House Health Care Bill (Pages 101-150)
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coverage, for the period of time beginning on the date of birth and ending on the date the child otherwise is covered under acceptable cov-erage (or, if earlier, the end of the month in which the 60-day period, beginning on the date of birth, ends), the child shall be deemed--
(i) to be a non-traditional Medicaid eligible individual (as defined in subsection (e)(5)) for purposes of this division and Medicaid; and
(ii) to have elected to enroll in Medicaid through the application of paragraph (3).
(B) EXTENDED TREATMENT AS TRADITIONAL MEDICAID ELIGIBLE INDIVIDUAL.--In the case of a child described in subparagraph
(A) who at the end of the period referred to in such subparagraph is not otherwise covered under acceptable coverage, the child shall be deemed (until such time as the child obtains such coverage or the State otherwise makes a determination of the child's eligibility for medical assistance under its Medicaid plan pursuant to section 1943(c)(1) of the Social Security Act) to be a traditional Medicaid eligible indi-
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vidual described in section 1902(l)(1)(B) of such Act.
(2) CHIP TRANSITION.--A child who, as of the day before the first day of Y1, is eligible for child health assistance under title XXI of the Social Security Act (including a child receiving coverage under an arrangement described in section 2101(a)(2) of such Act) is deemed as of such first day to be an Exchange-eligible individual unless the individual is a traditional Medicaid eligible individual as of such day.
(3) AUTOMATIC ENROLLMENT OF MEDICAID EL-IGIBLE INDIVIDUALS INTO MEDICAID.--The Commissioner shall provide for a process under which an individual who is described in section 202(d)(3) and has not elected to enroll in an Exchange-participating health benefits plan is automatically enrolled under Medicaid.
(4) NOTIFICATIONS.--The Commissioner shall notify each State in Y1 and for purposes of section 1902(gg)(1) of the Social Security Act (as added by section 1703(a)) whether the Health Insurance Exchange can support enrollment of children described in paragraph (2) in such State in such year.
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(e) MEDICAID COVERAGE FOR MEDICAID ELIGIBLE INDIVIDUALS.--
(1) IN GENERAL.--
(A) CHOICE FOR LIMITED EXCHANGE-ELIGIBLE INDIVIDUALS.--As part of the enrollment process under subsection (b), the Commissioner shall provide the option, in the case of an Exchange-eligible individual described in section 202(d)(3), for the individual to elect to enroll under Medicaid instead of under an Exchange-participating health benefits plan. Such an individual may change such election during an enrollment period under subsection (b)(2).
(B) MEDICAID ENROLLMENT OBLIGATION.--An Exchange eligible individual may
apply, in the manner described in section 241(b)(1), for a determination of whether the individual is a Medicaid-eligible individual. If the individual is determined to be so eligible, the Commissioner, through the Medicaid memorandum of understanding, shall provide for the enrollment of the individual under the State
Medicaid plan in accordance with the Medicaid memorandum of understanding under paragraph (4). In the case of such an enrollment,
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the State shall provide for the same periodic re- determination of eligibility under Medicaid as would otherwise apply if the individual had directly applied for medical assistance to the State Medicaid agency.
(2) NON-TRADITIONAL MEDICAID ELIGIBLE INDIVIDUALS.--In the case of a non-traditional Medicaid eligible individual described in section 202(d)(3) who elects to enroll under Medicaid under paragraph (1)(A), the Commissioner shall provide for the enrollment of the individual under the State Medicaid plan in accordance with the Medicaid memorandum of understanding under paragraph (4).
(3) COORDINATED ENROLLMENT WITH STATE THROUGH MEMORANDUM OF UNDERSTANDING.-- The Commissioner, in consultation with the Secretary of Health and Human Services, shall enter into a memorandum of understanding with each State (each in this division referred to as a ''Medicaid memorandum of understanding'') with respect to coordinating enrollment of individuals in Exchange-participating health benefits plans and under the State's Medicaid program consistent with this section and to otherwise coordinate the implementa-
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tion of the provisions of this division with respect to the Medicaid program. Such memorandum shall permit the exchange of information consistent with the limitations described in section 1902(a)(7) of the Social Security Act. Nothing in this section shall be construed as permitting such memorandum to modify or vitiate any requirement of a State Medicaid plan.
(4) MEDICAID ELIGIBLE INDIVIDUALS.--For purposes of this division:
(A) MEDICAID ELIGIBLE INDIVIDUAL.-- The term ''Medicaid eligible individual'' means an individual who is eligible for medical assistance under Medicaid.
(B) TRADITIONAL MEDICAID ELIGIBLE INDIVIDUAL.--The term ''traditional Medicaid eligible individual'' means a Medicaid eligible individual other than an individual who is--
(i) a Medicaid eligible individual by reason of the application of subclause (VIII) of section 1902(a)(10)(A)(i) of the Social Security Act; or
(ii) a childless adult not described in section 1902(a)(10)(A) or (C) of such Act
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(as in effect as of the day before the date of the enactment of this Act).
(C) NON-TRADITIONAL MEDICAID ELIGIBLE INDIVIDUAL.--The term ''non-traditional Medicaid eligible individual'' means a Medicaid eligible individual who is not a traditional Medicaid eligible individual.
(f) EFFECTIVE CULTURALLY AND LINGUISTICALLY APPROPRIATE COMMUNICATION.--In carrying out this section, the Commissioner shall establish effective methods for communicating in plain language and a culturally and linguistically appropriate manner. SEC. 206. OTHER FUNCTIONS.
(a) COORDINATION OF AFFORDABILITY CREDITS.-- The Commissioner shall coordinate the distribution of affordability premium and cost-sharing credits under sub-title C to QHBP offering entities offering Exchange-participating health benefits plans.
(b) COORDINATION OF RISK POOLING.--The Commissioner shall establish a mechanism whereby there is an adjustment made of the premium amounts payable among QHBP offering entities offering Exchange-participating health benefits plans of premiums collected for such plans that takes into account (in a manner specified by the Commissioner) the differences in the risk characteristics of in-
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dividuals and employers enrolled under the different Exchange-participating health benefits plans offered by such entities so as to minimize the impact of adverse selection of enrollees among the plans offered by such entities.
(c) SPECIAL INSPECTOR GENERAL FOR THE HEALTH INSURANCE EXCHANGE.--
(1) ESTABLISHMENT; APPOINTMENT.--There is hereby established the Office of the Special Inspector General for the Health Insurance Exchange, to be headed by a Special Inspector General for the Health Insurance Exchange (in this subsection referred to as the ''Special Inspector General'') to be appointed by the President, by and with the advice and consent of the Senate. The nomination of an individual as Special Inspector General shall be made as soon as practicable after the establishment of the program under this subtitle.
(2) DUTIES.--The Special Inspector General shall--
(A) conduct, supervise, and coordinate audits, evaluations and investigations of the Health Insurance Exchange to protect the integrity of the Health Insurance Exchange, as well as the health and welfare of participants in the Exchange;
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(B) report both to the Commissioner and to the Congress regarding program and management problems and recommendations to correct them;
(C) have other duties (described in paragraphs (2) and (3) of section 121 of division A of Public Law 110-343) in relation to the duties described in the previous subparagraphs; and
(D) have the authorities provided in section 6 of the Inspector General Act of 1978 in carrying out duties under this paragraph.
(3) APPLICATION OF OTHER SPECIAL INSPECTOR GENERAL PROVISIONS.--The provisions of subsections (b) (other than paragraphs (1) and (3)), (d) (other than paragraph (1)), and (e) of section 121 of division A of the Emergency Economic Stabilization Act of 2009 (Public Law 110-343) shall apply to the Special Inspector General under this sub-section in the same manner as such provisions apply to the Special Inspector General under such section.
(4) REPORTS.--Not later than one year after the confirmation of the Special Inspector General, and annually thereafter, the Special Inspector General shall submit to the appropriate committees of
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Congress a report summarizing the activities of the Special Inspector General during the one year period ending on the date such report is submitted.
(5) TERMINATION.--The Office of the Special Inspector General shall terminate five years after the date of the enactment of this Act.
SEC. 207. HEALTH INSURANCE EXCHANGE TRUST FUND.
(a) ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE TRUST FUND.--There is created within the Treasury of the United States a trust fund to be known as the ''Health Insurance Exchange Trust Fund'' (in this section referred to as the ''Trust Fund''), consisting of such amounts as may be appropriated or credited to the Trust Fund under this section or any other provision of law.
(b) PAYMENTS FROM TRUST FUND.--The Commissioner shall pay from time to time from the Trust Fund such amounts as the Commissioner determines are necessary to make payments to operate the Health Insurance Exchange, including payments under subtitle C (relating to affordability credits).
(c) TRANSFERS TO TRUST FUND.--
(1) DEDICATED PAYMENTS.--There is hereby appropriated to the Trust Fund amounts equivalent to the following:
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(A) TAXES ON INDIVIDUALS NOT OBTAINING ACCEPTABLE COVERAGE.--The amounts received in the Treasury under section 59B of the Internal Revenue Code of 1986 (relating to requirement of health insurance coverage for individuals).
(B) EMPLOYMENT TAXES ON EMPLOYERS NOT PROVIDING ACCEPTABLE COVERAGE.--The amounts received in the Treasury under section 3111(c) of the Internal Revenue Code of 1986 (relating to employers electing to not provide health benefits).
(C) EXCISE TAX ON FAILURES TO MEET CERTAIN HEALTH COVERAGE REQUIREMENTS.--The amounts received in the Treasury under section 4980H(b) (relating to excise tax with respect to failure to meet health coverage participation requirements).
(2) APPROPRIATIONS TO COVER GOVERNMENT CONTRIBUTIONS.--There are hereby appropriated, out of any moneys in the Treasury not otherwise appropriated, to the Trust Fund, an amount equivalent to the amount of payments made from the Trust Fund under subsection (b) plus such amounts as are
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necessary reduced by the amounts deposited under paragraph (1).
(d) APPLICATION OF CERTAIN RULES.--Rules similar to the rules of subchapter B of chapter 98 of the Internal Revenue Code of 1986 shall apply with respect to the
Trust Fund.
SEC. 208. OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE EXCHANGES.
(a) IN GENERAL.--If--
(1) a State (or group of States, subject to the approval of the Commissioner) applies to the Commissioner for approval of a State-based Health Insurance Exchange to operate in the State (or group of States); and
(2) the Commissioner approves such State-based Health Insurance Exchange, then, subject to subsections (c) and (d), the State-based Health Insurance Exchange shall operate, instead of the Health Insurance Exchange, with respect to such State (or group of States). The Commissioner shall approve a State-based Health Insurance Exchange if it meets the requirements for approval under subsection (b).
(b) REQUIREMENTS FOR APPROVAL.--The Commis-
sioner may not approve a State-based Health Insurance
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Exchange under this section unless the following requirements are met:
(1) The State-based Health Insurance Exchange must demonstrate the capacity to and provide assurances satisfactory to the Commissioner that the State-based Health Insurance Exchange will carry out the functions specified for the Health Insurance Exchange in the State (or States) involved, including--
(A) negotiating and contracting with QHBP offering entities for the offering of Exchange-participating health benefits plan, which satisfy the standards and requirements of this title and title I;
(B) enrolling Exchange-eligible individuals and employers in such State in such plans;
(C) the establishment of sufficient local offices to meet the needs of Exchange-eligible individuals and employers;
(D) administering affordability credits under subtitle B using the same methodologies (and at least the same income verification methods) as would otherwise apply under such subtitle and at a cost to the Federal Govern-
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ment which does exceed the cost to the Federal Government if this section did not apply; and (E) enforcement activities consistent with federal requirements.
(2) There is no more than one Health Insurance Exchange operating with respect to any one State.
(3) The State provides assurances satisfactory to the Commissioner that approval of such an Exchange will not result in any net increase in expenditures to the Federal Government.
(4) The State provides for reporting of such information as the Commissioner determines and assurances satisfactory to the Commissioner that it will vigorously enforce violations of applicable requirements.
(5) Such other requirements as the Commissioner may specify.
(c) CEASING OPERATION.--
(1) IN GENERAL.--A State-based Health Insurance Exchange may, at the option of each State involved, and only after providing timely and reasonable notice to the Commissioner, cease operation as such an Exchange, in which case the Health Insurance Exchange shall operate, instead of such State-
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based Health Insurance Exchange, with respect to such State (or States).
(2) TERMINATION; HEALTH INSURANCE EXCHANGE RESUMPTION OF FUNCTIONS.--The Commissioner may terminate the approval (for some or all functions) of a State-based Health Insurance Exchange under this section if the Commissioner determines that such Exchange no longer meets the requirements of subsection (b) or is no longer capable of carrying out such functions in accordance with the requirements of this subtitle. In lieu of terminating such approval, the Commissioner may temporarily assume some or all functions of the State-based Health Insurance Exchange until such time as the Commissioner determines the State-based Health Insurance Exchange meets such require-
ments of subsection (b) and is capable of carrying out such functions in accordance with the require-ments of this subtitle.
(3) EFFECTIVENESS.--The ceasing or termination of a State-based Health Insurance Exchange under this subsection shall be effective in such time and manner as the Commissioner shall specify.
(d) RETENTION OF AUTHORITY.--
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(1) AUTHORITY RETAINED.--Enforcement authorities of the Commissioner shall be retained by the Commissioner.
(2) DISCRETION TO RETAIN ADDITIONAL AUTHORITY.--The Commissioner may specify functions of the Health Insurance Exchange that--
(A) may not be performed by a State-based Health Insurance Exchange under this
section; or
(B) may be performed by the Commissioner and by such a State-based Health Insurance Exchange.
(e) REFERENCES.--In the case of a State-based Health Insurance Exchange, except as the Commissioner may otherwise specify under subsection (d), any references in this subtitle to the Health Insurance Exchange or to the Commissioner in the area in which the State-based Health Insurance Exchange operates shall be deemed a reference to the State-based Health Insurance Exchange and the head of such Exchange, respectively.
(f) FUNDING.--In the case of a State-based Health Insurance Exchange, there shall be assistance provided for the operation of such Exchange in the form of a matching grant with a State share of expenditures required.
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Subtitle B--Public Health
Insurance Option
SEC. 221. ESTABLISHMENT AND ADMINISTRATION OF A PUBLIC HEALTH INSURANCE OPTION AS AN EXCHANGE-QUALIFIED HEALTH BENEFITS PLAN.
(a) ESTABLISHMENT.--For years beginning with Y1, the Secretary of Health and Human Services (in this sub- title referred to as the ''Secretary'') shall provide for the offering of an Exchange-participating health benefits plan (in this division referred to as the ''public health insurance option'') that ensures choice, competition, and stability of affordable, high quality coverage throughout the United States in accordance with this subtitle. In designing the option, the Secretary's primary responsibility is to create a low-cost plan without comprimising quality or access to
care.
(b) OFFERING AS AN EXCHANGE-PARTICIPATING HEALTH BENEFITS PLAN.--
(1) EXCLUSIVE TO THE EXCHANGE.--The public health insurance option shall only be made available through the Health Insurance Exchange.
(2) ENSURING A LEVEL PLAYING FIELD.--Consistent with this subtitle, the public health insurance option shall comply with requirements that are ap-
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plicable under this title to an Exchange-participating health benefits plan, including requirements related to benefits, benefit levels, provider networks, notices, consumer protections, and cost sharing.
(3) PROVISION OF BENEFIT LEVELS.--The public health insurance option--
(A) shall offer basic, enhanced, and premium plans; and
(B) may offer premium-plus plans.
(c) ADMINISTRATIVE CONTRACTING.--The Secretary may enter into contracts for the purpose of performing administrative functions (including functions described in subsection (a)(4) of section 1874A of the Social Security Act) with respect to the public health insurance option in the same manner as the Secretary may enter into con- tracts under subsection (a)(1) of such section. The Secretary has the same authority with respect to the public health insurance option as the Secretary has under subsections (a)(1) and (b) of section 1874A of the Social Security Act with respect to title XVIII of such Act. Contracts under this subsection shall not involve the transfer of insurance risk to such entity.
(d) OMBUDSMAN.--The Secretary shall establish an office of the ombudsman for the public health insurance option which shall have duties with respect to the public
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health insurance option similar to the duties of the Medi-care Beneficiary Ombudsman under section 1808(c)(2) of the Social Security Act.
(e) DATA COLLECTION.--The Secretary shall collect such data as may be required to establish premiums and payment rates for the public health insurance option and for other purposes under this subtitle, including to im- prove quality and to reduce racial, ethnic, and other disparities in health and health care.
(f) TREATMENT OF PUBLIC HEALTH INSURANCE OPTION.--With respect to the public health insurance option, the Secretary shall be treated as a QHBP offering entity offering an Exchange-participating health benefits plan.
(g) ACCESS TO FEDERAL COURTS.--The provisions of Medicare (and related provisions of title II of the Social Security Act) relating to access of Medicare beneficiaries to Federal courts for the enforcement of rights under Medicare, including with respect to amounts in controversy, shall apply to the public health insurance option and individuals enrolled under such option under this title in the same manner as such provisions apply to Medicare and Medicare beneficiaries.
SEC. 222. PREMIUMS AND FINANCING.
(a) ESTABLISHMENT OF PREMIUMS.--
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(1) IN GENERAL.--The Secretary shall establish geographically-adjusted premium rates for the public health insurance option in a manner--
(A) that complies with the premium rules established by the Commissioner under section 113 for Exchange-participating health benefit plans; and
(B) at a level sufficient to fully finance the costs of--
(i) health benefits provided by the public health insurance option; and
(ii) administrative costs related to operating the public health insurance option.
(2) CONTINGENCY MARGIN.--In establishing premium rates under paragraph (1), the Secretary shall include an appropriate amount for a contingency margin.
(b) ACCOUNT.--
(1) ESTABLISHMENT.--There is established in the Treasury of the United States an Account for the receipts and disbursements attributable to the operation of the public health insurance option, including the start-up funding under paragraph (2). Section 1854(g) of the Social Security Act shall apply to receipts described in the previous sentence
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in the same manner as such section applies to payments or premiums described in such section.
(2) START-UP FUNDING.--
(A) IN GENERAL.--In order to provide for the establishment of the public health insurance option there is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, $2,000,000,000. In order to provide for initial claims reserves before the collection of premiums, there is hereby appropriated to the Secretary, out of any funds in the Treasury not otherwise appropriated, such sums as necessary to cover 90 days worth of claims reserves based on projected enrollment.
(B) AMORTIZATION OF START-UP FUNDING.--The Secretary shall provide for the repayment of the startup funding provided under subparagraph (A) to the Treasury in an amortized manner over the 10-year period beginning with Y1.
(C) LIMITATION ON FUNDING.--Nothing in this section shall be construed as authorizing any additional appropriations to the Account, other than such amounts as are otherwise pro-
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vided with respect to other Exchange-participating health benefits plans
SEC. 223. PAYMENT RATES FOR ITEMS AND SERVICES.
(a) RATES ESTABLISHED BY SECRETARY.--
(1) IN GENERAL.--The Secretary shall establish payment rates for the public health insurance option for services and health care providers consistent with this section and may change such payment rates in accordance with section 224.
(2) INITIAL PAYMENT RULES.--
(A) IN GENERAL.--Except as provided in subparagraph (B) and subsection (b)(1), during Y1, Y2, and Y3, the Secretary shall base the payment rates under this section for services and providers described in paragraph (1) on the payment rates for similar services and providers under parts A and B of Medicare.
(B) EXCEPTIONS.--
(i) PRACTITIONERS' SERVICES.--Payment rates for practitioners' services otherwise established under the fee schedule under section 1848 of the Social Security Act shall be applied without regard to the provisions under subsection (f) of such section and the update under subsection
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(d)(4) under such section for a year as applied under this paragraph shall be not less than 1 percent.
(ii) ADJUSTMENTS.--The Secretary may determine the extent to which Medicare adjustments applicable to base payment rates under parts A and B of Medicare shall apply under this subtitle.
(3) FOR NEW SERVICES.--The Secretary shall modify payment rates described in paragraph (2) in order to accommodate payments for services, such as well-child visits, that are not otherwise covered under Medicare.
(4) PRESCRIPTION DRUGS.--Payment rates under this section for prescription drugs that are not paid for under part A or part B of Medicare shall be at rates negotiated by the Secretary.
(b) INCENTIVES FOR PARTICIPATING PROVIDERS.--
(1) INITIAL INCENTIVE PERIOD.--
(A) IN GENERAL.--The Secretary shall provide, in the case of services described in subparagraph (B) furnished during Y1, Y2, and Y3, for payment rates that are 5 percent greater than the rates established under subsection (a).
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(B) SERVICES DESCRIBED.--The services described in this subparagraph are items and professional services, under the public health insurance option by a physician or other health care practitioner who participates in both Medicare and the public health insurance option.
(C) SPECIAL RULES.--A pediatrician and any other health care practitioner who is a type of practitioner that does not typically participate in Medicare (as determined by the Secretary) shall also be eligible for the increased payment rates under subparagraph (A).
(2) SUBSEQUENT PERIODS.-- Beginning with Y4 and for subsequent years, the Secretary shall continue to use an administrative process to set such
rates in order to promote payment accuracy, to ensure adequate beneficiary access to providers, and to promote affordablility and the efficient delivery of
medical care consistent with section 221(a). Such rates shall not be set at levels expected to increase overall medical costs under the option beyond what would be expected if the process under subsection (a)(2) and paragraph (1) of this subsection were continued.
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(3) ESTABLISHMENT OF A PROVIDER NETWORK.--Health care providers participating under Medicare are participating providers in the public health insurance option unless they opt out in a process established by the Secretary.
(c) ADMINISTRATIVE PROCESS FOR SETTING RATES.--Chapter 5 of title 5, United States Code shall apply to the process for the initial establishment of payment rates under this section but not to the specific methodology for establishing such rates or the calculation of such rates.
(d) CONSTRUCTION.--Nothing in this subtitle shall be construed as limiting the Secretary's authority to correct for payments that are excessive or deficient, taking
into account the provisions of section 221(a) and the amounts paid for similar health care providers and services under other Exchange-participating health benefits plans.
(e) CONSTRUCTION.--Nothing in this subtitle shall be construed as affecting the authority of the Secretary to establish payment rates, including payments to provide for the more efficient delivery of services, such as the initiatives provided for under section 224.
(f) LIMITATIONS ON REVIEW.--There shall be no administrative or judicial review of a payment rate or meth-
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odology established under this section or under section 224.
SEC. 224. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM REFORM.
(a) IN GENERAL.--For plan years beginning with Y1, the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value-based purchasing, bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers.
(b) REQUIREMENTS FOR INNOVATIVE PAYMENTS.-- The Secretary shall design and implement the payment mechanisms and policies under this section in a manner that--
(1) seeks to--
(A) improve health outcomes;
(B) reduce health disparities (including racial, ethnic, and other disparities);
(C) provide efficent and affordable care;
(D) address geographic variation in the provision of health services; or
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(E) prevent or manage chronic illness; and
(2) promotes care that is integrated, patient-centered, quality, and efficient.
(c) ENCOURAGING THE USE OF HIGH VALUE SERVICES.--To the extent allowed by the benefit standards applied to all Exchange-participating health benefits plans, the public health insurance option may modify cost sharing and payment rates to encourage the use of services that promote health and value.
(d) NON-UNIFORMITY PERMITTED.--Nothing in this subtitle shall prevent the Secretary from varying payments based on different payment structure models (such as accountable care organizations and medical homes) under the public health insurance option for different geographic areas.
SEC. 225. PROVIDER PARTICIPATION.
(a) IN GENERAL.--The Secretary shall establish conditions of participation for health care providers under the public health insurance option.
(b) LICENSURE OR CERTIFICATION.--The Secretary shall not allow a health care provider to participate in the public health insurance option unless such provider is appropriately licensed or certified under State law.
(c) PAYMENT TERMS FOR PROVIDERS.--
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(1) PHYSICIANS.--The Secretary shall provide for the annual participation of physicians under the public health insurance option, for which payment may be made for services furnished during the year, in one of 2 classes:
(A) PREFERRED PHYSICIANS.--Those physicians who agree to accept the payment rate established under section 223 (without regard to cost-sharing) as the payment in full.
(B) PARTICIPATING, NON-PREFERRED PHYSICIANS.--Those physicians who agree not to impose charges (in relation to the payment rate described in section 223 for such physicians) that exceed the ratio permitted under section 1848(g)(2)(C) of the Social Security Act.
(2) OTHER PROVIDERS.--The Secretary shall provide for the participation (on an annual or other basis specified by the Secretary) of health care providers (other than physicians) under the public health insurance option under which payment shall only be available if the provider agrees to accept the payment rate established under section 223 (without regard to cost-sharing) as the payment in full.
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(d) EXCLUSION OF CERTAIN PROVIDERS.--The Secretary shall exclude from participation under the public health insurance option a health care provider that is excluded from participation in a Federal health care program (as defined in section 1128B(f) of the Social Security Act).
SEC. 226. APPLICATION OF FRAUD AND ABUSE PROVISIONS.
Provisions of law (other than criminal law provisions) identified by the Secretary by regulation, in consultation with the Inspector General of the Department of Health and Human Services, that impose sanctions with respect to waste, fraud, and abuse under Medicare, such as the False Claims Act (31 U.S.C. 3729 et seq.), shall also apply to the public health insurance option.
Subtitle C--Individual
Affordability Credits
SEC. 241. AVAILABILITY THROUGH HEALTH INSURANCE EXCHANGE.
(a) IN GENERAL.--Subject to the succeeding provisions of this subtitle, in the case of an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan--
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(1) the individual shall be eligible for, in accordance with this subtitle, affordability credits consisting of--
(A) an affordability premium credit under section 243 to be applied against the premium for the Exchange-participating health benefits plan in which the individual is enrolled; and
(B) an affordability cost-sharing credit under section 244 to be applied as a reduction of the cost-sharing otherwise applicable to such plan; and
(2) the Commissioner shall pay the QHBP offering entity that offers such plan from the Health Insurance Exchange Trust Fund the aggregate amount of affordability credits for all affordable credit eligible individuals enrolled in such plan.
(b) APPLICATION.--
(1) IN GENERAL.--An Exchange eligible individual may apply to the Commissioner through the Health Insurance Exchange or through another entity under an arrangement made with the Commissioner, in a form and manner specified by the Commissioner. The Commissioner through the Health Insurance Exchange or through another public entity under an arrangement made with the Commis-
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sioner shall make a determination as to eligibility of an individual for affordability credits under this subtitle.The Commissioner shall establish a process whereby, on the basis of information otherwise available, individuals may be deemed to be affordable credit eligible individuals. In carrying this subtitle, the Commissioner shall establish effective methods that ensure that individuals with limited English proficiency are able to apply for affordability credits.
(2) USE OF STATE MEDICAID AGENCIES.--If the Commissioner determines that a State Medicaid agency has the capacity to make a determination of eligibility for affordability credits under this subtitle and under the same standards as used by the Commissioner, under the Medicaid memorandum of understanding (as defined in section 205(c)(4))--
(A) the State Medicaid agency is authorized to conduct such determinations for any Exchange-eligible individual who requests such a determination; and
(B) the Commissioner shall reimburse the State Medicaid agency for the costs of conducting such determinations.
(3) MEDICAID SCREEN AND ENROLL OBLIGATION.--In the case of an application made under
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paragraph (1), there shall be a determination of whether the individual is a Medicaid-eligible individual. If the individual is determined to be so eligible, the Commissioner, through the Medicaid memorandum of understanding, shall provide for the enrollment of the individual under the State Medicaid plan in accordance with the Medicaid memorandum of understanding. In the case of such an enrollment, the State shall provide for the same periodic redetermination of eligibility under Medicaid as would otherwise apply if the individual had directly applied for medical assistance to the State Medicaid agency.
(c) USE OF AFFORDABILITY CREDITS.--
(1) IN GENERAL.--In Y1 and Y2 an affordable credit eligible individual may use an affordability credit only with respect to a basic plan.
(2) FLEXIBILITY IN PLAN ENROLLMENT AUTHORIZED.--Beginning with Y3, the Commissioner shall establish a process to allow an affordability credit to be used for enrollees in enhanced or premium plans. In the case of an affordable credit eligible individual who enrolls in an enhanced or premium plan, the individual shall be responsible for any difference between the premium for such plan
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and the affordable credit amount otherwise applicable if the individual had enrolled in a basic plan.
(d) ACCESS TO DATA.--In carrying out this subtitle, the Commissioner shall request from the Secretary of the Treasury consistent with section 6103 of the Internal Revenue Code of 1986 such information as may be required to carry out this subtitle.
(e) NO CASH REBATES.--In no case shall an affordable credit eligible individual receive any cash payment as a result of the application of this subtitle.
SEC. 242. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.
(a) DEFINITION.--
(1) IN GENERAL.--For purposes of this division, the term ''affordable credit eligible individual'' means, subject to subsection (b), an individual who is lawfully present in a State in the United States (other than as a nonimmigrant described in a sub-paragraph (excluding subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of the Immigration and Nationality Act)--
(A) who is enrolled under an Exchange-participating health benefits plan and is not enrolled under such plan as an employee (or dependent of an employee) through an employer
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qualified health benefits plan that meets the requirements of section 312;
(B) with family income below 400 percent of the Federal poverty level for a family of the size involved; and
(C) who is not a Medicaid eligible individual, other than an individual described in
section 202(d)(3) or an individual during a transition period under section 202(d)(4)
(B)(ii).
(2) TREATMENT OF FAMILY.--Except as the Commissioner may otherwise provide, members of the same family who are affordable credit eligible individuals shall be treated as a single affordable credit individual eligible for the applicable credit for such a family under this subtitle.
(b) LIMITATIONS ON EMPLOYEE AND DEPENDENT DISQUALIFICATION.--
(1) IN GENERAL.--Subject to paragraph (2), the term ''affordable credit eligible individual'' does not include a full-time employee of an employer if the employer offers the employee coverage (for the employee and dependents) as a full-time employee under a group health plan if the coverage and employer contribution under the plan meet the requirements of section 312.
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(2) EXCEPTIONS.--
(A) FOR CERTAIN FAMILY CIRCUMSTANCES.--The Commissioner shall establish such exceptions and special rules in the case described in paragraph (1) as may be appropriate in the case of a divorced or separated individual or such a dependent of an employee who would otherwise be an affordable credit eligible individual.
(B) FOR UNAFFORDABLE EMPLOYER COVERAGE.--Beginning in Y2, in the case of full-time employees for which the cost of the employee premium for coverage under a group health plan would exceed 11 percent of current family income (determined by the Commissioner on the basis of verifiable documentation and
without regard to section 245), paragraph (1) shall not apply.
(c) INCOME DEFINED.--
(1) IN GENERAL.--In this title, the term ''income'' means modified adjusted gross income (as defined in section 59B of the Internal Revenue Code of 1986).
(2) STUDY OF INCOME DISREGARDS.--The Commissioner shall conduct a study that examines
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the application of income disregards for purposes of this subtitle. Not later than the first day of Y2, the Commissioner shall submit to Congress a report on such study and shall include such recommendations as the Commissioner determines appropriate.
(d) CLARIFICATION OF TREATMENT OF AFFORDABILITY CREDITS.--Affordabilty credits under this subtitle shall not be treated, for purposes of title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, to be a benefit provided under section 403 of such title.
SEC. 243. AFFORDABLE PREMIUM CREDIT.
(a) IN GENERAL.--The affordability premium credit under this section for an affordable credit eligible individual enrolled in an Exchange-participating health benefits plan is in an amount equal to the amount (if any) by which the premium for the plan (or, if less, the reference premium amount specified in subsection (c)), exceeds the affordable premium amount specified in subsection (b) for the individual.
(b) AFFORDABLE PREMIUM AMOUNT.--
(1) IN GENERAL.--The affordable premium amount specified in this subsection for an individual for monthly premium in a plan year shall be equal to 1⁄12 of the product of--
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(A) the premium percentage limit specified in paragraph (2) for the individual based upon the individual's family income for the plan year; and
(B) the individual's family income for such plan year.
(2) PREMIUM PERCENTAGE LIMITS BASED ON TABLE.--The Commissioner shall establish premium percentage limits so that for individuals whose family income is within an income tier specified in the table in subsection (d) such percentage limits shall increase, on a sliding scale in a linear manner, from the initial premium percentage to the final premium percentage specified in such table for such income tier.
(c) REFERENCE PREMIUM AMOUNT.--The reference premium amount specified in this subsection for a plan year for an individual in a premium rating area is equal
to the average premium for the 3 basic plans in the area for the plan year with the lowest premium levels. In computing such amount the Commissioner may exclude plans with extremely limited enrollments.
(d) TABLE OF PREMIUM PERCENTAGE LIMITS AND ACTUARIAL VALUE PERCENTAGES BASED ON INCOME TIER.--
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(1) IN GENERAL.--For purposes of this subtitle, the table specified in this subsection is as follows: In the case of family income (expressed as a percent of FPL) within the following income tier: The initial premium percentage is-- The final premium percentage is-- The actuarial value percentage is--
133% through 150% 1.5% 3% 97%
150% through 200% 3% 5% 93%
200% through 250% 5% 7% 85%
250% through 300% 7% 9% 78%
300% through 350% 9% 10% 72%
350% through 400% 10% 11% 70%
(2) SPECIAL RULES.--For purposes of applying the table under paragraph (1)--
(A) FOR LOWEST LEVEL OF INCOME.--In the case of an individual with income that does not exceed 133 percent of FPL, the individual shall be considered to have income that is 133% of FPL.
(B) APPLICATION OF HIGHER ACTUARIAL VALUE PERCENTAGE AT TIER TRANSITION POINTS.--If two actuarial value percentages may be determined with respect to an individual, the actuarial value percentage shall be the higher of such percentages.
SEC. 244. AFFORDABILITY COST-SHARING CREDIT.
(a) IN GENERAL.--The affordability cost-sharing credit under this section for an affordable credit eligible individual enrolled in an Exchange-participating health
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benefits plan is in the form of the cost-sharing reduction described in subsection (b) provided under this section for the income tier in which the individual is classified based on the individual's family income.
(b) COST-SHARING REDUCTIONS.--The Commissioner shall specify a reduction in cost-sharing amounts and the annual limitation on cost-sharing specified in section 122(c)(2)(B) under a basic plan for each income tier specified in the table under section 243(d), with respect to a year, in a manner so that, as estimated by the Commissioner, the actuarial value of the coverage with such reduced cost-sharing amounts (and the reduced annual cost-sharing limit) is equal to the actuarial value percentage (specified in the table under section 243(d) for the income tier involved) of the full actuarial value if there were no cost-sharing imposed under the plan.
(c) DETERMINATION AND PAYMENT OF COST-SHARING AFFORDABILITY CREDIT.--In the case of an affordable credit eligible individual in a tier enrolled in an Exchange-participating health benefits plan offered by a QHBP offering entity, the Commissioner shall provide for payment to the offering entity of an amount equivalent to the increased actuarial value of the benefits under the plan provided under section 203(c)(2)(B) resulting from the reduction in cost-sharing described in subsection (b).
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SEC. 245. INCOME DETERMINATIONS.
(a) IN GENERAL.--In applying this subtitle for an affordability credit for an individual for a plan year, the individual's income shall be the income (as defined in section 242(c)) for the individual for the most recent taxable year (as determined in accordance with rules of the Commissioner). The Federal poverty level applied shall be such level in effect as of the date of the application.
(b) PROGRAM INTEGRITY; INCOME VERIFICATION PROCEDURES.--
(1) PROGRAM INTEGRITY.--The Commissioner shall take such steps as may be appropriate to ensure the accuracy of determinations and redeterminations under this subtitle.
(2) INCOME VERIFICATION.--
(A) IN GENERAL.--Upon an initial application of an individual for an affordability credit under this subtitle (or in applying section 242(b)) or upon an application for a change in the affordability credit based upon a significant change in family income described in subparagraph (A)--
(i) the Commissioner shall request from the Secretary of the Treasury the disclosure to the Commissioner of such information as may be permitted to verify the
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information contained in such application; and
(ii) the Commissioner shall use the information so disclosed to verify such information.
(B) ALTERNATIVE PROCEDURES.--The Commissioner shall establish procedures for the verification of income for purposes of this subtitle if no income tax return is available for the most recent completed tax year.
(c) SPECIALRULES.--
(1) CHANGES IN INCOME AS A PERCENT OF FPL.--In the case that an individual's income (expressed as a percentage of the Federal poverty level
for a family of the size involved) for a plan year is expected (in a manner specified by the Commissioner) to be significantly different from the income (as so expressed) used under subsection (a), the Commissioner shall establish rules requiring an individual to report, consistent with the mechanism established under paragraph (2), significant changes in such income (including a significant change in family composition) to the Commissioner and requiring the substitution of such income for the incomeotherwise applicable.
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(2) REPORTING OF SIGNIFICANT CHANGES IN INCOME.--The Commissioner shall establish rules under which an individual determined to be an affordable credit eligible individual would be required to inform the Commissioner when there is a significant change in the family income of the individual (expressed as a percentage of the FPL for a family of the size involved) and of the information regarding such change. Such mechanism shall provide for guidelines that specify the circumstances that qualify as a significant change, the verifiable information
required to document such a change, and the process for submission of such information. If the Commissioner receives new information from an individual
regarding the family income of the individual,the Commissioner shall provide for a redetermination of the individual's eligibility to be an affordable credit eligible individual.
(3) TRANSITION FOR CHIP.--In the case of a child described in section 202(d)(2), the Commissioner shall establish rules under which the family income of the child is deemed to be no greater than the family income of the child as most recently determined before Y1 by the State under title XXI of the Social Security Act.
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(4) STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF FPL.--The Commissioner shall examine the feasibility and implication of adjusting the
application of the Federal poverty level under this subtitle for different geographic areas so as to reflect the variations in cost-of-living among different areas within the United States. If the Commissioner determines that an adjustment is feasible, the study should include a methodology to make such an adjustment. Not later than the first day of Y2, the Commissioner shall submit to Congress a report on such study and shall include such recommendations as the Commissioner determines appropriate.
(d) PENALTIES FORMISREPRESENTATION.--In the case of an individual intentionally misrepresents family income or the individual fails (without regard to intent) to disclose to the Commissioner a significant change in family income under subsection (c) in a manner that results in the individual becoming an affordable credit eligible individual when the individual is not or in the amount of
the affordability credit exceeding the correct amount--
(1) the individual is liable for repayment of the amount of the improper affordability credit; ;and
(2) in the case of such an intentional misrepresentation or other egregious circumstances specified
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by the Commissioner, the Commissioner may impose an additional penalty.
SEC. 246. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.
Nothing in this subtitle shall allow Federal payments for affordability credits on behalf of individuals who are not lawfully present in the United States.
TITLE III--SHARED
RESPONSIBILITY
Subtitle A--Individual
Responsibility
SEC. 301. INDIVIDUAL RESPONSIBILITY.
For an individual's responsibility to obtain acceptable coverage, see section 59B of the Internal Revenue Code of 1986 (as added by section 401 of this Act).
Subtitle B--Employer
Responsibility
PART 1--HEALTH COVERAGE PARTICIPATION REQUIREMENTS
SEC. 311. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.
An employer meets the requirements of this section if such employer does all of the following:
(1) OFFER OF COVERAGE.--The employer offers each employee individual and family coverage
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under a qualified health benefits plan (or under a current employment-based health plan (within the meaning of section 102(b))) in accordance with section 312.
(2) CONTRIBUTION TOWARDS COVERAGE.--If an employee accepts such offer of coverage, the employer makes timely contributions towards such coverage in accordance with section 312.
(3) CONTRIBUTION IN LIEU OF COVERAGE.-- Beginning with Y2, if an employee declines such offer but otherwise obtains coverage in an Exchange-participating health benefits plan (other than by reason of being covered by family coverage as a spouse or dependent of the primary insured), the employer shall make a timely contribution to the Health Insurance Exchange with respect to each such employee in accordance with section 313.
SEC. 312. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARDS EMPLOYEE AND DEPENDENT COVERAGE.
(a) IN GENERAL.--An employer meets the requirements of this section with respect to an employee if the following requirements are met:
(1) OFFERING OF COVERAGE.--The employer offers the coverage described in section 311(1) either
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through an Exchange-participating health benefits plan or other than through such a plan.
(2) EMPLOYER REQUIRED CONTRIBUTION.-- The employer timely pays to the issuer of such coverage an amount not less than the employer required contribution specified in subsection (b) for such coverage.
(3) PROVISION OF INFORMATION.--The employer provides the Health Choices Commissioner, the Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable, with such information as the Commissioner may require to ascertain compliance with the requirements of this section.
(4) AUTOENROLLMENT OF EMPLOYEES.--The employer provides for autoenrollment of the employee in accordance with subsection (c).
(b) REDUCTION OF EMPLOYEE PREMIUMS THROUGH MINIMUM EMPLOYER CONTRIBUTION.--
(1) FULL-TIME EMPLOYEES.--The minimum employer contribution described in this subsection for coverage of a full-time employee (and, if any, the employee's spouse and qualifying children (as defined in section 152(c) of the Internal Revenue Code
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of 1986) under a qualified health benefits plan (or current employment-based health plan) is equal to--
(A) in case of individual coverage, not less than 72.5 percent of the applicable premium (as defined in section 4980B(f)(4) of such Code, subject to paragraph (2)) of the lowest cost plan offered by the employer that is a qualified health benefits plan (or is such current employment-based health plan); and
(B) in the case of family coverage which includes coverage of such spouse and children, not less 65 percent of such applicable premium of such lowest cost plan.
(2) APPLICABLE PREMIUM FOR EXCHANGE COVERAGE.--In this subtitle, the amount of the applicable premium of the lowest cost plan with respect to coverage of an employee under an Exchange-participating health benefits plan is the reference premium amount under section 243(c) for individual coverage (or, if elected, family coverage) for the premium rating area in which the individual or family resides.
(3) MINIMUM EMPLOYER CONTRIBUTION FOR EMPLOYEES OTHER THAN FULL-TIME EMPLOYEES.--In the case of coverage for an employee who is not a full-time employee, the amount of the min-
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imum employer contribution under this subsection shall be a proportion (as determined in accordance with rules of the Health Choices Commissioner, the
Secretary of Labor, the Secretary of Health and Human Services, and the Secretary of the Treasury, as applicable) of the minimum employer contribution under this subsection with respect to a full-time employee that reflects the proportion of--
(A) the average weekly hours of employment of the employee by the employer, to
(B) the minimum weekly hours specified by the Commissioner for an employee to be a full-time employee.
(4) SALARY REDUCTIONS NOT TREATED AS EMPLOYER CONTRIBUTIONS.--For purposes of this section, any contribution on behalf of an employee with respect to which there is a corresponding reduction in the compensation of the employee shall not be treated as an amount paid by the employer.
(c) AUTOMATIC ENROLLMENT FOR EMPLOYER SPONSORED HEALTH BENEFITS.--
(1) IN GENERAL.--The requirement of this subsection with respect to an employer and an employee is that the employer automatically enroll suchs employee into the employment-based health benefits
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plan for individual coverage under the plan option with the lowest applicable employee premium.
(2) OPT-OUT.--In no case may an employer automatically enroll an employee in a plan under paragraph (1) if such employee makes an affirmative election to opt out of such plan or to elect coverage under an employment-based health benefits plan offered by such employer. An employer shall provide an employee with a 30-day period to make such an affirmative election before the employer may automatically enroll the employee in such a plan.
(3) NOTICE REQUIREMENTS.--
(A) IN GENERAL.--Each employer described in paragraph (1) who automatically enrolls an employee into a plan as described in such paragraph shall provide the employees, within a reasonable period before the beginning of each plan year (or, in the case of new employees, within a reasonable period before the
end of the enrollment period for such a new employee), written notice of the employees' rights and obligations relating to the automatic enrollment requirement under such paragraph. Such notice must be comprehensive and understood
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by the average employee to whom the automatic enrollment requirement applies.
(B) INCLUSION OF SPECIFIC INFORMATION.--The written notice under subparagraph (A) must explain an employee's right to opt out of being automatically enrolled in a plan and in the case that more than one level of benefits or employee premium level is offered by the employer involved, the notice must explain which level of benefits and employee premium level the employee will be automatically enrolled in the absence of an affirmative election by the employee.
SEC. 313. EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE.
(a) IN GENERAL.--A contribution is made in accordance with this section with respect to an employee if such contribution is equal to an amount equal to 8 percent of the average wages paid by the employer during the period of enrollment (determined by taking into account all employees of the employer and in such manner as the Commissioner provides, including rules providing for the appropriate aggregation of related employers). Any such contribution--
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(1) shall be paid to the Health Choices Commissioner for deposit into the Health Insurance Exchange Trust Fund, and
(2) shall not be applied against the premium of the employee under the Exchange-participating health benefits plan in which the employee is enrolled.
(b) SPECIAL RULES FOR SMALL EMPLOYERS.--
(1) IN GENERAL.--In the case of any employer who is a small employer for any calendar year, subsection (a) shall be applied by substituting the applicable percentage determined in accordance with the following table for ''8 percent'':
If the annual payroll of such employer for the preceding calendar year: The applicable percentage is:
Does not exceed $250,000 ..................................... 0 percent
Exceeds $250,000, but does not exceed $300,000 2 percent
Exceeds $300,000, but does not exceed $350,000 4 percent
Exceeds $350,000, but does not exceed $400,000 6 percent
(2) SMALL EMPLOYER.--For purposes of this subsection, the term ''small employer'' means any employer for any calendar year if the annual payroll of such employer for the preceding calendar year does not exceed $400,000.
(3) ANNUAL PAYROLL.--For purposes of this paragraph, the term ''annual payroll'' means, with respect to any employer for any calendar year, the...