II
110th CONGRESS
1st Session
S. 1019
IN THE SENATE OF THE UNITED STATES
March 28, 2007
Mr. Coburn (for himself, Mr. Burr, Mr. Chambliss, and Mr. Inhofe) introduced the following bill; which was read twice and referred to the Committee on Finance
A BILL
To provide comprehensive reform of the health care system of the United States, and for other purposes.
Short title; table of contents
Short title
This Act may be cited as the
Universal Health Care Choice and
Access Act
.
Table of contents
The table of contents for this Act is as follows:
Sec. 1. Short title; table of contents.
Sec. 2. Findings.
TITLE I—Prevention and Wellness
Sec. 101. Strategic approach to outcome-based prevention.
Sec. 102. State grants for outcome-based prevention effort.
Sec. 103. Keeping the food stamp program focused on nutrition.
Sec. 104. Immunizations.
TITLE II—Tax incentives to encourage purchase of health care insurance
Subtitle A—Health Savings Accounts
Sec. 201. Expansion of health savings accounts.
Sec. 202. Exception to requirement for employers to make comparable health savings account contributions.
Subtitle B—MediChoice tax rebates
Sec. 211. Refundable credit for health insurance coverage.
Sec. 212. Advance payment of credit for purchasers of qualified health insurance.
Sec. 213. Termination of employer-provided health care coverage exclusion.
TITLE III—Health insurance modernization
Subtitle A—Employee choice
Sec. 301. Clarification of definition of group health plan under HIPAA.
Subtitle B—Access to health care
Sec. 311. State high risk pools.
Sec. 312. Federally qualified health centers.
Subtitle C—Interstate market for health insurance
Sec. 321. Short title.
Sec. 322. Specification of constitutional authority for enactment of law.
Sec. 323. Findings.
Sec. 324. Cooperative governing of individual health insurance coverage.
Sec. 325. Severability.
TITLE IV—Improvements to the Medicare program
Subtitle A—MediChoice for Seniors
Sec. 401. Setting the benchmark equal to the national average bid.
Sec. 402. Enhancement of beneficiary rebates.
Sec. 403. Alternative benefit design to original medicare fee-for-service benefits.
Sec. 404. Medicare advantage HSA plans.
Sec. 405. Review of adjustment mechanism used under the Medicare Advantage program.
Subtitle B—Enhancements to the Medicare Fee-For-Service Program
Sec. 411. Elimination of annual indexing of income thresholds for reduced part B premium subsidies.
Sec. 412. Authority to adjust amount of Medicare part B premium to reward positive health behavior.
Sec. 413. Recapture of Medicare DSH funds.
Sec. 414. Price transparency requirements for Medicare providers.
Subtitle C—Value-Based Purchasing
Sec. 421. Repeal of physician ownership referral prohibitions based on compensation arrangements.
Sec. 422. Revision of designated health services subject to ownership referral prohibition.
Sec. 423. Exceptions to ownership referral prohibitions.
Sec. 424. Effective date.
Subtitle D—Securing Medicare's future for tomorrow's seniors
Sec. 431. Medical Retirement Accounts.
TITLE V—Keeping Medicaid on Mission
Sec. 501. Restructuring of Medicaid funding.
Sec. 502. Medicaid Advantage program.
Sec. 503. High performance bonuses.
TITLE VI—Administrative health care tribunals
Sec. 601. State grants to create administrative health care tribunals.
TITLE VII—Health information technology
Subtitle A—Assisting the development of health information technology
Sec. 701. Purpose.
Sec. 702. Health record banking.
Sec. 703. Application of Federal and State security and confidentiality standards.
Subtitle B—Promoting the use of health information technology to better coordinate health care
Sec. 711. Safe harbors to antikickback civil penalties and criminal penalties for provision of health information technology and training services.
Sec. 712. Exception to limitation on certain physician referrals (under stark) for provision of health information technology and training services to health care professionals.
Sec. 713. Rules of construction regarding use of consortia.
TITLE VIII—Miscellaneous
Sec. 801. Dedication of Medicaid and revenue savings to strengthening the financial solvency of the Federal Hospital Insurance Trust Fund.
Sec. 802. Health care choice for veterans.
Sec. 803. Health care choice for Indians.
Findings
Congress makes the following findings:
Nine out of 10 Americans think the United States health care system needs fundamental changes.
The United States spends approximately 16 percent of its Gross Domestic Product on health care and experts estimate that percentage will rise to 20 percent by 2015.
The Federal Government spends more on health care than it does on national defense.
As much as $1 out of every $4 health care dollars do not go towards making Americans healthy.
Nearly 75 percent of American health care spending goes toward the treatment of chronic diseases. Five preventable chronic diseases (heart disease, cancer, stroke, chronic obstructive pulmonary disease, and diabetes) cause two-thirds of American deaths.
Since 2000, premiums for family health coverage have increased by 87 percent, compared with cumulative inflation of 18 percent and cumulative wage growth of 20 percent. During this same period, the percentage of employers offering health benefits has fallen from 69 percent to 61 percent, and the percentage of workers covered by their own employer also has fallen. The current employer-based system offers little choice in health plans to employees: 88 percent of American firms offer only 1 health plan type.
Medicaid was designed as a safety net to ensure that the poorest Americans have access to health care at a cost of $1,000,000,000 in its first year. Today, more than 1 out of every 6 Americans is in Medicaid at a total cost of more than $338,000,000,000 in 2006. The program is expected to cost nearly $5,000,000,000,000 over the next decade. In 2003, for the first time ever, Medicaid spending replaced education as the largest component of State budgets, consuming 22 percent of State spending.
The unfunded liabilities of the Medicare Program over the next 75 years are estimated to be $32,100,000,000,000 and $70,500,000,000,000 on the infinite horizon. The Federal Hospital Insurance Trust Fund is projected to be exhausted by 2018. Without any change in the program, Medicare will consume 23.1 percent of all Federal income taxes by 2020 and 37.5 percent of all Federal income taxes by 2030. Under the current system, physician reimbursements will be cut by 34 percent by the year 2015, leading to decreased access to physicians' services for seniors.
Our current civil justice system is adversely affecting patient access to health care services, better patient care, and cost-efficient health care, in that the health care liability system is a costly and ineffective mechanism for resolving claims of health care liability and compensating injured patients, and is a deterrent to the sharing of information among health care professionals which impedes efforts to improve patient safety and quality of care. Economists estimate that between 5 and 9 percent of health care spending is related to defensive medicine.
The adoption of health information technology will significantly reduce health care spending while simultaneously increasing the quality of health care.
Prevention and Wellness
Strategic approach to outcome-based prevention
Interagency coordinating committee
In general
The Secretary of Health and Human Services
(referred to in this title as the Secretary
) shall convene an
interagency coordinating committee to develop a national strategic plan for
prevention. The Secretary shall serve as the chairperson of the
committee.
Composition
In carrying out paragraph (1), the Secretary shall include the participation of—
the Director of the National Institutes of Health;
The Director of the Centers for Disease Control and Prevention;
the Administrator of the Agency for Healthcare Research and Quality;
the Administrator of the Substance Abuse and Mental Health Services Administration;
the Administrator of the Health Resources and Services Administration;
the Secretary of Agriculture;
the Director of the Centers for Medicare & Medicaid Services;
the Administrator of the Environmental Protection Agency;
the Director of the Indian Health Service;
the Administrator of the Administration on Aging;
the Secretary of Veterans Affairs;
the Secretary of Defense;
the Secretary of Education; and
the Secretary of Labor.
Report and plan
Not later than 1 year after the date of enactment of this Act, the Secretary, acting through the coordinating committee convened under paragraph (1), shall submit to Congress a report concerning the recommendation of the committee for health promotion and disease prevention activities. Such report shall include a specific strategic plan that shall include—
a list of national priorities on health promotion and disease prevention to address lifestyle behavior modification (smoking cessation, proper nutrition, and appropriate exercise) and the prevention measures for the 5 leading disease killers in the United States;
specific science-based initiatives to achieve the measurable goals of Healthy People 2010 regarding nutrition, exercise, and smoking cessation, and targeting the 5 leading disease killers in the United States;
specific plans for consolidating Federal health programs and Centers that exist to promote healthy behavior and reduce disease risk (including eliminating programs and offices determined to be ineffective in meeting the priority goals of Health People 2010), that include transferring the nutrition guideline development responsibility from the Secretary of Agriculture to the Director of the Centers for Disease Control and Prevention;
specific plans to ensure that all Federal health care programs are fully coordinated with science-based prevention recommendations promulgated by the Director of the Centers for Disease Control and Prevention;
specific plans to ensure that all non-Department of Health and Human Services prevention programs are based on the science-based guidelines developed by the Centers for Disease Control and Prevention under subparagraph (D); and
a list of new non-Federal and non-government partners identified by the committee to build Federal capacity in health promotion and disease prevention efforts.
Annual request to give testimony
The Secretary shall annually request an opportunity to testify before Congress concerning the progress made by the United States in meeting the outcome-based standards of Healthy People 2010 with respect to disease prevention and measurable outcomes and effectiveness of Federal programs related to this goal.
Periodic reviews
The Secretary shall conduct periodic reviews, not less than every 5 years, and grading of every Federal disease prevention and health promotion initiatives, programs, and agencies. Such reviews shall be evaluated based on effectiveness in meeting metrics-based goals with an analysis posted on such agencies’ public Internet websites.
Federal messaging on health promotion and disease prevention
Media campaigns
In general
Not later than 1 year after the date of enactment of this Act, the Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall establish and implement a national science-based media campaign on health promotion and disease prevention.
Requirements of campaign
The campaign implemented under subparagraph (A)—
shall be designed to address proper nutrition, regular exercise, smoking cessation, obesity reduction, the 5 leading disease killers in the United States, and secondary prevention through disease screening promotion;
shall be carried out through competitively bid contracts awarded to entities providing for the professional production and design of such campaign;
may include the use of television, radio, Internet, and other commercial marketing venues and may be targeted to specific age groups based on peer-reviewed social research;
shall not be duplicative of any other Federal efforts relating to health promotion and disease prevention; and
may include the use of humor and nationally-recognized positive role models.
Evaluation
The Secretary shall ensure that the campaign implemented under subparagraph (A) is subject to an independent evaluation every 2 years and shall report every 2 years to Congress on the effectiveness of such campaigns towards meeting science-based metrics.
Website
The Secretary, in consultation with private-sector experts, shall maintain or enter into a contract to maintain an Internet website to provide science-based information on guidelines for nutrition, regular exercise, obesity reduction, smoking cessation, and specific chronic disease prevention. Such website shall be designed to provide information to health care providers and consumers.
Dissemination of information through providers
The Secretary, acting through the Centers for Disease Control and Prevention, shall develop and implement a plan for the dissemination of health promotion and disease prevention information consistent with national priorities described in the strategic and implementing plan under subsection (a)(3)(A), through health care providers who participate in Federal programs, including programs administered by the Indian Health Service, the Department of Veterans Affairs, the Department of Defense, and the Health Resources and Services Administration, and the Medicare and Medicaid Programs.
Personalized prevention plans
Contract
The Secretary, acting through the Director of the Centers for Disease Control and Prevention, shall enter into a contract with a qualified entity for the development and operation of a Federal Internet website personalized prevention plan tool.
Use
The website developed under subparagraph (A) shall be designed to be used as a source of the most up-to-date scientific evidence relating to disease prevention for use by individuals. Such website shall contain a component that enables an individual to determine their disease risk (based on personal health and family history, BMI, and other relevant information) relating to the 5 leading diseases in the United States, and obtain personalized suggestions for preventing such diseases.
Internet portal
The Secretary shall establish an Internet portal for accessing risk-assessment tools developed and maintained by private and academic entities.
Priority funding
Funding for the activities authorized under this section shall take priority over funding from the Centers for Disease Control and Prevention provided for grants to States and other entities for similar purposes and goals as provided for in this section. Not to exceed $500,000,000 shall be expended on the campaigns and activities required under this Act.
State grants for outcome-based prevention effort
In general
If the Secretary determines that it is essential to meeting the national priorities described in the plan required under section 101(a)(3)(A), the Secretary may award grants to States for the conduct of specific health promotion and disease prevention activities.
Eligibility
To be eligible to receive a grant under subsection (a), a State shall submit to the Secretary an application at such time, in such manner, and containing such information as the Secretary may require, including a strategic plan that shall—
describe the specific health promotion and disease prevention activities to be carried out under this grant;
include a list of the barriers that exist within the State to meeting specific goals of Healthy People 2010;
include targeted demographic indicators and measurable objectives with respect to health promotion and disease prevention;
contain a set of process outcomes and milestones, based on the process outcomes and milestones developed by the Secretary, for measuring the effectiveness of activities carried out under the grant in the State; and
outline the manner in which interventions to be carried out under this grant will reduce morbidity and mortality within the State over a 5-year period (or over a 10-year period, if the Secretary determines such period appropriate for adequately measuring progress).
Process outcomes and milestones
In general
The Secretary shall develop process outcomes and milestones to be used to measure the effectiveness of activities carried out under a grant under this section by a State.
Determinations
If, beginning 2 years after the date on which a grant is awarded to a State under this section, the Secretary determines that the State is failing to make adequate progress in meeting the outcomes and milestones contained in the State plan under subsection (b)(4), the Secretary shall provide the State with technical assistance on how to make such progress. Such technical assistance shall continue for a period of 2 years.
Continued failure to meet objectives
If after the expiration of the 2-year period described in paragraph (2), the Secretary determines that the State is failing to make adequate progress in meeting the outcomes and milestones contained in the State plan under subsection (b)(4) over a 5-year period, the Secretary shall terminate all funding to the State under a grant under this section.
Regional activities
A State may use an amount, not to exceed 15 percent of the total grant amount to such State, to carry out regional activities in conjunction with other States.
Targeted activities
A State may use grant funds to target specific populations within the State to achieve specific outcomes described in Healthy People 2010.
Innovative incentive structures
The Secretary may award grants to States for the purposes of developing innovative incentive structures to encourage individuals to adopt specific prevention behaviors such as reducing their body mass index or for smoking cessation.
Wellness bonuses
In general
The Secretary shall award wellness bonus payments to at least 5, but not more than 10, States that demonstrate the greatest progress in reducing disease rates and risk factors and increasing heathy behaviors.
Requirement
To be eligible to receive a bonus payment under paragraph (1), a State shall demonstrate—
the progress described in paragraph (1); and
that the State has met a specific floor for progress outlined in the science-based metrics of Healthy People 2010.
Use of payments
Bonus payments under this subsection may only be used by a State for the purposes of health promotion and disease prevention.
Funding
Out of funds appropriated to the Director of the Centers for Disease Control and Prevention for each fiscal year beginning with fiscal year 2008, the Director shall give priority to using $50,000,000 of such funds to make bonus payments under this subsection.
Administrative expenses
A State may use not more than 5 percent of the amount of a grant under this section to carry out administrative activities.
State
In this section, the term State means the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, Samoa, the United States Virgin Islands, and the Commonwealth of the Northern Mariana Islands.
Authorization of appropriations
Funding for the activities authorized under this section shall take priority over funding from the Centers for Disease Control and Prevention provided for grants to States and other entities for similar purposes and goals as provided for in this section, not to exceed $300,000,000 for each fiscal year.
Keeping the food stamp program focused on nutrition
Counseling brochure
The Director of the Centers for Disease Control and Prevention shall develop, and the Secretary of Agriculture shall distribute to each individual and family enrolled in the Food Stamp Program under the Food Stamp Act of 1977 (7 U.S.C. 2011 et seq.), a science-based nutrition counseling brochure.
Limitations on food stamp purchases
In general
Not later than 6 months after the date of enactment of this Act, the Secretary of Agriculture shall, based on scientific, peer-reviewed recommendations provided by a Commission that includes public health, medical, and nutrition experts and the Director of the Centers for Disease Control and Prevention, develop lists of foods that do not meet science-based standards for proper nutrition and that may not be purchased under the food stamp program. Such list shall be updated on an annual basis to ensure the most current science-based recommendations are applied to the food stamp program.
Automated enforcement
The Secretary of Agriculture shall, through regulations, ensure that the limitations on food purchases under paragraph (1) is enforced through the food stamp program’s automated system.
Implementation
The Secretary of Agriculture shall promulgate the regulations described in paragraph (2) by the date that is not later than 1 year after the date of enactment of this section.
Immunizations
Purchase of vaccines
Notwithstanding any other provision of law, a State may use amounts provided under section 317 of the Public Health Service Act (42 U.S.C. 247b) for immunization programs to purchase vaccines for use in health care provider offices and schools.
Technical assistance and reduction in funding
If a State does not achieve a benchmark of 80 percent coverage within the State for Centers for Disease Control and Prevention-recommended vaccines, the Director of the Centers shall provide technical assistance to the State for a period of 2 years. If after the expiration of such 2-year period the State continues to fail to achieve such benchmark, the Secretary shall reduce funding provided under section 317 of the Public Health Service Act to such State by 5 percent.
Bonus grant
A State achieving a benchmark of 90 percent or greater coverage within the State for Centers for Disease Control and Prevention-recommended vaccines shall be eligible for a bonus grant from amounts appropriated under subsection (d).
Authorization of appropriations
Out of funds appropriated to the Director of the Centers for Disease Control and Prevention for each fiscal year beginning with fiscal year 2008, there shall be made available to carry out this section, $50,000,000 for each fiscal year.
Funding for section 317
Section 317(j)(1) of the Public Health
Service Act (42 U.S.C. 247b(j)(1)) is amended by striking 2005
and inserting 2010
.
Tax incentives to encourage purchase of health care insurance
Health Savings Accounts
Expansion of health savings accounts
Increase in monthly contribution limit
In general
Paragraph (2) of section 223(b) of the Internal Revenue Code of 1986 (relating to limitations) is amended to read as follows:
Monthly limitation
In general
In the case of an eligible individual who has coverage under a high deductible health plan, the monthly limitation for any month of such coverage is 1/12 of the sum of—
the greater of—
the sum of the annual deductible and the other annual out-of-pocket expenses (other than for premiums) required to be paid under the plan by the eligible individual for covered benefits, or
in the case of an eligible individual who has—
self-only coverage under a high deductible health plan as of the first day of such month, $2,250, or
family coverage under a high deductible health plan as of the first day of such month, $4,500, and
in the case of an eligible individual who has coverage under a qualified long-term care insurance contract (as defined in section 7702B(b)), the lesser of—
the annual premium for such coverage, or
$1,000.
Special rules relating to out-of-pocket expenses
Reduction for separate plan
The annual out-of-pocket expenses taken into account under subparagraph (A)(i)(I) with respect to any eligible individual shall be reduced by any out-of-pocket expense payable under a separate plan covering the individual.
Secretarial authority
The Secretary may by regulations provide that annual out-of-pocket expenses will not be taken into account under subparagraph (A)(i)(I) to the extent that there is only a remote likelihood that such amounts will be required to be paid.
.
Application of special rules for married individuals
Paragraph (5) of section 223(b) of such Code (relating to limitations) is amended to read as follows:
Special rules for married individuals
In general
In the case of individuals who are married to each other and who are both eligible individuals, the limitation under paragraph (1) for each spouse shall be equal to the spouse's applicable share of the combined marital limit.
Combined marital limit
For purposes of subparagraph (A), the combined marital limit is the excess (if any) of—
the lesser of—
subject to subparagraph (C), the sum of the limitations computed separately under paragraph (1) for each spouse (including any additional contribution amount under paragraph (3)), or
the dollar amount in effect under subsection (c)(2)(A)(ii)(II), over
the aggregate amount paid to Archer MSAs of such spouses for the taxable year.
Special rule where both spouses have family coverage
For purposes of subparagraph (B)(i)(I), if either spouse has family coverage which covers both spouses, both spouses shall be treated as having only such coverage (and if both spouses each have such coverage under different plans, shall be treated as having only family coverage with the plan with respect to which the lowest amount is determined under paragraph (2)(A)(i)(I)).
Applicable share
For purposes of subparagraph (A), a spouse's applicable share is ½ of the combined marital limit unless both spouses agree on a different division.
Couples not married entire year
The Secretary shall prescribe rules for the application of this paragraph in the case of any taxable year for which the individuals were not married to each other during all months included in the taxable year, including rules which allow individuals in appropriate cases to take into account coverage prior to marriage in computing the combined marital limit for purposes of this paragraph.
.
Self-only coverage
Paragraph (4) of section 223(c) of such Code (relating to definitions and special rules) is amended to read as follows:
Coverage
Family coverage
The term family coverage means any coverage other than self-only coverage.
Self-only coverage
If more than 1 individual is covered by a high deductible health plan but only 1 of the individuals is an eligible individual, the coverage shall be treated as self-only coverage.
.
Conforming amendments
Section 223(b)(3)(A) of such Code is
amended by striking subparagraphs (A) and (B) of
.
Section 223(d)(1)(A)(ii)(I) of such Code is
amended by striking subsection (b)(2)(B)(ii)
and inserting
subsection (c)(2)(A)(ii)(II)
.
Clause (ii) of section 223(c)(2)(D) of such Code is amended to read as follows:
Certain items disregarded in computing monthly limitation
Such plan's annual deductible, and such plan's annual out-of-pocket limitation, for services provided outside of such network shall not be taken into account for purposes of subsection (b)(2).
Subsection (g) of section 223 of such Code is amended to read as follows:
Cost-of-living adjustment
In general
In the case of any taxable year beginning in a calendar year after 2008, each dollar amount contained in subsections (b)(2)(A) and (c)(2)(A) shall be increased by an amount equal to—
such dollar amount, multiplied by
the cost-of-living adjustment determined under paragraph (2) for the calendar year in which such taxable year begins.
Cost-of-living adjustment
For purposes of paragraph (1), the cost-of-living adjustment for any calendar year is the percentage (if any) by which—
the GDP for the preceding calendar year, exceeds
the GDP—
for calendar year 1997, in the case of each dollar amount in subsection (b)(2)(A)(i),
for calendar year 2007, in the case of the dollar amount in subsection (b)(2)(A)(ii), and
for calendar year 2003 in the case of each dollar amount in subsection (c)(2)(A).
GDP for any calendar year
For purposes of paragraph (2), the GDP for any calendar year is the average of the chain-weighted price index for the gross domestic product as of the close of the 12-month period ending on March 31 of such calendar year.
Chain-weighted price index for the gross domestic product
For purposes of paragraph (3), the term chain-weighted price index for the gross domestic product means the last chain-weighted price index for the gross domestic product published by the Department of Commerce.
Rounding
Any increase determined under paragraph (1) shall be rounded to the nearest multiple of $50.
.
Use of account for individual high deductible health plan premiums
Section 223(d)(2)(C) of the Internal
Revenue Code of 1986 (relating to exceptions) is amended by striking
or
at the end of clause (iii), by striking the period at the end
of clause (iv) and inserting , or
, and by adding at the end the
following new clause:
a high deductible health plan, but only if—
the plan is not a group health plan (as defined in section 5000(b)(1) without regard to section 5000(d)), and
the expenses are for coverage for a month with respect to which the account beneficiary is an eligible individual by reason of the coverage under the plan.
For purposes of clause (v), an arrangement which constitutes individual health insurance shall not be treated as a group health plan, notwithstanding that an employer or employee organization negotiates the cost of benefits of such arrangement.
.
Safe harbor for absence of maintenance of chronic disease
Section 223(c)(2)(C) of the Internal Revenue Code of 1986 (safe harbor for absence of preventive care deductible) is amended—
by inserting or maintenance of
chronic disease, or both
after the Secretary)
,
and
by inserting or maintenance of chronic
disease
in the heading after preventive
care
.
Clarification of treatment of capitated primary care payments as amounts paid for medical care
Section 213(d) of the Internal Revenue Code of 1986 (relating to definitions) is amended by adding at the end the following new paragraph:
Treatment of capitated primary care payments
Capitated primary care payments shall be treated as amounts paid for medical care.
.
Special rule for individuals eligible for veterans or Indian health benefits
Section 223(c)(1) of the Internal Revenue Code of 1986 (defining eligible individual) is amended by adding at the end the following new subparagraph:
Special rule for individuals eligible for veterans or Indian health benefits
For purposes of subparagraph (A)(ii), an individual shall not be treated as covered under a health plan described in such subparagraph merely because the individual receives periodic hospital care or medical services under any law administered by the Secretary of Veterans Affairs or the Bureau of Indian Affairs.
.
Effective dates
In general
Except as provided in paragraph (2), the amendments made by this section shall apply to taxable years beginning after December 31, 2007.
Capitated primary care payments
The amendment made by subsection (d) shall apply to amounts paid before, on, or after the date of the enactment of this Act.
Exception to requirement for employers to make comparable health savings account contributions
Greater employer-provided contributions to HSAs for chronically ill employees treated as meeting comparability requirements
Subsection (b) of section 4980G of the Internal Revenue Code of 1986 (relating to failure of employer to make comparable health savings account contributions) is amended to read as follows:
Rules and requirements
In general
Except as provided in paragraph (2), rules and requirements similar to the rules and requirements of section 4980E shall apply for purposes of this section.
Treatment of employer-provided contributions to HSAs for chronically ill employees
For purposes of this section—
In general
Any contribution by an employer to a health savings account of an employee who is (or the spouse or any dependent of the employee who is) a chronically ill individual in an amount which is greater than a contribution to a health savings account of a comparable participating employee who is not a chronically ill individual shall not fail to be considered a comparable contribution.
Nondiscrimination requirement
Subparagraph (A) shall not apply unless the excess employer contributions described in subparagraph (A) are the same for all chronically ill individuals who are similarly situated.
Chronically ill individual
For purposes of this paragraph, the term chronically ill individual means any individual whose qualified medical expenses for any taxable year are more than 50 percent greater than the average qualified medical expenses of all employees of the employer for such year.
.
Effective date
The amendment made by this section shall apply to taxable years beginning after December 31, 2007.
MediChoice tax rebates
Refundable credit for health insurance coverage
In general
Subpart C of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 (relating to refundable credits) is amended by redesignating section 36 as section 37 and by inserting after section 35 the following new section:
MediChoice tax rebates
In general
In the case of an individual, there shall be allowed as a credit against the tax imposed by this subtitle an amount equal to the amount paid during the taxable year for qualified health insurance for the taxpayer and the taxpayer's spouse or dependent.
Limitations
In general
The amount allowed as a credit under subsection (a) to the taxpayer for the taxable year shall not exceed the sum of the monthly limitations for coverage months during such taxable year for the individual referred to in subsection (a) for whom the taxpayer paid during the taxable year any amount for coverage under qualified health insurance.
Monthly limitation
In general
The monthly limitation for an individual for each coverage month of such individual during the taxable year is the amount equal to 1/12 of the qualified health insurance amount.
Qualified health insurance amount
For purposes of this paragraph, the qualified health insurance amount is—
$2,000 if such individual is the taxpayer,
$2,000 if such individual is the spouse of the taxpayer, the taxpayer and such spouse are married as of the first day of such month, and the taxpayer files a joint return for the taxable year, or
$500 if such individual is an individual for whom a deduction under section 151(c) is allowable to the taxpayer for such taxable year.
Limitation on dependents
Not more than 2 individuals may be taken into account by the taxpayer under subparagraph (B)(iii).
Coverage month
For purposes of this subsection—
In general
The term coverage month means, with respect to an individual, any month if—
as of the first day of such month such individual is covered by qualified health insurance, and
the premium for coverage under such insurance for such month is paid by the taxpayer.
Medicare
Such term shall not include any month with respect to an individual if, as of the first day of such month, such individual has not made an election to establish and maintain a Medical Retirement Account under section 252(a)(2) of the Social Security Act and is entitled to benefits under title XVIII of the Social Security Act.
Certain other coverage
Such term shall not include any month during a taxable year with respect to an individual if, at any time during such year, any benefit is provided to such individual under—
chapter 55 of title 10, United States Code,
chapter 17 of title 38, United States Code, or
any medical care program under the Indian Health Care Improvement Act.
Prisoners
Such term shall not include any month with respect to an individual if, as of the first day of such month, such individual is imprisoned under Federal, State, or local authority.
Insufficient presence in United States
Such term shall not include any month during a taxable year with respect to an individual if such individual is present in the United States on fewer than 183 days during such year (determined in accordance with section 7701(b)(7)).
Qualified health insurance
For purposes of this section—
In general
The term qualified health insurance means any health plan (within the meaning of section 223(c)(2)) determined without regard to any annual deductible requirement.
Annual wellness exam
Such term shall include an annual wellness exam fee not to exceed $150 ($100 in the case of an annual child wellness exam) if such exam is not covered by the insurance.
Archer MSA and health savings account contributions
In general
If a deduction would (but for paragraph (2)) be allowed under section 220 or 223 to the taxpayer for a payment for the taxable year to the Archer MSA or health savings account of an individual, subsection (a) shall be applied by treating such payment as a payment for qualified health insurance for such individual.
Denial of double benefit
No deduction shall be allowed under section 220 or 223 for that portion of the payments otherwise allowable as a deduction under section 220 or 223 for the taxable year which is equal to the amount of credit allowed for such taxable year by reason of this subsection.
Special rules
For purposes of this section—
Married couples must file joint return
If the taxpayer is married at the close of the taxable year, the credit shall be allowed under subsection (a) only if the taxpayer and the taxpayer's spouse file a joint return for the taxable year.
Denial of credit to dependents
No credit shall be allowed under this section to any individual with respect to whom a deduction under section 151 is allowable to another taxpayer for a taxable year beginning in the calendar year in which such individual’s taxable year begins.
Denial of double benefit
No credit shall be allowed under subsection (a) if the credit under section 35 is allowed and no credit shall be allowed under 35 if a credit is allowed under this section.
Coordination with deduction for health insurance costs
In the case of a taxpayer who is eligible to deduct any amount under section 162(l) or 213 for the taxable year, this section shall apply only if the taxpayer elects not to claim any amount as a deduction under such section for such year.
Election not to claim credit
This section shall not apply to a taxpayer for any taxable year if such taxpayer elects to have this section not apply for such taxable year.
Inflation adjustment
In general
In the case of any taxable year beginning in a calendar year after 2008, each dollar amount contained in subsection (b)(2)(B) shall be increased by an amount equal to—
such dollar amount, multiplied by
the cost-of-living adjustment determined under subparagraph (B) for the calendar year in which such taxable year begins.
Cost-of-living adjustment
For purposes of subparagraph (A), the cost-of-living adjustment for any calendar year is the percentage (if any) by which—
the GDP for the preceding calendar year, exceeds
the GDP for calendar year 2007.
GDP for any calendar year
For purposes of subparagraph (B), the GDP for any calendar year is the average of the chain-weighted price index for the gross domestic product as of the close of the 12-month period ending on March 31 of such calendar year.
Chain-weighted price index for the gross domestic product
For purposes of subparagraph (C), the term chain-weighted price index for the gross domestic product means the last chain-weighted price index for the gross domestic product published by the Department of Commerce.
Rounding
Any increase determined under subparagraph (A) shall be rounded to the nearest multiple of $50.
.
Information reporting
In general
Subpart B of part III of subchapter A of chapter 61 of the Internal Revenue Code of 1986 (relating to information concerning transactions with other persons) is amended by inserting after section 6050V the following new section:
Returns relating to payments for qualified health insurance
In general
Any person who, in connection with a trade or business conducted by such person, receives payments during any calendar year from any individual for coverage of such individual or any other individual under creditable health insurance, shall make the return described in subsection (b) (at such time as the Secretary may by regulations prescribe) with respect to each individual from whom such payments were received.
Form and manner of returns
A return is described in this subsection if such return—
is in such form as the Secretary may prescribe, and
contains—
the name, address, and TIN of the individual from whom payments described in subsection (a) were received,
the name, address, and TIN of each individual who was provided by such person with coverage under creditable health insurance by reason of such payments and the period of such coverage, and
such other information as the Secretary may reasonably prescribe.
Creditable health insurance
For purposes of this section, the term creditable health insurance means qualified health insurance (as defined in section 36(c)) other than, to the extent provided in regulations prescribed by the Secretary, any insurance covering an individual if no credit is allowable under section 36 with respect to such coverage.
Statements To be furnished to individuals with respect to whom information is required
Every person required to make a return under subsection (a) shall furnish to each individual whose name is required under subsection (b)(2)(A) to be set forth in such return a written statement showing—
the name and address of the person required to make such return and the phone number of the information contact for such person,
the aggregate amount of payments described in subsection (a) received by the person required to make such return from the individual to whom the statement is required to be furnished, and
the information required under subsection (b)(2)(B) with respect to such payments.
Returns which would be required To be made by 2 or more persons
Except to the extent provided in regulations prescribed by the Secretary, in the case of any amount received by any person on behalf of another person, only the person first receiving such amount shall be required to make the return under subsection (a).
.
Assessable penalties
Subparagraph (B) of section 6724(d)(1) of such Code (relating to definitions) is amended by redesignating clauses (xv) through (xx) as clauses (xvi) through (xxi), respectively, and by inserting after clause (xi) the following new clause:
section 6050W (relating to returns relating to payments for qualified health insurance),
.
Paragraph (2) of section 6724(d) of such
Code is amended by striking the period at the end of subparagraph (CC) and
inserting , or
and by adding at the end the following new
subparagraph:
section 6050W(d) (relating to returns relating to payments for qualified health insurance).
.
Clerical amendment
The table of sections for subpart B of part III of subchapter A of chapter 61 of such Code is amended by inserting after the item relating to section 6050V the following new item:
Sec. 6050W. Returns relating to payments for qualified health insurance.
.
Conforming amendments
Paragraph (2) of section 1324(b) of title
31, United States Code, is amended by inserting before the period , or
from section 36 of such Code
.
The table of sections for subpart C of part IV of subchapter A of chapter 1 of the Internal Revenue Code of 1986 is amended by striking the last item and inserting the following new items:
Sec. 36. MediChoice tax rebates.
Sec. 37. Overpayments of tax.
.
Effective date
The amendments made by this section shall apply to taxable years beginning after December 31, 2007.
Advance payment of credit for purchasers of qualified health insurance
In general
Chapter 77 of the Internal Revenue Code of 1986 (relating to miscellaneous provisions) is amended by adding at the end the following new section:
Advance payment of MediChoice tax rebates
General rule
In the case of an eligible individual, the Secretary shall make payments to the provider of such individual’s qualified health insurance equal to such individual’s qualified health insurance credit advance amount with respect to such provider.
Eligible individual
For purposes of this section, the term eligible individual means any individual—
who purchases qualified health insurance (as defined in section 36(c)), and
for whom a qualified health insurance credit eligibility certificate is in effect.
Qualified health insurance credit eligibility certificate
For purposes of this section, a qualified health insurance credit eligibility certificate is a statement furnished by an individual to the Secretary which—
certifies that the individual will be eligible to receive the credit provided by section 36 for the taxable year,
estimates the amount of such credit for such taxable year, and
provides such other information as the Secretary may require for purposes of this section.
Qualified health insurance credit advance amount
For purposes of this section, the term qualified health insurance credit advance amount means, with respect to any provider of qualified health insurance, the Secretary’s estimate of the amount of credit allowable under section 36 to the individual for the taxable year which is attributable to the insurance provided to the individual by such provider.
Regulations
The Secretary shall prescribe such regulations as may be necessary to carry out the purposes of this section.
.
Clerical amendment
The table of sections for chapter 77 of the Internal Revenue Code of 1986 is amended by adding at the end the following new item:
Sec. 7529. Advance payment of MediChoice tax rebates.
.
Effective date
The amendments made by this section shall apply to taxable years beginning after December 31, 2007.
Termination of employer-provided health care coverage exclusion
In general
Section 106 of the Internal Revenue Code of 1986 (relating to contributions by employer to accident and health plans) is amended by adding at the end the following new subsection:
Termination of employer-provided health care coverage exclusion
In general
The amount of any exclusion under subsection (a) for any taxable year beginning after December 31, 2007, with respect to—
any employer-provided coverage under an accident or health plan which constitutes medical care, and
any employer contribution to an Archer MSA or a health savings account which is treated by subsection (b) or (d) as employer-provided coverage for medical expenses under an accident or health plan,
Medical care defined
For purposes of paragraph (1), the term medical care has the meaning given to such term in section 213(d) determined without regard to—
paragraph (1)(C) thereof, and
so much of paragraph (1)(D) thereof as relates to qualified long-term care insurance.
.
Termination of health care expense reimbursement under cafeteria plans
Section 125 of the Internal Revenue Code of 1986 (relating to cafeteria plans) is amended by redesignating subsection (h) as subsection (i) and by inserting after subsection (g) the following new subsection:
Termination
This section shall not apply to health benefits coverage in any taxable year beginning after December 31, 2007.
.
Termination of deduction for health insurance costs of self-employed individuals
The table contained in section 162(l)(1)(B)
of the Internal Revenue Code of 1986 (relating to applicable percentage) is
amended by striking and thereafter
and inserting through
2007
.
Payroll taxes
In general
Section 3121(a) of the Internal Revenue
Code of 1986 (defining wages) is amended by adding at the end the following new
sentence: In the case of any calendar year beginning after December 31,
2007, paragraphs (2) and (4) shall not apply to payments on account of
sickness.
.
Railroad retirement
Section 3231(e)(1) of such Code (defining
wages) is amended by adding at the end the following new sentence: In
the case of any calendar year beginning after December 31, 2007, this paragraph
shall not apply to payments on account of sickness.
.
Unemployment
Section 3306(b) of such Code (defining
wages) is amended by adding at the end the following new sentence: In
the case of any calendar year beginning after December 31, 2007, paragraphs (2)
and (4) shall not apply to payments on account of sickness.
.
Effective dates
In general
Except as provided in paragraph (2), the amendments made by this section shall apply to taxable years beginning after December 31, 2007.
Payroll taxes
The amendments made by subsection (d) shall apply to calendar years beginning after December 31, 2007.
Health insurance modernization
Employee choice
Clarification of definition of group health plan under HIPAA
ERISA
Section 733(a)(1) of the Employee
Retirement Income Security Act of 1974 (29 U.S.C. 1191b(a)(1)) is amended by
adding at the end the following: Such term does not include an
arrangement maintained by an employer the sole effect of which is to provide
reimbursement to employees for the purchase by such employees of health
insurance coverage offered in the individual market (as defined in section
2791(e)(1)) of the Public Health Service Act), notwithstanding that the
employer or an employee organization negotiates the cost or benefits of the
arrangement.
.
PHSA
Section 2791(a)(1) of the Public Health
Service Act (42 U.S.C. 300gg–91(a)(1)) is amended by adding at the end the
following: Such term does not include an arrangement maintained by an
employer the sole effect of which is to provide reimbursement to employees for
the purchase by such employees of health insurance coverage offered in the
individual market, notwithstanding that the employer or an employee
organization negotiates the cost or benefits of the
arrangement.
.
IRC
Section 9832(a) of the Internal Revenue
Code of 1986 (relating to definitions) is amended by inserting before the
period the following: , except that such term does not include an
arrangement maintained by an employer the sole effect of which is to provide
reimbursement to employees for the purchase by such employees of health
insurance coverage offered in the individual market (as defined in section
2791(e)(1)) of the Public Health Service Act), notwithstanding that the
employer or an employee organization negotiates the cost or benefits of the
arrangement.
.
Effective date
The amendments made by this section shall apply to plan years beginning after December 31, 2007.
Access to health care
State high risk pools
In general
Not later than 1 year after the date of enactment of this Act, each State shall have established, and be operating, a qualified high risk pool (as defined for purposes of section 2745 of the Public Health Service Act (42 U.S.C. 300gg–45)) or a State-designated alternative that ensures access to private health insurance for medically uninsurable individuals.
Bonus for compliance
One-time payment
If the Secretary of Health and Human Services determines that a State has satisfied the requirement of subsection (a) with respect to a fiscal year, the Secretary shall increase the total amount of Federal payments made to the State under section 1903(a) of the Social Security Act (42 U.S.C. 1396b(a)) for the succeeding fiscal year by an amount equal to 1 percent of such payments (or, if such succeeding fiscal year is fiscal year 2010 or any fiscal year thereafter, by an amount equal to 1 percent of the State Medicaid assistance allotment determined for the State for such succeeding fiscal year under section 1939(b) of such Act). The additional amount paid to a State for a fiscal year pursuant to this paragraph shall be used for maintenance and operational costs of a qualified high risk pool (as so defined) or a State-designated alternative that ensures access to private health insurance for medically uninsurable individuals.
Authorization of appropriations
There are authorized to be appropriated for any fiscal year such sums as may be necessary to carry out this subsection.
Federally qualified health centers
Evaluation
Not later than 5 years after the date of enactment of this Act, and every 5 years thereafter, the Secretary of Health and Human Services shall evaluate the effect of federally qualified health centers on proximate rural hospitals.
Limitation on grants
Notwithstanding any other provision of law, if the Secretary of Health and Human Services determines, based on an evaluation conducted under subsection (a), that a federally qualified health center is having a detrimental effect on a private hospital facility, the Secretary may revoke a grant awarded by the Secretary to such health center or limit the scope of services of the health center under such a grant.
Interstate market for health insurance
Short title
This subtitle may be cited as
Health Care Choice Act of
2007
.
Specification of constitutional authority for enactment of law
This subtitle is enacted pursuant to the power granted Congress under article I, section 8, clause 3, of the United States Constitution.
Findings
Congress finds the following:
The application of numerous and significant variations in State law impacts the ability of insurers to offer, and individuals to obtain, affordable individual health insurance coverage, thereby impeding commerce in individual health insurance coverage.
Individual health insurance coverage is increasingly offered through the Internet, other electronic means, and by mail, all of which are inherently part of interstate commerce.
In response to these issues, it is appropriate to encourage increased efficiency in the offering of individual health insurance coverage through a collaborative approach by the States in regulating this coverage.
The establishment of risk-retention groups has provided a successful model for the sale of insurance across State lines, as the acts establishing those groups allow insurance to be sold in multiple States but regulated by a single State.
Cooperative governing of individual health insurance coverage
In general
Title XXVII of the Public Health Service Act (42 U.S.C. 300gg et seq.) is amended by adding at the end the following new part:
Cooperative governing of individual health insurance coverage
Definitions
In this part:
Primary State
The term primary State means, with respect to individual health insurance coverage offered by a health insurance issuer, the State designated by the issuer as the State whose covered laws shall govern the health insurance issuer in the sale of such coverage under this part. An issuer, with respect to a particular policy, may only designate 1 such State as its primary State with respect to all such coverage it offers. Such an issuer may not change the designated primary State with respect to individual health insurance coverage once the policy is issued, except that such a change may be made upon renewal of the policy. With respect to such designated State, the issuer is deemed to be doing business in that State.
Secondary State
The term secondary State means, with respect to individual health insurance coverage offered by a health insurance issuer, any State that is not the primary State. In the case of a health insurance issuer that is selling a policy in, or to a resident of, a secondary State, the issuer is deemed to be doing business in that secondary State.
Health insurance issuer
The term health insurance issuer has the meaning given such term in section 2791(b)(2), except that such an issuer must be licensed in the primary State and be qualified to sell individual health insurance coverage in that State.
Individual health insurance coverage
The term individual health insurance coverage means health insurance coverage offered in the individual market, as defined in section 2791(e)(1).
Applicable State authority
The term applicable State authority means, with respect to a health insurance issuer in a State, the State insurance commissioner or official or officials designated by the State to enforce the requirements of this title for the State with respect to the issuer.
Hazardous financial condition
The term hazardous financial condition means that, based on its present or reasonably anticipated financial condition, a health insurance issuer is unlikely to be able—
to meet obligations to policyholders with respect to known claims and reasonably anticipated claims; or
to pay other obligations in the normal course of business.
Covered laws
The term covered laws means the laws, rules, regulations, agreements, and orders governing the insurance business pertaining to—
individual health insurance coverage issued by a health insurance issuer;
the offer, sale, and issuance of individual health insurance coverage to an individual; and
the provision to an individual in relation to individual health insurance coverage of—
health care and insurance related services;
management, operations, and investment activities of a health insurance issuer; and
loss control and claims administration for a health insurance issuer with respect to liability for which the issuer provides insurance.
State
The term State means only the 50 States and the District of Columbia.
Unfair claims settlement practices
The term unfair claims settlement practices means only the following practices:
Knowingly misrepresenting to claimants and insured individuals relevant facts or policy provisions relating to coverage at issue.
Failing to acknowledge with reasonable promptness pertinent communications with respect to claims arising under policies.
Failing to adopt and implement reasonable standards for the prompt investigation and settlement of claims arising under policies.
Failing to effectuate prompt, fair, and equitable settlement of claims submitted in which liability has become reasonably clear.
Refusing to pay claims without conducting a reasonable investigation.
Failing to affirm or deny coverage of claims within a reasonable period of time after having completed an investigation related to those claims.
Fraud and abuse
The term fraud and abuse means an act or omission committed by a person who, knowingly and with intent to defraud, commits, or conceals any material information concerning, 1 or more of the following:
Presenting, causing to be presented or preparing with knowledge or belief that it will be presented to or by an insurer, a reinsurer, broker or its agent, false information as part of, in support of or concerning a fact material to 1 or more of the following:
An application for the issuance or renewal of an insurance policy or reinsurance contract.
The rating of an insurance policy or reinsurance contract.
A claim for payment or benefit pursuant to an insurance policy or reinsurance contract.
Premiums paid on an insurance policy or reinsurance contract.
Payments made in accordance with the terms of an insurance policy or reinsurance contract.
A document filed with the commissioner or the chief insurance regulatory official of another jurisdiction.
The financial condition of an insurer or reinsurer.
The formation, acquisition, merger, reconsolidation, dissolution or withdrawal from 1 or more lines of insurance or reinsurance in all or part of a State by an insurer or reinsurer.
The issuance of written evidence of insurance.
The reinstatement of an insurance policy.
Solicitation or acceptance of new or renewal insurance risks on behalf of an insurer reinsurer or other person engaged in the business of insurance by a person who knows or should know that the insurer or other person responsible for the risk is insolvent at the time of the transaction.
Transaction of the business of insurance in violation of laws requiring a license, certificate of authority, or other legal authority for the transaction of the business of insurance.
Attempt to commit, aiding or abetting in the commission of, or conspiracy to commit the acts or omissions specified in this paragraph.
Application of law
In general
The covered laws of the primary State shall apply to individual health insurance coverage offered by a health insurance issuer in the primary State and in any secondary State, but only if the coverage and issuer comply with the conditions of this section with respect to the offering of coverage in any secondary State.
Exemptions from covered laws in a secondary State
Except as provided in this section, a health insurance issuer with respect to its offer, sale, renewal, and issuance of individual health insurance coverage in any secondary State is exempt from any covered laws of the secondary State (and any rules, regulations, agreements, or orders sought or issued by such State under or related to such covered laws) to the extent that such laws would—
make unlawful, or regulate, directly or indirectly, the operation of the health insurance issuer operating in the secondary State, except that any secondary State may require such an issuer—
to pay, on a nondiscriminatory basis, applicable premium and other taxes (including high risk pool assessments) which are levied on insurers and surplus lines insurers, brokers, or policyholders under the laws of the State;
to register with and designate the State insurance commissioner as its agent solely for the purpose of receiving service of legal documents or process;
to submit to an examination of its financial condition by the State insurance commissioner in any State in which the issuer is doing business to determine the issuer’s financial condition, if—
the State insurance commissioner of the primary State has not done an examination within the period recommended by the National Association of Insurance Commissioners; and
any such examination is conducted in accordance with the examiners’ handbook of the National Association of Insurance Commissioners and is coordinated to avoid unjustified duplication and unjustified repetition;
to comply with a lawful order issued—
in a delinquency proceeding commenced by the State insurance commissioner if there has been a finding of financial impairment under subparagraph (C); or
in a voluntary dissolution proceeding;
to comply with an injunction issued by a court of competent jurisdiction, upon a petition by the State insurance commissioner alleging that the issuer is in hazardous financial condition;
to participate, on a nondiscriminatory basis, in any insurance insolvency guaranty association or similar association to which a health insurance issuer in the State is required to belong;
to comply with any State law regarding fraud and abuse (as defined in section 2795(10)), except that if the State seeks an injunction regarding the conduct described in this subparagraph, such injunction must be obtained from a court of competent jurisdiction; or
to comply with any State law regarding unfair claims settlement practices (as defined in section 2795(9));
require any individual health insurance coverage issued by the issuer to be countersigned by an insurance agent or broker residing in that Secondary State; or
otherwise discriminate against the issuer issuing insurance in both the primary State and in any secondary State.
Clear and conspicuous disclosure
A health insurance issuer shall provide the following notice, in 12-point bold type, in any insurance coverage offered in a secondary State under this part by such a health insurance issuer and at renewal of the policy, with the 5 blank spaces therein being appropriately filled with the name of the health insurance issuer, the name of the primary State, and the name of the secondary State, respectively, for the coverage concerned:
‘This policy is issued by _____ and is governed by the laws and regulations of the State of _____, and it has met all the laws of that State as determined by that State’s Department of Insurance. This policy may be less expensive than others because it is not subject to all of the insurance laws and regulations of the State of _____, including coverage of some services or benefits mandated by the law of the State of _____. Additionally, this policy is not subject to all of the consumer protection laws or restrictions on rate changes of the State of _____. As with all insurance products, before purchasing this policy, you should carefully review the policy and determine what health care services the policy covers and what benefits it provides, including any exclusions, limitations, or conditions for such services or benefits.’.Prohibition on certain reclassifications and premium increases
In general
For purposes of this section, a health insurance issuer that provides individual health insurance coverage to an individual under this part in a primary or secondary State may not upon renewal—
move or reclassify the individual insured under the health insurance coverage from the class such individual is in at the time of issue of the contract based on the health-status related factors of the individual; or
increase the premiums assessed the individual for such coverage based on a health-status related factor or change of a health-status related factor or the past or prospective claim experience of the insured individual.
Construction
Nothing in paragraph (1) shall be construed to prohibit a health insurance issuer—
from terminating or discontinuing coverage or a class of coverage in accordance with subsections (b) and (c) of section 2742;
from raising premium rates for all policyholders within a class based on claims experience;
from changing premiums or offering discounted premiums to individuals who engage in wellness activities at intervals prescribed by the issuer, if such premium changes or incentives—
are disclosed to the consumer in the insurance contract;
are based on specific wellness activities that are not applicable to all individuals; and
are not obtainable by all individuals to whom coverage is offered;
from reinstating lapsed coverage; or
from retroactively adjusting the rates charged an individual insured individual if the initial rates were set based on material misrepresentation by the individual at the time of issue.
Prior offering of policy in primary State
A health insurance issuer may not offer for sale individual health insurance coverage in a secondary State unless that coverage is currently offered for sale in the primary State.
Licensing of agents or brokers for health insurance issuers
Any State may require that a person acting, or offering to act, as an agent or broker for a health insurance issuer with respect to the offering of individual health insurance coverage obtain a license from that State, except that a State may not impose any qualification or requirement which discriminates against a nonresident agent or broker.
Documents for submission to State insurance commissioner
Each health insurance issuer issuing individual health insurance coverage in both primary and secondary States shall submit—
to the insurance commissioner of each State in which it intends to offer such coverage, before it may offer individual health insurance coverage in such State—
a copy of the plan of operation or feasibility study or any similar statement of the policy being offered and its coverage (which shall include the name of its primary State and its principal place of business);
written notice of any change in its designation of its primary State; and
written notice from the issuer of the issuer’s compliance with all the laws of the primary State; and
to the insurance commissioner of each secondary State in which it offers individual health insurance coverage, a copy of the issuer’s quarterly financial statement submitted to the primary State, which statement shall be certified by an independent public accountant and contain a statement of opinion on loss and loss adjustment expense reserves made by—
a member of the American Academy of Actuaries; or
a qualified loss reserve specialist.
Power of courts To enjoin conduct
Nothing in this section shall be construed to affect the authority of any Federal or State court to enjoin—
the solicitation or sale of individual health insurance coverage by a health insurance issuer to any person or group who is not eligible for such insurance; or
the solicitation or sale of individual health insurance coverage by, or operation of, a health insurance issuer that is in hazardous financial condition.
State powers To enforce State laws
In general
Subject to the provisions of subsection (b)(1)(G) (relating to injunctions) and paragraph (2), nothing in this section shall be construed to affect the authority of any State to make use of any of its powers to enforce the laws of such State with respect to which a health insurance issuer is not exempt under subsection (b).
Courts of competent jurisdiction
If a State seeks an injunction regarding the conduct described in paragraphs (1) and (2) of subsection (h), such injunction must be obtained from a Federal or State court of competent jurisdiction.
States’ authority To sue
Nothing in this section shall affect the authority of any State to bring action in any Federal or State court.
Generally applicable laws
Nothing in this section shall be construed to affect the applicability of State laws generally applicable to persons or corporations.
Primary State must meet Federal floor before issuer may sell into secondary States
A health insurance issuer may not offer, sell, or issue individual health insurance coverage in a secondary State if the primary State does not meet the following requirements:
The State insurance commissioner must use a risk-based capital formula for the determination of capital and surplus requirements for all health insurance issuers.
The State must have legislation or
regulations in place establishing an independent review process for individuals
who are covered by individual health insurance coverage unless the issuer
provides an independent review mechanism functionally equivalent (as determined
by the primary State insurance commissioner or official) to that prescribed in
the Health Carrier External Review
Model Act
of the National Association of Insurance
Commissioners for all individuals who purchase insurance coverage under the
terms of this part.
Enforcement
In general
Subject to subsection (b), with respect to specific individual health insurance coverage the primary State for such coverage has sole jurisdiction to enforce the primary State’s covered laws in the primary State and any secondary State.
Secondary State’s authority
Nothing in subsection (a) shall be construed to affect the authority of a secondary State to enforce its laws as set forth in the exception specified in section 2796(b)(1).
Court interpretation
In reviewing action initiated by the applicable secondary State authority, the court of competent jurisdiction shall apply the covered laws of the primary State.
Notice of compliance failure
In the case of individual health insurance coverage offered in a secondary State that fails to comply with the covered laws of the primary State, the applicable State authority of the secondary State may notify the applicable State authority of the primary State.
.
Effective date
The amendment made by subsection (a) shall apply to individual health insurance coverage offered, issued, or sold after the date of the enactment of this Act.
Severability
If any provision of this subtitle or the application of such provision to any person or circumstance is held to be unconstitutional, the remainder of this subtitle and the application of the provisions of such to any other person or circumstance shall not be affected.
Improvements to the Medicare program
MediChoice for Seniors
Setting the benchmark equal to the national average bid
Setting benchmark
Local plans
Section 1853 of the Social Security Act (42 U.S.C. 1395w–23) is amended—
in subsection (j)(1)(A)—
by striking beginning with
2007
and inserting for 2007 and 2008
; and
by inserting (or, beginning with
2009, an amount equal to the national average MA statutory non-drug monthly bid
amount computed under subsection (l))
after for the
area
; and
by inserting and adjusted as
appropriate (for years beginning with 2009) using the geographic adjustment
methodology established under subsection (m)
before ;
or
; and
by adding at the end the following new subsections:
Computation of national average MA statutory non-drug monthly bid amount
In general
For each year (beginning with 2009) the Secretary shall compute a national average MA statutory non-drug monthly bid amount equal to the average of the unadjusted MA statutory non-drug monthly bid amount (as defined in section 1854(b)(2)(E)) for each MA plan, including an MA regional plan.
Weighted average
The national average MA statutory non-drug monthly bid amount computed under subparagraph (A) shall be a weighted average, with the weight for each plan being equal to the average number of beneficiaries enrolled under such plan in the previous year.
Methodology for geographically adjusting the national average MA statutory non-drug monthly bid amount
In general
Subject to paragraph (2), the Secretary shall establish an appropriate methodology for adjusting the amount of the national average MA statutory non-drug monthly bid amount in a year to take into account, in a budget neutral manner, variations in input costs based on the provision of items and services in different geographic areas.
Maximize plan participation
The Secretary shall establish the methodology under paragraph (1) in a manner that maximizes participation of plans in the program under this part.
.
Regional plans
Section 1858(f)(1) of the Social Security Act (42 U.S.C. 1395w–27a(f)(1)) is amended to read as follows:
Computation for regions
For purposes of section 1853(j)(2) and this section, subject to subsection (e), the term MA region-specific non-drug monthly benchmark amount means, with respect to an MA region for a month in a year—
for 2006, 2007, and 2008, the sum of the 2 components described in paragraph (2) for the region and year; and
for 2009 and each subsequent year, the national average MA statutory non-drug monthly bid amount computed under section 1853(l) as adjusted as appropriate using the geographic adjustment methodology established under section 1853(m).
.
Conforming amendments
1853(b)(1)(B) of the Social Security Act (42 U.S.C. 1395w–23(b)(1)(B)) is amended—
in clause (i)(I), by inserting and
the MA area-specific non-drug monthly benchmark amount under subsection (j),
including the geographic adjusters under subsection (l) to be used in computing
such amount, for each MA payment area for the year
before the period at
the end; and
in clause (ii), by inserting ,
including the geographic adjusters under section 1853(l) to be used in
computing such amount
before the period at the end.
Study and report to Congress
Review
Not less frequently that once every five years, the Secretary of Health and Human Services shall conduct a review that compares—
the national average MA statutory non-drug monthly bid amount (as determined under subsection (l) of section 1853 of the Social Security Act (42 U.S.C. 1395w–23), as added by subsection (a)); and
the average per capita cost for the United States, as estimated by the Secretary under section 1876(a)(4) of such Act (42 U.S.C. 1395mm(a)(4)).
Report to Congress
The Secretary of Health and Human Services shall submit a report to Congress on each review conducted under paragraph (1).
Enhancement of beneficiary rebates
Section
1854(b)(1)(C)(i) of the Social Security Act (42 U.S.C. 1395w–24(b)(1)(C)(i)) is
amended by inserting (or 100 percent in the case of plan years beginning
on or after January 1, 2009)
after 75 percent
.
Alternative benefit design to original medicare fee-for-service benefits
Part C of title XVIII of the Social Security Act is amended by adding at the end the following new section:
Alternative benefit design to original medicare fee-for-service benefits
Benefits
In general
Notwithstanding the provisions of this part and subject to paragraph (2), beginning with 2009, under procedures established by the Secretary, a Medicare Advantage plan offered by a Medicare Advantage organization may provide different benefits than those required under section 1852(a) so long as the Secretary finds that the benefit design meets requirements under the Employee Retirement Income Security Act of 1974 or that the benefit design may be offered in any State under applicable State law.
Requirement
A Medicare Advantage organization may not offer an alternative benefit design plan described in paragraph (1) for a year unless the organization also offers a Medicare Advantage plan that is not an alternative benefit design plan described in paragraph (1) for the year. Such plan is not required to be offered in the same area as the alternative benefit design plan described in paragraph (1).
Special rules
The following rules shall apply to an alternative benefit design plan described in subsection (a)(1):
Payment to plans for non-drug benefits
Payment to an organization for benefits under the plan (other than prescription drug benefits) shall be determined in the same manner as payments are determined under clauses (i) and (ii) of section 1853(a)(1)(B), except that in applying such clauses the monthly bid amount described in paragraph (2)(B)(i) of this subsection shall be substituted for the unadjusted MA statutory non-drug monthly bid amount.
Submission of bids
Notwithstanding paragraph (6) of section 1854(a), the information required to be submitted under such section is as follows:
The monthly aggregate bid amount for the provision of all items and services under the plan, which amount shall be based on average revenue requirements (as used for purposes of section 1302(8) of the Public Health Service Act) in the payment area for an enrollee with a national average risk profile for the factors described in section 1853(a)(1)(C) (as specified by the Secretary).
The proportions of such bid amount that are attributable to—
the provision of items and services other than prescription drug coverage; and
the provision of basic prescription drug coverage and supplemental prescription drug coverage.
The actuarial basis for determining the amount under subparagraph (A) and the proportions described in subparagraph (B) and such additional information as the Secretary may require to verify such actuarial bases and the projected number of enrollees in each MA local area.
A description of deductibles, coinsurance, and copayments applicable under the plan and the actuarial value of such deductibles, coinsurance, and copayments, described in section 1854(e)(4)(A).
With respect to qualified prescription drug coverage, the information required under section 1860D–4, as incorporated under section 1860D–11(b)(2), with respect to such coverage.
Premium
In determining the monthly amount (if any) of the premium charged to an individual enrolled in the plan—
section 1854(b) shall be applied by substituting the monthly bid amount described in paragraph (2)(B)(i) of this subsection for the unadjusted MA statutory non-drug monthly bid amount; and
subparagraphs (C) and (D) of paragraph (2) of such section shall not apply.
Application
No affect on special benefit rules for regional plans
The provisions of this section shall not affect the special benefit rules for MA regional plans under section 1852(a)(6).
No effect on prescription drug coverage
The provisions of this section shall not effect the provision of prescription drug coverage under this part.
Bid not taken into account when determining the national average MA statutory non-drug monthly bid amount
The bid for an alternative benefit design plan described in subsection (a)(1) shall not be taken into account when computing the national average MA statutory non-drug monthly bid amount under section 1853(l).
Waiver
To facilitate the offering of alternative benefit design plans described in subsection (a)(1) under this part, the Secretary may waiver or modify requirements under this part.
.
Medicare advantage HSA plans
Providing medicare advantage HSA plans as a type of plan under the Medicare Advantage program
Section 1851(a)(2) of the Social Security Act (42 U.S.C. 1395w–21(a)(2)) is amended by adding at the end the following new subparagraph:
Combination of HSA plan and contributions to HSA
A Medicare Advantage HSA plan, as defined in section 1859(b)(7), and a contribution into a Medicare Advantage health savings account (HSA).
.
Definition of Medicare Advantage HSA plan
Section 1859(b) of the Social Security Act (42 U.S.C. 1395w–28(b)) is amended by adding at the end the following new paragraph:
Medicare Advantage HSA plan
In general
The term Medicare Advantage HSA
plan
means a Medicare Advantage plan that—
is a high deductible health plan (as defined in section 223(c)(2) of the Internal Revenue Code of 1986, including the application of subparagraphs (C) and (D) of such section);
has a service area of—
not less than an entire State or territory; or
in the case of the District of Columbia, not less than the District of Columbia and 1 contiguous State;
provides reimbursement for at least the items and services described in section 1852(a)(1) in a year but only after the enrollee incurs countable expenses (as specified under the plan) equal to the amount of the annual deductible (as determined under section 223(c)(2)(A)(i) of the Internal Revenue Code of 1986);
counts as such expenses (for purposes of such deductible) at least all amounts that would have been payable under parts A and B, and that would have been payable by the enrollee as deductibles, coinsurance, or copayments, if the enrollee had elected to receive benefits through the provisions of such parts; and
provides, after such deductible is met for a year and for all subsequent expenses for items and services referred to in clause (iii) in the year, for a level of reimbursement that is not less than—
100 percent of such expenses, or
100 percent of the amounts that would have been paid (without regard to any deductibles or coinsurance) under parts A and B with respect to such expenses,
.
Special rules for HSA plans
Part C of title XVIII of the Social Security Act is amended by inserting after section 1858 the following new section:
Special rules for Medicare Advantage HSA plans
In general
Except for the modifications described in the succeeding provisions of this section, a Medicare Advantage HSA plan shall be treated in the same manner as an MSA plan is treated under this title.
Special payment rules
In general
Section 1853(e) shall be applied—
in the heading, by substituting
HSA
for MSA
;
in paragraph (1)—
by substituting HSA premium (as
defined in section 1858A(b)(2))
for MSA premium (as defined in
section 1854(b)(2)(C))
; and
by substituting HSA
for
MSA
each place it appears;
in paragraph (2)—
in the heading, by substituting
health
for medical
;
in the matter preceding subparagraph (A),
by substituting a Medicare Advantage HSA plan for an MSA
plan
;
in subparagraph (A), by substituting
HSA (as defined in section 138(b) of the Internal Revenue Code of
1986)
for MSA (as defined in section 138(b)(2) of the Internal
Revenue Code of 1986)
; and
in subparagraph (B), by substituting
HSA
for MSA
each place it appears; and
without regard to paragraph (3) (requiring a lump-sum deposit of a medical savings account contribution during the first month election is effective).
Definition of Medicare Advantage monthly HSA premium
The term
Medicare Advantage monthly HSA premium
has the same meaning
given the term Medicare Advantage monthly MSA premium
under
section 1854(b)(2)(D).
Treatment of Medicare Advantage HSA plans under part D
Rules with respect to prescription drug coverage under part D for MSA plans shall not apply to a Medicare Advantage HSA plan. For purposes of part D, a Medicare Advantage HSA plan shall be treated in the same manner as a coordinated care plan (as described in section 1851(a)(2)(A)(i)) is treated under such part.
.
Tax treatment of Medicare Advantage HSA plans
In general
Part III of subchapter B of chapter 1 of the Internal Revenue Code of 1986 is amended by inserting after section 139A the following new section:
Medicare Advantage HSA
Exclusion
Gross income shall not include—
any payment to the Medicare Advantage HSA of an individual by the Secretary of Health and Human Services under part C of title XVIII of the Social Security Act,
any amount contributed to such Medicare Advantage HSA by or on behalf of the individual under section 223, including the individual's employer as described in section 106(d), and
an amount equal to any one-time qualified rollover from any of the individual's health savings accounts, health reimbursement accounts, flexible spending accounts, and medical savings accounts (including any Medicare Advantage MSA).
Medicare Advantage HSA
For purposes of this section, the term Medicare Advantage HSA means a health savings account (as defined in section 223(d))—
which is designated as a Medicare Advantage HSA,
with respect to which no contribution may be made other than—
a contribution described in subsection (a), or
a trustee-to-trustee transfer described in subsection (c)(4),
the governing instrument of which provides that trustee-to-trustee transfers described in subsection (c)(4) may be made to and from such account, and
which is established in connection with an HSA plan described in section 1859(b)(7) of the Social Security Act.
Special rules for distributions
Distributions for qualified medical expenses
In applying section 223 to a Medicare Advantage HSA, qualified medical expenses shall not include amounts paid for medical care for any individual other than the account holder.
Penalty for distributions from Medicare Advantage HSA not used for qualified medical expenses if minimum balance not maintained
In general
The tax imposed by this chapter for any taxable year in which there is a payment or distribution from a Medicare Advantage HSA which is not used exclusively to pay the qualified medical expenses of the account holder shall be increased by 50 percent of the excess (if any) of—
the amount of such payment or distribution, over
the excess (if any) of—
the fair market value of the assets in such HSA as of the close of the calendar year preceding the calendar year in which the taxable year begins, over
an amount equal to 60 percent of the deductible under the Medicare Advantage HSA plan covering the account holder as of January 1 of the calendar year in which the taxable year begins.
Exceptions
Subparagraph (A) shall not apply if the payment or distribution is made on or after the date the account holder—
becomes disabled within the meaning of section 72(m)(7), or
dies.
Special rules
For purposes of subparagraph (A)—
all Medicare Advantage HSAs of the account holder shall be treated as 1 account,
all payments and distributions not used exclusively to pay the qualified medical expenses of the account holder during any taxable year shall be treated as 1 distribution, and
any distribution of property shall be taken into account at its fair market value on the date of the distribution.
Withdrawal of erroneous contributions
Section 223(f)(2) and paragraph (2) of this subsection shall not apply to any payment or distribution from a Medicare Advantage HSA to the Secretary of Health and Human Services of an erroneous contribution to such HSA and of the net income attributable to such contribution.
Trustee-to-trustee transfers
Section 223(f)(2) and paragraph (2) of this subsection shall not apply to any trustee-to-trustee transfer from a Medicare Advantage HSA of an account holder to another Medicare Advantage HSA of such account holder.
Special rules for treatment of account after death of account holder
In applying section 223(f)(8)(A) to an account which was a Medicare Advantage HSA of a decedent, the rules of section 223(f) shall apply in lieu of the rules of subsection (c) of this section with respect to the spouse as the account holder of such Medicare Advantage HSA.
Reports
In the case of a Medicare Advantage HSA, the report under section 223(h)—
shall include the fair market value of the assets in such Medicare Advantage HSA as of the close of each calendar year, and
shall be furnished to the account holder—
not later than January 31 of the calendar year following the calendar year to which such reports relate, and
in such manner as the Secretary prescribes in such regulations.
.
Clerical amendment
The table of sections for part III of subchapter B of chapter 1 of such Code is amended by inserting after the item relating to section 139A the following new item:
Sec. 139B. Medicare Advantage HSA.
.
Effective date
The amendments made by this section shall take effect on January 1, 2009.
Review of adjustment mechanism used under the Medicare Advantage program
Review
Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services shall conduct a review of the adjustment mechanism used to adjust payments to Medicare Advantage organizations under section 1853(a)(1)(C) of the Social Security Act (42 U.S.C. 1395w–23(a)(1)(C)). The Secretary shall take into account the results of such review in making payments to Medicare Advantage organizations for plan years beginning on or after January 1, 2009.
Consultation
In conducting the review under subsection (a), the Secretary of Health and Human Services shall consult with industry representatives and other individuals and organizations that the Secretary determines appropriate.
Enhancements to the Medicare Fee-For-Service Program
Elimination of annual indexing of income thresholds for reduced part B premium subsidies
Paragraph (5) of section 1839(i) of the Social Security Act (42 U.S.C. 1395r(i)) is repealed.
Authority to adjust amount of Medicare part B premium to reward positive health behavior
Section 1839 of the Social Security Act (42 U.S.C. 1395r) is amended—
in subsection (a)(2), by striking
and (i)
and inserting (i), and (j)
; and
by adding at the end the following new subsection:
With respect to the monthly premium amount for months after December 2008, the Secretary may adjust (under procedures established by the Secretary) the amount of such premium for an individual based on whether or not the individual participates in certain healthy behaviors, such as weight management, exercise, nutrition counseling, refraining from tobacco use, designating a health home, and other behaviors determined appropriate by the Secretary.
In making the adjustments under paragraph (1) for a month, the Secretary shall ensure that the total amount of premiums to be paid under this part for the month is equal to the total amount of premiums that would have been paid under this part for the month if no such adjustments had been made, as estimated by the Secretary.
.
Recapture of Medicare DSH funds
In general
Section 1886(d)(5)(F)(i) of the Social
Security Act (42 U.S.C. 1395ww(d)(5)(F)(i)) is amended by inserting and
before January 1, 2010,
after May 1, 1986,
.
Savings to part A Trust Fund
The savings to the Federal Hospital Insurance Trust Fund under section 1817 of the Social Security Act (42 U.S.C. 1395i) by reason of the amendment made by paragraph (1) shall be used to strengthen the financial solvency of such Trust Fund.
Price transparency requirements for Medicare providers
Transparency
Title XVIII of the Social Security Act is amended by adding at the end the following new section:
Price transparency requirements
Pre-treatment disclosure
A provider of services (as defined in section 1861(u)) and a supplier (as defined in section 1861(d)) shall provide to each individual (regardless of whether or not the individual is a beneficiary under this title) who is scheduled to receive a treatment (or to begin a course of treatment) that is not for an emergency medical condition the estimated price that the provider of services or supplier will charge for the treatment (or course of treatment). Such price shall be determined at the time of scheduling.
Post-treatment disclosure
A provider of services (as so defined) and a supplier (as so defined) shall include with any bill that includes the charges for a treatment with respect to an individual (regardless of whether or not the individual is a beneficiary under this title), an itemized list of component charges for such treatment, including charges for drugs and medical equipment involved, as determined at the time of billing. With respect to each item included on such list, the provider of services or supplier shall include the price charged for the item.
.
Effective date
The amendment made by subsection (a) shall apply to providers of services and suppliers on and after January 1, 2009.
Value-Based Purchasing
Repeal of physician ownership referral prohibitions based on compensation arrangements
In General
Section 1877(a)(2) of the
Social Security Act (42 U.S.C.
1395nn(a)(2)) is amended by striking is—
and all that follows
through equity,
and inserting the following: is (except
as provided in subsection (c)) an ownership or investment interest in the
entity through equity,
.
Conforming Amendments
Section 1877 of the Social Security Act (42 U.S.C. 1395nn) is amended as follows:
In subsection (b)—
in the heading, by striking
to both ownership and
compensation arrangement prohibitions
and inserting
where financial
relationship exists
; and
by redesignating paragraphs (4) and (5) as paragraphs (7) and (8).
In subsection (c)—
by amending the heading to read as follows:
Exception for ownership
or investment interest in publicly traded securities and mutual
funds
; and
in the matter preceding paragraph (1), by
striking subsection (a)(2)(A)
and inserting subsection
(a)(2)
.
In subsection (d)—
by striking the heading and the matter preceding paragraph (1);
in paragraph (3), by striking
paragraph (1)
and inserting paragraph (4)
;
and
by redesignating paragraphs (1), (2), and (3) as paragraphs (4), (5), and (6), and by transferring and inserting such paragraphs after paragraph (3) of subsection (b).
By striking subsection (e).
In subsection (f)—
in the matter preceding paragraph (1), by
striking ownership, investment, and compensation
and inserting
ownership and investment
; and
in paragraph (2)—
by striking subsection
(a)(2)(A)
and all that follows through subsection
(a)(2)(B)),
and inserting subsection (a)(2)),
;
and
in paragraph (2), by striking or who
have such a compensation relationship with the entity
.
In subsection (h)—
by striking paragraphs (1), (2), and (3);
in paragraph (4)(A)—
by striking clauses (iv) and (vi);
in clause (iii), by adding
and
at the end;
by redesignating clause (v) as clause (iv); and
in clause (iv), as redesignated by clause
(iii), by striking , and
and inserting a period;
in paragraph (4)(B), by striking
rules.—
and all that follows through
(ii) Faculty
and inserting
rules for
faculty
; and
by adding at the end of paragraph (4) the following new subparagraph:
Member of a group
A physician is a member
of a
group if the physician is an owner or a bona fide employee, or both, of the
group.
.
Revision of designated health services subject to ownership referral prohibition
In General
Section 1877(h)(6) of the Social Security Act (42 U.S.C. 1395nn(h)(6)) is amended by striking subparagraphs (B) through (K) and inserting the following:
Parenteral and enteral nutrients, equipment, and supplies.
Radiology services, including magnetic resonance imaging, computerized tomography, and ultrasound services.
Outpatient physical or occupational therapy services.
.
Conforming Amendments
Section 1877(b)(2) of the
Social Security Act (42 U.S.C.
1395nn(b)(2)), in the matter preceding subparagraph (A), is amended by striking
services
and all that follows through supplies)—
and inserting services—
.
Section 1877(h)(5)(C) of the Social Security Act (42 U.S.C. 1395nn(h)(5)(C)) is amended—
by striking , a request by a
radiologist for diagnostic radiology services, and a request by a radiation
oncologist for radiation therapy,
and inserting and a request by
a radiologist for magnetic resonance imaging or for computerized
tomography
; and
by striking radiologist, or
radiation oncologist
and inserting or
radiologist
.
Exceptions to ownership referral prohibitions
Revisions to Exception for In-Office Ancillary Services
Repeal of site-of-service requirement
Section 1877 of the Social Security Act (42 U.S.C. 1395nn) is amended—
in subsection (b)(2), by striking subparagraph (A) and inserting the following new subparagraph:
that are furnished personally by the referring physician, personally by a physician who is a member of the same group practice as the referring physician, or personally by individuals who are under the general supervision of the physician or of another physician in the group practice; and
, and
in subsection (h), by adding at the end following new paragraph:
General supervision
An individual is considered to be under the
general supervision
of a physician if the physician (or group
practice of which the physician is a member) is legally responsible for the
services performed by the individual and for ensuring that the individual meets
licensure and certification requirements, if any, applicable under other
provisions of law, regardless of whether or not the physician is physically
present when the individual furnishes an item or
service.
.
Clarification of treatment of physician owners of group practice
Section 1877(b)(2)(B) of the
Social Security Act (42 U.S.C.
1395nn(b)(2)(B)) is amended by striking physician or such group
practice
and inserting physician, such group practice, or the
physician owners of such group practice
.
Conforming amendment
The heading of section 1877(b)(2) of the
Social Security Act (42 U.S.C.
1395nn(b)(2)) is amended by striking In-office ancillary services
and inserting
Ancillary services
furnished personally or through group practice
.
Clarification of Exception for Services Furnished in a Rural Area
Paragraph (5)(A) of section 1877(b) of the
Social Security Act (42 U.S.C.
1395nn(b)), as transferred by section 421(b)(3)(C), is amended by striking
substantially all
and inserting not less than 75
percent
.
Revision of Exception for Certain Managed Care Arrangements
Section 1877(b)(3) of the Social Security Act (42 U.S.C. 1395nn(b)(3)) is amended—
in the heading by inserting
; managed care
arrangements
after Prepaid plans
;
in the matter preceding subparagraph (A),
by striking organization—
and inserting organization,
directly or through contractual arrangements with other entities, to
individuals enrolled with the organization—
;
in subparagraph (A), by inserting or
part C
after section 1876
;
in subparagraph (D), by striking
or
at the end;
in subparagraph (E), by striking the period
at the end and inserting or which provides or arranges for the provision
of health care items or services pursuant to a written agreement between the
organization and an individual or entity if the written agreement places the
individual or entity at substantial financial risk for the cost or utilization
of the items or services which the individual or entity is obligated to
provide, whether through a withhold, capitation, incentive pool, per diem
payment, or any other similar risk arrangement which places the individual or
entity at substantial financial risk, or
; and
by adding at the end the following new subparagraph:
with a contract with a State to provide services under the State plan under title XIX (in accordance with section 1903(m)).
.
New Exception for Shared Facility Services
In general
Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)), as amended by paragraphs (1)(B) and (3)(C) of section 421(b), is amended—
by redesignating paragraphs (4) through (8) as paragraphs (5) through (9); and
by inserting after paragraph (3) the following new paragraph:
Shared facility services
In the case of a designated health service consisting of a shared facility service of a shared facility—
that is furnished—
personally by the referring physician who is a shared facility physician or personally by an individual directly employed by or under the general supervision of such a physician;
by a shared facility in a building in which the referring physician furnishes substantially all of the services of the physician that are unrelated to the furnishing of shared facility services; and
to a patient of a shared facility physician; and
that is billed by the referring physician or a group practice of which the physician is a member.
.
Definitions
Section 1877(h) of the Social Security Act (42 U.S.C. 1395nn(h)), as amended by section 421(b)(6), is amended by inserting before paragraph (4) the following new paragraph:
Shared facility related definitions
Shared facility service
The term shared facility service means, with respect to a shared facility, a designated health service furnished by the facility to patients of shared facility physicians.
Shared facility
The term shared facility means an entity that furnishes shared facility services under a shared facility arrangement.
Shared facility physician
The term shared facility physician means, with respect to a shared facility, a physician (or a group practice of which the physician is a member) who has a financial relationship under a shared facility arrangement with the facility.
Shared facility arrangement
The term shared facility arrangement means, with respect to the provision of shared facility services in a building, a financial arrangement—
which is only between physicians who are providing services (unrelated to shared facility services) in the same building;
in which the overhead expenses of the facility are shared, in accordance with methods previously determined by the physicians in the arrangement, among the physicians in the arrangement; and
which, in the case of a corporation, is wholly owned and controlled by shared facility physicians.
.
New Exception for Services Furnished in Communities With No Alternative Providers
Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)), as amended by paragraphs (1)(B) and (3)(C) of section 421(b) and subsection (d)(1), is amended—
by redesignating paragraphs (5) through (9) as paragraphs (6) through (10); and
by inserting after paragraph (4) the following new paragraph:
No alternative providers in area
In the case of a designated health service furnished in any area with respect to which the Secretary determines that individuals residing in the area do not have reasonable access to such a designated health service for which subsection (a)(1) does not apply.
.
New Exception for Services Furnished in Ambulatory Surgical Centers
Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)), as amended by paragraphs (1)(B) and (3)(C) of section 421(b), subsection (d)(1), and subsection (e)(1), is amended—
by redesignating paragraphs (6) through (10) as paragraphs (7) through (11); and
by inserting after paragraph (5) the following new paragraph:
Services furnished in ambulatory surgical centers
In the case of a designated health service furnished in an ambulatory surgical center described in section 1832(a)(2)(F)(i).
.
New Exception for Services Furnished in Renal Dialysis Facilities
Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)), as amended by paragraphs (1)(B) and (3)(C) of section 421(b), subsection (d)(1), subsection (e)(1), and subsection (f), is amended—
by redesignating paragraphs (7) through (11) as paragraphs (8) through (12); and
by inserting after paragraph (6) the following new paragraph:
Services furnished in renal dialysis facilities
In the case of a designated health service furnished in a renal dialysis facility under section 1881.
.
New Exception for Services Furnished in a Hospice
Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)), as amended by paragraphs (1)(B) and (3)(C) of section 421(b), subsection (d)(1), subsection (e)(1), subsection (f), and subsection (g), is amended—
by redesignating paragraphs (8) through (12) as paragraphs (9) through (13); and
by inserting after paragraph (7) the following new paragraph:
Services furnished by a hospice program
In the case of a designated health service furnished by a hospice program (as defined in section 1861(dd)(2)).
.
New Exception for Services Furnished in a Comprehensive Outpatient Rehabilitation Facility
Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)), as amended by paragraphs (1)(B) and (3)(C) of section 421(b), subsection (d)(1), subsection (e)(1), subsection (f), subsection (g), and subsection (h), is amended—
by redesignating paragraphs (9) through (13) as paragraphs (10) through (14); and
by inserting after paragraph (8) the following new paragraph:
Services furnished in a comprehensive outpatient rehabilitation facility
In the case of a designated health service furnished in a comprehensive outpatient rehabilitation facility (as defined in section 1861(cc)(2)).
.
Definition of Referral
Section 1877(h)(5)(A) of the Social Security Act (42 U.S.C. 1395nn(h)(5)(A)) is amended—
by striking an item or
service
and inserting a designated health service
;
and
by striking the item or
service
and inserting the designated health
service
.
Conforming amendment
Section 1877(g)(6)(B) of the
Social Security Act (42 U.S.C.
1395nn(g)(6)(B)) is amended by striking subsection (b)(4)
and
inserting subsection (b)(13)
.
Transparency
The Secretary of Health and Human Services shall establish procedures for requiring a physician making a referral to an entity that would have been prohibited under section 1877 of the Social Security Act (42 U.S.C. 1395nn) if the amendments made by this section had not been made to disclose to the individual being referred the financial relationship that the physician has with the entity.
Effective date
The amendments made by this subtitle shall apply to referrals made on or after the date of the enactment of this Act, regardless of whether or not regulations are promulgated to carry out such amendments.
Securing Medicare's future for tomorrow's seniors
Medical Retirement Accounts
In general
Title II of the Social Security Act (42 U.S.C. 401 et seq.) is amended—
by inserting before section 201 the following:
Insurance benefits
;
and
by adding at the end the following:
Medical Retirement Accounts
Medical Retirement Account Fund
Establishment
In general
There shall be established and maintained in the Treasury of the United States a Medical Retirement Account Fund in the same manner as the Thrift Savings Fund under section 8437 of title 5, United States Code (excluding paragraphs (4) and (5) of subsection (c) thereof).
Contents of fund
There is hereby appropriated to the Medical Retirement Account Fund amounts equivalent to—
the contributions received in the Treasury under sections 3101(b), 3111(b), and 1401(b) of the Internal Revenue Code of 1986 with respect to each eligible individual on and after the date of an election under section 252(a)(2), and
the aggregate of the contributions described in subparagraphs (B)(, (C), and (D) of section 252(c)(1) with respect to such eligible individuals.
Investment of Medical Retirement Account Fund
Amounts in the Medical Retirement Account Fund shall be invested in the same manner as amounts in the Thrift Savings Fund are invested under section 8438 of title 5, United States Code.
Accounting and information
The Executive Director of the Medical Retirement Account Board shall maintain accounts and provide information in the same manner as the Executive Director of the Thrift Savings Fund is required to maintain accounts and provide information with respect to the Thrift Savings Fund under section 8439 of title 5, United States Code.
Medical Retirement Accounts
Establishment
In general
Within 30 days after receiving the first contribution under subsection (c) with respect to an eligible individual, the Medical Retirement Account Board shall establish a Medical Retirement Account for such individual in the Medical Retirement Account Fund. Each account shall be identified to the account holder by means of the account holder’s social security account number.
Eligible individual
For purposes of this part, the term eligible individual means any individual who, under regulations prescribed by the Secretary of Health and Human Services, makes an irrevocable election on or after the effective date of this part to renounce eligibility under the Medicare Program under title XVIII and establish a Medical Retirement Account.
Treatment of account
Except as provided in this section, a Medical Retirement Account shall be treated for purposes of the Internal Revenue Code of 1986 in the same manner as a health savings account under section 223 of such Code (determined without regard to subsections (d)(1)(A)((ii) and (d)(2)(B) thereof).
Contributions
In general
The Medical Retirement Account Board shall credit to the Medical Retirement Account of an eligible individual—
except as provided in paragraph (2), an amount equal to the sum of any amounts transferred to the Medical Retirement Account Fund under section 251(a)(2)(A) which are attributable to the contributions paid by or on behalf of such individual under sections 3101(b), 3111(b), and 1401(b) of the Internal Revenue Code of 1986, plus
at the time of such individual's retirement date determined under subsection (d)(1), an amount equal to the sum of any amounts transferred to the Federal Hospital Insurance Trust Fund under section 1817 which is attributable to such contributions paid on average by or on behalf of individuals in the same age cohort as such eligible individual under sections 3101(b), 3111(b), and 1401(b) of the Internal Revenue Code of 1986 (including any Trust Fund earnings on such amount), plus
any amount contributed to such Medical Retirement Account by the eligible individual or the eligible individual's employer, including, in the case of an eligible individual who is a State government employee, any contribution under an applicable State law, to the extent the aggregate amount of contributions under this subparagraph for any calendar year does not exceed $10,000, adjusted for inflation in the same manner as the applicable dollar amount under section 402(g)(1)(B) of the Internal Revenue Code of 1986, and reduced in the same manner as under section 408A(c)(3) of such Code, plus
an amount equal to any one-time qualified rollover at the time of such individual's retirement from any of the eligible individual's health savings accounts, health reimbursement accounts, flexible spending accounts, and medical savings accounts.
Redistribution
Not later than 90 days after the end of each taxable year, the Secretary shall transfer such portion of the contributions paid under section 3111(b) or 1401(b) of the Internal Revenue Code of 1986 by or on behalf of eligible individuals whose wages or net earnings from self-employment exceed the contribution and benefit base under section 230 for such taxable year to Medical Retirement Accounts of eligible individuals whose wages and net earnings from self-employment do not exceed such base for such taxable year in an amount per each Medical Retirement Account so as not to exceed 2.9 percent of the national average salary for each such Account.
Distributions
In general
Except as provided in paragraph (2), distributions may only be made from a Medical Retirement Account of an eligible individual on and after the date the eligible individual attains—
retirement age (as determined under section 216), or
if elected by such individual, early retirement age, but only if such individual presents proof of the purchase of a lifetime catastrophic health insurance policy upon such election.
Distribution in the event of death before the date of initial distribution
If the eligible individual dies before the date determined under paragraph (1), the balance in such individual’s Medical Retirement Account shall be distributed in a lump sum, under rules established by the Medical Retirement Account Board—
to the Medical Retirement Account of a surviving spouse of such individual, and
in the case there is no surviving spouse or such spouse waives the right to such funds, to the Medical Retirement Accounts of the eligible individual’s heirs.
Divorce
The Medical Retirement Account Board shall issue regulations which provide that, in the case of an eligible individual with a Medical Retirement Account who becomes divorced after at least 10 years of marriage to the same spouse, contributions to the Account during the marriage and earnings on the Account during the marriage shall be divided evenly between the Account of such individual and a Medical Retirement Account of such individual’s former spouse.
Medical Retirement Account Board
In general
There shall be established and maintained in the Social Security Administration a Medical Retirement Account Board in the same manner as the Federal Retirement Thrift Investment Board under subchapter VII of chapter 84 of title 5, United States Code.
Executive director
The Medical Retirement Account Board shall appoint an Executive Director in the same manner and with the same functions as the Executive Director of the Thrift Savings Board under section 8474 of title 5, United States Code.
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Tax treatment of certain contributions to Medical Retirement Accounts
In general
Part III of subchapter B of chapter 1 of the Internal Revenue Code of 1986, as amended by this Act, is amended by inserting after section 139B the following new section:
Medical Retirement Account contributions
Gross income shall not include any contribution to a Medical Retirement Account specified under section 252(c) of the Social Security Act or any earnings on such contributions.
.
Clerical amendment
The table of section for part III of subchapter B of chapter 1 of such Code, as amended by this Act, is amended by inserting after the item relating to section 139B the following new item:
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Conforming amendments to the Medicare program
Part A entitlement
Section 1811 of the Social Security Act (42
U.S.C. 1395d) is amended by adding at the end the following new sentence:
On and after the effective date of part B of title II, the entitlement
under the preceding sentence shall only apply to an individual who is not an
eligible individual (as defined in section 252(a)(2)).
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Part A trust fund
The third sentence of section 1817 of the
Social Security Act (42 U.S.C. 1395i) is amended in each of paragraphs (1) and
(2) by inserting subject to section 251(a)(2)(A),
before
the taxes imposed
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Part B eligibility
Section 1836 of the Social Security Act (42
U.S.C. 1395o) is amended by adding at the end the following new sentence:
On and after the effective date of part B of title II, the eligibility
under the preceding sentence shall only apply to an individual who is not an
eligible individual (as defined in section 252(a)(2)).
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Effective dates
In general
Except as provided in paragraph (2), the amendments made by this section shall take effect on January 1, 2009.
Internal revenue code
The amendments made by subsection (b) shall apply to taxable years beginning after December 31, 2008.
Keeping Medicaid on Mission
Restructuring of Medicaid funding
Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is amended—
by redesignating section 1939 as section 1940; and
by inserting after section 1938, the following:
Medicaid Modernized and On Mission
State Medicaid assistance allotments
Notwithstanding any other provision of this title, beginning with fiscal year 2010, and for each fiscal year thereafter—
no State shall receive a payment under section 1903(a); and
only in the case of a State with a State plan under this title that satisfies the conditions described in subsection (c), the Secretary shall pay such State the State Medicaid assistance allotment for the State determined under subsection (b).
Determination of amount of allotments
In general
Subject to paragraphs (4) and (5), the State Medicaid assistance allotment payable to a State (other than a State referred to in subparagraph (B)(ii)) for a fiscal year shall be the amount that bears the same ratio to the amount appropriated under subsection (f) for the fiscal year (reduced by the amount of the allotments made under paragraph (2)), as the ratio of—
the sum of—
the population of the State;
the number of individuals residing in the State whose family income does not exceed the poverty line (as defined in section 2110(c)(5) applicable to a family of the size involved);
the number of individuals residing in the State who are full-benefit dual eligible individuals (as defined in section 1935(c)(6)); and
the number of disabled individuals residing in the State; to
the sum of the amounts determined under subparagraph (A).
Allotments to territories
In general
Subject to paragraphs (4) and (5), the State Medicaid assistance allotment payable to a commonwealth or territory referred to in subparagraph (B) for a fiscal year shall be the amount that bears the same ratio to 0.25 percent of the amount appropriated under subsection (f) for the fiscal year, as the percentage specified in subparagraph (B)) for the commonwealth or territory bears to the sum of such percentages for all such commonwealths and territories so described.
Percentage
The percentage specified in this subparagraph for—
Puerto Rico is 91.6 percent,
Guam is 3.5 percent,
the Virgin Islands is 2.6 percent,
American Samoa is 1.2 percent, and
the Northern Mariana Islands is 1.1 percent.
Determination of population and number of individuals
The Secretary shall determine the State populations and numbers of individuals described in paragraph (1) on the basis of the most recent American Community Survey of the Bureau of the Census (or, until such data is available, on the basis of the 3 most recent Annual Social and Economic Supplements of the Current Population Survey of the Bureau of the Census) and such other data as the Secretary determines is necessary.
Phase-in; transition assistance
Phased-in change in funding amounts
Notwithstanding paragraph (1) and (2), subject to subparagraph (B), the State Medicaid assistance allotment determined for a State for each of fiscal years 2010 through 2013 shall be the amount equal to the following:
Fiscal year 2010
In the case of fiscal year 2010, the amount equal to the sum of—
80 percent of the amount paid to the State under section 1903(a) for fiscal year 2006; and
20 percent of the amount of the State Medicaid assistance allotment that would be paid to the State under paragraph (1) or (2) (as applicable) without regard to this paragraph.
Fiscal year 2011
In the case of fiscal year 2011, the amount equal to the sum of—
60 percent of the amount paid to the State under section 1903(a) for fiscal year 2006; and
40 percent of the amount of the State Medicaid assistance allotment that would be paid to the State under paragraph (1) or (2) (as applicable) without regard to this paragraph.
Fiscal year 2012
In the case of fiscal year 2012, the amount equal to the sum of—
40 percent of the amount paid to the State under section 1903(a) for fiscal year 2006; and
60 percent of the amount of the State Medicaid assistance allotment that would be paid to the State under paragraph (1) or (2) (as applicable) without regard to this paragraph.
Fiscal year 2013
In the case of fiscal year 2013, the amount equal to the sum of—
20 percent of the amount paid to the State under section 1903(a) for fiscal year 2006; and
80 percent of the amount of the State Medicaid assistance allotment that would be paid to the State under paragraph (1) or (2) (as applicable) without regard to this paragraph.
Transition assistance
The State Medicaid assistance allotment paid to a State for any of fiscal years 2010 through 2014 shall not be less than the approximate total amount paid to the State under section 1903(a) for fiscal year 2006.
Conditions described
For purposes of subsection (a), the conditions described in this subsection are the following:
Populations covered
In general
Subject to subparagraph (B), the State uses its State Medicaid assistance allotment to provide medical assistance (subject, notwithstanding section 1916 or 1916A, to payment of premiums or other cost-sharing charges (set on a sliding scale based on income) that the State may determine) only for populations of individuals—
who are eligible for medical assistance under the State plan on January 1, 2008; or
whose family income does not exceed 133 percent of the poverty line (as defined in section 2110(c)(5)).
Priority for mandatory populations
In determining the populations eligible for medical assistance under the State plan in accordance with subparagraph (A), the State shall give priority to making populations described in section 1902(a)(10)(A)(i) eligible for such assistance.
Option to risk-adjust premiums
With respect to populations covered in accordance with this paragraph, a State may impose risk-adjusted premiums based on chronic disease conditions.
Benefits
In general
The State does not provide medical assistance for purposes of any item or service that is not described in section 1905(a) as in effect on January 1, 2008 or authorized to be provided by any State under a waiver approved under section 1115, 1915, or otherwise, as in effect on January 1, 2008.
Health promotion and disease prevention
At State option, the State implements initiatives designed to educate the population of the State with respect to health promotion and disease prevention of the top 3 lethal diseases for the State.
Matching requirement
The State provides non-Federal matching funds of not less than $1 for every $3 of Federal funds received under this section.
Limitation on administrative expenditures
The total amount of reasonable costs incurred by the State to administer the State plan for a fiscal year shall not exceed the amount equal to 3 percent of the State Medicaid assistance allotment paid to the State under this section for such fiscal year.
Application of restrictions on use of funds
The restrictions on the use of Federal funds appropriated to carry out this title contained in title V of division F of the Consolidated Appropriations Act, 2005, shall apply to the State Medicaid assistance allotments paid to States under this section for fiscal year 2010 and each fiscal year thereafter in the same manner as such restrictions apply to amounts appropriated under division F of such Act.
Promotion of price and quality transparency in the private market
The State provides an assurance that the State has implemented initiatives—
to promote price and quality transparency with respect to each type of health insurance offered by health insurance issuers in the State; and
to ensure that any provider of a health care item or service that is paid for (in whole or in part) with Federal or State funds publishes price information with respect to such item or service and makes the information readily available to consumers.
Annual report on health coverage
The State submits annual reports to the Secretary that—
describe the State's expenditure of the State Medicaid assistance allotment;
include—
the number of individuals provided medical assistance through such allotment;
the average per beneficiary spending of the allotment with respect to—
acute care; and
long-term care; and
the number of individuals in the State who are enrolled in private health coverage.
Option To subsidize purchase of private market coverage
In general
Subject to paragraph (4), a State may elect to permit individuals eligible for medical assistance in accordance with subsection (c)(1) to opt-out of enrollment under the State plan (on a risk-adjusted basis) in return for payment on the individual's behalf of the individual health insurance purchase subsidy amount determined under paragraph (2) to an issuer of health insurance coverage within the private market.
Individual health insurance purchase subsidy
For purposes of paragraph (1), the individual health insurance purchase subsidy amount determined under this paragraph is equal to the actuarial average cost of providing coverage under the State plan under this title to all enrollees in such plan.
Authority to combine subsidy with refundable credit for health insurance coverage
Payment of an individual health insurance purchase subsidy on behalf of an individual under this subsection shall not be taken into account for purposes of determining the amount the individual is allowed as a credit under section 36 of the Internal Revenue Code of 1986 for qualified health insurance.
Enrollment information and assistance
A State may only make the election described in paragraph (1) if the State—
makes available to the individuals described in paragraph (1) benefit enrollment counselors to assist the individuals with selecting coverage within the individual market; and
has implemented procedures to ensure that accurate and complete plan information is provided to such individuals prior to their enrollment in a plan within such market.
Facilitation of use of federal tax credit to elect catastrophic or other private market coverage
A State may establish mechanisms to facilitate the enrollment of individuals who elect to opt-out of the State plan in private health insurance or in qualified health insurance for purposes of such individuals being allowed a credit under section 36 of the Internal Revenue Code of 1986.
Availability
Amounts paid to a State under this section shall remain available for expenditure without fiscal year limitation.
Appropriations
In general
Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated for making State Medicaid assistance allotments to States under this section—
for fiscal year 2010, $212,000,000,000; and
for each of fiscal years 2011 through 2017, the amount appropriated under this subsection for the preceding fiscal year, increased by the percentage increase (if any) in the chain-weighted consumer price index for all urban consumers (all items; United States city average) for the previous fiscal year.
Additional appropriation for transition years; hold harmless
Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated for the period of fiscal years 2010 through 2014, $20,000,000,000, for purposes of carrying out subsection (b)(4)(B).
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Medicaid Advantage program
Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.), as amended by section 501, is amended by—
redesignating section 1940 as section 1941; and
inserting after section 1939 the following new section:
Medicaid advantage program
Definitions
In this section:
Medicaid advantage eligible individual
The term
Medicaid Advantage eligible individual
means an individual
who—
is a full-benefit dual eligible individual (as defined in section 1935(c)(6)); and
resides in a participating State.
Participating state
The term participating State
means a State that elects to offer a State Medicaid Advantage program under
this section.
Program
The term program
means a
State Medicaid Advantage program.
State medicaid advantage program
The term State
Medicaid Advantage program
means a program offered by a State that
provides individuals enrolled in the program a medical home where they receive
a seamless continuum of medical care and care management that meets the
following requirements:
Operation
The primary manager of the program is the State.
Integrated coverage
The program provides integrated health care benefits to Medicaid Advantage eligible individuals.
Establishment
In general
Beginning with fiscal year 2010, a State may elect to provide benefits to Medicaid Advantage eligible individuals who elect to enroll in a program established under this section. Such benefits shall be provided instead of benefits under title XVIII or under a State plan under this title.
Enrollment
In general
A participating State shall establish procedures to enroll Medicaid Advantage eligible individuals in the program. Such procedures shall ensure that a Medicaid Advantage eligible individual may elect to not enroll and to disenroll upon request from the program.
Preservation of original medicare and medicaid benefits
Nothing in this section shall be construed to limit the right of a Medicaid Advantage eligible individual who is entitled to benefits under title XVIII or under a State plan under this title to receive such benefits if the individual elects to not enroll or to disenroll from the program.
Payments
In general
The Secretary shall develop a system for making risk-adjusted payments on a capitated basis to participating States for the cost of providing items and services to each individual enrolled in the program that would, but for the application of this section, be covered under—
title XVIII, including the cost of providing qualified prescription drug coverage under part D of such title; or
a State plan under this title.
Determination of payment amount
The Secretary shall use actuarial data and payment history in determining the payment amount under such system with respect to each individual enrolled in the program, and shall adjust the payment amount to take into account the comparative frailty of such individuals and such other factors as the Secretary determines to be appropriate.
Update of payment system
The Secretary shall update the payment system developed under this paragraph as appropriate.
State procedures
A participating State shall establish such procedures for the submission of claims and the transmission of data as the Secretary determines appropriate in order to carry out the payment system developed under this paragraph.
Scope of benefits
A participating State shall provide individuals enrolled in the program, regardless of the source of payment and directly or under contracts with other entities, at a minimum—
all items and services covered under title XVIII and all items and services covered under this title, except that States shall have authority and flexibility to design benefit packages that meet the specific needs of Medicaid Advantage eligible individuals, including the needs of such individuals with mental illness;
qualified prescription drug coverage (as defined in section 1860D–2(a)(1)); and
such other items and services as the State determines appropriate.
Responsibilities of participating states
Bidding process for health plans
In general
A participating State shall establish procedures for health plans to participate in a bidding process to enter into a contract under paragraph (2) to provide services to Medicaid Advantage eligible individuals under the program.
Bid submission
Each health plan participating in the bidding process established under paragraph (1) shall submit a bid representing the estimated cost to such plans of providing Medicaid Advantage eligible individuals the benefits described in subsection (b)(4).
Contracts with health plans
In general
A participating State shall enter into contracts with health plans, including managed care health plans, in order to provide integrated health care benefits to Medicaid Advantage eligible individuals enrolled in the program.
Responsibility for providing care
Each contract entered into under this paragraph shall provide that the health plan is responsible for—
providing the benefits described in subsection (b)(4) to individuals enrolled in the program;
collecting performance data on treatments and outcomes for each such individual; and
providing such data to the State for use in monitoring the program under this section.
Ensuring quality and value
Promoting competition
A participating State shall provide incentives for health plans to compete with respect to the quality and value of the services provided to Medicaid Advantage eligible individuals who are enrolled in the program.
Rewarding efficiency
A participating State may reward health plans that provide higher quality care at a reduced price under the program.
Choice of plans
A participating State shall establish procedures to allow Medicaid Advantage eligible individuals to choose from among the competing plans that the State enters into a contract with under paragraph (2).
Payment procedures
A participating State shall establish procedures with respect to payments in accordance with subsection (b)(3)(D).
Monitoring and enforcement
A participating State shall share responsibility with the Secretary for—
carefully monitoring health plans that the State enters into a contract with under paragraph (2); and
bringing action against those health plans that do not meet their obligations under such contracts.
Federal responsibilities
Payments to participating States
The Secretary shall provide for payments to participating States in accordance with subsection (b)(3).
Monitoring and enforcement
Goals
The Secretary shall set and monitor goals for programs.
Monitoring and enforcement
The Secretary shall share responsibility with a participating State for—
carefully monitoring health plans that the State enters into a contract with under subsection (c)(2); and
bringing appropriate action against those health plans that do not meet their obligations under such contracts.
Access to prescription drug data
In general
Notwithstanding any provision of law, the Secretary shall ensure that States have access to prescription drug data submitted by prescription drug plans and MA–PD plans under part D of title XVIII for the purpose of carrying out the program under this section.
Safeguards
The Secretary shall ensure that States have in place appropriate safeguards to protect against the unauthorized disclosure of data provided under subparagraph (A).
Waivers of requirements
With respect to carrying out a State Medicaid Advantage program under this section, the following requirements of this title (and regulations relating to such requirements) shall not apply:
Section 1902(a)(1), relating to any requirement that a program or benefits under such a program be provided in all areas of a State.
Section 1902(a)(10), insofar as such section relates to comparability of services among different population groups.
Sections 1902(a)(23) and 1915(b)(4), relating to freedom of choice of providers under a program.
Section 1903(m)(2)(A), insofar as it restricts a program from receiving prepaid capitation payments.
Such other provisions of this title that the Secretary determines are inapplicable to carrying out a program under this section.
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High performance bonuses
Section 1939 of the Social Security Act, as added by section 501, is amended by adding at the end the following:
Bonus To reward high performance states
In general
In addition to the State Medicaid assistance allotments paid to States in accordance with the preceding provisions of this section, the Secretary shall make a payment pursuant to this subsection to each State for each bonus year for which the State is a high performing State.
Amount of payment
In general
Subject to subparagraph (B), the Secretary shall determine the amount of the payment under this subsection to a high performing State for a bonus year.
Limitation
The amount payable to a State under this subsection for a bonus year shall not exceed 5 percent of the State Medicaid assistance allotment paid to the State under subsection (a).
Use of funds
Amounts paid to a State under this subsection shall be used to facilitate the enrollment of uninsured individuals who reside in the State in private health insurance or to maintain the enrollment of individuals in such health insurance.
Definitions
As used in this paragraph:
Bonus year
The term bonus year means each of fiscal years 2010 through 2017.
High performing state
The term high performing State means, with respect to a bonus year, a State that—
with respect to, each of bonus years 2010 and 2011, the Secretary determines that at least 90 percent of the total population of the State is enrolled in private health insurance coverage; and
with respect to each of bonus years 2012 through 2017, the Secretary determines that—
at least 95 percent of the total population of the State is enrolled in private health insurance coverage; and
the State has satisfies the conditions in subsection (c).
Appropriation
Out of any money in the Treasury of the United States not otherwise appropriated, there are appropriated for the period of fiscal years 2010 through 2017, $5,000,000,000 for making payments under this subsection.
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Administrative health care tribunals
State grants to create administrative health care tribunals
Part P of title III of the Public Health Service Act (42 U.S.C. 280g et seq.) is amended by adding at the end the following:
State grants to create administrative health care tribunals
In general
The Secretary may award grants to States for the development, implementation, and evaluation of administrative health care tribunals that comply with this section, for the resolution of disputes concerning injuries allegedly caused by health care providers.
Conditions for demonstration grants
To be eligible to receive a grant under this section, a State shall submit to the Secretary an application at such time, in such manner, and containing such information as may be required by the Secretary. A grant shall be awarded under this section on such terms and conditions as the Secretary determines appropriate.
Representation by counsel
A State that receives a grant under this section may not preclude any party to a dispute before an administrative health care tribunal operated under such grant from obtaining legal representation during any review by the expert panel under subsection (d), the administrative health care tribunal under subsection (e), or a State court under subsection (f).
Expert panel review and early offer guidelines
In general
Prior to the submission of any dispute concerning injuries allegedly caused by health care providers to an administrative health care tribunal under this section, such allegations shall first be reviewed by an expert panel.
Composition
In general
An expert panel under this subsection shall be composed of 3 medical experts (either physicians or health care professionals) and 3 attorneys to be appointed by the head of the State agency responsible for health.
Licensure and expertise
Each physician or health care professional appointed to an expert panel under subparagraph (A) shall—
be appropriately credentialed or licensed in 1 or more States to deliver health care services; and
typically treat the condition, make the diagnosis, or provide the type of treatment that is under review.
Independence
In general
Subject to clause (ii), each individual appointed to an expert panel under this paragraph shall—
not have a material familial, financial, or professional relationship with a party involved in the dispute reviewed by the panel; and
not otherwise have a conflict of interest with such a party.
Exception
Nothing in clause (i) shall be construed to prohibit an individual who has staff privileges at an institution where the treatment involved in the dispute was provided from serving as a member of an expert panel merely on the basis of such affiliation, if the affiliation is disclosed to the parties and neither party objects.
Practicing health care professional in same field
In general
In a dispute before an expert panel that involves treatment, or the provision of items or services—
by a physician, the medical experts on the expert panel shall be practicing physicians (allopathic or osteopathic) of the same or similar specialty as a physician who typically treats the condition, makes the diagnosis, or provides the type of treatment under review; or
by a health care professional other than a physician, at least two medical experts on the expert panel shall be practicing physicians (allopathic or osteopathic) of the same or similar specialty as the health care professional who typically treats the condition, makes the diagnosis, or provides the type of treatment under review, and, if determined appropriate by the State agency, the third medical expert shall be a practicing health care professional (other than such a physician) of such a same or similar specialty.
Practicing defined
In this paragraph, the term practicing means, with respect to an individual who is a physician or other health care professional, that the individual provides health care services to individual patients on average at least 2 days a week.
Pediatric expertise
In the case of dispute relating to a child, at least 1 medical expert on the expert panel shall have expertise described in subparagraph (D)(i) in pediatrics.
Determination
After a review under paragraph (1), an expert panel shall make a determination as to the liability of the parties involved and compensation.
Acceptance
If the parties to a dispute before an expert panel under this subsection accept the determination of the expert panel concerning liability and compensation, such compensation shall be paid to the claimant and the claimant shall agree to forgo any further action against the health care providers involved.
Failure to accept
If any party decides not to accept the expert panel’s determination, the matter shall be referred to an administrative health care tribunal created pursuant to this section.
Administrative health care tribunals
In general
Upon the failure of any party to accept the determination of an expert panel under subsection (d), the parties shall have the right to request a hearing concerning the liability or compensation involved by an administrative health care tribunal established by the State involved.
Requirements
In establishing an administrative health care tribunal under this section, a State shall—
ensure that such tribunals are presided over by special judges with health care expertise;
provide authority to such judges to make binding rulings, rendered in written decisions, on standards of care, causation, compensation, and related issues with reliance on independent expert witnesses commissioned by the tribunal;
establish negligence as the legal standard for the tribunal;
allow the admission into evidence of the recommendation made by the expert panel under subsection (d); and
provide for an appeals process to allow for review of decisions by State courts.
Review by State court after exhaustion of administrative remedies
Right to file
If any party to a dispute before a health care tribunal under subsection (e) is not satisfied with the determinations of the tribunal, the party shall have the right to file their claim in a State court of competent jurisdiction.
Forfeit of awards
Any party filing an action in a State court in accordance with paragraph (1) shall forfeit any compensation award made under subsection (e).
Admissibility
The determinations of the expert panel and the administrative health care tribunal pursuant to subsections (d) and (e) with respect to a State court proceeding under paragraph (1) shall be admissible into evidence in any such State court proceeding.
Definition
In this section, the term health care provider has the meaning given such term for purposes of part A of title VII.
Funding
One-time increase in Medicaid payment
In the case of a State awarded a grant to carry out this section, the total amount of Federal payments made to the State under section 1903(a) of the Social Security Act or section 1939(b)of such Act (in the case of fiscal year 2010 or any fiscal year thereafter) for the first fiscal year for which such grant is awarded shall be increased by an amount equal to 1 percent of of the total amount of such payments made to the State for the preceding fiscal year under such 1903(a) or 1939(b) (as applicable) for purposes of carrying out this section. Amounts paid to a State pursuant to this subsection shall remain available until expended.
Authorization of appropriations
There are authorized to be appropriated for any fiscal year such sums as may be necessary for purposes of making payments to States pursuant to paragraph (1).
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Health information technology
Assisting the development of health information technology
Purpose
It is the purpose of this subtitle to promote the utilization of health record banking by improving the coordination of health information through an infrastructure for the secure and authorized exchange and use of healthcare information.
Health record banking
Establishment
Not later than 1 year after the date of enactment of this Act, the Secretary of Health and Human Services shall promulgate regulations to provide for the certification and auditing of the banking of electronic medical records.
General rights
An individual who has a health record contained in a health record bank shall maintain ownership over the health record and shall have the right to review the contents of the record.
Application of Federal and State security and confidentiality standards
In general
Current Federal security and confidentiality standards and State security and confidentiality laws shall apply to this subtitle until such time as Congress acts to amend such standards.
Definitions
In this section:
Current Federal security and confidentiality standards
The term current Federal security and confidentiality standards means the Federal privacy standards established pursuant to section 264(c) of the Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. 1320d–2 note) and security standards established under section 1173(d) of the Social Security Act (42 U.S.C. 1320d–2(d)).
State security and confidentiality laws
The term State security and confidentiality laws means State laws and regulations relating to the privacy and confidentiality of individually identifiable health information or to the security of such information.
State
The term State has the meaning given such term for purposes of title XI of the Social Security Act, as provided under section 1101(a) of such Act (42 U.S.C. 1301(a)).
Promoting the use of health information technology to better coordinate health care
Safe harbors to antikickback civil penalties and criminal penalties for provision of health information technology and training services
For Civil Penalties
Section 1128A of the Social Security Act (42 U.S.C. 1320a–7a) is amended—
in subsection (b), by adding at the end the following new paragraph:
For purposes of this subsection, inducements to reduce or limit services described in paragraph (1) shall not include the practical or other advantages resulting from health information technology or related installation, maintenance, support, or training services.
; and
in subsection (i), by adding at the end the following new paragraph:
The term health information technology means hardware, software, license, right, intellectual property, equipment, or other information technology (including new versions, upgrades, and connectivity) designed or provided primarily for the electronic creation, maintenance, or exchange of health information to better coordinate care or improve health care quality, efficiency, or research.
.
For Criminal Penalties
Section 1128B of such Act (42 U.S.C. 1320a–7b) is amended—
in subsection (b)(3)—
in subparagraph (G), by striking
and
at the end;
in the subparagraph (H) added by section 237(d) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173; 117 Stat. 2213)—
by moving such subparagraph 2 ems to the left; and
by striking the period at the end and inserting a semicolon;
in the subparagraph (H) added by section 431(a) of such Act (117 Stat. 2287)—
by redesignating such subparagraph as subparagraph (I);
by moving such subparagraph 2 ems to the left; and
by striking the period at the end and
inserting ; and
; and
by adding at the end the following new subparagraph:
any nonmonetary remuneration (in the form of health information technology, as defined in section 1128A(i)(8), or related installation, maintenance, support or training services) made to a person by a specified entity (as defined in subsection (g)) if—
the provision of such remuneration is without an agreement between the parties or legal condition that—
limits or restricts the use of the health information technology to services provided by the physician to individuals receiving services at the specified entity;
limits or restricts the use of the health information technology in conjunction with other health information technology; or
conditions the provision of such remuneration on the referral of patients or business to the specified entity;
such remuneration is arranged for in a written agreement that is signed by the parties involved (or their representatives) and that specifies the remuneration solicited or received (or offered or paid) and states that the provision of such remuneration is made for the primary purpose of better coordination of care or improvement of health quality, efficiency, or research; and
the specified entity providing the remuneration (or a representative of such entity) has not taken any action to disable any basic feature of any hardware or software component of such remuneration that would permit interoperability.
; and
by adding at the end the following new subsection:
Specified Entity Defined
For purposes of subsection (b)(3)(J), the term specified entity means an entity that is a hospital, group practice, prescription drug plan sponsor, a Medicare Advantage organization, or any other such entity specified by the Secretary, considering the goals and objectives of this section, as well as the goals to better coordinate the delivery of health care and to promote the adoption and use of health information technology.
.
Effective Date and Effect on State Laws
Effective date
The amendments made by subsections (a) and (b) shall take effect on the date that is 120 days after the date of the enactment of this Act.
Preemption of state laws
No State (as defined in section 1101(a) of the Social Security Act (42 U.S.C. 1301(a)) for purposes of title XI of such Act) shall have in effect a State law that imposes a criminal or civil penalty for a transaction described in section 1128A(b)(4) or section 1128B(b)(3)(J) of such Act, as added by subsections (a)(1) and (b), respectively, if the conditions described in the respective provision, with respect to such transaction, are met.
Study and Report To Assess Effect of Safe Harbors on Health System
In general
The Secretary of Health and Human Services shall conduct a study to determine the impact of each of the safe harbors described in paragraph (3). In particular, the study shall examine the following:
The effectiveness of each safe harbor in increasing the adoption of health information technology.
The types of health information technology provided under each safe harbor.
The extent to which the financial or other business relationships between providers under each safe harbor have changed as a result of the safe harbor in a way that adversely affects or benefits the health care system or choices available to consumers.
The impact of the adoption of health information technology on health care quality, cost, and access under each safe harbor.
Report
Not later than 3 years after the effective date described in subsection (c)(1), the Secretary of Health and Human Services shall submit to Congress a report on the study under paragraph (1).
Safe harbors described
For purposes of paragraphs (1) and (2), the safe harbors described in this paragraph are—
the safe harbor under section 1128A(b)(4) of such Act (42 U.S.C. 1320a–7a(b)(4)), as added by subsection (a)(1); and
the safe harbor under section 1128B(b)(3)(J) of such Act (42 U.S.C. 1320a–7b(b)(3)(J)), as added by subsection (b).
Exception to limitation on certain physician referrals (under stark) for provision of health information technology and training services to health care professionals
In General
Section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)) is amended by adding at the end the following new paragraph:
Information technology and training services
In general
Any nonmonetary remuneration (in the form of health information technology or related installation, maintenance, support or training services) made by a specified entity to a physician if—
the provision of such remuneration is without an agreement between the parties or legal condition that—
limits or restricts the use of the health information technology to services provided by the physician to individuals receiving services at the specified entity;
limits or restricts the use of the health information technology in conjunction with other health information technology; or
conditions the provision of such remuneration on the referral of patients or business to the specified entity;
such remuneration is arranged for in a written agreement that is signed by the parties involved (or their representatives) and that specifies the remuneration made and states that the provision of such remuneration is made for the primary purpose of better coordination of care or improvement of health quality, efficiency, or research; and
the specified entity (or a representative of such entity) has not taken any action to disable any basic feature of any hardware or software component of such remuneration that would permit interoperability.
Health information technology defined
For purposes of this paragraph, the term health information technology means hardware, software, license, right, intellectual property, equipment, or other information technology (including new versions, upgrades, and connectivity) designed or provided primarily for the electronic creation, maintenance, or exchange of health information to better coordinate care or improve health care quality, efficiency, or research.
Specified entity defined
For purposes of this paragraph, the term specified entity means an entity that is a hospital, group practice, prescription drug plan sponsor, a Medicare Advantage organization, or any other such entity specified by the Secretary, considering the goals and objectives of this section, as well as the goals to better coordinate the delivery of health care and to promote the adoption and use of health information technology.
.
Effective Date; Effect on State Laws
Effective date
The amendment made by subsection (a) shall take effect on the date that is 120 days after the date of the enactment of this Act.
Preemption of state laws
No State (as defined in section 1101(a) of the Social Security Act (42 U.S.C. 1301(a)) for purposes of title XI of such Act) shall have in effect a State law that imposes a criminal or civil penalty for a transaction described in section 1877(b)(6) of such Act, as added by subsection (a), if the conditions described in such section, with respect to such transaction, are met.
Study and Report To Assess Effect of Exception on Health System
In general
The Secretary of Health and Human Services shall conduct a study to determine the impact of the exception under section 1877(b)(6) of such Act (42 U.S.C. 1395nn(b)(6)), as added by subsection (a). In particular, the study shall examine the following:
The effectiveness of the exception in increasing the adoption of health information technology.
The types of health information technology provided under the exception.
The extent to which the financial or other business relationships between providers under the exception have changed as a result of the exception in a way that adversely affects or benefits the health care system or choices available to consumers.
The impact of the adoption of health information technology on health care quality, cost, and access under the exception.
Report
Not later than 3 years after the effective date described in subsection (b)(1), the Secretary of Health and Human Services shall submit to Congress a report on the study under paragraph (1).
Rules of construction regarding use of consortia
Application to Safe Harbor From Criminal Penalties
Section 1128B(b)(3)
of the Social Security Act (42 U.S.C.
1320a–7b(b)(3)) is amended by adding after and below subparagraph (J), as added
by section 711(b)(1), the following: For purposes of subparagraph (J),
nothing in such subparagraph shall be construed as preventing a specified
entity, consistent with the specific requirements of such subparagraph, from
forming a consortium composed of health care providers, payers, employers, and
other interested entities to collectively purchase and donate health
information technology, or from offering health care providers a choice of
health information technology products in order to take into account the
varying needs of such providers receiving such products.
.
Application to Stark Exception
Paragraph (6) of section 1877(b) of the Social Security Act (42 U.S.C. 1395nn(b)), as added by section 712(a), is amended by adding at the end the following new subparagraph:
Rule of construction
For purposes of subparagraph (A), nothing in such subparagraph shall be construed as preventing a specified entity, consistent with the specific requirements of such subparagraph, from—
forming a consortium composed of health care providers, payers, employers, and other interested entities to collectively purchase and donate health information technology; or
offering health care providers a choice of health information technology products in order to take into account the varying needs of such providers receiving such products.
.
Miscellaneous
Dedication of Medicaid and revenue savings to strengthening the financial solvency of the Federal Hospital Insurance Trust Fund
The third sentence of section 1817(a) of the Social Security Act (42 U.S.C. 1395(i)) is amended—
in paragraph (1), by striking
and
at the end;
in paragraph (2), by striking the period at
the end and inserting ; and
; and
by adding at the end the following:
the revenues made available as a result of the amendments to title XIX and the Internal Revenue Code of 1986 made by the Universal Health Care Choice and Access Act (as determined by the Secretary of the Treasury).
.
Health care choice for veterans
Beginning not later than 2 years after the date of the enactment of this Act, the Secretary of Veterans Affairs shall—
permit veterans, and survivors and dependents of veterans, who are eligible for health care and services under the laws administered by the Secretary to receive such care and services through such non-Department of Veterans Affairs providers and facilities as the Secretary shall approve for purposes of this section; and
pursuant to such procedures as the Secretary of Veteran Affairs shall prescribe for purposes of this section, make payments to such providers and facilities for the provision of such care and services to veterans, and such survivors and dependents, at such rates as the Secretary shall specify in such procedures and in such manner so that the Secretary ensures that the aggregate payments made by the Secretary to such providers and facilities do not exceed the aggregate amounts which the Secretary would have paid for such care and services if this section had not been enacted.
Health care choice for Indians
In general
Beginning not later than 2 years after the date of enactment of this Act, the Secretary of Health and Human Services shall—
permit Indians who are eligible for health care and services under a health care program operated or financed by the Indian Health Service or by an Indian Tribe, Tribal Organization, or Urban Indian Organization (and any such other individuals who are so eligible as the Secretary may specify), to receive such care and services through such non- Indian Health Service, Indian Tribe, Tribal Organization, or Urban Indian Organization providers and facilities as the Secretary shall approve for purposes of this section; and
pursuant to such procedures as the Secretary of Health and Human Services shall prescribe for purposes of this section, make payments to such providers and facilities for the provision of such care and services to Indians and individuals described in paragraph (1), at such rates as the Secretary shall specify in such procedures and in such manner so that the Secretary ensures that the aggregate payments made by the Secretary to such providers and facilities do not exceed the aggregate amounts which the Secretary would have paid for such care and services if this section had not been enacted.
Definitions
In this section, the terms Indian, Indian Health Program, Indian Tribe, Tribal Organization, and Urban Indian Organization have the meanings given those terms in section 4 of the Indian Health Care Improvement Act.