I 
111TH CONGRESS 
1ST SESSION 
H. R. 956 
To expand the number of individuals and families with health insurance 
coverage, and for other purposes. 
IN THE HOUSE OF REPRESENTATIVES 
FEBRUARY 10, 2009 
Ms. KAPTUR (for herself and Mr. LATOURETTE) introduced the following bill; 
which was referred to the Committee on Energy and Commerce, and in 
addition to the Committees on Ways and Means, Education and Labor, 
and Rules, for a period to be subsequently determined by the Speaker, 
in each case for consideration of such provisions as fall within the juris-
diction of the committee concerned 
A BILL 
To expand the number of individuals and families with health 
insurance coverage, and for other purposes. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE; TABLE OF CONTENTS. 
(a) SHORT TITLE.—This Act may be cited as the 
‘‘Health Coverage, Affordability, Responsibility, and Eq-
uity Act of 2009’’ or the ‘‘HealthCARE Act of 2009’’. 
(b) TABLE OF CONTENTS.—The table of contents of 
this Act is as follows: 
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Sec. 1. Short title; table of contents. 
TITLE I—STATE WAIVERS 
Sec. 101. State waivers. 
TITLE II—IMPROVING QUALITY AND SAFETY THROUGH PREVEN-
TIVE SERVICES, CARE COORDINATION, AND THE USE OF 
HEALTH INFORMATION TECHNOLOGY 
Sec. 201. Additional waiver authority. 
TITLE III—INCREASING HEALTH CARE COVERAGE 
Subtitle A—Medicaid and SCHIP 
Sec. 301. State option to offer medicaid coverage based on need. 
Sec. 302. State option to provide coverage of children under SCHIP in excess 
of the State’s allotment. 
Subtitle B—Refundable Tax Credit for Health Insurance Costs of Low- 
Income Individuals and Families 
Sec. 311. Credit for health insurance costs of certain low-income individuals. 
Sec. 312. Advance payment of credit for health insurance costs of eligible low- 
income individuals. 
TITLE IV—IMPROVING ACCESS TO HEALTH PLANS 
Sec. 401. Definitions. 
Sec. 402. Establishment of health insurance purchasing pools. 
Sec. 403. Purchasing pools. 
Sec. 404. Purchasing pool operators. 
Sec. 405. Contracts with participating insurers. 
Sec. 406. Options for health benefits coverage. 
Sec. 407. Enrollment process for eligible individuals. 
Sec. 408. Plan premiums. 
Sec. 409. Enrollee premium share. 
Sec. 410. Payments to purchasing pool operators and payments to participating 
insurers. 
Sec. 411. State-based reinsurance programs. 
Sec. 412. Coverage under individual health insurance. 
Sec. 413. Use of premium subsidies to unify family coverage with members en-
rolled in medicaid and SCHIP. 
Sec. 414. Coverage through employer-sponsored health insurance. 
Sec. 415. Participation by small employers. 
Sec. 416. Report. 
Sec. 417. Authorization of appropriations. 
TITLE V—NATIONAL ADVISORY COMMISSION ON EXPANDED 
ACCESS TO HEALTH CARE 
Sec. 501. National Advisory Commission on Expanded Access to Health Care. 
Sec. 502. Congressional action. 
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TITLE I—STATE WAIVERS 
SEC. 101. STATE WAIVERS. 
(a) IN GENERAL.—Notwithstanding any other provi-
sion of law, a State may apply to the Secretary of Health 
and Human Services (in this Act referred to as the ‘‘Sec-
retary’’) for waivers of such provisions of law as may be 
necessary for the State to implement policies that make 
comprehensive, affordable health coverage available for all 
State residents, including access to essential benefits with 
limits on cost-sharing, as provided in the most recent re-
port under section 501(e)(2). 
(b) REQUIREMENTS.—In order to ensure that waivers 
under this section benefit rather than harm health care 
consumers, a State shall not be eligible for a waiver under 
this section unless— 
(1) the State reasonably expects to achieve a 
level of enrollment in coverage described in sub-
section (a) that is at least equal to the level of cov-
erage (taking into account the number of insured in-
dividuals, covered benefits, and premium and out-of- 
pocket costs to the consumer for such coverage) that 
the State would have achieved if the State had fully 
implemented the coverage options available under ti-
tles III and IV of this Act; 
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(2) no individual who would have qualified for 
assistance under the State medicaid program under 
title XIX of the Social Security Act or the State 
children’s health insurance program under title XXI 
of such Act, as of either the date of the waiver re-
quest or the date of enactment of this Act, will be 
denied eligibility for such program, have a reduction 
in benefits under such program, have reduced access 
to geographically and linguistically appropriate care 
or essential community providers, or be subject to 
increased premiums or cost-sharing under the waiver 
program under this section; and 
(3) the State agrees to comply with such stand-
ards or guidelines as the Secretary of Health and 
Human Services may require to ensure that the re-
quirements of paragraphs (1) and (2) are satisfied. 
(c) FEDERAL PAYMENTS.— 
(1) IN GENERAL.—The Secretary of Health and 
Human Services shall pay a State with a waiver ap-
proved under this section an amount each quarter 
equal to the sum of— 
(A) the Federal payments the State and 
residents of the State (including, but not lim-
ited to, through the credit allowed under section 
36A of the Internal Revenue Code of 1986 for 
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health insurance costs) would have received if 
the State had exercised the coverage options 
under titles III and IV of this Act with respect 
to residents of the State who have not attained 
age 65; and 
(B) the amount of any grants authorized 
by this Act that the State would have received 
if the State had applied for such grants. 
(2) ADDITIONAL
PAYMENT
FOR
MEDICARE 
BENEFICIARIES UNDER AGE 65.— 
(A) IN GENERAL.—In the case of a State 
that elects to enroll an individual described in 
subparagraph (B) in coverage described in sub-
section (a), the amount described in paragraph 
(1) with respect to a quarter shall be increased 
by the amount described in subparagraph (C). 
(B) INDIVIDUAL
DESCRIBED.—An indi-
vidual is described in this subparagraph if the 
individual— 
(i) has not attained age 65; 
(ii) is eligible for coverage under title 
XVIII of the Social Security Act; and 
(iii) voluntarily elects to enroll in cov-
erage described in subsection (a). 
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(C) AMOUNT
DESCRIBED.—The amount 
described in this subparagraph is the amount 
equal to the amount that the Federal Govern-
ment would have incurred with respect to a 
quarter for providing coverage to an individual 
described in subparagraph (B) under title 
XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.). 
(d) IMPLEMENTATION DATE.—No State may submit 
a request for a waiver under this section before October 
1, 2011. 
TITLE II—IMPROVING QUALITY 
AND SAFETY THROUGH PRE-
VENTIVE SERVICES, CARE CO-
ORDINATION, AND THE USE 
OF 
HEALTH 
INFORMATION 
TECHNOLOGY 
SEC. 201. ADDITIONAL WAIVER AUTHORITY. 
(a) IN
GENERAL.—Notwithstanding the require-
ments to submit a state waiver under title I, the Secretary 
shall establish a process by which States may apply for 
a waiver to implement policies that emphasize the use of 
preventive services, care coordination by a personal physi-
cian, and health information technology (in this section 
referred to as a qualified patient-centered medical home). 
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(b) DEFINITIONS.—For purposes of this title: 
(1) QUALIFIED
PATIENT-CENTERED
MEDICAL 
HOME.—The term ‘‘qualified patient-centered med-
ical home’’ or ‘‘PC–MH’’ means a physician-directed 
practice that has voluntarily participated in a quali-
fication process to demonstrate it has the capabili-
ties to achieve improvements in the management and 
coordination of care of eligible beneficiaries, includ-
ing those with multiple chronic diseases, by incor-
porating attributes of the care management model. 
(2) CARE
MANAGEMENT
MODEL.—The term 
‘‘care management model’’ means a model that uses 
health information and other physician practice in-
novations to improve the management and coordina-
tion of care provided to patients with one or more 
chronic illnesses. Attributes of the model include the 
following: 
(A) Practices advocate for their patients to 
support the attainment of optimal, patient-cen-
tered outcomes that are defined by a care plan-
ning process driven by a compassionate, robust 
partnership between physicians, patients, and 
the patient’s family. 
(B) Evidence-based medicine and clinical 
decision-support tools guide decision making. 
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