under this
title except on the basis of bills or charges that are submitted electronically
in a manner specified by the Secretary.
`(1) IN GENERAL- Except as otherwise provided in this title, the definitions
contained in section 1861 shall apply for purposes of this title in the
same manner as they apply for purposes of title XVIII.
`(2) STATE; UNITED STATES- (A) The term `State' means the 50 States and
includes the District of Columbia, Puerto Rico, the Virgin Islands, Guam,
American Samoa, and the Northern Mariana Islands.
`(B) The term `United States' means all the States.
`(c) CERTIFICATION, PROVIDER QUALIFICATION, ETC- The provisions of sections
1863 through 1875, sections 1877 through 1880, section 1883, section 1885,
and sections 1887 through 1895 shall apply to this title in the same manner
as they apply to title XVIII.
`(d) TITLE XI PROVISIONS- The following provisions shall apply to this title
in the same manner as they apply to title XVIII:
`(1) Sections 1124, 1126, and 1128 through 1128E (relating to fraud and
abuse).
`(2) Section 1134 (relating to nonprofit hospital philanthropy).
`(3) Section 1138 (relating to hospital protocols for organ procurement
and standards for organ procurement agencies).
`(4) Section 1142 (relating to research on outcomes of health care services
and procedures), except that any reference in such section to a Trust
Fund is deemed a reference to the AmeriCare Trust Fund.
`(5) Part B of title XI (relating to peer review of the utilization and
quality of health care services).
`(6) Part C of title XI (relating to administrative simplification).
`(e) OTHER PROVISIONS- The provisions of section 201(i) shall apply to this
title and the AmeriCare Trust Fund in the same manner as they apply to title
XVIII and the Federal Hospital Insurance Trust Fund.
`SEC. 2263. STATE MAINTENANCE OF EFFORT PAYMENTS.
`(a) CONDITION OF COVERAGE- Notwithstanding any other provision of this
title, no individual who is a resident of a State is eligible for benefits
under this title for a month in a calendar year, unless the State provides
(in a manner and at a time specified by the Secretary) for payment to the
AmeriCare Trust Fund of 1/12 th of the amount specified in subsection (b)
for the year. Such funds shall be used offset the costs of providing subsidies
for low-income individuals under section 202.
`(b) MAINTENANCE OF EFFORT AMOUNT-
`(1) IN GENERAL- Subject to paragraph (3), the amount of payment specified
in this subsection for a State for a year is equal to the amount of payment
(net of Federal payments) made by a State under its State plans under
titles XIX and XXI for 2007 for medical assistance for benefits described
in paragraph (2).
`(2) BENEFITS DESCRIBED- The benefits described in this paragraph with
respect to State plans of a State under titles XIX and XXI are benefits
which--
`(A) would be available under this title for low-income individuals
if this title had been in effect in 2007; and
`(B) are for low-income individuals who--
`(i) with respect to the State plan under title XIX, were required
to be furnished medical assistance under such title XIX; or
`(ii) with respect to a State child health plan under title XXI, were
low-income children.
`SEC. 2264. MODIFICATION OF MEDICAID AND OTHER PROGRAMS TO AVOID DUPLICATION
OF BENEFITS.
`(a) IN GENERAL- Notwithstanding any other provision of law--
`(1) a State plan under title XIX and a State child health plan under
title XXI shall not provide any medical assistance for benefits with respect
to which any payments may be made under this title; and
`(2) a health benefits plan under chapter 89 of title 5, United States
Code, shall not provide benefits for which any payment may be made under
this title.
`(b) REVIEW OF APPLICATION TO OTHER PROGRAMS- The Secretary shall conduct
a review of the feasibility of applying the policy described in subsection
(a) to additional Federal programs, such as the TRICARE program under title
10, United States Code. Not later than January 1, 2010, the Secretary submit
to Congress on such review and shall include in such report such recommendations
for extending such policy to other Federal programs as the Secretary deems
appropriate.
`SEC. 2265. CONSTRUCTION REGARDING CONTINUATION OF OBLIGATIONS UNDER CURRENT
GROUP HEALTH PLAN CONTRACTS AND PROVISION OF ADDITIONAL BENEFITS.
`Nothing in this title shall be construed as--
`(1) affecting obligations for health care benefits under group health
plans as in effect on the date of the enactment of this title, including
such plans established or maintained under or pursuant to one or more
collective bargaining agreements;
`(2) limiting the additional benefits that may be provided under a group
health plan to employees or their dependents, or to former employees or
their dependents; or
`(3) limiting the benefits that may be made available under a State program
to residents of the State at the expense of the State.
`SEC. 2266. STANDARDS AND REQUIREMENTS FOR AMERICARE SUPPLEMENTAL POLICIES.
`(a) CERTIFICATION REQUIRED-
`(1) IN GENERAL- The Secretary shall establish rules and procedures consistent
with this section under which AmeriCare supplemental policies may only
be issued if they are certified by the Secretary or under a State regulatory
program approved by the Secretary as meeting standards established under
subsection (b).
`(2) ENFORCEMENT- Any person who issues an AmeriCare supplemental policy
in violation of paragraph (1) is subject to a civil money penalty of not
to exceed $25,000 for each such violation. The provisions of section 1128A
(other than the first sentence of subsection (a) and other than subsection
(b)) shall apply to a civil money penalty under the previous sentence
in the same manner as such provisions apply to a penalty or proceeding
under section 1128A(a).
`(3) AMERICARE SUPPLEMENTAL POLICY- For purposes of this section, the
term `AmeriCare supplemental policy' is a health insurance policy or other
health benefit plan offered by a private entity to individuals who are
entitled to have payment made under this title, which provides reimbursement
for expenses incurred for services and items for which payment may be
made under this title but which are not reimbursable by reason of the
application of deductibles, coinsurance amounts, or other limitations
imposed pursuant to this title; but does not include--
`(A) any such policy or plan of the trustees of a fund established by
one or more employers or labor organizations (or combination thereof)
if the policy or plan offers benefits as a direct service organization
under section 1833, or
`(B) a policy or plan of a health maintenance organization which offers
benefits under this title under section 2221(k).
For purposes of this section, the term `policy' includes a certificate
issued under such policy.
`(b) Certification Standards-
`(1) ISSUANCE- The Secretary shall develop and publish specific standards
consistent with this section for AmeriCare supplemental policies and shall
consult with the Secretary of Labor regarding the application of such
standards to employee welfare benefit plans under title I of the Employee
Retirement Income Security Act of 1974.
`(2) MORE STRINGENT STATE STANDARDS PERMITTED- In the case of insured
AmeriCare supplemental policies (as defined in subsection (d)(3)), a State
may implement standards that are more stringent than the standards established
under paragraph (1), including--
`(A) additional limitations on pre-existing exclusion limitations described
in subsection (c)(1)(B);
`(B) additional restrictions on the groups of benefits described in
subsection (c)(2) that may be offered in AmeriCare supplemental policies
in the State, so long as a core-only benefit package described in subparagraph
(A)(i) of such subsection may be offered in the State; and
`(C) requiring a higher loss-ratios than those specified in subsection
(c)(3);
`(c) STANDARDS- The Secretary shall establish standards for AmeriCare supplemental
policies consistent with the following:
`(1) NO DISCRIMINATION BASED ON HEALTH STATUS-
`(A) IN GENERAL- Except as provided under subparagraph (B), an AmeriCare
supplemental policy may not deny, limit, or condition the coverage under
(or benefits of) the policy, or vary premiums charged, based on the
health status, claims experience, receipt of health care, medical history,
or lack of evidence of insurability, of an individual.
`(B) LIMITATION ON USE OF PRE-EXISTING CONDITION EXCLUSIONS- An AmeriCare
supplemental policy may exclude coverage with respect to services related
to treatment of a pre-existing condition, except that--
`(i) the period of such exclusion may not exceed 6 months;
`(ii) such exclusion shall not apply to services furnished to newborns;
and
`(iii) the period of exclusion under clause (i) shall be reduced by
1 month for each month in a period of continuous health benefits coverage
(as defined by the Secretary) for the services involved.
For purposes of this subparagraph, a condition is not pre-existing unless
it was diagnosed or treated during the 3-month period ending on the
day before the first date of such coverage.
`(2) SIMPLIFICATION OF BENEFITS-
`(A) IN GENERAL- Each AmeriCare supplemental policy shall only offer
benefits consistent with the standards, promulgated by the Secretary,
that provide--
`(i) limitations on the groups or packages of benefits, including
a core group of basic benefits and not to exceed 9 other different
benefit packages, that may be offered under an AmeriCare supplemental
policy;
`(ii) that a person may not issue an AmeriCare supplemental policy
without offering such a policy with only the core-group of basic benefits
and without providing an outline of coverage in a standard form approved
by the Secretary;
`(iii) uniform language and definitions to be used with respect to
such benefits, and
`(iv) uniform format to be used in the policy with respect to such
benefits.
`(B) INNOVATION- The Secretary may approve the offering of new or innovative
and cost-effective benefit packages in addition to those provided under
subparagraph (A).
`(3) MINIMUM LOSS RATIO REQUIRED- An AmeriCare supplemental policy, a
specific disease policy (as defined by the Secretary), or a hospital confinement
indemnity policy (as defined by the Secretary) may not be issued or renewed
unless the policy--
`(A) can be expected (in accordance with a uniform methodology developed
by the Secretary and for periods beginning 24 months after the date
of original issue) to return to policyholders in the form of aggregate
benefits at least 85 percent of the aggregate amount of premiums collected
in the case of group policies or at least 75 percent in the case of
individual policies (as defined by the Secretary); and
`(B) provides refunds and credits (in a manner specified by the Secretary)
for premiums collected in excess of those consistent with subparagraph
(A).
`(4) GUARANTEED RENEWABILITY AND CONVERTIBILITY- Each AmeriCare supplemental
policy--
`(A) shall be guaranteed renewable and may not be cancelled or nonrenewed
solely on the ground of health status of the individual or for any reason
other than nonpayment of premium or material misrepresentation; and
`(i) a right of conversion to an individual policy (with continuation
of benefits) in the case of termination by a group policyholder or
termination by a certificateholder of membership in a group through
which the individual obtained coverage;
`(ii) a right of continued coverage in the case of a group policy
that succeeds another group policy; and
`(iii) suspension of coverage (for up to 24 months and in a manner
specified) in the case of a policyholder who becomes entitled to benefits
under this title as a low-income individual and who provides a timely
notice of election of such suspension.
`(5) ADDITIONAL STANDARDS APPLICABLE ONLY TO INSURED POLICIES- A carrier
that offers an insured AmeriCare supplemental policy (as defined in paragraph
(6)) to individuals and groups in a State shall also comply with the following
requirements:
`(A) OPEN ENROLLMENT- The carrier must offer the same policy to any
other individual or group in the State on a continuous, year-round basis;
except that--
`(i) in the case of policies offered through an association which
is composed exclusively of employers (which may include self-employed
individuals) and which has been formed for purposes other than obtaining
health insurance, such requirement shall only apply to such employers
(and individuals) who are members of the association; and
`(ii) a health maintenance organization may deny enrollment with respect
to an individual based on the uniform application of a geographic
service area or overall enrollment limitation based on its financial
or administrative capacity.
`(B) NOTICES AND RENEWAL PERIODS- The carrier shall provide advance
notice of terms for policy renewal, which terms shall--
`(i) be the same as the terms of issuance, except for rates and administrative
changes;
`(ii) provide the same premium rates as for a new issue; and
`(iii) provide a period of renewal of not less than 12 months.
`(c) Additional Requirements-
`(1) PROHIBITION OF DUPLICATION- The Secretary shall--
`(A) establish requirements that prohibit (other than as required under
Federal or State law) the knowing sale or issuance to an individual
entitled to benefits under this title of health insurance that duplicates
benefits under this title, of an AmeriCare supplemental policy that
duplicates another AmeriCare supplemental policy, or of another health
insurance policy that duplicates other benefits to which the individual
is entitled; and
`(B) provide exceptions to the prohibition in subparagraph (A) for enrollment
in group health plans and similar employment-based policies and for
policies which provide benefits directly and without regard to other
coverage and notice of such duplication.
`(2) DISCLOSURE REQUIREMENT- The Secretary shall establish a requirement
that prohibits the sale or issuance of an AmeriCare supplemental policy
to an individual, other than as a replacement policy, without obtaining
a statement (in a form specified by the Secretary) that discloses other
health benefits coverage and that acknowledges limitations on the need
for an AmeriCare supplemental policy, particularly in the case of a low-income
individual.
`(3) APPLICATION OF FALSE STATEMENT SANCTIONS- The provisions of paragraphs
(1) and (2) of section 1882(d) shall apply to an AmeriCare supplemental
policy under this section in the same manner as they apply to medicare
supplemental policies under such section.
`(4) Limitations on sales commissions-
`(A) IN GENERAL- It is unlawful for a person who provides for a commission
or other compensation to an agent or other representatives with respect
to the sale of an AmeriCare supplemental policy (or certificate)--
`(i) to provide for a first year commission or other first year compensation
that exceeds 200 percent of the commission or other compensation for
the selling or servicing of the policy or certificate in a second
or subsequent year; or
`(ii) to provide for compensation with respect to replacement of such
a policy or certificate that is greater than the compensation that
would apply to the renewal of the policy or certificate.
`(B) DEFINITION- In subparagraph (A), the term `compensation' includes
pecuniary and nonpecuniary compensation of any kind relating to the
sale or renewal of a policy or certificate and specifically includes
bonuses, gifts, prizes, awards, and finders' fees.
`(d) INFORMATION DISCLOSURE- The Secretary shall provide, to all individuals
entitled to benefits under this title, such information as will permit such
individuals to evaluate the value of AmeriCare supplemental policies to
them and the relationship of any such policies to benefits provided under
this title. Such information shall include information on--
`(1) the requirements and prohibitions under this section;
`(2) State and Federal agencies responsible for compliance with such requirements
and enforcement of such prohibitions; and
`(3) the manner of submitting complaints regarding violations of such
requirements and prohibitions.
`(e) DEFINITIONS- In this section:
`(1) CARRIER- The term `carrier' means any person that offers an AmeriCare
supplemental policy.
`(2) GROUP- The term `group' means 2 or more employees of the same employer
who normally perform on a monthly basis at least 17 1/2 hours of service
per week for that employer.
`(3) HEALTH MAINTENANCE ORGANIZATION- The term `health maintenance organization'
has the meaning given the term `eligible organization' in section 1876(b).
`(4) INSURED AMERICARE SUPPLEMENTAL POLICY- The term `insured AmeriCare
supplemental policy' means any AmeriCare supplemental policy provided
through insurance.'.
TITLE II--FINANCING PROVISIONS
Subtitle A--Individual Contributions
SEC. 201. GENERAL OBLIGATION FOR INDIVIDUALS.
(a) Payment of Plan Premium-
(1) IN GENERAL- Each individual eligible for coverage under title XXII
of the Social Security Act is liable for payment of the premium established
under this section for such coverage of the individual and family members.
An individual who is not receiving such coverage due to coverage under
a group health plan described in section 2202(d) of such Act is not liable
for payment of such premium with respect to such individual.
(2) DETERMINATION OF PREMIUM- Such premium shall be established by the
Secretary of Health and Human Services on the basis of the cost of coverage
(determined on a State by State basis and including administrative costs)
and shall be determined separately based on the class of enrollment for
the individual (as determined under section 2202 of the Social Security
Act).
(3) Joint and several liability- If more than one individual is liable
under this subsection for payment of a premium for coverage of the same
individual under title XXII of the Social Security Act, such individual
shall be jointly and severally liable with each other individual who is
so liable.
(b) Reduction for Employer Contributions and Low Income Subsidies- An individual's
liability under subsection (a) is reduced by--
(1) the amount of any contributions made by the individual's employer
(or employers) under subtitle B or otherwise (including voluntary employer
contributions) with respect to coverage of the individual and family members,
and
(2) the amount of any premium subsidies provided with respect to the individual
under section 202.
(c) Timing and Manner of Payment- Each individual that is liable for a premium
under subsection (a) shall pay such premium in such form and manner as the
Secretary of the Treasury may specify. Except as otherwise provided by the
Secretary of the Treasury, for purposes of subtitle F of such Code, the
liabilities imposed under subsection (a) shall be treated as if they were
a tax imposed under section 1 of such Code. The Secretary of the Treasury
shall provide for the withholding of such payments from wages under rules
similar to the rules of chapter 24 of such Code. The Secretary of the Treasury
may prescribe special rules for withholding payments from wages of individuals
who work seasonally, part-time, or for more than one employer.
SEC. 202. ADDITIONAL PREMIUM SUBSIDIES.
(a) Eligibility for Additional Premium Subsidies-
(1) IN GENERAL- Each premium subsidy eligible individual is entitled to
a premium subsidy in accordance with this section.
(2) PREMIUM SUBSIDY ELIGIBLE INDIVIDUAL- In this section, the term `premium
subsidy eligible individual' means an individual receiving coverage under
title XXII of the Social Security Act who--
(A) with respect to premiums for a taxable year ending in a year, has
family income (as defined in paragraph (3)(A)) that is less than 300
percent of the applicable poverty level, or
(B) with respect to a premium for a month, is an TANF or SSI recipient
for the month.
(3) ADDITIONAL DEFINITIONS- In this section:
(A) FAMILY INCOME- The term `family income' means, with respect to an
individual who--
(i) is not a dependent of another individual, the sum of the modified
adjusted gross incomes (as defined in subparagraph (B)) for the individual,
the individual's spouse, and children who are dependents of the individual,
or
(ii) is a dependent of another individual, the sum of the modified
adjusted gross incomes (as defined in subparagraph (B)) for the other
individual, the other individual's spouse, and children who are dependents
of the other individual.
(B) MODIFIED ADJUSTED GROSS INCOME- The term `modified adjusted gross
income' means adjusted gross income (as defined in the Internal Revenue
Code of 1986)--
(i) determined without regard to sections 911, 931, and 933 of such
Code, and
(I) the amount of interest received or accrued by the individual
during the taxable year which is exempt from tax, and
(II) the amount of the social security benefits (as defined in section
86(d) of such Code) received during the taxable year to the extent
not included in gross income under section 86 of such Code.
The determination under the preceding sentence shall be made without
regard to any carryover or carryback.
(C) APPLICABLE POVERTY LEVEL-
(i) IN GENERAL- The term `applicable poverty level' means, for a family
for a year, the official poverty line (as defined by the Secretary
of Health and Human Services) applicable to a family of the size involved
for 2010 adjusted by the percentage increase or decrease described
in clause (ii) for the year involved.
(ii) PERCENTAGE ADJUSTMENT- The percentage increase or decrease described
in this clause for a year is the percentage increase or decrease by
which the average Consumer Price Index for all urban consumers (U.S.
city average), as published by the Bureau of Labor Statistics, for
the 12-month-period ending with August 31 of the preceding year exceeds
such average for the 12-month period ending with August 31, 2010.
(iii) ROUNDING- Any adjustment made under clause (ii) for a year shall
be rounded to the nearest multiple of $100.
(D) TANF RECIPIENT- The term `TANF recipient' means, for a month, an
individual who is receiving aid or assistance under any plan of the
State approved under title I, X, XIV, or XVI, or part A or part E of
title IV, of the Social Security Act, for the month.
(E) SSI RECIPIENT- The term `SSI recipient' means, for a month, an individual--
(i) with respect to whom supplemental security income benefits are
being paid under title XVI of the Social Security Act for the month,
(ii) who is receiving a supplementary payment under section 1616 of
such Act or under section 212 of Public Law 93-66 for the month, or
(iii) who is receiving monthly benefits under section 1619(a) of the
Social Security Act (whether or not pursuant to section 1616(c)(3)
of such Act) for the month.
(b) Amount of Premium Subsidy-
(1) LOWEST INCOME INDIVIDUALS-
(A) IN GENERAL- In the case of an individual described in subparagraph
(B), the premium subsidy under this section is the amount which would
(without regard to this section) reduce the premium obligation of the
individual (and family members) under section 201 to zero.
(B) LOWEST INCOME INDIVIDUALS DESCRIBED- An individual described in
this subparagraph is a premium subsidy eligible individual who would
still be such an individual under subsection (a)(2) if `200 percent'
were substituted for `300 percent' in subparagraph (A) of such subsection.
(A) IN GENERAL- In the case of a premium subsidy eligible individual
not described in paragraph (1), the premium subsidy under this section
is the product of--
(i) the premium obligation of the individual (and family members)
under section 201, multiplied by
(ii) the number of percentage points by which the individual's family
income (expressed as a percent of the applicable poverty level) is
less than 300 percent.
(B) TABLE- The Secretary may provide for a table which establishes the
values for premium subsidies under this paragraph.
(c) GENERAL REVENUE FINANCING FOR LOW INCOME SUBSIDIES- There are authorized
to be appropriated to the Americare Trust Fund from amounts in the Treasury
not otherwise appropriated, such sums as may be necessary to cover the costs
of premium subsidies provided under this section.
SEC. 203. EFFECTIVE DATE.
The provisions of this subtitle shall apply with respect to periods beginning
on or after January 1, 2010.
Subtitle B--Employer Contributions
SEC. 211. GENERAL OBLIGATION FOR EMPLOYERS.
(1) IN GENERAL- Subject to the succeeding provisions of this subsection,
each employer shall make a financial contribution toward the cost of health
insurance coverage for employees in accordance with this section.
(2) ELIMINATION OF LIABILITY IN CASE OF CERTAIN GROUP HEALTH PLAN COVERAGE-
(A) IN GENERAL- Subject to subparagraph (B), an employer shall not be
liable for any contribution under this section with respect to any employee
who is covered under a group health plan of the employer described in
section 2202(d) if such employer pays at least 80 percent of the cost
of such health plan, as determined by the Secretary of Health and Human
Services.
(B) SURCHARGE PERMISSIBLE TO PREVENT ADVERSE SELECTION- The Secretary
may impose liability for a contribution under this section with respect
to an employee described in subparagraph (A) in an amount (not to exceed
the amount specified under subsection (b)) insofar as the Secretary
determines it necessary to prevent adverse selection of the individuals
enrolled under this title as a result of the operation of such subparagraph.
(b) Amount of Contribution-
(1) FULL-TIME EMPLOYEES- In the case of an employee receiving coverage
under title XXII of the Social Security Act, the amount of the financial
contribution is equal to at least 80 percent of the premium determined
with respect to such employee and family members under section 201 (based
on class of enrollment and without regard to subsection (b) thereof) or
at least 80 percent of the cost of coverage under such group health plan,
respectively.
(2) REDUCTION FOR PART-TIME EMPLOYEES- In the case of a part-time employee,
the employer contribution requirements of paragraph (1) shall be treated
as satisfied if the employer contribution with respect to such employee
is not less than the part-time employment ratio of the contribution required
under paragraph (1).
(3) RULES RELATED TO PART-TIME EMPLOYMENT- For purposes of this subsection--
(A) PART-TIME EMPLOYEE- The term `part-time employee' means, with respect
to any month, an employee who works on average fewer than 40 hours per
week.
(B) PART-TIME EMPLOYMENT RATIO- The term `part-time employment ratio'
means, with respect to a part-time employee of an employer in a month,
a fraction--
(i) the numerator of which is the number of hours in the employee's
normal work week, and
(ii) the denominator of which is 40 hours.
(C) SPECIAL RULES- Under rules prescribed by the Secretary of Health
and Human Services, in consultation with the Secretary of the Treasury,
in the case of an employee for an employer whose defined work week for
full-time employees is less than 40 hours, any reference in this subsection
to 40 hours is deemed a reference to the number of hours in the work
week so defined.
(D) CONVERSION TO HOURS OF EMPLOYMENT- The Secretary of Health and Human
Services, in consultation with the Secretary of the Treasury, shall
establish rules for the conversion of compensation to hours of employment,
for purposes of this subsection in the case of employees that receive
compensation on a salaried basis, or on the basis of a commission, or
other contingent or bonus basis, rather than based on an hourly wage.
(1) IN GENERAL- Each employer that is required to make a financial contribution
with respect to an employee under this section (other than with respect
to coverage under a group health plan) or a surcharge under subsection
(a)(2)(B) shall pay such contribution or surcharge in a form and manner,
specified by the Secretary of the Treasury, based upon the form and manner
in which employer excise taxes are required to be paid under section 3111
of the Internal Revenue Code of 1986.
(2) NON-ENROLLING EMPLOYERS- In the case of an employee who is covered
under the class of enrollment of a family member, the Secretary of the
Treasury shall provide that the financial contribution of the employer
with respect to such employee is paid directly or indirectly to the employer
of such family member.
SEC. 212. EFFECTIVE DATE.
(a) IN GENERAL- Subject to subsection (b), the provisions of this subtitle
shall apply with respect to periods beginning on or after January 1, 2010.
(b) ADDITIONAL PERIOD FOR SMALL EMPLOYERS- The provisions of this subtitle
shall not apply with respect to an employer that has fewer than 100 employees
(as determined by the Secretary of the Treasury in consultation with the
Secretary of Health and Human Services) for periods beginning before January
1, 2013.
END
