1.Short title; table of
contents
(a)This Act may be cited as the AmeriCare Health Care Act of
2009
.
(b)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—Entitlement Verification System
Sec. 2251. Requirement for entitlement verification
system.
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.
<enum>I</enum><header>Health Care
Eligibility and Benefits</header>
<section id="H3824EC62B0734EB18823F78019A300B6"><enum>101.</enum><header>Eligibility and
benefits</header>
<subsection id="H80B38ED45D174573008083CFDE2C813F"><enum>(a)</enum><header>In
general</header><text display-inline="yes-display-inline">The Social Security
Act is amended by adding at the end the following new title:</text>
<quoted-block display-inline="no-display-inline" id="H7C594822C2304AD7A0CEE4111718749B" style="OLC">
<title id="H6A4DB94219A84D0BA9D524D99597C400"><enum>XXII</enum><header>AmeriCare
Health Benefits</header>
<part id="HC69FC9E3B13E4BDAA1731C03FD94E044"><enum>A</enum><header>Eligibility</header>
<section id="H1D94E277D0A14BDDB677C03148528EAA"><enum>2201.</enum><header>Eligibility</header>
<subsection id="H264C10A146064CB0A96230900081B336"><enum>(a)</enum><header>Universal
eligibility for residents</header>
<paragraph id="HF07F14E44968490298CEF42838BA08BC"><enum>(1)</enum><header>In
general</header><text>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.</text>
</paragraph><paragraph id="HE3D4E052C0834F42B8D1A5D2F129AAD2"><enum>(2)</enum><header>Effective date
for benefits</header><text>This title shall apply to items and services
furnished on or after January 1, 2011.</text>
</paragraph></subsection><subsection id="H2CBA257E65F3449AA3EB6F631FA00086"><enum>(b)</enum><header>Special
eligibility groups</header><text>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:</text>
<paragraph id="H1162D245849B41109088B33E48221322"><enum>(1)</enum><text>Children (as
defined in section 2261(a)(1)).</text>
</paragraph><paragraph id="H6C4C4B41F1674AA488541136D21EEBE3"><enum>(2)</enum><text>Low-income
individuals (as defined in section 2261(a)(2)).</text>
</paragraph><paragraph id="H76CCE813ED8D4AD8005CD420F502C01D"><enum>(3)</enum><text>Pregnant women (as
defined in section 2261(a)(3)).</text>
</paragraph></subsection><subsection id="H5BC1F77DEEC242B2B3C0A27C7656F6E7"><enum>(c)</enum><header>Reciprocal
coverage of nonresidents</header><text>An individual who—</text>
<paragraph id="H991B7A29CCCC465EAB2510BFDA4B8F39"><enum>(1)</enum><text>is not a resident
of the United States,</text>
</paragraph><paragraph id="HFCE5945477624E67A26FF3FE3F00DCB6"><enum>(2)</enum><text>is in the United
States, and</text>
</paragraph><paragraph id="H97D57B61B66A41E2943C13003CDF28ED"><enum>(3)</enum><text>is a national of a
foreign state which provides health benefits to nationals of the United States
who are nonresidents in that state,</text>
</paragraph><continuation-text continuation-text-level="subsection">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.</continuation-text></subsection></section><section id="H079D0AB8C5B64F66813621B4B225BCC"><enum>2202.</enum><header>Enrollment and
AmeriCare Cards</header>
<subsection id="H326D4F7220994406910924604EC84B18"><enum>(a)</enum><header>Enrollment</header><text display-inline="yes-display-inline">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.</text>
</subsection><subsection id="H32FCEC34F20744C9B35467C9DF4455BD"><enum>(b)</enum><header>Classes of
enrollment</header><text display-inline="yes-display-inline">The mechanism
under subsection (a) shall provide for individuals to be enrolled on the basis
of the following classes of enrollment:</text>
<paragraph id="H5543B0690911498593D68512F68F4DC"><enum>(1)</enum><text display-inline="yes-display-inline">Coverage only of an individual.</text>
</paragraph><paragraph id="H2879DDAE89264933BA0278E3C65F5332"><enum>(2)</enum><text>Coverage of a
married couple without children.</text>
</paragraph><paragraph id="H75B2BEA05E5D4779BDA68D68FE862F3B"><enum>(3)</enum><text>Coverage of an
unmarried individual and one or more children.</text>
</paragraph><paragraph id="H5693A6957892402490120740FE8D9725"><enum>(4)</enum><text>Coverage of a
married couple and one or more children.</text>
</paragraph></subsection><subsection id="H4F2D14A9F3594CD28EB71716929BEA19"><enum>(c)</enum><header>Enrollment at
birth</header><text display-inline="yes-display-inline">The mechanism under
subsection (a) shall include a process for the automatic enrollment of
individuals at the time of birth in the United States.</text>
</subsection><subsection id="H364535520FA5433AA83EFBA41120F70"><enum>(d)</enum><header>Opt for Those
Covered Under Group Health Plan</header><text display-inline="yes-display-inline">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.</text>
</subsection></section></part><part id="HD204DA4EE7CE4D8799000766832FC728"><enum>B</enum><header>Benefits</header>
<section id="H0E30C63F8E764D18BFF8AB3F17B34048"><enum>2221.</enum><header>Scope of
benefits</header>
<subsection id="H41E35586B33F46D1A20858CB72001B6B"><enum>(a)</enum><header>In
general</header><text>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.</text>
</subsection><subsection id="HBE82D2B25AEC4C39BAC4AB65A0635306"><enum>(b)</enum><header>Change in the
cost-sharing</header>
<paragraph id="H2ACA7529BB6A44158660F39EA66B1401"><enum>(1)</enum><header>Deductible</header><text>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).</text>
</paragraph><paragraph id="HE596101762674EA18D168E38BEF251FA"><enum>(2)</enum><header>Coinsurance</header><text>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.</text>
</paragraph><paragraph id="H9B6D9268DEA44F78A7FEA06033553156"><enum>(3)</enum><header>Limit on
out-of-pocket expenses and total expenses</header>
<subparagraph id="HA697528AEEED45DC8C7EDC293FB7178F"><enum>(A)</enum><header>Limitation on
cost-sharing</header><text>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.</text>
</subparagraph><subparagraph id="HBA29E5A7FFC2494D85C0435EDC7000E2"><enum>(B)</enum><header>Limitation on
premiums and cost-sharing for certain individuals based on income</header>
<clause id="H8B193011F86A4167A32FCC5CA434FBD6"><enum>(i)</enum><header>Income between
200 and 300 percent of poverty line</header><text>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—</text>
<subclause id="HD6EEB1CBA515400B977EFDF57843A7A0"><enum>(I)</enum><text>no additional
premiums shall be imposed for remaining months in the year; and</text>
</subclause><subclause id="HCF71905205E6405D8F4FEAD0714CFF9C"><enum>(II)</enum><text>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.</text>
</subclause></clause><clause id="HB7F9EFAC423845F08EA23495E90080FF"><enum>(ii)</enum><header>Income between
300 and 500 percent of poverty line</header><text>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—</text>
<subclause id="H13E59D8340894D7EA909E62B5BDE1CF1"><enum>(I)</enum><text>no additional
premiums shall be imposed for remaining months in the year; and</text>
</subclause><subclause id="H037E3AC1E00F4E398CF5B19395BB45F8"><enum>(II)</enum><text>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.</text>
</subclause></clause></subparagraph><subparagraph id="H640FCB5D965849029570B8A30026EADE"><enum>(C)</enum><header>Counting all
expenses for premiums, deductibles and coinsurance without regard to true
out-of-pocket costs</header><text>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.</text>
</subparagraph></paragraph><paragraph id="H17CF631F6BB54AC7878BBB83BD2FC5CF"><enum>(4)</enum><header>Indexing dollar
amounts by cpi</header><text>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 2009 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.</text>
</paragraph></subsection><subsection id="H59260882FD9D4906A03C828FB8D700A5"><enum>(c)</enum><header>Prescription
drugs</header><text>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 2008.</text>
</subsection><subsection id="H07DCA1BC2F4D4C7082D7D880048701C6"><enum>(d)</enum><header>Children</header>
<paragraph id="H9BF9107504254AB7B2FBF833961900E8"><enum>(1)</enum><header>No deductibles
or coinsurance</header><text>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)).</text>
</paragraph><paragraph id="H6F2D7CCC5E6D465D8388004238BC6341"><enum>(2)</enum><header>Additional
preventive benefits</header>
<subparagraph id="HCF435D0C83BA439D86EDEF5B00D3BBD4"><enum>(A)</enum><header>In
general</header><text>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:</text>
<clause id="H34C03750F3B5429EBDA733921544A51F"><enum>(i)</enum><text>Newborn and
well-baby care, including normal newborn care and pediatrician services for
high-risk deliveries.</text>
</clause><clause id="H9DA1F661AA7E4B1E8D05D138677C6ED2"><enum>(ii)</enum><text>Well-child care,
including routine office visits, routine immunizations (including the vaccine
itself), routine laboratory tests, and preventive dental care.</text>
</clause></subparagraph><subparagraph id="H409574D7476C48D7A5D790CA646E3C74"><enum>(B)</enum><header>Periodicity
schedule</header><text>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.</text>
</subparagraph></paragraph><paragraph id="H29437AD885EC4D799F9E0153B2A7848"><enum>(3)</enum><header>Coverage of
epsdt</header><text>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).</text>
</paragraph><paragraph id="HC676494E67A64E678B62267CA5CDB6AB"><enum>(4)</enum><header>Other additional
services for children</header><text>For children, benefits also shall be
available under this title for the following:</text>
<subparagraph id="H320750612E87492C9EBDFE4CB7E15E9B"><enum>(A)</enum><text>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)).</text>
</subparagraph><subparagraph id="HA65891779F244D00B6DFB7CF3719409E"><enum>(B)</enum><text>Eyeglasses and
hearing aids, and examinations therefor.</text>
</subparagraph></paragraph></subsection><subsection id="H4AFBA52718744A04813812A5877C629C"><enum>(e)</enum><header>Pregnancy-related
services</header><text>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:</text>
<paragraph id="HB545444DDE20426A8F39767D91A712A9"><enum>(1)</enum><text>Prenatal care,
including care for all complications of pregnancy.</text>
</paragraph><paragraph id="H37B9E2A3D33F4B5BBFBE6CFFFDD4095"><enum>(2)</enum><text>Inpatient labor and
delivery services.</text>
</paragraph><paragraph id="H0EC78EBDF92A441A9DDE7CD8455E87B9"><enum>(3)</enum><text>Postnatal
care.</text>
</paragraph></subsection><subsection id="HBD3C34A064B149C6B92C93AEC7AE6900"><enum>(f)</enum><header>Lower-income
individuals</header>
<paragraph id="H9BFAA6367A8141F6986743DD329E833"><enum>(1)</enum><header>Limitations on
deductibles and coinsurance</header>
<subparagraph id="H65070320061F41909E98AA2FD9F33CD"><enum>(A)</enum><header>None for
low-income individuals</header><text>In the case of a low-income individual,
there shall be no deductible or coinsurance under this title.</text>
</subparagraph><subparagraph id="H134BC110869B4DD9A9DCA4B1B9D8C2C2"><enum>(B)</enum><header>Phase-in for
other lower-income individuals</header><text>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—</text>
<clause id="HDDFD8B64F3F04779B46C74650004A0C0"><enum>(i)</enum><text>the excess of the
applicable modified gross income over the poverty level, bears to</text>
</clause><clause id="H79FBC5CF23B5479CB64380917D3CDB31"><enum>(ii)</enum><text>the poverty
level.</text>
</clause><continuation-text continuation-text-level="subparagraph">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.</continuation-text></subparagraph></paragraph><paragraph id="HF58FAA0A78E341648BDF2F429D65BE0"><enum>(2)</enum><header>Additional
benefits for low-income individuals</header><text>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:</text>
<subparagraph id="H70C7C2AAB8034FB2A261F52281F4C983"><enum>(A)</enum><text>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)).</text>
</subparagraph><subparagraph id="H99ACDA9433204528A4DD671F886E44F"><enum>(B)</enum><text>Eyeglasses and
hearing aids and examinations therefor.</text>
</subparagraph></paragraph></subsection><subsection id="H0EBC121ACCBC4041BCBC4D12DAEE6671"><enum>(g)</enum><header>Preventive
benefits</header><text>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.</text>
</subsection><subsection id="HB0E94E2B342F44C4A34495C14C65FD38"><enum>(h)</enum><header>Mental health
parity and substance abuse benefits</header><text>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.</text>
</subsection><subsection id="H1BFD053D9CBF4939AAC822054E8C61A3"><enum>(i)</enum><header>Family planning
services</header><text>Benefits shall be made available under this title for
family planning services.</text>
</subsection><subsection id="HF283A8BE435C4C5700BE86367660953B"><enum>(j)</enum><header>Conforming
medicare benefits</header><text>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.</text>
</subsection><subsection id="HD8471C8B893045A8B8DD46905CCAED00"><enum>(k)</enum><header>Enrollment in
health plans</header><text>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.</text>
</subsection></section><section id="HA5E1AFAA2C9845588F43B520D6BB12F"><enum>2222.</enum><header>Exclusions</header>
<subsection id="HABB8F1CC5DE84EBBA1E3CD723EF3602"><enum>(a)</enum><header>In
general</header><text>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.</text>
</subsection><subsection id="H34B8AAED2C154F068FDD0408628D1E99"><enum>(b)</enum><header>Benefits
exception</header>
<paragraph id="H4622900443B945D0B88379261412D02F"><enum>(1)</enum><header>Children’s
services</header><text>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).</text>
</paragraph><paragraph id="H8CED89E0C6E94DF19D5D475800C0FDED"><enum>(2)</enum><header>Treatment of
eyeglasses and hearing aids for children and low-income
individuals</header><text>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.</text>
</paragraph></subsection><subsection id="HC37FC3B186F9468A9DBEED2B1C120085"><enum>(c)</enum><header>Coordination of
payments</header>
<paragraph id="H5F463E4A53CE427DBDC3C5EE8D3648C"><enum>(1)</enum><header>Primary to group
health plans</header><text>Section 1862(b)(1) (relating to requirements of
group health plans) shall not apply under this title.</text>
</paragraph><paragraph id="H69D707C793254A1DBBAE168E9B0791F7"><enum>(2)</enum><header>Secondary to
medicare</header><text>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.</text>
</paragraph></subsection></section></part><part id="HB86C9D1628C648DBB400BA7022012D00"><enum>C</enum><header>Payment for
Benefits and Financing</header>
<section id="H643C2EE2A0D749AEAFD6D1CAEDCDF71B"><enum>2241.</enum><header>Payments for
benefits</header>
<subsection id="HB6C347300916422E843EF8DB315939A4"><enum>(a)</enum><header>In
general</header><text>Except as otherwise provided in this section and in
section 2221—</text>
<paragraph id="H64D199E047AF43D3BB73D1517922EBBA"><enum>(1)</enum><text>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</text>
</paragraph><paragraph id="HCBB6CB22B4D3414A8DC9F61491C34517"><enum>(2)</enum><text>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.</text>
</paragraph></subsection><subsection id="H678B7339A3904EAF80014707D43B5F93"><enum>(b)</enum><header>No extra billing
permitted</header><text>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).</text>
</subsection><subsection id="H0C660D36E0154A5BAB64A2AC1996DF70"><enum>(c)</enum><header>Adjustment of
payments</header>
<paragraph id="HF71C8F0CA0754E9398EDEFF77BAC69BA"><enum>(1)</enum><header>Establishment of
new drgs and weights</header><text>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.</text>
</paragraph><paragraph id="H2E2E1F1597F1451FB200F6D49D2BBD27"><enum>(2)</enum><header>Payment for
obstetrical services</header>
<subparagraph id="H3E8C97A630E646AC943405EAF19620D0"><enum>(A)</enum><header>Global
fee</header><text>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.</text>
</subparagraph><subparagraph id="HA206FD715E634EF0A26EA93D5D7CEF98"><enum>(B)</enum><header>Bonus for early
presentation</header><text>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.</text>
</subparagraph></paragraph></subsection><subsection id="H71BAB32DCBBF4CB9955C003EB442A0B9"><enum>(d)</enum><header>Conditions of
and limitations on payments</header><text>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.</text>
</subsection><subsection id="H3538EB6ACE6347DE905B0081EBCCAD5"><enum>(e)</enum><header>Use of trust
fund</header><text>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.</text>
</subsection><subsection id="HE51A2E70EF1841EF80250021585C435C"><enum>(f)</enum><header>Payment for
outpatient prescription drugs and biologicals</header><text>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.</text>
</subsection></section><section id="HB297697576D7472494568091D65E77A5"><enum>2242.</enum><header>AmeriCare
trust fund</header>
<subsection id="HCF83A31205824E6699B262061EF8E296"><enum>(a)</enum><header>Establishment</header>
<paragraph display-inline="no-display-inline" id="HBB4D5204BD5A4E24BF41B200F25495FE"><enum>(1)</enum><text>There is hereby
created on the books of the Treasury of the United States a trust fund to be
known as the <quote>AmeriCare Trust Fund</quote> (in this section referred to
as the <quote>Trust Fund</quote>). 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).</text>
</paragraph><paragraph id="H46F7CF811CE94FFF884C776788F85230"><enum>(2)</enum><text>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 2009. 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.</text>
</paragraph></subsection><subsection id="HB1E9B7AE135E40C590FEF89DD2A0B847"><enum>(b)</enum><header>Incorporation of
provisions</header>
<paragraph id="H6EAC2097576842468DA8B923BDD3E5D7"><enum>(1)</enum><header>In
general</header><text>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.</text>
</paragraph><paragraph id="H3356C4EA2B574B8E9280726D5D6CAD68"><enum>(2)</enum><header>Exceptions</header><text>In
applying paragraph (1)—</text>
<subparagraph id="H53BC08C212AF4D7295DBEA088F99F7EB"><enum>(A)</enum><text>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</text>
</subparagraph><subparagraph id="HDB2B957234424BEE8356890500A25751"><enum>(B)</enum><text>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.</text>
</subparagraph></paragraph></subsection></section></part><part id="H60740492C2514FC8863CDB00FFFB3FC"><enum>D</enum><header>Entitlement
Verification System</header>
<section id="H7F085EDDED55465A822430EE67444E9F"><enum>2251.</enum><header>Requirement
for entitlement verification system</header>
<subsection id="H64EF1BCCBDD94C2BA9F00E85804DB85"><enum>(a)</enum><header>In
general</header>
<paragraph id="H789C856E5D414A9D9114DB702116520"><enum>(1)</enum><header>Requirement</header><text>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.</text>
</paragraph><paragraph id="H1F18D5762F92499196EA002DBBEA0048"><enum>(2)</enum><header>Deadline for
application of requirement</header><text>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).</text>
</paragraph></subsection><subsection id="H9963C995DB3749EA9CCD0278ABC21DAF"><enum>(b)</enum><header>Standards for
entitlement verification systems</header>
<paragraph id="HADA3D601D1D44C24ACC5B79C4710EDFF"><enum>(1)</enum><header>In
general</header><text>The Secretary shall establish standards consistent with
this subsection respecting the requirements for certification of entitlement
verification systems.</text>
</paragraph><paragraph id="H376708E4C9FD495BBE8EB501AD3135F9"><enum>(2)</enum><header>Information
available</header><text>Such standards shall require a system to provide
information, with respect to individuals, concerning the following:</text>
<subparagraph id="HF06C9DBD6CB34272B22565DFECECAE4B"><enum>(A)</enum><text>The specific
benefits to which the individual is entitled under the plan.</text>
</subparagraph><subparagraph id="H90636B731AA34C4EB32D012411A9A28E"><enum>(B)</enum><text>Current status of
the individual with respect to fulfillment of deductibles, coinsurance, and
out-of-pocket limits on cost-sharing.</text>
</subparagraph><subparagraph id="H18E786E280FA4C778027D4F02E6C24A0"><enum>(C)</enum><text>Restrictions on
providers who may provide covered services, including utilization controls
(such as preadmission certification).</text>
</subparagraph></paragraph><paragraph id="HC98CCA97FC0E4B07844B05B5C89D6946"><enum>(3)</enum><header>Form of
inquiry</header><text>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.</text>
</paragraph><paragraph id="HE15E41E5F4EF44F58192C2C2D3BC7EFB"><enum>(4)</enum><header>Form of
response</header><text>Each such system shall be capable of responding to such
inquiries under this subsection in a variety of electronic and other forms,
including—</text>
<subparagraph id="H6FB6FBD7011D46C59025D85D9BF5C0A8"><enum>(A)</enum><text>through modem
transmission of information,</text>
</subparagraph><subparagraph id="H2F50AE1F7778479AA9C8001773897636"><enum>(B)</enum><text>through computer
synthesized voice communication, and</text>
</subparagraph><subparagraph id="HB9C4C8EAA991415EA805CB58CB4C731E"><enum>(C)</enum><text>through
transmission of information to a facsimile (fax) machine.</text>
</subparagraph><continuation-text continuation-text-level="paragraph">The system
shall also provide, for an additional fee, for the response to inquiries in a
nonelectronic form.</continuation-text></paragraph><paragraph id="HA2C1B8EC91BE4B66811657C6EDCBE914"><enum>(5)</enum><header>Limitation on
fees</header><text>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.</text>
</paragraph><paragraph id="HAD903FD9BA50429D84509F93A5CBFB7E"><enum>(6)</enum><header>Website
availability to providers</header><text>The Secretary shall establish and
maintain a website through which—</text>
<subparagraph id="H7C0C3A5C69684AB29E00BDC857E1EFAF"><enum>(A)</enum><text>health service
providers may make inquiries, and receive responses, with respect to the
eligibility and benefits of an individual under plans; and</text>
</subparagraph><subparagraph id="HB6B9532BF4AB4C6FBE615CCD2D2FF5F9"><enum>(B)</enum><text>AmeriCare
supplemental plans may make inquiries, and receive responses, to determine the
liability of other plans for the provision or payment of benefits.</text>
</subparagraph></paragraph><paragraph id="H094BB3503FC64EF985C0F7D6C0DCF71B"><enum>(7)</enum><header>Deadline</header><text>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.</text>
</paragraph></subsection><subsection id="H7FD6B5D8239B46CDA87311093E94516D"><enum>(c)</enum><header>Health service
provider defined</header><text>In this section, the term <term>health service
provider</term> includes a provider of services (as defined in section
1861(u)), physician, supplier, and other entity furnishing health care
services.</text>
</subsection></section></part><part id="H781D26D1135E4E9EA63036869B8C78A6"><enum>E</enum><header>General
Provisions</header>
<section id="H3A40F5A755DC46359420ADF74CD45598"><enum>2261.</enum><header>Definitions
relating to beneficiaries and income</header>
<subsection id="H29A927AB2DAE46059CA3A937F47B4D9E"><enum>(a)</enum><header>Terms relating
to beneficiaries</header><text>In this title:</text>
<paragraph id="H2C8F27DA7BE24B37BF57ECB819D0964D"><enum>(1)</enum><header>Child</header><text>The
term <term>child</term> means an individual who throughout a month has not
attained 24 years of age.</text>
</paragraph><paragraph id="H60F20661C9634EFB87B7E410ED9E302F"><enum>(2)</enum><header>Low-income
individual</header><text>The term <term>low-income individual</term> 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.</text>
</paragraph><paragraph id="H5010F0238C824B6B87ABCD93081BFAEC"><enum>(3)</enum><header>Pregnant
woman</header><text>The term <term>pregnant woman</term> 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.</text>
</paragraph></subsection><subsection id="H8C124676235544F289B9C31F5C8F76A9"><enum>(b)</enum><header>Terms relating
to income</header><text>In this title:</text>
<paragraph id="H9978106BFF134B3882933EFCD050CB14"><enum>(1)</enum><header>Applicable
modified gross income</header>
<subparagraph id="HA53A0F37C7B847B78BE48AF240711AF"><enum>(A)</enum><header>In
general</header><text>Except as provided in this paragraph, the term
<term>applicable modified gross income</term> 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 2009) 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.</text>
</subparagraph><subparagraph id="HAAE93378E5964639975F8865CE86FA46"><enum>(B)</enum><header>Application of
current year modified gross income</header>
<clause id="HEEE8965B4642469D83A05B5EA6A7EAAF"><enum>(i)</enum><header>In
general</header><text>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.</text>
</clause><clause id="H88774AB6707841C8A4A390B1AD6289C2"><enum>(ii)</enum><header>Limitation on
application</header><text>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.</text>
</clause><clause id="HA4AEB32E1FB048378928AB6D7F9188B6"><enum>(iii)</enum><header>Requirement
for return</header><text>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.</text>
</clause><clause id="H217A780D67E04A049804C658A9D5AF78"><enum>(iv)</enum><header>Collection for
overpayments</header><text>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.</text>
</clause></subparagraph><subparagraph id="H9D468E6B4FC44FA396D0071654C9D45"><enum>(C)</enum><header>Transmittal of
information</header><text>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.</text>
</subparagraph></paragraph><paragraph id="H20FBF8CBBBEC4AD49F33E4303E6EB0E8"><enum>(2)</enum><header>Poverty
level</header><text>The term <term>poverty level</term> 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.</text>
</paragraph></subsection></section><section id="HA867F69F9DE340B1B3EA98BB921D527"><enum>2262.</enum><header>Incorporation
of certain medicare provisions and other provisions</header>
<subsection id="H24BD3808E5DC46108CDD366178BC2871"><enum>(a)</enum><header>Use of medicare
administrative contractors</header><text>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.</text>
</subsection><subsection id="H7D3F0EA3893E4F8A824820B3822496C5"><enum>(b)</enum><header>Definitions</header>
<paragraph id="HCFC7649A1C5E47B2986710C0E8450137"><enum>(1)</enum><header>In
general</header><text>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.</text>
</paragraph><paragraph id="H48E8B7E0F50F4027A8DDFA077470004D"><enum>(2)</enum><header>State; united
states</header><subparagraph commented="no" display-inline="yes-display-inline" id="H5EBE288958CD41BD95D76C93D3CD9D60"><enum>(A)</enum><text>The
term <term>State</term> means the 50 States and includes the District of
Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the
Northern Mariana Islands.</text>
</subparagraph><subparagraph id="H5012E0369E6A40DD9EBF31005B6B7B5E" indent="up1"><enum>(B)</enum><text>The term <term>United States</term>
means all the States.</text>
</subparagraph></paragraph></subsection><subsection id="H574B703B6DD14AC09B49BBA17E5DFC91"><enum>(c)</enum><header>Certification,
provider qualification, etc</header><text>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.</text>
</subsection><subsection id="HDC797823FC2943D78D0005227847C882"><enum>(d)</enum><header>Title XI
provisions</header><text>The following provisions shall apply to this title in
the same manner as they apply to title XVIII:</text>
<paragraph id="HEB47A838594E43A4835445E84B3E7C16"><enum>(1)</enum><text>Sections 1124,
1126, and 1128 through 1128E (relating to fraud and abuse).</text>
</paragraph><paragraph id="H1683EA62D6714CC3AEAA795E619084E8"><enum>(2)</enum><text>Section 1134
(relating to nonprofit hospital philanthropy).</text>
</paragraph><paragraph id="H771BABB0EB5445BDBCC856441BED3602"><enum>(3)</enum><text>Section 1138
(relating to hospital protocols for organ procurement and standards for organ
procurement agencies).</text>
</paragraph><paragraph id="HA7F956C66C404F11A2A233EACE50F7F5"><enum>(4)</enum><text>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.</text>
</paragraph><paragraph id="H9830D67D047746BD971669068CA2996F"><enum>(5)</enum><text>Part B of title XI
(relating to peer review of the utilization and quality of health care
services).</text>
</paragraph><paragraph id="H9461E24735024EA9AF71CC67B5BA0864"><enum>(6)</enum><text>Part C of title XI
(relating to administrative simplification).</text>
</paragraph></subsection><subsection id="H6CA76DE286EB46588F37E6825CF08E63"><enum>(e)</enum><header>Other
provisions</header><text>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.</text>
</subsection></section><section id="HB7653A233592433B8B285D0800705B16"><enum>2263.</enum><header>State
maintenance of effort payments</header>
<subsection id="H5DB5A6E41BDB40E08D5378CCC9EE6349"><enum>(a)</enum><header>Condition of
coverage</header><text display-inline="yes-display-inline">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 1/12th 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 of the
AmeriCare Health Care Act of 2009.</text>
</subsection><subsection id="HDAE2451ECFA6486F8658A5A9D08CEAD6"><enum>(b)</enum><header>Maintenance of
effort amount</header>
<paragraph id="H0A79E486ED0A46B0A526B786D9700D4"><enum>(1)</enum><header>In
general</header><text>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 2008 for medical assistance for benefits described in paragraph
(2).</text>
</paragraph><paragraph id="HB6E39D38AA28431CB2183B71005CB178"><enum>(2)</enum><header>Benefits
described</header><text>The benefits described in this paragraph with respect
to State plans of a State under titles XIX and XXI are benefits which—</text>
<subparagraph id="H14203B56A81D40B4AFBFC26E8FA05892"><enum>(A)</enum><text>would be available
under this title for low-income individuals if this title had been in effect in
2008; and</text>
</subparagraph><subparagraph id="HA557D758AA914AAEA4FC31D0521B004B"><enum>(B)</enum><text>are for low-income
individuals who—</text>
<clause id="H27855123C96D41A5B913D200B26355EC"><enum>(i)</enum><text>with respect to
the State plan under title XIX, were required to be furnished medical
assistance under such title XIX; or</text>
</clause><clause id="H310F3173536548EE94BC1CD700FC5CBD"><enum>(ii)</enum><text>with respect to a
State child health plan under title XXI, were low-income children.</text>
</clause></subparagraph></paragraph></subsection></section><section id="HC16092D5E8204B04B6C95B78AA853B00"><enum>2264.</enum><header>Modification
of medicaid and other programs to avoid duplication of benefits</header>
<subsection id="H77D0FCDF77DB411599E8DA3EB6E289F"><enum>(a)</enum><header>In
general</header><text>Notwithstanding any other provision of law—</text>
<paragraph id="H58E357FAB48D43E38C1CAF8854B29B88"><enum>(1)</enum><text>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</text>
</paragraph><paragraph id="HF8744C48CD36455280FD1107103367EE"><enum>(2)</enum><text>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.</text>
</paragraph></subsection><subsection id="HF2DBBA820C1B4555BB940470A3C83512"><enum>(b)</enum><header>Review of
application to other programs</header><text>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, 2011, 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.</text>
</subsection></section><section id="HDF77D77BBF494E23BFC7CE734DFF8859"><enum>2265.</enum><header>Construction
regarding continuation of obligations under current group health plan contracts
and provision of additional benefits</header><text display-inline="no-display-inline">Nothing in this title shall be construed
as—</text>
<paragraph id="H72DE72B36ED941729E11C4CCC37CCF10"><enum>(1)</enum><text>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;</text>
</paragraph><paragraph id="HEFCE1F8E34534A83814B58E6004956B8"><enum>(2)</enum><text>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</text>
</paragraph><paragraph id="H3914D41988F54420BBD33E440506FF67"><enum>(3)</enum><text>limiting the
benefits that may be made available under a State program to residents of the
State at the expense of the State.</text>
</paragraph></section><section id="HA24BE046659B4D51941221D584FB3171"><enum>2266.</enum><header>Standards and
requirements for AmeriCare supplemental policies</header>
<subsection id="H4E151545A0274CFB8F2790B7BB32A393"><enum>(a)</enum><header>Certification
required</header>
<paragraph id="H76538E84B6D5433396682052BFAEE519"><enum>(1)</enum><header>In
general</header><text>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).</text>
</paragraph><paragraph id="H6E495B5407624BE69297425342D31354"><enum>(2)</enum><header>Enforcement</header><text>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).</text>
</paragraph><paragraph id="HB278AED747DB4A7A92F3B05DD891E7DD"><enum>(3)</enum><header>AmeriCare
supplemental policy</header><text>For purposes of this section, the term
<term>AmeriCare supplemental policy</term> 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—</text>
<subparagraph id="H55ED84E422454B1EBFBD7228D3255C67"><enum>(A)</enum><text>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</text>
</subparagraph><subparagraph id="H804BC7E35EAC42F69000D30096C2E4A2"><enum>(B)</enum><text>a policy or plan
of a health maintenance organization which offers benefits under this title
under section 2221(k).</text>
</subparagraph><continuation-text continuation-text-level="paragraph">For
purposes of this section, the term <term>policy</term> includes a certificate
issued under such policy.</continuation-text></paragraph></subsection><subsection id="HB698D7C85A154D2FBCA478A205EE3D01"><enum>(b)</enum><header>Certification
standards</header>
<paragraph id="HA3CA8FB06B2E442D913D831EAF61F586"><enum>(1)</enum><header>Issuance</header><text>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.</text>
</paragraph><paragraph id="HAE2581E05B834907B900760049697D9F"><enum>(2)</enum><header>More stringent
state standards permitted</header><text>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—</text>
<subparagraph id="HE8EB5F998D3342B1BDCEC1215C0475CB"><enum>(A)</enum><text>additional
limitations on pre-existing exclusion limitations described in subsection
(c)(1)(B);</text>
</subparagraph><subparagraph id="H6146A2753B1D46AEB2C53C0270A9A090"><enum>(B)</enum><text>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; and</text>
</subparagraph><subparagraph id="H43349AAAC9C44F5FAD8BE326B617A94C"><enum>(C)</enum><text>requiring a higher
loss-ratios than those specified in subsection (c)(3);</text>
</subparagraph></paragraph></subsection><subsection id="H6AD6E7C2AC5949A6A0E967F3197E7EA1"><enum>(c)</enum><header>Standards</header><text>The
Secretary shall establish standards for AmeriCare supplemental policies
consistent with the following:</text>
<paragraph id="HFBFAF140A4C542EB879FD32F9B68D131"><enum>(1)</enum><header>No
discrimination based on health status</header>
<subparagraph id="H47CC763C5F524C0F92E00369144302EC"><enum>(A)</enum><header>In
general</header><text>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.</text>
</subparagraph><subparagraph id="H5E26BFEE706E492F8FA1FC9BCBCAA3DA"><enum>(B)</enum><header>Limitation on
use of pre-existing condition exclusions</header><text>An AmeriCare
supplemental policy may exclude coverage with respect to services related to
treatment of a pre-existing condition, except that—</text>
<clause id="H37D1850A516A441BADE1577CEB3C3EAB"><enum>(i)</enum><text>the period of such
exclusion may not exceed 6 months;</text>
</clause><clause id="H51B6E25094E74FEFAADB0003A498E407"><enum>(ii)</enum><text>such exclusion
shall not apply to services furnished to newborns; and</text>
</clause><clause id="H473678D5DE5D465B96260004D9C1FD24"><enum>(iii)</enum><text>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.</text>
</clause><continuation-text continuation-text-level="subparagraph">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.</continuation-text></subparagraph></paragraph><paragraph id="H70EB2C4551294710A00914A026C211B"><enum>(2)</enum><header>Simplification of
benefits</header>
<subparagraph id="H53492B3208AE42BF9F35279CF1A758C7"><enum>(A)</enum><header>In
general</header><text>Each AmeriCare supplemental policy shall only offer
benefits consistent with the standards, promulgated by the Secretary, that
provide—</text>
<clause id="HD6C50FD2681D41CC9850D992EBB482A5"><enum>(i)</enum><text>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;</text>
</clause><clause id="H9C593DD33A4248E195AEC68D7ADD888"><enum>(ii)</enum><text>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;</text>
</clause><clause id="H9901023F3EC24653A5009B5921C8ACDD"><enum>(iii)</enum><text>uniform language
and definitions to be used with respect to such benefits; and</text>
</clause><clause id="H75BF9FD25A164A74AE498DD7AE5413ED"><enum>(iv)</enum><text>uniform format to
be used in the policy with respect to such benefits.</text>
</clause></subparagraph><subparagraph id="H350A1B3406E74A0ABAC382E61A2D4D9"><enum>(B)</enum><header>Innovation</header><text>The
Secretary may approve the offering of new or innovative and cost-effective
benefit packages in addition to those provided under subparagraph (A).</text>
</subparagraph></paragraph><paragraph id="HD6AF6E023B5142BF965561544C295C34"><enum>(3)</enum><header>Minimum loss
ratio required</header><text>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—</text>
<subparagraph id="H5D23C2942083481ABEDBB8EE105498F4"><enum>(A)</enum><text>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</text>
</subparagraph><subparagraph id="H75EBE230B62349849DD1DD2E5CFA6CBE"><enum>(B)</enum><text>provides refunds
and credits (in a manner specified by the Secretary) for premiums collected in
excess of those consistent with subparagraph (A).</text>
</subparagraph></paragraph><paragraph id="H3399BE42CEA247A7AAC0C94DF1314FE"><enum>(4)</enum><header>Guaranteed
renewability and convertibility</header><text>Each AmeriCare supplemental
policy—</text>
<subparagraph id="H4F2A6ACF95A6488CA52190B3D69E89DB"><enum>(A)</enum><text>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</text>
</subparagraph><subparagraph id="H13E069455BA7413C82BECC56827400B0"><enum>(B)</enum><text>shall provide
for—</text>
<clause id="H283384060B674A880000748EE991200"><enum>(i)</enum><text>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;</text>
</clause><clause id="HDC2DD40FC2EC4FA6BDE17DBFD365663D"><enum>(ii)</enum><text>a
right of continued coverage in the case of a group policy that succeeds another
group policy; and</text>
</clause><clause id="H14A2100F6B1F41D0924DD81333DDFC50"><enum>(iii)</enum><text>suspension of
coverage (for up to 24 months and in a manner specified) in the case of a
policyholder who becomes entitled to benefits under this title as a low-income
individual and who provides a timely notice of election of such
suspension.</text>
</clause></subparagraph></paragraph><paragraph id="HE886A7EDBB3D480B8B2B93D947409BC2"><enum>(5)</enum><header>Additional
standards applicable only to insured policies</header><text>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:</text>
<subparagraph id="H76929761D7DB4120A41688E7F3A7B108"><enum>(A)</enum><header>Open
enrollment</header><text>The carrier must offer the same policy to any other
individual or group in the State on a continuous, year-round basis; except
that—</text>
<clause id="H9F230ECC1D3948AC86C847FCD5C926C1"><enum>(i)</enum><text>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</text>
</clause><clause id="H763EB84606724CAC88C319C7090090CD"><enum>(ii)</enum><text>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.</text>
</clause></subparagraph><subparagraph id="H2A67F6DE269447E1877252008667B397"><enum>(B)</enum><header>Notices and
renewal periods</header><text>The carrier shall provide advance notice of terms
for policy renewal, which terms shall—</text>
<clause id="HAD91DDA508F14C10A533FC5B54AFAF9"><enum>(i)</enum><text>be
the same as the terms of issuance, except for rates and administrative
changes;</text>
</clause><clause id="H072BE8B9DF5F42A59EA9C400B488FC6"><enum>(ii)</enum><text>provide the same
premium rates as for a new issue; and</text>
</clause><clause id="H9665674972CF41539D3835D0B857F97"><enum>(iii)</enum><text>provide a period
of renewal of not less than 12 months.</text>
</clause></subparagraph></paragraph></subsection><subsection id="H164A04796D1E488FA904AE168ECC737E"><enum>(d)</enum><header>Additional
requirements</header>
<paragraph id="H5FA6B649C11C4B47998CFE8287F9A8A"><enum>(1)</enum><header>Prohibition of
duplication</header><text>The Secretary shall—</text>
<subparagraph id="H359ACB737B8D4411A8704580729EC2B4"><enum>(A)</enum><text>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</text>
</subparagraph><subparagraph id="H29994806F15542AAAC263C771DC6E21"><enum>(B)</enum><text>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.</text>
</subparagraph></paragraph><paragraph id="HFA47D236E9684B099945C96B6CD6261B"><enum>(2)</enum><header>Disclosure
requirement</header><text>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.</text>
</paragraph><paragraph id="HBE85D53D5DAC4F80921C23D191AEBDE"><enum>(3)</enum><header>Application of
false statement sanctions</header><text>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.</text>
</paragraph><paragraph id="H44A14A1C6FA548E185A2FC59406A3F5"><enum>(4)</enum><header>Limitations on
sales commissions</header>
<subparagraph id="HD449486C7EC841ECBEF0DF0596331BAE"><enum>(A)</enum><header>In
general</header><text>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)—</text>
<clause id="H257B2E6BF7A249799F3E24CFD10099BB"><enum>(i)</enum><text>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</text>
</clause><clause id="H038DCFD938B54F1900074C2544D4A839"><enum>(ii)</enum><text>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.</text>
</clause></subparagraph><subparagraph id="HA34D9473C49445CBAFE3D2780047C493"><enum>(B)</enum><header>Definition</header><text>In
subparagraph (A), the term <term>compensation</term> 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.</text>
</subparagraph></paragraph></subsection><subsection id="HD6DA4F136FC4421F8400A8C7DCCD5967"><enum>(e)</enum><header>Information
disclosure</header><text>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—</text>
<paragraph id="HF3AA09F3C9FD4766AD11A3F6C4C705E6"><enum>(1)</enum><text>the requirements
and prohibitions under this section;</text>
</paragraph><paragraph id="H8708BC1CEF32410EAF7E7FEDE5F5EEC"><enum>(2)</enum><text>State and Federal
agencies responsible for compliance with such requirements and enforcement of
such prohibitions; and</text>
</paragraph><paragraph id="H7A3F10F4FF634C9B9CBDB1A90988AE1B"><enum>(3)</enum><text>the manner of
submitting complaints regarding violations of such requirements and
prohibitions.</text>
</paragraph></subsection><subsection id="H743142788D104749A59FFB2D8CE773F7"><enum>(f)</enum><header>Definitions</header><text>In
this section:</text>
<paragraph id="HBA349C4CCF5C4967008381631EC8BF35"><enum>(1)</enum><header>Carrier</header><text>The
term <term>carrier</term> means any person that offers an AmeriCare
supplemental policy.</text>
</paragraph><paragraph id="H3355754631624270A202BD41213D0067"><enum>(2)</enum><header>Group</header><text>The
term <term>group</term> means 2 or more employees of the same employer who
normally perform on a monthly basis at least 171/2 hours of service per week
for that employer.</text>
</paragraph><paragraph id="HF3C4D2E68DFC4E7AA1CE4492664BECD"><enum>(3)</enum><header>Health
maintenance organization</header><text>The term <term>health maintenance
organization</term> has the meaning given the term <term>eligible
organization</term> in section 1876(b).</text>
</paragraph><paragraph id="H2365653FE70B43DFA712B39D9248389E"><enum>(4)</enum><header>Insured
AmeriCare supplemental policy</header><text>The term <term>insured AmeriCare
supplemental policy</term> means any AmeriCare supplemental policy provided
through
insurance.</text>
</paragraph></subsection></section></part>.
<enum>II</enum><header>Financing
Provisions</header>
<subtitle id="H7D4589B0E0AE49659DC0000BCE4BAD"><enum>A</enum><header>Individual
Contributions</header>
<section id="H4DCC4550506B428EA184A8BBEB3ED989"><enum>201.</enum><header>General
obligation for individuals</header>
<subsection id="H5C6F3C0E3D8C421AA39E4CA6C46EB05"><enum>(a)</enum><header>Payment of plan
premium</header>
<paragraph id="H16881B022B714683001E4051E78BE65E"><enum>(1)</enum><header>In
general</header><text>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.</text>
</paragraph><paragraph id="H76098553AD23452EA927B37CBC859E55"><enum>(2)</enum><header>Determination of
premium</header><text>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).</text>
</paragraph><paragraph id="H24C9CB16D2C2446700BD976B0958C853"><enum>(3)</enum><header>Joint and
several liability</header><text>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.</text>
</paragraph></subsection><subsection id="H358F2B4F4E754186A5907F79288596F8"><enum>(b)</enum><header>Reduction for
employer contributions and low income subsidies</header><text>An individual’s
liability under subsection (a) is reduced by—</text>
<paragraph id="HFD057ED9713A41DD93D9EE10CCAD7200"><enum>(1)</enum><text>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</text>
</paragraph><paragraph id="H103E87B7CB5A43F4AF6595A3DD6210D"><enum>(2)</enum><text>the amount of any
premium subsidies provided with respect to the individual under section
202.</text>
</paragraph></subsection><subsection id="HB09B50F7A892466E9D907D6DA2FEBB5"><enum>(c)</enum><header>Timing and manner
of payment</header><text>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.</text>
</subsection></section><section id="HA963911B80CC47098FF982ECFF714162"><enum>202.</enum><header>Additional
premium subsidies</header>
<subsection id="H78A49304E1F7467DA048DFD8EADAA1E"><enum>(a)</enum><header>Eligibility for
additional premium subsidies</header>
<paragraph id="H021E4CCAEFB04A20BF00CC3491A9B9DB"><enum>(1)</enum><header>In
general</header><text>Each premium subsidy eligible individual is entitled to a
premium subsidy in accordance with this section.</text>
</paragraph><paragraph id="H7B09ACDD73C94FB9A461FCD1669128E"><enum>(2)</enum><header>Premium subsidy
eligible individual</header><text>In this section, the term <term>premium
subsidy eligible individual</term> means an individual receiving coverage under
title XXII of the Social Security Act who—</text>
<subparagraph id="H6C599B71F1434341BE4F3B95F08538EB"><enum>(A)</enum><text>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</text>
</subparagraph><subparagraph id="HA32BA1F5931A4F74A8EC24F90699FDF0"><enum>(B)</enum><text>with respect to a
premium for a month, is an TANF or SSI recipient for the month.</text>
</subparagraph></paragraph><paragraph id="H0A0CBF0724AB4E0482FC1DC311D4E1D1"><enum>(3)</enum><header>Additional
definitions</header><text>In this section:</text>
<subparagraph id="HB081C1B528FA47628D00F2EEF67B0501"><enum>(A)</enum><header>Family
income</header><text>The term <term>family income</term> means, with respect to
an individual who—</text>
<clause id="HC8A9F9D4C7D941A8A6B6A898E25ECE44"><enum>(i)</enum><text>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</text>
</clause><clause id="H52F7C545653A43438FFADAAD286B6C43"><enum>(ii)</enum><text>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.</text>
</clause></subparagraph><subparagraph id="H6445F4F8C07F4C709DF24C25C714ECB0"><enum>(B)</enum><header>Modified
adjusted gross income</header><text>The term <term>modified adjusted gross
income</term> means adjusted gross income (as defined in the Internal Revenue
Code of 1986)—</text>
<clause id="HA31B16E4FD79411C96ECC659F6F8CC4"><enum>(i)</enum><text>determined without
regard to sections 911, 931, and 933 of such Code, and</text>
</clause><clause id="H4CBBD6C1D0064D1DA95FFA1555B72373"><enum>(ii)</enum><text>increased
by—</text>
<subclause id="HCBA68967F2D84227A39B7234578967DF"><enum>(I)</enum><text>the amount of
interest received or accrued by the individual during the taxable year which is
exempt from tax, and</text>
</subclause><subclause id="HB3F74A17CCA141A684DB1CAB6B4C77F7"><enum>(II)</enum><text>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.</text>
</subclause><continuation-text continuation-text-level="clause">The
determination under the preceding sentence shall be made without regard to any
carryover or carryback.</continuation-text></clause></subparagraph><subparagraph id="HC2E62EC3A778408886003C3F4F7E96D5"><enum>(C)</enum><header>Applicable
poverty level</header>
<clause id="H0E2299281F0B4EF395A537A6E23D0120"><enum>(i)</enum><header>In
general</header><text>The term <term>applicable poverty level</term> 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 2011
adjusted by the percentage increase or decrease described in clause (ii) for
the year involved.</text>
</clause><clause id="HF1F2F08FC99D41FEB8581FCD782CAEF9"><enum>(ii)</enum><header>Percentage
adjustment</header><text>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, 2011.</text>
</clause><clause id="HE6D5C5E74D9341B5B78F72B5275521B7"><enum>(iii)</enum><header>Rounding</header><text>Any
adjustment made under clause (ii) for a year shall be rounded to the nearest
multiple of $100.</text>
</clause></subparagraph><subparagraph id="H7454D5A0C66E43059CF36F73495D27A"><enum>(D)</enum><header>TANF
recipient</header><text>The term <term>TANF recipient</term> 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.</text>
</subparagraph><subparagraph id="H097D7B7BDD4E48319BA23EEA607DF100"><enum>(E)</enum><header>SSI
recipient</header><text>The term <term>SSI recipient</term> means, for a month,
an individual—</text>
<clause id="H8DB96A447AF64C8BACDBCC7843E8A308"><enum>(i)</enum><text>with
respect to whom supplemental security income benefits are being paid under
title XVI of the Social Security Act for the month,</text>
</clause><clause id="H58B4A044638A43C1001DA7D078676FEC"><enum>(ii)</enum><text>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</text>
</clause><clause id="H4FF03DC17B0C4A118539D356E7A3AF2E"><enum>(iii)</enum><text>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.</text>
</clause></subparagraph></paragraph></subsection><subsection id="H15DB743C825B412C8CE8C43374E11D78"><enum>(b)</enum><header>Amount of
premium subsidy</header>
<paragraph id="HE9615CAEC4AF4F8E81F2AD43F488AAEB"><enum>(1)</enum><header>Lowest income
individuals</header>
<subparagraph id="H48DFADE95CF944999824E1ED5F297DB8"><enum>(A)</enum><header>In
general</header><text>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.</text>
</subparagraph><subparagraph id="H9CF7150707414136B3B900E168E75CDE"><enum>(B)</enum><header>Lowest income
individuals described</header><text>An individual described in this
subparagraph is a premium subsidy eligible individual who would still be such
an individual under subsection (a)(2) if <quote>200 percent</quote> were
substituted for <quote>300 percent</quote> in subparagraph (A) of such
subsection.</text>
</subparagraph></paragraph><paragraph id="H23D0B8AF304549F8968BF9BAC2B828D1"><enum>(2)</enum><header>Other
individuals</header>
<subparagraph id="H734181BEC02842A59032D532D23B6E34"><enum>(A)</enum><header>In
general</header><text>In the case of a premium subsidy eligible individual not
described in paragraph (1), the premium subsidy under this section is the
product of—</text>
<clause id="H3197A4692F70482A85B3F22FA7FF4F2"><enum>(i)</enum><text>the
premium obligation of the individual (and family members) under section 201,
multiplied by</text>
</clause><clause id="H4C558C36D8314A819916CDC96756D2B"><enum>(ii)</enum><text>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.</text>
</clause></subparagraph><subparagraph id="H9A20039DFB924F83B7267FF21183788"><enum>(B)</enum><header>Table</header><text>The
Secretary may provide for a table which establishes the values for premium
subsidies under this paragraph.</text>
</subparagraph></paragraph></subsection><subsection id="H9D6CB6082E00474594B294F3CD8E6153"><enum>(c)</enum><header>General revenue
financing for low income subsidies</header><text>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.</text>
</subsection></section><section id="H86E182CA7B2A4AA900D1B9003F60E843"><enum>203.</enum><header>Effective
date</header><text display-inline="no-display-inline">The provisions of this
subtitle shall apply with respect to periods beginning on or after January 1,
2011.</text>
</section></subtitle><subtitle id="H8CABB12EB8CF417D85A488E176BE46A0"><enum>B</enum><header>Employer
Contributions</header>
<section id="H8C9E12F06B1B400BBD44C578B38F0620"><enum>211.</enum><header>General
obligation for employers</header>
<subsection id="HCB94BAA785AA4C4AA4813C7F5F11C6FB"><enum>(a)</enum><header>General
obligation</header>
<paragraph id="H92EBC1473D2F4FDEB29D001E794E6732"><enum>(1)</enum><header>In
general</header><text>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.</text>
</paragraph><paragraph id="HE9080AFC6264486287DA9F22E2001FCD"><enum>(2)</enum><header>Elimination of
liability in case of certain group health plan coverage</header>
<subparagraph id="H288149DDE1744A57BE7EFFC95B996D4F"><enum>(A)</enum><header>In
general</header><text>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.</text>
</subparagraph><subparagraph id="HDB66A1A994984C14B7BE8177EAEEE42E"><enum>(B)</enum><header>Surcharge
permissible to prevent adverse selection</header><text>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.</text>
</subparagraph></paragraph></subsection><subsection id="HE0A7E92C191F48CD87D2475134E201B"><enum>(b)</enum><header>Amount of
contribution</header>
<paragraph id="H9D3B1D23CBE3454082262BAF601BAE4B"><enum>(1)</enum><header>Full-time
employees</header><text>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.</text>
</paragraph><paragraph id="HA1CB819BA98348D9ACA2AE4455060053"><enum>(2)</enum><header>Reduction for
part-time employees</header><text>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).</text>
</paragraph><paragraph id="HBDABB4798A99436881D0518261CDB3A5"><enum>(3)</enum><header>Rules related to
part-time employment</header><text>For purposes of this subsection—</text>
<subparagraph id="HD36F7E6731204150B6CC3FBEF524EA5C"><enum>(A)</enum><header>Part-time
employee</header><text>The term <term>part-time employee</term> means, with
respect to any month, an employee who works on average fewer than 40 hours per
week.</text>
</subparagraph><subparagraph id="HEDAD3FE90767409290B171AC6066F6DE"><enum>(B)</enum><header>Part-time
employment ratio</header><text>The term <term>part-time employment ratio</term>
means, with respect to a part-time employee of an employer in a month, a
fraction—</text>
<clause id="H33F4239B47C943AAB1E4F57C3C21AC13"><enum>(i)</enum><text>the
numerator of which is the number of hours in the employee’s normal work week,
and</text>
</clause><clause id="H6A18065974D243EF92993656FA8100D3"><enum>(ii)</enum><text>the
denominator of which is 40 hours.</text>
</clause></subparagraph><subparagraph id="HC921887A78C24CE5A412C6F1B6E37348"><enum>(C)</enum><header>Special
rules</header><text>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.</text>
</subparagraph><subparagraph id="H332C93A0CA4E447BBC4173842B86009F"><enum>(D)</enum><header>Conversion to
hours of employment</header><text>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.</text>
</subparagraph></paragraph></subsection><subsection id="HA961644E5D9B418798AAC1B8BAD2F178"><enum>(c)</enum><header>Timing and
manner</header>
<paragraph id="HBF67DCAEB67D4D2C8815E90599D2B8EC"><enum>(1)</enum><header>In
general</header><text>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.</text>
</paragraph><paragraph id="H430ED0AFC8624B0EAA75749DA7B0DA6B"><enum>(2)</enum><header>Non-enrolling
employers</header><text>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.</text>
</paragraph></subsection></section><section id="HA57C8B0796804EB296549899CCC1713C"><enum>212.</enum><header>Effective
date</header>
<subsection id="H28F0A722507D440AA91F4597F582CC3F"><enum>(a)</enum><header>In
general</header><text>Subject to subsection (b), the provisions of this
subtitle shall apply with respect to periods beginning on or after January 1,
2011.</text>
</subsection><subsection id="HC64E04B6BAE54F6700B24D77ADEE3FC7"><enum>(b)</enum><header>Additional
period for small employers</header><text>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,
2014.</text>
</subsection></section></subtitle>