ith congressst session to provide affordable quality health care for all americans and reducethe growth in health care spending and for other purposesin the house of representativesoctober mr dingell for himself mr rangel mr waxman mr george millerof california mr stark mr pallone and mr andrews introducedthe following bill which was referred to the committee on energy andcommerce and in addition to the committees on education and labor ways and means oversight and government reform the budget rules natural resources and the judiciary for a period to be subsequently determinedby the speaker in each case for consideration of such provisionsas fall within the jurisdiction of the committee concerneda billto provide affordable quality health care for all americansand reduce the growth in health care spending andfor other purposes be it enacted by the senate and house of representatives of the united states of america in congress assembled section short title table of divisions titles and subtitles a short title this act be cited as the affordable health care for america act with bills hr ih table of divisions titles and subtitles this act is divided into divisions titles and subtitles as follows division a affordable health care choicestitle immediate reformstitle protections and standards for qualifiedhealth benefits planssubtitle a general standardssubtitle standards guaranteeing access to affordable coveragesubtitle standards guaranteeing access to essential benefitssubtitle additional consumer protectionssubtitle governancesubtitle relation to other requirements miscellaneoustitle iii health insurance exchange and related provisionssubtitle a health insurance exchangesubtitle public health insurance optionsubtitle individual affordability creditstitle iv shared responsibilitysubtitle a individual responsibilitysubtitle employer responsibilitytitle amendments to internal revenue code of subtitle a shared responsibilitysubtitle credit for small business employee health coverage expensessubtitle disclosures to carry out health insurance exchange subsidiessubtitle other revenue provisionsdivision medicare and medicaid improvementstitle improving health care valuesubtitle a provisions related to medicare part asubtitle provisions related to part bsubtitle provisions related to medicare parts a and bsubtitle medicare advantage reformssubtitle improvements to medicare part dsubtitle medicare rural access protectionstitle medicare beneficiary improvementssubtitle a improving and simplifying financial assistance for low incomemedicare beneficiariessubtitle reducing health disparitiessubtitle miscellaneous improvementstitle iii promoting primary care mental health services and coordinated caretitle iv qualitysubtitle a comparative effectiveness researchsubtitle nursing home transparencysubtitle quality measurementssubtitle physician payments sunshine provisionsubtitle public reporting on health care associated infectionstitle medicare graduate medical educationtitle vi program integrity with bills hr ih subtitle a increased funding to fight waste fraud and abuse subtitle enhanced penalties for fraud and abuse subtitle enhanced program and provider protectionssubtitle access to information needed to prevent fraud waste and abusetitle vii medicaid and chipsubtitle a medicaid and health reformsubtitle preventionsubtitle accesssubtitle coveragesubtitle financingsubtitle waste fraud and abusesubtitle puerto rico and the territoriessubtitle miscellaneoustitle viii revenue related provisionstitle ix miscellaneous provisionsdivision public health and workforce developmenttitle community health centerstitle workforcesubtitle a primary care workforcesubtitle nursing workforcesubtitle public health workforcesubtitle adapting workforce to evolving health system needstitle iii prevention and wellnesstitle iv quality and surveillancetitle other provisionssubtitle a drug discount for rural and other hospitals program integritysubtitle programssubtitle food and drug administrationsubtitle community living assistance services and supportssubtitle miscellaneousdivision indian health care improvementtitle amendments to indian lawstitle improvement of indian health care providedunder the social security act division a affordable health care choices sec purpose table of contents of division general definitions a purpose in general the purpose of this division is to provide affordable quality health care for all with bills hr ih americans and reduce the growth in health care spending building on current system this division achieves this purpose by building on what works in today health care system while repairing the aspects that are broken insurance reforms this division a enacts strong insurance market reforms creates a new health insurance exchange with a public health insurance option alongside private plans includes sliding scale affordability credits and initiates shared responsibility among workers employers and the government so that all americans have coverage of essential health benefits 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 table of contents of division the table of contents of this division is as follows sec purpose table of contents of division general definitions with bills hr ihtitle immediate reformssec national high risk pool programsec ensuring value and lower premiumssec ending health insurance rescission abusesec sunshine on price gouging by health insurance issuerssec requiring the option of extension of dependent coverage for uninsuredyoung adultssec limitations on preexisting condition exclusions in group health plansin advance of applicability of new prohibition of preexistingcondition exclusionssec prohibiting acts of domestic violence from being treated as preexistingconditionssec ending health insurance denials and delays of necessary treatmentfor children with deformitiessec elimination of lifetime limitssec prohibition against postretirement reductions of retiree health benefitsby group health planssec reinsurance program for retireessec wellness program grantssec extension of cobra continuation coveragesec state health access program grantssec administrative simplificationtitle protections and standards for qualifiedhealth benefits planssubtitle a general standardssec requirements reforming health insurance marketplacesec protecting the choice to keep current coveragesubtitle standards guaranteeing access to affordable coveragesec prohibiting preexisting condition exclusionssec guaranteed issue and renewal for insured plans and prohibiting rescissionssec insurance rating rulessec nondiscrimination in benefits parity in mental health and substanceabuse disorder benefitssec ensuring adequacy of provider networkssec requiring the option of extension of dependent coverage for uninsuredyoung adultssec consistency of costs and coverage under qualified health benefitsplans during plan yearsubtitle standards guaranteeing access to essential benefitssec coverage of essential benefits packagesec essential benefits package definedsec health benefits advisory committeesec process for adoption of recommendations adoption of benefit standardssubtitle additional consumer protectionssec requiring fair marketing practices by health insurers with bills hr ihsec requiring fair grievance and appeals mechanismssec requiring information transparency and plan disclosuresec application to qualified health benefits plans not offered through thehealth insurance exchangesec timely payment of claimssec standardized rules for coordination and subrogation of benefitssec application of administrative simplificationsec state prohibitions on discrimination against health care providerssec protection of physician prescriber informationsec dissemination of advance care planning informationsubtitle governancesec health choices administration health choices commissionersec duties and authority of commissionersec consultation and coordinationsec health insurance ombudsmansubtitle relation to other requirements miscellaneoussec relation to other requirementssec prohibiting discrimination in health caresec whistleblower protectionsec construction regarding collective bargainingsec severabilitysec treatment of hawaii prepaid health care actsec actions by state attorneys generalsec application of state and federal laws regarding abortionsec nondiscrimination on abortion and respect for rights of consciencesec authority of federal trade commissionsec construction regarding standard of caresec restoring application of antitrust laws to health sector insurerssec study and report on methods to increase ehr use by small healthcare providerstitle iii health insurance exchange and relatedprovisionssubtitle a health insurance exchangesec establishment of health insurance exchange outline of duties definitionssec exchange eligible individuals and employerssec benefits package levelssec contracts for the offering of exchange participating health benefitsplanssec outreach and enrollment of exchange eligible individuals and employersin exchange participating health benefits plansec other functionssec health insurance exchange trust fundsec optional operation of state based health insurance exchangessec interstate health insurance compactssec health insurance cooperativessec retention of dod and va authoritysubtitle public health insurance option with bills hr ihsec establishment and administration of a public health insurance optionas an exchange qualified health benefits plansec premiums and financingsec payment rates for items and servicessec modernized payment initiatives and delivery system reformsec provider participationsec application of fraud and abuse provisionssec application of hipaa insurance requirementssec application of health information privacy security and electronictransaction requirementssec enrollment in public health insurance option is voluntarysec enrollment in public health insurance option by members of congresssec reimbursement of secretary of veterans affairssubtitle individual affordability creditssec availability through health insurance exchangesec affordable credit eligible individualsec affordability premium creditsec affordability cost sharing creditsec income determinationssec special rules for application to territoriessec no federal payment for undocumented alienstitle iv shared responsibilitysubtitle a individual responsibilitysec individual responsibilitysubtitle employer responsibilitypart health coverage participation requirementssec health coverage participation requirementssec employer responsibility to contribute toward employee and dependentcoveragesec employer contributions in lieu of coveragesec authority related to improper steeringsec impact study on employer responsibility requirementssec study on employer hardship exemptionpart satisfaction of health coverage participationrequirementssec satisfaction of health coverage participation requirements under theemployee retirement income security act of sec satisfaction of health coverage participation requirements under theinternal revenue code of sec satisfaction of health coverage participation requirements under thepublic health service actsec additional rules relating to health coverage participation requirementstitle amendments to internal revenue code of subtitle a provisions relating to health care reform with bills hr ihpart shared responsibilitysubpart a individual responsibilitysec tax on individuals without acceptable health care coveragesubpart employer responsibilitysec election to satisfy health coverage participation requirementssec health care contributions of nonelecting employerspart credit for small business employee health coverageexpensessec credit for small business employee health coverage expensespart limitations on health care related expendituressec distributions for medicine qualified only if for prescribed drug or insulinsec limitation on health flexible spending arrangements under cafeteriaplanssec increase in penalty for nonqualified distributions from health savingsaccountssec denial of deduction for federal subsidies for prescription drug planswhich have been excluded from gross incomepart other provisions to carry out health insurance reformsec disclosures to carry out health insurance exchange subsidiessec offering of exchange participating health benefits plans through cafeteriaplanssec exclusion from gross income of payments made under reinsuranceprogram for retireessec class program treated in same manner as long term care insurancesec exclusion from gross income for medical care provided for indianssubtitle other revenue provisionspart general provisionssec surcharge on high income individualssec excise tax on medical devicessec expansion of information reporting requirementssec delay in application of worldwide allocation of interestpart prevention of tax avoidancesec limitation on treaty benefits for certain deductible paymentssec codification of economic substance doctrine penaltiessec certain large or publicly traded persons made subject to a more likelythan not standard for avoiding penalties on underpaymentspart parity in health benefitssec certain health related benefits applicable to spouses and dependentsextended to eligible beneficiaries with bills hr ih general definitions except as otherwise provided in this division acceptable coverage the term acceptable coverage has the meaning given such term in section basic plan the term basic plan has the meaning given such term in section commissioner the term commissioner means the health choices commissioner established under section cost sharing the term cost sharing includes deductibles coinsurance copayments and similar charges but does not include premiums balance billing amounts for non network providers or spending for non covered services dependent the term dependent has the meaning given such term by the commissioner and includes a spouse employment based health plan the term employment based health plan a means a group health plan as defined in section a of the employee retirement income security act of includes such a plan that is the following with bills hr ih federal state and tribal governmental plans a governmental plan as defined in section of the employee retirement income security act of including a health benefits plan offered under chapter of title united states code church plans a church plan as defined in section of the employee retirement income security act of and excludes coverage described in section relating to tricare enhanced plan the term enhanced plan has the meaning given such term in section essential benefits package the term essential benefits package is defined in section a exchange participating health benefits plan the term exchange participating health benefits plan means a qualified health benefits plan that is offered through the health insurance exchange and be purchased directly from with bills hr ih the entity offering the plan or through enrollment agents and brokers family the term family means an individual and includes the individual dependents federal poverty level fpl the terms federal poverty level and fpl have the meaning given the term poverty line in section of the community services block grant act usc including any revision required by such section health benefits plan the term health benefits plan means health insurance coverage and an employment based health plan and includes the public health insurance option health insurance coverage the term health insurance coverage has the meaning given such term in section of the public health service act but does not include coverage in relation to its provision of excepted benefits a described in paragraph of subsection of such section or described in paragraph or of such subsection if the benefits are provided under a separate policy certificate or contract of insurance with bills hr ih health insurance issuer the term health insurance issuer has the meaning given such term in section of the public health service act health insurance exchange the term health insurance exchange means the health insurance exchange established under section indian the term indian has the meaning given such term in section of the indian health care improvement act usc indian health care provider the term indian health care provider means a health care program operated by the indian health service an indian tribe tribal organization or urban indian organization as such terms are defined in section of the indian health care improvement act usc medicaid the term medicaid means a state plan under title xix of the social security act whether or not the plan is operating under a waiver under section of such act medicaid eligible individual the term medicaid eligible individual means an indi with bills hr ih vidual who is eligible for medical assistance under medicaid medicare the term medicare means the health insurance programs under title xviii of the social security act plan sponsor the term plan sponsor has the meaning given such term in section of the employee retirement income security act of plan year the term plan year means a with respect to an employment based health plan a plan year as specified under such plan or with respect to a health benefits plan other than an employment based health plan a month period as specified by the commissioner premium plan premium plus plan the terms premium plan and premium plus plan have the meanings given such terms in section qhbp offering entity the terms qhbp offering entity means with respect to a health benefits plan that is with bills hr ih a a group health plan as defined subject to subsection in section a of the employee retirement income security act of the plan sponsor in relation to such group health plan except that in the case of a plan maintained jointly by or more employers and or more employee organizations and with respect to which an employer is the primary source of financing such term means such employer health insurance coverage the health insurance issuer offering the coverage the public health insurance option the secretary of health and human services a non federal governmental plan as defined in section 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 a federal governmental plan as defined in section of the public health service act the appropriate federal official with bills hr ih qualified health benefits plan the term qualified health benefits plan means a health benefits plan that a meets the requirements for such a plan under title and includes the public health insurance option and is offered by a qhbp offering entity that meets the applicable requirements of such title with respect to such plan public health insurance option the term public health insurance option means the public health insurance option as provided under subtitle of title iii service area premium rating area the terms service area and premium rating area mean with respect to health insurance coverage 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 offered through the health insurance exchange such an area as established by such entity in accordance with applicable state law with bills hr ih and applicable rules of the commissioner for exchange participating health benefits plans state the term state means the states and the district of columbia and includes a for purposes of title puerto rico the virgin islands guam american samoa and the northern mariana islands and for purposes of titles and iii as elected under and subject to section puerto rico the virgin islands guam american samoa and the northern mariana islands state medicaid agency the term state medicaid agency means with respect to a medicaid plan the single state agency responsible for administering such plan under title xix of the social security act y etc the terms y y and similar subsequently numbered terms mean and subsequent years respectively title immediate reforms sec national high risk pool program a in general the secretary of health and human services in this section referred to as the secretary shall establish a temporary national high risk with bills hr ih pool program in this section referred to as the program to provide health benefits to eligible individuals during the period beginning on january and subject to subsection ending on the date on which the health insurance exchange is established administration the secretary carry out this section directly or pursuant to agreements grants or contracts with states through state high risk pool programs provided that the requirements of this section are met eligibility for purposes of this section the term eligible individual means an individual who a is not eligible for benefits under title xviii xix or xxi of the social security act or coverage under an employmentbased health plan not including coverage under a cobra continuation provision as defined in section and who is an eligible individual under section of the public health service act or with bills hr ih is medically eligible for the program by virtue of being an individual described in subsection at any time during the month period ending on the date the individual applies for high risk pool coverage under this section who is the spouse or dependent of an individual who is described in paragraph or who has not had health insurance coverage or coverage under an employment based health plan for at least the month period immediately preceding the date of the individual application for high risk pool coverage under this section for purposes of paragraph a a person who is in a waiting period as defined in section of the public health service act shall not be considered to be eligible for coverage under an employment based health plan medically eligible requirements for purposes of subsection an individual described in this subsection is an individual who during the month period ending on the date the individual applies for high risk pool coverage under this section applied for individual health insurance coverage and with bills hr ih a was denied such coverage because of a preexisting condition or health status or was offered such coverage under terms that limit the coverage for such a preexisting condition or at a premium rate that is above the premium rate for high risk pool coverage under this section or who has an eligible medical condition as defined by the secretary in making a determination under paragraph of whether an individual was offered individual coverage at a premium rate above the premium rate for high risk pool coverage the secretary shall make adjustments to offset differences in premium rating that are attributable solely to differences in age rating enrollment to enroll in coverage in the program an individual shall submit to the secretary an application for participation in the program at such time in such manner and containing such information as the secretary shall require attest that the individual is an eligible individual and is a resident of one of the states or the district of columbia and with bills hr ih if the individual had other prior health insurance coverage or coverage under an employmentbased health plan during the previous months provide information as to the nature and source of such coverage and reasons for its discontinuance protection against dumping risks by insurers in general the secretary shall establish criteria for determining whether health insurance issuers and employment based health plans have discouraged an individual from remaining enrolled in prior coverage based on that individual health status sanctions an issuer or employmentbased health plan shall be responsible for reimbursing the program for the medical expenses incurred by the program for an individual who based on criteria established by the secretary the secretary finds was encouraged by the issuer to disenroll from health benefits coverage prior to enrolling in the program the criteria shall include at least the following circumstances a in the case of prior coverage obtained through an employer the provision by the employer group health plan or the issuer of with bills hr ih money or other financial consideration for disenrolling from the coverage in the case of prior coverage obtained directly from an issuer or under an employment based health plan the provision by the issuer or plan of money or other financial consideration for disenrolling from the coverage or in the case of an individual whose premium for the prior coverage exceeded the premium required by the program adjusted based on the age factors applied to the prior coverage the prior coverage is a policy that is no longer being actively marketed as defined by the secretary by the issuer or the prior coverage is a policy for which duration of coverage form issue or health status are factors that can be considered in determining premiums at renewal construction nothing in this subsection shall be construed as constituting exclusive remedies for violations of criteria established under with bills hr ih paragraph or as preventing states from applying or enforcing such paragraph or other provisions under law with respect to health insurance issuers covered benefits cost sharing premiums and consumer protections premium the monthly premium charged to eligible individuals for coverage under the program a vary by age so long as the ratio of the highest such premium to the lowest such premium does not exceed the ratio of to shall be set at a level that does not exceed percent of the prevailing standard rate for comparable coverage in the individual market and shall be adjusted for geographic variation in costs health insurance issuers shall provide such information as the secretary require to determine prevailing standard rates under this paragraph the secretary shall establish standard rates in consultation with the national association of insurance commissioners covered benefits covered benefits under the program shall be determined by the sec with bills hr ih retary and shall be consistent with the basic categories in the essential benefits package described in section under such benefits package a the annual deductible for such benefits not be higher than for an individual or such higher amount for a family as determined by the secretary there not be annual or lifetime limits and the maximum cost sharing with respect to an individual or family for a year shall not exceed for an individual or for a family no preexisting condition exclusion periods no preexisting condition exclusion period shall be imposed on coverage under the program appeals the secretary shall establish an appeals process for individuals to appeal a determination of the secretary a with respect to claims submitted under this section and with respect to eligibility determinations made by the secretary under this section state contribution maintenance of effort as a condition of providing health bene with bills hr ih fits under this section to eligible individual residing in a state a in the case of a state in which a qualified high risk pool as defined under section of the public health service act was in effect as of july the secretary shall require the state make a maintenance of effort payment each year that the high risk pool is in effect equal to an amount not less than the amount of all sources of funding for high risk pool coverage made by that state in the year ending july and in the case of a state which required health insurance issuers to contribute to a state high risk pool or similar arrangement for the assessment against such issuers for pool losses the state shall maintain such a contribution arrangement among such issuers limiting program expenditures the secretary shall with respect to the program a establish procedures to protect against fraud waste and abuse under the program and provide for other program integrity methods with bills hr ih treatment as creditable coverage coverage under the program shall be treated for purposes of applying the definition of creditable coverage under the provisions of title xxvii of the public health service act part of subtitle of title of employee retirement income security act of and chapter of the internal revenue code of and any other provision of law that references such provisions in the same manner as if it were coverage under a state health benefits risk pool described in section of the public health service act funding termination of authority in general there is appropriated to the secretary out of any moneys in the treasury not otherwise appropriated to pay claims against and administrative costs of the high risk pool under this section in excess of the premiums collected with respect to eligible individuals enrolled in the high risk pool such funds shall be available without fiscal year limitation insufficient funds if the secretary estimates for any fiscal year that the aggregate amounts available for payment of expenses of the high risk pool will be less than the amount of the ex with bills hr ih penses the secretary shall make such adjustments as are necessary to eliminate such deficit including reducing benefits increasing premiums or establishing waiting lists termination of authority a in general except as provided in subparagraph coverage of eligible individuals under a high risk pool shall terminate as of the date on which the health insurance exchange is established transition to exchange the secretary shall develop procedures to provide for the transition of eligible individuals who are enrolled in health insurance coverage offered through a high risk pool established under this section to be enrolled in acceptable coverage such procedures shall ensure that there is no lapse in coverage with respect to the individual and extend coverage offered through such a high risk pool beyond if the secretary determines necessary to avoid such a lapse sec ensuring value and lower premiums a group health insurance coverage title xxvii of the public health service act is amended by inserting after section the following new section with bills hr ih sec ensuring value and lower premiums a in general each health insurance issuer that offers health insurance coverage in the small or large group market shall provide that for any plan year in which the coverage has a medical loss ratio below a level specified by the secretary but not less than percent the issuer shall provide in a manner specified by the secretary for rebates to enrollees of the amount by which the issuer medical loss ratio is less than the level so specified implementation the secretary shall establish a uniform definition of medical loss ratio and methodology for determining how to calculate it based on the average medical loss ratio in a health insurance issuer book of business for the small and large group market such methodology shall be designed to take into account the special circumstances of smaller plans different types of plans and newer plans in determining the medical loss ratio the secretary shall exclude state taxes and licensing or regulatory fees such methodology shall be designed and exceptions shall be established to ensure adequate participation by health insurance issuers competition in the health insurance market and value for consumers so that their premiums are used for services sunset subsections a and shall not apply to health insurance coverage on and after the first with bills hr ih date that health insurance coverage is offered through the health insurance exchange individual health insurance coverage such title is further amended by inserting after section the following new section sec ensuring value and lower premiums the provisions of section shall apply to health insurance coverage offered in the individual market in the same manner as such provisions apply to health insurance coverage offered in the small or large group market except to the extent the secretary determines that the application of such section destabilize the existing individual market immediate implementation the amendments made by this section shall apply in the group and individual market for plan years beginning on or after january or as soon as practicable after such date sec ending health insurance rescission abuse a clarification regarding application of guaranteed renewability of individual and group health insurance coverage sections and of the public health service act usc gg– gg– are each amended in its heading by inserting and continuation in force including prohibiverdatenov oct jkt po frm fmt sfmt bills hih with bills hr ih tion of rescission after guaranteed renewability and in subsection a by inserting including without rescission after continue in force secretarial guidance regarding rescissions group health insurance market section of such act usc gg– is amended by adding at the end the following rescission a health insurance issuer rescind group health insurance coverage only upon clear and convincing evidence of fraud described in subsection under procedures that provide for independent external third party review individual health market section of such act usc gg– is amended by adding at the end the following rescission a health insurance issuer rescind individual health insurance coverage only upon clear and convincing evidence of fraud described in subsection under procedures that provide for independent external third party review guidance the secretary of health and human services no later than days after the date of the enactment of this act shall issue guid with bills hr ih ance implementing the amendments made by paragraphs and including procedures for independent external third party review opportunity for independent external third party review in certain cases individual market subpart of part of title xxvii of such act usc gg– et seq is amended by adding at the end the following sec opportunity for independent external third party review in cases of rescission a notice and review right if a health insurance issuer determines to rescind health insurance coverage for an individual in the individual market before such rescission take effect the issuer shall provide the individual with notice of such proposed rescission and an opportunity for a review of such determination by an independent external third party under procedures specified by the secretary under section independent determination if the individual requests such review by an independent external third party of a rescission of health insurance coverage the coverage shall remain in effect until such third party determines that the coverage be rescinded under the guidance issued by the secretary under section with bills hr ih application to group health insurance such title is further amended by adding after section the following new section sec opportunity for independent external third party review in cases of rescission the provisions of section shall apply to group health insurance coverage in the same manner as such provisions apply to individual health insurance coverage except that any reference to section is deemed a reference to section effective date the amendments made by this section shall take effect on the date of the enactment of this act and shall apply to rescissions occurring on and after july with respect to health insurance coverage issued before on or after such date sec sunshine on price gouging by health insurance issuers the secretary of health and human services in conjunction with states shall establish a process for the annual review of increases in premiums for health insurance coverage such process shall require health insurance issuers to submit a justification for any premium increases prior to implementation of the increase with bills hr ih sec requiring the option of extension of dependent coverage for uninsured young adults a under group health plans phsa title xxvii of the public health service act is amended by inserting after section the following new section sec requiring the option of extension of dependent coverage for uninsured young adults a in general a group health plan and a health insurance issuer offering health insurance coverage in connection with a group health plan that provides coverage for dependent children shall make available such coverage at the option of the participant involved for one or more qualified children as defined in subsection of the participant qualified child defined in this section the term qualified child means with respect to a participant in a group health plan or group health insurance coverage an individual who but for age would be treated as a dependent child of the participant under such plan or coverage and who is under years of age and is not enrolled as a participant beneficiary or enrollee other than under this section with bills hr ih section or section of the employee retirement income security act of under any health insurance coverage or group health plan premiums nothing in this section shall be construed as preventing a group health plan or health insurance issuer with respect to group health insurance coverage from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the secretary based upon family size employee retirement income security act of a in general part of subtitle of title of the employee retirement income security act of is amended by inserting after section the following new section sec requiring the option of extension of dependent coverage for uninsured young adults a in general a group health plan and a health insurance issuer offering health insurance coverage in connection with a group health plan that provides coverage for dependent children shall make available such coverage at the option of the participant involved for one or more with bills hr ih qualified children as defined in subsection of the participant qualified child defined in this section the term qualified child means with respect to a participant in a group health plan or group health insurance coverage an individual who but for age would be treated as a dependent child of the participant under such plan or coverage and who is under years of age and is not enrolled as a participant beneficiary or enrollee other than under this section under any health insurance coverage or group health plan premiums nothing in this section shall be construed as preventing a group health plan or health insurance issuer with respect to group health insurance coverage from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the secretary based upon family size clerical amendment the table of contents of such act is amended by inserting after the item relating to section the following new item sec requiring the option of extension of dependent coverage for uninsuredyoung adults with bills hr ih irc a in general subchapter a of chapter of the internal revenue code of is amended by adding at the end the following new section sec requiring the option of extension of dependent coverage for uninsured young adults a in general a group health plan that provides coverage for dependent children shall make available such coverage at the option of the participant involved for one or more qualified children as defined in subsection of the participant qualified child defined in this section the term qualified child means with respect to a participant in a group health plan an individual who but for age would be treated as a dependent child of the participant under such plan and who is under years of age and is not enrolled as a participant beneficiary or enrollee other than under this section section of the employee retirement income security act of or section or of the public health service act under any health insurance coverage or group health plan with bills hr ih premiums nothing in this section shall be construed as preventing a group health plan from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the secretary based upon family size clerical amendment the table of sections of such chapter is amended by inserting after the item relating to section the following sec requiring the option of extension of dependent coverage for uninsuredyoung adults individual health insurance coverage title xxvii of the public health service act is amended by inserting after section the following new section sec requiring the option of extension of dependent coverage for uninsured young adults the provisions of section shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as they apply to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market effective dates group health plans the amendments made by subsection a shall apply to group health with bills hr ih plans for plan years beginning on or after january individual health insurance coverage section of the public health service act as inserted by subsection shall apply with respect to health insurance coverage offered sold issued renewed in effect or operated in the individual market on or after january sec limitations on preexisting condition exclusions in group health plans in advance of applicability of new prohibition of preexisting condition exclusions a amendments to the employee retirement income security act of reduction in look back period section a of the employee retirement income security act of usc a is amended by striking month period and inserting day period reduction in permitted preexisting condition limitation period section a of such act usc a is amended by striking months and inserting months with bills hr ih and by striking months and inserting months sunset of interim limitation section of such act usc is amended by adding at the end the following new subsection termination this section shall cease to apply to any group health plan as of the date that such plan becomes subject to the requirements of section of the relating to prohibiting preexisting condition exclusions amendments to the internal revenue code of reduction in look back period section a of the internal revenue code of is amended by striking month period and inserting day period reduction in permitted preexisting condition limitation period section a of such code is amended by striking months and inserting months and by striking months and inserting months sunset of interim limitation section of such code is amended by adding at the end the following new subsection with bills hr ih termination this section shall cease to apply to any group health plan as of the date that such plan becomes subject to the requirements of section of the relating to prohibiting preexisting condition exclusions amendments to public health service act reduction in look back period section a of the public health service act usc gg a is amended by striking month period and inserting day period reduction in permitted preexisting condition limitation period section a of such act usc gg a is amended by striking months and inserting months and by striking months and inserting months sunset of interim limitation section of such act usc gg is amended by adding at the end the following new subsection termination this section shall cease to apply to any group health plan as of the date that such plan becomes subject to the requirements of section of the relating to prohibiting preexisting condition exclusions with bills hr ih miscellaneous technical amendment section a of such act usc gg– is amended by striking and inserting effective date in general except as provided in paragraph the amendments made by this section shall apply with respect to group health plans for plan years beginning on or after january special rule for collective bargaining agreements in the case of a group health plan maintained pursuant to or more collective bargaining agreements between employee representatives and or more employers ratified before the date of the enactment of this act the amendments made by this section shall not apply to plan years beginning before the earlier of a the date on which the last of the collective bargaining agreements relating to the plan terminates determined without regard to any extension thereof agreed to after the date of the enactment of this act years after the date of the enactment of this act with bills hr ih sec prohibiting acts of domestic violence from being treated as preexisting conditions a erisa section of the employee retirement income security act of usc is amended in the heading by inserting or domestic violence after pregnancy and by inserting or domestic violence after relating to pregnancy phsa group market section of the public health service act usc gg is amended a in the heading by inserting or domestic violence after pregnancy and by inserting or domestic violence after relating to pregnancy individual market title xxvii of such act is amended by inserting after section the following new section sec prohibition on domestic violence as preexisting condition a health insurance issuer offering health insurance coverage in the individual market not on the basis of domestic violence impose any preexisting condition ex with bills hr ih clusion as defined in section a with respect to such coverage irc section of the internal revenue code of is amended in the heading by inserting or domestic violence after pregnancy and by inserting or domestic violence after relating to pregnancy effective dates except as otherwise provided in this subsection the amendments made by this section shall apply with respect to group health plans and health insurance issuers offering group health insurance coverage for plan years beginning on or after january the amendment made by subsection shall apply with respect to health insurance coverage offered sold issued renewed in effect or operated in the individual market on or after such date sec ending health insurance denials and delays of necessary treatment for children with deformities a amendments to the employee retirement income security act of with bills hr ih in general subpart of part of subtitle of title of the employee retirement income security act of is amended by adding at the end the following new section sec standards relating to benefits for minor child congenital or developmental deformity or disorder a requirements for treatment for children with deformities in general a group health plan and a health insurance issuer offering group health insurance coverage that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child congenital or developmental deformity disease or injury a minor child shall include any individual who is years of age or younger treatment defined a in general in this section the term treatment includes reconstructive surgical procedures procedures that are generally performed to improve function but also be performed to approximate a normal appearance that are performed on abnormal structures of the body caused by congenital defects with bills hr ih developmental abnormalities trauma infection tumors or disease including procedures that do not materially affect the function of the body part being treated and procedures for secondary conditions and follow up treatment exception such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self esteem notice a group health plan under this part shall comply with the notice requirement under section other than paragraph with respect to the requirements of this section conforming amendment a subsection of section of such act is amended by striking section and inserting sections and the table of contents in section of such act is amended by inserting after the item relating to section the following new item sec standards relating to benefits for minor child congenital or developmentaldeformity or disorder amendments to the internal revenue code of with bills hr ih in general subchapter of chapter of the internal revenue code of is amended by adding at the end the following new section sec standards relating to benefits for minor child congenital or developmental deformity or disorder a requirements for treatment for children with deformities a group health plan that provides coverage for surgical benefits shall provide coverage for outpatient and inpatient diagnosis and treatment of a minor child congenital or developmental deformity disease or injury a minor child shall include any individual who is years of age or younger treatment defined in general in this section the term treatment includes reconstructive surgical procedures procedures that are generally performed to improve function but also be performed to approximate a normal appearance that are performed on abnormal structures of the body caused by congenital defects developmental abnormalities trauma infection tumors or disease including a procedures that do not materially affect the function of the body part being treated and with bills hr ih procedures for secondary conditions and follow up treatment exception such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self esteem clerical amendment the table of sections for subchapter of chapter of such code is amended by adding at the end the following new item sec standards relating to benefits for minor child congenital or developmentaldeformity or disorder amendments to the public health service act in general subpart of part a of title xxvii of the public health service act is amended by adding at the end the following new section sec standards relating to benefits for minor child congenital or developmental deformity or disorder a requirements for treatment for children with deformities in general a group health plan and a health insurance issuer offering group health insurance coverage that provides coverage for surgical benefits shall provide coverage for outpatient and in with bills hr ih patient diagnosis and treatment of a minor child congenital or developmental deformity disease or injury a minor child shall include any individual who is years of age or younger treatment defined a in general in this section the term treatment includes reconstructive surgical procedures procedures that are generally performed to improve function but also be performed to approximate a normal appearance that are performed on abnormal structures of the body caused by congenital defects developmental abnormalities trauma infection tumors or disease including procedures that do not materially affect the function of the body part being treated and procedures for secondary conditions and follow up treatment exception such term does not include cosmetic surgery performed to reshape normal structures of the body to improve appearance or self esteem notice a group health plan under this part shall comply with the notice requirement under section with bills hr ih of the employee retirement income security act of with respect to the requirements of this section as if such section applied to such plan individual health insurance subpart of part of title xxvii of the public health service act as amended by section is further amended by adding at the end the following new section sec standards relating to benefits for minor child congenital or developmental deformity or disorder the provisions of section shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as such provisions apply to health insurance coverage offered by a health insurance issuer in connection with a group health plan in the small or large group market conforming amendments a section of such act usc gg– is amended by striking section and inserting sections and section of such act usc gg– is amended by striking with bills hr ih section and inserting sections and effective dates the amendments made by this section shall apply with respect to group health plans and health insurance issuers offering group health insurance coverage for plan years beginning on or after january the amendment made by subsection shall apply with respect to health insurance coverage offered sold issued renewed in effect or operated in the individual market on or after such date coordination section of the health insurance portability and accountability act of is amended by striking and the amendments made by this subtitle and section and inserting part of subtitle of title of the employee retirement income security act of parts a and of title xxvii of the public health service act and chapter of the internal revenue code of sec elimination of lifetime limits a amendments to the employee retirement income security act of in general subpart of part of subtitle of title of the employee retirement income with bills hr ih security act of usc et seq as amended by section is amended by adding at the end the following sec elimination of lifetime aggregate limits a in general a group health plan and a health insurance issuer providing health insurance coverage in connection with a group health plan not impose an aggregate dollar lifetime limit with respect to benefits payable under the plan or coverage definition in this section the term aggregate dollar lifetime limit means with respect to benefits under a group health plan or health insurance coverage offered in connection with a group health plan a dollar limitation on the total amount that be paid with respect to such benefits under the plan or health insurance coverage with respect to an individual or other coverage unit on a lifetime basis clerical amendment the table of contents in section of such act is amended by inserting after the item relating to section the following new item sec elimination of lifetime aggregate limits amendments to the internal revenue code of in general subchapter of chapter of the internal revenue code of as with bills hr ih amended by section is amended by adding at the end the following new section sec elimination of lifetime aggregate limits a in general a group health plan not impose an aggregate dollar lifetime limit with respect to benefits payable under the plan definition in this section the term aggregate dollar lifetime limit means with respect to benefits under a group health plan a dollar limitation on the total amount that be paid with respect to such benefits under the plan with respect to an individual or other coverage unit on a lifetime basis clerical amendment the table of sections for subchapter of chapter of such code as amended by section is amended by adding at the end the following new item sec standards relating to benefits for minor child congenital or developmentaldeformity or disorder amendment to the public health service act relating to the group market in general subpart of part a of title xxvii of the public health service act usc gg– et seq as amended by section is amended by adding at the end the following with bills hr ih sec elimination of lifetime aggregate limits a in general a group health plan and a health insurance issuer providing health insurance coverage in connection with a group health plan not impose an aggregate dollar lifetime limit with respect to benefits payable under the plan or coverage definition in this section the term aggregate dollar lifetime limit means with respect to benefits under a group health plan or health insurance coverage a dollar limitation on the total amount that be paid with respect to such benefits under the plan or health insurance coverage with respect to an individual or other coverage unit on a lifetime basis individual market subpart of part of title xxvii of the public health service act usc gg– et seq as amended by section is amended by adding at the end the following sec elimination of annual or lifetime aggregate limits the provisions of section shall apply to health insurance coverage offered by a health insurance issuer in the individual market in the same manner as they apply to health insurance coverage offered by a health insurance with bills hr ih issuer in connection with a group health plan in the small or large group market effective dates the amendments made by this section shall apply with respect to group health plans and health insurance issuers offering group health insurance coverage for plan years beginning on or after january the amendment made by subsection shall apply with respect to health insurance coverage offered sold issued renewed in effect or operated in the individual market on or after such date sec prohibition against postretirement reductions of retiree health benefits by group health plans a in general part of subtitle of title of the employee retirement income security act of as amended by sections and is amended by inserting after section the following new section sec protection against postretirement reduction of retiree health benefits a in general every group health plan shall contain a provision which expressly bars the plan or any fiduciary of the plan from reducing the benefits provided under the plan to a retired participant or beneficiary of with bills hr ih such participant if such reduction affects the benefits provided to the participant or beneficiary as of the date the participant retired for purposes of the plan and such reduction occurs after the participant retirement unless such reduction is also made with respect to active participants nothing in this section shall prohibit a plan from enforcing a total aggregate cap on amounts paid for retiree health coverage that is part of the plan at the time of retirement no reduction notwithstanding that a group health plan contain a provision reserving the general power to amend or terminate the plan or a provision specifically authorizing the plan to make post retirement reductions in retiree health benefits it shall be prohibited for any group health plan whether through amendment or otherwise to reduce the benefits provided to a retired participant or the participant beneficiary under the terms of the plan if such reduction of benefits occurs after the date the participant retired for purposes of the plan and reduces benefits that were provided to the participant or the participant beneficiary as of the date the participant retired unless such reduction is also made with respect to active participants reduction described for purposes of this section a reduction in benefits with bills hr ih with respect to premiums occurs under a group health plan when a participant or beneficiary share of the total premium or in the case of a self insured plan the costs of coverage of the plan substantially increases or with respect to other cost sharing and benefits under a group health plan occurs when there is a substantial decrease in the actuarial value of the benefit package under the plan for purposes of this section the term substantial means an increase in the total premium share or a decrease in the actuarial value of the benefit package that is greater than percent conforming amendment the table of contents in section of such act as amended by sections and is amended by inserting after the item relating to section the following new item sec protection against postretirement reduction of retiree health benefits waiver an employer in a form and manner which shall be prescribed by the secretary of labor apply for a waiver from this provision if the employer can reasonably demonstrate that meeting the requirements of this section would impose an undue hardship on the employer with bills hr ih effective date the amendments made by this section shall take effect on the date of the enactment of this act sec reinsurance program for retirees a establishment in general not later than days after the date of the enactment of this act the secretary of health and human services shall establish a temporary reinsurance program in this section referred to as the reinsurance program to provide reimbursement to assist participating employment based plans with the cost of providing health benefits to retirees and to eligible spouses surviving spouses and dependents of such retirees definitions for purposes of this section a the term eligible employment based plan means a group health plan or employment based health plan that is maintained by one or more employers including without limitation any state or political subdivision thereof or any agency or instrumentality of any of the foregoing former with bills hr ih employers or employee organizations or associations or a voluntary employees beneficiary association or a committee or board of individuals appointed to administer such plan or a multiemployer plan as defined in section of the employee retirement income security act of and provides health benefits to retirees the term health benefits means medical surgical hospital prescription drug and such other benefits as shall be determined by the secretary whether self funded or delivered through the purchase of insurance or otherwise the term participating employmentbased plan means an eligible employmentbased plan that is participating in the reinsurance program the term retiree means with respect to a participating employment benefit plan an individual who is years of age or older with bills hr ih is not eligible for coverage under title xviii of the social security act and iii is not an active employee of an employer maintaining the plan or of any employer that makes or has made substantial contributions to fund such plan the term secretary means secretary of health and human services participation to be eligible to participate in the reinsurance program an eligible employment based plan shall submit to the secretary an application for participation in the program at such time in such manner and containing such information as the secretary shall require payment submission of claims a in general under the reinsurance program a participating employment based plan shall submit claims for reimbursement to the secretary which shall contain documentation of the actual costs of the items and services for which each claim is being submitted basis for claims each claim submitted under subparagraph a shall be based on the actual amount expended by the partici with bills hr ih pating employment based plan involved within the plan year for the appropriate employment based health benefits provided to a retiree or to the spouse surviving spouse or dependent of a retiree in determining the amount of any claim for purposes of this subsection the participating employment based plan shall take into account any negotiated price concessions such as discounts direct or indirect subsidies rebates and direct or indirect remunerations obtained by such plan with respect to such health benefits for purposes of calculating the amount of any claim the costs paid by the retiree or by the spouse surviving spouse or dependent of the retiree in the form of deductibles copayments and coinsurance shall be included along with the amounts paid by the participating employment based plan program payments and limit if the secretary determines that a participating employment based plan has submitted a valid claim under paragraph the secretary shall reimburse such plan for percent of that portion of the costs attributable to such claim that exceeds but is less than such amounts shall be adjusted with bills hr ih each year based on the percentage increase in the medical care component of the consumer price index rounded to the nearest multiple of for the year involved use of payments amounts paid to a participating employment based plan under this subsection shall only be used to reduce the costs of health care provided by the plan by reducing premium costs for the employer or employee association maintaining the plan and reducing premium contributions deductibles copayments coinsurance or other out of pocket costs for plan participants and beneficiaries where the benefits are provided by an employer to members of a represented bargaining unit the allocation of payments among these purposes shall be subject to collective bargaining amounts paid to the plan under this subsection shall not be used as general revenues by the employer or employee association maintaining the plan or for any other purposes the secretary shall develop a mechanism to monitor the appropriate use of such payments by such plans appeals and program protections the secretary shall establish with bills hr ih a an appeals process to permit participating employment based plans to appeal a determination of the secretary with respect to claims submitted under this section and procedures to protect against fraud waste and abuse under the program audits the secretary shall conduct annual audits of claims data submitted by participating employment based plans under this section to ensure that they are in compliance with the requirements of this section retiree reserve trust fund establishment a in general there is established in the treasury of the united states a trust fund to be known as the retiree reserve trust fund referred to in this section as the trust fund that shall consist of such amounts as be appropriated or credited to the trust fund as provided for in this subsection to enable the secretary to carry out the reinsurance program such amounts shall remain available until expended funding there are hereby appropriated to the trust fund out of any moneys with bills hr ih in the treasury not otherwise appropriated an amount requested by the secretary as necessary to carry out this section except that the total of all such amounts requested shall not exceed appropriations from the trust fund in general amounts in the trust fund are appropriated to provide funding to carry out the reinsurance program and shall be used to carry out such program limitation to available funds the secretary has the authority to stop taking applications for participation in the program or take such other steps in reducing expenditures under the reinsurance program in order to ensure that expenditures under the reinsurance program do not exceed the funds available under this subsection sec wellness program grants a allowance of grant in general for purposes of this section the secretaries of health and human services and with bills hr ih labor shall jointly award wellness grants as determined under this section wellness program grants shall be awarded to small employers as defined by the secretary for any plan year in an amount equal to percent of the costs paid or incurred by such employers in connection with a qualified wellness program during the plan year for purposes of the preceding sentence in the case of any qualified wellness program offered as part of an employmentbased health plan only costs attributable to the qualified wellness program and not to the health plan or health insurance coverage offered in connection with such a plan be taken into account limitations a period a wellness grant awarded to an employer under this section shall be for up to years amount the amount of the grant under paragraph for an employer shall not exceed the product of and the number of employees of the employer for any plan year and for the entire period of the grant with bills hr ih qualified wellness program for purposes of this section qualified wellness program the term qualified wellness program means a program that a includes any wellness components described in subsection and is to be certified jointly by the secretary of health and human services and the secretary of labor in coordination with the director of the centers for disease control and prevention as a qualified wellness program under this section programs must be consistent with research and best practices a in general the secretary of health and human services and the secretary of labor shall not certify a program as a qualified wellness program unless the program is consistent with evidence based research and best practices as identified by persons with expertise in employer health promotion and wellness programs includes multiple evidence based strategies which are based on the existing with bills hr ih and emerging research and careful scientific reviews including the guide to community preventative services the guide to clinical preventative services and the national registry for effective programs and iii includes strategies which focus on prevention and support for employee populations at risk of poor health outcomes periodic updating and review the secretaries of health and human services and labor in consultation with other appropriate agencies shall jointly establish procedures for periodic review evaluation and update of the programs under this subsection health literacy and accessibility the secretaries of health and human services and labor shall jointly as part of the certification process a ensure that employers make the programs culturally competent physically and programmatically accessible including for individuals with disabilities and appropriate to the health literacy needs of the employees covered by the programs with bills hr ih require a health literacy component to provide special assistance and materials to employees with low literacy skills limited english and from underserved populations and require the secretaries to compile and disseminate to employer health plans information on model health literacy curricula instructional programs and effective intervention strategies wellness program components for purposes of this section the wellness program components described in this subsection are the following health awareness component a health awareness component which provides for the following a health education the dissemination of health information which addresses the specific needs and health risks of employees health screenings the opportunity for periodic screenings for health problems and referrals for appropriate follow up measures employee engagement component an employee engagement component which provides for the active engagement of employees in worksite with bills hr ih wellness programs through worksite assessments and program planning onsite delivery evaluation and improvement efforts behavioral change component a behavioral change component which encourages healthy living through counseling seminars on line programs self help materials or other programs which provide technical assistance and problem solving skills such component include programs relating to a tobacco use obesity stress management physical fitness nutrition substance abuse depression and mental health promotion supportive environment component a supportive environment component which includes the following a on site policies policies and services at the worksite which promote a healthy lifestyle including policies relating to tobacco use at the worksite with bills hr ih the nutrition of food available at the worksite through cafeterias and vending options iii minimizing stress and promoting positive mental health in the workplace and iv the encouragement of physical activity before during and after work hours participation requirement no grant shall be allowed under subsection a unless the secretaries of health and human services and labor in consultation with other appropriate agencies jointly certify as a part of any certification described in subsection that each wellness program component of the qualified wellness program shall be available to all employees of the employer shall not mandate participation by employees and provide a financial reward for participation of an individual in such program so long as such reward is not tied to the premium or cost sharing of the individual under the health benefits plan privacy protections data gathered for purposes of the employer wellness program be used solely with bills hr ih for the purposes of administering the program the secretaries of health and human services and labor shall develop standards to ensure such data remain confidential and are not used for purposes beyond those for administering the program certain costs not included for purposes of this section costs paid or incurred by an employer for food or health insurance shall not be taken into account under subsection a outreach the secretaries of health and human services and labor in conjunction with other appropriate agencies and members of the business community shall jointly institute an outreach program to inform businesses about the availability of the wellness program grant as well as to educate businesses on how to develop programs according to recognized and promising practices and on how to measure the success of implemented programs effective date this section shall take effect on july authorization of appropriations there are authorized to be appropriated such sums as are necessary to carry out this section with bills hr ih sec extension of cobra continuation coverage a extension of current periods of continuation coverage in general in the case of any individual who is under a cobra continuation coverage provision covered under cobra continuation coverage on or after the date of the enactment of this act the required period of any such coverage which has not subsequently terminated under the terms of such provision for any reason other than the expiration of a period of a specified number of months shall notwithstanding such provision and subject to subsection extend to the earlier of the date on which such individual becomes eligible for acceptable coverage or the date on which such individual becomes eligible for health insurance coverage through the health insurance exchange or a state based health insurance exchange operating in a state or group of states notice as soon as practicable after the date of the enactment of this act the secretary of labor in consultation with the secretary of the treasury and the secretary of health and human services shall in consultation with administrators of the group health plans or other entities that with bills hr ih provide or administer the cobra continuation coverage involved provide rules setting forth the form and manner in which prompt notice to individuals of the continued availability of cobra continuation coverage to such individuals under paragraph continued effect of other terminating events notwithstanding subsection a any required period of cobra continuation coverage which is extended under such subsection shall terminate upon the occurrence prior to the date of termination otherwise provided in such subsection of any terminating event specified in the applicable continuation coverage provision other than the expiration of a period of a specified number of months access to state health benefits risk pools this section shall supersede any provision of the law of a state or political subdivision thereof to the extent that such provision has the effect of limiting or precluding access by a qualified beneficiary whose cobra continuation coverage has been extended under this section to a state health benefits risk pool recognized by the commissioner for purposes of this section solely by reason of the extension of such coverage beyond the date on which such coverage otherwise would have expired definitions for purposes of this section with bills hr ih cobra continuation coverage the term cobra continuation coverage means continuation coverage provided pursuant to part of subtitle of title of the employee retirement income security act of other than under section title xxii of the public health service act section of the internal revenue code of other than subsection of such section insofar as it relates to pediatric vaccines or section a of title united states code or under a state program that provides comparable continuation coverage such term does not include coverage under a health flexible spending arrangement under a cafeteria plan within the meaning of section of the internal revenue code of cobra continuation provision the term cobra continuation provision means the provisions of law described in paragraph sec state health access program grants a in general the secretary of health and human services in this section referred to as the secretary shall provide grants to states as defined for purposes of title xix of the social security act to establish programs to expand access to affordable health care coverage for the uninsured populations in that state in a with bills hr ih manner consistent with reforms to take effect under this division in types of programs the types of programs for which grants are available under subsection a include the following state insurance exchanges state insurance exchanges that develop new less expensive portable benefit packages for small employers and part time and seasonal workers community coverage program community coverage with shared responsibility between employers governmental or nonprofit entity and the individual reinsurance plan program reinsurance plans that subsidize a certain share of carrier losses within a certain risk corridor health insurance premium assistance transparent marketplace program transparent marketplace that provides an organized structure for the sale of insurance products such as a web exchange or portal automated enrollment program statewide or automated enrollment systems for public assistance programs with bills hr ih innovative strategies innovative strategies to insure low income childless adults purchasing collaboratives business consumer collaborative that provides direct contract health care service purchasing options for group plan sponsors eligibility and administration implementation of key statutory or regulatory changes in order to be awarded a grant under this section for a program a state shall demonstrate that a it has achieved the key state and local statutory or regulatory changes required to begin implementing the new program within year after the initiation of funding under the grant and it will be able to sustain the program without federal funding after the end of the period of the grant ineligibility a state that has already developed a comprehensive health insurance access program is not eligible for a grant under this section application required no state shall receive a grant under this section unless the state with bills hr ih has approved by the secretary such an application in such form and manner as the secretary specifies administration based on current program the program under this section is intended to build on the state health access program funded under the omnibus appropriations act public law – funding limitations in general a grant under this section shall a only be available for expenditures before and only be used to supplement and not supplant funds otherwise provided matching fund requirement a in general subject to subparagraph no grant be awarded to a state unless the state demonstrates the seriousness of its effort by matching at least percent of the grant amount through non federal resources which be a combination of state local private dollars from insurers providers and other private organizations waiver the secretary waive the requirement of subparagraph a if the with bills hr ih state demonstrates to the secretary financial hardship in complying with such requirement study the secretary shall review study and benchmark the progress and results of the programs funded under this section report each state receiving a grant under this section shall submit to the secretary a report on best practices and lessons learned through the grant to inform the health reform coverage expansions under this division beginning in funding there are authorized to be appropriated such sums as be necessary to carry out this section sec administrative simplification a standardizing electronic administrative transactions in general part of title xi of the social security act usc et seq is amended by inserting after section the following new sections sec a standardize electronic administrative transactions a standards for financial and administrative transactions with bills hr ih in general the secretary shall adopt and regularly update standards consistent with the goals described in paragraph goals for financial and administrative transactions the goals for standards under paragraph are that such standards shall to the extent practicable a be unique with no conflicting or redundant standards be authoritative permitting no additions or constraints for electronic transactions including companion guides be comprehensive efficient and robust requiring minimal augmentation by paper transactions or clarification by further communications enable the real time or near realtime determination of an individual financial responsibility at the point of service and to the extent possible prior to service including whether the individual is eligible for a specific service with a specific physician at a specific facility on a specific date or range of dates include utilization of a machine readable health with bills hr ih plan beneficiary identification card or similar mechanism enable where feasible near real time adjudication of claims provide for timely acknowledgment response and status reporting applicable to any electronic transaction deemed appropriate by the secretary describe all data elements such as reason and remark codes in unambiguous terms not permit optional fields require that data elements be either required or conditioned upon set values in other fields and prohibit additional conditions except where required by or to implement state or federal law or to protect against fraud and abuse and harmonize all common data elements across administrative and clinical transaction standards time for adoption not later than years after the date of the enactment of this section the secretary shall adopt standards under this section by interim final rule with bills hr ih requirements for specific standards the standards under this section shall be developed adopted and enforced so as to a clarify refine complete and expand as needed the standards required under section require paper versions of standardized transactions to comply with the same standards as to data content such that a fully compliant equivalent electronic transaction can be populated from the data from a paper version enable electronic funds transfers in order to allow automated reconciliation with the related health care payment and remittance advice require timely and transparent claim and denial management processes including uniform claim edits uniform reason and remark denial codes tracking adjudication and appeal processing require the use of a standard electronic transaction with which health care providers quickly and efficiently enroll with a with bills hr ih health plan to conduct the other electronic transactions provided for in this part and provide for other requirements relating to administrative simplification as identified by the secretary in consultation with stakeholders building on existing standards in adopting the standards under this section the secretary shall consider existing and planned standards implementation and enforcement not later than months after the date of the enactment of this section the secretary shall submit to the appropriate committees of congress a plan for the implementation and enforcement by not later than years after such date of enactment of the standards under this section such plan shall include a a process and timeframe with milestones for developing the complete set of standards a proposal for accommodating necessary changes between version changes and a process for upgrading standards as often as annually by interim final rulemaking with bills hr ih programs to provide incentives for and ease the burden of implementation for certain health care providers with special consideration given to such providers serving rural or underserved areas and ensure coordination with standards implementation specifications and certification criteria being adopted under the hitech act programs to provide incentives for and ease the burden of health care providers who volunteer to participate in the process of setting standards for electronic transactions an estimate of total funds needed to ensure timely completion of the implementation plan and an enforcement process that includes timely investigation of complaints random audits to ensure compliance civil monetary and programmatic penalties for noncompliance consistent with existing laws and regulations and a fair and reasonable appeals process building off of enforcement provisions under this part and concurrent state enforcement jurisdiction the secretary promulgate an annual audit and certification process to ensure that all health plans with bills hr ih and clearinghouses are both syntactically and functionally compliant with all the standard transactions mandated pursuant to the administrative simplification provisions of this part and the health insurance portability and accountability act of limitations on use of data nothing in this section shall be construed to permit the use of information collected under this section in a manner that would violate state or federal law protection of data the secretary shall ensure through the promulgation of regulations or otherwise that all data collected pursuant to subsection a are used and disclosed in a manner that meets the hipaa privacy and security law as defined in section a of the public health service act including any privacy or security standard adopted under section of such act sec interim companion guides including operating rules a in general the secretary shall adopt a single binding comprehensive companion guide that includes operating rules for each version transaction described in section a to be effective until the new version of these transactions which comply with section a are adopted and implemented with bills hr ih companion guide and operating rules development in adopting such interim companion guide and rules the secretary shall comply with section except that a nonprofit entity that meets the following criteria shall also be consulted the entity focuses its mission on administrative simplification the entity uses a multistakeholder process that creates consensus based companion guides including operating rules using a voting process that ensures balanced representation by the critical stakeholders including health plans and health care providers so that no one group dominates the entity and shall include others such as standards development organizations and relevant federal or state agencies the entity has in place a public set of guiding principles that ensure the companion guide and operating rules and process are open and transparent the entity coordinates its activities with the hit policy committee and the hit standards committee established under title xxx of the public health service act and complements the efforts with bills hr ih of the office of the national healthcare coordinator and its related health information exchange goals the entity incorporates the standards issued under health insurance portability and accountability act of and this part and in developing the companion guide and operating rules does not change the definition data condition or use of a data element or segment in a standard add any elements or segments to the maximum defined data set use any codes or data elements that are either marked not used in the standard implementation specifications or are not in the standard implementation specifications or change the meaning or intent of the standard implementation specifications the entity uses existing market research and proven best practices the entity has a set of measures that allow for the evaluation of their market impact and public reporting of aggregate stakeholder impact the entity supports nondiscrimination and conflict of interest policies that demonstrate a commitment to open fair and nondiscriminatory practices with bills hr ih the entity allows for public reviews and comment on updates of the companion guide including the operating rules implementation the secretary shall adopt a single binding companion guide including operating rules under this section for each transaction to become effective with the version transaction implementation or as soon thereafter as feasible the companion guide including operating rules for the transactions for eligibility for health plan and health claims status under this section shall be adopted not later than october in a manner such that such set of rules is effective beginning not later than january the companion guide including operating rules for the remainder of the transactions described in section a shall be adopted not later than october in a manner such that such set of rules is effective beginning not later than january definitions section of such act usc is amended a in paragraph by inserting and associated operational guidelines and instructions as determined appropriate by the secretary after medical procedure codes and with bills hr ih by adding at the end the following new paragraph operating rules the term operating rules means business rules for using and processing transactions such as service level requirements which do not impact the implementation specifications or other data content requirements conforming amendment section a of such act usc d– a is amended in the matter before paragraph a by inserting on behalf of an individual after and by inserting on behalf of an individual after for a financial institution and standards for claims attachments and coordination of benefits standard for health claims attachments not later than year after the date of the enactment of this act the secretary of health and human services shall promulgate an interim final rule to establish a standard for health claims attachment transaction described in section a of the social security act usc d– a and coordination of benefits with bills hr ih revision in processing payment transactions by financial institutions a in general section of the social security act usc d– is amended in the matter before paragraph by striking or is engaged and inserting and is engaged and by inserting other than as a business associate for a covered entity after for a financial institution compliance date the amendments made by subparagraph a shall apply to transactions occurring on or after such date not later than january as the secretary of health and human services shall specify standards for first report of injury not later than january the secretary of health and human services shall promulgate an interim final rule to establish a standard for the first report of injury transaction described in section a of the social security act usc d– a unique health plan identifier not later october the secretary of health and human services shall promulgate an interim final rule to establish with bills hr ih a unique health plan identifier described in section of the social security act usc d– based on the input of the national committee of vital and health statistics and consultation with health plans health care providers and other interested parties expansion of electronic transactions in medicare section a of the social security act usc a is amended in paragraph by striking or at the end in paragraph by striking the period and inserting or and by inserting after paragraph the following new paragraph subject to subsection not later than january for which the payment is other than by electronic funds transfer eft so long as the secretary has adopted and implemented a standard for electronic funds transfer under section a expansion of penalties section of such act usc d– is amended by adding at the end the following new subsection expansion of penalty authority the secretary in addition to the penalties provided under with bills hr ih subsections a and provide for the imposition of penalties for violations of this part that are comparable in the case of health plans to the sanctions the secretary is authorized to impose under part or of title xviii in the case of a plan that violates a provision of such part or in the case of a health care provider to the sanctions the secretary is authorized to impose under part a or of title xviii in the case of a health care provider that violations a provision of such part with respect to that provider title protections and standards for qualified health benefits plans subtitle a general standards sec 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 requirements for qualified health benefits plans on or after the first day of a health benefits plan shall not be a qualified health benefits plan with bills hr ih under this division unless the plan meets the applicable requirements of the following subtitles for the type of plan and plan year involved subtitle relating to affordable coverage subtitle relating to essential benefits subtitle relating to consumer protection terminology in this division enrollment in employment based health plans an individual shall be treated as being enrolled in an employment based health plan if the individual is a participant or beneficiary as such terms are defined in section and respectively of the employee retirement income security act of in such plan individual and group health insurance coverage the terms individual health insurance coverage and group health insurance coverage mean health insurance coverage offered in the individual market or large or small group market respectively as defined in section of the public health service act with bills hr ih sec 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 grandfathered health insurance coverage means individual health insurance coverage that is offered and in force and effect before the first day of if the following conditions are met limitation on new enrollment 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 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 limitation on changes in terms or conditions subject to paragraph 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 with bills hr ih 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 grace period for current employmentbased health plans grace period a in general the commissioner shall establish a grace period whereby for plan years beginning after the end of the year period beginning with an employment based health plan in operation as of the day before the first day of must meet the same requirements as apply to a qualified health benefits plan under section including the essential benefit package requirement under section 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 with bills hr ih any coverage described in section a iv of division of the american recovery and reinvestment act of public law – excepted benefits as defined in section of the employee retirement income security act of including coverage under a specified disease or illness policy described in paragraph a of such section iii such other limited benefits as the commissioner specify 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 through iii be treated as acceptable coverage under this division transitional treatment as acceptable coverage during the grace period specified in paragraph a an employment based health plan which be a high deducible health plan as defined in section of the internal revenue code of that is described in such paragraph shall be treated as acceptable coverage under this division with bills hr ih limitation on individual health insurance coverage in general individual health insurance coverage that is not grandfathered health insurance coverage under subsection a only be offered on or after the first day of as an exchange participating health benefits plan separate excepted coverage permitted nothing in a paragraph shall prevent the offering of excepted benefits described in section of the public health service act so long as such benefits are offered outside the health insurance exchange and are priced separately from health insurance coverage and this division shall be construed to prevent the offering of a standalone plan that offers coverage of excepted benefits described in section a of the public health service act relating to limited scope dental or vision benefits for individuals and families from a statelicensed dental and vision carrier or as applying requirements for a qualified health benefits plan to such a with bills hr ih stand alone plan that is offered and priced separately from a qualified health benefits plan subtitle standards guaranteeing access to affordable coverage sec prohibiting preexisting condition exclusions a qualified health benefits plan not impose any preexisting condition exclusion as defined in section 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 of the following health status medical condition claims experience receipt of health care medical history genetic information evidence of insurability disability or source of injury including conditions arising out of acts of domestic violence or any similar factors sec guaranteed issue and renewal for insured plans and prohibiting rescissions the requirements of sections other than subsections and and other than paragraphs and of subsection and subsection of the public health service act relating to guaranteed availability and with bills hr ih 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 in the same manner as such sections apply to employers and health insurance coverage offered in the small group market except that such section shall apply only if before nonrenewal or discontinuation of coverage the issuer has provided the enrollee with notice of nonpayment of premiums and there is a grace period during which the enrollee has an opportunity to correct such nonpayment rescissions of such coverage shall be prohibited except in cases of fraud as defined in section of such act sec insurance rating rules a in general the premium rate charged for a qualified health benefits plan that is health insurance coverage not vary except as follows 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 to with bills hr ih 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 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 actuarial value of optional service coverage 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 a considerations in making such estimate the commissioner a take into account the impact on overall costs of the inclusion of such coverage but not take into account any cost reduction estimated to result from such services in with bills hr ih cluding prenatal care delivery or postnatal care shall estimate such costs as if such coverage were included for the entire population covered and not estimate such a cost at less than per enrollee per month study and reports 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 a the types of employers by key characteristics including size that purchase insured products versus those that self insure the similarities and differences between typical insured and self insured health plans the financial solvency and capital reserve levels of employers that self insure by employer size with bills hr ih the risk of self insured employers not being able to pay obligations or otherwise becoming financially insolvent the extent to which rating rules are likely to cause adverse selection in the large group market or to encourage small and midsize employers to self insure reports not later than 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 such report shall include any recommendations the commissioner deems appropriate to ensure that the law does not provide incentives for small and midsize employers to self insure or create adverse selection in the risk pools of large group insurers and self insured employers not later than months after the first day of the commissioner shall submit to congress and the applicable agencies an updated report on such study including updates on such recommendations with bills hr ih sec nondiscrimination in benefits parity in mental health and substance abuse disorder benefits a nondiscrimination in benefits a qualified health benefits plan shall comply with standards established by the commissioner to prohibit discrimination in health benefits or benefit structures for qualifying health benefits plans building from section of the employee retirement income security act of section of the public health service act and section of the internal revenue code of parity in mental health and substance abuse disorder benefits to the extent such provisions are not superceded by or inconsistent with subtitle the provisions of section other than subsections a a and 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 sec ensuring adequacy of provider networks a in general a qualified health benefits plan that uses a provider network for items and services shall meet such standards respecting provider networks as the commissioner establish to assure the adequacy of such networks in ensuring enrollee access to such items with bills hr ih and services and transparency in the cost sharing differentials among providers participating in the network and policies for accessing out of network providers internet access to information a qualified health benefits plan that uses a provider network shall provide a current listing of all providers in its network on its website and such data shall be available on the health insurance exchange website as a part of the basic information on that plan the commissioner shall also establish an on line system whereby an individual select by name any medical provider as defined by the commissioner and be informed of the plan or plans with which that provider is contracting provider network defined in this division the term provider network means the providers with respect to which covered benefits treatments and services are available under a health benefits plan sec requiring the option of extension of dependent coverage for uninsured young adults a in general a qualified health benefits plan shall make available at the option of the principal enrollee under the plan coverage for one or more qualified children as defined in subsection of the enrollee with bills hr ih qualified child defined in this section the term qualified child means with respect to a principal enrollee in a qualified health benefits plan an individual who but for age would be treated as a dependent child of the enrollee under such plan and who is under years of age and is not enrolled in a health benefits plan other than under this section premiums nothing in this section shall be construed as preventing a qualified health benefits plan from increasing the premiums otherwise required for coverage provided under this section consistent with standards established by the commissioner based upon family size under section a sec consistency of costs and coverage under qualified health benefits plans during plan year in the case of health insurance coverage offered under a qualified health benefits plan if the coverage decreases or the cost sharing increases the issuer of the coverage shall notify enrollees of the change at least days before the change takes effect or such shorter period of time in cases where the change is necessary to ensure the health and safety of enrollees with bills hr ih subtitle standards guaranteeing access to essential benefits sec 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 for the essential benefits package described in section for the plan year involved choice of coverage 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 offer such coverage in addition to the essential benefits package as the qhbp offering entity specify exchange participating health benefits plans in the case of an exchange participating health benefits plan such plan is required under section to provide specified levels of benefits and in the case of a plan offering a premiumplus level of benefits provide additional benefits continuation of offering of separate excepted benefits coverage nothing in this division shall be construed as affecting the offering with bills hr ih outside of the health insurance exchange and under state law of health benefits in the form of excepted benefits described in section if such benefits are offered under a separate policy contract or certificate of insurance clinical appropriateness nothing in this act shall be construed to prohibit a group health plan or health insurance issuer from using medical management practices so long as such management practices are based on valid medical evidence and are relevant to the patient whose medical treatment is under review provision of benefits nothing in this division shall be construed as prohibiting a qualified health benefits plan from subcontracting with stand alone health insurance issuers or insurers for the provision of dental vision mental health and other benefits and services sec essential benefits package defined a in general in this division the term essential benefits package means health benefits coverage consistent with standards adopted under section to ensure the provision of quality health care and financial security that provides payment for the items and services described in subsection in accordance with gen with bills hr ih erally accepted standards of medical or other appropriate clinical or professional practice limits cost sharing for such covered health care items and services in accordance with such benefit standards consistent with subsection does not impose any annual or lifetime limit on the coverage of covered health care items and services complies with section a relating to network adequacy and is equivalent in its scope of benefits as certified by office of the actuary of the centers for medicare medicaid services to the average prevailing employer sponsored coverage in in order to carry out paragraph the secretary of labor shall conduct a survey of employer sponsored coverage to determine the benefits typically covered by employers including multiemployer plans and provide a report on such survey to the health benefits advisory committee and to the secretary of health and human services minimum services to be covered subject to subsection the items and services described in this subsection are the following hospitalization with bills hr ih outpatient hospital and outpatient clinic services including emergency department services professional services of physicians and other health professionals such services equipment and supplies incident to the services of a physician or a health professional delivery of care in institutional settings physician offices patients homes or place of residence or other settings as appropriate prescription drugs rehabilitative and habilitative services mental health and substance use disorder services including behavioral health treatments preventive services including those services recommended with a grade of a or 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 maternity care well baby and well child care and oral health vision and hearing services equipment and supplies for children under years of age durable medical equipment prosthetics orthotics and related supplies with bills hr ih requirements relating to cost sharing and minimum actuarial value no cost sharing for preventive services there shall be no cost sharing under the essential benefits package for a preventive items and services recommended with a grade of a or 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 or well baby and well child care annual limitation 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 applicable level the applicable level specified in this subparagraph for is not to exceed for an individual and not to exceed for a family such levels shall be increased rounded to the nearest for each subsequent year by the annual percentage increase in the enrollment weighted with bills hr ih average of premium increases for basic plans applicable to such year except that secretary shall adjust such increase to ensure that the applicable level specified in this subparagraph meets the minimum actuarial value required under paragraph 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 minimum actuarial value 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 percent of the full actuarial value of the benefits provided under the reference benefits package described in subparagraph reference benefits package described the reference benefits package described in this subparagraph is the essential benefits package if there were no cost sharing imposed with bills hr ih assessment and counseling for domestic violence the secretary shall support the need for an assessment and brief counseling for domestic violence as part of a behavioral health assessment or primary care visit and determine the appropriate coverage for such assessment and counseling abortion coverage prohibited as part of minimum benefits package prohibition of required coverage the health benefits advisory committee not recommend under section and the secretary not adopt in standards under section the services described in paragraph a or as part of the essential benefits package and the commissioner not require such services for qualified health benefits plans to participate in the health insurance exchange 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 a or and the qhbp offering entity shall determine whether such coverage is provided with bills hr ih coverage under public health insurance option the public health insurance option shall provide coverage for services described in paragraph 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 a abortion services 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 months before the beginning of the plan year involved 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 months before the beginning of the plan year involved with bills hr ih report regarding inclusion of oral health care in essential benefits package not later than year after the date of the enactment of this act the secretary of health and human services shall submit to congress a report containing the results of a study determining the need and cost of providing accessible and affordable oral health care to adults as part of the essential benefits package sec health benefits advisory committee a establishment 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 chair the surgeon general shall be a member and the chair of the health benefits advisory committee membership the health benefits advisory committee shall be composed of the following members in addition to the surgeon general a nine members who are not federal employees or officers and who are appointed by the president with bills hr ih nine 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 of the social security act such even number of members not to exceed who are federal employees and officers as the president appoint such initial appointments shall be made not later than days after the date of the enactment of this act terms each member of the health benefits advisory committee shall serve a 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 participation the membership of the health benefits advisory committee shall at least reflect providers patient representatives employers including small employers labor health insurance issuers experts in health care financing and delivery experts in oral health care experts in racial and with bills hr ih ethnic disparities experts on health care needs and disparities of individuals with disabilities representatives of relevant governmental agencies and at least one practicing physician or other health professional and an expert in child and adolescent 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 duties 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 secretary benefit standards as defined in paragraph 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 deadline the health benefits advisory committee shall recommend initial benefit standards to the secretary not later than year after the date of the enactment of this act with bills hr ih state input the health benefits advisory committee shall examine the health coverage laws and benefits of each state in developing recommendations under this subsection and incorporate such coverage and benefits as the committee determines to be appropriate and consistent with this act the health benefits advisory committee shall also seek input from the states and consider recommendations on how to ensure quality of health coverage in all states public input the health benefits advisory committee shall allow for public input as a part of developing recommendations under this subsection benefit standards defined in this subtitle the term benefit standards means standards respecting a the essential benefits package described in section including categories of covered treatments items and services within benefit classes and cost sharing consistent with subsection of such section and the cost sharing levels for enhanced plans and premium plans as provided under section consistent with paragraph with bills hr ih levels of cost sharing for enhanced and premium plans a enhanced plan the level of costsharing for enhanced plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately percent of the actuarial value of the benefits provided under the reference benefits package described in section premium plan the level of costsharing for premium plans shall be designed so that such plans have benefits that are actuarially equivalent to approximately percent of the actuarial value of the benefits provided under the reference benefits package described in section c operations 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 of chapter of title united states code and shall otherwise serve without additional pay members not treated as federal employees members of the health benefits advi with bills hr ih sory committee shall not be considered employees of the federal government solely by reason of any service on the committee except such members shall be considered to be within the meaning of section a of title united states code for the purposes of disclosure and management of conflicts of interest application of faca the federal advisory committee act usc app other than section shall apply to the health benefits advisory committee 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 sec process for adoption of recommendations adoption of benefit standards a process for adoption of recommendations review of recommended standards not later than days after the date of receipt of benefit standards recommended under section including such standards as modified under paragraph the secretary shall review such with bills hr ih standards and shall determine whether to propose adoption of such standards as a package determination to adopt standards if the secretary determines a to propose adoption of benefit standards so recommended as a package the secretary shall by regulation under section of title united states code propose adoption of such standards or 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 contingency if because of the application of paragraph the secretary would otherwise be unable to propose initial adoption of such recommended standards by the deadline specified in subsection the secretary shall by regulation under section of title united states code with bills hr ih propose adoption of initial benefit standards by such deadline publication the secretary shall provide for publication in the federal register of all determinations made by the secretary under this subsection adoption of standards initial standards not later than 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 periodic updating standards under subsection a the secretary shall provide for the periodic updating of the benefit standards previously adopted under this section requirement the secretary 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 including subsection and with bills hr ih subtitle additional consumer protections sec requiring fair marketing practices by health insurers the commissioner shall establish uniform marketing standards that all qhbp offering entities shall meet with respect to qualified health benefits plans that are health insurance coverage sec requiring fair grievance and appeals mechanisms a in general a qhbp offering entity shall provide for timely grievance and appeals mechanisms with respect to qualified health benefits plans that the commissioner shall establish consistent with this section the commissioner shall establish time limits for each of such mechanisms and implement them in a manner that is protective to the needs of patients 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 – of title code of federal regulations as published on november fed reg with bills hr ih and shall update such process in accordance with any standards that the commissioner establish external review process 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 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 time limits the commissioner shall establish time limits for each of these processes and implement them in a manner that is protective to the patient construction nothing in this section shall be construed as affecting the availability of judicial review under state law for adverse decisions under subsection or subject to section sec requiring information transparency and plan disclosure a accurate and timely disclosure with bills hr ih for exchange participating health benefits plans a qhbp offering entity offering an exchange participating health benefits plan shall comply with standards established by the commissioner for the accurate and timely disclosure to the commissioner and the public 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 employment based health plans the secretary of labor shall update and harmonize the secretary rules concerning the accurate and timely disclosure to participants by group health plans of plan disclosure plan terms and conditions and periodic financial disclosure with the standards established by the commissioner under paragraph use of plain language a in general the disclosures under paragraphs and shall be provided in plain language with bills hr ih definition in this paragraph the term plain language means language that the intended audience including individuals with limited english proficiency can readily understand and use because that language is concise well organized and follows other best practices of plain language writing guidance the commissioner and the secretary of labor shall jointly develop and issue guidance on best practices of plain language writing information on rights the information disclosed under this subsection shall include information on enrollee and participant rights under this division cost sharing transparency a qualified health benefits plan shall allow individuals to learn the amount of cost sharing including deductibles copayments and coinsurance under the individual plan or coverage that the individual would be responsible for paying with respect to the furnishing of a specific item or service by a participating provider in a timely manner upon request at a minimum this information shall be made available with bills hr ih to such individual via an internet website and other means for individuals without access to the internet contracting reimbursement a qualified health benefits plan 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 pharmacy benefit managers transparency requirements in general if a qhbp offering entity contracts with a pharmacy benefit manager or other entity in this subsection referred to as a pbm to manage prescription drug coverage or otherwise control prescription drug costs under a qualified health benefits plan the pbm shall provide at least annually to the commissioner and to the qhbp offering entity offering such plan the following information in a form and manner to be determined by the commissioner a information on the number and total cost of prescriptions under the contract that are filled via mail order and at retail pharmacies an estimate of aggregate average payments under the contract per prescription weighted by prescription volume made to mail with bills hr ih order and retail pharmacies and the average amount per prescription that the pbm was paid by the plan for prescriptions filled at mail order and retail pharmacists 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 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 information on the percentage and number of cases under the contract in which individuals were switched because of pbm policies or at the direct or indirect control of the pbm from a prescribed drug that had a lower with bills hr ih cost for the qhbp offering entity to a drug that had a higher cost for the qhbp offering entity the rationale for these switches and a description of the pbm policies governing such switches confidentiality of information 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 only by the commissioner a to permit state or federal law enforcement authorities to use the information provided for program compliance purposes and for the purpose of combating waste fraud and abuse to permit the comptroller general the medicare payment advisory commission or the secretary of health and human services to review the information provided and with bills hr ih to permit the director of the congressional budget office to review the information provided annual public report on an annual basis the commissioner shall prepare a public report providing industrywide aggregate or average information to be used in assessing the overall impact of pbms on prescription drug prices and spending such report shall not disclose the identity of a specific pbm or prices charged by such pbm or a specific retailer manufacturer or wholesaler or any other confidential or trade secret information penalties the provisions of subsection of section shall apply to a pbm that fails to provide information required under subsection a or that knowingly provides false information in the same manner as such provisions apply to a manufacturer with an agreement under such section that fails to provide information under subsection a of such section or knowingly provides false information under such section respectively with bills hr ih sec application to qualified health benefits plans not offered through the health insurance exchange the requirements of the previous provisions of this subtitle shall apply to qualified health benefits plans that are not being offered through the health insurance exchange only to the extent specified by the commissioner sec timely payment of claims a qhbp offering entity shall comply with the requirements of section of the social security act with respect to a qualified health benefits plan it offers in the same manner as a medicare advantage organization is required to comply with such requirements with respect to a medicare advantage plan it offers under part of medicare sec standardized rules for coordination and subrogation of benefits the commissioner shall establish standards for the coordination and subrogation of benefits and reimbursement of payments in cases of qualified health benefits plans involving individuals and multiple plan coverage sec application of administrative simplification a qhbp offering entity is required to comply with administrative simplification provisions under part of with bills hr ih title xi of the social security act with respect to qualified health benefits plans it offers sec state prohibitions on discrimination against health care providers this act and the amendments made by this act shall not be construed as superseding laws as they now or hereinafter exist of any state or jurisdiction designed to prohibit a qualified health benefits plan from discriminating with respect to participation reimbursement covered services indemnification or related requirements under such plan against a health care provider that is acting within the scope of that provider license or certification under applicable state law sec protection of physician prescriber information a study the secretary of health and human services shall conduct a study on the use of physician prescriber information in sales and marketing practices of pharmaceutical manufacturers report based on the study conducted under subsection a the secretary shall submit to congress a report on actions needed to be taken by the congress or the secretary to protect providers from biased marketing and sales practices with bills hr ih sec dissemination of advance care planning information a in general the qhbp offering entity shall provide for the dissemination of information related to end of life planning to individuals seeking enrollment in exchange participating health benefits plans offered through the exchange shall present such individuals with a the option to establish advanced directives and physician orders for life sustaining treatment according to the laws of the state in which the individual resides and information related to other planning tools and shall not promote suicide assisted suicide euthanasia or mercy killing the information presented under paragraph shall not presume the withdrawal of treatment and shall include end of life planning information that includes options to maintain all or most medical interventions construction nothing in this section shall be construed to require an individual to complete an advanced directive or a physician order for life sustaining treatment or other end of life planning document with bills hr ih to require an individual to consent to restrictions on the amount duration or scope of medical benefits otherwise covered under a qualified health benefits plan or to promote suicide assisted suicide euthanasia or mercy killing advanced directive defined in this section the term advanced directive includes a living will a comfort care order or a durable power of attorney for health care prohibition on the promotion of assisted suicide in general subject to paragraph information provided to meet the requirements of subsection a shall not include advanced directives or other planning tools that list or describe as an option suicide assisted suicide euthanasia or mercy killing regardless of legality construction nothing in paragraph shall be construed to apply to or affect any option to a withhold or withdraw of medical treatment or medical care withhold or withdraw of nutrition or hydration and with bills hr ih provide palliative or hospice care or use an item good benefit or service furnished for the purpose of alleviating pain or discomfort even if such use increase the risk of death so long as such item good benefit or service is not also furnished for the purpose of causing or the purpose of assisting in causing death for any reason no preemption of state law nothing in this section shall be construed to preempt or otherwise have any effect on state laws regarding advance care planning palliative care or end of life decision making subtitle governance sec health choices administration health choices commissioner a in general there is hereby established as an independent agency in the executive branch of the government a health choices administration in this division referred to as the administration commissioner in general the administration shall be headed by a health choices commissioner in this division referred to as the commissioner who with bills hr ih shall be appointed by the president by and with the advice and consent of the senate compensation etc the provisions of paragraphs and of subsection a relating to compensation terms general powers rulemaking and delegation of section of the social security act usc shall apply to the commissioner and the administration in the same manner as such provisions apply to the commissioner of social security and the social security administration inspector general for provision establishing an office of the inspector general for the health choices administration see section sec duties and authority of commissioner a duties the commissioner is responsible for carrying out the following functions under this division qualified plan standards the establishment of qualified health benefits plan standards under this title including the enforcement of such standards in coordination with state insurance regulators and the secretaries of labor and the treasury with bills hr ih health insurance exchange the establishment and operation of a health insurance exchange under subtitle a of title iii individual affordability credits the administration of individual affordability credits under subtitle of title iii including determination of eligibility for such credits additional functions such additional functions as be specified in this division promoting accountability in general the commissioner shall undertake activities in accordance with this subtitle to promote accountability of qhbp offering entities in meeting federal health insurance requirements regardless of whether such accountability is with respect to qualified health benefits plans offered through the health insurance exchange or outside of such exchange compliance examination and audits a in general the commissioner shall in coordination with states conduct audits of qualified health benefits plan compliance with federal requirements such audits include random compliance audits and targeted with bills hr ih audits in response to complaints or other suspected noncompliance recoupment of costs in connection with examination and audits the commissioner is authorized to recoup from qualified health benefits plans reimbursement for the costs of such examinations and audit of such qhbp offering entities data collection the commissioner shall collect data for purposes of carrying out the commissioner duties including for purposes of promoting quality and value protecting consumers and addressing disparities in health and health care and share such data with the secretary of health and human services sanctions authority in general in the case that the commissioner determines that a qhbp offering entity violates a requirement of this title the commissioner in coordination with state insurance regulators and the secretary of labor provide in addition to any other remedies authorized by law for any of the remedies described in paragraph remedies the remedies described in this paragraph with respect to a qualified health benefits plan offered by a qhbp offering entity are with bills hr ih a civil money penalties of not more than the amount that would be applicable under similar circumstances for similar violations under section of the social security act suspension of enrollment of individuals under such plan after the date the commissioner notifies the entity of a determination under paragraph and until the commissioner is satisfied that the basis for such determination has been corrected and is not likely to recur in the case of an exchange participating health benefits plan suspension of payment to the entity under the health insurance exchange for individuals enrolled in such plan after the date the commissioner notifies the entity of a determination under paragraph and until the secretary is satisfied that the basis for such determination has been corrected and is not likely to recur or working with state insurance regulators to terminate plans for repeated failure by the offering entity to meet the requirements of this title with bills hr ih standard definitions of insurance and medical terms the commissioner shall provide for the development of standards for the definitions of terms used in health insurance coverage including insurance related terms efficiency in administration the commissioner shall issue regulations for the effective and efficient administration of the health insurance exchange and affordability credits under subtitle including with respect to the determination of eligibility for affordability credits the use of personnel who are employed in accordance with the requirements of title united states code to carry out the duties of the commissioner or in the case of sections and the use of state personnel who are employed in accordance with standards prescribed by the office of personnel management pursuant to section of the intergovernmental personnel act of usc sec consultation and coordination a consultation in carrying out the commissioner duties under this division the commissioner as appropriate shall consult at least with the following state attorneys general and state insurance regulators including concerning the standards for health insurance coverage that is a qualified health with bills hr ih benefits plan under this title and enforcement of such standards the national association of insurance commissioners including for purposes of using model guidelines established by such association for purposes of subtitles and appropriate state agencies specifically concerning the administration of individual affordability credits under subtitle of title iii and the offering of exchange participating health benefits plans to medicaid eligible individuals under subtitle a of such title the federal trade commission specifically concerning the development and issuance of guidance rules or standards regarding fair marketing practices under section or otherwise or any consumer disclosure requirements under section or otherwise other appropriate federal agencies indian tribes and tribal organizations coordination in general in carrying out the functions of the commissioner including with respect to the enforcement of the provisions of this division the commissioner shall work in coordination with with bills hr ih existing federal and state entities to the maximum extent feasible consistent with this division and in a manner that prevents conflicts of interest in duties and ensures effective enforcement uniform standards the commissioner in coordination with such entities shall seek to achieve uniform standards that adequately protect consumers in a manner that does not unreasonably affect employers and insurers sec health insurance ombudsman a in general the commissioner shall appoint within the health choices administration a qualified health benefits plan ombudsman who shall have expertise and experience in the fields of health care and education of and assistance to individuals duties the qualified health benefits plan ombudsman shall in a linguistically appropriate manner receive complaints grievances and requests for information submitted by individuals through means such as the mail by telephone electronically and in person provide assistance with respect to complaints grievances and requests referred to in paragraph including with bills hr ih a helping individuals determine the relevant information needed to seek an appeal of a decision or determination assistance to such individuals in choosing a qualified health benefits plan in which to enroll assistance to such individuals with any problems arising from disenrollment from such a plan and assistance to such individuals in presenting information under subtitle relating to affordability credits and submit annual reports to congress and the commissioner that describe the activities of the ombudsman and that include such recommendations for improvement in the administration of this division as the ombudsman determines appropriate the ombudsman shall not serve as an advocate for any increases in payments or new coverage of services but identify issues and problems in payment or coverage policies with bills hr ih subtitle relation to other requirements miscellaneous sec relation to other requirements a coverage not offered through exchange in general in the case of health insurance coverage not offered through the health insurance exchange whether or not offered in connection with an employment based health plan and in the case of employment based health plans the requirements of this title do not supercede any requirements applicable under titles xxii and xxvii of the public health service act parts and of subtitle of title of the employee retirement income security act of or state law except insofar as such requirements prevent the application of a requirement of this division as determined by the commissioner construction nothing in paragraphs or shall be construed as affecting the application of section of the employee retirement income security act of coverage offered through exchange with bills hr ih in general in the case of health insurance coverage offered through the health insurance exchange a the requirements of this title do not supercede any requirements including requirements relating to genetic information nondiscrimination and mental health parity applicable under title xxvii of the public health service act or under state law except insofar as such requirements prevent the application of a requirement of this division as determined by the commissioner and individual rights and remedies under state laws shall apply construction in the case of coverage described in paragraph nothing in such paragraph shall be construed as preventing the application of rights and remedies under state laws to health insurance issuers generally with respect to any requirement referred to in paragraph a the previous sentence shall not be construed as providing for the applicability of rights or remedies under state laws with respect to requirements applicable to employers or other plan sponsors in connection with arrangements which are treated as group with bills hr ih health plans under section a of the employee retirement income security act of sec prohibiting discrimination in health care a in general except as otherwise explicitly permitted by this act and by subsequent regulations consistent with this act all health care and related services including insurance coverage and public health activities covered by this act shall be provided without regard to personal characteristics extraneous to the provision of high quality health care or related services implementation to implement the requirement set forth in subsection a the secretary of health and human services shall not later than months after the date of the enactment of this act promulgate such regulations as are necessary or appropriate to insure that all health care and related services including insurance coverage and public health activities covered by this act are provided whether directly or through contractual licensing or other arrangements without regard to personal characteristics extraneous to the provision of high quality health care or related services sec whistleblower protection a retaliation prohibited no employer discharge any employee or otherwise discriminate against any employee with respect to his compensation terms with bills hr ih conditions or other privileges of employment because the employee or any person acting pursuant to a request of the employee provided caused to be provided or is about to provide or cause to be provided to the employer the federal government or the attorney general of a state information relating to any violation of or any act or omission the employee reasonably believes to be a violation of any provision of this act or any order rule or regulation promulgated under this act testified or is about to testify in a proceeding concerning such violation assisted or participated or is about to assist or participate in such a proceeding or objected to or refused to participate in any activity policy practice or assigned task that the employee or other such person reasonably believed to be in violation of any provision of this act or any order rule or regulation promulgated under this act enforcement action an employee covered by this section who alleges discrimination by an employer in violation of subsection a bring an action governed by the rules procedures legal burdens of proof and rem with bills hr ih edies set forth in section of the consumer product safety act usc employer defined as used in this section the term employer means any person including one or more individuals partnerships associations corporations trusts professional membership organization including a certification disciplinary or other professional body unincorporated organizations nongovernmental organizations or trustees engaged in profit or nonprofit business or industry whose activities are governed by this act and any agent contractor subcontractor grantee or consultant of such person rule of construction the rule of construction set forth in section of title united states code shall also apply to this section sec construction regarding collective bargaining nothing in this division shall be construed to alter or supersede any statutory or other obligation to engage in collective bargaining over the terms or conditions of employment related to health care any plan amendment made pursuant to a collective bargaining agreement relating to the plan which amends the plan solely to conform to any requirement added by this division shall not be with bills hr ih treated as a termination of such collective bargaining agreement sec severability if any provision of this act or any application of such provision to any person or circumstance is held to be unconstitutional the remainder of the provisions of this act and the application of the provision to any other person or circumstance shall not be affected sec treatment of hawaii prepaid health care act a in general subject to this section nothing in this division or an amendment made by this division shall be construed to modify or limit the application of the exemption for the hawaii prepaid health care act haw rev stat §§ – et seq as provided for under section of the employee retirement income security act of usc and such exemption shall also apply with respect to the provisions of this division and for purposes of this division and the amendments made by this division coverage provided pursuant to the hawaii prepaid health care act shall be treated as a qualified health benefits plan providing acceptable coverage so long as the with bills hr ih secretary of labor determines that such coverage for employees taking into account the benefits and the cost to employees for such benefits is substantially equivalent to or greater than the coverage provided for employees pursuant to the essential benefits package coordination with state law of hawaii the commissioner shall based on ongoing consultation with the appropriate officials of the state of hawaii make adjustments to rules and regulations of the commissioner under this division as be necessary as determined by the commissioner to most effectively coordinate the provisions of this division with the provisions of the hawaii prepaid health care act taking into account any changes made from time to time to the hawaii prepaid health care act and related laws of such state sec actions by state attorneys general any state attorney general bring a civil action in the name of such state as parens patriae on behalf of natural persons residing in such state in any district court of the united states or state court having jurisdiction of the defendant to secure monetary or equitable relief for violation of any provisions of this title or regulations issued thereunder nothing in this section shall be con with bills hr ih strued as affecting the application of section of the employee retirement income security act of sec application of state and federal laws regarding abortion a no preemption of state laws regarding abortion nothing in this act shall be construed to preempt or otherwise have any effect on state laws regarding the prohibition of or requirement of coverage funding or procedural requirements on abortions including parental notification or consent for the performance of an abortion on a minor no effect on federal laws regarding abortion in general nothing in this act shall be construed to have any effect on federal laws regarding a conscience protection willingness or refusal to provide abortion and discrimination on the basis of the willingness or refusal to provide pay for cover or refer for abortion or to provide or participate in training to provide abortion no effect on federal civil rights law nothing in this section shall alter the rights and obliga with bills hr ih tions of employees and employers under title vii of the civil rights act of sec nondiscrimination on abortion and respect for rights of conscience a nondiscrimination a federal agency or program and any state or local government that receives federal financial assistance under this act or an amendment made by this act not subject any individual or institutional health care entity to discrimination or require any health plan created or regulated under this act or an amendment made by this act to subject any individual or institutional health care entity to discrimination on the basis that the health care entity does not provide pay for provide coverage of or refer for abortions definition in this section the term health care entity includes an individual physician or other health care professional a hospital a provider sponsored organization a health maintenance organization a health insurance plan or any other kind of health care facility organization or plan administration the office for civil rights of the department of health and human services is designated to receive complaints of discrimination based on with bills hr ih this section and coordinate the investigation of such complaints sec authority of federal trade commission section of the federal trade commission act usc is amended by striking and prepare reports and all that follows and inserting the following and prepare reports and to share information under clauses and relating to the business of insurance notwithstanding section such authority shall include the authority to conduct studies and prepare reports and to share information under clauses and relating to the business of insurance without regard to whether the entity or entities that is the subject of such studies reports or information is a for profit or not for profit entity sec construction regarding standard of care a in general the development recognition or implementation of any guideline or other standard under a provision described in subsection shall not be construed to establish the standard of care or duty of care owed by health care providers to their patients in any medical malpractice action or claim as defined in section of the health care quality improvement act of usc with bills hr ih provisions described the provisions described in this subsection are the following section relating to modernized payment initiatives and delivery system reform under the public health option the amendments made by section relating to reducing potentially preventable hospital readmissions the amendments made by section relating to health care acquired conditions section of the public health service act relating to the task force on clinical preventive services added by section part of title ix of the public health service act relating to implementation of best practices in the delivery of health care added by section sec restoring application of antitrust laws to health sector insurers a amendment to mccarran ferguson act section of the act of march usc commonly known as the mccarran ferguson act is amended by adding at the end the following except as provided in paragraph nothing contained in this act shall modify impair or supersede with bills hr ih the operation of any of the antitrust laws with respect to price fixing market allocation or monopolization or attempting to monopolize by a a person engaged in the business of health insurance in connection with providing health insurance or a person engaged in the business of medical malpractice insurance in connection with providing medical malpractice insurance paragraph shall not apply to a collecting compiling classifying or disseminating historical loss data determining a loss development factor applicable to historical loss data performing actuarial services if doing so does not involve a restraint of trade or information gathering and rate setting activities of a state insurance commission or other state regulatory entity with authority to set insurance rates for purposes of this subsection a the term antitrust laws has the meaning given it in subsection a of the first section of the clayton act except that such term includes section of the federal trade commission act to the ex with bills hr ih tent that such section applies to unfair methods of competition the term historical loss data means information respecting claims paid or reserves held for claims reported by any person engaged in the business of insurance and the term loss development factor means an adjustment to be made to the aggregate of losses incurred during a prior period of time that have been paid or for which claims have been received and reserves are being held in order to estimate the aggregate of the losses incurred during such period that will ultimately be paid related provision for purposes of section of the federal trade commission act usc to the extent such section applies to unfair methods of competition section of the mccarran ferguson act shall apply with respect to the business of health insurance and with respect to the business of medical malpractice insurance without regard to whether such business is carried on for profit notwithstanding the definition of corporation contained in section of the federal trade commission act related preservation of antitrust laws except as provided in subsections a and with bills hr ih nothing in this act or in the amendments made by this act shall be construed to modify impair or supersede the operation of any of the antitrust laws for purposes of the preceding sentence the term antitrust laws has the meaning given it in subsection a of the first section of the clayton act except that it includes section of the federal trade commission act to the extent that such section applies to unfair methods of competition sec study and report on methods to increase ehr use by small health care providers a study the secretary of health and human services shall conduct a study of potential methods to increase the use of qualified electronic health records as defined in section of the public health service act by small health care providers such study shall consider at least the following methods providing for higher rates of reimbursement or other incentives for such health care providers to use electronic health records taking into consideration initiatives by private health insurance companies and incentives provided under medicare under title xviii of the social security act medicaid under title xix of such act and other programs with bills hr ih promoting low cost electronic health record software packages that are available for use by such health care providers including software packages that are available to health care providers through the veterans administration and other sources training and education of such health care providers on the use of electronic health records providing assistance to such health care providers on the implementation of electronic health records report not later than december the secretary of health and human services shall submit to congress a report containing the results of the study conducted under subsection a including recommendations for legislation or administrative action to increase the use of electronic health records by small health care providers that include the use of both public and private funding sources with bills hr ih title iii health insurance exchange and related provisions subtitle a health insurance exchange sec establishment of health insurance exchange outline of duties definitions a establishment there is established within the health choices administration and under the direction of the commissioner a health insurance exchange in order to facilitate access of individuals and employers through a transparent process to a variety of choices of affordable quality health insurance coverage including a public health insurance option outline of duties of commissioner in accordance with this subtitle and in coordination with appropriate federal and state officials as provided under section the commissioner shall under section establish standards for accept bids from and negotiate and enter into contracts with qhbp offering entities for the offering of health benefits plans through the health insurance exchange with different levels of benefits required under section and including with respect to oversight and enforcement with bills hr ih under section facilitate outreach and enrollment in such plans of exchange eligible individuals and employers described in section and conduct such activities related to the health insurance exchange as required including establishment of a risk pooling mechanism under section and consumer protections under subtitle of title sec exchange eligible individuals and employers a access to coverage in accordance with this section all individuals are eligible to obtain coverage through enrollment in an exchange participating health benefits plan offered through the health insurance exchange unless such individuals are enrolled in another qualified health benefits plan or other acceptable coverage definitions in this division exchange eligible individual the term exchange eligible individual means an individual who is eligible under this section to be enrolled through the health insurance exchange in an exchange participating health benefits plan and with respect to family coverage includes dependents of such individual with bills hr ih exchange eligible employer the term exchange eligible employer means an employer that is eligible under this section to enroll through the health insurance exchange employees of the employer and their dependents in exchangeeligible health benefits plans employment related definitions the terms employer employee full time employee and part time employee have the meanings given such terms by the commissioner for purposes of this division transition individuals and employers shall only be eligible to enroll or participate in the health insurance exchange in accordance with the following transition schedule first year in as defined in section a individuals described in subsection including individuals described in subsection and smallest employers described in subsection second year in a individuals and employers described in paragraph and with bills hr ih smaller employers described in subsection third and subsequent years in a individuals and employers described in paragraph small employers described in subsection and larger employers as permitted by the commissioner under subsection individuals individual described subject to the succeeding provisions of this subsection an individual described in this paragraph is an individual who a is not enrolled in coverage described in subparagraph or of paragraph and is not enrolled in coverage as a fulltime employee or as a dependent of such an employee under a group health plan if the coverage and an employer contribution under the plan meet the requirements of section for purposes of subparagraph in the case of an individual who is self employed who has at least employee and who meets the requirements of section with bills hr ih such individual shall be deemed a full time employee described in such subparagraph acceptable coverage for purposes of this division the term acceptable coverage means any of the following a qualified health benefits plan coverage coverage under a qualified health benefits plan grandfathered health insurance coverage coverage under current group health plan coverage under a grandfathered health insurance coverage as defined in subsection a of section or under a current group health plan described in subsection of such section medicare coverage under part a of title xviii of the social security act medicaid coverage for medical assistance under title xix of the social security act excluding such coverage that is only available because of the application of subsection or aa of section of such act members of the armed forces and dependents including tricare coverage under chapter of title united with bills hr ih states code including similar coverage furnished under section of title of such code va coverage under the veteran health care program under chapter of title united states code other coverage such other health benefits coverage such as a state health benefits risk pool as the commissioner in coordination with the secretary of the treasury recognizes for purposes of this paragraph the commissioner shall make determinations under this paragraph in coordination with the secretary of the treasury continuing eligibility permitted a in general except as provided in subparagraph once an individual qualifies as an exchange eligible individual under this subsection including as an employee or dependent of an employee of an exchange eligible employer and enrolls under an exchange participating health benefits plan through the health insurance exchange the individual shall continue to be treated as an exchange eligible individual until the individual is no longer enrolled with bills hr ih with an exchange participating health benefits plan exceptions in general subparagraph a shall not apply to an individual once the individual becomes eligible for coverage under part a of the medicare program under the medicaid program as a medicaid eligible individual except as permitted under clause or iii in such other circumstances as the commissioner provide transition period in the case described in clause the commissioner shall permit the individual to continue treatment under subparagraph a until such limited time as the commissioner determines it is administratively feasible consistent with minimizing disruption in the individual access to health care transition for chip eligibles an individual who is eligible for child health assistance under title xxi of the social security act for a pe with bills hr ih riod during shall not be an exchange eligible individual during such period employers smallest employer subject to paragraph smallest employers described in this paragraph are employers with or fewer employees smaller employers subject to paragraph smaller employers described in this paragraph are employers that are not smallest employers described in paragraph and have or fewer employees small employers subject to paragraph small employers described in this paragraph are employers that are not described in paragraph or and have or fewer employees larger employers a in general beginning with the commissioner permit employers not described in paragraph or to be exchange eligible employers phase in in applying subparagraph a the commissioner phase in the application of such subparagraph based on the number of full time employees of an employer and with bills hr ih such other considerations as the commissioner deems appropriate continuing eligibility once an employer is permitted to be an exchange eligible employer under this subsection and enrolls employees through the health insurance exchange the employer shall continue to be treated as an exchangeeligible employer for each subsequent plan year regardless of the number of employees involved unless and until the employer meets the requirement of section a through paragraph of such section by offering a group health plan and not through offering an exchange participating health benefits plan employer participation and contributions a satisfaction of employer responsibility for any year in which an employer is an exchange eligible employer such employer meet the requirements of section with respect to employees of such employer by offering such employees the option of enrolling with exchange participating health benefits plans through the health insurance exchange con with bills hr ih sistent with the provisions of subtitle of title iv employee choice any employee offered exchange participating health benefits plans by the employer of such employee under subparagraph a choose coverage under any such plan that choice includes with respect to family coverage coverage of the dependents of such employee affiliated groups any employer which is part of a group of employers who are treated as a single employer under subsection or of section of the internal revenue code of shall be treated for purposes of this subtitle as a single employer treatment of multi employer plans the plan sponsor of a group health plan as defined in section a of the employee retirement income security act of that is a multi employer plan as defined in section of such act obtain health insurance coverage with respect to participants in the plan through the exchange to the same extent that an employer not described in paragraph or is permitted by the commissioner to obtain health insurance coverage with bills hr ih through the exchange as an exchange eligible employer other counting rules the commissioner shall establish rules relating to how employees are counted for purposes of carrying out this subsection special situation authority the commissioner shall have the authority to establish such rules as be necessary to deal with special situations with regard to uninsured individuals and employers participating as exchange eligible individuals and employers such as transition periods for individuals and employers who gain or lose exchange eligible participation status and to establish grace periods for premium payment surveys of individuals and employers the commissioner shall provide for periodic surveys of exchange eligible individuals and employers concerning satisfaction of such individuals and employers with the health insurance exchange and exchange participating health benefits plans exchange access study in general the commissioner shall conduct a study of access to the health insurance exchange for individuals and for employers including individuals and employers who are not eligible and with bills hr ih enrolled in exchange participating health benefits plans the goal of the study is to determine if there are significant groups and types of individuals and employers who are not exchange eligible individuals or employers but who would have improved benefits and affordability if made eligible for coverage in the exchange items included in study such study also shall examine a the terms conditions and affordability of group health coverage offered by employers and qhbp offering entities outside of the exchange compared to exchange participating health benefits plans and the affordability test standard for access of certain employed individuals to coverage in the health insurance exchange report not later than january of in and thereafter the commissioner shall submit to congress a report on the study conducted under this subsection and shall include in such report recommendations regarding changes in standards for exchange eligibility for individuals and employers with bills hr ih sec benefits package levels a in general the commissioner shall specify the benefits to be made available under exchange participating health benefits plans during each plan year consistent with subtitle of title and this section limitation on health benefits plans offered by offering entities the commissioner not enter into a contract with a qhbp offering entity under section for the offering of an exchange participating health benefits plan in a service area unless the following requirements are met required offering of basic plan the entity offers only one basic plan for such service area optional offering of enhanced plan if and only if the entity offers a basic plan for such service area the entity offer one enhanced plan for such area optional offering of premium plan if and only if the entity offers an enhanced plan for such service area the entity offer one premium plan for such area optional offering of premium plus plans if and only if the entity offers a premium plan for such service area the entity offer one or more premium plus plans for such area with bills hr ih all such plans be offered under a single contract with the commissioner specification of benefit levels for plans in general the commissioner shall establish the following standards consistent with this subsection and title a basic enhanced and premium plans standards for levels of exchangeparticipating health benefits plans basic enhanced and premium in this division referred to as a basic plan enhanced plan and premium plan respectively premium plus plan benefits standards for additional benefits that be offered consistent with this subsection and subtitle of title under a premium plan such a plan with additional benefits referred to in this division as a premium plus plan basic plan a in general a basic plan shall offer the essential benefits package required under title for a qualified health benefits plan with an actuarial value of percent of the full ac with bills hr ih tuarial value of the benefits provided under the reference benefits package tiered cost sharing for affordable credit eligible individuals in the case of an affordable credit eligible individual as defined in section a enrolled in an exchange participating health benefits plan the benefits under a basic plan are modified to provide for the reduced cost sharing for the income tier applicable to the individual under section enhanced plan an enhanced plan shall offer in addition to the level of benefits under the basic plan a lower level of cost sharing as provided under title consistent with section a premium plan a premium plan shall offer in addition to the level of benefits under the basic plan a lower level of cost sharing as provided under title consistent with section premium plus plan a premium plus plan is a premium plan that also provides additional benefits such as adult oral health and vision care approved by the commissioner the portion of the premium that is attributable to such additional benefits shall be separately specified with bills hr ih range of permissible variation in cost sharing the commissioner shall establish a permissible range of variation of cost sharing for each basic enhanced and premium plan except with respect to any benefit for which there is no costsharing permitted under the essential benefits package such variation shall permit a variation of not more than plus or minus percent in cost sharing with respect to each benefit category specified under section nothing in this subtitle shall be construed as prohibiting tiering in cost sharing including through preferred and participating providers and prescription drugs in applying this paragraph a health benefits plan increase the costsharing by percent within each category or tier as applicable and decrease or eliminate costsharing in any category or tier as compared to the essential benefits package treatment of state benefit mandates insofar as a state requires a health insurance issuer offering health insurance coverage to include benefits beyond the essential benefits package such requirement shall continue to apply to an exchange participating health benefits plan if the state has entered into an arrangement satisfactory to the commissioner to reimburse the com with bills hr ih missioner for the amount of any net increase in affordability premium credits under subtitle as a result of an increase in premium in basic plans as a result of application of such requirement rules regarding coverage of and affordability credits for specified services assured availability of varied coverage through the health insurance exchange the commissioner shall assure that of the exchange participating health benefits plan offered in each premium rating area of the health insurance exchange a there is at least one such plan that provides coverage of services described in subparagraphs a and of section and there is at least one such plan that does not provide coverage of services described in section a which plan also be one that does not provide coverage of services described in section segregation of funds if a qualified health benefits plan provides coverage of services described in section a the plan shall pro with bills hr ih vide assurances satisfactory to the commissioner that a any affordability credits provided under subtitle of title are not used for purposes of paying for such services and only premium amounts attributable to the actuarial value described in section are used for such purpose sec contracts for the offering of exchangeparticipating health benefits plans a contracting duties in carrying out section and consistent with this subtitle offering entity and plan standards the commissioner shall a establish standards necessary to implement the requirements of this title and title for qhbp offering entities for the offering of an exchange participating health benefits plan and exchange participating health benefits plans and certify qhbp offering entities and qualified health benefits plans as meeting such with bills hr ih standards and requirements of this title and title for purposes of this subtitle soliciting and negotiating bids contracts a bid solicitation the commissioner shall solicit bids from qhbp offering entities for the offering of exchange participating health benefits plans such bids shall include justification for proposed premiums bid review and negotiation the commissioner shall based upon a review of such bids including the premiums and their affordability negotiate with such entities for the offering of such plans denial of excessive premiums the commissioner shall deny excessive premiums and premium increases contracts the commissioner shall enter into contracts with such entities for the offering of such plans through the health insurance exchange under terms consistent with this title negotiated between the commissioner and such entities federal acquisition regulation in carrying out this subtitle the commissioner with bills hr ih waive such provisions of the federal acquisition regulation that the commissioner determines to be inconsistent with the furtherance of this subtitle other than provisions relating to confidentiality of information competitive procedures shall be used in awarding contracts under this subtitle to the extent that such procedures are consistent with this subtitle standards for qhbp offering entities to offer exchange participating health benefits plans the standards established under subsection a a shall require that in order for a qhbp offering entity to offer an exchange participating health benefits plan the entity must meet the following requirements licensed the entity shall be licensed to offer health insurance coverage under state law for each state in which it is offering such coverage data reporting the entity shall provide for the reporting of such information as the commissioner specify including information necessary to administer the risk pooling mechanism described in section and information to address disparities in health and health care affordability the entity shall provide for affordable premiums with bills hr ih implementing affordability credits the entity shall provide for implementation of the affordability credits provided for enrollees under subtitle including the reduction in cost sharing under section enrollment the entity shall accept all enrollments under this subtitle subject to such exceptions such as capacity limitations in accordance with the requirements under title for a qualified health benefits plan the entity shall notify the commissioner if the entity projects or anticipates reaching such a capacity limitation that would result in a limitation in enrollment risk pooling participation the entity shall participate in such risk pooling mechanism as the commissioner establishes under section essential community providers with respect to the basic plan offered by the entity the entity shall include within the plan network those essential community providers where available that serve predominantly low income medically underserved individuals such as health care providers defined in section a of the public health service act and providers described in section iv of the social security act as with bills hr ih amended by section of public law – the commissioner shall specify the extent to which and manner in which the previous sentence shall apply in the case of a basic plan with respect to which the commissioner determines provides substantially all benefits through a health maintenance organization as defined in section of the public health service act this paragraph shall not be construed to require a basic plan to contract with a provider if such provider refuses to accept the generally applicable payment rates of such plan culturally and linguistically appropriate services and communications the entity shall provide for culturally and linguistically appropriate communication and health services special rules with respect to indian enrollees and indian health care providers a choice of providers the entity shall demonstrate to the satisfaction of the commissioner that it has contracted with a sufficient number of indian health care providers to ensure timely access to covered services furnished by such pro with bills hr ih viders to individual indians through the entity exchange participating health benefits plan and agree to pay indian health care providers whether such providers are participating or nonparticipating providers with respect to the entity for covered services provided to those enrollees who are eligible to receive services from such providers at a rate that is not less than the level and amount of payment which the entity would make for the services of a participating provider which is not an indian health care provider special rule relating to indian health care providers provision of services by an indian health care provider exclusively to indians and their dependents shall not constitute discrimination under this act program integrity standards the entity shall establish and operate a program to protect and promote the integrity of exchange participating health benefits plans it offers in accordance with standards and functions established by the commissioner with bills hr ih additional requirements the entity shall comply with other applicable requirements of this title as specified by the commissioner which shall include standards regarding billing and collection practices for premiums and related grace periods and which include standards to ensure that the entity does not use coercive practices to force providers not to contract with other entities offering coverage through the health insurance exchange contracts bid application to be eligible to enter into a contract under this section a qhbp offering entity shall submit to the commissioner a bid at such time in such manner and containing such information as the commissioner require term each contract with a qhbp offering entity under this section shall be for a term of not less than one year but be made automatically renewable from term to term in the absence of notice of termination by either party enforcement of network adequacy in the case of a health benefits plan of a qhbp offering entity that uses a provider network the contract under this section with the entity shall provide that if with bills hr ih a the commissioner determines that such provider network does not meet such standards as the commissioner shall establish under section and an individual enrolled in such plan receives an item or service from a provider that is not within such network then any cost sharing for such item or service shall be equal to the amount of such cost sharing that would be imposed if such item or service was furnished by a provider within such network oversight and enforcement responsibilities the commissioner shall establish processes in coordination with state insurance regulators to oversee monitor and enforce applicable requirements of this title with respect to qhbp offering entities offering exchange participating health benefits plans including the marketing of such plans such processes shall include the following a grievance and complaint mechanisms the commissioner shall establish in coordination with state insurance regulators a process under which exchange eligible individuals and employers file complaints concerning violations of such standards with bills hr ih enforcement in carrying out authorities under this division relating to the health insurance exchange the commissioner impose one or more of the intermediate sanctions described in section termination in general the commissioner terminate a contract with a qhbp offering entity under this section for the offering of an exchange participating health benefits plan if such entity fails to comply with the applicable requirements of this title any determination by the commissioner to terminate a contract shall be made in accordance with formal investigation and compliance procedures established by the commissioner under which the commissioner provides the entity with the reasonable opportunity to develop and implement a corrective action plan to correct the deficiencies that were the basis of the commissioner determination and the commissioner provides the entity with reasonable notice and with bills hr ih opportunity for hearing including the right to appeal an initial decision before terminating the contract exception for imminent and serious risk to health clause shall not apply if the commissioner determines that a delay in termination resulting from compliance with the procedures specified in such clause prior to termination would pose an imminent and serious risk to the health of individuals enrolled under the qualified health benefits plan of the qhbp offering entity construction nothing in this subsection shall be construed as preventing the application of other sanctions under subtitle of title with respect to an entity for a violation of such a requirement special rule related to cost sharing and indian health care providers the contract under this section with a qhbp offering entity for a health benefits plan shall provide that if an individual who is an indian is enrolled in such a plan and such individual receives a covered item or service from an indian health care provider regardless with bills hr ih of whether such provider is in the plan provider network the cost sharing for such item or service shall be equal to the amount of cost sharing that would be imposed if such item or service a had been furnished by another provider in the plan provider network or in the case that the plan has no such network was furnished by a non indian provider national plan nothing in this section shall be construed as preventing the commissioner from entering into a contract under this subsection with a qhbp offering entity for the offering of a health benefits plan with the same benefits in every state so long as such entity is licensed to offer such plan in each state and the benefits meet the applicable requirements in each such state no discrimination on the basis of provision of abortion no exchange participating health benefits plan discriminate against any individual health care provider or health care facility because of its willingness or unwillingness to provide pay for provide coverage of or refer for abortions with bills hr ih sec outreach and enrollment of exchange eligible individuals and employers in exchange participating health benefits plan a in general outreach the commissioner shall conduct outreach activities consistent with subsection including through use of appropriate entities as described in paragraph of such subsection to inform and educate individuals and employers about the health insurance exchange and exchange participating health benefits plan options such outreach shall include outreach specific to vulnerable populations such as children individuals with disabilities individuals with mental illness and individuals with other cognitive impairments eligibility the commissioner shall make timely determinations of whether individuals and employers are exchange eligible individuals and employers as defined in section enrollment the commissioner shall establish and carry out an enrollment process for exchange eligible individuals and employers including at community locations in accordance with subsection enrollment process with bills hr ih in general the commissioner shall establish a process consistent with this title for enrollments in exchange participating health benefits plans such process shall provide for enrollment through means such as the mail by telephone electronically and in person enrollment periods a open enrollment period the commissioner shall establish an annual open enrollment period during which an exchange eligible individual or employer elect to enroll in an exchange participating health benefits plan for the following plan year and an enrollment period for affordability credits under subtitle such periods shall be during september through november of each year or such other time that would maximize timeliness of income verification for purposes of such subtitle the open enrollment period shall not be less than days special enrollment the commissioner shall also provide for special enrollment periods to take into account special circumstances of individuals and employers such as an individual who with bills hr ih loses acceptable coverage experiences a change in marital or other dependent status iii moves outside the service area of the exchange participating health benefits plan in which the individual is enrolled or iv experiences a significant change in income enrollment information the commissioner shall provide for the broad dissemination of information to prospective enrollees on the enrollment process including before each open enrollment period in carrying out the previous sentence the commissioner work with other appropriate entities to facilitate such provision of information automatic enrollment for non medicaid eligible individuals a in general the commissioner shall provide for a process under which individuals who are exchange eligible individuals described in subparagraph are automatically enrolled under an appropriate exchange participating health benefits plan such process involve a random assignment or some other with bills hr ih form of assignment that takes into account the health care providers used by the individual involved or such other relevant factors as the commissioner specify subsidized individuals described an individual described in this subparagraph is an exchange eligible individual who is either of the following affordability credit eligible individuals the individual has applied for and been determined eligible for affordability credits under subtitle has not opted out from receiving such affordability credit and iii does not otherwise enroll in another exchange participating health benefits plan individuals enrolled in a terminated plan the individual who is enrolled in an exchange participating health benefits plan that is terminated during or at the end of a plan year and who does not otherwise enroll in another with bills hr ih exchange participating health benefits plan direct payment of premiums to plans under the enrollment process individuals enrolled in an exchange participating health benefits plan shall pay such plans directly and not through the commissioner or the health insurance exchange coverage information and assistance coverage information the commissioner shall provide for the broad dissemination of information on exchange participating health benefits plans offered under this title such information shall be provided in a comparative manner and shall include information on benefits premiums costsharing quality provider networks and consumer satisfaction consumer assistance with choice to provide assistance to exchange eligible individuals and employers the commissioner shall a provide for the operation of a toll free telephone hotline to respond to requests for assistance and maintain an internet web site through which individuals obtain informa with bills hr ih tion on coverage under exchange participating health benefits plans and file complaints develop and disseminate information to exchange eligible enrollees on their rights and responsibilities assist exchange eligible individuals in selecting exchange participating health benefits plans and obtaining benefits through such plans and ensure that the internet web site described in subparagraph a and the information described in subparagraph is developed using plain language as defined in section a use of other entities in carrying out this subsection the commissioner work with other appropriate entities to facilitate the dissemination of information under this subsection and to provide assistance as described in paragraph coverage for certain newborns under medicaid in general in the case of a child born in the united states who at the time of birth is not otherwise covered under acceptable coverage for the period of time beginning on the date of birth and with bills hr ih ending on the date the child otherwise is covered under acceptable coverage or if earlier the end of the month in which the day period beginning on the date of birth ends the child shall be deemed a to be a medicaid eligible individual for purposes of this division and medicaid and to be automatically enrolled in medicaid as a traditional medicaid eligible individual as defined in section of the social security act extended treatment as medicaid eligible individual in the case of a child described in paragraph who at the end of the period referred to in such paragraph is not otherwise covered under acceptable coverage the child shall be deemed until such time as the child obtains such coverage or the state otherwise makes a determination of the child eligibility for medical assistance under its medicaid plan pursuant to section of the social security act to be a medicaid eligible individual described in section of such act medicaid coverage for medicaid eligible individuals with bills hr ih medicaid enrollment obligation an individual apply in the manner described in section for a determination of whether the individual is a medicaid eligible individual if the individual is determined to be so eligible the commissioner through the medicaid memorandum of understanding under paragraph shall provide for the enrollment of the individual under the state medicaid plan in accordance with such memorandum of understanding in the case of such an enrollment the state shall provide for the same periodic redetermination of eligibility under medicaid as would otherwise apply if the individual had directly applied for medical assistance to the state medicaid agency coordinated enrollment with state through memorandum of understanding the commissioner in consultation with the secretary of health and human services shall enter into a memorandum of understanding with each state with respect to coordinating enrollment of individuals in exchange participating health benefits plans and under the state medicaid program consistent with this section and to otherwise coordinate the implementation of the provisions of this division with respect to the medicaid program such memo with bills hr ih randum shall permit the exchange of information consistent with the limitations described in section a of the social security act nothing in this section shall be construed as permitting such memorandum to modify or vitiate any requirement of a state medicaid plan effective culturally and linguistically appropriate communication in carrying out this section the commissioner shall establish effective methods for communicating in plain language and a culturally and linguistically appropriate manner role for enrollment agents and brokers nothing in this division shall be construed to affect the role of enrollment agents and brokers under state law including with regard to the enrollment of individuals and employers in qualified health benefits plans including the public health insurance option assistance for small employers in general the commissioner in consultation with the small business administration shall establish and carry out a program to provide to small employers counseling and technical assistance with respect to the provision of health insurance to employees of such employers through the health insurance exchange with bills hr ih duties the program established under paragraph shall include the following services a educational activities to increase awareness of the health insurance exchange and available small employer health plan options distribution of information to small employers with respect to the enrollment and selection process for health plans available under the health insurance exchange including standardized comparative information on the health plans available under the health insurance exchange distribution of information to small employers with respect to available affordability credits or other financial assistance referrals to appropriate entities of complaints and questions relating to the health insurance exchange enrollment and plan selection assistance for employers with respect to the health insurance exchange responses to questions relating to the health insurance exchange and the program established under paragraph with bills hr ih authority to provide services directly or by contract the commissioner provide services under paragraph directly or by contract with nonprofit entities that the commissioner determines capable of carrying out such services small employer defined in this subsection the term small employer means an employer with less than employees participation of small employer benefit arrangements in general the commissioner enter into contracts with small employer benefit arrangements to provide consumer information outreach and assistance in the enrollment of small employers and their employees who are members of such an arrangement under exchange participating health benefits plans small employer benefit arrangement defined in this subsection the term small employer benefit arrangement means a not for profit agricultural or other cooperative that a consists solely of its members and is operated for the primary purpose of providing affordable employee benefits to its members with bills hr ih only has as members small employers in the same industry or line of business has no member that has more than a percent voting interest in the cooperative and is governed by a board of directors elected by its members sec other functions a coordination of affordability credits the commissioner shall coordinate the distribution of affordability premium and cost sharing credits under subtitle to qhbp offering entities offering exchange participating health benefits plans coordination of risk pooling the commissioner shall establish a mechanism whereby there is an adjustment made of the premium amounts payable among qhbp offering entities offering exchange participating health benefits plans of premiums collected for such plans that takes into account in a manner specified by the commissioner the differences in the risk characteristics of individuals and employees enrolled under the different exchange participating health benefits plans offered by such entities so as to minimize the impact of adverse selection of enrollees among the plans offered by such entities for purposes of the previous sentence the commissioner utilize data regarding enrollee demographics inpatient with bills hr ih and outpatient diagnoses in a similar manner as such data are used under parts and of title xviii of the social security act and such other information as the secretary determines be necessary such as the actual medical costs of enrollees during the previous year sec health insurance exchange trust fund a establishment of health insurance exchange trust fund there is created within the treasury of the united states a trust fund to be known as the health insurance exchange trust fund in this section referred to as the trust fund consisting of such amounts as be appropriated or credited to the trust fund under this section or any other provision of law payments from trust fund the commissioner shall pay from time to time from the trust fund such amounts as the commissioner determines are necessary to make payments to operate the health insurance exchange including payments under subtitle relating to affordability credits transfers to trust fund dedicated payments there are hereby appropriated to the trust fund amounts equivalent to the following with bills hr ih a taxes on individuals not obtaining acceptable coverage the amounts received in the treasury under section of the internal revenue code of relating to requirement of health insurance coverage for individuals employment taxes on employers not providing acceptable coverage the amounts received in the treasury under sections and of the internal revenue code of relating to employers electing to not provide health benefits excise tax on failures to meet certain health coverage requirements the amounts received in the treasury under section relating to excise tax with respect to failure to meet health coverage participation requirements appropriations to cover government contributions there are hereby appropriated out of any moneys in the treasury not otherwise appropriated to the trust fund an amount equivalent to the amount of payments made from the trust fund under subsection plus such amounts as are with bills hr ih necessary reduced by the amounts deposited under paragraph application of certain rules rules similar to the rules of subchapter of chapter of the internal revenue code of shall apply with respect to the trust fund sec optional operation of state based health insurance exchanges a in general if a state or group of states subject to the approval of the commissioner applies to the commissioner for approval of a state based health insurance exchange to operate in the state or group of states and the commissioner approves such statebased health insurance exchange then subject to subsections and the state based health insurance exchange shall operate instead of the health insurance exchange with respect to such state or group of states the commissioner shall approve a state based health insurance exchange if it meets the requirements for approval under subsection requirements for approval in general the commissioner not approve a state based health insurance exchange with bills hr ih under this section unless the following requirements are met a the state based health insurance exchange must demonstrate the capacity to and provide assurances satisfactory to the commissioner that the state based health insurance exchange will carry out the functions specified for the health insurance exchange in the state or states involved including negotiating and contracting with qhbp offering entities for the offering of exchange participating health benefits plans which satisfy the standards and requirements of this title and title ii enrolling exchange eligible individuals and employers in such state in such plans iii the establishment of sufficient local offices to meet the needs of exchange eligible individuals and employers iv administering affordability credits under subtitle using the same methodologies and at least the same income verification methods as would otherwise apply under such subtitle and at a cost to with bills hr ih the federal government which does exceed the cost to the federal government if this section did not apply and enforcement activities consistent with federal requirements there is no more than one health insurance exchange operating with respect to any one state the state provides assurances satisfactory to the commissioner that approval of such an exchange will not result in any net increase in expenditures to the federal government the state provides for reporting of such information as the commissioner determines and assurances satisfactory to the commissioner that it will vigorously enforce violations of applicable requirements such other requirements as the commissioner specify presumption for certain state operated exchanges a in general in the case of a state operating an exchange prior to january that seeks to operate the state based health insurance exchange under this section with bills hr ih the commissioner shall presume that such exchange meets the standards under this section unless the commissioner determines after completion of the process established under subparagraph that the exchange does not comply with such standards process the commissioner shall establish a process to work with a state described in subparagraph a to provide assistance necessary to assure that the state exchange comes into compliance with the standards for approval under this section ceasing operation in general a state based health insurance exchange at the option of each state involved and only after providing timely and reasonable notice to the commissioner cease operation as such an exchange in which case the health insurance exchange shall operate instead of such statebased health insurance exchange with respect to such state or states termination health insurance exchange resumption of functions the commissioner terminate the approval for some or all functions of a state based health insurance ex with bills hr ih change under this section if the commissioner determines that such exchange no longer meets the requirements of subsection or is no longer capable of carrying out such functions in accordance with the requirements of this subtitle in lieu of terminating such approval the commissioner temporarily assume some or all functions of the statebased health insurance exchange until such time as the commissioner determines the state based health insurance exchange meets such requirements of subsection and is capable of carrying out such functions in accordance with the requirements of this subtitle effectiveness the ceasing or termination of a state based health insurance exchange under this subsection shall be effective in such time and manner as the commissioner shall specify retention of authority authority retained enforcement authorities of the commissioner shall be retained by the commissioner discretion to retain additional authority the commissioner specify functions of the health insurance exchange that with bills hr ih a not be performed by a statebased health insurance exchange under this section or be performed by the commissioner and by such a state based health insurance exchange references in the case of a state based health insurance exchange except as the commissioner otherwise specify under subsection any references in this subtitle to the health insurance exchange or to the commissioner in the area in which the state based health insurance exchange operates shall be deemed a reference to the state based health insurance exchange and the head of such exchange respectively funding in the case of a state based health insurance exchange there shall be assistance provided for the operation of such exchange in the form of a matching grant with a state share of expenditures required sec interstate health insurance compacts a in general effective january or more states form health care choice compacts in this section referred to as compacts to facilitate the purchase of individual health insurance coverage across state lines with bills hr ih model guidelines the secretary of health and human services in this section referred to as the secretary shall request the national association of insurance commissioners in this section referred to as naic to develop model guidelines for the creation of compacts in developing such guidelines the naic shall consult with consumers health insurance issuers the secretary and other interested parties such guidelines shall provide for the sale of health insurance coverage to residents of all compacting states subject to the laws and regulations of a primary state designated by the health insurance issuer require health insurance issuers issuing health insurance coverage in secondary states to maintain licensure in every such state preserve the authority of the state of an individual residence to address a market conduct unfair trade practices network adequacy consumer protection standards grievance and appeals fair claims payment requirements and prompt payment of claims with bills hr ih permit state insurance commissioners and other state agencies in secondary states access to the records of a health insurance issuer to the same extent as if the policy were written in that state and provide for clear and conspicuous disclosure to consumers that the policy not be subject to all the laws and regulations of the state in which the purchaser resides required consideration if model guidelines developed under subsection are submitted to the secretary by january the secretary shall issue them as regulations if the naic fails to submit such model guidelines by such date the secretary shall no later than october develop and promulgate the regulations implementing model guidelines described in subsection no requirement to compact nothing in this section shall be construed to require a state to join a compact state authority a state not enter into a compact under this subsection unless the state enacts a law after the date of enactment of this act that specifically authorizes the state to enter into such compact consumer protections if a state enters into a compact it must retain responsibility for the consumer with bills hr ih protections of its residents and its residents retain the right to bring a claim in a state court in the state in which the resident resides assistance to compacting states in general beginning january the secretary shall make awards from amounts appropriated under paragraph to states in the amount specified in paragraph for the uses described in paragraph amount specified a in general for each fiscal year the secretary shall determine the total amount that the secretary will make available for grants under this subsection state amount for each state that is awarded a grant under paragraph the amount of such grants shall be based on a formula established by the secretary not to exceed million per state under which states shall receive an award in the amount that is based on the following two components a minimum amount for each state an additional amount based on population of the state with bills hr ih use of funds a state shall use amounts awarded under this subsection for activities including planning activities related regulating health insurance coverage sold in secondary states renewability of grant the secretary renew a grant award under paragraph if the state receiving the grant continues to be a member of a compact authorization of appropriations there are authorized to be appropriated such sums as be necessary to carry out this subsection in each of fiscal years through sec health insurance cooperatives a establishment not later than months after the date of the enactment of this act the commissioner in consultation with the secretary of the treasury shall establish a consumer operated and oriented plan program in this section referred to as the co–op program under which the commissioner make grants and loans for the establishment and initial operation of not for profit member–run health insurance cooperatives in this section individually referred to as a cooperative that provide insurance through the health insurance exchange or a state based health insurance exchange with bills hr ih under section nothing in this section shall be construed as requiring a state to establish such a cooperative start up and solvency grants and loans in general not later than months after the date of the enactment of this act the commissioner acting through the co–op program make a loans of such period and with such terms as the secretary specify to cooperatives to assist such cooperatives with start up costs and grants to cooperatives to assist such cooperatives in meeting state solvency requirements in the states in which such cooperative offers or issues insurance coverage conditions a grant or loan not be awarded under this subsection with respect to a cooperative unless the following conditions are met a the cooperative is structured as a notfor profit member organization under the law of each state in which such cooperative offers intends to offer or issues insurance coverage with the membership of the cooperative being with bills hr ih made up entirely of beneficiaries of the insurance coverage offered by such cooperative the cooperative did not offer insurance on or before july and the cooperative is not an affiliate or successor to an insurance company offering insurance on or before such date the governing documents of the cooperative incorporate ethical and conflict of interest standards designed to protect against insurance industry involvement and interference in the governance of the cooperative the cooperative is not sponsored by a state government substantially all of the activities of the cooperative consist of the issuance of qualified health benefits plans through the health insurance exchange or a state based health insurance exchange the cooperative is licensed to offer insurance in each state in which it offers insurance the governance of the cooperative must be subject to a majority vote of its members with bills hr ih as provided in guidance issued by the secretary of health and human services the cooperative operates with a strong consumer focus including timeliness responsiveness and accountability to members any profits made by the cooperative are used to lower premiums improve benefits or to otherwise improve the quality of health care delivered to members priority the commissioner in making grants and loans under this subsection shall give priority to cooperatives that a operate on a statewide basis use an integrated delivery system or have a significant level of financial support from nongovernmental sources rules of construction nothing in this section shall be construed to prevent a cooperative established in one state from integrating with a cooperative established in another state the administration issuance of coverage or other activities related to acting as a qhbp offering entity nothing in this section shall be construed as preventing state governments from taking actions to permit such integration with bills hr ih amortization of grants and loans the secretary shall provide for the repayment of grants or loans provided under this subsection to the treasury in an amortized manner over a year period repayment for violations of terms of program if a cooperative violates the terms of the co–op program and fails to correct the violation within a reasonable period of time as determined by the commissioner the cooperative shall repay the total amount of any loan or grant received by such cooperative under this section plus interest at a rate determined by the secretary authorization of appropriations there is authorized to be appropriated for the period of fiscal years through to provide for grants and loans under this subsection definitions for purposes of this section state the term state means each of the states and the district of columbia member the term member with respect to a cooperative means an individual who after the cooperative offers health insurance coverage is enrolled in such coverage with bills hr ih sec retention of dod and va authority nothing in this subtitle shall be construed as affecting any authority under title united states code or chapter of title united states code subtitle public health insurance option sec establishment and administration of a public health insurance option as an exchange qualified health benefits plan a establishment for years beginning with the secretary of health and human services in this subtitle referred to as the secretary shall provide for the offering of an exchange participating health benefits plan in this division referred to as the public health insurance option that ensures choice competition and stability of affordable high quality coverage throughout the united states in accordance with this subtitle in designing the option the secretary primary responsibility is to create a low cost plan without compromising quality or access to care offering as an exchange participating health benefits plan exclusive to the exchange the public health insurance option shall only be made available through the health insurance exchange with bills hr ih ensuring a level playing field consistent with this subtitle the public health insurance option shall comply with requirements that are applicable under this title to an exchange participating health benefits plan including requirements related to benefits benefit levels provider networks notices consumer protections and cost sharing provision of benefit levels the public health insurance option a shall offer basic enhanced and premium plans and offer premium plus plans administrative contracting the secretary enter into contracts for the purpose of performing administrative functions including functions described in subsection a of section a of the social security act with respect to the public health insurance option in the same manner as the secretary enter into contracts under subsection a of such section the secretary has the same authority with respect to the public health insurance option as the secretary has under subsections a and of section a of the social security act with respect to title xviii of such act contracts under this subsection shall not involve the transfer of insurance risk to such entity with bills hr ih ombudsman the secretary shall establish an office of the ombudsman for the public health insurance option which shall have duties with respect to the public health insurance option similar to the duties of the medicare beneficiary ombudsman under section of the social security act data collection the secretary shall collect such data as be required to establish premiums and payment rates for the public health insurance option and for other purposes under this subtitle including to improve quality and to reduce racial ethnic and other disparities in health and health care nothing in this subtitle be construed as authorizing the secretary or any employee or contractor to create or maintain lists of nonmedical personal property treatment of public health insurance option with respect to the public health insurance option the secretary shall be treated as a qhbp offering entity offering an exchange participating health benefits plan access to federal courts the provisions of medicare and related provisions of title of the social security act relating to access of medicare beneficiaries to federal courts for the enforcement of rights under medicare including with respect to amounts in controversy shall apply to the public health insurance option with bills hr ih and individuals enrolled under such option under this title in the same manner as such provisions apply to medicare and medicare beneficiaries sec premiums and financing a establishment of premiums in general the secretary shall establish geographically adjusted premium rates for the public health insurance option a in a manner that complies with the premium rules established by the commissioner under section for exchange participating health benefits plans and at a level sufficient to fully finance the costs of health benefits provided by the public health insurance option and administrative costs related to operating the public health insurance option contingency margin in establishing premium rates under paragraph the secretary shall include an appropriate amount for a contingency margin which shall be not less than days of estimated claims before setting such appropriate amount for years starting with the secretary with bills hr ih shall solicit a recommendation on such amount from the american academy of actuaries account establishment there is established in the treasury of the united states an account for the receipts and disbursements attributable to the operation of the public health insurance option including the start up funding under paragraph section of the social security act shall apply to receipts described in the previous sentence in the same manner as such section applies to payments or premiums described in such section start up funding a in general in order to provide for the establishment of the public health insurance option there is hereby appropriated to the secretary out of any funds in the treasury not otherwise appropriated in order to provide for initial claims reserves before the collection of premiums there are hereby appropriated to the secretary out of any funds in the treasury not otherwise appropriated such sums as necessary to cover days worth of claims reserves based on projected enrollment with bills hr ih amortization of start up funding the secretary shall provide for the repayment of the startup funding provided under subparagraph a to the treasury in an amortized manner over the year period beginning with limitation on funding nothing in this section shall be construed as authorizing any additional appropriations to the account other than such amounts as are otherwise provided with respect to other exchange participating health benefits plans no bailouts in no case shall the public health insurance option receive any federal funds for purposes of insolvency in any manner similar to the manner in which entities receive federal funding under the troubled assets relief program of the secretary of the treasury sec payment rates for items and services a negotiation of payment rates in general the secretary shall negotiate payment for the public health insurance option for health care providers and items and services including prescription drugs consistent with this section and section with bills hr ih manner of negotiation the secretary shall negotiate such rates in a manner that results in payment rates that are not lower in the aggregate than rates under title xviii of the social security act and not higher in the aggregate than the average rates paid by other qhbp offering entities for services and health care providers innovative payment methods nothing in this subsection shall be construed as preventing the use of innovative payment methods such as those described in section in connection with the negotiation of payment rates under this subsection establishment of a provider network in general health care providers including physicians and hospitals participating in medicare are participating providers in the public health insurance option unless they opt out in a process established by the secretary consistent with this subsection requirements for opt out process under the process established under paragraph a providers described in such paragraph shall be provided at least a year period prior with bills hr ih to the first day of to opt out of participating in the public health insurance option no provider shall be subject to a penalty for not participating in the public health insurance option the secretary shall include information on how providers participating in medicare who chose to opt out of participating in the public health insurance option opt back in and there shall be an annual enrollment period in which providers decide whether to participate in the public health insurance option rulemaking not later than months before the first day of the secretary shall promulgate rules pursuant to notice and comment for the process described in paragraph limitations on review there shall be no administrative or judicial review of a payment rate or methodology established under this section or under section sec modernized payment initiatives and delivery system reform a in general for plan years beginning with the secretary utilize innovative payment mechanisms with bills hr ih and policies to determine payments for items and services under the public health insurance option the payment mechanisms and policies under this section include patient centered medical home and other care management payments accountable care organizations valuebased purchasing bundling of services differential payment rates performance or utilization based payments partial capitation and direct contracting with providers requirements for innovative payments the secretary shall design and implement the payment mechanisms and policies under this section in a manner that seeks to a improve health outcomes reduce health disparities including racial ethnic and other disparities provide efficient and affordable care address geographic variation in the provision of health services or prevent or manage chronic illness and promotes care that is integrated patientcentered quality and efficient encouraging the use of high value services to the extent allowed by the benefit standards applied to all exchange participating health benefits plans with bills hr ih the public health insurance option modify cost sharing and payment rates to encourage the use of services that promote health and value promotion of delivery system reform the secretary shall monitor and evaluate the progress of payment and delivery system reforms under this act and shall seek to implement such reforms subject to the following to the extent that the secretary finds a payment and delivery system reform successful in improving quality and reducing costs the secretary shall implement such reform on as large a geographic scale as practical and economical the secretary delay the implementation of such a reform in geographic areas in which such implementation would place the public health insurance option at a competitive disadvantage the secretary prioritize implementation of such a reform in high cost geographic areas or otherwise in order to reduce total program costs or to promote high value care non uniformity permitted nothing in this subtitle shall prevent the secretary from varying payments based on different payment structure models such as accountable care organizations and medical homes under with bills hr ih the public health insurance option for different geographic areas sec provider participation a in general the secretary shall establish conditions of participation for health care providers under the public health insurance option licensure or certification in general except as provided in paragraph the secretary shall not allow a health care provider to participate in the public health insurance option unless such provider is appropriately licensed certified or otherwise permitted to practice under state law special rule for ihs facilities and providers the requirements under paragraph shall not apply to a a facility that is operated by the indian health service a facility operated by an indian tribe or tribal organization under the indian self determination act public law – a health care professional employed by the indian health service or a health care professional with bills hr ih who is employed to provide health care services in a facility operated by an indian tribe or tribal organization under the indian self determination act and who is licensed or certified in any state payment terms for providers physicians the secretary shall provide for the annual participation of physicians under the public health insurance option for which payment be made for services furnished during the year in one of classes a preferred physicians those physicians who agree to accept the payment under section without regard to cost sharing as the payment in full participating non preferred physicians those physicians who agree not to impose charges in relation to the payment described in section for such physicians that exceed the sum of the in network costsharing plus percent of the total payment for each item and service the secretary shall reduce the payment described in section for such physicians with bills hr ih other providers the secretary shall provide for the participation on an annual or other basis specified by the secretary of health care providers other than physicians under the public health insurance option under which payment shall only be available if the provider agrees to accept the payment under section without regard to costsharing as the payment in full exclusion of certain providers the secretary shall exclude from participation under the public health insurance option a health care provider that is excluded from participation in a federal health care program as defined in section of the social security act sec application of fraud and abuse provisions provisions of civil law identified by the secretary by regulation in consultation with the inspector general of the department of health and human services that impose sanctions with respect to waste fraud and abuse under medicare such as sections through of title united states code commonly known as the false claims act shall also apply to the public health insurance option with bills hr ih sec application of hipaa insurance requirements the requirements of sections through of the public health service act shall apply to the public health insurance option in the same manner as they apply to health insurance coverage offered by a health insurance issuer in the individual market sec application of health information privacy security and electronic transaction requirements part of title xi of the social security act relating to standards for protections against the wrongful disclosure of individually identifiable health information health information security and the electronic exchange of health care information shall apply to the public health insurance option in the same manner as such part applies to other health plans as defined in section of such act sec enrollment in public health insurance option is voluntary nothing in this division shall be construed as requiring anyone to enroll in the public health insurance option enrollment in such option is voluntary with bills hr ih sec enrollment in public health insurance option by members of congress notwithstanding any other provision of this act members of congress enroll in the public health insurance option sec reimbursement of secretary of veterans affairs the secretary of health and human services shall seek to enter into a memorandum of understanding with the secretary of veterans affairs regarding the recovery of costs related to non service connected care or services provided by the secretary of veterans affairs to an individual covered under the public health insurance option in a manner consistent with recovery of costs related to non service connected care from private health insurance plans subtitle individual affordability credits sec availability through health insurance exchange a in general subject to the succeeding provisions of this subtitle in the case of an affordable credit eligible individual enrolled in an exchange participating health benefits plan with bills hr ih the individual shall be eligible for in accordance with this subtitle affordability credits consisting of a an affordability premium credit under section to be applied against the premium for the exchange participating health benefits plan in which the individual is enrolled and an affordability cost sharing credit under section to be applied as a reduction of the cost sharing otherwise applicable to such plan and the commissioner shall pay the qhbp offering entity that offers such plan from the health insurance exchange trust fund the aggregate amount of affordability credits for all affordable credit eligible individuals enrolled in such plan application in general an exchange eligible individual apply to the commissioner through the health insurance exchange or through another entity under an arrangement made with the commissioner in a form and manner specified by the commissioner the commissioner through the health insurance exchange or through another public entity under an arrangement made with the commis with bills hr ih sioner shall make a determination as to eligibility of an individual for affordability credits under this subtitle the commissioner shall establish a process whereby on the basis of information otherwise available individuals be deemed to be affordable credit eligible individuals in carrying this subtitle the commissioner shall establish effective methods that ensure that individuals with limited english proficiency are able to apply for affordability credits use of state medicaid agencies if the commissioner determines that a state medicaid agency has the capacity to make a determination of eligibility for affordability credits under this subtitle and under the same standards as used by the commissioner under the medicaid memorandum of understanding under section a the state medicaid agency is authorized to conduct such determinations for any exchange eligible individual who requests such a determination and the commissioner shall reimburse the state medicaid agency for the costs of conducting such determinations medicaid screen and enroll obligation in the case of an application made under with bills hr ih paragraph there shall be a determination of whether the individual is a medicaid eligible individual if the individual is determined to be so eligible the commissioner through the medicaid memorandum of understanding under section shall provide for the enrollment of the individual under the state medicaid plan in accordance with such medicaid memorandum of understanding in the case of such an enrollment the state shall provide for the same periodic redetermination of eligibility under medicaid as would otherwise apply if the individual had directly applied for medical assistance to the state medicaid agency application and verification of requirement of citizenship or lawful presence in the united states a requirement no individual shall be an affordable credit eligible individual as defined in section a unless the individual is a citizen or national of the united states or is lawfully present in a state in the united states other than as a nonimmigrant described in a subparagraph excluding subparagraphs and of section with bills hr ih a of the immigration and nationality act declaration of citizenship or lawful immigration status no individual shall be an affordable credit eligible individual unless there has been a declaration made in a form and manner specified by the health choices commissioner similar to the manner required under section of the social security act and under penalty of perjury that the individual is a citizen or national of the united states or is not such a citizen or national but is lawfully present in a state in the united states other than as a nonimmigrant described in a subparagraph excluding subparagraphs and of section a of the immigration and nationality act such declaration shall be verified in accordance with subparagraph or as the case be verification process for citizens with bills hr ih in general in the case of an individual making the declaration described in subparagraph subject to clause section ee of the social security act shall apply to such declaration in the same manner as such section applies to a declaration described in paragraph of such section special rules in applying section ee of such act under clause any reference in such section to a state is deemed a reference to the commissioner or other public entity making the eligibility determination any reference to medical assistance or enrollment under a state plan is deemed a reference to provision of affordability credits under this subtitle iii a reference to a newly enrolled individual under paragraph a of such section is deemed a reference to an individual newly in re with bills hr ih ceipt of an affordability credit under this subtitle iv approval by the secretary shall not be required in applying paragraph of such section paragraph of such section shall not apply and vi before the end of the health choices commissioner in consultation with the commissioner of social security extend the periods specified in paragraph of such section verification process for noncitizens in general in the case of an individual making the declaration described in subparagraph subject to clause the verification procedures of paragraphs through of section of the social security act shall apply to such declaration in the same manner as such procedures apply to a declaration described in paragraph of such section with bills hr ih special rules in applying such paragraphs of section of such act under clause any reference in such paragraphs to a state is deemed a reference to the health choices commissioner and any reference to benefits under a program is deemed a reference to affordability credits under this subtitle iii application to state based exchanges in the case of the application of the verification process under this subparagraph to a state based health insurance exchange approved under section section of such act shall apply to the health choices commissioner in relation to the state annual reports the health choices commissioner shall report to congress annually on the number of applicants for affordability credits under this subtitle their citizenship or immigration status and the disposition of their applications such report shall be with bills hr ih made publicly available and shall include information on the number of applicants whose declaration of citizenship or immigration status name or social security account number was not consistent with records maintained by the commissioner of social security or the department of homeland security and of such applicants the number who contested the inconsistency and sought to document their citizenship or immigration status name or social security account number or to correct the information maintained in such records and of those the results of such contestations and the administrative costs of conducting the status verification under this paragraph gao report not later than the end of the comptroller general of the united states shall submit to the committee on ways and means the committee on energy and commerce the committee on education and labor and the committee on the judiciary of with bills hr ih the house of representatives and the committee on finance the committee on health education labor and pensions and the committee on the judiciary of the senate a report examining the effectiveness of the citizenship and immigration verification systems applied under this paragraph such report shall include an analysis of the following the causes of erroneous determinations under such systems the effectiveness of the processes used in remedying such erroneous determinations iii the impact of such systems on individuals health care providers and federal and state agencies including the effect of erroneous determinations under such systems iv the effectiveness of such systems in preventing ineligible individuals from receiving for affordability credits the characteristics of applicants described in subparagraph prohibition of database nothing in this paragraph or the amendments made by with bills hr ih paragraph shall be construed as authorizing the health choices commissioner or the commissioner of social security to establish a database of information on citizenship or immigration status initial funding in general out of any funds in the treasury not otherwise appropriated there is appropriated to the commissioner of social security to be available without fiscal year limit to carry out this paragraph and section of the social security act funding limitation in no case shall funds from the social security administration limitation on administrative expenses be used to carry out activities related to this paragraph or section of the social security act agreement with social security commissioner a in general the health choices commissioner shall enter into and maintain an agreement described in section of the with bills hr ih social security act with the commissioner of social security funding the agreement entered into under subparagraph a shall for each fiscal year beginning with fiscal year provide funds to the commissioner of social security for the full costs of the responsibilities of the commissioner of social security under paragraph including acquiring installing and maintaining technological equipment and systems necessary for the fulfillment of the responsibilities of the commissioner of social security under paragraph but only that portion of such costs that are attributable to such responsibilities and responding to individuals who contest with the commissioner of social security a reported inconsistency with records maintained by the commissioner of social security or the department of homeland security relating to citizenship or immigration with bills hr ih status name or social security account number under paragraph based on an estimating methodology agreed to by the commissioner of social security and the health choices commissioner provide such funds within calendar days of the beginning of the fiscal year for the first quarter and in advance for all subsequent quarters in that fiscal year and iii provide for an annual accounting and reconciliation of the actual costs incurred and the funds provided under the agreement review of accounting the annual accounting and reconciliation conducted pursuant to subparagraph iii shall be reviewed by the inspectors general of the social security administration and the health choices administration including an analysis of consistency with the requirements of paragraph contingency in any case in which agreement with respect to the provisions required under subparagraph for any fiscal year has not been reached as of the first day with bills hr ih of such fiscal year the latest agreement with respect to such provisions shall be deemed in effect on an interim basis for such fiscal year until such time as an agreement relating to such provisions is subsequently reached in any case in which an interim agreement applies for any fiscal year under this subparagraph the commissioner of social security shall not later than the first day of such fiscal year notify the appropriate committees of the congress of the failure to reach the agreement with respect to such provisions for such fiscal year until such time as the agreement with respect to such provisions has been reached for such fiscal year the commissioner of social security shall not later than the end of each day period after october of such fiscal year notify such committees of the status of negotiations between such commissioner and the health choices commissioner in order to reach such an agreement application to public entities administering affordability credits if the health choices commissioner provides for the conduct of verifications under paragraph with bills hr ih through a public entity the health choices commissioner shall require the public entity to enter into an agreement with the commissioner of social security which provides the same terms as the agreement described in this paragraph and section of the social security act between the health choices commissioner and the commissioner of social security except that the health choices commissioner shall be responsible for providing funds for the commissioner of social security in accordance with subparagraphs through amendments to social security act a coordination of information between social security administration and health choices administration in general section of the social security act usc is amended by adding at the end the following new subsection coordination of information with health choices administration the health choices commissioner collect and use the names and social security account numbers of individuals as required to provide for verification with bills hr ih of citizenship under subsection of section of the affordable health care for america act in connection with determinations of eligibility for affordability credits under such section a the commissioner of social security shall enter into and maintain an agreement with the health choices commissioner for the purpose of establishing in compliance with the requirements of section ee as applied pursuant to section of the affordable health care for america act a program for verifying information required to be collected by the health choices commissioner under such section the agreement entered into pursuant to subparagraph a shall include such safeguards as are necessary to ensure the maintenance of confidentiality of any information disclosed for purposes of verifying information described in subparagraph a and to provide procedures for permitting the health choices commissioner to use the information for purposes of maintaining the records of the health choices administration the agreement entered into pursuant to subparagraph a shall provide that information provided by the commissioner of social security to the health choices commissioner pursuant to the agreement shall be provided with bills hr ih at such time at such place and in such manner as the commissioner of social security determines appropriate information provided by the commissioner of social security to the health choices commissioner pursuant to an agreement entered into pursuant to subparagraph a shall be considered as strictly confidential and shall be used only for the purposes described in this paragraph and for carrying out such agreement any officer or employee or former officer or employee of the health choices commissioner or any officer or employee or former officer or employee of a contractor of the health choices commissioner who without the written authority of the commissioner of social security publishes or communicates any information in such individual possession by reason of such employment or position as such an officer shall be guilty of a felony and upon conviction thereof shall be fined or imprisoned or both as described in section the agreement entered into under paragraph shall provide for funding to the commissioner of social security consistent with section of affordable health care for america act this subsection shall apply in the case of a public entity that conducts verifications under section of the affordable health care for america act with bills hr ih and the obligations of this subsection shall apply to such an entity in the same manner as such obligations apply to the health choices commissioner when such commissioner is conducting such verifications conforming amendment section c of such act usc c is amended by adding at the end the following new clause for purposes of the administration of the verification procedures described in section of the affordable health care for america act the health choices commissioner collect and use social security account numbers as provided for in section improving the integrity of data and effectiveness of save section of the social security act usc b– is amended by adding at the end the following new paragraphs a with respect to the use by any agency of the system described in subsection by programs specified in subsection or any other use of such system the us citizenship and immigration services and any other agency charged with the management of the system shall establish appropriate safeguards necessary to protect and with bills hr ih improve the integrity and accuracy of data relating to individuals by establishing a process though which such individuals are provided access to and the ability to amend correct and update their own personally identifiable information contained within the system providing a written response without undue delay to any individual who has made such a request to amend correct or update such individual own personally identifiable information contained within the system and iii developing a written notice for user agencies to provide to individuals who are denied a benefit due to a determination of ineligibility based on a final verification determination under the system the notice described in subparagraph a shall include information about the reason for such notice a description of the right of the recipient of the notice under subparagraph a to contest such notice iii a description of the right of the recipient under subparagraph a to access and attempt to amend correct and update the recipient own per with bills hr ih sonally identifiable information contained within records of the system described in paragraph and iv instructions on how to contest such notice and attempt to correct records of such system relating to the recipient including contact information for relevant agencies streamlining administration of verification process for united states citizens section ee of the social security act usc a ee is amended by adding at the end the following in carrying out the verification procedures under this subsection with respect to a state if the commissioner of social security determines that the records maintained by such commissioner are not consistent with an individual allegation of united states citizenship pursuant to procedures which shall be established by the state in coordination with the commissioner of social security the secretary of homeland security and the secretary of health and human services the commissioner of social security shall inform the state of the inconsistency upon being so informed of the inconsistency the state shall submit the information on the with bills hr ih individual to the secretary of homeland security for a determination of whether the records of the department of homeland security indicate that the individual is a citizen iii upon making such determination the department of homeland security shall inform the state of such determination and iv information provided by the commissioner of social security shall be considered as strictly confidential and shall only be used by the state and the secretary of homeland security for the purposes of such verification procedures verification of status eligibility pursuant to the procedures established under this subsection shall be deemed a verification of status eligibility for purposes of this title title xxi and affordability credits under section of the affordable health care for america act regardless of the program in which the individual is applying for benefits use of affordability credits in general in and an affordable credit eligible individual use an affordability credit only with respect to a basic plan flexibility in plan enrollment authorized beginning with the commissioner with bills hr ih shall establish a process to allow an affordability premium credit under section but not the affordability cost sharing credit under section to be used for enrollees in enhanced or premium plans in the case of an affordable credit eligible individual who enrolls in an enhanced or premium plan the individual shall be responsible for any difference between the premium for such plan and the affordability credit amount otherwise applicable if the individual had enrolled in a basic plan prohibition of use of public funds for abortion coverage an affordability credit not be used for payment for services described in section a access to data in carrying out this subtitle the commissioner shall request from the secretary of the treasury consistent with section of the internal revenue code of such information as be required to carry out this subtitle no cash rebates in no case shall an affordable credit eligible individual receive any cash payment as a result of the application of this subtitle sec affordable credit eligible individual a definition with bills hr ih in general for purposes of this division the term affordable credit eligible individual means subject to subsection and section an individual who is lawfully present in a state in the united states other than as a nonimmigrant described in a subparagraph excluding subparagraphs and of section a of the immigration and nationality act a who is enrolled under an exchangeparticipating health benefits plan and is not enrolled under such plan as an employee or dependent of an employee through an employer qualified health benefits plan that meets the requirements of section with modified adjusted gross income below percent of the federal poverty level for a family of the size involved who is not a medicaid eligible individual other than an individual during a transition period under section and subject to paragraph who is not enrolled in acceptable coverage other than an exchange participating health benefits plan treatment of family except as the commissioner otherwise provide members of with bills hr ih the same family who are affordable credit eligible individuals shall be treated as a single affordable credit individual eligible for the applicable credit for such a family under this subtitle special rule for indians subparagraph of paragraph shall not apply to an individual who has coverage that is treated as acceptable coverage for purposes of section of the internal revenue code of but is not treated as acceptable coverage for purposes of this division limitations on employee and dependent disqualification in general subject to paragraph the term affordable credit eligible individual does not include a full time employee of an employer if the employer offers the employee coverage for the employee and dependents as a full time employee under a group health plan if the coverage and employer contribution under the plan meet the requirements of section exceptions a for certain family circumstances the commissioner shall establish such exceptions and special rules in the with bills hr ih case described in paragraph as be appropriate in the case of a divorced or separated individual or such a dependent of an employee who would otherwise be an affordable credit eligible individual for unaffordable employer coverage beginning in in the case of fulltime employees for which the cost of the employee premium for coverage under a group health plan would exceed percent of current modified adjusted gross income determined by the commissioner on the basis of verifiable documentation paragraph shall not apply income defined in general in this title the term income means modified adjusted gross income as defined in section of the internal revenue code of study of income disregards the commissioner shall conduct a study that examines the application of income disregards for purposes of this subtitle not later than the first day of the commissioner shall submit to congress a report on such study and shall include such recommendations as the commissioner determines appropriate with bills hr ih clarification of treatment of affordability credits affordability credits under this subtitle shall not be treated for purposes of title iv of the personal responsibility and work opportunity reconciliation act of to be a benefit provided under section of such title sec affordability premium credit a in general the affordability premium credit under this section for an affordable credit eligible individual enrolled in an exchange participating health benefits plan is in an amount equal to the amount if any by which the reference premium amount specified in subsection exceeds the affordable premium amount specified in subsection for the individual except that in no case shall the affordable premium credit exceed the premium for the plan affordable premium amount in general the affordable premium amount specified in this subsection for an individual for the annual premium in a plan year shall be equal to the product of a the premium percentage limit specified in paragraph for the individual based upon the individual modified adjusted gross income for the plan year and with bills hr ih the individual modified adjusted gross income for such plan year premium percentage limits based on table the commissioner shall establish premium percentage limits so that for individuals whose modified adjusted gross income is within an income tier specified in the table in subsection such percentage limits shall increase on a sliding scale in a linear manner from the initial premium percentage to the final premium percentage specified in such table for such income tier reference premium amount the reference premium amount specified in this subsection for a plan year for an individual in a premium rating area is equal to the average premium for the basic plans in the area for the plan year with the lowest premium levels in computing such amount the commissioner exclude plans with extremely limited enrollments table of premium percentage limits actuarial value percentages and out of pocket limits for based on income tier in general for purposes of this subtitle subject to paragraph and section the table specified in this subsection is as follows with bills hr ihin the case ofmodified adjustedgross income expressedas a percentof fpl withinthe following incometier the initialpremiumpercentageis the finalpremiumpercentageis the actuarialvaluepercentageis the out ofpocketlimitfor is % through%% % % % through%% % % % through%% % % % through%% % % % through%% % % % through%% % % special rules for purposes of applying the table under paragraph a for lowest level of income in the case of an individual with income that does not exceed percent of fpl the individual shall be considered to have income that is percent of fpl application of higher actuarial value percentage at tier transition points if two actuarial value percentages be determined with respect to an individual the actuarial value percentage shall be the higher of such percentages indexing for years after the commissioner shall adjust the initial and final premium percentages to maintain the ratio of governmental to with bills hr ih enrollee shares of premiums over time for each income tier identified in the table in paragraph sec affordability cost sharing credit a in general the affordability cost sharing credit under this section for an affordable credit eligible individual enrolled in an exchange participating health benefits plan is in the form of the cost sharing reduction described in subsection provided under this section for the income tier in which the individual is classified based on the individual modified adjusted gross income cost sharing reductions the commissioner shall specify a reduction in cost sharing amounts and the annual limitation on cost sharing specified in section under a basic plan for each income tier specified in the table under section with respect to a year in a manner so that as estimated by the commissioner the actuarial value of the coverage with such reduced cost sharing amounts and the reduced annual cost sharing limit is equal to the actuarial value percentage specified in the table under section for the income tier involved of the full actuarial value if there were no cost sharing imposed under the plan and with bills hr ih the annual limitation on cost sharing specified in section is reduced to a level that does not exceed the maximum out of pocket limit specified in subsection c maximum out of pocket limit in general subject to paragraph the maximum out of pocket limit specified in this subsection for an individual within an income tier a for individual coverage for is the out of pocket limit for specified in subsection in the table under section for the income tier involved or for a subsequent year is such outof pocket limit for the previous year under this subparagraph increased rounded to the nearest for each subsequent year by the percentage increase in the enrollment weighted average of premium increases for basic plans applicable to such year or for family coverage is twice the maximum out of pocket limit under subparagraph a for the year involved with bills hr ih adjustment the commissioner shall adjust the maximum out of pocket limits under paragraph to ensure that such limits meet the actuarial value percentage specified in the table under section for the income tier involved determination and payment of cost sharing affordability credit in the case of an affordable credit eligible individual in a tier enrolled in an exchange participating health benefits plan offered by a qhbp offering entity the commissioner shall provide for payment to the offering entity of an amount equivalent to the increased actuarial value of the benefits under the plan provided under section resulting from the reduction in cost sharing described in subsections and sec income determinations a in general in applying this subtitle for an affordability credit for an individual for a plan year the individual income shall be the income as defined in section for the individual for the most recent taxable year as determined in accordance with rules of the commissioner the federal poverty level applied shall be such level in effect as of the date of the application program integrity income verification procedures with bills hr ih program integrity the commissioner shall take such steps as be appropriate to ensure the accuracy of determinations and redeterminations under this subtitle income verification a in general upon an initial application of an individual for an affordability credit under this subtitle or in applying section or upon an application for a change in the affordability credit based upon a significant change in modified adjusted gross income described in subsection the commissioner shall request from the secretary of the treasury the disclosure to the commissioner of such information as be permitted to verify the information contained in such application and the commissioner shall use the information so disclosed to verify such information alternative procedures the commissioner shall establish procedures for the verification of income for purposes of this sub with bills hr ih title if no income tax return is available for the most recent completed tax year special rules changes in income as a percent of fpl in the case that an individual income expressed as a percentage of the federal poverty level for a family of the size involved for a plan year is expected in a manner specified by the commissioner to be significantly different from the income as so expressed used under subsection a the commissioner shall establish rules requiring an individual to report consistent with the mechanism established under paragraph significant changes in such income including a significant change in family composition to the commissioner and requiring the substitution of such income for the income otherwise applicable reporting of significant changes in income the commissioner shall establish rules under which an individual determined to be an affordable credit eligible individual would be required to inform the commissioner when there is a significant change in the modified adjusted gross income of the individual expressed as a percentage of the fpl for a family of the size involved and of the in with bills hr ih formation regarding such change such mechanism shall provide for guidelines that specify the circumstances that qualify as a significant change the verifiable information required to document such a change and the process for submission of such information if the commissioner receives new information from an individual regarding the modified adjusted gross income of the individual the commissioner shall provide for a redetermination of the individual eligibility to be an affordable credit eligible individual transition for chip in the case of a child described in section the commissioner shall establish rules under which the modified adjusted gross income of the child is deemed to be no greater than the family income of the child as most recently determined before by the state under title xxi of the social security act study of geographic variation in application of fpl a in general the secretary of health and human services shall conduct a study to examine the feasibility and implication of adjusting the application of the federal poverty level under this subtitle for different geo with bills hr ih graphic areas so as to reflect the variations in cost of living among different areas within the united states if the secretary determines that an adjustment is feasible the study should include a methodology to make such an adjustment not later than the first day of the secretary shall submit to congress a report on such study and shall include such recommendations as the secretary determines appropriate inclusion of territories in general the secretary shall ensure that the study under subparagraph a covers the territories of the united states and that special attention is paid to the disparity that exists among poverty levels and the cost of living in such territories and to the impact of such disparity on efforts to expand health coverage and ensure health care territories defined in this subparagraph the term territories of the united states includes the commonwealth of puerto rico the united states virgin islands guam the northern mar with bills hr ih iana islands and any other territory or possession of the united states penalties for misrepresentation in the case of an individual who intentionally misrepresents modified adjusted gross income or the individual fails without regard to intent to disclose to the commissioner a significant change in modified adjusted gross income under subsection in a manner that results in the individual becoming an affordable credit eligible individual when the individual is not or in the amount of the affordability credit exceeding the correct amount the individual is liable for repayment of the amount of the improper affordability credit and in the case of such an intentional misrepresentation or other egregious circumstances specified by the commissioner the commissioner impose an additional penalty sec special rules for application to territories a one time election for treatment and application of funding in general a territory elect in a form and manner specified by the commissioner in consultation with the secretary of health and with bills hr ih human services and the secretary of the treasury and not later than october either a to be treated as a state for purposes of applying this title and title or not to be so treated but instead to have the dollar limitation otherwise applicable to the territory under subsections and of section of the social security act usc for a fiscal year increased by a dollar amount equivalent to the cap amount determined under subsection for the territory as applied by the secretary for the fiscal year involved conditions for acceptance the commissioner has the nonreviewable authority to accept or reject an election described in paragraph a any such acceptance is a contingent upon entering into an agreement described in subsection between the commissioner and the territory and subsection and subject to the approval of the secretary of health and human services and the secretary of the treasury and subject to such other terms and conditions as the commis with bills hr ih sioner in consultation with such secretaries specify default rule a territory failing to make such an election or having an election under paragraph a not accepted under paragraph shall be treated as having made the election described in paragraph agreement for substitution of percentages for affordability credits negotiation in the case of a territory making an election under subsection a a in this section referred to as an electing territory the commissioner in consultation with the secretaries of health and human services and the treasury shall enter into negotiations with the government of such territory so that before there is an agreement reached between the parties on the percentages that shall be applied under paragraph for that territory the commissioner shall not enter into such an agreement unless a payments made under this subtitle with respect to residents of the territory are consistent with the cap established under subsection for such territory and with subsection and with bills hr ih the requirements of paragraphs and are met application of substitute percentages and dollar amounts in the case of an electing territory there shall be substituted in section a and in the table in section for percent percent and other percentages and dollar amounts specified in such table such respective percentages and dollar amounts as are established under the agreement under paragraph consistent with the following a no income gap between medicaid and affordability credits the substituted percentages shall be specified in a manner so as to prevent any gap in coverage for individuals between income level at which medical assistance is available through medicaid and the income level at which affordability credits are available adjustment for out of pocket responsibility for premiums and costsharing in relation to income the substituted percentages of fpl for income tiers under such table shall be specified in a manner so that with bills hr ih affordable credit eligible individuals residing in the territory bear the same out of pocket responsibility for premiums and cost sharing in relation to average income for residents in that territory as the out of pocket responsibility for premiums and cost sharing for affordable credit eligible individuals residing in the states or the district of columbia in relation to average income for such residents special rules with respect to application of tax and penalty provisions the electing territory shall enact one or more laws under which provisions similar to the following provisions apply with respect to such territory a section of the internal revenue code of except that any resident of the territory who is not an affordable credit eligible individual but who would be an affordable credit eligible individual if such resident were a resident of one of the states and any qualifying child residing with such individual be treated as covered by acceptable coverage section of the internal revenue code of and section of with bills hr ih the employee retirement income security act of section of the internal revenue code of implementation of insurance reform and consumer protection requirements the electing territory shall enact and implement such laws and regulations as be required to apply the requirements of title with respect to health insurance coverage offered in the territory cap on additional expenditures in general in entering into an agreement with an electing territory under subsection the commissioner shall ensure that the aggregate expenditures under this subtitle with respect to residents of such territory during the period beginning with and ending with will not exceed the cap amount specified in paragraph for such territory the commissioner shall adjust from time to time the percentages applicable under such agreement as needed in order to carry out the previous sentence cap amount a in general the cap amount specified in this paragraph with bills hr ih for puerto rico is increased by the amount if any elected under subparagraph or for another territory is the portion of negotiated for such territory under subparagraph negotiation for certain territories the commissioner in consultation with the secretary of health and human services shall negotiate with the governments of the territories other than puerto rico to allocate the amount specified in subparagraph a among such territories optional supplementation for puerto rico in general puerto rico elect in a form and manner specified by the secretary of health and human services in consultation with the commissioner to increase the dollar amount specified in subparagraph a by up to offset in medicaid cap if puerto rico makes the election described in clause the secretary shall decrease with bills hr ih the dollar limitation otherwise applicable to puerto rico under subsections and of section of the social security act usc for a fiscal year by the additional aggregate payments the secretary estimates will be payable under this section for the fiscal year because of such election limitation on funding in no case shall this section including the agreement under subsection permit the obligation of funds for expenditures under this subtitle for periods beginning on or after january or any increase in the dollar limitation described in subsection a for any portion of any fiscal year occurring on or after such date sec no federal payment for undocumented aliens nothing in this subtitle shall allow federal payments for affordability credits on behalf of individuals who are not lawfully present in the united states with bills hr ih title iv shared responsibility subtitle a individual responsibility sec individual responsibility for an individual responsibility to obtain acceptable coverage see section of the internal revenue code of as added by section of this act subtitle employer responsibility part health coverage participation requirements sec health coverage participation requirements an employer meets the requirements of this section if such employer does all of the following offer of coverage the employer offers each employee individual and family coverage under a qualified health benefits plan or under a current employment based health plan within the meaning of section in accordance with section contribution towards coverage if an employee accepts such offer of coverage the em with bills hr ih ployer makes timely contributions towards such coverage in accordance with section contribution in lieu of coverage beginning with if an employee declines such offer but otherwise obtains coverage in an exchangeparticipating health benefits plan other than by reason of being covered by family coverage as a spouse or dependent of the primary insured the employer shall make a timely contribution to the health insurance exchange with respect to each such employee in accordance with section sec employer responsibility to contribute toward employee and dependent coverage a in general an employer meets the requirements of this section with respect to an employee if the following requirements are met offering of coverage the employer offers the coverage described in section in the case of an exchange eligible employer the employer offer such coverage either through an exchange participating health benefits plan or other than through such a plan employer required contribution the employer timely pays to the issuer of such cov with bills hr ih erage an amount not less than the employer required contribution specified in subsection for such coverage provision of information the employer provides the health choices commissioner the secretary of labor the secretary of health and human services and the secretary of the treasury as applicable with such information as the commissioner require to ascertain compliance with the requirements of this section including the following a the name date and employer identification number of the employer a certification as to whether the employer offers to its full time employees and their dependents the opportunity to enroll in a qualified health benefits plan or a current employment based health plan within the meaning of section if the employer certifies that the employer did offer to its full time employees and their dependents the opportunity to so enroll the months during the calendar year for which such coverage was available and with bills hr ih the monthly premium for the lowest cost option in each of the enrollment categories under each such plan offered to employees the name address and tin of each full time employee during the calendar year and the months if any during which such employee and any dependents were covered under any such plans autoenrollment of employees the employer provides for autoenrollment of the employee in accordance with subsection this subsection shall supersede any law of a state which would prevent automatic payroll deduction of employee contributions to an employment based health plan reduction of employee premiums through minimum employer contribution full time employees the minimum employer contribution described in this subsection for coverage of a full time employee and if any the employee spouse and qualifying children as defined in section of the internal revenue code of under a qualified health benefits plan or current employment based health plan is equal to with bills hr ih a in case of individual coverage not less than percent of the applicable premium as defined in section of such code subject to paragraph of the lowest cost plan offered by the employer that is a qualified health benefits plan or is such current employment based health plan and in the case of family coverage which includes coverage of such spouse and children not less percent of such applicable premium of such lowest cost plan applicable premium for exchange coverage in this subtitle the amount of the applicable premium of the lowest cost plan with respect to coverage of an employee under an exchange participating health benefits plan is the reference premium amount under section for individual coverage or if elected family coverage for the premium rating area in which the individual or family resides minimum employer contribution for employees other than full time employees in the case of coverage for an employee who is not a full time employee the amount of the minimum employer contribution under this subsection shall be a proportion as determined in accordance with bills hr ih with rules of the health choices commissioner the secretary of labor the secretary of health and human services and the secretary of the treasury as applicable of the minimum employer contribution under this subsection with respect to a full time employee that reflects the proportion of a the average weekly hours of employment of the employee by the employer to the minimum weekly hours specified by the commissioner for an employee to be a full time employee salary reductions not treated as employer contributions for purposes of this section any contribution on behalf of an employee with respect to which there is a corresponding reduction in the compensation of the employee shall not be treated as an amount paid by the employer automatic enrollment for employer sponsored health benefits in general the requirement of this subsection with respect to an employer and an employee is that the employer automatically enroll such employee into the employment based health benefits plan for individual coverage under the plan option with the lowest applicable employee premium with bills hr ih opt out in no case an employer automatically enroll an employee in a plan under paragraph if such employee makes an affirmative election to opt out of such plan or to elect coverage under an employment based health benefits plan offered by such employer an employer shall provide an employee with a day period to make such an affirmative election before the employer automatically enroll the employee in such a plan notice requirements a in general each employer described in paragraph who automatically enrolls an employee into a plan as described in such paragraph shall provide the employees within a reasonable period before the beginning of each plan year or in the case of new employees within a reasonable period before the end of the enrollment period for such a new employee written notice of the employees rights and obligations relating to the automatic enrollment requirement under such paragraph such notice must be comprehensive and understood by the average employee to whom the automatic enrollment requirement applies with bills hr ih inclusion of specific information the written notice under subparagraph a must explain an employee right to opt out of being automatically enrolled in a plan and in the case that more than one level of benefits or employee premium level is offered by the employer involved the notice must explain which level of benefits and employee premium level the employee will be automatically enrolled in the absence of an affirmative election by the employee sec employer contributions in lieu of coverage a in general a contribution is made in accordance with this section with respect to an employee if such contribution is equal to an amount equal to percent of the average wages paid by the employer during the period of enrollment determined by taking into account all employees of the employer and in such manner as the commissioner provides including rules providing for the appropriate aggregation of related employers but not to exceed the minimum employer contribution described in section a any such contribution with bills hr ih shall be paid to the health choices commissioner for deposit into the health insurance exchange trust fund and shall not be applied against the premium of the employee under the exchange participating health benefits plan in which the employee is enrolled special rules for small employers in general in the case of any employer who is a small employer for any calendar year subsection a shall be applied by substituting the applicable percentage determined in accordance with the following table for percent if the annual payroll of such employer forthe preceding calendar year the applicablepercentage is does not exceed percentexceeds but does not exceed percentexceeds but does not exceed percentexceeds but does not exceed percent small employer for purposes of this subsection the term small employer means any employer for any calendar year if the annual payroll of such employer for the preceding calendar year does not exceed annual payroll for purposes of this paragraph the term annual payroll means with respect to any employer for any calendar year the with bills hr ih aggregate wages paid by the employer during such calendar year aggregation rules related employers and predecessors shall be treated as a single employer for purposes of this subsection sec authority related to improper steering the health choices commissioner in coordination with the secretary of labor the secretary of health and human services and the secretary of the treasury shall have authority to set standards for determining whether employers or insurers are undertaking any actions to affect the risk pool within the health insurance exchange by inducing individuals to decline coverage under a qualified health benefits plan or current employment based health plan within the meaning of section offered by the employer and instead to enroll in an exchange participating health benefits plan an employer violating such standards shall be treated as not meeting the requirements of this section sec impact study on employer responsibility requirements a in general the secretary of labor shall conduct a study to examine the effect of the exemptions under section a and coverage thresholds under this division in this section referred to collectively as ?employer re with bills hr ih sponsibility requirements on employment based health plan sponsorship generally and within specific industries and the effect of such requirements and thresholds on employers employment based health plans and employees in each industry annual report the secretary of labor annually shall submit to congress a report on findings on how employer responsibility requirements have impacted and are likely to impact employers plans and employees during the previous year and projected trends legislative recommendations no later than january and on an annual basis thereafter the secretary of labor shall submit legislative recommendations to congress to modify the employer responsibility requirements if the secretary determines that the requirements are detrimentally affecting or will detrimentally affect employer plan sponsorship or otherwise creating inequities among employers health plans and employees the secretary also submit such recommendations as the secretary determines necessary to improve and strengthen employment based health plan sponsorship employer responsibility and related proposals that would enhance the delivery of health care benefits between employers and employees with bills hr ih sec study on employer hardship exemption a in general the secretary of labor together with the secretary of treasury the secretary of health and human services and the commissioner shall conduct a study to examine the impact of the employer responsibility requirements described in section a and make a recommendation to congress about whether an employer hardship exemption would be appropriate items included in study within such study the secretaries and commissioner shall examine cases where such employer responsibility requirements pose a particular hardship and specifically look at employers by industry profit margin length of time in business and size in this examination the economic conditions shall be considered including the rate of increase in business costs the availability of short term credit lines and abilities to restructure debt in addition the study shall examine the impact an employer hardship waiver could have on employees report not later than january the secretaries and commissioner shall report to congress on their findings and make a recommendation regarding the need or lack of need for a partial or complete employer hardship waiver the secretaries and commissioner also submit recommendations about the criteria congress should include when developing eligibility requirements for with bills hr ih the employer hardship waiver and what safeguards are necessary to protect the employees of that employer part satisfaction of health coverage participation requirements sec satisfaction of health coverage participation requirements under the employee retirement income security act of a in general subtitle of title of the employee retirement income security act of is amended by adding at the end the following new part part national health coverage participation requirements sec election of employer to be subject to national health coverage participation requirements a in general an employer make an election with the secretary to be subject to the health coverage participation requirements time and manner an election under subsection a be made at such time and in such form and manner as the secretary prescribe with bills hr ih sec treatment of coverage resulting from election a in general if an employer makes an election to the secretary under section such election shall be treated as the establishment and maintenance of a group health plan as defined in section a for purposes of this title subject to section of the and the health coverage participation requirements shall be deemed to be included as terms and conditions of such plan periodic investigations to discover noncompliance the secretary shall regularly audit a representative sampling of employers and group health plans and conduct investigations and other activities under section with respect to such sampling of plans so as to discover noncompliance with the health coverage participation requirements in connection with such plans the secretary shall communicate findings of noncompliance made by the secretary under this subsection to the secretary of the treasury and the health choices commissioner the secretary shall take such timely enforcement action as appropriate to achieve compliance recordkeeping to facilitate the audits described in subsection the secretary shall promulgate recordkeeping requirements for employers to account for with bills hr ih both employees of the employer and individuals whom the employer has not treated as employees of the employer but with whom the employer in the course of its trade or business has engaged for the performance of labor or services the scope and content of such recordkeeping requirements shall be determined by the secretary and shall be designed to ensure that employees who are not properly treated as such be identified and properly treated sec health coverage participation requirements for purposes of this part the term health coverage participation requirements means the requirements of part of subtitle of title iv of division a of as in effect on the date of the enactment of such act sec rules for applying requirements a affiliated groups in the case of any employer which is part of a group of employers who are treated as a single employer under subsection or of section of the internal revenue code of the election under section shall be made by such employer as the secretary provide any such election once made shall apply to all members of such group separate elections under regulations prescribed by the secretary separate elections be made under section with respect to with bills hr ih separate lines of business and full time employees and employees who are not full time employees sec termination of election in cases of substantial noncompliance the secretary terminate the election of any employer under section if the secretary in coordination with the health choices commissioner determines that such employer is in substantial noncompliance with the health coverage participation requirements and shall refer any such determination to the secretary of the treasury as appropriate sec regulations the secretary promulgate such regulations as be necessary or appropriate to carry out the provisions of this part in accordance with section a of the the secretary promulgate any interim final rules as the secretary determines are appropriate to carry out this part enforcement of health coverage participation requirements section of such act usc is amended in subsection a by striking paragraph and all that follows through subsection with bills hr ih and inserting paragraph or of subsection and in subsection by redesignating the second paragraph as paragraph and by inserting after the first paragraph the following new paragraph health coverage participation requirements a civil penalties in the case of any employer who fails during any period with respect to which an election under section a is in effect to satisfy the health coverage participation requirements with respect to any employee the secretary assess a civil penalty against the employer of for each day in the period beginning on the date such failure first occurs and ending on the date such failure is corrected health coverage participation requirements for purposes of this paragraph the term health coverage participation requirements has the meaning provided in section limitations on amount of penalty with bills hr ih penalty not to apply where failure not discovered exercising reasonable diligence no penalty shall be assessed under subparagraph a with respect to any failure during any period for which it is established to the satisfaction of the secretary that the employer did not know or exercising reasonable diligence would not have known that such failure existed penalty not to apply to failures corrected within days no penalty shall be assessed under subparagraph a with respect to any failure if such failure was due to reasonable cause and not to willful neglect and such failure is corrected during the day period beginning on the st date that the employer knew or exercising reasonable diligence would have known that such failure existed with bills hr ih iii overall limitation for unintentional failures in the case of failures which are due to reasonable cause and not to willful neglect the penalty assessed under subparagraph a for failures during any year period shall not exceed the amount equal to the lesser of percent of the aggregate amount paid or incurred by the employer or predecessor employer during the preceding year period for group health plans or advance notification of failure prior to assessment before a reasonable time prior to the assessment of any penalty under this paragraph with respect to any failure by an employer the secretary shall inform the employer in writing of such failure and shall provide the employer information regarding efforts and procedures which be undertaken by the employer to correct such failure coordination with excise tax under regulations prescribed in accordance with section of the the secretary and the with bills hr ih secretary of the treasury shall coordinate the assessment of penalties under this section in connection with failures to satisfy health coverage participation requirements with the imposition of excise taxes on such failures under section of the internal revenue code of so as to avoid duplication of penalties with respect to such failures deposit of penalty collected any amount of penalty collected under this paragraph shall be deposited as miscellaneous receipts in the treasury of the united states clerical amendments the table of contents in section of such act is amended by inserting after the item relating to section the following new items part national health coverage participation requirements sec election of employer to be subject to national health coverage participationrequirements sec treatment of coverage resulting from election sec health coverage participation requirements sec rules for applying requirements sec termination of election in cases of substantial noncompliance sec regulations effective date the amendments made by this section shall apply to periods beginning after december with bills hr ih sec satisfaction of health coverage participation requirements under the internal revenue code of a failure to elect or substantially comply with health coverage participation requirements for employment tax on employers who fail to elect or substantially comply with the health coverage participation requirements described in part see section of the internal revenue code of as added by section of this act other failures for excise tax on other failures of electing employers to comply with such requirements see section of the internal revenue code of as added by section of this act sec satisfaction of health coverage participation requirements under the public health service act a in general part of title xxvii of the public health service act is amended by adding at the end the following new section sec national health coverage participation requirements a election of employer to be subject to national health coverage participation requirements with bills hr ih in general an employer make an election with the secretary to be subject to the health coverage participation requirements time and manner an election under paragraph be made at such time and in such form and manner as the secretary prescribe treatment of coverage resulting from election in general if an employer makes an election to the secretary under subsection a a such election shall be treated as the establishment and maintenance of a group health plan for purposes of this title subject to section of the affordable health care for america act and the health coverage participation requirements shall be deemed to be included as terms and conditions of such plan periodic investigations to determine compliance with health coverage participation requirements the secretary shall regularly audit a representative sampling of employers and conduct investigations and other activities with respect to such sampling of employers so as to dis with bills hr ih cover noncompliance with the health coverage participation requirements in connection with such employers during any period with respect to which an election under subsection a is in effect the secretary shall communicate findings of noncompliance made by the secretary under this subsection to the secretary of the treasury and the health choices commissioner the secretary shall take such timely enforcement action as appropriate to achieve compliance recordkeeping to facilitate the audits described in subsection the secretary shall promulgate recordkeeping requirements for employers to account for both employees of the employer and individuals whom the employer has not treated as employees of the employer but with whom the employer in the course of its trade or business has engaged for the performance of labor or services the scope and content of such recordkeeping requirements shall be determined by the secretary and shall be designed to ensure that employees who are not properly treated as such be identified and properly treated health coverage participation requirements for purposes of this section the term health with bills hr ih coverage participation requirements means the requirements of part of subtitle of title iv of division a of the as in effect on the date of the enactment of this section separate elections under regulations prescribed by the secretary separate elections be made under subsection a with respect to full time employees and employees who are not full time employees termination of election in cases of substantial noncompliance the secretary terminate the election of any employer under subsection a if the secretary in coordination with the health choices commissioner determines that such employer is in substantial noncompliance with the health coverage participation requirements and shall refer any such determination to the secretary of the treasury as appropriate enforcement of health coverage participation requirements civil penalties in the case of any employer who fails during any period with respect to which the election under subsection a is in effect to satisfy the health coverage participation requirements with respect to any employee the secretary assess a civil penalty against the employer of for each day in the period beginning on the with bills hr ih date such failure first occurs and ending on the date such failure is corrected limitations on amount of penalty a penalty not to apply where failure not discovered exercising reasonable diligence no penalty shall be assessed under paragraph with respect to any failure during any period for which it is established to the satisfaction of the secretary that the employer did not know or exercising reasonable diligence would not have known that such failure existed penalty not to apply to failures corrected within days no penalty shall be assessed under paragraph with respect to any failure if such failure was due to reasonable cause and not to willful neglect and such failure is corrected during the day period beginning on the st date that the employer knew or exercising reasonable diligence would have known that such failure existed overall limitation for unintentional failures in the case of failures with bills hr ih which are due to reasonable cause and not to willful neglect the penalty assessed under paragraph for failures during any year period shall not exceed the amount equal to the lesser of percent of the aggregate amount paid or incurred by the employer or predecessor employer during the preceding taxable year for group health plans or advance notification of failure prior to assessment before a reasonable time prior to the assessment of any penalty under paragraph with respect to any failure by an employer the secretary shall inform the employer in writing of such failure and shall provide the employer information regarding efforts and procedures which be undertaken by the employer to correct such failure actions to enforce assessments the secretary bring a civil action in any district court of the united states to collect any civil penalty under this subsection with bills hr ih coordination with excise tax under regulations prescribed in accordance with section of the the secretary and the secretary of the treasury shall coordinate the assessment of penalties under paragraph in connection with failures to satisfy health coverage participation requirements with the imposition of excise taxes on such failures under section of the internal revenue code of so as to avoid duplication of penalties with respect to such failures deposit of penalty collected any amount of penalty collected under this subsection shall be deposited as miscellaneous receipts in the treasury of the united states regulations the secretary promulgate such regulations as be necessary or appropriate to carry out the provisions of this section in accordance with section a of the the secretary promulgate any interim final rules as the secretary determines are appropriate to carry out this section effective date the amendments made by subsection a shall apply to periods beginning after december with bills hr ih sec additional rules relating to health coverage participation requirements a assuring coordination the officers consisting of the secretary of labor the secretary of the treasury the secretary of health and human services and the health choices commissioner shall ensure through the execution of an interagency memorandum of understanding among such officers that regulations rulings and interpretations issued by such officers relating to the same matter over which two or more of such officers have responsibility under subpart of part of subtitle of title of the employee retirement income security act of section of the internal revenue code of and section of the public health service act are administered so as to have the same effect at all times and coordination of policies relating to enforcing the same requirements through such officers in order to have a coordinated enforcement strategy that avoids duplication of enforcement efforts and assigns priorities in enforcement multiemployer plans in the case of a group health plan that is a multiemployer plan as defined in section of the employee retirement income security act of the regulations prescribed in accordance with bills hr ih with subsection a by the officers referred to in subsection a shall provide for the application of the health coverage participation requirements to the plan sponsor and contributing employers of such plan for purposes of this division contributions made pursuant to a collective bargaining agreement or other agreement to such a group health plan shall be treated as amounts paid by the employer title amendments to internal revenue code of subtitle a provisions relating to health care reform part shared responsibility subpart a individual responsibility sec tax on individuals without acceptable health care coverage a in general subchapter a of chapter of the internal revenue code of is amended by adding at the end the following new part part viii health care related taxes subpart a tax on individuals without acceptable health carecoverage subpart a tax on individuals without acceptable health care coverage sec tax on individuals without acceptable health care coverage with bills hr ih sec tax on individuals without acceptable health care coverage a tax imposed in the case of any individual who does not meet the requirements of subsection at any time during the taxable year there is hereby imposed a tax equal to percent of the excess of the taxpayer modified adjusted gross income for the taxable year over the amount of gross income specified in section a with respect to the taxpayer limitations tax limited to average premium a in general the tax imposed under subsection a with respect to any taxpayer for any taxable year shall not exceed the applicable national average premium for such taxable year applicable national average premium in general for purposes of subparagraph a the applicable national average premium means with respect to any taxable year the average premium as determined by the secretary in coordination with the health choices commissioner for self only coverage under a basic with bills hr ih plan which is offered in a health insurance exchange for the calendar year in which such taxable year begins failure to provide coverage for more than one individual in the case of any taxpayer who fails to meet the requirements of subsection with respect to more than one individual during the taxable year clause shall be applied by substituting family coverage for self only coverage proration for part year failures the tax imposed under subsection a with respect to any taxpayer for any taxable year shall not exceed the amount which bears the same ratio to the amount of tax so imposed determined without regard to this paragraph and after application of paragraph as a the aggregate periods during such taxable year for which such individual failed to meet the requirements of subsection bears to the entire taxable year exceptions with bills hr ih dependents subsection a shall not apply to any individual for any taxable year if a deduction is allowable under section with respect to such individual to another taxpayer for any taxable year beginning in the same calendar year as such taxable year nonresident aliens subsection a shall not apply to any individual who is a nonresident alien individuals residing outside united states any qualified individual as defined in section and any qualifying child residing with such individual shall be treated for purposes of this section as covered by acceptable coverage during the period described in subparagraph a or of section whichever is applicable individuals residing in possessions of the united states any individual who is a bona fide resident of any possession of the united states as determined under section a for any taxable year and any qualifying child residing with such individual shall be treated for purposes of this section as covered by acceptable coverage during such taxable year religious conscience exemption with bills hr ih a in general subsection a shall not apply to any individual and any qualifying child residing with such individual for any period if such individual has in effect an exemption which certifies that such individual is a member of a recognized religious sect or division thereof described in section and an adherent of established tenets or teachings of such sect or division as described in such section exemption an application for the exemption described in subparagraph a shall be filed with the secretary at such time and in such form and manner as the secretary prescribe the secretary treat an application for exemption under section as an application for exemption under this section or otherwise coordinate applications under such sections as the secretary determines appropriate any such exemption granted by the secretary shall be effective for such period as the secretary determines appropriate acceptable coverage requirement in general the requirements of this subsection are met with respect to any individual for with bills hr ih any period if such individual and each qualifying child of such individual is covered by acceptable coverage at all times during such period acceptable coverage for purposes of this section the term acceptable coverage means any of the following a qualified health benefits plan coverage coverage under a qualified health benefits plan as defined in section of the grandfathered health insurance coverage coverage under grandfathered employment based health plan coverage under a grandfathered health insurance coverage as defined in subsection a of section of the or under a current employment based health plan within the meaning of subsection of such section medicare coverage under part a of title xviii of the social security act medicaid coverage for medical assistance under title xix of the social security act members of the armed forces and dependents including tricare with bills hr ih coverage under chapter of title united states code including similar coverage furnished under section of title of such code va coverage under the veteran health care program under chapter of title united states code members of indian tribes health care services made available through the indian health service a tribal organization as defined in section of the indian health care improvement act or an urban indian organization as defined in such section to members of an indian tribe as defined in such section other coverage such other health benefits coverage as the secretary in coordination with the health choices commissioner recognizes for purposes of this subsection other definitions and special rules qualifying child for purposes of this section the term qualifying child has the meaning given such term by section with respect to any period during which health coverage for a child must be provided by an individual pursuant to a with bills hr ih child support order such child shall be treated as a qualifying child of such individual and not as a qualifying child of any other individual basic plan for purposes of this section the term basic plan has the meaning given such term under section of the health insurance exchange for purposes of this section the term health insurance exchange has the meaning given such term under section of the including any state based health insurance exchange approved for operation under section of such act family coverage for purposes of this section the term family coverage means any coverage other than self only coverage modified adjusted gross income for purposes of this section the term modified adjusted gross income means adjusted gross income increased by a any amount excluded from gross income under section and any amount of interest received or accrued by the taxpayer during the taxable year which is exempt from tax with bills hr ih not treated as tax imposed by this chapter for certain purposes the tax imposed under this section shall not be treated as tax imposed by this chapter for purposes of determining the amount of any credit under this chapter or for purposes of section regulations the secretary shall prescribe such regulations or other guidance as be necessary or appropriate to carry out the purposes of this section including regulations or other guidance developed in coordination with the health choices commissioner which provide exemption from the tax imposed under subsection a in cases of de minimis lapses of acceptable coverage and a waiver of the application of subsection a in cases of hardship including a process for applying for such a waiver information reporting in general subpart of part iii of subchapter a of chapter of such code is amended by inserting after section the following new section with bills hr ih sec returns relating to health insurance coverage a requirement of reporting every person who provides acceptable coverage as defined in section to any individual during any calendar year shall at such time as the secretary prescribe make the return described in subsection with respect to such individual form and manner of returns a return is described in this subsection if such return is in such form as the secretary prescribe and contains a the name address and tin of the primary insured and the name of each other individual obtaining coverage under the policy the period for which each such individual was provided with the coverage referred to in subsection a and such other information as the secretary require 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 primary insured whose with bills hr ih name is required 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 and the information required to be shown on the return with respect to such individual the written statement required under the preceding sentence shall be furnished on or before january of the year following the calendar year for which the return under subsection a is required to be made coverage provided by governmental units in the case of coverage provided by any governmental unit or any agency or instrumentality thereof the officer or employee who enters into the agreement to provide such coverage or the person appropriately designated for purposes of this section shall make the returns and statements required by this section penalty for failure to file a return subparagraph of section of such code is amended by striking or at the end of clause xxii by striking and at the end of clause xxiii and inserting or and by adding at the end the following new clause with bills hr ih xxiv section relating to returns relating to health insurance coverage and statement paragraph of section of such code is amended by striking or at the end of subparagraph ee by striking the period at the end of subparagraph ff and inserting or and by inserting after subparagraph ff the following new subparagraph gg section relating to returns relating to health insurance coverage return requirement subsection a of section of such code is amended by inserting after paragraph the following new paragraph every individual to whom section a applies and who fails to meet the requirements of section with respect to such individual or any qualifying child as defined in section of such individual clerical amendments the table of parts for subchapter a of chapter of the internal revenue code of is amended by adding at the end the following new item part viii health care related taxes with bills hr ih the table of sections for subpart of part iii of subchapter a of chapter is amended by adding at the end the following new item sec returns relating to health insurance coverage section not to apply the amendment made by subsection a shall not be treated as a change in a rate of tax for purposes of section of the internal revenue code of effective date in general the amendments made by this section shall apply to taxable years beginning after december returns the amendments made by subsection shall apply to calendar years beginning after december subpart employer responsibility sec election to satisfy health coverage participation requirements a in general chapter of the internal revenue code of is amended by adding at the end the following new section sec election with respect to health coverage participation requirements a election of employer responsibility to provide health coverage with bills hr ih in general subsection shall apply to any employer with respect to whom an election under paragraph is in effect time and manner an employer make an election under this paragraph at such time and in such form and manner as the secretary prescribe affiliated groups in the case of any employer which is part of a group of employers who are treated as a single employer under subsection or of section the election under paragraph shall be made by such person as the secretary provide any such election once made shall apply to all members of such group separate elections under regulations prescribed by the secretary separate elections be made under paragraph with respect to a separate lines of business and full time employees and employees who are not full time employees termination of election in cases of substantial noncompliance the secretary terminate the election of any employer under paragraph if the secretary in coordination with with bills hr ih the health choices commissioner determines that such employer is in substantial noncompliance with the health coverage participation requirements excise tax with respect to failure to meet health coverage participation requirements in general in the case of any employer who fails during any period with respect to which the election under subsection a is in effect to satisfy the health coverage participation requirements with respect to any employee to whom such election applies there is hereby imposed on each such failure with respect to each such employee a tax of for each day in the period beginning on the date such failure first occurs and ending on the date such failure is corrected limitations on amount of tax a tax not to apply where failure not discovered exercising reasonable diligence no tax shall be imposed by paragraph on any failure during any period for which it is established to the satisfaction of the secretary that the employer neither knew nor exercising reasonable diligence would have known that such failure existed with bills hr ih tax not to apply to failures corrected within days no tax shall be imposed by paragraph on any failure if such failure was due to reasonable cause and not to willful neglect and such failure is corrected during the day period beginning on the st date that the employer knew or exercising reasonable diligence would have known that such failure existed overall limitation for unintentional failures in the case of failures which are due to reasonable cause and not to willful neglect the tax imposed by subsection a for failures during the taxable year of the employer shall not exceed the amount equal to the lesser of percent of the aggregate amount paid or incurred by the employer or predecessor employer during the preceding taxable year for employment based health plans or coordination with other enforcement provisions the tax imposed with bills hr ih under paragraph with respect to any failure shall be reduced but not below zero by the amount of any civil penalty collected under section of the employee retirement income security act of or section of the public health service act with respect to such failure health coverage participation requirements for purposes of this section the term health coverage participation requirements means the requirements of part of subtitle of title iv of the as in effect on the date of the enactment of this section clerical amendment the table of sections for chapter of such code is amended by adding at the end the following new item sec election with respect to health coverage participation requirements effective date the amendments made by this section shall apply to periods beginning after december sec health care contributions of nonelecting employers a in general section of the internal revenue code of is amended by redesignating subsection as subsection and by inserting after subsection the following new subsection with bills hr ih employers electing not to provide health benefits in general in addition to other taxes there is hereby imposed on every nonelecting employer an excise tax with respect to having individuals in his employ equal to percent of the wages as defined in section a paid by him with respect to employment as defined in section special rules for small employers a in general in the case of any employer who is small employer for any calendar year paragraph shall be applied by substituting the applicable percentage determined in accordance with the following table for percent if the annual payroll of such employer forthe preceding calendar year the applicablepercentage is does not exceed percentexceeds but does not exceed percentexceeds but does not exceed percentexceeds but does not exceed percent small employer for purposes of this paragraph the term small employer means any employer for any calendar year if the annual payroll of such employer for the preceding calendar year does not exceed with bills hr ih annual payroll for purposes of this paragraph the term annual payroll means with respect to any employer for any calendar year the aggregate wages as defined in section a paid by him with respect to employment as defined in section during such calendar year nonelecting employer for purposes of paragraph the term nonelecting employer means any employer for any period with respect to which such employer does not have an election under section a in effect special rule for separate elections in the case of an employer who makes a separate election described in section a for any period paragraph shall be applied for such period by taking into account only the wages paid to employees who are not subject to such election aggregation predecessors for purposes of this subsection a all persons treated as a single employer under subsection or of section shall be treated as employer and with bills hr ih any reference to any person shall be treated as including a reference to any predecessor of such person definitions section of such code is amended by adding at the end the following new subsection aa special rules for tax on employers electing not to provide health benefits for purposes of section paragraphs and of subsection shall not apply paragraph of subsection shall apply by treating all services as not covered by the retirement systems referred to in subparagraphs and thereof subsection shall not apply and the term state shall include the district of columbia conforming amendment subsection of section of such code as redesignated by this section is amended by striking this section and inserting subsections a and application to railroads in general section of such code is amended by redesignating subsection as sub with bills hr ih section and by inserting after subsection the following new subsection employers electing not to provide health benefits in general in addition to other taxes there is hereby imposed on every nonelecting employer an excise tax with respect to having individuals in his employ equal to percent of the compensation paid during any calendar year by such employer for services rendered to such employer exception for small employers rules similar to the rules of section shall apply for purposes of this subsection nonelecting employer for purposes of paragraph the term nonelecting employer means any employer for any period with respect to which such employer does not have an election under section a in effect special rule for separate elections in the case of an employer who makes a separate election described in section a for any period subsection a shall be applied for such period by taking into account only the compensation paid to employees who are not subject to such election with bills hr ih definitions subsection of section of such code is amended by adding at the end the following new paragraph special rules for tax on employers electing not to provide health benefits for purposes of section a paragraph shall be applied without regard to the third sentence thereof paragraph shall not apply conforming amendment subsection of section of such code as redesignated by this section is amended by striking subsections a and see section and inserting this section see paragraphs and of section effective date the amendments made by this section shall apply to periods beginning after december part credit for small business employee health coverage expenses sec credit for small business employee health coverage expenses a in general subpart of part iv of subchapter a of chapter of the internal revenue code of with bills hr ih relating to business related credits is amended by adding at the end the following new section sec small business employee health coverage credit a in general for purposes of section in the case of a qualified small employer the small business employee health coverage credit determined under this section for the taxable year is an amount equal to the applicable percentage of the qualified employee health coverage expenses of such employer for such taxable year applicable percentage in general for purposes of this section the applicable percentage is percent phaseout based on average compensation of employees in the case of an employer whose average annual employee compensation for the taxable year exceeds the percentage specified in paragraph shall be reduced by a number of percentage points which bears the same ratio to as such excess bears to limitations phaseout based on employer size in the case of an employer who employs more than qualified employees during the taxable year the credit determined under subsection a shall be re with bills hr ih duced by an amount which bears the same ratio to the amount of such credit determined without regard to this paragraph and after the application of the other provisions of this section as a the excess of the number of qualified employees employed by the employer during the taxable year over bears to credit not allowed with respect to certain highly compensated employees no credit shall be determined under subsection a with respect to qualified employee health coverage expenses paid or incurred with respect to any employee for any taxable year if the aggregate compensation paid by the employer to such employee during such taxable year exceeds credit allowed for only taxable years no credit shall be determined under subsection a with respect to any employer for any taxable year unless the employer elects to have this section apply for such taxable year an employer elect the application of this section with respect to not more than taxable years with bills hr ih qualified employee health coverage expenses for purposes of this section in general the term qualified employee health coverage expenses means with respect to any employer for any taxable year the aggregate amount paid or incurred by such employer during such taxable year for coverage of any qualified employee of the employer including any family coverage which covers such employee under qualified health coverage qualified health coverage the term qualified health coverage means acceptable coverage as defined in section which a is provided pursuant to an election under section a and satisfies the requirements referred to in section other definitions for purposes of this section qualified small employer for purposes of this section the term qualified small employer means any employer for any taxable year if with bills hr ih a the number of qualified employees employed by such employer during the taxable year does not exceed and the average annual employee compensation of such employer for such taxable year does not exceed the sum of the dollar amounts in effect under subsection qualified employee the term qualified employee means any employee of an employer for any taxable year of the employer if such employee received at least of compensation from such employer for services performed in the trade or business of such employer during such taxable year average annual employee compensation the term average annual employee compensation means with respect to any employer for any taxable year the average amount of compensation paid by such employer to qualified employees of such employer during such taxable year compensation the term compensation has the meaning given such term in section a family coverage the term family coverage means any coverage other than self only coverage with bills hr ih special rules for purposes of this section special rule for partnerships and self employed in the case of a partnership or a trade or business carried on by an individual which has one or more qualified employees determined without regard to this paragraph with respect to whom the election under section a applies each partner or in the case of a trade or business carried on by an individual such individual shall be treated as an employee aggregation rule all persons treated as a single employer under subsection or of section shall be treated as employer predecessors any reference in this section to an employer shall include a reference to any predecessor of such employer denial of double benefit any deduction otherwise allowable with respect to amounts paid or incurred for health insurance coverage to which subsection a applies shall be reduced by the amount of the credit determined under this section inflation adjustment in the case of any taxable year beginning after each of the with bills hr ih dollar amounts in subsections and shall be increased by an amount equal to a such dollar amount multiplied by the cost of living adjustment determined under section for the calendar year in which the taxable year begins determined by substituting calendar year for calendar year in subparagraph thereof if any increase determined under this paragraph is not a multiple of such increase shall be rounded to the next lowest multiple of credit to be part of general business credit subsection of section of such code relating to general business credit is amended by striking plus at the end of paragraph by striking the period at the end of paragraph and inserting plus and by adding at the end the following new paragraph in the case of a qualified small employer as defined in section the small business employee health coverage credit determined under section a clerical amendment the table of sections for subpart of part iv of subchapter a of chapter with bills hr ih of such code is amended by inserting after the item relating to section the following new item sec small business employee health coverage credit effective date the amendments made by this section shall apply to taxable years beginning after december part limitations on health care related expenditures sec distributions for medicine qualified only if for prescribed drug or insulin a hsas subparagraph a of section of the internal revenue code of is amended by adding at the end the following such term shall include an amount paid for medicine or a drug only if such medicine or drug is a prescribed drug or is insulin archer msas subparagraph a of section of such code is amended by adding at the end the following such term shall include an amount paid for medicine or a drug only if such medicine or drug is a prescribed drug or is insulin health flexible spending arrangements and health reimbursement arrangements section of such code is amended by adding at the end the following new subsection reimbursements for medicine restricted to prescribed drugs and insulin for purposes of with bills hr ih this section and section reimbursement for expenses incurred for a medicine or a drug shall be treated as a reimbursement for medical expenses only if such medicine or drug is a prescribed drug or is insulin effective dates the amendment made by this section shall apply to expenses incurred after december sec limitation on health flexible spending arrangements under cafeteria plans a in general section of the internal revenue code of is amended by redesignating subsections and as subsections and respectively and by inserting after subsection the following new subsection limitation on health flexible spending arrangements in general for purposes of this section if a benefit is provided under a cafeteria plan through employer contributions to a health flexible spending arrangement such benefit shall not be treated as a qualified benefit unless the cafeteria plan provides that an employee not elect for any taxable year to have salary reduction contributions in excess of made to such arrangement with bills hr ih inflation adjustment in the case of any taxable year beginning after the dollar amount in paragraph shall be increased by an amount equal to a such dollar amount multiplied by the cost of living adjustment determined under section for the calendar year in which the taxable year begins determined by substituting calendar year for calendar year in subparagraph thereof if any increase determined under this paragraph is not a multiple of such increase shall be rounded to the next lowest multiple of effective date the amendments made by this section shall apply to taxable years beginning after december sec increase in penalty for nonqualified distributions from health savings accounts a in general subparagraph a of section of the internal revenue code of is amended by striking percent and inserting percent with bills hr ih effective date the amendment made by this section shall apply to taxable years beginning after december sec denial of deduction for federal subsidies for prescription drug plans which have been excluded from gross income a in general section a of the internal revenue code of is amended by striking the second sentence effective date the amendment made by this section shall apply to taxable years beginning after december part other provisions to carry out health insurance reform sec disclosures to carry out health insurance exchange subsidies a in general subsection of section of the internal revenue code of is amended by adding at the end the following new paragraph disclosure of return information to carry out health insurance exchange subsidies a in general the secretary upon written request from the health choices com with bills hr ih missioner or the head of a state based health insurance exchange approved for operation under section of the shall disclose to officers and employees of the health choices administration or such state based health insurance exchange as the case be return information of any taxpayer whose income is relevant in determining any affordability credit described in subtitle of title iii of the such return information shall be limited to taxpayer identity information with respect to such taxpayer the filing status of such taxpayer iii the modified adjusted gross income of such taxpayer as defined in section iv the number of dependents of the taxpayer such other information as is prescribed by the secretary by regulation as might indicate whether the taxpayer is eligible for such affordability credits and the amount thereof and with bills hr ih vi the taxable year with respect to which the preceding information relates or if applicable the fact that such information is not available restriction on use of disclosed information return information disclosed under subparagraph a be used by officers and employees of the health choices administration or such state based health insurance exchange as the case be only for the purposes of and to the extent necessary in establishing and verifying the appropriate amount of any affordability credit described in subtitle of title iii of the and providing for the repayment of any such credit which was in excess of such appropriate amount procedures and recordkeeping related to disclosures paragraph of section of such code is amended by inserting or any entity described in subsection after or in the matter preceding subparagraph a by inserting or any entity described in subsection after or a in subparagraph and with bills hr ih by inserting or any entity described in subsection after or both places it appears in the matter after subparagraph unauthorized disclosure or inspection paragraph of section a of such code is amended by striking or and inserting or sec offering of exchange participating health benefits plans through cafeteria plans a in general subsection of section of the internal revenue code of is amended by adding at the end the following new paragraph certain exchange participating health benefits plans not qualified a in general the term qualified benefit shall not include any exchange participating health benefits plan as defined in section of the exception for exchange eligible employers subparagraph a shall not apply with respect to any employee if such employee employer is an exchange eligible employer as defined in section of the conforming amendments subsection of section of such code is amended with bills hr ih by striking for purposes of this section the term and inserting for purposes of this section in general the term and by striking such term shall not include and inserting the following long term care insurance not qualified the term qualified benefit shall not include effective date the amendments made by this section shall apply to taxable years beginning after december sec exclusion from gross income of payments made under reinsurance program for retirees a in general section a of the internal revenue code of is amended by striking gross income and inserting the following a federal subsidies for prescription drug plans gross income and by adding at the end the following new subsection federal reinsurance program for retirees a rule similar to the rule of subsection a shall with bills hr ih apply with respect to payments made under section of the affordable health care for america act conforming amendment the heading of section a of such code and the item relating to such section in the table of sections for part iii of subchapter of chapter of such code is amended by inserting and retiree health plans after prescription drug plans effective date the amendments made by this section shall apply to taxable years ending after the date of the enactment of this act sec class program treated in same manner as long term care insurance a in general subsection of section of the internal revenue code of is amended by striking state long term care plan in paragraph a and inserting government longterm care plan by redesignating paragraph as paragraph and by inserting after paragraph the following new paragraph government long term care plan for purposes of this subsection the term government long term care plan means with bills hr ih a the class program established under title xxxii of the public health service act and any state long term care plan conforming amendments paragraph of section of such code as redesignated by subsection a is amended by striking paragraph and inserting this subsection subsection of section of such code is amended by striking state maintained in the heading thereof and inserting government effective date the amendments made by this section shall apply to taxable years ending after december sec exclusion from gross income for medical care provided for indians a in general part iii of subchapter of chapter of the internal revenue code of relating to items specifically excluded from gross income is amended by inserting after section the following new section sec medical care provided for indians a in general gross income does not include with bills hr ih health services or benefits provided or purchased by the indian health service either directly or indirectly through a grant to or a contract or compact with an indian tribe or tribal organization or through programs of third parties funded by the indian health service medical care provided by an indian tribe or tribal organization to a member of an indian tribe including for this purpose to the member spouse or dependents through any one of the following provided or purchased medical care services accident or health insurance or an arrangement having the effect of accident or health insurance or amounts paid directly or indirectly to reimburse the member for expenses incurred for medical care the value of accident or health plan coverage provided by an indian tribe or tribal organization for medical care to a member of an indian tribe including for this purpose coverage that extends to such member spouse or dependents under an accident or health plan or through an arrangement having the effect of accident or health insurance and any other medical care provided by an indian tribe that supplements replaces or substitutes with bills hr ih for the programs and services provided by the federal government to indian tribes or indians definitions for purposes of this section in general the terms accident or health insurance and accident or health plan have the same meaning as when used in sections and medical care the term medical care has the meaning given such term in section dependent the term dependent has the meaning given such term in section determined without regard to subsections and indian tribe the term indian tribe means any indian tribe band nation pueblo or other organized group or community including any alaska native village or regional or village corporation as defined in or established pursuant to the alaska native claims settlement act usc et seq which is recognized as eligible for the special programs and services provided by the united states to indians because of their status as indians tribal organization the term tribal organization has the meaning given such term in with bills hr ih section of the indian self determination and education assistance act usc clerical amendment the table of sections for such part iii is amended by inserting after the item relating to section the following new item sec medical care provided for indians effective date the amendments made by this section shall apply to health benefits and coverage provided after the date of enactment of this act no inference nothing in the amendments made by this section shall be construed to create an inference with respect to the exclusion from gross income of benefits provided by indian tribes that are not within the scope of this section and health benefits or coverage provided by indian tribes prior to the effective date of this section subtitle other revenue provisions part general provisions sec surcharge on high income individuals a in general part viii of subchapter a of chapter of the internal revenue code of as added by this title is amended by adding at the end the following new subpart subpart surcharge on high income individuals sec surcharge on high income individuals with bills hr ih sec surcharge on high income individuals a general rule in the case of a taxpayer other than a corporation there is hereby imposed in addition to any other tax imposed by this subtitle a tax equal to percent of so much of the modified adjusted gross income of the taxpayer as exceeds taxpayers not making a joint return in the case of any taxpayer other than a taxpayer making a joint return under section or a surviving spouse as defined in section a subsection a shall be applied by substituting for modified adjusted gross income for purposes of this section the term modified adjusted gross income means adjusted gross income reduced by any deduction not taken into account in determining adjusted gross income allowed for investment interest as defined in section in the case of an estate or trust adjusted gross income shall be determined as provided in section special rules nonresident alien in the case of a nonresident alien individual only amounts taken into account in connection with the tax imposed under section shall be taken into account under this section with bills hr ih citizens and residents living abroad the dollar amount in effect under subsection a after the application of subsection shall be decreased by the excess of a the amounts excluded from the taxpayer gross income under section over the amounts of any deductions or exclusions disallowed under section with respect to the amounts described in subparagraph a charitable trusts subsection a shall not apply to a trust all the unexpired interests in which are devoted to one or more of the purposes described in section not treated as tax imposed by this chapter for certain purposes the tax imposed under this section shall not be treated as tax imposed by this chapter for purposes of determining the amount of any credit under this chapter or for purposes of section clerical amendment the table of subparts for part viii of subchapter a of chapter of such code as added by this title is amended by inserting after the item relating to subpart a the following new item subpart surcharge on high income individuals with bills hr ih section not to apply the amendment made by subsection a shall not be treated as a change in a rate of tax for purposes of section of the internal revenue code of effective date the amendments made by this section shall apply to taxable years beginning after december sec excise tax on medical devices a in general chapter of the internal revenue code of is amended by adding at the end the following new subchapter subchapter medical devices sec medical devices sec medical devices a in general there is hereby imposed on the first taxable sale of any medical device a tax equal to percent of the price for which so sold first taxable sale for purposes of this section in general the term first taxable sale means the first sale for a purpose other than for resale after production manufacture or importation with bills hr ih exception for sales at retail establishments such term shall not include the sale of any medical device if a such sale is made at a retail establishment on terms which are available to the general public and such medical device is of a type and purchased in a quantity which is purchased by the general public exception for exports etc rules similar to the rules of sections other than paragraphs and of subsection a thereof and shall apply for purposes of this section to the extent provided by the secretary section be extended to and made applicable with respect to the exemption provided by paragraph sales to patients not treated as resales if a medical device is sold for use in connection with providing any health care service to an individual such sale shall not be treated as being for the purpose of resale even if such device is sold to such individual other definitions and special rules for purposes of this section with bills hr ih medical device the term medical device means any device as defined in section of the federal food drug and cosmetic act intended for humans lease treated as sale rules similar to the rules of section shall apply use treated as sale a in general if any person uses a medical device before the first taxable sale of such device then such person shall be liable for tax under such subsection in the same manner as if such use were the first taxable sale of such device exceptions the preceding sentence shall not apply to use of a medical device as material in the manufacture or production of or as a component part of another medical device to be manufactured or produced by such person or use of a medical device after a sale described in subsection determination of price with bills hr ih a in general rules similar to the rules of subsections a and of section shall apply for purposes of this section constructive sale price if a medical device is sold otherwise than through an arm length transaction at less than the fair market price or a person is liable for tax for a use described in paragraph the tax under this section shall be computed on the price for which such or similar devices are sold in the ordinary course of trade as determined by the secretary resales pursuant to certain contract arrangements a in general in the case of a specified contract sale of a medical device the seller referred to in subparagraph shall be entitled to recover from the producer manufacturer or importer referred to in subparagraph the amount of the tax paid by such seller under this section with respect to such sale specified contract sale for purposes of this paragraph the term specified contract sale means with respect to any med with bills hr ih ical device the first taxable sale of such device if the seller is not the producer manufacturer or importer of such device the price at which such device is so sold is determined in accordance with a contract between the producer manufacturer or importer of such device and the person to whom such device is so sold special rules related to credits and refunds in the case of any credit or refund under section of the tax imposed under this section on a specified contract sale of a medical device such credit or refund shall be allowed or made only if the seller has filed with the secretary the written consent of the producer manufacturer or importer referred to in subparagraph to the allowance of such credit or the making of such refund and the amount of tax taken into account under subparagraph a shall be reduced by the amount of such credit or refund with bills hr ih conforming amendments paragraph of section of such code is amended a by inserting or after under section and by adding at the end the following in the case of the tax imposed by section subparagraphs and shall not apply the table of subchapters for chapter of such code is amended by adding at the end the following new item subchapter medical devices effective date the amendments made by this section shall apply to sales and leases and uses treated as sales after december sec expansion of information reporting requirements a in general section of the internal revenue code of is amended by adding at the end the following new subsections application to corporations notwithstanding any regulation prescribed by the secretary before the date of the enactment of this subsection for purposes of this section the term person includes any corporation with bills hr ih that is not an organization exempt from tax under section a regulations the secretary prescribe such regulations and other guidance as be appropriate or necessary to carry out the purposes of this section including rules to prevent duplicative reporting of transactions payments for property and other gross proceeds subsection a of section of the internal revenue code of is amended by inserting amounts in consideration for property after wages by inserting gross proceeds after emoluments or other and by inserting gross proceeds after setting forth the amount of such effective date the amendments made by this section shall apply to payments made after december sec delay in application of worldwide allocation of interest a in general paragraphs and of section of the internal revenue code of are each amended by striking december and inserting december with bills hr ih transition subsection of section of such code is amended by striking paragraph part prevention of tax avoidance sec limitation on treaty benefits for certain deductible payments a in general section of the internal revenue code of relating to income affected by treaty is amended by adding at the end the following new subsection limitation on treaty benefits for certain deductible payments in general in the case of any deductible related party payment any withholding tax imposed under chapter and any tax imposed under subpart a or of this part with respect to such payment not be reduced under any treaty of the united states unless any such withholding tax would be reduced under a treaty of the united states if such payment were made directly to the foreign parent corporation deductible related party payment for purposes of this subsection the term deductible related party payment means any payment made directly or indirectly by any person to any other person if the payment is allowable as a de with bills hr ih duction under this chapter and both persons are members of the same foreign controlled group of entities foreign controlled group of entities for purposes of this subsection a in general the term foreign controlled group of entities means a controlled group of entities the common parent of which is a foreign corporation controlled group of entities the term controlled group of entities means a controlled group of corporations as defined in section a except that more than percent shall be substituted for at least percent each place it appears therein and the determination shall be made without regard to subsections a and of section a partnership or any other entity other than a corporation shall be treated as a member of a controlled group of entities if such entity is controlled within the meaning of section by members of such group includ with bills hr ih ing any entity treated as a member of such group by reason of this sentence foreign parent corporation for purposes of this subsection the term foreign parent corporation means with respect to any deductible related party payment the common parent of the foreign controlled group of entities referred to in paragraph a regulations the secretary prescribe such regulations or other guidance as are necessary or appropriate to carry out the purposes of this subsection including regulations or other guidance which provide for a the treatment of two or more persons as members of a foreign controlled group of entities if such persons would be the common parent of such group if treated as one corporation and the treatment of any member of a foreign controlled group of entities as the common parent of such group if such treatment is appropriate taking into account the economic relationships among such entities with bills hr ih effective date the amendment made by this section shall apply to payments made after the date of the enactment of this act sec codification of economic substance doctrine penalties a in general section of the internal revenue code of is amended by redesignating subsection as subsection and by inserting after subsection the following new subsection clarification of economic substance doctrine application of doctrine in the case of any transaction to which the economic substance doctrine is relevant such transaction shall be treated as having economic substance only if a the transaction changes in a meaningful way apart from federal income tax effects the taxpayer economic position and the taxpayer has a substantial purpose apart from federal income tax effects for entering into such transaction special rule where taxpayer relies on profit potential a in general the potential for profit of a transaction shall be taken into ac with bills hr ih count in determining whether the requirements of subparagraphs a and of paragraph are met with respect to the transaction only if the present value of the reasonably expected pre tax profit from the transaction is substantial in relation to the present value of the expected net tax benefits that would be allowed if the transaction were respected treatment of fees and foreign taxes fees and other transaction expenses and foreign taxes shall be taken into account as expenses in determining pre tax profit under subparagraph a state and local tax benefits for purposes of paragraph any state or local income tax effect which is related to a federal income tax effect shall be treated in the same manner as a federal income tax effect financial accounting benefits for purposes of paragraph achieving a financial accounting benefit shall not be taken into account as a purpose for entering into a transaction if the origin of such financial accounting benefit is a reduction of federal income tax with bills hr ih definitions and special rules for purposes of this subsection a economic substance doctrine the term economic substance doctrine means the common law doctrine under which tax benefits under subtitle a with respect to a transaction are not allowable if the transaction does not have economic substance or lacks a business purpose exception for personal transactions of individuals in the case of an individual paragraph shall apply only to transactions entered into in connection with a trade or business or an activity engaged in for the production of income other common law doctrines not affected except as specifically provided in this subsection the provisions of this subsection shall not be construed as altering or supplanting any other rule of law and the requirements of this subsection shall be construed as being in addition to any such other rule of law determination of application of doctrine not affected the determination with bills hr ih of whether the economic substance doctrine is relevant to a transaction or series of transactions shall be made in the same manner as if this subsection had never been enacted regulations the secretary shall prescribe such regulations as be necessary or appropriate to carry out the purposes of this subsection penalty for underpayments attributable to transactions lacking economic substance in general subsection of section of such code is amended by inserting after paragraph the following new paragraph any disallowance of claimed tax benefits by reason of a transaction lacking economic substance within the meaning of section or failing to meet the requirements of any similar rule of law increased penalty for nondisclosed transactions section of such code is amended by adding at the end the following new subsection increase in penalty in case of nondisclosed noneconomic substance transactions with bills hr ih in general in the case of any portion of an underpayment which is attributable to one or more nondisclosed noneconomic substance transactions subsection a shall be applied with respect to such portion by substituting percent for percent nondisclosed noneconomic substance transactions for purposes of this subsection the term nondisclosed noneconomic substance transaction means any portion of a transaction described in subsection with respect to which the relevant facts affecting the tax treatment are not adequately disclosed in the return nor in a statement attached to the return special rule for amended returns except as provided in regulations in no event shall any amendment or supplement to a return of tax be taken into account for purposes of this subsection if the amendment or supplement is filed after the earlier of the date the taxpayer is first contacted by the secretary regarding the examination of the return or such other date as is specified by the secretary with bills hr ih conforming amendment subparagraph of section a of such code is amended a by striking section and inserting subsections or of section and by striking gross valuation misstatement penalty in the heading and inserting certain increased underpayment penalties reasonable cause exception not applicable to noneconomic substance transactions and tax shelters reasonable cause exception for underpayments subsection of section of such code is amended a by redesignating paragraphs and as paragraphs and respectively by striking paragraph in paragraph a as so redesignated and inserting paragraph and by inserting after paragraph the following new paragraph exception paragraph shall not apply to any portion of an underpayment which is with bills hr ih attributable to one or more tax shelters as defined in section or transactions described in section reasonable cause exception for reportable transaction understatements subsection of section of such code is amended a by redesignating paragraphs and as paragraphs and respectively by striking paragraph in paragraph as so redesignated and inserting paragraph and by inserting after paragraph the following new paragraph exception paragraph shall not apply to any portion of a reportable transaction understatement which is attributable to one or more tax shelters as defined in section or transactions described in section application of penalty for erroneous claim for refund or credit to noneconomic substance transactions section of such code is amended by redesignating subsection as subsection and inserting after subsection the following new subsection with bills hr ih noneconomic substance transactions treated as lacking reasonable basis for purposes of this section any excessive amount which is attributable to any transaction described in section shall not be treated as having a reasonable basis effective date in general except as otherwise provided in this subsection the amendments made by this section shall apply to transactions entered into after the date of the enactment of this act underpayments the amendments made by subsections and shall apply to underpayments attributable to transactions entered into after the date of the enactment of this act understatements the amendments made by subsection shall apply to understatements attributable to transactions entered into after the date of the enactment of this act refunds and credits the amendment made by subsection shall apply to refunds and credits attributable to transactions entered into after the date of the enactment of this act with bills hr ih sec certain large or publicly traded persons made subject to a more likely than not standard for avoiding penalties on underpayments a in general subsection of section of the internal revenue code of as amended by section is amended by redesignating paragraphs and as paragraphs and respectively by striking paragraph in paragraph a as so redesignated and inserting paragraph and by inserting after paragraph the following new paragraph special rule for certain large or publicly traded persons a in general in the case of any specified person paragraph shall apply to the portion of an underpayment which is attributable to any item only if such person has a reasonable belief that the tax treatment of such item by such person is more likely than not the proper tax treatment of such item specified person for purposes of this paragraph the term specified person means with bills hr ih any person required to file periodic or other reports under section of the securities exchange act of and any corporation with gross receipts in excess of for the taxable year involved all persons treated as a single employer under section a shall be treated as one person for purposes of clause nonapplication of substantial authority and reasonable basis standards for reducing understatements paragraph of section of such code is amended by adding at the end the following new subparagraph reduction not to apply to certain large or publicly traded persons subparagraph shall not apply to any specified person as defined in section c effective date in general except as provided in paragraph the amendments made by this section shall apply to underpayments attributable to transactions entered into after the date of the enactment of this act with bills hr ih nonapplication of understatement reduction the amendment made by subsection shall apply to understatements attributable to transactions entered into after the date of the enactment of this act part parity in health benefits sec certain health related benefits applicable to spouses and dependents extended to eligible beneficiaries a application of accident and health plans to eligible beneficiaries exclusion of contributions section of the internal revenue code of relating to contributions by employer to accident and health plans as amended by section is amended by adding at the end the following new subsection coverage provided for eligible beneficiaries of employees in general subsection a shall apply with respect to any eligible beneficiary of the employee eligible beneficiary for purposes of this subsection the term eligible beneficiary means any individual who is eligible to receive benefits or coverage under an accident or health plan with bills hr ih exclusion of amounts expended for medical care the first sentence of section of such code relating to amounts expended for medical care is amended a by striking and his dependents and inserting his dependents and by inserting before the period the following and any eligible beneficiary within the meaning of section with respect to the taxpayer payroll taxes a section a of such code is amended by striking or any of his dependents in the matter preceding subparagraph a and inserting any of his dependents or any eligible beneficiary within the meaning of section with respect to the employee by striking or any of his dependents in subparagraph a and inserting any of his dependents or any eligible beneficiary within the meaning of section with respect to the employee and with bills hr ih iii by striking and their dependents both places it appears and inserting and such employees dependents and eligible beneficiaries within the meaning of section section of such code is amended by striking or any of his dependents and inserting any of his dependents or any eligible beneficiary within the meaning of section with respect to the employee and by striking and their dependents both places it appears and inserting and such employees dependents and eligible beneficiaries within the meaning of section section of such code is amended by striking or any of his dependents in the matter preceding subparagraph a and inserting any of his dependents or any eligible beneficiary within the meaning of section with respect to the employee with bills hr ih by striking or any of his dependents in subparagraph a and inserting any of his dependents or any eligible beneficiary within the meaning of section with respect to the employee and iii by striking and their dependents both places it appears and inserting and such employees dependents and eligible beneficiaries within the meaning of section section a of such code is amended by striking or at the end of paragraph by striking the period at the end of paragraph and inserting or and by inserting after paragraph the following new paragraph for any payment made to or for the benefit of an employee or any eligible beneficiary within the meaning of section if at the time of such payment it is reasonable to believe that the employee will be able to exclude such payment from income under section or under section by reference in section to section with bills hr ih expansion of dependency for purposes of deduction for health insurance costs of selfemployed individuals in general paragraph of section of the internal revenue code of relating to special rules for health insurance costs of selfemployed individuals is amended to read as follows allowance of deduction in the case of a taxpayer who is an employee within the meaning of section there shall be allowed as a deduction under this section an amount equal to the amount paid during the taxable year for insurance which constitutes medical care for a the taxpayer the taxpayer spouse the taxpayer dependents any individual who satisfies the age requirements of section a bears a relationship to the taxpayer described in section and iii meets the requirements of section and one individual who with bills hr ih does not satisfy the age requirements of section a bears a relationship to the taxpayer described in section iii meets the requirements of section d and iv is not the spouse of the taxpayer and does not bear any relationship to the taxpayer described in subparagraphs a through of section conforming amendment subparagraph of section of such code is amended by inserting any dependent or individual described in subparagraph or of paragraph with respect to after spouse extension to eligible beneficiaries of sick and accident benefits provided to members of a voluntary employees beneficiary association and their dependents section of the internal revenue code of relating to list of exempt organizations is amended by adding at the end the following new sentence for purposes of providing for the payment of sick and accident benefits to members of such an association and their dependents the term dependents shall include any individual who is an eligible beneficiary with bills hr ih within the meaning of section as determined under the terms of a medical benefit health insurance or other program under which members and their dependents are entitled to sick and accident benefits flexible spending arrangements and health reimbursement arrangements the secretary of treasury shall issue guidance of general applicability providing that medical expenses that otherwise qualify for reimbursement from a flexible spending arrangement under regulations in effect on the date of the enactment of this act be reimbursed from an employee flexible spending arrangement notwithstanding the fact that such expenses are attributable to any individual who is not the employee spouse or dependent within the meaning of section of the internal revenue code of but is an eligible beneficiary within the meaning of section of such code under the flexible spending arrangement with respect to the employee and for reimbursement from a health reimbursement arrangement under regulations in effect on the date of the enactment of this act be reimbursed from an employee health reimbursement arrange with bills hr ih ment notwithstanding the fact that such expenses are attributable to an individual who is not a spouse or dependent within the meaning of section of such code but is an eligible beneficiary within the meaning of section of such code under the health reimbursement arrangement with respect to the employee effective date the amendments made by this section shall apply to taxable years beginning after december division medicare and medicaid improvements sec table of contents of division the table of contents of this division is as follows sec table of contents of divisiontitle improving health care valuesubtitle a provisions related to medicare part apart market basket updatessec skilled nursing facility payment updatesec inpatient rehabilitation facility payment updatesec incorporating productivity improvements into market basket updatesthat do not already incorporate such improvementspart other medicare part a provisionssec payments to skilled nursing facilitiessec medicare dsh report and payment adjustments in response to coverageexpansionsec extension of hospice regulation moratoriumsec permitting physician assistants to order post hospital extended careservices and to provide for recognition of attending physicianassistants as attending physicians to serve hospice patientssubtitle provisions related to part bpart physicians services with bills hr ihsec resource based feedback program for physicians in medicaresec misvalued codes under the physician fee schedulesec payments for efficient areassec modifications to the physician quality reporting initiative pqri sec adjustment to medicare payment localitiespart market basket updatessec incorporating productivity improvements into market basket updatesthat do not already incorporate such improvementspart other provisionssec rental and purchase of power driven wheelchairssec a election to take ownership or to decline ownership of a certainitem of complex durable medical equipment after the monthcapped rental period endssec extension of payment rule for brachytherapysec home infusion therapy report to congresssec require ambulatory surgical centers ascs to submit cost data andother datasec treatment of certain cancer hospitalssec payment for imaging servicessec durable medical equipment program improvementssec medpac study and report on bone mass measurementsec timely access to post mastectomy itemssec a payment for biosimilar biological productssec study and report on dme competitive bidding processsubtitle provisions related to medicare parts a and bsec reducing potentially preventable hospital readmissionssec post acute care services payment reform plan and bundling pilotprogramsec home health payment update for sec payment adjustments for home health caresec incorporating productivity improvements into market basket updatefor home health servicessec a medpac study on variation in home health marginssec permitting home health agencies to assign the most appropriateskilled service to make the initial assessment visit under amedicare home health plan of care for rehabilitation casessec limitation on medicare exceptions to the prohibition on certain physicianreferrals made to hospitalssec institute of medicine study of geographic adjustment factors undermedicaresec revision of medicare payment systems to address geographic inequitiessec institute of medicine study of geographic variation in health carespending and promoting high value health caresec implementation and congressional review of proposal to revisemedicare payments to promote high value health caresubtitle medicare advantage reformspart payment and administration with bills hr ihsec phase in of payment based on fee for service costs quality bonuspaymentssec authority for secretarial coding intensity adjustment authoritysec simplification of annual beneficiary election periodssec extension of reasonable cost contractssec limitation of waiver authority for employer group planssec improving risk adjustment for paymentssec elimination of ma regional plan stabilization fundsec study regarding the effects of calculating medicare advantage paymentrates on a regional average of medicare fee for serviceratespart beneficiary protections and anti fraudsec limitation on cost sharing for individual health servicessec continuous open enrollment for enrollees in plans with enrollmentsuspensionsec information for beneficiaries on ma plan administrative costssec strengthening audit authoritysec authority to deny plan bidssec a state authority to enforce standardized marketing requirementspart treatment of special needs planssec limitation on enrollment outside open enrollment period of individualsinto chronic care specialized ma plans for special needsindividualssec extension of authority of special needs plans to restrict enrollment service area moratorium for certain snpssec extension of medicare senior housing planssubtitle improvements to medicare part dsec elimination of coverage gapsec discounts for certain part drugs in original coverage gapsec repeal of provision relating to submission of claims by pharmacieslocated in or contracting with long term care facilitiessec including costs incurred by aids drug assistance programs and indianhealth service in providing prescription drugs toward theannual out of pocket threshold under part dsec no mid year formulary changes permittedsec negotiation of lower covered part drug prices on behalf of medicarebeneficiariessec accurate dispensing in long term care facilitiessec free generic fillsec state certification prior to waiver of licensure requirements undermedicare prescription drug programsubtitle medicare rural access protectionssec telehealth expansion and enhancementssec extension of outpatient hold harmless provisionsec extension of section hospital reclassificationssec extension of geographic floor for worksec extension of payment for technical component of certain physicianpathology servicessec extension of ambulance add ons with bills hr ihtitle medicare beneficiary improvementssubtitle a improving and simplifying financial assistance for low incomemedicare beneficiariessec improving assets tests for medicare savings program and low incomesubsidy programsec elimination of part cost sharing for certain non institutionalizedfull benefit dual eligible individualssec eliminating barriers to enrollmentsec enhanced oversight relating to reimbursements for retroactive lowincome subsidy enrollmentsec intelligent assignment in enrollmentsec special enrollment period and automatic enrollment process for certainsubsidy eligible individualssec application of ma premiums prior to rebate and quality bonus paymentsin calculation of low income subsidy benchmarksubtitle reducing health disparitiessec ensuring effective communication in medicaresec demonstration to promote access for medicare beneficiaries withlimited english proficiency by providing reimbursement for culturallyand linguistically appropriate servicessec iom report on impact of language access servicessec definitionssubtitle miscellaneous improvementssec extension of therapy caps exceptions processsec extended months of coverage of immunosuppressive drugs for kidneytransplant patients and other renal dialysis provisionssec voluntary advance care planning consultationsec part special enrollment period and waiver of limited enrollmentpenalty for tricare beneficiariessec exception for use of more recent tax year in case of gains from saleof primary residence in computing part income related premiumsec demonstration program on use of patient decisions aidstitle iii promoting primary care mental healthservices and coordinated caresec accountable care organization pilot programsec medical home pilot programsec payment incentive for selected primary care servicessec increased reimbursement rate for certified nurse midwivessec coverage and waiver of cost sharing for preventive servicessec waiver of deductible for colorectal cancer screening tests regardlessof coding subsequent diagnosis or ancillary tissue removalsec excluding clinical social worker services from coverage under themedicare skilled nursing facility prospective payment systemand consolidated paymentsec coverage of marriage and family therapist services and mentalhealth counselor servicessec extension of physician fee schedule mental health add onsec expanding access to vaccines with bills hr ihsec expansion of medicare covered preventive services at federallyqualified health centerssec independence at home demonstration programsec recognition of certified diabetes educators as certified providers forpurposes of medicare diabetes outpatient self managementtraining servicestitle iv qualitysubtitle a comparative effectiveness researchsec comparative effectiveness researchsubtitle nursing home transparencypart improving transparency of information on skilled nursingfacilities nursing facilities and other long term care facilitiessec required disclosure of ownership and additional disclosable partiesinformationsec accountability requirementssec nursing home compare medicare websitesec reporting of expendituressec standardized complaint formsec ensuring staffing accountabilitysec nationwide program for national and state background checks ondirect patient access employees of long term care facilities andproviderspart targeting enforcementsec civil money penaltiessec national independent monitor pilot programsec notification of facility closurepart improving staff trainingsec dementia and abuse prevention trainingsec study and report on training required for certified nurse aides andsupervisory staffsec qualification of director of food services of a skilled nursing facilityor nursing facilitysubtitle quality measurementssec establishment of national priorities for quality improvementsec development of new quality measures gao evaluation of data collectionprocess for quality measurementsec multi stakeholder pre rulemaking input into selection of qualitymeasuressec application of quality measuressec consensus based entity fundingsubtitle physician payments sunshine provision with bills hr ihsec reports on financial relationships between manufacturers and distributorsof covered drugs devices biologicals or medical suppliesunder medicare medicaid or chip and physicians andother health care entities and between physicians and otherhealth care entitiessubtitle public reporting on health care associated infectionssec requirement for public reporting by hospitals and ambulatory surgicalcenters on health care associated infectionstitle medicare graduate medical educationsec distribution of unused residency positionssec increasing training in nonprovider settingssec rules for counting resident time for didactic and scholarly activitiesand other activitiessec preservation of resident cap positions from closed hospitalssec improving accountability for approved medical residency trainingtitle vi program integritysubtitle a increased funding to fight waste fraud and abusesec increased funding and flexibility to fight fraud and abusesubtitle enhanced penalties for fraud and abusesec enhanced penalties for false statements on provider or supplier enrollmentapplicationssec enhanced penalties for submission of false statements material toa false claimsec enhanced penalties for delaying inspectionssec enhanced hospice program safeguardssec enhanced penalties for individuals excluded from program participationsec enhanced penalties for provision of false information by medicareadvantage and part planssec enhanced penalties for medicare advantage and part marketingviolationssec enhanced penalties for obstruction of program auditssec exclusion of certain individuals and entities from participation inmedicare and state health care programssec oig authority to exclude from federal health care programs officersand owners of entities convicted of fraudsec self referral disclosure protocolsubtitle enhanced program and provider protectionssec enhanced cms program protection authoritysec enhanced medicare medicaid and chip program disclosure requirementsrelating to previous affiliationssec required inclusion of payment modifier for certain evaluation andmanagement servicessec evaluations and reports required under medicare integrity programsec require providers and suppliers to adopt programs to reduce waste fraud and abuse with bills hr ihsec maximum period for submission of medicare claims reduced to notmore than monthssec physicians who order durable medical equipment or home healthservices required to be medicare enrolled physicians or eligibleprofessionalssec requirement for physicians to provide documentation on referrals toprograms at high risk of waste and abusesec face to face encounter with patient required before eligibility certificationsfor home health services or durable medical equipmentsec extension of testimonial subpoena authority to program exclusioninvestigationssec required repayments of medicare and medicaid overpaymentssec expanded application of hardship waivers for oig exclusions tobeneficiaries of any federal health care programsec access to certain information on renal dialysis facilitiessec billing agents clearinghouses or other alternate payees required toregister under medicaresec conforming civil monetary penalties to false claims act amendmentssec requiring provider and supplier payments under medicare to bemade through direct deposit or electronic funds transfer eft at insured depository institutionssec inspector general for the health choices administrationsubtitle access to information needed to prevent fraud waste andabusesec access to information necessary to identify fraud waste andabusesec elimination of duplication between the healthcare integrity andprotection data bank and the national practitioner databanksec compliance with hipaa privacy and security standardstitle vii medicaid and chipsec table of contents øtemporary¿subtitle a medicaid and health reformsec eligibility for individuals with income below percent of the federalpoverty levelsec requirements and special rules for certain medicaid eligible individualssec chip and medicaid maintenance of eligibilitysec reduction in medicaid dshsec expanded outstationingsubtitle preventionsec required coverage of preventive servicessec tobacco cessationsec optional coverage of nurse home visitation servicessec state eligibility option for family planning servicessubtitle access with bills hr ihsec payments to primary care practitionerssec medical home pilot programsec translation or interpretation servicessec optional coverage for freestanding birth center servicessec inclusion of public health clinics under the vaccines for children programsec requiring coverage of services of podiatristssec a requiring coverage of services of optometristssec therapeutic foster caresec assuring adequate payment levels for servicessec preserving medicaid coverage for youths upon release from publicinstitutionssec quality measures for maternity and adult health services undermedicaid and chipsec a accountable care organization pilot programsec fqhc coveragesubtitle coveragesec optional medicaid coverage of low income hiv infected individualssec extending transitional medicaid assistance tma sec requirement of month continuous coverage under certain chipprogramssec preventing the application under chip of coverage waiting periodsfor certain childrensec adult day health care servicessec medicaid coverage for citizens of freely associated statessec continuing requirement of medicaid coverage of nonemergencytransportation to medically necessary servicessec state option to disregard certain income in providing continuedmedicaid coverage for certain individuals with extremely highprescription costssec provisions relating to community living assistance services and supports class subtitle financingsec payments to pharmacistssec prescription drug rebatessec extension of prescription drug discounts to enrollees of medicaidmanaged care organizationssec payments for graduate medical educationsec nursing facility supplemental payment programsec report on medicaid paymentssec reviews of medicaidsec extension of delay in managed care organization provider tax eliminationsec extension of arra increase in fmapsubtitle waste fraud and abusesec health care acquired conditionssec evaluations and reports required under medicaid integrity programsec require providers and suppliers to adopt programs to reduce waste fraud and abusesec overpayments with bills hr ihsec managed care organizationssec termination of provider participation under medicaid and chip ifterminated under medicare or other state plan or child healthplansec medicaid and chip exclusion from participation relating to certainownership control and management affiliationssec requirement to report expanded set of data elements under mmisto detect fraud and abusesec billing agents clearinghouses or other alternate payees required toregister under medicaidsec denial of payments for litigation related misconductsec mandatory state use of national correct coding initiativesubtitle payments to the territoriessec payment to territoriessubtitle miscellaneoussec technical correctionssec extension of qi programsec assuring transparency of informationsec medicaid and chip payment and access commissionsec outreach and enrollment of medicaid and chip eligible individualssec prohibitions on federal medicaid and chip payment for undocumentedalienssec demonstration project for stabilization of emergency medical conditionsby institutions for mental diseasessec application of medicaid improvement fundsec treatment of certain medicaid brokerssec rule for changes requiring state legislationtitle viii revenue related provisionssec disclosures to facilitate identification of individuals likely to be ineligiblefor the low income assistance under the medicare prescriptiondrug program to assist social security administration soutreach to eligible individualssec comparative effectiveness research trust fund financing fortrust fundtitle ix miscellaneous provisionssec repeal of trigger provisionsec repeal of comparative cost adjustment cca programsec extension of gainsharing demonstrationsec grants to states for quality home visitation programs for familieswith young children and families expecting childrensec improved coordination and protection for dual eligiblessec assessment of medicare cost intensive diseases and conditionssec establishment of center for medicare and medicaid innovationwithin cmssec application of emergency services lawssec disregard under the supplemental security income program of compensationfor participation in clinical trials for rare diseases orconditions with bills hr ih title improving health care value subtitle a provisions related to medicare part a part market basket updates sec skilled nursing facility payment update a in general section of the social security act usc yy is amended in subclause iii by striking and at the end by redesignating subclause iv as subclause vi and by inserting after subclause iii the following new subclauses iv for each of fiscal years through the rate computed for the previous fiscal year increased by the skilled nursing facility market basket percentage change for the fiscal year involved for fiscal year the rate computed for the previous fiscal year and with bills hr ih delayed effective date section of the social security act as inserted by subsection a shall not apply to payment for days before january sec inpatient rehabilitation facility payment update a in general section of the social security act usc ww is amended by striking and and inserting through delayed effective date the amendment made by subsection a shall not apply to payment units occurring before january sec incorporating productivity improvements into market basket updates that do not already incorporate such improvements a inpatient acute hospitals section of the social security act usc ww is amended in clause iii a by striking iii for purposes of this subparagraph and inserting iii for purposes of this subparagraph subject to the productivity adjustment described in subclause and with bills hr ih by adding at the end the following new subclause the productivity adjustment described in this subclause with respect to an increase or change for a fiscal year or year or cost reporting period or other annual period is a productivity offset in the form of a reduction in such increase or change equal to the percentage change in the year moving average of annual economy wide private nonfarm business multi factor productivity as recently published in final form before the promulgation or publication of such increase for the year or period involved except as otherwise provided any reference to the increase described in this clause shall be a reference to the percentage increase described in subclause minus the percentage change under this subclause in the first sentence of clause viii by inserting but not below zero after shall be reduced and in the first sentence of clause ix a by inserting determined without regard to clause iii after clause the second time it appears and by inserting but not below zero after reduced with bills hr ih skilled nursing facilities section of such act usc yy is amended by inserting subject to the productivity adjustment described in section iii after as calculated by the secretary long term care hospitals section of the social security act usc ww is amended by adding at the end the following new paragraph productivity adjustment in implementing the system described in paragraph for discharges occurring on or after january during the rate year ending in or any subsequent rate year for a hospital to the extent that an annual percentage increase factor applies to a standard federal rate for such discharges for the hospital such factor shall be subject to the productivity adjustment described in subsection iii inpatient rehabilitation facilities the second sentence of section of the social security act usc ww is amended by inserting subject to the productivity adjustment described in subsection iii after appropriate percentage increase with bills hr ih psychiatric hospitals section of the social security act usc ww is amended by adding at the end the following new subsection prospective payment for psychiatric hospitals reference to establishment and implementation of system for provisions related to the establishment and implementation of a prospective payment system for payments under this title for inpatient hospital services furnished by psychiatric hospitals as described in clause of subsection and psychiatric units as described in the matter following clause of such subsection see section of the medicare medicaid and schip balanced budget refinement act of productivity adjustment in implementing the system described in paragraph for days occurring during the rate year ending in or any subsequent rate year for a psychiatric hospital or unit described in such paragraph to the extent that an annual percentage increase factor applies to a base rate for such days for the hospital or unit respectively such factor shall be subject to with bills hr ih the productivity adjustment described in subsection iii hospice care subclause vii of section of the social security act usc is amended by inserting after the market basket percentage increase the following which is subject to the productivity adjustment described in section iii effective dates ipps the amendments made by subsection a shall apply to annual increases effected for fiscal years beginning with fiscal year but only with respect to discharges occurring on or after january snf and irf the amendments made by subsections and shall apply to annual increases effected for fiscal years beginning with fiscal year hospice care the amendment made by subsection shall apply to annual increases effected for fiscal years beginning with fiscal year but only with respect to days of care occurring on or after january with bills hr ih part other medicare part a provisions sec payments to skilled nursing facilities a change in recalibration factor analysis the secretary of health and human services shall conduct using calendar year claims data an initial analysis comparing total payments under title xviii of the social security act for skilled nursing facility services under the rug– and under the rug– classification systems adjustment in recalibration factor based on the initial analysis under paragraph the secretary shall adjust the case mix indexes under section of the social security act usc yy for fiscal year by the appropriate recalibration factor as proposed in the proposed rule for medicare skilled nursing facilities issued by such secretary on may federal register et seq change in payment for nontherapy ancillary nta services and therapy services changes under current snf classification system a in general subject to subparagraph the secretary of health and human services shall under the system for payment of with bills hr ih skilled nursing facility services under section of the social security act usc yy increase payment by percent for non therapy ancillary services as specified by the secretary in the notice issued on november federal register et seq and shall decrease payment for the therapy case mix component of such rates by percent effective date the changes in payment described in subparagraph a shall apply for days on or after january and until the secretary implements an alternative case mix classification system for payment of skilled nursing facility services under section of the social security act usc yy implementation notwithstanding any other provision of law the secretary implement by program instruction or otherwise the provisions of this paragraph changes under a future snf case mix classification system a analysis in general the secretary of health and human services shall analyze with bills hr ih payments for non therapy ancillary services under a future skilled nursing facility classification system to ensure the accuracy of payment for non therapy ancillary services such analysis shall consider use of appropriate predictors which include age physical and mental status ability to perform activities of daily living prior nursing home stay diagnoses broad rug category and a proxy for length of stay application such analysis shall be conducted in a manner such that the future skilled nursing facility classification system is implemented to apply to services furnished during a fiscal year beginning with fiscal year consultation in conducting the analysis under subparagraph a the secretary shall consult with interested parties including the medicare payment advisory commission and other interested stakeholders to identify appropriate predictors of nontherapy ancillary costs rulemaking the secretary shall include the result of the analysis under sub with bills hr ih paragraph a in the fiscal year rulemaking cycle for purposes of implementation beginning for such fiscal year implementation subject to subparagraph and consistent with subparagraph a the secretary shall implement changes to payments for non therapy ancillary services which shall include a separate rate component for non therapy ancillary services and include use of a model that predicts payment amounts applicable for non therapy ancillary services under such future skilled nursing facility services classification system as the secretary determines appropriate based on the analysis conducted pursuant to subparagraph a budget neutrality the secretary shall implement changes described in subparagraph in a manner such that the estimated expenditures under such future skilled nursing facility services classification system for a fiscal year beginning with fiscal year with such changes would be equal to the estimated expenditures that would otherwise occur under title xviii of the social security act under with bills hr ih such future skilled nursing facility services classification system for such year without such changes outlier policy for nta and therapy section of the social security act usc yy is amended by adding at the end the following new paragraph outliers for nta and therapy a in general with respect to outliers because of unusual variations in the type or amount of medically necessary care beginning with october the secretary shall provide for an addition or adjustment to the payment amount otherwise made under this section with respect to non therapy ancillary services in the case of such outliers and provide for such an addition or adjustment to the payment amount otherwise made under this section with respect to therapy services in the case of such outliers outliers based on aggregate costs outlier adjustments or additional payments described in subparagraph a shall be with bills hr ih based on aggregate costs during a stay in a skilled nursing facility and not on the number of days in such stay budget neutrality the secretary shall reduce estimated payments that would otherwise be made under the prospective payment system under this subsection with respect to a fiscal year by percent the total amount of the additional payments or payment adjustments for outliers made under this paragraph with respect to a fiscal year not exceed percent of the total payments projected or estimated to be made based on the prospective payment system under this subsection for the fiscal year conforming amendments section of such act usc yy is amended in subparagraph a a by striking and before adjustments and by inserting and adjustment under section of the affordable health care for america act before the semicolon at the end with bills hr ih in subparagraph by striking and in subparagraph by striking the period and inserting and and by adding at the end the following new subparagraph the establishment of outliers under paragraph sec medicare dsh report and payment adjustments in response to coverage expansion a dsh report in general not later than january the secretary of health and human services shall submit to congress a report on medicare dsh taking into account the impact of the health care reforms carried out under division a in reducing the number of uninsured individuals the report shall include recommendations relating to the following a the appropriate amount targeting and distribution of medicare dsh to compensate for higher medicare costs associated with serving low income beneficiaries taking into account variations in the empirical justification for medicare dsh attributable to hospital characteristics including bed size con with bills hr ih sistent with the original intent of medicare dsh the appropriate amount targeting and distribution of medicare dsh to hospitals given their continued uncompensated care costs to the extent such costs remain coordination with medicaid dsh report the secretary shall coordinate the report under this subsection with the report on medicaid dsh under section a payment adjustments in response to coverage expansion in general if there is a significant decrease in the national rate of uninsurance as a result of this act as determined under paragraph a then the secretary of health and human services shall beginning in fiscal year implement the following adjustments to medicare dsh a in lieu of the amount of medicare dsh payment that would otherwise be made under section of the social security act the amount of medicare dsh payment shall be an amount based on the recommendations of the report under subsection a a and shall take into account variations in the with bills hr ih empirical justification for medicare dsh attributable to hospital characteristics including bed size subject to paragraph make an additional payment to a hospital by an amount that is estimated based on the amount of uncompensated care provided by the hospital based on criteria for uncompensated care as determined by the secretary which shall exclude bad debt significant decrease in national rate of uninsurance as a result of this act for purposes of this subsection a in general there is a significant decrease in the national rate of uninsurance as a result of this act if there is a decrease in the national rate of uninsurance as defined in subparagraph from to that exceeds percentage points national rate of uninsurance defined the term national rate of uninsurance means for a year such rate for the under population for the year as determined and published by the bureau of the cen with bills hr ih sus in its current population survey in or about september of the succeeding year uncompensated care increase a computation of dsh savings for each fiscal year beginning with fiscal year the secretary shall estimate the aggregate reduction in the amount of medicare dsh payment that would be expected to result from the adjustment under paragraph a structure of payment increase the secretary shall compute the additional payment to a hospital as described in paragraph for a fiscal year in accordance with a formula established by the secretary that provides that the estimated aggregate amount of such increase for the fiscal year does not exceed percent of the aggregate reduction in medicare dsh estimated by the secretary for such fiscal year and hospitals with higher levels of uncompensated care receive a greater increase medicare dsh in this section the term medicare dsh means adjustments in payments under with bills hr ih section of the social security act usc ww for inpatient hospital services furnished by disproportionate share hospitals sec extension of hospice regulation moratorium section a of division of the american recovery and reinvestment act of public law – is amended by striking october and inserting october and by striking for fiscal year and inserting for fiscal years and sec permitting physician assistants to order post hospital extended care services and to provide for recognition of attending physician assistants as attending physicians to serve hospice patients a ordering post hospital extended care services section a of the social security act usc a is amended in paragraph in the matter preceding subparagraph a is amended by striking nurse practitioner or clinical nurse specialist and insert with bills hr ih ing nurse practitioner a clinical nurse specialist or a physician assistant in the second sentence by striking or clinical nurse specialist and inserting clinical nurse specialist or physician assistant recognition of attending physician assistants as attending physicians to serve hospice patients in general section dd of such act usc dd is amended a by striking or nurse and inserting the nurse and by inserting or the physician assistant as defined in such subsection after subsection aa conforming amendment section a a of such act usc a a is amended by inserting or a physician assistant after a nurse practitioner construction nothing in the amendments made by this subsection shall be construed as changing the requirements of section of the social security act usc with respect to payment for serv with bills hr ih ices of physician assistants under part of title xviii of such act effective date the amendments made by this section shall apply to items and services furnished on or after january subtitle provisions related to part part physicians services sec resource based feedback program for physicians in medicare section of the social security act usc w– is amended by adding at the end the following new paragraph feedback implementation plan a timeline for feedback program evaluation during the secretary shall conduct the evaluation specified in subparagraph expansion the secretary shall expand the program under this subsection as specified in subparagraph establishment of nature of reports with bills hr ih in general the secretary shall develop and specify the nature of the reports that will be disseminated under this subsection based on results and findings from the program under this subsection as in existence before the date of the enactment of this paragraph such reports be based on a per capita basis an episode basis that combines separate but clinically related physicians services and other items and services furnished or ordered by a physician into an episode of care as appropriate or both timeline for development the nature of the reports described in clause shall be developed by not later than january iii public availability the secretary shall make the details of the nature of the reports developed under clause available to the public analysis of data the secretary shall for purposes of preparing reports under this subsection establish methodologies as appropriate such as to with bills hr ih attribute items and services in whole or in part to physicians identify appropriate physicians for purposes of comparison under subparagraph and iii aggregate items and services attributed to a physician under clause into a composite measure per individual feedback program the secretary shall engage in efforts to disseminate reports under this subsection in disseminating such reports the secretary shall consider the following direct meetings between contracted physicians facilitated by the secretary to discuss the contents of reports under this subsection including any reasons for divergence from local or national averages contract with local non profit entities engaged in quality improvement efforts at the community level such entities shall use the reports under this subsection or such equivalent tool as specified by the secretary any exchange of data under this with bills hr ih paragraph shall be protected by appropriate privacy safeguards iii mailings or other methods of communication that facilitate large scale dissemination iv other methods specified by the secretary evaluation and expansion evaluation the secretary shall evaluate the methods specified in subparagraph with regard to their efficacy in changing practice patterns to improve quality and decrease costs expansion taking into account the cost of each method specified in subparagraph the secretary shall develop a plan to disseminate reports under this subsection in a significant manner in the regions and cities of the country with the highest utilization of services under this title to the extent practicable reports under this subsection shall be disseminated to increasing numbers of physicians each year such that during and subsequent years reports are disseminated at with bills hr ih least to physicians with utilization rates among the highest percent of the nation subject the authority to focus under paragraph administration chapter of title united states code shall not apply to this paragraph notwithstanding any other provision of law the secretary implement the provisions of this paragraph by program instruction or otherwise sec misvalued codes under the physician fee schedule a in general section of the social security act usc is amended by adding at the end the following new subparagraphs potentially misvalued codes in general the secretary shall periodically identify services as being potentially misvalued using criteria specified in clause and review and make appropriate adjustments to the relative val with bills hr ih ues established under this paragraph for services identified as being potentially misvalued under subclause identification of potentially misvalued codes for purposes of identifying potentially misvalued services pursuant to clause the secretary shall examine as the secretary determines to be appropriate codes and families of codes as appropriate for which there has been the fastest growth codes and families of codes as appropriate that have experienced substantial changes in practice expenses codes for new technologies or services within an appropriate period such as three years after the relative values are initially established for such codes multiple codes that are frequently billed in conjunction with furnishing a single service codes with low relative values particularly those that are often billed multiple times for a single treatment codes which have not been subject to review since the implementation of the rbrvs the socalled harvard valued codes and such with bills hr ih other codes determined to be appropriate by the secretary iii review and adjustments the secretary use existing processes to receive recommendations on the review and appropriate adjustment of potentially misvalued services described clause ii the secretary conduct surveys other data collection activities studies or other analyses as the secretary determines to be appropriate to facilitate the review and appropriate adjustment described in clause iii the secretary use analytic contractors to identify and analyze services identified under clause conduct surveys or collect data and make recommendations on the review and appropriate adjustment of services described in clause with bills hr ih iv the secretary coordinate the review and appropriate adjustment described in clause with the periodic review described in subparagraph as part of the review and adjustment described in clause including with respect to codes with low relative values described in clause the secretary make appropriate coding revisions including using existing processes for consideration of coding changes which include consolidation of individual services into bundled codes for payment under the fee schedule under subsection vi the provisions of subparagraph ii shall apply to adjustments to relative value units made pursuant to this subparagraph in the same manner as such provisions apply to adjustments under subparagraph ii with bills hr ih validating relative value units in general the secretary shall establish a process to validate relative value units under the fee schedule under subsection components and elements of work the process described in clause include validation of work elements such as time mental effort and professional judgment technical skill and physical effort and stress due to risk involved with furnishing a service and include validation of the pre post and intra service components of work iii scope of codes the validation of work relative value units shall include a sampling of codes for services that is the same as the codes listed under subparagraph iv methods the secretary conduct the validation under this subparagraph using methods described in subclauses through of subparagraph with bills hr ih iii as the secretary determines to be appropriate adjustments the secretary shall make appropriate adjustments to the work relative value units under the fee schedule under subsection the provisions of subparagraph ii shall apply to adjustments to relative value units made pursuant to this subparagraph in the same manner as such provisions apply to adjustments under subparagraph ii implementation funding for purposes of carrying out the provisions of subparagraphs and of of the social security act as added by subsection a in addition to funds otherwise available out of any funds in the treasury not otherwise appropriated there are appropriated to the secretary of health and human services for the center for medicare medicaid services program management account for fiscal year and each subsequent fiscal year amounts appropriated under this paragraph for a fiscal year shall be available until expended with bills hr ih administration a chapter of title united states code and the provisions of the federal advisory committee act usc app shall not apply to this section or the amendment made by this section notwithstanding any other provision of law the secretary implement subparagraphs and of of the social security act as added by subsection a by program instruction or otherwise section of the balanced budget act of is repealed except for provisions related to confidentiality of information the provisions of the federal acquisition regulation shall not apply to this section or the amendment made by this section focusing cms resources on potentially overvalued codes section a of the social security act ee a is repealed sec payments for efficient areas section of the social security act usc is amended by adding at the end the following new subsection with bills hr ih incentive payments for efficient areas in general in the case of services furnished under the physician fee schedule under section on or after january and before january by a supplier that is paid under such fee schedule in an efficient area as identified under paragraph in addition to the amount of payment that would otherwise be made for such services under this part there also shall be paid on a monthly or quarterly basis an amount equal to percent of the payment amount for the services under this part identification of efficient areas a in general based upon available data the secretary shall identify those counties or equivalent areas in the united states in the lowest fifth percentile of utilization based on per capita spending under this part and part a for services provided in the most recent year for which data are available as of the date of the enactment of this subsection as standardized to eliminate the effect of geographic adjustments in payment rates with bills hr ih identification of counties where service is furnished for purposes of paying the additional amount specified in paragraph if the secretary uses the digit postal zip code where the service is furnished the dominant county of the postal zip code as determined by the united states postal service or otherwise shall be used to determine whether the postal zip code is in a county described in subparagraph a limitation on review there shall be no administrative or judicial review under section or otherwise respecting the identification of a county or other area under subparagraph a or the assignment of a postal zip code to a county or other area under subparagraph publication of list of counties posting on website with respect to a year for which a county or area is identified under this paragraph the secretary shall identify such counties or areas as part of the proposed and final rule to implement the physician fee with bills hr ih schedule under section for the applicable year the secretary shall post the list of counties identified under this paragraph on the internet website of the centers for medicare medicaid services sec modifications to the physician quality reporting initiative pqri a feedback section of the social security act usc w– is amended by adding at the end the following new subparagraph feedback the secretary shall provide timely feedback to eligible professionals on the performance of the eligible professional with respect to satisfactorily submitting data on quality measures under this subsection appeals such section is further amended in subparagraph by striking there shall be and inserting except as provided in subparagraph there shall be and by adding at the end the following new subparagraph informal appeals process by not later than january the secretary shall establish and have in place an informal process for eligible professionals to seek a re with bills hr ih view of the determination that an eligible professional did not satisfactorily submit data on quality measures under this subsection integration of physician quality reporting and ehr reporting section of such act is amended by adding at the end the following new paragraph integration of physician quality reporting and ehr reporting not later than january the secretary shall develop a plan to integrate clinical reporting on quality measures under this subsection with reporting requirements under subsection relating to the meaningful use of electronic health records such integration shall consist of the following a the development of measures the reporting of which would both demonstrate meaningful use of an electronic health record for purposes of subsection and clinical quality of care furnished to an individual the collection of health data to identify deficiencies in the quality and coordination with bills hr ih of care for individuals eligible for benefits under this part such other activities as specified by the secretary extension of incentive payments section of such act usc w– is amended in subparagraph a by striking and inserting and in subparagraph by striking and and inserting for each of the years through sec adjustment to medicare payment localities a in general section of the social security act uscw– is amended by adding at the end the following new paragraph transition to use of msas as fee schedule areas in california a in general revision subject to clause and notwithstanding the previous provisions of this subsection for services furnished on or after january the secretary shall revise the fee schedule with bills hr ih areas used for payment under this section applicable to the state of california using the metropolitan statistical area msa iterative geographic adjustment factor methodology as follows the secretary shall configure the physician fee schedule areas using the metropolitan statistical areas each in this paragraph referred to as an msa as defined by the director of the office of management and budget and published in the federal register using the most recent available decennial population data as of the date of the enactment of the affordable health care for america act as the basis for the fee schedule areas for purposes of this clause the secretary shall treat all areas not included in an msa as a single rest of the state msa iii the secretary shall list all msas within the state by geographic adjustment factor described in para with bills hr ih graph in this paragraph referred to as a gaf in descending order iv in the first iteration the secretary shall compare the gaf of the highest cost msa in the state to the weighted average gaf of all the remaining msas in the state including the rest of state msa described in subclause if the ratio of the gaf of the highest cost msa to the weighted average of the gaf of remaining lower cost msas is or greater the highest cost msa shall be a separate fee schedule area in the next iteration the secretary shall compare the gaf of the msa with the second highest gaf to the weighted average gaf of the all the remaining msas excluding msas that become separate fee schedule areas if the ratio of the secondhighest msa gaf to the weightedaverage of the remaining lower cost msas is or greater the secondhighest msa shall be a separate fee with bills hr ih schedule area vi the iterative process shall continue until the ratio of the gaf of the msa with highest remaining gaf to the weighted average of the remaining msas with lower gafs is less than and the remaining group of msas with lower gafs shall be treated as a single fee schedule area vi for purposes of the iterative process described in this clause if two msas have identical gafs they shall be combined transition for services furnished on or after january and before january in the state of california after calculating the work practice expense and malpractice geographic indices that would otherwise be determined under clauses and iii of paragraph a for a fee schedule area determined under clause if the index for a county within a fee schedule area is less than the index in effect for such county on december the secretary shall in with bills hr ih stead apply the index in effect for such county on such date subsequent revisions after the transition described in subparagraph a not less than every years the secretary shall review and update the fee schedule areas using the methodology described in subparagraph a and any updated msas as defined by the director of the office of management and budget and published in the federal register the secretary shall review and make any changes pursuant to such reviews concurrent with the application of the periodic review of the adjustment factors required under paragraph for california references to fee schedule areas effective for services furnished on or after january for the state of california any reference in this section to a fee schedule area shall be deemed a reference to an msa in the state including the single rest of state msa described in subparagraph a conforming amendment to definition of fee schedule area section of the social with bills hr ih security act usc is amended by striking the term and inserting except as provided in subsection the term part market basket updates sec incorporating productivity improvements into market basket updates that do not already incorporate such improvements a outpatient hospitals in general section iv of the social security act usc iv is amended a in the first sentence by inserting which is subject to the productivity adjustment described in subclause of such section after iii and by inserting but not below after reduced and in the second sentence by inserting and which is subject beginning with to the productivity adjustment described in section iii with bills hr ih effective date the amendments made by this subsection shall apply to increase factors for services furnished in years beginning with ambulance services section of such act usc is amended by inserting before the period at the end the following and in the case of years beginning with subject to the productivity adjustment described in section iii ambulatory surgical center services section of such act usc is amended by redesignating clause as clause vi and by inserting after clause iv the following new clause in implementing the system described in clause for services furnished during or any subsequent year to the extent that an annual percentage change factor applies such factor shall be subject to the productivity adjustment described in section iii laboratory services section a of such act usc a is amended with bills hr ih in clause by striking for each of the years through and inserting for and clause a by striking and at the end of subclause iii by striking the period at the end of subclause iv and inserting and and by adding at the end the following new subclause the annual adjustment in the fee schedules determined under clause for years beginning with shall be subject to the productivity adjustment described in section iii certain durable medical equipment section a of such act usc a is amended in subparagraph by inserting before the semicolon at the end the following subject to the productivity adjustment described in section iii in subparagraph by inserting after june the following subject to the productivity adjustment described in section iii with bills hr ih in subparagraph by inserting after june the following subject to the productivity adjustment described in section iii and in subparagraph by inserting before the period at the end the following subject to the productivity adjustment described in section iii part other provisions sec rental and purchase of power driven wheelchairs a in general section a a iii of the social security act usc a a iii is amended in the heading by inserting certain complex rehabilitative after option for and by striking power driven wheelchair and inserting complex rehabilitative power driven wheelchair recognized by the secretary as classified within group or higher effective date the amendments made by subsection a shall take effect on january and shall apply to power driven wheelchairs furnished on or after such date such amendments shall not apply to contracts entered into under section of the social secu with bills hr ih rity act usc w– pursuant to a bid submitted under such section before october under subsection a of such section sec a election to take ownership or to decline ownership of a certain item of complex durable medical equipment after the month capped rental period ends a in general section a a of the social security act usc a a is amended in clause a by striking rental on and inserting rental in general except as provided in subclause on and by adding at the end the following new subclause option to accept or reject transfer of title to group support surface aa in general during the th continuous month during which payment is made for the rental of a group support with bills hr ih surface under clause the supplier of such item shall offer the individual the option to accept or reject transfer of title to a group support surface after the th continuous month during which payment is made for the rental of the group support surface under clause such title shall be transferred to the individual only if the individual notifies the supplier not later than month after the supplier makes such offer that the individual agrees to accept transfer of the title to the group support surface unless the individual accepts transfer of title to the group support surface in the manner set forth in this subclause the individual shall be deemed to have rejected transfer of title if the individual agrees to accept the transfer of the title to the group support surface the supplier shall trans with bills hr ih fer such title to the individual on the first day that begins after the th continuous month during which payment is made for the rental of the group support surface under clause bb special rule if on the effective date of this subclause an individual rental period for a group support surface has exceeded continuous months but the first day that begins after the th continuous month during which payment is made for the rental under clause has not been reached the supplier shall within month following such effective date offer the individual the option to accept or reject transfer of title to a group support surface such title shall be transferred to the individual only if the individual notifies the supplier not later than month after the supplier with bills hr ih makes such offer that the individual agrees to accept transfer of title to the group support surface unless the individual accepts transfer of title to the group support surface in the manner set forth in this subclause the individual shall be deemed to have rejected transfer of title if the individual agrees to accept the transfer of the title to the group support surface the supplier shall transfer such title to the individual on the first day that begins after the th continuous month during which payment is made for the rental of the group support surface under clause unless that day has passed in which case the supplier shall transfer such title to the individual not later than month after notification that the individual accepts transfer of title with bills hr ih cc treatment of subsequent resupply within period of reasonable useful lifetime of group support surface in case of need if an individual rejects transfer of title to a group support surface under this subclause and the individual requires such support surface at any subsequent time during the period of the reasonable useful lifetime of such equipment as defined by the secretary beginning with the first month for which payment is made for the rental of such equipment under clause the supplier shall supply the equipment without charge to the individual or the program under this title during the remainder of such period other than payment for maintenance and servicing during such period which would otherwise have been paid if the with bills hr ih individual had accepted title to such equipment the previous sentence shall not affect the payment of amounts under this part for such equipment after the end of such period of the reasonable useful lifetime of the equipment dd payments maintenance and servicing payments shall be made in accordance with clause iv in the case of a supplier that transfers title to the group support surface under this subclause after such transfer and in the case of an individual who rejects transfer of title under this subclause after the end of the period of medical need during which payment is made under clause and in clause iv by inserting or in the case of an individual who rejects transfer of title to a group support surface under clause after the end of the period of medical need during which pay with bills hr ih ment is made under clause after under clause effective date the amendments made by this section shall apply with respect to durable medical equipment not later than january sec extension of payment rule for brachytherapy section of the social security act usc as amended by section of the medicare improvements for patients and providers act of public law – is amended by striking the first place it appears january and inserting january sec home infusion therapy report to congress not later than july the medicare payment advisory commission shall submit to congress a report on the following the scope of coverage for home infusion therapy in the fee for service medicare program under title xviii of the social security act medicare advantage under part of such title the veteran health care program under chapter of title united states code and among private payers including an analysis of the scope of services pro with bills hr ih vided by home infusion therapy providers to their patients in such programs the benefits and costs of providing such coverage under the medicare program including a calculation of the potential savings achieved through avoided or shortened hospital and nursing home stays as a result of medicare coverage of home infusion therapy an assessment of sources of data on the costs of home infusion therapy that might be used to construct payment mechanisms in the medicare program recommendations if any on the structure of a payment system under the medicare program for home infusion therapy including an analysis of the payment methodologies used under medicare advantage plans and private health plans for the provision of home infusion therapy and their applicability to the medicare program sec require ambulatory surgical centers ascs to submit cost data and other data a cost reporting with bills hr ih in general section of the social security act usc is amended by adding at the end the following new paragraph the secretary shall require as a condition of the agreement described in section a the submission of such cost report as the secretary specify taking into account the requirements for such reports under section in the case of a hospital development of cost report not later than years after the date of the enactment of this act the secretary of health and human services shall develop a cost report form for use under section of the social security act as added by paragraph audit requirement the secretary shall provide for periodic auditing of cost reports submitted under section of the social security act as added by paragraph effective date the amendment made by paragraph shall apply to agreements applicable to cost reporting periods beginning months after the date the secretary develops the cost report form under paragraph additional data on quality with bills hr ih in general section of such act usc is amended a in subparagraph by inserting subject to subparagraph after otherwise provide and by adding at the end the following new subparagraph under subparagraph the secretary shall require the reporting of such additional data relating to quality of services furnished in an ambulatory surgical facility including data on health care associated infections as the secretary specify effective date the amendment made by paragraph shall to reporting for years beginning with sec treatment of certain cancer hospitals section of the social security act usc is amended by adding at the end the following new paragraph authorization of adjustment for cancer hospitals a study the secretary shall conduct a study to determine if under the system under this subsection costs incurred by hospitals described in section with respect with bills hr ih to ambulatory payment classification groups exceed those costs incurred by other hospitals furnishing services under this subsection as determined appropriate by the secretary authorization of adjustment insofar as the secretary determines under subparagraph a that costs incurred by hospitals described in section exceed those costs incurred by other hospitals furnishing services under this subsection the secretary shall provide for an appropriate adjustment under paragraph to reflect those higher costs effective for services furnished on or after january sec payment for imaging services a adjustment in practice expense to reflect a presumed level of utilization section of the social security act usc w– is amended in subsection a in subparagraph by striking subparagraph a and inserting this paragraph and by adding at the end the following new subparagraph with bills hr ih adjustment in practice expense to reflect a presumed level of utilization consistent with the methodology for computing the number of practice expense relative value units under subsection c with respect to advanced diagnostic imaging services as defined in section furnished on or after january the secretary shall adjust such number of units so it reflects a presumed rate of utilization of imaging equipment of percent and in subsection by adding at the end the following new subclause iii change in presumed utilization level of certain advanced diagnostic imaging services effective for fee schedules established beginning with reduced expenditures attributable to the presumed utilization of percent under subsection instead of a presumed utilization of imaging equipment of percent adjustment in technical component discount on single session imaging to consecutive with bills hr ih body parts section of such act usc w– is further amended in subsection by adding at the end the following new subparagraph adjustment in technical component discount on single session imaging involving consecutive body parts for services furnished on or after january the secretary shall increase the reduction in expenditures attributable to the multiple procedure payment reduction applicable to the technical component for imaging under the final rule published by the secretary in the federal register on november part of title code of federal regulations from percent to percent and in subsection by adding at the end the following new subclause iii additional reduced payment for multiple imaging procedures effective for fee schedules established beginning with reduced expenditures attributable to the increase in the multiple procedure payment reduction from with bills hr ih percent to percent as described in subsection sec durable medical equipment program improvements a waiver of surety bond requirement section a of the social security act usc a is amended by adding at the end the following sentence the requirement for a surety bond described in subparagraph shall not apply in the case of a pharmacy or supplier that exclusively furnishes eyeglasses or contact lenses described in section if the pharmacy or supply has been enrolled under section as a supplier of durable medical equipment prosthetics orthotics and supplies and has been issued which include renewal of a supplier number as described in the first sentence of this paragraph for at least years and if a final adverse action as defined in section a of title code of federal regulations has never been imposed for such pharmacy or supplier ensuring supply of oxygen equipment in general section a of the social security act usc a is amended with bills hr ih a in clause by striking after the and inserting except as provided in clause iii after the and by adding at the end the following new clause iii continuation of supply in the case of a supplier furnishing such equipment to an individual under this subsection as of the th month of the months described in clause the supplier furnishing such equipment as of such month shall continue to furnish such equipment to such individual either directly or though arrangements with other suppliers of such equipment during any subsequent period of medical need for the remainder of the reasonable useful lifetime of the equipment as determined by the secretary regardless of the location of the individual unless another supplier has accepted responsibility for continuing to furnish such equipment during the remainder of such period effective date the amendments made by paragraph shall take effect as of the date of with bills hr ih the enactment of this act and shall apply to the furnishing of equipment to individuals for whom the th month of a continuous period of use of oxygen equipment described in section a of the social security act occurs on or after july treatment of current accreditation applications section a of such act usc a is amended in clause a by striking clause and inserting clauses and iii and by striking and at the end by striking the period at the end of clause ii and by inserting a semicolon by inserting after clause the following new clauses iii the requirement for accreditation described in clause shall not apply for purposes of supplying diabetic testing supplies canes and crutches in the case of a pharmacy that is enrolled under section as a supplier of durable medical equipment prosthetics orthotics and supplies and with bills hr ih iv a supplier that has submitted an application for accreditation before august shall retain the supplier provider or supplier number until an independent accreditation organization determines if such supplier complies with requirements under this paragraph and by adding at the end the following new sentence nothing in clauses iii and iv shall be construed as affecting the application of an accreditation requirement for suppliers to qualify for bidding in a competitive acquisition area under section restoring month oxygen rental period in case of supplier bankruptcy for certain individuals section a of such act usc a as amended by subsection is further amended by adding at the end the following new clause iv exception for bankruptcy if a supplier who furnishes oxygen and oxygen equipment to an individual is declared bankrupt and its assets are liquidated and at the time of such declaration and liquidation more than months of rental payments have been made such in with bills hr ih dividual begin a new month rental period under this subparagraph with another supplier of oxygen sec medpac study and report on bone mass measurement a in general the medicare payment advisory commission shall conduct a study regarding bone mass measurement including computed tomography duel energy ray absorptriometry and vertebral fracture assessment the study shall focus on the following an assessment of the adequacy of medicare payment rates for such services taking into account costs of acquiring the necessary equipment professional work time and practice expense costs the impact of medicare payment changes since on beneficiary access to bone mass measurement benefits in general and in rural and minority communities specifically a review of the clinically appropriate and recommended use among medicare beneficiaries and how usage rates among such beneficiaries compares to such recommendations in conjunction with the findings under recommendations if necessary regarding methods with bills hr ih for reaching appropriate use of bone mass measurement studies among medicare beneficiaries report the commission shall submit a report to the congress not later than months after the date of the enactment of this act containing a description of the results of the study conducted under subsection a and the conclusions and recommendations if any regarding each of the issues described in paragraphs and of such subsection sec timely access to post mastectomy items a in general section of the social security act usc is amended by redesignating subparagraph as subparagraph and by inserting after subparagraph the following new subparagraph special payment rule for postmastectomy external breast prosthesis garments payment for post mastectomy external breast prosthesis garments shall be made regardless of whether such items are supplied to the beneficiary prior to or after the mastectomy procedure or other breast cancer surgical procedure the secretary shall develop policies to ensure appropriate beneficiary access and utiliza with bills hr ih tion safeguards for such items supplied to a beneficiary prior to the mastectomy or other breast cancer surgical procedure effective date this amendment shall apply not later than january sec a payment for biosimilar biological products a in general section a of the social security act usc w–a is amended in subsection a in subparagraph a by striking or at the end in subparagraph by striking the period at the end and inserting or and by adding at the end the following new subparagraph in the case of one or more interchangeable biological products as defined in subsection and their reference biological product as defined in subsection which shall be included in the same billing and payment code the sum of the average sales price as determined using the methodology described in paragraph applied to such interchange with bills hr ih able and reference products for all national drug codes assigned to such products in the same manner as such paragraph is applied to multiple source drugs and percent of the amount determined under clause in the case of a biosimilar biological product as defined in subsection the sum of the average sales price as determined using the methodology described in paragraph applied to such biosimilar biological product for all national drug codes assigned to such product in the same manner as such paragraph is applied to a single source drug and percent of the amount determined under paragraph or the amount determined under subparagraph as the case be for the reference biological product as defined in subsection or in the case of a reference biological product for both an interchangeable biological with bills hr ih product and a biosimilar product the amount determined in subparagraph and in subsection a by amending subparagraph to read as follows a biological including a reference biological product for a biosimilar product but excluding a biosimilar biological product an interchangeable biological product iii a reference biological product for an interchangeable biological product and iv a reference biological product for both an interchangeable biological product and a biosimilar product or and by adding at the end the following new subparagraphs biosimilar biological product the term biosimilar biological product means a biological product licensed as a biosimilar bio with bills hr ih logical product under section of the public health service act interchangeable biological product the term interchangeable biological product means a biological product licensed as an interchangeable biological product under section of the public health service act reference biological product the term reference biological product means the biological product that is referred to in the application for a biosimilar or interchangeable biological product licensed under section of the public health service act effective date the amendments made by subsection a shall apply to payments for biosimilar biological products interchangeable biological products and reference biological products beginning with the first day of the second calendar quarter after the date of the enactment of this act sec study and report on dme competitive bidding process a study the comptroller general of the united states shall conduct a study to evaluate the potential establishment of a program under medicare under title xviii of the social security act to acquire durable med with bills hr ih ical equipment and supplies through a competitive bidding process among manufacturers of such equipment and supplies such study shall address the following identification of types of durable medical equipment and supplies that would be appropriate for bidding under such a program recommendations on how to structure such an acquisition program in order to promote fiscal responsibility while also ensuring beneficiary access to high quality equipment and supplies recommendations on how such a program could be phased in and on what geographic level would bidding be most appropriate in addition to price recommendations on criteria that could be factored into the bidding process recommendations on how suppliers could be compensated for furnishing and servicing equipment and supplies acquired under such a program comparison of such a program to the current competitive bidding program under medicare for durable medical equipment as well as any other similar federal acquisition programs such as the general services administration vehicle purchasing program with bills hr ih any other consideration relevant to the acquisition supply and service of durable medical equipment and supplies that is deemed appropriate by the comptroller general report not later than months after the date of the enactment of this act the comptroller general of the united states shall submit to congress a report on the findings of the study under subsection a subtitle provisions related to medicare parts a and sec reducing potentially preventable hospital readmissions a hospitals in general section of the social security act usc ww as amended by section a is amended by adding at the end the following new subsection adjustment to hospital payments for excess readmissions in general with respect to payment for discharges from an applicable hospital as defined in paragraph occurring during a fiscal year beginning on or after october in order to account for excess readmissions in the hospital the secretary shall reduce the payments that would with bills hr ih otherwise be made to such hospital under subsection or section as the case be for such a discharge by an amount equal to the product of a the base operating drg payment amount as defined in paragraph for the discharge and the adjustment factor described in paragraph a for the hospital for the fiscal year base operating drg payment amount a in general except as provided in subparagraph for purposes of this subsection the term base operating drg payment amount means with respect to a hospital for a fiscal year the payment amount that would otherwise be made under subsection for a discharge if this subsection did not apply reduced by any portion of such amount that is attributable to payments under subparagraphs and of paragraph adjustments for purposes of subparagraph a in the case of a hospital that is paid under section the term base with bills hr ih operating drg payment amount means the payment amount under such section adjustment factor a in general for purposes of paragraph the adjustment factor under this paragraph for an applicable hospital for a fiscal year is equal to the greater of the ratio described in subparagraph for the hospital for the applicable period as defined in paragraph for such fiscal year or the floor adjustment factor specified in subparagraph ratio the ratio described in this subparagraph for a hospital for an applicable period is equal to minus the ratio of the aggregate payments for excess readmissions as defined in paragraph a with respect to an applicable hospital for the applicable period and the aggregate payments for all discharges as defined in paragraph with respect to such applicable hospital for such applicable period with bills hr ih floor adjustment factor for purposes of subparagraph a the floor adjustment factor specified in this subparagraph for fiscal year is fiscal year is iii fiscal year is or iv a subsequent fiscal year is aggregate payments excess readmission ratio defined for purposes of this subsection a aggregate payments for excess readmissions the term aggregate payments for excess readmissions means for a hospital for a fiscal year the sum for applicable conditions as defined in paragraph a of the product for each applicable condition of the base operating drg payment amount for such hospital for such fiscal year for such condition the number of admissions for such condition for such hospital for such fiscal year and iii the excess readmissions ratio as defined in subparagraph for such hos with bills hr ih pital for the applicable period for such fiscal year minus aggregate payments for all discharges the term aggregate payments for all discharges means for a hospital for a fiscal year the sum of the base operating drg payment amounts for all discharges for all conditions from such hospital for such fiscal year excess readmission ratio in general subject to clauses and iii the term excess readmissions ratio means with respect to an applicable condition for a hospital for an applicable period the ratio but not less than of the risk adjusted readmissions based on actual readmissions as determined consistent with a readmission measure methodology that has been endorsed under paragraph a for an applicable hospital for such condition with respect to the applicable period to the risk adjusted expected readmissions as determined con verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih sistent with such a methodology for such hospital for such condition with respect to such applicable period exclusion of certain readmissions for purposes of clause with respect to a hospital excess readmissions shall not include readmissions for an applicable condition for which there are fewer than a minimum number as determined by the secretary of discharges for such applicable condition for the applicable period and such hospital iii adjustment in order to promote a reduction over time in the overall rate of readmissions for applicable conditions the secretary provide beginning with discharges for fiscal year for the determination of the excess readmissions ratio under subparagraph to be based on a ranking of hospitals by readmission ratios from lower to higher readmission ratios normalized to a benchmark that is lower than the th percentile definitions for purposes of this subsection verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih a applicable condition the term applicable condition means subject to subparagraph a condition or procedure selected by the secretary among conditions and procedures for which readmissions as defined in subparagraph that represent conditions or procedures that are high volume or high expenditures under this title or other criteria specified by the secretary and measures of such readmissions have been endorsed by the entity with a contract under section a and such endorsed measures have appropriate exclusions for readmissions that are unrelated to the prior discharge such as a planned readmission or transfer to another applicable hospital expansion of applicable conditions beginning with fiscal year the secretary shall expand the applicable conditions beyond the conditions for which measures have been endorsed as described in subpara verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih graph a as of the date of the enactment of this subsection to the additional conditions that have been so identified by the medicare payment advisory commission in its report to congress in june and to other conditions and procedures which include an all condition measure of readmissions as determined appropriate by the secretary in expanding such applicable conditions the secretary shall seek the endorsement described in subparagraph a but apply such measures without such an endorsement applicable hospital the term applicable hospital means a subsection hospital or a hospital that is paid under section applicable period the term applicable period means with respect to a fiscal year such period as the secretary shall specify for purposes of determining excess readmissions readmission the term readmission means in the case of an individual who is discharged from an applicable hospital the admission of the individual to the same or anotherverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih applicable hospital within a time period specified by the secretary from the date of such discharge insofar as the discharge relates to an applicable condition for which there is an endorsed measure described in subparagraph a such time period such as days shall be consistent with the time period specified for such measure limitations on review there shall be no administrative or judicial review under section section or otherwise of a the determination of base operating drg payment amounts the methodology for determining the adjustment factor under paragraph including excess readmissions ratio under paragraph aggregate payments for excess readmissions under paragraph a and aggregate payments for all discharges under paragraph and applicable periods and applicable conditions under paragraph the measures of readmissions as described in paragraph a and the determination of a targeted hospital under paragraph the increase inverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih payment under paragraph the aggregate cap under paragraph the hospital specific limit under paragraph and the form of payment made by the secretary under paragraph monitoring inappropriate changes in admissions practices the secretary shall monitor the activities of applicable hospitals to determine if such hospitals have taken steps to avoid patients at risk in order to reduce the likelihood of increasing readmissions for applicable conditions or taken other inappropriate steps involving readmissions or transfers if the secretary determines that such a hospital has taken such a step after notice to the hospital and opportunity for the hospital to undertake action to alleviate such steps the secretary impose an appropriate sanction assistance to certain hospitals a in general for purposes of providing funds to applicable hospitals to take steps described in subparagraph to address factors that impact readmissions of individuals who are discharged from such a hospital for fiscal years beginning on or after october the secretary shall make a pay verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih ment adjustment for a hospital described in subparagraph with respect to each such fiscal year by a percent estimated by the secretary to be consistent with subparagraph the secretary shall provide priority to hospitals that serve medicare beneficiaries at highest risk for readmission or for a poor transition from such a hospital to a post hospital site of care targeted hospitals subparagraph a shall apply to an applicable hospital that had or in the case of an hospital otherwise would have had a disproportionate patient percentage as defined in section of at least percent using the latest available data as estimated by the secretary and provides assurances satisfactory to the secretary that the increase in payment under this paragraph shall be used for purposes described in subparagraph caps aggregate cap the aggregate amount of the payment adjustment underverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih this paragraph for a fiscal year shall not exceed percent of the estimated difference in the spending that would occur for such fiscal year with and without application of the adjustment factor described in paragraph and applied pursuant to paragraph hospital specific limit the aggregate amount of the payment adjustment for a hospital under this paragraph shall not exceed the estimated difference in spending that would occur for such fiscal year for such hospital with and without application of the adjustment factor described in paragraph and applied pursuant to paragraph form of payment the secretary make the additional payments under this paragraph on a lump sum basis a periodic basis a claim by claim basis or otherwise use of additional payment in general funding under this paragraph shall be used by targeted hospitals for activities designed to address the patient noncompliance issues that re verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih sult in higher than normal readmission rates including transitional care services described in clause and any or all of the other activities described in clause iii transitional care services the transitional care services described in this clause are transitional care services furnished by a qualified transitional care provider such as a nurse or other health professional who meets relevant experience and training requirements as specified by the secretary that support a beneficiary under this section beginning on the date of an individual admission to a hospital for inpatient hospital services and ending at the latest on the last day of the day period beginning on the date of the individual discharge from the applicable hospital the secretary shall determine and update services to be included in transitional care services under this clause as appropriate based on evidence of their effectiveness in reducing hospital readmissions and improving health outcomes such services shall include the following verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih conduct of an assessment prior to discharge which assessment include an assessment of the individual physical and mental condition cognitive and functional capacities medication regimen and adherence social and environmental needs and primary caregiver needs and resources development of a evidencebased plan of transitional care for the individual developed after consultation with the individual and the individual primary caregiver and other health team members as appropriate such plan shall include a list of current therapies prescribed treatment goals and include other items or elements as determined by the secretary such as identifying list of potential health risks and future services for both the individual and any primary caregiververdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih iii other activities the other activities described in this clause are the following providing other care coordination services not described under clause ii hiring translators and interpreters iii increasing services offered by discharge planners iv ensuring that individuals receive a summary of care and medication orders upon discharge developing a quality improvement plan to assess and remedy preventable readmission rates vi assigning appropriate follow up care for discharged individuals vii doing other activities as determined appropriate by the secretary gao report on use of funds not later than years after the date on which funds are first made available under this paragraph the comptroller general of the unitedverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih states shall submit to congress a report on the use of such funds such report shall consider information on the effective uses of such funds how the uses of such funds affected hospital readmission rates including at months postdischarge health outcomes and quality reductions in expenditures under this title and the experiences of beneficiaries primary caregivers and providers as well as any appropriate recommendations application to critical access hospitals section of the social security act usc is amended in paragraph a by striking and at the end of subparagraph by striking the period at the end of subparagraph and inserting and by inserting at the end the following new subparagraph the methodology for determining the adjustment factor under paragraph including the determination of aggregate payments for actual and expected readmissions applicable periods applicable conditions and measures of readmissions andverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih by redesignating such paragraph as paragraph and by inserting after paragraph the following new paragraph the adjustment factor described in section shall apply to payments with respect to a critical access hospital with respect to a cost reporting period beginning in fiscal year and each subsequent fiscal year after application of paragraph of this subsection in a manner similar to the manner in which such section applies with respect to a fiscal year to an applicable hospital as described in section post acute care providers interim policy a in general with respect to a readmission to an applicable hospital or a critical access hospital as described in section of the social security act from a post acute care provider as defined in paragraph and such a readmission is not governed by section of title code of federal regulations if the claim submitted by such a postacute care provider under title xviii of the social security act indicates that the individual was readmitted to a hospital from such a post verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih acute care provider or admitted from home and under the care of a home health agency within days of an initial discharge from an applicable hospital or critical access hospital the payment under such title on such claim shall be the applicable percent specified in subparagraph of the payment that would otherwise be made under the respective payment system under such title for such post acute care provider if this subsection did not apply in applying the previous sentence the secretary shall exclude a period of day from the date the individual is first admitted to or under the care of the post acute care provider applicable percent defined for purposes of subparagraph a the applicable percent is for fiscal or rate year is for fiscal or rate year is and iii for fiscal or rate year is effective date subparagraph shall apply to discharges or services furnishedverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih as the case be with respect to the applicable post acute care provider on or after the first day of the fiscal year or rate year beginning on or after october with respect to the applicable post acute care provider development and application of performance measures a in general the secretary of health and human services shall develop appropriate measures of readmission rates for post acute care providers the secretary shall seek endorsement of such measures by the entity with a contract under section a of the social security act but adopt and apply such measures under this paragraph without such an endorsement the secretary shall expand such measures in a manner similar to the manner in which applicable conditions are expanded under paragraph of section of the social security act as added by subsection a implementation the secretary shall apply on or after october with respect to post acute care providers policies similar to the policies applied with respect toverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih applicable hospitals and critical access hospitals under the amendments made by subsection a the provisions of paragraph shall apply with respect to any period on or after october and before such application date described in the previous sentence in the same manner as such provisions apply with respect to fiscal or rate year monitoring and penalties the provisions of paragraph of such section shall apply to providers under this paragraph in the same manner as they apply to hospitals under such section definitions for purposes of this subsection a post acute care provider the term post acute care provider means a skilled nursing facility as defined in section a of the social security act an inpatient rehabilitation facility described in section a of such act iii a home health agency as defined in section of such act andverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih iv a long term care hospital as defined in section ccc of such act other terms the terms applicable condition applicable hospital and readmission have the meanings given such terms in section of the social security act as added by subsection a physicians study the secretary of health and human services shall conduct a study to determine how the readmissions policy described in the previous subsections could be applied to physicians considerations in conducting the study the secretary shall consider approaches such as a creating a new code or codes and payment amount or amounts under the fee schedule in section of the social security act in a budget neutral manner for services furnished by an appropriate physician who sees an individual within the first week after discharge from a hospital or critical access hospital developing measures of rates of readmission for individuals treated by physicians verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih applying a payment reduction for physicians who treat the patient during the initial admission that results in a readmission and methods for attributing payments or payment reductions to the appropriate physician or physicians report the secretary shall issue a public report on such study not later than the date that is one year after the date of the enactment of this act funding for purposes of carrying out the provisions of this section in addition to funds otherwise available out of any funds in the treasury not otherwise appropriated there are appropriated to the secretary of health and human services for the center for medicare medicaid services program management account for each fiscal year beginning with amounts appropriated under this subsection for a fiscal year shall be available until expended sec post acute care services payment reform plan and bundling pilot program a plan in general the secretary of health and human services in this section referred to as the secretary shall develop a detailed plan to reformverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih payment for post acute care pac services under the medicare program under title xviii of the social security act in this section referred to as the medicare program the goals of such payment reform are to a improve the coordination quality and efficiency of such services and improve outcomes for individuals such as reducing the need for readmission to hospitals from providers of such services bundling post acute services the plan described in paragraph shall include detailed specifications for a bundled payment for post acute services in this section referred to as the post acute care bundle and include other approaches determined appropriate by the secretary post acute services for purposes of this section the term post acute services means services for which payment be made under the medicare program that are furnished by skilled nursing facilities inpatient rehabilitation facilities long term care hospitals hospital based outpatient rehabilitation facilities and home health agencies to an individual after discharge of such individual fromverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih a hospital and such other services determined appropriate by the secretary details the plan described in subsection a shall include consideration of the following issues the nature of payments under a post acute care bundle including the type of provider or entity to whom payment should be made the scope of activities and services included in the bundle whether payment for physicians services should be included in the bundle and the period covered by the bundle whether the payment should be consolidated with the payment under the inpatient prospective system under section of the social security act in this section referred to as ms–drgs or a separate payment should be established for such bundle and if a separate payment is established whether it should be made only upon use of post acute care services or for every discharge whether the bundle should be applied across all categories of providers of inpatient services including critical access hospitals and post acute care services or whether it should be limited to certain categories of providers services or discharges such as high volume or high cost ms– drgsverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih the extent to which payment rates could be established to achieve offsets for efficiencies that could be expected to be achieved with a bundle payment whether such rates should be established on a national basis or for different geographic areas should vary according to discharge case mix outliers and geographic differences in wages or other appropriate adjustments and how to update such rates the nature of protections needed for individuals under a system of bundled payments to ensure that individuals receive quality care are furnished the level and amount of services needed as determined by an appropriate assessment instrument are offered choice of provider and the extent to which transitional care services would improve quality of care for individuals and the functioning of a bundled post acute system the nature of relationships that be required between hospitals and providers of post acute care services to facilitate bundled payments including the application of gainsharing anti referral anti kickback and anti trust laws quality measures that would be appropriate for reporting by hospitals and post acute providersverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih such as measures that assess changes in functional status and quality measures appropriate for each type of post acute services provider including how the reporting of such quality measures could be coordinated with other reporting of such quality measures by such providers otherwise required how cost sharing for a post acute care bundle should be treated relative to current rules for cost sharing for inpatient hospital home health skilled nursing facility and other services how other programmatic issues should be treated in a post acute care bundle including rules specific to various types of post acute providers such as the post acute transfer policy three day hospital stay to qualify for services furnished by skilled nursing facilities and the coordination of payments and care under the medicare program and the medicaid program such other issues as the secretary deems appropriate consultations and analysis consultation with stakeholders in developing the plan under subsection a the secretary shall consult with relevant stakeholders and shall consider experience with such research studiesverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih and demonstrations that the secretary determines appropriate analysis and data collection in developing such plan the secretary shall a analyze the issues described in subsection and other issues that the secretary determines appropriate analyze the impacts including geographic impacts of post acute service reform approaches including bundling of such services on individuals hospitals post acute care providers and physicians use existing data such as data submitted on claims and collect such data as the secretary determines are appropriate to develop such plan required in this section and if patient functional status measures are appropriate for the analysis to the extent practical build upon the care tool being developed pursuant to section of the deficit reduction act of administration funding for purposes of carrying out the provisions of this section in addition to funds otherwise available out of any funds in the treasuryverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih not otherwise appropriated there are appropriated to the secretary for the center for medicare medicaid services program management account for each of the fiscal years through amounts appropriated under this paragraph for a fiscal year shall be available until expended expedited data collection chapter of title united states code shall not apply to this section public reports interim reports the secretary shall issue interim public reports on a periodic basis on the plan described in subsection a the issues described in subsection and impact analyses as the secretary determines appropriate final report not later than the date that is years after the date of the enactment of this act the secretary shall issue a final public report on such plan including analysis of issues described in subsection and impact analyses conversion of acute care episode demonstration to pilot program and expansion to include post acute services verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih in general part of title xviii of the social security act is amended by inserting after section the following new section conversion of acute care episode demonstration to pilot program and expansion to include post acute services sec a conversion and expansion in general by not later than january the secretary shall for the purpose of promoting the use of bundled payments to promote efficient coordinated and high quality delivery of care a convert the acute care episode demonstration program conducted under section to a pilot program and subject to subsection expand such program as so converted to include post acute services and such other services the secretary determines to be appropriate which include transitional services bundled payment structures a in general in carrying out paragraph the secretary apply bundled payments with respect to hospitals and physicians verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih hospitals and post acute care providers iii hospitals physicians and postacute care providers or iv combinations of post acute providers further application in general in carrying out paragraph the secretary shall apply bundled payments in a manner so as to include collaborative care networks and continuing care hospitals collaborative care network defined for purposes of this subparagraph the term collaborative care network means a consortium of health care providers that provides a comprehensive range of coordinated and integrated health care services to low income patient populations including the uninsured which include coordinated and comprehensive care by safety net providers to reduce any unnecessary use of items and services furnished in emergency departments manage chronic conditions improve quality andverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih efficiency of care increase preventive services and promote adherence to post acute and follow up care plans iii continuing care hospital defined for purposes of this subparagraph the term continuing care hospital means an entity that has demonstrated the ability to meet patient care and patient safety standards and that provides under common management the medical and rehabilitation services provided in inpatient rehabilitation hospitals and units as defined in section longterm care hospitals as defined in section iv and skilled nursing facilities as defined in section a that are located in a hospital described in section scope the secretary shall set specific goals for the number of acute and post acute bundling test sites under the pilot program to ensure that over time the pilot program is of sufficient size and scope to test the approaches under the pilot program in a variety of settings including urban rural and underserved areas verdate nov oct jkt po frm fmt sfmt bills hih ih include geographic areas and additional conditions that account for significant program spending as defined by the secretary and subject to subsection disseminate the pilot program rapidly on a national basis to the extent that the secretary finds inpatient and post acute care bundling to be successful in improving quality and reducing costs the secretary shall implement such mechanisms and reforms under the pilot program on as large a geographic scale as practical and economical consistent with subsection nothing in this subsection shall be construed as limiting the number of hospital and physician groups or the number of hospital and post acute provider groups that participate in the pilot program limitation the secretary shall only expand the pilot program under subsection a if the secretary finds that the demonstration program under section and pilot program under this section maintain or increase the quality of care received by individuals enrolled under this title and such demonstration program and pilot program reduce program expenditures and based on the certification under subsection that the expansion of such pilot program would result in esti verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih mated spending that would be less than what spending would otherwise be in the absence of this section certification for purposes of subsection the chief actuary of the centers for medicare medicaid services shall certify whether expansion of the pilot program under this section would result in estimated spending that would be less than what spending would otherwise be in the absence of this section voluntary participation nothing in this paragraph shall be construed as requiring the participation of an entity in the pilot program under this section evaluation on cost and quality of care the secretary shall conduct an evaluation of the pilot program under subsection a to study the effect of such program on costs and quality of care the findings of such evaluation shall be included in the final report required under section of the affordable health care for america act study of additional bundling and episode based payment for physicians services in general the secretary shall provide for a study of and development of a plan for testing additional ways to increase bundling of payments for physicians in connection with an episode of care such as in connection with outpatient hospital serv verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih ices or services rendered in physicians offices other than those provided under the pilot program application the secretary implement such a plan through a demonstration program conforming amendment section of the social security act usc cc– is amended by striking the secretary and inserting subject to section the secretary sec home health payment update for section of the social security act usc fff is amended in subclause iv by striking and by redesignating subclause as subclause vii and by inserting after subclause iv the following new subclauses and subject to clause the home health market basket percentage increase vi subject to clause percent and verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih sec payment adjustments for home health care a acceleration of adjustment for case mix changes section of the social security act usc fff is amended in clause iv by striking insofar as and inserting subject to clause vi insofar as and by adding at the end the following new clause vi special rule for case mix changes for in general with respect to the case mix adjustments established in section a of title code of federal regulations the secretary shall apply in the adjustment established in paragraph of such section for in addition to applying the adjustment established in paragraph for construction nothing in this clause shall be construed as limiting the amount of adjustment for case mix for or if more recent data indicate an appropriate adjustment that is greater than theverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih amount established in the section described in subclause rebasing home health prospective payment amount section a of the social security act usc fff a is amended in clause a in subclause iii by inserting and before after after the period described in subclause and by inserting after subclause iii the following new subclauses iv subject to clause iii for such amount or amounts shall be adjusted by a uniform percentage determined to be appropriate by the secretary based on analysis of factors such as changes in the average number and types of visits in an episode the change in intensity of visits in an episode growth in cost per episode and other factors that the secretary considers to be relevant subject to clause iii for a year after such a amount or amounts shall be equal to theverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih amount or amounts determined under this clause for the previous year updated under subparagraph and by adding at the end the following new clause iii special rule in case of inability to effect timely rebasing application of proxy amount for if the secretary is not able to compute the amount or amounts under clause iv so as to permit on a timely basis the application of such clause for the secretary shall substitute for such amount or amounts percent of the amount or amounts that would otherwise be specified under clause iii if it applied for adjustment for subsequent years based on data if the secretary applies subclause the secretary before july shall compare the amount or amounts applied under such sub verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih clause with the amount or amounts that should have been applied under clause iv the secretary shall decrease or increase the prospective payment amount or amounts under clause for or at the secretary discretion over a period of several years beginning with by the amount if any by which the amount or amounts applied under subclause is greater or less respectively than the amount or amounts that should have been applied under clause iv sec incorporating productivity improvements into market basket update for home health services a in general section of the social security act usc fff is amended in clause iii by inserting including being subject to the productivity adjustment described in section iii after in the same manner andverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih in clause by inserting but not below after reduced effective date the amendments made by subsection a shall apply to home health market basket percentage increases for years beginning with sec a medpac study on variation in home health margins a in general the medicare payment advisory commission shall conduct a study regarding variation in performance of home health agencies in an effort to explain variation in medicare margins for such agencies such study shall include an examination of at least the following issues the demographic characteristics of individuals served and the geographic distribution associated with transportation costs the characteristics of such agencies such as whether such agencies operate hours each day provide charity care or are part of an integrated health system the socio economic status of individuals served such as the proportion of such individuals who are dually eligible for medicare and medicaid benefitsverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih the presence of severe and or chronic disease or disability in individuals served as evidenced by multiple discontinuous home health episodes with a high number of visits per episode the differences in services provided such as therapy and non therapy services report not later than june the commission shall submit a report to the congress on the results of the study conducted under subsection a and shall include in the report the commission conclusions and recommendations if appropriate regarding each of the issues described in paragraphs and of such subsection sec permitting home health agencies to assign the most appropriate skilled service to make the initial assessment visit under a medicare home health plan of care for rehabilitation cases a in general notwithstanding section a of title of the code of federal regulations or any other provision of law a home health agency determine the most appropriate skilled therapist to make the initial assessment visit for an individual who is referred and be eligible for home health services under title xviii of the social security act but who doesverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih not require skilled nursing care as long as the skilled service for which that therapist is qualified to provide the service is included as part of the plan of care for home health services for such individual rule of construction nothing in subsection a shall be construed to provide for initial eligibility for coverage of home health services under title xviii of the social security act on the basis of a need for occupational therapy sec limitation on medicare exceptions to the prohibition on certain physician referrals made to hospitals a in general section of the social security act usc nn is amended in subsection a in subparagraph a by striking and at the end in subparagraph by striking the period at the end and inserting and and by adding at the end the following new subparagraph in the case where the entity is a hospital the hospital meets the requirements of paragraph in subsection verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih a in subparagraph by striking and at the end in subparagraph by striking the period at the end and inserting and and by adding at the end the following new subparagraph the hospital meets the requirements described in subsection by amending subsection to read as follows reporting and disclosure requirements in general each entity providing covered items or services for which payment be made under this title shall provide the secretary with the information concerning the entity ownership investment and compensation arrangements including a the covered items and services provided by the entity and the names and unique physician identification numbers of all physicians with an ownership or investment interest as described in subsection a a or with a compensation arrangement as described in subsectionverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih a in the entity or whose immediate relatives have such an ownership or investment interest or who have such a compensation relationship with the entity such information shall be provided in such form manner and at such times as the secretary shall specify the requirement of this subsection shall not apply to designated health services provided outside the united states or to entities which the secretary determines provide services for which payment be made under this title very infrequently requirements for hospitals with physician ownership or investment in the case of a hospital that meets the requirements described in subsection the hospital shall a submit to the secretary an initial report and periodic updates at a frequency determined by the secretary containing a detailed description of the identity of each physician owner and physician investor and any other owners or investors of the hospital require that any referring physician owner or investor discloses to the individual being referred by a time that permits the individual to make a meaningful decision regardingverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih the receipt of services as determined by the secretary the ownership or investment interest as applicable of such referring physician in the hospital and disclose the fact that the hospital is partially or wholly owned by one or more physicians or has one or more physician investors on any public website for the hospital and in any public advertising for the hospital the information to be reported or disclosed under this paragraph shall be provided in such form manner and at such times as the secretary shall specify the requirements of this paragraph shall not apply to designated health services furnished outside the united states or to entities which the secretary determines provide services for which payment be made under this title very infrequently publication of information the secretary shall publish and periodically update the information submitted by hospitals under paragraph a on the public internet website of the centers for medicare medicaid services verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih by amending subsection to read as follows failure to report or disclose information a reporting any person who is required but fails to meet a reporting requirement of paragraphs and a of subsection is subject to a civil money penalty of not more than for each day for which reporting is required to have been made disclosure any physician who is required but fails to meet a disclosure requirement of subsection or a hospital that is required but fails to meet a disclosure requirement of subsection is subject to a civil money penalty of not more than for each case in which disclosure is required to have been made application the provisions of section a other than the first sentence of subsection a and other than subsection shall apply to a civil money penalty under subparagraphs a and in the same manner as such provisions apply to a penalty or proceeding under section a a andverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih by adding at the end the following new subsection requirements to qualify for rural provider and hospital ownership exceptions to self referral prohibition requirements described for purposes of subsection d the requirements described in this paragraph are as follows a provider agreement the hospital had physician ownership or investment on january and a provider agreement under section in effect on such date prohibition on physician ownership or investment the percentage of the total value of the ownership or investment interests held in the hospital or in an entity whose assets include the hospital by physician owners or investors in the aggregate does not exceed such percentage as of the date of enactment of this subsection prohibition on expansion of facility capacity except as provided in paragraph the number of operating rooms pro verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih cedure rooms or beds of the hospital at any time on or after the date of the enactment of this subsection are no greater than the number of operating rooms procedure rooms or beds respectively as of such date ensuring bona fide ownership and investment any ownership or investment interests that the hospital offers to a physician are not offered on more favorable terms than the terms offered to a person who is not in a position to refer patients or otherwise generate business for the hospital the hospital or any investors in the hospital does not directly or indirectly provide loans or financing for any physician owner or investor in the hospital iii the hospital or any investors in the hospital does not directly or indirectly guarantee a loan make a payment toward a loan or otherwise subsidize a loan for any physician owner or investor or group of physician owners or investors that is re verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih lated to acquiring any ownership or investment interest in the hospital iv ownership or investment returns are distributed to each owner or investor in the hospital in an amount that is directly proportional to the ownership or investment interest of such owner or investor in the hospital the investment interest of the owner or investor is directly proportional to the owner or investor capital contributions made at the time the ownership or investment interest is obtained vi physician owners and investors do not receive directly or indirectly any guaranteed receipt of or right to purchase other business interests related to the hospital including the purchase or lease of any property under the control of other owners or investors in the hospital or located near the premises of the hospital vii the hospital does not offer a physician owner or investor the opportunity to purchase or lease any property under the control of the hospital or anyverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih other owner or investor in the hospital on more favorable terms than the terms offered to a person that is not a physician owner or investor viii the hospital does not condition any physician ownership or investment interests either directly or indirectly on the physician owner or investor making or influencing referrals to the hospital or otherwise generating business for the hospital patient safety in the case of a hospital that does not offer emergency services the hospital has the capacity to provide assessment and initial treatment for medical emergencies and if the hospital lacks additional capabilities required to treat the emergency involved refer and transfer the patient with the medical emergency to a hospital with the required capability limitation on application to certain converted facilities the hospital was not converted from an ambulatory surgical center to a hospital on or after the date of enactment of this subsectionverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih exception to prohibition on expansion of facility capacity a process establishment the secretary shall establish and implement a process under which a hospital apply for an exception from the requirement under paragraph opportunity for community input the process under clause shall provide persons and entities in the community in which the hospital applying for an exception is located with the opportunity to provide input with respect to the application iii timing for implementation the secretary shall implement the process under clause on the date that is one month after the promulgation of regulations described in clause iv iv regulations not later than the first day of the month beginning months after the date of the enactment of this subsection the secretary shall promulgate regulations to carry out the processverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih under clause the secretary issue such regulations as interim final regulations frequency the process described in subparagraph a shall permit a hospital to apply for an exception up to once every years permitted increase in general subject to clause and subparagraph a hospital granted an exception under the process described in subparagraph a increase the number of operating rooms procedure rooms or beds of the hospital above the baseline number of operating rooms procedure rooms or beds respectively of the hospital or if the hospital has been granted a previous exception under this paragraph above the number of operating rooms procedure rooms or beds respectively of the hospital after the application of the most recent increase under such an exception percent increase limitation the secretary shall not permit an increase in the number of operating rooms verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih procedure rooms or beds of a hospital under clause to the extent such increase would result in the number of operating rooms procedure rooms or beds of the hospital exceeding percent of the baseline number of operating rooms procedure rooms or beds of the hospital iii baseline number of operating rooms procedure rooms or beds in this paragraph the term baseline number of operating rooms procedure rooms or beds means the number of operating rooms procedure rooms or beds of a hospital as of the date of enactment of this subsection increase limited to facilities on the main campus of the hospital any increase in the number of operating rooms procedure rooms or beds of a hospital pursuant to this paragraph only occur in facilities on the main campus of the hospital conditions for approval of an increase in facility capacity the secretary grant an exception under the proc verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih ess described in subparagraph a only to a hospital that is located in a county in which the percentage increase in the population during the most recent year period for which data are available is estimated to be at least percent of the percentage increase in the population growth of the state in which the hospital is located during that period as estimated by bureau of the census and available to the secretary whose annual percent of total inpatient admissions that represent inpatient admissions under the program under title xix is estimated to be equal to or greater than the average percent with respect to such admissions for all hospitals located in the county in which the hospital is located iii that does not discriminate against beneficiaries of federal health care programs and does not permit physicians practicing at the hospital to discriminate against such beneficiaries iv that is located in a state in which the average bed capacity in theverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih state is estimated to be less than the national average bed capacity that has an average bed occupancy rate that is estimated to be greater than the average bed occupancy rate in the state in which the hospital is located and vi that meets other conditions as determined by the secretary procedure rooms in this subsection the term procedure rooms includes rooms in which catheterizations angiographies angiograms and endoscopies are furnished but such term shall not include emergency rooms or departments except for rooms in which catheterizations angiographies angiograms and endoscopies are furnished publication of final decisions not later than days after receiving a complete application under this paragraph the secretary shall publish on the public internet website of the centers for medicare medicaid services the final decision with respect to such application limitation on review there shall be no administrative or judicial reviewverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih under section section or otherwise of the exception process under this paragraph including the establishment of such process and any determination made under such process physician owner or investor defined for purposes of this subsection and subsection the term physician owner or investor means a physician or an immediate family member of such physician with a direct or an indirect ownership or investment interest in the hospital patient safety requirement in the case of a hospital to which the requirements of paragraph apply insofar as the hospital admits a patient and does not have any physician available on the premises hours per day days per week before admitting the patient a the hospital shall disclose such fact to the patient and following such disclosure the hospital shall receive from the patient a signed acknowledgment that the patient understands such fact clarification nothing in this subsection shall be construed as preventing the secretary from terminating a hospital provider agree verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih ment if the hospital is not in compliance with regulations pursuant to section verifying compliance the secretary of health and human services shall establish policies and procedures to verify compliance with the requirements described in subsections and of section of the social security act as added by subsection a the secretary use unannounced site reviews of hospitals and audits to verify compliance with such requirements implementation funding for purposes of carrying out the amendments made by subsection a and the provisions of subsection in addition to funds otherwise available out of any funds in the treasury not otherwise appropriated there are appropriated to the secretary of health and human services for the centers for medicare medicaid services program management account for each fiscal year beginning with fiscal year amounts appropriated under this paragraph for a fiscal year shall be available until expended administration chapter of title united states code shall not apply to the amend verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih ments made by subsection a and the provisions of subsection sec institute of medicine study of geographic adjustment factors under medicare a in general the secretary of health and human services shall enter into a contract with the institute of medicine of the national academy of science to conduct a comprehensive empirical study and provide recommendations as appropriate on the accuracy of the geographic adjustment factors established under sections and of the social security act usc w– ww matters included such study shall include an evaluation and assessment of the following with respect to such adjustment factors empirical validity of the adjustment factors methodology used to determine the adjustment factors measures used for the adjustment factors taking into account a timeliness of data and frequency of revisions to such data sources of data and the degree to which such data are representative of costs andverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih operational costs of providers who participate in medicare evaluation such study shall within the context of the united states health care marketplace evaluate and consider the following the effect of the adjustment factors on the level and distribution of the health care workforce and resources including a recruitment and retention that takes into account workforce mobility between urban and rural areas ability of hospitals and other facilities to maintain an adequate and skilled workforce and patient access to providers and needed medical technologies the effect of the adjustment factors on population health and quality of care the effect of the adjustment factors on the ability of providers to furnish efficient high value care report the contract under subsection a shall provide for the institute of medicine to submit not later than year after the date of the enactment of this act to the secretary and the congress a report containingverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih results and recommendations of the study conducted under this section funding there are authorized to be appropriated to carry out this section such sums as be necessary sec revision of medicare payment systems to address geographic inequities a revision of medicare payment systems taking into account the recommendations described in the report under section and notwithstanding the geographic adjustments that would otherwise apply under section and section of the social security act usc w– ww the secretary of health and human services shall include in proposed rules applicable to the rulemaking cycle for payment systems for physicians services and inpatient hospital services under sections and section of such act respectively proposals as the secretary determines to be appropriate to revise the geographic adjustment factors used in such systems such proposals rules shall be contained in the next rulemaking cycle following the submission to the secretary of the report described in section payment adjustments verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih funding for improvements for years before the secretary shall ensure that the additional expenditures resulting from the implementation of the provisions of this section as estimated by the secretary do not exceed and do not exceed half of such amount in any payment year hold harmless in carrying out this subsection a for payment years before the secretary shall not reduce the geographic adjustment below the factor that applied for such payment system in the payment year before such changes and for payment years beginning with the secretary shall implement the geographic adjustment in a manner that does not result in any net change in aggregate expenditures under title xviii of the social security act from the amount of such expenditures that the secretary estimates would have occurred if no geographic adjustment had occurred under this section medicare improvement fund amounts in the medicare improvement fund under section of the social security act verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih as amended by paragraph shall be available to the secretary to make changes to the geographic adjustments factors as described in subsections a and with respect to services furnished before january no more than one half of such amounts shall be available with respect to services furnished in any one payment year section of the social security act usc iii is amended a by amending paragraph a to read as follows a the period beginning with fiscal year and ending with fiscal year and and by adding at the end the following new paragraph adjustment for underfunding for fiscal year or a subsequent fiscal year specified by the secretary the amount available to the fund under subsection a shall be increased by the secretary estimate of the amount based on data on actual expenditures by which a the additional expenditures resulting from the implementation of subsection a of section of the affordable health care forverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih america act for the period before fiscal year is less than the maximum amount of funds available under subsection a of such section for funding for such expenditures sec institute of medicine study of geographic variation in health care spending and promoting high value health care a in general the secretary of health and human services in this section and the succeeding section referred to as the secretary shall enter into an agreement with the institute of medicine of the national academies referred to in this section as the institute to conduct a study on geographic variation and growth in volume and intensity of services in per capita health care spending among the medicare medicaid privately insured and uninsured populations such study draw on recent relevant reports of the institute and shall include each of the following an evaluation of the extent and range of such variation using various units of geographic measurement including micro areas within larger areasverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih an evaluation of the extent to which geographic variation can be attributed to differences in input prices health status practice patterns access to medical services supply of medical services socioeconomic factors including race ethnicity gender age income and educational status and provider and payer organizational models an evaluation of the extent to which variations in spending are correlated with patient access to care insurance status distribution of health care resources health care outcomes and consensusbased measures of health care quality an evaluation of the extent to which variation can be attributed to physician and practitioner discretion in making treatment decisions and the degree to which discretionary treatment decisions are made that could be characterized as different from the best available medical evidence an evaluation of the extent to which variation can be attributed to patient preferences and patient compliance with treatment protocols an assessment of the degree to which variation cannot be explained by empirical evidence for medicare beneficiaries an evaluation of the extent to which variations in spending are cor verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih related with insurance status prior to enrollment in the medicare program under title xviii of the social security act and institutionalization status whether beneficiaries are dually eligible for the medicare program and medicaid under title xix of such act and whether beneficiaries are enrolled in fee for service medicare or medicare advantage an evaluation of such other factors as the institute deems appropriate the institute shall conduct public hearings and provide an opportunity for comments prior to completion of the reports under subsection recommendations taking into account the findings under subsection a and the changes to the payment systems made by this act the institute shall recommend changes to payment for items and services under parts a and of title xviii of the social security act for addressing variation in medicare per capita spending for items and services not including add ons for graduate medical education disproportionate share payments and health information technology as specified in sections and respectively of such act by promoting highvalue care as defined in subsection with particular attention to high volume high cost conditions in makingverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih such recommendations the institute shall consider each of the following measurement and reporting on quality and population health reducing fragmented and duplicative care promoting the practice of evidence based medicine empowering patients to make value based care decisions leveraging the use of health information technology the role of financial and other incentives affecting provision of care variation in input costs the characteristics of the patient population including socio economic factors including race ethnicity gender age income and educational status and whether the beneficiaries are dually eligible for the medicare program under title xviii of the social security act and medicaid under title xix of such act other topics the institute deems appropriate in making such recommendations the institute shall consider an appropriate phase in that takes into account theverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih impact of payment changes on providers and facilities and preserves access to care for medicare beneficiaries specific considerations in making the recommendations under subsection the institute shall specifically address whether payment systems under title xviii of the social security act for physicians and hospitals should be further modified to incentivize high value care in so doing the institute shall consider the adoption of a value index based on a composite of appropriate measures of quality and cost that would adjust provider payments on a regional or provider level basis if the institute finds that application of such a value index would significantly incentivize providers to furnish high value care it shall make specific recommendations on how such an index would be designed and implemented in so doing it should identify specific measures of quality and cost appropriate for use in such an index and include a thorough analysis including on a geographic basis of how payments and spending under such title would be affected by such an index additional considerations the institute shall consider the experience of governmental and community based programs that promote high value care reports verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih not later than april the institute shall submit to the secretary and each house of congress a report containing findings and recommendations of the study conducted under this section following submission of the report under paragraph the institute shall use the data collected and analyzed in this section to issue a subsequent report or series of reports on how best to address geographic variation or efforts to promote high value care for items and services reimbursed by private insurance or other programs such reports shall include a comparison to the institute findings and recommendations regarding the medicare program such reports and any recommendations would not be subject to the procedures outlined in section high value care defined for purposes of this section the term high value care means the efficient delivery of high quality evidence based patient centered care appropriations there is appropriated from amounts in the general fund of the treasury not otherwise appropriated to carry out this section such sums are authorized to remain available until expendedverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih sec implementation and congressional review of proposal to revise medicare payments to promote high value health care a preparation and submission of implementation plans final implementation plan not later than days after the date of receipt by the secretary and each house of congress of the report under section the secretary shall submit to each house of congress a final implementation plan describing proposed changes to payment for items and services under parts a and of title xviii of the social security act which include payment for inpatient and outpatient hospital services for services furnished in pps and pps exempt hospitals physicians services dialysis facility services skilled nursing facility services home health services hospice care clinical laboratory services durable medical equipment and other items and services but which shall exclude add on payments for graduate medical education disproportionate share payments and health information technology as specified in sections and respectively of the social security act taking intoverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih consideration as appropriate the recommendations of the report submitted under section and the changes to the payment systems made by this act to the extent such implementation plan requires a substantial change to the payment system it shall include a transition phase in that takes into consideration possible disruption to provider participation in the medicare program under title xviii of the social security act and preserves access to care for medicare beneficiaries preliminary implementation plan not later than days after the date the institute of medicine submits to each house of congress the report under section the secretary shall submit to each house of congress a preliminary version of the implementation plan provided for under paragraph a no increase in budget expenditures the secretary shall include with the submission of the final implementation plan under paragraph a certification by the chief actuary of the centers for medicare medicaid services that over the initial year period in which the plan is implemented the aggregate level of net expenditures under the medicare program under title xviii ofverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih the social security act will not exceed the aggregate level of such expenditures that would have occurred if the plan were not implemented waivers required to the extent the final implementation plan under paragraph proposes changes that are not otherwise permitted under title xviii of the social security act the secretary shall specify in the plan the specific waivers required under such title to implement such changes except as provided in subsection the secretary is authorized to waive the requirements so specified in order to implement such changes assessment of impact in addition both the preliminary and final implementation plans under this subsection shall include a detailed assessment of the effects of the proposed payment changes by provider or supplier type and state relative to the payments that would otherwise apply review by medpac and gao not later than days after the date the preliminary implementation plan is received by each house of congress under subsection a the medicare payment advisory committee and the comptroller general of the united states shall each evaluate such plan and submit to each house of congress a report containing its analysis and recommenda verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih tions regarding implementation of the plan including an analysis of the effects of the proposed changes in the plan on payments and projected spending implementation in general the secretary shall include in applicable proposed rules for the next rulemaking cycle beginning after the congressional action deadline appropriate proposals to revise payments under title xviii of the social security act in accordance with the final implementation plan submitted under subsection a and the waivers specified in subsection a to the extent required to carry out such plan are effective unless a joint resolution described in subsection a with respect to such plan is enacted by not later than such deadline if such a joint resolution is enacted the secretary is not authorized to implement such plan and the waiver authority provided under subsection a shall no longer be effective congressional action deadline for purposes of this section the term congressional action deadline means with respect to a final implementation plan under subsection a may or if later the date that is days after theverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih date of receipt of such plan by each house of congress under subsection a congressional procedures introduction on the day on which the final implementation plan is received by the house of representatives and the senate under subsection a a joint resolution specified in paragraph a shall be introduced in the house of representatives by the majority leader and minority leader of the house of representatives and in the senate by the majority leader and minority leader of the senate if either house is not in session on the day on which such a plan is received the joint resolution with respect to such plan shall be introduced in that house as provided in the preceding sentence on the first day thereafter on which that house is in session consideration in the house of representatives a reporting and discharge any committee of the house of representatives to which a joint resolution introduced under paragraph is referred shall report such joint resolution to the house not later than legislative days after the applicable date of introduction of the joint resolution if a committee failsverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih to report such joint resolution within that period a motion to discharge the committee from further consideration of the joint resolution shall be in order such a motion shall be in order only at a time designated by the speaker in the legislative schedule within two legislative days after the day on which the proponent announces an intention to offer the motion notice not be given on an anticipatory basis such a motion shall not be in order after the last committee authorized to consider the joint resolution reports it to the house or after the house has disposed of a motion to discharge the joint resolution the previous question shall be considered as ordered on the motion to its adoption without intervening motion except minutes of debate equally divided and controlled by the proponent and an opponent a motion to reconsider the vote by which the motion is disposed of shall not be in order proceeding to consideration after each committee authorized to consider a joint resolution reports such joint resolution to the house of representatives or has been discharged from its consideration a motion to pro verdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih ceed to consider such joint resolution shall be in order such a motion shall be in order only at a time designated by the speaker in the legislative schedule within two legislative days after the day on which the proponent announces an intention to offer the motion notice not be given on an anticipatory basis such a motion shall not be in order after the house of representatives has disposed of a motion to proceed on the joint resolution the previous question shall be considered as ordered on the motion to its adoption without intervening motion a motion to reconsider the vote by which the motion is disposed of shall not be in order consideration the joint resolution shall be considered in the house and shall be considered as read all points of order against a joint resolution and against its consideration are waived the previous question shall be considered as ordered on the joint resolution to its passage without intervening motion except two hours of debate equally divided and controlled by the proponent and an opponent a motion to reconsider the vote on passage of a joint resolution shall not be in orderverdate nov oct jkt po frm fmt sfmt bills hih rmajette on dsksybprod with bills hr ih consideration in the senate a repo