I 
110TH CONGRESS 
2D SESSION 
H. R. 6699 
To amend title XVIII of the Social Security Act to reform Medicare payments 
to physicians and certain other providers and improve Medicare benefits, 
to encourage the offering of health coverage by small businesses, to 
provide tax incentives for the purchase of health insurance by individuals, 
to increase access to health care for veterans, to address the nursing 
shortage, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
JULY 31, 2008 
Mr. LATHAM introduced the following bill; which was referred to the Com-
mittee on Energy and Commerce, and in addition to the Committees on 
Education and Labor, Ways and Means, Veterans’ Affairs, and Armed 
Services, for a period to be subsequently determined by the Speaker, in 
each case for consideration of such provisions as fall within the jurisdic-
tion of the committee concerned 
A BILL 
To amend title XVIII of the Social Security Act to reform 
Medicare payments to physicians and certain other pro-
viders and improve Medicare benefits, to encourage the 
offering of health coverage by small businesses, to pro-
vide tax incentives for the purchase of health insurance 
by individuals, to increase access to health care for vet-
erans, to address the nursing shortage, and for other 
purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
VerDate Aug 31 2005 
21:34 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00001
Fmt 6652
Sfmt 6201
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Health Security for All Americans Act of 2008’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
Sec. 1. Short title; table of contents. 
TITLE I—MEDICARE 
Sec. 101. Medicare physician payment update reform. 
Sec. 102. Medicare GPCI floors. 
Sec. 103. Annual physical examinations under Medicare. 
Sec. 104. Medicare outreach campaign on availability of welcome to Medicare 
physicals. 
Sec. 105. Improvements to the Medicare-dependent hospital (MDH) program. 
Sec. 106. Improvements to the Medicare inpatient hospital payment adjustment 
for low-volume hospitals. 
Sec. 107. Ensuring proportional representation of interests of rural areas on 
MedPAC. 
TITLE II—SMALL BUSINESS HEALTH PLANS 
Subtitle A—Enhanced Marketplace Pools 
Sec. 201. Rules governing enhanced marketplace pools. 
‘‘PART 8—RULES GOVERNING ENHANCED MARKETPLACE POOLS 
‘‘Sec. 801. Small business health plans. 
‘‘Sec. 802. Alternative Market Pooling Organizations. 
‘‘Sec. 803. Certification of small business health plans. 
‘‘Sec. 804. Requirements relating to sponsors and boards of trustees. 
‘‘Sec. 805. Participation and coverage requirements. 
‘‘Sec. 806. Other requirements relating to plan documents, contribution 
rates, and benefit options. 
‘‘Sec. 807. Requirements for application and related requirements. 
‘‘Sec. 808. Notice requirements for voluntary termination. 
‘‘Sec. 809. Implementation and application authority by Secretary. 
‘‘Sec. 810. Definitions and rules of construction. 
Sec. 202. Cooperation between Federal and State authorities. 
Sec. 203. Effective date and transitional and other rules. 
Subtitle B—Market Relief 
Sec. 211. Market relief. 
‘‘TITLE XXX—HEALTH CARE INSURANCE MARKETPLACE 
MODERNIZATION 
‘‘Sec. 3001. General insurance definitions. 
‘‘Sec. 3002. Implementation and application authority by Secretary. 
VerDate Aug 31 2005 
22:47 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00002
Fmt 6652
Sfmt 6211
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS
‘‘Subtitle A—Market Relief 
‘‘PART I—RATING REQUIREMENTS 
‘‘Sec. 3011. Definitions. 
‘‘Sec. 3012. Rating rules. 
‘‘Sec. 3013. Application and preemption. 
‘‘Sec. 3014. Civil actions and jurisdiction. 
‘‘Sec. 3015. Ongoing review. 
‘‘PART II—AFFORDABLE PLANS 
‘‘Sec. 3021. Definitions. 
‘‘Sec. 3022. Offering affordable plans. 
‘‘Sec. 3023. Application and preemption. 
‘‘Sec. 3024. Civil actions and jurisdiction. 
‘‘Sec. 3025. Rules of construction. 
Subtitle C—Harmonization of Health Insurance Standards 
Sec. 221. Health Insurance Standards Harmonization. 
‘‘Subtitle B—Standards Harmonization 
‘‘Sec. 3031. Definitions. 
‘‘Sec. 3032. Harmonized standards. 
‘‘Sec. 3033. Application and preemption. 
‘‘Sec. 3034. Civil actions and jurisdiction. 
‘‘Sec. 3035. Authorization of appropriations; rule of construction. 
TITLE III—TAX–RELATED HEALTH INCENTIVES 
Sec. 301. SECA tax deduction for health insurance costs. 
Sec. 302. Deduction for qualified health insurance costs of individuals. 
TITLE IV—INCREASING ACCESS TO VA HEALTH CARE 
Sec. 401. Requirement for payments to facilities other than the Department of 
Veterans Affairs for covered health services. 
Sec. 402. Authority of Department of Veterans Affairs pharmacies to dispense 
medications to veterans on prescriptions written by private 
practitioners. 
TITLE V—NURSING SHORTAGE 
Sec. 501. Child care assistance for individuals pursuing advanced nursing de-
grees. 
Sec. 502. Nurse faculty program. 
‘‘PART E—NURSE FACULTY PROJECT 
‘‘Sec. 771. Purposes. 
‘‘Sec. 772. Assistance authorized. 
‘‘Sec. 773. Applications. 
‘‘Sec. 774. Authorization of appropriations. 
‘‘Sec. 775. Definition. 
Sec. 503. Additional capacity for R.N. students or graduate-level nursing stu-
dents. 
VerDate Aug 31 2005 
21:34 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00003
Fmt 6652
Sfmt 6211
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS
‘‘PART F—ADDITIONAL CAPACITY FOR R.N. STUDENTS OR GRADUATE- 
LEVEL NURSING STUDENTS 
‘‘Sec. 781. Additional capacity for R.N. students or graduate-level nursing 
students. 
Sec. 504. Programs to increase the number of nurses within the Armed Forces. 
TITLE VI—RESERVE COMPONENTS OF THE ARMED FORCES 
Sec. 601. Effective date of active duty for purposes of entitlement to active 
duty health care of members of the reserve components of the 
armed forces receiving alert order anticipating a call or order 
to active duty in support of a contingency operation. 
TITLE I—MEDICARE 
SEC. 101. MEDICARE PHYSICIAN PAYMENT UPDATE RE-
FORM. 
(a) SUBSTITUTION OF MEI INCREASE FOR SGR AD-
JUSTMENTS.—Section 1848(d) of the Social Security Act 
(42 U.S.C. 1395w–4(d)), as amended by section 131(a) 
of the Medicare Improvements for Patients and Providers 
Act of 2008 (Public Law 110–275), is amended— 
(1) in paragraph (1)(A), by inserting ‘‘and be-
fore 2010’’ after ‘‘beginning with 2001’’; 
(2) in paragraph (1)(A), by inserting before the 
period at the end the following: ‘‘, and for years be-
ginning with 2010, multiplied by the update estab-
lished under paragraph (10) applicable to the year 
involved’’; and 
(3) in paragraph (4)— 
(A) in the heading by striking ‘‘YEARS BE-
GINNING WITH 2001’’ and inserting ‘‘2001, 2002, 
AND 2003’’; and 
VerDate Aug 31 2005 
21:34 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00004
Fmt 6652
Sfmt 6201
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS
(B) in subparagraph (A), by inserting 
‘‘and ending with 2003’’ after ‘‘beginning with 
2001’’; and 
(4) by adding at the end the following new 
paragraph: 
‘‘(10) UPDATE
BEGINNING
WITH
2010.—The 
update to the single conversion factor established in 
paragraph (1)(C) for 2010 and each succeeding year 
shall be the percentage increase in the MEI (as de-
fined in section 1842(i)(3)) for the year involved 
minus 1 percentage point.’’. 
(b) 
ENDING
APPLICATION
OF
SUSTAINABLE 
GROWTH RATE (SGR).—Section 1848(f)(1)(B) of such 
Act (42 U.S.C. 1395w–4(f)(1)(B)) is amended by insert-
ing ‘‘(and before 2009)’’ after ‘‘each succeeding year’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to payment for services furnished 
on or after January 1, 2010. 
SEC. 102. MEDICARE GPCI FLOORS. 
Section 1848(e)(1) of the Social Security Act (42 
U.S.C. 1395w–4(e)(1)) is amended— 
(1) in subparagraph (A), by striking ‘‘and (G)’’ 
and inserting ‘‘(G), (H), and (I)’’; and 
(2) by adding at the end the following new sub-
paragraphs: 
VerDate Aug 31 2005 
21:34 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00005
Fmt 6652
Sfmt 6201
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS
‘‘(H) FLOOR
AT
1.0
FOR
PRACTICE
EX-
PENSE INDEX.—After calculating the practice 
expense index in subparagraph (A)(ii), for pur-
poses of payment for services furnished on or 
after January 1, 2009, the Secretary shall in-
crease the practice expense geographic index to 
1.00 for any locality for which such practice ex-
pense geographic index is less than 1.00. 
‘‘(I) FLOOR AT 1.0 FOR WORK EXPENSES 
INDEX.—After calculating the practice expense 
index in subparagraph (A)(ii), for purposes of 
payment for services furnished on or after Jan-
uary 1, 2009, the Secretary shall increase the 
practice expense geographic index to 1.00 for 
any locality for which such practice expense ge-
ographic index is less than 1.00.’’. 
SEC. 103. ANNUAL PHYSICAL EXAMINATIONS UNDER MEDI-
CARE. 
(a) IN GENERAL.—Section 1861 of the Social Secu-
rity Act (42 U.S.C. 1395x) is amended— 
(1) in each of subparagraphs (W) and (AA)(i) 
of subsection (s)(2), by striking ‘‘initial’’ and insert-
ing ‘‘annual’’; 
(2) in the heading of subsection (ww), by strik-
ing ‘‘Initial’’ and inserting ‘‘Annual’’; and 
VerDate Aug 31 2005 
21:34 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00006
Fmt 6652
Sfmt 6201
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS
(3) by amending paragraph (1) of subsection 
(ww) to read as follows: 
‘‘(1) The term ‘annual preventive physical ex-
amination’ means professional services of a physi-
cian, or of a nurse practitioner or physician assist-
ant which the practitioner or assistant is authorized 
to provide under State law, consisting of a physical 
examination (including, as medically appropriate, 
measurement of height, weight, body mass index, 
and blood pressure) with the goal of health pro-
motion and disease detection and includes education, 
counseling, and referral with respect to screening 
and other preventive services described in paragraph 
(2) and end-of-life planning (as defined in paragraph 
(3)) upon the agreement with the individual, as well 
as related clinical laboratory tests and such other 
preventive services in connection with the same visit 
as the Secretary may provide (taking into account 
services typically included in an annual physical ex-
amination covered under private health benefit 
plans).’’. 
(b) 
MODIFICATION
OF
EXCLUSIONS.—Section 
1862(a) of such Act (42 U.S.C. 1395y(a)) is amended— 
(1) in paragraph (1), by amending subpara-
graph (K) to read as follows: 
VerDate Aug 31 2005 
21:34 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00007
Fmt 6652
Sfmt 6201
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS
‘‘(K) in the case of an annual preventive 
physical examination, which is performed for an 
individual more frequently than once in any 12- 
month period,’’; and 
(2) in paragraph (7), by inserting ‘‘(other than 
annual preventive physical examinations)’’ after 
‘‘routine physical checkups’’. 
(c) CONFORMING AMENDMENT.—Section 1833(b)(9) 
of such Act (42 U.S.C. 1395l(b)(9)), as inserted by section 
101(b)(2)(B) of the Medicare Improvements for Patients 
and Providers Act of 2008 (Public Law 110–275), is 
amended by striking ‘‘initial’’ and inserting ‘‘annual’’. 
(d) EFFECTIVE DATE.—The amendments made by 
this section shall apply to services furnished on or after 
January 1 of the first year beginning more than 60 days 
after the date of the enactment of this Act. 
SEC. 104. MEDICARE OUTREACH CAMPAIGN ON AVAIL-
ABILITY 
OF 
WELCOME 
TO 
MEDICARE 
PHYSICALS. 
(a) IN GENERAL.—The Secretary of Health and 
Human Services shall conduct a national campaign to pro-
vide information to the public on the availability of an ini-
tial preventive physical examination (as defined in section 
1861(ww) of the Social Security Act (42 U.S.C. 
1395x(ww))) for beneficiaries of the Medicare program 
VerDate Aug 31 2005 
21:34 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00008
Fmt 6652
Sfmt 6201
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS
under title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.). 
(b) AUTHORIZATION OF APPROPRIATIONS.—There is 
authorized to be appropriated to carry out this section 
$1,000,000 for each of fiscal years 2009 through 2013. 
SEC. 105. IMPROVEMENTS TO THE MEDICARE-DEPENDENT 
HOSPITAL (MDH) PROGRAM. 
(a) USE OF NON-WAGE ADJUSTED PPS RATE.— 
Section 1886(d)(5)(G) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(G)) is amended by adding at the 
end the following new clause: 
‘‘(v) In the case of discharges occurring on or after 
October 1, 2008, and before October 1, 2011, in deter-
mining the amount under paragraph (1)(A)(iii) for pur-
poses of clauses (i) and (ii)(II) of this subparagraph, such 
amount shall, if it results in greater payments to the hos-
pital, be determined without regard to any adjustment for 
different area wage levels under paragraph (3)(E).’’. 
(b) ENHANCED PAYMENT FOR AMOUNT BY WHICH 
THE
TARGET
EXCEEDS
THE
PPS RATE.—Section 
1886(d)(5)(G)(ii)(II) 
of 
such 
Act 
(42 
U.S.C. 
1395ww(d)(5)(G)(ii)(II)) is amended by inserting ‘‘and 
before October 1, 2008, or 85 percent in the case of dis-
charges occurring on or after October 1, 2008, and before 
October 1, 2011’’ after ‘‘October 1, 2006’’. 
VerDate Aug 31 2005 
21:34 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00009
Fmt 6652
Sfmt 6201
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS
SEC. 106. IMPROVEMENTS TO THE MEDICARE INPATIENT 
HOSPITAL PAYMENT ADJUSTMENT FOR LOW- 
VOLUME HOSPITALS. 
Section 1886(d)(12) of the Social Security Act (42 
U.S.C. 1395ww(d)(12)) is amended— 
(1) in subparagraph (A), by inserting ‘‘or (D)’’ 
after ‘‘subparagraph (B)’’; 
(2) in subparagraph (B), by adding at the end 
of the heading ‘‘FOR FISCAL YEARS 2005 THROUGH 
2008’’; 
(3) in subparagraph (B), in the matter pre-
ceding clause (i), by striking ‘‘The Secretary’’ and 
inserting ‘‘For discharges occurring in fiscal years 
2005 through 2008, the Secretary’’; 
(4) in subparagraph (C)(i)— 
(A) by inserting ‘‘(or, with respect to fiscal 
year 2009 and each subsequent fiscal year, 15 
road miles)’’ after ‘‘25 road miles’’; and 
(B) by inserting ‘‘(or, with respect to fiscal 
year 2009 and each subsequent fiscal year, 
2,000 discharges of individuals entitled to, or 
enrolled for, benefits under part A)’’ after ‘‘800 
discharges’’; and 
(5) by adding at the end the following new sub-
paragraph: 
VerDate Aug 31 2005 
21:34 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00010
Fmt 6652
Sfmt 6201
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS
‘‘(D) APPLICABLE PERCENTAGE INCREASE 
BEGINNING
IN
FISCAL
YEAR
2009.—For dis-
charges occurring in fiscal year 2009 and each 
subsequent fiscal year, the Secretary shall de-
termine an applicable percentage increase for 
purposes of subparagraph (A) using a linear 
sliding scale ranging from 25 percent for low- 
volume hospitals with fewer than an appro-
priate number (as determined by the Secretary) 
of discharges of individuals entitled to, or en-
rolled for, benefits under part A in the fiscal 
year to 0 percent for low-volume hospitals with 
greater than 2,000 discharges of such individ-
uals in the fiscal year.’’. 
SEC. 107. ENSURING PROPORTIONAL REPRESENTATION OF 
INTERESTS OF RURAL AREAS ON MEDPAC. 
(a) IN GENERAL.—Section 1805(c)(2) of the Social 
Security Act (42 U.S.C. 1395b–6(c)(2)) is amended— 
(1) in subparagraph (A), by inserting ‘‘con-
sistent with subparagraph (E)’’ after ‘‘rural rep-
resentatives’’; and 
(2) by adding at the end the following new sub-
paragraph: 
‘‘(E) PROPORTIONAL REPRESENTATION OF 
INTERESTS OF RURAL AREAS.—In order to pro-
VerDate Aug 31 2005 
21:34 Aug 04, 2008
Jkt 069200
PO 00000
Frm 00011
Fmt 6652
Sfmt 6201
E:\BILLS\H6699.IH
H6699
mstockstill on PROD1PC66 with BILLS