4-5
pages longPatient
Protection and Affordable Care Act: Description and analysis. For this
assignment the students are stimulated to deeply and acutely describe and
investigate why the Patient Protection and Affordable Act Passed and all their
implication in the Health Care environment
1.
Defining
the Problem (10%)
What
is the problem to be addressed?
What
was the event or series of events that was a catalyst for action?
Is
it a problem or crisis that demands immediate attention?
Is
the problem one of national security, economic development, diplomacy?
What
interests are at stake for the actor (e.g.state) overall?
2.
Establishing goals: (20%)
How
will you translate the aforementioned problem in to a specific set of goals? What is the relationship
between those goals and the problem that was identified? What government-non-government
organizations are involved in making this decision? Which ones are not involved?
3.
Selecting
a policy (20%). Based on your research and understanding of the
situation, select a policy, and consider the following:
What
other alternatives were considered?
Why
were the other alternatives rejected? For rational or political reasons? Describe the tradeoffs policy
makers must accept based on your selection–what tradeoffs do policy makers see as inherent in the
selected policy?
4. Implementing a policy (20%)
What
agency or organization implemented the policy? Was the policy implemented according
to original design?
Has
the agency changed or skewed the policy to reflect its own interests and goals?
Which changes were
made from the original design and why are they important?
In your opinion, could another
agency have implemented the policy better?
5. Evaluating the policy (20%)
Did the policy achieve its goals?
Did
the policy solve the original problem? Or did the policy solve a different problem
that the one originally identified?
What
were the costs and consequences of the policy?
Did
the policy achieve its goals at a reasonable cost?
Overall,
was the policy a “success “or a “failure”
Evaluation will be based on how clearly you respond to the
above, in particular:
a) The precision with which you analyses the articles;
b) The complexity, possibility, and organization of your
paper; and,
c) Your conclusions, including a description of the impact
of these articles and Chapters on any Health Care Setting.
04738_teitelbaum_ppt_chap_09.ppt04738_teitelbaum_ppt_chap_10.pptplaw_111publ148.pdfChapter 9:
Health Reform in the United
States
Chapter Overview
• Chapter 9 discusses the history of health
reform in the United States and details the key
provisions of the Affordable Care Act (ACA)
• Chapter 9 focuses on:
– Previous attempts at national health reform
– Why health reform is difficulty to achieve
– The passage and provisions of the Affordable
Care Act
Health Reform
• There have been numerous health reform
attempts in the U.S.
– Prior to 2010, all attempts at national health reform
to crate universal or near-universal coverage have
failed
– Some successes at the state level
Health Reform –
Difficulty of Reform in the U.S.
•
•
•
•
Individualistic culture
Dislike of big government
Lack of consensus
Federal system rules and structure make it
difficult to achieve major reform
• States generally home to social welfare issues
• Powerful interest groups against national health
reform
• Path dependency
Health Reform – Key Failed Attempts
at National Health Reform
• 1912 Progressive Party candidate Teddy Roosevelt
supported social insurance platform that included
health insurance
• 1915 American Association for Labor Legislation
proposal for working class health insurance
• President Truman supported national health reform
upon taking office, won re-election on national health
insurance platform in 1948
• President Nixon initial health reform proposal in
1969 and revised proposal in 1972
• President Clinton Health Security Act in 1993
The Affordable Care Act (ACA)
• Why did the Affordable Care Act pass when so
many prior attempts had failed?
– Commitment and leadership
– Learned lessons from past failures
– Political pragmatism
The Affordable Care Act (ACA)
• Individual Mandate: most people have to
purchase health insurance or pay a penalty
starting in 2014
– Exemptions for certain populations and based on
affordability
• Controversy
– Too much government interference in private
lives?
– Constitutional?
The Affordable Care Act (ACA)
• State Health Insurance Exchanges
– American Health Benefit Exchanges for
individuals
– Small Business Health Options program for small
businesses
– Must offer essential health benefits (Abortion
compromise)
– Four cost levels for plans based on actuarial value
The Affordable Care Act (ACA):
Premium and Cost Sharing Subsidies
• Premium tax credits available for individuals who
purchase insurance in an exchange and have income
between 133%–400% of poverty
• Cost sharing subsidies available for individuals who
purchase insurance in an exchange and have income
up to 250% of poverty
• To quality, must be a US citizen or legal resident,
not eligible for any type of public insurance, and not
have access to employer-sponsored insurance
The Affordable Care Act (ACA):
Employer Mandate
• In 2014, employers with 50 or more employees
must provide affordable health insurance or
pay a penalty
– Insurance is affordable if it has an actuarial value
of at least 60% or is not more than 9.5% of an
employee’s income
– Penalty is per employee after first 30 employees
The Affordable Care Act (ACA)
• Private Insurance Market Changes
–
–
–
–
No pre-existing condition exclusion
Dependent coverage to age 26
Preventive services without cost sharing
Prohibitions against lifetime and annual coverage
limits
– No rescission without fraud
– New appeals process
– Premium rate reviews
The Affordable Care Act (ACA)
• Private Insurance Market Changes, cont.
–
–
–
–
Guaranteed issue and renewability
Rate variation limits
Essential health benefits
Wellness plans
• Some plans may be grandfathered in and not
subject to all of these changes
The Affordable Care Act (ACA):
Financing health reform
• Changes to Medicare provider reimbursement
• Changes to Medicare Advantage
reimbursement
• Medicare Part A increases for high earners
• Changes in Medicare Part D subsidies
• Changes in Medicare employer subsidy
The Affordable Care Act (ACA):
Financing health reform
• Changes in Disproportionate Share payments
• Increase Medicaid prescription drug rebate
paid by manufacturers
• Income tax code changes
• Health industry fees
• Tax on high cost health insurance plans
Chapter 10:
Government Health Insurance
Programs: Medicaid, CHIP,
and Medicare
Chapter Overview
• Chapter 10 provides a basic overview of the
major public health insurance programs in the
United States, including changes to the
programs under the Affordable Care Act.
• Chapter 10 focuses on:
– Medicaid
– Children’s Health Insurance Program
– Medicare
Entitlements v. Block Grants
• Entitlement: Everyone who is eligible for and
enrolled in the program is legally entitled to receive
benefits from the program. Beneficiaries may not be
refused service for lack of funds or other reasons.
• Block Grants: A defined sum of money (often from
the federal government to the states) that is allocated
for a particular program over a certain amount of
time. Beneficiaries may be refused service for lack of
funds or other reasons.There is no legal entitlement to
the benefits.
Medicaid
• Overview: A federal-state public health insurance
program for the indigent.
• Program administration
– Federal: Center for Medicare and Medicaid
Services (CMS) outlines mandatory and optional
populations and benefits covered under Medicaid
– State: state Medicaid agencies run programs, select
which optional populations and benefits to cover in
the state program
• All states participate in Medicaid
Medicaid – Eligibility
• Medicaid generally covers low-income
• Pregnant women
• Children
• Adults in families with dependent children
• Individuals with disabilities
• Elderly
• Must meet 5 eligibility requirements: Categorical,
Income level, Resources, Residency and Immigration
status
Medicaid — Benefits
• Medicaid covers extensive acute care and Long-Term
Care benefits
– Some benefits are mandatory, others are optional
– Early and Periodic Screening Diagnostic and
Testing services are a comprehensive set of
mandatory services for children
• Deficit Reduction Act of 2006 (DRA) created a new
benefit option that allows states to use one of 5
benchmark or benchmark equivalent options to set
their benefit package
Medicaid — Financing
• Medicaid is jointly financed by the federal and state
governments
• Matching system
– Federal Medical Assistance Percentage determines the
matching rate; rate is tied to each state’s per capita
income with poorer states receive a higher federal
match, and must be at least 50/50
• Beneficiary cost-sharing
– Prior to DRA, very limited cost-sharing allowed
– DRA provides expanded cost-sharing options
Medicaid –
Provider Reimbursement
• Reimbursement levels vary by state and type of
provider
– States have a lot of discretion in setting rates
• Fee-for-service provides paid on a state-determined
fee schedule
• Managed care providers paid according to contracts
between the state and the managed care organization
• Medicaid reimbursement is typically much lower than
private insurance or Medicare reimbursement
Medicaid — Waivers
• States may apply to the federal government for
waivers of Medicaid requirements
• Section 1115 waivers
– Secretary of Health and Human Services may
grant a section 1115 waiver to allow for a research
and demonstration project that “assists in
promoting the objectives” of Medicaid
– Use states as “policy laboratories” to test health
reform ideas
– Health Insurance Flexibility and Accountability
Act
Affordable Care Act Changes to Medicaid:
Significant eligibility expansion
• All non-Medicare eligible adults under 65 with
incomes up to 133% of poverty will be eligible in
every state
– Do not have to fit a category
– Standardized resource test
• Also, must cover all children 6–19 at 133% of
poverty
• Immigrants still have 5 year bar but states have option
to cover legal immigrant pregnant women and
children who have been in the country > than 5 years
Affordable Care Act Changes to Medicaid
• Benefits
– Newly eligible individuals entitled to essential
health benefit package, not traditional Medicaid
services
• Financing
– Federal government pays 100% of newly eligible
expansion for two years then phases down to
covering 90% by 2020
• States have a maintenance of effort
requirement for adults and children
CHIP
• Overview: A 10-year, $40 billion block grant
program designed to provide health insurance
to low-income children whose family income
is above the Medicaid eligibility level in their
state
– Reauthorized in 2009 and extended in the ACA;
Authorization through 2019, funding through 2015
• All states participate in CHIP
CHIP – Structure
• Three options for CHIP structures
– Incorporate CHIP into Medicaid program as an
expansion population
– Create separate CHIP program
– Hybrid program: Some CHIP children are in
Medicaid and some are in a separate CHIP
program
• All three types of options are used by the states
CHIP — Financing
• Federal-state matching program
– “Enhanced” match — CHIP match will always be
higher than the state’s Medicaid match
• States receive payments in 2-year allotments
– If Beneficiary cost-sharing requirements are
allowed
CHIP — Eligibility
• States may cover children up to 300% Federal
Poverty Level (FPL)
– Children who are eligible for Medicaid must be
enrolled in Medicaid, not CHIP
• States may impose waiting periods, enrollment
caps, and other measures to limit expenses
CHIP — Benefits
• CHIP programs must provide “basic” benefits
– Inpatient and outpatient hospital care
– Physician services
– Laboratory
– X-ray
– Well-baby & well-child
• CHIP programs may provide additional benefits such
as Prescription drugs, Mental health, vision, and
hearing
CHIP — Benefits
• Benefit packages are based on one of five
benchmark health plans
– Similar to DRA option in Medicaid
• Overall, Medicaid programs generally offer
much more comprehensive benefits than CHIP
programs
CHIP — Waivers
• States may apply to the federal government for
waivers of CHIP requirements
• States may cover pregnant women without a
waiver but no new waivers will be granted for
other adults
• States also use waiver for premium assistance
Medicare
• Overview: A federally-funded health insurance
program for the elderly and some persons with
disabilities.
• Medicare is administered by CMS
– No state administration
– National rules, apply uniformly in all states
Medicare — Eligibility
• Medicare covers two main groups of people – elderly
and disabled
• Elderly requirements
– At least 65 years old
– Eligible for Social Security by having worked and
contributed to Social Security for at least 10 years
• Disabled requirements
– Individual is totally and permanently disabled and has
received Social Security Disability Insurance for at least 24
months OR
– Has End Stage Renal disease
Medicare — Benefits
• Medicare split into 4 parts, each with its own set of
benefits
• Part A: Hospital Insurance: Inpatient hospital, skilled
nursing facility, hospice
• Part B: Supplemental Medical Insurance: Physician
services, outpatient services, limited preventive
services
Medicare — Benefits
• Part C: Managed Care: Same services (sometimes
receive additional services) delivered through a
managed care arrangement; Part C includes other
types of plans as well
• Part D: Prescription Drug Coverage: May receive
through private drug plans or managed care
arrangement
Medicare — Financing
• Part A
– trust fund funded through a mandatory payroll tax
– deductibles and cost-sharing paid by beneficiaries
• Part B
– general federal tax revenues
– monthly premiums, deductibles, and cost-sharing
paid by beneficiaries
Medicare — Financing
• Part C
– Receives funding for Part A and B services
through funding sources described above; Plans
may also require monthly premiums, deductibles,
and cost sharing to be paid by beneficiaries
• Part D
– General federal tax revenues
– Monthly premiums, deductibles, and cost-sharing
paid by beneficiaries
– State payments for dual enrollees
Medicare –
Provider Reimbursement
• Physicians
– Paid on a fee-for-service basis according to a Medicare fee
schedule
• Hospitals
– Paid on a prospective payment system based on diagnosis
• Diagnostic Related Groups for inpatient care
• Ambulatory Payment Classification for outpatient care
• Managed Care
– Plans paid a negotiated capitated rate by the federal
government
Affordable Care Act Changes to Medicare
• New coverage for preventive services without cost
sharing
• Eventually closes Part D doughnut hole
– Short-term relief as well
•
•
•
•
Reimbursement changes
Cost changes to beneficiaries
Creation of Independent Payment Advisory Board
CMS innovation center
PUBLIC LAW 111–148—MAR. 23, 2010
124 STAT. 119
Public Law 111–148
111th Congress
An Act
Mar. 23, 2010
[H.R. 3590]
Entitled The Patient Protection and Affordable Care Act.
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 ‘‘Patient Protection and Affordable Care Act’’.
(b) TABLE OF CONTENTS.—The table of contents of this Act
is as follows:
Patient
Protection and
Affordable Care
Act.
42 USC 18001
note.
Sec. 1. Short title; table of contents.
TITLE I—QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS
Subtitle A—Immediate Improvements in Health Care Coverage for All Americans
Sec. 1001. Amendments to the Public Health Service Act.
‘‘PART A—INDIVIDUAL
AND
GROUP MARKET REFORMS
‘‘SUBPART II—IMPROVING COVERAGE
‘‘Sec. 2711. No lifetime or annual limits.
‘‘Sec. 2712. Prohibition on rescissions.
‘‘Sec. 2713. Coverage of preventive health services.
‘‘Sec. 2714. Extension of dependent coverage.
‘‘Sec. 2715. Development and utilization of uniform explanation of coverage
documents and standardized definitions.
‘‘Sec. 2716. Prohibition of discrimination based on salary.
‘‘Sec. 2717. Ensuring the quality of care.
‘‘Sec. 2718. Bringing down the cost of health care coverage.
‘‘Sec. 2719. Appeals process.
Sec. 1002. Health insurance consumer information.
Sec. 1003. Ensuring that consumers get value for their dollars.
Sec. 1004. Effective dates.
Subtitle B—Immediate Actions to Preserve and Expand Coverage
Sec. 1101. Immediate access to insurance for uninsured individuals with a preexisting condition.
Sec. 1102. Reinsurance for early retirees.
Sec. 1103. Immediate information that allows consumers to identify affordable coverage options.
Sec. 1104. Administrative simplification.
Sec. 1105. Effective date.
Subtitle C—Quality Health Insurance Coverage for All Americans
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PART I—HEALTH INSURANCE MARKET REFORMS
Sec. 1201. Amendment to the Public Health Service Act.
‘‘SUBPART I—GENERAL REFORM
‘‘Sec. 2704. Prohibition of preexisting condition exclusions or other discrimination based on health status.
‘‘Sec. 2701. Fair health insurance premiums.
‘‘Sec. 2702. Guaranteed availability of coverage.
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PUBLIC LAW 111–148—MAR. 23, 2010
‘‘Sec. 2703. Guaranteed renewability of coverage.
‘‘Sec. 2705. Prohibiting discrimination against individual participants and
beneficiaries based on health status.
‘‘Sec. 2706. Non-discrimination in health care.
‘‘Sec. 2707. Comprehensive health insurance coverage.
‘‘Sec. 2708. Prohibition on excessive waiting periods.
PART II—OTHER PROVISIONS
Sec. 1251. Preservation of right to maintain existing coverage.
Sec. 1252. Rating reforms must apply uniformly to all health insurance issuers and
group health plans.
Sec. 1253. Effective dates.
Subtitle D—Available Coverage Choices for All Americans
Sec.
Sec.
Sec.
Sec.
1301.
1302.
1303.
1304.
PART I—ESTABLISHMENT OF QUALIFIED HEALTH PLANS
Qualified health plan defined.
Essential health benefits requirements.
Special rules.
Related definitions.
PART II—CONSUMER CHOICES AND INSURANCE COMPETITION THROUGH HEALTH
BENEFIT EXCHANGES
Sec. 1311. Affordable choices of health benefit plans.
Sec. 1312. Consumer choice.
Sec. 1313. Financial integrity.
PART III—STATE FLEXIBILITY RELATING TO EXCHANGES
Sec. 1321. State flexibility in operation and enforcement of Exchanges and related
requirements.
Sec. 1322. Federal program to assist establishment and operation of nonprofit,
member-run health insurance issuers.
Sec. 1323. Community health insurance option.
Sec. 1324. Level playing field.
PART IV—STATE FLEXIBILITY TO ESTABLISH ALTERNATIVE PROGRAMS
Sec. 1331. State flexibility to establish basic health programs for low-income individuals not eligible for Medicaid.
Sec. 1332. Waiver for State innovation.
Sec. 1333. Provisions relating to offering of plans in more than one State.
PART V—REINSURANCE AND RISK ADJUSTMENT
Sec. 1341. Transitional reinsurance program for individual and small group markets in each State.
Sec. 1342. Establishment of risk corridors for plans in individual and small group
markets.
Sec. 1343. Risk adjustment.
Subtitle E—Affordable Coverage Choices for All Americans
PART I—PREMIUM TAX CREDITS
AND
COST-SHARING REDUCTIONS
SUBPART A—PREMIUM TAX CREDITS AND COST-SHARING REDUCTIONS
Sec. 1401. Refundable tax credit providing premium assistance for coverage under
a qualified health plan.
Sec. 1402. Reduced cost-sharing for individuals enrolling in qualified health plans.
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SUBPART B—ELIGIBILITY DETERMINATIONS
Sec. 1411. Procedures for determining eligibility for Exchange participation, premium tax credits and reduced cost-sharing, and individual responsibility
exemptions.
Sec. 1412. Advance determination and payment of premium tax credits and costsharing reductions.
Sec. 1413. Streamlining of procedures for enrollment through an exchange and
State Medicaid, CHIP, and health subsidy programs.
Sec. 1414. Disclosures to carry out eligibility requirements for certain programs.
Sec. 1415. Premium tax credit and cost-sharing reduction payments disregarded for
Federal and Federally-assisted programs.
PART II—SMALL BUSINESS TAX CREDIT
Sec. 1421. Credit for employee health insurance expenses of small businesses.
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PUBLIC LAW 111–148—MAR. 23, 2010
124 STAT. 121
Subtitle F—Shared Responsibility for Health Care
PART I—INDIVIDUAL RESPONSIBILITY
Sec. 1501. Requirement to maintain minimum essential coverage.
Sec. 1502. Reporting of health insurance coverage.
Sec.
Sec.
Sec.
Sec.
Sec.
1511.
1512.
1513.
1514.
1515.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
1551.
1552.
1553.
1554.
1555.
1556.
1557.
1558.
1559.
1560.
1561.
1562.
1563.
PART II—EMPLOYER RESPONSIBILITIES
Automatic enrollment for employees of large employers.
Employer requirement to inform employees of coverage options.
Shared responsibility for employers.
Reporting of employer health insurance coverage.
Offering of Exchange-participating qualified health plans through cafeteria plans.
Subtitle G—Miscellaneous Provisions
Definitions.
Transparency in government.
Prohibition against discrimination on assisted suicide.
Access to therapies.
Freedom not to participate in Federal health insurance programs.
Equity for certain eligible survivors.
Nondiscrimination.
Protections for employees.
Oversight.
Rules of construction.
Health information technology enrollment standards and protocols.
Conforming amendments.
Sense of the Senate promoting fiscal responsibility.
TITLE II—ROLE OF PUBLIC PROGRAMS
Subtitle A—Improved Access to Medicaid
Sec. 2001. Medicaid coverage for the lowest income populations.
Sec. 2002. Income eligibility for nonelderly determined using modified gross income.
Sec. 2003. Requirement to offer premium assistance for employer-sponsored insurance.
Sec. 2004. Medicaid coverage for former foster care children.
Sec. 2005. Payments to territories.
Sec. 2006. Special adjustment to FMAP determination for certain States recovering
from a major disaster.
Sec. 2007. Medicaid Improvement Fund rescission.
Subtitle B—Enhanced Support for the Children’s Health Insurance Program
Sec. 2101. Additional federal financial participation for CHIP.
Sec. 2102. Technical corrections.
Subtitle C—Medicaid and CHIP Enrollment Simplification
Sec. 2201. Enrollment Simplification and coordination with State Health Insurance
Exchanges.
Sec. 2202. Permitting hospitals to make presumptive eligibility determinations for
all Medicaid eligible populations.
Sec.
Sec.
Sec.
Sec.
2301.
2302.
2303.
2304.
Subtitle D—Improvements to Medicaid Services
Coverage for freestanding birth center services.
Concurrent care for children.
State eligibility option for family planning services.
Clarification of definition of medical assistance.
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Subtitle E—New Options for States to Provide Long-Term Services and Supports
Sec. 2401. Community First Choice Option.
Sec. 2402. Removal of barriers to providing home and community-based services.
Sec. 2403. Money Follows the Person Rebalancing Demonstration.
Sec. 2404. Protection for recipients of home and community-based services against
spousal impoverishment.
Sec. 2405. Funding to expand State Aging and Disability Resource Centers.
Sec. 2406. Sense of the Senate regarding long-term care.
Subtitle F—Medicaid Prescription Drug Coverage
Sec. 2501. Prescription drug rebates.
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PUBLIC LAW 111–148—MAR. 23, 2010
Sec. 2502. Elimination of exclusion of coverage of certain drugs.
Sec. 2503. Providing adequate pharmacy reimbursement.
Subtitle G—Medicaid Disproportionate Share Hospital (DSH) Payments
Sec. 2551. Disproportionate share hospital payments.
Subtitle H—Improved Coordination for Dual Eligible Beneficiaries
Sec. 2601. 5-year period for demonstration projects.
Sec. 2602. Providing Federal coverage and payment coordination for dual eligible
beneficiaries.
Subtitle I—Improving the Quality of Medicaid for Patients and Providers
Sec. 2701. Adult health quality measures.
Sec. 2702. Payment Adjustment for Health Care-Acquired Conditions.
Sec. 2703. State option to provide health homes for enrollees with chronic conditions.
Sec. 2704. Demonstration project to evaluate integrated care around a hospitalization.
Sec. 2705. Medicaid Global Payment System Demonstration Project.
Sec. 2706. Pediatric Accountable Care Organization Demonstration Project.
Sec. 2707. Medicaid emergency psychiatric demonstration project.
Subtitle J—Improvements to the Medicaid and CHIP Payment and Access
Commission (MACPAC)
Sec. 2801. MACPAC assessment of policies affecting all Medicaid beneficiaries.
Subtitle K—Protections for American Indians and Alaska Natives
Sec. 2901. Special rules relating to Indians.
Sec. 2902. Elimination of sunset for reimbursement for all medicare part B services
furnished by certain indian hospitals and clinics.
Sec.
Sec.
Sec.
Sec.
Sec.
2951.
2952.
2953.
2954.
2955.
Subtitle L—Maternal and Child Health Services
Maternal, infant, and early childhood home visiting programs.
Support, education, and research for postpartum depression.
Personal responsibility education.
Restoration of funding for abstinence education.
Inclusion of information about the importance of having a health care
power of attorney in transition planning for children aging out of foster
care and independent living programs.
TITLE III—IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE
Subtitle A—Transforming the Health Care Delivery System
PART I—LINKING PAYMENT TO QUALITY OUTCOMES UNDER THE MEDICARE PROGRAM
Sec. 3001. Hospital Value-Based purchasing program.
Sec. 3002. Improvements to the physician quality reporting system.
Sec. 3003. Improvements to the physician feedback program.
Sec. 3004. Quality reporting for long-term care hospitals, inpatient rehabilitation
hospitals, and hospice programs.
Sec. 3005. Quality reporting for PPS-exempt cancer hospitals.
Sec. 3006. Plans for a Value-Based purchasing program for skilled nursing facilities
and home health agencies.
Sec. 3007. Value-based payment modifier under the physician fee schedule.
Sec. 3008. Payment adjustment for conditions acquired in hospitals.
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Sec.
Sec.
Sec.
Sec.
Sec.
PART II—NATIONAL STRATEGY TO IMPROVE HEALTH CARE QUALITY
3011. National strategy.
3012. Interagency Working Group on Health Care Quality.
3013. Quality measure development.
3014. Quality measurement.
3015. Data collection; public reporting.
PART III—ENCOURAGING DEVELOPMENT OF NEW PATIENT CARE MODELS
Sec. 3021. Establishment of Center for Medicare and Medicaid Innovation within
CMS.
Sec. 3022. Medicare shared savings program.
Sec. 3023. National pilot program on payment bundling.
Sec. 3024. Independence at home demonstration program.
Sec. 3025. Hospital readmissions reduction program.
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PUBLIC LAW 111–148—MAR. 23, 2010
124 STAT. 123
Sec. 3026. Community-Based Care Transitions Program.
Sec. 3027. Extension of gainsharing demonstration.
Subtitle B—Improving Medicare for Patients and Providers
PART I—ENSURING BENEFICIARY ACCESS TO PHYSICIAN CARE AND OTHER SERVICES
Sec. 3101. Increase in the physician payment update.
Sec. 3102. Extension of the work geographic index floor and revisions to the practice expense geographic adjustment under the Medicare physician fee
schedule.
Sec. 3103. Extension of exceptions process for Medicare therapy caps.
Sec. 3104. Extension of payment for technical component of certain physician pathology services.
Sec. 3105. Extension of ambulance add-ons.
Sec. 3106. Extension of certain payment rules for long-term care hospital services
and of moratorium on the establishment of certain hospitals and facilities.
Sec. 3107. Extension of physician fee schedule mental health add-on.
Sec. 3108. Permitting physician assistants to order post-Hospital extended care
services.
Sec. 3109. Exemption of certain pharmacies from accreditation requirements.
Sec. 3110. Part B special enrollment period for disabled TRICARE beneficiaries.
Sec. 3111. Payment for bone density tests.
Sec. 3112. Revision to the Medicare Improvement Fund.
Sec. 3113. Treatment of certain complex diagnostic laboratory tests.
Sec. 3114. Improved access for certified nurse-midwife services.
PART II—RURAL PROTECTIONS
Sec. 3121. Extension of outpatient hold harmless provision.
Sec. 3122. Extension of Medicare reasonable costs payments for certain clinical diagnostic laboratory tests furnished to hospital patients in certain rural
areas.
Sec. 3123. Extension of the Rural Community Hospital Demonstration Program.
Sec. 3124. Extension of the Medicare-dependent hospital (MDH) program.
Sec. 3125. Temporary improvements to the Medicare inpatient hospital payment
adjustment for low-volume hospitals.
Sec. 3126. Improvements to the demonstration project on community health integration models in certain rural counties.
Sec. 3127. MedPAC study on adequacy of Medicare payments for health care providers serving in rural areas.
Sec. 3128. Technical correction related to critical access hospital services.
Sec. 3129. Extension of and revisions to Medicare rural hospital flexibility program.
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PART III—IMPROVING PAYMENT ACCURACY
Sec. 3131. Payment adjustments for home health care.
Sec. 3132. Hospice reform.
Sec. 3133. Improvement to medicare disproportionate share hospital (DSH) payments.
Sec. 3134. Misvalued codes under the physician fee schedule.
Sec. 3135. Modification of equipment utilization factor for advanced imaging services.
Sec. 3136. Revision of payment for power-driven wheelchairs.
Sec. 3137. Hospital wage index improvement.
Sec. 3138. Treatment of certain cancer hospitals.
Sec. 3139. Payment for biosimilar biological products.
Sec. 3140. Medicare hospice concurrent care demonstration program.
Sec. 3141. Application of budget neutrality on a national basis in the calculation of
the Medicare hospital wage index floor.
Sec. 3142. HHS study on urban Medicare-dependent hospitals.
Sec. 3143. Protecting home health benefits.
Subtitle C—Provisions Relating to Part C
Sec. 3201. Medicare Advantage payment.
Sec. 3202. Benefit protection and simplification.
Sec. 3203. Application of coding intensity adjustment during MA payment transition.
Sec. 3204. Simplification of annual beneficiary election periods.
Sec. 3205. Extension for specialized MA plans for special needs individuals.
Sec. 3206. Extension of reasonable cost contracts.
Sec. 3207. Technical correction to MA private fee-for-service plans.
Sec. 3208. Making senior housing facility demonstration permanent.
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Sec. 3209. Authority to deny plan bids.
Sec. 3210. Development of new standards for certain Medigap plans.
Subtitle D—Medicare Part D Improvements for Prescription Drug Plans and MA–
PD Plans
Sec. 3301. Medicare coverage gap discount program.
Sec. 3302. Improvement in determination of Medicare part D low-income benchmark premium.
Sec. 3303. Voluntary de minimis policy for subsidy eligible individuals under prescription drug plans and MA–PD plans.
Sec. 3304. Special rule for widows and widowers regarding eligibility for low-income assistance.
Sec. 3305. Improved information for subsidy eligible individuals reassigned to prescription drug plans and MA–PD plans.
Sec. 3306. Funding outreach and assistance for low-income programs.
Sec. 3307. Improving formulary requirements for prescription drug plans and MA–
PD plans with respect to certain categories or classes of drugs.
Sec. 3308. Reducing part D premium subsidy for high-income beneficiaries.
Sec. 3309. Elimination of cost sharing for certain dual eligible individuals.
Sec. 3310. Reducing wasteful dispensing of outpatient prescription drugs in longterm care facilities under prescription drug plans and MA–PD plans.
Sec. 3311. Improved Medicare prescription drug plan and MA–PD plan complaint
system.
Sec. 3312. Uniform exceptions and appeals process for prescription drug plans and
MA–PD plans.
Sec. 3313. Office of the Inspector General studies and reports.
Sec. 3314. Including costs incurred by AIDS drug assistance programs and Indian
Health Service in providing prescription drugs toward the annual outof-pocket threshold under part D.
Sec. 3315. Immediate reduction in coverage gap in 2010.
Subtitle E—Ensuring Medicare Sustainability
Sec. 3401. Revision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not already incorporate such improvements.
Sec. 3402. Temporary adjustment to the calculation of part B premiums.
Sec. 3403. Independent Medicare Advisory Board.
Subtitle F—Health Care Quality Improvements
Sec. 3501. Health care delivery system research; Quality improvement technical assistance.
Sec. 3502. Establishing community health teams to support the patient-centered
medical home.
Sec. 3503. Medication management services in treatment of chronic disease.
Sec. 3504. Design and implementation of regionalized systems for emergency care.
Sec. 3505. Trauma care centers and service availability.
Sec. 3506. Program to facilitate shared decisionmaking.
Sec. 3507. Presentation of prescription drug benefit and risk information.
Sec. 3508. Demonstration program to integrate quality improvement and patient
safety training into clinical education of health professionals.
Sec. 3509. Improving women’s health.
Sec. 3510. Patient navigator program.
Sec. 3511. Authorization of appropriations.
Subtitle G—Protecting and Improving Guaranteed Medicare Benefits
Sec. 3601. Protecting and improving guaranteed Medicare benefits.
Sec. 3602. No cuts in guaranteed benefits.
TITLE IV—PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC
HEALTH
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Sec.
Sec.
Sec.
Sec.
Subtitle A—Modernizing Disease Prevention and Public Health Systems
4001. National Prevention, Health Promotion and Public Health Council.
4002. Prevention and Public Health Fund.
4003. Clinical and community preventive services.
4004. Education and outreach campaign regarding preventive benefits.
Subtitle B—Increasing Access to Clinical Preventive Services
Sec. 4101. School-based health centers.
Sec. 4102. Oral healthcare prevention activities.
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124 STAT. 125
Sec. 4103. Medicare coverage of annual wellness visit providing a personalized prevention plan.
Sec. 4104. Removal of barriers to preventive services in Medicare.
Sec. 4105. Evidence-based coverage of preventive services in Medicare.
Sec. 4106. Improving access to preventive services for eligible adults in Medicaid.
Sec. 4107. Coverage of comprehensive tobacco cessation services for pregnant
women in Medicaid.
Sec. 4108. Incentives for prevention of chronic diseases in medicaid.
Subtitle C—Creating Healthier Communities
Sec. 4201. Community transformation grants.
Sec. 4202. Healthy aging, living well; evaluation of community-based prevention
and wellness programs for Medicare beneficiaries.
Sec. 4203. Removing barriers and improving access to wellness for individuals with
disabilities.
Sec. 4204. Immunizations.
Sec. 4205. Nutrition labeling of standard menu items at chain restaurants.
Sec. 4206. Demonstration project concerning individualized wellness plan.
Sec. 4207. Reasonable break time for nursing mothers.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Subtitle D—Support for Prevention and Public Health Innovation
4301. Research on optimizing the delivery of public health services.
4302. Understanding health disparities: data collection and analysis.
4303. CDC and employer-based wellness programs.
4304. Epidemiology-Laboratory Capacity Grants.
4305. Advancing research and treatment for pain care management.
4306. Funding for Childhood Obesity Demonstration Project.
Subtitle E—Miscellaneous Provisions
Sec. 4401. Sense of the Senate concerning CBO scoring.
Sec. 4402. Effectiveness of Federal health and wellness initiatives.
TITLE V—HEALTH CARE WORKFORCE
Subtitle A—Purpose and Definitions
Sec. 5001. Purpose.
Sec. 5002. Definitions.
Subtitle B—Innovations in the Health Care Workforce
Sec. 5101. National health care workforce commission.
Sec. 5102. State health care workforce development grants.
Sec. 5103. Health care workforce assessment.
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Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Subtitle C—Increasing the Supply of the Health Care Workforce
5201. Federally supported student loan funds.
5202. Nursing student loan program.
5203. Health care workforce loan repayment programs.
5204. Public health workforce recruitment and retention programs.
5205. Allied health workforce recruitment and retention programs.
5206. Grants for State and local programs.
5207. Funding for National Health Service Corps.
5208. Nurse-managed health clinics.
5209. Elimination of cap on commissioned corps.
5210. Establishing a Ready Reserve Corps.
Subtitle D—Enhancing Health Care Workforce Education and Training
Sec. 5301. Training in family medicine, general internal medicine, general pediatrics, and physician assistantship.
Sec. 5302. Training opportunities for direct care workers.
Sec. 5303. Training in general, pediatric, and public health dentistry.
Sec. 5304. Alternative dental health care providers demonstration project.
Sec. 5305. Geriatric education and training; career awards; comprehensive geriatric
education.
Sec. 5306. Mental and behavioral health education and training grants.
Sec. 5307. Cultural competency, prevention, and public health and individuals with
disabilities training.
Sec. 5308. Advanced nursing education grants.
Sec. 5309. Nurse education, practice, and retention grants.
Sec. 5310. Loan repayment and scholarship program.
Sec. 5311. Nurse faculty loan program.
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Sec.
Sec.
Sec.
Sec.
5312.
5313.
5314.
5315.
Authorization of appropriations for parts B through D of title VIII.
Grants to promote the community health workforce.
Fellowship training in public health.
United States Public Health Sciences Track.
Sec.
Sec.
Sec.
Sec.
Sec.
5401.
5402.
5403.
5404.
5405.
Subtitle E—Supporting the Existing Health Care Workforce
Centers of excellence.
Health care professionals training for diversity.
Interdisciplinary, community-based linkages.
Workforce diversity grants.
Primary care extension program.
Subtitle F—Strengthening Primary Care and Other Workforce Improvements
Sec. 5501. Expanding access to primary care services and general surgery services.
Sec. 5502. Medicare Federally qualified health center improvements.
Sec. 5503. Distribution of additional residency positions.
Sec. 5504. Counting resident time in nonprovider settings.
Sec. 5505. Rules for counting resident time for didactic and scholarly activities and
other activities.
Sec. 5506. Preservation of resident cap positions from closed hospitals.
Sec. 5507. Demonstration projects To address health professions workforce needs;
extension of family-to-family health information centers.
Sec. 5508. Increasing teaching capacity.
Sec. 5509. Graduate nurse education demonstration.
Subtitle G—Improving Access to Health Care Services
Sec. 5601. Spending for Federally Qualified Health Centers (FQHCs).
Sec. 5602. Negotiated rulemaking for development of methodology and criteria for
designating medically underserved populations and health professions
shortage areas.
Sec. 5603. Reauthorization of the Wakefield Emergency Medical Services for Children Program.
Sec. 5604. Co-locating primary and specialty care in community-based mental
health settings.
Sec. 5605. Key National indicators.
Subtitle H—General Provisions
Sec. 5701. Reports.
TITLE VI—TRANSPARENCY AND PROGRAM INTEGRITY
Subtitle A—Physician Ownership and Other Transparency
Sec. 6001. Limitation on Medicare exception to the prohibition on certain physician
referrals for hospitals.
Sec. 6002. Transparency reports and reporting of physician ownership or investment interests.
Sec. 6003. Disclosure requirements for in-office ancillary services exception to the
prohibition on physician self-referral for certain imaging services.
Sec. 6004. Prescription drug sample transparency.
Sec. 6005. Pharmacy benefit managers transparency requirements.
Subtitle B—Nursing Home Transparency and Improvement
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PART I—IMPROVING TRANSPARENCY OF INFORMATION
Sec. 6101. Required disclosure of ownership and additional disclosable parties information.
Sec. 6102. Accountability requirements for skilled nursing facilities and nursing facilities.
Sec. 6103. Nursing home compare Medicare website.
Sec. 6104. Reporting of expenditures.
Sec. 6105. Standardized complaint form.
Sec. 6106. Ensuring staffing accountability.
Sec. 6107. GAO study and report on Five-Star Quality Rating System.
Sec.
Sec.
Sec.
Sec.
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6113.
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Civil money penalties.
National independent monitor demonstration project.
Notification of facility closure.
National demonstration projects on culture change and use of information technology in nursing homes.
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PART III—IMPROVING STAFF TRAINING
Sec. 6121. Dementia and abuse prevention training.
Subtitle C—Nationwide Program for National and State Background Checks on
Direct Patient Access Employees of Long-term Care Facilities and Providers
Sec. 6201. Nationwide program for National and State background checks on direct
patient access employees of long-term care facilities and providers.
Subtitle D—Patient-Centered Outcomes Research
Sec. 6301. Patient-Centered Outcomes Research.
Sec. 6302. Federal coordinating council for comparative effectiveness research.
Subtitle E—Medicare, Medicaid, and CHIP Program Integrity Provisions
Sec. 6401. Provider screening and other enrollment requirements under Medicare,
Medicaid, and CHIP.
Sec. 6402. Enhanced Medicare and Medicaid program integrity provisions.
Sec. 6403. Elimination of duplication between the Healthcare Integrity and Protection Data Bank and the National Practitioner Data Bank.
Sec. 6404. Maximum period for submission of Medicare claims reduced to not more
than 12 months.
Sec. 6405. Physicians who order items or services required to be Medicare enrolled
physicians or eligible professionals.
Sec. 6406. Requirement for physicians to provide documentation on referrals to programs at high risk of waste and abuse.
Sec. 6407. Face to face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment
under Medicare.
Sec. 6408. Enhanced penalties.
Sec. 6409. Medicare self-referral disclosure protocol.
Sec. 6410. Adjustments to the Medicare durable medical equipment, prosthetics,
orthotics, and supplies competitive acquisition program.
Sec. 6411. Expansion of the Recovery Audit Contractor (RAC) program.
Subtitle F—Additional Medicaid Program Integrity Provisions
Sec. 6501. Termination of provider participation under Medicaid if terminated
under Medicare or other State plan.
Sec. 6502. Medicaid exclusion from participation relating to certain ownership, control, and management affiliations.
Sec. 6503. Billing agents, clearinghouses, or other alternate payees required to register under Medicaid.
Sec. 6504. Requirement to report expanded set of data elements under MMIS to detect fraud and abuse.
Sec. 6505. Prohibition on payments to institutions or entities located outside of the
United States.
Sec. 6506. Overpayments.
Sec. 6507. Mandatory State use of national correct coding initiative.
Sec. 6508. General effective date.
Subtitle G—Additional Program Integrity Provisions
Prohibition on false statements and representations.
Clarifying definition.
Development of model uniform report form.
Applicability of State law to combat fraud and abuse.
Enabling the Department of Labor to issue administrative summary
cease and desist orders and summary seizures orders against plans that
are in financially hazardous condition.
Sec. 6606. MEWA plan registration with Department of Labor.
Sec. 6607. Permitting evidentiary privilege and confidential communications.
Sec.
Sec.
Sec.
Sec.
Sec.
6601.
6602.
6603.
6604.
6605.
Subtitle H—Elder Justice Act
Sec. 6701. Short title of subtitle.
Sec. 6702. Definitions.
Sec. 6703. Elder Justice.
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Subtitle I—Sense of the Senate Regarding Medical Malpractice
Sec. 6801. Sense of the Senate regarding medical malpractice.
TITLE VII—IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES
Subtitle A—Biologics Price Competition and Innovation
Sec. 7001. Short title.
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Sec. 7002. Approval pathway for biosimilar biological products.
Sec. 7003. Savings.
Subtitle B—More Affordable Medicines for Children and Underserved Communities
Sec. 7101. Expanded participation in 340B program.
Sec. 7102. Improvements to 340B program integrity.
Sec. 7103. GAO study to make recommendations on improving the 340B program.
TITLE VIII—CLASS ACT
Sec. 8001. Short title of title.
Sec. 8002. Establishment of national voluntary insurance program for purchasing
community living assistance services and support.
TITLE IX—REVENUE PROVISIONS
Sec.
Sec.
Sec.
Sec.
9001.
9002.
9003.
9004.
Sec. 9005.
Sec. 9006.
Sec. 9007.
Sec. 9008.
Sec. 9009.
Sec. 9010.
Sec. 9011.
Sec. 9012.
Sec. 9013.
Sec. 9014.
Sec. 9015.
Sec. 9016.
Sec. 9017.
Subtitle A—Revenue Offset Provisions
Excise tax on high cost employer-sponsored health coverage.
Inclusion of cost of employer-sponsored health coverage on W–2.
Distributions for medicine qualified only if for prescribed drug or insulin.
Increase in additional tax on distributions from HSAs and Archer MSAs
not used for qualified medical expenses.
Limitation on health flexible spending arrangements under cafeteria
plans.
Expansion of information reporting requirements.
Additional requirements for charitable hospitals.
Imposition of annual fee on branded prescription pharmaceutical manufacturers and importers.
Imposition of annual fee on medical device manufacturers and importers.
Imposition of annual fee on health insurance providers.
Study and report of effect on veterans health care.
Elimination of deduction for expenses allocable to Medicare Part D subsidy.
Modification of itemized deduction for medical expenses.
Limitation on excessive remuneration paid by certain health insurance
providers.
Additional hospital insurance tax on high-income taxpayers.
Modification of section 833 treatment of certain health organizations.
Excise tax on elective cosmetic medical procedures.
Subtitle B—Other Provisions
Sec. 9021. Exclusion of health benefits provided by Indian tribal governments.
Sec. 9022. Establishment of simple cafeteria plans for small businesses.
Sec. 9023. Qualifying therapeutic discovery project credit.
TITLE X—STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR
ALL AMERICANS
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
10101.
10102.
10103.
10104.
10105.
10106.
10107.
10108.
10109.
Subtitle A—Provisions Relating to Title I
Amendments to subtitle A.
Amendments to subtitle B.
Amendments to subtitle C.
Amendments to subtitle D.
Amendments to subtitle E.
Amendments to subtitle F.
Amendments to subtitle G.
Free choice vouchers.
Development of standards for financial and administrative transactions.
Subtitle B—Provisions Relating to Title II
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PART I—MEDICAID AND CHIP
Sec. 10201. Amendments to the Social Security Act and title II of this Act.
Sec. 10202. Incentives for States to offer home and community-based services as a
long-term care alternative to nursing homes.
Sec. 10203. Extension of funding for CHIP through fiscal year 2015 and other
CHIP-related provisions.
PART II—SUPPORT
Sec. 10211. Definitions.
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124 STAT. 129
Sec. 10212. Establishment of pregnancy assistance fund.
Sec. 10213. Permissible uses of Fund.
Sec. 10214. Appropriations.
PART III—INDIAN HEALTH CARE IMPROVEMENT
Sec. 10221. Indian health care improvement.
Subtitle C—Provisions Relating to Title III
Sec. 10301. Plans for a Value-Based purchasing program for ambulatory surgical
centers.
Sec. 10302. Revision to national strategy for quality improvement in health care.
Sec. 10303. Development of outcome measures.
Sec. 10304. Selection of efficiency measures.
Sec. 10305. Data collection; public reporting.
Sec. 10306. Improvements under the Center for Medicare and Medicaid Innovation.
Sec. 10307. Improvements to the Medicare shared savings program.
Sec. 10308. Revisions to national pilot program on payment bundling.
Sec. 10309. Revisions to hospital readmissions reduction program.
Sec. 10310. Repeal of physician payment update.
Sec. 10311. Revisions to extension of ambulance add-ons.
Sec. 10312. Certain payment rules for long-term care hospital services and moratorium on the establishment of certain hospitals and facilities.
Sec. 10313. Revisions to the extension for the rural community hospital demonstration program.
Sec. 10314. Adjustment to low-volume hospital provision.
Sec. 10315. Revisions to home health care provisions.
Sec. 10316. Medicare DSH.
Sec. 10317. Revisions to extension of section 508 hospital provisions.
Sec. 10318. Revisions to transitional extra benefits under Medicare Advantage.
Sec. 10319. Revisions to market basket adjustments.
Sec. 10320. Expansion of the scope of, and additional improvements to, the Independent Medicare Advisory Board.
Sec. 10321. Revision to community health teams.
Sec. 10322. Quality reporting for psychiatric hospitals.
Sec. 10323. Medicare coverage for individuals exposed to environmental health hazards.
Sec. 10324. Protections for frontier States.
Sec. 10325. Revision to skilled nursing facility prospective payment system.
Sec. 10326. Pilot testing pay-for-performance programs for certain Medicare providers.
Sec. 10327. Improvements to the physician quality reporting system.
Sec. 10328. Improvement in part D medication therapy management (MTM) programs.
Sec. 10329. Developing methodology to assess health plan value.
Sec. 10330. Modernizing computer and data systems of the Centers for Medicare &
Medicaid services to support improvements in care delivery.
Sec. 10331. Public reporting of performance information.
Sec. 10332. Availability of medicare data for performance measurement.
Sec. 10333. Community-based collaborative care networks.
Sec. 10334. Minority health.
Sec. 10335. Technical correction to the hospital value-based purchasing program.
Sec. 10336. GAO study and report on Medicare beneficiary access to high-quality
dialysis services.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
Sec.
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Sec.
Sec.
Sec.
Sec.
Sec.
Subtitle D—Provisions Relating to Title IV
Amendments to subtitle A.
Amendments to subtitle B.
Amendments to subtitle C.
Amendments to subtitle D.
Amendments to subtitle E.
Amendment relating to waiving coinsurance for preventive services.
Better diabetes care.
Grants for small businesses to provide comprehensive workplace
wellness programs.
10409. Cures Acceleration Network.
10410. Centers of Excellence for Depression.
10411. Programs relating to congenital heart disease.
10412. Automated Defibrillation in Adam’s Memory Act.
10413. Young women’s breast health awareness and support of young women
diagnosed with breast cancer.
10401.
10402.
10403.
10404.
10405.
10406.
10407.
10408.
Subtitle E—Provisions Relating to Title V
Sec. 10501. Amendments to the Public Health Service Act, the Social Security Act,
and title V of this Act.
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Sec. 10502. Infrastructure to Expand Access to Care.
Sec. 10503. Community Health Centers and the National Health Service Corps
Fund.
Sec. 10504. Demonstration project to provide access to affordable care.
Subtitle F—Provisions Relating to Title VI
Sec. 10601. Revisions to limitation on medicare exception to the prohibition on certain physician referrals for hospitals.
Sec. 10602. Clarifications to patient-centered outcomes research.
Sec. 10603. Striking provisions relating to individual provider application fees.
Sec. 10604. Technical correction to section 6405.
Sec. 10605. Certain other providers permitted to conduct face to face encounter for
home health services.
Sec. 10606. Health care fraud enforcement.
Sec. 10607. State demonstration programs to evaluate alternatives to current medical tort litigation.
Sec. 10608. Extension of medical malpractice coverage to free clinics.
Sec. 10609. Labeling changes.
Subtitle G—Provisions Relating to Title VIII
Sec. 10801. Provisions relating to title VIII.
Subtitle H—Provisions Relating to Title IX
Sec. 10901. Modifications to excise tax on high cost employer-sponsored health coverage.
Sec. 10902. Inflation adjustment of limitation on health flexible spending arrangements under cafeteria plans.
Sec. 10903. Modification of limitation on charges by charitable hospitals.
Sec. 10904. Modification of annual fee on medical device manufacturers and importers.
Sec. 10905. Modification of annual fee on health insurance providers.
Sec. 10906. Modifications to additional hospital insurance tax on high-income taxpayers.
Sec. 10907. Excise tax on indoor tanning services in lieu of elective cosmetic medical procedures.
Sec. 10908. Exclusion for assistance provided to participants in State student loan
repayment programs for certain health professionals.
Sec. 10909. Expansion of adoption credit and adoption assistance programs.
TITLE I—QUALITY, AFFORDABLE
HEALTH CARE FOR ALL AMERICANS
Subtitle A—Immediate Improvements in
Health Care Coverage for All Americans
SEC. 1001. AMENDMENTS TO THE PUBLIC HEALTH SERVICE ACT.
Part A of title XXVII of the Public Health Service Act (42
U.S.C. 300gg et seq.) is amended—
(1) by striking the part heading and inserting the following:
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‘‘PART A—INDIVIDUAL AND GROUP MARKET
REFORMS’’;
(2) by redesignating sections 2704 through 2707 as sections
2725 through 2728, respectively;
(3) by redesignating sections 2711 through 2713 as sections
2731 through 2733, respectively;
(4) by redesignating sections 2721 through 2723 as sections
2735 through 2737, respectively; and
(5) by inserting after section 2702, the following:
42 USC
300gg–4—
300gg–7,
300gg–25—
300gg–28.
42 USC
300gg–11—
300gg–13,
300gg–9.
42 USC
300gg–21—
300gg–23.
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124 STAT. 131
‘‘Subpart II—Improving Coverage
‘‘SEC. 2711. NO LIFETIME OR ANNUAL LIMITS.
‘‘(a) IN GENERAL.—A group health plan and a health insurance
issuer offering group or individual health insurance coverage may
not establish—
‘‘(1) lifetime limits on the dollar value of benefits for any
participant or beneficiary; or
‘‘(2) unreasonable annual limits (within the meaning of
section 223 of the Internal Revenue Code of 1986) on the
dollar value of benefits for any participant or beneficiary.
‘‘(b) PER BENEFICIARY LIMITS.—Subsection (a) shall not be construed to prevent a group health plan or health insurance coverage
that is not required to provide essential health benefits under
section 1302(b) of the Patient Protection and Affordable Care Act
from placing annual or lifetime per beneficiary limits on specific
covered benefits to the extent that such limits are otherwise permitted under Federal or State law.
‘‘SEC. 2712. PROHIBITION ON RESCISSIONS.
‘‘A group health plan and a health insurance issuer offering
group or individual health insurance coverage shall not rescind
such plan or coverage with respect to an enrollee once the enrollee
is covered under such plan or coverage involved, except that this
section shall not apply to a covered individual who has performed
an act or practice that constitutes fraud or makes an intentional
misrepresentation of material fact as prohibited by the terms of
the plan or coverage. Such plan or coverage may not be cancelled
except with prior notice to the enrollee, and only as permitted
under section 2702(c) or 2742(b).
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‘‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES.
‘‘(a) IN GENERAL.—A group health plan and a health insurance
issuer offering group or individual health insurance coverage shall,
at a minimum provide coverage for and shall not impose any
cost sharing requirements for—
‘‘(1) evidence-based items or services that have in effect
a rating of ‘A’ or ‘B’ in the current recommendations of the
United States Preventive Services Task Force;
‘‘(2) immunizations that have in effect a recommendation
from the Advisory Committee on Immunization Practices of
the Centers for Disease Control and Prevention with respect
to the individual involved; and
‘‘(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for
in the comprehensive guidelines supported by the Health
Resources and Services Administration.
‘‘(4) with respect to women, such additional preventive
care and screenings not described in paragraph (1) as provided
for in comprehensive guidelines supported by the Health
Resources and Services Administration for purposes of this
paragraph.
‘‘(5) for the purposes of this Act, and for the purposes
of any other provision of law, the current recommendations
of the United States Preventive Service Task Force regarding
breast cancer screening, mammography, and prevention shall
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42 USC
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42 USC
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PUBLIC LAW 111–148—MAR. 23, 2010
be considered the most current other than those issued in
or around November 2009.
Nothing in this subsection shall be construed to prohibit a plan
or issuer from providing coverage for services in addition to those
recommended by United States Preventive Services Task Force
or to deny coverage for services that are not recommended by
such Task Force.
‘‘(b) INTERVAL.—
‘‘(1) IN GENERAL.—The Secretary shall establish a minimum
interval between the date on which a recommendation described
in subsection (a)(1) or (a)(2) or a guideline under subsection
(a)(3) is issued and the plan year with respect to which the
requirement described in subsection (a) is effective with respect
to the service described in such recommendation or guideline.
‘‘(2) MINIMUM.—The interval described in paragraph (1)
shall not be less than 1 year.
‘‘(c) VALUE-BASED INSURANCE DESIGN.—The Secretary may
develop guidelines to permit a group health plan and a health
insurance issuer offering group or individual health insurance coverage to utilize value-based insurance designs.
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300gg–14.
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‘‘SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.
‘‘(a) IN GENERAL.—A group health plan and a health insurance
issuer offering group or individual health insurance coverage that
provides dependent coverage of children shall continue to make
such coverage available for an adult child (who is not married)
until the child turns 26 years of age. Nothing in this section shall
require a health plan or a health insurance issuer described in
the preceding sentence to make coverage available for a child of
a child receiving dependent coverage.
‘‘(b) REGULATIONS.—The Secretary shall promulgate regulations
to define the dependents to which coverage shall be made available
under subsection (a).
‘‘(c) RULE OF CONSTRUCTION.—Nothing in this section shall
be construed to modify the definition of ‘dependent’ as used in
the Internal Revenue Code of 1986 with respect to the tax treatment
of the cost of coverage.
42 USC
300gg–15.
‘‘SEC. 2715. DEVELOPMENT AND UTILIZATION OF UNIFORM EXPLANATION OF COVERAGE DOCUMENTS AND STANDARDIZED
DEFINITIONS.
Deadline.
‘‘(a) IN GENERAL.—Not later than 12 months after the date
of enactment of the Patient Protection and Affordable Care Act,
the Secretary shall develop standards for use by a group health
plan and a health insurance issuer offering group or individual
health insurance coverage, in compiling and providing to enrollees
a summary of benefits and coverage explanation that accurately
describes the benefits and coverage under the applicable plan or
coverage. In developing such standards, the Secretary shall consult
with the National Association of Insurance Commissioners (referred
to in this section as the ‘NAIC’), a working group composed of
representatives of health insurance-related consumer advocacy
organizations, health insurance issuers, health care professionals,
patient advocates including those representing individuals with limited English proficiency, and other qualified individuals.
‘‘(b) REQUIREMENTS.—The standards for the summary of benefits and coverage developed under subsection (a) shall provide for
the following:
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‘‘(1) APPEARANCE.—The standards shall ensure that the
summary of benefits and coverage is presented in a uniform
format that does not exceed 4 pages in length and does not
include print smaller than 12-point font.
‘‘(2) LANGUAGE.—The standards shall ensure that the summary is presented in a culturally and linguistically appropriate
manner and utilizes terminology understandable by the average
plan enrollee.
‘‘(3) CONTENTS.—The standards shall ensure that the summary of benefits and coverage includes—
‘‘(A) uniform definitions of standard insurance terms
and medical terms (consistent with subsection (g)) so that
consumers may compare health insurance coverage and
understand the terms of coverage (or exception to such
coverage);
‘‘(B) a description of the coverage, including cost
sharing for—
‘‘(i) each of the categories of the essential health
benefits described in subparagraphs (A) through (J)
of section 1302(b)(1) of the Patient Protection and
Affordable Care Act; and
‘‘(ii) other benefits, as identified by the Secretary;
‘‘(C) the exceptions, reductions, and limitations on coverage;
‘‘(D) the cost-sharing provisions, including deductible,
coinsurance, and co-payment obligations;
‘‘(E) the renewability and continuation of coverage
provisions;
‘‘(F) a coverage facts label that includes examples to
illustrate common benefits scenarios, including pregnancy
and serious or chronic medical conditions and related cost
sharing, such scenarios to be based on recognized clinical
practice guidelines;
‘‘(G) a statement of whether the plan or coverage—
‘‘(i) provides minimum essential coverage (as
defined under section 5000A(f) of the Internal Revenue
Code 1986); and
‘‘(ii) ensures that the plan or coverage share of
the total allowed costs of benefits provided under the
plan or coverage is not less than 60 percent of such
costs;
‘‘(H) a statement that the outline is a summary of
the policy or certificate and that the coverage document
itself should be consulted to determine the governing
contractual provisions; and
‘‘(I) a contact number for the consumer to call with
additional questions and an Internet web address where
a copy of the actual individual coverage policy or group
certificate of coverage can be reviewed and obtained.
‘‘(c) PERIODIC REVIEW AND UPDATING.—The Secretary shall
periodically review and update, as appropriate, the standards developed under this section.
‘‘(d) REQUIREMENT TO PROVIDE.—
‘‘(1) IN GENERAL.—Not later than 24 months after the date
of enactment of the Patient Protection and Affordable Care
Act, each entity described in paragraph (3) shall provide, prior
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Deadline.
Fine.
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Regulations.
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to any enrollment restriction, a summary of benefits and coverage explanation pursuant to the standards developed by
the Secretary under subsection (a) to—
‘‘(A) an applicant at the time of application;
‘‘(B) an enrollee prior to the time of enrollment or
reenrollment, as applicable; and
‘‘(C) a policyholder or certificate holder at the time
of issuance of the policy or delivery of the certificate.
‘‘(2) COMPLIANCE.—An entity described in paragraph (3)
is deemed to be in compliance with this section if the summary
of benefits and coverage described in subsection (a) is provided
in paper or electronic form.
‘‘(3) ENTITIES IN GENERAL.—An entity described in this
paragraph is—
‘‘(A) a health insurance issuer (including a group health
plan that is not a self-insured plan) offering health insurance coverage within the United States; or
‘‘(B) in the case of a self-insured group health plan,
the plan sponsor or designated administrator of the plan
(as such terms are defined in section 3(16) of the Employee
Retirement Income Security Act of 1974).
‘‘(4) NOTICE OF MODIFICATIONS.—If a group health plan
or health insurance issuer makes any material modification
in any of the terms of the plan or coverage involved (as defined
for purposes of section 102 of the Employee Retirement Income
Security Act of 1974) that is not reflected in the most recently
provided summary of benefits and coverage, the plan or issuer
shall provide notice of such modification to enrollees not later
than 60 days prior to the date on which such modification
will become effective.
‘‘(e) PREEMPTION.—The standards developed under subsection
(a) shall preempt any related State standards that require a summary of benefits and coverage that provides less information to
consumers than that required to be provided under this section,
as determined by the Secretary.
‘‘(f) FAILURE TO PROVIDE.—An entity described in subsection
(d)(3) that willfully fails to provide the information required under
this section shall be subject to a fine of not more than $1,000
for each such failure. Such failure with respect to each enrollee
shall constitute a separate offense for purposes of this subsection.
‘‘(g) DEVELOPMENT OF STANDARD DEFINITIONS.—
‘‘(1) IN GENERAL.—The Secretary shall, by regulation, provide for the development of standards for the definitions of
terms used in health insurance coverage, including the insurance-related terms described in paragraph (2) and the medical
terms described in paragraph (3).
‘‘(2) INSURANCE-RELATED TERMS.—The insurance-related
terms described in this paragraph are premium, deductible,
co-insurance, co-payment, out-of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, UCR
(usual, customary and reasonable) fees, excluded services, grievance and appeals, and such other terms as the Secretary determines are important to define so that consumers may compare
health insurance coverage and understand the terms of their
coverage.
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‘‘(3) MEDICAL TERMS.—The medical terms described in this
paragraph are hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage,
durable medical equipment, home health care, skilled nursing
care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as the Secretary
determines are important to define so that consumers may
compare the medical benefits offered by health insurance and
understand the extent of those medical benefits (or exceptions
to those benefits).
‘‘SEC. 2716. PROHIBITION OF DISCRIMINATION BASED ON SALARY.
‘‘(a) IN GENERAL.—The plan sponsor of a group health plan
(other than a self-insured plan) may not establish rules relating
to the health insurance coverage eligibility (including continued
eligibility) of any full-time employee under the terms of the plan
that are based on the total hourly or annual salary of the employee
or otherwise establish eligibility rules that have the effect of
discriminating in favor of higher wage employees.
‘‘(b) LIMITATION.—Subsection (a) shall not be construed to prohibit a plan sponsor from establishing contribution requirements
for enrollment in the plan or coverage that provide for the payment
by employees with lower hourly or annual compensation of a lower
dollar or percentage contribution than the payment required of
similarly situated employees with a higher hourly or annual compensation.
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‘‘SEC. 2717. ENSURING THE QUALITY OF CARE.
‘‘(a) QUALITY REPORTING.—
‘‘(1) IN GENERAL.—Not later than 2 years after the date
of enactment of the Patient Protection and Affordable Care
Act, the Secretary, in consultation with experts in health care
quality and stakeholders, shall develop reporting requirements
for use by a group health plan, and a health insurance issuer
offering group or individual health insurance coverage, with
respect to plan or coverage benefits and health care provider
reimbursement structures that—
‘‘(A) improve health outcomes through the implementation of activities such as quality reporting, effective case
management, care coordination, chronic disease management, and medication and care compliance initiatives,
including through the use of the medical homes model
as defined for purposes of section 3602 of the Patient
Protection and Affordable Care Act, for treatment or services under the plan or coverage;
‘‘(B) implement activities to prevent hospital readmissions through a comprehensive program for hospital discharge that includes patient-centered education and counseling, comprehensive discharge planning, and post discharge reinforcement by an appropriate health care professional;
‘‘(C) implement activities to improve patient safety and
reduce medical errors through the appropriate use of best
clinical practices, evidence based medicine, and health
information technology under the plan or coverage; and
‘‘(D) implement wellness and health promotion activities.
‘‘(2) REPORTING REQUIREMENTS.—
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300gg–17.
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Deadline.
42 USC
300gg–18.
Reports.
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‘‘(A) IN GENERAL.—A group health plan and a health
insurance issuer offering group or individual health insurance coverage shall annually submit to the Secretary, and
to enrollees under the plan or coverage, a report on whether
the benefits under the plan or coverage satisfy the elements
described in subparagraphs (A) through (D) of paragraph
(1).
‘‘(B) TIMING OF REPORTS.—A report under subparagraph (A) shall be made available to an enrollee under
the plan or coverage during each open enrollment period.
‘‘(C) AVAILABILITY OF REPORTS.—The Secretary shall
make reports submitted under subparagraph (A) available
to the public through an Internet website.
‘‘(D) PENALTIES.—In developing the reporting requirements under paragraph (1), the Secretary may develop
and impose appropriate penalties for non-compliance with
such requirements.
‘‘(E) EXCEPTIONS.—In developing the reporting requirements under paragraph (1), the Secretary may provide
for exceptions to such requirements for group health plans
and health insurance issuers that substantially meet the
goals of this section.
‘‘(b) WELLNESS AND PREVENTION PROGRAMS.—For purposes of
subsection (a)(1)(D), wellness and health promotion activities may
include personalized wellness and prevention services, which are
coordinated, maintained or delivered by a health care provider,
a wellness and prevention plan manager, or a health, wellness
or prevention services organization that conducts health risk assessments or offers ongoing face-to-face, telephonic or web-based intervention efforts for each of the program’s participants, and which
may include the following wellness and prevention efforts:
‘‘(1) Smoking cessation.
‘‘(2) Weight management.
‘‘(3) Stress management.
‘‘(4) Physical fitness.
‘‘(5) Nutrition.
‘‘(6) Heart disease prevention.
‘‘(7) Healthy lifestyle support.
‘‘(8) Diabetes prevention.
‘‘(c) REGULATIONS.—Not later than 2 years after the date of
enactment of the Patient Protection and Affordable Care Act, the
Secretary shall promulgate regulations that provide criteria for
determining whether a reimbursement structure is described in
subsection (a).
‘‘(d) STUDY AND REPORT.—Not later than 180 days after the
date on which regulations are promulgated under subsection (c),
the Government Accountability Office shall review such regulations
and conduct a study and submit to the Committee on Health,
Education, Labor, and Pensions of the Senate and the Committee
on Energy and Commerce of the House of Representatives a report
regarding the impact the activities under this section have had
on the quality and cost of health care.
‘‘SEC. 2718. BRINGING DOWN THE COST OF HEALTH CARE COVERAGE.
‘‘(a) CLEAR ACCOUNTING FOR COSTS.—A health insurance issuer
offering group or individual health insurance coverage shall, with
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respect to each plan year, submit to the Secretary a report concerning the percentage of total premium revenue that such coverage
expends—
‘‘(1) on reimbursement for clinical services provided to
enrollees under such coverage;
‘‘(2) for activities that improve health care quality; and
‘‘(3) on all other non-claims costs, including an explanation
of the nature of such costs, and excluding State taxes and
licensing or regulatory fees.
The Secretary shall make reports received under this section available to the public on the Internet website of the Department of
Health and Human Services.
‘‘(b) ENSURING THAT CONSUMERS RECEIVE VALUE FOR THEIR
PREMIUM PAYMENTS.—
‘‘(1) REQUIREMENT TO PROVIDE VALUE FOR PREMIUM PAYMENTS.—A health insurance issuer offering group or individual
health insurance coverage shall, with respect to each plan
year, provide an annual rebate to each enrollee under such
coverage, on a pro rata basis, in an amount that is equal
to the amount by which premium revenue expended by the
issuer on activities described in subsection (a)(3) exceeds—
‘‘(A) with respect to a health insurance issuer offering
coverage in the group market, 20 percent, or such lower
percentage as a State may by regulation determine; or
‘‘(B) with respect to a health insurance issuer offering
coverage in the individual market, 25 percent, or such
lower percentage as a State may by regulation determine,
except that such percentage shall be adjusted to the extent
the Secretary determines that the application of such
percentage with a State may destabilize the existing individual market in such State.
‘‘(2) CONSIDERATION IN SETTING PERCENTAGES.—In determining the percentages under paragraph (1), a State shall
seek to ensure adequate participation by health insurance
issuers, competition in the health insurance market in the
State, and value for consumers so that premiums are used
for clinical services and quality improvements.
‘‘(3) TERMINATION.—The provisions of this subsection shall
have no force or effect after December 31, 2013.
‘‘(c) STANDARD HOSPITAL CHARGES.—Each hospital operating
within the United States shall for each year establish (and update)
and make public (in accordance with guidelines developed by the
Secretary) a list of the hospital’s standard charges for items and
services provided by the hospital, including for diagnosis-related
groups established under section 1886(d)(4) of the Social Security
Act.
‘‘(d) DEFINITIONS.—The Secretary, in consultation with the
National Association of Insurance Commissions, shall establish uniform definitions for the activities reported under subsection (a).
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‘‘SEC. 2719. APPEALS PROCESS.
‘‘A group health plan and a health insurance issuer offering
group or individual health insurance coverage shall implement an
effective appeals process for appeals of coverage determinations
and claims, under which the plan or issuer shall, at a minimum—
‘‘(1) have in effect an internal claims appeal process;
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Public
information.
Web posting.
42 USC
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‘‘(2) provide notice to enrollees, in a culturally and linguistically appropriate manner, of available internal and external
appeals processes, and the availability of any applicable office
of health insurance consumer assistance or ombudsman established under section 2793 to assist such enrollees with the
appeals processes;
‘‘(3) allow an enrollee to review their file, to present evidence and testimony as part of the appeals process, and to
receive continued coverage pending the outcome of the appeals
process; and
‘‘(4) provide an external review process for such plans and
issuers that, at a minimum, includes the consumer protections
set forth in the Uniform External Review Model Act promulgated by the National Association of Insurance Commissioners
and is binding on such plans.’’.
Notification.
SEC. 1002. HEALTH INSURANCE CONSUMER INFORMATION.
Part C of title XXVII of the Public Health Service Act (42
U.S.C. 300gg–91 et seq.) is amended by adding at the end the
following:
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42 USC
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Grants.
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‘‘SEC. 2793. HEALTH INSURANCE CONSUMER INFORMATION.
‘‘(a) IN GENERAL.—The Secretary shall award grants to States
to enable such States (or the Exchanges operating in such States)
to establish, expand, or provide support for—
‘‘(1) offices of health insurance consumer assistance; or
‘‘(2) health insurance ombudsman programs.
‘‘(b) ELIGIBILITY.—
‘‘(1) IN GENERAL.—To be eligible to receive a grant, a State
shall designate an independent office of health insurance consumer assistance, or an ombudsman, that, directly or in
coordination with State health insurance regulators and consumer assistance organizations, receives and responds to
inquiries and complaints concerning health insurance coverage
with respect to Federal health insurance requirements and
under State law.
‘‘(2) CRITERIA.—A State that receives a grant under this
section shall comply with criteria established by the Secretary
for carrying out activities under such grant.
‘‘(c) DUTIES.—The office of health insurance consumer assistance or health insurance ombudsman shall—
‘‘(1) assist with the filing of complaints and appeals,
including filing appeals with the internal appeal or grievance
process of the group health plan or health insurance issuer
involved and providing information about the external appeal
process;
‘‘(2) collect, track, and quantify problems and inquiries
encountered by consumers;
‘‘(3) educate consumers on their rights and responsibilities
with respect to group health plans and health insurance coverage;
‘‘(4) assist consumers with enrollment in a group health
plan or health insurance coverage by providing information,
referral, and assistance; and
‘‘(5) resolve problems with obtaining premium tax credits
under section 36B of the Internal Revenue Code of 1986.
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‘‘(d) DATA COLLECTION.—As a condition of receiving a grant
under subsection (a), an office of health insurance consumer assistance or ombudsman program shall be required to collect and report
data to the Secretary on the types of problems and inquiries encountered by consumers. The Secretary shall utilize such data to identify
areas where more enforcement action is necessary and shall share
such information with State insurance regulators, the Secretary
of Labor, and the Secretary of the Treasury for use in the enforcement activities of such agencies.
‘‘(e) FUNDING.—
‘‘(1) INITIAL FUNDING.—There is hereby appropriated to
the Secretary, out of any funds in the Treasury not otherwise
appropriated, $30,000,000 for the first fiscal year for which
this section applies to carry out this section. Such amount
shall remain available without fiscal year limitation.
‘‘(2) AUTHORIZATION FOR SUBSEQUENT YEARS.—There is
authorized to be appropriated to the Secretary for each fiscal
year following the fiscal year described in paragraph (1), such
sums as may be necessary to carry out this section.’’.
SEC. 1003. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS.
Part C of title XXVII of the Public Health Service Act (42
U.S.C. 300gg–91 et seq.), as amended by section 1002, is further
amended by adding at the end the following:
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‘‘SEC. 2794. ENSURING THAT CONSUMERS GET VALUE FOR THEIR DOLLARS.
‘‘(a) INITIAL PREMIUM REVIEW PROCESS.—
‘‘(1) IN GENERAL.—The Secretary, in conjunction with
States, shall establish a process for the annual review, beginning with the 2010 plan year and subject to subsection (b)(2)(A),
of unreasonable increases in premiums for health insurance
coverage.
‘‘(2) JUSTIFICATION AND DISCLOSURE.—The process established under paragraph (1) shall require health insurance
issuers to submit to the Secretary and the relevant State a
justification for an unreasonable premium increase prior to
the implementation of the increase. Such issuers shall prominently post such information on their Internet websites. The
Secretary shall ensure the public disclosure of information on
such increases and justifications for all health insurance
issuers.
‘‘(b) CONTINUING PREMIUM REVIEW PROCESS.—
‘‘(1) INFORMING SECRETARY OF PREMIUM INCREASE PATTERNS.—As a condition of receiving a grant under subsection
(c)(1), a State, through its Commissioner of Insurance, shall—
‘‘(A) provide the Secretary with information about
trends in premium increases in health insurance coverage
in premium rating areas in the State; and
‘‘(B) make recommendations, as appropriate, to the
State Exchange about whether particular health insurance
issuers should be excluded from participation in the
Exchange based on a pattern or practice of excessive or
unjustified premium increases.
‘‘(2) MONITORING BY SECRETARY OF PREMIUM INCREASES.—
‘‘(A) IN GENERAL.—Beginning with plan years beginning in 2014, the Secretary, in conjunction with the States
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and consistent with the provisions of subsection (a)(2), shall
monitor premium increases of health insurance coverage
offered through an Exchange and outside of an Exchange.
‘‘(B) CONSIDERATION IN OPENING EXCHANGE.—In determining under section 1312(f)(2)(B) of the Patient Protection
and Affordable Care Act whether to offer qualified health
plans in the large group market through an Exchange,
the State shall take into account any excess of premium
growth outside of the Exchange as compared to the rate
of such growth inside the Exchange.
‘‘(c) GRANTS IN SUPPORT OF PROCESS.—
‘‘(1) PREMIUM REVIEW GRANTS DURING 2010 THROUGH 2014.—
The Secretary shall carry out a program to award grants to
States during the 5-year period beginning with fiscal year 2010
to assist such States in carrying out subsection (a), including—
‘‘(A) in reviewing and, if appropriate under State law,
approving premium increases for health insurance coverage; and
‘‘(B) in providing information and recommendations
to the Secretary under subsection (b)(1).
‘‘(2) FUNDING.—
‘‘(A) IN GENERAL.—Out of all funds in the Treasury
not otherwise appropriated, there are appropriated to the
Secretary $250,000,000, to be available for expenditure for
grants under paragraph (1) and subparagraph (B).
‘‘(B) FURTHER AVAILABILITY FOR INSURANCE REFORM
AND CONSUMER PROTECTION.—If the amounts appropriated
under subparagraph (A) are not fully obligated under
grants under paragraph (1) by the end of fiscal year 2014,
any remaining funds shall remain available to the Secretary for grants to States for planning and implementing
the insurance reforms and consumer protections under part
A.
‘‘(C) ALLOCATION.—The Secretary shall establish a formula for determining the amount of any grant to a State
under this subsection. Under such formula—
‘‘(i) the Secretary shall consider the number of
plans of health insurance coverage offered in each State
and the population of the State; and
‘‘(ii) no State qualifying for a grant under paragraph (1) shall receive less than $1,000,000, or more
than $5,000,000 for a grant year.’’.
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SEC. 1004. EFFECTIVE DATES.
(a) IN GENERAL.—Except as provided for in subsection (b),
this subtitle (and the amendments made by this subtitle) shall
become effective for plan years beginning on or after the date
that is 6 months after the date of enactment of this Act, except
that the amendments made by sections 1002 and 1003 shall become
effective for fiscal years beginning with fiscal year 2010.
(b) SPECIAL RULE.—The amendments made by sections 1002
and 1003 shall take effect on the date of enactment of this Act.
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Subtitle B—Immediate Actions to Preserve
and Expand Coverage
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SEC. 1101. IMMEDIATE ACCESS TO INSURANCE FOR UNINSURED
INDIVIDUALS WITH A PREEXISTING CONDITION.
42 USC 18001.
(a) IN GENERAL.—Not later than 90 days after the date of
enactment of this Act, the Secretary shall establish a temporary
high risk health insurance pool program to provide health insurance
coverage for eligible individuals during the period beginning on
the date on which such program is established and ending on
January 1, 2014.
(b) ADMINISTRATION.—
(1) IN GENERAL.—The Secretary may carry out the program
under this section directly or through contracts to eligible entities.
(2) ELIGIBLE ENTITIES.—To be eligible for a contract under
paragraph (1), an entity shall—
(A) be a State or nonprofit private entity;
(B) submit to the Secretary an application at such
time, in such manner, and containing such information
as the Secretary may require; and
(C) agree to utilize contract funding to establish and
administer a qualified high risk pool for eligible individuals.
(3) MAINTENANCE OF EFFORT.—To be eligible to enter into
a contract with the Secretary under this subsection, a State
shall agree not to reduce the annual amount the State expended
for the operation of one or more State high risk pools during
the year preceding the year in which such contract is entered
into.
(c) QUALIFIED HIGH RISK POOL.—
(1) IN GENERAL.—Amounts made available under this section shall be used to establish a qualified high risk pool that
meets the requirements of paragraph (2).
(2) REQUIREMENTS.—A qualified high risk pool meets the
requirements of this paragraph if such pool—
(A) provides to all eligible individuals health insurance
coverage that does not impose any preexisting condition
exclusion with respect to such coverage;
(B) provides health insurance coverage—
(i) in which the issuer’s share of the total allowed
costs of benefits provided under such coverage is not
less than 65 percent of such costs; and
(ii) that has an out of pocket limit not greater
than the applicable amount described in section
223(c)(2) of the Internal Revenue Code of 1986 for
the year involved, except that the Secretary may
modify such limit if necessary to ensure the pool meets
the actuarial value limit under clause (i);
(C) ensures that with respect to the premium rate
charged for health insurance coverage offered to eligible
individuals through the high risk pool, such rate shall—
(i) except as provided in clause (ii), vary only as
provided for under section 2701 of the Public Health
Service Act (as amended by this Act and notwithstanding the date on which such amendments take
effect);
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PUBLIC LAW 111–148—MAR. 23, 2010
(ii) vary on the basis of age by a factor of not
greater than 4 to 1; and
(iii) be established at a standard rate for a
standard population; and
(D) meets any other requirements determined appropriate by the Secretary.
(d) ELIGIBLE INDIVIDUAL.—An individual shall be deemed to
be an eligible individual for purposes of this section if such individual—
(1) is a citizen or national of the United States or is
lawfully present in the United States (as determined in accordance with section 1411);
(2) has not been covered under creditable coverage (as
defined in section 2701(c)(1) of the Public Health Service Act
as in effect on the date of enactment of this Act) during the
6-month period prior to the date on which such individual
is applying for coverage through the high risk pool; and
(3) has a pre-existing condition, as determined in a manner
consistent with guidance issued by the Secretary.
(e) PROTECTION AGAINST DUMPING RISK BY INSURERS.—
(1) IN GENERAL.—The Secretary shall establish criteria for
determining whether health insurance issuers and employmentbased health plans have discouraged an individual from
remaining enrolled in prior coverage based on that individual’s
health status.
(2) SANCTIONS.—An issuer or employment-based health
plan shall be responsible for reimbursing the program under
this section for the medical expenses incurred by the program
for an individual who, based on criteria established by the
Secretary, the Secretary finds was encouraged by the issuer
to disenroll from health benefits coverage prior to enrolling
in coverage through the program. The criteria shall include
at least the following circumstances:
(A) In the case of prior coverage obtained through
an employer, the provision by the employer, group health
plan, or the issuer of money or other financial consideration
for disenrolling from the coverage.
(B) In the case of prior coverage obtained directly from
an issuer or under an employment-based health plan—
(i) the provision by the issuer or plan of money
or other financial consideration for disenrolling from
the coverage; or
(ii) in the case of an individual whose premium
for the prior coverage exceeded the premium required
by the program (adjusted based on the age factors
applied to the prior coverage)—
(I) the prior coverage is a policy that is no
longer being actively marketed (as defined by the
Secretary) by the issuer; or
(II) the prior coverage is a policy for which
duration of coverage form issue or health status
are factors that can be considered in determining
premiums at renewal.
(3) CONSTRUCTION.—Nothing in this subsection shall be
construed as constituting exclusive remedies for violations of
criteria established under paragraph (1) or as preventing States
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from applying or enforcing such paragraph or other provisions
under law with respect to health insurance issuers.
(f) OVERSIGHT.—The Secretary shall establish—
(1) an appeals process to enable individuals to appeal a
determination under this section; and
(2) procedures to protect against waste, fraud, and abuse.
(g) FUNDING; TERMINATION OF AUTHORITY.—
(1) IN GENERAL.—There is appropriated to the Secretary,
out of any moneys in the Treasury not otherwise appropriated,
$5,000,000,000 to pay claims against (and the administrative
costs of) the high risk pool under this section that are in
excess of the amount of premiums collected from eligible
individuals enrolled in the high risk pool. Such funds shall
be available without fiscal year limitation.
(2) INSUFFICIENT FUNDS.—If the Secretary estimates for
any fiscal year that the aggregate amounts available for the
payment of the expenses of the high risk pool will be less
than the actual amount of such expenses, the Secretary shall
make such adjustments as are necessary to eliminate such
deficit.
(3) TERMINATION OF AUTHORITY.—
(A) IN GENERAL.—Except as provided in subparagraph
(B), coverage of eligible individuals under a high risk pool
in a State shall terminate on January 1, 2014.
(B) TRANSITION TO EXCHANGE.—The Secretary shall
develop procedures to provide for the transition of eligible
individuals enrolled in health insurance coverage offered
through a high risk pool established under this section
into qualified health plans offered through an Exchange.
Such procedures shall ensure that there is no lapse in
coverage with respect to the individual and may extend
coverage after the termination of the risk pool involved,
if the Secretary determines necessary to avoid such a lapse.
(4) LIMITATIONS.—The Secretary has the authority to stop
taking applications for participation in the program under this
section to comply with the funding limitation provided for in
paragraph (1).
(5) RELATION TO STATE LAWS.—The standards established
under this section shall supersede any State law or regulation
(other than State licensing laws or State laws relating to plan
solvency) with respect to qualified high risk pools which are
established in accordance with this section.
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SEC. 1102. REINSURANCE FOR EARLY RETIREES.
42 USC 18002.
(a) ADMINISTRATION.—
(1) IN GENERAL.—Not later than 90 days after the date
of enactment of this Act, the Secretary shall establish a temporary reinsurance program to provide reimbursement to
participating employment-based plans for a portion of the cost
of providing health insurance coverage to early retirees (and
to the eligible spouses, surviving spouses, and dependents of
such retirees) during the period beginning on the date on which
such program is established and ending on January 1, 2014.
(2) REFERENCE.—In this section:
(A) HEALTH BENEFITS.—The term ‘‘health benefits’’
means medical, surgical, hospital, prescription drug, and
such other benefits as shall be determined by the Secretary,
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whether self-funded, or delivered through the purchase
of insurance or otherwise.
(B) EMPLOYMENT-BASED PLAN.—The term ‘‘employment-based plan’’ means a group health benefits plan
that—
(i) is—
(I) maintained by one or more current or
former employers (including without limitation any
State or local government or political subdivision
thereof), employee organization, a voluntary
employees’ beneficiary association, or a committee
or board of individuals appointed to administer
such plan; or
(II) a multiemployer plan (as defined in section
3(37) of the Employee Retirement Income Security
Act of 1974); and
(ii) provides health benefits to early retirees.
(C) EARLY RETIREES.—The term ‘‘early retirees’’ means
individuals who are age 55 and older but are not eligible
for coverage under title XVIII of the Social Security Act,
and who are not active employees of an employer
maintaining, or currently contributing to, the employmentbased plan or of any employer that has made substantial
contributions to fund such plan.
(b) PARTICIPATION.—
(1) EMPLOYMENT-BASED PLAN ELIGIBILITY.—A participating
employment-based plan is an employment-based plan that—
(A) meets the requirements of paragraph (2) with
respect to health benefits provided under the plan; and
(B) submits to the Secretary an application for participation in the program, at such time, in such manner,
and containing such information as the Secretary shall
require.
(2) EMPLOYMENT-BASED HEALTH BENEFITS.—An employment-based plan meets the requirements of this paragraph
if the plan—
(A) implements programs and procedures to generate
cost-savings with respect to participants with chronic and
high-cost conditions;
(B) provides documentation of the actual cost of medical
claims involved; and
(C) is certified by the Secretary.
(c) PAYMENTS.—
(1) SUBMISSION OF CLAIMS.—
(A) IN GENERAL.—A participating employment-based
plan shall submit claims for reimbursement to the Secretary which shall contain documentation of the actual
costs of the items and services for which each claim is
being submitted.
(B) BASIS FOR CLAIMS.—Claims submitted under
subparagraph (A) shall be based on the actual amount
expended by the participating employment-based plan
involved within the plan year for the health benefits provided to an early retiree or the spouse, surviving spouse,
or dependent of such retiree. In determining the amount
of a claim for purposes of this subsection, the participating
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employment-based plan shall take into account any negotiated price concessions (such as discounts, direct or
indirect subsidies, rebates, and direct or indirect remunerations) obtained by such plan with respect to such health
benefit. For purposes of determining the amount of any
such claim, the costs paid by the early retiree or the
retiree’s spouse, surviving spouse, or dependent in the form
of deductibles, co-payments, or co-insurance shall be
included in the amounts paid by the participating employment-based plan.
(2) PROGRAM PAYMENTS.—If the Secretary determines that
a participating employment-based plan has submitted a valid
claim under paragraph (1), the Secretary shall reimburse such
plan for 80 percent of that portion of the costs attributable
to such claim that exceed $15,000, subject to the limi…
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