ing the vaccine itself), routine laboratory 
tests, and preventive dental care. 
‘‘(B) PERIODICITY SCHEDULE.—The Sec-
retary, in consultation with the American Acad-
emy of Pediatrics and the American Dental As-
sociation, shall establish a schedule of perio-
dicity which reflects the general, appropriate 
frequency with which services listed in subpara-
graph (A) should be provided to healthy chil-
dren. 
‘‘(3) COVERAGE OF EPSDT.—For children, ben-
efits also shall be available under this title for early 
and periodic screening, diagnostic, and treatment 
services (as defined in section 1905(r)) not otherwise 
covered under paragraph (2). 
‘‘(4) OTHER ADDITIONAL SERVICES FOR CHIL-
DREN.—For children, benefits also shall be available 
under this title for the following: 
‘‘(A) Inpatient hospital services (without 
regard to the restrictions described in sub-
sections (a)(1) and (b)(1) of section 1812 and 
the 
coinsurance 
described 
in 
section 
1813(a)(1)). 
‘‘(B) Eyeglasses and hearing aids, and ex-
aminations therefor. 
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‘‘(e) PREGNANCY-RELATED SERVICES.—In the case 
of a pregnant woman (as defined in section 2261(a)(3)), 
benefits under this title shall include entitlement to have 
payment made for the following, without the application 
of a deductible or coinsurance: 
‘‘(1) Prenatal care, including care for all com-
plications of pregnancy. 
‘‘(2) Inpatient labor and delivery services. 
‘‘(3) Postnatal care. 
‘‘(f) LOWER-INCOME INDIVIDUALS.— 
‘‘(1) LIMITATIONS ON DEDUCTIBLES AND COIN-
SURANCE.— 
‘‘(A) NONE
FOR
LOW-INCOME
INDIVID-
UALS.—In the case of a low-income individual, 
there shall be no deductible or coinsurance 
under this title. 
‘‘(B) PHASE-IN
FOR
OTHER
LOWER-IN-
COME INDIVIDUALS.—In the case of an indi-
vidual whose applicable modified gross income 
(as defined in section 2261(b)(1)) exceeds twice 
the poverty level (as defined in section 
2261(b)(2)) but does not exceed three times the 
poverty level, the deductible and coinsurance 
applicable under this title shall bear the same 
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ratio to the deductible or coinsurance otherwise 
applicable as— 
‘‘(i) the excess of the applicable modi-
fied gross income over the poverty level, 
bears to 
‘‘(ii) the poverty level. 
If the ratio determined under the preceding 
sentence is not a multiple of 25 percentage 
points, such ratio shall be rounded to the near-
est 25 percentage points. 
‘‘(2) ADDITIONAL BENEFITS FOR LOW-INCOME 
INDIVIDUALS.—In the case of low-income individuals 
(as defined in section 2261(a)(2)), benefits under 
this title shall also include entitlement to have pay-
ment made for the following, without the application 
of a deductible or coinsurance: 
‘‘(A) Inpatient hospital services (without 
regard to the restrictions described in sub-
sections (a)(1) and (b)(1) of section 1812 and 
the 
coinsurance 
described 
in 
section 
1813(a)(1)). 
‘‘(B) Eyeglasses and hearing aids and ex-
aminations therefor. 
‘‘(g) PREVENTIVE BENEFITS.—Benefits shall also be 
made available under this title, without the application of 
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any deductible or coinsurance for preventive services that 
are recommended by the United States Preventive Serv-
ices Task Force. 
‘‘(h) MENTAL HEALTH PARITY
AND SUBSTANCE 
ABUSE BENEFITS.—Benefits shall be made available 
under this title for mental health services and for sub-
stance abuse treatment in the same manner as such bene-
fits are made available for medical and surgical services. 
‘‘(i) FAMILY PLANNING SERVICES.—Benefits 
shall be made available under this title for family 
planning services. 
‘‘(j) CONFORMING MEDICARE BENEFITS.—Notwith-
standing any other provision of law, benefits under title 
XVIII shall be expanded and conformed to the benefits 
made available under this title (including the application 
of a single deductible and uniform coinsurance amounts, 
a limitation on the coinsurance, and additional benefits for 
low-income individuals under subsection (f)), but nothing 
in this subsection shall be construed as providing for any 
such additional benefits under this title rather than under 
such title. 
‘‘(k) ENROLLMENT IN HEALTH PLANS.—The Sec-
retary shall provide for the offering of benefits under this 
title through enrollment in a health benefit plan that 
meets the same (or similar) requirements as the require-
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ments that apply to Medicare Advantage plans under part 
C of title XVIII (other than any such requirements that 
relate to part D of such title). In the case of individuals 
enrolled under this title in such a plan, the payment rate 
to the plan under this title shall be based on adjusted aver-
age per capita cost (AAPCC) payment rate methodology 
described in section 1853(c)(1)(D) for benefits under this 
title and for individuals entitled to benefits under this title 
who are not enrolled in such a plan. 
‘‘SEC. 2222. EXCLUSIONS. 
‘‘(a) IN GENERAL.—Except as provided in this sec-
tion, section 1862 shall apply to expenses incurred for 
items and services provided under this title the same man-
ner as such section applies to items and services provided 
under title XVIII. 
‘‘(b) BENEFITS EXCEPTION.— 
‘‘(1) CHILDRENS’ SERVICES.—In applying sec-
tion 1862(a) with respect to services described in 
section 2221(d)(2)(A) (relating to well-child serv-
ices), payment shall not be denied under paragraph 
(1), (7), or (12) of such section 1862(a) if the serv-
ices are provided in accordance with the periodicity 
schedule described in section 2221(d)(2)(B). 
‘‘(2) TREATMENT OF EYEGLASSES AND HEAR-
ING AIDS FOR CHILDREN AND LOW-INCOME INDIVID-
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UALS.—Payment shall not be denied under this title 
under section 1862(a)(7) with respect to eyeglasses 
and hearing aids and examinations therefor in the 
case of children and low-income individuals. 
‘‘(c) COORDINATION OF PAYMENTS.— 
‘‘(1) PRIMARY
TO
GROUP
HEALTH
PLANS.— 
Section 1862(b)(1) (relating to requirements of 
group health plans) shall not apply under this title. 
‘‘(2) SECONDARY
TO
MEDICARE.—Payment 
shall not be made under this title with respect to 
benefits to the extent that payment for such benefits 
may be made under title XVIII. 
‘‘PART C—PAYMENT FOR BENEFITS AND FINANCING 
‘‘SEC. 2241. PAYMENTS FOR BENEFITS. 
‘‘(a) IN GENERAL.—Except as otherwise provided in 
this section and in section 2221— 
‘‘(1) payment of benefits under this title with 
respect to benefits shall be made on the same basis 
as payment is made with respect to such benefits 
under title XVIII, and 
‘‘(2) the provisions of sections 1814, 1833, 
1834, 1842, 1848, and 1886 shall apply to payment 
of benefits under this title in the same manner as 
they apply to benefits under title XVIII. 
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‘‘(b) NO EXTRA BILLING PERMITTED.—Payment 
under this title may only be made on an assignment-re-
lated basis (as defined in section 1842(i)(1)). If an entity 
knowingly and willfully presents or causes to be presented 
a claim or bills an individual enrolled under this title for 
charges for services other than on an assignment-related 
basis, the Secretary may apply sanctions against such en-
tity in accordance with section 1842(j)(2). 
‘‘(c) ADJUSTMENT OF PAYMENTS.— 
‘‘(1) ESTABLISHMENT
OF
NEW
DRGS
AND 
WEIGHTS.—In making payment under this title with 
respect to inpatient hospital services, the Secretary 
shall establish such additional diagnosis-related 
groups (and weighting factors with respect to dis-
charges within such groups) and make such adjust-
ments in the diagnosis-related groups and weighting 
factors with respect to discharges within such groups 
otherwise established under section 1886(d)(4) as 
may be necessary to reflect the types of discharges 
occurring under this title which are not occurring 
under title XVIII. 
‘‘(2) PAYMENT FOR OBSTETRICAL SERVICES.— 
‘‘(A) GLOBAL FEE.—In making payment 
under this title with respect to the group of ob-
stetrical services typical of treatment through-
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out a course of pregnancy, the Secretary shall 
establish, as a schedule under section 1848, a 
global fee with respect to such group of serv-
ices. 
‘‘(B) 
BONUS
FOR
EARLY
PRESEN-
TATION.—The fee schedule amount with respect 
to obstetrical services under this title shall be 
increased by 5 percent in the case of services 
furnished to women who have presented for pre-
natal care during the first trimester. 
‘‘(d) CONDITIONS OF AND LIMITATIONS ON PAY-
MENTS.—The provisions of sections 1814 and 1835 shall 
apply to payment for services under this title in the same 
manner as they apply to payment for services under parts 
A and B, respectively, of title XVIII. 
‘‘(e) USE OF TRUST FUND.—In carrying out this sec-
tion, any reference in title XVIII to a trust fund shall be 
treated as a reference to the AmeriCare Trust Fund estab-
lished under section 2242. 
‘‘(f) PAYMENT
FOR
OUTPATIENT
PRESCRIPTION 
DRUGS AND BIOLOGICALS.—The Secretary shall establish 
a fee schedule for the payment for outpatient prescription 
drugs and biologicals under this title and, notwithstanding 
section 1860D–11(i)(1), under title XVIII. The Secretary 
shall negotiate with pharmaceutical manufacturers with 
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respect to the purchase price of such drugs and biologicals 
and shall encourage the use of more affordable therapeutic 
equivalents to the extent such practices do not override 
medical necessity, as determined by the prescribing physi-
cian. To the extent practicable and consistent with the 
previous sentence, the Secretary shall implement strate-
gies similar to those used by other Federal purchasers of 
prescription drugs, and other strategies, to reduce the pur-
chase cost of outpatient prescription drugs and biologicals. 
‘‘SEC. 2242. AMERICARE TRUST FUND. 
‘‘(a) ESTABLISHMENT.—(1) There is hereby created 
on the books of the Treasury of the United States a trust 
fund to be known as the ‘AmeriCare Trust Fund’ (in this 
section referred to as the ‘Trust Fund’). The Trust Fund 
shall consist of such gifts and bequests as may be made 
as provided in section 201(i)(1) and amounts appropriated 
under paragraph (2). 
‘‘(2) There are hereby appropriated to the Trust 
Fund amounts equivalent to 100 percent of the increase 
in revenues to the Treasury by reason of the provisions 
of and amendments made by title II of the AmeriCare 
Health Care Act of 2006. The amounts appropriated by 
the preceding sentence shall be transferred from time to 
time from the general fund in the Treasury to the Trust 
Fund, such amounts to be determined on the basis of esti-
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mates by the Secretary of the Treasury of the increase 
in revenues which are paid to or deposited into the Treas-
ury; and proper adjustments shall be made in amounts 
subsequently transferred to the extent prior estimates 
were in excess of or were less than such increase. 
‘‘(b) INCORPORATION OF PROVISIONS.— 
‘‘(1) IN GENERAL.—Subject to paragraph (2), 
the provisions of subsections (b) through (e) and (g) 
through (i) of section 1817 shall apply to the Trust 
Fund in the same manner as they apply to the Fed-
eral Hospital Insurance Trust Fund. 
‘‘(2) EXCEPTIONS.—In applying paragraph 
(1)— 
‘‘(A) the Board of Trustees and Managing 
Trustee of the Trust Fund shall be composed of 
the members of the Board of Trustees and the 
Managing Trustee, respectively, of the Federal 
Hospital Insurance Trust Fund; and 
‘‘(B) any reference in section 1817 to the 
Federal Hospital Insurance Trust Fund or to 
title XVIII (or part A thereof) is deemed a ref-
erence to the Trust Fund under this section 
and this title, respectively. 
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‘‘PART D—ADMINISTRATIVE SIMPLIFICATION 
‘‘SEC. 
2251. 
REQUIREMENT 
FOR 
ENTITLEMENT 
VERIFICATION SYSTEM. 
‘‘(a) IN GENERAL.— 
‘‘(1) REQUIREMENT.—The Secretary with re-
spect to the plan provided under this title, and each 
AmeriCare supplemental plan (as defined in section 
2279(3)), shall provide for an electronic system, that 
is certified by the Secretary as meeting the stand-
ards established under subsection (b), for the 
verification of an individual’s entitlement to benefits 
under such plan. 
‘‘(2) DEADLINE FOR APPLICATION OF REQUIRE-
MENT.—The deadline specified under this paragraph 
for the requirement under paragraph (1) is 6 
months after the date the standards are established 
under subsection (b). 
‘‘(b) STANDARDS FOR ENTITLEMENT VERIFICATION 
SYSTEMS.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish standards consistent with this subsection re-
specting the requirements for certification of entitle-
ment verification systems. 
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‘‘(2) INFORMATION
AVAILABLE.—Such stand-
ards shall require a system to provide information, 
with respect to individuals, concerning the following: 
‘‘(A) The specific benefits to which the in-
dividual is entitled under the plan. 
‘‘(B) Current status of the individual with 
respect to fulfillment of deductibles, coinsur-
ance, and out-of-pocket limits on cost-sharing. 
‘‘(C) Restrictions on providers who may 
provide covered services, including utilization 
controls (such as preadmission certification). 
‘‘(3) FORM OF INQUIRY.—Each verification sys-
tem shall be capable of accepting inquiries under 
this subsection from health care providers in a vari-
ety of electronic forms. The system shall also pro-
vide, for an additional fee, for the acceptance of in-
quiries in a nonelectronic form. 
‘‘(4) FORM OF RESPONSE.—Each such system 
shall be capable of responding to such inquiries 
under this subsection in a variety of electronic and 
other forms, including— 
‘‘(A) through modem transmission of infor-
mation, 
‘‘(B) through computer synthesized voice 
communication, and 
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‘‘(C) through transmission of information 
to a facsimile (fax) machine. 
The system shall also provide, for an additional fee, 
for the response to inquiries in a nonelectronic form. 
‘‘(5) LIMITATION ON FEES.—Neither the Sec-
retary nor an AmeriCare supplemental plan may im-
pose a fee for the acceptance or response to an in-
quiry under this subsection except where the accept-
ance or response is in a nonelectronic form. 
‘‘(6) WEBSITE AVAILABILITY TO PROVIDERS.— 
The Secretary shall establish and maintain a website 
through which— 
‘‘(A) health service providers may make in-
quiries, and receive responses, with respect to 
the eligibility and benefits of an individual 
under plans; and 
‘‘(B) AmeriCare supplemental plans may 
make inquiries, and receive responses, to deter-
mine the liability of other plans for the provi-
sion or payment of benefits. 
‘‘(7) DEADLINE.—The Secretary shall first es-
tablish the standards under this subsection (and 
shall establish the website under paragraph (6)) by 
not later than 12 months after the date of the enact-
ment of this title. 
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‘‘SEC. 2252. REQUIREMENTS FOR UNIFORM CLAIMS AND 
ELECTRONIC CLAIMS DATA SET. 
‘‘(a) REQUIREMENTS.— 
‘‘(1) SUBMISSION
OF
CLAIMS.—Each health 
service provider that furnishes services in the United 
States for which payment may be made under this 
title or under an AmeriCare supplemental plan shall 
submit any claim for payment for such services only 
in a form and manner consistent with standards es-
tablished under subsection (c). 
‘‘(2) ACCEPTANCE OF CLAIMS.—The Secretary 
and an AmeriCare supplemental plan may not reject 
a claim for payment under this title or the plan on 
the basis of the form or manner in which the claim 
is submitted if the claim is submitted in accordance 
with the standards established under subsection (c). 
‘‘(3) EFFECTIVE DATE.—This subsection shall 
apply to claims for services furnished on or after the 
date that is 6 months after the date standards are 
established under subsection (c). 
‘‘(b) ENFORCEMENT THROUGH CIVIL MONEY PEN-
ALTIES.— 
‘‘(1) IN GENERAL.— 
‘‘(A) PROVIDERS.—In the case of a health 
service provider that submits a claim in viola-
tion of subsection (a)(1), the provider is subject 
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to a civil money penalty of not to exceed $100 
(or, if greater, the amount of the claim) for 
each such violation. 
‘‘(B) 
PLANS.—In 
the 
case 
of 
an 
AmeriCare supplemental plan that rejects a 
claim in violation of subsection (a)(2), the plan 
is subject to a civil money penalty of not to ex-
ceed $100 (or, if greater, the amount of the 
claim) for each such violation. 
‘‘(2) PROCESS.—The provisions of section 
1128A of the Social Security Act (other than sub-
sections (a) and (b)) shall apply to a civil money 
penalty under paragraph (1) in the same manner as 
such provisions apply to a penalty or proceeding 
under section 1128A(a) of such Act. 
‘‘(c) STANDARDS RELATING TO UNIFORM CLAIMS 
AND ELECTRONIC CLAIMS DATA SET.— 
‘‘(1) ESTABLISHMENT
OF
STANDARDS.—The 
Secretary shall establish standards that— 
‘‘(A) relate to the form and manner of sub-
mission of claims for benefits under this title 
and under an AmeriCare supplemental plan, 
and 
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‘‘(B) define the data elements to be con-
tained in a uniform electronic claims data set to 
be used with respect to such claims. 
‘‘(2) SCOPE OF INFORMATION.— 
‘‘(A) ENSURING
ACCOUNTABILITY
FOR 
CLAIMS SUBMITTED ELECTRONICALLY.—In es-
tablishing standards under this section, the Sec-
retary, in consultation with appropriate agen-
cies, shall include such methods of ensuring 
provider responsibility and accountability for 
claims submitted electronically that are de-
signed to control fraud and abuse in the sub-
mission of such claims. 
‘‘(B) COMPONENTS.—In establishing such 
standards the Secretary shall— 
‘‘(i) with respect to data elements, de-
fine data fields, formats, and medical no-
menclature, and plan benefit and insurance 
information; 
‘‘(ii) develop a single, uniform coding 
system for diagnostic and procedure codes; 
and 
‘‘(iii) provide for standards for the 
uniform electronic transmission of such 
elements. 
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‘‘(3) COORDINATION
WITH
STANDARDS
FOR 
ELECTRONIC
MEDICAL
RECORDS.—In establishing 
standards under this subsection, the Secretary shall 
assure that— 
‘‘(A) the development of such standards is 
coordinated with the development of the stand-
ards for electronic medical records under sec-
tion 2253, and 
‘‘(B) the coding of data elements under the 
uniform electronic claims data set and the cod-
ing of the same elements in the uniform hos-
pital clinical data set are consistent. 
‘‘(4) USE
OF
TASK
FORCES.—In adopting 
standards under this subsection— 
‘‘(A) the Secretary shall take into account 
the recommendations of current task forces; 
and 
‘‘(B) the Secretary shall provide that the 
electronic transmission standards are con-
sistent, to the extent practicable, with the appli-
cable standards established by the Accredited 
Standards Committee X–12 of the American 
National Standards Institute. 
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‘‘(5) UNIFORM, UNIQUE PROVIDER IDENTIFICA-
TION CODES.—In establishing standards under this 
subsection— 
‘‘(A) the Secretary shall provide for a 
unique identifier code for each health service 
provider that furnishes services for which a 
claim may be submitted under this title or 
under an AmeriCare supplemental plan, and 
‘‘(B) in the case of a provider that has a 
unique identifier issued for purposes of title 
XVIII, the code provided under subparagraph 
(A) shall be the same as such unique identifier. 
‘‘(6) WEBSITE AVAILABILITY TO PROVIDERS.— 
The Secretary shall establish and maintain a website 
that will enable health service providers, without 
charge, to submit claims and to receive verification 
of claims status electronically. 
‘‘(7) STANDARDS
FOR
PAPER
CLAIMS.—The 
standards shall provide for a uniform paper claims 
form which is consistent with data elements required 
for the submission of claims electronically. 
‘‘(8) STANDARDS
FOR
CLAIMS
FOR
CLINICAL 
LABORATORY TESTS.—The standards shall provide 
that claims for clinical laboratory tests for which 
benefits are provided under this title or under an 
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AmeriCare supplemental plan shall be submitted di-
rectly by the person or entity that performed (or su-
pervised the performance of) the tests to the plan in 
a manner consistent with (and subject to such excep-
tions as are provided under) the requirement for di-
rect submission of such claims under title XVIII. 
‘‘(9) DEADLINE.—The Secretary shall first pro-
vide for the standards for the uniform claims under 
this subsection (and shall develop and make avail-
able the software under paragraph (6)) by not later 
than 1 year after the date of the enactment of this 
title. 
‘‘(d) USE UNDER THIS TITLE AND MEDICARE AND 
MEDICAID PROGRAMS.— 
‘‘(1) REQUIREMENT FOR PROVIDERS.—In the 
case of a health service provider that submits a 
claim for services furnished under this title in viola-
tion of subsection (a)(1), no payment shall be made 
under this title for such services. 
‘‘(2) REQUIREMENTS OF MEDICARE ADMINIS-
TRATIVE
CONTRACTORS
UNDER
MEDICARE
PRO-
GRAM.—The Secretary shall provide, in regulations 
promulgated to carry out this title, that the claims 
process provided under this title conforms to the 
standards established under subsection (c). 
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‘‘(3) REQUIREMENTS
OF
STATE
MEDICAID 
PLANS.—As a condition for the approval of State 
plans under the medicaid program, effective as of 
the effective date specified in subsection (a)(3), each 
such plan shall provide, in accordance with regula-
tions of the Secretary, that the claims process pro-
vided under the plan is modified to the extent re-
quired to conform to the standards established under 
subsection (c). 
‘‘SEC. 2253. ELECTRONIC MEDICAL RECORDS AND REPORT-
ING. 
‘‘(a) 
STANDARDS
FOR
ELECTRONIC
MEDICAL 
RECORDS.— 
‘‘(1) PROMULGATION OF STANDARDS.— 
‘‘(A) IN GENERAL.—Not later than Janu-
ary 1, 2008, the Secretary shall promulgate 
standards described in paragraph (2) for hos-
pitals and other health care providers con-
cerning electronic medical records. Such stand-
ards shall include the standards established 
under part C of title XI. 
‘‘(B) REVISION.—The Secretary may from 
time to time revise the standards promulgated 
under this paragraph. 
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‘‘(2) CONTENTS OF STANDARDS.—The stand-
ards promulgated under paragraph (1) shall include 
at least the following: 
‘‘(A) A definition of a uniform provider 
clinical data set, including a definition of the 
set of comprehensive data elements, for use by 
utilization and quality control peer review orga-
nizations. 
‘‘(B) Standards for an electronic patient 
care information system with data obtained at 
the point of care. 
‘‘(C) A specification of, and manner of 
presentation of, the individual data elements of 
the set and system under this paragraph. 
‘‘(D) Standards concerning the trans-
mission of electronic medical data. 
‘‘(E) Standards relating to confidentiality 
of patient-specific information, which include 
the physical security of electronic data and the 
use of keys, passwords, encryption, and other 
means to ensure the protection of the confiden-
tiality and privacy of electronic data. 
‘‘(3) COORDINATION
WITH
STANDARDS
FOR 
UNIFORM ELECTRONIC CLAIMS DATA SET.—In es-
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tablishing standards under this subsection, the Sec-
retary shall assure that— 
‘‘(A) the development of such standards is 
coordinated with the development of the stand-
ards for the uniform electronic claims data set 
under subsection (b), and 
‘‘(B) the coding of data elements under the 
uniform provider clinical data set and the cod-
ing of the same elements under the uniform 
electronic claims data set are consistent. 
‘‘(4) CONSULTATION.—In establishing stand-
ards under this subsection, the Secretary shall— 
‘‘(A) consult with the American National 
Standards Institute, hospitals and other health 
care providers, health benefit plans, and other 
interested parties, and 
‘‘(B) take into consideration, in developing 
standards under paragraph (2)(A), the data set 
used by the utilization and quality control peer 
review program under part B of title XI. 
‘‘(b) REQUIREMENT
FOR APPLICATION
OF ELEC-
TRONIC RECORDS STANDARDS.— 
‘‘(1) AS CONDITION OF MEDICARE, MEDICAID, 
SCHIP, AND AMERICARE PARTICIPATION.—Effective 
January 1, 2009, each hospital or other institutional 
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or noninstitutional health care provider, as a re-
quirement of each participation agreement under 
this title, title XVIII, title XIX, and title XXI, shall, 
in accordance with the standards promulgated under 
subsection (a)(1)— 
‘‘(A) maintain clinical data included in the 
uniform provider clinical data set under sub-
section (a)(2)(A) in electronic form on all pa-
tients, 
‘‘(B) upon request of the Secretary or of a 
utilization and quality control peer review orga-
nization (with which the Secretary has entered 
into a contract under part B of title XI), trans-
mit electronically data requested from such 
data set, and 
‘‘(C) upon request of the Secretary, or of 
a fiscal intermediary or carrier, transmit elec-
tronically any data (with respect to a claim) 
from such data set. 
‘‘(2) APPLICATION
OF
PRESENTATION
AND 
TRANSMISSION STANDARDS TO ELECTRONIC TRANS-
MISSION TO FEDERAL AGENCIES.—Effective Janu-
ary 1, 2008, if a hospital or other health care pro-
vider is required under a Federal program to trans-
mit a data element that is subject to a standard, 
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promulgated under subsection (a)(1), described in 
subparagraph (C) or (D) of subsection (a)(2), the 
head of the Federal agency responsible for such pro-
gram (if not otherwise authorized) is authorized to 
require the provider to present and transmit the 
data element electronically in accordance with such 
a standard. 
‘‘(c) LIMITATION ON DATA REQUIREMENTS WHERE 
STANDARDS IN EFFECT.— 
‘‘(1) IN
GENERAL.—On or after January 1, 
2008, the Secretary under this title or under title 
XVIII (including any carrier or fiscal intermediary 
or any utilization and quality control peer review or-
ganization) and an AmeriCare supplemental plan 
may not require, for the purpose of utilization review 
or as a condition of providing benefits or making 
payments under this title, title XVIII, or the plan, 
that a hospital or other health care provider— 
‘‘(A) provide any data element not in the 
uniform provider clinical data set specified 
under the standards promulgated under sub-
section (a), or 
‘‘(B) transmit or present any such data 
element in a manner inconsistent with such 
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standards applicable to such transmission or 
presentation. 
‘‘(2) COMPLIANCE.—The Secretary may impose 
a civil money penalty on any AmeriCare supple-
mental plan that fails to comply with paragraph (1) 
in an amount not to exceed $100 for each such fail-
ure. The provisions of section 1128A of the Social 
Security Act (other than the first sentence of sub-
section (a) and other than subsection (b)) shall 
apply to a civil money penalty under this paragraph 
in the same manner as such provisions apply to a 
penalty or proceeding under section 1128A(a) of 
such Act. 
‘‘(3) APPLICATION TO MEDICAID PROGRAM.—As 
a condition for the approval of State plans under the 
medicaid program and in accordance with regula-
tions of the Secretary, effective as of January 1, 
2008, each such plan may not require that a hos-
pital or other health care provider, for the purpose 
of utilization review or as a condition of providing 
benefits or making payments under the plan— 
‘‘(A) provide any data element not in the 
uniform provider clinical data set specified 
under the standards promulgated under sub-
section (a), or 
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‘‘(B) transmit or present any such data 
element in a manner inconsistent with such 
standards applicable to such transmission or 
presentation. 
‘‘(d) PREEMPTION OF STATE QUILL PEN LAWS.— 
‘‘(1) IN GENERAL.—Any provision of State law 
that requires medical or health insurance records 
(including billing information) to be maintained in 
written, rather than electronic, form shall deemed to 
be satisfied if the records are maintained in an elec-
tronic form that meets standards established by the 
Secretary under paragraph (2). 
‘‘(2) SECRETARIAL
AUTHORITY.—Not later 
than 1 year after the date of the enactment of this 
title, the Secretary shall issue regulations to carry 
out paragraph (1). The regulations shall provide for 
an electronic substitute that is in the form of a 
unique identifier (assigned to each authorized indi-
vidual) that serves the functional equivalent of a sig-
nature. The regulations may provide for such excep-
tions to paragraph (1) as the Secretary determines 
to be necessary to prevent fraud and abuse, to pre-
vent the illegal distribution of controlled substances, 
and in such other cases as the Secretary deems ap-
propriate. 
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‘‘(3) EFFECTIVE
DATE.—Paragraph (1) shall 
take effect on the first day of the first month that 
begins more than 30 days after the date the Sec-
retary issues the regulations referred to in para-
graph (2). 
‘‘SEC. 2254. UNIFORM HOSPITAL COST REPORTING. 
‘‘Each hospital, as a requirement under a participa-
tion agreement under this title for each cost reporting pe-
riod beginning during or after fiscal year 2007, shall pro-
vide for the reporting of information to the Secretary with 
respect to any hospital care provided in a uniform manner 
consistent with standards established by the Secretary to 
carry out section 4007(c) of the Omnibus Budget Rec-
onciliation Act of 1987 and in an electronic form con-
sistent with standards established by the Secretary. 
‘‘SEC. 2255. HEALTH SERVICE PROVIDER DEFINED. 
‘‘In this part, the term ‘health service provider’ in-
cludes a provider of services (as defined in section 
1861(u)), physician, supplier, and other entity furnishing 
health care services. 
‘‘PART E—GENERAL PROVISIONS 
‘‘SEC. 2261. DEFINITIONS RELATING TO BENEFICIARIES 
AND INCOME. 
‘‘(a) TERMS RELATING TO BENEFICIARIES.—In this 
title: 
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‘‘(1) CHILD.—The term ‘child’ means an indi-
vidual who throughout a month has not attained 24 
years of age. 
‘‘(2) LOW-INCOME
INDIVIDUAL.—The term 
‘low-income individual’ means an individual whose 
applicable modified gross income (as defined in sub-
section (b)(1)) is less than 200 percent of the pov-
erty level (as defined in subsection (b)(2)). The de-
termination that an individual is a low-income indi-
vidual shall be effective for a period of one year and 
shall be redetermined on an annual basis. 
‘‘(3) PREGNANT WOMAN.—The term ‘pregnant 
woman’ means a woman (regardless of age) who has 
been certified by a physician (in a manner specified 
by the Secretary) as being pregnant, until the last 
day of the month in which the 60-day period (begin-
ning on the date of termination of the pregnancy) 
ends. 
‘‘(b) TERMS RELATING TO INCOME.—In this title: 
‘‘(1) APPLICABLE MODIFIED GROSS INCOME.— 
‘‘(A) IN GENERAL.—Except as provided in 
this paragraph, the term ‘applicable modified 
gross income’ means, for a calendar year for an 
individual, the modified gross income (as de-
fined in section 202(a)(3)(B) of the Americare 
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Health Care Act of 2006) of the taxpayer (or 
the taxpayer for whom the individual may be 
claimed as a dependent) for the taxable year 
ending in the second previous calendar year. 
‘‘(B) APPLICATION
OF
CURRENT
YEAR 
MODIFIED GROSS INCOME.— 
‘‘(i) IN GENERAL.—Subject to clause 
(ii), the Secretary shall establish a proce-
dure under which an individual may file a 
declaration of estimated modified gross in-
come for a taxable year ending in a cal-
endar year, which modified gross income 
will apply under this subsection as the ap-
plicable modified gross income for the cal-
endar year. Subject to clause (ii), such pro-
cedure shall be applicable regardless of 
whether or not the individual filed a tax 
return for the taxable year ending in the 
second previous calendar year. 
‘‘(ii) LIMITATION ON APPLICATION.— 
The Secretary may limit the application of 
clause (i), in the case of individuals who 
have filed tax returns for the taxable year 
ending in the second previous calendar 
year, to individuals with respect to whom 
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the applicable modified gross income will 
be reduced by at least 20 percent as a re-
sult of the application of such clause. 
‘‘(iii) REQUIREMENT FOR RETURN.— 
Any individual who has filed a declaration 
under clause (i) for a calendar year is re-
quired to file an income tax return for the 
taxable year in the calendar year, regard-
less of whether any income tax is actually 
owed for the year. The failure of the indi-
vidual to file such a return makes the indi-
vidual liable for overpayments under this 
title under clause (iv) in the same manner 
as if this paragraph had not applied. 
‘‘(iv) COLLECTION
FOR
OVERPAY-
MENTS.—If a declaration of estimated 
modified gross income is made applicable 
to a calendar year under clause (i) and the 
actual modified gross income for that tax-
able year exceeds such estimated modified 
gross income, the individual shall be liable 
to the United States for 110 percent of the 
amount of additional payments made 
under this title as a result of the use of 
such estimated modified gross income in-
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stead of the actual modified gross income 
for that taxable year. 
‘‘(C) TRANSMITTAL OF INFORMATION.—By 
not later than October 1 of each year, the Sec-
retary of the Treasury shall transmit to the 
Secretary such information relating to the ap-
plicable modified gross income of individuals for 
the taxable year ending in the previous year as 
may be necessary to apply this title in the suc-
ceeding calendar year. 
‘‘(2) POVERTY
LEVEL.—The term ‘poverty 
level’ means, for an individual in a family, the offi-
cial poverty line (as defined by the Office of Man-
agement and Budget, and revised annually in ac-
cordance with section 673(2) of the Omnibus Budget 
Reconciliation Act of 1981) applicable to a family of 
the size involved. 
‘‘SEC. 2262. INCORPORATION OF CERTAIN MEDICARE PRO-
VISIONS AND OTHER PROVISIONS. 
‘‘(a) USE OF MEDICARE ADMINISTRATIVE CONTRAC-
TORS.—The Secretary shall provide for the administration 
of this title through the use of medicare administrative 
contractors in the same manner as title XVIII is carried 
out through the use of such contractors, except that no 
payment shall be made under this title except on the basis 
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of bills or charges that are submitted electronically in a 
manner specified by the Secretary. 
‘‘(b) DEFINITIONS.— 
‘‘(1) IN GENERAL.—Except as otherwise pro-
vided in this title, the definitions contained in sec-
tion 1861 shall apply for purposes of this title in the 
same manner as they apply for purposes of title 
XVIII. 
‘‘(2) STATE; UNITED STATES.—(A) The term 
‘State’ means the 50 States and includes the Dis-
trict of Columbia, Puerto Rico, the Virgin Island, 
Guam, American Samoa, and the Northern Mariana 
Islands. 
‘‘(B) The term ‘United States’ means all the 
States. 
‘‘(c) CERTIFICATION, PROVIDER
QUALIFICATION, 
ETC.—The provisions of sections 1863 through 1875, sec-
tions 1877 through 1880, section 1883, section 1885, and 
sections 1887 through 1895 shall apply to this title in the 
same manner as they apply to title XVIII. 
‘‘(d) TITLE XI PROVISIONS.—The following provi-
sions shall apply to this title in the same manner as they 
apply to title XVIII: 
‘‘(1) Sections 1124, 1126, and 1128 through 
1128E (relating to fraud and abuse). 
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‘‘(2) Section 1134 (relating to nonprofit hos-
pital philanthropy). 
‘‘(3) Section 1138 (relating to hospital proto-
cols for organ procurement and standards for organ 
procurement agencies). 
‘‘(4) Section 1142 (relating to research on out-
comes of health care services and procedures), ex-
cept that any reference in such section to a Trust 
Fund is deemed a reference to the AmeriCare Trust 
Fund. 
‘‘(5) Part B of title XI (relating to peer review 
of the utilization and quality of health care services). 
‘‘(6) Part C of title XI (relating to administra-
tive simplification). 
‘‘(e) OTHER PROVISIONS.—The provisions of section 
201(i) shall apply to this title and the AmeriCare Trust 
Fund in the same manner as they apply to title XVIII 
and the Federal Hospital Insurance Trust Fund. 
‘‘SEC. 2263. STATE MAINTENANCE OF EFFORT PAYMENTS. 
‘‘(a) CONDITION
OF COVERAGE.—Notwithstanding 
any other provision of this title, no individual who is a 
resident of a State is eligible for benefits under this title 
for a month in a calendar year, unless the State provides 
(in a manner and at a time specified by the Secretary) 
for payment to the AmeriCare Trust Fund of 1⁄12th of the 
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amount specified in subsection (b) for the year. Such 
funds shall be used offset the costs of providing subsidies 
for low-income individuals under section 202. 
‘‘(b) MAINTENANCE OF EFFORT AMOUNT.— 
‘‘(1) IN GENERAL.—Subject to paragraph (3), 
the amount of payment specified in this subsection 
for a State for a year is equal to the amount of pay-
ment (net of Federal payments) made by a State 
under its State plans under titles XIX and XXI for 
2006 for medical assistance for benefits described in 
paragraph (2). 
‘‘(2) BENEFITS DESCRIBED.—The benefits de-
scribed in this paragraph with respect to State plans 
of a State under titles XIX and XXI are benefits 
which— 
‘‘(A) would be available under this title for 
low-income individuals if this title had been in 
effect in 2006; and 
‘‘(B) are for low-income individuals who— 
‘‘(i) with respect to the State plan 
under title XIX, were required to be fur-
nished medical assistance under such title 
XIX; or 
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‘‘(ii) with respect to a State child 
health plan under title XXI, were low-in-
come children. 
‘‘SEC. 2264. MODIFICATION OF MEDICAID AND OTHER PRO-
GRAMS TO AVOID DUPLICATION OF BENE-
FITS. 
‘‘(a) IN GENERAL.—Notwithstanding any other pro-
vision of law— 
‘‘(1) a State plan under title XIX and a State 
child health plan under title XXI shall not provide 
any medical assistance for benefits with respect to 
which any payments may be made under this title; 
and 
‘‘(2) a health benefits plan under chapter 89 of 
title 5, United States Code, shall not provide bene-
fits for which any payment may be made under this 
title. 
‘‘(b) REVIEW
OF APPLICATION
TO OTHER PRO-
GRAMS.—The Secretary shall conduct a review of the fea-
sibility of applying the policy described in subsection (a) 
to additional Federal programs, such as the TRICARE 
program under title 10, United States Code. Not later 
than January 1, 2009, the Secretary submit to Congress 
on such review and shall include in such report such rec-
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ommendations for extending such policy to other Federal 
programs as the Secretary deems appropriate. 
‘‘SEC. 2265. CONSTRUCTION REGARDING CONTINUATION 
OF OBLIGATIONS UNDER CURRENT GROUP 
HEALTH PLAN CONTRACTS AND PROVISION 
OF ADDITIONAL BENEFITS. 
‘‘Nothing in this title shall be construed as— 
‘‘(1) affecting obligations for health care bene-
fits under group health plans as in effect on the date 
of the enactment of this title, including such plans 
established or maintained under or pursuant to one 
or more collective bargaining agreements; 
‘‘(2) limiting the additional benefits that may 
be provided under a group health plan to employees 
or their dependents, or to former employees or their 
dependents; or 
‘‘(3) limiting the benefits that may be made 
available under a State program to residents of the 
State at the expense of the State. 
‘‘SEC. 
2266. 
STANDARDS 
AND 
REQUIREMENTS 
FOR 
AMERICARE SUPPLEMENTAL POLICIES. 
‘‘(a) CERTIFICATION REQUIRED.— 
‘‘(1) IN GENERAL.—The Secretary shall estab-
lish rules and procedures consistent with this section 
under which AmeriCare supplemental policies may 
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only be issued if they are certified by the Secretary 
or under a State regulatory program approved by 
the Secretary as meeting standards established 
under subsection (b). 
‘‘(2) ENFORCEMENT.—Any person who issues 
an AmeriCare supplemental policy in violation of 
paragraph (1) is subject to a civil money penalty of 
not to exceed $25,000 for each such violation. The 
provisions of section 1128A (other than the first 
sentence of subsection (a) and other than subsection 
(b)) shall apply to a civil money penalty under the 
previous sentence in the same manner as such provi-
sions apply to a penalty or proceeding under section 
1128A(a). 
‘‘(3) AMERICARE
SUPPLEMENTAL
POLICY.— 
For purposes of this section, the term ‘AmeriCare 
supplemental policy’ is a health insurance policy or 
other health benefit plan offered by a private entity 
to individuals who are entitled to have payment 
made under this title, which provides reimbursement 
for expenses incurred for services and items for 
which payment may be made under this title but 
which are not reimbursable by reason of the applica-
tion of deductibles, coinsurance amounts, or other 
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limitations imposed pursuant to this title; but does 
not include— 
‘‘(A) any such policy or plan of the trust-
ees of a fund established by one or more em-
ployers or labor organizations (or combination 
thereof) if the policy or plan offers benefits as 
a direct service organization under section 
1833, or 
‘‘(B) a policy or plan of a health mainte-
nance organization which offers benefits under 
this title under section 2221(k). 
For purposes of this section, the term ‘policy’ in-
cludes a certificate issued under such policy. 
‘‘(b) CERTIFICATION STANDARDS.— 
‘‘(1) ISSUANCE.—The Secretary shall develop 
and publish specific standards consistent with this 
section for AmeriCare supplemental policies and 
shall consult with the Secretary of Labor regarding 
the application of such standards to employee wel-
fare benefit plans under title I of the Employee Re-
tirement Income Security Act of 1974. 
‘‘(2) MORE STRINGENT STATE STANDARDS PER-
MITTED.—In the case of insured AmeriCare supple-
mental policies (as defined in subsection (d)(3)), a 
State may implement standards that are more strin-
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gent than the standards established under para-
graph (1), including— 
‘‘(A) additional limitations on pre-existing 
exclusion limitations described in subsection 
(c)(1)(B); 
‘‘(B) additional restrictions on the groups 
of benefits described in subsection (c)(2) that 
may be offered in AmeriCare supplemental poli-
cies in the State, so long as a core-only benefit 
package described in subparagraph (A)(i) of 
such subsection may be offered in the State; 
‘‘(C) requiring a higher loss-ratios than 
those specified in subsection (c)(3); 
‘‘(c) STANDARDS.—The Secretary shall establish 
standards for AmeriCare supplemental policies consistent 
with the following: 
‘‘(1) NO DISCRIMINATION BASED ON HEALTH 
STATUS.— 
‘‘(A) IN
GENERAL.—Except as provided 
under subparagraph (B), an AmeriCare supple-
mental policy may not deny, limit, or condition 
the coverage under (or benefits of) the policy, 
or vary premiums charged, based on the health 
status, claims experience, receipt of health care, 
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medical history, or lack of evidence of insur-
ability, of an individual. 
‘‘(B) LIMITATION ON USE OF PRE-EXIST-
ING
CONDITION
EXCLUSIONS.—An AmeriCare 
supplemental policy may exclude coverage with 
respect to services related to treatment of a 
pre-existing condition, except that— 
‘‘(i) the period of such exclusion may 
not exceed 6 months; 
‘‘(ii) such exclusion shall not apply to 
services furnished to newborns; and 
‘‘(iii) the period of exclusion under 
clause (i) shall be reduced by 1 month for 
each month in a period of continuous 
health benefits coverage (as defined by the 
Secretary) for the services involved. 
For purposes of this subparagraph, a condition 
is not pre-existing unless it was diagnosed or 
treated during the 3-month period ending on 
the day before the first date of such coverage. 
‘‘(2) SIMPLIFICATION OF BENEFITS.— 
‘‘(A) IN GENERAL.—Each AmeriCare sup-
plemental policy shall only offer benefits con-
sistent with the standards, promulgated by the 
Secretary, that provide— 
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‘‘(i) limitations on the groups or pack-
ages of benefits, including a core group of 
basic benefits and not to exceed 9 other 
different benefit packages, that may be of-
fered under an AmeriCare supplemental 
policy; 
‘‘(ii) that a person may not issue an 
AmeriCare supplemental policy without of-
fering such a policy with only the core- 
group of basic benefits and without pro-
viding an outline of coverage in a standard 
form approved by the Secretary; 
‘‘(iii) uniform language and defini-
tions to be used with respect to such bene-
fits, and 
‘‘(iv) uniform format to be used in the 
policy with respect to such benefits. 
‘‘(B) INNOVATION.—The Secretary may 
approve the offering of new or innovative and 
cost-effective benefit packages in addition to 
those provided under subparagraph (A). 
‘‘(3) MINIMUM
LOSS
RATIO
REQUIRED.—An 
AmeriCare supplemental policy, a specific disease 
policy (as defined by the Secretary), or a hospital 
confinement indemnity policy (as defined by the Sec-
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retary) may not be issued or renewed unless the pol-
icy— 
‘‘(A) can be expected (in accordance with 
a uniform methodology developed by the Sec-
retary and for periods beginning 24 months 
after the date of original issue) to return to pol-
icyholders in the form of aggregate benefits at 
least 85 percent of the aggregate amount of 
premiums collected in the case of group policies 
or at least 75 percent in the case of individual 
policies (as defined by the Secretary); and 
‘‘(B) provides refunds and credits (in a 
manner specified by the Secretary) for pre-
miums collected in excess of those consistent 
with subparagraph (A). 
‘‘(4) GUARANTEED
RENEWABILITY
AND
CON-
VERTIBILITY.—Each AmeriCare supplemental pol-
icy— 
‘‘(A) shall be guaranteed renewable and 
may not be cancelled or nonrenewed solely on 
the ground of health status of the individual or 
for any reason other than nonpayment of pre-
mium or material misrepresentation; and 
‘‘(B) shall provide for— 
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‘‘(i) a right of conversion to an indi-
vidual policy (with continuation of bene-
fits) in the case of termination by a group 
policyholder 
or 
termination 
by 
a 
certificateholder of membership in a group 
through which the individual obtained cov-
erage; 
‘‘(ii) a right of continued coverage in 
the case of a group policy that succeeds 
another group policy; and 
‘‘(iii) suspension of coverage (for up 
to 24 months and in a manner specified ) 
in the case of a policy holder who becomes 
entitled to benefits under this title as a 
low-income individual and who provides a 
timely notice of election of such suspen-
sion. 
‘‘(5) ADDITIONAL
STANDARDS
APPLICABLE 
ONLY TO INSURED POLICIES.—A carrier that offers 
an insured AmeriCare supplemental policy (as de-
fined in paragraph (6)) to individuals and groups in 
a State shall also comply with the following require-
ments: 
‘‘(A) OPEN
ENROLLMENT.—The carrier 
must offer the same policy to any other indi-
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vidual or group in the State on a continuous, 
year-round basis; except that— 
‘‘(i) in the case of policies offered 
through an association which is composed 
exclusively of employers (which may in-
clude self-employed individuals) and which 
has been formed for purposes other than 
obtaining health insurance, such require-
ment shall only apply to such employers 
(and individuals) who are members of the 
association; and 
‘‘(ii) a health maintenance organiza-
tion may deny enrollment with respect to 
an individual based on the uniform appli-
cation of a geographic service area or over-
all enrollment limitation based on its finan-
cial or administrative capacity. 
‘‘(B) NOTICES AND RENEWAL PERIODS.— 
The carrier shall provide advance notice of 
terms for policy renewal, which terms shall— 
‘‘(i) be the same as the terms of 
issuance, except for rates and administra-
tive changes; 
‘‘(ii) provide the same premium rates 
as for a new issue; and 
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‘‘(iii) provide a period of renewal of 
not less than 12 months. 
‘‘(c) ADDITIONAL REQUIREMENTS.— 
‘‘(1) PROHIBITION OF DUPLICATION.—The Sec-
retary shall— 
‘‘(A) establish requirements that prohibit 
(other than as required under Federal or State 
law) the knowing sale or issuance to an indi-
vidual entitled to benefits under this title of 
health insurance that duplicates benefits under 
this title, of an AmeriCare supplemental policy 
that duplicates another AmeriCare supple-
mental policy, or of another health insurance 
policy that duplicates other benefits to which 
the individual is entitled; and 
‘‘(B) provide exceptions to the prohibition 
in subparagraph (A) for enrollment in group 
health plans and similar employment-based poli-
cies and for policies which provide benefits di-
rectly and without regard to other coverage and 
notice of such duplication. 
‘‘(2) DISCLOSURE
REQUIREMENT.—The Sec-
retary shall establish a requirement that prohibits 
the sale or issuance of an AmeriCare supplemental 
policy to an individual, other than as a replacement 
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policy, without obtaining a statement (in a form 
specified by the Secretary) that discloses other 
health benefits coverage and that acknowledges limi-
tations on the need for an AmeriCare supplemental 
policy, particularly in the case of a low-income indi-
vidual. 
‘‘(3) APPLICATION
OF
FALSE
STATEMENT 
SANCTIONS.—The provisions of paragraphs (1) and 
(2) of section 1882(d) shall apply to an AmeriCare 
supplemental policy under this section in the same 
manner as they apply to medicare supplemental poli-
cies under such section. 
‘‘(4) LIMITATIONS ON SALES COMMISSIONS.— 
‘‘(A) IN GENERAL.—It is unlawful for a 
person who provides for a commission or other 
compensation to an agent or other representa-
tives with respect to the sale of an AmeriCare 
supplemental policy (or certificate)— 
‘‘(i) to provide for a first year com-
mission or other first year compensation 
that exceeds 200 percent of the commis-
sion or other compensation for the selling 
or servicing of the policy or certificate in 
a second or subsequent year; or 
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sroberts on PROD1PC70 with BILLS
‘‘(ii) to provide for compensation with 
respect to replacement of such a policy or 
certificate that is greater than the com-
pensation that would apply to the renewal 
of the policy or certificate. 
‘‘(B) DEFINITION.—In subparagraph (A), 
the term ‘compensation’ includes pecuniary and 
nonpecuniary compensation of any kind relating 
to the sale or renewal of a policy or certificate 
and specifically includes bonuses, gifts, prizes, 
awards, and finders’ fees. 
‘‘(d) INFORMATION
DISCLOSURE.—The Secretary 
shall provide, to all individuals entitled to benefits under 
this title, such information as will permit such individuals 
to evaluate the value of AmeriCare supplemental policies 
to them and the relationship of any such policies to bene-
fits provided under this title. Such information shall in-
clude information on— 
‘‘(1) the requirements and prohibitions under 
this section; 
‘‘(2) State and Federal agencies responsible for 
compliance with such requirements and enforcement 
of such prohibitions; and 
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sroberts on PROD1PC70 with BILLS
‘‘(3) the manner of submitting complaints re-
garding violations of such requirements and prohibi-
tions. 
‘‘(e) DEFINITIONS.—In this section: 
‘‘(1) CARRIER.—The term ‘carrier’ means any 
person that offers an AmeriCare supplemental pol-
icy. 
‘‘(2) GROUP.—The term ‘group’ means 2 or 
more employees of the same employer who normally 
perform on a monthly basis at least 171⁄2 hours of 
service per week for that employer. 
‘‘(3) HEALTH MAINTENANCE ORGANIZATION.— 
The term ‘health maintenance organization’ has the 
meaning given the term ‘eligible organization’ in sec-
tion 1876(b). 
‘‘(4) INSURED
AMERICARE
SUPPLEMENTAL 
POLICY.—The term ‘insured AmeriCare supple-
mental policy’ means any AmeriCare supplemental 
policy provided through insurance.’’. 
TITLE II—FINANCING 
PROVISIONS 
Subtitle A—INDIVIDUAL 
CONTRIBUTIONS 
SEC. 201. GENERAL OBLIGATION FOR INDIVIDUALS. 
(a) PAYMENT OF PLAN PREMIUM.— 
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(1) IN GENERAL.—Each individual eligible for 
coverage under title XXII of the Social Security Act 
is liable for payment of the premium established 
under this section for such coverage of the individual 
and family members. An individual who is not re-
ceiving such coverage due to coverage under a group 
health plan described in section 2202(d) of such Act 
is not liable for payment of such premium with re-
spect to such individual. 
(2) DETERMINATION OF PREMIUM.—Such pre-
mium shall be established by the Secretary of Health 
and Human Services on the basis of the cost of cov-
erage (determined on a State by State basis and in-
cluding administrative costs) and shall be deter-
mined separately based on the class of enrollment 
for the individual (as determined under section 2202 
of the Social Security Act). 
(3) JOINT AND SEVERAL LIABILITY.—If more 
than one individual is liable under this subsection 
for payment of a premium for coverage of the same 
individual under title XXII of the Social Security 
Act, such individual shall be jointly and severally lia-
ble with each other individual who is so liable. 
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(b) REDUCTION
FOR EMPLOYER CONTRIBUTIONS 
AND LOW INCOME SUBSIDIES.—An individual’s liability 
under subsection (a) is reduced by— 
(1) the amount of any contributions made by 
the individual’s employer (or employers) under sub-
title B or otherwise (including voluntary employer 
contributions) with respect to coverage of the indi-
vidual and family members, and 
(2) the amount of any premium subsidies pro-
vided with respect to the individual under section 
202. 
(c) TIMING AND MANNER OF PAYMENT.—Each indi-
vidual that is liable for a premium under subsection (a) 
shall pay such premium in such form and manner as the 
Secretary of the Treasury may specify. Except as other-
wise provided by the Secretary of the Treasury, for pur-
poses of subtitle F of such Code, the liabilities imposed 
under subsection (a) shall be treated as if they were a 
tax imposed under section 1 of such Code. The Secretary 
of the Treasury shall provide for the withholding of such 
payments from wages under rules similar to the rules of 
chapter 24 of such Code. The Secretary of the Treasury 
may prescribe special rules for withholding payments from 
wages of individuals who work seasonally, part-time, or for 
more than one employer. 
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SEC. 202. ADDITIONAL PREMIUM SUBSIDIES. 
(a) ELIGIBILITY FOR ADDITIONAL PREMIUM SUB-
SIDIES.— 
(1) IN GENERAL.—Each premium subsidy eligi-
ble individual is entitled to a premium subsidy in ac-
cordance with this section. 
(2) 
PREMIUM
SUBSIDY
ELIGIBLE
INDI-
VIDUAL.—In this section, the term ‘‘premium sub-
sidy eligible individual’’ means an individual receiv-
ing coverage under title XXII of the Social Security 
Act who— 
(A) with respect to premiums for a taxable 
year ending in a year, has family income (as de-
fined in paragraph (3)(A)) that is less than 300 
percent of the applicable poverty level, or 
(B) with respect to a premium for a 
month, is an TANF or SSI recipient for the 
month. 
(3) ADDITIONAL DEFINITIONS.—In this section: 
(A) FAMILY INCOME.—The term ‘‘family 
income’’ means, with respect to an individual 
who— 
(i) is not a dependent of another indi-
vidual, the sum of the modified adjusted 
gross incomes (as defined in subparagraph 
(B)) for the individual, the individual’s 
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spouse, and children who are dependents of 
the individual, or 
(ii) is a dependent of another indi-
vidual, the sum of the modified adjusted 
gross incomes (as defined in subparagraph 
(B)) for the other individual, the other in-
dividual’s spouse, and children who are de-
pendents of the other individual. 
(B) MODIFIED
ADJUSTED
GROSS
IN-
COME.—The term ‘‘modified adjusted gross in-
come’’ means adjusted gross income (as defined 
in the Internal Revenue Code of 1986)— 
(i) determined without regard to sec-
tions 911, 931, and 933 of such Code, and 
(ii) increased by— 
(I) the amount of interest re-
ceived or accrued by the individual 
during the taxable year which is ex-
empt from tax, and 
(II) the amount of the social se-
curity benefits (as defined in section 
86(d) of such Code) received during 
the taxable year to the extent not in-
cluded in gross income under section 
86 of such Code. 
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The determination under the preceding sen-
tence shall be made without regard to any car-
ryover or carryback. 
(C) APPLICABLE POVERTY LEVEL.— 
(i) IN GENERAL.—The term ‘‘applica-
ble poverty level’’ means, for a family for 
a year, the official poverty line (as defined 
by the Secretary of Health and Human 
Services) applicable to a family of the size 
involved for 2010 adjusted by the percent-
age increase or decrease described in 
clause (ii) for the year involved. 
(ii) PERCENTAGE ADJUSTMENT.—The 
percentage increase or decrease described 
in this clause for a year is the percentage 
increase or decrease by which the average 
Consumer Price Index for all urban con-
sumers (U.S. city average), as published by 
the Bureau of Labor Statistics, for the 12- 
month-period ending with August 31 of the 
preceding year exceeds such average for 
the 12-month period ending with August 
31, 2009. 
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(iii) 
ROUNDING.—Any 
adjustment 
made under clause (ii) for a year shall be 
rounded to the nearest multiple of $100. 
(D) 
TANF 
RECIPIENT.—The 
term 
‘‘TANF recipient’’ means, for a month, an indi-
vidual who is receiving aid or assistance under 
any plan of the State approved under title I, X, 
XIV, or XVI, or part A or part E of title IV, 
of the Social Security Act, for the month. 
(E) SSI RECIPIENT.—The term ‘‘SSI re-
cipient’’ means, for a month, an individual— 
(i) with respect to whom supplemental 
security income benefits are being paid 
under title XVI of the Social Security Act 
for the month, 
(ii) who is receiving a supplementary 
payment under section 1616 of such Act or 
under section 212 of Public Law 93–66 for 
the month, or 
(iii) who is receiving monthly benefits 
under section 1619(a) of the Social Secu-
rity Act (whether or not pursuant to sec-
tion 1616(c)(3) of such Act) for the 
month. 
(b) AMOUNT OF PREMIUM SUBSIDY.— 
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(1) LOWEST INCOME INDIVIDUALS.— 
(A) IN GENERAL.—In the case of an indi-
vidual described in subparagraph (B), the pre-
mium subsidy under this section is the amount 
which would (without regard to this section) re-
duce the premium obligation of the individual 
(and family members) under section 201 to 
zero. 
(B) LOWEST
INCOME
INDIVIDUALS
DE-
SCRIBED.—An individual described in this sub-
paragraph is a premium subsidy eligible indi-
vidual who would still be such an individual 
under subsection (a)(2) if ‘‘200 percent’’ were 
substituted for ‘‘300 percent’’ in subparagraph 
(A) of such subsection. 
(2) OTHER INDIVIDUALS.— 
(A) IN GENERAL.—In the case of a pre-
mium subsidy eligible individual not described 
in paragraph (1), the premium subsidy under 
this section is the product of— 
(i) the premium obligation of the indi-
vidual (and family members) under section 
201, multiplied by 
(ii) the number of percentage points 
by which the individual’s family income 
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sroberts on PROD1PC70 with BILLS
(expressed as a percent of the applicable 
poverty level) is less than 300 percent. 
(B) TABLE.—The Secretary may provide 
for a table which establishes the values for pre-
mium subsidies under this paragraph. 
(c) GENERAL REVENUE FINANCING FOR LOW IN-
COME SUBSIDIES.—There are authorized to be appro-
priated to the Americare Trust Fund from amounts in the 
Treasury not otherwise appropriated, such sums as may 
be necessary to cover the costs of premium subsidies pro-
vided under this section. 
SEC. 203. EFFECTIVE DATE. 
The provisions of this subtitle shall apply with respect 
to periods beginning on or after January 1, 2010. 
Subtitle B—Employer 
Contributions 
SEC. 211. GENERAL OBLIGATION FOR EMPLOYERS. 
(a) GENERAL OBLIGATION.— 
(1) IN
GENERAL.—Subject to the succeeding 
provisions of this subsection, each employer shall 
make a financial contribution toward the cost of 
health insurance coverage for employees in accord-
ance with this section. 
(2) ELIMINATION
OF
LIABILITY
IN
CASE
OF 
CERTAIN GROUP HEALTH PLAN COVERAGE.— 
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(A) IN
GENERAL.—Subject to subpara-
graph (B), an employer shall not be liable for 
any contribution under this section with respect 
to any employee who is covered under a group 
health plan of the employer described in section 
2202(d) if such employer pays at least 80 per-
cent of the cost of such health plan, as deter-
mined by the Secretary of Health and Human 
Services. 
(B) SURCHARGE
PERMISSIBLE
TO
PRE-
VENT
ADVERSE
SELECTION.—The Secretary 
may impose liability for a contribution under 
this section with respect to an employee de-
scribed in subparagraph (A) in an amount (not 
to exceed the amount specified under subsection 
(b)) insofar as the Secretary determines it nec-
essary to prevent adverse selection of the indi-
viduals enrolled under this title as a result of 
the operation of such subparagraph. 
(b) AMOUNT OF CONTRIBUTION.— 
(1) FULL-TIME EMPLOYEES.—In the case of an 
employee receiving coverage under title XXII of the 
Social Security Act, the amount of the financial con-
tribution is equal to at least 80 percent of the pre-
mium determined with respect to such employee and 
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family members under section 201 (based on class of 
enrollment and without regard to subsection (b) 
thereof) or at least 80 percent of the cost of cov-
erage under such group health plan, respectively. 
(2) REDUCTION FOR PART-TIME EMPLOYEES.— 
In the case of a part-time employee, the employer 
contribution requirements of paragraph (1) shall be 
treated as satisfied if the employer contribution with 
respect to such employee is not less than the part- 
time employment ratio of the contribution required 
under paragraph (1). 
(3) RULES RELATED TO PART-TIME EMPLOY-
MENT.—For purposes of this subsection— 
(A) PART-TIME
EMPLOYEE.—The term 
‘‘part-time employee’’ means, with respect to 
any month, an employee who works on average 
fewer than 40 hours per week. 
(B) PART-TIME
EMPLOYMENT
RATIO.— 
The term ‘‘part-time employment ratio’’ means, 
with respect to a part-time employee of an em-
ployer in a month, a fraction— 
(i) the numerator of which is the 
number of hours in the employee’s normal 
work week, and 
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(ii) the denominator of which is 40 
hours. 
(C) SPECIAL
RULES.—Under rules pre-
scribed by the Secretary of Health and Human 
Services, in consultation with the Secretary of 
the Treasury, in the case of an employee for an 
employer whose defined work week for full-time 
employees is less than 40 hours, any reference 
in this subsection to 40 hours is deemed a ref-
erence to the number of hours in the work week 
so defined. 
(D) CONVERSION TO HOURS OF EMPLOY-
MENT.—The Secretary of Health and Human 
Services, in consultation with the Secretary of 
the Treasury, shall establish rules for the con-
version of compensation to hours of employ-
ment, for purposes of this subsection in the 
case of employees that receive compensation on 
a salaried basis, or on the basis of a commis-
sion, or other contingent or bonus basis, rather 
than based on an hourly wage. 
(c) TIMING AND MANNER.— 
(1) IN GENERAL.—Each employer that is re-
quired to make a financial contribution with respect 
to an employee under this section (other than with 
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respect to coverage under a group health plan) or a 
surcharge under subsection (a)(2)(B) shall pay such 
contribution or surcharge in a form and manner, 
specified by the Secretary of the Treasury, based 
upon the form and manner in which employer excise 
taxes are required to be paid under section 3111 of 
the Internal Revenue Code of 1986. 
(2) NON-ENROLLING EMPLOYERS.—In the case 
of an employee who is covered under the class of en-
rollment of a family member, the Secretary of the 
Treasury shall provide that the financial contribu-
tion of the employer with respect to such employee 
is paid directly or indirectly to the employer of such 
family member. 
SEC. 212. EFFECTIVE DATE. 
(a) IN GENERAL.—Subject to subsection (b), the pro-
visions of this subtitle shall apply with respect to periods 
beginning on or after January 1, 2010. 
(b) ADDITIONAL PERIOD FOR SMALL EMPLOYERS.— 
The provisions of this subtitle shall not apply with respect 
to an employer that has fewer than 100 employees (as de-
termined by the Secretary of the Treasury in consultation 
with the Secretary of Health and Human Services) for pe-
riods beginning before January 1, 2012. 
Æ 
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