AmeriCare Health Care Act of 2006 - Adds a new title XXII to the Social Security Act (SSA) entitled "AmeriCare Health Benefits." Makes all U.S. residents eligible for AmeriCare benefits, including prescription drugs and biologicals. Requires the development of an AmeriCare enrollment mechanism that includes automatic enrollment at birth and the issuance of AmeriCare cards for identification and claims processing purposes.
Provides that an individual may elect not to be enrolled for benefits under AmeriCare if the individual has health benefits coverage under a group health plan at least equivalent to AmeriCare coverage.
Provides the same benefits under AmeriCare as are provided under parts A (Hospital Insurance) and B (Supplementary Medical Insurance) of SSA title XVIII (Medicare).
Provides additional AmeriCare coverage to children under age 24, pregnant women, and low-income individuals.
Establishes the AmeriCare Trust Fund.
Requires the modification of Medicaid (SSA title XIX), SCHIP (SSA title XXI (State Children's Health Insurance Program), and other federal health programs to avoid their duplication of AmeriCare coverage.
Provides for the regulation of AmeriCare supplemental policies.
Establishes the general obligations for individuals and employers for the cost of health insurance coverage provided under this Act.
Provides for additional premium subsidies.
[Congressional Bills 109th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5886 Introduced in House (IH)]
109th CONGRESS
2d Session
H. R. 5886
To amend the Social Security Act and the Internal Revenue Code of 1986
to provide for an AmeriCare that assures the provision of health
insurance coverage to all residents, and for other purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
July 25, 2006
Mr. Stark (for himself, Ms. Schakowsky, Mr. McDermott, Mr. Rangel, Mr.
Lewis of Georgia, Mr. Brown of Ohio, Mr. George Miller of California,
Mr. Waxman, Mr. Becerra, Ms. Corrine Brown of Florida, Ms. Carson, Mrs.
Christensen, Mr. Conyers, Mr. Davis of Illinois, Mr. Filner, Mr.
Grijalva, Mr. Hinchey, Ms. Norton, Ms. Jackson-Lee of Texas, Ms.
Kilpatrick of Michigan, Mr. Lantos, Ms. Lee, Mr. McGovern, Mr. Nadler,
Mr. Owens, Mr. Pallone, Mr. Thompson of Mississippi, Mr. Towns, Ms.
Woolsey, and Ms. Solis) introduced the following bill; which was
referred to the Committee on Energy and Commerce, and in addition to
the Committees on Ways and Means and Education and the Workforce, for a
period to be subsequently determined by the Speaker, in each case for
consideration of such provisions as fall within the jurisdiction of the
committee concerned
_______________________________________________________________________
A BILL
To amend the Social Security Act and the Internal Revenue Code of 1986
to provide for an AmeriCare that assures the provision of health
insurance coverage to all residents, and for other purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE; TABLE OF CONTENTS.
(a) Short Title.--This Act may be cited as ``AmeriCare Health Care
Act of 2006''.
(b) Table of Contents.--The table of contents of this Act is as
follows:
Sec. 1. Short title; table of contents.
TITLE I--HEALTH CARE ELIGIBILITY AND BENEFITS
Sec. 101. Eligibility and benefits.
``TITLE XXII--AMERICARE HEALTH BENEFITS
``Part A--Eligibility
``Sec. 2201. Eligibility.
``Sec. 2202. Enrollment and AmeriCare cards.
``Part B--Benefits
``Sec. 2221. Scope of benefits.
``Sec. 2222. Exclusions.
``Part C--Payment for Benefits and Financing
``Sec. 2241. Payments for benefits.
``Sec. 2242. AmeriCare Trust Fund.
``Part D--Administrative Simplification
``Sec. 2251. Requirement for entitlement verification system.
``Sec. 2252. Requirements for uniform claims and electronic
claims data set.
``Sec. 2253. Electronic medical records and reporting.
``Sec. 2254. Uniform hospital cost reporting.
``Sec. 2255. Health service provider defined.
``Part E--General Provisions
``Sec. 2261. Definitions relating to beneficiaries and income.
``Sec. 2262. Incorporation of certain medicare provisions and
other provisions.
``Sec. 2263. State maintenance of effort payments.
``Sec. 2264. Modification of medicaid and other programs to
avoid duplication of benefits.
``Sec. 2265. Construction regarding continuation of obligations
under current group health plan contracts
and provision of additional benefits.
``Sec. 2266. Standards and requirements for AmeriCare
supplemental policies.
TITLE II--FINANCING PROVISIONS
Subtitle A--Individual Contributions
Sec. 201. General obligation for individuals.
Sec. 202. Additional premium subsidies.
Sec. 203. Effective date.
Subtitle B--Employer Contributions
Sec. 211. General obligation for employers.
Sec. 212. Effective date.
TITLE I--HEALTH CARE ELIGIBILITY AND BENEFITS
SEC. 101. ELIGIBILITY AND BENEFITS.
(a) In General.--The Social Security Act is amended by adding at
the end the following new title:
``TITLE XXII--AMERICARE HEALTH BENEFITS
``Part A--Eligibility
``SEC. 2201. ELIGIBILITY.
``(a) Universal Eligibility for Residents.--
(1) In general.--Except as provided in section 2263(a),
each individual who is a resident of the United States is
entitled to health insurance benefits under this title.
``(2) Effective date for benefits.--This title shall apply
to items and services furnished on or after January 1, 2010.
``(b) Special Eligibility Groups.--For purposes of this title, an
individual described in subsection (a) may obtain special benefits
under this title on the basis of one or more of the following special
eligibility groups:
``(1) Children (as defined in section 2261(a)(1)).
``(2) Low-income individuals (as defined in section
2261(a)(2)).
``(3) Pregnant women (as defined in section 2261(a)(3)).
``(c) Reciprocal Coverage of Nonresidents.--An individual who--
``(1) is not a resident of the United States,
``(2) is in the United States, and
``(3) is a national of a foreign state which provides
health benefits to nationals of the United States who are
nonresidents in that state,
is entitled to such health insurance benefits under this title, but
only to the extent the Secretary determines that such benefits would be
available to nationals of the United States similarly situated as a
nonresident in the foreign state.
``SEC. 2202. ENROLLMENT AND AMERICARE CARDS.
``(a) Enrollment.--The Secretary shall provide a mechanism for the
enrollment of individuals entitled to benefits under this title and, in
conjunction with such enrollment, the issuance of an AmeriCare card
which may be used for purposes of identification and processing of
claims for benefits under this title. AmeriCare cards shall identify
(as appropriate) the date of birth (for purposes of identifying
children) and provide a coded means for identifying whether the
individual is a low-income individual for the year involved.
``(b) Classes of Enrollment.--The mechanism under subsection (a)
shall provide for individuals to be enrolled on the basis of the
following classes of enrollment:
(1) Coverage only of an individual.
(2) Coverage of a married couple without children.
(3) Coverage of an unmarried individual and one or more
children.
(4) Coverage of a married couple and one or more children.
``(c) Enrollment at Birth.--The mechanism under subsection (a)
shall include a process for the automatic enrollment of individuals at
the time of birth in the United States.
``(d) Opt Out for Those Covered Under Group Health Plan.--
Notwithstanding any other provision of this title, an individual may
elect not to be enrolled for benefits under this title if the
individual demonstrates to the satisfaction of the Secretary that the
individual has health benefits coverage under a group health plan (as
defined in section 5000(b)(1) of the Internal Revenue Code of 1986)
that is at least equivalent to the coverage otherwise provided under
this title, as certified by the Secretary.
``Part B--Benefits
``SEC. 2221. SCOPE OF BENEFITS.
``(a) In General.--Except as provided in the succeeding provisions
of this part, the benefits provided to an individual described in
section 2201(a) by the program established by this title shall consist
of entitlement to the same benefits as are provided under parts A and B
of title XVIII to individuals entitled to benefits under part A, and
enrolled under part B, of title XVIII.
``(b) Change in the Cost-Sharing.--
``(1) Deductible.--Except as provided in the succeeding
provisions of this part, the amount of expenses (other than
expenses for benefits described in subsection (c)) with respect
to which an individual is entitled to have payment made under
this title for any year shall first be reduced by a deductible
of $350, except that in no case shall the amount of the
deductible for all the members of a family exceed $500. Such
deductible shall be instead of the deductible for inpatient
hospital services under the first sentence of section
1813(a)(1) and the deductible under section 1833(b).
``(2) Coinsurance.--After the application of the deductible
under paragraph (1), the expenses referred to in such paragraph
shall be subject to a coinsurance of 20 percent until the limit
on out-of-pocket expenses under paragraph (3) is met.
``(3) Limit on out-of-pocket expenses and total expenses.--
``(A) Limitation on cost-sharing.--Subject to
subparagraph (B), whenever in a calendar year an
individual's expenses for the deductible and
coinsurance with respect to services covered under this
title (including expenses for benefits described in
subsection (c)) and furnished during the year equals
$2,500, or $4,000 for all the members of a family,
payment of benefits under this title for the individual
(or for the members of such family, respectively) for
services furnished during the remainder of the year
shall be paid without the application of any
coinsurance.
``(B) Limitation on premiums and cost-sharing for
certain individuals based on income.--
``(i) Income between 200 and 300 percent of
poverty line.--In the case of a family whose
applicable modified gross income (expressed as
a percentage of the poverty level, as defined
in section 2261(b)(2)) is equal to or exceeds
200 percent, but does not exceed 300 percent,
of the poverty level applicable to a family of
the size involved, whenever in a calendar year
an individual's expenses in the family for
premiums under this title and for the
deductible and coinsurance with respect to
services covered under this title (including
expenses for benefits described in subsection
(c)) and furnished during the year equals 5
percent of the amount of such applicable
modified gross income for the family--
``(I) no additional premiums shall
be imposed for remaining months in the
year; and
``(II) payment of benefits under
this title for members of such family
for services furnished during the
remainder of the year shall be paid
without the application of any
deductible or coinsurance.
``(ii) Income between 300 and 500 percent
of poverty line.--In the case of a family whose
applicable modified gross income (expressed as
a percentage of the poverty level, as defined
in section 2261(b)(2)) exceeds 300 percent, but
does not exceed 500 percent, of such poverty
level applicable to a family of the size
involved, whenever in a calendar year an
individual's expenses in the family for
premiums under this title and for the
deductible and coinsurance with respect to
services covered under this title (including
expenses for benefits described in subsection
(c)) and furnished during the year equals 7.5
percent of the amount of such applicable
modified gross income for the family--
``(I) no additional premiums shall
be imposed for remaining months in the
year; and
``(II) payment of benefits under
this title for members of such family
for services furnished during the
remainder of the year shall be paid
without the application of any
deductible or coinsurance.
``(C) Counting all expenses for premiums,
deductibles and coinsurance without regard to true out-
of-pocket costs.--.In applying subparagraphs (A) and
(B), expenses for an individual's premiums, deductible,
and coinsurance shall be counted without regard to
whether such expenses are paid, payable, reimbursed, or
reimbursable by another person, including through a
group health plan, insurance or otherwise, or other
third party payment arrangement.
``(4) Indexing dollar amounts by cpi.--Each dollar amount
specified in paragraphs (1) and (3)(A) shall be increased to
the year involved by the compounded sum of the increase in the
consumer price index for all urban consumers (U.S. City
average, as published by the Bureau of Labor Statistics of the
Department of Labor) for each year after 2006 and up to the
year involved. Any increase under this paragraph for a year
shall be rounded, with respect to paragraph (1), to the nearest
multiple of $5 and, with respect to paragraph (2), to the
nearest multiple of $100.
``(c) Prescription Drugs.--Benefits shall also be made available
under this title (as specified by the Secretary) for prescription drugs
and biologicals which are not less than the benefits for such drugs and
biologicals under the standard option for the service benefit plan
described in section 8903(1) of title 5, United States Code, offered
during 2005.
``(d) Children.--
``(1) No deductibles or coinsurance.--In the case of
children (as defined in section 2261(a)(1)), there shall be no
deductible or coinsurance applicable to covered benefits
(including benefits described in paragraphs (2) and (3)).
``(2) Additional preventive benefits.--
``(A) In general.--Subject to the periodicity
schedule established with respect to the services under
subparagraph (B), for children benefits shall be
available under this title for the following items and
services:
``(i) Newborn and well-baby care, including
normal newborn care and pediatrician services
for high-risk deliveries.
``(ii) Well-child care, including routine
office visits, routine immunizations (including
the vaccine itself), routine laboratory tests,
and preventive dental care.
``(B) Periodicity schedule.--The Secretary, in
consultation with the American Academy of Pediatrics
and the American Dental Association, shall establish a
schedule of periodicity which reflects the general,
appropriate frequency with which services listed in
subparagraph (A) should be provided to healthy
children.
``(3) Coverage of epsdt.--For children, benefits also shall
be available under this title for early and periodic screening,
diagnostic, and treatment services (as defined in section
1905(r)) not otherwise covered under paragraph (2).
``(4) Other additional services for children.--For
children, benefits also shall be available under this title for
the following:
``(A) Inpatient hospital services (without regard
to the restrictions described in subsections (a)(1) and
(b)(1) of section 1812 and the coinsurance described in
section 1813(a)(1)).
``(B) Eyeglasses and hearing aids, and examinations
therefor.
``(e) Pregnancy-Related Services.--In the case of a pregnant woman
(as defined in section 2261(a)(3)), benefits under this title shall
include entitlement to have payment made for the following, without the
application of a deductible or coinsurance:
``(1) Prenatal care, including care for all complications
of pregnancy.
``(2) Inpatient labor and delivery services.
``(3) Postnatal care.
``(f) Lower-Income Individuals.--
``(1) Limitations on deductibles and coinsurance.--
``(A) None for low-income individuals.--In the case
of a low-income individual, there shall be no
deductible or coinsurance under this title.
``(B) Phase-in for other lower-income
individuals.--In the case of an individual whose
applicable modified gross income (as defined in section
2261(b)(1)) exceeds twice the poverty level (as defined
in section 2261(b)(2)) but does not exceed three times
the poverty level, the deductible and coinsurance
applicable under this title shall bear the same ratio
to the deductible or coinsurance otherwise applicable
as--
``(i) the excess of the applicable modified
gross income over the poverty level, bears to
``(ii) the poverty level.
If the ratio determined under the preceding sentence is
not a multiple of 25 percentage points, such ratio
shall be rounded to the nearest 25 percentage points.
``(2) Additional benefits for low-income individuals.--In
the case of low-income individuals (as defined in section
2261(a)(2)), benefits under this title shall also include
entitlement to have payment made for the following, without the
application of a deductible or coinsurance:
``(A) Inpatient hospital services (without regard
to the restrictions described in subsections (a)(1) and
(b)(1) of section 1812 and the coinsurance described in
section 1813(a)(1)).
``(B) Eyeglasses and hearing aids and examinations
therefor.
``(g) Preventive Benefits.--Benefits shall also be made available
under this title, without the application of any deductible or
coinsurance for preventive services that are recommended by the United
States Preventive Services Task Force.
``(h) Mental Health Parity and Substance Abuse Benefits.--Benefits
shall be made available under this title for mental health services and
for substance abuse treatment in the same manner as such benefits are
made available for medical and surgical services.
``(i) Family Planning Services.--Benefits shall be made
available under this title for family planning services.
``(j) Conforming Medicare Benefits.--Notwithstanding any other
provision of law, benefits under title XVIII shall be expanded and
conformed to the benefits made available under this title (including
the application of a single deductible and uniform coinsurance amounts,
a limitation on the coinsurance, and additional benefits for low-income
individuals under subsection (f)), but nothing in this subsection shall
be construed as providing for any such additional benefits under this
title rather than under such title.
``(k) Enrollment in Health Plans.--The Secretary shall provide for
the offering of benefits under this title through enrollment in a
health benefit plan that meets the same (or similar) requirements as
the requirements that apply to Medicare Advantage plans under part C of
title XVIII (other than any such requirements that relate to part D of
such title). In the case of individuals enrolled under this title in
such a plan, the payment rate to the plan under this title shall be
based on adjusted average per capita cost (AAPCC) payment rate
methodology described in section 1853(c)(1)(D) for benefits under this
title and for individuals entitled to benefits under this title who are
not enrolled in such a plan.
``SEC. 2222. EXCLUSIONS.
``(a) In General.--Except as provided in this section, section 1862
shall apply to expenses incurred for items and services provided under
this title the same manner as such section applies to items and
services provided under title XVIII.
``(b) Benefits Exception.--
``(1) Childrens' services.--In applying section 1862(a)
with respect to services described in section 2221(d)(2)(A)
(relating to well-child services), payment shall not be denied
under paragraph (1), (7), or (12) of such section 1862(a) if
the services are provided in accordance with the periodicity
schedule described in section 2221(d)(2)(B).
``(2) Treatment of eyeglasses and hearing aids for children
and low-income individuals.--Payment shall not be denied under
this title under section 1862(a)(7) with respect to eyeglasses
and hearing aids and examinations therefor in the case of
children and low-income individuals.
``(c) Coordination of Payments.--
``(1) Primary to group health plans.--Section 1862(b)(1)
(relating to requirements of group health plans) shall not
apply under this title.
``(2) Secondary to medicare.--Payment shall not be made
under this title with respect to benefits to the extent that
payment for such benefits may be made under title XVIII.
``Part C--Payment for Benefits and Financing
``SEC. 2241. PAYMENTS FOR BENEFITS.
``(a) In General.--Except as otherwise provided in this section and
in section 2221--
``(1) payment of benefits under this title with respect to
benefits shall be made on the same basis as payment is made
with respect to such benefits under title XVIII, and
``(2) the provisions of sections 1814, 1833, 1834, 1842,
1848, and 1886 shall apply to payment of benefits under this
title in the same manner as they apply to benefits under title
XVIII.
``(b) No Extra Billing Permitted.--Payment under this title may
only be made on an assignment-related basis (as defined in section
1842(i)(1)). If an entity knowingly and willfully presents or causes to
be presented a claim or bills an individual enrolled under this title
for charges for services other than on an assignment-related basis, the
Secretary may apply sanctions against such entity in accordance with
section 1842(j)(2).
``(c) Adjustment of Payments.--
``(1) Establishment of new drgs and weights.--In making
payment under this title with respect to inpatient hospital
services, the Secretary shall establish such additional
diagnosis-related groups (and weighting factors with respect to
discharges within such groups) and make such adjustments in the
diagnosis-related groups and weighting factors with respect to
discharges within such groups otherwise established under
section 1886(d)(4) as may be necessary to reflect the types of
discharges occurring under this title which are not occurring
under title XVIII.
``(2) Payment for obstetrical services.--
``(A) Global fee.--In making payment under this
title with respect to the group of obstetrical services
typical of treatment throughout a course of pregnancy,
the Secretary shall establish, as a schedule under
section 1848, a global fee with respect to such group
of services.
``(B) Bonus for early presentation.--The fee
schedule amount with respect to obstetrical services
under this title shall be increased by 5 percent in the
case of services furnished to women who have presented
for prenatal care during the first trimester.
``(d) Conditions of and Limitations on Payments.--The provisions of
sections 1814 and 1835 shall apply to payment for services under this
title in the same manner as they apply to payment for services under
parts A and B, respectively, of title XVIII.
``(e) Use of Trust Fund.--In carrying out this section, any
reference in title XVIII to a trust fund shall be treated as a
reference to the AmeriCare Trust Fund established under section 2242.
``(f) Payment for Outpatient Prescription Drugs and Biologicals.--
The Secretary shall establish a fee schedule for the payment for
outpatient prescription drugs and biologicals under this title and,
notwithstanding section 1860D-11(i)(1), under title XVIII. The
Secretary shall negotiate with pharmaceutical manufacturers with
respect to the purchase price of such drugs and biologicals and shall
encourage the use of more affordable therapeutic equivalents to the
extent such practices do not override medical necessity, as determined
by the prescribing physician. To the extent practicable and consistent
with the previous sentence, the Secretary shall implement strategies
similar to those used by other Federal purchasers of prescription
drugs, and other strategies, to reduce the purchase cost of outpatient
prescription drugs and biologicals.
``SEC. 2242. AMERICARE TRUST FUND.
``(a) Establishment.--(1) There is hereby created on the books of
the Treasury of the United States a trust fund to be known as the
`AmeriCare Trust Fund' (in this section referred to as the `Trust
Fund'). The Trust Fund shall consist of such gifts and bequests as may
be made as provided in section 201(i)(1) and amounts appropriated under
paragraph (2).
``(2) There are hereby appropriated to the Trust Fund amounts
equivalent to 100 percent of the increase in revenues to the Treasury
by reason of the provisions of and amendments made by title II of the
AmeriCare Health Care Act of 2006. The amounts appropriated by the
preceding sentence shall be transferred from time to time from the
general fund in the Treasury to the Trust Fund, such amounts to be
determined on the basis of estimates by the Secretary of the Treasury
of the increase in revenues which are paid to or deposited into the
Treasury; and proper adjustments shall be made in amounts subsequently
transferred to the extent prior estimates were in excess of or were
less than such increase.
``(b) Incorporation of Provisions.--
``(1) In general.--Subject to paragraph (2), the provisions
of subsections (b) through (e) and (g) through (i) of section
1817 shall apply to the Trust Fund in the same manner as they
apply to the Federal Hospital Insurance Trust Fund.
``(2) Exceptions.--In applying paragraph (1)--
``(A) the Board of Trustees and Managing Trustee of
the Trust Fund shall be composed of the members of the
Board of Trustees and the Managing Trustee,
respectively, of the Federal Hospital Insurance Trust
Fund; and
``(B) any reference in section 1817 to the Federal
Hospital Insurance Trust Fund or to title XVIII (or
part A thereof) is deemed a reference to the Trust Fund
under this section and this title, respectively.
``Part D--Administrative Simplification
``SEC. 2251. REQUIREMENT FOR ENTITLEMENT VERIFICATION SYSTEM.
``(a) In General.--
``(1) Requirement.--The Secretary with respect to the plan
provided under this title, and each AmeriCare supplemental plan
(as defined in section 2279(3)), shall provide for an
electronic system, that is certified by the Secretary as
meeting the standards established under subsection (b), for the
verification of an individual's entitlement to benefits under
such plan.
``(2) Deadline for application of requirement.--The
deadline specified under this paragraph for the requirement
under paragraph (1) is 6 months after the date the standards
are established under subsection (b).
``(b) Standards for Entitlement Verification Systems.--
``(1) In general.--The Secretary shall establish standards
consistent with this subsection respecting the requirements for
certification of entitlement verification systems.
``(2) Information available.--Such standards shall require
a system to provide information, with respect to individuals,
concerning the following:
``(A) The specific benefits to which the individual
is entitled under the plan.
``(B) Current status of the individual with respect
to fulfillment of deductibles, coinsurance, and out-of-
pocket limits on cost-sharing.
``(C) Restrictions on providers who may provide
covered services, including utilization controls (such
as preadmission certification).
``(3) Form of inquiry.--Each verification system shall be
capable of accepting inquiries under this subsection from
health care providers in a variety of electronic forms. The
system shall also provide, for an additional fee, for the
acceptance of inquiries in a nonelectronic form.
``(4) Form of response.--Each such system shall be capable
of responding to such inquiries under this subsection in a
variety of electronic and other forms, including--
``(A) through modem transmission of information,
``(B) through computer synthesized voice
communication, and
``(C) through transmission of information to a
facsimile (fax) machine.
The system shall also provide, for an additional fee, for the
response to inquiries in a nonelectronic form.
``(5) Limitation on fees.--Neither the Secretary nor an
AmeriCare supplemental plan may impose a fee for the acceptance
or response to an inquiry under this subsection except where
the acceptance or response is in a nonelectronic form.
``(6) Website availability to providers.--The Secretary
shall establish and maintain a website through which--
``(A) health service providers may make inquiries,
and receive responses, with respect to the eligibility
and benefits of an individual under plans; and
``(B) AmeriCare supplemental plans may make
inquiries, and receive responses, to determine the
liability of other plans for the provision or payment
of benefits.
``(7) Deadline.--The Secretary shall first establish the
standards under this subsection (and shall establish the
website under paragraph (6)) by not later than 12 months after
the date of the enactment of this title.
``SEC. 2252. REQUIREMENTS FOR UNIFORM CLAIMS AND ELECTRONIC CLAIMS DATA
SET.
``(a) Requirements.--
``(1) Submission of claims.--Each health service provider
that furnishes services in the United States for which payment
may be made under this title or under an AmeriCare supplemental
plan shall submit any claim for payment for such services only
in a form and manner consistent with standards established
under subsection (c).
``(2) Acceptance of claims.--The Secretary and an AmeriCare
supplemental plan may not reject a claim for payment under this
title or the plan on the basis of the form or manner in which
the claim is submitted if the claim is submitted in accordance
with the standards established under subsection (c).
``(3) Effective date.--This subsection shall apply to
claims for services furnished on or after the date that is 6
months after the date standards are established under
subsection (c).
``(b) Enforcement Through Civil Money Penalties.--
``(1) In general.--
``(A) Providers.--In the case of a health service
provider that submits a claim in violation of
subsection (a)(1), the provider is subject to a civil
money penalty of not to exceed $100 (or, if greater,
the amount of the claim) for each such violation.
``(B) Plans.--In the case of an AmeriCare
supplemental plan that rejects a claim in violation of
subsection (a)(2), the plan is subject to a civil money
penalty of not to exceed $100 (or, if greater, the
amount of the claim) for each such violation.
``(2) Process.--The provisions of section 1128A of the
Social Security Act (other than subsections (a) and (b)) shall
apply to a civil money penalty under paragraph (1) in the same
manner as such provisions apply to a penalty or proceeding
under section 1128A(a) of such Act.
``(c) Standards Relating to Uniform Claims and Electronic Claims
Data Set.--
``(1) Establishment of standards.--The Secretary shall
establish standards that--
``(A) relate to the form and manner of submission
of claims for benefits under this title and under an
AmeriCare supplemental plan, and
``(B) define the data elements to be contained in a
uniform electronic claims data set to be used with
respect to such claims.
``(2) Scope of information.--
``(A) Ensuring accountability for claims submitted
electronically.--In establishing standards under this
section, the Secretary, in consultation with
appropriate agencies, shall include such methods of
ensuring provider responsibility and accountability for
claims submitted electronically that are designed to
control fraud and abuse in the submission of such
claims.
``(B) Components.--In establishing such standards
the Secretary shall--
``(i) with respect to data elements, define
data fields, formats, and medical nomenclature,
and plan benefit and insurance information;
``(ii) develop a single, uniform coding
system for diagnostic and procedure codes; and
``(iii) provide for standards for the
uniform electronic transmission of such
elements.
``(3) Coordination with standards for electronic medical
records.--In establishing standards under this subsection, the
Secretary shall assure that--
``(A) the development of such standards is
coordinated with the development of the standards for
electronic medical records under section 2253, and
``(B) the coding of data elements under the uniform
electronic claims data set and the coding of the same
elements in the uniform hospital clinical data set are
consistent.
``(4) Use of task forces.--In adopting standards under this
subsection--
``(A) the Secretary shall take into account the
recommendations of current task forces; and
``(B) the Secretary shall provide that the
electronic transmission standards are consistent, to
the extent practicable, with the applicable standards
established by the Accredited Standards Committee X-12
of the American National Standards Institute.
``(5) Uniform, unique provider identification codes.--In
establishing standards under this subsection--
``(A) the Secretary shall provide for a unique
identifier code for each health service provider that
furnishes services for which a claim may be submitted
under this title or under an AmeriCare supplemental
plan, and
``(B) in the case of a provider that has a unique
identifier issued for purposes of title XVIII, the code
provided under subparagraph (A) shall be the same as
such unique identifier.
``(6) Website availability to providers.--The Secretary
shall establish and maintain a website that will enable health
service providers, without charge, to submit claims and to
receive verification of claims status electronically.
``(7) Standards for paper claims.--The standards shall
provide for a uniform paper claims form which is consistent
with data elements required for the submission of claims
electronically.
``(8) Standards for claims for clinical laboratory tests.--
The standards shall provide that claims for clinical laboratory
tests for which benefits are provided under this title or under
an AmeriCare supplemental plan shall be submitted directly by
the person or entity that performed (or supervised the
performance of) the tests to the plan in a manner consistent
with (and subject to such exceptions as are provided under) the
requirement for direct submission of such claims under title
XVIII.
``(9) Deadline.--The Secretary shall first provide for the
standards for the uniform claims under this subsection (and
shall develop and make available the software under paragraph
(6)) by not later than 1 year after the date of the enactment
of this title.
``(d) Use Under This Title and Medicare and Medicaid Programs.--
``(1) Requirement for providers.--In the case of a health
service provider that submits a claim for services furnished
under this title in violation of subsection (a)(1), no payment
shall be made under this title for such services.
``(2) Requirements of medicare administrative contractors
under medicare program.--The Secretary shall provide, in
regulations promulgated to carry out this title, that the
claims process provided under this title conforms to the
standards established under subsection (c).
``(3) Requirements of state medicaid plans.--As a condition
for the approval of State plans under the medicaid program,
effective as of the effective date specified in subsection
(a)(3), each such plan shall provide, in accordance with
regulations of the Secretary, that the claims process provided
under the plan is modified to the extent required to conform to
the standards established under subsection (c).
``SEC. 2253. ELECTRONIC MEDICAL RECORDS AND REPORTING.
``(a) Standards for Electronic Medical Records.--
``(1) Promulgation of standards.--
``(A) In general.--Not later than January 1, 2008,
the Secretary shall promulgate standards described in
paragraph (2) for hospitals and other health care
providers concerning electronic medical records. Such
standards shall include the standards established under
part C of title XI.
``(B) Revision.--The Secretary may from time to
time revise the standards promulgated under this
paragraph.
``(2) Contents of standards.--The standards promulgated
under paragraph (1) shall include at least the following:
``(A) A definition of a uniform provider clinical
data set, including a definition of the set of
comprehensive data elements, for use by utilization and
quality control peer review organizations.
``(B) Standards for an electronic patient care
information system with data obtained at the point of
care.
``(C) A specification of, and manner of
presentation of, the individual data elements of the
set and system under this paragraph.
``(D) Standards concerning the transmission of
electronic medical data.
``(E) Standards relating to confidentiality of
patient-specific information, which include the
physical security of electronic data and the use of
keys, passwords, encryption, and other means to ensure
the protection of the confidentiality and privacy of
electronic data.
``(3) Coordination with standards for uniform electronic
claims data set.--In establishing standards under this
subsection, the Secretary shall assure that--
``(A) the development of such standards is
coordinated with the development of the standards for
the uniform electronic claims data set under subsection
(b), and
``(B) the coding of data elements under the uniform
provider clinical data set and the coding of the same
elements under the uniform electronic claims data set
are consistent.
``(4) Consultation.--In establishing standards under this
subsection, the Secretary shall--
``(A) consult with the American National Standards
Institute, hospitals and other health care providers,
health benefit plans, and other interested parties, and
``(B) take into consideration, in developing
standards under paragraph (2)(A), the data set used by
the utilization and quality control peer review program
under part B of title XI.
``(b) Requirement for Application of Electronic Records
Standards.--
``(1) As condition of medicare, medicaid, schip, and
americare participation.--Effective January 1, 2009, each
hospital or other institutional or noninstitutional health care
provider, as a requirement of each participation agreement
under this title, title XVIII, title XIX, and title XXI, shall,
in accordance with the standards promulgated under subsection
(a)(1)--
``(A) maintain clinical data included in the
uniform provider clinical data set under subsection
(a)(2)(A) in electronic form on all patients,
``(B) upon request of the Secretary or of a
utilization and quality control peer review
organization (with which the Secretary has entered into
a contract under part B of title XI), transmit
electronically data requested from such data set, and
``(C) upon request of the Secretary, or of a fiscal
intermediary or carrier, transmit electronically any
data (with respect to a claim) from such data set.
``(2) Application of presentation and transmission
standards to electronic transmission to federal agencies.--
Effective January 1, 2008, if a hospital or other health care
provider is required under a Federal program to transmit a data
element that is subject to a standard, promulgated under
subsection (a)(1), described in subparagraph (C) or (D) of
subsection (a)(2), the head of the Federal agency responsible
for such program (if not otherwise authorized) is authorized to
require the provider to present and transmit the data element
electronically in accordance with such a standard.
``(c) Limitation on Data Requirements Where Standards In Effect.--
``(1) In general.--On or after January 1, 2008, the
Secretary under this title or under title XVIII (including any
carrier or fiscal intermediary or any utilization and quality
control peer review organization) and an AmeriCare supplemental
plan may not require, for the purpose of utilization review or
as a condition of providing benefits or making payments under
this title, title XVIII, or the plan, that a hospital or other
health care provider--
``(A) provide any data element not in the uniform
provider clinical data set specified under the
standards promulgated under subsection (a), or
``(B) transmit or present any such data element in
a manner inconsistent with such standards applicable to
such transmission or presentation.
``(2) Compliance.--The Secretary may impose a civil money
penalty on any AmeriCare supplemental plan that fails to comply
with paragraph (1) in an amount not to exceed $100 for each
such failure. The provisions of section 1128A of the Social
Security Act (other than the first sentence of subsection (a)
and other than subsection (b)) shall apply to a civil money
penalty under this paragraph in the same manner as such
provisions apply to a penalty or proceeding under section
1128A(a) of such Act.
``(3) Application to medicaid program.--As a condition for
the approval of State plans under the medicaid program and in
accordance with regulations of the Secretary, effective as of
January 1, 2008, each such plan may not require that a hospital
or other health care provider, for the purpose of utilization
review or as a condition of providing benefits or making
payments under the plan--
``(A) provide any data element not in the uniform
provider clinical data set specified under the
standards promulgated under subsection (a), or
``(B) transmit or present any such data element in
a manner inconsistent with such standards applicable to
such transmission or presentation.
``(d) Preemption of State Quill Pen Laws.--
``(1) In general.--Any provision of State law that requires
medical or health insurance records (including billing
information) to be maintained in written, rather than
electronic, form shall deemed to be satisfied if the records
are maintained in an electronic form that meets standards
established by the Secretary under paragraph (2).
``(2) Secretarial authority.--Not later than 1 year after
the date of the enactment of this title, the Secretary shall
issue regulations to carry out paragraph (1). The regulations
shall provide for an electronic substitute that is in the form
of a unique identifier (assigned to each authorized individual)
that serves the functional equivalent of a signature. The
regulations may provide for such exceptions to paragraph (1) as
the Secretary determines to be necessary to prevent fraud and
abuse, to prevent the illegal distribution of controlled
substances, and in such other cases as the Secretary deems
appropriate.
``(3) Effective date.--Paragraph (1) shall take effect on
the first day of the first month that begins more than 30 days
after the date the Secretary issues the regulations referred to
in paragraph (2).
``SEC. 2254. UNIFORM HOSPITAL COST REPORTING.
``Each hospital, as a requirement under a participation agreement
under this title for each cost reporting period beginning during or
after fiscal year 2007, shall provide for the reporting of information
to the Secretary with respect to any hospital care provided in a
uniform manner consistent with standards established by the Secretary
to carry out section 4007(c) of the Omnibus Budget Reconciliation Act
of 1987 and in an electronic form consistent with standards established
by the Secretary.
``SEC. 2255. HEALTH SERVICE PROVIDER DEFINED.
``In this part, the term `health service provider' includes a
provider of services (as defined in section 1861(u)), physician,
supplier, and other entity furnishing health care services.
``Part E--General Provisions
``SEC. 2261. DEFINITIONS RELATING TO BENEFICIARIES AND INCOME.
``(a) Terms Relating to Beneficiaries.--In this title:
``(1) Child.--The term `child' means an individual who
throughout a month has not attained 24 years of age.
``(2) Low-income individual.--The term `low-income
individual' means an individual whose applicable modified gross
income (as defined in subsection (b)(1)) is less than 200
percent of the poverty level (as defined in subsection (b)(2)).
The determination that an individual is a low-income individual
shall be effective for a period of one year and shall be
redetermined on an annual basis.
``(3) Pregnant woman.--The term `pregnant woman' means a
woman (regardless of age) who has been certified by a physician
(in a manner specified by the Secretary) as being pregnant,
until the last day of the month in which the 60-day period
(beginning on the date of termination of the pregnancy) ends.
``(b) Terms Relating to Income.--In this title:
``(1) Applicable modified gross income.--
``(A) In general.--Except as provided in this
paragraph, the term `applicable modified gross income'
means, for a calendar year for an individual, the
modified gross income (as defined in section
202(a)(3)(B) of the Americare Health Care Act of 2006)
of the taxpayer (or the taxpayer for whom the
individual may be claimed as a dependent) for the
taxable year ending in the second previous calendar
year.
``(B) Application of current year modified gross
income.--
``(i) In general.--Subject to clause (ii),
the Secretary shall establish a procedure under
which an individual may file a declaration of
estimated modified gross income for a taxable
year ending in a calendar year, which modified
gross income will apply under this subsection
as the applicable modified gross income for the
calendar year. Subject to clause (ii), such
procedure shall be applicable regardless of
whether or not the individual filed a tax
return for the taxable year ending in the
second previous calendar year.
``(ii) Limitation on application.--The
Secretary may limit the application of clause
(i), in the case of individuals who have filed
tax returns for the taxable year ending in the
second previous calendar year, to individuals
with respect to whom the applicable modified
gross income will be reduced by at least 20
percent as a result of the application of such
clause.
``(iii) Requirement for return.--Any
individual who has filed a declaration under
clause (i) for a calendar year is required to
file an income tax return for the taxable year
in the calendar year, regardless of whether any
income tax is actually owed for the year. The
failure of the individual to file such a return
makes the individual liable for overpayments
under this title under clause (iv) in the same
manner as if this paragraph had not applied.
``(iv) Collection for overpayments.--If a
declaration of estimated modified gross income
is made applicable to a calendar year under
clause (i) and the actual modified gross income
for that taxable year exceeds such estimated
modified gross income, the individual shall be
liable to the United States for 110 percent of
the amount of additional payments made under
this title as a result of the use of such
estimated modified gross income instead of the
actual modified gross income for that taxable
year.
``(C) Transmittal of information.--By not later
than October 1 of each year, the Secretary of the
Treasury shall transmit to the Secretary such
information relating to the applicable modified gross
income of individuals for the taxable year ending in
the previous year as may be necessary to apply this
title in the succeeding calendar year.
``(2) Poverty level.--The term `poverty level' means, for
an individual in a family, the official poverty line (as
defined by the Office of Management and Budget, and revised
annually in accordance with section 673(2) of the Omnibus
Budget Reconciliation Act of 1981) applicable to a family of
the size involved.
``SEC. 2262. INCORPORATION OF CERTAIN MEDICARE PROVISIONS AND OTHER
PROVISIONS.
``(a) Use of Medicare Administrative Contractors.--The Secretary
shall provide for the administration of this title through the use of
medicare administrative contractors in the same manner as title XVIII
is carried out through the use of such contractors, except that no
payment shall be made under this title except on the basis of bills or
charges that are submitted electronically in a manner specified by the
Secretary.
``(b) Definitions.--
``(1) In general.--Except as otherwise provided in this
title, the definitions contained in section 1861 shall apply
for purposes of this title in the same manner as they apply for
purposes of title XVIII.
``(2) State; united states.--(A) The term `State' means the
50 States and includes the District of Columbia, Puerto Rico,
the Virgin Island, Guam, American Samoa, and the Northern
Mariana Islands.
``(B) The term `United States' means all the States.
``(c) Certification, Provider Qualification, etc.--The provisions
of sections 1863 through 1875, sections 1877 through 1880, section
1883, section 1885, and sections 1887 through 1895 shall apply to this
title in the same manner as they apply to title XVIII.
``(d) Title XI Provisions.--The following provisions shall apply to
this title in the same manner as they apply to title XVIII:
``(1) Sections 1124, 1126, and 1128 through 1128E (relating
to fraud and abuse).
``(2) Section 1134 (relating to nonprofit hospital
philanthropy).
``(3) Section 1138 (relating to hospital protocols for
organ procurement and standards for organ procurement
agencies).
``(4) Section 1142 (relating to research on outcomes of
health care services and procedures), except that any reference
in such section to a Trust Fund is deemed a reference to the
AmeriCare Trust Fund.
``(5) Part B of title XI (relating to peer review of the
utilization and quality of health care services).
``(6) Part C of title XI (relating to administrative
simplification).
``(e) Other Provisions.--The provisions of section 201(i) shall
apply to this title and the AmeriCare Trust Fund in the same manner as
they apply to title XVIII and the Federal Hospital Insurance Trust
Fund.
``SEC. 2263. STATE MAINTENANCE OF EFFORT PAYMENTS.
``(a) Condition of Coverage.--Notwithstanding any other provision
of this title, no individual who is a resident of a State is eligible
for benefits under this title for a month in a calendar year, unless
the State provides (in a manner and at a time specified by the
Secretary) for payment to the AmeriCare Trust Fund of \1/12\th of the
amount specified in subsection (b) for the year. Such funds shall be
used offset the costs of providing subsidies for low-income individuals
under section 202.
``(b) Maintenance of Effort Amount.--
``(1) In general.--Subject to paragraph (3), the amount of
payment specified in this subsection for a State for a year is
equal to the amount of payment (net of Federal payments) made
by a State under its State plans under titles XIX and XXI for
2006 for medical assistance for benefits described in paragraph
(2).
``(2) Benefits described.--The benefits described in this
paragraph with respect to State plans of a State under titles
XIX and XXI are benefits which--
``(A) would be available under this title for low-
income individuals if this title had been in effect in
2006; and
``(B) are for low-income individuals who--
``(i) with respect to the State plan under
title XIX, were required to be furnished
medical assistance under such title XIX; or
``(ii) with respect to a State child health
plan under title XXI, were low-income children.
``SEC. 2264. MODIFICATION OF MEDICAID AND OTHER PROGRAMS TO AVOID
DUPLICATION OF BENEFITS.
``(a) In General.--Notwithstanding any other provision of law--
``(1) a State plan under title XIX and a State child health
plan under title XXI shall not provide any medical assistance
for benefits with respect to which any payments may be made
under this title; and
``(2) a health benefits plan under chapter 89 of title 5,
United States Code, shall not provide benefits for which any
payment may be made under this title.
``(b) Review of Application to Other Programs.--The Secretary shall
conduct a review of the feasibility of applying the policy described in
subsection (a) to additional Federal programs, such as the TRICARE
program under title 10, United States Code. Not later than January 1,
2009, the Secretary submit to Congress on such review and shall include
in such report such recommendations for extending such policy to other
Federal programs as the Secretary deems appropriate.
``SEC. 2265. CONSTRUCTION REGARDING CONTINUATION OF OBLIGATIONS UNDER
CURRENT GROUP HEALTH PLAN CONTRACTS AND PROVISION OF
ADDITIONAL BENEFITS.
``Nothing in this title shall be construed as--
``(1) affecting obligations for health care benefits under
group health plans as in effect on the date of the enactment of
this title, including such plans established or maintained
under or pursuant to one or more collective bargaining
agreements;
``(2) limiting the additional benefits that may be provided
under a group health plan to employees or their dependents, or
to former employees or their dependents; or
``(3) limiting the benefits that may be made available
under a State program to residents of the State at the expense
of the State.
``SEC. 2266. STANDARDS AND REQUIREMENTS FOR AMERICARE SUPPLEMENTAL
POLICIES.
``(a) Certification Required.--
``(1) In general.--The Secretary shall establish rules and
procedures consistent with this section under which AmeriCare
supplemental policies may only be issued if they are certified
by the Secretary or under a State regulatory program approved
by the Secretary as meeting standards established under
subsection (b).
``(2) Enforcement.--Any person who issues an AmeriCare
supplemental policy in violation of paragraph (1) is subject to
a civil money penalty of not to exceed $25,000 for each such
violation. The provisions of section 1128A (other than the
first sentence of subsection (a) and other than subsection (b))
shall apply to a civil money penalty under the previous
sentence in the same manner as such provisions apply to a
penalty or proceeding under section 1128A(a).
``(3) AmeriCare supplemental policy.--For purposes of this
section, the term `AmeriCare supplemental policy' is a health
insurance policy or other health benefit plan offered by a
private entity to individuals who are entitled to have payment
made under this title, which provides reimbursement for
expenses incurred for services and items for which payment may
be made under this title but which are not reimbursable by
reason of the application of deductibles, coinsurance amounts,
or other limitations imposed pursuant to this title; but does
not include--
``(A) any such policy or plan of the trustees of a
fund established by one or more employers or labor
organizations (or combination thereof) if the policy or
plan offers benefits as a direct service organization
under section 1833, or
``(B) a policy or plan of a health maintenance
organization which offers benefits under this title
under section 2221(k).
For purposes of this section, the term `policy' includes a
certificate issued under such policy.
``(b) Certification Standards.--
``(1) Issuance.--The Secretary shall develop and publish
specific standards consistent with this section for AmeriCare
supplemental policies and shall consult with the Secretary of
Labor regarding the application of such standards to employee
welfare benefit plans under title I of the Employee Retirement
Income Security Act of 1974.
``(2) More stringent state standards permitted.--In the
case of insured AmeriCare supplemental policies (as defined in
subsection (d)(3)), a State may implement standards that are
more stringent than the standards established under paragraph
(1), including--
``(A) additional limitations on pre-existing
exclusion limitations described in subsection
(c)(1)(B);
``(B) additional restrictions on the groups of
benefits described in subsection (c)(2) that may be
offered in AmeriCare supplemental policies in the
State, so long as a core-only benefit package described
in subparagraph (A)(i) of such subsection may be
offered in the State;
``(C) requiring a higher loss-ratios than those
specified in subsection (c)(3);
``(c) Standards.--The Secretary shall establish standards for
AmeriCare supplemental policies consistent with the following:
``(1) No discrimination based on health status.--
``(A) In general.--Except as provided under
subparagraph (B), an AmeriCare supplemental policy may
not deny, limit, or condition the coverage under (or
benefits of) the policy, or vary premiums charged,
based on the health status, claims experience, receipt
of health care, medical history, or lack of evidence of
insurability, of an individual.
``(B) Limitation on use of pre-existing condition
exclusions.--An AmeriCare supplemental policy may
exclude coverage with respect to services related to
treatment of a pre-existing condition, except that--
``(i) the period of such exclusion may not
exceed 6 months;
``(ii) such exclusion shall not apply to
services furnished to newborns; and
``(iii) the period of exclusion under
clause (i) shall be reduced by 1 month for each
month in a period of continuous health benefits
coverage (as defined by the Secretary) for the
services involved.
For purposes of this subparagraph, a condition is not
pre-existing unless it was diagnosed or treated during
the 3-month period ending on the day before the first
date of such coverage.
``(2) Simplification of benefits.--
``(A) In general.--Each AmeriCare supplemental
policy shall only offer benefits consistent with the
standards, promulgated by the Secretary, that provide--
``(i) limitations on the groups or packages
of benefits, including a core group of basic
benefits and not to exceed 9 other different
benefit packages, that may be offered under an
AmeriCare supplemental policy;
``(ii) that a person may not issue an
AmeriCare supplemental policy without offering
such a policy with only the core-group of basic
benefits and without providing an outline of
coverage in a standard form approved by the
Secretary;
``(iii) uniform language and definitions to
be used with respect to such benefits, and
``(iv) uniform format to be used in the
policy with respect to such benefits.
``(B) Innovation.--The Secretary may approve the
offering of new or innovative and cost-effective
benefit packages in addition to those provided under
subparagraph (A).
``(3) Minimum loss ratio required.--An AmeriCare
supplemental policy, a specific disease policy (as defined by
the Secretary), or a hospital confinement indemnity policy (as
defined by the Secretary) may not be issued or renewed unless
the policy--
``(A) can be expected (in accordance with a uniform
methodology developed by the Secretary and for periods
beginning 24 months after the date of original issue)
to return to policyholders in the form of aggregate
benefits at least 85 percent of the aggregate amount of
premiums collected in the case of group policies or at
least 75 percent in the case of individual policies (as
defined by the Secretary); and
``(B) provides refunds and credits (in a manner
specified by the Secretary) for premiums collected in
excess of those consistent with subparagraph (A).
``(4) Guaranteed renewability and convertibility.--Each
AmeriCare supplemental policy--
``(A) shall be guaranteed renewable and may not be
cancelled or nonrenewed solely on the ground of health
status of the individual or for any reason other than
nonpayment of premium or material misrepresentation;
and
``(B) shall provide for--
``(i) a right of conversion to an
individual policy (with continuation of
benefits) in the case of termination by a group
policyholder or termination by a
certificateholder of membership in a group
through which the individual obtained coverage;
``(ii) a right of continued coverage in the
case of a group policy that succeeds another
group policy; and
``(iii) suspension of coverage (for up to
24 months and in a manner specified ) in the
case of a policy holder who becomes entitled to
benefits under this title as a low-income
individual and who provides a timely notice of
election of such suspension.
``(5) Additional standards applicable only to insured
policies.--A carrier that offers an insured AmeriCare
supplemental policy (as defined in paragraph (6)) to
individuals and groups in a State shall also comply with the
following requirements:
``(A) Open enrollment.--The carrier must offer the
same policy to any other individual or group in the
State on a continuous, year-round basis; except that--
``(i) in the case of policies offered
through an association which is composed
exclusively of employers (which may include
self-employed individuals) and which has been
formed for purposes other than obtaining health
insurance, such requirement shall only apply to
such employers (and individuals) who are
members of the association; and
``(ii) a health maintenance organization
may deny enrollment with respect to an
individual based on the uniform application of
a geographic service area or overall enrollment
limitation based on its financial or
administrative capacity.
``(B) Notices and renewal periods.-- The carrier
shall provide advance notice of terms for policy
renewal, which terms shall--
``(i) be the same as the terms of issuance,
except for rates and administrative changes;
``(ii) provide the same premium rates as
for a new issue; and
``(iii) provide a period of renewal of not
less than 12 months.
``(c) Additional Requirements.--
``(1) Prohibition of duplication.--The Secretary shall--
``(A) establish requirements that prohibit (other
than as required under Federal or State law) the
knowing sale or issuance to an individual entitled to
benefits under this title of health insurance that
duplicates benefits under this title, of an AmeriCare
supplemental policy that duplicates another AmeriCare
supplemental policy, or of another health insurance
policy that duplicates other benefits to which the
individual is entitled; and
``(B) provide exceptions to the prohibition in
subparagraph (A) for enrollment in group health plans
and similar employment-based policies and for policies
which provide benefits directly and without regard to
other coverage and notice of such duplication.
``(2) Disclosure requirement.--The Secretary shall
establish a requirement that prohibits the sale or issuance of
an AmeriCare supplemental policy to an individual, other than
as a replacement policy, without obtaining a statement (in a
form specified by the Secretary) that discloses other health
benefits coverage and that acknowledges limitations on the need
for an AmeriCare supplemental policy, particularly in the case
of a low-income individual.
``(3) Application of false statement sanctions.--The
provisions of paragraphs (1) and (2) of section 1882(d) shall
apply to an AmeriCare supplemental policy under this section in
the same manner as they apply to medicare supplemental policies
under such section.
``(4) Limitations on sales commissions.--
``(A) In general.--It is unlawful for a person who
provides for a commission or other compensation to an
agent or other representatives with respect to the sale
of an AmeriCare supplemental policy (or certificate)--
``(i) to provide for a first year
commission or other first year compensation
that exceeds 200 percent of the commission or
other compensation for the selling or servicing
of the policy or certificate in a second or
subsequent year; or
``(ii) to provide for compensation with
respect to replacement of such a policy or
certificate that is greater than the
compensation that would apply to the renewal of
the policy or certificate.
``(B) Definition.--In subparagraph (A), the term
`compensation' includes pecuniary and nonpecuniary
compensation of any kind relating to the sale or
renewal of a policy or certificate and specifically
includes bonuses, gifts, prizes, awards, and finders'
fees.
``(d) Information Disclosure.--The Secretary shall provide, to all
individuals entitled to benefits under this title, such information as
will permit such individuals to evaluate the value of AmeriCare
supplemental policies to them and the relationship of any such policies
to benefits provided under this title. Such information shall include
information on--
``(1) the requirements and prohibitions under this section;
``(2) State and Federal agencies responsible for compliance
with such requirements and enforcement of such prohibitions;
and
``(3) the manner of submitting complaints regarding
violations of such requirements and prohibitions.
``(e) Definitions.--In this section:
``(1) Carrier.--The term `carrier' means any person that
offers an AmeriCare supplemental policy.
``(2) Group.--The term `group' means 2 or more employees of
the same employer who normally perform on a monthly basis at
least 17\1/2\ hours of service per week for that employer.
``(3) Health maintenance organization.--The term `health
maintenance organization' has the meaning given the term
`eligible organization' in section 1876(b).
``(4) Insured americare supplemental policy.--The term
`insured AmeriCare supplemental policy' means any AmeriCare
supplemental policy provided through insurance.''.
TITLE II--FINANCING PROVISIONS
Subtitle A--INDIVIDUAL CONTRIBUTIONS
SEC. 201. GENERAL OBLIGATION FOR INDIVIDUALS.
(a) Payment of Plan Premium.--
(1) In general.--Each individual eligible for coverage
under title XXII of the Social Security Act is liable for
payment of the premium established under this section for such
coverage of the individual and family members. An individual
who is not receiving such coverage due to coverage under a
group health plan described in section 2202(d) of such Act is
not liable for payment of such premium with respect to such
individual.
(2) Determination of premium.--Such premium shall be
established by the Secretary of Health and Human Services on
the basis of the cost of coverage (determined on a State by
State basis and including administrative costs) and shall be
determined separately based on the class of enrollment for the
individual (as determined under section 2202 of the Social
Security Act).
(3) Joint and several liability.--If more than one
individual is liable under this subsection for payment of a
premium for coverage of the same individual under title XXII of
the Social Security Act, such individual shall be jointly and
severally liable with each other individual who is so liable.
(b) Reduction for Employer Contributions and Low Income
Subsidies.--An individual's liability under subsection (a) is reduced
by--
(1) the amount of any contributions made by the
individual's employer (or employers) under subtitle B or
otherwise (including voluntary employer contributions) with
respect to coverage of the individual and family members, and
(2) the amount of any premium subsidies provided with
respect to the individual under section 202.
(c) Timing and Manner of Payment.--Each individual that is liable
for a premium under subsection (a) shall pay such premium in such form
and manner as the Secretary of the Treasury may specify. Except as
otherwise provided by the Secretary of the Treasury, for purposes of
subtitle F of such Code, the liabilities imposed under subsection (a)
shall be treated as if they were a tax imposed under section 1 of such
Code. The Secretary of the Treasury shall provide for the withholding
of such payments from wages under rules similar to the rules of chapter
24 of such Code. The Secretary of the Treasury may prescribe special
rules for withholding payments from wages of individuals who work
seasonally, part-time, or for more than one employer.
SEC. 202. ADDITIONAL PREMIUM SUBSIDIES.
(a) Eligibility for Additional Premium Subsidies.--
(1) In general.--Each premium subsidy eligible individual
is entitled to a premium subsidy in accordance with this
section.
(2) Premium subsidy eligible individual.--In this section,
the term ``premium subsidy eligible individual'' means an
individual receiving coverage under title XXII of the Social
Security Act who--
(A) with respect to premiums for a taxable year
ending in a year, has family income (as defined in
paragraph (3)(A)) that is less than 300 percent of the
applicable poverty level, or
(B) with respect to a premium for a month, is an
TANF or SSI recipient for the month.
(3) Additional definitions.--In this section:
(A) Family income.--The term ``family income''
means, with respect to an individual who--
(i) is not a dependent of another
individual, the sum of the modified adjusted
gross incomes (as defined in subparagraph (B))
for the individual, the individual's spouse,
and children who are dependents of the
individual, or
(ii) is a dependent of another individual,
the sum of the modified adjusted gross incomes
(as defined in subparagraph (B)) for the other
individual, the other individual's spouse, and
children who are dependents of the other
individual.
(B) Modified adjusted gross income.--The term
``modified adjusted gross income'' means adjusted gross
income (as defined in the Internal Revenue Code of
1986)--
(i) determined without regard to sections
911, 931, and 933 of such Code, and
(ii) increased by--
(I) the amount of interest received
or accrued by the individual during the
taxable year which is exempt from tax,
and
(II) the amount of the social
security benefits (as defined in
section 86(d) of such Code) received
during the taxable year to the extent
not included in gross income under
section 86 of such Code.
The determination under the preceding sentence shall be
made without regard to any carryover or carryback.
(C) Applicable poverty level.--
(i) In general.--The term ``applicable
poverty level'' means, for a family for a year,
the official poverty line (as defined by the
Secretary of Health and Human Services)
applicable to a family of the size involved for
2010 adjusted by the percentage increase or
decrease described in clause (ii) for the year
involved.
(ii) Percentage adjustment.--The percentage
increase or decrease described in this clause
for a year is the percentage increase or
decrease by which the average Consumer Price
Index for all urban consumers (U.S. city
average), as published by the Bureau of Labor
Statistics, for the 12-month-period ending with
August 31 of the preceding year exceeds such
average for the 12-month period ending with
August 31, 2009.
(iii) Rounding.--Any adjustment made under
clause (ii) for a year shall be rounded to the
nearest multiple of $100.
(D) TANF recipient.--The term ``TANF recipient''
means, for a month, an individual who is receiving aid
or assistance under any plan of the State approved
under title I, X, XIV, or XVI, or part A or part E of
title IV, of the Social Security Act, for the month.
(E) SSI recipient.--The term ``SSI recipient''
means, for a month, an individual--
(i) with respect to whom supplemental
security income benefits are being paid under
title XVI of the Social Security Act for the
month,
(ii) who is receiving a supplementary
payment under section 1616 of such Act or under
section 212 of Public Law 93-66 for the month,
or
(iii) who is receiving monthly benefits
under section 1619(a) of the Social Security
Act (whether or not pursuant to section
1616(c)(3) of such Act) for the month.
(b) Amount of Premium Subsidy.--
(1) Lowest income individuals.--
(A) In general.--In the case of an individual
described in subparagraph (B), the premium subsidy
under this section is the amount which would (without
regard to this section) reduce the premium obligation
of the individual (and family members) under section
201 to zero.
(B) Lowest income individuals described.--An
individual described in this subparagraph is a premium
subsidy eligible individual who would still be such an
individual under subsection (a)(2) if ``200 percent''
were substituted for ``300 percent'' in subparagraph
(A) of such subsection.
(2) Other individuals.--
(A) In general.--In the case of a premium subsidy
eligible individual not described in paragraph (1), the
premium subsidy under this section is the product of--
(i) the premium obligation of the
individual (and family members) under section
201, multiplied by
(ii) the number of percentage points by
which the individual's family income (expressed
as a percent of the applicable poverty level)
is less than 300 percent.
(B) Table.--The Secretary may provide for a table
which establishes the values for premium subsidies
under this paragraph.
(c) General Revenue Financing for Low Income Subsidies.--There are
authorized to be appropriated to the Americare Trust Fund from amounts
in the Treasury not otherwise appropriated, such sums as may be
necessary to cover the costs of premium subsidies provided under this
section.
SEC. 203. EFFECTIVE DATE.
The provisions of this subtitle shall apply with respect to periods
beginning on or after January 1, 2010.
Subtitle B--Employer Contributions
SEC. 211. GENERAL OBLIGATION FOR EMPLOYERS.
(a) General Obligation.--
(1) In general.--Subject to the succeeding provisions of
this subsection, each employer shall make a financial
contribution toward the cost of health insurance coverage for
employees in accordance with this section.
(2) Elimination of liability in case of certain group
health plan coverage.--
(A) In general.--Subject to subparagraph (B), an
employer shall not be liable for any contribution under
this section with respect to any employee who is
covered under a group health plan of the employer
described in section 2202(d) if such employer pays at
least 80 percent of the cost of such health plan, as
determined by the Secretary of Health and Human
Services.
(B) Surcharge permissible to prevent adverse
selection.--The Secretary may impose liability for a
contribution under this section with respect to an
employee described in subparagraph (A) in an amount
(not to exceed the amount specified under subsection
(b)) insofar as the Secretary determines it necessary
to prevent adverse selection of the individuals
enrolled under this title as a result of the operation
of such subparagraph.
(b) Amount of Contribution.--
(1) Full-time employees.--In the case of an employee
receiving coverage under title XXII of the Social Security Act,
the amount of the financial contribution is equal to at least
80 percent of the premium determined with respect to such
employee and family members under section 201 (based on class
of enrollment and without regard to subsection (b) thereof) or
at least 80 percent of the cost of coverage under such group
health plan, respectively.
(2) Reduction for part-time employees.--In the case of a
part-time employee, the employer contribution requirements of
paragraph (1) shall be treated as satisfied if the employer
contribution with respect to such employee is not less than the
part-time employment ratio of the contribution required under
paragraph (1).
(3) Rules related to part-time employment.--For purposes of
this subsection--
(A) Part-time employee.--The term ``part-time
employee'' means, with respect to any month, an
employee who works on average fewer than 40 hours per
week.
(B) Part-time employment ratio.--The term ``part-
time employment ratio'' means, with respect to a part-
time employee of an employer in a month, a fraction--
(i) the numerator of which is the number of
hours in the employee's normal work week, and
(ii) the denominator of which is 40 hours.
(C) Special rules.--Under rules prescribed by the
Secretary of Health and Human Services, in consultation
with the Secretary of the Treasury, in the case of an
employee for an employer whose defined work week for
full-time employees is less than 40 hours, any
reference in this subsection to 40 hours is deemed a
reference to the number of hours in the work week so
defined.
(D) Conversion to hours of employment.--The
Secretary of Health and Human Services, in consultation
with the Secretary of the Treasury, shall establish
rules for the conversion of compensation to hours of
employment, for purposes of this subsection in the case
of employees that receive compensation on a salaried
basis, or on the basis of a commission, or other
contingent or bonus basis, rather than based on an
hourly wage.
(c) Timing and Manner.--
(1) In general.--Each employer that is required to make a
financial contribution with respect to an employee under this
section (other than with respect to coverage under a group
health plan) or a surcharge under subsection (a)(2)(B) shall
pay such contribution or surcharge in a form and manner,
specified by the Secretary of the Treasury, based upon the form
and manner in which employer excise taxes are required to be
paid under section 3111 of the Internal Revenue Code of 1986.
(2) Non-enrolling employers.--In the case of an employee
who is covered under the class of enrollment of a family
member, the Secretary of the Treasury shall provide that the
financial contribution of the employer with respect to such
employee is paid directly or indirectly to the employer of such
family member.
SEC. 212. EFFECTIVE DATE.
(a) In General.--Subject to subsection (b), the provisions of this
subtitle shall apply with respect to periods beginning on or after
January 1, 2010.
(b) Additional period for small employers.--The provisions of this
subtitle shall not apply with respect to an employer that has fewer
than 100 employees (as determined by the Secretary of the Treasury in
consultation with the Secretary of Health and Human Services) for
periods beginning before January 1, 2012.
<all>
Introduced in House
Introduced in House
Sponsor introductory remarks on measure. (CR E1530-1531)
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Subcommittee on Employer-Employee Relations.
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