I 

111TH CONGRESS 

1ST SESSION H. R. 193 

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 

JANUARY 6, 2009 

Mr. STARK 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, 

3 SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 

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

5 ‘‘AmeriCare Health Care Act of 2009’’. 

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

7 this Act is as follows: 


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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—ENTITLEMENT VERIFICATION SYSTEM

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

‘‘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 

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. 


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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 

7 HEALTH BENEFITS 

8 ‘‘PART A—ELIGIBILITY 

9 ‘‘SEC. 2201. ELIGIBILITY. 

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

11 ‘‘(1) IN GENERAL.—Except as provided in sec12 tion 2263(a), each individual who is a resident of 

13 the United States is entitled to health insurance 

14 benefits under this title. 

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

16 title shall apply to items and services furnished on 

17 or after January 1, 2011. 

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

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

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

21 or more of the following special eligibility groups: 

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

23 2261(a)(1)). 

24 ‘‘(2) Low-income individuals (as defined in sec25 tion 2261(a)(2)). 


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

2 2261(a)(3)). 

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

4 An individual who— 

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

6 ‘‘(2) is in the United States, and 

7 ‘‘(3) is a national of a foreign state which pro8 vides health benefits to nationals of the United 

9 States who are nonresidents in that state, 

10 is entitled to such health insurance benefits under this 

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

12 such benefits would be available to nationals of the United 

13 States similarly situated as a nonresident in the foreign 

14 state. 

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

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

17 mechanism for the enrollment of individuals entitled to 

18 benefits under this title and, in conjunction with such en19 rollment, the issuance of an AmeriCare card which may 

20 be used for purposes of identification and processing of 

21 claims for benefits under this title. AmeriCare cards shall 

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

23 of identifying children) and provide a coded means for 

24 identifying whether the individual is a low-income indi25 vidual for the year involved. 


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

2 under subsection (a) shall provide for individuals to be en3 rolled on the basis of the following classes of enrollment: 

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

5 ‘‘(2) Coverage of a married couple without chil6 dren. 

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

8 one or more children. 

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

10 more children. 

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

12 under subsection (a) shall include a process for the auto13 matic enrollment of individuals at the time of birth in the 

14 United States. 

15 ‘‘(d) OPT FOR THOSE COVERED UNDER GROUP

16 HEALTH PLAN.—Notwithstanding any other provision of 

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

18 benefits under this title if the individual demonstrates to 

19 the satisfaction of the Secretary that the individual has 

20 health benefits coverage under a group health plan (as de21 fined in section 5000(b)(1) of the Internal Revenue Code 

22 of 1986) that is at least equivalent to the coverage other23 wise provided under this title, as certified by the Sec24 retary. 


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1 ‘‘PART B—BENEFITS 

2 ‘‘SEC. 2221. SCOPE OF BENEFITS. 

3 ‘‘(a) IN GENERAL.—Except as provided in the suc4 ceeding provisions of this part, the benefits provided to 

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

6 established by this title shall consist of entitlement to the 

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

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

9 enrolled under part B, of title XVIII. 

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

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

12 succeeding provisions of this part, the amount of ex13 penses (other than expenses for benefits described in 

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

15 entitled to have payment made under this title for 

16 any year shall first be reduced by a deductible of 

17 $350, except that in no case shall the amount of the 

18 deductible for all the members of a family exceed 

19 $500. Such deductible shall be instead of the deduct20 ible for inpatient hospital services under the first 

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

22 under section 1833(b). 

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

24 the deductible under paragraph (1), the expenses re25 ferred to in such paragraph shall be subject to a coVerDate Nov 24 2008 21:11 Jan 12, 2009 Jkt 079200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H193.IH H193

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1 insurance of 20 percent until the limit on out-of2 pocket expenses under paragraph (3) is met. 

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

4 TOTAL EXPENSES.— 

5 ‘‘(A) LIMITATION ON COST-SHARING.— 

6 Subject to subparagraph (B), whenever in a cal7 endar year an individual’s expenses for the de8 ductible and coinsurance with respect to serv9 ices covered under this title (including expenses 

10 for benefits described in subsection (c)) and 

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

12 $4,000 for all the members of a family, pay13 ment of benefits under this title for the indi14 vidual (or for the members of such family, re15 spectively) for services furnished during the re16 mainder of the year shall be paid without the 

17 application of any coinsurance. 

18 ‘‘(B) LIMITATION ON PREMIUMS AND

19 COST-SHARING FOR CERTAIN INDIVIDUALS

20 BASED ON INCOME.— 

21 ‘‘(i) INCOME BETWEEN 200 AND 300

22 PERCENT OF POVERTY LINE.—In the case 

23 of a family whose applicable modified gross 

24 income (expressed as a percentage of the 

25 poverty level, as defined in section 


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1 2261(b)(2)) is equal to or exceeds 200 per2 cent, but does not exceed 300 percent, of 

3 the poverty level applicable to a family of 

4 the size involved, whenever in a calendar 

5 year an individual’s expenses in the family 

6 for premiums under this title and for the 

7 deductible and coinsurance with respect to 

8 services covered under this title (including 

9 expenses for benefits described in sub10 section (c)) and furnished during the year 

11 equals 5 percent of the amount of such ap12 plicable modified gross income for the fam13 ily— 

14 ‘‘(I) no additional premiums shall 

15 be imposed for remaining months in 

16 the year; and 

17 ‘‘(II) payment of benefits under 

18 this title for members of such family 

19 for services furnished during the re20 mainder of the year shall be paid 

21 without the application of any deduct22 ible or coinsurance. 

23 ‘‘(ii) INCOME BETWEEN 300 AND 500

24 PERCENT OF POVERTY LINE.—In the case 

25 of a family whose applicable modified gross 


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1 income (expressed as a percentage of the 

2 poverty level, as defined in section 

3 2261(b)(2)) exceeds 300 percent, but does 

4 not exceed 500 percent, of such poverty 

5 level applicable to a family of the size in6 volved, whenever in a calendar year an in7 dividual’s expenses in the family for pre8 miums under this title and for the deduct9 ible and coinsurance with respect to serv10 ices covered under this title (including ex11 penses for benefits described in subsection 

12 (c)) and furnished during the year equals 

13 7.5 percent of the amount of such applica14 ble modified gross income for the family— 

15 ‘‘(I) no additional premiums shall 

16 be imposed for remaining months in 

17 the year; and 

18 ‘‘(II) payment of benefits under 

19 this title for members of such family 

20 for services furnished during the re21 mainder of the year shall be paid 

22 without the application of any deduct23 ible or coinsurance. 

24 ‘‘(C) COUNTING ALL EXPENSES FOR PRE25 MIUMS, DEDUCTIBLES AND COINSURANCE


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1 WITHOUT REGARD TO TRUE OUT-OF-POCKET

2 COSTS.—In applying subparagraphs (A) and 

3 (B), expenses for an individual’s premiums, de4 ductible, and coinsurance shall be counted with5 out regard to whether such expenses are paid, 

6 payable, reimbursed, or reimbursable by an7 other person, including through a group health 

8 plan, insurance or otherwise, or other third 

9 party payment arrangement. 

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

11 Each dollar amount specified in paragraphs (1) and 

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

13 compounded sum of the increase in the consumer 

14 price index for all urban consumers (U.S. City aver15 age, as published by the Bureau of Labor Statistics 

16 of the Department of Labor) for each year after 

17 2009 and up to the year involved. Any increase 

18 under this paragraph for a year shall be rounded, 

19 with respect to paragraph (1), to the nearest mul20 tiple of $5 and, with respect to paragraph (2), to the 

21 nearest multiple of $100. 

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

23 made available under this title (as specified by the Sec24 retary) for prescription drugs and biologicals which are 

25 not less than the benefits for such drugs and biologicals 


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1 under the standard option for the service benefit plan de2 scribed in section 8903(1) of title 5, United States Code, 

3 offered during 2008. 

4 ‘‘(d) CHILDREN.— 

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

6 the case of children (as defined in section 

7 2261(a)(1)), there shall be no deductible or coinsur8 ance applicable to covered benefits (including bene9 fits described in paragraphs (2) and (3)). 

10 ‘‘(2) ADDITIONAL PREVENTIVE BENEFITS.— 

11 ‘‘(A) IN GENERAL.—Subject to the perio12 dicity schedule established with respect to the 

13 services under subparagraph (B), for children 

14 benefits shall be available under this title for 

15 the following items and services: 

16 ‘‘(i) Newborn and well-baby care, in17 cluding normal newborn care and pediatri18 cian services for high-risk deliveries. 

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

20 office visits, routine immunizations (includ21 ing the vaccine itself), routine laboratory 

22 tests, and preventive dental care. 

23 ‘‘(B) PERIODICITY SCHEDULE.—The Sec24 retary, in consultation with the American Acad25 emy of Pediatrics and the American Dental AsVerDate Nov 24 2008 21:11 Jan 12, 2009 Jkt 079200 PO 00000 Frm 00011 Fmt 6652 Sfmt 6201 E:\BILLS\H193.IH H193

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1 sociation, shall establish a schedule of perio2 dicity which reflects the general, appropriate 

3 frequency with which services listed in subpara4 graph (A) should be provided to healthy chil5 dren. 

6 ‘‘(3) COVERAGE OF EPSDT.—For children, ben7 efits also shall be available under this title for early 

8 and periodic screening, diagnostic, and treatment 

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

10 covered under paragraph (2). 

11 ‘‘(4) OTHER ADDITIONAL SERVICES FOR CHIL12 DREN.—For children, benefits also shall be available 

13 under this title for the following: 

14 ‘‘(A) Inpatient hospital services (without 

15 regard to the restrictions described in sub16 sections (a)(1) and (b)(1) of section 1812 and 

17 the coinsurance described in section 

18 1813(a)(1)). 

19 ‘‘(B) Eyeglasses and hearing aids, and ex20 aminations therefor. 

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

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

23 benefits under this title shall include entitlement to have 

24 payment made for the following, without the application 

25 of a deductible or coinsurance: 


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1 ‘‘(1) Prenatal care, including care for all com2 plications of pregnancy. 

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

4 ‘‘(3) Postnatal care. 

5 ‘‘(f) LOWER-INCOME INDIVIDUALS.— 

6 ‘‘(1) LIMITATIONS ON DEDUCTIBLES AND COIN7 SURANCE.— 

8 ‘‘(A) NONE FOR LOW-INCOME INDIVID9 UALS.—In the case of a low-income individual, 

10 there shall be no deductible or coinsurance 

11 under this title. 

12 ‘‘(B) PHASE-IN FOR OTHER LOWER-IN13 COME INDIVIDUALS.—In the case of an indi14 vidual whose applicable modified gross income 

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

16 the poverty level (as defined in section 

17 2261(b)(2)) but does not exceed three times the 

18 poverty level, the deductible and coinsurance 

19 applicable under this title shall bear the same 

20 ratio to the deductible or coinsurance otherwise 

21 applicable as— 

22 ‘‘(i) the excess of the applicable modi23 fied gross income over the poverty level, 

24 bears to 

25 ‘‘(ii) the poverty level. 


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1 If the ratio determined under the preceding 

2 sentence is not a multiple of 25 percentage 

3 points, such ratio shall be rounded to the near4 est 25 percentage points. 

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

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

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

8 this title shall also include entitlement to have pay9 ment made for the following, without the application 

10 of a deductible or coinsurance: 

11 ‘‘(A) Inpatient hospital services (without 

12 regard to the restrictions described in sub13 sections (a)(1) and (b)(1) of section 1812 and 

14 the coinsurance described in section 

15 1813(a)(1)). 

16 ‘‘(B) Eyeglasses and hearing aids and ex17 aminations therefor. 

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

19 made available under this title, without the application of 

20 any deductible or coinsurance for preventive services that 

21 are recommended by the United States Preventive Serv22 ices Task Force. 

23 ‘‘(h) MENTAL HEALTH PARITY AND SUBSTANCE

24 ABUSE BENEFITS.—Benefits shall be made available 

25 under this title for mental health services and for subVerDate Nov 24 2008 21:11 Jan 12, 2009 Jkt 079200 PO 00000 Frm 00014 Fmt 6652 Sfmt 6201 E:\BILLS\H193.IH H193

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1 stance abuse treatment in the same manner as such bene2 fits are made available for medical and surgical services. 

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

4 made available under this title for family planning serv5 ices. 

6 ‘‘(j) CONFORMING MEDICARE BENEFITS.—Notwith7 standing any other provision of law, benefits under title 

8 XVIII shall be expanded and conformed to the benefits 

9 made available under this title (including the application 

10 of a single deductible and uniform coinsurance amounts, 

11 a limitation on the coinsurance, and additional benefits for 

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

13 in this subsection shall be construed as providing for any 

14 such additional benefits under this title rather than under 

15 such title. 

16 ‘‘(k) ENROLLMENT IN HEALTH PLANS.—The Sec17 retary shall provide for the offering of benefits under this 

18 title through enrollment in a health benefit plan that 

19 meets the same (or similar) requirements as the require20 ments that apply to Medicare Advantage plans under part 

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

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

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

24 to the plan under this title shall be based on adjusted aver25 age per capita cost (AAPCC) payment rate methodology 


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

2 title and for individuals entitled to benefits under this title 

3 who are not enrolled in such a plan. 

4 ‘‘SEC. 2222. EXCLUSIONS. 

5 ‘‘(a) IN GENERAL.—Except as provided in this sec6 tion, section 1862 shall apply to expenses incurred for 

7 items and services provided under this title the same man8 ner as such section applies to items and services provided 

9 under title XVIII. 

10 ‘‘(b) BENEFITS EXCEPTION.— 

11 ‘‘(1) CHILDREN’S SERVICES.—In applying sec12 tion 1862(a) with respect to services described in 

13 section 2221(d)(2)(A) (relating to well-child serv14 ices), payment shall not be denied under paragraph 

15 (1), (7), or (12) of such section 1862(a) if the serv16 ices are provided in accordance with the periodicity 

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

18 ‘‘(2) TREATMENT OF EYEGLASSES AND HEAR19 ING AIDS FOR CHILDREN AND LOW-INCOME INDIVID20 UALS.—Payment shall not be denied under this title 

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

22 and hearing aids and examinations therefor in the 

23 case of children and low-income individuals. 

24 ‘‘(c) COORDINATION OF PAYMENTS.— 


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

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

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

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

5 shall not be made under this title with respect to 

6 benefits to the extent that payment for such benefits 

7 may be made under title XVIII. 

8 ‘‘PART C—PAYMENT FOR BENEFITS AND 

9 FINANCING 

10 ‘‘SEC. 2241. PAYMENTS FOR BENEFITS. 

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

12 this section and in section 2221— 

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

14 respect to benefits shall be made on the same basis 

15 as payment is made with respect to such benefits 

16 under title XVIII, and 

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

18 1834, 1842, 1848, and 1886 shall apply to payment 

19 of benefits under this title in the same manner as 

20 they apply to benefits under title XVIII. 

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

22 under this title may only be made on an assignment-re23 lated basis (as defined in section 1842(i)(1)). If an entity 

24 knowingly and willfully presents or causes to be presented 

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


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1 charges for services other than on an assignment-related 

2 basis, the Secretary may apply sanctions against such en3 tity in accordance with section 1842(j)(2). 

4 ‘‘(c) ADJUSTMENT OF PAYMENTS.— 

5 ‘‘(1) ESTABLISHMENT OF NEW DRGS AND

6 WEIGHTS.—In making payment under this title with 

7 respect to inpatient hospital services, the Secretary 

8 shall establish such additional diagnosis-related 

9 groups (and weighting factors with respect to dis10 charges within such groups) and make such adjust11 ments in the diagnosis-related groups and weighting 

12 factors with respect to discharges within such groups 

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

14 may be necessary to reflect the types of discharges 

15 occurring under this title which are not occurring 

16 under title XVIII. 

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

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

19 under this title with respect to the group of ob20 stetrical services typical of treatment through21 out a course of pregnancy, the Secretary shall 

22 establish, as a schedule under section 1848, a 

23 global fee with respect to such group of serv24 ices. 


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1 ‘‘(B) BONUS FOR EARLY PRESEN2 TATION.—The fee schedule amount with respect 

3 to obstetrical services under this title shall be 

4 increased by 5 percent in the case of services 

5 furnished to women who have presented for pre6 natal care during the first trimester. 

7 ‘‘(d) CONDITIONS OF AND LIMITATIONS ON PAY8 MENTS.—The provisions of sections 1814 and 1835 shall 

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

10 manner as they apply to payment for services under parts 

11 A and B, respectively, of title XVIII. 

12 ‘‘(e) USE OF TRUST FUND.—In carrying out this sec13 tion, any reference in title XVIII to a trust fund shall be 

14 treated as a reference to the AmeriCare Trust Fund estab15 lished under section 2242. 

16 ‘‘(f) PAYMENT FOR OUTPATIENT PRESCRIPTION

17 DRUGS AND BIOLOGICALS.—The Secretary shall establish 

18 a fee schedule for the payment for outpatient prescription 

19 drugs and biologicals under this title and, notwithstanding 

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

21 shall negotiate with pharmaceutical manufacturers with 

22 respect to the purchase price of such drugs and biologicals 

23 and shall encourage the use of more affordable therapeutic 

24 equivalents to the extent such practices do not override 

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1 cian. To the extent practicable and consistent with the 

2 previous sentence, the Secretary shall implement strate3 gies similar to those used by other Federal purchasers of 

4 prescription drugs, and other strategies, to reduce the pur5 chase cost of outpatient prescription drugs and biologicals. 

6 ‘‘SEC. 2242. AMERICARE TRUST FUND. 

7 ‘‘(a) ESTABLISHMENT.— 

8 ‘‘(1) There is hereby created on the books of 

9 the Treasury of the United States a trust fund to 

10 be known as the ‘AmeriCare Trust Fund’ (in this 

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

12 Fund shall consist of such gifts and bequests as may 

13 be made as provided in section 201(i)(1) and 

14 amounts appropriated under paragraph (2). 

15 ‘‘(2) There are hereby appropriated to the 

16 Trust Fund amounts equivalent to 100 percent of 

17 the increase in revenues to the Treasury by reason 

18 of the provisions of and amendments made by title 

19 II of the AmeriCare Health Care Act of 2009. The 

20 amounts appropriated by the preceding sentence 

21 shall be transferred from time to time from the gen22 eral fund in the Treasury to the Trust Fund, such 

23 amounts to be determined on the basis of estimates 

24 by the Secretary of the Treasury of the increase in 

25 revenues which are paid to or deposited into the 


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1 Treasury; and proper adjustments shall be made in 

2 amounts subsequently transferred to the extent prior 

3 estimates were in excess of or were less than such 

4 increase. 

5 ‘‘(b) INCORPORATION OF PROVISIONS.— 

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

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

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

9 Fund in the same manner as they apply to the Fed10 eral Hospital Insurance Trust Fund. 

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

12 (1)— 

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

14 Trustee of the Trust Fund shall be composed of 

15 the members of the Board of Trustees and the 

16 Managing Trustee, respectively, of the Federal 

17 Hospital Insurance Trust Fund; and 

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

19 Federal Hospital Insurance Trust Fund or to 

20 title XVIII (or part A thereof) is deemed a ref21 erence to the Trust Fund under this section 

22 and this title, respectively. 


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1 ‘‘PART D—ENTITLEMENT VERIFICATION SYSTEM 

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. 

24 ‘‘(2) INFORMATION AVAILABLE.—Such stand25 ards shall require a system to provide information, 

26 with respect to individuals, concerning the following: 


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1 ‘‘(A) The specific benefits to which the in2 dividual is entitled under the plan. 

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

4 respect to fulfillment of deductibles, coinsur5 ance, and out-of-pocket limits on cost-sharing. 

6 ‘‘(C) Restrictions on providers who may 

7 provide covered services, including utilization 

8 controls (such as preadmission certification). 

9 ‘‘(3) FORM OF INQUIRY.—Each verification sys10 tem shall be capable of accepting inquiries under 

11 this subsection from health care providers in a vari12 ety of electronic forms. The system shall also pro13 vide, for an additional fee, for the acceptance of in14 quiries in a nonelectronic form. 

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

16 shall be capable of responding to such inquiries 

17 under this subsection in a variety of electronic and 

18 other forms, including— 

19 ‘‘(A) through modem transmission of infor20 mation, 

21 ‘‘(B) through computer synthesized voice 

22 communication, and 

23 ‘‘(C) through transmission of information 

24 to a facsimile (fax) machine. 


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

2 for the response to inquiries in a nonelectronic form. 

3 ‘‘(5) LIMITATION ON FEES.—Neither the Sec4 retary nor an AmeriCare supplemental plan may im5 pose a fee for the acceptance or response to an in6 quiry under this subsection except where the accept7 ance or response is in a nonelectronic form. 

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

9 The Secretary shall establish and maintain a website 

10 through which— 

11 ‘‘(A) health service providers may make in12 quiries, and receive responses, with respect to 

13 the eligibility and benefits of an individual 

14 under plans; and 

15 ‘‘(B) AmeriCare supplemental plans may 

16 make inquiries, and receive responses, to deter17 mine the liability of other plans for the provi18 sion or payment of benefits. 

19 ‘‘(7) DEADLINE.—The Secretary shall first es20 tablish the standards under this subsection (and 

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

22 not later than 12 months after the date of the enact23 ment of this title. 

24 ‘‘(c) HEALTH SERVICE PROVIDER DEFINED.—In 

25 this section, the term ‘health service provider’ includes a 


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1 provider of services (as defined in section 1861(u)), physi2 cian, supplier, and other entity furnishing health care 

3 services. 

4 ‘‘PART E—GENERAL PROVISIONS 

5 ‘‘SEC. 2261. DEFINITIONS RELATING TO BENEFICIARIES 

6 AND INCOME. 

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

8 title: 

9 ‘‘(1) CHILD.—The term ‘child’ means an indi10 vidual who throughout a month has not attained 24 

11 years of age. 

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

13 ‘low-income individual’ means an individual whose 

14 applicable modified gross income (as defined in sub15 section (b)(1)) is less than 200 percent of the pov16 erty level (as defined in subsection (b)(2)). The de17 termination that an individual is a low-income indi18 vidual shall be effective for a period of one year and 

19 shall be redetermined on an annual basis. 

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

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

22 been certified by a physician (in a manner specified 

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

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1 ning on the date of termination of the pregnancy) 

2 ends. 

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

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

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

6 this paragraph, the term ‘applicable modified 

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

8 individual, the modified gross income (as de9 fined in section 202(a)(3)(B) of the AmeriCare 

10 Health Care Act of 2009) of the taxpayer (or 

11 the taxpayer for whom the individual may be 

12 claimed as a dependent) for the taxable year 

13 ending in the second previous calendar year. 

14 ‘‘(B) APPLICATION OF CURRENT YEAR

15 MODIFIED GROSS INCOME.— 

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

17 (ii), the Secretary shall establish a proce18 dure under which an individual may file a 

19 declaration of estimated modified gross in20 come for a taxable year ending in a cal21 endar year, which modified gross income 

22 will apply under this subsection as the ap23 plicable modified gross income for the cal24 endar year. Subject to clause (ii), such pro25 cedure shall be applicable regardless of 


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1 whether or not the individual filed a tax 

2 return for the taxable year ending in the 

3 second previous calendar year. 

4 ‘‘(ii) LIMITATION ON APPLICATION.— 

5 The Secretary may limit the application of 

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

7 have filed tax returns for the taxable year 

8 ending in the second previous calendar 

9 year, to individuals with respect to whom 

10 the applicable modified gross income will 

11 be reduced by at least 20 percent as a re12 sult of the application of such clause. 

13 ‘‘(iii) REQUIREMENT FOR RETURN.— 

14 Any individual who has filed a declaration 

15 under clause (i) for a calendar year is re16 quired to file an income tax return for the 

17 taxable year in the calendar year, regard18 less of whether any income tax is actually 

19 owed for the year. The failure of the indi20 vidual to file such a return makes the indi21 vidual liable for overpayments under this 

22 title under clause (iv) in the same manner 

23 as if this paragraph had not applied. 

24 ‘‘(iv) COLLECTION FOR OVERPAY25 MENTS.—If a declaration of estimated 


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1 modified gross income is made applicable 

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

3 actual modified gross income for that tax4 able year exceeds such estimated modified 

5 gross income, the individual shall be liable 

6 to the United States for 110 percent of the 

7 amount of additional payments made 

8 under this title as a result of the use of 

9 such estimated modified gross income in10 stead of the actual modified gross income 

11 for that taxable year. 

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

13 not later than October 1 of each year, the Sec14 retary of the Treasury shall transmit to the 

15 Secretary such information relating to the ap16 plicable modified gross income of individuals for 

17 the taxable year ending in the previous year as 

18 may be necessary to apply this title in the suc19 ceeding calendar year. 

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

21 level’ means, for an individual in a family, the offi22 cial poverty line (as defined by the Office of Man23 agement and Budget, and revised annually in ac24 cordance with section 673(2) of the Omnibus Budget 


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1 Reconciliation Act of 1981) applicable to a family of 

2 the size involved. 

3 ‘‘SEC. 2262. INCORPORATION OF CERTAIN MEDICARE PRO4 VISIONS AND OTHER PROVISIONS. 

5 ‘‘(a) USE OF MEDICARE ADMINISTRATIVE CONTRAC6 TORS.—The Secretary shall provide for the administration 

7 of this title through the use of medicare administrative 

8 contractors in the same manner as title XVIII is carried 

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

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

11 of bills or charges that are submitted electronically in a 

12 manner specified by the Secretary. 

13 ‘‘(b) DEFINITIONS.— 

14 ‘‘(1) IN GENERAL.—Except as otherwise pro15 vided in this title, the definitions contained in sec16 tion 1861 shall apply for purposes of this title in the 

17 same manner as they apply for purposes of title 

18 XVIII. 

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

20 ‘State’ means the 50 States and includes the Dis21 trict of Columbia, Puerto Rico, the Virgin Islands, 

22 Guam, American Samoa, and the Northern Mariana 

23 Islands. 

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

25 States. 


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1 ‘‘(c) CERTIFICATION, PROVIDER QUALIFICATION, 

2 ETC.—The provisions of sections 1863 through 1875, sec3 tions 1877 through 1880, section 1883, section 1885, and 

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

5 same manner as they apply to title XVIII. 

6 ‘‘(d) TITLE XI PROVISIONS.—The following provi7 sions shall apply to this title in the same manner as they 

8 apply to title XVIII: 

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

10 1128E (relating to fraud and abuse). 

11 ‘‘(2) Section 1134 (relating to nonprofit hos12 pital philanthropy). 

13 ‘‘(3) Section 1138 (relating to hospital proto14 cols for organ procurement and standards for organ 

15 procurement agencies). 

16 ‘‘(4) Section 1142 (relating to research on out17 comes of health care services and procedures), ex18 cept that any reference in such section to a Trust 

19 Fund is deemed a reference to the AmeriCare Trust 

20 Fund. 

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

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

23 ‘‘(6) Part C of title XI (relating to administra24 tive simplification). 


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

2 201(i) shall apply to this title and the AmeriCare Trust 

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

4 and the Federal Hospital Insurance Trust Fund. 

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

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

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

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

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

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

11 for payment to the AmeriCare Trust Fund of 1/12th of 

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

13 funds shall be used offset the costs of providing subsidies 

14 for low-income individuals under section 202 of the 

15 AmeriCare Health Care Act of 2009. 

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

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

18 the amount of payment specified in this subsection 

19 for a State for a year is equal to the amount of pay20 ment (net of Federal payments) made by a State 

21 under its State plans under titles XIX and XXI for 

22 2008 for medical assistance for benefits described in 

23 paragraph (2). 

24 ‘‘(2) BENEFITS DESCRIBED.—The benefits de25 scribed in this paragraph with respect to State plans 


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1 of a State under titles XIX and XXI are benefits 

2 which— 

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

4 low-income individuals if this title had been in 

5 effect in 2008; and 

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

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

8 under title XIX, were required to be fur9 nished medical assistance under such title 

10 XIX; or 

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

12 health plan under title XXI, were low-in13 come children. 

14 ‘‘SEC. 2264. MODIFICATION OF MEDICAID AND OTHER PRO15 GRAMS TO AVOID DUPLICATION OF BENE16 FITS. 

17 ‘‘(a) IN GENERAL.—Notwithstanding any other pro18 vision of law— 

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

20 child health plan under title XXI shall not provide 

21 any medical assistance for benefits with respect to 

22 which any payments may be made under this title; 

23 and 

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

25 title 5, United States Code, shall not provide beneVerDate Nov 24 2008 21:11 Jan 12, 2009 Jkt 079200 PO 00000 Frm 00032 Fmt 6652 Sfmt 6201 E:\BILLS\H193.IH H193

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1 fits for which any payment may be made under this 

2 title. 

3 ‘‘(b) REVIEW OF APPLICATION TO OTHER PRO4 GRAMS.—The Secretary shall conduct a review of the fea5 sibility of applying the policy described in subsection (a) 

6 to additional Federal programs, such as the TRICARE 

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

8 than January 1, 2011, the Secretary submit to Congress 

9 on such review and shall include in such report such rec10 ommendations for extending such policy to other Federal 

11 programs as the Secretary deems appropriate. 

12 ‘‘SEC. 2265. CONSTRUCTION REGARDING CONTINUATION 

13 OF OBLIGATIONS UNDER CURRENT GROUP 

14 HEALTH PLAN CONTRACTS AND PROVISION 

15 OF ADDITIONAL BENEFITS. 

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

17 ‘‘(1) affecting obligations for health care bene18 fits under group health plans as in effect on the date 

19 of the enactment of this title, including such plans 

20 established or maintained under or pursuant to one 

21 or more collective bargaining agreements; 

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

23 be provided under a group health plan to employees 

24 or their dependents, or to former employees or their 

25 dependents; or 


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

2 available under a State program to residents of the 

3 State at the expense of the State. 

4 ‘‘SEC. 2266. STANDARDS AND REQUIREMENTS FOR 

5 AMERICARE SUPPLEMENTAL POLICIES. 

6 ‘‘(a) CERTIFICATION REQUIRED.— 

7 ‘‘(1) IN GENERAL.—The Secretary shall estab8 lish rules and procedures consistent with this section 

9 under which AmeriCare supplemental policies may 

10 only be issued if they are certified by the Secretary 

11 or under a State regulatory program approved by 

12 the Secretary as meeting standards established 

13 under subsection (b). 

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

15 an AmeriCare supplemental policy in violation of 

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

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

18 provisions of section 1128A (other than the first 

19 sentence of subsection (a) and other than subsection 

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

21 previous sentence in the same manner as such provi22 sions apply to a penalty or proceeding under section 

23 1128A(a). 

24 ‘‘(3) AMERICARE SUPPLEMENTAL POLICY.—For 

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1 plemental policy’ is a health insurance policy or 

2 other health benefit plan offered by a private entity 

3 to individuals who are entitled to have payment 

4 made under this title, which provides reimbursement 

5 for expenses incurred for services and items for 

6 which payment may be made under this title but 

7 which are not reimbursable by reason of the applica8 tion of deductibles, coinsurance amounts, or other 

9 limitations imposed pursuant to this title; but does 

10 not include— 

11 ‘‘(A) any such policy or plan of the trust12 ees of a fund established by one or more em13 ployers or labor organizations (or combination 

14 thereof) if the policy or plan offers benefits as 

15 a direct service organization under section 

16 1833, or 

17 ‘‘(B) a policy or plan of a health mainte18 nance organization which offers benefits under 

19 this title under section 2221(k). 

20 For purposes of this section, the term ‘policy’ in21 cludes a certificate issued under such policy. 

22 ‘‘(b) CERTIFICATION STANDARDS.— 

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

24 and publish specific standards consistent with this 

25 section for AmeriCare supplemental policies and 


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1 shall consult with the Secretary of Labor regarding 

2 the application of such standards to employee wel3 fare benefit plans under title I of the Employee Re4 tirement Income Security Act of 1974. 

5 ‘‘(2) MORE STRINGENT STATE STANDARDS PER6 MITTED.—In the case of insured AmeriCare supple7 mental policies (as defined in subsection (d)(3)), a 

8 State may implement standards that are more strin9 gent than the standards established under para10 graph (1), including— 

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

12 exclusion limitations described in subsection 

13 (c)(1)(B); 

14 ‘‘(B) additional restrictions on the groups 

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

16 may be offered in AmeriCare supplemental poli17 cies in the State, so long as a core-only benefit 

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

19 such subsection may be offered in the State; 

20 and 

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

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

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

24 standards for AmeriCare supplemental policies consistent 

25 with the following: 


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1 ‘‘(1) NO DISCRIMINATION BASED ON HEALTH

2 STATUS.— 

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

4 under subparagraph (B), an AmeriCare supple5 mental policy may not deny, limit, or condition 

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

7 or vary premiums charged, based on the health 

8 status, claims experience, receipt of health care, 

9 medical history, or lack of evidence of insur10 ability, of an individual. 

11 ‘‘(B) LIMITATION ON USE OF PRE-EXIST12 ING CONDITION EXCLUSIONS.—An AmeriCare 

13 supplemental policy may exclude coverage with 

14 respect to services related to treatment of a 

15 pre-existing condition, except that— 

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

17 not exceed 6 months; 

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

19 services furnished to newborns; and 

20 ‘‘(iii) the period of exclusion under 

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

22 each month in a period of continuous 

23 health benefits coverage (as defined by the 

24 Secretary) for the services involved. 


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1 For purposes of this subparagraph, a condition 

2 is not pre-existing unless it was diagnosed or 

3 treated during the 3-month period ending on 

4 the day before the first date of such coverage. 

5 ‘‘(2) SIMPLIFICATION OF BENEFITS.— 

6 ‘‘(A) IN GENERAL.—Each AmeriCare sup7 plemental policy shall only offer benefits con8 sistent with the standards, promulgated by the 

9 Secretary, that provide— 

10 ‘‘(i) limitations on the groups or pack11 ages of benefits, including a core group of 

12 basic benefits and not to exceed 9 other 

13 different benefit packages, that may be of14 fered under an AmeriCare supplemental 

15 policy; 

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

17 AmeriCare supplemental policy without of18 fering such a policy with only the core19 group of basic benefits and without pro20 viding an outline of coverage in a standard 

21 form approved by the Secretary; 

22 ‘‘(iii) uniform language and defini23 tions to be used with respect to such bene24 fits; and 


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

2 policy with respect to such benefits. 

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

4 approve the offering of new or innovative and 

5 cost-effective benefit packages in addition to 

6 those provided under subparagraph (A). 

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

8 AmeriCare supplemental policy, a specific disease 

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

10 confinement indemnity policy (as defined by the Sec11 retary) may not be issued or renewed unless the pol12 icy— 

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

14 a uniform methodology developed by the Sec15 retary and for periods beginning 24 months 

16 after the date of original issue) to return to pol17 icyholders in the form of aggregate benefits at 

18 least 85 percent of the aggregate amount of 

19 premiums collected in the case of group policies 

20 or at least 75 percent in the case of individual 

21 policies (as defined by the Secretary); and 

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

23 manner specified by the Secretary) for pre24 miums collected in excess of those consistent 

25 with subparagraph (A). 


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1 ‘‘(4) GUARANTEED RENEWABILITY AND CON2 VERTIBILITY.—Each AmeriCare supplemental pol3 icy— 

4 ‘‘(A) shall be guaranteed renewable and 

5 may not be cancelled or nonrenewed solely on 

6 the ground of health status of the individual or 

7 for any reason other than nonpayment of pre8 mium or material misrepresentation; and 

9 ‘‘(B) shall provide for— 

10 ‘‘(i) a right of conversion to an indi11 vidual policy (with continuation of bene12 fits) in the case of termination by a group 

13 policyholder or termination by a 

14 certificateholder of membership in a group 

15 through which the individual obtained cov16 erage; 

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

18 the case of a group policy that succeeds 

19 another group policy; and 

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

21 to 24 months and in a manner specified) 

22 in the case of a policyholder who becomes 

23 entitled to benefits under this title as a 

24 low-income individual and who provides a 


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1 timely notice of election of such suspen2 sion. 

3 ‘‘(5) ADDITIONAL STANDARDS APPLICABLE

4 ONLY TO INSURED POLICIES.—A carrier that offers 

5 an insured AmeriCare supplemental policy (as de6 fined in paragraph (6)) to individuals and groups in 

7 a State shall also comply with the following require8 ments: 

9 ‘‘(A) OPEN ENROLLMENT.—The carrier 

10 must offer the same policy to any other indi11 vidual or group in the State on a continuous, 

12 year-round basis; except that— 

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

14 through an association which is composed 

15 exclusively of employers (which may in16 clude self-employed individuals) and which 

17 has been formed for purposes other than 

18 obtaining health insurance, such require19 ment shall only apply to such employers 

20 (and individuals) who are members of the 

21 association; and 

22 ‘‘(ii) a health maintenance organiza23 tion may deny enrollment with respect to 

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1 all enrollment limitation based on its finan2 cial or administrative capacity. 

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

4 The carrier shall provide advance notice of 

5 terms for policy renewal, which terms shall— 

6 ‘‘(i) be the same as the terms of 

7 issuance, except for rates and administra8 tive changes; 

9 ‘‘(ii) provide the same premium rates 

10 as for a new issue; and 

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

12 not less than 12 months. 

13 ‘‘(d) ADDITIONAL REQUIREMENTS.— 

14 ‘‘(1) PROHIBITION OF DUPLICATION.—The Sec15 retary shall— 

16 ‘‘(A) establish requirements that prohibit 

17 (other than as required under Federal or State 

18 law) the knowing sale or issuance to an indi19 vidual entitled to benefits under this title of 

20 health insurance that duplicates benefits under 

21 this title, of an AmeriCare supplemental policy 

22 that duplicates another AmeriCare supple23 mental policy, or of another health insurance 

24 policy that duplicates other benefits to which 

25 the individual is entitled; and 


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1 ‘‘(B) provide exceptions to the prohibition 

2 in subparagraph (A) for enrollment in group 

3 health plans and similar employment-based poli4 cies and for policies which provide benefits di5 rectly and without regard to other coverage and 

6 notice of such duplication. 

7 ‘‘(2) DISCLOSURE REQUIREMENT.—The Sec8 retary shall establish a requirement that prohibits 

9 the sale or issuance of an AmeriCare supplemental 

10 policy to an individual, other than as a replacement 

11 policy, without obtaining a statement (in a form 

12 specified by the Secretary) that discloses other 

13 health benefits coverage and that acknowledges limi14 tations on the need for an AmeriCare supplemental 

15 policy, particularly in the case of a low-income indi16 vidual. 

17 ‘‘(3) APPLICATION OF FALSE STATEMENT

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

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

20 supplemental policy under this section in the same 

21 manner as they apply to medicare supplemental poli22 cies under such section. 

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

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

25 person who provides for a commission or other 


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1 compensation to an agent or other representa2 tives with respect to the sale of an AmeriCare 

3 supplemental policy (or certificate)— 

4 ‘‘(i) to provide for a first year com5 mission or other first year compensation 

6 that exceeds 200 percent of the commis7 sion or other compensation for the selling 

8 or servicing of the policy or certificate in 

9 a second or subsequent year; or 

10 ‘‘(ii) to provide for compensation with 

11 respect to replacement of such a policy or 

12 certificate that is greater than the com13 pensation that would apply to the renewal 

14 of the policy or certificate. 

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

16 the term ‘compensation’ includes pecuniary and 

17 nonpecuniary compensation of any kind relating 

18 to the sale or renewal of a policy or certificate 

19 and specifically includes bonuses, gifts, prizes, 

20 awards, and finders’ fees. 

21 ‘‘(e) INFORMATION DISCLOSURE.—The Secretary 

22 shall provide, to all individuals entitled to benefits under 

23 this title, such information as will permit such individuals 

24 to evaluate the value of AmeriCare supplemental policies 

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1 fits provided under this title. Such information shall in2 clude information on— 

3 ‘‘(1) the requirements and prohibitions under 

4 this section; 

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

6 compliance with such requirements and enforcement 

7 of such prohibitions; and 

8 ‘‘(3) the manner of submitting complaints re9 garding violations of such requirements and prohibi10 tions. 

11 ‘‘(f) DEFINITIONS.—In this section: 

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

13 person that offers an AmeriCare supplemental pol14 icy. 

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

16 more employees of the same employer who normally 

17 perform on a monthly basis at least 171/2 hours of 

18 service per week for that employer. 

19 ‘‘(3) HEALTH MAINTENANCE ORGANIZATION.— 

20 The term ‘health maintenance organization’ has the 

21 meaning given the term ‘eligible organization’ in sec22 tion 1876(b). 

23 ‘‘(4) INSURED AMERICARE SUPPLEMENTAL

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1 mental policy’ means any AmeriCare supplemental 

2 policy provided through insurance.’’. 

3 TITLE II—FINANCING 

4 PROVISIONS 

5 Subtitle A—Individual 

6 Contributions 

7 SEC. 201. GENERAL OBLIGATION FOR INDIVIDUALS. 

8 (a) PAYMENT OF PLAN PREMIUM.— 

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

10 coverage under title XXII of the Social Security Act 

11 is liable for payment of the premium established 

12 under this section for such coverage of the individual 

13 and family members. An individual who is not re14 ceiving such coverage due to coverage under a group 

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

16 is not liable for payment of such premium with re17 spect to such individual. 

18 (2) DETERMINATION OF PREMIUM.—Such pre19 mium shall be established by the Secretary of Health 

20 and Human Services on the basis of the cost of cov21 erage (determined on a State by State basis and in22 cluding administrative costs) and shall be deter23 mined separately based on the class of enrollment 

24 for the individual (as determined under section 2202 

25 of the Social Security Act). 


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

2 than one individual is liable under this subsection 

3 for payment of a premium for coverage of the same 

4 individual under title XXII of the Social Security 

5 Act, such individual shall be jointly and severally lia6 ble with each other individual who is so liable. 

7 (b) REDUCTION FOR EMPLOYER CONTRIBUTIONS

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

9 under subsection (a) is reduced by— 

10 (1) the amount of any contributions made by 

11 the individual’s employer (or employers) under sub12 title B or otherwise (including voluntary employer 

13 contributions) with respect to coverage of the indi14 vidual and family members, and 

15 (2) the amount of any premium subsidies pro16 vided with respect to the individual under section 

17 202. 

18 (c) TIMING AND MANNER OF PAYMENT.—Each indi19 vidual that is liable for a premium under subsection (a) 

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

21 Secretary of the Treasury may specify. Except as other22 wise provided by the Secretary of the Treasury, for pur23 poses of subtitle F of such Code, the liabilities imposed 

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

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


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1 of the Treasury shall provide for the withholding of such 

2 payments from wages under rules similar to the rules of 

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

4 may prescribe special rules for withholding payments from 

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

6 more than one employer. 

7 SEC. 202. ADDITIONAL PREMIUM SUBSIDIES. 

8 (a) ELIGIBILITY FOR ADDITIONAL PREMIUM SUB9 SIDIES.— 

10 (1) IN GENERAL.—Each premium subsidy eligi11 ble individual is entitled to a premium subsidy in ac12 cordance with this section. 

13 (2) PREMIUM SUBSIDY ELIGIBLE INDI14 VIDUAL.—In this section, the term ‘‘premium sub15 sidy eligible individual’’ means an individual receiv16 ing coverage under title XXII of the Social Security 

17 Act who— 

18 (A) with respect to premiums for a taxable 

19 year ending in a year, has family income (as de20 fined in paragraph (3)(A)) that is less than 300 

21 percent of the applicable poverty level, or 

22 (B) with respect to a premium for a 

23 month, is an TANF or SSI recipient for the 

24 month. 

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


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

2 income’’ means, with respect to an individual 

3 who— 

4 (i) is not a dependent of another indi5 vidual, the sum of the modified adjusted 

6 gross incomes (as defined in subparagraph 

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

8 spouse, and children who are dependents of 

9 the individual, or 

10 (ii) is a dependent of another indi11 vidual, the sum of the modified adjusted 

12 gross incomes (as defined in subparagraph 

13 (B)) for the other individual, the other in14 dividual’s spouse, and children who are de15 pendents of the other individual. 

16 (B) MODIFIED ADJUSTED GROSS IN17 COME.—The term ‘‘modified adjusted gross in18 come’’ means adjusted gross income (as defined 

19 in the Internal Revenue Code of 1986)— 

20 (i) determined without regard to sec21 tions 911, 931, and 933 of such Code, and 

22 (ii) increased by— 

23 (I) the amount of interest re24 ceived or accrued by the individual 


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1 during the taxable year which is ex2 empt from tax, and 

3 (II) the amount of the social se4 curity benefits (as defined in section 

5 86(d) of such Code) received during 

6 the taxable year to the extent not in7 cluded in gross income under section 

8 86 of such Code. 

9 The determination under the preceding 

10 sentence shall be made without regard to 

11 any carryover or carryback. 

12 (C) APPLICABLE POVERTY LEVEL.— 

13 (i) IN GENERAL.—The term ‘‘applica14 ble poverty level’’ means, for a family for 

15 a year, the official poverty line (as defined 

16 by the Secretary of Health and Human 

17 Services) applicable to a family of the size 

18 involved for 2011 adjusted by the percent19 age increase or decrease described in 

20 clause (ii) for the year involved. 

21 (ii) PERCENTAGE ADJUSTMENT.—The 

22 percentage increase or decrease described 

23 in this clause for a year is the percentage 

24 increase or decrease by which the average 

25 Consumer Price Index for all urban conVerDate Nov 24 2008 23:10 Jan 13, 2009 Jkt 079200 PO 00000 Frm 00050 Fmt 6652 Sfmt 6201 E:\BILLS\H193.IH H193

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1 sumers (U.S. city average), as published by 

2 the Bureau of Labor Statistics, for the 12- 

3 month-period ending with August 31 of the 

4 preceding year exceeds such average for 

5 the 12-month period ending with August 

6 31, 2011. 

7 (iii) ROUNDING.—Any adjustment 

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

9 rounded to the nearest multiple of $100. 

10 (D) TANF RECIPIENT.—The term 

11 ‘‘TANF recipient’’ means, for a month, an indi12 vidual who is receiving aid or assistance under 

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

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

15 of the Social Security Act, for the month. 

16 (E) SSI RECIPIENT.—The term ‘‘SSI re17 cipient’’ means, for a month, an individual— 

18 (i) with respect to whom supplemental 

19 security income benefits are being paid 

20 under title XVI of the Social Security Act 

21 for the month, 

22 (ii) who is receiving a supplementary 

23 payment under section 1616 of such Act or 

24 under section 212 of Public Law 93–66 for 

25 the month, or 


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1 (iii) who is receiving monthly benefits 

2 under section 1619(a) of the Social Secu3 rity Act (whether or not pursuant to sec4 tion 1616(c)(3) of such Act) for the 

5 month. 

6 (b) AMOUNT OF PREMIUM SUBSIDY.— 

7 (1) LOWEST INCOME INDIVIDUALS.— 

8 (A) IN GENERAL.—In the case of an indi9 vidual described in subparagraph (B), the pre10 mium subsidy under this section is the amount 

11 which would (without regard to this section) re12 duce the premium obligation of the individual 

13 (and family members) under section 201 to 

14 zero. 

15 (B) LOWEST INCOME INDIVIDUALS DE16 SCRIBED.—An individual described in this sub17 paragraph is a premium subsidy eligible indi18 vidual who would still be such an individual 

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

20 substituted for ‘‘300 percent’’ in subparagraph 

21 (A) of such subsection. 

22 (2) OTHER INDIVIDUALS.— 

23 (A) IN GENERAL.—In the case of a pre24 mium subsidy eligible individual not described 


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1 in paragraph (1), the premium subsidy under 

2 this section is the product of— 

3 (i) the premium obligation of the indi4 vidual (and family members) under section 

5 201, multiplied by 

6 (ii) the number of percentage points 

7 by which the individual’s family income 

8 (expressed as a percent of the applicable 

9 poverty level) is less than 300 percent. 

10 (B) TABLE.—The Secretary may provide 

11 for a table which establishes the values for pre12 mium subsidies under this paragraph. 

13 (c) GENERAL REVENUE FINANCING FOR LOW IN14 COME SUBSIDIES.—There are authorized to be appro15 priated to the AmeriCare Trust Fund from amounts in 

16 the Treasury not otherwise appropriated, such sums as 

17 may be necessary to cover the costs of premium subsidies 

18 provided under this section. 

19 SEC. 203. EFFECTIVE DATE. 

20 The provisions of this subtitle shall apply with respect 

21 to periods beginning on or after January 1, 2011. 

22 Subtitle B—Employer 

23 Contributions 

24 SEC. 211. GENERAL OBLIGATION FOR EMPLOYERS. 

25 (a) GENERAL OBLIGATION.— 


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

2 provisions of this subsection, each employer shall 

3 make a financial contribution toward the cost of 

4 health insurance coverage for employees in accord5 ance with this section. 

6 (2) ELIMINATION OF LIABILITY IN CASE OF

7 CERTAIN GROUP HEALTH PLAN COVERAGE.— 

8 (A) IN GENERAL.—Subject to subpara9 graph (B), an employer shall not be liable for 

10 any contribution under this section with respect 

11 to any employee who is covered under a group 

12 health plan of the employer described in section 

13 2202(d) if such employer pays at least 80 per14 cent of the cost of such health plan, as deter15 mined by the Secretary of Health and Human 

16 Services. 

17 (B) SURCHARGE PERMISSIBLE TO PRE18 VENT ADVERSE SELECTION.—The Secretary 

19 may impose liability for a contribution under 

20 this section with respect to an employee de21 scribed in subparagraph (A) in an amount (not 

22 to exceed the amount specified under subsection 

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1 viduals enrolled under this title as a result of 

2 the operation of such subparagraph. 

3 (b) AMOUNT OF CONTRIBUTION.— 

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

5 employee receiving coverage under title XXII of the 

6 Social Security Act, the amount of the financial con7 tribution is equal to at least 80 percent of the pre8 mium determined with respect to such employee and 

9 family members under section 201 (based on class of 

10 enrollment and without regard to subsection (b) 

11 thereof) or at least 80 percent of the cost of cov12 erage under such group health plan, respectively. 

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

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

15 contribution requirements of paragraph (1) shall be 

16 treated as satisfied if the employer contribution with 

17 respect to such employee is not less than the part18 time employment ratio of the contribution required 

19 under paragraph (1). 

20 (3) RULES RELATED TO PART-TIME EMPLOY21 MENT.—For purposes of this subsection— 

22 (A) PART-TIME EMPLOYEE.—The term 

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

24 any month, an employee who works on average 

25 fewer than 40 hours per week. 


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1 (B) PART-TIME EMPLOYMENT RATIO.— 

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

3 with respect to a part-time employee of an em4 ployer in a month, a fraction— 

5 (i) the numerator of which is the 

6 number of hours in the employee’s normal 

7 work week, and 

8 (ii) the denominator of which is 40 

9 hours. 

10 (C) SPECIAL RULES.—Under rules pre11 scribed by the Secretary of Health and Human 

12 Services, in consultation with the Secretary of 

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

14 employer whose defined work week for full-time 

15 employees is less than 40 hours, any reference 

16 in this subsection to 40 hours is deemed a ref17 erence to the number of hours in the work week 

18 so defined. 

19 (D) CONVERSION TO HOURS OF EMPLOY20 MENT.—The Secretary of Health and Human 

21 Services, in consultation with the Secretary of 

22 the Treasury, shall establish rules for the con23 version of compensation to hours of employ24 ment, for purposes of this subsection in the 

25 case of employees that receive compensation on 


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1 a salaried basis, or on the basis of a commis2 sion, or other contingent or bonus basis, rather 

3 than based on an hourly wage. 

4 (c) TIMING AND MANNER.— 

5 (1) IN GENERAL.—Each employer that is re6 quired to make a financial contribution with respect 

7 to an employee under this section (other than with 

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

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

10 contribution or surcharge in a form and manner, 

11 specified by the Secretary of the Treasury, based 

12 upon the form and manner in which employer excise 

13 taxes are required to be paid under section 3111 of 

14 the Internal Revenue Code of 1986. 

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

16 of an employee who is covered under the class of en17 rollment of a family member, the Secretary of the 

18 Treasury shall provide that the financial contribu19 tion of the employer with respect to such employee 

20 is paid directly or indirectly to the employer of such 

21 family member. 

22 SEC. 212. EFFECTIVE DATE. 

23 (a) IN GENERAL.—Subject to subsection (b), the pro24 visions of this subtitle shall apply with respect to periods 

25 beginning on or after January 1, 2011. 


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1 (b) ADDITIONAL PERIOD FOR SMALL EMPLOYERS.— 

2 The provisions of this subtitle shall not apply with respect 

3 to an employer that has fewer than 100 employees (as de4 termined by the Secretary of the Treasury in consultation 

5 with the Secretary of Health and Human Services) for pe6 riods beginning before January 1, 2014. 

Æ 


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