S.Amdt. 2839

SA 2839. 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 8 on page 188, 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 care coverage
that provides value, choice, competition, and stability of
affordable, high quality coverage throughout the United
States.
(2) Community health insurance option.--In this section,
the term ``community health insurance option'' means health
insurance coverage that--
(A) except as specifically provided for in this section,
complies with the requirements for being a qualified health
plan;
(B) provides high value for the premium charged;
(C) reduces administrative costs and promotes
administrative simplification for beneficiaries;
(D) promotes high quality clinical care;
(E) provides high quality customer service to
beneficiaries;
(F) offers a sufficient choice of providers; and
(G) complies with State laws (if any), except as otherwise
provided for in this title, relating to the laws described in
section 1324(b).
(3) Essential health benefits.--
(A) General rule.--Except as provided in subparagraph (B),
a community health insurance option offered under this
section shall provide coverage only for the essential health
benefits described in section 1302(b).
(B) States may offer additional benefits.--Nothing in this
section shall preclude a State from requiring that benefits
in addition to the essential health benefits required under
subparagraph (A) be provided to enrollees of a community
health insurance option offered in such State.
(C) Credits.--
(i) In general.--An individual enrolled in a community
health insurance option under this section shall be eligible
for credits under section 36B of the Internal Revenue Code of
1986 in the same manner as an individual who is enrolled in a
qualified health plan.
(ii) No additional federal cost.--A requirement by a State
under subparagraph (B) that benefits in addition to the
essential health benefits required under subparagraph (A) be
provided to enrollees of a community health insurance option
shall not affect the amount of a premium tax credit provided
under section 36B of the Internal Revenue Code of 1986 with
respect to such plan.
(D) State must assume cost.--A State shall make payments to
or on behalf of an eligible individual to defray the cost of
any additional benefits described in subparagraph (B).
(E) Ensuring access to all services.--Nothing in this Act
shall prohibit an individual enrolled in a community health
insurance option from paying out-of-pocket the full cost of
any item or service not included as an essential health
benefit or otherwise covered as a benefit by a health plan.
Nothing in subparagraph (B) shall prohibit any type of
medical provider from accepting an out-of-pocket payment from
an individual enrolled in a community health insurance option
for a service otherwise not included as an essential health
benefit.
(F) Protecting access to end of life care.--A community
health insurance option offered under this section shall be
prohibited from limiting access to end of life care.
(4) Cost sharing.--A community health insurance option
shall offer coverage at each of the levels of coverage
described in section 1302(d).
(5) Premiums.--
(A) Premiums sufficient to cover costs.--The Secretary
shall establish geographically adjusted premium rates in an
amount sufficient to cover expected costs (including claims
and administrative costs) using methods in general use by
qualified health plans.
(B) Applicable rules.--The provisions of title XXVII of the
Public Health Service Act relating to premiums shall apply to
community health insurance options under this section,
including modified community rating provisions under section
2701 of such Act.
(C) Collection of data.--The Secretary shall collect data
as necessary to set premium rates under subparagraph (A).
(D) National pooling.--Notwithstanding any other provision
of law, the Secretary may treat all enrollees in community
health insurance options as members of a single pool.
(E) Contingency margin.--In establishing premium rates
under subparagraph (A), the Secretary shall include an
appropriate amount for a contingency margin.
(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 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 affordablility 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

[[Page S12252]]

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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