S.Amdt. 2838

SA 2838. Mr. SANDERS submitted an amendment intended to be proposed
to amendment SA 2786 proposed by Mr. Reid (for himself, Mr. Baucus, Mr.
Dodd, and Mr. Harkin) to the bill H.R. 3590, to amend the Internal
Revenue Code of 1986 to modify the first-time homebuyers credit in the
case of members of the Armed Forces and certain other Federal
employees, and for other purposes; which was ordered to lie on the
table; as follows:

Beginning on page 182, strike line 20 and all that follows
through line 11 on page 183, and insert the following:
(b) Establishment of Community Health Insurance Option.--
(1) Establishment.--The Secretary shall establish a
community health insurance option to offer, through the
Exchanges established under this title, health
Beginning on page 187, strike line 17 and all that follows
through line 8 on page 188, and insert the following:
(6) Reimbursement rates.--
(A) Rates established by secretary.--
(i) In general.--The Secretary shall establish payment
rates for the community health insurance option for services
and health care providers consistent with this section and
may change such payment rates.
(ii) Initial payment rules.--

(I) In general.--Except as provided in subclause (II),
during the first 3 years in which the community health
insurance option if offered, the Secretary shall base the
payment rates under this section for services and providers
described in subparagraph (A) on the payment rates for
similar services and providers under parts A and B of
Medicare under title XVIII of the Social Security Act.
(II) Exceptions.--

(aa) Payment rates for practitioners services.--Payment
rates for practitioners services otherwise established under
the fee schedule under section 1848 of the Social Security
Act shall be applied without regard to the provisions under
subsection (f) of such section and the update under
subsection (d)(4) under such section for a year as applied
under this subparagraph shall be not less than 1 percent.
(bb) Adjustments.--The Secretary may determine the extent
to which Medicare adjustments applicable to base payment
rates under parts A and B of Medicare shall apply under this
section.
(iii) For new services.--The Secretary shall modify payment
rates described in clause (ii) in order to accommodate
payments for services, such as well-child visits, that are
not otherwise covered under Medicare.
(iv) Prescription drugs.--Payment rates under this
paragraph for prescription drugs that are not paid for under
part A or part B of Medicare shall be at rates negotiated by
the Secretary.
(B) Incentives for participating providers.--
(i) Initial incentive period.--

(I) In general.--The Secretary shall provide, in the case
of services described in subclause (II) furnished during the
first 3 years in which a community health insurance option is
offered, for payment rates that are 5 percent greater than
the rates established under subparagraph (A).
(II) Services described.--The services described in this
subclause are items and professional services, under the
community health insurance option by a physician or other
health care practitioner who participates in both Medicare
and the community health insurance option.
(III) Special rules.--A pediatrician and any other health
care practitioner who is a type of practitioner that does not
typically participate in Medicare (as determined by

[[Page S12251]]

the Secretary) shall also be eligible for the increased
payment rates under subclause (I).

(ii) Subsequent periods.--Beginning with the fourth year in
which the community health insurance option is offered, and
for subsequent years, the Secretary shall continue to use an
administrative process to set such rates in order to promote
payment accuracy, to ensure adequate beneficiary access to
providers, and to promote affordability and the efficient
delivery of medical care. Such rates shall not be set at
levels expected to increase overall medical costs under the
option beyond what would be expected if the process under
subparagraph (A)(ii) and clause (i) of this subparagraph were
continued.
(iii) Establishment of a provider network.--Health care
providers participating under Medicare are participating
providers in the community health insurance option unless
they opt out in a process established by the Secretary.
(C) Administrative process for setting rates.--Chapter 5 of
title 5, United States Code shall apply to the process for
the initial establishment of payment rates under this
paragraph but not to the specific methodology for
establishing such rates or the calculation of such rates.
(D) Construction.--Nothing in this subtitle shall be
construed--
(i) as limiting the Secretary's authority to correct for
payments that are excessive or deficient, taking into account
the amounts paid for similar health care providers and
services under other Exchange-participating qualified health
plans.
(ii) as affecting the authority of the Secretary to
establish payment rates, including payments to provide for
the more efficient delivery of services.
(E) Limitation on review.--There shall be no administrative
or judicial review of a payment rate or methodology
established under this paragraph.
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