H. R. 3590—786 
‘‘(3) otherwise complies with the minimum standards pre-
scribed for carriers offering health benefits plans under section 
8902(e) of title 5, United States Code, to the extent that such 
standards do not conflict with a provision of this title; and 
‘‘(4) meets such other requirements as determined appro-
priate by the Director, in consultation with the Secretary. 
‘‘(c) REQUIREMENTS
FOR
MULTI-STATE
QUALIFIED
HEALTH 
PLAN.— 
‘‘(1) IN
GENERAL.—A multi-State qualified health plan 
meets the requirements of this subsection if, in the determina-
tion of the Director— 
‘‘(A) the plan offers a benefits package that is uniform 
in each State and consists of the essential benefits 
described in section 1302; 
‘‘(B) the plan meets all requirements of this title with 
respect to a qualified health plan, including requirements 
relating to the offering of the bronze, silver, and gold levels 
of coverage and catastrophic coverage in each State 
Exchange; 
‘‘(C) except as provided in paragraph (5), the issuer 
provides for determinations of premiums for coverage under 
the plan on the basis of the rating requirements of part 
A of title XXVII of the Public Health Service Act; and 
‘‘(D) the issuer offers the plan in all geographic regions, 
and in all States that have adopted adjusted community 
rating before the date of enactment of this Act. 
‘‘(2) STATES MAY OFFER ADDITIONAL BENEFITS.—Nothing in 
paragraph (1)(A) shall preclude a State from requiring that 
benefits in addition to the essential health benefits required 
under such paragraph be provided to enrollees of a multi- 
State qualified health plan offered in such State. 
‘‘(3) CREDITS.— 
‘‘(A) IN GENERAL.—An individual enrolled in a multi- 
State qualified health plan under this section shall be 
eligible for credits under section 36B of the Internal Rev-
enue Code of 1986 and cost sharing assistance under sec-
tion 1402 in the same manner as an individual who is 
enrolled in a qualified health plan. 
‘‘(B) NO
ADDITIONAL
FEDERAL
COST.—A requirement 
by a State under paragraph (2) that benefits in addition 
to the essential health benefits required under paragraph 
(1)(A) be provided to enrollees of a multi-State qualified 
health plan shall not affect the amount of a premium 
tax credit provided under section 36B of the Internal Rev-
enue Code of 1986 with respect to such plan. 
‘‘(4) STATE MUST ASSUME COST.—A State shall make pay-
ments— 
‘‘(A) to an individual enrolled in a multi-State qualified 
health plan offered in such State; or 
‘‘(B) on behalf of an individual described in subpara-
graph (A) directly to the multi-State qualified health plan 
in which such individual is enrolled; 
to defray the cost of any additional benefits described in para-
graph (2). 
‘‘(5) APPLICATION
OF
CERTAIN
STATE
RATING
REQUIRE-
MENTS.—With respect to a multi-State qualified health plan 
that is offered in a State with age rating requirements that
H. R. 3590—787 
are lower than 3:1, the State may require that Exchanges 
operating in such State only permit the offering of such multi- 
State qualified health plans if such plans comply with the 
State’s more protective age rating requirements. 
‘‘(d) PLANS DEEMED TO BE CERTIFIED.—A multi-State qualified 
health plan that is offered under a contract under subsection (a) 
shall be deemed to be certified by an Exchange for purposes of 
section 1311(d)(4)(A). 
‘‘(e) PHASE-IN.—Notwithstanding paragraphs (1) and (2) of sub-
section (b), the Director shall enter into a contract with a health 
insurance issuer for the offering of a multi-State qualified health 
plan under subsection (a) if— 
‘‘(1) with respect to the first year for which the issuer 
offers such plan, such issuer offers the plan in at least 60 
percent of the States; 
‘‘(2) with respect to the second such year, such issuer 
offers the plan in at least 70 percent of the States; 
‘‘(3) with respect to the third such year, such issuer offers 
the plan in at least 85 percent of the States; and 
‘‘(4) with respect to each subsequent year, such issuer 
offers the plan in all States. 
‘‘(f) APPLICABILITY.—The requirements under chapter 89 of title 
5, United States Code, applicable to health benefits plans under 
such chapter shall apply to multi-State qualified health plans pro-
vided for under this section to the extent that such requirements 
do not conflict with a provision of this title. 
‘‘(g) CONTINUED SUPPORT FOR FEHBP.— 
‘‘(1) MAINTENANCE
OF
EFFORT.—Nothing in this section 
shall be construed to permit the Director to allocate fewer 
financial or personnel resources to the functions of the Office 
of Personnel Management related to the administration of the 
Federal Employees Health Benefit Program under chapter 89 
of title 5, United States Code. 
‘‘(2) SEPARATE RISK POOL.—Enrollees in multi-State quali-
fied health plans under this section shall be treated as a 
separate risk pool apart from enrollees in the Federal 
Employees Health Benefit Program under chapter 89 of title 
5, United States Code. 
‘‘(3) AUTHORITY
TO
ESTABLISH
SEPARATE
ENTITIES.—The 
Director may establish such separate units or offices within 
the Office of Personnel Management as the Director determines 
to be appropriate to ensure that the administration of multi- 
State qualified health plans under this section does not inter-
fere with the effective administration of the Federal Employees 
Health Benefit Program under chapter 89 of title 5, United 
States Code. 
‘‘(4) EFFECTIVE OVERSIGHT.—The Director may appoint such 
additional personnel as may be necessary to enable the Director 
to carry out activities under this section. 
‘‘(5) ASSURANCE OF SEPARATE PROGRAM.—In carrying out 
this section, the Director shall ensure that the program under 
this section is separate from the Federal Employees Health 
Benefit Program under chapter 89 of title 5, United States 
Code. Premiums paid for coverage under a multi-State qualified 
health plan under this section shall not be considered to be 
Federal funds for any purposes.
H. R. 3590—788 
‘‘(6) FEHBP PLANS
NOT
REQUIRED
TO
PARTICIPATE.— 
Nothing in this section shall require that a carrier offering 
coverage under the Federal Employees Health Benefit Program 
under chapter 89 of title 5, United States Code, also offer 
a multi-State qualified health plan under this section. 
‘‘(h) ADVISORY BOARD.—The Director shall establish an advisory 
board to provide recommendations on the activities described in 
this section. A significant percentage of the members of such board 
shall be comprised of enrollees in a multi-State qualified health 
plan, or representatives of such enrollees. 
‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is authorized 
to be appropriated, such sums as may be necessary to carry out 
this section.’’. 
(r) Section 1341 of this Act is amended— 
(1) in the section heading, by striking ‘‘AND SMALL GROUP 
MARKETS’’ and inserting ‘‘MARKET’’; 
(2) in subsection (b)(2)(B), by striking ‘‘paragraph (1)(A)’’ 
and inserting ‘‘paragraph (1)(B)’’; and 
(3) in subsection (c)(1)(A), by striking ‘‘and small group 
markets’’ and inserting ‘‘market’’. 
SEC. 10105. AMENDMENTS TO SUBTITLE E. 
(a) Section 36B(b)(3)(A)(ii) of the Internal Revenue Code of 
1986, as added by section 1401(a) of this Act, is amended by 
striking ‘‘is in excess of’’ and inserting ‘‘equals or exceeds’’. 
(b) Section 36B(c)(1)(A) of the Internal Revenue Code of 1986, 
as added by section 1401(a) of this Act, is amended by inserting 
‘‘equals or’’ before ‘‘exceeds’’. 
(c) Section 36B(c)(2)(C)(iv) of the Internal Revenue Code of 
1986, as added by section 1401(a) of this Act, is amended by 
striking 
‘‘subsection 
(b)(3)(A)(ii)’’ 
and 
inserting 
‘‘subsection 
(b)(3)(A)(iii)’’. 
(d) Section 1401(d) of this Act is amended by adding at the 
end the following: 
‘‘(3) Section 6211(b)(4)(A) of the Internal Revenue Code 
of 1986 is amended by inserting ‘36B,’ after ‘36A,’.’’. 
(e)(1) Subparagraph (B) of section 45R(d)(3) of the Internal 
Revenue Code of 1986, as added by section 1421(a) of this Act, 
is amended to read as follows: 
‘‘(B) DOLLAR
AMOUNT.—For purposes of paragraph 
(1)(B) and subsection (c)(2)— 
‘‘(i) 2010, 2011, 2012, AND 2013.—The dollar amount 
in effect under this paragraph for taxable years begin-
ning in 2010, 2011, 2012, or 2013 is $25,000. 
‘‘(ii) SUBSEQUENT YEARS.—In the case of a taxable 
year beginning in a calendar year after 2013, the dollar 
amount in effect under this paragraph shall be equal 
to $25,000, multiplied by the cost-of-living adjustment 
under section 1(f)(3) for the calendar year, determined 
by substituting ‘calendar year 2012’ for ‘calendar year 
1992’ in subparagraph (B) thereof.’’. 
(2) Subsection (g) of section 45R of the Internal Revenue Code 
of 1986, as added by section 1421(a) of this Act, is amended by 
striking ‘‘2011’’ both places it appears and inserting ‘‘2010, 2011’’. 
(3) Section 280C(h) of the Internal Revenue Code of 1986, 
as added by section 1421(d)(1) of this Act, is amended by striking 
‘‘2011’’ and inserting ‘‘2010, 2011’’.
H. R. 3590—789 
(4) Section 1421(f) of this Act is amended by striking ‘‘2010’’ 
both places it appears and inserting ‘‘2009’’. 
(5) The amendments made by this subsection shall take effect 
as if included in the enactment of section 1421 of this Act. 
(f) Part I of subtitle E of title I of this Act is amended by 
adding at the end of subpart B, the following: 
‘‘SEC. 1416. STUDY OF GEOGRAPHIC VARIATION IN APPLICATION OF 
FPL. 
‘‘(a) IN GENERAL.—The Secretary shall conduct a study to 
examine the feasibility and implication of adjusting the application 
of the Federal poverty level under this subtitle (and the amend-
ments made by this subtitle) for different geographic areas so 
as to reflect the variations in cost-of-living among different areas 
within the United States. If the Secretary determines that an 
adjustment is feasible, the study should include a methodology 
to make such an adjustment. Not later than January 1, 2013, 
the Secretary shall submit to Congress a report on such study 
and shall include such recommendations as the Secretary deter-
mines appropriate. 
‘‘(b) INCLUSION OF TERRITORIES.— 
‘‘(1) IN
GENERAL.—The Secretary shall ensure that the 
study under subsection (a) covers the territories of the United 
States and that special attention is paid to the disparity that 
exists among poverty levels and the cost of living in such 
territories and to the impact of such disparity on efforts to 
expand health coverage and ensure health care. 
‘‘(2) TERRITORIES DEFINED.—In this subsection, the term 
‘territories of the United States’ includes the Commonwealth 
of Puerto Rico, the United States Virgin Islands, Guam, the 
Northern Mariana Islands, and any other territory or possession 
of the United States.’’. 
SEC. 10106. AMENDMENTS TO SUBTITLE F. 
(a) Section 1501(a)(2) of this Act is amended to read as follows: 
‘‘(2) EFFECTS ON THE NATIONAL ECONOMY AND INTERSTATE 
COMMERCE.—The effects described in this paragraph are the 
following: 
‘‘(A) The requirement regulates activity that is commer-
cial and economic in nature: economic and financial 
decisions about how and when health care is paid for, 
and when health insurance is purchased. In the absence 
of the requirement, some individuals would make an eco-
nomic and financial decision to forego health insurance 
coverage and attempt to self-insure, which increases finan-
cial risks to households and medical providers. 
‘‘(B) Health insurance and health care services are 
a significant part of the national economy. National health 
spending is projected to increase from $2,500,000,000,000, 
or 
17.6 
percent 
of 
the 
economy, 
in 
2009 
to 
$4,700,000,000,000 in 2019. Private health insurance 
spending is projected to be $854,000,000,000 in 2009, and 
pays for medical supplies, drugs, and equipment that are 
shipped in interstate commerce. Since most health insur-
ance is sold by national or regional health insurance compa-
nies, health insurance is sold in interstate commerce and 
claims payments flow through interstate commerce.