Utopia Talk / Politics / HC bill basics

habebe Member	Mon Mar 22 12:25:39 Well, here are the basics of the bill. http://onl...ml?mod=WSJ_hpp_MIDDLTopStories I would copy it over, but the characters tend to get fucked up and this is bullet based.
habebe Member	Mon Mar 22 12:38:17 gonna try to copy it see how the characters coome over. 2010 Coverage Subsidies begin for small businesses to provide coverage to employees. Insurance companies barred from denying coverage to children with pre-existing illness. Children permitted to stay on their parents' insurance policies until their 26th birthday.
habebe Member	Mon Mar 22 12:39:52 Hey thats not so bad, I'll do the rest 2011 Coverage Set up long-term care program under which people pay premiums into system for at least five years and become eligible for support payments if they need assistance in daily living. Taxes and fees Drug makers face annual fee of $2.5 billion (rises in subsequent years). ------------------------------- 2013 Taxes and fees New Medicare taxes on individuals earning more than $200,000 a year and couples filing jointly earning more than $250,000 a year. Tax on wages rises to 2.35% from 1.45%. New 3.8% tax on unearned income such as dividends and interest. Excise tax of 2.9% imposed on sale of medical devices. Cost control Medicare pilot program begins to test bundled payments for care, in a bid to pay for quality rather than quantity of services. -------------------------------- 2014 Coverage Create exchanges where people without employer coverage, as well as small businesses, can shop for health coverage. Insurance companies barred from denying coverage to anyone with pre-existing illness. Requirement begins for most people to have health insurance. Subsidies begin for lower and middle-income people. People at 133% of federal poverty level pay maximum of 3% of income for coverage. People at 400% of poverty level pay up to 9.5% of income. (Poverty level currently is about $22,000 for a family of four.) Medicaid, the federal-state program for the poor, expands to all Americans with income up to 133% of federal poverty level. Subsidies for small businesses to provide coverage increase. Businesses with 10 or fewer employees and average annual wages of less than $25,000 receive tax credit of up to 50% of employer's contribution. Tax credits phase out for larger businesses. Taxes and fees Employers with more than 50 employees that don't provide affordable coverage must pay a fine if employees receive tax credits to buy insurance. Fine is up to $3,000 per employee, excluding first 30 employees. Insurance industry must pay annual fee of $8 billion (rises in subsequent years). Cost control Independent Medicare board must begin to submit recommendations to curb Medicare spending, if costs are rising faster than inflation. ------------------------------- 2016 Taxes and fees Penalty for those who don't carry coverage rises to 2.5% of taxable income or $695, whichever is greater. ----------------------- 2017 Coverage Businesses with more than 100 employees can buy coverage on insurance exchanges, if state permits it. ------------------------ 2018 Taxes and fees Excise tax of 40% imposed on health plans valued at more than $10,200 for individual coverage and $27,500 for family coverage.
Hellfire Member	Mon Mar 22 12:48:06 http://www.reuters.com/article/idUSN1914020220100319 WITHIN THE FIRST YEAR OF ENACTMENT *Insurance companies will be barred from dropping people from coverage when they get sick. Lifetime coverage limits will be eliminated and annual limits are to be restricted. *Insurers will be barred from excluding children for coverage because of pre-existing conditions. *Young adults will be able to stay on their parents' health plans until the age of 26. Many health plans currently drop dependents from coverage when they turn 19 or finish college. *Uninsured adults with a pre-existing conditions will be able to obtain health coverage through a new program that will expire once new insurance exchanges begin operating in 2014. *A temporary reinsurance program is created to help companies maintain health coverage for early retirees between the ages of 55 and 64. This also expires in 2014. *Medicare drug beneficiaries who fall into the "doughnut hole" coverage gap will get a $250 rebate. The bill eventually closes that gap which currently begins after $2,700 is spent on drugs. Coverage starts again after $6,154 is spent. *A tax credit becomes available for some small businesses to help provide coverage for workers. *A 10 percent tax on indoor tanning services that use ultraviolet lamps goes into effect on July 1. WHAT HAPPENS IN 2011 *Medicare provides 10 percent bonus payments to primary care physicians and general surgeons. *Medicare beneficiaries will be able to get a free annual wellness visit and personalized prevention plan service. New health plans will be required to cover preventive services with little or no cost to patients. *A new program under the Medicaid plan for the poor goes into effect in October that allows states to offer home and community based care for the disabled that might otherwise require institutional care. *Payments to insurers offering Medicare Advantage services are frozen at 2010 levels. These payments are to be gradually reduced to bring them more in line with traditional Medicare. *Employers are required to disclose the value of health benefits on employees' W-2 tax forms. *An annual fee is imposed on pharmaceutical companies according to market share. The fee does not apply to companies with sales of $5 million or less. WHAT HAPPENS IN 2012 *Physician payment reforms are implemented in Medicare to enhance primary care services and encourage doctors to form "accountable care organizations" to improve quality and efficiency of care. *An incentive program is established in Medicare for acute care hospitals to improve quality outcomes. *The Centers for Medicare and Medicaid Services, which oversees the government programs, begin tracking hospital readmission rates and puts in place financial incentives to reduce preventable readmissions. WHAT HAPPENS IN 2013 *A national pilot program is established for Medicare on payment bundling to encourage doctors, hospitals and other care providers to better coordinate patient care. *The threshold for claiming medical expenses on itemized tax returns is raised to 10 percent from 7.5 percent of income. The threshold remains at 7.5 percent for the elderly through 2016. *The Medicare payroll tax is raised to 2.35 percent from 1.45 percent for individuals earning more than $200,000 and married couples with incomes over $250,000. The tax is imposed on some investment income for that income group. *A 2.9 percent excise tax in imposed on the sale of medical devices. Anything generally purchased at the retail level by the public is excluded from the tax. WHAT HAPPENS IN 2014 *State health insurance exchanges for small businesses and individuals open. *Most people will be required to obtain health insurance coverage or pay a fine if they don't. Healthcare tax credits become available to help people with incomes up to 400 percent of poverty purchase coverage on the exchange. *Health plans no longer can exclude people from coverage due to pre-existing conditions. *Employers with 50 or more workers who do not offer coverage face a fine of $2,000 for each employee if any worker receives subsidized insurance on the exchange. The first 30 employees aren't counted for the fine. *Health insurance companies begin paying a fee based on their market share. WHAT HAPPENS IN 2015 *Medicare creates a physician payment program aimed at rewarding quality of care rather than volume of services. WHAT HAPPENS IN 2018 *An excise tax on high cost employer-provided plans is imposed. The first $27,500 of a family plan and $10,200 for individual coverage is exempt from the tax. Higher levels are set for plans covering retirees and people in high risk professions. (Reporting by Donna Smith; Editing by David Alexander and Eric Beech)
habebe Member	Mon Mar 22 12:55:08 Hellfire has the right idea. I do not mean for this thread to be a debate, but since 90% of the new threads are involving this bill it would be nice to have an on-site reference of the gist.
The Powers That Be Member	Mon Mar 22 13:11:50 Thanks for this. My biggest question was what actually was enacted THIS YEAR compared to next year and beyond.
111111 New Member	Mon Mar 22 15:14:46 Rollover any line of text to comment and/or link to it. HR 3200 IHRHCommentsClose CommentsPermalink Union Calendar No. 168CommentsClose CommentsPermalink 111th CONGRESSCommentsClose CommentsPermalink 1st SessionCommentsClose CommentsPermalink H. R. 3200CommentsClose CommentsPermalink [Report No. 111-299, Parts I, II, and III]CommentsClose CommentsPermalink 18 To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.CommentsClose CommentsPermalink IN THE HOUSE OF REPRESENTATIVESCommentsClose CommentsPermalink July 14, 2009CommentsClose CommentsPermalink Mr. DINGELL (for himself, Mr. RANGEL, Mr. WAXMAN, Mr. GEORGE MILLER of California, Mr. STARK, Mr. PALLONE, and Mr. ANDREWS) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, Education and Labor, Oversight and Government Reform, and the Budget, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concernedCommentsClose CommentsPermalink October 14, 2009CommentsClose CommentsPermalink Additional sponsors: Mr. KILDEE, Mrs. MALONEY, and Mr. BACACommentsClose CommentsPermalink October 14, 2009CommentsClose CommentsPermalink Reported from the Committee on Energy and Commerce with an amendmentCommentsClose CommentsPermalink [Strike out all after the enacting clause (other than sections 321 and 322, title IV of division A, subtitle A of title I of division B, and title VIII of division B) and insert the part printed in italic]CommentsClose CommentsPermalink [For text of sections 321 and 322, title IV of division A, subtitle A of title I of division B, and title VIII of division B, see copy of bill as introduced on July 14, 2009]CommentsClose CommentsPermalink October 14, 2009CommentsClose CommentsPermalink Reported from the Committee on Ways and Means with an amendmentCommentsClose CommentsPermalink [Strike out all after the enacting clause (other than title VII of division B and division C) and insert the part printed in boldface roman]CommentsClose CommentsPermalink [For text of title VII of division B and for division C (and the original sections of the bill that fall within the jurisdiction of the Committee on Ways and Means), see copy of bill as introduced on July 14, 2009]CommentsClose CommentsPermalink October 14, 2009CommentsClose CommentsPermalink Reported from the Committee on Education and Labor with an amendmentCommentsClose CommentsPermalink [Strike out all after the enacting clause (other than sections 161 through 163, 322, and 323 and title IV of division A, division B, section 2002 and titles I through IV of division C, and subtitles A, B, C, and E of title V of division C) and insert the part printed in boldface italic]CommentsClose CommentsPermalink [For text of sections 161 through 163, 322, and 323 and title IV of division A, division B, section 2002 and titles I through IV of division C, and subtitles A, B, C, and E of title V of division C, see copy of bill as introduced on July 14, 2009]CommentsClose CommentsPermalink October 14, 2009CommentsClose CommentsPermalink Committees on Oversight and Government Reform and the Budget discharged; committed to the Committee of the Whole House on the State of the Union and ordered to be printedCommentsClose CommentsPermalink A BILLCommentsClose CommentsPermalink To provide affordable, quality health care for all Americans and reduce the growth in health care spending, and for other purposes.CommentsClose CommentsPermalink Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled, CommentsClose CommentsPermalink SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, AND SUBTITLES. (a) Short Title- This Act may be cited as the â??Americaâ??s Affordable Health Choices Act of 2009â??. CommentsClose CommentsPermalink (b) Table of Divisions, Titles, and Subtitles- This Act is divided into divisions, titles, and subtitles as follows: CommentsClose CommentsPermalink DIVISION A--AFFORDABLE HEALTH CARE CHOICES TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS CommentsClose CommentsPermalink Subtitle A--General Standards CommentsClose CommentsPermalink Subtitle B--Standards Guaranteeing Access to Affordable Coverage CommentsClose CommentsPermalink Subtitle C--Standards Guaranteeing Access to Essential Benefits CommentsClose CommentsPermalink Subtitle D--Additional Consumer Protections CommentsClose CommentsPermalink Subtitle E--Governance CommentsClose CommentsPermalink Subtitle F--Relation to Other Requirements; Miscellaneous CommentsClose CommentsPermalink Subtitle G--Early Investments CommentsClose CommentsPermalink TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS CommentsClose CommentsPermalink Subtitle A--Health Insurance Exchange CommentsClose CommentsPermalink Subtitle B--Public Health Insurance Option CommentsClose CommentsPermalink Subtitle C--Individual Affordability Credits CommentsClose CommentsPermalink Subtitle D--Health Insurance Cooperatives CommentsClose CommentsPermalink TITLE III--SHARED RESPONSIBILITY CommentsClose CommentsPermalink Subtitle A--Individual Responsibility Subtitle B--Employer Responsibility Subtitle A--Individual Responsibility CommentsClose CommentsPermalink Subtitle B--Employer Responsibility CommentsClose CommentsPermalink TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 CommentsClose CommentsPermalink Subtitle A--Shared Responsibility CommentsClose CommentsPermalink Subtitle B--Credit for Small Business Employee Health Coverage Expenses CommentsClose CommentsPermalink Subtitle C--Disclosures To Carry Out Health Insurance Exchange Subsidies CommentsClose CommentsPermalink Subtitle D--Other Revenue Provisions CommentsClose CommentsPermalink DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS TITLE I--IMPROVING HEALTH CARE VALUE CommentsClose CommentsPermalink Subtitle A--Provisions Related to Medicare Part A CommentsClose CommentsPermalink Subtitle B--Provisions Related to Part BMedicare Part B CommentsClose CommentsPermalink Subtitle C--Provisions Related to Medicare Parts A and B CommentsClose CommentsPermalink Subtitle D--Medicare Advantage Reforms CommentsClose CommentsPermalink Subtitle E--Improvements to Medicare Part D CommentsClose CommentsPermalink Subtitle F--Medicare Rural Access Protections CommentsClose CommentsPermalink TITLE II--MEDICARE BENEFICIARY IMPROVEMENTS CommentsClose CommentsPermalink Subtitle A--Improving and Simplifying Financial Assistance for Low Income Medicare Beneficiaries CommentsClose CommentsPermalink Subtitle B--Reducing Health Disparities CommentsClose CommentsPermalink Subtitle C--Miscellaneous Improvements CommentsClose CommentsPermalink TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND COORDINATED CARE CommentsClose CommentsPermalink TITLE IV--QUALITY CommentsClose CommentsPermalink Subtitle A--Comparative Effectiveness Research CommentsClose CommentsPermalink Subtitle B--Nursing Home Transparency Subtitle B--Nursing Home Transparency CommentsClose CommentsPermalink Subtitle C--Quality Measurements CommentsClose CommentsPermalink Subtitle D--Physician Payments Sunshine Provision CommentsClose CommentsPermalink Subtitle E--Public Reporting on Health Care-Associated Infections CommentsClose CommentsPermalink TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION CommentsClose CommentsPermalink TITLE VI--PROGRAM INTEGRITY CommentsClose CommentsPermalink Subtitle A--Increased Funding To Fight Waste, Fraud, and Abuse CommentsClose CommentsPermalink Subtitle B--Enhanced Penalties for Fraud and Abuse CommentsClose CommentsPermalink Subtitle C--Enhanced Program and Provider Protections CommentsClose CommentsPermalink Subtitle D--Access to Information Needed To Prevent Fraud, Waste, and Abuse CommentsClose CommentsPermalink TITLE VII--MEDICAID AND CHIP CommentsClose CommentsPermalink Subtitle A--Medicaid and Health Reform CommentsClose CommentsPermalink Subtitle B--Prevention Subtitle C--Access Subtitle D--Coverage Subtitle B--Prevention CommentsClose CommentsPermalink Subtitle C--Access CommentsClose CommentsPermalink Subtitle D--Coverage CommentsClose CommentsPermalink Subtitle E--Financing CommentsClose CommentsPermalink Subtitle F--Waste, Fraud, and Abuse CommentsClose CommentsPermalink Subtitle G--Puerto Rico and the Territoriesayments to the Territories CommentsClose CommentsPermalink Subtitle H--Miscellaneous CommentsClose CommentsPermalink TITLE VIII--REVENUE-RELATED PROVISIONS CommentsClose CommentsPermalink TITLE IX--MISCELLANEOUS PROVISIONS CommentsClose CommentsPermalink DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT TITLE I--COMMUNITY HEALTH CENTERS CommentsClose CommentsPermalink TITLE II--WORKFORCE CommentsClose CommentsPermalink Subtitle A--Primary Care Workforce CommentsClose CommentsPermalink Subtitle B--Nursing Workforce CommentsClose CommentsPermalink Subtitle C--Public Health Workforce CommentsClose CommentsPermalink Subtitle D--Adapting Workforce to Evolving Health System Needs CommentsClose CommentsPermalink TITLE III--PREVENTION AND WELLNESS CommentsClose CommentsPermalink TITLE IV--QUALITY AND SURVEILLANCE CommentsClose CommentsPermalink TITLE V--OTHER PROVISIONS CommentsClose CommentsPermalink Subtitle A--Drug Discount for Rural and Other Hospitals CommentsClose CommentsPermalink Subtitle B--School-Based Health Clinics Subtitle C--National Medical Device Registry Subtitle D--Grants for Comprehensive Programs To Provide Education to Nurses and Create a Pipeline to Nursing Subtitle B--Programs CommentsClose CommentsPermalink Subtitle C--Food and Drug Administration CommentsClose CommentsPermalink Subtitle D--Community Living Assistance Services and Supports CommentsClose CommentsPermalink Subtitle E--States Failing To Adhere to Certain Employment ObligationMiscellaneous CommentsClose CommentsPermalink DIVISION A--AFFORDABLE HEALTH CARE CHOICES CommentsClose CommentsPermalink SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS. (a) Purpose- CommentsClose CommentsPermalink (1) IN GENERAL- The purpose of this division is to provide affordable, quality health care for all Americans and reduce the growth in health care spending. CommentsClose CommentsPermalink (2) BUILDING ON CURRENT SYSTEM- This division achieves this purpose by building on what works in todayâ??s health care system, while repairing the aspects that are broken. CommentsClose CommentsPermalink (3) INSURANCE REFORMS- This division-- CommentsClose CommentsPermalink (A) enacts strong insurance market reforms; CommentsClose CommentsPermalink (B) creates a new Health Insurance Exchange, with a public health insurance option alongside private plans and cooperatives under subtitle D of title II; CommentsClose CommentsPermalink (C) includes sliding scale affordability credits; and CommentsClose CommentsPermalink (D) initiates shared responsibility among workers, employers, and the government; CommentsClose CommentsPermalink so that all Americans have coverage of essential health benefits. CommentsClose CommentsPermalink (4) HEALTH DELIVERY REFORM- This division institutes health delivery system reforms both to increase quality and to reduce growth in health spending so that health care becomes more affordable for businesses, families, and government. CommentsClose CommentsPermalink (b) Table of Contents of Division- The table of contents of this division is as follows: CommentsClose CommentsPermalink Sec. 100. Purpose; table of contents of division; general definitions. CommentsClose CommentsPermalink TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS Subtitle A--General Standards Sec. 101. Requirements reforming health insurance marketplace. CommentsClose CommentsPermalink Sec. 102. Protecting the choice to keep current coverage. CommentsClose CommentsPermalink Subtitle B--Standards Guaranteeing Access to Affordable Coverage Sec. 111. Prohibiting pre-existing condition exclusions. CommentsClose CommentsPermalink Sec. 112. Guaranteed issue and renewal for insured plans. CommentsClose CommentsPermalink Sec. 113. Insurance rating rules. CommentsClose CommentsPermalink Sec. 114. Nondiscrimination in benefits; parity in mental health and substance abuse disorder benefits. CommentsClose CommentsPermalink Sec. 115. Ensuring adequacy of provider networks. CommentsClose CommentsPermalink Sec. 116. Ensuring value and lower premiums. CommentsClose CommentsPermalink Subtitle C--Standards Guaranteeing Access to Essential Benefits Sec. 121. Coverage of essential benefits package. CommentsClose CommentsPermalink Sec. 122. Essential benefits package defined. CommentsClose CommentsPermalink Sec. 123. Health Benefits Advisory Committee. CommentsClose CommentsPermalink Sec. 124. Process for adoption of recommendations; adoption of benefit standards. CommentsClose CommentsPermalink Sec. 125. Prohibition of discrimination in health care services based on religious or spiritual content. CommentsClose CommentsPermalink Subtitle D--Additional Consumer Protections Sec. 131. Requiring fair marketing practices by health insurers. CommentsClose CommentsPermalink Sec. 132. Requiring fair grievance and appeals mechanisms. CommentsClose CommentsPermalink Sec. 133. Requiring information transparency and plan disclosure. CommentsClose CommentsPermalink Sec. 134. Application to qualified health benefits plans not offered through the Health Insurance Exchange. CommentsClose CommentsPermalink Sec. 135. Timely payment of claims. CommentsClose CommentsPermalink Sec. 136. Standardized rules for coordination and subrogation of benefits. CommentsClose CommentsPermalink Sec. 137. Application of administrative simplification. CommentsClose CommentsPermalink Sec. 138. Information on end-of-life planning. CommentsClose CommentsPermalink Sec. 139. Utilization review activities. CommentsClose CommentsPermalink Sec. 139A. Internal appeals procedures. CommentsClose CommentsPermalink Sec. 139B. External appeals procedures. CommentsClose CommentsPermalink Subtitle E--Governance Sec. 141. Health Choices Administration; Health Choices Commissioner. CommentsClose CommentsPermalink Sec. 142. Duties and authority of Commissioner. CommentsClose CommentsPermalink Sec. 143. Consultation and coordination. CommentsClose CommentsPermalink Sec. 144. Health Insurance Ombudsman. CommentsClose CommentsPermalink Subtitle F--Relation to Other Requirements; Miscellaneous Sec. 151. Relation to other requirements. CommentsClose CommentsPermalink Sec. 152. Prohibiting discrimination in health care. CommentsClose CommentsPermalink Sec. 153. Whistleblower protection. CommentsClose CommentsPermalink Sec. 154. Construction regarding collective bargaining. CommentsClose CommentsPermalink Sec. 155. Severability. CommentsClose CommentsPermalink Sec. 156. Application of State and Federal laws regarding abortion. CommentsClose CommentsPermalink 14 Sec. 157. Non-discrimination on abortion and respect for rights of conscience. CommentsClose CommentsPermalink Subtitle G--Early Investments Sec. 161. Ensuring value and lower premiums. CommentsClose CommentsPermalink Sec. 162. Ending health insurance rescission abuse. CommentsClose CommentsPermalink Sec. 163. Ending health insurance denials and delays of necessary treatment for children with deformities. CommentsClose CommentsPermalink Sec. 164. Administrative simplification. CommentsClose CommentsPermalink Sec. 1645. Expansion of electronic transactions in medicare. CommentsClose CommentsPermalink Sec. 166. Reinsurance program for retirees. CommentsClose CommentsPermalink Sec. 167. Limitations on preexisting condition exclusions in group health plans and health insurance coverage in the group and individual markets in advance of applicability of new prohibition of preexisting condition exclusions. CommentsClose CommentsPermalink TITLE II--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS Subtitle A--Health Insurance Exchange Sec. 201. Establishment of Health Insurance Exchange; outline of duties; definitions. CommentsClose CommentsPermalink Sec. 202. Exchange-eligible individuals and employers. CommentsClose CommentsPermalink Sec. 203. Benefits package levels. CommentsClose CommentsPermalink Sec. 204. Contracts for the offering of Exchange-participating health benefits plans. CommentsClose CommentsPermalink Sec. 205. Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plans. CommentsClose CommentsPermalink Sec. 206. Other functions. CommentsClose CommentsPermalink Sec. 207. Health Insurance Exchange Trust Fund. CommentsClose CommentsPermalink Sec. 208. Optional operation of State-based health insurance exchanges. CommentsClose CommentsPermalink Sec. 209. Limitation on premium increases under Exchange-participating health benefits plans. CommentsClose CommentsPermalink Subtitle B--Public Health Insurance Option Sec. 221. Establishment and administration of a public health insurance option as an Exchange-qualified health benefits plan. CommentsClose CommentsPermalink Sec. 222. Premiums and financing. CommentsClose CommentsPermalink Sec. 223. PNegotiated payment rates for items and services. CommentsClose CommentsPermalink Sec. 224. Modernized payment initiatives and delivery system reform. CommentsClose CommentsPermalink Sec. 225. Provider participation. CommentsClose CommentsPermalink Sec. 226. Application of fraud and abuse provisions. CommentsClose CommentsPermalink Sec. 227. Application of HIPAA insurance requirements. CommentsClose CommentsPermalink Sec. 228. Application of health information privacy, security, and electronic transaction requirements. CommentsClose CommentsPermalink Sec. 229. Enrollment in public health insurance option is voluntary. CommentsClose CommentsPermalink Subtitle C--Individual Affordability Credits Sec. 241. Availability through Health Insurance Exchange. CommentsClose CommentsPermalink Sec. 242. Affordable credit eligible individual. CommentsClose CommentsPermalink Sec. 243. Affordable premium credit. CommentsClose CommentsPermalink Sec. 244. Affordability cost-sharing credit. CommentsClose CommentsPermalink Sec. 245. Income determinations. CommentsClose CommentsPermalink 11 Sec. 246. No Federal payment for undocumented aliens. CommentsClose CommentsPermalink Subtitle D--Health Insurance Cooperatives Sec. 251. Establishment. CommentsClose CommentsPermalink Sec. 252. Start-up and solvency grants and loans. CommentsClose CommentsPermalink Sec. 253. Definitions. CommentsClose CommentsPermalink TITLE III--SHARED RESPONSIBILITY Subtitle A--Individual Responsibility Sec. 301. Individual responsibility. CommentsClose CommentsPermalink Subtitle B--Employer Responsibility Part 1--Health Coverage Participation Requirements Sec. 311. Health coverage participation requirements. CommentsClose CommentsPermalink Sec. 312. Employer responsibility to contribute towards employee and dependent coverage. CommentsClose CommentsPermalink Sec. 313. Employer contributions in lieu of coverage. CommentsClose CommentsPermalink Sec. 314. Authority related to improper steering. CommentsClose CommentsPermalink Part 2--Satisfaction of Health Coverage Participation Requirements Sec. 321. Satisfaction of health coverage participation requirements under the Employee Retirement Income Security Act of 1974. CommentsClose CommentsPermalink Sec. 322. Satisfaction of health coverage participation requirements under the Internal Revenue Code of 1986. CommentsClose CommentsPermalink Sec. 323. Satisfaction of health coverage participation requirements under the Public Health Service Act. CommentsClose CommentsPermalink Sec. 324. Additional rules relating to health coverage participation requirements. CommentsClose CommentsPermalink TITLE IV--AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 Subtitle A--Shared Responsibility Part 1--Individual Responsibility
111111 Member	Mon Mar 22 15:15:08 Sec. 401. Tax on individuals without acceptable health care coverage. CommentsClose CommentsPermalink Part 2--Employer Responsibility Sec. 411. Election to satisfy health coverage participation requirements. CommentsClose CommentsPermalink Sec. 412. Responsibilities of nonelecting employers. CommentsClose CommentsPermalink Subtitle B--Credit for Small Business Employee Health Coverage Expenses Sec. 421. Credit for small business employee health coverage expenses. CommentsClose CommentsPermalink Subtitle C--Disclosures To Carry Out Health Insurance Exchange Subsidies Sec. 431. Disclosures to carry out health insurance exchange subsidies. CommentsClose CommentsPermalink Subtitle D--Other Revenue Provisions Part 1--General Provisions Sec. 441. Surcharge on high income individuals. CommentsClose CommentsPermalink Sec. 442. Delay in application of worldwide allocation of interest. CommentsClose CommentsPermalink Part 2--Prevention of Tax Avoidance Sec. 451. Limitation on treaty benefits for certain deductible payments. CommentsClose CommentsPermalink Sec. 452. Codification of economic substance doctrine. CommentsClose CommentsPermalink Sec. 453. Penalties for underpayments. CommentsClose CommentsPermalink (c) General Definitions- Except as otherwise provided, in this division: CommentsClose CommentsPermalink (1) ACCEPTABLE COVERAGE- The term â??acceptable coverageâ?? has the meaning given such term in section 202(d)(2). CommentsClose CommentsPermalink (2) BASIC PLAN- The term â??basic planâ?? has the meaning given such term in section 203(c). CommentsClose CommentsPermalink (3) COMMISSIONER- The term â??Commissionerâ?? means the Health Choices Commissioner established under section 141. CommentsClose CommentsPermalink (4) COST-SHARING- The term â??cost-sharingâ?? includes deductibles, coinsurance, copayments, and similar charges but does not include premiums or any network payment differential for covered services or spending for non-covered services. CommentsClose CommentsPermalink (5) DEPENDENT- The term â??dependentâ?? has the meaning given such term by the Commissioner and includes a spouse. CommentsClose CommentsPermalink (6) EMPLOYMENT-BASED HEALTH PLAN- The term â??employment-based health planâ??-- CommentsClose CommentsPermalink (A) means a group health plan (as defined in section 733(a)(1) of the Employee Retirement Income Security Act of 1974); and CommentsClose CommentsPermalink (B) includes such a plan that is the following: CommentsClose CommentsPermalink (i) FEDERAL, STATE, AND TRIBAL GOVERNMENTAL PLANS- A governmental plan (as defined in section 3(32) of the Employee Retirement Income Security Act of 1974), including a health benefits plan offered under chapter 89 of title 5, United States Code. CommentsClose CommentsPermalink (ii) CHURCH PLANS- A church plan (as defined in section 3(33) of the Employee Retirement Income Security Act of 1974). CommentsClose CommentsPermalink (7) ENHANCED PLAN- The term â??enhanced planâ?? has the meaning given such term in section 203(c). CommentsClose CommentsPermalink (8) ESSENTIAL BENEFITS PACKAGE- The term â??essential benefits packageâ?? is defined in section 122(a). CommentsClose CommentsPermalink (9) FAMILY- The term â??familyâ?? means an individual and includes the individualâ??s dependents. CommentsClose CommentsPermalink (10) FEDERAL POVERTY LEVEL; FPL- The terms â??Federal poverty levelâ?? and â??FPLâ?? have the meaning given the term â??poverty lineâ?? in section 673(2) of the Community Services Block Grant Act (42 U.S.C. 9902(2)), including any revision required by such section. CommentsClose CommentsPermalink (11) HEALTH BENEFITS PLAN- The terms â??health benefits planâ?? means health insurance coverage and an employment-based health plan and includes the public health insurance option.(12) HEALTH INSURANCE COVERAGE; HEALTH INSURANCE and cooperatives under subtitle D of title II. CommentsClose CommentsPermalink (12) HEALTH INSURANCE COVERAGE; HEALTH INSURANCE ISSUER- The terms â??health insurance coverageâ?? and â??health insurance issuerâ?? have the meanings given such terms in section 2791 of the Public Health Service Act. CommentsClose CommentsPermalink (13) HEALTH INSURANCE EXCHANGE- The term â??Health Insurance Exchangeâ?? means the Health Insurance Exchange established under section 201. CommentsClose CommentsPermalink (14) MEDICAID- The term â??Medicaidâ?? means a State plan under title XIX of the Social Security Act (whether or not the plan is operating under a waiver under section 1115 of such Act). CommentsClose CommentsPermalink (15) MEDICARE- The term â??Medicareâ?? means the health insurance programs under title XVIII of the Social Security Act. CommentsClose CommentsPermalink (16) PLAN SPONSOR- The term â??plan sponsorâ?? has the meaning given such term in section 3(16)(B) of the Employee Retirement Income Security Act of 1974. CommentsClose CommentsPermalink (17) PLAN YEAR- The term â??plan yearâ?? means-- CommentsClose CommentsPermalink (A) with respect to an employment-based health plan, a plan year as specified under such plan; or CommentsClose CommentsPermalink (B) with respect to a health benefits plan other than an employment-based health plan, a 12-month period as specified by the Commissioner. CommentsClose CommentsPermalink (18) PREMIUM PLAN; PREMIUM-PLUS PLAN- The terms â??premium planâ?? and â??premium-plus planâ?? have the meanings given such terms in section 203(c). CommentsClose CommentsPermalink (19) QHBP OFFERING ENTITY- The terms â??QHBP offering entityâ?? means, with respect to a health benefits plan that is-- CommentsClose CommentsPermalink (A) a group health plan (as defined, subject to subsection (d), in section 733(a)(1) of the Employee Retirement Income Security Act of 1974), the plan sponsor in relation to such group health plan, except that, in the case of a plan maintained jointly by 1 or more employers and 1 or more employee organizations and with respect to which an employer is the primary source of financing, such term means such employer; CommentsClose CommentsPermalink (B) health insurance coverage, the health insurance issuer offering the coverage;(C) the public health, including a cooperative under subtitle D of title II; CommentsClose CommentsPermalink (C) the public health insurance option, the Secretary of Health and Human Services; CommentsClose CommentsPermalink (D) a non-Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the State or political subdivision of a State (or agency or instrumentality of such State or subdivision) which establishes or maintains such plan; or CommentsClose CommentsPermalink (E) a Federal governmental plan (as defined in section 2791(d) of the Public Health Service Act), the appropriate Federal official. CommentsClose CommentsPermalink (20) QUALIFIED HEALTH BENEFITS PLAN- The term â??qualified health benefits planâ?? means a health benefits plan that meets the requirements for such a plan under title I and includes the public health insurance option.(21) PUBLIC HEALTH INSURANCE and cooperatives under subtitle D of title II. CommentsClose CommentsPermalink (21) PUBLIC HEALTH INSURANCE OPTION- The term â??public health insurance optionâ?? means the public health insurance option as provided under subtitle B of title II. CommentsClose CommentsPermalink (22) SERVICE AREA; PREMIUM RATING AREA- The terms â??service areaâ?? and â??premium rating areaâ?? mean with respect to health insurance coverage-- CommentsClose CommentsPermalink (A) offered other than through the Health Insurance Exchange, such an area as established by the QHBP offering entity of such coverage in accordance with applicable State law; and CommentsClose CommentsPermalink (B) offered through the Health Insurance Exchange, such an area as established by such entity in accordance with applicable State law and applicable rules of the Commissioner for Exchange-participating health benefits plans. CommentsClose CommentsPermalink (23) STATE- The term â??Stateâ?? means the 50 States and the District of Columbia. CommentsClose CommentsPermalink (24) STATE MEDICAID AGENCY- The term â??State Medicaid agencyâ?? means, with respect to a Medicaid plan, the single State agency responsible for administering such plan under title XIX of the Social Security Act. CommentsClose CommentsPermalink (25) Y1, Y2, ETC.- The terms â??Y1â?? , â??Y2â??, â??Y3â??, â??Y4â??, â??Y5â??, and similar subsequently numbered terms, mean 2013 and subsequent years, respectively. CommentsClose CommentsPermalink TITLE I--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS CommentsClose CommentsPermalink Subtitle A--General Standards CommentsClose CommentsPermalink SEC. 101. REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE. (a) Purpose- The purpose of this title is to establish standards to ensure that new health insurance coverage and employment-based health plans that are offered meet standards guaranteeing access to affordable coverage, essential benefits, and other consumer protections. CommentsClose CommentsPermalink (b) Requirements for Qualified Health Benefits Plans- On or after the first day of Y1, a health benefits plan shall not be a qualified health benefits plan under this division unless the plan meets the applicable requirements of the following subtitles for the type of plan and plan year involved: CommentsClose CommentsPermalink (1) Subtitle B (relating to affordable coverage). CommentsClose CommentsPermalink (2) Subtitle C (relating to essential benefits). CommentsClose CommentsPermalink (3) Subtitle D (relating to consumer protection). CommentsClose CommentsPermalink (c) Terminology- In this division: CommentsClose CommentsPermalink (1) ENROLLMENT IN EMPLOYMENT-BASED HEALTH PLANS- An individual shall be treated as being â??enrolledâ?? in an employment-based health plan if the individual is a participant or beneficiary (as such terms are defined in section 3(7) and 3(8), respectively, of the Employee Retirement Income Security Act of 1974) in such plan. CommentsClose CommentsPermalink (2) INDIVIDUAL AND GROUP HEALTH INSURANCE COVERAGE- The terms â??individual health insurance coverageâ?? and â??group health insurance coverageâ?? mean health insurance coverage offered in the individual market or large or small group market, respectively, as defined in section 2791 of the Public Health Service Act. CommentsClose CommentsPermalink SEC. 102. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE. (a) Grandfathered Health Insurance Coverage Defined- Subject to the succeeding provisions of this section, for purposes of establishing acceptable coverage under this division, the term â??grandfathered health insurance coverageâ?? means individual health insurance coverage that is offered and in force and effect before the first day of Y1 if the following conditions are met: CommentsClose CommentsPermalink (1) LIMITATION ON NEW ENROLLMENT- CommentsClose CommentsPermalink (A) IN GENERAL- Except as provided in this paragraph, the individual health insurance issuer offering such coverage does not enroll any individual in such coverage if the first effective date of coverage is on or after the first day of Y1. CommentsClose CommentsPermalink (B) DEPENDENT COVERAGE PERMITTED- Subparagraph (A) shall not affect the subsequent enrollment of a dependent of an individual who is covered as of such first day. CommentsClose CommentsPermalink (2) LIMITATION ON CHANGES IN TERMS OR CONDITIONS- Subject to paragraph (3) and except as required by law, the issuer does not change any of its terms or conditions, including benefits and cost-sharing, from those in effect as of the day before the first day of Y1. CommentsClose CommentsPermalink (3) RESTRICTIONS ON PREMIUM INCREASES- The issuer cannot vary the percentage increase in the premium for a risk group of enrollees in specific grandfathered health insurance coverage without changing the premium for all enrollees in the same risk group at the same rate, as specified by the Commissioner. CommentsClose CommentsPermalink (b) Grace Period for Current Employment-based Health Plans- CommentsClose CommentsPermalink (1) GRACE PERIOD- CommentsClose CommentsPermalink (A) IN GENERAL- The Commissioner shall establish a grace period whereby, for plan years beginning after the end of the 5-year period beginning with Y1, an employment-based health plan in operation as of the day before the first day of Y1 must meet the same requirements as apply to a qualified health benefits plan under section 101, including the essential benefit package requirement under section 121. CommentsClose CommentsPermalink (B) EXCEPTION FOR LIMITED BENEFITS PLANS- Subparagraph (A) shall not apply to an employment-based health plan in which the coverage consists only of one or more of the following: CommentsClose CommentsPermalink (i) Any coverage described in section 3001(a)(1)(B)(ii)(IV) of division B of the American Recovery and Reinvestment Act of 2009 (Public LawL 111-5). CommentsClose CommentsPermalink (ii) Excepted benefits (as defined in section 733(c) of the Employee Retirement Income Security Act of 1974), including coverage under a specified disease or illness policy described in paragraph (3)(A) of such section. CommentsClose CommentsPermalink (iii) Such other limited benefits as the Commissioner may specify. CommentsClose CommentsPermalink In no case shall an employment-based health plan in which the coverage consists only of one or more of the coverage or benefits described in clauses (i) through (iii) be treated as acceptable coverage under this division CommentsClose CommentsPermalink (2) TRANSITIONAL TREATMENT AS ACCEPTABLE COVERAGE- During the grace period specified in paragraph (1)(A), an employment-based health plan that is described in such paragraph shall be treated as acceptable coverage under this division. CommentsClose CommentsPermalink (c) Limitation on Individual Health Insurance Coverage- CommentsClose CommentsPermalink (1) IN GENERAL- Individual health insurance coverage that is not grandfathered health insurance coverage under subsection (a) may only be offered on or after the first day of Y1 as an Exchange-participating health benefits plan. CommentsClose CommentsPermalink (2) SEPARATE, EXCEPTED COVERAGE PERMITTED- Excepted benefits (as defined in section 2791(c) of the Public Health Service Act) are not included within the definition of health insurance coverage. Nothing in paragraph (1) shall prevent the offering, other than through the Health Insurance Exchange, of excepted benefits so long as it is offered and priced separately from health insurance coverage. CommentsClose CommentsPermalink (3) STAND-ALONE DENTAL AND VISION COVERAGE PERMITTED- Nothing in this division shall be construed-- CommentsClose CommentsPermalink (A) to prevent the offering of a stand-alone plans that offer coverage of excepted benefits described in section 2791(c)(2)(A) of the Public Health Service Act (relating to limited scope dental or vision benefits)for individuals and families from a State licensed dental and vision carrier; or CommentsClose CommentsPermalink (B) as applying requirements for a qualified health benefits plan to such stand-alone plans that is offered and priced separately from a qualified health benefits plan. CommentsClose CommentsPermalink Subtitle B--Standards Guaranteeing Access to Affordable Coverage CommentsClose CommentsPermalink SEC. 111. PROHIBITING PRE-EXISTING CONDITION EXCLUSIONS. A qualified health benefits plan may not impose any pre-existing condition exclusion (as defined in section 2701(b)(1)(A) of the Public Health Service Act) or otherwise impose any limit or condition on the coverage under the plan with respect to an individual or dependent based on any health status-related factors (as defined in section 2791(d)(9) of the Public Health Service Act) in relation to the individual or dependent. CommentsClose CommentsPermalink SEC. 112. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS. The requirements of sections 2711 (other than subsections (c) and (e)) and 2712 (other than paragraphs (3), and (6) of subsection (b) and subsection (e)) of the Public Health Service Act, relating to guaranteed availability and renewability of health insurance coverage, shall apply to individuals and employers in all individual and group health insurance coverage, whether offered to individuals or employers through the Health Insurance Exchange, through any employment-based health plan, or otherwise, and shall apply to the public health insurance option, in the same manner as such sections apply to employers and health insurance coverage offered in the small group market, except that such section 2712(b)(1) shall apply only if, before nonrenewal or discontinuation of coverage, the issuer has provided the enrollee with notice of non-payment of premiums and there is a grace period during which the enrollees has an opportunity to correct such nonpayment. Rescissions of such coverage shall be prohibited except in cases of fraud as defined in sections 2712(b)(2) of such Act. CommentsClose CommentsPermalink SEC. 113. INSURANCE RATING RULES. (a) In General- The premium rate charged for an insured qualified health benefits plan and for coverage under the public health insurance option may not vary except as follows: CommentsClose CommentsPermalink (1) LIMITED AGE VARIATION PERMITTED- By age (within such age categories as the Commissioner shall specify) so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of 2 to 1. CommentsClose CommentsPermalink (2) BY AREA- By premium rating area (as permitted by State insurance regulators or, in the case of Exchange-participating health benefits plans, as specified by the Commissioner in consultation with such regulators). CommentsClose CommentsPermalink (3) BY FAMILY ENROLLMENT- By family enrollment (such as variations within categories and compositions of families) so long as the ratio of the premium for family enrollment (or enrollments) to the premium for individual enrollment is uniform, as specified under State law and consistent with rules of the Commissioner. CommentsClose CommentsPermalink (b) Actuarial Value of Optional Service Coverage- CommentsClose CommentsPermalink (1) IN GENERAL- The Commissioner shall estimate the basic per enrollee, per month cost, determined on an average actuarial basis, for including coverage under a basic plan of the services described in section 122(d)(4)(A). CommentsClose CommentsPermalink (2) CONSIDERATIONS- In making such estimate the Commissioner-- CommentsClose CommentsPermalink (A) may take into account the impact on overall costs of the inclusion of such coverage, but may not take into account any cost reduction estimated to result from such services, including prenatal care, delivery, or postnatal care; CommentsClose CommentsPermalink (B) shall estimate such costs as if such coverage were included for the entire population covered; and CommentsClose CommentsPermalink (C) may not estimate such a cost at less than $1 per enrollee, per month. CommentsClose CommentsPermalink (c) Study and Reports- CommentsClose CommentsPermalink (1) STUDY- The Commissioner, in coordination with the Secretary of Health and Human Services and the Secretary of Labor, shall conduct a study of the large group insured and self-insured employer health care markets. Such study shall examine the following: CommentsClose CommentsPermalink (A) The types of employers by key characteristics, including size, that purchase insured products versus those that self-insure. CommentsClose CommentsPermalink (B) The similarities and differences between typical insured and self-insured health plans. CommentsClose CommentsPermalink (C) The financial solvency and capital reserve levels of employers that self-insure by employer size. CommentsClose CommentsPermalink (D) The risk of self-insured employers not being able to pay obligations or otherwise becoming financially insolvent. CommentsClose CommentsPermalink (E) The extent to which rating rules are likely to cause adverse selection in the large group market or to encourage small and mid size employers to self-insure CommentsClose CommentsPermalink (2) REPORTS- Not later than 18 months after the date of the enactment of this Act, the Commissioner shall submit to Congress and the applicable agencies a report on the study conducted under paragraph (1). Such report shall include any recommendations the Commissioner deems appropriate to ensure that the law does not provide incentives for small and mid-size employers to self-insure or create adverse selection in the risk pools of large group insurers and self-insured employers. Not later than 18 months after the first day of Y1, the Commissioner shall submit to Congress and the applicable agencies an updated report on such study, including updates on such recommendations. CommentsClose CommentsPermalink SEC. 114. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND SUBSTANCE ABUSE DISORDER BENEFITS. (a) Nondiscrimination in Benefits- A qualified health benefits plan (including the public health insurance option) shall comply with standards established by the Commissioner to prohibit discrimination in health benefits or benefit structures for qualifying health benefits plans, building from sections 702 of Employee Retirement Income Security Act of 1974, 2702 of the Public Health Service Act, and section 9802 of the Internal Revenue Code of 1986. CommentsClose CommentsPermalink (b) Parity in Mental Health and Substance Abuse Disorder Benefits- To the extent such provisions are not superceded by or inconsistent with subtitle C, the provisions of section 2705 (other than subsections (a)(1), (a)(2), and (c)) of section 2705 of the Public Health Service Act shall apply to a qualified health benefits plan, regardless of whether it is offered in the individual or group market, in the same manner as such provisions apply to health insurance coverage offered in the large group market. CommentsClose CommentsPermalink SEC. 115. ENSURING ADEQUACY OF PROVIDER NETWORKS. (a) In General- A qualified health benefits plan that(including the public health insurance option) that uses a provider network for items and services shall meet such standards respecting provider networks as the Commissioner may establish to assure the adequacy of such networks in ensuring enrollee access to such items and services and transparency in the cost-sharing differentials between in-network coverage and out-of-network coverage. CommentsClose CommentsPermalink (b) Provider Network Defined- In this division, the term â??provider networkâ?? means the providers with respect to which covered benefits, treatments, and services are available under a health benefits plan. CommentsClose CommentsPermalink SEC. 116. ENSURING VALUE AND LOWER PREMIUMS. (a) In General- A qualified health benefits plan shall meet a medical loss ratio as defined by the Commissioner. For any plan year in which the qualified health benefits plan does not meet such medical loss ratio, QHBP offering entity shall provide in a manner specified by the Commissioner for rebates to enrollees of payment sufficient to meet such loss ratio. CommentsClose CommentsPermalink (b) Building on Interim Rules- In implementing subsection (a), the Commissioner shall build on the definition and methodology developed by the Secretary of Health and Human Services under the amendments made by section 161 for determining how to calculate the medical loss ratio. Such methodology shall be set at the highest level medical loss ratio possible that is designed to ensure adequate participation by QHBP offering entities, competition in the health insurance market in and out of the Health Insurance Exchange, and value for consumers so that their premiums are used for services. CommentsClose CommentsPermalink Subtitle C--Standards Guaranteeing Access to Essential Benefits CommentsClose CommentsPermalink SEC. 121. COVERAGE OF ESSENTIAL BENEFITS PACKAGE. (a) In General- A qualified health benefits plan shall provide coverage that at least meets the benefit standards adopted under section 124 for the essential benefits package described in section 122 for the plan year involved. CommentsClose CommentsPermalink (b) Choice of Coverage- CommentsClose CommentsPermalink (1) NON-EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of a qualified health benefits plan that is not an Exchange-participating health benefits plan, such plan may offer such coverage in addition to the essential benefits package as the QHBP offering entity may specify. CommentsClose CommentsPermalink (2) EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS- In the case of an Exchange-participating health benefits plan, such plan is required under section 203 to provide specified levels of benefits and, in the case of a plan offering a premium-plus level of benefits, provide additional benefits. CommentsClose CommentsPermalink (3) CONTINUATION OF OFFERING OF SEPARATE EXCEPTED BENEFITS COVERAGE- Nothing in this division shall be construed as affecting the offering of health benefits in the form of excepted benefits (described in section 102(b)(1)(B)(ii)) if such benefits are offered under a separate policy, contract, or certificate of insurance. CommentsClose CommentsPermalink (c) No Restrictions on Coverage Unrelated to Clinical Appropriateness- A qualified health benefits plan may not impose any restriction (other than cost-sharing) unrelated to clinical appropriateness on the coverage of the health care items and services. CommentsClose CommentsPermalink SEC. 122. ESSENTIAL BENEFITS PACKAGE DEFINED. (a) In General- In this division, the term â??essential benefits packageâ?? means health benefits coverage, consistent with standards adopted under section 124 to ensure the provision of quality health care and financial security, that-- CommentsClose CommentsPermalink (1) provides payment for the items and services described in subsection (b) in accordance with generally accepted standards of medical or other appropriate clinical or professional practice; CommentsClose CommentsPermalink (2) limits cost-sharing for such covered health care items and services in accordance with such benefit standards, consistent with subsection (c); CommentsClose CommentsPermalink (3) does not impose any annual or lifetime limit on the coverage of covered health care items and services; CommentsClose CommentsPermalink (4) complies with section 115(a) (relating to network adequacy); and CommentsClose CommentsPermalink (5) is equivalent, as certified by Office of the Actuary of the Centers for Medicare & Medicaid Services, to the average prevailing employer-sponsored coverage. CommentsClose CommentsPermalink (b) Minimum Services Tto Be Covered- TSubject to subsection (d), the items and services described in this subsection are the following: CommentsClose CommentsPermalink (1) Hospitalization. CommentsClose CommentsPermalink (2) Outpatient hospital and outpatient clinic services, including emergency department services. CommentsClose CommentsPermalink (3) Professional services of physicians and other health professionals. CommentsClose CommentsPermalink (4) Such services, equipment, and supplies incident to the services of a physicianâ??s or a health professionalâ??s delivery of care in institutional settings, physician offices, patientsâ?? homes or place of residence, or other settings, as appropriate. CommentsClose CommentsPermalink (5) Prescription drugs. CommentsClose CommentsPermalink (6) Rehabilitative and habilitative services. CommentsClose CommentsPermalink (7) Mental health and substance use disorder services, including behavioral health treatments. CommentsClose CommentsPermalink (8) Preventive services, including those services recommended with a grade of A or B by the Task Force on Clinical Preventive Services and those vaccines recommended for use by the Director of the Centers for Disease Control and Prevention. CommentsClose CommentsPermalink (9) Maternity care. CommentsClose CommentsPermalink (10) Well baby and well child care; treatment of a congenital or developmental deformity, disease, or injury; and oral health, vision, and hearing services, equipment, and supplies at least for children under 21 years of age. CommentsClose CommentsPermalink (c) Requirements Relating to Cost-sharing and Minimum Actuarial Value- CommentsClose CommentsPermalink (1) NO COST-SHARING FOR PREVENTIVE SERVICES- There shall be no cost-sharing under the essential benefits package for preventive items and services (as specified under the benefit standards), including well baby and well child care. CommentsClose CommentsPermalink (2) ANNUAL LIMITATION- CommentsClose CommentsPermalink (A) ANNUAL LIMITATION- The cost-sharing incurred under the essential benefits package with respect to an individual (or family) for a year does not exceed the applicable level specified in subparagraph (B). CommentsClose CommentsPermalink (B) APPLICABLE LEVEL- The applicable level specified in this subparagraph for Y1 is $5,000 for an individual and $10,000 for a family. Such levels shall be increased (rounded to the nearest $100) for each subsequent year by the annual percentage increase in the Consumer Price Index (United States city average) applicable to such year. CommentsClose CommentsPermalink (C) USE OF COPAYMENTS- In establishing cost-sharing levels for basic, enhanced, and premium plans under this subsection, the Secretary shall, to the maximum extent possible, use only copayments and not coinsurance. CommentsClose CommentsPermalink (3) MINIMUM ACTUARIAL VALUE- CommentsClose CommentsPermalink (A) IN GENERAL- The cost-sharing under the essential benefits package shall be designed to provide a level of coverage that is designed to provide benefits that are actuarially equivalent to approximately 70 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph (B). CommentsClose CommentsPermalink (B) REFERENCE BENEFITS PACKAGE DESCRIBED- The reference benefits package described in this subparagraph is the essential benefits package if there were no cost-sharing imposed. CommentsClose CommentsPermalink (d) Abortion Coverage Prohibited as Part of Minimum Benefits Package- CommentsClose CommentsPermalink (1) PROHIBITION OF REQUIRED COVERAGE- The Health Benefits Advisory Committee may not recommend under section 123(b) and the Secretary may not adopt in standards under section 124(b), the services described in paragraph (4)(A) or (4)(B) as part of the essential benefits package and the Commissioner may not require such services for qualified health benefits plans to participate in the Health Insurance Exchange. CommentsClose CommentsPermalink (2) VOLUNTARY CHOICE OF COVERAGE BY PLAN- In the case of a qualified health benefits plan, the plan is not required (or prohibited) under this Act from providing coverage of services described in paragraph (4)(A) or (4)(B) and the QHBP offering entity shall determine whether such coverage is provided. CommentsClose CommentsPermalink (3) COVERAGE UNDER PUBLIC HEALTH INSURANCE OPTION- The public health insurance option shall provide coverage for services described in paragraph (4)(B). Nothing in this Act shall be construed as preventing the public health insurance option from providing for or prohibiting coverage of services described in paragraph (4)(A). CommentsClose CommentsPermalink (4) ABORTION SERVICES- CommentsClose CommentsPermalink (A) ABORTIONS FOR WHICH PUBLIC FUNDING IS PROHIBITED- The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is not permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. CommentsClose CommentsPermalink (B) ABORTIONS FOR WHICH PUBLIC FUNDING IS ALLOWED- The services described in this subparagraph are abortions for which the expenditure of Federal funds appropriated for the Department of Health and Human Services is permitted, based on the law as in effect as of the date that is 6 months before the beginning of the plan year involved. CommentsClose CommentsPermalink (e) Stand-alone Coverage- CommentsClose CommentsPermalink (1) NO APPLICATION TO ADULT COVERAGE- Nothing in this subtitle shall be construed as requiring an individual who is 21 years of age or older to be provided stand-alone dental-only or vision-only coverage. CommentsClose CommentsPermalink (2) TREATMENT OF COMBINED COVERAGE- The combination of stand-alone coverage described in paragraph (1) and a qualified health benefits plan without coverage of such oral and vision services shall be treated as satisfying the essential benefits package under this division. CommentsClose CommentsPermalink SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE. (a) Establishment- CommentsClose CommentsPermalink (1) IN GENERAL- There is established a private-public advisory committee which shall be a panel of medical and other experts to be known as the Health Benefits Advisory Committee to recommend covered benefits and essential, enhanced, and premium plans. CommentsClose CommentsPermalink (2) CHAIR- The Surgeon General shall be a member and the chair of the Health Benefits Advisory Committee. CommentsClose CommentsPermalink (3) MEMBERSHIP- The Health Benefits Advisory Committee shall be composed of the following members, in addition to the Surgeon General: CommentsClose CommentsPermalink (A) 9 members who are not Federal employees or officers and who are appointed by the President. CommentsClose CommentsPermalink (B) 9 members who are not Federal employees or officers and who are appointed by the Comptroller General of the United States in a manner similar to the manner in which the Comptroller General appoints members to the Medicare Payment Advisory Commission under section 1805(c) of the Social Security Act. CommentsClose CommentsPermalink (C) Such even number of members (not to exceed 8) who are Federal employees and officers, as the President may appoint. CommentsClose CommentsPermalink Such initial appointments shall be made not later than 60 days after the date of the enactment of this Act. CommentsClose CommentsPermalink (4) TERMS- Each member of the Health Benefits Advisory Committee shall serve a 3-year term on the Committee, except that the terms of the initial members shall be adjusted in order to provide for a staggered term of appointment for all such members. CommentsClose CommentsPermalink (5) PARTICIPATION- The membership of the Health Benefits Advisory Committee shall at least reflect providers, consumer representatives, employers, labor, health insurance issuers, experts in health care financing and delivery, experts in racial and ethnic disparities, experts in care for those with disabilities, representatives of relevant governmental agencies. and at least one practicing physician or other health professional and an expert on childrenâ??s health and shall represent a balance among various sectors of the health care system so that no single sector unduly influences the recommendations of such Committee. Not less than 25 percent of the members of the Committee shall be practicing health care practitioners who, as of the date of their appointment, practice in a rural area and who have practiced in a rural area for at least the 5-year period preceding such date. CommentsClose CommentsPermalink (b) Duties- CommentsClose CommentsPermalink (1) RECOMMENDATIONS ON BENEFIT STANDARDS- The Health Benefits Advisory Committee shall recommend to the Secretary of Health and Human Services (in this subtitle referred to as the â??Secretaryâ??) benefit standards (as defined in paragraph (4)), and periodic updates to such standards. In developing such recommendations, the Committee shall take into account innovation in health care and consider how such standards could reduce health disparities. CommentsClose CommentsPermalink (2) DEADLINE- The Health Benefits Advisory Committee shall recommend initial benefit standards to the Secretary not later than 1 year after the date of the enactment of this Act. CommentsClose CommentsPermalink (3) PUBLIC INPUT- The Health Benefits Advisory Committee shall allow for public input as a part of developing recommendations under this subsection. CommentsClose CommentsPermalink (4) BENEFIT STANDARDS DEFINED- In this subtitle, the term â??benefit standardsâ?? means standards respecting-- CommentsClose CommentsPermalink (A) the essential benefits package described in section 122, including categories of covered treatments, items and services within benefit classes, and cost-sharing consistent with subsection (d) of such section; and CommentsClose CommentsPermalink (B) the cost-sharing levels for enhanced plans and premium plans (as provided under section 203(c)) consistent with paragraph (5). CommentsClose CommentsPermalink (5) LEVELS OF COST-SHARING FOR ENHANCED AND PREMIUM PLANS- CommentsClose CommentsPermalink (A) ENHANCED PLAN- The level of cost-sharing for enhanced plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 85 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B). CommentsClose CommentsPermalink (B) PREMIUM PLAN- The level of cost-sharing for premium plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately 95 percent of the actuarial value of the benefits provided under the reference benefits package described in section 122(c)(3)(B). CommentsClose CommentsPermalink (c) Operations- CommentsClose CommentsPermalink (1) PER DIEM PAY- Each member of the Health Benefits Advisory Committee shall receive travel expenses, including per diem in accordance with applicable provisions under subchapter I of chapter 57 of title 5, United States Code, and shall otherwise serve without additional pay. CommentsClose CommentsPermalink (2) MEMBERS NOT TREATED AS FEDERAL EMPLOYEES- Members of the Health Benefits Advisory Committee shall not be considered employees of the Federal government solely by reason of any service on the Committee. CommentsClose CommentsPermalink (3) APPLICATION OF FACA- The Federal Advisory Committee Act (5 U.S.C. App.), other than section 14, shall apply to the Health Benefits Advisory Committee. CommentsClose CommentsPermalink (d) Publication- The Secretary shall provide for publication in the Federal Register and the posting on the Internet website of the Department of Health and Human Services of all recommendations made by the Health Benefits Advisory Committee under this section. CommentsClose CommentsPermalink SEC. 124. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION OF BENEFIT STANDARDS. (a) Process for Adoption of Recommendations- CommentsClose CommentsPermalink (1) REVIEW OF RECOMMENDED STANDARDS- Not later than 45 days after the date of receipt of benefit standards recommended under section 123 (including such standards as modified under paragraph (2)(B)), the Secretary shall review such standards and shall determine whether to propose adoption of such standards as a package. CommentsClose CommentsPermalink (2) DETERMINATION TO ADOPT STANDARDS- If the Secretary determines-- CommentsClose CommentsPermalink (A) to propose adoption of benefit standards so recommended as a package, the Secretary shall, by regulation undersection 553 of title 5, United States Code, propose adoption such standards; or CommentsClose CommentsPermalink (B) not to propose adoption of such standards as a package, the Secretary shall notify the Health Benefits Advisory Committee in writing of such determination and the reasons for not proposing the adoption of such recommendation and provide the Committee with a further opportunity to modify its previous recommendations and submit new recommendations to the Secretary on a timely basis. CommentsClose CommentsPermalink (3) CONTINGENCY- If, because of the application of paragraph (2)(B), the Secretary would otherwise be unable to propose initial adoption of such recommended standards by the deadline specified in subsection (b)(1), the Secretary shall, by regulation undersection 553 of title 5, United States Code, propose adoption of initial benefit standards by such deadline. CommentsClose CommentsPermalink (4) PUBLICATION- The Secretary shall provide for publication in the Federal Register of all determinations made by the Secretary under this subsection. CommentsClose CommentsPermalink (b) Adoption of Standards- CommentsClose CommentsPermalink (1) INITIAL STANDARDS- Not later than 18 months after the date of the enactment of this Act, the Secretary shall, through the rulemaking process consistent with subsection (a), adopt an initial set of benefit standards. CommentsClose CommentsPermalink (2) PERIODIC UPDATING STANDARDS- Under subsection (a), the Secretary shall provide for the periodic updating of the benefit standards previously adopted under this section. CommentsClose CommentsPermalink (3) REQUIREMENT- The Secretary may not adopt any benefit standards for an essential benefits package or for level of cost-sharing that are inconsistent with the requirements for such a package or level under sections 122 (including subsection (d)) and 123(b)(5). CommentsClose CommentsPermalink SEC. 125. PROHIBITION OF DISCRIMINATION IN HEALTH CARE SERVICES BASED ON RELIGIOUS OR SPIRITUAL CONTENT. Neither the Commissioner nor any health insurance issuer offering health insurance coverage through the Health Insurance Exchange shall discriminate in approving or covering a health care service on the basis of its religious or spiritual content if expenditures for such a health care service are allowable as a deduction under section 213(d) of the Internal Revenue Code of 1986, as in effect on January 1, 2009. CommentsClose CommentsPermalink Subtitle D--Additional Consumer Protections CommentsClose CommentsPermalink SEC. 131. REQUIRING FAIR MARKETING PRACTICES BY HEALTH INSURERS. The Commissioner shall establish uniform marketing standards that all insured QHBP offering entities shall meet. CommentsClose CommentsPermalink SEC. 132. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS. (a) In General- A QHBP offering entity shall provide for timely grievance and appeals mechanisms that the Commissioner shall establish.(b) Internal Claims and Appeals Process- Under a qualified health benefits plan the QHBP offering entity shall provide an internal claims and appeals process that initially incorporates the claims and appeals procedures (including urgent claims) set forth at section 2560.503-1 of title 29, Code of Federal Regulations, as published on November 21, 2000 (65 Fed. Reg. 70246) and shall update such process in accordance with any standards that the Commissioner may establish.(c) External Review Process-(1) IN GENERAL- The Commissioner shall establish an external review process (including procedures for expedited reviews of urgent claims) that provides for an impartial, independent, and de novo review of denied claims under this division.(2) REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS- A determination made, with respect to a qualified health benefits plan offered by a QHBP offering entity, under the external review process established under this subsection shall be binding on the plan and the entity.(d) Construction- Nothing in this section shall be construed as affecting the availability of judicial review under State law for adverse decisions under subsection (b) or (c), subject to section 151as the Commissioner shall establish consistent with sections 139 through 139B. CommentsClose CommentsPermalink SEC. 133. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE. (a) Accurate and Timely Disclosure- CommentsClose CommentsPermalink (1) IN GENERAL- A qualified health benefits plan (including the public health insurance option) shall comply with standards established by the Commissioner for the accurate and timely disclosure of plan documents, plan terms and conditions, claims payment policies and practices, periodic financial disclosure, data on enrollment, data on disenrollment, data on the number of claims denials, data on rating practices, information on cost-sharing and payments with respect to any out-of-network coverage, and other information as determined appropriate by the Commissioner. The Commissioner shall require that such disclosure be provided in plain language. CommentsClose CommentsPermalink (2) PLAIN LANGUAGE- In this subsection, the term â??plain languageâ?? means language that the intended audience, including individuals with limited English proficiency, can readily understand and use because that language is clean, concise, well-organized, and follows other best practices of plain language writing. CommentsClose CommentsPermalink (3) GUIDANCE- The Commissioner shall develop and issue guidance on best practices of plain language writing. CommentsClose CommentsPermalink (b) Contracting Reimbursement- A qualified health benefits plan shall comply with standards established by the Commissioner to ensure(including the public health insurance option) shall comply with standards established by the Commissioner to ensure transparency to each health care provider relating to reimbursement arrangements between such plan and such provider. CommentsClose CommentsPermalink (c) Advance Notice of Plan Changes- A change in a qualified health benefits plan shall not be made without such reasonable and timely advance notice to enrollees of such change(including the public health insurance option) shall not be made without such reasonable and timely advance notice to enrollees of such change. CommentsClose CommentsPermalink (d) Pharmacy Benefit Managers Transparency Requirements- CommentsClose CommentsPermalink (1) IN GENERAL- Notwithstanding any other provision of law, a qualified health benefits plan shall enter into a contract with a pharmacy benefit managers (in this subsection referred to as a â??PBMâ??) to manage the prescription drug coverage provided under such plan, or to control the costs of such prescription drug coverage, only if as a condition of such contract the PBM is required to provide at least annually to the Commissioner and to the QHBP offering entity offering such plan the following information: CommentsClose CommentsPermalink (A) Information on the volume of prescriptions under the contract that are filled via mail order and at retail pharmacies. CommentsClose CommentsPermalink (B) An estimate of aggregate average payments under the contract, per prescription (weighted by prescription volume), made to mail order and retail pharmacists, and the average amount, per prescription, that the PBM was paid by the plan for prescriptions filled at mail order and retail pharmacists. CommentsClose CommentsPermalink (C) An estimate of the aggregate average payment per prescription (weighted by prescription volume) under the contract received from pharmaceutical manufacturers, including all rebates, discounts, prices concessions, or administrative, and other payments from pharmaceutical manufacturers, and a description of the types of payments, and the amount of these payments that were shared with the plan, and a description of the percentage of prescriptions for which the PBM received such payments. CommentsClose CommentsPermalink (D) Information on the overall percentage of generic drugs dispensed under the contract at retail and mail order pharmacies, and the percentage of cases in which a generic drug is dispensed when available. CommentsClose CommentsPermalink (E) Information on the percentage and number of cases under the contract in which individuals were switched from a prescribed drug that was less expensive to a drug that was more expensive, the rationale for these switches, and a description of the PBM policies governing such switches. CommentsClose CommentsPermalink (2) CONFIDENTIALITY OF INFORMATION- Notwithstanding any other provision of law, information disclosed by a PBM to the Commissioner or a QHBP offering entity under this subsection is confidential and shall not be disclosed by the Commissioner or the QHBP offering entity in a form which discloses the identity of a specific PBM or prices charged by such PBM or a specific retailer, manufacturer, or wholesaler, except-- CommentsClose CommentsPermalink (A) as the Commissioner determines to be necessary to carry out this subsection; CommentsClose CommentsPermalink (B) to permit the Comptroller General to review the information provided; CommentsClose CommentsPermalink (C) to permit the Director of the Congressional Budget Office to review the information provided; and CommentsClose CommentsPermalink (D) to permit the Commissioner to disclose industry-wide aggregate or average information to be used in assessing the overall impact of PBMs on prescription drug prices and spending.
Average European Member	Mon Mar 22 15:18:57 The HC bill in three words: We are fucked.
habebe Member	Mon Mar 22 15:20:12 Could someone pls delete 11111111's posts.
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