I 
111TH CONGRESS 
1ST SESSION H. R. 1321 
To provide affordable, guaranteed private health coverage that will make 
Americans healthier and can never be taken away. 
IN THE HOUSE OF REPRESENTATIVES 
MARCH 5, 2009 
Ms. ESHOO (for herself, Ms. HARMAN, Ms. WASSERMAN SCHULTZ, Mr. COO-
PER, Mrs. EMERSON, Mr. CASTLE, and Mr. WELCH) introduced the fol-
lowing bill; which was referred to the Committee on Energy and Com-
merce, and in addition to the Committees on Ways and Means, Education 
and Labor, and Oversight and Government Reform, 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 con-
cerned 
A BILL 
To provide affordable, guaranteed private health coverage 
that will make Americans healthier and can never be 
taken away. 
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 
‘‘Healthy Americans Act’’. 
(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. 
Sec. 2. Findings. 
Sec. 3. Definitions. 
TITLE I—HEALTHY AMERICANS PRIVATE INSURANCE PLANS 
Subtitle A—Guaranteed Private Coverage 
Sec. 101. Guarantee of Healthy Americans Private Insurance coverage. 
Sec. 102. Individual responsibility to enroll in a Healthy Americans Private In-
surance plan. 
Sec. 103. Health coverage plans offered by employers. 
Sec. 104. Coordination of supplemental coverage under the Medicaid program 
to HAPI plan coverage for nondisabled, nonelderly adult indi-
viduals. 
Subtitle B—Standards for Healthy Americans Private Insurance Coverage 
Sec. 111. Healthy Americans Private Insurance plans. 
Sec. 112. Specific coverage requirements. 
Sec. 113. Updating Healthy Americans Private Insurance plan requirements. 
Subtitle C—Eligibility for Premium and Personal Responsibility Contribution 
Subsidies 
Sec. 121. Eligibility for premium subsidies. 
Sec. 122. Eligibility for personal responsibility contribution subsidies. 
Sec. 123. Definitions and special rules. 
Subtitle D—Wellness Programs 
Sec. 131. Requirements for wellness programs. 
TITLE II—HEALTHY START FOR CHILDREN 
Subtitle A—Benefits and Eligibility 
Sec. 201. HAPI plan coverage for children. 
Sec. 202. Coordination of supplemental coverage under the Medicaid program 
with HAPI plan coverage for children. 
Subtitle B—Service Providers 
Sec. 211. Inclusion of providers under HAPI plans. 
Sec. 212. Use of, and grants for, school-based health centers. 
TITLE III—BETTER HEALTH FOR OLDER AND DISABLED 
AMERICANS 
Subtitle A—Assurance of Supplemental Medicaid Coverage 
Sec. 301. Coordination of supplemental coverage under the Medicaid program 
for elderly and disabled individuals. 
Subtitle B—Enpowering Individuals and State To Improve Long-Term Care 
Choices 
Sec. 311. New, automatic Medicaid option for State choices for long-term care 
program. 
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Sec. 312. Simpler and more affordable long-term care insurance coverage. 
TITLE IV—HEALTHIER MEDICARE 
Subtitle A—Authority To Adjust Amount of Part B Premium To Reward 
Positive Health Behavior 
Sec. 401. Authority to adjust amount of Medicare part B premium to reward 
positive health behavior. 
Subtitle B—Promoting Primary Care for Medicare Beneficiaries 
Sec. 411. Primary care services management payment. 
Subtitle C—Chronic Care Disease Management 
Sec. 421. Chronic care disease management. 
Sec. 422. Chronic Care Education Centers. 
Subtitle D—Improving Quality in Hospitals for All Patients 
Sec. 431. Improving quality in hospitals for all patients. 
Subtitle E—Additional Provisions 
Sec. 441. Additional cost information. 
Sec. 442. Reducing Medicare paperwork and regulatory burdens. 
TITLE V—STATE HEALTH HELP AGENCIES 
Sec. 501. Establishment. 
Sec. 502. Responsibilities and authorities. 
Sec. 503. Appropriations for Transition to State Health Help Agencies. 
TITLE VI—SHARED RESPONSIBILITIES 
Subtitle A—Individual Responsibilities 
Sec. 601. Individual responsibility to ensure HAPI plan coverage. 
Subtitle B—Employer Responsibilities 
Sec. 611. Health care responsibility payments. 
Sec. 612. Distribution of individual responsibility payments to HHAs. 
Subtitle C—Insurer Responsibilities 
Sec. 621. Insurer responsibilities. 
Subtitle D—State Responsibilities 
Sec. 631. State responsibilities. 
Sec. 632. Empowering States to innovate through waivers. 
Subtitle E—Federal Fallback Guarantee Responsibility 
Sec. 641. Federal guarantee of access to coverage. 
Subtitle F—Federal Financing Responsibilities 
Sec. 651. Appropriation for subsidy payments. 
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Sec. 652. Recapture of Medicare and 90 percent of Medicaid Federal DSH 
funds to strengthen Medicare and ensure continued support for 
public health programs. 
Subtitle G—Tax Treatment of Health Care Coverage Under Healthy Ameri-
cans Program; Termination of Coverage Under Other Governmental Pro-
grams and Transition Rules for Medicaid and SCHIP 
PART 1—TAX TREATMENT OF HEALTH CARE COVERAGE UNDER HEALTHY 
AMERICANS PROGRAM 
Sec. 661. Limited employee income and payroll tax exclusion for employer 
shared responsibility payments, historic retiree health contribu-
tions, and transitional coverage contributions. 
Sec. 662. Exclusion for limited employer-provided health care fringe benefits. 
Sec. 663. Limited employer deduction for employer shared responsibility pay-
ments, historic retiree health contributions, and other health 
care expenses. 
Sec. 664. Refundable credit for individual shared responsibility payments. 
Sec. 665. Modification of other tax incentives to complement Healthy Ameri-
cans program. 
Sec. 666. Termination of certain employer incentives when replaced by lower 
health care costs. 
PART 2—CLARIFICATION OF ERISA TREATMENT; TERMINATION 
OF COVERAGE UNDER OTHER GOVERNMENTAL PROGRAMS 
AND TRANSITION RULES FOR MEDICAID AND CHIP 
Sec. 671. Clarification of ERISA applicability to employer-sponsored HAPI 
plans. 
Sec. 672. Federal Employees Health Benefits Plan. 
Sec. 673. Medicaid and SCHIP. 
TITLE VII—PURCHASING HEALTH SERVICES AND PRODUCTS 
THAT ARE MOST EFFECTIVE 
Sec. 701. One time disallowance of deduction for advertising and promotional 
expenses for certain prescription pharmaceuticals. 
Sec. 702. Enhanced new drug and device approval. 
Sec. 703. Medical schools and finding what works in health care. 
Sec. 704. Finding affordable health care providers nearby. 
TITLE VIII—ENHANCED HEALTH CARE VALUE 
Sec. 801. Research on comparative effectiveness of health care items and serv-
ices. 
Sec. 802. Health Care Comparative Effectiveness Research Trust Fund; financ-
ing for Trust Fund. 
Sec. 803. Improved coordination of health services research. 
TITLE IX—CONTAINING MEDICAL COSTS AND GETTING MORE 
VALUE FOR THE HEALTH CARE DOLLAR 
Sec. 901. Cost-containment results of the Healthy Americans Act. 
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SEC. 2. FINDINGS. 
Congress makes the following findings: 
(1) Americans want affordable, guaranteed pri-
vate health coverage that makes them healthier and 
can never be taken away. 
(2) American health care provides primarily 
‘‘sick care’’ and does not do enough to prevent 
chronic illnesses like heart disease, stroke, and dia-
betes. This results in significantly higher health 
costs for all Americans. 
(3) Staying as healthy as possible often requires 
an individual to change behavior and assume more 
personal responsibility for his or her health. 
(4) Personal responsibility for one’s health 
should include purchasing one’s own private health 
care coverage. 
(5) To accompany this new focus on staying 
healthy and personal responsibility, our government 
must guarantee that all Americans receive private 
affordable health coverage that can never be taken 
away. 
(6) Financing this guarantee should be a 
shared responsibility between individuals, the Gov-
ernment, and employers. 
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(7) The $2,200,000,000,000 spent annually on 
American health care must be spent more effectively 
in order to meet this guarantee. 
(8) This guarantee must include easier access 
to understandable information about the quality, 
cost, and effectiveness of health care providers, prod-
ucts, and services. 
(9) The fact that businesses in the United 
States compete globally against businesses whose 
governments pay for health care, coupled with the 
aging of the American population and the explosive 
growth of preventable health problems, makes the 
status quo in American health care unacceptable. 
SEC. 3. DEFINITIONS. 
In this Act: 
(1) ADULT INDIVIDUAL.—The term ‘‘adult indi-
vidual’’ means an individual who— 
(A) is— 
(i) age 19 or older; 
(ii) a resident of a State; 
(iii)(I) a United States citizen; or 
(II) an alien with permanent resi-
dence; 
(iv) not a dependent child; and 
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(v) not an alien unlawfully present in 
the United States; and 
(B) in the case of an incarcerated indi-
vidual, such an individual who is incarcerated 
for less than 1 month. 
(2) ALIEN
WITH
PERMANENT
RESIDENCE.— 
The term ‘‘alien with permanent residence’’ has the 
meaning given the term ‘‘qualified alien’’ in section 
431 of the Personal Responsibility and Work Oppor-
tunity Reconciliation Act of 1996 (8 U.S.C. 1641). 
(3) COVERED INDIVIDUAL.—The term ‘‘covered 
individual’’ means an individual who is enrolled in a 
HAPI plan. 
(4) DEPENDENT CHILD.—The term ‘‘dependent 
child’’ has the meaning given the term ‘‘qualifying 
child’’ in section 152(c) of the Internal Revenue 
Code of 1986. 
(5) HAPI PLAN.—The term ‘‘HAPI plan’’ 
means a Healthy Americans Private Insurance plan 
described under subtitle B of title I or an employer- 
sponsored health coverage plan described under sec-
tion 103 offered by an employer. 
(6) HHA.—The term ‘‘HHA’’ means the 
Health Help Agency of a State as described under 
title V. 
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(7) HEALTH
INSURANCE
ISSUER.—The term 
‘‘health insurance issuer’’ means an insurance com-
pany, insurance service, or insurance organization 
(including a health maintenance organization, as de-
fined in paragraph (8)) which is licensed to engage 
in the business of insurance in a State and which is 
subject to State law which regulates insurance (with-
in the meaning of section 514(b)(2) of the Employee 
Retirement Income Security Act of 1974). Such 
term does not include a group health plan. 
(8) HEALTH MAINTENANCE ORGANIZATION.— 
The 
term 
‘‘health 
maintenance 
organization’’ 
means— 
(A) a federally qualified health mainte-
nance organization (as defined in section 
1301(a)), 
(B) an organization recognized under State 
law as a health maintenance organization, or 
(C) a similar organization regulated under 
State law for solvency in the same manner and 
to the same extent as such a health mainte-
nance organization. 
(9) PERSONAL
RESPONSIBILITY
CONTRIBU-
TION.—The term ‘‘personal responsibility contribu-
tion’’ means a payment made by a covered individual 
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to a health care provider or a health insurance 
issuer with respect to the provision of health care 
services under a HAPI plan, not including any 
health insurance premium payment. 
(10) 
QUALIFIED
COLLECTIVE
BARGAINING 
AGREEMENT.— 
(A) IN
GENERAL.—The term ‘‘qualified 
collective bargaining agreement’’ means an 
agreement between a qualified collective bar-
gaining employer and an employee organization 
that represents the employees of such employer, 
including an agreement under section 302(c)(5) 
of the Labor-Management Relations Act, 1947, 
that is entered into before the date of the en-
actment of this Act and that is in effect until 
the date that is the earlier of— 
(i) January 1 of the first year which 
is more than 9 years after the date of en-
actment of this Act, or 
(ii) the date the agreement expires. 
(B) QUALIFIED COLLECTIVE BARGAINING 
EMPLOYER.—The term ‘‘qualified collective bar-
gaining employer’’ means an employer who pro-
vides health insurance to employees under the 
terms of a collective bargaining agreement 
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which is entered into before the date of the en-
actment of this Act. 
(11) 
SECRETARY.—The 
term 
‘‘Secretary’’ 
means the Secretary of Health and Human Services. 
(12) STATE.—The term ‘‘State’’ means each of 
the several States of the United States, the District 
of Columbia, the Commonwealth of Puerto Rico, the 
Virgin Islands, American Samoa, Guam, the Com-
monwealth of the Northern Mariana Islands, and 
other territories of the United States. 
(13) STATE OF RESIDENCE.—The term ‘‘State 
of residence’’, with respect to an individual, means 
the State in which the individual has primary resi-
dence. 
TITLE I—HEALTHY AMERICANS 
PRIVATE INSURANCE PLANS 
Subtitle A—Guaranteed Private 
Coverage 
SEC. 101. GUARANTEE OF HEALTHY AMERICANS PRIVATE 
INSURANCE COVERAGE. 
Not later than the date that is 4 years after the date 
of enactment of this Act, each adult individual shall have 
the opportunity to purchase a Healthy Americans Private 
Insurance plan that meets the requirements of subtitle B, 
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declines health plan coverage due to a reliance 
on healing using spiritual means through prayer 
alone. 
(2) DEPENDENT CHILDREN.—Each adult indi-
vidual shall have the responsibility to enroll each de-
pendent child of the adult individual in a HAPI 
plan, unless the adult individual— 
(A) provides evidence that the dependent 
child is receiving coverage under any program 
described in paragraph (1)(A); or 
(B) is described in paragraph (1)(B). 
(3) VERIFICATION OF RELIGIOUS EXCEPTION.— 
Each State shall develop guidelines for determining 
and verifying the individuals who qualify for the ex-
ception under paragraph (1)(B). 
(b) PENALTY
FOR FAILURE TO PURCHASE COV-
ERAGE.— 
(1) PENALTY.— 
(A) IN GENERAL.—In the case of an indi-
vidual described in subparagraph (B), such in-
dividual shall be subject to a late enrollment 
penalty in an amount determined under sub-
paragraph (C). 
(B) INDIVIDUALS SUBJECT TO PENALTY.— 
An individual described in this subparagraph is 
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an adult individual for whom there is a contin-
uous period of 63 days or longer, beginning on 
the applicable date (as defined in subparagraph 
(E)) and ending on the date of enrollment in a 
HAPI plan, during all of which the individual— 
(i) was not covered under a HAPI 
plan or a health plan offered through a 
program described in paragraph (1)(A) of 
section 102(a); and 
(ii) was not described in paragraph 
(1)(B) of such section. 
(C) AMOUNT OF PENALTY.— 
(i) IN GENERAL.—The amount deter-
mined under this subparagraph for an in-
dividual is an amount equal to the sum 
of— 
(I) the number of uncovered 
months multiplied by the weighted av-
erage of the monthly premium for 
HAPI plans of the same class of cov-
erage as the individual’s in the appli-
cable coverage area (determined with-
out regard to any subsidy under sec-
tion 121); and 
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(II) 15 percent of the amount de-
termined under subclause (I). 
(ii) UNCOVERED MONTH DEFINED.— 
For purposes of this subsection, the term 
‘‘uncovered month’’ means, with respect to 
an individual, any month beginning on or 
after the applicable date (as defined in 
subparagraph (E)) unless the individual 
can demonstrate that the individual— 
(I) was covered under a HAPI 
plan or a health plan offered through 
a program described in paragraph 
(1)(A) of section 102(a) for any por-
tion of such month; or 
(II) was described in paragraph 
(1)(B) of such section for any portion 
of such month. 
A month shall not be treated as an uncov-
ered month if the individual has already 
paid a late enrollment penalty under this 
subsection for such month or if the indi-
vidual was incarcerated for the entire 
month. 
(D) PAYMENT.—Payment of any late en-
rollment penalty by an individual under this 
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subsection shall be made to the HHA of the in-
dividual’s State of residence under procedures 
established by the State. 
(E) APPLICABLE
DATE.—In this para-
graph, the term ‘‘applicable date’’ means the 
earlier of— 
(i) the day after the end of the State’s 
first open enrollment period for HAPI 
plans (during which all adult individuals 
are eligible to enroll); and 
(ii) the day after the end of the first 
enrollment period for a fallback HAPI plan 
in the State. 
(2) WAIVER.—An HHA of a State may reduce 
or waive the amount of any late enrollment penalty 
applicable to an individual under this subsection if 
payment of such penalty would constitute a hardship 
(determined under procedures established by the 
State). 
(3) ENFORCEMENT.—Each State shall deter-
mine appropriate mechanisms, which may not in-
clude revocation or ineligibility for coverage under a 
HAPI plan, to enforce the responsibility of each 
adult individual to purchase HAPI plan coverage for 
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such individual and any dependent children of such 
individual under subsection (a). 
(c) OTHER INSURANCE COVERAGE.—Nothing in this 
Act shall be construed to prohibit an individual from en-
rolling in a health insurance plan that is not a HAPI plan. 
SEC. 103. HEALTH COVERAGE PLANS OFFERED BY EMPLOY-
ERS. 
(a) PLAN REQUIREMENTS.— 
(1) IN GENERAL.—A health coverage plan de-
scribed in section 105(h)(6) of the Internal Revenue 
Code of 1986 (relating to self-insured plans) that is 
offered by an employer shall be subject to— 
(A) the requirements of subtitle B, other 
than subsections (a), (d)(2), and (d)(4) of sec-
tion 111; and 
(B) a risk-adjustment mechanism used to 
spread risks across all health plans. 
(2) OTHER
PLANS.—A health coverage plan 
that is not described in section 105(h)(6) of the In-
ternal Revenue Code of 1986 that is offered by an 
employer shall be subject to the requirements of sub-
title B, other than section 111(a). 
(b) DISTRIBUTION
OF INFORMATION.—Employers 
that offer an employer-sponsored health coverage plan 
shall distribute to employees standardized, unbiased infor-
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mation on HAPI plans and supplemental health insurance 
options provided by the State HAA under section 502(b). 
(c) PLANS OFFERED THROUGH EMPLOYERS.—An 
employer-sponsored health coverage plan shall be offered 
by an employer and not through the applicable State 
HHA. 
SEC. 104. COORDINATION OF SUPPLEMENTAL COVERAGE 
UNDER THE MEDICAID PROGRAM TO HAPI 
PLAN COVERAGE FOR NONDISABLED, NON-
ELDERLY ADULT INDIVIDUALS. 
(a) ASSURANCE OF SUPPLEMENTAL COVERAGE.— 
Subject to section 631(d), the Secretary, States, and 
health insurance issuers shall ensure that any nondisabled, 
nonelderly adult individual eligible under title XIX of the 
Social Security Act (including any nondisabled, nonelderly 
adult individual eligible under a waiver under such title 
or under section 1115 of such Act (42 U.S.C. 1315)) cov-
ered under a HAPI plan provided through the State HHA 
receives medical assistance under State Medicaid plans in 
a manner that— 
(1) is provided in coordination with, and as a 
supplement to, the coverage provided the non-
disabled, nonelderly adult individual under the 
HAPI plan in which the individual is enrolled; 
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(b) GUIDANCE TO STATES AND HEALTH INSURANCE 
ISSUERS.—The Secretary shall issue regulations and guid-
ance to States and health insurance issuers implementing 
this section not later than 6 months prior to the date on 
which coverage under a HAPI plan first begins. 
Subtitle B—Standards for Healthy 
Americans 
Private 
Insurance 
Coverage 
SEC. 111. HEALTHY AMERICANS PRIVATE INSURANCE 
PLANS. 
(a) OPTIONS.—A State HHA— 
(1) shall require that at least 2 HAPI plans 
that comply with the requirements of subsection (b), 
be offered through the HHA to each individual in 
the State; 
(2) shall require the offering of 1 or more 
HAPI plans that include coverage for benefits, 
items, or services in addition to the standardized 
benefits, items, or services required under subsection 
(b) for HAPI plans if— 
(A) such additional benefits, items, and 
services build upon the standardized benefits 
package; 
(B) a list of such additional benefits, 
items, or services, and the prices applicable to 
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such additional benefits, items, and services, is 
displayed in a manner that is separate from the 
description of the standardized benefits, items, 
or services required under the plan under this 
section (and consistent with the manner in 
which such items are displayed by medigap poli-
cies) and that enables a consumer to identify 
such additional benefits, items, and services and 
the cost associated with such; and 
(C) no premium subsidies are available 
under subtitle C for any portion of the pre-
miums for a HAPI plan that are attributable to 
such additional benefits, items, or services; and 
(3) may permit the offering of 1 or more actu-
arially equivalent HAPI plans through the HHA as 
provided for in subsection (c). 
(b) STANDARDIZED COVERAGE REQUIREMENTS FOR 
HAPI PLANS.— 
(1) IN
GENERAL.—Each HAPI plan offered 
through an HHA shall— 
(A) provide benefits for— 
(i) health care items and services that 
are actuarially equivalent or greater in 
value than the benefits offered as of Janu-
ary 1, 2009, under the Blue Cross/Blue 
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Shield Standard Plan provided under the 
Federal Employees Health Benefit Pro-
gram under chapter 89 of title 5, United 
States Code, including coverage of an ini-
tial primary care assessment and annual 
physical examinations; 
(ii) catastrophic medical events that 
result in out-of-pocket costs for an indi-
vidual or family if lifetime limits are ex-
hausted; and 
(iii) comprehensive disease prevention, 
early detection, disease management, and 
chronic condition management that meets 
minimum standards developed by the Sec-
retary; 
(B) designate a health care provider, such 
as a primary care physician, nurse practitioner, 
or other qualified health provider, to monitor 
the health and health care of a covered individ-
uals (such provider shall be known as the 
‘‘health home’’ of the covered individual); 
(C) ensure that, as part of the first visit 
with a primary care physician or the health 
home of a covered individual, such provider and 
individual determine a care plan to maximize 
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the health of the individual through wellness 
and prevention activities; 
(D) provide for the application of personal 
responsibility contribution requirements with re-
spect to covered benefits in a manner that may 
be similar to the cost-sharing requirements ap-
plied as of January 1, 2009, under the Blue 
Cross/Blue Shield Standard Plan provided 
under the Federal Employees Health Benefit 
Program under chapter 89 of title 5, United 
States Code, except that no contributions shall 
be required for— 
(i) preventive items or services; and 
(ii) early detection, disease manage-
ment, or chronic pain treatment items or 
services; 
(E) provide benefits for family planning 
services (as defined for purposes of title X of 
the Public Health Service Act); and 
(F) comply with the requirements of sec-
tion 112. 
(2) DETERMINATION
OF
BENEFITS
BY
SEC-
RETARY.—Not later than 1 year after the date of 
enactment of this Act, the Secretary shall promul-
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gate guidelines concerning the benefits, items, and 
services that are covered under paragraph (1). 
(3) RULE OF CONSTRUCTION.—Nothing in this 
subsection shall be construed to prohibit a HAPI 
plan from providing coverage for benefits, items, and 
services in addition to the coverage required under 
this subsection. No premium subsidies shall be avail-
able under subtitle C for any portion of the pre-
miums for a HAPI plan that are attributable to 
such additional benefits, items, or services. 
(c) ACTUARIALLY EQUIVALENT HEALTHY AMERICAN 
PLANS.—Each actuarially equivalent HAPI plan offered 
through an HHA— 
(1) shall cover all treatments, items, services, 
and providers at least to the same extent as those 
covered under a HAPI plan that— 
(A) preventive items and services (includ-
ing well baby care and well child care and ap-
propriate immunizations); 
(B) disease management services; 
(C) inpatient and outpatient hospital serv-
ices; 
(D) physicians’ surgical and medical serv-
ices; and 
(E) laboratory and x-ray services; 
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(2) may include additional supplemental bene-
fits to the extent approved by the State and provided 
for in advance in the plan contract; and 
(3) ensure that no personal responsibility con-
tribution requirements are applied for prevention 
and chronic disease management benefits, items, or 
services. 
(d) CLASSES
OF COVERAGE.—With respect to a 
HAPI plan, a health insurance issuer shall provide for the 
following classes of coverage: 
(1) Coverage of an individual. 
(2) Coverage of a married couple or domestic 
partnership (as determined by a State) without de-
pendent children. 
(3) Coverage of an adult individual with 1 or 
more dependent children. 
(4) Coverage of a married couple or domestic 
partnership (as determined by a State) with 1 or 
more dependent children. 
(e) PREMIUMS AND RATING REQUIREMENTS.— 
(1) DETERMINATIONS OF PREMIUMS.—With re-
spect to each class of coverage described in sub-
section (d), a health insurance issuer shall determine 
the premium amount for a HAPI plan using ad-
justed community rating principles, including a risk- 
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adjustment mechanism, as described in paragraphs 
(2) and (3) established by the State. States may 
permit premium variations based only on geography, 
tobacco use, and family size. A State may determine 
to have no variation. 
(2) REWARDS.—A State shall permit a health 
insurance issuer to provide premium discounts and 
other incentives to enrollees based on the participa-
tion of such enrollees in wellness, chronic disease 
management, and other programs designed to im-
prove the health of the enrollees. 
(3) LIMITATION.—A health insurance issuer 
shall not consider age, gender, industry, health sta-
tus, or claims experience in determining premiums 
under this subsection. 
(f) APPLICATION OF STATE MANDATE LAWS.—State 
benefit mandate laws that would otherwise be applicable 
to HAPI plans shall be preempted. 
(g) DEFINITION OF PREVENTIVE ITEMS OR SERV-
ICES.—In this section, the term ‘‘preventive items or serv-
ices’’ means clinical activities that help prevent or detect 
disease, illness, or disability and may include— 
(1) immunizations and preventive physical ex-
aminations; 
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(2) screening tests for blood pressure, high cho-
lesterol, diabetes, cancer, and mental illness; and 
(3) other services that the Secretary determines 
to be reasonable and necessary for the prevention or 
early detection of a disease, illness, or disability. 
SEC. 112. SPECIFIC COVERAGE REQUIREMENTS. 
(a) IN GENERAL.—Each HAPI plan offered through 
a HHA shall— 
(1) provide for increased portability through 
limitations on the application of preexisting condi-
tion exclusions, consistent with that provided for 
under section 2701 of the Public Health Service Act 
(42 U.S.C. 300gg), as such section existed on the 
day before the date of enactment of this Act, except 
that the State shall develop procedures to ensure 
that preexisting exclusion limitations do not apply to 
new enrollees who had no applicable creditable cov-
erage immediately prior to the first enrollment pe-
riod; 
(2) provide for the guaranteed availability of 
coverage to prospective enrollees in a manner similar 
to that provided for under section 2711 of the Pub-
lic Health Service Act (42 U.S.C. 300gg–11), as 
such section existed on the day before the date of 
enactment of this Act; 
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(3) provide for the guaranteed renewability of 
coverage in a manner similar to that provided for 
under section 2712 of the Public Health Service Act 
(42 U.S.C. 300gg–12), as such section existed on 
the day before the date of enactment of this Act, ex-
cept that the prohibition on market reentry provided 
for under such section shall be deemed to be 2 years; 
(4) prohibit discrimination against individual 
enrollees and prospective enrollees based on health 
status in a manner similar to that provided for 
under section 2702 of the Public Health Service Act 
(42 U.S.C. 300gg–1), as such section existed on the 
day before the date of enactment of this Act; 
(5) provide coverage protections for enrollees 
who are mothers and newborns in a manner similar 
to that provided for under section 2704 of the Pub-
lic Health Service Act (42 U.S.C. 300gg–3), as such 
section existed on the day before the date of enact-
ment of this Act; 
(6) provide for full parity in the application of 
certain limits to mental health benefits in a manner 
similar to that provided for under section 2705 of 
the Public Health Service Act (42 U.S.C. 300gg–4), 
as such section existed on the day before the date 
of the enactment of this Act; 
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(7) provide coverage for reconstructive surgery 
following a mastectomy in a manner similar to that 
provided for under section 2706 of the Public 
Health Service Act (42 U.S.C. 300gg–5), as such 
section existed on the day before the date of enact-
ment of this Act; and 
(8) prohibit discrimination on the basis of ge-
netic information, as provided for under the amend-
ments made by the Genetic Information Non-
discrimination Act of 2008 (Public Law 110–233), 
as such amendments were in effect on the day before 
the date of enactment of this Act. 
(b) GUIDELINES.—Not later than 1 year after the 
date of enactment of this Act, the Secretary shall develop 
guidelines for the application of the requirements of this 
section. 
SEC. 113. UPDATING HEALTHY AMERICANS PRIVATE IN-
SURANCE PLAN REQUIREMENTS. 
(a) IN GENERAL.—The Secretary shall establish the 
Healthy America Advisory Committee (referred to in this 
section as the ‘‘Advisory Committee’’) to provide rec-
ommendations to the Secretary and Congress concerning 
modifications to the benefits, items, and services required 
under section 111(a)(1). 
(b) COMPOSITION.— 
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(1) IN
GENERAL.—The Advisory Committee 
shall be composed of 15 members to be appointed by 
the Comptroller General, of which— 
(A) at least 1 such member shall be a 
health economist; 
(B) at least 1 such member shall be an 
ethicist; 
(C) at least 1 such member shall be a rep-
resentative of health care providers, including 
nurses and other nonphysician providers; 
(D) at least 1 such member shall be a rep-
resentative of health insurance issuers; 
(E) at least 1 such member shall be a 
health care consumer; 
(F) at least 1 such member shall be a rep-
resentative of the United States Preventive 
Services Task Force; and 
(G) at least 1 such member shall be an ac-
tuary. 
(2) GEOGRAPHIC BALANCE.—The Comptroller 
General shall ensure the geographic diversity of the 
members appointed under paragraph (1). 
(c) TERMS, VACANCIES.—Members of the Advisory 
Committee shall be appointed for a term of 3 years and 
may be reappointed for 1 additional term. In appointing 
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members, the Comptroller General shall stagger the terms 
of the initial members so that the terms of one-third of 
the members expire each year. Vacancies in the member-
ship of the Advisory Committee shall not affect the Com-
mittee’s ability to carry out its functions. The Comptroller 
General shall appoint an individual to fill the remaining 
term of a vacant member within 2 months of being noti-
fied of such vacancy. 
(d) COMPENSATION AND EXPENSES.—Each member 
of the Advisory Committee who is not otherwise employed 
by the United States Government shall receive compensa-
tion at a rate equal to the daily rate prescribed for GS– 
18 under the General Schedule under section 5332 of title 
5, United States Code, for each day, including travel time, 
such member is engaged in the actual performance of du-
ties as a member of the Committee. A member of the Advi-
sory Committee who is an officer or employee of the 
United States Government shall serve without additional 
compensation. All members of the Advisory Committee 
shall be reimbursed for travel, subsistence, and other nec-
essary expenses incurred by them in the performance of 
their duties. 
(e) REPORTS.— 
(1) ANNUAL REPORTS.—Not later than Decem-
ber 31 of the fourth full calendar year following the 
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date of enactment of this Act, and each December 
31 thereafter, the Advisory Committee shall provide 
to Congress and the Secretary a report that— 
(A) describes any recommendations for 
modifications to the benefits, items, and serv-
ices that are required to be covered under a 
HAPI plan; and 
(B) includes any recommendations to mod-
ify HAPI plans to improve the quality of life for 
United States citizens and to ensure that bene-
fits in such plans are medically- and cost-effec-
tive. 
(2) REPORT ON STANDARDIZATION OF ENROLL-
MENT.—Not later than December 31 of the second 
full calendar year following the date of enactment of 
this Act, the Advisory Committee, in consultation 
with the States, shall provide to Congress and the 
Secretary a report that includes recommendations 
relating to the standardization of enrollment forms 
for HAPI plans throughout the country and the 
transfer of basic information (such as identity and 
basic health information) from one HAPI plan to 
another HAPI plan, including across State lines. 
(f) APPLICATION OF FACA.—The Federal Advisory 
Committee Act (5 U.S.C. App.) shall apply to the Advisory 
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Committee, except that section 14 of such Act shall not 
apply. 
Subtitle C—Eligibility for Premium 
and 
Personal 
Responsibility 
Contribution Subsidies 
SEC. 121. ELIGIBILITY FOR PREMIUM SUBSIDIES. 
(a) INDIVIDUALS AND FAMILIES AT OR BELOW THE 
POVERTY LINE.—For any calendar year, in the case of 
a covered individual who is determined to have a modified 
adjusted gross income that is at or below 100 percent of 
the poverty line, as applicable to a family of the size in-
volved, the covered individual is entitled under this section 
to an income-related premium subsidy equal to the basic 
premium subsidy amount. 
(b) PARTIAL SUBSIDY FOR OTHER INDIVIDUALS AND 
FAMILIES.— 
(1) IN GENERAL.—For any calendar year, in 
the case of a covered individual who is determined 
to have a modified adjusted gross income that is 
greater than 100 percent of the poverty line, as ap-
plicable to a family of the size involved, but below 
400 percent of the poverty line, as applicable to a 
family of the size involved, the covered individual is 
entitled under this section to an income-related pre-
mium subsidy equal to the basic premium subsidy 
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amount reduced by the amount determined under 
paragraph (2). 
(2) AMOUNT OF REDUCTION.—The amount of 
the reduction determined under this paragraph is 
the amount that bears the same ratio to the basic 
premium subsidy amount as— 
(A) the excess of— 
(i) such individual’s modified adjusted 
gross income, over 
(ii) an amount equal to 100 percent of 
the poverty line as applicable to a family of 
the size involved, bears to 
(B) the excess of— 
(i) an amount equal to 400 percent of 
the poverty line as applicable to a family of 
the size involved, over 
(ii) an amount equal to 100 percent of 
the poverty line as applicable to a family of 
the size involved. 
(c) BASIC PREMIUM SUBSIDY AMOUNT.—For pur-
poses of this section, the term ‘‘basic premium subsidy 
amount’’ means, with respect to any individual, the lesser 
of— 
(1) the annual premium for the HAPI plan 
under which the individual is a covered individual; or 
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(2) the weighted average of the premium for 
HAPI plans of the same class of coverage (as de-
scribed in section 111(d)) as in the individual’s class 
of coverage in the applicable coverage area. 
(d) CHANGE IN STATUS NOTIFICATION.— 
(1) IN GENERAL.—If an individual’s modified 
adjusted income changes such that the individual be-
comes eligible or ineligible for a subsidy under this 
section, the individual shall report that change to 
the HHA of the individual’s State of residence not 
more than 60 days after the change takes effect. If 
an individual reports the change within 60 days 
under the preceding sentence, the individual’s HAPI 
plan coverage shall be deemed credible coverage for 
the purposes of maintaining coverage for preexisting 
conditions. 
(2) ADJUSTMENT.—The HHA shall adjust the 
premium subsidy of such individual to take effect on 
the first month after the date of the notification 
under paragraph (1) for which the next premium 
payment would be due from the individual. 
(e) CATASTROPHIC EVENT.—A State may develop 
mechanisms to ensure that covered individuals do not have 
a break in coverage due to a catastrophic financial event. 
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SEC. 122. ELIGIBILITY FOR PERSONAL RESPONSIBILITY 
CONTRIBUTION SUBSIDIES. 
(a) FULL SUBSIDY.—To meet the eligibility require-
ments under subtitle B for an HHA, for any taxable year, 
in the case of a covered individual who is determined to 
have a modified adjusted gross income that is below 100 
percent of the poverty line as applicable to a family of 
the size involved, an HHA shall provide to such an indi-
vidual a subsidy equal to the full amount of any personal 
responsibility contributions applicable to such individual. 
(b) PARTIAL SUBSIDY.—To meet the eligibility re-
quirements under subtitle B for an HHA, for any taxable 
year, in the case of a covered individual who is determined 
to have a modified adjusted gross income that is at or 
above 100 percent of the poverty line as applicable to a 
family of the size involved, an HHA may provide to such 
an individual a subsidy equal to part of the amount of 
any personal responsibility contributions applicable to 
such individual. 
SEC. 123. DEFINITIONS AND SPECIAL RULES. 
(a) DETERMINATION
OF
MODIFIED
ADJUSTED 
GROSS INCOME.— 
(1) IN GENERAL.—In this subtitle, the term 
‘‘modified adjusted gross income’’ means adjusted 
gross income (as defined in section 62 of the Inter-
nal Revenue Code of 1986)— 
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(A) determined without regard to sections 
86, 135, 137, 199, 221, 222, 911, 931, and 
933 of such Code; and 
(B) increased by— 
(i) the amount of interest received or 
accrued during the taxable year which is 
exempt from tax under such Code; and 
(ii) the amount of any social security 
benefits (as defined in section 86(d) of 
such Code) received or accrued during the 
taxable year. 
(2) TAXABLE YEAR TO BE USED TO DETER-
MINE MODIFIED ADJUSTED GROSS INCOME.—In ap-
plying this subtitle to determine an individual’s an-
nual premiums, the covered individual’s modified ad-
justed gross income shall be such income determined 
using the individual’s most recent income tax return 
or other information furnished to the Secretary by 
such individual, as the Secretary may require. 
(b) POVERTY LINE.—In this subtitle, the term ‘‘pov-
erty line’’ has the meaning given such term in section 
673(2) of the Community Health Services Block Grant 
Act (42 U.S.C. 9902(2)), including any revision required 
by such section. 
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(c) OTHER PROCEDURES TO DETERMINE SUB-
SIDIES.—The Secretary shall promulgate regulations to be 
used by HHAs to calculate the premium subsidies under 
section 121 and personal responsibility subsidies under 
section 122 for individuals whose modified adjusted gross 
income described in subsection (a)(2) is significantly lower 
than the modified adjusted gross income of the year in-
volved. 
(d) SPECIAL RULE
FOR UNLAWFULLY PRESENT 
ALIENS.—A health insurance issuer shall remit to the 
Federal Government any funding, including any subsidy 
payments, received by such issuer from the Federal Gov-
ernment on behalf of any adult alien who is unlawfully 
present in the United States. 
(e) SPECIAL RULE FOR ALIENS.—The Secretary of 
Homeland Security may not extend or renew an alien’s 
eligibility for status in the United States or adjust the sta-
tus of an alien in the United States if the alien owes— 
(1) a premium payment for a HAPI plan that 
is past due; or 
(2) a penalty incurred for failing to pay such a 
premium. 
(f) NO DISCHARGE IN BANKRUPTCY.—In the case of 
any bankruptcy filed by or on behalf of any person after 
the date that is 4 years after the date of enactment of 
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this Act, under title 11, United States Code, any penalty 
imposed with respect to such person for failure to pay a 
HAPI plan premium shall not be subject to discharge 
under such title. 
Subtitle D—Wellness Programs 
SEC. 131. REQUIREMENTS FOR WELLNESS PROGRAMS. 
(a) DEFINITION.—In this Act, the term ‘‘wellness 
program’’ means a program that consists of a combination 
of activities that are designed to increase awareness, as-
sess risks, educate, and promote voluntary behavior 
change to improve the health of an individual, modify his 
or her consumer health behavior, enhance his or her per-
sonal well-being and productivity, and prevent illness and 
injury. 
(b) DISCOUNTS.— 
(1) ELIGIBILITY.—With respect to a HAPI 
plan that is offered in a State that permits premium 
discounts for enrollees who participate in a wellness 
program, to be eligible to receive such a discount, 
the administrator of the wellness program, on behalf 
of the enrollee, shall certify in writing to the plan 
that— 
(A) the enrollee, or the dependent child of 
the enrollee, is participating in an approved 
wellness program; and 
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(B) the wellness program meets the re-
quirements of this subsection. 
(2) 
REQUIREMENTS.—A 
wellness 
program 
meets the requirements of this paragraph if such 
program— 
(A) is reasonably designed (as determined 
by the HAPI plan) to promote good health and 
prevent disease for program participants; 
(B) has been determined by the HAPI 
plan to be eligible for participation discounts; 
(C) is offered to all enrollees in a HAPI 
plan regardless of health status; 
(D) permits any enrollee for whom it is un-
reasonably difficult to meet the initial program 
standard for participation due to a medical con-
dition, or for whom it is medically inadvisable 
to attempt, an opportunity to meet a reasonable 
alternative participation standard— 
(i) that is developed prior to enroll-
ment of the enrollee or, after a determina-
tion has been made that the enrollee can-
not safely meet the program participation 
standard, in consultation with the enrollee 
after enrollment of the enrollee; and 
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(ii) the availability of which is dis-
closed in the original documents relating to 
participation in the program; 
(E) applies procedures for determining 
whether an enrollee is participating in a mean-
ingful manner in the program, including proce-
dures to determine if such participation is re-
sulting in lifestyle changes that are indicative of 
an improved health outcome or outcomes; and 
(F) meets any other requirements imposed 
by the HAPI plan. 
(3) RELATION TO HEALTH STATUS.—Participa-
tion in a wellness program may not be used by a 
HAPI plan to make rate or discount determinations 
with respect to the health status of an enrollee. 
(4) AVAILABILITY OF DISCOUNTS.— 
(A) 
OFFERING
OF
ENROLLMENT.—A 
HAPI plan shall provide enrollees with the op-
portunity to participate in a wellness program 
(for purposes of qualifying for premium dis-
counts) at least once each year. 
(B) 
DETERMINATIONS.—Determinations 
with respect to the successful participation by 
an enrollee in a wellness program for purposes 
of qualifying for premium discounts shall be 
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made by the HAPI plan based on a retrospec-
tive review of the scope of activities of the en-
rollee under the program. The HAPI plan may 
require a minimum level of successful participa-
tion in such a program prior to applying any 
premium discount. 
(C) PARTICIPATION
IN
MULTIPLE
PRO-
GRAMS.—An enrollee may participate in mul-
tiple wellness programs to reach the maximum 
premium discount permitted by the HAPI plan 
under applicable State law. 
(5) PERSONAL RESPONSIBILITY CONTRIBUTION 
DISCOUNT.—A HAPI plan may elect to provide dis-
counts in the amount of the personal responsibility 
contribution that is required of an enrollee if the en-
rollee participates in an approved wellness program. 
(c) EMPLOYER INCENTIVE
FOR WELLNESS PRO-
GRAMS.—For provisions relating to employers deducting 
the costs of offering wellness programs or worksite health 
centers see section 162(l) of the Internal Revenue Code 
of 1986. 
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TITLE II—HEALTHY START FOR 
CHILDREN 
Subtitle A—Benefits and Eligibility 
SEC. 201. HAPI PLAN COVERAGE FOR CHILDREN. 
(a) AUTHORIZATION OF APPROPRIATIONS.—There is 
authorized to be appropriated, such sums as may be nec-
essary for each fiscal year to enable the Secretary to pro-
vide assistance to States to enable such States to ensure 
that each child who is a member of a family with a modi-
fied adjusted gross income that is below 300 percent of 
the poverty line as applicable to a family of the size in-
volved, who is not otherwise eligible for coverage as a de-
pendent under a HAPI plan maintained by his or her par-
ents, is covered under a HAPI plan provided through the 
State HHA. 
(b) POLICIES
AND PROCEDURES.—The Secretary 
shall develop policies and procedures to be applied by the 
States to identify children described in subsection (a) and 
to provide such children with coverage under a HAPI plan. 
States shall determine, in consultation with health insur-
ance issuers, a separate class of coverage to assure afford-
able child coverage. 
(c) DEFINITION.—In this title, the term ‘‘child’’ 
means an individual who is under the age of 19 years or, 
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in the case of an individual in foster care, under the age 
of 21 years. 
SEC. 202. COORDINATION OF SUPPLEMENTAL COVERAGE 
UNDER THE MEDICAID PROGRAM WITH HAPI 
PLAN COVERAGE FOR CHILDREN. 
(a) ASSURANCE OF SUPPLEMENTAL COVERAGE.— 
Subject to section 631(d), the Secretary, States, and 
health insurance issuers shall ensure that any child eligible 
under title XIX of the Social Security Act (including any 
child eligible under a waiver under such title or under sec-
tion 1115 of such Act (42 U.S.C. 1315)) covered under 
a HAPI plan provided through the State HHA receives 
medical assistance under State Medicaid plans in a man-
ner that— 
(1) is provided in coordination with, and as a 
supplement to, the coverage provided the child under 
the HAPI plan in which the child is enrolled; 
(2) does not supplant the child’s coverage under 
a HAPI plan; 
(3) ensures that the child receives all items or 
services that are not available (or are otherwise lim-
ited) under the HAPI plan in which they are en-
rolled but that is provided under the State plan (or 
provided to a greater extent or in a less restrictive 
manner) under title XIX of the Social Security Act 
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(including any waiver under such title or under sec-
tion 1115 of such Act (42 U.S.C. 1315)) of the 
State in which the child resides; and 
(4) ensures that the family of the child is not 
charged premiums, deductibles, or other cost-sharing 
that is greater than would have been charged under 
the State plan under title XIX of the Social Security 
Act of the State in which the child resides if such 
coverage was not provided as a supplement to the 
coverage provided the child under the HAPI plan in 
which the child is enrolled. 
(b) GUIDANCE TO STATES AND HEALTH INSURANCE 
ISSUERS.—The Secretary shall issue regulations and guid-
ance to States and health insurance issuers implementing 
this section not later than 6 months prior to the date on 
which coverage under a HAPI plan first begins. 
(c) RULE OF CONSTRUCTION.—Nothing in this sec-
tion shall be construed as affecting a State’s requirement 
to provide items and services described in section 
1905(a)(4)(B) of the Social Security Act (relating to early 
and periodic screening, diagnostic, and treatment services 
defined in section 1905(r) of such Act and provided in 
accordance with the requirements of section 1902(a)(43) 
of such Act). 
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(d) CHILD.—In this section, the term ‘‘child’’ has the 
meaning given that term under section 201(c) and may 
include, upon application by a State to the Secretary and 
with the approval of the Secretary on a budget neutral 
basis, any individual who would be considered a child 
under the Medicaid program of the State as of the date 
of the enactment of this Act. 
Subtitle B—Service Providers 
SEC. 211. INCLUSION OF PROVIDERS UNDER HAPI PLANS. 
(a) IN GENERAL.—To ensure that children have ac-
cess to health care in their communities, and that such 
care is provided to such children for no cost or on a reim-
bursable basis, a HAPI plan shall ensure that health care 
items and services may be obtained by such children from, 
at a minimum, the providers described in subsection (b) 
if available in the area involved. 
(b) PROVIDERS
DESCRIBED.—The providers de-
scribed in this subsection include the following: 
(1) A school-based health center (in accordance 
with section 212). 
(2) A health center funded under section 330 of 
the Public Health Service Act (42 U.S.C. 254b). 
(3) A federally qualified health center. 
(4) A rural health clinic under title XVIII of 
the Social Security Act (42 U.S.C. 1395 et seq.). 
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(5) An Indian Health Service facility. 
SEC. 212. USE OF, AND GRANTS FOR, SCHOOL-BASED 
HEALTH CENTERS. 
(a) DEFINITION.—In this section, the term ‘‘school- 
based health center’’ means a health center that— 
(1) is located within an elementary or secondary 
school facility; 
(2) is operated in collaboration with the school 
in which such center is located; 
(3) is administered by a community-based orga-
nization including a hospital, public health depart-
ment, community health center, or nonprofit health 
care agency; 
(4) at a minimum, provides to school-aged chil-
dren— 
(A) primary health care services, including 
comprehensive health assessments, and diag-
nosis and treatment of minor, acute, and chron-
ic medical conditions and Healthy Start bene-
fits; 
(B) mental health services, including crisis 
intervention, counseling, and emergency psy-
chiatric care at the school or by referral; 
(C) the availability of services at the school 
when the school is open and 24-hour coverage 
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through an on-call system with other providers 
to ensure access when the school or health cen-
ter is closed; 
(D) services through the use of a qualified 
and appropriately credentialed individual, in-
cluding a nurse practitioner or physician assist-
ant, a mental health professional, a physician, 
and a health assistant; and 
(E) by not later than January 1, 2018, an 
electronic medical record relating to the indi-
vidual; and 
(5) may provide optional preventive dental serv-
ices, consistent with State licensure law, through the 
use of dental hygienists or dental assistants that 
provide preventive services such as basic oral exams, 
cleanings, and sealants. 
(b) ACCESS
TO
SCHOOL-BASED
HEALTH
CEN-
TERS.— 
(1) IN GENERAL.—A school-based health center 
may provide services to students in more than 1 
school if the school district or other supervising 
State entity determine that capacity and geographic 
location make such provision of services appropriate. 
(2) ENROLLMENT.—Upon the enrollment of a 
student in a school with a school-based health cen-
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ter, the center will provide the student with the op-
portunity to enroll, after parental consent, to receive 
health care from the center. 
(3) REIMBURSEMENT FOR SERVICES.— 
(A) IN GENERAL.—A school-based health 
center may seek reimbursement from a third 
party payer if available, including a HAPI plan, 
if a child receives health care items or services 
through the center. 
(B) USE
OF
FUNDS.—Amounts received 
from a third party payer under subparagraph 
(A) shall be allocated to the school-based health 
center that provided the care for which the re-
imbursement was provided for use by that cen-
ter for providing additional health care items 
and services. 
(c) DEVELOPMENTAL GRANTS.— 
(1) IN GENERAL.—The Secretary shall award 
grants to local school districts and communities for 
the establishment and operation of school-based 
health centers. 
(2) ELIGIBILITY.—To be eligible for a grant 
under paragraph (1), a local school district or local 
community shall submit to the Secretary an applica-
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tion at such time, in such manner, and containing 
such information as the Secretary may require. 
(3) SELECTION CRITERIA.—In awarding grants 
under this subsection, the Secretary shall give pri-
ority to— 
(A) an applicant that will use amounts 
under the grant to establish a school-based 
health center in a medically underserved area, 
or an area for which there are extended dis-
tances between the school involved and appro-
priate providers of care for school-aged children 
in the geographic area involved; 
(B) an applicant that will use amounts 
under the grant to establish a school-based 
health center in a school that serves students 
with the highest incidence of unmet medical 
and psycho-social needs; and 
(C) an applicant that can demonstrate that 
State, local, or community partners, or any 
combination of such entities, have provided at 
least 50 percent of the funding for the school- 
based health center involved to ensure the ongo-
ing operation of the center. 
(4) USE
OF
FUNDS.—A grantee shall use 
amounts received under a grant under this sub-
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section to establish and operate a school-based 
health center. Not less than 50 percent of the 
amounts received under the grant shall be used for 
the ongoing operations of the center. 
(d) COVERAGE BY FEDERAL TORT CLAIMS ACT.— 
In providing health care items and services to students 
through a school-based health care center, a health care 
provider shall be deemed to be an employee of the govern-
ment for purposes of the application of chapter 171 of 
title 28, United States Code (the Federal Tort Claims Act) 
if such provider was acting within the scope of his or her 
license. 
TITLE III—BETTER HEALTH FOR 
OLDER AND DISABLED AMER-
ICANS 
Subtitle A—Assurance of 
Supplemental Medicaid Coverage 
SEC. 301. COORDINATION OF SUPPLEMENTAL COVERAGE 
UNDER THE MEDICAID PROGRAM FOR EL-
DERLY AND DISABLED INDIVIDUALS. 
(a) ASSURANCE OF SUPPLEMENTAL COVERAGE.— 
Subject to section 631(d), the Secretary, States, and 
health insurance issuers shall ensure that any elderly or 
disabled individual eligible under title XIX of the Social 
Security Act (including any such individual eligible pursu-
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ant to a waiver under such title or under section 1115 
of such Act (42 U.S.C. 1315)) covered under a HAPI plan 
provided through the State HHA receives medical assist-
ance under State Medicaid plans in a manner that— 
(1) is provided in coordination with, and as a 
supplement to, the coverage provided the individual 
under the HAPI plans in which the individual is en-
rolled; 
(2) does not supplant the individual’s coverage 
under a HAPI plan; 
(3) ensures that the elderly or disabled indi-
vidual receives all items or services, including insti-
tutional care or home and community-based services 
that are not available (or are otherwise limited) 
under the HAPI plan in which they are enrolled but 
that is provided (or provided to a greater extent or 
in a less restrictive manner) under the State plan 
under title XIX of the Social Security Act (including 
through any waiver under such title or under section 
1115 of such Act (42 U.S.C. 1315)) of the State in 
which the individual resides; and 
(4) ensures that the elderly or disabled indi-
vidual is not charged premiums, deductibles and 
other cost-sharing that is greater than would have 
been charged under the State plan under title XIX 
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of the Social Security Act (including any waiver 
under such title or under section 1115 of such Act 
(42 U.S.C. 1315)) of the State in which the indi-
vidual resides if such coverage was not provided as 
a supplement to the coverage provided the individual 
under the HAPI plan in which the individual is en-
rolled. 
(b) GUIDANCE TO STATES AND HEALTH INSURANCE 
ISSUERS.—The Secretary shall issue regulations and guid-
ance to States and health insurance issuers implementing 
this section that takes into account the special health care 
needs of elderly and disabled individuals who are eligible 
for medical assistance under State Medicaid programs, 
particularly with respect to institutionalized care or home 
and community-based services, not later than 6 months 
prior to the date on which coverage under a HAPI plan 
first begins. 
(c) DEFINITIONS.—In this section— 
(1) the term ‘‘institutionalized care’’ means the 
health care provided under the Medicaid plan of the 
State of residence of an elderly or disabled individual 
who is a patient in a hospital, nursing facility, inter-
mediate care facility for the mentally retarded, or an 
institution for mental diseases (as such terms are 
defined for purposes of such plan); and 
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(2) the term ‘‘home and community-based serv-
ices’’ means any services which may be offered 
under the Medicaid plan of the State of residence of 
an elderly or disabled individual under a home and 
community-based waiver authorized for a State 
under section 1115 of the Social Security Act (42 
U.S.C. 1315) or under subsection (c), (d), or (i) of 
section 1915 of such Act (42 U.S.C. 1396n). 
Subtitle 
B—Enpowering 
Individ-
uals 
and 
State 
To 
Improve 
Long-Term Care Choices 
SEC. 311. NEW, AUTOMATIC MEDICAID OPTION FOR STATE 
CHOICES FOR LONG-TERM CARE PROGRAM. 
(a) IN GENERAL.—Title XIX of the Social Security 
Act is amended by adding at the end the following new 
section: 
‘‘SEC. 1943. STATE CHOICES FOR LONG-TERM CARE PRO-
GRAM. 
‘‘(a) IN GENERAL.—Notwithstanding any other pro-
vision of this title, the Secretary shall permit a State to 
establish and operate under the State plan under this title 
(including such a plan operating under a statewide waiver 
under section 1115) a State Choices for Long-Term Care 
Program in accordance with this section. 
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‘‘(b) PROGRAM REQUIREMENTS.—A program estab-
lished under the authority of this section shall satisfy the 
following requirements: 
‘‘(1) INDIVIDUALIZED
BENEFIT
PACKAGE.— 
Each individual enrolled in the program shall be pro-
vided with long-term care coverage consisting of 
medical assistance for long-term care services that 
are provided according to the specific needs of the 
individual and that best reflect the individual’s needs 
and preferences, based on a clinical assessment of 
the individual. 
‘‘(2) PERSONAL CASE MANAGERS.—Each indi-
vidual enrolled in the program shall be provided with 
a personal case manager who shall assist the indi-
vidual in— 
‘‘(A) determining the individual’s needs 
and preferences for the long-term care services 
that are contained within the individual’s ben-
efit package, including the selection of the serv-
ice providers for such services; 
‘‘(B) identifying community resources that 
are available to provide support for the indi-
vidual; and 
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‘‘(C) addressing issues related to ensuring 
the safety and quality of the long-term care 
services provided to the individual. 
‘‘(3) INFORMED CHOICE.—The program shall 
have procedures to ensure that each individual that 
is likely to satisfy the eligibility criteria established 
for the program under paragraph (6) who is dis-
charged from a hospital or who resides in a nursing 
facility, intermediate care facility for the mentally 
retarded, or institution for mental diseases and who 
requires long-term care services is informed of the 
options available to the individual under the pro-
gram for obtaining such services. 
‘‘(4) SELF-DIRECTED
OPTION.—The program 
shall provide an individual enrolled in the program 
with the option to elect to plan and purchase the 
long-term care services that are contained in the in-
dividual’s benefit package under the direction and 
control of the individual (or the individual’s author-
ized representative), subject to an individualized 
budget developed for, and with the involvement of, 
the individual (or the individual’s authorized rep-
resentative). 
‘‘(5) EQUAL ACCESS TO INSTITUTIONAL CARE 
AND HOME AND COMMUNITY-BASED SERVICES.—The 
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program shall provide an individual enrolled in the 
program who, because of the individual’s mental or 
physical condition, requires a level of care for long- 
term care services that is above a level of care for 
such services that can appropriately be provided 
solely through home and community-based providers 
(as defined by the State and approved by the Sec-
retary), with equal access to long-term care services 
provided through institutional facilities and long- 
term care services provided through home and com-
munity-based providers. 
‘‘(6) ELIGIBILITY; PRIORITIZATION OF NEED.— 
The program shall apply eligibility criteria for indi-
viduals desiring to enroll in the program that is es-
tablished by the State and approved by the Sec-
retary. The eligibility criteria established by the 
State shall— 
‘‘(A) require that an individual enrolled in 
the program— 
‘‘(i) be eligible for medical assistance 
under the State plan (or under a statewide 
waiver of such plan) for nursing facility 
services, services in an intermediate care 
facility for the mentally retarded, services 
in an institution for mental diseases, or 
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services provided under a home and com-
munity-based waiver approved for the 
State; and 
‘‘(ii) satisfy such other criteria as the 
State shall establish; and 
‘‘(B) be based on a strategy for prioritizing 
and allocating expenditures so that those indi-
viduals with the highest level of need for long- 
term care services are assured of receiving such 
services through an institutional facility or 
through a home and community-based provider, 
based on the individual’s needs and preferences. 
‘‘(c) ADDITIONAL REQUIREMENTS.—A State may not 
establish and operate a program under this section unless 
it satisfies the following requirements: 
‘‘(1) AGREEMENT TO LIMIT FEDERAL EXPENDI-
TURES.— 
‘‘(A) IN GENERAL.—The State agrees to 
an aggregate limit for a 5-year period for Fed-
eral payments under section 1903(a) for ex-
penditures for medical assistance for long-term 
care services under the State plan and adminis-
trative expenditures related to the provision of 
such assistance. 
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‘‘(B) 
CALCULATION
OF
AGGREGATE 
LIMIT.—The 5-year aggregate limit applicable 
to a State under subparagraph (A) shall be de-
termined by the State and the Secretary based 
on the following: 
‘‘(i) HISTORICAL
AND
PROJECTED 
CASELOADS.—The historical and projected 
State caseloads (determined for a 5-year 
period, respectively) of individuals receiving 
nursing facility services, services in an in-
termediate care facility for the mentally re-
tarded, services in an institution for men-
tal diseases, or services provided under a 
home and community-based waiver ap-
proved for the State under the State plan, 
based on data from the Secretary, the Bu-
reau of the Census, the Commissioner of 
Social Security, and such other sources as 
the Secretary may approve. 
‘‘(ii) HISTORICAL
AND
PROJECTED 
EXPENDITURES.—The historical and pro-
jected expenditures (determined for a 5- 
year period, respectively) for the services 
identified in clause (i). Projected expendi-
tures shall be determined without regard to 
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the program established under this section 
and shall take into account the percentage 
change (if any) in the medical care compo-
nent of the consumer price index for all 
urban consumers (U.S. city average) for 
each year of the period. 
‘‘(C) RULE OF CONSTRUCTION.—Nothing 
in this paragraph shall be construed as affect-
ing the requirement for a State to incur State 
expenditures for medical assistance for long- 
term care services in order to be paid the Fed-
eral medical assistance percentage determined 
for the State for such expenditures (not to ex-
ceed the aggregate 5-year limit on Federal pay-
ments for such expenditures applicable under 
subparagraph (A)). 
‘‘(2) PLAN
FOR
CAPACITY
BUILDING
AND 
SKILLS
ENHANCEMENT.—The State establishes a 
plan for building the capacity of the long-term care 
services system within the State, particularly with 
respect to the delivery of home and community- 
based services, and for enhancing the skill levels of 
the caregivers for individuals eligible for medical as-
sistance for such services under the State plan. 
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‘‘(3) DEDICATION OF PROGRAM SAVINGS FOR 
PREVENTION OR EARLY INTERVENTION SERVICES.— 
The State agrees that for each fiscal year in which 
the program is operated, the State will expend an 
amount equal to the State share of the expenditures 
that the State would have made under the State 
plan for providing medical assistance for long-term 
care services for individuals enrolled in the program 
but for the operation of such program, for the provi-
sion of prevention or early intervention services for 
nonenrolled individuals residing in the State who re-
quire a level of long-term care services that is below 
the level that individuals enrolled in the program re-
quire (regardless of whether such nonenrolled indi-
viduals are eligible for medical assistance under the 
State plan). 
‘‘(d) OPTION TO OPERATE PROGRAM THROUGH A 
MANAGED CARE PLAN.—A State may operate a program 
under this section through an arrangement on a capitated 
basis with a Medicaid managed care organization (as de-
fined in section 1903(m)(1)(A)). 
‘‘(e) INDEPENDENT EVALUATION AND REPORT.— 
‘‘(1) IN GENERAL.—The Secretary shall con-
tract with a nongovernmental organization or aca-
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demic institution to conduct an ongoing independent 
evaluation of the program that assesses— 
‘‘(A) the quality of the long-term care serv-
ices provided under the program; 
‘‘(B) the cost-effectiveness of such services; 
‘‘(C) consumer satisfaction; and 
‘‘(D) the consistency and accuracy with 
which the prioritization of need criteria required 
under subsection (b)(6)(B) is applied. 
‘‘(2) BIENNIAL REPORTS.—The organization or 
institution conducting the evaluation required under 
this subsection shall submit biennial reports to the 
Secretary regarding the results of the evaluation. 
‘‘(f) DEFINITION OF LONG-TERM CARE SERVICES.— 
For purposes of this section, the term ‘long-term care 
services’ has the meaning given such term by a State es-
tablishing and operating a program under this section, 
subject to approval by the Secretary.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) takes effect on the date of enactment of 
this Act. 
SEC. 312. SIMPLER AND MORE AFFORDABLE LONG-TERM 
CARE INSURANCE COVERAGE. 
(a) QUALIFIED LONG-TERM CARE INSURANCE CON-
TRACT MUST SATISFY QUALIFIED LONG-TERM CARE 
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PLAN REQUIREMENTS.—Section 7702B(b)(1)(A) of the 
Internal Revenue Code of 1986 (defining qualified long- 
term care insurance contract) is amended by inserting 
‘‘through a qualified long-term care plan’’ after ‘‘qualified 
long-term care services’’. 
(b) QUALIFIED LONG-TERM CARE PLAN.—Section 
7702B of such Code is amended by adding at the end the 
following new subsection: 
‘‘(h) QUALIFIED LONG-TERM CARE PLAN.—For pur-
poses of this section— 
‘‘(1) IN GENERAL.—The term ‘qualified long- 
term care plan’ means an insurance plan that meets 
the standards and requirements set forth in para-
graph (2) (including the 2009–2010 NAIC Model 
Regulation or 2009–2010 Federal Regulation (as 
the case may be)) on or after the date specified in 
paragraph (5). 
‘‘(2) DEVELOPMENT OF STANDARDS AND RE-
QUIREMENTS
FOR
QUALIFIED
LONG-TERM
CARE 
PLANS.— 
‘‘(A) IN GENERAL.—If, within 9 months 
after the date of the enactment of this sub-
section, the National Association of Insurance 
Commissioners (in this subsection referred to as 
the ‘Association’) adopts a model regulation (in 
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this section referred to as the ‘2009–2010 
NAIC Model Regulation’) to incorporate— 
‘‘(i) limitations on the groups or pack-
ages of benefits that may be offered under 
a long-term care insurance policy con-
sistent with paragraphs (3) and (4), 
‘‘(ii) uniform language and definitions 
to be used with respect to such benefits, 
‘‘(iii) uniform format to be used in the 
policy with respect to such benefits, and 
‘‘(iv) other standards required by the 
Secretary of Health and Human Services 
paragraph (1) shall be applied in each State, ef-
fective for policies issued to policyholders on 
and after the date specified in paragraph (5). 
‘‘(B) SECRETARIAL
RESPONSIBILITY.—If 
the Association does not adopt the 2009–2010 
NAIC Model Regulation within the 9-month pe-
riod specified in subparagraph (A), the Sec-
retary shall promulgate, not later than 9 
months after the end of such period, a regula-
tion (in this section referred to as the ‘2009– 
2010 Federal Regulation’) and paragraph (1) 
shall be applied in each State, effective for poli-
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cies issued to policyholders on and after the 
date specified in paragraph (5). 
‘‘(C) CONSULTATION.—In promulgating 
standards and requirements under this para-
graph, the Association or Secretary shall con-
sult with a working group composed of rep-
resentatives of issuers of long-term care insur-
ance policies, consumer groups, long-term care 
insurance beneficiaries, and other qualified indi-
viduals. Such representatives shall be selected 
in a manner so as to insure balanced represen-
tation among the interested groups. 
‘‘(3) LIMITATIONS OF GROUPS OR PACKAGES OF 
BENEFITS.—The benefits under the 2009–2010 
NAIC Model Regulation or 2009–2010 Federal Reg-
ulation shall provide— 
‘‘(A) for such groups or packages of bene-
fits as may be appropriate taking into account 
the considerations specified in paragraph (4) 
and the requirements of the succeeding sub-
paragraphs, 
‘‘(B) for identification of a core group of 
basic benefits common to all policies, and 
‘‘(C) that the total number of different 
benefit packages (counting the core group of 
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basic benefits described in subparagraph (B) 
and each other combination of benefits that 
may be offered as a separate benefit package) 
that may be established in all the States and by 
all issuers shall not exceed 10. 
‘‘(4) SPECIFIC CONSIDERATIONS.—The benefits 
under paragraph (3) shall, to the extent possible— 
‘‘(A) provide for benefits that offer con-
sumers the ability to purchase the benefits that 
are available in the market as of November 5, 
2009, and 
‘‘(B) balance the objectives of— 
‘‘(i) simplifying the market to facili-
tate comparisons among policies, 
‘‘(ii) avoiding adverse selection, 
‘‘(iii) providing consumer choice, 
‘‘(iv) providing market stability, and 
‘‘(v) promoting competition. 
‘‘(5) EFFECTIVE DATE.— 
‘‘(A) IN
GENERAL.—Subject to subpara-
graph (B), the date specified in this paragraph 
shall be the date the State adopts the 2009– 
2010 NAIC Model Regulation or 2009–2010 
Federal Regulation or 1 year after the date the 
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Association or the Secretary first adopts such 
standards, whichever is earlier. 
‘‘(B) REQUIRED STATE LEGISLATION.—In 
the case of a State which the Secretary identi-
fies, in consultation with the Association, as— 
‘‘(i) requiring State legislation (other 
than legislation appropriating funds) in 
order for long-term care insurance policies 
to meet the 2009–2010 NAIC Model Regu-
lation or 2009–2010 Federal Regulation, 
but 
‘‘(ii) having a legislature which is not 
scheduled to meet in 2009 in a legislative 
session in which such legislation may be 
considered, 
the date specified in this paragraph is the first 
day of the first calendar quarter beginning after 
the close of the first legislative session of the 
State legislature that begins on or after Janu-
ary 1, 2011. For purposes of the preceding sen-
tence, in the case of a State that has a 2-year 
legislative session, each year of such session 
shall be deemed to be a separate regular session 
of the State legislature.’’. 
(c) ADDITIONAL CONSUMER PROTECTIONS.— 
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(1) IN GENERAL.—Section 7702B(g)(1) of such 
Code (relating to consumer protection provisions) is 
amended— 
(A) by striking subparagraph (A) and in-
serting the following new paragraph: 
‘‘(1) the requirements of the 1993 NAIC model 
regulation and model Act described in paragraph (2) 
and the 2000 NAIC model regulation and model Act 
described in paragraph (5),’’, 
(B) by striking ‘‘and’’ at the end of sub-
paragraph (B), 
(C) by striking the period at the end of 
subparagraph (C) and inserting ‘‘, and’’, and 
(D) by adding at the end the following new 
subparagraph: 
‘‘(D) the requirements relating to manda-
tory offer and information under paragraph 
(6).’’. 
(2) NAIC MODEL REGULATION AND ACT.—Sec-
tion 7702B(g) of such Code is amended— 
(A) by inserting ‘‘1993 NAIC’’ after ‘‘RE-
QUIREMENTS OF’’ in the heading for paragraph 
(2), 
(B) by redesignating paragraph (5) as 
paragraph (7), and 
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(C) by inserting after paragraph (4) the 
following new paragraph: 
‘‘(5) REQUIREMENTS OF 2000 NAIC MODEL REG-
ULATION AND ACT.— 
‘‘(A) IN GENERAL.—The requirements of 
this paragraph are met with respect to any con-
tract if such contract meets— 
‘‘(i) MODEL
REGULATION.—The fol-
lowing requirements of the model regula-
tion: 
‘‘(I) Section 6A (other than para-
graph (5) thereof) and the require-
ments of section 6B of the model Act 
relating to such section 6A. 
‘‘(II) Section 6B (other than 
paragraph (7) thereof). 
‘‘(III) Sections 6C, 6D, 6E, and 
7. 
‘‘(IV) Section 8 (other than sec-
tions 8F, 8G, 8H, and 8I thereof). 
‘‘(V) Sections 9, 11, 12, 14, 15, 
and 22. 
‘‘(VI) Section 23, including inac-
curate completion of medical histories 
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(other than paragraphs (1), (6), and 
(9) of section 23C). 
‘‘(VII) Sections 24 and 25. 
‘‘(VIII) The provisions of section 
26 relating to contingent nonforfeiture 
benefits, if the policyholder declines 
the offer of a nonforfeiture provision 
described in paragraph (4). 
‘‘(IX) Sections 29 and 30. 
‘‘(ii) MODEL ACT.—The following re-
quirements of the model Act: 
‘‘(I) Sections 6C and 6D. 
‘‘(II) The provisions of section 8 
relating to contingent nonforfeiture 
benefits. 
‘‘(III) Sections 6F, 6G, 6H, 6J, 
6K, and 7. 
‘‘(B) DEFINITIONS.—For purposes of this 
paragraph— 
‘‘(i) MODEL PROVISIONS.—The terms 
‘model regulation’ and ‘model Act’ mean 
the long-term care insurance model regula-
tion, and the long-term care insurance 
model Act, respectively, promulgated by 
the National Association of Insurance 
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Commissioners (as adopted as of October 
2000). 
‘‘(ii) COORDINATION.—Any provision 
of the model regulation or model Act listed 
under clause (i) or (ii) of subparagraph 
(A) shall be treated as including any other 
provision of such regulation or Act nec-
essary to implement the provision. 
‘‘(iii) 
DETERMINATION.—For 
pur-
poses of this section and section 4980C, 
the determination of whether any require-
ment of a model regulation or the model 
Act has been met shall be made by the 
Secretary.’’. 
(d) MANDATORY OFFER AND INFORMATION.—Sec-
tion 7702B(g) of such Code, as amended by subsection 
(c), is amended by inserting after paragraph (5) the fol-
lowing new paragraph: 
‘‘(6) MANDATORY OFFER AND INFORMATION.— 
The requirements of this paragraph are met if— 
‘‘(A) MANDATORY
OFFER.—Any person 
who sells a long-term care insurance policy to 
an individual shall make available for sale to 
the individual a long-term care insurance policy 
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with only the core group of basic benefits (de-
scribed in subsection (h)(3)(B)). 
‘‘(B) INFORMATION.—Any person who sells 
a long-term care insurance policy to an indi-
vidual shall provide the individual, before the 
sale of the policy, an outline of coverage which 
describes the benefits under the policy. Such 
outline shall be on a standard form approved by 
the State regulatory program or the Secretary 
(as the case may be) consistent with the 2009– 
2010 NAIC Model Regulation or 2009–2010 
Federal Regulation.’’. 
(e) STATE REGULATION
OF OUT-OF-STATE CON-
TRACTS.—Section 7702B of such Code is amended by 
adding at the end the following new subsection: 
‘‘(i) STATE REGULATION OF OUT-OF-STATE CON-
TRACTS.—Nothing in this section shall be construed so as 
to affect the right of any State to regulate long-term care 
insurance policies which, under the provisions of this sec-
tion, are considered to be issued in another State.’’. 
(f) EFFECTIVE DATE.—The amendments made by 
this section shall apply to contracts issued after December 
31, 2009. 
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TITLE IV—HEALTHIER 
MEDICARE 
Subtitle A—Authority To Adjust 
Amount of Part B Premium To 
Reward Positive Health Behav-
ior 
SEC. 401. AUTHORITY TO ADJUST AMOUNT OF MEDICARE 
PART B PREMIUM TO REWARD POSITIVE 
HEALTH BEHAVIOR. 
Section 1839 of the Social Security Act (42 U.S.C. 
1395r) is amended— 
(1) in subsection (a)(2), by striking ‘‘and (i)’’ 
and inserting ‘‘(i), and (j)’’; and 
(2) by adding at the end the following new sub-
section: 
‘‘(j)(1) With respect to the monthly premium amount 
for months after December 2010, the Secretary may ad-
just (under procedures established by the Secretary) the 
amount of such premium for an individual based on 
whether or not the individual participates in certain 
healthy behaviors, such as weight management, exercise, 
nutrition counseling, refraining from tobacco use, desig-
nating a health home, and other behaviors determined ap-
propriate by the Secretary. 
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‘‘(2) In making the adjustments under paragraph (1) 
for a month, the Secretary shall ensure that the total 
amount of premiums to be paid under this part for the 
month is equal to the total amount of premiums that 
would have been paid under this part for the month if 
no such adjustments had been made, as estimated by the 
Secretary.’’. 
Subtitle B—Promoting Primary 
Care for Medicare Beneficiaries 
SEC. 411. PRIMARY CARE SERVICES MANAGEMENT PAY-
MENT. 
Title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.) is amended by inserting after section 1807 
the following new section: 
‘‘SEC. 1807A. PRIMARY CARE MANAGEMENT PAYMENT FOR 
COORDINATING CARE. 
‘‘(a) PAYMENT.— 
‘‘(1) IN GENERAL.—Not later than January 1, 
2010, the Secretary, subject to paragraph (2), shall 
establish procedures for providing primary care and 
participating providers with a management fee (as 
determined appropriate by the Secretary, in con-
sultation with the Medicare Payment Advisory Com-
mission established under section 1805) that reflects 
the amount of time spent with a Medicare bene-
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ficiary, and the family of such beneficiary, providing 
chronic care disease management services or other 
services in assisting in coordinating care. 
‘‘(2) REQUIREMENT
FOR
DESIGNATION
AS 
HEALTH HOME.—The management fee under para-
graph (1) shall not be provided to a primary care 
provider with respect to a Medicare beneficiary un-
less the provider has been designated (under proce-
dures established by the Secretary) as the health 
home by the beneficiary. 
‘‘(b) DEFINITIONS.—In this section: 
‘‘(1) HEALTH HOME.—The term ‘health home’ 
means a health care provider that a Medicare bene-
ficiary has designated to monitor the health and 
health care of the beneficiary. 
‘‘(2) 
MEDICARE
BENEFICIARY.—The 
term 
‘Medicare beneficiary’ means an individual who is 
entitled to, or enrolled for, benefits under part A, 
enrolled under part B, or both. 
‘‘(3) PRIMARY CARE PROVIDER.— 
‘‘(A) IN
GENERAL.—The term ‘primary 
care provider’ means a primary care physician 
(as defined in subparagraph (B)), a nurse prac-
titioner (as defined in section 1861aa(5)(A)), or 
a physician assistant (as so defined). 
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‘‘(B) PRIMARY CARE PHYSICIAN.—In sub-
paragraph (A), the term ‘primary care physi-
cian’ means a physician, such as a family prac-
titioner or internist, who is chosen by an indi-
vidual to provide continuous medical care, who 
is able to give a wide range of care, including 
prevention and treatment, and who can refer 
the individual to a specialist.’’. 
Subtitle C—Chronic Care Disease 
Management 
SEC. 421. CHRONIC CARE DISEASE MANAGEMENT. 
Title XVIII of the Social Security Act (42 U.S.C. 
1395 et seq.), as amended by section 411, is amended by 
inserting after section 1807A the following new section: 
‘‘SEC. 1807B. CHRONIC CARE DISEASE MANAGEMENT PRO-
GRAM. 
‘‘(a) ESTABLISHMENT.— 
‘‘(1) IN GENERAL.—Not later than January 1, 
2010, the Secretary shall develop and implement a 
chronic care disease management program (in this 
section referred to as the ‘program’). The program 
shall be designed to provide chronic care disease 
management to all Medicare beneficiaries with re-
spect to at least the 5 most prevalent diseases within 
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the population of such beneficiaries (as determined 
by the Secretary). 
‘‘(2) DEVELOPMENT.—In developing and imple-
menting the program under paragraph (1), the Sec-
retary shall— 
‘‘(A) take into consideration— 
‘‘(i) the results of chronic care im-
provement programs conducted under sec-
tion 1807, including the independent eval-
uations of such programs conducted under 
section 1807(b)(5) and any outcomes re-
ports 
submitted 
under 
section 
1807(e)(4)(A); and 
‘‘(ii) the results of the payments to 
primary care providers under section 
1807A; and 
‘‘(B) consult individuals with expertise in 
chronic care disease management. 
‘‘(b) IDENTIFICATION AND ENROLLMENT.—The Sec-
retary shall establish procedures for identifying and enroll-
ing Medicare beneficiaries who may benefit from participa-
tion in the program. 
‘‘(c) CHRONIC CARE DISEASE MANAGEMENT PAY-
MENT FOR NON-PRIMARY CARE PHYSICIANS.— 
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‘‘(1) IN GENERAL.—Under the program, a non- 
primary care physician shall receive a chronic care 
disease management payment if the physician serves 
the Medicare beneficiary by assuring the beneficiary 
receives appropriate and comprehensive care, includ-
ing referral of the individual to specialists, and as-
suring the beneficiary receives preventive services. 
‘‘(2) AMOUNT OF PAYMENT.—The amount of 
the management payment under the program shall 
be an amount determined appropriate by the Sec-
retary, in consultation with the Medicare Payment 
Advisory Commission established under section 
1805. Such amount shall reflect the amount of time 
spent with a Medicare beneficiary, and the family of 
such beneficiary, providing chronic care disease man-
agement services. 
‘‘(d) DEFINITIONS.—In this section: 
‘‘(1) 
MEDICARE
BENEFICIARY.—The 
term 
‘Medicare beneficiary’ means an individual who is 
entitled to, or enrolled for, benefits under part A, 
enrolled under part B, or both. 
‘‘(2) NON-PRIMARY
CARE
PHYSICIAN.—The 
term ‘non-primary care physician’ means a physician 
who— 
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Subtitle D—Improving Quality in 
Hospitals for All Patients 
SEC. 431. IMPROVING QUALITY IN HOSPITALS FOR ALL PA-
TIENTS. 
(a) IMPROVING HEALTH CARE QUALITY FOR ALL 
PATIENTS.— 
(1) IN GENERAL.—Section 1866(a)(1) of the 
Social Security Act (42 U.S.C. 1395cc(a)(1)) is 
amended— 
(A) in subparagraph (U), by striking 
‘‘and’’ at the end; 
(B) in subparagraph (V), by striking the 
period at the end and inserting ‘‘, and’’; and 
(C) by inserting after subparagraph (V) 
the following new subparagraph: 
‘‘(W) in the case of hospitals, to demonstrate to 
accrediting bodies measurable improvement in qual-
ity control with respect to all patients and to have 
in place quality control programs that are directed 
at care for all patients and that include— 
‘‘(i) rapid response teams that can assist 
patients with unstable vital signs; 
‘‘(ii) heart attack treatments with proven 
reliability; 
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‘‘(iii) procedures that reduce medication 
errors; 
‘‘(iv) aggressive infection prevention, with 
special focus on surgeries and infections with 
the highest death rates; 
‘‘(v) procedures that reduce the threat of 
pneumonia, with special focus on the incidence 
of ventilator-related illness; and 
‘‘(vi) such other elements as the Secretary 
determines appropriate.’’. 
(2) EFFECTIVE DATE.—The amendments made 
by paragraph (1) shall apply to hospitals as of the 
date that is 2 years after the date of enactment of 
this Act. 
(b) PANEL OF INDEPENDENT EXPERTS.—Beginning 
not later than the date that is 4 years after the date of 
enactment of this Act, in order to ensure that hospitals 
practice state-of-the-art quality control, the Secretary 
shall convene a panel of independent experts to update the 
measures of quality control and the types of quality con-
trol programs, including the elements of such programs, 
required under section 1866(a)(1)(W) of the Social Secu-
rity Act, as added by subsection (a), not less frequently 
than on an annual basis. 
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Subtitle E—Additional Provisions 
SEC. 441. ADDITIONAL COST INFORMATION. 
(a) IN GENERAL.—Section 1857(e) of the Social Se-
curity Act (42 U.S.C. 1395w–27(e)) is amended by adding 
at the end the following new paragraph: 
‘‘(4) ADDITIONAL COST INFORMATION.—A con-
tract under this section shall require a Medicare Ad-
vantage Organization to aggregate claims informa-
tion into episodes of care and to provide such infor-
mation to the Secretary so that costs for specific 
hospitals and physicians may be measured and com-
pared. The Secretary shall make such information 
public on an annual basis.’’. 
(b) EFFECTIVE DATE.—The amendment made by 
subsection (a) shall apply to contracts entered into on or 
after the date of enactment of this Act. 
SEC. 442. REDUCING MEDICARE PAPERWORK AND REGU-
LATORY BURDENS. 
Not later than 18 months after the date of enactment 
of this Act, the Secretary shall provide to Congress a plan 
for reducing regulations and paperwork in the Medicare 
program under title XVIII of the Social Security Act (42 
U.S.C. 1395 et seq.). Such plan shall focus initially on 
regulations that do not directly enhance the quality of pa-
tient care provided under such program. 
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TITLE V—STATE HEALTH HELP 
AGENCIES 
SEC. 501. ESTABLISHMENT. 
As a condition of receiving payment under section 
503, a State shall, not later than the date that is 4 years 
after the date of enactment of this Act, establish or des-
ignate a State agency, to be known as the ‘‘Health Help 
Agency’’ (referred to in this Act as a ‘‘HHA’’) to— 
(1) carry out the administration of HAPI plans 
to individuals in such State; and 
(2) carry out the functions described in section 
502. 
SEC. 502. RESPONSIBILITIES AND AUTHORITIES. 
(a) PROMOTION OF PREVENTION AND WELLNESS.— 
Each HHA shall promote prevention and wellness for all 
State residents, including through the implementation of 
programs that— 
(1) educate residents about responsibility for in-
dividual health and the health of children; 
(2) upon request, distribute information to cov-
ered individuals regarding the availability of wellness 
programs; 
(3) make available to the public, with respect to 
each health insurance issuer and each HAPI plan, 
the number of covered individuals who have des-
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ignated a health home described in section 111(b); 
and 
(4) promote the use and understanding of 
health information technology. 
(b) ENROLLMENT OVERSIGHT.—Each HHA shall 
oversee enrollment in HAPI plans by— 
(1) providing standardized, unbiased informa-
tion on HAPI plans and supplemental health insur-
ance options; 
(2) not less than once per year, administering 
open enrollment periods for individuals; 
(3) allowing a covered individual to make en-
rollment changes during a 30-day period following 
marriage, divorce, birth, adoption or placement for 
adoption, and other circumstances; 
(4) establish procedures for health insurance 
issuers to report to the HHA of each State in which 
the issuer offers a HAPI plan, the health insurance 
status of State residents in order for the HHA to 
report annual on the number of uninsured and other 
relevant data; 
(5) establish procedures for default enrollment 
of uninsured individuals into low-cost HAPI plans 
for individuals or families who do not enroll, are not 
covered under a health plan offered through a pro-
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gram described in paragraphs (1)(A) of section 
102(a), and are not described in paragraph (1)(B) 
of such section; 
(6) establish procedures for hospitals and other 
providers to report to the HHA if an individual 
seeks care and is uninsured or does not know his or 
her health insurance status; 
(7) ensure that the enrollment of all individuals 
into HAPI plans, including those individuals assisted 
by an employer, insurance agent, or other person, is 
administered by the HHA; 
(8) develop standardized language for HAPI 
plan terms and conditions and require participating 
health insurance issuers to use such language in 
plan information documents; 
(9) provide prospective enrollees with a com-
parative document that describes all the HAPI plans 
in which the individual may enroll; and 
(10) to assist consumers in choosing a HAPI 
plan, publish information that includes loss ratios, 
outcome data regarding wellness programs, disease 
detection and chronic care management programs 
categorized by health insurance issuer, and other 
data as the HHA determines appropriate. 
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(c) DETERMINATION
AND
ADMINISTRATION
OF 
HAPI PLAN SUBSIDIES.—Each HHA shall oversee the 
determination and administration of HAPI plan subsidies 
by— 
(1) informing State residents about how subsidy 
eligibility determinations are made; 
(2) obtaining necessary information about in-
come from individuals and Federal and State agen-
cies; 
(3) making eligibility determinations on an indi-
vidual basis and informing individuals of such deter-
minations; 
(4) establishing a process by which an indi-
vidual may appeal an eligibility determination; 
(5) collecting from health insurance issuers an 
administrative fee for joining the HHA system and 
offering a HAPI plan in a State; 
(6) collecting premium payments made by, or 
on behalf of, covered individuals, and remitting such 
payments to the HAPI plans; and 
(7) collecting Federal premium subsidies for 
covered individuals and remitting such subsidies to 
HAPI plans. 
(d) PREMIUM RATING RULES.—Each HHA shall en-
sure that the premium payments for each HAPI plan are 
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determined in accordance with the rating rules described 
in section 111(e). 
(e) DETERMINATION OF PLAN COVERAGE AREAS.— 
Each HHA shall establish, and may revise, HAPI plan 
coverage areas for the State in which the HHA is located. 
The service area of a HAPI plan shall consist of an entire 
coverage area established under the preceding sentence. 
(f) COOPERATION
AMONG
STATES.—States that 
share 1 or more metropolitan statistical area may enter 
into agreements to share administrative responsibilities 
described under this section. 
(g) TRANSITION FROM MEDICAID AND SCHIP; CO-
ORDINATION OF SUPPLEMENTAL MEDICAL ASSISTANCE 
FOR ELDERLY AND DISABLED MEDICAID ELIGIBLES.— 
Each HHA shall work with the Secretary to ensure that 
the requirements of section 301 of this Act, section 1944 
of the Social Security Act (as added by section 673(a) of 
this Act), and subsections (a) and (b) of section 1943 of 
the Social Security Act (as added by section 311 of this 
Act) are met. 
SEC. 503. APPROPRIATIONS FOR TRANSITION TO STATE 
HEALTH HELP AGENCIES. 
(a) APPROPRIATION.—There is authorized to be ap-
propriated and there is appropriated, for each of the 4 
full fiscal years immediately following the date of enact-
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ment of this Act, such sums as may be necessary for the 
purpose of enabling each State to carry out the purposes 
of this title. The sums made available under this section 
shall be used for making payments to States that have 
submitted, and had approved by the Secretary, an HHA 
plan under this section. 
(b) SUBMISSION OF STATE HHA PLAN.—Each HHA 
plan submitted by a State shall provide for— 
(1) the establishment of an HHA within such 
State by the date that is 4 years after the date of 
enactment of this Act; 
(2) the administration by State of such HHA in 
accordance with the requirements described under 
this Act; and 
(3) the compliance by the State of the require-
ments described under section 631. 
(c) PAYMENT TO STATES.—From the sums appro-
priated under subsection (a), the Secretary shall pay to 
each State that has an HHA plan approved under this 
section, an amount necessary for the State to implement 
such plan for the applicable fiscal year. 
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TITLE VI—SHARED 
RESPONSIBILITIES 
Subtitle A—Individual 
Responsibilities 
SEC. 601. INDIVIDUAL RESPONSIBILITY TO ENSURE HAPI 
PLAN COVERAGE. 
(a) OPEN SEASON.—An adult individual, on behalf 
of such individual and the dependent children of such indi-
vidual, shall— 
(1) enroll in a HAPI plan through the HHA of 
the individual’s State of residence during an open 
enrollment period; and 
(2) submit necessary documentation to the ap-
plicable HHA so that such HHA may determine in-
dividual eligibility for premium and personal respon-
sibility contribution subsidies. 
An adult individual may carry out the activities described 
under paragraphs (1) and (2) on behalf of the spouse of 
such adult individual. 
(b) DURING PLAN YEAR.—A covered individual 
shall— 
(1) submit any required monthly premium pay-
ments; 
(2) submit any personal responsibility contribu-
tions as required; and 
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(3) inform such HHA of any changes in the 
family status or residence of such individual. 
Subtitle B—Employer 
Responsibilities 
SEC. 611. HEALTH CARE RESPONSIBILITY PAYMENTS. 
(a) PAYMENT REQUIREMENTS.— 
(1) IN GENERAL.—Subtitle C of the Internal 
Revenue Code of 1986 is amended by inserting after 
chapter 24 the following new chapter: 
‘‘CHAPTER 24A—HEALTH CARE 
RESPONSIBILITY PAYMENTS 
‘‘SUBCHAPTER A—EMPLOYER SHARED RESPONSIBILITY PAYMENTS 
‘‘SUBCHAPTER B—INDIVIDUAL SHARED RESPONSIBILITY PAYMENTS 
‘‘SUBCHAPTER C—GENERAL PROVISIONS 
‘‘Subchapter A—Employer Shared 
Responsibility Payments 
‘‘Sec. 3411. Payment requirement. 
‘‘Sec. 3412. Instrumentalities of the United States. 
‘‘SEC. 3411. PAYMENT REQUIREMENT. 
‘‘(a) EMPLOYER
SHARED
RESPONSIBILITY
PAY-
MENTS.—Every employer shall pay an employer shared re-
sponsibility payment for each calendar year in an amount 
equal to the product of— 
‘‘(1) the number of full-time equivalent employ-
ees employed by the employer during the preceding 
calendar year, multiplied by 
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‘‘(2) the applicable percentage of the average 
HAPI plan premium amount for such calendar year. 
‘‘(b) APPLICABLE PERCENTAGE.—For purposes of 
subsection (a)(2)— 
‘‘(1) IN GENERAL.—The applicable percentage 
shall be determined as follows: 
‘‘Revenue per employee national percentile of the 
taxpayer for the preceding calendar year: 
Large 
employer: 
Small 
employer: 
0–20th percentile ........................................................
18% 
3%
21st–40th percentile ...................................................
20% 
5%
41st–60th percentile ...................................................
22% 
7%
61st–80th percentile ...................................................
24% 
9%
81st–99th percentile ...................................................
26% 
11%. 
‘‘(2) APPLICABLE PERCENTAGE FOR CERTAIN 
NON-REVENUE PRODUCING ENTITIES.—In the case 
of an employer which is a nonprofit entity, a State 
or local government, or any other type of entity for 
which the Secretary determines that calculating rev-
enue per employee is not appropriate, the applicable 
percentage shall be— 
‘‘(A) in the case of a large employer, 18 
percent, and 
‘‘(B) in the case of a small employer, 3 
percent. 
‘‘(3) APPLICABLE PERCENTAGE FOR CERTAIN 
LARGE EMPLOYERS.—In the case of any large em-
ployer which did not provide health insurance cov-
erage for employees on the day before the date of 
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enactment of the Healthy Americans Act, the table 
contained in paragraph (1) shall be applied by sub-
stituting ‘30%’ for ‘24%’ and by substituting ‘32%’ 
for ‘26%’ with respect the each of the first 4 cal-
endar years to which this section applies. 
‘‘(4) ADDITIONAL RATE FOR CERTAIN SMALL 
EMPLOYERS.— 
‘‘(A) IN GENERAL.—In the case of a small 
employer, the applicable percentage determined 
under paragraph (1) shall be increased by 0.1 
percent for each full-time equivalent employee 
employed by the employer during the preceding 
calendar year in excess of 50. 
‘‘(B) MAXIMUM ADDITIONAL RATE.—The 
increase in the applicable percentage deter-
mined under this paragraph shall not exceed 15 
percent. 
‘‘(5) REVENUE PER EMPLOYEE NATIONAL PER-
CENTILE RANK.—At the beginning of each calendar 
year, the Secretary, in consultation with the Sec-
retary of Labor, shall publish a table, based on sam-
pling of employers, to be used in determining the na-
tional percentile for revenue per employee amounts 
for the preceding calendar year. 
‘‘(c) TRANSITION RATES.— 
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‘‘(1) TRANSITION RATE FOR EMPLOYERS PRE-
VIOUSLY PROVIDING HEALTH INSURANCE.— 
‘‘(A) IN GENERAL.—In the case of the first 
four calendar years to which this section ap-
plies, in the case of any employer who provided 
health insurance coverage for employees on the 
day before the date of enactment of the Healthy 
Americans Act, the employer shared responsi-
bility payment shall be, in lieu of the amount 
determined under subsection (a), an amount 
equal to— 
‘‘(i) 100 percent of the designated em-
ployee health insurance premium amount 
of such employer, minus 
‘‘(ii) the employee salary investment 
amount. 
‘‘(B) EMPLOYEE
SALARY
INVESTMENT 
AMOUNT.—For purposes of this paragraph— 
‘‘(i) IN
GENERAL.—The term ‘em-
ployee salary investment amount’ means 
the lesser of— 
‘‘(I) the excess of the amount of 
average yearly wages paid to all em-
ployees for such year over the amount 
of average yearly wages paid to such 
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employee for the year before the first 
year this section applies, or 
‘‘(II) the designated employee 
health insurance premium amount of 
such employer. 
‘‘(ii) NONDISCRIMINATION
RULES.— 
No amount paid by an employer shall be 
treated as an employee salary investment 
amount unless such amount is distributed 
to all employees on a basis that is propor-
tional to the designated employee health 
insurance premium amount paid with re-
spect to such employee before such dis-
tribution. 
‘‘(iii) 
NOTICE
REQUIREMENT.—No 
amount paid by an employer shall be treat-
ed as an employee salary investment 
amount unless the employer gives each em-
ployee notice of the amount of the des-
ignated employee health insurance pre-
mium amount paid by the employer with 
respect to the employee. 
‘‘(iv) TREATMENT
OF
AMOUNT.—An 
employee salary investment amount shall 
not be treated as income or otherwise 
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taken into account for purposes of deter-
mining any individual’s eligibility for bene-
fits or assistance under any governmental 
assistance program. 
‘‘(C) EMPLOYER SHARED RESPONSIBILITY 
CREDIT.—The Secretary may provide a credit 
to private employers who provided health insur-
ance benefits greater than the 80th percentile 
of the national average in the 2 years prior to 
enactment of the Healthy Americans Act, if 
such employer can demonstrate the benefits 
provided encouraged prevention and wellness 
activities as defined in such Act, and that the 
employer continues to provide wellness pro-
grams. 
‘‘(D) SPECIAL
RULE
FOR
SELF-INSURED 
EMPLOYERS.—In the case of any employer who 
provided health care coverage for employees 
through self-insurance, ‘average HAPI plan 
premium amount for the first year this section 
applies’ shall be substituted for ‘designated em-
ployee health insurance premium amount of 
such employer’ in subparagraphs (A)(i) and 
(B)(i)(II). 
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‘‘(E) REGULATIONS.—The Secretary may 
establish such rules and regulations as nec-
essary to carry out the purposes of this para-
graph. 
‘‘(2) TRANSITION RATE FOR OTHER EMPLOY-
ERS.— 
‘‘(A) IN GENERAL.—In the case of an em-
ployer who did not provide health insurance to 
employees on the day before the date of enact-
ment of the Healthy Americans Act— 
‘‘(i) the employer shared responsibility 
payment for the first year this section ap-
plies shall be an amount equal to 1⁄3 of the 
amount otherwise required under this sec-
tion (determined without regard to this 
subsection), and 
‘‘(ii) the employer shared responsi-
bility payment for the second year this sec-
tion applies shall be an amount equal to 2⁄3 
of the amount otherwise required under 
this section (determined without regard to 
this subsection). 
‘‘(B) TRANSITION RATE DOES NOT APPLY 
TO
CERTAIN
LARGE
EMPLOYERS.—Subpara-
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graph (A) shall not apply to any large employer 
covered by subsection (b)(3). 
‘‘SEC. 3412. INSTRUMENTALITIES OF THE UNITED STATES. 
‘‘Notwithstanding any other provision of law (wheth-
er enacted before or after the enactment of this section) 
which grants to any instrumentality of the United States 
an exemption from taxation, such instrumentality shall 
not be exempt from the payment required by section 3411 
unless such provision of law grants a specific exemption, 
by reference to section 3111 from the payment required 
by such section. 
‘‘Subchapter B—Individual Shared 
Responsibility Payments 
‘‘Sec. 3421. Amount of payment. 
‘‘Sec. 3422. Deduction of tax from wages. 
‘‘SEC. 3421. AMOUNT OF PAYMENT. 
‘‘(a) IN GENERAL.—Every individual shall pay an in-
dividual shared responsibility payment in an amount equal 
to the HAPI plan premium amount of such individual. 
‘‘(b) EXCEPTION.—This section shall not apply to 
any individual— 
‘‘(1) who is covered under a HAPI plan of an-
other individual, or 
‘‘(2) who provides such documentation as re-
quired by the Secretary demonstrating that such in-
dividual has paid such HAPI plan premium amount, 
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but only for the period with respect to which such 
amount is shown to be paid. 
‘‘SEC. 3422. DEDUCTION OF INDIVIDUAL SHARED RESPON-
SIBILITY PAYMENT FROM WAGES. 
‘‘(a) IN GENERAL.—The individual shared responsi-
bility payment imposed by section 3421 shall be collected 
by the employer by deducting the amount of the payment 
from the wages as and when paid. The preceding sentence 
shall not apply to any employer who has fewer than 10 
employees. 
‘‘(b) NONDEDUCTIBILITY BY EMPLOYER.—The indi-
vidual shared responsibility payment deducted and with-
held by the employer under subsection (a) shall not be al-
lowed as a deduction to the employer in computing taxable 
income under subtitle A. 
‘‘(c) INDEMNIFICATION
OF
EMPLOYER; SPECIAL 
RULE FOR TIPS.—Rules similar to the rules of subsections 
(b) and (c) of section 3102 shall apply for purposes of 
this section. 
‘‘Subchapter C—General Provisions 
‘‘Sec. 3431. Definitions and special rules. 
‘‘Sec. 3432. Labor contracts. 
‘‘SEC. 3431. DEFINITIONS AND SPECIAL RULES. 
‘‘(a) DEFINITIONS.—For purposes of this chapter— 
‘‘(1) 
AVERAGE
HAPI
PLAN
PREMIUM 
AMOUNT.—The term ‘average HAPI plan premium 
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amount’ means the national average yearly premium 
for HAPI plans with standard coverage (as deter-
mined under section 111(b) of the Healthy Ameri-
cans Act), determined without regard to differing 
classes of coverage. 
‘‘(2) DESIGNATED EMPLOYEE HEALTH INSUR-
ANCE
PREMIUM
AMOUNT.—The term ‘designated 
employee health insurance premium amount’ means 
the greater of— 
‘‘(A) the yearly premium paid by an em-
ployer for health insurance coverage for employ-
ees for the most recent calendar year ending be-
fore the date of enactment of the Healthy 
Americans Act, or 
‘‘(B) the yearly premium paid by an em-
ployer for health insurance coverage for employ-
ees for the year before the first year this section 
applies. 
‘‘(3) EMPLOYER.— 
‘‘(A) IN GENERAL.—The term ‘employer’ 
has the meaning given such term under section 
3401(d). 
‘‘(B) AGGREGATION RULES.—For purposes 
of this chapter, all persons treated as a single 
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employer under subsection (a) or (b) of section 
52 shall be treated as 1 person. 
‘‘(4) EMPLOYMENT.—The term ‘employment’ 
has the meaning given such term under section 
3121(b). 
‘‘(5) FULL-TIME
EQUIVALENT
EMPLOYEE.— 
The term ‘full-time equivalent employee’ means the 
equivalent number of full-time employees of an em-
ployer determined for any year under the following 
formula: 
‘‘(A) The sum of the number of full-time 
employees employed by the employer for more 
than 3 months during such year, plus 
‘‘(B) The quotient of— 
‘‘(i) the sum of the average weekly 
hours worked during such year for each 
employee of the employer (including com-
mon law employees) who— 
‘‘(I) was employed by such em-
ployer during such year for more than 
3 months, and 
‘‘(II) is not a full-time employee, 
divided by 
‘‘(ii) 40. 
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102 
‘‘(B) Section 3123 (relating to deductions 
as constructive payments). 
‘‘(C) Section 3125 (relating to returns in 
the case of governmental employees in States, 
Guam, American Samoa, and the District of 
Columbia). 
‘‘(D) Section 3126 (relating to return and 
payment by government employer). 
‘‘(E) Section 3127 (relating to exemption 
for employers and their employees where both 
are members of religious faiths opposed to par-
ticipation in Social Security Act programs). 
‘‘SEC. 3432. LABOR CONTRACTS. 
‘‘(a) IN GENERAL.—This chapter shall not apply with 
respect to any qualified collective bargaining employee of 
any qualified collective bargaining employer before the 
earlier of— 
‘‘(1) January 1 of the first year which is more 
than 9 years after the date of the enactment of this 
chapter, or 
‘‘(2) the date the collective bargaining agree-
ment expires. 
‘‘(b) DEFINITIONS.—For purposes of this section— 
‘‘(1) QUALIFIED COLLECTIVE BARGAINING EM-
PLOYER.—The term ‘qualified collective bargaining 
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103 
employer’ means an employer who provides health 
insurance to employees under the terms of a collec-
tive bargaining agreement which is entered into be-
fore the date of the enactment of this chapter. 
‘‘(2) QUALIFIED COLLECTIVE BARGAINING EM-
PLOYEE.—The term ‘qualified collective bargaining 
employee’ means an employee of a qualified collec-
tive bargaining employer who is covered by a collec-
tive bargaining agreement governing the employee’s 
health insurance.’’. 
(2) CONFORMING AMENDMENT.—The table of 
chapters of the Internal Revenue Code of 1986 is 
amended by inserting after the item relating to 
chapter 24 the following new item: 
‘‘CHAPTER 24A—HEALTH CARE RESPONSIBILITY PAYMENTS’’. 
(b) COLLECTION OF INDIVIDUAL SHARED RESPONSI-
BILITY PAYMENTS THROUGH ESTIMATED TAXES.—Sec-
tion 6654 of the Internal Revenue Code of 1986 (relating 
to failure by individual to pay estimated tax) is amended— 
(1) in subsection (a), by striking ‘‘and the tax 
under chapter 2’’ and inserting ‘‘, the tax under 
chapter 2, and the individual shared responsibility 
payment required under subchapter B of chapter 
24A’’, and 
(2) in subsection (f)— 
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104 
(A) by striking ‘‘minus’’ at the end of 
paragraph (2) and inserting ‘‘plus’’, 
(B) by redesignating paragraph (3) as 
paragraph (5), and 
(C) by inserting after paragraph (2) the 
following new paragraphs: 
‘‘(3) the individual shared responsibility pay-
ment required under subchapter B of chapter 24A, 
minus 
‘‘(4) the amount withheld as an individual 
shared responsibility payment under section 3422, 
minus’’. 
(c) EFFECTIVE DATE.—The amendments made by 
this section shall apply to calendar years beginning at 
least 4 years after the date of the enactment of this Act. 
SEC. 612. DISTRIBUTION OF INDIVIDUAL RESPONSIBILITY 
PAYMENTS TO HHAS. 
(a) IN GENERAL.—The Secretary of the Treasury 
shall pay to the HHA in each State an amount equal to 
the amount of individual shared responsibility payments 
received under section 3421 of the Internal Revenue Code 
of 1986 with respect to each individual residing in such 
State. 
(b) TREATMENT OF PAYMENTS.—Any amount paid 
to a State under subsection (a) shall be treated as an 
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105 
amount paid by the individual as a premium for the HAPI 
plan in which such individual is enrolled. 
Subtitle C—Insurer 
Responsibilities 
SEC. 621. INSURER RESPONSIBILITIES. 
(a) IN GENERAL.—To offer a HAPI plan through an 
HHA, a State shall require that a health insurance issuer 
meet the requirements of this section. 
(b) REQUIREMENTS.—A health insurance issuer of-
fering a HAPI plan in a State shall— 
(1) implement and emphasize prevention, early 
detection and chronic disease management; 
(2) ensure that a wellness program as described 
in section 131 is available to all covered individuals 
so long as such a wellness program meets the re-
quirements of the health insurance issuers and other 
relevant requirements; 
(3) demonstrate how the provider reimburse-
ment methodology used by such an issuer has been 
adjusted to reward providers for achieving quality 
and cost efficiency in prevention, early detection of 
disease, and chronic care management; 
(4) ensure enrollees have the opportunity to 
designate a health home as described in section 
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106 
111(b) and make public how many enrollees per pol-
icy have designated a health home; 
(5) upon enrollment, make available to each 
covered individual an initial physical and a care 
plan; 
(6) create and implement an electronic medical 
record for each covered individual, unless the indi-
vidual submits a notification to the issuer that the 
individual declines to have such a record; 
(7) contribute to the financing of the HHAs by 
incorporating into the administration component of 
premiums an additional amount to reimburse HHAs 
for administrative costs; 
(8) comply with loss ratios as established by the 
Secretary under subsection (e); 
(9) use standardized common claims forms and 
uniform billing practices as provided for under sub-
section (c); 
(10) require that hospitals, as a condition of re-
ceiving payment, send bills that are in an amount 
more than $5,000 to the covered individual (without 
regard to whether the covered individual is respon-
sible for full or partial payment of the bill) and pro-
vide the individual the contact information of a per-
son who can discuss the bill with the individual; 
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107 
(11) provide incentives such as premium dis-
counts— 
(A) for parents, if a covered child partici-
pates in wellness activities and the health of 
such child improves; and 
(B) for covered adults for participation in 
prevention, wellness and chronic disease man-
agement programs; 
(12) report to the HHA of the State in which 
the issuer offers HAPI plans outcome data regard-
ing wellness program, disease detection and chronic 
care management, and loss ratio information, so 
that the HHAs may make such data available to the 
public in a consumer-friendly format; 
(13) work with the Agency for Healthcare Re-
search and Quality, medical experts, and patient 
groups to make information on high quality afford-
able health providers available to all Americans with-
in 4 years of the date of enactment of this Act 
through a Web site searchable by zip code; 
(14) provide to the HHA of each State in which 
the issuer offers a HAPI plan, detailed information 
on the HAPI plans offered by such issuer, using 
standardized language as required by the HHA, so 
that the HHA may compile a document that com-
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108 
pares the HAPI plans for use by prospective enroll-
ees; 
(15) pay to the HHA of each State in which 
the issuer seeks to offer a HAPI plan the amount 
of the administrative fee assessed by the HHA 
under section 502(c)(5) to enter the HHA system of 
that State; and 
(16) provide for prompt payment of providers 
for claims received in accordance with State law, but 
in no case later than 45 days after the date of re-
ceipt of a claim that has no defect or impropriety or 
particular circumstance requiring special treatment 
that prevents timely payment from being made on 
the claim under the plan. 
(c) UNIFORM BILLING PRACTICES.— 
(1) IN GENERAL.—A health insurance issuer of-
fering a HAPI plan in a State shall agree to use 
standardized common claim forms prescribed by the 
applicable State HHA consistent with paragraph (2) 
and to provide a copy of such form to the insured. 
(2) CONTENTS OF CLAIM FORM.—Each com-
mon claims form shall show— 
(A) the cost of the entire episode of care 
provided to the insured; 
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109 
(B) the percentage of the cost covered by 
the issuer; and 
(C) the percentage of the cost paid by the 
insured. 
(3) EXCEPTION.—Paragraph (1) shall not 
apply to any State worker’s compensation system. 
(d) CHRONIC
CARE
PROGRAMS
OFFERED
BY 
ISSUERS.— 
(1) IN GENERAL.—A health insurance issuer of-
fering a HAPI plan in a State shall provide a chron-
ic care program to provide early identification and 
management of chronic diseases. 
(2) DETERMINATION OF CHRONIC CARE PRO-
GRAM.—Each State HHA shall determine what con-
stitutes a chronic care program under this sub-
section and whether to collect and report financial 
information related to chronic care programs. 
(3) UNIFORM CLINICAL PERFORMANCE STAND-
ARDS.—Each chronic care program offered by a 
health insurance issuer shall use a uniform set of 
clinical performance standards prescribed by the 
HHA of the State in which the issuer offers a HAPI 
plan (in consultation with the State Medicare quality 
improvement organizations and patient and physi-
cian organizations) which should include encourage-
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110 
ment that the issuers not require personal responsi-
bility contributions for clinically-needed services to 
treat or manage a covered individual’s chronic dis-
ease, particularly if the individual is taking an active 
management role in working with their provider to 
manage any such disease. 
(4) REPORTING BY ISSUERS.—Seven years after 
the date of enactment of this Act and on an annual 
basis thereafter, each health insurance issuer shall 
report to the applicable State Insurance Commis-
sioner, State Secretary of Health or other State en-
tity selected by the State HHA, the chronic care 
management performance of the issuer as measured 
by the uniform clinical performance standards de-
scribed in paragraph (3). The issuer shall make such 
performance public in a manner accessible to the 
public. 
(e) PRIVATE INSURANCE COMPANY LOSS RATIO.— 
(1) IN GENERAL.—The Secretary, in consulta-
tion with consumer and patient organizations, the 
National Association of Insurance Commissioners, 
and health insurance issuers (including health main-
tenance organizations) shall establish a loss ratio for 
issuers of HAPI plans. 
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111 
(2) DETERMINATION OF LOSS RATIO.—In de-
termining the loss ratio, administrative costs shall be 
defined as expenses consisting of all actual, allow-
able, allocable, and reasonable expenses incurred in 
the adjudication of subscriber benefit claims or in-
curred in the health insurance issuer’s overall oper-
ation of the business. 
(3) ADMINISTRATIVE EXPENSES.— 
(A) IN GENERAL.—Unless otherwise deter-
mined by an agreement between a State HHA 
and a health insurance issuer, the administra-
tive expenses of an issuer shall— 
(i) include all taxes (excluding pre-
mium taxes) reinsurance premiums, med-
ical and dental consultants used in the ad-
judication process, concurrent or managed 
care review when not billed by a health 
care provider and other forms of utilization 
review, the cost of maintaining eligibility 
files, legal expenses incurred in the litiga-
tion of benefit payments, and bank charges 
for letters of credit; and 
(ii) not include the cost of personnel, 
equipment, and facilities directly used in 
the delivery of health care services (benefit 
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112 
costs), payments to HHAs for establish-
ment and administration of HHAs, and 
the cost of overseeing chronic disease man-
agement programs and wellness programs. 
Subtitle D—State Responsibilities 
SEC. 631. STATE RESPONSIBILITIES. 
(a) GENERAL REQUIREMENTS.—As a condition of re-
ceiving payment under section 503, each State shall— 
(1) designate or create a Health Help Agency 
as described in title V; 
(2) ensure that the HAPI plans offered in the 
State— 
(A) are sold only through the State HHA 
(except for employer-sponsored health coverage 
plans described under section 103 offered by 
employers); and 
(B) comply with the requirements of this 
Act; 
(3) ensure that health insurance issuers offer-
ing a HAPI plan in such State comply with the re-
quirements described in section 621; 
(4) make risk-adjusted payments to all health 
insurance issuers and employers offering a HAPI 
plan in such State to account for the specific popu-
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lation covered by the plan, in accordance with guide-
lines established by the Secretary; 
(5) ensure that HAPI plans offer premium dis-
counts and incentives for participation in wellness 
programs; 
(6) implement mechanisms to collect premium 
payments not otherwise collected under chapter 24A 
of the Internal Revenue Code of 1986 (as added by 
this Act); 
(7) continue to apply State law with respect 
to— 
(A) solvency and financial standards for 
health insurance issuers; 
(B) fair marketing practices for health in-
surance issuers; 
(C) grievances and appeals for covered in-
dividuals; and 
(D) patient protection; 
(8) ensure that providers receiving payment 
from the State HHA, when appropriate, provide in-
formation to patients seeking treatment on the dif-
ferent treatment options, the costs of these treat-
ment options, and any comparative effectiveness in-
formation available through the research on com-
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114 
parative effectiveness conducted under the amend-
ments made by title VIII; and 
(9) comply with subsections (b) and (c). 
(b) ENSURING
MAXIMUM
ENROLLMENT.—Each 
State shall— 
(1) collect and exchange data with Federal and 
other public agencies as necessary to maintain a 
database containing information on the health insur-
ance enrollment status of all State residents; 
(2) implement methods to check enrollment sta-
tus and enroll individuals in HAPI plans, such as 
through the Department of Motor Vehicles of the 
State, the enrollment of children in elementary and 
secondary schools, the voter registration authority of 
the State, and other checkpoints determined appro-
priate by the State; 
(3) implement mechanisms, which may not in-
clude revocation or ineligibility for coverage under a 
HAPI plan, to enforce the responsibility of each 
adult individual to purchase HAPI plan coverage for 
such individual and any dependent children of such 
individual; and 
(4) implement a mechanism to automatically 
enroll individuals in a HAPI plan who present in 
emergency departments without health insurance. 
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(c) MAINTENANCE OF EFFORT.—Each State shall 
submit an annual report to the Secretary that dem-
onstrates that, for each State fiscal year that begins on 
or after January 1 of the first calendar year in which 
HAPI coverage begins under this Act, State expenditures 
for health services (as defined by the Secretary) are not 
less than the amount equal to— 
(1) in the case of the first State fiscal year for 
which such a report is submitted, 100 percent of the 
total amount of the State share of expenditures for 
such services under all public health programs oper-
ated in the State that are funded in whole or in part 
with State expenditures (including the Medicaid pro-
gram) for the most recent State fiscal year ending 
before January 1 of the first calendar year in which 
HAPI coverage begins under this Act; and 
(2) in the case of any subsequent State fiscal 
year for which such a report is submitted, the 
amount applicable under this subsection for the pre-
ceding State fiscal year increased by the percentage 
change, if any, in the consumer price index for all 
urban consumers over the previous Federal fiscal 
year. 
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SEC. 632. EMPOWERING STATES TO INNOVATE THROUGH 
WAIVERS. 
(a) IN GENERAL.—A State that meets the require-
ments of subsection (b) shall be eligible for a waiver of 
applicable Federal health-related program requirements. 
(b) ELIGIBILITY REQUIREMENTS.—A State shall be 
eligible to receive a waiver under this section if— 
(1) the State approves a plan to provide health 
care coverage to its residents that is at least as com-
prehensive as the coverage required under a HAPI 
plan; and 
(2) the State submits to the Secretary an appli-
cation at such time, in such manner, and containing 
such information as the Secretary may require, in-
cluding a comprehensive description of the State leg-
islation or plan for implementing the State-based 
health plan. 
(c) DETERMINATIONS BY SECRETARY.— 
(1) IN
GENERAL.—Not later than 180 days 
after the receipt of an application from a State 
under subsection (b)(2), the Secretary shall make a 
determination with respect to the granting of a waiv-
er under this section to such State. 
(2) GRANTING OF WAIVER.—If the Secretary 
determines that a waiver should be granted under 
this section, the Secretary shall notify the State in-
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117 
volved of such determination and the terms and ef-
fectiveness of such waiver. 
(3) REFUSAL TO GRANT WAIVER.—If the Sec-
retary refuses to grant a waiver under this section, 
the Secretary shall— 
(A) notify the State involved of such deter-
mination, and the reasons therefore; and 
(B) notify the appropriate committees of 
Congress of such determination and the reasons 
therefore. 
(d) SCOPE OF WAIVERS.—The Secretary shall deter-
mine the scope of a waiver granted to a State under this 
section, including which Federal laws and requirements 
will not apply to the State under the waiver. 
Subtitle E—Federal Fallback 
Guarantee Responsibility 
SEC. 641. FEDERAL GUARANTEE OF ACCESS TO COVERAGE. 
(a) FEDERAL GUARANTEE.— 
(1) IN GENERAL.—If a State does not establish 
an HHA in compliance with title V by the date that 
is 4 years after the date of enactment of this Act, 
the Secretary shall ensure that each individual has 
available, consistent with paragraph (2), a choice of 
enrollment in at least 2 HAPI plans in the coverage 
area in which the individual resides. In any such 
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118 
case in which such plans are not available, the indi-
vidual shall be given the opportunity to enroll in a 
fallback HAPI plan. 
(2) REQUIREMENT
FOR
DIFFERENT
PLAN 
SPONSORS.—The requirement in paragraph (1) is 
not satisfied with respect to a coverage area if only 
1 entity offers all the HAPI plans in the area. 
(b) CONTRACTS.— 
(1) IN
GENERAL.—The Secretary shall enter 
into contracts under this subsection with entities for 
the offering of fallback HAPI plans in coverage 
areas in which the guarantee under subsection (a) is 
not met. 
(2) COMPETITIVE
PROCEDURES.—Competitive 
procedures (as defined in section 4(5) of the Office 
of Federal Procurement Policy Act (41 U.S.C. 
403(5))) shall be used to enter into a contract under 
this subsection. 
(c) FALLBACK HAPI PLAN.—For purposes of this 
section, the term ‘‘fallback HAPI plan’’ means a HAPI 
plan that— 
(1) meets the requirements described in section 
111(b) and does not provide actuarially equivalent 
coverage described in section 111(c); and 
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119 
(2) meets such other requirements as the Sec-
retary may specify. 
Subtitle F—Federal Financing 
Responsibilities 
SEC. 651. APPROPRIATION FOR SUBSIDY PAYMENTS. 
There is authorized to be appropriated and there is 
appropriated for each fiscal year such sums as may be 
necessary to fund the insurance premium subsidies under 
section 121. 
SEC. 652. RECAPTURE OF MEDICARE AND 90 PERCENT OF 
MEDICAID 
FEDERAL 
DSH 
FUNDS 
TO 
STRENGTHEN MEDICARE AND ENSURE CON-
TINUED SUPPORT FOR PUBLIC HEALTH PRO-
GRAMS. 
(a) RECAPTURE OF MEDICARE DSH FUNDS.— 
(1) IN GENERAL.—Section 1886(d)(5)(F)(i) of 
the 
Social 
Security 
Act 
(42 
U.S.C. 
1395ww(d)(5)(F)(i)) is amended by inserting ‘‘and 
before January 1 of the first calendar year in which 
coverage under a HAPI plan begins under the 
Healthy Americans Act,’’ after ‘‘May 1, 1986,’’. 
(2) SAVINGS TO PART A TRUST FUND.—The 
savings to the Federal Hospital Insurance Trust 
Fund by reason of the amendment made by para-
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120 
graph (1) shall be used to strengthen the financial 
solvency of such Trust Fund. 
(b) RECAPTURE OF 90 PERCENT OF MEDICAID DSH 
FUNDS.— 
(1) HEALTHY
AMERICANS
PUBLIC
HEALTH 
TRUST FUND.—Subchapter A of chapter 98 of the 
Internal Revenue Code of 1986 (relating to Trust 
Fund code) is amended by adding at the end the fol-
lowing new section: 
‘‘SEC. 9511. HEALTHY AMERICANS PUBLIC HEALTH TRUST 
FUND. 
‘‘(a) CREATION OF TRUST FUND.—There is estab-
lished in the Treasury of the United States a Trust Fund 
to be known as the ‘Healthy Americans Public Health 
Trust Fund’, consisting of any amount appropriated or 
credited to the Trust Fund as provided in this section or 
section 9602(b). 
‘‘(b) TRANSFER TO TRUST FUND OF 90 PERCENT 
OF MEDICAID DSH FUNDS.—There are hereby appro-
priated to the Healthy Americans Public Health Trust 
Fund the following amounts: 
‘‘(1) In the case of the second, third, and 
fourth quarters of the first fiscal year in which cov-
erage under a HAPI plan begins under the Healthy 
Americans Act, an amount equal to 90 percent of 
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121 
the amount that would otherwise have been appro-
priated for the purpose of making payments to 
States under section 1903(a) of the Social Security 
Act for the Federal share of disproportionate share 
hospital payments made under section 1923 of such 
Act for such quarters of that fiscal year but for sub-
sections (c)(2) and (d)(2)(D) of section 1944 of the 
such Act, as determined by the Secretary of Health 
and Human Services. 
‘‘(2) In the case of each succeeding fiscal year, 
an amount equal to 90 percent of the amount that 
would otherwise have been appropriated for the pur-
pose of making payments to States under section 
1903(a) of the Social Security Act for the Federal 
share of disproportionate share hospital payments 
made under section 1923 of such Act for that fiscal 
year but for subsections (c)(1) and (d)(2)(D) of sec-
tion 1944 of such Act, as determined by the Sec-
retary of Health and Human Services, taking into 
account the percentage change, if any, in the con-
sumer price index for all urban consumers (U.S. city 
average) for the preceding fiscal year. 
‘‘(c) EXPENDITURES FROM TRUST FUND.—With re-
spect to each fiscal year for which transfers are made 
under subsection (b), amounts in the Healthy Americans 
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Public Health Trust Fund shall be available for that fiscal 
year for the following purposes: 
‘‘(1) PROVIDING PREMIUM AND PERSONAL RE-
SPONSIBILITY
CONTRIBUTION
SUBSIDIES.—For 
making appropriations authorized under section 651 
of the Healthy Americans Act for providing pre-
mium and personal responsibility contribution sub-
sidies in accordance with section 122 of such Act. 
‘‘(2) REDUCING THE FEDERAL BUDGET DEF-
ICIT.—The Secretary shall transfer any amounts in 
the Trust Fund that are not expended as of Sep-
tember 30 of a fiscal year for a purpose described 
in paragraph (1) to the general revenues account of 
the Treasury.’’. 
(2) CLERICAL AMENDMENT.—The table of sec-
tions for such subchapter is amended by adding at 
the end the following new item: 
‘‘Sec. 9511. Healthy Americans Public Health Trust Fund.’’. 
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123 
Subtitle 
G—Tax 
Treatment 
of 
Health Care Coverage Under 
Healthy 
Americans 
Program; 
Termination of Coverage Under 
Other Governmental Programs 
and Transition Rules for Med-
icaid and SCHIP 
PART 1—TAX TREATMENT OF HEALTH CARE COV-
ERAGE UNDER HEALTHY AMERICANS PRO-
GRAM 
SEC. 661. LIMITED EMPLOYEE INCOME AND PAYROLL TAX 
EXCLUSION FOR EMPLOYER SHARED RE-
SPONSIBILITY 
PAYMENTS, 
HISTORIC 
RE-
TIREE HEALTH CONTRIBUTIONS, AND TRAN-
SITIONAL COVERAGE CONTRIBUTIONS. 
(a) INCOME TAX EXCLUSION.— 
(1) IN
GENERAL.—Subsection (a) of section 
106 of the Internal Revenue Code of 1986 (relating 
to contributions by employer to accident and health 
plans) is amended to read as follows: 
‘‘(a) GENERAL RULE.—Gross income of an individual 
does not include— 
‘‘(1) if such individual is an employee, shared 
responsibility payments made by an employer under 
section 3411, 
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‘‘(2) if such individual is a former employee be-
fore the first calendar year beginning 4 years after 
the date of the enactment of the Healthy Americans 
Act, employer-provided coverage under an accident 
or health plan, 
‘‘(3) if such individual is a qualified collective 
bargaining employee under an accident or health 
plan in effect on January 1 of the first calendar year 
beginning 4 years after the date of the enactment of 
the Healthy Americans Act, employer-provided cov-
erage under such plan during any transition period 
described in section 3432, and 
‘‘(4) employer-provided coverage for qualified 
long-term care services (as defined in section 
7702B(c)).’’. 
(2) CONFORMING AMENDMENTS.—Section 106 
of such Code is amended— 
(A) by adding at the end of subsection (b) 
the following new paragraph: 
‘‘(8) TERMINATION.—This subsection shall not 
apply to contributions made in any calendar year be-
ginning at least 4 years after the date of the enact-
ment of the Healthy Americans Act.’’, 
(B) by inserting ‘‘and before the first cal-
endar year beginning 4 years after the date of 
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the enactment of the Healthy Americans Act,’’ 
after ‘‘January 1, 1997,’’ in subsection (c)(1), 
and 
(C) by striking ‘‘shall be treated as em-
ployer-provided coverage for medical expenses 
under an accident or health plan’’ in subsection 
(d)(1) and inserting ‘‘shall not be included in 
such employee’s gross income’’. 
(b) PAYROLL TAXES.— 
(1) IN
GENERAL.—Section 3121(a) (defining 
wages) is amended by adding at the end the fol-
lowing new sentence: ‘‘In the case of any calendar 
year beginning at least 4 years after the date of the 
enactment of the Healthy Americans Act, para-
graphs (2) and (3) shall apply to payments on ac-
count of sickness only if such payments are de-
scribed in section 106(a).’’. 
(2) 
RAILROAD
RETIREMENT.—Section 
3231(e)(1) (defining wages) is amended by adding 
at the end the following new sentence: ‘‘In the case 
of any calendar year beginning at least 4 years after 
the date of the enactment of the Healthy Americans 
Act, this paragraph shall apply to payments on ac-
count of sickness only if such payments are de-
scribed in section 106(a).’’. 
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