110th CONGRESS
1st Session
S. 334
To provide affordable, guaranteed private health coverage that
will make Americans healthier and can never be taken away.
IN THE SENATE OF THE UNITED STATES
January 18, 2007
Mr. WYDEN introduced the following bill; which was read twice and referred
to the Committee on Finance
A BILL
To provide affordable, guaranteed private health coverage that
will make Americans healthier and can never be taken away.
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 `Healthy Americans Act'.
Sec. 1. Short title; table of contents.
TITLE I--HEALTHY AMERICANS PRIVATE INSURANCE PLANS
Subtitle A--Guaranteed Private Coverage
Sec. 101. Guarantee of Healthy Americans Private Insurance coverage.
Sec. 102. Individual responsibility to enroll in a Healthy Americans Private
Insurance plan.
Subtitle B--Standards for Healthy Americans Private Insurance Coverage
Sec. 111. Healthy Americans Private Insurance plans.
Sec. 112. Specific coverage requirements.
Sec. 113. Updating Healthy Americans Private Insurance plan requirements.
Subtitle C--Eligibility for Premium and Personal Responsibility Contribution
Subsidies
Sec. 121. Eligibility for premium subsidies.
Sec. 122. Eligibility for personal responsibility contribution subsidies.
Sec. 123. Definitions and special rules.
Subtitle D--Wellness Programs
Sec. 131. Requirements for wellness programs.
TITLE II--HEALTHY START FOR CHILDREN
Subtitle A--Benefits and Eligibility
Sec. 201. General goal and authorization of appropriations for HAPI plan
coverage for children.
Sec. 202. Coordination of supplemental coverage under the Medicaid program
to HAPI plan coverage for children.
Subtitle B--Service Providers
Sec. 211. Inclusion of providers under HAPI plans.
Sec. 212. Use of, and grants for, school-based health centers.
TITLE III--BETTER HEALTH FOR OLDER AND DISABLED AMERICANS
Subtitle A--Assurance of Supplemental Medicaid Coverage
Sec. 301. Coordination of supplemental coverage under the Medicaid program
for elderly and disabled individuals.
Subtitle B--Empowering Individuals and States To Improve Long-Term Care
Choices
Sec. 311. New, automatic Medicaid option for State choices for long-term
care program.
Sec. 312. Simpler and more affordable long-term care insurance coverage.
TITLE IV--HEALTHIER MEDICARE
Subtitle A--Authority To Adjust Amount of Part B Premium To Reward Positive
Health Behavior
Sec. 401. Authority to adjust amount of Medicare part B premium to reward
positive health behavior.
Subtitle B--Promoting Primary Care for Medicare Beneficiaries
Sec. 411. Primary care services management payment.
Subtitle C--Chronic Care Disease Management
Sec. 421. Chronic care disease management.
Sec. 422. Chronic Care Education Centers.
Subtitle D--Part D Improvements
Sec. 431. Negotiating fair prices for Medicare prescription drugs.
Sec. 432. Process for individuals entering the Medicare coverage gap to
switch to a plan that provides coverage in the gap.
Subtitle E--Improving Quality in Hospitals for All Patients
Sec. 441. Improving quality in hospitals for all patients.
Subtitle F--End-of-Life Care Improvements
Sec. 451. Patient empowerment and following a patient's health care wishes.
Sec. 452. Permitting hospice beneficiaries to receive curative care.
Sec. 453. Providing beneficiaries with information regarding end-of-life
care clearinghouse.
Subtitle G--Additional Provisions
Sec. 461. Additional cost information.
Sec. 462. Reducing Medicare paperwork and regulatory burdens.
TITLE V--STATE HEALTH HELP AGENCIES
Sec. 502. Responsibilities and authorities.
Sec. 503. Appropriations for transition to State Health Help Agencies.
TITLE VI--SHARED RESPONSIBILITIES
Subtitle A--Individual Responsibilities
Sec. 601. Individual responsibility to ensure HAPI plan coverage.
Subtitle B--Employer Responsibilities
Sec. 611. Health care responsibility payments.
Sec. 612. Distribution of individual responsibility payments to HHAs.
Subtitle C--Insurer Responsibilities
Sec. 621. Insurer responsibilities.
Subtitle D--State Responsibilities
Sec. 631. State responsibilities.
Sec. 632. Empowering States to innovate through waivers.
Subtitle E--Federal Fallback Guarantee Responsibility
Sec. 641. Federal guarantee of access to coverage.
Subtitle F--Federal Financing Responsibilities
Sec. 651. Appropriation for subsidy payments.
Sec. 652. Recapture of Medicare and 90 percent of Medicaid Federal DSH
funds to strengthen Medicare and ensure continued support for public health
programs.
Subtitle G--Tax Treatment of Health Care Coverage Under Healthy Americans
Program; Termination of Coverage Under Other Governmental Programs and Transition
Rules for Medicaid and SCHIP
Part I--Tax Treatment of Health Care Coverage Under Healthy Americans
Program
Sec. 661. Limited employee income and payroll tax exclusion for employer
shared responsibility payments, historic retiree health contributions,
and transitional coverage contributions.
Sec. 662. Exclusion for limited employer-provided health care fringe benefits.
Sec. 663. Limited employer deduction for employer shared responsibility
payments, historic retiree health contributions, and other health care
expenses.
Sec. 664. Health care standard deduction.
Sec. 665. Modification of other tax incentives to complement Healthy Americans
program.
Sec. 666. Termination of certain employer incentives when replaced by
lower health care costs.
Part II--Termination of Coverage Under Other Governmental Programs and
Transition Rules for Medicaid and SCHIP
Sec. 671. Group and individual health plan requirements not applicable
to HAPI plans.
Sec. 672. Federal Employees Health Benefits Plan.
Sec. 673. Medicaid and SCHIP.
TITLE VII--PURCHASING HEALTH SERVICES AND PRODUCTS THAT ARE MOST EFFECTIVE
Subtitle A--Effective Health Services and Products
Sec. 701. One time disallowance of deduction for advertising and promotional
expenses for certain prescription pharmaceuticals.
Sec. 702. Enhanced new drug and device approval.
Sec. 703. Medical schools and finding what works in health care.
Sec. 704. Finding affordable health care providers nearby.
Subtitle B--Other Provisions to Improve Health Care Services and Quality
Sec. 711. Individual medical records.
Sec. 712. Bonus payment for medical malpractice reform.
TITLE VIII--CONTAINING MEDICAL COSTS AND GETTING MORE VALUE FOR THE HEALTH
CARE DOLLAR
Sec. 801. Cost-containment results of the Healthy Americans Act.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) Americans want affordable, guaranteed private health coverage that
makes them healthier and can never be taken away.
(2) American health care provides primarily `sick care' and does not do
enough to prevent chronic illnesses like heart disease, stroke, and diabetes.
This results in significantly higher health costs for all Americans.
(3) Staying as healthy as possible often requires an individual to change
behavior and assume more personal responsibility for his or her health.
(4) Personal responsibility for one's health should include purchasing
one's own private health care coverage.
(5) To accompany this new focus on staying healthy and personal responsibility,
our government must guarantee that all Americans receive private affordable
health coverage that can never be taken away.
(6) Financing this guarantee should be a shared responsibility between
individuals, the Government, and employers.
(7) The $2,200,000,000,000 spent annually on American health care must
be spent more effectively in order to meet this guarantee.
(8) This guarantee must include easier access to understandable information
about the quality, cost, and effectiveness of health care providers, products,
and services.
(9) The fact that businesses in the United States compete globally against
businesses whose governments pay for health care, coupled with the aging
of the American population and the explosive growth of preventable health
problems, makes the status quo in American health care unacceptable.
SEC. 3. DEFINITIONS.
(1) ADULT INDIVIDUAL- The term `adult individual' means an individual
who--
(ii) a resident of a State;
(iii)(I) a United States citizen; or
(II) an alien with permanent residence;
(iv) not a dependent child; and
(v) not an alien unlawfully present in the United States; and
(B) in the case of an incarcerated individual, such an individual who
is incarcerated for less than 1 month.
(2) ALIEN WITH PERMANENT RESIDENCE- The term `alien with permanent residence'
has the meaning given the term `qualified alien' in section 431 of the
Personal Responsibility and Work Opportunity Reconciliation Act of 1996
(8 U.S.C. 1641).
(3) COVERED INDIVIDUAL- The term `covered individual' means an individual
who is enrolled in a HAPI plan.
(4) DEPENDENT CHILD- The term `dependent child' has the meaning given
the term `qualifying child' in section 152(c) of the Internal Revenue
Code of 1986.
(5) HAPI PLAN- The term `HAPI plan' means a Healthy Americans Private
Insurance plan described under subtitle B of title I.
(6) HHA- The term `HHA' means the Health Help Agency of a State as described
under title V.
(7) HEALTH INSURANCE ISSUER- The term `health insurance issuer' means
an insurance company, insurance service, or insurance organization (including
a health maintenance organization, as defined in paragraph (7)) which
is licensed to engage in the business of insurance in a State and which
is subject to State law which regulates insurance (within the meaning
of section 514(b)(2) of the Employee Retirement Income Security Act of
1974). Such term does not include a group health plan.
(8) HEALTH MAINTENANCE ORGANIZATION- The term `health maintenance organization'
means--
(A) a federally qualified health maintenance organization (as defined
in section 1301(a)),
(B) an organization recognized under State law as a health maintenance
organization, or
(C) a similar organization regulated under State law for solvency in
the same manner and to the same extent as such a health maintenance
organization.
(9) PERSONAL RESPONSIBILITY CONTRIBUTION- The term `personal responsibility
contribution' means a payment made by a covered individual to a health
care provider or a health insurance issuer with respect to the provision
of health care services under a HAPI plan, not including any health insurance
premium payment.
(10) QUALIFIED COLLECTIVE BARGAINING AGREEMENT-
(A) IN GENERAL- The term `qualified collective bargaining agreement'
means an agreement between a qualified collective bargaining employer
and an employee organization that represents the employees of such employer
that is in effect until the date that is the earlier of--
(i) January 1 of the first year which is more than 7 years after the
date of enactment of this Act, or
(ii) the date the collective bargaining agreement expires.
(B) QUALIFIED COLLECTIVE BARGAINING EMPLOYER- The term `qualified collective
bargaining employer' means an employer who provides health insurance
to employees under the terms of a collective bargaining agreement which
is entered into before the date of the enactment of this Act.
(11) SECRETARY- The term `Secretary' means the Secretary of Health and
Human Services.
(12) STATE- The term `State' means each of the several States of the United
States, the District of Columbia, the Commonwealth of Puerto Rico, the
Virgin Islands, American Samoa, Guam, the Commonwealth of the Northern
Mariana Islands, and other territories of the United States.
(13) STATE OF RESIDENCE- The term `State of residence', with respect to
an individual, means the State in which the individual has primary residence.
TITLE I--HEALTHY AMERICANS PRIVATE INSURANCE PLANS
Subtitle A--Guaranteed Private Coverage
SEC. 101. GUARANTEE OF HEALTHY AMERICANS PRIVATE INSURANCE COVERAGE.
Not later than the date that is 2 years after the date of enactment of this
Act, each adult individual shall have the opportunity to purchase a Healthy
Americans Private Insurance plan that meets the requirements of subtitle
B, (referred to in this Act as `HAPI plan') for such individual and the
dependent children of such individual.
SEC. 102. INDIVIDUAL RESPONSIBILITY TO ENROLL IN A HEALTHY AMERICANS PRIVATE
INSURANCE PLAN.
(a) Individual Responsibility-
(1) ADULT INDIVIDUALS- Each adult individual shall have the responsibility
to enroll in a HAPI plan offered through the HHA of the adult individual's
State of residence, unless the adult individual--
(A) provides evidence of receipt of coverage under, or enrollment in
a health plan offered through--
(i) the Medicare program under title XVIII of the Social Security
Act;
(ii) a health insurance plan offered by the Department of Defense;
(iii) an employee benefit plan through a former employer;
(iv) a qualified collective bargaining agreement;
(v) the Department of Veterans Affairs; or
(vi) the Indian Health Service; or
(B) is opposed to health plan coverage for religious reasons, including
an individual who declines health plan coverage due to a reliance on
healing using spiritual means through prayer alone.
(2) DEPENDENT CHILDREN- Each adult individual shall have the responsibility
to enroll each dependent child of the adult individual in a HAPI plan
offered through the HHA of the adult individual's State of residence,
unless the adult individual--
(A) provides evidence that the dependent child is enrolled in a health
plan offered through a program described in paragraph (1)(A); or
(B) is described in paragraph (1)(B).
(3) VERIFICATION OF RELIGIOUS EXCEPTION- Each State shall develop guidelines
for determining and verifying the individuals who qualify for the exception
under paragraph (1)(B).
(b) Penalty for Failure To Purchase Coverage-
(A) IN GENERAL- In the case of an individual described in subparagraph
(B), such individual shall be subject to a late enrollment penalty in
an amount determined under subparagraph (C).
(B) INDIVIDUALS SUBJECT TO PENALTY- An individual described in this
subparagraph is an adult individual for whom there is a continuous period
of 63 days or longer, beginning on the applicable date (as defined in
subparagraph (E)) and ending on the date of enrollment in a HAPI plan,
during all of which the individual--
(i) was not covered under a HAPI plan or a health plan offered through
a program described in paragraph (1)(A) of section 102(a); and
(ii) was not described in paragraph (1)(B) of such section.
(i) IN GENERAL- The amount determined under this subparagraph for
an individual is an amount equal to the sum of--
(I) the number of uncovered months multiplied by the weighted average
of the monthly premium for HAPI plans of the same class of coverage
as the individual's in the applicable coverage area (determined
without regard to any subsidy under section 121); and
(II) 15 percent of the amount determined under subclause (I).
(ii) UNCOVERED MONTH DEFINED- For purposes of this subsection, the
term `uncovered month' means, with respect to an individual, any month
beginning on or after the applicable date (as defined in subparagraph
(E)) unless the individual can demonstrate that the individual--
(I) was covered under a HAPI plan or a health plan offered through
a program described in paragraph (1)(A) of section 102(a) for any
portion of such month; or
(II) was described in paragraph (1)(B) of such section for any portion
of such month.
A month shall not be treated as an uncovered month if the individual
has already paid a late enrollment penalty under this subsection for
such month or if the individual was incarcerated for the entire month.
(D) PAYMENT- Payment of any late enrollment penalty by an individual
under this subsection shall be made to the HHA of the individual's State
of residence under procedures established by the State.
(E) APPLICABLE DATE- In this paragraph, the term `applicable date' means
the earlier of--
(i) the day after the end of the State's first open enrollment period
for HAPI plans (during which all adult individuals are eligible to
enroll); and
(ii) the day after the end of the first enrollment period for a fallback
HAPI plan in the State.
(2) WAIVER- An HHA of a State may reduce or waive the amount of any late
enrollment penalty applicable to an individual under this subsection if
payment of such penalty would constitute a hardship (determined under
procedures established by the State).
(3) ENFORCEMENT- Each State shall determine appropriate mechanisms, which
may not include revocation or ineligibility for coverage under a HAPI
plan, to enforce the responsibility of each adult individual to purchase
HAPI plan coverage for such individual and any dependent children of such
individual under subsection (a).
(c) Other Insurance Coverage- Nothing in this Act shall be construed to
prohibit an individual from enrolling in a health insurance plan that is
not a HAPI plan.
Subtitle B--Standards for Healthy Americans Private Insurance Coverage
SEC. 111. HEALTHY AMERICANS PRIVATE INSURANCE PLANS.
(a) Options- A State HHA--
(1) shall require that at least 2 HAPI plans that comply with the requirements
of subsection (b), be offered through the HHA to each individual in the
State;
(2) may require the offering of 1 or more HAPI plans that include coverage
for benefits, items, or services required by the State in addition to
the standardized benefits, items, or services required under subsection
(b) for HAPI plans if--
(A) such additional benefits, items, and services build upon the standardized
benefits package;
(B) a list of such additional benefits, items, or services, and the
prices applicable to such additional benefits, items, and services,
is displayed in a manner that is separate from the description of the
standardized benefits, items, or services required under the plan under
this section (and consistent with the manner in which such items are
displayed by medigap policies) and that enables a consumer to identify
such additional benefits, items, and services and the cost associated
with such; and
(C) no premium subsidies are available under subtitle C for any portion
of the premiums for a HAPI plan that are attributable to such additional
benefits, items, or services; and
(3) may permit the offering of 1 or more actuarially equivalent HAPI plans
through the HHA as provided for in subsection (c).
(b) Standardized Coverage Requirements for HAPI Plans-
(1) IN GENERAL- Each HAPI plan offered through an HHA shall--
(A) provide benefits for health care items and services that are actuarially
equivalent or greater in value than the benefits offered as of January
1, 2007, under the Blue Cross/Blue Shield Standard Plan provided under
the Federal Employees Health Benefit Program under chapter 89 of title
5, United States Code, including coverage of an initial primary care
assessment and annual physical examinations;
(B) provide benefits for wellness programs and incentives to promote
the use of such programs;
(C) provide coverage for catastrophic medical events that result in
out-of-pocket costs for an individual or family if lifetime limits are
exhausted;
(D) designate a health care provider, such as a primary care physician,
nurse practitioner, or other qualified health provider, to monitor the
health and health care of a covered individuals (such provider shall
be known as the `health home' of the covered individual);
(E) ensure that, as part of the first visit with a primary care physician
or the health home of a covered individual, such provider and individual
determine a care plan to maximize the health of the individual through
wellness and prevention activities;
(F) provide benefits for comprehensive disease prevention, early detection,
disease management, and chronic condition management that meets minimum
standards developed by the Secretary;
(G) provide for the application of personal responsibility contribution
requirements with respect to covered benefits in a manner that may be
similar to the cost sharing requirements applied as of January 1, 2007,
under the Blue Cross/Blue Shield Standard Plan provided under the Federal
Employees Health Benefit Program under chapter 89 of title 5, United
States Code, except that no contributions shall be required for--
(i) preventive items or services; and
(ii) early detection, disease management, or chronic pain treatment
items or services; and
(H) comply with the requirements of section 112.
(2) DETERMINATION OF BENEFITS BY SECRETARY- Not later than 1 year after
the date of enactment of this Act, the Secretary shall promulgate guidelines
concerning the benefits, items, and services that are covered under paragraph
(1).
(3) COVERAGE FOR FAMILY PLANNING-
(A) IN GENERAL- Except as provided in subparagraph (B), a health insurance
issuer shall make available supplemental coverage for abortion services
that may be purchased in conjunction with enrollment in a HAPI plan
or an actuarially equivalent healthy American plan.
(B) RELIGIOUS AND MORAL EXCEPTION- Nothing in this paragraph shall be
construed to require a health insurance issuer affiliated with a religious
institution to provide the coverage described in subparagraph (A).
(4) RULE OF CONSTRUCTION- Nothing in this subsection shall be construed
to prohibit a HAPI plan from providing coverage for benefits, items, and
services in addition to the coverage required under this subsection. No
premium subsidies shall be available under subtitle C for any portion
of the premiums for a HAPI plan that are attributable to such additional
benefits, items, or services.
(c) Actuarially Equivalent Healthy American Plans- Each actuarially equivalent
healthy American plan offered through an HHA shall--
(1) cover all treatments, items, services, and providers at least to the
same extent as those covered under a HAPI plan that--
(A) shall include coverage for--
(i) preventive items and services (including well baby care and well
child care and appropriate immunizations) and disease management services;
(ii) inpatient and outpatient hospital services;
(iii) physicians' surgical and medical services; and
(iv) laboratory and x-ray services; and
(B) may include additional supplemental benefits to the extent approved
by the State and provided for in advance in the plan contract; and
(2) ensure that no personal responsibility contribution requirements are
applied for prevention and chronic disease management benefits, items,
or services.
(d) Premiums and Rating Requirements-
(1) CLASSES OF COVERAGE- With respect to a HAPI plan, a health insurance
issuer shall provide for the following classes of coverage:
(A) Coverage of an individual.
(B) Coverage of a married couple or domestic partnership (as determined
by a State) without dependent children.
(C) Coverage of an adult individual with 1 or more dependent children.
(D) Coverage of a married couple or domestic partnership (as determined
by a State) with 1 or more dependent children.
(2) DETERMINATIONS OF PREMIUMS- With respect to each class of coverage
described in paragraph (1), a health insurance issuer shall determine
the premium amount for a HAPI plan using adjusted community rating principals,
as described in paragraphs (3) and (4) established by the State. States
may permit premium variations based only on geography, tobacco use, and
family size. A State may determine to have no variation.
(3) REWARDS- A State shall permit a health insurance issuer to provide
premium discounts and other incentives to enrollees based on the participation
of such enrollees in wellness, chronic disease management, and other programs
designed to improve the health of the enrollees.
(4) LIMITATION- A health insurance issuer shall not consider age, gender,
industry, health status, or claims experience in determining premiums
under this subsection.
(e) Application of State Mandate Laws- State benefit mandate laws that would
otherwise be applicable to HAPI plans shall be preempted.
SEC. 112. SPECIFIC COVERAGE REQUIREMENTS.
(a) In General- Each HAPI plan offered through a HHA shall--
(1) provide for increased portability through limitations on the application
of preexisting condition exclusions, in a manner similar to that provided
for under section 2701 of the Public Health Service Act (42 U.S.C. 300gg),
as such section existed on the day before the date of enactment of this
Act, except that the State shall develop procedures to ensure that preexisting
exclusion limitations do not apply to new enrollees who had no applicable
creditable coverage immediately prior to the first enrollment period;
(2) provide for the guaranteed availability of coverage to prospective
enrollees in a manner similar to that provided for under section 2711
of the Public Health Service Act (42 U.S.C. 300gg-11), as such section
existed on the day before the date of enactment of this Act;
(3) provide for the guaranteed renewability of coverage in a manner similar
to that provided for under section 2712 of the Public Health Service Act
(42 U.S.C. 300gg-12), as such section existed on the day before the date
of enactment of this Act, except that the prohibition on market reentry
provided for under such section shall be deemed to be 2 years;
(4) prohibit discrimination against individual enrollees and prospective
enrollees based on health status in a manner similar to that provided
for under section 2702 of the Public Health Service Act (42 U.S.C. 300gg-1),
as such section existed on the day before the date of enactment of this
Act;
(5) provide coverage protections for enrollees who are mothers and newborns
in a manner similar to that provided for under section 2704 of the Public
Health Service Act (42 U.S.C. 300gg-3), as such section existed on the
day before the date of enactment of this Act;
(6) provide for full parity in the application of certain limits to mental
health benefits in a manner similar to that provided for under section
2705 of the Public Health Service Act (42 U.S.C. 300gg-4), as such section
existed on the day before the date of enactment of this Act;
(7) provide coverage for reconstructive surgery following a mastectomy
in a manner similar to that provided for under section 2706 of the Public
Health Service Act (42 U.S.C. 300gg-5), as such section existed on the
day before the date of enactment of this Act; and
(8) prohibit discrimination on the basis of genetic information, as provided
for under subsection (b).
(b) Genetic Nondiscrimination-
(1) PROHIBITION ON GENETIC INFORMATION AS A CONDITION OF ELIGIBILITY-
A HAPI plan shall not establish rules for the eligibility (including continued
eligibility) of any individual to enroll in coverage under the plan based
on genetic information (including information about a request for or receipt
of genetic services by an individual or family member of such individual).
(2) PROHIBITION ON GENETIC INFORMATION IN SETTING PREMIUM RATES- A HAPI
plan shall not adjust premium or personal responsibility contribution
amounts for an individual on the basis of genetic information concerning
the individual or a family member of the individual (including information
about a request for or receipt of genetic services by an individual or
family member of such individual).
(A) LIMITATION ON REQUESTING OR REQUIRING GENETIC TESTING- A HAPI plan
shall not request or require an individual or a family member of such
individual to undergo a genetic test.
(B) RULE OF CONSTRUCTION- Nothing in this subsection shall be construed
to--
(i) limit the authority of a health care professional who is providing
health care services with respect to an individual to request that
such individual or a family member of such individual undergo a genetic
test;
(ii) limit the authority of a health care professional who is employed
by or affiliated with a HAPI plan and who is providing health care
services to an individual as part of a bona fide wellness program
to notify such individual of the availability of a genetic test or
to provide information to such individual regarding such genetic test;
or
(iii) authorize or permit a health care professional to require that
an individual undergo a genetic test.
(c) Guidelines- Not later than 1 year after the date of enactment of this
Act, the Secretary shall develop guidelines for the application of the requirements
of this section.
SEC. 113. UPDATING HEALTHY AMERICANS PRIVATE INSURANCE PLAN REQUIREMENTS.
(a) In General- The Secretary shall establish the Healthy America Advisory
Committee (referred to in this section as the `Advisory Committee') to provide
annual recommendations to the Secretary and Congress concerning modifications
to the benefits, items, and services required under section 111(a)(1).
(1) IN GENERAL- The Advisory Committee shall be composed of 15 members
to be appointed by the Comptroller General, of which--
(A) at least 1 such member shall be a health economist;
(B) at least 1 such member shall be an ethicist;
(C) at least 1 such member shall be a representative of health care
providers, including nurses and other nonphysician providers;
(D) at least 1 such member shall be a representative of health insurance
issuers;
(E) at least 1 such member shall be a health care consumer;
(F) at least 1 such member shall be a representative of the United States
Preventive Services Task Force; and
(G) at least 1 such member shall be an actuary.
(2) GEOGRAPHIC BALANCE- The Comptroller General shall ensure the geographic
diversity of the members appointed under paragraph (1).
(c) Terms, Vacancies- Members of the Advisory Committee shall be appointed
for a term of 3 years and may be reappointed for 1 additional term. In appointing
members, the Comptroller General shall stagger the terms of the initial
members so that the terms of one-third of the members expire each year.
Vacancies in the membership of the Advisory Committee shall not affect the
Committee's ability to carry out its functions. The Comptroller General
shall appoint an individual to fill the remaining term of a vacant member
within 2 months of being notified of such vacancy.
(d) Compensation and Expenses- Each member of the Advisory Committee who
is not otherwise employed by the United States Government shall receive
compensation at a rate equal to the daily rate prescribed for GS-18 under
the General Schedule under section 5332 of title 5, United States Code,
for each day, including travel time, such member is engaged in the actual
performance of duties as a member of the Committee. A member of the Advisory
Committee who is an officer or employee of the United States Government
shall serve without additional compensation. All members of the Advisory
Committee shall be reimbursed for travel, subsistence, and other necessary
expenses incurred by them in the performance of their duties.
(e) Action by Secretary- Not later than December 31 of the second full calendar
year following the date of enactment of this Act, and each December 31 thereafter,
the Advisory Committee shall provide to Congress and the Secretary a report
that--
(1) describes any recommendations for modifications to the benefits, items,
and services that are required to be covered under a HAPI plan; and
(2) includes any recommendations to modify HAPI plans to improve the quality
of life for United States citizens and to ensure that benefits in such
plans are medically- and cost-effective.
(f) Application of FACA- The Federal Advisory Committee Act (5 U.S.C. App.)
shall apply to the Advisory Committee, except that section 14 of such Act
shall not apply.
Subtitle C--Eligibility for Premium and Personal Responsibility Contribution
Subsidies
SEC. 121. ELIGIBILITY FOR PREMIUM SUBSIDIES.
(a) Individuals and Families At or Below the Poverty Line- For any calendar
year, in the case of a covered individual who is determined to have a modified
adjusted gross income that is at or below 100 percent of the poverty line,
as applicable to a family of the size involved, the covered individual is
entitled under this section to an income-related premium subsidy equal to
the basic premium subsidy amount.
(b) Partial Subsidy for Other Individuals and Families-
(1) IN GENERAL- For any calendar year, in the case of a covered individual
who is determined to have a modified adjusted gross income that is greater
than 100 percent of the poverty line, as applicable to a family of the
size involved, but below the applicable percentage of the poverty line,
as applicable to a family of the size involved, the covered individual
is entitled under this section to an income-related premium subsidy equal
to the basic premium subsidy amount reduced by the amount determined under
paragraph (2).
(2) AMOUNT OF REDUCTION- The amount of the reduction determined under
this paragraph is the amount that bears the same ratio to the basic premium
subsidy amount as--
(i) such individual's modified adjusted gross income, over
(ii) an amount equal to 100 percent of the poverty line as applicable
to a family of the size involved, bears to
(i) an amount equal to the applicable percentage of the poverty line
as applicable to a family of the size involved, over
(ii) an amount equal to 100 percent of the poverty line as applicable
to a family of the size involved.
(3) APPLICABLE PERCENTAGE- For purposes of this subsection, the applicable
percentage is 400 percent.
(c) Basic Premium Subsidy Amount- For purposes of this section, the term
`basic premium subsidy amount' means, with respect to any individual, the
lesser of--
(1) the annual premium for the HAPI plan under which the individual is
a covered individual; or
(2) the weighted average of the premium for HAPI plans of the same class
of coverage (as described in section 111(d)(1)) as the individual's in
the applicable coverage area.
(d) Change in Status Notification-
(1) IN GENERAL- If an individual's modified adjusted income changes such
that the individual becomes eligible or ineligible for a subsidy under
this section, the individual shall report that change to the HHA of the
individual's State of residence not more than 60 days after the change
takes effect. If an individual reports the change within 60 days under
the preceding sentence, the individual's HAPI plan coverage shall be deemed
credible coverage for the purposes of maintaining coverage for preexisting
conditions.
(2) ADJUSTMENT- The HHA shall adjust the premium subsidy of such individual
to take effect on the first month after the date of the notification under
paragraph (1) for which the next premium payment would be due from the
individual.
(e) Catastrophic Event- A State may develop mechanisms to ensure that covered
individuals do not have a break in coverage due to a catastrophic financial
event.
SEC. 122. ELIGIBILITY FOR PERSONAL RESPONSIBILITY CONTRIBUTION SUBSIDIES.
(a) Full Subsidy- To meet the eligibility requirements under subtitle B
for an HHA, for any taxable year, in the case of a covered individual who
is determined to have a modified adjusted gross income that is below 100
percent of the poverty line as applicable to a family of the size involved,
an HHA shall provide to such an individual a subsidy equal to the full amount
of any personal responsibility contributions applicable to such individual.
(b) Partial Subsidy- To meet the eligibility requirements under subtitle
B for an HHA, for any taxable year, in the case of a covered individual
who is determined to have a modified adjusted gross income that is at or
above 100 percent of the poverty line as applicable to a family of the size
involved, an HHA may provide to such an individual a subsidy equal to the
part of the amount of any personal responsibility contributions applicable
to such individual.
SEC. 123. DEFINITIONS AND SPECIAL RULES.
(a) Determination of Modified Adjusted Gross Income-
(1) IN GENERAL- In this subtitle, the term `modified adjusted gross income'
means adjusted gross income (as defined in section 62 of the Internal
Revenue Code of 1986)--
(A) determined without regard to sections 86, 135, 137, 199, 221, 222,
911, 931, and 933 of such Code; and
(i) the amount of interest received or accrued during the taxable
year which is exempt from tax under such Code; and
(ii) the amount of any social security benefits (as defined in section
86(d) of such Code) received or accrued during the taxable year.
(2) TAXABLE YEAR TO BE USED TO DETERMINE MODIFIED ADJUSTED GROSS INCOME-
In applying this subtitle to determine an individual's annual premiums,
the covered individual's modified adjusted gross income shall be such
income determined using the individual's most recent income tax return
or other information furnished to the Secretary by such individual, as
the Secretary may require.
(b) Poverty Line- In this subtitle, the term `poverty line' has the meaning
given such term in section 673(2) of the Community Health Services Block
Grant Act (42 U.S.C. 9902(2)), including any revision required by such section.
(c) Other Procedures To Determine Subsidies- The Secretary shall promulgate
regulations to be used by HHAs to calculate the premium subsidies under
section 121 and personal responsibility subsidies under section 122 for
individuals whose modified adjusted gross income described in subsection
(a)(2) is significantly lower than the modified adjusted gross income of
the year involved.
(d) Special Rule for Unlawfully Present Aliens- A health insurance issuer
shall remit to the Federal Government any funding, including any subsidy
payments, received by such issuer from the Federal Government on behalf
of any adult alien who is unlawfully present in the United States.
(e) Special Rule for Aliens- The Secretary of Homeland Security may not
extend or renew an alien's eligibility for status in the United States or
adjust the status of an alien in the United States if the alien owes--
(1) a premium payment for a HAPI plan that is past due; or
(2) a penalty incurred for failing to pay such a premium.
(f) No Discharge in Bankruptcy- In the case of any bankruptcy filed by or
on behalf of any person after the date that is 2 years after the date of
enactment of this Act, under title 11, United States Code, any penalty imposed
with respect to such person for failure to pay a HAPI plan premium shall
not be subject to discharge under such title.
Subtitle D--Wellness Programs
SEC. 131. REQUIREMENTS FOR WELLNESS PROGRAMS.
(a) Definition- In this Act, the term `wellness program' means a program
that consists of a combination of activities that are designed to increase
awareness, assess risks, educate, and promote voluntary behavior change
to improve the health of an individual, modify his or her consumer health
behavior, enhance his or her personal well-being and productivity, and prevent
illness and injury.
(1) ELIGIBILITY- With respect to a HAPI plan that is offered in a State
that permits premium discounts for enrollees who participate in a wellness
program, to be eligible to receive such a discount, the administrator
of the wellness program, on behalf of the enrollee, shall certify in writing
to the plan that--
(A)(i) the enrollee is participating in an approved wellness program;
or
(ii) the dependent child of the enrollee is participating in an approved
wellness program; and
(B) the wellness program meets the requirements of this subsection.
(2) REQUIREMENTS- A wellness program meets the requirements of this paragraph
if such program--
(A) is reasonably designed (as determined by the HAPI plan) to promote
good health and prevent disease for program participants;
(B) has been approved by the HAPI plan for purposes of applying participation
discounts;
(C) is offered to all enrollees in a HAPI plan regardless of health
status;
(D) permits any enrollee for whom it is unreasonably difficult to meet
the initial program standard for participation due to a medical condition
(or for whom it is medically inadvisable to attempt) an opportunity
to meet a reasonable alternative participation standard--
(i)(I) that is developed prior to enrollment of the enrollee; or
(II) that is developed in consultation with the enrollee after enrollment
of the enrollee, after a determination has been made that the enrollee
cannot safely meet the program participation standard; and
(ii) the availability of which is disclosed in the original documents
relating to participation in the program;
(E) applies procedures for determining whether an enrollee is participating
in a meaningful manner in the program, including procedures to determine
if such participation is resulting in lifestyle changes that are indicative
of an improved health outcome or outcomes; and
(F) meets any other requirements imposed by the HAPI plan.
(3) RELATION TO HEALTH STATUS- Participation in a wellness program may
not be used by a HAPI plan to make rate or discount determinations with
respect to the health status of an enrollee.
(4) AVAILABILITY OF DISCOUNTS-
(A) OFFERING OF ENROLLMENT- A HAPI plan shall provide enrollees with
the opportunity to participate in a wellness program (for purposes of
qualifying for premium discounts) at least once each year.
(B) DETERMINATIONS- Determinations with respect to the successful participation
by an enrollee in a wellness program for purposes of qualifying for
discounts shall be made by the HAPI plan based on a retrospective review
of the scope of activities of the enrollee under the program. The HAPI
plan may require a minimum level of successful participation in such
a program prior to applying any premium discount.
(C) PARTICIPATION IN MULTIPLE PROGRAMS- An enrollee may participate
in multiple wellness programs to reach the maximum premium discount
permitted by the HAPI plan under applicable State law.
(5) PERSONAL RESPONSIBILITY CONTRIBUTION DISCOUNT- A HAPI plan may elect
to provide discounts in the amount of the personal responsibility contribution
that is required of an enrollee if the enrollee participates in an approved
wellness program.
(c) Employer Incentive for Wellness Programs- For provisions relating to
employers deducting the costs of offering wellness programs or worksite
health centers see section 162(l) of the Internal Revenue Code of 1986.
TITLE II--HEALTHY START FOR CHILDREN
Subtitle A--Benefits and Eligibility
SEC. 201. GENERAL GOAL AND AUTHORIZATION OF APPROPRIATIONS FOR HAPI PLAN
COVERAGE FOR CHILDREN.
(a) General Goal- It is the general goal of this Act to provide essential,
good quality, affordable, and prevention-oriented health care coverage for
all children in the United States.
(b) Authorization of Appropriations- There is authorized to be appropriated,
such sums as may be necessary for each fiscal year to enable the Secretary
to provide assistance to States to enable such States to ensure that each
child who is a member of a family with a modified adjusted gross income
that is below 300 percent of the poverty line as applicable to a family
of the size involved, who is not otherwise eligible for coverage as a dependent
under a HAPI plan maintained by his or her parents, is covered under a HAPI
plan provided through the State HHA.
(c) Policies and Procedures- The Secretary shall develop policies and procedures
to be applied by the States to identify children described in subsection
(a) and to provide such children with coverage under a HAPI plan. States
shall determine, in consultation with health insurance issuers, a separate
class of coverage to assure affordable child coverage.
(d) Definition- In this title, the term `child' means an individual who
is under the age of 19 years or, in the case of an individual in foster
care, under the age of 21 years.
SEC. 202. COORDINATION OF SUPPLEMENTAL COVERAGE UNDER THE MEDICAID PROGRAM
TO HAPI PLAN COVERAGE FOR CHILDREN.
(a) Assurance of Supplemental Coverage- The Secretary shall provide guidance
to States and health insurance issuers that ensures that, after December
31 of the last calendar year ending before the first calendar year in which
coverage under a HAPI plan begins, any child covered under a HAPI plan provided
through the State HHA continues to receive medical assistance under State
Medicaid plans in a manner that--
(1) is provided in coordination with, and as a supplement to, the coverage
provided the child under the HAPI plan in which the child is enrolled;
(2) does not supplant the child's coverage under a HAPI plan; and
(3) ensures that the child receives any items or services that are not
available under the HAPI plan in which they are enrolled but that the
child would have received under the Medicaid program of the State in which
the child resides if the Healthy Americans Act had not been enacted, including
items and 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)).
(b) Definition- In this section, the term `child', in addition to the meaning
given that term under section 201(d), includes any individual who would
be considered a child under the Medicaid program of the State in which the
individual resides.
Subtitle B--Service Providers
SEC. 211. INCLUSION OF PROVIDERS UNDER HAPI PLANS.
(a) In General- To ensure that children have access to health care in their
communities, and that such care is provided to such children for no cost
or on a reimbursable basis, a HAPI plan shall ensure that health care items
and services may be obtained by such children from, at a minimum, the providers
described in subsection (b) if available in the area involved.
(b) Providers Described- The providers described in this subsection include
the following:
(1) A school-based health center (in accordance with section 212).
(2) A health center funded under section 330 of the Public Health Service
Act (42 U.S.C. 254b).
(3) A federally qualified health center.
(4) A rural health clinic under title XVIII of the Social Security Act
(42 U.S.C. 1395 et seq.).
(5) An Indian health service facility.
SEC. 212. USE OF, AND GRANTS FOR, SCHOOL-BASED HEALTH CENTERS.
(a) Definition- In this section, the term `school-based health center' means
a health center that--
(1) is located within an elementary or secondary school facility;
(2) is operated in collaboration with the school in which such center
is located;
(3) is administered by a community-based organization including a hospital,
public health department, community health center, or nonprofit health
care agency;
(4) at a minimum, provides to school-aged children--
(A) primary health care services, including comprehensive health assessments,
and diagnosis and treatment of minor, acute, and chronic medical conditions
and Healthy Start benefits;
(B) mental health services, including crisis intervention, counseling,
and emergency psychiatric care at the school or by referral;
(C) the availability of services at the school when the school is open
and 24-hour coverage through an on-call system with other providers
to ensure access when the school or health center is closed;
(D) services through the use of a qualified and appropriately credentialed
individual, including a nurse practitioner or physician assistant, a
mental health professional, a physician, and a health assistant; and
(E) by not later than January 1, 2010, an electronic medical record
relating to the individual; and
(5) may provide optional preventive dental services, consistent with State
licensure law, through the use of dental hygienists or dental assistants
that provide preventive services such as basic oral exams, cleanings,
and sealants.
(b) Access to School-Based Health Centers-
(1) IN GENERAL- A school-based health center may provide services to students
in more than 1 school if the school district or other supervising State
entity determined that capacity and geographic location make such provision
of services appropriate.
(2) ENROLLMENT- Upon the enrollment of a student in a school with a school-based
health center, the center will provide the student with the opportunity
to enroll, after parental consent, to receive health care from the center.
(3) REIMBURSEMENT FOR SERVICES-
(A) IN GENERAL- A school-based health center may seek reimbursement
from a third party payer if available, including a HAPI plan, if a child
receives health care items or services through the center.
(B) USE OF FUNDS- Amounts received from a third party payer under subparagraph
(A) shall be allocated to the school-based health center that provided
the care for which the reimbursement was provided for use by that center
for providing additional health care items and services.
(c) Developmental Grants-
(1) IN GENERAL- The Secretary shall award grants to local school districts
and communities for the establishment and operation of school-based health
centers.
(2) ELIGIBILITY- To be eligible for a grant under paragraph (1), a local
school district or local community shall submit to the Secretary an application
at such time, in such manner, and containing such information as the Secretary
may require.
(3) SELECTION CRITERIA- In awarding grants under this subsection, the
Secretary shall give priority to--
(A) an applicant that will use amounts under the grant to establish
a school-based health center in a medically underserved area, or an
area for which there are extended distances between the school involved
and appropriate providers of care for school-aged children in the geographic
area involved;
(B) an applicant that will use amounts under the grant to establish
a school-based health center in a school that serves students with the
highest incidence of unmet medical and psycho-social needs; and
(C) an applicant that can demonstrate that State, local, or community
partners, or any combination of such entities, have provided at least
50 percent of the funding for the school-based health center involved
to ensure the ongoing operation of the center.
(4) USE OF FUNDS- A grantee shall use amounts received under a grant under
this subsection to establish and operate a school-based health center.
Not less than 50 percent of the amounts received under the grant shall
be used for the ongoing operations of the center.
(d) Coverage by Federal Tort Claims Act- In providing health care items
and services to students through a school-based health care center, a health
care provider shall be deemed to be an employee of the government for purposes
of the application of chapter 171 of title 28, United States Code (the Federal
Tort Claims Act) if such provider was acting within the scope of his or
her license.
(e) Authorization of Appropriations- There is authorized to be appropriated,
such sums as may be necessary for each fiscal year to carry out this section.
TITLE III--BETTER HEALTH FOR OLDER AND DISABLED AMERICANS
Subtitle A--Assurance of Supplemental Medicaid Coverage
SEC. 301. COORDINATION OF SUPPLEMENTAL COVERAGE UNDER THE MEDICAID PROGRAM
FOR ELDERLY AND DISABLED INDIVIDUALS.
(a) Coordination of Care- The Secretary shall provide guidance to States
and insurers that--
(1) takes into account the special health care needs of elderly and disabled
individuals who are eligible for medical assistance under State Medicaid
programs, particularly with respect to institutionalized care or home
and community-based services; and
(2) ensures that, after December 31 of the last calendar year ending before
the first calendar year in which coverage under a HAPI plan begins, each
such individual continues to receive medical assistance under State Medicaid
programs in a manner that--
(A) is provided in coordination with, and as a supplement to, the coverage
provided the individual under the HAPI plans in which the individual
is enrolled;
(B) does not supplant the individual's coverage under a HAPI plan; and
(C) ensures that the individual receives any items or services that
are not available under the HAPI plan in which the individual is enrolled
but that the individual would have received under the Medicaid program
of the State in which the individual resides if the Healthy Americans
Act had not been enacted.
(b) Definitions- In this section--
(1) the term `institutionalized care' means the health care provided under
the Medicaid plan of the State of residence of an elderly or disabled
individual who is a patient in a hospital, nursing facility, intermediate
care facility for the mentally retarded, or an institution for mental
diseases (as such terms are defined for purposes of such plan); and
(2) the term `home and community-based services' means any services which
may be offered under the Medicaid plan of the State of residence of an
elderly or disabled individual under a home and community-based waiver
authorized for a State under section 1115 of the Social Security Act (42
U.S.C. 1315) or under subsection (c), (d), or (i) of section 1915 of such
Act (42 U.S.C. 1396n).
Subtitle B--Empowering Individuals and States To Improve Long-Term Care
Choices
SEC. 311. NEW, AUTOMATIC MEDICAID OPTION FOR STATE CHOICES FOR LONG-TERM
CARE PROGRAM.
(a) In General- Title XIX of the Social Security Act is amended by adding
at the end the following new section:
`STATE CHOICES FOR LONG-TERM CARE PROGRAM
`Sec. 1940. (a) In General- Notwithstanding any other provision of this
title, the Secretary shall permit a State to establish and operate under
the State plan under this title (including such a plan operating under a
statewide waiver under section 1115) a State Choices for Long-Term Care
Program in accordance with this section.
`(b) Program Requirements- A program established under the authority of
this section shall satisfy the following requirements:
`(1) INDIVIDUALIZED BENEFIT PACKAGE- Each individual enrolled in the program
shall be provided with long-term care coverage consisting of medical assistance
for long-term care services that are provided according to the specific
needs of the individual and that best reflect the individual's needs and
preferences, based on a clinical assessment of the individual.
`(2) PERSONAL CASE MANAGERS- Each individual enrolled in the program shall
be provided with a personal case manager who shall assist the individual
in--
`(A) determining the individual's needs and preferences for the long-term
care services that are contained within the individual's benefit package,
including the selection of the service providers for such services;
`(B) identifying community resources that are available to provide support
for the individual; and
`(C) addressing issues related to ensuring the safety and quality of
the long-term care services provided to the individual.
`(3) INFORMED CHOICE- The program shall have procedures to ensure that
each individual that is likely to satisfy the eligibility criteria established
for the program under paragraph (6) who is discharged from a hospital
or who resides in a nursing facility, intermediate care facility for the
mentally retarded, or institution for mental diseases and who requires
long-term care services is informed of the options available to the individual
under the program for obtaining such services.
`(4) SELF-DIRECTED OPTION- The program shall provide an individual enrolled
in the program with the option to elect to plan and purchase the long-term
care services that are contained in the individual's benefit package under
the direction and control of the individual (or the individual's authorized
representative), subject to an individualized budget developed for, and
with the involvement of, the individual (or the individual's authorized
representative).
`(5) EQUAL ACCESS TO INSTITUTIONAL CARE AND HOME AND COMMUNITY-BASED SERVICES-
The program shall provide an individual enrolled in the program who, because
of the individual's mental or physical condition, requires a level of
care for long term care services that is above a level of care for such
services that can appropriately be provided solely through home and community-based
providers (as defined by the State and approved by the Secretary), with
equal access to long-term care services provided through institutional
facilities and long-term care services provided through home and community-based
providers.
`(6) ELIGIBILITY; PRIORITIZATION OF NEED- The program shall apply eligibility
criteria for individuals desiring to enroll in the program that is established
by the State and approved by the Secretary. The eligibility criteria established
by the State shall--
`(A) require that an individual enrolled in the program--
`(i) be eligible for medical assistance under the State plan (or under
a statewide waiver of such plan) for nursing facility services, services
in an intermediate care facility for the mentally retarded, services
in an institution for mental diseases, or services provided under
a home and community-based waiver approved for the State; and
`(ii) satisfy such other criteria as the State shall establish; and
`(B) be based on a strategy for prioritizing and allocating expenditures
so that those individuals with the highest level of need for long-term
care services are assured of receiving such services through an institutional
facility or through a home and community-based provider, based on the
individual's needs and preferences.
`(c) Additional Requirements- A State may not establish and operate a program
under this section unless it satisfies the following requirements:
`(1) AGREEMENT TO LIMIT FEDERAL EXPENDITURES-
`(A) IN GENERAL- The State agrees to an aggregate limit for a 5-year
period for Federal payments under section 1903(a) for expenditures for
medical assistance for long-term care services under the State plan
and administrative expenditures related to the provision of such assistance.
`(B) CALCULATION OF AGGREGATE LIMIT- The 5-year aggregate limit applicable
to a State under subparagraph (A) shall be determined by the State and
the Secretary based on the following:
`(i) HISTORICAL AND PROJECTED CASELOADS- The historical and projected
State caseloads (determined for a 5-year period, respectively) of
individuals receiving nursing facility services, services in an intermediate
care facility for the mentally retarded, services in an institution
for mental diseases, or services provided under a home and community-based
waiver approved for the State under the State plan, based on data
from the Secretary, the Bureau of the Census, the Commissioner of
Social Security, and such other sources as the Secretary may approve.
`(ii) HISTORICAL AND PROJECTED EXPENDITURES- The historical and projected
expenditures (determined for a 5-year period, respectively) for the
services identified in clause (i). Projected expenditures shall be
determined without regard to the program established under this section
and shall take into account the percentage change (if any) in the
medical care component of the consumer price index for all urban consumers
(U.S. city average) for each year of the period.
`(C) RULE OF CONSTRUCTION- Nothing in this paragraph shall be construed
as affecting the requirement for a State to incur State expenditures
for medical assistance for long-term care services in order to be paid
the Federal medical assistance percentage determined for the State for
such expenditures (not to exceed the aggregate 5-year limit on Federal
payments for such expenditures applicable under subparagraph (A)).
`(2) PLAN FOR CAPACITY BUILDING AND SKILLS ENHANCEMENT- The State establishes
a plan for building the capacity of the long-term care services system
within the State, particularly with respect to the delivery of home and
community-based services, and for enhancing the skill levels of the caregivers
for individuals eligible for medical assistance for such services under
the State plan.
`(3) DEDICATION OF PROGRAM SAVINGS FOR PREVENTION OR EARLY INTERVENTION
SERVICES- The State agrees that for each fiscal year in which the program
is operated, the State will expend an amount equal to the State share
of the expenditures that the State would have made under the State plan
for providing medical assistance for long-term care services for individuals
enrolled in the program but for the operation of such program, for the
provision of prevention or early intervention services for nonenrolled
individuals residing in the State who require a level of long-term care
services that is below the level that individuals enrolled in the program
require (regardless of whether such nonenrolled individuals are eligible
for medical assistance under the State plan).
`(d) Option To Operate Program Through a Managed Care Plan- A State may
operate a program under this section through an arrangement on a capitated
basis with a medicaid managed care organization (as defined in section 1903(m)(1)(A)).
`(e) Independent Evaluation and Report-
`(1) IN GENERAL- The Secretary shall contract with a nongovernmental organization
or academic institution to conduct an ongoing independent evaluation of
the program that assesses--
`(A) the quality of the long-term care services provided under the program;
`(B) the cost-effectiveness of such services;
`(C) consumer satisfaction; and
`(D) the consistency and accuracy with which the prioritization of need
criteria required under subsection (b)(6)(B) is applied.
`(2) BIENNIAL REPORTS- The organization or institution conducting the
evaluation required under this subsection shall submit biennial reports
to the Secretary regarding the results of the evaluation.
`(f) Definition of Long-Term Care Services- For purposes of this section,
the term `long-term care services' has the meaning given such term by a
State establishing and operating a program under this section, subject to
approval by the Secretary.'.
(b) Effective Date- The amendment made by subsection (a) takes effect on
the date of enactment of this Act.
SEC. 312. SIMPLER AND MORE AFFORDABLE LONG-TERM CARE INSURANCE COVERAGE.
(a) Qualified Long-Term Care Insurance Contract Must Satisfy Qualified Long-Term
Care Plan Requirements- Section 7702B(b)(1)(A) (defining qualified long-term
care insurance contract) is amended by inserting `through a qualified long-term
care plan' after `qualified long-term care services'.
(b) Qualified Long-Term Care Plan- Section 7702B is amended by adding at
the end the following new subsection:
`(h) Qualified Long-Term Care Plan- For purposes of this section--
`(1) IN GENERAL- The term `qualified long-term care plan' means an insurance
plan that meets the standards and requirements set forth in paragraph
(2) (including the 2009 NAIC Model Regulation or 2009 Federal Regulation
(as the case may be)) on or after the date specified in paragraph (5).
`(2) DEVELOPMENT OF STANDARDS AND REQUIREMENTS FOR QUALIFIED LONG-TERM
CARE PLANS-
`(A) IN GENERAL- If, within 9 months after the date of the enactment
of this subsection, the National Association of Insurance Commissioners
(in this subsection referred to as the `Association') adopts a model
regulation (in this section referred to as the `2009 NAIC Model Regulation')
to incorporate--
`(i) limitations on the groups or packages of benefits that may be
offered under a long-term care insurance policy consistent with paragraphs
(3) and (4),
`(ii) uniform language and definitions to be used with respect to
such benefits,
`(iii) uniform format to be used in the policy with respect to such
benefits, and
`(iv) other standards required by the Secretary of Health and Human
Services
paragraph (1) shall be applied in each State, effective for policies
issued to policyholders on and after the date specified in paragraph
(5).
`(B) SECRETARIAL RESPONSIBILITY- If the Association does not adopt the
2009 NAIC Model Regulation within the 9-month period specified in subparagraph
(A), the Secretary shall promulgate, not later than 9 months after the
end of such period, a regulation (in this section referred to as the
`2009 Federal Regulation') and paragraph (1) shall be applied in each
State, effective for policies issued to policyholders on and after the
date specified in paragraph (5).
`(C) CONSULTATION- In promulgating standards and requirements under
this paragraph, the Association or Secretary shall consult with a working
group composed of representatives of issuers of long-term care insurance
policies, consumer groups, long-term care insurance beneficiaries, and
other qualified individuals. Such representatives shall be selected
in a manner so as to insure balanced representation among the interested
groups.
`(3) LIMITATIONS OF GROUPS OR PACKAGES OF BENEFITS- The benefits under
the 2009 NAIC Model Regulation or 2009 Federal Regulation shall provide--
`(A) for such groups or packages of benefits as may be appropriate taking
into account the considerations specified in paragraph (4) and the requirements
of the succeeding subparagraphs,
`(B) for identification of a core group of basic benefits common to
all policies, and
`(C) that the total number of different benefit packages (counting the
core group of basic benefits described in subparagraph (B) and each
other combination of benefits that may be offered as a separate benefit
package) that may be established in all the States and by all issuers
shall not exceed 10.
`(4) SPECIFIC CONSIDERATIONS- The benefits under paragraph (3) shall,
to the extent possible--
`(A) provide for benefits that offer consumers the ability to purchase
the benefits that are available in the market as of November 5, 2008,
and
`(B) balance the objectives of--
`(i) simplifying the market to facilitate comparisons among policies,
`(ii) avoiding adverse selection,
`(iii) providing consumer choice,
`(iv) providing market stability, and
`(v) promoting competition.
`(A) IN GENERAL- Subject to subparagraph (B), the date specified in
this paragraph shall be the date the State adopts the 2009 NAIC Model
Regulation or 2009 Federal Regulation or 1 year after the date the Association
or the Secretary first adopts such standards, whichever is earlier.
`(B) REQUIRED STATE LEGISLATION- In the case of a State which the Secretary
identifies, in consultation with the Association, as--
`(i) requiring State legislation (other than legislation appropriating
funds) in order for long-term care insurance policies to meet the
2009 NAIC Model Regulation or 2009 Federal Regulation, but
`(ii) having a legislature which is not scheduled to meet in 2009
in a legislative session in which such legislation may be considered,
the date specified in this paragraph is the first day of the first calendar
quarter beginning after the close of the first legislative session of
the State legislature that begins on or after January 1, 2010. For purposes
of the preceding 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.'.
(c) Additional Consumer Protections-
(1) IN GENERAL- Section 7702B(g)(1) (relating to consumer protection provisions)
is amended--
(A) by striking subparagraph (A) and inserting the following new paragraph:
`(1) the requirements of the 1993 NAIC model regulation and model Act
described in paragraph (2) and the 2000 NAIC model regulation and model
Act described in paragraph (5),',
(B) by striking `and' at the end of subparagraph (B),
(C) by striking the period at the end of subparagraph (C) and inserting
`, and', and
(D) by adding at the end the following new subparagraph:
`(D) the requirements relating to mandatory offer and information under
paragraph (6).'.
(2) NAIC MODEL REGULATION AND ACT- Section 7702B(g) is amended--
(A) by inserting `1993 NAIC' after `REQUIREMENTS OF' in the heading
for paragraph (2),
(B) by redesignating paragraph (5) as paragraph (7), and
(C) by inserting after paragraph (4) the following new paragraph:
`(5) REQUIREMENTS OF 2000 NAIC MODEL REGULATION AND ACT-
`(A) IN GENERAL- The requirements of this paragraph are met with respect
to any contract if such contract meets--
`(i) MODEL REGULATION- The following requirements of the model regulation:
`(I) Section 6A (other than paragraph (5) thereof) and the requirements
of section 6B of the model Act relating to such section 6A.
`(II) Section 6B (other than paragraph (7) thereof).
`(III) Sections 6C, 6D, 6E, and 7.
`(IV) Section 8 (other than sections 8F, 8G, 8H, and 8I thereof).
`(V) Sections 9, 11, 12, 14, 15, and 22.
`(VI) Section 23, including inaccurate completion of medical histories
(other than paragraphs (1), (6), and (9) of section 23C).
`(VII) Sections 24 and 25.
`(VIII) The provisions of section 26 relating to contingent nonforfeiture
benefits, if the policyholder declines the offer of a nonforfeiture
provision described in paragraph (4).
`(IX) Sections 29 and 30.
`(ii) MODEL ACT- The following requirements of the model Act:
`(II) The provisions of section 8 relating to contingent nonforfeiture
benefits.
`(III) Sections 6F, 6G, 6H, 6J, 6K, and 7.
`(B) DEFINITIONS- For purposes of this paragraph--
`(i) MODEL PROVISIONS- The terms `model regulation' and `model Act'
mean the long-term care insurance model regulation, and the long-term
care insurance model Act, respectively, promulgated by the National
Association of Insurance Commissioners (as adopted as of October 2000).
`(ii) COORDINATION- Any provision of the model regulation or model
Act listed under clause (i) or (ii) of subparagraph (A) shall be treated
as including any other provision of such regulation or Act necessary
to implement the provision.
`(iii) DETERMINATION- For purposes of this section and section 4980C,
the determination of whether any requirement of a model regulation
or the model Act has been met shall be made by the Secretary.'.
(d) Mandatory Offer and Information- Section 7702B(g), as amended by subsection
(c), is amended by inserting after paragraph (5) the following new paragraph:
`(6) MANDATORY OFFER AND INFORMATION- The requirements of this paragraph
are met if--
`(A) MANDATORY OFFER- Any person who sells a long-term care insurance
policy to an individual shall make available for sale to the individual
a long-term care insurance policy with only the core group of basic
benefits (described in subsection (h)(3)(B)).
`(B) INFORMATION- Any person who sells a long-term care insurance policy
to an individual shall provide the individual, before the sale of the
policy, an outline of coverage which describes the benefits under the
policy. Such outline shall be on a standard form approved by the State
regulatory program or the Secretary (as the case may be) consistent
with the 2009 NAIC Model Regulation or 2009 Federal Regulation.'.
(e) State Regulation of Out-of-State Contracts- Section 7702B is amended
by adding at the end the following new subsection:
`(i) State Regulation of Out-of-State Contracts- Nothing in this section
shall be construed so as to affect the right of any State to regulate long-term
care insurance policies which, under the provisions of this section, are
considered to be issued in another State.'.
(f) Effective Date- The amendments made by this section shall apply to contracts
issued after December 31, 2008.
TITLE IV--HEALTHIER MEDICARE
Subtitle A--Authority To Adjust Amount of Part B Premium To Reward Positive
Health Behavior
SEC. 401. AUTHORITY TO ADJUST AMOUNT OF MEDICARE PART B PREMIUM TO REWARD
POSITIVE HEALTH BEHAVIOR.
Section 1839 of the Social Security Act (42 U.S.C. 1395r) is amended--
(1) in subsection (a)(2), by striking `and (i)' and inserting `(i), and
(j)'; and
(2) by adding at the end the following new subsection:
`(j)(1) With respect to the monthly premium amount for months after December
2008, the Secretary may adjust (under procedures established by the Secretary)
the amount of such premium for an individual based on whether or not the
individual participates in certain healthy behaviors, such as weight management,
exercise, nutrition counseling, refraining from tobacco use, designating
a health home, and other behaviors determined appropriate by the Secretary.
`(2) In making the adjustments under paragraph (1) for a month, the Secretary
shall ensure that the total amount of premiums to be paid under this part
for the month is equal to the total amount of premiums that would have been
paid under this part for the month if no such adjustments had been made,
as estimated by the Secretary.'.
Subtitle B--Promoting Primary Care for Medicare Beneficiaries
SEC. 411. PRIMARY CARE SERVICES MANAGEMENT PAYMENT.
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is amended
by inserting after section 1807 the following new section:
`SEC. 1807A. PRIMARY CARE MANAGEMENT PAYMENT FOR COORDINATING CARE.
`(1) IN GENERAL- Not later than January 1, 2008, the Secretary, subject
to paragraph (2), shall establish procedures for providing primary care
and participating providers with a management fee (as determined appropriate
by the Secretary, in consultation with the Medicare Payment Advisory Commission
established under section 1805) that reflects the amount of time spent
with a Medicare beneficiary, and the family of such beneficiary, providing
chronic care disease management services or other services in assisting
in coordinating care.
`(2) REQUIREMENT FOR DESIGNATION AS HEALTH HOME- The management fee under
paragraph (1) shall not be provided to a primary care provider with respect
to a Medicare beneficiary unless the provider has been designated (under
procedures established by the Secretary) as the health home by the beneficiary.
`(b) Definitions- In this section:
`(1) HEALTH HOME- The term `health home' means a health care provider
that a Medicare beneficiary has designated to monitor the health and health
care of the beneficiary.
`(2) MEDICARE BENEFICIARY- The term `Medicare beneficiary' means an individual
who is entitled to, or enrolled for, benefits under part A, enrolled under
part B, or both.
`(3) PRIMARY CARE PROVIDER-
`(A) IN GENERAL- The term `primary care provider' means a primary care
physician (as defined in subparagraph (B), a nurse practitioner (as
defined in section 1861aa(5)(A)), or a physician assistant (as so defined).
`(B) PRIMARY CARE PHYSICIAN- In subparagraph (A), the term `primary
care physician' means a physician, such as a family practitioner or
internist, who is chosen by an individual to provide continuous medical
care, who is able to give a wide range of care, including prevention
and treatment, and who can refer the individual to a specialist.'.
Subtitle C--Chronic Care Disease Management
SEC. 421. CHRONIC CARE DISEASE MANAGEMENT.
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), as amended
by section 411, is amended by inserting after section 1807A the following
ne
