Medicare-based eligibility and benefits for individuals with a 9/11 disaster-connected health condition

(a)

In general

Title XVIII of the Social Security Act is amended by inserting after section 1808 the following new section:

1809.

Benefits for individuals with a 9/11 disaster-connected health condition

(a)

In general

Every 9/11 impacted individual (as defined in subsection (b)(1)(A)) who has a 9/11 disaster-connected health condition (as defined in subsection (b)(2))— (1)is entitled to 9/11-related benefits (as defined in subsection (c)(1)) under this title without payment of any premium; and (2)if the individual is not otherwise entitled to benefits under part A (or enrolled under part B), is eligible to enroll under subsection (d) for benefits under parts A, B, and D that are in addition to the 9/11-related benefits provided under paragraph (1).

Paragraph (1) shall apply regardless of whether or not the individual is otherwise entitled to benefits under part A, B, or D. Paragraph (2) shall apply regardless of whether the individual is covered under a group health plan or otherwise has other health insurance or benefits coverage.

(b)

Eligibility

(1)

9/11 impacted individual defined

(A)

In general

For purposes of this section, the term 9/11 impacted individual means any of the following: (i)

Emergency services or rescue and recovery personnel

Any emergency services or rescue and recovery personnel who responded to the 9/11 New York terrorist attacks at any time during the period beginning on September 11, 2001, and ending on August 31, 2002. (ii)

Individuals exposed to hazardous substances, pollutants, or contaminants

Any individual exposed in New York City to hazardous substances, pollutants, or contaminants released from the collapse of the World Trade Center that occurred in the 9/11 New York terrorist attacks or from the fires that occurred, or from the handling of resulting debris, thereafter. (iii)

Other individuals

Any other individual whom the Secretary determines to be appropriate. (B)

Emergency services or rescue and recovery personnel included

For purposes of this paragraph, the term emergency services personnel or rescue and recovery personnel includes any of the following: (i)A Federal, State, or city employee who responded to the 9/11 New York terrorist attacks. (ii)An individual who, as a worker or volunteer, was involved in clean-up, repair, or infrastructure restoration activities related to the 9/11 New York terrorist attacks. (iii)An individual participating in a search and rescue team, or who assisted in the recovery of human remains, after the 9/11 New York terrorist attacks. (iv)Any other relief or rescue worker who the Secretary determines to be appropriate. (C)

Presumption of exposure to hazardous substances, pollutants, or contaminants

(i)

In general

An individual shall be treated as described in subparagraph (A)(ii) if the individual resided, owned a business, was employed, or attended school, child care, or adult day care in a building that was exposed to hazardous substances, pollutants, or contaminants released from the collapse of the World Trade Center that occurred during such attacks on or after September 11, 2001 or from the fires that occurred, or from the handling of resulting debris, thereafter. (ii)

Treatment of buildings

For purposes of clause (i), any building in Manhattan, Brooklyn, Queens, Staten Island, or Northern New Jersey (as delineated by the Secretary) shall be treated as being described in such clause if there is evidence that the building was exposed to hazardous substances, pollutants, or contaminants released from the collapse of the World Trade Center or from the fires that occurred thereafter at any time during the period beginning on September 11, 2001, and ending on December 31, 2001. (2)

9/11 disaster-connected health condition defined

(A)

In general

For purposes of this section, the term 9/11 disaster-connected health condition means an adverse health condition (including the exacerbation of a pre-existing health condition), which also may be an adverse mental health condition, that, in the judgment of a qualified medical practitioner (including a therapist in the case of an adverse mental health condition), can reasonably be considered to be associated with exposure to the 9/11 New York terrorist attacks. (B)

9/11 New York terrorist attacks defined

For purposes of this section, the term 9/11 New York terrorist attacks means the terrorist attacks that occurred on September 11, 2001, in New York City, New York. (C)

Treatment of adverse mental health condition

For purposes of subparagraph (A), an individual shall be considered to have a 9/11 disaster-connected health condition if the individual has an adverse emotional or psychological health impact that— (i)has been formally diagnosed by a qualified medical practitioner or therapist; and (ii)can be reasonably considered, in the judgment of such practitioner or therapist, to be associated with exposure to the 9/11 New York terrorist attacks. (3)

Criteria

Not later than 30 days after the date of establishment of the Consortium established under section 3 of the 9/11 Comprehensive Health Benefits Act of 2006, the Secretary, in consultation with such Consortium, shall initially develop standardized criteria for medical practitioners to consult with for assistance in their determination of whether an individual has a 9/11 disaster-connected health condition consistent with this subsection. The Secretary shall periodically review such criteria and may, from time to time and in consultation with the Consortium, modify such criteria as the Secretary determines appropriate. (4)

Appeals process

The Secretary shall specify a process for the appeal of a determination that an individual is not eligible for benefits under this section. Such process shall be consistent with the process under section 1869 for the appeal of a determination that an individual is entitled to benefits under parts A and B. (5)

Treatment of nonresidents and undocumented aliens

Nothing in this section shall be construed as making an individual ineligible for benefits under this section because the individual is not a resident of New York or the United States or because the individual is an alien or is not authorized to reside in the United States. Nothing in this paragraph shall be construed to provide for any benefits under this title for items and services furnished outside the United States, except as may otherwise be authorized under this title. (c)

9/11-related benefits defined

(1)

In general

For purposes of this section, the term 9/11-related benefits means benefits under parts A, B, and D for the treatment of any 9/11 disaster-related health condition, subject to the following modifications with respect to such treatment: (A)

No cost-sharing

No deductibles, coinsurance, copayments, or other cost-sharing shall be applicable. (B)

Elimination of day or dollar limitations

Any day or dollar limitations on coverage with respect to such treatment, including such limitations under sections 1812, 1833(g), and 1860D–2(b)(3), shall not be applicable. (2)

Entitlement without premiums

An individual entitled to 9/11-related benefits under this section is deemed to be entitled to benefits under parts A, B, and D with respect to such 9/11-related benefits without requirement for payment for any premium. The entitlement to such benefits shall begin on the date that the individual is determined to be eligible for such benefits, but in no case before the date of the enactment of this section. (3)

Relation to part C

Except in the case of an individual enrolled under part A or B under subsection (d) or otherwise, 9/11-related benefits are not available through enrollment in a Medicare Advantage plan under part C. (d)

Enrollment option for additional medicare benefits

(1)

In general

With respect to the enrollment option described in subsection (a)(2), an eligible individual may enroll under part A or B (or both), and under part D, in a manner and form prescribed in regulations. Such regulations shall provide for continuous open enrollment for such individuals. (2)

Premiums

(A)

In general

Except as provided in this paragraph, the premium for enrollment under part A under this subsection shall be the same as the premium established under subsection (d) of section 1818 for enrollment under such section, subject to any reduction provided under such subsection. (B)

Elimination of premium based on quarters of coverage

No premium shall be imposed under subparagraph (A) in the case of an individual if the individual would be entitled, based solely on the number of quarters of coverage under title II, to benefits under part A under section 226(a), 226(b), or 226A. (C)

No late enrollment penalty

An individual enrolling under part A, B, or D under this subsection shall not be subject to any late enrollment penalty, including under sections 1839(b) and 1860D–13(b). (3)

Enrollment under parts b and d

For purposes of parts B and D, in the case of an individual eligible to enroll under this subsection, the individual’s initial enrollment period under such parts shall be treated as beginning on the date of such eligibility and having no end date. (4)

Coverage

(A)

In general

The period (in this subsection referred to as a coverage period) during which an individual enrolled under this subsection is entitled to benefits under the respective part shall begin on the first day of the first month that begins at least 15 days after the date of the individual’s enrollment under such part. (B)

Termination

An individual's coverage period under this subsection under a part shall continue until the individual's enrollment under such part is terminated as follows: (i)As of the month following the month in which the individual files notice that the individual no longer wishes to be enrolled in the part under this subsection. (ii)For nonpayment of any applicable premiums under such part. (iii)With respect to coverage under part D, as of the month in which the individual is neither enrolled in part A nor enrolled in part B.

The termination of a coverage period under clause (ii) shall take effect on a date determined under regulations, which may be determined so as to provide a grace period in which overdue premiums may be paid and coverage continued. The grace period determined under the preceding sentence shall not exceed 90 days; except that it may be extended to not to exceed 180 days in any case where the Secretary determines that there was good cause for failure to pay the overdue premiums within such 90-day period.

(e)

Payment-related provisions

(1)

Authorization of appropriations to cover additional benefits

There are authorized to be appropriated to the Federal Hospital Insurance Trust Fund and the Federal Supplementary Medical Insurance Trust Fund, and the Medicare Prescription Drug Account in such Trust Fund, such sums as may be necessary to cover the costs under such Trust Funds and Account of providing benefits under this section, net of any premiums paid with respect to such benefits under subsection (d). Nothing in this section shall be construed as conditioning the provision of benefits under this section upon the making of such appropriations. (2)

Reimbursement of prescription drug plans and MA plans for 9/11-related benefits

With respect to benefits under a prescription drug plan under part D or under a Medicare Advantage plan under part C, the Secretary shall provide for reimbursement to the plan from the appropriate Trust Funds and Accounts under this title for the cost of 9/11-related benefits provided under the plan under this section, including costs related to the application of the benefit modifications described in subsection (c)(1).

(b)

Medicare secondary payor for 9/11-related coverage; no discrimination against individuals in employment-based health insurance

Section 1862(b) of such Act (42 U.S.C. 1395y(b)) is amended— (1)by redesignating subparagraph (D) of paragraph (1) as subparagraph (G) and by moving it to the end of such paragraph; (2)by inserting after subparagraph (C) of paragraph (1) the following new subparagraph:

(D)

Individuals with a 9/11-disaster connected health condition

(i)

In general

A group health plan, individual health insurance coverage, or any other form of health benefits coverage— (I)may not take into account that an individual who is covered under the plan or coverage is entitled to 9/11-related benefits under this title under section 1809; and (II)shall provide that any covered individual shall be entitled to the same benefits under the plan with respect to treatment of a 9/11 disaster-related health condition (as defined in section 1809(b)(2)(A)) under the same conditions as any similarly situated individual who is not so entitled. (ii)

Enforcement

(I)

Civil money penalties

Any plan or coverage that violates clause (i) is subject to a civil money penalty of not to exceed $25,000 for each such violation. The provisions of section 1128A (other than subsections (a) and (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). (II)

Private cause of action

An individual adversely affected by a violation of clause (i) may bring a private cause of action to enjoin the violation and to obtain damages (which shall be in an amount double the amount otherwise provided and may include reasonable attorney’s fees) resulting from such a violation.

; and

(3)in the second sentence of paragraph (2)(A), by inserting after large group health plan the following: or other coverage described in paragraph (1)(D)(i); (4)in paragraph (2)(B)(vi), by inserting or other coverage described in paragraph (1)(D)(i) after employer group health plan; and (5)in paragraph (3)(C)— (A)in the heading by inserting

or other coverage

after

large group health plan

; and (B)by inserting or other coverage described in paragraph (1)(D)(i) after large group health plan. (c)

Prohibition of discrimination in workers’ compensation and employment

(1)

Workers’ compensation

(A)

Discrimination prohibited

A workers’ compensation law or plan may not discriminate against an individual by virtue of the individual’s entitlement to benefits under title XVIII of the Social Security Act under section 1809 of such Act, as inserted by subsection (a). (B)

Private cause of action

An individual adversely affected by a violation of subparagraph (A) may bring a private cause of action to enjoin the violation and to obtain damages (which shall be in an amount double the amount such individual was otherwise entitled to under such law or plan and may include reasonable attorney’s fees) resulting from such a violation. (2)

Employment

(A)

Discrimination prohibited

An employer may not discriminate against an individual in regards to hiring, advancement, compensation, or other terms, conditions, and privileges of employment by virtue of the individual’s entitlement to benefits under title XVIII of the Social Security Act under section 1809 of such Act, as inserted by subsection (a). (B)

Enforcement

The powers, remedies, and procedures provided in sections 705, 706, 707, 709, 710, and 711 of the Civil Rights Act of 1964 (42 U.S.C. 2000e–4 et seq.) to the Equal Employment Opportunity Commission, the Attorney General, or any person, alleging a violation of title VII of that Act (42 U.S.C. 2000e et seq.) shall be the powers, remedies, and procedures this subsection provides to the Equal Employment Opportunity Commission, the Attorney General, or any person, respectively, alleging discrimination in violation of subparagraph (A), except that any employer found by a court to have intentionally engaged in discrimination in violation of subparagraph (A) shall be additionally subject to a civil penalty of not to exceed $25,000 for each such violation. (C)

Employer defined

As used in this paragraph, the term employer has the same meaning given that term in section 101(5) of the Americans with Disabilities Act of 1990 (42 U.S.C. 12112(5)). (d)

Conforming amendments

(1)

Application of enrollment correction provisions

Section 1837(h) of the Social Security Act (42 U.S.C. 1395p(h)) is amended by inserting or section 1809(d) after 1818. (2)

Conforming reference

The second sentence of section 1818(a) of such Act (42 U.S.C. 1395i–2(a)) is amended by inserting or 1809(d) after 1818A . (3)

Application of QMB provisions

Section 1905(p)(1)(A) of such Act (42 U.S.C. 1396d(p)(1)(A)) is amended by inserting or 1809(d) after 1818.