1.This Act may be cited as
the Small Business Empowerment
Act
.
2.
(a)In this Act, the terms health benefits plan,
carrier, and dependent have the meanings given such
terms in section 8901 of title 5, United States Code.
(b)In this Act:
(1)The
term Administrator means the entity that enters into the contract
under section 3(b).
(2)The
term Commission means the National Health Coverage Commission
established under section 8.
(3)The
term employee has the meaning given such term under section 3(6)
of the Employee Retirement Income Security Act
of 1974 (29 U.S.C. 1002(6)). Such term shall not include an employee
of the Federal Government.
(4)The
term employer has the meaning given such term under section 3(5)
of the Employee Retirement Income Security Act
of 1974 (29 U.S.C. 1002(5)), except that such term shall include
only employers who employed an average of at least 1 but not more than 100
employees on business days during the year preceding the date of application.
Such term shall not include the Federal Government.
(5)The term health insurance issuer
has the meaning given such term in section 2791(b)(2) of the Public Health
Service Act (42 U.S.C. 300gg–91(b)(2)), except that such term shall include the
sponsor of a group health plan.
(6)The
term Office means the Office of Personnel Management.
(7)The term participating employer means an
employer that—
(A)elects to provide
health insurance coverage under this Act to its employees;
(B)is not offering
other comprehensive health insurance coverage to such employees; and
(C)agrees to provide
the employer contribution as required under section 6(a).
(8)The
term Secretary means the Secretary of Health and Human
Services.
(c)Application of
Certain Rules in Determination of Employer SizeFor purposes of
subsection (b)(2):
(1)Application of
aggregation rule for employersAll persons treated as a single
employer under subsection (b), (c), (m), or (o) of section 414 of the Internal
Revenue Code of 1986 shall be treated as 1 employer.
(2)Employers not
in existence in preceding yearIn the case of an employer which
was not in existence for the full year prior to the date on which the employer
applies to participate, the determination of whether such employer meets the
requirements of subsection (b)(2) shall be based on the average number of
employees that it is reasonably expected such employer will employ on business
days in the employer’s first full year.
(3)Any
reference in this subsection to an employer shall include a reference to any
predecessor of such employer.
(d)Waiver and
Continuation of Participation
(1)The
Office may waive the limitations relating to the size of an employer which may
participate in the health insurance program established under this Act on a
case by case basis if the Office determines that such employer makes a
compelling case for such a waiver. In making determinations under this
paragraph, the Office may consider the effects of the employment of temporary
and seasonal workers and other factors.
(2)Continuation of
participationAn employer participating in the program under this
Act that experiences an increase in the number of employees so that such
employer has in excess of 100 employees, may not be excluded from participation
solely as a result of such increase in employees.
3.National small
employer and individuals risk pool
(a)The
Secretary, in consultation with the Director of the Office, shall established a
national program to make quality, affordable health insurance available to
small employers and self-employed individuals in a manner that will spread risk
on a national basis. The program shall be modeled on the Federal employees
health benefit program under chapter 89 of title 5, United States Code.
(b)Contract for
administration
(1)The Secretary, in consultation with the Director of the
Office, shall enter into a contract with an eligible entity for the
administration of the program established under subsection (a).
(2)The program under subsection (a) shall be administered by
a private entity under a contract entered into with the Department of Health
and Human Services. An entity shall be eligible to enter into such contract if
such entity—
(A)is a medicare
fiscal intermediary, a health insurance issuer, a health care provider
organization, a third party administrator, or any other entity determined
appropriate by the Secretary; and
(B)can demonstrate
the ability to administer the insurance program under this Act, for a
population significantly larger than that populations served under the Federal
Employees Health Benefits Program under chapter 89 of title 5, United States
Code.
(c)In
no event shall the enactment of this Act result in—
(1)any increase in
the level of individual or Federal Government contributions required under
chapter 89 of title 5, United States Code, including copayments or
deductibles;
(2)any decrease in
the types of benefits offered under such chapter 89; or
(3)any other change
that would adversely affect the coverage afforded under such chapter 89 to
employees and annuitants and members of family under that chapter.
4.
(a)The Administrator may enter into contracts with qualified
carriers offering health benefits plans of the type described in section 8903
or 8903a of title 5, United States Code, without regard to section 5 of title
41, United States Code, or other statutes requiring competitive bidding, to
provide health insurance coverage to employees of participating employers and
individuals under this Act. Each contract shall be for a uniform term of at
least 1 year, but may be made automatically renewable from term to term in the
absence of notice of termination by either party. In entering into such
contracts, the Administrator shall ensure that health benefits coverage is
provided for individuals only, individuals with one or more children, married
individuals without children, and married individuals with one or more
children. As a condition of entering into such a contract, a qualified carrier
shall agree to pay the monthly assessment required under section 11(c).
(b)A
carrier shall be eligible to enter into a contract under subsection (a) if such
carrier—
(1)is licensed to
offer health benefits plan coverage in each State in which the plan is offered;
and
(2)meets such other
requirements as determined appropriate by the Secretary.
(c)
(1)
(A)The Administrator shall establish a pilot program to
provide for the offering, by carriers, of a model health benefits plan that is
developed using the model provided for under section 8(c)(1).
(B)Not
later than 5 years after the date on which the pilot program is established
under subparagraph (A), the Administrator shall contract with the Institute of
Medicine for the conduct of an assessment on the impact of the pilot program on
health care coverage costs and access.
(2)Each contract under this Act shall contain a detailed
statement of benefits offered and shall include information concerning such
maximums, limitations, exclusions, and other definitions of benefits as the
Administrator considers necessary or desirable.
(3)Ensuring a
range of plansThe Administrator shall ensure that a range of
health benefits plans are available to participating employers under this
Act.
(d)The
minimum standards prescribed for health benefits plans under section 8902(e) of
title 5, United States Code, and for carriers offering plans, shall apply to
plans and carriers under this Act. Approval of a plan may be withdrawn by the
Administrator only after notice and opportunity for hearing to the carrier
concerned without regard to subchapter II of chapter 5 and chapter 7 of title
5, United States Code.
(e)
(1)A contract may not be made or a plan approved under this
section if the carrier under such contract or plan does not offer to each
enrollee whose enrollment in the plan is ended, except by a cancellation of
enrollment, a temporary extension of coverage during which the individual may
exercise the option to convert, without evidence of good health, to a nongroup
contract providing health benefits. An enrollee who exercises this option shall
pay the full periodic charges of the nongroup contract.
(2)The
benefits and coverage made available under paragraph (1) may not be canceled by
the carrier except for fraud, over-insurance, or nonpayment of periodic
charges.
(f)Requirement of
Payment for or Provision of Health ServiceEach contract entered
into under this Act shall require the carrier to agree to pay for or provide a
health service or supply in an individual case if the Administrator finds that
the employee, annuitant, family member, former spouse, or person having
continued coverage under section 8905a of title 5, United States Code, is
entitled thereto under the terms of the contract.
5.An individual shall be eligible to enroll in
a plan under this Act if such individual—
(1)is an employee of
a small employer described in section 2(b)(2), or is a self employed individual
as defined in section 401(c)(1)(B) of the Internal Revenue Code of 1986, that
elects to provide coverage for its employees under this Act; or
(2)is not otherwise
enrolled or eligible for enrollment or coverage of the type described in
section 2701(c)(1) of the Public Health Service Act.
6.Application of
provisions
(a)Except
as provided in this section, the provisions of chapter 89 of title 5, United
States Code, relating to employer contributions for coverage, requirements for
rating, guaranteed issue and renewability, and other provisions determined
appropriate by the Secretary (in consultation with the Director of the Office)
shall apply with respect to health coverage provided under this Act.
(b)
(1)With
respect to the determination of premium amounts for health benefits plans under
this Act, the only rating factor permitted shall be an age-related
factor.
(2)A
qualified carrier shall ensure that the loss-ratio of any health benefits plan
offered by such carrier under this Act not be less than 85 percent with respect
to the amount of premiums expended for patient care.
(c)Continued
Applicability of State Law
(1)Health
insurance or plans
(A)With
respect to a contract entered into under this Act under which a carrier will
offer health benefits plan coverage, State mandated benefit laws in effect in
the State in which the plan is offered shall continue to apply.
(B)The rating and other requirements described in subsections
(a) and (b) shall supercede State rating rules for qualified plans under this
Act.
(2)Nothing
in this subsection shall be construed to preempt—
(A)any State or
local law or regulation except those laws and regulations described in
subparagraph (B) of paragraph (1);
(B)any State
grievance, claims, and appeals procedure law, except to the extent that such
law is preempted under section 514 of the Employee Retirement Income Security Act of
1974; and
(C)State network
adequacy laws.
7.
(a)The
Secretary, in consultation with the Director of the Office, shall prescribe
regulations providing for employer participation under this Act, including the
offering of health benefits plans under this Act to employees.
(b)Enrollment and
Offering of Other Coverage
(1)A
participating employer shall ensure that each eligible employee has an
opportunity to enroll in a plan under this Act.
(2)Prohibition on
offering other comprehensive health benefit coverageA
participating employer may not offer a health insurance plan providing
comprehensive health benefits coverage to employees participating in the
program under this Act other than a health benefits plan that—
(A)meets the
requirements described in section 4(a); and
(B)is offered only
through the enrollment process established by the Administrator under section
3.
(3)Offer of
supplemental coverage options
(A)A participating employer may offer supplementary coverage
options to employees.
(B)In
subparagraph (A), the term supplementary coverage means benefits
described as excepted benefits
under section 2791(c) of the
Public Health Service Act (42 U.S.C.
300gg–91(c)).
8.National health
coverage commission
(a)There
is established a commission to be known as the National Health Coverage
Commission
to carry out the duties activities described in subsection
(c).
(b)
(1)The
Commission shall be composed of 15 members to be appointed by the President,
after consultation with and recommendations from the Institute of Medicine of
the National Academy of Sciences, from among representatives of employers,
employees, health care providers, health services researchers, economists, and
other health care stakeholders and experts determined appropriate by the
Institute of Medicine.
(2)Chairperson,
vice-chairperson, and meetingsNot later than 30 days after the
date on which all members of the Commission are appointed under paragraph (1),
such members shall meet to elect a Chairperson and Vice Chairperson from among
such members and shall determine a schedule of Commission meetings.
(3)Terms,
vacancies, and quorum
(A)An
individual appointed under paragraph (1) shall serve a term of 3 years.
(B)Any
vacancy in the Commission shall not affect its powers and shall be filled in
the same manner in which the original appointment was made.
(C)A majority of the members of the Commission
shall constitute a quorum, but a lesser number of members may hold
hearings.
(c)The Commission
shall—
(1)develop a model that ensures adequate
coverage for medically necessary services, promotes disease and chronic disease
management, provides incentives for health provider compliance with best
practices protocols, and that does not discriminate against individuals based
on the nature of their medically necessary condition, but provides appropriate
coverage limits based on scientifically-determined models of care;
(2)as part of the model under paragraph (1),
establish a standardized benefit package for health benefit plans provided
under contracts entered into under this Act;
(3)develop model cost sharing mechanisms that
do not discriminate and that accommodate lower income individuals;
(4)establish a systematic means of ensuring
that the health care system adopts best practices;
(5)provide for the establishment of a
partnership between health care providers, manufacturers of health products,
health care economists, and policy experts in the areas of health financing and
delivery, to—
(A)develop a systematic means of ensuring that
the health care system adopts best practices;
(B)develop procedures to combat price gouging
by the manufacturers of new health products; and
(C)determine cost sharing mechanisms that do
not discriminate and that accommodate low income individuals; and
(6)carry out any
other activities determined appropriate by the Secretary to assist in carrying
out this Act.
(d)
(1)The
Commission may hold such hearings, meet and act at such times and places, and
receive such evidence as may be necessary to carry out the functions of the
Commission.
(2)Information from
Federal agencies
(A)The Commission may
access, to the extent authorized by law, from any executive department, bureau,
agency, board, commission, office, independent establishment, or
instrumentality of the Federal Government such information, suggestions,
estimates, and statistics as the Commission considers necessary to carry out
this Act.
(B)On written request of the Chairperson of the
Commission, each department, bureau, agency, board, commission, office,
independent establishment, or instrumentality shall, to the extent authorized
by law, provide the requested information to the Commission.
(C)Receipt,
handling, storage, and disseminationInformation shall only be
received, handled, stored, and disseminated by members of the Commission and
its staff consistent with all applicable statutes, regulations, and Executive
orders.
(3)Assistance from
Federal agencies
(A)General services
administrationOn request of
the Chairperson of the Commission, the Administrator of General Services shall
provide to the Commission, on a reimbursable basis, administrative support and
other assistance necessary for the Commission to carry out its duties.
(B)Other
departments and agenciesIn addition to the assistance provided
for under subparagraph (A), departments and agencies of the United States may
provide to the Commission such assistance as they may determine advisable and
as authorized by law.
(4)The
Commission may enter into contracts to enable the Commission to discharge its
duties under this Act.
(5)The
Commission may accept, use, and dispose of donations of services or
property.
(6)The Commission may use the United States mails in the
same manner and under the same conditions as a department or agency of the
United States.
(e)
(1)The Chairperson of the Commission, in consultation with
the Vice Chairperson, in accordance with rules agreed upon by the Commission,
may appoint and fix the compensation of a staff director and such other
personnel as may be necessary to enable the Commission to carry out its
functions, in accordance with the provisions of title 5, United States Code,
except that no rate of pay fixed under this subsection may exceed the
equivalent of that payable for a position at level V of the Executive Schedule
under section
5316 of title 5, United States Code.
(2)Staff of Federal
agenciesUpon request of the
Chairperson of the Commission, the head of any executive department, bureau,
agency, board, commission, office, independent establishment, or
instrumentality of the Federal Government may detail, without reimbursement,
any of its personnel to the Commission to assist it in carrying out its duties
under this Act. Any detail of an employee shall be without interruption or loss
of civil service status or privilege.
(3)The Commission is authorized to procure the services of
experts and consultants in accordance with
section
3109 of title 5, United States Code, but at rates not to exceed
the daily rate paid a person occupying a position at level IV of the Executive
Schedule under section 5315 of title 5, United
States Code.
(f)
(1)Not
later than 3 years after the date on which all of the members of the Commission
are appointed under subsection (b), the Commission shall submit to the
appropriate committees of Congress a report concerning the activities of the
Commission which shall include recommendations for coverage and benefits under
the program under this Act.
(2)The
Commission shall terminate on the date on which the report is submitted under
paragraph (1).
9.Public education
campaign
(a)In carrying out this Act, the Secretary, in consultation
with the Director of the Office, shall develop, and the Administrator shall
implement, an educational campaign to provide information to employers and the
general public concerning the health insurance program developed under this
Act.
(b)Not later than 1 year and 2 years after the
implementation of the campaign under subsection (a), the Administrator shall
submit to the appropriate committees of Congress a report that describes the
activities of the Administrator under subsection (a), including a determination
by the Administrator of the percentage of employers with knowledge of the
health benefits programs provided for under this Act.
(c)Public
Education CampaignThere is authorized to be appropriated to
carry out this section, such sums as may be necessary for each of fiscal years
2009 and 2010.
10.During the period prior
to the date on which assessments begin under section 11(c), the Administrator
shall adjust the annual premium amount assessed for coverage under a health
benefits plan to reflect the median premium amount that is assessed for
coverage 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 for the year involved.
11.
(a)Not later than 1 year after the date of enactment of
this Act, the Secretary shall establish a program to provide reinsurance to
qualified carriers offering health benefit plans under this Act.
(b)Amount of
reinsurance payments
(1)Under the program established under subsection (a), the
Secretary shall, using amounts in the trust fund established under subsection
(d), pay to a qualified carrier an amount determined under paragraph (2) for
each large claim paid by such carrier under a health benefits plan under this
Act.
(2)The
amount of a payment under paragraph (1) shall be equal to 90 percent of the
amount of the large claim paid by the carrier under this Act.
(3)In this subsection, the term large claim means
a claim paid by a qualified carrier on behalf of a enrollee under a health
benefits plan under this Act that is excess of $5,000, but less than
$75,000.
(4)The Secretary shall develop procedures to provide for the
annual payment of amounts to qualified carriers under the program under this
section.
(c)
(1)The Secretary shall require the payment of monthly
assessments by each health insurance issuer offering health insurance
coverage.
(2)
(A)Establishment
of base amount by SecretaryNot later than 1 year after the date
of enactment of this Act, the Secretary shall determine the base amount of the
assessment under paragraph (1).
(B)With respect to a health insurance issuer, the amount of
the monthly assessment under this subsection shall be the product of the base
amount under subparagraph (A) and the number of lives covered under the health
benefits plans offered by the issuer during the month involved.
(d)
(1)There
is established in the Treasury of the Untied States a trust fund to be known as
the Small Business Health Coverage Trust Fund
, consisting of
such amounts as may be appropriated or credited to such Trust Fund as provided
in this subsection.
(2)There are hereby appropriated to the Small Business
Health Coverage Trust Fund amounts equivalent to the net revenues received in
the Treasury from the assessments paid under subsection (c).
12.There are authorized to be appropriated,
such sums as may be necessary in each fiscal year for the development and
administration of the program under this Act.