[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5886 Introduced in House (IH)]


109th CONGRESS
  2d Session
                                H. R. 5886

To amend the Social Security Act and the Internal Revenue Code of 1986 
   to provide for an AmeriCare that assures the provision of health 
      insurance coverage to all residents, and for other purposes.


_______________________________________________________________________


                    IN THE HOUSE OF REPRESENTATIVES

                             July 25, 2006

Mr. Stark (for himself, Ms. Schakowsky, Mr. McDermott, Mr. Rangel, Mr. 
 Lewis of Georgia, Mr. Brown of Ohio, Mr. George Miller of California, 
Mr. Waxman, Mr. Becerra, Ms. Corrine Brown of Florida, Ms. Carson, Mrs. 
   Christensen, Mr. Conyers, Mr. Davis of Illinois, Mr. Filner, Mr. 
   Grijalva, Mr. Hinchey, Ms. Norton, Ms. Jackson-Lee of Texas, Ms. 
Kilpatrick of Michigan, Mr. Lantos, Ms. Lee, Mr. McGovern, Mr. Nadler, 
  Mr. Owens, Mr. Pallone, Mr. Thompson of Mississippi, Mr. Towns, Ms. 
   Woolsey, and Ms. Solis) introduced the following bill; which was 
 referred to the Committee on Energy and Commerce, and in addition to 
the Committees on Ways and Means and Education and the Workforce, for a 
 period to be subsequently determined by the Speaker, in each case for 
consideration of such provisions as fall within the jurisdiction of the 
                          committee concerned

_______________________________________________________________________

                                 A BILL


 
To amend the Social Security Act and the Internal Revenue Code of 1986 
   to provide for an AmeriCare that assures the provision of health 
      insurance coverage to all residents, and for other purposes.

    Be it enacted by the Senate and House of Representatives of the 
United States of America in Congress assembled,

SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This Act may be cited as ``AmeriCare Health Care 
Act of 2006''.
    (b) Table of Contents.--The table of contents of this Act is as 
follows:

Sec. 1. Short title; table of contents.
             TITLE I--HEALTH CARE ELIGIBILITY AND BENEFITS

Sec. 101. Eligibility and benefits.
                ``TITLE XXII--AMERICARE HEALTH BENEFITS

                         ``Part A--Eligibility

        ``Sec. 2201. Eligibility.
        ``Sec. 2202. Enrollment and AmeriCare cards.
                           ``Part B--Benefits

        ``Sec. 2221. Scope of benefits.
        ``Sec. 2222. Exclusions.
              ``Part C--Payment for Benefits and Financing

        ``Sec. 2241. Payments for benefits.
        ``Sec. 2242. AmeriCare Trust Fund.
                ``Part D--Administrative Simplification

        ``Sec. 2251. Requirement for entitlement verification system.
        ``Sec. 2252. Requirements for uniform claims and electronic 
                            claims data set.
        ``Sec. 2253. Electronic medical records and reporting.
        ``Sec. 2254. Uniform hospital cost reporting.
        ``Sec. 2255. Health service provider defined.
                      ``Part E--General Provisions

        ``Sec. 2261. Definitions relating to beneficiaries and income.
        ``Sec. 2262. Incorporation of certain medicare provisions and 
                            other provisions.
        ``Sec. 2263. State maintenance of effort payments.
        ``Sec. 2264. Modification of medicaid and other programs to 
                            avoid duplication of benefits.
        ``Sec. 2265. Construction regarding continuation of obligations 
                            under current group health plan contracts 
                            and provision of additional benefits.
        ``Sec. 2266. Standards and requirements for AmeriCare 
                            supplemental policies.
                     TITLE II--FINANCING PROVISIONS

                  Subtitle A--Individual Contributions

Sec. 201. General obligation for individuals.
Sec. 202. Additional premium subsidies.
Sec. 203. Effective date.
                   Subtitle B--Employer Contributions

Sec. 211. General obligation for employers.
Sec. 212. Effective date.

             TITLE I--HEALTH CARE ELIGIBILITY AND BENEFITS

SEC. 101. ELIGIBILITY AND BENEFITS.

    (a) In General.--The Social Security Act is amended by adding at 
the end the following new title:

                ``TITLE XXII--AMERICARE HEALTH BENEFITS

                         ``Part A--Eligibility

``SEC. 2201. ELIGIBILITY.

    ``(a) Universal Eligibility for Residents.--
            (1) In general.--Except as provided in section 2263(a), 
        each individual who is a resident of the United States is 
        entitled to health insurance benefits under this title.
    
            ``(2) Effective date for benefits.--This title shall apply 
        to items and services furnished on or after January 1, 2010.
    ``(b) Special Eligibility Groups.--For purposes of this title, an 
individual described in subsection (a) may obtain special benefits 
under this title on the basis of one or more of the following special 
eligibility groups:
            ``(1) Children (as defined in section 2261(a)(1)).
            ``(2) Low-income individuals (as defined in section 
        2261(a)(2)).
            ``(3) Pregnant women (as defined in section 2261(a)(3)).
    ``(c) Reciprocal Coverage of Nonresidents.--An individual who--
            ``(1) is not a resident of the United States,
            ``(2) is in the United States, and
            ``(3) is a national of a foreign state which provides 
        health benefits to nationals of the United States who are 
        nonresidents in that state,
is entitled to such health insurance benefits under this title, but 
only to the extent the Secretary determines that such benefits would be 
available to nationals of the United States similarly situated as a 
nonresident in the foreign state.

``SEC. 2202. ENROLLMENT AND AMERICARE CARDS.

    ``(a) Enrollment.--The Secretary shall provide a mechanism for the 
enrollment of individuals entitled to benefits under this title and, in 
conjunction with such enrollment, the issuance of an AmeriCare card 
which may be used for purposes of identification and processing of 
claims for benefits under this title. AmeriCare cards shall identify 
(as appropriate) the date of birth (for purposes of identifying 
children) and provide a coded means for identifying whether the 
individual is a low-income individual for the year involved.
    ``(b) Classes of Enrollment.--The mechanism under subsection (a) 
shall provide for individuals to be enrolled on the basis of the 
following classes of enrollment:
            (1) Coverage only of an individual.
            (2) Coverage of a married couple without children.
            (3) Coverage of an unmarried individual and one or more 
        children.
            (4) Coverage of a married couple and one or more children.
    ``(c) Enrollment at Birth.--The mechanism under subsection (a) 
shall include a process for the automatic enrollment of individuals at 
the time of birth in the United States.
    ``(d) Opt Out for Those Covered Under Group Health Plan.--
Notwithstanding any other provision of this title, an individual may 
elect not to be enrolled for benefits under this title if the 
individual demonstrates to the satisfaction of the Secretary that the 
individual has health benefits coverage under a group health plan (as 
defined in section 5000(b)(1) of the Internal Revenue Code of 1986) 
that is at least equivalent to the coverage otherwise provided under 
this title, as certified by the Secretary.

                           ``Part B--Benefits

``SEC. 2221. SCOPE OF BENEFITS.

    ``(a) In General.--Except as provided in the succeeding provisions 
of this part, the benefits provided to an individual described in 
section 2201(a) by the program established by this title shall consist 
of entitlement to the same benefits as are provided under parts A and B 
of title XVIII to individuals entitled to benefits under part A, and 
enrolled under part B, of title XVIII.
    ``(b) Change in the Cost-Sharing.--
            ``(1) Deductible.--Except as provided in the succeeding 
        provisions of this part, the amount of expenses (other than 
        expenses for benefits described in subsection (c)) with respect 
        to which an individual is entitled to have payment made under 
        this title for any year shall first be reduced by a deductible 
        of $350, except that in no case shall the amount of the 
        deductible for all the members of a family exceed $500. Such 
        deductible shall be instead of the deductible for inpatient 
        hospital services under the first sentence of section 
        1813(a)(1) and the deductible under section 1833(b).
            ``(2) Coinsurance.--After the application of the deductible 
        under paragraph (1), the expenses referred to in such paragraph 
        shall be subject to a coinsurance of 20 percent until the limit 
        on out-of-pocket expenses under paragraph (3) is met.
            ``(3) Limit on out-of-pocket expenses and total expenses.--
                    ``(A) Limitation on cost-sharing.--Subject to 
                subparagraph (B), whenever in a calendar year an 
                individual's expenses for the deductible and 
                coinsurance with respect to services covered under this 
                title (including expenses for benefits described in 
                subsection (c)) and furnished during the year equals 
                $2,500, or $4,000 for all the members of a family, 
                payment of benefits under this title for the individual 
                (or for the members of such family, respectively) for 
                services furnished during the remainder of the year 
                shall be paid without the application of any 
                coinsurance.
                    ``(B) Limitation on premiums and cost-sharing for 
                certain individuals based on income.--
                            ``(i) Income between 200 and 300 percent of 
                        poverty line.--In the case of a family whose 
                        applicable modified gross income (expressed as 
                        a percentage of the poverty level, as defined 
                        in section 2261(b)(2)) is equal to or exceeds 
                        200 percent, but does not exceed 300 percent, 
                        of the poverty level applicable to a family of 
                        the size involved, whenever in a calendar year 
                        an individual's expenses in the family for 
                        premiums under this title and for the 
                        deductible and coinsurance with respect to 
                        services covered under this title (including 
                        expenses for benefits described in subsection 
                        (c)) and furnished during the year equals 5 
                        percent of the amount of such applicable 
                        modified gross income for the family--
                                    ``(I) no additional premiums shall 
                                be imposed for remaining months in the 
                                year; and
                                    ``(II) payment of benefits under 
                                this title for members of such family 
                                for services furnished during the 
                                remainder of the year shall be paid 
                                without the application of any 
                                deductible or coinsurance.
                            ``(ii) Income between 300 and 500 percent 
                        of poverty line.--In the case of a family whose 
                        applicable modified gross income (expressed as 
                        a percentage of the poverty level, as defined 
                        in section 2261(b)(2)) exceeds 300 percent, but 
                        does not exceed 500 percent, of such poverty 
                        level applicable to a family of the size 
                        involved, whenever in a calendar year an 
                        individual's expenses in the family for 
                        premiums under this title and for the 
                        deductible and coinsurance with respect to 
                        services covered under this title (including 
                        expenses for benefits described in subsection 
                        (c)) and furnished during the year equals 7.5 
                        percent of the amount of such applicable 
                        modified gross income for the family--
                                    ``(I) no additional premiums shall 
                                be imposed for remaining months in the 
                                year; and
                                    ``(II) payment of benefits under 
                                this title for members of such family 
                                for services furnished during the 
                                remainder of the year shall be paid 
                                without the application of any 
                                deductible or coinsurance.
                    ``(C) Counting all expenses for premiums, 
                deductibles and coinsurance without regard to true out-
                of-pocket costs.--.In applying subparagraphs (A) and 
                (B), expenses for an individual's premiums, deductible, 
                and coinsurance shall be counted without regard to 
                whether such expenses are paid, payable, reimbursed, or 
                reimbursable by another person, including through a 
                group health plan, insurance or otherwise, or other 
                third party payment arrangement.
            ``(4) Indexing dollar amounts by cpi.--Each dollar amount 
        specified in paragraphs (1) and (3)(A) shall be increased to 
        the year involved by the compounded sum of the increase in the 
        consumer price index for all urban consumers (U.S. City 
        average, as published by the Bureau of Labor Statistics of the 
        Department of Labor) for each year after 2006 and up to the 
        year involved. Any increase under this paragraph for a year 
        shall be rounded, with respect to paragraph (1), to the nearest 
        multiple of $5 and, with respect to paragraph (2), to the 
        nearest multiple of $100.
    ``(c) Prescription Drugs.--Benefits shall also be made available 
under this title (as specified by the Secretary) for prescription drugs 
and biologicals which are not less than the benefits for such drugs and 
biologicals under the standard option for the service benefit plan 
described in section 8903(1) of title 5, United States Code, offered 
during 2005.
    ``(d) Children.--
            ``(1) No deductibles or coinsurance.--In the case of 
        children (as defined in section 2261(a)(1)), there shall be no 
        deductible or coinsurance applicable to covered benefits 
        (including benefits described in paragraphs (2) and (3)).
            ``(2) Additional preventive benefits.--
                    ``(A) In general.--Subject to the periodicity 
                schedule established with respect to the services under 
                subparagraph (B), for children benefits shall be 
                available under this title for the following items and 
                services:
                            ``(i) Newborn and well-baby care, including 
                        normal newborn care and pediatrician services 
                        for high-risk deliveries.
                            ``(ii) Well-child care, including routine 
                        office visits, routine immunizations (including 
                        the vaccine itself), routine laboratory tests, 
                        and preventive dental care.
                    ``(B) Periodicity schedule.--The Secretary, in 
                consultation with the American Academy of Pediatrics 
                and the American Dental Association, shall establish a 
                schedule of periodicity which reflects the general, 
                appropriate frequency with which services listed in 
                subparagraph (A) should be provided to healthy 
                children.
            ``(3) Coverage of epsdt.--For children, benefits also shall 
        be available under this title for early and periodic screening, 
        diagnostic, and treatment services (as defined in section 
        1905(r)) not otherwise covered under paragraph (2).
            ``(4) Other additional services for children.--For 
        children, benefits also shall be available under this title for 
        the following:
                    ``(A) Inpatient hospital services (without regard 
                to the restrictions described in subsections (a)(1) and 
                (b)(1) of section 1812 and the coinsurance described in 
                section 1813(a)(1)).
                    ``(B) Eyeglasses and hearing aids, and examinations 
                therefor.
    ``(e) Pregnancy-Related Services.--In the case of a pregnant woman 
(as defined in section 2261(a)(3)), benefits under this title shall 
include entitlement to have payment made for the following, without the 
application of a deductible or coinsurance:
            ``(1) Prenatal care, including care for all complications 
        of pregnancy.
            ``(2) Inpatient labor and delivery services.
            ``(3) Postnatal care.
    ``(f) Lower-Income Individuals.--
            ``(1) Limitations on deductibles and coinsurance.--
                    ``(A) None for low-income individuals.--In the case 
                of a low-income individual, there shall be no 
                deductible or coinsurance under this title.
                    ``(B) Phase-in for other lower-income 
                individuals.--In the case of an individual whose 
                applicable modified gross income (as defined in section 
                2261(b)(1)) exceeds twice the poverty level (as defined 
                in section 2261(b)(2)) but does not exceed three times 
                the poverty level, the deductible and coinsurance 
                applicable under this title shall bear the same ratio 
                to the deductible or coinsurance otherwise applicable 
                as--
                            ``(i) the excess of the applicable modified 
                        gross income over the poverty level, bears to
                            ``(ii) the poverty level.
                If the ratio determined under the preceding sentence is 
                not a multiple of 25 percentage points, such ratio 
                shall be rounded to the nearest 25 percentage points.
            ``(2) Additional benefits for low-income individuals.--In 
        the case of low-income individuals (as defined in section 
        2261(a)(2)), benefits under this title shall also include 
        entitlement to have payment made for the following, without the 
        application of a deductible or coinsurance:
                    ``(A) Inpatient hospital services (without regard 
                to the restrictions described in subsections (a)(1) and 
                (b)(1) of section 1812 and the coinsurance described in 
                section 1813(a)(1)).
                    ``(B) Eyeglasses and hearing aids and examinations 
                therefor.
    ``(g) Preventive Benefits.--Benefits shall also be made available 
under this title, without the application of any deductible or 
coinsurance for preventive services that are recommended by the United 
States Preventive Services Task Force.
    ``(h) Mental Health Parity and Substance Abuse Benefits.--Benefits 
shall be made available under this title for mental health services and 
for substance abuse treatment in the same manner as such benefits are 
made available for medical and surgical services.
            ``(i) Family Planning Services.--Benefits shall be made 
        available under this title for family planning services.
    ``(j) Conforming Medicare Benefits.--Notwithstanding any other 
provision of law, benefits under title XVIII shall be expanded and 
conformed to the benefits made available under this title (including 
the application of a single deductible and uniform coinsurance amounts, 
a limitation on the coinsurance, and additional benefits for low-income 
individuals under subsection (f)), but nothing in this subsection shall 
be construed as providing for any such additional benefits under this 
title rather than under such title.
    ``(k) Enrollment in Health Plans.--The Secretary shall provide for 
the offering of benefits under this title through enrollment in a 
health benefit plan that meets the same (or similar) requirements as 
the requirements that apply to Medicare Advantage plans under part C of 
title XVIII (other than any such requirements that relate to part D of 
such title). In the case of individuals enrolled under this title in 
such a plan, the payment rate to the plan under this title shall be 
based on adjusted average per capita cost (AAPCC) payment rate 
methodology described in section 1853(c)(1)(D) for benefits under this 
title and for individuals entitled to benefits under this title who are 
not enrolled in such a plan.

``SEC. 2222. EXCLUSIONS.

    ``(a) In General.--Except as provided in this section, section 1862 
shall apply to expenses incurred for items and services provided under 
this title the same manner as such section applies to items and 
services provided under title XVIII.
    ``(b) Benefits Exception.--
            ``(1) Childrens' services.--In applying section 1862(a) 
        with respect to services described in section 2221(d)(2)(A) 
        (relating to well-child services), payment shall not be denied 
        under paragraph (1), (7), or (12) of such section 1862(a) if 
        the services are provided in accordance with the periodicity 
        schedule described in section 2221(d)(2)(B).
            ``(2) Treatment of eyeglasses and hearing aids for children 
        and low-income individuals.--Payment shall not be denied under 
        this title under section 1862(a)(7) with respect to eyeglasses 
        and hearing aids and examinations therefor in the case of 
        children and low-income individuals.
    ``(c) Coordination of Payments.--
            ``(1) Primary to group health plans.--Section 1862(b)(1) 
        (relating to requirements of group health plans) shall not 
        apply under this title.
            ``(2) Secondary to medicare.--Payment shall not be made 
        under this title with respect to benefits to the extent that 
        payment for such benefits may be made under title XVIII.

              ``Part C--Payment for Benefits and Financing

``SEC. 2241. PAYMENTS FOR BENEFITS.

    ``(a) In General.--Except as otherwise provided in this section and 
in section 2221--
            ``(1) payment of benefits under this title with respect to 
        benefits shall be made on the same basis as payment is made 
        with respect to such benefits under title XVIII, and
            ``(2) the provisions of sections 1814, 1833, 1834, 1842, 
        1848, and 1886 shall apply to payment of benefits under this 
        title in the same manner as they apply to benefits under title 
        XVIII.
    ``(b) No Extra Billing Permitted.--Payment under this title may 
only be made on an assignment-related basis (as defined in section 
1842(i)(1)). If an entity knowingly and willfully presents or causes to 
be presented a claim or bills an individual enrolled under this title 
for charges for services other than on an assignment-related basis, the 
Secretary may apply sanctions against such entity in accordance with 
section 1842(j)(2).
    ``(c) Adjustment of Payments.--
            ``(1) Establishment of new drgs and weights.--In making 
        payment under this title with respect to inpatient hospital 
        services, the Secretary shall establish such additional 
        diagnosis-related groups (and weighting factors with respect to 
        discharges within such groups) and make such adjustments in the 
        diagnosis-related groups and weighting factors with respect to 
        discharges within such groups otherwise established under 
        section 1886(d)(4) as may be necessary to reflect the types of 
        discharges occurring under this title which are not occurring 
        under title XVIII.
            ``(2) Payment for obstetrical services.--
                    ``(A) Global fee.--In making payment under this 
                title with respect to the group of obstetrical services 
                typical of treatment throughout a course of pregnancy, 
                the Secretary shall establish, as a schedule under 
                section 1848, a global fee with respect to such group 
                of services.
                    ``(B) Bonus for early presentation.--The fee 
                schedule amount with respect to obstetrical services 
                under this title shall be increased by 5 percent in the 
                case of services furnished to women who have presented 
                for prenatal care during the first trimester.
    ``(d) Conditions of and Limitations on Payments.--The provisions of 
sections 1814 and 1835 shall apply to payment for services under this 
title in the same manner as they apply to payment for services under 
parts A and B, respectively, of title XVIII.
    ``(e) Use of Trust Fund.--In carrying out this section, any 
reference in title XVIII to a trust fund shall be treated as a 
reference to the AmeriCare Trust Fund established under section 2242.
    ``(f) Payment for Outpatient Prescription Drugs and Biologicals.--
The Secretary shall establish a fee schedule for the payment for 
outpatient prescription drugs and biologicals under this title and, 
notwithstanding section 1860D-11(i)(1), under title XVIII. The 
Secretary shall negotiate with pharmaceutical manufacturers with 
respect to the purchase price of such drugs and biologicals and shall 
encourage the use of more affordable therapeutic equivalents to the 
extent such practices do not override medical necessity, as determined 
by the prescribing physician. To the extent practicable and consistent 
with the previous sentence, the Secretary shall implement strategies 
similar to those used by other Federal purchasers of prescription 
drugs, and other strategies, to reduce the purchase cost of outpatient 
prescription drugs and biologicals.

``SEC. 2242. AMERICARE TRUST FUND.

    ``(a) Establishment.--(1) There is hereby created on the books of 
the Treasury of the United States a trust fund to be known as the 
`AmeriCare Trust Fund' (in this section referred to as the `Trust 
Fund'). The Trust Fund shall consist of such gifts and bequests as may 
be made as provided in section 201(i)(1) and amounts appropriated under 
paragraph (2).
    ``(2) There are hereby appropriated to the Trust Fund amounts 
equivalent to 100 percent of the increase in revenues to the Treasury 
by reason of the provisions of and amendments made by title II of the 
AmeriCare Health Care Act of 2006. The amounts appropriated by the 
preceding sentence shall be transferred from time to time from the 
general fund in the Treasury to the Trust Fund, such amounts to be 
determined on the basis of estimates by the Secretary of the Treasury 
of the increase in revenues which are paid to or deposited into the 
Treasury; and proper adjustments shall be made in amounts subsequently 
transferred to the extent prior estimates were in excess of or were 
less than such increase.
    ``(b) Incorporation of Provisions.--
            ``(1) In general.--Subject to paragraph (2), the provisions 
        of subsections (b) through (e) and (g) through (i) of section 
        1817 shall apply to the Trust Fund in the same manner as they 
        apply to the Federal Hospital Insurance Trust Fund.
            ``(2) Exceptions.--In applying paragraph (1)--
                    ``(A) the Board of Trustees and Managing Trustee of 
                the Trust Fund shall be composed of the members of the 
                Board of Trustees and the Managing Trustee, 
                respectively, of the Federal Hospital Insurance Trust 
                Fund; and
                    ``(B) any reference in section 1817 to the Federal 
                Hospital Insurance Trust Fund or to title XVIII (or 
                part A thereof) is deemed a reference to the Trust Fund 
                under this section and this title, respectively.

                ``Part D--Administrative Simplification

``SEC. 2251. REQUIREMENT FOR ENTITLEMENT VERIFICATION SYSTEM.

    ``(a) In General.--
            ``(1) Requirement.--The Secretary with respect to the plan 
        provided under this title, and each AmeriCare supplemental plan 
        (as defined in section 2279(3)), shall provide for an 
        electronic system, that is certified by the Secretary as 
        meeting the standards established under subsection (b), for the 
        verification of an individual's entitlement to benefits under 
        such plan.
            ``(2) Deadline for application of requirement.--The 
        deadline specified under this paragraph for the requirement 
        under paragraph (1) is 6 months after the date the standards 
        are established under subsection (b).
    ``(b) Standards for Entitlement Verification Systems.--
            ``(1) In general.--The Secretary shall establish standards 
        consistent with this subsection respecting the requirements for 
        certification of entitlement verification systems.
            ``(2) Information available.--Such standards shall require 
        a system to provide information, with respect to individuals, 
        concerning the following:
                    ``(A) The specific benefits to which the individual 
                is entitled under the plan.
                    ``(B) Current status of the individual with respect 
                to fulfillment of deductibles, coinsurance, and out-of-
                pocket limits on cost-sharing.
                    ``(C) Restrictions on providers who may provide 
                covered services, including utilization controls (such 
                as preadmission certification).
            ``(3) Form of inquiry.--Each verification system shall be 
        capable of accepting inquiries under this subsection from 
        health care providers in a variety of electronic forms. The 
        system shall also provide, for an additional fee, for the 
        acceptance of inquiries in a nonelectronic form.
            ``(4) Form of response.--Each such system shall be capable 
        of responding to such inquiries under this subsection in a 
        variety of electronic and other forms, including--
                    ``(A) through modem transmission of information,
                    ``(B) through computer synthesized voice 
                communication, and
                    ``(C) through transmission of information to a 
                facsimile (fax) machine.
        The system shall also provide, for an additional fee, for the 
        response to inquiries in a nonelectronic form.
            ``(5) Limitation on fees.--Neither the Secretary nor an 
        AmeriCare supplemental plan may impose a fee for the acceptance 
        or response to an inquiry under this subsection except where 
        the acceptance or response is in a nonelectronic form.
            ``(6) Website availability to providers.--The Secretary 
        shall establish and maintain a website through which--
                    ``(A) health service providers may make inquiries, 
                and receive responses, with respect to the eligibility 
                and benefits of an individual under plans; and
                    ``(B) AmeriCare supplemental plans may make 
                inquiries, and receive responses, to determine the 
                liability of other plans for the provision or payment 
                of benefits.
            ``(7) Deadline.--The Secretary shall first establish the 
        standards under this subsection (and shall establish the 
        website under paragraph (6)) by not later than 12 months after 
        the date of the enactment of this title.

``SEC. 2252. REQUIREMENTS FOR UNIFORM CLAIMS AND ELECTRONIC CLAIMS DATA 
              SET.

    ``(a) Requirements.--
            ``(1) Submission of claims.--Each health service provider 
        that furnishes services in the United States for which payment 
        may be made under this title or under an AmeriCare supplemental 
        plan shall submit any claim for payment for such services only 
        in a form and manner consistent with standards established 
        under subsection (c).
            ``(2) Acceptance of claims.--The Secretary and an AmeriCare 
        supplemental plan may not reject a claim for payment under this 
        title or the plan on the basis of the form or manner in which 
        the claim is submitted if the claim is submitted in accordance 
        with the standards established under subsection (c).
            ``(3) Effective date.--This subsection shall apply to 
        claims for services furnished on or after the date that is 6 
        months after the date standards are established under 
        subsection (c).
    ``(b) Enforcement Through Civil Money Penalties.--
            ``(1) In general.--
                    ``(A) Providers.--In the case of a health service 
                provider that submits a claim in violation of 
                subsection (a)(1), the provider is subject to a civil 
                money penalty of not to exceed $100 (or, if greater, 
                the amount of the claim) for each such violation.
                    ``(B) Plans.--In the case of an AmeriCare 
                supplemental plan that rejects a claim in violation of 
                subsection (a)(2), the plan is subject to a civil money 
                penalty of not to exceed $100 (or, if greater, the 
                amount of the claim) for each such violation.
            ``(2) Process.--The provisions of section 1128A of the 
        Social Security Act (other than subsections (a) and (b)) shall 
        apply to a civil money penalty under paragraph (1) in the same 
        manner as such provisions apply to a penalty or proceeding 
        under section 1128A(a) of such Act.
    ``(c) Standards Relating to Uniform Claims and Electronic Claims 
Data Set.--
            ``(1) Establishment of standards.--The Secretary shall 
        establish standards that--
                    ``(A) relate to the form and manner of submission 
                of claims for benefits under this title and under an 
                AmeriCare supplemental plan, and
                    ``(B) define the data elements to be contained in a 
                uniform electronic claims data set to be used with 
                respect to such claims.
            ``(2) Scope of information.--
                    ``(A) Ensuring accountability for claims submitted 
                electronically.--In establishing standards under this 
                section, the Secretary, in consultation with 
                appropriate agencies, shall include such methods of 
                ensuring provider responsibility and accountability for 
                claims submitted electronically that are designed to 
                control fraud and abuse in the submission of such 
                claims.
                    ``(B) Components.--In establishing such standards 
                the Secretary shall--
                            ``(i) with respect to data elements, define 
                        data fields, formats, and medical nomenclature, 
                        and plan benefit and insurance information;
                            ``(ii) develop a single, uniform coding 
                        system for diagnostic and procedure codes; and
                            ``(iii) provide for standards for the 
                        uniform electronic transmission of such 
                        elements.
            ``(3) Coordination with standards for electronic medical 
        records.--In establishing standards under this subsection, the 
        Secretary shall assure that--
                    ``(A) the development of such standards is 
                coordinated with the development of the standards for 
                electronic medical records under section 2253, and
                    ``(B) the coding of data elements under the uniform 
                electronic claims data set and the coding of the same 
                elements in the uniform hospital clinical data set are 
                consistent.
            ``(4) Use of task forces.--In adopting standards under this 
        subsection--
                    ``(A) the Secretary shall take into account the 
                recommendations of current task forces; and
                    ``(B) the Secretary shall provide that the 
                electronic transmission standards are consistent, to 
                the extent practicable, with the applicable standards 
                established by the Accredited Standards Committee X-12 
                of the American National Standards Institute.
            ``(5) Uniform, unique provider identification codes.--In 
        establishing standards under this subsection--
                    ``(A) the Secretary shall provide for a unique 
                identifier code for each health service provider that 
                furnishes services for which a claim may be submitted 
                under this title or under an AmeriCare supplemental 
                plan, and
                    ``(B) in the case of a provider that has a unique 
                identifier issued for purposes of title XVIII, the code 
                provided under subparagraph (A) shall be the same as 
                such unique identifier.
            ``(6) Website availability to providers.--The Secretary 
        shall establish and maintain a website that will enable health 
        service providers, without charge, to submit claims and to 
        receive verification of claims status electronically.
            ``(7) Standards for paper claims.--The standards shall 
        provide for a uniform paper claims form which is consistent 
        with data elements required for the submission of claims 
        electronically.
            ``(8) Standards for claims for clinical laboratory tests.--
        The standards shall provide that claims for clinical laboratory 
        tests for which benefits are provided under this title or under 
        an AmeriCare supplemental plan shall be submitted directly by 
        the person or entity that performed (or supervised the 
        performance of) the tests to the plan in a manner consistent 
        with (and subject to such exceptions as are provided under) the 
        requirement for direct submission of such claims under title 
        XVIII.
            ``(9) Deadline.--The Secretary shall first provide for the 
        standards for the uniform claims under this subsection (and 
        shall develop and make available the software under paragraph 
        (6)) by not later than 1 year after the date of the enactment 
        of this title.
    ``(d) Use Under This Title and Medicare and Medicaid Programs.--
            ``(1) Requirement for providers.--In the case of a health 
        service provider that submits a claim for services furnished 
        under this title in violation of subsection (a)(1), no payment 
        shall be made under this title for such services.
            ``(2) Requirements of medicare administrative contractors 
        under medicare program.--The Secretary shall provide, in 
        regulations promulgated to carry out this title, that the 
        claims process provided under this title conforms to the 
        standards established under subsection (c).
            ``(3) Requirements of state medicaid plans.--As a condition 
        for the approval of State plans under the medicaid program, 
        effective as of the effective date specified in subsection 
        (a)(3), each such plan shall provide, in accordance with 
        regulations of the Secretary, that the claims process provided 
        under the plan is modified to the extent required to conform to 
        the standards established under subsection (c).

``SEC. 2253. ELECTRONIC MEDICAL RECORDS AND REPORTING.

    ``(a) Standards for Electronic Medical Records.--
            ``(1) Promulgation of standards.--
                    ``(A) In general.--Not later than January 1, 2008, 
                the Secretary shall promulgate standards described in 
                paragraph (2) for hospitals and other health care 
                providers concerning electronic medical records. Such 
                standards shall include the standards established under 
                part C of title XI.
                    ``(B) Revision.--The Secretary may from time to 
                time revise the standards promulgated under this 
                paragraph.
            ``(2) Contents of standards.--The standards promulgated 
        under paragraph (1) shall include at least the following:
                    ``(A) A definition of a uniform provider clinical 
                data set, including a definition of the set of 
                comprehensive data elements, for use by utilization and 
                quality control peer review organizations.
                    ``(B) Standards for an electronic patient care 
                information system with data obtained at the point of 
                care.
                    ``(C) A specification of, and manner of 
                presentation of, the individual data elements of the 
                set and system under this paragraph.
                    ``(D) Standards concerning the transmission of 
                electronic medical data.
                    ``(E) Standards relating to confidentiality of 
                patient-specific information, which include the 
                physical security of electronic data and the use of 
                keys, passwords, encryption, and other means to ensure 
                the protection of the confidentiality and privacy of 
                electronic data.
            ``(3) Coordination with standards for uniform electronic 
        claims data set.--In establishing standards under this 
        subsection, the Secretary shall assure that--
                    ``(A) the development of such standards is 
                coordinated with the development of the standards for 
                the uniform electronic claims data set under subsection 
                (b), and
                    ``(B) the coding of data elements under the uniform 
                provider clinical data set and the coding of the same 
                elements under the uniform electronic claims data set 
                are consistent.
            ``(4) Consultation.--In establishing standards under this 
        subsection, the Secretary shall--
                    ``(A) consult with the American National Standards 
                Institute, hospitals and other health care providers, 
                health benefit plans, and other interested parties, and
                    ``(B) take into consideration, in developing 
                standards under paragraph (2)(A), the data set used by 
                the utilization and quality control peer review program 
                under part B of title XI.
    ``(b) Requirement for Application of Electronic Records 
Standards.--
            ``(1) As condition of medicare, medicaid, schip, and 
        americare participation.--Effective January 1, 2009, each 
        hospital or other institutional or noninstitutional health care 
        provider, as a requirement of each participation agreement 
        under this title, title XVIII, title XIX, and title XXI, shall, 
        in accordance with the standards promulgated under subsection 
        (a)(1)--
                    ``(A) maintain clinical data included in the 
                uniform provider clinical data set under subsection 
                (a)(2)(A) in electronic form on all patients,
                    ``(B) upon request of the Secretary or of a 
                utilization and quality control peer review 
                organization (with which the Secretary has entered into 
                a contract under part B of title XI), transmit 
                electronically data requested from such data set, and
                    ``(C) upon request of the Secretary, or of a fiscal 
                intermediary or carrier, transmit electronically any 
                data (with respect to a claim) from such data set.
            ``(2) Application of presentation and transmission 
        standards to electronic transmission to federal agencies.--
        Effective January 1, 2008, if a hospital or other health care 
        provider is required under a Federal program to transmit a data 
        element that is subject to a standard, promulgated under 
        subsection (a)(1), described in subparagraph (C) or (D) of 
        subsection (a)(2), the head of the Federal agency responsible 
        for such program (if not otherwise authorized) is authorized to 
        require the provider to present and transmit the data element 
        electronically in accordance with such a standard.
    ``(c) Limitation on Data Requirements Where Standards In Effect.--
            ``(1) In general.--On or after January 1, 2008, the 
        Secretary under this title or under title XVIII (including any 
        carrier or fiscal intermediary or any utilization and quality 
        control peer review organization) and an AmeriCare supplemental 
        plan may not require, for the purpose of utilization review or 
        as a condition of providing benefits or making payments under 
        this title, title XVIII, or the plan, that a hospital or other 
        health care provider--
                    ``(A) provide any data element not in the uniform 
                provider clinical data set specified under the 
                standards promulgated under subsection (a), or
                    ``(B) transmit or present any such data element in 
                a manner inconsistent with such standards applicable to 
                such transmission or presentation.
            ``(2) Compliance.--The Secretary may impose a civil money 
        penalty on any AmeriCare supplemental plan that fails to comply 
        with paragraph (1) in an amount not to exceed $100 for each 
        such failure. The provisions of section 1128A of the Social 
        Security Act (other than the first sentence of subsection (a) 
        and other than subsection (b)) shall apply to a civil money 
        penalty under this paragraph in the same manner as such 
        provisions apply to a penalty or proceeding under section 
        1128A(a) of such Act.
            ``(3) Application to medicaid program.--As a condition for 
        the approval of State plans under the medicaid program and in 
        accordance with regulations of the Secretary, effective as of 
        January 1, 2008, each such plan may not require that a hospital 
        or other health care provider, for the purpose of utilization 
        review or as a condition of providing benefits or making 
        payments under the plan--
                    ``(A) provide any data element not in the uniform 
                provider clinical data set specified under the 
                standards promulgated under subsection (a), or
                    ``(B) transmit or present any such data element in 
                a manner inconsistent with such standards applicable to 
                such transmission or presentation.
    ``(d) Preemption of State Quill Pen Laws.--
            ``(1) In general.--Any provision of State law that requires 
        medical or health insurance records (including billing 
        information) to be maintained in written, rather than 
        electronic, form shall deemed to be satisfied if the records 
        are maintained in an electronic form that meets standards 
        established by the Secretary under paragraph (2).
            ``(2) Secretarial authority.--Not later than 1 year after 
        the date of the enactment of this title, the Secretary shall 
        issue regulations to carry out paragraph (1). The regulations 
        shall provide for an electronic substitute that is in the form 
        of a unique identifier (assigned to each authorized individual) 
        that serves the functional equivalent of a signature. The 
        regulations may provide for such exceptions to paragraph (1) as 
        the Secretary determines to be necessary to prevent fraud and 
        abuse, to prevent the illegal distribution of controlled 
        substances, and in such other cases as the Secretary deems 
        appropriate.
            ``(3) Effective date.--Paragraph (1) shall take effect on 
        the first day of the first month that begins more than 30 days 
        after the date the Secretary issues the regulations referred to 
        in paragraph (2).

``SEC. 2254. UNIFORM HOSPITAL COST REPORTING.

    ``Each hospital, as a requirement under a participation agreement 
under this title for each cost reporting period beginning during or 
after fiscal year 2007, shall provide for the reporting of information 
to the Secretary with respect to any hospital care provided in a 
uniform manner consistent with standards established by the Secretary 
to carry out section 4007(c) of the Omnibus Budget Reconciliation Act 
of 1987 and in an electronic form consistent with standards established 
by the Secretary.

``SEC. 2255. HEALTH SERVICE PROVIDER DEFINED.

    ``In this part, the term `health service provider' includes a 
provider of services (as defined in section 1861(u)), physician, 
supplier, and other entity furnishing health care services.

                      ``Part E--General Provisions

``SEC. 2261. DEFINITIONS RELATING TO BENEFICIARIES AND INCOME.

    ``(a) Terms Relating to Beneficiaries.--In this title:
            ``(1) Child.--The term `child' means an individual who 
        throughout a month has not attained 24 years of age.
            ``(2) Low-income individual.--The term `low-income 
        individual' means an individual whose applicable modified gross 
        income (as defined in subsection (b)(1)) is less than 200 
        percent of the poverty level (as defined in subsection (b)(2)). 
        The determination that an individual is a low-income individual 
        shall be effective for a period of one year and shall be 
        redetermined on an annual basis.
            ``(3) Pregnant woman.--The term `pregnant woman' means a 
        woman (regardless of age) who has been certified by a physician 
        (in a manner specified by the Secretary) as being pregnant, 
        until the last day of the month in which the 60-day period 
        (beginning on the date of termination of the pregnancy) ends.
    ``(b) Terms Relating to Income.--In this title:
            ``(1) Applicable modified gross income.--
                    ``(A) In general.--Except as provided in this 
                paragraph, the term `applicable modified gross income' 
                means, for a calendar year for an individual, the 
                modified gross income (as defined in section 
                202(a)(3)(B) of the Americare Health Care Act of 2006) 
                of the taxpayer (or the taxpayer for whom the 
                individual may be claimed as a dependent) for the 
                taxable year ending in the second previous calendar 
                year.
                    ``(B) Application of current year modified gross 
                income.--
                            ``(i) In general.--Subject to clause (ii), 
                        the Secretary shall establish a procedure under 
                        which an individual may file a declaration of 
                        estimated modified gross income for a taxable 
                        year ending in a calendar year, which modified 
                        gross income will apply under this subsection 
                        as the applicable modified gross income for the 
                        calendar year. Subject to clause (ii), such 
                        procedure shall be applicable regardless of 
                        whether or not the individual filed a tax 
                        return for the taxable year ending in the 
                        second previous calendar year.
                            ``(ii) Limitation on application.--The 
                        Secretary may limit the application of clause 
                        (i), in the case of individuals who have filed 
                        tax returns for the taxable year ending in the 
                        second previous calendar year, to individuals 
                        with respect to whom the applicable modified 
                        gross income will be reduced by at least 20 
                        percent as a result of the application of such 
                        clause.
                            ``(iii) Requirement for return.--Any 
                        individual who has filed a declaration under 
                        clause (i) for a calendar year is required to 
                        file an income tax return for the taxable year 
                        in the calendar year, regardless of whether any 
                        income tax is actually owed for the year. The 
                        failure of the individual to file such a return 
                        makes the individual liable for overpayments 
                        under this title under clause (iv) in the same 
                        manner as if this paragraph had not applied.
                            ``(iv) Collection for overpayments.--If a 
                        declaration of estimated modified gross income 
                        is made applicable to a calendar year under 
                        clause (i) and the actual modified gross income 
                        for that taxable year exceeds such estimated 
                        modified gross income, the individual shall be 
                        liable to the United States for 110 percent of 
                        the amount of additional payments made under 
                        this title as a result of the use of such 
                        estimated modified gross income instead of the 
                        actual modified gross income for that taxable 
                        year.
                    ``(C) Transmittal of information.--By not later 
                than October 1 of each year, the Secretary of the 
                Treasury shall transmit to the Secretary such 
                information relating to the applicable modified gross 
                income of individuals for the taxable year ending in 
                the previous year as may be necessary to apply this 
                title in the succeeding calendar year.
            ``(2) Poverty level.--The term `poverty level' means, for 
        an individual in a family, the official poverty line (as 
        defined by the Office of Management and Budget, and revised 
        annually in accordance with section 673(2) of the Omnibus 
        Budget Reconciliation Act of 1981) applicable to a family of 
        the size involved.

``SEC. 2262. INCORPORATION OF CERTAIN MEDICARE PROVISIONS AND OTHER 
              PROVISIONS.

    ``(a) Use of Medicare Administrative Contractors.--The Secretary 
shall provide for the administration of this title through the use of 
medicare administrative contractors in the same manner as title XVIII 
is carried out through the use of such contractors, except that no 
payment shall be made under this title except on the basis of bills or 
charges that are submitted electronically in a manner specified by the 
Secretary.
    ``(b) Definitions.--
            ``(1) In general.--Except as otherwise provided in this 
        title, the definitions contained in section 1861 shall apply 
        for purposes of this title in the same manner as they apply for 
        purposes of title XVIII.
            ``(2) State; united states.--(A) The term `State' means the 
        50 States and includes the District of Columbia, Puerto Rico, 
        the Virgin Island, Guam, American Samoa, and the Northern 
        Mariana Islands.
            ``(B) The term `United States' means all the States.
    ``(c) Certification, Provider Qualification, etc.--The provisions 
of sections 1863 through 1875, sections 1877 through 1880, section 
1883, section 1885, and sections 1887 through 1895 shall apply to this 
title in the same manner as they apply to title XVIII.
    ``(d) Title XI Provisions.--The following provisions shall apply to 
this title in the same manner as they apply to title XVIII:
            ``(1) Sections 1124, 1126, and 1128 through 1128E (relating 
        to fraud and abuse).
            ``(2) Section 1134 (relating to nonprofit hospital 
        philanthropy).
            ``(3) Section 1138 (relating to hospital protocols for 
        organ procurement and standards for organ procurement 
        agencies).
            ``(4) Section 1142 (relating to research on outcomes of 
        health care services and procedures), except that any reference 
        in such section to a Trust Fund is deemed a reference to the 
        AmeriCare Trust Fund.
            ``(5) Part B of title XI (relating to peer review of the 
        utilization and quality of health care services).
            ``(6) Part C of title XI (relating to administrative 
        simplification).
    ``(e) Other Provisions.--The provisions of section 201(i) shall 
apply to this title and the AmeriCare Trust Fund in the same manner as 
they apply to title XVIII and the Federal Hospital Insurance Trust 
Fund.

``SEC. 2263. STATE MAINTENANCE OF EFFORT PAYMENTS.

    ``(a) Condition of Coverage.--Notwithstanding any other provision 
of this title, no individual who is a resident of a State is eligible 
for benefits under this title for a month in a calendar year, unless 
the State provides (in a manner and at a time specified by the 
Secretary) for payment to the AmeriCare Trust Fund of \1/12\th of the 
amount specified in subsection (b) for the year. Such funds shall be 
used offset the costs of providing subsidies for low-income individuals 
under section 202.
    ``(b) Maintenance of Effort Amount.--
            ``(1) In general.--Subject to paragraph (3), the amount of 
        payment specified in this subsection for a State for a year is 
        equal to the amount of payment (net of Federal payments) made 
        by a State under its State plans under titles XIX and XXI for 
        2006 for medical assistance for benefits described in paragraph 
        (2).
            ``(2) Benefits described.--The benefits described in this 
        paragraph with respect to State plans of a State under titles 
        XIX and XXI are benefits which--
                    ``(A) would be available under this title for low-
                income individuals if this title had been in effect in 
                2006; and
                    ``(B) are for low-income individuals who--
                            ``(i) with respect to the State plan under 
                        title XIX, were required to be furnished 
                        medical assistance under such title XIX; or
                            ``(ii) with respect to a State child health 
                        plan under title XXI, were low-income children.

``SEC. 2264. MODIFICATION OF MEDICAID AND OTHER PROGRAMS TO AVOID 
              DUPLICATION OF BENEFITS.

    ``(a) In General.--Notwithstanding any other provision of law--
            ``(1) a State plan under title XIX and a State child health 
        plan under title XXI shall not provide any medical assistance 
        for benefits with respect to which any payments may be made 
        under this title; and
            ``(2) a health benefits plan under chapter 89 of title 5, 
        United States Code, shall not provide benefits for which any 
        payment may be made under this title.
    ``(b) Review of Application to Other Programs.--The Secretary shall 
conduct a review of the feasibility of applying the policy described in 
subsection (a) to additional Federal programs, such as the TRICARE 
program under title 10, United States Code. Not later than January 1, 
2009, the Secretary submit to Congress on such review and shall include 
in such report such recommendations for extending such policy to other 
Federal programs as the Secretary deems appropriate.

``SEC. 2265. CONSTRUCTION REGARDING CONTINUATION OF OBLIGATIONS UNDER 
              CURRENT GROUP HEALTH PLAN CONTRACTS AND PROVISION OF 
              ADDITIONAL BENEFITS.

    ``Nothing in this title shall be construed as--
            ``(1) affecting obligations for health care benefits under 
        group health plans as in effect on the date of the enactment of 
        this title, including such plans established or maintained 
        under or pursuant to one or more collective bargaining 
        agreements;
            ``(2) limiting the additional benefits that may be provided 
        under a group health plan to employees or their dependents, or 
        to former employees or their dependents; or
            ``(3) limiting the benefits that may be made available 
        under a State program to residents of the State at the expense 
        of the State.

``SEC. 2266. STANDARDS AND REQUIREMENTS FOR AMERICARE SUPPLEMENTAL 
              POLICIES.

    ``(a) Certification Required.--
            ``(1) In general.--The Secretary shall establish rules and 
        procedures consistent with this section under which AmeriCare 
        supplemental policies may only be issued if they are certified 
        by the Secretary or under a State regulatory program approved 
        by the Secretary as meeting standards established under 
        subsection (b).
            ``(2) Enforcement.--Any person who issues an AmeriCare 
        supplemental policy in violation of paragraph (1) is subject to 
        a civil money penalty of not to exceed $25,000 for each such 
        violation. The provisions of section 1128A (other than the 
        first sentence of subsection (a) and other than subsection (b)) 
        shall apply to a civil money penalty under the previous 
        sentence in the same manner as such provisions apply to a 
        penalty or proceeding under section 1128A(a).
            ``(3) AmeriCare supplemental policy.--For purposes of this 
        section, the term `AmeriCare supplemental policy' is a health 
        insurance policy or other health benefit plan offered by a 
        private entity to individuals who are entitled to have payment 
        made under this title, which provides reimbursement for 
        expenses incurred for services and items for which payment may 
        be made under this title but which are not reimbursable by 
        reason of the application of deductibles, coinsurance amounts, 
        or other limitations imposed pursuant to this title; but does 
        not include--
                    ``(A) any such policy or plan of the trustees of a 
                fund established by one or more employers or labor 
                organizations (or combination thereof) if the policy or 
                plan offers benefits as a direct service organization 
                under section 1833, or
                    ``(B) a policy or plan of a health maintenance 
                organization which offers benefits under this title 
                under section 2221(k).
        For purposes of this section, the term `policy' includes a 
        certificate issued under such policy.
    ``(b) Certification Standards.--
            ``(1) Issuance.--The Secretary shall develop and publish 
        specific standards consistent with this section for AmeriCare 
        supplemental policies and shall consult with the Secretary of 
        Labor regarding the application of such standards to employee 
        welfare benefit plans under title I of the Employee Retirement 
        Income Security Act of 1974.
            ``(2) More stringent state standards permitted.--In the 
        case of insured AmeriCare supplemental policies (as defined in 
        subsection (d)(3)), a State may implement standards that are 
        more stringent than the standards established under paragraph 
        (1), including--
                    ``(A) additional limitations on pre-existing 
                exclusion limitations described in subsection 
                (c)(1)(B);
                    ``(B) additional restrictions on the groups of 
                benefits described in subsection (c)(2) that may be 
                offered in AmeriCare supplemental policies in the 
                State, so long as a core-only benefit package described 
                in subparagraph (A)(i) of such subsection may be 
                offered in the State;
                    ``(C) requiring a higher loss-ratios than those 
                specified in subsection (c)(3);
    ``(c) Standards.--The Secretary shall establish standards for 
AmeriCare supplemental policies consistent with the following:
            ``(1) No discrimination based on health status.--
                    ``(A) In general.--Except as provided under 
                subparagraph (B), an AmeriCare supplemental policy may 
                not deny, limit, or condition the coverage under (or 
                benefits of) the policy, or vary premiums charged, 
                based on the health status, claims experience, receipt 
                of health care, medical history, or lack of evidence of 
                insurability, of an individual.
                    ``(B) Limitation on use of pre-existing condition 
                exclusions.--An AmeriCare supplemental policy may 
                exclude coverage with respect to services related to 
                treatment of a pre-existing condition, except that--
                            ``(i) the period of such exclusion may not 
                        exceed 6 months;
                            ``(ii) such exclusion shall not apply to 
                        services furnished to newborns; and
                            ``(iii) the period of exclusion under 
                        clause (i) shall be reduced by 1 month for each 
                        month in a period of continuous health benefits 
                        coverage (as defined by the Secretary) for the 
                        services involved.
                For purposes of this subparagraph, a condition is not 
                pre-existing unless it was diagnosed or treated during 
                the 3-month period ending on the day before the first 
                date of such coverage.
            ``(2) Simplification of benefits.--
                    ``(A) In general.--Each AmeriCare supplemental 
                policy shall only offer benefits consistent with the 
                standards, promulgated by the Secretary, that provide--
                            ``(i) limitations on the groups or packages 
                        of benefits, including a core group of basic 
                        benefits and not to exceed 9 other different 
                        benefit packages, that may be offered under an 
                        AmeriCare supplemental policy;
                            ``(ii) that a person may not issue an 
                        AmeriCare supplemental policy without offering 
                        such a policy with only the core-group of basic 
                        benefits and without providing an outline of 
                        coverage in a standard form approved by the 
                        Secretary;
                            ``(iii) uniform language and definitions to 
                        be used with respect to such benefits, and
                            ``(iv) uniform format to be used in the 
                        policy with respect to such benefits.
                    ``(B) Innovation.--The Secretary may approve the 
                offering of new or innovative and cost-effective 
                benefit packages in addition to those provided under 
                subparagraph (A).
            ``(3) Minimum loss ratio required.--An AmeriCare 
        supplemental policy, a specific disease policy (as defined by 
        the Secretary), or a hospital confinement indemnity policy (as 
        defined by the Secretary) may not be issued or renewed unless 
        the policy--
                    ``(A) can be expected (in accordance with a uniform 
                methodology developed by the Secretary and for periods 
                beginning 24 months after the date of original issue) 
                to return to policyholders in the form of aggregate 
                benefits at least 85 percent of the aggregate amount of 
                premiums collected in the case of group policies or at 
                least 75 percent in the case of individual policies (as 
                defined by the Secretary); and
                    ``(B) provides refunds and credits (in a manner 
                specified by the Secretary) for premiums collected in 
                excess of those consistent with subparagraph (A).
            ``(4) Guaranteed renewability and convertibility.--Each 
        AmeriCare supplemental policy--
                    ``(A) shall be guaranteed renewable and may not be 
                cancelled or nonrenewed solely on the ground of health 
                status of the individual or for any reason other than 
                nonpayment of premium or material misrepresentation; 
                and
                    ``(B) shall provide for--
                            ``(i) a right of conversion to an 
                        individual policy (with continuation of 
                        benefits) in the case of termination by a group 
                        policyholder or termination by a 
                        certificateholder of membership in a group 
                        through which the individual obtained coverage;
                            ``(ii) a right of continued coverage in the 
                        case of a group policy that succeeds another 
                        group policy; and
                            ``(iii) suspension of coverage (for up to 
                        24 months and in a manner specified ) in the 
                        case of a policy holder who becomes entitled to 
                        benefits under this title as a low-income 
                        individual and who provides a timely notice of 
                        election of such suspension.
            ``(5) Additional standards applicable only to insured 
        policies.--A carrier that offers an insured AmeriCare 
        supplemental policy (as defined in paragraph (6)) to 
        individuals and groups in a State shall also comply with the 
        following requirements:
                    ``(A) Open enrollment.--The carrier must offer the 
                same policy to any other individual or group in the 
                State on a continuous, year-round basis; except that--
                            ``(i) in the case of policies offered 
                        through an association which is composed 
                        exclusively of employers (which may include 
                        self-employed individuals) and which has been 
                        formed for purposes other than obtaining health 
                        insurance, such requirement shall only apply to 
                        such employers (and individuals) who are 
                        members of the association; and
                            ``(ii) a health maintenance organization 
                        may deny enrollment with respect to an 
                        individual based on the uniform application of 
                        a geographic service area or overall enrollment 
                        limitation based on its financial or 
                        administrative capacity.
                    ``(B) Notices and renewal periods.-- The carrier 
                shall provide advance notice of terms for policy 
                renewal, which terms shall--
                            ``(i) be the same as the terms of issuance, 
                        except for rates and administrative changes;
                            ``(ii) provide the same premium rates as 
                        for a new issue; and
                            ``(iii) provide a period of renewal of not 
                        less than 12 months.
    ``(c) Additional Requirements.--
            ``(1) Prohibition of duplication.--The Secretary shall--
                    ``(A) establish requirements that prohibit (other 
                than as required under Federal or State law) the 
                knowing sale or issuance to an individual entitled to 
                benefits under this title of health insurance that 
                duplicates benefits under this title, of an AmeriCare 
                supplemental policy that duplicates another AmeriCare 
                supplemental policy, or of another health insurance 
                policy that duplicates other benefits to which the 
                individual is entitled; and
                    ``(B) provide exceptions to the prohibition in 
                subparagraph (A) for enrollment in group health plans 
                and similar employment-based policies and for policies 
                which provide benefits directly and without regard to 
                other coverage and notice of such duplication.
            ``(2) Disclosure requirement.--The Secretary shall 
        establish a requirement that prohibits the sale or issuance of 
        an AmeriCare supplemental policy to an individual, other than 
        as a replacement policy, without obtaining a statement (in a 
        form specified by the Secretary) that discloses other health 
        benefits coverage and that acknowledges limitations on the need 
        for an AmeriCare supplemental policy, particularly in the case 
        of a low-income individual.
            ``(3) Application of false statement sanctions.--The 
        provisions of paragraphs (1) and (2) of section 1882(d) shall 
        apply to an AmeriCare supplemental policy under this section in 
        the same manner as they apply to medicare supplemental policies 
        under such section.
            ``(4) Limitations on sales commissions.--
                    ``(A) In general.--It is unlawful for a person who 
                provides for a commission or other compensation to an 
                agent or other representatives with respect to the sale 
                of an AmeriCare supplemental policy (or certificate)--
                            ``(i) to provide for a first year 
                        commission or other first year compensation 
                        that exceeds 200 percent of the commission or 
                        other compensation for the selling or servicing 
                        of the policy or certificate in a second or 
                        subsequent year; or
                            ``(ii) to provide for compensation with 
                        respect to replacement of such a policy or 
                        certificate that is greater than the 
                        compensation that would apply to the renewal of 
                        the policy or certificate.
                    ``(B) Definition.--In subparagraph (A), the term 
                `compensation' includes pecuniary and nonpecuniary 
                compensation of any kind relating to the sale or 
                renewal of a policy or certificate and specifically 
                includes bonuses, gifts, prizes, awards, and finders' 
                fees.
    ``(d) Information Disclosure.--The Secretary shall provide, to all 
individuals entitled to benefits under this title, such information as 
will permit such individuals to evaluate the value of AmeriCare 
supplemental policies to them and the relationship of any such policies 
to benefits provided under this title. Such information shall include 
information on--
            ``(1) the requirements and prohibitions under this section;
            ``(2) State and Federal agencies responsible for compliance 
        with such requirements and enforcement of such prohibitions; 
        and
            ``(3) the manner of submitting complaints regarding 
        violations of such requirements and prohibitions.
    ``(e) Definitions.--In this section:
            ``(1) Carrier.--The term `carrier' means any person that 
        offers an AmeriCare supplemental policy.
            ``(2) Group.--The term `group' means 2 or more employees of 
        the same employer who normally perform on a monthly basis at 
        least 17\1/2\ hours of service per week for that employer.
            ``(3) Health maintenance organization.--The term `health 
        maintenance organization' has the meaning given the term 
        `eligible organization' in section 1876(b).
            ``(4) Insured americare supplemental policy.--The term 
        `insured AmeriCare supplemental policy' means any AmeriCare 
        supplemental policy provided through insurance.''.

                     TITLE II--FINANCING PROVISIONS

                  Subtitle A--INDIVIDUAL CONTRIBUTIONS

SEC. 201. GENERAL OBLIGATION FOR INDIVIDUALS.

    (a) Payment of Plan Premium.--
            (1) In general.--Each individual eligible for coverage 
        under title XXII of the Social Security Act is liable for 
        payment of the premium established under this section for such 
        coverage of the individual and family members. An individual 
        who is not receiving such coverage due to coverage under a 
        group health plan described in section 2202(d) of such Act is 
        not liable for payment of such premium with respect to such 
        individual.
            (2) Determination of premium.--Such premium shall be 
        established by the Secretary of Health and Human Services on 
        the basis of the cost of coverage (determined on a State by 
        State basis and including administrative costs) and shall be 
        determined separately based on the class of enrollment for the 
        individual (as determined under section 2202 of the Social 
        Security Act).
            (3) Joint and several liability.--If more than one 
        individual is liable under this subsection for payment of a 
        premium for coverage of the same individual under title XXII of 
        the Social Security Act, such individual shall be jointly and 
        severally liable with each other individual who is so liable.
    (b) Reduction for Employer Contributions and Low Income 
Subsidies.--An individual's liability under subsection (a) is reduced 
by--
            (1) the amount of any contributions made by the 
        individual's employer (or employers) under subtitle B or 
        otherwise (including voluntary employer contributions) with 
        respect to coverage of the individual and family members, and
            (2) the amount of any premium subsidies provided with 
        respect to the individual under section 202.
    (c) Timing and Manner of Payment.--Each individual that is liable 
for a premium under subsection (a) shall pay such premium in such form 
and manner as the Secretary of the Treasury may specify. Except as 
otherwise provided by the Secretary of the Treasury, for purposes of 
subtitle F of such Code, the liabilities imposed under subsection (a) 
shall be treated as if they were a tax imposed under section 1 of such 
Code. The Secretary of the Treasury shall provide for the withholding 
of such payments from wages under rules similar to the rules of chapter 
24 of such Code. The Secretary of the Treasury may prescribe special 
rules for withholding payments from wages of individuals who work 
seasonally, part-time, or for more than one employer.

SEC. 202. ADDITIONAL PREMIUM SUBSIDIES.

    (a) Eligibility for Additional Premium Subsidies.--
            (1) In general.--Each premium subsidy eligible individual 
        is entitled to a premium subsidy in accordance with this 
        section.
            (2) Premium subsidy eligible individual.--In this section, 
        the term ``premium subsidy eligible individual'' means an 
        individual receiving coverage under title XXII of the Social 
        Security Act who--
                    (A) with respect to premiums for a taxable year 
                ending in a year, has family income (as defined in 
                paragraph (3)(A)) that is less than 300 percent of the 
                applicable poverty level, or
                    (B) with respect to a premium for a month, is an 
                TANF or SSI recipient for the month.
            (3) Additional definitions.--In this section:
                    (A) Family income.--The term ``family income'' 
                means, with respect to an individual who--
                            (i) is not a dependent of another 
                        individual, the sum of the modified adjusted 
                        gross incomes (as defined in subparagraph (B)) 
                        for the individual, the individual's spouse, 
                        and children who are dependents of the 
                        individual, or
                            (ii) is a dependent of another individual, 
                        the sum of the modified adjusted gross incomes 
                        (as defined in subparagraph (B)) for the other 
                        individual, the other individual's spouse, and 
                        children who are dependents of the other 
                        individual.
                    (B) Modified adjusted gross income.--The term 
                ``modified adjusted gross income'' means adjusted gross 
                income (as defined in the Internal Revenue Code of 
                1986)--
                            (i) determined without regard to sections 
                        911, 931, and 933 of such Code, and
                            (ii) increased by--
                                    (I) the amount of interest received 
                                or accrued by the individual during the 
                                taxable year which is exempt from tax, 
                                and
                                    (II) the amount of the social 
                                security benefits (as defined in 
                                section 86(d) of such Code) received 
                                during the taxable year to the extent 
                                not included in gross income under 
                                section 86 of such Code.
                The determination under the preceding sentence shall be 
                made without regard to any carryover or carryback.
                    (C) Applicable poverty level.--
                            (i) In general.--The term ``applicable 
                        poverty level'' means, for a family for a year, 
                        the official poverty line (as defined by the 
                        Secretary of Health and Human Services) 
                        applicable to a family of the size involved for 
                        2010 adjusted by the percentage increase or 
                        decrease described in clause (ii) for the year 
                        involved.
                            (ii) Percentage adjustment.--The percentage 
                        increase or decrease described in this clause 
                        for a year is the percentage increase or 
                        decrease by which the average Consumer Price 
                        Index for all urban consumers (U.S. city 
                        average), as published by the Bureau of Labor 
                        Statistics, for the 12-month-period ending with 
                        August 31 of the preceding year exceeds such 
                        average for the 12-month period ending with 
                        August 31, 2009.
                            (iii) Rounding.--Any adjustment made under 
                        clause (ii) for a year shall be rounded to the 
                        nearest multiple of $100.
                    (D) TANF recipient.--The term ``TANF recipient'' 
                means, for a month, an individual who is receiving aid 
                or assistance under any plan of the State approved 
                under title I, X, XIV, or XVI, or part A or part E of 
                title IV, of the Social Security Act, for the month.
                    (E) SSI recipient.--The term ``SSI recipient'' 
                means, for a month, an individual--
                            (i) with respect to whom supplemental 
                        security income benefits are being paid under 
                        title XVI of the Social Security Act for the 
                        month,
                            (ii) who is receiving a supplementary 
                        payment under section 1616 of such Act or under 
                        section 212 of Public Law 93-66 for the month, 
                        or
                            (iii) who is receiving monthly benefits 
                        under section 1619(a) of the Social Security 
                        Act (whether or not pursuant to section 
                        1616(c)(3) of such Act) for the month.
    (b) Amount of Premium Subsidy.--
            (1) Lowest income individuals.--
                    (A) In general.--In the case of an individual 
                described in subparagraph (B), the premium subsidy 
                under this section is the amount which would (without 
                regard to this section) reduce the premium obligation 
                of the individual (and family members) under section 
                201 to zero.
                    (B) Lowest income individuals described.--An 
                individual described in this subparagraph is a premium 
                subsidy eligible individual who would still be such an 
                individual under subsection (a)(2) if ``200 percent'' 
                were substituted for ``300 percent'' in subparagraph 
                (A) of such subsection.
            (2) Other individuals.--
                    (A) In general.--In the case of a premium subsidy 
                eligible individual not described in paragraph (1), the 
                premium subsidy under this section is the product of--
                            (i) the premium obligation of the 
                        individual (and family members) under section 
                        201, multiplied by
                            (ii) the number of percentage points by 
                        which the individual's family income (expressed 
                        as a percent of the applicable poverty level) 
                        is less than 300 percent.
                    (B) Table.--The Secretary may provide for a table 
                which establishes the values for premium subsidies 
                under this paragraph.
    (c) General Revenue Financing for Low Income Subsidies.--There are 
authorized to be appropriated to the Americare Trust Fund from amounts 
in the Treasury not otherwise appropriated, such sums as may be 
necessary to cover the costs of premium subsidies provided under this 
section.

SEC. 203. EFFECTIVE DATE.

    The provisions of this subtitle shall apply with respect to periods 
beginning on or after January 1, 2010.

                   Subtitle B--Employer Contributions

SEC. 211. GENERAL OBLIGATION FOR EMPLOYERS.

    (a) General Obligation.--
            (1) In general.--Subject to the succeeding provisions of 
        this subsection, each employer shall make a financial 
        contribution toward the cost of health insurance coverage for 
        employees in accordance with this section.
            (2) Elimination of liability in case of certain group 
        health plan coverage.--
                    (A) In general.--Subject to subparagraph (B), an 
                employer shall not be liable for any contribution under 
                this section with respect to any employee who is 
                covered under a group health plan of the employer 
                described in section 2202(d) if such employer pays at 
                least 80 percent of the cost of such health plan, as 
                determined by the Secretary of Health and Human 
                Services.
                    (B) Surcharge permissible to prevent adverse 
                selection.--The Secretary may impose liability for a 
                contribution under this section with respect to an 
                employee described in subparagraph (A) in an amount 
                (not to exceed the amount specified under subsection 
                (b)) insofar as the Secretary determines it necessary 
                to prevent adverse selection of the individuals 
                enrolled under this title as a result of the operation 
                of such subparagraph.
    (b) Amount of Contribution.--
            (1) Full-time employees.--In the case of an employee 
        receiving coverage under title XXII of the Social Security Act, 
        the amount of the financial contribution is equal to at least 
        80 percent of the premium determined with respect to such 
        employee and family members under section 201 (based on class 
        of enrollment and without regard to subsection (b) thereof) or 
        at least 80 percent of the cost of coverage under such group 
        health plan, respectively.
            (2) Reduction for part-time employees.--In the case of a 
        part-time employee, the employer contribution requirements of 
        paragraph (1) shall be treated as satisfied if the employer 
        contribution with respect to such employee is not less than the 
        part-time employment ratio of the contribution required under 
        paragraph (1).
            (3) Rules related to part-time employment.--For purposes of 
        this subsection--
                    (A) Part-time employee.--The term ``part-time 
                employee'' means, with respect to any month, an 
                employee who works on average fewer than 40 hours per 
                week.
                    (B) Part-time employment ratio.--The term ``part-
                time employment ratio'' means, with respect to a part-
                time employee of an employer in a month, a fraction--
                            (i) the numerator of which is the number of 
                        hours in the employee's normal work week, and
                            (ii) the denominator of which is 40 hours.
                    (C) Special rules.--Under rules prescribed by the 
                Secretary of Health and Human Services, in consultation 
                with the Secretary of the Treasury, in the case of an 
                employee for an employer whose defined work week for 
                full-time employees is less than 40 hours, any 
                reference in this subsection to 40 hours is deemed a 
                reference to the number of hours in the work week so 
                defined.
                    (D) Conversion to hours of employment.--The 
                Secretary of Health and Human Services, in consultation 
                with the Secretary of the Treasury, shall establish 
                rules for the conversion of compensation to hours of 
                employment, for purposes of this subsection in the case 
                of employees that receive compensation on a salaried 
                basis, or on the basis of a commission, or other 
                contingent or bonus basis, rather than based on an 
                hourly wage.
    (c) Timing and Manner.--
            (1) In general.--Each employer that is required to make a 
        financial contribution with respect to an employee under this 
        section (other than with respect to coverage under a group 
        health plan) or a surcharge under subsection (a)(2)(B) shall 
        pay such contribution or surcharge in a form and manner, 
        specified by the Secretary of the Treasury, based upon the form 
        and manner in which employer excise taxes are required to be 
        paid under section 3111 of the Internal Revenue Code of 1986.
            (2) Non-enrolling employers.--In the case of an employee 
        who is covered under the class of enrollment of a family 
        member, the Secretary of the Treasury shall provide that the 
        financial contribution of the employer with respect to such 
        employee is paid directly or indirectly to the employer of such 
        family member.

SEC. 212. EFFECTIVE DATE.

    (a) In General.--Subject to subsection (b), the provisions of this 
subtitle shall apply with respect to periods beginning on or after 
January 1, 2010.
    (b) Additional period for small employers.--The provisions of this 
subtitle shall not apply with respect to an employer that has fewer 
than 100 employees (as determined by the Secretary of the Treasury in 
consultation with the Secretary of Health and Human Services) for 
periods beginning before January 1, 2012.
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