I 

110TH CONGRESS 

1ST SESSION H. R. 1841 

To amend the Social Security Act and the Internal Revenue Code of 1986 

to provide for an AmeriCare that assures the provision of health insurance coverage to all residents, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

MARCH 29, 2007 

Mr. STARK (for himself, Ms. SCHAKOWSKY, Mr. BECERRA, Ms. CORRINE

BROWN of Florida, Ms. CARSON, Mrs. CHRISTENSEN, Mr. COHEN, Mr. 

CONYERS, Mr. FILNER, Mr. GRIJALVA, Mr. HINCHEY, Ms. NORTON, Mr. 

JACKSON of Illinois, Ms. KILPATRICK, Ms. LEE, Mr. LEWIS of Georgia, 

Mr. MCNULTY, Mr. GEORGE MILLER of California, Mr. NADLER, Mr. 

PASTOR, Mr. RANGEL, Mr. THOMPSON of Mississippi, Mr. TOWNS, Mr. 

WAXMAN, and Ms. WOOLSEY) introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to 

the Committees on Ways and Means and Education and Labor, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To amend the Social Security Act and the Internal Revenue 

Code of 1986 to provide for an AmeriCare that assures 

the provision of health insurance coverage to all residents, and for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 


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1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

2 (a) SHORT TITLE.—This Act may be cited as the 

3 ‘‘AmeriCare Health Care Act of 2007’’. 

4 (b) TABLE OF CONTENTS.—The table of contents of 

5 this Act is as follows: 

Sec. 1. Short title; table of contents. 

TITLE I—HEALTH CARE ELIGIBILITY AND BENEFITS 

Sec. 101. Eligibility and benefits. 

‘‘TITLE XXII—AMERICARE HEALTH BENEFITS 

‘‘PART A—ELIGIBILITY

‘‘Sec. 2201. Eligibility. 

‘‘Sec. 2202. Enrollment and AmeriCare cards. 

‘‘PART B—BENEFITS

‘‘Sec. 2221. Scope of benefits. 

‘‘Sec. 2222. Exclusions. 

‘‘PART C—PAYMENT FOR BENEFITS AND FINANCING

‘‘Sec. 2241. Payments for benefits. 

‘‘Sec. 2242. AmeriCare Trust Fund. 

‘‘PART D—ADMINISTRATIVE SIMPLIFICATION

‘‘Sec. 2251. Requirement for entitlement verification system. 

‘‘Sec. 2252. Requirements for uniform claims and electronic claims data 

set. 

‘‘Sec. 2253. Electronic medical records and reporting. 

‘‘Sec. 2254. Uniform hospital cost reporting. 

‘‘Sec. 2255. Health service provider defined. 

‘‘PART E—GENERAL PROVISIONS

‘‘Sec. 2261. Definitions relating to beneficiaries and income. 

‘‘Sec. 2262. Incorporation of certain medicare provisions and other provisions. 

‘‘Sec. 2263. State maintenance of effort payments. 

‘‘Sec. 2264. Modification of medicaid and other programs to avoid duplication of benefits. 

‘‘Sec. 2265. Construction regarding continuation of obligations under current group health plan contracts and provision of additional benefits. 

‘‘Sec. 2266. Standards and requirements for AmeriCare supplemental policies. 

TITLE II—FINANCING PROVISIONS 


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Subtitle A—Individual Contributions 

Sec. 201. General obligation for individuals. 

Sec. 202. Additional premium subsidies. 

Sec. 203. Effective date. 

Subtitle B—Employer Contributions 

Sec. 211. General obligation for employers. 

Sec. 212. Effective date. 

1 TITLE I—HEALTH CARE 

2 ELIGIBILITY AND BENEFITS 

3 SEC. 101. ELIGIBILITY AND BENEFITS. 

4 (a) IN GENERAL.—The Social Security Act is amend5 ed by adding at the end the following new title: 

6 ‘‘TITLE XXII—AMERICARE HEALTH BENEFITS 

7 ‘‘PART A—ELIGIBILITY

8 ‘‘SEC. 2201. ELIGIBILITY. 

9 ‘‘(a) UNIVERSAL ELIGIBILITY FOR RESIDENTS.— 

10 ‘‘(1) IN GENERAL.—Except as provided in sec11 tion 2263(a), each individual who is a resident of 

12 the United States is entitled to health insurance 

13 benefits under this title. 

14 ‘‘(2) EFFECTIVE DATE FOR BENEFITS.—This 

15 title shall apply to items and services furnished on 

16 or after January 1, 2010. 

17 ‘‘(b) SPECIAL ELIGIBILITY GROUPS.—For purposes 

18 of this title, an individual described in subsection (a) may 

19 obtain special benefits under this title on the basis of one 

20 or more of the following special eligibility groups: 


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1 ‘‘(1) Children (as defined in section 

2 2261(a)(1)). 

3 ‘‘(2) Low-income individuals (as defined in sec4 tion 2261(a)(2)). 

5 ‘‘(3) Pregnant women (as defined in section 

6 2261(a)(3)). 

7 ‘‘(c) RECIPROCAL COVERAGE OF NONRESIDENTS.— 

8 An individual who— 

9 ‘‘(1) is not a resident of the United States, 

10 ‘‘(2) is in the United States, and 

11 ‘‘(3) is a national of a foreign state which pro12 vides health benefits to nationals of the United 

13 States who are nonresidents in that state, 

14 is entitled to such health insurance benefits under this 

15 title, but only to the extent the Secretary determines that 

16 such benefits would be available to nationals of the United 

17 States similarly situated as a nonresident in the foreign 

18 state. 

19 ‘‘SEC. 2202. ENROLLMENT AND AMERICARE CARDS. 

20 ‘‘(a) ENROLLMENT.—The Secretary shall provide a 

21 mechanism for the enrollment of individuals entitled to 

22 benefits under this title and, in conjunction with such en23 rollment, the issuance of an AmeriCare card which may 

24 be used for purposes of identification and processing of 

25 claims for benefits under this title. AmeriCare cards shall 


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1 identify (as appropriate) the date of birth (for purposes 

2 of identifying children) and provide a coded means for 

3 identifying whether the individual is a low-income indi4 vidual for the year involved. 

5 ‘‘(b) CLASSES OF ENROLLMENT.—The mechanism 

6 under subsection (a) shall provide for individuals to be en7 rolled on the basis of the following classes of enrollment: 

8 ‘‘(1) Coverage only of an individual. 

9 ‘‘(2) Coverage of a married couple without chil10 dren. 

11 ‘‘(3) Coverage of an unmarried individual and 

12 one or more children. 

13 ‘‘(4) Coverage of a married couple and one or 

14 more children. 

15 ‘‘(c) ENROLLMENT AT BIRTH.—The mechanism 

16 under subsection (a) shall include a process for the auto17 matic enrollment of individuals at the time of birth in the 

18 United States. 

19 ‘‘(d) OPT OUT FOR THOSE COVERED UNDER GROUP

20 HEALTH PLAN.—Notwithstanding any other provision of 

21 this title, an individual may elect not to be enrolled for 

22 benefits under this title if the individual demonstrates to 

23 the satisfaction of the Secretary that the individual has 

24 health benefits coverage under a group health plan (as de25 fined in section 5000(b)(1) of the Internal Revenue Code 


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1 of 1986) that is at least equivalent to the coverage other2 wise provided under this title, as certified by the Sec3 retary. 

4 ‘‘PART B—BENEFITS

5 ‘‘SEC. 2221. SCOPE OF BENEFITS. 

6 ‘‘(a) IN GENERAL.—Except as provided in the suc7 ceeding provisions of this part, the benefits provided to 

8 an individual described in section 2201(a) by the program 

9 established by this title shall consist of entitlement to the 

10 same benefits as are provided under parts A and B of title 

11 XVIII to individuals entitled to benefits under part A, and 

12 enrolled under part B, of title XVIII. 

13 ‘‘(b) CHANGE IN THE COST-SHARING.— 

14 ‘‘(1) DEDUCTIBLE.—Except as provided in the 

15 succeeding provisions of this part, the amount of ex16 penses (other than expenses for benefits described in 

17 subsection (c)) with respect to which an individual is 

18 entitled to have payment made under this title for 

19 any year shall first be reduced by a deductible of 

20 $350, except that in no case shall the amount of the 

21 deductible for all the members of a family exceed 

22 $500. Such deductible shall be instead of the deduct23 ible for inpatient hospital services under the first 

24 sentence of section 1813(a)(1) and the deductible 

25 under section 1833(b). 


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1 ‘‘(2) COINSURANCE.—After the application of 

2 the deductible under paragraph (1), the expenses re3 ferred to in such paragraph shall be subject to a co4 insurance of 20 percent until the limit on out-of5 pocket expenses under paragraph (3) is met. 

6 ‘‘(3) LIMIT ON OUT-OF-POCKET EXPENSES AND

7 TOTAL EXPENSES.— 

8 ‘‘(A) LIMITATION ON COST-SHARING.— 

9 Subject to subparagraph (B), whenever in a cal10 endar year an individual’s expenses for the de11 ductible and coinsurance with respect to serv12 ices covered under this title (including expenses 

13 for benefits described in subsection (c)) and 

14 furnished during the year equals $2,500, or 

15 $4,000 for all the members of a family, pay16 ment of benefits under this title for the indi17 vidual (or for the members of such family, re18 spectively) for services furnished during the re19 mainder of the year shall be paid without the 

20 application of any coinsurance. 

21 ‘‘(B) LIMITATION ON PREMIUMS AND

22 COST-SHARING FOR CERTAIN INDIVIDUALS

23 BASED ON INCOME.— 

24 ‘‘(i) INCOME BETWEEN 200 AND 300

25 PERCENT OF POVERTY LINE.—In the case 


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1 of a family whose applicable modified gross 

2 income (expressed as a percentage of the 

3 poverty level, as defined in section 

4 2261(b)(2)) is equal to or exceeds 200 per5 cent, but does not exceed 300 percent, of 

6 the poverty level applicable to a family of 

7 the size involved, whenever in a calendar 

8 year an individual’s expenses in the family 

9 for premiums under this title and for the 

10 deductible and coinsurance with respect to 

11 services covered under this title (including 

12 expenses for benefits described in sub13 section (c)) and furnished during the year 

14 equals 5 percent of the amount of such ap15 plicable modified gross income for the fam16 ily— 

17 ‘‘(I) no additional premiums shall 

18 be imposed for remaining months in 

19 the year; and 

20 ‘‘(II) payment of benefits under 

21 this title for members of such family 

22 for services furnished during the re23 mainder of the year shall be paid 

24 without the application of any deduct25 ible or coinsurance. 


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1 ‘‘(ii) INCOME BETWEEN 300 AND 500

2 PERCENT OF POVERTY LINE.—In the case 

3 of a family whose applicable modified gross 

4 income (expressed as a percentage of the 

5 poverty level, as defined in section 

6 2261(b)(2)) exceeds 300 percent, but does 

7 not exceed 500 percent, of such poverty 

8 level applicable to a family of the size in9 volved, whenever in a calendar year an in10 dividual’s expenses in the family for pre11 miums under this title and for the deduct12 ible and coinsurance with respect to serv13 ices covered under this title (including ex14 penses for benefits described in subsection 

15 (c)) and furnished during the year equals 

16 7.5 percent of the amount of such applica17 ble modified gross income for the family— 

18 ‘‘(I) no additional premiums shall 

19 be imposed for remaining months in 

20 the year; and 

21 ‘‘(II) payment of benefits under 

22 this title for members of such family 

23 for services furnished during the re24 mainder of the year shall be paid 


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1 without the application of any deduct2 ible or coinsurance. 

3 ‘‘(C) COUNTING ALL EXPENSES FOR PRE4 MIUMS, DEDUCTIBLES AND COINSURANCE

5 WITHOUT REGARD TO TRUE OUT-OF-POCKET

6 COSTS.—In applying subparagraphs (A) and 

7 (B), expenses for an individual’s premiums, de8 ductible, and coinsurance shall be counted with9 out regard to whether such expenses are paid, 

10 payable, reimbursed, or reimbursable by an11 other person, including through a group health 

12 plan, insurance or otherwise, or other third 

13 party payment arrangement. 

14 ‘‘(4) INDEXING DOLLAR AMOUNTS BY CPI.— 

15 Each dollar amount specified in paragraphs (1) and 

16 (3)(A) shall be increased to the year involved by the 

17 compounded sum of the increase in the consumer 

18 price index for all urban consumers (U.S. City aver19 age, as published by the Bureau of Labor Statistics 

20 of the Department of Labor) for each year after 

21 2007 and up to the year involved. Any increase 

22 under this paragraph for a year shall be rounded, 

23 with respect to paragraph (1), to the nearest mul24 tiple of $5 and, with respect to paragraph (2), to the 

25 nearest multiple of $100. 


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1 ‘‘(c) PRESCRIPTION DRUGS.—Benefits shall also be 

2 made available under this title (as specified by the Sec3 retary) for prescription drugs and biologicals which are 

4 not less than the benefits for such drugs and biologicals 

5 under the standard option for the service benefit plan de6 scribed in section 8903(1) of title 5, United States Code, 

7 offered during 2006. 

8 ‘‘(d) CHILDREN.— 

9 ‘‘(1) NO DEDUCTIBLES OR COINSURANCE.—In 

10 the case of children (as defined in section 

11 2261(a)(1)), there shall be no deductible or coinsur12 ance applicable to covered benefits (including bene13 fits described in paragraphs (2) and (3)). 

14 ‘‘(2) ADDITIONAL PREVENTIVE BENEFITS.— 

15 ‘‘(A) IN GENERAL.—Subject to the perio16 dicity schedule established with respect to the 

17 services under subparagraph (B), for children 

18 benefits shall be available under this title for 

19 the following items and services: 

20 ‘‘(i) Newborn and well-baby care, in21 cluding normal newborn care and pediatri22 cian services for high-risk deliveries. 

23 ‘‘(ii) Well-child care, including routine 

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1 ing the vaccine itself), routine laboratory 

2 tests, and preventive dental care. 

3 ‘‘(B) PERIODICITY SCHEDULE.—The Sec4 retary, in consultation with the American Acad5 emy of Pediatrics and the American Dental As6 sociation, shall establish a schedule of perio7 dicity which reflects the general, appropriate 

8 frequency with which services listed in subpara9 graph (A) should be provided to healthy chil10 dren. 

11 ‘‘(3) COVERAGE OF EPSDT.—For children, ben12 efits also shall be available under this title for early 

13 and periodic screening, diagnostic, and treatment 

14 services (as defined in section 1905(r)) not otherwise 

15 covered under paragraph (2). 

16 ‘‘(4) OTHER ADDITIONAL SERVICES FOR CHIL17 DREN.—For children, benefits also shall be available 

18 under this title for the following: 

19 ‘‘(A) Inpatient hospital services (without 

20 regard to the restrictions described in sub21 sections (a)(1) and (b)(1) of section 1812 and 

22 the coinsurance described in section 

23 1813(a)(1)). 

24 ‘‘(B) Eyeglasses and hearing aids, and ex25 aminations therefor. 


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1 ‘‘(e) PREGNANCY-RELATED SERVICES.—In the case 

2 of a pregnant woman (as defined in section 2261(a)(3)), 

3 benefits under this title shall include entitlement to have 

4 payment made for the following, without the application 

5 of a deductible or coinsurance: 

6 ‘‘(1) Prenatal care, including care for all com7 plications of pregnancy. 

8 ‘‘(2) Inpatient labor and delivery services. 

9 ‘‘(3) Postnatal care. 

10 ‘‘(f) LOWER-INCOME INDIVIDUALS.— 

11 ‘‘(1) LIMITATIONS ON DEDUCTIBLES AND COIN12 SURANCE.— 

13 ‘‘(A) NONE FOR LOW-INCOME INDIVID14 UALS.—In the case of a low-income individual, 

15 there shall be no deductible or coinsurance 

16 under this title. 

17 ‘‘(B) PHASE-IN FOR OTHER LOWER-IN18 COME INDIVIDUALS.—In the case of an indi19 vidual whose applicable modified gross income 

20 (as defined in section 2261(b)(1)) exceeds twice 

21 the poverty level (as defined in section 

22 2261(b)(2)) but does not exceed three times the 

23 poverty level, the deductible and coinsurance 

24 applicable under this title shall bear the same 


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1 ratio to the deductible or coinsurance otherwise 

2 applicable as— 

3 ‘‘(i) the excess of the applicable modi4 fied gross income over the poverty level, 

5 bears to 

6 ‘‘(ii) the poverty level. 

7 If the ratio determined under the preceding 

8 sentence is not a multiple of 25 percentage 

9 points, such ratio shall be rounded to the near10 est 25 percentage points. 

11 ‘‘(2) ADDITIONAL BENEFITS FOR LOW-INCOME

12 INDIVIDUALS.—In the case of low-income individuals 

13 (as defined in section 2261(a)(2)), benefits under 

14 this title shall also include entitlement to have pay15 ment made for the following, without the application 

16 of a deductible or coinsurance: 

17 ‘‘(A) Inpatient hospital services (without 

18 regard to the restrictions described in sub19 sections (a)(1) and (b)(1) of section 1812 and 

20 the coinsurance described in section 

21 1813(a)(1)). 

22 ‘‘(B) Eyeglasses and hearing aids and ex23 aminations therefor. 

24 ‘‘(g) PREVENTIVE BENEFITS.—Benefits shall also be 

25 made available under this title, without the application of 


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1 any deductible or coinsurance for preventive services that 

2 are recommended by the United States Preventive Serv3 ices Task Force. 

4 ‘‘(h) MENTAL HEALTH PARITY AND SUBSTANCE

5 ABUSE BENEFITS.—Benefits shall be made available 

6 under this title for mental health services and for sub7 stance abuse treatment in the same manner as such bene8 fits are made available for medical and surgical services. 

9 ‘‘(i) FAMILY PLANNING SERVICES.—Benefits shall be 

10 made available under this title for family planning serv11 ices. 

12 ‘‘(j) CONFORMING MEDICARE BENEFITS.—Notwith13 standing any other provision of law, benefits under title 

14 XVIII shall be expanded and conformed to the benefits 

15 made available under this title (including the application 

16 of a single deductible and uniform coinsurance amounts, 

17 a limitation on the coinsurance, and additional benefits for 

18 low-income individuals under subsection (f)), but nothing 

19 in this subsection shall be construed as providing for any 

20 such additional benefits under this title rather than under 

21 such title. 

22 ‘‘(k) ENROLLMENT IN HEALTH PLANS.—The Sec23 retary shall provide for the offering of benefits under this 

24 title through enrollment in a health benefit plan that 

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1 ments that apply to Medicare Advantage plans under part 

2 C of title XVIII (other than any such requirements that 

3 relate to part D of such title). In the case of individuals 

4 enrolled under this title in such a plan, the payment rate 

5 to the plan under this title shall be based on adjusted aver6 age per capita cost (AAPCC) payment rate methodology 

7 described in section 1853(c)(1)(D) for benefits under this 

8 title and for individuals entitled to benefits under this title 

9 who are not enrolled in such a plan. 

10 ‘‘SEC. 2222. EXCLUSIONS. 

11 ‘‘(a) IN GENERAL.—Except as provided in this sec12 tion, section 1862 shall apply to expenses incurred for 

13 items and services provided under this title the same man14 ner as such section applies to items and services provided 

15 under title XVIII. 

16 ‘‘(b) BENEFITS EXCEPTION.— 

17 ‘‘(1) CHILDREN’S SERVICES.—In applying sec18 tion 1862(a) with respect to services described in 

19 section 2221(d)(2)(A) (relating to well-child serv20 ices), payment shall not be denied under paragraph 

21 (1), (7), or (12) of such section 1862(a) if the serv22 ices are provided in accordance with the periodicity 

23 schedule described in section 2221(d)(2)(B). 

24 ‘‘(2) TREATMENT OF EYEGLASSES AND HEAR25 ING AIDS FOR CHILDREN AND LOW-INCOME INDIVIDVerDate Aug 31 2005 22:10 Apr 10, 2007 Jkt 059200 PO 00000 Frm 00016 Fmt 6652 Sfmt 6201 E:\BILLS\H1841.IH H1841

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1 UALS.—Payment shall not be denied under this title 

2 under section 1862(a)(7) with respect to eyeglasses 

3 and hearing aids and examinations therefor in the 

4 case of children and low-income individuals. 

5 ‘‘(c) COORDINATION OF PAYMENTS.— 

6 ‘‘(1) PRIMARY TO GROUP HEALTH PLANS.— 

7 Section 1862(b)(1) (relating to requirements of 

8 group health plans) shall not apply under this title. 

9 ‘‘(2) SECONDARY TO MEDICARE.—Payment 

10 shall not be made under this title with respect to 

11 benefits to the extent that payment for such benefits 

12 may be made under title XVIII. 

13 ‘‘PART C—PAYMENT FOR BENEFITS AND FINANCING

14 ‘‘SEC. 2241. PAYMENTS FOR BENEFITS. 

15 ‘‘(a) IN GENERAL.—Except as otherwise provided in 

16 this section and in section 2221— 

17 ‘‘(1) payment of benefits under this title with 

18 respect to benefits shall be made on the same basis 

19 as payment is made with respect to such benefits 

20 under title XVIII, and 

21 ‘‘(2) the provisions of sections 1814, 1833, 

22 1834, 1842, 1848, and 1886 shall apply to payment 

23 of benefits under this title in the same manner as 

24 they apply to benefits under title XVIII. 


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1 ‘‘(b) NO EXTRA BILLING PERMITTED.—Payment 

2 under this title may only be made on an assignment-re3 lated basis (as defined in section 1842(i)(1)). If an entity 

4 knowingly and willfully presents or causes to be presented 

5 a claim or bills an individual enrolled under this title for 

6 charges for services other than on an assignment-related 

7 basis, the Secretary may apply sanctions against such en8 tity in accordance with section 1842(j)(2). 

9 ‘‘(c) ADJUSTMENT OF PAYMENTS.— 

10 ‘‘(1) ESTABLISHMENT OF NEW DRGS AND

11 WEIGHTS.—In making payment under this title with 

12 respect to inpatient hospital services, the Secretary 

13 shall establish such additional diagnosis-related 

14 groups (and weighting factors with respect to dis15 charges within such groups) and make such adjust16 ments in the diagnosis-related groups and weighting 

17 factors with respect to discharges within such groups 

18 otherwise established under section 1886(d)(4) as 

19 may be necessary to reflect the types of discharges 

20 occurring under this title which are not occurring 

21 under title XVIII. 

22 ‘‘(2) PAYMENT FOR OBSTETRICAL SERVICES.— 

23 ‘‘(A) GLOBAL FEE.—In making payment 

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1 out a course of pregnancy, the Secretary shall 

2 establish, as a schedule under section 1848, a 

3 global fee with respect to such group of serv4 ices. 

5 ‘‘(B) BONUS FOR EARLY PRESEN6 TATION.—The fee schedule amount with respect 

7 to obstetrical services under this title shall be 

8 increased by 5 percent in the case of services 

9 furnished to women who have presented for pre10 natal care during the first trimester. 

11 ‘‘(d) CONDITIONS OF AND LIMITATIONS ON PAY12 MENTS.—The provisions of sections 1814 and 1835 shall 

13 apply to payment for services under this title in the same 

14 manner as they apply to payment for services under parts 

15 A and B, respectively, of title XVIII. 

16 ‘‘(e) USE OF TRUST FUND.—In carrying out this sec17 tion, any reference in title XVIII to a trust fund shall be 

18 treated as a reference to the AmeriCare Trust Fund estab19 lished under section 2242. 

20 ‘‘(f) PAYMENT FOR OUTPATIENT PRESCRIPTION

21 DRUGS AND BIOLOGICALS.—The Secretary shall establish 

22 a fee schedule for the payment for outpatient prescription 

23 drugs and biologicals under this title and, notwithstanding 

24 section 1860D–11(i)(1), under title XVIII. The Secretary 

25 shall negotiate with pharmaceutical manufacturers with 


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1 respect to the purchase price of such drugs and biologicals 

2 and shall encourage the use of more affordable therapeutic 

3 equivalents to the extent such practices do not override 

4 medical necessity, as determined by the prescribing physi5 cian. To the extent practicable and consistent with the 

6 previous sentence, the Secretary shall implement strate7 gies similar to those used by other Federal purchasers of 

8 prescription drugs, and other strategies, to reduce the pur9 chase cost of outpatient prescription drugs and biologicals. 

10 ‘‘SEC. 2242. AMERICARE TRUST FUND. 

11 ‘‘(a) ESTABLISHMENT.—(1) There is hereby created 

12 on the books of the Treasury of the United States a trust 

13 fund to be known as the ‘AmeriCare Trust Fund’ (in this 

14 section referred to as the ‘Trust Fund’). The Trust Fund 

15 shall consist of such gifts and bequests as may be made 

16 as provided in section 201(i)(1) and amounts appropriated 

17 under paragraph (2). 

18 ‘‘(2) There are hereby appropriated to the Trust 

19 Fund amounts equivalent to 100 percent of the increase 

20 in revenues to the Treasury by reason of the provisions 

21 of and amendments made by title II of the AmeriCare 

22 Health Care Act of 2007. The amounts appropriated by 

23 the preceding sentence shall be transferred from time to 

24 time from the general fund in the Treasury to the Trust 

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1 mates by the Secretary of the Treasury of the increase 

2 in revenues which are paid to or deposited into the Treas3 ury; and proper adjustments shall be made in amounts 

4 subsequently transferred to the extent prior estimates 

5 were in excess of or were less than such increase. 

6 ‘‘(b) INCORPORATION OF PROVISIONS.— 

7 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

8 the provisions of subsections (b) through (e) and (g) 

9 through (i) of section 1817 shall apply to the Trust 

10 Fund in the same manner as they apply to the Fed11 eral Hospital Insurance Trust Fund. 

12 ‘‘(2) EXCEPTIONS.—In applying paragraph 

13 (1)— 

14 ‘‘(A) the Board of Trustees and Managing 

15 Trustee of the Trust Fund shall be composed of 

16 the members of the Board of Trustees and the 

17 Managing Trustee, respectively, of the Federal 

18 Hospital Insurance Trust Fund; and 

19 ‘‘(B) any reference in section 1817 to the 

20 Federal Hospital Insurance Trust Fund or to 

21 title XVIII (or part A thereof) is deemed a ref22 erence to the Trust Fund under this section 

23 and this title, respectively. 


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1 ‘‘PART D—ADMINISTRATIVE SIMPLIFICATION

2 ‘‘SEC. 2251. REQUIREMENT FOR ENTITLEMENT 

3 VERIFICATION SYSTEM. 

4 ‘‘(a) IN GENERAL.— 

5 ‘‘(1) REQUIREMENT.—The Secretary with re6 spect to the plan provided under this title, and each 

7 AmeriCare supplemental plan (as defined in section 

8 2279(3)), shall provide for an electronic system, that 

9 is certified by the Secretary as meeting the stand10 ards established under subsection (b), for the 

11 verification of an individual’s entitlement to benefits 

12 under such plan. 

13 ‘‘(2) DEADLINE FOR APPLICATION OF REQUIRE14 MENT.—The deadline specified under this paragraph 

15 for the requirement under paragraph (1) is 6 

16 months after the date the standards are established 

17 under subsection (b). 

18 ‘‘(b) STANDARDS FOR ENTITLEMENT VERIFICATION

19 SYSTEMS.— 

20 ‘‘(1) IN GENERAL.—The Secretary shall estab21 lish standards consistent with this subsection re22 specting the requirements for certification of entitle23 ment verification systems. 


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1 ‘‘(2) INFORMATION AVAILABLE.—Such stand2 ards shall require a system to provide information, 

3 with respect to individuals, concerning the following: 

4 ‘‘(A) The specific benefits to which the in5 dividual is entitled under the plan. 

6 ‘‘(B) Current status of the individual with 

7 respect to fulfillment of deductibles, coinsur8 ance, and out-of-pocket limits on cost-sharing. 

9 ‘‘(C) Restrictions on providers who may 

10 provide covered services, including utilization 

11 controls (such as preadmission certification). 

12 ‘‘(3) FORM OF INQUIRY.—Each verification sys13 tem shall be capable of accepting inquiries under 

14 this subsection from health care providers in a vari15 ety of electronic forms. The system shall also pro16 vide, for an additional fee, for the acceptance of in17 quiries in a nonelectronic form. 

18 ‘‘(4) FORM OF RESPONSE.—Each such system 

19 shall be capable of responding to such inquiries 

20 under this subsection in a variety of electronic and 

21 other forms, including— 

22 ‘‘(A) through modem transmission of infor23 mation, 

24 ‘‘(B) through computer synthesized voice 

25 communication, and 


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1 ‘‘(C) through transmission of information 

2 to a facsimile (fax) machine. 

3 The system shall also provide, for an additional fee, 

4 for the response to inquiries in a nonelectronic form. 

5 ‘‘(5) LIMITATION ON FEES.—Neither the Sec6 retary nor an AmeriCare supplemental plan may im7 pose a fee for the acceptance or response to an in8 quiry under this subsection except where the accept9 ance or response is in a nonelectronic form. 

10 ‘‘(6) WEBSITE AVAILABILITY TO PROVIDERS.— 

11 The Secretary shall establish and maintain a website 

12 through which— 

13 ‘‘(A) health service providers may make in14 quiries, and receive responses, with respect to 

15 the eligibility and benefits of an individual 

16 under plans; and 

17 ‘‘(B) AmeriCare supplemental plans may 

18 make inquiries, and receive responses, to deter19 mine the liability of other plans for the provi20 sion or payment of benefits. 

21 ‘‘(7) DEADLINE.—The Secretary shall first es22 tablish the standards under this subsection (and 

23 shall establish the website under paragraph (6)) by 

24 not later than 12 months after the date of the enact25 ment of this title. 


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1 ‘‘SEC. 2252. REQUIREMENTS FOR UNIFORM CLAIMS AND 

2 ELECTRONIC CLAIMS DATA SET. 

3 ‘‘(a) REQUIREMENTS.— 

4 ‘‘(1) SUBMISSION OF CLAIMS.—Each health 

5 service provider that furnishes services in the United 

6 States for which payment may be made under this 

7 title or under an AmeriCare supplemental plan shall 

8 submit any claim for payment for such services only 

9 in a form and manner consistent with standards es10 tablished under subsection (c). 

11 ‘‘(2) ACCEPTANCE OF CLAIMS.—The Secretary 

12 and an AmeriCare supplemental plan may not reject 

13 a claim for payment under this title or the plan on 

14 the basis of the form or manner in which the claim 

15 is submitted if the claim is submitted in accordance 

16 with the standards established under subsection (c). 

17 ‘‘(3) EFFECTIVE DATE.—This subsection shall 

18 apply to claims for services furnished on or after the 

19 date that is 6 months after the date standards are 

20 established under subsection (c). 

21 ‘‘(b) ENFORCEMENT THROUGH CIVIL MONEY PEN22 ALTIES.— 

23 ‘‘(1) IN GENERAL.— 

24 ‘‘(A) PROVIDERS.—In the case of a health 

25 service provider that submits a claim in viola26 tion of subsection (a)(1), the provider is subject 


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1 to a civil money penalty of not to exceed $100 

2 (or, if greater, the amount of the claim) for 

3 each such violation. 

4 ‘‘(B) PLANS.—In the case of an 

5 AmeriCare supplemental plan that rejects a 

6 claim in violation of subsection (a)(2), the plan 

7 is subject to a civil money penalty of not to ex8 ceed $100 (or, if greater, the amount of the 

9 claim) for each such violation. 

10 ‘‘(2) PROCESS.—The provisions of section 

11 1128A of the Social Security Act (other than sub12 sections (a) and (b)) shall apply to a civil money 

13 penalty under paragraph (1) in the same manner as 

14 such provisions apply to a penalty or proceeding 

15 under section 1128A(a) of such Act. 

16 ‘‘(c) STANDARDS RELATING TO UNIFORM CLAIMS

17 AND ELECTRONIC CLAIMS DATA SET.— 

18 ‘‘(1) ESTABLISHMENT OF STANDARDS.—The 

19 Secretary shall establish standards that— 

20 ‘‘(A) relate to the form and manner of sub21 mission of claims for benefits under this title 

22 and under an AmeriCare supplemental plan, 

23 and 


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1 ‘‘(B) define the data elements to be con2 tained in a uniform electronic claims data set to 

3 be used with respect to such claims. 

4 ‘‘(2) SCOPE OF INFORMATION.— 

5 ‘‘(A) ENSURING ACCOUNTABILITY FOR

6 CLAIMS SUBMITTED ELECTRONICALLY.—In es7 tablishing standards under this section, the Sec8 retary, in consultation with appropriate agen9 cies, shall include such methods of ensuring 

10 provider responsibility and accountability for 

11 claims submitted electronically that are de12 signed to control fraud and abuse in the sub13 mission of such claims. 

14 ‘‘(B) COMPONENTS.—In establishing such 

15 standards the Secretary shall— 

16 ‘‘(i) with respect to data elements, de17 fine data fields, formats, and medical no18 menclature, and plan benefit and insurance 

19 information; 

20 ‘‘(ii) develop a single, uniform coding 

21 system for diagnostic and procedure codes; 

22 and 

23 ‘‘(iii) provide for standards for the 

24 uniform electronic transmission of such 

25 elements. 


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1 ‘‘(3) COORDINATION WITH STANDARDS FOR

2 ELECTRONIC MEDICAL RECORDS.—In establishing 

3 standards under this subsection, the Secretary shall 

4 assure that— 

5 ‘‘(A) the development of such standards is 

6 coordinated with the development of the stand7 ards for electronic medical records under sec8 tion 2253, and 

9 ‘‘(B) the coding of data elements under the 

10 uniform electronic claims data set and the cod11 ing of the same elements in the uniform hos12 pital clinical data set are consistent. 

13 ‘‘(4) USE OF TASK FORCES.—In adopting 

14 standards under this subsection— 

15 ‘‘(A) the Secretary shall take into account 

16 the recommendations of current task forces; 

17 and 

18 ‘‘(B) the Secretary shall provide that the 

19 electronic transmission standards are con20 sistent, to the extent practicable, with the appli21 cable standards established by the Accredited 

22 Standards Committee X–12 of the American 

23 National Standards Institute. 


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1 ‘‘(5) UNIFORM, UNIQUE PROVIDER IDENTIFICA2 TION CODES.—In establishing standards under this 

3 subsection— 

4 ‘‘(A) the Secretary shall provide for a 

5 unique identifier code for each health service 

6 provider that furnishes services for which a 

7 claim may be submitted under this title or 

8 under an AmeriCare supplemental plan, and 

9 ‘‘(B) in the case of a provider that has a 

10 unique identifier issued for purposes of title 

11 XVIII, the code provided under subparagraph 

12 (A) shall be the same as such unique identifier. 

13 ‘‘(6) WEBSITE AVAILABILITY TO PROVIDERS.— 

14 The Secretary shall establish and maintain a website 

15 that will enable health service providers, without 

16 charge, to submit claims and to receive verification 

17 of claims status electronically. 

18 ‘‘(7) STANDARDS FOR PAPER CLAIMS.—The 

19 standards shall provide for a uniform paper claims 

20 form which is consistent with data elements required 

21 for the submission of claims electronically. 

22 ‘‘(8) STANDARDS FOR CLAIMS FOR CLINICAL

23 LABORATORY TESTS.—The standards shall provide 

24 that claims for clinical laboratory tests for which 

25 benefits are provided under this title or under an 


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1 AmeriCare supplemental plan shall be submitted di2 rectly by the person or entity that performed (or su3 pervised the performance of) the tests to the plan in 

4 a manner consistent with (and subject to such excep5 tions as are provided under) the requirement for di6 rect submission of such claims under title XVIII. 

7 ‘‘(9) DEADLINE.—The Secretary shall first pro8 vide for the standards for the uniform claims under 

9 this subsection (and shall develop and make avail10 able the software under paragraph (6)) by not later 

11 than 1 year after the date of the enactment of this 

12 title. 

13 ‘‘(d) USE UNDER THIS TITLE AND MEDICARE AND

14 MEDICAID PROGRAMS.— 

15 ‘‘(1) REQUIREMENT FOR PROVIDERS.—In the 

16 case of a health service provider that submits a 

17 claim for services furnished under this title in viola18 tion of subsection (a)(1), no payment shall be made 

19 under this title for such services. 

20 ‘‘(2) REQUIREMENTS OF MEDICARE ADMINIS21 TRATIVE CONTRACTORS UNDER MEDICARE PRO22 GRAM.—The Secretary shall provide, in regulations 

23 promulgated to carry out this title, that the claims 

24 process provided under this title conforms to the 

25 standards established under subsection (c). 


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1 ‘‘(3) REQUIREMENTS OF STATE MEDICAID

2 PLANS.—As a condition for the approval of State 

3 plans under the medicaid program, effective as of 

4 the effective date specified in subsection (a)(3), each 

5 such plan shall provide, in accordance with regula6 tions of the Secretary, that the claims process pro7 vided under the plan is modified to the extent re8 quired to conform to the standards established under 

9 subsection (c). 

10 ‘‘SEC. 2253. ELECTRONIC MEDICAL RECORDS AND REPORT11 ING. 

12 ‘‘(a) STANDARDS FOR ELECTRONIC MEDICAL

13 RECORDS.— 

14 ‘‘(1) PROMULGATION OF STANDARDS.— 

15 ‘‘(A) IN GENERAL.—Not later than Janu16 ary 1, 2009, the Secretary shall promulgate 

17 standards described in paragraph (2) for hos18 pitals and other health care providers con19 cerning electronic medical records. Such stand20 ards shall include the standards established 

21 under part C of title XI. 

22 ‘‘(B) REVISION.—The Secretary may from 

23 time to time revise the standards promulgated 

24 under this paragraph. 


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1 ‘‘(2) CONTENTS OF STANDARDS.—The stand2 ards promulgated under paragraph (1) shall include 

3 at least the following: 

4 ‘‘(A) A definition of a uniform provider 

5 clinical data set, including a definition of the 

6 set of comprehensive data elements, for use by 

7 utilization and quality control peer review orga8 nizations. 

9 ‘‘(B) Standards for an electronic patient 

10 care information system with data obtained at 

11 the point of care. 

12 ‘‘(C) A specification of, and manner of 

13 presentation of, the individual data elements of 

14 the set and system under this paragraph. 

15 ‘‘(D) Standards concerning the trans16 mission of electronic medical data. 

17 ‘‘(E) Standards relating to confidentiality 

18 of patient-specific information, which include 

19 the physical security of electronic data and the 

20 use of keys, passwords, encryption, and other 

21 means to ensure the protection of the confiden22 tiality and privacy of electronic data. 

23 ‘‘(3) COORDINATION WITH STANDARDS FOR

24 UNIFORM ELECTRONIC CLAIMS DATA SET.—In esVerDate Aug 31 2005 22:10 Apr 10, 2007 Jkt 059200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6201 E:\BILLS\H1841.IH H1841

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1 tablishing standards under this subsection, the Sec2 retary shall assure that— 

3 ‘‘(A) the development of such standards is 

4 coordinated with the development of the stand5 ards for the uniform electronic claims data set 

6 under subsection (b), and 

7 ‘‘(B) the coding of data elements under the 

8 uniform provider clinical data set and the cod9 ing of the same elements under the uniform 

10 electronic claims data set are consistent. 

11 ‘‘(4) CONSULTATION.—In establishing stand12 ards under this subsection, the Secretary shall— 

13 ‘‘(A) consult with the American National 

14 Standards Institute, hospitals and other health 

15 care providers, health benefit plans, and other 

16 interested parties, and 

17 ‘‘(B) take into consideration, in developing 

18 standards under paragraph (2)(A), the data set 

19 used by the utilization and quality control peer 

20 review program under part B of title XI. 

21 ‘‘(b) REQUIREMENT FOR APPLICATION OF ELEC22 TRONIC RECORDS STANDARDS.— 

23 ‘‘(1) AS CONDITION OF MEDICARE, MEDICAID, 

24 SCHIP, AND AMERICARE PARTICIPATION.—Effective 

25 January 1, 2010, each hospital or other institutional 


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1 or noninstitutional health care provider, as a re2 quirement of each participation agreement under 

3 this title, title XVIII, title XIX, and title XXI, shall, 

4 in accordance with the standards promulgated under 

5 subsection (a)(1)— 

6 ‘‘(A) maintain clinical data included in the 

7 uniform provider clinical data set under sub8 section (a)(2)(A) in electronic form on all pa9 tients, 

10 ‘‘(B) upon request of the Secretary or of a 

11 utilization and quality control peer review orga12 nization (with which the Secretary has entered 

13 into a contract under part B of title XI), trans14 mit electronically data requested from such 

15 data set, and 

16 ‘‘(C) upon request of the Secretary, or of 

17 a fiscal intermediary or carrier, transmit elec18 tronically any data (with respect to a claim) 

19 from such data set. 

20 ‘‘(2) APPLICATION OF PRESENTATION AND

21 TRANSMISSION STANDARDS TO ELECTRONIC TRANS22 MISSION TO FEDERAL AGENCIES.—Effective Janu23 ary 1, 2009, if a hospital or other health care pro24 vider is required under a Federal program to trans25 mit a data element that is subject to a standard, 


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1 promulgated under subsection (a)(1), described in 

2 subparagraph (C) or (D) of subsection (a)(2), the 

3 head of the Federal agency responsible for such pro4 gram (if not otherwise authorized) is authorized to 

5 require the provider to present and transmit the 

6 data element electronically in accordance with such 

7 a standard. 

8 ‘‘(c) LIMITATION ON DATA REQUIREMENTS WHERE

9 STANDARDS IN EFFECT.— 

10 ‘‘(1) IN GENERAL.—On or after January 1, 

11 2009, the Secretary under this title or under title 

12 XVIII (including any carrier or fiscal intermediary 

13 or any utilization and quality control peer review or14 ganization) and an AmeriCare supplemental plan 

15 may not require, for the purpose of utilization review 

16 or as a condition of providing benefits or making 

17 payments under this title, title XVIII, or the plan, 

18 that a hospital or other health care provider— 

19 ‘‘(A) provide any data element not in the 

20 uniform provider clinical data set specified 

21 under the standards promulgated under sub22 section (a), or 

23 ‘‘(B) transmit or present any such data 

24 element in a manner inconsistent with such 


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1 standards applicable to such transmission or 

2 presentation. 

3 ‘‘(2) COMPLIANCE.—The Secretary may impose 

4 a civil money penalty on any AmeriCare supple5 mental plan that fails to comply with paragraph (1) 

6 in an amount not to exceed $100 for each such fail7 ure. The provisions of section 1128A of the Social 

8 Security Act (other than the first sentence of sub9 section (a) and other than subsection (b)) shall 

10 apply to a civil money penalty under this paragraph 

11 in the same manner as such provisions apply to a 

12 penalty or proceeding under section 1128A(a) of 

13 such Act. 

14 ‘‘(3) APPLICATION TO MEDICAID PROGRAM.—As 

15 a condition for the approval of State plans under the 

16 medicaid program and in accordance with regula17 tions of the Secretary, effective as of January 1, 

18 2009, each such plan may not require that a hos19 pital or other health care provider, for the purpose 

20 of utilization review or as a condition of providing 

21 benefits or making payments under the plan— 

22 ‘‘(A) provide any data element not in the 

23 uniform provider clinical data set specified 

24 under the standards promulgated under sub25 section (a), or 


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1 ‘‘(B) transmit or present any such data 

2 element in a manner inconsistent with such 

3 standards applicable to such transmission or 

4 presentation. 

5 ‘‘(d) PREEMPTION OF STATE QUILL PEN LAWS.— 

6 ‘‘(1) IN GENERAL.—Any provision of State law 

7 that requires medical or health insurance records 

8 (including billing information) to be maintained in 

9 written, rather than electronic, form shall deemed to 

10 be satisfied if the records are maintained in an elec11 tronic form that meets standards established by the 

12 Secretary under paragraph (2). 

13 ‘‘(2) SECRETARIAL AUTHORITY.—Not later 

14 than 1 year after the date of the enactment of this 

15 title, the Secretary shall issue regulations to carry 

16 out paragraph (1). The regulations shall provide for 

17 an electronic substitute that is in the form of a 

18 unique identifier (assigned to each authorized indi19 vidual) that serves the functional equivalent of a sig20 nature. The regulations may provide for such excep21 tions to paragraph (1) as the Secretary determines 

22 to be necessary to prevent fraud and abuse, to pre23 vent the illegal distribution of controlled substances, 

24 and in such other cases as the Secretary deems ap25 propriate. 


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1 ‘‘(3) EFFECTIVE DATE.—Paragraph (1) shall 

2 take effect on the first day of the first month that 

3 begins more than 30 days after the date the Sec4 retary issues the regulations referred to in para5 graph (2). 

6 ‘‘SEC. 2254. UNIFORM HOSPITAL COST REPORTING. 

7 ‘‘Each hospital, as a requirement under a participa8 tion agreement under this title for each cost reporting pe9 riod beginning during or after fiscal year 2008, shall pro10 vide for the reporting of information to the Secretary with 

11 respect to any hospital care provided in a uniform manner 

12 consistent with standards established by the Secretary to 

13 carry out section 4007(c) of the Omnibus Budget Rec14 onciliation Act of 1987 and in an electronic form con15 sistent with standards established by the Secretary. 

16 ‘‘SEC. 2255. HEALTH SERVICE PROVIDER DEFINED. 

17 ‘‘In this part, the term ‘health service provider’ in18 cludes a provider of services (as defined in section 

19 1861(u)), physician, supplier, and other entity furnishing 

20 health care services. 

21 ‘‘PART E—GENERAL PROVISIONS

22 ‘‘SEC. 2261. DEFINITIONS RELATING TO BENEFICIARIES 

23 AND INCOME. 

24 ‘‘(a) TERMS RELATING TO BENEFICIARIES.—In this 

25 title: 


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1 ‘‘(1) CHILD.—The term ‘child’ means an indi2 vidual who throughout a month has not attained 24 

3 years of age. 

4 ‘‘(2) LOW-INCOME INDIVIDUAL.—The term 

5 ‘low-income individual’ means an individual whose 

6 applicable modified gross income (as defined in sub7 section (b)(1)) is less than 200 percent of the pov8 erty level (as defined in subsection (b)(2)). The de9 termination that an individual is a low-income indi10 vidual shall be effective for a period of one year and 

11 shall be redetermined on an annual basis. 

12 ‘‘(3) PREGNANT WOMAN.—The term ‘pregnant 

13 woman’ means a woman (regardless of age) who has 

14 been certified by a physician (in a manner specified 

15 by the Secretary) as being pregnant, until the last 

16 day of the month in which the 60-day period (begin17 ning on the date of termination of the pregnancy) 

18 ends. 

19 ‘‘(b) TERMS RELATING TO INCOME.—In this title: 

20 ‘‘(1) APPLICABLE MODIFIED GROSS INCOME.— 

21 ‘‘(A) IN GENERAL.—Except as provided in 

22 this paragraph, the term ‘applicable modified 

23 gross income’ means, for a calendar year for an 

24 individual, the modified gross income (as de25 fined in section 202(a)(3)(B) of the Americare 


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1 Health Care Act of 2007) of the taxpayer (or 

2 the taxpayer for whom the individual may be 

3 claimed as a dependent) for the taxable year 

4 ending in the second previous calendar year. 

5 ‘‘(B) APPLICATION OF CURRENT YEAR

6 MODIFIED GROSS INCOME.— 

7 ‘‘(i) IN GENERAL.—Subject to clause 

8 (ii), the Secretary shall establish a proce9 dure under which an individual may file a 

10 declaration of estimated modified gross in11 come for a taxable year ending in a cal12 endar year, which modified gross income 

13 will apply under this subsection as the ap14 plicable modified gross income for the cal15 endar year. Subject to clause (ii), such pro16 cedure shall be applicable regardless of 

17 whether or not the individual filed a tax 

18 return for the taxable year ending in the 

19 second previous calendar year. 

20 ‘‘(ii) LIMITATION ON APPLICATION.— 

21 The Secretary may limit the application of 

22 clause (i), in the case of individuals who 

23 have filed tax returns for the taxable year 

24 ending in the second previous calendar 

25 year, to individuals with respect to whom 


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1 the applicable modified gross income will 

2 be reduced by at least 20 percent as a re3 sult of the application of such clause. 

4 ‘‘(iii) REQUIREMENT FOR RETURN.— 

5 Any individual who has filed a declaration 

6 under clause (i) for a calendar year is re7 quired to file an income tax return for the 

8 taxable year in the calendar year, regard9 less of whether any income tax is actually 

10 owed for the year. The failure of the indi11 vidual to file such a return makes the indi12 vidual liable for overpayments under this 

13 title under clause (iv) in the same manner 

14 as if this paragraph had not applied. 

15 ‘‘(iv) COLLECTION FOR OVERPAY16 MENTS.—If a declaration of estimated 

17 modified gross income is made applicable 

18 to a calendar year under clause (i) and the 

19 actual modified gross income for that tax20 able year exceeds such estimated modified 

21 gross income, the individual shall be liable 

22 to the United States for 110 percent of the 

23 amount of additional payments made 

24 under this title as a result of the use of 

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1 stead of the actual modified gross income 

2 for that taxable year. 

3 ‘‘(C) TRANSMITTAL OF INFORMATION.—By 

4 not later than October 1 of each year, the Sec5 retary of the Treasury shall transmit to the 

6 Secretary such information relating to the ap7 plicable modified gross income of individuals for 

8 the taxable year ending in the previous year as 

9 may be necessary to apply this title in the suc10 ceeding calendar year. 

11 ‘‘(2) POVERTY LEVEL.—The term ‘poverty 

12 level’ means, for an individual in a family, the offi13 cial poverty line (as defined by the Office of Man14 agement and Budget, and revised annually in ac15 cordance with section 673(2) of the Omnibus Budget 

16 Reconciliation Act of 1981) applicable to a family of 

17 the size involved. 

18 ‘‘SEC. 2262. INCORPORATION OF CERTAIN MEDICARE PRO19 VISIONS AND OTHER PROVISIONS. 

20 ‘‘(a) USE OF MEDICARE ADMINISTRATIVE CONTRAC21 TORS.—The Secretary shall provide for the administration 

22 of this title through the use of medicare administrative 

23 contractors in the same manner as title XVIII is carried 

24 out through the use of such contractors, except that no 

25 payment shall be made under this title except on the basis 


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1 of bills or charges that are submitted electronically in a 

2 manner specified by the Secretary. 

3 ‘‘(b) DEFINITIONS.— 

4 ‘‘(1) IN GENERAL.—Except as otherwise pro5 vided in this title, the definitions contained in sec6 tion 1861 shall apply for purposes of this title in the 

7 same manner as they apply for purposes of title 

8 XVIII. 

9 ‘‘(2) STATE; UNITED STATES.—(A) The term 

10 ‘State’ means the 50 States and includes the Dis11 trict of Columbia, Puerto Rico, the Virgin Islands, 

12 Guam, American Samoa, and the Northern Mariana 

13 Islands. 

14 ‘‘(B) The term ‘United States’ means all the 

15 States. 

16 ‘‘(c) CERTIFICATION, PROVIDER QUALIFICATION, 

17 ETC.—The provisions of sections 1863 through 1875, sec18 tions 1877 through 1880, section 1883, section 1885, and 

19 sections 1887 through 1895 shall apply to this title in the 

20 same manner as they apply to title XVIII. 

21 ‘‘(d) TITLE XI PROVISIONS.—The following provi22 sions shall apply to this title in the same manner as they 

23 apply to title XVIII: 

24 ‘‘(1) Sections 1124, 1126, and 1128 through 

25 1128E (relating to fraud and abuse). 


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1 ‘‘(2) Section 1134 (relating to nonprofit hos2 pital philanthropy). 

3 ‘‘(3) Section 1138 (relating to hospital proto4 cols for organ procurement and standards for organ 

5 procurement agencies). 

6 ‘‘(4) Section 1142 (relating to research on out7 comes of health care services and procedures), ex8 cept that any reference in such section to a Trust 

9 Fund is deemed a reference to the AmeriCare Trust 

10 Fund. 

11 ‘‘(5) Part B of title XI (relating to peer review 

12 of the utilization and quality of health care services). 

13 ‘‘(6) Part C of title XI (relating to administra14 tive simplification). 

15 ‘‘(e) OTHER PROVISIONS.—The provisions of section 

16 201(i) shall apply to this title and the AmeriCare Trust 

17 Fund in the same manner as they apply to title XVIII 

18 and the Federal Hospital Insurance Trust Fund. 

19 ‘‘SEC. 2263. STATE MAINTENANCE OF EFFORT PAYMENTS. 

20 ‘‘(a) CONDITION OF COVERAGE.—Notwithstanding 

21 any other provision of this title, no individual who is a 

22 resident of a State is eligible for benefits under this title 

23 for a month in a calendar year, unless the State provides 

24 (in a manner and at a time specified by the Secretary) 

for payment to the AmeriCare Trust Fund of 1 25 ⁄12th of the 


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1 amount specified in subsection (b) for the year. Such 

2 funds shall be used offset the costs of providing subsidies 

3 for low-income individuals under section 202. 

4 ‘‘(b) MAINTENANCE OF EFFORT AMOUNT.— 

5 ‘‘(1) IN GENERAL.—Subject to paragraph (3), 

6 the amount of payment specified in this subsection 

7 for a State for a year is equal to the amount of pay8 ment (net of Federal payments) made by a State 

9 under its State plans under titles XIX and XXI for 

10 2007 for medical assistance for benefits described in 

11 paragraph (2). 

12 ‘‘(2) BENEFITS DESCRIBED.—The benefits de13 scribed in this paragraph with respect to State plans 

14 of a State under titles XIX and XXI are benefits 

15 which— 

16 ‘‘(A) would be available under this title for 

17 low-income individuals if this title had been in 

18 effect in 2007; and 

19 ‘‘(B) are for low-income individuals who— 

20 ‘‘(i) with respect to the State plan 

21 under title XIX, were required to be fur22 nished medical assistance under such title 

23 XIX; or 


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1 ‘‘(ii) with respect to a State child 

2 health plan under title XXI, were low-in3 come children. 

4 ‘‘SEC. 2264. MODIFICATION OF MEDICAID AND OTHER PRO5 GRAMS TO AVOID DUPLICATION OF BENE6 FITS. 

7 ‘‘(a) IN GENERAL.—Notwithstanding any other pro8 vision of law— 

9 ‘‘(1) a State plan under title XIX and a State 

10 child health plan under title XXI shall not provide 

11 any medical assistance for benefits with respect to 

12 which any payments may be made under this title; 

13 and 

14 ‘‘(2) a health benefits plan under chapter 89 of 

15 title 5, United States Code, shall not provide bene16 fits for which any payment may be made under this 

17 title. 

18 ‘‘(b) REVIEW OF APPLICATION TO OTHER PRO19 GRAMS.—The Secretary shall conduct a review of the fea20 sibility of applying the policy described in subsection (a) 

21 to additional Federal programs, such as the TRICARE 

22 program under title 10, United States Code. Not later 

23 than January 1, 2010, the Secretary submit to Congress 

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1 ommendations for extending such policy to other Federal 

2 programs as the Secretary deems appropriate. 

3 ‘‘SEC. 2265. CONSTRUCTION REGARDING CONTINUATION 

4 OF OBLIGATIONS UNDER CURRENT GROUP 

5 HEALTH PLAN CONTRACTS AND PROVISION 

6 OF ADDITIONAL BENEFITS. 

7 ‘‘Nothing in this title shall be construed as— 

8 ‘‘(1) affecting obligations for health care bene9 fits under group health plans as in effect on the date 

10 of the enactment of this title, including such plans 

11 established or maintained under or pursuant to one 

12 or more collective bargaining agreements; 

13 ‘‘(2) limiting the additional benefits that may 

14 be provided under a group health plan to employees 

15 or their dependents, or to former employees or their 

16 dependents; or 

17 ‘‘(3) limiting the benefits that may be made 

18 available under a State program to residents of the 

19 State at the expense of the State. 

20 ‘‘SEC. 2266. STANDARDS AND REQUIREMENTS FOR 

21 AMERICARE SUPPLEMENTAL POLICIES. 

22 ‘‘(a) CERTIFICATION REQUIRED.— 

23 ‘‘(1) IN GENERAL.—The Secretary shall estab24 lish rules and procedures consistent with this section 

25 under which AmeriCare supplemental policies may 


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1 only be issued if they are certified by the Secretary 

2 or under a State regulatory program approved by 

3 the Secretary as meeting standards established 

4 under subsection (b). 

5 ‘‘(2) ENFORCEMENT.—Any person who issues 

6 an AmeriCare supplemental policy in violation of 

7 paragraph (1) is subject to a civil money penalty of 

8 not to exceed $25,000 for each such violation. The 

9 provisions of section 1128A (other than the first 

10 sentence of subsection (a) and other than subsection 

11 (b)) shall apply to a civil money penalty under the 

12 previous sentence in the same manner as such provi13 sions apply to a penalty or proceeding under section 

14 1128A(a). 

15 ‘‘(3) AMERICARE SUPPLEMENTAL POLICY.— 

16 For purposes of this section, the term ‘AmeriCare 

17 supplemental policy’ is a health insurance policy or 

18 other health benefit plan offered by a private entity 

19 to individuals who are entitled to have payment 

20 made under this title, which provides reimbursement 

21 for expenses incurred for services and items for 

22 which payment may be made under this title but 

23 which are not reimbursable by reason of the applica24 tion of deductibles, coinsurance amounts, or other 


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1 limitations imposed pursuant to this title; but does 

2 not include— 

3 ‘‘(A) any such policy or plan of the trust4 ees of a fund established by one or more em5 ployers or labor organizations (or combination 

6 thereof) if the policy or plan offers benefits as 

7 a direct service organization under section 

8 1833, or 

9 ‘‘(B) a policy or plan of a health mainte10 nance organization which offers benefits under 

11 this title under section 2221(k). 

12 For purposes of this section, the term ‘policy’ in13 cludes a certificate issued under such policy. 

14 ‘‘(b) CERTIFICATION STANDARDS.— 

15 ‘‘(1) ISSUANCE.—The Secretary shall develop 

16 and publish specific standards consistent with this 

17 section for AmeriCare supplemental policies and 

18 shall consult with the Secretary of Labor regarding 

19 the application of such standards to employee wel20 fare benefit plans under title I of the Employee Re21 tirement Income Security Act of 1974. 

22 ‘‘(2) MORE STRINGENT STATE STANDARDS PER23 MITTED.—In the case of insured AmeriCare supple24 mental policies (as defined in subsection (d)(3)), a 

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1 gent than the standards established under para2 graph (1), including— 

3 ‘‘(A) additional limitations on pre-existing 

4 exclusion limitations described in subsection 

5 (c)(1)(B); 

6 ‘‘(B) additional restrictions on the groups 

7 of benefits described in subsection (c)(2) that 

8 may be offered in AmeriCare supplemental poli9 cies in the State, so long as a core-only benefit 

10 package described in subparagraph (A)(i) of 

11 such subsection may be offered in the State; 

12 and 

13 ‘‘(C) requiring a higher loss-ratios than 

14 those specified in subsection (c)(3); 

15 ‘‘(c) STANDARDS.—The Secretary shall establish 

16 standards for AmeriCare supplemental policies consistent 

17 with the following: 

18 ‘‘(1) NO DISCRIMINATION BASED ON HEALTH

19 STATUS.— 

20 ‘‘(A) IN GENERAL.—Except as provided 

21 under subparagraph (B), an AmeriCare supple22 mental policy may not deny, limit, or condition 

23 the coverage under (or benefits of) the policy, 

24 or vary premiums charged, based on the health 

25 status, claims experience, receipt of health care, 


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1 medical history, or lack of evidence of insur2 ability, of an individual. 

3 ‘‘(B) LIMITATION ON USE OF PRE-EXIST4 ING CONDITION EXCLUSIONS.—An AmeriCare 

5 supplemental policy may exclude coverage with 

6 respect to services related to treatment of a 

7 pre-existing condition, except that— 

8 ‘‘(i) the period of such exclusion may 

9 not exceed 6 months; 

10 ‘‘(ii) such exclusion shall not apply to 

11 services furnished to newborns; and 

12 ‘‘(iii) the period of exclusion under 

13 clause (i) shall be reduced by 1 month for 

14 each month in a period of continuous 

15 health benefits coverage (as defined by the 

16 Secretary) for the services involved. 

17 For purposes of this subparagraph, a condition 

18 is not pre-existing unless it was diagnosed or 

19 treated during the 3-month period ending on 

20 the day before the first date of such coverage. 

21 ‘‘(2) SIMPLIFICATION OF BENEFITS.— 

22 ‘‘(A) IN GENERAL.—Each AmeriCare sup23 plemental policy shall only offer benefits con24 sistent with the standards, promulgated by the 

25 Secretary, that provide— 


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1 ‘‘(i) limitations on the groups or pack2 ages of benefits, including a core group of 

3 basic benefits and not to exceed 9 other 

4 different benefit packages, that may be of5 fered under an AmeriCare supplemental 

6 policy; 

7 ‘‘(ii) that a person may not issue an 

8 AmeriCare supplemental policy without of9 fering such a policy with only the core10 group of basic benefits and without pro11 viding an outline of coverage in a standard 

12 form approved by the Secretary; 

13 ‘‘(iii) uniform language and defini14 tions to be used with respect to such bene15 fits, and 

16 ‘‘(iv) uniform format to be used in the 

17 policy with respect to such benefits. 

18 ‘‘(B) INNOVATION.—The Secretary may 

19 approve the offering of new or innovative and 

20 cost-effective benefit packages in addition to 

21 those provided under subparagraph (A). 

22 ‘‘(3) MINIMUM LOSS RATIO REQUIRED.—An 

23 AmeriCare supplemental policy, a specific disease 

24 policy (as defined by the Secretary), or a hospital 

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1 retary) may not be issued or renewed unless the pol2 icy— 

3 ‘‘(A) can be expected (in accordance with 

4 a uniform methodology developed by the Sec5 retary and for periods beginning 24 months 

6 after the date of original issue) to return to pol7 icyholders in the form of aggregate benefits at 

8 least 85 percent of the aggregate amount of 

9 premiums collected in the case of group policies 

10 or at least 75 percent in the case of individual 

11 policies (as defined by the Secretary); and 

12 ‘‘(B) provides refunds and credits (in a 

13 manner specified by the Secretary) for pre14 miums collected in excess of those consistent 

15 with subparagraph (A). 

16 ‘‘(4) GUARANTEED RENEWABILITY AND CON17 VERTIBILITY.—Each AmeriCare supplemental pol18 icy— 

19 ‘‘(A) shall be guaranteed renewable and 

20 may not be cancelled or nonrenewed solely on 

21 the ground of health status of the individual or 

22 for any reason other than nonpayment of pre23 mium or material misrepresentation; and 

24 ‘‘(B) shall provide for— 


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1 ‘‘(i) a right of conversion to an indi2 vidual policy (with continuation of bene3 fits) in the case of termination by a group 

4 policyholder or termination by a 

5 certificateholder of membership in a group 

6 through which the individual obtained cov7 erage; 

8 ‘‘(ii) a right of continued coverage in 

9 the case of a group policy that succeeds 

10 another group policy; and 

11 ‘‘(iii) suspension of coverage (for up 

12 to 24 months and in a manner specified) 

13 in the case of a policyholder who becomes 

14 entitled to benefits under this title as a 

15 low-income individual and who provides a 

16 timely notice of election of such suspen17 sion. 

18 ‘‘(5) ADDITIONAL STANDARDS APPLICABLE

19 ONLY TO INSURED POLICIES.—A carrier that offers 

20 an insured AmeriCare supplemental policy (as de21 fined in paragraph (6)) to individuals and groups in 

22 a State shall also comply with the following require23 ments: 

24 ‘‘(A) OPEN ENROLLMENT.—The carrier 

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1 vidual or group in the State on a continuous, 

2 year-round basis; except that— 

3 ‘‘(i) in the case of policies offered 

4 through an association which is composed 

5 exclusively of employers (which may in6 clude self-employed individuals) and which 

7 has been formed for purposes other than 

8 obtaining health insurance, such require9 ment shall only apply to such employers 

10 (and individuals) who are members of the 

11 association; and 

12 ‘‘(ii) a health maintenance organiza13 tion may deny enrollment with respect to 

14 an individual based on the uniform appli15 cation of a geographic service area or over16 all enrollment limitation based on its finan17 cial or administrative capacity. 

18 ‘‘(B) NOTICES AND RENEWAL PERIODS.— 

19 The carrier shall provide advance notice of 

20 terms for policy renewal, which terms shall— 

21 ‘‘(i) be the same as the terms of 

22 issuance, except for rates and administra23 tive changes; 

24 ‘‘(ii) provide the same premium rates 

25 as for a new issue; and 


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1 ‘‘(iii) provide a period of renewal of 

2 not less than 12 months. 

3 ‘‘(c) ADDITIONAL REQUIREMENTS.— 

4 ‘‘(1) PROHIBITION OF DUPLICATION.—The Sec5 retary shall— 

6 ‘‘(A) establish requirements that prohibit 

7 (other than as required under Federal or State 

8 law) the knowing sale or issuance to an indi9 vidual entitled to benefits under this title of 

10 health insurance that duplicates benefits under 

11 this title, of an AmeriCare supplemental policy 

12 that duplicates another AmeriCare supple13 mental policy, or of another health insurance 

14 policy that duplicates other benefits to which 

15 the individual is entitled; and 

16 ‘‘(B) provide exceptions to the prohibition 

17 in subparagraph (A) for enrollment in group 

18 health plans and similar employment-based poli19 cies and for policies which provide benefits di20 rectly and without regard to other coverage and 

21 notice of such duplication. 

22 ‘‘(2) DISCLOSURE REQUIREMENT.—The Sec23 retary shall establish a requirement that prohibits 

24 the sale or issuance of an AmeriCare supplemental 

25 policy to an individual, other than as a replacement 


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1 policy, without obtaining a statement (in a form 

2 specified by the Secretary) that discloses other 

3 health benefits coverage and that acknowledges limi4 tations on the need for an AmeriCare supplemental 

5 policy, particularly in the case of a low-income indi6 vidual. 

7 ‘‘(3) APPLICATION OF FALSE STATEMENT

8 SANCTIONS.—The provisions of paragraphs (1) and 

9 (2) of section 1882(d) shall apply to an AmeriCare 

10 supplemental policy under this section in the same 

11 manner as they apply to medicare supplemental poli12 cies under such section. 

13 ‘‘(4) LIMITATIONS ON SALES COMMISSIONS.— 

14 ‘‘(A) IN GENERAL.—It is unlawful for a 

15 person who provides for a commission or other 

16 compensation to an agent or other representa17 tives with respect to the sale of an AmeriCare 

18 supplemental policy (or certificate)— 

19 ‘‘(i) to provide for a first year com20 mission or other first year compensation 

21 that exceeds 200 percent of the commis22 sion or other compensation for the selling 

23 or servicing of the policy or certificate in 

24 a second or subsequent year; or 


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1 ‘‘(ii) to provide for compensation with 

2 respect to replacement of such a policy or 

3 certificate that is greater than the com4 pensation that would apply to the renewal 

5 of the policy or certificate. 

6 ‘‘(B) DEFINITION.—In subparagraph (A), 

7 the term ‘compensation’ includes pecuniary and 

8 nonpecuniary compensation of any kind relating 

9 to the sale or renewal of a policy or certificate 

10 and specifically includes bonuses, gifts, prizes, 

11 awards, and finders’ fees. 

12 ‘‘(d) INFORMATION DISCLOSURE.—The Secretary 

13 shall provide, to all individuals entitled to benefits under 

14 this title, such information as will permit such individuals 

15 to evaluate the value of AmeriCare supplemental policies 

16 to them and the relationship of any such policies to bene17 fits provided under this title. Such information shall in18 clude information on— 

19 ‘‘(1) the requirements and prohibitions under 

20 this section; 

21 ‘‘(2) State and Federal agencies responsible for 

22 compliance with such requirements and enforcement 

23 of such prohibitions; and 


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1 ‘‘(3) the manner of submitting complaints re2 garding violations of such requirements and prohibi3 tions. 

4 ‘‘(e) DEFINITIONS.—In this section: 

5 ‘‘(1) CARRIER.—The term ‘carrier’ means any 

6 person that offers an AmeriCare supplemental pol7 icy. 

8 ‘‘(2) GROUP.—The term ‘group’ means 2 or 

9 more employees of the same employer who normally 

perform on a monthly basis at least 171 10 ⁄2 hours of 

11 service per week for that employer. 

12 ‘‘(3) HEALTH MAINTENANCE ORGANIZATION.— 

13 The term ‘health maintenance organization’ has the 

14 meaning given the term ‘eligible organization’ in sec15 tion 1876(b). 

16 ‘‘(4) INSURED AMERICARE SUPPLEMENTAL

17 POLICY.—The term ‘insured AmeriCare supple18 mental policy’ means any AmeriCare supplemental 

19 policy provided through insurance.’’. 

20 TITLE II—FINANCING 

21 PROVISIONS 

22 Subtitle A—Individual 

23 Contributions 

24 SEC. 201. GENERAL OBLIGATION FOR INDIVIDUALS. 

25 (a) PAYMENT OF PLAN PREMIUM.— 


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1 (1) IN GENERAL.—Each individual eligible for 

2 coverage under title XXII of the Social Security Act 

3 is liable for payment of the premium established 

4 under this section for such coverage of the individual 

5 and family members. An individual who is not re6 ceiving such coverage due to coverage under a group 

7 health plan described in section 2202(d) of such Act 

8 is not liable for payment of such premium with re9 spect to such individual. 

10 (2) DETERMINATION OF PREMIUM.—Such pre11 mium shall be established by the Secretary of Health 

12 and Human Services on the basis of the cost of cov13 erage (determined on a State by State basis and in14 cluding administrative costs) and shall be deter15 mined separately based on the class of enrollment 

16 for the individual (as determined under section 2202 

17 of the Social Security Act). 

18 (3) JOINT AND SEVERAL LIABILITY.—If more 

19 than one individual is liable under this subsection 

20 for payment of a premium for coverage of the same 

21 individual under title XXII of the Social Security 

22 Act, such individual shall be jointly and severally lia23 ble with each other individual who is so liable. 


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1 (b) REDUCTION FOR EMPLOYER CONTRIBUTIONS

2 AND LOW INCOME SUBSIDIES.—An individual’s liability 

3 under subsection (a) is reduced by— 

4 (1) the amount of any contributions made by 

5 the individual’s employer (or employers) under sub6 title B or otherwise (including voluntary employer 

7 contributions) with respect to coverage of the indi8 vidual and family members, and 

9 (2) the amount of any premium subsidies pro10 vided with respect to the individual under section 

11 202. 

12 (c) TIMING AND MANNER OF PAYMENT.—Each indi13 vidual that is liable for a premium under subsection (a) 

14 shall pay such premium in such form and manner as the 

15 Secretary of the Treasury may specify. Except as other16 wise provided by the Secretary of the Treasury, for pur17 poses of subtitle F of such Code, the liabilities imposed 

18 under subsection (a) shall be treated as if they were a 

19 tax imposed under section 1 of such Code. The Secretary 

20 of the Treasury shall provide for the withholding of such 

21 payments from wages under rules similar to the rules of 

22 chapter 24 of such Code. The Secretary of the Treasury 

23 may prescribe special rules for withholding payments from 

24 wages of individuals who work seasonally, part-time, or for 

25 more than one employer. 


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1 SEC. 202. ADDITIONAL PREMIUM SUBSIDIES. 

2 (a) ELIGIBILITY FOR ADDITIONAL PREMIUM SUB3 SIDIES.— 

4 (1) IN GENERAL.—Each premium subsidy eligi5 ble individual is entitled to a premium subsidy in ac6 cordance with this section. 

7 (2) PREMIUM SUBSIDY ELIGIBLE INDI8 VIDUAL.—In this section, the term ‘‘premium sub9 sidy eligible individual’’ means an individual receiv10 ing coverage under title XXII of the Social Security 

11 Act who— 

12 (A) with respect to premiums for a taxable 

13 year ending in a year, has family income (as de14 fined in paragraph (3)(A)) that is less than 300 

15 percent of the applicable poverty level, or 

16 (B) with respect to a premium for a 

17 month, is an TANF or SSI recipient for the 

18 month. 

19 (3) ADDITIONAL DEFINITIONS.—In this section: 

20 (A) FAMILY INCOME.—The term ‘‘family 

21 income’’ means, with respect to an individual 

22 who— 

23 (i) is not a dependent of another indi24 vidual, the sum of the modified adjusted 

25 gross incomes (as defined in subparagraph 

26 (B)) for the individual, the individual’s 


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1 spouse, and children who are dependents of 

2 the individual, or 

3 (ii) is a dependent of another indi4 vidual, the sum of the modified adjusted 

5 gross incomes (as defined in subparagraph 

6 (B)) for the other individual, the other in7 dividual’s spouse, and children who are de8 pendents of the other individual. 

9 (B) MODIFIED ADJUSTED GROSS IN10 COME.—The term ‘‘modified adjusted gross in11 come’’ means adjusted gross income (as defined 

12 in the Internal Revenue Code of 1986)— 

13 (i) determined without regard to sec14 tions 911, 931, and 933 of such Code, and 

15 (ii) increased by— 

16 (I) the amount of interest re17 ceived or accrued by the individual 

18 during the taxable year which is ex19 empt from tax, and 

20 (II) the amount of the social se21 curity benefits (as defined in section 

22 86(d) of such Code) received during 

23 the taxable year to the extent not in24 cluded in gross income under section 

25 86 of such Code. 


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1 The determination under the preceding sen2 tence shall be made without regard to any car3 ryover or carryback. 

4 (C) APPLICABLE POVERTY LEVEL.— 

5 (i) IN GENERAL.—The term ‘‘applica6 ble poverty level’’ means, for a family for 

7 a year, the official poverty line (as defined 

8 by the Secretary of Health and Human 

9 Services) applicable to a family of the size 

10 involved for 2010 adjusted by the percent11 age increase or decrease described in 

12 clause (ii) for the year involved. 

13 (ii) PERCENTAGE ADJUSTMENT.—The 

14 percentage increase or decrease described 

15 in this clause for a year is the percentage 

16 increase or decrease by which the average 

17 Consumer Price Index for all urban con18 sumers (U.S. city average), as published by 

19 the Bureau of Labor Statistics, for the 12- 

20 month-period ending with August 31 of the 

21 preceding year exceeds such average for 

22 the 12-month period ending with August 

23 31, 2010. 


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1 (iii) ROUNDING.—Any adjustment 

2 made under clause (ii) for a year shall be 

3 rounded to the nearest multiple of $100. 

4 (D) TANF RECIPIENT.—The term 

5 ‘‘TANF recipient’’ means, for a month, an indi6 vidual who is receiving aid or assistance under 

7 any plan of the State approved under title I, X, 

8 XIV, or XVI, or part A or part E of title IV, 

9 of the Social Security Act, for the month. 

10 (E) SSI RECIPIENT.—The term ‘‘SSI re11 cipient’’ means, for a month, an individual— 

12 (i) with respect to whom supplemental 

13 security income benefits are being paid 

14 under title XVI of the Social Security Act 

15 for the month, 

16 (ii) who is receiving a supplementary 

17 payment under section 1616 of such Act or 

18 under section 212 of Public Law 93–66 for 

19 the month, or 

20 (iii) who is receiving monthly benefits 

21 under section 1619(a) of the Social Secu22 rity Act (whether or not pursuant to sec23 tion 1616(c)(3) of such Act) for the 

24 month. 

25 (b) AMOUNT OF PREMIUM SUBSIDY.— 


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1 (1) LOWEST INCOME INDIVIDUALS.— 

2 (A) IN GENERAL.—In the case of an indi3 vidual described in subparagraph (B), the pre4 mium subsidy under this section is the amount 

5 which would (without regard to this section) re6 duce the premium obligation of the individual 

7 (and family members) under section 201 to 

8 zero. 

9 (B) LOWEST INCOME INDIVIDUALS DE10 SCRIBED.—An individual described in this sub11 paragraph is a premium subsidy eligible indi12 vidual who would still be such an individual 

13 under subsection (a)(2) if ‘‘200 percent’’ were 

14 substituted for ‘‘300 percent’’ in subparagraph 

15 (A) of such subsection. 

16 (2) OTHER INDIVIDUALS.— 

17 (A) IN GENERAL.—In the case of a pre18 mium subsidy eligible individual not described 

19 in paragraph (1), the premium subsidy under 

20 this section is the product of— 

21 (i) the premium obligation of the indi22 vidual (and family members) under section 

23 201, multiplied by 

24 (ii) the number of percentage points 

25 by which the individual’s family income 


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1 (expressed as a percent of the applicable 

2 poverty level) is less than 300 percent. 

3 (B) TABLE.—The Secretary may provide 

4 for a table which establishes the values for pre5 mium subsidies under this paragraph. 

6 (c) GENERAL REVENUE FINANCING FOR LOW IN7 COME SUBSIDIES.—There are authorized to be appro8 priated to the Americare Trust Fund from amounts in the 

9 Treasury not otherwise appropriated, such sums as may 

10 be necessary to cover the costs of premium subsidies pro11 vided under this section. 

12 SEC. 203. EFFECTIVE DATE. 

13 The provisions of this subtitle shall apply with respect 

14 to periods beginning on or after January 1, 2010. 

15 Subtitle B—Employer 

16 Contributions 

17 SEC. 211. GENERAL OBLIGATION FOR EMPLOYERS. 

18 (a) GENERAL OBLIGATION.— 

19 (1) IN GENERAL.—Subject to the succeeding 

20 provisions of this subsection, each employer shall 

21 make a financial contribution toward the cost of 

22 health insurance coverage for employees in accord23 ance with this section. 

24 (2) ELIMINATION OF LIABILITY IN CASE OF

25 CERTAIN GROUP HEALTH PLAN COVERAGE.— 


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1 (A) IN GENERAL.—Subject to subpara2 graph (B), an employer shall not be liable for 

3 any contribution under this section with respect 

4 to any employee who is covered under a group 

5 health plan of the employer described in section 

6 2202(d) if such employer pays at least 80 per7 cent of the cost of such health plan, as deter8 mined by the Secretary of Health and Human 

9 Services. 

10 (B) SURCHARGE PERMISSIBLE TO PRE11 VENT ADVERSE SELECTION.—The Secretary 

12 may impose liability for a contribution under 

13 this section with respect to an employee de14 scribed in subparagraph (A) in an amount (not 

15 to exceed the amount specified under subsection 

16 (b)) insofar as the Secretary determines it nec17 essary to prevent adverse selection of the indi18 viduals enrolled under this title as a result of 

19 the operation of such subparagraph. 

20 (b) AMOUNT OF CONTRIBUTION.— 

21 (1) FULL-TIME EMPLOYEES.—In the case of an 

22 employee receiving coverage under title XXII of the 

23 Social Security Act, the amount of the financial con24 tribution is equal to at least 80 percent of the pre25 mium determined with respect to such employee and 


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1 family members under section 201 (based on class of 

2 enrollment and without regard to subsection (b) 

3 thereof) or at least 80 percent of the cost of cov4 erage under such group health plan, respectively. 

5 (2) REDUCTION FOR PART-TIME EMPLOYEES.— 

6 In the case of a part-time employee, the employer 

7 contribution requirements of paragraph (1) shall be 

8 treated as satisfied if the employer contribution with 

9 respect to such employee is not less than the part10 time employment ratio of the contribution required 

11 under paragraph (1). 

12 (3) RULES RELATED TO PART-TIME EMPLOY13 MENT.—For purposes of this subsection— 

14 (A) PART-TIME EMPLOYEE.—The term 

15 ‘‘part-time employee’’ means, with respect to 

16 any month, an employee who works on average 

17 fewer than 40 hours per week. 

18 (B) PART-TIME EMPLOYMENT RATIO.— 

19 The term ‘‘part-time employment ratio’’ means, 

20 with respect to a part-time employee of an em21 ployer in a month, a fraction— 

22 (i) the numerator of which is the 

23 number of hours in the employee’s normal 

24 work week, and 


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1 (ii) the denominator of which is 40 

2 hours. 

3 (C) SPECIAL RULES.—Under rules pre4 scribed by the Secretary of Health and Human 

5 Services, in consultation with the Secretary of 

6 the Treasury, in the case of an employee for an 

7 employer whose defined work week for full-time 

8 employees is less than 40 hours, any reference 

9 in this subsection to 40 hours is deemed a ref10 erence to the number of hours in the work week 

11 so defined. 

12 (D) CONVERSION TO HOURS OF EMPLOY13 MENT.—The Secretary of Health and Human 

14 Services, in consultation with the Secretary of 

15 the Treasury, shall establish rules for the con16 version of compensation to hours of employ17 ment, for purposes of this subsection in the 

18 case of employees that receive compensation on 

19 a salaried basis, or on the basis of a commis20 sion, or other contingent or bonus basis, rather 

21 than based on an hourly wage. 

22 (c) TIMING AND MANNER.— 

23 (1) IN GENERAL.—Each employer that is re24 quired to make a financial contribution with respect 

25 to an employee under this section (other than with 


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1 respect to coverage under a group health plan) or a 

2 surcharge under subsection (a)(2)(B) shall pay such 

3 contribution or surcharge in a form and manner, 

4 specified by the Secretary of the Treasury, based 

5 upon the form and manner in which employer excise 

6 taxes are required to be paid under section 3111 of 

7 the Internal Revenue Code of 1986. 

8 (2) NON-ENROLLING EMPLOYERS.—In the case 

9 of an employee who is covered under the class of en10 rollment of a family member, the Secretary of the 

11 Treasury shall provide that the financial contribu12 tion of the employer with respect to such employee 

13 is paid directly or indirectly to the employer of such 

14 family member. 

15 SEC. 212. EFFECTIVE DATE. 

16 (a) IN GENERAL.—Subject to subsection (b), the pro17 visions of this subtitle shall apply with respect to periods 

18 beginning on or after January 1, 2010. 

19 (b) ADDITIONAL PERIOD FOR SMALL EMPLOYERS.— 

20 The provisions of this subtitle shall not apply with respect 

21 to an employer that has fewer than 100 employees (as de22 termined by the Secretary of the Treasury in consultation 

23 with the Secretary of Health and Human Services) for pe24 riods beginning before January 1, 2013. 

Æ 


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