[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[S. 391 Introduced in Senate (IS)]
111th CONGRESS
1st Session
S. 391
To provide affordable, guaranteed private health coverage that will
make Americans healthier and can never be taken away.
_______________________________________________________________________
IN THE SENATE OF THE UNITED STATES
February 5, 2009
Mr. Wyden (for himself, Mr. Bennett, Mr. Inouye, Mr. Specter, Mr.
Lieberman, Ms. Landrieu, Mr. Crapo, Mr. Nelson of Florida, Ms.
Stabenow, Ms. Cantwell, Mr. Graham, Mr. Alexander, and Mr. Merkley)
introduced the following bill; which was read twice and referred to the
Committee on Finance
_______________________________________________________________________
A BILL
To provide affordable, guaranteed private health coverage that will
make Americans healthier and can never be taken away.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as the ``Healthy Americans
Act''.
(b) Table of Contents.--
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
Sec. 3. Definitions.
TITLE I--HEALTHY AMERICANS PRIVATE INSURANCE PLANS
Subtitle A--Guaranteed Private Coverage
Sec. 101. Guarantee of Healthy Americans Private Insurance coverage.
Sec. 102. Individual responsibility to enroll in a Healthy Americans
Private Insurance plan.
Sec. 103. Guaranteeing you can keep the coverage you have.
Sec. 104. Coordination of supplemental coverage under the Medicaid
program to HAPI plan coverage for
nondisabled, nonelderly adult individuals.
Subtitle B--Standards for Healthy Americans Private Insurance Coverage
Sec. 111. Healthy Americans Private Insurance Plans.
Sec. 112. Specific coverage requirements.
Sec. 113. Updating Healthy Americans Private Insurance plan
requirements.
Subtitle C--Eligibility for Premium and Personal Responsibility
Contribution Subsidies
Sec. 121. Eligibility for premium subsidies.
Sec. 122. Eligibility for personal responsibility contribution
subsidies.
Sec. 123. Definitions and special rules.
Subtitle D--Wellness Programs
Sec. 131. Requirements for wellness programs.
TITLE II--HEALTHY START FOR CHILDREN
Subtitle A--Benefits and Eligibility
Sec. 201. General goal and authorization of appropriations for HAPI
plan coverage for children.
Sec. 202. Coordination of supplemental coverage under the Medicaid
program with HAPI plan coverage for
children.
Subtitle B--Service Providers
Sec. 211. Inclusion of providers under HAPI plans.
Sec. 212. Use of, and grants for, school-based health centers.
TITLE III--BETTER HEALTH FOR OLDER AND DISABLED AMERICANS
Subtitle A--Assurance of Supplemental Medicaid Coverage
Sec. 301. Coordination of supplemental coverage under the Medicaid
program for elderly and disabled
individuals.
Subtitle B--Empowering Individuals and States To Improve Long-Term Care
Choices
Sec. 311. New, automatic Medicaid option for State Choices for Long-
Term Care Program.
Sec. 312. Simpler and more affordable long-term care insurance
coverage.
TITLE IV--HEALTHIER MEDICARE
Subtitle A--Authority To Adjust Amount of Part B Premium To Reward
Positive Health Behavior
Sec. 401. Authority to adjust amount of Medicare part B premium to
reward positive health behavior.
Subtitle B--Promoting Primary Care for Medicare Beneficiaries
Sec. 411. Primary care services management payment.
Subtitle C--Chronic Care Disease Management
Sec. 421. Chronic care disease management.
Sec. 422. Chronic Care Education Centers.
Subtitle D--Part D Improvements
Sec. 431. Process for individuals entering the Medicare coverage gap to
switch to a plan that provides coverage in
the gap.
Subtitle E--Improving Quality in Hospitals for All Patients
Sec. 441. Improving quality in hospitals for all patients.
Subtitle F--End-of-Life Care Improvements
Sec. 451. Patient empowerment and following a patient's health care
wishes.
Sec. 452. Permitting hospice beneficiaries to receive curative care.
Sec. 453. Providing beneficiaries with information regarding end-of-
life care clearinghouse.
Sec. 454. Clearinghouse.
Subtitle G--Additional Provisions
Sec. 461. Additional cost information.
Sec. 462. Reducing Medicare paperwork and regulatory burdens.
TITLE V--STATE HEALTH HELP AGENCIES
Sec. 501. Establishment.
Sec. 502. Responsibilities and authorities.
Sec. 503. Appropriations for Transition to State Health Help Agencies.
TITLE VI--SHARED RESPONSIBILITIES
Subtitle A--Individual Responsibilities
Sec. 601. Individual responsibility to ensure HAPI plan coverage.
Subtitle B--Employer Responsibilities
Sec. 611. Health care responsibility payments.
Sec. 612. Distribution of individual responsibility payments to HHAs.
Subtitle C--Insurer Responsibilities
Sec. 621. Insurer responsibilities.
Subtitle D--State Responsibilities
Sec. 631. State responsibilities.
Sec. 632. Empowering states to innovate through waivers.
Subtitle E--Federal Fallback Guarantee Responsibility
Sec. 641. Federal guarantee of access to coverage.
Subtitle F--Federal Financing Responsibilities
Sec. 651. Appropriation for subsidy payments.
Sec. 652. Recapture of Medicare and 90 percent of Medicaid Federal DSH
funds to strengthen Medicare and ensure
continued support for public health
programs.
Subtitle G--Tax Treatment of Health Care Coverage Under Healthy
Americans Program; Termination of Coverage Under Other Governmental
Programs and Transition Rules for Medicaid and CHIP
Part I--Tax Treatment of Health Care Coverage Under Healthy Americans
Program
Sec. 661. Limited employee income and payroll tax exclusion for
employer shared responsibility payments,
historic retiree health contributions, and
transitional coverage contributions.
Sec. 662. Exclusion for limited employer-provided health care fringe
benefits.
Sec. 663. Limited employer deduction for employer shared responsibility
payments, historic retiree health
contributions, and other health care
expenses.
Sec. 664. Health care standard deduction.
Sec. 665. Modification of other tax incentives to complement Healthy
Americans program.
Part II--Clarification of ERISA Treatment; Termination of Coverage
Under Other Governmental Programs and Transition Rules for Medicaid and
CHIP
Sec. 671. Clarification of ERISA applicability to employer-sponsored
HAPI plans.
Sec. 672. Federal Employees Health Benefits Plan.
Sec. 673. Medicaid and CHIP.
TITLE VII--PURCHASING HEALTH SERVICES AND PRODUCTS THAT ARE MOST
EFFECTIVE
Subtitle A--Effective Health Services and Products
Sec. 701. One time disallowance of deduction for advertising and
promotional expenses for certain
prescription pharmaceuticals.
Sec. 702. Enhanced new drug and device approval.
Sec. 703. Medical schools and finding what works in health care.
Sec. 704. Finding affordable health care providers nearby.
Subtitle B--Other Provisions to Improve Health Care Services and
Quality
Sec. 711. Individual medical records.
Sec. 712. Bonus payment for medical malpractice reform.
Sec. 713. Prioritizing health care employment and training activities.
TITLE VIII--CONTAINING MEDICAL COSTS AND GETTING MORE VALUE FOR THE
HEALTH CARE DOLLAR
Sec. 801. Cost-containment results of the Healthy Americans Act.
SEC. 2. FINDINGS.
Congress makes the following findings:
(1) Americans want affordable, guaranteed private health
coverage that makes them healthier and can never be taken away.
(2) American health care provides primarily ``sick care''
and does not do enough to prevent chronic illnesses like heart
disease, stroke, and diabetes. This results in significantly
higher health costs for all Americans.
(3) Staying as healthy as possible often requires an
individual to change behavior and assume more personal
responsibility for his or her health.
(4) Personal responsibility for one's health should include
purchasing one's own private health care coverage.
(5) To accompany this new focus on staying healthy and
personal responsibility, our government must guarantee that all
Americans receive private affordable health coverage that can
never be taken away.
(6) Financing this guarantee should be a shared
responsibility between individuals, the Government, and
employers.
(7) The $2,200,000,000,000 spent annually on American
health care must be spent more effectively in order to meet
this guarantee.
(8) This guarantee must include easier access to
understandable information about the quality, cost, and
effectiveness of health care providers, products, and services.
(9) The fact that businesses in the United States compete
globally against businesses whose governments pay for health
care, coupled with the aging of the American population and the
explosive growth of preventable health problems, makes the
status quo in American health care unacceptable.
SEC. 3. DEFINITIONS.
In this Act:
(1) Adult individual.--The term ``adult individual'' means
an individual who--
(A) is--
(i) age 19 or older;
(ii) a resident of a State;
(iii)(I) a United States citizen; or
(II) an alien with permanent residence;
(iv) not a dependent child; and
(v) not an alien unlawfully present in the
United States; and
(B) in the case of an incarcerated individual, such
an individual who is incarcerated for less than 1
month.
(2) Alien with permanent residence.--The term ``alien with
permanent residence'' has the meaning given the term
``qualified alien'' in section 431 of the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996
(8 U.S.C. 1641).
(3) Covered individual.--The term ``covered individual''
means an individual who is enrolled in a HAPI plan.
(4) Dependent child.--The term ``dependent child'' has the
meaning given the term ``qualifying child'' in section 152(c)
of the Internal Revenue Code of 1986.
(5) HAPI plan.--The term ``HAPI plan'' means--
(A) a Healthy Americans Private Insurance plan
described under subtitle B of title I; or
(B) an employer-sponsored health coverage plan
described under section 103 offered by an employer.
(6) HHA.--The term ``HHA'' means the Health Help Agency of
a State as described under title V.
(7) Health insurance issuer.--The term ``health insurance
issuer'' means an insurance company, insurance service, or
insurance organization (including a health maintenance
organization, as defined in paragraph (7)) which is licensed to
engage in the business of insurance in a State and which is
subject to State law which regulates insurance (within the
meaning of section 514(b)(2) of the Employee Retirement Income
Security Act of 1974). Such term does not include a group
health plan.
(8) Health maintenance organization.--The term ``health
maintenance organization'' means--
(A) a federally qualified health maintenance
organization (as defined in section 1301(a)),
(B) an organization recognized under State law as a
health maintenance organization, or
(C) a similar organization regulated under State
law for solvency in the same manner and to the same
extent as such a health maintenance organization.
(9) Personal responsibility contribution.--The term
``personal responsibility contribution'' means a payment made
by a covered individual to a health care provider or a health
insurance issuer with respect to the provision of health care
services under a HAPI plan, not including any health insurance
premium payment.
(10) Qualified collective bargaining agreement.--
(A) In general.--The term ``qualified collective
bargaining agreement'' means an agreement between a
qualified collective bargaining employer and an
employee organization that represents the employees of
such employer that is in effect until the date that is
the earlier of--
(i) January 1 of the first year which is
more than 7 years after the date of enactment
of this Act, or
(ii) the date the collective bargaining
agreement expires.
(B) Qualified collective bargaining employer.--The
term ``qualified collective bargaining employer'' means
an employer who provides health insurance to employees
under the terms of a collective bargaining agreement
which is entered into before the date of the enactment
of this Act.
(11) Secretary.--The term ``Secretary'' means the Secretary
of Health and Human Services.
(12) State.--The term ``State'' means each of the several
States of the United States, the District of Columbia, the
Commonwealth of Puerto Rico, the Virgin Islands, American
Samoa, Guam, the Commonwealth of the Northern Mariana Islands,
and other territories of the United States.
(13) State of residence.--The term ``State of residence'',
with respect to an individual, means the State in which the
individual has primary residence.
TITLE I--HEALTHY AMERICANS PRIVATE INSURANCE PLANS
Subtitle A--Guaranteed Private Coverage
SEC. 101. GUARANTEE OF HEALTHY AMERICANS PRIVATE INSURANCE COVERAGE.
Not later than the date that is 2 years after the date of enactment
of this Act, each adult individual shall have the opportunity to
purchase a Healthy Americans Private Insurance plan that meets the
requirements of subtitle B (referred to in this Act as ``HAPI plan''),
for such individual and the dependent children of such individual.
SEC. 102. INDIVIDUAL RESPONSIBILITY TO ENROLL IN A HEALTHY AMERICANS
PRIVATE INSURANCE PLAN.
(a) Individual Responsibility.--
(1) Adult individuals.--Each adult individual shall have
the responsibility to enroll in a HAPI plan, unless the adult
individual--
(A) provides evidence of receipt of coverage under,
or enrollment in a health plan offered through--
(i) the Medicare program under title XVIII
of the Social Security Act;
(ii) a health insurance plan offered by the
Department of Defense;
(iii) an employee benefit plan through a
former employer;
(iv) a qualified collective bargaining
agreement;
(v) the Department of Veterans Affairs; or
(vi) the Indian Health Service; or
(B) is opposed to health plan coverage for
religious reasons, including an individual who declines
health plan coverage due to a reliance on healing using
spiritual means through prayer alone.
(2) Dependent children.--Each adult individual shall have
the responsibility to enroll each dependent child of the adult
individual in a HAPI plan, unless the adult individual--
(A) provides evidence that the dependent child is
enrolled in a health plan offered through a program
described in paragraph (1)(A); or
(B) is described in paragraph (1)(B).
(3) Verification of religious exception.--Each State shall
develop guidelines for determining and verifying the
individuals who qualify for the exception under paragraph
(1)(B).
(b) Penalty for Failure To Purchase Coverage.--
(1) Penalty.--
(A) In general.--In the case of an individual
described in subparagraph (B), such individual shall be
subject to a late enrollment penalty in an amount
determined under subparagraph (C).
(B) Individuals subject to penalty.--An individual
described in this subparagraph is an adult individual
for whom there is a continuous period of 63 days or
longer, beginning on the applicable date (as defined in
subparagraph (E)) and ending on the date of enrollment
in a HAPI plan, during all of which the individual--
(i) was not covered under a HAPI plan or a
health plan offered through a program described
in paragraph (1)(A) of subsection (a); and
(ii) was not described in paragraph (1)(B)
of such section.
(C) Amount of penalty.--
(i) In general.--The amount determined
under this subparagraph for an individual is an
amount equal to the sum of--
(I) the number of uncovered months
multiplied by the weighted average of
the monthly premium for HAPI plans of
the same class of coverage as the
individual's in the applicable coverage
area (determined without regard to any
subsidy under section 121); and
(II) 15 percent of the amount
determined under subclause (I).
(ii) Uncovered month defined.--For purposes
of this subsection, the term ``uncovered
month'' means, with respect to an individual,
any month beginning on or after the applicable
date (as defined in subparagraph (E)) unless
the individual can demonstrate that the
individual--
(I) was covered under a HAPI plan
or a health plan offered through a
program described in paragraph (1)(A)
of subsection (a) for any portion of
such month; or
(II) was described in paragraph
(1)(B) of such section for any portion
of such month.
A month shall not be treated as an uncovered
month if the individual has already paid a late
enrollment penalty under this subsection for
such month or if the individual was
incarcerated for the entire month.
(D) Payment.--Payment of any late enrollment
penalty by an individual under this subsection shall be
made to the HHA of the individual's State of residence
under procedures established by the State.
(E) Applicable date.--In this paragraph, the term
``applicable date'' means the earlier of--
(i) the day after the end of the State's
first open enrollment period for HAPI plans
(during which all adult individuals are
eligible to enroll); and
(ii) the day after the end of the first
enrollment period for a fallback HAPI plan in
the State.
(2) Waiver.--An HHA of a State may reduce or waive the
amount of any late enrollment penalty applicable to an
individual under this subsection if payment of such penalty
would constitute a hardship (determined under procedures
established by the State).
(3) Enforcement.--Each State shall determine appropriate
mechanisms, which may not include revocation or ineligibility
for coverage under a HAPI plan, to enforce the responsibility
of each adult individual to purchase HAPI plan coverage for
such individual and any dependent children of such individual
under subsection (a).
(c) Other Insurance Coverage.--Nothing in this Act shall be
construed to prohibit an individual from enrolling in a health
insurance plan that is not a HAPI plan.
SEC. 103. GUARANTEEING YOU CAN KEEP THE COVERAGE YOU HAVE.
(a) Plan Requirements.--
(1) In general.--A health coverage plan described in
section 105(h)(6) of the Internal Revenue Code of 1986
(relating to self-insured plans) that is offered by an employer
shall be subject to--
(A) the requirements of subtitle B (except for
subsections (a), (d)(2), and (d)(4) of section 111);
and
(B) a risk-adjustment mechanism used to spread risk
across all health plans.
(2) Other plans.--A health coverage plan that is not
described in section 105(h)(6) of the Internal Revenue Code of
1986 that is offered by an employer shall be subject to the
requirements of subtitle B (except for subsection (a) of
section 111).
(b) Distribution of Information.--Employers that offer an employer-
sponsored health coverage plan shall distribute to employees
standardized, unbiased information on HAPI plans and supplemental
health insurance options provided by the State HHA under section
502(b).
(c) Plans Offered Through Employers.--An employer-sponsored health
coverage plan shall be offered by an employer and not through the
applicable State HHA.
SEC. 104. COORDINATION OF SUPPLEMENTAL COVERAGE UNDER THE MEDICAID
PROGRAM TO HAPI PLAN COVERAGE FOR NONDISABLED, NONELDERLY
ADULT INDIVIDUALS.
(a) Assurance of Supplemental Coverage.--Subject to section 631(d),
the Secretary, States, and health insurance issuers shall ensure that
any nondisabled, nonelderly adult individual eligible under title XIX
of the Social Security Act (including any nondisabled, nonelderly adult
individual eligible under a waiver under such title or under section
1115 of such Act (42 U.S.C. 1315)) covered under a HAPI plan provided
through the State HHA receives medical assistance under State Medicaid
plans in a manner that--
(1) is provided in coordination with, and as a supplement
to, the coverage provided the nondisabled, nonelderly adult
individual under the HAPI plan in which the individual is
enrolled;
(2) does not supplant the nondisabled, nonelderly adult
individual's coverage under a HAPI plan;
(3) ensures that the nondisabled, nonelderly adult
individual receives all items or services that are not
available (or are otherwise limited) under the HAPI plan in
which they are enrolled but that is provided under the State
plan (or provided to a greater extent or in a less restrictive
manner) under title XIX of the Social Security Act (including
any waiver under such title or under section 1115 of such Act
(42 U.S.C. 1315)) of the State in which the nondisabled,
nonelderly adult individual resides; and
(4) ensures that the family of the nondisabled, nonelderly
adult individual is not charged premiums, deductibles, or other
cost-sharing that is greater than would have been charged under
the State plan under title XIX of the Social Security Act of
the State in which the nondisabled, nonelderly adult individual
resides if such coverage was not provided as a supplement to
the coverage provided the child under the HAPI plan in which
the nondisabled, nonelderly adult individual is enrolled.
(b) Guidance to States and Health Insurance Issuers.--The Secretary
shall issue regulations and guidance to States and health insurance
issuers implementing this section not later than 6 months prior to the
date on which coverage under a HAPI plan first begins.
Subtitle B--Standards for Healthy Americans Private Insurance Coverage
SEC. 111. HEALTHY AMERICANS PRIVATE INSURANCE PLANS.
(a) Options.--A State HHA--
(1) shall require that at least 2 HAPI plans that comply
with the requirements of subsection (b), be offered through the
HHA to each individual in the State;
(2) may require the offering of 1 or more HAPI plans that
include coverage for benefits, items, or services required by
the State in addition to the standardized benefits, items, or
services required under subsection (b) for HAPI plans if--
(A) such additional benefits, items, and services
build upon the standardized benefits package;
(B) a list of such additional benefits, items, or
services, and the prices applicable to such additional
benefits, items, and services, is displayed in a manner
that is separate from the description of the
standardized benefits, items, or services required
under the plan under this section (and consistent with
the manner in which such items are displayed by medigap
policies) and that enables a consumer to identify such
additional benefits, items, and services and the cost
associated with such; and
(C) no premium subsidies are available under
subtitle C for any portion of the premiums for a HAPI
plan that are attributable to such additional benefits,
items, or services; and
(3) may permit the offering of 1 or more actuarially
equivalent HAPI plans through the HHA as provided for in
subsection (c).
(b) Standardized Coverage Requirements for HAPI Plans.--
(1) In general.--Each HAPI plan offered through an HHA
shall--
(A) provide benefits for health care items and
services that are actuarially equivalent or greater in
value than the benefits offered as of January 1, 2009,
under the Blue Cross/Blue Shield Standard Plan provided
under the Federal Employees Health Benefit Program
under chapter 89 of title 5, United States Code,
including coverage of an initial primary care
assessment and annual physical examinations;
(B) provide benefits for wellness programs and
incentives to promote the use of such programs;
(C) provide coverage for catastrophic medical
events that result in out-of-pocket costs for an
individual or family if lifetime limits are exhausted;
(D) designate a health care provider, such as a
primary care physician, nurse practitioner, or other
qualified health provider, to monitor the health and
health care of a covered individuals (such provider
shall be known as the ``health home'' of the covered
individual);
(E) ensure that, as part of the first visit with a
primary care physician or the health home of a covered
individual, such provider and individual determine a
care plan to maximize the health of the individual
through wellness and activities prevention;
(F) provide benefits for comprehensive disease
prevention, early detection, disease management, and
chronic condition management that meets minimum
standards developed by the Secretary;
(G) provide for the application of personal
responsibility contribution requirements with respect
to covered benefits in a manner that may be similar to
the cost sharing requirements applied as of January 1,
2009, under the Blue Cross/Blue Shield Standard Plan
provided under the Federal Employees Health Benefit
Program under chapter 89 of title 5, United States
Code, except that no contributions shall be required
for--
(i) preventive items or services; and
(ii) early detection, disease management,
or chronic pain treatment items or services;
and
(H) comply with the requirements of section 112.
(2) Determination of benefits by secretary.--Not later than
1 year after the date of enactment of this Act, the Secretary
shall promulgate guidelines concerning the benefits, items, and
services that are covered under paragraph (1).
(3) Coverage for family planning.--
(A) In general.--Except as provided in subparagraph
(B), a health insurance issuer shall make available
supplemental coverage for abortion services that may be
purchased in conjunction with enrollment in a HAPI plan
or an actuarially equivalent healthy American plan.
(B) Religious and moral exception.--Nothing in this
paragraph shall be construed to require a health
insurance issuer affiliated with a religious
institution to provide the coverage described in
subparagraph (A).
(4) Rule of construction.--Nothing in this subsection shall
be construed to prohibit a HAPI plan from providing coverage
for benefits, items, and services in addition to the coverage
required under this subsection. No premium subsidies shall be
available under subtitle C for any portion of the premiums for
a HAPI plan that are attributable to such additional benefits,
items, or services.
(c) Actuarially Equivalent Healthy American Plans.--Each
actuarially equivalent healthy American plan offered through an HHA
shall--
(1) cover all treatments, items, services, and providers at
least to the same extent as those covered under a HAPI plan
that--
(A) shall include coverage for--
(i) preventive items or services (including
well baby care and well child care and
appropriate immunizations) and disease
management services;
(ii) inpatient and outpatient hospital
services;
(iii) physicians' surgical and medical
services; and
(iv) laboratory and x-ray services; and
(B) may include additional supplemental benefits to
the extent approved by the State and provided for in
advance in the plan contract; and
(2) ensure that no personal responsibility contribution
requirements are applied for benefits, items, or services and
chronic disease management prevention.
(d) Premiums and Rating Requirements.--
(1) Classes of coverage.--With respect to a HAPI plan, a
health insurance issuer shall provide for the following classes
of coverage:
(A) Coverage of an individual.
(B) Coverage of a married couple or domestic
partnership (as determined by a State) without
dependent children.
(C) Coverage of an adult individual with 1 or more
dependent children.
(D) Coverage of a married couple or domestic
partnership (as determined by a State) with 1 or more
dependent children.
(2) Determinations of premiums.--With respect to each class
of coverage described in paragraph (1), a health insurance
issuer shall determine the premium amount for a HAPI plan using
adjusted community rating principals (including a risk-
adjustment mechanism), as described in paragraphs (3) and (4)
established by the State. States may permit premium variations
based only on geography, tobacco use, and family size. A State
may determine to have no variation.
(3) Rewards.--A State shall permit a health insurance
issuer to provide premium discounts and other incentives to
enrollees based on the participation of such enrollees in
wellness, chronic disease management, and other programs
designed to improve the health of the enrollees.
(4) Limitation.--A health insurance issuer shall not
consider age, gender, industry, health status, or claims
experience in determining premiums under this subsection.
(e) Application of State Mandate Laws.--State benefit mandate laws
that would otherwise be applicable to HAPI plans shall be preempted.
(f) Definition of Preventive Items or Services.--In this section,
the term ``preventive items or services'' means clinical activities
that help prevent or detect disease, illness, or disability and may
include--
(1) immunizations and preventive physical examinations;
(2) screening tests for blood pressure, high cholesterol,
diabetes, cancer, and mental illness; and
(3) other services that the Secretary determines to be
reasonable and necessary for the prevention or early detection
of a disease, illness, or disability.
SEC. 112. SPECIFIC COVERAGE REQUIREMENTS.
(a) In General.--Each HAPI plan offered through a HHA shall--
(1) provide for increased portability through limitations
on the application of preexisting condition exclusions,
consistent with that provided for under section 2701 of the
Public Health Service Act (42 U.S.C. 300gg), as such section
existed on the day before the date of enactment of this Act,
except that the State shall develop procedures to ensure that
preexisting exclusion limitations do not apply to new enrollees
who had no applicable creditable coverage immediately prior to
the first enrollment period;
(2) provide for the guaranteed availability of coverage to
prospective enrollees in a manner similar to that provided for
under section 2711 of the Public Health Service Act (42 U.S.C.
300gg-11), as such section existed on the day before the date
of enactment of this Act;
(3) provide for the guaranteed renewability of coverage in
a manner similar to that provided for under section 2712 of the
Public Health Service Act (42 U.S.C. 300gg-12), as such section
existed on the day before the date of enactment of this Act,
except that the prohibition on market reentry provided for
under such section shall be deemed to be 2 years;
(4) prohibit discrimination against individual enrollees
and prospective enrollees based on health status in a manner
similar to that provided for under section 2702 of the Public
Health Service Act (42 U.S.C. 300gg-1), as such section existed
on the day before the date of enactment of this Act;
(5) provide coverage protections for enrollees who are
mothers and newborns in a manner similar to that provided for
under section 2704 of the Public Health Service Act (42 U.S.C.
300gg-3), as such section existed on the day before the date of
enactment of this Act;
(6) provide for full parity in the application of certain
limits to mental health benefits in a manner similar to that
provided for under section 2705 of the Public Health Service
Act (42 U.S.C. 300gg-4), as such section existed on the day
before the date of enactment of this Act;
(7) provide coverage for reconstructive surgery following a
mastectomy in a manner similar to that provided for under
section 2706 of the Public Health Service Act (42 U.S.C. 300gg-
5), as such section existed on the day before the date of
enactment of this Act; and
(8) prohibit discrimination on the basis of genetic
information, as provided for under the amendments made by the
Genetic Information Nondiscrimination Act of 2008 (Public Law
110-233).
(b) Guidelines.--Not later than 1 year after the date of enactment
of this Act, the Secretary shall develop guidelines for the application
of the requirements of this section.
SEC. 113. UPDATING HEALTHY AMERICANS PRIVATE INSURANCE PLAN
REQUIREMENTS.
(a) In General.--The Secretary shall establish the Healthy America
Advisory Committee (referred to in this section as the ``Advisory
Committee'') to provide annual recommendations to the Secretary and
Congress concerning modifications to the benefits, items, and services
required under section 111(a)(1).
(b) Composition.--
(1) In general.--The Advisory Committee shall be composed
of 15 members to be appointed by the Comptroller General, of
which--
(A) at least 1 such member shall be a health
economist;
(B) at least 1 such member shall be an ethicist;
(C) at least 1 such member shall be a
representative of health care providers, including
nurses and other nonphysician providers;
(D) at least 1 such member shall be a
representative of health insurance issuers;
(E) at least 1 such member shall be a health care
consumer;
(F) at least 1 such member shall be a
representative of the United States Preventive Services
Task Force; and
(G) at least 1 such member shall be an actuary.
(2) Geographic balance.--The Comptroller General shall
ensure the geographic diversity of the members appointed under
paragraph (1).
(c) Terms, Vacancies.--Members of the Advisory Committee shall be
appointed for a term of 3 years and may be reappointed for 1 additional
term. In appointing members, the Comptroller General shall stagger the
terms of the initial members so that the terms of one-third of the
members expire each year. Vacancies in the membership of the Advisory
Committee shall not affect the Committee's ability to carry out its
functions. The Comptroller General shall appoint an individual to fill
the remaining term of a vacant member within 2 months of being notified
of such vacancy.
(d) Compensation and Expenses.--Each member of the Advisory
Committee who is not otherwise employed by the United States Government
shall receive compensation at a rate equal to the daily rate prescribed
for GS-18 under the General Schedule under section 5332 of title 5,
United States Code, for each day, including travel time, such member is
engaged in the actual performance of duties as a member of the
Committee. A member of the Advisory Committee who is an officer or
employee of the United States Government shall serve without additional
compensation. All members of the Advisory Committee shall be reimbursed
for travel, subsistence, and other necessary expenses incurred by them
in the performance of their duties.
(e) Action by Secretary.--Not later than December 31 of the second
full calendar year following the date of enactment of this Act, and
each December 31 thereafter, the Advisory Committee shall provide to
Congress and the Secretary a report that--
(1) describes any recommendations for modifications to the
benefits, items, and services that are required to be covered
under a HAPI plan; and
(2) includes any recommendations to modify HAPI plans to
improve the quality of life for United States citizens and to
ensure that benefits in such plans are medically- and cost-
effective.
(f) Application of FACA.--The Federal Advisory Committee Act (5
U.S.C. App.) shall apply to the Advisory Committee, except that section
14 of such Act shall not apply.
Subtitle C--Eligibility for Premium and Personal Responsibility
Contribution Subsidies
SEC. 121. ELIGIBILITY FOR PREMIUM SUBSIDIES.
(a) Individuals and Families At or Below the Poverty Line.--For any
calendar year, in the case of a covered individual who is determined to
have a modified adjusted gross income that is at or below 100 percent
of the poverty line, as applicable to a family of the size involved,
the covered individual is entitled under this section to an income-
related premium subsidy equal to the basic premium subsidy amount.
(b) Partial Subsidy for Other Individuals and Families.--
(1) In general.--For any calendar year, in the case of a
covered individual who is determined to have a modified
adjusted gross income that is greater than 100 percent of the
poverty line, as applicable to a family of the size involved,
but below the applicable percentage of the poverty line, as
applicable to a family of the size involved, the covered
individual is entitled under this section to an income-related
premium subsidy equal to the basic premium subsidy amount
reduced by the amount determined under paragraph (2).
(2) Amount of reduction.--The amount of the reduction
determined under this paragraph is the amount that bears the
same ratio to the basic premium subsidy amount as--
(A) the excess of--
(i) such individual's modified adjusted
gross income, over
(ii) an amount equal to 100 percent of the
poverty line as applicable to a family of the
size involved, bears to
(B) the excess of--
(i) an amount equal to the applicable
percentage of the poverty line as applicable to
a family of the size involved, over
(ii) an amount equal to 100 percent of the
poverty line as applicable to a family of the
size involved.
(3) Applicable percentage.--For purposes of this
subsection, the applicable percentage is 400 percent.
(c) Basic Premium Subsidy Amount.--For purposes of this section,
the term ``basic premium subsidy amount'' means, with respect to any
individual, the lesser of--
(1) the annual premium for the HAPI plan under which the
individual is a covered individual; or
(2) the weighted average of the premium for HAPI plans of
the same class of coverage (as described in section 111(d)(1))
as the individual's in the applicable coverage area.
(d) Change in Status Notification.--
(1) In general.--If an individual's modified adjusted
income changes such that the individual becomes eligible or
ineligible for a subsidy under this section, the individual
shall report that change to the HHA of the individual's State
of residence not more than 60 days after the change takes
effect. If an individual reports the change within 60 days
under the preceding sentence, the individual's HAPI plan
coverage shall be deemed credible coverage for the purposes of
maintaining coverage for preexisting conditions.
(2) Adjustment.--The HHA shall adjust the premium subsidy
of such individual to take effect on the first month after the
date of the notification under paragraph (1) for which the next
premium payment would be due from the individual.
(e) Catastrophic Event.--A State may develop mechanisms to ensure
that covered individuals do not have a break in coverage due to a
catastrophic financial event.
SEC. 122. ELIGIBILITY FOR PERSONAL RESPONSIBILITY CONTRIBUTION
SUBSIDIES.
(a) Full Subsidy.--To meet the eligibility requirements under
subtitle B for an HHA, for any taxable year, in the case of a covered
individual who is determined to have a modified adjusted gross income
that is below 100 percent of the poverty line as applicable to a family
of the size involved, an HHA shall provide to such an individual a
subsidy equal to the full amount of any personal responsibility
contributions applicable to such individual.
(b) Partial Subsidy.--To meet the eligibility requirements under
subtitle B for an HHA, for any taxable year, in the case of a covered
individual who is determined to have a modified adjusted gross income
that is at or above 100 percent of the poverty line as applicable to a
family of the size involved, an HHA may provide to such an individual a
subsidy equal to the part of the amount of any personal responsibility
contributions applicable to such individual.
SEC. 123. DEFINITIONS AND SPECIAL RULES.
(a) Determination of Modified Adjusted Gross Income.--
(1) In general.--In this subtitle, the term ``modified
adjusted gross income'' means adjusted gross income (as defined
in section 62 of the Internal Revenue Code of 1986)--
(A) determined without regard to sections 86, 135,
137, 199, 221, 222, 911, 931, and 933 of such Code; and
(B) increased by--
(i) the amount of interest received or
accrued during the taxable year which is exempt
from tax under such Code; and
(ii) the amount of any social security
benefits (as defined in section 86(d) of such
Code) received or accrued during the taxable
year.
(2) Taxable year to be used to determine modified adjusted
gross income.--In applying this subtitle to determine an
individual's annual premiums, the covered individual's modified
adjusted gross income shall be such income determined using the
individual's most recent income tax return or other information
furnished to the Secretary by such individual, as the Secretary
may require.
(b) Poverty Line.--In this subtitle, the term ``poverty line'' has
the meaning given such term in section 673(2) of the Community Health
Services Block Grant Act (42 U.S.C. 9902(2)), including any revision
required by such section.
(c) Other Procedures To Determine Subsidies.--The Secretary shall
promulgate regulations to be used by HHAs to calculate the premium
subsidies under section 121 and personal responsibility subsidies under
section 122 for individuals whose modified adjusted gross income
described in subsection (a)(2) is significantly lower than the modified
adjusted gross income of the year involved.
(d) Special Rule for Unlawfully Present Aliens.--A health insurance
issuer shall remit to the Federal Government any funding, including any
subsidy payments, received by such issuer from the Federal Government
on behalf of any adult alien who is unlawfully present in the United
States.
(e) Special Rule for Aliens.--The Secretary of Homeland Security
may not extend or renew an alien's eligibility for status in the United
States or adjust the status of an alien in the United States if the
alien owes--
(1) a premium payment for a HAPI plan that is past due; or
(2) a penalty incurred for failing to pay such a premium.
(f) No Discharge in Bankruptcy.--In the case of any bankruptcy
filed by or on behalf of any person after the date that is 2 years
after the date of enactment of this Act, under title 11, United States
Code, any penalty imposed with respect to such person for failure to
pay a HAPI plan premium shall not be subject to discharge under such
title.
Subtitle D--Wellness Programs
SEC. 131. REQUIREMENTS FOR WELLNESS PROGRAMS.
(a) Definition.--In this Act, the term ``wellness program'' means a
program that consists of a combination of activities that are designed
to increase awareness, assess risks, educate, and promote voluntary
behavior change to improve the health of an individual, modify his or
her consumer health behavior, enhance his or her personal well-being
and productivity, and prevent illness and injury.
(b) Discounts.--
(1) Eligibility.--With respect to a HAPI plan that is
offered in a State that permits premium discounts for enrollees
who participate in a wellness program, to be eligible to
receive such a discount, the administrator of the wellness
program, on behalf of the enrollee, shall certify in writing to
the plan that--
(A)(i) the enrollee is participating in an approved
wellness program; or
(ii) the dependent child of the enrollee is
participating in an approved wellness program; and
(B) the wellness program meets the requirements of
this subsection.
(2) Requirements.--A wellness program meets the
requirements of this paragraph if such program--
(A) is reasonably designed (as determined by the
HAPI plan) to promote good health and prevent disease
for program participants;
(B) has been approved by the HAPI plan for purposes
of applying participation discounts;
(C) is offered to all enrollees in a HAPI plan
regardless of health status;
(D) permits any enrollee for whom it is
unreasonably difficult to meet the initial program
standard for participation due to a medical condition
(or for whom it is medically inadvisable to attempt) an
opportunity to meet a reasonable alternative
participation standard--
(i)(I) that is developed prior to
enrollment of the enrollee; or
(II) that is developed in consultation with
the enrollee after enrollment of the enrollee,
after a determination has been made that the
enrollee cannot safely meet the program
participation standard; and
(ii) the availability of which is disclosed
in the original documents relating to
participation in the program;
(E) applies procedures for determining whether an
enrollee is participating in a meaningful manner in the
program, including procedures to determine if such
participation is resulting in lifestyle changes that
are indicative of an improved health outcome or
outcomes; and
(F) meets any other requirements imposed by the
HAPI plan.
(3) Relation to health status.--Participation in a wellness
program may not be used by a HAPI plan to make rate or discount
determinations with respect to the health status of an
enrollee.
(4) Availability of discounts.--
(A) Offering of enrollment.--A HAPI plan shall
provide enrollees with the opportunity to participate
in a wellness program (for purposes of qualifying for
premium discounts) at least once each year.
(B) Determinations.--Determinations with respect to
the successful participation by an enrollee in a
wellness program for purposes of qualifying for
discounts shall be made by the HAPI plan based on a
retrospective review of the scope of activities of the
enrollee under the program. The HAPI plan may require a
minimum level of successful participation in such a
program prior to applying any premium discount.
(C) Participation in multiple programs.--An
enrollee may participate in multiple wellness programs
to reach the maximum premium discount permitted by the
HAPI plan under applicable State law.
(5) Personal responsibility contribution discount.--A HAPI
plan may elect to provide discounts in the amount of the
personal responsibility contribution that is required of an
enrollee if the enrollee participates in an approved wellness
program.
(c) Employer Incentive for Wellness Programs.--For provisions
relating to employers deducting the costs of offering wellness programs
or worksite health centers see section 162(l) of the Internal Revenue
Code of 1986.
TITLE II--HEALTHY START FOR CHILDREN
Subtitle A--Benefits and Eligibility
SEC. 201. GENERAL GOAL AND AUTHORIZATION OF APPROPRIATIONS FOR HAPI
PLAN COVERAGE FOR CHILDREN.
(a) General Goal.--It is the general goal of this Act to provide
essential, good quality, affordable, and prevention-oriented health
care coverage for all children in the United States.
(b) Authorization of Appropriations.--There is authorized to be
appropriated, such sums as may be necessary for each fiscal year to
enable the Secretary to provide assistance to States to enable such
States to ensure that each child who is a member of a family with a
modified adjusted gross income that is below 300 percent of the poverty
line as applicable to a family of the size involved, who is not
otherwise eligible for coverage as a dependent under a HAPI plan
maintained by his or her parents, is covered under a HAPI plan provided
through the State HHA.
(c) Policies and Procedures.--The Secretary shall develop policies
and procedures to be applied by the States to identify children
described in subsection (a) and to provide such children with coverage
under a HAPI plan. States shall determine, in consultation with health
insurance issuers, a separate class of coverage to assure affordable
child coverage.
(d) Definition.--In this title, the term ``child'' means an
individual who is under the age of 19 years or, in the case of an
individual in foster care, under the age of 21 years.
SEC. 202. COORDINATION OF SUPPLEMENTAL COVERAGE UNDER THE MEDICAID
PROGRAM WITH HAPI PLAN COVERAGE FOR CHILDREN.
(a) Assurance of Supplemental Coverage.--Subject to section 631(d),
the Secretary, States, and health insurance issuers shall ensure that
any child eligible under title XIX of the Social Security Act
(including any child eligible under a waiver under such title or under
section 1115 of such Act (42 U.S.C. 1315)) covered under a HAPI plan
provided through the State HHA receives medical assistance under State
Medicaid plans in a manner that--
(1) is provided in coordination with, and as a supplement
to, the coverage provided the child under the HAPI plan in
which the child is enrolled;
(2) does not supplant the child's coverage under a HAPI
plan;
(3) ensures that the child receives all items or services
that are not available (or are otherwise limited) under the
HAPI plan in which they are enrolled but that is provided under
the State plan (or provided to a greater extent or in a less
restrictive manner) under title XIX of the Social Security Act
(including any waiver under such title or under section 1115 of
such Act (42 U.S.C. 1315)) of the State in which the child
resides; and
(4) ensures that the family of the child is not charged
premiums, deductibles, or other cost-sharing that is greater
than would have been charged under the State plan under title
XIX of the Social Security Act of the State in which the child
resides if such coverage was not provided as a supplement to
the coverage provided the child under the HAPI plan in which
the child is enrolled.
(b) Guidance to States and Health Insurance Issuers.--The Secretary
shall issue regulations and guidance to States and health insurance
issuers implementing this section not later than 6 months prior to the
date on which coverage under a HAPI plan first begins.
(c) Rule of Construction.--Nothing in this section shall be
construed as affecting a State's requirement to provide items and
services described in section 1905(a)(4)(B) (relating to early and
periodic screening, diagnostic, and treatment services defined in
section 1905(r) and provided in accordance with the requirements of
section 1902(a)(43)).
(d) Child.--In this section, the term ``child'' has the meaning
given that term under section 201(d), and includes any individual who
would be considered a child under the Medicaid program of the State in
which the individual resides.
Subtitle B--Service Providers
SEC. 211. INCLUSION OF PROVIDERS UNDER HAPI PLANS.
(a) In General.--To ensure that children have access to health care
in their communities, and that such care is provided to such children
for no cost or on a reimbursable basis, a HAPI plan shall ensure that
health care items and services may be obtained by such children from,
at a minimum, the providers described in subsection (b) if available in
the area involved.
(b) Providers Described.--The providers described in this
subsection include the following:
(1) A school-based health center (in accordance with
section 212).
(2) A health center funded under section 330 of the Public
Health Service Act (42 U.S.C. 254b).
(3) A federally qualified health center.
(4) A rural health clinic under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.).
(5) An Indian health service facility.
SEC. 212. USE OF, AND GRANTS FOR, SCHOOL-BASED HEALTH CENTERS.
(a) Definition.--In this section, the term ``school-based health
center'' means a health center that--
(1) is located within an elementary or secondary school
facility;
(2) is operated in collaboration with the school in which
such center is located;
(3) is administered by a community-based organization
including a hospital, public health department, community
health center, or nonprofit health care agency;
(4) at a minimum, provides to school-aged children--
(A) primary health care services, including
comprehensive health assessments, and diagnosis and
treatment of minor, acute, and chronic medical
conditions and Healthy Start benefits;
(B) mental health services, including crisis
intervention, counseling, and emergency psychiatric
care at the school or by referral;
(C) the availability of services at the school when
the school is open and 24-hour coverage through an on-
call system with other providers to ensure access when
the school or health center is closed;
(D) services through the use of a qualified and
appropriately credentialed individual, including a
nurse practitioner or physician assistant, a mental
health professional, a physician, and a health
assistant; and
(E) by not later than January 1, 2012, an
electronic medical record relating to the individual;
and
(5) may provide optional preventive dental services,
consistent with State licensure law, through the use of dental
hygienists or dental assistants that provide preventive
services such as basic oral exams, cleanings, and sealants.
(b) Access to School-Based Health Centers.--
(1) In general.--A school-based health center may provide
services to students in more than 1 school if the school
district or other supervising State entity determined that
capacity and geographic location make such provision of
services appropriate.
(2) Enrollment.--Upon the enrollment of a student in a
school with a school-based health center, the center will
provide the student with the opportunity to enroll, after
parental consent (subject to State and local law), to receive
health care from the center.
(3) Reimbursement for services.--
(A) In general.--A school-based health center may
seek reimbursement from a third party payer if
available, including a HAPI plan, if a child receives
health care items or services through the center.
(B) Use of funds.--Amounts received from a third
party payer under subparagraph (A) shall be allocated
to the school-based health center that provided the
care for which the reimbursement was provided for use
by that center for providing additional health care
items and services.
(c) Developmental Grants.--
(1) In general.--The Secretary shall award grants to local
school districts and communities for the establishment and
operation of school-based health centers.
(2) Eligibility.--To be eligible for a grant under
paragraph (1), a local school district or local community shall
submit to the Secretary an application at such time, in such
manner, and containing such information as the Secretary may
require.
(3) Selection criteria.--In awarding grants under this
subsection, the Secretary shall give priority to--
(A) an applicant that will use amounts under the
grant to establish a school-based health center in a
medically underserved area, or an area for which there
are extended distances between the school involved and
appropriate providers of care for school-aged children
in the geographic area involved;
(B) an applicant that will use amounts under the
grant to establish a school-based health center in a
school that serves students with the highest incidence
of unmet medical and psycho-social needs; and
(C) an applicant that can demonstrate that State,
local, or community partners, or any combination of
such entities, have provided at least 50 percent of the
funding for the school-based health center involved to
ensure the ongoing operation of the center.
(4) Use of funds.--A grantee shall use amounts received
under a grant under this subsection to establish and operate a
school-based health center (including purchasing and
maintaining electronic medical records). Not less than 50
percent of the amounts received under the grant shall be used
for the ongoing operations of the center (including such
purchases and maintenance).
(d) Coverage by Federal Tort Claims Act.--In providing health care
items and services to students through a school-based health care
center, a health care provider shall be deemed to be an employee of the
government for purposes of the application of chapter 171 of title 28,
United States Code (the Federal Tort Claims Act) if such provider was
acting within the scope of his or her license.
(e) Authorization of Appropriations.--There is authorized to be
appropriated, such sums as may be necessary for each fiscal year to
carry out this section.
TITLE III--BETTER HEALTH FOR OLDER AND DISABLED AMERICANS
Subtitle A--Assurance of Supplemental Medicaid Coverage
SEC. 301. COORDINATION OF SUPPLEMENTAL COVERAGE UNDER THE MEDICAID
PROGRAM FOR ELDERLY AND DISABLED INDIVIDUALS.
(a) Assurance of Supplemental Coverage.--Subject to section 631(d),
the Secretary, States, and health insurance issuers shall ensure that
any elderly or disabled individual eligible under title XIX of the
Social Security Act (including any such individual eligible pursuant to
a waiver under such title or under section 1115 of such Act (42 U.S.C.
1315)) covered under a HAPI plan provided through the State HHA
receives medical assistance under State Medicaid plans in a manner
that--
(1) is provided in coordination with, and as a supplement
to, the coverage provided the individual under the HAPI plans
in which the individual is enrolled;
(2) does not supplant the individual's coverage under a
HAPI plan;
(3) ensures that the elderly or disabled individual
receives all items or services, including institutional care or
home and community-based services that are not available (or
are otherwise limited) under the HAPI plan in which they are
enrolled but that is provided (or provided to a greater extent
or in a less restrictive manner) under the State plan under
title XIX of the Social Security Act (including through any
waiver under such title or under section 1115 of such Act (42
U.S.C. 1315)) of the State in which the individual resides;
(4) ensures that the elderly or disabled individual is not
charged premiums, deductibles and other cost-sharing that is
greater than would have been charged under the State plan under
title XIX of the Social Security Act (including any waiver
under such title or under section 1115 of such Act (42 U.S.C.
1315)) of the State in which the individual resides if such
coverage was not provided as a supplement to the coverage
provided the individual under the HAPI plan in which the
individual is enrolled.
(b) Guidance to States and Health Insurance Issuers.--The Secretary
shall issue regulations and guidance to States and health insurance
issuers implementing this section that takes into account the special
health care needs of elderly and disabled individuals who are eligible
for medical assistance under State Medicaid programs, particularly with
respect to institutionalized care or home and community-based services,
not later than 6 months prior to the date on which coverage under a
HAPI plan first begins.
(c) Definitions.--In this section--
(1) the term ``institutionalized care'' means the health
care provided under the Medicaid plan of the State of residence
of an elderly or disabled individual who is a patient in a
hospital, nursing facility, intermediate care facility for the
mentally retarded, or an institution for mental diseases (as
such terms are defined for purposes of such plan); and
(2) the term ``home and community-based services'' means
any services which may be offered under the Medicaid plan of
the State of residence of an elderly or disabled individual
under a home and community-based waiver authorized for a State
under section 1115 of the Social Security Act (42 U.S.C. 1315)
or under subsection (c), (d), or (i) of section 1915 of such
Act (42 U.S.C. 1396n).
Subtitle B--Empowering Individuals and States To Improve Long-Term Care
Choices
SEC. 311. NEW, AUTOMATIC MEDICAID OPTION FOR STATE CHOICES FOR LONG-
TERM CARE PROGRAM.
(a) In General.--Title XIX of the Social Security Act (42 U.S.C.
1396 et seq.) is amended by adding at the end the following new
section:
``state choices for long-term care program
``Sec. 1942. (a) In General.--Notwithstanding any other provision
of this title, the Secretary shall permit a State to establish and
operate under the State plan under this title (including such a plan
operating under a statewide waiver under section 1115) a State Choices
for Long-Term Care Program in accordance with this section.
``(b) Program Requirements.--A program established under the
authority of this section shall satisfy the following requirements:
``(1) Individualized benefit package.--Each individual
enrolled in the program shall be provided with long-term care
coverage consisting of medical assistance for long-term care
services that are provided according to the specific needs of
the individual and that best reflect the individual's needs and
preferences, based on a clinical assessment of the individual.
``(2) Personal case managers.--Each individual enrolled in
the program shall be provided with a personal case manager who
shall assist the individual in--
``(A) determining the individual's needs and
preferences for the long-term care services that are
contained within the individual's benefit package,
including the selection of the service providers for
such services;
``(B) identifying community resources that are
available to provide support for the individual; and
``(C) addressing issues related to ensuring the
safety and quality of the long-term care services
provided to the individual.
``(3) Informed choice.--The program shall have procedures
to ensure that each individual that is likely to satisfy the
eligibility criteria established for the program under
paragraph (6) who is discharged from a hospital or who resides
in a nursing facility, intermediate care facility for the
mentally retarded, or institution for mental diseases and who
requires long-term care services is informed of the options
available to the individual under the program for obtaining
such services.
``(4) Self-directed option.--The program shall provide an
individual enrolled in the program with the option to elect to
plan and purchase the long-term care services that are
contained in the individual's benefit package under the
direction and control of the individual (or the individual's
authorized representative), subject to an individualized budget
developed for, and with the involvement of, the individual (or
the individual's authorized representative).
``(5) Equal access to institutional care and home and
community-based services.--The program shall provide an
individual enrolled in the program who, because of the
individual's mental or physical condition, requires a level of
care for long term care services that is above a level of care
for such services that can appropriately be provided solely
through home and community-based providers (as defined by the
State and approved by the Secretary), with equal access to
long-term care services provided through institutional
facilities and long-term care services provided through home
and community-based providers.
``(6) Eligibility; prioritization of need.--The program
shall apply eligibility criteria for individuals desiring to
enroll in the program that is established by the State and
approved by the Secretary. The eligibility criteria established
by the State shall--
``(A) require that an individual enrolled in the
program--
``(i) be eligible for medical assistance
under the State plan (or under a statewide
waiver of such plan) for nursing facility
services, services in an intermediate care
facility for the mentally retarded, services in
an institution for mental diseases, or services
provided under a home and community-based
waiver approved for the State; and
``(ii) satisfy such other criteria as the
State shall establish; and
``(B) be based on a strategy for prioritizing and
allocating expenditures so that those individuals with
the highest level of need for long-term care services
are assured of receiving such services through an
institutional facility or through a home and community-
based provider, based on the individual's needs and
preferences.
``(c) Additional Requirements.--A State may not establish and
operate a program under this section unless it satisfies the following
requirements:
``(1) Agreement to limit federal expenditures.--
``(A) In general.--The State agrees to an aggregate
limit for a 5-year period for Federal payments under
section 1903(a) for expenditures for medical assistance
for long-term care services under the State plan and
administrative expenditures related to the provision of
such assistance.
``(B) Calculation of aggregate limit.--The 5-year
aggregate limit applicable to a State under
subparagraph (A) shall be determined by the State and
the Secretary based on the following:
``(i) Historical and projected caseloads.--
The historical and projected State caseloads
(determined for a 5-year period, respectively)
of individuals receiving nursing facility
services, services in an intermediate care
facility for the mentally retarded, services in
an institution for mental diseases, or services
provided under a home and community-based
waiver approved for the State under the State
plan, based on data from the Secretary, the
Bureau of the Census, the Commissioner of
Social Security, and such other sources as the
Secretary may approve.
``(ii) Historical and projected
expenditures.--The historical and projected
expenditures (determined for a 5-year period,
respectively) for the services identified in
clause (i). Projected expenditures shall be
determined without regard to the program
established under this section and shall take
into account the percentage change (if any) in
the medical care component of the consumer
price index for all urban consumers (U.S. city
average) for each year of the period.
``(C) Rule of construction.--Nothing in this
paragraph shall be construed as affecting the
requirement for a State to incur State expenditures for
medical assistance for long-term care services in order
to be paid the Federal medical assistance percentage
determined for the State for such expenditures (not to
exceed the aggregate 5-year limit on Federal payments
for such expenditures applicable under subparagraph
(A)).
``(2) Plan for capacity building and skills enhancement.--
The State establishes a plan for building the capacity of the
long-term care services system within the State, particularly
with respect to the delivery of home and community-based
services, and for enhancing the skill levels of the caregivers
for individuals eligible for medical assistance for such
services under the State plan.
``(3) Dedication of program savings for prevention or early
intervention services.--The State agrees that for each fiscal
year in which the program is operated, the State will expend an
amount equal to the State share of the expenditures that the
State would have made under the State plan for providing
medical assistance for long-term care services for individuals
enrolled in the program but for the operation of such program,
for the provision of prevention or early intervention services
for nonenrolled individuals residing in the State who require a
level of long-term care services that is below the level that
individuals enrolled in the program require (regardless of
whether such nonenrolled individuals are eligible for medical
assistance under the State plan).
``(d) Option To Operate Program Through a Managed Care Plan.--A
State may operate a program under this section through an arrangement
on a capitated basis with a medicaid managed care organization (as
defined in section 1903(m)(1)(A)).
``(e) Independent Evaluation and Report.--
``(1) In general.--The Secretary shall contract with a
nongovernmental organization or academic institution to conduct
an ongoing independent evaluation of the program that
assesses--
``(A) the quality of the long-term care services
provided under the program;
``(B) the cost-effectiveness of such services;
``(C) consumer satisfaction; and
``(D) the consistency and accuracy with which the
prioritization of need criteria required under
subsection (b)(6)(B) is applied.
``(2) Biennial reports.--The organization or institution
conducting the evaluation required under this subsection shall
submit biennial reports to the Secretary regarding the results
of the evaluation.
``(f) Definition of Long-Term Care Services.--For purposes of this
section, the term `long-term care services' has the meaning given such
term by a State establishing and operating a program under this
section, subject to approval by the Secretary.''.
(b) Effective Date.--The amendment made by subsection (a) takes
effect on the date of enactment of this Act.
SEC. 312. SIMPLER AND MORE AFFORDABLE LONG-TERM CARE INSURANCE
COVERAGE.
(a) Qualified Long-Term Care Insurance Contract Must Satisfy
Qualified Long-Term Care Plan Requirements.--Section 7702B(b)(1)(A) of
the Internal Revenue Code of 1986 (defining qualified long-term care
insurance contract) is amended by inserting ``through a qualified long-
term care plan'' after ``qualified long-term care services''.
(b) Qualified Long-Term Care Plan.--Section 7702B of such Code is
amended by adding at the end the following new subsection:
``(h) Qualified Long-Term Care Plan.--For purposes of this
section--
``(1) In general.--The term `qualified long-term care plan'
means an insurance plan that meets the standards and
requirements set forth in paragraph (2) (including the 2011
NAIC Model Regulation or 2011 Federal Regulation (as the case
may be)) on or after the date specified in paragraph (5).
``(2) Development of standards and requirements for
qualified long-term care plans.--
``(A) In general.--If, within 9 months after the
date of the enactment of this subsection, the National
Association of Insurance Commissioners (in this
subsection referred to as the `Association') adopts a
model regulation (in this section referred to as the
`2011 NAIC Model Regulation') to incorporate--
``(i) limitations on the groups or packages
of benefits that may be offered under a long-
term care insurance policy consistent with
paragraphs (3) and (4),
``(ii) uniform language and definitions to
be used with respect to such benefits,
``(iii) uniform format to be used in the
policy with respect to such benefits, and
``(iv) other standards required by the
Secretary of Health and Human Services,
paragraph (1) shall be applied in each State, effective
for policies issued to policyholders on and after the
date specified in paragraph (5).
``(B) Secretarial responsibility.--If the
Association does not adopt the 2011 NAIC Model
Regulation within the 9-month period specified in
subparagraph (A), the Secretary shall promulgate, not
later than 9 months after the end of such period, a
regulation (in this section referred to as the `2011
Federal Regulation') and paragraph (1) shall be applied
in each State, effective for policies issued to
policyholders on and after the date specified in
paragraph (5).
``(C) Consultation.--In promulgating standards and
requirements under this paragraph, the Association or
Secretary shall consult with a working group composed
of representatives of issuers of long-term care
insurance policies, consumer groups, long-term care
insurance beneficiaries, and other qualified
individuals. Such representatives shall be selected in
a manner so as to insure balanced representation among
the interested groups.
``(3) Limitations of groups or packages of benefits.--The
benefits under the 2011 NAIC Model Regulation or 2011 Federal
Regulation shall provide--
``(A) for such groups or packages of benefits as
may be appropriate taking into account the
considerations specified in paragraph (4) and the
requirements of the succeeding subparagraphs,
``(B) for identification of a core group of basic
benefits common to all policies, and
``(C) that the total number of different benefit
packages (counting the core group of basic benefits
described in subparagraph (B) and each other
combination of benefits that may be offered as a
separate benefit package) that may be established in
all the States and by all issuers shall not exceed 10.
``(4) Specific considerations.--The benefits under
paragraph (3) shall, to the extent possible--
``(A) provide for benefits that offer consumers the
ability to purchase the benefits that are available in
the market as of November 5, 2010, and
``(B) balance the objectives of--
``(i) simplifying the market to facilitate
comparisons among policies,
``(ii) avoiding adverse selection,
``(iii) providing consumer choice,
``(iv) providing market stability, and
``(v) promoting competition.
``(5) Effective date.--
``(A) In general.--Subject to subparagraph (B), the
date specified in this paragraph shall be the date the
State adopts the 2011 NAIC Model Regulation or 2011
Federal Regulation or 1 year after the date the
Association or the Secretary first adopts such
standards, whichever is earlier.
``(B) Required state legislation.--In the case of a
State which the Secretary identifies, in consultation
with the Association, as--
``(i) requiring State legislation (other
than legislation appropriating funds) in order
for long-term care insurance policies to meet
the 2011 NAIC Model Regulation or 2011 Federal
Regulation, but
``(ii) having a legislature which is not
scheduled to meet in 2011 in a legislative
session in which such legislation may be
considered,
the date specified in this paragraph is the first day
of the first calendar quarter beginning after the close
of the first legislative session of the State
legislature that begins on or after January 1, 2012.
For purposes of the preceding sentence, in the case of
a State that has a 2-year legislative session, each
year of such session shall be deemed to be a separate
regular session of the State legislature.''.
(c) Additional Consumer Protections.--
(1) In general.--Section 7702B(g)(1) of such Code (relating
to consumer protection provisions) is amended--
(A) by striking subparagraph (A) and inserting the
following new paragraph:
``(1) the requirements of the 1993 NAIC model regulation
and model Act described in paragraph (2) and the 2000 NAIC
model regulation and model Act described in paragraph (5),'',
(B) by striking ``and'' at the end of subparagraph
(B),
(C) by striking the period at the end of
subparagraph (C) and inserting ``, and'', and
(D) by adding at the end the following new
subparagraph:
``(D) the requirements relating to mandatory offer
and information under paragraph (6).''.
(2) NAIC model regulation and act.--Section 7702B(g) of
such Code is amended--
(A) by inserting ``1993 naic'' after ``Requirements
of'' in the heading for paragraph (2),
(B) by redesignating paragraph (5) as paragraph
(7), and
(C) by inserting after paragraph (4) the following
new paragraph:
``(5) Requirements of 2000 naic model regulation and act.--
``(A) In general.--The requirements of this
paragraph are met with respect to any contract if such
contract meets--
``(i) Model regulation.--The following
requirements of the model regulation:
``(I) Section 6A (other than
paragraph (5) thereof) and the
requirements of section 6B of the model
Act relating to such section 6A.
``(II) Section 6B (other than
paragraph (7) thereof).
``(III) Sections 6C, 6D, 6E, and 7.
``(IV) Section 8 (other than
sections 8F, 8G, 8H, and 8I thereof).
``(V) Sections 9, 11, 12, 14, 15,
and 22.
``(VI) Section 23, including
inaccurate completion of medical
histories (other than paragraphs (1),
(6), and (9) of section 23C).
``(VII) Sections 24 and 25.
``(VIII) The provisions of section
26 relating to contingent nonforfeiture
benefits, if the policyholder declines
the offer of a nonforfeiture provision
described in paragraph (4).
``(IX) Sections 29 and 30.
``(ii) Model act.--The following
requirements of the model Act:
``(I) Sections 6C and 6D.
``(II) The provisions of section 8
relating to contingent nonforfeiture
benefits.
``(III) Sections 6F, 6G, 6H, 6J,
6K, and 7.
``(B) Definitions.--For purposes of this
paragraph--
``(i) Model provisions.--The terms `model
regulation' and `model Act' mean the long-term
care insurance model regulation, and the long-
term care insurance model Act, respectively,
promulgated by the National Association of
Insurance Commissioners (as adopted as of
October 2000).
``(ii) Coordination.--Any provision of the
model regulation or model Act listed under
clause (i) or (ii) of subparagraph (A) shall be
treated as including any other provision of
such regulation or Act necessary to implement
the provision.
``(iii) Determination.--For purposes of
this section and section 4980C, the
determination of whether any requirement of a
model regulation or the model Act has been met
shall be made by the Secretary.''.
(d) Mandatory Offer and Information.--Section 7702B(g) of such
Code, as amended by subsection (c), is amended by inserting after
paragraph (5) the following new paragraph:
``(6) Mandatory offer and information.--The requirements of
this paragraph are met if--
``(A) Mandatory offer.--Any person who sells a
long-term care insurance policy to an individual shall
make available for sale to the individual a long-term
care insurance policy with only the core group of basic
benefits (described in subsection (h)(3)(B)).
``(B) Information.--Any person who sells a long-
term care insurance policy to an individual shall
provide the individual, before the sale of the policy,
an outline of coverage which describes the benefits
under the policy. Such outline shall be on a standard
form approved by the State regulatory program or the
Secretary (as the case may be) consistent with the 2011
NAIC Model Regulation or 2011 Federal Regulation.''.
(e) State Regulation of Out-of-State Contracts.--Section 7702B of
such Code, as amended by subsection (b), is amended by adding at the
end the following new subsection:
``(i) State Regulation of Out-of-State Contracts.--Nothing in this
section shall be construed so as to affect the right of any State to
regulate long-term care insurance policies which, under the provisions
of this section, are considered to be issued in another State.''.
(f) Effective Date.--The amendments made by this section shall
apply to contracts issued after December 31, 2010.
TITLE IV--HEALTHIER MEDICARE
Subtitle A--Authority To Adjust Amount of Part B Premium To Reward
Positive Health Behavior
SEC. 401. AUTHORITY TO ADJUST AMOUNT OF MEDICARE PART B PREMIUM TO
REWARD POSITIVE HEALTH BEHAVIOR.
Section 1839 of the Social Security Act (42 U.S.C. 1395r) is
amended--
(1) in subsection (a)(2), by striking ``and (i)'' and
inserting ``(i), and (j)''; and
(2) by adding at the end the following new subsection:
``(j)(1) With respect to the monthly premium amount for months
after December 2010, the Secretary may adjust (under procedures
established by the Secretary) the amount of such premium for an
individual based on whether or not the individual participates in
certain healthy behaviors, such as weight management, exercise,
nutrition counseling, refraining from tobacco use, designating a health
home, and other behaviors determined appropriate by the Secretary.
``(2) In making the adjustments under paragraph (1) for a month,
the Secretary shall ensure that the total amount of premiums to be paid
under this part for the month is equal to the total amount of premiums
that would have been paid under this part for the month if no such
adjustments had been made, as estimated by the Secretary.''.
Subtitle B--Promoting Primary Care for Medicare Beneficiaries
SEC. 411. PRIMARY CARE SERVICES MANAGEMENT PAYMENT.
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) is
amended by inserting after section 1807 the following new section:
``SEC. 1807A. PRIMARY CARE MANAGEMENT PAYMENT FOR COORDINATING CARE.
``(a) Payment.--
``(1) In general.--Not later than January 1, 2010, the
Secretary, subject to paragraph (2), shall establish procedures
for providing primary care and participating providers with a
management fee (as determined appropriate by the Secretary, in
consultation with the Medicare Payment Advisory Commission
established under section 1805) that reflects the amount of
time spent with a Medicare beneficiary, and the family of such
beneficiary, providing chronic care disease management services
or other services in assisting in coordinating care.
``(2) Requirement for designation as health home.--The
management fee under paragraph (1) shall not be provided to a
primary care provider with respect to a Medicare beneficiary
unless the provider has been designated (under procedures
established by the Secretary) as the health home by the
beneficiary.
``(b) Definitions.--In this section:
``(1) Health home.--The term `health home' means a health
care provider that a Medicare beneficiary has designated to
monitor the health and health care of the beneficiary.
``(2) Medicare beneficiary.--The term `Medicare
beneficiary' means an individual who is entitled to, or
enrolled for, benefits under part A, enrolled under part B, or
both.
``(3) Primary care provider.--
``(A) In general.--The term `primary care provider'
means a primary care physician (as defined in
subparagraph (B)), a nurse practitioner (as defined in
section 1861aa(5)(A)), or a physician assistant (as so
defined).
``(B) Primary care physician.--In subparagraph (A),
the term `primary care physician' means a physician,
such as a family practitioner or internist, who is
chosen by an individual to provide continuous medical
care, who is able to give a wide range of care,
including prevention and treatment, and who can refer
the individual to a specialist.''.
Subtitle C--Chronic Care Disease Management
SEC. 421. CHRONIC CARE DISEASE MANAGEMENT.
Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), as
amended by section 411, is amended by inserting after section 1807A the
following new section:
``SEC. 1807B. CHRONIC CARE DISEASE MANAGEMENT PROGRAM.
``(a) Establishment.--
``(1) In general.--Not later than January 1, 2010, the
Secretary shall develop and implement a chronic care disease
management program (in this section referred to as the
`program'). The program shall be designed to provide chronic
care disease management to all Medicare beneficiaries with
respect to at least the 5 most prevalent diseases within the
population of such beneficiaries (as determined by the
Secretary).
``(2) Development.--In developing and implementing the
program under paragraph (1), the Secretary shall--
``(A) take into consideration--
``(i) the results of chronic care
improvement programs conducted under section
1807, including the independent evaluations of
such programs conducted under section
1807(b)(5) and any outcomes reports submitted
under section 1807(e)(4)(A); and
``(ii) the results of the payments to
primary care providers under section 1807A; and
``(B) consult individuals with expertise in chronic
care disease management.
``(b) Identification and Enrollment.--The Secretary shall establish
procedures for identifying and enrolling Medicare beneficiaries who may
benefit from participation in the program.
``(c) Chronic Care Disease Management Payment for Non-Primary Care
Physicians.--
``(1) In general.--Under the program, a non-primary care
physician shall receive a chronic care disease management
payment if the physician serves the Medicare beneficiary by
assuring the beneficiary receives appropriate and comprehensive
care, including referral of the individual to specialists, and
assuring the beneficiary receives preventive services.
``(2) Amount of payment.--The amount of the management
payment under the program shall be an amount determined
appropriate by the Secretary, in consultation with the Medicare
Payment Advisory Commission established under section 1805.
Such amount shall reflect the amount of time spent with a
Medicare beneficiary, and the family of such beneficiary,
providing chronic care disease management services.
``(d) Definitions.--In this section:
``(1) Medicare beneficiary.--The term `Medicare
beneficiary' means an individual who is entitled to, or
enrolled for, benefits under part A, enrolled under part B, or
both.
``(2) Non-primary care physician.--The term `non-primary
care physician' means a physician who--
``(A) is not a primary care physician (as defined
in section 1807A(b)(3)(B)); and
``(B) provides chronic care disease management
services to a Medicare beneficiary under the
program.''.
SEC. 422. CHRONIC CARE EDUCATION CENTERS.
(a) Establishment.--The Secretary shall establish Chronic Care
Education Centers.
(b) Purpose.--The Chronic Care Education Centers established under
subsection (a) shall serve as clearinghouses for information on health
care providers who have expertise in the management of chronic disease.
(c) Use of Certain Information.--In developing the information
described in subsection (b), the Secretary shall utilize--
(1) information on the performance of providers in chronic
disease demonstration projects and pay for performance efforts;
and
(2) additional information determined appropriate by the
Secretary.
Subtitle D--Part D Improvements
SEC. 431. PROCESS FOR INDIVIDUALS ENTERING THE MEDICARE COVERAGE GAP TO
SWITCH TO A PLAN THAT PROVIDES COVERAGE IN THE GAP.
(a) Process.--Notwithstanding any other provision of law, by not
later than 30 days after the date of enactment of this Act, the
Secretary shall establish a process under which an applicable
individual may terminate enrollment in the prescription drug plan or
the MA-PD plan in which they are enrolled and enroll in any
prescription drug plan or MA-PD plan--
(1) that provides some coverage of covered part D drugs (as
defined in subsection (e) of section 1860D-2 of the Social
Security Act (42 U.S.C. 1395w-102)) after the individual has
reached the initial coverage limit under the plan but has not
reached the annual out-of-pocket threshold under subsection
(b)(4)(B) of such section; and
(2) subject to subsection (b), that serves the area in
which the individual resides.
(b) Special Rule Permitting Applicable Individuals To Enroll in a
Prescription Drug Plan Outside of the Region in Which the Individual
Resides.--In the case of an applicable individual who resides in a PDP
region under section 1860D-11(a)(2) of the Social Security Act (42
U.S.C. 1395w-111(a)(2)) in which there is no prescription drug plan
available that provides some coverage of brand name covered part D
drugs (as so defined) after the individual has reached the initial
coverage limit under the plan but before the individual has reached
such annual out-of-pocket threshold, the Secretary shall ensure that
the process established under subsection (a) permits the individual to
enroll in a prescription drug plan that provides such coverage but is
in another PDP region. The Secretary shall determine the PDP region in
which the individual may enroll in such a prescription drug plan.
(c) Notification of Applicable Individuals.--Under the process
established under subsection (a), the Secretary shall notify, or
require sponsors of prescription drug plans and organizations offering
MA-PD plans to notify, applicable individuals of the option to change
plans under such process. Such notice shall be provided to an
applicable individual within 30 days of meeting the definition of such
an individual.
(d) Process in Effect Through 2014.--The process established under
subsection (a) shall remain in effect through December 31, 2014.
(e) Definitions.--In this section:
(1) Applicable individual.--The term ``applicable
individual'' means a part D eligible individual (as defined in
section 1860D-1(a)(3)(A) of the Social Security Act (42 U.S.C.
1395w-101(a)(3)(A)) who, with respect to a year--
(A) is enrolled in a prescription drug plan or an
MA-PD plan that does not provide any coverage of
covered part D drugs (as so defined) after the
individual has reached the initial coverage limit under
the plan but has not reached such annual out-of-pocket
threshold; and
(B) has reached such initial coverage limit or is
within $750 of reaching such limit.
(2) Prescription drug plan; ma-pd plan.--The terms
``prescription drug plan'' and ``MA-PD plan'' have the meanings
given those terms in section 1860D-41(a)(14) of the Social
Security Act (42 U.S.C. 1395w-151(a)(14)) and section 1860D-
1(a)(3)(C) of such Act (42 U.S.C. 1395w-101(a)(3)(C)),
respectively.
Subtitle E--Improving Quality in Hospitals for All Patients
SEC. 441. IMPROVING QUALITY IN HOSPITALS FOR ALL PATIENTS.
(a) Improving Healthcare Quality for All Patients.--
(1) In general.--Section 1866(a)(1) of the Social Security
Act (42 U.S.C. 1395cc(a)(1)) is amended--
(A) in subparagraph (U), by striking ``and'' at the
end;
(B) in subparagraph (V), by striking the period at
the end and inserting ``, and''; and
(C) by inserting after subparagraph (V) the
following new subparagraph:
``(W) in the case of hospitals, to demonstrate to
accrediting bodies measurable improvement in quality control
with respect to all patients and to have in place quality
control programs that are directed at care for all patients and
that include--
``(i) rapid response teams that can assist patients
with unstable vital signs;
``(ii) heart attack treatments with proven
reliability;
``(iii) procedures that reduce medication errors;
``(iv) aggressive infection prevention, with
special focus on surgeries and infections with the
highest death rates;
``(v) procedures that reduce the threat of
pneumonia, with special focus on the incidence of
ventilator-related illness; and
``(vi) such other elements as the Secretary
determines appropriate.''.
(2) Effective date.--The amendments made by paragraph (1)
shall apply to hospitals as of the date that is 2 years after
the date of enactment of this Act.
(b) Panel of Independent Experts.--Beginning not later than the
date that is 2 years after the date of enactment of this Act, in order
to ensure that hospitals practice state-of-the-art quality control, the
Secretary shall convene a panel of independent experts to update the
measures of quality control and the types of quality control programs,
including the elements of such programs, required under section
1866(a)(1)(W) of the Social Security Act, as added by subsection (a),
not less frequently than on an annual basis.
Subtitle F--End-of-Life Care Improvements
SEC. 451. PATIENT EMPOWERMENT AND FOLLOWING A PATIENT'S HEALTH CARE
WISHES.
(a) In General.--Section 1866(a)(1) of the Social Security Act (42
U.S.C. 1395cc(a)(1)), as amended by section 441(a), is amended--
(1) in subparagraph (V), by striking ``and'' at the end;
(2) in subparagraph (W), by striking the period at the end
and inserting ``, and''; and
(3) by inserting after subparagraph (W) the following new
subparagraph:
``(X) to provide each patient with a document designed to
promote patient autonomy by documenting the patient's treatment
preferences (and coordinating these preferences with physician
orders) that at a minimum--
``(i) transfers with the patient from one setting
to another;
``(ii) provides a summary of treatment preferences
in multiple scenarios by the patient or the patient's
guardian and a physician or other practitioner's order
for care;
``(iii) is easy to read in an emergency situation;
``(iv) reduces repetitive activities in complying
with the Patient Self Determination Act;
``(v) ensures that the use of the document is
voluntary by the patient or the patient's guardian;
``(vi) is easily accessible in a patient's medical
chart; and
``(vii) does not supplant State health care proxy,
living wills, or other end-of-life care forms.''.
(b) Effective Date.--The amendments made by subsection (a) shall
apply to entities as of the date that is 2 years after the date of
enactment of this Act.
SEC. 452. PERMITTING HOSPICE BENEFICIARIES TO RECEIVE CURATIVE CARE.
(a) In General.--Section 1812 of the Social Security Act (42 U.S.C.
1395d) is amended--
(1) in subsection (a)(4), by striking ``in lieu of certain
other benefits,''; and
(2) in subsection (d)--
(A) in paragraph (1), by striking ``instead of
certain other benefits under this title''; and
(B) in paragraph (2)(A), by striking ``to be--''
and all that follows before the period and inserting
``to be equivalent to (or duplicative of) hospice
care''.
(b) Conforming Amendment.--Section 1862(a)(1) of the Social
Security Act (42 U.S.C. 1395y(a)(1)) is amended by striking
subparagraph (C).
(c) Effective Date.--The amendment made by this section shall apply
to services furnished on or after the date of enactment of this Act.
SEC. 453. PROVIDING BENEFICIARIES WITH INFORMATION REGARDING END-OF-
LIFE CARE CLEARINGHOUSE.
Section 1804 of the Social Security Act (42 U.S.C. 1395b-2) is
amended--
(1) in the heading, by inserting ``; end-of-life care
information'' after ``information''; and
(2) by adding at the end the following new subsection:
``(d) Not later than 1 year after the date of enactment of the
Healthy Americans Act, the Secretary shall establish procedures to
ensure that each individual, at the time the individual applies for
benefits under part A or enrolls under part B, is provided with contact
information for the clearinghouse described in section 454 of such
Act.''.
SEC. 454. CLEARINGHOUSE.
(a) In General.--Not later than 1 year after the date of enactment
of this Act, the Secretary shall provide for the establishment of a
national, toll-free, information clearinghouse that the public may
access to find out about State-specific information regarding advance
directive and end-of-life care decisions. If the Secretary determines
that such a clearinghouse exists and is administered by a not-for-
profit organization and meets standards developed by the Secretary to
assure the easy access of the public to State-specific information and
forms concerning advance directives and end-of-life care decisions
through the Internet and a national toll free information line, the
Secretary shall support such clearinghouse.
(b) Authorization of Appropriations.--There are authorized to be
appropriated $1,000,000 for fiscal year 2009 and each subsequent fiscal
year to carry out this section.
Subtitle G--Additional Provisions
SEC. 461. ADDITIONAL COST INFORMATION.
(a) In General.--Section 1857(e) of the Social Security Act (42
U.S.C. 1395w-27(e)) is amended by adding at the end the following new
paragraph:
``(4) Additional cost information.--A contract under this
section shall require a Medicare Advantage Organization to
aggregate claims information into episodes of care and to
provide such information to the Secretary so that costs for
specific hospitals and physicians may be measured and compared.
The Secretary shall make such information public on an annual
basis.''.
(b) Effective Date.--The amendment made by subsection (a) shall
apply to contracts entered into on or after the date of enactment of
this Act.
SEC. 462. REDUCING MEDICARE PAPERWORK AND REGULATORY BURDENS.
Not later than 18 months after the date of enactment of this Act,
the Secretary shall provide to Congress a plan for reducing regulations
and paperwork in the Medicare program under title XVIII of the Social
Security Act (42 U.S.C. 1395 et seq.). Such plan shall focus initially
on regulations that do not directly enhance the quality of patient care
provided under such program.
TITLE V--STATE HEALTH HELP AGENCIES
SEC. 501. ESTABLISHMENT.
As a condition of receiving payment under section 503, a State
shall, not later than the date that is 2 years after the date of
enactment of this Act, establish or designate a State agency, to be
known as the State ``Health Help Agency'' (referred to in this Act as a
``HHA'') to--
(1) carry out the administration of HAPI plans to
individuals in such State; and
(2) carry out the functions described in section 502.
SEC. 502. RESPONSIBILITIES AND AUTHORITIES.
(a) Promotion of Prevention and Wellness.--Each HHA shall promote
prevention and wellness for all State residents, including through the
implementation of programs that--
(1) educate residents about responsibility for individual
health and the health of children;
(2) upon request, distribute information to covered
individuals regarding the availability of wellness programs;
(3) make available to the public, with respect to each
health insurance issuer and each HAPI plan, the number of
covered individuals who have designated a health home described
in section 111(b); and
(4) promote the use and understanding of health information
technology.
(b) Enrollment Oversight.--Each HHA shall oversee enrollment in
HAPI plans by--
(1) providing standardized, unbiased information on HAPI
plans and supplemental health insurance options;
(2) not less than once per year, administering open
enrollment periods for individuals;
(3) allowing a covered individual to make enrollment
changes during a 30-day period following marriage, divorce,
birth, adoption or placement for adoption, and other
circumstances;
(4) establish procedures for health insurance issuers to
report to the HHA of each State in which the issuer offers a
HAPI plan, the health insurance status of State residents in
order for the HHA to report annual on the number of uninsured
and other relevant data;
(5) establish procedures for default enrollment of
uninsured individuals into low-cost HAPI plans for individuals
or families who do not enroll, are not covered under a health
plan offered through a program described in paragraphs (1)(A)
of section 102(a), and are not described in paragraph (1)(B) of
such section;
(6) establish procedures for hospitals and other providers
to report to the HHA if an individual seeks care and is
uninsured or does not know his or her health insurance status;
(7) ensure that the enrollment of all individuals into HAPI
plans, including those individuals assisted by an employer,
insurance agent, or other person, is administered by the HHA;
(8) develop standardized language for HAPI plan terms and
conditions and require participating health insurance issuers
to use such language in plan information documents;
(9) provide prospective enrollees with a comparative
document that describes all the HAPI plans in which the
individual may enroll; and
(10) to assist consumers in choosing a HAPI plan, publish
information that includes loss ratios, outcome data regarding
wellness programs, disease detection and chronic care
management programs categorized by health insurance issuer, and
other data as the HHA determines appropriate.
(c) Determination and Administration of HAPI Plan Subsidies.--Each
HHA shall oversee the determination and administration of HAPI plan
subsidies by--
(1) informing State residents about how subsidy eligibility
determinations are made;
(2) obtaining necessary information about income from
individuals and Federal and State agencies;
(3) making eligibility determinations on an individual
basis and informing individuals of such determinations;
(4) establishing a process by which an individual may
appeal an eligibility determination;
(5) collecting from health insurance issuers an
administrative fee for joining the HHA system and offering a
HAPI plan in a State;
(6) collecting premium payments made by, or on behalf of,
covered individuals, and remitting such payments to the HAPI
plans; and
(7) collecting Federal premium subsidies for covered
individuals and remitting such subsidies to HAPI plans.
(d) Premium Rating Rules.--Each HHA shall ensure that the premium
payments for each HAPI plan are determined in accordance with the
rating rules described in section 111(d).
(e) Empowerment of Individuals To Make Health Care Decisions.--Each
HHA shall, upon enrollment of an individual in a HAPI plan, provide
such individual with information regarding--
(1) the right of individuals to refuse treatment and to
make end-of-life care decisions;
(2) State laws relating to end-of-life care, including
applicable State law with respect to health care proxies,
advanced directives, living wills, and other documentation by
which individuals may make their care decisions known;
(3) contact information for any State end-of-life care
advocates; and
(4) applicable State forms on health proxies, advanced
directives, living wills, and other such documentation.
(f) Determination of Plan Coverage Areas.--Each HHA shall
establish, and may revise, HAPI plan coverage areas for the State in
which the HHA is located. The service area of a HAPI plan shall consist
of an entire coverage area established under the preceding sentence.
(g) Cooperation Among States.--States that share 1 or more
metropolitan statistical area may enter into agreements to share
administrative responsibilities described under this section.
(h) Transition From Medicaid and CHIP; Coordination of Supplemental
Medical Assistance for Elderly and Disabled Medicaid Eligibles.--Each
HHA shall work with the Secretary to ensure that the requirements of
section 301 of this Act, section 1943 of the Social Security Act (as
added by section 673(a) of this Act), and subsections (a) and (b) of
section 1942 of the Social Security Act (as added by section 311 of
this Act) are met.
SEC. 503. APPROPRIATIONS FOR TRANSITION TO STATE HEALTH HELP AGENCIES.
(a) Appropriation.--There is authorized to be appropriated and
there is appropriated, for each of the 2 full fiscal years immediately
following the date of enactment of this Act, such sums as may be
necessary for the purpose of enabling each State to carry out the
purposes of this title. The sums made available under this section
shall be used for making payments to States that have submitted, and
had approved by the Secretary, an HHA plan under this section.
(b) Submission of State HHA Plan.--Each HHA plan submitted by a
State shall provide for--
(1) the establishment of an HHA within such State by the
date that is 2 years after the date of enactment of this Act;
(2) the administration by with State of such HHA in
accordance with the requirements described under this Act; and
(3) the compliance by the State of the requirements
described under section 631.
(c) Payment to States.--From the sums appropriated under subsection
(a), the Secretary shall pay to each State that has an HHA plan
approved under this section, an amount necessary for the State to
implement such plan for the applicable fiscal year.
TITLE VI--SHARED RESPONSIBILITIES
Subtitle A--Individual Responsibilities
SEC. 601. INDIVIDUAL RESPONSIBILITY TO ENSURE HAPI PLAN COVERAGE.
(a) Open Season.--An adult individual, on behalf of such individual
and the dependent children of such individual, shall--
(1) enroll in a HAPI plan through the HHA of the
individual's State of residence during an open enrollment
period; and
(2) submit necessary documentation to the applicable HHA so
that such HHA may determine individual eligibility for premium
and personal responsibility contribution subsidies.
An adult individual may carry out the activities described under
paragraphs (1) and (2) on behalf of the spouse of such adult
individual.
(b) During Plan Year.--A covered individual shall--
(1) submit any required monthly premium payments;
(2) submit any personal responsibility contributions as
required; and
(3) inform such HHA of any changes in the family status or
residence of such individual.
Subtitle B--Employer Responsibilities
SEC. 611. HEALTH CARE RESPONSIBILITY PAYMENTS.
(a) Payment Requirements.--
(1) In general.--Subtitle C of the Internal Revenue Code of
1986 is amended by inserting after chapter 24 the following new
chapter:
``CHAPTER 24A--HEALTH CARE RESPONSIBILITY PAYMENTS
``subchapter a--employer shared responsibility payments
``subchapter b--individual shared responsibility payments
``subchapter c--general provisions
``Subchapter A--Employer Shared Responsibility Payments
``Sec. 3411. Payment requirement.
``Sec. 3412. Instrumentalities of the United States.
``SEC. 3411. PAYMENT REQUIREMENT.
``(a) Employer Shared Responsibility Payments.--Every employer
shall pay an employer shared responsibility payment for each calendar
year in an amount equal to the product of--
``(1) the number of full-time equivalent employees employed
by the employer during the preceding calendar year, multiplied
by
``(2) the applicable percentage of the average HAPI plan
premium amount for such calendar year.
``(b) Applicable Percentage.--For purposes of subsection (a)(2)--
``(1) In general.--The applicable percentage shall be
determined as follows:
------------------------------------------------------------------------
``Revenue per employee national percentile of Large Small
the taxpayer for the preceding calendar year: employer: employer:
------------------------------------------------------------------------
0-20th percentile............................... 17% 2%
21st-40th percentile............................ 19% 4%
41st-60th percentile............................ 21% 6%
61st-80th percentile............................ 23% 8%
81st-99th percentile............................ 25% 10%.
------------------------------------------------------------------------
``(2) Applicable percentage for certain non-revenue
producing entities.--In the case of an employer which is a
nonprofit entity, a State or local government, or any other
type of entity for which the Secretary determines that
calculating revenue per employee is not appropriate, the
applicable percentage shall be--
``(A) in the case of a large employer, 17 percent,
and
``(B) in the case of a small employer, 2 percent.
``(3) Additional rate for certain small employers.--
``(A) In general.--In the case of a small employer,
the applicable percentage determined under paragraph
(1) shall be increased by 0.1 percent for each full-
time equivalent employee employed by the employer
during the preceding calendar year in excess of 50.
``(B) Maximum additional rate.--The increase in the
applicable percentage determined under this paragraph
shall not exceed 15 percent.
``(4) Revenue per employee national percentile rank.--At
the beginning of each calendar year, the Secretary, in
consultation with the Secretary of Labor, shall publish a
table, based on sampling of employers, to be used in
determining the national percentile for revenue per employee
amounts for the preceding calendar year.
``(c) Transition Rates.--
``(1) Transition rate for employers previously providing
health insurance.--
``(A) In general.--In the case of the first and
second calendar years to which this section applies, in
the case of any employer who provided health insurance
coverage for employees on the day before the date of
enactment of the Healthy Americans Act, the employer
shared responsibility payment shall be, in lieu of the
amount determined under subsection (a), an amount equal
to--
``(i) 100 percent of the designated
employee health insurance premium amount of
such employer, minus
``(ii) the employee salary investment
amount.
``(B) Employee salary investment amount.--For
purposes of this paragraph--
``(i) In general.--The term `employee
salary investment amount' means the lesser of--
``(I) the excess of the amount of
average yearly wages paid to all
employees for such year over the amount
of average yearly wages paid to such
employee for the year before the first
year this section applies, or
``(II) the designated employee
health insurance premium amount of such
employer.
``(ii) Nondiscrimination rules.--No amount
paid by an employer shall be treated as an
employee salary investment amount unless such
amount is distributed to all employees on a
basis that is proportional to the designated
employee health insurance premium amount paid
with respect to such employee before such
distribution.
``(iii) Notice requirement.--No amount paid
by an employer shall be treated as an employee
salary investment amount unless the employer
gives each employee notice of the amount of the
designated employee health insurance premium
amount paid by the employer with respect to the
employee.
``(C) Employer shared responsibility credit.--The
Secretary may provide a credit to private employers who
provided health insurance benefits greater than the
80th percentile of the national average in the 2 years
prior to enactment of this Act, can demonstrate the
benefits provided encouraged prevention and wellness
activities as defined in this Act, and continue to
provide wellness programs.
``(D) Special rule for self-insured employers.--In
the case of any employer who provided health care
coverage for employees through self-insurance, `average
HAPI plan premium amount for the first year this
section applies' shall be substituted for `designated
employee health insurance premium amount of such
employer' in subparagraphs (A)(i) and (B)(i)(II).
``(E) Regulations.--The Secretary may establish
such rules and regulations as necessary to carry out
the purposes of this paragraph.
``(2) Transition rate for other employers.--In the case of
any employer who did not provide health insurance to employees
on the day before the date of enactment of the Healthy
Americans Act--
``(A) the employer shared responsibility payment
for the first year this section applies shall be an
amount equal \1/3\ of the amount otherwise required
under this section (determined without regard to this
subsection), and
``(B) the employer shared responsibility payment
for the second year this section applies shall be an
amount equal \2/3\ of the amount otherwise required
under this section (determined without regard to this
subsection).
``SEC. 3412. INSTRUMENTALITIES OF THE UNITED STATES.
``Notwithstanding any other provision of law (whether enacted
before or after the enactment of this section) which grants to any
instrumentality of the United States an exemption from taxation, such
instrumentality shall not be exempt from the payment required by
section 3411 unless such provision of law grants a specific exemption,
by reference to section 3111 from the payment required by such section.
``Subchapter B--Individual Shared Responsibility Payments
``Sec. 3421. Amount of payment.
``Sec. 3422. Deduction of tax from wages.
``SEC. 3421. AMOUNT OF PAYMENT.
``(a) In General.--Every individual shall pay an individual shared
responsibility payment in an amount equal to the HAPI plan premium
amount of such individual.
``(b) Exception.--This section shall not apply to any individual--
``(1) who is covered under a HAPI plan of another
individual, or
``(2) who provides such documentation as required by the
Secretary demonstrating that such individual has paid such HAPI
plan premium amount, but only for the period with respect to
which such amount is shown to be paid.
``SEC. 3422. DEDUCTION OF INDIVIDUAL SHARED RESPONSIBILITY PAYMENT FROM
WAGES.
``(a) In General.--The individual shared responsibility payment
imposed by section 3421 shall be collected by the employer by deducting
the amount of the payment from the wages as and when paid. The
preceding sentence shall not apply to any employer who employs an
average of less than 10 full-time equivalent employees during such
year.
``(b) Nondeductibility by Employer.--The individual shared
responsibility payment deducted and withheld by the employer under
subsection (a) shall not be allowed as a deduction to the employer in
computing taxable income under subtitle A.
``(c) Indemnification of Employer; Special Rule for Tips.--Rules
similar to the rules of subsections (b) and (c) of section 3102 shall
apply for purposes of this section.
``Subchapter C--General Provisions
``Sec. 3431. Definitions and special rules.
``Sec. 3432. Labor contracts.
``SEC. 3431. DEFINITIONS AND SPECIAL RULES.
``(a) Definitions.--For purposes of this chapter--
``(1) Average hapi plan premium amount.--The term `average
HAPI plan premium amount' means the national average yearly
premium for HAPI plans with standard coverage (as determined
under section 111(b) of the Healthy Americans Act), determined
without regard to differing classes of coverage.
``(2) Designated employee health insurance premium
amount.--The term `designated employee health insurance premium
amount' means the greater of--
``(A) the yearly premium paid by an employer for
health insurance coverage for employees for the most
recent calendar year ending before the date of
enactment of the Healthy Americans Act, or
``(B) the yearly premium paid by an employer for
health insurance coverage for employees for the year
before the first year this section applies.
``(3) Employer.--
``(A) In general.--The term `employer' has the
meaning given such term under section 3401(d).
``(B) Aggregation rules.--For purposes of this
chapter, all persons treated as a single employer under
subsection (a) or (b) of section 52 shall be treated as
1 person.
``(4) Employment.--The term `employment' has the meaning
given such term under section 3121(b).
``(5) Full-time equivalent employee.--The term `full-time
equivalent employee' means the equivalent number of full-time
employees of an employer determined for any year under the
following formula:
``(A) The sum of the number of full-time employees
employed by the employer for more than 3 months during
such year, plus
``(B) The quotient of--
``(i) the sum of the average weekly hours
worked during such year for each employee of
the employer (including common law employees)
who--
``(I) was employed by such employer
during such year for more than 3
months, and
``(II) is not a full-time employee,
divided by
``(ii) 40.
``(6) Full-time employee.--The term `full-time employee'
means an employee (including a common law employee) who during
an average workweek performs, or can reasonably be expected to
perform, at least 40 hours of work. The Secretary may prescribe
alternative rules for determining full-time equivalent
employees in occupations or industries not using a standard
workweek.
``(7) HAPI plan.--The term `HAPI plan' has the meaning
given such term under section 3 of the Healthy Americans Act.
``(8) HAPI plan premium amount.--The term `HAPI plan
premium amount' means, with respect to any individual, the
monthly premium for the HAPI plan under which such individual
is enrolled, determined after taking into account any subsidy
provided to such individual under section 131 of the Healthy
Americans Act.
``(9) Large employer.--The term `large employer' means,
with respect to any year, an employer who employs an average of
over 200 full-time equivalent employees during such year.
``(10) Revenue per employee.--The term `revenue per
employee' means, with respect to any employer for any year, the
gross receipts of the employer for such year divided by the
number of full-time equivalent employees employed by such
employer for such year.
``(11) Small employer.--The term `small employer' means,
with respect to any year, an employer who employs an average of
200 or fewer full-time equivalent employees during such year.
``(12) Wages.--The term `wages' has the meaning given such
term under section 3401(a).
``(b) Special Rules.--
``(1) Special rule for self-employed individuals.--For
purposes of this chapter, a self-employed individual (as
defined by section 401(c)(1)(B)) shall be treated as both a
full-time equivalent employee and as an employer.
``(2) Treatment of payments.--For purposes of this title,
the payments required by sections 3411 and 3421 shall be
treated as a tax imposed by such sections, respectively.
``(3) Other special rules.--For purposes of this chapter,
rules similar to rules under the following provisions shall
apply:
``(A) Section 3122 (relating to Federal service).
``(B) Section 3123 (relating to deductions as
constructive payments).
``(C) Section 3125 (relating to returns in the case
of governmental employees in States, Guam, American
Samoa, and the District of Columbia).
``(D) Section 3126 (relating to return and payment
by government employer).
``(E) Section 3127 (relating to exemption for
employers and their employees where both are members of
religious faiths opposed to participation in social
security act programs).
``SEC. 3432. LABOR CONTRACTS.
``(a) In General.--This chapter shall not apply with respect to any
qualified collective bargaining employee of any qualified collective
bargaining employer before the earlier of--
``(1) January 1 of the first year which is more than 7
years after the date of the enactment of this chapter, or
``(2) the date the collective bargaining agreement expires.
``(b) Definitions.--For purposes of this section--
``(1) Qualified collective bargaining employer.--The term
`qualified collective bargaining employer' means an employer
who provides health insurance to employees under the terms of a
collective bargaining agreement which is entered into before
the date of the enactment of this chapter.
``(2) Qualified collective bargaining employee.--The term
`qualified collective bargaining employee' means an employee of
a qualified collective bargaining employer who is covered by a
collective bargaining agreement governing the employee's health
insurance.''.
(2) Conforming amendment.--The table of chapters of the
Internal Revenue Code of 1986 is amended by inserting after the
item relating to chapter 24 the following new item:
``CHAPTER 24A--Health Care Responsibility Payments''.
(b) Collection of Individual Shared Responsibility Payments Through
Estimated Taxes.--Section 6654 of the Internal Revenue Code of 1986
(relating to failure by individual to pay estimated tax) is amended--
(1) in subsection (a), by striking ``and the tax under
chapter 2'' and inserting ``, the tax under chapter 2, and the
individual shared responsibility payment required under
subchapter B of chapter 24A'', and
(2) in subsection (f)--
(A) by striking ``minus'' at the end of paragraph
(2) and inserting ``plus'',
(B) by redesignating paragraph (3) as paragraph
(5), and
(C) by inserting after paragraph (2) the following
new paragraphs:
``(3) the individual shared responsibility payment required
under subchapter B of chapter 24A, minus
``(4) the amount withheld as an individual shared
responsibility payment under section 3422, minus''.
(c) Effective Date.--The amendments made by this section shall
apply to calendar years beginning at least 2 years after the date of
the enactment of this Act.
SEC. 612. DISTRIBUTION OF INDIVIDUAL RESPONSIBILITY PAYMENTS TO HHAS.
(a) In General.--The Secretary of the Treasury shall pay to the HHA
in each State an amount equal to the amount of individual shared
responsibility payments received under section 3421 of the Internal
Revenue Code of 1986 with respect to each individual residing in such
State.
(b) Treatment of Payments.--Any amount paid to a State under
subsection (a) shall be treated as an amount paid by the individual as
a premium for the HAPI plan in which such individual is enrolled.
Subtitle C--Insurer Responsibilities
SEC. 621. INSURER RESPONSIBILITIES.
(a) In General.--To offer a HAPI plan through an HHA, a State shall
require that a health insurance issuer meet the requirements of this
section.
(b) Requirements.--A health insurance issuer offering a HAPI plan
in a State shall--
(1) implement and emphasize prevention, early detection and
chronic disease management;
(2) ensure that a wellness program as described in section
131 is available to all covered individuals so long as such a
wellness program meets the requirements of the health insurance
issuers and other relevant requirements;
(3) demonstrate how the provider reimbursement methodology
used by such an issuer has been adjusted to reward providers
for achieving quality and cost efficiency in prevention, early
detection of disease, and chronic care management;
(4) ensure enrollees have the opportunity to designate a
health home as described in section 111(b) and make public how
many enrollees per policy have designated a health home;
(5) upon enrollment, make available to each covered
individual an initial physical and a care plan;
(6) create and implement an electronic medical record for
each covered individual, unless the individual submits a
notification to the issuer that the individual declines to have
such a record;
(7) contribute to the financing of the HHAs by
incorporating into the administration component of premiums an
additional amount to reimburse HHAs for administrative costs;
(8) comply with loss ratios as established by the Secretary
under subsection (e);
(9) use standardized common claims forms and uniform
billing practices as provided for under subsection (c);
(10) require that hospitals, as a condition of receiving
payment, send bills that are in an amount more than $5,000 to
the covered individual (without regard to whether the covered
individual is responsible for full or partial payment of the
bill) and provide the individual the contact information of a
person who can discuss the bill with the individual;
(11) provide incentives such as premium discounts--
(A) for parents, if a covered child participates in
wellness activities and the health of such child
improves; and
(B) for adults covered by a plan to participate in
prevention, wellness and chronic disease management
programs;
(12) report to the HHA of the State in which the issuer
offers HAPI plans, outcome data regarding wellness program,
disease detection and chronic care management, and loss ratio
information, so that the HHAs may make such data available to
the public in a consumer-friendly format;
(13) work with the Agency for Healthcare Research and
Quality, medical experts, and patient groups to make
information on high quality affordable health providers
available to all Americans within 2 years of the date of
enactment of this Act through a website searchable by zip code;
(14) provide to the HHA of each State in which the issuer
offers a HAPI plan, detailed information on the HAPI plans
offered by such issuer, using standardized language as required
by the HHA, so that the HHA may compile a document that
compares the HAPI plans for use by prospective enrollees; and
(15) paying to the HHA of each State in which the issuer
seeks to offer a HAPI plan the amount of the administrative fee
assessed by the HHA under section 502(c)(5) to enter the HHA
system of that State.
(c) Uniform Billing Practices.--
(1) In general.--A health insurance issuer offering a HAPI
plan in a State shall not receive subsidy payments from the
applicable State HHA unless such issuer agrees to use
standardized common claim forms prescribed by the applicable
State HHA.
(2) Exception.--Paragraph (1) shall not apply to any State
worker's compensation system.
(d) Chronic Care Programs Offered by Issuers.--
(1) In general.--A health insurance issuer offering a HAPI
plan in a State shall provide a chronic care program to provide
early identification and management of chronic diseases.
(2) Determination of chronic care program.--Each State HHA
shall determine what constitutes a chronic care program under
this subsection and whether to collect and report financial
information related to chronic care programs.
(3) Uniform clinical performance standards.--Each chronic
care program offered by a health insurance issuer shall use a
uniform set of clinical performance standards prescribed by the
HHA of the State in which the issuer offers a HAPI plan (in
consultation with the State Medicare quality improvement
organizations and patient and physician organizations) which
should include encouragement that the issuers not require
personal responsibility contributions for clinically needed
services to treat or manage a covered individual's chronic
disease, particularly if the individual is taking an active
management role in working with their provider to manage any
such disease.
(4) Reporting by issuers.--Five years after the date of
enactment of this Act and on an annual basis thereafter, each
health insurance issuer shall report to the applicable State
Insurance Commissioner, State Secretary of Health or other
state entity selected by the State HHA, the chronic care
management performance of the issuer as measured by the uniform
clinical performance standards described in paragraph (3). The
issuer shall make such performance public in a manner
accessible to the public.
(e) Private Insurance Company Loss Ratio.--
(1) In general.--The Secretary, in consultation with
consumer and patient organizations, the National Association of
Insurance Commissioners, and health insurance issuers
(including health maintenance organizations) shall establish a
loss ratio for issuers of HAPI plans.
(2) Determination of loss ratio.--In determining the loss
ratio, administrative costs shall be defined as expenses
consisting of all actual, allowable, allocable, and reasonable
expenses incurred in the adjudication of subscriber benefit
claims or incurred in the health insurance issuer's overall
operation of the business.
(3) Administrative expenses.--Unless otherwise determined
by an agreement between a State HHA and a health insurance
issuer, the administrative expenses of an issuer shall--
(A) include all taxes (excluding premium taxes)
reinsurance premiums, medical and dental consultants
used in the adjudication process, concurrent or managed
care review when not billed by a health care provider
and other forms of utilization review, the cost of
maintaining eligibility files, legal expenses incurred
in the litigation of benefit payments, and bank charges
for letters of credit; and
(B) not include the cost of personnel, equipment,
and facilities directly used in the delivery of health
care services (benefit costs), payments to HHAs for
establishment and administration of HHAs, and the cost
of overseeing chronic disease management programs and
wellness programs.
Subtitle D--State Responsibilities
SEC. 631. STATE RESPONSIBILITIES.
(a) General Requirements.--As a condition of receiving payment
under section 503, each State shall--
(1) designate or create a Health Help Agency as described
in title V;
(2) ensure that the HAPI plans offered in the State--
(A) are sold only through the State HHA (except for
employer-sponsored health coverage plans described
under section 103 offered by employers); and
(B) comply with the requirements of this Act;
(3) ensure that health insurance issuers offering a HAPI
plan in such State comply with the requirements described in
section 621;
(4) make risk-adjusted payments to all health insurance
issuers and employers offering a HAPI plan in such State to
account for the specific population covered by the plan, in
accordance with guidelines established by the Secretary;
(5) ensure that HAPI plans offer premium discounts and
incentives for participation in wellness programs;
(6) implement mechanisms to collect premium payments not
otherwise collected under chapter 24A of the Internal Revenue
Code of 1986 (as added by this Act);
(7) continue to apply State law with respect to--
(A) solvency and financial standards for health
insurance issuers;
(B) fair marketing practices for health insurance
issuers;
(C) grievances and appeals for covered individuals;
and
(D) patient protection;
(8) eliminate fictitious group prohibitions; and
(9) comply with subsections (b), (c), and (d).
(b) Ensuring Maximum Enrollment.--Each State shall--
(1) collect and exchange data with Federal and other public
agencies as necessary to maintain a database containing
information on the health insurance enrollment status of all
State residents;
(2) implement methods to check enrollment status and enroll
individuals in HAPI plans, such as through the Department of
Motor Vehicles of the State, the enrollment of children in
elementary and secondary schools, the voter registration
authority of the State, and other checkpoints determined
appropriate by the State;
(3) implement mechanisms, which may not include revocation
or ineligibility for coverage under a HAPI plan, to enforce the
responsibility of each adult individual to purchase HAPI plan
coverage for such individual and any dependent children of such
individual; and
(4) implement a mechanism to automatically enroll
individuals in a HAPI plan who present in emergency departments
without health insurance.
(c) Maintenance of Effort.--Each State shall submit an annual
report to the Secretary that demonstrates that, for each State fiscal
year that begins on or after January 1 of the first calendar year in
which HAPI coverage begins under this Act, State expenditures for
health services (as defined by the Secretary) are not less than the
amount equal to--
(1) in the case of the first State fiscal year for which
such a report is submitted, 100 percent of the total amount of
the State share of expenditures for such services under all
public health programs operated in the State that are funded in
whole or in part with State expenditures (including the
Medicaid program) for the most recent State fiscal year ending
before January 1 of the first calendar year in which HAPI
coverage begins under this Act; and
(2) in the case of any subsequent State fiscal year for
which such a report is submitted, the amount applicable under
this subsection for the preceding State fiscal year increased
by the percentage change, if any, in the consumer price index
for all urban consumers over the previous Federal fiscal year.
(d) Maintenance of Eligibility and Benefits Under State Medicaid
Programs.--A State shall ensure that eligibility and benefits under the
State plan under title XIX of the Social Security Act (including
eligibility or benefits provided through any waiver under such title or
under section 1115 of such Act (42 U.S.C. 1315) and premiums,
deductibles, co-payments, or other cost-sharing imposed for benefits
under such plan or waiver), are no more restrictive than the
eligibility or benefits, respectively, under such plan or waiver as in
effect on the date of enactment of the Healthy Americans Act.
SEC. 632. EMPOWERING STATES TO INNOVATE THROUGH WAIVERS.
(a) In General.--A State that meets the requirements of subsection
(b) shall be eligible for a waiver of applicable Federal health-related
program requirements.
(b) Eligibility Requirements.--A State shall be eligible to receive
a waiver under this section if--
(1) the State approves a plan to provide health care
coverage to its residents that is at least as comprehensive as
the coverage required under a HAPI plan; and
(2) the State submits to the Secretary an application at
such time, in such manner, and containing such information as
the Secretary may require, including a comprehensive
description of the State legislation or plan for implementing
the State-based health plan.
(c) Determinations by Secretary.--
(1) In general.--Not later than 180 days after the receipt
of an application from a State under subsection (b)(2), the
Secretary shall make a determination with respect to the
granting of a waiver under this section to such State.
(2) Granting of waiver.--If the Secretary determines that a
waiver should be granted under this section, the Secretary
shall notify the State involved of such determination and the
terms and effectiveness of such waiver.
(3) Refusal to grant waiver.--If the Secretary refuses to
grant a waiver under this section, the Secretary shall--
(A) notify the State involved of such
determination, and the reasons therefore; and
(B) notify the appropriate committees of Congress
of such determination and the reasons therefore.
(d) Scope of Waivers.--The Secretary shall determine the scope of a
waiver granted to a State under this section, including which Federal
laws and requirements will not apply to the State under the waiver.
Subtitle E--Federal Fallback Guarantee Responsibility
SEC. 641. FEDERAL GUARANTEE OF ACCESS TO COVERAGE.
(a) Federal Guarantee.--
(1) In general.--If a State does not establish an HHA in
compliance with title V by the date that is 2 years after the
date of enactment of this Act, the Secretary shall ensure that
each individual has available, consistent with paragraph (2), a
choice of enrollment in at least 2 HAPI plans in the coverage
area in which the individual resides. In any such case in which
such plans are not available, the individual shall be given the
opportunity to enroll in a fallback HAPI plan.
(2) Requirement for different plan sponsors.--The
requirement in paragraph (1) is not satisfied with respect to a
coverage area if only 1 entity offers all the HAPI plans in the
area.
(b) Contracts.--
(1) In general.--The Secretary shall enter into contracts
under this subsection with entities for the offering of
fallback HAPI plans in coverage areas in which the guarantee
under subsection (a) is not met.
(2) Competitive procedures.--Competitive procedures (as
defined in section 4(5) of the Office of Federal Procurement
Policy Act (41 U.S.C. 403(5))) shall be used to enter into a
contract under this subsection.
(c) Fallback HAPI Plan.--For purposes of this section, the term
``fallback HAPI plan'' means a HAPI plan that--
(1) meets the requirements described in section 111(b) and
does not provide actuarially equivalent coverage described in
section 111(c); and
(2) meets such other requirements as the Secretary may
specify.
Subtitle F--Federal Financing Responsibilities
SEC. 651. APPROPRIATION FOR SUBSIDY PAYMENTS.
There is authorized to be appropriated and there is appropriated
for each fiscal year such sums as may be necessary to fund the
insurance premium subsidies under section 121.
SEC. 652. RECAPTURE OF MEDICARE AND 90 PERCENT OF MEDICAID FEDERAL DSH
FUNDS TO STRENGTHEN MEDICARE AND ENSURE CONTINUED SUPPORT
FOR PUBLIC HEALTH PROGRAMS.
(a) Recapture of Medicare DSH Funds.--
(1) In general.--Section 1886(d)(5)(F)(i) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(F)(i)) is amended by
inserting ``and before January 1 of the first calendar year in
which coverage under a HAPI plan begins under the Healthy
Americans Act,'' after ``May 1, 1986,''.
(2) Savings to part a trust fund.--The savings to the
Federal Hospital Insurance Trust Fund by reason of the
amendment made by paragraph (1) shall be used to strengthen the
financial solvency of such Trust Fund.
(b) Recapture of 90 Percent of Medicaid DSH Funds.--
(1) Healthy americans public health trust fund.--Subchapter
A of chapter 98 of the Internal Revenue Code of 1986 (relating
to trust fund code) is amended by adding at the end the
following new section:
``SEC. 9511. HEALTHY AMERICANS PUBLIC HEALTH TRUST FUND.
``(a) Creation of Trust Fund.--There is established in the Treasury
of the United States a trust fund to be known as the `Healthy Americans
Public Health Trust Fund', consisting of any amount appropriated or
credited to the Trust Fund as provided in this section or section
9602(b).
``(b) Transfer to Trust Fund of 90 Percent of Medicaid DSH Funds.--
There are hereby appropriated to the Healthy Americans Public Health
Trust Fund the following amounts:
``(1) In the case of the second, third, and fourth quarters
of the first fiscal year in which coverage under a HAPI plan
begins under the Healthy Americans Act, an amount equal to 90
percent of the amount that would otherwise have been
appropriated for the purpose of making payments to States under
section 1903(a) of the Social Security Act for the Federal
share of disproportionate share hospital payments made under
section 1923 of such Act for such quarters of that fiscal year
but for subsections (c)(2) and (d)(2)(D) of section 1943 of the
such Act, as determined by the Secretary of Health and Human
Services.
``(2) In the case of each succeeding fiscal year, an amount
equal to 90 percent of the amount that would otherwise have
been appropriated for the purpose of making payments to States
under section 1903(a) of the Social Security Act for the
Federal share of disproportionate share hospital payments made
under section 1923 of such Act for that fiscal year but for
subsections (c)(1) and (d)(2)(D) of section 1943 of such Act,
as determined by the Secretary of Health and Human Services,
taking into account the percentage change, if any, in the
consumer price index for all urban consumers (U.S. city
average) for the preceding fiscal year.
``(c) Expenditures From Trust Fund.--With respect to each fiscal
year for which transfers are made under subsection (b), amounts in the
Healthy Americans Public Health Trust Fund shall be available for that
fiscal year for the following purposes:
``(1) Providing premium and personal responsibility
contribution subsidies.--For making appropriations authorized
under section 651 of the Healthy Americans Act for providing
premium and personal responsibility contribution subsidies in
accordance with section 122 of such Act.
``(2) Making bonus payments to states for implementing
medical malpractice reform.--For making appropriations for
bonus payments to States in accordance with section 802 of such
Act for implementing a State medical malpractice reform law
that complies with subsection (b) of such section.
``(3) Reducing the federal budget deficit.--The Secretary
shall transfer any amounts in the Trust Fund that are not
expended as of September 30 of a fiscal year for a purpose
described in paragraph (1), (2), or (3) to the general revenues
account of the Treasury.''.
(2) Clerical amendment.--The table of sections for such
subchapter is amended by adding at the end the following new
item:
``Sec. 9511. Healthy Americans Public Health Trust Fund.''.
Subtitle G--Tax Treatment of Health Care Coverage Under Healthy
Americans Program; Termination of Coverage Under Other Governmental
Programs and Transition Rules for Medicaid and CHIP
PART I--TAX TREATMENT OF HEALTH CARE COVERAGE UNDER HEALTHY AMERICANS
PROGRAM
SEC. 661. LIMITED EMPLOYEE INCOME AND PAYROLL TAX EXCLUSION FOR
EMPLOYER SHARED RESPONSIBILITY PAYMENTS, HISTORIC RETIREE
HEALTH CONTRIBUTIONS, AND TRANSITIONAL COVERAGE
CONTRIBUTIONS.
(a) Income Tax Exclusion.--
(1) In general.--Subsection (a) of section 106 of the
Internal Revenue Code of 1986 (relating to contributions by
employer to accident and health plans) is amended to read as
follows:
``(a) General Rule.--Gross income of an individual does not
include--
``(1) if such individual is an employee, shared
responsibility payments made by an employer under section 3411,
``(2) if such individual is a former employee before the
first calendar year beginning 2 years after the date of the
enactment of the Healthy Americans Act, employer-provided
coverage under an accident or health plan,
``(3) if such individual is a qualified collective
bargaining employee under an accident or health plan in effect
on January 1 of the first calendar year beginning 2 years after
the date of the enactment of the Healthy Americans Act,
employer-provided coverage under such plan during any
transition period described in section 3432, and
``(4) employer-provided coverage for qualified long-term
care services (as defined in section 7702B(c)).''.
(2) Conforming amendments.--Section 106 of such Code is
amended--
(A) by adding at the end of subsection (b) the
following new paragraph:
``(8) Termination.--This subsection shall not apply to
contributions made in any calendar year beginning at least 2
years after the date of the enactment of the Healthy Americans
Act.'',
(B) by inserting ``and before the first calendar
year beginning 2 years after the date of the enactment
of the Healthy Americans Act,'' after ``January 1,
1997,'' in subsection (c)(1), and
(C) by striking ``shall be treated as employer-
provided coverage for medical expenses under an
accident or health plan'' in subsection (d)(1) and
inserting ``shall not be included in such employee's
gross income''.
(b) Payroll Taxes.--
(1) In general.--Section 3121(a) (defining wages) is
amended by adding at the end the following new sentence: ``In
the case of any calendar year beginning at least 2 years after
the date of the enactment of the Healthy Americans Act,
paragraphs (2) and (3) shall apply to payments on account of
sickness only if such payments are described in section
106(a).''.
(2) Railroad retirement.--Section 3231(e)(1) (defining
wages) is amended by adding at the end the following new
sentence: ``In the case of any calendar year beginning at least
2 years after the date of the enactment of the Healthy
Americans Act, this paragraph shall apply to payments on
account of sickness only if such payments are described in
section 106(a).''.
(3) Unemployment.--Section 3306(b) (defining wages) is
amended by adding at the end the following new sentence: ``In
the case of any calendar year beginning at least 2 years after
the date of the enactment of the Healthy Americans Act,
paragraphs (2) and (4) shall apply to payments on account of
sickness only if such payments are described in section
106(a).''.
(c) Effective Date.--The amendments made by this section shall
apply to calendar years beginning at least 2 years after the date of
the enactment of the Healthy Americans Act.
SEC. 662. EXCLUSION FOR LIMITED EMPLOYER-PROVIDED HEALTH CARE FRINGE
BENEFITS.
(a) In General.--Section 132(a) of the Internal Revenue Code of
1986 (relating to certain fringe benefits) is amended by striking
``or'' at the end of paragraph (7), by striking the period at the end
of paragraph (8) and inserting ``, or'', and by adding at the end the
following new paragraph:
``(9) qualified health care fringe.''.
(b) Qualified Health Care Fringe.--
(1) In general.--Section 132 of the Internal Revenue Code
of 1986 is amended by redesignating subsection (o) as
subsection (p) and by inserting after subsection (n) the
following new subsection:
``(o) Qualified Health Care Fringe.--For purposes of this section,
the term `qualified health care fringe' means--
``(1) any wellness program described in section 131 of the
Healthy Americans Act, and
``(2) any on-site first aid coverage for employees.''.
(2) Nondiscriminatory treatment.--Section 132(j)(1) of such
Code (relating to exclusions under subsection (a)(1) and (2)
apply to highly compensated employees only if no
discrimination) is amended--
(A) by striking ``Paragraphs (1) and (2) of
subsection (a)'' and inserting ``Paragraphs (1), (2),
and (9) of subsection (a)'', and
(B) by striking ``subsection (a)(1) and (2)'' in
the heading and inserting ``subsections (a)(1), (2),
and (9)''.
(c) Effective Date.--The amendments made by this section shall
apply to calendar years beginning at least 2 years after the date of
the enactment of the Healthy Americans Act.
SEC. 663. LIMITED EMPLOYER DEDUCTION FOR EMPLOYER SHARED RESPONSIBILITY
PAYMENTS, HISTORIC RETIREE HEALTH CONTRIBUTIONS, AND
OTHER HEALTH CARE EXPENSES.
(a) In General.--Subsection (l) of section 162 of the Internal
Revenue Code of 1986 (relating to trade or business expenses) is
amended to read as follows:
``(l) Limitation on Deductible Employer Health Care Expenditures.--
No deduction shall be allowed under this chapter for any employer
contribution to an accident or health plan other than--
``(1) any shared responsibility payment made under section
3411,
``(2) any accident or health plan coverage for individuals
who are former employees before the first calendar year
beginning 2 years after the date of the enactment of the
Healthy Americans Act,
``(3) any accident or health plan in effect on January 1 of
the first calendar year beginning 2 years after the date of the
enactment of the Healthy Americans Act with respect to coverage
for qualified collective bargaining employees during a
transition period described in section 3432,
``(4) any accident or health plan which qualifies as a
wellness program described in section 131 of such Act,
``(5) any accident or health plan which constitutes on-site
first aid coverage for employees, and
``(6) any accident or health plan which is a qualified
long-term care insurance contract.''.
(b) Conforming Amendment.--Section 162 of the Internal Revenue Code
of 1986 is amended by striking subsection (n).
(c) Effective Date.--The amendments made by this section shall
apply to calendar years beginning at least 2 years after the date of
the enactment of the Healthy Americans Act.
SEC. 664. HEALTH CARE STANDARD DEDUCTION.
(a) In General.--Section 62(a) of the Internal Revenue Code of 1986
(defining adjusted gross income) is amended by inserting after
paragraph (21) the following new paragraph:
``(22) Individual shared responsibility payments.--
``(A) In general.--In the case of a taxpayer with
gross income for the taxable year exceeding 100 percent
of the poverty line (adjusted for the size of the
family involved) for the calendar year in which such
taxable year begins and who is enrolled in a HAPI plan
under the Healthy Americans Act, the deduction
allowable under section 213 by reason of subsection
(d)(1)(D) thereof (determined without regard to any
income limitation under subsection (a) thereof) in an
amount equal to the applicable fraction times, in the
case of--
``(i) coverage of an individual, $6,025,
``(ii) coverage of a married couple or
domestic partnership (as determined by a State)
without dependent children, $12,050,
``(iii) coverage of an unmarried individual
with 1 or more dependent children, $8,610, plus
$2,000 for each dependent child, and
``(iv) coverage of a married couple or
domestic partnership (as determined by a State)
with 1 or more dependent children, $15,210,
plus $2,000 for each dependent child.
``(B) Applicable fraction.--For purposes of
subparagraph (A), the applicable fraction is the
fraction (not to exceed 1)--
``(i) the numerator of which is the gross
income of the taxpayer for the taxable year
expressed as a percentage of the poverty line
(adjusted for the size of the family involved)
minus such poverty line for the calendar year
in which such taxable year begins, and
``(ii) the denominator of which is 400
percent of the poverty line (adjusted for the
size of the family involved) minus such poverty
line.
``(C) Phaseout of deduction amount.--
``(i) In general.--The amount otherwise
determined under subparagraph (A) for any
taxable year shall be reduced by the amount
determined under clause (ii).
``(ii) Amount of reduction.--The amount
determined under this clause shall be the
amount which bears the same ratio to the amount
determined under subparagraph (A) as--
``(I) the excess of the taxpayer's
modified adjusted gross income for such
taxable year, over $62,500 ($125,000 in
the case of a joint return), bears to
``(II) $62,500 ($125,000 in the
case of a joint return).
Any amount determined under this clause which
is not a multiple of $1,000 shall be rounded to
the next lowest $1,000.
``(D) Inflation adjustment.--In the case of any
taxable year beginning in a calendar year after 2011,
each dollar amount contained in subparagraph (A) and
subparagraph (C)(ii)(I) shall be increased by an amount
equal to such dollar amount, multiplied by the cost-of-
living adjustment determined under section 1(f)(3) for
the calendar year in which the taxable year begins,
determined by substituting `calendar year 2010' for
`calendar year 1992' in subparagraph (B) thereof. Any
increase determined under the preceding sentence shall
be rounded to the nearest multiple of $50 ($1,000 in
the case of the dollar amount contained in subparagraph
(C)(ii)(I)).
``(E) Determination of modified adjusted gross
income.--
``(i) In general.--For purposes of this
paragraph, the term `modified adjusted gross
income' means adjusted gross income--
``(ii) determined without regard to this
section and sections 86, 135, 137, 199, 221,
222, 911, 931, and 933, and
``(iii) increased by--
``(I) the amount of interest
received or accrued during the taxable
year which is exempt from tax under
this title, and
``(II) the amount of any social
security benefits (as defined in
section 86(d)) received or accrued
during the taxable year.
``(F) Poverty line.--For purposes of this
paragraph, the term `poverty line' has the meaning
given such term in section 673(2) of the Community
Health Services Block Grant Act (42 U.S.C. 9902(2)),
including any revision required by such section.''.
(b) Conforming Amendment.--Section 213(d)(1)(D) of the Internal
Revenue Code of 1986 is amended by inserting ``amounts paid under
section 3421 and'' after ``including''.
(c) Effective Date.--The amendments made by this section shall
apply to payments made in calendar years beginning at least 2 years
after the date of the enactment of this Act.
SEC. 665. MODIFICATION OF OTHER TAX INCENTIVES TO COMPLEMENT HEALTHY
AMERICANS PROGRAM.
(a) Termination of Credit for Health Insurance Costs of Eligible
Individuals.--Section 35 of the Internal Revenue Code of 1986 (relating
to health insurance costs of eligible individuals) is amended by adding
at the end the following new subsection:
``(h) Termination.--This section shall not apply to payments made
in any calendar year beginning at least 2 years after the date of the
enactment of the Healthy Americans Act.''.
(b) Termination of Health Care Expense Reimbursement Under
Cafeteria Plans.--
(1) In general.--Section 125 of the Internal Revenue Code
of 1986 (relating to cafeteria plans) is amended by
redesignating subsection (i) as subsection (j) and by inserting
after subsection (h) the following new subsection:
``(i) Termination.--This section shall not apply to health benefits
coverage in any calendar year beginning at least 2 years after the date
of the enactment of the Healthy Americans Act.''.
(2) Long-term care allowed under cafeteria plans.--
(A) In general.--Section 125(f) of such Code
(defining qualified benefits) is amended by striking
the last sentence.
(B) Effective date.--The amendment made by this
paragraph shall apply to contracts issued with respect
to any calendar year beginning at least 2 years after
the date of the enactment of this Act.
(c) Termination of Archer MSA Contributions.--Section 220 of the
Internal Revenue Code of 1986 (relating to Archer MSAs) is amended--
(1) by inserting ``and made before the first calendar year
beginning 2 years after the date of the enactment of the
Healthy Americans Act'' after ``in cash'' in subsection
(d)(1)(A)(i), and
(2) by adding at the end the following new subsection:
``(k) Termination.--This section shall not apply to contributions
made in any calendar year beginning at least 2 years after the date of
the enactment of the Healthy Americans Act.''.
(d) Health Savings Accounts Allowed in Conjunction With High
Deductible HAPI Plans.--
(1) In general.--Section 223 of the Internal Revenue Code
of 1986 (relating to health savings accounts) is amended--
(A) by inserting ``qualified'' before ``high
deductible health plan'' each place it appears in the
text (other than subsection (c)(2)(A)),
(B) by striking ``The term `high deductible health
plan' means a health plan'' in subsection (c)(2)(A) and
inserting ``The term `qualified high deductible health
plan' means a HAPI plan under the Healthy Americans
Act'',
(C) by striking subparagraphs (B) and (C) of
subsection (c)(2) and by redesignating subparagraph (D)
of subsection (c)(2) as subparagraph (B), and
(D) by striking ``High'' in the heading for
paragraph (2) of subsection (c) and inserting
``Qualified high''.
(2) Effective date.--The amendments made by this subsection
shall apply to payments made in calendar years beginning at
least 2 years after the date of the enactment of this Act.
PART II--CLARIFICATION OF ERISA TREATMENT; TERMINATION OF COVERAGE
UNDER OTHER GOVERNMENTAL PROGRAMS AND TRANSITION RULES FOR MEDICAID AND
CHIP
SEC. 671. CLARIFICATION OF ERISA APPLICABILITY TO EMPLOYER-SPONSORED
HAPI PLANS.
(a) ERISA.--Section 3(1) of Employee Retirement Income Security Act
of 1974 (29 U.S.C. 1002(1)) is amended by adding at the end the
following new sentence: ``Such terms include the provision of medical,
surgical, or hospital care or benefits through a HAPI plan described
under section 103 of the Healthy Americans Act.''.
(b) Internal Revenue Code of 1986.--Section 5000 of the Internal
Revenue Code of 1986 (relating to certain group health plans) is
amended by adding at the end the following new subsection:
``(e) HAPI Plans.--For purposes of this section, the terms `group
health plan' and `large group health plan' include any HAPI plan
described under section 103 of the Healthy Americans Act.''.
(c) Public Health Service Act.--Section 2791(b)(5) of the Public
Health Service Act (42 U.S.C. 300gg-91(b)(5)) is amended by adding at
the end the following new sentence: ``Such term includes health
insurance coverage offered to individuals through a HAPI plan described
under section 103 of the Healthy Americans Act.''.
SEC. 672. FEDERAL EMPLOYEES HEALTH BENEFITS PLAN.
(a) In General.--Chapter 89 of title 5, United States Code, is
amended by adding at the end the following new section:
``Sec. 8915. Termination
``No contract shall be entered into under this chapter or chapters
89A and 89B with respect to any coverage period occurring in any
calendar year beginning at least 2 years after the date of the
enactment of the Healthy Americans Act.''.
(b) Conforming Amendment.--The table of sections for such chapter
89 is amended by adding at the end the following new item:
``8915. Termination.''.
SEC. 673. MEDICAID AND CHIP.
(a) In General.--Title XIX of the Social Security Act, as amended
by section 311, is amended by adding at the end the following new
section:
``transition to coverage under hapi plans; requirement to provide
supplemental coverage; termination of unnecessary provisions
``Sec. 1943. (a) Transition and Supplemental Coverage
Requirements.--The Secretary shall provide technical assistance to
States and health insurance issuers of HAPI plans to ensure that
individuals receiving medical assistance under State Medicaid plans
under this title or child health assistance under child health plans
under title XXI are--
``(1) informed of--
``(A) the guarantee of private coverage for
essential services for all Americans established by the
Healthy Americans Act; and
``(B) each individual's personal responsibility--
``(i) for health care prevention;
``(ii) to enroll (or to be enrolled on
their behalf) in a HAPI plan through the
applicable State HHA during an open enrollment
period; and
``(iii) to submit necessary documentation
to their State HHA so that the HHA may
determine the individual's eligibility for
premium and personal responsibility
contribution subsidies;
``(2) provided with appropriate assistance in transitioning
from receiving medical assistance under State Medicaid plans or
child health assistance under child health plans for their
primary health coverage to obtaining such coverage through
enrollment in HAPI plans in a manner that ensures continuation
of coverage for such individuals;
``(3) notwithstanding any other provision of this title,
after December 31 of the last calendar year ending before the
first calendar year in which coverage under a HAPI plan begins
in accordance with the Healthy Americans Act, provided with
medical assistance that consists of supplemental coverage that
meets the requirements of sections 202 and 301 of such Act; and
``(4) if the State elects to establish a State Choices for
Long-Term Care Program under section 1942 and the individual is
likely to be eligible for the program, informed of the coverage
available under the program and how to enroll.
``(b) Maintenance of Medicare Cost-Sharing.--For each month
beginning after the last month of the last calendar year ending before
the first calendar year in which coverage under a HAPI plan begins in
accordance with the Healthy Americans Act--
``(1) a State shall continue to provide medical assistance
for medicare cost-sharing to individuals described in section
1902(a)(10)(E) as if the Healthy Americans Act had not been
enacted; and
``(2) the Secretary shall continue to reimburse the State
for the provision of such medical assistance.
``(c) Continued Support for DSH Expenditures.--
``(1) In general.--Notwithstanding any other provision of
this title, with respect to each fiscal year that begins after
the first calendar year in which coverage under a HAPI plan
begins in accordance with the Healthy Americans Act, the DSH
allotment for each State otherwise applicable under section
1923(f) for that fiscal year shall be reduced by 90 percent and
no payment shall be made under section 1903(a) to a State with
respect to any payment adjustment made under section 1923 for
hospitals in the State for quarters in the fiscal year in
excess of the reduced DSH allotment for the State applicable
for such year.
``(2) Special rule for last 3 quarters of first fiscal year
in which coverage under a hapi plan begins.--With respect to
the first fiscal year in which coverage under a HAPI plan
begins in accordance with the Healthy Americans Act, the
Secretary shall reduce the DSH allotment for each State that is
otherwise applicable under section 1923(f) for that fiscal year
so that each such DSH allotment reflects a 90 percent reduction
in the allotment for the second, third, and fourth quarters of
that fiscal year.
``(d) Termination of All Federal Payments Under This Title Other
Than for Medicare Cost-Sharing, Supplemental Medical Assistance, or a
State Choices for Long-Term Care Program.--Notwithstanding any other
provision of this title:
``(1) no individual other than an individual to which
section 202, 301, or 311 of the Healthy Americans Act applies
is entitled to medical assistance under a State plan approved
under this title for any item or service furnished after
December 31 of the last calendar year ending before the first
calendar year in which coverage under a HAPI plan begins in
accordance with such Act; and
``(2) no payment shall be made to a State under section
1903(a) for any item or service furnished after that date or
for any other sums expended by a State for which a payment
would have been made under such section, other than for the
Federal medical assistance percentage of the total amount
expended by a State for each fiscal year quarter beginning
after that date for providing--
``(A) medical assistance for the maintenance of
medicare cost-sharing in accordance with subsection
(b);
``(B) medical assistance for individuals who are
eligible for supplemental medical assistance under this
title after such date in accordance with section 202 or
301 of the Healthy Americans Act;
``(C) payments for expenditures for establishing
and operating a State Choices for Long-Term Care
Program under section 1942 (subject to the aggregate 5-
year limit established under subsection (c)(1) of such
section); and
``(D) payment adjustments under section 1923 for
hospitals in the State that do not exceed the reduced
DSH allotment for the State determined under subsection
(c).''.
(b) Application to CHIP.--
(1) Application of transition requirements.--Section
2107(e)(1) of the Social Security Act (42 U.S.C. 1397gg(e)(1))
is amended by adding at the end the following:
``(E) Section 1943(a) (relating to transition to
coverage under HAPI plans and, in the case of paragraph
(3) of such section, the requirement to provide
supplemental medical assistance for targeted low-income
children who are provided child health assistance as
optional targeted low-income children under title
XIX).''.
(2) Termination.--Title XXI of the Social Security Act is
amended by adding at the end the following new section:
``termination
``Sec. 2111. Notwithstanding any other provision of this title, no
payment shall be made to a State under section 2105(a) with respect to
child health assistance for any item or service furnished after
December 31 of the last calendar year ending before the first calendar
year in which coverage under a HAPI plan begins in accordance with the
Healthy Americans Act.''.
TITLE VII--PURCHASING HEALTH SERVICES AND PRODUCTS THAT ARE MOST
EFFECTIVE
Subtitle A--Effective Health Services and Products
SEC. 701. ONE TIME DISALLOWANCE OF DEDUCTION FOR ADVERTISING AND
PROMOTIONAL EXPENSES FOR CERTAIN PRESCRIPTION
PHARMACEUTICALS.
(a) In General.--Part IX of subchapter B of chapter 1 of subtitle A
of the Internal Revenue Code of 1986 (relating to items not deductible)
is amended by adding at the end the following new section:
``SEC. 280I. ONE TIME DISALLOWANCE OF DEDUCTION FOR CERTAIN
PRESCRIPTION PHARMACEUTICALS ADVERTISING AND PROMOTIONAL
EXPENSES.
``(a) In General.--No deduction shall be allowed under this chapter
for expenses relating to advertising or promoting the sale and use of
prescription pharmaceuticals other than drugs for rare diseases or
conditions (within the meaning of section 45C) for any taxable year
which includes any portion of--
``(1) the 3-year period which begins on the date of a new
drug application approval with respect to such a
pharmaceutical, unless the manufacturer of such pharmaceutical
demonstrates to the satisfaction of the Secretary that such
pharmaceutical is subject to a comparison effectiveness study,
including over-the-counter medication (if appropriate), or
``(2) the 1-year period which ends with the availability of
a generic drug substitute, unless such advertising or promotion
includes a statement that a lower cost alternative may soon be
available and includes the chemical name of such alternative.
``(b) Advertising or Promoting.--For purposes of this section, the
term `advertising or promoting' includes direct-to-consumer advertising
and any activity designed to promote the use of a prescription
pharmaceutical directed to providers or others who may make decisions
about the use of prescription pharmaceuticals (including the provision
of product samples, free trials, and starter kits).''.
(b) Conforming Amendment.--The table of sections for such part IX
is amended by adding after the item relating to section 280H the
following new item:
``Sec. 280I. One time disallowance of deduction for certain
prescription pharmaceuticals advertising
and promotional expenses.''.
(c) Effective Date.--The amendments made by this section shall
apply to taxable years beginning with or within calendar years
beginning at least 2 years after the date of the enactment of this Act.
SEC. 702. ENHANCED NEW DRUG AND DEVICE APPROVAL.
(a) In General.--
(1) New drugs.--Section 505 of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355) is amended by adding at the end
the following:
``(v)(1) The sponsor of a new drug application under subsection (b)
may include as part of such application a full report of an
investigation which has been made to show, with respect to the new drug
that is the subject of the application--
``(A) the population for whom the drug is appropriate; and
``(B) the effectiveness of the drug when compared to the
effectiveness of drugs on the market as of the date that the
application is submitted.
``(2) If a sponsor of a new drug application under subsection (b)
includes in such application the report described under paragraph (1)
then, notwithstanding any other provision of law, the Secretary shall
apply section 505A(b) to the drug that is the subject of such
application in the same manner as the Secretary applies such section to
a new drug in the pediatric population that is the subject of a study
described in such section.
``(3) If a sponsor of a new drug application under subsection (b)
does not include in such application the report described under
paragraph (1) then, notwithstanding any other provision of law, the
Secretary shall require that--
``(A) all promotional material with respect to such drug
include the following disclosure: `This drug has not been
proven to be more effective than other drugs on the market for
any condition or illness mentioned in this advertisement.'; and
``(B) such disclosure--
``(i) appears at the beginning and end of any audio
and visual promotional material;
``(ii) constitutes not less than 20 percent of the
time of any audio and visual promotional material; and
``(iii)(I) in any promotional material, includes a
clear and conspicuous printed statement that is larger
than other print used in such promotional material; and
``(II) in any audio and visual promotional
material, includes such statement in audio as well as
visual format.''.
(2) New devices.--Section 515(c) of the Federal Food, Drug,
and Cosmetic Act (21 U.S.C. 360e) is amended by adding at the
end the following:
``(5)(A) A person that files a report seeking premarket approval
under this subsection may include as part of such report a full
description of an investigation which has been made to show, with
respect to the device that is the subject of the report--
``(i) the population for whom the device is appropriate;
and
``(ii) the effectiveness of the device when compared to the
effectiveness of devices on the market as of the date that the
report is submitted.
``(B) If a person that files a report seeking premarket approval
under this subsection includes in such report the description referred
to under subparagraph (A), then the Secretary shall certify to the
Director of the United States Patent and Trademark Office that such
person included such description in such report so that the Director
may extend the patent with respect to such device under section 702(b)
of the Healthy Americans Act.
``(C) If a person that files a report seeking premarket approval
under this subsection does not include in such report the description
referred to under subparagraph (A) then, notwithstanding any other
provision of law, the Secretary shall require that--
``(i) all promotional material with respect to such device
include the following disclosure: `This device has not been
proven to be more effective than other devices on the market
for any condition or illness mentioned in this advertisement.';
and
``(ii) such disclosure--
``(I) appears at the beginning and end of any audio
and visual promotional material;
``(II) constitutes not less than 20 percent of the
time of any audio and visual promotional material; and
``(III)(aa) in any promotional material, includes a
clear and conspicuous printed statement that is larger
than other print used in such promotional material; and
``(bb) in any audio and visual promotional
material, includes such statement in audio as well as
visual format.''.
(b) Extension of Device Patents.--If the Director of the United
States Patent and Trademark Office receives a certification from the
Secretary pursuant to section 515(c)(5) of the Federal Food, Drug, and
Cosmetic Act (as added under subsection (a)), the Director shall
extend, for a period of 2 years, the patent in effect with respect to
such device under title 35 of the United States Code.
(c) Effective Date.--This section shall apply to new drug
applications filed under section 505(b) of the Federal Food, Drug, and
Cosmetic Act (21 U.S.C. 355(b)) and to applications for premarket
approval of devices under section 515 of such Act (21 U.S.C. 350e) 180
days after the date of enactment of this Act.
SEC. 703. MEDICAL SCHOOLS AND FINDING WHAT WORKS IN HEALTH CARE.
Part B of title IX of the Public Health Service Act (42 U.S.C. 299b
et seq.) is amended by adding at the end the following:
``SEC. 918. MEDICAL SCHOOLS AND FINDING WHAT WORKS IN HEALTH CARE.
``(a) Establishment of Website.--Not later than 1 year after the
date of enactment of the Healthy Americans Act, the Agency shall
establish an Internet website--
``(1) on which researchers at medical schools and other
institutions may post the results of their research concerning
evidence-informed best practices for improving the quality and
efficiency of care; and
``(2) that--
``(A) includes a description on how to implement
such best practices; and
``(B) clearly identifies the funding source for the
research.
``(b) Pilot Program.--
``(1) Establishment.--Using the information about evidence-
informed best practices from the website under subsection (a)
and other sources, the Agency, through the National Research
Training Program and in consultation with medical schools,
shall develop a pilot program to establish methods by which
medical school curricula and training may be updated regularly
to reflect best practices to improve quality and efficiency in
medical practice.
``(2) Application to participate.--To participate in the
pilot program, an entity shall--
``(A) be an accredited medical school; and
``(B) submit an application at such time, in such
manner, and containing such information as the
Secretary may require.
``(3) Participants.--The Secretary shall ensure that not
less than 28 medical schools shall be included in the pilot
program.
``(4) Duration; publication of results.--The Agency shall--
``(A) operate the pilot program for 3 years;
``(B) not later than 180 days after the date of the
completion of the pilot program, publish and make
public the results of the pilot program; and
``(C) include, as part of the published results
under subparagraph (B), recommendations on how to
assure that all medical school curricula is updated on
a regular basis to reflect best practices to improve
quality and efficiency in medical practice.''.
SEC. 704. FINDING AFFORDABLE HEALTH CARE PROVIDERS NEARBY.
(a) In General.--Not later than 2 years after the date of enactment
of this Act, the Secretary, in consultation with each HHA and health
insurance issuers that offer a HAPI plan, shall establish an Internet
website to assist covered individuals with locating health care
providers in their State of residence who provide affordable, high-
quality health care services.
(b) Quality of Care Standard.--To develop the information displayed
on the website with respect to the quality of care of a health care
provider, the Secretary shall--
(1) on the date of establishment of the website, use
information on the performance of providers in quality
initiatives under the Medicare program, including demonstration
projects, reporting initiatives, and pay for performance
efforts; and
(2) not later than 3 years after the date of establishment
of the website, in addition to the information used under
paragraph (1), use quality of care standards developed in
consultation with, and similar to standards used by, Medicare
quality improvement organizations of each State.
(c) Affordability Standard.--Not later than 2 years after the date
of enactment of this Act, the Secretary shall, in consultation with
health insurance issuers that offer a HAPI plan, develop guidelines by
which each health care provider reports to the Secretary with respect
to the affordability of services by such provider. The Secretary shall
ensure that such guidelines--
(1) on the date of establishment of such guidelines,
provide for the reporting of affordability of primary care
services; and
(2) by a date that is no later than 3 years after the date
of enactment of this Act, provide for the reporting of other
services.
Subtitle B--Other Provisions to Improve Health Care Services and
Quality
SEC. 711. INDIVIDUAL MEDICAL RECORDS.
The Secretary shall establish procedures to ensure that an
individual's medical record is considered the property of such
individual.
SEC. 712. BONUS PAYMENT FOR MEDICAL MALPRACTICE REFORM.
(a) In General.--Effective 3 years after the date of enactment of
this Act, a State shall be eligible for bonus payments under this Act
if the State has enacted and is implementing a State medical
malpractice reform law that complies with subsection (b).
(b) Requirements for State Reform Law.--A State medical malpractice
reform law complies with this subsection if such law--
(1) requires that an individual who files a medical
malpractice action in State court have the facts of such
individual's case reviewed prior to such filing by a panel that
consists of--
(A) not less than 1 qualified medical expert,
chosen in consultation with the State Medicare quality
improvement organizations or physician speciality
society, whose expertise is appropriate for case;
(B) not less than 1 legal expert; and
(C) not less than 1 community representative to
verify that there is reasonable cause to believe that a
malpractice claim exists;
(2) permits an individual to engage in voluntary non-
binding mediation with respect to the malpractice claim
involved prior to filing an action in State court;
(3) imposes sanctions against plaintiffs and attorneys who
file frivolous medical malpractice claims in State courts;
(4) prohibits attorneys who file 3 frivolous medical
malpractice actions in State courts from filing any another
medical malpractice action in such courts for a period of 10
years; and
(5) provides for the application of a presumption of
reasonableness with respect to a medical malpractice action if
the defendant establishes that the defendant provided the items
or services involved in accordance with accepted clinical
practice guidelines established by the specialty of which the
defendant is board certified or listed in the National
Guideline Clearinghouse, unless such presumption is rebutted by
a preponderance of the evidence.
(c) Use of Bonus Payments.--A State shall use bonus payments
received under this section to carry out activities related to disease
and illness prevention and for the provision of enhanced health care
services for children.
(d) Procedures.--The Secretary, in consultation with the Attorney
General, shall by regulation establish guidelines for the
implementation of this section.
SEC. 713. PRIORITIZING HEALTH CARE EMPLOYMENT AND TRAINING ACTIVITIES.
(a) Definitions.--In this section:
(1) Employment and training activity.--The term
``employment and training activity'' means--
(A) a workforce investment activity;
(B) a program or activity described in subsection
(b)(1)(B) of section 121 of such Act (29 U.S.C. 2841),
and a program described in subsection (b)(2)(B) of such
section if the entity carrying out the program is a
one-stop partner for the one-stop delivery system
involved, other than the provision of housing, health
insurance, or another supportive service that is wholly
unrelated to employment, service, or training
assistance (as determined by the Secretary of Labor);
and
(C) any other activity described in title I or V of
that Act (29 U.S.C. 2801 et seq., 9271 et seq.), other
than the provision of housing, health insurance, or
another supportive service that is wholly unrelated to
employment, service, or training assistance (as so
determined).
(2) Health care providers.--The term ``health care
providers'' includes nurses and other nonphysician providers.
(3) One-stop partner; workforce investment activity.--The
terms ``one-stop partner'' and ``workforce investment
activity'' have the meanings given the terms in section 101 of
that Act (29 U.S.C. 2801).
(4) Stimulus or authorization funds.--The term ``stimulus
or authorization funds'' means--
(A) appropriations made available for fiscal year
2009, in an Act enacted after January 1, 2009, for a
program that provides an employment and training
activity; or
(B) appropriations made available for a program
that provides an employment and training activity, if
Congress has passed legislation after January 1, 2009,
that
(i) becomes law; and
(ii)(I) authorizes appropriations for such
program; or
(II) extends the authorization of
appropriations for, or duration of, such
program.
(b) Priority.--In using stimulus or authorization funds to provide
services for individuals, the Secretary of Labor, or any other Federal
officer to whom such funds are made available, shall give priority to
individuals who seek employment in or training for positions as health
care providers.
(c) Construction.--No provision of law shall be considered to
supersede or modify this section unless the provision refers
specifically to this section.
TITLE VIII--CONTAINING MEDICAL COSTS AND GETTING MORE VALUE FOR THE
HEALTH CARE DOLLAR
SEC. 801. COST-CONTAINMENT RESULTS OF THE HEALTHY AMERICANS ACT.
Congress finds that the Healthy Americans Act will result in the
following:
(1) Private insurance companies will be forced to hold down
costs and will slow the rate of growth because they are
required to offer standardized Healthy American Private
Insurance plans.
(2) Administrative savings will be derived from reducing
employers' and insurers' administrative costs relating to
health care.
(3) Private insurance companies will implement uniform
billing and common claims forms.
(4) Congress will reclaim Medicare and Medicaid
disproportionate share hospital (DSH) payments because
previously uninsured persons will go to providers on an
outpatient basis instead of an emergency department.
(5) State and local governments will save money on programs
they operated for the uninsured before enactment of this Act.
(6) The Federal Government will save money on Federal tax
subsidies that reward inefficient care and are regressive.
(7) The Federal Government and the private sector will save
money if the Food and Drug Administration determines whether
products provide new value.
(8) Reducing medical errors will save the government and
the private sector money.
(9) Requiring hospitals to send large bills to patients for
their review will reduce errors in medical billing and force
major providers to be more cost conscious.
(10) Requiring insurers to reimburse for quality and cost
effective services will hold down private sector costs.
(11) Reduction of Medicare's restriction on bargaining
power for prescription drugs will reduce costs for sole source
drugs and other medications.
(12) Establishment of electronic medical records by
insurers will create savings.
(13) Publication of cost and quality data will enable
people to look up by zip code affordable high-quality
providers.
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